Barriers to Research Utilization in Nursing: A Systematic Review (2002-2021)

Affiliation.

  • 1 National University, Manila, Philippines.
  • PMID: 35600005
  • PMCID: PMC9118897
  • DOI: 10.1177/23779608221091073

Introduction: There is an existing gap between what people learned from theory and what they clinically practiced, as revealed in research studies in nursing. This gap is primarily due to identified barriers in utilizing the research findings in actual nursing practice.

Objective: To present a scientific mapping of the Scopus-indexed literature published from 2002 to 2021, which studied barriers to research utilization in nursing using the BARRIER scale.

Methods: This systematic review utilized bibliometric analysis. One hundred seventy-nine extracted literature from Scopus was manually reviewed, and the study included 53 documents for further analysis.

Results: Remarkably, almost three-fourths of the documents identified setting-related factors as the most common barrier to research utilization in nursing (n = 39, 73.58%). This is followed by presentation-related factors (n = 16.98%) and nurse-related factors (n = 5, 9.43%), respectively. Findings revealed that insufficient time at work in implementing new ideas was perceived as the top barrier in research utilization in nursing.

Conclusion: It is crucial to determine the hindrances to the utilization of research findings. The results of this study establish the connection between research and evidence-based practice which stimulates in meeting the gap in the current nursing practice. Future studies must include research utilization studies that apply tools other than the BARRIER scale.

Keywords: barriers; bibliometric; nursing; research use; research utilization; systematic review.

© The Author(s) 2022.

U.S. flag

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

  • Advanced Search
  • Journal List
  • Implement Sci

Logo of implemsci

Individual determinants of research utilization by nurses: a systematic review update

Janet e squires.

1 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

Carole A Estabrooks

2 Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada

Petter Gustavsson

3 Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

Lars Wallin

4 Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet; and Clinical Research Utilization (CRU), Karolinska University Hospital, Stockholm, Sweden

Associated Data

Interventions that have a better than random chance of increasing nurses' use of research are important to the delivery of quality patient care. However, few reports exist of successful research utilization in nursing interventions. Systematic identification and evaluation of individual characteristics associated with and predicting research utilization may inform the development of research utilization interventions.

To update the evidence published in a previous systematic review on individual characteristics influencing research utilization by nurses.

As part of a larger systematic review on research utilization instruments, 12 online bibliographic databases were searched. Hand searching of specialized journals and an ancestry search was also conducted. Randomized controlled trials, clinical trials, and observational study designs examining the association between individual characteristics and nurses' use of research were eligible for inclusion. Studies were limited to those published in the English, Danish, Swedish, and Norwegian languages. A vote counting approach to data synthesis was taken.

A total of 42,770 titles were identified, of which 501 were retrieved. Of these 501 articles, 45 satisfied our inclusion criteria. Articles assessed research utilization in general (n = 39) or kinds of research utilization (n = 6) using self-report survey measures. Individual nurse characteristics were classified according to six categories: beliefs and attitudes, involvement in research activities, information seeking, education, professional characteristics, and socio-demographic/socio-economic characteristics. A seventh category, critical thinking, emerged in studies examining kinds of research utilization. Positive relationships, at statistically significant levels, for general research utilization were found in four categories: beliefs and attitudes, information seeking, education, and professional characteristics. The only characteristic assessed in a sufficient number of studies and with consistent findings for the kinds of research utilization was attitude towards research; this characteristic had a positive association with instrumental and overall research utilization.

Conclusions

This review reinforced conclusions in the previous review with respect to positive relationships between general research utilization and: beliefs and attitudes, and current role. Furthermore, attending conferences/in-services, having a graduate degree in nursing, working in a specialty area, and job satisfaction were also identified as individual characteristics important to research utilization. While these findings hold promise as potential targets of future research utilization interventions, there were methodological problems inherent in many of the studies that necessitate their findings be replicated in further research using more robust study designs and multivariate assessment methods.

In this paper, we update the evidence published in a previous systematic review on individual characteristics that influence nurses' use of research evidence in clinical practice. Research utilization refers to 'that process by which specific research-based knowledge (science) is implemented in practice' [ 1 ]. In recent years, research utilization by nurses has received increased attention in the literature and has been conceptualized and measured in terms of four kinds or types of research use: instrumental, conceptual, persuasive (or symbolic), and overall [ 1 - 3 ]. Instrumental research utilization refers to the concrete application of research findings in clinical practice. Conceptual research utilization refers to the cognitive use of research where the research may be used to change one's thinking about a specific practice, but may or may not result in a change in action. Persuasive or symbolic research utilization is the use of research as a persuasive or political tool to legitimate a position or influence the practice of others. Overall research utilization is an omnibus construct and refers to the use of any kind of research in any way [ 1 , 4 ].

Research utilization scholars continuously express concern about whether nurses use the best available scientific ( i.e ., research) evidence to guide their clinical practice [ 4 - 7 ]. This disparity between the availability of research evidence and its use in practice is often referred to as the 'research-practice gap.' The nature of this gap has been the subject of debate in the nursing literature. Larsen et al . [ 8 ], for example, have argued that there is no theory-practice gap; that the knowledge forms at issue in theory-practice gap discourse are radically different in kind. This stands in contrast to the views of other well-respected theorists ( e.g ., Allmark [ 9 ] and Fealy [ 10 ]) who articulate the nature of the gap, its origins, and in some cases, solutions to it. While, several examples of the research-practice gap have been highlighted in the nursing literature, most of the evidence is anecdotal due to difficulties surrounding attempts to measure whether or not nursing practice is research-based [ 11 ]. It remains generally accepted however that a research-practice gap exists.

Despite increased knowledge of the benefits of adopting a research-based approach to providing nursing care and of increased availability of research findings for nurses, the use of research findings in nursing practice remains, at best, slow and haphazard [ 12 - 14 ]. As a result, patients frequently do not receive best (or even optimal) nursing care. In response, there is an accelerated research agenda calling for the implementation of interventions to increase research use by nurses. However, relatively few reports of research utilization interventions in nursing exist and more importantly, where they do exist, positive findings are generally not reported [ 15 ]. One review examining interventions to increase research utilization by nurses has been published. Thompson et al . [ 16 ] concluded findings on the effectiveness of interventions to increase research use in nursing are equivocal and at best, a combination of educational interventions and local opinion leaders or multidisciplinary teamwork may be effective. One reason for this relative lack of knowledge on successful research utilization interventions in nursing, we argue, is the lack of systematic identification and evaluation of factors (individual, contextual, and organizational) associated with research utilization.

In a previous systematic review of individual characteristics related to research utilization by nurses, Estabrooks et al . [ 17 ] identified 95 characteristics that they grouped into six core categories: beliefs and attitudes, involvement in research activities, information seeking, education, professional characteristics, and other socio-economic factors. The six categories were not predetermined but emerged from the data extraction. By using a vote-counting approach to synthesis, Estabrooks et al . [ 17 ] concluded the most frequently studied individual characteristic and the only one with a consistently positive effect was 'attitude towards research', which is part of the larger category 'beliefs and attitudes.' Findings for other individual characteristics were highly equivocal and were characterized by serious study design and methodological flaws. In this paper, we update the evidence on individual characteristics of research utilization by searching additional electronic databases and by adding the results of studies published between 2001 and 2008 to the evidence reported in the previous review. We also expand on the previous review by reporting on the magnitude of effect between individual nurse characteristics and research utilization and by searching for and examining literature on kinds of research utilization ( i.e ., instrumental, conceptual, persuasive, overall) with respect to individual characteristics important to research utilization in nursing.

Selection criteria for studies

Types of study.

Randomized controlled trials, clinical trials, and observational ( i.e ., quasi-experimental, cohort, case-control, cross-sectional) designs that examined the association between individual characteristics and nurses' use of research in practice were eligible for inclusion. Case reports and editorials were excluded. Studies were further limited to those published in the English, Danish, Swedish, and Norwegian languages. There were no restrictions on the basis of country of origin, when the study was undertaken, or publication status.

Type of participant, characteristic, and outcome

We considered studies that examined relationships between individual characteristics and nurses' use of research. A nurse was defined as a professional who provides care in a clinical setting; this definition includes registered nurses, licensed practical nurses, nurse leaders, and clinical nurse educators. All individual characteristics, modifiable and non-modifiable, were eligible for inclusion. The outcome of interest was research utilization. We defined research utilization as the use of research-based information -- that is, information that is empirically derived. This information could be reported in a primary research article, review/synthesis report, or protocol. If the study involved the use of a protocol, the authors were required to make the research-basis for the protocol apparent in the report. We excluded articles that reported on: the adherence to clinical practice guidelines, rationale being that clinical practice guidelines can be based on non-research evidence ( e.g ., expert opinion), and the use of one specific-research-based practice if the purpose was not to examine nurses' use of research in practice generally. We did include nurses' use of protocols where the research-base of the protocol was made explicit in the research report. We also required that the relationship between the individual characteristic(s) and research utilization be expressed quantitatively (and tested statistically).

Search strategy for identification of studies

This review was conducted as part of a larger review on research utilization instruments [ 18 ]. The objectives of the larger review are: to identify instruments used to measure research utilization by healthcare providers, healthcare decision makers, and in healthcare organizations; and to assess the psychometric properties of these instruments. Research utilization instruments refer to self-report measures that assess healthcare providers' and decision makers' use of research-based knowledge in their daily practice. We searched the following 12 online bibliographic databases: Cochrane Database of Systematic Reviews (CDSR), Health and Psychosocial Instruments (HAPI), MEDLINE, CINAHL, EMBASE, Web of Science, SCOPUS, OCLC Papers First, OCLC WorldCat, Sociological Abstracts, Proquest Dissertation Abstracts, and Proquest ABI Inform. Key words and medical subject headings related to research utilization were identified prior to initiating the search. Additional File 1 displays a summary of the search strategy used in the larger review. We also hand searched the journals Implementation Science (a specialized journal in the research utilization field) and Nursing Research as well as the bibliographies of articles identified for inclusion in the review.

Study identification and quality assessment

One investigator (JES) and a research assistant screened the titles and abstracts of the articles identified by the search strategy. Articles that potentially met our inclusion criteria, or where there was insufficient information to make a decision regarding inclusion, were retrieved and assessed for relevance by one investigator (JES) and a research assistant. Disagreements throughout the selection process were resolved by consensus. To assess methodological quality of the final set of articles, we adapted two previously used tools: Estabrooks' Quality Assessment and Validity Tool for Cross-Sectional Studies, and the Quality Assessment Tool for Quantitative Studies. Each article had a quality appraisal performed by two reviewers. Articles were classified as weak, moderate-weak, moderate-strong, or strong using a system developed based on work by De Vet et al . [ 19 ] that has been used in other published systematic reviews [ 17 , 20 , 21 ]. All discrepancies in quality assessment were resolved through consensus.

Estabrooks' Quality Assessment and Validity Tool was developed based on the Cochrane Collaboration guidelines (in existence in 2001) and medical literature [ 22 , 23 ]. The tool contains a maximum of 16 total points covering three core domains: sample, measurement, and statistical analysis (Additional File 2 ). In order to derive a final score for each of the included articles (cross-sectional design), the total number of points obtained was divided by the total number of possible points, allowing for a score between 0 and 1 for each article. The articles were then classified as weak (<0.50), moderate-weak (0.51 to 0.65), moderate-strong (0.66 to 0.79), or strong (0.80 to 1.00).

The Quality Assessment Tool for Quantitative Studies Tool, developed for the Canadian Effective Public Health Practice Project, has been judged suitable to be used in systematic reviews of interventions [ 24 , 25 ]. The tool contains a maximum of 18 total points covering six content areas: selection bias (is the study sample representative of the target population), allocation bias (extent that assessments of exposure and outcome are likely to be independent), confounders (were important confounders reported and appropriately managed), blinding (were the outcome assessor(s) blinded to the intervention or exposure status of participants), data collection methods (reliability and validity of data collection methods and instruments), and withdrawals and dropouts (percentage of participants completing the study) (Additional File 3 ). Each article is scored as weak, moderate, strong, or not applicable in each of these six areas according to preset criteria that accompany the tool. The tool developers do not provide a means for calculating an overall quality score. However, in order to compare the quality scores for each included article that used an intervention design (assessed with this tool) to the included articles that used cross-sectional designs (assessed with Estabrooks' Quality Assessment and Validity Tool), we derived an overall quality score for each article. To derive this score, we assigned values of 1, 2, and 3 to the categorizations of weak, moderate, and strong in each content area respectively. A final quality score for each article was then obtained by dividing the summative score obtained by the number of applicable content areas ( i.e ., by 6 - the number of points not applicable for the article). The articles were then classified as weak (1.0 to 2.0), moderate-weak (2.1 to 2.34), moderate-strong (2.35 to 2.66), or strong (2.67 to 3.0).

Data extraction and analysis

One reviewer (JES) extracted data from all included articles. Extracted data was double checked by a research assistant for accuracy. Data were extracted on study design, objectives, sample and subject characteristics, theoretical framework, instruments used, reliability, validity, and key findings with respect to relationships between individual characteristics and nurses' research utilization (Tables ​ (Tables1 1 and ​ and2 2 and Additional File 4 ). All discrepancies in data extraction were resolved through consensus.

Summary of findings for studies reporting research utilization in general (n = 39 articles)

*Significance: NS = not significant, S = significant at p < 0.05

Summary of findings for studies reporting kinds of research utilization (n = 6 articles)

1 Managers vs educators

2 RNs vs educators

We present the findings from this review update descriptively according to: the individual characteristics assessed, and whether research utilization was assessed as a general phenomenon or as specific kinds. We used the same six categories of individual nurse characteristics suggested in the earlier review by Estabrooks et al . (2003) for comparability: beliefs and attitudes, involvement in research activities, information seeking, education, professional characteristics, and other socioeconomic factors. A seventh category, critical thinking, emerged and is reported on in this review with respect to kinds of research utilization. Examples of the characteristics that fall within each of these categories can be seen in Tables ​ Tables1 1 and ​ and2 2 .

We used a vote-counting approach to data synthesis. That is, the overall assessment of evidence for the association between an individual characteristic and research utilization was based on the relative number of studies demonstrating, and failing to demonstrate, statistically significant associations. As recommended by Grimshaw et al . [ 26 ], we supplemented this approach by also extracting all associations showing a positive direction of effect and the magnitude of effect for statistically significant effects (regardless of direction) when it was provided in the articles. These details are presented in Tables ​ Tables1 1 and ​ and2. 2 . However, because of large inconsistencies in how the associations were evaluated between studies, limited conclusions on the magnitude of the associations between research utilization and specific individual characteristics could be drawn.

We developed the following set of a priori rules to guide our synthesis:

1. In order to reach a conclusion as to whether or not an individual characteristic was associated with research utilization by nurses, it had to be assessed in a minimum of four articles. Characteristics assessed in less than four articles were coded as inconsistent ( i.e ., insufficient evidence to reach a conclusion). There is no agreed benchmark with respect to the number of studies required to reach a conclusion concerning the relationship between two or more variables when conducting a systematic review. Within the Cochrane Collaboration, where higher levels of evidence ( e.g ., randomized controlled trials, pseudo-randomized controlled trials) are routinely utilized, at least one high quality study is recommended; with more studies desired. When only lower levels of evidence ( e.g ., non-randomised studies, observational studies) are available, no direction with respect to the number of studies required is offered [ 27 ]. A recent review [ 28 ] (utilizing observational studies) that examined the extent to which social cognitive theories (that are comprised of individual characteristics) explain healthcare professionals' intention to adopt clinical behavior used a cut-off of three studies. In this review, we set our cut-off slightly higher, at four studies, to ensure we did not draw conclusions based on occasional/random findings.

2. Characteristics that were assessed in four or more articles were coded as significant, not significant, or equivocal, depending on which of these three categories 60% or more of the articles fell within. For example, if four articles existed and two of these articles found the characteristic to be significant and two articles not significant, the characteristic was coded as equivocal.

3. Where bivariate and multivariate statistics were both offered in an article as evidence, we used the more robust multivariate findings in our synthesis to reach a conclusion as to whether or not a relationship existed between the individual characteristic(s) and research utilization.

Description of studies

Figure ​ Figure1 1 summarizes article selection for this review. The database and hand searches yielded 42,770 titles and abstracts. Of these 42,770 articles, 501 were identified as being potentially relevant after a title and abstract review. A total of 456 articles were excluded for not meeting our inclusion criteria, leaving 45 articles for inclusion in this review, and 31 (69%) of these articles are additions to the previous review). The 45 articles represent 41 original studies; four studies have two reports each: McCleary and Brown [ 29 , 30 ]; Estabrooks [ 31 , 32 ]; McCloskey [ 33 , 34 ]; and Parahoo [ 35 , 36 ]. A list of all (n = 45) included articles can be found in Additional File 4 . The original review [ 17 ] included 22 articles. This review update excluded eight of these articles, leaving 14 of the original articles in the update. The eight articles were excluded for one of three reasons: they did not include a measure of research utilization as we defined it for this review update (n = 5) [ 37 - 41 ], they did not report on individual characteristics (n = 2, these two articles represented a second report of a study that did not report individual characteristics - the first report of each study, which did report on individual characteristics, were included) [ 2 , 42 ], or did not provide a quantitative (statistical) test of the association between the individual characteristic(s) and research utilization (n = 1) [ 43 ].

An external file that holds a picture, illustration, etc.
Object name is 1748-5908-6-1-1.jpg

Selection of articles for review .

A variety of self-report instruments, multi-item and single item, were used to measure research utilization in the 45 included articles. Multi-item instruments used included: the Nurses Practice Questionnaire (n = 8) [ 12 , 14 , 44 - 49 ]; the Research Utilization Questionnaire (n = 11) [ 33 , 34 , 50 - 58 ]; the Edmonton Research Orientation Survey (n = 3) [ 29 , 30 , 59 ]; and three research utilization indexes, each used in a single study [ 60 - 62 ]. Single-item instruments used included: Estabrooks Kinds of Research Utilization Items (n = 9) [ 31 , 32 , 63 - 69 ]; Parahoo's Item (n = 2) [ 35 , 36 ]; Past, Present, and Future Use Items (n = 3) [ 70 - 72 ]; and other single items, each used in a single study (n = 6) [ 73 - 78 ]. The majority of articles examined research utilization by nurses in the United States (n = 18, 40%) followed by Canada (n = 14, 31%), Europe (n = 8, 18%), Australia (n = 2, 4.5%), China (n = 2, 4.5%), and Africa (n = 1, 2%). The most commonly reported setting was hospitals (n = 28, 62%) followed by a mixture of settings, e.g ., sampling from a provincial or state nursing roster (n = 13, 29%), nursing homes (n = 2, 4.5%), an educational setting (n = 1, 2%), and a flight team setting (n = 1, 2%). With respect to year of publication, the vast majority of articles were published since 1995 (n = 40, 89%). Further details on the characteristics of the included articles can be found in Additional File 4 .

Methodological quality of included studies

Methodological quality of the articles included in this review is reported in Additional Files 2 and 3 . All articles used an observational design: the majority (n = 43, 96%) used a cross-sectional design while two articles (4%) used a quasi-experimental design. Of the 45 included articles, one (2%) was rated as strong, 13 (29%) as moderate-strong, 18 (40%) as moderate-weak, and 13 (29%) as weak. Discrepancies in quality assessment related mainly to sample representativeness, treatment of missing data, and appropriateness of the statistical test(s) used.

The outcome: individual characteristics and research utilization

Data on individual characteristics were extracted into the original six categories from the previous review [ 17 ]: beliefs and attitudes, involvement in research activities, information seeking, education, professional characteristics, socio-demographic and socio-economic factors (relabeled from other socio-economic factors), and one additional category, and critical thinking. Relationships between these characteristics and research utilization in general, and kinds of research utilization, are summarized next with additional details presented in Tables ​ Tables1 1 and ​ and2 2 respectively.

Research utilization in general

A total of 39 (87%) articles examined relationships between individual characteristics and nurses' research utilization in general (Table ​ (Table1 1 ).

Beliefs and attitudes

Fourteen articles assessed one or more individual characteristic in the beliefs and attitudes category. Of these 14 articles, six were rated as weak methodologically, five were rated as moderate-weak, and three were rated as moderate-strong (Additional Files 2 and 3 ). Sample sizes varied from a low of 20 participants [ 54 ] to a high of 1,117 participants [ 62 ] (Additional File 4 ). The most frequently assessed characteristic in this category was attitude towards research, assessed in eight articles. The majority of these eight articles were rated as weak (n = 3) or moderate-weak (n = 4) methodologically while one article received a quality rating of moderate-strong (Additional Files 2 and 3 ). In all eight articles, attitude towards research was measured using multi-item summated scales. A 21-item scale developed by Champion and Leach [ 50 ] with items tapping nurses' feelings about incorporating research into practice was used in four of the eight articles [ 50 , 52 , 56 , 57 ]. Similar multi-item measures, with six [ 31 , 61 ], 12 [ 54 ] and 15 items [ 72 ] were used in the remaining four studies. A positive association with research utilization, at statistically significant levels, was found in all eight articles. The magnitude of effect, on average, was high moderate, with correlation coefficients ranging from 0.41 to 0.82. Other belief and attitudinal characteristics were assessed in less than four articles and therefore their results cannot be considered with any confidence.

Involvement in research activities

Thirteen articles assessed one or more individual characteristic related to nurses' involvement in research activities. Of these articles, three were rated as weak methodologically, eight were rated as moderate-weak, and two were rated as moderate-strong (Additional Files 2 and 3 ). Sample sizes also varied from a low of 82 participants [ 55 ] to a high of 1,100 participants [ 49 ] (Additional File 4 ). Examples of activities assessed that were reflective of involvement in research activities included: participation in a research study [ 44 , 55 ], participation in quality improvement initiatives [ 58 ], participation in quality management [ 29 ], and data collection for others conducting research [ 71 ]. Additional examples can be found in Table ​ Table1. 1 . A total of 13 individual characteristics were identified in this category overall. However, each characteristic was assessed in less than four articles, precluding us from drawing conclusions on the relationships between individual characteristics typical of involvement in research activities and nurses' use of research findings in practice.

Information-seeking

A total of 15 articles reported individual characteristics consistent with information-seeking behavior. Two articles were rated as weak methodologically, five articles as moderate-weak, and the remaining eight articles as moderate-strong (Additional Files 2 and 3 ). Sample sizes varied largely from a low of 92 participants [ 57 ] to a high of 5,948 participants [ 69 ] (Additional File 4 ). Several articles examined the relationships between different reading practices and research utilization. For example, reading professional journals [ 46 ]; hours spent reading professional journals [ 44 , 47 , 48 ]; the number of journals read [ 12 , 49 , 72 ]; and reading specific journals such as Heart and Lung [ 47 , 48 ], Nursing Research [ 44 , 48 ], and RN [ 44 ], were studied. Different combinations of these six reading characteristics were tested a total of 12 times (some articles assessed more than one of the reading practices simultaneously). Findings from these investigations were equivocal with seven articles (58%) reporting statistically significant findings and five articles (42%) not finding statistically significant findings. Thus, no conclusion can be drawn as to the effect of reading practices on nurses' use of research in practice.

The second most commonly studied information-seeking characteristic was attendance at conferences and/or attendance at in-services, examined in five articles [ 31 , 47 - 49 , 71 ]. Four of these articles [ 31 , 47 - 49 ], all rated moderate-strong with respect to methodological quality, found positive relationships, at statistically significant levels, between conference and/or in-service attendance and research utilization. The overall magnitude of this effect, however, is not computable since each article used a different test of statistical association. The remainder of individual characteristics falling within the category of information seeking were only investigated in one or two articles, precluding us from considering their findings (Table ​ (Table1 1 ).

A total of 28 articles reported individual characteristics within the domain of education, making it the most commonly studied category of characteristics in this review. Of the 28 articles, 10 were rated as weak methodologically, nine were rated as moderate-weak, and nine were rated as moderate-strong (Additional Files 2 and 3 ). Sample sizes varied from a low of 20 participants [ 54 ] to a high of 5,948 participants [ 69 ] (Additional File 4 ).

Twenty-five of the articles in this category examined one of three characteristics related to formal nursing education: increasing levels of education ( i.e ., diploma, bachelor degree, masters degree, PhD degree, but without post hoc analyses to determine between which levels noted differences lied), type of degree: bachelor versus diploma, and type of degree: graduate degree (masters or PhD) versus lower (bachelor and/or diploma). Increasing levels of education was assessed in seven articles [ 12 , 44 , 47 , 49 , 54 , 55 , 77 ]. Findings from these investigations were equivocal with only four (57%) of these articles [ 12 , 49 , 54 , 77 ] finding positive relationships, at statistically significant levels, between higher levels of education and research utilization. A total of 11 articles [ 14 , 29 , 31 , 46 , 57 , 61 , 62 , 69 , 71 , 73 , 76 ] examined the relationship between research utilization and type of degree: bachelor versus diploma. Eight of these articles [ 14 , 31 , 46 , 57 , 61 , 62 , 73 , 76 ] did not find a significant association between bachelor degree versus diploma and research utilization, leading to the conclusion that type of degree: bachelor versus diploma is not an important characteristic to nurses' use of research. An additional seven articles (six studies) [ 29 , 33 , 34 , 48 , 50 , 59 , 60 ] examined the relationship between research utilization and type of degree: graduate degree (masters or PhD) versus lower (bachelor and/or diploma). The majority of these articles (n = 5, 71%) found a statistically significant relationship between graduate degree versus bachelor degree/diploma and research utilization [ 29 , 33 , 34 , 48 , 50 , 59 ]. Overall, findings from all 25 articles examining characteristics related to formal nursing education levels indicate that a positive effect exists for level of education, when a nurse holds a graduate degree compared to a bachelor degree/diploma but not when a nurse holds a bachelor degree compared to a diploma.

Another educational characteristic assessed in greater than four articles was completion of research classes [ 12 , 30 , 44 , 47 , 55 ]. Findings showed that this characteristic however was not significantly related to research utilization. Two articles [ 12 , 30 ], rated as weak and moderate-strong methodologically respectively, found a positive relationship, at statistically significant levels, while three articles (60%) [ 44 , 47 , 55 ], one rated as weak methodologically and two rated as moderate-strong, did not find evidence of a statistically significant relationship.

The remaining individual characteristics related to education ( e.g ., well prepared in education process, working towards a degree, number of degrees, see Table ​ Table1) 1 ) were assessed in less than four articles and therefore, were not considered.

Professional characteristics

The second most commonly studied category of individual characteristics, assessed in 27 of the 39 included articles, was professional characteristics. Of these articles, 12 were rated as weak methodologically, eight as moderate-weak, and eight as moderate-strong (Additional Files 2 and 3 ). Sample sizes varied from a low of 20 participants [ 54 ] to a high of 5,948 participants [ 69 ] (Additional File 4 ).The most commonly reported characteristics in this category were: experience ( i.e ., years employed as a nurse) (n = 12 articles), current role ( e.g ., leadership compared to staff nurse) (n = 10 articles), clinical specialty ( e.g ., critical care compared to medical/surgical (n = 9 articles) and job satisfaction (n = 5 articles) (Table ​ (Table1). 1 ). Of these characteristics, consistent statistically significant relationships with research utilization were found for current role, specialty, and job satisfaction. Experience was not related to research utilization.

Ten articles (nine studies) examined the impact of current role on research utilization. Six (60%) of these articles (three rated as weak methodologically, two as moderate-weak, and one as moderate- strong, see Additional Files 2 and 3 ) found that nurses practicing in advanced practice or leadership roles had significantly higher research utilization scores compared to staff nurses [ 33 , 34 , 52 , 59 , 69 , 71 ]. However, nurses in such advanced practice and leadership roles generally have higher levels of education, which may have confounded this finding. Nine articles examined the impact of clinical specialty on research utilization. Six (67%) of these articles (two rated as weak, as moderate-weak, and as moderate-strong respectively, see Additional File 2 ) found a significant relationship between specialty and research utilization; nurses who worked on specialty wards ( e.g ., critical care, diabetes care) reported higher frequencies of research utilization in comparison to nurses who worked in more generalized units ( e.g ., medical or surgical floors) [ 14 , 36 , 53 , 55 , 60 , 62 ]. Five articles examined the impact of job satisfaction on research utilization. Three (60%) of these articles (one rated as moderate-weak methodologically and two as moderate-strong, see Additional File 2 ) found a statistically significant relationship between job satisfaction and research utilization [ 47 , 62 , 69 ]. Experience, assessed in 12 articles, was not related to research utilization at statistically significant levels in the majority (n = 10 of 12, 83%) of these articles (Table ​ (Table1 1 ).

Socio-demographic and socio-economic factors

Of the ten articles reporting other socio-demographic and socio-economic nurse characteristics (four rated as weak methodologically, three as moderate-weak, and three as moderate-strong, see Additional File 2 ), none reported a significant association with research utilization. Further, with the exception of age, which was assessed in nine studies, the characteristics were assessed in less than four studies, precluding the drawing of conclusions.

Kinds of research utilization

While the majority of articles identified in this review update assessed associations between individual characteristics and nurses' use of research in general, there is also a beginning trend in the literature to examine kinds of research utilization. A total of six articles (one rated as weak methodologically, two as moderate-weak, two as moderate-strong, and one as strong, see Additional File 2 ) were identified that explicitly examined the relationship between individual characteristics and nurses' use of one or more kinds of research utilization. The following section presents an overview of the findings from these six articles. More details on these findings can be found in Table ​ Table2 2 .

The only individual characteristic assessed in a sufficient number of articles ( i.e ., in four or more articles) was a nurse's attitude towards research. All four articles reported a positive relationship, at statistically significant levels, between a nurse's attitude towards research and at least one kind of research utilization [ 32 , 63 , 66 , 67 ]. Only instrumental and overall kinds of research utilization were assessed in four articles. A positive relationship was found in three articles (75%) for both of these kinds of research utilization: instrumental [ 32 , 63 , 67 ] and overall [ 32 , 66 , 67 ]. All remaining characteristics were assessed in less than four articles, precluding conclusions.

One individual characteristic, critical thinking dispositions, was assessed in two articles examining kinds of research utilization. Critical thinking dispositions refers to a "set of attitudes that define a personal disposition to prize and to use critical thinking in one's personal, professional, and civic affairs" [ 79 ]. Both articles assessed critical thinking dispositions using the California Critical Thinking Disposition Inventory that measures seven dispositional components: truth-seeking, open-mindedness, analyticity, systematicity, self-confidence, inquisitiveness, and maturity [ 79 ]. Both identified studies found a positive relationship, at statistically significant levels, between nurses' ability to think critically (as measured by an average of all seven dispositions) and each of the four kinds of research utilization [ 64 , 65 ]. The magnitude of this effect was small to moderate with correlation coefficients ranging from 0.15 to 0.35, depending on the kind of research utilization (Table ​ (Table2 2 ).

Comparison with previous review

This systematic review update focused on individual nurse characteristics that have been studied empirically with respect to nurses' use of research in practice. By extending the search criteria of the previous review, 31 additional studies were identified for inclusion in this update. This more than doubles the evidence available for review specifically examining the relationships between individual characteristics and research utilization by nurses. Unfortunately, studies continue to vary greatly in terms of sample selection (source of participants), sample size, study methods and rigor, statistical tests used, and the instrument (items) used to measure the outcome variable -- research utilization. Promisingly, though, a trend in the most recent included studies for more robust analyses ( i.e ., multivariate regression versus bivariate correlations and/or tests of difference) and less variability in choice of outcome measures is evident. Nevertheless, given the continuing heterogeneity between studies, only general statements can be made regarding the relationships between individual characteristics and research utilization by nurses at this time. That is, at this point in time we can only say which characteristics are associated with research utilization and not which characteristics predict research utilization by nurses.

Taken collectively, the now significantly larger body of evidence suggests promise for the following individual characteristics as being important to ( i.e ., related to an increase in) nurses' use of research in their practice: positive attitude towards research, attending conferences and/or in-services, having a graduate degree (compared to a bachelors degree or diploma), current role ( i.e ., leadership and/or advanced practice compared to staff nurse), clinical specialty (working in critical care areas compared to general hospital units), and job satisfaction. An additional three characteristics were shown not to be important to research utilization by nurses: completion of research classes, experience, and age. While, overall, the extent to which many individual characteristics influence research utilization remains largely unknown, there is support for the above-mentioned characteristics. This represents a significant increase in knowledge over the previous review. Table ​ Table3 3 compares conclusions made in our review update with the original review.

Comparison of conclusion between previous review and review update

In addition to examining the relationships between individual characteristics and research utilization generally, we also looked for relationships between individual characteristics and kinds ( i.e ., instrumental, conceptual, persuasive, and overall) of research utilization. Estabrooks [ 2 ] confirmed the existence of the four kinds of research utilization in a study of Canadian registered nurses, and additional studies since then have shown differential relationships between individual and contextual characteristics and the different kinds of research utilization [ 32 , 63 , 66 , 67 ]. Therefore, we elected to report on these articles separately and not combine them with the articles that report on research utilization in general. While few articles were identified that have assessed relationships between individual characteristics and kinds of research utilization, some promising findings did emerge in those that were identified. For example, critical thinking, which was assessed in two articles showed positive, statistically significant correlations with each kind of research utilization in both articles [ 64 , 65 ]. These two articles were moderate-weak and moderate-high in methodological quality and had relatively small sample sizes of 143 and 287 nurses, respectively (Additional Files 2 and 4 ). This, combined with the limited number of studies conducted, precluded us from drawing a conclusion. While there is insufficient evidence at this time to conclude that a relationship does exist (and that nurses' critical thinking dispositions could be a target of future intervention studies), it may be a fruitful avenue for future research.

Despite a limited number of articles addressing kinds of research utilization, one characteristic -- attitude towards research -- was assessed in a sufficient number of articles ( i.e ., four articles) to be able to conclude a positive relationship between attitude towards research and nurses' instrumental and overall use of research exists. This relationship was also found in all eight articles examining attitude towards research on research utilization in general. This finding is consistent with known theories of human behavior. For example, the Theory of Planned Behavior, which is frequently used in psychological research, states human behavior (such as research utilization) is guided by three kinds of considerations: behavioral beliefs ( i.e ., beliefs about the likely outcomes of a behavior), normative beliefs ( i.e ., beliefs about the normative expectations of others and motivation to comply with these expectations), and control beliefs ( i.e ., beliefs about the presence of factors that may facilitate or impede performing the behavior) [ 80 ]. Behavioral beliefs are further known to produce a favorable or unfavorable attitude toward the behavior [ 80 ], supporting our findings.

Godin et al . [ 28 ], in a systematic review of healthcare professionals' (that included nurses) intentions and clinical behaviors, found the Theory of Planned Behavior to be an appropriate theory for examining attitudes and beliefs in relation to specific actions or behaviors. Specifically, they found healthcare professionals' beliefs about their own capabilities and the consequences of their behavior to be consistently and positively associated, at statistically significant levels, with predicting their clinical behavior. Beliefs were also positively and significantly associated with healthcare professionals' intention to change their behavior. These findings illustrate the potential benefit that using this theory, beyond the measurement of nurses' attitudes in general towards research utilization, may have in research utilization studies. For example, added value could be obtained by measuring nurses' beliefs and attitudes in relation to specific behaviors ( i.e ., their use of specific research-based findings in practice). Future research should also focus on determining what causes nurses to form favorable (positive) attitudes towards the use of research, both of research utilization in general and of its kinds, as well as of the use of specific research-based findings in practice.

Methodological implications for future research

Systematic reviews typically identify and comment on problems with internal validity of the research under scrutiny, and this review update is no exception. Future studies examining individual characteristics related to research utilization need to attend to methodological quality to reduce bias and to increase confidence in this growing body of knowledge. This will allow for the design of theory-informed research utilization interventions with the intention of improving the quality of patient care.

Four important limitations of studies conducted to date on individual characteristics and research utilization by nurses are: methodological quality, statistical rigor, inconsistency in measurement of the outcome measure (research utilization), and limited use of research utilization or other related theory. First, few studies examining the relationship between individual characteristics and research utilization in this review were of moderate-strong or strong methodological quality, illustrating a clear need for well-designed, robust studies that examine the association between different individual characteristics and research utilization by nurses. Second, in order to effectively design research utilization interventions tailored for individual nurse characteristics, we need to know which characteristics predict (not just which ones are related to) research utilization. This will require multivariate statistical assessments. There is no need for continued bivariate assessments, especially given the clear evidence of inter-correlations among different individual characteristics [ 81 ]. Third, there is inconsistency in the measures being used for the outcome of interest, research utilization. By this we mean that we observed a lack of standard measures of research utilization across studies. While a few instruments that measure research use by nurses have been used in multiple studies ( e.g ., Nurses Practice Questionnaire [ 12 , 14 , 44 - 49 ], Research utilization Questionnaire [ 33 , 34 , 50 - 58 ]), Edmonton Research Orientation Survey [ 29 , 30 , 59 ], Estabrooks Kinds of Research Utilization Items [ 31 , 32 , 63 - 69 ]), by far, the most common approach to measuring research utilization has been the use of a single-item developed for an individual study. This absence of commonly used measures across studies makes it difficult, if not impossible, to build a consistent body of knowledge on which individual characteristics influence research utilization by nurses. Finally, only one-third (n = 14) of the articles identified in this review reported their investigation was based on research utilization or other appropriate theory (Additional File 4 ). For the vast majority of these articles, Rogers Diffusion of Innovations theory was used to guide the development of a measure of and/or calculation of a research utilization score, but not the selection of variables of included or the design and evaluation of the study. Future research utilization investigations should utilize appropriate theory in both instrument and study design/evaluation.

Limitations

While rigorous methods were used for this review, there were limitations. First, while an attempt was made to review grey literature ( e.g ., searching dissertation databases) we did not search all grey literature databases, and, as such, this review update may not be representative of all relevant work in the field. Second, where details of study methods were not clear, we did not attempt to clarify these details by contacting the article authors. This may have resulted in aspects of methods being scored low in the quality assessment phase, possibly reflecting quality of the reporting rather than the actual methods used. Third, studies published in languages other than those of the research team were excluded. Finally, because of the inconsistency in how associations between individual characteristics and research utilization were determined and reported in the included studies, we were forced to use a vote-counting approach to data synthesis. There are several weaknesses associated with using vote counting. For example, this approach to synthesis fails to account for: effect sizes (vote counting gives equal weight to all associations, regardless of magnitude) and precision of the estimate from the primary studies (vote counting gives equal weight to comparisons irrespective of sample size). To lessen these problems, we reported the following as recommended by Grimshaw et al . [ 26 ]: all associations showing a positive direction of effect, the number of comparisons showing statistically significant effects (regardless of direction), and the magnitude of effect for significant findings when it was provided in the articles.

This review update points to an increased body of research on the study of individual characteristics and research utilization by nurses. However, methodological problems inherent in many of the studies included in the review update mean that robust evidence to support individual characteristics that predict research utilization is scarce. Current evidence suggests that a nurse's attitude towards research is the only individual characteristic that is consistently (with a positive effect) related to research utilization in general and the different kinds of research utilization. Other individual characteristics with evidence for a positive association with research utilization (in general) include: attending conferences and/or in-services, having a graduate degree, current role, clinical specialty, and job satisfaction. These characteristics may hold promise as targets of future research utilization interventions. While all of these characteristics are potentially modifiable, some can be more easily manipulated and thus incorporated into interventions to increase research utilization. For example, attitude towards research and attendance at conferences and/or in-services are two characteristics that we believe can and should be the focus of future research utilization interventions. The remaining characteristics identified in this review as having a positive statistically significant association with research utilization, while modifiable, would require more effort and time to implement (e.g., increasing the number of nurses employed within a clinical setting that hold a graduate degree).

We also recommend that programmatic research in the area of research utilization in nursing be undertaken. Programmatic research differs from conducting a research study in that it seeks to break a large research topic into smaller, more manageable pieces, allowing for more detailed analyses. Importantly, programmatic research addresses each piece sequentially in an effort to build a coherent picture from the smaller studies' findings, and allows investigators to build upon their own and others' research. Such programs in research utilization in nursing would have several concurrent streams examining, for example, different settings (acute care adults, acute care pediatrics, long-term care, community/home healthcare), different classes of determinants (individual characteristics, contextual factors, and organizational factors), and interventions to increase research use and subsequently patient outcomes. Without such programmatic research, we believe substantial advances in understanding how to increase the use of research by nurses and thereby improve patient care will be difficult, if not impossible, to achieve.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

All authors participated in designing the study, securing funding for the project, and developing the search strategy. JES undertook the article selection; data extraction and quality assessment; and drafted the manuscript. CAE, PG, and LW provided valuable advice throughout the study. All authors provided critical commentary on the manuscript and approved the final version.

Supplementary Material

Search strategy . A summary of the search strategy used in the review.

Quality assessment for included cross sectional articles . A description of the findings from the quality assessment of included articles describing studies that used a cross sectional study design.

Quality assessment for the included quasi-experimental articles . A description of the findings from the quality assessment of included articles describing studies that used a quasi-experimental study design.

Characteristics of the included studies . A detailed summary of the characteristics of all articles included in the review.

Acknowledgements

This project was made possible by the support of the Canadian Institutes of Health Research (CIHR) Knowledge Translation Synthesis Program (KRS 86255). JES holds CIHR Postdoctoral and Bisby Fellowships; at the time of this research she held Killam, CIHR and Alberta Heritage Foundation for Medical Research (AHFMR) doctoral fellowships. CAE holds a CIHR Canada Research Chair in Knowledge Translation. PG holds a grant from AFA Insurance and LW is supported by the Center for Care Sciences at Karolinska Institutet.

We would like to thank the following individuals for their contribution to the project reported in this paper: Dagmara Chojecki, MLIS, for her support in finalizing the search strategy and Hannah O'Rourke, research assistant, for her assistance with screening and quality assessment.

  • Estabrooks CA, Wallin L, Milner M. Measuring knowledge utilization in health care. International Journal of Policy Analysis & Evaluation. 2003; 1 :3–36. [ Google Scholar ]
  • Estabrooks CA. The conceptual structure of research utilization. Research in Nursing and Health. 1999; 22 (3):203–216. doi: 10.1002/(SICI)1098-240X(199906)22:3<203::AID-NUR3>3.0.CO;2-9. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Stetler C. Research utilization: Defining the concept. Image:The Journal of Nursing Scholarship. 1985; 17 :40–44. doi: 10.1111/j.1547-5069.1985.tb01415.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Estabrooks CA. Will Evidence-Based Nursing Practice Make Practice Perfect? Canadian Journal of Nursing Research. 1998; 30 (1):15–36. [ PubMed ] [ Google Scholar ]
  • English I. Nursing as a research based profession: 22 years after Briggs. British Journal of Nursing. 1994; 3 (8):402–406. [ PubMed ] [ Google Scholar ]
  • Dobbins M, Ciliska D, Mitchell A. PhD Thesis. University of Toronto: Faculty of Nursing; 1998. Dissemination and use of research evidence for policy and practice by nurses: A model of development and implementation strategies. [ Google Scholar ]
  • Veeramah V. Utilization of research findings by graduate nurses and midwives. Journal of Advanced Nursing. 2004; 47 (2):183–191. doi: 10.1111/j.1365-2648.2004.03077.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Larsen K, Adamsen L, Bjerregaard L, Madsen L. There is no gap 'per se' between theory and practice: Research knowledge and clinical knowledge are developed in different contexts and follow their own logic. Nursing Outlook. 2002; 50 (5):204–212. doi: 10.1067/mno.2002.127724. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Allmark P. A classical view of the theory-practice gap in nursing. Journal of Advanced Nursing. 1995; 22 (1):18–23. doi: 10.1046/j.1365-2648.1995.22010018.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Fealy G. The theory-practice relationship in nursing: An exploration of contemporary discourse. Journal of Advanced Nursing. 1997; 25 (5):1061–1069. doi: 10.1046/j.1365-2648.1997.19970251061.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Bircumshaw D. The utilization of research findings in clinical nursing practice. Journal of Advanced Nursing. 1990; 15 :1272–1280. doi: 10.1111/j.1365-2648.1990.tb01742.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Rodgers SE. The extent of nursing research utilization in general medical and surgical wards. Journal of Advanced Nursing. 2000; 32 (1):182–193. doi: 10.1046/j.1365-2648.2000.01416.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Parahoo K. Barriers to, and facilitators of, research utilization among nurses in Northern Ireland. Journal of Advanced Nursing. 2000; 31 (1):89–98. doi: 10.1046/j.1365-2648.2000.01256.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Squires JE, Moralejo D, LeFort SM. Exploring the role of organizational policies and procedures in promoting research utilization in registered nurses. Implementation Science. 2007; 2 (1) doi: 10.1186/1748-5908-2-17. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Wallin L. Knowledge translation and implementation research in nursing. International Journal of Nursing Studies. 2009; 46 :576–587. doi: 10.1016/j.ijnurstu.2008.05.006. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Thompson DS, Estabrooks CA, Scott-Findlay S, Moore K, Wallin L, Thompson DS, Estabrooks CA, Scott-Findlay S, Moore K, Wallin L. Interventions aimed at increasing research use in nursing: a systematic review. Implementation Science. 2007; 2 :15. doi: 10.1186/1748-5908-2-15. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Estabrooks CA, Floyd JA, Scott-Findlay S, O'Leary KA, Gushta M. Individual determinants of research utilization: A systematic review. Journal of Advanced Nursing. 2003; 43 (5):506–520. doi: 10.1046/j.1365-2648.2003.02748.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Squires J, Estabrooks C, Wallin L, Gustavsson P. A systematic review of the psychometric properties of instruments used to measure knowledge translation in healthcare professionals technical report. Edmonton, Alberta: Faculty of Nursing, University of Alberta; 2009. [ Google Scholar ]
  • De Vet HCW, De Bie RA, Van Der Heijden GJMG, Verhagen AP, Sijpkes P, Knipschild PG. Systematic reviews on the basis of methodological criteria. Physiotherapy. 1997; 83 (6):284–289. doi: 10.1016/S0031-9406(05)66175-5. [ CrossRef ] [ Google Scholar ]
  • Cummings G, Estabrooks C. The effects of hospital restructuring that included layoffs on individual nurses who remained employed: A systematic report of impact. International Journal of Sociology and Social Policy. 2003; 8 :8–53. doi: 10.1108/01443330310790633. [ CrossRef ] [ Google Scholar ]
  • Estabrooks C, Cummings G, Olivo S, Squires J, Gibin C, Simpson N. Effects of shift length on quality of patient care and health provider outcomes: systematic review. Quality and Safety in Healthcare. 2009; 18 :181–188. doi: 10.1136/qshc.2007.024232. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Khan K, Ter Riet G, Popay J, Nixon J, Kleijnen J, Satge I. Undertaking systematic reviews of research effectiveness CDC's guidance for those carrying out or commissioning reviews. Centre of Reviews and Dissemination UoY; 2001. Conducting the review: Phase 5 study quality assessment; pp. 1–20. [ Google Scholar ]
  • Kmet L, Lee R, Cook L. Standard quality assessment criteria for evaluating primary research papers from a variety of fields. Edmonton: Alberta Heritage Foundation for Medical Research; 2004. pp. 1–22. [ Google Scholar ]
  • Jackson N, Waters E. Criteria for the systematic review of health promotion and public health interventions. Health Promotion International. 2005; 20 (4):367–374. doi: 10.1093/heapro/dai022. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Deeks JJ, Dinnes J, D'Amico R, Sowden AJ, Sakarovitch C, Song F, Petticrew M, Altman DG. Evaluating non-randomised intervention studies. Health Technology Assessment (Winchester, England) 2003; 7 (27) [ PubMed ] [ Google Scholar ]
  • Grimshaw J, McAuley LM, Bero LA, Grilli R, Oxman AD, Ramsay C, Vale L, Zwarenstein M. Systematic reviews of the effectiveness of quality improvement strategies and programmes. Quality & Safety in Health Care. 2003; 12 (4):298–303. [ PMC free article ] [ PubMed ] [ Google Scholar ]
  • Levels of Evidence. http://consumers.cochrane.org/levels-evidence
  • Godin G, Belanger-Gravel A, Eccles M, Grimshaw G. Healthcare professionals' intentions and behaviours: A systematic review of studies based on social cognitive theories. Implementation Science. 2008; 3 (36) [ PMC free article ] [ PubMed ] [ Google Scholar ]
  • McCleary L, Brown GT. Use of the Edmonton research orientation scale with nurses. Journal of Nursing Measurement. 2002; 10 (3):263–275. doi: 10.1891/jnum.10.3.263.52559. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • McCleary L, Brown GT. Association between nurses' education about research and their reseach use. Nurse Education Today. 2003; 23 (8):556–565. doi: 10.1016/S0260-6917(03)00084-4. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Estabrooks CA. Modeling the individual determinants of research utilization. Western Journal of Nursing Research. 1999; 21 (6):758–772. doi: 10.1177/01939459922044171. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Estabrooks CA, Kenny DJ, Adewale AJ, Cummings GG, Mallidou AA. A comparison of research utilization among nurses working in Canadian civilian and United States Army healthcare settings. Research in Nursing and Health. 2007; 30 (3):282–296. doi: 10.1002/nur.20218. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • McCloskey DJ. PhD Thesis. George Mason University; 2005. The relationship between organizational factors and nurse factors affecting the conduct and utilization of nursing research. [ Google Scholar ]
  • McCloskey DJ, McCloskey DJ. Nurses' perceptions of research utilization in a corporate health care system. Journal of Nursing Scholarship. 2008; 40 (1):39–45. doi: 10.1111/j.1547-5069.2007.00204.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Parahoo K. A comparison of pre-Project 2000 and Project 2000 nurses' perceptions of their research training, research needs and of their use of research in clinical areas. Journal of Advanced Nursing. 1999; 29 (1):237–245. doi: 10.1046/j.1365-2648.1999.00882.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Parahoo K, McCaughan EM. Research utilization among medical and surgical nurses: A comparison of their self reports and perceptions of barriers and facilitators. Journal of Nursing Management. 2001; 9 (1):21–30. doi: 10.1046/j.1365-2834.2001.00237.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Bostrom J, Suter WN. Research utilization: making the link to practice. Journal of Nursing Staff Development. 1993; 9 (1):28–34. [ PubMed ] [ Google Scholar ]
  • Kirchhoff KT. A diffusion survey of coronary precautions. Nursing Research. 1982; 31 (4):196–201. doi: 10.1097/00006199-198207000-00002. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Davies BL. Dissertation/Thesis. University of Toronto (Canada); 1999. Evaluation of two strategies for the transfer of research results about labour support and electronic fetal monitoring into practice. [ Google Scholar ]
  • Winter JC. Brief: relationship between sources of knowledge and use of research findings. Journal of Continuing Education in Nursing. 1990; 21 (3):138–140. [ PubMed ] [ Google Scholar ]
  • Lia-Hoagberg B, Schaffer M, Strohschein S. Public health nursing practice guidelines: an evaluation of dissemination and use. Public Health Nursing. 1999; 16 (6):397–404. doi: 10.1046/j.1525-1446.1999.00397.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Brett JL. Organizational integrative mechanisms and adoption of innovations by nurses. Nursing Research. 1989; 38 (2):105–110. [ PubMed ] [ Google Scholar ]
  • Parahoo K. Research utilization and attitudes towards research among psychiatric nurses in Northern Ireland. Journal of Psychiatric and Mental Health Nursing. 1999; 6 (2):125–135. doi: 10.1046/j.1365-2850.1999.620125.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Brett JL. Use of nursing practice research findings. Nursing Research. 1987; 36 (6):344–349. [ PubMed ] [ Google Scholar ]
  • Barta KM. Information-seeking, research utilization, and barriers to research utilization of pediatric nurse educators. Journal of professional nursing: official journal of the American Association of Colleges of Nursing. 1995; 11 (1):49–57. [ PubMed ] [ Google Scholar ]
  • Berggren A. Swedish midwives' awareness of, attitudes to and use of selected research findings. Journal of Advanced Nursing. 1996; 23 (3):462–470. doi: 10.1111/j.1365-2648.1996.tb00007.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Coyle LA, Sokop AG. Innovation adoption behavior among nurses. Nursing Research. 1990; 39 (3):176–180. doi: 10.1097/00006199-199005000-00016. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Michel Y, Sneed NV. Dissemination and use of research findings in nursing practice. Journal of Professional Nursing. 1995; 11 (5):306–311. doi: 10.1016/S8755-7223(05)80012-2. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Rutledge DN, Greene P, Mooney K, Nail LM, Ropka M. Use of research-based practices by oncology staff nurses. Oncology Nursing Forum. 1996; 23 (8):1235–1244. [ PubMed ] [ Google Scholar ]
  • Champion VL, Leach A. Variables related to research utilization in nursing: an empirical investigation. Journal of Advanced Nursing. 1989; 14 (9):705–710. doi: 10.1111/j.1365-2648.1989.tb01634.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Bostrom AM, Kajermo KN, Nordstrom G, Wallin L. Barriers to research utilization and research use among registered nurses working in the care of older people: Does the BARRIERS Scale discriminate between research users and non-research users on perceptions of barriers? Implementation Science. 2008; 3 (1) [ PMC free article ] [ PubMed ] [ Google Scholar ]
  • Hatcher S, Tranmer J. A survey of variables related to research utilization in nursing practice in the acute care setting. Canadian Journal of Nursing Administration. 1997; 10 (3):31–53. [ PubMed ] [ Google Scholar ]
  • Humphris D, Hamilton S, O'Halloran P, Fisher S, Littlejohns P. Do diabetes nurse specialists utilise research evidence? Practical Diabetes International. 1999; 16 (2):47–50. doi: 10.1002/pdi.1960160213. [ CrossRef ] [ Google Scholar ]
  • Lacey EA. Research utilization in nursing practice -- a pilot study. Journal of Advanced Nursing. 1994; 19 (5):987–995. doi: 10.1111/j.1365-2648.1994.tb01178.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Nash MA. PhD Thesis. Gonzaga University; 2005. Research utilization among Idaho nurses. [ Google Scholar ]
  • Prin PL, Mills MD, Gerdin U. Nursing informatics: the impact of nursing knowledge on health care informatics proceedings of NI'97, Sixth Triennial International Congress of IMIA-NI, Nursing Informatics of International Medical Informatics Association. Vol. 46. Amsterdam, Netherlands: IOS Press; 1997. Nurses' MEDLINE usage and research utilization; pp. 451–456. [ PubMed ] [ Google Scholar ]
  • Tranmer JE, Lochhaus-Gerlach J, Lam M. The effect of staff nurse participation in a clinical nursing research project on attitude towards, access to, support of and use of research in the acute care setting. Canadian Journal of Nursing Leadership. 2002; 15 (1):18–26. [ PubMed ] [ Google Scholar ]
  • Wallin L, Bostrom A, Wikblad K, Ewald U. Sustainability in changing clinical practice promotes evidence-based nursing care. Journal of Advanced Nursing. 2003; 41 (5):509–518. doi: 10.1046/j.1365-2648.2003.02574.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Bonner A, Sando J. Examining the knowledge, attitude and use of research by nurses. Journal of Nursing Management. 2008; 16 (3):334–343. doi: 10.1111/j.1365-2834.2007.00808.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Stiefel KA. Dissertation/Thesis. University of South Carolina; 1996. Career commitment, nursing unit culture, and nursing research utilization. [ Google Scholar ]
  • Varcoe C, Hilton A. Factors affecting acute-care nurses' use of research findings. Canadian Journal of Nursing Research. 1995; 27 (4):51–71. [ PubMed ] [ Google Scholar ]
  • Forbes SA, Bott MJ, Taunton RL. Control over nursing practice: a construct coming of age. Journal of Nursing Measurement. 1997; 5 (2):179–190. [ PubMed ] [ Google Scholar ]
  • Kenny DJ. Nurses' use of research in practice at three US Army hospitals. Canadian journal of nursing leadership. 2005; 18 (3):45–67. [ PubMed ] [ Google Scholar ]
  • Profetto-McGrath J, Hesketh KL, Lang S, Estabrooks CA. A study of critical thinking and research utilization among nurses. West J Nurs Res. 2003; 25 (3):322–337. doi: 10.1177/0193945902250421. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Profetto-McGrath J, Smith KB, Hugo K, Patel A, Dussault B. Nurse educators' critical thinking dispositions and research utilization. Nurse Education in Practice. 2009; 9 (3):199–208. doi: 10.1016/j.nepr.2008.06.003. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Connor N. MN Thesis. Dalhousie University (Canada); 2007. The relationship between organizational culture and research utilization practices among nursing home departmental staff. [ Google Scholar ]
  • Milner FM, Estabrooks CA, Humphrey C. Clinical nurse educators as agents for change: increasing research utilization. International Journal of Nursing Studies. 2005; 42 (8):899–914. doi: 10.1016/j.ijnurstu.2004.11.006. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Cummings GG, Estabrooks CA, Midodzi WK, Wallin L, Hayduk L. Influence of organizational characteristics and context on research utilization. Nurs Res. 2007; 56 (4 Suppl):S24–39. doi: 10.1097/01.NNR.0000280629.63654.95. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Wallin L, Estabrooks CA, Midodzi WK, Cummings GG. Development and validation of a derived measure of research utilization by nurses. Nursing Research. 2006; 55 (3):149–160. doi: 10.1097/00006199-200605000-00001. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Brown DS. Nursing education and nursing research utilization: is there a connection in clinical settings? Journal of Continuing Education in Nursing. 1997; 28 (6):258–262. quiz 284. [ PubMed ] [ Google Scholar ]
  • Butler L. Valuing research in clinical practice: a basis for developing a strategic plan for nursing research. The Canadian journal of nursing research. 1995; 27 (4):33–49. [ PubMed ] [ Google Scholar ]
  • Wells N, Baggs JG. A survey of practicing nurses' research interests and activities. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice. 1994; 8 (3):145–151. doi: 10.1097/00002800-199405000-00009. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Ofi B, Sowunmi L, Edet D, Anarado N, Ofi B, Sowunmi L, Edet D, Anarado N. Professional nurses' opinion on research and research utilization for promoting quality nursing care in selected teaching hospitals in Nigeria. International Journal of Nursing Practice. 2008; 14 (3):243–255. doi: 10.1111/j.1440-172X.2008.00684.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Tsai S. Nurses' participation and utilization of research in the Republic of China. International Journal of Nursing Studies. 2000; 37 (5):435–444. doi: 10.1016/S0020-7489(00)00023-7. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Tsai S. The effects of a research utilization in-service program on nurses. International Journal of Nursing Studies. 2003; 40 (2):105–113. doi: 10.1016/S0020-7489(02)00036-6. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Erler CJ, Fiege AB, Thompson CB. Flight nurse research activities. Air Medical Journal. 2000; 19 (1):13–18. doi: 10.1016/S1067-991X(00)90086-5. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Logsdon C, Davis DW, Hawkins B, Parker B, Peden A. Factors related to research utilization by registered nurses in Kentucky. Kentucky Nurse. 1998; 46 (1):23–26. [ PubMed ] [ Google Scholar ]
  • Wright A, Brown P, Sloman R. Nurses' perceptions of the value of nursing research for practice. Australian Journal of Advanced Nursing. 1996; 13 (4):15–18. [ PubMed ] [ Google Scholar ]
  • Facione N, Facione P, Sanchez C. Critical thinking disposition as a measure of competent clinical judgement: The development of the California Critical Thinking Disposition Inventory. Journal of Nursing Education. 1994; 33 (8):345–350. [ PubMed ] [ Google Scholar ]
  • Ajzen I. The theory of planned behavior. Organizational Behavior and Human Decision Processes. 1991; 50 :179–211. doi: 10.1016/0749-5978(91)90020-T. [ CrossRef ] [ Google Scholar ]
  • Estabrooks C. A program of research in knowledge translation. Nursing Research. 2007; 56 (Supplement):S4–S5. doi: 10.1097/01.NNR.0000280637.24644.fd. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Systematic review
  • Open access
  • Published: 27 July 2011

A systematic review of the psychometric properties of self-report research utilization measures used in healthcare

  • Janet E Squires 1 ,
  • Carole A Estabrooks 2 ,
  • Hannah M O'Rourke 2 ,
  • Petter Gustavsson 3 ,
  • Christine V Newburn-Cook 2 &
  • Lars Wallin 4  

Implementation Science volume  6 , Article number:  83 ( 2011 ) Cite this article

20k Accesses

69 Citations

1 Altmetric

Metrics details

In healthcare, a gap exists between what is known from research and what is practiced. Understanding this gap depends upon our ability to robustly measure research utilization.

The objectives of this systematic review were: to identify self-report measures of research utilization used in healthcare, and to assess the psychometric properties (acceptability, reliability, and validity) of these measures.

We conducted a systematic review of literature reporting use or development of self-report research utilization measures. Our search included: multiple databases, ancestry searches, and a hand search. Acceptability was assessed by examining time to complete the measure and missing data rates. Our approach to reliability and validity assessment followed that outlined in the Standards for Educational and Psychological Testing .

Of 42,770 titles screened, 97 original studies (108 articles) were included in this review. The 97 studies reported on the use or development of 60 unique self-report research utilization measures. Seven of the measures were assessed in more than one study. Study samples consisted of healthcare providers (92 studies) and healthcare decision makers (5 studies). No studies reported data on acceptability of the measures. Reliability was reported in 32 (33%) of the studies, representing 13 of the 60 measures. Internal consistency (Cronbach's Alpha) reliability was reported in 31 studies; values exceeded 0.70 in 29 studies. Test-retest reliability was reported in 3 studies with Pearson's r coefficients > 0.80. No validity information was reported for 12 of the 60 measures. The remaining 48 measures were classified into a three-level validity hierarchy according to the number of validity sources reported in 50% or more of the studies using the measure. Level one measures (n = 6) reported evidence from any three (out of four possible) Standards validity sources (which, in the case of single item measures, was all applicable validity sources). Level two measures (n = 16) had evidence from any two validity sources, and level three measures (n = 26) from only one validity source.

Conclusions

This review reveals significant underdevelopment in the measurement of research utilization. Substantial methodological advances with respect to construct clarity, use of research utilization and related theory, use of measurement theory, and psychometric assessment are required. Also needed are improved reporting practices and the adoption of a more contemporary view of validity ( i.e. , the Standards ) in future research utilization measurement studies.

Peer Review reports

Clinical and health services research produces vast amounts of new research every year. Despite increased access by healthcare providers and decision-makers to this knowledge, uptake into practice is slow [ 1 , 2 ] and has resulted in a 'research-practice gap.'

Measuring research utilization

Recognition of, and a desire to narrow, the research-practice gap, has led to the accumulation of a considerable body of knowledge on research utilization and related terms, such as knowledge translation, knowledge utilization, innovation adoption, innovation diffusion, and research implementation. Despite gains in the understanding of research utilization theoretically [ 3 , 4 ], a large and rapidly expanding literature addressing the individual factors associated with research utilization [ 5 , 6 ], and the implementation of clinical practice guidelines in various health disciplines [ 7 , 8 ], little is known about how to robustly measure research utilization.

We located three theoretical papers explicitly addressing the measurement of knowledge utilization (of which research utilization is a component) [ 9 – 11 ], and one integrative review that examined the psychometric properties of self-report research utilization measures used in professions allied to medicine [ 12 ]. Within each of these papers, a need for conceptual clarity and pluralism in measurement was stressed. Weiss [ 11 ] also argued for specific foci ( i.e ., focus on specific studies, people, issues, or organizations) when measuring knowledge utilization. Shortly thereafter, Dunn [ 9 ], proposed a linear four-step process for measuring knowledge utilization: conceptualization (what is knowledge utilization and how it is defined and classified); methods (given a particular conceptualization, what methods are available to observe knowledge use); measures (what scales are available to measure knowledge use); and reliability and validity. Dunn specifically urged that greater emphasis be placed on step four (reliability and validity). A decade later, Rich [ 10 ] provided a comprehensive overview of issues influencing knowledge utilization across many disciplines. He emphasized the complexity of the measurement process, suggesting that knowledge utilization may not always be tied to a specific action, and that it may exist as more of an omnibus concept.

The only review of research utilization measures to date was conducted in 2003 by Estabrooks et al. [ 12 ]. The review was limited to self-report research utilization measures used in professions allied to medicine and to the specific data on validity that was extracted. That is, only data that was (by the original authors) explicitly interpreted as validity in the study reports was extracted as 'supporting validity evidence'. A total of 43 articles from three online databases (CINAHL, Medline, and Pubmed) comprised the final sample of articles included in the review. Two commonly used multi-item self-report measures (published in 16 papers) were identified--the Nurses Practice Questionnaire and the Research Utilization Questionnaire. An additional 16 published papers were identified that used single-item self-report questions to measure research utilization. Several problems with these research utilization measures were identified: lack of construct clarity of research utilization, lack of use of research utilization theories, lack of use of measurement theory, and finally, lack of standard psychometric assessment.

The four papers [ 9 – 12 ] discussed above point to a persistent and unresolved problem--an inability to robustly measure research utilization. This presents both an important and a practical challenge to researchers and decision-makers who rely on such measures to evaluate the uptake and effectiveness of research findings to improve patient and organizational outcomes. There are multiple reasons why we believe the measurement of research utilization is important. The most important reason relates to designing and evaluating the effectiveness of interventions to improve patient outcomes. Research utilization is commonly assumed to have a positive impact on patient outcomes by assisting with eliminating ineffective and potentially harmful practices, and implementing more effective (research-based) practices. However, we can only determine if patient outcomes are sensitive to varying levels of research utilization if we can first measure research utilization in a reliable and valid manner. If patient outcomes are sensitive to the use of research and we do not measure it, we, in essence, do the field more harm than good by ignoring a 'black box' of causal mechanisms that can influence research utilization. The causal mechanisms within this back box can, and should, be used to inform the design of interventions that aim to improve patient outcomes by increasing research utilization by care providers.

Study purpose and objectives

The study reported in this paper is a systematic review of the psychometric properties of self-report measures of research utilization used in healthcare. Specific objectives of this study were to: identify self-report measures of research utilization used in healthcare ( i.e ., used to measure research utilization by healthcare providers, healthcare decision makers, and in healthcare organizations); and assess the psychometric properties of these measures.

Study selection (inclusion and exclusion) criteria

Studies were included that met the following inclusion criteria: reported on the development or use of a self-report measure of research utilization; and the study population comprised one or more of the following groups--healthcare providers, healthcare decision makers, or healthcare organizations. We defined research utilization as the use of research-based (empirically derived) information. This information could be reported in a primary research article, review/synthesis report, or a protocol. Where the study involved the use of a protocol, we required the research-basis for the protocol to be apparent in the article. We excluded articles that reported on adherence to clinical practice guidelines, the rationale being that clinical practice guidelines can be based on non-research evidence ( e.g ., expert opinion). We also excluded articles reporting on the use of one specific-research-based practice if the overall purpose of the study was not to examine research utilization.

Search strategy for identification of studies

We searched 12 bibliographic databases; details of the search strategy are located in Additional File 1 . We also hand searched the journal Implementation Science (a specialized journal in the research utilization field) and assessed the reference lists of all retrieved articles. The final set of included articles was restricted to those published in the English, Danish, Swedish, and Norwegian languages (the official languages of the research team). There were no restrictions based on when the study was undertaken or publication status.

Selection of Studies

Two team members (JES and HMO) independently screened all titles and abstracts (n = 42,770). Full text copies were retrieved for 501 titles, which represented all titles identified as having potential relevance to our objectives or where there was insufficient information to make a decision as to relevance. A total of 108 articles (representing 97 original studies) comprised the final sample. Disagreements were resolved by consensus. When consensus could not be reached, a third senior member of the review team (CAE, LW) acted as an arbitrator and made the final decision (n = 9 articles). Figure 1 summarizes the results of the screening/selection process. A list of retrieved articles that were excluded can be found in Additional File 2 .

figure 1

Article screening and selection .

Data Extraction

Two reviewers (JES and HMO) performed data extraction: one reviewer extracted the data, which was then checked for accuracy by a second reviewer. We extracted data on: year of publication, study design, setting, sampling, subject characteristics, methods, the measure of research utilization used, substantive theory, measurement theory, responsiveness (the extent to which the measure can assess change over time), reliability (information on variances and standard deviations of measurement errors, item response theory test information functions, and reliability coefficients where extracted where it existed), reported statements of traditional validity (content validity, criterion validity, construct validity), and study findings reflective of the four sources of validity evidence (content, response processes, internal structure, and relations to other variables) outlined in the Standards for Educational and Psychological Testing (the Standards ) [ 13 ]. Content evidence refers to the extent to which the items in a self-report measure adequately represent the content domain of the concept or construct of interest. Response processes evidence refers to how respondents interpret, process, and elaborate upon item content and whether this behaviour is in accordance with the concept or construct being measured. Internal structure evidence examines the relationships between the items on a self-report measure to evaluate its dimensionality. Relations to other variables evidence provide the fourth source of validity evidence. External variables may include measures of criteria that the concept or construct of interest is expected to predict, as well as relationships to other scales hypothesized to measure the same concepts or constructs, and variables measuring related or different concepts or constructs [ 13 ]. In the Standards , validity is a unitary construct in which multiple evidence sources contribute to construct validity. A higher number of validity sources indicate stronger construct validity. An overview of the Standards approach to reliability and validity assessment is in Additional File 3 . All disagreements in data extraction were resolved by consensus.

There are no universal criteria to grade the quality of self-report measures. Therefore, in line with other recent measurement reviews [ 14 , 15 ], we did not use restrictive criteria to rate the quality of each study. Instead, we focused on performing a comprehensive assessment of the psychometric properties of the scores obtained using the research utilization measures reported in each study. In performing this assessment, we adhered to the Standards , considered best practice in the field of psychometrics [ 16 ]. Accordingly, we extracted data on all study results that could be grouped according to the Standards' critical reliability information and four validity evidence sources. To assess relations to other variables, we a priori (based on commonly used research utilization theories and systematic reviews) identified established relationships between research utilization and other (external) variables (See Additional File 3 ). The external variables included: individual characteristics ( e.g ., attitude towards research use), contextual characteristics ( e.g ., role), organizational characteristics ( e.g ., hospital size), and interventions ( e.g ., use of reminders). All relationships between research use and external variables in the final set of included articles were then interpreted as supporting or refuting validity evidence. The relationship was coded as 'supporting validity evidence' if it was in the same direction and had the significance predicted, and as 'refuting validity evidence' if it was in the opposite direction or did not have the significance predicted.

Data Synthesis

The findings from the review are presented in narrative form. To synthesize the large volume of data extracted on validity, we developed a three-level hierarchy of self-report research utilization measures based on the number of validity sources reported in 50% or more of the studies for each measure. In the Standards , no one source of validity evidence is considered always superior to the other sources. Therefore, in our hierarchy, level one, two, and three measures provided evidence from any three, two, and one validity sources respectively. In the case of single-item measures, only three validity sources are applicable; internal structure validity evidence is not applicable as it assesses relationships between items. Therefore, a single-item measure within level one has evidence from all applicable validity sources.

Objective 1: Identification and characteristics of self-report research utilization measures used in healthcare

In total, 60 unique self-report research utilization measures were identified. We grouped them into 10 classes as follows:

Nurses Practice Questionnaire (n = 1 Measure)

Research Utilization Survey (n = 1 Measure)

Edmonton Research Orientation Survey (n = 1 Measure)

Knott and Wildavsky Standards (n = 1 Measure)

Other Specific Practices Indices (n = 4 Measures) (See Additional File 4 )

Other General Research Utilization Indices (n = 10 Measures) (See Additional File 4 )

Past, Present, Future Use (n = 1 Measure)

Parahoo's Measure (n = 1 Measure)

Estabrooks' Kinds of Research Utilization (n = 1 Measure)

Other Single-Item Measures (n = 39 Measures)

Table 1 provides a description of each class of measures. Classes one through six contain multiple-item measures, while classes seven through ten contain single-item measures; similar proportions of articles reported multi- and single-item measures (n = 51 and n = 59 respectively, two articles reported both multi- and single-item measures). Only seven measures were assessed in multiple studies: Nurses Practice Questionnaire; Research Utilization Survey; Edmonton Research Orientation Survey; a Specific Practice Index [ 17 , 18 ]; Past, Present, Future Use; Parahoo's Measure; and Estabrooks' Kinds of Research Utilization. All study reports claimed to measure research utilization; however, 13 of the 60 measures identified were proxy measures of research utilization. That is, they measure variables related to using research ( e.g ., reading research articles) but not research utilization directly. The 13 proxy measures are: Nurses Practice Questionnaire, Research Utilization Questionnaire, Edmonton Research Orientation Survey, and the ten Other General Research Utilization Indices.

The majority (n = 54) of measures were assessed with healthcare providers. Professional nurses comprised the sample in 56 studies (58%), followed by allied healthcare professionals (n = 25 studies, 26%), physicians (n = 7 studies, 7%), and multiple clinical staff groups (n = 5 studies, 5%). A small proportion of studies (n = 5 studies, 5%) measured research utilization by healthcare decision makers. The decision makers, in each study, were members of senior management with direct responsibility for making decisions for a healthcare organization and included: medical officers and program directors [ 19 ]; managers in ministries and regional health authorities [ 20 ]; senior administrators [ 21 ]; hospital managers [ 22 ]; and executive directors [ 23 ]. A different self-report measure was used in each of these six studies. The unit/organization was the unit of analysis in 6 of the 97 (6%) included studies [ 22 – 27 ]; a unit-level score for research utilization was calculated by aggregating the mean scores of individual care providers.

Most studies were conducted in North America (United States: n = 43, 44% and Canada: n = 22, 23%), followed by Europe (n = 22, 23%). Other geographic areas represented included: Australia (n = 5, 5%), Iran (n = 1, 1%), Africa (n = 2, 2%), and Taiwan (n = 2, 2%). With respect to date of publication, the first report included in this review was published in 1976 [ 28 ]. The majority of reports (n = 90, 83%) were published within the last 13 years (See Figure 2 ).

figure 2

Publication timeline .

Objective 2: Psychometric assessment of the self-report research utilization measures

Our psychometric assessment involved three components: acceptability, reliability, and validity.

Acceptability

Acceptability in terms of time required to complete the research utilization measures and missing data (specific to the research utilization items) was not reported.

Reliability

Reliability was reported in 32 (33%) of the studies (See Table 2 and Additional File 5 ). Internal consistency (Cronbach's Alpha) was the most commonly reported reliability statistic--it was reported for 13 of the 18 multi-item measures (n = 65, 67% of studies). Where reliability (Cronbach's Alpha) was reported, it almost always (n = 29 of 31 studies, 94%) exceeded the accepted standard (> 0.70) for scales intended to compare groups, as recommended by Nunnally and Bernstein [ 29 ]. The two exceptions were assessments of the Nurses Practice Questionnaire [ 30 – 32 ]. This tendency to only report reliability coefficients that exceed the accepted standard may potentially reflect a reporting bias.

Stability, or test-retest, reliability was reported for only three (3%) of the studies: two studies assessing the Nurses Practice Questionnaire [ 33 – 35 ], and one study assessing Stiefel's Research Use Index [ 36 ]. All three studies reported Pearson r coefficients greater than 0.80 using one-week intervals (Table 2 ). One study also assessed inter-rater reliability. Pain et al. [ 37 ] had trained research staff and study respondents rate their (respondents) use of research on a 7-point scale. Inter-rater reliability among the interviewers was acceptable with pair wise correlations ranging from 0.80 to 0.91 (Table 2 ). No studies reported other critical reliability information consistent with the Standards , such as variances or standard deviations of measurement errors, item response theory test information functions, or parallel forms coefficients.

No single research utilization measure had supporting validity evidence from all four evidence sources outlined in the Standards . For 12 measures [ 38 – 49 ], each in the 'other single-item' class, there were no reported findings that could be classified as validity evidence. The remaining 48 measures were classified as level one (n = 6), level two (n = 16), or level three (n = 26) measures, according to whether the average number of validity sources reported in 50% or more of the studies describing an assessment of the measure was three, two, or one, respectively. Level one measures displayed the highest number of validity sources and thus, the strongest construct validity. A summary of the hierarchy is presented in Tables 3 , 4 , and 5 . More detailed validity data is located in Additional File 6 .

Measures reporting three sources of validity evidence (level one)

Six measures were grouped as level one: Specific Practices Indices (n = 1), General Research Utilization Indices (n = 3), and Other-Single Items (n = 2) (Table 3 ). Each measure was assessed in a single study. Five [ 24 , 50 – 52 ] of the six measures displayed content, response processes, and relations to other variables validity evidence, while the assessment of one measure [ 36 ] provided internal structure validity evidence. A detailed summary of the level one measures is located in Table 6 .

Measures reporting two sources of validity evidence (level two)

Sixteen measures were grouped as level two: Nurses Practice Questionnaire (n = 1); Knott and Wildvasky Standards (n = 1); General Research Utilization Indices (n = 4); Specific Practices Indices (n = 2); Estabrooks' Kinds of Research Utilization (n = 1); Past, Present, Future Use (n = 1); and Other Single-Items (n = 6) (Table 4 ). Most assessments occurred with nurses in hospitals. No single validity source was reported for all level two measures. For the 16 measures in level two, the most commonly reported evidence source was relations to other variables (reported for 12 [75%] of the measures), followed by response processes (n = 7 [44%] of the measures), content (n = 6 [38%] of the measures), and lastly, internal structure (n = 1 [6%] of the measures). Four of the measures were assessed in multiple studies: Nurses Practice Questionnaire, a Specific Practices Index [ 17 , 18 ], Parahoo's Measure, and Estabrooks' Kinds of Research Utilization.

Measures reporting one source of validity evidence (level three)

The majority (n = 26) of research utilization measures identified fell into level three: Champion and Leach's Research Utilization Survey (n = 1); Edmonton Research Orientation Survey (n = 1); General Research Utilization Indices (n = 3); Specific Practices Indices (n = 1); Past, Present, Future Use (n = 1); and, Other Single-Item Measures (n = 19) (Table 5 ). The majority of level three measures are single-items (n = 20) and have been assessed in a single study (n = 23). Similar to level two, there was no single source of validity evidence common across all of the level three measures. The most commonly reported validity source was content (reported for 12 [46%] of the measures), followed by response processes (n = 10, 38%), relations to other variables (n = 10, 38%), and lastly, internal structure evidence (n = 1, 4%). Three level three measures were assessed in multiple studies: the Research Utilization Questionnaire; Past, Present, Future Use items; and the Edmonton Research Orientation Survey.

Additional properties

As part of our validity assessment, we paid special attention to how each measure 'functioned'. That is, 'were the measures behaving as they should' . All six level one measures and the majority of level two measures (n = 12 of 16) displayed 'relations to other (external) variables' evidence, indicating that the measures are functioning as the literature hypothesizes a research utilization measure should function. Fewer measures in level three (n = 10 of 26) displayed optimal functioning (Table 5 and Additional File 5 ). We also looked for evidence of responsiveness of the measures (the extent to which the measure captures change over time); no evidence was reported.

Our discussion is organized around three areas: the state of the science of research utilization measurement, construct validity, and our proposed hierarchy of measures.

State of the science

In 2003, Estabrooks et al. [ 12 ] completed a review of self-report research utilization measures. By significantly extending the search criteria of that review, we identified 42 additional self-report research utilization measures, a substantial increase in the number of measures available. While, on the surface, this gives the impression of an optimistic picture of research utilization measurement, detailed inspection of the 108 articles included in our review revealed several limitations to these measures. These limitations seriously constrain our ability to validly measure research utilization. The limitations center on ambiguity between different measures and between studies using the same measure, and methodological problems with the design and evaluation of the measures.

Ambiguity in self-report research utilization measures

There is ambiguity with respect to the naming of self-report research utilization measures. For example, similar measures have different names. Parahoo's Measure [ 53 ] and Pettengil's single item [ 54 ], for example, both ask participants one question--whether they have used research findings in their practice in the past two years or three years, respectively. Conversely, other measures that ask substantially different questions are similarly named; for example, Champion and Leach [ 55 ], Linde [ 56 ], and Tsai [ 57 , 58 ] all describe a Research Utilization Questionnaire. Further ambiguity was seen in the articles that described the modification of a pre-existing research utilization measure. In most cases, despite making significant modifications to the measure, the authors retained the original measure's name and, thus, masked the need for additional validity testing. The Nurses Practice Questionnaire is an example of this. Brett [ 33 ] originally developed the Nurses Practice Questionnaire, which consisted of 14 research-based practices, to assess research utilization by hospital nurses. The Nurses Practice Questionnaire was subsequently modified (the number of and actual practices assessed, as well as the items that follow each of the practices) and used in eight additional studies [ 30 – 32 , 35 , 59 – 63 ], but each study retained the Nurses Practice Questionnaire name.

Methodological problems

In the earlier research utilization measurement review, Estabrooks et al. [ 12 ] identified four core methodological problems, lack of: construct clarity, use of research utilization theory, use of measurement theory, and psychometric assessment. In our review, we found that, despite an additional 10 years of research, 42 new measures and 65 new reports of self-report research utilization measures, these problems and others persist.

Lack of construct clarity

Research utilization has been, and is likely to remain, a complex and contested construct. Issues around clarity of research utilization measurement stems from four areas: a lack of definitional precision of research utilization, confusion around the formal structure of research utilization, lack of substantive theory to develop and evaluate research utilization measures, and confusion between factors associated with research utilization and the use of research per se .

Lack of definitional precision with respect to research utilization is well documented. In 1991, knowledge utilization scholar Thomas Backer [ 64 ] declared lack of definitional precision as part of a serious challenge of fragmentation that was facing researchers in the knowledge (utilization) field. Since then, there have been substantial efforts to understand what does and does not make research utilization happen. However, the issue of definitional precision continues to be largely ignored. In our review, definitions of research utilization were infrequently reported in the articles (n = 36 studies, 37%) [ 3 , 20 , 23 , 30 , 32 , 36 , 37 , 40 , 51 , 53 , 57 , 63 , 65 – 90 ] and even less frequently incorporated into the administered measures (n = 8 studies, 8%) [ 3 , 67 – 70 , 74 , 80 , 86 , 88 ]. Where definitions of research utilization were offered, they varied significantly between studies (even studies of the same measure) with one exception: Estabrooks' Kinds of Research Utilization. In this latter measure, the definitions offered were consistent in both the study reports and the administered measure.

A second reason for the lack of clarity in research utilization measurement is confusion around the formal structure of research utilization. The literature is characterized by multiple conceptualizations of research utilization. These conceptualizations influence how we define research utilization and, consequently, how we measure the construct and interpret the scores obtained from such measurement. Two prevailing conceptualizations dominating the field are research utilization as process ( i.e ., consists of a series of stages/steps) and research utilization as variable or discrete event (a 'variance' approach). Despite debate in the literature with respect to these two conceptualizations, this review revealed that the vast majority of measures that quantify research utilization do so using a 'variable' approach. Only two measures were identified that assess research utilization using a 'process' conceptualization: Nurses Practice Questionnaire [ 33 ] (which is based on Rogers' Innovation Decision Process Theory [ 91 , 92 ]) and Knott and Wildavsky's Standards measure (developed by Belkhodja et al. and based on Knott and Wildavsky's Standards of Research Use model [ 93 ]). Some scholars also prescribe research utilization as typological in addition to being a variable or a process. For example, Stetler [ 88 ] and Estabrooks [ 3 , 26 , 66 – 70 , 74 , 80 , 86 ] both have single items that measure multiple kinds of research utilization, with each kind individually conceptualized as a variable. Grimshaw et al. [ 8 ], in a systematic review of guideline dissemination and implementation strategies, reported a similar finding with respect to limited construct clarity in the measurement of guideline adherence in healthcare professionals. Measurement of intervention uptake, they argued, is problematic because measures are mostly around the 'process' of uptake rather than on the 'outcomes' of uptake. While both reviews point to lack of construct clarity with respect to process versus variable/outcome measures, they report converse findings with respect to the dominant conceptualization in existing measures. This finding suggests a comprehensive review targeting the psychometric properties of self-report measures used in guideline adherence is also needed. While each conceptualization (process, variable, typological) of research utilization is valid, there is, to date, no consensus regarding which one is best or the most valid.

A third reason for the lack of clarity in research utilization measurement is limited use of substantive theory in the development of research utilization measures. There are numerous theories, frameworks, and models of research utilization and of related constructs, from the fields of nursing ( e.g ., [ 94 – 96 ]), organizational behaviour ( e.g ., [ 97 – 99 ]), and the social sciences ( e.g ., [ 100 ]). However, only 1 of the 60 measures identified in this review explicitly reported using research utilization theory in its development. The Nurses Practice Questionnaire [ 33 ] was developed based of Rogers' Innovation-Decision Process theory (one component of Rogers' larger Diffusion of Innovations theory [ 91 ]). The Innovation-Decision Process theory describes five stages to the adoption of an innovation (research): awareness, persuasion, decision, implementation, and confirmation. A similar finding regarding limited use of substantive theory was also reported by Grimshaw et al. [ 8 ] in their review of guideline dissemination and implementation strategies. This limited use of theory in the development and testing of self-report measures may therefore reflect the more general state of the science in the research utilization and related ( e.g ., knowledge translation) fields that requires addressing.

A fourth and final reason that we identified for the lack of clarity in research utilization measurement is confusion between factors associated with research utilization and the use of research per se . The Nurses Practice Questionnaire [ 33 ] and all 10 Other General Research Utilization Indices ([ 24 , 36 , 50 , 73 , 84 , 101 – 105 ]) claim to directly measure research utilization. However, their items, which while compatible with a process view of research utilization, do not directly measure research utilization. For example, 'reading research' is an individual factor that fits into the awareness stage of Rogers' Innovation Decision-Process theory. The Nurses Practice Questionnaire uses this item to create an overall 'adoption' score, which is interpreted as 'research use' , but it is not 'use' . A majority of the General Research Utilization Indices also includes reading research as an item. In these measures, such individual factors are treated as proxies for research utilization. We caution researchers that while many individual factors like 'reading research' may be a desirable quality for making research utilization happen, they are not research utilization. Therefore, when selecting a research utilization measure to use, the aim of the investigation is paramount; if the aim is to examine research utilization as an event, then measures that incorporate proxies should be avoided.

Lack of measurement theory

Foundational to the development of any measure is measurement theory. The two most commonly used measurement theories are classical test score theory, and modern measurement (or item response) theory. Classical test score theory proposes that an individual's observed score on a construct is the additive composite of their true score and random error. This theory forms the basis for traditional reliability theory (Cronbach's Alpha) [ 106 , 107 ]. Item response theory is a model-based theory that relates the probability of an individual's response to an item on an underlying trait. It proposes that as an individual's level of a trait (research utilization) increases, the probability of a correct (or in the case of research utilization, a more positive) response also increases [ 108 , 109 ].

Similar to the previous review by Estabrooks et al. [ 12 ], none of the reports in our review explicitly stated that consideration of any kind was given to measurement theory in either the development or assessment of the respective measures. However, in our review, for 14 (23%) of the measures, there was reliability evidence consistent with the adoption of a classical test score theory approach. For example: Cronbach's alpha coefficients were reported on 13 (22%) measures (Table 2 ) and principal components (factor) analysis and item total correlations were reported on 2 (3%) measures (Tables 3 and 4 ).

Lack of psychometric assessment

In the previous review, Estabrooks et al. [ 12 ] concluded, 'All of the current studies lack significant psychometric assessment of used instruments.' They further stated that over half of the studies in their review did not mention validity, and that only two measures displayed construct validity. This latter finding, we argue, may be attributed to the adoption of a traditional conceptualization of validity where only evidence labeled as validity by the original study authors were considered. In our review, a more positive picture was displayed, with only 12 (20%) of the self-report research utilization measures identified showing no evidence of construct validity. We attribute this, in part, to our implementation of the Standards as a framework for validity. Using this framework, we scrutinized all results (not just those labeled as validity), in terms of whether or not they added to overall construct validity.

Additional limitations to the field

Several additional limitations in research utilization measurement were also noted as a result of this review. They include: limited reporting of data reflective of reliability beyond standard internal consistency (Cronbach's Alpha) coefficients; limited reporting of study findings reflective of validity; limited assessments of the same measure in multiple (> 1) studies; lack of assessment of acceptability and responsiveness; overreliance on the assessment made in the index (original) study of a measure; and failure to re-establish validity when modifications are made and/or the measure is assessed in a new population or context.

Construct validity (the standards)

Traditionally, validity has been conceptualized according to three distinct types: content, criterion, and construct. While this way of thinking about validity has been useful, it has also caused problems. For example, it has led to compartmentalized thinking about validity, making it 'easier' to overlook the fact that construct validity is really the whole of validity theory. It has also led to the incorrect view of validity as a property of a measure rather than of the scores (and resulting interpretations) obtained with the measure. A more contemporary conceptualization of validity (seen in the Standards ) was taken in this review. Using this approach, validity was conceptualized as a unitary concept with multiple sources of evidence, each contributing to overall (construct) validity [ 13 ]. We believe this conceptualization is both more relevant and more applicable to the study of research utilization than is the traditional conceptualization that dominates the literature [ 16 , 110 ].

All self-report measures require validity assessments. Without such assessments little to no intrinsic value can be placed on findings obtained with the measure. Validity is associated with the interpretations assigned to the scores obtained using a measure, and thus is intended to be hypothesis-based [ 110 , 111 ]. Hence, to establish validity, desired score interpretations are first hypothesized to allow for the deliberate collection of data to support or refute the hypotheses [ 112 ]. In line with this thinking, data collected using a research utilization self-report measure will always be more or less valid depending on the purpose of the assessment, the population and setting, and timing of the assessment ( e.g ., before or after an intervention). As a result, we are not able to declare any of the measures we identified in our review as valid or invalid, but only as more or less valid for selected populations, settings, and situations. This deviates substantially from traditional thinking, which suggests that validity either exists or not.

According to Cronbach and Meehl [ 113 ], construct validity rests in a nomological network that generates testable propositions that relate scores obtained with self-report measures (as representations of a construct) to other constructs, in order to better understand the nature of the construct being measured [ 113 ]. This view is comparable to the traditional conceptualization of construct validity as existing or not, and is also in line with the views of philosophers of science from the first half of the 20th century ( e.g ., Duhem [ 114 ] and Lakatos [ 115 ]). Duhem and Lakatos both contended that any theory could be fully justified or falsified based on empirical evidence ( i.e ., based on data collected with an specific measure). From this perspective, construct validity exists or not. In the second half of the 20th century, however, movement away from justification to what was described by Feyerabend [ 116 ] and Kuhn [ 117 ] as 'nonjustificationism' occurred. In nonjustificationism, a theory is never fully justified or falsified. Instead, at any given time, it is a closer or further approximation of the truth than another (competing) theory. From this perspective, construct validity is a matter of degree ( i.e ., more or less valid) and can change with the sample, setting, and situation being assessed. This is in line with a more contemporary (the Standards ) conceptualization of validity.

Self-report research utilization measure hierarchy

The Standards [ 13 ] provided us with a framework to create a hierarchy of research utilization measures and thus, synthesize a large volume of psychometric data. In an attempt to display the overall extent of construct validity of the measures identified, our hierarchy (consistent with the Standards ) placed equal weight on all four evidential sources. While we were able to categorize 48 of the 60 self-report research utilization measures identified into the hierarchy, several cautions exist with respect to use of the hierarchy. First, the levels in the hierarchy are based on the number of validity sources reported, and not on the actual source or quality of evidence within each source. Second, some measures in our hierarchy may appear to have strong validity only because they have been subjected to limited testing. For example, the six measures in level one have only been tested in a single study. Third, the hierarchy included all 48 measures that displayed any validity evidence. Some of these measures, however, are proxies of research utilization. Overall, the hierarchy is intended to present an overview of validity testing to date on the research utilization measures identified. It is meant to inform researchers regarding what testing has been done and, importantly, where additional testing is needed.

Limitations

Although rigorous and comprehensive methods were used for this review, there are three study limitations. First, while we reviewed dissertation databases, we did not search all grey literature sources. Second, due to limited reporting of findings consistent with the four sources of validity evidence in the Standards , we may have concluded lower levels of validity for some measures than actually exist. In the latter case, our findings may reflect poor reporting rather than less validity. Third, our decision to exclude articles that reported on healthcare providers' adherence to clinical practice guidelines may be responsible for the limited number of articles sampling physicians included in the review. A systematic review conducted by Grimshaw et al. [ 8 ] on clinical practice guidelines reported physicians alone were the target of 174 (74%) of the 235 studies included in that review. A future review examining the psychometric properties of self-report measures used to quantify guideline adherence would therefore be a fruitful avenue of inquiry.

In this review, we identified 60 unique self-report research utilization measures used in healthcare. While this appears to be a large and definite set of measures, our assessment paints a rather discouraging picture of research utilization measurement. Several of the measures, while labeled research utilization measures, did not assess research utilization per se . Substantial methodological advances in the research utilization field, focusing in the area of measurement (in particular with respect to construct clarity, use of measurement theory, and psychometric assessment) are urgently needed. These advances are foundational to ensuring the availability of defensible self-report measures of research utilization. Also needed are improved reporting practices and the adoption of a more contemporary view of validity (the Standards ) in future research utilization measurement studies.

Haines A, Jones R: Implementing findings of research. BMJ. 1994, 308 (6942): 1488-1492.

CAS   PubMed   PubMed Central   Google Scholar  

Glaser EM, Abelson HH, Garrison KN: Putting Knowledge to Use: Facilitating the Diffusion of Knowledge and the Implementation of Planned Change. 1983, San Francisco: Jossey-Bass

Google Scholar  

Estabrooks CA: The conceptual structure of research utilization. Research in Nursing and Health. 1999, 22 (3): 203-216. 10.1002/(SICI)1098-240X(199906)22:3<203::AID-NUR3>3.0.CO;2-9.

CAS   PubMed   Google Scholar  

Stetler C: Research utilization: Defining the concept. Image:The Journal of Nursing Scholarship. 1985, 17: 40-44. 10.1111/j.1547-5069.1985.tb01415.x.

Godin G, Belanger-Gravel A, Eccles M, Grimshaw G: Healthcare professionals' intentions and behaviours: A systematic review of studies based on social cognitive theories. Implementation Science. 2008, 3 (36):

Squires J, Estabrooks C, Gustavsson P, Wallin L: Individual determinants of research utilization by nurses: A systematic review update. Implementation Science. 2011, 6 (1):

Grimshaw JM, Eccles MP, Walker AE, Thomas RE: Changing physicians' behavior: What works and thoughts on getting more things to work. Journal of Continuing Education in the Health Professions. 2002, 22 (4): 237-243. 10.1002/chp.1340220408.

PubMed   Google Scholar  

Grimshaw JM, Thomas RE, MacIennan G, Fraser CR, Vale L, Whity P, Eccles MP, Matowe L, Shirran L, Wensing M: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment. 2004, 8 (6): 1-72.

Dunn WN: Measuring knowledge use. Knowledge: Creation, Diffusion, Utilization. 1983, 5 (1): 120-133.

Rich RF: Measuring knowledge utilization processes and outcomes. Knowledge and Policy: International Journal of Knowledge Transfer and Utilization. 1997, 3: 11-24.

Weiss CH: Measuring the use of evaluation. Utilizing evaluation: Concepts and measurement techniques. Edited by: Ciarlo JA. 1981, Beverly Hills, CA: Sage, 17-33.

Estabrooks C, Wallin L, Milner M: Measuring knowledge utilization in health care. International Journal of Policy Analysis & Evaluation. 2003, 1: 3-36.

American Educational Research Association, American Psychological Association, National Council on Measurement in Education: Standards for Educational and Psychological Testing. 1999, Washington, D.C.: American Educational Research Association

Shaneyfelt T, Baum K, Bell D, Feldstein D, Houston T, Kaatz S, Whelan C, Green M: Instruments for Evaluating Education in Evidence-Based Practice. JAMA. 2006, 296: 1116-1127. 10.1001/jama.296.9.1116.

Kirkova J, Davis M, Walsh D, Tiernan E, O'Leary N, LeGrand S, Lagman R, Mitchell-Russell K: Cancer symptom assessment instruments: A systematic review. Journal of Clinical Oncology. 2006, 24 (9): 1459-1473. 10.1200/JCO.2005.02.8332.

Streiner D, Norman G: Health Measurement Scales: A practical Guide to their Development and Use. 2008, Oxford: Oxford University Press, 4

Tita ATN, Selwyn BJ, Waller DK, Kapadia AS, Dongmo S: Evidence-based reproductive health care in Cameroon: population-based study of awareness, use and barriers. Bulletin of the World Health Organization. 2005, 83 (12): 895-903.

Tita AT, Selwyn BJ, Waller DK, Kapadia AS, Dongmo S, Tita ATN: Factors associated with the awareness and practice of evidence-based obstetric care in an African setting. BJOG: An International Journal of Obstetrics & Gynaecology. 2006, 113 (9): 1060-1066. 10.1111/j.1471-0528.2006.01042.x.

CAS   Google Scholar  

Dobbins M, Cockerill R, Barnsley J: Factors affecting the utilization of systematic reviews. A study of public health decision makers. International Journal of Technology Assessment in Health Care. 2001, 17 (2): 203-214. 10.1017/S0266462300105069.

Belkhodja O, Amara N, Landry Rj, Ouimet M: The extent and organizational determinants of research utilization in canadian health services organizations. Science Communication. 2007, 28: 377-417. 10.1177/1075547006298486.

Knudsen HK, Roman PM: Modeling the use of innovations in private treatment organizations: The role of absorptive capacity. Journal of Substance Abuse Treatment. 2004, 26 (1): 353-361.

Meehan SMS: An exploratory study of research management programs: Enhancing use of health services research results in health care organizations. (Volumes I and II). Thesis. 1988, The George Washington University

Barwick MA, Boydell KM, Stasiulis E, Ferguson HB, Blase K, Fixsen D: Research utilization among children's mental health providers. Implementation Science. 2008, 3: 19-19. 10.1186/1748-5908-3-19.

PubMed   PubMed Central   Google Scholar  

Reynolds MIA: An Investigation of Organizational Factors Affecting Research Utilization in Nursing Organizations. Thesis. 1981, University of Michigan

Molassiotis A: Nursing research within bone marrow transplantation in Europe: An evaluation. European Journal of Cancer Care. 1997, 6 (4): 257-261. 10.1046/j.1365-2354.1997.00034.x.

Estabrooks CA, Scott S, Squires JE, Stevens B, O'Brien-Pallas L, Watt-Watson J, Profetto-McGrath J, McGilton K, Golden-Biddle K, Lander J: Patterns of research utilization on patient care units. Implementation Science. 2008, 3: 31-10.1186/1748-5908-3-31.

Pepler CJ, Edgar L, Frisch S, Rennick J, Swidzinski M, White C, Brown TG, Gross J: Unit culture and research-based nursing practice in acute care. Canadian Journal of Nursing Research. 2005, 37 (3): 66-85.

Kirk SA, Osmalov MJ: Social workers involvement in research. Clinical social work: research and practice. Edited by: Russell MN. 1976, Newbury Park, Calif.: Sage Publications, 121-124.

Nunnally J, Bernstein I: Psychometric Theory. 1994, New York: McGraw-Hill, 3

Rodgers SE: A study of the utilization of research in practice and the influence of education. Nurse Education Today. 2000, 20 (4): 279-287. 10.1054/nedt.1999.0395.

Rodgers SE: The extent of nursing research utilization in general medical and surgical wards. Journal of Advanced Nursing. 2000, 32 (1): 182-193. 10.1046/j.1365-2648.2000.01416.x.

Berggren A: Swedish midwives' awareness of, attitudes to and use of selected research findings. Journal of Advanced Nursing. 1996, 23 (3): 462-470. 10.1111/j.1365-2648.1996.tb00007.x.

Brett JL: Use of nursing practice research findings. Nursing Research. 1987, 36 (6): 344-349.

Brett JL: Organizational integrative mechanisms and adoption of innovations by nurses. Nursing Research. 1989, 38 (2): 105-110.

Thompson CJ: Extent and factors influencing research utilization among critical care nurses. Thesis. 1997, Texas Woman's University, College of Nursing

Stiefel KA: Career commitment, nursing unit culture, and nursing research utilization. Thesis. 1996, University of South Carolina

Pain K, Magill-Evans J, Darrah J, Hagler P, Warren S: Effects of profession and facility type on research utilization by rehabilitation professionals. Journal of Allied Health. 2004, 33 (1): 3-9.

Dysart AM, Tomlin GS: Factors related to evidence-based practice among U.S. occupational therapy clinicians. American Journal of Occupational Therapy. 2002, 56: 275-284. 10.5014/ajot.56.3.275.

Ersser SJ, Plauntz L, Sibley A, Ersser SJ, Plauntz L, Sibley A: Research activity and evidence-based practice within DNA: a survey. Dermatology Nursing. 2008, 20 (3): 189-194.

Heathfield ADM: Research utilization in hand therapy practice using a World Wide Web survey design. Thesis. 2000, Grand Valley State University

Kelly KA: Translating research into practice: The physicians' perspective. Thesis. 2008, State University of New York at Albany

Mukohara K, Schwartz MD: Electronic delivery of research summaries for academic generalist doctors: A randomised trial of an educational intervention. Medical Education. 2005, 39 (4): 402-409. 10.1111/j.1365-2929.2005.02109.x.

Niederhauser VP, Kohr L: Research endeavors among pediatric nurse practitioners (REAP) study. Journal of Pediatric Health Care. 2005, 19 (2): 80-89.

Olympia RP, Khine H, Avner JR: The use of evidence-based medicine in the management of acutely ill children. Pediatric Emergency Care. 2005, 21 (8): 518-522. 10.1097/01.pec.0000175451.38663.d3.

Scott I, Heyworth R, Fairweather P: The use of evidence-based medicine in the practice of consultant physicians: Results of a questionnaire survey. Australian and New Zealand Journal of Medicine. 2000, 30 (3): 319-326. 10.1111/j.1445-5994.2000.tb00832.x.

Upton D: Clinical effectiveness and EBP 3: application by health-care professionals. British Journal of Therapy & Rehabilitation. 1999, 6 (2): 86-90.

Veeramah V: The use of research findings in nursing practice. Nursing Times. 2007, 103 (1): 32-33.

Walczak JR, McGuire DB, Haisfield ME, Beezley A: A survey of research-related activities and perceived barriers to research utilization among professional oncology nurses. Oncology Nursing Forum. 1994, 21 (4): 710-715.

Bjorkenheim J: Knowledge and social work in health care - the case of Finland. Social Work in Health Care. 2007, 44 (3): 261-10.1300/J010v44n03_09.

Varcoe C, Hilton A: Factors affecting acute-care nurses' use of research findings. Canadian Journal of Nursing Research. 1995, 27 (4): 51-71.

Dobbins M, Cockerill R, Barnsley J: Factors affecting the utilization of systematic reviews: A study of public health decision makers. International Journal of Technology Assessment in Health Care. 2001, 17 (2): 203-214. 10.1017/S0266462300105069.

Suter E, Vanderheyden LC, Trojan LS, Verhoef MJ, Armitage GD: How important is research-based practice to chiropractors and massage therapists?. Journal of Manipulative and Physiological Therapeutics. 2007, 30 (2): 109-115. 10.1016/j.jmpt.2006.12.013.

Parahoo K: Research utilization and research related activities of nurses in Northern Ireland. International Journal of Nursing Studies. 1998, 35 (5): 283-291. 10.1016/S0020-7489(98)00041-8.

Pettengill MM, Gillies DA, Clark CC: Factors encouraging and discouraging the use of nursing research findings. Image--the Journal of Nursing Scholarship. 1994, 26 (2): 143-147. 10.1111/j.1547-5069.1994.tb00934.x.

Champion VL, Leach A: Variables related to research utilization in nursing: an empirical investigation. Journal of Advanced Nursing. 1989, 14 (9): 705-710. 10.1111/j.1365-2648.1989.tb01634.x.

Linde BJ: The effectiveness of three interventions to increase research utilization among practicing nurses. Thesis. 1989, The University of Michigan

Tsai S: Nurses' participation and utilization of research in the Republic of China. International Journal of Nursing Studies. 2000, 37 (5): 435-444. 10.1016/S0020-7489(00)00023-7.

Tsai S: The effects of a research utilization in-service program on nurses. International Journal of Nursing Studies. 2003, 40 (2): 105-113. 10.1016/S0020-7489(02)00036-6.

Barta KM: Information-seeking, research utilization, and barriers to research utilization of pediatric nurse educators. Journal of Professional Nursing: Official Journal of the American Association of Colleges of Nursing. 1995, 11 (1): 49-57.

Coyle LA, Sokop AG: Innovation adoption behavior among nurses. Nursing Research. 1990, 39 (3): 176-180.

Michel Y, Sneed NV: Dissemination and use of research findings in nursing practice. Journal of Professional Nursing. 1995, 11 (5): 306-311. 10.1016/S8755-7223(05)80012-2.

Rutledge DN, Greene P, Mooney K, Nail LM, Ropka M: Use of research-based practices by oncology staff nurses. Oncology Nursing Forum. 1996, 23 (8): 1235-1244.

Squires JE, Moralejo D, LeFort SM: Exploring the role of organizational policies and procedures in promoting research utilization in registered nurses. Implementation Science. 2007, 2 (1):

Backer TE: Knowledge utilization: The third wave. Knowledge: Creation, Diffusion, Utilization. 1991, 12 (3): 225-240.

Butler L: Valuing research in clinical practice: a basis for developing a strategic plan for nursing research. The Canadian Journal of Nursing Research. 1995, 27 (4): 33-49.

Cobban SJ, Profetto-McGrath J: A pilot study of research utilization practices and critical thinking dispositions of Alberta dental hygienists. International Journal of Dental Hygiene. 2008, 6 (3): 229-237. 10.1111/j.1601-5037.2008.00299.x.

Connor N: The relationship between organizational culture and research utilization practices among nursing home departmental staff. Thesis. 2007, Dalhousie University

Estabrooks CA: Modeling the individual determinants of research utilization. Western Journal of Nursing Research. 1999, 21 (6): 758-772. 10.1177/01939459922044171.

Estabrooks CA, Kenny DJ, Adewale AJ, Cummings GG, Mallidou AA: A comparison of research utilization among nurses working in Canadian civilian and United States Army healthcare settings. Research in Nursing and Health. 2007, 30 (3): 282-296. 10.1002/nur.20218.

Profetto-McGrath J, Hesketh KL, Lang S, Estabrooks CA: A study of critical thinking and research utilization among nurses. Western Journal of Nursing Research. 2003, 25 (3): 322-337. 10.1177/0193945902250421.

Hansen HE, Biros MH, Delaney NM, Schug VL: Research utilization and interdisciplinary collaboration in emergency care. Academic Emergency Medicine. 1999, 6 (4): 271-279. 10.1111/j.1553-2712.1999.tb00388.x.

Hatcher S, Tranmer J: A survey of variables related to research utilization in nursing practice in the acute care setting. Canadian Journal of Nursing Administration. 1997, 10 (3): 31-53.

Karlsson U, Tornquist K: What do Swedish occupational therapists feel about research? A survey of perceptions, attitudes, intentions, and engagement. Scandinavian Journal of Occupational Therapy. 2007, 14 (4): 221-229. 10.1080/11038120601111049.

Kenny DJ: Nurses' use of research in practice at three US Army hospitals. Canadian Journal of Nursing Leadership. 2005, 18 (3): 45-67.

Lacey EA: Research utilization in nursing practice -- a pilot study. Journal of Advanced Nursing. 1994, 19 (5): 987-995. 10.1111/j.1365-2648.1994.tb01178.x.

McCleary L, Brown GT: Research utilization among pediatric health professionals. Nursing and Health Sciences. 2002, 4 (4): 163-171. 10.1046/j.1442-2018.2002.00124.x.

McCleary L, Brown GT: Use of the Edmonton research orientation scale with nurses. Journal of Nursing Measurement. 2002, 10 (3): 263-275. 10.1891/jnum.10.3.263.52559.

McCleary L, Brown GT: Association between nurses' education about research and their reseach use. Nurse Education Today. 2003, 23 (8): 556-565. 10.1016/S0260-6917(03)00084-4.

McCloskey DJ: The relationship between organizational factors and nurse factors affecting the conduct and utilization of nursing research. Thesis. 2005, George Mason University

Milner FM, Estabrooks CA, Humphrey C: Clinical nurse educators as agents for change: increasing research utilization. International Journal of Nursing Studies. 2005, 42 (8): 899-914. 10.1016/j.ijnurstu.2004.11.006.

Nash MA: Research utilization among Idaho nurses. Thesis. 2005, Gonzaga University

Ohrn K, Olsson C, Wallin L: Research utilization among dental hygienists in Sweden -- a national survey. International Journal of Dental Hygiene. 2005, 3 (3): 104-111. 10.1111/j.1601-5037.2005.00135.x.

Olade RA: Evidence-based practice and research utilization activities among rural nurses. Journal of Nursing Scholarship. 2004, 36 (3): 220-225. 10.1111/j.1547-5069.2004.04041.x.

Pelz DC, A HJ, Ciarlo JA: Measuring utilization of nursing research. Utilizing evaluation: Concepts and measurement techniques. Edited by: Anonymous. 1981, Beverly Hills, CA: Sage, 125-149.

Prin PL, Mills MD, Gerdin U: Nurses' MEDLINE usage and research utilization. Nursing informatics: the impact of nursing knowledge on health care informatics proceedings of NI'97, Sixth Triennial International Congress of IMIA-NI, Nursing Informatics of International Medical Informatics Association. Edited by: Amsterdam. 1997, Netherlands: IOS Press, 46: 451-456.

Profetto-McGrath J, Smith KB, Hugo K, Patel A, Dussault B: Nurse educators' critical thinking dispositions and research utilization. Nurse Education in Practice. 2009, 9 (3): 199-208. 10.1016/j.nepr.2008.06.003.

Sekerak DK: Characteristics of physical therapists and their work environments which foster the application of research in clinical practice. Thesis. 1992, The University of North Carolina at Chapel Hill

Stetler CB, DiMaggio G: Research utilization among clinical nurse specialists. Clinical Nurse Specialist. 1991, 5 (3): 151-155.

Wallin L, Bostrom A, Wikblad K, Ewald U: Sustainability in changing clinical practice promotes evidence-based nursing care. Journal of Advanced Nursing. 2003, 41 (5): 509-518. 10.1046/j.1365-2648.2003.02574.x.

Wells N, Baggs JG: A survey of practicing nurses' research interests and activities. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice. 1994, 8 (3): 145-151. 10.1097/00002800-199405000-00009.

Rogers EM: Diffusion of Innovations. 1983, New York: The Free Press, 3

Rogers E: Diffusion of Innovations. 1995, New York: The Free Press, 4

Knott J, Wildavsky A: If dissemination is the solution, what is the problem?. Knowledge: Creation, Diffusion, Utilization. 1980, 1 (4): 537-578.

Titler MG, Kleiber C, Steelman VJ, Rakel BA, Budreau G, Everett LQ, Buckwalter KC, Tripp-Reimer T, Goode CJ: The Iowa Model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America. 2001, 13 (4): 497-509.

Kitson A, Harvey G, McCormack B: Enabling the implementation of evidence based practice: a conceptual framework. Quality in Health Care. 1998, 7 (3): 149-158. 10.1136/qshc.7.3.149.

Logan J, Graham ID: Toward a comprehensive interdisciplinary model of health care research use. Science Communication. 1998, 20 (2): 227-246. 10.1177/1075547098020002004.

Abrahamson E, Rosenkopf L: Institutional and competitive bandwagons - Using mathematical-modeling as a tool to explore innovation diffusion. Academy of Management Review. 1993, 18 (3): 487-517.

Warner K: A 'desperation-reaction' model of medical diffusion. Health Services Research. 1975, 10 (4): 369-383.

Orlikowski WJ: Improvising organizational transformation over time: A situated change perspective. Information Systems Research. 1996, 7 (1): 63-92. 10.1287/isre.7.1.63.

Weiss C: The many meanings of research utilization. Public Administration Review. 1979, 39 (5): 426-431. 10.2307/3109916.

Forbes SA, Bott MJ, Taunton RL: Control over nursing practice: a construct coming of age. Journal of Nursing Measurement. 1997, 5 (2): 179-190.

Grasso AJ, Epstein I, Tripodi T: Agency-Based Research Utilization in a Residential Child Care Setting. Administration in Social Work. 1988, 12 (4): 61-

Morrow-Bradley C, Elliott R: Utilization of psychotherapy research by practicing psychotherapists. American Psychologist. 1986, 41 (2): 188-197.

Rardin DK: The Mesh of research Tand practice: The effect of cognitive style on the use of research in practice of psychotherapy. Thesis. 1986, University of Maryland College Park

Kamwendo K, Kamwendo K: What do Swedish physiotherapists feel about research? A survey of perceptions, attitudes, intentions and engagement. Physiotherapy Research International. 2002, 7 (1): 23-34. 10.1002/pri.238.

Hambleton R, Jones R: Comparison of classical test theory and item response theory and their applications to test development. Educational Measurement: Issues & Practice. 1993, 12 (3):

Ellis BB, Mead AD: Item analysis: Theory and practice using classical and modern test theory. Handbook of Research Methods in Industrial and Organizational Psychology. 2002, Blackwell Publications, 324-343.

Hambleton R, Swaminathan H, Rogers J: Fundamentals of Item Response Theory. Newbury Park, CA: Sage. 1991

Van der Linden W, Hambleton R: Handbook of Modern Item Response Theory. New York: Springer. 1997

Downing S: Validity: on the meaningful interpretation of assessment data. Medical Education. 2003, 37: 830-837. 10.1046/j.1365-2923.2003.01594.x.

Kane M: Validating high-stakes testing programs. Educational Measurement: Issues and Practice. 2002, Spring 2002: 31-41.

Kane MT: An argument-based approach to validity. Psychological Bulletin. 1992, 112 (3): 527-535.

Cronbach LJ, Meehl PE: Construct validity in psychological tests. Psychological Bulletin. 1955, 52: 281-302.

Duhem P: The Aim and Structure of Physical Theory. 1914, Princeton University Press

Lakatos I: Criticism and methodology of scientific research programs. Proceeding of the Aristotelian Society for the Systematic Study of Philosophy. 1968, 69: 149-186.

Feyerabend P: How to be a good empiricist - a plea for tolerance in matters epistemological. Philosophy of Science: The Central Issues. Edited by: Curd M, Cover J. 1963, New York: W.W. Norton & Company, 922-949.

Kuhn TS: The Structure of Scientific Revolutions. 1970, Chicago: University of Chicago Press, 2

Bostrom A, Wallin L, Nordstrom G: Research use in the care of older people: a survey among healthcare staff. International Journal of Older People Nursing. 2006, 1 (3): 131-140. 10.1111/j.1748-3743.2006.00014.x.

Bostrom AM, Wallin L, Nordstrom G: Evidence-based practice and determinants of research use in elderly care in Sweden. Journal of Evaluation in Clinical Practice. 2007, 13 (4): 665-10.1111/j.1365-2753.2007.00807.x.

Bostrom AM, Kajermo KN, Nordstrom G, Wallin L: Barriers to research utilization and research use among registered nurses working in the care of older people: Does the BARRIERS Scale discriminate between research users and non-research users on perceptions of barriers?. Implementation Science. 2008, 3 (1):

Humphris D, Hamilton S, O'Halloran P, Fisher S, Littlejohns P: Do diabetes nurse specialists utilise research evidence?. Practical Diabetes International. 1999, 16 (2): 47-50. 10.1002/pdi.1960160213.

Humphris D, Littlejohns P, Victor C, O'Halloran P, Peacock J: Implementing evidence-based practice: factors that influence the use of research evidence by occupational therapists. British Journal of Occupational Therapy. 2000, 63 (11): 516-222.

McCloskey DJ, McCloskey DJ: Nurses' perceptions of research utilization in a corporate health care system. Journal of Nursing Scholarship. 2008, 40 (1): 39-45. 10.1111/j.1547-5069.2007.00204.x.

Tranmer JE, Lochhaus-Gerlach J, Lam M: The effect of staff nurse participation in a clinical nursing research project on attitude towards, access to, support of and use of research in the acute care setting. Canadian Journal of Nursing Leadership. 2002, 15 (1): 18-26.

Pain K, Hagler P, Warren S: Development of an instrument to evaluate the research orientation of clinical professionals. Canadian Journal of Rehabilitation. 1996, 9 (2): 93-100.

Bonner A, Sando J: Examining the knowledge, attitude and use of research by nurses. Journal of Nursing Management. 2008, 16 (3): 334-343. 10.1111/j.1365-2834.2007.00808.x.

Henderson A, Winch S, Holzhauser K, De Vries S: The motivation of health professionals to explore research evidence in their practice: an intervention study. Journal of Clinical Nursing. 2006, 15 (12): 1559-1564. 10.1111/j.1365-2702.2006.01637.x.

Waine M, Magill-Evans J, Pain K: Alberta occupational therapisits' perspectives on and participation in research. Canadian Journal of Occupational Therapy. 1997, 64 (2): 82-88.

Aron J: The utilization of psychotherapy research on depression by clinical psychologists. Thesis. 1990, Auburn University

Brown DS: Nursing education and nursing research utilization: is there a connection in clinical settings?. Journal of Continuing Education in Nursing. 1997, 28 (6): 258-262. quiz 284

Parahoo K: A comparison of pre-Project 2000 and Project 2000 nurses' perceptions of their research training, research needs and of their use of research in clinical areas. Journal of Advanced Nursing. 1999, 29 (1): 237-245. 10.1046/j.1365-2648.1999.00882.x.

Parahoo K: Research utilization and attitudes towards research among psychiatric nurses in Northern Ireland. Journal of Psychiatric and Mental Health Nursing. 1999, 6 (2): 125-135. 10.1046/j.1365-2850.1999.620125.x.

Parahoo K, McCaughan EM: Research utilization among medical and surgical nurses: A comparison of their self reports and perceptions of barriers and facilitators. Journal of Nursing Management. 2001, 9 (1): 21-30. 10.1046/j.1365-2834.2001.00237.x.

Parahoo K, Barr O, McCaughan E: Research utilization and attitudes towards research among learning disability nurses in Northern Ireland. Journal of Advanced Nursing. 2000, 31 (3): 607-613. 10.1046/j.1365-2648.2000.01316.x.

Valizadeh L, Zamanzadeh V: Research in brief: Research utilization and research attitudes among nurses working in teaching hospitals in Tabriz, Iran. Journal of Clinical Nursing. 2003, 12: 928-930. 10.1046/j.1365-2702.2003.00798.x.

Veeramah V: Utilization of research findings by graduate nurses and midwives. Journal of Advanced Nursing. 2004, 47 (2): 183-191. 10.1111/j.1365-2648.2004.03077.x.

Callen JL, Fennell K, McIntosh JH: Attitudes to, and use of, evidence-based medicine in two Sydney divisions of general practice. Australian Journal of Primary Health. 2006, 12 (1): 40-46. 10.1071/PY06007.

Cameron KAV, Ballantyne S, Kulbitsky A, Margolis-Gal M, Daugherty T, Ludwig F: Utilization of evidence-based practice by registered occupational therapists. Occupational Therapy International. 2005, 12 (3): 123-136. 10.1002/oti.1.

Elliott V, Wilson SE, Svensson J, Brennan P: Research utilisation in sonographic practice: Attitudes and barriers. Radiography. 2008

Erler CJ, Fiege AB, Thompson CB: Flight nurse research activities. Air Medical Journal. 2000, 19 (1): 13-18. 10.1016/S1067-991X(00)90086-5.

Logsdon C, Davis DW, Hawkins B, Parker B, Peden A: Factors related to research utilization by registered nurses in Kentucky. Kentucky Nurse. 1998, 46 (1): 23-26.

Miller JP: Speech-language pathologists' use of evidence-based practice in assessing children and adolescents with cognitive-communicative disabilities: a survey. Thesis. 2007, Eastern Washington University

Nelson TD, Steele RG: Predictors of practitioner self-reported use of evidence-based practices: Practitioner training, clinical setting, and attitudes toward research. Administration and Policy in Mental Health and Mental Health Services Research. 2007, 34 (4): 319-330. 10.1007/s10488-006-0111-x.

Ofi B, Sowunmi L, Edet D, Anarado N, Ofi B, Sowunmi L, Edet D, Anarado N: Professional nurses' opinion on research and research utilization for promoting quality nursing care in selected teaching hospitals in Nigeria. International Journal of Nursing Practice. 2008, 14 (3): 243-255. 10.1111/j.1440-172X.2008.00684.x.

Oliveri RS, Gluud C, Wille-Jorgensen PA: Hospital doctors' self-rated skills in and use of evidence-based medicine - a questionnaire survey. Journal of Evaluation in Clinical Practice. 2004, 10 (2): 219-10.1111/j.1365-2753.2003.00477.x.

Sweetland J, Craik C: The use of evidence-based practice by occupational therapists who treat adult stroke patients. British Journal of Occupational Therapy. 2001, 64 (5): 256-260.

Veeramah V: A study to identify the attitudes and needs of qualified staff concerning the use of research findings in clinical practice within mental health care settings. Journal of Advanced Nursing. 1995, 22 (5): 855-861.

Wood CK: Adoption of innovations in a medical community: The case of evidence-based medicine. Thesis. 1996, University of Hawaii

Wright A, Brown P, Sloman R: Nurses' perceptions of the value of nursing research for practice. Australian Journal of Advanced Nursing. 1996, 13 (4): 15-18.

Download references

Acknowledgements

This project was made possible by the support of the Canadian Institutes of Health Research (CIHR) Knowledge Translation Synthesis Program (KRS 86255). JES is supported by CIHR postdoctoral and Bisby fellowships. CAE holds a CIHR Canada Research Chair in Knowledge Translation. HMO holds Alberta Heritage Foundation for Medical Research (AHFMR) and KT Canada (CIHR) doctoral scholarships. PG holds a grant from AFA Insurance, and LW is supported by the Center for Care Sciences at Karolinska Institutet. We would like to thank Dagmara Chojecki, MLIS for her support in finalizing the search strategy.

Author information

Authors and affiliations.

Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada

Janet E Squires

Faculty of Nursing, University of Alberta, Edmonton, Canada

Carole A Estabrooks, Hannah M O'Rourke & Christine V Newburn-Cook

Department of Clinical Neuroscience (Division of Psychology), Karolinska Institutet, Stockholm, Sweden

Petter Gustavsson

Department of Neurobiology, Care Sciences and Society (Division of Nursing), Karolinska Institutet, Stockholm, Sweden

Lars Wallin

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Janet E Squires .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors' contributions

JES, CAE, PG, and LW participated in designing the study and securing funding for the project. JES, CAE, HMO, PG, and LW participated in developing the search strategy, study relevance, and data extraction tools. JES and HMO undertook the article selection and data extraction. All authors participated in data synthesis. JES drafted the manuscript. All authors provided critical commentary on the manuscript and approved the final version.

Electronic supplementary material

13012_2010_399_moesm1_esm.pdf.

Additional File 1: Search Strategy. This file contains the details of the search strategy used for the review. (PDF 74 KB)

13012_2010_399_MOESM2_ESM.PDF

Additional File 2: Exclusion List by Reason (N = 393). This file contains a list of the retrieved articles that were excluded from the review and the reason each article was excluded. (PDF 412 KB)

13012_2010_399_MOESM3_ESM.PDF

Additional File 3: The Standards . This file contains an overview of the Standards for Educational and Psychological Testing Validity Framework and sample predictions used to assess 'relations to other variables' validity evidence according to this framework. (PDF 192 KB)

13012_2010_399_MOESM4_ESM.PDF

Additional File 4: Description of Other Specific Practices Indices and Other General Research Use Indices. This file contains a description of the four measures included in the class 'Other Specific Practices Indices' and the ten measures included in the class 'Other General Research Use Indices'. (PDF 112 KB)

13012_2010_399_MOESM5_ESM.PDF

Additional File 5: Reported Reliability of Self-Report Research Utilization Measures. This file contains the reliability coefficients reported in the included studies. (PDF 85 KB)

13012_2010_399_MOESM6_ESM.PDF

Additional file 6: Supporting Validity Evidence by Self-Report Research Utilization Measure. This file contains the detailed validity evidence on each included self-report research utilization measure. (PDF 355 KB)

Authors’ original submitted files for images

Below are the links to the authors’ original submitted files for images.

Authors’ original file for figure 1

Authors’ original file for figure 2, rights and permissions.

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

Squires, J.E., Estabrooks, C.A., O'Rourke, H.M. et al. A systematic review of the psychometric properties of self-report research utilization measures used in healthcare. Implementation Sci 6 , 83 (2011). https://doi.org/10.1186/1748-5908-6-83

Download citation

Received : 20 August 2010

Accepted : 27 July 2011

Published : 27 July 2011

DOI : https://doi.org/10.1186/1748-5908-6-83

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Item Response Theory
  • Research Utilization
  • Validity Evidence
  • Guideline Adherence
  • Knowledge Utilization

Implementation Science

ISSN: 1748-5908

  • Submission enquiries: Access here and click Contact Us
  • General enquiries: [email protected]

systematic review of research utilization

  • Evidence Utilization

Methods to support a systematic approach to research utilization

Illustration of the four-stage research utilization framework

Kate Plourde

systematic review of research utilization

Kirsten Krueger

Public health decision makers need accurate information about which interventions will be most effective within their given context. The evidence-to-practice gap in public health is well documented however (and described in this previous post ). In this post, we propose that there are methodical procedures, or research utilization methods, that can and should be applied to support a systematic approach to facilitate the uptake of evidence in practice. Research utilization methods can support identification of evidence gaps, produce practice-based evidence, demonstrate efficacy, support dissemination to improve awareness, and facilitate intervention adaptations and adoption.

Our colleagues Christine Kim et al. (2018) used decades of experience to develop a four-phase research utilization framework “to guide global health and development efforts that seek to apply evidence to policies and programs” (p. 1). As we move across the phases in this framework in our own work, we are continually reminded that just as research requires systematic procedures, so does research utilization. We find, however, that the science behind research utilization is not well understood by those outside of the field and that within the field of research utilization we do not do a great job of documenting and sharing the methods we are using. Here we present the framework from the original Kim et al. article and also share applied methods relevant for each stage.

It is important to note that the process of research utilization is cyclical, and many of the methods that are listed for a particular stage can also support others. The summaries below are by no means exhaustive; rather they are illustrative of the various methodologies that can support the research utilization science.

Illustration of the four-stage research utilization framework

Figure 1: Research utilization framework; Source: Christine Kim et al. (2018)

Foundational phase

Understanding the existing body of evidence to determine the best practices to address a particular health disparity, as well as the implementation and impact of those practices across contexts and populations, is key to ensuring evidence-based public health. As stated by Greene and Glasgow (2006) , “If we want more evidence-based practice, we need more practice-based evidence.”

We find these research utilization methods relevant to the foundational phase.

  • Literature review : Literature reviews provide a systematic approach for summarizing evidence to support decision makers with planning programs and prioritizing funding ( Brownson et al., 2018 ). There are a multitude of literature review methods to utilize such as a systematic review , scoping review , realist review , systematic review of reviews (umbrella review), meta-analysis and narrative review .
  • Ex-ante policy analysis : An ex-ante policy analysis prior to implementation offers an examination of potential policy alternatives, their impact and the implementation process. Methods often only include a retrospective or comparative analysis to understand policy approaches ( Patton et al., 2016 ). Results from an ex-ante (before) analysis supports decision makers with identifying the most appropriate and informed intervention option for their context.
  • Collection of practice-based evidence : Traditional sources of evidence, such as formal research and published, peer-reviewed manuscripts, often fail to capture the experiential knowledge of those implementing public health interventions in real-world settings. As such, the use of practice-based evidence to inform evidence-based practice is increasingly important (Green and Glasgow, 2006). Methods to collect practice-based evidence typically include community-based participatory research approaches and participatory systems science methods ( Ammerman et al., 2014 ). The application of approaches such as whole-system-in-the-room , while less rigorous, have successfully elucidated this type of evidence and its value.

Research phase

One major contributor to the persistence of public health’s challenges as described by Glasgow and colleagues (2003) is “the assumption that effectiveness… naturally and logically follows from successful efficacy research.” And Martin et al. (2016) show us intervention efficacy testing often includes procedures such as randomization and intervention manipulation, that do not occur in real-world settings. Thus, the impact of interventions brought to scale outside of a study context may be minimized, if not negated.

We find these research utilization methods relevant to the research phase.

  • Process evaluation : Moore et al. (2014) describe a growing recognition for process evaluation to inform intervention adaptation and scale-up. Process evaluations examine the quality and quantity of intervention activities, as well as why specific components were (or were not) implemented. Implementation tracking is one approach to support process evaluation; our colleagues at FHI 360 developed a novel intervention tracking tool to document implementation during the research phase.
  • Costing study : A basic cost analysis involves the collection of information about the various resources needed to implement or replicate an intervention. This information informs future cost-benefit or cost-effectiveness analysis. The results of costing studies are extremely valuable to decision makers in resource-limited settings as they prioritize investments in approaches to address the public’s health.

Translation phase

Institutionalization phase.

We find these research utilization methods relevant to the institutionalization phase.

  • Acceptability assessment : An acceptability assessment helps identify whether an evidence-based intervention is appropriate for adaptation and scale-up in a new context; and if so, what potential adaptations are needed to ensure it remains effective within that new context ( Ayala and Elder, 2011 ). Qualitative methods such as focus group discussions and interviews are often utilized to collect evidence of acceptability.
  • Situation analysis : The World Health Organization (WHO) defines a situation analysis as “an assessment of the current health situation … [that] is fundamental to designing and updating national policies, strategies and plans” ( WHO, 2016 ). A situation analysis explores the full system in which an intervention will be implemented and includes an assessment of the current health challenges and determinants of health, demand for services, health system capacity and performance, existing resources, and stakeholder positions (WHO, 2016). A situation analysis helps elucidate evidence about the feasibility of and readiness of a health system to successfully support implementation of an evidence-based intervention.
  • Participatory action research (PAR) and community-based participatory research (CBPR): Wallerstein and Duran (2010) say participatory research methods “create space for postcolonial and hybrid knowledge, including culturally supported interventions, indigenous theories and community advocacy.” During the institutionalization phase, Ammerman et al. (2014) show participatory methods provide unique insight into community needs and provide an approach through which to engage a variety of stakeholders to gather input on how evidence-based practices can best be adopted, brought to scale and maintained in a current context.
  • Case study research : Case study research seeks to capture information about how, what and why a particular phenomenon occurs and collects evidence that informs future adaptations and scale-up activities ( Yin, 2009 ).
  • Ex-post policy analysis : An ex-post policy analysis involves the evaluation of a policy once implemented. The analysis includes policy monitoring and the examination of factors such as actual versus planned performance, cost benefit and cost effectiveness, and policy revisions (Patton et al., 2016). The type of information collected via ex-post policy analyses informs future work at the start of a new research utilization cycle.

In the comments below, please share with us examples of how you have used the approaches we present in this article as well as other relevant methods for each phase of the cycle! Photo caption: Research utilization framework Photo credit: Christine Kim et al. (2018)

Sharing is caring!

How likely are you to recommend this blog post to a friend or colleague? Select 0 - Not likely 1 2 3 4 5 6 7 8 9 10 - Highly likely

How satisfied are you with what you found on this blog today? Did not meet my needs Somewhat met my needs Met my needs Exceeded my expectations I did not have any specific needs

Please share any other comments or feedback.

Related Posts

Two Indian women examining a family planning flowchart; one teaching the other

Research utilization is the connective tissue between evidence and action

School Support Officer conducting a pupil assessment in an empty classroom in Northern Nigeria

How to pick the right survey tool for your COVID-19 context

Stay up to date

Never miss an email

  • Monthly summaries only

Our use of cookies

Privacy overview.

  • Open access
  • Published: 30 May 2024

Barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with psychosis: a scoping review protocol

  • Cláudia C. Gonçalves   ORCID: orcid.org/0000-0001-6767-0920 1 ,
  • Zoe Waters 2 ,
  • Shae E. Quirk 1 ,
  • Peter M. Haddad 1 , 3 ,
  • Ashleigh Lin 4 ,
  • Lana J. Williams 1 &
  • Alison R. Yung 1 , 5  

Systematic Reviews volume  13 , Article number:  143 ( 2024 ) Cite this article

92 Accesses

Metrics details

The prevalence of psychosis has been shown to be disproportionately high amongst sexual and gender minority individuals. However, there is currently little consideration of the unique needs of this population in mental health treatment, with LGBTQA+ individuals facing barriers in accessing timely and non-stigmatising support for psychotic experiences. This issue deserves attention as delays to help-seeking and poor engagement with treatment predict worsened clinical and functional outcomes for people with psychosis. The present protocol describes the methodology for a scoping review which will aim to identify barriers and facilitators faced by LGBTQA+ individuals across the psychosis spectrum in help-seeking and accessing mental health support.

A comprehensive search strategy will be used to search Medline, PsycINFO, Embase, Scopus, LGBTQ+ Source, and grey literature. Original studies of any design, setting, and publication date will be included if they discuss barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with experiences of psychosis. Two reviewers will independently screen titles/abstracts and full-text articles for inclusion in the review. Both reviewers will then extract the relevant data according to pre-determined criteria, and study quality will be assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Key data from included studies will be synthesised in narrative form according to the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews.

The results of this review will provide a comprehensive account of the current and historical barriers and facilitators to mental healthcare faced by LGBTQA+ people with psychotic symptoms and experiences. It is anticipated that the findings from this review will be relevant to clinical and community services and inform future research. Findings will be disseminated through publication in a peer-reviewed journal and presented at conferences.

Scoping review registration

This protocol is registered in Open Science Framework Registries ( https://doi.org/10.17605/OSF.IO/AT6FC ).

Peer Review reports

The prevalence of psychotic disorders in the general population has been estimated to be around 0.27–0.75% [ 1 , 2 ], with the lifetime prevalence of ever having a psychotic experience being estimated at 5.8% [ 3 ]. However, rates of psychotic symptoms and experiences are disproportionately high amongst LGBTQA+ populations, with non-heterosexual individuals estimated to be 1.99–3.75 times more likely to experience psychosis than their heterosexual peers [ 4 , 5 , 6 , 7 ]. Additionally, it has been estimated that transgender or gender non-conforming (henceforth trans) individuals are 2.46–49.7 times more likely than their cisgender peers (i.e. individuals whose gender identity is the same as their birth registered sex) to receive a psychotic disorder diagnosis [ 8 , 9 ]. The increased rates of psychotic experiences noted amongst gender and sexual minorities may be explained by evidence indicating that LGBTQA+ people are also exposed to risk factors for psychosis at a far greater rate than members of the general population, such as childhood adversity [ 10 , 11 , 12 ], minority stress [ 13 ], discrimination [ 14 ], and stigma [ 15 , 16 ]. Furthermore, there is added potential for diagnostic biases leading to over-diagnosing psychosis in gender diverse individuals, whose gender expression and dysphoria may be pathologized by mental health service providers [ 8 ].

Despite these concerning statistics, there is very little research examining the experiences of LGBTQA+ people with psychosis, and limited consideration of the unique needs these individuals may have in accessing and engaging with mental health services. While timely access to treatment has consistently been associated with better symptomatic and functional outcomes for people with psychosis [ 17 , 18 ], there are often delays to treatment initiation which are worsened for LGBTQA+ individuals [ 19 , 20 ]. These individuals face additional barriers to accessing adequate mental health support compared to cisgender/heterosexual people [ 19 ] and may need to experiment with several mental health services before finding culturally competent care [ 20 ]. This in turn may lead to longer duration of untreated psychosis. Additionally, there seems to be a lack of targeted support for this population from healthcare providers, with LGBTQA+ individuals with serious mental health concerns reporting higher rates of dissatisfaction with psychiatric services than their cisgender and heterosexual counterparts [ 7 , 14 , 21 ]. However, the extent of these differences varies across contexts [ 22 ], potentially due to improved education around stigma and LGBTQA+ issues within a subset of mental health services.

Nonetheless, stigma remains one of the highest cited barriers to help-seeking for mental health problems, particularly with regard to concerns around disclosure [ 23 ], which can be particularly challenging for people experiencing psychosis [ 24 , 25 ]. Stigma stress in young people at risk for psychosis is associated with less positive attitudes towards help-seeking regarding both psychiatric medication and psychotherapy [ 26 ], potentially partly due to fears of judgement and being treated differently by service providers [ 27 ]. This issue may be compounded for people who also belong to minoritized groups [ 23 , 28 ], particularly as LGBTQA+ individuals have reported experiencing frequent stigma and encountering uninformed staff when accessing mental healthcare [ 7 , 29 ]. Furthermore, stigma-fuelled hesitance to access services may be heightened for trans people [ 30 ] whose identities have historically been pathologized and conflated with experiences of psychosis [ 31 ].

Even when individuals manage to overcome barriers to access support, there are added challenges to maintaining adequate treatment engagement. In a large online study, half of trans and nearly one third of LGB participants reported having stopped using mental health services in the past because of negative experiences related to their gender identity or sexuality [ 20 ]. This can be particularly problematic as experiences of stigma predict poorer medication adherence in psychosis [ 32 ] which subsequently multiplies the risk for relapse and suicide [ 33 ]. While no research to date has explored non-adherence rates in people with psychosis who are LGBTQA+, concerns around suicidality are heightened for individuals who are gender and sexuality diverse [ 34 , 35 , 36 ].

Generally, there is rising demand for mental healthcare that specifically addresses the needs of gender and sexual minority individuals and promotes respect for diversity, equity, and inclusion [ 29 , 37 ]. This is particularly salient as positive relationships with staff are associated with better medication adherence for people with psychosis [ 38 ] and healthcare providers with LGBTQA+-specific mandates have demonstrated higher satisfaction rates for LGBTQA+ individuals [ 20 ]. Mental health services need to adapt treatment options to acknowledge minority stress factors for those with stigmatised identities and, perhaps more importantly, how these intersect and interact to increase inequalities in people from minoritized groups accessing and benefiting from treatment [ 37 , 39 ].

Additionally, gender affirming care needs to be recognised as an important facet of mental health treatment for many trans individuals, as it is associated with positive outcomes such as improvements in quality of life and psychological functioning [ 40 , 41 , 42 ] and reductions in psychiatric symptom severity and need for subsequent mental health treatment [ 8 , 43 ]. While there are additional barriers in access to gender affirming care for individuals with psychosis, this treatment has shown success in parallel with treatment to address psychosis symptom stabilisation [ 19 , 44 ]. The importance of affirmation is echoed by the finding that many negative experiences of LGBTQA+ participants with mental health services could be avoided simply by respecting people’s pronouns and using gender-neutral language [ 20 ].

To ensure timely access to appropriate treatment for LGBTQA+ people with psychosis, there is a need for improved understanding of the factors which challenge and facilitate help-seeking and engagement with mental health support. A preliminary search of Google Scholar, Medline, the Cochrane Database of Systematic Reviews, and PROSPERO was conducted and revealed no existing or planned reviews exploring benefits and/or obstacles to mental health treatment specific to this population. Therefore, the proposed review seeks to comprehensively search and appraise the existing literature to identify and summarise a range of barriers and facilitators to adequate mental health support faced by LGBTQA+ people with experiences of psychosis. This will allow for the mapping of the types of evidence available and identification of any knowledge gaps. Moreover, we hope to guide future decision-making in mental healthcare to improve service accessibility for LGBTQA+ individuals with psychosis and to set the foundations for future research that centres this marginalised population. Based on published guidance [ 45 , 46 , 47 ], a scoping review methodology was identified as the most appropriate approach to address these aims.

Selection criteria

This scoping review protocol has been developed in compliance with the JBI Manual for Evidence Synthesis [ 48 ] and, where relevant, the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist [ 49 ] (see Additional file 1). In the event of protocol amendments, the date, justification, and description for each amendment will be provided.

Due to the limited literature around the topic of this review, any primary original study design, setting, and publication date will be considered for inclusion. Publications written in English will be included, and articles in other languages may be considered pending time and cost constraints around translation. Publications will be excluded if the full text is not available upon request from authors.

The PCC (Population, Concept, Context) framework was used to develop the inclusion criteria for this scoping review:

This review will include individuals of any age who are LGBTQA+ and have had experiences of psychosis. For the purposes of this review, ‘LGBTQA+ individuals’ will be broadly defined as any individual that is not heterosexual and/or cisgender or anyone who engages in same-gender sexual behaviour. Studies may include participants who are cisgender and heterosexual if they separately report outcomes for LGBTQA+ individuals. Within this review, the term ‘psychosis’ includes (i) any diagnosis of a psychotic disorder, such as schizophrenia spectrum disorders, mood disorders with psychotic features, delusional disorders, and drug-induced psychotic disorders, (ii) sub-threshold psychotic symptoms, such as those present in ultra-high risk (UHR), clinical high risk (CHR), or at risk mental state (ARMS) individuals, and (iii) any psychotic-like symptoms or experiences. Studies may include participants with multiple diagnoses if they separately report outcomes for individuals on the psychosis spectrum.

This review will include publications which discuss potential barriers and/or facilitators to mental health help-seeking and/or engagement with mental health treatment. ‘Barriers’ will be operationalised as any factors which may delay or prevent individuals from accessing and engaging with appropriate mental health support. These may include lack of mental health education, experienced or internalised stigma, experiences of discrimination from health services, and lack of inclusivity in health services. ‘Facilitators’ will be operationalised as any factors which may promote timely help-seeking and engagement with sources of support. These may include improved access to mental health education, positive sources of social support, and welcoming and inclusive services. Mental health help-seeking will be broadly defined as any attempt to seek and access formal or informal support to address a mental health concern related to experiences of psychosis (e.g. making an initial appointment with a service provider, seeking help from a friend). Mental health treatment engagement will be broadly defined as adherence and active participation in the treatment that is offered by a source of support (e.g. attending scheduled appointments, taking medication as prescribed, openly communicating with service providers).

This review may include research encompassing any setting in which mental healthcare is provided. This is likely to include formal healthcare settings such as community mental health teams or inpatient clinics as well as informal settings such as LGBTQA+ spaces or informal peer support. Studies will be excluded if they focus exclusively on physical health treatment.

Search strategy

Database searches will be conducted in Medline, PsycINFO, Embase, Scopus, and LGBTQ+ Source. The full search strategy for this protocol is available (see Additional file 2). This strategy has been collaboratively developed and evaluated by a scholarly services health librarian. Searches will include subject headings relevant to each database and title/abstract keywords relating to three main concepts: (i) LGBTQA+ identity, (ii) experiences of psychosis, and (iii) mental health treatment. Keywords for each concept will be combined using the Boolean operator ‘OR’, and the three concepts will be combined using ‘AND’. This search strategy was appropriately translated for each of the selected databases. There will be no limitations on language or publication date at this stage to maximise the breadth of the literature captured. Publications returned from these searches will be exported to EndNote. Searches will be re-run prior to the final analysis to capture any newly published studies.

The database searches will be supplemented by searching the grey literature as per the eligibility criteria detailed above. These may include theses and dissertations, conference proceedings, reports from mental health services, and policy documents from LGBTQA+ groups. Google and Google Scholar will be searched using a combination of clauses for psychosis (Psychosis OR psychotic OR schizophrenia OR schizoaffective), treatment (treatment or “help-seeking”), and queer identity. The latter concept will have three clauses for three separate searches, with one including broad queer identity (LGBT), one specific to non-heterosexual individuals (gay OR lesbian OR homosexual OR bisexual OR queer OR asexual), and one specific to trans individuals (transgender OR transsexual OR transexual OR “non-binary” OR “gender minority”). Additionally, reference lists and citing literature will be manually searched for each paper included in the review to capture any articles and policy documents not previously identified.

Data selection

Search results will be imported into Covidence using EndNote, and duplicates will be eliminated. Titles and abstracts will be screened by the first and second authors according to pre-defined screening criteria, which will be discussed by the authors and piloted prior to screening. These criteria will consider whether the articles included LGBTQA+ participants with experiences of psychosis (as operationalised above) in relation to mental health help-seeking and/or treatment. Full texts of relevant articles will then be obtained and screened by the first and second reviewer in accordance with the full inclusion and exclusion criteria after initial piloting to maximise inter-rater reliability. Decisions on inclusion and exclusion will be blinded and recorded on Covidence. Potential discrepancies will be resolved through discussion, and when consensus cannot be reached, these will be resolved by the supervising author. The process of study selection will be documented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram [ 50 ].

Data extraction

Data extraction will be performed independently by two reviewers using Covidence. Prior to beginning final extraction, both reviewers will independently pilot the extraction tool using a sample of five included studies and discuss any necessary changes. Information extracted is planned to include the following: title, author name(s), year of publication, country in which the study was conducted, study design, sample size, population of focus (i.e. sexual minorities, gender minorities, or both), sample demographics (i.e. age, gender identity, and sexual orientation), setting (e.g. early intervention service, community mental health team, etc.), psychosis characteristics (e.g. diagnoses included, severity of symptoms, etc.), type of treatment (e.g. cognitive behavioural therapy, antipsychotic medication, etc.), and any barriers and/or facilitators identified according to the aforementioned operationalised definitions. Disagreements will be resolved through discussion between the two reviewers and, when necessary, final decisions will be made by a senior supervisor. Once extracted, information will be recorded in Excel. Lead authors of papers will be contacted by the primary review author in cases where there is missing or insufficient data.

Quality assessment

Due to the expected heterogeneity in the types of studies that may be included in this review (e.g. qualitative studies, randomised controlled trials, case control studies, case reports), the relevant revised Joanna Briggs Institute (JBI) critical appraisal checklists [ 51 ] will be used to assess risk of bias and study quality for each study design. Two reviewers will independently use these checklists to assess each paper that is included following the full-text screening. If there are discrepancies in article ratings, these will be resolved through discussion between the two authors. If no consensus is reached, discrepancies will be resolved by a senior supervisor. In line with the scoping nature of this review, low-quality studies will not be excluded from the synthesis.

Evidence synthesis

Data from included studies will be synthesised using a narrative synthesis approach in accordance with the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews [ 52 ]. A preliminary descriptive synthesis will be conducted by tabulating the extracted data elements from each study alongside quality assessment results and developing an initial description of the barriers and facilitators to (1) accessing and (2) engaging with mental health support that are identified in the literature. This initial synthesis will then be interrogated and refined to contextualise these barriers and facilitators in the setting, population, and methodology of each study to form the basis for an interpretative synthesis.

This review will not use a pre-existing thematic framework to categorise barriers and facilitators as it is expected that the factors identified will not neatly fit into existing criteria. Instead, these will be conceptualised according to overarching themes as interrelated factors, so that potentially complex interactions between barriers and facilitators within and across relevant studies may be explored through concept mapping. If most of the studies included are qualitative, there may also be scope for a partial meta-synthesis. To avoid oversimplifying the concept of ‘barriers and facilitators’ (see criticism by Bach-Mortensen & Verboom [ 53 ]), this data synthesis will be followed by a critical reflection of the findings through the lens of the socio-political contexts which may give rise to the barriers and facilitators identified, exploring the complexities necessary for any changes to be implemented in mental health services.

If the extracted data indicate that gender minority and sexual minority individuals experience unique or different barriers and/or facilitators to each other, these population groups will be analysed separately as opposed to findings being generalised across the LGBTQA+ spectrum. Furthermore, if there is scope to do so, analyses may be conducted to investigate how perceived barriers and facilitators for this population may have changed over time (i.e. according to publication date) as definitions of psychosis evolve and LGBTQA+ individuals gain visibility in clinical services.

The proposed review will add to the literature around mental health treatment for LGBTQA+ people with psychosis. It will provide a thorough account of the barriers and facilitators to accessing and engaging with support faced by this population and may inform future research and clinical practice.

In terms of limitations, this review will be constrained by the existing literature and may therefore not be sufficiently comprehensive in reflecting the barriers and facilitators experienced by subgroups within the broader LGBTQA+ community. Additionally, although broad inclusion criteria are necessary to capture the full breadth of research conducted in this topic, included studies are likely to be heterogeneous and varied in terms of their methodology and population which may complicate data synthesis.

Nonetheless, it is anticipated that the findings from this review will provide the most comprehensive synthesis to date of the issues driving low help-seeking and treatment engagement in people across the psychosis spectrum who are LGBTQA+. This review will likely also identify gaps in the literature which may inform avenues for future research, and the factors identified in this review will be considered in subsequent research by the authors.

Additionally, findings will be relevant to healthcare providers that offer support to people with psychosis who may have intersecting LGBTQA+ identities as well as LGBTQA+ organisations which offer support to LGBTQA+ people who may be experiencing distressing psychotic experiences. These services are likely to benefit from an increased awareness of the factors which may improve or hinder accessibility for these subsets of their target populations. Therefore, results from this review may inform decision-making around the implementation of service-wide policy changes.

The findings of this review will be disseminated through the publication of an article in a peer-reviewed journal and presented at relevant conferences in Australia and/or internationally. Additionally, the completed review will form part of the lead author’s doctoral thesis.

Availability of data and materials

Not applicable for this protocol.

Abbreviations

  • At risk mental state

Clinical high risk for psychosis

Joanna Briggs Institute

Lesbian, gay, and bisexual

Lesbian, gay, bisexual, transgender, queer or questioning, asexual or aromantic, and more

Population, Concept, Context

Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols

Ultra-high risk for psychosis

Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease Study (GBD) Results. Seattle, WA: IHME, University of Washington. 2020. https://vizhub.healthdata.org/gbd-results/ . Accessed 26 May 2023

Moreno-Kustner B, Martin C, Pastor L. Prevalence of psychotic disorders and its association with methodological issues. A systematic review and meta-analyses. PLoS One. 2018;13(4):e0195687. https://doi.org/10.1371/journal.pone.0195687 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

McGrath JJ, Saha S, Al-Hamzawi A, Alonso J, Bromet EJ, Bruffaerts R, et al. Psychotic experiences in the general population: a cross-national analysis based on 31 261 respondents from 18 countries. JAMA Psychiatry. 2015;72(7):697–705. https://doi.org/10.1001/jamapsychiatry.2015.0575 .

Article   PubMed   PubMed Central   Google Scholar  

Chakraborty A, McManus S, Brugha TS, Bebbington P, King M. Mental health of the non-heterosexual population of England. Br J Psychiatry. 2011;198(2):143–8. https://doi.org/10.1192/bjp.bp.110.082271 .

Article   PubMed   Google Scholar  

Gevonden M, Selten J, Myin-Germeys I, De Graaf R, Ten Have M, Van Dorsselaer S, et al. Sexual minority status and psychotic symptoms: findings from the Netherlands Mental Health Survey and Incidence Studies (NEMESIS). Psychol Med. 2014;44(2):421–33. https://doi.org/10.1017/S0033291713000718 .

Article   CAS   PubMed   Google Scholar  

Jacob L, Smith L, McDermott D, Haro JM, Stickley A, Koyanagi A. Relationship between sexual orientation and psychotic experiences in the general population in England. Psychol Med. 2021;51(1):138–46. https://doi.org/10.1017/S003329171900309X .

Welch S, Collings SCD, Howden-Chapman P. Lesbians in New Zealand: their mental health and satisfaction with mental health services. Aust N Z J Psychiatry. 2000;34(2):256–63. https://doi.org/10.1080/j.1440-1614.2000.00710.x .

Barr SM, Roberts D, Thakkar KN. Psychosis in transgender and gender non-conforming individuals: a review of the literature and a call for more research. Psychiatry Res. 2021;306:114272. https://doi.org/10.1016/j.psychres.2021.114272 .

Hanna B, Desai R, Parekh T, Guirguis E, Kumar G, Sachdeva R. Psychiatric disorders in the U.S. transgender population. Ann Epidemiol. 2019;39:1–7. https://doi.org/10.1016/j.annepidem.2019.09.009 .

Schneeberger AR, Dietl MF, Muenzenmaier KH, Huber CG, Lang UE. Stressful childhood experiences and health outcomes in sexual minority populations: a systematic review. Soc Psychiatry Psychiatr Epidemiol. 2014;49:1427–45. https://doi.org/10.1007/s00127-014-0854-8 .

Stanton KJ, Denietolis B, Goodwin BJ, Dvir Y. Childhood trauma and psychosis: an updated review. Child Adolesc Psychiatr Clin N Am. 2020;29(1):115–29. https://doi.org/10.1016/j.chc.2019.08.004 .

Varese F, Smeets F, Drukker M, Lieverse R, Lataster T, Viechtbauer W, et al. Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophr Bull. 2012;38(4):661–71. https://doi.org/10.1093/schbul/sbs050 .

Mongelli F, Perrone D, Balducci J, Saccheti A, Ferrari S, Mattei G, et al. Minority stress and mental health among LGBT populations: an update on the evidence. Minerva Psichiatr. 2019;60(1):27–50. https://doi.org/10.23736/S0391-1772.18.01995-7 .

Article   Google Scholar  

Kidd SA, Howison M, Pilling M, Ross LE, McKenzie K. Severe mental illness in LGBT populations: a scoping review. Psychiatr Serv. 2016;67(7):779–83. https://doi.org/10.1176/appi.ps.201500209 .

Hatzenbuehler ML, Pachankis JE. Stigma and minority stress as social determinants of health among lesbian, gay, bisexual, and transgender youth. Pediatr Clin North Am. 2016;63(6):985–97. https://doi.org/10.1016/j.pcl.2016.07.003 .

Rüsch N, Heekeren K, Theodoridou A, Müller M, Corrigan PW, Mayer B, et al. Stigma as a stressor and transition to schizophrenia after one year among young people at risk of psychosis. Schizophr Res. 2015;166(1–3):43–8. https://doi.org/10.1016/j.schres.2015.05.027 .

Howes OD, Whitehurst T, Shatalina E, Townsend L, Onwordi EC, Mak TLA, et al. The clinical significance of duration of untreated psychosis: an umbrella review and random-effects meta-analysis. World Psychiatry. 2021;20(1):75–95. https://doi.org/10.1002/wps.20822 .

McGorry PD. Early intervention in psychosis: obvious, effective, overdue. J Nerv Ment Dis. 2015;203(5):310–308. https://doi.org/10.1097/NMD.0000000000000284 .

Peta JL. The Oxford Handbook of Sexual and Gender Minority Mental Health. Oxford (GB): Oxford University Press; 2020. Chapter 11, Schizophrenia spectrum and other psychotic disorders among sexual and gender minority populations; 125-134. Available from: The Oxford Handbook of Sexual and Gender Minority Mental Health - Google Books. Accessed 01 Jun 2023

Simeonov D, Steele LS, Anderson S, Ross LE. Perceived satisfaction with mental health services in the lesbian, gay, bisexual, transgender, and transsexual communities in Ontario, Canada: an internet-based survey. Can J Commun Ment Health. 2015;34(1):31–44. https://doi.org/10.7870/cjcmh-2014-037 .

Avery AM, Hellman RE, Sudderth LK. Satisfaction with mental health services among sexual minorities with major mental illness. Am J Public Health. 2001;91(6):990–1. https://doi.org/10.2105/AJPH.91.6.990 .

Plöderl M, Mestel R, Fartacek C. Differences by sexual orientation in treatment outcome and satisfaction with treatment among inpatients of a German psychiatric clinic. PLoS ONE. 2022;17(1):e0262928. https://doi.org/10.1371/journal.pone.0262928 .

Clement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, Bezborodovs N, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med. 2015;45(1):11–27. https://doi.org/10.1017/S0033291714000129 .

Pyle M, Morrison AP. “It’s just a very taboo and secretive kind of thing”: making sense of living with stigma and discrimination from accounts of people with psychosis. Psychosis. 2014;6(3):195–205. https://doi.org/10.1080/17522439.2013.834458 .

Wood L, Burke E, Byrne R, Pyle M, Chapman N, Morrison AP. Stigma in psychosis: a thematic synthesis of current qualitative evidence. Psychosis. 2015;7(2):152–65. https://doi.org/10.1080/17522439.2014.926561 .

Rüsch N, Heekeren K, Theodoridou A, Dvorsky D, Müller M, Paust T, et al. Attitudes towards help-seeking and stigma among young people at risk for psychosis. Psychiatry Res. 2013;210(3):1313–5. https://doi.org/10.1016/j.psychres.2013.08.028 .

Gronholm PC, Thornicroft G, Laurens KR, Evans-Lacko S. Mental health-related stigma and pathways to care for people at risk of psychotic disorders or experiencing first-episode psychosis: a systematic review. Psychol Med. 2017;47(11):1867–79. https://doi.org/10.1017/S0033291717000344 .

Rossman K, Salamanca P, Macapagal K. A qualitative study examining young adults’ experiences of disclosure and nondisclosure of LGBTQ identity to health care providers. J Homosex. 2017;64(10):1390–410. https://doi.org/10.1080/00918369.2017.1321379 .

Rees SM, Crowe M, Harris S. The lesbian, gay, bisexual and transgender communities’ mental health care needs and experiences of mental health services: an integrative review of qualitative studies. J Psychiat Mental Health Nurs. 2020;28(4):578–89. https://doi.org/10.1111/jpm.12720 .

Shipherd JC, Green KE, Abramovitz A. Transgender clients: identifying and minimizing barriers to mental health treatment. J Gay Lesbian Ment Health. 2010;14(2):94–108. https://doi.org/10.1080/19359701003622875 .

Hoening J, Kenna JC. The nosological position of transsexualism. Arch Sex Behav. 1974;3:273–87. https://doi.org/10.1007/BF01541490 .

Eliasson ET, McNamee L, Swanson L, Lawrie SM, Schwannauer M. Unpacking stigma: meta-analyses of correlates and moderators of personal stigma in psychosis. Clin Psychol Rev. 2021;89:102077. https://doi.org/10.1016/j.cpr.2021.102077 .

Lally J, MacCabe JH. Antipsychotic medication in schizophrenia: a review. Br Med Bull. 2015;114(1):169–79. https://doi.org/10.1093/bmb/ldv017 .

De Lange J, Baams L, van Bergen D, Bos HMW, Bosker RJ. Minority stress and suicidal ideation and suicide attempts among LGBT adolescents and young adults: a meta-analysis. LGBT Health. 2022;9(4):222–37. https://doi.org/10.1089/lgbt.2021.0106 .

Skerrett DM, Kolves K, De Leo D. Are LGBT populations at higher risk for suicidal behaviours in Australia? Research findings and implications. J Homosex. 2015;62(7):883–901. https://doi.org/10.1080/00918369.2014.1003009 .

Strauss P, Cook A, Winter S, Watson V, Toussaint DW, Lin A. Trans Pathways: the mental health experiences and care pathways of trans young people: summary of results. Perth, Australia: Telethon Kids Institute. 2017. trans-pathways-report.pdf (telethonkids.org.au). Accessed 16 June 2023

DeLuca JS, Novacek DM, Adery LH, Herrera SN, Landa Y, Corcoran CM, et al. Equity in mental health services for youth at clinical high risk for psychosis: considering marginalized identities and stressors. Evid Based Pract Child Adolesc Ment Health. 2022;7(2):176–97. https://doi.org/10.1080/23794925.2022.2042874 .

Day JC, Bentall RP, Roberts C, Randall F, Rogers A, Cattell D, et al. Attitudes toward antipsychotic medication: the impact of clinical variables and relationships with health professionals. Arch Gen Psychiatry. 2005;62(7):717–24. https://doi.org/10.1001/archpsyc.62.7.717 .

Coyne CA, Poquiz JL, Janssen A, Chen D. Evidence-based psychological practice for transgender and non-binary youth: defining the need, framework for treatment adaptation, and future directions. Evid Based Pract Child Adolesc Ment Health. 2020;5(3):340–53. https://doi.org/10.1080/23794925.2020.1765433 .

Baker KE, Wilson LM, Sharma R, Dukhanin V, McArthur K, Robinson KA. Hormone therapy, mental health, and quality of life among transgender people: a systematic review. J Endocr Soc. 2021;5(4):bvab011. https://doi.org/10.1210/jendso/bvab011 .

Hughto JMW, Reisner SL. A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgend Health. 2016;1(1):21–31. https://doi.org/10.1089/trgh.2015.0008 .

Wernick JA, Busa S, Matouk K, Nicholson J, Janssen A. A systematic review of the psychological benefits of gender-affirming surgery. Urol Clin North Am. 2019;46(4):475–86. https://doi.org/10.1016/j.ucl.2019.07.002 .

Bränström R, Packanhkis JE. Reductions in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study. Am J Psychiatry. 2019;177(8):727–34. https://doi.org/10.1176/appi.ajp.2019.19010080 .

Meijer JH, Eeckhout GM, van Vlerken RHT, de Vries ALC. Gender dysphoria and co-existing psychosis: review and four case examples of successful gender affirmative treatment. LGBT Health. 2017;4(2):106–14. https://doi.org/10.1089/lgbt.2016.0133 .

Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143. https://doi.org/10.1186/s12874-018-0611-x .

Munn Z, Pollock D, Khalil H, Alexander L, McInerney P, Godfrey CM, et al. What are scoping reviews? Providing a formal definition of scoping reviews as a type of evidence synthesis. JBI Evid Synth. 2022;20(4):950–2. https://doi.org/10.11124/JBIES-21-00483 .

Peters MDJ, Marnie C, Colquhoun H, Garritty CM, Hempel S, Horsley T, et al. Scoping reviews: reinforcing and advancing the methodology and application. Syst Rev. 2021;10(1):263. https://doi.org/10.1186/s13643-021-01821-3 .

Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis. JBI; 2024. https://synthesismanual.jbi.global . https://doi.org/10.46658/JBIMES-24-01

Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;350: g7647. https://doi.org/10.1136/bmj.g7647 .

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

Barker TH, Stone JC, Sears K, Klugar M, Leonardi-Bee J, Tufanaru C, et al. Revising the JBI quantitative critical appraisal tools to improve their applicability: an overview of methods and the development process. JBI Evid Synth. 2023;21(3):478–93. https://doi.org/10.11124/JBIES-22-00125 .

Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews: a product from the ESRC methods programme. Lancaster University; 2006. https://doi.org/10.13140/2.1.1018.4643

Bach-Mortensen AM, Verboom B. Barriers and facilitators systematic reviews in health: a methodological review and recommendations for reviewers. Res Synth Methods. 2020;11(6):743–59. https://doi.org/10.1002/jrsm.1447 .

Download references

Acknowledgements

The authors would like to acknowledge the support of Ms Olivia Larobina, Scholarly Services Librarian (STEMM) at Deakin University, in the development of the search strategy.

CCG is funded by a Deakin University Postgraduate Research (DUPR) Scholarship. ZW is funded by a University of Western Australia Research Training Program (RTP) Scholarship. AL is supported by a National Health and Medical Research Council (NHMRC) Emerging Leaders Fellowship (2010063). LJW is supported by a NHMRC Emerging Leaders Fellowship (1174060). ARY is supported by a NHMRC Principal Research Fellowship (1136829). The funding providers had no role in the design and conduct of the study, or in the preparation, review, or approval of this manuscript.

Author information

Authors and affiliations.

Institute for Mental and Physical Health and Clinical Translation, Deakin University, Geelong, VIC, 3220, Australia

Cláudia C. Gonçalves, Shae E. Quirk, Peter M. Haddad, Lana J. Williams & Alison R. Yung

Telethon Kids Institute, University of Western Australia, Perth, WA, 6009, Australia

University Hospital Geelong, Barwon Health, Geelong, VIC, 3220, Australia

Peter M. Haddad

School of Population and Global Health, University of Western Australia, Perth, WA, 6009, Australia

Ashleigh Lin

School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK

Alison R. Yung

You can also search for this author in PubMed   Google Scholar

Contributions

CCG is the guarantor. CCG conceptualised the review, developed the study design, and drafted the manuscript. CCG, ZW, and SQ collaborated with OL (Scholarly Services Librarian) to develop the search strategy. All authors critically reviewed the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Cláudia C. Gonçalves .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

In the last 3 years, PMH has received honoraria for lecturing from Janssen, NewBridge Pharmaceuticals, and Otsuka and royalties from edited textbooks (Cambridge University Press, Oxford University Press).

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1. prisma-p 2015 checklist. completed prisma-p checklist for this systematic review protocol., 13643_2024_2566_moesm2_esm.docx.

Additional file 2. Search Strategy. Detailed search strategy for this systematic review, including search terms and relevant controlled vocabulary terms for each included database.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Gonçalves, C.C., Waters, Z., Quirk, S.E. et al. Barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with psychosis: a scoping review protocol. Syst Rev 13 , 143 (2024). https://doi.org/10.1186/s13643-024-02566-5

Download citation

Received : 04 July 2023

Accepted : 17 May 2024

Published : 30 May 2024

DOI : https://doi.org/10.1186/s13643-024-02566-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Treatment access
  • Treatment engagement
  • Facilitators
  • Clinical high risk
  • Ultra-high risk
  • Psychotic experiences

Systematic Reviews

ISSN: 2046-4053

  • Submission enquiries: Access here and click Contact Us
  • General enquiries: [email protected]

systematic review of research utilization

Loading metrics

Open Access

Peer-reviewed

Research Article

Factors influencing the participation of pregnant and lactating women in clinical trials: A mixed-methods systematic review

Contributed equally to this work with: Mridula Shankar, Alya Hazfiarini

Roles Data curation, Formal analysis, Methodology, Project administration, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia

ORCID logo

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

Roles Formal analysis, Methodology, Writing – review & editing

Roles Methodology, Writing – review & editing

Affiliation Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia

Roles Data curation, Methodology, Writing – review & editing

Affiliation University Library, University of Melbourne, Carlton, Victoria, Australia

Affiliation Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India

Affiliation Concept Foundation, Geneva, Switzerland/Bangkok, Thailand

Roles Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing

  • Mridula Shankar, 
  • Alya Hazfiarini, 
  • Rana Islamiah Zahroh, 
  • Joshua P. Vogel, 
  • Annie R. A. McDougall, 
  • Patrick Condron, 
  • Shivaprasad S. Goudar, 
  • Yeshita V. Pujar, 
  • Manjunath S. Somannavar, 

PLOS

  • Published: May 30, 2024
  • https://doi.org/10.1371/journal.pmed.1004405
  • Peer Review
  • Reader Comments

Fig 1

Poor representation of pregnant and lactating women and people in clinical trials has marginalised their health concerns and denied the maternal–fetal/infant dyad benefits of innovation in therapeutic research and development. This mixed-methods systematic review synthesised factors affecting the participation of pregnant and lactating women in clinical trials, across all levels of the research ecosystem.

Methods and findings

We searched 8 databases from inception to 14 February 2024 to identify qualitative, quantitative, and mixed-methods studies that described factors affecting participation of pregnant and lactating women in vaccine and therapeutic clinical trials in any setting. We used thematic synthesis to analyse the qualitative literature and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. We compared quantitative data against the thematic synthesis findings to assess areas of convergence or divergence. We mapped review findings to the Theoretical Domains Framework (TDF) and Capability, Opportunity, and Motivation Model of Behaviour (COM-B) to inform future development of behaviour change strategies.

We included 60 papers from 27 countries. We grouped 24 review findings under 5 overarching themes: (a) interplay between perceived risks and benefits of participation in women’s decision-making; (b) engagement between women and the medical and research ecosystems; (c) gender norms and decision-making autonomy; (d) factors affecting clinical trial recruitment; and (e) upstream factors in the research ecosystem. Women’s willingness to participate in trials was affected by: perceived risk of the health condition weighed against an intervention’s risks and benefits, therapeutic optimism, intervention acceptability, expectations of receiving higher quality care in a trial, altruistic motivations, intimate relationship dynamics, and power and trust in medicine and research. Health workers supported women’s participation in trials when they perceived clinical equipoise, had hope for novel therapeutic applications, and were convinced an intervention was safe. For research staff, developing reciprocal relationships with health workers, having access to resources for trial implementation, ensuring the trial was visible to potential participants and health workers, implementing a woman-centred approach when communicating with potential participants, and emotional orientations towards the trial were factors perceived to affect recruitment. For study investigators and ethics committees, the complexities and subjectivities in risk assessments and trial design, and limited funding of such trials contributed to their reluctance in leading and approving such trials. All included studies focused on factors affecting participation of cisgender pregnant women in clinical trials; future research should consider other pregnancy-capable populations, including transgender and nonbinary people.

Conclusions

This systematic review highlights diverse factors across multiple levels and stakeholders affecting the participation of pregnant and lactating women in clinical trials. By linking identified factors to frameworks of behaviour change, we have developed theoretically informed strategies that can help optimise pregnant and lactating women’s engagement, participation, and trust in such trials.

Author summary

Why was this study done.

  • Pregnant and lactating women and people are routinely excluded from participating in drug and vaccine clinical trials, resulting in limited options for prevention and treatment of medical conditions.
  • Challenges to including pregnant and lactating women and people in clinical research have been identified at multiple levels of the research and health systems, but the full range of barriers and facilitators to participation are not well known.

What did the researchers do and find?

  • We conducted a mixed-methods systematic review and identified 60 research articles from 27 countries on the views and experiences of pregnant and lactating women’s participation in clinical research, from the perspectives of cisgender women, family and community members, health workers, and people involved in the conduct of clinical research.
  • Using a thematic synthesis approach, we identified barriers affecting participation including women having a limited appetite for risk during pregnancy and lactation, concerns about women’s bodily autonomy during pregnancy, and challenges in obtaining ethical approval for clinical research with pregnant women.
  • We also identified facilitators of participation including the potential for personal health benefits, expectations of higher quality care, trust in the medical and research systems, and strong teamwork between researchers and health workers.

What do these findings mean?

  • Our findings demonstrate the need for multipronged strategies to address barriers and reinforce facilitators across the various levels of the research and health systems.
  • The actions that are needed to overcome these barriers and reinforce facilitators must be discussed, prioritised, and adapted to specific contexts.
  • All included studies focused on factors affecting participation of cisgender pregnant women in clinical trials; future research should consider other pregnancy-capable populations, including transgender and nonbinary people.

Citation: Shankar M, Hazfiarini A, Zahroh RI, Vogel JP, McDougall ARA, Condron P, et al. (2024) Factors influencing the participation of pregnant and lactating women in clinical trials: A mixed-methods systematic review. PLoS Med 21(5): e1004405. https://doi.org/10.1371/journal.pmed.1004405

Received: December 20, 2023; Accepted: April 19, 2024; Published: May 30, 2024

Copyright: © 2024 Shankar 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: The research in this publication was supported by funding from MSD (grant MFM-22-159697 to Concept Foundation), through its MSD for Mothers initiative ( https://www.msdformothers.com/ ) and is the sole responsibility of the authors. MSD for Mothers is an initiative of Merck & Co., Inc., Rahway, NJ, U.S.A. MAB’s time is supported by an Australian Research Council Discovery Early Career Researcher Award (DE200100264) and a Dame Kate Campbell Fellowship (University of Melbourne Faculty of Medicine, Dentistry and Health Sciences). JPV is supported by an Australian National Health and Medical Research Council (NHMRC) Investigator grant (GNT1194248). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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

Abbreviations: BCW, Behaviour Change Wheel; COM-B, Capability, Opportunity, and Motivation Model of Behaviour; MMAT, Mixed Methods Appraisal Tool; TDF, Theoretical Domains Framework

Introduction

Clinical trials are the foundation for knowledge on the efficacy and safety of biomedical interventions to protect health and treat illness. The fundamental questions of who participates and whose data contributes to trials have implications for understanding the risks and benefits of interventions, and the societal value of such interventions to specific populations. Pregnant and lactating women and people have long been underrepresented or excluded entirely from participating in therapeutic and vaccine clinical trials [ 1 ]. Notwithstanding valid concerns regarding fetal and infant safety, an outright exclusionary response to this complex issue has denied the maternal–fetal/infant dyad the health benefits of biomedical innovation, despite demonstrated public health need [ 2 , 3 ]. As a recent example, during the COVID-19 pandemic, pregnant women and people were excluded from early therapeutic and vaccine trials despite greater severity of infection-related illness [ 4 – 9 ].

Including pregnant and lactating women and people as research participants is vital: pregnancy is a unique physiological state where the body undergoes adaptations that can lead to pregnancy-specific disorders or worsen preexisting conditions [ 10 ]. These changes can influence how effective a drug is, whether and how the body responds to the drug, and the dosages at which the drug is optimally effective and minimally harmful. Most pregnant women take at least 1 medication during pregnancy [ 11 ], yet many of these medications are provided with limited information on efficacy, appropriate dosing, and safety in these populations [ 1 ]. Pregnant and lactating women with preexisting illnesses may also be advised to discontinue medications to minimise potential harms, without full appreciation of the possible consequences of unmedicated disease progression [ 12 ].

The current state of maternal health and the limited therapeutic options available for pregnant and lactating populations illustrates the consequences of these evidence gaps. Each year, complications of pregnancy and childbirth result in approximately 287,000 maternal deaths [ 13 ], 1.9 million stillbirths [ 14 ], and 2.3 million neonatal deaths [ 15 ]. Most of these deaths occur from preventable or treatable obstetric causes (e.g., postpartum haemorrhage, preeclampsia/eclampsia, sepsis) that are generally treated using repurposed medications that were originally developed and approved for use in other non-obstetric conditions [ 16 ]. Over the past 3 decades, only 2 drugs have been registered to specifically treat pregnancy-related complications: Atosiban—a tocolytic to prevent preterm birth, and Carbetocin—an oxytocin analogue for managing postpartum haemorrhage [ 17 ]. Pregnancy-specific medicines rarely progress through the research and development pipeline due to a multitude of factors, including the absence of public stewardship, chronic underinvestment, and regulatory and market barriers [ 18 , 19 ]. Maternal mortality rates have largely remained static in the Sustainable Development Goal era: progress has halted or reversed in 150 countries [ 13 ]. Without significant investments in pharmaceutical development, the 2030 target of a global maternal mortality ratio less than 70 maternal deaths per 100,000 live births [ 20 ] is unlikely to be achieved.

Poor representation of pregnant and lactating women and people in clinical research, and the absence of a pregnancy-focused research and development agenda violates fundamental ethical principles of justice and equity [ 12 , 21 ]. Challenges to equitable inclusion operate across all research stages: “upstream” barriers include a lack of appropriate animal models, pharmaceutical industry risk aversion, and clinical trials and liability insurance challenges [ 12 , 18 , 22 , 23 ]. “Downstream” barriers include perceptions that pregnant and lactating women do not want to take part in clinical trials, or that their inclusion makes research activities too risky or onerous [ 23 ]. Overall, there is a lack of a comprehensive understanding of the full range of these factors from the perspectives of key stakeholder groups. This mixed-methods systematic review seeks to address this gap by synthesising current research evidence on factors (i.e., barriers and facilitators) affecting the participation of pregnant and lactating women in vaccine and therapeutic clinical trials. We use behavioural [ 24 , 25 ] frameworks to provide a theory-informed basis for the development and implementation of appropriate behaviour change intervention strategies to promote their meaningful inclusion.

This review is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( S1 Appendix ), Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement ( S2 Appendix ), and based on guidance from the Cochrane Effective Practice and Organisation of Care group [ 26 ]. The protocol has been registered (PROSPERO: CRD42023462449).

Types of studies

We included primary qualitative, quantitative, and mixed-methods studies. There were no limitations on publication date, language, or country.

We excluded publications that were not primary research, including conceptual scholarship on the ethics of inclusion/exclusion, case reports, reviews, commentaries, short communications, editorials, news articles, letters to the editor, conference abstracts, workshop summaries, theses or dissertations, book chapters, book reviews, and regulatory or committee guidance or decisions.

Topic of interest

This review focuses on systematically identifying the factors, including barriers and facilitators, influencing the participation of pregnant and lactating women in drug or vaccine trials (i.e., therapeutic or prophylactic trials). We recognise that people who are capable of pregnancy have diverse gender identities. We use the terminology “pregnant and lactating women,” acknowledging that empirical literature on this topic has been focused on the experiences of cisgender women. Extrapolating these data to apply to people with other gender identities may lead to inaccurate or incomplete conclusions.

We included studies that described the attitudes, perspectives, and experiences of multiple stakeholders: women who participated and declined participation in clinical trials during pregnancy and lactation, partners or husbands, family members, community leaders, health workers, research staff, study investigators, ethics committee members, regulators, funders, pharmaceutical representatives, policy makers, and other relevant stakeholders.

We excluded the following types of interventions from this review: (a) lifestyle or behavioural interventions; (b) trials of diagnostics or medical devices; (b) workforce interventions to improve clinical care outcomes; (c) alternative or complementary medicine; (d) trials evaluating health policies or clinical protocols; (e) fetal tissue research, bio-banking, and genetic testing; (f) facilitators and barriers to engaging pregnant women in observational research; (g) supports to clinicians or pregnant or lactating women regarding decision-making on medication; and (h) research solely focused on substance use prevention and treatment, due to the particularly distinct barriers and facilitators given overlapping vulnerabilities among substance-using pregnant women, and unique considerations in relation to fetal health such as in utero exposure to alcohol and other substances. We also excluded clinical trial protocols and publications of randomised controlled trials that did not contain data related to facilitators or barriers to trial participation.

Search methods for identification of relevant studies

We searched 8 databases from inception to 14 February 2024: MEDLINE (Ovid), CINAHL Complete, Family & Society Studies Worldwide, SocINDEX, Scopus, Web of Science Core Collection, Embase (Ovid), and Global Health (Ovid). PC, an Information Specialist developed the final search strategy ( S3 Appendix ), using a combination of terms relevant to pregnant and lactating women, and perspectives and experiences of stakeholders regarding their inclusion/exclusion and participation in drug or vaccine clinical trials. No restrictions were placed on publication year, language, or geographical setting.

Selection of studies

We imported the search results into Covidence [ 27 ] and removed duplicates. Five review authors (MS, AH, MAB, AM, and AA) independently screened titles and abstracts. Titles and abstracts of non-English publications were screened with the assistance of Google Translate. Three reviewers (MS, AH, and AM) independently reviewed full texts. One French publication that met the inclusion criteria was translated to English using ChatGPT [ 28 ], and translation accuracy was subsequently verified with a native French speaker in our research network. At each screening stage, differences in decisions regarding record inclusion were resolved through discussion and final decisions were made through consensus with a third review author (MAB).

Data extraction and assessing methodological limitations

Two review authors (MS and AH) extracted relevant data, including study aims, methodological characteristics, geographical settings, population of interest (pregnant women, lactating women, or both), intervention type (therapy or vaccine), specific areas of research, and study findings (author-generated themes, supporting explanations, participant quotes, survey results, and relevant tables and figures). We developed a data extraction form and refined it by extracting data from a subset of 6 studies. All extracted data was cross-checked for accuracy and completeness, and differences resolved via consensus.

Two reviewers (MS and AH) independently assessed the methodological limitations of each study using an adapted Mixed Methods Appraisal Tool (MMAT) [ 29 ]. For qualitative studies, evaluative criteria included alignment of methodology and data collection with research aims, rigour in data analysis and reporting of study findings, ethical considerations, and researcher reflexivity. We assessed quantitative studies based on the suitability of sampling strategy, reporting on sample representativeness, use of appropriate measures, level of nonresponse bias, ethical considerations, and relevance of statistical analyses conducted. In addition to the aforementioned criteria, we assessed mixed-methods studies to determine whether authors demonstrated sufficient rationale for the use of a mixed-methods approach, effectiveness of integration of study components and outputs, and discussion of data triangulation. All differences in assessments between the 2 review authors were resolved through discussion. The assessment of methodological limitations did not affect the inclusion or exclusion of studies but rather served as a mechanism for determining confidence in the evidence.

Data analysis and synthesis

We used a thematic synthesis approach to analyse qualitative data [ 30 ]. After selecting 6 data-rich studies, 2 reviewers (MS and AH) independently applied line-by-line coding to the textual data to create summative codes. Codes were discussed for consistency in meaning and refined if necessary. The remaining studies were each coded by one of the 2 reviewers, and new codes were added as necessary. Through discussion, we subsumed codes of similar meaning under broader categories, gradually developing “summary layers” in a hierarchical grouping structure. We applied the gender domains of the gender analysis matrix [ 31 ] as a lens to our findings to understand how our data on factors influencing participation were shaped by aspects such as distribution of labour and roles, gender norms and beliefs, access to resources, decision-making power, and institutional policies. We consolidated our results into a set of 5 overarching themes and 24 review findings through an iterative process of identifying, comparing, and discussing conceptual boundaries between and among thematic data outputs.

Two review authors (MS and AH) used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach [ 32 , 33 ] to assess our confidence in each of the 24 qualitative review findings. GRADE-CERQual assesses confidence in the evidence, based on the following 4 key components [ 26 ]:

  • methodological limitations of included studies [ 34 ];
  • coherence of the review finding [ 35 ];
  • adequacy of the data contributing to the review finding [ 36 ]; and
  • relevance of the included studies to the review question [ 37 ].

After assessing each component, we made a judgement via consensus about the overall confidence—rated as high, moderate, low, or very low—in the evidence supporting the review finding [ 32 ]. Detailed descriptions of the GRADE-CERQual assessments are in S4 Appendix .

We then mapped data from the quantitative studies onto the findings of the qualitative evidence synthesis, and determined areas of convergence or divergence, and whether any additional factors arose that had previously not been discussed. We regarded the quantitative data as (a) “supporting” of a qualitative evidence synthesis finding if the information synthesised from the contributory quantitative studies were similar to the finding; (b) “extending” if the data offered additional details in line with a review finding; and (c) “contradictory” if the data conflicted with a review finding. Summaries of the quantitative findings are presented in S5 Appendix .

Finally, we mapped our review findings to the Theoretical Domains Framework (TDF) [ 24 ] and the Capability, Opportunity, and Motivation (COM-B) [ 25 ] models of behavioural determinants and the Behaviour Change Wheel (BCW) to identify and provide a rational basis for the development and implementation of appropriate behaviour change strategies.

Review team and reflexivity

The review author team has diverse personal backgrounds, including gender, personal experiences of pregnancy, countries of origin and residence, and linguistic traditions. Our professional and academic backgrounds and experiences are varied, and include the social, behavioural, and biomedical sciences, medicine, clinical epidemiology, and public health. Some review authors have led and implemented trials in maternal and perinatal health. As an interdisciplinary team with diverse social and professional backgrounds, we maintained a reflexive stance through all stages of the review process by engaging in multiple reflective dialogues to interrogate and interpret the data and findings. Through this process, we named and critiqued assumptions that underpinned the analysis and challenged disciplinary biases. In doing so, we aimed to develop review findings that were inclusive of different disciplinary lenses.

Sixty papers from 53 studies met the inclusion criteria [ 38 – 97 ]. Fig 1 presents the PRISMA flowchart. Table 1 reports the summary characteristics of included papers and S6 Appendix includes more detailed individual characteristics of the included papers.

thumbnail

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

https://doi.org/10.1371/journal.pmed.1004405.g001

thumbnail

https://doi.org/10.1371/journal.pmed.1004405.t001

Description of papers

Thirty-nine papers used qualitative methodologies [ 39 , 40 , 42 – 48 , 53 , 54 , 56 – 66 , 69 , 70 , 72 – 74 , 78 , 81 , 82 , 84 – 87 , 89 – 92 , 96 ], 18 papers used quantitative methodologies [ 38 , 41 , 50 – 52 , 67 , 68 , 71 , 75 – 77 , 79 , 80 , 88 , 93 – 95 , 97 ], and 3 papers used mixed-methods study designs [ 49 , 55 , 83 ].

The 60 papers present data from 27 countries and 4 geographic regions: 13 countries in Africa [ 44 – 47 , 65 , 73 , 78 , 84 , 85 ], 8 countries in Europe [ 38 , 39 , 41 , 48 – 50 , 53 – 56 , 58 , 59 , 61 , 62 , 64 , 67 – 69 , 72 , 74 , 80 – 83 , 86 , 89 , 90 , 92 , 94 , 96 ], 3 countries in the Americas [ 42 , 43 , 51 , 52 , 57 , 60 , 63 , 66 , 70 , 71 , 75 , 77 , 79 , 85 , 88 , 91 , 93 , 95 ], and 3 countries in the Western Pacific [ 40 , 76 , 87 , 97 ].

Fifty-one papers focused on pregnant women only [ 38 – 41 , 44 , 47 – 50 , 52 , 53 , 55 – 70 , 72 – 94 , 97 ], 2 papers focused on lactating women only [ 46 , 96 ], and 7 papers focused on pregnant and lactating women [ 42 , 43 , 45 , 51 , 54 , 71 , 95 ]. Thirty-seven papers addressed a therapeutic drug-related intervention [ 38 , 40 , 41 , 44 – 49 , 53 , 56 , 59 – 62 , 66 , 69 , 70 , 72 , 73 , 77 , 79 – 90 , 92 , 93 , 96 , 97 ], 11 papers focused on a vaccine-related intervention [ 50 , 51 , 55 , 57 , 58 , 63 , 64 , 67 , 68 , 78 , 94 ], and 12 papers were about pregnant and/or lactating women’s participation in interventional clinical trials generally [ 39 , 42 , 43 , 52 , 54 , 65 , 71 , 74 – 76 , 91 , 95 ].

Twenty-five papers included perspectives of pregnant women [ 38 , 45 , 47 , 48 , 51 , 57 , 58 , 60 , 61 , 64 , 65 , 67 , 71 – 75 , 77 , 85 , 89 – 91 , 94 , 95 , 97 ], 28 papers included perspectives of postpartum women [ 39 – 41 , 44 – 46 , 49 , 51 , 56 , 57 , 59 , 62 , 63 , 69 – 71 , 74 , 79 – 87 , 92 , 95 ], and 14 papers included health workers’ perspectives [ 44 , 47 , 50 , 52 – 54 , 61 , 64 , 65 , 67 , 87 , 88 , 91 , 94 ]. For other stakeholder groups, please refer to Table 1 .

Methodological limitations of included studies

Assessments of methodological limitations of the included studies are available in S7 Appendix . Across qualitative studies, the most common methodological limitations concerned recruitment approaches and strategies, descriptions of analytical methods, ethical considerations, specifically steps or precautions taken to protect from loss of privacy and confidentiality, data security and integrity, and most studies did not include a reflexivity statement. Across quantitative studies, authors rarely reported on indicators of sample representativeness of the target population, most did not report on or were judged at high risk of nonresponse bias, and ethical considerations pertaining to data security and integrity were frequently missing. For the 3 mixed-methods studies, limitations were identified at the level of integrating methodological approaches at the methods, interpretation, and reporting levels.

Themes and findings from the qualitative and quantitative evidence synthesis

We developed 5 overarching themes and 24 review findings in the qualitative evidence synthesis ( Table 2 ):

  • interplay between perceived risks and benefits of participation in women’s decision-making (9 review findings);
  • engagement between women and the medical and research ecosystems (2 review findings);
  • gender norms and decision-making autonomy (3 review findings);
  • factors affecting clinical trial recruitment (7 review findings); and
  • upstream factors in the research ecosystem (3 review findings).

thumbnail

https://doi.org/10.1371/journal.pmed.1004405.t002

We graded 6 review findings as high confidence, 11 as moderate confidence, and 7 as low confidence. An explanation for each GRADE-CERQual assessment is presented in the evidence profile ( S4 Appendix ).

Interplay between perceived risks and benefits of participation in women’s decision-making

Findings 1 to 9 are categorised under this theme with 48 studies exploring women’s perspectives on clinical trial participation and factors influencing their decision-making. These factors include balancing risks and benefits, experiences and expectations of high quality care, understanding of study design features, acceptability and stigma associated with the intervention, altruistic motivations and financial incentives.

Finding 1 : Women have a limited appetite and higher perception of risk during pregnancy or lactation . Perception of risks influenced pregnant and lactating women’s willingness to participate in trials, which varied based on their individual levels of risk tolerance, previous trial experiences, observations of others’ experiences, stage of pregnancy or lactation, existing health conditions, and a sense of responsibility for their health and that of the fetus/infant. Women were more likely to decline participation if the experimental intervention was previously untested and were more confident to participate when convinced of no harm (high confidence) [ 39 , 40 , 47 , 48 , 57 , 58 , 60 , 63 – 65 , 69 , 72 , 74 , 83 , 84 , 87 , 89 , 91 , 92 , 96 ].

The most salient factors affecting perceptions of risk were concerns of potential harm to the fetus or baby, including in the longer term, and fears of side-effects [ 39 , 48 , 57 , 58 , 60 , 63 , 69 , 72 , 74 , 83 , 84 , 87 , 89 , 91 , 92 , 96 ]. The uncertainty of these negative outcomes contributed to women’s reluctance to take medications [ 48 , 64 , 69 , 72 ] or participate in experimental interventions, with some likening the experience to being treated as “guinea pigs” [ 39 , 56 , 58 , 69 , 90 ]. Women willing to consider participation wanted proof of safety from previous research evidence [ 57 , 58 , 84 ], online resources [ 96 ], discussions with research staff and health workers [ 96 ], and knowing the experiences of others who had taken the intervention [ 47 , 96 ].

Quantitative evidence supported the qualitative findings that women were apprehensive about taking an experimental product during pregnancy or lactation [ 79 ] primarily due to concerns of fetal or infant harm [ 38 , 51 , 67 , 71 , 75 , 83 , 94 , 95 ], side-effects [ 77 , 80 ], and the possibility of unknown longer-term negative sequelae [ 67 , 75 , 77 ]. Prior knowledge of the health condition [ 68 ], information about drug safety in pregnant and nonpregnant populations [ 51 ], and information that large numbers of pregnant women had already enrolled in the trial [ 67 ] were factors that increased willingness to participate.

Finding 2 : Making trade-offs between risk and severity of the condition and risk-benefit ratio of intervention . Before participating, women weighed the risk of their medical condition and its impact, especially on the baby, against the risks of an intervention and its potential benefits. Women were less likely to participate if they felt healthy or perceived themselves at low risk of experiencing or being negatively affected by the condition, believed they had nothing to gain from participating, or felt concerned that the intervention risks were too high (moderate confidence) [ 39 , 48 , 57 – 60 , 63 , 64 , 69 , 72 , 74 , 87 , 91 , 96 ].

Women were more willing to participate when they had concerns about their risk factors [ 70 ], had previously experienced the condition [ 48 , 70 ], or personally knew someone who had [ 48 ], were anxious about the baby suffering health problems [ 57 – 60 ], or perceived the intervention to be helpful based on past use [ 87 ], or the only course of action to avoid (further) ill-health [ 57 – 59 , 63 , 91 ]. For some women with preconceived notions that research entailed significant risks, their perceptions did not change in the presence of information, including about intervention safety [ 48 ].

Quantitative evidence supported the qualitative findings that, when coupled with risks that were considered minimal or manageable [ 83 ], women with greater knowledge about [ 83 ] or direct exposure to the condition [ 94 ] were more likely to participate in a vaccine or therapeutic trial. However, prior exposure to the medical condition did not consistently lead to higher participation in trials [ 51 ].

Finding 3 : Benefits to health arising from participation . A key motivating factor for pregnant and lactating women to participate in trials was the expectation of personal health benefits, such as improved knowledge about how the condition affected them, protecting their fetus or infant from harm, and reducing mother-to-child disease transmission. When women saw the potential for these benefits, deciding not to participate was viewed as potentially putting the baby’s life at risk (high confidence) [ 40 , 47 , 55 , 60 , 61 , 63 , 64 , 70 , 73 , 83 , 84 , 87 , 90 – 92 , 96 ].

Quantitative evidence supported this finding that women were more willing to participate in a trial when they were convinced about the potential short and longer-term benefits of the intervention for the health of the fetus [ 38 , 51 , 75 , 77 , 80 ], and their own health [ 38 , 41 , 51 , 75 , 80 , 95 ] and education [ 41 , 95 ].

Finding 4 : Experiences and expectations of high-quality care motivate participation . Pregnant and lactating women were motivated to participate as a token of appreciation to health workers who provided good quality care. Additionally, women were more likely to participate when they perceived that it would result in higher quality clinical care or access to vaccines or therapeutic products that had previously been denied or were otherwise not accessible outside the context of a trial (high confidence) [ 39 , 48 , 49 , 60 , 63 , 70 , 72 , 83 , 84 , 86 , 87 , 92 , 96 ].

In addition to free medications and vaccines, women’s perceptions of higher quality care were linked to greater frequency of diagnostic and monitoring tests [ 72 , 83 , 84 , 92 ], detailed information regarding care provided [ 63 ], and closer and continuous clinical observation [ 49 , 63 , 70 , 92 ]. Occasionally, women perceived care associated with a trial as lower quality due to the “experimental” nature of the intervention [ 39 ].

Quantitative evidence supported the qualitative finding that women expected trial participation to engender more and better quality care through enhanced monitoring [ 38 , 41 , 67 , 68 , 80 ], more tests [ 67 ], better therapeutic treatment [ 38 , 49 ], and the general feeling of being provided a high standard of medical care [ 51 , 75 , 80 ].

Finding 5 : Knowledge of the rationale for study design features . The rationale behind certain trial design features such as randomisation, blinding or inclusion of a placebo arm could be a source of confusion, concern, or reassurance for potential participants, impacting their decisions to participate. These features could be viewed as preferential treatment of one group over another, adding burden with little opportunity for personal benefit, a mechanism to reduce bias or conversely for researchers to avoid accountability for an adverse outcome (moderate confidence) [ 39 , 40 , 45 , 59 , 62 , 63 , 69 , 72 , 74 , 87 , 91 , 92 ].

Quantitative evidence extended understanding of women’s views about participation in placebo-controlled trials. Some women expressed reluctance to participate due to the possibility of being assigned to the control or placebo group [ 67 , 77 , 79 , 83 ]. However, others expressed that the uncertainty of assignment would not affect their decision, and for a minority, the possibility of assignment to the control condition motivated their participation as it could minimise risk but still provide ancillary benefits [ 67 ]. Women were keen to be unblinded regarding the arm to which they were assigned, once the trial was complete [ 80 ].

Finding 6 : Acceptability of the intervention is key to pregnant and lactating women’s willingness to participate in a trial and for research staff to recruit for a trial . Interventions that were most acceptable to women and research staff were those that simplified intervention delivery, were less onerous or painful than usual care, had negligible risk, were noninvasive, placed limited demands on time, did not involve invasive procedures, and where prior knowledge about the condition intersected with positive attitudes towards the therapeutic product (high confidence) [ 40 , 45 , 48 , 53 , 54 , 61 , 64 , 65 , 72 , 73 , 81 , 83 , 86 , 87 , 90 – 92 , 96 ].

For health workers involved in recruitment and trial operations, acceptability of the intervention was closely linked to their perceptions of the safety of the experimental therapy, derived from previous positive experiences administering the drug in a different clinical setting [ 53 ].

Quantitative evidence supported this qualitative finding that some women might be more willing to participate in a trial when they were less likely to be inconvenienced by or experience discomfort from trial procedures, additional and lengthy study visits [ 38 , 41 , 80 ]. Decliners cited blood tests, additional scans, and availability of suitable noninvasive alternatives as reasons for nonparticipation [ 51 , 83 ]. In the case of vaccine trials, quantitative data extended this qualitative finding by suggesting that women indicated greater acceptability of inactivated virus vaccines compared to live-attenuated virus vaccines [ 51 ].

Finding 7 : Fears around data sharing and use . Some women feared that trial participation, including provision of blood samples, could expose them to stigmatisation and judgement due to unwanted diagnoses and disclosure of disease status, data sharing regarding sensitive behaviours, and the threat of their data being used in ways that would compromise confidentiality and safety (low confidence) [ 65 , 85 , 86 ]. In the context of HIV trials, some women discussed concerns that an HIV diagnosis would lead to abandonment by their husbands [ 85 ].

No quantitative evidence was identified in this domain.

Finding 8 : Altruistic motivations . Pregnant women expressed willingness to participate in trials for the purpose of contributing to societal benefits of research, including the potential to improve health and healthcare for pregnant women in the future. Altruistic motivations could act as a stand-alone stimulus, secondary to or alongside beliefs around personal benefit, or conditional on no additional risk for participation (moderate confidence) [ 39 , 40 , 47 , 48 , 55 – 61 , 63 , 64 , 70 , 72 – 74 , 83 , 86 , 87 , 89 , 91 , 92 ].

In addition to helping other women, altruistic sentiments were linked to perceptions that the research effort was worthy [ 48 , 59 , 61 ], well-intentioned [ 61 ], filled an important scientific gap [ 58 , 70 , 72 ], and addressed a pressing need [ 48 , 63 , 73 , 91 ].

Quantitative evidence supported the qualitative finding that altruistic motivations influenced willingness to participate in trials, alongside personal benefits [ 38 , 41 , 49 , 51 , 67 , 77 , 80 , 95 ]. Women expressed having a sense of fulfilment that participation would have a positive impact on women’s health in the future.

Finding 9 : Financial incentives . Pregnant and lactating women had mixed attitudes to financial incentives for research participation. Some viewed financial incentives as acceptable, with higher remuneration as an appropriate strategy to encourage participation, whereas others viewed financial incentives as potentially coercive, especially in the context of poverty. Some women felt that financial reimbursements did not play a substantial role in women’s decision-making (low confidence) [ 39 , 55 , 65 , 83 , 96 ].

Negative views on renumeration arose from concerns that financial incentives would entice women to enrol multiple times [ 65 ], or make it challenging for them to withdraw from the study [ 39 ].

Quantitative evidence extended this qualitative finding by suggesting that attitudes to financial compensation differed based on levels of education attainment [ 97 ]. In one study, less than 1 in 10 women discussed that financial incentives would increase their likelihood of participation in medication or vaccine-based research [ 75 ], whereas in another, 4 in 10 women agreed that they volunteered to participate due to financial compensation [ 41 ].

Engagement between women and the medical and research ecosystems

Findings 10 and 11 are categorised under this theme, with 34 contributing studies examining factors operating at the intersection of women and the medical and research ecosystems. The factors include women’s reliance on health workers’ clinical opinions to assist decision-making, and the role of therapeutic hope and optimism in women’s decisions to participate and health worker and research staffs’ motivations to administer trials.

Finding 10 : Roles of trust and power in the medical and research ecosystem . Pregnant and lactating women’s willingness to participate in trials was driven by trust, confidence, and faith in medicine and research, and women relied on the opinions of the health workers that they consulted with regarding the efficacy and safety of the intervention. Simultaneously, power imbalances between women and health workers, coupled with women’s therapeutic misconceptions, could lead to coercion in participation. This ethical dilemma was recognised by study investigators, ethics committee members, and women, especially in the context of the dual roles of clinician-researchers; however, power and credibility when combined with good rapport and clear communication generated trust to participate or comfort to decline. While rare, some women had larger concerns about the vested interests of pharmaceutical companies (high confidence) [ 39 , 40 , 42 – 45 , 47 – 49 , 56 – 61 , 65 , 69 , 70 , 72 – 74 , 81 , 82 , 86 , 87 , 89 , 91 , 92 ].

Quantitative data supported the qualitative finding that trust (or lack thereof) in health workers, research teams, and pharmaceutical companies affected participation [ 38 , 51 , 75 , 95 ]. Some women felt pressured to participate by health workers and were disappointed by the lack of an individualised approach to recruitment [ 80 ]. Among decliners of a vaccine trial, some noted that recommendations from a health worker could motivate a change of mind [ 51 ].

Finding 11 : The role of therapeutic hope and optimism . Therapeutic hope and optimism played a critical role for health workers and research staff to administer trials, and for pregnant and lactating women to participate in trials. Prior knowledge about and experience with using the intervention, observation of potential beneficial effects, and trust in health workers shaped feelings of therapeutic hope and optimism. However, for some women, a lack of understanding of the differences between research and clinical care when combined with therapeutic hope led to therapeutic misconceptions and unmet expectations about the personal benefits arising from trial participation (moderate confidence) [ 42 , 45 , 47 , 53 , 65 , 70 , 74 , 81 , 82 , 87 ].

Health workers expressed the importance of women and themselves comprehending the differences between research and clinical care to minimise participation arising from therapeutic misconceptions [ 47 ].

Gender norms and decision-making autonomy

Findings 12 to 14 are categorised under this theme with 24 contributing studies discussing women’s roles as mothers and caregivers, mixed perceptions of women’s autonomous decision-making, and intimate male partner involvement in decision-making.

Finding 12 : Expectations of women’s roles as mothers and caregivers . Pregnant and lactating women’s decisions to participate in clinical trials were often influenced by their strong sense of responsibility towards the health and care of their fetus or infant, themselves, and their families. This sense of responsibility was endorsed and reinforced by familial and societal expectations of what it means to be a good mother (low confidence) [ 60 , 61 , 64 , 91 , 96 ].

For some women, this responsibility to protect their baby translated to not engaging in any actions that might risk jeopardising the baby’s health [ 91 ].

Finding 13 : Role of bodily autonomy in decision-making . Some women, health workers, ethics committee members, and regulators perceived that pregnant women might not be able to make decisions by themselves about trial participation due to fetal involvement, inability to make rational choices during pregnancy, hormones, the stressful context of hospitalisation and financial inducements. However, research staff and some women believed in the right to bodily autonomy to make decisions by themselves despite having discussions with partners, family members, support persons, or health workers. Women viewed other people making decisions regarding their participation as a violation of this right, though some women declined participation due to pressure from family members (moderate confidence) [ 39 , 40 , 43 , 47 , 54 , 56 , 72 , 74 , 81 , 82 , 85 , 87 , 90 , 92 ].

Women also believed that research could be an avenue through which women demanded their rights in the healthcare [ 65 ].

Quantitative evidence supported qualitative findings that women believed in their capability to make decisions regarding trial participation, with some doing so autonomously and others receiving support from family members [ 38 , 83 ].

Finding 14 : Relationship dynamics , gender roles , and norms are key to women’s attitudes to partner involvement and paternal consent . Pregnant women often discussed the benefits and risks of trial participation with their partners—especially in the context of fetal involvement—and their final decision may or may not have been influenced by their partners’ own attitudes. In some settings, pregnant women’s trial participation was contingent on partners’ buy-in, and the formality justified in the context of gender norms and roles. These could be the partner being the household head, to allay men’s suspicions about women’s whereabouts and interactions, and to minimise any misunderstanding related to positive tests or disease status that might cast doubt on women’s fidelity to their husbands (moderate confidence) [ 39 , 40 , 42 , 43 , 47 , 60 , 64 , 65 , 69 , 72 , 74 , 81 , 83 , 85 , 87 , 90 , 91 ].

Partner involvement was not preferred when that partner was abusive or uninvolved, or when a woman was unmarried, or the pregnancy had occurred in the context of rape [ 85 ]. Furthermore, imposing a paternal consent rule in these circumstances was a serious barrier to participation [ 85 ]. When research participation violated gender roles and norms, it sometimes resulted in partner violence, marital breakdown, or rejection of the baby [ 85 ].

Factors affecting clinical trial recruitment

Findings 15 through 21 are categorised under this theme with 41 contributing studies exploring the importance of cultural acceptability and safety of intervention procedures, development of reciprocal relationships between research staff and health workers, the importance of resource availability, trial visibility and emotional orientations, and woman-centred approach to recruitment.

Finding 15 : Developing trusting and reciprocal relationships with the community as part of the research process . Designing and embedding research within communities required engaging with community norms, beliefs, and practices. Some community members expressed how they viewed research negatively in the context of historical and ongoing oppressions that people experience due to colonisation, corruption, extractive practices, and civil and political conflict. Central to the acceptability and cultural safety of the research were investments in developing trusting relationships with community representatives and leaders (moderate confidence) [ 44 , 45 , 60 , 65 , 66 , 74 , 78 , 83 , 90 , 92 ].

This was achieved through dialogue and engagement starting at research conceptualisation, collaborating with community representatives and previous research participants to develop communication and mobilisation strategies, providing accurate information about study procedures, and ensuring alignment of these procedures with community norms, beliefs, and practices.

Finding 16 : Increasing visibility and awareness of the trial . Increasing visibility and awareness of the trial to potential participants, health workers, and community representatives influenced trial recruitment. Recommended strategies included paper and electronic promotional materials, regular physical presence of research staff in the areas where recruitment was taking place, and reminders to health workers about recruitment pathways and trial protocols through trainings (low confidence) [ 54 , 62 , 65 , 74 , 87 ].

Quantitative evidence extended the qualitative finding that women preferred to have information about trials through their health workers [ 67 ].

Finding 17 : Inadequate resources . Inadequate physical infrastructure, time, finances, and insufficient quantity and quality of human resources were barriers for research staff to recruit women for clinical trials. For health workers specifically, heavy workloads made it challenging to incorporate trial recruitment into clinical workflows, and the added burden and sometimes insufficient compensation, contributed to poor morale (low confidence) [ 44 , 54 , 55 , 62 , 87 , 89 ].

In terms of competency of human resources, research staff shared that their recruiting capability was built through practice and working alongside more experienced colleagues [ 54 ]. A key limiting factor in the recruitment of women from non-English speaking backgrounds was the unavailability of interpreters [ 87 ].

Quantitative evidence similarly reported that lack of infrastructure and limited time due to heavy workloads for health workers were barriers to including pregnant women in trials [ 50 , 67 , 88 ].

Finding 18 : Engaging health workers in trials . Research staff perceived the importance of building reciprocal and collaborative relationships with health workers because some acted as gatekeepers. Some health workers, however, were reluctant to engage women in clinical trials due to a lack of knowledge about trial design and the research value, varying levels of acceptability of risk, perceived obligation to protect women, and a lack of trust in the research team. Health workers supported inclusion when trial protocols included close monitoring of risks and when there was clinical equipoise alongside therapeutic hope in the trial intervention. These factors were informed by their clinical knowledge, previous clinical experiences using the intervention, and observed outcomes in the current trial (high confidence) [ 47 , 53 – 55 , 60 , 62 , 64 , 65 , 87 , 89 – 91 ].

Quantitative evidence supported qualitative findings that knowledge of the relevance, feasibility, and ethical obligations to include pregnant and lactating women in trials, perceptions that pregnant women were a vulnerable population, lack of interest in trials, and preferences for noninvasive treatment were factors influencing whether health workers encouraged pregnant women’s clinical trial participation [ 50 , 52 , 67 , 88 , 94 , 95 ].

Finding 19 : Research staff’s emotional orientations towards clinical trials . Having a sense of trial ownership, supportive teamwork, a shared sense of team achievement and motivation to achieve recruitment targets could support successful trial recruitment. However, feeling pressured by the recruitment process, seeing it as a procedural activity and needing to implement complex study designs impacted research staffs’ ability to recruit women, leading to frustration and lower enthusiasm (low confidence) [ 53 , 54 , 62 ].

Finding 20 : Women-centred approach encourages participation . Women valued an individualised, humanised, and transparent approach to communication, and adequate time during trial recruitment to discuss details and concerns related to the trial. These helped ensure they had sufficient capacity and opportunity to make informed decisions. Similarly, research staff found that approaching potential participants at the “right time” and in an appropriate manner by considering their physical and mental state, providing adequate information and engaging in discussions increased recruitment success (moderate confidence) [ 39 , 40 , 54 , 56 , 62 , 66 , 69 , 70 , 72 , 74 , 86 , 87 , 92 ].

To support an individualised recruitment approach, research staff reviewed obstetric information from women’s charts [ 54 , 86 ] and had discussions with health workers [ 86 ] to tailor the recruitment information to women’s personal situations. They also discussed using intuition to determine when and whom to approach for trial participation [ 54 ], considering the extent to which women looked sick or unwell at the time of recruitment [ 86 ].

Quantitative data supported this qualitative finding of women noting the significance of having detailed and well-explained trial information, including about risks and benefits, and adequate time to make decisions regarding participation [ 80 , 95 ]. Some women expressed disappointment when they felt they had been ill-informed about study procedures by research staff [ 80 ].

Finding 21 : Recruitment for intrapartum research . Pain, intensity, and duration of labour motivated pregnant women to participate in intrapartum clinical trials. However, women, their partners, and research staff recognised the challenges in ensure women make informed decisions during this sensitive time, as decisions had to be made quickly, and partners were reluctant to make decisions on women’s behalf, even during emergencies, due to fears of negative outcomes. To optimise women making informed decisions, research staff provided information clearly and succinctly during the intrapartum period and tried to offer adequate time for decision-making. Most women recommended having trial information provided in the antenatal period, and revisiting trial details, including having a de-briefing about one’s own experience, prior to discharge (moderate confidence) [ 43 , 49 , 56 , 59 , 61 , 62 , 81 , 82 , 86 , 91 ].

Quantitative data extended this qualitative finding with most ethics committee members considering consent in-labour as ethical. Factors that ethics committee members considered when approving labour trials, included the level of risk involved and women’s ability to provide informed consent [ 76 ]. Most ethics committee members also supported the involvement of partners in the consent process [ 76 ]. Aligned with the qualitative data, women expressed a preference to be approached for a labour trial earlier to have adequate time for discussion and an informed decision [ 79 , 80 ].

Upstream factors affecting the research ecosystem

Findings 22 to 24 are categorised under this theme with 13 studies discussing factors operating at the level of study investigators, ethics committees, and funders. The factors include study investigators’ personal and professional motivations to pursue research with pregnant women, complexities in obtaining ethical approval, and limited interest of funders to support clinical trials with pregnant and lactating women.

Finding 22 : Factors affecting motivation of study investigators . The underlying factors that motivated many study investigators to conduct research with pregnant women were ethical responsibility, passion towards equity, and dedication to improving women’s health status and care, and filling scientific gaps. Additionally, lived experience of being pregnant, having mentors in this area in early careers, and previous research experiences with pregnant women contributed to study investigators’ motivations. However, concerns about risks of teratogenicity demotivated some investigators (moderate confidence) [ 42 , 43 , 66 , 78 , 89 , 91 ].

Finding 23 : Challenges in gaining ethical approvals for trials with pregnant women . While some regulators, ethics committee members, and study investigators strongly support inclusion of pregnant women in clinical trials, most stakeholders start from a presumption of minimal risk to the fetus. This results in women’s exclusion, especially in the context of poor public stewardship, ambiguous guidelines, insufficient data on intervention safety, complexities and subjectivities in risk assessment, poor agreement on appropriate trial design, time-consuming ethical processes, and concerns about reputation (moderate confidence) [ 42 , 43 , 66 , 78 , 82 , 89 – 91 ].

Study investigators and ethics committee members reported that these challenges could be overcome through shared institutional commitment to pregnant women’s inclusion, close collaboration between investigators and ethics committee members from protocol inception, mutual understanding about each other roles, responsibilities, and intentions, development and implementation of practical guidance for consistency in regulatory interpretation and risk assessment, safety monitoring during implementation, and safeguards for injury compensation [ 42 , 66 , 78 , 89 , 91 ].

Quantitative evidence supported qualitative findings that obtaining regulatory approval for clinical trials that include pregnant women was challenging [ 88 ] due to ethics committees’ preference for observational studies over trials [ 93 ], and varied opinions on the inclusion of pregnant women and what constituted minimal risk [ 76 , 93 ]. Most ethics committee members were also aware that they did not have adequate policy or guidance to inform their decisions to ensure equitable subject selection [ 76 , 93 ].

Finding 24 : Role of funders . Limited interest of public and private funders and pharmaceutical companies to financially invest in trials due to the ethical complexities, potential for adverse events, liability, and possibility of political fallout was a barrier to conduct trials with pregnant and lactating women. When funding was available, funders’ requests might facilitate the inclusion of pregnant women or create ethical challenges in conducting trials (low confidence) [ 54 , 62 , 66 , 78 ].

Mapping review findings to TDF, COM-B, and potential implementation strategies

Table 3 presents the mapping of review findings to the applicable TDF [ 24 ] and COM-B model domains [ 25 ], and the BCW intervention types to inform proposed strategies that address these factors. The strategies that we have identified are designed to provide a theoretically informed guide to the types of actions that can be taken to address barriers at various levels associated with different stakeholder groups. Which actions are appropriate for a given context should therefore be discussed, prioritised, and adapted to a particular setting.

thumbnail

https://doi.org/10.1371/journal.pmed.1004405.t003

Some of these strategies may already be in place as part of ethical conduct for trial recruitment, for example, sharing information transparently with potential participants about safety, risks, benefits, and side effects of the trial intervention (BCW intervention type: education). Given pregnant and lactating women’s concerns around risks of the intervention, such strategies can be enhanced through personalised discussions about how the intervention relates to women’s personal and clinical circumstances, for example, using a decision-aid tool (BCW intervention type: enablement). Developing clear and context-specific ways to explain study design features in plain language, and involvement of trusted sources (such as health workers), to communicate trial information can aid the decision-making process. Engaging with patient advocates and women’s groups and conducting formative research with potential participants to receive feedback on acceptability of trial components can streamline trial procedures and enhance acceptability and contextual alignment. Considerations should include how societal and gender norms, and gender roles impact various aspects of participation.

Given potential concerns among health workers regarding safety of interventions during pregnancy, providing access to credible resources on the risks, benefits and potential side-effects of the product being trialled, and elaborating on the trial rationale, potential benefits, and where the trial fits into existing evidence can help address fear and uncertainty regarding intervention safety (BCW intervention type: education, training).

At the health systems-level, strategies include creating a research-friendly environment within health facilities. In addition to promoting buy-in from hospital leadership, this would include infrastructural enhancements such as creating research spaces within health facilities (e.g., offices, meeting rooms, labs, data storage, research information systems), and hiring and training research support staff (e.g., research midwives), among other aspects.

Strategies to promote alignment between study investigators and ethics committee members include: educating ethics committee members about the health consequences of excluding pregnant women from research, and useful approaches for monitoring and managing risks associated with trial inclusion (BCW intervention type: education); developing a shared institutional commitment to inclusion of pregnant women research as the standard, and developing a common understanding of regulatory guidelines and associated documentation such as standard operating procedures, worksheets, and checklists to facilitate consistency in guideline application by institutional ethics committees and researchers.

This review provides a comprehensive overview of the range of factors affecting the participation of pregnant and lactating women in clinical trials across the research ecosystem. At the upstream levels, we identified barriers arising from limited interest of funders to invest in clinical trials with pregnant and lactating women, and reluctance of ethics committees to approve protocols due to potential for risks, particularly to fetal health. Factors at the interface between health systems and communities included developing trusting and reciprocal relationships among community members, research staff, and healthcare workers, and taking a woman-centred approach to recruitment. For women, determining the risk-benefit ratio of participation, trust (or lack thereof) in medicine and research, the potential to access high-quality care through trial participation, and altruistic motivations were key factors. Incorporating a gender lens to the data, we found that participation was impacted by gender relations of power sustained by gender norms, gender role expectations of women as mothers and caregivers, and mixed opinions regarding bodily and decisional autonomy during pregnancy.

Our findings on factors influencing pregnant women’s decisions regarding participation are aligned with those identified by Van der Zande and colleagues [ 98 ] who found that the potential for personal benefits alongside altruistic motivations were crucial drivers, while participation burdens, risks, and mistrust in research were key barriers to participation. Some of these findings, such as the role of altruism and potential for personal benefit, concerns about randomisation and other study design features, burdensome trial procedures, fears associated with taking an experimental therapy, and health worker attitudes towards trials are also consistent with the broader literature on factors associated with trial participation [ 99 – 101 ]. Across the findings, women and research staff emphasised the importance of a woman-centred approach to trial recruitment, with careful consideration of women’s individual clinical and personal circumstances, transparency in information, and support for informed and unhurried decision-making. These aspects were found to be challenging to navigate in intrapartum trials, given the timing of recruitment coinciding with birth, often in the context of impending or ongoing complications. For example, a recent analysis of uterotonic trials for prevention of postpartum haemorrhage found considerable variability between trials in the timing of informed consent—most obtained consent during labour, with a minority in the antenatal period [ 102 ]. Our findings suggest that women prefer consent in the antenatal period to optimise informed and unhurried decision-making. However, there are ethical concerns about seeking antenatal consent as it may exclude participation of women who do not regularly access antenatal care [ 102 ]. Indeed, the informed consent process in intrapartum trials is an issue of current debate and ethical interest [ 103 ], and more empirical work is needed to understand women’s preferences and needs to optimise informed decision-making.

We found that healthcare workers’ engagement was crucial in recruiting women as they play a vital role in bridging communication between potential participants and research staff. Many studies reported that women relied on health workers advice in making decisions about participation. Health workers in turn encouraged or discouraged participation based on their own attitudes towards clinical research in pregnancy and knowledge about or personal experience using the therapy under investigation. Given the roles of trust and power in women’s decision-making processes, it is important to promote transparent and open communication between women and health workers regarding trials, and their associated risks and benefits [ 104 , 105 ]. It is also important to clarify differences between clinical trial and regular clinical care to minimise the potential for therapeutic misconceptions, the consequences of which could lead to the eroding of trust in the medical system, affecting future health-seeking behaviour.

The complicated issue of autonomy in decision-making during pregnancy was raised by multiple stakeholders. Many women discussed trial participation with their partners and other family members but considered the final decision to be their own. In some settings, usually in the context of rigid gender norms, women required partners’ permission to participate; if violated, this could result in the threat of violence or marital discord. Separately, the imposition of a paternal consent requirement was viewed as a significant barrier for women who were in unstable relationships, unmarried, or wanted to exercise fully autonomous decision-making. Widmer and colleagues [ 102 ] argue that it is the role of research staff to guarantee and protect women’s autonomy. We found that women’s decisional autonomy was impacted by intimate partner relationship dynamics, and wider sociocultural and gender norms that required nuanced understandings of the context and multistakeholder engagement to create an enabling environment for women to exercise choice.

We also identified barriers experienced by researchers, ethics committees, and funders of clinical trials. Study investigators had trouble obtaining ethical approval as ethics committees have mixed perspectives on the inclusion of pregnant and lactating women in trials, particularly in the absence of clear guidelines. In line with previously reported upstream barriers [ 16 , 23 ], limited interest in funding clinical trials with pregnant and lactating women due to potential risks, high liability, and reputational consequences also inhibits the implementation of trials. These findings demonstrate a need to develop holistic strategies addressing barriers experienced by stakeholders operating at the upstream levels of clinical research.

The TDF and COM-B mapping in our review (Table 3) can be used by study investigators, research staff, health workers, ethics committees, and funders to inform the development of implementation strategies to address barriers to pregnant and lactating women’s participation in clinical trials. Formative research to identify specific barriers and facilitators in specific settings and contexts is a recommended starting point before developing appropriate strategies.

A limitation is that we did not include grey literature, which may have expanded the types of evidence and/or contexts of the review. However, our search strategies yielded high coverage of published literature. The studies included in the review had good coverage of countries from the African region, but sparse representation of countries from Latin America, and no representation of countries in the Eastern Mediterranean or South-East Asian regions. A growing number of trials addressing maternal and perinatal health are being implemented in these settings [ 106 ], calling for significantly greater focus in formative and process evaluation research with pregnant and lactating women and people, family members, health workers, local researchers, and ethics committee members to understand context-specific motivations for and concerns regarding conduct of and participation in research during pregnancy and lactation. The AIM-Gender project [ 107 ] aims to address this limitation through qualitative research on the topic in India and Nigeria—2 countries that together account for 37% of global maternal deaths [ 13 ]. Future work must also consider inclusion of pregnancy-capable transgender and nonbinary people, as knowledge gaps regarding factors affecting their participation in pregnancy and lactation clinical research are particularly pronounced. We also draw attention to 2 relevant reviews on factors affecting participation of racial and ethnically marginalised populations in pregnancy and lactation research, a related topic that was beyond the scope of this review [ 108 , 109 ].

Our review builds on previous work [ 98 ] by examining the full range of factors and perspectives of multiple stakeholders operating at the upstream and downstream levels of the research ecosystem. We optimised the available data by including qualitative, quantitative, and mixed-methods primary research. We applied the GRADE-CERQual approach to assess confidence in each finding, i.e., the extent to which the finding adequately represented the phenomenon of interest [ 32 , 33 ]. These assessments have important practical implications for increasing the applicability and usability of these findings by stakeholders seeking to enhance research and development in maternal health. This review additionally integrates the use of behavioural frameworks [ 24 , 25 ] to propose a theory-informed set of behaviour change interventions to address factors affecting clinical trial participation among pregnant and lactating women.

Supporting information

S1 appendix. preferred reporting items for systematic reviews and meta-analyses (prisma) reporting checklist..

https://doi.org/10.1371/journal.pmed.1004405.s001

S2 Appendix. Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) reporting checklist.

https://doi.org/10.1371/journal.pmed.1004405.s002

S3 Appendix. Search strategies.

https://doi.org/10.1371/journal.pmed.1004405.s003

S4 Appendix. GRADE-CERQual evidence profile.

https://doi.org/10.1371/journal.pmed.1004405.s004

S5 Appendix. Summaries of quantitative findings.

https://doi.org/10.1371/journal.pmed.1004405.s005

S6 Appendix. Characteristics of included papers.

https://doi.org/10.1371/journal.pmed.1004405.s006

S7 Appendix. Critical appraisal.

https://doi.org/10.1371/journal.pmed.1004405.s007

Acknowledgments

We are grateful to Alessandra Fleurent at Concept Foundation for her assistance with verifying the accuracy of the translated French paper included in this review.

  • View Article
  • PubMed/NCBI
  • Google Scholar
  • 12. Task Force on Research Specific to Pregnant Women and Lactating Women. Report to Secretary, Health and Human Services, Congress. 2018. Available from: https://www.nichd.nih.gov/sites/default/files/2018-09/PRGLAC_Report.pdf .
  • 13. World Health Organization. Trends in maternal mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023. 9240069259.
  • 14. UN Inter-agency Group for Child Mortality Estimation. Never forgotten–the situation of stillbirth around the globe. New York: United Nations Children’s Fund; 2023.
  • 15. UN Inter-agency Group for Child Mortality Estimation. Levels and trends in child mortality: Report 2022 estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation. New York: United Nations Children’s Fund; 2023.
  • 17. Bhattacharya S. Safe and effective medicines for use in pregnancy: A call to action. Birmingham: University of Birmingham, 2021. Available from: https://www.birmingham.ac.uk/documents/college-mds/centres/bctu/21560-policy-commission-maternal-health-report.pdf .
  • 18. Concept Foundation. Market challenges and potential solutions for the development and introduction of medicines for pregnancy specific conditions. Geneva Concept Foundation; 2021. Available from: https://www.conceptfoundation.org/wp-content/uploads/2023/04/Maternal-health-medicines-market.pdf .
  • 20. U. N. General Assembly. Transforming our world: The 2030 Agenda for Sustainable Development. New York: United Nations; 2015.
  • 27. Veritas Health Innovation. Covidence systematic review software [internet]. 2023.
  • 28. OpenAI. Chatgpt. 2023.
  • 29. Hong QN, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M, et al. Mixed Methods Appraisal Tool (MMAT), version 2018. Registration of copyright (#1148552), Canadian Intellectual Property Office, Industry Canada. 2018.
  • 107. Concept Foundation. Accelerating innovation for mothers—AIM Gender. 2023 [cited 2023 Nov 10]. Available from: https://www.conceptfoundation.org/accelerating-innovation-for-mothers/aim-gender/ .

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • View all journals
  • My Account Login
  • Explore content
  • About the journal
  • Publish with us
  • Sign up for alerts
  • Open access
  • Published: 02 June 2024

Point prevalence of evidence-based antimicrobial use among hospitalized patients in sub-Saharan Africa: a systematic review and meta-analysis

  • Minyahil Tadesse Boltena   ORCID: orcid.org/0000-0002-5081-1480 1 , 2 ,
  • Mirkuzie Wolde 1 , 3 ,
  • Belachew Hailu 2 ,
  • Ziad El-Khatib 4 ,
  • Veronika Steck 5 ,
  • Selam Woldegerima 6 ,
  • Yibeltal Siraneh 1 &
  • Sudhakar Morankar 1  

Scientific Reports volume  14 , Article number:  12652 ( 2024 ) Cite this article

Metrics details

  • Health care
  • Medical research

Excessive and improper use of antibiotics causes antimicrobial resistance which is a major threat to global health security. Hospitals in sub-Saharan Africa (SSA) has the highest prevalence of antibiotic use. This systematic review and meta-analysis aimed to determine the pooled point prevalence (PPP) of evidence-based antimicrobial use among hospitalized patients in SSA. Literature was retrieved from CINAHL, EMBASE, Google Scholar, PubMed, Scopus, and Web of Science databases. Meta-analysis was conducted using STATA version 17. Forest plots using the random-effect model were used to present the findings. The heterogeneity and publication bias were assessed using the I 2  statistics and Egger’s test. The protocol was registered in PROSPERO with code CRD42023404075. The review was conducted according to PRISMA guidelines. A total of 26, 272 study participants reported by twenty-eight studies published from 10 countries in SSA were included. The pooled point prevalence of antimicrobial use in SSA were 64%. The pooled estimate of hospital wards with the highest antibiotic use were intensive care unit (89%). The pooled prevalence of the most common clinical indication for antibiotic use were community acquired infection (41%). The pooled point prevalence of antimicrobial use among hospitalized patients were higher in SSA. Higher use of antibiotics was recorded in intensive care units. Community acquired infection were most common clinical case among hospitalized patients. Health systems in SSA must design innovative digital health interventions to optimize clinicians adhere to evidence-based prescribing guidelines and improve antimicrobial stewardship.

Similar content being viewed by others

systematic review of research utilization

Pharmacist-led antimicrobial stewardship programme in a small hospital without infectious diseases physicians

systematic review of research utilization

RETRACTED ARTICLE: Pharmacist-driven antimicrobial stewardship program in a long-term care facility by assessment of appropriateness

systematic review of research utilization

Secular trend analysis of antibiotic utilisation in some hospitals in Southern Sichuan from 2010 to 2020

Introduction.

Global antibiotic consumption rates surged by 46%, indicating that the defined daily dose (DDD) per 1000 population per day rose from 9.8 to 14.3 between 2000 and 2018 1 . In low- and middle-income countries (LMICs), antibiotic usage increased by 76% and is projected to continue rising by 2030 2 . Hospitals in SSA have a higher prevalence of antibiotic usage (50%), including the use of broad-spectrum cephalosporins and penicillin 3 .

With improving economies and enhanced access to pharmaceuticals, many of LMICs now revealed antibiotic consumption rates comparable to or even surpassing those of high-income countries 4 . Sub-Saharan African countries are experiencing a similar trend in antibiotic consumption, which could be exacerbated by the region’s exceptionally high infectious disease burden 5 . This sharp rise in antibiotic usage with or without prescription, has become a pressing public health concern due to its strong association with the development of antimicrobial resistance in low resource clinical context 6 , 7 .

The misuse and overuse of antibiotics have led to increased rates of antimicrobial resistance, higher levels of morbidity and mortality, and escalated healthcare costs in low-income countries 8 , 9 . To address this issue, evaluating antibiotic prescribing patterns among patients in healthcare facilities is essential in identifying opportunities for antimicrobial stewardship to promote appropriate antibiotic use 10 , 11 .

Point prevalence studies have proven to be reliable and valid methods for measuring antibiotic use among hospitalized patients 12 . They provide crucial insights into the current state of antibiotic use within healthcare settings, aiding in the identification of patterns and deviations from recommended practices 13 . This data can inform targeted interventions to improve guideline adherence, optimize antibiotic selection, dosing, and duration, and reduce inappropriate prescriptions 14 , 15 . By promoting evidence-based clinical decisions, these studies contribute to the prevention of antibiotic overuse, the emergence of antimicrobial resistance, and the enhancement of patient outcomes, thus serving as a vital tool in advancing the quality and effectiveness of real-world healthcare practices 16 , 17 .

In sub-Saharan Africa, several point prevalence studies have reported a high rate of antibiotic use among hospitalized patients, along with inappropriate usage in healthcare facilities 18 . However, there is limited regional-level data available to describe the point prevalence of antibiotic use among hospitalized patients in SSA 19 . Understanding the epidemiology of antibiotic use in this context and assessing the quality of antibiotic prescribing are critical steps in designing effective antimicrobial stewardship interventions aimed at encouraging the rational use of antibiotics and improving clinical outcomes for patients 20 . Therefore, this systematic review and meta-analysis aimed to determine the pooled point prevalence of antibiotic use among hospitalized patients in sub-Saharan Africa.

Search strategy and selection of studies

The search strategy aimed to find both published and unpublished literature. Initially, a preliminary search was conducted on the Google Scholar to identify indexed full texts or metadata of scholarly literature on the topic. We adapted key terms as needed for each database, utilizing a combination of MeSH terms and text words, employing Boolean operators “AND” and “OR” for searches in databases like CINAHL, PubMed, EMBASE, Scopus, and Web of Science ( Appendix I ). Additionally, we examined the reference lists of selected studies for potential additional sources. No restrictions were imposed based on language or publication year. After the search, all identified citations were organized and imported into EndNote version 15.0, with duplicates removed. Two independent reviewers (MTB and BH) screened titles and abstracts, and a third reviewer (ZEK) cross-checked them against the inclusion and exclusion criteria. Relevant studies meeting the criteria were obtained in full, along with their citation details. Studies reporting the point prevalence of antibiotic use among hospitalized patients in SSA, which were published from 2013 to 2023 were eligible for inclusion. Excluded were systematic reviews, Studies having participants sampled inappropriately and the setting not described in detail studies, data analysis not conducted with sufficient coverage of the identified sample, and literature from high-income countries. Two independent reviewers (MTB and BH) assessed the full text of selected citations against the inclusion criteria, with a third reviewer (LWT) conducting a double-check. Reasons for excluding studies failing to meet the inclusion criteria upon full text review were documented. Any disagreements between reviewers at each stage of the study selection process were resolved through discussion or by consulting a third reviewer. The PRISMA checklist ( Appendix II ) and flow chart was used to describe the matching pages in the manuscript with the number of articles identified, included, and excluded with justifications. The results of the search were fully reported in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram (Fig.  1 ) 21 .

figure 1

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

Operational definitions

Point prevalence survey of antimicrobial use.

Is a structured assessment done in healthcare settings to determine the percentage of patients receiving antimicrobial treatment at a particular moment 22 . Its goal is to assess the appropriateness of antimicrobial use, including choice, dosage, and duration, to enhance antimicrobial stewardship practices and combat antimicrobial resistance, ensuring effective and sustainable use of these essential medications 23 , 24 .

Evidence-based antimicrobial stewardship practice

Refers to healthcare professionals utilizing scientific evidence, clinical guidelines, and patient data to guide decisions on selecting, dosing, and timing antimicrobial treatment. Its objective is to enhance patient outcomes by reducing antimicrobial resistance and adverse effects, ensuring optimal treatment effectiveness 25 , 26 , 27 , 28 .

Data extraction

The data were extracted from included studies using the data extraction tool prepared by MTB. The tool includes variables such as the name of the author, publication year, study design, data collection period, sample size, study area, and the point prevalence of antimicrobial use. The data extraction tool contains information on the indication for antibiotic use; prevalence of antibiotic use in different wards, classes of antibiotics used, types of antibiotics used, and AWaRe classification. BH extracted the data, and LWT and MTB cross-checked the extracted data for its validity and cleanness. Authors of papers were contacted to request missing or additional data.

Data quality and risk of bias assessment

Eligible studies were critically appraised by two independent reviewers (MTB and BH). Full texts screening including the methodological quality assessment were examined using the JBI’s critical appraisal instrument for prevalence studies 29 . Studies that fulfill at least seven out of the nine domains of the JBI criteria questions were eligible for meta-analysis. The results of the critical appraisal were reported in narrative form and a table. A lower risk of bias (94%) observed after assessment ( Appendix III ). Studies with inadequate sample size, inappropriate sampling frame and poor data analysis were excluded. Articles were reviewed using titles, abstracts, and full text screening.

Data analysis

Included studies were pooled in a statistical meta-analysis using STATA version 17.0. Effect sizes were expressed as a proportion with 95% confidence intervals around the summary estimate. Heterogeneity was assessed using the standard chi-square I 2 test. A random-effects model was used. As pooled proportions from individual cross-sectional design point-prevalence studies are prone to variance instability and can violate the assumption of normality. Therefore, to address this, we did the double arcsine transformation method to stabilize variances, ensuring our meta-analysis results to be more reliable 30 . Sensitivity analyses were conducted to test decisions made regarding the included studies. Visual examination of funnel plot asymmetry ( Appendix IV ) and Egger’s regression tests were used to check for publication bias 31 . A Forest plot with 95% CI was computed to estimate the pooled point prevalence of evidence-based antimicrobial use among hospitalized patients in SSA.

Protocol registration

The review protocol has been registered in PROSPERO with protocol registration number CRD42023404075.

Ethical approval

Not applicable. Unlike primary studies, systematic reviews do not include the collection of deeply personal, sensitive, and confidential information from the study participants. Systematic reviews involve the use of publicly accessible data as evidence and are not required to seek an institutional ethics approval before commencement.

A total of 2260 articles were obtained from CINAHL, EMBASE, Google Scholar, PubMed, Scopus, and Web of Science databases. Following the removal of 605 duplicates, at the title/abstract screening phase (n = 2016) and during the full-article screening (n = 212) articles were excluded. Accordingly, 32 studies were eligible for quality assessment. Finally, 28 studies were included in this meta-analysis (Fig.  1 ).

Study characteristics

The total sample size of this systematic review was 26, 272, ranging from 113 in Malawi 32 to 4, 407 in South Africa 33 . Nine studies were reported from Nigeria 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 . Six articles were published from Ghana 43 , 44 , 45 , 46 , 47 , 48 . Four studies were reported from Kenya 49 , 50 , 51 , 52 . Equally two studies were reported from South Africa 33 , 53 and Tanzania 54 , 55 . Bennin 56 , Botswana 57 , Ethiopia 58 , Malawi 32 , and Uganda 59 reported only one study respectively (Table 1 ).

Antibiotic use by wards among hospitalized patients in sub-Saharan Africa

The use of antibiotics from highest to lowest were surgical (5764), medical (5440), intensive care (4676), obstetrics and gynecology (2410), neonatal (830), oncology (207), and orthopedic (30) wards respectively (Table 2 ).

Most commonly used antibiotics among hospitalized patients in sub-Saharan Africa

Ceftriaxone 32 , 33 , 34 , 37 , 39 , 40 , 41 , 45 , 46 , 47 , 52 , 54 , 55 , 60 , 61 , metronidazole 32 , 34 , 37 , 39 , 40 , 42 , 43 , 44 , 46 , 47 , 52 , 54 , 55 , 59 , gentamicin 33 , 34 , 37 , 39 , 46 , 47 , 52 , 54 , 55 , 59 , ampicillin 33 , 38 , 46 , 54 , 55 , 60 , and cefuroxime 37 , 40 , 42 , 44 , 45 , 46 were the most commonly used antibiotics (Table 3 ). Six studies equally reported ciprofloxacin 32 , 34 , 37 , 39 , 44 , 46 and amoxicillin-clavulanate 33 , 34 , 39 , 42 , 61 , 62 . Only three studies reported ampicillin-cloxacillin combination 39 , 54 , 59 and amoxicillin 32 , 38 , 46 as antibiotics used in hospitals in SSA (Table 3 ).

WHO AWARE classification of antibiotics used by hospitalized patients in sub-Saharan Africa

Only five studies reported antibiotics used based on the WHO’s access, watch, and reserve (AWaRe) classification 33 , 37 , 49 , 53 , 59 (Table 4 ). The most commonly used antibiotics were the access group and ranged between 46.3 and 97.9% 33 , 37 , 49 , 53 , 59 , followed by the watch and reserve group that accounted for 1.8–53.5% 33 , 37 , 49 , 53 , 59 , and 0.0–5.0% 33 , 37 , 49 , 53 , 59 respectively (Table 4 ).

Indications for antibiotic prescription among hospitalized patients in SSA

Community-acquired infection ranged from 27.7 to 61%, surgical antibiotic prophylaxis ranged from 14.6 to 45.3%, hospital-acquired infections ranged from 1.2 to 40.3%, and, medical prophylaxis ranged from 0.5 to 29.1% were the most common clinical indications (Table 5 ). Antibiotic prescription for 938 inpatients were done for unknown clinical indications (Table 5 ).

Pooled point prevalence of evidence-based use of antibiotics in SSA

The pooled point prevalence of evidence-based use of antimicrobials were 64.15% (95%CI: 58.31–69.79%) (Fig.  2 ).

figure 2

The pooled point prevalence of evidence-based use of antibiotics among hospitalized patients in sub-Saharan Africa.

The pooled prevalence of evidence-based antibiotic use in different wards in hospitals of SSA

Only seven studies from four countries reported the use of antibiotics in intensive care units 41 , 49 , 50 , 51 , 52 , 55 , 58 , ranging from 179 (66.5%) to 1565 (85.9%) (Table 3 ). The pooled point prevalence of antibiotics use in ICU were 87.90% (95% CI: 77.93–95.19%) (Fig.  3 ).

figure 3

The pooled point prevalence of evidence-based use of antibiotics in intensive care units in hospitals of sub-Saharan Africa.

The uptake of antimicrobials in medical wards ranged from 63 (19.6%) to 236 (73.5%) as reported by thirteen studies 34 , 36 , 37 , 41 , 43 , 49 , 50 , 51 , 52 , 54 , 55 , 58 , 61 from five countries (Table 3 ). The pooled prevalence of use of antibiotics in medical wards were 54.01% (95% CI: 47.24–60.71%) (Fig.  4 ).

figure 4

The pooled point prevalence of evidence-based use of antibiotics in medical wards in hospitals of sub-Saharan Africa.

Antibiotic use in obstetrics and gynecology wards ranges from 22 (6.9%) to 234 (72.9%)The pooled prevalence of antibiotics use in obstetrics and gynecology wards obtained from data extracted from eight studies published from Ethiopia 58 , Ghana 45 , Kenya 49 , 50 , 51 , 52 , and Nigeria 34 , 37 (Table 3 ), were 45.70% (95% CI: 33.04–58.64) (Fig.  5 ).

figure 5

The pooled point prevalence of evidence-based use of antibiotics in obstetrics and gynecology wards in hospitals of sub-Saharan Africa.

Five counties from hospitals in sub-Saharan Africa, including Ethiopia 58 , Ghana 61 , Kenya 49 , 50 , 51 , 52 , Nigeria 34 , 37 , 41 , and Tanzania 54 , 55 , produced twelve articles that revealed the antimicrobials uptake in surgical wards with the lowest 74 (23%) to the highest 781 (82.4%) (Table 3 ). The pooled prevalence of antibiotics use in surgical wards were 57.74% (95% CI: 48.64–66.58) (Fig.  6 ).

figure 6

The pooled point prevalence of evidence-based use of antibiotics in surgical wards in hospitals of sub-Saharan Africa.

The pooled prevalence of clinical indications for evidence-based antibiotic use in SSA

Twenty studies from seven countries in SSA such as, Botswana 57 , Ethiopia 58 , Nigeria 35 , 37 , 39 , 40 , 41 , 42 , 63 , Ghana 43 , 46 , 47 , 48 , 61 , Kenya 49 , 50 , 52 , Tanzania 54 , 55 , and Uganda 59 , reported that community- and hospital acquired infections were the most common clinical indications for antibiotics use (Table 5 ). The pooled prevalence of community- and hospital acquired infections for point of care antibiotics use were 40.99% (95% CI: 35.28–46.82%) (Fig.  7 ) and 11.15% (95% CI: 6.02–17.56%) (Fig.  8 ) respectively.

figure 7

The pooled prevalence of evidence-based use of antibiotics for community acquired infections in hospitals of sub-Saharan Africa.

figure 8

The pooled prevalence of evidence-based use of antibiotics for hospital acquired infections in hospitals of sub-Saharan Africa.

Seven countries including Botswana 57 , Ethiopia 58 , Nigeria 34 , 35 , 37 , 39 , 40 , 41 , Ghana 45 , 47 , 61 , 64 , 65 , Kenya 49 , 50 , 52 , Tanzania 54 , 66 , Malawi 32 , and Uganda 59 conducted eighteen studies which reported medical and surgical prophylaxis were the second most common clinical indications for evidence-based uptake of antimicrobials (Table 5 ). The pooled prevalence of medical—and surgical prophylaxis for antibiotics use were 11.86% (95% CI: 8.02–16.33%) (Fig.  9 ) and 28.54% (95% CI: 25.29–31.91%) (Fig.  10 ) respectively.

figure 9

The pooled prevalence of evidence-based use of antibiotics for medical prophylaxis in hospitals of sub-Saharan Africa.

figure 10

The pooled prevalence of evidence-based use of antibiotics for surgical prophylaxis in hospitals of sub-Saharan Africa.

The pooled prevalence of the use of antibiotics at point of care for unknown clinical indications reported from 15 articles conducted in five countries Ethiopia 58 , Ghana 46 , 47 , 48 , 62 , 64 , Kenya 49 , 50 , Nigeria 34 , 35 , 37 , 39 , 40 , 41 , and Tanzania 54 (Table 5 ) were 7.67% (95% CI: 4.55–11.33%) (Fig.  11 ).

figure 11

The pooled prevalence of evidence-based use of antibiotics for unknown clinical indications in hospitals of sub-Saharan Africa.

Visual funnel plots asymmetry examination and Egger’s regression tests revealed that there was no publication bias 67 .

This systematic review and meta-analysis aimed to determine the pooled point prevalence of evidence-based antimicrobial use among hospitalized patients in sub-Saharan Africa. A total of 26, 272 patients admitted to twenty-eight hospitals of ten countries in SSA were included. The pooled point prevalence of antimicrobial use at point of care was 64%. The finding of this study is higher than the antibiotic use in hospitals of Middle East (28.3%) 68 and Europe (30.5%) 69 . This could be attributed to misuse and overuse of antibiotics 70 , 71 , poor infection and disease prevention and control 72 , and, water, sanitation and hygiene practice in health-care facilities 73 , and poor surveillance of antimicrobial resistance in SSA 74 , 75 . The pooled point prevalence of antibiotic use in intensive care unit of hospitals in SSA were 89%. This finding is higher than a point prevalence of use of antimicrobials in ICUs in the United States 62.2%  76 and Poland 59.6% 77 .

The uses of antimicrobials at point of care in surgical and medical wards were 58% and 54% in SSA. The overuse or inappropriate use of antimicrobials at the point of care in medical and surgical wards can lead to antibiotic resistance 8 , which can make infections harder to treat. Moreover, unnecessary antimicrobial use can disrupt the balance of the microbiome, leading to complications like Clostridium difficile infections 78 . The pooled estimate of antibiotics used by inpatients admitted to obstetrics and gynecology wards of the hospitals in SSA were 46%. The finding of this study was higher than the antibiotic consumption in obstetrics and gynecology departments of Peruvian hospital 31% 79 . Higher antibiotic use in obstetrics and gynecology wards in SSA can be attributed to factors such as a higher prevalence of surgical procedures 80 , which often require prophylactic antibiotics to prevent post-operative infections 81 . Additionally, cases of infections related to childbirth, such as postpartum infections or complications following gynecological procedures, may necessitate antibiotic treatment in SSA 82 , 83 .

The pooled prevalence of community and hospital acquired infections in SSA were 41% and 11.15% respectively. The pooled estimate of this review was higher than a study in East Africa that reported 34% CAI 84 . This could be due to non-standardized antibiotic use in SSA. Our review result revealed that HAI in SSA were lower than the finding from LMICs 17.9% 85 .

The misuse of antibiotics in both community and hospital-acquired infections has far-reaching consequences 86 . In the community, inappropriate antibiotic use contributes to the development of antibiotic-resistant bacteria, rendering infections harder to treat and increasing healthcare costs 87 , 88 . Patients may experience treatment failures, longer hospital stays, and increased mortality rates 89 . Moreover, the continued misuse of antibiotics fuels the global crisis of antibiotic resistance, jeopardizing the effectiveness of these essential drugs for future generations 90 , 91 . In hospital settings, similar consequences are exacerbated by the potential for widespread outbreaks of antibiotic-resistant infections among vulnerable patients 92 . The resulting challenges in managing infections can strain healthcare systems, diminish the success of medical interventions, and underscore the critical need for stringent antibiotic stewardship practices to preserve the efficacy of antibiotics.

The pooled prevalence of the most common clinical indications for antibiotic use in hospitals of SSA were community acquired infection (40.99%), surgical prophylaxis (28.54%), medical prophylaxis (11.86%), and hospital acquired infection (11.15%).

This study revealed that the pooled prevalence of HAI (11.15%) is lower than the global estimate (14%) 93 . This could be attributed to inadequate infection control measures 94 , limited resources 95 , overcrowding 96 , and a higher burden of infectious diseases 97 . Poor sanitation and healthcare infrastructure can contribute to the increased risk of infections within healthcare facilities in SSA 98 .

According to this study, the pooled estimate of surgical prophylaxis is higher than Europe (16.8%) 99 and the global surgical antibiotic prophylaxis at point of care (22.8%) 17 . The surgical prophylaxis in SSA is lower than a study reported in Myanmar (34.3%) 100 . Higher surgical antibiotic prophylaxis may be attributed to surgeon’s overuse of antibiotics to mitigate infection risks in environments with higher prevalence of surgical site infections and limited access to post-operative care in SSA 101 , 102 , 103 . Surgeons may also lack awareness of appropriate guidelines, and patients may expect antibiotics due to a perception of their effectiveness 103 .

The pooled point prevalence of medical prophylaxis in this study is lower than European region (24.9%) 69 and Indonesia (47.1%) 104 . A lower point prevalence of medical prophylaxis in SSA suggests limited access and utilization of preventative medical interventions 105 . This may be indicative of healthcare system challenges, resource constraints, or insufficient awareness and education 106 , 107 . It can result in a higher disease burden, increased healthcare costs, and potentially poorer clinical and public health outcomes for the population 10 , 108 .

This review indicated that the pooled prevalence of community acquired infection is higher than a study conducted in the Middle East (16.8%) 68 . Community acquired infection in SSA according to this study were lower than Northern Ireland (66.2%) 109 . Higher prevalence of CAI could be due to lack of essential medical supplies, suboptimal sterilization procedures, and inadequate training in infection control 110 , 111 . High patient-to-nurse ratios and frequent patient turnover can further hinder the implementation of rigorous infection prevention measures, increasing the risk of infections spreading within healthcare settings 112 , 113 .

Antibiotic use for unknown clinical indications in SSA hospitals may occur due to inadequate training on antibiotic stewardship and a lack of access to timely microbiological testing 3 , 114 . Clinicians may resort to broad-spectrum antibiotics as a precautionary measure in the absence of specific diagnostic information, contributing to antibiotic misuse and resistance 114 .

The pooled point prevalence of antimicrobial use among hospitalized patients were higher in SSA. Higher use of antibiotics in intensive care unit, surgical, medical, and obstetrics and gynecology wards of hospital in SSA were recorded. Community acquired infection, surgical and medica prophylaxis, and hospital acquired infection were clinical indications reported to have the highest to lowest pooled point prevalence of antibiotics used. Health systems in SSA must design innovative interventions to optimize clinicians adhere to evidence-based prescribing guidelines and improve antimicrobial stewardship.

Implications for evidence-informed policy and clinical practice

A higher pooled point prevalence of antimicrobial use in sub-Saharan Africa implies a need for immediate policy and clinical practice interventions. Policymakers should prioritize allocation of scarce resources for antimicrobial stewardship programs and infection control measures. Innovative intervention must be in place to optimize clinicians adhere to evidence-based prescribing guidelines to combat antimicrobial resistance, reduce adverse effects, and improve patient outcomes.

Health systems in sub-Saharan Africa must emphasize the importance of leveraging clinical decision support digital health interventions to augment evidence-based antimicrobial stewardship. This evidence synthesis informs the policy decision makers to encourage the implementation of such tools to guide clinicians in evidence-based antimicrobial prescribing, reducing inappropriate use, combating resistance, and improving patient care in the context of resource constrained health system. Clinicians can benefit from real-time patient information, aiding in evidence-based prescribing and infection control efforts, significantly improving patient care. Collaboration between policymakers, clinicians, and healthcare facilities is crucial to mitigate the impact of these issues on public health.

Data availability

The datasets are available from the corresponding author on reasonable request.

Abbreviations

Antimicrobial resistance

The Armauer Hansen Research Institute

Defined daily dose

The Joanna Briggs Institute

Low- and Middle-Income Countries

Preferred reporting items for systematic reviews and meta-analyses

International prospective registry of systematic reviews

Sustainable development goal

  • Sub-Saharan Africa

The World Health Organization

Browne, A. J. et al. Global antibiotic consumption and usage in humans, 2000–18: A spatial modelling study. Lancet Planet. Health 5 , e893–e904 (2021).

Article   PubMed   PubMed Central   Google Scholar  

Klein, E. Y. et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc. Natl. Acad. Sci. U. S. A. 115 , E3463-e3470 (2018).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Siachalinga, L. et al. Current antibiotic use among hospitals in the sub-Saharan Africa region; findings and implications. Infect. Drug Resist. 2023 , 2179–2190 (2023).

Article   Google Scholar  

Versporten, A. et al. Antimicrobial consumption and resistance in adult hospital inpatients in 53 countries: Results of an internet-based global point prevalence survey. Lancet Glob. Health 6 , e619–e629 (2018).

Article   PubMed   Google Scholar  

Belachew, S. A., Hall, L. & Selvey, L. A. Non-prescription dispensing of antibiotic agents among community drug retail outlets in Sub-Saharan African countries: A systematic review and meta-analysis. Antimicrob. Resist. Infect. Control 10 , 13 (2021).

Bell, B. G., Schellevis, F., Stobberingh, E., Goossens, H. & Pringle, M. A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance. BMC Infect. Dis. 14 , 1–25 (2014).

Organization, W. H. WHO Report on Surveillance of Antibiotic Consumption: 2016–2018 Early Implementation (Springer, 2018).

Ayukekbong, J. A., Ntemgwa, M. & Atabe, A. N. The threat of antimicrobial resistance in developing countries: Causes and control strategies. Antimicrob. Resist. Infect. Control 6 , 47 (2017).

Founou, R. C., Founou, L. L. & Essack, S. Y. Clinical and economic impact of antibiotic resistance in developing countries: A systematic review and meta-analysis. PloS one 12 , e0189621 (2017).

Godman, B. et al. Strategies to improve antimicrobial utilization with a special focus on developing countries. Life 11 , 528 (2021).

Article   ADS   PubMed   PubMed Central   Google Scholar  

Majumder, M. A. A. et al. Antimicrobial stewardship: Fighting antimicrobial resistance and protecting global public health. Infect. Drug Resist. 2020 , 4713–4738 (2020).

Sartelli, M. et al. Ten golden rules for optimal antibiotic use in hospital settings: The WARNING call to action. World J. Emerg. Surg. 18 , 50 (2023).

Katyali, D., Kawau, G., Blomberg, B. & Manyahi, J. Antibiotic use at a tertiary hospital in Tanzania: Findings from a point prevalence survey. Antimicrob. Resist. Infect. Control 12 , 112 (2023).

Levy Hara, G. et al. Point prevalence survey of antibiotic use in hospitals in Latin American countries. J. Antimicrob. Chemother. 77 , 807–815 (2022).

Moulin, E. et al. Point prevalence study of antibiotic appropriateness and possibility of early discharge from hospital among patients treated with antibiotics in a Swiss University Hospital. Antimicrob. Resist. Infect. Control 11 , 66 (2022).

Charani, E. et al. Optimising antimicrobial use in humans–review of current evidence and an interdisciplinary consensus on key priorities for research. Lancet Reg. Health-Europe 2021 , 7 (2021).

Google Scholar  

Porto, A. M., Goossens, H., Versporten, A., Costa, S. F. & Group, B. G. P. W. Global point prevalence survey of antimicrobial consumption in Brazilian hospitals. J. Hospit. Infect. 104 , 165–171 (2020).

Article   CAS   Google Scholar  

Bahta, M. et al. Dispensing of antibiotics without prescription and associated factors in drug retail outlets of Eritrea: A simulated client method. PLoS One 15 , e0228013 (2020).

Ayalew, M. B. Self-medication practice in Ethiopia: A systematic review. Patient Preference Adherence 2017 , 401–413 (2017).

Acam, J., Kuodi, P., Medhin, G. & Makonnen, E. Antimicrobial prescription patterns in East Africa: A systematic review. Syst. Rev. 12 , 18 (2023).

Page, M. J. et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Int. J. Surg. 88 , 105906 (2021).

Zingg, W. et al. Antimicrobial use in acute care hospitals: National point prevalence survey on healthcare-associated infections and antimicrobial use, Switzerland, 2017. Eurosurveillance 24 , 1900015 (2019).

PubMed   PubMed Central   Google Scholar  

Vandael, E. et al. Point prevalence survey of antimicrobial use and healthcare-associated infections in Belgian acute care hospitals: Results of the Global-PPS and ECDC-PPS 2017. Antimicrob. Resist. Infect. Control 9 , 1–13 (2020).

Gugliotta, C. et al. Prevalence study on health-care associated infections and on the use of antimicrobials carried out with the light protocol of the European Centre for Disease Prevention and Control. Ann. Ig 32 , 357–367 (2020).

CAS   PubMed   Google Scholar  

Glasziou, P., Dartnell, J., Biezen, R., Morgan, M. & Manski-Nankervis, J. A. Antibiotic stewardship: A review of successful, evidence-based primary care strategies. Aust. J. Gen. Pract. 51 , 15–20 (2022).

Magin, P., Davey, A. & Davis, J. Evidence-based strategies for better antibiotic prescribing. Austral. J. Gener. Practition. 51 , 21–24 (2022).

Borek, A. J. et al. Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice. Implement. Sci. Commun. 2 , 1–16 (2021).

Mar, C. D., Hoffmann, T. & Bakhit, M. How can general practitioners reduce antibiotic prescribing in collaboration with their patients?. Austral. J. Gener. Pract. 51 , 25–30 (2022).

Migliavaca, C. B., Stein, C., Colpani, V., Munn, Z. & Falavigna, M. Quality assessment of prevalence studies: A systematic review. J. Clin. Epidemiol. 127 , 59–68 (2020).

Barker, T. H. et al. Conducting proportional meta-analysis in different types of systematic reviews: A guide for synthesisers of evidence. BMC Med. Res. Methodol. 21 , 189 (2021).

Iddagoda, M. T. & Flicker, L. Clinical systematic reviews—a brief overview. BMC Med. Res. Methodol. 23 , 226 (2023).

Bunduki, G. K., Feasey, N., Henrion, M. Y., Noah, P. & Musaya, J. Healthcare-associated infections and antimicrobial use in surgical wards of a large urban central hospital in Blantyre, Malawi: A point prevalence survey. Infect. Prevent. Practice 3 , 100163 (2021).

Skosana, P. et al. A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications. Expert Rev. Anti-infect. Therapy 19 , 1353–1366 (2021).

Abubakar, U. Antibiotic use among hospitalized patients in northern Nigeria: A multicenter point-prevalence survey. BMC Infect. Dis. 20 , 86 (2020).

Umeokonkwo, C. D. et al. Point prevalence survey of antimicrobial prescription in a tertiary hospital in South East Nigeria: A call for improved antibiotic stewardship. J. Glob. Antimicrob. Resist. 17 , 291–295 (2019).

Manga, M. et al. Empirical antibiotherapy as a potential driver of antibiotic resistance: Observations from a point prevalence survey of antibiotic consumption and resistance in Gombe, Nigeria. Afr. J. Clin. Exp. Microbiol. 22 , 273–278 (2021).

Aboderin, A. O. et al. Antimicrobial use among hospitalized patients: A multi-center, point prevalence survey across public healthcare facilities, Osun State, Nigeria. Germs 11 , 523 (2021).

Chijioke, A. N. et al. Prevalence of antimicrobial use in major hospitals in Owerri, Nigeria. EC Microbiol. 3 , 522–527 (2016).

Fowotade, A. et al. Point prevalence survey of antimicrobial prescribing in a Nigerian Hospital: Findings and implications on antimicrobial resistance. West Afr. J. Med. 37 , 216–220 (2020).

Nnadozie, U. U. et al. Patterns of antimicrobial use in a specialized surgical hospital in Southeast Nigeria: Need for a standardized protocol of antimicrobial use in the tropics. Niger. J. Med. 30 , 187–191 (2021).

Oduyebo, O. et al. A point prevalence survey of antimicrobial prescribing in four Nigerian Tertiary Hospitals. Ann. Trop. Pathol. 8 , 42 (2017).

Ogunleye, O. O. et al. A multicentre point prevalence study of antibiotics utilization in hospitalized patients in an urban secondary and a tertiary healthcare facilities in Nigeria: Findings and implications. Expert Rev. Anti-infect. Therapy 20 , 297–306 (2022).

Labi, A.-K. et al. Antibiotic use in a tertiary healthcare facility in Ghana: A point prevalence survey. Antimicrob. Resist. Infect. Control 7 , 1–9 (2018).

Labi, A.-K. et al. Antimicrobial use in hospitalized patients: A multicentre point prevalence survey across seven hospitals in Ghana. JAC-Antimicrob. Resist. 3 , 087 (2021).

Labi, A.-K. et al. Antibiotic prescribing in paediatric inpatients in Ghana: A multi-centre point prevalence survey. BMC Pediatr. 18 , 1–9 (2018).

Amponsah, O. K. O. et al. Point prevalence survey of antibiotic consumption across three hospitals in Ghana. JAC Antimicrob. Resist. 3 , 008 (2021).

Bediako-Bowan, A. A. et al. Antibiotic use in surgical units of selected hospitals in Ghana: A multi-centre point prevalence survey. BMC Public Health 19 , 1–10 (2019).

Ankrah, D. et al. Point prevalence survey of antimicrobial utilization in Ghana’s premier hospital: Implications for antimicrobial stewardship. Antibiot. Basel 2021 , 10 (2021).

Kamita, M. et al. Point prevalence survey to assess antibiotic prescribing pattern among hospitalized patients in a county referral hospital in Kenya. Front. Antibiot. 1 , 993271 (2022).

Okoth, C. et al. Point prevalence survey of antibiotic use and resistance at a referral hospital in Kenya: Findings and implications. Hosp. Pract. 1995 (46), 128–136 (2018).

Omulo, S. et al. Point-prevalence survey of antibiotic use at three public referral hospitals in Kenya. Plos one 17 , e0270048 (2022).

Momanyi, L. et al. Antibiotic prescribing patterns at a leading referral hospital in Kenya: A point prevalence survey. J. Res. Pharm. Pract. 8 , 149–154 (2019).

Skosana, P. et al. A national, multicentre, web-based point prevalence survey of antimicrobial use and quality indices among hospitalised paediatric patients across South Africa. J. Glob. Antimicrob. Resist. 29 , 542–550 (2022).

Article   CAS   PubMed   Google Scholar  

Horumpende, P. G. et al. Point prevalence survey of antimicrobial use in three hospitals in North-Eastern Tanzania. Antimicrob. Resist. Infect. Control 9 , 1–6 (2020).

Seni, J. et al. Antimicrobial use across six referral hospitals in Tanzania: A point prevalence survey. BMJ Open 10 , e042819 (2020).

Ahoyo, T. A. et al. Prevalence of nosocomial infections and anti-infective therapy in Benin: Results of the first nationwide survey in 2012. Antimicrob. Resist. Infect. Control 3 , 17 (2014).

Anand Paramadhas, B. D. et al. Point prevalence study of antimicrobial use among hospitals across Botswana; findings and implications. Expert Rev. Anti Infect. Ther. 17 , 535–546 (2019).

Fentie, A. M. et al. Multicentre point-prevalence survey of antibiotic use and healthcare-associated infections in Ethiopian hospitals. BMJ Open 12 , e054541 (2022).

Kiggundu, R. et al. Point prevalence survey of antibiotic use across 13 hospitals in Uganda. Antibiotics 11 , 199 (2022).

Kiggundu, R. et al. Point prevalence survey of antibiotic use across 13 hospitals in Uganda. Antibiot. Basel 2022 , 11 (2022).

Labi, A. K. et al. Antimicrobial use in hospitalized patients: A multicentre point prevalence survey across seven hospitals in Ghana. JAC Antimicrob. Resist. 3 , 087 (2021).

Labi, A. K. et al. Antibiotic use in a tertiary healthcare facility in Ghana: A point prevalence survey. Antimicrob. Resist. Infect. Control 7 , 15 (2018).

Abubakar, U. Point-prevalence survey of hospital acquired infections in three acute care hospitals in Northern Nigeria. Antimicrob. Resist. Infect. Control 9 , 63 (2020).

Labi, A. K. et al. Antibiotic prescribing in paediatric inpatients in Ghana: A multi-centre point prevalence survey. BMC Pediatr. 18 , 391 (2018).

Amponsah, O. K. O. et al. Point prevalence survey of antibiotic consumption across three hospitals in Ghana. JAC-Antimicrob. Resist. 3 , 008 (2021).

Seni, J. et al. Multicentre evaluation of significant bacteriuria among pregnant women in the cascade of referral healthcare system in North-western Tanzania: Bacterial pathogens, antimicrobial resistance profiles and predictors. J. Glob. Antimicrob. Resist. 17 , 173–179 (2019).

Lin, L. & Chu, H. Quantifying publication bias in meta-analysis. Biometrics 74 , 785–794 (2018).

Article   MathSciNet   PubMed   Google Scholar  

Alothman, A. et al. Prevalence of infections and antimicrobial use in the acute-care hospital setting in the Middle East: Results from the first point-prevalence survey in the region. Int. J. Infect. Dis. 101 , 249–258 (2020).

Plachouras, D. et al. Antimicrobial use in European acute care hospitals: Results from the second point prevalence survey (PPS) of healthcare-associated infections and antimicrobial use, 2016 to 2017. Euro Surveill 2018 , 23 (2018).

Mallah, N., Orsini, N., Figueiras, A. & Takkouche, B. Income level and antibiotic misuse: A systematic review and dose–response meta-analysis. Eur. J. Health Econ. 23 , 1015–1035 (2022).

Mallah, N., Orsini, N., Figueiras, A. & Takkouche, B. Education level and misuse of antibiotics in the general population: A systematic review and dose–response meta-analysis. Antimicrob. Resist. Infect. Control 11 , 24 (2022).

Barrera-Cancedda, A. E., Riman, K. A., Shinnick, J. E. & Buttenheim, A. M. Implementation strategies for infection prevention and control promotion for nurses in Sub-Saharan Africa: A systematic review. Implement. Sci. 14 , 111 (2019).

Bouzid, M., Cumming, O. & Hunter, P. R. What is the impact of water sanitation and hygiene in healthcare facilities on care seeking behaviour and patient satisfaction? A systematic review of the evidence from low-income and middle-income countries. BMJ Glob. Health 3 , e000648 (2018).

Moyo, P. et al. Prevention of antimicrobial resistance in sub-Saharan Africa: What has worked? What still needs to be done?. J. Infect. Public Health 16 , 632–639 (2023).

Kariuki, S., Kering, K., Wairimu, C., Onsare, R. & Mbae, C. Antimicrobial resistance rates and surveillance in sub-saharan africa: Where are we now?. Infect. Drug Resist. 15 , 3589–3609 (2022).

Magill, S. S. et al. Antimicrobial Use in US Hospitals: Comparison of results from emerging infections program prevalence surveys, 2015 and 2011. Clin. Infect. Dis. 72 , 1784–1792 (2020).

Article   ADS   Google Scholar  

Trejnowska, E. et al. Surveillance of antibiotic prescribing in intensive care units in Poland. Can. J. Infect. Dis. Med. Microbiol. 2018 , 14 (2018).

Patangia, D. V., Anthony Ryan, C., Dempsey, E., Paul Ross, R. & Stanton, C. Impact of antibiotics on the human microbiome and consequences for host health. Microbiol. Open 11 , e1260 (2022).

Arteaga-Livias, K. et al. Compliance with antibiotic prophylaxis in obstetric and gynecological surgeries in two peruvian hospitals. Antibiotics 12 , 808 (2023).

Eddy, K. E. et al. Factors affecting the use of antibiotics and antiseptics to prevent maternal infection at birth: A global mixed-methods systematic review. Plos one 17 , e0272982 (2022).

Vippadapu, P. et al. Choice of antimicrobials in surgical prophylaxis - overuse and surgical site infection outcomes from a tertiary-level care hospital. Front. Pharmacol. 2022 , 13 (2022).

Ngonzi, J. et al. Incidence of postpartum infection, outcomes and associated risk factors at Mbarara regional referral hospital in Uganda. BMC Pregn. Childbirth 18 , 270 (2018).

Abdel Jalil, M. H. et al. Surgical site infections following caesarean operations at a Jordanian teaching hospital: Frequency and implicated factors. Sci. Rep. 7 , 12210 (2017).

Beletew, B., Bimerew, M., Mengesha, A., Wudu, M. & Azmeraw, M. Prevalence of pneumonia and its associated factors among under-five children in East Africa: A systematic review and meta-analysis. BMC Pediatr. 20 , 254 (2020).

Murni, I. K. et al. Risk factors for healthcare-associated infection among children in a low-and middle-income country. BMC Infect. Dis. 22 , 406 (2022).

Dadgostar, P. Antimicrobial resistance: Implications and costs. Infect. Drug Resist. 12 , 3903–3910 (2019).

Prestinaci, F., Pezzotti, P. & Pantosti, A. Antimicrobial resistance: A global multifaceted phenomenon. Pathogens Glob. Health 109 , 309–318 (2015).

Erku, D. A., Mekuria, A. B. & Belachew, S. A. Inappropriate use of antibiotics among communities of Gondar town, Ethiopia: A threat to the development of antimicrobial resistance. Antimicrob. Resist. Infect. Control 6 , 112 (2017).

Chinemerem Nwobodo, D. et al. Antibiotic resistance: The challenges and some emerging strategies for tackling a global menace. J. Clin. Lab. Anal. 36 , e24655 (2022).

Aslam, B. et al. Antibiotic resistance: A rundown of a global crisis. Infect. Drug rResist. 2018 , 1645–1658 (2018).

Adebisi, Y. A. Balancing the risks and benefits of antibiotic use in a globalized world: The ethics of antimicrobial resistance. Globaliz. Health 19 , 27 (2023).

Sukhum, K. V. et al. Antibiotic-resistant organisms establish reservoirs in new hospital built environments and are related to patient blood infection isolates. Commun. Med. 2 , 62 (2022).

Raoofi, S. et al. Global prevalence of nosocomial infection: A systematic review and meta-analysis. PLoS One 18 , e0274248 (2023).

Lowe, H. et al. Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: A qualitative study. Conflict Health 15 , 94 (2021).

Spencer, S. A. et al. A health systems approach to critical care delivery in low-resource settings: A narrative review. Intens. Care Med. 49 , 772–784 (2023).

Improta, G. et al. A case study to investigate the impact of overcrowding indices in emergency departments. BMC Emerg. Med. 22 , 143 (2022).

Daw, M. A., Mahamat, M. H., Wareg, S. E., El-Bouzedi, A. H. & Ahmed, M. O. Epidemiological manifestations and impact of healthcare-associated infections in Libyan national hospitals. Antimicrob. Resist. Infect. Control 12 , 122 (2023).

Taye, Z. W., Abebil, Y. A., Akalu, T. Y., Tessema, G. M. & Taye, E. B. Incidence and determinants of nosocomial infection among hospital admitted adult chronic disease patients in University of Gondar Comprehensive Specialized Hospital, North-West Ethiopia, 2016–2020. Front. Public Health 11 , 1087407 (2023).

Zarb, P. et al. The European Centre for Disease Prevention and Control (ECDC) pilot point prevalence survey of healthcare-associated infections and antimicrobial use. Eurosurveillance 17 , 20316 (2012).

Oo, W. T. et al. Point-prevalence surveys of antimicrobial consumption and resistance at a paediatric and an adult tertiary referral hospital in Yangon, Myanmar. Infect. Prevent. Pract. 4 , 100197 (2022).

Mehtar, S. et al. Implementation of surgical site infection surveillance in low- and middle-income countries: A position statement for the International Society for Infectious Diseases. Int. J. Infect. Dis. 100 , 123–131 (2020).

Sefah, I. A. et al. Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: Findings and implications. JAC-Antimicrob. Resist. 2022 , 4 (2022).

Mwita, J. C. et al. Key issues surrounding appropriate antibiotic use for prevention of surgical site infections in low-and middle-income countries: A narrative review and the implications. Int. J. Gener. Med. 2017 , 515–530 (2021).

Karmila, A. et al. The prevalence and factors associated with prophylactic antibiotic use during delivery: A hospital-based retrospective study in Palembang, Indonesia. Antibiot. Basel 2021 , 10 (2021).

Alemu, A. Y. et al. Healthcare-associated infection and its determinants in Ethiopia: A systematic review and meta-analysis. PLoS One 15 , e0241073 (2020).

Ayed, H. B. et al. Prevalence and risk factors of health care–associated infections in a limited resources country: A cross-sectional study. Am. J. Infect. Control 47 , 945–950 (2019).

Saleem, Z. et al. Antibiotic utilization patterns for different wound types among surgical patients: Findings and implications. Antibiotics 12 , 678 (2023).

Ataiyero, Y., Dyson, J. & Graham, M. Barriers to hand hygiene practices among health care workers in sub-Saharan African countries: A narrative review. Am. J. Infect. Control 47 , 565–573 (2019).

Alahmadi, Y. et al. Point-prevalence surveys of antibiotic use and HAIs. Hospital Pharm. Europe Pharm. Pract. 84 , 27–29 (2016).

Fraser, J. L., Mwatondo, A., Alimi, Y. H., Varma, J. K. & Vilas, V. J. D. R. Healthcare-associated outbreaks of bacterial infections in Africa, 2009–2018: A review. Int. J. Infect. Dis. 103 , 469–477 (2021).

Abubakar, U., Amir, O. & Rodríguez-Baño, J. Healthcare-associated infections in Africa: A systematic review and meta-analysis of point prevalence studies. J. Pharm. Policy Pract. 15 , 99 (2022).

Gidey, K., Gidey, M. T., Hailu, B. Y., Gebreamlak, Z. B. & Niriayo, Y. L. Clinical and economic burden of healthcare-associated infections: A prospective cohort study. Plos one 18 , e0282141 (2023).

Igunma, A. & Adebudo, O. Healthcare-associated infections and control strategies. Niger. J. Med. Dental Educ. 5 , 81–87 (2023).

Sono, T. M. et al. Current rates of purchasing of antibiotics without a prescription across sub-saharan Africa; rationale and potential programmes to reduce inappropriate dispensing and resistance. Expert Rev. Anti-infective Therapy 21 , 1025–1055 (2023).

Download references

Acknowledgements

We would like to acknowledge the Ethiopian Evidence Based Health Care and Development Centre, A JBI Centre of Excellence, and the Armauer Hansen Research Institute for proving the training on comprehensive systematic review, meta-analysis, and access to databases.

Author information

Authors and affiliations.

Ethiopian Evidence Based Health Care Centre: A Joanna Briggs Institute’s Center of Excellence, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia

Minyahil Tadesse Boltena, Mirkuzie Wolde, Yibeltal Siraneh & Sudhakar Morankar

Armauer Hansen Research Institute, Ministry of Health, Addis Ababa, Ethiopia

Minyahil Tadesse Boltena & Belachew Hailu

University of Technology Sydney, Sydney, Australia

Mirkuzie Wolde

Global Public Health Department, Karolinska Institute, Solna, Sweden

Ziad El-Khatib

Department of Pharmacology and Therapeutics, Faculty of Life Sciences, McGill University, Montreal, Canada

Veronika Steck

Nuffield Department of Population Health, University of Oxford, Oxford, UK

Selam Woldegerima

You can also search for this author in PubMed   Google Scholar

Contributions

MTB and SM was involved in a principal role in the conception of ideas, developing methodologies, and writing the article. MTB, SM, MW, SWG, VS, YS, BH and ZEK were involved in the analysis, interpretation and writing. All authors involved in proofreading and writing. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Minyahil Tadesse Boltena .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary information., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Boltena, M.T., Wolde, M., Hailu, B. et al. Point prevalence of evidence-based antimicrobial use among hospitalized patients in sub-Saharan Africa: a systematic review and meta-analysis. Sci Rep 14 , 12652 (2024). https://doi.org/10.1038/s41598-024-62651-6

Download citation

Received : 06 January 2024

Accepted : 20 May 2024

Published : 02 June 2024

DOI : https://doi.org/10.1038/s41598-024-62651-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Antibiotic prescribing
  • Antimicrobial use
  • Evidence-based healthcare
  • Hospitalized patients
  • Point prevalence survey

By submitting a comment you agree to abide by our Terms and Community Guidelines . If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.

Quick links

  • Explore articles by subject
  • Guide to authors
  • Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

systematic review of research utilization

  • Systematic Review
  • Open access
  • Published: 30 May 2024

Patient experiences: a qualitative systematic review of chemotherapy adherence

  • Amineh Rashidi 1 ,
  • Susma Thapa 1 ,
  • Wasana Sandamali Kahawaththa Palliya Guruge 1 &
  • Shubhpreet Kaur 1  

BMC Cancer volume  24 , Article number:  658 ( 2024 ) Cite this article

122 Accesses

Metrics details

Adherence to chemotherapy treatment is recognized as a crucial health concern, especially in managing cancer patients. Chemotherapy presents challenges for patients, as it can lead to potential side effects that may adversely affect their mobility and overall function. Patients may sometimes neglect to communicate these side effects to health professionals, which can impact treatment management and leave their unresolved needs unaddressed. However, there is limited understanding of how patients’ experiences contribute to improving adherence to chemotherapy treatment and the provision of appropriate support. Therefore, gaining insights into patients’ experiences is crucial for enhancing the accompaniment and support provided during chemotherapy.

This review synthesizes qualitative literature on chemotherapy adherence within the context of patients’ experiences. Data were collected from Medline, Web of Science, CINAHL, PsychINFO, Embase, Scopus, and the Cochrane Library, systematically searched from 2006 to 2023. Keywords and MeSH terms were utilized to identify relevant research published in English. Thirteen articles were included in this review. Five key themes were synthesized from the findings, including positive outlook, receiving support, side effects, concerns about efficacy, and unmet information needs. The review underscores the importance for healthcare providers, particularly nurses, to focus on providing comprehensive information about chemotherapy treatment to patients. Adopting recommended strategies may assist patients in clinical practice settings in enhancing adherence to chemotherapy treatment and improving health outcomes for individuals living with cancer.

Peer Review reports

Introduction

Cancer can affect anyone and is recognized as a chronic disease characterized by abnormal cell multiplication in the body [ 1 ]. While cancer is prevalent worldwide, approximately 70% of cancer-related deaths occur in low- to middle-income nations [ 1 ]. Disparities in cancer outcomes are primarily attributed to variations in the accessibility of comprehensive diagnosis and treatment among countries [ 1 , 2 ]. Cancer treatment comes in various forms; however, chemotherapy is the most widely used approach [ 3 ]. Patients undergoing chemotherapy experience both disease-related and treatment-related adverse effects, significantly impacting their quality of life [ 4 ]. Despite these challenges, many cancer patients adhere to treatment in the hope of survival [ 5 ]. However, some studies have shown that concerns about treatment efficacy may hinder treatment adherence [ 6 ]. Adherence is defined as “the extent to which a person’s behaviour aligns with the recommendations of healthcare providers“ [ 7 ]. Additionally, treatment adherence is influenced by the information provided by healthcare professionals following a cancer diagnosis [ 8 ]. Patient experiences suggest that the decision to adhere to treatment is often influenced by personal factors, with family support playing a crucial role [ 8 ]. Furthermore, providing adequate information about chemotherapy, including its benefits and consequences, can help individuals living with cancer gain a better understanding of the advantages associated with adhering to chemotherapy treatment [ 9 ].

Recognizing the importance of adhering to chemotherapy treatment and understanding the impact of individual experiences of chemotherapy adherence would aid in identifying determinants of adherence and non-adherence that are modifiable through effective interventions [ 10 ]. Recently, systematic reviews have focused on experiences and adherence in breast cancer [ 11 ], self-management of chemotherapy in cancer patients [ 12 ], and the influence of medication side effects on adherence [ 13 ]. However, these reviews were narrow in scope, and to date, no review has integrated the findings of qualitative studies designed to explore both positive and negative experiences regarding chemotherapy treatment adherence. This review aims to synthesize the qualitative literature on chemotherapy adherence within the context of patients’ experiences.

This review was conducted in accordance with the Joanna Briggs Institute [ 14 ] guidelines for systemic review involving meta-aggregation. This review was registered in PROSPERO (CRD42021270459).

Search methods

The searches for peer reviewed publications in English from January 2006-September 2023 were conducted by using keywords, medical subject headings (MeSH) terms and Boolean operators ‘AND’ and ‘OR’, which are presented in the table in Appendix 1 . The searches were performed in a systematic manner in core databases such including Embase, Medline, PsycINFO, CINAHL, Web of Science, Cochrane Library, Scopus and the Joanna Briggs Institute (JBI). The search strategy was developed from keywords and medical subject headings (MeSH) terms. Librarian’s support and advice were sought in forming of the search strategies.

Study selection and inclusion criteria

The systematic search was conducted on each database and all articles were exported to Endnote and duplicates records were removed. Then, title and abstract of the full text was screened by two independent reviewers against the inclusion criteria. For this review, populations were patients aged 18 and over with cancer, the phenomenon of interest was experiences on chemotherapy adherence and context was considered as hospitals, communities, rehabilitation centres, outpatient clinics, and residential aged care. All peer-reviewed qualitative study design were also considered for inclusion. Studies included in this review were classified as primary research, published in English since 2006, some intervention implemented to improve adherence to treatment. This review excluded any studies that related to with cancer and mental health condition, animal studies and grey literature.

Quality appraisal and data extraction

The JBI Qualitative Assessment and Review Instrument for qualitative studies was used to assess the methodological quality of the included studies, which was conducted by the primary and second reviewers independently. There was no disagreement between the reviews. The qualitative data on objectives, study population, context, study methods, and the phenomena of interest and findings form the included studies were extracted.

Data synthesis

The meta-aggregation approach was used to combine the results with similar meaning. The primary and secondary reviewers created categories based on the meanings and concept. These categories were supported by direct quotations from participants. The findings were assess based on three levels of evidence, including unequivocal, credible, and unsupported [ 15 , 16 ]. Findings with no quotation were not considered for synthesis in this review. The categories and findings were also discussed by the third and fourth reviewers until a consensus was reached. The review was approved by the Edith Cowan University Human Research Ethics Committee (2021–02896).

Study inclusion

A total of 4145 records were identified through a systematic search. Duplicates ( n  = 647) were excluded. Two independent reviewers conducted screening process. The remaining articles ( n  = 3498) were examined for title and abstract screening. Then, the full text screening conducted, yielded 13 articles to be included in the final synthesis see Appendix 2 .

Methodological quality of included studies

All included qualitative studies scored between 7 and 9, which is displayed in Appendix 3 . The congruity between the research methodology and the research question or objectives, followed by applying appropriate data collection and data analysis were observed in all included studies. Only one study [ 17 ] indicated the researcher’s statement regarding cultural or theoretical perspectives. Three studies [ 18 , 19 , 20 ] identified the influence of the researcher on the research and vice-versa.

Characteristics of included studies

Most of studies conducted semi-structured and in-depth interviews, one study used narrative stories [ 19 ], one study used focus group discussion [ 21 ], and one study combined focus group and interview [ 22 ] to collect data. All studies conducted outpatient’s clinic, community, or hospital settings [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. The study characteristics presented in Appendix 4 .

Review findings

Eighteen findings were extracted and synthesised into five categories: positive outlook, support, side effects, concern about efficacy and unmet information needs.

Positive outlook

Five studies discussed the link between positivity and hope and chemotherapy adherence [ 19 , 20 , 23 , 27 , 28 ]. Five studies commented that feeling positive and avoid the negativity and worry could encourage people to adhere in their mindset chemotherapy: “ I think the main thing for me was just keeping a positive attitude and not worrying, not letting myself worry about it ” [ 20 ]. Participants also considered the positive thoughts as a coping mechanism, that would help them to adhere and complete chemotherapy: “ I’m just real positive on how everything is going. I’m confident in the chemo, and I’m hoping to get out of her soon ” [ 23 ]. Viewing chemotherapy as part of their treatment regimen and having awareness of negative consequences of non-adherence to chemotherapy encouraged them to adhere chemotherapy: “ If I do not take medicine, I do not think I will be able to live ” [ 28 ]. Adhering chemotherapy was described as a survivor tool which helped people to control cancer-related symptoms: “ it is what is going to restore me. If it wasn’t this treatment, maybe I wasn’t here talking to you. So, I have to focus in what he is going to give me, life !” [ 27 ]. Similarly, people accepted the medical facts and prevent their life from worsening; “ without the treatment, it goes the wrong way. It is hard, but I have accepted it from the beginning, yes. This is how it is. I cannot do anything about it. Just have to accept it ” [ 19 ].

Finding from six studies contributed to this category [ 20 , 21 , 23 , 24 , 25 , 29 ]. Providing support from families and friends most important to the people. Receiving support from family members enhanced a sense responsibility towards their families, as they believed to survive for their family even if suffered: “ yes, I just thought that if something comes back again and I say no, then I have to look my family and friends in the eye and say I could have prevented it, perhaps. Now, if something comes back again, I can say I did everything I could. Cancer is bad enough without someone saying: It’s your own fault!!” [ 29 ]. Also, emotional support from family was described as important in helping and meeting their needs, and through facilitation helped people to adhere chemotherapy: “ people who genuinely mean the support that they’re giving […] just the pure joy on my daughter’s face for helping me. she was there day and night for me if I needed it, and that I think is the main thing not to have someone begrudgingly looking after you ” [ 20 ]. Another study discussed the role family, friends and social media as the best source of support during their treatment to adhere and continue “ I have tons of friends on Facebook, believe it or not, and it’s amazing how many people are supportive in that way, you know, just sending get-well wishes. I can’t imagine going through this like 10 years ago whenever stuff like that wasn’t around ” [ 23 ]. Receiving support from social workers was particularly helpful during chemotherapy in encouraging adherence to the chemotherapy: “ the social worker told me that love is courage. That was a huge encouragement, and I began to encourage myself ” [ 25 ].

Side effects

Findings from five studies informed this category [ 17 , 21 , 22 , 25 , 26 ]. Physical side effects were described by some as the most unpleasure experience: “ the side effects were very uncomfortable. I felt pain, fatigue, nausea, and dizziness that limited my daily activities. Sometimes, I was thinking about not keeping to my chemotherapy schedule due to those side effect ” [ 17 ]. The impact of side effects affected peoples’ ability to maintain their independence and self-care: “ I couldn’t walk because I didn’t have the energy, but I wouldn’t have dared to go out because the diarrhoea was so bad. Sometimes I couldn’t even get to the toilet; that’s very embarrassing because you feel like you’re a baby ” [ 26 ]. Some perceived that this resulted in being unable to perform independently: “ I was incredibly weak and then you still have to do things and you can’t manage it ” [ 22 ]. These side effect also decreased their quality of life “ I felt nauseated whenever I smelled food. I simply had no appetite when food was placed in front of me. I lost my sense of taste. Food had no taste anymore ” [ 25 ]. Although, the side effects impacted on patients´ leisure and free-time activities, they continued to undertake treatment: “ I had to give up doing the things I liked the most, such as going for walks or going to the beach. Routines, daily life in general were affected ” [ 21 ].

Concern about efficacy

Findings form four studies informed this category [ 17 , 18 , 24 , 28 ]. Although being concerned about the efficacy of the chemotherapy and whether or not chemotherapy treatment would be successful, one participant who undertook treatment described: “the efficacy is not so great. It is said to expect about 10% improvement, but I assume that it declines over time ” [ 28 ]. People were worried that such treatment could not cure their cancer and that their body suffered more due to the disease: “ I was really worried about my treatment effectiveness, and I will die shortly ” [ 17 ]. There were doubts expressed about remaining the cancer in the body after chemotherapy: “ there’s always sort of hidden worries in there that whilst they’re not actually taking the tumour away, then you’re wondering whether it’s getting bigger or what’s happening to it, whether it’s spreading or whatever, you know ” [ 24 ]. Uncertainty around the outcome of such treatment, or whether recovering from cancer or not was described as: “it makes you feel confused. You don’t know whether you are going to get better or else whether the illness is going to drag along further” [ 18 ].

Unmet information needs

Five studies contributed to this category [ 17 , 21 , 22 , 23 , 26 ]. The need for adequate information to assimilate information and provide more clarity when discussing complex information were described. Providing information from clinicians was described as minimal: “they explain everything to you and show you the statistics, then you’re supposed to take it all on-board. You could probably go a little bit slower with the different kinds of chemo and grappling with these statistics” [ 26 ]. People also used the internet search to gain information about their cancer or treatments, “I’ve done it (consult google), but I stopped right away because there’s so much information and you don’t know whether it’s true or not ” [ 21 ]. The need to receive from their clinicians to obtain clearer information was described as” I look a lot of stuff up online because it is not explained to me by the team here at the hospital ” [ 23 ]. Feeling overwhelmed with the volume of information could inhibit people to gain a better understanding of chemotherapy treatment and its relevant information: “ you don’t absorb everything that’s being said and an awful lot of information is given to you ” [ 22 ]. People stated that the need to know more information about their cancer, as they were never dared to ask from their clinicians: “ I am a low educated person and come from a rural area; I just follow the doctor’s advice for my health, and I do not dare to ask anything” [ 17 ].

The purpose of this review was to explore patient’s experiences about the chemotherapy adherence. After finalizing the searches, thirteen papers were included in this review that met the inclusion criteria.

The findings of the present review suggest that social support is a crucial element in people’s positive experiences of adhering to chemotherapy. Such support can lead to positive outcomes by providing consistent and timely assistance from family members or healthcare professionals, who play vital roles in maintaining chemotherapy adherence [ 30 ]. Consistent with our study, previous research has highlighted the significant role of family members in offering emotional and physical support, which helps individuals cope better with chemotherapy treatment [ 31 , 32 ]. However, while receiving support from family members reinforces individuals’ sense of responsibility in managing their treatment and their family, it also instils a desire to survive cancer and undergo chemotherapy. One study found that assuming self-responsibility empowers patients undergoing chemotherapy, as they feel a sense of control over their therapy and are less dependent on family members or healthcare professionals [ 33 ]. A qualitative systematic review reported that support from family members enables patients to become more proactive and effective in adhering to their treatment plan [ 34 ]. This review highlights the importance of maintaining a positive outlook and rational beliefs as essential components of chemotherapy adherence. Positive thinking helps individuals recognize their role in chemotherapy treatment and cope more effectively with their illness by accepting it as part of their treatment regimen and viewing it as a tool for survival. This finding is supported by previous studies indicating that positivity and positive affirmations play critical roles in helping individuals adapt to their reality and construct attitudes conducive to chemotherapy adherence [ 35 , 36 ]. Similarly, maintaining a positive mindset can foster more favourable thoughts regarding chemotherapy adherence, ultimately enhancing adherence and overall well-being [ 37 ].

This review identified side effects as a significant negative aspect of the chemotherapy experience, with individuals expressing concerns about how these side effects affected their ability to perform personal self-care tasks and maintain independent living in their daily lives. Previous studies have shown that participants with a history of chemotherapy drug side effects were less likely to adhere to their treatment regimen due to worsening symptoms, which increased the burden of medication side effects [ 38 , 39 ]. For instance, cancer patients who experienced minimal side effects from chemotherapy were at least 3.5 times more likely to adhere to their treatment plan compared to those who experienced side effects [ 40 ]. Despite experiencing side effects, patients were generally willing to accept and adhere to their treatment program, although one study in this review indicated that side effects made some patients unable to maintain treatment adherence. Side effects also decreased quality of life and imposed restrictions on lifestyle, as seen in another study where adverse effects limited individuals in fulfilling daily commitments and returning to normal levels of functioning [ 41 ]. Additionally, unmet needs regarding information on patients’ needs and expectations were common. Healthcare professionals were considered the most important source of information, followed by consultation with the internet. Providing information from healthcare professionals, particularly nurses, can support patients effectively and reinforce treatment adherence [ 42 , 43 ]. Chemotherapy patients often preferred to base their decisions on the recommendations of their care providers and required adequate information retention. Related studies have highlighted that unmet needs among cancer patients are known factors associated with chemotherapy adherence, emphasizing the importance of providing precise information and delivering it by healthcare professionals to improve adherence [ 44 , 45 ]. Doubts about the efficacy of chemotherapy treatment, as the disease may remain latent, were considered negative experiences. Despite these doubts, patients continued their treatment, echoing findings from a study where doubts regarding efficacy were identified as a main concern for chemotherapy adherence. Further research is needed to understand how doubts about treatment efficacy can still encourage patients to adhere to chemotherapy treatment.

Strengths and limitation

The strength of this review lies in its comprehensive search strategy across databases to select appropriate articles. Additionally, the use of JBI guidelines provided a comprehensive and rigorous methodological approach in conducting this review. However, the exclusion of non-English studies, quantitative studies, and studies involving adolescents and children may limit the generalizability of the findings. Furthermore, this review focuses solely on chemotherapy treatment and does not encompass other types of cancer treatment.

Conclusion and practical implications

Based on the discussion of the findings, it is evident that maintaining a positive mentality and receiving social support can enhance chemotherapy adherence. Conversely, experiencing treatment side effects, concerns about efficacy, and unmet information needs may lead to lower adherence. These findings present an opportunity for healthcare professionals, particularly nurses, to develop standardized approaches aimed at facilitating chemotherapy treatment adherence, with a focus on providing comprehensive information. By assessing patients’ needs, healthcare professionals can tailor approaches to promote chemotherapy adherence and improve the survival rates of people living with cancer. Raising awareness and providing education about cancer and chemotherapy treatment can enhance patients’ understanding of the disease and its treatment options. Utilizing videos and reading materials in outpatient clinics and pharmacy settings can broaden the reach of educational efforts. Policy makers and healthcare providers can collaborate to develop sustainable patient education models to optimize patient outcomes in the context of cancer care. A deeper understanding of individual processes related to chemotherapy adherence is necessary to plan the implementation of interventions effectively. Further research examining the experiences of both adherent and non-adherent patients is essential to gain a comprehensive understanding of this topic.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. on our submission system as well.

World Health Organization. Cancer 2021 [ https://www.who.int/news-room/fact-sheets/detail/cancer .

Klapheke A, Yap SA, Pan K, Cress RDDHSDCA. Sociodemographic disparities in chemotherapy treatment and impact on survival among patients with metastatic bladder cancer. Urologic Oncology: Seminars Original Investigations. 2018;36(6):19–308.

Article   Google Scholar  

Moth EB, Kiely BE, Naganathan V, Martin A, Blinman P. How do oncologists make decisions about chemotherapy for their older patients with cancer? A survey of Australian oncologists. Support Care Cancer. 2018;26(2):451–60.

Article   CAS   PubMed   Google Scholar  

Khamboon T, Pakanta I. Intervention for symptom cluster management of fatigue, loss of appetite, and anxiety among patients with lung cancer undergoing chemotherapy. Asia-Pacific J Oncol Nurs. 2021;8(3):267–75.

Garcia ACM, Camargos Junior JB, Sarto KK, Silva Marcelo CAd, Paiva EMC, Nogueira DA, Mills J. Quality of life, self-compassion and mindfulness in cancer patients undergoing chemotherapy: a cross-sectional study. Eur J Oncol Nurs. 2021;51:N.PAG-N.PAG.

Horne R, Chapman SCE, Parham R, Freemantle N, Forbes A, Cooper V. Understanding patients’ adherence-related beliefs about Medicines prescribed for long-term conditions: a Meta-Analytic Review of the necessity-concerns Framework. PLoS ONE. 2013;8(12):e80633.

Article   PubMed   PubMed Central   Google Scholar  

WHO. Adherence to long-term therapies: evidence for action. Geneva, Switzerland: World Health Organisation; 2003.

Google Scholar  

Warby A, Dhillon HM, Kao S, Vardy JL. A survey of patient and caregiver experience with malignant pleural mesothelioma. Support Care Cancer. 2019;27(12):4675–86.

Article   PubMed   Google Scholar  

Arunachalam SS, Shetty AP, Panniyadi N, Meena C, Kumari J, Rani B, et al. Study on knowledge of chemotherapy’s adverse effects and their self-care ability to manage - the cancer survivors impact. Clin Epidemiol Global Health. 2021;11:100765.

Article   CAS   Google Scholar  

Nizet P, Touchefeu Y, Pecout S, Cauchin E, Beaudouin E, Mayol S, et al. Exploring the factors influencing adherence to oral anticancer drugs in patients with digestive cancer: a qualitative study. Support Care Cancer. 2022;30(3):2591–604.

Clancy C, Lynch J, Oconnor P, Dowling M. Breast cancer patients’ experiences of adherence and persistence to oral endocrine therapy: a qualitative evidence synthesis. Eur J Oncol Nurs. 2020;44.

Magalhães B, Fernandes C, Lima L, Martinez-Galiano JM, Santos C. Cancer patients’ experiences on self-management of chemotherapy treatment-related symptoms: A systematic review and thematic synthesis. Eur J Oncol Nurs. 2020;49.

Peddie N, Agnew S, Crawford M, Dixon D, MacPherson I, Fleming L. The impact of medication side effects on adherence and persistence to hormone therapy in breast cancer survivors: a qualitative systematic review and thematic synthesis. Breast. 2021;58:147–59.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ: Br Med J. 2009;339(7716):332–6.

Joanna Briggs Institute. The Joanna Briggs Institute critical appraisal tools for use in JBI systematic reviews. Checklist for qualitative research. 2017.

Zachary M, Kylie P, Craig L, Edoardo A, Alan P. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC Med Res Methodol [Internet]. 2014;14(1):108.

Iskandarsyah A, de Klerk C, Suardi DR, Soemitro MP, Sadarjoen SS, Passchier J. Psychosocial and cultural reasons for Delay in seeking help and Nonadherence to treatment in Indonesian women with breast Cancer: a qualitative study. Health Psychol. 2014;33(3):214–21.

Chircop D, Scerri J. The lived experience of patients with Non-hodgkin’s lymphoma undergoing chemotherapy. Eur J Oncol Nurs. 2018;35:117–21.

Kvåle K, Synnes O. Living with life-prolonging chemotherapy—control and meaning‐making in the tension between life and death. Eur J Cancer Care. 2018;27(1):1.

Staneva AA, Beesley VL, Niranjan N, Gibson AF, Rowlands I, Webb PM. I wasn’t gonna let it stop me: exploring women’s experiences of getting through chemotherapy for ovarian cancer. Cancer Nurs. 2019;42(2):E31–8.

Talens A, Guilabert M, Lumbreras B, Aznar MT, López-Pintor E. Medication Experience and Adherence to Oral Chemotherapy: A Qualitative Study of Patients’ and Health Professionals’ Perspectives. Int J Environ Res Public Health. 2021;18(8).

Dumas L, Lidington E, Appadu L, Jupp P, Husson O, Banerjee S, et al. Exploring older women’s attitudes to and experience of treatment for advanced ovarian cancer: a qualitative phenomenological study. Cancers. 2021;13(6):1207.

Albrecht TA, Keim-Malpass J, Boyiadzis M, Rosenzweig M. Psychosocial experiences of young adults diagnosed with acute leukemia during hospitalization for induction chemotherapy treatment. J Hospice Palliat Nurs. 2019;21(2):167–73.

Beaver K, Williamson S, Briggs J. Exploring patient experiences of neo-adjuvant chemotherapy for breast cancer. Eur J Oncol Nurs. 2016;20:77–86.

Chou J-F, Lu YY. Intraperitoneal chemotherapy: the lived experiences of Taiwanese patients with ovarian cancer. Clin J Oncol Nurs. 2019;23(6):E100–6.

Farrell C, Heaven C. Understanding the impact of chemotherapy on dignity for older people and their partners. Eur J Oncol Nurs. 2018;36:82–8.

Wakiuchi J, Silva Marcon S, de Oliveira DC, Aparecida Sales C. Rebuilding subjectivity from the experience of cancer and its treatment. Revista Brasileira De Enfermagem. 2019;72(1):125–33.

Yagasaki K, Komatsu H, Takahashi T. Inner conflict in patients receiving oral anticancer agents: a qualitative study. BMJ Open [Internet]. 2015; 5(4).

Gassmann C, Kolbe N, Brenner A. Experiences and coping strategies of oncology patients undergoing oral chemotherapy: first steps of a grounded theory study. Eur J Oncol Nurs. 2016;23:106–14.

Tang GX, Yan PP, Yan CL, Fu B, Zhu SJ, Zhou LQ, et al. Determinants of suicidal ideation in gynecological cancer patients. Psycho-oncology. 2016;25(1):97–103.

Oven Ustaalioglu B, Acar E, Caliskan M. The predictive factors for perceived social support among cancer patients and caregiver burden of their family caregivers in Turkish population. Int J Psychiatry Clin Pract. 2018;22(1):63–9.

Levkovich I, Cohen M, Karkabi K. The experience of fatigue in breast Cancer patients 1–12 Month Post-chemotherapy: a qualitative study. Behav Med. 2019;45(1):7–18.

Simchowitz B, Shiman L, Spencer J, Brouillard D, Gross A, Connor M, Weingart SN. Perceptions and experiences of patients receiving oral chemotherapy. Clin J Oncol Nurs. 2010;14(4):447–53.

Rashidi A, Kaistha P, Whitehead L, Robinson S. Factors that influence adherence to treatment plans amongst people living with cardiovascular disease: a review of published qualitative research studies. Int J Nurs Stud 2020;110(103727).

Aydogan U, Doganer YC, Komurcu S, Ozturk B, Ozet A, Saglam K. Coping attitudes of cancer patients and their caregivers and quality of life of caregivers. Indian J Palliat Care. 2016;22(2):150–6.

Langford DJ, Morgan S, Cooper B, Paul S, Kober K, Wright F, et al. Association of personality profiles with coping and adjustment to cancer among patients undergoing chemotherapy. Psycho-oncology. 2020;29(6):1060–7.

Jamie MJ, Pensak NA, Sporn NJ, MacDonald JJ, Lennes IT, Safren SA et al. Treatment satisfaction and adherence to oral chemotherapy in patients with Cancer. J Oncol Pract. 2017;13(2).

Tsai Y-F, Huang W-C, Cho S-F, Hsiao H-H, Liu Y-C, Lin S-F, et al. Side effects and medication adherence of tyrosine kinase inhibitors for patients with chronic myeloid leukemia in Taiwan. Medicine. 2018;97(26):415.

D S, M P, G R, S H. Importance of medication adherence and factors affecting it. IP Int J Compr Adv Pharmacolog. 2020;3(2):69–77.

Bekalu YE, Wudu MA, Gashu AW. Adherence to Chemotherapy and Associated factors among patients with Cancer in Amhara Region, Northeastern Ethiopia, 2022. A cross-sectional study. Cancer Control. 2023;30.

Hsu H-C, Liou W-S, Chiang A-J, Tsai S-Y, Jeang S-R, Wu S-L, et al. Longitudinal perceptions of the side effects of chemotherapy in patients with gynecological cancer. Support Care Cancer. 2017;25(11):3457–64.

Gow K, Rashidi A, Whithead L. Factors influencing medication adherence among adults living with diabetes and comorbidities: a qualitative systematic review. Curr Diab Rep. 2023:1–7.

Rashidi A, Whitehead L, Kaistha P. Nurses’ perceptions of factors influencing treatment engagement among patients with cardiovascular diseases: a systematic review. BMC Nurs. 2021;20(1):251.

Zebrack BJ, Block R, Hayes-Lattin B, Embry L, Aguilar C, Meeske KA, et al. Psychosocial service use and unmet need among recently diagnosed adolescent and young adult cancer patients. Cancer. 2013;119(1):201–14.

Timmers L, Boons CCLM, van den Verbrugghe M, Van Hecke A, Hugtenburg JG. Supporting adherence to oral anticancer agents: clinical practice and clues to improve care provided by physicians, nurse practitioners, nurses and pharmacists. BMC Cancer. 2017;17(1).

Download references

Acknowledgements

Not applicable.

Author information

Authors and affiliations.

School of Nursing and Midwifery, Edith Cowan University, 270 Joondalup Drive, Joondalup, Perth, WA, 6027, Australia

Amineh Rashidi, Susma Thapa, Wasana Sandamali Kahawaththa Palliya Guruge & Shubhpreet Kaur

You can also search for this author in PubMed   Google Scholar

Contributions

First author (AR) and second author (ST) conceived the review and the second author oversight for all stages of the review provided by the second author. All authors (AR), (ST), (WG) and (SK) undertook the literature search. Data extraction, screening the included papers and quality appraisal were undertaken by all authors (AR), (ST), (WG) and (SK). First and second authors (AR) and (ST) analysed the data and wrote the first draft of the manuscript and revised the manuscript and all authors (AR), (ST), (WG) and (SK) approved the final version of the manuscript.

Corresponding author

Correspondence to Amineh Rashidi .

Ethics declarations

Ethics approval and consent to participate.

The review was approved by the Edith Cowan University Human Research Ethics Committee (2021–02896). A proposal for the systematic review was assessed by the Edith Cowan University Human Research Ethics Committee and deemed not appropriate for full ethical review. However, a Data Management Plan (2021-02896-RASHIDI) was approved and monitored as part of this procedure. Raw data was extracted from the published manuscripts and authors could not identify individual participants during or after this process.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, supplementary material 3, supplementary material 4, supplementary material 5, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Rashidi, A., Thapa, S., Kahawaththa Palliya Guruge, W. et al. Patient experiences: a qualitative systematic review of chemotherapy adherence. BMC Cancer 24 , 658 (2024). https://doi.org/10.1186/s12885-024-12353-z

Download citation

Received : 17 November 2023

Accepted : 07 May 2024

Published : 30 May 2024

DOI : https://doi.org/10.1186/s12885-024-12353-z

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Chemotherapy treatment
  • Medication adherence
  • Qualitative research
  • Patients experiences

ISSN: 1471-2407

systematic review of research utilization

  • Systematic Review
  • Open access
  • Published: 24 May 2024

Turnover intention and its associated factors among nurses in Ethiopia: a systematic review and meta-analysis

  • Eshetu Elfios 1 ,
  • Israel Asale 1 ,
  • Merid Merkine 1 ,
  • Temesgen Geta 1 ,
  • Kidist Ashager 1 ,
  • Getachew Nigussie 1 ,
  • Ayele Agena 1 ,
  • Bizuayehu Atinafu 1 ,
  • Eskindir Israel 2 &
  • Teketel Tesfaye 3  

BMC Health Services Research volume  24 , Article number:  662 ( 2024 ) Cite this article

348 Accesses

Metrics details

Nurses turnover intention, representing the extent to which nurses express a desire to leave their current positions, is a critical global public health challenge. This issue significantly affects the healthcare workforce, contributing to disruptions in healthcare delivery and organizational stability. In Ethiopia, a country facing its own unique set of healthcare challenges, understanding and mitigating nursing turnover are of paramount importance. Hence, the objectives of this systematic review and meta-analysis were to determine the pooled proportion ofturnover intention among nurses and to identify factors associated to it in Ethiopia.

A comprehensive search carried out for studies with full document and written in English language through an electronic web-based search strategy from databases including PubMed, CINAHL, Cochrane Library, Embase, Google Scholar and Ethiopian University Repository online. Checklist from the Joanna Briggs Institute (JBI) was used to assess the studies’ quality. STATA version 17 software was used for statistical analyses. Meta-analysis was done using a random-effects method. Heterogeneity between the primary studies was assessed by Cochran Q and I-square tests. Subgroup and sensitivity analyses were carried out to clarify the source of heterogeneity.

This systematic review and meta-analysis incorporated 8 articles, involving 3033 nurses in the analysis. The pooled proportion of turnover intention among nurses in Ethiopia was 53.35% (95% CI (41.64, 65.05%)), with significant heterogeneity between studies (I 2  = 97.9, P  = 0.001). Significant association of turnover intention among nurses was found with autonomous decision-making (OR: 0.28, CI: 0.14, 0.70) and promotion/development (OR: 0.67, C.I: 0.46, 0.89).

Conclusion and recommendation

Our meta-analysis on turnover intention among Ethiopian nurses highlights a significant challenge, with a pooled proportion of 53.35%. Regional variations, such as the highest turnover in Addis Ababa and the lowest in Sidama, underscore the need for tailored interventions. The findings reveal a strong link between turnover intention and factors like autonomous decision-making and promotion/development. Recommendations for stakeholders and concerned bodies involve formulating targeted retention strategies, addressing regional variations, collaborating for nurse welfare advocacy, prioritizing career advancement, reviewing policies for nurse retention improvement.

Peer Review reports

Turnover intention pertaining to employment, often referred to as the intention to leave, is characterized by an employee’s contemplation of voluntarily transitioning to a different job or company [ 1 ]. Nurse turnover intention, representing the extent to which nurses express a desire to leave their current positions, is a critical global public health challenge. This issue significantly affects the healthcare workforce, contributing to disruptions in healthcare delivery and organizational stability [ 2 ].

The global shortage of healthcare professionals, including nurses, is an ongoing challenge that significantly impacts the capacity of healthcare systems to provide quality services [ 3 ]. Nurses, as frontline healthcare providers, play a central role in patient care, making their retention crucial for maintaining the functionality and effectiveness of healthcare delivery. However, the phenomenon of turnover intention, reflecting a nurse’s contemplation of leaving their profession, poses a serious threat to workforce stability [ 4 ].

Studies conducted globally shows that high turnover rates among nurses in several regions, with notable figures reported in Alexandria (68%), China (63.88%), and Jordan (60.9%) [ 5 , 6 , 7 ]. In contrast, Israel has a remarkably low turnover rate of9% [ 8 ], while Brazil reports 21.1% [ 9 ], and Saudi hospitals26% [ 10 ]. These diverse turnover rates highlight the global nature of the nurse turnover phenomenon, indicating varying degrees of workforce mobility in different regions.

The magnitude and severity of turnover intention among nurses worldwide underscore the urgency of addressing this issue. High turnover rates not only disrupt healthcare services but also result in a loss of valuable skills and expertise within the nursing workforce. This, in turn, compromises the continuity and quality of patient care, with potential implications for patient outcomes and overall health service delivery [ 11 ]. Extensive research conducted worldwide has identified a range of factors contributing to turnover intention among nurses [ 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. These factors encompass both individual and organizational aspects, such as high workload, inadequate support, limited career advancement opportunities, job satisfaction, conflict, payment or reward, burnout sense of belongingness to their work environment. The complex interplay of these factors makes addressing turnover intention a multifaceted challenge that requires targeted interventions.

In Ethiopia, a country facing its own unique set of healthcare challenges, understanding and mitigating nursing turnover are of paramount importance. The healthcare system in Ethiopia grapples with issues like resource constraints, infrastructural limitations, and disparities in healthcare access [ 18 ]. Consequently, the factors influencing nursing turnover in Ethiopia may differ from those in other regions. Previous studies conducted in the Ethiopian context have started to unravel some of these factors, emphasizing the need for a more comprehensive examination [ 18 , 19 ].

Although many cross-sectional studies have been conducted on turnover intention among nurses in Ethiopia, the results exhibit variations. The reported turnover intention rates range from a minimum of 30.6% to a maximum of 80.6%. In light of these disparities, this systematic review and meta-analysis was undertaken to ascertain the aggregated prevalence of turnover intention among nurses in Ethiopia. By systematically analyzing findings from various studies, we aimed to provide a nuanced understanding of the factors influencing turnover intention specific to the Ethiopian healthcare context. Therefore, this systematic review and meta-analysis aimed to answer the following research questions.

What is the pooled prevalence of turnover intention among nurses in Ethiopia?

What are the factors associated with turnover intention among nurses in Ethiopia?

The primary objective of this review was to assess the pooled proportion of turnover intention among nurses in Ethiopia. The secondary objective was identifying the factors associated to turnover intention among nurses in Ethiopia.

Study design and search strategy

A comprehensive systematic review and meta-analysis was conducted, examining observational studies on turnover intention among nurses in Ethiopia. The procedure for this systematic review and meta-analysis was developed in accordance with the Preferred Reporting Items for Systematic review and Meta-analysis Protocols (PRISMA-P) statement [ 20 ]. PRISMA-2015 statement was used to report the findings [ 21 , 22 ]. This systematic review and meta-analysis were registered on PROSPERO with the registration number of CRD42024499119.

We conducted systematic and an extensive search across multiple databases, including PubMed, CINAHL, Cochrane Library, Embase, Google Scholar and Ethiopian University Repository online to identify studies reporting turnover intention among nurses in Ethiopia. We reviewed the database available at http://www.library.ucsf.edu and the Cochrane Library to ensure that the intended task had not been previously undertaken, preventing any duplication. Furthermore, we screened the reference lists to retrieve relevant articles. The process involved utilizing EndNote (version X8) software for downloading, organizing, reviewing, and citing articles. Additionally, a manual search for cross-references was performed to discover any relevant studies not captured through the initial database search. The search employed a comprehensive set of the following search terms:“prevalence”, “turnover intention”, “intention to leave”, “attrition”, “employee attrition”, “nursing staff turnover”, “Ethiopian nurses”, “nurses”, and “Ethiopia”. These terms were combined using Boolean operators (AND, OR) to conduct a thorough and systematic search across the specified databases.

Eligibility criteria

Inclusion criteria.

The established inclusion criteria for this meta-analysis and systematic review are as follows to guide the selection of articles for inclusion in this review.

Population: Nurses working in Ethiopia.

Study period: studies conducted or published until 23November 2023.

Study design: All observational study designs, such as cross-sectional, longitudinal, and cohort studies, were considered.

Setting: Only studies conducted in Ethiopia were included.

Outcome; turnover intention.

Study: All studies, whether published or unpublished, in the form of journal articles, master’s theses, and dissertations, were included up to the final date of data analysis.

Language: This study exclusively considered studies in the English language.

Exclusion criteria

Excluded were studies lacking full text or Studies with a Newcastle–Ottawa Quality Assessment Scale (NOS) score of 6 or less. Studies failing to provide information on turnover intention among nurses or studies for which necessary details could not be obtained were excluded. Three authors (E.E., T.G., K.A) independently assessed the eligibility of retrieved studies, other two authors (E.I & M.M) input sought for consensus on potential in- or exclusion.

Quality assessment and data extraction

Two authors (E.E, A.A, G.N) independently conducted a critical appraisal of the included studies. Joanna Briggs Institute (JBI) checklists of prevalence study was used to assess the quality of the studies. Studies with a Newcastle–Ottawa Quality Assessment Scale (NOS) score of seven or more were considered acceptable [ 23 ]. The tool has nine parameters, which have yes, no, unclear, and not applicable options [ 24 ]. Two reviewers (I.A, B.A) were involved when necessary, during the critical appraisal process. Accordingly, all studies were included in our review. ( Table  1 ) Questions to evaluate the methodological quality of studies on turnover intention among nurses and its associated factors in Ethiopia are the followings:

Q1 = was the sample frame appropriate to address the target population?

Q2. Were study participants sampled appropriately.

Q3. Was the sample size adequate?

Q4. Were the study subjects and the setting described in detail?

Q5. Was the data analysis conducted with sufficient coverage of the identified sample?

Q6. Were the valid methods used for the identification of the condition?

Q7. Was the condition measured in a standard, reliable way for all participants?

Q8. Was there appropriate statistical analysis?

Q9. Was the response rate adequate, and if not, was the low response rate.

managed appropriately?

Data was extracted and recorded in a Microsoft Excel as guided by the Joanna Briggs Institute (JBI) data extraction form for observational studies. Three authors (E.E, M.G, T.T) independently conducted data extraction. Recorded data included the first author’s last name, publication year, study setting or country, region, study design, study period, sample size, response rate, population, type of management, proportion of turnover intention, and associated factors. Discrepancies in data extraction were resolved through discussion between extractors.

Data processing and analysis

Data analysis procedures involved importing the extracted data into STATA 14 statistical software for conducting a pooled proportion of turnover intention among nurses. To evaluate potential publication bias and small study effects, both funnel plots and Egger’s test were employed [ 25 , 26 ]. We used statistical tests such as the I statistic to quantify heterogeneity and explore potential sources of variability. Additionally, subgroup analyses were conducted to investigate the impact of specific study characteristics on the overall results. I 2 values of 0%, 25%, 50%, and 75% were interpreted as indicating no, low, medium, and high heterogeneity, respectively [ 27 ].

To assess publication bias, we employed several methods, including funnel plots and Egger’s test. These techniques allowed us to visually inspect asymmetry in the distribution of study results and statistically evaluate the presence of publication bias. Furthermore, we conducted sensitivity analyses to assess the robustness of our findings to potential publication bias and other sources of bias.

Utilizing a random-effects method, a meta-analysis was performed to assess turnover intention among nurses, employing this method to account for observed variability [ 28 ]. Subgroup analyses were conducted to compare the pooled magnitude of turnover intention among nurses and associated factors across different regions. The results of the pooled prevalence were visually presented in a forest plot format with a 95% confidence interval.

Study selection

After conducting the initial comprehensive search concerning turnover intention among nurses through Medline, Cochran Library, Web of Science, Embase, Ajol, Google Scholar, and other sources, a total of 1343 articles were retrieved. Of which 575 were removed due to duplication. Five hundred ninety-three articles were removed from the remaining 768 articles by title and abstract. Following theses, 44 articles which cannot be retrieved were removed. Finally, from the remaining 131 articles, 8 articles with a total 3033 nurses were included in the systematic review and meta-analysis (Fig.  1 ).

figure 1

PRISMA flow diagram of the selection process of studies on turnover intention among nurses in Ethiopia, 2024

Study characteristics

All included 8 studies had a cross-sectional design and of which, 2 were from Tigray region, 2 were from Addis Ababa(Capital), 1 from south region, 1 from Amhara region, 1 from Sidama region, and 1 was multiregional and Nationwide. The prevalence of turnover intention among nurses ‘ranges from 30.6 to 80.6%. Table  2 .

Pooled prevalence of turnover intention among nurses in Ethiopia

Our comprehensive meta-analysis revealed a notable turnover intention rate of 53.35% (95% CI: 41.64, 65.05%) among Ethiopian nurses, accompanied by substantial heterogeneity between studies (I 2  = 97.9, P  = 0.000) as depicted in Fig.  2 . Given the observed variability, we employed a random-effects model to analyze the data, ensuring a robust adjustment for the significant heterogeneity across the included studies.

figure 2

Forest plot showing the pooled proportion of turnover intention among nurses in Ethiopia, 2024

Subgroup analysis of turnover intention among nurses in Ethiopia

To address the observed heterogeneity, we conducted a subgroup analysis based on regions. The results of the subgroup analysis highlighted considerable variations, with the highest level of turnover intention identified in Addis Ababa at 69.10% (95% CI: 46.47, 91.74%) and substantial heterogeneity (I 2  = 98.1%). Conversely, the Sidama region exhibited the lowest level of turnover intention among nurses at 30.6% (95% CI: 25.18, 36.02%), accompanied by considerable heterogeneity (I 2  = 100.0%) ( Fig.  3 ).

figure 3

Subgroup analysis of systematic review and meta-analysis by region of turnover intention among nurses in Ethiopia, 2024

Publication bias of turnover intention among nurses in Ethiopia

The Egger’s test result ( p  = 0.64) is not statistically significant, indicating no evidence of publication bias in the meta-analysis (Table  3 ). Additionally, the symmetrical distribution of included studies in the funnel plot (Fig.  4 ) confirms the absence of publication bias across studies.

figure 4

Funnel plot of systematic review and meta-analysis on turnover intention among nurses in Ethiopia, 2024

Sensitivity analysis

The leave-out-one sensitivity analysis served as a meticulous evaluation of the influence of individual studies on the comprehensive pooled prevalence of turnover intention within the context of Ethiopian nurses. In this systematic process, each study was methodically excluded from the analysis one at a time. The outcomes of this meticulous examination indicated that the exclusion of any particular study did not lead to a noteworthy or statistically significant alteration in the overall pooled estimate of turnover intention among nurses in Ethiopia. The findings are visually represented in Fig.  5 , illustrating the stability and robustness of the overall pooled estimate even with the removal of specific studies from the analysis.

figure 5

Sensitivity analysis of pooled prevalence for each study being removed at a time for systematic review and meta-analysis of turnover intention among nurses in Ethiopia

Factors associated with turnover intention among nurses in Ethiopia

In our meta-analysis, we comprehensively reviewed and conducted a meta-analysis on the determinants of turnover intention among nurses in Ethiopia by examining eight relevant studies [ 6 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. We identified a significant association between turnover intention with autonomous decision-making (OR: 0.28, CI: 0.14, 0.70) (Fig.  6 ) and promotion/development (OR: 0.67, CI: 0.46, 0.89) (Fig.  7 ). In both instances, the odds ratios suggest a negative association, signifying that increased levels of autonomous decision-making and promotion/development were linked to reduced odds of turnover intention.

figure 6

Forest plot of the association between autonomous decision making with turnover intention among nurses in Ethiopia2024

figure 7

Forest plot of the association between promotion/developpment with turnover intention among nurses in Ethiopia, 2024

In our comprehensive meta-analysis exploring turnover intention among nurses in Ethiopia, our findings revealed a pooled proportion of turnover intention at 53.35%. This significant proportion warrants a comparative analysis with turnover rates reported in other global regions. Distinct variations emerge when compared with turnover rates in Alexandria (68%), China (63.88%), and Jordan (60.9%) [ 5 , 6 , 7 ]. This comparison highlights that the multifaceted nature of turnover intention, influenced by diverse contextual, cultural, and organizational factors. Conversely, Ethiopia’s turnover rate among nurses contrasts with substantially lower figures reported in Israel (9%) [ 8 ], Brazil (21.1%) [ 9 ], and Saudi hospitals (26%) [ 10 ]. Challenges such as work overload, economic constraints, limited promotional opportunities, lack of recognition, and low job rewards are more prevalent among nurses in Ethiopia, contributing to higher turnover intention compared to their counterparts [ 7 , 29 , 36 ].

The highest turnover intention was observed in Addis Ababa, while Sidama region displayed the lowest turnover intention among nurses, These differences highlight the complexity of turnover intention among Ethiopian nurses, showing the importance of specific interventions in each region to address unique factors and improve nurses’ retention.

Our systematic review and meta-analysis in the Ethiopian nursing context revealed a significant inverse association between turnover intention and autonomous decision-making. The odd of turnover intention is approximately reduced by 72% in employees with autonomous decision-making compared to those without autonomous decision-making. This finding was supported by other similar studies conducted in South Africa, Tanzania, Kenya, and Turkey [ 37 , 38 , 39 , 40 ].

The significant association of turnover intention with promotion/development in our study underscores the crucial role of career advancement opportunities in alleviating turnover intention among nurses. Specifically, our analysis revealed that individuals with promotion/development had approximately 33% lower odds of turnover intention compared to those without such opportunities. These results emphasize the pivotal influence of organizational support in shaping the professional environment for nurses, providing substantive insights for the formulation of evidence-based strategies targeted at enhancing workforce retention. This finding is in line with former researches conducted in Taiwan, Philippines and Italy [ 41 , 42 , 43 ].

Our meta-analysis on turnover intention among Ethiopian nurses reveals a considerable challenge, with a pooled proportion of 53.35%. Regional variations highlight the necessity for region-specific strategies, with Addis Ababa displaying the highest turnover intention and Sidama region the lowest. A significant inverse association was found between turnover intention with autonomous decision-making and promotion/development. These insights support the formulation of evidence-based strategies and policies to enhance nurse retention, contributing to the overall stability of the Ethiopian healthcare system.

Recommendations

Federal ministry of health (fmoh).

The FMoH should consider the regional variations in turnover intention and formulate targeted retention strategies. Investment in professional development opportunities and initiatives to enhance autonomy can be integral components of these strategies.

Ethiopian nurses association (ENA)

ENA plays a pivotal role in advocating for the welfare of nurses. The association is encouraged to collaborate with healthcare institutions to promote autonomy, create mentorship programs, and advocate for improved working conditions to mitigate turnover intention.

Healthcare institutions

Hospitals and healthcare facilities should prioritize the provision of career advancement opportunities and recognize the value of professional autonomy in retaining nursing staff. Tailored interventions based on regional variations should be considered.

Policy makers

Policymakers should review existing healthcare policies to identify areas for improvement in nurse retention. Policy changes that address challenges such as work overload, limited promotional opportunities, and economic constraints can positively impact turnover rates.

Future research initiatives

Further research exploring the specific factors contributing to turnover intention in different regions of Ethiopia is recommended. Understanding the nuanced challenges faced by nurses in various settings will inform the development of more targeted interventions.

Strength and limitations

Our systematic review and meta-analysis on nurse turnover intention in Ethiopia present several strengths. The comprehensive inclusion of diverse studies provides a holistic view of the issue, enhancing the generalizability of our findings. The use of a random-effects model accounts for potential heterogeneity, ensuring a more robust and reliable synthesis of data.

However, limitations should be acknowledged. The heterogeneity observed across studies, despite the use of a random-effects model, may impact the precision of the pooled estimate. These considerations should be taken into account when interpreting and applying the results of our analysis.

Data availability

Data set used on this analysis will available from corresponding author upon reasonable request.

Abbreviations

Ethiopian Nurses Association

Federal Ministry of Health

Joanna Briggs Institute

Preferred Reporting Items for Systematic review and Meta-analysis Protocols

Kanchana L, Jayathilaka R. Factors impacting employee turnover intentions among professionals in Sri Lankan startups. PLoS ONE. 2023;18(2):e0281729.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Boateng AB, et al. Factors influencing turnover intention among nurses and midwives in Ghana. Nurs Res Pract. 2022;2022:4299702.

PubMed   PubMed Central   Google Scholar  

Organization WH. WHO Guideline on Health Workforce Development Attraction, Recruitment and Retention in Rural and Remote Areas, 2021, pp. 1-104.

Hayes LJ, et al. Nurse turnover: a literature review. Int J Nurs Stud. 2006;43(2):237–63.

Article   PubMed   Google Scholar  

Yang H, et al. Validation of work pressure and associated factors influencing hospital nurse turnover: a cross-sectional investigation in Shaanxi Province, China. BMC Health Serv Res. 2017;17:1–11.

Article   Google Scholar  

Ayalew E et al. Nurses’ intention to leave their job in sub-Saharan Africa: A systematic review and meta-analysis. Heliyon, 2021. 7(6).

Al Momani M. Factors influencing public hospital nurses’ intentions to leave their current employment in Jordan. Int J Community Med Public Health. 2017;4(6):1847–53.

DeKeyser Ganz F, Toren O. Israeli nurse practice environment characteristics, retention, and job satisfaction. Isr J Health Policy Res. 2014;3(1):1–8.

de Oliveira DR, et al. Intention to leave profession, psychosocial environment and self-rated health among registered nurses from large hospitals in Brazil: a cross-sectional study. BMC Health Serv Res. 2017;17(1):21.

Article   PubMed   PubMed Central   Google Scholar  

Dall’Ora C, et al. Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries. BMJ Open. 2015;5(9):e008331.

Lu H, Zhao Y, While A. Job satisfaction among hospital nurses: a literature review. Int J Nurs Stud. 2019;94:21–31.

Ramoo V, Abdullah KL, Piaw CY. The relationship between job satisfaction and intention to leave current employment among registered nurses in a teaching hospital. J Clin Nurs. 2013;22(21–22):3141–52.

Al Sabei SD, et al. Nursing work environment, turnover intention, Job Burnout, and Quality of Care: the moderating role of job satisfaction. J Nurs Scholarsh. 2020;52(1):95–104.

Wang H, Chen H, Chen J. Correlation study on payment satisfaction, psychological reward satisfaction and turnover intention of nurses. Chin Hosp Manag. 2018;38(03):64–6.

Google Scholar  

Loes CN, Tobin MB. Interpersonal conflict and organizational commitment among licensed practical nurses. Health Care Manag (Frederick). 2018;37(2):175–82.

Wei H, et al. The state of the science of nurse work environments in the United States: a systematic review. Int J Nurs Sci. 2018;5(3):287–300.

Nantsupawat A, et al. Effects of nurse work environment on job dissatisfaction, burnout, intention to leave. Int Nurs Rev. 2017;64(1):91–8.

Article   CAS   PubMed   Google Scholar  

Ayalew F, et al. Factors affecting turnover intention among nurses in Ethiopia. World Health Popul. 2015;16(2):62–74.

Debie A, Khatri RB, Assefa Y. Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis. BMC Health Serv Res. 2022;22(1):866.

Moher D, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Reviews. 2015;4(1):1–9.

Moher D, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9.

Moher D et al. Group, P.-P.(2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement.

Institute JB. Checklist for Prevalence Studies. Checkl prevalance Stud [Internet]. 2016;7.

Sakonidou S, et al. Interventions to improve quantitative measures of parent satisfaction in neonatal care: a systematic review. BMJ Paediatr Open. 2020;4(1):e000613.

Egger M, Smith GD. Meta-analysis: potentials and promise. BMJ. 1997;315(7119):1371.

Tura G, Fantahun M, Worku A. The effect of health facility delivery on neonatal mortality: systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013;13:18.

Lin L. Comparison of four heterogeneity measures for meta-analysis. J Eval Clin Pract. 2020;26(1):376–84.

McFarland LV. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol. 2006;101(4):812–22.

Asegid A, Belachew T, Yimam E. Factors influencing job satisfaction and anticipated turnover among nurses in Sidama zone public health facilities, South Ethiopia Nursing research and practice, 2014. 2014.

Wubetie A, Taye B, Girma B. Magnitude of turnover intention and associated factors among nurses working in emergency departments of governmental hospitals in Addis Ababa, Ethiopia: a cross-sectional institutional based study. BMC Nurs. 2020;19:97.

Getie GA, Betre ET, Hareri HA. Assessment of factors affecting turnover intention among nurses working at governmental health care institutions in east Gojjam, Amhara region, Ethiopia, 2013. Am J Nurs Sci. 2015;4(3):107–12.

Gebregziabher D, et al. The relationship between job satisfaction and turnover intention among nurses in Axum comprehensive and specialized hospital Tigray, Ethiopia. BMC Nurs. 2020;19(1):79.

Negarandeh R et al. Magnitude of nurses’ intention to leave their jobs and its associated factors of nurses working in tigray regional state, north ethiopia: cross sectional study 2020.

Nigussie Bolado G, et al. The magnitude of turnover intention and Associated factors among nurses working at Governmental Hospitals in Southern Ethiopia: a mixed-method study. Nursing: Research and Reviews; 2023. pp. 13–29.

Woldekiros AN, Getye E, Abdo ZA. Magnitude of job satisfaction and intention to leave their present job among nurses in selected federal hospitals in Addis Ababa, Ethiopia. PLoS ONE. 2022;17(6):e0269540.

Rhoades L, Eisenberger R. Perceived organizational support: a review of the literature. J Appl Psychol. 2002;87(4):698.

Lewis M. Causal factors that influence turnover intent in a manufacturing organisation. University of Pretoria (South Africa); 2008.

Kuria S, Alice O, Wanderi PM. Assessment of causes of labour turnover in three and five star-rated hotels in Kenya International journal of business and social science, 2012. 3(15).

Blaauw D, et al. Comparing the job satisfaction and intention to leave of different categories of health workers in Tanzania, Malawi, and South Africa. Global Health Action. 2013;6(1):19287.

Masum AKM, et al. Job satisfaction and intention to quit: an empirical analysis of nurses in Turkey. PeerJ. 2016;4:e1896.

Song L. A study of factors influencing turnover intention of King Power Group at Downtown Area in Bangkok, Thailand. Volume 2. International Review of Research in Emerging Markets & the Global Economy; 2016. 3.

Karanikola MN, et al. Moral distress, autonomy and nurse-physician collaboration among intensive care unit nurses in Italy. J Nurs Manag. 2014;22(4):472–84.

Labrague LJ, McEnroe-Petitte DM, Tsaras K. Predictors and outcomes of nurse professional autonomy: a cross-sectional study. Int J Nurs Pract. 2019;25(1):e12711.

Download references

No funding was received.

Author information

Authors and affiliations.

School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia

Eshetu Elfios, Israel Asale, Merid Merkine, Temesgen Geta, Kidist Ashager, Getachew Nigussie, Ayele Agena & Bizuayehu Atinafu

Department of Midwifery, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia

Eskindir Israel

Department of Midwifery, College of Health Science and Medicine, Wachamo University, Hossana, Ethiopia

Teketel Tesfaye

You can also search for this author in PubMed   Google Scholar

Contributions

E.E. conceptualized the study, designed the research, performed statistical analysis, and led the manuscript writing. I.A, T.G, M.M contributed to the study design and provided critical revisions. K.A., G.N, B.A., E.I., and T.T. participated in data extraction and quality assessment. M.M. and T.G. K.A. and G.N. contributed to the literature review. I.A, A.A. and B.A. assisted in data interpretation. E.I. and T.T. provided critical revisions to the manuscript. All authors read and approved the final version.

Corresponding author

Correspondence to Eshetu Elfios .

Ethics declarations

Ethical approval.

Ethical approval and informed consent are not required, as this study is a systematic review and meta-analysis that only involved the use of previously published data.

Ethical guidelines

Not applicable.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Elfios, E., Asale, I., Merkine, M. et al. Turnover intention and its associated factors among nurses in Ethiopia: a systematic review and meta-analysis. BMC Health Serv Res 24 , 662 (2024). https://doi.org/10.1186/s12913-024-11122-9

Download citation

Received : 20 January 2024

Accepted : 20 May 2024

Published : 24 May 2024

DOI : https://doi.org/10.1186/s12913-024-11122-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Turnover intention
  • Systematic review
  • Meta-analysis

BMC Health Services Research

ISSN: 1472-6963

systematic review of research utilization

A systematic literature review of empirical research on ChatGPT in education

  • Open access
  • Published: 26 May 2024
  • Volume 3 , article number  60 , ( 2024 )

Cite this article

You have full access to this open access article

systematic review of research utilization

  • Yazid Albadarin   ORCID: orcid.org/0009-0005-8068-8902 1 ,
  • Mohammed Saqr 1 ,
  • Nicolas Pope 1 &
  • Markku Tukiainen 1  

416 Accesses

Explore all metrics

Over the last four decades, studies have investigated the incorporation of Artificial Intelligence (AI) into education. A recent prominent AI-powered technology that has impacted the education sector is ChatGPT. This article provides a systematic review of 14 empirical studies incorporating ChatGPT into various educational settings, published in 2022 and before the 10th of April 2023—the date of conducting the search process. It carefully followed the essential steps outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines, as well as Okoli’s (Okoli in Commun Assoc Inf Syst, 2015) steps for conducting a rigorous and transparent systematic review. In this review, we aimed to explore how students and teachers have utilized ChatGPT in various educational settings, as well as the primary findings of those studies. By employing Creswell’s (Creswell in Educational research: planning, conducting, and evaluating quantitative and qualitative research [Ebook], Pearson Education, London, 2015) coding techniques for data extraction and interpretation, we sought to gain insight into their initial attempts at ChatGPT incorporation into education. This approach also enabled us to extract insights and considerations that can facilitate its effective and responsible use in future educational contexts. The results of this review show that learners have utilized ChatGPT as a virtual intelligent assistant, where it offered instant feedback, on-demand answers, and explanations of complex topics. Additionally, learners have used it to enhance their writing and language skills by generating ideas, composing essays, summarizing, translating, paraphrasing texts, or checking grammar. Moreover, learners turned to it as an aiding tool to facilitate their directed and personalized learning by assisting in understanding concepts and homework, providing structured learning plans, and clarifying assignments and tasks. However, the results of specific studies (n = 3, 21.4%) show that overuse of ChatGPT may negatively impact innovative capacities and collaborative learning competencies among learners. Educators, on the other hand, have utilized ChatGPT to create lesson plans, generate quizzes, and provide additional resources, which helped them enhance their productivity and efficiency and promote different teaching methodologies. Despite these benefits, the majority of the reviewed studies recommend the importance of conducting structured training, support, and clear guidelines for both learners and educators to mitigate the drawbacks. This includes developing critical evaluation skills to assess the accuracy and relevance of information provided by ChatGPT, as well as strategies for integrating human interaction and collaboration into learning activities that involve AI tools. Furthermore, they also recommend ongoing research and proactive dialogue with policymakers, stakeholders, and educational practitioners to refine and enhance the use of AI in learning environments. This review could serve as an insightful resource for practitioners who seek to integrate ChatGPT into education and stimulate further research in the field.

Similar content being viewed by others

systematic review of research utilization

Empowering learners with ChatGPT: insights from a systematic literature exploration

systematic review of research utilization

Incorporating AI in foreign language education: An investigation into ChatGPT’s effect on foreign language learners

systematic review of research utilization

Large language models in education: A focus on the complementary relationship between human teachers and ChatGPT

Avoid common mistakes on your manuscript.

1 Introduction

Educational technology, a rapidly evolving field, plays a crucial role in reshaping the landscape of teaching and learning [ 82 ]. One of the most transformative technological innovations of our era that has influenced the field of education is Artificial Intelligence (AI) [ 50 ]. Over the last four decades, AI in education (AIEd) has gained remarkable attention for its potential to make significant advancements in learning, instructional methods, and administrative tasks within educational settings [ 11 ]. In particular, a large language model (LLM), a type of AI algorithm that applies artificial neural networks (ANNs) and uses massively large data sets to understand, summarize, generate, and predict new content that is almost difficult to differentiate from human creations [ 79 ], has opened up novel possibilities for enhancing various aspects of education, from content creation to personalized instruction [ 35 ]. Chatbots that leverage the capabilities of LLMs to understand and generate human-like responses have also presented the capacity to enhance student learning and educational outcomes by engaging students, offering timely support, and fostering interactive learning experiences [ 46 ].

The ongoing and remarkable technological advancements in chatbots have made their use more convenient, increasingly natural and effortless, and have expanded their potential for deployment across various domains [ 70 ]. One prominent example of chatbot applications is the Chat Generative Pre-Trained Transformer, known as ChatGPT, which was introduced by OpenAI, a leading AI research lab, on November 30th, 2022. ChatGPT employs a variety of deep learning techniques to generate human-like text, with a particular focus on recurrent neural networks (RNNs). Long short-term memory (LSTM) allows it to grasp the context of the text being processed and retain information from previous inputs. Also, the transformer architecture, a neural network architecture based on the self-attention mechanism, allows it to analyze specific parts of the input, thereby enabling it to produce more natural-sounding and coherent output. Additionally, the unsupervised generative pre-training and the fine-tuning methods allow ChatGPT to generate more relevant and accurate text for specific tasks [ 31 , 62 ]. Furthermore, reinforcement learning from human feedback (RLHF), a machine learning approach that combines reinforcement learning techniques with human-provided feedback, has helped improve ChatGPT’s model by accelerating the learning process and making it significantly more efficient.

This cutting-edge natural language processing (NLP) tool is widely recognized as one of today's most advanced LLMs-based chatbots [ 70 ], allowing users to ask questions and receive detailed, coherent, systematic, personalized, convincing, and informative human-like responses [ 55 ], even within complex and ambiguous contexts [ 63 , 77 ]. ChatGPT is considered the fastest-growing technology in history: in just three months following its public launch, it amassed an estimated 120 million monthly active users [ 16 ] with an estimated 13 million daily queries [ 49 ], surpassing all other applications [ 64 ]. This remarkable growth can be attributed to the unique features and user-friendly interface that ChatGPT offers. Its intuitive design allows users to interact seamlessly with the technology, making it accessible to a diverse range of individuals, regardless of their technical expertise [ 78 ]. Additionally, its exceptional performance results from a combination of advanced algorithms, continuous enhancements, and extensive training on a diverse dataset that includes various text sources such as books, articles, websites, and online forums [ 63 ], have contributed to a more engaging and satisfying user experience [ 62 ]. These factors collectively explain its remarkable global growth and set it apart from predecessors like Bard, Bing Chat, ERNIE, and others.

In this context, several studies have explored the technological advancements of chatbots. One noteworthy recent research effort, conducted by Schöbel et al. [ 70 ], stands out for its comprehensive analysis of more than 5,000 studies on communication agents. This study offered a comprehensive overview of the historical progression and future prospects of communication agents, including ChatGPT. Moreover, other studies have focused on making comparisons, particularly between ChatGPT and alternative chatbots like Bard, Bing Chat, ERNIE, LaMDA, BlenderBot, and various others. For example, O’Leary [ 53 ] compared two chatbots, LaMDA and BlenderBot, with ChatGPT and revealed that ChatGPT outperformed both. This superiority arises from ChatGPT’s capacity to handle a wider range of questions and generate slightly varied perspectives within specific contexts. Similarly, ChatGPT exhibited an impressive ability to formulate interpretable responses that were easily understood when compared with Google's feature snippet [ 34 ]. Additionally, ChatGPT was compared to other LLMs-based chatbots, including Bard and BERT, as well as ERNIE. The findings indicated that ChatGPT exhibited strong performance in the given tasks, often outperforming the other models [ 59 ].

Furthermore, in the education context, a comprehensive study systematically compared a range of the most promising chatbots, including Bard, Bing Chat, ChatGPT, and Ernie across a multidisciplinary test that required higher-order thinking. The study revealed that ChatGPT achieved the highest score, surpassing Bing Chat and Bard [ 64 ]. Similarly, a comparative analysis was conducted to compare ChatGPT with Bard in answering a set of 30 mathematical questions and logic problems, grouped into two question sets. Set (A) is unavailable online, while Set (B) is available online. The results revealed ChatGPT's superiority in Set (A) over Bard. Nevertheless, Bard's advantage emerged in Set (B) due to its capacity to access the internet directly and retrieve answers, a capability that ChatGPT does not possess [ 57 ]. However, through these varied assessments, ChatGPT consistently highlights its exceptional prowess compared to various alternatives in the ever-evolving chatbot technology.

The widespread adoption of chatbots, especially ChatGPT, by millions of students and educators, has sparked extensive discussions regarding its incorporation into the education sector [ 64 ]. Accordingly, many scholars have contributed to the discourse, expressing both optimism and pessimism regarding the incorporation of ChatGPT into education. For example, ChatGPT has been highlighted for its capabilities in enriching the learning and teaching experience through its ability to support different learning approaches, including adaptive learning, personalized learning, and self-directed learning [ 58 , 60 , 91 ]), deliver summative and formative feedback to students and provide real-time responses to questions, increase the accessibility of information [ 22 , 40 , 43 ], foster students’ performance, engagement and motivation [ 14 , 44 , 58 ], and enhance teaching practices [ 17 , 18 , 64 , 74 ].

On the other hand, concerns have been also raised regarding its potential negative effects on learning and teaching. These include the dissemination of false information and references [ 12 , 23 , 61 , 85 ], biased reinforcement [ 47 , 50 ], compromised academic integrity [ 18 , 40 , 66 , 74 ], and the potential decline in students' skills [ 43 , 61 , 64 , 74 ]. As a result, ChatGPT has been banned in multiple countries, including Russia, China, Venezuela, Belarus, and Iran, as well as in various educational institutions in India, Italy, Western Australia, France, and the United States [ 52 , 90 ].

Clearly, the advent of chatbots, especially ChatGPT, has provoked significant controversy due to their potential impact on learning and teaching. This indicates the necessity for further exploration to gain a deeper understanding of this technology and carefully evaluate its potential benefits, limitations, challenges, and threats to education [ 79 ]. Therefore, conducting a systematic literature review will provide valuable insights into the potential prospects and obstacles linked to its incorporation into education. This systematic literature review will primarily focus on ChatGPT, driven by the aforementioned key factors outlined above.

However, the existing literature lacks a systematic literature review of empirical studies. Thus, this systematic literature review aims to address this gap by synthesizing the existing empirical studies conducted on chatbots, particularly ChatGPT, in the field of education, highlighting how ChatGPT has been utilized in educational settings, and identifying any existing gaps. This review may be particularly useful for researchers in the field and educators who are contemplating the integration of ChatGPT or any chatbot into education. The following research questions will guide this study:

What are students' and teachers' initial attempts at utilizing ChatGPT in education?

What are the main findings derived from empirical studies that have incorporated ChatGPT into learning and teaching?

2 Methodology

To conduct this study, the authors followed the essential steps of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) and Okoli’s [ 54 ] steps for conducting a systematic review. These included identifying the study’s purpose, drafting a protocol, applying a practical screening process, searching the literature, extracting relevant data, evaluating the quality of the included studies, synthesizing the studies, and ultimately writing the review. The subsequent section provides an extensive explanation of how these steps were carried out in this study.

2.1 Identify the purpose

Given the widespread adoption of ChatGPT by students and teachers for various educational purposes, often without a thorough understanding of responsible and effective use or a clear recognition of its potential impact on learning and teaching, the authors recognized the need for further exploration of ChatGPT's impact on education in this early stage. Therefore, they have chosen to conduct a systematic literature review of existing empirical studies that incorporate ChatGPT into educational settings. Despite the limited number of empirical studies due to the novelty of the topic, their goal is to gain a deeper understanding of this technology and proactively evaluate its potential benefits, limitations, challenges, and threats to education. This effort could help to understand initial reactions and attempts at incorporating ChatGPT into education and bring out insights and considerations that can inform the future development of education.

2.2 Draft the protocol

The next step is formulating the protocol. This protocol serves to outline the study process in a rigorous and transparent manner, mitigating researcher bias in study selection and data extraction [ 88 ]. The protocol will include the following steps: generating the research question, predefining a literature search strategy, identifying search locations, establishing selection criteria, assessing the studies, developing a data extraction strategy, and creating a timeline.

2.3 Apply practical screen

The screening step aims to accurately filter the articles resulting from the searching step and select the empirical studies that have incorporated ChatGPT into educational contexts, which will guide us in answering the research questions and achieving the objectives of this study. To ensure the rigorous execution of this step, our inclusion and exclusion criteria were determined based on the authors' experience and informed by previous successful systematic reviews [ 21 ]. Table 1 summarizes the inclusion and exclusion criteria for study selection.

2.4 Literature search

We conducted a thorough literature search to identify articles that explored, examined, and addressed the use of ChatGPT in Educational contexts. We utilized two research databases: Dimensions.ai, which provides access to a large number of research publications, and lens.org, which offers access to over 300 million articles, patents, and other research outputs from diverse sources. Additionally, we included three databases, Scopus, Web of Knowledge, and ERIC, which contain relevant research on the topic that addresses our research questions. To browse and identify relevant articles, we used the following search formula: ("ChatGPT" AND "Education"), which included the Boolean operator "AND" to get more specific results. The subject area in the Scopus and ERIC databases were narrowed to "ChatGPT" and "Education" keywords, and in the WoS database was limited to the "Education" category. The search was conducted between the 3rd and 10th of April 2023, which resulted in 276 articles from all selected databases (111 articles from Dimensions.ai, 65 from Scopus, 28 from Web of Science, 14 from ERIC, and 58 from Lens.org). These articles were imported into the Rayyan web-based system for analysis. The duplicates were identified automatically by the system. Subsequently, the first author manually reviewed the duplicated articles ensured that they had the same content, and then removed them, leaving us with 135 unique articles. Afterward, the titles, abstracts, and keywords of the first 40 manuscripts were scanned and reviewed by the first author and were discussed with the second and third authors to resolve any disagreements. Subsequently, the first author proceeded with the filtering process for all articles and carefully applied the inclusion and exclusion criteria as presented in Table  1 . Articles that met any one of the exclusion criteria were eliminated, resulting in 26 articles. Afterward, the authors met to carefully scan and discuss them. The authors agreed to eliminate any empirical studies solely focused on checking ChatGPT capabilities, as these studies do not guide us in addressing the research questions and achieving the study's objectives. This resulted in 14 articles eligible for analysis.

2.5 Quality appraisal

The examination and evaluation of the quality of the extracted articles is a vital step [ 9 ]. Therefore, the extracted articles were carefully evaluated for quality using Fink’s [ 24 ] standards, which emphasize the necessity for detailed descriptions of methodology, results, conclusions, strengths, and limitations. The process began with a thorough assessment of each study's design, data collection, and analysis methods to ensure their appropriateness and comprehensive execution. The clarity, consistency, and logical progression from data to results and conclusions were also critically examined. Potential biases and recognized limitations within the studies were also scrutinized. Ultimately, two articles were excluded for failing to meet Fink’s criteria, particularly in providing sufficient detail on methodology, results, conclusions, strengths, or limitations. The review process is illustrated in Fig.  1 .

figure 1

The study selection process

2.6 Data extraction

The next step is data extraction, the process of capturing the key information and categories from the included studies. To improve efficiency, reduce variation among authors, and minimize errors in data analysis, the coding categories were constructed using Creswell's [ 15 ] coding techniques for data extraction and interpretation. The coding process involves three sequential steps. The initial stage encompasses open coding , where the researcher examines the data, generates codes to describe and categorize it, and gains a deeper understanding without preconceived ideas. Following open coding is axial coding , where the interrelationships between codes from open coding are analyzed to establish more comprehensive categories or themes. The process concludes with selective coding , refining and integrating categories or themes to identify core concepts emerging from the data. The first coder performed the coding process, then engaged in discussions with the second and third authors to finalize the coding categories for the first five articles. The first coder then proceeded to code all studies and engaged again in discussions with the other authors to ensure the finalization of the coding process. After a comprehensive analysis and capturing of the key information from the included studies, the data extraction and interpretation process yielded several themes. These themes have been categorized and are presented in Table  2 . It is important to note that open coding results were removed from Table  2 for aesthetic reasons, as it included many generic aspects, such as words, short phrases, or sentences mentioned in the studies.

2.7 Synthesize studies

In this stage, we will gather, discuss, and analyze the key findings that emerged from the selected studies. The synthesis stage is considered a transition from an author-centric to a concept-centric focus, enabling us to map all the provided information to achieve the most effective evaluation of the data [ 87 ]. Initially, the authors extracted data that included general information about the selected studies, including the author(s)' names, study titles, years of publication, educational levels, research methodologies, sample sizes, participants, main aims or objectives, raw data sources, and analysis methods. Following that, all key information and significant results from the selected studies were compiled using Creswell’s [ 15 ] coding techniques for data extraction and interpretation to identify core concepts and themes emerging from the data, focusing on those that directly contributed to our research questions and objectives, such as the initial utilization of ChatGPT in learning and teaching, learners' and educators' familiarity with ChatGPT, and the main findings of each study. Finally, the data related to each selected study were extracted into an Excel spreadsheet for data processing. The Excel spreadsheet was reviewed by the authors, including a series of discussions to ensure the finalization of this process and prepare it for further analysis. Afterward, the final result being analyzed and presented in various types of charts and graphs. Table 4 presents the extracted data from the selected studies, with each study labeled with a capital 'S' followed by a number.

This section consists of two main parts. The first part provides a descriptive analysis of the data compiled from the reviewed studies. The second part presents the answers to the research questions and the main findings of these studies.

3.1 Part 1: descriptive analysis

This section will provide a descriptive analysis of the reviewed studies, including educational levels and fields, participants distribution, country contribution, research methodologies, study sample size, study population, publication year, list of journals, familiarity with ChatGPT, source of data, and the main aims and objectives of the studies. Table 4 presents a comprehensive overview of the extracted data from the selected studies.

3.1.1 The number of the reviewed studies and publication years

The total number of the reviewed studies was 14. All studies were empirical studies and published in different journals focusing on Education and Technology. One study was published in 2022 [S1], while the remaining were published in 2023 [S2]-[S14]. Table 3 illustrates the year of publication, the names of the journals, and the number of reviewed studies published in each journal for the studies reviewed.

3.1.2 Educational levels and fields

The majority of the reviewed studies, 11 studies, were conducted in higher education institutions [S1]-[S10] and [S13]. Two studies did not specify the educational level of the population [S12] and [S14], while one study focused on elementary education [S11]. However, the reviewed studies covered various fields of education. Three studies focused on Arts and Humanities Education [S8], [S11], and [S14], specifically English Education. Two studies focused on Engineering Education, with one in Computer Engineering [S2] and the other in Construction Education [S3]. Two studies focused on Mathematics Education [S5] and [S12]. One study focused on Social Science Education [S13]. One study focused on Early Education [S4]. One study focused on Journalism Education [S9]. Finally, three studies did not specify the field of education [S1], [S6], and [S7]. Figure  2 represents the educational levels in the reviewed studies, while Fig.  3 represents the context of the reviewed studies.

figure 2

Educational levels in the reviewed studies

figure 3

Context of the reviewed studies

3.1.3 Participants distribution and countries contribution

The reviewed studies have been conducted across different geographic regions, providing a diverse representation of the studies. The majority of the studies, 10 in total, [S1]-[S3], [S5]-[S9], [S11], and [S14], primarily focused on participants from single countries such as Pakistan, the United Arab Emirates, China, Indonesia, Poland, Saudi Arabia, South Korea, Spain, Tajikistan, and the United States. In contrast, four studies, [S4], [S10], [S12], and [S13], involved participants from multiple countries, including China and the United States [S4], China, the United Kingdom, and the United States [S10], the United Arab Emirates, Oman, Saudi Arabia, and Jordan [S12], Turkey, Sweden, Canada, and Australia [ 13 ]. Figures  4 and 5 illustrate the distribution of participants, whether from single or multiple countries, and the contribution of each country in the reviewed studies, respectively.

figure 4

The reviewed studies conducted in single or multiple countries

figure 5

The Contribution of each country in the studies

3.1.4 Study population and sample size

Four study populations were included: university students, university teachers, university teachers and students, and elementary school teachers. Six studies involved university students [S2], [S3], [S5] and [S6]-[S8]. Three studies focused on university teachers [S1], [S4], and [S6], while one study specifically targeted elementary school teachers [S11]. Additionally, four studies included both university teachers and students [S10] and [ 12 , 13 , 14 ], and among them, study [S13] specifically included postgraduate students. In terms of the sample size of the reviewed studies, nine studies included a small sample size of less than 50 participants [S1], [S3], [S6], [S8], and [S10]-[S13]. Three studies had 50–100 participants [S2], [S9], and [S14]. Only one study had more than 100 participants [S7]. It is worth mentioning that study [S4] adopted a mixed methods approach, including 10 participants for qualitative analysis and 110 participants for quantitative analysis.

3.1.5 Participants’ familiarity with using ChatGPT

The reviewed studies recruited a diverse range of participants with varying levels of familiarity with ChatGPT. Five studies [S2], [S4], [S6], [S8], and [S12] involved participants already familiar with ChatGPT, while eight studies [S1], [S3], [S5], [S7], [S9], [S10], [S13] and [S14] included individuals with differing levels of familiarity. Notably, one study [S11] had participants who were entirely unfamiliar with ChatGPT. It is important to note that four studies [S3], [S5], [S9], and [S11] provided training or guidance to their participants before conducting their studies, while ten studies [S1], [S2], [S4], [S6]-[S8], [S10], and [S12]-[S14] did not provide training due to the participants' existing familiarity with ChatGPT.

3.1.6 Research methodology approaches and source(S) of data

The reviewed studies adopted various research methodology approaches. Seven studies adopted qualitative research methodology [S1], [S4], [S6], [S8], [S10], [S11], and [S12], while three studies adopted quantitative research methodology [S3], [S7], and [S14], and four studies employed mixed-methods, which involved a combination of both the strengths of qualitative and quantitative methods [S2], [S5], [S9], and [S13].

In terms of the source(s) of data, the reviewed studies obtained their data from various sources, such as interviews, questionnaires, and pre-and post-tests. Six studies relied on interviews as their primary source of data collection [S1], [S4], [S6], [S10], [S11], and [S12], four studies relied on questionnaires [S2], [S7], [S13], and [S14], two studies combined the use of pre-and post-tests and questionnaires for data collection [S3] and [S9], while two studies combined the use of questionnaires and interviews to obtain the data [S5] and [S8]. It is important to note that six of the reviewed studies were quasi-experimental [S3], [S5], [S8], [S9], [S12], and [S14], while the remaining ones were experimental studies [S1], [S2], [S4], [S6], [S7], [S10], [S11], and [S13]. Figures  6 and 7 illustrate the research methodologies and the source (s) of data used in the reviewed studies, respectively.

figure 6

Research methodologies in the reviewed studies

figure 7

Source of data in the reviewed studies

3.1.7 The aim and objectives of the studies

The reviewed studies encompassed a diverse set of aims, with several of them incorporating multiple primary objectives. Six studies [S3], [S6], [S7], [S8], [S11], and [S12] examined the integration of ChatGPT in educational contexts, and four studies [S4], [S5], [S13], and [S14] investigated the various implications of its use in education, while three studies [S2], [S9], and [S10] aimed to explore both its integration and implications in education. Additionally, seven studies explicitly explored attitudes and perceptions of students [S2] and [S3], educators [S1] and [S6], or both [S10], [S12], and [S13] regarding the utilization of ChatGPT in educational settings.

3.2 Part 2: research questions and main findings of the reviewed studies

This part will present the answers to the research questions and the main findings of the reviewed studies, classified into two main categories (learning and teaching) according to AI Education classification by [ 36 ]. Figure  8 summarizes the main findings of the reviewed studies in a visually informative diagram. Table 4 provides a detailed list of the key information extracted from the selected studies that led to generating these themes.

figure 8

The main findings in the reviewed studies

4 Students' initial attempts at utilizing ChatGPT in learning and main findings from students' perspective

4.1 virtual intelligent assistant.

Nine studies demonstrated that ChatGPT has been utilized by students as an intelligent assistant to enhance and support their learning. Students employed it for various purposes, such as answering on-demand questions [S2]-[S5], [S8], [S10], and [S12], providing valuable information and learning resources [S2]-[S5], [S6], and [S8], as well as receiving immediate feedback [S2], [S4], [S9], [S10], and [S12]. In this regard, students generally were confident in the accuracy of ChatGPT's responses, considering them relevant, reliable, and detailed [S3], [S4], [S5], and [S8]. However, some students indicated the need for improvement, as they found that answers are not always accurate [S2], and that misleading information may have been provided or that it may not always align with their expectations [S6] and [S10]. It was also observed by the students that the accuracy of ChatGPT is dependent on several factors, including the quality and specificity of the user's input, the complexity of the question or topic, and the scope and relevance of its training data [S12]. Many students felt that ChatGPT's answers were not always accurate and most of them believed that it requires good background knowledge to work with.

4.2 Writing and language proficiency assistant

Six of the reviewed studies highlighted that ChatGPT has been utilized by students as a valuable assistant tool to improve their academic writing skills and language proficiency. Among these studies, three mainly focused on English education, demonstrating that students showed sufficient mastery in using ChatGPT for generating ideas, summarizing, paraphrasing texts, and completing writing essays [S8], [S11], and [S14]. Furthermore, ChatGPT helped them in writing by making students active investigators rather than passive knowledge recipients and facilitated the development of their writing skills [S11] and [S14]. Similarly, ChatGPT allowed students to generate unique ideas and perspectives, leading to deeper analysis and reflection on their journalism writing [S9]. In terms of language proficiency, ChatGPT allowed participants to translate content into their home languages, making it more accessible and relevant to their context [S4]. It also enabled them to request changes in linguistic tones or flavors [S8]. Moreover, participants used it to check grammar or as a dictionary [S11].

4.3 Valuable resource for learning approaches

Five studies demonstrated that students used ChatGPT as a valuable complementary resource for self-directed learning. It provided learning resources and guidance on diverse educational topics and created a supportive home learning environment [S2] and [S4]. Moreover, it offered step-by-step guidance to grasp concepts at their own pace and enhance their understanding [S5], streamlined task and project completion carried out independently [S7], provided comprehensive and easy-to-understand explanations on various subjects [S10], and assisted in studying geometry operations, thereby empowering them to explore geometry operations at their own pace [S12]. Three studies showed that students used ChatGPT as a valuable learning resource for personalized learning. It delivered age-appropriate conversations and tailored teaching based on a child's interests [S4], acted as a personalized learning assistant, adapted to their needs and pace, which assisted them in understanding mathematical concepts [S12], and enabled personalized learning experiences in social sciences by adapting to students' needs and learning styles [S13]. On the other hand, it is important to note that, according to one study [S5], students suggested that using ChatGPT may negatively affect collaborative learning competencies between students.

4.4 Enhancing students' competencies

Six of the reviewed studies have shown that ChatGPT is a valuable tool for improving a wide range of skills among students. Two studies have provided evidence that ChatGPT led to improvements in students' critical thinking, reasoning skills, and hazard recognition competencies through engaging them in interactive conversations or activities and providing responses related to their disciplines in journalism [S5] and construction education [S9]. Furthermore, two studies focused on mathematical education have shown the positive impact of ChatGPT on students' problem-solving abilities in unraveling problem-solving questions [S12] and enhancing the students' understanding of the problem-solving process [S5]. Lastly, one study indicated that ChatGPT effectively contributed to the enhancement of conversational social skills [S4].

4.5 Supporting students' academic success

Seven of the reviewed studies highlighted that students found ChatGPT to be beneficial for learning as it enhanced learning efficiency and improved the learning experience. It has been observed to improve students' efficiency in computer engineering studies by providing well-structured responses and good explanations [S2]. Additionally, students found it extremely useful for hazard reporting [S3], and it also enhanced their efficiency in solving mathematics problems and capabilities [S5] and [S12]. Furthermore, by finding information, generating ideas, translating texts, and providing alternative questions, ChatGPT aided students in deepening their understanding of various subjects [S6]. It contributed to an increase in students' overall productivity [S7] and improved efficiency in composing written tasks [S8]. Regarding learning experiences, ChatGPT was instrumental in assisting students in identifying hazards that they might have otherwise overlooked [S3]. It also improved students' learning experiences in solving mathematics problems and developing abilities [S5] and [S12]. Moreover, it increased students' successful completion of important tasks in their studies [S7], particularly those involving average difficulty writing tasks [S8]. Additionally, ChatGPT increased the chances of educational success by providing students with baseline knowledge on various topics [S10].

5 Teachers' initial attempts at utilizing ChatGPT in teaching and main findings from teachers' perspective

5.1 valuable resource for teaching.

The reviewed studies showed that teachers have employed ChatGPT to recommend, modify, and generate diverse, creative, organized, and engaging educational contents, teaching materials, and testing resources more rapidly [S4], [S6], [S10] and [S11]. Additionally, teachers experienced increased productivity as ChatGPT facilitated quick and accurate responses to questions, fact-checking, and information searches [S1]. It also proved valuable in constructing new knowledge [S6] and providing timely answers to students' questions in classrooms [S11]. Moreover, ChatGPT enhanced teachers' efficiency by generating new ideas for activities and preplanning activities for their students [S4] and [S6], including interactive language game partners [S11].

5.2 Improving productivity and efficiency

The reviewed studies showed that participants' productivity and work efficiency have been significantly enhanced by using ChatGPT as it enabled them to allocate more time to other tasks and reduce their overall workloads [S6], [S10], [S11], [S13], and [S14]. However, three studies [S1], [S4], and [S11], indicated a negative perception and attitude among teachers toward using ChatGPT. This negativity stemmed from a lack of necessary skills to use it effectively [S1], a limited familiarity with it [S4], and occasional inaccuracies in the content provided by it [S10].

5.3 Catalyzing new teaching methodologies

Five of the reviewed studies highlighted that educators found the necessity of redefining their teaching profession with the assistance of ChatGPT [S11], developing new effective learning strategies [S4], and adapting teaching strategies and methodologies to ensure the development of essential skills for future engineers [S5]. They also emphasized the importance of adopting new educational philosophies and approaches that can evolve with the introduction of ChatGPT into the classroom [S12]. Furthermore, updating curricula to focus on improving human-specific features, such as emotional intelligence, creativity, and philosophical perspectives [S13], was found to be essential.

5.4 Effective utilization of CHATGPT in teaching

According to the reviewed studies, effective utilization of ChatGPT in education requires providing teachers with well-structured training, support, and adequate background on how to use ChatGPT responsibly [S1], [S3], [S11], and [S12]. Establishing clear rules and regulations regarding its usage is essential to ensure it positively impacts the teaching and learning processes, including students' skills [S1], [S4], [S5], [S8], [S9], and [S11]-[S14]. Moreover, conducting further research and engaging in discussions with policymakers and stakeholders is indeed crucial for the successful integration of ChatGPT in education and to maximize the benefits for both educators and students [S1], [S6]-[S10], and [S12]-[S14].

6 Discussion

The purpose of this review is to conduct a systematic review of empirical studies that have explored the utilization of ChatGPT, one of today’s most advanced LLM-based chatbots, in education. The findings of the reviewed studies showed several ways of ChatGPT utilization in different learning and teaching practices as well as it provided insights and considerations that can facilitate its effective and responsible use in future educational contexts. The results of the reviewed studies came from diverse fields of education, which helped us avoid a biased review that is limited to a specific field. Similarly, the reviewed studies have been conducted across different geographic regions. This kind of variety in geographic representation enriched the findings of this review.

In response to RQ1 , "What are students' and teachers' initial attempts at utilizing ChatGPT in education?", the findings from this review provide comprehensive insights. Chatbots, including ChatGPT, play a crucial role in supporting student learning, enhancing their learning experiences, and facilitating diverse learning approaches [ 42 , 43 ]. This review found that this tool, ChatGPT, has been instrumental in enhancing students' learning experiences by serving as a virtual intelligent assistant, providing immediate feedback, on-demand answers, and engaging in educational conversations. Additionally, students have benefited from ChatGPT’s ability to generate ideas, compose essays, and perform tasks like summarizing, translating, paraphrasing texts, or checking grammar, thereby enhancing their writing and language competencies. Furthermore, students have turned to ChatGPT for assistance in understanding concepts and homework, providing structured learning plans, and clarifying assignments and tasks, which fosters a supportive home learning environment, allowing them to take responsibility for their own learning and cultivate the skills and approaches essential for supportive home learning environment [ 26 , 27 , 28 ]. This finding aligns with the study of Saqr et al. [ 68 , 69 ] who highlighted that, when students actively engage in their own learning process, it yields additional advantages, such as heightened motivation, enhanced achievement, and the cultivation of enthusiasm, turning them into advocates for their own learning.

Moreover, students have utilized ChatGPT for tailored teaching and step-by-step guidance on diverse educational topics, streamlining task and project completion, and generating and recommending educational content. This personalization enhances the learning environment, leading to increased academic success. This finding aligns with other recent studies [ 26 , 27 , 28 , 60 , 66 ] which revealed that ChatGPT has the potential to offer personalized learning experiences and support an effective learning process by providing students with customized feedback and explanations tailored to their needs and abilities. Ultimately, fostering students' performance, engagement, and motivation, leading to increase students' academic success [ 14 , 44 , 58 ]. This ultimate outcome is in line with the findings of Saqr et al. [ 68 , 69 ], which emphasized that learning strategies are important catalysts of students' learning, as students who utilize effective learning strategies are more likely to have better academic achievement.

Teachers, too, have capitalized on ChatGPT's capabilities to enhance productivity and efficiency, using it for creating lesson plans, generating quizzes, providing additional resources, generating and preplanning new ideas for activities, and aiding in answering students’ questions. This adoption of technology introduces new opportunities to support teaching and learning practices, enhancing teacher productivity. This finding aligns with those of Day [ 17 ], De Castro [ 18 ], and Su and Yang [ 74 ] as well as with those of Valtonen et al. [ 82 ], who revealed that emerging technological advancements have opened up novel opportunities and means to support teaching and learning practices, and enhance teachers’ productivity.

In response to RQ2 , "What are the main findings derived from empirical studies that have incorporated ChatGPT into learning and teaching?", the findings from this review provide profound insights and raise significant concerns. Starting with the insights, chatbots, including ChatGPT, have demonstrated the potential to reshape and revolutionize education, creating new, novel opportunities for enhancing the learning process and outcomes [ 83 ], facilitating different learning approaches, and offering a range of pedagogical benefits [ 19 , 43 , 72 ]. In this context, this review found that ChatGPT could open avenues for educators to adopt or develop new effective learning and teaching strategies that can evolve with the introduction of ChatGPT into the classroom. Nonetheless, there is an evident lack of research understanding regarding the potential impact of generative machine learning models within diverse educational settings [ 83 ]. This necessitates teachers to attain a high level of proficiency in incorporating chatbots, such as ChatGPT, into their classrooms to create inventive, well-structured, and captivating learning strategies. In the same vein, the review also found that teachers without the requisite skills to utilize ChatGPT realized that it did not contribute positively to their work and could potentially have adverse effects [ 37 ]. This concern could lead to inequity of access to the benefits of chatbots, including ChatGPT, as individuals who lack the necessary expertise may not be able to harness their full potential, resulting in disparities in educational outcomes and opportunities. Therefore, immediate action is needed to address these potential issues. A potential solution is offering training, support, and competency development for teachers to ensure that all of them can leverage chatbots, including ChatGPT, effectively and equitably in their educational practices [ 5 , 28 , 80 ], which could enhance accessibility and inclusivity, and potentially result in innovative outcomes [ 82 , 83 ].

Additionally, chatbots, including ChatGPT, have the potential to significantly impact students' thinking abilities, including retention, reasoning, analysis skills [ 19 , 45 ], and foster innovation and creativity capabilities [ 83 ]. This review found that ChatGPT could contribute to improving a wide range of skills among students. However, it found that frequent use of ChatGPT may result in a decrease in innovative capacities, collaborative skills and cognitive capacities, and students' motivation to attend classes, as well as could lead to reduced higher-order thinking skills among students [ 22 , 29 ]. Therefore, immediate action is needed to carefully examine the long-term impact of chatbots such as ChatGPT, on learning outcomes as well as to explore its incorporation into educational settings as a supportive tool without compromising students' cognitive development and critical thinking abilities. In the same vein, the review also found that it is challenging to draw a consistent conclusion regarding the potential of ChatGPT to aid self-directed learning approach. This finding aligns with the recent study of Baskara [ 8 ]. Therefore, further research is needed to explore the potential of ChatGPT for self-directed learning. One potential solution involves utilizing learning analytics as a novel approach to examine various aspects of students' learning and support them in their individual endeavors [ 32 ]. This approach can bridge this gap by facilitating an in-depth analysis of how learners engage with ChatGPT, identifying trends in self-directed learning behavior, and assessing its influence on their outcomes.

Turning to the significant concerns, on the other hand, a fundamental challenge with LLM-based chatbots, including ChatGPT, is the accuracy and quality of the provided information and responses, as they provide false information as truth—a phenomenon often referred to as "hallucination" [ 3 , 49 ]. In this context, this review found that the provided information was not entirely satisfactory. Consequently, the utilization of chatbots presents potential concerns, such as generating and providing inaccurate or misleading information, especially for students who utilize it to support their learning. This finding aligns with other findings [ 6 , 30 , 35 , 40 ] which revealed that incorporating chatbots such as ChatGPT, into education presents challenges related to its accuracy and reliability due to its training on a large corpus of data, which may contain inaccuracies and the way users formulate or ask ChatGPT. Therefore, immediate action is needed to address these potential issues. One possible solution is to equip students with the necessary skills and competencies, which include a background understanding of how to use it effectively and the ability to assess and evaluate the information it generates, as the accuracy and the quality of the provided information depend on the input, its complexity, the topic, and the relevance of its training data [ 28 , 49 , 86 ]. However, it's also essential to examine how learners can be educated about how these models operate, the data used in their training, and how to recognize their limitations, challenges, and issues [ 79 ].

Furthermore, chatbots present a substantial challenge concerning maintaining academic integrity [ 20 , 56 ] and copyright violations [ 83 ], which are significant concerns in education. The review found that the potential misuse of ChatGPT might foster cheating, facilitate plagiarism, and threaten academic integrity. This issue is also affirmed by the research conducted by Basic et al. [ 7 ], who presented evidence that students who utilized ChatGPT in their writing assignments had more plagiarism cases than those who did not. These findings align with the conclusions drawn by Cotton et al. [ 13 ], Hisan and Amri [ 33 ] and Sullivan et al. [ 75 ], who revealed that the integration of chatbots such as ChatGPT into education poses a significant challenge to the preservation of academic integrity. Moreover, chatbots, including ChatGPT, have increased the difficulty in identifying plagiarism [ 47 , 67 , 76 ]. The findings from previous studies [ 1 , 84 ] indicate that AI-generated text often went undetected by plagiarism software, such as Turnitin. However, Turnitin and other similar plagiarism detection tools, such as ZeroGPT, GPTZero, and Copyleaks, have since evolved, incorporating enhanced techniques to detect AI-generated text, despite the possibility of false positives, as noted in different studies that have found these tools still not yet fully ready to accurately and reliably identify AI-generated text [ 10 , 51 ], and new novel detection methods may need to be created and implemented for AI-generated text detection [ 4 ]. This potential issue could lead to another concern, which is the difficulty of accurately evaluating student performance when they utilize chatbots such as ChatGPT assistance in their assignments. Consequently, the most LLM-driven chatbots present a substantial challenge to traditional assessments [ 64 ]. The findings from previous studies indicate the importance of rethinking, improving, and redesigning innovative assessment methods in the era of chatbots [ 14 , 20 , 64 , 75 ]. These methods should prioritize the process of evaluating students' ability to apply knowledge to complex cases and demonstrate comprehension, rather than solely focusing on the final product for assessment. Therefore, immediate action is needed to address these potential issues. One possible solution would be the development of clear guidelines, regulatory policies, and pedagogical guidance. These measures would help regulate the proper and ethical utilization of chatbots, such as ChatGPT, and must be established before their introduction to students [ 35 , 38 , 39 , 41 , 89 ].

In summary, our review has delved into the utilization of ChatGPT, a prominent example of chatbots, in education, addressing the question of how ChatGPT has been utilized in education. However, there remain significant gaps, which necessitate further research to shed light on this area.

7 Conclusions

This systematic review has shed light on the varied initial attempts at incorporating ChatGPT into education by both learners and educators, while also offering insights and considerations that can facilitate its effective and responsible use in future educational contexts. From the analysis of 14 selected studies, the review revealed the dual-edged impact of ChatGPT in educational settings. On the positive side, ChatGPT significantly aided the learning process in various ways. Learners have used it as a virtual intelligent assistant, benefiting from its ability to provide immediate feedback, on-demand answers, and easy access to educational resources. Additionally, it was clear that learners have used it to enhance their writing and language skills, engaging in practices such as generating ideas, composing essays, and performing tasks like summarizing, translating, paraphrasing texts, or checking grammar. Importantly, other learners have utilized it in supporting and facilitating their directed and personalized learning on a broad range of educational topics, assisting in understanding concepts and homework, providing structured learning plans, and clarifying assignments and tasks. Educators, on the other hand, found ChatGPT beneficial for enhancing productivity and efficiency. They used it for creating lesson plans, generating quizzes, providing additional resources, and answers learners' questions, which saved time and allowed for more dynamic and engaging teaching strategies and methodologies.

However, the review also pointed out negative impacts. The results revealed that overuse of ChatGPT could decrease innovative capacities and collaborative learning among learners. Specifically, relying too much on ChatGPT for quick answers can inhibit learners' critical thinking and problem-solving skills. Learners might not engage deeply with the material or consider multiple solutions to a problem. This tendency was particularly evident in group projects, where learners preferred consulting ChatGPT individually for solutions over brainstorming and collaborating with peers, which negatively affected their teamwork abilities. On a broader level, integrating ChatGPT into education has also raised several concerns, including the potential for providing inaccurate or misleading information, issues of inequity in access, challenges related to academic integrity, and the possibility of misusing the technology.

Accordingly, this review emphasizes the urgency of developing clear rules, policies, and regulations to ensure ChatGPT's effective and responsible use in educational settings, alongside other chatbots, by both learners and educators. This requires providing well-structured training to educate them on responsible usage and understanding its limitations, along with offering sufficient background information. Moreover, it highlights the importance of rethinking, improving, and redesigning innovative teaching and assessment methods in the era of ChatGPT. Furthermore, conducting further research and engaging in discussions with policymakers and stakeholders are essential steps to maximize the benefits for both educators and learners and ensure academic integrity.

It is important to acknowledge that this review has certain limitations. Firstly, the limited inclusion of reviewed studies can be attributed to several reasons, including the novelty of the technology, as new technologies often face initial skepticism and cautious adoption; the lack of clear guidelines or best practices for leveraging this technology for educational purposes; and institutional or governmental policies affecting the utilization of this technology in educational contexts. These factors, in turn, have affected the number of studies available for review. Secondly, the utilization of the original version of ChatGPT, based on GPT-3 or GPT-3.5, implies that new studies utilizing the updated version, GPT-4 may lead to different findings. Therefore, conducting follow-up systematic reviews is essential once more empirical studies on ChatGPT are published. Additionally, long-term studies are necessary to thoroughly examine and assess the impact of ChatGPT on various educational practices.

Despite these limitations, this systematic review has highlighted the transformative potential of ChatGPT in education, revealing its diverse utilization by learners and educators alike and summarized the benefits of incorporating it into education, as well as the forefront critical concerns and challenges that must be addressed to facilitate its effective and responsible use in future educational contexts. This review could serve as an insightful resource for practitioners who seek to integrate ChatGPT into education and stimulate further research in the field.

Data availability

The data supporting our findings are available upon request.

Abbreviations

  • Artificial intelligence

AI in education

Large language model

Artificial neural networks

Chat Generative Pre-Trained Transformer

Recurrent neural networks

Long short-term memory

Reinforcement learning from human feedback

Natural language processing

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

AlAfnan MA, Dishari S, Jovic M, Lomidze K. ChatGPT as an educational tool: opportunities, challenges, and recommendations for communication, business writing, and composition courses. J Artif Intell Technol. 2023. https://doi.org/10.37965/jait.2023.0184 .

Article   Google Scholar  

Ali JKM, Shamsan MAA, Hezam TA, Mohammed AAQ. Impact of ChatGPT on learning motivation. J Engl Stud Arabia Felix. 2023;2(1):41–9. https://doi.org/10.56540/jesaf.v2i1.51 .

Alkaissi H, McFarlane SI. Artificial hallucinations in ChatGPT: implications in scientific writing. Cureus. 2023. https://doi.org/10.7759/cureus.35179 .

Anderson N, Belavý DL, Perle SM, Hendricks S, Hespanhol L, Verhagen E, Memon AR. AI did not write this manuscript, or did it? Can we trick the AI text detector into generated texts? The potential future of ChatGPT and AI in sports & exercise medicine manuscript generation. BMJ Open Sport Exerc Med. 2023;9(1): e001568. https://doi.org/10.1136/bmjsem-2023-001568 .

Ausat AMA, Massang B, Efendi M, Nofirman N, Riady Y. Can chat GPT replace the role of the teacher in the classroom: a fundamental analysis. J Educ. 2023;5(4):16100–6.

Google Scholar  

Baidoo-Anu D, Ansah L. Education in the Era of generative artificial intelligence (AI): understanding the potential benefits of ChatGPT in promoting teaching and learning. Soc Sci Res Netw. 2023. https://doi.org/10.2139/ssrn.4337484 .

Basic Z, Banovac A, Kruzic I, Jerkovic I. Better by you, better than me, chatgpt3 as writing assistance in students essays. 2023. arXiv preprint arXiv:2302.04536 .‏

Baskara FR. The promises and pitfalls of using chat GPT for self-determined learning in higher education: an argumentative review. Prosiding Seminar Nasional Fakultas Tarbiyah dan Ilmu Keguruan IAIM Sinjai. 2023;2:95–101. https://doi.org/10.47435/sentikjar.v2i0.1825 .

Behera RK, Bala PK, Dhir A. The emerging role of cognitive computing in healthcare: a systematic literature review. Int J Med Inform. 2019;129:154–66. https://doi.org/10.1016/j.ijmedinf.2019.04.024 .

Chaka C. Detecting AI content in responses generated by ChatGPT, YouChat, and Chatsonic: the case of five AI content detection tools. J Appl Learn Teach. 2023. https://doi.org/10.37074/jalt.2023.6.2.12 .

Chiu TKF, Xia Q, Zhou X, Chai CS, Cheng M. Systematic literature review on opportunities, challenges, and future research recommendations of artificial intelligence in education. Comput Educ Artif Intell. 2023;4:100118. https://doi.org/10.1016/j.caeai.2022.100118 .

Choi EPH, Lee JJ, Ho M, Kwok JYY, Lok KYW. Chatting or cheating? The impacts of ChatGPT and other artificial intelligence language models on nurse education. Nurse Educ Today. 2023;125:105796. https://doi.org/10.1016/j.nedt.2023.105796 .

Cotton D, Cotton PA, Shipway JR. Chatting and cheating: ensuring academic integrity in the era of ChatGPT. Innov Educ Teach Int. 2023. https://doi.org/10.1080/14703297.2023.2190148 .

Crawford J, Cowling M, Allen K. Leadership is needed for ethical ChatGPT: Character, assessment, and learning using artificial intelligence (AI). J Univ Teach Learn Pract. 2023. https://doi.org/10.53761/1.20.3.02 .

Creswell JW. Educational research: planning, conducting, and evaluating quantitative and qualitative research [Ebook]. 4th ed. London: Pearson Education; 2015.

Curry D. ChatGPT Revenue and Usage Statistics (2023)—Business of Apps. 2023. https://www.businessofapps.com/data/chatgpt-statistics/

Day T. A preliminary investigation of fake peer-reviewed citations and references generated by ChatGPT. Prof Geogr. 2023. https://doi.org/10.1080/00330124.2023.2190373 .

De Castro CA. A Discussion about the Impact of ChatGPT in education: benefits and concerns. J Bus Theor Pract. 2023;11(2):p28. https://doi.org/10.22158/jbtp.v11n2p28 .

Deng X, Yu Z. A meta-analysis and systematic review of the effect of Chatbot technology use in sustainable education. Sustainability. 2023;15(4):2940. https://doi.org/10.3390/su15042940 .

Eke DO. ChatGPT and the rise of generative AI: threat to academic integrity? J Responsib Technol. 2023;13:100060. https://doi.org/10.1016/j.jrt.2023.100060 .

Elmoazen R, Saqr M, Tedre M, Hirsto L. A systematic literature review of empirical research on epistemic network analysis in education. IEEE Access. 2022;10:17330–48. https://doi.org/10.1109/access.2022.3149812 .

Farrokhnia M, Banihashem SK, Noroozi O, Wals AEJ. A SWOT analysis of ChatGPT: implications for educational practice and research. Innov Educ Teach Int. 2023. https://doi.org/10.1080/14703297.2023.2195846 .

Fergus S, Botha M, Ostovar M. Evaluating academic answers generated using ChatGPT. J Chem Educ. 2023;100(4):1672–5. https://doi.org/10.1021/acs.jchemed.3c00087 .

Fink A. Conducting research literature reviews: from the Internet to Paper. Incorporated: SAGE Publications; 2010.

Firaina R, Sulisworo D. Exploring the usage of ChatGPT in higher education: frequency and impact on productivity. Buletin Edukasi Indonesia (BEI). 2023;2(01):39–46. https://doi.org/10.56741/bei.v2i01.310 .

Firat, M. (2023). How chat GPT can transform autodidactic experiences and open education.  Department of Distance Education, Open Education Faculty, Anadolu Unive .‏ https://orcid.org/0000-0001-8707-5918

Firat M. What ChatGPT means for universities: perceptions of scholars and students. J Appl Learn Teach. 2023. https://doi.org/10.37074/jalt.2023.6.1.22 .

Fuchs K. Exploring the opportunities and challenges of NLP models in higher education: is Chat GPT a blessing or a curse? Front Educ. 2023. https://doi.org/10.3389/feduc.2023.1166682 .

García-Peñalvo FJ. La percepción de la inteligencia artificial en contextos educativos tras el lanzamiento de ChatGPT: disrupción o pánico. Educ Knowl Soc. 2023;24: e31279. https://doi.org/10.14201/eks.31279 .

Gilson A, Safranek CW, Huang T, Socrates V, Chi L, Taylor A, Chartash D. How does ChatGPT perform on the United States medical Licensing examination? The implications of large language models for medical education and knowledge assessment. JMIR Med Educ. 2023;9: e45312. https://doi.org/10.2196/45312 .

Hashana AJ, Brundha P, Ayoobkhan MUA, Fazila S. Deep Learning in ChatGPT—A Survey. In   2023 7th international conference on trends in electronics and informatics (ICOEI) . 2023. (pp. 1001–1005). IEEE. https://doi.org/10.1109/icoei56765.2023.10125852

Hirsto L, Saqr M, López-Pernas S, Valtonen T. (2022). A systematic narrative review of learning analytics research in K-12 and schools.  Proceedings . https://ceur-ws.org/Vol-3383/FLAIEC22_paper_9536.pdf

Hisan UK, Amri MM. ChatGPT and medical education: a double-edged sword. J Pedag Educ Sci. 2023;2(01):71–89. https://doi.org/10.13140/RG.2.2.31280.23043/1 .

Hopkins AM, Logan JM, Kichenadasse G, Sorich MJ. Artificial intelligence chatbots will revolutionize how cancer patients access information: ChatGPT represents a paradigm-shift. JNCI Cancer Spectr. 2023. https://doi.org/10.1093/jncics/pkad010 .

Househ M, AlSaad R, Alhuwail D, Ahmed A, Healy MG, Latifi S, Sheikh J. Large Language models in medical education: opportunities, challenges, and future directions. JMIR Med Educ. 2023;9: e48291. https://doi.org/10.2196/48291 .

Ilkka T. The impact of artificial intelligence on learning, teaching, and education. Minist de Educ. 2018. https://doi.org/10.2760/12297 .

Iqbal N, Ahmed H, Azhar KA. Exploring teachers’ attitudes towards using CHATGPT. Globa J Manag Adm Sci. 2022;3(4):97–111. https://doi.org/10.46568/gjmas.v3i4.163 .

Irfan M, Murray L, Ali S. Integration of Artificial intelligence in academia: a case study of critical teaching and learning in Higher education. Globa Soc Sci Rev. 2023;8(1):352–64. https://doi.org/10.31703/gssr.2023(viii-i).32 .

Jeon JH, Lee S. Large language models in education: a focus on the complementary relationship between human teachers and ChatGPT. Educ Inf Technol. 2023. https://doi.org/10.1007/s10639-023-11834-1 .

Khan RA, Jawaid M, Khan AR, Sajjad M. ChatGPT—Reshaping medical education and clinical management. Pak J Med Sci. 2023. https://doi.org/10.12669/pjms.39.2.7653 .

King MR. A conversation on artificial intelligence, Chatbots, and plagiarism in higher education. Cell Mol Bioeng. 2023;16(1):1–2. https://doi.org/10.1007/s12195-022-00754-8 .

Kooli C. Chatbots in education and research: a critical examination of ethical implications and solutions. Sustainability. 2023;15(7):5614. https://doi.org/10.3390/su15075614 .

Kuhail MA, Alturki N, Alramlawi S, Alhejori K. Interacting with educational chatbots: a systematic review. Educ Inf Technol. 2022;28(1):973–1018. https://doi.org/10.1007/s10639-022-11177-3 .

Lee H. The rise of ChatGPT: exploring its potential in medical education. Anat Sci Educ. 2023. https://doi.org/10.1002/ase.2270 .

Li L, Subbareddy R, Raghavendra CG. AI intelligence Chatbot to improve students learning in the higher education platform. J Interconnect Netw. 2022. https://doi.org/10.1142/s0219265921430325 .

Limna P. A Review of Artificial Intelligence (AI) in Education during the Digital Era. 2022. https://ssrn.com/abstract=4160798

Lo CK. What is the impact of ChatGPT on education? A rapid review of the literature. Educ Sci. 2023;13(4):410. https://doi.org/10.3390/educsci13040410 .

Luo W, He H, Liu J, Berson IR, Berson MJ, Zhou Y, Li H. Aladdin’s genie or pandora’s box For early childhood education? Experts chat on the roles, challenges, and developments of ChatGPT. Early Educ Dev. 2023. https://doi.org/10.1080/10409289.2023.2214181 .

Meyer JG, Urbanowicz RJ, Martin P, O’Connor K, Li R, Peng P, Moore JH. ChatGPT and large language models in academia: opportunities and challenges. Biodata Min. 2023. https://doi.org/10.1186/s13040-023-00339-9 .

Mhlanga D. Open AI in education, the responsible and ethical use of ChatGPT towards lifelong learning. Soc Sci Res Netw. 2023. https://doi.org/10.2139/ssrn.4354422 .

Neumann, M., Rauschenberger, M., & Schön, E. M. (2023). “We Need To Talk About ChatGPT”: The Future of AI and Higher Education.‏ https://doi.org/10.1109/seeng59157.2023.00010

Nolan B. Here are the schools and colleges that have banned the use of ChatGPT over plagiarism and misinformation fears. Business Insider . 2023. https://www.businessinsider.com

O’Leary DE. An analysis of three chatbots: BlenderBot, ChatGPT and LaMDA. Int J Intell Syst Account, Financ Manag. 2023;30(1):41–54. https://doi.org/10.1002/isaf.1531 .

Okoli C. A guide to conducting a standalone systematic literature review. Commun Assoc Inf Syst. 2015. https://doi.org/10.17705/1cais.03743 .

OpenAI. (2023). https://openai.com/blog/chatgpt

Perkins M. Academic integrity considerations of AI large language models in the post-pandemic era: ChatGPT and beyond. J Univ Teach Learn Pract. 2023. https://doi.org/10.53761/1.20.02.07 .

Plevris V, Papazafeiropoulos G, Rios AJ. Chatbots put to the test in math and logic problems: A preliminary comparison and assessment of ChatGPT-3.5, ChatGPT-4, and Google Bard. arXiv (Cornell University) . 2023. https://doi.org/10.48550/arxiv.2305.18618

Rahman MM, Watanobe Y (2023) ChatGPT for education and research: opportunities, threats, and strategies. Appl Sci 13(9):5783. https://doi.org/10.3390/app13095783

Ram B, Verma P. Artificial intelligence AI-based Chatbot study of ChatGPT, google AI bard and baidu AI. World J Adv Eng Technol Sci. 2023;8(1):258–61. https://doi.org/10.30574/wjaets.2023.8.1.0045 .

Rasul T, Nair S, Kalendra D, Robin M, de Oliveira Santini F, Ladeira WJ, Heathcote L. The role of ChatGPT in higher education: benefits, challenges, and future research directions. J Appl Learn Teach. 2023. https://doi.org/10.37074/jalt.2023.6.1.29 .

Ratnam M, Sharm B, Tomer A. ChatGPT: educational artificial intelligence. Int J Adv Trends Comput Sci Eng. 2023;12(2):84–91. https://doi.org/10.30534/ijatcse/2023/091222023 .

Ray PP. ChatGPT: a comprehensive review on background, applications, key challenges, bias, ethics, limitations and future scope. Internet Things Cyber-Phys Syst. 2023;3:121–54. https://doi.org/10.1016/j.iotcps.2023.04.003 .

Roumeliotis KI, Tselikas ND. ChatGPT and Open-AI models: a preliminary review. Future Internet. 2023;15(6):192. https://doi.org/10.3390/fi15060192 .

Rudolph J, Tan S, Tan S. War of the chatbots: Bard, Bing Chat, ChatGPT, Ernie and beyond. The new AI gold rush and its impact on higher education. J Appl Learn Teach. 2023. https://doi.org/10.37074/jalt.2023.6.1.23 .

Ruiz LMS, Moll-López S, Nuñez-Pérez A, Moraño J, Vega-Fleitas E. ChatGPT challenges blended learning methodologies in engineering education: a case study in mathematics. Appl Sci. 2023;13(10):6039. https://doi.org/10.3390/app13106039 .

Sallam M, Salim NA, Barakat M, Al-Tammemi AB. ChatGPT applications in medical, dental, pharmacy, and public health education: a descriptive study highlighting the advantages and limitations. Narra J. 2023;3(1): e103. https://doi.org/10.52225/narra.v3i1.103 .

Salvagno M, Taccone FS, Gerli AG. Can artificial intelligence help for scientific writing? Crit Care. 2023. https://doi.org/10.1186/s13054-023-04380-2 .

Saqr M, López-Pernas S, Helske S, Hrastinski S. The longitudinal association between engagement and achievement varies by time, students’ profiles, and achievement state: a full program study. Comput Educ. 2023;199:104787. https://doi.org/10.1016/j.compedu.2023.104787 .

Saqr M, Matcha W, Uzir N, Jovanović J, Gašević D, López-Pernas S. Transferring effective learning strategies across learning contexts matters: a study in problem-based learning. Australas J Educ Technol. 2023;39(3):9.

Schöbel S, Schmitt A, Benner D, Saqr M, Janson A, Leimeister JM. Charting the evolution and future of conversational agents: a research agenda along five waves and new frontiers. Inf Syst Front. 2023. https://doi.org/10.1007/s10796-023-10375-9 .

Shoufan A. Exploring students’ perceptions of CHATGPT: thematic analysis and follow-up survey. IEEE Access. 2023. https://doi.org/10.1109/access.2023.3268224 .

Sonderegger S, Seufert S. Chatbot-mediated learning: conceptual framework for the design of Chatbot use cases in education. Gallen: Institute for Educational Management and Technologies, University of St; 2022. https://doi.org/10.5220/0010999200003182 .

Book   Google Scholar  

Strzelecki A. To use or not to use ChatGPT in higher education? A study of students’ acceptance and use of technology. Interact Learn Environ. 2023. https://doi.org/10.1080/10494820.2023.2209881 .

Su J, Yang W. Unlocking the power of ChatGPT: a framework for applying generative AI in education. ECNU Rev Educ. 2023. https://doi.org/10.1177/20965311231168423 .

Sullivan M, Kelly A, McLaughlan P. ChatGPT in higher education: Considerations for academic integrity and student learning. J ApplLearn Teach. 2023;6(1):1–10. https://doi.org/10.37074/jalt.2023.6.1.17 .

Szabo A. ChatGPT is a breakthrough in science and education but fails a test in sports and exercise psychology. Balt J Sport Health Sci. 2023;1(128):25–40. https://doi.org/10.33607/bjshs.v127i4.1233 .

Taecharungroj V. “What can ChatGPT do?” analyzing early reactions to the innovative AI chatbot on Twitter. Big Data Cognit Comput. 2023;7(1):35. https://doi.org/10.3390/bdcc7010035 .

Tam S, Said RB. User preferences for ChatGPT-powered conversational interfaces versus traditional methods. Biomed Eng Soc. 2023. https://doi.org/10.58496/mjcsc/2023/004 .

Tedre M, Kahila J, Vartiainen H. (2023). Exploration on how co-designing with AI facilitates critical evaluation of ethics of AI in craft education. In: Langran E, Christensen P, Sanson J (Eds).  Proceedings of Society for Information Technology and Teacher Education International Conference . 2023. pp. 2289–2296.

Tlili A, Shehata B, Adarkwah MA, Bozkurt A, Hickey DT, Huang R, Agyemang B. What if the devil is my guardian angel: ChatGPT as a case study of using chatbots in education. Smart Learn Environ. 2023. https://doi.org/10.1186/s40561-023-00237-x .

Uddin SMJ, Albert A, Ovid A, Alsharef A. Leveraging CHATGPT to aid construction hazard recognition and support safety education and training. Sustainability. 2023;15(9):7121. https://doi.org/10.3390/su15097121 .

Valtonen T, López-Pernas S, Saqr M, Vartiainen H, Sointu E, Tedre M. The nature and building blocks of educational technology research. Comput Hum Behav. 2022;128:107123. https://doi.org/10.1016/j.chb.2021.107123 .

Vartiainen H, Tedre M. Using artificial intelligence in craft education: crafting with text-to-image generative models. Digit Creat. 2023;34(1):1–21. https://doi.org/10.1080/14626268.2023.2174557 .

Ventayen RJM. OpenAI ChatGPT generated results: similarity index of artificial intelligence-based contents. Soc Sci Res Netw. 2023. https://doi.org/10.2139/ssrn.4332664 .

Wagner MW, Ertl-Wagner BB. Accuracy of information and references using ChatGPT-3 for retrieval of clinical radiological information. Can Assoc Radiol J. 2023. https://doi.org/10.1177/08465371231171125 .

Wardat Y, Tashtoush MA, AlAli R, Jarrah AM. ChatGPT: a revolutionary tool for teaching and learning mathematics. Eurasia J Math, Sci Technol Educ. 2023;19(7):em2286. https://doi.org/10.29333/ejmste/13272 .

Webster J, Watson RT. Analyzing the past to prepare for the future: writing a literature review. Manag Inf Syst Quart. 2002;26(2):3.

Xiao Y, Watson ME. Guidance on conducting a systematic literature review. J Plan Educ Res. 2017;39(1):93–112. https://doi.org/10.1177/0739456x17723971 .

Yan D. Impact of ChatGPT on learners in a L2 writing practicum: an exploratory investigation. Educ Inf Technol. 2023. https://doi.org/10.1007/s10639-023-11742-4 .

Yu H. Reflection on whether Chat GPT should be banned by academia from the perspective of education and teaching. Front Psychol. 2023;14:1181712. https://doi.org/10.3389/fpsyg.2023.1181712 .

Zhu C, Sun M, Luo J, Li T, Wang M. How to harness the potential of ChatGPT in education? Knowl Manag ELearn. 2023;15(2):133–52. https://doi.org/10.34105/j.kmel.2023.15.008 .

Download references

The paper is co-funded by the Academy of Finland (Suomen Akatemia) Research Council for Natural Sciences and Engineering for the project Towards precision education: Idiographic learning analytics (TOPEILA), Decision Number 350560.

Author information

Authors and affiliations.

School of Computing, University of Eastern Finland, 80100, Joensuu, Finland

Yazid Albadarin, Mohammed Saqr, Nicolas Pope & Markku Tukiainen

You can also search for this author in PubMed   Google Scholar

Contributions

YA contributed to the literature search, data analysis, discussion, and conclusion. Additionally, YA contributed to the manuscript’s writing, editing, and finalization. MS contributed to the study’s design, conceptualization, acquisition of funding, project administration, allocation of resources, supervision, validation, literature search, and analysis of results. Furthermore, MS contributed to the manuscript's writing, revising, and approving it in its finalized state. NP contributed to the results, and discussions, and provided supervision. NP also contributed to the writing process, revisions, and the final approval of the manuscript in its finalized state. MT contributed to the study's conceptualization, resource management, supervision, writing, revising the manuscript, and approving it.

Corresponding author

Correspondence to Yazid Albadarin .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

See Table  4

The process of synthesizing the data presented in Table  4 involved identifying the relevant studies through a search process of databases (ERIC, Scopus, Web of Knowledge, Dimensions.ai, and lens.org) using specific keywords "ChatGPT" and "education". Following this, inclusion/exclusion criteria were applied, and data extraction was performed using Creswell's [ 15 ] coding techniques to capture key information and identify common themes across the included studies.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Albadarin, Y., Saqr, M., Pope, N. et al. A systematic literature review of empirical research on ChatGPT in education. Discov Educ 3 , 60 (2024). https://doi.org/10.1007/s44217-024-00138-2

Download citation

Received : 22 October 2023

Accepted : 10 May 2024

Published : 26 May 2024

DOI : https://doi.org/10.1007/s44217-024-00138-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Large language models
  • Educational technology
  • Systematic review

Advertisement

  • Find a journal
  • Publish with us
  • Track your research
  • Open access
  • Published: 24 May 2024

Systematic review and meta-analysis of hepatitis E seroprevalence in Southeast Asia: a comprehensive assessment of epidemiological patterns

  • Ulugbek Khudayberdievich Mirzaev 1 , 2 ,
  • Serge Ouoba 1 , 3 ,
  • Zayar Phyo 1 ,
  • Chanroth Chhoung 1 ,
  • Akuffo Golda Ataa 1 ,
  • Aya Sugiyama 1 ,
  • Tomoyuki Akita 1 &
  • Junko Tanaka 1  

BMC Infectious Diseases volume  24 , Article number:  525 ( 2024 ) Cite this article

197 Accesses

1 Altmetric

Metrics details

The burden of hepatitis E in Southeast Asia is substantial, influenced by its distinct socio-economic and environmental factors, as well as variations in healthcare systems. The aim of this study was to assess the pooled seroprevalence of hepatitis E across countries within the Southeast Asian region by the UN division.

The study analyzed 66 papers across PubMed, Web of Science, and Scopus databases, encompassing data from of 44,850 individuals focusing on anti-HEV seroprevalence. The investigation spanned nine countries, excluding Brunei and East Timor due to lack of data. The pooled prevalence of anti-HEV IgG was determined to be 21.03%, with the highest prevalence observed in Myanmar (33.46%) and the lowest in Malaysia (5.93%). IgM prevalence was highest in Indonesia (12.43%) and lowest in Malaysia (0.91%). The study stratified populations into high-risk (farm workers, chronic patients) and low-risk groups (general population, blood donors, pregnant women, hospital patients). It revealed a higher IgG—28.9%, IgM—4.42% prevalence in the former group, while the latter group exhibited figures of 17.86% and 3.15%, respectively, indicating occupational and health-related vulnerabilities to HEV.

A temporal analysis (1987–2023), indicated an upward trend in both IgG and IgM prevalence, suggesting an escalating HEV burden.

These findings contribute to a better understanding of HEV seroprevalence in Southeast Asia, shedding light on important public health implications and suggesting directions for further research and intervention strategies.

Research Question

Investigate the seroprevalence of hepatitis E virus (HEV) in Southeast Asian countries focusing on different patterns, timelines, and population cohorts.

Sporadic Transmission of IgG and IgM Prevalence:

• Pooled anti-HEV IgG prevalence: 21.03%

• Pooled anti-HEV IgM prevalence: 3.49%

Seroprevalence among specific groups:

High-risk group (farm workers and chronic patients):

• anti-HEV IgG: 28.9%

• anti-HEV IgM: 4.42%

Low-risk group (general population, blood donors, pregnant women, hospital patients):

• anti-HEV IgG: 17.86%

• anti-HEV IgM: 3.15%

Temporal Seroprevalence of HEV:

Anti-HEV IgG prevalence increased over decades (1987–1999; 2000–2010; 2011–2023): 12.47%, 18.43%, 29.17% as an anti-HEV IgM prevalence: 1.92%, 2.44%, 5.27%

Provides a comprehensive overview of HEV seroprevalence in Southeast Asia.

Highlights variation in seroprevalence among different population groups.

Reveals increasing trend in HEV seroprevalence over the years.

Distinguishes between sporadic and epidemic cases for a better understanding of transmission dynamics.

Peer Review reports

Introduction

Hepatitis E is a major global health concern caused by the hepatitis E virus (HEV), which is a small, nonenveloped, single-stranded, positive-sense RNA virus belonging to the Paslahepevirus genus in the Hepeviridae family. There are eight genotypes of HEV: HEV-1 and HEV-2 infect only humans, HEV-3, HEV-4, and HEV-7 infect both humans and animals, while HEV-5, HEV-6, and HEV-8 infect only animals [ 1 ].

HEV infections affect millions of people worldwide each year, resulting in a significant number of symptomatic cases and deaths. In 2015, the World Health Organization (WHO) reported approximately 44,000 deaths from hepatitis E, accounting for 3.3% of overall mortality attributed to viral hepatitis [ 2 ]. The primary mode of transmission for hepatitis E is through the fecal–oral route. Outbreaks of the disease are often associated with heavy rainfall and flooding [ 3 , 4 ]. Additionally, sporadic cases can occur due to poor sanitation, vertical transmission, blood transfusion or close contact with infected animals, which serve as hosts for the virus [ 5 ]. Southeast Asia carries a substantial burden of hepatitis E, influenced by its unique socio-economic and environmental factors as well as variations in healthcare systems. Understanding the seroprevalence of hepatitis E in this region is crucial for implementing targeted public health interventions and allocating resources. To achieve the effective control and prevention of HEV, it is required to address the waterborne transmission and considering the specific characteristics of each region. By taking these measures, healthcare authorities can work towards reducing the global impact of hepatitis E on public health. Systematic reviews and meta-analyses on hepatitis E play a crucial role in synthesizing and integrating existing research findings, providing comprehensive insights into the epidemiology, transmission, and burden of the disease, thereby aiding evidence-based decision-making and public health strategies [ 6 , 7 ].

Recent systematic reviews and meta-analysis conducted on hepatitis E have varied in their scope or were limited by a smaller number of source materials [ 8 , 9 ]. The objective of this study was to determine the pooled seroprevalence of hepatitis E in countries within Southeast Asia by aggregating findings from a multitude of primary studies conducted across the region.

To commence this systematic review and meta-analysis, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and used the PRISMA assessment checklist [Supplementary Table  1 ]. The study included pertinent research conducted within the population of Southeast Asian countries, as outlined by the United Nations [ 10 ], and perform a meta-analysis on the seroprevalence of hepatitis E in this specific region.

PICOT assessment

In this systematic review and meta-analysis, the eligible population comprised individuals from the Southeast Asia region, irrespective of age, gender, ethnic characteristics, or specific chronic diseases. However, studies involving populations outside the designated countries, travelers, migrants, animal species studies, and those lacking clear descriptions of the study population were excluded.

Intervention and comparison

Intervention and comparison are not applicable to the prevalence studies.

Anti-HEV antibodies positivity either total antibodies or IgG or IgM among the Southeast Asian countries' population was assessed.

All studies conducted between 1987 and 2023 were included in this meta-analysis.

Search strategy

To conduct the data search, we utilized three databases, namely “PubMed”, “Scopus”, and “Web of Science”. The search terms comprised keywords related to the Hepatitis E virus, such as “Hepatitis E virus” OR “Hepatitis E” OR “HEV” AND names of each country “Brunei”, “Cambodia”, “Timor-Leste” OR “East-Timor”, “Laos” OR “Lao PDR”, “Indonesia”, “Malaysia”, “Myanmar” OR “Burma”, “Philippines”, “Singapore”, “Thailand”, “Vietnam” and “Southeast Asia”.

The search process in the databases finished on May 29 th , 2023, with two members of the study team conducting independent searches. Subsequently, the search results were unified. A grey literature search was performed from June 25 th to 30 th , 2023, by examining the references of review manuscripts and conference materials, along with using specific keywords in the Google Scholar database. Notably, during the gray literature search, additional studies from the Philippines that were initially missing in the first search were identified and included. Moreover, due to the diverse language expertise of the team, studies in Russian and French related to Cambodia and Vietnam were also considered for inclusion.

After applying the inclusion and exclusion criteria, each article selected for this systematic review (SR) was considered relevant. The quality assessment of each article was conducted using specific JBI critical appraisal instruments [ 11 ] [Supplementary Table  2 ].

Sporadic transmission of HEV infection

For the systematic review and meta-analysis of sporadic infection of HEV, we divided the study population into cohorts by countries, by risk of acquiring HEV—low and high risk. The low risk cohort included the general population (apparently healthy individuals, students, some ethnic populations, or individuals included in original studies as “general population”), blood donors, pregnant women, and hospital patients, while pig farmers, those with chronic hepatitis, HIV positive patients, and solid organ transplant patients in the high-risk group.

Lastly, we analyzed data in three decades—1987–1999, 2000–2010, and 2011–2023—to reveal seroprevalence rates over time.

Epidemic outbreaks of HEV infection

We separated epidemic outbreaks from sporadic cases due to distinct patterns and scale of transmission in epidemy. Epidemics are characterized by rapid and widespread transmission, affecting a large population within a short period and often following a specific pattern or route of propagation.

Statistical analysis

A meta-analysis of proportions was conducted using the 'meta' and 'metafor' packages in the R statistical software. To account for small proportions, the Freeman-Tukey double arcsine method was applied to transform the data. The Dersimonian and Laird method, which employs a random-effects model, was utilized for the meta-analysis, and the results were presented in a forest plot. Confidence intervals (CIs) for the proportions of individual studies were computed using the Clopper-Pearson method.

Heterogeneity was evaluated using the Cochran Q test and quantified by the I 2 index. Heterogeneity was considered significant if the p -value of the Cochran Q test was below 0.05.

For the assessment of publication bias, a funnel plot displaying the transformed proportions against the sample size was created. The symmetry of the plot was examined using the Egger test ( p  < 0.1).

The initial search yielded 1641 articles, which covered 9 out of 11 Southeast Asia countries. We couldn't find any information on hepatitis E from Brunei. We excluded a study from East Timor because it focused on the wrong population (US Army troops). The final screening resulted in the selection of 57 relevant studies, and the grey literature search added 9 more papers that met our inclusion criteria (Fig.  1 ). Among 9 papers through a grey literature, two relevant studies from the Philippines [ 12 , 13 ], one each from Indonesia [ 14 ] and Lao PDR [ 15 ], one study covered both Vietnam and Cambodia [ 16 ], one study provided HEV seroepidemiology information for Myanmar, Thailand, and Vietnam [ 17 ], two studies reported in Russian [ 18 , 19 ] (from Vietnam) and one reported in French [ 16 ] (from Vietnam and Cambodia). In total, our analysis included 66 papers from which we extracted data. This involved a total of 44,850 individuals (Table  1 ).

figure 1

Flowchart of the identification, inclusion, and exclusion of the study. Table under flowchart informing about the studies which were found by the initial search in databases

Sporadic transmission IgG and IgM prevalence in Southeast Asian countries (excluding outbreak settings)

The sporadic cases involving 42,248 participants out of 44,850 participants (the remaining 2,602 people are considered in the “ Epidemic outbreaks ” section) from Southeast Asian countries the pooled prevalence of IgG was found to be 21.03%, while for IgM, it was 3.49% among 34,480 individuals who were tested (Fig. 2 ). Among these countries, Myanmar registered the highest pooled prevalence of IgG at 33.46%, while Malaysia had the lowest at 5.93%. For IgM prevalence, Indonesia had the highest rate at 12.43%, and Malaysia again had the lowest at 0.91% (Table  2 ) [Supplementary Figures  1 and 6 ].

figure 2

Forest plot of meta-analysis of the prevalence of anti-HEV IgG ( A ) and anti-HEV IgM ( B ) in Southeast Asian countries. The plot includes the number of study participants for each country

Seroprevalence among specific groups

High risk of acquiring hev.

The high-risk group, which included farm workers and chronic patients, demonstrated a pooled anti-HEV IgG prevalence of 28.9%, with IgM prevalence at 4.42% [Supplementary Figures  2 and 8 ].

Chronic patients

This group, comprising individuals with chronic liver disease, HIV infection, or solid organ transplantation, exhibited the highest prevalence of pooled IgG among all cohorts, standing at 29.2%. Additionally, IgM prevalence was 3.9% [Supplementary Figures  2 and 7 ].

Farm workers

Farm workers were divided into several subgroups based on exposure to animals (reservoirs of HEV), including pig or ruminant farmers, slaughterhouse workers, butchers, and meat retailers. Among this group, the highest IgG prevalence was observed at 28.4%, while the pooled IgM level was 6.21% [Supplementary Figures  2 and 7 ].

Low risk of acquiring HEV

The low-risk group, comprising the general population, blood donors, pregnant women, and hospital patients, exhibited anti-HEV IgG and IgM prevalence of 17.86% and 3.15%, respectively. [Supplementary Figures  2 and 9 ].

General population

The general population in Southeast Asian countries, represented by 22,571 individuals, showed a presence of IgG in 21.4% of them. IgM was tested in 10,304 participants, and 2.63% of acute infection cases were identified [Supplementary Figures  2 and 7 ].

Blood donors

Blood donors, as a selected subgroup of the general population, exhibit differences in health status, age, gender distribution, and representativeness, warranting separate assessment. Among blood donors in Southeast Asian countries, the pooled prevalence of IgG and IgM were found to be 11.77% and 0.83%, respectively [Supplementary Figures  2 and 7 ].

Pregnant women

Pregnant women considered a vulnerable group regarding disease consequences, demonstrated an anti-HEV IgG prevalence of 18.56% among 1,670 individuals included in the study. Furthermore, 1.54% of them tested positive for anti-HEV IgM [Supplementary Figures  2 and 7 ].

Hospital patients

A group of 18,792 patients who visited hospitals with clinical signs of acute infection, jaundice, high temperature, and elevated liver enzymes, showed anti-HEV IgG and IgM prevalence of 16.3% and 4.45%, respectively [Supplementary Figures  2 and 7 ].

Temporal seroprevalence of HEV

Given the studies' long duration, the data was presented by decades: 1987–1999, 2000–2010, and 2011–2023. The prevalence of IgG showed an upward trend over these decades, with rates of 12.47%, 18.43%, and 29.17%. Similarly, for IgM, the prevalence rates were 1.92%, 2.44%, and 5.27% for the first, second, and third decades, respectively (Fig. 3 ).

figure 3

The prevalence of anti-HEV IgG and IgM in Southeast Asian countries throughout the decades

Evaluating the trend of seroprevalence over decades within the same population and country proved challenging due to the limited availability of research papers. Consequently, we assessed anti-HEV antibody prevalence over decades, considering population cohorts and individual countries.

In Fig.  4 , we can see that all population groups show a consistent increase in the prevalence of both IgG and IgM antibodies over the decades. Figure  5 , we analyze the prevalence of anti-HEV antibodies in different countries over time, except for Indonesia and Malaysia, where we observe an increase in prevalence.

figure 4

The epidemiological data regarding the occurrence of anti-HEV IgG ( A ) and anti-HEV IgM ( B ) antibodies within population cohorts across Southeast Asian nations divided by decades. The population cohorts delineated by the disrupted lines in the figure lack comprehensive data representation, as they provide information for only two out of three decades. Blood donors group has the anti-HEV IgM only for the last decade

figure 5

The epidemiological data regarding the occurrence of anti-HEV IgG ( A ) and anti-HEV IgM ( B ) antibodies within countries of Southeast Asia divided by decades. The countries delineated by the disrupted lines in the figure lack comprehensive data representation, as they provide information for only two out of three decades. Philippines has the anti-HEV IgG antibodies information only for the first decade. Philippines, Myanmar, Singapore have anti-HEV IgM information only for single decade

Some studies lacked information on the collection time of the samples [ 13 , 19 , 41 , 48 , 59 , 62 , 64 , 82 ]. In these studies, the pooled IgG and IgM prevalence was 26.5% and 4.75%, respectively [Supplementary Figures  3 , 4 , 5 , 10 , 11 , 12 ].

Epidemic outbreaks

We separated epidemic outbreaks from sporadic cases due to distinct patterns and scale of transmission in epidemy. Epidemics are characterized by rapid and widespread transmission, affecting a large population within a short period and often following a specific pattern or route of propagation. The outbreaks occurred between 1987 and 1998 in several Southeast Asian countries, namely Indonesia [ 31 , 33 , 34 ], Vietnam [ 77 ], and Myanmar [ 54 ] [Supplementary Figure  13 ]. These outbreak investigations involved a total of 2,602 individuals, with most participants from Indonesia (2,292 individuals). The studies were mainly conducted using a case–control design. Among the participants, 876 were considered controls, while 1,726 were classified as cases. The pooled prevalence of total anti-HEV immunoglobulins was estimated as 61.6% (95% CI 57.1–66) (Table  2 ).

Assessment of publication bias

We checked for publication bias using a funnel plot and Egger's test. Both the studies on anti-HEV IgG and IgM showed asymmetry with Egger's test indicating a p -value less than 0.001 for both cases (Fig. 6 ).

figure 6

Funnel plot of anti-HEV IgG ( A ) and anti-HEV IgM prevalence. Double arcsine transformed proportion of individual studies is plotted against the sample size. The distribution of studies in the funnel plot revealed the presence of publication bias

A paper search yielded varying numbers of manuscripts from Southeast Asian countries. The Philippines had the fewest studies, while Thailand had the highest with 15 studies. No data was found for Brunei Darussalam and East Timor or Timor Leste on the human species.

The results of this study provide valuable insights into the seroprevalence of IgG and IgM antibodies against HEV in different populations across Southeast Asian countries. Understanding the prevalence of these antibodies is essential for assessing the burden of HEV infection and identifying high-risk groups.

The extensive analysis of anti-HEV IgG prevalence in this study covered a wide range of population groups in Southeast Asia, including the general population, blood donors, pregnant women, hospital patients, farm workers, and chronic patients. The results unveiled an overall pooled prevalence of 21.03%, indicating significant exposure to the Hepatitis E virus among individuals in the region at some point in their lives. Moreover, a consistent increase in IgG prevalence was observed over the years, with the highest prevalence occurring in the most recent decade (2011–2023). This suggests a progressive rise in HEV exposure within the region.

Upon examining the prevalence data across different decades and population cohorts, a uniform upward trend in HEV antibody prevalence became apparent across all groups. Several factors could be assessed as potential contributors to this trend:

Notably, the expanding population in Southeast Asian nations during this timeframe increased the number of individuals at risk of Hepatitis E infection.

The rapid urbanization, characterized by the migration from rural to urban areas, led to higher population density and conditions conducive to Hepatitis E virus transmission [ 84 ]. Access to clean drinking water and adequate sanitation facilities emerged as critical factors in preventing Hepatitis E. Regions with inadequate infrastructure, particularly in water and sanitation, faced an elevated risk due to contaminated water sources. Climate-related events, such as heavy rainfall and flooding, significantly impacted waterborne diseases like Hepatitis E. The increasing frequency and severity of such events emphasized the importance of considering climate-related factors in assessing prevalence trends [ 85 ]. Consumption of contaminated or undercooked meat, particularly pork, was identified as a source of Hepatitis E transmission. Changes in food consumption habits over time may have contributed to changes in seroprevalence [ 86 ]. Limited access to healthcare facilities in certain areas exacerbated the spread of Hepatitis E. Increased awareness together with advances in medical research and the establishment of robust surveillance systems likely improved the detection and reporting of Hepatitis E cases, contributing to the observed increase in seroprevalence [ 87 , 88 , 89 ]. These multifaceted factors have likely played a collective role in shaping the changing landscape of Hepatitis E seroprevalence in Southeast Asian nations over the past decades. The upward trend emphasizes the importance of continued monitoring, intervention, and public health measures to mitigate the spread of Hepatitis E in the region.

Among specific populations, pregnant women exhibited an IgG prevalence of 18.56%, indicating that a considerable number of pregnant individuals have been exposed to HEV. Pregnant women are particularly vulnerable to the consequences of HEV infection, as it can lead to severe outcomes for both the mother and the foetus.

Hospital patients with clinical signs of acute infection showed an IgG prevalence of 16.3%, suggesting that HEV is still a significant cause of acute hepatitis cases in the hospital setting. Similarly, farm workers, especially those exposed to animals (reservoirs of HEV), had a high prevalence of IgG (28.4%), highlighting the occupational risk associated with zoonotic transmission.

Chronic patients, including individuals with chronic liver disease, HIV infection, or solid organ transplantation, exhibited the highest pooled IgG prevalence among all cohorts at 29.2%. This finding underscores the importance of monitoring HEV infection in immunocompromised individuals, as they may develop chronic HEV infection, which can lead to severe liver complications.

The prevalence of IgM antibodies, which are indicative of recent or acute HEV infection, was lower overall compared to IgG. The general population showed an IgM prevalence of 2.63% among acute infection cases. Among hospital patients exhibiting clinical signs of acute infection, the prevalence of IgM antibodies indicative of recent or acute HEV infection was higher at 4.45%.

Farm workers, particularly those exposed to animals, demonstrated the highest IgM prevalence at 6.21%. This finding highlights the occupational risk of acquiring acute HEV infection in this population due to direct or indirect contact with infected animals.

The study also identified a high-risk group, consisting of farm workers and chronic patients, with a pooled IgG prevalence of 28.9% and an IgM prevalence of 4.42%. This group is particularly susceptible to HEV infection and requires targeted interventions to reduce transmission and prevent severe outcomes.

Overall, this study provides valuable data on the seroprevalence of HEV antibodies in different populations in Southeast Asian countries. It highlights the importance of continued surveillance and public health interventions to control HEV transmission, especially in vulnerable groups. Understanding the prevalence trends over time can aid in developing effective strategies for the prevention and management of HEV infections in the region. However, further research and studies are warranted to explore the underlying factors contributing to the observed seroprevalence trends and to design targeted interventions to reduce HEV transmission in specific populations. Among the countries of Southeast Asia Myanmar was the most for HEV infection, while Malaysia registered the lowest seroprevalence.

This study has some limitations that we should be aware of. We looked at studies in three languages (English, Russian, and French), but we couldn't find data from two out of the 11 countries. This means we might not have a complete picture of the disease's prevalence in the whole region.

The way we divided the groups based on occupation or status could be questioned. Different criteria might give us different results, so it's something we need to consider. Another challenge is that the study covers a long time from 1989 to 2023 by published research and involves many different countries. This makes it difficult to compare the results because the tests used, and the diagnostic abilities might have changed over time and vary across countries.

Despite these limitations, our study presents a detailed epidemiologic report of combined seroprevalence data for HEV in Southeast Asian countries following the UN division. It gives us a basic understanding of the disease's prevalence in the region and offers some insights into potential risk factors. However, to get a more accurate picture, future research should address these limitations and include data from all countries in the region. Furthermore, certain countries such as Myanmar and the Philippines have not reported HEV prevalence data since 2006 and 2015, respectively. The absence of recent HEV prevalence reports from certain countries raises concerns about the availability of up-to-date epidemiological data for assessing the current status of hepatitis E virus infections in these regions.

Our comprehensive analysis study involving Southeast Asian countries provides significant insights into the seroprevalence of hepatitis E virus (HEV) infection in this region and in various populations. The rates of anti-HEV antibodies observed among different groups, as well as the increasing trend in seroprevalence over decades, emphasize the dynamic nature of HEV transmission in the region. These findings contribute to a better understanding of HEV prevalence across countries, populations, and time periods in Southeast Asia, shedding light on important public health implications and suggesting directions for further research and intervention strategies.

Availability of data and materials

All data generated or analyzed during this study were included in this paper either in the results or supplementary information.

Abbreviations

Hepatitis E Virus

Preferred reporting items for systematic review and meta-analysis

Enzyme-Linked Immunosorbent Essay

Hepatitis E virus Immunoglobulin G

Hepatitis E Virus Immunoglobulin M

Smith DB, Izopet J, Nicot F, Simmonds P, Jameel S, Meng XJ, et al. Update: proposed reference sequences for subtypes of hepatitis E virus (species Orthohepevirus A). J Gen Virol. 2020 [cited 2023 Aug 3];101(7):692. Available from: /pmc/articles/PMC7660235/.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Hepatitis E. Available from: https://www.who.int/news-room/fact-sheets/detail/hepatitis-e . Accessed 22 July 2023.

Viswanathan R. A review of the literature on the epidemiology of infectious hepatitis. Indian J Med Res. 1957;45:145–55.

CAS   PubMed   Google Scholar  

Naik SR, Aggarwal R, Salunke PN, Mehrotra NN. A large waterborne viral hepatitis E epidemic in Kanpur, India. Bull World Health Organ. 1992 [cited 2023 Jul 20];70(5):597. Available from: /pmc/articles/PMC2393368/?report=abstract.

CAS   PubMed   PubMed Central   Google Scholar  

Aslan AT, Balaban HY. Hepatitis E virus: epidemiology, diagnosis, clinical manifestations, and treatment. World J Gastroenterol. 2020;26(37):5543–60.

Mulrow CD. Rationale for systematic reviews. BMJ. 1994 [cited 2023 Jul 20];309(6954):597–9. Available from: https://pubmed.ncbi.nlm.nih.gov/8086953/ .

Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med. 1997;126(5):376–80.

Article   CAS   PubMed   Google Scholar  

Wasuwanich P, Thawillarp S, Ingviya T, Karnsakul W. Hepatitis E in Southeast Asia. Siriraj Med J. 2020 [cited 2023 Jul 20];72(3):259–64. Available from: https://he02.tci-thaijo.org/index.php/sirirajmedj/article/view/240129 .

Article   Google Scholar  

Raji YE, Peck Toung O, Mohd N, Zamberi T, Sekawi B, MohdTaib N, et al. A systematic review of the epidemiology of hepatitis E virus infection in South – Eastern Asia. Virulence. 2021 [cited 2023 Jul 20];12(1):114. Available from: /pmc/articles/PMC7781573/.

South East Asia. Available from: https://www.unep.org/ozonaction/south-east-asia . Accessed 28 May 2023.

Chapter 5: Systematic reviews of prevalence and incidence - JBI Manual for Evidence Synthesis - JBI Global Wiki. [accessed 2023 May 20]. Available from: https://jbi-global-wiki.refined.site/space/MANUAL/4688607/Chapter+5%3A+Systematic+reviews+of+prevalence+and+incidence .

Gloriani-Barzaga N, Cabanban A, Graham RR, Florese RH. Hepatitis E virus infection diagnosed by serology: a report of cases at the San Lazaro Hospital Manila. Phil J Microbiol Infect Dis. 1997;26(4):169–72.

Google Scholar  

Lorenzo AA, De Guzman TS, Su GLS. Detection of IgM and IgG antibodies against hepatitis E virus in donated blood bags from a national voluntary blood bank in Metro Manila Philippines. Asian Pac J Trop Dis. 2015;5(8):604–5.

Article   CAS   Google Scholar  

Jennings GB, Lubis I, Listiyaningsih E, Burans JP, Hyams KC. Hepatitis E virus in Indonesia. Trans R Soc Trop Med Hyg. 1994 [cited 2023 Jul 24];88(1):57. Available from: https://pubmed.ncbi.nlm.nih.gov/8154003/ .

Pauly M, Muller CP, Black AP, Snoeck CJ. Intense human-animal interaction and limited capacity for the surveillance of zoonoses as drivers for hepatitis E virus infections among animals and humans in Lao PDR. Int J Infect Dis. 2016 [cited 2023 Jul 24];53:18. Available from: http://www.ijidonline.com/article/S1201971216312693/fulltext .

Buchy P, Monchy D, An TT, Srey CT, Tri DV, Son S, Glaziou P, Chien BT. Prévalence de marqueurs d’infection des hépatites virales A, B, C et E chez des patients ayant une hypertransaminasémie a Phnom Penh (Cambodge) et Nha Trang (Centre Vietnam) [Prevalence of hepatitis A, B, C and E virus markers among patients with elevated levels of Alanine aminotransferase and Aspartate aminotransferase in Phnom Penh (Cambodia) and Nha Trang (Central Vietnam)]. Bull Soc Pathol Exot. 2004;97(3):165–71.

Abe K, Li T, Ding X, Win KM, Shrestha PK, Quang VX, Ngoc TT, Taltavull TC, Smirnov AV, Uchaikin VF, Luengrojanakul P. International collaborative survey on epidemiology of hepatitis E virus in 11 countries. Southeast Asian J Trop Med Public Health. 2006;37(1):90–5.

PubMed   Google Scholar  

Lichnaia EV, Pham THG, Petrova OA, Tran TN, Bui TTN, Nguyen TT, et al. Hepatitis e virus seroprevalence in indigenous residents of the Hà Giang northern province of Vietnam. Russ J Infect Immun. 2021;11(4):692–700.

Ostankova YuV, Semenov AV, Valutite DE, Zueva EB, Serikova EN, Shchemelev AN, et al. Enteric viral hepatitis in the Socialist Republic of Vietnam (Southern Vietnam). Jurnal Infektologii. 2021;13(4):72–8. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85123451810&doi=10.22625%2f2072-6732-2021-13-4-72-78&partnerID=40&md5=968b7e50231d40b12aded0e0da133936 .

Kasper MR, Blair PJ, Touch S, Sokhal B, Yasuda CY, Williams M, et al. Infectious etiologies of acute febrile illness among patients seeking health care in south-central Cambodia. Am J Trop Med Hyg. 2012;86(2):246–53. Available from: https://pubmed.ncbi.nlm.nih.gov/22302857/ .

Article   PubMed   PubMed Central   Google Scholar  

Nouhin J, Madec Y, Prak S, Ork M, Kerleguer A, Froehlich Y, et al. Declining hepatitis E virus antibody prevalence in Phnom Penh, Cambodia during 1996–2017. Epidemiol Infect. 2018;147:e26. Available from: https://pubmed.ncbi.nlm.nih.gov/30309396/ .

Nouhin J, Prak S, Madec Y, Barennes H, Weissel R, Hok K, et al. Hepatitis E virus antibody prevalence, RNA frequency, and genotype among blood donors in Cambodia (Southeast Asia). Transfusion (Paris). 2016;56(10):2597–601. Available from: https://pubmed.ncbi.nlm.nih.gov/27480100/ .

Nouhin J, Barennes H, Madec Y, Prak S, Hou SV, Kerleguer A, et al. Low frequency of acute hepatitis E virus (HEV) infections but high past HEV exposure in subjects from Cambodia with mild liver enzyme elevations, unexplained fever or immunodeficiency due to HIV-1 infection. J Clin Virol. 2015;71:22–7. Available from: https://pubmed.ncbi.nlm.nih.gov/26370310/ .

Article   PubMed   Google Scholar  

Yamada H, Takahashi K, Lim O, Svay S, Chuon C, Hok S, et al. Hepatitis E Virus in Cambodia: prevalence among the general population and complete genome sequence of genotype 4. PLoS One. 2015;10:e0136903. Available from: https://pubmed.ncbi.nlm.nih.gov/26317620/ .

Chhour YM, Ruble G, Hong R, Minn K, Kdan Y, Sok T, et al. Hospital-based diagnosis of hemorrhagic fever, encephalitis, and hepatitis in Cambodian children. Emerg Infect Dis. 2002;8(5):485–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2732496/pdf/01-0236-FinalR.pdf .

Utsumi T, Hayashi Y, Lusida MI, Amin M, Soetjipto, Hendra A, et al. Prevalence of hepatitis E virus among swine and humans in two different ethnic communities in Indonesia. Arch Virol. 2011;156(4):689–93. Available from: https://pubmed.ncbi.nlm.nih.gov/21191625/ .

Mizuo H, Suzuki K, Takikawa Y, Sugai Y, Tokita H, Akahane Y, et al. Polyphyletic strains of hepatitis E virus are responsible for sporadic cases of acute hepatitis in Japan. J Clin Microbiol. 2002 [cited 2023 Jul 24];40(9):3209. Available from: /pmc/articles/PMC130758/.

Achwan WA, Muttaqin Z, Zakaria E, Depamede SA, Mulyanto, Sumoharjo S, et al. Epidemiology of hepatitis B, C, and E viruses and human immunodeficiency virus infections in Tahuna, Sangihe-Talaud Archipelago Indonesia. Intervirology. 2007;50(6):408–11. Available from: https://pubmed.ncbi.nlm.nih.gov/18185013/ .

Surya IG, Kornia K, Suwardewa TG, Mulyanto, Tsuda F, Mishiro S. Serological markers of hepatitis B, C, and E viruses and human immunodeficiency virus type-1 infections in pregnant women in Bali Indonesia. J Med Virol. 2005;75(4):499–503. Available from: https://pubmed.ncbi.nlm.nih.gov/15714491/ .

Wibawa ID, Suryadarma IG, Mulyanto, Tsuda F, Matsumoto Y, Ninomiya M, et al. Identification of genotype 4 hepatitis E virus strains from a patient with acute hepatitis E and farm pigs in Bali Indonesia. J Med Virol. 2007;79(8):1138–46. Available from: https://pubmed.ncbi.nlm.nih.gov/17596841/ .

Sedyaningsih-Mamahit ER, Larasati RP, Laras K, Sidemen A, Sukri N, Sabaruddin N, et al. First documented outbreak of hepatitis E virus transmission in Java, Indonesia. Trans R Soc Trop Med Hyg. 2002;96(4):398–404. Available from: https://pubmed.ncbi.nlm.nih.gov/12497976/ .

Widasari DI, Yano Y, Utsumi T, Heriyanto DS, Anggorowati N, Rinonce HT, et al. Hepatitis E virus infection in two different regions of Indonesia with identification of swine HEV genotype 3. Microbiol Immunol. 2013;57(10):692–703. Available from: https://pubmed.ncbi.nlm.nih.gov/23865729/ .

Corwin A, Putri MP, Winarno J, Lubis I, Suparmanto S, Sumardiati A, et al. Epidemic and sporadic hepatitis E virus transmission in West Kalimantan (Borneo). Indonesia Am J Trop Med Hyg. 1997;57(1):62–5. Available from: https://pubmed.ncbi.nlm.nih.gov/9242320/ .

Corwin A, Jarot K, Lubis I, Nasution K, Suparmawo S, Sumardiati A, et al. Two years’ investigation of epidemic hepatitis E virus transmission in West Kalimantan (Borneo), Indonesia. Trans R Soc Trop Med Hyg. 1995 [cited 2023 Jul 20];89(3):262–5. Available from: https://pubmed.ncbi.nlm.nih.gov/7660427/ .

Wibawa ID, Muljono DH, Mulyanto, Suryadarma IG, Tsuda F, Takahashi M, et al. Prevalence of antibodies to hepatitis E virus among apparently healthy humans and pigs in Bali, Indonesia: identification of a pig infected with a genotype 4 hepatitis E virus. J Med Virol. 2004;73(1):38–44. Available from: https://pubmed.ncbi.nlm.nih.gov/15042646/ .

Goldsmith R, Yarbough PO, Reyes GR, Fry KE, Gabor KA, Kamel M, et al. Enzyme-linked immunosorbent assay for diagnosis of acute sporadic hepatitis E in Egyptian children. Lancet. 1992 [cited 2023 Jul 25];339(8789):328–31. Available from: https://pubmed.ncbi.nlm.nih.gov/1346411/ .

Bounlu K, Insisiengmay S, Vanthanouvong K, Saykham, Widjaja S, Iinuma K, et al. Acute jaundice in Vientiane, Lao People’s Democratic Republic. Clin Infect Dis. 1998;27(4):717–21. Available from: https://pubmed.ncbi.nlm.nih.gov/9798023/ .

Khounvisith V, Saysouligno S, Souvanlasy B, Billamay S, Mongkhoune S, Vongphachanh B, et al. Hepatitis B virus and other transfusion-transmissible infections in child blood recipients in Lao People’s Democratic Republic: a hospital-based study. Arch Dis Child. 2023;108(1):15–9. Available from: https://pubmed.ncbi.nlm.nih.gov/36344216/ .

Khounvisith V, Tritz S, Khenkha L, Phoutana V, Keosengthong A, Pommasichan S, et al. High circulation of hepatitis E virus in pigs and professionals exposed to pigs in Laos. Zoonoses Public Health. 2018;65(8):1020–6. Available from: https://pubmed.ncbi.nlm.nih.gov/30152201/ .

Tritz SE, Khounvisith V, Pommasichan S, Ninnasopha K, Keosengthong A, Phoutana V, et al. Evidence of increased hepatitis E virus exposure in Lao villagers with contact to ruminants. Zoonoses Public Health. 2018;65(6):690–701. Available from: https://pubmed.ncbi.nlm.nih.gov/29888475/ .

Bisayher S, Barennes H, Nicand E, Buisson Y. Seroprevalence and risk factors of hepatitis E among women of childbearing age in the Xieng Khouang province (Lao People’s Democratic Republic), a cross-sectional survey. Trans R Soc Trop Med Hyg. 2019;113(6):298–304. Available from: https://pubmed.ncbi.nlm.nih.gov/31034060/ .

Holt HR, Inthavong P, Khamlome B, Blaszak K, Keokamphe C, Somoulay V, et al. Endemicity of zoonotic diseases in pigs and humans in lowland and upland Lao PDR: identification of socio-cultural risk factors. PLoS Negl Trop Dis. 2016;10(4):e0003913. Available from: https://pubmed.ncbi.nlm.nih.gov/27070428/ .

Syhavong B, Rasachack B, Smythe L, Rolain JM, Roque-Afonso AM, Jenjaroen K, et al. The infective causes of hepatitis and jaundice amongst hospitalised patients in Vientiane, Laos. Trans R Soc Trop Med Hyg. 2010;104(7):475–83. Available from: https://pubmed.ncbi.nlm.nih.gov/20378138/ .

Chansamouth V, Thammasack S, Phetsouvanh R, Keoluangkot V, Moore CE, Blacksell SD, et al. The aetiologies and impact of fever in pregnant inpatients in Vientiane, Laos. PLoS Negl Trop Dis. 2016;10(4):e0004577.

Wong LP, Tay ST, Chua KH, Goh XT, Alias H, Zheng Z, et al. Serological evidence of Hepatitis E virus (HEV) infection among ruminant farmworkers: a retrospective study from Malaysia. Infect Drug Resist. 2022;15:5533–41. Available from: https://pubmed.ncbi.nlm.nih.gov/36164335/ .

Wong LP, Lee HY, Khor CS, Abdul-Jamil J, Alias H, Abu-Amin N, et al. The risk of transfusion-transmitted hepatitis E virus: evidence from seroprevalence screening of blood donations. Indian J Hematol Blood Transfus. 2022;38(1):145–52. Available from: https://pubmed.ncbi.nlm.nih.gov/33879981/ .

Wong LP, Alias H, Choy SH, Goh XT, Lee SC, Lim YAL, et al. The study of seroprevalence of hepatitis E virus and an investigation into the lifestyle behaviours of the aborigines in Malaysia. Zoonoses Public Health. 2020;67(3):263–70. Available from: https://pubmed.ncbi.nlm.nih.gov/31927794/ .

Ng KP, He J, Saw TL, Lyles CM. A seroprevalence study of viral hepatitis E infection in human immunodeficiency virus type 1 infected subjects in Malaysia. Med J Malaysia. 2000;55(1):58–64. Available from: https://pubmed.ncbi.nlm.nih.gov/11072492/ .

Hudu SA, Niazlin MT, Nordin SA, Harmal NS, Tan SS, Omar H, et al. Hepatitis E virus isolated from chronic hepatitis B patients in Malaysia: sequences analysis and genetic diversity suggest zoonotic origin. Alexandria J Med. 2018;54(4):487–94. Available from: https://www.tandfonline.com/doi/pdf/10.1016/j.ajme.2017.07.003 .

Anderson DA, Li F, Riddell M, Howard T, Seow HF, Torresi J, et al. ELISA for IgG-class antibody to hepatitis E virus based on a highly conserved, conformational epitope expressed in Escherichia coli. J Virol Methods. 1999 [cited 2023 Jul 25];81(1–2):131–42. Available from: https://pubmed.ncbi.nlm.nih.gov/10488771/ .

Seow HF, Mahomed NM, Mak JW, Riddell MA, Li F, Anderson DA. Seroprevalence of antibodies to hepatitis E virus in the normal blood donor population and two aboriginal communities in Malaysia. J Med Virol. 1999;59(2):164–8. Available from: https://pubmed.ncbi.nlm.nih.gov/10459151/ .

Saat Z, Sinniah M, Kin TL, Baharuddin R, Krishnasamy M. A four year review of acute viral hepatitis cases in the east coast of Peninsular Malaysia. Southeast Asian J Trop Med Public Health. 1999;30(1):106–9.

Li TC, Yamakawa Y, Suzuki K, Tatsumi M, Razak MA, Uchida T, et al. Expression and self-assembly of empty virus-like particles of hepatitis E virus. J Virol. 1997 [cited 2023 Jul 25];71(10):7207–13. Available from: https://pubmed.ncbi.nlm.nih.gov/9311793/ .

Uchida T, Aye TT, Ma X, Iida F, Shikata T, Ichikawa M, et al. An epidemic outbreak of hepatitis E in Yangon of Myanmar: antibody assay and animal transmission of the virus. Acta Pathol Jpn. 1993;43(3):94–8. Available from: https://pubmed.ncbi.nlm.nih.gov/8257479/ .

Nakai K, Win KM, Oo SS, Arakawa Y, Abe K. Molecular characteristic-based epidemiology of hepatitis B, C, and E viruses and GB virus C/hepatitis G virus in Myanmar. J Clin Microbiol. 2001;39(4):1536–9. Available from: https://pubmed.ncbi.nlm.nih.gov/11283083/ .

Chow WC, Ng HS, Lim GK, Oon CJ. Hepatitis E in Singapore–a seroprevalence study. Singapore Med J. 1996;37(6):579–81. Available from: https://pubmed.ncbi.nlm.nih.gov/9104052/ .

Wong CC, Thean SM, Ng Y, Kang JSL, Ng TY, Chau ML, et al. Seroepidemiology and genotyping of hepatitis E virus in Singapore reveal rise in number of cases and similarity of human strains to those detected in pig livers. Zoonoses Public Health. 2019 [cited 2023 Jul 24];66(7):773–82. Available from: https://pubmed.ncbi.nlm.nih.gov/31293095/ .

Tan LTC, Tan J, Ang LW, Chan KP, Chiew KT, Cutter J, et al. Epidemiology of acute hepatitis E in Singapore. J Infect. 2013 [cited 2023 Jul 24];66(5):453–9. Available from: https://pubmed.ncbi.nlm.nih.gov/23286967/ .

Pourpongporn P, Samransurp K, Rojanasang P, Wiwattanakul S, Srisurapanon S. The prevalence of anti-hepatitis E in occupational risk groups. J Med Assoc Thai. 2009;92:S38–42. Available from: https://pubmed.ncbi.nlm.nih.gov/19705545/ .

Siripanyaphinyo U, Boon-Long J, Louisirirotchanakul S, Takeda N, Chanmanee T, Srimee B, et al. Occurrence of hepatitis E virus infection in acute hepatitis in Thailand. J Med Virol. 2014;86(10):1730–5. Available from: https://pubmed.ncbi.nlm.nih.gov/24984976/ .

Poovorawan K, Jitmitrapab S, Treeprasertsuk S, Tangkijvanich P, Komolmitr P, Poovorawan Y. Acute hepatitis E in Thailand, 2009–2012. J Gastroenterol Hepatol. 2012;27:233.

Maneerat Y, Wilairatana P, Pongponratn E, Chaisri U, Puthavatana P, Snitbhan R, et al. Etiology of acute non-A, B, C hepatitis in Thai patients: preliminary study. Southeast Asian J Trop Med Public Health. 1996;27(4):844–6. Available from: https://pubmed.ncbi.nlm.nih.gov/9253895/ .

Sa-nguanmoo P, Posuwan N, Vichaiwattana P, Wutthiratkowit N, Owatanapanich S, Wasitthankasem R, et al. Swine is a possible source of hepatitis E virus infection by comparative study of hepatitis A and E seroprevalence in Thailand. PLoS One. 2015;10:e0126184. Available from: https://pubmed.ncbi.nlm.nih.gov/25927925/ .

Pilakasiri C, Gibbons RV, Jarman RG, Supyapoung S, Myint KSA. Hepatitis antibody profile of Royal Thai Army nursing students. Trop Med Int Health. 2009;14(6):609–11. Available from: https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/j.1365-3156.2009.02264.x?download=true .

Louisirirotchanakul S, Myint KS, Srimee B, Kanoksinsombat C, Khamboonruang C, Kunstadter P, et al. The prevalence of viral hepatitis among the Hmong people of northern Thailand. Southeast Asian J Trop Med Public Health. 2002;33(4):837–44. Available from: https://pubmed.ncbi.nlm.nih.gov/12757235/ .

Jupattanasin S, Chainuvati S, Chotiyaputta W, Chanmanee T, Supapueng O, Charoonruangrit U, et al. A nationwide survey of the seroprevalence of hepatitis E virus infections among blood donors in Thailand. Viral Immunol. 2019;32(7):302–7. Available from: https://pubmed.ncbi.nlm.nih.gov/31403386/ .

Hinjoy S, Nelson KE, Gibbons RV, Jarman RG, Mongkolsirichaikul D, Smithsuwan P, et al. A cross-sectional study of hepatitis E virus infection in healthy people directly exposed and unexposed to pigs in a rural community in northern Thailand. Zoonoses Public Health. 2013;60(8):555–62. Available from: https://pubmed.ncbi.nlm.nih.gov/23280251/ .

Getsuwan S, Pasomsub E, Yutthanakarnwikom P, Tongsook C, Butsriphum N, Tanpowpong P, et al. Seroprevalence of hepatitis E virus after pediatric liver transplantation. J Trop Pediatr. 2023;69(2):fmad011. Available from: https://pubmed.ncbi.nlm.nih.gov/36811578/ .

Gonwong S, Chuenchitra T, Khantapura P, Islam D, Sirisopana N, Mason CJ. Pork consumption and seroprevalence of hepatitis E virus, Thailand, 2007–2008. Emerg Infect Dis. 2014;20:1531–4. Available from: https://pubmed.ncbi.nlm.nih.gov/25148245/ .

Komolmit P, Oranrap V, Suksawatamnuay S, Thanapirom K, Sriphoosanaphan S, Srisoonthorn N, et al. Clinical significance of post-liver transplant hepatitis E seropositivity in high prevalence area of hepatitis E genotype 3: a prospective study. Sci Rep. 2020;10(1):7352. Available from: https://pubmed.ncbi.nlm.nih.gov/32355268/ .

Jutavijittum P, Jiviriyawat Y, Jiviriyawat W, Yousukh A, Hayashi S, Itakura H, et al. Seroprevalence of antibody to hepatitis E virus in voluntary blood donors in Northern Thailand. Trop Med. 2000;42(2):135–9. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0033638431&partnerID=40&md5=12c324fd502945b8c8dc425274f7cad2 .

Boonyai A, Thongput A, Sisaeng T, Phumchan P, Horthongkham N, Kantakamalakul W, et al. Prevalence and clinical correlation of hepatitis E virus antibody in the patients’ serum samples from a tertiary care hospital in Thailand during 2015–2018. Virol J. 2021;18(1):145. Available from: https://pubmed.ncbi.nlm.nih.gov/34247642/ .

Huy PX, Chung DT, Linh DT, Hang NT, Rachakonda S, Pallerla SR, et al. Low prevalence of HEV infection and no associated risk of HEV transmission from mother to child among pregnant women in Vietnam. Pathogens. 2021;10(10):1340. Available from: https://pubmed.ncbi.nlm.nih.gov/34684289/ .

Hoan NX, Huy PX, Sy BT, Meyer CG, Son TV, Binh MT, et al. High hepatitis E virus (HEV) Positivity among domestic pigs and risk of HEV infection of individuals occupationally exposed to pigs and pork meat in Hanoi, Vietnam. Open Forum Infect Dis. 2019;6(9):ofz306. Available from: https://pubmed.ncbi.nlm.nih.gov/31660396/ .

Hoan NX, Tong HV, Hecht N, Sy BT, Marcinek P, Meyer CG, et al. Hepatitis E virus superinfection and clinical progression in hepatitis B patients. EBioMedicine. 2015;2(12):2080–6. Available from: https://pubmed.ncbi.nlm.nih.gov/26844288/ .

Hau CH, Hien TT, Tien NT, Khiem HB, Sac PK, Nhung VT, et al. Prevalence of enteric hepatitis A and E viruses in the Mekong River delta region of Vietnam. Am J Trop Med Hyg. 1999;60(2):277–80. Available from: https://pubmed.ncbi.nlm.nih.gov/10072151/ .

Corwin AL, Dai TC, Duc DD, Suu PI, Van NT, Ha LD, et al. Acute viral hepatitis in Hanoi, Viet Nam. Trans R Soc Trop Med Hyg. 1996;90(6):647–8. Available from: https://pubmed.ncbi.nlm.nih.gov/9015503/ .

Corwin AL, Khiem HB, Clayson ET, Pham KS, Vo TT, Vu TY, et al. A waterborne outbreak of hepatitis E virus transmission in southwestern Vietnam. Am J Trop Med Hyg. 1996;54(6):559–62. Available from: https://pubmed.ncbi.nlm.nih.gov/8686771/ .

Berto A, Pham HA, Thao TTN, Vy NHT, Caddy SL, Hiraide R, et al. Hepatitis E in southern Vietnam: seroepidemiology in humans and molecular epidemiology in pigs. Zoonoses Public Health. 2018 [cited 2023 Jul 24];65(1):43–50. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/zph.12364 .

Li TC, Zhang J, Shinzawa H, Ishibashi M, Sata M, Mast EE, et al. Empty virus-like particle-based enzyme-linked immunosorbent assay for antibodies to hepatitis E virus. J Med Virol. 2000;62(3):327–33.

Shimizu K, Hamaguchi S, Ngo CC, Li TC, Ando S, Yoshimatsu K, et al. Serological evidence of infection with rodent-borne hepatitis E virus HEV-C1 or antigenically related virus in humans. J Vet Med Sci. 2016 [cited 2023 Jul 24];78(11):1677–81. Available from: https://pubmed.ncbi.nlm.nih.gov/27499185/ .

Nghiem XH, Pham XH, Trinh VS, Dao PG, Mai TB, Dam TA, et al. HEV positivity in domesticated pigs and a relative risk of HEV zoonosis among occupationally exposed individuals in Vietnam. J Hepatol. 2018 [cited 2023 Jul 24];68:S186–7. Available from: https://www.researchgate.net/publication/324700980 .

Tran HTT, Ushijima H, Quang VX, Phuong N, Li TC, Hayashi S, et al. Prevalence of hepatitis virus types B through E and genotypic distribution of HBV and HCV in Ho Chi Minh City. Vietnam Hepatology Research. 2003 [cited 2023 Jul 24];26(4):275–80. Available from: https://pubmed.ncbi.nlm.nih.gov/12963426/ .

South-East Asia | Demographic Changes. Available from: https://www.population-trends-asiapacific.org/data/sea . Accessed May 18 2023.

Sentian J, Payus CM, Herman F, Kong VWY. Climate change scenarios over Southeast Asia. APN Sci Bull. 2022 [cited 2023 Sep 28];12(1):102–22. Available from: https://www.apn-gcr.org/bulletin/?p=1927 .

Lee T HJ. Southeast Asia’s growing meat demand and its implications for feedstuffs imports. Amber Waves: The Economics of Food, Farming, Natural Resources, and Rural America. 2019;(03).  https://ideas.repec.org/a/ags/uersaw/302703.html . https://www.ers.usda.gov/amber-waves/2019/april/southeast-asia-s-growing-meat-demand-and-its-implications-forfeedstuffs-imports/ .

Rossi-Tamisier M, Moal V, Gerolami R, Colson P. Discrepancy between anti-hepatitis E virus immunoglobulin G prevalence assessed by two assays in kidney and liver transplant recipients. J Clin Virol. 2013 [cited 2023 Jul 27];56(1):62–4. Available from: https://pubmed.ncbi.nlm.nih.gov/23089569/ .

Wenzel JJ, Preiss J, Schemmerer M, Huber B, Jilg W. Test performance characteristics of Anti-HEV IgG assays strongly influence hepatitis E seroprevalence estimates. J Infect Dis. 2013 [cited 2023 Jul 27];207(3):497–500. Available from: https://pubmed.ncbi.nlm.nih.gov/23148290/ .

Chongsuvivatwong V, Phua KH, Yap MT, Pocock NS, Hashim JH, Chhem R, et al. Health and health-care systems in southeast Asia: diversity and transitions. Lancet. 2011;377(9763):429–37.

Download references

Acknowledgements

The authors would like to thank all researchers of the primary research included in this study.

This work was supported by Project Research Center for Epidemiology and Prevention of Viral Hepatitis and Hepatocellular Carcinoma, Hiroshima University led by Prof. Junko Tanaka (PI).

Author information

Authors and affiliations.

Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Hiroshima, Minami, 734-8551, Japan

Ulugbek Khudayberdievich Mirzaev, Serge Ouoba, Ko Ko, Zayar Phyo, Chanroth Chhoung, Akuffo Golda Ataa, Aya Sugiyama, Tomoyuki Akita & Junko Tanaka

Department of Hepatology, Research Institute of Virology, Tashkent, Uzbekistan

Ulugbek Khudayberdievich Mirzaev

Unité de Recherche Clinique de Nanoro (URCN), Institut de Recherche en Sciences de La Santé (IRSS), Nanoro, Burkina Faso

Serge Ouoba

You can also search for this author in PubMed   Google Scholar

Contributions

UM, TA, and JT conceptualized the study. UM and SO contributed to developing the study design and data acquisition. UM, CC, ZP, AG, SO, and JT analysed and interpreted the data. UM, KK, and AS drafted the manuscript. TA, AS, KK, SO, and JT contributed to the intellectual content of the manuscript. All authors read and approved the final manuscript. JT and TA shared the co-correspondence. 

Corresponding authors

Correspondence to Tomoyuki Akita or Junko Tanaka .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary material 1., supplementary material 2., supplementary material 3., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Mirzaev, U.K., Ouoba, S., Ko, K. et al. Systematic review and meta-analysis of hepatitis E seroprevalence in Southeast Asia: a comprehensive assessment of epidemiological patterns. BMC Infect Dis 24 , 525 (2024). https://doi.org/10.1186/s12879-024-09349-2

Download citation

Received : 30 October 2023

Accepted : 24 April 2024

Published : 24 May 2024

DOI : https://doi.org/10.1186/s12879-024-09349-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Hepatitis E virus
  • Southeast Asia
  • Immunoglobulins
  • Systematic review
  • Meta-analysis
  • Epidemiologic patterns

BMC Infectious Diseases

ISSN: 1471-2334

systematic review of research utilization

  • Open access
  • Published: 30 May 2024

Assessing the impact of contraceptive use on mental health among women of reproductive age – a systematic review

  • Shayesteh Jahanfar 1 ,
  • Julie Mortazavi 1 ,
  • Amy Lapidow 1 ,
  • Cassandra Cu 1 ,
  • Jude Al Abosy 1 ,
  • Katherine Morris 1 ,
  • Juan Camilo Becerra-Mateus 2 ,
  • Paola Andrenacci 3 ,
  • Marwa Badawy 4 ,
  • Meredith Steinfeldt 1 ,
  • Olivia Maurer 1 ,
  • Bohang Jiang 1 &
  • Moazzam Ali 5  

BMC Pregnancy and Childbirth volume  24 , Article number:  396 ( 2024 ) Cite this article

116 Accesses

Metrics details

Contraceptive use is the principal method by which women avoid unintended pregnancy. An unintended pregnancy can induce long-term distress related to the medical, emotional, and social consequences of carrying that pregnancy to term.

This review investigates the effects of modern contraception techniques such as birth control pills, long-acting reversible contraceptives (e.g., intrauterine devices, implants), and condoms on mental health status.

We searched multiple databases from inception until February 2022, with no geographical boundaries. RCTs underwent a quality assessment using the GRADE approach while the quality of observational studies was assessed using the Downs and Black scoring system. Data were analyzed through meta-analysis and relative risk and mean difference were calculated and forest plots were created for each outcome when two or more data points were eligible for analysis.

Main results

The total number of included studies was 43. In women without previous mental disorders, both RCTs (3 studies, SMD 0.18, 95% CI [0.02, 0.34], high quality of evidence) and cohort studies (RR 1.04 95% CI [1.03, 1.04]) detected a slight increase in the risk of depression development. In women with previous mental disorders, both RCTs (9 studies, SMD − 0.15, 95% CI [-0.30, -0.00], high quality of evidence) and cohort studies (SMD − 0.26, 95% CI [-0.37, -0.15]) detected slight protective effects of depression development. It was also noticed that HC demonstrated protective effects for anxiety in both groups (SMD − 0.20, 95% CI [-0.40, -0.01]).

Conclusions

Among women with pre-existing mental disorders who use hormonal contraceptives, we reported protective association with decreased depressive symptoms. However, the study also draws attention to some potential negative effects, including an increase in the risk of depression and antidepressant use among contraceptive users, a risk that is higher among women who use the hormonal IUD, implant, or patch/ring methods. Providers should select contraceptive methods taking individual aspects into account to maximize benefits and minimize risks.

Peer Review reports

The utilization of contraception has experienced a significant upsurge among women globally. The number of women employing modern contraceptives has increased from 663 million to 851 million in the past two decades [ 1 ], and it is estimated that an additional 70 million women will utilize contraception by 2030 as access improves [ 1 ]. Modern contraceptive methods are categorized into short-acting, long-acting, and one-time barrier forms. Short-acting contraceptives, such as the pill (151 million users, 16%), injectables (74 million users, 8%), and patches and vaginal rings (less than 15 million users, less than 2%) [ 1 ], are widely used. Long-acting contraceptives, including intrauterine devices (159 million users, 17%), implants (23 million users, 2%), and female sterilization (219 million users, 24%) [ 1 ], are also popular. However, the prevalence of use for one-time barrier contraceptives, such as sponges, diaphragms, cervical caps, spermicide, female condoms, and male condoms, is low, except for male condom use (189 million users, 21%) [ 1 ].

Beyond preventing pregnancy, there are additional benefits to the use of contraception that are frequently overlooked. Evidence suggests that hormonal contraception has non-reproductive health advantages, including enhanced mental health status [ 2 ]. Within the United States, an estimated 1.5 million women use birth control pills for reasons other than pregnancy prevention, which has significant implications for women worldwide.

Hormonal fluctuations occur in women across various life stages, including puberty, menstrual cycles, pregnancy, and menopause, and these fluctuations of female ovarian hormones have a complex connection to mental health outcomes. The impact of modern contraception methods on the risk of adverse mental health outcomes such as depression, suicide, and anxiety is not yet clear. Depression and anxiety are among the most prevalent and disabling chronic diseases affecting reproductive-aged women globally, contributing to negative outcomes in reproductive health, including an increased risk of unintended pregnancy and its health and social consequences. Moreover, these conditions are precursors to numerous adverse perinatal and postpartum outcomes, including maternal and infant morbidity, obstetrical complications, preterm labor, stillbirth, low birth weight, and antepartum and postpartum depression. When pregnancy is unintended, the severity of these health events may be exacerbated [ 3 ]. Therefore, effective contraception plays a vital role in helping women who seek to prevent unintended pregnancy maintain a stable mental health status.

It is worth noting that studies are not immune from the “nocebo” effect. The nocebo effect is a psychological phenomenon in which the expectation of a negative outcome can itself contribute to negative outcomes. This can be observed when individuals anticipate or are told about possible side effects of a treatment, and as a result, they may experience those side effects even if the treatment is inert or harmless.

Theoretical framework/ theory of change

Evidence suggests that modern contraception contributes to improved women’s health by reducing unintended and high-risk pregnancies, both of which can be stressful for any person [ 4 ]. Additionally, it is known that women who practice appropriate spacing of pregnancies and births (> 18 months) can focus more on their own physical and mental health as well as the health of other children and other family members [ 5 ]. Moreover, the impact of contraception on women’s socioeconomic status is well documented. Contraceptive use enables girls to remain in school for a longer period, leading to better occupation opportunities and empowering women economically. As a woman’s socioeconomic status improves, stressful economic events can be avoided [ 6 ]. For this reason, modern contraception is believed to improve the socioeconomic status of women as well as their dependents, which has positive effects on mental health status [ 7 ]. Additionally, lowered risk of unwanted pregnancy can increase enjoyment when engaging in sexual experiences with use of contraception can lead to improved quality of life and mental health [ 8 ] (See Fig.  1 ).

figure 1

Family planning and its impact on mental health

It is also important to consider the potential effects of contraceptive use on neurochemical and hormonal balance. It is widely agreed that depression and anxiety are impacted in part by deficiencies in neurotransmitters that affect mood [ 9 , 10 ]. Conflicting research exists regarding whether a link exists between contraceptive use and neurotransmitter deficiency. One review reported no evidence for an association between the biochemical mechanisms of combined oral contraceptives (COC) and mood side effects reported by users [ 11 ]. Other prospective population-based cohort studies report similar or even lower rates of depression or mood symptoms in COC users when compared to nonusers [ 12 ]. Many of these recent studies have relied upon observational and cross-sectional designs and small sample sizes, so more research is needed that utilizes prospective, longitudinal, and randomized controlled trial designs to provide a more definitive assessment of the effects of contraception and mental health.

Contraceptives are currently recommended as part of a treatment for premenstrual dysphoric disorder, a subtype of depression [ 13 ]. Premenstrual dysphoric disorder is a time-limited and hormone-linked depression. Neurotransmitters, particularly gamma-aminobutyric acid and serotonin, appear to be linked with the manifestations of pre-menstrual disorder and premenstrual dysphoric disorder [ 14 ]. Research shows that lower levels of gamma-aminobutyric acid circulate during the luteal phase of the menstrual cycle [ 15 ]. This may help explain the benefit of combined hormonal contraceptives in treating premenstrual dysphoric disorder. However, some research suggests that progesterone’s involvement in the etiology of depression increases a woman’s risk for the use of antidepressants and a diagnosis of depression [ 16 ]. Therefore, it is important to create an accurate depiction of existing research on contraceptive use as it relates to mental health and highlight areas for future analysis.

It is also critical to focus on women of reproductive age as a population of interest. When compared to men, American women are more likely to experience a depressive or anxiety disorder [ 17 ]. This is an issue affected by intersectionality, as low-income, underinsured, and minority women are at an increased risk for both mental health disorders and adverse reproductive outcomes. Some research suggests that risk assessment, planning, social learning, decreased motivation and desire for self-care, excessive worry, and diminished perceptions of susceptibility to pregnancy may impact cognition and lead to suboptimal contraceptive choices among women with depression and anxiety [ 18 ]. Research has also shown that unilateral or bilateral oophorectomy can increase a woman’s overall risk of depression [ 19 ], due to substantial drops in estrogen production. It is important to utilize this information so that women seeking contraceptive methods or reproductive care can make the best possible decisions according to their specific pre-existing conditions and needs. This study aims to identify and evaluate evidence that focuses on the use of contraceptives and their impact on mental health status among women of reproductive age.

This study is a registered systematic review of Prospero (CRD42022332647) and aims to examine the quantitative evidence regarding the use of contraceptives and their impact on mental health outcomes among women of reproductive age. The study adheres to the Population, Intervention, Comparison, Outcome, and Study design framework. The inclusion criteria specified that the study population should comprise women of reproductive age (14–49 years) presenting to primary healthcare clinics. The intervention considered modern contraception methods as effective and acceptable methods [ 20 ]. Observational studies were included, with contraceptive use as the primary exposure. Studies that combined contraception with other medications or modalities were excluded. The comparison was no contraceptive use. The outcome of interest was any effect on mental health status, including mood disorders such as depression, bipolar, and anxiety disorders, and psychotic disorders such as schizophrenia and post-traumatic stress disorder (PTSD). The study designs included were parallel or cluster randomized controlled trials, controlled clinical trials, controlled before and after studies, interrupted time series studies, cohort or longitudinal analyses, regression discontinuity designs, and case-control studies. A control group with no contraceptive usage was used to ensure that only studies with a comparison group were included.

To minimize publication bias, the study conducted a comprehensive search for published or unpublished studies from inception to February 2022 with no language or geographical boundaries. The search was performed in multiple databases, including CINAHL (1981–2022), OVID Medline (1946–2022), EMBASE (1947–2022), Psycho INFO (the 1800s-2022), Maternity & Infant Care (1857–2022), LILACS (1982–2022), clinical trial.gov (2000–2022), web of science (1900–2022), SCOPUS (2004–2022), and CENTRAL (1996–2022). Local databases of the World Health Organization (WHO) in various regions were also included in the search. We included WHO local databases as follows: Africa (AIM), Latin America and the Caribbean (LILACS), A network of Health Science Libraries across Asia (HELLIR), Virtual Health Sciences Library, IBECS (ibecs.isciii.es), SciELO (Scientific Electronic Library Online; www.scielo.br ), LILACS (Latin American and Caribbean Health Sciences Literature; lilacs.bvsalud.org/en), PAHO (Pan American Health Library; www1.paho.org/english/DD/IKM/LI/library.htm), WHOLIS (WHO Library; dosei.who.int), WPRO (Western Pacific Region Index Medicus; www.wprim.org ), Index Medicus for the South-East Asia Region (IMSEAR; imsear.hellis.org), IndMED (Indian medical journals; indmed.nic.in; 1985 onwards), Native Health Research Database (hscssl.unm.edu/nhd/).

In the inception phase of this systematic review, the inclusion criteria were initially limited to randomized controlled trials (RCT), but due to a paucity of available studies, quasi-experimental and observational studies, specifically cohort and case-control studies, were also incorporated. We used the Cochrane quality assessment (with Seven domains including selection bias, performance bias, detection bias, attrition bias, reporting bias, and other biases. This systematic review was done before changes were made in the Cochrane assessment to five domains.) for RCTs and Dawn and Black scale (with 27 questions relating to the quality of reporting (ten questions), external validity (three questions), internal validity (bias and confounding) (13 questions), and statistical power (one question) to assess the quality of observational studies. A GRADE table of summary of findings (incorporating the elements of risk of bias, inconsistency, indirectness, imprecision, and publication bias), was prepared for RCTs. All included articles were examined for a risk of bias using the critical appraisal checklists developed by the Cochrane Collaboration. The data extraction process was intended to be conducted by two independent reviewers, but due to resource constraints, only one reviewer was responsible for the extraction, with the other conducting checks. The targeted population in the protocol consisted of women of reproductive age (15–49 years), although several large cohort studies included both women of reproductive age and a small number of postmenopausal women whose data could not be separated. As a result, data from a few postmenopausal women were included in the review. Initially, the plan was to contact the primary authors of the studies to request clarification or obtain missing data, but time constraints precluded this approach. The inclusion criteria were initially limited to English-language studies, but the decision was made to expand the search to include studies in all languages to mitigate language-based bias in study selection. Non-English studies were translated into English. (See Appendix 1 for search strategy, and data sources).

We conducted a meta-analysis when we had two data points or more for each comparison and each outcome. Studies were combined for meta-analysis only when identical family planning devices/tools/drugs, dosages, and regimens were compared. Odds ratios (OR) or mean differences (MD) with a 95% confidence interval (95%CI) were calculated for each dichotomous or continuous outcome, respectively. The characteristics of included studies were recorded in a table, including the name of the first author, year of publication, country or study, study setting (public/private or rural/urban), type of family planning, dosage of contraception (if applicable), route of administration (if available), type of outcome studies, and effect measures associated with each outcome. Heterogeneity was visually examined by comparing study designs, target populations, and primary outcome measures across included studies. The homogeneity of trials combined in a meta‐analysis was assessed using both fixed‐effect and random‐effects models. The classical measure of heterogeneity, Cochran’s Q, was calculated as the weighted sum of squared differences between individual study effects and the pooled effect across studies, with the weights being those used in the pooling method. Q was distributed as a chi-square statistic, and the alpha level was set at 0.10 since the Chi2 test for heterogeneity is a low-power test. The I 2 score was then used to identify the magnitude of heterogeneity. Any score of I 2 above 50% was investigated for the clinical and methodological diversity of the studies. Pooling data from studies that had different contraceptive methods (e.g., contraceptive pills and transdermal patches), different doses of the same method, or different criteria for defining morbidity was not done. Subgroup analysis was conducted using different types of contraception, dose, and route of administration when possible. Sensitivity analysis was planned based on the study quality. It was also employed to test the robustness of any results that appeared to be based on heterogeneous combinations by examining the effect of deleting each study. Finally, sensitivity analyses were conducted based on rates of loss to follow‐up, and studies that had rates of loss to follow‐up over 20% were excluded.

The Prisma chart in Fig.  2 demonstrates the number of studies included in the search from different sources as well as the number of studies screened and included in the review.

figure 2

Flow diagram. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: https://doi.org/10.1136/bmj.n71 . For more information, visit: http://www.prisma-statement.org/

The total number of included studies was 43, 23 of which were RCTs and 20 of which were cohort studies. Table S1 (See Appendix 2) shows some of the characteristics of RCTs, including country of origin, year of publication, number of facilities, type of health facility, level of health facility, sample size, study design, population, type of contraception studied, the outcome of interest extracted, and quality of study based on study design. Similar data (with exposure instead of intervention) was extracted for observational studies (See Appendix 2, Table S2 , and Table S3 ). Most of the studies were from 2000 onward, while a handful of studies were published before 2000 ( n  = 5).

Studies focused on either one contraception (oral contraception, ring/patch, implant, injection, intrauterine device (IUD), condoms, sterilization), a combination of contraceptives, or all hormonal contraceptives.

Comparisons were set based on available literature and the protocol on either all hormonal contraceptives versus no contraceptive use or oral contraceptive use versus no use. In cases where other types of contraceptives were studied, comparisons were made between use and non-use. Subgroup analysis can be seen in some of the forest plots where different contraceptives are used (pills versus IUDs, etc.)

Outcomes of interest included various aspects of mental illness, including depression, antidepressant use, anxiety, and suicide.

Quality assessment

Figure  3 presents the quality of assessment figures for RCT-included studies are presented below.

figure 3

Risk of bias graph for included studies

Table S4 shows the quality assessment of observational studies using the Black and Dawn scoring system. We considered the overall quality of evidence to be moderate for our review (mean: 13.65 ± 1.93, median = 14 min = 9, max = 16). Overall, we concluded that the quality of our evidence is moderate. (See appendix 2, Table S4 )

Randomized clinical trials

The frequency of reporting this outcome and its clinical importance in non-reproductive health outcomes pertaining to oral contraceptive pill (OCP) use make this variable an attractive one to analyze. Depression was reported in nine studies for women with previous mental disorders, comparing OCP users with non-users [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. The scales used to measure depression varied from comprehensive tools to depression as an item on a more elaborated tool like the Daily Record of Severity of Problems (DRSP). The meta-analysis showed a slightly protective difference between users and non-users of OCP in terms of depression in women with previous mental disorders (standardized mean differences (SMD): -0.09 (5 studies, high quality of evidence), 95% confidence interval (CI) -0.34, 0.15). Caution should be used in the interpretation of this analysis due to the high heterogeneity of 91%. (Fig.  4 ) The high level of heterogeneity did not change when we used random effect (-0.21 [-0.46, 0.04] with I 2 of 89%) or run sensitivity analysis.

figure 4

Forest plot on depression and OCP use for women with previous mental disorders in nine studies

Since we had nine studies in this analysis, we created a funnel plot to assess the risk of publication bias. An asymmetric funnel plot showed publication bias is not likely (See Appendix 3, Figure S1 ).

We found five papers that reported depression as a continuous variable using the Montgomery-Asberg Depression Rating Scale [ 23 , 25 , 26 , 27 , 28 ]. Hence, we reported these separately. The mean difference for these studies was protective as the mean difference was found to be -0.09 (95% CI -0.34, 0.15, high quality of evidence). (See Appendix 3, Figure S2 ).

In three studies involving women without previous mental disorders, depression was reported as a continuous variable, and OCP users were compared with non-users. The mean difference for these studies did not indicate a protective effect, as the mean difference was calculated to be 0.18 (95% CI 0.02, 0.34, high quality of evidence). (See Appendix 3, Figure S3 ).

Table S5 shows the GRADE assessment of the above-noted papers. All three variables discussed had moderate to high-quality evidence.

Cohort studies.

The risk ratio for depression was found to be 1.13 (95% CI 1.04–1.24) among all hormonal contraceptive users compared with non-users. This analysis contained women without previous mental disorders reported by two large studies [ 16 , 30 ]. The risk is similarly reported to be significantly higher on the user side for implants, progesterone pills/patches/rings, and hormonal IUDs. Heterogeneity was high (I 2  = 99%). (Fig.  5 )

figure 5

Use of hormonal contraceptives versus non-use for the dichotomous outcome of depression in women without previous mental disorders

Use of antidepressants was reported in 3 studies [ 31 , 32 , 33 ] with a total sample size of over one million and the number of events reported as around 30,000 incidents in women without previous mental disorders or general women. When all hormonal contraceptives (HC) were compared with no contraceptive use, the overall effect size was 45% higher among users compared to non-users (1.45, 95% CI 1.41, 1.49). The risk ratio from one study [ 30 ] for oral contraceptive users only was 0.89 (95% CI 0.55–1.44), demonstrating a non-significant but protective effect. Heterogeneity was high (I 2  = 78.7%). This could be due to clinical heterogeneity (different study settings, type of contraception, etc.). However, the number of studies was low, not allowing for further investigation. (See Appendix 3, Figure S4 ).

Some studies [ 34 – 35 ] reported depression scores as a continuous variable using various tools (DRSP and the Quick Inventory of Depressive Symptomatology-Self-Report) in women with previous mental disorders. The standardized mean difference for depression among all hormonal contraceptive users was − 0.26 (-0.37, -0.15), which suggests a protective effect. The heterogeneity is low in this analysis (I 2  = 0%). (See Appendix 3, Figure S5 )

For the outcome of anxiety, we found two studies. Anxiety score was reported using different tools. Yonkers [ 34 ] used DRSP with six levels, while Hamstra [ 36 ] utilized the Interpersonal Sensitivity Measure. We, therefore, used the standardized mean difference to analyze the data. The Hamstra study’s participants were Premenstrual Syndrome-free women, while the participants of the Yonkers study were women who sought treatment for Premenstrual Syndrome. There was a significant difference in the SMD of anxiety between hormonal contraceptive users compared with non-users (-0.20, [95% CI -0.40, -0.01]). In other words, HC users had 20% lower scores of anxiety compared to non-users. (Fig.  6 )

figure 6

Use of hormonal contraceptives versus non-use for the continuous outcome of anxiety

The risk ratio for suicide was not significant among users of OCP compared with non-users in general women (1.17, [95% CI 0.96, 1.42]). The heterogeneity for this analysis was relatively high (I 2  = 40%). (See Appendix 3, Figure S6 )

We were unable to draw forest plots for other outcomes (suicide attempt as hazard ratio, risk of diagnosis of depression at 12 months, PTSD, anxiety as a dichotomous outcome, and number of major depressive episodes) but a summary of each study can be found in Appendices (See Appendix 2, Table S2 ).

Summary of main results

Different results were observed regarding the association between HC use and mental health outcomes in women with and without previous mental disorders. In the meta-analysis of RCTs conducted on women with previous mental disorders, a slightly significant protective effect was observed, while the analysis on women without previous mental disorders showed a significant risk in depression scores. Cohort studies showed similar results for depression and antidepressant use. HC demonstrated protective effects for anxiety in both groups. OCP users did not show a significant risk of suicide compared to non-users. However, a subgroup analysis conducted by contraceptive type revealed that women who use hormonal IUD, implant, or patch/ring methods have a significantly higher risk of depression than other contraceptive methods. For oral contraceptive methods, varying results were observed, and the difference in effect on depression is not well understood when subgrouping by COC and POP types. Additionally, modification effects of age were observed across several studies. The risk of depression, antidepressants, or psychotropic drug use decreases as age increases from adolescence to adulthood.

Overall completeness and applicability of evidence

A noteworthy attribute of this review is the extensive search strategy employed, which encompassed several electronic databases and produced a diverse array of studies. However, the task of generating suitable recommendations concerning the utilization of contraceptives to enhance non-reproductive health outcomes in women is beset with difficulties arising from heterogeneity concerns.

Quality of evidence

In order to synthesize and communicate the findings pertaining to various variables, a Grades of Recommendation, Assessment, Development, and Evaluation evidence table was constructed for our RCT investigations, which reflected a high quality of evidence.

As the primary exposure in our review was contraceptive use, it was predominantly self-reported in most of the studies. The presence of recall and information biases represents a significant concern for investigations reliant on self-reported data on contraceptive use, as this may potentially lead to an underestimation of the true effect of contraceptive use on our targeted outcomes. In future research, recording techniques such as an on-time injection checklist or electronic pill count should be prioritized.

Agreements and disagreements with other studies

While our study identified negative mental health effects among women using contraceptives, it’s noteworthy to consider the contrasting findings from previous research. Schaffir’s study, for instance, reported either no effect or even a beneficial effect on mood among combined hormonal contraceptive users with no history of mental health issues [ 37 ]. In alignment with our study’s outcomes, Pérez-López’s investigation indicated a significantly higher risk of suicide among women treated with hormonal contraceptives [ 38 ]. Interestingly, a study on levonorgestrel intrauterine device users found no adverse effects on mental health, a result inconsistent with our findings, which indicated a higher risk of depression and increased antidepressant use among these users [ 39 ]. Moreover, this particular study highlighted a link between sexual dysfunction or low sexual function elevated depressive symptoms, and lower quality of life. It is worth noting that none of the studies explored the potential synergistic effect of sexual dysfunction and contraceptive use on mental health outcomes. Among women with pre-existing depressive or bipolar disorders who use hormonal contraceptives, we reported no association with increased depressive symptoms, similar to another review conducted [ 40 ]. Regrettably, none of the included studies investigated the association between contraceptives and the development of postpartum depression, highlighting a notable gap in the existing literature. These nuanced insights underscore the need for comprehensive research addressing the multifaceted relationship between contraceptive use and mental health outcomes, including potential synergies with sexual dysfunction and the postpartum period.

Initially, a comprehensive search was conducted in the databases for all relevant studies, encompassing outdated as well as current contraceptive methods, with a wide scope of coverage. Subsequently, our investigations covered diseases and conditions that are commonly observed in women of reproductive age, for each outcome category. For a few of these outcomes, we identified a handful of studies that produced larger pooled sample sizes, resulting in enhanced statistical power, narrower confidence intervals, and more trustworthy findings. Furthermore, in addition to exploring the efficacy of contraception for its intended contraceptive purposes, we also investigated its effectiveness as a treatment. This supplementary evidence supports the use of contraception as a treatment in clinical settings and justifies reasonable insurance coverage.

Limitations

One limitation is that the duration of contraception use varied across studies, which could be an explanation for the heterogeneity. RCTs are shorter in duration compared to cohort studies, so the long-term effects of HC use on depression in a controlled setting are not fully understood. There is a complex interrelation between female hormones, how they fluctuate throughout the menstrual cycle, and mental health outcomes. Our study did not account for the menstrual cycle phase and how it interacts with contraceptives. Another limitation is the varying HC dosages and methods used across studies. We did not perform subgroup analysis on HC methods among our RCT studies, so we are unable to distinguish which drug dosage range and method is most effective at reducing or preventing mental health outcome risks. Time to depression occurrence and other mental health outcomes were not considered. Most of the included studies were on OCP users, with limited studies looking at the associations of long-term contraceptive types. As long-term contraceptive methods become more popular, it is essential to have more information on the long-term side effects of these methods. Another important limitation to mention is the lack of understanding we have about the context of the women’s lives who were included in the study. Studies greatly varied on important demographic risk factors collected such as parity, smoking and alcohol use, socioeconomic status, employment status, contraception history, etc. Varying scales were used, bringing into question the validity of the various tools used to measure the outcome of interest. Due to a lack of a common definition of mental health outcomes, bias in outcome measurement is a concern. Heterogeneity was a significant issue in this study, limiting our ability to investigate contraceptives’ effects further. Heterogeneity could be a result of variability in the population samples and definitions used to diagnose depression. To further investigate this issue, subgroup analysis should be performed to reduce the variability in the samples being compared across studies. For instance, some studies were conducted among healthy women, while some were conducted among women with existing mental health conditions, or among women serving in the military. Issues with randomization showed imbalances in intervention vs. placebo groups within several studies, showing that the intervention group had higher proportions of women with depression assigned to them compared to the control group. Some of the findings may also be limited to generalizability due to homogenous samples.

In cohort studies relying solely on registry data, the concept of a “large false negative population in the control group” underscores a significant limitation. This means that within the group designated as the control—individuals not exposed to a specific intervention or condition—there is a notable number of cases where the actual presence of the condition or outcome under investigation is inaccurately recorded in the registry data. This introduces a risk of misclassification and could lead to an underestimation of the true prevalence of the condition in the control group. Furthermore, the term “likely selective prescribing of LNG IUD in the depression group” highlights another potential challenge. It suggests a bias in the prescription patterns of the levonorgestrel intrauterine device (LNG IUD) toward individuals with depression. In other words, those with depression might be more likely to receive the LNG IUD compared to individuals without depression. This introduces a source of bias, as the intervention is not randomly assigned but rather influenced by the presence of a specific condition, potentially impacting the study’s internal validity and generalizability of findings.

The absence of contraceptive usage in a control group warrants careful consideration and discussion in research, as it introduces potential complexities and differences within the study population. The question of why individuals in the control group are not using contraception is crucial, as it can signify various factors that may influence the study outcomes.

The decision not to use contraception could stem from factors such as a lack of perceived need, personal beliefs, cultural considerations, access barriers, or fertility-related intentions. Each of these reasons introduces inherent differences within the control group, making it inherently distinct from individuals who actively choose or require contraception.

This divergence in baseline characteristics can pose challenges in isolating the specific effects of the contraceptive method under investigation. The comparison between a group actively using contraception and another not using any introduces confounding variables, potentially clouding the interpretation of results. Researchers need to thoroughly explore and discuss these differences to provide a comprehensive understanding of the study population and to acknowledge potential sources of bias.

Implications for practice

The results of our research shed light on the complex relationship between hormonal contraception (HC) use and mental health outcomes among women, revealing divergent findings based on previous mental health status and contraceptive methods. While a slightly significant protective effect of HC was observed in women with previous mental disorders, a significant risk in depression scores was noted among women without prior mental health issues. Interestingly, anxiety showed a protective effect across both groups. Notably, subgroup analysis highlighted a significantly higher risk of depression among users of hormonal IUDs, implants, or patches/rings compared to other methods. However, the distinction in the effect on depression between combined oral contraceptives (COC) and progestogen-only pills (POP) remains unclear. Moreover, age emerged as a modifying factor, with a decreasing risk of depression and antidepressant use observed as age increases from adolescence to adulthood. Despite the comprehensive search strategy employed, generating recommendations for contraceptive use to improve non-reproductive health outcomes in women remains challenging due to heterogeneity concerns. Nonetheless, our high-quality evidence underscores the importance of future research endeavors focusing on standardized measurement tools, exploring the contextual factors of contraceptive use, and investigating the long-term effects of various contraceptive methods on mental health outcomes. These findings provide valuable insights for clinicians, researchers, and stakeholders to optimize contraceptive selection and monitoring practices, ultimately promoting the holistic well-being of women.

Implications for research

The present study provides implications for subsequent research in this area. Our work suggests that different lengths of contraceptive use may have health effects in different directions and to different degrees. Therefore, the non-reproductive health benefits of different durations of contraceptive use should be further examined. Time-to-event analysis should be conducted to further understand the association between the start of contraception and the incidence of depression and other mental health outcomes. This study did not focus on the health effects of hormonal contraceptives with various components and doses. As more new contraceptive methods become available, research on the benefits of different hormonal components and doses on non-reproductive health may provide more guidance for clinical use. More studies on long-term modern contraception methods are needed as well as studies accounting for menstrual phases. To generalize findings to the larger population, future RCTs should use strict definitions of mental illness and selection criteria to ensure reproducibility across studies. Also important is the ability to understand the context of the women participating in these studies. Common predictors across studies should be used to properly account for confounders and track them. Additionally, future studies should consider the impacts of unintended pregnancy on postpartum women using contraceptives as well as the duration of contractive use and its impact on mental health.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Combined oral contraceptive

Confidence interval

Daily Record of Severity of Problems

Hormonal contraceptive

Intrauterine device

Oral contraceptive

Oral contraceptive pill

Post-traumatic stress disorder

Randomized controlled trial

Standardized mean differences

World Health Organization

Contraceptive use by Method 2019: Data Booklet . (2019). United Nations.

Creanga AA, Berg CJ, Ko JY, Farr SL, Tong VT, Bruce FC, Callaghan WM. Maternal mortality and morbidity in the United States: where are we now? J Womens Health (Larchmt). 2014;23(1):3–9. https://doi.org/10.1089/jwh.2013.4617 .

Article   PubMed   Google Scholar  

Alder J, Fink N, Bitzer J, Hosli I, Holzgreve W. Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. J Matern Fetal Neonatal Med. 2007;20(3):189–209. https://doi.org/10.1080/14767050701209560 .

Bahamondes L, Fernandes A, Monteiro I, Bahamondes MV. Long-acting reversible contraceptive (LARCs) methods. Best Pract Res Clin Obstet Gynaecol. 2020;66:28–40. https://doi.org/10.1016/j.bpobgyn.2019.12.002 .

De Leo V, Musacchio MC, Cappelli V, Piomboni P, Morgante G. Hormonal contraceptives: pharmacology tailored to women’s health. Hum Reprod Update. 2016;22(5):634–46. https://doi.org/10.1093/humupd/dmw016 .

Article   CAS   PubMed   Google Scholar  

Bain LE, Zweekhorst MBM, de Buning C, T. Prevalence and determinants of unintended pregnancy in sub -Saharan Africa: a systematic review. Afr J Reprod Health. 2020;24(2):187–205. https://doi.org/10.29063/ajrh2020/v24i2.18 .

Onarheim KH, Iversen JH, Bloom DE. Economic benefits of investing in women’s health: a systematic review. PLoS ONE. 2016;11(3):e0150120. https://doi.org/10.1371/journal.pone.0150120 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Gruskin S, Yadav V, Castellanos-Usigli A, Khizanishvili G, Kismodi E. Sexual health, sexual rights and sexual pleasure: meaningfully engaging the perfect triangle. Sex Reprod Health Matters. 2019;27(1):1593787. https://doi.org/10.1080/26410397.2019.1593787 .

Filatova EV, Shadrina MI, Slominsky PA. Major Depression: one brain, one disease, one set of intertwined processes. Cells. 2021;10(6). https://doi.org/10.3390/cells10061283 .

Martin EI, Ressler KJ, Binder E, Nemeroff CB. The neurobiology of anxiety disorders: brain imaging, genetics, and psychoneuroendocrinology. Psychiatr Clin North Am. 2009;32(3):549–75. https://doi.org/10.1016/j.psc.2009.05.004 .

Article   PubMed   PubMed Central   Google Scholar  

Robinson SA, Dowell M, Pedulla D, McCauley L. Do the emotional side-effects of hormonal contraceptives come from pharmacologic or psychological mechanisms? Med Hypotheses. 2004;63(2):268–73. https://doi.org/10.1016/j.mehy.2004.02.013 .

O’Connell K, Davis AR, Kerns J. Oral contraceptives: side effects and depression in adolescent girls. Contraception. 2007;75(4):299–304. https://doi.org/10.1016/j.contraception.2006.09.008 .

Ross RA, Kaiser UB. Reproductive endocrinology: the emotional cost of contraception. Nat Rev Endocrinol. 2016;13(1):7–9. https://doi.org/10.1038/nrendo.2016.194 .

Imai A, Ichigo S, Matsunami K, Takagi H. Premenstrual syndrome: management and pathophysiology. Clin Exp Obstet Gynecol. 2015;42(2):123–8. https://www.ncbi.nlm.nih.gov/pubmed/26054102 .

Epperson CN, Haga K, Mason GF, Sellers E, Gueorguieva R, Zhang W, Weiss E, Rothman DL, Krystal JH. Cortical gamma-aminobutyric acid levels across the menstrual cycle in healthy women and those with premenstrual dysphoric disorder: a proton magnetic resonance spectroscopy study. Arch Gen Psychiatry. 2002;59(9):851–8. https://doi.org/10.1001/archpsyc.59.9.851 .

Skovlund CW, Morch LS, Kessing LV, Lidegaard O. Association of Hormonal Contraception with Depression. JAMA Psychiatry. 2016;73(11):1154–62. https://doi.org/10.1001/jamapsychiatry.2016.2387 .

Vahratian A, Blumberg SJ, Terlizzi EP, Schiller JS. Symptoms of anxiety or depressive disorder and use of Mental Health Care among adults during the COVID-19 pandemic - United States, August 2020-February 2021. MMWR Morb Mortal Wkly Rep. 2021;70(13):490–4. https://doi.org/10.15585/mmwr.mm7013e2 .

Farr SL, Dietz PM, Williams JR, Gibbs FA, Tregear S. Depression screening and treatment among nonpregnant women of reproductive age in the United States, 1990–2010. Prev Chronic Dis. 2011;8(6):A122.

PubMed   PubMed Central   Google Scholar  

Beck AT. Cognitive models of depression. J Cogn Psychother. 1987;1:5–37.

Google Scholar  

Hubacher D, Trussell J. A definition of modern contraceptive methods. Contraception. 2015;92(5):420-1. https://doi.org/10.1016/j.contraception.2015.08.008 . Epub 2015 Aug 11. PMID: 26276245.

Bengtsdotter H, Lundin C, Gemzell Danielsson K, Bixo M, Baumgart J, Marions L, Brynhildsen J, Malmborg A, Lindh I, Poromaa S, I. Ongoing or previous mental disorders predispose to adverse mood reporting during combined oral contraceptive use. Eur J Contracept Reprod Health Care. 2018;23(1):45–51.

Chan AF, Mortola JF, Wood SH, Yen SS. Persistence of premenstrual syndrome during low-dose administration of the progesterone antagonist RU 486. Obstet Gynecol. 1994;84(6):1001–5. https://www.ncbi.nlm.nih.gov/pubmed/7970453 .

CAS   PubMed   Google Scholar  

Comasco E, Kopp Kallner H, Bixo M, Hirschberg AL, Nyback S, de Grauw H, Epperson CN, Sundstrom-Poromaa I. Ulipristal acetate for treatment of Premenstrual Dysphoric disorder: a proof-of-Concept Randomized Controlled Trial. Am J Psychiatry. 2021;178(3):256–65. https://doi.org/10.1176/appi.ajp.2020.20030286 .

Eisenlohr-Moul TA, Girdler SS, Johnson JL, Schmidt PJ, Rubinow DR. Treatment of premenstrual dysphoria with continuous versus intermittent dosing of oral contraceptives: results of a three-arm randomized controlled trial. Depress Anxiety. 2017;34(10):908–17. https://doi.org/10.1002/da.22673 .

Gingnell M, Engman J, Frick A, Moby L, Wikstrom J, Fredrikson M, Sundstrom-Poromaa I. Oral contraceptive use changes brain activity and mood in women with previous negative affect on the pill–a double-blinded, placebo-controlled randomized trial of a levonorgestrel-containing combined oral contraceptive. Psychoneuroendocrinology. 2013;38(7):1133–44. https://doi.org/10.1016/j.psyneuen.2012.11.006 .

Joffe H, Petrillo LF, Viguera AC, Gottshcall H, Soares CN, Hall JE, Cohen LS. Treatment of premenstrual worsening of depression with adjunctive oral contraceptive pills: a preliminary report. J Clin Psychiatry. 2007;68(12):1954–62. https://doi.org/10.4088/jcp.v68n1218 .

Lascurain MB, Camunas-Palacin A, Thomas N, Breadon C, Gavrilidis E, Hudaib AR, Gurvich C, Kulkarni J. Improvement in depression with oestrogen treatment in women with schizophrenia. Arch Womens Ment Health. 2020;23(2):149–54. https://doi.org/10.1007/s00737-019-00959-3 .

Peters W, Freeman MP, Kim S, Cohen LS, Joffe H. Treatment of Premenstrual breakthrough of Depression with adjunctive oral contraceptive pills compared with placebo. J Clin Psychopharmacol. 2017;37(5):609–14. https://doi.org/10.1097/JCP.0000000000000761 .

Yonkers KA, Brown C, Pearlstein TB, Foegh M, Sampson-Landers C, Rapkin A. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstet Gynecol. 2005;106(3):492–501. https://doi.org/10.1097/01.AOG.0000175834.77215.2e .

Lundin C, Wikman A, Lampa E, Bixo M, Gemzell-Danielsson K, Wikman P, Ljung R, Poromaa S, I. There is no association between combined oral hormonal contraceptives and depression: a Swedish register-based cohort study. BJOG. 2021;129(6):917–25. https://doi.org/10.1111/1471-0528.17028 .

de Wit AE, Booij SH, Giltay EJ, Joffe H, Schoevers RA, Oldehinkel AJ. Association of Use of oral contraceptives with depressive symptoms among adolescents and Young women. JAMA Psychiatry. 2020;77(1):52–9. https://doi.org/10.1001/jamapsychiatry.2019.2838 .

Ditch S, Hansen S, Roberts T. Association of Hormonal Contraception Initiation with subsequent depression diagnosis and antidepressant use in United States Military Health System beneficiaries: a Cohort Study. J Adolesc Health. 2019;64(2):S34. https://doi.org/10.1016/j.jadohealth.2018.10.078 .

Article   Google Scholar  

Zettermark S, Khalaf K, Perez-Vicente R, Leckie G, Mulinari D, Merlo J. Population heterogeneity in associations between hormonal contraception and antidepressant use in Sweden: a prospective cohort study applying intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). BMJ Open. 2021;11(10):e049553. https://doi.org/10.1136/bmjopen-2021-049553 .

Yonkers KA, Cameron B, Gueorguieva R, Altemus M, Kornstein SG. The influence of cyclic hormonal contraception on expression of Premenstrual Syndrome. J Womens Health (Larchmt). 2017;26(4):321–8. https://doi.org/10.1089/jwh.2016.5941 .

Young EA, Kornstein SG, Harvey AT, Wisniewski SR, Barkin J, Fava M, Trivedi MH, Rush AJ. Influences of hormone-based contraception on depressive symptoms in premenopausal women with major depression. Psychoneuroendocrinology. 2007;32(7):843–53. https://doi.org/10.1016/j.psyneuen.2007.05.013 .

Hamstra DA, de Kloet ER, de Rover M, Van der Does W. Oral contraceptives positively affect mood in healthy PMS-free women: a longitudinal study. J Psychosom Res. 2017;103:119–26. https://doi.org/10.1016/j.jpsychores.2017.10.011 .

Schaffir J, Worly BL, Gur TL. Combined hormonal contraception and its effects on mood: a critical review. Eur J Contracept Reprod Health Care. 2016;21(5):347–55. https://doi.org/10.1080/13625187.2016.1217327 .

Pérez-López FR, Pérez-Roncero GR, López-Baena MT, Santabárbara J, Chedraui P. Hormonal contraceptives and the risk of suicide: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020;251:28–35. https://doi.org/10.1016/j.ejogrb.2020.04.053 .

Bürger Z, Bucher AM, Comasco E, Henes M, Hübner S, Kogler L, Derntl B. Association of levonorgestrel intrauterine devices with stress reactivity, mental health, quality of life and sexual functioning: a systematic review. Front Neuroendocr. 2021;63:100943. https://doi.org/10.1016/j.yfrne.2021.100943 .

Article   CAS   Google Scholar  

Pagano HP, Zapata LB, Berry-Bibee EN, Nanda K, Curtis KM. Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review. Contraception. 2016;94(6):641–9. https://doi.org/10.1016/j.contraception.2016.06.012 .

Download references

Acknowledgements

The authors would like to gratefully acknowledge comments and suggestions from the WHO Technical Advisory Group (TAG) consisting of (listed in Alphabetical order): Dr. Ann Biddlecom; Dr. Harriet Birungi; Professor Herbert Peterson; Dr. Iqbal Shah; Dr. James Kiarie; Professor John Cleland; Dr. John Townsend; Dr. Manala Makua and Professor Sonalde Desai. We would like to especially acknowledge the support and guidance of Dr. James Kiarie (WHO) throughout the process of completing the project. We thank him for his efforts. We acknowledge the support of USAID who provided input on the research questions. USAID did not participate in the data abstraction, analysis, or interpretation or the decision to submit it for publication. The analysis, interpretation, writing up, and the decision to submit the paper was coordinated by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO. All authors were consultants and one author was a staff member. Furthermore, we are grateful to Amy Lapidow for her assistance in developing the search strategies and helping us to conduct a literature search that yielded over 7,000 studies. We would also like to thank all at Tufts University School of Medicine who have supported completing this research. Many thanks go to them. A team of researchers from the Cochrane Fertility Group contributed intellectually to providing support for this project. The team members are Alison Edelman, Motu Makaplapua, and Jullian Henderson.

This study received support from the USAID consolidated grant 7200GH21IO00005.

Author information

Authors and affiliations.

Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, US

Shayesteh Jahanfar, Julie Mortazavi, Amy Lapidow, Cassandra Cu, Jude Al Abosy, Katherine Morris, Meredith Steinfeldt, Olivia Maurer & Bohang Jiang

Universidad de Antioquia, Columbia, USA

Juan Camilo Becerra-Mateus

Coordinator Cochrane US Mentoring Program, Tufts University School of Medicine, Boston, US

Paola Andrenacci

Cochrane mentee, US Mentoring Program, Tufts University School of Medicine, Boston, US

Marwa Badawy

Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva 27, Geneva, CH-1211, Switzerland

Moazzam Ali

You can also search for this author in PubMed   Google Scholar

Contributions

Conceptualization: Shayesteh Jahanfar, Moazzam Ali, Julie Mortazavi. Background and discussion: Paula Andrenacci, Marwa Badawy. Data Curation: Shayesteh Jahanfar, Amy Lapidow, Julie Mortazavi, Katherine Morris, Jude Al Abosy, Bohang Jiang, Juan Camilo Becerra-Mateus, Cassandra Cu. Formal Analysis: Shayesteh Jahanfar, Meredith Steinfeldt. Writing – original draft: Shayesteh Jahanfar, Julie Mortazavi, Olivia Maurer, Meredith Steinfeldt, Bohang Jiang. Writing – review, and editing: Shayesteh Jahanfar, Julie Mortazavi, Olivia Maurer, Meredith Steinfeldt, Moazzam Ali.

Corresponding author

Correspondence to Moazzam Ali .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

The named authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions or the policies of the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) or the World Health Organization (WHO).

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, supplementary material 3, supplementary material 4, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Jahanfar, S., Mortazavi, J., Lapidow, A. et al. Assessing the impact of contraceptive use on mental health among women of reproductive age – a systematic review. BMC Pregnancy Childbirth 24 , 396 (2024). https://doi.org/10.1186/s12884-024-06587-9

Download citation

Received : 26 July 2023

Accepted : 15 May 2024

Published : 30 May 2024

DOI : https://doi.org/10.1186/s12884-024-06587-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Contraception
  • Mental health
  • Systematic review

BMC Pregnancy and Childbirth

ISSN: 1471-2393

systematic review of research utilization

IMAGES

  1. systematic review of research utilization

    systematic review of research utilization

  2. systematic review of research utilization

    systematic review of research utilization

  3. systematic review of research utilization

    systematic review of research utilization

  4. What is a Systematic Review

    systematic review of research utilization

  5. A Step by Step Guide for Conducting a Systematic Review

    systematic review of research utilization

  6. How to Conduct a Systematic Review

    systematic review of research utilization

VIDEO

  1. Statistical Procedure in Meta-Essentials

  2. Introduction to Systematic Review Software: Covidence

  3. Research Utilization Reporting. NSG 204

  4. Introduction to Systematic Review of Research

  5. سؤل البحث عند كتابة ورقة بطريقة ممنهجة Research question for systematic review paper

  6. Progress Report II

COMMENTS

  1. Barriers to Research Utilization in Nursing: A Systematic Review (2002-2021)

    Research Utilization. Research utilization is described as applying scientific research findings to clinical practice. Scientific evidence and conclusions in this field are relevant to practitioners to make optimal decisions and improve patient conditions and outcomes (Da'seh & Rababa, 2021).However, there is a limited study on the barriers of research utilization in nursing, including the ...

  2. Barriers to Research Utilization in Nursing: A Systematic Review (2002

    This gap is primarily due to identified barriers in utilizing the research findings in actual nursing practice. Objective: To present a scienti fic mapping of the Scopus-indexed literature published from 2002 to 2021, which studied barriers to research utilization in nursing using the BARRIER scale.

  3. Revisiting the Barriers to and Facilitators of Research Utilization in

    Purpose: This systematic review aimed to critically identify, select, appraise, and synthesize research evidence about the barriers to and facilitators of research utilization.

  4. Barriers to Research Utilization in Nursing: A Systematic Review (2002

    Objective: To present a scientific mapping of the Scopus-indexed literature published from 2002 to 2021, which studied barriers to research utilization in nursing using the BARRIER scale. Methods: This systematic review utilized bibliometric analysis. One hundred seventy-nine extracted literature from Scopus was manually reviewed, and the study ...

  5. Individual determinants of research utilization by nurses: a systematic

    As part of a larger systematic review on research utilization instruments, 12 online bibliographic databases were searched. Hand searching of specialized journals and an ancestry search was also conducted. Randomized controlled trials, clinical trials, and observational study designs examining the association between individual characteristics ...

  6. Individual determinants of research utilization by nurses: a systematic

    To update the evidence published in a previous systematic review on individual characteristics influencing research utilization by nurses. As part of a larger systematic review on research utilization instruments, 12 online bibliographic databases were searched. Hand searching of specialized journals and an ancestry search was also conducted.

  7. Revisiting the Barriers to and Facilitators of Research Utilization in

    Conclusion: Despite extensive studies conducted addressing the barriers to research utilization, the findings suggest a consistent reproach on the capability of nurses to maximize and utilize research. The same elements that may serve as barriers to, can likewise become the impetus in gaining sufficient research utilization among nurses. Keywords

  8. Barriers to Research Utilization in Nursing: A Systematic Review (2002

    Methods This systematic review utilized bibliometric analysis. One hundred seventy-nine extracted literature from Scopus was manually reviewed, and the study included 53 documents for further ...

  9. Individual determinants of research utilization: a systematic review

    In order to design interventions that increase research use in nursing, it is necessary to have an understanding of what influences research use. Objective. To report findings on a systematic review of studies that examine individual characteristics of nurses and how they influence the utilization of research. Search strategy.

  10. Individual determinants of research utilization: a systematic review

    CONTEXT In order to design interventions that increase research use in nursing, it is necessary to have an understanding of what influences research use. OBJECTIVE To report findings on a systematic review of studies that examine individual characteristics of nurses and how they influence the utilization of research.

  11. Revisiting the Barriers to and Facilitators of Research Utilization in

    DOI: 10.14710/NMJN.V9I1.20827 Corpus ID: 198586708; Revisiting the Barriers to and Facilitators of Research Utilization in Nursing: A Systematic Review @article{Tuppal2019RevisitingTB, title={Revisiting the Barriers to and Facilitators of Research Utilization in Nursing: A Systematic Review}, author={Cyruz P. Tuppal and Paolo D Vega and Marina Magnolia G. Ninobla and Mark Donald C. Re{\~n}osa ...

  12. Barriers to Research Utilization in Nursing: A Systematic Review (2002

    A scientific mapping of the Scopus-indexed literature published from 2002 to 2021, which studied barriers to research utilization in nursing using the BARRIER scale, established the connection between research and evidence-based practice which stimulates in meeting the gap in the current nursing practice. Introduction There is an existing gap between what people learned from theory and what ...

  13. Individual determinants of research utilization: a systematic review

    In order to design interventions that increase research use in nursing, it is necessary to have an understanding of what influences research use. Objective. To report findings on a systematic review of studies that examine individual characteristics of nurses and how they influence the utilization of research. Search strategy.

  14. The BARRIERS scale -- the barriers to research utilization scale: A

    A commonly recommended strategy for increasing research use in clinical practice is to identify barriers to change and then tailor interventions to overcome the identified barriers. In nursing, the BARRIERS scale has been used extensively to identify barriers to research utilization. The aim of this systematic review was to examine the state of knowledge resulting from use of the BARRIERS ...

  15. Analysis of instruments measuring nurses' attitudes towards research

    Analysis of instruments measuring nurses' attitudes towards research utilization: a systematic review. Aim. This paper is a report of a systematic review describing instruments used to measure nurses' attitudes towards research utilization. Background. Researchers need to have the tools to measure nurses' attitudes.

  16. A systematic review of the psychometric properties of self-report

    In healthcare, a gap exists between what is known from research and what is practiced. Understanding this gap depends upon our ability to robustly measure research utilization. The objectives of this systematic review were: to identify self-report measures of research utilization used in healthcare, and to assess the psychometric properties (acceptability, reliability, and validity) of these ...

  17. Methods to support a systematic approach to research utilization

    Research utilization methods can support identification of evidence gaps, produce practice-based evidence, demonstrate efficacy, support dissemination to improve awareness, and facilitate intervention adaptations and adoption. Our colleagues Christine Kim et al. (2018) used decades of experience to develop a four-phase research utilization ...

  18. Barriers and facilitators to mental health treatment access and

    The results of this review will provide a comprehensive account of the current and historical barriers and facilitators to mental healthcare faced by LGBTQA+ people with psychotic symptoms and experiences. It is anticipated that the findings from this review will be relevant to clinical and community services and inform future research.

  19. Factors influencing the participation of pregnant and lactating women

    What did the researchers do and find? We conducted a mixed-methods systematic review and identified 60 research articles from 27 countries on the views and experiences of pregnant and lactating women's participation in clinical research, from the perspectives of cisgender women, family and community members, health workers, and people involved in the conduct of clinical research.

  20. Point prevalence of evidence-based antimicrobial use among ...

    This systematic review and meta-analysis aimed to determine the pooled point prevalence (PPP) of evidence-based antimicrobial use among hospitalized patients in SSA.

  21. Patient experiences: a qualitative systematic review of chemotherapy

    Studies included in this review were classified as primary research, published in English since 2006, some intervention implemented to improve adherence to treatment. ... (2021-02896). A proposal for the systematic review was assessed by the Edith Cowan University Human Research Ethics Committee and deemed not appropriate for full ethical ...

  22. Turnover intention and its associated factors among nurses in Ethiopia

    This systematic review and meta-analysis incorporated 8 articles, involving 3033 nurses in the analysis. The pooled proportion of turnover intention among nurses in Ethiopia was 53.35% (95% CI (41.64, 65.05%)), with significant heterogeneity between studies (I2 = 97.9, P = 0.001). ... Extensive research conducted worldwide has identified a ...

  23. A systematic literature review of empirical research on ChatGPT in

    Over the last four decades, studies have investigated the incorporation of Artificial Intelligence (AI) into education. A recent prominent AI-powered technology that has impacted the education sector is ChatGPT. This article provides a systematic review of 14 empirical studies incorporating ChatGPT into various educational settings, published in 2022 and before the 10th of April 2023—the ...

  24. Systematic review and meta-analysis of hepatitis E seroprevalence in

    To commence this systematic review and meta-analysis, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and used the PRISMA assessment checklist [Supplementary Table 1].The study included pertinent research conducted within the population of Southeast Asian countries, as outlined by the United Nations [], and perform a meta-analysis on the ...

  25. Research utilization and clinical nurse educators: a systematic review

    Background Clinical nurse educators and other linking agents such as clinical nurse specialists, advanced nurse practitioners, and nurses working in research leadership positions are an important link in the facilitation of evidence-based practice in health care organizations.. Aim The purpose of this paper is to report the findings of a systematic review of the literature regarding clinical ...

  26. Barriers to Research Utilization in Nursing: A Systematic Review (2002

    There is a discrepancy between the knowledge gained from theoretical research and actual clinical practice (Benton et al., 2020; Mackey & Bassendowski, 2017).A significant number of research studies have focused on developing and applying practical research ideas in practice from the past five years (Estabrooks, 1999a).The clinical application coexists with evidence-based practice (Mackey ...

  27. Assessing the impact of contraceptive use on mental health among women

    The utilization of contraception has experienced a significant upsurge among women globally. ... Research shows that lower levels of gamma-aminobutyric acid circulate during the luteal phase of the menstrual cycle ... In the inception phase of this systematic review, the inclusion criteria were initially limited to randomized controlled trials ...