the scoping study methodology

Good review practice: a researcher guide to systematic review methodology in the sciences of food and health

• About this guide
• Part A: Systematic review method
• What are Good Practice points?
• Part C: The core steps of the SR process
• 1.1 Setting eligibility criteria
• 1.2 Identifying search terms
• 1.3 Protocol development
• 2. Searching for studies
• 3. Screening the results
• 4. Evaluation of included studies: quality assessment
• 5. Data extraction
• 6. Data synthesis and summary
• 7. Presenting results
• Links to current versions of the reference guidelines
• Download templates
• Food science databases
• Process management tools
• Screening tools
• Reference management tools
• Grey literature sources
• Links for access to protocol repository and platforms for registration
• Links for access to PRISMA frameworks
• Links for access to 'Risk of Bias' assessment tools for quantitative and qualitative studies
• Links for access to grading checklists
• Links for access to reporting checklists
• What questions are suitable for the systematic review methodology?
• How to assess feasibility of using the method?
• What is a scoping study and how to construct one?
• How to construct a systematic review protocol?
• How to construct a comprehensive search?
• Study designs and levels of evidence
• Download a pdf version This link opens in a new window

Scoping Study

Do you need a scoping study.

A scoping study is usually carried out before a full systematic review, to assess the breath of the research around the topic of interest. It may be used to determine how well the subject is researched and whether there is enough evidence or a real need to conduct a full systematic review. They are also planned to map keywords to relevant concepts and put the research topics in context. Scoping exercises are  not  mandatory and are only planned if there is a need to overview the state of the art for the topic of interest. 

In relevance to systematic reviews, they are widely used to:

• investigate the volume and state of available literature, 
• map concepts, keywords, and policies,
• to narrow down the scope of broad questions and make them suitable for the use of the SR methodology. 

The method of scoping research topics was first developed by the EPPI-Centre to pilot systematic reviews of environmental questions. They were then extended to clinical and social science topics and are gradually being adopted in other scientific disciplines.

How to conduct a scoping study

Scoping studies are descriptive and often not comprehensive, but they provide a roadmap of literature. They follow similar steps to a systematic review process to summarise the state of current research on a topic  without  the need for data extraction, quality assessment or sensitivity analysis. 

A standard framework proposed by Arksey, and O’Malley  [2] is commonly used in clinical and healthcare research. This framework can be adapted and applied in other fields as well.  

It consists of the following 5 steps:     Step 1: Identifying the research question,    Step 2: Identifying relevant studies,     Step 3: Study selection,     Step 4: Charting the data,     Step 5: Collating, summarising, and reporting results.

Identifying the research question : the objective of the review question and the purpose of the scoping study determine which aspects of the study are important and what details are needed to provide an appropriate description. For example, to assess different applications of an intervention, a map of relevant literature to find all subpopulation might be planned.

Identifying relevant studies : regardless of the topic, at least 2 key elements of the research question set the foundation for a scoping study: the population and the outcome of interest. But unlike systematic review questions scoping questions seek to describe important aspects of relevant research. For instance, an intervention question can be centered around “what kind” of interventions have been applied to a particular subject for an outcome of interest.

Study selection : the search strategies of scoping studies are often designed to capture a broader spectrum of literature. As a result, the study selection process often is done at two different levels to manage the volume. First, all irrelevant and out of focus literature are removed by screening through citations or titles and abstracts. Then the screening procedure is followed for the full texts of relevant literature. 

Charting the data : this stage of the scoping method can differ considerably based on the purpose. These details can include study characteristics, details of the populations, type and volume of relevant primary studies, details of various concepts and topics, etc. 

Collating, summarising, and reporting results : The presentation formats are also guided by the purpose of the scoping review and often consist of tabulated forms that are used to organise and chart the data accordingly. When inputs or agreements from different field experts are needed, an optional consultation step is sometimes carried out in the end.

Good practice point : For the purpose of good practice this stage should be managed by at least 2 reviewers to make sure all relevant literatures are included.  If the scoping review is intended for publication, a  protocol  should be developed before undertaking it, to outline the methods and objectives. 

Links to access examples of scoping studies

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• Last Updated: May 17, 2024 6:08 PM
• URL: https://ifis.libguides.com/systematic_reviews

• Open access
• Published: 08 October 2021

Scoping reviews: reinforcing and advancing the methodology and application

• Micah D. J. Peters 1 , 2 , 3 ,
• Casey Marnie 1 ,
• Heather Colquhoun 4 , 5 ,
• Chantelle M. Garritty 6 ,
• Susanne Hempel 7 ,
• Tanya Horsley 8 ,
• Etienne V. Langlois 9 ,
• Erin Lillie 10 ,
• Kelly K. O’Brien 5 , 11 , 12 ,
• Ӧzge Tunçalp 13 ,
• Michael G. Wilson 14 , 15 , 16 ,
• Wasifa Zarin 17 &
• Andrea C. Tricco   ORCID: orcid.org/0000-0002-4114-8971 17 , 18 , 19  

Systematic Reviews volume  10 , Article number:  263 ( 2021 ) Cite this article

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Scoping reviews are an increasingly common approach to evidence synthesis with a growing suite of methodological guidance and resources to assist review authors with their planning, conduct and reporting. The latest guidance for scoping reviews includes the JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses—Extension for Scoping Reviews. This paper provides readers with a brief update regarding ongoing work to enhance and improve the conduct and reporting of scoping reviews as well as information regarding the future steps in scoping review methods development. The purpose of this paper is to provide readers with a concise source of information regarding the difference between scoping reviews and other review types, the reasons for undertaking scoping reviews, and an update on methodological guidance for the conduct and reporting of scoping reviews.

Despite available guidance, some publications use the term ‘scoping review’ without clear consideration of available reporting and methodological tools. Selection of the most appropriate review type for the stated research objectives or questions, standardised use of methodological approaches and terminology in scoping reviews, clarity and consistency of reporting and ensuring that the reporting and presentation of the results clearly addresses the review’s objective(s) and question(s) are critical components for improving the rigour of scoping reviews.

Rigourous, high-quality scoping reviews should clearly follow up to date methodological guidance and reporting criteria. Stakeholder engagement is one area where further work could occur to enhance integration of consultation with the results of evidence syntheses and to support effective knowledge translation. Scoping review methodology is evolving as a policy and decision-making tool. Ensuring the integrity of scoping reviews by adherence to up-to-date reporting standards is integral to supporting well-informed decision-making.

Peer Review reports

Introduction

Given the readily increasing access to evidence and data, methods of identifying, charting and reporting on information must be driven by new, user-friendly approaches. Since 2005, when the first framework for scoping reviews was published, several more detailed approaches (both methodological guidance and a reporting guideline) have been developed. Scoping reviews are an increasingly common approach to evidence synthesis which is very popular amongst end users [ 1 ]. Indeed, one scoping review of scoping reviews found that 53% (262/494) of scoping reviews had government authorities and policymakers as their target end-user audience [ 2 ]. Scoping reviews can provide end users with important insights into the characteristics of a body of evidence, the ways, concepts or terms have been used, and how a topic has been reported upon. Scoping reviews can provide overviews of either broad or specific research and policy fields, underpin research and policy agendas, highlight knowledge gaps and identify areas for subsequent evidence syntheses [ 3 ].

Despite or even potentially because of the range of different approaches to conducting and reporting scoping reviews that have emerged since Arksey and O’Malley’s first framework in 2005, it appears that lack of consistency in use of terminology, conduct and reporting persist [ 2 , 4 ]. There are many examples where manuscripts are titled ‘a scoping review’ without citing or appearing to follow any particular approach [ 5 , 6 , 7 , 8 , 9 ]. This is similar to how many reviews appear to misleadingly include ‘systematic’ in the title or purport to have adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement without doing so. Despite the publication of the PRISMA Extension for Scoping Reviews (PRISMA-ScR) and other recent guidance [ 4 , 10 , 11 , 12 , 13 , 14 ], many scoping reviews continue to be conducted and published without apparent (i.e. cited) consideration of these tools or only cursory reference to Arksey and O’Malley’s original framework. We can only speculate at this stage why many authors appear to be either unaware of or unwilling to adopt more recent methodological guidance and reporting items in their work. It could be that some authors are more familiar and comfortable with the older, less prescriptive framework and see no reason to change. It could be that more recent methodologies such as JBI’s guidance and the PRISMA-ScR appear more complicated and onerous to comply with and so may possibly be unfit for purpose from the perspective of some authors. In their 2005 publication, Arksey and O’Malley themselves called for scoping review (then scoping study) methodology to continue to be advanced and built upon by subsequent authors, so it is interesting to note a persistent resistance or lack of awareness from some authors. Whatever the reason or reasons, we contend that transparency and reproducibility are key markers of high-quality reporting of scoping reviews and that reporting a review’s conduct and results clearly and consistently in line with a recognised methodology or checklist is more likely than not to enhance rigour and utility. Scoping reviews should not be used as a synonym for an exploratory search or general review of the literature. Instead, it is critical that potential authors recognise the purpose and methodology of scoping reviews. In this editorial, we discuss the definition of scoping reviews, introduce contemporary methodological guidance and address the circumstances where scoping reviews may be conducted. Finally, we briefly consider where ongoing advances in the methodology are occurring.

What is a scoping review and how is it different from other evidence syntheses?

A scoping review is a type of evidence synthesis that has the objective of identifying and mapping relevant evidence that meets pre-determined inclusion criteria regarding the topic, field, context, concept or issue under review. The review question guiding a scoping review is typically broader than that of a traditional systematic review. Scoping reviews may include multiple types of evidence (i.e. different research methodologies, primary research, reviews, non-empirical evidence). Because scoping reviews seek to develop a comprehensive overview of the evidence rather than a quantitative or qualitative synthesis of data, it is not usually necessary to undertake methodological appraisal/risk of bias assessment of the sources included in a scoping review. Scoping reviews systematically identify and chart relevant literature that meet predetermined inclusion criteria available on a given topic to address specified objective(s) and review question(s) in relation to key concepts, theories, data and evidence gaps. Scoping reviews are unlike ‘evidence maps’ which can be defined as the figural or graphical presentation of the results of a broad and systematic search to identify gaps in knowledge and/or future research needs often using a searchable database [ 15 ]. Evidence maps can be underpinned by a scoping review or be used to present the results of a scoping review. Scoping reviews are similar to but distinct from other well-known forms of evidence synthesis of which there are many [ 16 ]. Whilst this paper’s purpose is not to go into depth regarding the similarities and differences between scoping reviews and the diverse range of other evidence synthesis approaches, Munn and colleagues recently discussed the key differences between scoping reviews and other common review types [ 3 ]. Like integrative reviews and narrative literature reviews, scoping reviews can include both research (i.e. empirical) and non-research evidence (grey literature) such as policy documents and online media [ 17 , 18 ]. Scoping reviews also address broader questions beyond the effectiveness of a given intervention typical of ‘traditional’ (i.e. Cochrane) systematic reviews or peoples’ experience of a particular phenomenon of interest (i.e. JBI systematic review of qualitative evidence). Scoping reviews typically identify, present and describe relevant characteristics of included sources of evidence rather than seeking to combine statistical or qualitative data from different sources to develop synthesised results.

Similar to systematic reviews, the conduct of scoping reviews should be based on well-defined methodological guidance and reporting standards that include an a priori protocol, eligibility criteria and comprehensive search strategy [ 11 , 12 ]. Unlike systematic reviews, however, scoping reviews may be iterative and flexible and whilst any deviations from the protocol should be transparently reported, adjustments to the questions, inclusion/exclusion criteria and search may be made during the conduct of the review [ 4 , 14 ]. Unlike systematic reviews where implications or recommendations for practice are a key feature, scoping reviews are not designed to underpin clinical practice decisions; hence, assessment of methodological quality or risk of bias of included studies (which is critical when reporting effect size estimates) is not a mandatory step and often does not occur [ 10 , 12 ]. Rapid reviews are another popular review type, but as yet have no consistent, best practice methodology [ 19 ]. Rapid reviews can be understood to be streamlined forms of other review types (i.e. systematic, integrative and scoping reviews) [ 20 ].

Guidance to improve the quality of reporting of scoping reviews

Since the first 2005 framework for scoping reviews (then termed ‘scoping studies’) [ 13 ], the popularity of this approach has grown, with numbers doubling between 2014 and 2017 [ 2 ]. The PRISMA-ScR is the most up-to-date and advanced approach for reporting scoping reviews which is largely based on the popular PRISMA statement and checklist, the JBI methodological guidance and other approaches for undertaking scoping reviews [ 11 ]. Experts in evidence synthesis including authors of earlier guidance for scoping reviews developed the PRISMA-ScR checklist and explanation using a robust and comprehensive approach. Enhancing transparency and uniformity of reporting scoping reviews using the PRISMA-ScR can help to improve the quality and value of a scoping review to readers and end users [ 21 ]. The PRISMA-ScR is not a methodological guideline for review conduct, but rather a complementary checklist to support comprehensive reporting of methods and findings that can be used alongside other methodological guidance [ 10 , 12 , 13 , 14 ]. For this reason, authors who are more familiar with or prefer Arksey and O’Malley’s framework; Levac, Colquhoun and O’Brien’s extension of that framework or JBI’s methodological guidance could each select their preferred methodological approach and report in accordance with the PRISMA-ScR checklist.

Reasons for conducting a scoping review

Whilst systematic reviews sit at the top of the evidence hierarchy, the types of research questions they address are not suitable for every application [ 3 ]. Many indications more appropriately require a scoping review. For example, to explore the extent and nature of a body of literature, the development of evidence maps and summaries; to inform future research and reviews and to identify evidence gaps [ 2 ]. Scoping reviews are particularly useful where evidence is extensive and widely dispersed (i.e. many different types of evidence), or emerging and not yet amenable to questions of effectiveness [ 22 ]. Because scoping reviews are agnostic in terms of the types of evidence they can draw upon, they can be used to bring together and report upon heterogeneous literature—including both empirical and non-empirical evidence—across disciplines within and beyond health [ 23 , 24 , 25 ].

When deciding between whether to conduct a systematic review or a scoping review, authors should have a strong understanding of their differences and be able to clearly identify their review’s precise research objective(s) and/or question(s). Munn and colleagues noted that a systematic review is likely the most suitable approach if reviewers intend to address questions regarding the feasibility, appropriateness, meaningfulness or effectiveness of a specified intervention [ 3 ]. There are also online resources for prospective authors [ 26 ]. A scoping review is probably best when research objectives or review questions involve exploring, identifying, mapping, reporting or discussing characteristics or concepts across a breadth of evidence sources.

Scoping reviews are increasingly used to respond to complex questions where comparing interventions may be neither relevant nor possible [ 27 ]. Often, cost, time, and resources are factors in decisions regarding review type. Whilst many scoping reviews can be quite large with numerous sources to screen and/or include, there is no expectation or possibility of statistical pooling, formal risk of bias rating, and quality of evidence assessment [ 28 , 29 ]. Topics where scoping reviews are necessary abound—for example, government organisations are often interested in the availability and applicability of tools to support health interventions, such as shared decision aids for pregnancy care [ 30 ]. Scoping reviews can also be applied to better understand complex issues related to the health workforce, such as how shift work impacts employee performance across diverse occupational sectors, which involves a diversity of evidence types as well as attention to knowledge gaps [ 31 ]. Another example is where more conceptual knowledge is required, for example, identifying and mapping existing tools [ 32 ]. Here, it is important to understand that scoping reviews are not the same as ‘realist reviews’ which can also be used to examine how interventions or programmes work. Realist reviews are typically designed to ellucide the theories that underpin a programme, examine evidence to reveal if and how those theories are relevant and explain how the given programme works (or not) [ 33 ].

Increased demand for scoping reviews to underpin high-quality knowledge translation across many disciplines within and beyond healthcare in turn fuels the need for consistency, clarity and rigour in reporting; hence, following recognised reporting guidelines is a streamlined and effective way of introducing these elements [ 34 ]. Standardisation and clarity of reporting (such as by using a published methodology and a reporting checklist—the PRISMA-ScR) can facilitate better understanding and uptake of the results of scoping reviews by end users who are able to more clearly understand the differences between systematic reviews, scoping reviews and literature reviews and how their findings can be applied to research, practice and policy.

Future directions in scoping reviews

The field of evidence synthesis is dynamic. Scoping review methodology continues to evolve to account for the changing needs and priorities of end users and the requirements of review authors for additional guidance regarding terminology, elements and steps of scoping reviews. Areas where ongoing research and development of scoping review guidance are occurring include inclusion of consultation with stakeholder groups such as end users and consumer representatives [ 35 ], clarity on when scoping reviews are the appropriate method over other synthesis approaches [ 3 ], approaches for mapping and presenting results in ways that clearly address the review’s research objective(s) and question(s) [ 29 ] and the assessment of the methodological quality of scoping reviews themselves [ 21 , 36 ]. The JBI Scoping Review Methodology group is currently working on this research agenda.

Consulting with end users, experts, or stakeholders has been a suggested but optional component of scoping reviews since 2005. Many of the subsequent approaches contained some reference to this useful activity. Stakeholder engagement is however often lost to the term ‘review’ in scoping reviews. Stakeholder engagement is important across all knowledge synthesis approaches to ensure relevance, contextualisation and uptake of research findings. In fact, it underlines the concept of integrated knowledge translation [ 37 , 38 ]. By including stakeholder consultation in the scoping review process, the utility and uptake of results may be enhanced making reviews more meaningful to end users. Stakeholder consultation can also support integrating knowledge translation efforts, facilitate identifying emerging priorities in the field not otherwise captured in the literature and may help build partnerships amongst stakeholder groups including consumers, researchers, funders and end users. Development in the field of evidence synthesis overall could be inspired by the incorporation of stakeholder consultation in scoping reviews and lead to better integration of consultation and engagement within projects utilising other synthesis methodologies. This highlights how further work could be conducted into establishing how and the extent to which scoping reviews have contributed to synthesising evidence and advancing scientific knowledge and understandings in a more general sense.

Currently, many methodological papers for scoping reviews are published in healthcare focussed journals and associated disciplines [ 6 , 39 , 40 , 41 , 42 , 43 ]. Another area where further work could also occur is to gain greater understanding on how scoping reviews and scoping review methodology is being used across disciplines beyond healthcare including how authors, reviewers and editors understand, recommend or utilise existing guidance for undertaking and reporting scoping reviews.

Whilst available guidance for the conduct and reporting of scoping review has evolved over recent years, opportunities remain to further enhance and progress the methodology, uptake and application. Despite existing guidance, some publications using the term ‘scoping review’ continue to be conducted without apparent consideration of available reporting and methodological tools. Because consistent and transparent reporting is widely recongised as important for supporting rigour, reproducibility and quality in research, we advocate for authors to use a stated scoping review methodology and to transparently report their conduct by using the PRISMA-ScR. Selection of the most appropriate review type for the stated research objectives or questions, standardising the use of methodological approaches and terminology in scoping reviews, clarity and consistency of reporting and ensuring that the reporting and presentation of the results clearly addresses the authors’ objective(s) and question(s) are also critical components for improving the rigour of scoping reviews. We contend that whilst the field of evidence synthesis and scoping reviews continues to evolve, use of the PRISMA-ScR is a valuable and practical tool for enhancing the quality of scoping reviews, particularly in combination with other methodological guidance [ 10 , 12 , 44 ]. Scoping review methodology is developing as a policy and decision-making tool, and so ensuring the integrity of these reviews by adhering to the most up-to-date reporting standards is integral to supporting well informed decision-making. As scoping review methodology continues to evolve alongside understandings regarding why authors do or do not use particular methodologies, we hope that future incarnations of scoping review methodology continues to provide useful, high-quality evidence to end users.

Availability of data and materials

All data and materials are available upon request.

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Acknowledgements

The authors would like to acknowledge the other members of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) working group as well as Shazia Siddiqui, a research assistant in the Knowledge Synthesis Team in the Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto.

The authors declare that no specific funding was received for this work. Author ACT declares that she is funded by a Tier 2 Canada Research Chair in Knowledge Synthesis. KKO is supported by a Canada Research Chair in Episodic Disability and Rehabilitation with the Canada Research Chairs Program.

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Authors and affiliations.

University of South Australia, UniSA Clinical and Health Sciences, Rosemary Bryant AO Research Centre, Playford Building P4-27, City East Campus, North Terrace, Adelaide, 5000, South Australia

Micah D. J. Peters & Casey Marnie

Adelaide Nursing School, Faculty of Health and Medical Sciences, The University of Adelaide, 101 Currie St, Adelaide, 5001, South Australia

Micah D. J. Peters

The Centre for Evidence-based Practice South Australia (CEPSA): a Joanna Briggs Institute Centre of Excellence, Faculty of Health and Medical Sciences, The University of Adelaide, 5006, Adelaide, South Australia

Department of Occupational Science and Occupational Therapy, University of Toronto, Terrence Donnelly Health Sciences Complex, 3359 Mississauga Rd, Toronto, Ontario, L5L 1C6, Canada

Heather Colquhoun

Rehabilitation Sciences Institute (RSI), University of Toronto, St. George Campus, 160-500 University Avenue, Toronto, Ontario, M5G 1V7, Canada

Heather Colquhoun & Kelly K. O’Brien

Knowledge Synthesis Group, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada

Chantelle M. Garritty

Southern California Evidence Review Center, University of Southern California, Los Angeles, CA, 90007, USA

Susanne Hempel

Royal College of Physicians and Surgeons of Canada, 774 Echo Drive, Ottawa, Ontario, K1S 5N8, Canada

Tanya Horsley

Partnership for Maternal, Newborn and Child Health (PMNCH), World Health Organisation, Avenue Appia 20, 1211, Geneva, Switzerland

Etienne V. Langlois

Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada

Erin Lillie

Department of Physical Therapy, University of Toronto, St. George Campus, 160-500 University Avenue, Toronto, Ontario, M5G 1V7, Canada

Kelly K. O’Brien

Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, St. George Campus, 155 College Street 4th Floor, Toronto, Ontario, M5T 3M6, Canada

UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organisation, Avenue Appia 20, 1211, Geneva, Switzerland

Ӧzge Tunçalp

McMaster Health Forum, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada

Michael G. Wilson

Department of Health Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada

Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada

Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1T8, Canada

Wasifa Zarin & Andrea C. Tricco

Epidemiology Division and Institute for Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St, Room 500, Toronto, Ontario, M5T 3M7, Canada

Andrea C. Tricco

Queen’s Collaboration for Health Care Quality Joanna Briggs Institute Centre of Excellence, School of Nursing, Queen’s University, 99 University Ave, Kingston, Ontario, K7L 3N6, Canada

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MDJP, CM, HC, CMG, SH, TH, EVL, EL, KKO, OT, MGW, WZ and AT all made substantial contributions to the conception, design and drafting of the work. MDJP and CM prepared the final version of the manuscript. All authors reviewed and approved the final version of the manuscript.

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Peters, M.D.J., Marnie, C., Colquhoun, H. et al. Scoping reviews: reinforcing and advancing the methodology and application. Syst Rev 10 , 263 (2021). https://doi.org/10.1186/s13643-021-01821-3

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Advancing scoping study methodology: a web-based survey and consultation of perceptions on terminology, definition and methodological steps

• Kelly K. O’Brien 1 , 2 , 3 ,
• Heather Colquhoun 3 , 4 ,
• Danielle Levac 5 ,
• Larry Baxter 6 ,
• Andrea C. Tricco 7 ,
• Sharon Straus 7 ,
• Lisa Wickerson 3 , 8 ,
• Ayesha Nayar 1 ,
• David Moher 9 , 10 &
• Lisa O’Malley 11  

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Scoping studies (or reviews) are a method used to comprehensively map evidence across a range of study designs in an area, with the aim of informing future research practice, programs and policy. However, no universal agreement exists on terminology, definition or methodological steps. Our aim was to understand the experiences of, and considerations for conducting scoping studies from the perspective of academic and community partners. Primary objectives were to 1) describe experiences conducting scoping studies including strengths and challenges; and 2) describe perspectives on terminology, definition, and methodological steps.

We conducted a cross-sectional web-based survey with clinicians, educators, researchers, knowledge users, representatives from community-based organizations, graduate students, and policy stakeholders with experience and/or interest in conducting scoping studies to gain an understanding of experiences and perspectives on the conduct and reporting of scoping studies. We administered an electronic self-reported questionnaire comprised of 22 items related to experiences with scoping studies, strengths and challenges, opinions on terminology, and methodological steps. We analyzed questionnaire data using descriptive statistics and content analytical techniques. Survey results were discussed during a multi-stakeholder consultation to identify key considerations in the conduct and reporting of scoping studies.

Of the 83 invitations, 54 individuals (65 %) completed the scoping questionnaire, and 48 (58 %) attended the scoping study meeting from Canada, the United Kingdom and United States. Many scoping study strengths were dually identified as challenges including breadth of scope, and iterative process. No consensus on terminology emerged, however key defining features that comprised a working definition of scoping studies included the exploratory mapping of literature in a field; iterative process, inclusion of grey literature; no quality assessment of included studies, and an optional consultation phase. We offer considerations for the conduct and reporting of scoping studies for researchers, clinicians and knowledge users engaging in this methodology.

Conclusions

Lack of consensus on scoping terminology, definition and methodological steps persists. Reasons for this may be attributed to diversity of disciplines adopting this methodology for differing purposes. Further work is needed to establish guidelines on the reporting and methodological quality assessment of scoping studies.

Peer Review reports

Scoping studies are a method to comprehensively synthesize evidence across a range of study designs. Scoping studies (or reviews) may be defined as “exploratory projects that systematically map the literature available on a topic, identifying key concepts, theories, sources of evidence and gaps in the research” [ 1 ]. Researchers may undertake a scoping study to examine the extent, range and nature of research activity, determine the value of undertaking a full systematic review, synthesize and disseminate findings, or identify gaps in existing literature [ 2 ].

Scoping studies have become increasingly popular in health research. The number of scoping studies has increased immensely in the past six years with over half of scoping studies published after 2012, demonstrating their growing potential to inform research agendas, and policy and practice recommendations [ 3 ]. Despite their increasing use and abundant promise for impact on practice, policy and research, no clear criteria exist to guide and evaluate scoping study rigor or reporting. While quality criteria and reporting guidelines exist for other methodological approaches, such as systematic reviews [ 4 – 6 ], and clinical practice guidelines [ 7 ], none have been established for scoping studies. Specific guidelines may enhance the reporting of scoping studies that address features related to breadth of purpose, evidence inclusion, and iterative nature of scoping studies that are unique from other syntheses.

In 2005, Arksey and O’Malley published a six-stage methodological framework for conducting scoping studies: identifying the research question, searching for relevant studies, selecting studies, charting the data, collating, summarizing and reporting the results, and consulting with stakeholders to inform or validate study findings [ 2 ]. In 2010, Levac et al. proposed recommendations, building on each stage of the scoping study framework, highlighting considerations for advancement, application and relevance of scoping studies in health research [ 8 ]. Additional recommendations for scoping study methodology have since been published, demonstrating the ongoing need and interest for advancement of this field [ 9 – 11 ]. Despite the progress to date, there remains no universal agreement on the definition or methodological steps for this approach [ 12 ].

We think it is important to address the methodological quality of this emerging method of evidence synthesis. Establishing a better understanding of current experiences including strengths and challenges of conducting scoping studies and exchanging knowledge and perspectives on terminology and methodological steps among stakeholders who share scoping study expertise is a first step to collaboratively advancing this methodology and providing a foundation for future development of methodological criteria in this field.

Our aim was to understand the experiences of, and considerations for conducting scoping studies from the perspective of clinicians, educators, researchers, graduate students and knowledge users with interest and experience in this methodology. Primary objectives were to 1) describe experiences conducting scoping studies including strengths and challenges, and 2) describe perspectives on terminology, definition and methodological steps. A secondary objective was to 3) discuss considerations in the conduct and reporting of scoping studies. Results will increase awareness of the methodological issues among researchers, clinicians and members of the knowledge user community to help inform future efforts on guidance of scoping study methodology.

We conducted a web-based survey followed by a multi-stakeholder consultation meeting. For the purposes of this work, we used the term ‘scoping study’ throughout in accordance with the original Arksey and O’Malley Framework [ 2 ].

We conducted a cross-sectional web-based survey with a sample of researchers, health professionals, graduate students, policy makers and people living with chronic diseases in Canada, the United States and United Kingdom who possessed expertise and interest in scoping study and knowledge synthesis methodology. Individuals were invited to participate in the survey followed by a 2 day scoping study meeting to gain an understanding of the experiences, including strengths and challenges in conducting scoping studies, and obtain views on terminology, definition and methodological steps inherent to rigorous conduct of scoping studies.

We discussed the survey results in a multi-stakeholder scoping study consultation meeting with clinicians, academics, graduate students, representatives from community-based organizations, community members living with chronic illnesses, and policy and funding stakeholders. The goal of this meeting was to translate research evidence related to scoping study methodology and to establish priorities for the future development of criteria in the conduct and reporting of scoping studies [ 13 ].

We received ethics approval from the University of Toronto Health Sciences Research Ethics Board (Protocol Reference #: 31214).

Participants

We administered a web-based self-administered questionnaire using a modified Dillman approach [ 14 ] and FluidSurveys [ 15 ] to all stakeholders who were invited to attend a 2 day scoping meeting in Toronto, Canada in June 2015.

We used a combination of snowball and purposive sampling to identify approximately 80 researchers, clinicians, graduate students, policy makers, and knowledge users in Canada, the United Kingdom (UK), and the United States. We asked researchers, knowledge users and collaborators for names and email addresses of individuals who they felt possessed an interest and expertise in scoping study methodology. Invited individuals also provided names and contact information of potential additional invitees. This process was critical in order to mobilize diverse participants who represent both developers and users of scoping studies in clinical practice, research and policy.

Given the consultative nature of this work, participants were likely persons whom members of the team previously worked with in an education, research or community-based capacity. In the case of the scoping study survey, completed questionnaires were considered implied consent. In the case of the meeting consultation, consent was based on the individual accepting the invitation and attending the meeting. All participants were invited to provide their name to be acknowledged in the manuscript (see Acknowledgements).

Data collection

Scoping study questionnaire.

We developed a scoping study questionnaire to describe the experiences, and views on scoping study terminology and methodological steps. The questionnaire was developed and pre-tested by four members of the scoping study team. The questionnaire took approximately 20 min to complete and included 22 items across six domains: 1) personal information; 2) experiences conducting scoping studies; 3) strengths and challenges of conducting scoping studies; 4) opinions on scoping study terminology, 5) key considerations for methodological steps and rigor, and 6) additional comments (see Additional file 1 – Scoping Study Questionnaire).

We sent an initial invitation email with an overview of the purpose of the scoping study survey and a link to the questionnaire. We sent three thank you / reminder emails at 1, 2 and 4 weeks after the initial email, thanking those who completed the questionnaire and asking those who had not responded to complete the questionnaire.

Scoping consultation meeting

The 2-day scoping study consultation meeting summarized the state of evidence in the field of scoping studies in the context of knowledge synthesis methodology. Sessions included a combination of structured presentations from speakers, a panel, and large and small group discussion segments to facilitate knowledge transfer and exchange of opinions for establishing a common definition and consensus surrounding methodological steps of scoping studies. Results from the web-based survey pertaining to terminology, definition and methodological steps were presented throughout the meeting followed by opportunities for discussion (see Additional file 2 – Scoping Study Meeting Agenda).

Perspectives on the scoping survey results were documented at the multi-stakeholder consultation through the following methods: 1) participants were asked to submit written considerations about the new and emerging issues in the field of scoping study methodology; 2) participants were encouraged to express their ideas as they pertained to the scoping study survey results related to terminology, definition, and methodological steps during the meeting discussion; and 3) six graduate student rapporteurs documented the discussion throughout the meeting. Responses on the questionnaire included information on the experiences, strengths and challenges of conducting scoping studies (objective #1). Collectively, data pertaining to perspectives and recommendations derived from the survey questionnaire and meeting sources provided the foundation for perspectives on terminology, definition and methodological steps (objective #2) and identifying key considerations for the conduct and reporting of scoping studies (objective #3).

Scoping Study Questionnaire : We calculated the view, participation and completion rates of the online questionnaire [ 16 ]. We analyzed questionnaire data using descriptive statistics using frequencies and percent (categorical items) and median and interquartile ranges (continuous items). We analyzed open ended response items using content analysis [ 17 ]. Three members of the core research team independently read the open-ended questions from the questionnaire to obtain an overall impression of the responses; and met to discuss overall impressions (KKO, HC, DL).

Scoping Study Meeting Rapporteur Notes : We analyzed the rapporteur data capturing the discussion at the scoping study meeting using content analysis [ 17 ]. Two members of the team independently read the rapporteur notes to obtain an overall impression of the reflections; and met to discuss overall impressions (KKO, LW). Rapporteur notes were independently coded by two members of the team (KKO, LW). Coding involved highlighting words or captions that captured key thoughts and concepts related to scoping study methodology. These codes were then clustered into broader categories that were collectively used to supplement the perspectives on terminology, definition and methodological steps and inform the key considerations for conduct and reporting of scoping studies.

The three reviewers for the questionnaire data (KKO, HC, DL) and two reviewers for the rapporteur summaries (KKO and LW) met twice to discuss the findings from the content analysis and six authors (KKO, LW, DL, HC, LB, AN) reviewed a preliminary version of the key considerations for refinement.

Results and discussion

Of the 83 invitations, 63 (76 %; 63/83) viewed the questionnaire, and 54 (65 %; 54/83) completed the questionnaire [ 16 ]. The majority of respondents self-identified as researchers, coordinators, or managers (54 %), followed by graduate students (24 %), knowledge translation brokers (7 %), educators (4 %), community members (4 %), clinicians (2 %), policy makers (2 %), librarians (2 %), and consultants (2 %). Most respondents were from Canada (92 %; n  = 50), with two participants from the UK (4 %) and two from the United States (4 %).

The scoping meeting was attended by 48 participants comprised of researchers (42 %; 20/48), graduate student trainees (29 %; 14/48), educators (13 %; 6/48), service providers (8 %; 4/48); community members (2 %; 1/48); and other professions (consultant, civil society representative and information specialist) (6 %; 3/48). The majority of meeting participants were affiliated with universities or academic institutions (58 %; 28/48), followed by community-based, not-for-profit, knowledge broker/translation, and government organizations (23 %; 11/48), research organizations (13 %; 6/48), and hospitals (6 %; 3/48). Most participants were from Canada (94 %; n  = 45), with two from the United States (4 %), and one from the UK (2 %). Given our recruitment strategy was primarily through snowball sampling, participants were knowledgeable or had an interest in the field of scoping studies.

We report the findings as derived from the scoping study questionnaire related to experiences, strengths and challenges of conducting scoping studies (objective #1), followed by collective interpretations from the survey questionnaire and meeting consultation as they relate to terminology, definition and methodological steps (objective #2). We then reflect on key considerations that emerged from the scoping questionnaire and meeting consultation for moving forward (objective #3).

Experiences, strengths and challenges of conducting scoping studies

Experience with scoping studies.

The majority of questionnaire respondents (85 %) had experience engaging in a scoping study with most (87 %) having completed at least one scoping study and almost half having had a scoping study published or in press in a peer-reviewed journal (46 %; 25/54) (Table  1 ). Roles ranged from conceptualizing and refining the research question, oversight, conducting literature searches / reviews, scanning titles and abstracts to determine study inclusion, data extraction, synthesizing the evidence, writing-up, and disseminating findings. Most respondents engaged in scoping studies to examine the extent, range, nature of research activity (91 %), to map a body of evidence, and to identify gaps in the field; which was similarly documented as common purposes for conducting scoping studies [ 11 ] (Table  1 ).

Of the 46 respondents (85 %) who were involved in a scoping study, 19 (41 %) had engaged in a stakeholder consultation, 7 (37 %) of which went through Research Ethics Board (REB) review for the process. Reasons for pursuing REB review were because investigators intended to publish results and/or conducted interviews with ‘experts’. Respondents chose not go through REB review when the scoping study was conducted by a community organization, when there was no formal REB process available, when respondents did not plan to publish in an academic journal, when the scoping study was done to inform a systematic review, or the consultation involved stakeholders as part of a steering committee who provided feedback throughout the study. Finally, the majority of participants utilized a framework opposed to only half of investigators in a previous review suggesting there is increasing appetite for adopting a more rigorous approach to this methodology [ 11 ].

Strengths and challenges of scoping studies

Many scoping study strengths were dually identified as challenges (Fig.  1 ). Respondents described the strengths of scoping studies in relation to their ability to provide an ‘ overview of the state of evidence in a field’ their ‘ breadth’ , ‘ broad scope’ and ‘ tool for mapping broad and diverse topics’ to inform future work. Strengths associated with scoping study methodology included their flexibility , inclusion of published and unpublished (grey) literature, inclusion of literature with a wide range of study designs and methodologies, and the potential to combine qualitative and quantitative synthesis approaches. Respondents highlighted the systematic process (replicable, transparent, rigorous) that provides the ability to explore and synthesize evidence on a newly emerging topic (or topic with little published evidence), using an approach that is ‘ not as rigid as systematic reviews’ . Additional strengths included the ability for scoping studies to focus on the state of research activity rather than evaluate the quality of existing literature, the ability to assist policy makers to make evidence-informed decisions, and engagement of stakeholders with expertise in a given content area throughout all stages of the process.

Strengths and Challenges of Scoping Studies

Challenges dually identified as strengths of scoping studies included the flexibility, broad scope and inclusion of grey literature which posed challenges when trying to establish boundaries to the study scope (Fig.  1 ). One challenge included the variability in terminology and unclear definitions of concepts of interest, which made identifying the study scope difficult. The flexible and iterative process of defining (and redefining) the research question, search strategy and selection criteria required increased time and resources which was difficult to ascertain at the beginning of the study. The broad scope combined with lack of clarity around boundaries left some with an overwhelming amount of data, posing challenges for feasibility as scoping studies were often time-consuming and took longer than originally anticipated. This could place a scoping study at risk of quickly becoming out of date. Some respondents expressed challenges with the utility of a final product or outcome that was sometimes uncertain at the outset of the study: “Sometimes it feels like a lot of work just to identify gaps or determine that more research is needed.”

Respondents expressed challenges with the lack of detailed steps, guidance, standards, or methodology (particularly if and how to synthesize data from selected studies). They described the need for more clarification about the need and steps associated with the consultation phase. Some described difficulty finding unpublished (or grey) forms of evidence, synthesizing evidence from diverse sources with different types of data, diversity of reviewers or investigators involved, and lack of clarity of how to conduct the synthesis (or analysis) leaving some with an overwhelming amount of data if the scope was broad; and the lack of quality appraisal that resulted in the need for caution in interpretation. Some described challenges with the feasibility conducting the stakeholder consultation. Finally, respondents described challenges of reporting results succinctly, and the difficulty publishing scoping studies with limitations in journal word counts.

Scoping terminology

The majority of respondents preferred the term ‘scoping review’ (68 %) over ‘scoping study’ (11 %) with remaining respondents unsure or having no opinion suggesting either term could be appropriate, depending on the study (20 %) (Table  2 ).

Respondents who preferred the term ‘scoping review’ tended to focus on the literature review component of the methodology stating ‘review’ is “ a more accurate description ”, “ consistent with methods of evidence synthesis such as systematic reviews and meta-analysis methods” . As one respondent stated:

“the term “review” aligns with the purpose of the research….to review what was published in the literature, and to do so in a somewhat systematic way. Although it technically is a “study”, calling it a “review” seems to be more precise in my mind.”

Respondents who preferred ‘scoping study’ did so because they “ take into account the analysis (thematic) component which differs from the mere summary or synthesis in other types of reviews” . Another participant stated his/her preference in relation to the analytical difference between scoping studies and other types of knowledge syntheses:

“Scoping studies have distinct goals and thus should be viewed as distinct entities and not as “less than” systematic reviews…. the intent is not only to review the literature but to conceptualize it in a manner that speaks to the research question. I do not feel that the term ‘review’ covers the extent of analytic work of this type of study.”

Others felt that the term ‘scoping study’ provided clear language that helps distinguish them from ‘scoping reviews’ that have become a “ catch-all term for everything that is not a systematic review” . Finally, scoping study terminology was preferred by those who felt the term ‘study’ encompassed the entire methodology, the literature (or evidence) review phase as well as the consultation phase. It was also acknowledged as the term coined by Arksey and O’Malley, the developers of the original Scoping Study Framework.

Defining features of scoping studies

Respondents described defining features of scoping studies, many of which were similar to strengths of the methodology (Table  1 ). Participants described the distinction of scoping studies from other forms of knowledge syntheses such as literature reviews, systematic or rapid reviews: “ [scoping studies] are not as rigorous as systematic reviews but more distinctive in methodology” and are “less likely to be strongly influenced by opinion than a traditional literature review”.

Others struggled to distinguish scoping studies from other forms of syntheses as one participant stated:

“This is challenging to distinguish. In many aspects scoping reviews are similar to systematic reviews in methodology with the capture of the broad research question, broad eligibility criteria, no quality assessment and consultation exercise.”

Given the similarities in comprehensiveness and systematic nature, “the difference in method is not as great as some might think”. Similarly another participant did not perceive there to be distinctions between scoping studies and other syntheses:

“I do not think that there is anything inherently distinct about scoping study methodology…I think that the ‘scoping study phenomenon’ is the product of a methodological title being applied widely and loosely for reasons that are completely logical given the current context of health sciences research.”

Overall, participants described similarities between scoping and systematic reviews in relation to transparency, rigor, and systematic nature, whereas the distinction between scoping and literature reviews were easier to distinguish with scoping studies taking on a more systematic and rigorous nature of methodology.

Methodological steps

The majority of respondents to the scoping questionnaire (90 %) agreed that scoping studies should involve grey literature, and 31 % (16/54) felt that quality assessments of individual included studies should become a part of scoping methodology. Some respondents felt that quality assessment depends on the nature of the research question; for example if a question pertained to effectiveness of an intervention then quality assessment may be critical opposed to the exploration or description of an emerging topic where there may be less formulated evidence in a field.

Perspectives on terminology, definition, and methodological steps

The following results include collective interpretations of the survey results from the meeting consultation as they relate to terminology, definition and methodological steps.

Terminology

Despite our intention, no consensus was achieved related to scoping terminology. Two opposing views appeared to emerge from the meeting: individuals who align scoping reviews (note the terminology) with other types of systematic reviews, and those who view scoping studies as distinct from other reviews. This may explain the lack of consensus surrounding terminology, methodological steps and positivist versus constructivist approaches (associated with reviews versus studies, respectively) to scoping the field of evidence. Others felt the distinction between ‘study’ over ‘review’ was attributed to the higher analytical level of synthesis of data from existing evidence (rather than reporting frequencies of literature characteristics) as well as the consultation phase that requires primary data collection and qualitative approaches to analysis, which results in a new outcome or product that is relevant and meaningful to the field; examples include a framework of existing evidence, or recommendations for future research priorities.

While the majority of questionnaire respondents (68 %) preferred the term scoping review (over study), the meeting provided insight to the historical development of the Scoping Study Framework from the perspective of Arksey and O’Malley. The preference for scoping review seemed to emerge from the methodological steps referencing review of the literature, and feeling that ‘scoping review’ provided more legitimacy and rigor if considered in the same classification of systematic reviews, which have clear established steps and reporting criteria [ 24 ]. However, the term ‘scoping study’ was intentionally chosen to distance itself from the ‘systematic review’ specifically aimed at determining clinical effectiveness of an intervention, to broaden awareness and inclusion of other types of evidence beyond the randomized controlled trial which may be traditionally favored in systematic reviews [ 13 ]. Scoping studies are intended to map a field and expose gaps in evidence. Developers borrowed elements from systematic reviews such as scoping studies as rigorous, systematic, replicable, and transparent while adding elements such as the iterative or flexible nature of the steps, lack of quality appraisal and addition of the consultation phase. Nevertheless, results suggest scoping studies may have evolved where researchers view them as a form of knowledge synthesis, hence adopting the term ‘review’. Overall, the way in which we distinguish scoping studies from other forms of reviews within the broader context of syntheses will be important for moving forward.

Challenges adopting universal terminology and a definition may be a reflection of the complex and diverse reasons in which someone may adopt scoping methodology, the diversity of research questions which this methodology may address (i.e. Arksey and O’Malley discuss four possible purposes alone), and the uptake across diverse disciplines using the methodology.

Another challenge distinguishing scoping studies from scoping reviews may be attributed to the systematic nature which both approaches adopt. Most survey respondents believed scoping studies (and reviews) are carried out systematically and it is the systematic characteristic that differentiates scoping studies (or reviews) from literature reviews. However, both terms (study and review) affiliate with similar characteristics with respect to their systematic, comprehensive and transparent nature, which may lead to difficulty in establishing how scoping studies are distinguished from other types of reviews. Peters et al. expressed the importance of distinguishing between scoping reviews and ‘comprehensive’ systematic reviews that also rely on synthesizing evidence from different study designs [ 25 ]: ‘While in a scoping review the goal is to determine what kind of evidence is available on the topic and to represent this evidence by mapping or charting the data, comprehensive systematic reviews are designed to answer a series of related but still very specific questions’ (Page 8) [ 25 ]. Scoping studies involve mapping the evidence describing the quantity, design and characteristics in a field opposed to systematic reviews which tend to address a specific narrowly defined research question [ 23 ]. This further highlights the importance of choosing the synthesis approach (and terminology) that best addresses the original research question. For instance, scoping studies may be better suited to exploratory questions in emerging fields that involve complex multi-factorial interventions with less high level randomized controlled trial evidence (e.g. rehabilitation), or areas with an abundance of grey but relevant literature that has not traditionally been taken up in a given field (e.g. policy). For example, scoping studies have been used to explore the emerging field of HIV and aging [ 26 ]. Authors characterized the literature describing the impact of aging on the health of older adults living with HIV (e.g. types of study design, participants, interventions (if applicable), health care domains addressed) and provided recommendations for future HIV and aging research [ 26 ].

Meeting participants generally agreed on a working definition of scoping studies as proposed by Colquhoun et al. [ 12 ] adapted to: ‘ a scoping study or scoping review is a form of knowledge synthesis that addresses an exploratory research question aimed at mapping key concepts, types of evidence, and gaps in research related to an emerging area or field by systematically and iteratively searching, selecting, summarizing and potentially synthesizing existing knowledge .’

Debate emerged over the extent to which data are summarized or synthesized in scoping studies, whether synthesis is a defining characteristic of scoping studies and whether this makes it distinct from a literature review. For instance, the step of ‘collating the data’ could span the spectrum of pure counting of characteristics (descriptive) to a more analytical (thematic or content analysis) for variables of interest such as characteristics of interventions, outcomes, and authors conclusions. Debate also ensued over whether scoping studies should always yield recommendations for practice and policy, which require a higher level of synthesis and interpretation, and whether recommendations should only be developed after the formal consultation phase.

Overall, results from the survey and multi-stakeholder consultation provided rich insight into the views and perspectives of scoping terminology, definition and methodological steps providing further insight into why a lack of consensus may exist. The diversity of fields increasingly adopting this methodology may offer some explanation to the challenges seen to date in adopting a universal term and definition. Nevertheless, for this methodology to maintain the rigor which it aspires to achieve and sustain, it is critical we consider adopting clear and consistent language that may be transferrable across disciplines.

Overall, meeting participants viewed scoping studies as systematic, rigorous and transparent, while allowing for flexibility of process. The following features emerged as distinct characteristics for each of the methodological steps: 1) research question and scoping purpose (exploratory, mapping, breadth); 2) search strategy and study selection (iterative, inclusive of grey literature and diverse study designs), 3) charting collating and summarizing (involves no quality assessment of included studies, may be iterative, synthesis could range from descriptive (counting characteristics of studies) to analytical (syntheses of qualitative and quantitative data involving thematic or content analysis) and 4) consultation phase conducted after the literature review (emerging from the field of qualitative research that involves consultation with knowledge users and community members to address the research question; an essential form of knowledge transfer and exchange).

While ongoing consultation may occur in other types of studies or reviews (providing expertise, context and interpretation), the consultation phase in scoping studies was viewed as a formalized and distinct phase involving key informants and/or stakeholders with expertise in the field of inquiry. The consultation phase in scoping studies, if undertaken, requires formal recruitment, data collection, qualitative approaches to analysis and interpretation, and ethics board review. Consultation goes beyond integrated or end-of-study knowledge translation and exchange and involves acquiring new information, enabling investigators to formally present findings from the literature synthesis, obtaining further experiential evidence and perspectives related to the scope of inquiry, and offering interpretations and considerations for the broader field. These characteristics provide a foundation from which to support our above proposed scoping study definition and will help to inform the development of future reporting guidelines.

Key considerations in scoping study methodology

To our knowledge this is the first study to explore experiences and opinions on scoping study methodology from the perspectives of researchers, clinicians, community members, representatives from community-based organizations, and policy stakeholders with expertise and/or interest in this methodology. This work directly builds on earlier work in an attempt to offer considerations related to terminology, definition and guidance on the methodological steps and rigor for the conduct and reporting of scoping studies [ 8 , 9 , 11 , 12 ].

We will now discuss key considerations for engaging in scoping study methodology that emerged from the survey and multi-stakeholder consultation with researchers, clinicians, knowledge users and policy stakeholders.

Ongoing debate of scoping terminology, definition, and purpose: Respondents expressed the need to develop clarity and consensus on terminology, definition, and purpose of conducting a scoping study. This will help to indicate when a scoping study is appropriate (and when it is not), and provide a foundation for developing detailed descriptions of each methodological step in conducting and reporting guidance for scoping studies. In the future we might consider whether clarity around the conceptual meaning of the terms ‘scoping study’ versus ‘scoping review’ may help to distinguish where this methodology lies on the spectrum of knowledge syntheses. Scoping studies also may be referred to either a map or syntheses, depending on whether they describe the characteristics versus synthesize the literature [ 27 ]. We did not specifically aim to determine how scoping study definitions and methodologies differ or align with other types of syntheses. This is an important focus of future work. Distinguishing ways in which scoping studies (or reviews) differ from other review methodologies for key dimensions including aims and approaches, structure and components; and breadth and depth, provides a strategy for clarifying the definition and purpose of this methodology [ 28 ].

Clarity of concept of interest and methodological steps : Clearly defining the concept of interest can help to establish boundaries for the scope of inquiry, search strategy and inform the study selection process. Specific steps respondents felt required more clarity and instruction included i) how to engage stakeholders throughout the process, ii) clarity around the consultation phase, iii) more detail on stage five of collating, summarizing and reporting the results, specifically how to go about the synthesis and reporting of grey literature, and how to synthesize, and report a combination of quantitative and qualitative synthesis techniques, and iv) adding a methodological step specific to knowledge translation of scoping study results. Piloting the process for study selection and data extraction can help to ensure universal understanding of the construct of interest, study selection criteria, and characteristics of interest for extraction among members of the team [ 8 ]. Recently published guidelines provide detailed steps on how to define these concepts in a study and how they can help to inform the selection criteria and search strategy [ 25 , 29 ]. Further insight is needed for ways to optimally present study findings to best represent the ‘mapping of evidence’ (e.g. framework, tables, and figures) within the context of journal requirements for publication.

Consultation phase: Respondents articulated the need to consider the consultation phase as distinct but complementary to ongoing consultation throughout the scoping process. The integrated consultative approach often is informal and does not require formal forms of data collection or analysis; the stakeholder is a member of the scoping team. Alternatively, consultation is a formal stage of the Arksey and O’Malley Framework whereby experts and key informants are formally consulted on the results of the literature review and provide further insight into experiential evidence, interpret what is found in the literature (strengths and gaps), and provide recommendations for moving forward [ 2 ]. The consultation phase involves sharing findings from the literature review and gaining additional expertise or perspectives on the construct of interest. In most cases the consultation phase will require a formal phase of recruitment and data collection requiring REB review. While increasing time and complexity, the consultation phase has the potential to enhance the quality and relevance of findings to the field [ 8 ].

Methodological quality assessment. Absence of methodological quality assessment was considered a distinct feature of scoping studies as the aim of this approach is to map the evidence produced in a given field rather than seeking out the best available evidence to answer a question related to policy and practice [ 25 ]. However, some recommend quality assessment to determine study inclusion [ 9 ]. If the lack of quality assessment is a defining feature of scoping studies, does introducing this component by nature no longer define it as a scoping study? Participants in this study felt that absence of methodological quality assessment as a defining feature of scoping studies requires further discussion. Methodological quality may be of value in certain circumstances depending on the research question, specifically if it relates to determining the impact or effect of an intervention or program. In these instances, a systematic review may be more appropriate. Overall, the increasing number of types of knowledge syntheses can result in a lack of clarity when choosing (or not choosing) to undertake a scoping study. The research question, the context of the field, and the type and level of evidence available are important considerations for choosing a scoping study over an alternate form of knowledge synthesis.

These considerations pose further inquiry and examination in order to move the field forward with clarity and consensus surrounding terminology, definition and methodological steps. Strategies to enhance methodological rigour that emerged from this work similarly reflect those documented in the literature such as clearly justifying the use of scoping study methodology over other forms of knowledge syntheses, and articulating a clear and focused scoping purpose which directly links to the research question and study objectives [ 8 , 25 , 29 ]. In the absence of clear consensus, we recommend continuing to follow the steps as outlined in the Scoping Study Framework by Arksey and O’Malley [ 2 ] and supplemented by Levac et al. [ 8 ] and Daudt and colleagues [ 9 ], while considering newly published recommendations on the methodological protocol of conducting and reporting scoping studies [ 25 , 29 ].

Considerations for interpretation

This consultation was built on the foundational work by Arksey and O’Malley who established the original Scoping Study Framework [ 2 ]. Using a combination of survey methods followed by a multi-stakeholder consultation enabled developers and users of scoping studies to reflect and consider views of scoping study terminology, definition and steps after participants at a 2-day meeting which included a historical background and overview from Lisa O’Malley (LOM). Four authors are rehabilitation professionals who work in areas of complex chronic disease, hence people living with chronic disease were key knowledge users involved throughout this work. These authors developed an interest in scoping study methodology after each completed a scoping study in separate areas of rehabilitation and experienced similar challenges implementing the methodology. Scoping studies offered a method to comprehensively synthesize evidence across a range of study designs where a paucity of randomized controlled trials can exists in the field of rehabilitation and chronic illness.

Our approach was not without limitations. First, this is a small sample primarily from Ontario, Canada with a diversity of expertise in scoping studies; hence the perspectives are not fully representative of experts and people conducting scoping reviews nationally or internationally. Nevertheless, participants represented a range of perspectives from those involved in developing the original Framework, other reporting guidelines, and participating in studies offering diverse perspectives and experiences form which to draw these considerations. Future work may consider expanding representation from other countries where the role for scoping studies is emerging. Lastly, the paper provides broad considerations for engaging in scoping study methodology. Next steps will be for researchers, clinicians and knowledge users to conduct a broader consultation to further advance the terminology and definition, develop a methods manual, reporting guidelines and methodological quality criteria of this budding field.

Overall we provide an overview of experiences, views on terminology, definition, methodological steps, and key considerations in the conduct and reporting of scoping studies. This work provides a foundation for researchers, clinicians and knowledge users to consider when thinking about using scoping study methodology. Results reflect the current state of the scoping study field as it evolves and is increasingly adopted by different disciplines. While a challenging time, it also reflects an exciting time and opportunities in which this methodology is being adopted by various disciplines. Further work is needed to clarify terminology and definitions in order to formulate methodological quality criteria for conducting and reporting the emerging field of scoping studies.

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Acknowledgements

We acknowledge all individuals who participated in the scoping study questionnaire and multi-stakeholder consultation. Some of who agreed to be acknowledged in this work include (in alphabetical order): Samantha Cheuk (McMaster University), Shaun Cleaver (University of Toronto), Lynn Cockburn (University of Toronto), Simon French (Queen’s University), Stephen J. Gentles (McMaster University), Michele Hamm (University of Alberta), Jill Hayden (Dalhousie University), Sander L. Hitzig (York University), Tanya Horsley (Royal College of Physicians and Surgeons of Canada), Emma Irvin (Institute for Work & Health), Anna Lambrinos (Health Quality Ontario), John N. Lavis (McMaster University), Erin Lillie (St. Michael’s Hospital), Zack Marshall (Memorial University), Michelle Mujoomdar (Canadian Agency for Drugs and Technologies in Health), Kate Murzin (Canadian Working Group on HIV and Rehabilitation), Stephanie Nixon (University of Toronto), Gillian Parker (University of York), Mai Pham (University of Guelph), Louise Rose (University of Toronto), Sergio Rueda (Centre for Addiction and Mental Health), Anne Sales (University of Michigan), Enid Selkirk (McMaster University), Nancy Sikich (Health Quality Ontario), Henry T. Stelfox (University of Calgary), Michelle Swab (Memorial University), Stephen Tattle (Canadian Working Group on HIV and Rehabilitation), Aliki Thomas (McGill University), Anne-Marie Tynan (St. Michael’s Hospital), Saipriya Vajravelu (McMaster University), Dwayne Van Eerd (Institute for Work & Health), Julie Vaughan-Graham (University of Toronto), Lisa Waddell (Public Health Agency of Canada), Tammy C. Yates (Canadian Working Group on HIV and Rehabilitation), and Wasifa Zarin (St. Michael’s Hospital).   

We acknowledge the rapporteurs from the Rehabilitation Sciences Institute (RSI) who were involved in documenting the discussion from the scoping study meeting including: Christie Welch, Lisa Wickerson, Katherine Stewart, Katie E. Mah, Alicia Hilderley and Emily S. Ho.

We acknowledge the principal knowledge users and community collaborators in this work including the Canadian Working Group on HIV and Rehabilitation (Tammy C. Yates, Stephen Tattle, Kate Murzin). We especially thank Erin Lillie and Wasifa Zarin, St. Michael’s Hospital for their involvement in the planning and implementation of the scoping study meeting, and Jennifer Deevy for her assistance in planning the meeting. We thank the Li Ka Shing Knowledge Institute of St. Michael’s Hospital for the provision of meeting space.

This work was funded by the Canadian Institutes of Health Research (CIHR) (Grant Number: MAG-133817). David Moher (DM) is funded by a University Research Chair. Kelly K. O’Brien (KKO) is supported by a CIHR New Investigator Award and Andrea Tricco (ACT) is supported by a CIHR Drug Safety and Effectiveness Network New Investigator Award in Knowledge Synthesis.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are not publicly available in accordance with our study protocol that was approved by the University of Toronto, Research Ethics Board. Data may be available upon reasonable request by contacting the corresponding author.

Authors’ contributions

KKO, HC, DL and LB led the conceptualization, planning and implementation of the scoping study survey and meeting which was further supported through ongoing consultation with ACT, SS, and AN. DM and LOM were collaborators and keynote speakers at the scoping study consultation meeting. KKO led the analysis which was refined by HC, DL, LB, ACT, SS, LW, and AN. LW and KKO conducted the content analysis from the scoping study meeting data. KKO drafted the original manuscript. DL, LB, HC, AN, SS, ACT, LW, DM, and LOM, reviewed and provided revisions to earlier versions of the manuscript. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

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Not applicable.

Ethics approval and consent to participate

This study received ethics approval from the University of Toronto Health Sciences Research Ethics Board (REB) (Protocol Reference #: 31214). For the scoping study survey, completed questionnaires were considered implied consent. For the meeting consultation, consent was based on the individual accepting the invitation and attending the meeting.

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Scoping Study Questionnaire. (PDF 159 kb)

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O’Brien, K.K., Colquhoun, H., Levac, D. et al. Advancing scoping study methodology: a web-based survey and consultation of perceptions on terminology, definition and methodological steps. BMC Health Serv Res 16 , 305 (2016). https://doi.org/10.1186/s12913-016-1579-z

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Received : 07 January 2016

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DOI : https://doi.org/10.1186/s12913-016-1579-z

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Updated methodological guidance for the conduct of scoping reviews

Peters, Micah D.J. 1,2,3 ; Marnie, Casey 1 ; Tricco, Andrea C. 4,5,6 ; Pollock, Danielle 7 ; Munn, Zachary 7 ; Alexander, Lyndsay 8,9 ; McInerney, Patricia 10,11 ; Godfrey, Christina M. 6,12 ; Khalil, Hanan 13,14

1 Rosemary Bryant AO Research Centre, UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia

2 School of Nursing, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia

3 The Centre for Evidence-based Practice South Australia (CEPSA): A JBI Centre of Excellence Adelaide, SA, Australia

4 Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada

5 Epidemiology Division and Institute of Health Management, Policy, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

6 Queen's Collaboration for Health Care Quality: A JBI Centre of Excellence Kingston, ON, Canada

7 JBI, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia

8 School of Health Sciences, Robert Gordon University, Aberdeen, UK

9 The Scottish Centre for Evidence-based Multi-professional Practice: A JBI Centre of Excellence Aberdeen, Scotland

10 Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, GT, South Africa

11 The Wits-JBI Centre for Evidence-Based Practice: A JBI Affiliated Group Johannesburg, GT, South Africa

12 School of Nursing, Queen's University, Kingston, ON, Canada

13 School of Psychology and Public Health, Department of Public Health, La Trobe University, Melbourne, Vic, Australia

14 The Queensland Centre of Evidence Based Nursing and Midwifery: A JBI Centre of Excellence, Brisbane, QLD, Australia

Correspondence: Micah D.J. Peters, [email protected]

ACT is a member of the JBI Evidence Synthesis Editorial Advisory Board. CMG is an associate editor of JBI Evidence Synthesis . Neither author was involved in the editorial processing of this manuscript. The other authors declare no conflict of interest.

Objective: 

The objective of this paper is to describe the updated methodological guidance for conducting a JBI scoping review, with a focus on new updates to the approach and development of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (the PRISMA-ScR).

Introduction: 

Scoping reviews are an increasingly common approach to informing decision-making and research based on the identification and examination of the literature on a given topic or issue. Scoping reviews draw on evidence from any research methodology and may also include evidence from non-research sources, such as policy. In this manner, scoping reviews provide a comprehensive overview to address broader review questions than traditionally more specific systematic reviews of effectiveness or qualitative evidence. The increasing popularity of scoping reviews has been accompanied by the development of a reporting guideline: the PRISMA-ScR. In 2014, the JBI Scoping Review Methodology Group developed guidance for scoping reviews that received minor updates in 2017 and was most recently updated in 2020. The updates reflect ongoing and substantial developments in approaches to scoping review conduct and reporting. As such, the JBI Scoping Review Methodology Group recognized the need to revise the guidance to align with the current state of knowledge and reporting standards in evidence synthesis.

Methods: 

Between 2015 and 2020, the JBI Scoping Review Methodology Group expanded its membership; extensively reviewed the literature; engaged via annual face-to-face meetings, regular teleconferences, and email correspondence; sought advice from methodological experts; facilitated workshops; and presented at scientific conferences. This process led to updated guidance for scoping reviews published in the JBI Manual for Evidence Synthesis . The updated chapter was endorsed by JBI's International Scientific Committee in 2020.

Results: 

The updated JBI guidance for scoping reviews includes additional guidance on several methodological issues, such as when a scoping review is (or is not) appropriate, and how to extract, analyze, and present results, and provides clarification for implications for practice and research. Furthermore, it is aligned with the PRISMA-ScR to ensure consistent reporting.

Conclusions: 

The latest JBI guidance for scoping reviews provides up-to-date guidance that can be used by authors when conducting a scoping review. Furthermore, it aligns with the PRISMA-ScR, which can be used to report the conduct of a scoping review. A series of ongoing and future methodological projects identified by the JBI Scoping Review Methodology Group to further refine the methodology are planned.

Introduction

Along with the increased production of primary research, the conduct and publication of evidence syntheses (reviews) has also increased and evolved over time. 1 The need to synthesize diverse types of evidence underpins the design and evolution of new approaches intended to rigorously identify and synthesize data to answer a range of pressing questions for end users in policy, research, and practice. In 2009, Grant and Booth identified 14 different types of reviews. 2 By 2016, this variety had increased to 25 evidence synthesis methods, 3 and by 2019, this reached 48 review types. 4

The scoping review, also sometimes referred to as “mapping review” or “scoping study,” is one approach to evidence synthesis that is increasingly being utilized internationally. 5-8 Although it is unclear when the first scoping review was conducted, the first methodological guide for these reviews was published by Arksey and O’Malley in 2005. 9 Arksey and O’Malley observed and reflected on the early appearance of scoping studies in the literature, noted similarities and a lack of uniformity, and proposed a seminal framework for their conduct. 9 They also noted the necessity for others to continue their work to further improve guidance for authors to conduct and report scoping reviews. This has occurred over the years and included extensions proposed by Levac and colleagues. 10

In 2014, the JBI International Scientific Committee convened a Scoping Review Methodology Group from members of JBI and the JBI Collaboration (JBIC). 11 This group extensively reviewed the literature; engaged via annual face-to-face meetings, regular teleconferences, and email correspondence; sought advice from methodological experts; facilitated workshops; and presented at scientific conferences. This process led to the publication of JBI's first chapter and peer-reviewed paper describing guidance for authors of scoping reviews. 12,13 As with guidance for the more traditional systematic reviews for which JBI is known, the guidance for scoping reviews explicitly addressed the need for scoping reviews to be rigorously conducted, transparent, and trustworthy. The chapter underwent minor updates in 2017, 14 and overall, the JBI guidance has since been used and cited by many review groups around the world from a range of disciplines, academic fields, and professional backgrounds. 15 In 2018, the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR) was developed by an international team of experts in scoping reviews and evidence synthesis, 16 including members of the JBI/JBIC working group, to be consistent with JBI's scoping review methodology and to provide reviewers with a reporting checklist for their reviews. 14

This methodological paper provides an overview of scoping review methods and highlights the most recent updates to JBI's guidance for the conduct of scoping reviews, which was recently published in the JBI Manual for Evidence Synthesis . 17 This updated guidance primarily takes into account the launch of the PRISMA-ScR, 16 which is recommended for use in tandem with the latest JBI guidance. The major areas of update include:

• inclusion of the PRISMA-ScR reporting guideline and checklist throughout the chapter;
• advice on when a scoping review is (or is not) appropriate, and how to extract, analyze, and present results;
• updates to many of the examples used throughout the chapter and the use of clearer language to remove ambiguity;
• discussion on the term “systematic” in relation to scoping reviews, and clarifying that the preferred terminology for this evidence synthesis approach is “scoping reviews” (while they still remain systematic);
• updated section on indications for conducting a scoping review;
• further discussion on the role of methodological appraisal in scoping reviews;
• clarification on implications for practice (now called “implications of the findings”);
• expanded background to the chapter.

Additionally, as interest in the methodology has grown, it has come to the authors’ attention that in addition to adding new sections, there were also areas throughout the guidance that required clarification, updates, and modification. Some of these changes were informed by feedback from scoping review authors using the guidance, 15 while others have been identified by group members themselves or by advances in the methodological literature. In light of this evidence, the authors hope an update to the guidance will support improved consistency and rigor in the undertaking and reporting of scoping reviews.

What are scoping reviews and why conduct a scoping review?

According to the Canadian Institutes of Health Research, scoping reviews are “exploratory projects that systematically map the literature available on a topic, identifying key concepts, theories, sources of evidence and gaps in the research.” 18 (p.34) Scoping reviews are conducted for several reasons, with the most common being to explore the breadth or depth of the literature, map and summarize the evidence, inform future research, and identify or address knowledge gaps. 19 Scoping reviews are particularly helpful when the literature is complex and heterogeneous. Scoping reviews can provide useful insight for decision-makers into the nature of a concept and how that concept has been studied in the literature over time. They can be used to develop a research agenda, advance the field, and identify areas for future systematic reviews or other types of evidence synthesis. Decision-makers in particular find that this method of evidence synthesis provides a useful overview of research previously undertaken and reported in the literature, often in regard to the types of programs or interventions that have been examined, informing options for consideration in future research. Indeed, the number of scoping reviews doubled from 2014 to 2017, 19 demonstrating the popularity of this method in the literature.

Need for scoping reviews to remain systematic

Initially, JBI's guidance used the terminology “systematic scoping review.” 12,14,17 This was to signpost the similarities between the JBI's guidance for scoping reviews and the JBI's guidance for other evidence syntheses, including systematic reviews, that focus on rigor, reproducibility, and transparency. In this latest update, the nomenclature has been refined to simply “scoping reviews” to recognize that all types of evidence synthesis should be conducted systematically, as well as to reduce the risk of confusion between different types of review. 19,20 In addition, “scoping review” is the most commonly used term to describe a scoping review, so removing the term “systematic” also improves consistency. 19 The authors argue that all types of evidence synthesis should be systematic and follow methodological guidance.

Choosing between a systematic or scoping review approach

Given the array of evidence synthesis methodologies and review types, it is critical that authors assess their objectives and intentions prior to undertaking any review. This is a particularly pertinent consideration when deciding between a systematic or scoping review, as both maintain particular, but separate, value for given aims or outcomes. Broadly speaking, if the intention of the review is to inform clinical decision-making (eg, determining the feasibility, appropriateness, meaningfulness, or effectiveness of a particular intervention), then a systematic review is more appropriate. 21 Scoping reviews, however, are more appropriate to assess and understand the extent of the knowledge in an emerging field or to identify, map, report, or discuss the characteristics or concepts in that field. For example, Harfield and colleagues’ scoping review identified the characteristics of Indigenous primary health care service delivery models. 22 Subsequently, they were able to develop and describe a new Indigenous Primary Health Care Service Delivery Model that focused on the local cultural values, customs, and beliefs of Indigenous people. 22

The value of scoping reviews to evidence-based health care and practice lies in their ability to incorporate various types of literature that are not limited specifically to research studies. For example, scoping reviews can be useful in developing policy maps. Mapping policy documents and research studies has been previously undertaken by Anderson and colleagues 6 in 2008 and Watson and colleagues 23 in 2011. Both authors used scoping reviews to examine research papers and policy documents to map complex topics.

In general, systematic reviews have more focused research questions than scoping reviews, which are much broader. Furthermore, scoping reviews are exploratory and descriptive in nature, whereas systematic reviews, those with meta-analysis or network meta-analysis, can be explanatory or analytical in nature. 24 An online tool exists to assist authors with selecting between a systematic review and a scoping review. 25 By providing general indication of the objective and topic to be reviewed, a user can generate a recommendation towards the most appropriate method of review. Results of scoping reviews can identify further areas for subsequent research and clarify whether a systematic review can be conducted to address a specific question as a consequence of mapping the literature. In general, the indications for scoping reviews can be summarized as follows 17,21 :

• as a precursor to a systematic review;
• to identify the types of evidence available in a given field;
• to identify and analyze knowledge gaps;
• to clarify key concepts and definitions in the literature;
• to examine how research is conducted on a certain topic or field;
• to identify key characteristics or factors related to a concept.

Although scoping review methodology has evolved, there is still some confusion of terms with other evidence synthesis approaches such as “evidence gap maps.” 4 Evidence gap maps share similarities to scoping reviews in terms of identifying a research question, conducting a systematic search, and providing descriptive analysis 26 ; however, evidence gap maps tend to limit the inclusion of evidence to systematic reviews and primary research studies, but may also include critical appraisal.

Methodological updates

As is characteristic of rigorous evidence synthesis approaches, scoping reviews should be well planned and driven by a protocol. Protocols are important for predefinition of the objective, question(s), and method, and they support transparent and unbiased reporting. The protocol should detail the review's inclusion and exclusion criteria and identify which and how data will be extracted and presented. Deviations from the protocol should be clearly highlighted and explained in the ensuing scoping review. Currently, scoping reviews are not able to be registered with the International Prospective Register of Systematic Reviews (PROSPERO). However, authors conducting a scoping review should consider publishing, registering, or making their protocol available via platforms such as Figshare, Open Science Framework, ResearchGate, Research Square, or similar so that it is freely available. The JBI journal JBI Evidence Synthesis is one avenue for publishing scoping review protocols (and their subsequent reviews) that follow the JBI methodology.

Title and review questions

The title of the protocol and corresponding review should give a clear indication of the topic and identify the manuscript as a scoping review protocol or review. It is also useful to ensure that key elements of the inclusion criteria are reflected in the title to enable easy identification by readers. The “PCC” mnemonic (population, concept, and context) is recommended as a guide to construct a clear and meaningful title and inclusion criteria for a scoping review. Use of the PCC mnemonic clearly identifies the focus and context of a review, further enabling utility for the reader. Specific outcomes, interventions, or phenomena of interest do not need to be stated for a scoping review, although these details might be helpful for some scoping review topics. There should be congruence between the title, review question(s), and inclusion criteria.

What quality-of-life questionnaires are available for pediatric patients following tonsillectomies with or without adenoidectomies for chronic infections or sleep disordered breathing?

What are the ages of the pediatric patients where quality-of-life questionnaires have been or could be used within the sources of evidence identified for the primary review question?

Inclusion criteria

A scoping review's inclusion criteria should be detailed in the protocol and should also provide information regarding the types of sources of evidence that will be considered for inclusion. Because scoping reviews are amenable to the inclusion of all methodologies as well as non-research sources, such as policy documents or websites, the protocol should state which sources will be examined. It is important to note that sources of evidence do not refer to the locations of where evidence will be sought (eg, online databases). These should be stated in the search strategy. The inclusion criteria aid the reader's understanding of the scope of the review and provide a guide for the reviewers themselves to make decisions regarding which sources to include or exclude.

Participants

The inclusion criteria should specify important characteristics of the review's participants (population). This may include age, sex, and other relevant factors appropriate to the review's objective and review question(s). Defining participants per se is not always necessary. For example, a scoping review with the objective of describing the details of research designs used in a specific area of study may not need to detail the types of participants involved in that research.

The scoping review's main concept(s) should be explained. Depending on the objective and question(s), the concept may include details similar to the elements detailed in a traditional systematic review, such as interventions, phenomena of interest, or outcomes. For example, the principal concept of interest in the example questions above is quality-of-life questionnaires used following tonsillectomies. Additional elements of this concept may also be of interest, such as the format (eg, paper or web-based), contents (ie, assessment domains) of the included instruments, and validity and reliability (ie, if and how they have been psychometrically tested). Outcomes may also be a component of a scoping review's concept and should be linked to the objective review question(s). For example, this scoping review could also identify and map any reported outcomes addressed within quality-of-life assessments. In other examples, the concept may relate to definitions (ie, which definitions have been used to define low-value care) or elements of research design (ie, methodological details and conduct).

A scoping review's context will vary depending on the objective and question(s), and may include details regarding geographic location (eg, a particular country or region) and/or specific social, cultural, or sex-based factors. Context may also include setting specifics (eg, acute care, primary health care, the community). The context in the example above has not been stated explicitly (ie, it is “open”) because sources of evidence from any contextual setting would be eligible for inclusion. Specifying the context will aid in refining the scope of the review, such as by focusing only on specific countries or particular health care settings.

Types of evidence sources

A scoping review can include any and all types of literature (eg, primary research studies, systematic reviews, meta-analyses, letters, guidelines, websites, blogs). However, reviewers may wish to impose limits based on the knowledge that particular types of sources would be most useful and appropriate. The example scoping review above sought certain quantitative studies only; qualitative studies, reviews, and conference abstracts were excluded because these were deemed by the reviewers not to be likely to contain relevant information to answer the review questions.

Search strategy

The search strategy for a scoping review should ideally aim to be as comprehensive as possible within the constraints of time and resources in order to identify published and unpublished (ie, gray literature) primary sources of evidence, as well as reviews. Any limitations in terms of the breadth and comprehensiveness of the search strategy should be detailed and justified. A complete search strategy for at least one major database should be included as an appendix to the protocol and in the subsequent review. The input of a research librarian or information scientist can be invaluable in designing and refining the search. McGowan and colleagues 27 developed an evidence-based guideline for Peer Review of Electronic Search Strategies (PRESS) for systematic reviews, health technology assessments, and other evidence syntheses, and recommended the main search be conducted by a librarian and subsequently peer-reviewed by another librarian. It is essential to keep clear and detailed documentation of the search strategy undertaken, including search dates and key terms used, sufficient to enable repetition of repeating searches (if required by other researchers). Other additional sources such as hand searching of specific journals should be detailed, including journal names and years searched. If authors were contacted for additional data, it must be stated in the review. The search for a scoping review may be quite iterative as reviewers become more familiar with the evidence base, additional keywords, and sources, and potentially useful search terms may be discovered and incorporated into the search strategy. If this is the case, it is crucial that the entire search strategy and results are transparent and auditable.

The language of sources of evidence that will be considered in the review must be pre-specified in the protocol. It is recommended that authors do not apply language restrictions to their protocols unless there is reasonable justification, such as feasibility or limitation of resources.

Evidence screening and selection

Study selection must be pre-specified in the protocol and based on the inclusion and exclusion criteria. Study selection starts with a review of both titles and abstracts using the inclusion criteria followed by full-text retrieval of potentially relevant evidence for further review against the inclusion criteria. This process is usually conducted by a minimum of two reviewers, and any disagreements should be resolved by either consensus or with a third reviewer. Description of the study selection process must be presented in both a narrative and flow diagram format as indicated in the PRISMA-ScR statement. 16 Details of excluded sources at full-text review must be appended to the review with reasons for their exclusion. It is recommended that pilot testing of this process be undertaken by the review team to ensure consistency of the approach taken in the study selection process.

Critical appraisal or risk of bias assessment is generally not recommended in scoping reviews because the aim is to map the available evidence rather than provide a synthesized and clinically meaningful answer to a question. For this reason, an assessment of methodological limitations or risk of bias of the evidence included within a scoping review is generally not performed (unless there is a specific requirement due to the nature of the scoping review aim). 11,12,16

Data extraction

Data that are extracted from the evidence sources should align with the objectives and research question of the scoping review. In scoping reviews, the data extraction process may be referred to as “data charting,” although to be consistent with other evidence synthesis approaches, the authors have used the term “data extraction” in the updated guidance. A draft charting table or form should be developed and piloted at the protocol stage to record the key information of the source, such as author, reference, and results or findings relevant to the review question(s). This may be further refined at the review stage and the charting table updated accordingly.

The scoping review protocol should include information about the potential data that could be extracted from the included evidence sources to allow for transparency and clarity. The process of data extraction should involve at least two reviewers to reduce the chance of errors and bias. Careful record keeping should be kept either through a standardized form or table. JBI offers an example of a standardized data extraction form that can be utilized by all authors to minimize potential bias. 17 However, these forms should be individualized to meet the needs of each scoping review. It is recommended that the standardized data extraction form be piloted with two or more members of the team on at least two to three studies prior to use to ensure that all necessary data will be captured appropriately. Data extraction in scoping reviews can be an iterative process, often requiring multiple refinements to be able to best meet the objectives and research question(s) of the scoping review. For example, an initial list of research characteristics may have been noted as important (eg, year of research, location, outcomes). However, once reading several articles, authors may want to list how those outcomes were measured to gain an in-depth understanding of how researchers applied them and arrived at the subsequent results.

Data analysis

An additional section in the updated guidance is a discussion on analyzing data in scoping reviews; this was highlighted as an area where additional information was required. 15 Analysis of the data in scoping reviews should be pre-specified within the protocol to ensure transparency and justification of the chosen approach. In most cases, the intention of a scoping review is not to synthesize the results or outcomes of the included sources. As such, for many scoping reviews, the analysis of the extracted data should not involve anything more than basic descriptive analysis (ie, frequency counts of concepts, populations, or location of studies). These descriptive results can then be mapped in various visual presentations, such as tables or graphs. The purpose of a scoping review and the type of data that emerge in answer to the review question are not the type of evidence that lends itself to a meta-analysis, and little value would be gained in performing such an analysis. It is difficult to envisage a case where further, in-depth quantitative analysis is required in scoping reviews, such as performing a meta-analysis. Qualitative data should also be mostly descriptive, and a synthesis utilizing a thematic or meta-aggregative approach is not within the remit of a scoping review. Descriptive qualitative techniques, such as basic coding of data to particular categories, may be a useful approach in some scoping reviews, particularly when the purpose is to identify or clarify concepts or definitions within a field or to identify key characteristics related to a concept. 22,28,29 In summary, the way data are extracted and analyzed in scoping reviews is largely dependent on the purpose of the review and subject to the authors’ judgment and creativity. The most important consideration regarding extraction and analysis is that the authors are transparent and explicit in the approach they have taken, including providing a rationale for their approach and clearly reporting extracted data and analyses.

Presentation of results

Data presentation approaches should be pre-specified in the protocol stage. This could be further refined in the review stage upon consideration of the contents of the included evidence. The results section of a scoping review could be considered to contain two broad sections, the first of which describes the results of the search strategy and selection process, including a PRISMA flow diagram. The second section provides the key information or results relevant to the objectives or questions for the scoping review.

There are many options for presenting data in scoping reviews. The results of a scoping review may be presented as a map of the data extracted from the included papers in a diagrammatic or tabular form, and/or in a descriptive format that aligns with the objective(s) and scope of the review. The elements of the PCC inclusion criteria may be useful to guide the best format(s) for presenting the results of the review to the audience. Presenting the results in a suitable and detailed format will allow the reviewers to identify gaps in the literature and map the available evidence.

The update of the JBI scoping review methodology was driven by the need to provide further clarification on when a scoping review is appropriate (and when it is not), and how to extract, analyze, and present results, as well as to align with the development of the PRISMA-ScR. This article has provided an overview of methods and up-to-date guidance for authors that align with the PRISMA-ScR to support reporting of scoping reviews. Further initiatives to develop scoping review methodology are planned by the JBI Scoping Review Methodology Group, with current work focused on producing guidance to appraise risk of bias (if required as an optional element of some reviews), an article identifying key challenges and potential solutions to scoping reviews, and a website to support dissemination and access to core scoping review methods. As with all evidence synthesis methodologies, approaches to conducting and reporting scoping reviews will be gradually enhanced and evolve in response to the needs of knowledge users as well as through the experiences and familiarity of authors using current approaches. The JBI Scoping Review Methodology Group will continue to provide authors with guidance and suggestions for improving scoping review conduct and reporting, and hopes that the latest iterations to the JBI methodology are clear, helpful, and informative.

Acknowledgments

The authors acknowledge the support, feedback, and advice they have received on the development of the updated scoping reviews methodology from the JBI Scientific Committee. They also acknowledge and thank previous members of the group for their past contributions.

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Enhancing the scoping study methodology: a large, inter-professional team’s experience with Arksey and O’Malley’s framework

• Helena ML Daudt 1 ,
• Catherine van Mossel 2 &
• Samantha J Scott 3  

BMC Medical Research Methodology volume  13 , Article number:  48 ( 2013 ) Cite this article

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Scoping studies are increasingly common for broadly searching the literature on a specific topic, yet researchers lack an agreed-upon definition of and framework for the methodology. In 2005, Arksey and O’Malley offered a methodological framework for conducting scoping studies. In their subsequent work, Levac et al. responded to Arksey and O’Malley’s call for advances to their framework. Our paper builds on this collective work to further enhance the methodology.

This paper begins with a background on what constitutes a scoping study, followed by a discussion about four primary subjects: (1) the types of questions for which Arksey and O’Malley’s framework is most appropriate, (2) a contribution to the discussion aimed at enhancing the six steps of Arskey and O’Malley’s framework, (3) the strengths and challenges of our experience working with Arksey and O’Malley’s framework as a large, inter-professional team, and (4) lessons learned. Our goal in this paper is to add to the discussion encouraged by Arksey and O’Malley to further enhance this methodology.

Performing a scoping study using Arksey and O’Malley’s framework was a valuable process for our research team even if how it was useful was unexpected. Based on our experience, we recommend researchers be aware of their expectations for how Arksey and O’Malley’s framework might be useful in relation to their research question, and remain flexible to clarify concepts and to revise the research question as the team becomes familiar with the literature. Questions portraying comparisons such as between interventions, programs, or approaches seem to be the most suitable to scoping studies. We also suggest assessing the quality of studies and conducting a trial of the method before fully embarking on the charting process in order to ensure consistency. The benefits of engaging a large, inter-professional team such as ours throughout every stage of Arksey and O’Malley’s framework far exceed the challenges and we recommend researchers consider the value of such a team. The strengths include breadth and depth of knowledge each team member brings to the study and time efficiencies. In our experience, the most significant challenges presented to our team were those related to consensus and resource limitations. Effective communication is key to the success of a large group. We propose that by clarifying the framework, the purposes of scoping studies are attainable and the definition is enriched.

Peer Review reports

Our research team, which is large and comprised of many disciplines, undertook a scoping study to investigate the information needs of people with colorectal cancer. We drew on the methods laid out in a 2005 framework by Arksey and O’Malley [ 1 ] who were among the first scholars to articulate a framework to clarify the usefulness of and methods inherent in a scoping study. They claim an interest in stimulating further discussion on the value of scoping studies and encourage others to further develop the methodology. Since their framework was published, a handful of researchers have taken up their challenge [ 2 – 8 ]. Levac et al. published the most prominent of these in 2010, addressing the framework’s strengths and limitations with the aim to encourage consistent methods across all scoping studies [ 8 ]. After reviewing our own research process and sharing our experiences with this methodology in this paper, we also contribute to the discussion that enhances Arksey and O’Malley’s framework. We offer a unique perspective on this framework because of our collective experience as a large, inter-professional team. We also propose that the definition, purposes, and methodological framework of scoping studies cannot be clarified in isolation but must be amended in tandem. We offer recommendations that, when added to those of other researchers such as Levac et al., generate a strengthened definition and position the purposes as attainable. Interestingly, some of our critiques and suggestions for the development of the methodology mirror those expressed by Levac et al. Since Levac et al’s paper was published while our team was concluding our scoping study; we reached our conclusions independently of their suggestions. The fact that we share some similar conclusions indicates that the collective suggestions from Levac’s team and ours are worth serious consideration for enhancing Arksey and O’Malley’s framework. We also offer some proposals for consideration not yet expressed by others engaged in scoping studies, primarily drawn from our experience as a large, inter-professional team. Our team of twelve people included academic researchers as well as clinical practitioners working in a cancer treatment centre from a range of disciplines and practices, including nutrition, radiation therapy, patient and family clinical counseling, nursing, biology, library and information science, and the social sciences. Each member of our team shared a common interest in colorectal cancer and a desire to improve the quality of care received by people with this diagnosis.

What is a scoping study?

Over the last two decades, scoping studies have become an increasingly common method of searching the literature on a specific topic. There is no one agreed upon definition for scoping studies, but there has been some effort among researchers to seek clarification. Levac et al. confirm this view in their work, pointing to seven recent authoritative scoping sources, each offering a different definition or purpose. In spite of the varying interpretations in this methodology’s definition, and because we used the original definition as laid out by Arksey and O’Malley in our research, we refer to the Arksey and O’Malley definition throughout this paper.

Arskey and O’Malley begin with Mays et al’s definition of scoping studies: “to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available, and can be undertaken as standalone projects in their own right, especially where an area is complex or has not been reviewed comprehensively before” [ 9 ]. The framework they developed serves to expand on this definition by identifying four main reasons for conducting a scoping study: (1) to examine the extent, range and nature of research activity; (2) to determine the value of undertaking a full systematic review; (3) to summarise and disseminate research findings; and (4) to identify research gaps in the existing literature. We identified the first and fourth goals as the most relevant for our own research. Arksey and O’Malley’s framework includes six stages, the sixth being optional: (1) identifying the research question, which is generally broad in nature; (2) identifying relevant studies, a process that is as comprehensive as possible; (3) study selection, with the establishment of inclusion/exclusion criteria, based on familiarity with the literature; (4) charting the data, a stage that includes sifting, charting, and sorting information according to key issues and themes; (5) collating, summarizing, and reporting the results, which provides both a descriptive and numerical summary of the data and a thematic analysis; and (6) a consultation exercise, an additional, parallel step involving key stakeholders to inform and validate study findings [ 1 ]. While Arksey and O’Malley’s framework offer the best framework for a scoping study to date, we argue that there is room for enhancement. Additional file 1 outlines the original framework, Levac et al’s recommendations, and our recommendations.

Matching research interests with Arksey and O’Malley’s framework

Based on our understanding of Arksey and O’Malley’s framework, our research team believed a scoping study was a methodology that would work well to answer our research question: What does the literature tell us about the information provided by health care professionals and needed by people with colorectal cancers across the cancer care continuum? We applied to and received funding from a Canadian federal research granting institute under a program specific for scoping studies. Receipt of this funding endorsed our belief that this methodology would enable us to answer our question. However, as we engaged more deeply with our work using Arksey and O’Malley’s framework and came to understand our data, we developed reservations that we could claim to understand people’s information needs. When analyzing our final data set, we were tempted (or perhaps eager) to draw conclusions about our interest. Instead, we were faced with the dilemma: “what can we really say about this data?” It became clear that this methodology did not give us the right tools to extract the information we sought. We were able to identify what issues researchers addressed , but not what information was wanted/needed by people with colorectal cancer . In an effort to deal with this tension, we revised our research question mid-way through the process into a question that we hoped our collected data and the Arksey and O’Malley framework could answer: What does the literature tell us about which aspects of the information provided by healthcare professionals and needed by people with colorectal cancer across the cancer care continuum have been addressed by researchers?

Our goals in undertaking a scoping study were to examine the extent, range, and nature of research activity, and to identify research gaps in the existing literature as they relate to information needs of people with colorectal cancer. We quickly learned that our findings were insufficiently specific enough to allow us to fully meet our research goals in the way we expected . We were able to identify the gaps in what researchers were paying attention to with regard to information needs of people with colorectal cancer and we did understand the extent, range, and nature of research activity about the information needs of people with colorectal cancer – there had not been much research activity. However, even though we reached our goals, we were not able to answer our original question because we could not say anything specific about those needs. For example: What information do people with colorectal cancer say they want and/or need? How have these needs been articulated? How and when do they want these needs met? What is the reason given for these needs?

Nevertheless, these findings proved useful as they contributed to our understanding of the state of the literature and how we needed to proceed. Importantly, the study revealed to us that there is very little literature that draws on the perspective of people diagnosed with colorectal cancer. This inattention to people’s voice represented a gap in research. It became apparent that additional, in-depth research would be required before we could draw conclusions. Thus, our research has been an essential first step towards developing a research agenda where we truly attend to the information needs of people with colorectal cancer. Our findings provided us with enough data to design a further, more in-depth research project, thereby positioning the scoping study as an important initial step from which we launched the next phase of our research.

We recognise that we chose the methodology and perhaps it was not the best to answer our original question. We determined it was important to remain mindful of the types of conclusions we could reasonably draw from our data gathered through our use of Arksey and O’Malley’s framework. Thus, we believe that the conversation about the scoping study methodology that Arksey and O’Malley encourage could benefit from guidance about the kinds of research questions for which scoping studies are most appropriate. Arksey and O’Malley illustrate their framework describing a comparison between programs to support carers of people with mental health problems. A PUBMED search using the terms scoping review or scoping study not systematic review on July 27, 2012 elicited 101 articles published between July 2007 and July 2012; 45 of these articles describe studies that can be classified as scoping studies, according to Arksey and O’Malley’s definition, and 34 of them (75%) portray some type of comparison such as among interventions, programs, and approaches. It seems that this latter kind of research is one to which the scoping study method is most often applied and is perhaps the most useful. Our experience has led us to ponder the appropriateness of a scoping study to answer a question that is broader in nature than the comparison of interventions or programs. We were not interested in comparisons of interventions and programs, for example. Rather, we hoped to extract data that would tell us something concrete about the information needs of people with colorectal cancer. As a result, we propose that the objective and appropriateness of the methodology need to be clearly understood by those contemplating its use. However, the boundaries of this methodology and the types of research it can best support are still to be defined and we urge others to contribute to these definitions. It appears that this methodology may be best suitable to research that examines comparisons between interventions or approaches. On the other hand, we want to be clear that our research was not in vain as we did accomplish two goals laid out by Arksey and O'Malley and we garnered data that compelled us forward into a more in-depth analysis to answer our initial question in specific detail. Additionally, we were able to say useful things about the state of academic interest in issues relating to the information needs of people with colorectal cancer, the results of which have been already published [ 10 ]. Because our work proved useful in unexpected ways, we encourage others to consider a scoping review as a constructive method in their broader research process in that it can contribute to the clarification of next steps. By sharing our experiences with this methodology in this paper, we hope we can contribute to the enhancement of Arksey and O’Malley’s framework.

Our recommendations in this paper are the results of the review of our own research process. We collected our team’s perspectives through a short survey comprised of three open-ended questions: (1) describe any significant challenges/successes that arose from using the Arksey O’Malley framework for scoping reviews; (2) describe any significant challenges/successes that arose from taking part in research with a large, multi-disciplinary group; and (3) additional comments. Each team member’s response was built not only upon memory in hindsight, but also upon notes taken throughout the research process. At least two key team members kept research diaries and a recorder kept minutes of each bi-weekly meeting about the challenges, discussions, reflections, and actions taken. The survey results, the notes, and minutes were collated and analyzed. Analysis included identifying themes among challenges and successes, identifying relations between statements related to any given theme, stating arguments and supporting them with evidence from the materials, making comparisons, and evaluating conclusions. Results were then linked to specific Arksey and O’Malley methodological stages for reporting in this paper.

Enhancing the six steps of Arksey and O’Malley’s framework: contributing to the conversation

Arksey and o’malley’s first step: identifying the research question.

Our research team initially found identifying an appropriate research question a straightforward task. We generated our question on the experience, observations, and concerns of our team’s health care providers and the findings of previous research projects of several team members. For example, after a diagnosis of colorectal cancer, there are multiple instances where information is exchanged and required by people diagnosed with colorectal cancer, their families, and health care providers. These may include diagnostic procedures, receiving the diagnosis, treatments and their side effects, and living beyond treatment. Our intent was to learn what information people with colorectal cancer needed and/or wanted, who or how it was best to provide it to them, and when. As per the framework’s first and fourth purposes for conducting a scoping study, we intended to examine the extent, range, and nature of research that addresses the information needs of people with colorectal cancer with a view to identifying gaps in the literature. With these two goals in mind, we linked our purpose to our research question. In an effort to advance the Arksey and O’Malley’s framework, Levac et al. suggest the need to clarify and link the purpose and the research question. Our team did so from the start.

In keeping with Arksey and O’Malley’s recommendation to avoid leading with a “highly focused research question,” [ 1 ] we believed our question was sufficiently broad in design; it helped us to capture an initial 10,753 papers. However, once our team delved into the literature and began analyzing the data, it became apparent that the research question required revision. Levac et al. propose researchers define the concepts in their research question to clarify the scope of the study. Similarly, Arksey and O’Malley suggest that “researchers will want to redefine search terms and undertake more sensitive searches of the literature” [ 1 ]. We held fast to the need for a question that was broad in nature. Levac et al’s useful advice was published after we finished collecting our data and had started our analysis. By this point in our research, we realized we could not say anything substantive about our research query. We revised our question to fit the data we collected instead of revising our question and literature search to get different data that would really illicit the specifics of our interest. In hindsight, we see Levac et al’s suggestion as complementary to Arksey and O’Malley’s suggestion.

To help us with this dilemma (and independent of Levac’s suggestion), we re-reviewed the 239 papers our study produced with an additional inclusion criteria – the voice of people with a diagnosis of colorectal cancer – and identified 64 articles that spoke to the information needs of people with colorectal cancer from their point of view. The realization of the need to clarify this research concept came late in our research process. Thus, it is only in retrospect that we realized how useful it would have been to us earlier. Had we added these inclusion criteria at the outset, we might have had fewer articles to analyse but they would have yielded the data we were looking for. We recommend that researchers follow this advice of Arksey and O’Malley and Levac et al. to reduce the need to adjust their question to fit the methodology (Additional file 1 ).

It is important to reiterate, however, that in spite of our challenging experience with Arksey and O’Malley’s framework, our scoping study was a productive research exercise. We learned what has captured the attention of researchers and by default, what has not. That we narrowed down the original 10,753 papers to a specific set of 239 papers indicates the limited amount of literature that addresses our subject [ 10 ]. Given the prevalence of colorectal cancer, we find this not only startling, but useful in directing our future research. We are now in the process of further examining the 64 papers that reveal the perspective of people with colorectal cancer.

Arksey and O’Malley’s second step: identifying relevant studies

This step requires comprehensiveness to be thorough. We searched for relevant studies using a general internet Google search and several electronic databases, including Google Scholar. In addition, we looked for current and closed clinical trials, practice guidelines, meeting abstracts and dissertations, and searched other sources of grey literature using the Grey Matters Checklist created by the 2011 Canadian Agency for Drugs and Technology in Health. Once we completed these electronic searches, we conducted a hand-search of four key journals and scanned the reference lists from relevant papers to identify other papers that may not have been found in the initial search. We also searched the Social Science Citation Index for papers that our initial searches may have missed [ 10 ]. We followed Arksey and O’Malley’s recommendation to conduct a very broad search since comprehensiveness is “the whole point of scoping the field” [ 1 ].

We started with a broad search strategy. Navigating and redefining the findings after this initial search added another level of complexity to the scoping process. “The process is not linear but iterative,” Arksey and O’Malley emphasize, “requiring researchers to engage with each stage in a reflexive way and, where necessary, repeat steps to ensure that the literature is covered in a comprehensive way” [ 1 ]. Specifically, Arksey and O’Malley suggest that researchers fine tune their search of the literature. As noted above, we neglected to do this step and, in hindsight, realize how useful it would have been. We agree that flexibility and comprehensive searches are important to successful scoping studies.

However, a fine balance must be struck between the laborious nature of study identification and the need for comprehensiveness on the one hand, with the need to complete a scoping study in a timely fashion, on the other. Levac et al. and others recognize this issue [ 2 , 4 ]. While Levac et al. recommend assembling a “suitable team with content and methodological expertise” [ 8 ] to identify studies, we recommend assembling a small suitable team to perform this task (Additional file 1 ). We were a large team and we quickly found it counterproductive for every team member to be actively involved at the beginning of the research process; with too many people, there may be the introduction of too many interpretations, thereby leading to inconsistent search results. In order to maintain consistency and control, we tasked our librarian team member with the design and execution of search strategies. Navigating this many references took considerable time and skill. Although our search produced such a significant number of references, it left our research team confident that we had scoped the field as comprehensively as possible. Additionally, the use of an online citation management software proved to be of immeasurable benefit. It allowed us to organize and cross-check our data and remove duplicates. It also allowed all those involved in the charting steps of the study easy access to the papers.

Arksey and O’Malley’s third step: study selection

Once we identified the relevant literature, our team established the exclusion and inclusion criteria to apply to the papers. The librarian and research assistant on our team applied these criteria to the paper abstracts. We included studies that mentioned in any way the information needs of people with a diagnosis of colorectal cancer, their families and caregivers, or the information sources used by them. We carefully set parameters around studies for exclusion. For example, we excluded studies related to screening, prevention, genetics, and studies that included other types of cancer in addition to colorectal cancer. By applying the exclusion criteria to the abstracts, we reduced the numbers of papers that needed to be read in detail to 869 papers.

Given our large team, we made an adjustment to Levac et al’s suggestion of engaging two reviewers to apply the inclusion/exclusion criteria to the papers. Specifically, we took a three-tiered approach to narrow down and cross-check our papers. First, we divided the research team into six teams of two people each. Each team was assigned one sixth of the 869 articles to review. Both members of each team independently reviewed the full text of each article to determine its eligibility for our study according to the inclusion and exclusion criteria. Second, team members then compared their results to reach an agreement about which articles they recommended to include or exclude. Third, if they could not reach an agreement, the research assistant or the librarian acted as a third reviewer. After concluding this process, a total of 239 papers met the inclusion criteria and were included in our study. We made this adjustment to Arksey and O’Malley’s framework due to the size of our research team. We wanted to give each of our twelve team members exposure to the data and to reduce the workload by dividing up the work tasks. Levac et al. reached a similar conclusion about how to adjust the application of the inclusion/exclusion criteria, confirming our own decision to modify this portion of the framework (Additional file 1 ).

Levac et al. and others [ 2 , 3 , 5 ] are concerned about Arksey and O’Malley’s framework’s inability to provide for an assessment of the quality of the literature. Because our research team is using our scoping study as the basis for our next stage of research, we did not focus too much on this concern (although it did concern us from the outset). However, in retrospect, we believe assessing for quality is a necessary component of scoping studies if they are to provide research that in itself can be disseminated to others in a way that is useful to practice or policymaking and for future researchers. We strongly recommend that assessing for quality be factored into Arksey and O’Malley’s framework and suggest adding these criteria to the selection of studies to be charted. Some suggested methods for assessing quality might include, for example, using validated instruments .

Arksey and O’Malley’s fourth step: charting the data

To organize data, Arksey and O’Malley recommend charting and sorting data according to key themes and issues. They suggest that data charted should include a mixture of general information about the study and specific information related to the study question. Arksey and O’Malley’s own scoping work, an examination of the literature about services or programs for a particular population, charted seven pieces of information on each article (general information: citation data, methodology, aims of the study, outcome measures, important results; specific information: intervention type, study population). Researchers can determine what categories to chart for their particular study. We opted to adapt a charting format from Rutten et al. [ 11 ], a systematic review investigating the information needs of people with cancer. The categories and subcategories used by Rutten et al. fit well with our research question as our goal was similar but focused on a specific type of cancer, colorectal. Because our team consisted of health care providers with extensive clinical experience, we were able to anticipate the complexity of patient information needs prior to conducting our scoping study. To this end, we expanded and modified the set of subcategories related specifically to information needs from the original 64 (from Rutten et al.) to a total of 82. Using such a comprehensive chart proved both a strength and a limitation of our research. It was a strength because our final set of data was rich. We collected more data than we had room to report in a single manuscript. On the other hand, it was time consuming to chart with such a large number of categories. Some of our team members who were busy, practicing health care providers found the detailed nature of the charting process challenging because it took time, first, to engage with the information we aimed to capture and, second, to actually capture that information.

Levac et al. suggest that research team members, independent of one another, chart the “first five to ten studies using the data-charting form and meet to determine whether their approach to data extraction is consistent with the research question and purpose” [ 8 ]. We undertook a similar step in that we conducted a trial charting exercise followed by a group consultation. This step added value by providing our team an opportunity to reach consensus about our data collection process and to include additional categories relevant to our research inquiry. It improved the quality and applicability of the chart used as well as consistency. We recommend researchers consider this step to ensure the data they collect are as rich as possible.

Using our revised Rutten chart, we repeated a similar process as in step three with our six teams of two members each, where each team member worked independently to chart the included articles and team members then compared their results to agree upon the charting of each article. However, we changed the membership of each team in an effort to ensure consistency in interpretation and validity in our results. The research assistant read and charted all 239 articles. All three reviewers discussed any discrepancies and agreed upon a final interpretation. Having one person read and chart each article ensured inter-reviewer reliability throughout the process and contributed to our confidence in the consistency of our data results; this process was an important and valuable part of our research. During this process, effective communication to maintain a clear framework and consistent charting methods cannot be underestimated, particularly for a large team.

Arksey and O’Malley’s framework recommended using Excel to chart each paper, but they did not advise their readers about a key feature of data management: the importance of assigning each paper a unique identifying number. We did this task early on as a way to conveniently and clearly track those articles we excluded and those we included. We also recommend this step because it provides a useful way for a large team to talk about a particular article without having to cite full references or get confused by the names of researchers who have published multiple papers.

It was during the charting step that we began to realize our inability to answer our research question. We charted that an article mentioned a particular information need, yet we could not say anything about that need. For example, did people with colorectal cancer say they wanted this information or did the authors note it as information given to people with colorectal cancer, and it was unconnected to the people receiving it?

Arksey and O’Malley’s fifth step: collating, summarizing, and reporting the results

When reporting the data in our study, it was imperative that we used a consistent, clear approach. Following Arksey and O’Malley’s framework, we charted the extent, nature, and distribution of the included articles. As previously mentioned, we made additions to the Rutten et al. charting categories to better suit the complex information needs of people with colorectal cancer. Our goal with the 15 categories (ten broadly defined categories of information needs and five broad information sources categories) was to gather high-level data about the types of information needs, while we hoped the 101 sub-categories (82 sub-categories of information needs and 19 sub-categories of information sources) would gather micro-level, specific data on these needs. We searched for this range of data in order to satisfy the varied interests of each of our inter-professional team members. These team members desired this level of detail in order to make sense of the data in relation to their own professional practice. This proved to be a real strength to our approach to scoping studies and affirmed the value of including health care providers on our research team. Our ability to capture a complexity of data did not necessarily get us closer to answering our original research question, but it did provide us with an indication of the types of information needs being discussed by researchers.

We made sense of our complex data with a focus on our research question. Once we gathered all of our data and produced some preliminary graphs portraying number of mentions and specific needs, we established a smaller working group to make meaning out of the data and to make choices about the data on which we should focus. By this point, we knew we were not answering our initial question. We then modified our question and followed Arksey and O’Malley’s suggestion to prioritize certain aspects of the literature according to implications for future research and what was most notable given our experience. With our research question in mind, we first quantified the data and produced graphs and charts to represent these numbers. We then did a thematic analysis that resulted in organizing our data into three overarching themes: the information needs of people with colorectal cancer, the sources of this information, and the timing of these information needs. Our steps mirrored Levac et al’s recommendation to add a stage resembling qualitative data analytical techniques, or a thematic analysis. We endorse Levac et al’s suggestion (Additional file 1 ).

We published our findings using a combination of tables with descriptions according to our themes [ 10 ]. This approach proved useful to us in our analysis and allowed us to clearly link our findings with our research goals: to examine the extent of the literature and to identify gaps. Our data also pointed very clearly to the need for future research to pay attention to the need for information as articulated by people with colorectal cancer. We do not offer a new recommendation in this regard, but support Levac et al. in their suggestions for this stage of the scoping study framework.

Arksey O’Malley sixth step: optional stage, consultation exercise

Arksey and O’Malley suggest an optional consultation stage with stakeholders, whereas Levac et al. suggest it should be a requirement. Based on our experience, we agree with Levac et al. (Additional file 1 ) but with room for interpretation of how that consultation is achieved. In our study, there were two groups of stakeholders: health care providers providing care to people with colorectal cancer and people with colorectal cancer themselves. Our research team included a significant number of health care providers. Their participation throughout the entire research process served the purpose of constant consultation and was a real strength of our inter-professional approach. We were able to extract multi-faceted perspectives in the literature and our findings throughout the entire research process rather than leaving it to the end of the project. As a result, we were able to revise the charting categories early on so it more accurately reflected people’s experience than if we had just borrowed one. The health care providers drew upon their experience to identify the gaps in the categories being un/attended to by researchers. We originally intended to consult with the second group of stakeholders, people diagnosed with cancer. However, we omitted that step after realizing that our study did not tell us anything about their information needs from their perspective because it gave us nothing substantive on which to seek their consultation. With Arksey and O’Malley’s framework, consultation only works if the results are germane to the group that researchers wish to consult. Moving forward with future research, we have built this consultation process into our current research with the 64 articles. We see it as a fundamental step to determine how what the literature says resonates with people with colorectal cancer.

Levac et al. and Brien et al. [ 5 , 8 ] discuss the importance of knowledge translation with stakeholders in the field, a perspective we share. In fact, Grant and Booth state that “scoping reviews are able to inform policymakers as to whether a full systematic review is needed” [ 4 ]. Although the methodology did not enable us to address our specific research question, the scoping study exercise did demonstrate that a further study is needed and it pointed out gaps in the literature. In fact, our experience led us to believe that scoping studies may be a useful step – perhaps even a necessary pre-requisite – toward a research project that allows for a deeper analysis, such as a knowledge synthesis methodology [ 12 ]. Indeed, our study has been valuable in part because it opened up questions to guide future research from which we will have findings we can share with stakeholders, including policymakers and health care providers to inform their practice.

Inviting suitable stakeholders to be part of the research team is one way to incorporate the consultation Levac et al. say is necessary. We recommend researchers consider this decision when possible as it makes the entire research process and, thus, the findings, rich. That being said, not all stakeholders will be appropriate to be involved on the research team and researchers must make this decision carefully. For example, previous experience with research is not necessarily a requirement but experience in a critical analysis of relevant literature is necessary. Effective team work skills are imperative, especially when large groups are assembled. Time availability to participate in all stages of the project is another important point to be considered.

A large, inter-professional team using Arksey and O’Malley’s framework: strengths and challenges

Our contribution to the conversation on scoping studies relates to our experience as a large, inter-professional team using Arksey and O’Malley’s framework. Levac et al. and others point to a multidisciplinary team as a benefit for scoping studies [ 2 , 13 ]. According to Anderson et al., a multidisciplinary team provides the required “expertise to map a subject” that is “not necessarily always found in one researcher” [ 2 ]. Our research team was not only multidisciplinary, but inter-professional in its composition. A multidisciplinary team is academic in character because it joins together members trained in different disciplines, whereas an inter-professional team is professional in character because it joins together members trained in program areas of clinical practice, plus academic researchers [ 14 ]. It is important to note that the challenges we experienced are not unique to scoping studies, but are faced commonly by all research projects conducted by large, inter-professional teams. However, critical discussions about inter-professional teams are absent from the current literature about scoping study methods.

The large, inter-professional character of our team brought both strengths and challenges to Arksey and O’Malley’s framework. On one hand, it was a strength because our team collectively brought a breadth and depth of clinical and research knowledge absent in a team comprised only of academic researchers. It also brought time efficiencies. Our team worked efficiently when it came to assigning and completing work tasks. We strategically divided up work tasks, which often meant a lighter workload for each individual team member. This type of time efficiency was especially evident at the inclusion/exclusion and charting stages of Arksey and O’Malley’s framework. The make up of our team also added to the rigor of the research process; twelve team members from diverse backgrounds provided many perspectives.

On the other hand, the large, inter-professional character of our team had some challenges relating to consensus, research experience, and resource limitations. The greater the number of team members, the greater the number of perspectives. At certain points, productivity decreased. Although such a team produced rich analysis, it was challenging to reach consensus because there were occasional competing perspectives. At times, we found it difficult to arrive at a common language or vocabulary for discussion and had to re-double our efforts during the research process to ensure consistency.

Finally, as with any research project, there is always a need to balance finite resources of time and money. With an inter-professional team, this need is greater because there are more competing interests, more professional schedules to coordinate, and more communication efforts required to explain, explore, and reach consensus about ideas. We found it helpful to designate one person or a small section of the team to take the lead at various stages of the research process to move the project forward. While we have noted at several steps of the process that communication and regular meetings are important, we also acknowledge that it may be challenging to organize meetings for so many team members and to ensure that all team members consistently produce deliverables at agreed upon deadlines. We recommend, however, that large, inter-professional teams pay special attention to this issue as communication is key to success.

Summary: lessons learned

Some authors have expressed their concerns about Arksey and O’Malley’s framework’s inability to provide for an assessment of the quality of the literature [ 2 , 3 , 5 , 8 ]. We believe assessing for quality is a necessary component of scoping studies. The assessment itself is a significant task and should be performed using validated instruments. This recommendation does not stand alone, however. We propose that the recommendations of Levac et al. to clarify the concepts in the research question and Arksey and O’Malley’s suggestion to redefine search terms will ensure the assessment of quality actually proves useful. To this end, the definition and purposes of scoping studies must be made in tandem with clarifying the methodological framework; no one can be done without the others.

We endorse Arksey and O’Malley’s purposes when taking into consideration Levac et al. and our own recommendations. As for the definition used by Arksey and O’Malley, we would remove the term “rapidly” and replace it with the need for scoping studies to be done thoroughly and thoughtfully. To be clear, scoping studies take time. Second, we think that adding a quality assessment step would alter the definition.

With a more detailed methodological framework according to the recommendations of Levac et al., our own, plus purposes that are more attainable, we suggest a definition of scoping studies as follows: Scoping studies aim to map the literature on a particular topic or research area and provide an opportunity to identify key concepts; gaps in the research; and types and sources of evidence to inform practice, policymaking, and research .

Creating a large, inter-professional team to engage in a scoping study offers tangible benefits to the research process. If using a revised framework set out by Arksey and O’Malley’s using Levac et al. and our recommendations, major tasks can be fairly divided without compromising the consistency of analysis. Additionally, each inter-disciplinary team member adds richness to the analysis as he/she brings his/her perspective to the research table.

A large, inter-professional team including health care providers allowed us to anticipate the complexity of information needs. Including suitable stakeholders on the research team builds in the consultation stage throughout and adds depth to all stages of the research process.

It is important that researchers fully understand the methodology’s boundaries and its inherent methods. It would be beneficial to include someone on the research team who is experienced with scoping studies. Most important is the work involved of matching the methodology with research interests and attending to suggestions to clarify concepts within the research question and/or focus the literature search as necessary to ensure researchers do not lose sight of their interests.

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Acknowledgements

The authors would like to acknowledge the other members of the research team: Heather Watson, Maxine Alford, Cheri Cosby, Nancy Payeur, Mary Ellen Purkis, Darcy Dennis, Ryna Levy-Milne, and particularly Alison Mitchell and Lorraine Leitz for their review of the manuscript. We are grateful for the funding for this research received from the Canadian Institutes of Health Research (CIHR).

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Each author (HMLD, CvM, and SJS) made substantial contributions to the conception, analysis, and interpretation of the data. Following a group discussion about the outline of the paper, SJS created the first draft of the manuscript, HMLD and CvM revised the draft and, thereafter, each author interactively participated in critically revising the content up to the final, submitted version. Each author read and approved the final manuscript.

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Daudt, H.M., van Mossel, C. & Scott, S.J. Enhancing the scoping study methodology: a large, inter-professional team’s experience with Arksey and O’Malley’s framework. BMC Med Res Methodol 13 , 48 (2013). https://doi.org/10.1186/1471-2288-13-48

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Twelve years after we published our paper 'Scoping studies: Advancing the Methodology' in the journal Implementation Science, we look back at the fortunate circumstance of luck, preparation and sage mentorship that spurred this fruitful endeavor.

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Scoping studies: advancing the methodology - Implementation Science

Background Scoping studies are an increasingly popular approach to reviewing health research evidence. In 2005, Arksey and O’Malley published the first methodological framework for conducting scoping studies. While this framework provides an excellent foundation for scoping study methodology, furthe…

Here, we reflect on the conceptualization, writing and publication of Advancing the Methodology , and describe three lessons drawn from the experience that have influenced our career trajectories.

We wrote Advancing the Methodology as trainees (DL and HC were PhD students, and KKO was a postdoctoral fellow) in the School of Rehabilitation Science at McMaster University. Each of us had recently used Arksey & O'Malley's (2005; fondly referred to hereafter as A&O) pioneering methodological paper  to undertake an (at the time!) novel method of knowledge synthesis: the scoping review. Their paper offered an excellent road map, but also illuminated new challenges. A&O deftly recognized the work to be done, stating:

“ One of the purposes of the present paper is to stimulate discussion about the merits of scoping studies, and help develop appropriate methods for conducting such reviews……We look forward to seeing how the debate progresses .”(p31)

As trainees, we felt ourselves to be less than ideal candidates to answer this call, but a fortuitous occasion of sage mentorship from DL’s doctoral supervisor, Dr. Cheryl Missiuna, changed our minds. Dr. Missiuna suggested that our collective experiences (published by DL in Research in Developmental  Disabilities , HC in the Canandian Journal of Occupational Therapy , and KKO in Aids and Behavior ) had value, and that the three of us partner to take on this challenge. Her encouragement gave us the confidence to undertake the work. She taught us Lesson #1:  Look for ways to foster confidence in your trainees . She embodied this lesson by promoting our independence. Once the seed was planted to write a paper about our collective experiences, we were left to organize ourselves and do the work. Which we did!  In addition to encouragement, Dr. Missiuna provided the funds to ensure the paper was open access. Her belief in our abilities, combined with the post-publication evidence of interest in the paper, nurtured our confidence as early career researchers, helping to establish us early on as methodologists in a rapidly developing field.

It helped that we were in the right place at the right time. Figure 1 illustrates the growth in scoping review (or scoping study) publications between 1997 and 2022, showing how the rate of scoping review publication was on the cusp of rapid acceleration following the 2005 A&O paper. However, we combined good luck with adequate preparation: we had each read widely, illuminating the gap that needed to be filled. In retrospect, we see this as Lesson #2 : Question the status quo . We embody this lesson in nudging our students (and our colleagues!) to consider how advancing existing methodologies could be a component of their work.

For example, HC was an external examiner on a student’s comprehensive exam that occurred just a week before publication of the PRISMA scoping review reporting guidance . She asked the student to reflect on how the new guidance might influence her (already written in preparation for publication!) review. That question, along with sage encouragement from HC, spurred the student to write an editorial based on their experiences of altering their paper to reflect the new reporting guidance . We encourage our trainees to follow existing methodical guidance, but we also prompt them to continually reflect on how a methodology could be adapted to better address the research question. Over the years, lesson #2 has motivated us to question the other aspects of our field that could benefit from disrupting the status quo.

Figure 1: Number of scoping reviews by year

Note: Figure was created by conducting an electronic search for ‘scoping study’ or ‘scoping review’ from 1997 to March 2022 in Medline, EMBASE, CINAHL, and PsycINFO.

Importantly, we also benefited from mentors who believed in the value of collaboration. Combining our experiences into one paper made it stronger than if any one of us had written it alone, leading us to Lesson #3 : Consider the process of doing the work to be equally important as its outcome . This can be difficult to remember in academia, where outcomes are key to advancement, specifically those that can be tallied in an annual progress or impact report. Yet the impactful, collaborative process of co-ideating and co-writing gave us an early model to replicate and expand in our subsequent careers.

Indeed, Advancing the Methodology spurred new collaborations with researchers doing similar knowledge synthesis methodological work, formalized in a Canadian Institutes of Health Research Knowledge Dissemination grant in 2015 led by KKO . The grant brought together an international working group in Toronto to discuss scoping review methodological improvements. At this meeting, Dr. O’Malley herself presented the historical perspectives and origins of the scoping study (NB: A&O used the term scoping study).  Figure 2 shows one of our brainstorming boards from this meeting – as you can see, a rich idea generation experience!

We joined forces with other groups working in this same area to continue collaborative efforts, including Drs S. Strauss and A. Tricco's group at the University of Toronto, who had expertise in knowledge syntheses and developing reporting guidelines (including a scoping review published in 2016 in BMC Research Methodology . This collaboration led to a 2014 Editorial in the Journal of Clinical Epidemiology  and the publication of the PRISMA guidelines for Scoping Reviews . Further collaborations expanded to include another team working on reporting guidance for scoping reviews: Mikah Peters from the Joanna Briggs Institute (JBI) .

Figure 2 : Graphic Facilitation from the Advancing the Field of Scoping Study Methodology International Meeting held in 2015 (funded by the Canadian Institutes of Health Research) brainstorming board.

Amazingly, as of March 2022 , Advancing the Methodology has been cited 6792 times (Google Scholar) and downloaded over 170,000 times. We never anticipated the attention the paper has received, nor the wide-ranging impacts of its publication on our careers. These impacts include the considerable time and energy spent on mentoring, advising, and presenting on scoping reviews, exposing us to a plethora of new research interests, perspectives, and worldviews.

Scoping reviews: Looking to the future

Many lively discussions have been held with the goal of debating the identity, conceptualization, definitions, and terminology related to scoping reviews. The most interesting were debates related to the value of quality assessment of included studies in a scoping review, the debate on terminology – is it a study, or is it a review? - and the pros and cons, from a scientific perspective, of the inherently iterative nature of the scoping process, as emphasized in the A&O paper. Interestingly, these issues remain relevant to this day. We also note emerging areas of debate such as how best to present scoping results for a wide range of stakeholders, how best to conduct a qualitative synthesis of data, and when to conduct the (optional) consultation exercise. We look forward to ongoing discussions!

We end with an expression of our collective gratitude for this experience. Publishing this paper had both measurable (the citations!) and immeasurable impacts on our career trajectories, influencing our dedication to the essential scientific pursuits of collaboration and mentorship. We would like to amplify A&O’s original call by encouraging others - at any stage of their careers - to join in methodological advancement efforts to benefit evidence-informed practice, research and policy.

Acknowledgements

The authors acknowledge the contributions of Sarah Zarshenas, Research Associate at University of Toronto, in gathering the data for and creating Figure 1.  Kelly K. O’Brien (KKO) is supported by a Canada Research Chair in Episodic Disability and Rehabilitation from the Canada Research Chairs Program.

  References

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• Levac, D., Rivard, L. & Missiuna, C. Defining the active ingredients of interactive computer play interventions for children with neuromotor impairments: A scoping review. Res. Dev. Disabil. 33 , (2012).
• Colquhoun, H. L., Letts, L. J., Law, M. C., MacDermid, J. C. & Missiuna, C. A. A scoping review of the use of theory in studies of knowledge translation. Can. J. Occup. Ther. 77 , 270–279 (2010).
• O’Brien, K., Wilkins, A., Zack, E. & Solomon, P. Scoping the field: identifying key research priorities in HIV and rehabilitation. AIDS Behav. 14 , 448–458 (2010).
• Tricco, A. C. et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann. Intern. Med. 169 , 467–473 (2018).
• Miller, E. & Colquhoun, H. The importance and value of reporting guidance for scoping reviews: A rehabilitation science example. Aust. J. Adv. Nurs. 37 , (2020).
• O’Brien, K. K. et al. Advancing scoping study methodology: A web-based survey and consultation of perceptions on terminology, definition and methodological steps. BMC Health Serv. Res. 16 , (2016).
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11.          Peters, M. D. J. et al. Scoping reviews: reinforcing and advancing the methodology and application. Syst. Rev. 10 , 263 (2021).

Contributors

Danielle Levac

Associate Professor, University of Montreal

Contributing authors

Heather Colquhoun

Associate Professor, University of Toronto

Kelly O'Brien

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After the paper | scoping studies: advancing the methodology.

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Enhancing the scoping study methodology: a large, inter-professional team's experience with Arksey and O'Malley's framework

Affiliation.

• 1 Clinical Research, British Columbia Cancer Agency, Vancouver Island Centre, 2410 Lee Avenue, Victoria, BC V8R 6V5, Canada. [email protected]
• PMID: 23522333
• PMCID: PMC3614526
• DOI: 10.1186/1471-2288-13-48

Background: Scoping studies are increasingly common for broadly searching the literature on a specific topic, yet researchers lack an agreed-upon definition of and framework for the methodology. In 2005, Arksey and O'Malley offered a methodological framework for conducting scoping studies. In their subsequent work, Levac et al. responded to Arksey and O'Malley's call for advances to their framework. Our paper builds on this collective work to further enhance the methodology.

Discussion: This paper begins with a background on what constitutes a scoping study, followed by a discussion about four primary subjects: (1) the types of questions for which Arksey and O'Malley's framework is most appropriate, (2) a contribution to the discussion aimed at enhancing the six steps of Arskey and O'Malley's framework, (3) the strengths and challenges of our experience working with Arksey and O'Malley's framework as a large, inter-professional team, and (4) lessons learned. Our goal in this paper is to add to the discussion encouraged by Arksey and O'Malley to further enhance this methodology.

Summary: Performing a scoping study using Arksey and O'Malley's framework was a valuable process for our research team even if how it was useful was unexpected. Based on our experience, we recommend researchers be aware of their expectations for how Arksey and O'Malley's framework might be useful in relation to their research question, and remain flexible to clarify concepts and to revise the research question as the team becomes familiar with the literature. Questions portraying comparisons such as between interventions, programs, or approaches seem to be the most suitable to scoping studies. We also suggest assessing the quality of studies and conducting a trial of the method before fully embarking on the charting process in order to ensure consistency. The benefits of engaging a large, inter-professional team such as ours throughout every stage of Arksey and O'Malley's framework far exceed the challenges and we recommend researchers consider the value of such a team. The strengths include breadth and depth of knowledge each team member brings to the study and time efficiencies. In our experience, the most significant challenges presented to our team were those related to consensus and resource limitations. Effective communication is key to the success of a large group. We propose that by clarifying the framework, the purposes of scoping studies are attainable and the definition is enriched.

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• DOI: 10.1080/21501378.2024.2357134
• Corpus ID: 271028760

Scoping Review Methodology: A Practical Guide for Counseling Researchers

• Gideon Litherland , Arien K. Muzacz , Gretchen Schulthes
• Published in Counseling Outcome Research… 2 July 2024
• Psychology, Education

49 References

Antiracist training programs for mental health professionals: a scoping review., clinical supervisor training: a ten-year scoping review across counseling, psychology, and social work, characteristics, methodological, and reporting quality of scoping reviews published in nursing journals: a systematic review., physical problems of prolonged use of personal protective equipment during the covid‐19 pandemic: a scoping review, systematic and other reviews: criteria and complexities, partnerships as third spaces for professional practice in initial teacher education: a scoping review, applying intersectionality in clinical supervision: a scoping review, learning styles in counseling: a scoping review of the empirical evidence, prisma 2020 statement: what's new and the importance of reporting guidelines., research focused on doctoral-level counselor education: a scoping review, related papers.

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• Published: 25 June 2024

A scoping review assessing the usability of digital health technologies targeting people with multiple sclerosis

• Fiona Tea 1   na1 ,
• Adam M. R. Groh 2   na1 ,
• Colleen Lacey 3 &
• Afolasade Fakolade   ORCID: orcid.org/0000-0003-3405-5782 4  

npj Digital Medicine volume  7 , Article number:  168 ( 2024 ) Cite this article

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Digital health technologies (DHTs) have become progressively more integrated into the healthcare of people with multiple sclerosis (MS). To ensure that DHTs meet end-users’ needs, it is essential to assess their usability. The objective of this study was to determine how DHTs targeting people with MS incorporate usability characteristics into their design and/or evaluation. We conducted a scoping review of DHT studies in MS published from 2010 to the present using PubMed, Web of Science, OVID Medline, CINAHL, Embase, and medRxiv. Covidence was used to facilitate the review. We included articles that focused on people with MS and/or their caregivers, studied DHTs (including mhealth, telehealth, and wearables), and employed quantitative, qualitative, or mixed methods designs. Thirty-two studies that assessed usability were included, which represents a minority of studies (26%) that assessed DHTs in MS. The most common DHT was mobile applications ( n  = 23, 70%). Overall, studies were highly heterogeneous with respect to what usability principles were considered and how usability was assessed. These findings suggest that there is a major gap in the application of standardized usability assessments to DHTs in MS. Improvements in the standardization of usability assessments will have implications for the future of digital health care for people with MS.

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Introduction.

Digital health technologies (DHTs) offer complementary methods to track and manage symptoms, improve treatment adherence, and increase access to healthcare for diverse patient populations 1 , 2 . In the context of a heterogeneous and prognostically challenging neurodegenerative disorder such as multiple sclerosis (MS), DHTs have significant potential to promote disease management and personalized patient care 3 , 4 . The potential impact of DHTs in MS is even more apparent when one considers the nature of clinical assessments in this population. Specifically, evaluations typically occur at 6-12-month intervals and require clinical visits for a comprehensive examination. This low frequency of patient consultation is reported to contribute to un/under-reported disease progression 5 . A potential solution is increasing the frequency of clinical consultations, but this is constrained by time, cost, and geography, leading to inequity in healthcare access. To address some of these gaps in care provision, DHTs have become more integrated into the long-term care of people with MS 6 , 7 , 8 .

While the need for innovative digital solutions in MS care is clear, a recent review of 30 unique mobile health applications found that they did not meet the needs of people with MS 9 . Several factors may potentially thwart the successful implementation of DHTs, including but not limited to, the level of digital and health literacy of end users and the perceived usefulness of, or satisfaction with, a DHT 10 . Indeed, it is well established that the incorporation of usability principles into the design and evaluation of DHTs is fundamental to ensuring they are appropriately targeted to the end users’ needs and adopted long-term 11 , 12 , 13 . Usability describes the extent to which DHTs can be “used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use” 14 , and typically considers core principles such as effectiveness, learnability, physical comfort/acceptance, ease of maintenance/repairability, and operability 15 . Indeed, the evaluation of usability is important in the process of development and commercialization of DHTs. Government authorities such as the Federal Drug Administration recommend that medical devices (including DHTs) not yet on the market provide a report summarizing potential target users, training necessary for the operation of the product, usability testing, and any problems encountered during technology evaluation 16 . Furthermore, the National Health Service in the UK requires consideration of usability and accessibility principles when approving health apps solicited from industry 17 . Despite such a clear need for usability evaluation of DHTs, there has yet to be a comprehensive assessment of DHT usability in the context of MS. Other groups have assessed the usability of mobile health applications 1 , 18 , but there is a need to conduct a comprehensive usability evaluation of all DHTs employed by people with MS, especially wearable technologies. The aim of this scoping review was, therefore, to examine the extent to which usability principles have been considered in DHTs for people with MS and to summarize the methods of usability evaluation. A preliminary search of the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports was conducted to confirm that there are no current or in-progress scoping or systematic reviews on the same topic.

By following a Population Concept Context mnemonic, we generated a primary review question: how has usability been considered in studies of DHTs targeting people with MS? This primary review question was then divided into four sub-questions:

What are the participant characteristics (e.g., age, gender, disease severity) included in studies of DHTs in the context of MS?

What are the components (e.g., type of technology and delivery platform, development stage) of DHTs targeting people with MS?

What assessment methods (e.g., questionnaires, interviews) of usability are incorporated into the design and/or evaluation of DHTs for people with MS?

What usability outcomes (e.g., accessibility, flexibility) are reported from the evaluation of DHTs for people with MS?

Selection of sources of evidence

A total of 5990 studies were identified in the search process (see Fig. 1 ). Following duplicate removal ( n  = 1432), the titles and abstracts of 4558 studies were screened, and 4262 studies were deemed irrelevant. A total of 279 studies moved to full-text review, where 247 articles were excluded; of note, 89 studies did not assess usability. Inter-rater agreement for title and abstract screening was 0.45, and between 0.57 and 0.73 for full-text review (given there were three raters for this stage). These values indicate moderate to substantial agreement between reviewers, respectively 19 . A total of 32 studies were included in the final narrative synthesis.

Data extracted from Covidence. Exclusion Criteria: 1. Review papers, animal studies, unpublished trial data, conference abstracts, opinion pieces, case studies, and letters.; 2. No reported usability outcome measure; 3. Studies with data in MS patients that is not accessible, or that is presented in conjunction with co-morbidities; 4. DHT not for patient populations with MS (primary diagnosis), healthcare practitioners, formal care providers, and researchers; 5. Machine learning and AI studies to assess healthcare data for MS. κ = Cohen’s kappa value.

Description of Included Studies and Participants

The characteristics of the included studies and participants are summarized in Table 1 . Most studies were conducted in Europe ( n  = 18, 56%), followed by North America ( n  = 9, 28%). Four studies (13%) involved multi-country investigations. More than half of the studies were published between 2020-2023 (n = 19, 59%). Most studies used a mixed-methods ( n  = 16, 50%) or quantitative ( n  = 15, 47%) design. One study (0.3%) used a qualitative design.

Across the studies, the total number of participants was 1213, with the sample sizes ranging between 4 and 126. Most participants were female (71%), with RRMS (73%). Two studies (6.3%) included people with CIS. Of the 28 (86%) studies that reported mean/median age of participants, the age ranged between 36.8 and 56.8 years old. Across all participants, the mean EDSS scores ranged between 1 and 6.5, while the mean disease duration ranged between 6 and 24 years. The education level of participants was reported in 11 (34%) studies and ranged between 8 th grade and doctorate level.

Description of Usability Components of Digital Health Technologies (DHTs)

The characteristics of the DHTs are summarized in Table 2 . The majority of DHTs were application-based (apps) ( n  = 23, 70%), followed by wearables ( n  = 7, 21%), Website/Internet ( n  = 6, 18%), and others (n = 2, 6%): a game console and a virtual reality system. Five studies used a combination of apps and wearables ( n  = 4) or apps and Internet/Website ( n  = 1). Most DHTs were implemented in the patient’s home or community ( n  = 30, 94%). The remaining two DHTs (6%) were used in a hospital/clinic setting. Of the 30 DHTs implemented in a patient’s home, eight were additionally evaluated within a research facility ( n  = 7) or hospital ( n  = 1). All DHTs were evaluated by people with MS ( n  = 32), with seven DHTs evaluated by two users (22%): people with MS and formal health/social care providers ( n  = 6) or family caregivers ( n  = 1). Over half the DHTs were the final versions ( n  = 17, 53%), while the remainder were in various stages of iterative development ( n  = 15, 47%). The DHTs were intended for various uses, including remote self-management, education, symptom assessment and monitoring, cognitive and physical rehabilitation, and supporting therapeutic interventions.

Methods of Usability Evaluation

The methods of usability evaluations within each study are detailed in Table 2 . When considering the number of methods used to evaluate DHTs across the studies, there was an even split, wherein half of the studies implemented a single method of evaluation ( n  = 16, 50%), while the remaining studies utilized two ( n  = 9, 28%) or more methods ( n  = 7, 22%). Usability of the DHTs was most commonly evaluated using questionnaires (n = 26, 81%), followed by interviews ( n  = 12, 37%), task completion tests ( n = 9, 28%), think aloud protocols ( n  = 4, 12%), focus groups ( n  = 3, 9%), and others ( n  = 4, 12%) which included patient feedback. Within the 26 studies that utilized questionnaires, most included scales developed by the research team ( n  = 15, 58%). Of the studies that used a standardized questionnaire, the most common scale was the System Usability Scale (SUS) 20 , used in seven studies (27%).

Description of Usability Outcomes

Table 2 summarizes the usability characteristics across the included studies. There was a wide variety and number of usability characteristics reported across studies, with 20 unique usability characteristics reported in over a third of studies ( n  = 12, 37.5%). Three studies (9%) reported usability as a general term. Across all studies, the most assessed usability characteristic was user satisfaction ( n  = 17, 53%). Other usability characteristics assessed were adherence ( n  = 6, 19%), acceptability ( n  = 5, 16%), feasibility ( n  = 5, 16%), usefulness ( n  = 4, 12.5%), and efficiency ( n  = 3, 9%). There were seven usability characteristics only reported by two independent studies. Most studies reported two ( n  = 13, 40.5%) or more ( n  = 13, 40.5%) usability characteristics, while six studies (19%) reported a single usability characteristic. While the overall conclusions from usability assessment varied, studies most often reported a combination of positive feedback and suggestions for improving future iterations of the DHTs. Two studies explicitly mentioned that participant feedback from usability assessment was incorporated into DHT development 21 , 22 .

The current scoping review is the first to examine usability characteristics and testing methods in DHTs with a specific focus on people with MS. Usability was evaluated in less than a third of relevant studies, indicating limited consideration of this important topic within the context of DHTs in MS. Evaluation of usability was highly heterogeneous across studies, both in terms of the number of reported characteristics and assessment methods. The most evaluated DHTs were mobile applications and most studies used different types of questionnaires to assess usability. DHTs were evaluated by people with MS, with limited inclusion of health/social care providers or family caregivers in the process. Below, we first summarize key findings and knowledge gaps, and subsequently make recommendations for future work to advance the design and implementation of DHTs in MS.

DHTs have become a rapidly evolving modern health intervention tool, especially amidst the COVID pandemic, and likely beyond 23 . The importance of evaluating the usability of DHTs has been recently highlighted in the context of other chronic diseases, such as Parkinson’s disease, and in elderly individuals 24 , 25 , 26 , 27 . A recent review of mobile applications in MS reported only six of 14 studies had evaluated usability 18 . In the current review, which encompassed the broad spectrum of DHTs, the 32 studies only represented 26% of relevant DHT studies in MS. There is a clear lack of usability assessment in over half of DHT studies in MS. Furthermore, we reported minimal involvement of caregivers and health/social care professionals. The inclusion of usability assessments by formal care providers and family caregivers should be considered given the importance of MS caregivers in patient care 28 , 29 . Evaluation of usability is a critical part of the development and effective use of DHTs, and therefore should be considered in emerging DHTs targeting people with MS.

Our findings show that the evaluation methods and usability outcomes assessed were very heterogeneous across studies. Indeed, this heterogeneity in usability assessment and lack of consistency across studies have been reported across other neurodegenerative and chronic diseases, such as dementia, diabetes, and cardiovascular disease 24 , 30 . Usability assessment approaches similarly varied more broadly in studies investigating medical devices across several populations depending on the DHT and its intended use 31 . In the current study, the most frequently used method to evaluate usability was questionnaires, and most studies implemented independent, non-validated, questionnaires developed by the research team. The most commonly used standardized questionnaire was the SUS. Although a valid and reliable measure, the SUS is a self-reported measure with inherent bias and was not intended to be comprehensive in its approach to evaluate usability 32 , 33 . Further, the SUS is not specific nor adapted to a particular DHT type, limiting its ability to describe specific aspects of usability.

The usability of a DHT can encompass a wide range of characteristics and these outcomes will vary based on the intended use of the DHT. We reported a large number of different usability outcome characteristics across studies, with the most common usability characteristic evaluated being user satisfaction. Indeed, the SUS questionnaire, the most used usability assessment method, primarily captures user satisfaction, with additional sub-scales for learnability and usability. The usability characteristics reported varied across studies but were somewhat consistent within DHT type. For example, DHT studies that incorporated a wearable component assessed tolerance or wear-time, whereas self-management DHTs used terms such as engagement and acceptability. Furthermore, there were a large number of studies that reported unique descriptors of usability. It is important to capture multiple characteristics of usability, however consistent terminology and descriptions of usability outcomes is important for cross-study comparisons and validation. There is a clear need to develop more standardized and comprehensive approaches to assess the usability of DHTs for people with MS.

The dramatic rise in remote patient management necessitates a framework to effectively evaluate the intended use and quality of DHTs to enhance and optimize user experience. Herein, we provide recommendations to advance research on DHTs in MS. Usability assessments and outcomes should be tailored for the intended use of the DHT and the target user. Usability testing does not require an enormous time investment, in fact, the likelihood of acquiring novel information after six to nine users is minimal 34 . We found an average of 35 participants assessed usability across the studies included in this review, which is indeed sufficient to reliably and effectively assess DHT usability. Half the evaluated studies were still undergoing development of their DHT, and only two studies explicitly reported that participant feedback from usability testing was incorporated into subsequent DHT development 21 . Future studies should also consider usability in the context of people with MS who experience additional barriers when accessing DHTs, such as low socio-economic status, rurality, older age, and more severe disability 35 .

The future of DHTs in MS requires an updated standardized usability framework, and more targeted usability outcomes specific to the type and application of DHT in patient care. Implementation of both qualitative and quantitative measures is important 36 , 37 . To update currently used standardized methods, like the SUS, objective and comprehensive measures of usability assessments are needed that do not rely only on self-report. Future work should therefore apply a mixed methods approach to assess usability and implement user feedback during stages of DHT development. Incorporating these considerations, we recommend the following to improve the assessment of DHT usability:

Common and clearly defined usability characteristics of DHTs should be evaluated. For example, user satisfaction and acceptability characteristics could be rated on a numeric scale.

Additional criterion specific to the type of DHT, and user (patient or caregiver) should be assessed separately. For example, wearables should include wear-time, and apps that require tests should include task completion time.

Qualitative measures, such as interviews or focus groups, should be conducted in conjunction with quantitative measures. These should assess user feedback and aim to report the subtle challenges with usability not captured by quantitative measures.

These usability metrics, if combined in the form of a summative score, could be useful to compare across studies of various DHT types. Usability results from these metrics should be integrated into the development of the DHT. Finally, the current scoping review highlights a major gap in the application of standardized usability evaluations and outcomes of current DHTs implemented in MS care. Importantly, our results highlight the opportunity to implement improved methods of usability assessment which will have major implications in the future of mobile care for people living with MS.

This review has several limitations that warrant consideration. First, we have included only English-language articles due to a lack of resources for translation. It is possible that articles published in other languages may have included additional information on usability evaluations of DHTs designed for people with MS. Telehealth and virtual telerehabilitation studies were also excluded in the current review. Furthermore, given the heterogeneity in usability principles and methods used to evaluate usability, it was not possible to synthesize the quantitative and qualitative data reported accurately. Nonetheless, we extracted and included these data in Supplementary Fig. 4 for interested readers. The usability of most DHTs was reported to be good, with satisfaction ranging from ~80-90%. The lowest usability scores were typically associated with wearable technologies. Few studies further evaluated the 10-20% of pwMS who struggled with DHT usage. Future research should focus on this sub-group of the MS population to understand how to develop more targeted and usable DHTs.

We followed the Joanna Briggs Institute guidance for scoping reviews 38 , 39 . The review is reported in accordance with the PRISMA Extension for Scoping Reviews 40 (Supplementary Fig. 1 ). We have registered our protocol prospectively in the Open Science Framework: https://osf.io/y7gqp/ .

Eligibility Criteria

Participants.

Studies focusing on adults (≥18 years old) with MS and/or their caregivers were considered for inclusion. Any subtype of MS, including Clinically/Radiologically Isolated Syndrome (CIS/RIS), Relapsing-Remitting MS (RRMS), Primary Progressive MS (PPMS), and Secondary Progressive MS (SPMS) was eligible for inclusion. We excluded animal studies and studies involving mixed populations (i.e., MS and other conditions) where data from people with MS could not be separated from other conditions. We further excluded studies focusing on formal health and/or social care professionals.

Studies that described usability characteristics (e.g., comfort, ease of use, accessibility, flexibility, etc.) and/or usability testing methods (e.g., questionnaires, task completion, “Think-Aloud” protocols, interviews, heuristic testing, and focus groups, etc.) of DHTs were included. We excluded multicomponent studies in which data on the DHT component could not be extracted. Studies on electronic medical records, medical monitoring devices, machine learning, artificial intelligence, biomedical applications, systems for intelligent processing of genetic data, and assistive devices, were excluded.

We considered studies conducted in any geographic location and setting (e.g., hospital settings, primary care, community care, or at home) and published in English. Our pre-screening results found limited studies on DHTs in the context of MS prior to 2010. Therefore, to focus on the most recent and relevant DHT studies, we considered studies published from 2010 until the present.

Types of Sources

We included peer-reviewed quantitative, qualitative, and mixed-methods studies. We recognize that computer-based digital technology development may be conducted outside of academia and published in non-traditional or non-peer-reviewed outlets – but in the context of providing evidence-based information for health and social care providers and researchers, peer-reviewed evidence is considered the gold standard. We excluded systematic and non-systematic reviews, dissertations, conference abstracts and proceedings, observational studies, case reports, opinion pieces, commentaries, and protocols.

Search Strategy

We implemented a systematic, peer-reviewed three-step search strategy in line with the framework developed by the Joanna Briggs Institute and in consultation with a health sciences librarian. The process began with a preliminary search in PubMed to find key articles relevant to the three components of the research question: usability, DHTs, and MS. Using these articles, a list of keywords was developed for the search strategy, and the syntax was modified such that it could be applied to the other databases. The systematic search was then run in five databases: Web of Science, OVID Medline, CINAHL, Embase, and medRxiv. Specific to the medRxiv search, only the MS search component was used. An example of the search terms used in Medline can be found in Supplementary Fig. 2 .

Selection of Sources of Evidence

All results were uploaded to Covidence (Veritas Health Innovation, Melbourne, Australia) to facilitate de-duplication, screening of titles and abstracts, full-text review, and extraction. Titles and abstract screening were pilot-tested by two reviewers on a random sample of 10 studies before screening. Following pilot testing, all authors were involved in both screening phases, with two independent reviewers examining each article. When reviewers disagreed about the inclusion status of a citation, another reviewer examined the citation, and a three-way discussion was held to reach a consensus. Full texts for all potentially relevant articles were uploaded to Covidence for further screening by three independent reviewers. Discrepancies in the inclusion/exclusion of full-text studies were resolved during a consensus meeting. A manual search of reference lists from the full-text articles included was then performed to identify additional studies that met the inclusion criteria.

Data Charting Process

Data extraction was completed using the Covidence 2.0 customizable template with categories adapted from the Joanna Briggs Institute 38 . Extracted variables included study characteristics (authors, year of publication, country of origin, study design), participant characteristics (age, sex, disease duration, Expanded Disability Status Scale (EDSS), and MS phenotype), DHT information (name, type, purpose, implementation setting, stage of DHT development) and usability considerations (evaluation method, questionnaire type, and DHT evaluator). We piloted the template, which led to the inclusion of “not reported” options for several items and the addition of examples to some item definitions to enhance consistency and ease of use. Three independent reviewers performed data extraction. When reviewers disagreed about the inclusion status of a citation, another reviewer examined the citation, and a three-way discussion was held to reach a consensus.

Data analysis

Data synthesis was performed in Microsoft Excel (Microsoft Office, 2019). We calculated inter-rater agreement during title and abstract and full-text screening (before the consensus meeting) using Cohen’s Kappa. No formal measures of agreement were used during the data extraction because differences in capitalization and punctuation generated messages of inconsistency, even if the critical content was the same between reviewers. Our focus was on the synthesis of descriptive features of the studies relative to usability, not on a synthesis of actual study results. We used descriptive statistics (frequencies, median and ranges), with data presented graphically and in tabular format as appropriate. We generated descriptive summaries of study characteristics (i.e., frequency/distribution of publication year, country in which the study was conducted, study design), participant characteristics (mean/median age, disease duration, and Expanded Disability Status Scale (EDSS), and frequency/distribution of sex, and MS phenotype), DHTs included in the literature (frequency/distribution of type, implementation setting, stage of DHT development), and usability considerations (frequency/distribution of usability characteristics, testing methods, and usability evaluator).

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

No data sets were generated or analyzed during the current study. The aggregated data analyzed in this study are available from the corresponding author upon reasonable request. This scoping review uses peer-reviewed articles and therefore does not require ethical approval.

Code availability

No code was generated during the current study.

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Acknowledgements

This work was completed as part of an endMS Scholar Program for Researchers IN Training (SPRINT) interdisciplinary learning project while Adam Groh, Colleen Lacey, and Fiona Tea were enrolled in the program. The SPRINT is part of the endMS National Training Program funded by MS Canada.

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Department of Neuroscience, Université de Montréal, Montreal, QC, Canada

Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, McGill University, Montreal, QC, Canada

Adam M. R. Groh

Department of Psychology, University of Victoria, Victoria, BC, Canada

Colleen Lacey

School of Rehabilitation Therapy, Queen’s University, Kingston, ON, Canada

Afolasade Fakolade

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Tea, F., Groh, A.M.R., Lacey, C. et al. A scoping review assessing the usability of digital health technologies targeting people with multiple sclerosis. npj Digit. Med. 7 , 168 (2024). https://doi.org/10.1038/s41746-024-01162-0

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Research Article

A gender-based review of workplace violence amongst the global health workforce—A scoping review of the literature

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

Affiliation Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

Roles Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Validation, Writing – original draft

* E-mail: [email protected]

Roles Formal analysis, Investigation, Methodology, Validation, Writing – original draft

Roles Formal analysis, Investigation, Software, Validation, Writing – review & editing

Affiliation Princess Margaret Cancer Centre, Toronto, Ontario, Canada

• Sioban Nelson, 
• Basnama Ayaz, 
• Andrea L. Baumann, 
• Graham Dozois

• Published: July 2, 2024
• https://doi.org/10.1371/journal.pgph.0003336
• Peer Review
• Reader Comments

Workplace violence (WPV) impacts all levels of the health workforce, including the individual provider, organization, and society. While there is a substantial body of literature on various aspects of WPV against the health workforce, gender-based WPV (GB-WPV) has received less attention. Violence in both the workplace and broader society is rooted in gendered socio-economic, cultural, and institutional factors. Developing a robust understanding of GB-WPV is crucial to explore the differing experiences, responses, and outcomes of GB-WPV with respect to gender. We conducted a scoping review and report on the prevalence and risk factors of GB-WPV in healthcare settings globally. The review followed the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We registered the scoping review protocol on the Open Science Framework on January 14, 2022, at https://osf.io/t4pfb/ . A systematic search was conducted of empirical literature in five health and social science databases. Of 13667, 226 studies were included in the analysis. Across the studies, more women than men experienced non-physical violence, including verbal abuse, sexual harassment, and bullying. Men experienced more physical violence compared to women. Younger age, less experience, shifting duties, specific clinical settings, lower professional status, organizational hierarchy, and minority status were found to be sensitive to gender, reflecting women’s structural disadvantages in the workplace. Given the high prevalence and impact of GB-WPV on women, we provided recommendations to address systemic issues in clinical practice, academia, policy, and research.

Citation: Nelson S, Ayaz B, Baumann AL, Dozois G (2024) A gender-based review of workplace violence amongst the global health workforce—A scoping review of the literature. PLOS Glob Public Health 4(7): e0003336. https://doi.org/10.1371/journal.pgph.0003336

Editor: Nazik Hammad, University of Toronto, CANADA

Received: December 26, 2023; Accepted: May 20, 2024; Published: July 2, 2024

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

Data Availability: The manuscript is a scoping review of workplace violence among healthcare professionals based on gender. All the abstracted data pertinent to the manuscript (226 studies) is tabulated in Table 1 and Table 2 . References are also included for all the sources used in the manuscript. All the references/ sources are publicly available.

Funding: The authors received no specific funding for this work.

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

Introduction

To achieve universal health coverage by 2030, the World Health Organization (WHO) and the Global Health Workforce Alliance adopted the global human resources for health (HRH) strategy in 2016. A foundational principle of the strategy is to "uphold the personal, employment, and professional rights of all health workers, including safe and decent working environments and freedom from all kinds of discrimination, coercion, and violence" [ 1 ], p.3. However, research demonstrates that workplace violence (WPV) is a significant issue impacting safe work environments for healthcare providers, with far-reaching impacts on individuals, healthcare organizations and society [ 2 ].

In 2002, the International Labour Office (ILO), the International Council of Nurses (ICN), the WHO, and Public Services International (PSI) launched a joint program aiming to develop a framework and guidelines for the prevention and elimination of WPV in the healthcare sector [ 3 ]. The general definition of violence adopted by the framework (2002) is "incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health" [ 3 ], p.3. Over time, this definition has been followed by diverse sources [ 2 , 4 ], including healthcare which is operationalized in this review. While definitions for various forms of WPV vary widely in different legal jurisdictions and various academic and research studies, we have considered definitions for this review listed in S1 Appendix .

Since the implementation of the above framework by ILO, ICN, WHO, and PSI [2002] to address WPV in the health sector, several studies have been conducted on various aspects of WPV, including the prevalence, risk factors [ 4 , 5 ], and interventions to de-escalate or eliminate WPV. Studies have been conducted in different clinical settings, geographic locations [ 6 – 8 ] and for different populations in the health workforce. Some studies reported the prevalence of WPV in the last 12 months or six months, while others did not specify the time period. Considering the heterogeneity, we included all the studies that reported gender-segregated data for WPV in the health workforce for this review.

Additionally, some studies reported the prevalence of WPV, which is alarmingly high in certain countries and professional groups. For instance, the prevalence of WPV for nurses was 91% in the USA [ 9 ] and 72% in China [ 10 ]. Higher incidences of WPV were also reported for physicians in India (41%) [ 11 ], and in Australia (58%) [ 12 ], and both nurses and physicians in Barbados, where nurses were twice (OR = 2,95% CI 1–5) as likely as physicians to experience verbal abuse [ 13 ]. While WPV can affect all healthcare providers, it is particularly problematic for women, who dominate the health workforce in most countries [ 2 ]. Some studies report differences in prevalence among male versus female healthcare providers [ 5 , 14 ]. Our initial impression of the literature is that the issue of gender-based workplace violence (GB-WPV) has received little attention in academic and policy literature, and it is to this aspect that we will now turn.

Influence of gender on workplace violence

Gender-based workplace violence (GB-WPV) is a worldwide issue rooted in a global culture of discrimination driven by socio-economic, cultural, and institutional factors [ 3 ]. While gender-based violence can affect people of all genders, it predominantly affects women, who experience discrimination at higher rates than men and are subjected to various kinds of violence in multiple contexts, most often carried out by men [ 15 , 16 ]. The United Nations Committee on the Elimination of Discrimination against Women (CEDAW) defined gender-based violence as “violence that is directed against a woman because she is a woman or that affects women disproportionately” [ 17 ]. In 2002 case studies were conducted in seven countries (Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand and Australia) as part of the ILO, ICN, WHO, and PSI joint program on workplace violence. The case studies revealed that more than 50% of the participants across all healthcare providers in each country, regardless of their profession and gender, experienced physical or psychological violence [ 18 ]. In more recent studies, WPV has been reported as particularly harmful to women due to their global preponderance in the health workforce and the impact of gendered power relations that disproportionally impact women [ 2 , 15 ]. Therefore, addressing the issue of GB-WPV is critical to meaningfully addressing the issue and supporting the recruitment and retention of women in the health professions [ 2 ].

We present a scoping review focused on understanding GB-WPV and related aspects of the global health workforce, including midwives, nurses, and physicians. Our preliminary literature review found that most sources understand gender-based violence as violence against women, including the CEDAW; however, GB-WPV affects everyone regardless of where they identify on the gender spectrum. Since most studies in this global review considered gender as binary (men and women; and a few studies [ 19 – 21 ] included non-binary personnel, which was less than 4% of the sample in those studies, in Table 1 , they also reported findings for men and women); to report data we defined gender as a binary (male/female) for this review. The specific objectives were:

• Map the most frequent forms and prevalence of GB-WPV for midwives, nurses, and physicians in different contexts and clinical settings.
• Identify the gendered dimensions of the health workforce that underpin violence against male or female health workers.
• Identify gaps in the state of knowledge to recommend empirical research studies.

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https://doi.org/10.1371/journal.pgph.0003336.t001

Protocol registration and study design

We conducted the scoping review according to Joanna Briggs Institute’s (JBI) revised guidelines [ 22 ]. The protocol ( S2 Appendix ) was registered on the Open Science Framework on January 14, 2022, and can be accessed at https://osf.io/t4pfb/ . We utilized the scoping literature review design to address the questions and to cater to the heterogeneous and complex literature because it is an appropriate method to explore the extent of the literature, map and summarize the evidence, and identify and analyze the knowledge gap to inform future research [ 23 ].

This framework consists of eight steps and originated from the seminal framework of Arksey and O’Malley’s scoping review [ 24 ], which was advanced by Levac and colleagues [ 25 ]. In the revised guidelines, JBI aligned the eight steps with the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [ 26 ], which is used to report the conduct of the scoping review that provided rigour, transparency, and trustworthiness [ 23 ]. Please see the filled PRISMA-ScR Checklist S3 Appendix . The first step of the scoping review framework is to align research objectives with the title and the inclusion criteria, which we have described in the earlier section and the inclusion criteria (see Box 1 ).

Box 1. Study selection criteria

Inclusion Criteria for Studies

1. The study participants included midwives, nurses, and/ or physicians who experienced WPV during their careers.

2. Provided sex-segregated data for any form of violence among midwives, nurses, and physicians, including students, globally.

3. Published in English and after 2010.

Exclusion criteria

4. Studies that did not provide sex-segregated data

5. Exclude qualitative studies, systematic/ scoping reviews, concept or theoretical papers, and theses.

Search strategy

The research team developed a comprehensive search strategy in consultation with the health sciences librarian. The search focused on the systematic search of published literature in the databases, including Ovid MEDLINE: Epub Ahead of Print, In-Process and Other Non-Indexed Citations; this search was then translated into CINAHL Plus, APA PsycINFO, Web of Science, Gender Studies Database, Applied Social Sciences Index & Abstracts (ASSIA) and Sociological Abstracts (see Ovid MEDLINE search strategy in S4 Appendix ).The search terms related to the population (midwifery, nursing, and physicians), concepts (violence and gender-based violence), and the context (healthcare) and appropriate combinations were used for searching for the scoping review [ 23 ]. These terms were identified from the preliminary literature search on different aspects of WPV using Google Scholar. The final search results were exported to EndNote. After de-duplication, these sources were imported into Covidence, an online program to streamline the screening process by two independent reviewers. To cover multifaceted gender-based WPV comprehensively from global perspectives required significant conceptual development and synthesis. The most recent search of the literature review for this study was conducted on 11 February 2024.

Evidence screening and selection

The identified sources were selected based on the set inclusion criteria in Box 1. Two independent reviewers screened the title and abstracts for shortlisted sources. The discrepancies were resolved with discussion and consensus and by reviewing the complete source, followed by a full-text review for selected sources against the set inclusion criteria by two reviewers and the abstraction of the information independently. The selection process is presented in the PRISMA diagram ( Fig 1 ).

https://doi.org/10.1371/journal.pgph.0003336.g001

Data extraction

Data from all included studies were extracted into Microsoft Excel; information was charted regarding author/s and year, title, source, country, objective/purpose, study design and methods of analysis, sample size, and category of health worker and sex/gender-segregated, key findings, and research gaps indicated by the author/s [ 23 ].

Data analysis and synthesis of results

Data from articles that reported descriptive statistics regarding sex/gender were included in mapping the prevalence of GB-WPV ( Table 1 ) for several types/forms of WPV and the clinical setting. Some studies treated gender as a risk factor or a predictor for the outcomes of WPV, harassment, and discrimination using inferential statistical analysis presented in Table 2 . We could not calculate a mean score for violence based on gender because of variability in the definition of the terms and the concepts from various contexts (Please see S1 Appendix for definitions of the various forms of WPV). Besides prevalence and gender as a risk factor, other data are described qualitatively, including the risk factors or predictors, the distribution of WPV based on professional category, the professional hierarchy, the perpetrators, reporting systems, and any preventive interventions and their outcomes.

https://doi.org/10.1371/journal.pgph.0003336.t002

Given the overall objective of the review to map the most frequent forms and prevalence of GB-WPV for midwives, nurses, and physicians in different contexts and clinical settings, a quality assessment of the identified sources was not conducted. This paper describes the prevalence of WPV based on gender, the influence of gender and the clinical setting, the professional status/role, and the professional hierarchy and gendered roles and responsibilities that have marginalized either males or females within the professional categories. Other aspects, such as perpetrators of GB-WPV and findings of qualitative studies, will be reported elsewhere.

Description of identified studies

After de-duplication, 9529 possible references were imported for screening in the Covidence. These studies were screened against the title by one person, 1751 were shortlisted to be screened (for title & abstract) by two independent reviewers, and 402 were assessed for full-text eligibility. After applying the inclusion and exclusion criteria, 226 studies were retained and analyzed to report on GB-WPV (PRISMA diagram, Fig 1 ). We included studies published between 2010–2024.

Study design and population

Fig 2 presents the proportion of studies (226) included in this paper that used a sample of nurses, physicians and/or the entire workforce.

https://doi.org/10.1371/journal.pgph.0003336.g002

We present findings for midwifery, nursing, and medical workforce samples and subsamples only from across the world. Most of the included studies were conducted in the USA (n = 63), followed by China (n = 20), Turkey (n = 9), Australia (n = 9 [2 studies also included New Zealand]), Italy (n = 9), Saudi Arabia (n = 9), Iran (n = 8), The UK (n = 6), Canada (n = 6), Jordan (n = 6), Brazil (n = 5), Greece (n = 5), Pakistan (n = 5), Ethiopia (n = 3), India (n = 3), Norway (n = 3); 11 countries/special regions including Bangladesh, Taiwan, Ghana, Spain, Germany, Kenya, Poland, South Africa, Switzerland, Palestine, and Cyprus had two studies each (n = 22); 29 other studies conducted one in each country and Six used a global sample from other platforms, such as conferences and professional/research forums.

Prevalence of gender-base workplace violence

A total of 226 studies provided sex-segregated descriptive data for WPV. Of the 226, 185 studies [ 5 , 7 , 11 – 14 , 19 – 21 , 27 – 202 ] provided sex-segregated prevalence data (descriptive) for different forms of WPV (see Table 1 ). Forty-one studies [ 203 – 243 ] provided inferential statistics for violence about gender as a risk factor or predictor of consequences of WPV ( Table 2 ). Of 185 studies that provided descriptive statistics for various forms of WPV, 119 studies (64%) reported a higher prevalence for women participants for all forms of violence as opposed to 31 studies (17%) that reported a higher prevalence for men participants ( Fig 3 ).

https://doi.org/10.1371/journal.pgph.0003336.g003

Furthermore, 35 studies (19%) reported a higher prevalence of various forms of violence for either men or women, such as in India, where physical violence was higher for men (16%) than women (4%). In contrast, threats were higher for women (58%) than men (47%) [ 11 ]. Similarly, the prevalence of physical violence was higher for men compared to women in Australia [ 83 ], USA [ 174 ], China [ 5 , 89 , 155 ], Iran [ 115 , 129 ], Iraq [ 123 ], Italy [ 198 ], Austria [ 150 ], and Pakistan [ 133 ]. On the other hand, non-physical violence was higher for females in Australia [ 83 ], China [ 5 , 89 ], Canada [ 95 ], Iran [ 115 , 129 ], Iraq [ 123 ], USA [ 174 ], and Austria [ 150 ]. A recent world-wide study collected responses (5405) from all healthcare professionals, including nurses and physicians from 79 countries reported on nature, risk factors and impact of violence [ 175 ]. Banga and colleagues (2023) reported higher emotional violence (30.6% Vs. 26%) and sexual violence (7.4% Vs.3.8%) among women and higher physical violence (24% Vs. 19%) among men. In the same study, being nurse had higher odds (OR = 1.95; 95% CI 1.46–2.59) of violence than physicians (OR = 1.70, 95% CI 1.33 to 2.18) and other providers (OR = 1.58; 95% CI 1.21 to 2.05).

Factors affecting workplace violence

Not all studies were aimed at assessing workplace violence based on gender; therefore, we included all studies that either provided data on gender-based workplace violence or findings that indicated gender was a factor for WPV or a predictor for various outcomes of WPV. The latter group of studies had various aims, including: to assess factors associated with workplace violence [ 19 , 27 – 33 , 139 , 204 – 207 , 243 ], to assess the association between aggression, psychological distress, and job satisfaction [ 34 , 35 , 120 , 187 ], to determine injuries resulting from physical assaults [ 203 ], to determine the relationship between WPV and psychological and behavioral responses [ 35 – 37 , 161 , 200 , 202 , 208 – 211 ], to assess effects of lateral violence and its consequences [ 38 , 212 ], and to assess the preparedness to respond to sexual harassment before and after a workshop [ 39 , 65 ]. In addition to gender as the basis for WPV, we classified other factors associated with WPV that were not explicitly gendered, such as age and status (presented below). However, these factors are implicitly aligned with the broader societal norms and the inherent patriarchal structure of the health system, including the health workforce that assigns roles and responsibilities to male and female healthcare providers based on their gender, leading to differential experiences, including exposure to workplace violence, we present in the following section.

Various forms of violence and gender differentials.

Gender influenced both female and male healthcare providers’ experiences of different forms of workplace violence. Women were the most targeted for non-physical violence, including verbal violence [ 5 , 7 , 13 , 40 , 41 , 80 , 83 , 92 , 98 – 100 , 103 , 106 , 108 , 110 , 114 , 115 , 117 , 123 , 125 , 129 , 133 , 135 , 147 , 150 , 166 , 175 , 178 , 183 , 185 , 188 – 190 , 198 , 213 ], sexual harassment [ 7 , 12 , 20 , 21 , 40 , 74 , 75 , 78 , 79 , 81 , 82 , 85 , 86 , 88 , 93 , 94 , 99 , 100 , 104 , 108 – 110 , 116 – 119 , 121 , 126 – 129 , 131 , 132 , 143 , 148 – 150 , 152 , 154 , 158 , 160 , 161 , 172 , 173 , 175 , 176 , 179 , 182 , 186 , 193 , 196 , 201 , 213 , 214 ], bullying [ 7 , 42 , 73 , 87 , 94 , 99 , 101 , 119 , 121 , 132 , 135 , 144 , 182 , 184 , 192 , 215 ], and discrimination [ 75 , 79 , 81 , 104 , 107 , 108 , 117 – 119 , 121 , 122 , 128 , 131 , 132 , 149 , 183 , 216 ]. However, women also experienced physical violence [ 7 , 99 , 106 , 110 , 114 , 124 , 125 , 136 , 142 , 148 , 164 , 176 , 178 , 183 , 188 – 191 , 214 ], threats [ 11 , 41 , 93 , 200 ], and aggression [ 90 , 113 , 166 ] from various sources. Men also experienced non-physical violence, including verbal [ 11 , 12 , 70 , 72 , 97 , 112 , 115 , 139 , 142 , 146 , 167 – 169 , 174 , 186 , 199 , 200 , 202 , 243 ], sexual harassment [ 115 , 156 , 164 , 167 , 186 , 199 , 200 ], bullying [ 43 , 120 , 129 , 145 , 182 , 211 , 217 , 218 ], and discrimination [ 95 ]. Physical violence was the only form of violence with a higher reported prevalence in men compared to women [ 11 , 12 , 29 , 31 , 70 , 71 , 83 , 89 , 97 , 103 , 112 , 115 , 123 , 128 , 129 , 133 , 146 , 155 , 156 , 166 – 171 , 174 , 175 , 181 , 195 , 198 , 202 , 204 , 219 – 224 , 243 ].

The studies also reported on the differential effects of WPV on men and women. For instance, women were significantly more likely than men to experience changes in mental health and social behaviours [ 89 , 96 , 117 , 130 , 191 , 200 , 208 ] because of violence. Violence is also reported to have affected female healthcare providers’ career goals and development [ 44 , 88 , 118 , 154 , 175 ], leading to dissatisfaction [ 34 , 118 , 175 ] and burnout [ 34 , 45 , 102 , 117 , 121 , 128 , 174 , 209 ], and leaving or considering leaving the workplace [ 7 , 46 , 80 , 175 , 212 , 217 , 219 , 225 ]. However, these consequences were rarely highlighted for men. A recent study compared and found an inverse association between workplace violence and patient safety behaviours among nursing interns in China, in that male nursing interns were more likely to exhibit poor patient care behaviour. In contrast, female nursing interns were more likely to exhibit poor mood [ 200 ]. In addition to gender, the following demographic factors were related to the risk of WPV among healthcare providers.

Younger age was found to be a significant risk factor for violence by several studies for both male and female healthcare providers [ 7 , 12 , 14 , 33 , 35 , 36 , 47 – 50 , 73 , 76 , 78 , 83 , 89 , 91 , 92 , 96 , 98 , 103 , 123 , 139 , 141 , 147 , 152 , 165 , 190 , 195 , 198 , 219 , 224 ]. The studies that reported a higher prevalence of WPV in general for women also reported that the younger age of the health care provider was associated with a higher risk of violence in various contexts, including verbal abuse [ 14 , 36 , 83 , 92 , 98 , 123 , 204 , 219 ], bullying, or mobbing [ 14 , 47 , 50 , 73 , 165 , 226 ], sexual harassment [ 12 , 36 , 44 , 49 , 78 , 152 , 224 ] and aggression [ 147 , 159 ]. A few studies reported a higher prevalence of violence among males, especially of a younger age, who were at increased risk of verbal violence [ 139 ] and bullying among nurses [ 211 , 218 ] and physical violence among physicians, nurses, and others [ 195 , 224 ]. Some studies found that advanced age was a protective factor that decreased the risk of WPV [ 36 , 89 , 91 , 191 ].

Work experience.

Several studies reported on an association between the years of experience and the occurrence of different forms of WPV, and most studies found this relationship to be inversely proportional [ 12 , 35 , 49 , 76 , 98 , 99 , 111 , 123 , 124 , 146 , 152 , 171 , 194 , 203 , 204 , 212 , 214 , 219 , 223 , 227 – 229 ]. We analyzed the forms of violence which had a higher prevalence for either men or women to examine any connection to years of work experience. Studies reported that men experiencing more verbal abuse [ 219 ], physical violence [ 123 , 146 , 171 ], and bullying [ 218 ] had the least work experience. Similarly, less experience as a factor for verbal abuse [ 98 ], sexual harassment [ 12 , 149 , 152 ], physical violence [ 124 ], horizontal violence [ 229 ], bullying [ 35 ] and aggression [ 159 ], in studies which reported women as victims of WPV. In addition, the increased experience seemed to be a protective factor against physical violence among nurses [ 228 ].

Professional and organizational hierarchy.

The professional hierarchy among midwives, nurses, physicians, and others [ 13 , 47 , 51 , 83 , 87 , 90 , 96 , 105 , 110 , 134 , 140 , 143 , 159 , 165 , 169 – 172 , 183 , 189 , 198 , 205 , 224 ] and the organizational hierarchy within or between different professionals [ 47 , 80 , 95 , 116 , 152 , 165 , 184 , 194 , 204 , 226 , 230 , 242 ] was found to contribute to various forms of workplace violence. Some studies reported a higher prevalence of WPV among women across the workforce; they reported that female nurses’ experience of WPV was higher than female physicians in Australia [ 83 ], Brazil [ 96 ], Canary Island [ 189 ], France [ 197 ], Kenya [ 183 ], Italy [ 31 , 105 ], Japan [ 110 ], Turkey [ 138 ], Ghana [ 36 ], and India [ 146 ]. Verbal abuse was prevalent for female nurses in the Caribbean [ 13 ], Norway [ 224 ], and Cyprus [ 231 ] from patients or relatives; aggression from staff and colleagues was prevalent in England [ 90 ], from patients and visitors in Switzerland [ 205 ], and from patients in Poland [ 51 ], Israel [ 176 ] and Italy [ 159 ]; mobbing was found to be prevalent for female nurses in Turkey [ 140 ] and Cyprus [ 165 ], and sexual harassment was found to be prevalent among female nurses in Nepal [ 143 ] and Saudi Arabia [ 172 ]. A smaller number of studies reported a higher prevalence of violence for males in Colorado, USA [ 134 ], Turkey [ 141 ], China [ 155 ], Jordan [ 169 ] and Saudi Arabia [ 170 , 171 ]. The last three studies in Jordan and Saudi Arabia reported more physical violence for men in emergency departments, where most assailants were patients and their relatives [ 169 – 171 ], which could be explained by overcrowding, increased waiting time, and increased workloads for health care providers [ 171 ].

In a Greek study, the prevalence of bullying was higher among women (nurses and physicians); however, women physicians self-labelled as being victims more often than nurses [ 87 ]. Another study in India reported that physician participants experienced more episodes of WPV (77%) followed by nurses (48%); the overall prevalence rates were higher for women [ 14 ]. In the context of Saudi Arabia, in a study, both physicians and nurses (68.5% vs 68%) [ 73 ], and in another study, nurses (82%) and medical residents (15%) experienced bullying from various sources [ 35 ]; both these studies found overall higher prevalence for women than men (66% vs.49%) [ 73 ], (69% vs. 31) [ 35 ], that explain gender intersection with professional hierarchy that victimized women.

The formal organizational hierarchy played a role in perpetuating workplace violence due to the inherent power dynamics in the health workforce. One study in Cyprus [ 165 ] reported that mobbing, which involves hostile and unethical communication directed systematically towards an individual, was prevalent among women in the workforce, with nurses significantly more affected than physicians. The same study also reported that chief and senior nurses were significantly less exposed to bullying behaviours than junior nurses (33.3% and 46.7% vs. 56.1%). Similarly, a study in a forensic hospital in California, USA, reported men experiencing a higher frequency of assaults in wards than men in clinics and supervisory positions [ 230 ]. Banga and colleagues [ 175 ] included participants from 79 countries who reported that 16% of the participants experienced aggression from their supervisors. In the study, nurses were more likely to experience higher levels of violence than physicians. Fifty-five percent of victims reported job dissatisfaction, and 25% were willing to quit.

Several studies reported exclusively on nursing personnel. A study conducted in Poland reported seniority as a protective factor against bullying and that nurse managers experienced a significantly lower level of bullying compared with clinical nurses and nurse coordinators [ 226 ]. In China, male nurses who had lower professional titles in intensive care units had higher odds of experiencing WPV [ 210 ]. Another study from Lebanon reported male nurses’ higher risk for exposure to violence, and managers/supervisors were found to be the most common perpetrators of verbal abuse [ 219 ]. In this Lebanese study, male nursing students reported experiencing discrimination in the female-dominated profession.

Interestingly male medical professionals likewise reported violence and discrimination based on gender. In fact, several studies reported a significant relationship between the role, seniority, and the experience of violence among medical personnel. For instance, male medical residents and General Practitioners (GPs) had higher odds of violence than specialists in an emergency department in Turkey [ 76 ], GPs in China [ 204 ], and junior residents in India [ 146 ]. On the other hand, female medical personnel experienced more harassment and discrimination throughout their career, including in academia, regardless of role or seniority. Of 185 descriptive studies, 46 (25%) reported that women in medicine experienced sexual harassment, with trainees and residents most affected [ 20 , 21 , 37 , 39 , 52 – 54 , 74 , 75 , 78 – 82 , 85 , 88 , 94 , 95 , 107 – 109 , 116 – 119 , 121 , 126 , 127 , 130 – 132 , 148 , 150 , 152 , 154 , 158 , 160 , 161 , 173 , 174 , 182 , 184 , 186 , 187 , 196 ]. On the other hand, both male (70%) and female (69%) residents in obstetrics and gynecology (OBGYN) experienced sexual harassment in the USA [ 66 ]. Another study [ 116 ] in a US medical college reported that one-third of respondents experienced sexual harassment, a finding that was inversely proportionate to the academic rank held: medical students (51.7%), residents/fellows (31%) and faculty members (25%). Similarly, sexual harassment was higher among women in vascular surgery who did not hold leadership or academic titles and were ranked lower than assistant professors [ 152 ]. This phenomenon holds true for multiple specialty areas in medicine: respondents from a study in Australia and New Zealand reported a higher proportion of sexual harassment, bullying, and discrimination among female trainees in ophthalmology compared to staff ophthalmologists [ 132 ]. An online survey of cardiothoracic surgeons also found higher rates of sexual harassment among trainees [ 85 ]. A recent study [ 184 ] reports for participants from 28 countries on Bullying, Undermining, and Harassment (BUH) in peripheral vascular disease department, where women’s experience of BUH was higher than men (53% vs. 38%). Medical students reported the highest prevalence of BUH (57%) followed by residents (65.7%), fellows (41%), and consultants (37%). Another study in France included midwifery, nursing and medical student reported higher prevalence of GBV for female student (93.7vs. 5.4%). In Canada, a higher proportion of women than men in family medicine experienced intimidation, harassment, or discrimination based on gender, and hierarchy was also identified as a factor [ 95 ]. Similarly, in orthopedics, women experienced gender-based harassment and sexual harassment significantly higher than men. Similarly, in orthopedics, women experienced gender-based harassment (98% vs.68%) and sexual harassment (83% vs. 71%) significantly higher than men. In this specific study men represented 72% of the sample [ 19 ]. One US study with a large, representative sample (n = 6000) from a national survey reported that greater women’s representation within a specialty is associated with lower sexual harassment for both men and women from coworkers and patients [ 206 ].

Clinical routines.

Workplace routines for all health workers were found to be risk factors for exposure to violence, including longer working hours [ 5 , 151 , 156 , 161 , 171 , 226 ], shifting duties, particularly night shifts [ 14 , 30 , 55 , 56 , 69 , 76 , 124 , 139 , 141 , 155 , 156 , 167 , 172 , 175 , 188 , 219 , 243 ], and direct patient care [ 153 , 159 , 172 ]. Night shifts were found to be a risk factor for WPV among male nurses in Bangladesh [ 30 ], Iran [ 69 ], Lebanon [ 219 ], Turkey [ 76 ], Korea [ 139 ], and China [ 155 , 167 , 243 ]. In Saudi Arabia, male nurses working with more than ten staff members were found to be at risk of verbal abuse [ 72 ]. Additionally, hours of work and type of position were found to be risk factors for WPV in several studies for women. Working full-time [ 153 ], shifting duties [ 124 ], overtime/more hours of work [ 226 ], and direct patient care [ 153 , 159 , 172 ] were all associated with higher rates of exposure to violence among female nurses. In the case of medical personnel, male GPs in Australia who worked full-time experienced higher levels of verbal abuse than part-time GPs [ 12 ].

Clinical setting.

Several studies examined specific clinical settings and the risk for physical and non-physical violent incidences. Most incidents occurred in the emergency department (ED) and psychiatric settings [ 72 , 76 , 89 , 105 , 110 , 111 , 138 , 153 , 166 , 169 – 172 , 178 , 181 , 188 , 202 , 203 , 221 , 232 , 243 ]. Several studies reported female nurses suffering non-physical violence in EDs in China [ 89 , 208 ] and Ethiopia [ 111 ] and in psychiatric units in the USA [ 153 ]; physical violence was experienced in pediatric clinics in Turkey [ 138 ] and China [ 208 ], psychiatric units in USA [ 203 ], and in the primary/secondary care facilities in Brazil [ 151 ]. Female nurses also experienced both physical and non-physical violence in ED [ 232 ] and ICU [ 214 ] in Greece, in adult health in Scotland [ 57 ] and in psychiatric units in Japan [ 110 ] ED in Iran [ 188 ], and South Africa [ 178 ]. Another study reported female nurses experiencing bullying in the operating rooms and maternity wards [ 43 ], and male nurses were reported to experience bullying in medical/surgical units, outpatient clinics, and critical care units [ 101 ]. Female physicians also experienced bullying and discrimination in laboratory-based specialties and surgical and medical settings [ 93 ]. Male nurses in Jordan [ 169 ] and Saudi Arabia [ 72 ] experienced verbal violence in EDs, as did male physicians in Turkey [ 76 ]. These studies demonstrate that WPV is persistently more prevalent among women and nurses across clinical settings.

Furthermore, several studies reported that more female medical personnel report sexual or gender harassment in male-dominated surgical specialties than in other settings [ 21 , 78 , 85 , 130 , 182 ]. In the surgical specialties, the prevalence was higher for women compared to men in cardiothoracic surgery [ 85 , 130 ], pediatric surgery (80%) and neurosurgery [ 130 ], and vascular surgery [ 21 ]. Similarly, sexual harassment was also experienced by female nurses in public hospitals in China [ 155 ], Rwanda [ 7 ], Ghana [ 80 ], and Japan [ 110 ]. In addition, both male and female nursing students in Taiwan [ 86 ] and Catalonia [ 179 ] experienced sexual violence during university education.

Ethnicity/nationality.

The nationality or ethnicity of the healthcare professionals also was a factor in the experiences of WPV among nurses and physicians. For instance, male nursing personnel in Iran with non-Farsi ethnicity experienced significantly higher levels of physical violence (OR- 2.34) [ 115 ]. Similarly, physical violence was significantly associated with non-Omani and non-Saudi nationality in Oman [ 71 ] and Saudi Arabia [ 171 ], respectively. In Saudi Arabia, workplace bullying was also more prevalent among expatriate non-Saudi health practitioners [ 35 , 73 ]. International Medical Graduates (IMG) in Australia, particularly general practitioners and registrars, experienced significantly higher aggression from patients compared to non-IMGs (63% vs. 52%), from relatives (15% vs. 12%) and coworkers (5.7% vs. 3.9%), and this was highest among female IMG staff [ 114 ]. In a large academic medical centre in the USA, white female physicians experienced fewer mistreatment episodes than black physicians and those of other races [ 37 ]. Further, in radiology, women graduates from foreign medical schools were more likely to report sexual harassment compared to the US graduates (77.1% vs. 54.1%) [ 82 ]. Similarly, in China, non-Asian individuals were more likely to experience harassment, and women reported being offered career advancement in exchange for sexual acts [ 88 ]. Additionally, bullying was more common among Asians (female faculty members) in a faculty of health sciences in South Africa [ 58 ]. Bullying and harassment among non-white vascular physicians were reported in 28 countries [ 184 ].

Discrimination based on gender experienced by women, where nationality was a factor, was frequently reported by surgical residents in Australia and New Zealand [ 94 ] and the USA [ 107 ], and in pediatrics (USA) [ 121 ]. While in Canada, there was no significant difference in the proportion of Canadians (46%) and IGMs (41%) in family medicine experiencing intimidation, harassment, and discrimination (IHD). However, more IMGs perceived IHD based on ethnicity, culture, or language [ 95 ]. Similarly, surgical residents (8.8%) in Spain experienced discrimination due to their country of origin, including both women and men [ 128 ]. The data revealed an association between WPV and the minority status globally, except for one instance in a public hospital ED in Saudi Arabia, where more Saudis (51.8%) than non-Saudis (33.8%) experienced incidences of all forms of violence [ 112 ].

In our comprehensive review of descriptive studies, an apparent gender disparity in the prevalence of workplace violence (WPV) emerged. Overall, 64% of descriptive studies reported a higher prevalence of all forms of WPV for women, including sexual violence, verbal abuse, discrimination, bullying and physical violence. On the other hand, only 17% of the descriptive studies reported men’s higher experience in all forms of WPV, including physical violence, verbal violence, bullying and sexual violence. The remaining 19% of the studies that reported higher prevalence for various forms of WPV, either for men or women, are presented in Table 1 . All these studies also reported several factors explaining the disparities in prevalence rates for different forms of violence among diverse groups. Firstly, some studies in our review reported insufficient data due to underreporting because of the retrospective nature of reporting mechanisms [ 83 , 156 , 166 , 203 , 232 ], as most of the incidents were reported after they had occurred, thus introducing the potential for recall bias. Retrospective reporting can also affect the participant’s ability to accurately recall the incident because, over time, they may tend to express feelings to friends and family members, which helps alleviate distress. Additionally, the reporting hierarchy in the organization and the research process [ 83 , 136 , 232 ] bring challenges to accurate reporting because of the fear of retaliation by the supervisors, as many were perpetrators of violence [ 74 , 233 , 237 ].

While these factors contributed to variability in data, they also provided insight for addressing gender-based workplace violence and achieving justice for affected individuals, particularly women, which involves multifaceted dimensions. First, it necessitates shielding individuals from existing and potential aggressors by bolstering policies and reporting efforts to safeguard rights in the workplace, such as fostering a comprehensive understanding of safety within the work environment. Secondly, addressing victims’ grievances requires strengthening institutional responses tailored to GB-WPV. Lastly, imposing stringent expectations and repercussions on perpetrators entails heightening the consequences for individuals perpetrating such acts and increasing awareness. This emphasizes three critical approaches: enhancing policies, fortifying institutional capacities, and implementing tailored intervention programs for those involved with GB-WPV [ 244 ]. In addition, research efforts should focus on understanding barriers to reporting and devising strategies to enhance reporting accuracy, working in tandem with healthcare institutions and supervisors to develop more effective reporting systems and policies that prioritize the well-being and safety of all staff in a way which protects victims of vertical violence. Further, institutions may consider using non-institutional groups to collect and manage information about GB-WPV. Using non-institutional mechanisms may reduce interference by institutional self-interests and reduce gender biases within healthcare [ 245 ].

Further, studies in this review reported methodological constraints, including sampling frames (small size, convenience sampling, self-selection, non-representative sample, etc.) [ 13 , 81 , 82 , 90 , 106 , 163 , 230 , 234 ], which may lead to findings biased toward one group or the other. Furthermore, different assessment methods and measurement tools [ 87 , 92 , 122 , 125 , 166 , 223 , 228 , 235 ] have been acknowledged to limit the generalizability of results. Additionally, differential operational definitions of terms [ 82 , 95 , 101 , 104 ] and their understanding can limit the reporting and lead to insufficient data. Though we did not critically appraise these studies, or include ‘grey literature’ sources, we acknowledge that these limitations also limited us to producing a cumulative prevalence in this review. Considering the limitations, we presented the proportions of studies that reported a higher prevalence of WPV for men and women and synthesized factors affecting the disproportionate perveances.

As this is a global study, some regions with limited research capacity are at risk of being omitted from this study. In such contexts, formal studies meeting scientific journal standards may not be feasible, leaving significant gaps in our understanding of GB-WPV prevalence and its impact. One of the studies included in this review sent a worldwide invitation for participation in the study about violence in the health system. Though the study received responses from 110 countries, the researchers excluded responses from 31 countries because of inappropriate responses that did not meet the rigor of the research process [ 175 ]. In those contexts, incidents of GB-WPV may be documented in various sources beyond traditional scientific literature, such as internal hospital documents and social media, if documented at all. The reliance on "grey data" introduces its own set of challenges, including issues of reliability, consistency, and accessibility, which this review did not undertake.

A recent systematic review of 253 studies could not determine any significant differences in the prevalence of any form of WPV according to sex, which was attributed to the sample of studies; only 27% of studies included in that review presented the sex-segregated findings [ 4 ]. In our scoping review, we report findings from 226 studies that provided sex-segregated data; WPV is a multifaceted topic where women’s experience of violence was disproportionately high for almost all forms and contexts. Developing gender-sensitive programs, processes, and policies in healthcare settings is crucial, including a gender-balanced workforce that could benefit both men and women [ 206 ]. This approach not only aims to safeguard those from prevalent forms of violence but also acknowledges and addresses the often-understated experiences of violence encountered by men. Training and education sessions have been deemed effective when there is a multidisciplinary approach; they focus on education to enhance knowledge and alter attitudes [ 244 ]. These tailored initiatives could help mitigate instances of violence [ 245 ]. In addition, the identified gender-based workplace violence (GB-WPV) trends among healthcare professionals should be investigated using rigorous scientific standards to better explore the phenomenon of GB-WPV and related factors [ 136 ]. Furthermore, studies must investigate GB-WPV in various clinical settings on a larger scale, including trialing interventions (policies and reporting mechanisms) and their impact by adopting longitudinal, prospective study designs [ 246 ]. The revised policies and interventions must consider gender mainstreaming (integrating gendered perspectives in all phases and including both men and women in developing programs and policies) before being implemented in the clinical settings.

Gendered power relations within organizational and professional hierarchies played a critical role in enabling WPV between and within professional groups. For instance, studies that included medical and nursing personnel [ 13 ] found that gender is a significant predictor (OR = 9) for WPV in primary care clinics. Female nurses and physicians were 11 times more likely to experience verbal abuse and nine times more likely to experience any form of violence than males. This study also reported that nurses have double the risk of experiencing verbal abuse compared to physicians [ 13 ]. The prevalence of gender-based discrimination was also higher for women within the medical profession in most high income countries, including Australia, the USA, and Canada [ 74 , 75 , 81 , 95 , 104 , 119 ], as well as Saudi Arabia and India [ 79 , 108 ]. These hierarchical gendered relations between men and women reflect those in society at large, and in most cultures and geographic locations, men hold most positions of authority. Preventative measures must be enacted, including robust policies against retaliation and comprehensive training for supervisors on appropriate behaviour. Reforms must consider and confront broader societal gender-based roles of men and women, often reinforcing power imbalances. Recognizing and challenging societal norms is essential to creating sustainable safeguards within healthcare settings, ensuring a more equitable distribution of power and opportunities for men and women. This could include support programs for those impacted. Interventions which expand access to social support are helpful when addressing issues of abuse [ 247 ]. By integrating gender-sensitive approaches and survivor considerations into these reforms, institutions can strive towards fostering a workplace culture that addresses workplace violence and promotes gender equality and inclusivity.

Historically, men have dominated decision-making, leadership roles, and participation in healthcare organizations as a direct result of patriarchal social structures [ 248 ]. Male professional domination could explain the higher prevalence of WPV among women in our review in various contexts. In that, men dominated healthcare organizations, specifically medicine, and they also held more institutional power than nurses [ 248 , 249 ]. Grant et al. [ 249 ] explained that women’s voices often face suppression within these arenas, influenced by the attitudes prevailing among those in positions of power and the prevalent culture of blaming victims [ 249 ]. Similarly, Salles et al. [ 248 ] elucidated that the scarcity of women in leadership positions within academic medicine reflects deeply ingrained biases, which are then reinforced by biases favouring men as inherently better leaders. This likely contributes to the disproportionate underrepresentation of women in healthcare leadership roles and less power. Based on the findings on risk factors, there is also a need to understand the interconnected nature of social categorizations and how they intersect with gender to shape the experiences of the health workforce in different situations.

Moreover, WPV involves individuals, groups, and the organization/community. Thus, there is a critical need for policies and interventions to address WPV to target eliminating gender inequality more broadly and to focus interventions at different levels [ 250 ]. At the level of the individual, interventions should create awareness about the forms of violence, existing policies and mechanisms for reporting that empower individuals to advocate for themselves [ 251 ] and others affected by the incidents [ 127 , 128 , 161 ]. We also recommend improving the structural factors, including physical conditions of work and equitable allocation of women and men in positions of authority in the workplace.

Intervention at the organizational level must target changing the organizational climate, focusing on developing and disseminating zero-tolerance policies [ 250 ] comprising transparent and trustworthy reporting mechanisms (regardless of the perpetrator, including patients or family members, supervisor, etc.). Proposed interventions include alert systems [ 166 ] and ‘hot-lines’ [ 211 ]. These mechanisms must be paired with clear and consistent action [ 132 ] to handle complaints for investigations that follow through with sanctions and penalties to the offender [ 85 , 250 ].

Moreover, given that gender intersects with other social determinants, strategies must consider these and how they may intersect. For example, the age and professional experience of the victim, the clinical setting, the patients’ complexity, the nature of work, and the location of an individual in the organizational hierarchy [ 113 ] need deliberate attention for inclusivity. The findings of studies included in this review also call for transformational interventions. For instance, in most cultures, women carry a disproportionate amount of domestic responsibility compared to men and thus may require support to manage their large home and work responsibilities. Flexibility in scheduling and supportive workplace cultures are key to changing the work culture at healthcare institutions. Awareness of the vulnerabilities and pressures on early career professionals who may experience additional pressures, including a higher risk of violence in the workplace and domestic/family pressures at home, is vital to building a sustainable health workforce. Besides, collaborative efforts must be made to alter the cultural and patriarchal systems that contribute to women’s exposure to GB-WPV by creating awareness and condemning GB-WPV through media and strategic advocacy directed at appropriate political, cultural, and religious leaders [ 252 ]. Finally, the programs and policies initiated to respond to GB-WPV should be tested empirically for their effectiveness [ 217 ], and interventions that are based on evidence must inform policies and procedures [ 12 , 83 ].

Sexual harassment is a form of violence that has significantly affected women in the health workforce and is enabled by the professional and organizational hierarchies rooted in organizational cultures that provide impunity to perpetrators [ 253 ]. In our review, 25% of studies reported harassment significantly affected women in the medical workforce, particularly the trainee medical residents in most contexts [ 20 , 21 , 37 , 39 , 52 – 54 , 74 , 75 , 78 – 82 , 85 , 88 , 94 , 95 , 107 – 109 , 116 – 119 , 121 , 126 , 127 , 130 – 132 , 148 , 150 , 152 , 154 , 158 , 160 , 161 ]. Women in nursing also experienced sexual harassment [ 36 , 40 , 49 , 86 , 99 , 129 ]. On the other hand, lateral violence or bullying was a significant issue highlighted in nursing and midwifery professions [ 36 , 212 , 229 ]. Considering the hierarchical levels that exist within professions and between professions, interventions must be directed to bring change at each level, including at individual (creating awareness and offering protection), organization (transparent and anonymous system for voicing change, flattened hierarchy and leadership training), and at the system level to prevent accumulation of power at the top. Open, transparent reporting relationships, diversity in career pathways and women’s inclusion at all levels of leadership have also been suggested as ways to address organizational hierarchy that may perpetuate GB-WPV [ 254 ]. In addition, mandatory training in programs tailored to recognize, manage, and prevent GB-WPV for all healthcare professionals is imperative [ 251 ]. Similarly, policy formulation and implementation for preventing and managing WPV at the national level (e.g., Ministry of Health and professional councils and associations) [ 218 , 252 ] and creating reforms for independent monitoring, reporting, and sanctioning to end impunity [ 250 ] are crucial steps. To address this issue, governments, irrespective of geographical location, ought to bolster the legal system’s capacity to handle cases of sexual abuse effectively including revising labour laws, introducing special legislation and enforcing the same [ 3 ]. Since the guidelines developed in 2002 by ILO, ICN, WHO, and PSI are useful in addressing workplace violence and guiding governments, we suggest the revision and joint efforts of the global health alliances to revise the "Framework Guidelines for Addressing Workplace Violence in the Health Sector" [ 3 ] with regards to strengthening legal systems in all counties. A recent analysis of Canadian court cases of violence against nurses revealed that despite having significant injuries, historically, being a nurse was not always considered an aggravating factor in sentencing under criminal law. Therefore, the authors highlighted the need for ongoing legal efforts to combat the widespread acceptance of workplace violence in healthcare and the enactment or stringent enforcement of laws to safeguard victims’ rights [ 255 ], thereby providing a more robust framework for protection and recourse against WPV.

Entrenched hierarchical structures often reflect traditional gender norms, where men predominantly hold leadership positions and women are confined to frontline care roles. Simplifying even patient-initiated GB-WPV as a by-product of physical proximity overlooks the deeper systemic issues. Our research reveals how GB-WPV is symptomatic of broader societal injustices rooted in sexism and discrimination, affecting marginalized groups, including women across the globe. These power imbalances create environments where women’s voices are marginalized, their concerns dismissed, and their experiences of violence trivialized. This marginalization not only limits their agency but also exacerbates their vulnerability to GB-WPV. Failing to acknowledge the gendered origins of WPV places countless women in healthcare at risk of experiencing clear violations to personhood and enduring adverse health outcomes and premature career disruptions. The repercussions of GB-WPV resonate throughout the healthcare system, resulting in substantial provider attrition, compromised patient care, and an overburdened healthcare infrastructure struggling to meet the needs of society. We acknowledge that looking at a single analytical category, such as gender, negates the complex ways in which other social categories influence experiences of WPV. Further evaluation is needed to understand the interconnected nature of social categories such as race, gender, sexual orientation, socioeconomic status, ethnicity, immigration status, and more, as well as how they intersect to shape the experiences of WPV.

Supporting information

S1 appendix. definitions of various forms of wpv..

https://doi.org/10.1371/journal.pgph.0003336.s001

S2 Appendix. Registered protocol for WPV among health workforce based on victims gender.

https://doi.org/10.1371/journal.pgph.0003336.s002

S3 Appendix. PRISMA-ScR filled-checklist.

https://doi.org/10.1371/journal.pgph.0003336.s003

S4 Appendix. Search strategy for the scoping review.

https://doi.org/10.1371/journal.pgph.0003336.s004

Acknowledgments

The authors would like to acknowledge Ms. Mikaela Gray, a Librarian in health sciences at the University of Toronto, for assisting with the search strategy development; and Adam Fuseini, a PhD student at UofT for assistance with software.

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• Published: 27 June 2024

Integrated surveillance systems for antibiotic resistance in a One Health context: a scoping review

• Léo Delpy 1 , 2 , 3 ,
• Chloe Clifford Astbury 4 , 5 ,
• Cécile Aenishaenslin 6 , 7 ,
• Arne Ruckert 8 ,
• Tarra L. Penney 4 , 5 ,
• Mary Wiktorowicz 5 , 9 ,
• Mamadou Ciss 3 ,
• Ria Benko 10 &
• Marion Bordier 1 , 2 , 3  

BMC Public Health volume  24 , Article number:  1717 ( 2024 ) Cite this article

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Antibiotic resistance (ABR) has emerged as a major threat to health. Properly informed decisions to mitigate this threat require surveillance systems that integrate information on resistant bacteria and antibiotic use in humans, animals, and the environment, in line with the One Health concept. Despite a strong call for the implementation of such integrated surveillance systems, we still lack a comprehensive overview of existing organizational models for integrated surveillance of ABR. To address this gap, we conducted a scoping review to characterize existing integrated surveillance systems for ABR.

The literature review was conducted using the PRISMA guidelines. The selected integrated surveillance systems were assessed according to 39 variables related to their organization and functioning, the socio-economic and political characteristics of their implementation context, and the levels of integration reached, together with their related outcomes. We conducted two distinct, complementary analyses on the data extracted: a descriptive analysis to summarize the characteristics of the integrated surveillance systems, and a multiple-correspondence analysis (MCA) followed by a hierarchical cluster analysis (HCA) to identify potential typology for surveillance systems.

The literature search identified a total of 1330 records. After the screening phase, 59 references were kept from which 14 integrated surveillance systems were identified. They all operate in high-income countries and vary in terms of integration, both at informational and structural levels. The different systems combine information from a wide range of populations and commodities -in the human, animal and environmental domains, collection points, drug-bacterium pairs, and rely on various diagnostic and surveillance strategies. A variable level of collaboration was found for the governance and/or operation of the surveillance activities. The outcomes of integration are poorly described and evidenced. The 14 surveillance systems can be grouped into four distinct clusters, characterized by integration level in the two dimensions. The level of resources and regulatory framework in place appeared to play a major role in the establishment and organization of integrated surveillance.

Conclusions

This study suggests that operationalization of integrated surveillance for ABR is still not well established at a global scale, especially in low and middle-income countries and that the surveillance scope is not broad enough to obtain a comprehensive understanding of the complex dynamics of ABR to appropriately inform mitigation measures. Further studies are needed to better characterize the various integration models for surveillance with regard to their implementation context and evaluate the outcome of these models.

Peer Review reports

Antimicrobial resistance (AMR) is a global threat to human health, animal health and the environment. According to O’Neill & al. (2016), AMR could cause 10 million deaths per year by 2050 [ 1 ]. These deaths will be mainly concentrated in low- or middle-income countries (LMICs), including 41.5% in Africa and 47.3% in Asia. AMR will also have great impacts on economic growth. The World Bank (2019) estimates that the economic consequences of AMR in 2050 will be more severe than the financial crisis in 2008 [ 2 ].

Antibiotic resistance (ABR) plays a critical role in this global crisis. Murray et al. (2019) estimate that ABR was associated with 4.95 million deaths in 2019 [ 3 ]. The misuse and overuse of antibiotics in human health, animal health, and food production have resulted in rising levels of ABR [ 4 , 5 ]. Between 2000 and 2015, global antibiotic consumption increased by 65% [ 6 ]. This has contributed to an increase in resistant bacterial strains [ 1 , 7 ]. ABR surveillance Footnote 1 is crucial to improve knowledge about ABR epidemiology, provide reliable information for evidence-based policy development, and assess the impact of interventions to reduce the threat represented by ABR [ 8 ]. In addition, ABR emergence and spread is related to the interactions between the human, animal and environmental sectors [ 9 , 10 , 11 ]; its management calls for the development and implementation of strategies in line with the One Health concept [ 12 ]. This concept recognizes that the health of humans, domestic and wild animals, plants, and the wider environment are closely linked and inter-dependent, and promotes collaborative efforts across multiple sectors, disciplines and communities at varying levels of society to foster well-being and tackle threats to health and ecosystems [ 13 ]. The development of surveillance systems that integrate information about ABR circulating in humans, animals and the environment is critical to enhance our understanding of the complex epidemiology of ABR and to inform policy development and implementation [ 14 ].

Since the 1990s, integrated surveillance systems have been widely developed in Europe and North America, including the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) in Canada [ 15 ], the National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS) in the United States [ 16 ], and the Danish Integrated Antimicrobial Resistance Monitoring and Research Programme in Denmark (DANMAP) [ 17 ]. There are also some initiatives aimed at compiling national surveillance data at a regional level (e.g. the Joint Interagency Antimicrobial Consumption and Resistance Analysis (JIACRA) programme in Europe [ 18 ]) or at the global level (e.g. the Global Antimicrobial Resistance and Use Surveillance System (GLASS) programme [ 19 ]). The World Health Assembly in 2015 adopted a Global Action Plan for AMR calling for the development of National Action Plans, which explicitly includes the implementation of systematic, integrated monitoring and surveillance of antimicrobial use (AMU) and AMR [ 20 ]. However, despite the existence of National Action Plans in most member states of the World Health Organization (WHO), implementing an integrated surveillance system for AMR and AMU remains a challenge for many countries, in particular in LMICs [ 21 ].

There is a growing body of literature describing the development of integrated surveillance for ABR [ 6 , 22 , 23 ]. Several studies examine the establishment of surveillance systems on a regional scale, such as in Asia [ 24 , 25 ], Africa [ 26 ], or Europe [ 27 ]. However, to our knowledge there is little published information on the organization and functioning of these existing integrated surveillance systems at a global scale, or on the potential contextual determinants driving their level of integration.

This article intends to fill this gap through a scoping review that analyses: (i) the organizational and functional characteristics of existing integrated surveillance systems for ABR; (ii) the socio-economic and political context in which they operate; and (iii) the levels of integration reached in these systems and their related outcomes. Based on these results, a typology of existing integrated surveillance systems is proposed in order to explore factors that may influence their level of integration.

Definitions

Several definitions have been suggested for integrated surveillance [ 14 , 23 , 28 ] and One Health surveillance [ 23 , 29 , 30 ]. Integrated surveillance conducted with a One Health approach can be defined as a system that applies a collaborative, intersectoral, multi-stakeholder, multi-scale and transdisciplinary approach to improve the functioning and performance of ABR surveillance. In the framework of our study, we use the term integrated surveillance systems to refer to systems that consist of two or more surveillance components implemented in at least two different sectors (of animal health, human health, the environment, and food safety), and that show collaboration at governance and/or operational level. By surveillance component, we refer to a surveillance programme that is supervised by a single institution and implemented by a specific network of actors, and that monitors ABR in one or several populations and/or commodities. By collaboration at the governance level, we refer to any collaborative mechanism (working group, committee, multi-sectoral institution, etc.) across sectors for the steering, coordination or scientific and technical support of the surveillance system. By collaboration at operational level, we refer to any intersectoral modalities for data collection (e.g. harmonized laboratory tests across sectoral surveillance components), data management and storage (e.g. interoperability of databases used in the different surveillance components), data analysis and interpretation (e.g. joint analysis of data collected in the different sectoral surveillance components) and results dissemination and communication (e.g. a joint report including results produced by the different surveillance components).

We recognize that terms AMR and ABR are often conflated, and that AMR is widely used in common language and in the academic literature to refer to ABR; however, we use the term ABR as our research was specifically funded to explore ABR surveillance systems.

Literature sources and search strategy

The scoping review was conducted according to the PRISMA-ScR guidelines (Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews) using a systematic search strategy [ 31 , 32 ]. The literature search focused on primary and secondary peer-reviewed literature in French and English published between 01/01/2000 and 01/08/2022. According to the definition of an integrated surveillance system set for this study, we identified three concepts to be characterized with relevant search terms (See Table  1 ). Based on these concepts and search terms, we developed strategies to search the following databases: Embase; PubMed; Scopus; and Web of Science. Only title, abstract, and search terms were targeted. The search string was “surveillance” AND “integration” AND “antibiotic resistance”. The complete search terms and index terms used in the search strategy in PubMed are available in Additional file 1 for example and complete replication.

Study selection

All documents retrieved from the bibliographic databases were screened by two reviewers following two distinct steps. For the first step, two inclusion criteria were applied to titles and abstracts: (i) the document describes an integrated surveillance system that meet the definition retained for this study (see the Definitions section); and (ii) the integrated surveillance system includes, at least, a focus on ABR. In the second step, three additional criteria were used: (i) the integrated surveillance system is described in detail, including its organization and operation; (ii) the surveillance system is operational on a continuous basis; and (iii) the surveillance system is operating at a national scale. Bibliographies of selected publications were screened to identify other relevant references. At this step, we also identified grey literature (e.g. reports). In addition, we consulted the websites of international organizations dealing with the ABR issue, e.g., the Food and Agriculture Organization of the United Nations (FAO), WHO, and World Organisation for Animal Health (WOAH, funded as OIE from the French Office International des Epizooties ), for evidence of existing national integrated surveillance systems.

When documents selected between the two reviewers were different, justification for selection was discussed to make a final decision.

Data extraction

The process of data extraction from included documents and additional sources is described below. The final list of the 39 variables used to develop the database is presented in Table  2 .

Data extraction from included documents

To meet the objective of the study, retrieved surveillance systems were characterized against a set of variables that were classified into five categories: (i) general characteristics of the systems (supervision, geographical area, scope, system framework); (ii) objectives and technical performance of the system; (iii) levels of integration for governance (steering, coordination, scientific and technical support); (iv) levels of integration for surveillance operations (data collection and management, data analysis and interpretation, communication and dissemination to decision-makers of the surveillance results); and (v) outcomes of the integration for surveillance (immediate outcomes, intermediate outcomes, ultimate outcomes) (See Table  2 ). Most of the variables, as well as their possible categories, were based on previous studies evaluating One Health surveillance [ 14 , 33 , 34 ]. However, during data extraction and analysis, some variables were added (e.g., absence or presence of surveillance components monitoring resistance to other antimicrobial agents), revised (e.g., bacteria families changed for bacteria categories depending on their pathogenicity status) or merged (e.g., variables related to steering and coordination merged into a single set of variables related to supervision). Others were dropped because available reliable information was too scarce or subject to a risk of bias (e.g., variables related to the technical and scientific support to the integrated surveillance system, antibiotic classes for which resistance levels were measured, disciplines of people involved in the governance of the systems). We worked extensively on fine-tuning the characterization of the different dimensions of integration that can be found in a surveillance system (see variables describing collaboration for governance and surveillance activities). For some variables (such as the ones related to technical performance, barriers, enablers and outcomes), no values were predetermined and a qualitative content analysis was applied to information available in the database to identify some recurrent themes [ 35 ].

If data were missing, additional searches were carried out on the institutional website of the coordinating institutions to retrieve the missing information.

To guarantee the quality of the database, the data extraction was carried out with a double-blind approach. When we identified differences between the two reviewers, differences were resolved by consensus.

Data extraction from additional sources

Following the work of Maugeri et al. [ 36 ], we included additional information about governance and demography to take into account the implementation context of surveillance. We completed the database obtained with the literature review with data extracted from three other databases: the Global Database for the Tripartite Antimicrobial Resistance (AMR) Country Self- assessment Survey [ 37 ] to add information about the countries’ progress regarding development of their respective National Action Plans on AMR, the World Bank Open Data website [ 38 ] to add information about human population density, and FAOSTAT [ 39 ] to add information about food animal population density.

Data analysis

We conducted two distinct and complementary analyses of the data collected.

First, we undertook a descriptive analysis of the full database to summarize the characteristics of the integrated surveillance systems retrieved through the scoping review based on the results of the included papers and additional data sources.

Second, we conducted a multiple-correspondence analysis (MCA) using a subset of variables of the full database, followed by a hierarchical cluster analysis (HCA) looking for a potential typology of integrated surveillance systems for ABR. Variables were selected among those for which information could be retrieved for most of the systems and based on their ability to discriminate between these systems and describe their major characteristics (Table  2 ). A Fisher exact test was applied to variables suspected of being highly correlated (such as “population/commodities under surveillance” and “collection points”). The HCA was applied to the Euclidean distance matrix of the first three axes of the MCA (representing 44% of variance). To check for the robustness of the hierarchical cluster analysis we also conducted a k -means clustering algorithm (see Additional file 4).

The literature search identified a total of 1,330 records. After the screening phase, 42 references were kept, and 17 additional references retrieved from the bibliographies of the selected references were added (See Fig.  1 ). From these 59 records, we identified 14 integrated surveillance systems that met our definition (see Table  3 ). Some systems were excluded from the study because not enough information was available to determine whether they met the inclusion criteria. In particular, systems were excluded for which it was impossible to assess whether they were operational on a continuous basis and not only at a pilot phase [ 30 , 40 ].

PRISMA-ScR flow chart describing the study selection process for the scoping review

Description of the integrated surveillance systems

General description of the integrated surveillance systems.

The retrieved systems were found to exclusively operate in high income countries, with domestic funds: 11 in Europe, two in North America, and one in Asia. They were all developed between 1995 and 2018. The surveillance systems include between two and 10 components, with a median of three. These 14 systems operate under different regulatory frameworks: 10 systems include at least one official component (owned and implemented by authorities), 10 at least one voluntary component (implemented without any regulatory obligation), seven at least one mandatory component (owned and implemented by the private sector to meet its regulatory obligations), and six at least one regulatory component (owned by authorities and implemented by other actors). While the stated objective of all the surveillance systems is to follow trends of ABR levels and to detect emergence of new resistances, their final purpose may vary. The most common purposes were developing and evaluating ABR policies, improving the awareness of consumers and health professionals, and improving knowledge and awareness of ABR. More rarely, surveillance systems aim to measure the risks related to ABR and to support the development of research in the ABR field.

The main barrier to the technical performance in these surveillance systems is the lack of harmonization across surveillance components, within and between sectors, in terms of laboratory methods (e.g. NethMap/MARAN, ANRESIS/ARCH-Vet), interpretative criteria (e.g. NethMap/MARAN, ANRESIS/ARCH-Vet, DANMAP), and antibiotic classes monitored (ANRESIS/ARCH-Vet). This leads to a lack of comparability across the data sets that hampers integrated data analysis and interpretation. The lack of harmonization is even more pronounced when there is a high number of surveillance components included, which makes coordination difficult (ONERBA). Articles also point out issues related to the completeness of the data collected, such as the lack of representativity (CIPARS, NethMap/MARAN), and the absence of data collected in the environment (CIPARS). Other hampering factors are more related to the operational organization of the surveillance system, such as the lack of an electronic database or of quality checks of data entry.

The governance of integrated surveillance systems is considered more effective by some authors [ 17 , 34 ] when an intersectoral committee is in place (DANMAP) or when a single organization is in charge of the supervision of the entire system (CIPARS). Conversely, other studies [ 29 , 41 ] underlined that intersectoral coordination remains costly and that funding for intersectoral activities are usually lacking, which hampers effective governance of integrated surveillance systems (UK surveillance system). Two systems, CIPARS and DANMAP, are frequently cited as examples of well-functioning surveillance systems, and have served as models for the development of other systems.

Information related to integration outcomes is rarely available in the literature. A few papers describe some immediate outcomes in terms of improvement of: (i) knowledge about ABR (DANMAP, ANRESIS/ARCH-Vet); (ii) surveillance capacity to detect correlation in ABR across sectors (ANRESIS/ARCH-Vet, CIPARS), as well as between ABU and ABR within and across sectors (DANMAP); and (iii) level of awareness on ABR and ABU (Swedres-Svarm). Intermediate outcomes (i.e., changes in behaviours, practices and interactions) were also described. For some systems, integration was found to support prescribers to transition towards a more responsible use of antibiotics (Swedres-Svarm) and to decrease the quantity of antibiotics used in animals and humans (CIPARS, DANMAP, NethMAp/MARAN). New research projects on ABR and ABU conducted with a One Health perspective were also listed among the outcomes of the establishment of integrated surveillance systems (NethMap/MARAN). Finally, in some cases, integrated surveillance has led to the integration of the One Health perspective into the development and implementation of sectoral or intersectoral policies (DANMAP, NARMS). To a lesser extent, we also identified ultimate outcomes of integration (i.e., changes that result from the intermediate outcomes of integration), in terms of changes in ABR levels (CIPARS). As an example, for this chain of outcomes, we can refer to the case of ceftiofur-resistant Salmonella in Canada . The integrated surveillance system (CIPARS) was able to detect a strong correlation between ceftiofur-resistant Salmonella enterica serovar Heidelberg isolated from retail chicken and incidence of ceftiofur-resistant Salmonella serovar Heidelberg infections in humans across Canada [ 42 ]. As a result, the poultry sector stopped using ceftiofur, which, in turn, triggered a decrease in the level of resistance to this antibiotic in salmonella.

Integration levels of the integrated surveillance systems

The analysis of the organization and functioning of the retrieved surveillance systems underlined that integration could be summarized along two dimensions: information integration and structural integration (see Fig.  2 ).

Information and structural integration in surveillance systems for antibiotic resistance. The figure describes the integration in surveillance systems. In the central part, the two structural integration levels are represented: the governance level and the operational level (data collection and management, data analysis and interpretation, communication and dissemination). Each circle represents a sector (human health, animal health, environment) where information may be integrated in terms of populations and commodities, collection points, resistances to other microorganisms, bacteria categories, antibiotic usage and consumption

By information integration, we refer to the ability of the system to combine: (i) data concerning different commodities or populations (human, animal, food, wildlife, water) with different health status (healthy or diseased) and at different collection points (community, health infrastructures, slaughterhouses, waste water management plants, etc.); (ii) data concerning different bacteria family with various pathogenicity characteristics (commensal, species-specific pathogen, zoonotic disease) and resistances to different antibiotic classes; (iii) data generated with different laboratory methods (phenotypic analysis, genotypic analysis) and surveillance strategies (active, event-based); and (iv) data originating from other domains, such as resistances to other microorganisms or usage and consumption data of antibiotics.

By structural integration, we refer to the collaborative mechanisms put in place for the governance and implementation of surveillance activities. At the governance level, collaboration across organizations may exist for the steering of the system (i.e. providing orientations and making decisions for the operations of the system), for its coordination (i.e. ensuring routine operations) and finally for supporting the system technically and scientifically (i.e. providing multidisciplinary support for effective data collection and analysis). At the operational level, collaborative efforts of varying intensity may exist for data collection and management, for data analysis and interpretation, and for the communication and dissemination of surveillance results.

Table 3 displays the descriptive results of the 14 selected systems regarding the variables describing the information and structural integration.

At the level of information integration, the surveillance systems collect samples from three to seven different populations or commodities among diseased humans, healthy humans, healthy food animals, diseased food animals, healthy companion animals, diseased companion animals, foods of animal origin, foods of plant origin, wildlife, and wastewater. For the majority (12 out of 14), they include at least one surveillance component in humans and one in food of animal origin. All surveillance systems collect samples from food animals, mainly at farms and slaughterhouses. Surveillance of human populations at hospital level is part of all systems, except two (ZoMo and FINRES-Vet). Despite the importance of the environment in the emergence and spread of ABR, few systems perform environmental surveillance. Four surveillance systems collect samples from wildlife (mainly in wild boars and foxes) and one system from wastewater (ANRESIS/ARCH-Vet). One system, the FINRES-Vet, also monitors resistances in fur animals, which is consistent with the importance of that sector in Finland. The study identified eight surveillance systems that include the monitoring of ABU. In addition, seven surveillance systems include surveillance components that monitor resistances to other microorganisms, such as fungi or viruses.

At the governance level of the structural integration dimension, five of the surveillance systems are supervised by a single sector, among which four are supervised by the human health sector. For others, the supervision is undertaken either by a multi-sectoral body (four systems) or separately and independently by each sector in charge of the supervision of the surveillance components (five systems). At the operation level of structural integration, all systems except one (CIPARS) demonstrate separate data collection and management operations in the different surveillance components, even if some of them have established some mechanisms to harmonize data collection across components (harmonization of laboratory methods, harmonization of laboratory data interpretation, harmonization of metrics for reporting, interoperable or common information systems, etc.). Integration is further developed during the data analysis and interpretation stage. In only two systems (ONERBA, UK surveillance system) are data separately analysed and interpreted for each of the surveillance components. Among the others, nine compare resistance trends between sectors, five explore resistance correlations between sectors, and eight investigate the link between ABU and ABR. Integration is further developed at dissemination and communication level. Only two surveillance systems (UK surveillance system, ZoMo) have no integration at this stage, while the others publish results using the same media (mainly a written report) intended for all types of audiences (community, decision-maker, etc.).

Typology of the integrated surveillance systems

The HCA applied to the MCA results demonstrates that the 14 integrated surveillance systems group into four distinct clusters (Table  3 and Additional files 2 and 3). The variables contributing most to variance between individuals (e.g. selected integrated surveillance systems) are: “populations/commodities under surveillance”, “sector involved” in the supervision, “organizational modalities” for data analysis and interpretation, and “organizational modalities” for dissemination to decision-makers and communication. The variable “collection points” was excluded from the MCA because it correlated too closely with the “populations/commodities under surveillance” variable. The values that contribute most to the first axis are: “human health” for the variable “sector involved” in supervision, “human” for the variable “populations/commodities under surveillance”, and “sector involved” for the variable “organizational modalities” for data analysis and interpretation. For axis two, the variable values that contribute most are “jointly by one” for the “communication modalities and “no animal health” and “no food safety” for the variable “sector involved” in supervision. Cluster analysis did not highlight a significant influence of the human and food-animal density on the organization and functioning of integrated surveillance systems, nor of the country progress with development of a National Action Plan on AMR.

Group 1 includes six of the 14 systems: BELMAP (Belgium), ONERBA (France), Japan surveillance system (Japan), NethMap/MARAN (Netherlands), ANRESIS / ARCH-Vet (Switzerland), and the surveillance system in the United Kingdom. In this group, systems consist of at least four surveillance components. Data analysis is carried out separately by the sectoral organizations in charge of the different surveillance components. The system that best represents this group according to the MCA results is the UK surveillance system. The different surveillance components are supervised separately by the leading organization in each sector. Four sectors (human health, animal health, food safety, environment) are involved in the supervision of the system. At the operational level, data analysis and interpretation are carried out separately for each component, and no comparison of ABR occurs among sectors.

Group 2 consists of the following systems: DANMAP (Denmark), NORM/NORM-VET (Norway), SWEDRES/SVARM (Sweden), and NARMS (USA). Unlike the first group, systems are characterized by a relatively limited number of surveillance components (two or three). In addition, except for NARMS, the systems integrate the surveillance of the environment, through the collection of data from wildlife. The DANMAP system best represents this second group. This system is characterized by a high level of information integration (high number of population or commodities under surveillance, inclusion of the surveillance of resistances for other microorganisms than bacteria and of ABU), and by a high level of structural integration at operational level (joint data analysis with comparison of trends across sectors and intersectoral correlation analysis, joint communication and dissemination through awareness campaigns, national reports, and a website). This group therefore differs from the previous one by its high level of integration at both structural and informational levels.

Group 3 includes the Canadian and Scottish systems, respectively CIPARS and SONAAR. These two systems are characterized by leadership of the human sector at governance level. Despite the inclusion of other sectors in surveillance activities (data collection and management, data analysis and interpretation), the human health sector is responsible for supervising these systems. The human health sector is also solely in charge of disseminating and communicating surveillance results. CIPARS best represents this group. It is characterized by strong governance leadership by the human sector. While some CIPARS components target animals and food, they are managed by the Public Health Agency of Canada.

Group 4 includes the German and Finnish surveillance systems, respectively ZoMo and FINRES-Vet. These two systems are supervised by the food safety sector, in collaboration with the animal health sector for the ZoMo surveillance system. Surveillance systems in this group do not collect samples from humans. ZoMo best represents this group. Groups 3 and 4 are opposed in terms of sectoral leadership at governance level. In Group 3, despite the human health leadership, the systems collect data from animals and food. Conversely, the surveillance systems in Group 4 only collect data in domains under their direct supervision (food and animals).

The scoping review retrieved 14 integrated surveillance systems that met the study definition, all operating in high-income countries. They are characterized by various degrees of integration both at information and structural levels. At the information level, they combined surveillance components that collect data about pathogenic or commensal bacteria in a wide range of possible populations and commodities, and some systems expand their coverage beyond ABR. Active surveillance is more frequent in animals, food and the environment, while surveillance in humans mainly relies on resistance data that are collected to orient diagnostic and treatment of patients. At the structural level, the integration modalities differ from one system to another both at governance and operational levels. At one end of the spectrum, we find surveillance systems where supervision is ensured by a single sector, with the consequence that surveillance operation is also highly integrated in terms of data analysis, results dissemination and communication. At the other end of the spectrum, surveillance systems consist of surveillance components that are supervised independently by the sectoral organizations respectively in charge of their operations. Consequently, integration at the operational level is also usually low. The study also found that the selected surveillance systems could be grouped into four distinct clusters. Group 2 is characterized by systems (four) with a high degree of integration, while systems in Group 1 (six) mainly operate in silos with few integration points between surveillance components. Groups 3 and 4 are characterized by the mono-sectoral lead of the systems (except ZoMo). While the two systems in Group 3 are supervised solely by the human health sector, systems in Group 4 (two) are supervised by the food sector, and also by the animal health sector for the ZoMo surveillance system.

Limits to the information integration in surveillance

Although environmental surveillance is key to understanding the full complexity of ABR and improving its management [ 75 , 76 ], our review identified very few systems that integrate the environment at both structural (UK surveillance system) and informational (DANMAP, NORM/NORM-VET, SWEDRES, ZoMo) levels. Where the environment is included, this mainly involves wildlife (four systems) or wastewater (one system). There may be several reasons for the lack of inclusion of environment in surveillance. First of all, the environment is a complex system to monitor. The environment is made up of a wide variety of elements (wild animals, plants, water, soil, etc.) and dynamics with different roles in the emergence of ABR. The potential causes of the presence of resistant bacteria in the environment are numerous, and are essentially due to the release of antibiotics from human activities (e.g., agriculture, pharmaceutical industries, hospitals, wastewater management). As a result, it is difficult to establish surveillance protocols, in terms of choice of bacteria, antibiotic families, collection points and sampling strategies. In addition, the environment sector was only introduced in the discussions around the One Health concept at a late stage [ 77 ], whereas the animal and human health sectors have a long history of collaboration on health issues [ 78 ]. Indeed, while the link between the health of humans and that of animals has been established a long time ago [ 79 ], their relation to the health of ecosystems and biodiversity is more difficult to grasp in the world of healthcare [ 80 ]. At the international institutional level, this is clearly marked by the integration of United Nations Environment Programme (UNEP) to the Tripartite partnership for One Health [ 81 ] in 2022, which was established in 2010 by FAO, WHO and WOAH [ 82 , 83 ]. Additionally, we did not identify any surveillance systems whose surveillance targets resistances in plant production, even though antibiotics are now used in agriculture to protect crops against pests [ 84 ].

Apart from ABU, which is recognised as a key driver of ABR, other potential drivers of ABR emergence and spread were not considered in the retrieved surveillance systems. However, ABR may be influenced more or less directly by a wide range of factors, such as climatic drivers (temperature, precipitations), meat consumption or chemical levels (responsible for potential co-selection of resistances), that could be easily included in integrated surveillance systems for a more comprehensive understanding of ABR epidemiology and a better orientation of interventions to mitigate the risk of ABR [ 85 , 86 , 87 ].

While information integration through the harmonization and combination of data from different sources will undoubtably improve the surveillance effectiveness, this should not be done at the expense of the surveillance needs in the respective sectors [ 88 ]. Moreover, better integration does not systematically bring greater surveillance performance, as integration is associated with a financial and social cost and may not achieve the expected positive outcomes if the implementation context is unsuitable (e.g. poor quality of data produced by the surveillance components) [ 21 ].

Integrated surveillance in low- and middle-income countries

A country's level of resources seems to play a predominant role in the implementation of integrated surveillance systems. Despite the adoption of many National Action Plans for AMR, the review was not able to identify operating integrated surveillance systems in LMICs [ 89 ]. This can be explained by several reasons. First, resources for disease prevention, and epidemiological surveillance in particular, are scarce compared to those for medical care. As a result, sectoral surveillance components are usually low-performing and produce data of a quality that is not suitable for further combination with other sources of data [ 88 ]. The literature highlights several technical (information technology systems, expertise, infrastructure), budgetary, and institutional (political instability, weak enforcement of regulations) constraints that hamper the implementation of integrated surveillance systems in LMIC [ 90 , 91 ]. In Nepal specifically, Malla et al. [ 92 ] highlight several gaps in sectoral surveillance performance that compromise the ability to further integrate the information across different domains, such as: the lack of appropriately trained personnel; high turnover of staff; poor access to good quality reagents; inadequate storage facilities of reagents; and frequent power cuts. Secondly, as described previously, integration of information requires a well-established structural integration through the development of mechanism to ensure an inter-sectoral governance of the surveillance. Indeed, only strong governance with coherent provisions can support the operationalization of the One Health concept, including the establishment of integrated surveillance systems [ 93 ]. Despite the international effort to support LMICs in establishing intersectoral mechanisms for health management at a high political level, One Health governance is still struggling to become operational in many countries and this hampers the development of integrated surveillance [ 94 ]. One Health policy-making is still fragmented and the distribution of roles and responsibilities among ministries for the establishment and operation of integrated surveillance lacks transparency [ 91 , 95 ]. Additionally, in LMICs, national action plans are generally drawn up under the impetus of international organisations, but rarely receive the required domestic resources to implement them. Finally, despite the alarming figures available on the costs and deaths incurred by resistant bacteria [ 96 , 97 ], the immediate and visible impacts of ABR on health and economics, as compared to other communicable or non-communicable diseases, are not always clear to stakeholders. As a result, ABR is not among the top priorities for governments who must manage a multitude of health issues on a day-to-day basis with limited resources [ 88 ]. This low inclusion of LMICs in the race for ABR surveillance performance is problematic, as they also play a role in the ABR crisis [ 98 , 99 ]. LMICs usually face high levels of resistance because of, among others, inappropriate prescription practices, inadequate antibiotic user education, limited diagnostic facilities, informal sale of antibiotics, lack of appropriate functioning drug regulatory mechanisms, and use of antibiotics in animal production [ 99 ]. Whether through international trade, particularly in the livestock sector [ 100 ], or international tourism [ 101 ], the spread of ABR is inevitable and therefore requires a global approach to mitigate the risk. As long as integrated surveillance is not generalized on a global scale, a gap will remain in the development of effective policies to curb the development of ABR.

Especially in LMICs, a tiered approach to integration is needed. First, it is essential that each surveillance component included in the integrated surveillance system can produce quality data. Then, a first step could consist of involving relatively standard collection, sharing and analysis of data. In a context of scarce resources, the prioritization of sources to be integrated into ABR surveillance systems could be based on the following criteria: availability of existing samples, that have been collected for other purposes (e.g. samples taken for diagnostic purposes), limited need for resources to carry out the sampling (e.g. samples taken at the abattoir), production of information to guide the implementation of prompt AMR containment measures, socio-economic and health characteristics of the implementation context (e.g. food consumption patterns in the human population and the expected prevalence of ABR in animal populations). Then, the system could progress to higher tiers by broadening data collection sources and by conducting more complex data analysis [ 14 , 22 ].

Integrated surveillance and international governance

The institutional and regulatory framework at a supranational level appeared to shape the organization and functioning of integrated surveillance systems. Among the 14 integrated surveillance systems that the scoping review identified, 11 were established in the member countries of the European Union (EU). This can be explained by the strong institutional regulatory framework for ABR surveillance and reporting that member countries must comply with. In addition to the fact that EU countries are required to implement intersectoral national plans in line with EU One Health Antimicrobial Resistance Action Plan to combat ABR [ 102 ], they are also requested to have systems in place to monitor ABR in humans and animals, from farm to fork. As a result, surveillance is usually strongly integrated along the food chain for food of animal origin in all countries of the EU, and depending on the countries, with the surveillance components in humans. EU countries are also required to report their AMR and AMU data through the European Antimicrobial Resistance Surveillance Network (EARS-Net) and the European Surveillance of Antimicrobial Consumption (ESAC-Net), supervised by the European Centre for Disease Prevention and Control (ECDC), which is responsible for compiling reports on the AMR and AMU situation at the EU level [ 18 ].

While a strong institutional and regulatory framework at regional level seems efficient to favour integrated surveillance, global policies struggle to deliver concrete results at country level. International organizations have issued strategies and guidelines to support the development of integrated systems. In addition to the Global Action Plan on AMR [ 20 ], the Codex Alimentarius released guidelines on integrated monitoring and surveillance of foodborne AMR in 2021 [ 103 ] and the WHO advisory group a guideline on Integrated Surveillance of Antimicrobial Resistance (AGISAR) in 2017 [ 104 ]. As a result, 90% of all countries, and 61% of LMICs, show a National Action Plan for AMR in 2023 [ 105 ], and the majority aim to develop integrated surveillance systems for AMR [ 106 ]. However, our scoping review did not identify operational integrated surveillance systems in LMICs. In addition to the technical, institutional, political and budgetary constraints mentioned previously, the lack of operationalization of global policies at national level in LMICs can also be explained by the failure to apply the same models in countries with heterogeneous socio-political and economic contexts [ 107 , 108 ] Because of considerable LMIC reliance on external budgets for their health policies, their national action plan is usually highly influenced by the agendas of the technical and financial partners who support them in the fight against AMR. As a result, countries are usually simply mimicking the Global Action Plan and may propose actions that are irrelevant to the local context and/or to the expectations and constraints of local actors who are the most impacted [ 94 ].

Limitations and perspectives

Our study has several limitations. First, we identified integrated surveillance systems only in high-income countries. We may have missed some more recent systems that are not yet covered in the published literature. Indeed, many institutional reports describing National Action Plans exist that include the establishment of integrated surveillance systems [ 89 ]. However, we were not able to verify whether those systems were implemented. In addition, the study failed to deeply characterize some aspects of integration reached in the surveillance systems, as well as the influence of integration on system outcomes. Indeed, information about performance and outcomes are particularly scarce in the literature. When available, the direct causal link with the integration is difficult to establish and information is subject to caution in terms of validity as it is usually provided by people in charge of the surveillance system, who may lack objectivity. Reliable information regarding performance and outcomes could only be found for systems at an advanced stage of maturity that have undertaken external evaluations [ 22 ]. This leads to a certain paradox in our results. Weaknesses and gaps were mainly found for the best-performing systems because they are the only ones subject to robust evaluation with the objective of continuous improvement. Less performant and more recent systems are usually not evaluated, and information about performance and positive outcomes gives an impression of being more aspirational than based on observed facts. The fact that few existing systems have been formally evaluated to assess their effectiveness and impacts can be partly explained by the lack of adapted tools and methods to evaluate the added value of integrated surveillance [ 14 , 94 ]. This study reiterates the need to enhance such methods and to conduct more evaluation of the impacts of integrated surveillance systems in order to better understand the mechanisms through which the integration process enhances surveillance effectiveness and value [ 21 ]. The use of mixed methods that integrate both quantitative and qualitative approaches could help address the complexity of the relationship between surveillance outputs and impact on decision-making [ 34 , 109 ]. This could help identify best practice for integrated surveillance system development by assessing the role that integration characteristics play in the success of surveillance system success – characteristics such as those described in our review, but also those for which data availability was too limited for inclusion (e.g., level of multi-disciplinarity in teams operating surveillance systems).

This scoping review led to the identification of 14 surveillance systems for ABR that demonstrate a great diversity of collaborative efforts for the governance and/or operation of surveillance activities between at least two distinct surveillance components. They can be grouped into four clusters characterized by the nature of integration at the informational and structural level. The study highlighted the absence of documented integrated surveillance systems in LMICs and the low inclusion of the environmental data and risk factors to ABR emergence and diffusion in surveillance efforts. Regarding the global dimension of the ABR crisis and the crucial role of the environment in the ABR dynamics, effective policies and interventions to reduce ABR levels can only be achieved if all countries embark on the establishment of integrated surveillance systems covering the key three sectors (human health, animal health, environment). Moreover, regarding the diversity of mechanisms driving global ABR, an extension of the surveillance scope beyond ABR and ABU data is needed to provide necessary information to support the development of efficient mitigation measures.

This study explored only partially the link between integration and context on the one hand and integration and outcomes on the other. The typology identified provides a starting point for investigating these two aspects more deeply, using adapted evaluation methods that would include both quantitative and qualitative approaches.

Moving towards an integrated surveillance system for ABR is a stepwise approach that must be tailored to the resource availability and the socio-economic and epidemiological characteristics of each country. Consequently, it is important to define a national roadmap for setting up an integrated surveillance system in a concerted and participatory manner with all local and central actors, in a way that the system is adapted to the broader context, other priorities and the expectations of the stakeholders, and is therefore accepted and sustainably implemented [ 94 ]. Our analysis can provide a starting point for governments when reflecting on the right integration set-up for building integrated ABR surveillance systems. But future research in this area needs to develop evaluation tools specific to integrated ABR surveillance in order to better understand how to improve surveillance effectiveness and demonstrate the added value of integration.

Availability of data and materials

The full dataset generated during the current study is available from the corresponding author on reasonable request.

“Surveillance” here is taken to mean the continuous collection of health data in a given population to study changes in health status over time and space, in order to inform decision-making for the reduction of related risks.

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Acknowledgements

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This study is part of the Designing One Health Governance for Antimicrobial Stewardship Interventions (DESIGN). It has been funded the French National Research Agency (ANR), Swedish International Development Cooperation Agency (SIDA), through the Joint Programming Initiative on Antimicrobial Resistance (JPI-AMR).

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Cécile Aenishaenslin

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M.B. and L.D. designed and coordinated the study, collected the data, analysed the results and wrote the original draft. C.C.A. participated in collecting and validating data. C.C.A., C.A., T.L.P., A.R., M.E.W. participated in the analysis of the results and in drafting the manuscript. R.B. and M.C. reviewed and edited the manuscript. All authors read and approved the final manuscript.

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Delpy, L., Astbury, C.C., Aenishaenslin, C. et al. Integrated surveillance systems for antibiotic resistance in a One Health context: a scoping review. BMC Public Health 24 , 1717 (2024). https://doi.org/10.1186/s12889-024-19158-6

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Scoping studies: advancing the methodology

2010, Implementation Science

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Enhancing the scoping study methodology: a large, inter-professional team’s experience with Arksey and O’Malley’s framework

Helena ml daudt.

1 Clinical Research, British Columbia Cancer Agency, Vancouver Island Centre, 2410 Lee Avenue, Victoria, BC V8R 6V5, Canada

Catherine van Mossel

2 University of Victoria, 1223 Oxford St., Victoria, BC V8V 2V6, Canada

Samantha J Scott

3 Interior Health Authority, Royal Inland Hospital, 311 Columbia Street, Kamloops, BC V2C 2T1, Canada

Associated Data

Scoping studies are increasingly common for broadly searching the literature on a specific topic, yet researchers lack an agreed-upon definition of and framework for the methodology. In 2005, Arksey and O’Malley offered a methodological framework for conducting scoping studies. In their subsequent work, Levac et al. responded to Arksey and O’Malley’s call for advances to their framework. Our paper builds on this collective work to further enhance the methodology.

This paper begins with a background on what constitutes a scoping study, followed by a discussion about four primary subjects: (1) the types of questions for which Arksey and O’Malley’s framework is most appropriate, (2) a contribution to the discussion aimed at enhancing the six steps of Arskey and O’Malley’s framework, (3) the strengths and challenges of our experience working with Arksey and O’Malley’s framework as a large, inter-professional team, and (4) lessons learned. Our goal in this paper is to add to the discussion encouraged by Arksey and O’Malley to further enhance this methodology.

Performing a scoping study using Arksey and O’Malley’s framework was a valuable process for our research team even if how it was useful was unexpected. Based on our experience, we recommend researchers be aware of their expectations for how Arksey and O’Malley’s framework might be useful in relation to their research question, and remain flexible to clarify concepts and to revise the research question as the team becomes familiar with the literature. Questions portraying comparisons such as between interventions, programs, or approaches seem to be the most suitable to scoping studies. We also suggest assessing the quality of studies and conducting a trial of the method before fully embarking on the charting process in order to ensure consistency. The benefits of engaging a large, inter-professional team such as ours throughout every stage of Arksey and O’Malley’s framework far exceed the challenges and we recommend researchers consider the value of such a team. The strengths include breadth and depth of knowledge each team member brings to the study and time efficiencies. In our experience, the most significant challenges presented to our team were those related to consensus and resource limitations. Effective communication is key to the success of a large group. We propose that by clarifying the framework, the purposes of scoping studies are attainable and the definition is enriched.

Our research team, which is large and comprised of many disciplines, undertook a scoping study to investigate the information needs of people with colorectal cancer. We drew on the methods laid out in a 2005 framework by Arksey and O’Malley [ 1 ] who were among the first scholars to articulate a framework to clarify the usefulness of and methods inherent in a scoping study. They claim an interest in stimulating further discussion on the value of scoping studies and encourage others to further develop the methodology. Since their framework was published, a handful of researchers have taken up their challenge [ 2 - 8 ]. Levac et al. published the most prominent of these in 2010, addressing the framework’s strengths and limitations with the aim to encourage consistent methods across all scoping studies [ 8 ]. After reviewing our own research process and sharing our experiences with this methodology in this paper, we also contribute to the discussion that enhances Arksey and O’Malley’s framework. We offer a unique perspective on this framework because of our collective experience as a large, inter-professional team. We also propose that the definition, purposes, and methodological framework of scoping studies cannot be clarified in isolation but must be amended in tandem. We offer recommendations that, when added to those of other researchers such as Levac et al., generate a strengthened definition and position the purposes as attainable. Interestingly, some of our critiques and suggestions for the development of the methodology mirror those expressed by Levac et al. Since Levac et al’s paper was published while our team was concluding our scoping study; we reached our conclusions independently of their suggestions. The fact that we share some similar conclusions indicates that the collective suggestions from Levac’s team and ours are worth serious consideration for enhancing Arksey and O’Malley’s framework. We also offer some proposals for consideration not yet expressed by others engaged in scoping studies, primarily drawn from our experience as a large, inter-professional team. Our team of twelve people included academic researchers as well as clinical practitioners working in a cancer treatment centre from a range of disciplines and practices, including nutrition, radiation therapy, patient and family clinical counseling, nursing, biology, library and information science, and the social sciences. Each member of our team shared a common interest in colorectal cancer and a desire to improve the quality of care received by people with this diagnosis.

What is a scoping study?

Over the last two decades, scoping studies have become an increasingly common method of searching the literature on a specific topic. There is no one agreed upon definition for scoping studies, but there has been some effort among researchers to seek clarification. Levac et al. confirm this view in their work, pointing to seven recent authoritative scoping sources, each offering a different definition or purpose. In spite of the varying interpretations in this methodology’s definition, and because we used the original definition as laid out by Arksey and O’Malley in our research, we refer to the Arksey and O’Malley definition throughout this paper.

Arskey and O’Malley begin with Mays et al’s definition of scoping studies: “to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available, and can be undertaken as standalone projects in their own right, especially where an area is complex or has not been reviewed comprehensively before” [ 9 ]. The framework they developed serves to expand on this definition by identifying four main reasons for conducting a scoping study: (1) to examine the extent, range and nature of research activity; (2) to determine the value of undertaking a full systematic review; (3) to summarise and disseminate research findings; and (4) to identify research gaps in the existing literature. We identified the first and fourth goals as the most relevant for our own research. Arksey and O’Malley’s framework includes six stages, the sixth being optional: (1) identifying the research question, which is generally broad in nature; (2) identifying relevant studies, a process that is as comprehensive as possible; (3) study selection, with the establishment of inclusion/exclusion criteria, based on familiarity with the literature; (4) charting the data, a stage that includes sifting, charting, and sorting information according to key issues and themes; (5) collating, summarizing, and reporting the results, which provides both a descriptive and numerical summary of the data and a thematic analysis; and (6) a consultation exercise, an additional, parallel step involving key stakeholders to inform and validate study findings [ 1 ]. While Arksey and O’Malley’s framework offer the best framework for a scoping study to date, we argue that there is room for enhancement. Additional file 1 outlines the original framework, Levac et al’s recommendations, and our recommendations.

Matching research interests with Arksey and O’Malley’s framework

Based on our understanding of Arksey and O’Malley’s framework, our research team believed a scoping study was a methodology that would work well to answer our research question: What does the literature tell us about the information provided by health care professionals and needed by people with colorectal cancers across the cancer care continuum? We applied to and received funding from a Canadian federal research granting institute under a program specific for scoping studies. Receipt of this funding endorsed our belief that this methodology would enable us to answer our question. However, as we engaged more deeply with our work using Arksey and O’Malley’s framework and came to understand our data, we developed reservations that we could claim to understand people’s information needs. When analyzing our final data set, we were tempted (or perhaps eager) to draw conclusions about our interest. Instead, we were faced with the dilemma: “what can we really say about this data?” It became clear that this methodology did not give us the right tools to extract the information we sought. We were able to identify what issues researchers addressed , but not what information was wanted/needed by people with colorectal cancer . In an effort to deal with this tension, we revised our research question mid-way through the process into a question that we hoped our collected data and the Arksey and O’Malley framework could answer: What does the literature tell us about which aspects of the information provided by healthcare professionals and needed by people with colorectal cancer across the cancer care continuum have been addressed by researchers?

Our goals in undertaking a scoping study were to examine the extent, range, and nature of research activity, and to identify research gaps in the existing literature as they relate to information needs of people with colorectal cancer. We quickly learned that our findings were insufficiently specific enough to allow us to fully meet our research goals in the way we expected . We were able to identify the gaps in what researchers were paying attention to with regard to information needs of people with colorectal cancer and we did understand the extent, range, and nature of research activity about the information needs of people with colorectal cancer – there had not been much research activity. However, even though we reached our goals, we were not able to answer our original question because we could not say anything specific about those needs. For example: What information do people with colorectal cancer say they want and/or need? How have these needs been articulated? How and when do they want these needs met? What is the reason given for these needs?

Nevertheless, these findings proved useful as they contributed to our understanding of the state of the literature and how we needed to proceed. Importantly, the study revealed to us that there is very little literature that draws on the perspective of people diagnosed with colorectal cancer. This inattention to people’s voice represented a gap in research. It became apparent that additional, in-depth research would be required before we could draw conclusions. Thus, our research has been an essential first step towards developing a research agenda where we truly attend to the information needs of people with colorectal cancer. Our findings provided us with enough data to design a further, more in-depth research project, thereby positioning the scoping study as an important initial step from which we launched the next phase of our research.

We recognise that we chose the methodology and perhaps it was not the best to answer our original question. We determined it was important to remain mindful of the types of conclusions we could reasonably draw from our data gathered through our use of Arksey and O’Malley’s framework. Thus, we believe that the conversation about the scoping study methodology that Arksey and O’Malley encourage could benefit from guidance about the kinds of research questions for which scoping studies are most appropriate. Arksey and O’Malley illustrate their framework describing a comparison between programs to support carers of people with mental health problems. A PUBMED search using the terms scoping review or scoping study not systematic review on July 27, 2012 elicited 101 articles published between July 2007 and July 2012; 45 of these articles describe studies that can be classified as scoping studies, according to Arksey and O’Malley’s definition, and 34 of them (75%) portray some type of comparison such as among interventions, programs, and approaches. It seems that this latter kind of research is one to which the scoping study method is most often applied and is perhaps the most useful. Our experience has led us to ponder the appropriateness of a scoping study to answer a question that is broader in nature than the comparison of interventions or programs. We were not interested in comparisons of interventions and programs, for example. Rather, we hoped to extract data that would tell us something concrete about the information needs of people with colorectal cancer. As a result, we propose that the objective and appropriateness of the methodology need to be clearly understood by those contemplating its use. However, the boundaries of this methodology and the types of research it can best support are still to be defined and we urge others to contribute to these definitions. It appears that this methodology may be best suitable to research that examines comparisons between interventions or approaches. On the other hand, we want to be clear that our research was not in vain as we did accomplish two goals laid out by Arksey and O'Malley and we garnered data that compelled us forward into a more in-depth analysis to answer our initial question in specific detail. Additionally, we were able to say useful things about the state of academic interest in issues relating to the information needs of people with colorectal cancer, the results of which have been already published [ 10 ]. Because our work proved useful in unexpected ways, we encourage others to consider a scoping review as a constructive method in their broader research process in that it can contribute to the clarification of next steps. By sharing our experiences with this methodology in this paper, we hope we can contribute to the enhancement of Arksey and O’Malley’s framework.

Our recommendations in this paper are the results of the review of our own research process. We collected our team’s perspectives through a short survey comprised of three open-ended questions: (1) describe any significant challenges/successes that arose from using the Arksey O’Malley framework for scoping reviews; (2) describe any significant challenges/successes that arose from taking part in research with a large, multi-disciplinary group; and (3) additional comments. Each team member’s response was built not only upon memory in hindsight, but also upon notes taken throughout the research process. At least two key team members kept research diaries and a recorder kept minutes of each bi-weekly meeting about the challenges, discussions, reflections, and actions taken. The survey results, the notes, and minutes were collated and analyzed. Analysis included identifying themes among challenges and successes, identifying relations between statements related to any given theme, stating arguments and supporting them with evidence from the materials, making comparisons, and evaluating conclusions. Results were then linked to specific Arksey and O’Malley methodological stages for reporting in this paper.

Enhancing the six steps of Arksey and O’Malley’s framework: contributing to the conversation

Arksey and o’malley’s first step: identifying the research question.

Our research team initially found identifying an appropriate research question a straightforward task. We generated our question on the experience, observations, and concerns of our team’s health care providers and the findings of previous research projects of several team members. For example, after a diagnosis of colorectal cancer, there are multiple instances where information is exchanged and required by people diagnosed with colorectal cancer, their families, and health care providers. These may include diagnostic procedures, receiving the diagnosis, treatments and their side effects, and living beyond treatment. Our intent was to learn what information people with colorectal cancer needed and/or wanted, who or how it was best to provide it to them, and when. As per the framework’s first and fourth purposes for conducting a scoping study, we intended to examine the extent, range, and nature of research that addresses the information needs of people with colorectal cancer with a view to identifying gaps in the literature. With these two goals in mind, we linked our purpose to our research question. In an effort to advance the Arksey and O’Malley’s framework, Levac et al. suggest the need to clarify and link the purpose and the research question. Our team did so from the start.

In keeping with Arksey and O’Malley’s recommendation to avoid leading with a “highly focused research question,” [ 1 ] we believed our question was sufficiently broad in design; it helped us to capture an initial 10,753 papers. However, once our team delved into the literature and began analyzing the data, it became apparent that the research question required revision. Levac et al. propose researchers define the concepts in their research question to clarify the scope of the study. Similarly, Arksey and O’Malley suggest that “researchers will want to redefine search terms and undertake more sensitive searches of the literature” [ 1 ]. We held fast to the need for a question that was broad in nature. Levac et al’s useful advice was published after we finished collecting our data and had started our analysis. By this point in our research, we realized we could not say anything substantive about our research query. We revised our question to fit the data we collected instead of revising our question and literature search to get different data that would really illicit the specifics of our interest. In hindsight, we see Levac et al’s suggestion as complementary to Arksey and O’Malley’s suggestion.

To help us with this dilemma (and independent of Levac’s suggestion), we re-reviewed the 239 papers our study produced with an additional inclusion criteria – the voice of people with a diagnosis of colorectal cancer – and identified 64 articles that spoke to the information needs of people with colorectal cancer from their point of view. The realization of the need to clarify this research concept came late in our research process. Thus, it is only in retrospect that we realized how useful it would have been to us earlier. Had we added these inclusion criteria at the outset, we might have had fewer articles to analyse but they would have yielded the data we were looking for. We recommend that researchers follow this advice of Arksey and O’Malley and Levac et al. to reduce the need to adjust their question to fit the methodology (Additional file 1 ).

It is important to reiterate, however, that in spite of our challenging experience with Arksey and O’Malley’s framework, our scoping study was a productive research exercise. We learned what has captured the attention of researchers and by default, what has not. That we narrowed down the original 10,753 papers to a specific set of 239 papers indicates the limited amount of literature that addresses our subject [ 10 ]. Given the prevalence of colorectal cancer, we find this not only startling, but useful in directing our future research. We are now in the process of further examining the 64 papers that reveal the perspective of people with colorectal cancer.

Arksey and O’Malley’s second step: identifying relevant studies

This step requires comprehensiveness to be thorough. We searched for relevant studies using a general internet Google search and several electronic databases, including Google Scholar. In addition, we looked for current and closed clinical trials, practice guidelines, meeting abstracts and dissertations, and searched other sources of grey literature using the Grey Matters Checklist created by the 2011 Canadian Agency for Drugs and Technology in Health. Once we completed these electronic searches, we conducted a hand-search of four key journals and scanned the reference lists from relevant papers to identify other papers that may not have been found in the initial search. We also searched the Social Science Citation Index for papers that our initial searches may have missed [ 10 ]. We followed Arksey and O’Malley’s recommendation to conduct a very broad search since comprehensiveness is “the whole point of scoping the field” [ 1 ].

We started with a broad search strategy. Navigating and redefining the findings after this initial search added another level of complexity to the scoping process. “The process is not linear but iterative,” Arksey and O’Malley emphasize, “requiring researchers to engage with each stage in a reflexive way and, where necessary, repeat steps to ensure that the literature is covered in a comprehensive way” [ 1 ]. Specifically, Arksey and O’Malley suggest that researchers fine tune their search of the literature. As noted above, we neglected to do this step and, in hindsight, realize how useful it would have been. We agree that flexibility and comprehensive searches are important to successful scoping studies.

However, a fine balance must be struck between the laborious nature of study identification and the need for comprehensiveness on the one hand, with the need to complete a scoping study in a timely fashion, on the other. Levac et al. and others recognize this issue [ 2 , 4 ]. While Levac et al. recommend assembling a “suitable team with content and methodological expertise” [ 8 ] to identify studies, we recommend assembling a small suitable team to perform this task (Additional file 1 ). We were a large team and we quickly found it counterproductive for every team member to be actively involved at the beginning of the research process; with too many people, there may be the introduction of too many interpretations, thereby leading to inconsistent search results. In order to maintain consistency and control, we tasked our librarian team member with the design and execution of search strategies. Navigating this many references took considerable time and skill. Although our search produced such a significant number of references, it left our research team confident that we had scoped the field as comprehensively as possible. Additionally, the use of an online citation management software proved to be of immeasurable benefit. It allowed us to organize and cross-check our data and remove duplicates. It also allowed all those involved in the charting steps of the study easy access to the papers.

Arksey and O’Malley’s third step: study selection

Once we identified the relevant literature, our team established the exclusion and inclusion criteria to apply to the papers. The librarian and research assistant on our team applied these criteria to the paper abstracts. We included studies that mentioned in any way the information needs of people with a diagnosis of colorectal cancer, their families and caregivers, or the information sources used by them. We carefully set parameters around studies for exclusion. For example, we excluded studies related to screening, prevention, genetics, and studies that included other types of cancer in addition to colorectal cancer. By applying the exclusion criteria to the abstracts, we reduced the numbers of papers that needed to be read in detail to 869 papers.

Given our large team, we made an adjustment to Levac et al’s suggestion of engaging two reviewers to apply the inclusion/exclusion criteria to the papers. Specifically, we took a three-tiered approach to narrow down and cross-check our papers. First, we divided the research team into six teams of two people each. Each team was assigned one sixth of the 869 articles to review. Both members of each team independently reviewed the full text of each article to determine its eligibility for our study according to the inclusion and exclusion criteria. Second, team members then compared their results to reach an agreement about which articles they recommended to include or exclude. Third, if they could not reach an agreement, the research assistant or the librarian acted as a third reviewer. After concluding this process, a total of 239 papers met the inclusion criteria and were included in our study. We made this adjustment to Arksey and O’Malley’s framework due to the size of our research team. We wanted to give each of our twelve team members exposure to the data and to reduce the workload by dividing up the work tasks. Levac et al. reached a similar conclusion about how to adjust the application of the inclusion/exclusion criteria, confirming our own decision to modify this portion of the framework (Additional file 1 ).

Levac et al. and others [ 2 , 3 , 5 ] are concerned about Arksey and O’Malley’s framework’s inability to provide for an assessment of the quality of the literature. Because our research team is using our scoping study as the basis for our next stage of research, we did not focus too much on this concern (although it did concern us from the outset). However, in retrospect, we believe assessing for quality is a necessary component of scoping studies if they are to provide research that in itself can be disseminated to others in a way that is useful to practice or policymaking and for future researchers. We strongly recommend that assessing for quality be factored into Arksey and O’Malley’s framework and suggest adding these criteria to the selection of studies to be charted. Some suggested methods for assessing quality might include, for example, using validated instruments .

Arksey and O’Malley’s fourth step: charting the data

To organize data, Arksey and O’Malley recommend charting and sorting data according to key themes and issues. They suggest that data charted should include a mixture of general information about the study and specific information related to the study question. Arksey and O’Malley’s own scoping work, an examination of the literature about services or programs for a particular population, charted seven pieces of information on each article (general information: citation data, methodology, aims of the study, outcome measures, important results; specific information: intervention type, study population). Researchers can determine what categories to chart for their particular study. We opted to adapt a charting format from Rutten et al. [ 11 ], a systematic review investigating the information needs of people with cancer. The categories and subcategories used by Rutten et al. fit well with our research question as our goal was similar but focused on a specific type of cancer, colorectal. Because our team consisted of health care providers with extensive clinical experience, we were able to anticipate the complexity of patient information needs prior to conducting our scoping study. To this end, we expanded and modified the set of subcategories related specifically to information needs from the original 64 (from Rutten et al.) to a total of 82. Using such a comprehensive chart proved both a strength and a limitation of our research. It was a strength because our final set of data was rich. We collected more data than we had room to report in a single manuscript. On the other hand, it was time consuming to chart with such a large number of categories. Some of our team members who were busy, practicing health care providers found the detailed nature of the charting process challenging because it took time, first, to engage with the information we aimed to capture and, second, to actually capture that information.

Levac et al. suggest that research team members, independent of one another, chart the “first five to ten studies using the data-charting form and meet to determine whether their approach to data extraction is consistent with the research question and purpose” [ 8 ]. We undertook a similar step in that we conducted a trial charting exercise followed by a group consultation. This step added value by providing our team an opportunity to reach consensus about our data collection process and to include additional categories relevant to our research inquiry. It improved the quality and applicability of the chart used as well as consistency. We recommend researchers consider this step to ensure the data they collect are as rich as possible.

Using our revised Rutten chart, we repeated a similar process as in step three with our six teams of two members each, where each team member worked independently to chart the included articles and team members then compared their results to agree upon the charting of each article. However, we changed the membership of each team in an effort to ensure consistency in interpretation and validity in our results. The research assistant read and charted all 239 articles. All three reviewers discussed any discrepancies and agreed upon a final interpretation. Having one person read and chart each article ensured inter-reviewer reliability throughout the process and contributed to our confidence in the consistency of our data results; this process was an important and valuable part of our research. During this process, effective communication to maintain a clear framework and consistent charting methods cannot be underestimated, particularly for a large team.

Arksey and O’Malley’s framework recommended using Excel to chart each paper, but they did not advise their readers about a key feature of data management: the importance of assigning each paper a unique identifying number. We did this task early on as a way to conveniently and clearly track those articles we excluded and those we included. We also recommend this step because it provides a useful way for a large team to talk about a particular article without having to cite full references or get confused by the names of researchers who have published multiple papers.

It was during the charting step that we began to realize our inability to answer our research question. We charted that an article mentioned a particular information need, yet we could not say anything about that need. For example, did people with colorectal cancer say they wanted this information or did the authors note it as information given to people with colorectal cancer, and it was unconnected to the people receiving it?

Arksey and O’Malley’s fifth step: collating, summarizing, and reporting the results

When reporting the data in our study, it was imperative that we used a consistent, clear approach. Following Arksey and O’Malley’s framework, we charted the extent, nature, and distribution of the included articles. As previously mentioned, we made additions to the Rutten et al. charting categories to better suit the complex information needs of people with colorectal cancer. Our goal with the 15 categories (ten broadly defined categories of information needs and five broad information sources categories) was to gather high-level data about the types of information needs, while we hoped the 101 sub-categories (82 sub-categories of information needs and 19 sub-categories of information sources) would gather micro-level, specific data on these needs. We searched for this range of data in order to satisfy the varied interests of each of our inter-professional team members. These team members desired this level of detail in order to make sense of the data in relation to their own professional practice. This proved to be a real strength to our approach to scoping studies and affirmed the value of including health care providers on our research team. Our ability to capture a complexity of data did not necessarily get us closer to answering our original research question, but it did provide us with an indication of the types of information needs being discussed by researchers.

We made sense of our complex data with a focus on our research question. Once we gathered all of our data and produced some preliminary graphs portraying number of mentions and specific needs, we established a smaller working group to make meaning out of the data and to make choices about the data on which we should focus. By this point, we knew we were not answering our initial question. We then modified our question and followed Arksey and O’Malley’s suggestion to prioritize certain aspects of the literature according to implications for future research and what was most notable given our experience. With our research question in mind, we first quantified the data and produced graphs and charts to represent these numbers. We then did a thematic analysis that resulted in organizing our data into three overarching themes: the information needs of people with colorectal cancer, the sources of this information, and the timing of these information needs. Our steps mirrored Levac et al’s recommendation to add a stage resembling qualitative data analytical techniques, or a thematic analysis. We endorse Levac et al’s suggestion (Additional file 1 ).

We published our findings using a combination of tables with descriptions according to our themes [ 10 ]. This approach proved useful to us in our analysis and allowed us to clearly link our findings with our research goals: to examine the extent of the literature and to identify gaps. Our data also pointed very clearly to the need for future research to pay attention to the need for information as articulated by people with colorectal cancer. We do not offer a new recommendation in this regard, but support Levac et al. in their suggestions for this stage of the scoping study framework.

Arksey O’Malley sixth step: optional stage, consultation exercise

Arksey and O’Malley suggest an optional consultation stage with stakeholders, whereas Levac et al. suggest it should be a requirement. Based on our experience, we agree with Levac et al. (Additional file 1 ) but with room for interpretation of how that consultation is achieved. In our study, there were two groups of stakeholders: health care providers providing care to people with colorectal cancer and people with colorectal cancer themselves. Our research team included a significant number of health care providers. Their participation throughout the entire research process served the purpose of constant consultation and was a real strength of our inter-professional approach. We were able to extract multi-faceted perspectives in the literature and our findings throughout the entire research process rather than leaving it to the end of the project. As a result, we were able to revise the charting categories early on so it more accurately reflected people’s experience than if we had just borrowed one. The health care providers drew upon their experience to identify the gaps in the categories being un/attended to by researchers. We originally intended to consult with the second group of stakeholders, people diagnosed with cancer. However, we omitted that step after realizing that our study did not tell us anything about their information needs from their perspective because it gave us nothing substantive on which to seek their consultation. With Arksey and O’Malley’s framework, consultation only works if the results are germane to the group that researchers wish to consult. Moving forward with future research, we have built this consultation process into our current research with the 64 articles. We see it as a fundamental step to determine how what the literature says resonates with people with colorectal cancer.

Levac et al. and Brien et al. [ 5 , 8 ] discuss the importance of knowledge translation with stakeholders in the field, a perspective we share. In fact, Grant and Booth state that “scoping reviews are able to inform policymakers as to whether a full systematic review is needed” [ 4 ]. Although the methodology did not enable us to address our specific research question, the scoping study exercise did demonstrate that a further study is needed and it pointed out gaps in the literature. In fact, our experience led us to believe that scoping studies may be a useful step – perhaps even a necessary pre-requisite – toward a research project that allows for a deeper analysis, such as a knowledge synthesis methodology [ 12 ]. Indeed, our study has been valuable in part because it opened up questions to guide future research from which we will have findings we can share with stakeholders, including policymakers and health care providers to inform their practice.

Inviting suitable stakeholders to be part of the research team is one way to incorporate the consultation Levac et al. say is necessary. We recommend researchers consider this decision when possible as it makes the entire research process and, thus, the findings, rich. That being said, not all stakeholders will be appropriate to be involved on the research team and researchers must make this decision carefully. For example, previous experience with research is not necessarily a requirement but experience in a critical analysis of relevant literature is necessary. Effective team work skills are imperative, especially when large groups are assembled. Time availability to participate in all stages of the project is another important point to be considered.

A large, inter-professional team using Arksey and O’Malley’s framework: strengths and challenges

Our contribution to the conversation on scoping studies relates to our experience as a large, inter-professional team using Arksey and O’Malley’s framework. Levac et al. and others point to a multidisciplinary team as a benefit for scoping studies [ 2 , 13 ]. According to Anderson et al., a multidisciplinary team provides the required “expertise to map a subject” that is “not necessarily always found in one researcher” [ 2 ]. Our research team was not only multidisciplinary, but inter-professional in its composition. A multidisciplinary team is academic in character because it joins together members trained in different disciplines, whereas an inter-professional team is professional in character because it joins together members trained in program areas of clinical practice, plus academic researchers [ 14 ]. It is important to note that the challenges we experienced are not unique to scoping studies, but are faced commonly by all research projects conducted by large, inter-professional teams. However, critical discussions about inter-professional teams are absent from the current literature about scoping study methods.

The large, inter-professional character of our team brought both strengths and challenges to Arksey and O’Malley’s framework. On one hand, it was a strength because our team collectively brought a breadth and depth of clinical and research knowledge absent in a team comprised only of academic researchers. It also brought time efficiencies. Our team worked efficiently when it came to assigning and completing work tasks. We strategically divided up work tasks, which often meant a lighter workload for each individual team member. This type of time efficiency was especially evident at the inclusion/exclusion and charting stages of Arksey and O’Malley’s framework. The make up of our team also added to the rigor of the research process; twelve team members from diverse backgrounds provided many perspectives.

On the other hand, the large, inter-professional character of our team had some challenges relating to consensus, research experience, and resource limitations. The greater the number of team members, the greater the number of perspectives. At certain points, productivity decreased. Although such a team produced rich analysis, it was challenging to reach consensus because there were occasional competing perspectives. At times, we found it difficult to arrive at a common language or vocabulary for discussion and had to re-double our efforts during the research process to ensure consistency.

Finally, as with any research project, there is always a need to balance finite resources of time and money. With an inter-professional team, this need is greater because there are more competing interests, more professional schedules to coordinate, and more communication efforts required to explain, explore, and reach consensus about ideas. We found it helpful to designate one person or a small section of the team to take the lead at various stages of the research process to move the project forward. While we have noted at several steps of the process that communication and regular meetings are important, we also acknowledge that it may be challenging to organize meetings for so many team members and to ensure that all team members consistently produce deliverables at agreed upon deadlines. We recommend, however, that large, inter-professional teams pay special attention to this issue as communication is key to success.

Summary: lessons learned

Some authors have expressed their concerns about Arksey and O’Malley’s framework’s inability to provide for an assessment of the quality of the literature [ 2 , 3 , 5 , 8 ]. We believe assessing for quality is a necessary component of scoping studies. The assessment itself is a significant task and should be performed using validated instruments. This recommendation does not stand alone, however. We propose that the recommendations of Levac et al. to clarify the concepts in the research question and Arksey and O’Malley’s suggestion to redefine search terms will ensure the assessment of quality actually proves useful. To this end, the definition and purposes of scoping studies must be made in tandem with clarifying the methodological framework; no one can be done without the others.

We endorse Arksey and O’Malley’s purposes when taking into consideration Levac et al. and our own recommendations. As for the definition used by Arksey and O’Malley, we would remove the term “rapidly” and replace it with the need for scoping studies to be done thoroughly and thoughtfully. To be clear, scoping studies take time. Second, we think that adding a quality assessment step would alter the definition.

With a more detailed methodological framework according to the recommendations of Levac et al., our own, plus purposes that are more attainable, we suggest a definition of scoping studies as follows: Scoping studies aim to map the literature on a particular topic or research area and provide an opportunity to identify key concepts; gaps in the research; and types and sources of evidence to inform practice, policymaking, and research .

Creating a large, inter-professional team to engage in a scoping study offers tangible benefits to the research process. If using a revised framework set out by Arksey and O’Malley’s using Levac et al. and our recommendations, major tasks can be fairly divided without compromising the consistency of analysis. Additionally, each inter-disciplinary team member adds richness to the analysis as he/she brings his/her perspective to the research table.

A large, inter-professional team including health care providers allowed us to anticipate the complexity of information needs. Including suitable stakeholders on the research team builds in the consultation stage throughout and adds depth to all stages of the research process.

It is important that researchers fully understand the methodology’s boundaries and its inherent methods. It would be beneficial to include someone on the research team who is experienced with scoping studies. Most important is the work involved of matching the methodology with research interests and attending to suggestions to clarify concepts within the research question and/or focus the literature search as necessary to ensure researchers do not lose sight of their interests.

Competing interests

All authors declare that they have no competing interest.

Authors’ contributions

Each author (HMLD, CvM, and SJS) made substantial contributions to the conception, analysis, and interpretation of the data. Following a group discussion about the outline of the paper, SJS created the first draft of the manuscript, HMLD and CvM revised the draft and, thereafter, each author interactively participated in critically revising the content up to the final, submitted version. Each author read and approved the final manuscript.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/13/48/prepub

Supplementary Material

Comparative recommendations to enhance Arksey and O’Malley’s six framework stages.

Acknowledgements

The authors would like to acknowledge the other members of the research team: Heather Watson, Maxine Alford, Cheri Cosby, Nancy Payeur, Mary Ellen Purkis, Darcy Dennis, Ryna Levy-Milne, and particularly Alison Mitchell and Lorraine Leitz for their review of the manuscript. We are grateful for the funding for this research received from the Canadian Institutes of Health Research (CIHR).

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• http://orcid.org/0009-0006-9680-7969 Hanna A A Röwer ,
• http://orcid.org/0000-0003-2602-9277 Franziska A Herbst and
• http://orcid.org/0000-0002-3575-3817 Sven Schwabe
• Institute for General Practice and Palliative Care , Hanover Medical School , Hanover , Germany
• Correspondence to Ms Hanna A A Röwer, Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany; roewer.hanna{at}mh-hannover.de

Background Regional hospice and palliative care networks (RHPCNs) are increasingly being established to improve integrative care for patients with life-limiting illnesses. This scoping review aimed at identifying and synthesising international literature on RHPCNs, focusing on structures, outcomes, benefits, success factors and good practices.

Method Following Arksey and O’Malley’s (2005) framework, a search of four electronic databases (CINAHL, Google Scholar, PubMed, Web of Science Core Collection) was conducted on 7 July 2023. Additionally, a manual search of reference lists of the identified articles was performed. Original research, qualification theses and descriptive reports on RHPCNs at a structural level were included.

Findings Two researchers analysed 777 article abstracts, screened 104 full texts and selected 24 articles. The included studies predominantly used qualitative designs. RHPCNs self-identify as local stakeholders, employ coordination offices and steering committees, and actively recruit network partners. Outcomes included improved professional practices, enhanced quality of care, increased patient utilisation of regional care offerings and improved patient transitions between care providers. Success factors included clear coordination, transparent communication, strategic planning and resource-securing strategies.

Conclusions The analysis identified key RHPCN success factors such as effective communication and adaptive leadership. Despite the need for further research, the findings emphasise RHPCNs’ potential to improve palliative care and encourage policymaker support.

Other This scoping review is part of the research project HOPAN, which aims at assessing and analysing RHPCNs in Germany. The project is funded by the German Innovation Fund of the Federal Joint Committee (G-BA) (Grant N° 01VSF22042; funding period: 01/2023–12/2024).

• Hospice care
• Palliative Care
• Case Management
• Supportive care
• Communication

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/spcare-2024-004974

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WHAT IS ALREADY KNOWN ON THIS TOPIC

The existing literature recognises regional hospice and palliative care networks (RHPCNs) as promising structural approaches for optimising end-of-life care. A comprehensive overview of RHPCN structures and benefits is lacking. A scoping review was considered appropriate to synthesise the literature and address research gaps.

WHAT THIS STUDY ADDS

The present review provided an understanding of RHPCNs’ nuanced organisational structures, multifaceted outcomes and benefits (eg, improved professional practices, enhanced client services), and specific success factors (eg, transparent communication, strategic planning, resource securing strategies for sustainability).

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

The findings may guide efforts to refine and strengthen RHPCN structures and activities, thereby bolstering the ability of RHPCNs to provide effective and integrated end-of-life care. Policymakers and stakeholders may use the findings to improve the structural frameworks and funding conditions of RHPCNs.

Introduction

Effective palliative care requires collaboration and coordination among various healthcare professionals, organisations and community resources. 1 2 Thus, the emergence of regional hospice and palliative care networks (RHPCNs) shows promise for enhancing the delivery of comprehensive and integrated care for patients with life-limiting illnesses at a structural level.

An RHPCN is a structured collaborative system encompassing a wide array of stakeholders in a specific geographic region. RHPCNs bring together various healthcare providers, organisations and services to address the complex and interconnected healthcare challenges faced by patients and communities. Unlike isolated cases of provider cooperation, RHPCNs collaborate at a structural level, with key stakeholders working together to improve healthcare delivery in palliative and hospice settings in their local region. RHPCNs aim at facilitating the sharing of expertise, resources and good practices, ultimately optimising the delivery of palliative care across different contexts, including hospitals, long-term care facilities and outpatient care settings. 3 4

Given the increasing implementation of RHPCNs, 5–8 a comprehensive understanding of their structures, benefits and success factors is crucial to guide their continued development and refinement. A scoping review may help to achieve this by mapping and synthesising the literature on RHPCNs, exploring the range of evidence available to identify key themes and research gaps.

The present scoping review aimed at generating an overview of the current knowledge and understanding of RHPCNs. Specifically, it addressed the following question: What is known about RHPCNs worldwide, with regard to (a) their structure, (b) their benefits and outcomes, and (c) their success factors and good practices?

Through this systematic scoping review, the study sought to inform both current and prospective RHPCN providers and funders about the state of knowledge on RHPCNs, while also drawing researchers’ attention to gaps in the scientific data. Additionally, the results aimed at guiding the further development of RHPCNS through recommendations and evaluation frameworks to improve network maturity. The work comprised part of the broader HOPAN research project. 9

The research question necessitated a methodology that would offer a comprehensive overview of the existing literature. Scoping reviews are designed to capture a wide range of information, allowing for a broad and diverse collection of knowledge. Consequently, for the present study, a scoping review was preferred to a systematic review, as the research question called for an open, exploratory approach.

The scoping review followed the five-step methodological framework of Arksey and O’Malley 10 : (1) identifying the research question(s), (2) identifying the relevant studies, (3) selecting the studies, (4) charting the data, and (5) collecting, summarising and reporting the results.

Protocol and registration

The present scoping review has not been registered. To enable transparent documentation and to ensure replicability, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist 11 and a review protocol were used to both plan and conduct the review, as well as to guide the reporting of the results.

Eligibility criteria

Articles were assessed and selected on the basis of the study population and setting, as well as the publication language and article type. As RHPCNs are a rather recent phenomenon, the review search period was left open. Publications in both German and English were included in the review. English contributions were accepted in order to capture results from around the world, while German articles were included to generate additional insights into the authors’ local context.

The review considered original research, scientific qualification theses and descriptive reports, as these types of publications typically follow rigorous methodologies, ensuring systematic and thorough investigation. Limiting the review to these types of publications also aimed at ensuring the credibility, validity and relevance of the included literature. Congress abstracts were excluded because these often lack sufficient detail on methodology and results to guarantee scientific quality.

Information sources

A comprehensive search of the electronic databases CINAHL, Google Scholar, PubMed and Web of Science Core Collection was conducted on 7 July 2023. These databases were selected to provide broad coverage of different disciplines. Additional databases were considered redundant or irrelevant. The compilation of full texts relied on the resources of the Hannover Medical School library.

Search strategy

The search strategy was developed by HR, with support from SvS and FH. The initial approach involved compiling a list of key articles deemed essential for answering the research question. 5 12–16 The search strategy was then iteratively adjusted until it included all of the identified key articles. Additional grey literature was sought via Google Scholar. Reference lists of the full texts were hand-searched to identify further relevant studies.

The following search strategy was used in PubMed:

(network[Tiab] OR networks[Tiab] OR networking[Tiab] AND rural[Tiab] OR regional[Tiab] OR local[Tiab] AND ‘palliative care’[MeSH Terms] OR ‘hospice care’[MeSH Terms] OR ‘terminal care’[MeSH Terms] OR palliative[Tiab] OR ‘terminally ill’[Tiab] OR ‘terminal illness’[Tiab] OR ‘terminal illnesses’[Tiab] OR ‘terminal disease’[Tiab] OR ‘terminal diseases’[Tiab] OR hospice[Tiab] OR hospices[Tiab] OR ‘end of life’[Tiab] OR eol[Tiab] OR ‘life’s end’[Tiab] OR ‘advanced care planning’[Tiab] OR ‘advanced illness’[Tiab] OR ‘advanced illnesses’[Tiab] OR ‘end stage disease’[Tiab] OR ‘end stage illness’[Tiab] OR ‘end stage illnesses’[Tiab] OR ‘end stage diseases’[Tiab])

This search strategy was adapted for the other databases according to the individual database standards, and retested to ensure that key articles in the respective databases were identified.

Selection of sources of evidence

To be included in the review, studies were required to focus specifically on RHPCNs comprised of interdisciplinary providers in hospice and palliative care settings, working at a structural level. Additionally, studies were only included if their population was a regional healthcare network promoting collaboration and coordination among different healthcare service providers in a specific geographic region. These networks were required to involve care providers from various health professions and disciplines, such as physicians, nurses, social workers, therapists and other experts from outpatient and/or inpatient facilities. Studies focused solely on specific cases of collaboration between individual providers were excluded, given the research objective to analyse structurally operating networks, rather than isolated instances of collaborative effort. Finally, studies were included only if they related to hospice or palliative care settings (ie, networks addressing the care of individuals with life-limiting illnesses at the end-of-life and their families).

Data charting

All of the retrieved articles were imported into EndNote 20 reference management software (Clarivate, Philadelphia, USA). After screening for duplicates, two researchers (HR and SvS) independently reviewed the titles and abstracts of the remaining studies. Documentation of the main reasons for exclusion was used to reach consensus. Both researchers independently moved excluded studies to separate EndNote groups according to the exclusion criteria: (1) other population, (2) other research setting, (3) other publication type or (4) other language. Researcher decisions were subsequently compared. In the event of disagreement, consensus was sought. Where consensus was not reached, a third researcher (FH) was consulted for clarification. In the next step, two researchers (HR and SvS) independently reviewed the full text of the remaining studies, according to the aforementioned criteria.

All of the included articles provided information on at least one of the three aspects covered by the research question. The analysis of RHPCN structures relied on data regarding their organisation and operational framework. The examination of benefits and outcomes referred to studies describing the effects of RHPCNs on patients and their families, as well as local professionals. Finally, the identification of RHPCN good practices and success factors relied on studies highlighting established and recognised methods and processes leading to optimal RHPCN conditions. Benefits, outcomes, good practices and success factors that were listed in articles as potentially significant but not actually observed were not included.

Critical appraisal of individual sources of evidence

No quality assessment of the reported evidence was conducted, due to the chosen form of review and the immediate need for evidence to support an ongoing research project.

Synthesis of results

Studies were included if they provided information on at least one of the following three topics: (1) structures, (2) benefits and outcomes, and (3) success factors and good practices. Information on these topics was compiled in a table.

The search resulted in 24 articles for the final review, including one article identified through a hand search.

A total of 1089 records were identified from CINAHL (n=248), Google Scholar (n=30), PubMed (n=362) and Web of Science Core Collection (n=449) (see figure 1 ). Prior to the screening process, 313 duplicate records were removed, leaving 776 unique records for further assessment. During the screening phase, the abstracts and titles of each of the 776 records were reviewed for study eligibility. This resulted in the exclusion of 670 records for the following reasons: study population other than structural networks (n=644), study setting other than hospice and palliative care settings (n=23), other publication type (n=2), or published in a language other than English or German (n=2). Following the initial screening, the full texts of 105 potentially relevant articles were sought for retrieval. However, two of these articles could not be retrieved. Hence, a total of 103 full texts were assessed for eligibility. From these articles, further exclusions were made based on the following criteria: study population other than structural networks (n=51), study setting other than hospice and palliative care settings (n=2), other publication type (n=15), or published in a language other than English or German (n=12). A hand search of the reference lists of the chosen full texts resulted in the inclusion of one further paper. Ultimately, 24 studies were included in the systematic review.

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Flow diagram.

Characteristics of sources of evidence

The included 24 studies focused on RHPCNs in different countries, with the majority (n=10) based in Canada. 3 17–25 Five articles provided insights into RHPCNs in different regions of Australia, 16 26–29 five originated from Germany 12–15 30 and two were based in the USA. 31 32 One article explored the formation and evaluation of RHPCNs in the Netherlands. 5 Finally, one article focused on the experiences of community nurses in RHPCNs based in the UK. 8 The earliest study was published in 1980 31 and only a small number of articles (n=6) were published in the last 10 years since the database search. 12–15 24 30 These more recent studies primarily stemmed from Germany. 12–15 Most articles were published in 2001, 8 28 between 2005 and 2007, 3 5 10 21 26 29 between 2009 and 2011, 16–20 22 and in 2017 12 13 (see figure 2 ).

Publications (full texts) by year and country of origin.

Thirteen studies drew on qualitative research in the form of interviews and focus groups. 3 5 8 12–14 19 21 22 26 27 29 30 Document analysis was applied in five studies, 3 5 16 18 19 mainly describing the establishment and structural composition of RHPCNs. While the use of surveys was noted in seven studies, 5 12 14 18 20–22 only one study used a survey as their sole data source. 20 The number of network participants varied across studies, from 1 15 19 23–25 27 30 32 to 13. 20 The number of interviewees in studies reporting this information ranged from 1 17 to 20, 19 with an average of 11. The number of focus group or workshop participants in studies reporting this data ranged from 8 32 to 106, 28 with an average of 42. The number of survey participants in studies reporting this data ranged from 12 26 to 61, 20 with an average of 25. Additionally, two studies 23 30 analysed a total of n=43 012 patient data sets.

Results of individual sources of evidence

In the following tables present the principal data pertaining to the articles and their content in relation to the research questions (see tables 1–6 ).

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Summarised characteristics of the included studies (part 1)

Summarised characteristics of the included studies (part 2)

Summarised characteristics of the included studies (part 3)

Summarised characteristics of the included studies (part 4)

Summarised characteristics of the included studies (part 5)

Summarised characteristics of the included studies (part 6)

The findings of the scoping review are presented in accordance with the three topics covered by the research question.

Seventeen articles 5 8 12 13 15 17–20 22 23 25 28–32 addressed RHPCN structures. Taken together, these articles provided a comprehensive overview of two central RHPCN themes: network role and organisational structure. In more detail, 14 articles 5 8 12 13 15 17 19 23 28–32 addressed network role and 14 articles 5 8 12 13 15 17–20 25 29–32 addressed organisational structure.

Network role

RHPCNs were found to contribute to collaboration and the efficient delivery of patient-centred care. Some studies emphasised the central role played by RHPCNs in sustaining interprofessional collaboration and cooperation. 17 21 30 Two studies described RHPCNs as a central point of information exchange between regional providers, 25 29 while other studies showed that RHPCNs aim at improving the flow of information through centralised information platforms. 19 Some articles positioned RHPCNs as strategic management tools within health systems, describing them as multi-institutional systems for coordination or consolidation, involved in planning and evaluation, rather than policy. 8 31 Several authors further indicated that RHPCNs act as catalysts for sustained collaboration, 20 engage in advocacy through coordination and programme evaluation, 32 and expand to new target groups, fostering diverse partnerships. 12 The included studies varied in their descriptions of the extended functions of RHPCNs, which included establishing new provider facilities (eg, branch offices) or completely new regional offerings, 15 and serving as catalysts for organisational and stakeholder organisation. 23 28 Several authors also indicated that RHPCNs may play a governance role, 19 highlighting diverse functions ranging from coordinating volunteers to exerting political influence, 28 29 while also suggesting the importance of formal structures to facilitate commitment and alignment.

Overall, the included studies showed that RHPCNs facilitate interprofessional collaboration through team-based approaches emphasising ethical awareness. 17 In addition, several authors argued that RHPCNs align with larger healthcare strategies, recognising their evolving nature. 8 12 15

Organisational structure

The included studies identified differing RHPCN organisational models, based on various forms of cooperation. These included cooperation agreements, 13 20 cooperation via coordination offices or steering committees, 13 15 and cooperation with no formal agreement in place but the intention to share costs. 32 This highlights the adaptive nature of these networks. A qualitative study of n=10 network coordinators described partnerships within RHPCNs as expansive, including hospitals, general practitioners, specialised doctors, outpatient care services, inpatient care homes, local authorities, pharmacies and aid suppliers. 12 One study found that some RHPCNs had approximately 100 member organisations. 18 The authors of three other papers described that RHPCNs focus on expanding local educational services, adapting to external policy frameworks and accommodating different palliative care service models. 15 23 28 One publication noted that local stakeholder-driven networks adopt inclusive structures, uniting leaders from numerous organisations. 21

Another study described that RHPCN organisational structures vary in accordance with internal and external factors, such as structural disparities and funding challenges. Variations in interorganisational cooperation may pose further complexities. 19 Two studies described RHPCNs as constantly evolving in response to government guidance. 8 29 These same studies also described how the influence of external policy frameworks on service models 8 29 can challenge structural uniformity. Furthermore, two studies reported structural inequalities within RHPCNs due to inadequate funding, variable palliative care capacity, and a lack of standardised information systems. 5 19

In summary, the investigated studies suggest that RHPCNs are remarkably adaptable to local contexts. Furthermore, they navigate challenges through diverse structures, promote interprofessional collaboration and contribute to strategic health priorities.

Outcomes and benefits

Eighteen articles 3 5 8 13 15 17–23 25–27 30–32 addressed the outcomes and benefits of RHPCNs, underlining two main themes: professional practice benefits and client service benefits. Both of these categories were covered by all of the 18 articles, with consistent themes emerging.

Professional practice benefits

Various studies described that interdisciplinary collaboration and a team-based approach could improve coordination and communication at an interdisciplinary level. 5 8 17 27 31 Some of the publications noted that the integration of comprehensive pain and bereavement management skills through networking could also contribute significantly to holistic patient care. 3 17 26–28 Two studies based in Australia and Canada, respectively, identified that networking improved both ethical awareness and knowledge of legislation, promoting greater compliance with legislation and models of ethical healthcare. 17 27 In addition, some authors argued that networking could facilitate greater collaboration between healthcare professionals and ensure a consistently high quality of patient care. 5 8 19–21 26 Professional practice was also described as being strengthened through the exchange of valuable information and further training within the network. 26 28 32

Studies also identified that improvements in symptom management and the introduction of regional standardised assessment procedures, both associated with RHPCNs, could significantly improve the effectiveness of patient care. 20 22 23 30 31 Four studies described that networking could promote the efficient use of resources, knowledge sharing and interdisciplinary cooperation, enabling the optimal use of healthcare resources. 13 15 23 30 In addition, three studies showed how the culture of collaboration fostered by RHPCNs, as evidenced by their greater transparency and promotion of effective conflict resolution, had a positive impact on primary caregiver satisfaction. 5 19 21

Client service benefits

In addition to the client benefits derived from the improved professional practice associated with RHPCNs, studies also identified a number of concrete benefits to local communities. As an example, six papers described that RHPCNs facilitate better communication and coordination among healthcare professionals, leading to improved access to healthcare services and continuity of care for their respective populations. 5 13 15 19 21 23 In addition, two studies identified a reduction in emergency visits and the introduction of evidence-based practices in RHPCNs as a result of networking. 22 31 Two further articles explained that bereavement support and strong ethical awareness among professionals may significantly contribute to the expansion of holistic end-of-life care offerings. 17 This outcome could also be promoted by more effective pain management skills in RHPCNs. 17 27 Studies also revealed that RHPCNs can increase public awareness and political influence with respect to local end-of-life issues. Increased public awareness of such issues could facilitate access and increase support from current or prospective funders. 18 19 23 32

Success factors and good practices

Twenty-four articles addressed RHPCN success factors and good practices. The articles strongly advocated for interdisciplinary collaboration and team-based approaches to improve patient care and coordination across healthcare providers. 8 13 16–19 21 25 Six studies also highlighted effective leadership and governance structures as crucial to the success of RHPCNs, ensuring clear direction, commitment and the ability to navigate complex dynamics. 8 13 16 17 19 21 Moreover, several authors argued that effective coordination is a crucial success factor for overall healthcare delivery, encompassing streamlined care coordination, standardised practices and centralised capacities. 13 15 20 21 30 Seven studies indicated that the establishment of robust networks and open communication are pivotal in facilitating collaboration, knowledge sharing and overall effectiveness in RHPCNs. 8 13 15 17 22 26 30 Four studies identified transparency and trust as critical factors for fostering effective relationships between stakeholders, healthcare providers and the community, thereby increasing a network’s impact. 15 21 22 30 Flexibility and adaptability were also emphasised, in recognition of the dynamic nature of healthcare environments and the need for RHPCNs to evolve in response to changing circumstances. 8 15 19 21

Seven articles stressed the need for sustainable resource management, including financial considerations and incentives, to ensure long-term viability and effectiveness. 5 8 17 18 22 30 In particular, sustainable healthcare practices, including efficient resource use, were highlighted as essential for the long-term success and impact of RHPCNs. 15 17 22

The provision of bereavement support was noted as an integral aspect of RHPCNs, underlining the importance of addressing the emotional and psychological needs of patients and their family caregivers. 17 22 28 Various articles 3 14 17–20 26 32 emphasised the importance of comprehensive patient care, including thorough pain management and bereavement support. In addition, four studies highlighted the implementation of patient-centred care, prioritising patient needs and preferences and ensuring more personalised and effective healthcare. 8 14 18 25 Continuous quality improvement and rigorous evaluation processes were also advocated to ensure the continued success and effectiveness of RHPCNs in meeting the evolving needs of patients and communities. 8 14 15 17 21 22 30 One study showed that the common language used within RHPCNs may help patients understand the procedures and implications across different settings, enabling them to make more informed decisions. 23

Seven studies identified education and training programmes as essential for healthcare professionals within these networks, promoting continuous learning, skills development, and the integration of innovative approaches, as well as professional confidence. 14 15 17 26 28 29 In this context, collaborative resource utilisation was emphasised as an effective strategy, encouraging the pooling of expertise and resources to optimise service delivery and improve overall healthcare outcomes. 26 28 32 One study showed that agreement over the sharing of medical aids (eg, diffusers, walking aids) across all RHPCN providers could simplify patient transfers between facilities. 23

Six studies recognised community engagement as another RHPCN success factor, emphasising public involvement in, awareness of, and support for healthcare initiatives. 17 18 20 21 29 32 In this vein, community outreach and the promotion of public awareness were highlighted as key strategies for fostering community involvement and understanding, while promoting the central role played by RHPCNs. 29 31 32 One paper identified political support and advocacy as influential for shaping favourable policies and creating environments conducive to the effective operation of healthcare networks. 17

Summary of the evidence

The results of the scoping review highlight the crucial role played by RHPCNs in fostering collaboration, enhancing patient care and contributing to the sustainability of the healthcare system. The identified success factors and good practices provide a roadmap for optimising the effectiveness and impact of RHPCNs in delivering quality, accessible and sustainable palliative care services to patients and communities in need. The geographical diversity of the studies—encompassing full texts from six countries across three continents, plus abstracts from seven other countries (including one from a fourth continent)—and nearly 40-year range of publication (ie, from 1980 to 2019), reflect the global importance and ongoing development of RHPCNs.

The findings can be compared with those of previous systematic reviews and meta-analyses on healthcare networks, particularly in terms of good practices and success factors. In line with the present review, these studies have underlined that healthcare networks are most effective when they have structural features that promote connection and communication, and when they are well managed with effective leadership. 33–36 One scoping review identified success factors such as clearly defined responsibilities and tasks, alongside a coordinating position where possible. Although effective leadership emerged as key to network performance in the present scoping review and other studies of health networks, 33–36 some studies have also shown that tensions can arise in healthcare networks between the moderating mechanisms of collaboration and control, due to the confluence of different structures, ways of working, and objectives. 37 38 The simultaneous use and development of new structures, behaviours and goals has been suggested as a way to manage these tensions. 37 This approach may also be relevant to RHPCNs, though it was not explicitly identified in the present review.

The ability to connect with other stakeholders based on commonly agreed standards is essential for the collaborative delivery of patient-centred and cost-effective services in healthcare networks. 39 Findings from qualitative studies of healthcare networks 33 suggest that networks with access to adequate funding and effective leadership and governance, combined with effective communication strategies and trust-based collaborative relationships, exhibit greater quality of care and patient outcomes. This is consistent with the results of the present scoping review, which identified intersections between good practices and success factors for healthcare networks in general, as well as those focused on end-of-life care.

Two systematic reviews on this topic have revealed some evidence that clinical networks can improve quality of care, network efficiency and patient outcomes, 33 40 based on a small number of studies. The present scoping review aligned with these previous works, as most of the studies, it investigated on the benefits and outcomes of networks emphasised improved patient outcomes and greater network effectiveness. However, the subjective experiences of professionals and patients have rarely been considered in studies of general networks 33 or RHPCNs, more specifically (as shown by the present results).

Strengths and limitations

The present scoping review used a robust methodological framework based on Arksey and O’Malley, 10 conducting a thorough search of multiple electronic databases (CINAHL, Google Scholar, PubMed, Web of Science) to ensure comprehensive coverage of the relevant literature. Clear inclusion criteria were established, focused on studies of networks in hospice and palliative care settings, including original research and reports of projects and initiatives. This ensured the relevance and applicability of the included studies. To minimise bias, two researchers independently reviewed abstracts and full texts to identify relevant articles. This transparent process helped to ensure the reliability of the review findings.

Overall, these strengths contribute to the credibility and reliability of the scoping review, making it a valuable resource for understanding the current landscape of RHPCNs and identifying areas for future research and practice.

At the same time, it is important to acknowledge certain limitations due to the inclusion criteria related to language. Some articles may have been excluded from the analysis because they were not available in the language(s) specified for the review. This language limitation may have led to the omission of valuable research and insights published in other languages. As a result, the findings and conclusions of this review may not fully represent the global landscape of RHPCNs.

It is also important to note the challenges involved in distinguishing between care and case networks, as many care structures work collaboratively or interprofessionally (eg, those funded by health insurance funds in Germany), without being active at a structural level. The types of networks included in the reviewed studies were not always clear. Thus, when the relevance of the network type was in doubt, the relevant article was excluded from the analysis. This may have influenced the final selection of studies. Furthermore, it was not always clear how the different conceptualizations of networks—which included varying degrees of formalisation—could be compared between studies. Consequently, it was not possible to establish a relationship between benefits/outcomes and degree of network organisation.

Conclusions

The present scoping review explored the structures, outcomes, benefits, success factors and good practices of healthcare networks in hospice and palliative care contexts. The investigated studies applied different research methods without time limitations, providing a broad overview of the research field.

Nevertheless, certain research gaps emerged from the review. While numerous qualitative studies have identified success factors, the lack of quantitative studies precludes any analysis of the relative importance and strength of these factors in facilitating effective networking. The RHPCN structures reported in this scoping review varied from loose collaboration to contractual relationships headed by a fully funded coordinating office. However, it is unclear which of these structures best supports good networking. It would also be useful to determine whether the financial participation of network members contributes to determining their commitment to network collaboration. Overall, there are no established quality criteria or reference points for determining RHPCN quality. Studies aimed at filling these gaps through comprehensive research and a balanced representation of perspectives would contribute significantly to our understanding of the functioning and impact of RHPCNs.

Furthermore, the present scoping review suggests potential implications not only for RHPNs but also for policymakers, encouraging them to support and invest in these networks to ensure long-term sustainability and facilitate moderation and coordination.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Acknowledgments.

The authors thank Nilab Kamandi, the student assistant involved in the research project HOPAN, for their support in testing the search strategy and obtaining the full texts. The authors also acknowledge Valerie Appleby’s professional copyediting of the manuscript.

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FAH and SS are joint senior authors.

Contributors HAAR and SvS conceived of the scoping review. HAAR, SvS and FAH designed and coordinated the review study. HAAR conducted the database search. HAAR and SvS screened the search results and extracted the data. FAH supervised the data screening process. HAAR wrote the first draft of the manuscript. SvS and FAH revised the manuscript critically for important intellectual content and contributed to the draft. All authors approved the final version of the manuscript. All contributors are responsible for the overall content, as guarantors.

Funding The present scoping review comprised part of the research project HOPAN, which aims at assessing and analyzing RHPCNs in Germany. The project is funded by the German Innovation Fund of the Federal Joint Committee (G-BA) (Grant N° 01VSF22042; funding period: 01/2023–12/2024). The funding body was not involved in the study design, the preparation of this paper, or the decision to submit the paper for publication.

Competing interests Non competing interests.

Provenance and peer review Not commissioned; internally peer reviewed.

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