approaches to literature review pdf

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Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.

Handbook of eHealth Evaluation: An Evidence-based Approach [Internet].

Chapter 9 methods for literature reviews.

Guy Paré and Spyros Kitsiou .

9.1. Introduction

Literature reviews play a critical role in scholarship because science remains, first and foremost, a cumulative endeavour ( vom Brocke et al., 2009 ). As in any academic discipline, rigorous knowledge syntheses are becoming indispensable in keeping up with an exponentially growing eHealth literature, assisting practitioners, academics, and graduate students in finding, evaluating, and synthesizing the contents of many empirical and conceptual papers. Among other methods, literature reviews are essential for: (a) identifying what has been written on a subject or topic; (b) determining the extent to which a specific research area reveals any interpretable trends or patterns; (c) aggregating empirical findings related to a narrow research question to support evidence-based practice; (d) generating new frameworks and theories; and (e) identifying topics or questions requiring more investigation ( Paré, Trudel, Jaana, & Kitsiou, 2015 ).

Literature reviews can take two major forms. The most prevalent one is the “literature review” or “background” section within a journal paper or a chapter in a graduate thesis. This section synthesizes the extant literature and usually identifies the gaps in knowledge that the empirical study addresses ( Sylvester, Tate, & Johnstone, 2013 ). It may also provide a theoretical foundation for the proposed study, substantiate the presence of the research problem, justify the research as one that contributes something new to the cumulated knowledge, or validate the methods and approaches for the proposed study ( Hart, 1998 ; Levy & Ellis, 2006 ).

The second form of literature review, which is the focus of this chapter, constitutes an original and valuable work of research in and of itself ( Paré et al., 2015 ). Rather than providing a base for a researcher’s own work, it creates a solid starting point for all members of the community interested in a particular area or topic ( Mulrow, 1987 ). The so-called “review article” is a journal-length paper which has an overarching purpose to synthesize the literature in a field, without collecting or analyzing any primary data ( Green, Johnson, & Adams, 2006 ).

When appropriately conducted, review articles represent powerful information sources for practitioners looking for state-of-the art evidence to guide their decision-making and work practices ( Paré et al., 2015 ). Further, high-quality reviews become frequently cited pieces of work which researchers seek out as a first clear outline of the literature when undertaking empirical studies ( Cooper, 1988 ; Rowe, 2014 ). Scholars who track and gauge the impact of articles have found that review papers are cited and downloaded more often than any other type of published article ( Cronin, Ryan, & Coughlan, 2008 ; Montori, Wilczynski, Morgan, Haynes, & Hedges, 2003 ; Patsopoulos, Analatos, & Ioannidis, 2005 ). The reason for their popularity may be the fact that reading the review enables one to have an overview, if not a detailed knowledge of the area in question, as well as references to the most useful primary sources ( Cronin et al., 2008 ). Although they are not easy to conduct, the commitment to complete a review article provides a tremendous service to one’s academic community ( Paré et al., 2015 ; Petticrew & Roberts, 2006 ). Most, if not all, peer-reviewed journals in the fields of medical informatics publish review articles of some type.

The main objectives of this chapter are fourfold: (a) to provide an overview of the major steps and activities involved in conducting a stand-alone literature review; (b) to describe and contrast the different types of review articles that can contribute to the eHealth knowledge base; (c) to illustrate each review type with one or two examples from the eHealth literature; and (d) to provide a series of recommendations for prospective authors of review articles in this domain.

9.2. Overview of the Literature Review Process and Steps

As explained in Templier and Paré (2015) , there are six generic steps involved in conducting a review article:

• formulating the research question(s) and objective(s),
• searching the extant literature,
• screening for inclusion,
• assessing the quality of primary studies,
• extracting data, and
• analyzing data.

Although these steps are presented here in sequential order, one must keep in mind that the review process can be iterative and that many activities can be initiated during the planning stage and later refined during subsequent phases ( Finfgeld-Connett & Johnson, 2013 ; Kitchenham & Charters, 2007 ).

Formulating the research question(s) and objective(s): As a first step, members of the review team must appropriately justify the need for the review itself ( Petticrew & Roberts, 2006 ), identify the review’s main objective(s) ( Okoli & Schabram, 2010 ), and define the concepts or variables at the heart of their synthesis ( Cooper & Hedges, 2009 ; Webster & Watson, 2002 ). Importantly, they also need to articulate the research question(s) they propose to investigate ( Kitchenham & Charters, 2007 ). In this regard, we concur with Jesson, Matheson, and Lacey (2011) that clearly articulated research questions are key ingredients that guide the entire review methodology; they underscore the type of information that is needed, inform the search for and selection of relevant literature, and guide or orient the subsequent analysis. Searching the extant literature: The next step consists of searching the literature and making decisions about the suitability of material to be considered in the review ( Cooper, 1988 ). There exist three main coverage strategies. First, exhaustive coverage means an effort is made to be as comprehensive as possible in order to ensure that all relevant studies, published and unpublished, are included in the review and, thus, conclusions are based on this all-inclusive knowledge base. The second type of coverage consists of presenting materials that are representative of most other works in a given field or area. Often authors who adopt this strategy will search for relevant articles in a small number of top-tier journals in a field ( Paré et al., 2015 ). In the third strategy, the review team concentrates on prior works that have been central or pivotal to a particular topic. This may include empirical studies or conceptual papers that initiated a line of investigation, changed how problems or questions were framed, introduced new methods or concepts, or engendered important debate ( Cooper, 1988 ). Screening for inclusion: The following step consists of evaluating the applicability of the material identified in the preceding step ( Levy & Ellis, 2006 ; vom Brocke et al., 2009 ). Once a group of potential studies has been identified, members of the review team must screen them to determine their relevance ( Petticrew & Roberts, 2006 ). A set of predetermined rules provides a basis for including or excluding certain studies. This exercise requires a significant investment on the part of researchers, who must ensure enhanced objectivity and avoid biases or mistakes. As discussed later in this chapter, for certain types of reviews there must be at least two independent reviewers involved in the screening process and a procedure to resolve disagreements must also be in place ( Liberati et al., 2009 ; Shea et al., 2009 ). Assessing the quality of primary studies: In addition to screening material for inclusion, members of the review team may need to assess the scientific quality of the selected studies, that is, appraise the rigour of the research design and methods. Such formal assessment, which is usually conducted independently by at least two coders, helps members of the review team refine which studies to include in the final sample, determine whether or not the differences in quality may affect their conclusions, or guide how they analyze the data and interpret the findings ( Petticrew & Roberts, 2006 ). Ascribing quality scores to each primary study or considering through domain-based evaluations which study components have or have not been designed and executed appropriately makes it possible to reflect on the extent to which the selected study addresses possible biases and maximizes validity ( Shea et al., 2009 ). Extracting data: The following step involves gathering or extracting applicable information from each primary study included in the sample and deciding what is relevant to the problem of interest ( Cooper & Hedges, 2009 ). Indeed, the type of data that should be recorded mainly depends on the initial research questions ( Okoli & Schabram, 2010 ). However, important information may also be gathered about how, when, where and by whom the primary study was conducted, the research design and methods, or qualitative/quantitative results ( Cooper & Hedges, 2009 ). Analyzing and synthesizing data : As a final step, members of the review team must collate, summarize, aggregate, organize, and compare the evidence extracted from the included studies. The extracted data must be presented in a meaningful way that suggests a new contribution to the extant literature ( Jesson et al., 2011 ). Webster and Watson (2002) warn researchers that literature reviews should be much more than lists of papers and should provide a coherent lens to make sense of extant knowledge on a given topic. There exist several methods and techniques for synthesizing quantitative (e.g., frequency analysis, meta-analysis) and qualitative (e.g., grounded theory, narrative analysis, meta-ethnography) evidence ( Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005 ; Thomas & Harden, 2008 ).

9.3. Types of Review Articles and Brief Illustrations

EHealth researchers have at their disposal a number of approaches and methods for making sense out of existing literature, all with the purpose of casting current research findings into historical contexts or explaining contradictions that might exist among a set of primary research studies conducted on a particular topic. Our classification scheme is largely inspired from Paré and colleagues’ (2015) typology. Below we present and illustrate those review types that we feel are central to the growth and development of the eHealth domain.

9.3.1. Narrative Reviews

The narrative review is the “traditional” way of reviewing the extant literature and is skewed towards a qualitative interpretation of prior knowledge ( Sylvester et al., 2013 ). Put simply, a narrative review attempts to summarize or synthesize what has been written on a particular topic but does not seek generalization or cumulative knowledge from what is reviewed ( Davies, 2000 ; Green et al., 2006 ). Instead, the review team often undertakes the task of accumulating and synthesizing the literature to demonstrate the value of a particular point of view ( Baumeister & Leary, 1997 ). As such, reviewers may selectively ignore or limit the attention paid to certain studies in order to make a point. In this rather unsystematic approach, the selection of information from primary articles is subjective, lacks explicit criteria for inclusion and can lead to biased interpretations or inferences ( Green et al., 2006 ). There are several narrative reviews in the particular eHealth domain, as in all fields, which follow such an unstructured approach ( Silva et al., 2015 ; Paul et al., 2015 ).

Despite these criticisms, this type of review can be very useful in gathering together a volume of literature in a specific subject area and synthesizing it. As mentioned above, its primary purpose is to provide the reader with a comprehensive background for understanding current knowledge and highlighting the significance of new research ( Cronin et al., 2008 ). Faculty like to use narrative reviews in the classroom because they are often more up to date than textbooks, provide a single source for students to reference, and expose students to peer-reviewed literature ( Green et al., 2006 ). For researchers, narrative reviews can inspire research ideas by identifying gaps or inconsistencies in a body of knowledge, thus helping researchers to determine research questions or formulate hypotheses. Importantly, narrative reviews can also be used as educational articles to bring practitioners up to date with certain topics of issues ( Green et al., 2006 ).

Recently, there have been several efforts to introduce more rigour in narrative reviews that will elucidate common pitfalls and bring changes into their publication standards. Information systems researchers, among others, have contributed to advancing knowledge on how to structure a “traditional” review. For instance, Levy and Ellis (2006) proposed a generic framework for conducting such reviews. Their model follows the systematic data processing approach comprised of three steps, namely: (a) literature search and screening; (b) data extraction and analysis; and (c) writing the literature review. They provide detailed and very helpful instructions on how to conduct each step of the review process. As another methodological contribution, vom Brocke et al. (2009) offered a series of guidelines for conducting literature reviews, with a particular focus on how to search and extract the relevant body of knowledge. Last, Bandara, Miskon, and Fielt (2011) proposed a structured, predefined and tool-supported method to identify primary studies within a feasible scope, extract relevant content from identified articles, synthesize and analyze the findings, and effectively write and present the results of the literature review. We highly recommend that prospective authors of narrative reviews consult these useful sources before embarking on their work.

Darlow and Wen (2015) provide a good example of a highly structured narrative review in the eHealth field. These authors synthesized published articles that describe the development process of mobile health (m-health) interventions for patients’ cancer care self-management. As in most narrative reviews, the scope of the research questions being investigated is broad: (a) how development of these systems are carried out; (b) which methods are used to investigate these systems; and (c) what conclusions can be drawn as a result of the development of these systems. To provide clear answers to these questions, a literature search was conducted on six electronic databases and Google Scholar . The search was performed using several terms and free text words, combining them in an appropriate manner. Four inclusion and three exclusion criteria were utilized during the screening process. Both authors independently reviewed each of the identified articles to determine eligibility and extract study information. A flow diagram shows the number of studies identified, screened, and included or excluded at each stage of study selection. In terms of contributions, this review provides a series of practical recommendations for m-health intervention development.

9.3.2. Descriptive or Mapping Reviews

The primary goal of a descriptive review is to determine the extent to which a body of knowledge in a particular research topic reveals any interpretable pattern or trend with respect to pre-existing propositions, theories, methodologies or findings ( King & He, 2005 ; Paré et al., 2015 ). In contrast with narrative reviews, descriptive reviews follow a systematic and transparent procedure, including searching, screening and classifying studies ( Petersen, Vakkalanka, & Kuzniarz, 2015 ). Indeed, structured search methods are used to form a representative sample of a larger group of published works ( Paré et al., 2015 ). Further, authors of descriptive reviews extract from each study certain characteristics of interest, such as publication year, research methods, data collection techniques, and direction or strength of research outcomes (e.g., positive, negative, or non-significant) in the form of frequency analysis to produce quantitative results ( Sylvester et al., 2013 ). In essence, each study included in a descriptive review is treated as the unit of analysis and the published literature as a whole provides a database from which the authors attempt to identify any interpretable trends or draw overall conclusions about the merits of existing conceptualizations, propositions, methods or findings ( Paré et al., 2015 ). In doing so, a descriptive review may claim that its findings represent the state of the art in a particular domain ( King & He, 2005 ).

In the fields of health sciences and medical informatics, reviews that focus on examining the range, nature and evolution of a topic area are described by Anderson, Allen, Peckham, and Goodwin (2008) as mapping reviews . Like descriptive reviews, the research questions are generic and usually relate to publication patterns and trends. There is no preconceived plan to systematically review all of the literature although this can be done. Instead, researchers often present studies that are representative of most works published in a particular area and they consider a specific time frame to be mapped.

An example of this approach in the eHealth domain is offered by DeShazo, Lavallie, and Wolf (2009). The purpose of this descriptive or mapping review was to characterize publication trends in the medical informatics literature over a 20-year period (1987 to 2006). To achieve this ambitious objective, the authors performed a bibliometric analysis of medical informatics citations indexed in medline using publication trends, journal frequencies, impact factors, Medical Subject Headings (MeSH) term frequencies, and characteristics of citations. Findings revealed that there were over 77,000 medical informatics articles published during the covered period in numerous journals and that the average annual growth rate was 12%. The MeSH term analysis also suggested a strong interdisciplinary trend. Finally, average impact scores increased over time with two notable growth periods. Overall, patterns in research outputs that seem to characterize the historic trends and current components of the field of medical informatics suggest it may be a maturing discipline (DeShazo et al., 2009).

9.3.3. Scoping Reviews

Scoping reviews attempt to provide an initial indication of the potential size and nature of the extant literature on an emergent topic (Arksey & O’Malley, 2005; Daudt, van Mossel, & Scott, 2013 ; Levac, Colquhoun, & O’Brien, 2010). A scoping review may be conducted to examine the extent, range and nature of research activities in a particular area, determine the value of undertaking a full systematic review (discussed next), or identify research gaps in the extant literature ( Paré et al., 2015 ). In line with their main objective, scoping reviews usually conclude with the presentation of a detailed research agenda for future works along with potential implications for both practice and research.

Unlike narrative and descriptive reviews, the whole point of scoping the field is to be as comprehensive as possible, including grey literature (Arksey & O’Malley, 2005). Inclusion and exclusion criteria must be established to help researchers eliminate studies that are not aligned with the research questions. It is also recommended that at least two independent coders review abstracts yielded from the search strategy and then the full articles for study selection ( Daudt et al., 2013 ). The synthesized evidence from content or thematic analysis is relatively easy to present in tabular form (Arksey & O’Malley, 2005; Thomas & Harden, 2008 ).

One of the most highly cited scoping reviews in the eHealth domain was published by Archer, Fevrier-Thomas, Lokker, McKibbon, and Straus (2011) . These authors reviewed the existing literature on personal health record ( phr ) systems including design, functionality, implementation, applications, outcomes, and benefits. Seven databases were searched from 1985 to March 2010. Several search terms relating to phr s were used during this process. Two authors independently screened titles and abstracts to determine inclusion status. A second screen of full-text articles, again by two independent members of the research team, ensured that the studies described phr s. All in all, 130 articles met the criteria and their data were extracted manually into a database. The authors concluded that although there is a large amount of survey, observational, cohort/panel, and anecdotal evidence of phr benefits and satisfaction for patients, more research is needed to evaluate the results of phr implementations. Their in-depth analysis of the literature signalled that there is little solid evidence from randomized controlled trials or other studies through the use of phr s. Hence, they suggested that more research is needed that addresses the current lack of understanding of optimal functionality and usability of these systems, and how they can play a beneficial role in supporting patient self-management ( Archer et al., 2011 ).

9.3.4. Forms of Aggregative Reviews

Healthcare providers, practitioners, and policy-makers are nowadays overwhelmed with large volumes of information, including research-based evidence from numerous clinical trials and evaluation studies, assessing the effectiveness of health information technologies and interventions ( Ammenwerth & de Keizer, 2004 ; Deshazo et al., 2009 ). It is unrealistic to expect that all these disparate actors will have the time, skills, and necessary resources to identify the available evidence in the area of their expertise and consider it when making decisions. Systematic reviews that involve the rigorous application of scientific strategies aimed at limiting subjectivity and bias (i.e., systematic and random errors) can respond to this challenge.

Systematic reviews attempt to aggregate, appraise, and synthesize in a single source all empirical evidence that meet a set of previously specified eligibility criteria in order to answer a clearly formulated and often narrow research question on a particular topic of interest to support evidence-based practice ( Liberati et al., 2009 ). They adhere closely to explicit scientific principles ( Liberati et al., 2009 ) and rigorous methodological guidelines (Higgins & Green, 2008) aimed at reducing random and systematic errors that can lead to deviations from the truth in results or inferences. The use of explicit methods allows systematic reviews to aggregate a large body of research evidence, assess whether effects or relationships are in the same direction and of the same general magnitude, explain possible inconsistencies between study results, and determine the strength of the overall evidence for every outcome of interest based on the quality of included studies and the general consistency among them ( Cook, Mulrow, & Haynes, 1997 ). The main procedures of a systematic review involve:

• Formulating a review question and developing a search strategy based on explicit inclusion criteria for the identification of eligible studies (usually described in the context of a detailed review protocol).
• Searching for eligible studies using multiple databases and information sources, including grey literature sources, without any language restrictions.
• Selecting studies, extracting data, and assessing risk of bias in a duplicate manner using two independent reviewers to avoid random or systematic errors in the process.
• Analyzing data using quantitative or qualitative methods.
• Presenting results in summary of findings tables.
• Interpreting results and drawing conclusions.

Many systematic reviews, but not all, use statistical methods to combine the results of independent studies into a single quantitative estimate or summary effect size. Known as meta-analyses , these reviews use specific data extraction and statistical techniques (e.g., network, frequentist, or Bayesian meta-analyses) to calculate from each study by outcome of interest an effect size along with a confidence interval that reflects the degree of uncertainty behind the point estimate of effect ( Borenstein, Hedges, Higgins, & Rothstein, 2009 ; Deeks, Higgins, & Altman, 2008 ). Subsequently, they use fixed or random-effects analysis models to combine the results of the included studies, assess statistical heterogeneity, and calculate a weighted average of the effect estimates from the different studies, taking into account their sample sizes. The summary effect size is a value that reflects the average magnitude of the intervention effect for a particular outcome of interest or, more generally, the strength of a relationship between two variables across all studies included in the systematic review. By statistically combining data from multiple studies, meta-analyses can create more precise and reliable estimates of intervention effects than those derived from individual studies alone, when these are examined independently as discrete sources of information.

The review by Gurol-Urganci, de Jongh, Vodopivec-Jamsek, Atun, and Car (2013) on the effects of mobile phone messaging reminders for attendance at healthcare appointments is an illustrative example of a high-quality systematic review with meta-analysis. Missed appointments are a major cause of inefficiency in healthcare delivery with substantial monetary costs to health systems. These authors sought to assess whether mobile phone-based appointment reminders delivered through Short Message Service ( sms ) or Multimedia Messaging Service ( mms ) are effective in improving rates of patient attendance and reducing overall costs. To this end, they conducted a comprehensive search on multiple databases using highly sensitive search strategies without language or publication-type restrictions to identify all rct s that are eligible for inclusion. In order to minimize the risk of omitting eligible studies not captured by the original search, they supplemented all electronic searches with manual screening of trial registers and references contained in the included studies. Study selection, data extraction, and risk of bias assessments were performed inde­­pen­dently by two coders using standardized methods to ensure consistency and to eliminate potential errors. Findings from eight rct s involving 6,615 participants were pooled into meta-analyses to calculate the magnitude of effects that mobile text message reminders have on the rate of attendance at healthcare appointments compared to no reminders and phone call reminders.

Meta-analyses are regarded as powerful tools for deriving meaningful conclusions. However, there are situations in which it is neither reasonable nor appropriate to pool studies together using meta-analytic methods simply because there is extensive clinical heterogeneity between the included studies or variation in measurement tools, comparisons, or outcomes of interest. In these cases, systematic reviews can use qualitative synthesis methods such as vote counting, content analysis, classification schemes and tabulations, as an alternative approach to narratively synthesize the results of the independent studies included in the review. This form of review is known as qualitative systematic review.

A rigorous example of one such review in the eHealth domain is presented by Mickan, Atherton, Roberts, Heneghan, and Tilson (2014) on the use of handheld computers by healthcare professionals and their impact on access to information and clinical decision-making. In line with the methodological guide­lines for systematic reviews, these authors: (a) developed and registered with prospero ( www.crd.york.ac.uk/ prospero / ) an a priori review protocol; (b) conducted comprehensive searches for eligible studies using multiple databases and other supplementary strategies (e.g., forward searches); and (c) subsequently carried out study selection, data extraction, and risk of bias assessments in a duplicate manner to eliminate potential errors in the review process. Heterogeneity between the included studies in terms of reported outcomes and measures precluded the use of meta-analytic methods. To this end, the authors resorted to using narrative analysis and synthesis to describe the effectiveness of handheld computers on accessing information for clinical knowledge, adherence to safety and clinical quality guidelines, and diagnostic decision-making.

In recent years, the number of systematic reviews in the field of health informatics has increased considerably. Systematic reviews with discordant findings can cause great confusion and make it difficult for decision-makers to interpret the review-level evidence ( Moher, 2013 ). Therefore, there is a growing need for appraisal and synthesis of prior systematic reviews to ensure that decision-making is constantly informed by the best available accumulated evidence. Umbrella reviews , also known as overviews of systematic reviews, are tertiary types of evidence synthesis that aim to accomplish this; that is, they aim to compare and contrast findings from multiple systematic reviews and meta-analyses ( Becker & Oxman, 2008 ). Umbrella reviews generally adhere to the same principles and rigorous methodological guidelines used in systematic reviews. However, the unit of analysis in umbrella reviews is the systematic review rather than the primary study ( Becker & Oxman, 2008 ). Unlike systematic reviews that have a narrow focus of inquiry, umbrella reviews focus on broader research topics for which there are several potential interventions ( Smith, Devane, Begley, & Clarke, 2011 ). A recent umbrella review on the effects of home telemonitoring interventions for patients with heart failure critically appraised, compared, and synthesized evidence from 15 systematic reviews to investigate which types of home telemonitoring technologies and forms of interventions are more effective in reducing mortality and hospital admissions ( Kitsiou, Paré, & Jaana, 2015 ).

9.3.5. Realist Reviews

Realist reviews are theory-driven interpretative reviews developed to inform, enhance, or supplement conventional systematic reviews by making sense of heterogeneous evidence about complex interventions applied in diverse contexts in a way that informs policy decision-making ( Greenhalgh, Wong, Westhorp, & Pawson, 2011 ). They originated from criticisms of positivist systematic reviews which centre on their “simplistic” underlying assumptions ( Oates, 2011 ). As explained above, systematic reviews seek to identify causation. Such logic is appropriate for fields like medicine and education where findings of randomized controlled trials can be aggregated to see whether a new treatment or intervention does improve outcomes. However, many argue that it is not possible to establish such direct causal links between interventions and outcomes in fields such as social policy, management, and information systems where for any intervention there is unlikely to be a regular or consistent outcome ( Oates, 2011 ; Pawson, 2006 ; Rousseau, Manning, & Denyer, 2008 ).

To circumvent these limitations, Pawson, Greenhalgh, Harvey, and Walshe (2005) have proposed a new approach for synthesizing knowledge that seeks to unpack the mechanism of how “complex interventions” work in particular contexts. The basic research question — what works? — which is usually associated with systematic reviews changes to: what is it about this intervention that works, for whom, in what circumstances, in what respects and why? Realist reviews have no particular preference for either quantitative or qualitative evidence. As a theory-building approach, a realist review usually starts by articulating likely underlying mechanisms and then scrutinizes available evidence to find out whether and where these mechanisms are applicable ( Shepperd et al., 2009 ). Primary studies found in the extant literature are viewed as case studies which can test and modify the initial theories ( Rousseau et al., 2008 ).

The main objective pursued in the realist review conducted by Otte-Trojel, de Bont, Rundall, and van de Klundert (2014) was to examine how patient portals contribute to health service delivery and patient outcomes. The specific goals were to investigate how outcomes are produced and, most importantly, how variations in outcomes can be explained. The research team started with an exploratory review of background documents and research studies to identify ways in which patient portals may contribute to health service delivery and patient outcomes. The authors identified six main ways which represent “educated guesses” to be tested against the data in the evaluation studies. These studies were identified through a formal and systematic search in four databases between 2003 and 2013. Two members of the research team selected the articles using a pre-established list of inclusion and exclusion criteria and following a two-step procedure. The authors then extracted data from the selected articles and created several tables, one for each outcome category. They organized information to bring forward those mechanisms where patient portals contribute to outcomes and the variation in outcomes across different contexts.

9.3.6. Critical Reviews

Lastly, critical reviews aim to provide a critical evaluation and interpretive analysis of existing literature on a particular topic of interest to reveal strengths, weaknesses, contradictions, controversies, inconsistencies, and/or other important issues with respect to theories, hypotheses, research methods or results ( Baumeister & Leary, 1997 ; Kirkevold, 1997 ). Unlike other review types, critical reviews attempt to take a reflective account of the research that has been done in a particular area of interest, and assess its credibility by using appraisal instruments or critical interpretive methods. In this way, critical reviews attempt to constructively inform other scholars about the weaknesses of prior research and strengthen knowledge development by giving focus and direction to studies for further improvement ( Kirkevold, 1997 ).

Kitsiou, Paré, and Jaana (2013) provide an example of a critical review that assessed the methodological quality of prior systematic reviews of home telemonitoring studies for chronic patients. The authors conducted a comprehensive search on multiple databases to identify eligible reviews and subsequently used a validated instrument to conduct an in-depth quality appraisal. Results indicate that the majority of systematic reviews in this particular area suffer from important methodological flaws and biases that impair their internal validity and limit their usefulness for clinical and decision-making purposes. To this end, they provide a number of recommendations to strengthen knowledge development towards improving the design and execution of future reviews on home telemonitoring.

9.4. Summary

Table 9.1 outlines the main types of literature reviews that were described in the previous sub-sections and summarizes the main characteristics that distinguish one review type from another. It also includes key references to methodological guidelines and useful sources that can be used by eHealth scholars and researchers for planning and developing reviews.

Typology of Literature Reviews (adapted from Paré et al., 2015).

As shown in Table 9.1 , each review type addresses different kinds of research questions or objectives, which subsequently define and dictate the methods and approaches that need to be used to achieve the overarching goal(s) of the review. For example, in the case of narrative reviews, there is greater flexibility in searching and synthesizing articles ( Green et al., 2006 ). Researchers are often relatively free to use a diversity of approaches to search, identify, and select relevant scientific articles, describe their operational characteristics, present how the individual studies fit together, and formulate conclusions. On the other hand, systematic reviews are characterized by their high level of systematicity, rigour, and use of explicit methods, based on an “a priori” review plan that aims to minimize bias in the analysis and synthesis process (Higgins & Green, 2008). Some reviews are exploratory in nature (e.g., scoping/mapping reviews), whereas others may be conducted to discover patterns (e.g., descriptive reviews) or involve a synthesis approach that may include the critical analysis of prior research ( Paré et al., 2015 ). Hence, in order to select the most appropriate type of review, it is critical to know before embarking on a review project, why the research synthesis is conducted and what type of methods are best aligned with the pursued goals.

9.5. Concluding Remarks

In light of the increased use of evidence-based practice and research generating stronger evidence ( Grady et al., 2011 ; Lyden et al., 2013 ), review articles have become essential tools for summarizing, synthesizing, integrating or critically appraising prior knowledge in the eHealth field. As mentioned earlier, when rigorously conducted review articles represent powerful information sources for eHealth scholars and practitioners looking for state-of-the-art evidence. The typology of literature reviews we used herein will allow eHealth researchers, graduate students and practitioners to gain a better understanding of the similarities and differences between review types.

We must stress that this classification scheme does not privilege any specific type of review as being of higher quality than another ( Paré et al., 2015 ). As explained above, each type of review has its own strengths and limitations. Having said that, we realize that the methodological rigour of any review — be it qualitative, quantitative or mixed — is a critical aspect that should be considered seriously by prospective authors. In the present context, the notion of rigour refers to the reliability and validity of the review process described in section 9.2. For one thing, reliability is related to the reproducibility of the review process and steps, which is facilitated by a comprehensive documentation of the literature search process, extraction, coding and analysis performed in the review. Whether the search is comprehensive or not, whether it involves a methodical approach for data extraction and synthesis or not, it is important that the review documents in an explicit and transparent manner the steps and approach that were used in the process of its development. Next, validity characterizes the degree to which the review process was conducted appropriately. It goes beyond documentation and reflects decisions related to the selection of the sources, the search terms used, the period of time covered, the articles selected in the search, and the application of backward and forward searches ( vom Brocke et al., 2009 ). In short, the rigour of any review article is reflected by the explicitness of its methods (i.e., transparency) and the soundness of the approach used. We refer those interested in the concepts of rigour and quality to the work of Templier and Paré (2015) which offers a detailed set of methodological guidelines for conducting and evaluating various types of review articles.

To conclude, our main objective in this chapter was to demystify the various types of literature reviews that are central to the continuous development of the eHealth field. It is our hope that our descriptive account will serve as a valuable source for those conducting, evaluating or using reviews in this important and growing domain.

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• Cite this Page Paré G, Kitsiou S. Chapter 9 Methods for Literature Reviews. In: Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.
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• Introduction
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• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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

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

 Statistics

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

Research bias

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

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

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

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

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

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

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

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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McCombes, S. (2023, September 11). How to Write a Literature Review | Guide, Examples, & Templates. Scribbr. Retrieved September 18, 2024, from https://www.scribbr.com/dissertation/literature-review/

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• 15 Medical Department II , LMU University Clinic , München , Germany
• 16 UNSW Microbiome Research Centre , University of New South Wales , Sydney , New South Wales , Australia
• Correspondence to Professor Mario Dinis-Ribeiro, Department of Gastroenterology, RISE—Health Research Network, Porto, 4200-072, Portugal; mario.ribeiro{at}ipoporto.min-saude.pt

Objective During the last decade, the management of gastric intestinal metaplasia (GIM) has been addressed by several distinct international evidence-based guidelines. In this review, we aimed to synthesise these guidelines and provide clinicians with a global perspective of the current recommendations for managing patients with GIM, as well as highlight evidence gaps that need to be addressed with future research.

Design We conducted a systematic review of the literature for guidelines and consensus statements published between January 2010 and February 2023 that address the diagnosis and management of GIM.

Results From 426 manuscripts identified, 16 guidelines were assessed. There was consistency across guidelines regarding the purpose of endoscopic surveillance of GIM, which is to identify prevalent neoplastic lesions and stage gastric preneoplastic conditions. The guidelines also agreed that only patients with high-risk GIM phenotypes (eg, corpus-extended GIM, OLGIM stages III/IV, incomplete GIM subtype), persistent refractory Helicobacter pylori infection or first-degree family history of gastric cancer should undergo regular-interval endoscopic surveillance. In contrast, low-risk phenotypes, which comprise most patients with GIM, do not require surveillance. Not all guidelines are aligned on histological staging systems. If surveillance is indicated, most guidelines recommend a 3-year interval, but there is some variability. All guidelines recommend H. pylori eradication as the only non-endoscopic intervention for gastric cancer prevention, while some offer additional recommendations regarding lifestyle modifications. While most guidelines allude to the importance of high-quality endoscopy for endoscopic surveillance, few detail important metrics apart from stating that a systematic gastric biopsy protocol should be followed. Notably, most guidelines comment on the role of endoscopy for gastric cancer screening and detection of gastric precancerous conditions, but with high heterogeneity, limited guidance regarding implementation, and lack of robust evidence.

Conclusion Despite heterogeneous populations and practices, international guidelines are generally aligned on the importance of GIM as a precancerous condition and the need for a risk-stratified approach to endoscopic surveillance, as well as H. pylori eradication when present. There is room for harmonisation of guidelines regarding (1) which populations merit index endoscopic screening for gastric cancer and GIM detection/staging; (2) objective metrics for high-quality endoscopy; (3) consensus on the need for histological staging and (4) non-endoscopic interventions for gastric cancer prevention apart from H. pylori eradication alone. Robust studies, ideally in the form of randomised trials, are needed to bridge the ample evidence gaps that exist.

• surveillance
• gastric carcinoma

Data availability statement

Data are available on reasonable request. All data analysed are available in proper databases depending on publisher.

https://doi.org/10.1136/gutjnl-2024-333029

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Since 2010, several guidelines and expert consensus statements have been published worldwide providing evidence-based recommendations for the management of patients with gastric intestinal metaplasia (GIM), a precancerous condition associated with increased risk of gastric cancer.

Likely due to heterogeneous populations, methods and wording across different guidelines, controversy, confusion and misperceptions remain in the management of patients with GIM, which might compromise the optimal care of these potentially high-risk patients.

WHAT THIS STUDY ADDS

We conducted a systematic review and synthesised all available, published international guidelines describing the management of patients with GIM and, here, provide the first unified, global perspective for clinicians.

Irrespective of the patient’s country of origin or ethnicity, the index or surveillance endoscopy must include staging of GIM by performing endoscopic and histopathological mapping (risk stratification).

Only individuals with a high-risk GIM phenotype (ie, corpus-extended GIM, OLGIM stages III/IV, moderate-to-severe GIM, incomplete GIM subtype, persistent refractory Helicobacter pylori infection or first-degree family history of gastric cancer) merit regular surveillance, with a 3-year interval unless multiple risk factors are present.

Individuals with focal GIM changes limited to the antrum and no other risk factors for gastric cancer do not require ongoing endoscopic surveillance follow-up.

H. pylori testing (and its eradication if present) is unanimously recommended.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Clinical recommendations and policies must include risk stratification of gastric cancer among individuals with GIM.

There is an opportunity to enhance the research agenda in this field to better define: populations who warrant screening; the optimal method for endoscopic surveillance (eg, endoscopic staging, use of image enhancement, etc) and the optimal interval for surveillance; development of non-invasive diagnostic and prognostic biomarkers for GIM; assessment of interventions beyond H. pylori eradication to prevent gastric cancer and management of GIM in specific situations (eg, autoimmune gastritis without H. pylori , hereditary syndromes), among others.

Introduction

Gastric adenocarcinoma (GC) is a preventable cancer. In 2022, there were approximately 970 000 new GC cases and nearly 760 000 related fatalities. The International Agency for Research on Cancer projects that the number of new GC cases will increase to 1.8 million by 2040, with an associated 1.3 million deaths if current trends continue. This projection underscores the critical importance of both primary and secondary prevention efforts. 1 2

Helicobacter pylori eradication, healthy dietary habits and smoking cessation are mainstays for primary GC prevention. However, primary prevention alone is insufficient for successfully decreasing GC burden and mortality, and effective secondary and tertiary prevention through strategies for early diagnosis is imperative. 3 4 In the majority of cases, intestinal-type GC develops through a cascade of gastric preneoplastic mucosal changes before neoplastic progression occurs. Furthermore, early gastric cancer (ie, prior to submucosal invasion) can be cured through endoscopic or surgical resection, whereas there are no curative options for advanced-stage diagnoses. The slow stepwise progression and the opportunity for curative resection of early lesions underlie the rationale and effectiveness of secondary and tertiary prevention for combatting GC burden and mortality. These key concepts can be extrapolated, in theory, to all countries that have the appropriate infrastructure, and this is reflected in international guidelines for gastric intestinal metaplasia (GIM) diagnosis and management.

The ‘Correa cascade’ considers the occurrence of GC in a chronic state of mucosal inflammation, including the presence of atrophic changes and GIM. GIM in most cases occurs on a background of atrophy, although atrophic changes may not be clinically apparent in the setting of diffuse GIM. 5 Conversely, atrophy may occur in the absence of GIM. Although moderate-to-severe gastric atrophy is associated with an increased risk of GC, the endoscopic and histopathological staging and risk stratification for gastric atrophy as compared with GIM are subject to more inter-observer, and even intra-observer, variability. Therefore, we have focused on guidance for GIM management as opposed to atrophy in the absence of confirmed GIM.

The prevalence of GIM when broadly considering all adults undergoing endoscopy with biopsies ranges from 5% to 30%, and is potentially even higher among individuals with additional risk factors. 6 7 Despite this high prevalence and known association with GC, no specific guidelines existed for the management of GIM until 2012 and this was reflected by significant heterogeneity in clinical practice for GIM and low adherence to endoscopic surveillance and appropriate staging protocols. 8 9 To address this, scientific societies internationally independently evaluated the published literature according to predefined methodology (eg, Grading of Recommendations, Assessment, Development and Evaluations (GRADE)) to develop evidence-based guidance on the management of precancerous conditions, specifically GIM.

Currently, non-invasive biomarkers have not demonstrated sufficient, reproducible accuracy for GIM diagnosis. Endoscopy and histology thus remain the mainstay for diagnosis, surveillance and staging of GIM. We hypothesise that the availability of multiple international guidelines with varying methodologies and presentation may confuse clinicians regarding GIM management, especially endoscopic surveillance, which invariably would impact clinical care.

We therefore conducted a systematic review and qualitative synthesis of all published and indexed evidence-based guidelines or expert consensus statements on GIM management, including which individuals should receive screening for staging of the gastric mucosa for future risk determination; and which individuals should undergo GIM surveillance. This work primarily aims to provide clinicians worldwide with a comprehensive perspective, and secondarily to inform future guideline processes as well as the research agenda.

We performed a systematic review in PubMed on 20 February 2024, with the following query: (guidelines OR statements OR consensus) AND (atrophy OR atrophic gastritis OR intestinal metaplasia OR precancerous OR premalignant OR preneoplasia OR dysplasia) AND (gastric OR stomach).

We limited the search to include publications between 1 January 2010 and the search date. We also searched the complete list of references of the included articles and used experts’ (authors’) knowledge of other references to determine other guidelines that might have been missed during the electronic search. We included all guidelines and consensus statements that evaluated and discussed the diagnosis and management of GIM. Documents were considered ‘guidelines’ or ‘consensus statements’ as long as they were commissioned by an accredited international or national GI society (eg, European Society for Gastrointestinal Endoscopy, American Gastroenterological Association) and described the methodological approach for delivering clinical recommendations or suggestions. We excluded documents that did not include GIM management. Hereafter, we use the term ‘guideline’ to also encompass consensus statements and clinical practice updates, with differences in methodology acknowledged where appropriate.

From each guideline, the following information was abstracted and summarised:

Scientific society(ies) supporting the guideline.

Year of publication and literature search dates.

Scope of the guideline (eg, management of GIM only vs other, eg, H. pylori eradication).

Geographic region and population to which the guideline refers.

Methodology (GRADE vs other).

Recommendations or discussions regarding upper gastrointestinal endoscopy (UGIE) screening for eligible populations to allow for the opportunistic identification of GC and/or gastric precancerous conditions (GIM).

Recommendations or suggestions regarding surveillance once GIM is diagnosed.

Recommended/Suggested endoscopic surveillance intervals in those considered eligible for surveillance.

The recommended/suggested endoscopic approach (quality parameters) to optimise the detection of gastric precancer/cancer, and staging.

The stated risk stratification parameters in patients with GIM, including histological staging systems, and respective definitions.

Recommendations/Suggestions regarding potential therapeutic interventions for GC prevention once GIM is diagnosed (eg, H. pylori testing/eradication; lifestyle modifications).

Intentionally, at least one author from each of the geographic regions encompassed was asked to co-author this manuscript. Each author was asked to critically review the summary for inconsistencies concerning their region’s published guidelines. The topics of endoscopic and histological diagnosis and staging of GIM are extensively described in prior literature and are not the focus of the article. An in-depth discussion of quality metrics in UGIE and population-based screening of GC and precancerous conditions is outside the scope of this article, apart from identifying whether these aspects are included in international guidelines and summarising the respective recommendations and guidance.

Literature search

The systematic literature search yielded 426 manuscripts, of which 411 were excluded based on title and abstract screening. No additional articles were identified through manual review of the references, and one was identified through co-authors’ expert knowledge. 10 A total of 16 articles met eligibility criteria and were included in this qualitative review. 10–25

Seven of these 16 articles were from Europe, 5 were from the Americas (3 from the USA, 2 from Latin America) and 4 were from the Asia-Pacific region (111 from China, 2 from Japan, 1 from Taiwan). The 2012 and 2019 updates of the European Society of Gastrointestinal Endoscopy (ESGE)/European Helicobacter and Microbiota Study Group/European Society of Pathology (ESP) guidelines (MAPS I and MAPS II, respectively), the British Society of Gastroenterology (BSG) guidelines (2019), Italian (2019), Asociación Española de Gastroenterología/Sociedad Española de Endoscopia Digestiva and Sociedad Española de Anatomía Patológica (2021), Asociacion Chilena de Endoscopia Digestiva/Sociedad Chilena de Gastroenterolgía (2014), American Gastroenterology Association (AGA) guidelines (2019), American Society of Gastrointestinal Endoscopy (ASGE, 2015) and Chinese guidelines (2023) were specifically dedicated to the management of precancerous conditions, including GIM. In contrast, the Maastricht, Taipei, Kyoto, Brazilian and Japan Gastroenterological Endoscopy Society guidelines primarily focused on H. pylori management and included statements or recommendations regarding the management of GIM. The Italian and Spanish guidelines are not adaptations of MAPS I and/or II, which is why they are considered separately in this review. The AGA Clinical Practice Update published in 2021 focuses on atrophic gastritis as a precancerous condition but provides guidance on GIM management including surveillance and is therefore included. All included guidelines used either GRADE methodology or a consensus approach. Nearly all the guidelines primarily addressing the management of precancerous conditions used GRADE methodology, with the exception of the Chinese Society of Gastroenterology, Cancer Collaboration Group of Chinese Society of Gastroenterology/Chinese Medical Association guidelines, which used a consensus approach. In contrast, guidelines that included GIM management as a secondary focus more often used a consensus approach ( table 1 ). Nevertheless, the overall clinical guidance regarding GIM management did not differ substantially based on the robustness of the methodology (ie, GRADE vs consensus).

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Description of included guidelines and consensus documents according to their main purpose/scope and geographic region

Opportunistic detection of GIM during screening or diagnostic endoscopy

GIM is typically asymptomatic and can only be detected endoscopically as currently available non-invasive biomarkers have not demonstrated reliable accuracy for the diagnosis. Thus, opportunities to diagnose GIM are either via screening UGIE in asymptomatic individuals (ie, opportunistic detection) or via diagnostic UGIE in individuals with a clinical indication for endoscopy. None of the international guidelines recommend screening for GIM per se; instead, screening is for early detection of GC. Some guidelines do, though, make clear statements that all endoscopies must include an assessment for the presence of precancerous changes, namely GIM. Many guidelines align in recommending that a high-quality endoscopic examination using virtual technologies (eg, narrow band imaging (NBI), linked colour imaging (LCI), blue light imaging (BLI)) or conventional chromoendoscopy, along with endoscopic biopsies, should be performed to enhance the endoscopic detection of GIM. One exception is the Japanese guideline, which does not recommend gastric biopsies. Instead, it relies solely on endoscopic detection and staging ( table 2 ). For those individuals diagnosed with GIM, many but not all guidelines also recommend the use of histological staging systems, primarily OLGIM, and histological subtyping of GIM given the implications for risk stratification ( table 2 ).

Recommendations for opportunistic diagnosis, surveillance and therapeutic interventions in individuals with GIM according to the diverse guidelines/consensus and their scope and region

Guidelines that include opportunistic detection through endoscopic screening . As of this writing, the Japanese guideline, the Spanish guideline, the British guideline and the Maastricht guideline offer recommendations regarding true population-based screening for GC. In Japan, references to GC risk stratification and potential non-invasive approaches are named. The Spanish guidelines recommend against the routine use of UGIE for GC screening in the general Spanish population given the low GC incidence overall, and suggest screening only for those with a family history of GC. This is similar to the recommendations of the German guideline and the Maastricht guideline. The Maastricht guideline, which is focused on H. pylori diagnosis and management, recommends that endoscopy with gastric biopsies be performed in asymptomatic individuals with a family history of GC starting at age 45 years and older. Neither the Spanish nor Maastricht guidelines call out other high-risk groups (eg, early generation immigrants from countries where GC is endemic). The 2019 British guidelines state there is insufficient evidence to support endoscopic screening in the overall low-risk UK population, but do provide a weak recommendation that UGIE screening with biopsies should be considered for individuals aged ≥50 years with multiple risk factors for GC, notably rating the quality of evidence as low but achieving 100% consensus agreement. The Chilean guidelines stipulate that age >40 years is sufficient for endoscopic screening for GC and its precancerous conditions considering that Chile is a high GC incidence country; however, the Chilean guidelines list an additional criterion that patients have at least one other clinical indication for endoscopy (eg, abdominal pain) and thus, this cannot be considered true population-based screening. The Italian guideline recommends that a family history of GC and long-term PPI use warrants offering UGIE screening for precancerous conditions; clearly, though, many individuals warranting long-term PPI use may qualify for a diagnostic as opposed to a screening endoscopy. The ASGE guidelines on GIM management do not include recommendations on GC screening, but a separate document on race and ethnic considerations in UGIE more broadly mentions that endoscopic GC screening may be considered in certain high-risk populations in the USA (eg, immigrants from high-risk regions, first-degree family history) starting at age 40 years; no other guidance, such as mucosal staging protocol or recommendations for subsequent surveillance intervals, is provided. 26

Guidelines that include opportunistic GIM detection through diagnostic endoscopy . The 2012 MAPS I guideline states that for H. pylori diagnosis and gastric mucosal staging, gastric samples from the antrum and corpus should be obtained during a diagnostic upper endoscopy. This recommendation was reiterated and refined in the updated 2019 MAPS II guideline. It mandated that all first-time diagnostic endoscopies include gastric antrum and corpus biopsies, without mention of whether this is necessary for patients who have been non-invasively tested for H. pylori already or who are otherwise considered low risk for GC. Similar to MAPS I/II, the Chinese guidelines recommend biopsies from the antrum and corpus to diagnose H. pylori and stage the gastric mucosa to determine the need for ongoing surveillance. The 2020 Japanese guidelines recommend endoscopic risk stratification using Kimura-Takemoto classification or virtual chromoendoscopy of GIM since advanced precancerous changes including GIM can be reliably detected endoscopically. 27

Guidelines that do not address opportunistic detection of GIM . The AGA guidelines do not address endoscopic screening or opportunistic detection during a diagnostic endoscopy for a non-screening indication. Instead, the document provides recommendations for the management of patients with already confirmed GIM, which is most often identified incidentally in the USA. The AGA guidelines acknowledge risk factors for GC, such as specific races and ethnicities, early generation immigrant groups and family history of GC, where an individualised approach may be considered.

In summary, there is high heterogeneity among guidelines regarding recommendations on the use of endoscopy for GC screening or opportunistic detection of GIM. It seems reasonable to consider that the index or surveillance endoscopy must include staging of GIM, if present. Revised or updated guidelines may consider clarifying these recommendations .

Individuals with established GIM diagnosis: surveillance versus no surveillance

All guidelines are aligned regarding the need to risk stratify patients with GIM to determine their need for ongoing surveillance, as well as in mandating H. pylori eradication if present.

All guidelines agree that patients with GIM are considered to have a high-risk phenotype if GIM affects both the gastric antrum (±incisura) and corpus (corpus-extended GIM), if there is moderate-to-severe GIM staged using OLGIM (ie, OLGIM III/IV), if GIM is of the incomplete subtype (vs complete subtype), and if there is a family history of GC in a first-degree relative. These are all factors consistently highlighted in the literature as the most important predictors of progression and may be used to identify individuals at the highest risk of GC, with most guidelines distinctly prioritising histological staging.

According to most guidelines, the presence of any high-risk phenotype is sufficient to identify those patients with GIM who merit surveillance. In contrast, the Spanish guidelines recommend surveillance for extensive GIM if at least one other risk factor, for example, incomplete type or family history of GC, is present.

All guidelines are also aligned in their recommendations that patients with a low-risk GIM phenotype, which is substantially more common than the high-risk phenotype, do not require ongoing endoscopic surveillance. Most guidelines agree that the presence of antrum-limited GIM that is non-severe (OLGIM I-II) may not warrant surveillance, assuming adequate staging metrics during the index gastroscopy and the absence of high-risk qualifiers, including persistent H. pylori infection, incomplete GIM subtype and family history of GC in a first-degree relative. However, factors such as tobacco smoking and dietary factors, which are associated with GC, are not fully accounted for as risk stratification metrics. In patients with limited, mild GIM but with additional risk factors for gastric cancer (eg, family history or high-risk race/ethnicity), MAPS II, BSG, China, Chilean and the AGA guidelines recommend endoscopic surveillance, whereas this is not mentioned in the Japanese, Taipei and Brazilian guidelines. However, the Japanese guideline recommends surveillance regardless of the extent of GIM because of the high GC incidence in the population and the relative availability of endoscopy.

Most guidelines do not provide guidance on how to properly risk stratify patients when information is missing. For example, if patients have insufficient biopsies (eg, only antrum), complete histological staging may not be possible. However, the AGA guidelines, MAPS I/II and the Spanish guidelines do provide guidance on short-interval endoscopy (<12 months) for risk stratification purposes if the quality of the initial examination is questionable.

In summary, advanced stages of GIM—such as GIM affecting both the gastric antrum (± incisura ) and corpus (corpus-extended GIM), moderate-to-severe GIM staged using OLGIM (ie, OLGIM III/IV ) or GIM of the incomplete subtype—are considered the phenotypes of interest for endoscopic surveillance to detect early neoplasia. In contrast, low-risk GIM phenotypes generally do not warrant surveillance in the absence of additional risk factors for advanced gastric neoplasia .

Approach to endoscopic surveillance

When surveillance is recommended, all guidelines recommend endoscopy as the only acceptable modality given the insufficient performance of currently available non-invasive biomarkers and biomarker panels. Few guidelines detail upper endoscopy quality metrics—for example, mucosal cleansing protocol, visualisation technique (high-definition white light±virtual or conventional chromoendoscopy), photodocumentation, or withdrawal time—within the guideline document, except for the BSG guidelines. Most guidelines do provide suggestions for the biopsy protocol, although with heterogeneity. Most guidelines suggest that biopsies from the antrum/incisura and corpus be obtained separately following a systematic protocol 5 to allow for histological staging, while targeted biopsies should also be obtained separately for lesions suspicious for advanced pathology. However, MAPS II states that the benefit of performing biopsies in patients under surveillance is not established, and biopsies should only be performed if any irregular area/suspicious lesion is identified. Figure 1 summarises these approaches. Some guidelines have accompanying articles (eg, AGA, Spanish society) that detail quality metrics in upper endoscopy with specific sections on best practices for the detection and surveillance of preneoplastic conditions. 28 29

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Synthesis of most commonly accepted biopsies protocols according to endoscopic findings. In the presence of gastric intestinal metaplasia (GIM), targeted biopsies should be performed. In the absence of GIM, random biopsies from the antrum and corpus are acceptable, with a biopsy from the incisura angularis being optimal but optional. 5 HD-WLE, high-definiton wight light endoscopy; IEE, image- enhanced endoscopy; NBI, narrow band imaging.

In summary, practice guidelines vary with respect to details and approach to the endoscopic surveillance exam .

Surveillance intervals

While there is generally agreement regarding who warrants surveillance, there is notable heterogeneity regarding recommended surveillance intervals. Surveillance every 3 years for patients with any high-risk GIM phenotype is the most commonly recommended (7 out of 16 guidelines) ( figure 2 ). If there is a family history of GC in a first-degree relative, MAPS II, the BSG and the Chinese guidelines suggest considering a shorter surveillance interval. In contrast, the Chilean, Brazilian, Japanese and Taiwanese guidelines also recommend considering an interval shorter than 3 years, but they do not provide additional criteria for determining who qualifies for the shortened interval.

Algorithm synthesising the major recommendations for managing individuals with gastric intestinal metaplasia (GIM) according to country of origin when applicable. Both the European Society of Gastrointestinal Endoscopy (ESGE) guidelines and three US guidance documents (two American Gastroenterology Association, one American Society of Gastrointestinal Endoscopy) are included. *Patients with gastric cancer (GC) should still undergo endoscopic and histological staging of the surrounding mucosa to facilitate additional risk stratification. EGD, esophagogastroduodenoscopy; Hp, Helicobacter pylori ; y, years; IEE, image-enhanced endoscopy.

The AGA, on the other hand, recommends that a surveillance interval of up to 5 years may also be acceptable, but does not provide additional information on who might qualify for this extended interval. Notably, the AGA Clinical Practice Update advocates for a 3-year interval in individuals with advanced atrophic gastritis with or without GIM.

In summary, international guidelines vary with respect to evidence-based guidance regarding appropriate endoscopic surveillance intervals among individuals with GIM enrolled in surveillance. Surveillance is generally suggested every 3 years, but the South American and Asian guidelines favour a lower threshold for more intensive surveillance in patients with additional risk factors, while the US guidelines allow for potentially longer intervals .

Non-endoscopic therapeutic interventions

Other than surveillance, there is no definitive endoscopic management for GIM in the absence of visible neoplastic lesions. The mainstay non-endoscopic intervention for patients with GIM is testing for H. pylori infection, either through histology or other non-invasive non-serological methods. Confirming eradication after treatment in those who test positive is a strong recommendation in all guidelines. GIM can progress even once H. pylori is successfully eradicated, and this fact is acknowledged in most guidelines.

There is more heterogeneity regarding non-endoscopic non- H. pylori interventions in patients with GIM for GC risk/mortality reduction. MAPS II and the Chinese guidelines suggest offering low-dose aspirin to patients at higher risk of GC who also have a cardiovascular indication. In contrast, the German guidelines advise against the use of aspirin if the sole indication is GC prevention. The Chinese recommendations also refer to the supplementation of certain vitamins/minerals, including selenium and folate, and garlic. The Maastricht guidelines state that medical and special dietary chemoprevention cannot be recommended in patients with severe GIM (or severe atrophy) post- H. pylori eradication in the absence of sufficient evidence for benefit. None of the other guidelines offered guidance for any other non-invasive interventions for individuals with GIM.

Specific situations

Management of individuals with GIM in special situations, for example, postpartial gastrectomy and hereditary syndromes (eg, Lynch syndrome, familial adenomatous polyposis) is not addressed in general. Many guidelines offer limited guidance for patients with autoimmune gastritis diagnosed with GIM and for those diagnosed with gastric neoplasia (dysplasia/GC). A comprehensive discussion of these topics is beyond the scope of this document.

Reducing the global burden of GC is a shared goal worldwide. Most GCs have precursor conditions and lesions that can be detected endoscopically and histologically, which facilitates opportunities for prevention and curative resection of early GC. Population-based screening for GC is not recommended outside of a few East Asian countries. 30 That said, several international societies including from Europe and the Americas acknowledge the potential impact of targeted screening for high-risk groups, although with varying definitions of what qualifies as ‘high-risk’, which most certainly reflects the limited literature. Current studies are conducted to determine the role of endoscopy and other measures for screening in Europe (eg, Towards Gastric Cancer Screening Implementation in the European Union (TOGAS EU4H–2022–PJ–01)). Endoscopic screening for early GC detection and prevention (eg, resection of dysplasia) must be balanced with the fact that endoscopy in most countries is a limited resource, is costly, invasive, inconvenient for patients and poses small but measurable risk.

GIM is a defined precancerous condition that is amenable to surveillance for early GC detection. However, most patients with GIM are at low risk of progression and the risk/burden of endoscopy likely outweighs the theoretical benefit of detecting early neoplasia in these patients. Accordingly, clinicians must be equipped with clear evidence-based guidance to ensure that resources are appropriately allocated to high-risk patients with GIM while minimising the burden and potentially unnecessary anxiety among low-risk patients with GIM. Furthermore, there is a push to maximise the sustainability of endoscopy for cancer prevention by optimising the populations for which it is recommended, and ensuring each exam generates the highest-quality information to minimise unnecessary repeat procedures. 31 32 The presence of GIM, along with the determination of a high-risk versus low-risk phenotype, is the most consistent marker for GC risk, and thus appropriate endoscopic surveillance and adjunct therapeutic interventions (eg, H. pylori eradication, smoking cessation) allow an invaluable opportunity for efficient secondary prevention of GC. For these reasons, we aimed to generate a document that summarises and compares the currently published guidelines and consensus documents on GIM management.

We conclude that international guidelines are aligned in two main recommendations regarding (1) the need for risk-stratified surveillance (as opposed to universal surveillance) and (2) mandatory H. pylori eradication in patients with GIM. Otherwise, there was heterogeneity regarding recommendations for opportunistic detection of GIM during UGIE, the execution of risk stratification (ie, use of histological staging systems such as OLGIM), the approach to the endoscopic examination with respect to defined quality metrics and gastric sampling protocols, surveillance intervals and adjunctive modalities for non-invasive interventions for GC risk reduction in patients with GIM (eg, chemoprevention agents apart from H. pylori eradication; diet modifications and supplementation). This heterogeneity reflects the current gaps in evidence and lack of robust, high-quality data, as well as the heterogeneity of the populations served by each of the guidelines. Indeed, it is expected that guidelines serving high-GC incidence populations (eg, Latin America, Asia-Pacific) may favour a stricter approach, for example, shorter endoscopic intervals, while those serving low-GC incidence populations may favour a less aggressive approach. However, this may not be appropriate, particularly since there are no compelling data to support changing surveillance practices based solely on the country of practice or patient ethnicity, independent of other risk parameters. 33

Certainly, the prevalence of gastric precancerous conditions and GC is higher in certain populations based on country of origin and ethnicity. Additionally, the risk of developing GC overall (and mortality) is higher in early generation immigrants from high-GC regions who have moved to low-GC regions. 34 35 However, among individuals already diagnosed with precancerous conditions, the risk of progression to GC is independent of the country of origin and ethnicity, 33 meaning that other factors (eg, GIM subtype, persistent H. pylori , family history) should be used to determine the need and intervals for surveillance. Thus, the variations in recommendations, especially regarding the surveillance interval, across international guidelines may relate to perceived risk of progression but lacks strong evidence. For example, the Chilean guidelines recommend a 1-year surveillance interval in patients with OLGIM III/IV, whereas the Spanish guidelines recommend surveillance only if there is at least one additional risk factor for progression (eg, family history of GC), and the AGA suggests that up to a 5-year interval may be appropriate.

Other nuances when considering recommendations for GIM management in the context of each guideline and the population served relate to the respective healthcare infrastructure and resource availability, age of the population as well as cultural, lifestyle and dietary practices. The training of the clinical providers including the endoscopists and pathologists and their familiarity with GIM detection and staging is also of relevance. For example, broadly speaking, endoscopists in the USA have lower familiarity with GIM detection and endoscopic staging versus endoscopists from high-GC incidence countries, particularly Japan and South Korea where routine population-based screening occurs. In the USA, histological staging with OLGIM and GIM subtyping are not routine practice, particularly compared with many European and Latin American countries. The primary benefit of endoscopic surveillance is the opportunity for early detection of neoplasia and curative resection, which has substantial implications for GC mortality reduction. However, the success of endoscopic surveillance hinges on the accurate detection of precancerous and cancerous lesions. Considering that the endoscopic miss rate for early GC is approximately 10% based on a meta-analysis, and may be higher in less experienced hands, interventions are needed to improve and standardise the endoscopic surveillance exam. To this end, few guidelines specify the quality metrics that must be achieved to qualify as a high-quality upper endoscopic exam. However, the importance of such metrics is becoming increasingly recognised. In 2024, the AGA published its first consensus report providing ‘best practice advice’ statements for how to perform a high-quality upper GI endoscopy and included metrics specific for the GIM surveillance exam, which complements the AGA guideline on GIM management published in 2020. 28 Similarly, the Spanish GI society also published a supplemental document on quality metrics in upper endoscopy to accompany the guideline, which lacked such metrics. The ESGE addresses appropriate biopsy sampling according to MAPS guidelines as a quality criterion together with others to define the quality of an upper endoscopy. 29 32

Accurate endoscopic and histological staging of GIM is critical, as this is a primary determinant for the branchpoint of whether or not to recommend endoscopic surveillance. While there was consistency regarding which factors (eg, OLGIM III/IV, incomplete GIM subtype, anatomic extension) constitute a high-risk phenotype, there was heterogeneity regarding which metrics are routinely recommended. For example, in the USA, there is no guideline recommendation for pathologists to perform OLGIM staging or to report the histological subtype when GIM is present, and therefore this information is rarely available for clinical decision-making. In addition, there was heterogeneity regarding the ‘weight’ of each risk stratification parameter. Family history and OLGIM III/IV generally hold the most weight and in some guidelines warrant a shorter than 3-year surveillance interval; however, other guidelines, such as the Spanish guidelines, recommended surveillance in patients with extensive GIM only if additional risk factors are present (eg, incomplete GIM, family history of GIM), or if there is a prior or current history of gastric neoplasia. This heterogeneity stems both from the lack of robust evidence, as no randomised clinical trials exist, and from the diverse classifications that determine the presence of this phenotype. 36–38 More robust and precise risk stratification markers (eg, tissue-based markers) could improve risk stratification and, ideally, consistency across guidelines.

Fortunately, most people with GIM who originate from low GC-risk countries fall into an overall low-risk phenotype and may not warrant or benefit from endoscopic surveillance. Accordingly, most guidelines are aligned in recommending against surveillance in patients with low-risk GIM phenotype. The two exceptions are the Chilean and Japanese guidelines, which recommend that all individuals with GIM should be surveilled once diagnosed. This universal recommendation reflects the high GC incidence and mortality in these countries and acknowledges that mild antrum-limited GIM carries some, although very low, level of elevated GC risk. However, the sustainability of such an approach has been questioned, given that endoscopy is a limited and costly resource. Among patients with GIM, the condition is extensive in 7%–25% based on studies from low GC incidence countries and in 16%–26% based on studies from high-incidence areas. 5 39 40 The true prevalence of incomplete GIM versus complete GIM (vs mixed) is not well established, and studies reporting these figures vary significantly. However, incomplete GIM is more commonly observed in patients with extensive GIM and those with prior or current H. pylori infection. Notably, all of the guidelines that mention histological subtyping of GIM consider the presence of incomplete GIM as sufficient for categorising someone as high-risk and warranting endoscopic surveillance. However, the merits of this classification are based solely on observational studies (and meta-analyses of these studies), which are subject to bias. Despite this, studies consistently demonstrate that incomplete GIM is associated with several-fold higher risk of GC compared with patients with only complete-type GIM.

Unmet needs

Randomised trials on GC screening, gastric precancer surveillance and intervention strategies are lacking, and this stands in stark contrast to colorectal cancer screening and postpolypectomy colonoscopy surveillance, as well as oesophageal adenocarcinoma screening and Barrett’s oesophagus surveillance. Generating robust evidence is a critical unmet need, particularly as it relates to endoscopic surveillance intervals and developing, validating and positioning risk stratification metrics with high discrimination values. Specific research priority areas include non-invasive and tissue-based biomarkers for diagnosis, staging and prognosis of GIM; improved uptake and consistency of adherence to guidelines, the development of quality metrics linked to patient-specific outcomes (eg, gastric neoplasia detection rate), leveraging non-invasive therapeutic interventions for halting or reversing GIM progression (eg, diet modifications; chemoprevention) apart from H. pylori eradication, leveraging newer technologies such as artificial intelligence and image-enhanced endoscopy to improve the detection of gastric preneoplasia/neoplasia and specific guidance regarding GIM management in special situations such as hereditary syndromes, postsurgical stomach, after endoscopic resection of neoplasia, and in autoimmune gastritis.

This is the first systematic review of all position statements regarding GIM. At the time of this writing, new guidelines are being updated or developed in the USA, Germany and by ESGE (MAPS III), but are not yet publicly available. Reassuringly, GIM guidelines have demonstrated increased uptake in clinical practice during the last decade. For example, retrospective studies from the USA, 41 reported that H. pylori diagnosis, multiple biopsies and the recommendation for surveillance significantly increased among US doctors following the 2019 AGA guideline. Also, in Europe, the ESGE considered biopsy sampling according to the so-called MAPS protocol as a minor but relevant quality parameter. 32

In conclusion, irrespective of the country of origin when performing an UGIE, the best care must include staging of GIM by performing histopathological mapping. In most guidelines, only individuals at a higher risk (corpus extended GIM, OLGIM stages III/IV, incomplete GIM subtype, persistent H. pylori infection or first-degree family history of gastric cancer) merit regular surveillance at a 3-year interval if no concurrent risk factors are present. Importantly, the most common group, those individuals with focal GIM changes limited to the antrum and no other risk factors for GC, do not require follow-up in most cases, but there are exceptions. H. pylori testing (and its eradication if present) is unanimously recommended and should be synergistically suggested for primary prevention of GC.

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MD-R and SS contributed equally.

Correction notice This article has been corrected since it publishes Online First. The first sentence of the results section in the abstract has been corrected.

Contributors MD-R, SS and EME-O developed the protocol, conducted the review and revised the final draft of the manuscript. All the authors collected data, provided input for the protocol and revised the draft of the manuscript, approving the final version. MD-R, SS and EME-O are the guarantors.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. JB is supported by the UK Medical Research Council in the context of the Clinical Academic Research Partnership (MRC CARP) scheme (Grant ref.: MR/W029960/1).

Competing interests No conflicts of interest are declared by MD-R, SS, HE-S, MB, NU, HT, LGC, DL, EL, AR, J-YF, LM, JB, EJK, EME-O. PM is a member of advisory board/lecturer of Aboca, Alfasigma, Allergosan, Bayer, Biocodex, Menarini advisory boards/lectures.

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• Commentary Commentary on: the management of patients with gastric intestinal metaplasia David Y Graham Yi-Chia Lee Gut 2024; - Published Online First: 18 Sep 2024. doi: 10.1136/gutjnl-2024-333684

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Relationship between mental health and students’ academic performance through a literature review

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• Published: 17 September 2024
• Volume 4 , article number  119 , ( 2024 )

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• Cynthia Lizeth Ramos-Monsivais 1 ,
• Sonia Rodríguez-Cano 2 ,
• Estefanía Lema-Moreira   ORCID: orcid.org/0000-0003-2286-4902 3 &
• Vanesa Delgado-Benito 2  

Mindfulness has become increasingly popular to improve physical and mental health. Its implementation transcends boundaries of disciplines that study its impact. The aim of this study is to identify and analyze the benefits of mindfulness on mental health, academic performance, well-being, mindfulness and prosocial behavior of university students, as well as to identify the most effective way to achieve habituation to the practice. An analysis and systematic review of papers published in the Scopus database was conducted. It was found that publications on the implementation of mindfulness in higher education began in 2004. Their study has been developed in 22 countries, 15 are European, 3 Asians, 2 North American, one Latin American and one from Oceania. Spain is the only Spanish-speaking country. Academically, mindfulness stimulates creativity, exploratory thinking, critical thinking, attention regulation, increases concentration and improves the learning experience. In addition, immersive virtual reality experiences were found to positively influence habituation towards mindfulness practice among university students.

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1 Introduction

In recent decades, mindfulness has gained popularity as a technique for reducing stress, anxiety, and depression. As well as increasing the well-being and quality of life of people who practice it [ 1 ]. Its origin is found in the Buddhist tradition, as a way to achieve clarity of thought [ 2 ]. Although this technique has been practiced in the East for more than 25 centuries, in the West its popularity is recent [ 3 ]. However, its application is expanding more and more in different disciplines [ 4 ].

Social-emotional learning has been introduced in education. It refers to the training of attention, through meditation techniques, such as mindfulness, the most recent update of the programs that seek emotional intelligence [ 5 ]. This type of education is also known as contemplative education, which seeks to enhance the learning experience through reflection and personal perception [ 6 ].

Dr. Jon Kabat-Zinn defines mindfulness as “awareness that develops by paying concrete, sustained, deliberate, and non-judgmental attention to the present moment” [ 7 , p. 13]. It facilitates maintaining mental calm and training attention [ 8 ]; in addition to increasing mental clarity and awareness [ 9 ].

In terms of operability, three qualities that people develop while practicing mindfulness and three qualities related to how the practice is carried out are recognized. The first are observation, description, and participation. While in the mode of practice, acceptance is required, in the present moment and in an effective manner [ 10 ].

Mindfulness can be practiced formally and informally. In formal practice, a specific time is set aside daily for guided meditations. Informal practice brings awareness to daily activities. That is, paying attention to sensations and perceptions while walking, driving, eating, cleaning, among other activities [ 7 ].

Mindfulness has been shown to improve physical and mental health. In terms of physical health, it favors the increase of Brain Derived Neurotrophic Factor (BNDF) [ 11 ]. While in mental health it reduces symptoms of anxiety [ 12 ], stress [ 13 , 14 , 15 , 16 ] and depression [ 12 ]. It also facilitates coping with change and uncertainty [ 14 ] and increases well-being [ 17 ].

1.1 How might the efficacy of mindfulness be evaluated?

Blood tests can be used to measure the effectiveness of mindfulness. A reduction in the levels of cortisol, the stress hormone [ 13 ]; and of increased BNDF can be observed after two weeks of practice [ 11 ]. Increased blood BNDF levels are a potential mediator between meditation practice and brain health [ 13 ]. BNDF measured in the blood by plasma or saliva is called peripheral BNDF [ 18 ].

BNDF is a modulator that regulates neuron growth. It allows the creation of new dendrites which improves communication between neurons; in other words, it promotes greater neuronal plasticity in the central and peripheral nervous system [ 11 , 13 , 18 , 19 , 20 ]. Its main function is at the level of the hippocampus and cerebral cortex, structures linked to learning and memory functions [ 13 ].

BNDF is produced in the central nervous system and peripheral tissues. Over time, its production tends to decrease. Its absence is related to psychiatric and neurological disorders such as emotional burnout, anxiety, depression and Alzheimer’s disease [ 13 ] However, some activities stimulate its production. Exercising, practicing yoga, undergoing controlled stress, traveling, acquiring new experiences, learning and mindfulness stimulate its production [ 13 , 20 ].

1.2 What are the reasons for integrating mindfulness into higher education?

The increase in mental health illnesses in college students has become a recognized concern [ 16 , 21 ]; which requires innovative interventions to address this reality [ 22 , 23 ]. In this sense, mindfulness emerges as a proposed solution [ 12 ], to prevent and reduce professional burnout [ 24 ]. Thus, there is growing interest in its applications in higher education [ 25 , 26 ].

In addition to the physical and mental health benefits, mindfulness practice promotes better academic performance [ 8 , 27 , 28 ]. Such as increased attention, learning and thinking [ 29 ]; and reduced pre-test anxiety [ 29 , 30 ].

Mindfulness practice also stimulates exploratory thinking [ 4 ], creative thinking [ 4 , 31 ], and critical thinking [ 2 ]. It increases spatial and sensory awareness [ 4 ], academic self-efficacy [ 32 , 33 ], productivity and task quality [ 8 ]; in addition to increasing the feeling of personal accomplishment [ 34 ].

On the other hand, it facilitates information retention [ 35 ], improves concentration [ 22 , 26 , 36 , 37 ], attention self-regulation skills [ 32 , 37 , 38 ] and allows for a perceived improvement in the overall learning experience [ 31 , 37 , 39 , 40 , 41 ]. This is because it is essentially training the brain that facilitates focusing attention. A faculty that, for William James, father of American psychology, constituted the root of judgment, character and will [ 42 ].

1.3 Technological immersion in mindfulness

Studies show that technology is increasingly present in the field of mindfulness practice. Evidence of that is the introduction of video games such as the one developed at the University of Wisconsin called tenacity. This is to improve mindfulness through breathing exercises [ 5 ]. Mobile applications such as Headspace and Calm have also been developed to promote meditation techniques [ 43 , 44 ].

In addition to the above, immersive environments incorporating Virtual Reality (VR) have been developed to stimulate mindfulness practice. Home meditation studio, tripp and maloka are some of the applications that virtual reality allows mindfulness practice in totally immersive environments.

1.4 Virtual reality and mindfulness in education

VR makes it possible to experience alternative realities perceived atmospherically [ 45 ]. It is applied in disciplines and sciences such as medicine, engineering, mathematics, dentistry and education [ 46 ]. In education it is used to improve academic performance [ 29 ], and increase attention, creativity, flow state, and habituation to practice [ 47 ].

Pascual et al. [ 48 ] state that, despite there being few studies related to the evaluation of mindfulness interventions using VR, it is considered a more effective platform than standalone mobile meditation apps for encouraging daily practice. Along those lines, results from Miller et al. [ 49 ] study indicates that VR-guided meditation practice is associated with increased positive affect compared to non-VR meditation.

In the case study by Malighetti et al. [ 50 ] it was found that techniques for the development of emotional intelligence such as increased awareness, identification of emotional states, increased resilience and self-control implemented through VR allowed greater mental regulation in terms of eating habits in patients with binge eating disorders. In that order, students with greater emotional regulation have greater self-efficacy [ 51 ].

VR mindfulness promotes mental health [ 52 ]. Studies show that it can reduce insomnia and stress [ 53 ] and improve learning [ 46 ]. Coupled with the above, Kwon et al. [ 30 ] found that incorporating virtual environments through VR is feasible for managing anxiety stemming from academic exams.

Kaplan-Rakowski et al. [ 29 ] study showed that students who meditated with VR performed better academically than those who meditated using videos. While Yang et al.’s [ 47 ] research, immersive virtual reality experiences were found to affect traits associated with students' creativity such as flow state and attention. When students were assigned creative challenges or challenges, those who participated in immersive VR produced better quality products. They also maintained a more stable attention level than the control group.

VR can impact long-term learning. According to Mohring and Brendel [ 45 ] it use in the educational context needs to be reflected upon, because it triggers human perception with far-reaching consequences and people using it hardly question the alternative reality experience it offers. Nevertheless, it can contribute significantly to students’ training through the development of enhanced digital skills and increased mindfulness.

According to Mohring and Brendel [ 45 ] VR can trace the path towards mindfulness in different educational contexts: in teaching and in transforming the relationship between society and the environment. A view that coincides with Whewell et al. [ 54 ] who argue that these immersive experiences contribute to the development of enhanced digital skills, increased student engagement, cultural competence and global mindfulness in university students. VR can foster the conditions for students to become global change agents “within the spheres of entrepreneurship and education” [ 54 , p.1].

However, mindfulness benefits require continuous practice. According to the study by Pascual et al. [ 48 ], meditation sessions are associated with a decrease in anxiety. Therefore, identifying how to introduce and implement an effective program is of the utmost relevance for updating the current educational system.

In that sense, this research aims to identify programs that have been implemented to incorporate mindfulness into higher education. From its beginnings to the present, it analyzes the scientific literature to understand the evolution of its implementation. It identifies the countries where these programs are carried out, the universities that participate, the years they have been carried out and the types of documents published.

Mindfulness's documented benefits for mental health, academic performance, well-being, and students' awareness and prosocial behavior are discussed. Finally, technology, specifically virtual reality, is addressed as a medium that facilitates mindfulness practice stimulation and habituation.

Therefore, the following research questions were defined: 1. How many publications are published per year? 2. In what language are they published? 3. What kind of documents are published? 4. Which universities are involved in the research? 5. In which countries are mindfulness and higher education being studied? 6. What is the impact of mindfulness on higher education students' mental health? 7. What is the impact of mindfulness on higher education students' academic performance? 8. What is the impact of mindfulness on higher education students’ well-being? 9. What is the impact of mindfulness on higher education students’ conscientiousness and prosocial behaviour? 10. Is virtual reality the most effective medium for fostering mindfulness among higher education students?

An analysis of scientific publications in the scopus database, which could be accessed through an institutional account of the University of Burgos in Spain as part of a research stay, was carried out. The information search was conducted using English keywords. The keywords used to elaborate the search string were mindfulness, meditation, university students and higher education students. This search string yielded 70 publications as of July 19, 2024.

All Scopus database publication types were considered inclusion criteria: articles, book chapters, papers, reviews, books and short surveys. In English and Spanish. All articles whose information was not available, were not aimed at higher education students, or did not address any meditation technique were excluded.

An Excel document with the articles' information was extracted for analysis. One article was not available so 69 documents were considered. It was found that 11 publications did not actually mention meditation techniques and were excluded. Also, 5 publications not directed at higher education students were not considered. This resulted in 53 selected research papers. Figure  1 illustrates the situation.

Flow diagram

To answer questions 6, 7 and 8, a subsequent analysis was carried out to identify the measurement variables used by the authors. Measurement variables were identified in the selected documents. The variables were divided into four categories. Mental health, academic achievement, well-being, and prosocial awareness and attitude.

The mental health category includes 9 variables: reduction of stress, anxiety, depression, emotional exhaustion, depersonalization burnout and negative mood. Also increased mental health, calmness and positive mood. Of the 53 items, 4 address some mental health elements and 23 also include elements from other categories.

Academic achievement is made up of 16 variables: academic performance, clinical performance, exploratory thinking, critical thinking, creative thinking, productivity, task quality, academic speed, persistence, observation skills, attention regulation skills, information retention, academic self-efficacy and concentration. Additionally, the learning experience and divergent and convergent creative writing will be improved. Of the 53 items, 5 address elements relating to academic achievement and 19 also include elements from other categories.

The well-being category consists of 13 variables: increased life satisfaction, well-being, sense of belonging, emotional self-regulation, quality of life, self-compassion, physical activity, resilience, non-judgmental acceptance, perceived social support, and sense of accomplishment. Also included are better dietary decision making and improved sleep quality. Of the 53 items, 1 addresses well-being items and 20 include items from other categories.

In the category awareness and prosocial behavior, 14 variables were integrated: increased mindfulness skills, spatial awareness, sensory awareness, self-awareness, dispositional mindfulness, empathy, benevolence, prosocial behavior, collectivism, a sense of transcendence, universalalism, mental clarity, responsibility and improved interpersonal relationships. Of the 53 items, one addresses element unique to prosocial awareness and behavior and 21 also include elements from other categories.

To answer question 8, an additional search integrating technology and virtual reality was included. Although the object of this study is directed primarily at higher education students, research that analyses mindfulness incorporation at other educational levels was considered in this question.

The results of the research are presented in this section. We start with the general findings and then answer the research questions.

3.1 General findings

Although all the investigations analysed are directed at higher education students, 27 do not specify the discipline or the educational program in which the students are enrolled. However, it was found that the educational programs where mindfulness effectiveness is most frequently studied is in medicine and nursing with six investigations, engineering with four, and then anaesthesiology, arts and design, sciences, modern dance, law midwifery, writing, pharmacy, literature, music, social work and design pedagogy with one respectively.

Regarding the duration of the programs, of the 53 studies analysed, 31 do not specify the duration of the practice in weeks, days or sessions. However, in six investigations the programs lasted 8 weeks and in five investigations, 6 weeks. The longest program consisted of 12 weeks and the shortest 1 day. About the analysis of keywords, Fig.  2 shows the identified word networks.

Visualization of keyword networks based on a VOSviewer version 1.6.20 elaboration

In this analysis, it was found that of the 418 keywords used, 30 have at least a frequency of occurrence of 5. It is highlighted that the words with a higher frequency of occurrence and greater connectivity are mindfulness and meditation. Next, the research questions are answered.

How many papers are published each year about mindfulness and higher education students?

According to Table  1 , publications on mindfulness in higher education began in 2004. In 2014, these rates began to remain constant. In the United States, the first publication was produced by the doctor Daniel Holland, associated with universities in Pennsylvania, Arkansas, Illinois, and Washington. At the University of Pennsylvania, the first program for developing resilience in children was developed. Furthermore, in the late 1990s, doctors Martin Seligman and Mihaly Csikszentmihalyi, both affiliated with the same university, pioneered positive psychology [ 55 ].

As part of positive education, positive psychology was introduced to institutions. The concept of positive education succeeds the concept of emotional education. In addition to emotions, this approach incorporates other elements such as meditation in order to increase well-being [ 56 ].

What is the language in which mindfulness research is published? There are 53 documents in the collection, 50 of which are in English and three of which are in Spanish

Are there any published documents that discuss mindfulness and students in higher education? Publications were classified into five categories: articles, reviews, book chapters, presentations and books. As shown in Table  2 , each type of document has a different quantity.

There are several different types of documents published. Articles are the most frequently published. Review articles, presentations, book chapters, and books follow.

What are the publications of universities on mindfulness and higher education students?

A summary of the publications produced, the universities that participate in collaborations, and the most important findings are presented in this section according to the type of document, the language, and the year.

3.2 Spanish-language articles

There have been only three articles published in Spanish. These include one by the University of Almería in Spain in 2009, another by the University of Lisbon in Portugal in 2022 and another by the University of Granada in Spain in 2024. A study by Justo and Luque [ 57 ] demonstrated that mindfulness leads to a deepening of reflection and self-awareness, which in turn stimulates prosocial values like benevolence, collectivism, and the sense of universalism and transcendence. Sobral and Caetano [ 58 ] conducted a study in which individual and collective activities were incorporated into two courses, including mindfulness, using students' portfolios and teachers’ notes. On the other hand, in the study by García-Pérez et al. [ 23 ] mindfulness is considered as a starting point to guarantee mental health and improve the well-being of university students.

3.3 Articles in English

In 2014, two English-language publications were published. One by Nottingham Trent University in the United Kingdom and one by Duke University Medical Center in the United States. Greeson et al. [ 59 ] found that the Koru mindfulness training program improved sleep, improved mindfulness skills, increased self-compassion, and decreased stress among college students.

According to Van Gordon et al. [ 3 ], the Meditation, Awareness Training (MAT) program has been evaluated by college students. During the eighth weeks of training, the students demonstrated improved well-being and self-regulation skills in terms of thoughts, feelings, and behavior. A significant increase was also observed in dispositional mindfulness.

In 2015 only one paper was published by Newcastle University in Australia. In this study, after 7 weeks of practicing mindfulness, students showed an improvement in their well-being, sleep quality, increased concentration, mental clarity and a reduction in negative mood was observed [ 22 ].

In 2016, two articles were published, one by Chatham University in the United States, and another where two universities from two different countries participated, the National University of Ireland and Coleraine University in the United Kingdom. In the study by Noone et al. [ 2 ] it was found that dispositional mindfulness facilitates critical thinking. While in the research of Spadaro and Hunker [ 38 ] it was found that after 8 weeks of practicing mindfulness online, nursing students in the United States reduced anxiety and stress. They also increased mindfulness self-regulation skills.

There were three articles published in 2017. The first study was conducted by Ohio State University in the United States, the second by Ryerson University in Canada, and the third by the Department of Psychiatry at MoleMann Hospital for Mental Health in the Netherlands.

Using reflective writing and guided mindfulness meditations, Klatt [ 60 ] conducted research at Ohio University to increase awareness of students' life goals. According to Schwind et al. [ 37 ], mindfulness and loving-kindness meditation practice after eight weeks reduced anxiety, improved learning experience, increased sense of calm, concentration, and attention self-regulation skills among Canadian university students.

While in the research of Van D’Ijk et al. [ 61 ] it was found that after 8 weekly sessions of two hours daily using the mindfulness-based stress reduction (MBSR) program, students from the Netherlands reduced anxiety and negative emotional states. Improved mental health, life satisfaction and increased mindfulness skills were also observed. However, empathy was not increased.

In 2018, three articles were published. One by the University of Seville in Spain, one by the National University of Ireland and one where an international collaboration between 5 universities took place. The University of Southampton in the UK, the Helvetiapraxis Medical Centre in Switzerland, Kings College London in the UK, the Coburg University of Applied Sciences and Arts in Germany and the Poznan University of Medical Sciences in Poland.

Research conducted by Bernárdez et al. [ 9 ] revealed that software engineering students at the University of Seville in Spain improved their academic self-efficacy after 6 weeks of practicing mindfulness.

Lynch et al. [ 25 ] evaluated mindfulness-based coping with university life (MBCUL), an adaptation of the MBSR program. College students increased their mindfulness skills, decreased stress, anxiety, and depression after eight weeks. The study by Noone and Hogan [ 62 ] found that practicing mindfulness using the headspace mobile app for 6 weeks or 30 sessions increased dispositional mindfulness, but not critical thinking. Students at the National University of Ireland participated in this study.

There were three articles published in 2019. In the United Kingdom, Birmingham City University submitted the first study, in the United States, Lousville University submitted the second, and in Iceland, the University of Rhode Island submitted the third.

A study conducted by Dutt et al. [ 84 ] from the University of Birmingham has demonstrated that mindfulness reduces stress and helps to make better dietary decisions. The University of Rhode Island conducted a study in which Lemay et al. [ 63 ] found that after 6 weeks of practicing viyansa yoga, pharmacy students were able to increase their mindfulness skills and reduce their levels of stress and anxiety. Weingartner et al. [ 39 ] found that mindfulness and compassion training increased mindfulness skills, dispositional mindfulness, and empathy in medical students at Lousville University. As a result, interpersonal relationships, resilience, nonjudgmental acceptance, observational skills, and learning experiences were also improved.

In 2020, four papers were published. In the United States, there are four, one from the University of North Carolina, one from the University of Florida, one from Juiz de Fora in Brazil, and one from the Department of Psychological and Behavioral Sciences at the London School of Economics and Political Science.

At the University of North Carolina, a slow sensory experience linked to meditation techniques is introduced in the modern dance program to improve concentration [ 64 ]. According to the study by Bóo et al. [ 27 ], mindfulness increases academic performance, emotional self-regulation, and self-awareness in the UK. However, Damião et al. [ 65 ] found no significant increase in mindfulness skills of medical students at the Federal University of Juiz de Fora, Brazil, following a 6-week mindfulness training program. Stress, anxiety, or depression did not decrease. Quality of life and mental health also showed no change.

A study by Williams et al. [ 40 ] concluded that medical students at the University of Florida improved their mindfulness skills, perceived social support, empathy, and prosocial behavior after 11 weeks participating in the Promoting Resilience in Medicine (PRIMe) program, although they did not reduce stress. Behaviors characterized by empathy and prosociality. As a result, the general well-being and learning experience have also improved.

There were three articles published in 2021. First, the University of Manitoba in Canada, second, Bilkent University in Turkey, and third, Johns Hopkins University in the United States. Altay and Porter [ 4 ] found that mindfulness practice among design psychology students in Turkey increased non-judgmental acceptance, exploratory thinking, creative thinking, spatial awareness, sensory awareness, and empathy.

An evaluation of the effectiveness of the Headspace mobile application was conducted by Carullo et al. [ 33 ]. Over the course of four months, anesthesiology and medical students from the United States practiced mindfulness. Depression levels were reduced and personal accomplishments were increased. The level of emotional exhaustion nor the level of depersonalization burnout, however, did not improve. Based on research conducted by Litwiller et al. [ 21 ] among college students in Canada, mindfulness, meditation, Tai Chi, yoga, exercise, and animal therapy have been found to be effective in reducing stress, anxiety, depression, and negative mood.

The year 2022 saw the publication of nine papers. The first was completed by the Aix-Marseille University in France, the second by the Department of Anthropology at the University of Missouri in the United States, and the third by the University of Central Arkansas in the United States in collaboration with the University of Missouri. It was also submitted by the University of Illinois in the United States, Kirikkale University in Turkey, Arizona State University in the United States, the University of Seville in Spain, Brock University in Canada, and the University of Lisbon in Portugal.

Researchers in Turkey found that mindfulness practice increases life satisfaction among nursing students. According to Bernárdez et al. [ 8 ], mindfulness enhanced academic performance, productivity, task quality, and academic speed in Spanish students. Devillers-Réolon et al. [ 66 ] found that stress, anxiety, and depression were reduced in their research. The ability of French university students to regulate their attention did not improve, despite improvements in their well-being.

Researchers at Arizona State University found that mindfulness practice increased concentration, non-judgmental acceptance, and resilience among arts and design students. An opinion survey conducted by Klonoff-Cohen [ 67 ] revealed that college students in Illinois believe meditation and mindfulness exercises are effective coping mechanisms. The study by Sensiper [ 26 ] from the Anthropology Department concluded that after 10 weeks of structured in-class meditations, mindfulness exercises, contemporary text readings, and reflective writing, college students exhibited reduced anxiety, improved well-being, increased emotional self-regulation, concentration, and dispositional mindfulness.

As part of the research conducted by Sobral and Caetano [ 58 ], the University of Lisbon conducted a self-study on emotional education. Teachers evaluated the students’ portfolios in order to identify recurrent problems, and students evaluated mindfulness practices, collective and individual projects.

Strickland et al. [ 68 ] reported that mindfulness combined with a modified version of Dr. Robert Boice’s blocked writers program increased positive mood and resilience to stress and anxiety in students and teachers in higher education.

According to Woloshyn et al. [ 31 ], mindful writing stimulates creative thinking, increases empathy and prosocial behavior in higher education students and teachers in Canada. A positive emotional state can also be achieved through non-judgmental acceptance, increased self-awareness, self-compassion, and non-judgmental acceptance. In addition, it enhances well-being and the learning experience.

Six papers have been published in 2023. One by the University of Rome in Italy, one by Griffith University in Australia, another is the result of a collaboration between the University of South Carolina and Winthrop University both in the United States; and another due to collaboration between the Institute of Psychology of Lorand University in Hungary, the University of Vienna and the University of Artois in France.

One paper is the result of a collaboration between the University of the West of England in United Kingdom, and Dongguk University in South Korea. And another article was the result of a collaboration between University of Limoges, University of Montpellier and University of Paris Cité in France and University of Brussels in Belgium.

In the research by Fagioli et al. [ 32 ] University students in Italy practice mindfulness online for 28 days. An improved sense of belonging increased academic self-efficacy and self-regulation of attention skills were observed. In the study by García et al. [ 69 ], mindfulness was practiced for 1 week, 5 min daily. This exercise reduced anxiety, increased physical activity and improved sleep in United States students. Nagy et al. [ 70 ] found that mindfulness practice can increase persistence in those with a strong disposition toward a growth mindset or mindfulness.

In the research of Hagège et al. [ 71 ] it was found that the Meditation-Based Ethics of Responsibility (MBER) program had a positive impact on sense of responsibility and convergent and divergent creative writing tasks in undergraduate science students. In undergraduate music therapy students, it was found that eight weeks of practicing mindfulness can reduce stress and improve mindfulness and well-being [ 72 ]. While Pearson’s [ 73 ] looks for strategies on how mindfulness can be introduced into law education programs in Australia.

So far in 2024, three papers have been published. One by the Virginia Tech College of engineering. Another by the collaboration of Idaho State University and the University of Wisconsin Oshkosh, in the United States. Another by Kaohsiung Medical University and Meiho University, both from Taiwan.

In the research of Giesler et al. [ 74 ] the Caring Action Leadership Mindfulness model is proposed to increase mental health and sense of belonging in undergraduate social work students. In the study by Liu et al. [ 75 ] it was found that practicing mindfulness for 50 min a week for 8 weeks reduced stress and increased mindfulness skills in nursing students. On the other hand, Martini et al. [ 76 ] found that although most engineering students after practicing mindfulness experienced a reduction in perceived stress, a sense of calm, increased energy, and greater concentration, other students who expressed feeling more tired and distressed after meditation practice.

3.4 Book chapters

Book chapters are rare. One by Queen Margaret University in 2015 and one by the University of Surrey in 2020, both UK universities. In the Oberski et al. [ 35 ] study, it was documented that mindfulness in college students allows for increased information retention and a positive emotional state. In Kilner-Johnson and Udofia’s [ 77 ] research, techniques for incorporating mindfulness in the humanities in higher education are proposed.

On the other hand, only one book was published by the University of Groningen in the Netherlands in 2021. This work addresses the benefits of incorporating mindfulness into higher education courses. It documents the results of the Munich model named mindfulness and meditation in the university context. It also includes practical exercises with instructions for implementation in educational institutions.

3.6 Conferences

Three conferences have been published from the United States. One in 2006 by the University of Arkansas, another by the University of Denver Colorado in 2021, and another by Northeastern University in 2023. Holland [ 6 ] presents a course developed and implemented in some universities in the United States through his personal experience, while Wu [ 41 ] states that sonic meditation for higher education students improves the learning experience. In the study by Grahame et al. [ 78 ] it was found that daily mindfulness practice enables engineering undergraduates to reduce stress.

3.7 Reviews

Six reviews have been published. One was in 2004 by Southeastern Illinois University in the United States. In 2017 there were 2 publications. One by the University of Portland in the United States and one by LaTrobe University in Australia. In 2019 the Medical Department of the University of Amsterdam in the Netherlands also published a review. In 2021, a collaboration between three UK universities—Queens University, the University of Suffolk and the University of York was published. In 2024 another was published by Padjadjaran University in Indonesia.

Holland [ 79 ] outlines how mindfulness can be incorporated into higher education and the benefits this can bring for students with disabilities and promote health. McConville et al. [ 33 ] found that mindfulness reduces stress, anxiety, and depression. It also increases mindfulness skills, empathy, a positive emotional state, and academic self-efficacy. Stillwell et al. [ 80 ] found that both the MBSR program, yoga, breath work, meditation, and mindfulness in nursing students reduced stress.

Breedvelt et al. [ 81 ] evaluated the effectiveness of meditation, yoga, and mindfulness on symptoms of depression, anxiety, and stress in college students. They concluded that most publications regarding mindfulness have a high risk of bias, are of poor quality, and do not specify which technique provides the benefits. For it is unclear whether it is mindfulness, yoga or another meditation technique that is effective. McVeigh et al. [ 28 ] found that mindfulness practice in nursing students reduces stress, increases clinical academic performance and self-awareness. In the research of Yosep et al. [ 82 ] it was found that digital mindfulness through audios and videos is effective in improving the mental health of university students.

What are the countries where mindfulness and higher education students are most widely published?

Based on the description of the universities in question three, Fig.  3 illustrates the countries and locations where publications on mindfulness and higher education students have been published.

Geographical location of countries where mindfulness research has been conducted. Font: Own elaboration in the Mapchart application [ 83 ]

As can be seen, the United States leads in mindfulness research and higher education students. It is followed by the United Kingdom, Canada, Australia and Spain. Spain is the only Spanish-speaking country on the list.

On the other hand, although the research is carried out in 22 countries, the collaboration networks include 14 countries. Figure  4 shows the collaboration networks detected.

Cross-country collaboration networks based on a VOSviewer version 1.6.20 elaboration

Figure  4 shows a collaborative network of 14 countries composed of four nodes. One is formed by Austria, Belgium, Canada, France and Hungary in red. In green by the United Kingdom, Turkey, South Korea and Ireland. In blue, Germany, Switzerland and Poland and in yellow, Australia and the Netherlands.

What are the benefits of mindfulness practice for higher education students’ mental health?

Mindfulness practice reduces stress [ 21 , 25 , 28 , 33 , 38 , 59 , 63 , 66 , 80 , 84 ] anxiety [ 21 , 25 , 26 , 33 , 37 , 38 , 61 , 63 , 66 , 69 ] and depression [ 21 , 25 , 33 , 34 , 66 ].

Mindfulness reduces negative mood [ 21 , 22 , 61 ]. As well as increasing positive mood [ 31 , 33 , 35 , 68 ]. In research by Bernárdez et al. [ 9 ], mindfulness was found to reduce emotional exhaustion and depersonalization burnout. While Van D’Ijk et al. [ 61 ], that it improves mental health. Schwind et al. [ 37 ] found that it increases the feeling of calm.

3.8 Stress reduction

In the case of Devillers-Réolon et al. [ 66 ] and Spadaro & Hunker [ 38 ] the mindfulness practice was conducted online and lasted for 17 days and 8 weeks respectively. Greeson et al. [ 59 ] study was also practiced online using the Koru program. Although the duration of this is not specified.

In Lynch et al. [ 25 ] research, the MBSR program was used for 8 weeks. While Stiwell et al. [ 80 ] the same program was used, although the duration of time is not specified. Of the five studies in which mindfulness is practiced traditionally through guided meditations, only one, that of Lemay et al. [ 63 ] indicates that the program lasted 6 weeks in 60-min sessions. The other investigations do not indicate weeks or practice sessions.

According to Yogeswaran and Morr [ 16 ] online mindfulness practice can be effective in addressing stress. However, at least for medical students, the evidence was not sufficient to prove its efficacy in decreasing symptoms of depression and anxiety. In contrast, the study by Ahmad et al. [ 12 ] found that, among university students in Toronto, Canada, internet-based Cognitive Behavioral Mindfulness Therapy interventions could reduce symptoms of anxiety, depression and stress after 8 weeks.

What are the benefits of mindfulness practice on higher education students’ academic performance?

Mindfulness increases clinical performance [ 28 ] and academic performance [ 8 , 27 , 28 ]. Stimulates exploratory thinking [ 4 ], creative thinking [ 4 , 31 ] and critical thinking [ 2 ].

It increases productivity, task quality and academic speed [ 8 ]. As well, it also increases academic self-efficacy [ 9 , 32 , 33 ], improves the learning experience [ 31 , 37 , 39 , 40 , 41 ], and improves observation skills [ 39 ].

Coupled with the above, it improves information retention [ 35 ], increases concentration [ 22 , 26 , 36 , 37 ], and attention self-regulation skills [ 32 , 37 , 38 ]. Another finding in relation to academic performance is that mindfulness can increase persistence in people with a strong disposition toward mindfulness or a growth mindset [ 70 ].

3.9 What benefits does mindfulness practice have on higher education students?

Mindfulness practice increased perceived social support [ 31 , 40 ], improves well-being [ 3 , 22 , 26 , 31 , 40 , 66 ] and improve dietary decision-making [ 84 ]. It also increases sense of belonging [ 32 ], life satisfaction [ 61 , 85 ], physical activity [ 69 ]; and improves sleep quality [ 22 , 59 , 69 ]. Damião´s et al. [ 65 ] research showed no improvements in quality of life after the intervention.

Mindfulness allows increasing self-compassion [ 31 , 59 ], sense of personal achievement [ 34 ], self-regulation of thoughts, feelings and behaviors [ 3 , 26 , 27 ]. It stimulates the development of resilience for stress and anxiety management [ 36 , 39 , 68 ]; and it helps to manage the judgmental voice. That is, it facilitates non-judgmental acceptance [ 4 , 31 , 36 , 39 ].

What are the benefits of mindfulness practice on mindfulness and prosocial behavior in higher education students?

Mindfulness allows for increases in self-awareness [ 27 , 28 , 31 ], sensory and spatial awareness [ 4 ], mindfulness skills [ 25 , 33 , 39 , 40 , 59 , 61 , 63 ] and disposition toward mindfulness [ 3 , 26 , 39 , 68 ].

It also stimulates prosocial behavior [ 40 ], collectivism [ 31 , 57 ]. It increases empathy [ 4 , 31 , 33 , 39 , 40 ] and benevolence [ 57 ]. It improves interpersonal relationships [ 31 , 39 , 40 ], clarity of thought [ 22 ]; and increases the sense of universalism and transcendence [ 57 ].

Is virtual reality the most effective way to promote mindfulness among higher education students?

Virtual reality could facilitate mindfulness habituation. In the study by Navarrete et al. [ 86 ] conducted with university medical students in Valencia, Spain, it was found that those who participated in the virtual reality program meditated twice as long as those who only practiced through regular guided meditation. Along these lines, Pascual et al. [ 48 ] found that health professionals who practiced meditation completed more sessions than those who did not use VR.

Likewise, in the study by Modrego-Alarcón et al. [ 15 ] and Miller et al. [ 49 ] it was found that VR students acquired greater immersion and mindfulness practice. Therefore, immersive virtual reality environments favor habituation toward mindfulness practice.

4 Discussion

The benefits of mindfulness in higher education students at the psychoemotional level have been widely documented [ 12 , 13 , 14 , 15 , 16 , 17 , 87 ]. One of the most frequently highlighted benefits of mindfulness in higher education students is the positive effect on self-esteem, as evidenced by the findings of several studies [ 88 , 89 ]. Additionally, mindfulness has been shown to reduce stress levels [ 25 , 33 , 39 , 40 , 59 , 61 , 63 , 90 ]. These types of benefits have also been observed in other demographic groups. For example, a study conducted by Chandna et al. [ 91 ] with an adult population demonstrated that mindfulness practice was associated with significant improvements in self-esteem and self-efficacy.

As previously stated, mindfulness practice has been identified as a potential solution to the emotional difficulties experienced by higher education students in the current context [ 12 ]. The positive effects of mindfulness on students’ psychoemotional well-being have been demonstrated in numerous studies [ 66 , 67 , 85 ]. It can thus be inferred that these benefits will also affect other areas of students’ lives, reducing their difficulties both psychoemotionally and academically, for example.

In terms of academic performance, the findings of Bóo et al. [ 27 ], Bernárdez et al. [ 8 ] and McVeigh et al. [ 28 ] are worthy of note. This is not exclusive to students in higher education. A study by Artika et al. [ 92 ] with a sample of 469 secondary school students indicates that mindfulness is a significant predictor of student participation in the school context, with an associated increase in participation through improved self-esteem. In contrast, Cordeiro et al. [ 93 ] conducted an experimental study with a control group of third-grade students and found that mindfulness significantly enhanced cognitive flexibility and handwriting fluency.

Prosocial behaviour has been identified as another key area of interest by a number of studies [ 4 , 22 , 31 , 33 , 39 , 40 , 57 ]. A study by Akhavan et al. [ 90 ] demonstrates the efficacy of mindfulness practice in a sample of teachers, including enhanced relationships with students and reduced stress.

With regard to the manner in which these mindfulness programmes can be supported, the utilisation of VR has been found to confer considerable benefits [ 15 , 48 , 49 , 86 ]. This is primarily attributable to the degree of adherence to the programme. In their seminal work, Friedlander et al. [ 94 ] introduced the concept of the ‘therapeutic alliance’ to describe this phenomenon of patient adherence in a therapeutic context. They posited that it represents a crucial factor in the efficacy of any therapeutic intervention. In this case, although it is an educational context, the effects of such adherence are similar; therefore, it is worthwhile to explore the potential of the VR format as a key factor for the success of mindfulness.

5 Conclusions

In response to the research questions initially posed, it can be stated that they have been addressed, resulting in comprehensive data pertaining to the volume, language and year of publication of the various research projects. It is notable that there has been a significant increase in publications over the past four years, as well as the prevalence of the article format. As is to be expected, the majority of publications have been in English. It is also evident that universities in countries with an Anglo-Saxon tradition have published the most research on this topic, with the USA being the country with the highest volume of studies.

In answer to questions 6, 7, 8 and 9, it might be stated that mindfulness practice has been shown to promote mental health, academic performance, awareness, prosocial behaviour and well-being in student populations. Mindfulness practice might promote mental health, and well-being in the student population. The positive impact of this practice is not limited to how it is performed. That is, whether it is through traditional guided meditations, mobile applications, videos, online exercises or virtual reality.

However, according to the available literature, habituation is easier to acquire. Therefore, additional benefits can be obtained by increasing the number of sessions completed or minutes of practice. In answer to question 10, in studies where VR was effective for mindfulness practice, students practiced longer than those in the control group. Therefore, VR could be a more effective way to introduce contemplative science by introducing meditation techniques in higher education.

The objective has been fulfilled by analysing the benefits of mindfulness on mental health, academic performance, well-being, mindfulness and prosocial behaviour of university students, as well as identifying the most effective way to achieve habituation to the practice. It is also noteworthy that these benefits are highly relevant, and it would be beneficial to introduce mindfulness practice in the context of higher education.

6 Limitation and implication

One of the issues highlighted is the lack of comprehensive data that would allow for a more thorough comparison. For example, aspects such as the geographical location of the study subjects or the duration of the mindfulness programme applied mean that there are a large number of studies whose effectiveness is not entirely clear. At the same time, this is a topic that is becoming increasingly relevant, but there is still no consensus among researchers.

With regard to prospective implications, it is evident that the implementation of mindfulness in educational settings offers substantial advantages. Consequently, higher education institutions should facilitate the availability of structured mindfulness programmes for students. Undoubtedly, this would prove to be a valuable addition to their psycho-emotional and academic development.

Data availability

The author confirms that all data generated or analysed during this study are included in this published article.

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C.L.R.M., S.M.C. and E. L. M have designed the study. C.L.R.M. and S.M.C. carried out the methodology and results sections. V. D. B. and C.L.R.M have written the Introduction C.L.R.M. and E.L.M. have written the Discussion, Conclusions and Limitations. All authors wrote and reviewed the manuscript.

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Ramos-Monsivais, C.L., Rodríguez-Cano, S., Lema-Moreira, E. et al. Relationship between mental health and students’ academic performance through a literature review. Discov Psychol 4 , 119 (2024). https://doi.org/10.1007/s44202-024-00240-4

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The use of energy simulations in residential design: a systematic literature review.

1. Introduction

• RQ: “What is the range of applications for energy simulations in residential design?”

2. Materials and Methods

• Studies conducted in the field of architectural design;
• Studies on residential buildings;
• Studies that used computer simulation in energy analysis;
• Studies published in the Web of Science database and written in English.

3. Findings

4. discussion, 4.1. cluster i, 4.2. cluster ii, 4.3. cluster iii, 4.4. cluster iv, 4.5. cluster v, 4.6. cluster vi, 4.7. theme 1 energy efficiency, 4.8. theme 2 architectural design strategies, 4.9. section summary, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Sağdıçoğlu, M.S.; Yenice, M.S.; Tel, M.Z. The Use of Energy Simulations in Residential Design: A Systematic Literature Review. Sustainability 2024 , 16 , 8138. https://doi.org/10.3390/su16188138

Sağdıçoğlu MS, Yenice MS, Tel MZ. The Use of Energy Simulations in Residential Design: A Systematic Literature Review. Sustainability . 2024; 16(18):8138. https://doi.org/10.3390/su16188138

Sağdıçoğlu, Mert Sercan, M. Serhat Yenice, and M. Zübeyr Tel. 2024. "The Use of Energy Simulations in Residential Design: A Systematic Literature Review" Sustainability 16, no. 18: 8138. https://doi.org/10.3390/su16188138

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