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CAREER FEATURE
04 December 2020
Correction 09 December 2020

How to write a superb literature review

Andy Tay is a freelance writer based in Singapore.

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Literature reviews are important resources for scientists. They provide historical context for a field while offering opinions on its future trajectory. Creating them can provide inspiration for one’s own research, as well as some practice in writing. But few scientists are trained in how to write a review — or in what constitutes an excellent one. Even picking the appropriate software to use can be an involved decision (see ‘Tools and techniques’). So Nature asked editors and working scientists with well-cited reviews for their tips.

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doi: https://doi.org/10.1038/d41586-020-03422-x

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Correction 09 December 2020 : An earlier version of the tables in this article included some incorrect details about the programs Zotero, Endnote and Manubot. These have now been corrected.

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Writing the Literature Review: Common Mistakes and Best Practices

First Online: 21 November 2023

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Kelly Heider 3

Part of the book series: Springer Texts in Education ((SPTE))

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The literature review is an essential component of academic research writing, providing a comprehensive overview of existing research and informing the development of new studies. However, writing an effective literature review can be a challenging task for many authors, particularly those new to academic writing. This chapter aims to guide authors through the process of writing a literature review by highlighting common mistakes and best practices. The chapter begins with three short narratives that describe difficulties both novice and prolific authors encounter when writing the literature review. A chapter activity follows with steps that guide authors through the process of developing a research question to frame the literature review. Authors are then prompted to complete a self-assessment activity which includes a series of questions designed to build their skills as academic research writers. The body of the chapter recommends strategies and techniques to help authors locate and evaluate sources that will serve as the building blocks for a literature review that is thorough, current, and well-written. The chapter concludes with a discussion of the threats and benefits of artificial intelligence-based text production in relationship to academic research writing. Overall, this chapter provides practical guidance for authors looking to improve their literature review writing skills and enhance the quality of their research output.

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Why, When, Who, What, How, and Where for Trainees Writing Literature Review Articles

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The Process of Scientific Writing: Developing a Research Question, Conducting a Literature Review, and Creating an Outline

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Issue: AI-Based Text Production in Academic Research Writing

Artificial Intelligence (AI) is a relatively new technological development that can be used to support academic research writing, particularly reviews of research. Although it holds promise as a research tool, there are also concerns that AI-based scholarly writing could threaten not only the integrity but also the creativity of academic research writing. ChatGPT, an advanced chatbot developed by OpenAI (a nonprofit research company founded by Elon Musk and Sam Altman in 2015) has been at the center of much controversy as of late because of its ability to produce academic papers using artificial intelligence-based text production that have fooled academics and academic journal publishers (Hern, 2022 ; Lucey & Dowling, 2023 ; TechTarget, 2023 ). To demonstrate ChatGPT’s capabilities, consider its response to the question, “What is artificial intelligence-based text production?”.

Artificial Intelligence-Based Text Production is a process where machine learning algorithms are used to generate written content such as articles, product descriptions, social media posts, and more. It involves training machine learning models with vast amounts of data to learn how to generate human-like text automatically. The process can involve different techniques such as Natural Language Processing (NLP), deep learning, and neural networks to analyze and understand language patterns, grammar, context, and semantics. The resulting AI-generated text can be used for a wide range of applications, including content marketing, chatbots, language translation, and more. One of the main benefits of AI-based text production is that it can help businesses and organizations automate their content creation process, saving time and resources while producing high-quality content. However, it is important to note that AI-generated text may not always be perfect and may require human editing and review to ensure accuracy and coherence.

This response was produced by ChatGPT in about ten seconds. According to Anson ( 2022 ), “cutting and pasting all or part of this auto-generated text into a new text box can continue to prompt further content. The material is not plagiarized from existing sources but freshly composed. For this reason, it usually evades plagiarism-detection programs like Turnitin” (p. 40).

How Might AI-Based Text Production Threaten Academic Research Writing?

Obviously, computer-generated text that evades plagiarism-detection programs threatens the integrity of academic research writing. Some academic publishers have already banned or limited the use of AI-generated text in papers submitted to their journals (Lucey & Dowling, 2023 ). However, that is easier said than done. OpenAI recently developed a tool that attempts to distinguish between human-written and AI-generated text to prevent chatbots like ChatGPT from being abused, but it is only 26% effective (Wiggers, 2023 ).

Lucey and Dowling ( 2023 ) tested the credibility of ChatGPT by having expert reviewers examine papers produced by the chatbot. First, they asked ChatGPT to generate four parts of a research study: (1) research idea, (2) literature review, (3) dataset, and (4) suggestions for testing and examination. They chose a broad subject and instructed the chatbot to create a paper that could be published in “a good finance journal” (para. 6). Second, they pasted 200 relevant abstracts into the ChatGPT search box and asked the chatbot to consider the abstracts when generating the four-part research study. Finally, they asked academic researchers to read both versions of the AI-generated text and make suggestions for improvement. A panel of thirty-two reviewers read all versions of the four-part research study and rated them. In all cases, the papers were considered acceptable by the reviewers, although the chatbot-created papers that also included input from academic researchers were rated higher. However, “a chatbot was deemed capable of generating quality academic research ideas. This raises fundamental questions around the meaning of creativity and ownership of creative ideas—questions to which nobody yet has solid answers” (Lucey & Dowling, 2023 , para. 10).

How Might AI-Based Text Production Benefit Academic Research Writing?

Despite several publishers deciding to ban the inclusion of AI-based text production in submissions, some researchers have already listed ChatGPT as a co-author on their papers (Lucey & Dowling, 2023 ). There are many who believe there is no difference between the way ChatGPT produces text and the way authors synthesize studies in their literature reviews. In fact, the chatbot’s review is much more exhaustive because it can analyze “billions of existing, human-produced texts and, through a process akin to the creation of neural networks, generate new text based on highly complex predictive machine analysis” (Anson, 2022 , p. 39).

There are other advantages to using AI-based text production. It has the potential to aid groups of researchers who lack funding to hire human research assistants such as emerging economy researchers, graduate students, and early career researchers. According to Lucey and Dowling ( 2023 ), AI-based text production “could help democratize the research process” (para. 18). Anson ( 2022 ) also sees the potential in AI-based text production to “spark some new human-generated ideas” (p. 42), extract keywords, and create abstracts. The development of AI-based text production might also force instructors to change the way they teach academic writing. Instead of trying to detect or prevent the use of chatbots like ChatGPT, “a more sensible approach could involve embracing the technology, showing students what it can and can’t do, and asking them to experiment with it” (Anson, 2022 , p. 44). In other words, students could be asked to write about writing which leads to a deeper understanding of the writing process and the ability to transfer that understanding to any writing project (Wardle & Downs, 2019 ).

The Responsible Use of AI-Based Text Production in Academic Research Writing

The responsible use of AI-based text production in academic research writing involves understanding the technology's capabilities and limitations, as well as considering its potential impact on the research process. Researchers must carefully evaluate the intended purpose and context of using AI-generated text and make certain they are not compromising the authenticity and integrity of their research work. To ensure responsible use, it is essential to balance the benefits of increased efficiency and new insights with the need for originality and critical thinking in academic research writing. Researchers must also be transparent in disclosing the use of AI-generated text when submitting their work for publication. By adopting a responsible and thoughtful approach to the use of AI-based text production, researchers can maximize the benefits of the technology while maintaining the quality and authenticity of their research.

Applications of Technology

How to Write a Paper in a Weekend : https://youtu.be/UY7sVKJPTMA

Note : University of Minnesota Chemistry Professor, Peter Carr is not advocating for procrastination. This video outlines a strategy for generating a first draft after you have all your reading and notes assembled.

Research Gap 101: What Is a Research Gap & How to Find One : https://youtu.be/Kabj0u8YQ4Y

Using Google Scholar for Academic Research : https://youtu.be/t8_CW6FV8Ac .

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Heider, K. (2023). Writing the Literature Review: Common Mistakes and Best Practices. In: Renck Jalongo, M., Saracho, O.N. (eds) Scholarly Writing. Springer Texts in Education. Springer, Cham. https://doi.org/10.1007/978-3-031-39516-1_3

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What Is Peer Review? | Types & Examples

What Is Peer Review? | Types & Examples

Published on December 17, 2021 by Tegan George . Revised on June 22, 2023.

Peer review, sometimes referred to as refereeing , is the process of evaluating submissions to an academic journal. Using strict criteria, a panel of reviewers in the same subject area decides whether to accept each submission for publication.

Peer-reviewed articles are considered a highly credible source due to the stringent process they go through before publication.

There are various types of peer review. The main difference between them is to what extent the authors, reviewers, and editors know each other’s identities. The most common types are:

Single-blind review
Double-blind review
Triple-blind review

Collaborative review

Open review.

Relatedly, peer assessment is a process where your peers provide you with feedback on something you’ve written, based on a set of criteria or benchmarks from an instructor. They then give constructive feedback, compliments, or guidance to help you improve your draft.

What is the purpose of peer review, types of peer review, the peer review process, providing feedback to your peers, peer review example, advantages of peer review, criticisms of peer review, other interesting articles, frequently asked questions about peer reviews.

Many academic fields use peer review, largely to determine whether a manuscript is suitable for publication. Peer review enhances the credibility of the manuscript. For this reason, academic journals are among the most credible sources you can refer to.

However, peer review is also common in non-academic settings. The United Nations, the European Union, and many individual nations use peer review to evaluate grant applications. It is also widely used in medical and health-related fields as a teaching or quality-of-care measure.

Peer assessment is often used in the classroom as a pedagogical tool. Both receiving feedback and providing it are thought to enhance the learning process, helping students think critically and collaboratively.

Prevent plagiarism. Run a free check.

Depending on the journal, there are several types of peer review.

Single-blind peer review

The most common type of peer review is single-blind (or single anonymized) review . Here, the names of the reviewers are not known by the author.

While this gives the reviewers the ability to give feedback without the possibility of interference from the author, there has been substantial criticism of this method in the last few years. Many argue that single-blind reviewing can lead to poaching or intellectual theft or that anonymized comments cause reviewers to be too harsh.

Double-blind peer review

In double-blind (or double anonymized) review , both the author and the reviewers are anonymous.

Arguments for double-blind review highlight that this mitigates any risk of prejudice on the side of the reviewer, while protecting the nature of the process. In theory, it also leads to manuscripts being published on merit rather than on the reputation of the author.

Triple-blind peer review

While triple-blind (or triple anonymized) review —where the identities of the author, reviewers, and editors are all anonymized—does exist, it is difficult to carry out in practice.

Proponents of adopting triple-blind review for journal submissions argue that it minimizes potential conflicts of interest and biases. However, ensuring anonymity is logistically challenging, and current editing software is not always able to fully anonymize everyone involved in the process.

In collaborative review , authors and reviewers interact with each other directly throughout the process. However, the identity of the reviewer is not known to the author. This gives all parties the opportunity to resolve any inconsistencies or contradictions in real time, and provides them a rich forum for discussion. It can mitigate the need for multiple rounds of editing and minimize back-and-forth.

Collaborative review can be time- and resource-intensive for the journal, however. For these collaborations to occur, there has to be a set system in place, often a technological platform, with staff monitoring and fixing any bugs or glitches.

Lastly, in open review , all parties know each other’s identities throughout the process. Often, open review can also include feedback from a larger audience, such as an online forum, or reviewer feedback included as part of the final published product.

While many argue that greater transparency prevents plagiarism or unnecessary harshness, there is also concern about the quality of future scholarship if reviewers feel they have to censor their comments.

In general, the peer review process includes the following steps:

First, the author submits the manuscript to the editor.
Reject the manuscript and send it back to the author, or
Send it onward to the selected peer reviewer(s)
Next, the peer review process occurs. The reviewer provides feedback, addressing any major or minor issues with the manuscript, and gives their advice regarding what edits should be made.
Lastly, the edited manuscript is sent back to the author. They input the edits and resubmit it to the editor for publication.

In an effort to be transparent, many journals are now disclosing who reviewed each article in the published product. There are also increasing opportunities for collaboration and feedback, with some journals allowing open communication between reviewers and authors.

It can seem daunting at first to conduct a peer review or peer assessment. If you’re not sure where to start, there are several best practices you can use.

Summarize the argument in your own words

Summarizing the main argument helps the author see how their argument is interpreted by readers, and gives you a jumping-off point for providing feedback. If you’re having trouble doing this, it’s a sign that the argument needs to be clearer, more concise, or worded differently.

If the author sees that you’ve interpreted their argument differently than they intended, they have an opportunity to address any misunderstandings when they get the manuscript back.

Separate your feedback into major and minor issues

It can be challenging to keep feedback organized. One strategy is to start out with any major issues and then flow into the more minor points. It’s often helpful to keep your feedback in a numbered list, so the author has concrete points to refer back to.

Major issues typically consist of any problems with the style, flow, or key points of the manuscript. Minor issues include spelling errors, citation errors, or other smaller, easy-to-apply feedback.

Tip: Try not to focus too much on the minor issues. If the manuscript has a lot of typos, consider making a note that the author should address spelling and grammar issues, rather than going through and fixing each one.

The best feedback you can provide is anything that helps them strengthen their argument or resolve major stylistic issues.

Give the type of feedback that you would like to receive

No one likes being criticized, and it can be difficult to give honest feedback without sounding overly harsh or critical. One strategy you can use here is the “compliment sandwich,” where you “sandwich” your constructive criticism between two compliments.

Be sure you are giving concrete, actionable feedback that will help the author submit a successful final draft. While you shouldn’t tell them exactly what they should do, your feedback should help them resolve any issues they may have overlooked.

As a rule of thumb, your feedback should be:

Easy to understand
Constructive

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Below is a brief annotated research example. You can view examples of peer feedback by hovering over the highlighted sections.

Influence of phone use on sleep

Studies show that teens from the US are getting less sleep than they were a decade ago (Johnson, 2019) . On average, teens only slept for 6 hours a night in 2021, compared to 8 hours a night in 2011. Johnson mentions several potential causes, such as increased anxiety, changed diets, and increased phone use.

The current study focuses on the effect phone use before bedtime has on the number of hours of sleep teens are getting.

For this study, a sample of 300 teens was recruited using social media, such as Facebook, Instagram, and Snapchat. The first week, all teens were allowed to use their phone the way they normally would, in order to obtain a baseline.

The sample was then divided into 3 groups:

Group 1 was not allowed to use their phone before bedtime.
Group 2 used their phone for 1 hour before bedtime.
Group 3 used their phone for 3 hours before bedtime.

All participants were asked to go to sleep around 10 p.m. to control for variation in bedtime . In the morning, their Fitbit showed the number of hours they’d slept. They kept track of these numbers themselves for 1 week.

Two independent t tests were used in order to compare Group 1 and Group 2, and Group 1 and Group 3. The first t test showed no significant difference ( p > .05) between the number of hours for Group 1 ( M = 7.8, SD = 0.6) and Group 2 ( M = 7.0, SD = 0.8). The second t test showed a significant difference ( p < .01) between the average difference for Group 1 ( M = 7.8, SD = 0.6) and Group 3 ( M = 6.1, SD = 1.5).

This shows that teens sleep fewer hours a night if they use their phone for over an hour before bedtime, compared to teens who use their phone for 0 to 1 hours.

Peer review is an established and hallowed process in academia, dating back hundreds of years. It provides various fields of study with metrics, expectations, and guidance to ensure published work is consistent with predetermined standards.

Protects the quality of published research

Peer review can stop obviously problematic, falsified, or otherwise untrustworthy research from being published. Any content that raises red flags for reviewers can be closely examined in the review stage, preventing plagiarized or duplicated research from being published.

Gives you access to feedback from experts in your field

Peer review represents an excellent opportunity to get feedback from renowned experts in your field and to improve your writing through their feedback and guidance. Experts with knowledge about your subject matter can give you feedback on both style and content, and they may also suggest avenues for further research that you hadn’t yet considered.

Helps you identify any weaknesses in your argument

Peer review acts as a first defense, helping you ensure your argument is clear and that there are no gaps, vague terms, or unanswered questions for readers who weren’t involved in the research process. This way, you’ll end up with a more robust, more cohesive article.

While peer review is a widely accepted metric for credibility, it’s not without its drawbacks.

Reviewer bias

The more transparent double-blind system is not yet very common, which can lead to bias in reviewing. A common criticism is that an excellent paper by a new researcher may be declined, while an objectively lower-quality submission by an established researcher would be accepted.

Delays in publication

The thoroughness of the peer review process can lead to significant delays in publishing time. Research that was current at the time of submission may not be as current by the time it’s published. There is also high risk of publication bias , where journals are more likely to publish studies with positive findings than studies with negative findings.

Risk of human error

By its very nature, peer review carries a risk of human error. In particular, falsification often cannot be detected, given that reviewers would have to replicate entire experiments to ensure the validity of results.

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

Normal distribution
Measures of central tendency
Chi square tests
Confidence interval
Quartiles & Quantiles
Cluster sampling
Stratified sampling
Thematic analysis
Discourse analysis
Cohort study
Ethnography

Research bias

Implicit bias
Cognitive bias
Conformity bias
Hawthorne effect
Availability heuristic
Attrition bias
Social desirability bias

Peer review is a process of evaluating submissions to an academic journal. Utilizing rigorous criteria, a panel of reviewers in the same subject area decide whether to accept each submission for publication. For this reason, academic journals are often considered among the most credible sources you can use in a research project– provided that the journal itself is trustworthy and well-regarded.

In general, the peer review process follows the following steps:

Reject the manuscript and send it back to author, or
Send it onward to the selected peer reviewer(s)
Next, the peer review process occurs. The reviewer provides feedback, addressing any major or minor issues with the manuscript, and gives their advice regarding what edits should be made.
Lastly, the edited manuscript is sent back to the author. They input the edits, and resubmit it to the editor for publication.

Peer review can stop obviously problematic, falsified, or otherwise untrustworthy research from being published. It also represents an excellent opportunity to get feedback from renowned experts in your field. It acts as a first defense, helping you ensure your argument is clear and that there are no gaps, vague terms, or unanswered questions for readers who weren’t involved in the research process.

Peer-reviewed articles are considered a highly credible source due to this stringent process they go through before publication.

Many academic fields use peer review , largely to determine whether a manuscript is suitable for publication. Peer review enhances the credibility of the published manuscript.

A credible source should pass the CRAAP test and follow these guidelines:

The information should be up to date and current.
The author and publication should be a trusted authority on the subject you are researching.
The sources the author cited should be easy to find, clear, and unbiased.
For a web source, the URL and layout should signify that it is trustworthy.

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Writing a Literature Review

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A literature review is a document or section of a document that collects key sources on a topic and discusses those sources in conversation with each other (also called synthesis ). The lit review is an important genre in many disciplines, not just literature (i.e., the study of works of literature such as novels and plays). When we say “literature review” or refer to “the literature,” we are talking about the research ( scholarship ) in a given field. You will often see the terms “the research,” “the scholarship,” and “the literature” used mostly interchangeably.

Where, when, and why would I write a lit review?

There are a number of different situations where you might write a literature review, each with slightly different expectations; different disciplines, too, have field-specific expectations for what a literature review is and does. For instance, in the humanities, authors might include more overt argumentation and interpretation of source material in their literature reviews, whereas in the sciences, authors are more likely to report study designs and results in their literature reviews; these differences reflect these disciplines’ purposes and conventions in scholarship. You should always look at examples from your own discipline and talk to professors or mentors in your field to be sure you understand your discipline’s conventions, for literature reviews as well as for any other genre.

A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. In these cases, the lit review just needs to cover scholarship that is important to the issue you are writing about; sometimes it will also cover key sources that informed your research methodology.

Lit reviews can also be standalone pieces, either as assignments in a class or as publications. In a class, a lit review may be assigned to help students familiarize themselves with a topic and with scholarship in their field, get an idea of the other researchers working on the topic they’re interested in, find gaps in existing research in order to propose new projects, and/or develop a theoretical framework and methodology for later research. As a publication, a lit review usually is meant to help make other scholars’ lives easier by collecting and summarizing, synthesizing, and analyzing existing research on a topic. This can be especially helpful for students or scholars getting into a new research area, or for directing an entire community of scholars toward questions that have not yet been answered.

What are the parts of a lit review?

Most lit reviews use a basic introduction-body-conclusion structure; if your lit review is part of a larger paper, the introduction and conclusion pieces may be just a few sentences while you focus most of your attention on the body. If your lit review is a standalone piece, the introduction and conclusion take up more space and give you a place to discuss your goals, research methods, and conclusions separately from where you discuss the literature itself.

Introduction:

An introductory paragraph that explains what your working topic and thesis is
A forecast of key topics or texts that will appear in the review
Potentially, a description of how you found sources and how you analyzed them for inclusion and discussion in the review (more often found in published, standalone literature reviews than in lit review sections in an article or research paper)
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 sentence to draw connections, comparisons, and contrasts.

Conclusion:

Summarize the key findings you have taken from the literature and emphasize their significance
Connect it back to your primary research question

How should I organize my lit review?

Lit reviews can take many different organizational patterns depending on what you are trying to accomplish with the review. Here are some examples:

Chronological : The simplest approach is to trace the development of the topic over time, which helps familiarize the audience with the topic (for instance if you are introducing something that is not commonly known in your field). If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred (as mentioned previously, this may not be appropriate in your discipline — check with a teacher or mentor if you’re unsure).
Thematic : If you have found some recurring central themes that you will continue working with throughout your piece, you can organize your literature review into subsections that address different aspects of the topic. For example, if you are reviewing literature about women and religion, key themes can include the role of women in churches and the religious attitude towards women.
Qualitative versus quantitative research
Empirical versus theoretical scholarship
Divide the research by sociological, historical, or cultural sources
Theoretical : In many humanities articles, the literature review is the foundation for the theoretical framework. You can use it to discuss various theories, models, and definitions of key concepts. You can argue for the relevance of a specific theoretical approach or combine various theorical concepts to create a framework for your research.

What are some strategies or tips I can use while writing my lit review?

Any lit review is only as good as the research it discusses; make sure your sources are well-chosen and your research is thorough. Don’t be afraid to do more research if you discover a new thread as you’re writing. More info on the research process is available in our "Conducting Research" resources .

As you’re doing your research, create an annotated bibliography ( see our page on the this type of document ). Much of the information used in an annotated bibliography can be used also in a literature review, so you’ll be not only partially drafting your lit review as you research, but also developing your sense of the larger conversation going on among scholars, professionals, and any other stakeholders in your topic.

Usually you will need to synthesize research rather than just summarizing it. This means drawing connections between sources to create a picture of the scholarly conversation on a topic over time. Many student writers struggle to synthesize because they feel they don’t have anything to add to the scholars they are citing; here are some strategies to help you:

It often helps to remember that the point of these kinds of syntheses is to show your readers how you understand your research, to help them read the rest of your paper.
Writing teachers often say synthesis is like hosting a dinner party: imagine all your sources are together in a room, discussing your topic. What are they saying to each other?
Look at the in-text citations in each paragraph. Are you citing just one source for each paragraph? This usually indicates summary only. When you have multiple sources cited in a paragraph, you are more likely to be synthesizing them (not always, but often
Read more about synthesis here.

The most interesting literature reviews are often written as arguments (again, as mentioned at the beginning of the page, this is discipline-specific and doesn’t work for all situations). Often, the literature review is where you can establish your research as filling a particular gap or as relevant in a particular way. You have some chance to do this in your introduction in an article, but the literature review section gives a more extended opportunity to establish the conversation in the way you would like your readers to see it. You can choose the intellectual lineage you would like to be part of and whose definitions matter most to your thinking (mostly humanities-specific, but this goes for sciences as well). In addressing these points, you argue for your place in the conversation, which tends to make the lit review more compelling than a simple reporting of other sources.

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Peer Review in Scientific Publications: Benefits, Critiques, & A Survival Guide

Affiliations.

1 Clinical Biochemistry, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, University of Toronto , Toronto, Ontario, Canada.
2 Clinical Biochemistry, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada; Chair, Communications and Publications Division (CPD), International Federation for Sick Clinical Chemistry (IFCC), Milan, Italy.
PMID: 27683470
PMCID: PMC4975196

Peer review has been defined as a process of subjecting an author's scholarly work, research or ideas to the scrutiny of others who are experts in the same field. It functions to encourage authors to meet the accepted high standards of their discipline and to control the dissemination of research data to ensure that unwarranted claims, unacceptable interpretations or personal views are not published without prior expert review. Despite its wide-spread use by most journals, the peer review process has also been widely criticised due to the slowness of the process to publish new findings and due to perceived bias by the editors and/or reviewers. Within the scientific community, peer review has become an essential component of the academic writing process. It helps ensure that papers published in scientific journals answer meaningful research questions and draw accurate conclusions based on professionally executed experimentation. Submission of low quality manuscripts has become increasingly prevalent, and peer review acts as a filter to prevent this work from reaching the scientific community. The major advantage of a peer review process is that peer-reviewed articles provide a trusted form of scientific communication. Since scientific knowledge is cumulative and builds on itself, this trust is particularly important. Despite the positive impacts of peer review, critics argue that the peer review process stifles innovation in experimentation, and acts as a poor screen against plagiarism. Despite its downfalls, there has not yet been a foolproof system developed to take the place of peer review, however, researchers have been looking into electronic means of improving the peer review process. Unfortunately, the recent explosion in online only/electronic journals has led to mass publication of a large number of scientific articles with little or no peer review. This poses significant risk to advances in scientific knowledge and its future potential. The current article summarizes the peer review process, highlights the pros and cons associated with different types of peer review, and describes new methods for improving peer review.

Keywords: journal; manuscript; open access; peer review; publication.

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Peer Reviewed Literature

What is peer review, terminology, peer review what does that mean, what types of articles are peer-reviewed, what information is not peer-reviewed, what about google scholar.

How do I find peer-reviewed articles?
Scholarly vs. Popular Sources

Research Librarian

For more help on this topic, please contact our Research Help Desk: [email protected] or 781-768-7303. Stay up-to-date on our current hours . Note: all hours are EST.

This Guide was created by Carolyn Swidrak (retired).

Research findings are communicated in many ways. One of the most important ways is through publication in scholarly, peer-reviewed journals.

Research published in scholarly journals is held to a high standard. It must make a credible and significant contribution to the discipline. To ensure a very high level of quality, articles that are submitted to scholarly journals undergo a process called peer-review.

Once an article has been submitted for publication, it is reviewed by other independent, academic experts (at least two) in the same field as the authors. These are the peers. The peers evaluate the research and decide if it is good enough and important enough to publish. Usually there is a back-and-forth exchange between the reviewers and the authors, including requests for revisions, before an article is published.

Peer review is a rigorous process but the intensity varies by journal. Some journals are very prestigious and receive many submissions for publication. They publish only the very best, most highly regarded research.

The terms scholarly, academic, peer-reviewed and refereed are sometimes used interchangeably, although there are slight differences.

Scholarly and academic may refer to peer-reviewed articles, but not all scholarly and academic journals are peer-reviewed (although most are.) For example, the Harvard Business Review is an academic journal but it is editorially reviewed, not peer-reviewed.

Peer-reviewed and refereed are identical terms.

From Peer Review in 3 Minutes [Video], by the North Carolina State University Library, 2014, YouTube (https://youtu.be/rOCQZ7QnoN0).

Peer reviewed articles can include:

Original research (empirical studies)
Review articles
Systematic reviews
Meta-analyses

There is much excellent, credible information in existence that is NOT peer-reviewed. Peer-review is simply ONE MEASURE of quality.

Much of this information is referred to as "gray literature."

Government Agencies

Government websites such as the Centers for Disease Control (CDC) publish high level, trustworthy information. However, most of it is not peer-reviewed. (Some of their publications are peer-reviewed, however. The journal Emerging Infectious Diseases, published by the CDC is one example.)

Conference Proceedings

Papers from conference proceedings are not usually peer-reviewed. They may go on to become published articles in a peer-reviewed journal.

Dissertations

Dissertations are written by doctoral candidates, and while they are academic they are not peer-reviewed.

Many students like Google Scholar because it is easy to use. While the results from Google Scholar are generally academic they are not necessarily peer-reviewed. Typically, you will find:

Peer reviewed journal articles (although they are not identified as peer-reviewed)
Unpublished scholarly articles (not peer-reviewed)
Masters theses, doctoral dissertations and other degree publications (not peer-reviewed)
Book citations and links to some books (not necessarily peer-reviewed)
Next: How do I find peer-reviewed articles? >>
Last Updated: Aug 14, 2024 10:25 AM
URL: https://libguides.regiscollege.edu/peer_review

University Library

Peer Review: An Introduction: Where to Find Peer Reviewed Sources

Why not just use Google or Wikipedia?
Where to Find Peer Reviewed Sources
Where to Get More Help

Need More Help?

Have more questions? Contact Scholarly Communication and Publishing at [email protected] for more information and guidance.

Ask a Librarian

The Ask a Librarian service for general reference is available during all of the hours when the Main Library is open. Visit the Ask a Librarian page to chat with a librarian.

Why is it so hard to find Peer-Reviewed Sources?

It isn't hard to find peer-reviewed sources: you just need to know where to look! If you start in the right place, you can usually find a relevant, peer-reviewed source for your research in as few clicks as a Google search, and you can even use many of the search techniques you use in Google and Wikipedia.

The easiest way to find a peer-reviewed article is by using one of the Library's numerous databases. All of the Library's databases are listed in the Online Journals and Databases index. The databases are divided by name and discipline.

Departmental libraries and library subject guides have created subject-focused lists of electronic and print research resources that are useful for their disciplines. You can search the library directory for links to the departmental libraries at the University of Illinois Library, or search library websites by college if you're not sure which departmental library serves your subject.

Peer-Reviewed Resources for Disciplinary Topics

There are numerous print and digital resources for specific disciplines, areas of study, and specialist fields. To find research resources and databases for your area, consult the comprehensive directory of LibGuides , the websites of specialist libraries, and above all, contact a librarian for help !

Here are a few major databases for finding peer-reviewed research sources in the humanities, social sciences, and sciences:

MLA International Bibliography This link opens in a new window Indexes critical materials on literature, languages, linguistics, and folklore. Proved access to citations from worldwide publications, including periodicals, books, essay collections, working papers, proceedings, dissertations and bibliographies. Use MLA International Bibliography in the NEW EBSCO user interface . more... less... Alternate Access Link
Web of Science (Core Collection) This link opens in a new window Web of Science indexes core journal articles, conference proceedings, data sets, and other resources in the sciences, social sciences, arts, and humanities.

A scholarly, multidisciplinary database providing indexing and abstracts for over 10,000 publications, including monographs, reports, conference proceedings, and others. Also includes full-text access to over 5,000 journals. Offers coverage of many areas of academic study including: archaeology, area studies, astronomy, biology, chemistry, civil engineering, electrical engineering, ethnic & multicultural studies, food science & technology, general science, geography, geology, law, mathematics, mechanical engineering, music, physics, psychology, religion & theology, women's studies, and other fields.

Alternate Access Link

IEEE Xplore This link opens in a new window Provides full-text access to IEEE transactions, IEEE and IEE journals, magazines, and conference proceedings published since 1988, and all current IEEE standards; brings additional search and access features to IEEE/IEE digital library users. Browsable by books & e-books, conference publications, education and learning, journals and magazines, standards and by topic. Also provides links to IEEE standards, IEEE spectrum and other sites.
Scopus This link opens in a new window Scopus is the largest abstract and citation database including peer-reviewed titles from international publishers, Open Access journals, conference proceedings, trade publications and quality web sources. Subject coverage includes: Chemistry, Physics, Mathematics and Engineering; Life and Health Sciences; Social Sciences, Psychology and Economics; Biological, Agricultural and Environmental Sciences.
Business Source Ultimate This link opens in a new window Provides bibliographic and full text content, including indexing and abstracts for scholarly business journals back as far as 1886 and full text journal articles in all disciplines of business, including marketing, management, MIS, POM, accounting, finance and economics. The database full text content includes financial data, books, monographs, major reference works, book digests, conference proceedings, case studies, investment research reports, industry reports, market research reports, country reports, company profiles, SWOT analyses and more. Use Business Source Ultimate in the NEW EBSCO user interface . more... less... Alternate Access Link
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Next: Where to Get More Help >>
Last Updated: Jun 20, 2024 1:47 PM
URL: https://guides.library.illinois.edu/peerreview

USU Library

Articles: Finding (and Identifying) Peer-Reviewed Articles: What is Peer Review?

What is Peer Review?
Finding Peer Reviewed Articles
Databases That Can Determine Peer Review

Peer Review in 3 Minutes

What is "Peer-Review"?

What are they.

Scholarly articles are papers that describe a research study.

Why are scholarly articles useful?

They report original research projects that have been reviewed by other experts before they are accepted for publication, so you can reasonably be assured that they contain valid information.

How do you identify scholarly or peer-reviewed articles?

They are usually fairly lengthy - most likely at least 7-10 pages
The authors and their credentials should be identified, at least the company or university where the author is employed
There is usually a list of References or Works Cited at the end of the paper, listing the sources that the authors used in their research

How do you find them?

Some of the library's databases contain scholarly articles, either exclusively or in combination with other types of articles.

Google Scholar is another option for searching for scholarly articles.

Know the Difference Between Scholarly and Popular Journals/Magazines

Peer reviewed articles are found in scholarly journals. The checklist below can help you determine if what you are looking at is peer reviewed or scholarly.

Both kinds of journals and magazines can be useful sources of information.
Popular magazines and newspapers are good for overviews, recent news, first-person accounts, and opinions about a topic.
Scholarly journals, often called scientific or peer-reviewed journals, are good sources of actual studies or research conducted about a particular topic. They go through a process of review by experts, so the information is usually highly reliable.


Author is an expert on the specific topic of the article	Author is usually a journalists who might or might not have particular expertise in the topic
Articles are "peer-reviewed" or evaluated by experts in the field	Reviewed by an editor and fact checker.
A list of references or citations appears at the end of the article	References usually aren't formally cited
Goal is to present results of research	Goal may be to inform, entertain, or persuade
Examples: ;	Examples: ;

Next: Finding Peer Reviewed Articles >>
Last Updated: May 21, 2024 8:45 AM
URL: https://libguides.usu.edu/peer-review

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License

Literature Reviews

What is a Literature Review?
Steps for Creating a Literature Review
Providing Evidence / Critical Analysis
Challenges when writing a Literature Review
Systematic Literature Reviews

Developing a Literature Review

1. Purpose and Scope

To help you develop a literature review, gather information on existing research, sub-topics, relevant research, and overlaps. Note initial thoughts on the topic - a mind map or list might be helpful - and avoid unfocused reading, collecting irrelevant content. A literature review serves to place your research within the context of existing knowledge. It demonstrates your understanding of the field and identifies gaps that your research aims to fill. This helps in justifying the relevance and necessity of your study.

To avoid over-reading, set a target word count for each section and limit reading time. Plan backwards from the deadline and move on to other parts of the investigation. Read major texts and explore up-to-date research. Check reference lists and citation indexes for common standard texts. Be guided by research questions and refocus on your topic when needed. Stop reading if you find similar viewpoints or if you're going off topic.

You can use a "Synthesis Matrix" to keep track of your reading notes. This concept map helps you to provide a summary of the literature and its connections is produced as a result of this study. Utilizing referencing software like RefWorks to obtain citations, you can construct the framework for composing your literature evaluation.

2. Source Selection

Focus on searching for academically authoritative texts such as academic books, journals, research reports, and government publications. These sources are critical for ensuring the credibility and reliability of your review.

Academic Books: Provide comprehensive coverage of a topic.
Journal Articles: Offer the most up-to-date research and are essential for a literature review.
Research Reports: Detailed accounts of specific research projects.
Government Publications: Official documents that provide reliable data and insights.

3. Thematic Analysis

Instead of merely summarizing sources, identify and discuss key themes that emerge from the literature. This involves interpreting and evaluating how different authors have tackled similar issues and how their findings relate to your research.

4. Critical Evaluation

Adopt a critical attitude towards the sources you review. Scrutinize, question, and dissect the material to ensure that your review is not just descriptive but analytical. This helps in highlighting the significance of various sources and their relevance to your research.

Each work's critical assessment should take into account:

Provenance: What qualifications does the author have? Are the author's claims backed up by proof, such as first-hand accounts from history, case studies, stories, statistics, and current scientific discoveries? Methodology: Were the strategies employed to locate, collect, and evaluate the data suitable for tackling the study question? Was the sample size suitable? Were the findings properly reported and interpreted? Objectivity : Is the author's viewpoint impartial or biased? Does the author's thesis get supported by evidence that refutes it, or does it ignore certain important facts? Persuasiveness: Which of the author's arguments is the strongest or weakest in terms of persuasiveness? Value: Are the author's claims and deductions believable? Does the study ultimately advance our understanding of the issue in any meaningful way?

5. Categorization

Organize your literature review by grouping sources into categories based on themes, relevance to research questions, theoretical paradigms, or chronology. This helps in presenting your findings in a structured manner.

6. Source Validity

Ensure that the sources you include are valid and reliable. Classic texts may retain their authority over time, but for fields that evolve rapidly, prioritize the most recent research. Always check the credibility of the authors and the impact of their work in the field.

7. Synthesis and Findings

Synthesize the information from various sources to draw conclusions about the current state of knowledge. Identify trends, controversies, and gaps in the literature. Relate your findings to your research questions and suggest future directions for research.

Practical Tips

Use a variety of sources, including online databases, university libraries, and reference lists from relevant articles. This ensures a comprehensive coverage of the literature.
Avoid listing sources without analysis. Use tables, bulk citations, and footnotes to manage references efficiently and make your review more readable.
Writing a literature review is an ongoing process. Start writing early and revise as you read more. This iterative process helps in refining your arguments and identifying additional sources as needed.

Brown University Library (2024) Organizing and Creating Information. Available at: https://libguides.brown.edu/organize/litreview (Accessed: 30 July 2024).

Pacheco-Vega, R. (2016) Synthesizing different bodies of work in your literature review: The Conceptual Synthesis Excel Dump (CSED) technique . Available at: http://www.raulpacheco.org/2016/06/synthesizing-different-bodies-of-work-in-your-literature-review-the-conceptual-synthesis-excel-dump-technique/ (Accessed: 30 July 2024).

Study Advice at the University of Reading (2024) Literature reviews . Available at: https://libguides.reading.ac.uk/literaturereview/developing (Accessed: 31 July 2024).

Water fetching and musculoskeletal health across the life-course in Sub-Saharan Africa: A scoping review

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

* E-mail: [email protected]

Affiliation Southern Medical Program, University of British Columbia, Kelowna, British Columbia, Canada

Roles Conceptualization, Supervision, Writing – review & editing

Affiliation Department of Geography and Environmental Management, University of Waterloo, Waterloo, Ontario, Canada

Roles Investigation, Writing – review & editing

Roles Supervision, Writing – review & editing

Affiliation Department of Family Medicine, University of British Columbia, Vancouver, British Columbia, Canada

Soren Meeuwisse,
Susan J. Elliott,
Alexa Bennett,
Videsh Kapoor

Published: September 3, 2024
https://doi.org/10.1371/journal.pgph.0003630
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The world is experiencing a global water crisis and Sub-Saharan Africa (SSA) is expected to be a hotspot for increasing global water scarcity in years to come. Water is quintessentially a gendered issue; indeed, sociocultural norms hold women responsible for household water collection, requiring them to travel far distances while carrying water. This paper reports the findings of a scoping review of peer-reviewed and grey literature that examines the relationship between water fetching and the musculoskeletal (MSK) health of women in SSA. The work is informed by a gendered life-course perspective, and the authors follow the PRISMA-ScR guidelines. Results indicate a bidirectional relationship between water fetching and poor MSK health as chronic and acute incidences of water carrying are highly related to MSK pain and dysfunction. This has negative implications for the overall health and wellbeing of women and their households. Gaps in the literature are identified, including the experiences of elderly people and people with various vulnerabilities. Recommendations from the literature are compiled to outline potential avenues of future research and innovation to better support the MSK health of water fetchers in SSA.

Citation: Meeuwisse S, Elliott SJ, Bennett A, Kapoor V (2024) Water fetching and musculoskeletal health across the life-course in Sub-Saharan Africa: A scoping review. PLOS Glob Public Health 4(9): e0003630. https://doi.org/10.1371/journal.pgph.0003630

Editor: Valentina Gallo, University of Groningen, NETHERLANDS, KINGDOM OF THE

Received: January 10, 2024; Accepted: July 30, 2024; Published: September 3, 2024

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

Data Availability: The PRISMA Checklist and Detailed Search Strategy of this manuscript has been published to the data repository figshare, which can be accessed with the following DOI link: https://doi.org/10.6084/m9.figshare.25796794.v1 . All data used in this review are included in the bibliography and the supplemental appendages provide the detailed search strategies for full transparency. Additional information may be requested by contacting the corresponding author.

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

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

Introduction

The population of Sub-Saharan Africa (SSA) is being faced with a combination of environmental, demographic, and social challenges that ultimately impact the musculoskeletal (MSK) health of women. Compared to the rest of the world, SSA countries experience high water insecurity and are expected to be the ‘hot spot’ of global water insecurity in years to come [ 1 – 4 ]. Water accessibility in SSA shows significant variation between countries and between rural and urban areas. Only 39% of the population has water connected to their homes, with this percentage dropping to just 19% in rural areas [ 5 ]. This water insecurity forces millions of women in rural and low-income communities of SSA to fetch and carry water daily [ 6 ] which can cause accelerated degenerative changes in their bodies [ 7 – 9 ]. There is a massive and unequal burden of MSK disease in SSA compared to the rest of the world [ 10 ], with women in SSA reporting a greater prevalence of mobility disability compared to men [ 11 ]. Due to sociocultural norms, women and female children are disproportionately impacted by water insecurity as they must assume the responsibility for collecting water for their households [ 6 , 12 – 14 ]. Many women’s daily lives revolve around water collection, as walking to and from water points and waiting in long queues consumes several hours of the day [ 15 , 16 ]. Water is quintessentially a gendered issue [ 17 ]; therefore, the United Nations calls for the prioritization of gender in water, sanitation, and hygiene (WaSH) reporting, policies, and agendas [ 18 ].

Concomitantly, the elderly population in SSA is expected to increase significantly over the coming decades, increasing from 31.9 million in 2019 to 101.4 million in 2050 [ 19 ]. An age-sensitive approach is crucial to accurately depict the complex and evolving challenges of water fetching at different life stages, throughout a lifespan, and across generations. A research perspective that is considerate of age is pivotal to formulating healthy growth, development, and aging strategies for the people of SSA as they face increasing water insecurity in years to come.

In 2018, Jo-Anne Geere and colleagues conducted the first systematic review of the impacts of water carrying on the water carrier’s overall health, which examined the physical, social, and mental health of water carriers around the world [ 20 ]. However, the relationship specifically between MSK health and water fetching has historically been neglected in academic research. Several recent studies attribute the consequences of water fetching to the global burden of MSK diseases, yet systematic and robust documentation of this phenomenon is lacking [ 20 , 21 ]. Building on the findings of Geere et al.’s systematic review [ 20 ], we first summarize their findings specifically related to MSK health in SSA, and then provide an update of the literature between 2017–2023. Further, few studies have explored the impacts of water insecurity through a life-course perspective [ 16 , 22 , 23 ], and these studies mainly focus on non -MSK health implications (ie. psychosocial health, overall wellbeing) in select countries (India and Kenya). The need for a life-course perspective [ 24 ] in the examination of water insecurity in low- and middle-income countries [LMIC] has been suggested in the literature, and this paper is the first to explore the relationship between water insecurity and MSK health in SSA through a gendered life-course perspective.

This paper aims to answer the following exploratory research question: What is the relationship between water fetching and the MSK health of females in SSA? This question involves a bi-directional exploration of the potential impact of water fetching on MSK health and the potential impact of MSK health on water fetching. First, we present the results within tables and narratively summarize themes according to age categories (children, adult women, and elderly women). Second, we discuss the implications of our findings with a particular focus on innovations and future research needed to address gaps in the literature and healthcare provision.

This paper contributes to our understanding of the progress towards achieving Sustainable Development Goal (SDG) 3 (Good Health & Well-Being), SDG 6 (Safe Water & Sanitization), and SDG 5 (Gender Equity). This research also contributes to the message advocated by Ma et al. [ 25 ] that injury prevention must be more properly recognized in the SDG agenda and included in the broad sector and stakeholder interests.

Three databases were searched to identify potentially relevant peer-reviewed and grey literature articles, including MEDINE (Ovid), EMBASE (Ovid), and CINHAL (EBSCO). Hand-searching was used to supplement our database searches, and as a result, three included papers were identified that are not indexed in the listed medical databases [ 26 – 28 ]. Grey literature was systematically searched, following the methodology outlined by Godin et al. [ 29 ], to identify articles from targeted websites, grey literature databases, search engines, and field experts. The detailed search strategy can be found in the Supporting Information section of this paper (see S1 – S7 Tables). Health Science librarians from the University of British Columbia and McMaster University were closely consulted for the database and grey literature searching strategies, and the database search strategy was adapted from the search protocol of Geere et al.’s systematic review [ 20 ]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist [ 30 ] and the Joanna Briggs Institute (JBI) Scoping Review Protocol [ 31 ] were resources used in structuring, conducting, and presenting this research.

Papers were included if they discussed MSK health (functioning, pain, disability, etc.) of people who fetch water for domestic purposes in SSA and were published in English. The type of negative MSK health outcomes analyzed in this review are preventable and related to the heavy load of carrying water or injuries experienced along the water fetching route due to environmental hazards (e.g. slippery terrain). MSK outcomes not analyzed in this review are related to genetic disorders, infectious diseases, or other health risk factors. Papers were excluded if they discuss health implications of water insecurity that do not impact the MSK system, do not impact the carrier of the water, or are not related to household water usage. Further, papers were excluded if MSK health was influenced by factors other than the physical loading of water and risks of walking paths (ie. sexual and gender-based violence, fights at water point queues, poor water quality, etc.). Despite the complex diversity across the large geographic area and between populations within SSA, the context of the included studies was limited to SSA to shed light on the females in this region with specific sociocultural norms, climate change impacts, demographic trends, MSK disability rates, natural resource availability, and economic states that may differ from other areas of the world. The inclusion dates of January 1, 2017, to current (March 15, 2023) were chosen to build on the systematic review findings presented by Geere et al. [ 20 ] which presents sources published between inception to 2017.

Both the primary investigator and an additional editor screened the titles/abstracts and completed full-text reviews for inclusion through Covidence. Data charting (Tables 1 and 2 ) and relevancy rating (within Table 2 ) were completed by the primary investigator and reviewed by all co-authors. No studies were excluded due to methodological quality; however, each article was assigned a relevancy rating by the primary investigator based on the methodologies and relevancy to this scoping review’s inclusion criteria and primary research question. High relevancy reflects that the article’s main purpose was to explore the relationship between MSK health and water carrying, and the study design and methodologies reflected this aim. Articles of medium relevancy include significant information on the MSK health of water carriers (which must be within the abstract results), but the main research purpose is not the link between MSK health and water fetching. Low relevancy means that the article provides some novel data or insight on the MSK health of water carriers, but it only has minimal, vague, anecdotal, or very general information. Articles of medium and low relevancy were included because, despite their relatively weaker data and less compatible methodologies for this review, sections of their results and discussion do contribute to the limited literature available on the MSK health of water fetchers. Three papers were assigned for high relevancy, three for medium relevancy, and six for low relevancy.

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https://doi.org/10.1371/journal.pgph.0003630.t001

https://doi.org/10.1371/journal.pgph.0003630.t002

The process of searching, screening, and selecting included articles can be reviewed in the PRISMA Flow Diagram ( Fig 1 ). Peer-reviewed database and grey literature searching retrieved 2,517 articles. After the removal of duplicates, 1,777 articles were screened based on title and abstract and 38 moved onto the full-text review. Twenty studies were included in this scoping review; the 8 articles included in Geere et al.’s [ 20 ] systematic review that are relevant to MSK health and SSA are summarized in Table 1 , and the 12 included papers published thereafter (2017–2023) are charted in Table 2 . A summary of the common themes that arose in the results is outlined in Table 3 .

https://doi.org/10.1371/journal.pgph.0003630.g001

https://doi.org/10.1371/journal.pgph.0003630.t003

These results indicate that water fetching is associated with poor MSK health that is chronic in nature due to habitual loading and acute in nature due to environmental hazard-related injuries while walking with heavy loads. It was found that water fetching influences MSK health, and in turn, MSK health influences the capability to fetch water. Women and children are primarily responsible for the task of water collection and commonly report poor MSK health related to water fetching. MSK consequences are most commonly reported in the low back, neck, chest, and upper and lower limbs. There are minor inconsistencies between studies on which area of the body most commonly experiences pain or injury, and these inconsistencies could be attributed to a) the population or age of study participants, b) differences in water fetching methods, distance, or tools, c) inconsistencies in the way in which MSK pain is defined, conceptualized, and measured in studies, or d) study design. One study found no significant correlation between water accessibility and reported physical outcomes [ 47 ]. However, this study noted that their findings are surprising, inconsistent with previous literature, and can be explained by the population sample and limitations of the study methodology [ 47 ].

No papers concluded that water fetching had an overall positive impact on MSK health. However, women and children do report some indirect benefits of water fetching. For example, water fetching permits positive socializing opportunities for women and children in their daily lives [ 45 , 48 ]. Further, women and children report feeling pride for carrying large amounts of water, which proves themselves to be suitable as a wife and provides a sense of self-worth and purpose. Thus, women and children often overload their water buckets with more than they can comfortably carry [ 12 , 41 , 49 , 50 ].

Two patterns of pain distribution were identified due to chronic loading. First, ‘axial compression’ due to head-loading is strongly associated with head, chest/rib, upper back, abdomen/stomach, and hand pain [ 20 ]. Second, ‘soft tissue strain’ is slightly associated with upper limb, low back, neck, and lower limb pain [ 20 ]. Geere et al. report that people who head-load have a much higher prevalence of pain compared to people who carry water by other means, and, unsurprisingly, people who do not carry water report a lower prevalence of pain [ 20 ]. Due to compressive loading, it is hypothesized that tissue deformation and long-term structural changes of bone and soft tissue are caused by water carrying. Previous studies have related head-loading to arthritis [ 12 , 51 ], cervical spine degeneration and cervical spondylosis [ 7 , 9 , 20 ], and low back pain related to muscular strain and L4/L5 vertebrae joint torque [ 52 ]. These conditions are common in women in Africa [ 53 ] and introduce great risk for neurological impairment and disability [ 20 , 51 ]. Further, fatigue and water carriage are moderately quantitatively related and strongly qualitatively related, with fatigue increasing the risk of MSK injury [ 20 ]. Water fetching injuries are significantly correlated with being female, higher household water insecurity scores, rural or periurban residence, use of off-premise water sources, and increased time spent collecting water [ 21 ].

Additionally, acute MSK injuries can occur due to risky terrain and falling while water fetching. Water fetchers perform an obstacle course, maneuvering their bodies in risky manners while navigating ditches, roadside laundry and cooking, wet and slippery ground, sharp objects, narrow spaces, clotheslines, trees, rocks, and more [ 20 , 21 , 52 , 54 , 55 ]. Sharing a walking path with a road increases the risk of traffic-related injuries, slips and falls are common, trash and other urban objects introduce dangerous obstacles, and hilly terrain increases the physical strain [ 54 , 56 ]. Acute injuries are of significance because they can lead to the inability to fetch water or maladaptive compensatory MSK patterns while water fetching, facilitating chronic MSK pain and injury.

The methods of transporting water from the point of collection to the home vary depending on available resources and socioeconomic status. Most commonly used are 20/25L jerry cans or buckets, however, containers holding up to 60L are also used. These vessels are often carried by hand, back, or most commonly head-loading [ 12 , 20 , 51 ]. Wheelbarrows, bicycles, donkey carts, or paid labourers are used if these resources can be accessed or afforded [ 15 , 57 ].

Not only does water carrying have negative implications for the water carrier’s MSK health, but the water carrier’s experience of pain or disability impacts their ability to fetch water [ 20 , 27 , 41 , 43 ]. Water fetchers that report pain tend to walk shorter distances to water [ 20 ] and carry less water [ 43 ], risking the quality of the water source and reducing the amount of water accessed. It is common for women to assume the risk of collecting nearby poor-quality water instead of higher-quality water from a further water point, thereby attempting to reduce the physical burden and time spent collecting water [ 58 ]. These examples showcase how the risk of MSK disability may present a barrier to obtaining adequate quantities of water from a safe source. This point is well portrayed by Geere et al. [ 20 ] (p22): “Because water is essential for life, but fetching it is often not safe, water carriage is also a barrier to ensuring safe and inclusive societies, and decent work for all, a further challenge to reducing poverty in all its forms.”

Life-course categories

Six studies included in this review focus on children, defined as being under the age of 18, with five of these studies included in Geere et al.’s review [ 32 , 34 , 36 – 38 ] and one study published more recently [ 45 ]. Children from several SSA countries associate their high rates of neck and back pain with their participation in hazardous water carrying [ 32 , 34 , 36 , 38 , 45 ]. Female children report more pain than male children [ 36 ], and children are aware of the MSK risks of water fetching, including how this can impact their long-term physical health and ability to function in society [ 45 ]. Kamya et al. assert that children, more than adult women, play a central role in household water fetching as most children report carrying water 2–3 times every day, even on school days which requires fetching in early and late hours [ 45 ]. These researchers recognize that this finding is different from many other papers that claim adult women are primarily responsible for household water collection, and they claim that the ‘misconception’ that adult women bear the largest burden is due to the underrepresentation of the voices of children [ 45 ]. Whereas 83.4% of children carried water via head-loading in this study, only 10.1% used a bicycle, and the vast majority of the bicycle users were male children [ 45 ]. Bicycles, carts, or other devices may reduce time spent fetching or change the physical loading more favourably. Male children may have a more positive physical experience with water fetching compared to female children due to their gendered access to such devices [ 36 , 45 , 51 ].

Adult women.

Seven included studies’ populations were adult women (>17 years old) [ 39 , 41 – 44 , 46 , 47 ] and five studies focused on the household level, which is non-specific in terms of age [ 12 , 15 , 21 , 27 , 35 ]. It is reported that the likelihood of MSK injury is 1.5 times greater for women water fetchers compared to male water fetchers in SSA [ 21 ]. Females may experience and report greater rates of MSK pain and injury compared to males for several reasons. First, females are socialized into gender roles that allocate primary responsibility for water collection; therefore, they are more exposed to the injury risks of water fetching [ 45 ]. Adult men rarely carry water, and it is often only men without a wife or family or with ill family members who fetch water [ 12 , 15 , 59 ]. Second, physiological differences, such as slender spines and less muscle mass, may predispose females to injury more than males [ 21 ]. Many areas of SSA have highly variable and unreliable water accessibility, therefore an uneven distribution of physical labour over time is often necessary to provide sufficient water to a household, increasing the risk of overloading, fatigue, pain, and injury [ 21 , 28 ]. ‘Maternal buffering’ can be defined as how women assume hardships to provide greater quantities of water for their families, which includes collecting water despite pain [ 28 , 39 ]. Sarkar [ 28 ](p217) explains that “[w]omen’s responsibility to fetch water for their household epitomises universal patriarchy, as it has been socially reinforced and culturally justified.”

The included studies also highlight complex vulnerabilities experienced by water fetchers, such as low socioeconomic status, motherhood, rural settings, people living with disability, people living with HIV, migrants, refugees, asylum seekers, stroke survivors, and pregnant and postpartum women. For instance, the adult stage of life includes the common child-bearing years; however, despite pregnancy and recent childbirth, women’s water collection responsibilities do not shift [ 39 ]. One study found that water carrying was the only self-reported factor associated with low back pain (LBP) pre-pregnancy and in the first trimester, and this chronic LBP impacted their ability to cope with daily life [ 42 ]. These findings are of significance because the SSA population has a high prevalence of pregnant women, and it is common for women to carry both water and a child over long distances, thus increasing their MSK strain. In a cohort of Tanzanian women water carriers with high rates of LBP and knee pain, 40% of the women had three to four children, an additional 40% had five or more children, and 64% had their first child as a teenager [ 44 ].

Furthermore, two included studies highlight the challenges introduced by physical disability. The assistance of family and friends was required to access enough water for physically challenged people living in homes for people with disabilities in Nigeria [ 41 ] and female stroke survivors in South Africa [ 27 ]. However, these research participants often also had to fetch water themselves which resulted in highly painful experiences and falling along the pathway. Other studies have reported that people with disabilities in LMICs experience discrimination, abuse, and stigma when using public water points [ 60 , 61 ], and that they face the least access to WaSH services [ 62 ]. Thus, while water fetching can cause physical disability, this physical disability in turn causes far-reaching physical, social, and mental health consequences. MSK dysfunction further exacerbates the vulnerabilities that lead to disability in the first place. It is a continuous cycle of water fetching causing reduced MSK health, and such health consequences further heighten an individual’s vulnerabilities, poor health status, and access to water. Living with a physical disability has broad negative implications on quality of life and economic stability in the short- and long-term for both an individual and their household [ 63 , 64 ].

Research related to water fetching and MSK health in SSA has focused primarily on child and adult women with very minimal research on older populations. Only one of the included studies focused specifically on older people over the age of 60 years, however, this study was rated as low relevancy [ 40 ]. Therefore, there were no studies found specifically examining the relationship between MSK health and water fetching in elderly populations despite this age group commonly having to fetch water. The challenges faced by this population include reduced physical strength, mobility restrictions, and age-related disabilities that restrict their access to water for daily survival needs [ 40 ]. The lack of published literature focusing on elderly people is significant given the expected tripling of the senior population of SSA over the coming years [ 19 ]. While the population of SSA is comprised of proportionately more youth than other age groups, the absolute number of elderly people in SSA is extremely large and growing at a significant rate that will impact health systems and population needs.

Given their essential economic, familial, and community roles, the physical functioning of many grandparents in SSA is particularly important in their later years [ 65 ]. For instance, many parents in SSA have either succumbed to diseases, particularly HIV/AIDS, or migrated to urban areas in search of better economic opportunities, leaving grandparents responsible for tasks such as water fetching and childcare [ 66 , 67 ]. Skipped generation households, where grandparents care for their grandchildren in the absence of the middle generation, are on the rise in SSA [ 68 ]. This trend increases the reliance on the well-being of many elderly individuals in these regions. Daily water fetching is challenging, painful, or often not physically possible for seniors with existing MSK disabilities [ 65 ], and this task may cause or exacerbate injuries. As a result, grandchildren often have to fetch water during school hours to ensure household survival, which compromises their educational opportunities and has long-term impacts on their livelihoods and overall wellbeing [ 65 , 69 ]. There is a pressing need for increased social resources to support these grandparents’ physical functioning and overall health, and this support will yield significant benefits for both the family and society [ 19 ].

Safe and accessible water has been declared an essential human right by the United Nations (UN) [ 70 ], and the sixth SDG aims for universal access to drinking water and sanitation by 2030 [ 71 ]. This review outlines how women in SSA are resigned to the harmful MSK impacts of water fetching to achieve a fundamental human right of water accessibility. Short of the SDG target, water is neither reasonably safe nor accessible when considering this population’s physical health. MSK health, or the lack thereof, has large implications for individual and household overall well-being, especially in low-resource settings in SSA where livelihood is largely dependent on physical labour. Fetching water is an everyday experience for millions of women around the world, and this practice is predicted to persist for many years due to deeply ingrained sociocultural gender norms and increasing water insecurity, as a result of climate change and population growth [ 4 , 72 ].

Due to complex interactions between gender, culture, environment, identity, class, and race, the unequal responsibility and health outcomes associated with water carrying are often accepted by women as a norm [ 73 ]. Pain and injury are often not questioned and assumed to be a necessary, unavoidable part of life. Females may also under-report pain and associated risks since water fetching is a socialized expected duty. Therefore, unfavourable experiences may be invisible to females [ 51 , 55 ]. Further, due to unequal power relations between men and women, maintaining sociocultural roles is often perceived as more important than the physical pain experienced by women [ 73 ]. Women’s household labour and related health outcomes are largely unknown due to the lack of research on the MSK health implications of water fetching in SSA and around the world. This lack of information risks perpetuating gender inequity in one of the most dangerous ways: invisibility. Therefore, this review aims to bring greater attention to the health of females of all ages by sharing their voices and highlighting neglected areas of physical healthcare.

Water scarcity greatly influences numerous facets of life in Sub-Saharan Africa, impacting individuals and society as whole. On the individual level, there are many physical, psychological, and sociocultural health implications of water insecurity [ 39 ]. Specifically related to water fetching, these consequences include malnutrition and anemia [ 13 ]; diarrheal diseases [ 74 ]; the economic and educational opportunity cost [ 34 , 75 – 77 ]; intimate partner violence and sexual and gender-based violence [ 78 – 80 ]; drowning at water sources [ 45 ]; and psychological stress [ 15 , 28 , 81 ]. At the population level, water scarcity has profound public health consequences. These impacts include: exposure to waterborne diseases, reduced access to hygiene and sanitation, and malnutrition; all of which have the common result of increased risk of disease transmission and epidemics [ 82 , 83 ]. Healthcare systems rely on access to clean water and face increased costs associated with treating water-related diseases and addressing the long-term health consequences of water scarcity. The health of pregnant women and children is influenced by their increased susceptibility to infectious agents, with access to clean water being essential for adequate prenatal and postnatal care [ 84 ]. Families may spend considerable time and resources fetching water from distant sources, limiting income-generating activities and educational opportunities for children [ 75 – 77 ]. Competition over limited water resources may exacerbate existing tensions and conflicts within communities and between neighboring regions [ 85 ]. Water access drives population displacement, migration, and urbanization that may further heighten these tensions and contribute to living scenarios that increase risk of disease transmission and other health consequences [ 86 – 88 ]. Lastly, as highlighted in this paper, gender inequality is a public health issue which is exacerbated by water scarcity. As women hold the primary responsibility for water fetching, they experience gender disparities in health outcomes and opportunities for personal and economic development. It is essential to consider the wide range of consequences stemming from water scarcity. By identifying patterns of MSK dysfunction related to water fetching and addressing knowledge gaps, this paper aims to inform future research and MSK healthcare interventions to prevent, reduce, and rehabilitate poor MSK health, and ultimately contribute to improved individual and societal health outcomes.

Innovations

Societal, cultural, behavioral, infrastructural, and ergonomic interventions must be strategized to reduce the burden of MSK pain and dysfunction in SSA. It is understood that women play a crucial role in household WaSH accessibility [ 89 ], yet women are largely excluded from water management, decision-making, and implementation processes which are often led by able-bodied men [ 15 , 90 , 91 ].

A transdisciplinary approach is required to address the complex nature of this issue. Many studies have suggested business or governmental policy models to improve water accessibility and reduce the need for carrying water, such as increased piped water. However, this is an unrealistic goal for millions of households for many years to come due to a combination of climate change, resource degradation, increasing populations, pollution, conflict, and gender inequity [ 15 ]. Further, water carrying is a complex sociocultural phenomenon with both positive and negative implications for women, children, and seniors. For now, water carrying exists and will persist due to strong sociocultural traditions tying women to this duty. Therefore, policies to improve water accessibility are crucial for the health and well-being of women and households in SSA.

Many authors have suggested policies to prevent such injustices or to alleviate suffering. These suggestions fall under the main categories of increased water accessibility [ 20 ], improved gender equity [ 21 ], public health messaging with the provision of water buckets [ 15 , 92 ], and improved healthcare accessibility. It has been suggested that there should be an increase in ergonomic aid availability, climate-resilient water-fetching tools, safer pathways, and public health messaging to promote male involvement in water fetching [ 21 , 93 ]. Additionally, there is a need for more non-communicable disease initiatives and water-related interventions to consider the link between MSK health and water accessibility [ 21 , 94 ].

Currently, available international WaSH indicators do not include factors of physical safety and accessibility [ 21 ]. Greater advocacy for local governments to improve WaSH accessibility is needed, particularly through a Gender and Social Inclusion lens to advocate for socially excluded groups and recognize social and gender inequality [ 15 , 16 , 27 , 40 – 42 , 44 ]. As water carrying and MSK disability are closely linked, the United Nations mission to “ensure equal access to persons with disabilities to clean water services” becomes highly relevant to water accessibility policies [ 95 ].

The WHO asserts that rehabilitation services are an essential component of universal health coverage [ 96 ]. More than 50% of the people who require rehabilitation services in LMICs do not have access to this essential service that helps them continue to live healthy, independent, and dignified lives, and COVID-19 largely reduced the provision and progress of such services [ 96 ]. There is minimal research on the causes of and healthcare solutions to MSK disorders in LMICs [ 44 ], and affordable context-specific MSK healthcare is required for the poor, vulnerable, and displaced people of SSA who fetch water daily [ 10 ]. SSA has an extreme lack of MSK healthcare services, workers, training programs, professional organizations, and regulating board requirements [ 97 – 100 ]. To support the water-fetching populations highlighted in this paper, MSK healthcare cannot be a luxury service available only to high-income countries or affluent populations, but rather a basic component of primary healthcare services available to the most vulnerable people.

A study on water fetching in India by Patil and Sangle [ 52 ] suggested the use of an innovative wheelbarrow-like device that reduces the torque on the L4/L5 joints and stress on the neck, trunk, and upper limbs. Vinay et al. [ 101 ], also in India, devised a backpack that reduced the time, distance, and energy of water fetching, thus increasing the quantity of water carried per trip. These technologies allow for postures that lower the risk of injury and pain and reduce energy utilized by the water fetcher compared to the traditional methods of head-loading. However, males are much more likely to have access to and use water-fetching aids such as bicycles and carts [ 36 , 45 , 51 , 91 ], indicating that regardless of the technology, males rather than females may have preferential access to other innovative devices. This may influence the real-world benefit of innovations introduced to water fetching communities. Further, even if a low-cost and sustainable innovation is successfully adopted in one community, that does not indicate transferable success in another community with different social, physical, economic, political, environmental, or intellectual infrastructures. There is no ‘magic bullet’ solution to improving the MSK health of water fetchers across the globe or within SSA countries. Water fetchers are the experts with local knowledge to lead ‘bottom-up’ innovative change [ 102 – 104 ].

While research and attempts to introduce innovations to assist water fetching in culturally safe manners can be beneficial, they may be short-term band-aid solutions to the greater and underlying issue of poor water accessibility. As water fetching is an integral part of life in SSA and will be for many years to come, such innovations of policies and technology may have the potential to help reduce the MSK health burden in SSA if they are prioritised by decision makers, developed with key stakeholder involvement for an inclusive design, thoroughly tested, and continuously re-evaluated.

Future research recommendations

Future studies are warranted to better understand the relationship between water fetching and the water carrier’s MSK health, permitting assessment of the true burden of inadequate water accessibility. Studies that examine this relationship through a life-course perspective and with specific interest in older populations and people experiencing additional vulnerabilities are greatly needed to account for many different lived experiences and to address the gap in the literature identified by this review. We also suggest that future studies assess the impact of water fetching beyond one individual’s lifespan; or in other words, evaluate how water insecurity relates to intergenerational MSK trauma, or how MSK trauma relates to intergenerational water insecurity.

Several studies recommend that future research quantifies the relationship between MSK health and water fetching in larger and longer epidemiological studies [ 20 , 44 ], with the application of a validated pain scale [ 20 , 21 ], biomechanical technology, or a clinical assessment by a trained healthcare professional to reduce the reliance upon subjective self-reported pain, injury, and disability [ 20 , 44 ]. Validated pain scales or clinical assessments can increase the objectivity of MSK health outcomes and reduce inherent biases of self-reported MSK health, thus permitting the measurement of progress toward the SDGs and other global health goals. Further, future research has been suggested to explore the specific features of water-carrying MSK injuries, such as prevalence, severity, implications, injury type, mechanism, environmental context, and bodily location [ 21 ].

Lastly, it is suggested that future papers clearly outline how MSK pain, injury, and disability are defined, conceptualized, and measured; and there should be consensus across papers for appropriate comparison. There are significant inconsistencies across studies for how MSK pain, injury, disability, dysfunction, or disease are defined, conceptualized, and measured. This terminology inconsistency is more significant than a limitation of this review or included papers, but it is an issue of this field of research overall and deserves thorough attention.

Most articles do not clearly outline the differences, similarities, and boundaries between these various terms that are used across studies and interchangeably within studies. Since many papers include self-reported data from participants, these terms are influenced by the participants’ and researchers’ understanding, perceptions, and communication. This terminology inconsistency makes it challenging to assess the similarities, differences, and patterns between the papers. Only one paper explicitly outlined their definition criteria of ‘pain’ and ‘disability’ [ 44 ], and importantly, these definitions seem to be more exclusive than other studies’ criteria of ‘pain’ or ‘disability.’

Furthermore, pain and disability are complex experiences influenced by many biological, sociocultural, and psychological factors, such as genetics, expectations, and norms [ 105 , 106 ]. For instance, mental stress and fatigue influence self-reported pain intensity, and pain is a symptom of injury or disability [ 21 ]. For many studies, it is unclear at what point pain becomes injury, and injury becomes disability. Geere et al. [ 20 ](p7) note that using self-reported pain is “appropriate and necessary” because pain is a “subjective and emotional experience” and that pain-intensity scales are a reliable and valid method of assessing pain. However, all studies in Geere et al.’s systematic review include self-reported pain without a validated pain scale. Out of the 12 studies included in this scoping review, most used surveys or interviews to assess MSK pain and injury experiences, three assessed pain with a validated pain scale [ 42 – 44 ], and one used objective technology to measure range of motion and proprioception [ 43 ]. Therefore, terminology inconsistencies introduce challenges to judiciously understanding the MSK health reported in the included studies and to assess the overall message provided by the body of literature.

Limitations of this scoping review

None of the included studies are longitudinal cohort designs so no causal or long-term relationships can be concluded about the MSK health of water fetchers. Therefore, the aim is to determine correlation rather than causation. Further, the quality of the included papers was not assessed, and no studies were excluded based on methodological quality.

The findings of this review are based upon many studies that neglect to account for the potential confounding impact of other types of load-carrying, such as firewood, or other types of habitual manual labour performed by the studied populations, such as cooking, cleaning, farming, and hawking. As such, confounding variables could be unaddressed in this review’s analyses. Two included studies account for other types of load-carrying, but they make no distinction between MSK pain related specifically to water fetching or other means [ 43 , 44 ]. A recent systematic review examined the combined health impacts of both water and solid fuel carrying around the world and concluded that women are most responsible for such transportation, head-loading is the most common method, and there is a significant MSK health burden [ 91 ]. One study reports that water is the most frequently carried material, but it ranks behind firewood and agricultural items in terms of difficulty and duration of loading [ 44 ]. Whereas, another study reports that water is more difficult to carry due to the unstable, ‘sloshing’ nature of transporting water compared to stable firewood [ 43 ]. These findings highlight the need to account for such confounding or compounding experiences that may influence other studies’ findings on the relationship between water fetching and MSK health. This paper does not assume that water carrying is the only nor the greatest contributor to MSK loading, but it focuses specifically on the loading of water to highlight how improved water accessibility can alleviate some burden of physical injury and disability in low-resource settings.

Lastly, by limiting the search criteria to SSA and only including English papers, research on the MSK health of water fetchers from other countries or from authors of different languages has not been included. This may have resulted in not identifying all papers that assess the MSK health of water fetchers, which could potentially provide data applicable to the SSA populations who carry water similarly.

The reported MSK pain, injuries, and disabilities in this review are preventable, and this is an important global public health problem that is socially normalized, under-measured, and underrepresented in the literature. Water is a human right and the distance travelled to water increases the risk of MSK injury throughout the water fetcher’s life via various acute and chronic mechanisms. This is a gendered issue that disproportionately impacts women, and it warrants greater research, policies, innovations, and healthcare services. Unpaid domestic labour such as water fetching is crucial for the functioning of a household and ultimately for national and global economies. African women are key players in the social progress, economic development, and climate resiliency needed in the decades to come. This research contributes to an academic movement that supports women’s physical movements , and therefore, women’s health and equity.

Supporting information

S1 table. ovid medline search strategy (n = 1344) [searched march 15, 2023]..

https://doi.org/10.1371/journal.pgph.0003630.s001

S2 Table. Ovid Embase search strategy (n = 692) [Searched March 15, 2023].

https://doi.org/10.1371/journal.pgph.0003630.s002

S3 Table. CINHAL search strategy (n = 439) [Searched March 15, 2023].

https://doi.org/10.1371/journal.pgph.0003630.s003

S4 Table. Grey literature database searching.

https://doi.org/10.1371/journal.pgph.0003630.s004

S5 Table. Customized Google searching.

https://doi.org/10.1371/journal.pgph.0003630.s005

S6 Table. Targeted website searching.

https://doi.org/10.1371/journal.pgph.0003630.s006

S7 Table. Consultation with experts in field of study.

https://doi.org/10.1371/journal.pgph.0003630.s007

S8 Table. All studies identified in literature search.

https://doi.org/10.1371/journal.pgph.0003630.s008

Acknowledgments

A special thanks to Sadaf Ullah, McMaster University Health Science librarian, and Jane Jun, University of British Columbia Southern Medical Program librarian, for their guidance in developing and applying the search strategy.

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Open access
Published: 02 September 2024

Benefits, barriers and recommendations for youth engagement in health research: combining evidence-based and youth perspectives

Katherine Bailey 1 , 2 na1 ,
Brooke Allemang 3 na1 ,
Ashley Vandermorris 4 , 5 ,
Sarah Munce 6 , 7 , 8 ,
Kristin Cleverley 1 , 9 , 10 ,
Cassandra Chisholm 11 ,
Eva Cohen 12 ,
Cedar Davidson 13 ,
Asil El Galad 14 ,
Dahlia Leibovich 15 ,
Trinity Lowthian 16 ,
Jeanna Pillainayagam 17 ,
Harshini Ramesh 18 ,
Anna Samson 19 ,
Vjura Senthilnathan 6 , 7 ,
Paul Siska 18 ,
Madison Snider 18 &
Alene Toulany 2 , 4 , 5

Research Involvement and Engagement volume 10 , Article number: 92 ( 2024 ) Cite this article

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Metrics details

Youth engagement refers to the collaboration between researchers and youth to produce research. Youth engagement in health research has been shown to inform effective interventions aimed at improving health outcomes. However, limited evidence has identified promising practices to meaningfully engage youth. This synthesis aims to describe youth engagement approaches, frameworks, and barriers, as well as provide both evidence-based and youth-generated recommendations for meaningful engagement.

This review occurred in two stages: 1) a narrative review of existing literature on youth engagement and 2) a Youth Advisory Council (YAC) to review and supplement findings with their perspectives, experiences, and recommendations. The terms ‘youth engagement’ and ‘health research’ were searched in Google Scholar, PubMed, Web of Science, Scopus, and PsycINFO. Articles and non-peer reviewed research works related to youth engagement in health research were included, reviewed, and summarized. The YAC met with research team members and in separate youth-only forums to complement the narrative review with their perspectives. Types of youth engagement include participation as research participants, advisors, partners, and co-investigators. Barriers to youth engagement were organized into youth- (e.g., time commitments), researcher- (e.g., attitudes towards youth engagement), organizational- (e.g., inadequate infrastructure to support youth engagement), and system-level (e.g., systemic discrimination and exclusion from research). To enhance youth engagement, recommendations focus on preparing and supporting youth by offering flexible communication approaches, mentorship opportunities, diverse and inclusive recruitment, and ensuring youth understand the commitment and benefits involved.

Conclusions

To harness the potential of youth engagement, researchers need to establish an inclusive and enabling environment that fosters collaboration, trust, and valuable contributions from youth. Future research endeavors should prioritize investigating the dynamics of power-sharing between researchers and youth, assessing the impact of youth engagement on young participants, and youth-specific evaluation frameworks.

Plain English summary

Engaging and partnering with youth in research related to healthcare is important, but often not done well. As researchers, we recognize that youth perspectives are needed to make sure we are asking the right questions, using appropriate research methods, and interpreting the results correctly. We searched the literature to identify challenges researchers have faced engaging youth in health research, as well as strategies to partner with youth in a meaningful way. We worked closely with 11 youth from across Canada with experience in healthcare, who formed a Youth Advisory Council. The youth advisors reviewed the literature we found and discussed how it fit with their own experiences and perspectives through group meetings with the research team. Youth advisors divided into four groups to co-author parts of this paper, including identifying the importance, benefits, and challenges of engaging in research and providing reflections on their positive and negative previous experiences as youth advisors. This paper provides an overview of recommendations for researchers to engage with youth in a meaningful way, including how they communicate and meet with youth, recognize their contributions, and implement feedback to improve the experiences of youth partners.

Peer Review reports

Introduction

Patient engagement in health research is essential to improving the relevance, processes, and impact of their findings [ 1 , 2 , 3 ]. Defined as the collaboration between researchers and those with lived experience in planning and conducting research, interpreting findings, and informing knowledge translation activities [ 1 ], patient engagement in research has been shown to produce and disseminate findings that are more applicable and comprehensible for patients, their families, and the greater community [ 3 , 4 , 5 , 6 , 7 ]. Youth engagement refers specifically to the involvement of youth populations in the research process, with youth often being defined as young people between the ages of 15 to 24 years old [ 8 , 9 , 10 , 11 ]. Youth, particularly those with chronic physical health (e.g., cystic fibrosis, congenital heart disease, diabetes), mental health (e.g., anxiety, depression), and neurodevelopmental conditions (e.g., cerebral palsy), face unique challenges in engaging with the healthcare system compared to adult populations. These include navigating healthcare transitions, developing relationships with multiple care providers, learning to advocate for themselves, and assuming greater responsibility for their healthcare as they grow and mature [ 12 , 13 ]. Existing research has shown that engaging youth in research leads to more effective and impactful interventions, policies, and healthcare services aimed at supporting health outcomes of young people, informed by the priorities and experiences of youth themselves [ 14 , 15 , 16 , 17 , 18 , 19 ]. Several nationally representative child health organizations and leaders have identified youth engagement as a priority area in youth health, highlighting the urgent imperative to include their voices in health research and public policy decisions [ 20 ]. Despite the evidence suggesting that youth are eager and capable of being engaged, there is limited evidence on the unique considerations needed to meaningfully involve youth in health research given their distinct developmental stage [ 8 , 10 , 19 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. These considerations include an emphasis on peer connections, mentorship, flexibility given competing priorities, and the use of technology to allow for broad participation [ 30 , 31 ]. In collaboration with a Youth Advisory Council (YAC), this review aims to:

Outline key types of youth engagement identified in the literature (Aim 1);

Review existing youth engagement frameworks identified in the literature (Aim 2);

Explore barriers to youth engagement identified in the literature and from YAC member perspectives (Aim 3);

Summarize recommendations for engaging youth in research identified in the literature and from YAC member perspectives (Aim 4).

The YAC identified a secondary aim, which was to:

Describe the benefits and impact of youth engagement from YAC member perspectives (Aim 5).

This project was comprised of two phases. First, the research team conducted a narrative review of the literature. Next, a project-specific YAC was established to review the literature findings and integrate the essential insights and perspectives of youth into the project. The methods pertaining to each phase are elaborated upon below. Our Research Ethics Board did not require a formal review of this project as it did not involve research participants.

Phase 1: Narrative Review

A narrative review was conducted to explore existing research on engaging youth in health research. Narrative review methodology is often employed to broadly describe the current state of the literature and provide insights for future research [ 32 ]. This review method was chosen to establish a broad understanding of the youth engagement literature and provide recommendations for researchers seeking to gain an overview of strategies for meaningful engagement. Narrative reviews also provide flexibility in terms of methodology (often based on the subjectivity of the research team) [ 33 ] and are less formal than other types of knowledge syntheses (e.g., systematic reviews) [ 34 , 35 ]. This review methodology allowed the research team to prioritize and integrate the perspectives of youth into the synthesis of information. Aims 1 to 4 were addressed in Phase 1. Aim 5 was not initially identified as an objective by the research team, and was therefore not included in the review of the literature. Upon establishment of the YAC, youth advisors deemed personal reflections on the benefits and impact of youth engagement from their perspectives critical to the manuscript.

Inclusion and Exclusion Criteria

Articles included in this narrative review met the following primary inclusion criteria: 1) published in English language, 2) published prior to April 2023, 3) focused on youth engagement in health research, and 4) described key types of youth engagement strategies (Aim 1), youth engagement frameworks (Aim 2), barriers to youth engagement (Aim 3), or recommendations for youth engagement (Aim 4). For the purposes of this review, ‘youth’ was defined as individuals between the ages of 15 to 24 years old, which is consistent with the definition provided by the United Nations [ 11 ], and ‘youth engagement’ was defined as the involvement of young people within this age range in research processes. This population was chosen for the focus of this review as the needs of youth are often distinct from children and adults due to their unique developmental stage (e.g., navigating healthcare transitions, increasing autonomy, etc.) [ 12 , 13 ]. Articles from any geographic location were included. Grey literature, websites, and non-peer reviewed research works (e.g., conference abstracts, theses) were also included using the same criteria as above.

Search Strategy and Synthesis

The search terms ‘youth engagement’ and ‘health research’ were searched in Google Scholar, PubMed, Web of Science, Scopus, and PsycInfo. Articles were hand-searched by members of the research team and selected according to the inclusion criteria above. Reference lists of relevant articles were also scanned. While other knowledge syntheses (e.g., systematic or scoping reviews) review all works identified by the literature search, narrative reviews do not aim to be inclusive of all literature available on a given topic [ 36 ]. As such, our review of the literature was concluded once we felt that sufficiency was achieved, which was characterized by reviewing works that yielded recurrent concepts. Additionally, the literature was reviewed iteratively following feedback from youth advisors who critically reviewed the narrative review manuscript. Some aspects of the manuscript were deemed critical to expand upon by youth advisors, and literature was reviewed again accordingly.

Relevant peer-reviewed and non-peer reviewed literature was organized and summarized descriptively according to study aims 1 to 4. Barriers to youth engagement were organized into individual-, organizational-, and systems-level. Recommendations for youth engagement were organized into common overarching themes.

Phase 2: Collaboration with Youth Advisory Council

The research team identified the criticality of collaborating with youth themselves in the review, formatting, and presentation of findings from the narrative review. As the review was being conducted and written, the research team began recruiting a group of youth advisors to contribute their perspectives, experiences, and recommendations for the manuscript. The development and procedural aspects of the YAC as they relate to the review are described below and in Fig. 1 . The operation of the YAC was guided by the McCain Model of Youth Engagement [ 31 ] and the Canadian Institutes of Health Research’s (CIHR) Patient Engagement Framework [ 1 ]. These frameworks, which prioritize reciprocity, respect, mutual learning, flexibility, and mentorship, supported the use of youth-driven and adaptable engagement strategies throughout the project [ 1 , 31 ]. Specifically, the research team employed engagement practices including co-building of a terms of reference document, inviting YAC members to co-chair meetings to foster mutual learning, and offering YAC members a menu of options for contribution, that aligned with the principles outlined in these models [ 1 , 31 ]. Aims 3 (i.e., identifying barriers to youth engagement) and 4 (i.e., summarizing recommendations for youth engagement) were expanded upon by the YAC in Phase 2. As described above, Aim 5 (i.e., benefits and impact of engagement on youth themselves) was deemed crucial by members of the YAC and was exclusively addressed in Phase 2 of this project. It should be noted that while the YAC specifically contributed reflections to Aims 3–5, each member critically reviewed the manuscript and offered feedback as co-authors.

Recruitment of Youth Advisory Council Members

Recruitment for the YAC began in June 2023 through distribution of a recruitment poster via professional contacts (e.g., researchers conducting youth-engaged research, youth advisory council facilitators), social media pages, and email lists (e.g., patient-oriented research listservs, youth advisory council lists). Eligible youth advisors were Canadian youth between the ages of 15–24 years with an expressed interest in youth engagement in health research. Youth applicants completed a Google Form to describe their motivations to become involved and past experience, if applicable. To ensure a diverse range of perspectives, we considered age, sex/gender, race and ethnicity, geographic location, and a range of previous experiences with research (from limited to extensive) in our recruitment process. The research team received interest from 55 individuals, of which 17 were invited to complete a 30-min virtual interview co-led by a researcher and a youth research partner. Eleven youth were selected to join the YAC, and all accepted the team’s invitation to participate. The youth invited to compose the YAC predominantly had previous experience with health care, including as a patient, advocate, youth advisor, research participant, or research assistant. Having and/or disclosing a diagnosis of a chronic health condition was not a criterion for participation in the YAC. A collective discussion was held with youth advisors and it was determined that members preferred not to share their demographic information, though there was representation of members with varying ages, ethnicities, years of experience with engagement, and from different provinces. The research team consisted of female-identified researchers, clinicians, and trainees across interdisciplinary professional backgrounds (e.g., medicine, nursing, social work) with experience engaging youth in research and/or clinical care. As many team members do not have previous youth lived experiences in research and/or clinical care, we were committed to closely collaborating and amplifying youth voices in our research, recognizing that our work, interpretations, and applications to the broader community were limited by our non-experiential understanding of youth engagement in research. The composition of the research team and YAC allowed for critical reflection on the roles of positionality, intersectionality, power, and privilege within youth engagement. The team engaged in reflexive discussions about the importance of prioritizing equity and addressing discrimination in engagement, especially for youth with marginalized identities.

Scheduling and Meetings

In July 2023, a Doodle Poll link was sent out to all youth advisors to find three meeting times that could accommodate the majority of the youth advisors and research team. Subsequently, Microsoft Teams invites were sent via email, and meetings were recorded and transcribed for notetaking purposes.

Prior to each meeting, a meeting agenda and documents were sent for review. Meetings lasted between 1.5 and 2 h and were recorded for those who could not attend. Both the recording and the minutes were collated following each meeting and made available to all youth advisors. Prior to the first meeting, a draft terms of reference document (ToR) was distributed to all youth advisors for review. The ToR contained the purpose and expectations of youth contributing to the project. A preliminary draft of the narrative review was provided to each youth advisor for their consideration both in advance of and during the meetings. Throughout the meetings, a range of communication methods, including Jamboards, chat messaging, and online verbal discussions, were employed to enable youth to exchange ideas and actively facilitate discussions.

During the initial meeting, youth advisors were provided with guidelines aimed at creating a secure environment using a digital interactive whiteboard on Google Jamboard. To maintain confidentiality and facilitate continuous improvement, the youth advisors proposed and subsequently implemented an anonymous feedback form, accessible for youth to complete at their discretion. Subsequently, the youth advisors engaged in a collaborative ideation session to conceptualize their contributions to the synthesis. It was decided that a Slack channel would serve as the primary platform for communication among the youth advisors.

In the second meeting, the council deliberated on the ToR initially formulated by the research team, with the ToR subsequently revised to incorporate the feedback and insights provided by the youth advisors. Additions to the ToR from YAC members included greater options for compensation, strategies for addressing microaggressions, more clarity regarding YAC tasks, roles, and responsibilities, and rationale for selecting 11 advisors for the group. Following this, the group engaged in a comprehensive discussion centered on their reflections concerning the draft of the narrative review. This dialogue highlighted the identified gaps and obstacles associated with involving youth in research from YAC members’ perspectives, proposed recommendations for future research endeavors, and stressed the importance of integrating youth voices into the research process.

In the third meeting, the focus shifted towards the establishment of more focused working groups. These smaller working groups were structured to address specific aspects, including 1) the rationale behind the research (the “why”), 2) reflections on past experiences with youth engagement, 3) methodologies for engaging youth in the context of this review, and 4) formulating recommendations for future research endeavors. Youth advisors were invited to complete a form to rank their areas of interest in these four areas. Based on their ranked responses, working groups were formed and considered the alignment between youth advisor’s preferred method of contribution (e.g., developing visuals, writing a personal reflection, contributing to a table) and the specific topic of the working group.

During the fourth meeting, which was co-chaired by a research team member and a youth advisor (TL) who volunteered for this role, youth advisors and members of the research team reviewed written materials from each working group, discussed each section of the paper, and reached consensus on how the sections would be presented within the article. It was determined that youth advisor work would be combined with the existing narrative review and showcased using textboxes, figures, and tables.

Independent Working Groups

All youth advisors worked in four designated working groups over a 3-week period. Youth advisors communicated via Slack channels, email or personal messaging, with the research team available for support and guidance, as needed. Guidelines for authorship, methods of contributing to each section of the paper (e.g., brainstorming, making point form notes, developing figures), and suggestions on length/format were discussed at YAC meetings. Youth advisors were also provided with a series of resources on a collaborative drive to support their contributions to the review, including a youth-friendly guide to academic writing and examples of reports/journal articles co-authored by youth. All groups worked independently and provided finalized drafts to the research team prior to the fourth meeting.

Compensation

All youth advisors were compensated $25 per hour at the end of their involvement. All youth advisors tracked their hours with a maximum of 20 h. Youth advisors were able to track meetings, self-directed work, and all time dedicated to the project outside of meetings.

Methodology used to engage the Youth Advisory Council in the co-development of this article. Figure developed by the Youth Advisory Council

A total of 65 articles were included, of which 56 were peer-reviewed and 9 were non-peer reviewed. Of the peer-reviewed articles, 14 were qualitative studies, 12 case studies, 7 mixed-methods, 6 commentaries, 2 curriculum development studies, and 2 randomized controlled trials. Additionally, 13 syntheses were included ( n = 7 unstructured literature reviews, n = 3 scoping reviews, n = 2 systematic reviews, n = 1 scoping review protocol). Of the non-peer reviewed studies, 4 were websites and 5 were reports. A table is available in Appendix A displaying included article citations, categorization of peer-reviewed versus non-peer reviewed works, and study methods used.

In this section of the article, results pertaining to each of the five aims are presented. Aims 1 to 4 were addressed in Phase 1 of this project to outline types, frameworks, and barriers to youth engagement and summarize the literature’s recommendations on how to meaningfully engage youth. Aims 3 and 4 were addressed in collaboration with youth advisors in Phase 2 to highlight the benefits and barriers of youth engagement and recommendations from the perspectives of the youth advisors on meaningful youth engagement. Aim 5 was identified as a priority for youth advisors and their reflections are provided on the benefits and impact of engagement on youth themselves.

Aim 1: Key Types of Youth Engagement

There are several approaches to youth engagement in health research, which are based on the aim(s) of a given project, resources available, and preferences of youth themselves (shown in Table 1 ) [ 37 ]. Youth may be involved as research participants , such as completing a survey or participating in a focus group [ 24 , 31 , 38 , 39 , 40 ]. Youth may also take on advisory or consultation roles , where they provide input on the research scope, recruitment strategies, and methods, as well as reviews analyses, results, and/or manuscripts, from which the researcher may decide if or how to implement their suggestions (e.g., advisory councils) [ 24 , 38 , 39 , 40 , 41 ]. Youth may assume co-production roles , which actively involves youth in the development of research objectives and design, funding proposals, study informational materials, recruitment of participants, data collection instruments, co-facilitating focus groups/interviews, analysis of data, presentations, manuscripts, and knowledge translation activities [ 10 , 24 , 41 ]. This may also be referred to as partnership , which involves active collaboration of youth with researchers to support and/or lead aspects of the project (e.g., collaborate on research methodology, lead certain research activities) [ 24 , 31 , 38 , 39 , 40 ]. Finally, youth-led research refers to projects that are entirely led by youth, with or without the support of an adult researcher [ 24 , 31 , 38 , 39 , 40 ].

A recent systematic review identified youth engagement practices in mental health-specific research, highlighting the most common youth engagement types were advisory roles, where youth were often involved in providing feedback on the research topic, analysis of qualitative data, and dissemination of findings, with less emphasis placed on co-production methods [ 10 ]. Authors identified one study which utilized a youth-led participatory action research approach in the mental health research setting, which is a power-equalizing methodology involving collaborative decision-making and viewing youth as experts based on their own lived experience [ 44 , 46 , 47 , 48 ].

Aim 2: Frameworks for Youth Engagement

A significant body of literature has proposed various frameworks for supporting patient engagement in research, with research teams more recently developing frameworks specific to youth engagement [ 49 ]. For example, the Youth Engagement in Research Framework , designed by youth and researchers at the University of Manitoba, identified seven strategies to create a culturally-inclusive research environment for youth to meaningfully contribute to the research process [ 50 ]. Strategies included 1) understanding motivations of youth to engage in research, 2) sharing intentions to implement research findings, 3) supporting diverse youth identities in engagement, 4) actively addressing the barriers to youth engagement, 5) reinforcing that engaging in research is a choice, 6) developing trusting relationships through listening and acknowledging contributions, and 7) respecting different forms of knowledge creation, acquisition, and dissemination [ 51 ].

Youth engagement has also been achieved through health research communities of practice , a framework aimed at promoting a space for youth to develop identity, build capacity for youth to develop research, communication, and advocacy skills, lead projects, and develop relationships with the research team [ 52 , 53 , 54 ]. A Canadian research team developed IN•GAUGE®, a health research community of practice which aims to promote collaboration between youth, families, researchers, and policy makers and support the development of strategies to improve child and family health [ 51 , 52 ]. This program uses Youth and Family Advisory Councils, a group of youth and family members who contribute to the direction of the project and provide input on research methods based on their own lived experiences [ 51 ]. This community of practice has built a robust network of youth and family researchers, which helps alleviate some challenges associated with finding youth to support a project.

Researchers at the Centre for Addiction and Mental Health (CAMH) in Toronto, Ontario, Canada have developed the McCain Model for Youth Engagement, which is specific to mental health populations [ 55 ]. This model is based on flexibility (i.e., the youth and research team work together to co-design deliverables/timelines and develop skills that are relevant to the youth’s goals), mentorship (i.e., in the development of research skills, incorporating youth strengths into research design), authentic decision-making (i.e., avoiding ‘tokenism’, carefully considering and implementing youth feedback), and reciprocal learning (i.e., both youth and researchers are ‘teachers’ and ‘learners’). Based on the implementation of the McCain Model, researchers propose that youth engagement should be established when research projects are in the early planning stages, reflect on organizational-level barriers to youth engagement and plan policies and practices around them, and train researchers on the value of engaging youth [ 55 ].

A recent commentary made key recommendations for youth engagement in the context of the COVID-19 pandemic [ 30 ]. First, authors propose adapting youth engagement strategies to facilitate rapid decision-making, such as utilizing connections with pre-existing youth advisory councils, providing additional compensation, and offering opportunities for online participation. Additionally, they suggest leveraging virtual platforms for youth engagement methods, while ensuring that youth with disabilities or chronic health conditions are offered appropriate accommodations. Finally, subsidies or shared tablets or computers may be offered to youth researchers to ensure virtual platforms are accessible and reduce technological barriers [ 30 ].

Aim 3: Barriers to Engaging Youth in Research

A series of barriers for engaging youth in health research have been identified in the literature through a narrative review. These barriers are grouped into individual, organizational, and systemic factors and are presented below. In Table 2 , a summary of these barriers, as outlined in the published literature is presented. Youth advisors were invited to review this list and provide their own expansions, reactions, and additions based on their knowledge and experiences. A key limitation in the exploration of barriers related to youth engagement is that much of the existing literature does not specify what level of youth enagagement was being employed.

Individual-Level Barriers: Youth-Specific

Many youth may be discouraged from engaging in research due to their own negative lived experiences with the healthcare system. For example, youth may be distrustful of adult clinicians and researchers, particularly those who may have had traumatic medical experiences (e.g., lengthy hospital/intensive care unit admissions, surgeries, invasive treatments), complex and chronic healthcare conditions, or marginalized identities [ 56 ]. While understanding these perspectives and experiences is crucial to improve health service structures and delivery, they may not be captured without carefully considering and applying appropriate youth engagement methods. Similarly, those with negative previous experiences with youth engagement may feel tokenized or patronized, particularly if they did not feel authentically valued or listened to by the research team [ 57 , 59 ].

Youth characteristics may also result in exclusion from youth engagement and/or exacerbate existing barriers to partnering, particularly the presence of physical disabilities, visual/hearing impairments, intellectual disabilities, neurological conditions, mental health conditions, and/or socioeconomic factors [ 69 , 70 , 78 ]. Youth with disabilities may experience mobility impairments preventing them from easily attending research team meetings, may require additional time and supports to complete research tasks, or utilize assistive devices (e.g., communication tools) [ 69 , 70 , 78 ]. Low literacy levels and/or language barriers may also make engagement inaccessible without appropriate accommodations [ 78 ].

Furthermore, youth priorities may impact willingness to engage in research. Specifically, youth may not feel valued without formal recognition for their contributions, such as financial compensation, volunteer hours, authorship on manuscripts, or opportunities to present research at academic meetings [ 59 ]. They may also not want youth engagement opportunities to infringe on their leisure or personal time, or may be hesitant to engage in projects with long time commitments [ 61 ]. A study highlighting experiences with engaging youth with Bipolar Disorder as peer researchers identified that attrition was also affected by illness relapse, as well as difficulties balancing the responsibilities of the research project with post-secondary education and employment commitments [ 44 ].

Individual-Level Barriers: Adult Researcher-Specific

Research team members may also hold specific beliefs or attitudes towards youth engagement. For example, some researchers may feel anxious about losing control over the research process, may not see youth as experts themselves, or hold biases about the value of youth perspectives [ 24 ]. Researchers may also perceive youth engagement as an added layer of complexity, fear that engagement may impact the scientific rigor of the research design, or be concerned that youth engagement may negatively impact the research quality [ 24 , 26 , 27 , 79 , 80 , 81 ]. Further, some studies have highlighted that researchers do not feel equipped with the skills or knowledge to engage and communicate with youth, or to design studies using youth engagement principles [ 24 , 62 ]. Finally, researchers may experience challenges navigating differing priorities between youth partners and members of the research team. For example, researchers may prioritize more traditional markers of research success, including peer-reviewed manuscripts and grant proposals which often require rapid turnaround times, and be concerned that youth engagement may add to the timeline of a project [ 24 , 62 ].

Organizational-Level Barriers

As youth engagement has emerged as a best practice recently, many academic institutions do not yet have the infrastructure or resources to support engagement opportunities [ 24 ]. While examples of capacity-building programs for youth co-researchers exist in the participatory action research literature [ 82 ], there is a need for further development of training resources to support youth who are engaging in health research [ 83 ]. Formal education on youth engagement is often not included in research training programs, despite many granting agencies recently making changes to require and/or promote patient engagement considerations in funding applications [ 1 , 62 ]. Further, many organizations have not adopted policies to outline best practices for youth engagement, and academic workplace culture also may not yet value youth engagement, resulting in limited willingness to adapt research practices [ 24 , 62 ]. These factors may exacerbate existing difficulties with securing sufficient time and resources to support relationship-building between youth partners and adult members of the research team, which is a commonly cited challenge with youth engagement [ 26 , 27 , 84 , 85 ].

System-Level Barriers

Youth with complex health conditions, such as those with developmental disabilities, often experience stigma and exclusion from clinical research [ 69 , 70 , 71 , 72 ]. Specifically, research teams may inaccurately perceive youth with chronic medical conditions as ‘vulnerable’ or ‘fragile’, thus deeming them unable or incapable to contribute meaningfully or complete study-related tasks [ 24 , 70 , 72 , 73 , 86 , 87 ]. Youth with marginalized identities, including Black, Indigenous, and 2SLGBTQIA+ youth, often experience discrimination within the healthcare system, with several studies suggesting mistrust of research institutions, researchers, and healthcare systems stemming from community experiences of mistreatment in research as the most significant barrier to participating in clinical research [ 65 , 66 , 67 , 68 ]. Furthermore, youth from racial and ethnic minorities often receive less information and attention from healthcare providers compared to white youth, potentially limiting awareness of the opportunities and/or value in contributing to health services research [ 68 , 88 ]. Notably, limited literature has considered the impact of other social and structural determinants of health on youth engagement, including income, housing, and geographic location.

Youth may also be apprehensive to share their perspectives, critiques, or suggestions for improvement with adult researchers due to inherent power imbalances [ 74 , 75 , 76 , 77 ]. Given the differences in power between adults and youth, as well as between patients and clinicians/researchers, youth engagement may involve researchers dominating the conversation, thus preventing equal contribution and collaboration. Ultimately, these dynamics have the potential to produce harmful cultures or practices for youth entering research environments, especially among youth from marginalized groups. These barriers and possible outcomes resulting from these power imbalances are elaborated on in Table 2 .

Finally, researchers themselves may face barriers as many major funding agencies have yet to prioritize or incorporate youth engagement in their strategy, resulting in limited funding opportunities to support this type of engagement work or a lack of dedicated time and resources for researchers to build relationships with youth [ 73 ]. Of note, the CIHR has developed a Strategy for Patient-Oriented Research, and requires grant proposals in certain funding streams to utilize patient engagement methods [ 1 ]. However, this is not yet universally implemented across funding agencies and does not guide engagement with youth specifically. Additionally, funding agencies often have strict eligibility and assessment criteria, including level of education and evidence of prior research and scholarly outputs, which may inherently exclude youth researchers from participating in funding applications. Finally, granting agencies have funding deadlines which may not accommodate the flexibility needed to build meaningful relationships with youth partners.

Further, while some academic journals have incorporated mandatory reporting on stakeholder and patient involvement in the research design, this is not a standard of practice, and many of these journals are engagement-focused [ 55 , 62 , 89 ]. Finally, there is a lack of consensus around how to report on engagement practice and outcomes of engagement across studies, which contributes to inconsistencies in what constitutes meaningful and effective engagement. While tools are emerging to enhance transparency in reporting engagement, including the Guidance for Reporting Involvement of Patients and the Public (GRIPP), no tools exist for youth engagement specifically [ 90 , 91 ]. Barriers to engaging youth in health research from both the literature and the perspectives of the youth advisors involved in this project are summarized in Table 2 .

Aim 4: Facilitators and Recommendations for Youth Engagement

Many studies have highlighted recommendations to improve the implementation of youth engagement across research contexts. Canada’s Youth Policy was created in 2020 to develop a greater understanding of the experiences and perspectives of youth living in Canada [ 92 ]. As part of this, funding opportunities through Canada’s major funding body for health research (CIHR) have begun to focus on providing meaningful opportunities to empower youth in research such as the Healthy Youth Initiative [ 93 ]. Our study findings are in line with these newly implemented policies as they lay the foundation for researchers on how to meaningfully engage youth in health research. In the following section, current strategies, strengths, and facilitators in the health sector that can support youth engagement are outlined, along with areas for improvement. As in Table 2 , these recommendations were reviewed and expanded upon by the YAC in Table 3 .

Engaging Youth from Structurally Marginalized Populations

Engagement of youth with intersecting marginalized identities, such as Black, Indigenous, or 2SLGBTQIA+ youth, and youth with disabilities, language/communication barriers, immigrants and refugees, experiencing homelessness, or living in foster care, may involve several unique considerations [ 31 ]. Research teams should engage both youth and researchers from communities with lived experience to provide insights and support engagement strategies [ 31 ]. It is also important to recognize that engaging youth from Indigenous communities may involve a unique approach. Practices adopted by Indigenous-led organizations may exist that focus on youth empowerment that are specific to their communities. For example, the ‘Indigenous Youth Voices Report ’ produced by The Yellowhead Institute at Toronto Metropolitan University in collaboration with the First Nations Child and Family Caring Society outlined requirements for engaging and conducting research with and by Indigenous youth, which included themes such as ensuring research is accessible, uplifting Indigenous youth to co-create research, relationship-building and reciprocity, and using holistic approaches to ensure Two-Spirit, 2SLGBTQ+ youth, and Elders are meaningfully included in research approaches [ 107 ]. Further, a recent study showed evidence supporting the use of web-conferencing technology to engage Aboriginal and Torres Strait Islander in Australia through co-facilitation of an Online Yarning Circle, an Indigenous methodology that involves sharing, listening, interpreting, and understanding information in an informal setting [ 108 , 109 ].

Additionally, teams should partner with researchers who have experience working with youth from these populations. Women’s College Hospital in Toronto, Ontario, Canada has recently developed an innovative and inclusive patient engagement model, called Equity-Mobilizing Partnerships in Community (EMPaCT) , designed to highlight the priorities and needs of diverse communities informed by the perspectives of individuals with lived experience [ 110 , 111 ]. Research teams can consult this service to identify approaches to advance equity and social justice within their projects [ 110 , 111 ]. Researchers may also consider using the ‘Valuing All Voices Framework’ , which is a trauma-informed, intersectional framework that guides researchers on how to embed a social justice and health equity lens into patient engagement, with the goal of enhancing inclusivity within health research [ 112 ]. This framework is based on four core concepts, including trust (e.g., focusing on resilience/strength rather than challenges, allowing time to build relationships), self-awareness (e.g., practicing honesty, creating safe spaces), empathy (e.g., allowing the space to share stories), and relationship building (e.g., share experiences, promote ongoing communication, show awareness and sensitivity towards cultural differences) [ 112 ].

All research team members engaged in this work should be offered training on best practices for communicating and engaging with specific populations [ 31 ]. Appropriate accommodations, such as communication tools, accessibility aids, and financial support for involvement, should be offered consistently to optimize engagement of youth with diverse experiences and perspectives [ 78 ]. While not specific to youth engagement, the National Health Service in the United Kingdom has a guidance document which outlines considerations to increase diversity in research participation, including a focus on building trust, conducting research in places familiar to participants, developing accessible recruitment materials, and incorporating peer-led activities [ 113 ]. Finally, researchers should adhere to existing ethical standards for specific marginalized communities, such as the CIHR guidelines for conducting research involving Indigenous people [ 114 ].

Evaluation of Youth Engagement

Robust evaluation of youth engagement strategies is a core component of youth involvement in research and should be used to enhance implementation of principles in research, provide feedback, and ensure researchers are held accountable in upholding best practices [ 104 , 115 ]. While there are no empirically-tested tools for the evaluation of youth engagement in research, qualitative, quantitative, and mixed methods may be used, including the Youth Engagement Guidebook developed through the CAMH [ 31 ], the Public and Patient Engagement Evaluation Tool (PPEET) [ 116 ], and the Patient Engagement in Research Scale (PEIRS) [ 117 ]. These instruments are co-designed by patients and are used to evaluate the quality of engagement strategies from the perspective of patient partners themselves [ 117 ]. It should be noted, however, that empirically-tested tools for measuring youth-adult partnerships more broadly do exist [ 118 , 119 , 120 ] and could likely contribute useful information to the measurement of youth engagement in research, specifically. It is also recommended to evaluate the impact of youth engagement from the researchers’ perspectives, which may include reflecting on how valuable the team considered youth partners to be, the extent of youth involvement, and the impact of youth engagement on project outcomes [ 31 ]. Alberta Health Services has developed a resource tool kit containing survey instruments to assist research teams with routine evaluation of their collaboration skills [ 121 ]. Research teams should carefully evaluate and iteratively modify their engagement strategies to ensure youth are meaningfully involved.

Capacity Development

Several independent training programs exist to educate researchers, community stakeholders, patients, youth, and caregivers on engaging patients in health research, including the Patient and Community Engagement in Research (PaCER) program [ 122 ], McMaster University Family Engagement in Research (FER) course [ 123 ], Patient-Oriented Research Curriculum in Child Health (PORCCH) [ 124 ], and Partners in Research (PiR) [ 125 ]. Further, a recent study was conducted to develop simulations in collaboration with interdisciplinary stakeholders to train researchers on how to engage youth in childhood disability research [ 126 ]. These simulation videos focused on aspects of the research process where challenges may arise based on previous experiences of youth and family advisors [ 126 ].

Aim 5: Youth Advisor Reflections on the Impact of Youth Engagement

While describing the evidence-based benefits of youth engagement in research within the literature was beyond the initial scope of the narrative review, youth advisors deemed it critical to present their experiences regarding their motivations for becoming involved in research and the impact of research opportunities on youth. Two youth advisors reflected on the benefits of youth engagement in research from their own experiences and collectively developed the content displayed in Table 4 in a small working group. The same two advisors considered their prior involvement in research and outlined the impact of engagement on their lives in Table 5 . They were invited to share any aspects of their experiences they felt were important to communicate with a broad audience, and selected the format and method of organization of their reflections. These reflections offer unique and valuable insights into the importance of creating opportunities for meaningful and conscientious youth engagement in research using youths’ own language.

Conclusions, Limitations & Future Directions

This narrative review provides an overview of the current literature in youth engagement in health research in combination with the perspectives of youth advisors themselves. The research team and YAC collectively identified key types and frameworks for youth engagement, synthesized several barriers and recommendations for implementing youth engagement, and provided critical reflections on the impact and benefits of youth engagement in the youth voice. While many evidence-based frameworks exist to incorporate and evaluate patient engagement in research, gaps remain in the identification of the best practices for youth engagement specifically [ 49 ]. Much of the available youth engagement literature has focused on involving youth in mental health research, with limited evidence regarding best practices to engage youth with chronic physical health and neurodevelopmental conditions [ 10 , 21 , 24 ]. Further, a paucity of evidence has highlighted the barriers and best practices to engaging youth with low income, those experiencing homelessness, and rural/remote communities in health research.

Limitations

This article employed narrative review methodology to provide an overview of existing research in youth engagement in research. A more structured and systematic review and critical appraisal of included literature by multiple independent reviewers was not within the scope of this paper, which may have excluded relevant literature. The information presented in this article may serve as a foundation for a systematic review of the literature on this topic, which our research team endeavours to complete in the future. Additionally, the search was limited to articles published in English, which may have excluded relevant literature, including potential barriers or recommendations specific to non-English speaking youth. Future research should consider a fulsome exploration of youth engagement strategies, barriers, and recommendations published in languages other than English. Demographic information of youth advisors was not collected or presented as part of this article due to YAC member preference. In addition, a previous diagnosis of a chronic health condition and/or lived experience as a patient was not a criterion for inclusion in the YAC. Rather, youth advisors had a diverse set of experiences with health care (e.g., as patients, advocates, previous youth advisors, research assistants, and/or research participants). Furthermore, youth members were self-selected by the research team, and not recruited from established youth organizations with elected representatives. As such, we are unable to determine whether the youth composing the YAC are representative of the target population. Future studies could examine how demographic characteristics and/or prior experiences with engagement influence youths’ perceptions of barriers, enablers, and recommendations for youth engagement.

Future Directions

To address many of the barriers identified in this review, further work is needed at the organizational- and systems-levels to build policies and programs that support youth engagement in research. As such, youth advisors developed a call to action for researchers and their hopes for the future of youth engagement in research, available in Table 6 . Finally, robust studies are needed to develop and validate youth engagement evaluation tools [ 31 ].

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

Youth Advisory Council

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Acknowledgements

The authors would like to acknowledge the Edwin S.H. Leong Centre for Healthy Children, The Hospital for Sick Children for supporting this work through the Leong Centre Studentship Award.

This work is supported by the Leong Centre Studentship Award received by Katherine Bailey and Dr. Alene Toulany. The other authors received no additional funding.

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Katherine Bailey and Brooke Allemang contributed equally as co-primary authors.

Authors and Affiliations

Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada

Katherine Bailey & Kristin Cleverley

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Katherine Bailey & Alene Toulany

Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada

Brooke Allemang

Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada

Ashley Vandermorris & Alene Toulany

Division of Adolescent Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada

KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada

Sarah Munce & Vjura Senthilnathan

Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada

Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada

Sarah Munce

Lawrence S. Bloomberg School of Nursing, University of Toronto, Toronto, ON, Canada

Kristin Cleverley

Margaret and Wallace McCain Centre for Child, Youth & Family Mental Health, Centre for Addiction and Mental Health, Toronto, ON, Canada

Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada

Cassandra Chisholm

Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada

Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada

Cedar Davidson

Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada

Asil El Galad

McGill University, Montreal, QC, Canada

Dahlia Leibovich

Department of Health Sciences, University of Ottawa, Ottawa, ON, Canada

Trinity Lowthian

McMaster University, Hamilton, ON, Canada

Jeanna Pillainayagam

Collaborator, Toronto, ON, Canada

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Patient Partner, Canadian Arthritis Patient Alliance, Toronto, ON, Canada

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KB synthesized the literature, drafted the initial manuscript, and approved the final manuscript as submitted. BA provided youth engagement expertise, facilitated youth advisor meetings, revised the manuscript, and approved the final manuscript as submitted. CC, EC, CD, AEG, DL, TL, JP, HR, AS, PS, MS contributed their perspectives and expertise as part of the Youth Advisory Council, drafted components of the manuscript, revised the manuscript, and approved the final manuscript as submitted. BA, AV, SM, KC, VS, and AT conceptualized the design and methods of this study, revised the manuscript, and approved the final manuscript as submitted.

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Bailey, K., Allemang, B., Vandermorris, A. et al. Benefits, barriers and recommendations for youth engagement in health research: combining evidence-based and youth perspectives. Res Involv Engagem 10 , 92 (2024). https://doi.org/10.1186/s40900-024-00607-w

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Case Report
Open access
Published: 31 August 2024

Multiple sclerosis and amyotrophic lateral sclerosis: is there an association or a red flag? A case report and literature review

Raseel Aljthalin 1 ,
Rawan Albalawi 1 ,
Atheer Alyahya 1 ,
Rawabi Alhathlool 1 &
Moustafa Alhashemi 1 , 2

BMC Neurology volume 24 , Article number: 307 ( 2024 ) Cite this article

Metrics details

Multiple sclerosis (MS) is an inflammatory disease of the central nervous system that causes damage to the myelin and axons and is caused by genetic or environmental factors. Amyotrophic lateral sclerosis (ALS) is characterized by rapidly progressive degeneration of the motor neurons resulting in the presence of upper and lower motor-neuron signs and symptoms.

Case presentation

A 46-year-old female patient presented with symmetrical weakness of the lower limbs and numbness that developed over weeks. Magnetic resonance imaging (MRI) of the brain exhibited typical demyelination features, high signal abnormality involving the periventricular and subcortical white matter, and an oval-shaped lesion. The patient was diagnosed with MS based on the clinical presentation and radiological examination. However, there was rapid progression of the symptoms, involvement of bulbar dysfunction, and muscle atrophy. Furthermore, the patient did not respond to acute therapy and immunotherapy, which made the diagnosis of MS less likely or suggested that it could be associated with another diagnosis. Her neurophysiological test met the criteria of ALS, and she was started on riluzole.

Literature review

We reviewed all articles from 1986 to 2023, and there were 32 reported cases describing the co-occurrence of ALS and MS in different populations. Our case is the 33rd, and to our knowledge, it is the only case reported in the Middle East and specifically in Saudi Arabia. The main proposed mechanism according to postmortem examinations is a combination of degenerative and inflammatory processes with a cascade of production of reactive oxygen species and nitric oxide, which lead to cell death and apoptosis during concomitant ALS with MS.

The co-occurrence of ALS and MS is extremely rare, but it can be explained by pathogenesis related to neurodegeneration, inflammation, or genetic susceptibility. Rapid progressive motor and bulbar symptoms could be red-flag symptoms, extensive evaluation might be needed for these patients.

Peer Review reports

Multiple sclerosis (MS) is an inflammatory disease of the central nervous system that causes damage to myelin and axons, influenced by genetic and environmental factors. The autoimmune process in MS leads to the degeneration of myelin sheaths. Common presenting symptoms include sensory, motor, and vision issues, as well as imbalance [ 1 , 2 ].

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease affecting the brain and spinal cord, characterized by the presence of upper and lower motor neuron signs and symptoms [ 3 ]. ALS impacts bulbar, cervical, lumbosacral, and thoracic motor neurons [ 4 ].

Both MS and ALS can exhibit non-motor symptoms. Neuropsychiatric symptoms in ALS most commonly include depression and anxiety, while cognitive impairment may arise due to frontal lobe dysfunction. Executive dysfunction is frequently reported in ALS [ 5 ]. In contrast, cognitive issues in MS can result from cortical lesions that lead to gray matter atrophy, causing a variety of cognitive symptoms. Other non-motor symptoms in both conditions include fatigue, pain, pseudobulbar affect, sialorrhea, and autonomic dysfunction [ 4 ]. Notably, autonomic dysfunction in ALS is an independent factor contributing to disease progression and is associated with more rapid rates of motor functional decline and shorter survival [ 6 ].

The co-occurrence of MS and ALS is rare; however, the proposed link involves genetic factors and demyelination activity affecting axon cells alongside the degeneration of anterior horn cells, leading to programmed cell death [ 3 ]. Activation of neuroinflammation and neurodegenerative processes due to environmental or genetic factors may explain the connection between these two diseases [ 7 , 8 ]. A notable case of co-occurrence involved a patient with ALS who exhibited features of MS, potentially driven by a hexanucleotide repeat expansion of C9ORF72 [ 1 ]. This case highlighted a challenging presentation of progressive bulbar symptoms, raising questions about whether the patient was experiencing a progressive form of MS or concomitant diseases.

We report on a middle-aged woman diagnosed with MS who was later found to have ALS, along with an overview of 32 additional cases and a description of the link between these two diseases.

The patient was a 46-year-old woman with a known case of type 2 diabetes mellitus. In April 2022, the patient started to have progressive symmetrical weakness of the lower limbs and numbness, which developed over weeks and was progressive in nature. She also started to have difficulty with walking and eventually required a wheelchair. She denied having any history of recent travel, raw-milk ingestion, vaccination, family history of the same presentation, illicit drug use, fever, or upper-respiratory-tract infection. She also denied having any gastrointestinal or genitourinary symptoms.

The patient was admitted to another facility, and the investigations performed included lumbar puncture and magnetic resonance imaging (MRI) of the brain. The MRI showed non-specific white-matter lesions, and the patient was diagnosed with demyelinating disease. She received pulse steroid therapy and was discharged, but there was minimal improvement regarding her muscle weakness after she went home.

In September 2022, her weakness progressed further with upper limb weakness, and she also developed difficulty in breathing and swallowing, along with worsening of her muscle weakness. Eventually, she was tracheostomized. During her admission to the other facility, she again received pulse steroid therapy, intravenous immunoglobulin, and one dose of ocrelizumab due to an impression of secondary progressive MS. Because she was not showing any improvement in functional status, she was eventually referred to our institution for further investigations and management (Fig. 1 ).

Timeline of the patient’s events

Clinical findings

The patient was on a mechanical ventilator with a trachea tube, nasogastric tube, and indwelling Foley catheter. She was awake, alert, and responding to commands. The results of cranial nerve examination were normal except for atrophy and fasciculation of the tongue with an exaggerated jaw reflex. Motor examination revealed atrophied thenar muscles, hypertonia of the upper limbs, and hypotonic lower limbs.

The Medical Research Council (MRC) grade of limb power for the upper limbs was + 2 for proximal muscles and + 3 distally at the level of the wrist and fingers. For the lower limbs, the MRC was + 2 proximally and + 1 distally at the level of the ankle, feet, and toes. The score for deep tendon reflexes was + 2 for the upper limbs with spreading reflexes, and the lower limbs were areflexic with mute plantar reflex, no clonus, and negative Hoffman sign. Sensory examination revealed decreased pinprick sensation and an absence of proprioception in the lower limb, and no sensory level was detected. The cerebellar examination was limited because of severe weakness.

Laboratory findings

The patient’s vitamin levels were all within normal limits, including vitamin B12 and its metabolites methylmalonic acid and homocysteine. The results of a thyroid function test including thyroid antibodies were normal. Her cerebrospinal fluid (CSF) showed a normal cell count, normal levels of glucose, protein, and lactate, negative culture results, and an oligoclonal band. Moreover, the results of serological and CSF tests for Campylobacter jejuni , cytomegalovirus, Epstein-Barr virus, and Haemophilus influenzae infection were negative. Autoimmunological diagnostic including antinuclear antibody (ANA), complement fixing ANA (C-ANA), and perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) were negative, as were tests for coeliac disease (antigliadin antibodies and antitransglutaminase antibodies). Moreover, paraneoplastic antibodies were sent through the serum and CSF, and the result was negative.

Radiological features

Brain and spine MRI showed evidence of scattered foci of hyperintense T2/FLAIR signal abnormality involving the periventricular and subcortical white matter in both cerebral hemispheres with limited involvement of the corpus callosum. Some of these lesions appeared perpendicular to the lateral surface of the lateral ventricle and suggested a demyelinating process. There was no pathological enhancement suggesting active disease. Imaging of the cord demonstrated normal alignment of the vertebral bodies. We performed 18-fluoro-2-deoxyglucose (FDG) whole-body positron emission tomography, which showed no detectable metabolically active lesions that could suggest malignancy in the rest of the scanned body. The MRI did not show the reason for rapid progression, and a diagnosis of MS was made based on radiological features (Fig. 2 ).

Axial and sagittal view of brain MRI showing scattered foci of hyperintense T2/FLAIR signal abnormality involving the periventricular and subcortical white matter in both cerebral hemispheres. Some of these lesions appeared perpendicular to the lateral surface of the lateral ventricle and suggested a demyelinating process

Electrophysiological diagnosis

Due to the presence of both upper and lower motor signs in examination, a nerve conduction study (NCS) and electromyography (EMG) were done. The motor NCS revealed that the right median to abductor pollicis brevis was absent, the right ulnar to abductor digiti minimi showed a very small compound motor action potential of 0.4 mV, the right tibial to adductor hallucis was absent, and so was the right peroneal to extensor digitorum brevis. The sensory NCS results were normal .

In EMG, three segments were sampled. In the bulbar segment, the right tongue showed features of active denervation (+ positive sharp waves and + fibrillations). The cervical segment (right deltoid, extensor digitorum communis, and biceps) showed features of active denervation (+ positive sharp waves and + fibrillations). The lumbar segment (right tibialis anterior and vastus medialis) showed features of active denervation (+ positive sharp waves and + fibrillations). These findings are compatible with widespread motor neuron disease (Fig. 3 ).

Nerve conduction study showing A very low compound motor action potential (CMAP) of right ulnar nerve responses, B absent CMAP of the left fibular nerve responses, and C , D normal sensory nerve action potential (SNAP) of upper and lower-limb sensory nerve stimulation sampled from the sural and median nerve. O: onset of the wave. P: peak of the wave. T: terminal part of the wave

The patient was diagnosed with MS and was managed based on the radiological features and clinical assessment. The rapid progression of the symptoms, involvement of bulbar dysfunction, and lack of response to acute therapy and immunotherapy made the diagnosis of MS less likely or suggested an association with another diagnosis. Clinical features and the results of the neurophysiological investigation met the El Escorial criteria for ALS. She was started on riluzole at 50 mg twice per day and was referred for multidisciplinary care.

The combination of MS and ALS is rare but can be explained by links between neurodegeneration, inflammation, and genetic susceptibility. In post-mortem pathological findings, demyelinating activity is observed, and degenerative processes of the anterior horn cells occur at multiple serial lumbosacral cord levels through an inflammatory cascade. This leads to the release of reactive oxygen species and nitric oxide, cell death, and apoptosis, which are observed concomitantly in ALS with MS [ 3 , 4 , 5 , 6 , 7 ]. In a case series study by Ismail et al., the co-occurrence of MS in a patient with ALS was explained as being driven in some way by a hexanucleotide repeat expansion of C9ORF72. The study highlighted that more than 1% of patients with ALS may have a history of MS [ 8 ]. Fiondella et al. reported one case of heterozygous mutation in FUS exon 15 [ 1 ].

So far, there have been 32 reported cases of the co-occurrence of ALS and MS in different populations, which have mainly occurred in Europe and North America. Our case is the 33rd to be reported and is the only case to our knowledge that has occurred in the Middle East and specifically in Saudi Arabia. We reviewed all related articles from 1986 to 2023. Most of the cases were females (25 out of 33), and 8 were males. The mean age of the onset of ALS is 52 years with a range of 34 to 72 years. The mean age of the onset of MS is 41 years. In some studies, no autopsies or genetic tests were performed, but clinical examinations, radiological findings, and neurophysiological observations were consistent with MS and ALS.

In the different cases, patients were diagnosed with MS initially and were later diagnosed with late-onset or rapid-onset ALS. Autopsy has shown a loss of myelinated axons and neuronal loss with gliosis of the motor neuron cells [ 8 ]. Only 5 patients have been reported to be positive for C9orf72 out of the 33 cases reviewed, but genetic tests were not done in all cases. HLA genotyping performed on genomic DNA has also been studied, and three cases showed positivity for HLA-B*18:01A according to Dattola et al. This antigen could play an important role in activating both neuroinflammation and neurodegenerative processes [ 9 ]. Table 1 shows the characteristics and diagnostic information of the 33 cases (Figs. 4 and 5 ).

Illustration of the main characteristics of the 33 cases of MS with ALS from 1986 to 2023. There is a predominance of females (25 cases). The onset of MS occurs at an average age of 41 years, with late-onset ALS diagnosis occurring at the age of 52 years. C9orf72 was found in only 5 cases

Worldwide distributions of patients with co-occurring MS/ALS diagnoses

The co-occurrence of ALS and MS is extremely rare, but it can be explained by a mix of pathogenesis involving neurodegeneration, inflammation, and genetic susceptibility. Careful evaluation is needed for patients with rapid progressive motor and bulbar symptoms who are initially diagnosed with MS as this presentation could be a red flag. Extensive evaluation might be needed for these patients. To gain more understanding of the co-occurrence, pathological testing, genetic testing, and HLA genotyping should be considered for diagnosis.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Data availability

No datasets were generated or analysed during the current study.

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Aljthalin, R., Albalawi, R., Alyahya, A. et al. Multiple sclerosis and amyotrophic lateral sclerosis: is there an association or a red flag? A case report and literature review. BMC Neurol 24 , 307 (2024). https://doi.org/10.1186/s12883-024-03821-x

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v.59(1); 2021

Peer review guidance: a primer for researchers

Olena zimba.

1 Department of Internal Medicine No. 2, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine

Armen Yuri Gasparyan

2 Departments of Rheumatology and Research and Development, Dudley Group NHS Foundation Trust (Teaching Trust of the University of Birmingham, UK), Russells Hall Hospital, Dudley, West Midlands, UK

The peer review process is essential for quality checks and validation of journal submissions. Although it has some limitations, including manipulations and biased and unfair evaluations, there is no other alternative to the system. Several peer review models are now practised, with public review being the most appropriate in view of the open science movement. Constructive reviewer comments are increasingly recognised as scholarly contributions which should meet certain ethics and reporting standards. The Publons platform, which is now part of the Web of Science Group (Clarivate Analytics), credits validated reviewer accomplishments and serves as an instrument for selecting and promoting the best reviewers. All authors with relevant profiles may act as reviewers. Adherence to research reporting standards and access to bibliographic databases are recommended to help reviewers draft evidence-based and detailed comments.

Introduction

The peer review process is essential for evaluating the quality of scholarly works, suggesting corrections, and learning from other authors’ mistakes. The principles of peer review are largely based on professionalism, eloquence, and collegiate attitude. As such, reviewing journal submissions is a privilege and responsibility for ‘elite’ research fellows who contribute to their professional societies and add value by voluntarily sharing their knowledge and experience.

Since the launch of the first academic periodicals back in 1665, the peer review has been mandatory for validating scientific facts, selecting influential works, and minimizing chances of publishing erroneous research reports [ 1 ]. Over the past centuries, peer review models have evolved from single-handed editorial evaluations to collegial discussions, with numerous strengths and inevitable limitations of each practised model [ 2 , 3 ]. With multiplication of periodicals and editorial management platforms, the reviewer pool has expanded and internationalized. Various sets of rules have been proposed to select skilled reviewers and employ globally acceptable tools and language styles [ 4 , 5 ].

In the era of digitization, the ethical dimension of the peer review has emerged, necessitating involvement of peers with full understanding of research and publication ethics to exclude unethical articles from the pool of evidence-based research and reviews [ 6 ]. In the time of the COVID-19 pandemic, some, if not most, journals face the unavailability of skilled reviewers, resulting in an unprecedented increase of articles without a history of peer review or those with surprisingly short evaluation timelines [ 7 ].

Editorial recommendations and the best reviewers

Guidance on peer review and selection of reviewers is currently available in the recommendations of global editorial associations which can be consulted by journal editors for updating their ethics statements and by research managers for crediting the evaluators. The International Committee on Medical Journal Editors (ICMJE) qualifies peer review as a continuation of the scientific process that should involve experts who are able to timely respond to reviewer invitations, submitting unbiased and constructive comments, and keeping confidentiality [ 8 ].

The reviewer roles and responsibilities are listed in the updated recommendations of the Council of Science Editors (CSE) [ 9 ] where ethical conduct is viewed as a premise of the quality evaluations. The Committee on Publication Ethics (COPE) further emphasizes editorial strategies that ensure transparent and unbiased reviewer evaluations by trained professionals [ 10 ]. Finally, the World Association of Medical Editors (WAME) prioritizes selecting the best reviewers with validated profiles to avoid substandard or fraudulent reviewer comments [ 11 ]. Accordingly, the Sarajevo Declaration on Integrity and Visibility of Scholarly Publications encourages reviewers to register with the Open Researcher and Contributor ID (ORCID) platform to validate and publicize their scholarly activities [ 12 ].

Although the best reviewer criteria are not listed in the editorial recommendations, it is apparent that the manuscript evaluators should be active researchers with extensive experience in the subject matter and an impressive list of relevant and recent publications [ 13 ]. All authors embarking on an academic career and publishing articles with active contact details can be involved in the evaluation of others’ scholarly works [ 14 ]. Ideally, the reviewers should be peers of the manuscript authors with equal scholarly ranks and credentials.

However, journal editors may employ schemes that engage junior research fellows as co-reviewers along with their mentors and senior fellows [ 15 ]. Such a scheme is successfully practised within the framework of the Emerging EULAR (European League Against Rheumatism) Network (EMEUNET) where seasoned authors (mentors) train ongoing researchers (mentees) how to evaluate submissions to the top rheumatology journals and select the best evaluators for regular contributors to these journals [ 16 ].

The awareness of the EQUATOR Network reporting standards may help the reviewers to evaluate methodology and suggest related revisions. Statistical skills help the reviewers to detect basic mistakes and suggest additional analyses. For example, scanning data presentation and revealing mistakes in the presentation of means and standard deviations often prompt re-analyses of distributions and replacement of parametric tests with non-parametric ones [ 17 , 18 ].

Constructive reviewer comments

The main goal of the peer review is to support authors in their attempt to publish ethically sound and professionally validated works that may attract readers’ attention and positively influence healthcare research and practice. As such, an optimal reviewer comment has to comprehensively examine all parts of the research and review work ( Table I ). The best reviewers are viewed as contributors who guide authors on how to correct mistakes, discuss study limitations, and highlight its strengths [ 19 ].

Structure of a reviewer comment to be forwarded to authors

Section	Notes
Introductory line	Summarizes the overall impression about the manuscript validity and implications
Evaluation of the title, abstract and keywords	Evaluates the title correctness and completeness, inclusion of all relevant keywords, study design terms, information load, and relevance of the abstract
Major comments	Specifically analyses each manuscript part in line with available research reporting standards, supports all suggestions with solid evidence, weighs novelty of hypotheses and methodological rigour, highlights the choice of study design, points to missing/incomplete ethics approval statements, rights to re-use graphics, accuracy and completeness of statistical analyses, professionalism of bibliographic searches and inclusion of updated and relevant references
Minor comments	Identifies language mistakes, typos, inappropriate format of graphics and references, length of texts and tables, use of supplementary material, unusual sections and order, completeness of scholarly contribution, conflict of interest, and funding statements
Concluding remarks	Reflects on take-home messages and implications

Some of the currently practised review models are well positioned to help authors reveal and correct their mistakes at pre- or post-publication stages ( Table II ). The global move toward open science is particularly instrumental for increasing the quality and transparency of reviewer contributions.

Advantages and disadvantages of common manuscript evaluation models

Models	Advantages	Disadvantages
In-house (internal) editorial review	Allows detection of major flaws and errors that justify outright rejections; rarely, outstanding manuscripts are accepted without delays	Journal staff evaluations may be biased; manuscript acceptance without external review may raise concerns of soft quality checks
Single-blind peer review	Masking reviewer identity prevents personal conflicts in small (closed) professional communities	Reviewer access to author profiles may result in biased and subjective evaluations
Double-blind peer review	Concealing author and reviewer identities prevents biased evaluations, particularly in small communities	Masking all identifying information is technically burdensome and not always possible
Open (public) peer review	May increase quality, objectivity, and accountability of reviewer evaluations; it is now part of open science culture	Peers who do not wish to disclose their identity may decline reviewer invitations
Post-publication open peer review	May accelerate dissemination of influential reports in line with the concept “publish first, judge later”; this concept is practised by some open-access journals (e.g., F1000 Research)	Not all manuscripts benefit from open dissemination without peers’ input; post-publication review may delay detection of minor or major mistakes
Post-publication social media commenting	May reveal some mistakes and misconduct and improve public perception of article implications	Not all communities use social media for commenting and other academic purposes

Since there are no universally acceptable criteria for selecting reviewers and structuring their comments, instructions of all peer-reviewed journal should specify priorities, models, and expected review outcomes [ 20 ]. Monitoring and reporting average peer review timelines is also required to encourage timely evaluations and avoid delays. Depending on journal policies and article types, the first round of peer review may last from a few days to a few weeks. The fast-track review (up to 3 days) is practised by some top journals which process clinical trial reports and other priority items.

In exceptional cases, reviewer contributions may result in substantive changes, appreciated by authors in the official acknowledgments. In most cases, however, reviewers should avoid engaging in the authors’ research and writing. They should refrain from instructing the authors on additional tests and data collection as these may delay publication of original submissions with conclusive results.

Established publishers often employ advanced editorial management systems that support reviewers by providing instantaneous access to the review instructions, online structured forms, and some bibliographic databases. Such support enables drafting of evidence-based comments that examine the novelty, ethical soundness, and implications of the reviewed manuscripts [ 21 ].

Encouraging reviewers to submit their recommendations on manuscript acceptance/rejection and related editorial tasks is now a common practice. Skilled reviewers may prompt the editors to reject or transfer manuscripts which fall outside the journal scope, perform additional ethics checks, and minimize chances of publishing erroneous and unethical articles. They may also raise concerns over the editorial strategies in their comments to the editors.

Since reviewer and editor roles are distinct, reviewer recommendations are aimed at helping editors, but not at replacing their decision-making functions. The final decisions rest with handling editors. Handling editors weigh not only reviewer comments, but also priorities related to article types and geographic origins, space limitations in certain periods, and envisaged influence in terms of social media attention and citations. This is why rejections of even flawless manuscripts are likely at early rounds of internal and external evaluations across most peer-reviewed journals.

Reviewers are often requested to comment on language correctness and overall readability of the evaluated manuscripts. Given the wide availability of in-house and external editing services, reviewer comments on language mistakes and typos are categorized as minor. At the same time, non-Anglophone experts’ poor language skills often exclude them from contributing to the peer review in most influential journals [ 22 ]. Comments should be properly edited to convey messages in positive or neutral tones, express ideas of varying degrees of certainty, and present logical order of words, sentences, and paragraphs [ 23 , 24 ]. Consulting linguists on communication culture, passing advanced language courses, and honing commenting skills may increase the overall quality and appeal of the reviewer accomplishments [ 5 , 25 ].

Peer reviewer credits

Various crediting mechanisms have been proposed to motivate reviewers and maintain the integrity of science communication [ 26 ]. Annual reviewer acknowledgments are widely practised for naming manuscript evaluators and appreciating their scholarly contributions. Given the need to weigh reviewer contributions, some journal editors distinguish ‘elite’ reviewers with numerous evaluations and award those with timely and outstanding accomplishments [ 27 ]. Such targeted recognition ensures ethical soundness of the peer review and facilitates promotion of the best candidates for grant funding and academic job appointments [ 28 ].

Also, large publishers and learned societies issue certificates of excellence in reviewing which may include Continuing Professional Development (CPD) points [ 29 ]. Finally, an entirely new crediting mechanism is proposed to award bonus points to active reviewers who may collect, transfer, and use these points to discount gold open-access charges within the publisher consortia [ 30 ].

With the launch of Publons ( http://publons.com/ ) and its integration with Web of Science Group (Clarivate Analytics), reviewer recognition has become a matter of scientific prestige. Reviewers can now freely open their Publons accounts and record their contributions to online journals with Digital Object Identifiers (DOI). Journal editors, in turn, may generate official reviewer acknowledgments and encourage reviewers to forward them to Publons for building up individual reviewer and journal profiles. All published articles maintain e-links to their review records and post-publication promotion on social media, allowing the reviewers to continuously track expert evaluations and comments. A paid-up partnership is also available to journals and publishers for automatically transferring peer-review records to Publons upon mutually acceptable arrangements.

Listing reviewer accomplishments on an individual Publons profile showcases scholarly contributions of the account holder. The reviewer accomplishments placed next to the account holders’ own articles and editorial accomplishments point to the diversity of scholarly contributions. Researchers may establish links between their Publons and ORCID accounts to further benefit from complementary services of both platforms. Publons Academy ( https://publons.com/community/academy/ ) additionally offers an online training course to novice researchers who may improve their reviewing skills under the guidance of experienced mentors and journal editors. Finally, journal editors may conduct searches through the Publons platform to select the best reviewers across academic disciplines.

Peer review ethics

Prior to accepting reviewer invitations, scholars need to weigh a number of factors which may compromise their evaluations. First of all, they are required to accept the reviewer invitations if they are capable of timely submitting their comments. Peer review timelines depend on article type and vary widely across journals. The rules of transparent publishing necessitate recording manuscript submission and acceptance dates in article footnotes to inform readers of the evaluation speed and to help investigators in the event of multiple unethical submissions. Timely reviewer accomplishments often enable fast publication of valuable works with positive implications for healthcare. Unjustifiably long peer review, on the contrary, delays dissemination of influential reports and results in ethical misconduct, such as plagiarism of a manuscript under evaluation [ 31 ].

In the times of proliferation of open-access journals relying on article processing charges, unjustifiably short review may point to the absence of quality evaluation and apparently ‘predatory’ publishing practice [ 32 , 33 ]. Authors when choosing their target journals should take into account the peer review strategy and associated timelines to avoid substandard periodicals.

Reviewer primary interests (unbiased evaluation of manuscripts) may come into conflict with secondary interests (promotion of their own scholarly works), necessitating disclosures by filling in related parts in the online reviewer window or uploading the ICMJE conflict of interest forms. Biomedical reviewers, who are directly or indirectly supported by the pharmaceutical industry, may encounter conflicts while evaluating drug research. Such instances require explicit disclosures of conflicts and/or rejections of reviewer invitations.

Journal editors are obliged to employ mechanisms for disclosing reviewer financial and non-financial conflicts of interest to avoid processing of biased comments [ 34 ]. They should also cautiously process negative comments that oppose dissenting, but still valid, scientific ideas [ 35 ]. Reviewer conflicts that stem from academic activities in a competitive environment may introduce biases, resulting in unfair rejections of manuscripts with opposing concepts, results, and interpretations. The same academic conflicts may lead to coercive reviewer self-citations, forcing authors to incorporate suggested reviewer references or face negative feedback and an unjustified rejection [ 36 ]. Notably, several publisher investigations have demonstrated a global scale of such misconduct, involving some highly cited researchers and top scientific journals [ 37 ].

Fake peer review, an extreme example of conflict of interest, is another form of misconduct that has surfaced in the time of mass proliferation of gold open-access journals and publication of articles without quality checks [ 38 ]. Fake reviews are generated by manipulating authors and commercial editing agencies with full access to their own manuscripts and peer review evaluations in the journal editorial management systems. The sole aim of these reviews is to break the manuscript evaluation process and to pave the way for publication of pseudoscientific articles. Authors of these articles are often supported by funds intended for the growth of science in non-Anglophone countries [ 39 ]. Iranian and Chinese authors are often caught submitting fake reviews, resulting in mass retractions by large publishers [ 38 ]. Several suggestions have been made to overcome this issue, with assigning independent reviewers and requesting their ORCID IDs viewed as the most practical options [ 40 ].

Conclusions

The peer review process is regulated by publishers and editors, enforcing updated global editorial recommendations. Selecting the best reviewers and providing authors with constructive comments may improve the quality of published articles. Reviewers are selected in view of their professional backgrounds and skills in research reporting, statistics, ethics, and language. Quality reviewer comments attract superior submissions and add to the journal’s scientific prestige [ 41 ].

In the era of digitization and open science, various online tools and platforms are available to upgrade the peer review and credit experts for their scholarly contributions. With its links to the ORCID platform and social media channels, Publons now offers the optimal model for crediting and keeping track of the best and most active reviewers. Publons Academy additionally offers online training for novice researchers who may benefit from the experience of their mentoring editors. Overall, reviewer training in how to evaluate journal submissions and avoid related misconduct is an important process, which some indexed journals are experimenting with [ 42 ].

The timelines and rigour of the peer review may change during the current pandemic. However, journal editors should mobilize their resources to avoid publication of unchecked and misleading reports. Additional efforts are required to monitor published contents and encourage readers to post their comments on publishers’ online platforms (blogs) and other social media channels [ 43 , 44 ].

The authors declare no conflict of interest.

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Drivers and consequences of land degradation on livestock productivity in sub-saharan africa: a systematic literature review.

1. Introduction

2. materials and methods, 2.1. study design, 2.2. pertinence and state of the matter studied, 2.3. literature search, 2.4. inclusion and exclusion criteria.

Criteria	Included	Excluded	Justification for Criteria Application
Language publication	English	All other languages	To increase readability and due to the researchers’ proficiency in the English language
Country or location of study	Sub-Saharan Africa-related papers	Non-sub-Saharan African papers	To remain within the scope of the systematic review
Article availability	Fully available paper using University of Fort Hare’s library subscription	Full paper not accessible	Access- related issues
Date of publication	Any article published before 30 June 2024	-	Used available papers from selected databases to have a contemporary perspective on drivers and the consequences of land degradation on livestock productivity
Research focus	Papers that included “drivers and consequences of land degradation in livestock” in general	Research focusing solely on agricultural crops without addressing livestock	To remain within the focused scope of the systematic review
Type of article	Peer-reviewed research journal articles, conference papers, book chapters, review papers	Gray literature, including reports and theses, unless they provided substantial empirical data	To increase the validity of the study findings

2.5. Data Extraction and Synthesis

2.6. data analysis, 3. results and discussion, 3.1. primary drivers of land degradation in sub-saharan rangelands.

Reference	Location	Biophysical Drivers	Socio-Economic Drivers	Methodology	Key Findings
[ ]	Botswana	Soil erosion, overgrazing, drought	Poverty, land tenure issues	Field survey, remote sensing	Local people identified drought as the main cause of increasing resource depletion, which impedes vegetation regeneration and induces land degradation. The situation is exacerbated by widespread poverty and inappropriate perceptions of solutions.
[ ]	Ethiopia	Bush encroachment, drought, water scarcity	Ban on traditional practices, increasing practice of crop cultivation on the rangelands	Survey	All respondents reported a dramatic decline in rangeland conditions, attributing it to past development policies based on equilibrium theories that opposed communal and traditional range management. Issues such as bush encroachment, bans on traditional burning practices, recurrent droughts, and the increasing practice of crop cultivation on rangelands were identified as serious threats to livestock production and traditional resource management.
[ ]	South Africa	Heavy grazing	-	Remote sensing, statistical analysis	Rainfall and degradation accounted for 38% and 20% of the AVHRR ZNDVI variance and 50% and 33% of the MODIS ZNDVI variance, respectively, indicating that degradation significantly influences long-term vegetation productivity. This challenges the nonequilibrium model, which predicts a negligible long-term grazing impact.
[ ]	South Africa	Land-use/land-cover change (LULCC), declining livestock, cultivation, renewable energy installations	-	Analysis of large data sets, repeat photographs	More than 95% of the Karoo has remained classified as natural and stable since 1990, with significant declines in cultivation and livestock over the last century. Vegetation productivity trends have remained unchanged over 90% of the biomes, with notable increases in nearly 10%, necessitating continuous monitoring to assess future LULCC impacts.
[ ]	Ethiopia, Kenya, Malawi	Soil texture, surface slope, rainfall	Market access, human and livestock population densities	High-resolution geospatial data analysis	Conservation agriculture (CA) aims to reduce soil degradation, conserve water, and enhance crop productivity. The study identified potential recommendation domains (RDs) for CA, with 39%, 12%, and 5% of cultivated areas in Malawi, Kenya, and Ethiopia, respectively, showing high potential, highlighting significant areas for CA adoption that are influenced by biophysical and socio-economic conditions.
[ ]	Ethiopia	Rainfall variability, land degradation, low soil fertility	Market access, human and livestock population densities	Field survey, IDSS tools (SWAT, APEX)	Rainfed agriculture in sub-Saharan Africa faces constraints from rainfall variability, land degradation, and low soil fertility. Small-scale irrigation in Ethiopia’s Robit and Dangishta watersheds shows potential for dry-season vegetable production, but groundwater recharge is insufficient; mulching and soil conservation can optimize irrigation by reducing soil evaporation.
[ ]	South Africa	Vegetation change	Expansion of human settlements	Survey	The study examined local people’s perceptions of rangeland resources in three communal grasslands, finding that locals view vegetation changes primarily in terms of species richness, diversity, and abundance, unlike ecologists who link them to degradation. Abiotic, biotic, and institutional factors were identified as primary drivers, while human settlement expansion poses a threat by reducing and fragmenting grazing resources.
[ ]	Namibia	Shrub encroachment, overgrazing	High livestock densities	Dynamic vegetation modeling	High livestock densities lead to shrub encroachment and severe decreases in fodder biomass, causing up to 100% losses in land productivity. Wildlife-based land use with a 40% browser to 60% grazer ratio is beneficial for plant structural and species diversity, enhancing ecosystem sustainability and resilience.
[ ]	South Africa	Decades of overstocking with small livestock, historical ploughing for fodder, climate change	Reduced land-use options, vulnerability to environmental and economic stressors, costs of restoration	Local-scale participatory restoration trial, assessment of regional-scale restoration costs	Ecological restoration is difficult and expensive; climate change exacerbates challenges; holistic land management actions needed to sustain livelihoods
[ ]	South Africa	Assumptions of overstocking and degradation, ecological models from large-scale commercial farming	Assumptions that increasing livestock sales and commercial farming improve productivity, belief that communal tenure causes degradation and that privatization is the solution	Examination of current policy, review of ecological and economic assumptions, analysis of the effectiveness of existing models	Current policies based on large-scale commercial farming models are inappropriate for rangeland commons; effective policy should support multiple livelihoods, strengthen common property management, and use diverse ecological and economic models for different contexts
[ ]	Zimbabwe	Changes in rangeland use and productivity, cropland conversion affecting feed resources	Local knowledge of rangeland resources, role of new institutions for cropland use, changes in common property management	Participatory rural appraisals, household surveys	User communities categorize rangelands by feed resources and changes over time, view rangelands as diverse and dynamic; croplands have become dual-purpose for food security and livestock feed; new institutions govern cropland use while those for common rangelands have weakened, presenting ecological challenges but also opportunities for innovative feed resource management
[ ]	Namibia	Overgrazing and climate change	Lack of grazing lands and feed followed by water scarcity and recurring droughts	Household surveys, focus group discussions	Respondents in all villages indicated that lack of grazing lands and feed followed by water scarcity and recurring droughts were the primary and secondary constraints of livestock production. Older respondents regarded overgrazing and climate change as the primary cause of rangeland degradation. Hence, the study concludes that communal rangelands are degraded and that degradation has resulted in gradual livestock population declining trends over the past years in communal areas due to feed shortages.
[ ]	Kenya	Soil nutrient decline, land degradation, low nutrient levels (decline of 1.7 kg P and 5.4 kg K ha half year ), low phosphorus and potassium stocks	Rising population, poverty (all households below the poverty line of 1 USD/day), low farm economic returns, low livestock productivity, and low yields of staple food crops	Soil nutrient monitoring, household surveys	Soil nutrient decline rates are low compared with macro-scale data, but low farm productivity and economic returns threaten sustainability; intercropping systems (maize–beans) improve the nutrient balance and household incomes; the study highlights the need to encourage intercropping and to consider localized sustainability strategies

3.2. Impact of Land Degradation on Livestock Health, Productivity, and Mortality

References	Study Areas	Health Impacts	Productivity Impacts	Mortality Rates	Methodology	Key Findings
[ ]	South Africa	Increased disease incidence	Reduced milk and meat yield	Higher calf mortality	Field experiments, veterinary records	Increased land degradation correlates with higher disease incidence and reduced productivity, leading to higher mortality.
[ ]	Namibia	Poor nutritional status	Decreased weight gain	Increased adult livestock deaths	Longitudinal study, surveys	Poor forage quality from degraded lands leads to poor nutrition, weight loss, and increased mortality.
[ ]	Botswana	Higher parasite loads	Lower reproductive rates	Elevated young livestock mortality	Cross-sectional study, lab analysis	Land degradation results in higher parasite burdens and lower reproductive success, increasing young livestock deaths.
[ ]	Kenya	Increased respiratory and digestive issues	Decline in wool and milk production	Higher lamb mortality	Observational study, interviews	Dust and poor vegetation from degraded lands contribute to respiratory and digestive problems, reducing wool and milk production, and increasing lamb mortality.
[ ]	Ethiopia	Malnutrition and weakened immunity	Lower overall herd productivity	Spike in drought-related deaths	Survey, field observation	Degradation-related malnutrition weakens immunity, reducing herd productivity and increasing mortality during drought periods.
[ ]	Tanzania	Reduced fertility rates	Lowered birth rates	Increased perinatal mortality	Case study, veterinary reports	Nutrient-deficient forage due to land degradation leads to reduced fertility and higher perinatal mortality, directly impacting herd sustainability.
[ ]	Zambia	Stress-related health conditions	Decreased milk yield	Higher incidence of miscarriages	Mixed-methods approach	Environmental stress from land degradation contributes to stress-related conditions, reducing milk yield and increasing miscarriage rates among pregnant livestock.
[ ]	Malawi	Increased susceptibility to zoonotic diseases	Decline in meat quality	Rising deaths during dry season	Field surveys, health monitoring	Land degradation exacerbates exposure to zoonotic diseases, affecting meat quality and increasing death rates during dry seasons due to limited resources.
[ ]	Zimbabwe	Compromised immune response	Lower weaning weights	Increased mortality during disease outbreaks	Longitudinal health monitoring	Land degradation results in compromised immune responses, leading to lower weaning weights and increased mortality during disease outbreaks, particularly in young livestock.

3.3. Socio-Economic Consequences of Reduced Livestock Productivity

References	Study Areas	Impact on Livelihoods	Impact on Food Security	Methodology	Key Findings
[ ]	Kenya	Reduced income from livestock sales	Increased food insecurity	Household surveys, economic analysis	Lower livestock productivity directly reduces household income and food security.
[ ]	Zimbabwe	Increased poverty	Reliance on food aid	Mixed methods, focus groups	Decreased livestock productivity exacerbates poverty, leading to a higher dependence on food aid.
[ ]	Ethiopia	Migration to urban areas	Nutritional deficiencies	Longitudinal survey, interviews	Reduced livestock yields lead to rural–urban migration and higher rates of nutritional deficiencies.
[ ]	South Africa	Loss of traditional livelihoods	Decline in dietary diversity	Case studies, participatory rural appraisal	Land degradation and reduced livestock productivity force communities to abandon traditional pastoral livelihoods, leading to a decline in dietary diversity and food security.
[ ]	Tanzania	Increased vulnerability to economic shocks	Lower access to animal-source foods	Cross-sectional survey, economic modeling	Declining livestock productivity heightens household vulnerability to economic shocks, reducing access to nutritious animal-source foods and worsening food insecurity.
[ ]	Zambia	Diversification into non-agricultural work	Reduced protein intake	Household surveys, livelihood assessments	As livestock productivity decreases, households diversify into non-agricultural work, leading to reduced protein intake due to the lower availability of animal products.

3.4. Effectiveness of Mitigation and Adaptation Strategies

References	Study Areas	Intervention	Effectiveness	Methodology	Key Findings
[ ]	Zambia	Rotational grazing	High	Controlled experiment, field observations	Rotational grazing significantly improves rangeland health and livestock productivity.
[ ]	Tanzania	Agroforestry	Moderate	Case studies, participatory research	Agroforestry practices help reduce soil erosion and improve forage quality with moderate success.
[ ]	Kenya	Soil conservation techniques	High	Field trials, farmer surveys	Soil conservation techniques, including terracing and mulching, show high effectiveness in reducing degradation and improving livestock yields.
[ ]	Malawi	Integrated livestock–crop systems	Moderate	Mixed methods, longitudinal study	Integrated livestock–crop systems enhance soil fertility and provide supplementary feed, but require careful management to be sustainable.
[ ]	Zimbabwe	Controlled burning	Low to moderate	Experimental plots, historical data	Controlled burning helps manage bush encroachment and improve grazing conditions, but its effectiveness varies based on the fire frequency and intensity.
[ ]	Botswana	Water harvesting techniques	High	Case studies, community workshops	Water harvesting techniques, such as small dams and ponds, significantly improve water availability for livestock during dry seasons, boosting productivity.
[ ]	Ethiopia	Community-based rangeland management	High	Participatory rural appraisal, interviews	Community-based rangeland management fosters collective action in rangeland restoration, leading to improved forage availability and livestock health.
[ ]	Uganda	Livestock restocking programs	Moderate	Household surveys, program evaluation	Livestock restocking programs help rebuild herds after droughts or disease outbreaks, with moderate success depending on follow-up support and training.
[ ]	Kenya	Drought-resistant forage species	High	Field trials, laboratory analysis	Introduction of drought-resistant forage species enhances rangeland resilience, ensuring consistent livestock feed during drought periods, leading to sustained productivity.
[ ]	Tanzania	Pasture improvement programs	Moderate to high	Experimental designs, participatory approaches	Pasture improvement programs, including reseeding and fertilization, show moderate to high effectiveness in increasing biomass and supporting livestock growth.
[ ]	Eswatini	Livestock health monitoring	High	Veterinary surveys, health records	Regular livestock health monitoring and vaccination programs significantly reduce disease incidence and improve overall herd productivity and survival rates.

3.5. Key Themes and Insights from the Word Cloud on Land Degradation, Rangelands, and Livestock in Sub-Saharan Africa

3.6. insights from the co-occurrence network diagram on land degradation, rangelands, and livestock in sub-saharan africa, 4. recommendations for policy makers in charge of these problems and future research directions, 5. potential limitations, 6. conclusions, author contributions, data availability statement, acknowledgments, conflicts of interest.

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Slayi, M.; Zhou, L.; Dzvene, A.R.; Mpanyaro, Z. Drivers and Consequences of Land Degradation on Livestock Productivity in Sub-Saharan Africa: A Systematic Literature Review. Land 2024 , 13 , 1402. https://doi.org/10.3390/land13091402

Slayi M, Zhou L, Dzvene AR, Mpanyaro Z. Drivers and Consequences of Land Degradation on Livestock Productivity in Sub-Saharan Africa: A Systematic Literature Review. Land . 2024; 13(9):1402. https://doi.org/10.3390/land13091402

Slayi, Mhlangabezi, Leocadia Zhou, Admire Rukudzo Dzvene, and Zolisanani Mpanyaro. 2024. "Drivers and Consequences of Land Degradation on Livestock Productivity in Sub-Saharan Africa: A Systematic Literature Review" Land 13, no. 9: 1402. https://doi.org/10.3390/land13091402

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