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Background of The Study – Examples and Writing Guide

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Background of The Study

Definition:

Background of the study refers to the context, circumstances, and history that led to the research problem or topic being studied. It provides the reader with a comprehensive understanding of the subject matter and the significance of the study.

The background of the study usually includes a discussion of the relevant literature, the gap in knowledge or understanding, and the research questions or hypotheses to be addressed. It also highlights the importance of the research topic and its potential contributions to the field. A well-written background of the study sets the stage for the research and helps the reader to appreciate the need for the study and its potential significance.

How to Write Background of The Study

Here are some steps to help you write the background of the study:

Identify the Research Problem

Start by identifying the research problem you are trying to address. This problem should be significant and relevant to your field of study.

Provide Context

Once you have identified the research problem, provide some context. This could include the historical, social, or political context of the problem.

Review Literature

Conduct a thorough review of the existing literature on the topic. This will help you understand what has been studied and what gaps exist in the current research.

Identify Research Gap

Based on your literature review, identify the gap in knowledge or understanding that your research aims to address. This gap will be the focus of your research question or hypothesis.

State Objectives

Clearly state the objectives of your research . These should be specific, measurable, achievable, relevant, and time-bound (SMART).

Discuss Significance

Explain the significance of your research. This could include its potential impact on theory , practice, policy, or society.

Finally, summarize the key points of the background of the study. This will help the reader understand the research problem, its context, and its significance.

How to Write Background of The Study in Proposal

The background of the study is an essential part of any proposal as it sets the stage for the research project and provides the context and justification for why the research is needed. Here are the steps to write a compelling background of the study in your proposal:

• Identify the problem: Clearly state the research problem or gap in the current knowledge that you intend to address through your research.
• Provide context: Provide a brief overview of the research area and highlight its significance in the field.
• Review literature: Summarize the relevant literature related to the research problem and provide a critical evaluation of the current state of knowledge.
• Identify gaps : Identify the gaps or limitations in the existing literature and explain how your research will contribute to filling these gaps.
• Justify the study : Explain why your research is important and what practical or theoretical contributions it can make to the field.
• Highlight objectives: Clearly state the objectives of the study and how they relate to the research problem.
• Discuss methodology: Provide an overview of the methodology you will use to collect and analyze data, and explain why it is appropriate for the research problem.
• Conclude : Summarize the key points of the background of the study and explain how they support your research proposal.

How to Write Background of The Study In Thesis

The background of the study is a critical component of a thesis as it provides context for the research problem, rationale for conducting the study, and the significance of the research. Here are some steps to help you write a strong background of the study:

• Identify the research problem : Start by identifying the research problem that your thesis is addressing. What is the issue that you are trying to solve or explore? Be specific and concise in your problem statement.
• Review the literature: Conduct a thorough review of the relevant literature on the topic. This should include scholarly articles, books, and other sources that are directly related to your research question.
• I dentify gaps in the literature: After reviewing the literature, identify any gaps in the existing research. What questions remain unanswered? What areas have not been explored? This will help you to establish the need for your research.
• Establish the significance of the research: Clearly state the significance of your research. Why is it important to address this research problem? What are the potential implications of your research? How will it contribute to the field?
• Provide an overview of the research design: Provide an overview of the research design and methodology that you will be using in your study. This should include a brief explanation of the research approach, data collection methods, and data analysis techniques.
• State the research objectives and research questions: Clearly state the research objectives and research questions that your study aims to answer. These should be specific, measurable, achievable, relevant, and time-bound.
• Summarize the chapter: Summarize the chapter by highlighting the key points and linking them back to the research problem, significance of the study, and research questions.

How to Write Background of The Study in Research Paper

Here are the steps to write the background of the study in a research paper:

• Identify the research problem: Start by identifying the research problem that your study aims to address. This can be a particular issue, a gap in the literature, or a need for further investigation.
• Conduct a literature review: Conduct a thorough literature review to gather information on the topic, identify existing studies, and understand the current state of research. This will help you identify the gap in the literature that your study aims to fill.
• Explain the significance of the study: Explain why your study is important and why it is necessary. This can include the potential impact on the field, the importance to society, or the need to address a particular issue.
• Provide context: Provide context for the research problem by discussing the broader social, economic, or political context that the study is situated in. This can help the reader understand the relevance of the study and its potential implications.
• State the research questions and objectives: State the research questions and objectives that your study aims to address. This will help the reader understand the scope of the study and its purpose.
• Summarize the methodology : Briefly summarize the methodology you used to conduct the study, including the data collection and analysis methods. This can help the reader understand how the study was conducted and its reliability.

Examples of Background of The Study

Here are some examples of the background of the study:

Problem : The prevalence of obesity among children in the United States has reached alarming levels, with nearly one in five children classified as obese.

Significance : Obesity in childhood is associated with numerous negative health outcomes, including increased risk of type 2 diabetes, cardiovascular disease, and certain cancers.

Gap in knowledge : Despite efforts to address the obesity epidemic, rates continue to rise. There is a need for effective interventions that target the unique needs of children and their families.

Problem : The use of antibiotics in agriculture has contributed to the development of antibiotic-resistant bacteria, which poses a significant threat to human health.

Significance : Antibiotic-resistant infections are responsible for thousands of deaths each year and are a major public health concern.

Gap in knowledge: While there is a growing body of research on the use of antibiotics in agriculture, there is still much to be learned about the mechanisms of resistance and the most effective strategies for reducing antibiotic use.

Edxample 3:

Problem : Many low-income communities lack access to healthy food options, leading to high rates of food insecurity and diet-related diseases.

Significance : Poor nutrition is a major contributor to chronic diseases such as obesity, type 2 diabetes, and cardiovascular disease.

Gap in knowledge : While there have been efforts to address food insecurity, there is a need for more research on the barriers to accessing healthy food in low-income communities and effective strategies for increasing access.

Examples of Background of The Study In Research

Here are some real-life examples of how the background of the study can be written in different fields of study:

Example 1 : “There has been a significant increase in the incidence of diabetes in recent years. This has led to an increased demand for effective diabetes management strategies. The purpose of this study is to evaluate the effectiveness of a new diabetes management program in improving patient outcomes.”

Example 2 : “The use of social media has become increasingly prevalent in modern society. Despite its popularity, little is known about the effects of social media use on mental health. This study aims to investigate the relationship between social media use and mental health in young adults.”

Example 3: “Despite significant advancements in cancer treatment, the survival rate for patients with pancreatic cancer remains low. The purpose of this study is to identify potential biomarkers that can be used to improve early detection and treatment of pancreatic cancer.”

Examples of Background of The Study in Proposal

Here are some real-time examples of the background of the study in a proposal:

Example 1 : The prevalence of mental health issues among university students has been increasing over the past decade. This study aims to investigate the causes and impacts of mental health issues on academic performance and wellbeing.

Example 2 : Climate change is a global issue that has significant implications for agriculture in developing countries. This study aims to examine the adaptive capacity of smallholder farmers to climate change and identify effective strategies to enhance their resilience.

Example 3 : The use of social media in political campaigns has become increasingly common in recent years. This study aims to analyze the effectiveness of social media campaigns in mobilizing young voters and influencing their voting behavior.

Example 4 : Employee turnover is a major challenge for organizations, especially in the service sector. This study aims to identify the key factors that influence employee turnover in the hospitality industry and explore effective strategies for reducing turnover rates.

Examples of Background of The Study in Thesis

Here are some real-time examples of the background of the study in the thesis:

Example 1 : “Women’s participation in the workforce has increased significantly over the past few decades. However, women continue to be underrepresented in leadership positions, particularly in male-dominated industries such as technology. This study aims to examine the factors that contribute to the underrepresentation of women in leadership roles in the technology industry, with a focus on organizational culture and gender bias.”

Example 2 : “Mental health is a critical component of overall health and well-being. Despite increased awareness of the importance of mental health, there are still significant gaps in access to mental health services, particularly in low-income and rural communities. This study aims to evaluate the effectiveness of a community-based mental health intervention in improving mental health outcomes in underserved populations.”

Example 3: “The use of technology in education has become increasingly widespread, with many schools adopting online learning platforms and digital resources. However, there is limited research on the impact of technology on student learning outcomes and engagement. This study aims to explore the relationship between technology use and academic achievement among middle school students, as well as the factors that mediate this relationship.”

Examples of Background of The Study in Research Paper

Here are some examples of how the background of the study can be written in various fields:

Example 1: The prevalence of obesity has been on the rise globally, with the World Health Organization reporting that approximately 650 million adults were obese in 2016. Obesity is a major risk factor for several chronic diseases such as diabetes, cardiovascular diseases, and cancer. In recent years, several interventions have been proposed to address this issue, including lifestyle changes, pharmacotherapy, and bariatric surgery. However, there is a lack of consensus on the most effective intervention for obesity management. This study aims to investigate the efficacy of different interventions for obesity management and identify the most effective one.

Example 2: Antibiotic resistance has become a major public health threat worldwide. Infections caused by antibiotic-resistant bacteria are associated with longer hospital stays, higher healthcare costs, and increased mortality. The inappropriate use of antibiotics is one of the main factors contributing to the development of antibiotic resistance. Despite numerous efforts to promote the rational use of antibiotics, studies have shown that many healthcare providers continue to prescribe antibiotics inappropriately. This study aims to explore the factors influencing healthcare providers’ prescribing behavior and identify strategies to improve antibiotic prescribing practices.

Example 3: Social media has become an integral part of modern communication, with millions of people worldwide using platforms such as Facebook, Twitter, and Instagram. Social media has several advantages, including facilitating communication, connecting people, and disseminating information. However, social media use has also been associated with several negative outcomes, including cyberbullying, addiction, and mental health problems. This study aims to investigate the impact of social media use on mental health and identify the factors that mediate this relationship.

Purpose of Background of The Study

The primary purpose of the background of the study is to help the reader understand the rationale for the research by presenting the historical, theoretical, and empirical background of the problem.

More specifically, the background of the study aims to:

• Provide a clear understanding of the research problem and its context.
• Identify the gap in knowledge that the study intends to fill.
• Establish the significance of the research problem and its potential contribution to the field.
• Highlight the key concepts, theories, and research findings related to the problem.
• Provide a rationale for the research questions or hypotheses and the research design.
• Identify the limitations and scope of the study.

When to Write Background of The Study

The background of the study should be written early on in the research process, ideally before the research design is finalized and data collection begins. This allows the researcher to clearly articulate the rationale for the study and establish a strong foundation for the research.

The background of the study typically comes after the introduction but before the literature review section. It should provide an overview of the research problem and its context, and also introduce the key concepts, theories, and research findings related to the problem.

Writing the background of the study early on in the research process also helps to identify potential gaps in knowledge and areas for further investigation, which can guide the development of the research questions or hypotheses and the research design. By establishing the significance of the research problem and its potential contribution to the field, the background of the study can also help to justify the research and secure funding or support from stakeholders.

Advantage of Background of The Study

The background of the study has several advantages, including:

• Provides context: The background of the study provides context for the research problem by highlighting the historical, theoretical, and empirical background of the problem. This allows the reader to understand the research problem in its broader context and appreciate its significance.
• Identifies gaps in knowledge: By reviewing the existing literature related to the research problem, the background of the study can identify gaps in knowledge that the study intends to fill. This helps to establish the novelty and originality of the research and its potential contribution to the field.
• Justifies the research : The background of the study helps to justify the research by demonstrating its significance and potential impact. This can be useful in securing funding or support for the research.
• Guides the research design: The background of the study can guide the development of the research questions or hypotheses and the research design by identifying key concepts, theories, and research findings related to the problem. This ensures that the research is grounded in existing knowledge and is designed to address the research problem effectively.
• Establishes credibility: By demonstrating the researcher’s knowledge of the field and the research problem, the background of the study can establish the researcher’s credibility and expertise, which can enhance the trustworthiness and validity of the research.

Disadvantages of Background of The Study

Some Disadvantages of Background of The Study are as follows:

• Time-consuming : Writing a comprehensive background of the study can be time-consuming, especially if the research problem is complex and multifaceted. This can delay the research process and impact the timeline for completing the study.
• Repetitive: The background of the study can sometimes be repetitive, as it often involves summarizing existing research and theories related to the research problem. This can be tedious for the reader and may make the section less engaging.
• Limitations of existing research: The background of the study can reveal the limitations of existing research related to the problem. This can create challenges for the researcher in developing research questions or hypotheses that address the gaps in knowledge identified in the background of the study.
• Bias : The researcher’s biases and perspectives can influence the content and tone of the background of the study. This can impact the reader’s perception of the research problem and may influence the validity of the research.
• Accessibility: Accessing and reviewing the literature related to the research problem can be challenging, especially if the researcher does not have access to a comprehensive database or if the literature is not available in the researcher’s language. This can limit the depth and scope of the background of the study.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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How to Write an Effective Background of the Study: A Comprehensive Guide

Table of Contents

The background of the study in a research paper offers a clear context, highlighting why the research is essential and the problem it aims to address.

As a researcher, this foundational section is essential for you to chart the course of your study, Moreover, it allows readers to understand the importance and path of your research.

Whether in academic communities or to the general public, a well-articulated background aids in communicating the essence of the research effectively.

While it may seem straightforward, crafting an effective background requires a blend of clarity, precision, and relevance. Therefore, this article aims to be your guide, offering insights into:

• Understanding the concept of the background of the study.
• Learning how to craft a compelling background effectively.
• Identifying and sidestepping common pitfalls in writing the background.
• Exploring practical examples that bring the theory to life.
• Enhancing both your writing and reading of academic papers.

Keeping these compelling insights in mind, let's delve deeper into the details of the empirical background of the study, exploring its definition, distinctions, and the art of writing it effectively.

What is the background of the study?

The background of the study is placed at the beginning of a research paper. It provides the context, circumstances, and history that led to the research problem or topic being explored.

It offers readers a snapshot of the existing knowledge on the topic and the reasons that spurred your current research.

When crafting the background of your study, consider the following questions.

• What's the context of your research?
• Which previous research will you refer to?
• Are there any knowledge gaps in the existing relevant literature?
• How will you justify the need for your current research?
• Have you concisely presented the research question or problem?

In a typical research paper structure, after presenting the background, the introduction section follows. The introduction delves deeper into the specific objectives of the research and often outlines the structure or main points that the paper will cover.

Together, they create a cohesive starting point, ensuring readers are well-equipped to understand the subsequent sections of the research paper.

While the background of the study and the introduction section of the research manuscript may seem similar and sometimes even overlap, each serves a unique purpose in the research narrative.

Difference between background and introduction

A well-written background of the study and introduction are preliminary sections of a research paper and serve distinct purposes.

Here’s a detailed tabular comparison between the two of them.

What is the relevance of the background of the study?

It is necessary for you to provide your readers with the background of your research. Without this, readers may grapple with questions such as: Why was this specific research topic chosen? What led to this decision? Why is this study relevant? Is it worth their time?

Such uncertainties can deter them from fully engaging with your study, leading to the rejection of your research paper. Additionally, this can diminish its impact in the academic community, and reduce its potential for real-world application or policy influence .

To address these concerns and offer clarity, the background section plays a pivotal role in research papers.

The background of the study in research is important as it:

• Provides context: It offers readers a clear picture of the existing knowledge, helping them understand where the current research fits in.
• Highlights relevance: By detailing the reasons for the research, it underscores the study's significance and its potential impact.
• Guides the narrative: The background shapes the narrative flow of the paper, ensuring a logical progression from what's known to what the research aims to uncover.
• Enhances engagement: A well-crafted background piques the reader's interest, encouraging them to delve deeper into the research paper.
• Aids in comprehension: By setting the scenario, it aids readers in better grasping the research objectives, methodologies, and findings.

How to write the background of the study in a research paper?

The journey of presenting a compelling argument begins with the background study. This section holds the power to either captivate or lose the reader's interest.

An effectively written background not only provides context but also sets the tone for the entire research paper. It's the bridge that connects a broad topic to a specific research question, guiding readers through the logic behind the study.

But how does one craft a background of the study that resonates, informs, and engages?

Here, we’ll discuss how to write an impactful background study, ensuring your research stands out and captures the attention it deserves.

Identify the research problem

The first step is to start pinpointing the specific issue or gap you're addressing. This should be a significant and relevant problem in your field.

A well-defined problem is specific, relevant, and significant to your field. It should resonate with both experts and readers.

Here’s more on how to write an effective research problem .

Provide context

Here, you need to provide a broader perspective, illustrating how your research aligns with or contributes to the overarching context or the wider field of study. A comprehensive context is grounded in facts, offers multiple perspectives, and is relatable.

In addition to stating facts, you should weave a story that connects key concepts from the past, present, and potential future research. For instance, consider the following approach.

• Offer a brief history of the topic, highlighting major milestones or turning points that have shaped the current landscape.
• Discuss contemporary developments or current trends that provide relevant information to your research problem. This could include technological advancements, policy changes, or shifts in societal attitudes.
• Highlight the views of different stakeholders. For a topic like sustainable agriculture, this could mean discussing the perspectives of farmers, environmentalists, policymakers, and consumers.
• If relevant, compare and contrast global trends with local conditions and circumstances. This can offer readers a more holistic understanding of the topic.

Literature review

For this step, you’ll deep dive into the existing literature on the same topic. It's where you explore what scholars, researchers, and experts have already discovered or discussed about your topic.

Conducting a thorough literature review isn't just a recap of past works. To elevate its efficacy, it's essential to analyze the methods, outcomes, and intricacies of prior research work, demonstrating a thorough engagement with the existing body of knowledge.

• Instead of merely listing past research study, delve into their methodologies, findings, and limitations. Highlight groundbreaking studies and those that had contrasting results.
• Try to identify patterns. Look for recurring themes or trends in the literature. Are there common conclusions or contentious points?
• The next step would be to connect the dots. Show how different pieces of research relate to each other. This can help in understanding the evolution of thought on the topic.

By showcasing what's already known, you can better highlight the background of the study in research.

Highlight the research gap

This step involves identifying the unexplored areas or unanswered questions in the existing literature. Your research seeks to address these gaps, providing new insights or answers.

A clear research gap shows you've thoroughly engaged with existing literature and found an area that needs further exploration.

How can you efficiently highlight the research gap?

• Find the overlooked areas. Point out topics or angles that haven't been adequately addressed.
• Highlight questions that have emerged due to recent developments or changing circumstances.
• Identify areas where insights from other fields might be beneficial but haven't been explored yet.

State your objectives

Here, it’s all about laying out your game plan — What do you hope to achieve with your research? You need to mention a clear objective that’s specific, actionable, and directly tied to the research gap.

How to state your objectives?

• List the primary questions guiding your research.
• If applicable, state any hypotheses or predictions you aim to test.
• Specify what you hope to achieve, whether it's new insights, solutions, or methodologies.

Discuss the significance

This step describes your 'why'. Why is your research important? What broader implications does it have?

The significance of “why” should be both theoretical (adding to the existing literature) and practical (having real-world implications).

How do we effectively discuss the significance?

• Discuss how your research adds to the existing body of knowledge.
• Highlight how your findings could be applied in real-world scenarios, from policy changes to on-ground practices.
• Point out how your research could pave the way for further studies or open up new areas of exploration.

Summarize your points

A concise summary acts as a bridge, smoothly transitioning readers from the background to the main body of the paper. This step is a brief recap, ensuring that readers have grasped the foundational concepts.

How to summarize your study?

• Revisit the key points discussed, from the research problem to its significance.
• Prepare the reader for the subsequent sections, ensuring they understand the research's direction.

Include examples for better understanding

Research and come up with real-world or hypothetical examples to clarify complex concepts or to illustrate the practical applications of your research. Relevant examples make abstract ideas tangible, aiding comprehension.

How to include an effective example of the background of the study?

• Use past events or scenarios to explain concepts.
• Craft potential scenarios to demonstrate the implications of your findings.
• Use comparisons to simplify complex ideas, making them more relatable.

Crafting a compelling background of the study in research is about striking the right balance between providing essential context, showcasing your comprehensive understanding of the existing literature, and highlighting the unique value of your research .

While writing the background of the study, keep your readers at the forefront of your mind. Every piece of information, every example, and every objective should be geared toward helping them understand and appreciate your research.

How to avoid mistakes in the background of the study in research?

To write a well-crafted background of the study, you should be aware of the following potential research pitfalls .

• Stay away from ambiguity. Always assume that your reader might not be familiar with intricate details about your topic.
• Avoid discussing unrelated themes. Stick to what's directly relevant to your research problem.
• Ensure your background is well-organized. Information should flow logically, making it easy for readers to follow.
• While it's vital to provide context, avoid overwhelming the reader with excessive details that might not be directly relevant to your research problem.
• Ensure you've covered the most significant and relevant studies i` n your field. Overlooking key pieces of literature can make your background seem incomplete.
• Aim for a balanced presentation of facts, and avoid showing overt bias or presenting only one side of an argument.
• While academic paper often involves specialized terms, ensure they're adequately explained or use simpler alternatives when possible.
• Every claim or piece of information taken from existing literature should be appropriately cited. Failing to do so can lead to issues of plagiarism.
• Avoid making the background too lengthy. While thoroughness is appreciated, it should not come at the expense of losing the reader's interest. Maybe prefer to keep it to one-two paragraphs long.
• Especially in rapidly evolving fields, it's crucial to ensure that your literature review section is up-to-date and includes the latest research.

Example of an effective background of the study

Let's consider a topic: "The Impact of Online Learning on Student Performance." The ideal background of the study section for this topic would be as follows.

In the last decade, the rise of the internet has revolutionized many sectors, including education. Online learning platforms, once a supplementary educational tool, have now become a primary mode of instruction for many institutions worldwide. With the recent global events, such as the COVID-19 pandemic, there has been a rapid shift from traditional classroom learning to online modes, making it imperative to understand its effects on student performance.

Previous studies have explored various facets of online learning, from its accessibility to its flexibility. However, there is a growing need to assess its direct impact on student outcomes. While some educators advocate for its benefits, citing the convenience and vast resources available, others express concerns about potential drawbacks, such as reduced student engagement and the challenges of self-discipline.

This research aims to delve deeper into this debate, evaluating the true impact of online learning on student performance.

Why is this example considered as an effective background section of a research paper?

This background section example effectively sets the context by highlighting the rise of online learning and its increased relevance due to recent global events. It references prior research on the topic, indicating a foundation built on existing knowledge.

By presenting both the potential advantages and concerns of online learning, it establishes a balanced view, leading to the clear purpose of the study: to evaluate the true impact of online learning on student performance.

As we've explored, writing an effective background of the study in research requires clarity, precision, and a keen understanding of both the broader landscape and the specific details of your topic.

From identifying the research problem, providing context, reviewing existing literature to highlighting research gaps and stating objectives, each step is pivotal in shaping the narrative of your research. And while there are best practices to follow, it's equally crucial to be aware of the pitfalls to avoid.

Remember, writing or refining the background of your study is essential to engage your readers, familiarize them with the research context, and set the ground for the insights your research project will unveil.

Drawing from all the important details, insights and guidance shared, you're now in a strong position to craft a background of the study that not only informs but also engages and resonates with your readers.

Now that you've a clear understanding of what the background of the study aims to achieve, the natural progression is to delve into the next crucial component — write an effective introduction section of a research paper. Read here .

Frequently Asked Questions

The background of the study should include a clear context for the research, references to relevant previous studies, identification of knowledge gaps, justification for the current research, a concise overview of the research problem or question, and an indication of the study's significance or potential impact.

The background of the study is written to provide readers with a clear understanding of the context, significance, and rationale behind the research. It offers a snapshot of existing knowledge on the topic, highlights the relevance of the study, and sets the stage for the research questions and objectives. It ensures that readers can grasp the importance of the research and its place within the broader field of study.

The background of the study is a section in a research paper that provides context, circumstances, and history leading to the research problem or topic being explored. It presents existing knowledge on the topic and outlines the reasons that spurred the current research, helping readers understand the research's foundation and its significance in the broader academic landscape.

The number of paragraphs in the background of the study can vary based on the complexity of the topic and the depth of the context required. Typically, it might range from 3 to 5 paragraphs, but in more detailed or complex research papers, it could be longer. The key is to ensure that all relevant information is presented clearly and concisely, without unnecessary repetition.

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What is the Background of a Study and How Should it be Written?

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Table of Contents

The background of a study is one of the most important components of a research paper. The quality of the background determines whether the reader will be interested in the rest of the study. Thus, to ensure that the audience is invested in reading the entire research paper, it is important to write an appealing and effective background. So, what constitutes the background of a study, and how must it be written?

What is the background of a study?

The background of a study is the first section of the paper and establishes the context underlying the research. It contains the rationale, the key problem statement, and a brief overview of research questions that are addressed in the rest of the paper. The background forms the crux of the study because it introduces an unaware audience to the research and its importance in a clear and logical manner. At times, the background may even explore whether the study builds on or refutes findings from previous studies. Any relevant information that the readers need to know before delving into the paper should be made available to them in the background.

How is a background different from the introduction?

The introduction of your research paper is presented before the background. Let’s find out what factors differentiate the background from the introduction.

• The introduction only contains preliminary data about the research topic and does not state the purpose of the study. On the contrary, the background clarifies the importance of the study in detail.
• The introduction provides an overview of the research topic from a broader perspective, while the background provides a detailed understanding of the topic.
• The introduction should end with the mention of the research questions, aims, and objectives of the study. In contrast, the background follows no such format and only provides essential context to the study.

How should one write the background of a research paper?

The length and detail presented in the background varies for different research papers, depending on the complexity and novelty of the research topic. At times, a simple background suffices, even if the study is complex. Before writing and adding details in the background, take a note of these additional points:

• Start with a strong beginning: Begin the background by defining the research topic and then identify the target audience.
• Cover key components: Explain all theories, concepts, terms, and ideas that may feel unfamiliar to the target audience thoroughly.
• Take note of important prerequisites: Go through the relevant literature in detail. Take notes while reading and cite the sources.
• Maintain a balance: Make sure that the background is focused on important details, but also appeals to a broader audience.
• Include historical data: Current issues largely originate from historical events or findings. If the research borrows information from a historical context, add relevant data in the background.
• Explain novelty: If the research study or methodology is unique or novel, provide an explanation that helps to understand the research better.
• Increase engagement: To make the background engaging, build a story around the central theme of the research

Avoid these mistakes while writing the background:

• Ambiguity: Don’t be ambiguous. While writing, assume that the reader does not understand any intricate detail about your research.
• Unrelated themes: Steer clear from topics that are not related to the key aspects of your research topic.
• Poor organization: Do not place information without a structure. Make sure that the background reads in a chronological manner and organize the sub-sections so that it flows well.

Writing the background for a research paper should not be a daunting task. But directions to go about it can always help. At Elsevier Author Services we provide essential insights on how to write a high quality, appealing, and logically structured paper for publication, beginning with a robust background. For further queries, contact our experts now!

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What Is Background in a Research Paper?

So you have carefully written your research paper  and probably ran it through your colleagues ten to fifteen times. While there are many elements to a good research article, one of the most important elements for your readers is the background of your study.

What is Background of the Study in Research

The background of your study will provide context to the information discussed throughout the research paper . Background information may include both important and relevant studies. This is particularly important if a study either supports or refutes your thesis.

Why is Background of the Study Necessary in Research?

The background of the study discusses your problem statement, rationale, and research questions. It links  introduction to your research topic  and ensures a logical flow of ideas.  Thus, it helps readers understand your reasons for conducting the study.

Providing Background Information

The reader should be able to understand your topic and its importance. The length and detail of your background also depend on the degree to which you need to demonstrate your understanding of the topic. Paying close attention to the following questions will help you in writing background information:

• Are there any theories, concepts, terms, and ideas that may be unfamiliar to the target audience and will require you to provide any additional explanation?
• Any historical data that need to be shared in order to provide context on why the current issue emerged?
• Are there any concepts that may have been borrowed from other disciplines that may be unfamiliar to the reader and need an explanation?

Related: Ready with the background and searching for more information on journal ranking? Check this infographic on the SCImago Journal Rank today!

Is the research study unique for which additional explanation is needed? For instance, you may have used a completely new method

How to Write a Background of the Study

The structure of a background study in a research paper generally follows a logical sequence to provide context, justification, and an understanding of the research problem. It includes an introduction, general background, literature review , rationale , objectives, scope and limitations , significance of the study and the research hypothesis . Following the structure can provide a comprehensive and well-organized background for your research.

Here are the steps to effectively write a background of the study.

1. Identify Your Audience:

Determine the level of expertise of your target audience. Tailor the depth and complexity of your background information accordingly.

2. Understand the Research Problem:

Define the research problem or question your study aims to address. Identify the significance of the problem within the broader context of the field.

3. Review Existing Literature:

Conduct a thorough literature review to understand what is already known in the area. Summarize key findings, theories, and concepts relevant to your research.

4. Include Historical Data:

Integrate historical data if relevant to the research, as current issues often trace back to historical events.

5. Identify Controversies and Gaps:

Note any controversies or debates within the existing literature. Identify gaps , limitations, or unanswered questions that your research can address.

6. Select Key Components:

Choose the most critical elements to include in the background based on their relevance to your research problem. Prioritize information that helps build a strong foundation for your study.

7. Craft a Logical Flow:

Organize the background information in a logical sequence. Start with general context, move to specific theories and concepts, and then focus on the specific problem.

8. Highlight the Novelty of Your Research:

Clearly explain the unique aspects or contributions of your study. Emphasize why your research is different from or builds upon existing work.

Here are some extra tips to increase the quality of your research background:

Example of a Research Background

Here is an example of a research background to help you understand better.

The above hypothetical example provides a research background, addresses the gap and highlights the potential outcome of the study; thereby aiding a better understanding of the proposed research.

What Makes the Introduction Different from the Background?

Your introduction is different from your background in a number of ways.

• The introduction contains preliminary data about your topic that  the reader will most likely read , whereas the background clarifies the importance of the paper.
• The background of your study discusses in depth about the topic, whereas the introduction only gives an overview.
• The introduction should end with your research questions, aims, and objectives, whereas your background should not (except in some cases where your background is integrated into your introduction). For instance, the C.A.R.S. ( Creating a Research Space ) model, created by John Swales is based on his analysis of journal articles. This model attempts to explain and describe the organizational pattern of writing the introduction in social sciences.

Points to Note

Your background should begin with defining a topic and audience. It is important that you identify which topic you need to review and what your audience already knows about the topic. You should proceed by searching and researching the relevant literature. In this case, it is advisable to keep track of the search terms you used and the articles that you downloaded. It is helpful to use one of the research paper management systems such as Papers, Mendeley, Evernote, or Sente. Next, it is helpful to take notes while reading. Be careful when copying quotes verbatim and make sure to put them in quotation marks and cite the sources. In addition, you should keep your background focused but balanced enough so that it is relevant to a broader audience. Aside from these, your background should be critical, consistent, and logically structured.

Writing the background of your study should not be an overly daunting task. Many guides that can help you organize your thoughts as you write the background. The background of the study is the key to introduce your audience to your research topic and should be done with strong knowledge and thoughtful writing.

The background of a research paper typically ranges from one to two paragraphs, summarizing the relevant literature and context of the study. It should be concise, providing enough information to contextualize the research problem and justify the need for the study. Journal instructions about any word count limits should be kept in mind while deciding on the length of the final content.

The background of a research paper provides the context and relevant literature to understand the research problem, while the introduction also introduces the specific research topic, states the research objectives, and outlines the scope of the study. The background focuses on the broader context, whereas the introduction focuses on the specific research project and its objectives.

When writing the background for a study, start by providing a brief overview of the research topic and its significance in the field. Then, highlight the gaps in existing knowledge or unresolved issues that the study aims to address. Finally, summarize the key findings from relevant literature to establish the context and rationale for conducting the research, emphasizing the need and importance of the study within the broader academic landscape.

The background in a research paper is crucial as it sets the stage for the study by providing essential context and rationale. It helps readers understand the significance of the research problem and its relevance in the broader field. By presenting relevant literature and highlighting gaps, the background justifies the need for the study, building a strong foundation for the research and enhancing its credibility.

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What is the Background of the Study and How to Write It

What is the Background of the Study in Research? 

The background of the study is the first section of a research paper and gives context surrounding the research topic. The background explains to the reader where your research journey started, why you got interested in the topic, and how you developed the research question that you will later specify. That means that you first establish the context of the research you did with a general overview of the field or topic and then present the key issues that drove your decision to study the specific problem you chose.

Once the reader understands where you are coming from and why there was indeed a need for the research you are going to present in the following—because there was a gap in the current research, or because there is an obvious problem with a currently used process or technology—you can proceed with the formulation of your research question and summarize how you are going to address it in the rest of your manuscript.

Why is the Background of the Study Important?

No matter how surprising and important the findings of your study are, if you do not provide the reader with the necessary background information and context, they will not be able to understand your reasons for studying the specific problem you chose and why you think your study is relevant. And more importantly, an editor who does not share your enthusiasm for your work (because you did not fill them in on all the important details) will very probably not even consider your manuscript worthy of their and the reviewers’ time and will immediately send it back to you.

To avoid such desk rejections , you need to make sure you pique the reader’s interest and help them understand the contribution of your work to the specific field you study, the more general research community, or the public. Introducing the study background is crucial to setting the scene for your readers.

Table of Contents:

• What is “Background Information” in a Research Paper?
• What Should the Background of a Research Paper Include?
• Where Does the Background Section Go in Your Paper?

Background of the Study Structure

Before writing your study background, it is essential to understand what to include. The following elements should all be included in the background and are presented in greater detail in the next section:

• A general overview of the topic and why it is important (overlaps with establishing the “importance of the topic” in the Introduction)
• The current state of the research on the topic or on related topics in the field
• Controversies about current knowledge or specific past studies that undergird your research methodology
• Any claims or assumptions that have been made by researchers, institutions, or politicians that might need to be clarified
• Methods and techniques used in the study or from which your study deviated in some way

Presenting the Study Background

As you begin introducing your background, you first need to provide a general overview and include the main issues concerning the topic. Depending on whether you do “basic” (with the aim of providing further knowledge) or “applied” research (to establish new techniques, processes, or products), this is either a literature review that summarizes all relevant earlier studies in the field or a description of the process (e.g., vote counting) or practice (e.g., diagnosis of a specific disease) that you think is problematic or lacking and needs a solution.

Example s of a general overview

If you study the function of a Drosophila gene, for example, you can explain to the reader why and for whom the study of fly genetics is relevant, what is already known and established, and where you see gaps in the existing literature. If you investigated how the way universities have transitioned into online teaching since the beginning of the Covid-19 pandemic has affected students’ learning progress, then you need to present a summary of what changes have happened around the world, what the effects of those changes have been so far, and where you see problems that need to be addressed. Note that you need to provide sources for every statement and every claim you make here, to establish a solid foundation of knowledge for your own study. 

Describing the current state of knowledge

When the reader understands the main issue(s), you need to fill them in more specifically on the current state of the field (in basic research) or the process/practice/product use you describe (in practical/applied research). Cite all relevant studies that have already reported on the Drosophila gene you are interested in, have failed to reveal certain functions of it, or have suggested that it might be involved in more processes than we know so far. Or list the reports from the education ministries of the countries you are interested in and highlight the data that shows the need for research into the effects of the Corona-19 pandemic on teaching and learning.

Discussing controversies, claims, and assumptions

Are there controversies regarding your topic of interest that need to be mentioned and/or addressed? For example, if your research topic involves an issue that is politically hot, you can acknowledge this here. Have any earlier claims or assumptions been made, by other researchers, institutions, or politicians, that you think need to be clarified?

Mentioning methodologies and approaches

While putting together these details, you also need to mention methodologies : What methods/techniques have been used so far to study what you studied and why are you going to either use the same or a different approach? Are any of the methods included in the literature review flawed in such a way that your study takes specific measures to correct or update? While you shouldn’t spend too much time here justifying your methods (this can be summarized briefly in the rationale of the study at the end of the Introduction and later in the Discussion section), you can engage with the crucial methods applied in previous studies here first.

When you have established the background of the study of your research paper in such a logical way, then the reader should have had no problem following you from the more general information you introduced first to the specific details you added later. You can now easily lead over to the relevance of your research, explain how your work fits into the bigger picture, and specify the aims and objectives of your study. This latter part is usually considered the “ statement of the problem ” of your study. Without a solid research paper background, this statement will come out of nowhere for the reader and very probably raise more questions than you were planning to answer.   

Where does the study background section go in a paper?

Unless you write a research proposal or some kind of report that has a specific “Background” chapter, the background of your study is the first part of your introduction section . This is where you put your work in context and provide all the relevant information the reader needs to follow your rationale. Make sure your background has a logical structure and naturally leads into the statement of the problem at the very end of the introduction so that you bring everything together for the reader to judge the relevance of your work and the validity of your approach before they dig deeper into the details of your study in the methods section .

Consider Receiving Professional Editing Services

Now that you know how to write a background section for a research paper, you might be interested in our AI text editor at Wordvice AI. And be sure to receive professional editing services , including academic editing and proofreading , before submitting your manuscript to journals. On the Wordvice academic resources website, you can also find many more articles and other resources that can help you with writing the other parts of your research paper , with making a research paper outline before you put everything together, or with writing an effective cover letter once you are ready to submit.

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Background information identifies and describes the history and nature of a well-defined research problem with reference to contextualizing existing literature. The background information should indicate the root of the problem being studied, appropriate context of the problem in relation to theory, research, and/or practice , its scope, and the extent to which previous studies have successfully investigated the problem, noting, in particular, where gaps exist that your study attempts to address. Background information does not replace the literature review section of a research paper; it is intended to place the research problem within a specific context and an established plan for its solution.

Fitterling, Lori. Researching and Writing an Effective Background Section of a Research Paper. Kansas City University of Medicine & Biosciences; Creating a Research Paper: How to Write the Background to a Study. DurousseauElectricalInstitute.com; Background Information: Definition of Background Information. Literary Devices Definition and Examples of Literary Terms.

Importance of Having Enough Background Information

Background information expands upon the key points stated in the beginning of your introduction but is not intended to be the main focus of the paper. It generally supports the question, what is the most important information the reader needs to understand before continuing to read the paper? Sufficient background information helps the reader determine if you have a basic understanding of the research problem being investigated and promotes confidence in the overall quality of your analysis and findings. This information provides the reader with the essential context needed to conceptualize the research problem and its significance before moving on to a more thorough analysis of prior research.

Forms of contextualization included in background information can include describing one or more of the following:

• Cultural -- placed within the learned behavior of a specific group or groups of people.
• Economic -- of or relating to systems of production and management of material wealth and/or business activities.
• Gender -- located within the behavioral, cultural, or psychological traits typically associated with being self-identified as male, female, or other form of  gender expression.
• Historical -- the time in which something takes place or was created and how the condition of time influences how you interpret it.
• Interdisciplinary -- explanation of theories, concepts, ideas, or methodologies borrowed from other disciplines applied to the research problem rooted in a discipline other than the discipline where your paper resides.
• Philosophical -- clarification of the essential nature of being or of phenomena as it relates to the research problem.
• Physical/Spatial -- reflects the meaning of space around something and how that influences how it is understood.
• Political -- concerns the environment in which something is produced indicating it's public purpose or agenda.
• Social -- the environment of people that surrounds something's creation or intended audience, reflecting how the people associated with something use and interpret it.
• Temporal -- reflects issues or events of, relating to, or limited by time. Concerns past, present, or future contextualization and not just a historical past.

Background information can also include summaries of important research studies . This can be a particularly important element of providing background information if an innovative or groundbreaking study about the research problem laid a foundation for further research or there was a key study that is essential to understanding your arguments. The priority is to summarize for the reader what is known about the research problem before you conduct the analysis of prior research. This is accomplished with a general summary of the foundational research literature [with citations] that document findings that inform your study's overall aims and objectives.

NOTE : Research studies cited as part of the background information of your introduction should not include very specific, lengthy explanations. This should be discussed in greater detail in your literature review section. If you find a study requiring lengthy explanation, consider moving it to the literature review section.

ANOTHER NOTE : In some cases, your paper's introduction only needs to introduce the research problem, explain its significance, and then describe a road map for how you are going to address the problem; the background information basically forms the introduction part of your literature review. That said, while providing background information is not required, including it in the introduction is a way to highlight important contextual information that could otherwise be hidden or overlooked by the reader if placed in the literature review section.

Background of the Problem Section: What do you Need to Consider? Anonymous. Harvard University; Hopkins, Will G. How to Write a Research Paper. SPORTSCIENCE, Perspectives/Research Resources. Department of Physiology and School of Physical Education, University of Otago, 1999; Green, L. H. How to Write the Background/Introduction Section. Physics 499 Powerpoint slides. University of Illinois; Pyrczak, Fred. Writing Empirical Research Reports: A Basic Guide for Students of the Social and Behavioral Sciences . 8th edition. Glendale, CA: Pyrczak Publishing, 2014; Stevens, Kathleen C. “Can We Improve Reading by Teaching Background Information?.” Journal of Reading 25 (January 1982): 326-329; Woodall, W. Gill. Writing the Background and Significance Section. Senior Research Scientist and Professor of Communication. Center on Alcoholism, Substance Abuse, and Addictions. University of New Mexico.

Structure and Writing Style

Providing background information in the introduction of a research paper serves as a bridge that links the reader to the research problem . Precisely how long and in-depth this bridge should be is largely dependent upon how much information you think the reader will need to know in order to fully understand the problem being discussed and to appreciate why the issues you are investigating are important.

From another perspective, the length and detail of background information also depends on the degree to which you need to demonstrate to your professor how much you understand the research problem. Keep this in mind because providing pertinent background information can be an effective way to demonstrate that you have a clear grasp of key issues, debates, and concepts related to your overall study.

The structure and writing style of your background information can vary depending upon the complexity of your research and/or the nature of the assignment. However, in most cases it should be limited to only one to two paragraphs in your introduction.

Given this, here are some questions to consider while writing this part of your introduction :

• Are there concepts, terms, theories, or ideas that may be unfamiliar to the reader and, thus, require additional explanation?
• Are there historical elements that need to be explored in order to provide needed context, to highlight specific people, issues, or events, or to lay a foundation for understanding the emergence of a current issue or event?
• Are there theories, concepts, or ideas borrowed from other disciplines or academic traditions that may be unfamiliar to the reader and therefore require further explanation?
• Is there a key study or small set of studies that set the stage for understanding the topic and frames why it is important to conduct further research on the topic?
• Y our study uses a method of analysis never applied before;
• Your study investigates a very esoteric or complex research problem;
• Your study introduces new or unique variables that need to be taken into account ; or,
• Your study relies upon analyzing unique texts or documents, such as, archival materials or primary documents like diaries or personal letters that do not represent the established body of source literature on the topic?

Almost all introductions to a research problem require some contextualizing, but the scope and breadth of background information varies depending on your assumption about the reader's level of prior knowledge . However, despite this assessment, background information should be brief and succinct and sets the stage for the elaboration of critical points or in-depth discussion of key issues in the literature review section of your paper.

Writing Tip

Background Information vs. the Literature Review

Incorporating background information into the introduction is intended to provide the reader with critical information about the topic being studied, such as, highlighting and expanding upon foundational studies conducted in the past, describing important historical events that inform why and in what ways the research problem exists, defining key components of your study [concepts, people, places, phenomena] and/or placing the research problem within a particular context. Although introductory background information can often blend into the literature review portion of the paper, essential background information should not be considered a substitute for a comprehensive review and synthesis of relevant research literature.

Hart, Cris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage, 1998; Pyrczak, Fred. Writing Empirical Research Reports: A Basic Guide for Students of the Social and Behavioral Sciences . 8th edition. Glendale, CA: Pyrczak Publishing, 2014.

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What is the Background in a Research Paper?

An effective Background section in your manuscript establishes the context for your study. And while original research requires novel findings, providing the necessary background information for these findings may be just as important. It lets your readers know that your findings are novel, important, and worthy of their time and attention.

Updated on October 3, 2022

A good Background section explains the history and nature of your research question in relation to existing literature – a “state of the art.” This section, along with the rationale, helps readers understand why you chose to study this problem and why your study is worthwhile. This article will show you how to do this.

Read on to better understand the:

• Real purpose of the Background section
• Typical length of a Background section and its placement
• Elements of an effective Background

What is the Background section of a research paper?

The Background section is an essential element of every study, answering:

• What do we already know about the topic?
• How does your study relate to what's been done so far in your field?
• What is its scope?
• Why does the topic warrant your interest and their interest?
• How did you develop the research question that you'll later introduce?

In grant writing, a Background section is often referred to as the “state of the art,” and this is a useful term to have in mind when writing this part of your paper.

What comes next?

After you make the above points,

• Formulate your research question/hypothesis . Research aims and objectives should be closely related to how you'll fill the gap you've identified in the literature. Your research gap is the central theme of your article and why people should read it.
• Summarize how you'll address it in the paper . Your methodology needs to be appropriate for addressing the “problem” you've identified.
• Describe the significance of your study . Show how your research fits into the bigger picture.

Note that the Background section isn't the same as the research rationale. Rather, it provides the relevant information the reader needs so they can follow your rationale. For example, it

• Explains scientific terms
• Provides available data and statistics on the topic
• Describes the methods used so far on your topic. Especially if these are different from what you're going to do. Take special care here, because this is often where peer reviewers focus intently.

This is a logical approach to what comes after the study's background. Use it and the reader can easily follow along from the broader information to the specific details that come later. Crucially, they'll have confidence that your analysis and findings are valid.

Where should the background be placed in a research paper?

Usually, the background comes after the statement of the problem, in the Introduction section. Logically, you need to provide the study context before discussing the research questions, methodology, and results.

The background can be found in:

The abstract

The background typically forms the first few sentences of the abstract. Why did you do the study? Most journals state this clearly. In an unstructured (no subheadings) abstract, it's the first sentence or two. In a structured abstract, it might be called the Introduction, Background, or State-of-the-Art.

PLOS Medicine , for example, asks for research article abstracts to be split into three sections: Background, Methods and Findings, and Conclusions. Journals in the humanities or social sciences might not clearly ask for it because articles sometimes have a looser structure than STEM articles.

The first part of the Introduction section

In the journal Nature , for example, the Introduction should be around 200 words and include

• Two to three sentences giving a basic introduction to the field.
• The background and rationale of the study are stated briefly.
• A simple phrase “Here we show ...”, or “In this study, we show ....” (to round out the Introduction).

The Journal of Organic Chemistry has similar author guidelines.

The Background as a distinct section

This is often the case for research proposals or some types of reports, as discussed above. Rather than reviewing the literature, this is a concise summary of what's currently known in the field relevant to the question being addressed in this proposed study.

How long should the Background section be?

As mentioned, there's no set length for the Background section. It generally depends on the journal and the content of your manuscript. Check the journal's author guidelines, the research center, granting agency, etc. If it's still not clear or if the instructions are contradictory, email or phone them directly.

The length of your background will depend on:

The manuscript length and content

A book-length study needs a more extensive Background than a four-page research article. Exploring a relatively unknown method or question might also need a longer Background.

For example, see this Frontiers article on the applications of artificial intelligence for developing COVID-19 vaccines. It has a seven-paragraph long Background (1,200 words) in a separate section. The authors need to discuss earlier successful uses of machine learning for therapy discovery to make a convincing case.

An academic paper published in an international journal is usually around 5,000 words. Your paper needs to be balanced, with appropriate text lengths used for the different sections: It would make no sense to have a 300-word introduction and then 4,000 words for the methods, for example. In a 5,000-word manuscript, you'll be able to use about 1,500 for the introduction, which includes the background.

How much you need to show your understanding of the topic

A lengthy grant application might need a longer Background (sub-)section. That's because if they're going to grant you money, they need a very good reason to. You'll need to show that the work is both interesting and doable. The Background is where you can do this.

What should the Background of a research manuscript include?

The Background of a research paper needs to show two things:

The study's territory ( scope )

First, provide a general overview of the field. Scientists in most disciplines should find it relatively easy to understand. Be broad, keep it interesting. Don't go into the specifics of your particular study.

Let's look at two examples:

• one from basic research (seeking to generate new knowledge)
• one from applied research (trying to solve or improve existing processes or products)

Applied research

This Frontiers in Artificial Intelligence article explores how AI can help discover treatments for COVID-19.

The background of the study can be found (i) in the abstract and (ii) in a separate section discussed at the end of this article. The abstract starts with this general overview: “SARS-COV-2 has roused the scientific community with a call to action to combat the growing pandemic.” ( Arshadi et al., 2020 ). This is broad, and it's interesting. This is a topic that many researchers (even from outside this specific area) may want to learn more about.

Think of any theories, models, concepts, or terms (maybe borrowed from different disciplines) that may be unfamiliar to your reader. Be sure to clarify them in plainer language, if necessary.

For example, this systematic review looks at the connections of physician burnout with career engagement and quality of patient care. The Background is in the Introduction section. It starts by defining what burnout is:

• “Burnout is defined as a syndrome related to work that involves three key dimensions.” ( Hodkinson et al., 2022 )

The authors go on to explain its three aspects: emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment.

Basic research

Imagine you're investigating how universities' moves to online teaching during the COVID-19 pandemic impacted students' learning outcomes in the United Kingdom. The overview could be:

• The COVID-19 pandemic and the ensuing lockdown generated tremendous challenges across the higher education sector. University campuses were forced to close. Face-to-face teaching and assessment transitioned into a virtual format.

2. The niche in the field (motivation)

To establish the niche in your field, describe what drove you to explore this specific topic.

• Explain how (un)successfully previous studies have investigated the problem.
• Note the knowledge gap or present a problem with a currently used process/practice/product.

After setting the stage, the abstract of the Frontiers in Artificial Intelligence article identifies a problem:

• “At the time of this writing, there are as yet no novel antiviral agents or approved vaccines available for deployment as a frontline defense.” ( Arshadi et al., 2020 )

The authors need to support their claim that computational methods can help discover new COVID-19 treatments. They do so by referring to previous research findings:

• “In the last decade, machine learning-based models, trained on specific biomolecules, have offered inexpensive and rapid implementation methods for the discovery of effective viral therapies.” ( Arshadi et al., 2020 )

Going back to the study on students' learning outcomes after universities introduced e-learning. The background section will next identify and describe the current knowledge gap and your proposed method of fixing it. It may be something like:

• Existing literature and studies by the UK Department for Education reveal x + y changes and effects on teaching and learning. Yet they provide little to no information on students' learning outcomes. Understanding the impact of online teaching and assessments on student outcomes is key to adopting future teaching practices and ensuring students from disadvantaged backgrounds are not left behind.

How is the background different from the literature review?

Both the background and literature review sections compile previous studies that are relevant and important to the topic.

Despite their similarities, they're different in scope and aims.

Overall, the research background could be seen as a small part of the detailed critical discussion in the literature review. Almost always, primary research articles do not include a detailed literature review.

How is the Background different from the Introduction section?

Although often part of the Introduction, the Background differs from the Introduction in scope and aim.

Breakdown of the Background in published articles

Consider this systematic review looking at the connections of physician burnout with career engagement and quality of patient care.

The Background is placed in the Introduction section. It's critical, consistent, and logically structured, moving from general to specific information.

You can also check out the summary paragraph breakdown provided by Nature. (Nature's “summary paragraph” is essentially an abstract.)

And if you're looking for some help, or have an article that's finished but needs a pre-submission review click here to connect with one of our expert AJE editors.

Gareth Dyke, PhD

Director of Global Content

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Tips for Writing an Effective Background of the Study

The Background of the Study is an integral part of any research paper that sets the context and the stage for the research presented in the paper. It's the section that provides a detailed context of the study by explaining the problem under investigation, the gaps in existing research that the study aims to fill, and the relevance of the study to the research field. It often incorporates aspects of the existing literature and gives readers an understanding of why the research is necessary and the theoretical framework that it is grounded in.

The Background of the Study holds a significant position in the process of research. It serves as the scaffold upon which the entire research project is built. It helps the reader understand the problem, its significance, and how your research will contribute to the existing body of knowledge. A well-articulated background can provide a clear roadmap for your study and assist others in understanding the direction and value of your research. Without it, readers may struggle to grasp the purpose and importance of your work.

The aim of this blog post is to guide budding researchers, students, and academicians on how to craft an effective Background of the Study section for their research paper. It is designed to provide practical tips, highlight key components, and elucidate common mistakes to avoid. By the end of this blog post, readers should have a clear understanding of how to construct a compelling background that successfully contextualizes their research, highlights its significance, and sets a clear path for their investigation.

Understanding the background of the study

The Background of the Study in a research context refers to a section of your research paper that discloses the basis and reasons behind the conduction of the study. It sets the broader context for your research by presenting the problem that your study intends to address, giving a brief overview of the subject domain, and highlighting the existing gaps in knowledge. This section also presents the theoretical or conceptual framework and states the research objectives, and often includes the research question or hypothesis . The Background of the Study gives your readers a deeper understanding of the purpose, importance, and direction of your study.

How it fits into the overall structure of a research paper

The Background of the Study typically appears after the introduction and before the literature review in the overall structure of a research paper. It acts as a bridge between the general introduction, where the topic is initially presented, and the more specific aspects of the paper such as the literature review, methodology , results , and discussion. It provides necessary information to help readers understand the relevance and value of the study in a wider context, before zooming in to specific details of your research.

Difference between the background of the study, introduction, and literature review

Now that we understand the role of the Background of the Study within a research paper, let's delve deeper to differentiate it from two other crucial components of the paper - the Introduction and the Literature Review.

• Background of the Study: This section provides a comprehensive context for the research, including a statement of the problem , the theoretical or conceptual framework, the gap that the study intends to fill, and the overall significance of the research. It guides the reader from a broad understanding of the research context to the specifics of your study.
• Introduction: This is the first section of the research paper that provides a broad overview of the topic , introduces the research question or hypothesis , and briefly mentions the methodology used in the study. It piques the reader's interest and gives them a reason to continue reading the paper.
• Literature Review: This section presents an organized summary of the existing research related to your study. It helps identify what we already know and what we do not know about the topic, thereby establishing the necessity for your research. The literature review allows you to demonstrate how your study contributes to and extends the existing body of knowledge.

While these three sections may overlap in some aspects, each serves a unique purpose and plays a critical role in the research paper.

Components of the background of the study

Statement of the problem.

This is the issue or situation that your research is intended to address. It should be a clear, concise declaration that explains the problem in detail, its context, and the negative impacts if it remains unresolved. This statement also explains why there's a need to study the problem, making it crucial for defining the research objectives.

Importance of the study

In this component, you outline the reasons why your research is significant. How does it contribute to the existing body of knowledge? Does it provide insights into a particular issue, offer solutions to a problem, or fill gaps in existing research? Clarifying the importance of your study helps affirm its value to your field and the larger academic community.

Relevant previous research and literature

Present an overview of the major studies and research conducted on the topic. This not only shows that you have a broad understanding of your field, but it also allows you to highlight the knowledge gaps that your study aims to fill. It also helps establish the context of your study within the larger academic dialogue.

Theoretical framework

The theoretical framework is the structure that can hold or support a theory of a research study. It presents the theories, concepts, or ideas which are relevant to the study and explains how these theories apply to your research. It helps to connect your findings to the broader constructs and theories in your field.

Research questions or hypotheses

These are the specific queries your research aims to answer or the predictions you are testing. They should be directly aligned with your problem statement and clearly set out what you hope to discover through your research.

Potential implications of the research

This involves outlining the potential applications of your research findings in your field and possibly beyond. What changes could your research inspire? How might it influence future studies? By explaining this, you underscore the potential impact of your research and its significance in a broader context.

How to write a comprehensive background of the study

Identify and articulate the problem statement.

To successfully identify and articulate your problem statement, consider the following steps:

• Start by clearly defining the problem your research aims to solve. The problem should be specific and researchable.
• Provide context for the problem. Where does it arise? Who or what is affected by it?
• Clearly articulate why the problem is significant. Is it a new issue, or has it been a long-standing problem in your field? How does it impact the broader field or society at large?
• Express the potential adverse effects if the problem remains unresolved. This can help underscore the urgency or importance of your research.
• Remember, while your problem statement should be comprehensive, aim for conciseness. You want to communicate the gravity of the issue in a precise and clear manner.

Conduct and summarize relevant literature review

A well-executed literature review is fundamental for situating your study within the broader context of existing research. Here's how you can approach it:

• Begin by conducting a comprehensive search for existing research that is relevant to your problem statement. Make use of academic databases, scholarly journals, and other credible sources of research.
• As you read these studies, pay close attention to their key findings, research methodologies, and any gaps in the research that they've identified. These elements will be crucial in the summary of your literature review.
• Make an effort to analyze, rather than just list, the studies. This means drawing connections between different research findings, contrasting methodologies, and identifying overarching trends or conflicts in the field.
• When summarizing the literature review, focus on synthesis . Explain how these studies relate to each other and how they collectively relate to your own research. This could mean identifying patterns, themes, or gaps that your research aims to address.

Describe the theoretical framework

The theoretical framework of your research is crucial as it grounds your work in established concepts and provides a lens through which your results can be interpreted. Here's how to effectively describe it:

• Begin by identifying the theories, ideas, or models upon which your research is based. These may come from your literature review or your understanding of the subject matter.
• Explain these theories or concepts in simple terms, bearing in mind that your reader may not be familiar with them. Be sure to define any technical terms or jargon that you use.
• Make connections between these theories and your research. How do they relate to your study? Do they inform your research questions or hypotheses?
• Show how these theories guide your research methodology and your analysis. For instance, do they suggest certain methods for data collection or specific ways of interpreting your data?
• Remember, your theoretical framework should act as the "lens" through which your results are viewed, so it needs to be relevant and applicable to your study.

Formulate your research questions or hypotheses

Crafting well-defined research questions or hypotheses is a crucial step in outlining the scope of your research. Here's how you can effectively approach this process:

• Begin by establishing the specific questions your research aims to answer. If your study is more exploratory in nature, you may formulate research questions. If it is more explanatory or confirmatory, you may state hypotheses.
• Ensure that your questions or hypotheses are researchable. They should be specific, clear, and measurable with the methods you plan to use.
• Check that your research questions or hypotheses align with your problem statement and research objectives. They should be a natural extension of the issues outlined in your background of the study.
• Finally, remember that well-crafted research questions or hypotheses will guide your research design and help structure your entire paper. They act as the anchors around which your research revolves.

Highlight the potential implications and significance of your research

To conclude your Background of the Study, it's essential to highlight the potential implications and significance of your work. Here's how to do it effectively:

• Start by providing a clear explanation of your research's potential implications. This could relate to the advancement of theoretical knowledge or practical applications in the real world.
• Discuss the importance of your research within the context of your field. How does it contribute to the existing body of knowledge? Does it challenge current theories or practices?
• Highlight how your research could influence future studies. Could it open new avenues of inquiry? Does it suggest a need for further research in certain areas?
• Finally, consider the practical applications of your research. How could your findings be used in policy-making, business strategies, educational practices, or other real-world scenarios?
• Always keep in mind that demonstrating the broader impact of your research increases its relevance and appeal to a wider audience, extending beyond the immediate academic circle.

Following these guidelines can help you effectively highlight the potential implications and significance of your research, thereby strengthening the impact of your study.

Practical tips for writing the background of the study

Keeping the section concise and focused.

Maintain clarity and brevity in your writing. While you need to provide sufficient detail to set the stage for your research, avoid unnecessary verbosity. Stay focused on the main aspects related to your research problem, its context, and your study's contribution.

Ensuring the background aligns with your research questions or hypotheses

Ensure a clear connection between your background and your research questions or hypotheses. Your problem statement, review of relevant literature, theoretical framework, and the identified gap in research should logically lead to your research questions or hypotheses.

Citing your sources correctly

Always attribute the ideas, theories, and research findings of others appropriately to avoid plagiarism . Correct citation not only upholds academic integrity but also allows your readers to access your sources if they wish to explore them in depth. The citation style may depend on your field of study or the requirements of the journal or institution.

Bridging the gap between existing research and your study

Identify the gap in existing research that your study aims to fill and make it explicit. Show how your research questions or hypotheses emerged from this identified gap. This helps to position your research within the broader academic conversation and highlights the unique contribution of your study.

Avoiding excessive jargon

While technical terms are often unavoidable in academic writing, use them sparingly and make sure to define any necessary jargon for your reader. Your Background of the Study should be understandable to people outside your field as well. This will increase the accessibility and impact of your research.

Common mistakes to avoid while writing the background of the study

Being overly verbose or vague.

While it's important to provide sufficient context, avoid being overly verbose in your descriptions. Also, steer clear of vague or ambiguous phrases. The Background of the Study should be clear, concise, and specific, giving the reader a precise understanding of the study's purpose and context.

Failing to relate the background to the research problem

The entire purpose of the Background of the Study is to set the stage for your research problem. If it doesn't directly relate to your problem statement, research questions, or hypotheses, it may confuse the reader. Always ensure that every element of the background ties back to your study.

Neglecting to mention important related studies

Not mentioning significant related studies is another common mistake. The Background of the Study section should give a summary of the existing literature related to your research. Omitting key pieces of literature can give the impression that you haven't thoroughly researched the topic.

Overusing technical jargon without explanation

While certain technical terms may be necessary, overuse of jargon can make your paper inaccessible to readers outside your immediate field. If you need to use technical terms, make sure you define them clearly. Strive for clarity and simplicity in your writing as much as possible.

Not citing sources or citing them incorrectly

Academic integrity is paramount in research writing. Ensure that every idea, finding, or theory that is not your own is properly attributed to its original source. Neglecting to cite, or citing incorrectly, can lead to accusations of plagiarism and can discredit your research. Always follow the citation style guide relevant to your field.

Writing an effective Background of the Study is a critical step in crafting a compelling research paper. It serves to contextualize your research, highlight its significance, and present the problem your study seeks to address. Remember, your background should provide a comprehensive overview of the current state of research, identify gaps in existing literature, and indicate how your research will fill these gaps. Keep your writing concise, focused, and jargon-free, making sure to correctly cite all sources. Avoiding common mistakes and adhering to the strategies outlined in this post will help you develop a robust and engaging background for your study. As you embark on your research journey, remember that the Background of the Study sets the stage for your entire research project, so investing time and effort into crafting it effectively will undoubtedly pay dividends in the end.

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In a research paper, what is the background of study?

Research papers should include a background of study statement that provides context for the study. Read the article and learn more about it!

Unless you provide the background information needed for the reader to understand your choice of the subject and why your study is important, they will not be able to grasp the significance of the findings of your research, regardless of how significant and fascinating they are. 

Research papers should include a background of study statement that provides context for the study. A reader’s interest in the rest of the study is determined by the quality of the background. It is therefore imperative to write an engaging and effective background. How should a study’s background be written, and how should it be presented?

What is the background of study in the research paper?

The background of a study outlines how your research began, your interest in the subject, and the development of your study question. In other words, you should provide a broad overview of the research that you performed, followed by a discussion of what motivated you to choose the particular problem that you studied. 

Your topic should be clearly understood by the reader. Whether and to what extent you need to explain your background depends on what you are writing about. 

A research paper’s background section

The background of a research paper acts as the first element readers will notice; so it is important that it is informative and fascinating enough to get them interested in reading further. In the background, the volume and the specifics vary according to the research paper, particularly if the topic is complex or novel. 

Complex studies can sometimes be simplified by a simple background. Reviewing previous literature on the topic of your study is typically part of your research background. After identifying the gaps in existing knowledge, you should explain how your study will fill them.

The difference between the background of the study and the introduction section

There are a number of ways in which your introduction differs from your background. In the introduction, you provide preliminary information about the paper that is likely to be studied by the reader, but in the background section, you explain why the paper is relevant. 

In your study’s background, you discuss the topic in great detail, in contrast to the introduction, which provides an overall view of the topic. You should conclude your introduction with reasons for conducting research, objectives, and research goals, not your background, other than when it is incorporated into the introduction.

Here are the steps to writing a background of study

• Defining the research topic and identifying the target audience is the best way to start the background.
• Provide a detailed discussion of all concepts, terminology, keywords, and information that may feel new to the intended audience.
• Examine the relevant literature in depth to learn more about the essential requirements. 
• Read carefully and make notes. Cite your sources when you are done.
• Be sure to strike a balance between emphasizing key points, as well as communicating to a wide audience.
• History is a significant source of current issues. Add relevant data in the background if your research relies on historical information.
• Provide an explanation to help people understand the research if it is groundbreaking or novel.
• Develop a compelling narrative around the research theme to increase engagement. Don’t forget to add the necessary infographics.

Here are some things to avoid in a study’s background

In the case of your research paper, when you established the background in an organized manner, you would have been able to lead the reader seamlessly throughout. Nevertheless, you should be careful as well, here are a few points to keep in mind.

• Avoid unclear language at all costs. Consider your reader as unaware of any complex details about your research while writing.
• Avoid writing an excessively long or short background. Write concisely while not forgetting to include everything that is important.  
• Don’t devote time to topics that don’t relate to the main thrust of the research.
• Putting information without a structure is a disorganized approach. A chronology should be followed for the background, and subsections should be ordered logically.
• Be sure to cite every source.

For more information on how to write research articles and papers, please visit our blog . 

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About Aayushi Zaveri

Aayushi Zaveri majored in biotechnology engineering. She is currently pursuing a master's degree in Bioentrepreneurship from Karolinska Institute. She is interested in health and diseases, global health, socioeconomic development, and women's health. As a science enthusiast, she is keen in learning more about the scientific world and wants to play a part in making a difference.

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Writing Research Background

Research background is a brief outline of the most important studies that have been conducted so far presented in a chronological order. Research background part in introduction chapter can be also headed ‘Background of the Study.” Research background should also include a brief discussion of major theories and models related to the research problem.

Specifically, when writing research background you can discuss major theories and models related to your research problem in a chronological order to outline historical developments in the research area.  When writing research background, you also need to demonstrate how your research relates to what has been done so far in the research area.

Research background is written after the literature review. Therefore, literature review has to be the first and the longest stage in the research process, even before the formulation of research aims and objectives, right after the selection of the research area. Once the research area is selected, the literature review is commenced in order to identify gaps in the research area.

Research aims and objectives need to be closely associated with the elimination of this gap in the literature. The main difference between background of the study and literature review is that the former only provides general information about what has been done so far in the research area, whereas the latter elaborates and critically reviews previous works.

John Dudovskiy

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How to Write the Background of the Study in Research (Part 1)

Background of the Study in Research: Definition and the Core Elements it Contains

Before we embark on a detailed discussion on how to write the background of the study of your proposed research or thesis, it is important to first discuss its meaning and the core elements that it should contain. This is obviously because understanding the nature of the background of the study in research and knowing exactly what to include in it allow us to have both greater control and clear direction of the writing process.

So, what really is the background of the study and what are the core elements that it should contain?

The background of the study, which usually forms the first section of the introduction to a research paper or thesis, provides the overview of the study. In other words, it is that section of the research paper or thesis that establishes the context of the study. Its main function is to explain why the proposed research is important and essential to understanding the main aspects of the study.

The background of the study, therefore, is the section of the research paper or thesis that identifies the problem or gap of the study that needs to addressed and justifies the need for conducting the study. It also articulates the main goal of the study and the thesis statement, that is, the main claim or argument of the paper.

Given this brief understanding of the background of the study, we can anticipate what readers or thesis committee members expect from it. As we can see, the background of the study should contain the following major points:

1) brief discussion on what is known about the topic under investigation; 2) An articulation of the research gap or problem that needs to be addressed; 3) What the researcher would like to do or aim to achieve in the study ( research goal); 4) The thesis statement, that is, the main argument or contention of the paper (which also serves as the reason why the researcher would want to pursue the study); 5) The major significance or contribution of the study to a particular discipline; and 6) Depending on the nature of the study, an articulation of the hypothesis of the study.

Thus, when writing the background of the study, you should plan and structure it based on the major points just mentioned. With this, you will have a clear picture of the flow of the tasks that need to be completed in writing this section of your research or thesis proposal.

Now, how do you go about writing the background of the study in your proposed research or thesis?

The next lessons will address this question.

How to Write the Opening Paragraphs of the Background of the Study?

To begin with, let us assume that you already have conducted a preliminary research on your chosen topic, that is, you already have read a lot of literature and gathered relevant information for writing the background of your study. Let us also assume that you already have identified the gap of your proposed research and have already developed the research questions and thesis statement. If you have not yet identified the gap in your proposed research, you might as well go back to our lesson on how to identify a research gap.

So, we will just put together everything that you have researched into a background of the study (assuming, again, that you already have the necessary information). But in this lesson, let’s just focus on writing the opening paragraphs.

It is important to note at this point that there are different styles of writing the background of the study. Hence, what I will be sharing with you here is not just “the” only way of writing the background of the study. As a matter of fact, there is no “one-size-fits-all” style of writing this part of the research or thesis. At the end of the day, you are free to develop your own. However, whatever style it would be, it always starts with a plan which structures the writing process into stages or steps. The steps that I will share with below are just some of the most effective ways of writing the background of the study in research.

So, let’s begin.

It is always a good idea to begin the background of your study by giving an overview of your research topic. This may include providing a definition of the key concepts of your research or highlighting the main developments of the research topic.

Let us suppose that the topic of your study is the “lived experiences of students with mathematical anxiety”.

Here, you may start the background of your study with a discussion on the meaning, nature, and dynamics of the term “mathematical anxiety”. The reason for this is too obvious: “mathematical anxiety” is a highly technical term that is specific to mathematics. Hence, this term is not readily understandable to non-specialists in this field.

So, you may write the opening paragraph of your background of the study with this:

“Mathematical anxiety refers to the individual’s unpleasant emotional mood responses when confronted with a mathematical situation.”

Since you do not invent the definition of the term “mathematical anxiety”, then you need to provide a citation to the source of the material from which you are quoting. For example, you may now say:

“Mathematical anxiety refers to the individual’s unpleasant emotional mood responses when confronted with a mathematical situation (Eliot, 2020).”

And then you may proceed with the discussion on the nature and dynamics of the term “mathematical anxiety”. You may say:

“Lou (2019) specifically identifies some of the manifestations of this type of anxiety, which include, but not limited to, depression, helplessness, nervousness and fearfulness in doing mathematical and numerical tasks.”

After explaining to your readers the meaning, nature, and dynamics (as well as some historical development if you wish to) of the term “mathematical anxiety”, you may now proceed to showing the problem or gap of the study. As you may already know, the research gap is the problem that needs to be addressed in the study. This is important because no research activity is possible without the research gap.

Let us suppose that your research problem or gap is: “Mathematical anxiety can negatively affect not just the academic achievement of the students but also their future career plans and total well-being. Also, there are no known studies that deal with the mathematical anxiety of junior high school students in New Zealand.” With this, you may say:

“If left unchecked, as Shapiro (2019) claims, this problem will expand and create a total avoidance pattern on the part of the students, which can be expressed most visibly in the form of cutting classes and habitual absenteeism. As we can see, this will negatively affect the performance of students in mathematics. In fact, the study conducted by Luttenberger and Wimmer (2018) revealed that the outcomes of mathematical anxiety do not only negatively affect the students’ performance in math-related situations but also their future career as professionals. Without a doubt, therefore, mathematical anxiety is a recurring problem for many individuals which will negatively affect the academic success and future career of the student.”

Now that you already have both explained the meaning, nature, and dynamics of the term “mathematical anxiety” and articulated the gap of your proposed research, you may now state the main goal of your study. You may say:

“Hence, it is precisely in this context that the researcher aims to determine the lived experiences of those students with mathematical anxiety. In particular, this proposed thesis aims to determine the lived experiences of the junior high school students in New Zealand and identify the factors that caused them to become disinterested in mathematics.”

Please note that you should not end the first paragraph of your background of the study with the articulation of the research goal. You also need to articulate the “thesis statement”, which usually comes after the research goal. As is well known, the thesis statement is the statement of your argument or contention in the study. It is more of a personal argument or claim of the researcher, which specifically highlights the possible contribution of the study. For example, you may say:

“The researcher argues that there is a need to determine the lived experiences of these students with mathematical anxiety because knowing and understanding the difficulties and challenges that they have encountered will put the researcher in the best position to offer some alternatives to the problem. Indeed, it is only when we have performed some kind of a ‘diagnosis’ that we can offer practicable solutions to the problem. And in the case of the junior high school students in New Zealand who are having mathematical anxiety, determining their lived experiences as well as identifying the factors that caused them to become disinterested in mathematics are the very first steps in addressing the problem.”

If we combine the bits and pieces that we have written above, we can now come up with the opening paragraphs of your background of the study, which reads:

As we can see, we can find in the first paragraph 5 essential elements that must be articulated in the background of the study, namely:

1) A brief discussion on what is known about the topic under investigation; 2) An articulation of the research gap or problem that needs to be addressed; 3) What the researcher would like to do or aim to achieve in the study (research goal); 4) The thesis statement , that is, the main argument or claim of the paper; and 5) The major significance or contribution of the study to a particular discipline. So, that’s how you write the opening paragraphs of your background of the study. The next lesson will talk about writing the body of the background of the study.

How to Write the Body of the Background of the Study?

If we liken the background of the study to a sitting cat, then the opening paragraphs that we have completed in the previous lesson would just represent the head of the cat.

This means we still have to write the body (body of the cat) and the conclusion (tail). But how do we write the body of the background of the study? What should be its content?

Truly, this is one of the most difficult challenges that fledgling scholars faced. Because they are inexperienced researchers and didn’t know what to do next, they just wrote whatever they wished to write. Fortunately, this is relatively easy if they know the technique.

One of the best ways to write the body of the background of the study is to attack it from the vantage point of the research gap. If you recall, when we articulated the research gap in the opening paragraphs, we made a bold claim there, that is, there are junior high school students in New Zealand who are experiencing mathematical anxiety. Now, you have to remember that a “statement” remains an assumption until you can provide concrete proofs to it. This is what we call the “epistemological” aspect of research. As we may already know, epistemology is a specific branch of philosophy that deals with the validity of knowledge. And to validate knowledge is to provide concrete proofs to our statements. Hence, the reason why we need to provide proofs to our claim that there are indeed junior high school students in New Zealand who are experiencing mathematical anxiety is the obvious fact that if there are none, then we cannot proceed with our study. We have no one to interview with in the first. In short, we don’t have respondents.

The body of the background of the study, therefore, should be a presentation and articulation of the proofs to our claim that indeed there are junior high school students in New Zealand who are experiencing mathematical anxiety. Please note, however, that this idea is true only if you follow the style of writing the background of the study that I introduced in this course.

So, how do we do this?

One of the best ways to do this is to look for literature on mathematical anxiety among junior high school students in New Zealand and cite them here. However, if there are not enough literature on this topic in New Zealand, then we need to conduct initial interviews with these students or make actual classroom observations and record instances of mathematical anxiety among these students. But it is always a good idea if we combine literature review with interviews and actual observations.

Assuming you already have the data, then you may now proceed with the writing of the body of your background of the study. For example, you may say:

“According to records and based on the researcher’s firsthand experience with students in some junior high schools in New Zealand, indeed, there are students who lost interest in mathematics. For one, while checking the daily attendance and monitoring of the students, it was observed that some of them are not always attending classes in mathematics but are regularly attending the rest of the required subjects.”

After this sentence, you may insert some literature that will support this position. For example, you may say:

“As a matter of fact, this phenomenon is also observed in the work of Estonanto. In his study titled ‘Impact of Math Anxiety on Academic Performance in Pre-Calculus of Senior High School’, Estonanto (2019) found out that, inter alia, students with mathematical anxiety have the tendency to intentionally prioritize other subjects and commit habitual tardiness and absences.”

Then you may proceed saying:

“With this initial knowledge in mind, the researcher conducted initial interviews with some of these students. The researcher learned that one student did not regularly attend his math subject because he believed that he is not good in math and no matter how he listens to the topic he will not learn.”

Then you may say:

“Another student also mentioned that she was influenced by her friends’ perception that mathematics is hard; hence, she avoids the subject. Indeed, these are concrete proofs that there are some junior high school students in New Zealand who have mathematical anxiety. As already hinted, “disinterest” or the loss of interest in mathematics is one of the manifestations of a mathematical anxiety.”

If we combine what we have just written above, then we can have the first two paragraphs of the body of our background of the study. It reads:

“According to records and based on the researcher’s firsthand experience with students in some junior high schools in New Zealand, indeed there are students who lost interest in mathematics. For one, while checking the daily attendance and monitoring of the students, it was observed that some of them are not always attending classes in mathematics but are regularly attending the rest of the required subjects. As a matter of fact, this phenomenon is also observed in the work of Estonanto. In his study titled ‘Impact of Math Anxiety on Academic Performance in Pre-Calculus of Senior High School’, Estonanto (2019) found out that, inter alia, students with mathematical anxiety have the tendency to intentionally prioritize other subjects and commit habitual tardiness and absences.

With this initial knowledge in mind, the researcher conducted initial interviews with some of these students. The researcher learned that one student did not regularly attend his math subject because he believed that he is not good in math and no matter how he listens to the topic he will not learn. Another student also mentioned that she was influenced by her friends’ perception that mathematics is hard; hence, she avoids the subject. Indeed, these are concrete proofs that there are some junior high school students in New Zealand who have mathematical anxiety. As already hinted, “disinterest” or the loss of interest in mathematics is one of the manifestations of a mathematical anxiety.”

And then you need validate this observation by conducting another round of interview and observation in other schools. So, you may continue writing the body of the background of the study with this:

“To validate the information gathered from the initial interviews and observations, the researcher conducted another round of interview and observation with other junior high school students in New Zealand.”

“On the one hand, the researcher found out that during mathematics time some students felt uneasy; in fact, they showed a feeling of being tensed or anxious while working with numbers and mathematical problems. Some were even afraid to seat in front, while some students at the back were secretly playing with their mobile phones. These students also show remarkable apprehension during board works like trembling hands, nervous laughter, and the like.”

Then provide some literature that will support your position. You may say:

“As Finlayson (2017) corroborates, emotional symptoms of mathematical anxiety involve feeling of helplessness, lack of confidence, and being nervous for being put on the spot. It must be noted that these occasionally extreme emotional reactions are not triggered by provocative procedures. As a matter of fact, there are no personally sensitive questions or intentional manipulations of stress. The teacher simply asked a very simple question, like identifying the parts of a circle. Certainly, this observation also conforms with the study of Ashcraft (2016) when he mentions that students with mathematical anxiety show a negative attitude towards math and hold self-perceptions about their mathematical abilities.”

And then you proceed:

“On the other hand, when the class had their other subjects, the students show a feeling of excitement. They even hurried to seat in front and attentively participating in the class discussion without hesitation and without the feeling of being tensed or anxious. For sure, this is another concrete proof that there are junior high school students in New Zealand who have mathematical anxiety.”

To further prove the point that there indeed junior high school students in New Zealand who have mathematical anxiety, you may solicit observations from other math teachers. For instance, you may say:

“The researcher further verified if the problem is also happening in other sections and whether other mathematics teachers experienced the same observation that the researcher had. This validation or verification is important in establishing credibility of the claim (Buchbinder, 2016) and ensuring reliability and validity of the assertion (Morse et al., 2002). In this regard, the researcher attempted to open up the issue of math anxiety during the Departmentalized Learning Action Cell (LAC), a group discussion of educators per quarter, with the objective of ‘Teaching Strategies to Develop Critical Thinking of the Students’. During the session, one teacher corroborates the researcher’s observation that there are indeed junior high school students in New Zealand who have mathematical anxiety. The teacher pointed out that truly there were students who showed no extra effort in mathematics class in addition to the fact that some students really avoided the subject. In addition, another math teacher expressed her frustrations about these students who have mathematical anxiety. She quipped: “How can a teacher develop the critical thinking skills or ability of the students if in the first place these students show avoidance and disinterest in the subject?’.”

Again, if we combine what we have just written above, then we can now have the remaining parts of the body of the background of the study. It reads:

So, that’s how we write the body of the background of the study in research . Of course, you may add any relevant points which you think might amplify your content. What is important at this point is that you now have a clear idea of how to write the body of the background of the study.

How to Write the Concluding Part of the Background of the Study?

Since we have already completed the body of our background of the study in the previous lesson, we may now write the concluding paragraph (the tail of the cat). This is important because one of the rules of thumb in writing is that we always put a close to what we have started.

It is important to note that the conclusion of the background of the study is just a rehashing of the research gap and main goal of the study stated in the introductory paragraph, but framed differently. The purpose of this is just to emphasize, after presenting the justifications, what the study aims to attain and why it wants to do it. The conclusion, therefore, will look just like this:

“Given the above discussion, it is evident that there are indeed junior high school students in New Zealand who are experiencing mathematical anxiety. And as we can see, mathematical anxiety can negatively affect not just the academic achievement of the students but also their future career plans and total well-being. Again, it is for this reason that the researcher attempts to determine the lived experiences of those junior high school students in New Zealand who are experiencing a mathematical anxiety.”

If we combine all that we have written from the very beginning, the entire background of the study would now read:

If we analyze the background of the study that we have just completed, we can observe that in addition to the important elements that it should contain, it has also addressed other important elements that readers or thesis committee members expect from it.

On the one hand, it provides the researcher with a clear direction in the conduct of the study. As we can see, the background of the study that we have just completed enables us to move in the right direction with a strong focus as it has set clear goals and the reasons why we want to do it. Indeed, we now exactly know what to do next and how to write the rest of the research paper or thesis.

On the other hand, most researchers start their research with scattered ideas and usually get stuck with how to proceed further. But with a well-written background of the study, just as the one above, we have decluttered and organized our thoughts. We have also become aware of what have and have not been done in our area of study, as well as what we can significantly contribute in the already existing body of knowledge in this area of study.

Please note, however, as I already mentioned previously, that the model that I have just presented is only one of the many models available in textbooks and other sources. You are, of course, free to choose your own style of writing the background of the study. You may also consult your thesis supervisor for some guidance on how to attack the writing of your background of the study.

Lastly, and as you may already know, universities around the world have their own thesis formats. Hence, you should follow your university’s rules on the format and style in writing your research or thesis. What is important is that with the lessons that you learned in this course, you can now easily write the introductory part of your thesis, such as the background of the study.

• Open access
• Published: 19 April 2024

A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact

• Aklilu Endalamaw 1 , 2 ,
• Resham B Khatri 1 , 3 ,
• Tesfaye Setegn Mengistu 1 , 2 ,
• Daniel Erku 1 , 4 , 5 ,
• Eskinder Wolka 6 ,
• Anteneh Zewdie 6 &
• Yibeltal Assefa 1  

BMC Health Services Research volume  24 , Article number:  487 ( 2024 ) Cite this article

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The growing adoption of continuous quality improvement (CQI) initiatives in healthcare has generated a surge in research interest to gain a deeper understanding of CQI. However, comprehensive evidence regarding the diverse facets of CQI in healthcare has been limited. Our review sought to comprehensively grasp the conceptualization and principles of CQI, explore existing models and tools, analyze barriers and facilitators, and investigate its overall impacts.

This qualitative scoping review was conducted using Arksey and O’Malley’s methodological framework. We searched articles in PubMed, Web of Science, Scopus, and EMBASE databases. In addition, we accessed articles from Google Scholar. We used mixed-method analysis, including qualitative content analysis and quantitative descriptive for quantitative findings to summarize findings and PRISMA extension for scoping reviews (PRISMA-ScR) framework to report the overall works.

A total of 87 articles, which covered 14 CQI models, were included in the review. While 19 tools were used for CQI models and initiatives, Plan-Do-Study/Check-Act cycle was the commonly employed model to understand the CQI implementation process. The main reported purposes of using CQI, as its positive impact, are to improve the structure of the health system (e.g., leadership, health workforce, health technology use, supplies, and costs), enhance healthcare delivery processes and outputs (e.g., care coordination and linkages, satisfaction, accessibility, continuity of care, safety, and efficiency), and improve treatment outcome (reduce morbidity and mortality). The implementation of CQI is not without challenges. There are cultural (i.e., resistance/reluctance to quality-focused culture and fear of blame or punishment), technical, structural (related to organizational structure, processes, and systems), and strategic (inadequate planning and inappropriate goals) related barriers that were commonly reported during the implementation of CQI.

Conclusions

Implementing CQI initiatives necessitates thoroughly comprehending key principles such as teamwork and timeline. To effectively address challenges, it’s crucial to identify obstacles and implement optimal interventions proactively. Healthcare professionals and leaders need to be mentally equipped and cognizant of the significant role CQI initiatives play in achieving purposes for quality of care.

Peer Review reports

Continuous quality improvement (CQI) initiative is a crucial initiative aimed at enhancing quality in the health system that has gradually been adopted in the healthcare industry. In the early 20th century, Shewhart laid the foundation for quality improvement by describing three essential steps for process improvement: specification, production, and inspection [ 1 , 2 ]. Then, Deming expanded Shewhart’s three-step model into ‘plan, do, study/check, and act’ (PDSA or PDCA) cycle, which was applied to management practices in Japan in the 1950s [ 3 ] and was gradually translated into the health system. In 1991, Kuperman applied a CQI approach to healthcare, comprising selecting a process to be improved, assembling a team of expert clinicians that understands the process and the outcomes, determining key steps in the process and expected outcomes, collecting data that measure the key process steps and outcomes, and providing data feedback to the practitioners [ 4 ]. These philosophies have served as the baseline for the foundation of principles for continuous improvement [ 5 ].

Continuous quality improvement fosters a culture of continuous learning, innovation, and improvement. It encourages proactive identification and resolution of problems, promotes employee engagement and empowerment, encourages trust and respect, and aims for better quality of care [ 6 , 7 ]. These characteristics drive the interaction of CQI with other quality improvement projects, such as quality assurance and total quality management [ 8 ]. Quality assurance primarily focuses on identifying deviations or errors through inspections, audits, and formal reviews, often settling for what is considered ‘good enough’, rather than pursuing the highest possible standards [ 9 , 10 ], while total quality management is implemented as the management philosophy and system to improve all aspects of an organization continuously [ 11 ].

Continuous quality improvement has been implemented to provide quality care. However, providing effective healthcare is a complicated and complex task in achieving the desired health outcomes and the overall well-being of individuals and populations. It necessitates tackling issues, including access, patient safety, medical advances, care coordination, patient-centered care, and quality monitoring [ 12 , 13 ], rooted long ago. It is assumed that the history of quality improvement in healthcare started in 1854 when Florence Nightingale introduced quality improvement documentation [ 14 ]. Over the passing decades, Donabedian introduced structure, processes, and outcomes as quality of care components in 1966 [ 15 ]. More comprehensively, the Institute of Medicine in the United States of America (USA) has identified effectiveness, efficiency, equity, patient-centredness, safety, and timeliness as the components of quality of care [ 16 ]. Moreover, quality of care has recently been considered an integral part of universal health coverage (UHC) [ 17 ], which requires initiatives to mobilise essential inputs [ 18 ].

While the overall objective of CQI in health system is to enhance the quality of care, it is important to note that the purposes and principles of CQI can vary across different contexts [ 19 , 20 ]. This variation has sparked growing research interest. For instance, a review of CQI approaches for capacity building addressed its role in health workforce development [ 21 ]. Another systematic review, based on random-controlled design studies, assessed the effectiveness of CQI using training as an intervention and the PDSA model [ 22 ]. As a research gap, the former review was not directly related to the comprehensive elements of quality of care, while the latter focused solely on the impact of training using the PDSA model, among other potential models. Additionally, a review conducted in 2015 aimed to identify barriers and facilitators of CQI in Canadian contexts [ 23 ]. However, all these reviews presented different perspectives and investigated distinct outcomes. This suggests that there is still much to explore in terms of comprehensively understanding the various aspects of CQI initiatives in healthcare.

As a result, we conducted a scoping review to address several aspects of CQI. Scoping reviews serve as a valuable tool for systematically mapping the existing literature on a specific topic. They are instrumental when dealing with heterogeneous or complex bodies of research. Scoping reviews provide a comprehensive overview by summarizing and disseminating findings across multiple studies, even when evidence varies significantly [ 24 ]. In our specific scoping review, we included various types of literature, including systematic reviews, to enhance our understanding of CQI.

This scoping review examined how CQI is conceptualized and measured and investigated models and tools for its application while identifying implementation challenges and facilitators. It also analyzed the purposes and impact of CQI on the health systems, providing valuable insights for enhancing healthcare quality.

Protocol registration and results reporting

Protocol registration for this scoping review was not conducted. Arksey and O’Malley’s methodological framework was utilized to conduct this scoping review [ 25 ]. The scoping review procedures start by defining the research questions, identifying relevant literature, selecting articles, extracting data, and summarizing the results. The review findings are reported using the PRISMA extension for a scoping review (PRISMA-ScR) [ 26 ]. McGowan and colleagues also advised researchers to report findings from scoping reviews using PRISMA-ScR [ 27 ].

Defining the research problems

This review aims to comprehensively explore the conceptualization, models, tools, barriers, facilitators, and impacts of CQI within the healthcare system worldwide. Specifically, we address the following research questions: (1) How has CQI been defined across various contexts? (2) What are the diverse approaches to implementing CQI in healthcare settings? (3) Which tools are commonly employed for CQI implementation ? (4) What barriers hinder and facilitators support successful CQI initiatives? and (5) What effects CQI initiatives have on the overall care quality?

Information source and search strategy

We conducted the search in PubMed, Web of Science, Scopus, and EMBASE databases, and the Google Scholar search engine. The search terms were selected based on three main distinct concepts. One group was CQI-related terms. The second group included terms related to the purpose for which CQI has been implemented, and the third group included processes and impact. These terms were selected based on the Donabedian framework of structure, process, and outcome [ 28 ]. Additionally, the detailed keywords were recruited from the primary health framework, which has described lists of dimensions under process, output, outcome, and health system goals of any intervention for health [ 29 ]. The detailed search strategy is presented in the Supplementary file 1 (Search strategy). The search for articles was initiated on August 12, 2023, and the last search was conducted on September 01, 2023.

Eligibility criteria and article selection

Based on the scoping review’s population, concept, and context frameworks [ 30 ], the population included any patients or clients. Additionally, the concepts explored in the review encompassed definitions, implementation, models, tools, barriers, facilitators, and impacts of CQI. Furthermore, the review considered contexts at any level of health systems. We included articles if they reported results of qualitative or quantitative empirical study, case studies, analytic or descriptive synthesis, any review, and other written documents, were published in peer-reviewed journals, and were designed to address at least one of the identified research questions or one of the identified implementation outcomes or their synonymous taxonomy as described in the search strategy. Based on additional contexts, we included articles published in English without geographic and time limitations. We excluded articles with abstracts only, conference abstracts, letters to editors, commentators, and corrections.

We exported all citations to EndNote x20 to remove duplicates and screen relevant articles. The article selection process includes automatic duplicate removal by using EndNote x20, unmatched title and abstract removal, citation and abstract-only materials removal, and full-text assessment. The article selection process was mainly conducted by the first author (AE) and reported to the team during the weekly meetings. The first author encountered papers that caused confusion regarding whether to include or exclude them and discussed them with the last author (YA). Then, decisions were ultimately made. Whenever disagreements happened, they were resolved by discussion and reconsideration of the review questions in relation to the written documents of the article. Further statistical analysis, such as calculating Kappa, was not performed to determine article inclusion or exclusion.

Data extraction and data items

We extracted first author, publication year, country, settings, health problem, the purpose of the study, study design, types of intervention if applicable, CQI approaches/steps if applicable, CQI tools and procedures if applicable, and main findings using a customized Microsoft Excel form.

Summarizing and reporting the results

The main findings were summarized and described based on the main themes, including concepts under conceptualizing, principles, teams, timelines, models, tools, barriers, facilitators, and impacts of CQI. Results-based convergent synthesis, achieved through mixed-method analysis, involved content analysis to identify the thematic presentation of findings. Additionally, a narrative description was used for quantitative findings, aligning them with the appropriate theme. The authors meticulously reviewed the primary findings from each included material and contextualized these findings concerning the main themes1. This approach provides a comprehensive understanding of complex interventions and health systems, acknowledging quantitative and qualitative evidence.

Search results

A total of 11,251 documents were identified from various databases: SCOPUS ( n  = 4,339), PubMed ( n  = 2,893), Web of Science ( n  = 225), EMBASE ( n  = 3,651), and Google Scholar ( n  = 143). After removing duplicates ( n  = 5,061), 6,190 articles were evaluated by title and abstract. Subsequently, 208 articles were assessed for full-text eligibility. Following the eligibility criteria, 121 articles were excluded, leaving 87 included in the current review (Fig.  1 ).

Article selection process

Operationalizing continuous quality improvement

Continuous Quality Improvement (CQI) is operationalized as a cyclic process that requires commitment to implementation, teamwork, time allocation, and celebrating successes and failures.

CQI is a cyclic ongoing process that is followed reflexive, analytical and iterative steps, including identifying gaps, generating data, developing and implementing action plans, evaluating performance, providing feedback to implementers and leaders, and proposing necessary adjustments [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ].

CQI requires committing to the philosophy, involving continuous improvement [ 19 , 38 ], establishing a mission statement [ 37 ], and understanding quality definition [ 19 ].

CQI involves a wide range of patient-oriented measures and performance indicators, specifically satisfying internal and external customers, developing quality assurance, adopting common quality measures, and selecting process measures [ 8 , 19 , 35 , 36 , 37 , 39 , 40 ].

CQI requires celebrating success and failure without personalization, leading each team member to develop error-free attitudes [ 19 ]. Success and failure are related to underlying organizational processes and systems as causes of failure rather than blaming individuals [ 8 ] because CQI is process-focused based on collaborative, data-driven, responsive, rigorous and problem-solving statistical analysis [ 8 , 19 , 38 ]. Furthermore, a gap or failure opens another opportunity for establishing a data-driven learning organization [ 41 ].

CQI cannot be implemented without a CQI team [ 8 , 19 , 37 , 39 , 42 , 43 , 44 , 45 , 46 ]. A CQI team comprises individuals from various disciplines, often comprising a team leader, a subject matter expert (physician or other healthcare provider), a data analyst, a facilitator, frontline staff, and stakeholders [ 39 , 43 , 47 , 48 , 49 ]. It is also important to note that inviting stakeholders or partners as part of the CQI support intervention is crucial [ 19 , 38 , 48 ].

The timeline is another distinct feature of CQI because the results of CQI vary based on the implementation duration of each cycle [ 35 ]. There is no specific time limit for CQI implementation, although there is a general consensus that a cycle of CQI should be relatively short [ 35 ]. For instance, a CQI implementation took 2 months [ 42 ], 4 months [ 50 ], 9 months [ 51 , 52 ], 12 months [ 53 , 54 , 55 ], and one year and 5 months [ 49 ] duration to achieve the desired positive outcome, while bi-weekly [ 47 ] and monthly data reviews and analyses [ 44 , 48 , 56 ], and activities over 3 months [ 57 ] have also resulted in a positive outcome.

Continuous quality improvement models and tools

There have been several models are utilized. The Plan-Do-Study/Check-Act cycle is a stepwise process involving project initiation, situation analysis, root cause identification, solution generation and selection, implementation, result evaluation, standardization, and future planning [ 7 , 36 , 37 , 45 , 47 , 48 , 49 , 50 , 51 , 53 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 ]. The FOCUS-PDCA cycle enhances the PDCA process by adding steps to find and improve a process (F), organize a knowledgeable team (O), clarify the process (C), understand variations (U), and select improvements (S) [ 55 , 71 , 72 , 73 ]. The FADE cycle involves identifying a problem (Focus), understanding it through data analysis (Analyze), devising solutions (Develop), and implementing the plan (Execute) [ 74 ]. The Logic Framework involves brainstorming to identify improvement areas, conducting root cause analysis to develop a problem tree, logically reasoning to create an objective tree, formulating the framework, and executing improvement projects [ 75 ]. Breakthrough series approach requires CQI teams to meet in quarterly collaborative learning sessions, share learning experiences, and continue discussion by telephone and cross-site visits to strengthen learning and idea exchange [ 47 ]. Another CQI model is the Lean approach, which has been conducted with Kaizen principles [ 52 ], 5 S principles, and the Six Sigma model. The 5 S (Sort, Set/Straighten, Shine, Standardize, Sustain) systematically organises and improves the workplace, focusing on sorting, setting order, shining, standardizing, and sustaining the improvement [ 54 , 76 ]. Kaizen principles guide CQI by advocating for continuous improvement, valuing all ideas, solving problems, focusing on practical, low-cost improvements, using data to drive change, acknowledging process defects, reducing variability and waste, recognizing every interaction as a customer-supplier relationship, empowering workers, responding to all ideas, and maintaining a disciplined workplace [ 77 ]. Lean Six Sigma, a CQI model, applies the DMAIC methodology, which involves defining (D) and measuring the problem (M), analyzing root causes (A), improving by finding solutions (I), and controlling by assessing process stability (C) [ 78 , 79 ]. The 5 C-cyclic model (consultation, collection, consideration, collaboration, and celebration), the first CQI framework for volunteer dental services in Aboriginal communities, ensures quality care based on community needs [ 80 ]. One study used meetings involving activities such as reviewing objectives, assigning roles, discussing the agenda, completing tasks, retaining key outputs, planning future steps, and evaluating the meeting’s effectiveness [ 81 ].

Various tools are involved in the implementation or evaluation of CQI initiatives: checklists [ 53 , 82 ], flowcharts [ 81 , 82 , 83 ], cause-and-effect diagrams (fishbone or Ishikawa diagrams) [ 60 , 62 , 79 , 81 , 82 ], fuzzy Pareto diagram [ 82 ], process maps [ 60 ], time series charts [ 48 ], why-why analysis [ 79 ], affinity diagrams and multivoting [ 81 ], and run chart [ 47 , 48 , 51 , 60 , 84 ], and others mentioned in the table (Table  1 ).

Barriers and facilitators of continuous quality improvement implementation

Implementing CQI initiatives is determined by various barriers and facilitators, which can be thematized into four dimensions. These dimensions are cultural, technical, structural, and strategic dimensions.

Continuous quality improvement initiatives face various cultural, strategic, technical, and structural barriers. Cultural dimension barriers involve resistance to change (e.g., not accepting online technology), lack of quality-focused culture, staff reporting apprehensiveness, and fear of blame or punishment [ 36 , 41 , 85 , 86 ]. The technical dimension barriers of CQI can include various factors that hinder the effective implementation and execution of CQI processes [ 36 , 86 , 87 , 88 , 89 ]. Structural dimension barriers of CQI arise from the organization structure, process, and systems that can impede the effective implementation and sustainability of CQI [ 36 , 85 , 86 , 87 , 88 ]. Strategic dimension barriers are, for example, the inability to select proper CQI goals and failure to integrate CQI into organizational planning and goals [ 36 , 85 , 86 , 87 , 88 , 90 ].

Facilitators are also grouped to cultural, structural, technical, and strategic dimensions to provide solutions to CQI barriers. Cultural challenges were addressed by developing a group culture to CQI and other rewards [ 39 , 41 , 80 , 85 , 86 , 87 , 90 , 91 , 92 ]. Technical facilitators are pivotal to improving technical barriers [ 39 , 42 , 53 , 69 , 86 , 90 , 91 ]. Structural-related facilitators are related to improving communication, infrastructure, and systems [ 86 , 92 , 93 ]. Strategic dimension facilitators include strengthening leadership and improving decision-making skills [ 43 , 53 , 67 , 86 , 87 , 92 , 94 , 95 ] (Table  2 ).

Impact of continuous quality improvement

Continuous quality improvement initiatives can significantly impact the quality of healthcare in a wide range of health areas, focusing on improving structure, the health service delivery process and improving client wellbeing and reducing mortality.

Structure components

These are health leadership, financing, workforce, technology, and equipment and supplies. CQI has improved planning, monitoring and evaluation [ 48 , 53 ], and leadership and planning [ 48 ], indicating improvement in leadership perspectives. Implementing CQI in primary health care (PHC) settings has shown potential for maintaining or reducing operation costs [ 67 ]. Findings from another study indicate that the costs associated with implementing CQI interventions per facility ranged from approximately $2,000 to $10,500 per year, with an average cost of approximately $10 to $60 per admitted client [ 57 ]. However, based on model predictions, the average cost savings after implementing CQI were estimated to be $5430 [ 31 ]. CQI can also be applied to health workforce development [ 32 ]. CQI in the institutional system improved medical education [ 66 , 96 , 97 ], human resources management [ 53 ], motivated staffs [ 76 ], and increased staff health awareness [ 69 ], while concerns raised about CQI impartiality, independence, and public accountability [ 96 ]. Regarding health technology, CQI also improved registration and documentation [ 48 , 53 , 98 ]. Furthermore, the CQI initiatives increased cleanliness [ 54 ] and improved logistics, supplies, and equipment [ 48 , 53 , 68 ].

Process and output components

The process component focuses on the activities and actions involved in delivering healthcare services.

Service delivery

CQI interventions improved service delivery [ 53 , 56 , 99 ], particularly a significant 18% increase in the overall quality of service performance [ 48 ], improved patient counselling, adherence to appropriate procedures, and infection prevention [ 48 , 68 ], and optimised workflow [ 52 ].

Coordination and collaboration

CQI initiatives improved coordination and collaboration through collecting and analysing data, onsite technical support, training, supportive supervision [ 53 ] and facilitating linkages between work processes and a quality control group [ 65 ].

Patient satisfaction

The CQI initiatives increased patient satisfaction and improved quality of life by optimizing care quality management, improving the quality of clinical nursing, reducing nursing defects and enhancing the wellbeing of clients [ 54 , 76 , 100 ], although CQI was not associated with changes in adolescent and young adults’ satisfaction [ 51 ].

CQI initiatives reduced medication error reports from 16 to 6 [ 101 ], and it significantly reduced the administration of inappropriate prophylactic antibiotics [ 44 ], decreased errors in inpatient care [ 52 ], decreased the overall episiotomy rate from 44.5 to 33.3% [ 83 ], reduced the overall incidence of unplanned endotracheal extubation [ 102 ], improving appropriate use of computed tomography angiography [ 103 ], and appropriate diagnosis and treatment selection [ 47 ].

Continuity of care

CQI initiatives effectively improve continuity of care by improving client and physician interaction. For instance, provider continuity levels showed a 64% increase [ 55 ]. Modifying electronic medical record templates, scheduling, staff and parental education, standardization of work processes, and birth to 1-year age-specific incentives in post-natal follow-up care increased continuity of care to 74% in 2018 compared to baseline 13% in 2012 [ 84 ].

The CQI initiative yielded enhanced efficiency in the cardiac catheterization laboratory, as evidenced by improved punctuality in procedure starts and increased efficiency in manual sheath-pulls inside [ 78 ].

Accessibility

CQI initiatives were effective in improving accessibility in terms of increasing service coverage and utilization rate. For instance, screening for cigarettes, nutrition counselling, folate prescription, maternal care, immunization coverage [ 53 , 81 , 104 , 105 ], reducing the percentage of non-attending patients to surgery to 0.9% from the baseline 3.9% [ 43 ], increasing Chlamydia screening rates from 29 to 60% [ 45 ], increasing HIV care continuum coverage [ 51 , 59 , 60 ], increasing in the uptake of postpartum long-acting reversible contraceptive use from 6.9% at the baseline to 25.4% [ 42 ], increasing post-caesarean section prophylaxis from 36 to 89% [ 62 ], a 31% increase of kangaroo care practice [ 50 ], and increased follow-up [ 65 ]. Similarly, the QI intervention increased the quality of antenatal care by 29.3%, correct partograph use by 51.7%, and correct active third-stage labour management, a 19.6% improvement from the baseline, but not significantly associated with improvement in contraceptive service uptake [ 61 ].

Timely access

CQI interventions improved the time care provision [ 52 ], and reduced waiting time [ 62 , 74 , 76 , 106 ]. For instance, the discharge process waiting time in the emergency department decreased from 76 min to 22 min [ 79 ]. It also reduced mean postprocedural length of stay from 2.8 days to 2.0 days [ 31 ].

Acceptability

Acceptability of CQI by healthcare providers was satisfactory. For instance, 88% of the faculty, 64% of the residents, and 82% of the staff believed CQI to be useful in the healthcare clinic [ 107 ].

Outcome components

Morbidity and mortality.

CQI efforts have demonstrated better management outcomes among diabetic patients [ 40 ], patients with oral mucositis [ 71 ], and anaemic patients [ 72 ]. It has also reduced infection rate in post-caesarean Sect. [ 62 ], reduced post-peritoneal dialysis peritonitis [ 49 , 108 ], and prevented pressure ulcers [ 70 ]. It is explained by peritonitis incidence from once every 40.1 patient months at baseline to once every 70.8 patient months after CQI [ 49 ] and a 63% reduction in pressure ulcer prevalence within 2 years from 2008 to 2010 [ 70 ]. Furthermore, CQI initiatives significantly reduced in-hospital deaths [ 31 ] and increased patient survival rates [ 108 ]. Figure  2 displays the overall process of the CQI implementations.

The overall mechanisms of continuous quality improvement implementation

In this review, we examined the fundamental concepts and principles underlying CQI, the factors that either hinder or assist in its successful application and implementation, and the purpose of CQI in enhancing quality of care across various health issues.

Our findings have brought attention to the application and implementation of CQI, emphasizing its underlying concepts and principles, as evident in the existing literature [ 31 , 32 , 33 , 34 , 35 , 36 , 39 , 40 , 43 , 45 , 46 ]. Continuous quality improvement has shared with the principles of continuous improvement, such as a customer-driven focus, effective leadership, active participation of individuals, a process-oriented approach, systematic implementation, emphasis on design improvement and prevention, evidence-based decision-making, and fostering partnership [ 5 ]. Moreover, Deming’s 14 principles laid the foundation for CQI principles [ 109 ]. These principles have been adapted and put into practice in various ways: ten [ 19 ] and five [ 38 ] principles in hospitals, five principles for capacity building [ 38 ], and two principles for medication error prevention [ 41 ]. As a principle, the application of CQI can be process-focused [ 8 , 19 ] or impact-focused [ 38 ]. Impact-focused CQI focuses on achieving specific outcomes or impacts, whereas process-focused CQI prioritizes and improves the underlying processes and systems. These principles complement each other and can be utilized based on the objectives of quality improvement initiatives in healthcare settings. Overall, CQI is an ongoing educational process that requires top management’s involvement, demands coordination across departments, encourages the incorporation of views beyond clinical area, and provides non-judgemental evidence based on objective data [ 110 ].

The current review recognized that it was not easy to implement CQI. It requires reasonable utilization of various models and tools. The application of each tool can be varied based on the studied health problem and the purpose of CQI initiative [ 111 ], varied in context, content, structure, and usability [ 112 ]. Additionally, overcoming the cultural, technical, structural, and strategic-related barriers. These barriers have emerged from clinical staff, managers, and health systems perspectives. Of the cultural obstacles, staff non-involvement, resistance to change, and reluctance to report error were staff-related. In contrast, others, such as the absence of celebration for success and hierarchical and rational culture, may require staff and manager involvement. Staff members may exhibit reluctance in reporting errors due to various cultural factors, including lack of trust, hierarchical structures, fear of retribution, and a blame-oriented culture. These challenges pose obstacles to implementing standardized CQI practices, as observed, for instance, in community pharmacy settings [ 85 ]. The hierarchical culture, characterized by clearly defined levels of power, authority, and decision-making, posed challenges to implementing CQI initiatives in public health [ 41 , 86 ]. Although rational culture, a type of organizational culture, emphasizes logical thinking and rational decision-making, it can also create challenges for CQI implementation [ 41 , 86 ] because hierarchical and rational cultures, which emphasize bureaucratic norms and narrow definitions of achievement, were found to act as barriers to the implementation of CQI [ 86 ]. These could be solved by developing a shared mindset and collective commitment, establishing a shared purpose, developing group norms, and cultivating psychological preparedness among staff, managers, and clients to implement and sustain CQI initiatives. Furthermore, reversing cultural-related barriers necessitates cultural-related solutions: development of a culture and group culture to CQI [ 41 , 86 ], positive comprehensive perception [ 91 ], commitment [ 85 ], involving patients, families, leaders, and staff [ 39 , 92 ], collaborating for a common goal [ 80 , 86 ], effective teamwork [ 86 , 87 ], and rewarding and celebrating successes [ 80 , 90 ].

The technical dimension barriers of CQI can include inadequate capitalization of a project and insufficient support for CQI facilitators and data entry managers [ 36 ], immature electronic medical records or poor information systems [ 36 , 86 ], and the lack of training and skills [ 86 , 87 , 88 ]. These challenges may cause the CQI team to rely on outdated information and technologies. The presence of barriers on the technical dimension may challenge the solid foundation of CQI expertise among staff, the ability to recognize opportunities for improvement, a comprehensive understanding of how services are produced and delivered, and routine use of expertise in daily work. Addressing these technical barriers requires knowledge creation activities (training, seminar, and education) [ 39 , 42 , 53 , 69 , 86 , 90 , 91 ], availability of quality data [ 86 ], reliable information [ 92 ], and a manual-online hybrid reporting system [ 85 ].

Structural dimension barriers of CQI include inadequate communication channels and lack of standardized process, specifically weak physician-to-physician synergies [ 36 ], lack of mechanisms for disseminating knowledge and limited use of communication mechanisms [ 86 ]. Lack of communication mechanism endangers sharing ideas and feedback among CQI teams, leading to misunderstandings, limited participation and misinterpretations, and a lack of learning [ 113 ]. Knowledge translation facilitates the co-production of research, subsequent diffusion of knowledge, and the developing stakeholder’s capacity and skills [ 114 ]. Thus, the absence of a knowledge translation mechanism may cause missed opportunities for learning, inefficient problem-solving, and limited creativity. To overcome these challenges, organizations should establish effective communication and information systems [ 86 , 93 ] and learning systems [ 92 ]. Though CQI and knowledge translation have interacted with each other, it is essential to recognize that they are distinct. CQI focuses on process improvement within health care systems, aiming to optimize existing processes, reduce errors, and enhance efficiency.

In contrast, knowledge translation bridges the gap between research evidence and clinical practice, translating research findings into actionable knowledge for practitioners. While both CQI and knowledge translation aim to enhance health care quality and patient outcomes, they employ different strategies: CQI utilizes tools like Plan-Do-Study-Act cycles and statistical process control, while knowledge translation involves knowledge synthesis and dissemination. Additionally, knowledge translation can also serve as a strategy to enhance CQI. Both concepts share the same principle: continuous improvement is essential for both. Therefore, effective strategies on the structural dimension may build efficient and effective steering councils, information systems, and structures to diffuse learning throughout the organization.

Strategic factors, such as goals, planning, funds, and resources, determine the overall purpose of CQI initiatives. Specific barriers were improper goals and poor planning [ 36 , 86 , 88 ], fragmentation of quality assurance policies [ 87 ], inadequate reinforcement to staff [ 36 , 90 ], time constraints [ 85 , 86 ], resource inadequacy [ 86 ], and work overload [ 86 ]. These barriers can be addressed through strengthening leadership [ 86 , 87 ], CQI-based mentoring [ 94 ], periodic monitoring, supportive supervision and coaching [ 43 , 53 , 87 , 92 , 95 ], participation, empowerment, and accountability [ 67 ], involving all stakeholders in decision-making [ 86 , 87 ], a provider-payer partnership [ 64 ], and compensating staff for after-hours meetings on CQI [ 85 ]. The strategic dimension, characterized by a strategic plan and integrated CQI efforts, is devoted to processes that are central to achieving strategic priorities. Roles and responsibilities are defined in terms of integrated strategic and quality-related goals [ 115 ].

The utmost goal of CQI has been to improve the quality of care, which is usually revealed by structure, process, and outcome. After resolving challenges and effectively using tools and running models, the goal of CQI reflects the ultimate reason and purpose of its implementation. First, effectively implemented CQI initiatives can improve leadership, health financing, health workforce development, health information technology, and availability of supplies as the building blocks of a health system [ 31 , 48 , 53 , 68 , 98 ]. Second, effectively implemented CQI initiatives improved care delivery process (counselling, adherence with standards, coordination, collaboration, and linkages) [ 48 , 53 , 65 , 68 ]. Third, the CQI can improve outputs of healthcare delivery, such as satisfaction, accessibility (timely access, utilization), continuity of care, safety, efficiency, and acceptability [ 52 , 54 , 55 , 76 , 78 ]. Finally, the effectiveness of the CQI initiatives has been tested in enhancing responses related to key aspects of the HIV response, maternal and child health, non-communicable disease control, and others (e.g., surgery and peritonitis). However, it is worth noting that CQI initiative has not always been effective. For instance, CQI using a two- to nine-times audit cycle model through systems assessment tools did not bring significant change to increase syphilis testing performance [ 116 ]. This study was conducted within the context of Aboriginal and Torres Strait Islander people’s primary health care settings. Notably, ‘the clinics may not have consistently prioritized syphilis testing performance in their improvement strategies, as facilitated by the CQI program’ [ 116 ]. Additionally, by applying CQI-based mentoring, uptake of facility-based interventions was not significantly improved, though it was effective in increasing community health worker visits during pregnancy and the postnatal period, knowledge about maternal and child health and exclusive breastfeeding practice, and HIV disclosure status [ 117 ]. The study conducted in South Africa revealed no significant association between the coverage of facility-based interventions and Continuous Quality Improvement (CQI) implementation. This lack of association was attributed to the already high antenatal and postnatal attendance rates in both control and intervention groups at baseline, leaving little room for improvement. Additionally, the coverage of HIV interventions remained consistently high throughout the study period [ 117 ].

Regarding health care and policy implications, CQI has played a vital role in advancing PHC and fostering the realization of UHC goals worldwide. The indicators found in Donabedian’s framework that are positively influenced by CQI efforts are comparable to those included in the PHC performance initiative’s conceptual framework [ 29 , 118 , 119 ]. It is clearly explained that PHC serves as the roadmap to realizing the vision of UHC [ 120 , 121 ]. Given these circumstances, implementing CQI can contribute to the achievement of PHC principles and the objectives of UHC. For instance, by implementing CQI methods, countries have enhanced the accessibility, affordability, and quality of PHC services, leading to better health outcomes for their populations. CQI has facilitated identifying and resolving healthcare gaps and inefficiencies, enabling countries to optimize resource allocation and deliver more effective and patient-centered care. However, it is crucial to recognize that the successful implementation of Continuous Quality Improvement (CQI) necessitates optimizing the duration of each cycle, understanding challenges and barriers that extend beyond the health system and settings, and acknowledging that its effectiveness may be compromised if these challenges are not adequately addressed.

Despite abundant literature, there are still gaps regarding the relationship between CQI and other dimensions within the healthcare system. No studies have examined the impact of CQI initiatives on catastrophic health expenditure, effective service coverage, patient-centredness, comprehensiveness, equity, health security, and responsiveness.

Limitations

In conducting this review, it has some limitations to consider. Firstly, only articles published in English were included, which may introduce the exclusion of relevant non-English articles. Additionally, as this review follows a scoping methodology, the focus is on synthesising available evidence rather than critically evaluating or scoring the quality of the included articles.

Continuous quality improvement is investigated as a continuous and ongoing intervention, where the implementation time can vary across different cycles. The CQI team and implementation timelines were critical elements of CQI in different models. Among the commonly used approaches, the PDSA or PDCA is frequently employed. In most CQI models, a wide range of tools, nineteen tools, are commonly utilized to support the improvement process. Cultural, technical, structural, and strategic barriers and facilitators are significant in implementing CQI initiatives. Implementing the CQI initiative aims to improve health system blocks, enhance health service delivery process and output, and ultimately prevent morbidity and reduce mortality. For future researchers, considering that CQI is context-dependent approach, conducting scale-up implementation research about catastrophic health expenditure, effective service coverage, patient-centredness, comprehensiveness, equity, health security, and responsiveness across various settings and health issues would be valuable.

Availability of data and materials

The data used and/or analyzed during the current study are available in this manuscript and/or the supplementary file.

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Endalamaw, A., Khatri, R.B., Mengistu, T.S. et al. A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact. BMC Health Serv Res 24 , 487 (2024). https://doi.org/10.1186/s12913-024-10828-0

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A scoping review of academic and grey literature on migrant health research conducted in Scotland

• G. Petrie 1 ,
• K. Angus 2 &
• R. O’Donnell 2  

BMC Public Health volume  24 , Article number:  1156 ( 2024 ) Cite this article

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Migration to Scotland has increased since 2002 with an increase in European residents and participation in the Asylum dispersal scheme. Scotland has become more ethnically diverse, and 10% of the current population were born abroad. Migration and ethnicity are determinants of health, and information on the health status of migrants to Scotland and their access to and barriers to care facilitates the planning and delivery of equitable health services. This study aimed to scope existing peer-reviewed research and grey literature to identify gaps in evidence regarding the health of migrants in Scotland.

A scoping review on the health of migrants in Scotland was carried out for dates January 2002 to March 2023, inclusive of peer-reviewed journals and grey literature. CINAHL/ Web of Science/SocIndex and Medline databases were systematically searched along with government and third-sector websites. The searches identified 2166 journal articles and 170 grey literature documents for screening. Included articles were categorised according to the World Health Organisation’s 2016 Strategy and Action Plan for Refugee and Migrant Health in the European region. This approach builds on a previously published literature review on Migrant Health in the Republic of Ireland.

Seventy-one peer reviewed journal articles and 29 grey literature documents were included in the review. 66% were carried out from 2013 onwards and the majority focused on asylum seekers or unspecified migrant groups. Most research identified was on the World Health Organisation’s strategic areas of right to health of refugees, social determinants of health and public health planning and strengthening health systems. There were fewer studies on the strategic areas of frameworks for collaborative action, preventing communicable disease, preventing non-communicable disease, health screening and assessment and improving health information and communication.

While research on migrant health in Scotland has increased in recent years significant gaps remain. Future priorities should include studies of undocumented migrants, migrant workers, and additional research is required on the issue of improving health information and communication.

Peer Review reports

The term migrant is defined by the International Organisation for Migration as “ a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons. The term includes several well-defined legal categories of people, including migrant workers; persons whose particular types of movements are legally-defined, such as smuggled migrants; as well as those whose status are not specifically defined under international law, such as international students.” [ 1 ] Internationally there are an estimated 281 million migrants – 3.6% of the world population, including 26.4 million refugees and 4.1 million asylum seekers – the highest number ever recorded [ 2 ]. The UN Refugee Society defines the term refugee as “ someone who has been forced to flee his or her country because of persecution, war or violence…most likely, they cannot return home or are afraid to do so .” The term asylum-seeker is defined as “someone whose request for sanctuary has yet to be processed.” [ 3 ].

Net-migration to Europe was negative in the 19th century due to higher levels of emigration, however in the mid-20th century immigration began to rise, because of an increase in migrant workers and following conflicts in the Middle East and North Africa [ 4 ]. Current migration drivers include conflicts alongside world-wide economic instability, exacerbated by the Covid-19 pandemic [ 5 ]. Environmental damage due to climate change is expected to inflate the number of asylum seekers entering Europe in future [ 6 ]. The increase in migration to Europe is not a short-term influx but a long-term phenomenon, and European nations must adapt and find solutions to resulting financial, safeguarding and health challenges [ 7 ].

Data on healthcare use by migrants in Europe is variable, which means cross-country comparisons are inadequate [ 8 ]. Many countries do not record migration information within health records and all use disparate criteria to classify migrant status. The lack of comparative data hinders public health surveillance and effective interventions [ 9 ]. Even where information is available, results can be contradictory due to the multifarious migrant population. Migrants have a wide range of origin countries, socio-economic position, age and journeys undertaken which can affect health status [ 10 ].

Migrants initially may have better health than the general population, known as the ‘Healthy Migrant effect’ [ 11 ]. However, health declines with increasing length of residence [ 12 ] and over time to levels comparable with the general population [ 13 ]. Second generation immigrants may have higher mortality than average [ 14 ]. The process of acculturation to the host country, with adoption of unhealthy lifestyle and behaviours, increases the risk for chronic disease [ 15 ]. In addition, inequalities in health of migrants compared to host populations has been confirmed by wide-ranging research [ 16 ].

Host countries may limit healthcare access, with undocumented migrants sometimes only entitled to emergency care [ 17 ]. Even when access is granted, inequitable services can affect quality of care due to language barriers and cultural factors [ 18 ]. Poor working/living conditions and discrimination can exacerbate health inequalities [ 12 ]. Processing facilities for asylum seekers are frequently overpopulated, stressful environments [ 19 ] and threat of deportation, lack of citizenship rights and integration can negatively affect health and access to care [ 20 ]. Undocumented workers are unprotected by health and safety legislation leading to dangerous working conditions and injuries [ 15 ].

A systematic review of migrant health in the European Union (EU) found migrants have worse self-perceived health than the general population [ 21 ]. Research evidence indicates increased prevalence of cardiovascular disease, diabetes, mental health disorders and adverse pregnancy outcomes. Exposure to conflict, harsh travel conditions and suboptimal vaccine programmes can mean higher risk of communicable disease [ 22 ]. Scoping reviews have also been conducted to describe trends within migration health research in the United Kingdom (UK) [ 23 ] and identify gaps for future research agendas in the UK [ 23 ] and in the Republic of Ireland [ 24 ].

Almost three-quarters (73%) of published migration health research in the UK has been conducted in England, focusing primarily on infectious diseases and mental health. There is limited evidence on the social determinants of health, access to and use of healthcare and structural and behavioural factors behaviours that influence migrant health in the UK [ 23 ]. By contrast, a large amount of the migration research conducted in the Republic of Ireland has focused on the social determinants of health, and on health system adaptations, with a paucity of research focusing on improving health information systems [ 24 ].

Migration and Health in Scotland

Immigration to Scotland began to rise in 2003 with the expansion of the EU [ 25 ]. The population in Scotland increased from 5.11 million to 5.47 million between 2005 and 2020 and is predicted to continue rising until 2028 [ 26 ] despite low birth rates, with the increased population resulting from inward migration [ 27 ]. Scotland’s population is becoming more ethnically diverse [ 28 ] and susceptibility to different health conditions varies by ethnic group, which has implications for the planning and provision of health services [ 29 ]. 7% of the current Scottish population are non-UK nationals and 10% were born outside Britain. The commonest countries of origin were Poland, Ireland, Italy, Nigeria and India [ 30 ].

Within Scotland, linking health data to ethnicity is standard in order to monitor and improve health of minority groups [ 31 ]. Ethnic background can differ from country of birth which means migration status cannot be assumed [ 32 ], although health inequalities experienced by migrants often extend to affect all ethnic minority groups [ 33 ]. The Scottish Health and Ethnicity Linkage Study (SHELS) linked census data to health records of 91% of the population which has provided information on mortality and morbidity by ethnic group and country of birth [ 34 ]. SHELS research indicates that the white-Scottish population have a higher mortality rate than other ethnic groups. This may be consequent to the comparatively poor health of the Scottish population relative to other European nations: high mortality rates in the general population may cause a perception that the health of minorities is more advantageous than in reality [ 35 ].

Cezard et al’s [ 13 ] analysis of self-perceived health among people in Scotland found that being born abroad had a positive impact on health status. Health declined with increased length of residence, which may be explained by cultural convergence with the majority population. Allik et al. [ 36 ] compared health inequalities by ethnic background and found that with increasing age, health differences reduced thus people aged over 75 of all ethnicities had similar or worse health status than White-Scottish people. While working-age migrants appear to be healthier than the White Scottish population, it cannot be assumed that in future this would extend to older age groups.

Research has shown deprivation as a cause of heath inequalities among ethnic minority and migrant groups [ 37 ]. The socio-economic status of minority ethnic groups in Scotland is unusual, as most are of similar or higher status than the white-Scottish population [ 38 ]. Therefore, public health interventions targeting deprivation may not address risk-factors for ethnic minorities and migrants [ 36 ]. Further research on determinants of health in migrants can help with planning and design of inclusive policies.

The 2011 census indicated that 50% of immigrants lived in the cities of Edinburgh, Glasgow, and Aberdeen. Glasgow had a greater percentage of non-European immigrants due to participation in the Asylum dispersal programme [ 39 ]. 10% of UK asylum seekers are placed in Glasgow, but records are not kept following approval of asylum claims, therefore the size of the refugee population is unknown [ 40 ]. While immigration is controlled by the British government, in policy areas devolved to the Scottish government, refugees and asylum seekers have more rights than elsewhere in UK, including access to primary healthcare for undocumented migrants [ 40 ]. Despite the mitigating effect of Scottish policies, asylum seekers’ health is worsened by the asylum process and associated poverty, marginalisation, and discrimination [ 40 ]. Health deteriorates with increasing length of time in the asylum system [ 40 ] and asylum seekers and refugees have additional health needs and require enhanced support [ 41 ]. Research on the health needs of asylum seekers in Scotland is required to ensure adequate healthcare.

Aim and objectives

While scoping reviews on migrant health have been carried out in Europe [ 12 ], Ireland [ 24 ] and the UK [ 23 ] none are currently specific to the Scottish context. Given the devolved government of Scotland and demographics described above, a targeted review would help to clarify research priorities, with the aim of improving health and health care within the migrant community in Scotland. This work therefore builds on the published scoping review of migrant health in the Republic of Ireland [ 24 ]. The authors recommend replication of the study in other countries to facilitate cross-country comparison. Our aim was to scope peer-reviewed research and grey literature on migrant health conducted in Scotland and identify any gaps in the evidence. Our objectives were to: [1] understand the extent of the available research by topic area [2] summarise the types of research already conducted, populations studied, topics covered and approaches taken [3], map the existing research conducted in Scotland and [4] identify areas for future research based on any gaps in the evidence identified.

A scoping review was conducted as they can aid detection of evidence gaps [ 42 ] and allow incorporation of grey literature in topics with insufficient published research [ 43 ]. Arksey and O’Malley’s [ 44 ] five stage scoping review framework was used.

Stage 1: identifying the research question

Arskey and O’Malley [ 44 ] suggest maintaining a broad approach to identifying the research question, in order to generate breadth of coverage. On this basis, and in line with the research question identified in the Villarroel et al. [ 24 ] scoping review, our research question was framed as follows: What is the scope, main topics and gaps in evidence in the existing literature on health of international migrants living in Scotland? Arksey and O’Malley [ 44 ] highlight the importance of defining terminology at the outset of scoping reviews. For consistency, we used the broad definition of ‘migrant’ as per Villaroel et al. [ 24 ], from the International Organisation for Migration (IOM) [ 1 ]. References to refugees or asylum seekers followed the United Nations Refugee Agency definitions [ 3 ].

Stage 2: identifying relevant studies

Electronic database searches identified reports alongside a grey literature search, in line with Arskey and O’Malley’s [ 44 ] guidance to search for evidence via different sources. CINAHL, Web of Science, SocIndex and Medline academic databases were selected with input from co-authors. Search terms for the review were based upon those used by Villaroel et al. [ 24 ] with additional relevant terms from Hannigan et al. [ 9 ] The strategy combined three sets of terms for: Migrants (e.g., refugee, migrant, immigrant or newcomer), Scotland and Health. Both free text terms and index terms were used and adapted to the 4 academic databases and searches were run on 10th March 2023 (see Additional File 1 for database search strategies). Thirteen Government, University, and third-sector websites in Scotland were scoped for selection then hand-searched for grey literature (listed in Additional File 1 ).

Stage 3: study selection

Net-migration to Scotland increased in the 2000s [ 27 ] hence a date range of January 2002-March 2023 was used to identify evidence. The search was limited to English only. Inclusion/exclusion criteria for the studies were based on those used by Villaroel et al. [ 24 ] and expanded upon following discussion with co-authors (see Table  1 ). Reports were included if based on primary or secondary research on the health of international migrants in Scotland and used qualitative, quantitative or mixed methods research design. International or UK based reports were only included if Scottish results were documented separately. Reports on the health of ethnic minority groups in Scotland was included if place of birth was recorded. Research on internal (non-international) migrants within Scotland, either moving from one Scottish area to another or from another part of the United Kingdom to Scotland, were excluded.

Stage 4: data charting

All records were saved to RefWorks for screening. Records were first screened at title/abstract stage with 10% independently checked by the co-authors. The remaining reports were single screened using full text by the first author. Data from the included records was extracted and organised in tabular form under the following headings, which were agreed by team members: article type (peer-reviewed article or grey literature), publication date, geographical setting, study/intervention’s target population, funding, primary research focus on migrant health (y/n), study objective, data collection method, study design (qualitative/quantitative/mixed) and main finding. Reports were not critically appraised in this scoping review.

Stage 5: collating, summarising and reporting results

A report (either a peer-reviewed journal article or grey literature report) is used as our unit of analysis. In order to present the range of research identified, reports were grouped by the different headings in our data charting table and the outcomes considered for relevance to our scoping review’s aim. Our Results summarise the recency, focus, study designs and funding sources of the identified research, followed by the geographical settings and whether Scotland was included in international research reports. Reports were grouped by their study population and further sub-divided by publication type and geographical area for summarising. Finally, the WHO’s European strategy and action plan (SAAP) for refugee and migrant health [ 7 ] is a policy framework designed to help governments and other stakeholders monitor and improve migrant health in Europe. There are nine strategic areas in the WHO’s SAAP, which prioritise the most salient issues. In line with Villaroel et al’s [ 24 ] approach and in order to compare scoping review outcomes, these areas were used to categorise the findings of this review. Each report was matched to the most appropriate SAAP:

Establishing a Framework for Collaborative Action.

Advocating for the right to health of refugees.

Addressing the social determinants of health.

Achieving public health preparedness and ensuring an effective response.

Strengthening health systems and their resilience.

Preventing communicable disease.

Preventing and reducing the risks caused by non-communicable disease.

Ensuring ethical and effective health screening and assessment.

Improving health information and communication.

The primary focus (aims and objectives) of each report was used to identify the relevant SAAP area/areas. To improve reliability, results were compared using coding criteria used in Villaroel et al’s study (MacFarlane 2023, personal communication, 31st May). 10% of the reports were checked by one co-author to ensure consistent coding to SAAP categories. Any instances of uncertainty in mapping reports to the relevant SAAP area/areas were discussed and resolved by team members.

This scoping review of the literature on migrant health in Scotland identified 2166 records from academic literature databases, following duplicate removal, and 170 records from website searches (see Fig.  1 ). Following screening, a total of 71 peer-reviewed journal articles and 29 grey literature studies (totalling 100 reports) were included for analysis (Results table and reference list are presented in Additional File 2 ).

Flow chart illustrating the identification of sources of evidence included in the scoping review

Overall findings

The majority of reports were published between 2013 and 2022. Fifty-eight reports (58%) focused exclusively on migrant health [ 18 , 39 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 ]. 23 centred on health but included other populations in addition to migrants – for example research on ethnic minorities or other vulnerable groups [ 13 , 31 , 35 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 ]. Seventeen reports were included where the sample population were migrants, but the primary topic was not health – for example destitution, integration, and service needs [ 27 , 73 , 74 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 ]. Health data was reported as part of the wider subject matter. One report [ 136 ] looked at the social determinants of breastfeeding including migrant status and one [ 137 ] compared attitudes to aging and family support between countries.

Funding sources were not declared for 35 (35%) of reports. The Scottish Government funded 20 reports (20%) [ 13 , 27 , 32 , 39 , 45 , 46 , 47 , 66 , 77 , 88 , 99 , 100 , 101 , 102 , 113 , 116 , 119 , 121 , 129 , 134 ]. Other common sources of funding included Government funded public bodies ( n  = 13) [ 45 , 48 , 49 , 50 , 51 , 52 , 53 , 104 , 107 , 113 , 116 , 131 , 136 ], the Scottish Health Service ( n  = 18) (either the National Health Service (NHS) [ 13 , 54 , 56 , 57 , 58 , 59 , 102 , 113 , 116 ], local NHS trusts [ 45 , 60 , 61 , 77 , 102 , 103 , 112 ] or by Public Health Scotland [ 13 , 113 ]) Eleven reports (11%) were funded by Universities. The charity sector financed 15 (15%) reports [ 53 , 63 , 66 , 69 , 70 , 71 , 72 , 73 , 74 , 103 , 111 , 123 , 125 , 132 , 138 ] and the EU and Scottish local authorities funded four reports each [ 45 , 62 , 75 , 76 , 77 , 102 , 125 , 135 ]. Professional bodies financed one report [ 126 ] as did the Japanese government [ 64 ]. No reports received funding from the business sector. The biggest sources of funding for grey literature were Refugee charities (40%) and the Scottish government (30%) (see Fig. 2 ).

Sources of funding for migrant health research in Scotland

Research methods and data collection

52% of reports used qualitative research methods. Forty-five reports (86%) collected data using 1–1 interviews and 24 (46%) used focus groups. Other methods of data collection included questionnaires (six studies (11%)), workshops (two studies (3.85%)) and observation (two studies (3.85%)). Oral/written evidence, guided play sessions, family case studies and participatory activity sessions were used in one report each.

28% of reports used quantitative research methods, most commonly cross section design (ten studies (36%)) and cohort design (18 studies (64%)). Information was obtained from databases including medical records, Census data and national records in 21 reports (75%). Questionnaires were used in six reports (21%). Other methods including body measurements, food diaries, blood samples, interviews and case reviews were used in 1 report each.

20% of reports used mixed methods. The most common method of data collection was questionnaires in 14 reports (70%), interviews in ten reports (50%), focus groups in seven reports (35%), workshops in three reports (13.6%), and databases in three reports (13.6%). Other methods included literature review in two reports (10%), case note reviews in two reports (10%) and one reports each used mapping and school records.

Geographical areas of study

Ninety-one reports were situated in Scotland, of which 35 (38.5%) covered the whole country and 56 (61.5%) specified a city or area where research was undertaken. Some UK and international reports also specified the area of Scotland. The largest share of research within Scotland overall was in Glasgow with 36 reports, followed by Edinburgh with 16 reports, Lothian with six reports, Aberdeen with five reports and Grampian with three reports. The Northeast, Stirling, Highlands, Inverness, Lanarkshire, Motherwell and Selkirk had one report in each area.

There were seven international reports, three on mortality by country of birth [ 75 , 76 , 78 ], one on cross cultural communication [ 79 ], one on maternity care in Poland and Scotland [ 99 ], one comparing attitudes to aging in China and Scotland [ 137 ] and one on the link between birthweights and integration of migrants [ 64 ]. The remaining two reports were UK based, one on immunisation of Roma and traveller communities [ 117 ] and one on the link between ethnic diversity and mortality [ 104 ]. All the included international and UK reports documented the Scottish data separately within results.

Migrant population

Thirty-one reports included all migrants in the study population. The remaining reports included 30 studies on asylum seekers/refugees, 11 on Polish migrants, ten on Africans, six each on South Asians/Chinese/European, three on Arabs, and two on Roma populations (see Fig.  3 ). Most reports did not specify the country of origin for Asylum seekers and refugees - where country of birth was specified, reports were also included in the appropriate category.

Migrant populations studied in health research in Scotland

Grey literature and peer-reviewed reports differed in population focus. The most common populations of interest in grey literature were asylum seekers/refugees consisting of 18 reports (62%) [ 27 , 47 , 54 , 55 , 59 , 63 , 70 , 71 , 72 , 73 , 74 , 123 , 125 , 127 , 128 , 132 , 134 , 138 ] while for peer-reviewed journals 24 reports (34%) focused on all migrants [ 13 , 35 , 45 , 48 , 64 , 76 , 78 , 79 , 80 , 81 , 104 , 105 , 108 , 109 , 113 , 114 , 115 , 116 , 118 , 120 , 121 , 122 , 136 ].

Migrant study population also differed by local area; Glasgow city, where the majority of research occurred, had 18 reports of 36 (50%) on Asylum seekers/refugees [ 47 , 48 , 52 , 53 , 54 , 55 , 58 , 63 , 70 , 71 , 72 , 82 , 83 , 127 , 128 , 130 , 138 , 139 ] eight reports (22%) on Africans [ 52 , 53 , 84 , 85 , 86 , 87 , 106 , 107 ], seven reports (19%) on all migrants [ 45 , 48 , 80 , 102 , 104 , 105 , 121 ] and two reports (5.5%) on Roma migrants [ 103 , 117 ]. Other populations had one reports each. In Edinburgh five reports of 16 (31%) were on the Polish population [ 56 , 67 , 68 , 89 , 90 ], and two reports (12.5%) on Asylum seekers/refugees [ 60 , 133 ], Chinese [ 62 , 137 ], South Asian [ 46 , 119 ], all migrants [ 105 , 121 ] and Africans [ 87 , 107 ]. The remaining migrant groups had one report each. Other areas of Scotland show no clear pattern with studies in disparate migrant population groups.

Number of reports per Strategic and Action Plan (SAAP) Area

SAAP Area mapping

1. establishing a framework for collaborative action.

Nine reports had a primary focus on collaborative action and were categorised under SAAP area 1 (see Fig.  4 ) [ 66 , 70 , 72 , 73 , 103 , 125 , 129 , 132 , 134 ]. Four reports (33%) used a mixed methods study design, the remaining five reports (67%) used a qualitative design. One report [ 66 ] focused on the epidemiology of female genital mutilation and a proposed intervention strategy. One report [ 66 ] focused on the epidemiology of female genital mutilation and a proposed intervention strategy. One report [ 103 ] evaluated service provision to the Roma community in Glasgow. The remaining reports focused on refugees and asylum seekers: four [ 73 , 125 , 132 , 134 ] evaluations of refugee integration projects, one [ 70 ] on services available to pregnant women, and one [ 72 ] an assessment of a peer-education service. One report [ 129 ] was a review of service provisions for migrants during the Covid-19 pandemic. All reports in SAAP area 1 were grey literature and three (37.5%) had a primary focus on migrant health while four (50%) focused on integration, one (11%) included data on ethnic minorities and one (11%) on services during the covid-19 pandemic. The majority (seven reports (78%)) were also categorised to another SAAP area most commonly area 2 (five studies (55%)) or area 5 (four studies (44%)).

2. Advocating for the right to health of refugees

Nineteen reports focused on SAAP area 2, advocating for the right to health of refugees (see Fig.  4 ) [ 47 , 52 , 53 , 54 , 55 , 63 , 70 , 71 , 83 , 103 , 123 , 124 , 125 , 127 , 128 , 129 , 134 , 138 , 140 ]. Sixteen reports (84%) had a qualitative study design and the remaining three (16%) reports used mixed methods. Nine reports (47%) focused on the health impact of the asylum system [ 52 , 55 , 71 , 74 , 123 , 127 , 128 , 129 , 138 ], five (26%) on health and access to care [ 47 , 54 , 83 , 103 , 124 ], two (10.5%) on maternity care [ 63 , 70 ], two (10.5%) on integration services [ 125 , 134 ] and one report on mental health in HIV positive migrants [ 53 ]. Nine reports (47%) had a primary focus on migrant health while the remaining 10 (53%) also involved wider social issues. The majority (15 (79%)) of reports were grey literature. All the articles in this group overlapped with another SAAP area. Area 3 is the most common joint category with ten reports (53%) followed by area 5 with seven reports (37%), area 1 shares five reports (26%), while areas 4 and 8 share one report each (5%).

3. Addressing the social determinants of health

Twenty-nine reports were categorised to SAAP area 3 – addressing the social determinants of health (see Fig.  4 ) [ 13 , 27 , 45 , 50 , 52 , 55 , 60 , 62 , 63 , 65 , 68 , 71 , 74 , 80 , 81 , 82 , 91 , 92 , 93 , 102 , 112 , 123 , 124 , 127 , 128 , 136 , 137 , 138 ]. The majority (14 (48%)) used a qualitative study method, eight (28%) used quantitative methodology and the remaining seven reports (24%) used mixed methods. Nineteen reports (65.5%) were peer-reviewed journals [ 13 , 45 , 50 , 52 , 60 , 62 , 63 , 65 , 68 , 80 , 81 , 82 , 91 , 92 , 93 , 104 , 112 , 124 , 136 , 137 ] and ten (34.5%) were grey literature [ 27 , 55 , 63 , 71 , 74 , 102 , 123 , 127 , 128 , 138 ]. Ten reports (34.5%) discussed the effects of the asylum system on health [ 27 , 52 , 63 , 71 , 74 , 123 , 124 , 127 , 128 , 137 ] and one (3.5%) migration and health [ 50 ]. Six reports (21%) focused on culture and ethnicity [ 82 , 92 , 102 , 104 , 112 , 137 ], five reports (17%) discussed economic and environmental determinants of health [ 13 , 45 , 67 , 81 , 93 ] and five reports (17%) the health impact of social activities [ 55 , 60 , 62 , 80 , 91 ]. Of the remaining reports, one [ 65 ] discussed Brexit and mental health of European migrants and one discussed the effect of coping strategies on wellbeing in Polish migrants [ 68 ]. Most reports, 18 (62%) had a primary focus on migrant health [ 45 , 50 , 52 , 55 , 60 , 62 , 63 , 65 , 67 , 68 , 71 , 80 , 81 , 82 , 91 , 92 , 93 , 102 ], six reports (21%) discussed wider social factors in addition to health [ 74 , 123 , 124 , 127 , 128 , 138 ]. Of the remaining reports three (10%) looked at ethnic background and country of birth [ 13 , 112 , 136 ], one [ 27 ] included other vulnerable groups and one [ 137 ] included people living in China and Chinese migrants to Scotland. Thirteen reports were also categorised to one or more additional SAAP area - ten (34%) were also applicable to area 2 [ 52 , 55 , 63 , 71 , 74 , 123 , 124 , 127 , 128 , 138 ], three (10%) to area 5 [ 63 , 82 , 92 ] and one (7%) to area 4 [ 27 ].

4. Achieving public health preparedness and ensuring an effective response

Twenty-one reports were assigned to SAAP area 4 (see Fig.  4 ) [ 27 , 31 , 35 , 39 , 47 , 57 , 64 , 75 , 76 , 77 , 78 , 94 , 104 , 108 , 109 , 111 , 113 , 114 , 116 , 120 , 135 ] of which fourteen (67%) used quantitative research methods, four (19%) mixed methods and three (14%) qualitative methods. Thirteen (62%) reports were peer-reviewed journals [ 35 , 59 , 64 , 75 , 78 , 104 , 108 , 109 , 111 , 113 , 114 , 116 , 120 ] and eight (38%) grey literature [ 27 , 31 , 39 , 47 , 57 , 77 , 94 , 135 ]. Most reports (12 (57%)) focused on morbidity and mortality in migrant populations [ 31 , 35 , 64 , 75 , 76 , 78 , 104 , 108 , 109 , 113 , 114 , 116 ]. Six (29%) investigated health status and healthcare needs in migrant groups in Scotland [ 39 , 47 , 57 , 77 , 94 , 135 ]. Two reports (9.5%) analysed the epidemiology of HIV infections [ 111 , 120 ] and the remaining report focused on the health needs of young people during the covid-19 pandemic [ 27 ]. Nine reports (43%) had a primary focus on migrant health [ 39 , 47 , 55 , 64 , 75 , 76 , 77 , 78 , 94 ] while eight (38%) also analysed data by ethnicity [ 31 , 35 , 104 , 108 , 109 , 113 , 114 , 116 ]. Of the remaining reports, three (14%) included other populations within Scotland [ 27 , 111 , 120 ] and one (5%) included other characteristics in addition to health information [ 135 ]. Ten reports (48%) were also categorised to another SAAP area; one to area 2 [ 47 ], one to area 3 [ 27 ], four to area 5 [ 47 , 57 , 77 , 135 ], two to area 6 [ 111 , 120 ] and two to area 9 [ 31 , 108 ].

5. Strengthening health systems and their resilience

Twenty-nine reports were assigned to SAAP area 5 (see Fig.  4 ) [ 18 , 47 , 48 , 49 , 54 , 57 , 63 , 69 , 70 , 72 , 77 , 79 , 82 , 83 , 92 , 95 , 96 , 97 , 99 , 101 , 103 , 118 , 119 , 126 , 129 , 131 , 133 , 135 , 141 ] of which 23 (79%) used qualitative research methods. Three reports used quantitative methods (10.3%) and the remaining three used mixed methods (10.3%). Twelve reports (41%) examined migrants needs and experiences of health care [ 47 , 49 , 54 , 57 , 58 , 77 , 83 , 95 , 103 , 119 , 129 , 135 ], eight (24%) focused on pregnancy and childcare [ 63 , 70 , 92 , 96 , 97 , 99 , 101 , 118 ] and two (7%) on barriers to healthcare access [ 48 , 131 ]. Two reports (7%) evaluated healthcare programmes [ 72 , 133 ] and two focused on communication in primary care [ 79 ] and maternity services [ 69 ]. The remaining three reports (10%) covered sexual health [ 82 ], health information needs of Syrian refugees [ 126 ] and general practitioner training [ 18 ]. Nineteen (65.5%) were peer reviewed journals [ 18 , 48 , 49 , 58 , 69 , 79 , 82 , 83 , 92 , 95 , 96 , 97 , 99 , 101 , 118 , 119 , 125 , 131 , 133 ] and ten (34.5%) were grey literature [ 47 , 54 , 57 , 63 , 70 , 72 , 77 , 103 , 129 , 135 ]. Twenty-one (72%) had a primary focus on migrant health [ 18 , 47 , 48 , 49 , 54 , 57 , 58 , 63 , 69 , 70 , 72 , 77 , 79 , 82 , 83 , 92 , 95 , 96 , 97 , 99 , 101 ]. Six reports (21%) included research on other characteristics or services [ 103 , 126 , 129 , 131 , 133 , 135 ]. The remaining two reports (7%) included ethnic groups as well as migrants in the data [ 118 , 119 ]. Nineteen reports (65.5%) were also assigned to one or more other category areas: five reports (17%) to area 1 [ 47 , 70 , 72 , 103 , 129 ], five reports (17%) to area 2 [ 54 , 63 , 83 , 103 , 129 ], three reports (10%) to area 3 [ 63 , 82 , 92 ], four reports (14%) to area 4 [ 47 , 57 , 77 , 135 ], one (3.5%) to area 7 [ 119 ] and one (3.5%) to area 9 [ 48 ].

6. Preventing communicable diseases

Fourteen reports were assigned to SAAP area 6 (see Fig.  4 ) [ 56 , 61 , 87 , 88 , 89 , 90 , 105 , 106 , 107 , 111 , 115 , 117 , 120 , 122 ] of which four (31%) used quantitative methods, five (38%) used qualitative methods and five (38%) used mixed methods. Five reports (38.5%) examined immunisation behaviour [ 56 , 61 , 89 , 90 , 117 ], five (38%) on epidemiology and treatment of HIV [ 106 , 107 , 111 , 120 , 122 ]. The remaining four reports (31%) focused on tuberculosis in healthcare workers [ 115 ], malaria [ 105 ] and sexual health services [ 87 , 88 ]. Only one reports was grey literature [ 88 ], the remainder were peer-reviewed journals. Six reports (46%) had a primary focus on migrant health [ 56 , 61 , 87 , 88 , 89 , 90 ] while seven reports (54%) also included other at-risk groups in the analysis. Four reports (31%) were also assigned to another SAAP category, two (15%) to area 4 [ 111 , 120 ] and two (15%) to area 8 [ 88 , 115 ].

7. Preventing and reducing the risks posed by non-communicable diseases

Eight reports were categorised to SAAP area 7 (see Fig.  4 ) [ 46 , 51 , 59 , 84 , 85 , 86 , 98 , 119 ] of which six (75%) used qualitative research methods, one (12.5%) used quantitative methods and one (12.5%) used mixed methods. Only one report (12.5%) was grey literature [ 59 ] the remaining seven reports (87.5%) were peer-reviewed journals [ 48 , 87 , 92 , 126 , 127 , 128 , 140 ]. Three reports (37.5%) focused on health behaviours [ 51 , 85 , 98 ], two (25%) on mental health, two (25%) on diabetes and one (12.5%) on chronic disease. Seven reports(87.5%) had a primary focus on migrant health [ 46 , 51 , 59 , 84 , 85 , 86 , 98 ], with the remaining report (12.5%) including ethnic minority groups [ 119 ]. One report (12.5%) was also assigned to SAAP area number 5 [ 119 ].

8. Ensuring ethical and effective health screening and assessment

There were six reports assigned to category 8 (see Fig.  4 ) [ 53 , 88 , 100 , 110 , 115 , 121 ] of which two (33%) used a quantitative research method, three (50%) used a qualitative method and one used mixed methods. One report (14%) was grey literature [ 88 ] the remaining five reports (83%) were peer reviewed journals [ 53 , 100 , 110 , 115 , 121 ]. Three reports (50%) focused on cancer screening in migrant women [ 21 , 100 , 110 ], one (17%) analysed access to HIV testing among African migrants [ 53 ], one (17%) on T.B in healthcare workers [ 72 ] and one (17%) on sexual health [ 36 ]. Three reports (50%) had a primary focus on migrant health [ 53 , 88 , 100 ] while the remaining three reports (50%) included other at-risk groups in the analysis [ 110 , 115 , 121 ]. There were three reports which overlapped with other SAAP areas: one [ 53 ] (17%) was categorised to area 2 while two [ 88 , 115 ] (33%) were categorised to area 6.

9. Improving health information and communication

Three reports were assigned to SAAP area 9 (see Fig.  4 ) [ 31 , 108 , 130 ]. One of these (33%) used a qualitative approach, one (33%) used a quantitative approach and one (33%) used mixed methods. Two [ 108 , 130 ] (66%) were peer-reviewed journal articles and one [ 31 ] (33%) was grey literature. Two reports (66%) focused on improving migrant demographics and health information using databases [ 31 , 108 ] while one (33%) described an information-needs matrix for refugees and asylum seekers [ 130 ]. Two [ 31 , 108 ] included ethnicities in the data while one [ 130 ] had a primary focus on migrant health. Two reports [ 31 , 108 ] (66%) also applied to SAAP area 4 while one report [ 130 ] (33%) was in SAAP area 9 only.

To our knowledge this is the first scoping review conducted on migrant health in Scotland. A previous rapid literature review [ 94 ] found most research focused on health behaviours, mental health, communicable disease and use of and access to healthcare; however, the review limited migrant definition to those who had immigrated within five years and asylum seekers were not included.

In our review, the majority of reports were published from 2013 onwards, aligning with the expansion in migrant research internationally [ 142 ]. 52% used qualitative research methods, 28% used quantitative methods and 20% used mixed methods. 58% focused on migrant health: the remaining papers included other populations or health as part of a wider remit. Research funding was mostly provided by the Scottish Government, NHS, refugee charities and Universities. No studies received funding from the private sector, although this sector has the potential resource and capacity to play a key role in funding future research to improve migrant health in Scotland. Geographically, most studies took place in Glasgow (36%), nationwide (38.5%) or Edinburgh (16%) – other areas were under-represented including Aberdeen (5%), despite being the city with the largest migrant population [ 30 ]. There was a lack of studies in rural localities. These findings concur with a UK migrant health review by Burns et al. [ 23 ] where research was concentrated in larger cities and data was sparse in rural areas relative to the migrant population.

Half of the research identified that was conducted in Glasgow focused on asylum seekers/refugees. Glasgow was previously the only Scottish city to host asylum seekers [ 143 ] and currently supports the most asylum seekers of any local authority in the UK [ 29 ]. In April 2022, the UK government widened the Asylum dispersal scheme to all local authorities [ 144 ]. Around 70% of Scotland’s refugee support services are based in Glasgow and the South-west [ 145 ]. As reduced access to services may impact the health of asylum seekers, research in Glasgow may not be generalizable to other regions of Scotland.

Almost one-third (30%) of all reports focused on asylum seekers and refugees – an overrepresentation given that only 18% of migrants to the UK are asylum seekers [ 146 ] and as low as 2% of all migrants in Scotland [ 147 ]. Asylum seekers and refugees are at risk of poor health due to trauma, difficult journeys, overcrowded camps, poor nutrition and lack of access to healthcare [ 148 ]. They have worse maternity outcomes and increased rates of mental illness [ 149 ]. Increased research on health of asylum seekers and refugees is necessary due to their additional vulnerabilities [ 142 ]. However, asylum seeker’s country of origin was generally not specified. Asylum seekers have heterogenic backgrounds [ 150 ] and nationality and trauma experience affect health status [ 151 ]. Further research focused on specific nationalities of asylum seekers would enhance understanding of the health needs in this population.

Almost one-third (31%) of studies did not specify a migrant group. This concurs with a Norwegian migrant health study by Laue et al. [ 152 ] where 36% of research did not identify country of birth. Where nationality was identified, Polish, African and South Asian were most prevalent. Poles are the largest migrant group in Scotland, however for the other most common immigrant groups of Irish, Italian and Nigerian [ 30 ] there was an absence of research. No studies took place on Nigerian migrants – nine studies indicated African populations, but country of birth was not specified. Since March 2022, 23,000 Ukrainians have migrated to Scotland [ 153 ], however no studies on Ukrainians were identified currently. Research may be underway which is yet to be published.

Only one study explored the impact of Brexit on European migrants’ health despite 56% of migrants to Scotland being EU nationals [ 30 ]. Again, research may be taking place currently, which is yet to be published. No studies involved undocumented migrants despite this populations’ high rates of poor physical/mental health exacerbated by poor housing and working conditions [ 154 ]. An estimated 7.2–9.5% of the workforce in the UK are migrant workers who have higher risks of poor working conditions and injury [ 155 ]. Scotland depends on a migrant workforce for some industries such as agriculture [ 156 ] but only two research papers specified migrant workers.

Most research papers related to the right to health of refugees (SAAP 2), social determinants of health (SAAP 3), public health planning (SAAP 4) and strengthening health systems (SAAP 5). Areas with less research were frameworks for collaborative action (SAAP 1), preventing communicable disease (SAAP 6), preventing non-communicable disease (SAAP 7) and health screening and assessment (SAAP 8). Only three studies related to improving health information and communication (SAAP 9). Lebano et al. [ 12 ] conducted a literature review of migrant health in Europe and found data collection unreliable and disorganised. There is a lack of data on the numbers and types of migrants entering Scotland and research tends not to differentiate between ethnic minorities and migrants [ 94 ]. As poor-quality information hinders surveillance and planning of services SAAP area 9 is an important consideration for increased research.

Villarroel et al. [ 24 ] also found more research in SAAP areas 3 to 5 and less in areas 6 to 9. However, their study returned no results in category 1, collaborative action, or 2, the right to health of refugees, while this study assigned 9% of articles to category 1 and 19% to category 2. Most articles in our study relating to categories 1 and 2 were grey literature, which was excluded from the original Irish scoping review. This highlights a potential difference in the focus of peer-reviewed articles compared to government/refugee charity commissioned reports. Collaborative action and the right to health of refugees and asylum seekers are entwined in Scotland due to the complex policy environment; the social determinants of health such as housing, education, welfare rights and social integration are influenced by a variety of UK and Scottish statutory bodies as well as third sector organisations [ 157 ]. Despite this complexity, organisations work well together [ 158 ]. Further academic research in this area would enhance joint working practices and networks.

A scoping review in the UK [ 23 ] found similar quantities of research corresponding to SAAP areas 3, 2 and 9. However in Scotland areas 1, 5 and 8 were a combined 44% of included papers compared with 27.8% of results on health systems and structures in Burns et al’s [ 23 ] study. Almost half of the articles in SAAP areas 1,5 and 8 were grey literature, which was not included in Burns et al’s [ 23 ] review. Conversely, Burns et al. [ 23 ] found 81.9% of research in the UK related to epidemiology, equivalent to SAAP categories 4,6 and 7. In a Norwegian scoping review of migrant health [ 152 ] 65% of research was related to epidemiological data on health and disease. Only 42% of the research in this current study related to epidemiological data; the quantity of evidence was reduced by excluding combined research from the UK. As Scotland has higher mortality and morbidity than elsewhere in the UK [ 29 ] it is important to undertake further epidemiological research limited to Scotland.

Strengths and weaknesses

Strengths of this review include the use of the WHO’s SAAP categories [ 7 ] to classify data, in accordance with the Villarroel et al’s [ 24 ] study: this means results are linked to policy on migrant health and facilitates comparability to the Irish study results. Additionally results include data on migrant groups, locality, and funding of included papers; these highlight potential omissions for future research consideration. Results include diverse research methods and published and grey literature giving a wide overview of available evidence, reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) checklist (see Additional File 3 ) [ 159 ].

Limitations included the lack of an open-access protocol and search limitations of English language and selected databases. This means some relevant reports may be omitted. Due to time and resource limitations no quality appraisal was planned for included reports. Whilst we did not synthesise the findings for each topic area and migrant group, future systematic reviews could be undertaken to address this limitation and build on this work.

Conclusions

Immigration and ethnic diversity in Scotland have increased since 2002 which is reflected in the expansion of migrant health research. This review highlights evidence gaps including a lack of research in rural areas, undocumented migrants and migrant workers. There is a tendency to cluster asylum seekers together rather than differentiate between national groups. Within the SAAP areas there is less evidence relating to collaborative action, preventing communicable disease, preventing non-communicable disease and health screening and assessment. Further research is required on improving health information and communication for migrant populations in Scotland – a significant omission given the importance of accurate information for health service planning.

Availability of data and materials

All data analysed during this review comes from the papers listed in Additional file 2 .

Abbreviations

European Union

Human Immunodeficiency Virus

National Health Service

Strategy and Action Plan

The Scottish Health and Ethnicity Linkage Study

United Kingdom

World Health Organisation

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Acknowledgements

Thank-you to Professor Anne MacFarlane and PHD student Anne Cronin, of the University of Limerick, Ireland for sharing the coding guidelines currently used in an update to Villarroel et. al’s 2019 study on Migrant Health in the Republic of Ireland.

No funding was received for this work, which was undertaken as G. Petrie’s Master of Public Health dissertation module at the University of Stirling.

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Petrie, G., Angus, K. & O’Donnell, R. A scoping review of academic and grey literature on migrant health research conducted in Scotland. BMC Public Health 24 , 1156 (2024). https://doi.org/10.1186/s12889-024-18628-1

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Published on 26.4.2024 in Vol 26 (2024)

Understanding Symptom Self-Monitoring Needs Among Postpartum Black Patients: Qualitative Interview Study

Authors of this article:

Original Paper

• Natalie Benda 1 , PhD   ; 
• Sydney Woode 2 , BSc   ; 
• Stephanie Niño de Rivera 1 , BS   ; 
• Robin B Kalish 3 , MD   ; 
• Laura E Riley 3 , MD   ; 
• Alison Hermann 4 , MD   ; 
• Ruth Masterson Creber 1 , MSc, PhD, RN   ; 
• Eric Costa Pimentel 5 , MS   ; 
• Jessica S Ancker 6 , MPH, PhD  

1 School of Nursing, Columbia University, New York, NY, United States

2 Department of Radiology, Early Lung and Cardiac Action Program, The Mount Sinai Health System, New York, NY, United States

3 Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, United States

4 Department of Psychiatry, Weill Cornell Medicine, New York, NY, United States

5 Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States

6 Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States

Corresponding Author:

Natalie Benda, PhD

School of Nursing

Columbia University

560 West 168th Street

New York, NY, 10032

United States

Phone: 1 212 305 9547

Email: [email protected]

Background: Pregnancy-related death is on the rise in the United States, and there are significant disparities in outcomes for Black patients. Most solutions that address pregnancy-related death are hospital based, which rely on patients recognizing symptoms and seeking care from a health system, an area where many Black patients have reported experiencing bias. There is a need for patient-centered solutions that support and encourage postpartum people to seek care for severe symptoms.

Objective: We aimed to determine the design needs for a mobile health (mHealth) patient-reported outcomes and decision-support system to assist Black patients in assessing when to seek medical care for severe postpartum symptoms. These findings may also support different perinatal populations and minoritized groups in other clinical settings.

Methods: We conducted semistructured interviews with 36 participants—15 (42%) obstetric health professionals, 10 (28%) mental health professionals, and 11 (31%) postpartum Black patients. The interview questions included the following: current practices for symptom monitoring, barriers to and facilitators of effective monitoring, and design requirements for an mHealth system that supports monitoring for severe symptoms. Interviews were audio recorded and transcribed. We analyzed transcripts using directed content analysis and the constant comparative process. We adopted a thematic analysis approach, eliciting themes deductively using conceptual frameworks from health behavior and human information processing, while also allowing new themes to inductively arise from the data. Our team involved multiple coders to promote reliability through a consensus process.

Results: Our findings revealed considerations related to relevant symptom inputs for postpartum support, the drivers that may affect symptom processing, and the design needs for symptom self-monitoring and patient decision-support interventions. First, participants viewed both somatic and psychological symptom inputs as important to capture. Second, self-perception; previous experience; sociocultural, financial, environmental, and health systems–level factors were all perceived to impact how patients processed, made decisions about, and acted upon their symptoms. Third, participants provided recommendations for system design that involved allowing for user control and freedom. They also stressed the importance of careful wording of decision-support messages, such that messages that recommend them to seek care convey urgency but do not provoke anxiety. Alternatively, messages that recommend they may not need care should make the patient feel heard and reassured.

Conclusions: Future solutions for postpartum symptom monitoring should include both somatic and psychological symptoms, which may require combining existing measures to elicit symptoms in a nuanced manner. Solutions should allow for varied, safe interactions to suit individual needs. While mHealth or other apps may not be able to address all the social or financial needs of a person, they may at least provide information, so that patients can easily access other supportive resources.

Introduction

This study focused on designing a culturally congruent mobile health (mHealth) app to support postpartum symptom monitoring, as the current practice does not adequately support patients in identifying the warning signs of pregnancy-related death (PRD). First, we describe the public health case for symptom monitoring and decision support for PRD, specifically among US-based, Black patients, a group that faces severe disparities [ 1 , 2 ]. Next, we discuss why the current mechanisms for symptom monitoring and decision support are insufficient. We then outline the existing solutions while also emphasizing the need for new interventions, particularly why those using a combination of mHealth and patient-reported outcomes (PROs) may be appropriate. Finally, we introduce a conceptual model used to accomplish our study objectives.

PRD and Associated Health Disparities

The pregnancy-related mortality ratio has increased by >200% in the United States in the past 2 decades, and in a recent review of PRDs, experts estimated that 80% of the deaths were preventable [ 3 ]. The Centers for Disease Control and Prevention (CDC) defines PRD as “the death of a woman while pregnant or within 1 year of the end of pregnancy from any cause related to or aggravated by the pregnancy” [ 4 , 5 ]. Mental health conditions (22.7%), hemorrhage (13.7%), cardiac and coronary conditions (12.8%), infection (9.2%), thrombotic embolism (8.7%), and cardiomyopathy (8.5%) have been cited as the most common causes for PRD [ 3 ]. Although the global maternal mortality rate has declined, the global rates are still high with 287,000 people dying following childbirth in 2020. There are significant disparities in maternal mortality based on a country’s income, with almost 95% of the cases occurring in low- and middle-income countries [ 6 ]. Stark disparities in pregnancy-related outcomes in the United States, such as PRD, exist based on race. Specifically, Black or African American (henceforth, referred to as “Black”) perinatal patients experience PRD 3 times more than White perinatal patients [ 1 , 2 , 7 - 10 ].

The disparities in maternal health outcomes experienced by Black patients in the United States are based on inequitable access to care, biased treatment, and inadequate communication, driven by systemic racism and all the cascading effects it creates. Black perinatal patients are significantly more likely to be uninsured and significantly less likely to have a usual source of medical care (eg, a primary care clinician) than White patients [ 7 , 10 ]. When Black patients seek care, they face implicit biases that negatively affect care quality and health outcomes [ 1 , 7 , 10 - 12 ]. Unsurprisingly, these biases have led to reduced trust in the health care system among Black patients [ 13 - 17 ]. Black patients also receive less patient-centered communication and feel that they have poorer access to communication with their medical team [ 10 , 18 , 19 ]. Our study aimed to improve the patient centeredness of information and support for Black patients in the postpartum period through a participatory design, an approach by which representative end users are involved throughout the design process [ 20 - 23 ]. While this study focused on Black postpartum patients in the United States, we believe that our findings may provide insights for improving perinatal support for patients from minority groups globally.

Challenges to Supporting Symptom Recognition and Treatment Seeking Post Partum

Patients encounter several challenges recognizing concerning postpartum symptoms. First, the initial postpartum visit occurs 6 weeks after birth, and 86% of PRD cases occur within the first 6 weeks post partum [ 24 , 25 ]. Second, most strategies for improving postpartum outcomes focus on hospital-based solutions, which rely on people recognizing symptoms and contacting a health professional [ 7 ]. Most counseling regarding the warning signs of PRD occurs during the discharge process following delivery, when people are physically exhausted from childbirth and primarily focused on infant care [ 24 ]. As such, this is a suboptimal time for patient education about postpartum risk factors. Discharge nurses report spending <10 minutes on the warning signs of postpartum issues, and most nurses could not correctly identify the leading causes of PRD, making it unlikely that their patients could recognize the warning signs [ 26 ]. There are many measures for postpartum symptom reporting, but the most common instruments focus narrowly on specific mental health issues, many of which are not specific to postpartum mental health or postpartum health–related quality of life [ 27 ]. While these are helpful measures to use in a clinic or hospital setting, they do not provide real-time decision support regarding the full spectrum of severe symptoms that may be indicative of PRD.

Suitability of Different Solutions for Supporting Symptom Monitoring

mHealth can address the need for tailored, dynamic symptom monitoring and support. The Association of Women’s Health, Obstetric, and Neonatal Nurses and the CDC have developed 1-page summaries to help patients identify the warning signs of PRD, such as the Urgent Maternal Warning Signs (UWS) [ 28 , 29 ]. These tools represent a positive step toward improving symptom management, but these solutions do not provide real-time, tailored support. Telephone-based support staffed by health professionals has been demonstrated to decrease postpartum depression and improve maternal self-efficacy [ 30 - 33 ]. However, 24-hour hotlines can be resource intensive, and people may still experience bias when accessing these services. The goal of this study was to conduct a qualitative needs assessment for the Maternal Outcome Monitoring and Support app, an mHealth system using PROs to provide decision support for postpartum symptom monitoring.

Mobile phones offer a viable, inclusive option for intervention delivery for Black people of childbearing age. In 2020, data from the Pew Research Center indicate that 83% of Black people owned smartphones, which is comparable to smartphone ownership among White people (85%). Smartphone ownership is also higher among people aged <50 years (96%), which encompasses most postpartum patients [ 34 ]. However, Black people are twice as likely as White people to be dependent on smartphones for internet access [ 35 ]. mHealth-based apps for blood pressure and weight tracking during pregnancy have demonstrated success among diverse groups, providing evidence that mHealth may be an acceptable means for symptom reporting in the target population [ 36 - 38 ].

Symptom education and PRO-based interventions have demonstrated success in improving knowledge, self-efficacy, and outcomes. Use of PROs has improved symptom knowledge, health awareness, communication with health care professionals, and prioritization of symptoms in patients with chronic disease and cancer [ 39 - 44 ]. Multiple studies have also demonstrated that educational interventions regarding expected symptoms in the postpartum period can improve self-efficacy, resourcefulness, breastfeeding practices, and mental health [ 12 , 38 , 45 - 47 ]. However, given the issues related to trust and disparities in patient-centered communication, it is critical to understand Black patients’ perspectives about how such a system should be designed and implemented.

Conceptual Model

To study the issue of supporting symptom monitoring, we combined 2 theoretical frameworks ( Figure 1 ): the common sense model of self-regulation (health behavior) by Diefenbach and Leventhal [ 48 ] and the model of human information processing (human factors engineering) by Wickens [ 49 ]. The model by Diefenbach and Leventhal [ 48 ] depicts patients as active problem solvers with a mental model of their conditions. Patients process their symptoms, both cognitively and emotionally, and then evaluate whether action is needed [ 48 ]. The patient’s mental model of their condition, personal experiences, and sociocultural factors impact processing, evaluation, and action. In the information processing model by Wickens [ 49 ], action occurs in 2 steps—selection and execution [ 48 ]. Environmental or organizational factors also affect patients’ selection of actions and whether they can execute an action. For example, a patient may suspect that they should visit the emergency room but may not go because they do not have insurance, transportation, or childcare. Our qualitative inquiry investigated how to better support symptom processing and appropriate response selection, while also uncovering the barriers to action that may need to be mitigated.

The goal of this study was to identify the design and implementation needs of an mHealth-based symptom self-monitoring and decision-support system to support Black patients in determining when to seek care from a health professional for signs of PRD in the postpartum period. This tool will support both somatic and psychological symptoms given their complex, critical, and connected presentation. We used the described conceptual model in qualitative inquiry and pragmatic intervention design to provide contributions regarding the following: (1) relevant symptom inputs for postpartum support, (2) drivers that may affect symptom processing, and (3) how the previous 2 aspects highlight the design needs for symptom self-monitoring and patient decision support. To address our study objective, we conducted semistructured interviews with postpartum Black patients, obstetrics health professionals, and mental health professionals.

The study was conducted in 3 tertiary care hospitals and affiliated clinics within the same health system in New York City. The 3 hospitals, taken together, are involved in the delivery of >14,000 babies annually. All participants were either patients who received obstetric care in the included sites or health professionals affiliated with the sites.

Eligible patients were identified by the institutions’ research informatics team using electronic health record data. First, the patients’ providers consented to their patients being contacted, and patients’ charts were reviewed by the primary obstetrician or designate to ensure that the patient was eligible for the study and that they had a delivery experience that would allow them to participate in the interview without undue stress. Next, the patients were sent an invitation to participate via the email address listed in their record. We also posted fliers in 2 high-risk, outpatient obstetric clinics.

Obstetric and mental health professionals were eligible if they were affiliated with one of the institutions in the obstetrics or mental health department. Brief presentations were given at relevant faculty meetings, and participants were contacted individually via email or through departmental listserves.

Interested participants from all groups used a link to schedule a time to speak with a researcher.

Ethical Considerations

The study was approved by the affiliated medical schools’ institutional review board (protocol number 20-08022582). All participants provided written informed consent. Study data were coded (ie, all identifying information was removed) to protect participant privacy. Each participant was compensated US $50 for their time via a physical or electronic gift card.

Study Design and Sample

The study used semistructured interviews with 3 key stakeholder groups: recent postpartum Black patients, obstetric health professionals, and mental health professionals. Eligible patients were within 12 months post partum of a live birth, self-identified their race as Black or African American, and had at least 1 somatic or psychological high-risk feature associated with their pregnancy. High-risk features included attendance at a high-risk clinic for prenatal or postnatal care, inpatient hospitalization within 12 months post partum, a prescription of an antidepressant or benzodiazepine within 12 months of the pregnancy, or a new diagnosis of depression or anxiety within 12 months of the pregnancy. High-risk clinics treated various conditions, but the most common conditions were gestational hypertension and gestational diabetes.

We adopted an interpretivist qualitative research paradigm to study patient and health professionals’ perspectives of how symptom recognition and care seeking may be better supported [ 50 ]. Our methodological orientation involved directed content analysis, adopting an abductive reasoning approach. First, we used the previously specified conceptual model to construct questions and thematically categorize responses [ 48 ]. Then, we allowed unique subthemes to inductively emerge from the data collected [ 51 ].

Interview Guide Development

Interview guides were iteratively developed by our team of researchers with expertise in obstetrics, perinatal mental health, nursing, consumer informatics, inclusive design, and qualitative methods. The guide for each stakeholder group was reviewed and piloted before enrollment of the first participant. Interview guides were tailored for patients or health professionals but followed a similar structure, based on our conceptual model ( Figure 1 ), such that participants were first asked about barriers to and facilitators of processing symptoms cognitively and emotionally (eg, Do they notice the symptom or realize its severity?), making decisions about symptoms they are experiencing (ie, When to seek help from a health professional?), and taking action on problematic symptoms. Probing questions encouraged participants to elaborate on experiential, educational, sociocultural, organizational, environmental, or health systems–level drivers of patients’ symptom management. Then, participants were asked a series of questions related to their thoughts regarding the design of the mHealth system, including how to best report symptoms, the wording of system decision support, the desired level of involvement of the obstetrics health professionals, the means for facilitating outreach to a health professional, additional information resources, and preferences for sharing information included in the system with a trusted friend or family members. During this process, obstetrics and mental health professionals were also shown a handout that outlined the draft of the symptom management algorithm for the system being developed (CDC’s UWS) and asked if they would make any changes, additions, or deletions [ 29 ]. Full interview guides are included in Multimedia Appendix 1 .

Data Collection

All interviewees provided consent electronically before the interview. A PhD-trained qualitative research expert (NB) completing a postdoctoral study in health informatics and population health conducted all the interviews via Zoom (Zoom Video Communications) or telephone. Participants had the option to request an in-person interview, but none of them chose this option. Interviews lasted 30 to 60 minutes and were audio recorded. We explicitly described the study objectives to each participant before the interview. Following the interview, participants completed a demographics survey electronically. All electronic survey information was collected using REDCap (Research Electronic Data Capture; Vanderbilt University).

Data Preparation and Analysis

Audio recordings were converted into transcripts using an electronic software (NVivo Transcription; QSR International) and manually checked for accuracy by a study team member who did not conduct the initial interviews. We completed all data analyses using NVivo (versions 12 and 13), but we manually analyzed the data and did not use computer-aided techniques (eg, computerized emotion detection or autocoding).

Data were analyzed using thematic analysis and the constant comparative process [ 51 - 53 ]. Specifically, each analyst open coded the transcripts, by coding segments that pertained to the research questions, as opposed to coding all words and phrases. We used thematic analysis to detect the common and divergent needs for postpartum symptom monitoring. We chose this method over other approaches such as grounded theory or sentiment analysis because our needs were pragmatic to solution design, and we were not attempting to establish theory, describe phenomena, or represent collective feeling about a topic.

The first deductive analysis was conducted using an initial theoretical model derived from the common sense model by Diefenbach and Leventhal [ 48 ] and the model of human information processing by Wickens [ 49 ] ( Figure 1 ). To promote reliability, 2 coders in addition to the interviewer were involved in the analysis, and each transcript was first analyzed independently by at least 2 people (NB, SW, or SNdR), followed by meetings to resolve discrepancies based on consensus coding. The analysis team created initial codes based on the conceptual model and added new items to the codebook inductively (ie, post hoc instead of a priori, as they arose in the data). The team used NVivo to maintain a working codebook of themes, definitions, and relevant quotes derived from the data. The codebook was periodically presented to coinvestigators with expertise in obstetrics and perinatal psychiatry to improve external validity [ 51 , 52 ]. The sufficiency of sample size was assessed according to the theoretical saturation of themes encountered, specifically based on the need to add additional subthemes to the codebook [ 54 , 55 ]. After all the transcripts had been coded, at least 2 members of the coding team reviewed the data code by code to ensure that meaning remained consistent throughout the analysis and to derive key emerging themes [ 51 ].

Participant Characteristics

This study included 36 participants—15 (42%) obstetrics health professionals, 10 (28%) mental health professionals, and 11 (31%) recent postpartum Black patients. Table 1 presents the self-reported demographic information. As shown, 19% (7/36) of the health professionals and 11% (4/36) of the patients had missing data (ie, did not complete the questionnaire). Participants could also selectively choose not to answer questions. “Other” affiliations were possible for health professionals because those who had a secondary affiliation with one of the included sites but primary affiliation with another organization were eligible.

a N/A: not applicable.

b Health professionals’ self-reported role of resident psychiatrist, chief resident in psychiatry, psychologist, and patient care director was combined into the other category for analysis purposes.

Structure of Themes

Our initial theoretical model, derived from the common sense model by Diefenbach and Leventhal [ 48 ] and the model of human information processing by Wickens [ 49 ] ( Figure 1 ), described that patients experience some inputs (psychological and somatic symptoms of PRD). Then, there is a series of drivers that affect how patients cognitively and emotionally process (eg, notice and realize symptom severity), make decisions about, and act on symptoms they are experiencing. The nature of these symptoms, how they are processed, how decisions are made, and how they are acted upon then drive a conversation regarding the design needs for symptom monitoring and decision support for PRD. The emerging themes were organized into the following categories: (1) symptoms of PRD; (2) drivers of processing, decision-making, and action; and (3) design needs for a symptom-reporting and decision-support system. Quotes are labeled with study-specific identifiers: OB denotes obstetric health professional, MHP denotes mental health professional, and PT denotes patient.

Inputs: Psychological and Somatic Symptoms of PRD

Concerning and routine symptoms were reported both from a psychological and somatic perspective. Sometimes, the distinction between routine and concerning symptoms was clear. Other times, it was more challenging to differentiate routine versus concerning symptoms particularly because they were related to psychological health. Mental health professionals also noted the challenge that routine symptoms can progress to something more serious over time:

In my mind, like normal becomes abnormal, when there is any kind of functioning [loss] that like withstands two to three weeks. [MHP 04]

We really hear a lot about postpartum depression and stuff...A lot of women think...postpartum depression is you just don’t want to. You don’t have it. You go into depression where you can’t take care of your child and you don’t want to hold your child. You don’t feel connected to your child. And I learned...it can be so many different things. [PT 09]

A clear distinction was not always present between psychological and somatic symptoms:

If someone...has pain in their chest or shortness of breath, the first thing you want to think about is it sort of like clots and other kind of physiologic reasons for that. Those are also very implicated and sort of obviously [associated with] panic attacks and anxiety. So, I think though those symptoms are also relevant of physical symptoms, [they] are also relevant for mental health. [MHP 05]

Drivers of Processing, Decision-Making, and Action Based on the Symptoms Experienced

Several drivers were reported to affect symptom processing (ie, whether they noticed the symptom and its severity), patients’ capacity to decide what should be done (ie, make decisions), and whether they were able to act on concerning symptoms ( Table 2 ).

Table 2 presents exemplary quotes for emerging themes under a single driver, but many quotes were coded under multiple drivers in our analysis process. The following passage, for example, highlights how self-perception, sociocultural concerns, and the health system can overlap to present a complex set of factors that may prevent women from receiving the care they need for the symptoms they are experiencing:

A lot of times I think that does get overlooked because people feel like, well, you’re OK, you’re fine. But what research shows us is that especially for Black women, it really doesn’t matter how much money you make or your income level, like our postpartum and perinatal health outcomes are the same across the board, which is really detrimental. So, yeah, I think they get overlooked because of that. I think they get overlooked or we get overlooked in the health care system. But I also think we get overlooked by our family and friends because we’re the strong ones. So, if anybody can deal with this, it’s you. [MHP 10]

a MHP: mental health professional.

b PT: patient.

c OB: obstetric health professional.

Design Needs for a Symptom-Reporting and Decision-Support System

Obstetric health professionals, mental health professionals, and patients discussed multiple needs for improved PRD symptom reporting and decision support. The key design requirements are embedded and italicized in the following text.

Participants generally agreed that although the proposed system focuses on postpartum symptoms, it would be advantageous to introduce the system during pregnancy, particularly in the third trimester :

You have to reach women before they give birth. They might look, they might not look, they might look at it and be concerned. But then they might forget about it and not have time to call. Those first six weeks are really chaotic. [MHP 06]

I think in the third trimester would be great because often we don’t really have anything to talk about in the office. It’s very quick visits like blood pressure and you’re still pregnant and we’re just waiting. And so, I think and they start to have a lot of questions about like, well, when I get home and how’s this going to go? So, I think that time is a good time. We’re all kind of just waiting for labor to happen or full term to get there, and this kind of gives them something to feel like they can prepare for. [OB 08]

Patients were open to reminders regarding entering symptoms they were experiencing, and participants described a desire for just-in-time symptom reporting and decision support, so that they could get quick feedback as they were experiencing the symptoms:

When people get home so much in their life has changed. And it’s probably a very hectic time. So maybe I think that’s a great idea reaching out again, either a few days or a week later to make sure they’re really able to use it and engage with it to the extent that’s helpful to them. [OB 02]

I think it would be a good idea to have like a system where you can report whenever you want. [PT 03]

I think for me, I would say in the moment. But then also having something at the end of every week to just, you know, to check in with yourself. I think that would be good as well. [PT 09]

In addition to considerations about how symptoms would be recorded, participants stressed the importance of the wording of the decision-support messages that patients receive . For messages that inform the patient that their symptom did not seem to require immediate medical attention, it was important to ensure that the patient still felt heard and that they did not leave the interaction feeling stuck with nothing to do regarding a symptom that was concerning to them:

Reframe the message. You know...we apologize that you were experiencing this. We just want to reassure you that this is normal. [PT 01]

[You] don’t want to make anyone feel like their feelings aren’t valid because that’s a horrible thing, especially in health care, especially if a person is convinced that something is wrong with them and you’re telling them that it’s normal and is perfectly fine. So, in that situation, I would just, depending on what the issue is, I would also share information of what to look out for. [PT 05]

The first thing is that it’s normal, but also something that you want to be able to do for comfort. For me, I don’t have to do too much, especially if I’m having anxiety, like if I get a text back that says here are some things you can do in this very moment to handle it. And then also, here are some links or information that you can also look up. [PT 09]

In the events where a concerning symptom was reported and it was recommended that the patient should reach out to a health professional, importance of conveying a sense of urgency without scaring the patient:

You don’t want to scare people, but it’s kind of hard to get around that when something is serious, and you don’t want to dumb it down. [PT 01]

Participants wanted multiple, easy-to-do methods for connecting with their health professional team, including having the number to call pop up, scheduling a time for someone to call them, and being able to start a live web-based chat:

I like all the options, especially that form or chat you can have like, you know, those online chat where like you really chatting with someone for those who like the type. I’m the type of person I just want to make a phone call, right? So, like for me, [it] will be a call. Maybe say maybe if it’s five, five or ten minutes then that will be great. Like especially, it’s going to make me feel like, OK, there’s someone out there that will care about my health. [PT 06]

However, participants noted that they would prefer not to use a symptom-reporting and decision-support tool, but instead reach out directly via phone if they were experiencing issues.

Participants, particularly mental health professionals, described a need for improved nuance or details regarding the different psychological symptoms patients could experience that are indicative of severe mental health issues:

Thoughts of hurting yourself or someone else is a good one...I would say I would add difficulty bonding. It would add something about not being able to sleep, even if you could sleep, you know, like or your anxiety that doesn’t go away, that changes your behavior. So, it changes the way that you interact with the baby or kind of do childcare. I guess I would want to say something about. psychotic thoughts, like fear that someone else may be hurting you or...recurrent worries or anxieties that don’t go away. [MHP 02]

Patients had differing opinions regarding whether the system should be integrated with other health technologies, particularly the patient portal:

I love the patient portal. I was able to be traveling to reach out to my OB, to reach out to all, you know, the nurses and stuff like that and just experience things that I needed. [PT 09]

I feel like...it’s an integral part of my medical history. So, even if it may seem somewhat insignificant for whatever reason, I would still want to have access. [PT 09]

I didn’t find it [the patient portal] very helpful... [PT 03]

On the basis of the feedback from health professionals that it may be challenging for postpartum patients to process and recognize certain symptoms, especially those related to mental health, we explored whether patient participants would be open to sharing educational information about symptoms to expect (rather than sharing the actual symptom reports) with trusted friends or family members. Similar to other design considerations, results were mixed, but it seemed helpful to have a patient-driven option for sharing symptom-related educational information with chosen friends or family members :

I think that there’s so much going on it would help to have someone with a different perspective equipped with this information. [PT 02]

There’s a lot of shame that comes with this. I’m not sure people would actually want other people to know. I can’t speak for the majority, but I didn’t really want people to know because I don’t want the kind of energy that came with people knowing. [PT 05]

We also discovered the competing needs of balancing the patient’s desire for their health professionals to be involved in symptom reporting with the need to avoid significant increases to health professional workload :

I sort of wonder from the health care provider perspective, how involved is the provider in that in the app? Like, do they get like a PDF of all the information? Is that more work for the provider? How does the provider interpret that data? [MHP 03]

I feel like they [the health professional] should be super involved. Especially because I’m not just going off of my experience because, you know, I don’t want to feel like they’re not really like I’m experiencing. And so, it’s scaring me. So, I just want to know that, you know, you’re hands on with everything. [PT 01]

Finally, the participants desired information beyond PRD symptoms to entice them to use the system . They were supportive of including various types of information, such as breastfeeding support resources, milestones and information regarding their child, other websites and apps with trusted maternal and child health information, further support resources for how they feel mentally, and links to social services (eg, food, housing, or other assistance).

Principal Findings

In this qualitative study, we interviewed obstetric health professionals, mental health professionals, and Black postpartum patients. Our findings helped to identify the design and implementation needs of an mHealth-based, symptom self-monitoring and decision-support system designed to support Black patients in determining when to seek care from a health professional for signs of PRD in the postpartum period. We encountered important findings related to (1) inputs, including psychological and somatic symptoms; (2) drivers of processing, decision-making, and action based on the symptoms experienced; and (3) design needs for a symptom-reporting and decision-support system. We have discussed how our findings may be helpful to other postpartum populations as well as the implications of our study for patient decision-support in other clinical settings.

First, our findings related to symptom inputs revealed the challenges caused by the overlapping presentation of somatic and psychological symptoms. This provides support for our approach of including psychological and somatic issues in a single app, particularly given that mental health conditions are a leading cause of PRD. A 2021 review found 15 PRO measures for assessing postpartum recovery. The measures typically focused on mental health or health-related quality of life, but few included both psychological and somatic outcomes, and none were targeted for PRD, such as the system [ 56 ].

Moreover, related to symptom inputs, we found that current tools for pinpointing severe symptoms, such as the CDC’s UWS did not provide sufficient nuance for concerning psychological symptoms. Symptom-reporting tools for PRD will either need to consider incorporating structured assessments, such as the Edinburgh Postnatal Depression Scale (EPDS) [ 56 ], or incorporating additional symptoms. The latter approach may have advantages as the EPDS focuses on depression (while providing subscales for anxiety) and PROs evaluated for use with anxiety disorders have limitations [ 57 ]. Furthermore, the EPDS has been validated in in-person laboratory settings but not in community settings or for web-based entry [ 58 ]. We must also consider how mistrust in the health system may lead to less truthful answers. Issues expressed around stigma related to mental health indicate that the way in which these symptoms are elicited may require further assessment to promote the normalcy of the symptoms and improve candid reporting. Technology-based approaches for supporting perinatal mental health have been described as uniformly positive but having limited evidence for use [ 59 ], suggesting that further exploration is needed in this area, also considering how adding somatic issues may be perceived by patients.

Second, there were several drivers that affected symptom processing, decision-making, and action that cannot typically be solved through a symptom-reporting and decision-support system. Challenges related to self-perception and lack of experience or expectations may be addressed based on the wording for how the symptoms are elicited and by providing concise, easy-to-understand depictions of what should be expected versus what are the causes for concern. However, many of the other issues described related to sociocultural, financial, and environmental factors and the health systems’ systemic racism issues cannot be addressed directly in a simple PRO-based app and decision-support system. Directly addressing these issues will likely require more systematic, multipronged approaches. Therefore, it seems advisable to couple patient decision-support aids with other social support interventions for perinatal health [ 60 , 61 ].

Drivers of processing, decision-making, and action are still important contextual elements to be considered in the design of the system. Another study tailoring an mHealth app for Latina patients to support health during pregnancy also found it important to address issues related to financial barriers, social support, health care accessibility, and cultural differences [ 62 ]. Our best attempt to address these issues may be to promote information transparency and inclusive design. For example, there may be a “frequently asked questions” section of an app, where patients can explore things such as supportive resources for childcare while they seek medical attention or information they may show their friends or family members regarding postpartum symptoms of concern. The system may also use common human-computer interaction principles, such as information filtering [ 63 ] and organizing the suggested resources (eg, for mental health care) based on whether they accept the patient’s insurance. The built environment can also be changed through the system, but it may offer mechanisms for remote monitoring, such as telemedicine-based support or linking the system to a blood pressure cuff, when clinically appropriate [ 64 , 65 ]. As noted, the system obviously cannot address issues related to systematic racism directly [ 66 ]. Instead, we used a participatory design approach, with the hope that the nature of the information presented may be more patient centered, acceptable, and better aligned with the beliefs and values of Black patients [ 67 ]. Issues related to systematic racism have commonly been described in the US health care system, but structural inequities also exist on a global scale. Future studies should investigate how our findings regarding design needs may extend to other minoritized perinatal patient groups.

A systematic review of patient decision aids for socially disadvantaged populations across clinical settings found that such tools can improve knowledge, enhance patient-clinician communication, and reduce decisional conflict [ 68 ]. However, descriptions of patient decision aids focus on the type of tool (eg, paper vs digital), how it was delivered, when it was delivered, and by whom, as opposed to describing the content the aid provides. Therefore, it is challenging to determine how other decision-support tools have addressed information regarding environmental, financial, or health system–level factors that may affect care seeking based on the decision aid. Some tools seem to address sociocultural needs by tailoring to the target population, but the aforementioned systematic review did not find differential effects on outcomes when tools were tailored versus not tailored [ 16 ]. Future studies on patient decision aids may benefit from including non-symptom related information. Providing appropriate informational support may involve a deeper study of the systemic needs that patients may have, even if these needs may not directly be addressed by the decision aid.

Third, descriptions of the design needs for PRD symptom monitoring revealed that there is likely not a one-size-fits-all solution related to reminders, involvement of health professionals, and how the tool is incorporated with other systems (eg, the patient portal). “User control and freedom” and “flexibility of use” are two of the key items in commonly used heuristics for user interface design [ 69 ]; therefore, it is important to include options for customization and varied but safe pathways for interaction with the proposed system. For example, some participants described that they may not be likely to access the symptom-reporting system through the patient portal. Although there may be safety and convenience-related reasons for having the system as part of the patients’ medical record, if the patient chooses, the system could, on the front end, appear more like a stand-alone app than something that must be accessed through the patient portal. Patients also had varying opinions related to how they may want to reach out to a health professional if a problematic symptom was reported. These preferences may differ from instance to instance; therefore, it is helpful to ensure that patients have a choice regarding how to reach out, but system designers must also create workflows with feedback loop, so that patients who are reporting problematic symptoms are not missed (ie, if patients do not reach out themselves, they never receive attention). Patient-level customizations and options for interaction also respects patients as individuals and may promote patient-centered interactions.

Furthermore, related to design needs, participants indicated that the wording of the decision-support messages was critical. Specifically, for reports that did not include currently urgent symptoms, it was important that the message still conveyed support and validation, clarified that the patient could still reach out for help, and provided additional means for managing their symptoms, so the patient did not feel frustrated by their report [ 70 ]. Regarding messages that recommended patients to reach out to their health professional team, it was crucial to note what the symptom meant (eg, what kind of disease it could indicate), encourage the patient to reach out without increasing anxiety, and provide different avenues for easy outreach. Going forward, we plan to incorporate the aforementioned elements into the messages built into the system. We will then complete additional acceptance and comprehension testing with a larger sample of postpartum patients. These findings also indicate that care must be taken in translating such tools, and the translated materials should be reviewed with the target end user groups before implementation. This may mitigate unintended consequences or inadvertent inclusion of language that does not support the needs of minoritized groups.

Strengths and Limitations

Our study highlighted the limitations and areas that would benefit from further exploration. First, our study involved recruitment sites that were within a single health system in New York City. Second, while we achieved thematic saturation of qualitative themes (a means for determining sample sufficiency in qualitative studies) [ 54 , 55 ], our conclusions are based on a sample of 36 participants from 3 stakeholder groups. Third, given the documented disparities, we deliberately focused on the needs of Black postpartum patients, but this may not represent the needs of the postpartum patients of other races. Furthermore, our sample should not be viewed as encompassing the opinions of all Black postpartum patients. Our findings revealed the need for individual customization and varied interaction patterns on a case-by-case basis. Fourth, all interviews were conducted remotely (via Zoom or telephone), which can have effects on the interaction. On the one hand, it may be harder to connect with the interviewee, and on the other hand, people may feel more anonymous and comfortable with sharing information. Finally, although we attempted to promote external validity through the review of the coding scheme by a subject matter expert, we did not have the opportunity to perform triangulation of the findings by returning the results to participants. To address these limitations, it would be beneficial to survey a larger group of postpartum patients, powered to assess the differences based on race and ethnicity. This would allow us to come to a stronger consensus regarding design choices, assess whether there are differences in design needs or preferences, and gain feedback from patients in areas outside New York City. Future studies may also explore how other underserved groups, such as those with limited English proficiency, may benefit from tailored symptom self-monitoring and decision support.

Conclusions

In this qualitative study regarding postpartum symptom monitoring and decision support, we found that the current structured reporting measures do not include the combination of somatic and psychological symptoms that may be indicative of severe outcomes in the postpartum period. While not explicitly related to symptom reporting and decision support, patient decision aids, particularly those focusing on minoritized groups, should consider how the aids may be coupled with other structural support interventions or, at least, information about how other resources may be accessed. As stated in the commonly accepted design heuristics, we also found that user control and freedom unsurprisingly remain important for a patient decision-support aid for Black postpartum patients. Finally, decision aid–related phrases must take care to convey urgency without inducing anxiety when action may be indicated and consider respect and empathy for the patients’ symptoms when action may not be indicated to ensure that they do not feel unheard and are empowered to report new or worsening symptoms.

Acknowledgments

This study was supported by the National Institute on Minority Health and Health Disparities (K99MD015781; principal investigator: NB).

Data Availability

The data sets generated and analyzed during this study are not publicly available due to institutional review board regulations but are available from the corresponding author on reasonable request.

Authors' Contributions

NB conceptualized the study and acquired funding under the advisement of RBK, LER, AH, RMC, and JSA. NB collected the data. NB, SW, and SNdR analyzed the data with input from all other authors. ECP completed the literature review and descriptive analysis of participants’ characteristics. NB drafted the paper and received substantial inputs from all other authors.

Conflicts of Interest

LER is an Up to Date contributor and an advisory board member for the New English Journal of Medicine, and Contemporary OB/GYN. She has also been a speaker for Medscape is an an expert reviewer for Pfizer on the RSV Vaccine. AH is an Up to Date contributor, a co-founder and medical consultant for Iris Ob Health, and a consultant for Progyny.

Semistructured interview guide questions for patients and health professionals.

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• O'Carroll J, Ando K, Yun R, Panelli D, Nicklin A, Kennedy N, et al. A systematic review of patient-reported outcome measures used in maternal postpartum anxiety. Am J Obstet Gynecol MFM. Sep 2023;5(9):101076. [ CrossRef ] [ Medline ]
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Abbreviations

Edited by A Mavragani; submitted 22.03.23; peer-reviewed by C Laranjeira; comments to author 15.01.24; revised version received 20.02.24; accepted 08.03.24; published 26.04.24.

©Natalie Benda, Sydney Woode, Stephanie Niño de Rivera, Robin B Kalish, Laura E Riley, Alison Hermann, Ruth Masterson Creber, Eric Costa Pimentel, Jessica S Ancker. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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Start Date: 5/6/2024 End Date: 5/2/2025 Number of Positions: 1 Hours per Week: 12hrs/week Weekends Required: No Evenings Required: No

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Key facts about Americans and guns

Guns are deeply ingrained in American society and the nation’s political debates.

The Second Amendment to the United States Constitution guarantees the right to bear arms, and about a third of U.S. adults say they personally own a gun. At the same time, in response to concerns such as rising gun death rates and  mass shootings , President Joe Biden has proposed gun policy legislation that would expand on the bipartisan gun safety bill Congress passed last year.

Here are some key findings about Americans’ views of gun ownership, gun policy and other subjects, drawn primarily from a Pew Research Center survey conducted in June 2023 .

Pew Research Center conducted this analysis to summarize key facts about Americans and guns. We used data from recent Center surveys to provide insights into Americans’ views on gun policy and how those views have changed over time, as well as to examine the proportion of adults who own guns and their reasons for doing so.

The analysis draws primarily from a survey of 5,115 U.S. adults conducted from June 5 to June 11, 2023. Everyone who took part in the surveys cited is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the  ATP’s methodology .

Here are the  questions used for the analysis on gun ownership , the questions used for the analysis on gun policy , and  the survey’s methodology .

Additional information about the fall 2022 survey of parents and its methodology can be found at the link in the text of this post.

Measuring gun ownership in the United States comes with unique challenges. Unlike many demographic measures, there is not a definitive data source from the government or elsewhere on how many American adults own guns.

The Pew Research Center survey conducted June 5-11, 2023, on the Center’s American Trends Panel, asks about gun ownership using two separate questions to measure personal and household ownership. About a third of adults (32%) say they own a gun, while another 10% say they do not personally own a gun but someone else in their household does. These shares have changed little from surveys conducted in 2021  and  2017 . In each of those surveys, 30% reported they owned a gun.

These numbers are largely consistent with rates of gun ownership reported by Gallup , but somewhat higher than those reported by NORC’s General Social Survey . Those surveys also find only modest changes in recent years.

The FBI maintains data on background checks on individuals attempting to purchase firearms in the United States. The FBI reported a surge in background checks in 2020 and 2021, during the coronavirus pandemic. The number of federal background checks declined in 2022 and through the first half of this year, according to FBI statistics .

About four-in-ten U.S. adults say they live in a household with a gun, including 32% who say they personally own one,  according to an August report based on our June survey. These numbers are virtually unchanged since the last time we asked this question in 2021.

There are differences in gun ownership rates by political affiliation, gender, community type and other factors.

• Republicans and Republican-leaning independents are more than twice as likely as Democrats and Democratic leaners to say they personally own a gun (45% vs. 20%).
• 40% of men say they own a gun, compared with 25% of women.
• 47% of adults living in rural areas report personally owning a firearm, as do smaller shares of those who live in suburbs (30%) or urban areas (20%).
• 38% of White Americans own a gun, compared with smaller shares of Black (24%), Hispanic (20%) and Asian (10%) Americans.

Personal protection tops the list of reasons gun owners give for owning a firearm.  About three-quarters (72%) of gun owners say that protection is a major reason they own a gun. Considerably smaller shares say that a major reason they own a gun is for hunting (32%), for sport shooting (30%), as part of a gun collection (15%) or for their job (7%). 

The reasons behind gun ownership have changed only modestly since our 2017 survey of attitudes toward gun ownership and gun policies. At that time, 67% of gun owners cited protection as a major reason they owned a firearm.

Gun owners tend to have much more positive feelings about having a gun in the house than non-owners who live with them. For instance, 71% of gun owners say they enjoy owning a gun – but far fewer non-gun owners in gun-owning households (31%) say they enjoy having one in the home. And while 81% of gun owners say owning a gun makes them feel safer, a narrower majority (57%) of non-owners in gun households say the same about having a firearm at home. Non-owners are also more likely than owners to worry about having a gun in the home (27% vs. 12%, respectively).

Feelings about gun ownership also differ by political affiliation, even among those who personally own firearms. Republican gun owners are more likely than Democratic owners to say owning a gun gives them feelings of safety and enjoyment, while Democratic owners are more likely to say they worry about having a gun in the home.

Non-gun owners are split on whether they see themselves owning a firearm in the future. About half (52%) of Americans who don’t own a gun say they could never see themselves owning one, while nearly as many (47%) could imagine themselves as gun owners in the future.

Among those who currently do not own a gun:

• 61% of Republicans and 40% of Democrats who don’t own a gun say they would consider owning one in the future.
• 56% of Black non-owners say they could see themselves owning a gun one day, compared with smaller shares of White (48%), Hispanic (40%) and Asian (38%) non-owners.

Americans are evenly split over whether gun ownership does more to increase or decrease safety. About half (49%) say it does more to increase safety by allowing law-abiding citizens to protect themselves, but an equal share say gun ownership does more to reduce safety by giving too many people access to firearms and increasing misuse.

Republicans and Democrats differ on this question: 79% of Republicans say that gun ownership does more to increase safety, while a nearly identical share of Democrats (78%) say that it does more to reduce safety.

Urban and rural Americans also have starkly different views. Among adults who live in urban areas, 64% say gun ownership reduces safety, while 34% say it does more to increase safety. Among those who live in rural areas, 65% say gun ownership increases safety, compared with 33% who say it does more to reduce safety. Those living in the suburbs are about evenly split.

Americans increasingly say that gun violence is a major problem. Six-in-ten U.S. adults say gun violence is a very big problem in the country today, up 9 percentage points from spring 2022. In the survey conducted this June, 23% say gun violence is a moderately big problem, and about two-in-ten say it is either a small problem (13%) or not a problem at all (4%).

Looking ahead, 62% of Americans say they expect the level of gun violence to increase over the next five years. This is double the share who expect it to stay the same (31%). Just 7% expect the level of gun violence to decrease.

A majority of Americans (61%) say it is too easy to legally obtain a gun in this country. Another 30% say the ease of legally obtaining a gun is about right, and 9% say it is too hard to get a gun. Non-gun owners are nearly twice as likely as gun owners to say it is too easy to legally obtain a gun (73% vs. 38%). Meanwhile, gun owners are more than twice as likely as non-owners to say the ease of obtaining a gun is about right (48% vs. 20%).

Partisan and demographic differences also exist on this question. While 86% of Democrats say it is too easy to obtain a gun legally, 34% of Republicans say the same. Most urban (72%) and suburban (63%) dwellers say it’s too easy to legally obtain a gun. Rural residents are more divided: 47% say it is too easy, 41% say it is about right and 11% say it is too hard.

About six-in-ten U.S. adults (58%) favor stricter gun laws. Another 26% say that U.S. gun laws are about right, and 15% favor less strict gun laws. The percentage who say these laws should be stricter has fluctuated a bit in recent years. In 2021, 53% favored stricter gun laws, and in 2019, 60% said laws should be stricter.

About a third (32%) of parents with K-12 students say they are very or extremely worried about a shooting ever happening at their children’s school, according to a fall 2022 Center survey of parents with at least one child younger than 18. A similar share of K-12 parents (31%) say they are not too or not at all worried about a shooting ever happening at their children’s school, while 37% of parents say they are somewhat worried.

Among all parents with children under 18, including those who are not in school, 63% see improving mental health screening and treatment as a very or extremely effective way to prevent school shootings. This is larger than the shares who say the same about having police officers or armed security in schools (49%), banning assault-style weapons (45%), or having metal detectors in schools (41%). Just 24% of parents say allowing teachers and school administrators to carry guns in school would be a very or extremely effective approach, while half say this would be not too or not at all effective.

There is broad partisan agreement on some gun policy proposals, but most are politically divisive,   the June 2023 survey found . Majorities of U.S. adults in both partisan coalitions somewhat or strongly favor two policies that would restrict gun access: preventing those with mental illnesses from purchasing guns (88% of Republicans and 89% of Democrats support this) and increasing the minimum age for buying guns to 21 years old (69% of Republicans, 90% of Democrats). Majorities in both parties also  oppose  allowing people to carry concealed firearms without a permit (60% of Republicans and 91% of Democrats oppose this).

Republicans and Democrats differ on several other proposals. While 85% of Democrats favor banning both assault-style weapons and high-capacity ammunition magazines that hold more than 10 rounds, majorities of Republicans oppose these proposals (57% and 54%, respectively).

Most Republicans, on the other hand, support allowing teachers and school officials to carry guns in K-12 schools (74%) and allowing people to carry concealed guns in more places (71%). These proposals are supported by just 27% and 19% of Democrats, respectively.

Gun ownership is linked with views on gun policies. Americans who own guns are less likely than non-owners to favor restrictions on gun ownership, with a notable exception. Nearly identical majorities of gun owners (87%) and non-owners (89%) favor preventing mentally ill people from buying guns.

Within both parties, differences between gun owners and non-owners are evident – but they are especially stark among Republicans. For example, majorities of Republicans who do not own guns support banning high-capacity ammunition magazines and assault-style weapons, compared with about three-in-ten Republican gun owners.

Among Democrats, majorities of both gun owners and non-owners favor these two proposals, though support is greater among non-owners. 

Note: This is an update of a post originally published on Jan. 5, 2016 .

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Katherine Schaeffer is a research analyst at Pew Research Center

About 1 in 4 U.S. teachers say their school went into a gun-related lockdown in the last school year

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Patients Fare Better With Women Doctors, Study Finds

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Patients treated by female doctors fare better than patients treated by male doctors, according to new research published Monday, despite the field struggling to improve female representation in research and among practitioners.

Female doctors are better for patient outcomes, research found.

Patients treated by female physicians in the U.S. had lower mortality rates and lower rates of readmission compared to patients treated by male physicians, according to peer reviewed research published in the Annals of Internal Medicine.

The findings come after researchers from the University of Tokyo in Japan analyzed data from the medical records of more than 700,000 Medicare patients aged 65 years or older hospitalized and treated between 2016 and 2019 to assess the differences between patients treated by male and female physicians.

Just under a third of the roughly 460,000 female and 320,000 male patients included in the study were treated by female physicians, the researchers said, and there were no significant differences between groups when it came to key metrics for evaluating hospital care including length of stay, spending, how likely a discharge to home was, management claims and the proportion of time spent under intensive evaluation.

While both male and female patients treated by female physicians fared better than those treated by male physicians in terms of lower death and readmission rates, the researchers found the difference was especially large and clinically meaningful for female patients, who are underrepresented in medical research and far more likely to suffer misdiagnoses and medical mistakes during treatment than men.

The researchers said multiple reasons could be behind the stark difference in outcomes for female patients when treated by female physicians, such as male physicians potentially underestimating the severity of illnesses in their female patients and female physicians probably having better communication skills and a more patient-centered approach when it comes to female patients.

Being treated by a female physician could also help alleviate the embarrassment, discomfort and social and cultural taboos that can arise for female patients during sensitive examinations, the researchers said.

Key Background

The finding that patients treated by female clinicians fare better than those treated by male clinicians has been repeatedly borne out by research around the world. For example, studies published last year from researchers in Sweden and Canada found people operated on by female surgeons had better outcomes and fewer problems during recovery than when male surgeons had been performing the operations. In the U.S., research has shown women who have heart attacks are more likely to survive when treated by a female doctor. The same is true of elderly hospital patients . While studies are typically observational and so cannot determine cause and effect, research has shown female doctors tend to listen to their patients more, spend more time with their patients and are more likely to follow guidelines and collaborate with specialists. While patients might fare better under female clinicians, women doctors face a variety of issues hindering their ability to enter and remain in the field. Female doctors tend to be paid less than their male counterparts, face systemic discrimination and struggle with higher rates of burnout amid efforts to manage brutal medical schedules with other commitments.

Surprising Fact

Despite decades of vowing to address systemic bias against women in healthcare and research, medical research still knowingly and consistently overlooks women and women are still underrepresented in clinical trials. The bias pervades the entirety of medical research, even down to the laboratory level, with animal subjects like mice and rats all overwhelmingly male.

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