literature review and research question

Literature Reviews

• Getting Started
• Choosing a Type of Review

Developing a Research Question

Finding example literature reviews.

• Searching the Literature
• Searching Tips
• ChatGPT [beta]
• Documenting your Search
• Using Citation Managers
• Concept Mapping
• Writing the Review
• Further Resources

Goldilocker Tool

UM Librarians have developed a quick tool called Goldilocker  to help beginners who are struggling to refine their Research Question. 

DEVELOPING A RESEARCH QUESTION

Before searching for sources, you need to formulate a Research Question — this is what you are trying to answer using the existing academic literature. The Research Question pinpoints the focus of the review .

Your first step involves choosing, exploring, and focusing a topic. At this stage you might discover that you need to tweak your topic or the scope of your research as you learn more about the topic in the literature.

THINGS TO KEEP IN MIND: 

• The question must be "researchable" — it can be answered with accessible facts and data
• Questions often start with How, Why, What, Which
• The question opens the door for other areas of inquiry — it identifies a gap in existing research
• Questions should be open-ended and focus on cause and effect

TRY TO AVOID: 

• Simple yes/no questions, or questions with an easy answer (what is the radius of the moon?)
• Questions that can only be answered by an opinion (does it smell nice when it rains?)
• Questions that involve secret information (what is the recipe for Coca-Cola?)
• Questions that are too broad or too narrow

REFINING YOUR RESEARCH QUESTION

Two examples of refining research questions that could be considered either too broad or too narrow.

USING DATABASE FILTER TOOLS

It can be helpful to read existing literature reviews on your topic to get an idea of major themes, how authors structure their arguments, or what reviews look like in your discipline.

DOCUMENT TYPE FILTERS

Many library databases have the option to highlight just Review Articles after you perform a search. Filters above show what the Document Type filter looks like, with a "Review" option. These examples are from Scopus and ProQuest. The "Review" filter here refers to free-standing, comprehensive Review Articles on a topic, as opposed to a shorter literature review inside a scholarly article.

LIT REVIEWS INSIDE ARTICLES

It is also worth taking a look at the shorter literature reviews inside scholarly articles. These can sometimes be called "Background" or "Background Literature." Look for a section typically following the Introduction that covers the history or gives context on the paper's topic.

EXAMPLE REVIEW ARTICLES

Here are a few examples of Review Articles in different disciplines. Note sometimes an article can be a Review Article without the word "review" in the title.

HUMANITIES — Art — " Art and Crime: Conceptualising Graffiti in the City " from the journal Geography Compass

SCIENCES — Climate Change — " Mercury Isotopes in Earth and Environmental Sciences " from the journal  Annual Review of Earth and Planetary Sciences

SOCIAL SCIENCES — Psychology — " Structural Competency and the Future of Firearm Research " from the journal Social Science & Medicine

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• 10 Research Question Examples to Guide Your Research Project

10 Research Question Examples to Guide your Research Project

Published on October 30, 2022 by Shona McCombes . Revised on October 19, 2023.

The research question is one of the most important parts of your research paper , thesis or dissertation . It’s important to spend some time assessing and refining your question before you get started.

The exact form of your question will depend on a few things, such as the length of your project, the type of research you’re conducting, the topic , and the research problem . However, all research questions should be focused, specific, and relevant to a timely social or scholarly issue.

Once you’ve read our guide on how to write a research question , you can use these examples to craft your own.

Note that the design of your research question can depend on what method you are pursuing. Here are a few options for qualitative, quantitative, and statistical research questions.

Other interesting articles

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

Methodology

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

 Statistics

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

Research bias

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

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

McCombes, S. (2023, October 19). 10 Research Question Examples to Guide your Research Project. Scribbr. Retrieved June 15, 2024, from https://www.scribbr.com/research-process/research-question-examples/

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• Research Guides

How to Write a Literature Review

• 1. Identify the Question
• Literature Reviews: A Recap
• Reading Journal Articles
• Does it Describe a Literature Review?

Identify the question

Developing a research question.

• 2. Review Discipline Styles
• Searching Article Databases
• Finding Full-Text of an Article
• Citation Chaining
• When to Stop Searching
• 4. Manage Your References
• 5. Critically Analyze and Evaluate
• 6. Synthesize
• 7. Write a Literature Review

From Topic to Question (Infographic)

This graphic emphasizes how reading various sources can play a role in defining your research topic.

( Click to Enlarge Image )

Text description of "From Topic to Question" for web accessibility

In some cases, such as for a course assignment or a research project you're working on with a faculty mentor, your research question will be determined by your professor. If that's the case, you can move on to the next step .  Otherwise, you may need to explore questions on your own. 

A few suggestions

Photo Credit: UO Libraries

According to The Craft of Research (2003) , a research question is more than a practical problem or something with a yes/no answer. A research question helps you learn more about something you don't already know and it needs to be significant enough to interest your readers.

Your Curiosity + Significance to Others = Research Question

How to get started.

In a research paper, you develop a unique question and then synthesize scholarly and primary sources into a paper that supports your argument about the topic.

• Identify your Topic (This is the starting place from where you develop a research question.)
• Refine by Searching (find background information) (Before you can start to develop a research question, you may need to do some preliminary background research to see (1) what has already been done on the topic and (2) what are the issues surrounding the topic.) HINT: Find background information in Google and Books.
• Refine by Narrowing (Once you begin to understand the topic and the issues surrounding it, you can start to narrow your topic and develop a research question. Do this by asking the 6 journalistic question words.

Ask yourself these 6 questions 

These 6 journalistic question words can help you narrow your focus from a broad topic to a specific question.

Who : Are you interested in a specific group of people? Can your topic be narrowed by gender, sex, age, ethnicity, socio-economic status or something else? Are there any key figures related to your topic?

What : What are the issues surrounding your topic? Are there subtopics? In looking at background information, did you notice any gaps or questions that seemed unanswered?

Where : Can your topic be narrowed down to a geographic location? Warning: Don't get too narrow here. You might not be able to find enough information on a town or state.

When : Is your topic current or historical? Is it confined to a specific time period? Was there a causative event that led your topic to become an area of study?

Why : Why are you interested in this topic? Why should others be interested?

How : What kinds of information do you need? Primary sources, statistics? What is your methodology?

Detailed description of, "Developing a Research Question" for web accessibility

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• Steps in Conducting a Literature Review

What is a literature review?

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

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

Why is it important?

A literature review is important because it:

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

APA7 Style resources

APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

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

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

2. Decide on the scope of your review

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

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

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

Make a list of the databases you will search. 

Where to find databases:

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

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

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

Review the literature

Some questions to help you analyze the research:

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

Tips: 

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

• Getting Started
• Define your Research Question
• Finding Sources
• Evaluating Sources
• Organizing the Review
• Cite and Manage your Sources

Additional Resources

• Developing Research Questions by Monash University
• Developing Strong Research Questions by Scribbr
• Formulating Your Research Question by Vanderbilt University
• Narrowing a Topic and Developing a Research Question by Indiana University

Develop your Research Question

Before you can begin your literature review, you will need to select a topic. It is helpful to think about your research topic as a question. For example, instead of a topic like "diversity", you could ask "How do diversity training programs impact hiring practices in retail organizations?"

A good research question is manageable in scope - not too broad, but not too narrow. If your topic is too broad, you may become overwhelmed and find it difficult to organize your ideas.  If your topic is too narrow, you may not be able to find enough information to include in your literature review.

As the video below describes in further detail , a good research question should be focused on a single problem or issue, researchable  using college resources, feasible within the constraints of your assignment, specific enough to find relevant sources about, complex enough to require thoughtful analysis, and relevant  to your interests and/or field of study.

Developing a Research Question - General Tips

It is often helpful to start with a broad idea, then narrow your focus by brainstorming related ideas. If you have a general area of interest, you can think about various issues in that general subject area.  Do any of your ideas present a puzzle or problem that you are interested in investigating?  Are there issues that make you wonder about causes or consequences?

The general steps of a research question, explained in detail in the below video, are:

• Choose a broad topic
• If necessary, do some preliminary reading to find out about issues related to the topic or interesting subtopics
• Narrow down a specific problem, issue, or subtopic to focus on
• Looking at this narrower topic, come up with a question that could guide your research going forward

Your Research Question and the Literature Review

Your literature review should be guided by a central research question.  Remember, it is not a collection of loosely related studies in a field but instead represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

As you begin to investigate and evaluate scholarly literature on your topic, you may find it necessary to revise your original research question based on what you learn.  Be sure to expand your literature search to include any new concepts you may identify along the way !

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

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

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

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Formulating a good research question: Pearls and pitfalls

Wilson fandino.

Guys' and St Thomas' Hospital National Health Service Foundation Trust, London, United Kingdom

The process of formulating a good research question can be challenging and frustrating. While a comprehensive literature review is compulsory, the researcher usually encounters methodological difficulties in the conduct of the study, particularly if the primary study question has not been adequately selected in accordance with the clinical dilemma that needs to be addressed. Therefore, optimising time and resources before embarking in the design of a clinical protocol can make an impact on the final results of the research project. Researchers have developed effective ways to convey the message of how to build a good research question that can be easily recalled under the acronyms of PICOT (population, intervention, comparator, outcome, and time frame) and FINER (feasible, interesting, novel, ethical, and relevant). In line with these concepts, this article highlights the main issues faced by clinicians, when developing a research question.

INTRODUCTION

What is your research question? This is very often one of the first queries made by statisticians, when researchers come up with an interesting idea. In fact, the findings of a study may only acquire relevance if they provide an accurate and unbiased answer to a specific question,[ 1 , 2 ] and it has been suggested that up to one-third of the time spent in the whole process—from the conception of an idea to the publication of the manuscript—could be invested in finding the right primary study question.[ 3 ] Furthermore, selecting a good research question can be a time-consuming and challenging task: in one retrospective study, Mayo et al . reported that 3 out of 10 articles published would have needed a major rewording of the question.[ 1 ] This paper explores some recommendations to consider before starting any research project, and outlines the main difficulties faced by young and experienced clinicians, when it comes time to turn an exciting idea into a valuable and feasible research question.

OPTIMISATION OF TIME AND RESOURCES

Focusing on the primary research question.

The process of developing a new idea usually stems from a dilemma inherent to the clinical practice.[ 2 , 3 , 4 ] However, once the problem has been identified, it is tempting to formulate multiple research questions. Conducting a clinical trial with more than one primary study question would not be feasible. First, because each question may require a different research design, and second, because the necessary statistical power of the study would demand unaffordable sample sizes. It is the duty of editors and reviewers to make sure that authors clearly identify the primary research question, and as a consequence, studies approaching more than one primary research question may not be suitable for publication.

Working in the right environment

Teamwork is essential to find the appropriate research question. Working in the right environment will enable the investigator to interact with colleagues with different backgrounds, and create opportunities to exchange experiences in a collaborative way between clinicians and researchers. Likewise, it is of paramount importance to get involved colleagues with expertise in the field (lead clinicians, education supervisors, research mentors, department chairs, epidemiologists, biostatisticians, and ethical consultants, among others), and ask for their guidance.[ 5 , 6 , 7 , 8 ]

Evaluating the pertinence of the study

The researcher should wonder if, on the basis of the research question formulated, there is a need for a study to address the problem, as clinical research usually entails a large investment of resources and workforce involvement. Thus, if the answer to the posed clinical question seems to be evident before starting the study, investing in research to address the problem would become superfluous. For example, in a clinical trial, Herzog-Niescery et al . compared laryngeal masks with cuffed and uncuffed tracheal tubes, in the context of surgeons' exposure to sevoflurane, in infants undergoing adenoidectomy. However, it appears obvious that cuffed tracheal tubes are preferred to minimise surgeons' exposure to volatile gases, as authors concluded after recruiting 60 patients.[ 9 ]

Conducting a thorough literature review

Any research project requires the identification of at least one of three problems: the evidence is scarce, the existing literature yields conflicting results, or the results could be improved. Hence, a comprehensive review of the topic is imperative, as it allows the researcher to identify this gap in the literature, formulate a hypothesis and develop a research question.[ 2 ] To this end, it is crucial to be attentive to new ideas, keep the imagination roaming with reflective attitude, and remain sceptical to the new-gained information.[ 4 , 7 ]

Narrowing the research question

A broad research question may encompass an unaffordable extensive topic. For instance, do supraglottic devices provide similar conditions for the visualization of the glottis aperture in a German hospital? Such a general research question usually needs to be narrowed, not only by cutting away unnecessary components (a German hospital is irrelevant in this context), but also by defining a target population, a specific intervention, an alternative treatment or procedure to be compared with the intervention, a measurable primary outcome, and a time frame of the study. In contrast, an example of a good research question would be: among children younger than 1 year of age undergoing elective minor procedures, to what extent the insertion times are different, comparing the Supreme™ laryngeal mask airway (LMA) to Proseal™ LMA, when placed after reaching a BIS index <60?[ 10 ] In this example, the core ingredients of the research question can be easily identified as: children <1 year of age undergoing minor elective procedures, Supreme™ LMA, Proseal™ LMA and insertion times at anaesthetic induction when reaching a BIS index <60. These components are usually gathered in the literature under the acronym of PICOT (population, intervention, comparator, outcome and time frame, respectively).[ 1 , 3 , 5 ]

PICOT FRAMEWORK

Table 1 summarises the foremost questions likely to be addressed when working on PICOT frame.[ 1 , 6 , 8 ] These components are also applicable to observational studies, where the exposure takes place of the intervention.[ 1 , 11 ] Remarkably, if after browsing the title and the abstract of a paper, the reader is not able to clearly identify the PICOT parameters, and elucidate the question posed by the authors, there should be reasonable scepticism regarding the scientific rigor of the work.[ 12 , 13 ] All these elements are crucial in the design and methodology of a clinical trial, as they can affect the feasibility and reliability of results. Having formulated the primary study question in the context of the PICOT framework [ Table 1 ],[ 1 , 6 , 8 ] the researcher should be able to elucidate which design is most suitable for their work, determine what type of data needs to be collected, and write a structured introduction tailored to what they want to know, explicitly mentioning the primary study hypothesis, which should lead to formulate the main research question.[ 1 , 2 , 6 , 8 ]

Key questions to be answered when working with the PICOT framework (population, intervention, comparator, outcome, and time frame) in a clinical research design

Occasionally, the intended population of the study needs to be modified, in order to overcome any potential ethical issues, and/or for the sake of convenience and feasibility of the project. Yet, the researcher must be aware that the external validity of the results may be compromised. As an illustration, in a randomised clinical trial, authors compared the ease of tracheal tube insertion between C-MAC video laryngoscope and direct laryngoscopy, in patients presenting to the emergency department with an indication of rapid sequence intubation. However, owing to the existence of ethical concerns, a substantial amount of patients requiring emergency tracheal intubation, including patients with major maxillofacial trauma and ongoing cardiopulmonary resuscitation, had to be excluded from the trial.[ 14 ] In fact, the design of prospective studies to explore this subset of patients can be challenging, not only because of ethical considerations, but because of the low incidence of these cases. In another study, Metterlein et al . compared the glottis visualisation among five different supraglottic airway devices, using fibreroptic-guided tracheal intubation in an adult population. Despite that the study was aimed to explore the ease of intubation in patients with anticipated difficult airway (thus requiring fibreoptic tracheal intubation), authors decided to enrol patients undergoing elective laser treatment for genital condylomas, as a strategy to hasten the recruitment process and optimise resources.[ 15 ]

Intervention

Anaesthetic interventions can be classified into pharmacological (experimental treatment) and nonpharmacological. Among nonpharmacological interventions, the most common include anaesthetic techniques, monitoring instruments and airway devices. For example, it would be appropriate to examine the ease of insertion of Supreme™ LMA, when compared with ProSeal™ LMA. Notwithstanding, a common mistake is the tendency to be focused on the data aimed to be collected (the “stated” objective), rather than the question that needs to be answered (the “latent” objective).[ 1 , 4 ] In one clinical trial, authors stated: “we compared the Supreme™ and ProSeal™ LMAs in infants by measuring their performance characteristics, including insertion features, ventilation parameters, induced changes in haemodynamics, and rates of postoperative complications”.[ 10 ] Here, the research question has been centered on the measurements (insertion characteristics, haemodynamic variables, LMA insertion characteristics, ventilation parameters) rather than the clinical problem that needs to be addressed (is Supreme™ LMA easier to insert than ProSeal™ LMA?).

Comparators in clinical research can also be pharmacological (e.g., gold standard or placebo) or nonpharmacological. Typically, not more than two comparator groups are included in a clinical trial. Multiple comparisons should be generally avoided, unless there is enough statistical power to address the end points of interest, and statistical analyses have been adjusted for multiple testing. For instance, in the aforementioned study of Metterlein et al .,[ 15 ] authors compared five supraglottic airway devices by recruiting only 10--12 participants per group. In spite of the authors' recommendation of using two supraglottic devices based on the results of the study, there was no mention of statistical adjustments for multiple comparisons, and given the small sample size, larger clinical trials will undoubtedly be needed to confirm or refute these findings.[ 15 ]

A clear formulation of the primary outcome results of vital importance in clinical research, as the primary statistical analyses, including the sample size calculation (and therefore, the estimation of the effect size and statistical power), will be derived from the main outcome of interest. While it is clear that using more than one primary outcome would not be appropriate, it would be equally inadequate to include multiple point measurements of the same variable as the primary outcome (e.g., visual analogue scale for pain at 1, 2, 6, and 12 h postoperatively).

Composite outcomes, in which multiple primary endpoints are combined, may make it difficult to draw any conclusions based on the study findings. For example, in a clinical trial, 200 children undergoing ophthalmic surgery were recruited to explore the incidence of respiratory adverse events, when comparing desflurane with sevoflurane, following the removal of flexible LMA during the emergence of the anaesthesia. The primary outcome was the number of respiratory events, including breath holding, coughing, secretions requiring suction, laryngospasm, bronchospasm, and mild desaturation.[ 16 ] Should authors had claimed a significant difference between these anaesthetic volatiles, it would have been important to elucidate whether those differences were due to serious adverse events, like laryngospasm or bronchospasm, or the results were explained by any of the other events (e.g., secretions requiring suction). While it is true that clinical trials evaluating the occurrence of adverse events like laryngospasm/bronchospasm,[ 16 , 17 ] or life-threating complications following a tracheal intubation (e.g., inadvertent oesophageal placement, dental damage or injury of the larynx/pharynx)[ 14 ] are almost invariably underpowered, because the incidence of such events is expected to be low, subjective outcomes like coughing or secretions requiring suction should be avoided, as they are highly dependent on the examiner's criteria.[ 16 ]

Secondary outcomes are useful to document potential side effects (e.g., gastric insufflation after placing a supraglottic device), and evaluate the adherence (say, airway leak pressure) and safety of the intervention (for instance, occurrence, or laryngospasm/bronchospasm).[ 17 ] Nevertheless, the problem of addressing multiple secondary outcomes without the adequate statistical power is habitual in medical literature. A good illustration of this issue can be found in a study evaluating the performance of two supraglottic devices in 50 anaesthetised infants and neonates, whereby authors could not draw any conclusions in regard to potential differences in the occurrence of complications, because the sample size calculated made the study underpowered to explore those differences.[ 17 ]

Among PICOT components, the time frame is the most likely to be omitted or inappropriate.[ 1 , 12 ] There are two key aspects of the time component that need to be clearly specified in the research question: the time of measuring the outcome variables (e.g. visual analogue scale for pain at 1, 2, 6, and 12 h postoperatively), and the duration of each measurement (when indicated). The omission of these details in the study protocol might lead to substantial differences in the methodology used. For instance, if a study is designed to compare the insertion times of three different supraglottic devices, and researchers do not specify the exact moment of LMA insertion in the clinical trial protocol (i.e., at the anaesthetic induction after reaching a BIS index < 60), placing an LMA with insufficient depth of anaesthesia would have compromised the internal validity of the results, because inserting a supraglottic device in those patients would have resulted in failed attempts and longer insertion times.[ 10 ]

FINER CRITERIA

A well-elaborated research question may not necessarily be a good question. The proposed study also requires being achievable from both ethical and realistic perspectives, interesting and useful to the clinical practice, and capable to formulate new hypotheses, that may contribute to the generation of knowledge. Researchers have developed an effective way to convey the message of how to build a good research question, that is usually recalled under the acronym of FINER (feasible, interesting, novel, ethical and relevant).[ 5 , 6 , 7 ] Table 2 highlights the main characteristics of FINER criteria.[ 7 ]

Main features of FINER criteria (Feasibility, interest, novelty, ethics, and relevance) to formulate a good research question. Adapted from Cummings et al .[ 7 ]

Novelty and relevance

Although it is clear that any research project should commence with an accurate literature interpretation, in many instances it represents the start and the end of the research: the reader will soon realise that the answer to several questions can be easily found in the published literature.[ 5 ] When the question overcomes the test of a thorough literature review, the project may become novel (there is a gap in the knowledge, and therefore, there is a need for new evidence on the topic) and relevant (the paper may contribute to change the clinical practice). In this context, it is important to distinguish the difference between statistical significance and clinical relevance: in the aforementioned study of Oba et al .,[ 10 ] despite the means of insertion times were reported as significant for the Supreme™ LMA, as compared with ProSeal™ LMA, the difference found in the insertion times (528 vs. 486 sec, respectively), although reported as significant, had little or no clinical relevance.[ 10 ] Conversely, a statistically significant difference of 12 sec might be of clinical relevance in neonates weighing <5 kg.[ 17 ] Thus, statistical tests must be interpreted in the context of a clinically meaningful effect size, which should be previously defined by the researcher.

Feasibility and ethical aspects

Among FINER criteria, there are two potential barriers that may prevent the successful conduct of the project and publication of the manuscript: feasibility and ethical aspects. These obstacles are usually related to the target population, as discussed above. Feasibility refers not only to the budget but also to the complexity of the design, recruitment strategy, blinding, adequacy of the sample size, measurement of the outcome, time of follow-up of participants, and commitment of clinicians, among others.[ 3 , 7 ] Funding, as a component of feasibility, may also be implicated in the ethical principles of clinical research, because the choice of the primary study question may be markedly influenced by the specific criteria demanded in the interest of potential funders.

Discussing ethical issues with local committees is compulsory, as rules applied might vary among countries.[ 18 ] Potential risks and benefits need to be carefully weighed, based upon the four principles of respect for autonomy, beneficence, non-maleficence, and justice.[ 19 ] Although many of these issues may be related to the population target (e.g., conducting a clinical trial in patients with ongoing cardiopulmonary resuscitation would be inappropriate, as would be anaesthetising patients undergoing elective LASER treatment for condylomas, to examine the performance of supraglottic airway devices),[ 14 , 15 ] ethical conflicts may also arise from the intervention (particularly those involving the occurrence of side effects or complications, and their potential for reversibility), comparison (e.g., use of placebo or sham procedures),[ 19 ] outcome (surrogate outcomes should be considered in lieu of long term outcomes), or time frame (e.g., unnecessary longer exposition to an intervention). Thus, FINER criteria should not be conceived without a concomitant examination of the PICOT checklist, and consequently, PICOT framework and FINER criteria should not be seen as separated components, but rather complementary ingredients of a good research question.

Undoubtedly, no research project can be conducted if it is deemed unfeasible, and most institutional review boards would not be in a position to approve a work with major ethical problems. Nonetheless, whether or not the findings are interesting, is a subjective matter. Engaging the attention of readers also depends upon a number of factors, including the manner of presenting the problem, the background of the topic, the intended audience, and the reader's expectations. Furthermore, the interest is usually linked to the novelty and relevance of the topic, and it is worth nothing that editors and peer reviewers of high-impact medical journals are usually reluctant to accept any publication, if there is no novelty inherent to the research hypothesis, or there is a lack of relevance in the results.[ 11 ] Nevertheless, a considerable number of papers have been published without any novelty or relevance in the topic addressed. This is probably reflected in a recent survey, according to which only a third of respondents declared to have read thoroughly the most recent papers downloaded, and at least half of those manuscripts remained unread.[ 20 ] The same study reported that up to one-third of papers examined remained uncited after 5 years of publication, and only 20% of papers accounted for 80% of the citations.[ 20 ]

Formulating a good research question can be fascinating, albeit challenging, even for experienced investigators. While it is clear that clinical experience in combination with the accurate interpretation of literature and teamwork are essential to develop new ideas, the formulation of a clinical problem usually requires the compliance with PICOT framework in conjunction with FINER criteria, in order to translate a clinical dilemma into a researchable question. Working in the right environment with the adequate support of experienced researchers, will certainly make a difference in the generation of knowledge. By doing this, a lot of time will be saved in the search of the primary study question, and undoubtedly, there will be more chances to become a successful researcher.

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Formulating a research question

• What are systematic reviews?
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Clarifying the review question leads to specifying what type of studies can best address that question and setting out criteria for including such studies in the review. This is often called inclusion criteria or eligibility criteria. The criteria could relate to the review topic, the research methods of the studies, specific populations, settings, date limits, geographical areas, types of interventions, or something else.

Systematic reviews address clear and answerable research questions, rather than a general topic or problem of interest. They also have clear criteria about the studies that are being used to address the research questions. This is often called inclusion criteria or eligibility criteria.

Six examples of types of question are listed below, and the examples show different questions that a review might address based on the topic of influenza vaccination. Structuring questions in this way aids thinking about the different types of research that could address each type of question. Mneumonics can help in thinking about criteria that research must fulfil to address the question. The criteria could relate to the context, research methods of the studies, specific populations, settings, date limits, geographical areas, types of interventions, or something else.

Examples of review questions

• Needs - What do people want? Example: What are the information needs of healthcare workers regarding vaccination for seasonal influenza?
• Impact or effectiveness - What is the balance of benefit and harm of a given intervention? Example: What is the effectiveness of strategies to increase vaccination coverage among healthcare workers. What is the cost effectiveness of interventions that increase immunisation coverage?
• Process or explanation - Why does it work (or not work)? How does it work (or not work)?  Example: What factors are associated with uptake of vaccinations by healthcare workers?  What factors are associated with inequities in vaccination among healthcare workers?
• Correlation - What relationships are seen between phenomena? Example: How does influenza vaccination of healthcare workers vary with morbidity and mortality among patients? (Note: correlation does not in itself indicate causation).
• Views / perspectives - What are people's experiences? Example: What are the views and experiences of healthcare workers regarding vaccination for seasonal influenza?
• Service implementation - What is happening? Example: What is known about the implementation and context of interventions to promote vaccination for seasonal influenza among healthcare workers?

Examples in practice :  Seasonal influenza vaccination of health care workers: evidence synthesis / Loreno et al. 2017

Example of eligibility criteria

Research question: What are the views and experiences of UK healthcare workers regarding vaccination for seasonal influenza?

• Population: healthcare workers, any type, including those without direct contact with patients.
• Context: seasonal influenza vaccination for healthcare workers.
• Study design: qualitative data including interviews, focus groups, ethnographic data.
• Date of publication: all.
• Country: all UK regions.
• Studies focused on influenza vaccination for general population and pandemic influenza vaccination.
• Studies using survey data with only closed questions, studies that only report quantitative data.

Consider the research boundaries

It is important to consider the reasons that the research question is being asked. Any research question has ideological and theoretical assumptions around the meanings and processes it is focused on. A systematic review should either specify definitions and boundaries around these elements at the outset, or be clear about which elements are undefined. 

For example if we are interested in the topic of homework, there are likely to be pre-conceived ideas about what is meant by 'homework'. If we want to know the impact of homework on educational attainment, we need to set boundaries on the age range of children, or how educational attainment is measured. There may also be a particular setting or contexts: type of school, country, gender, the timeframe of the literature, or the study designs of the research.

Research question: What is the impact of homework on children's educational attainment?

• Scope : Homework - Tasks set by school teachers for students to complete out of school time, in any format or setting.
• Population: children aged 5-11 years.
• Outcomes: measures of literacy or numeracy from tests administered by researchers, school or other authorities.
• Study design: Studies with a comparison control group.
• Context: OECD countries, all settings within mainstream education.
• Date Limit: 2007 onwards.
• Any context not in mainstream primary schools.
• Non-English language studies.

Mnemonics for structuring questions

Some mnemonics that sometimes help to formulate research questions, set the boundaries of question and inform a search strategy.

Intervention effects

PICO  Population – Intervention– Outcome– Comparison

Variations: add T on for time, or ‘C’ for context, or S’ for study type,

Policy and management issues

ECLIPSE : Expectation – Client group – Location – Impact ‐ Professionals involved – Service

Expectation encourages  reflection on what the information is needed for i.e. improvement, innovation or information.  Impact looks at what  you would like to achieve e.g. improve team communication .

• How CLIP became ECLIPSE: a mnemonic to assist in searching for health policy/management information / Wildridge & Bell, 2002

Analysis tool for management and organisational strategy

PESTLE:  Political – Economic – Social – Technological – Environmental ‐ Legal

An analysis tool that can be used by organizations for identifying external factors which may influence their strategic development, marketing strategies, new technologies or organisational change.

• PESTLE analysis / CIPD, 2010

Service evaluations with qualitative study designs

SPICE:  Setting (context) – Perspective– Intervention – Comparison – Evaluation

Perspective relates to users or potential users. Evaluation is how you plan to measure the success of the intervention.

• Clear and present questions: formulating questions for evidence based practice / Booth, 2006

Read more about some of the frameworks for constructing review questions:

• Formulating the Evidence Based Practice Question: A Review of the Frameworks / Davis, 2011
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Literature Reviews

• 1. Define your research question
• Getting started
• Types of reviews

Define topic

Brainstorming, limit scope, how ai can help, helpful resources.

• 2. Plan your search
• 3. Search the literature
• 4. Organize your results
• 5. Synthesize your findings
• 6. Write the review
• Artificial intelligence (AI) tools
• Thompson Writing Studio This link opens in a new window
• Need to write a systematic review? This link opens in a new window

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For example, the following research question is too broad.

Does social media affect mental health in college students?

A more focused research question could be:

Does social media play a role in the number of eating disorder diagnoses in college-aged women?

Need some guidance? Contact your subject librarian for a research consultation or reach out to [email protected] .

Start the brainstorming process:

• Begin by identifying a broad topic of research interest (the more you're personally interested in it, the better!). Write it down to clarify your focus.
• Narrow down your scope  by considering specific areas within this topic that you want to explore.
• Identify key themes and elements  related to these specific areas. These will be the building blocks of your investigation.
• Finally,  integrate these key areas and elements  into a well-crafted research question.

One way to brainstorm is to use a flowchart.

The scope of a topic  encompasses the boundaries and constraints you set for your research. The more precise your research question, the smoother the research process becomes.

Feeling stuck? Here are some ways you can narrow down your topic:

• geographic location
• time period
• discipline/field of study
• age group, etc.

You:  I need to conduct a literature review about social media, mental health, and college students. What are some example research questions within this topic?

ChatGPT: 

• How does the frequency and nature of social media use impact the mental health of college students?
• What role do specific social media platforms play in influencing the mental well-being of college students?
• How do online social interactions on platforms like Facebook, Instagram, or Twitter relate to the mental health outcomes of college students?
• Are there differences in the association between social media use and mental health outcomes based on demographic factors such as gender, age, or academic major among college students?
• What strategies do college students employ to cope with negative mental health effects associated with social media use?
• How does the perception of social support through online platforms affect the mental health of college students?
• To what extent does the comparison of oneself to others on social media contribute to mental health challenges among college students?
• What interventions or educational programs are effective in promoting positive mental health behaviors in the context of social media use for college students?
• How do social media literacy and awareness programs impact the mental health attitudes and behaviors of college students?
• What is the relationship between the use of social media for academic and social purposes and the mental health outcomes of college students?

Generative AI tools : ChatGPT , Google Gemini (formerly Bard) , Claude , Microsoft Copilot

For more information on how to incorporate AI tools into your research, check out the section on AI Tools .

• Developing Your Research Question
• Developing a Researchable Question
• Brainstorming tips from UNC Writing Center
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How to Conduct a Literature Review (Health Sciences and Beyond)

• What is a Literature Review?

The Research Questions

• Selection Criteria
• Database Search
• Documenting Your Search
• Organize Key Findings
• Reference Management

Background vs. Foreground Questions

You may need to find answers to background questions (i.e. about general knowledge) before seeking answers to foreground questions (i.e. about specific knowledge, such as information that might inform a clinical decision).

The research questions on this page are for foreground questions.

A well-formulated research question:

• starts your entire search process
• provides focus for your searches
• guides the selection of literature sources

Question formats are helpful tools researchers can use to structure a question that will facilitate a focused search. Such formats include: PICO , PEO , SPIDER , and  COSMIN . Other formats can be found here .  

The  PICO  format is commonly used in evidence-based clinical practice.  This format creates a "well-built" question that identifies four concepts: (1) the P atient problem or P opulation, (2) the I ntervention, (3) the C omparison (if there is one), and (4) the O utcome(s) .

Example : In adults with recurrent furunculosis (skin boils), do prophylactic antibiotics, compared to no treatment, reduce the recurrence rate?  ( Cochrane Library Tutorial, 2005 )

The  PEO  question format is useful for qualitative research questions. Questions based on this format identify three concepts: (1) P opulation, (2) E xposure, and (3) O utcome(s) .

Example:  In infants, is there an association between exposure to soy milk and the subsequent development of peanut allergy ( Levine, Ioannidis, Haines, & Guyatt, 2014 )?

The  SPIDER  question format was adapted from the PICO tool to search for qualitative and mixed-methods research.  Questions based on this format identify the following concepts: (1) S ample, (2) P henomenon of I nterest, (3) D esign, (4) E valuation, and (5) R esearch type .

Example:  What are young parents’ experiences of attending antenatal education? 

Search for ( S  AND  P of I   AND ( D  OR  E ) AND  R ) ( Cooke, Smith, & Booth, 2012 ).

The COSMIN  ( CO nsensus-based  S tandards for the selection of health status M easurement IN struments ) format is used for systematic review of measurement properties.  Questions based on this format identify (1) the construct or the name(s) of the outcome measurement instrument(s) of interest,  (2) the target population, (3) the type of measurement instrument of interest, and (4) the measurement properties on which the review focuses.

Visit the COSMIN website to view the COSMIN manual and checklist.

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Libraries | Research Guides

Literature reviews.

• What is a Literature Review?
• Planning the Review

Determining Your Research Question

Refining your research question, mapping your research topic.

• Choosing Where to Search
• Organizing the Review
• Writing the Review

When determining your research question, one method is to start with a topic and work through these questions:

1. What do you want to know about this topic?

Example: "I want to research the effects of high educational costs"

2. What population or context do you want to study?

Example: "I want to focus on college students"

3. What interventions, variables, or relationships do you want to explore?

Example: "I want to know what the impact of using Open Educational Resources"

4. What is the research scope?

Example: "I will interview college students participating in classes using OERs and ask them about the impact of these free resources on their college experience."

To refine your research question, you can ask more questions

• Is your topic clear enough that the audience can understand it?
• Is your topic narrow enough that it can be addressed within the size of the project?
• Does your topic require synthesis of sources and ideas to adequately address the question?
• Are the answers to your research question able to be discussed and debated, rather than just being standard facts?
• Is your topic doable in the amount of time that you have to complete the project?

One technique to help you define your scope is to take each component from your topic and list them from the least focused to the most focused. This will give you the ability to scale up and scale down.

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Literature Reviews

Define your research question.

• What is a literature review?
• Steps in the Literature Review Process
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support

Defining your research question is the key to beginning, so while you may be clear on the area you want to study, chances are there are some nuances that you need to think through. 

Part of this process may require exploratory searching in databases so that you can see what's already been published on your topic. Even if it's a new area, it's likely something has already been published in at least an adjacent area of study. 

Some things to consider:

• What is my central question or issue that the literature can help define?
• What is already known about the topic?
• Is the scope of the literature being reviewed wide or narrow enough?
• Is there a conflict or debate in the literature?
• What connections can be made between the texts being reviewed?
• What sort of literature should be reviewed? Historical? Theoretical? Methodological? Quantitative? Qualitative?
• What criteria should be used to evaluate the literature being reviewed?
• How will reviewing the literature justify the topic I plan to investigate?

Source:  https://libguides.library.kent.edu/c.php?g=389868&p=2645658

For more on the research question:  https://writingcenter.gmu.edu/guides/how-to-write-a-research-question

Video on Defining the Research Question

When you pick your topic, it's not set in stone. Picking and adjusting your topic is an integral part of the research process! This video is published under a Creative Commons 3.0 BY-NC-SA US license. (3 minutes)

• Last Updated: Oct 26, 2022 2:49 PM
• URL: https://guides.lib.utexas.edu/literaturereviews

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Literature Review: Research Questions

• Introduction
• Types of Literature Reviews
• Research Questions
• Search the Literature
• Manage and Evaluate References
• Nursing Literature Review Search Tips

Look up Discipline Examples

Literature reviews differ throughout the academic disciplines. Look at published journal articles to become familiar with how literature reviews are presented in your discipline.

• Sample literature reviews for Communication Arts
• Sample literature reviews for Nursing 1 and 2

Also look for literature reviews in our  databases  by using the search term "literature review."

Define Your Research Question

Research questions are the beginning to all of your research processes. A research question provides focus to your searches and guides you in selecting the correct sources for your literature review. Either way, research questions:

• Must be clear and concise in order to be effective.
• Must be complex enough to require research and analysis
• Must consider key themes and elements of the assigned topic.
• Must be of interest to you - you want to learn more about the topic, not dread doing your research!

Choose a topic that is neither too broad nor too narrow so that you find too much or too little research on your topic.

• Narrow down your research question by exploring the topic online or in books and then think about what issues you want to research in your literature review. 

Narrowing down topics like this is essential to creating an effective and complex research question:

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• Last Updated: Sep 12, 2023 10:51 AM
• URL: https://library.madonna.edu/literaturereview

Writing a Literature Review

• Steps for Conducting a Lit Review
• Finding "The Literature"
• Organizing/Writing
• Peer Review
• Citation/Style Guides

1. Choose a topic. Define your research question.

Your literature review should be guided by a central research question.  Remember, it is not a collection of loosely related studies in a field but instead represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

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

2. Decide on the scope of your review.

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

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

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

Make a list of the databases you will search.  You can use a Discovery Service , such as and individual database.   

Tips: 

• Look at the library's research guides in your discipline to select discipline-specific databases.  Don't forget to look at books!
• Make an appointment with or contact your librarian to make sure you aren't missing major databases.

4. Conduct your searches and find the literature. Keep track of your searches!

• Review the abstracts of research studies carefully. This will save you time.
• Write down the searches you conduct in each database so that you may duplicate them if you need to later (or avoid dead-end searches   that you'd forgotten you'd already tried).
• Save your searches and results by creating an account and signing in.
• Use the bibliographies and references of research studies you find to locate others.
• Ask your professor or a scholar in the field if you are missing any key works in the field.
• Keep track of your searches by using Zotero or another bibliographic tool.

5. Review the literature.

Some questions to help you analyze the research:

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

Conducting a literature review is usually recursive, meaning that somewhere along the way, you'll find yourself repeating steps out-of-order.

That is actually a good sign.  

Reviewing the research should lead to more research questions and those questions will likely lead you to either revise your initial research question or go back and find more literature related to a more specific aspect of your research question.

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• Last Updated: Jun 13, 2024 1:51 PM
• URL: https://westlibrary.txwes.edu/writing_a_literature_review

Literature Reviews for the Health Sciences: Research Question

• Introduction
• Research Question
• How to search
• Where to search
• Grey Literature in Health This link opens in a new window
• Reference Management Software
• Resources on Literature Reviews

The Research Question

A good research question will provide a strong foundation for any literature review and research project. It expresses the focus and purpose of the research, whilst also ensuring it is structured to avoid missing relevant studies, or collecting a biased results set.

It should be - 

• Focused on a single problem or issue
• Researchable using primary and/or secondary sources
• Feasible to answer within time and practical restrains
• Specific enough to answer thoroughly 
• Complex enough to answer over the space of a paper or thesis
• Relevant , and at least partially original, in your area of study ¹ 

Preliminary Searches

Before you finalise your research question you should conduct preliminary searches for literature, this is where you:

• Conduct scoping searches to help refine your concepts
• Check that your proposed research question hasn't already been answered
• Confirm that enough literature is available in your research area 
• Identify additional terminology and possibly noted authors in your research area (5)

PICOT question frameworks for quantitative studies

The PICOT research question format is a helpful approach for summarizing research questions that explore the effect of therapy in health-related research

• Population refers to the sample of subjects you wish to recruit for your study - consider the age, sex, ethnicity, socioeconomic status etc.
• Intervention refers to the treatment that will be provided to subjects enrolled in your study - therapeutic measure, medication, diagnostic test etc.
• Comparison or control  identifies what you plan on using as a reference group to compare with your treatment intervention. Many study designs refer to this as the control group - another intervention, placebo, standard of care, diagnostic gold standard. (Not always needed)
• Outcome represents what result you plan on measuring to examine the effectiveness of your intervention - the desired outcome should be measurable
• Time describes the duration for your data collection - for example "in the first 4 hours post-op" (not always needed)

PICOTT includes the elements of the PICOT research framework, but adds the types of studies that will be looked at to answer the research question, e.g. randomised controlled trials, cohort studies etc.

• PICO(T) Question Templates
• Types of Evidence & Databases for PICO(T) (2)

SPICE research question frameworks for qualitative evidence

SPICE  can be used for quantitative studies. SPICE stands for 

• S etting (where?), 
• P erspective (for whom?), 
• I ntervention (what?), 
• C omparison (compared with what?) 
• E valuation (with what result?)

Sample topic:  What are the coping skills of parents of children with autism undergoing behavioural therapy in schools?

S  - Schools

P  - Parents of children with autism

I  - Behavioural therapy

C  - None

E  - Coping skills

PICo research question frameworks for qualitative studies

PICo is a modified version of PICO(T) used for qualitative research questions

• Population - what are the characteristics of the patient or population? What is the condition or disease you are interested in?
• Interest - what is the phenomena of interest? A defined event, activity, experience or process?
• Context - what is the setting or distinct characteristics?

Example PICo question: 

What are caregivers' experiences with providing home-based care to patients with HIV/AIDS in Africa?

P  - Caregivers providing home-based care to persons with HIV/AIDS

I  - Experiences

Co  - Africa

SPIDER research question frameworks for qualitative and mixed methods evidence

The  SPIDER  framework is an alternative search strategy tool (based on PICo) for qualitative/mixed methods research.

• Sample - who is the sample or population of interest?                                                                                   
• Phenomenon of Interest - what is the phenomena of interest? A defined event, activity, experience or process?
• Design - what types of study methods are you interested in?
• Evaluation - what are the evaluation outcomes? (May be subjective - opinions, feelings etc.)
• Research type   -  what type of research are you interested in? Qualitative or mixed method (qualitative & quantitative)?

Sample topic:  What are the experiences of women undergoing IVF treatment?

S  - Women

PI  - IVF treatment

D  - Questionnaire or survey or interview

E  - Experiences or views or attitudes or feelings

R  - Qualitative or mixed method

This framework is useful for questions relating to health policy and management issues. Expectation encourages reflection on what the information is needed for, i.e. improvement, innovation or information. Impact looks at what you would like to achieve e.g. improve team communication (3)

• Expectation - what does the search requester want the information for
• Client group 
• Location  
• Impact - what is the change in the service, if any, which is being looked for? What would constitute success? How is this being measured?
• Professional involved 
• Service - for which service are you looking for information? For example, outpatient services, nurse-led clinics, intermediate care

Create a research question using PICO(T)

(1) Scribbr, https://www.scribbr.com/research-process/research-questions/ 

(2) Melknyl B, & Fineout-Overholt E, (2010) Evidence-based practise in nursing and healthcare New York, LippincottWilliams and wilkins

Curtin University Libguide - Systematic Reviews in the Health Sciences

(3) Wildridge, V. and Bell, L. (2002), How CLIP became ECLIPSE: a mnemonic to assist in searching for health policy/management information. Health Information & Libraries Journal, 19: 113-115. https://doi.org/10.1046/j.1471-1842.2002.00378.x

(4) Brown P, Brunnhuber K, Chalkidou K, Chalmers I, Clarke M, Fenton M et al. How to formulate research recommendations BMJ 2006; 333 :804 doi:10.1136/bmj.38987.492014.94

(5) USA subject Guide: Systematic Reviews https://guides.library.unisa.edu.au/SystematicReviews 

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• Next: How to search >>
• Last Updated: Mar 15, 2024 1:31 PM
• URL: https://canberra.libguides.com/c.php?g=940615

University of Tasmania, Australia

Systematic reviews for health: 1. formulate the research question.

• Handbooks / Guidelines for Systematic Reviews
• Standards for Reporting
• Registering a Protocol
• Tools for Systematic Review
• Online Tutorials & Courses
• Books and Articles about Systematic Reviews
• Finding Systematic Reviews
• Critical Appraisal
• Library Help
• Bibliographic Databases
• Grey Literature
• Handsearching
• Citation Searching
• 1. Formulate the Research Question
• 2. Identify the Key Concepts
• 3. Develop Search Terms - Free-Text
• 4. Develop Search Terms - Controlled Vocabulary
• 5. Search Fields
• 6. Phrase Searching, Wildcards and Proximity Operators
• 7. Boolean Operators
• 8. Search Limits
• 9. Pilot Search Strategy & Monitor Its Development
• 10. Final Search Strategy
• 11. Adapt Search Syntax
• Documenting Search Strategies
• Handling Results & Storing Papers

Step 1. Formulate the Research Question

A systematic review is based on a pre-defined specific research question ( Cochrane Handbook, 1.1 ). The first step in a systematic review is to determine its focus - you should clearly frame the question(s) the review seeks to answer  ( Cochrane Handbook, 2.1 ). It may take you a while to develop a good review question - it is an important step in your review.  Well-formulated questions will guide many aspects of the review process, including determining eligibility criteria, searching for studies, collecting data from included studies, and presenting findings ( Cochrane Handbook, 2.1 ).

The research question should be clear and focused - not too vague, too specific or too broad.

You may like to consider some of the techniques mentioned below to help you with this process. They can be useful but are not necessary for a good search strategy.

PICO - to search for quantitative review questions

Richardson, WS, Wilson, MC, Nishikawa, J & Hayward, RS 1995, 'The well-built clinical question: A key to evidence-based decisions', ACP Journal Club , vol. 123, no. 3, pp. A12-A12 .

We do not have access to this article at UTAS.

A variant of PICO is PICOS . S stands for Study designs . It establishes which study designs are appropriate for answering the question, e.g. randomised controlled trial (RCT). There is also PICO C (C for context) and PICO T (T for timeframe).

You may find this document on PICO / PIO / PEO useful:

• Framing a PICO / PIO / PEO question Developed by Teesside University

SPIDER - to search for qualitative and mixed methods research studies

Cooke, A, Smith, D & Booth, A 2012, 'Beyond pico the spider tool for qualitative evidence synthesis', Qualitative Health Research , vol. 22, no. 10, pp. 1435-1443.

This article is only accessible for UTAS staff and students.

SPICE - to search for qualitative evidence

Cleyle, S & Booth, A 2006, 'Clear and present questions: Formulating questions for evidence based practice', Library hi tech , vol. 24, no. 3, pp. 355-368.

ECLIPSE - to search for health policy/management information

Wildridge, V & Bell, L 2002, 'How clip became eclipse: A mnemonic to assist in searching for health policy/management information', Health Information & Libraries Journal , vol. 19, no. 2, pp. 113-115.

There are many more techniques available. See the below guide from the CQUniversity Library for an extensive list:

• Question frameworks overview from Framing your research question guide, developed by CQUniversity Library

This is the specific research question used in the example:

"Is animal-assisted therapy more effective than music therapy in managing aggressive behaviour in elderly people with dementia?"

Within this question are the four PICO concepts :

S - Study design

This is a therapy question. The best study design to answer a therapy question is a randomised controlled trial (RCT). You may decide to only include studies in the systematic review that were using a RCT, see  Step 8 .

See source of example

Need More Help? Book a consultation with a  Learning and Research Librarian  or contact  [email protected] .

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• Next: 2. Identify the Key Concepts >>
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Article Contents

Introduction, conclusions, recommendations and limitations of the study, supplementary data, data availability.

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A systematic review of literature examining the application of a social model of health and wellbeing

• Article contents
• Figures & tables
• Supplementary Data

Rachel Rahman, Caitlin Reid, Philip Kloer, Anna Henchie, Andrew Thomas, Reyer Zwiggelaar, A systematic review of literature examining the application of a social model of health and wellbeing, European Journal of Public Health , Volume 34, Issue 3, June 2024, Pages 467–472, https://doi.org/10.1093/eurpub/ckae008

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Following years of sustained pressure on the UK health service, there is recognition amongst health professionals and stakeholders that current models of healthcare are likely to be inadequate going forward. Therefore, a fundamental review of existing social models of healthcare is needed to ascertain current thinking in this area, and whether there is a need to change perspective on current thinking.

Through a systematic research review, this paper seeks to address how previous literature has conceptualized a social model of healthcare and, how implementation of the models has been evaluated. Analysis and data were extracted from 222 publications and explored the country of origin, methodological approach, and the health and social care contexts which they were set.

The publications predominantly drawn from the USA, UK, Australia, Canada and Europe identified five themes namely: the lack of a clear and unified definition of a social model of health and wellbeing; the need to understand context; the need for cultural change; improved integration and collaboration towards a holistic and person-centred approach; measuring and evaluating the performance of a social model of health.

The review identified a need for a clear definition of a social model of health and wellbeing. Furthermore, consideration is needed on how a model integrates with current models and whether it will act as a descriptive framework or, will be developed into an operational model. The review highlights the importance of engagement with users and partner organizations in the co-creation of a model of healthcare.

Following years of sustained and increasing pressure brought about through inadequate planning and chronic under-resourcing including the unprecedented challenges of the Covid-19 pandemic, the UK NHS is at crisis point. 1 The incidents of chronic disease continue to increase alongside an ageing population who have more complex health and wellbeing needs, whilst recruitment and retention of staff continue to be insufficient to meet these increased demands. 1 Furthermore, the Covid-19 pandemic has only served to exacerbate pressures, resulting in delays in; patient presentation, 2 poor public mental health 3 strain and burnout amongst workforce. 4 However, preceding the pandemic there was already recognition of a need for a change to the current biomedical model of care to better prevent and treat the needs of the population. 5

While it is recognized that demands on the healthcare system are increasing rapidly, the biomedical model used to deal with these issues (which is the current model of healthcare provision in the UK) has largely remained unchanged over the years. The biomedical model takes the perspective that ill-health stems from biological factors and operates on the theory that good health and wellbeing is merely the absence of illness. Application of the model therefore focuses treatment on the management of symptoms and cure of disease from a biological perspective. This suggests that the biomedical approach is mainly reactive in nature and whilst rapid advancements in technology such as diagnostics and robotics have significantly improved patient outcomes and identification of early onset of disease, it does not fully extend into managing the social determinants that can play an important role in the prevention of disease. Therefore, despite its contribution in advancing many areas of biological and health research, the biomedical model has come under increasing scrutiny. 6 This is in part due to the growing recognition of the impact of those wider social determinants on health, ill-health and wellbeing including physical, mental and social wellbeing which moves the focus beyond individual physical abilities or dysfunction. 7–9 In order to address these determinants, action needs to be taken through developing policies in a range of non-medical areas such as social, economic and environment so that they regulate the commercial and corporate determinants. In this sense, we can quickly see that the traditional biological model rapidly becomes inadequate. With the current model, health care and clinical staff can do little to affect these determinants and as such can do little to assist the individual patient or society. The efficiency and effectiveness of clinical work will undoubtedly improve if staff have the ability to observe and understand the wider social determinants and consequences of the individual patients’ condition. Therefore, in order to provide a basis for understanding the determinants of disease and arriving at rational treatments and patterns of health care, a medical model must also take into account the patient, the social context in which they live, and a system devised by society to deal with the disruptive effects of illness, that is, the physician’s role and that of the health care system. Models such as Engel’s biopsychosocial model, 9 , 10 the social model of disability, social–ecological models of health 10 , 11 including the World Health Organisation’s framework for action on social determinants of health 8 , 9 are all proposed as attempting to integrate these wider social determinants.

However, the ability of health systems to effectively transition away from a dominant biomedical model to the adoption of a social model of health and care have yet to be fully developed. Responsibility for taking action on these social determinants will need to come from other sectors and policy areas and so future health policy will need to evolve into a more comprehensive and holistic social model of health and wellbeing. Wales’ flagship Wellbeing of Future Generations Act 12 for instance outlines ways of working towards sustainable development and includes the need to collaborate with society and communities in developing and achieving wellbeing goals. However, developing and implementing an effective operational model that allows multi-stakeholder integration will prove far more difficult to achieve than creating the polices. Furthermore, if the implementation of a robust model of social health is achievable, it’s efficiency, effectiveness and ability to deliver has yet to be proven. Therefore, any future model will need to extend past its conceptual development and provide an ability to manage the complex interactions that will exist between the stakeholders and polices.

Therefore, the use of the term ‘model’ poses its own challenges and debates. Different disciplines attribute differing parameters to what constitutes a model and this in turn may influence the interpretations or expectations surrounding what a model should comprise of or deliver. 13 According to numerous authors, a model has no ontological category and as such anything from physical entities, theoretical concepts, descriptive frameworks or equations can feasibly be considered a model. 14 It appears therefore, that much discussion has focussed on the move towards a ‘descriptive’ Social Model of Health and Wellbeing in an attempt to view health more holistically and identify a wider range of determinants that can impact on the health of the population. However, in defining an operational social model of health that can facilitate organizational change, there may be a need to consider a more systems- or process-based approach.

As a result, this review seeks to systematically explore the academic literature in order to better understand how a social model of health and wellbeing is conceptualized, implemented, operationalized and evaluated in health and social care.

The review seeks to address the research questions:

How is ‘a social model of health and wellbeing’ conceptualized?

How have social models of health and wellbeing been implemented and evaluated?

A systematic search of the literature was carried out between 6 January 2022 and 20 January 2022. Using the search terms shown in table 1 , a systematic search was carried out using online databases PsycINFO, ASSIA, IBSS, Medline, Web of Science, CINHAL and SCOPUS. English language and peer-reviewed journals were selected as limiters.

Search terms

Selection and extraction criteria

The search strategy considered research that explicitly included, framed, or adopted a ‘social model of health and wellbeing’. Each paper was checked for relevance and screened. The authors reviewed the literature using the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) method using the updated guidelines from 2020. 15   Figure 1 represents the process followed.

PRISMA flow chart.

Data extraction and analysis

A systematic search of the literature identified 222 eligible papers for inclusion in the final review. A data extraction table was used to extract information regarding location of the research, type of paper (e.g. review, empirical), service of interest and key findings. Quantitative studies were explored with a view to conducting a quantitative meta-analysis; however, given the disparate nature of the outcome measures, and research designs, this was deemed unfeasible. All included papers were coded using NVivo software with the identified research questions in mind, and re-analysed using Thematic Analysis 16 to explore common themes of relevance.

The majority of papers were from the USA (34%), with the UK (28%), Australia (16%), Canada (6%) and wider Europe (10%) also contributing to the field. The ‘other’ category (6%) was made up of single papers from other countries. Papers ranged in date from 1983 to 2021 with no noticeable temporal patterns in country of origin, health context or model definition. However, the volume of papers published relating to the social model for healthcare in each decade increased significantly, thus suggesting the increasing research interest towards the social model of healthcare. Table 2 shows the number of publications per decade that were identified from this study.

Publications identifying social models of healthcare.

Most of the papers were narrative reviews ( n  = 90) with a smaller number of systematic reviews ( n  = 9) and empirical research studies including qualitative ( n  = 47), quantitative ( n  = 39) and mixed methods ( n  = 14) research. The remaining papers ( n  = 23) comprised small samples of, for example, clinical commentaries, cost effectiveness analysis, discussion papers and impact assessment development papers. The qualitative meta-analysis identified five overarching themes in relation to the research questions, some with underlying sub-themes, which are outlined in figure 2 .

Overview of meta-synthesis themes.

The lack of a clear and unified definition of a social model of health and wellbeing

There was common recognition amongst the papers that a key aim of applying a social model of health and wellbeing was to better address the social determinants of health. Papers identified and reviewed relevant frameworks and models, which they later used to conceptualize or frame their approach when attempting to apply a social model of health. Amongst the most commonly referenced was the WHO’s framework. 17 Engel’s biopsychosocial model 9 which was referred to as a seminal framework by many of the researchers. However, once criticism of the biopsychosocial model was its inability to fully address social needs. As a result, a number of papers reported the development of new or enhanced models that used the biopsychosocial model as their underpinning ‘social model’ 18 , 19 but then extended their work by including a wider set of social elements in their resulting models. 20 The Social ecological model, 11 the Society-Behaviour-Biology Nexus, 21 and the Environmental Affordances Model are such examples. 22 Further examples of ‘Social Models’ included the Model of Social Determinants of Health 23 which framed specific determinants of interest (namely social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food and transport). Similarly, Dahlgren and Whitehead’s ‘social model’ 10 illustrates social determinants via a range of influential factors from the individual to the wider cultural and socioeconomic influences. However, none of these papers formally developed a working ‘definition’ of a social model of health and wellbeing, instead applying guiding principles and philosophies associated with a social model to their discussions or interventions. 24 , 25

The need to understand context

Numerous articles highlight that in order to move towards a social model of health and wellbeing, it is important to understand the context of the environment in which the model will need to operate. This includes balancing the needs of the individual with the resulting model to have been co-created, developed and implemented within the community whilst ensuring that the complexity of interaction between the social determinants of health and their influence on health and wellbeing outcomes are delivered effectively and efficiently.

The literature identified the complex multi-disciplinary nature of a variety of conditions or situations involving medical care. These included issues such as, but not exclusively, chronic pain, 26 cancer, 27 older adult care 28 and dementia, 29 thus indicating the complex arrangement of medical issues that a model will need to address and, where many authors acknowledged that the frequently used biomedical models failed to fully capture the holistic nature and need of patients. Papers outlined some of the key social determinants of health affecting the specific population of interest in their own context, highlighting the interactions between wider socioeconomic and cultural factors such as poverty, housing, isolation and transport and health and wellbeing outcomes. Interventions that had successfully addressed individual needs and successful embedded services in communities reported improved outcomes for end users and staff in the form of empowerment, agency, education and belonging. 30 There was also recognition that the transition to more community-based care could be challenging for health and social care providers who were having to work outside of their traditional models of care and accept a certain level of risk.

The need for cultural change

A number of papers referred to the need for a ‘culture change’ or ‘cultural shift’ in order to move towards a social model of health and wellbeing. Papers identified how ‘culture change models’ were implemented as a way of adapting to a social model. It was recognized that for culture change models to be effective, staff and the general public needed to be fully engaged with the entire move towards a social model, informing and shaping the mechanisms for the cultural shift as well as the application of the model itself.

Integration and collaboration towards a holistic and person-centred approach

The importance of integration and collaboration between health professionals, (which includes public, private and third sector organizations), services users and patients were emphasized in the ambition to achieve best practice when applying a social model of health and wellbeing. Papers identified the reported benefits of improved collaboration between, and integration of services which included improved continuity of care throughout complex pathways, 31 improved return to home or other setting on discharge, 25 and social connectedness. 32 Numerous papers discussed the importance of multi-disciplinary teams who were able to support individuals beyond the medicalized model.

A number of papers suggested specific professional roles or structures that would be ideal to act as champions or integrators of collaborative services and communities. 25 , 33 These could act as a link between secondary, primary and community level care helping to identify patient needs and supporting the integration of relevant services.

Measuring and evaluating a social model of health

Individual papers applying and evaluating interventions based on a social model used a variety of methods to evaluate success. Amongst these, some of the most common outcome measures included; general self-report measures of outcomes such as mental health and perceptions of safety, 34 wellbeing, 35 life satisfaction and health social networks and support 19 Some included condition specific self-report outcomes relevant to the condition in question (e.g. pregnancy, anxiety) and pain inventories. 36 Other papers considered the in-depth experiences of users or service implementers through qualitative techniques such as in-person interviews. 37 , 38

However, the complexity of developing effective methods to evaluate social models of health were recognized. The need to consider the complex interactions between social determinants, and health, wellbeing, economic and societal outcomes posed particular challenges in developing consistency across evaluations that would enable a conclusive evaluation of the benefits of social models to wider health systems and societal health. Some criticized the over-reliance of quantitative and evidence-based practice methods of evaluation highlighting how these could fail to fully capture the complexity of human behaviour and the manner in which their lives could be affected.

The aim of this systematic review was to better understand how a social model of health and wellbeing is conceptualized, implemented and evaluated in health and social care. The review sought to address the research questions identified in the ‘Introduction’ section of this paper.

With regards to the conceptualization of a social model of health and wellbeing, analysis of the literature suggests that whilst the ethos, values and aspirations of achieving a unified model appears to have consensus. However, a fundamental weakness exists in that there is no single unified definition or operational model of a social model of health and wellbeing applied to the health and social care sector. The decision about how best to conceptualize a ‘social model’ is important both in terms of its operational value but also the implication of the associated semantics. However, without a single or unified definition then implementation or further, operationalization of any model will be almost impossible to develop. Furthermore, use of the term ‘social model’ arguably loses site of the biological factors that are clearly relevant in many elements of clinical medicine. Furthermore, there is no clarification in the literature about what would ‘not’ be considered a social model of health and wellbeing, potentially leading to confusion within health and social care sectors when addressing their wider social remit. This raises questions and requires decisions about whether implementation of a social model of health and wellbeing will need to work alongside or replace the existing biomedical approach.

Authors have advocated that a social model provides a way of ‘thinking’ or articulating an organization’s values and culture. 24 Common elements of the values associated with a social model amongst the papers reviewed included recognition and awareness of the social determinants of health, increased focus on preventative rather than reactive care, and similarly the importance of quality of ‘life’ as opposed to a focus on quality of ‘care’. However, whilst this approach enables individual services to consider how well their own practices align with a social model, the authors suggest that this does not provide large organizations such as the NHS, with multifaceted services and complex internal and external connections and networks, sufficient guidance to enable large scale evaluation or transition to a widespread operational model of a social model of health and wellbeing. This raises questions about what the model should be: whether its function is to support communication of a complex ethos to encourage reflection and engagement of its staff and end users, or to develop the current illustrative framework into a predictive model that can be utilized as an evaluative tool to inform and measure the success of widespread systems change.

Regarding the potential implementation of a future social model of health and wellbeing, none of the papers evaluated the complex widespread organizational implementation of a social model, instead focusing on specific organizational contexts of services such as long-term care in care homes, etc. Despite this, common elements of successful implementation did emerge from the synthesis. This included the need to wholeheartedly engage and be inclusive of end users in policy and practice change to fully understand the complexity of their social worlds and to ensure that changes to practice and policy were ‘developed with’, as opposed to ‘create for’, the wider public. This also involved ensuring that health, social care and wider multi-disciplinary teams were actively included in the process of culture change from an early stage.

Implications for future research

The analysis identifies that a significant change of mindset and removal of perceived and actual hierarchical structures (that are historically embedded in health and social care structures) amongst both staff and public is needed although, eradicating socially embedded hierarchies will pose significant challenges in practice. Furthermore, the study revealed that many of the models proposed were conceptually underdeveloped and lacked the capability to be operationalized which in turn compromised their ability to be empirically tested. Therefore, in order that a future ‘implementable and operational’ model of social care and wellbeing can be created, further research into organizational behaviours, organizational learning and stakeholder theory (amongst others) applied to the social care and health environment is needed.

Towards defining a social model of health and wellbeing

In attempting to conceptualize a definition for a social model of health and wellbeing, it is important to note that the model needs to be sufficiently broad in scope in order to include the prevailing biomedical while also including the need to draw in the social determinants that provide a view and future trajectory towards social health and wellbeing. Therefore, the authors suggest that the ‘preventative’ approach brought by the improvements in the social health determinants (social, cultural, political, environmental ) need to be balanced effectively with the ‘remedial/preventative’ focus of the biomedical model (and the associated advancements in diagnostics, technology, vaccines, etc), ensuring that a future model drives cultural change; improved integration and collaboration towards a holistic and person-centred approach whilst ensuring engagement with citizens, users, multi-disciplinary teams and partner organizations to ensure that transition towards a social model of health and wellbeing is undertaken.

Through a comprehensive literature analysis, this paper has provided evidence that advocates a move towards a social model of health and wellbeing. However, the study has predominantly considered mainly literature from the USA, UK, Canada and Australia and therefore is limited in scope at this stage. The authors are aware of the need to consider research undertaken in non-English speaking countries where a considerable body of knowledge also exists and which will add to further discussion about how that work dovetails into this body of literature and, how it aligns with the biomedical perspective. There is a need for complex organizations such as the NHS and allied organizations to agree a working definition of their model of health and wellbeing, whether that be a social model of health and wellbeing, a biopsychosocial model, a combined model, or indeed a new or revised perspective. 39

One limitation seen of the models within this study is that at a systems level, most models were conceptual models that characterized current systems or conditions and interventions to the current system that result in localized improvements in systems’ performance. However, for meaningful change to occur, a ‘future state’ model may need to focus on a behavioural systems approach allowing modelling of the complete system to take place in order to understand how the elements within the model 40 behave under different external conditions and how these behaviours affect overall system performance.

Furthermore, considerable work will be required to engage on a more equal footing with the public, health and social care staff as well as wider supporting organizations in developing workable principles and processes that fully embrace the equality of a social model and challenging the ‘power’ imbalances of the current biomedical model.

Supplementary data are available at EURPUB online.

This research was funded/commissioned by Hywel Dda University Health Board. The research was funded in two phases.

Conflicts of interest: None declared.

The datasets generated and/or analysed during the current study are available in the Data Archive at Aberystwyth University and have been included in the supplementary file attached to this submission. A full table of references for studies included in the review will be provided as a supplementary document. The references below refer to citations in the report which are in addition to the included studies of the synthesis.

The review identified five themes namely: the lack of a clear definition of a social model of health and wellbeing; the need to understand context; the need for cultural change; improved integration and collaboration towards a holistic and person-centred approach; measuring and evaluating the performance of a social model of health.

The review identified a need for organizations to decide on how a social model is to be defined especially at the interfaces between partner organizations and communities.

The implications for public policy in this paper highlights the importance of engagement with citizens, users, multi-disciplinary teams and partner organizations to ensure that transition towards a social model of health and wellbeing is undertaken with holistic needs as a central value.

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• Library Guides
• Literature Reviews

Developing a Research Question

Literature reviews: developing a research question, developing a research question.

Before searching for sources, you need to formulate a Research Question — this is what you are trying to answer using the existing academic literature. The Research Question pinpoints the focus of the review .

Your first step involves choosing, exploring, and focusing a topic. At this stage you might discover that you need to tweak your topic or the scope of your research as you learn more about the topic in the literature.

THINGS TO KEEP IN MIND: 

• The question must be "researchable" — it can be answered with accessible facts and data
• Questions often start with How, Why, What, Which
• The question opens the door for other areas of inquiry — it identifies a gap in existing research
• Questions should be open-ended and focus on cause and effect

TRY TO AVOID: 

• Simple yes/no questions, or questions with an easy answer (what is the radius of the moon?)
• Questions that can only be answered by an opinion (does it smell nice when it rains?)
• Questions that involve secret information (what is the recipe for Coca-Cola?)
• Questions that are too broad or too narrow

REFINING YOUR RESEARCH QUESTION

Two examples of refining research questions that could be considered either too broad or too narrow.

Finding Example Literature Reviews

Using database filter tools.

It can be helpful to read existing literature reviews on your topic to get an idea of major themes, how authors structure their arguments, or what reviews look like in your discipline.

DOCUMENT TYPE FILTERS

Many library databases have the option to highlight just Review Articles after you perform a search. Filters above show what the Document Type filter looks like, with a "Review" option. These examples are from Scopus and ProQuest. The "Review" filter here refers to free-standing, comprehensive Review Articles on a topic, as opposed to a shorter literature review inside a scholarly article.

LIT REVIEWS INSIDE ARTICLES

It is also worth taking a look at the shorter literature reviews inside scholarly articles. These can sometimes be called "Background" or "Background Literature." Look for a section typically following the Introduction that covers the history or gives context on the paper's topic.

EXAMPLE REVIEW ARTICLES

Here are a few examples of Review Articles in different disciplines. Note sometimes an article can be a Review Article without the word "review" in the title.

• HUMANITIES — Art — "Art and Crime: Conceptualising Graffiti in the City" from the journal Geography Compass
• SCIENCES — Climate Change — "Mercury Isotopes in Earth and Environmental Sciences" from the journal Annual Review of Earth and Planetary Sciences
• SOCIAL SCIENCES — Psychology — "Structural Competency and the Future of Firearm Research" from the journal Social Science & Medicine

Attribution

Thanks to Librarian Jamie Niehof at the University of Michigan for providing permission to reuse and remix this Literature Reviews guide.

Goldilocker Tool

UM Librarians have developed a quick tool called Goldilocker  to help beginners who are struggling to refine their Research Question. 

• Last Updated: Jun 10, 2024 12:05 PM
• URL: https://info.library.okstate.edu/literaturereviews

• Research article
• Open access
• Published: 13 July 2022

Goal setting with young people for anxiety and depression: What works for whom in therapeutic relationships? A literature review and insight analysis

• Jenna Jacob   ORCID: orcid.org/0000-0003-1006-1547 1 ,
• Milos Stankovic 2 ,
• Inga Spuerck 2 &
• Farhad Shokraneh 3  

BMC Psychology volume  10 , Article number:  171 ( 2022 ) Cite this article

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Goal setting and goal-focused work is widely used in young people’s mental health settings. However, little is known about how, why or for whom this is helpful. This study aims to explore the mechanisms of collaborative goal setting as part of therapeutic relationships: is it helpful for young people experiencing anxiety and/or depression, how and why/not, for whom, and under what circumstances?

Online database searches generated 10,907 records. Seven unique studies are included, combined with insight analysis from directed discussions with international advisors with lived experience of anxiety and/or depression and therapy (N = 8; mean age = 20.8), and mental health academics/clinicians (N = 6).

Findings are presented as a narrative synthesis and suggest that goal setting is helpful to young people experiencing anxiety and/or depression because it helps build good therapeutic relationships through open communication and building trust. Goal setting helps make things more manageable, enabling young people to feel supported and have ownership of their care. Individual preferences, or high levels of distress, trauma, low confidence, hopelessness, negative past experiences of goal setting, perfectionism, and rumination are considered limiting factors to goal setting. Additionally, contextual factors including country and long-term therapy are explored.

Whilst the resultant sample is small, emphasis on the voices of young people in the research is both prominent and of paramount importance. Several key literature gaps are identified, including evidenced links to the reduction in symptoms. Priority must be given to researching unhelpful mechanisms of goal setting for young people experiencing anxiety and/or depression, to avoid any potential iatrogenic effects.

Peer Review reports

Collaborative goal setting within therapeutic mental health settings refers to agreements made between young people and practitioners about specific therapy areas of focus: topics of personalised and meaningful outcome. Goals are concrete representations of intended endpoints, which fill the perceived gap between the current and desired end state [ 1 ]. Goals are usually formulated at the start of therapeutic interventions through a series of discussions. These differ from academic, physical rehabilitation, or general life goals, although there could be overlap. Progress towards these agreed goals may then be tracked over time, often through ratings on numerical scales, and there are tools available to support this. For example, the Goal Based Outcome tool (GBO; [ 2 ]) which comprises setting up to three goals and scoring progress between 0 and 10, is widely used to track progress against goal setting in youth mental health settings. Whilst goal tracking may lead to a shift in practitioners’ work to be goal focused [ 3 ], goals may also sit alongside usual clinical work, to track progress [ 4 ]. Goals set in therapy tend to be focused and specific, e.g., to deal with something in the immediacy, like a phobia [ 5 ], but it is important that these goals attain to more global goals [ 6 ], or are viewed as a “means to an end”.

Goals may take time to set, and can change and become more specific during the therapeutic process, for example, at the beginning of contact with a practitioner, a young person might have a general goal like “to feel less depressed”, but over time the young person, along with the practitioner, may learn more about the mechanisms behind the depression and may define more precise goals like “being able to stop negative thinking” or “being able to cope with flashbacks”. The types of phrases used by practitioners to help young people define goals may include: “what do you want to be different?”, “what will you get off your back?”, “where do you want to get to?”, and “how do you want things to change?” [ 4 , 6 ].

Goal setting and tracking in therapeutic settings is grounded in motivation theory [ 7 , 8 , 9 ] such that working towards goals is a continuous feedback loop which builds on self-efficacy, self-determination and motivation to continue to strive towards goals, acting as a self-regulation strategy [ 10 , 11 ]. Goal setting may be more feasible or acceptable to individuals with particular personality traits e.g., individuals who attribute successes and failures to external factors are less likely to find meaning in striving towards goals than those who attribute successes and failures to their own actions [ 12 ].

Further, young people have described recovery from depression as nested within relationships (e.g., [ 13 ]), portraying recovery as an intentional process, contingent on shared goals and joint action in relationships [ 14 ]. Good therapeutic relationships are considered a key element of effective therapy [ 15 , 16 , 17 , 18 ]. Also known as working relationships, or working/therapeutic alliance, this refers to the connection, bond or partnership between the young person and practitioner. Three key elements of therapeutic alliance have been identified in the literature: bond, tasks, and goals [ 19 ]. In a recent review of the effects of cognitive behavioural therapy (CBT) for young people experiencing anxiety and/or depression, three studies reported small-to-medium effect sizes for the correlational relationship between therapeutic alliance and symptom reduction [ 20 ]. This provides limited evidence linking goal collaboration to reduced anxiety/depression symptoms for young people, despite fair evidence supporting links between goal collaboration and positive adult anxiety and depression outcomes [ 21 ]. It is argued that goal agreement is a fundamental element missing from much work with young people, and it has been referred to as a “social contract” [ 22 ]. This emphasis on relationships is particularly important when working with young people with acute, or multifarious difficulties, where relationships are complex, difficult to develop and maintain (e.g., [ 23 ]).

Existing evidence suggests that there are certain elements of mental health support for young people that are effective, but there is a lack of identification and knowledge about mechanisms to refine and improve this support [ 24 ]. Specifically, there is a paucity of research exploring the mechanisms underpinning why goal setting may be helpful for some young people, and not others. There are likely to be confounding variables which interplay the effectiveness of goals, depression and/or anxiety, cognition, and motivation, yet there is little research that has explored this in clinical settings with young people.

The aim of this study is to summarise existing literature, supplemented by discussions with international advisors to contextualise and aid interpretation of the findings. The research question is:

“Is collaborative goal setting helpful or unhelpful to young people experiencing anxiety and/or depression, as an element of therapeutic relationships? a. Why/why not and how? b. For whom? c. Under what circumstances?”

A mixed methodological approach combined reviews of peer-reviewed, grey literature and additional sources (e.g., websites), with consultation with experts by experience. The risk of expert view biasing the findings was mitigated via the validating steps outlined below. The study was designed by the lead researcher, and other researchers in the team, in collaboration with the peer researchers.

Whilst it is acknowledged that there are important outcome areas such as quality of life and existential factors, aside from symptom reduction, the focus of this study was to specifically explore the research questions in relation to potential anxiety and depression symptom reduction. Anxiety and depression were focused on as the most common mental health difficulties worldwide. This focus on medicalised symptomology differs from quality of life, which is a multi-dimensional construct comprised of several domains, such as psychological, physical, and social wellbeing. Anxiety, depression, therapeutic relationships, and goal progress are routinely measured using self- and proxy-reported outcome measures, with numerical rating scales. It was anticipated that the research question would not be adequately explored through findings from outcome measures alone. Based on some initial scoping work, we determined that there would be more evidence on the effectiveness of goal setting and tracking via qualitative enquiry, including narratives. The exploration of the nuances identified in the research question was key to the study, and so it was important to give precedence to young people’s voices through existing research and youth advisors, combined with findings from any relevant supporting measures. Such explorations would not be possible through quantitative enquiry of outcome measure data.

Goal setting alongside usual clinical work and goals work (goal focused interventions) were differentiated from implicit goal-oriented practice, non-directive approaches and paternalistic approaches to support in this study. This meant that to be included in the literature synthesis, goals needed to be explicitly identified as an approach to progress tracking, and/or informing the work. This study also focused on individual settings, and whilst these relationships may include parents/carers in a triad, the primary focus was on the relationship built between the practitioner and the young person. This was due to the complexities and potential dilution of agreeing goals and developing therapeutic relationships in group work and with parents/carers in addition. Ethical approval was not required because this study did not involve collection nor analysis of primary data, and youth advisors were consulted on in the capacity of being part of the advisory group, rather than within the capacity of research participants [ 25 ].

Literature review

First, search terms and inclusion and exclusion criteria were agreed in collaboration with the academic/clinical and youth advisors (See Additional file 1 : Appendix 1 Inclusion and exclusion criteria and Search Strategies). The project was registered with PROSPERO (number: CRD42021259611).

Second, searches of ten online databases were conducted (PsycINFO (OVID), MEDLINE (OVID), EMBASE (OVID), Web of Science core collection, current contents connect, SciELOCitation Index, Cochrane Library of Systematic Reviews, CINAHL (EBSCO), ERIC (EBSCO), and child and adolescent studies (EBSCO)). The search strategy developed for each database comprised three concepts: anxiety and/or depression (condition), goals (intervention) and therapeutic alliance or general views on goal setting, e.g., perspective, view, narrative (intervention/outcome). Searches were restricted to the past 20 years (2000-present). Citation tracking of included papers was performed. Retrieved hits were exported to EndNote 20 [ 26 ], Rayyan [ 27 ] and Excel for title/abstract screening.

Third, two researchers (FS, JJ) independently screened titles and abstracts. Where one researcher (JJ) was an author in retrieved studies, screening was conducted by the other researcher (FS), to ensure unbiased screening. Fourth, two researchers (JJ, IS) explored resultant literature main texts, extracting and synthesising relevant information. Key literature identified by researchers and advisors was added. The quality of the studies was assessed using criteria for qualitative studies ([ 28 ]; See Additional file 1 : Appendix 2 Core Criteria for Quality Assessment of Qualitative Studies).

Grey literature search

Google and Google Scholar title search, Google Books, PsycEXTRA, PsyArXiv, and ProQuest Dissertations and Theses were used. Google's Site Search was used to search American Psychological Association, British Psychological Society, Australian Psychological Society, European Federation of Psychologists' Associations, International Association of Applied Psychology, Association for Psychological Science, International Union of Psychological Science, Canadian Psychological Association, and UN-affiliated websites (.int domains). To identify more relevant literature, ResearchRabbit.ai was used to track the citations to the included studies. As a result of Google title search, websites were identified and browsed. The searches were restricted to those: (1) written in English, (2) published from January 2000 to August 2021, (3) focused on goal setting with young people experiencing mental health difficulties. Two researchers (FS, JJ) independently screened titles and abstracts of the resultant sources for relevance.

Insight analysis

An advisory group was formed at the study’s outset, comprising: (1) young people with lived experience of anxiety and/or depression and therapy (N = 8; age range 15–26 years; mean age = 20.8; female (includes transgender) N = 5; and male (includes transgender) N = 3; located in Brazil, Pakistan, Spain, Turkey, and UK); and (2) academics and clinicians (N = 6; female N = 1, male N = 5; located in Norway and UK). Criteria for youth advisors to take part where that they were around the age of interest (14–24 years) and had lived experience of anxiety and/or depression and had previously -or currently-experienced receiving a mental health intervention. Youth advisors’ experience of anxiety and/or depression was balanced across advisors. Youth advisors were recruited via adverts circulated by a European network of peer advisors with international reach, and signed an agreement at the outset of the project, by way of consent to participate, which included specific duties and responsibilities of what would be expected of them, as well as hours and reimbursement details. For those under 18 years old, parent/carer consent and agreements were gained. One-to-one meetings between each youth advisor and the participation lead for the study were conducted before and after the study took place. A written agreement was made between the lead research organisation, and the participation organisation which facilitates the network of peer advisors.

Academic/clinical advisors were experienced and specialised in goals work and were recruited via existing networks. Criteria for academic/clinical advisors were that they had research and/or clinical experience in the field of mental health goal setting with young people (academic N = 6; clinical N = 4; categories not mutually exclusive). Written agreements were made between the lead research organisation, and each academic/clinical advisor.

Directed discussions were held at six advisory group meetings (two academic/clinical and four youth) facilitated by two researchers (JJ, MS) and conducted in English. All advisors spoke English, but time was given in the meetings to check understanding, as English was not a native language for many. The academic/clinical and youth advisors met separately, enabling the youth advisors to share openly with their peers. These discussions focused on the research question and drawing inferences about resultant findings, as well as appraising the evidence to identify key literature gaps. The summary of findings from the literature review was presented via PowerPoint to the advisors. The questions asked were broadly: is setting goals an important part of the relationship with the therapist and why/not; do these findings align with your experiences; is there anything you can think of that has not been considered; are there any elements of these findings that do not make sense in your experience; how do you interpret and understand these findings within the context of your own experience? Youth advisors were asked additional questions about the nature of language, for example, what do you think about the term “goal”? Is it the word you use, is it understandable, how does it translate to your national languages?. Field notes were taken, alongside notes in advisors’ own words on the JamBoard interactive workspace, allowing for anonymous contributions. Analysis comprised four stages. First, one researcher (MS) organised field notes and comments into a narrative summary. Second, one researcher (JJ) used the nuanced elements of the research question to organise the summary. Third, feedback was sought from advisors to evaluate and assess whether it was a true reflection of the discussions. Fourth, one researcher (JJ) refined and renamed the themes.

Online searches generated 10,907 records. Ten potentially eligible studies were identified. Upon screening full texts, seven unique studies met the selection criteria (See Fig.  1 and Table 1 ).

PRISMA flow chart of the study selection process. From: Page, M.J., McKenzie, J.E., Bossuyt, P.M., Boutron, I., Hoffmann, T.C., Mulrow, C.D. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372(n71)

Included studies comprised three narrative case studies [ 29 , 30 , 31 ] a randomised control trial [ 32 ]; a narrative review [ 33 ] a practitioners’ guidance document [ 34 ]; and a naturalistic study [ 35 ]. Critical appraisal of the evidence (Table 1 ) demonstrates that caution must be exercised when considering the findings. The main strength of the included studies is the voice of young people through verbatim quotes, and for some, strong consideration of the researchers’ impact. However, less strength is attributed to the dependability or generalisability of the findings, mainly due to the high proportion of small-and-homogenous samples. The advisors’ discussion summaries were organised into themes within the nuances of the research question: Why/why not and how? For whom? Under what circumstances?”, and presented as a narrative synthesis.

Why/why not and how (mechanisms)

A conduit for open communication.

Six studies described collaborative goal setting as a conduit for communication [ 29 , 30 , 31 , 33 , 34 , 35 ]. Specifically, agreement on goals leads to open communication, a shared understanding of difficulties and ways forward [ 29 , 31 , 35 ]. Formulating goals was described as key to helping young people to feeling understood, valued and that practitioners are listening to them [ 33 , 34 , 35 ]. Collaborative goal setting enables young people and practitioners to make genuine disclosures, not necessarily otherwise possible [ 30 ] and facilitates mutual support [ 31 ].

Both academic/clinical and youth advisors said that open communication and trust were key, broadly agreeing that goal setting could be helpful to support building trusting relationships. It was agreed that collaboratively agreeing goals may take time and should not happen immediately. Rather, practitioners should work flexibly, aiming to understand what is comfortable for young people experiencing anxiety and/or depression. Some youth advisors said that relationships need to be built first, with trust established prior to goal setting, particularly when goal setting feels complicated. It was agreed by youth and academic/clinical advisors that goal setting should be led by young people and guided by practitioners, sharing responsibility. Youth advisors considered open communication the most crucial factor in therapy, with a sense that much therapeutic work cannot take place without it.

Feel supported and involved

Young people value receiving support to split actions into smaller manageable steps, with encouragement from practitioners stimulating validation that their goals are achievable ([ 35 ], and youth advisors). Being given choice about goal content and how this translates into the options for care was identified as an important part of the process in the literature [ 35 ]. Evidence suggests that this leads to a sense of autonomy and control over what happens to young people and enables them to feel involved in the process and increases engagement [ 30 , 33 , 35 ]. This was not directly addressed by the academic/clinical advisors in their discussions.

Nature of difficulties

All seven studies, and youth and academic/clinical advisors, suggested that goal setting was a helpful element of therapeutic relationships for young people experiencing anxiety and/or depression, and more broadly with other undefined presenting difficulties. Both academic/clinical and youth advisors agreed that there was no need to separate specific attributes of anxiety or depression, due in part, to high proportions of comorbidity.

Age, and previous experiences

Three studies described difficulties for young people engaging in goal setting [ 32 , 33 , 34 ]. These were: age-appropriate quests for independence interfering with establishing collaborative relationships with adults [ 32 ]; significant and repeated traumas impacting development, relationships and challenges ordering thoughts, particularly within the context of long-term therapy [ 34 ]; low confidence or feelings of hopelessness; and poor previous experiences of goal setting [ 33 ]. Youth advisors agreed that previous life experiences were important, e.g., views of goal setting in therapeutic settings were impacted by how successful they had been in achieving past goals, regardless of goal type. Academic/clinical advisors agreed that personal factors such as previous experiences and factors surrounding—or leading to—difficulties, may lead to challenges setting goals in the first instance.

Levels of distress, personality traits and preferences

Youth and academic/clinical advisors suggested that specific unhelpful elements may depend on the young person, and sometimes levels of distress, rather than the nature of difficulties. Some youth advisors expressed preferences for practitioner-directed work, particularly in times of high distress, e.g.,: “If I’m going through something very bad, I can be very frustrated/sad so I can’t think clear” (youth advisor) . It was also agreed that goals may exacerbate anxiety, particularly at times of overwhelm, whilst for others this could be a helpful anxiety reduction approach, e.g., in exposure therapy. Youth advisors said that ensuring goals are achievable is key to building good therapeutic relationships, and the impact on anxiety/depression; the individual’s capacity to set goals should be considered, e.g., someone struggling with day-to-day tasks may find even small goals too challenging. Youth advisors considered perfectionism to be important, where some people may feel pressure to achieve goals. A sense of hopelessness, or procrastination, and rumination also, where delaying tasks may result in delaying work on goals. For some youth advisors, goal setting felt especially important, whilst for others it was not, rather a supportive relationship was identified as most important, and they could not see how that would be developed through goal setting. Academic/clinical advisors said that young people’s preferences to work on goals, or not, was in itself of key importance to the therapeutic relationship. There was no evidence from the included literature to support/oppose these points.

Language and power dynamics

Linked to preferences, youth advisors said that young people tend not to like the term “goal” because they attribute it to work and formal settings, whereas “therapeutic goals” are personal with deeper meaning. Academic/clinical advisors discussed using alternative language for goal setting and goal directed work, and the importance of being led by the young person. Posing questions such as “What do you want to change?” is suggested as an alternative in the literature ([ 33 ]; p.47). Youth advisors said that whilst some young people may feel able to say they do not want to set goals, others may not, due to the young person-practitioner power imbalance, which has implications for relationships, and therapeutic work. There was no further evidence from the included literature to support/oppose these points.

Under what circumstances (contextual factors)

Broadly helpful.

All seven studies suggested that goal setting was a helpful element of therapeutic relationships for young people within the research contexts. This included year-long narrative therapy with interpersonal therapy and CBT techniques in alliance with the family [ 29 ]; multimodal family therapy [ 31 ]; Gestalt therapy [ 30 ]; either CBT, short-term psychoanalytic psychotherapy or brief psychosocial intervention [ 32 ]; UK child and adolescent mental health services [ 33 , 34 ] and UK inpatient settings [ 35 ]. All studies were based in Western high-income countries. Academic/clinical and youth advisors agreed with this assessment.

Review points and referral routes

Reviewing progress towards goals too frequently could give the impression that practitioners are more interested in gauging their own success, rather than in the young person as a whole person, and rating could end up being done by rote, making goals increasingly meaningless [ 34 ] . Academic/clinical and youth advisors agreed with this, discussing the need to work with goals in a flexible manner. Additionally, young people may not recognise the symptoms identified, particularly when referred for treatment by another party (e.g., parents/carers), which is crucial to enable collaborative goal setting [ 32 ]. Challenges associated with thinking of goals in this way was addressed by the academic/clinical and youth advisors in wider discussions elsewhere (see therapy contexts).

Culture and therapy contexts

Youth and academic/clinical advisors located in Western high-income countries agreed that it may depend on types of interventions offered and practitioner’s preferred working style, but young people largely have agency to set goals. However, it was recognised by the youth and academic/clinical advisors that some young people in some countries do not have agency to set goals. There, decisions are made by families, in collaboration with practitioners, and so less consideration is given to young people’s perspectives. It was suggested that, in some countries, there is no concept of setting goals (e.g., a youth advisor discussed their experience in Pakistan), and ongoing stigma associated with mental health difficulties, which may lead to distrust, scepticism in, and a disconnect with practitioners. Youth advisors said that this may also be true in other countries not represented. A youth advisor suggested that young people in Brazil were relaxed towards goal setting and would not mind if goals were not achieved; directed therapy was considered more helpful.

Youth and academic/clinical advisors discussed goals in long-term therapy as potentially feeling restrictive, with challenges associated with thinking of what goals might be. Both long-and short-term goal setting within this context may feel meaningless, which if then pressed by the practitioner, has a negative impact on relationships. Academic/clinical advisors said that the feasibility of goal setting in the first instance is likely to be attributable to the factors young people who might be offered long-term therapy might have, rather than the work itself leading to these challenges. Youth and academic/clinical advisors also said that where there are multiple needs and risks, goals need to be simpler to feel manageable. Youth advisors said that sometimes there were concerns about the achievement of goals equating to treatment ending, which felt unsettling. There was no evidence from the included literature to support/oppose these points.

This study aimed to provide a synthesis of existing literature, identifying knowledge gaps. Whilst much may be drawn from related research, caution must be exercised when translating findings into other contexts [ 11 ], and whilst promising, generalising adult findings to youth must be exercised with an abundance of caution. Evidence suggests that adults and children think differently; as children grow, their cognitive processes develop, and their contexts and perspectives change, impacting on understandings of the self and the world around them. Further, models of recovery from depression are notably different between adults and young people [ 14 ]. As such, we have focused on evidence from the youth field in our discussion, and further highlight the paucity of research with young people in this area.

The included evidence originates from Western high-income and largely specialist settings; further research in majority world countries is urgently required. Many studies identified in initial searches only partially met inclusion criteria. This evidence paucity may suggest goal setting is not embedded in service standards or practice in most countries, or other limiting factors such as the general underfunding of youth mental health research. Some examples were derived from the insight analysis, highlighting the advisors’ value, who helped contextualise and interpret evidence, grounded in lived experience. However, whilst the research question pertained to the effectiveness of goal setting as part of therapeutic relationships, the findings were related to the feasibility, or acceptability of goal setting itself. Links between effective goal setting, good therapeutic relationships and positive outcomes are inferred based on evidence that partially supports the research question, and the discussions with the advisory group, but no evidence relating to anxiety or depression outcomes was found in this study. Future research should consider in depth explorations of mechanisms of goal setting within therapeutic relationships, for young people experiencing anxiety and/or depression.

For many young people, goal setting is a helpful tool for building good therapeutic relationships via open communication. These findings support previous research which partially address the research question: young people find goal setting to be helpful to therapeutic relationships through the development of a shared language and understanding [ 3 ]. It has been suggested that goals are a mechanism of change via a means for “common ground” to be established [ 3 ]. Finding common ground and a shared understanding are particularly pertinent in youth mental health settings, where there are multiple stakeholders involved [ 36 , 37 , 38 ], which can be a balancing act [ 39 ]. Establishing this mutuality of situations is considered the key facilitator of engagement when referred for therapy by others [ 40 ]. Further, ownership of goals located with young people is important [ 41 ], which in turn gives young people ownership of their care, which can be motivational [ 42 , 43 ]. Young people experiencing anxiety may find goal setting an effective strategy due to links with avoidance motivation; such that they have reported pursuing approach goals to avoid negative emotional consequences of not doing so [ 44 ]. The ability of young people to maintain focus on the pursuit of personal goals has also been demonstrated as a moderator of depression and suicide [ 45 ].

One included study explicitly discussed parents/carers within collaborative goals and therapeutic relationships, as a foundation for mutual support [ 31 ]. Stronger relationships between both young people, parents/carers and practitioners and/or involving both young people and parents/carers in decision-making have been demonstrated to predict more positive outcomes [ 39 , 46 ]. Young people are often referred by their parents/carers, which must be considered, particularly where literature highlights challenges of setting goals when young people do not agree with the referral or recognise the difficulties [ 22 , 32 ]. Prior research has demonstrated that young people from minoritized ethnic groups are more likely to be referred for mental health support via social care and the youth justice system compared to their White British counterparts, who are commonly referred via primary care in the UK [ 47 ]. Further, evidence suggests that increases in emotional autonomy result in a shift from dependence on adults in adolescence, to reliance upon peers for support [ 48 ] particularly amongst girls [ 49 ], which may align with the developmental interference with building relationships outside of goal setting found by Cirasola and colleagues [ 32 ]. It has been argued that for young people who have difficulties building and maintaining relationships, the therapeutic relationship is particularly important (e.g., [ 23 ]). It is also noteworthy that young people in some countries may not have agency to set goals, a significant limiting factor. There are cultural and service level factors which were not explored. In some cultures, advice is sought from family and religious leaders over mental health professionals (e.g., [ 50 ]). Organisational level factors have also been found to hinder and influence therapeutic processes [ 40 ]. Further research is needed into referral routes, and intersections between systems, practice, and young people’s preferences.

Several elements of goal setting were identified as unhelpful for young people experiencing anxiety and/or depression, supporting previous literature. These discussions centred on the feasibility/acceptability of goals, rather than goal setting being detrimental to therapeutic relationships per se. Nevertheless, it is suggested that these factors were primarily related to the person, and that “personal” factors may be driven by underlying difficulties. For example, low confidence, hopelessness, levels of distress, perfectionism, and rumination (e.g., [ 51 , 52 , 53 , 54 , 55 ], may all be elements of anxiety and/or depression. Academic/clinical and youth advisors agreed that goals may become clearer over time, particularly for young people experiencing depression and purposeless, and through collaboration, goals could be formulated. The importance of considering specific challenges of goal setting during long-term therapy was highlighted. Academic/clinical and youth advisors discussed challenges associated with identifying priority areas for work, and that goals continue to flex and change, with the potential for goals work to feel too restrictive. This is in support of previous research suggesting that it is important that goals are worked on flexibly [ 3 ] with space for them to change; specifically in relation to depression. Compared to those with low levels of depression, young people with high levels of depression are more able to disengage with unhelpful goals over time and to set new goals, which in turn may predict lower levels of depressive symptoms over a year later [ 56 ]. This sense of goals flexing, feeling unique and changeable has been mirrored in descriptions of therapeutic relationships themselves [ 23 ]. There was a clear steer from youth advisors that the relationship independent of goal setting was key to good outcomes, and that this was a priority; that without the trusting relationship, there is no facilitator for goal setting. This is an important contradiction to the literature, warranting further exploration. One suggestion is that the initial goals for long-term therapy should be on relationship building, but reviewed, so the therapeutic relationship itself does not remain the primary goal [ 34 ]. Another key finding is that goals take time to establish, and pressure to set goals may render them meaningless, which also supports previous research [ 51 ]. Young people often do not know what their goals are [ 57 ], which impacts trust building, relationships and thus, therapeutic work. In support of prior research which defines recovery as contingent on shared goals and joint action in relationships [ 14 ], links found between goals, trust building and therapeutic relationships in the present study align with research on trauma informed care, and emotional and relational safety (see, [ 58 ]). Further consideration should be given to this area, particularly clinical implications, and interactions with levels of distress.

Whilst support approaches that incorporate structured goal setting are often characterised by a greater emphasis on client-centredness, the links between personally meaningful outcomes and the specific behaviour change techniques required to progress towards goals are not clear. Further, the person-centred focus is hypothesised as a conduit to positive ratings of self-efficacy, quality of life and service satisfaction, but evidence is lacking [ 11 ]. Whilst previous literature from within the youth mental health field suggests that working on goals is motivating and increases self-efficacy [ 34 , 42 ], evidence is still limited. Goal setting may be useful to young people because, whilst not necessarily synonymous, it has been demonstrated as a facilitative element of shared decision-making [ 59 , 60 ]. This collaborative way of working through shared understanding and the development of good therapeutic relationships [ 61 ] may be especially helpful to young people experiencing depression as it enables them to exercise control over their own feelings and behaviour [ 43 ] at a time when they may be experiencing feelings of hopelessness and purposeless. Whilst educated links are made to shared decision-making, further research should explore whether there is an embedded link to goals and therapeutic relationships.

Strengths and limitations

The mixed-methodological approach was a particular strength, with literature findings bolstered by lived experience. However, whilst advisors were from diverse demographic groups, not all groups were represented.

Whilst every attempt was made to include as many goal setting search terms as possible, the language is broad and fluid, meaning certain terms may have been missed. Still, the high number of results returned from literature searches suggests the strategy may need refinement. Nevertheless, we chose to ensure a large return given the subject’s broad nature. At the screening stage, the focus on explicitly identified goal setting and goal work made the identification of included studies less ambiguous, but meant that studies focused on implicit goals work would not have been included, reducing the number of studies included in the final synthesis.

Prior assumptions and knowledge of this topic will have influenced the researchers’ interpretation of the findings, even subconsciously. This includes the decision to use the nuanced elements of the research question to organise the findings. The researchers were located in Belgium, Germany, and the UK at the time of the study, which risks the perpetuation of the status quo of Western high-income-originating dominated research. Further, the findings were contextualised and linked to prior theory primarily by a researcher outside the age range of interest (JJ). The impact of both issues was mitigated via advisors, particularly those within majority world countries and the age range of interest, and the peer researchers entrenched in the research team (MS, IS), who provided contextual depth and understanding to the findings.

Literature focused on goal setting as helpful for young people with anxiety and/or depression is overwhelmingly supportive, but this leaves research gaps regarding in which ways, for whom and under what circumstances goal setting might be unhelpful. Priority must be given to researching unhelpful mechanisms of goal setting, to avoid potential iatrogenic effects. Accessibility could be improved through exploration of the intersections between systems/contexts (e.g., country), therapeutic practice (e.g., practitioner’s training/preferences) and young people’s preferences. Further research is also needed to explore mechanisms by which goal setting may help to reduce anxiety and/or depression symptoms, as well as other important areas of outcome, such as quality of life, using e.g., mediation analysis.

Scaling up in countries with well-developed systems could mean embedding goals in guidelines for anxiety and/or depression; in service specifications, including monitoring and reporting change mechanisms; staff training in consistency; and some interagency forums to align goal processes. For majority world countries with less developed systems, largely relying on non-specialist services e.g., NGOs, goals may be paradoxically more important for maximising limited resources. Despite nothing suggesting goal setting could not practically be scaled-up globally, cultural considerations may be a limiting factor in some places.

Preferences to not work on goals may be driven by the limiting factors identified, such as hopelessness or high distress. Practitioners should work through this first, reviewing the option to work on goals over time, respecting young people’s preferences. Flexibility is important, and ownership of goals located with young people is essential, particularly to those experiencing depression, enabling them to exercise control over their feelings and behaviour when they may be feeling hopeless and/or purposeless. Finally, there may be a unique opportunity for goals to facilitate work with young people experiencing high distress levels or who have experienced trauma, due to links to emotional and relational safety and building trusting relationships.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available to protect the confidentiality of the small number of advisors, but may be available from the corresponding author’s organisation, on reasonable request.

Abbreviations

Cognitive behavioural therapy

Goal based outcomes tool

United Kingdom

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Acknowledgements

The authors would like to thank the advisors, for their invaluable contribution from start to finish, including useful comments an early draft: Duncan Law, Elmas Aybike Yılmaz, Hanne Oddli, Isabella Valério, Jacob People, Josh D., Julian Edbrooke-Childs, Katya Proctor, Laura Calomarde Juárez, Mick Cooper, Nick Morgan, Panos Vostanis, Syeda Zeenat R., and Theo Jackson. Thank you to Bernice Appiah, Shade Davies and Shadia Robertson for helpful discussions about the findings, and assistance with evidence synthesis, and to Inês Pote from the Wellcome Active Ingredients team, and Jasmine Harju-Seppanen, for useful comments on a previous draft. The authors also wish to thank Zoe Thomas for incredibly useful advice and guidance regarding literature searches.

This work was funded by a Wellcome Trust Mental Health Priority Area “Active Ingredients” 2021 commission awarded to JJ at the Anna Freud Centre. It was a requirement of the funding team that the research design comprised a literature review, and that the involved and worked collaboratively with young people with lived experience of anxiety and/or depression throughout the course of the project. Members of the funding team provided feedback on an early draft of this manuscript.

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Contributions

JJ conceptualised the study, prepared the first draft protocol and search strategy, refining this with the study authors and advisors. JJ undertook the library database searches for published literature, partially screened the titles and abstracts of literature, screened all full texts, led communication with study authors and advisors, led four advisory group meetings, maintained the databases which were used to extract and manage study data, prepared, and revised the manuscript. MS contributed to the first draft protocol and search strategy, led communication with youth advisors, led two advisory group meetings, created the narrative summaries, and contributed to the manuscript. IS contributed to the first draft protocol and search strategy, supported communication with youth advisors, screened full texts for further relevant literature, and contributed to the manuscript. FS conducted the grey literature searches, screened all potential title and abstracts from all searches (published and unpublished literature), maintained the databases which were used to extract and manage study data, and contributed to the manuscript. All study advisors were invited to comment on the protocol and initial search terms, and were invited to comment on earlier drafts of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Jenna Jacob .

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Ethical approval for this research was not required because it does not involve collection nor analysis of primary data, and youth advisors were consulted on in the capacity of being part of the advisory group, to discuss their interpretation of the findings, rather than within the capacity of research participants.

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Competing interests

JJ works on the Child Outcomes Research Consortium (CORC) project at the Anna Freud National Centre for Children and Families, which encourages the use of outcome measures in youth mental health settings amongst its members. No other authors report any competing interests.

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Additional file 1. appendix 1..

Inclusion and exclusion criteria and Search Strategies. Appendix 2 Core Criteria for Quality Assessment of Qualitative Studies.

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Jacob, J., Stankovic, M., Spuerck, I. et al. Goal setting with young people for anxiety and depression: What works for whom in therapeutic relationships? A literature review and insight analysis. BMC Psychol 10 , 171 (2022). https://doi.org/10.1186/s40359-022-00879-5

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