research paper body

How to Write a Research Paper: Parts of the Paper

• Choosing Your Topic
• Citation & Style Guides This link opens in a new window
• Critical Thinking
• Evaluating Information
• Parts of the Paper
• Writing Tips from UNC-Chapel Hill
• Librarian Contact

Parts of the Research Paper Papers should have a beginning, a middle, and an end. Your introductory paragraph should grab the reader's attention, state your main idea, and indicate how you will support it. The body of the paper should expand on what you have stated in the introduction. Finally, the conclusion restates the paper's thesis and should explain what you have learned, giving a wrap up of your main ideas.

1. The Title The title should be specific and indicate the theme of the research and what ideas it addresses. Use keywords that help explain your paper's topic to the reader. Try to avoid abbreviations and jargon. Think about keywords that people would use to search for your paper and include them in your title.

2. The Abstract The abstract is used by readers to get a quick overview of your paper. Typically, they are about 200 words in length (120 words minimum to  250 words maximum). The abstract should introduce the topic and thesis, and should provide a general statement about what you have found in your research. The abstract allows you to mention each major aspect of your topic and helps readers decide whether they want to read the rest of the paper. Because it is a summary of the entire research paper, it is often written last. 

3. The Introduction The introduction should be designed to attract the reader's attention and explain the focus of the research. You will introduce your overview of the topic,  your main points of information, and why this subject is important. You can introduce the current understanding and background information about the topic. Toward the end of the introduction, you add your thesis statement, and explain how you will provide information to support your research questions. This provides the purpose and focus for the rest of the paper.

4. Thesis Statement Most papers will have a thesis statement or main idea and supporting facts/ideas/arguments. State your main idea (something of interest or something to be proven or argued for or against) as your thesis statement, and then provide your supporting facts and arguments. A thesis statement is a declarative sentence that asserts the position a paper will be taking. It also points toward the paper's development. This statement should be both specific and arguable. Generally, the thesis statement will be placed at the end of the first paragraph of your paper. The remainder of your paper will support this thesis.

Students often learn to write a thesis as a first step in the writing process, but often, after research, a writer's viewpoint may change. Therefore a thesis statement may be one of the final steps in writing. 

Examples of Thesis Statements from Purdue OWL

5. The Literature Review The purpose of the literature review is to describe past important research and how it specifically relates to the research thesis. It should be a synthesis of the previous literature and the new idea being researched. The review should examine the major theories related to the topic to date and their contributors. It should include all relevant findings from credible sources, such as academic books and peer-reviewed journal articles. You will want  to:

• Explain how the literature helps the researcher understand the topic.
• Try to show connections and any disparities between the literature.
• Identify new ways to interpret prior research.
• Reveal any gaps that exist in the literature.

More about writing a literature review. . .

6. The Discussion ​The purpose of the discussion is to interpret and describe what you have learned from your research. Make the reader understand why your topic is important. The discussion should always demonstrate what you have learned from your readings (and viewings) and how that learning has made the topic evolve, especially from the short description of main points in the introduction.Explain any new understanding or insights you have had after reading your articles and/or books. Paragraphs should use transitioning sentences to develop how one paragraph idea leads to the next. The discussion will always connect to the introduction, your thesis statement, and the literature you reviewed, but it does not simply repeat or rearrange the introduction. You want to: 

• Demonstrate critical thinking, not just reporting back facts that you gathered.
• If possible, tell how the topic has evolved over the past and give it's implications for the future.
• Fully explain your main ideas with supporting information.
• Explain why your thesis is correct giving arguments to counter points.

7. The Conclusion A concluding paragraph is a brief summary of your main ideas and restates the paper's main thesis, giving the reader the sense that the stated goal of the paper has been accomplished. What have you learned by doing this research that you didn't know before? What conclusions have you drawn? You may also want to suggest further areas of study, improvement of research possibilities, etc. to demonstrate your critical thinking regarding your research.

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How to Write a Research Paper

If you already have a headache trying to understand what research paper is all about, we have created an ultimate guide for you on how to write a research paper. You will find all the answers to your questions regarding structure, planning, doing investigation, finding the topic that appeals to you. Plus, you will find out the secret to an excellent paper. Are you at the edge of your seat? Let us start with the basics then.

• What is a Research Paper
• Reasons for Writing a Research Paper
• Report Papers and Thesis Papers
• How to Start a Research Paper
• How to Choose a Topic for a Research Paper
• How to Write a Proposal for a Research Paper
• How to Write a Research Plan
• How to Do Research
• How to Write an Outline for a Research Paper
• How to Write a Thesis Statement for a Research Paper
• How to Write a Research Paper Rough Draft
• How to Write an Introduction for a Research Paper
• How to Write a Body of a Research Paper
• How to Write a Conclusion for a Research Paper
• How to Write an Abstract for a Research Paper
• How to Revise and Edit a Research Paper
• How to Write a Bibliography for a Research Paper
• What Makes a Good Research Paper

Research Paper Writing Services

What is a research paper.

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You probably know the saying ‘the devil is not as black as he is painted’. This particular saying is absolutely true when it comes to writing a research paper. Your feet are cold even with the thought of this assignment. You have heard terrifying stories from older students. You have never done this before, so certainly you are scared. What is a research paper? How should I start? What are all these requirements about?

Luckily, you have a friend in need. That is our writing service. First and foremost, let us clarify the definition. A research paper is a piece of academic writing that provides information about a particular topic that you’ve researched . In other words, you choose a topic: about historical events, the work of some artist, some social issues etc. Then you collect data on the given topic and analyze it. Finally, you put your analysis on paper. See, it is not as scary as it seems. If you are still having doubts, whether you can handle it yourself, we are here to help you. Our team of writers can help you choose the topic, or give you advice on how to plan your work, or how to start, or craft a paper for you. Just contact us 24/7 and see everything yourself.

5 Reasons for Writing a Research Paper

Why should I spend my time writing some academic paper? What is the use of it? Is not some practical knowledge more important? The list of questions is endless when it comes to a research paper. That is why we have outlined 5 main reasons why writing a research paper is a good thing.

• You will learn how to organize your time

If you want to write a research paper, you will have to learn how to manage your time. This type of assignment cannot be done overnight. It requires careful planning and you will need to learn how to do it. Later, you will be able to use these time-managing skills in your personal life, so why not developing them?

• You will discover your writing skills

You cannot know something before you try it. This rule relates to writing as well. You cannot claim that you cannot write until you try it yourself. It will be really difficult at the beginning, but then the words will come to your head themselves.

• You will improve your analytical skills

Writing a research paper is all about investigation and analysis. You will need to collect data, examine and classify it. These skills are needed in modern life more than anything else is.

• You will gain confidence

Once you do your own research, it gives you the feeling of confidence in yourself. The reason is simple human brain likes solving puzzles and your assignment is just another puzzle to be solved.

• You will learn how to persuade the reader

When you write your paper, you should always remember that you are writing it for someone to read. Moreover, you want this someone to believe in your ideas. For this reason, you will have to learn different convincing methods and techniques. You will learn how to make your writing persuasive. In turns, you will be able to use these methods in real life.

What is the Difference between Report and Thesis Papers?

A common question is ‘what is the difference between a report paper and a thesis paper?’ The difference lies in the aim of these two assignments. While the former aims at presenting the information, the latter aims at providing your opinion on the matter. In other words, in a report paper you have to summarize your findings. In a thesis paper, you choose some issue and defend your point of view by persuading the reader. It is that simple.

A thesis paper is a more common assignment than a report paper. This task will help a professor to evaluate your analytical skills and skills to present your ideas logically. These skills are more important than just the ability to collect and summarize data.

How to Write a Research Paper Step by Step

Research comes from the French word  rechercher , meaning “to seek out.” Writing a research paper requires you to seek out information about a subject, take a stand on it, and back it up with the opinions, ideas, and views of others. What results is a printed paper variously known as a term paper or library paper, usually between five and fifteen pages long—most instructors specify a minimum length—in which you present your views and findings on the chosen subject.

It is not a secret that the majority of students hate writing a research paper. The reason is simple it steals your time and energy. Not to mention, constant anxiety that you will not be able to meet the deadline or that you will forget about some academic requirement.

We will not lie to you; a research paper is a difficult assignment. You will have to spend a lot of time. You will need to read, to analyze, and to search for the material. You will probably be stuck sometimes. However, if you organize your work smart, you will gain something that is worth all the effort – knowledge, experience, and high grades.

The reason why many students fail writing a research paper is that nobody explained them how to start and how to plan their work. Luckily, you have found our writing service and we are ready to shed the light on this dark matter.

We have created a step by step guide for you on how to write a research paper. We will dwell upon the structure, the writing tips, the writing strategies as well as academic requirements. Read this whole article and you will see that you can handle writing this assignment and our team of writers is here to assist you.

How to Start a Research Paper?

It all starts with the assignment. Your professor gives you the task. It may be either some general issue or specific topic to write about. Your assignment is your first guide to success. If you understand what you need to do according to the assignment, you are on the road to high results. Do not be scared to clarify your task if you need to. There is nothing wrong in asking a question if you want to do something right. You can ask your professor or you can ask our writers who know a thing or two in academic writing.

It is essential to understand the assignment. A good beginning makes a good ending, so start smart.

Learn how to start a research paper .

Choosing a Topic for a Research Paper

We have already mentioned that it is not enough to do great research. You need to persuade the reader that you have made some great research. What convinces better that an eye-catching topic? That is why it is important to understand how to choose a topic for a research paper.

First, you need to delimit the general idea to a more specific one. Secondly, you need to find what makes this topic interesting for you and for the academia. Finally, you need to refine you topic. Remember, it is not something you will do in one day. You can be reshaping your topic throughout your whole writing process. Still, reshaping not changing it completely. That is why keep in your head one main idea: your topic should be precise and compelling .

Learn how to choose a topic for a research paper .

How to Write a Proposal for a Research Paper?

If you do not know what a proposal is, let us explain it to you. A proposal should answer three main questions:

• What is the main aim of your investigation?
• Why is your investigation important?
• How are you going to achieve the results?

In other words, proposal should show why your topic is interesting and how you are going to prove it. As to writing requirements, they may differ. That is why make sure you find out all the details at your department. You can ask your departmental administrator or find information online at department’s site. It is crucial to follow all the administrative requirements, as it will influence your grade.

Learn how to write a proposal for a research paper .

How to Write a Research Plan?

The next step is writing a plan. You have already decided on the main issues, you have chosen the bibliography, and you have clarified the methods. Here comes the planning. If you want to avoid writer’s block, you have to structure you work. Discuss your strategies and ideas with your instructor. Think thoroughly why you need to present some data and ideas first and others second. Remember that there are basic structure elements that your research paper should include:

• Thesis Statement
• Introduction
• Bibliography

You should keep in mind this skeleton when planning your work. This will keep your mind sharp and your ideas will flow logically.

Learn how to write a research plan .

How to Do Research?

Your research will include three stages: collecting data, reading and analyzing it, and writing itself.

First, you need to collect all the material that you will need for you investigation: films, documents, surveys, interviews, and others. Secondly, you will have to read and analyze. This step is tricky, as you need to do this part smart. It is not enough just to read, as you cannot keep in mind all the information. It is essential that you make notes and write down your ideas while analyzing some data. When you get down to the stage number three, writing itself, you will already have the main ideas written on your notes. Plus, remember to jot down the reference details. You will then appreciate this trick when you will have to write the bibliography.

If you do your research this way, it will be much easier for you to write the paper. You will already have blocks of your ideas written down and you will just need to add some material and refine your paper.

Learn how to do research .

How to Write an Outline for a Research Paper?

To make your paper well organized you need to write an outline. Your outline will serve as your guiding star through the writing process. With a great outline you will not get sidetracked, because you will have a structured plan to follow. Both you and the reader will benefit from your outline. You present your ideas logically and you make your writing coherent according to your plan. As a result, this outline guides the reader through your paper and the reader enjoys the way you demonstrate your ideas.

Learn how to write an outline for a research paper . See research paper outline examples .

How to Write a Thesis Statement for a Research Paper?

Briefly, the thesis is the main argument of your research paper. It should be precise, convincing and logical. Your thesis statement should include your point of view supported by evidence or logic. Still, remember it should be precise. You should not beat around the bush, or provide all the possible evidence you have found. It is usually a single sentence that shows your argument. In on sentence you should make a claim, explain why it significant and convince the reader that your point of view is important.

Learn how to write a thesis statement for a research paper . See research paper thesis statement examples .

Should I Write a Rough Draft for a Research Paper?

Do you know any writer who put their ideas on paper, then never edited them and just published? Probably, no writer did so. Writing a research paper is no exception. It is impossible to cope with this assignment without writing a rough draft.

Your draft will help you understand what you need to polish to make your paper perfect. All the requirements, academic standards make it difficult to do everything flawlessly at the first attempt. Make sure you know all the formatting requirements: margins, words quantity, reference requirements, formatting styles etc.

Learn how to write a rough draft for a research paper .

How to Write an Introduction for a Research Paper?

Let us make it more vivid for you. We have narrowed down the tips on writing an introduction to the three main ones:

• Include your thesis in your introduction

Remember to include the thesis statement in your introduction. Usually, it goes at the end of the first paragraph.

• Present the main ideas of the body

You should tell the main topics you are going to discuss in the main body. For this reason, before writing this part of introduction, make sure you know what is your main body is going to be about. It should include your main ideas.

• Polish your thesis and introduction

When you finish the main body of your paper, come back to the thesis statement and introduction. Restate something if needed. Just make it perfect; because introduction is like the trailer to your paper, it should make the reader want to read the whole piece.

Learn how to write an introduction for a research paper . See research paper introduction examples .

How to Write a Body of a Research Paper?

A body is the main part of your research paper. In this part, you will include all the needed evidence; you will provide the examples and support your argument.

It is important to structure your paragraphs thoroughly. That is to say, topic sentence and the evidence supporting the topic. Stay focused and do not be sidetracked. You have your outline, so follow it.

Here are the main tips to keep in head when writing a body of a research paper:

• Let the ideas flow logically
• Include only relevant information
• Provide the evidence
• Structure the paragraphs
• Make the coherent transition from one paragraph to another

See? When it is all structured, it is not as scary as it seemed at the beginning. Still, if you have doubts, you can always ask our writers for help.

Learn how to write a body of a research paper . See research paper transition examples .

How to Write a Conclusion for a Research Paper?

Writing a good conclusion is important as writing any other part of the paper. Remember that conclusion is not a summary of what you have mentioned before. A good conclusion should include your last strong statement.

If you have written everything according to the plan, the reader already knows why your investigation is important. The reader has already seen the evidence. The only thing left is a strong concluding thought that will organize all your findings.

Never include any new information in conclusion. You need to conclude, not to start a new discussion.

Learn how to write a conclusion for a research paper .

How to Write an Abstract for a Research Paper?

An abstract is a brief summary of your paper, usually 100-200 words. You should provide the main gist of your paper in this short summary. An abstract can be informative, descriptive or proposal. Depending on the type of abstract, you need to write, the requirements will differ.

To write an informative abstract you have to provide the summary of the whole paper. Informative summary. In other words, you need to tell about the main points of your work, the methods used, the results and the conclusion of your research.

To write a descriptive abstract you will not have to provide any summery. You should write a short teaser of your paper. That is to say, you need to write an overview of your paper. The aim of a descriptive abstract is to interest the reader.

Finally, to write a proposal abstract you will need to write the basic summary as for the informative abstract. However, the difference is the following: you aim at persuading someone to let you write on the topic. That is why, a proposal abstract should present your topic as the one worth investigating.

Learn how to write an abstract for a research paper .

Should I Revise and Edit a Research Paper?

Revising and editing your paper is essential if you want to get high grades. Let us help you revise your paper smart:

• Check your paper for spelling and grammar mistakes
• Sharpen the vocabulary
• Make sure there are no slang words in your paper
• Examine your paper in terms of structure
• Compare your topic, thesis statement to the whole piece
• Check your paper for plagiarism

If you need assistance with proofreading and editing your paper, you can turn to the professional editors at our service. They will help you polish your paper to perfection.

Learn how to revise and edit a research paper .

How to Write a Bibliography for a Research Paper?

First, let us make it clear that bibliography and works cited are two different things. Works cited are those that you cited in your paper. Bibliography should include all the materials you used to do your research. Still, remember that bibliography requirements differ depending on the formatting style of your paper. For this reason, make sure you ask you professor all the requirements you need to meet to avoid any misunderstanding.

Learn how to write a bibliography for a research paper .

The Key Secret to a Good Research Paper

Now when you know all the stages of writing a research paper, you are ready to find the key to a good research paper:

• Choose the topic that really interests you
• Make the topic interesting for you even if it is not at the beginning
• Follow the step by step guide and do not get sidetracked
• Be persistent and believe in yourself
• Really do research and write your paper from scratch
• Learn the convincing writing techniques and use them
• Follow the requirements of your assignment
• Ask for help if needed from real professionals

Feeling more confident about your paper now? We are sure you do. Still, if you need help, you can always rely on us 24/7.

We hope we have made writing a research paper much easier for you. We realize that it requires lots of time and energy. We believe when you say that you cannot handle it anymore. For this reason, we have been helping students like you for years. Our professional team of writers is ready to tackle any challenge.

All our authors are experienced writers crafting excellent academic papers. We help students meet the deadline and get the top grades they want. You can see everything yourself. All you need to do is to place your order online and we will contact you. Writing a research paper with us is truly easy, so why do not you check it yourself?

Additional Resources for Research Paper Writing:

• Anthropology Research
• Career Research
• Communication Research
• Criminal Justice Research
• Health Research
• Political Science Research
• Psychology Research
• Sociology Research

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How to start your research paper [step-by-step guide]

1. Choose your topic

2. find information on your topic, 3. create a thesis statement, 4. create a research paper outline, 5. organize your notes, 6. write your introduction, 7. write your first draft of the body, 9. write your conclusion, 10. revise again, edit, and proofread, frequently asked questions about starting your research paper, related articles.

Research papers can be short or in-depth, but no matter what type of research paper, they all follow pretty much the same pattern and have the same structure .

A research paper is a paper that makes an argument about a topic based on research and analysis.

There will be some basic differences, but if you can write one type of research paper, you can write another. Below is a step-by-step guide to starting and completing your research paper.

Choose a topic that interests you. Writing your research paper will be so much more pleasant with a topic that you actually want to know more about. Your interest will show in the way you write and effort you put into the paper. Consider these issues when coming up with a topic:

• make sure your topic is not too broad
• narrow it down if you're using terms that are too general

Academic search engines are a great source to find background information on your topic. Your institution's library will most likely provide access to plenty of online research databases. Take a look at our guide on how to efficiently search online databases for academic research to learn how to gather all the information needed on your topic.

Tip: If you’re struggling with finding research, consider meeting with an academic librarian to help you come up with more balanced keywords.

If you’re struggling to find a topic for your thesis, take a look at our guide on how to come up with a thesis topic .

The thesis statement is one of the most important elements of any piece of academic writing. It can be defined as a very brief statement of what the main point or central message of your paper is. Our thesis statement guide will help you write an excellent thesis statement.

In the next step, you need to create your research paper outline . The outline is the skeleton of your research paper. Simply start by writing down your thesis and the main ideas you wish to present. This will likely change as your research progresses; therefore, do not worry about being too specific in the early stages of writing your outline.

Then, fill out your outline with the following components:

• the main ideas that you want to cover in the paper
• the types of evidence that you will use to support your argument
• quotes from secondary sources that you may want to use

Organizing all the information you have gathered according to your outline will help you later on in the writing process. Analyze your notes, check for accuracy, verify the information, and make sure you understand all the information you have gathered in a way that you can communicate your findings effectively.

Start with the introduction. It will set the direction of your paper and help you a lot as you write. Waiting to write it at the end can leave you with a poorly written setup to an otherwise well-written paper.

The body of your paper argues, explains or describes your topic. Start with the first topic from your outline. Ideally, you have organized your notes in a way that you can work through your research paper outline and have all the notes ready.

After your first draft, take some time to check the paper for content errors. Rearrange ideas, make changes and check if the order of your paragraphs makes sense. At this point, it is helpful to re-read the research paper guidelines and make sure you have followed the format requirements. You can also use free grammar and proof reading checkers such as Grammarly .

Tip: Consider reading your paper from back to front when you undertake your initial revision. This will help you ensure that your argument and organization are sound.

Write your conclusion last and avoid including any new information that has not already been presented in the body of the paper. Your conclusion should wrap up your paper and show that your research question has been answered.

Allow a few days to pass after you finished writing the final draft of your research paper, and then start making your final corrections. The University of North Carolina at Chapel Hill gives some great advice here on how to revise, edit, and proofread your paper.

Tip: Take a break from your paper before you start your final revisions. Then, you’ll be able to approach your paper with fresh eyes.

As part of your final revision, be sure to check that you’ve cited everything correctly and that you have a full bibliography. Use a reference manager like Paperpile to organize your research and to create accurate citations.

The first step to start writing a research paper is to choose a topic. Make sure your topic is not too broad; narrow it down if you're using terms that are too general.

The format of your research paper will vary depending on the journal you submit to. Make sure to check first which citation style does the journal follow, in order to format your paper accordingly. Check Getting started with your research paper outline to have an idea of what a research paper looks like.

The last step of your research paper should be proofreading. Allow a few days to pass after you finished writing the final draft of your research paper, and then start making your final corrections. The University of North Carolina at Chapel Hill gives some great advice here on how to revise, edit and proofread your paper.

There are plenty of software you can use to write a research paper. We recommend our own citation software, Paperpile , as well as grammar and proof reading checkers such as Grammarly .

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• A Research Guide
• Research Paper Guide

Research Paper Body Paragraph Structure

Introduction.

• Referrences
• Ways to start paragraph
• Step by step guide
• Research paragraph examples

Learning the basics of a paragraph structure

• Title (cover page).
• Introduction.
• Literature review.
• Research methodology.
• Data analysis.
• Conclusion.
• Reference page.

5 winning ways to start a body paragraph

• Topic Sentence : it should provide a clear focus and introduce the specific aspect you will discuss. For example, “One key factor influencing climate change is…”.
• Opening Statement: grab your readers’ attention with a thought-provoking or surprising statement related to your topic. For instance, “The alarming increase in global temperatures has reached a critical point, demanding immediate action.”
• Quotation: find a relevant quote from a reputable source. It won’t only add credibility to your research but will also engage the reader right from the start.
• Anecdote or example: start your academic paragraph with a funny story or a real-world example that illustrates the significance of your research topic.
• Background information : provide a brief background or context for the topic you are about to discuss. For example, “In recent years, the prevalence of cyber-attacks has skyrocketed, posing a severe threat to individuals, organizations, and even national security.”

A step-by-step guide to starting a concise body paragraph

Step 1: introduce the main point or argument., step 2: provide evidence or examples., step 3: explain and analyze., step 4: connect to the main argument., step 5: review and revise., flawless body paragraph example: how does it look.

• Topic Sentence: Rising global temperatures have significant implications for ecosystems and biodiversity.
• Evidence/Example 1: According to a study by the Intergovernmental Panel on Climate Change (IPCC), global average temperatures have increased by 1.1 degrees Celsius since pre-industrial times (IPCC, 2021). This temperature rise has led to melting polar ice caps and glaciers, rising sea levels, and coastal erosion (Smith et al., 2019).
• Explanation/Analysis 1: The significant increase in global temperatures has caused observable changes in the Earth’s physical environment. The melting of polar ice caps not only contributes to the rise in sea levels but also disrupts marine ecosystems.
• Evidence/Example 2: In addition to the loss of coastal habitats, higher temperatures have also resulted in shifts in the geographical distribution of species. Research by Parmesan and Yohe (2019) indicates that many plant and animal species have altered their ranges and migration patterns in response to changing climate conditions.
• Explanation/Analysis 2: The observed shifts in species distribution highlight the vulnerability of ecosystems to climate change. As temperature zone modification, species that cannot adapt or migrate to suitable habitats may face reduced reproductive success and increased risk of extinction.
• Connect to the main argument: These examples demonstrate that the rising global temperatures associated with climate change have profound implications for ecosystems and biodiversity.

The bottom line

• Writing a Research Paper
• Research Paper Title
• Research Paper Sources
• Research Paper Problem Statement
• Research Paper Thesis Statement
• Hypothesis for a Research Paper
• Research Question
• Research Paper Outline
• Research Paper Summary
• Research Paper Prospectus
• Research Paper Proposal
• Research Paper Format
• Research Paper Styles
• AMA Style Research Paper
• MLA Style Research Paper
• Chicago Style Research Paper
• APA Style Research Paper
• Research Paper Structure
• Research Paper Cover Page
• Research Paper Abstract
• Research Paper Introduction
• Research Paper Body Paragraph
• Research Paper Literature Review
• Research Paper Background
• Research Paper Methods Section
• Research Paper Results Section
• Research Paper Discussion Section
• Research Paper Conclusion
• Research Paper Appendix
• Research Paper Bibliography
• APA Reference Page
• Annotated Bibliography
• Bibliography vs Works Cited vs References Page
• Research Paper Types
• What is Qualitative Research

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Home » Research Paper – Structure, Examples and Writing Guide

Research Paper – Structure, Examples and Writing Guide

Table of Contents

Research Paper

Definition:

Research Paper is a written document that presents the author’s original research, analysis, and interpretation of a specific topic or issue.

It is typically based on Empirical Evidence, and may involve qualitative or quantitative research methods, or a combination of both. The purpose of a research paper is to contribute new knowledge or insights to a particular field of study, and to demonstrate the author’s understanding of the existing literature and theories related to the topic.

Structure of Research Paper

The structure of a research paper typically follows a standard format, consisting of several sections that convey specific information about the research study. The following is a detailed explanation of the structure of a research paper:

The title page contains the title of the paper, the name(s) of the author(s), and the affiliation(s) of the author(s). It also includes the date of submission and possibly, the name of the journal or conference where the paper is to be published.

The abstract is a brief summary of the research paper, typically ranging from 100 to 250 words. It should include the research question, the methods used, the key findings, and the implications of the results. The abstract should be written in a concise and clear manner to allow readers to quickly grasp the essence of the research.

Introduction

The introduction section of a research paper provides background information about the research problem, the research question, and the research objectives. It also outlines the significance of the research, the research gap that it aims to fill, and the approach taken to address the research question. Finally, the introduction section ends with a clear statement of the research hypothesis or research question.

Literature Review

The literature review section of a research paper provides an overview of the existing literature on the topic of study. It includes a critical analysis and synthesis of the literature, highlighting the key concepts, themes, and debates. The literature review should also demonstrate the research gap and how the current study seeks to address it.

The methods section of a research paper describes the research design, the sample selection, the data collection and analysis procedures, and the statistical methods used to analyze the data. This section should provide sufficient detail for other researchers to replicate the study.

The results section presents the findings of the research, using tables, graphs, and figures to illustrate the data. The findings should be presented in a clear and concise manner, with reference to the research question and hypothesis.

The discussion section of a research paper interprets the findings and discusses their implications for the research question, the literature review, and the field of study. It should also address the limitations of the study and suggest future research directions.

The conclusion section summarizes the main findings of the study, restates the research question and hypothesis, and provides a final reflection on the significance of the research.

The references section provides a list of all the sources cited in the paper, following a specific citation style such as APA, MLA or Chicago.

How to Write Research Paper

You can write Research Paper by the following guide:

• Choose a Topic: The first step is to select a topic that interests you and is relevant to your field of study. Brainstorm ideas and narrow down to a research question that is specific and researchable.
• Conduct a Literature Review: The literature review helps you identify the gap in the existing research and provides a basis for your research question. It also helps you to develop a theoretical framework and research hypothesis.
• Develop a Thesis Statement : The thesis statement is the main argument of your research paper. It should be clear, concise and specific to your research question.
• Plan your Research: Develop a research plan that outlines the methods, data sources, and data analysis procedures. This will help you to collect and analyze data effectively.
• Collect and Analyze Data: Collect data using various methods such as surveys, interviews, observations, or experiments. Analyze data using statistical tools or other qualitative methods.
• Organize your Paper : Organize your paper into sections such as Introduction, Literature Review, Methods, Results, Discussion, and Conclusion. Ensure that each section is coherent and follows a logical flow.
• Write your Paper : Start by writing the introduction, followed by the literature review, methods, results, discussion, and conclusion. Ensure that your writing is clear, concise, and follows the required formatting and citation styles.
• Edit and Proofread your Paper: Review your paper for grammar and spelling errors, and ensure that it is well-structured and easy to read. Ask someone else to review your paper to get feedback and suggestions for improvement.
• Cite your Sources: Ensure that you properly cite all sources used in your research paper. This is essential for giving credit to the original authors and avoiding plagiarism.

Research Paper Example

Note : The below example research paper is for illustrative purposes only and is not an actual research paper. Actual research papers may have different structures, contents, and formats depending on the field of study, research question, data collection and analysis methods, and other factors. Students should always consult with their professors or supervisors for specific guidelines and expectations for their research papers.

Research Paper Example sample for Students:

Title: The Impact of Social Media on Mental Health among Young Adults

Abstract: This study aims to investigate the impact of social media use on the mental health of young adults. A literature review was conducted to examine the existing research on the topic. A survey was then administered to 200 university students to collect data on their social media use, mental health status, and perceived impact of social media on their mental health. The results showed that social media use is positively associated with depression, anxiety, and stress. The study also found that social comparison, cyberbullying, and FOMO (Fear of Missing Out) are significant predictors of mental health problems among young adults.

Introduction: Social media has become an integral part of modern life, particularly among young adults. While social media has many benefits, including increased communication and social connectivity, it has also been associated with negative outcomes, such as addiction, cyberbullying, and mental health problems. This study aims to investigate the impact of social media use on the mental health of young adults.

Literature Review: The literature review highlights the existing research on the impact of social media use on mental health. The review shows that social media use is associated with depression, anxiety, stress, and other mental health problems. The review also identifies the factors that contribute to the negative impact of social media, including social comparison, cyberbullying, and FOMO.

Methods : A survey was administered to 200 university students to collect data on their social media use, mental health status, and perceived impact of social media on their mental health. The survey included questions on social media use, mental health status (measured using the DASS-21), and perceived impact of social media on their mental health. Data were analyzed using descriptive statistics and regression analysis.

Results : The results showed that social media use is positively associated with depression, anxiety, and stress. The study also found that social comparison, cyberbullying, and FOMO are significant predictors of mental health problems among young adults.

Discussion : The study’s findings suggest that social media use has a negative impact on the mental health of young adults. The study highlights the need for interventions that address the factors contributing to the negative impact of social media, such as social comparison, cyberbullying, and FOMO.

Conclusion : In conclusion, social media use has a significant impact on the mental health of young adults. The study’s findings underscore the need for interventions that promote healthy social media use and address the negative outcomes associated with social media use. Future research can explore the effectiveness of interventions aimed at reducing the negative impact of social media on mental health. Additionally, longitudinal studies can investigate the long-term effects of social media use on mental health.

Limitations : The study has some limitations, including the use of self-report measures and a cross-sectional design. The use of self-report measures may result in biased responses, and a cross-sectional design limits the ability to establish causality.

Implications: The study’s findings have implications for mental health professionals, educators, and policymakers. Mental health professionals can use the findings to develop interventions that address the negative impact of social media use on mental health. Educators can incorporate social media literacy into their curriculum to promote healthy social media use among young adults. Policymakers can use the findings to develop policies that protect young adults from the negative outcomes associated with social media use.

References :

• Twenge, J. M., & Campbell, W. K. (2019). Associations between screen time and lower psychological well-being among children and adolescents: Evidence from a population-based study. Preventive medicine reports, 15, 100918.
• Primack, B. A., Shensa, A., Escobar-Viera, C. G., Barrett, E. L., Sidani, J. E., Colditz, J. B., … & James, A. E. (2017). Use of multiple social media platforms and symptoms of depression and anxiety: A nationally-representative study among US young adults. Computers in Human Behavior, 69, 1-9.
• Van der Meer, T. G., & Verhoeven, J. W. (2017). Social media and its impact on academic performance of students. Journal of Information Technology Education: Research, 16, 383-398.

Appendix : The survey used in this study is provided below.

Social Media and Mental Health Survey

• How often do you use social media per day?
• Less than 30 minutes
• 30 minutes to 1 hour
• 1 to 2 hours
• 2 to 4 hours
• More than 4 hours
• Which social media platforms do you use?
• Others (Please specify)
• How often do you experience the following on social media?
• Social comparison (comparing yourself to others)
• Cyberbullying
• Fear of Missing Out (FOMO)
• Have you ever experienced any of the following mental health problems in the past month?
• Do you think social media use has a positive or negative impact on your mental health?
• Very positive
• Somewhat positive
• Somewhat negative
• Very negative
• In your opinion, which factors contribute to the negative impact of social media on mental health?
• Social comparison
• In your opinion, what interventions could be effective in reducing the negative impact of social media on mental health?
• Education on healthy social media use
• Counseling for mental health problems caused by social media
• Social media detox programs
• Regulation of social media use

Thank you for your participation!

Applications of Research Paper

Research papers have several applications in various fields, including:

• Advancing knowledge: Research papers contribute to the advancement of knowledge by generating new insights, theories, and findings that can inform future research and practice. They help to answer important questions, clarify existing knowledge, and identify areas that require further investigation.
• Informing policy: Research papers can inform policy decisions by providing evidence-based recommendations for policymakers. They can help to identify gaps in current policies, evaluate the effectiveness of interventions, and inform the development of new policies and regulations.
• Improving practice: Research papers can improve practice by providing evidence-based guidance for professionals in various fields, including medicine, education, business, and psychology. They can inform the development of best practices, guidelines, and standards of care that can improve outcomes for individuals and organizations.
• Educating students : Research papers are often used as teaching tools in universities and colleges to educate students about research methods, data analysis, and academic writing. They help students to develop critical thinking skills, research skills, and communication skills that are essential for success in many careers.
• Fostering collaboration: Research papers can foster collaboration among researchers, practitioners, and policymakers by providing a platform for sharing knowledge and ideas. They can facilitate interdisciplinary collaborations and partnerships that can lead to innovative solutions to complex problems.

When to Write Research Paper

Research papers are typically written when a person has completed a research project or when they have conducted a study and have obtained data or findings that they want to share with the academic or professional community. Research papers are usually written in academic settings, such as universities, but they can also be written in professional settings, such as research organizations, government agencies, or private companies.

Here are some common situations where a person might need to write a research paper:

• For academic purposes: Students in universities and colleges are often required to write research papers as part of their coursework, particularly in the social sciences, natural sciences, and humanities. Writing research papers helps students to develop research skills, critical thinking skills, and academic writing skills.
• For publication: Researchers often write research papers to publish their findings in academic journals or to present their work at academic conferences. Publishing research papers is an important way to disseminate research findings to the academic community and to establish oneself as an expert in a particular field.
• To inform policy or practice : Researchers may write research papers to inform policy decisions or to improve practice in various fields. Research findings can be used to inform the development of policies, guidelines, and best practices that can improve outcomes for individuals and organizations.
• To share new insights or ideas: Researchers may write research papers to share new insights or ideas with the academic or professional community. They may present new theories, propose new research methods, or challenge existing paradigms in their field.

Purpose of Research Paper

The purpose of a research paper is to present the results of a study or investigation in a clear, concise, and structured manner. Research papers are written to communicate new knowledge, ideas, or findings to a specific audience, such as researchers, scholars, practitioners, or policymakers. The primary purposes of a research paper are:

• To contribute to the body of knowledge : Research papers aim to add new knowledge or insights to a particular field or discipline. They do this by reporting the results of empirical studies, reviewing and synthesizing existing literature, proposing new theories, or providing new perspectives on a topic.
• To inform or persuade: Research papers are written to inform or persuade the reader about a particular issue, topic, or phenomenon. They present evidence and arguments to support their claims and seek to persuade the reader of the validity of their findings or recommendations.
• To advance the field: Research papers seek to advance the field or discipline by identifying gaps in knowledge, proposing new research questions or approaches, or challenging existing assumptions or paradigms. They aim to contribute to ongoing debates and discussions within a field and to stimulate further research and inquiry.
• To demonstrate research skills: Research papers demonstrate the author’s research skills, including their ability to design and conduct a study, collect and analyze data, and interpret and communicate findings. They also demonstrate the author’s ability to critically evaluate existing literature, synthesize information from multiple sources, and write in a clear and structured manner.

Characteristics of Research Paper

Research papers have several characteristics that distinguish them from other forms of academic or professional writing. Here are some common characteristics of research papers:

• Evidence-based: Research papers are based on empirical evidence, which is collected through rigorous research methods such as experiments, surveys, observations, or interviews. They rely on objective data and facts to support their claims and conclusions.
• Structured and organized: Research papers have a clear and logical structure, with sections such as introduction, literature review, methods, results, discussion, and conclusion. They are organized in a way that helps the reader to follow the argument and understand the findings.
• Formal and objective: Research papers are written in a formal and objective tone, with an emphasis on clarity, precision, and accuracy. They avoid subjective language or personal opinions and instead rely on objective data and analysis to support their arguments.
• Citations and references: Research papers include citations and references to acknowledge the sources of information and ideas used in the paper. They use a specific citation style, such as APA, MLA, or Chicago, to ensure consistency and accuracy.
• Peer-reviewed: Research papers are often peer-reviewed, which means they are evaluated by other experts in the field before they are published. Peer-review ensures that the research is of high quality, meets ethical standards, and contributes to the advancement of knowledge in the field.
• Objective and unbiased: Research papers strive to be objective and unbiased in their presentation of the findings. They avoid personal biases or preconceptions and instead rely on the data and analysis to draw conclusions.

Advantages of Research Paper

Research papers have many advantages, both for the individual researcher and for the broader academic and professional community. Here are some advantages of research papers:

• Contribution to knowledge: Research papers contribute to the body of knowledge in a particular field or discipline. They add new information, insights, and perspectives to existing literature and help advance the understanding of a particular phenomenon or issue.
• Opportunity for intellectual growth: Research papers provide an opportunity for intellectual growth for the researcher. They require critical thinking, problem-solving, and creativity, which can help develop the researcher’s skills and knowledge.
• Career advancement: Research papers can help advance the researcher’s career by demonstrating their expertise and contributions to the field. They can also lead to new research opportunities, collaborations, and funding.
• Academic recognition: Research papers can lead to academic recognition in the form of awards, grants, or invitations to speak at conferences or events. They can also contribute to the researcher’s reputation and standing in the field.
• Impact on policy and practice: Research papers can have a significant impact on policy and practice. They can inform policy decisions, guide practice, and lead to changes in laws, regulations, or procedures.
• Advancement of society: Research papers can contribute to the advancement of society by addressing important issues, identifying solutions to problems, and promoting social justice and equality.

Limitations of Research Paper

Research papers also have some limitations that should be considered when interpreting their findings or implications. Here are some common limitations of research papers:

• Limited generalizability: Research findings may not be generalizable to other populations, settings, or contexts. Studies often use specific samples or conditions that may not reflect the broader population or real-world situations.
• Potential for bias : Research papers may be biased due to factors such as sample selection, measurement errors, or researcher biases. It is important to evaluate the quality of the research design and methods used to ensure that the findings are valid and reliable.
• Ethical concerns: Research papers may raise ethical concerns, such as the use of vulnerable populations or invasive procedures. Researchers must adhere to ethical guidelines and obtain informed consent from participants to ensure that the research is conducted in a responsible and respectful manner.
• Limitations of methodology: Research papers may be limited by the methodology used to collect and analyze data. For example, certain research methods may not capture the complexity or nuance of a particular phenomenon, or may not be appropriate for certain research questions.
• Publication bias: Research papers may be subject to publication bias, where positive or significant findings are more likely to be published than negative or non-significant findings. This can skew the overall findings of a particular area of research.
• Time and resource constraints: Research papers may be limited by time and resource constraints, which can affect the quality and scope of the research. Researchers may not have access to certain data or resources, or may be unable to conduct long-term studies due to practical limitations.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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The research paper writing process

In the first article of this two part series, we discussed how to research a term paper . In this article, we will discuss how to write a term or research paper.

Write your thesis statement

After you have spent some time finding your sources and absorbing the information, you should then be able to come up with a thesis statement that tells the reader how you will interpret the significance of the subject matter. This statement is a road map for the research paper, telling the reader what to expect. It usually consists of a single sentence somewhere in your first paragraph and makes a claim that others might later dispute!

For optimal organization, take the time to write an outline that indicates the main aspects to be discussed. This includes deciding on the order of your sub-topics and which key points you will use as evidence to support your position.

Keep the body of your research paper in good shape

The body is the largest part of a research paper; in it you collect and arrange evidence that will persuade the reader of your argument. It should, therefore, have a logical organization. If the paper is long, it is a good idea to partition the body into sections using headings and sub-headings. This includes using parenthetical citations when referencing another author's work in the body of your text.

Sometimes the beginning isn't the best place to start...

Write the introduction and conclusion of your research paper last in order to ensure accuracy. The introduction is the key to letting your readers know where you are headed and what you hope to accomplish. Remember that while the organization of your research paper may be clear to you, it may not necessarily be clear to your readers. Therefore, the introduction should acquaint them with the journey ahead, making it easier for them to understand what follows and helping to improve their evaluation of your work. Tell your readers in concise terms what the subject of the paper is, what it is that you hope to find out, and how you will go about doing so.

Encapsulating your findings in the conclusion is not the only place in the research paper where you make your voice heard. Your analysis should appear throughout. A common ESL mistake is reciting facts in the body of their essay and then waiting until the conclusion to say what they mean. Good research papers bring data, events, and other material together, interpreting the facts throughout. The conclusion should summarize what you have said in the body and should stress the evidence that supports your analysis.

Don't forget your references

Once your research paper is finished, compile your reference list. This is an alphabetical listing of all the sources you referenced in the body of your paper. If you made notes about your sources, this task should be straightforward. Be sure to follow whatever style guide your professor or school recommends. We have an example APA Reference page and an example MLA Works Cited for your reference.

Edit your research paper to ensure clarity

Once you have the pieces of your research paper in place, it's time to polish, polish, polish! Double-check everything. Ensure you have correctly cited your sources, checked your spelling and grammar, and re-read your paper several times, checking for sense, logical structure, and organization. Readers will judge your paper not only on the quality of research, but also on the quality of the writing.

Ta da! You've done it—your research paper is complete! Just think about what you've learned: not just about your subject, but about the whole investigative process.

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• Research guides

Writing an Educational Research Paper

Research paper sections, customary parts of an education research paper.

There is no one right style or manner for writing an education paper. Content aside, the writing style and presentation of papers in different educational fields vary greatly. Nevertheless, certain parts are common to most papers, for example:

Title/Cover Page

Contains the paper's title, the author's name, address, phone number, e-mail, and the day's date.

Not every education paper requires an abstract. However, for longer, more complex papers abstracts are particularly useful. Often only 100 to 300 words, the abstract generally provides a broad overview and is never more than a page. It describes the essence, the main theme of the paper. It includes the research question posed, its significance, the methodology, and the main results or findings. Footnotes or cited works are never listed in an abstract. Remember to take great care in composing the abstract. It's the first part of the paper the instructor reads. It must impress with a strong content, good style, and general aesthetic appeal. Never write it hastily or carelessly.

Introduction and Statement of the Problem

A good introduction states the main research problem and thesis argument. What precisely are you studying and why is it important? How original is it? Will it fill a gap in other studies? Never provide a lengthy justification for your topic before it has been explicitly stated.

Limitations of Study

Indicate as soon as possible what you intend to do, and what you are not going to attempt. You may limit the scope of your paper by any number of factors, for example, time, personnel, gender, age, geographic location, nationality, and so on.

Methodology

Discuss your research methodology. Did you employ qualitative or quantitative research methods? Did you administer a questionnaire or interview people? Any field research conducted? How did you collect data? Did you utilize other libraries or archives? And so on.

Literature Review

The research process uncovers what other writers have written about your topic. Your education paper should include a discussion or review of what is known about the subject and how that knowledge was acquired. Once you provide the general and specific context of the existing knowledge, then you yourself can build on others' research. The guide Writing a Literature Review will be helpful here.

Main Body of Paper/Argument

This is generally the longest part of the paper. It's where the author supports the thesis and builds the argument. It contains most of the citations and analysis. This section should focus on a rational development of the thesis with clear reasoning and solid argumentation at all points. A clear focus, avoiding meaningless digressions, provides the essential unity that characterizes a strong education paper.

After spending a great deal of time and energy introducing and arguing the points in the main body of the paper, the conclusion brings everything together and underscores what it all means. A stimulating and informative conclusion leaves the reader informed and well-satisfied. A conclusion that makes sense, when read independently from the rest of the paper, will win praise.

Works Cited/Bibliography

See the Citation guide .

Education research papers often contain one or more appendices. An appendix contains material that is appropriate for enlarging the reader's understanding, but that does not fit very well into the main body of the paper. Such material might include tables, charts, summaries, questionnaires, interview questions, lengthy statistics, maps, pictures, photographs, lists of terms, glossaries, survey instruments, letters, copies of historical documents, and many other types of supplementary material. A paper may have several appendices. They are usually placed after the main body of the paper but before the bibliography or works cited section. They are usually designated by such headings as Appendix A, Appendix B, and so on.

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9.2 Writing Body Paragraphs

Learning objectives.

• Select primary support related to your thesis.
• Support your topic sentences.

If your thesis gives the reader a roadmap to your essay, then body paragraphs should closely follow that map. The reader should be able to predict what follows your introductory paragraph by simply reading the thesis statement.

The body paragraphs present the evidence you have gathered to confirm your thesis. Before you begin to support your thesis in the body, you must find information from a variety of sources that support and give credit to what you are trying to prove.

Select Primary Support for Your Thesis

Without primary support, your argument is not likely to be convincing. Primary support can be described as the major points you choose to expand on your thesis. It is the most important information you select to argue for your point of view. Each point you choose will be incorporated into the topic sentence for each body paragraph you write. Your primary supporting points are further supported by supporting details within the paragraphs.

Remember that a worthy argument is backed by examples. In order to construct a valid argument, good writers conduct lots of background research and take careful notes. They also talk to people knowledgeable about a topic in order to understand its implications before writing about it.

Identify the Characteristics of Good Primary Support

In order to fulfill the requirements of good primary support, the information you choose must meet the following standards:

• Be specific. The main points you make about your thesis and the examples you use to expand on those points need to be specific. Use specific examples to provide the evidence and to build upon your general ideas. These types of examples give your reader something narrow to focus on, and if used properly, they leave little doubt about your claim. General examples, while they convey the necessary information, are not nearly as compelling or useful in writing because they are too obvious and typical.
• Be relevant to the thesis. Primary support is considered strong when it relates directly to the thesis. Primary support should show, explain, or prove your main argument without delving into irrelevant details. When faced with lots of information that could be used to prove your thesis, you may think you need to include it all in your body paragraphs. But effective writers resist the temptation to lose focus. Choose your examples wisely by making sure they directly connect to your thesis.
• Be detailed. Remember that your thesis, while specific, should not be very detailed. The body paragraphs are where you develop the discussion that a thorough essay requires. Using detailed support shows readers that you have considered all the facts and chosen only the most precise details to enhance your point of view.

Prewrite to Identify Primary Supporting Points for a Thesis Statement

Recall that when you prewrite you essentially make a list of examples or reasons why you support your stance. Stemming from each point, you further provide details to support those reasons. After prewriting, you are then able to look back at the information and choose the most compelling pieces you will use in your body paragraphs.

Choose one of the following working thesis statements. On a separate sheet of paper, write for at least five minutes using one of the prewriting techniques you learned in Chapter 8 “The Writing Process: How Do I Begin?” .

• Unleashed dogs on city streets are a dangerous nuisance.
• Students cheat for many different reasons.
• Drug use among teens and young adults is a problem.
• The most important change that should occur at my college or university is ____________________________________________.

Select the Most Effective Primary Supporting Points for a Thesis Statement

After you have prewritten about your working thesis statement, you may have generated a lot of information, which may be edited out later. Remember that your primary support must be relevant to your thesis. Remind yourself of your main argument, and delete any ideas that do not directly relate to it. Omitting unrelated ideas ensures that you will use only the most convincing information in your body paragraphs. Choose at least three of only the most compelling points. These will serve as the topic sentences for your body paragraphs.

Refer to the previous exercise and select three of your most compelling reasons to support the thesis statement. Remember that the points you choose must be specific and relevant to the thesis. The statements you choose will be your primary support points, and you will later incorporate them into the topic sentences for the body paragraphs.

Collaboration

Please share with a classmate and compare your answers.

When you support your thesis, you are revealing evidence. Evidence includes anything that can help support your stance. The following are the kinds of evidence you will encounter as you conduct your research:

• Facts. Facts are the best kind of evidence to use because they often cannot be disputed. They can support your stance by providing background information on or a solid foundation for your point of view. However, some facts may still need explanation. For example, the sentence “The most populated state in the United States is California” is a pure fact, but it may require some explanation to make it relevant to your specific argument.
• Judgments. Judgments are conclusions drawn from the given facts. Judgments are more credible than opinions because they are founded upon careful reasoning and examination of a topic.
• Testimony. Testimony consists of direct quotations from either an eyewitness or an expert witness. An eyewitness is someone who has direct experience with a subject; he adds authenticity to an argument based on facts. An expert witness is a person who has extensive experience with a topic. This person studies the facts and provides commentary based on either facts or judgments, or both. An expert witness adds authority and credibility to an argument.
• Personal observation. Personal observation is similar to testimony, but personal observation consists of your testimony. It reflects what you know to be true because you have experiences and have formed either opinions or judgments about them. For instance, if you are one of five children and your thesis states that being part of a large family is beneficial to a child’s social development, you could use your own experience to support your thesis.

Writing at Work

In any job where you devise a plan, you will need to support the steps that you lay out. This is an area in which you would incorporate primary support into your writing. Choosing only the most specific and relevant information to expand upon the steps will ensure that your plan appears well-thought-out and precise.

You can consult a vast pool of resources to gather support for your stance. Citing relevant information from reliable sources ensures that your reader will take you seriously and consider your assertions. Use any of the following sources for your essay: newspapers or news organization websites, magazines, encyclopedias, and scholarly journals, which are periodicals that address topics in a specialized field.

Choose Supporting Topic Sentences

Each body paragraph contains a topic sentence that states one aspect of your thesis and then expands upon it. Like the thesis statement, each topic sentence should be specific and supported by concrete details, facts, or explanations.

Each body paragraph should comprise the following elements.

topic sentence + supporting details (examples, reasons, or arguments)

As you read in Chapter 8 “The Writing Process: How Do I Begin?” , topic sentences indicate the location and main points of the basic arguments of your essay. These sentences are vital to writing your body paragraphs because they always refer back to and support your thesis statement. Topic sentences are linked to the ideas you have introduced in your thesis, thus reminding readers what your essay is about. A paragraph without a clearly identified topic sentence may be unclear and scattered, just like an essay without a thesis statement.

Unless your teacher instructs otherwise, you should include at least three body paragraphs in your essay. A five-paragraph essay, including the introduction and conclusion, is commonly the standard for exams and essay assignments.

Consider the following the thesis statement:

Author J.D. Salinger relied primarily on his personal life and belief system as the foundation for the themes in the majority of his works.

The following topic sentence is a primary support point for the thesis. The topic sentence states exactly what the controlling idea of the paragraph is. Later, you will see the writer immediately provide support for the sentence.

Salinger, a World War II veteran, suffered from posttraumatic stress disorder, a disorder that influenced themes in many of his works.

In Note 9.19 “Exercise 2” , you chose three of your most convincing points to support the thesis statement you selected from the list. Take each point and incorporate it into a topic sentence for each body paragraph.

Supporting point 1: ____________________________________________

Topic sentence: ____________________________________________

Supporting point 2: ____________________________________________

Supporting point 3: ____________________________________________

Draft Supporting Detail Sentences for Each Primary Support Sentence

After deciding which primary support points you will use as your topic sentences, you must add details to clarify and demonstrate each of those points. These supporting details provide examples, facts, or evidence that support the topic sentence.

The writer drafts possible supporting detail sentences for each primary support sentence based on the thesis statement:

Thesis statement: Unleashed dogs on city streets are a dangerous nuisance.

Supporting point 1: Dogs can scare cyclists and pedestrians.

Supporting details:

• Cyclists are forced to zigzag on the road.
• School children panic and turn wildly on their bikes.
• People who are walking at night freeze in fear.

Supporting point 2:

Loose dogs are traffic hazards.

• Dogs in the street make people swerve their cars.
• To avoid dogs, drivers run into other cars or pedestrians.
• Children coaxing dogs across busy streets create danger.

Supporting point 3: Unleashed dogs damage gardens.

• They step on flowers and vegetables.
• They destroy hedges by urinating on them.
• They mess up lawns by digging holes.

The following paragraph contains supporting detail sentences for the primary support sentence (the topic sentence), which is underlined.

Salinger, a World War II veteran, suffered from posttraumatic stress disorder, a disorder that influenced the themes in many of his works. He did not hide his mental anguish over the horrors of war and once told his daughter, “You never really get the smell of burning flesh out of your nose, no matter how long you live.” His short story “A Perfect Day for a Bananafish” details a day in the life of a WWII veteran who was recently released from an army hospital for psychiatric problems. The man acts questionably with a little girl he meets on the beach before he returns to his hotel room and commits suicide. Another short story, “For Esmé – with Love and Squalor,” is narrated by a traumatized soldier who sparks an unusual relationship with a young girl he meets before he departs to partake in D-Day. Finally, in Salinger’s only novel, The Catcher in the Rye , he continues with the theme of posttraumatic stress, though not directly related to war. From a rest home for the mentally ill, sixteen-year-old Holden Caulfield narrates the story of his nervous breakdown following the death of his younger brother.

Using the three topic sentences you composed for the thesis statement in Note 9.18 “Exercise 1” , draft at least three supporting details for each point.

Thesis statement: ____________________________________________

Primary supporting point 1: ____________________________________________

Supporting details: ____________________________________________

Primary supporting point 2: ____________________________________________

Primary supporting point 3: ____________________________________________

You have the option of writing your topic sentences in one of three ways. You can state it at the beginning of the body paragraph, or at the end of the paragraph, or you do not have to write it at all. This is called an implied topic sentence. An implied topic sentence lets readers form the main idea for themselves. For beginning writers, it is best to not use implied topic sentences because it makes it harder to focus your writing. Your instructor may also want to clearly identify the sentences that support your thesis. For more information on the placement of thesis statements and implied topic statements, see Chapter 8 “The Writing Process: How Do I Begin?” .

Print out the first draft of your essay and use a highlighter to mark your topic sentences in the body paragraphs. Make sure they are clearly stated and accurately present your paragraphs, as well as accurately reflect your thesis. If your topic sentence contains information that does not exist in the rest of the paragraph, rewrite it to more accurately match the rest of the paragraph.

Key Takeaways

• Your body paragraphs should closely follow the path set forth by your thesis statement.
• Strong body paragraphs contain evidence that supports your thesis.
• Primary support comprises the most important points you use to support your thesis.
• Strong primary support is specific, detailed, and relevant to the thesis.
• Prewriting helps you determine your most compelling primary support.
• Evidence includes facts, judgments, testimony, and personal observation.
• Reliable sources may include newspapers, magazines, academic journals, books, encyclopedias, and firsthand testimony.
• A topic sentence presents one point of your thesis statement while the information in the rest of the paragraph supports that point.
• A body paragraph comprises a topic sentence plus supporting details.

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Body paragraphs: Moving from general to specific information

Your paper should be organized in a manner that moves from general to specific information. Every time you begin a new subject, think of an inverted pyramid - The broadest range of information sits at the top, and as the paragraph or paper progresses, the author becomes more and more focused on the argument ending with specific, detailed evidence supporting a claim. Lastly, the author explains how and why the information she has just provided connects to and supports her thesis (a brief wrap-up or warrant).

Moving from General to Specific Information

The four elements of a good paragraph (TTEB)

A good paragraph should contain at least the following four elements: T ransition, T opic sentence, specific E vidence and analysis, and a B rief wrap-up sentence (also known as a warrant ) –TTEB!

• A T ransition sentence leading in from a previous paragraph to assure smooth reading. This acts as a hand-off from one idea to the next.
• A T opic sentence that tells the reader what you will be discussing in the paragraph.
• Specific E vidence and analysis that supports one of your claims and that provides a deeper level of detail than your topic sentence.
• A B rief wrap-up sentence that tells the reader how and why this information supports the paper’s thesis. The brief wrap-up is also known as the warrant. The warrant is important to your argument because it connects your reasoning and support to your thesis, and it shows that the information in the paragraph is related to your thesis and helps defend it.

Supporting evidence (induction and deduction)

Induction is the type of reasoning that moves from specific facts to a general conclusion. When you use induction in your paper, you will state your thesis (which is actually the conclusion you have come to after looking at all the facts) and then support your thesis with the facts. The following is an example of induction taken from Dorothy U. Seyler’s Understanding Argument :

There is the dead body of Smith. Smith was shot in his bedroom between the hours of 11:00 p.m. and 2:00 a.m., according to the coroner. Smith was shot with a .32 caliber pistol. The pistol left in the bedroom contains Jones’s fingerprints. Jones was seen, by a neighbor, entering the Smith home at around 11:00 p.m. the night of Smith’s death. A coworker heard Smith and Jones arguing in Smith’s office the morning of the day Smith died.

Conclusion: Jones killed Smith.

Here, then, is the example in bullet form:

• Conclusion: Jones killed Smith
• Support: Smith was shot by Jones’ gun, Jones was seen entering the scene of the crime, Jones and Smith argued earlier in the day Smith died.
• Assumption: The facts are representative, not isolated incidents, and thus reveal a trend, justifying the conclusion drawn.

When you use deduction in an argument, you begin with general premises and move to a specific conclusion. There is a precise pattern you must use when you reason deductively. This pattern is called syllogistic reasoning (the syllogism). Syllogistic reasoning (deduction) is organized in three steps:

• Major premise
• Minor premise

In order for the syllogism (deduction) to work, you must accept that the relationship of the two premises lead, logically, to the conclusion. Here are two examples of deduction or syllogistic reasoning:

• Major premise: All men are mortal.
• Minor premise: Socrates is a man.
• Conclusion: Socrates is mortal.
• Major premise: People who perform with courage and clear purpose in a crisis are great leaders.
• Minor premise: Lincoln was a person who performed with courage and a clear purpose in a crisis.
• Conclusion: Lincoln was a great leader.

So in order for deduction to work in the example involving Socrates, you must agree that (1) all men are mortal (they all die); and (2) Socrates is a man. If you disagree with either of these premises, the conclusion is invalid. The example using Socrates isn’t so difficult to validate. But when you move into more murky water (when you use terms such as courage , clear purpose , and great ), the connections get tenuous.

For example, some historians might argue that Lincoln didn’t really shine until a few years into the Civil War, after many Union losses to Southern leaders such as Robert E. Lee.

The following is a clear example of deduction gone awry:

• Major premise: All dogs make good pets.
• Minor premise: Doogle is a dog.
• Conclusion: Doogle will make a good pet.

If you don’t agree that all dogs make good pets, then the conclusion that Doogle will make a good pet is invalid.

When a premise in a syllogism is missing, the syllogism becomes an enthymeme. Enthymemes can be very effective in argument, but they can also be unethical and lead to invalid conclusions. Authors often use enthymemes to persuade audiences. The following is an example of an enthymeme:

If you have a plasma TV, you are not poor.

The first part of the enthymeme (If you have a plasma TV) is the stated premise. The second part of the statement (you are not poor) is the conclusion. Therefore, the unstated premise is “Only rich people have plasma TVs.” The enthymeme above leads us to an invalid conclusion (people who own plasma TVs are not poor) because there are plenty of people who own plasma TVs who are poor. Let’s look at this enthymeme in a syllogistic structure:

• Major premise: People who own plasma TVs are rich (unstated above).
• Minor premise: You own a plasma TV.
• Conclusion: You are not poor.

To help you understand how induction and deduction can work together to form a solid argument, you may want to look at the United States Declaration of Independence. The first section of the Declaration contains a series of syllogisms, while the middle section is an inductive list of examples. The final section brings the first and second sections together in a compelling conclusion.

Writing a Research Paper

This page lists some of the stages involved in writing a library-based research paper.

Although this list suggests that there is a simple, linear process to writing such a paper, the actual process of writing a research paper is often a messy and recursive one, so please use this outline as a flexible guide.

Discovering, Narrowing, and Focusing a Researchable Topic

• Try to find a topic that truly interests you
• Try writing your way to a topic
• Talk with your course instructor and classmates about your topic
• Pose your topic as a question to be answered or a problem to be solved

Finding, Selecting, and Reading Sources

You will need to look at the following types of sources:

• library catalog, periodical indexes, bibliographies, suggestions from your instructor
• primary vs. secondary sources
• journals, books, other documents

Grouping, Sequencing, and Documenting Information

The following systems will help keep you organized:

• a system for noting sources on bibliography cards
• a system for organizing material according to its relative importance
• a system for taking notes

Writing an Outline and a Prospectus for Yourself

Consider the following questions:

• What is the topic?
• Why is it significant?
• What background material is relevant?
• What is my thesis or purpose statement?
• What organizational plan will best support my purpose?

Writing the Introduction

In the introduction you will need to do the following things:

• present relevant background or contextual material
• define terms or concepts when necessary
• explain the focus of the paper and your specific purpose
• reveal your plan of organization

Writing the Body

• Use your outline and prospectus as flexible guides
• Build your essay around points you want to make (i.e., don’t let your sources organize your paper)
• Integrate your sources into your discussion
• Summarize, analyze, explain, and evaluate published work rather than merely reporting it
• Move up and down the “ladder of abstraction” from generalization to varying levels of detail back to generalization

Writing the Conclusion

• If the argument or point of your paper is complex, you may need to summarize the argument for your reader.
• If prior to your conclusion you have not yet explained the significance of your findings or if you are proceeding inductively, use the end of your paper to add your points up, to explain their significance.
• Move from a detailed to a general level of consideration that returns the topic to the context provided by the introduction.
• Perhaps suggest what about this topic needs further research.

Revising the Final Draft

• Check overall organization : logical flow of introduction, coherence and depth of discussion in body, effectiveness of conclusion.
• Paragraph level concerns : topic sentences, sequence of ideas within paragraphs, use of details to support generalizations, summary sentences where necessary, use of transitions within and between paragraphs.
• Sentence level concerns: sentence structure, word choices, punctuation, spelling.
• Documentation: consistent use of one system, citation of all material not considered common knowledge, appropriate use of endnotes or footnotes, accuracy of list of works cited.

Academic and Professional Writing

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The impact of stress on body function: A review

Habib yaribeygi.

1 Neurosciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran

Yunes Panahi

2 Clinical Pharmacy Department, Faculty of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran

Hedayat Sahraei

Thomas p. johnston.

3 Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri, USA

Amirhossein Sahebkar

4 Biotechnology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Any intrinsic or extrinsic stimulus that evokes a biological response is known as stress. The compensatory responses to these stresses are known as stress responses. Based on the type, timing and severity of the applied stimulus, stress can exert various actions on the body ranging from alterations in homeostasis to life-threatening effects and death. In many cases, the pathophysiological complications of disease arise from stress and the subjects exposed to stress, e.g. those that work or live in stressful environments, have a higher likelihood of many disorders. Stress can be either a triggering or aggravating factor for many diseases and pathological conditions. In this study, we have reviewed some of the major effects of stress on the primary physiological systems of humans.

Abbreviations

ACTH: Adrenocorticotropic hormone

CNS: Central nervous system

CRH: Corticotropin releasing hormone

GI: Gastrointestinal

LTP: Long-term potentiation

NMDA : N-methyl-D-aspartate

VTA: Ventral tegmental area

Stress and the Brain Function Complications

For a long time, researchers suggested that hormones have receptors just in the peripheral tissues and do not gain access to the central nervous system (CNS) (Lupien and Lepage, 2001[ 63 ]). However, observations have demonstrated the effect of anti-inflammatory drugs (which are considered synthetic hormones) on behavioral and cognitive disorders and the phenomenon called “Steroid psychosis” (Clark et al., 1952[ 16 ]). In the early sixties, neuropeptides were recognized as compounds devoid of effects on the peripheral endocrine system. However, it was determined that hormones are able to elicit biological effects on different parts of the CNS and play an important role in behavior and cognition (De Kloet, 2000[ 22 ]). In 1968, McEven suggested for the first time that the brain of rodents is capable of responding to glucocorticoid (as one of the operators in the stress cascade). This hypothesis that stress can cause functional changes in the CNS was then accepted (McEwen et al., 1968[ 74 ]). From that time on, two types of corticotropic receptors (glucocorticosteroids and mineralocorticoids) were recognized (de Kloet et al., 1999[ 23 ]). It was determined that the affinity of glucocorticosteroid receptors to cortisol and corticosterone was about one tenth of that of mineralocorticoids (de Kloet et al., 1999[ 23 ]). The hippocampus area has both types of receptors, while other points of the brain have only glucocorticosteroid receptors (de Kloet et al., 1999[ 23 ]).

The effects of stress on the nervous system have been investigated for 50 years (Thierry et al., 1968[ 115 ]). Some studies have shown that stress has many effects on the human nervous system and can cause structural changes in different parts of the brain (Lupien et al., 2009[ 65 ]). Chronic stress can lead to atrophy of the brain mass and decrease its weight (Sarahian et al., 2014[ 100 ]). These structural changes bring about differences in the response to stress, cognition and memory (Lupien et al., 2009[ 65 ]). Of course, the amount and intensity of the changes are different according to the stress level and the duration of stress (Lupien et al., 2009[ 65 ]). However, it is now obvious that stress can cause structural changes in the brain with long-term effects on the nervous system (Reznikov et al., 2007[ 89 ]). Thus, it is highly essential to investigate the effects of stress on different aspects of the nervous system (Table 1 (Tab. 1) ; References in Table 1: Lupien et al., 2001[ 63 ]; Woolley et al., 1990[ 122 ]; Sapolsky et al., 1990[ 99 ]; Gould et al., 1998[ 35 ]; Bremner, 1999[ 10 ]; Seeman et al., 1997[ 108 ]; Luine et al., 1994[ 62 ]; Li et al., 2008[ 60 ]; Scholey et al., 2014[ 101 ]; Borcel et al., 2008[ 9 ]; Lupien et al., 2002[ 66 ]).

Stress and Memory

Memory is one of the important functional aspects of the CNS and it is categorized as sensory, short term, and long-term. Short term memory is dependent on the function of the frontal and parietal lobes, while long-term memory depends on the function of large areas of the brain (Wood et al., 2000[ 121 ]). However, total function of memory and the conversion of short term memory to long-term memory are dependent on the hippocampus; an area of the brain that has the highest density of glucocorticosteroid receptors and also represents the highest level of response to stress (Scoville and Milner, 1957[ 107 ]; Asalgoo et al., 2015[ 1 ]). Therefore, during the past several decades, the relationship between the hippocampus and stress have been hotly debated (Asalgoo et al., 2015[ 1 ]; Lupien and Lepage, 2001[ 63 ]). In 1968, it was proven that there were cortisol receptors in the hippocampus of rats (McEwen et al., 1968[ 74 ]). Later, in 1982, by using specific agonists of glucocorticosteroid and mineralocorticoid receptors, the existence of these two receptors in the brain and hippocampus area of rats was proven (Veldhuis et al., 1982[ 119 ]). It should also be noted that the amygdala is very important to assessing the emotional experiences of memory (Roozendaal et al., 2009[ 91 ]).

The results of past studies have demonstrated the effect of stress on the process of memory (Ghodrat et al., 2014[ 32 ]). Various studies have shown that stress can cause functional and structural changes in the hippocampus section of the brain (McEwen, 1999[ 72 ]). These structural changes include atrophy and neurogenesis disorders (Lupien and Lepage, 2001[ 63 ]). Also, chronic stress and, consequently, an increase in plasma cortisol, leads to a reduction in the number of dendritic branches (Woolley et al., 1990[ 122 ]) and the number of neurons (Sapolsky et al., 1990[ 99 ]), as well as structural changes in synaptic terminals (Sapolsky et al., 1990[ 99 ]) and decreased neurogenesis in the hippocampus tissue (Gould et al., 1998[ 35 ]). Glucocorticosteroids can induce these changes by either effecting the cellular metabolism of neurons (Lawrence and Sapolsky, 1994[ 58 ]), or increasing the sensitivity of hippocampus cells to stimulatory amino acids (Sapolsky and Pulsinelli, 1985[ 98 ]) and/or increasing the level of extracellular glutamate (Sapolsky and Pulsinelli, 1985[ 98 ]).

High concentrations of stress hormones can cause declarative memory disorders (Lupien and Lepage, 2001[ 63 ]). Animal studies have shown that stress can cause a reversible reduction in spatial memory as a result of atrophy of the hippocampus (Luine et al., 1994[ 62 ]). In fact, high plasma concentrations of glucocorticosteroids for extended periods of time can cause atrophy of the hippocampus leading to memory disorders (Issa et al., 1990[ 45 ]). Additionally, people with either Cushing's syndrome (with an increased secretion of glucocorticosteroids), or people who receive high dosages of exogenous synthetic anti-inflammatory drugs, are observed to have atrophy of the hippocampus and associated memory disorders (Ling et al., 1981[ 61 ]). MRI images taken from the brains of people with post-traumatic stress disorder (PTSD) have demonstrated a reduction in the volume of the hippocampus along with neurophysiologic effects such as a weak verbal memory (Bremner, 1999[ 10 ]). Several human studies have suggested that even common therapeutic doses of glucocorticosteroids and dexamethasone can cause problems with explicit memory (Keenan et al., 1995[ 49 ]; Kirschbaum et al., 1996[ 53 ]). Thus, there is an inverse relationship between the level of cortisol and memory (Ling et al., 1981[ 61 ]), such that increasing levels of plasma cortisol following prolonged stress leads to a reduction in memory (Kirschbaum et al., 1996[ 53 ]), which improves when the level of plasma cortisol decreases (Seeman et al., 1997[ 108 ]).

Stress also has negative effects on learning. Results from hippocampus-dependent loading data demonstrate that subjects are not as familiar with a new environment after having been exposed to a new environment (Bremner, 1999[ 10 ]). Moreover, adrenal steroids lead to alteration in long-term potentiation (LTP), which is an important process in memory formation (Bliss and Lømo, 1973[ 7 ]).

Two factors are involved in the memory process during stress. The first is noradrenaline, which creates emotional aspects of memories in the basolateral amygdala area (Joëls et al., 2011[ 47 ]). Secondly, this process is facilitated by corticosteroids. However, if the release of corticosteroids occurs a few hours earlier, it causes inhibition of the amygdala and corresponding behaviors (Joëls et al., 2011[ 47 ]). Thus, there is a mutual balance between these two hormones for creating a response in the memory process (Joëls et al., 2011[ 47 ]).

Stress does not always affect memory. Sometimes, under special conditions, stress can actually improve memory (McEwen and Lupien, 2002[ 71 ]). These conditions include non-familiarity, non-predictability, and life-threatening aspects of imposed stimulation. Under these specific conditions, stress can temporarily improve the function of the brain and, therefore, memory. In fact, it has been suggested that stress can sharpen memory in some situations (Schwabe et al., 2010[ 105 ]). For example, it has been shown that having to take a written examination can improve memory for a short period of time in examination participants. Interestingly, this condition is associated with a decrease in the level of cortisol in the saliva (Vedhara et al., 2000[ 118 ]). Other studies have shown that impending stress before learning occurs can also lead to either an increase in the power of memory (Domes et al., 2002[ 27 ]; Schwabe et al., 2008[ 102 ]), or decrease in the capacity for memory (Diamond et al., 2006[ 26 ]; Kirschbaum et al., 1996[ 53 ]). This paradox results from the type of imposed stress and either the degree of emotional connection to the stressful event (Payne et al., 2007[ 83 ]; Diamond et al., 2007[ 25 ]), or the period of time between the imposing stress and the process of learning (Diamond et al., 2007[ 25 ]).

The process of strengthening memory is usually reinforced after stress (Schwabe et al., 2012[ 103 ]). Various studies on animal and human models have shown that administration of either glucocorticosteroids, or stress shortly after learning has occurred facilitates memory (Schwabe et al., 2012[ 103 ]). Also, it has been shown that glucocorticosteroids (not mineralocorticoids) are necessary to improve learning and memory (Lupien et al., 2002[ 66 ]). However, the retrieval of events in memory after exposure to stress will be decreased (Schwabe et al., 2012[ 103 ]), which may result from the competition of updated data for storage in memory in a stressful state (de Kloet et al., 1999[ 23 ]). Some investigations have shown that either exposure to stress, or injection of glucocorticosteroids before a test to assess retention, decreases the power of memory in humans and rodents (Schwabe and Wolf, 2009[ 104 ]).

In summary, it has been concluded that the effect of stress on memory is highly dependent on the time of exposure to the stressful stimulus and, in terms of the timing of the imposed stress, memory can be either better or worse (Schwabe et al., 2012[ 103 ]). Moreover, recent studies have shown that using a specific-timed schedule of exposure to stress not only affects hippocampus-dependent memory, but also striatum-dependent memory, which highlights the role of timing of the imposed stressful stimulus (Schwabe et al., 2010[ 105 ]).

Stress, Cognition and Learning

Cognition is another important feature of brain function. Cognition means reception and perception of perceived stimuli and its interpretation, which includes learning, decision making, attention, and judgment (Sandi, 2013[ 95 ]). Stress has many effects on cognition that depend on its intensity, duration, origin, and magnitude (Sandi, 2013[ 95 ]). Similar to memory, cognition is mainly formed in the hippocampus, amygdala, and temporal lobe (McEwen and Sapolsky, 1995[ 73 ]). The net effect of stress on cognition is a reduction in cognition and thus, it is said that any behavioral steps undertaken to reduce stress leads to increase in cognition (Scholey et al., 2014[ 101 ]). In fact, stress activates some physiological systems, such as the autonomic nervous system, central neurotransmitter and neuropeptide system, and the hypothalamus-pituitary-adrenal axis, which have direct effects on neural circuits in the brain involved with data processing (Sandi, 2013[ 95 ]). Activation of stress results in the production and release of glucocorticosteroids. Because of the lipophilic properties of glucocorticosteroids, they can diffuse through the blood-brain barrier and exert long-term effects on processing and cognition (Sandi, 2013[ 95 ]).

It appears that being exposed to stress can cause pathophysiologic changes in the brain, and these changes can be manifested as behavioral, cognitive, and mood disorders (Li et al., 2008[ 60 ]). In fact, studies have shown that chronic stress can cause complications such as increased IL-6 and plasma cortisol, but decreased amounts of cAMP responsive element binding protein and brain-derived neurotrophic factor (BDNF), which is very similar to what is observed in people with depression and mood disorders that exhibit a wide range of cognitive problems (Song et al., 2006[ 114 ]). Additionally, the increased concentrations of inflammatory factors, like interleukins and TNF-α (which play an important role in creating cognitive disorders), proves a physiologic relationship between stress and mood-based cognitive disorders (Solerte et al., 2000[ 113 ]; Marsland et al., 2006[ 68 ]; Li et al., 2008[ 60 ]). Studies on animals suggest that cognitive disorders resulting from stress are created due to neuroendocrine and neuroamine factors and neurodegenerative processes (Li et al., 2008[ 60 ]). However, it should be noted that depression may not always be due to the over activation of the physiological-based stress response (Osanloo et al., 2016[ 81 ]).

Cognitive disorders following exposure to stress have been reported in past studies (Lupien and McEwen, 1997[ 64 ]). Stress has effects on cognition both acutely (through catecholamines) and chronically (through glucocorticosteroids) (McEwen and Sapolsky, 1995[ 73 ]). Acute effects are mainly caused by beta-adrenergic effects, while chronic effects are induced in a long-term manner by changes in gene expression mediated by steroids (McEwen and Sapolsky, 1995[ 73 ]). In general, many mechanisms modulate the effects of stress on cognition (McEwen and Sapolsky, 1995[ 73 ]; Mendl, 1999[ 75 ]). For instance, adrenal steroids affect the function of the hippocampus during cognition and memory retrieval in a biphasic manner (McEwen and Sapolsky, 1995[ 73 ]). In chronic stress, these steroids can destroy neurons with other stimulatory neurotransmitters (Sandi, 2013[ 95 ]). Exposure to stress can also cause disorders in hippocampus-related cognition; specifically, spatial memory (Borcel et al., 2008[ 9 ]; Sandi et al., 2003[ 96 ]). Additionally, stress can halt or decrease the genesis of neurons in the dentate gyrus area of the hippocampus (this area is one of the limited brain areas in which neurogenesis occurs in adults) (Gould and Tanapat, 1999[ 34 ]; Köhler et al., 2010[ 54 ]). Although age is a factor known to affect cognition, studies on animals have demonstrated that young rats exposed to high doses of adrenal steroids show the same level of decline in their cognition as older adult animals with normal plasma concentrations of glucocorticoids (Landfield et al., 1978[ 57 ]). Also, a decrease in the secretion of glucocorticosteroids causes preservation of spatial memory in adults and has also been shown to have neuroprotective effects (Montaron et al., 2006[ 78 ]). Other studies have shown that stress (or the injection of adrenal steroids) results in varied effects on cognition. For instance, injection of hydrocortisone at the time of its maximum plasma concentration (in the afternoon) leads to a decrease in reaction time and improves cognition and memory (Lupien et al., 2002[ 66 ]).

In summary, the adverse effects of stress on cognition are diverse and depend on the type, timing, intensity, and duration (Sandi, 2013[ 95 ]). Generally, it is believed that mild stress facilitates an improvement in cognitive function, especially in the case of virtual or verbal memory. However, if the intensity of stress passes beyond a predetermined threshold (which is different in each individual), it causes cognitive disorders, especially in memory and judgment. The disruption to memory and judgment is due to the effects of stress on the hippocampus and prefrontal cortex (Sandi, 2013[ 95 ]). Of course, it must be realized that factors like age and gender may also play a role in some cognitive disorders (Sandi, 2013[ 95 ]). Importantly, it should be emphasized that different people may exhibit varied responses in cognition when exposed to the very same stressful stimulus (Hatef et al., 2015[ 39 ]).

Stress and Immune System Functions

The relationship between stress and the immune system has been considered for decades (Khansari et al., 1990[ 50 ]; Dantzer and Kelley, 1989[ 21 ]). The prevailing attitude between the association of stress and immune system response has been that people under stress are more likely to have an impaired immune system and, as a result, suffer from more frequent illness (Khansari et al., 1990[ 50 ]). Also, old anecdotes describing resistance of some people to severe disease using the power of the mind and their thought processes, has promoted this attitude (Khansari et al., 1990[ 50 ]). In about 200 AC, Aelius Galenus (Galen of Pergamon) declared that melancholic women (who have high levels of stress and, thus, impaired immune function) are more likely to have cancer than women who were more positive and exposed to less stress (Reiche et al., 2004[ 88 ]). This may be the first recorded case about the relationship between the immune system and stress. In an old study in the early 1920's, researchers found that the activity of phagocytes in tuberculosis decreased when emotional stress was induced. In fact, it was also suggested that living with stress increases the risk of tuberculosis by suppressing the immune system (Ishigami, 1919[ 44 ]). Following this study, other researchers suggested that the probability of disease appearance increases following a sudden, major, and extremely stressful life style change (Holmes and Rahe, 1967[ 41 ]; Calabrese et al., 1987[ 12 ]).

Over the past several decades, there have been many studies investigating the role of stress on immune system function (Dantzer and Kelley, 1989[ 21 ]; Segerstrom and Miller, 2004[ 109 ]). These studies have shown that stress mediators can pass through the blood-brain barrier and exert their effects on the immune system (Khansari et al., 1990[ 50 ]). Thus, the effect of stress on the immune system is now an accepted relationship or association.

Stress can affect the function of the immune system by modulating processes in the CNS and neuroendocrine system (Khansari et al., 1990[ 50 ]; Kiecolt-Glaser and Glaser, 1991[ 51 ]). Following stress, some neuroendocrine and neural responses result in the release of corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH), and other stress mediators (Carrasco and Van de Kar, 2003[ 13 ]). However, evidence suggests that the lymphatic system, which is a part of the immune system, also plays a role in releasing these mediators (Khansari et al., 1990[ 50 ]). For instance, thymus peptides, such as thymopentine, thymopoietin, and thymosin fraction-5, cause an increase in ACTH production (Goya et al., 1993[ 36 ]). Additionally, the existence of CRH in thymus has been proven (Redei, 1992[ 87 ]). It has also been proven that interleukin-1 released from phagocytes has a role in ACTH secretion (Berkenbosch et al., 1987[ 4 ]). On the other hand, natural or synthetic glucocorticosteroids (which are the final stress operators) are known as anti-inflammatory drugs and immune suppressants and their role in the inhibition of lymphocytes and macrophages has been demonstrated as well (Elenkov et al., 1999[ 28 ]; Reiche et al., 2004[ 88 ]). Moreover, their role in inhibiting the production of cytokines and other immune mediators and decreasing their effect on target cells during exposure to stress has also been determined (Reiche et al., 2004[ 88 ]).

In addition to adrenal steroids, other hormones are affected during stress. For example, the secretion of growth hormone will be halted during severe stress. A study showed that long-term administration of CRH into the brain ventricles leads to a cessation in the release of growth hormone (Rivier and Vale, 1985[ 90 ]). Stress also causes the release of opioid peptides to be changed during the time period over which the person is exposed to stress (McCarthy et al., 2001[ 70 ]). In fact, stress modifies the secretion of hormones that play a critical role in the function of the immune system (Khansari et al., 1990[ 50 ]). To date, it has been shown that various receptors for a variety of hormones involved in immune system function are adversely affected by stress. For example, ACTH, vasoactive intestinal peptide (VIP), substance P, growth hormone, prolactin, and steroids all have receptors in various tissues of the immune system and can modulate its function (De la Fuente et al., 1996[ 24 ]; Gala, 1991[ 30 ]; Mantyh, 1991[ 67 ]). In addition, active immune cells are also able to secrete several hormones; thus, some researchers believe that these hormones, as mediators of immune system, play a significant role in balancing its function (Blalock et al., 1985[ 6 ]).

Severe stress can lead to malignancy by suppressing the immune system (Reiche et al., 2004[ 88 ]). In fact, stress can decrease the activity of cytotoxic T lymphocytes and natural killer cells and lead to growth of malignant cells, genetic instability, and tumor expansion (Reiche et al., 2004[ 88 ]). Studies have shown that the plasma concentration of norepinephrine, which increases after the induction stress, has an inverse relationship with the immune function of phagocytes and lymphocytes (Reiche et al., 2004[ 88 ]). Lastly, catecholamines and opioids that are released following stress have immune-suppressing properties (Reiche et al., 2004[ 88 ]).

Stress and the Function of the Cardiovascular System

The existence of a positive association between stress and cardiovascular disease has been verified (Rozanski et al., 1999[ 93 ]). Stress, whether acute or chronic, has a deleterious effect on the function of the cardiovascular system (Rozanski et al., 1999[ 93 ]; Kario et al., 2003[ 48 ]; Herd, 1991[ 40 ]). The effects of stress on the cardiovascular system are not only stimulatory, but also inhibitory in nature (Engler and Engler, 1995[ 29 ]). It can be postulated that stress causes autonomic nervous system activation and indirectly affects the function of the cardiovascular system (Lazarus et al., 1963[ 59 ]; Vrijkotte et al., 2000[ 120 ]). If these effects occur upon activation of the sympathetic nervous system, then it mainly results in an increase in heart rate, strength of contraction, vasodilation in the arteries of skeletal muscles, a narrowing of the veins, contraction of the arteries in the spleen and kidneys, and decreased sodium excretion by the kidneys (Herd, 1991[ 40 ]). Sometimes, stress activates the parasympathetic nervous system (Pagani et al., 1991[ 82 ]). Specifically, if it leads to stimulation of the limbic system, it results in a decrease, or even a total stopping of the heart-beat, decreased contractility, reduction in the guidance of impulses by the heart stimulus-transmission network, peripheral vasodilatation, and a decline in blood pressure (Cohen et al., 2000[ 17 ]). Finally, stress can modulate vascular endothelial cell function and increase the risk of thrombosis and ischemia, as well as increase platelet aggregation (Rozanski et al., 1999[ 93 ]).

The initial effect of stress on heart function is usually on the heart rate (Vrijkotte et al., 2000[ 120 ]). Depending upon the direction of the shift in the sympatho-vagal response, the heart beat will either increase or decrease (Hall et al., 2004[ 38 ]). The next significant effect of stress on cardiovascular function is blood pressure (Laitinen et al., 1999[ 56 ]). Stress can stimulate the autonomic sympathetic nervous system to increase vasoconstriction, which can mediate an increase in blood pressure, an increase in blood lipids, disorders in blood clotting, vascular changes, atherogenesis; all, of which, can cause cardiac arrhythmias and subsequent myocardial infarction (Rozanski et al., 1999[ 93 ]; Vrijkotte et al., 2000[ 120 ]; Sgoifo et al., 1998[ 111 ]). These effects from stress are observed clinically with atherosclerosis and leads to an increase in coronary vasoconstriction (Rozanski et al., 1999[ 93 ]). Of course, there are individual differences in terms of the level of autonomic-based responses due to stress, which depends on the personal characteristics of a given individual (Rozanski et al., 1999[ 93 ]). Thus, training programs for stress management are aimed at reducing the consequences of stress and death resulting from heart disease (Engler and Engler, 1995[ 29 ]). In addition, there are gender-dependent differences in the cardiovascular response to stress and, accordingly, it has been estimated that women begin to exhibit heart disease ten years later that men, which has been attributed to the protective effects of the estrogen hormone (Rozanski et al., 1999[ 93 ]).

Studies have shown that psychological stress can cause alpha-adrenergic stimulation and, consequently, increase heart rate and oxygen demand (Rozanski et al., 1998[ 92 ], 1999[ 93 ]; Jiang et al., 1996[ 46 ]). As a result, coronary vasoconstriction is enhanced, which may increase the risk of myocardial infarction (Yeung et al., 1991[ 124 ]; Boltwood et al., 1993[ 8 ]; Dakak et al., 1995[ 20 ]). Several studies have demonstrated that psychological stress decreases the microcirculation in the coronary arteries by an endothelium-dependent mechanism and increases the risk of myocardial infarction (Dakak et al., 1995[ 20 ]). On the other hand, mental stress indirectly leads to potential engagement in risky behaviors for the heart, such as smoking, and directly leads to stimulation of the neuroendocrine system as part of the autonomic nervous system (Hornstein, 2004[ 43 ]). It has been suggested that severe mental stress can result in sudden death (Pignalberi et al., 2002[ 84 ]). Generally, stress-mediated risky behaviors that impact cardiovascular health can be summarized into five categories: an increase in the stimulation of the sympathetic nervous system, initiation and progression of myocardial ischemia, development of cardiac arrhythmias, stimulation of platelet aggregation, and endothelial dysfunction (Wu, 2001[ 123 ]).

Stress and Gastrointestinal Complications

The effects of stress on nutrition and the gastrointestinal (GI) system can be summarized with two aspects of GI function.

First, stress can affect appetite (Bagheri Nikoo et al., 2014[ 2 ]; Halataei et al., 2011[ 37 ]; Ranjbaran et al., 2013[ 86 ]). This effect is related to involvement of either the ventral tegmental area (VTA), or the amygdala via N-methyl-D-aspartate (NMDA) glutamate receptors (Nasihatkon et al., 2014[ 80 ]; Sadeghi et al., 2015[ 94 ]). However, it should also be noted that nutrition patterns have effects on the response to stress (Ghanbari et al., 2015[ 31 ]), and this suggests a bilateral interaction between nutrition and stress.

Second, stress adversely affects the normal function of GI tract. There are many studies concerning the effect of stress on the function of the GI system (Söderholm and Perdue, 2001[ 112 ]; Collins, 2001[ 18 ]). For instance, studies have shown that stress affects the absorption process, intestinal permeability, mucus and stomach acid secretion, function of ion channels, and GI inflammation (Collins, 2001[ 18 ]; Nabavizadeh et al., 2011[ 79 ]). Stress also increases the response of the GI system to inflammation and may reactivate previous inflammation and accelerate the inflammation process by secretion of mediators such as substance P (Collins, 2001[ 18 ]). As a result, there is an increase in the permeability of cells and recruitment of T lymphocytes. Lymphocyte aggregation leads to the production of inflammatory markers, activates key pathways in the hypothalamus, and results in negative feedback due to CRH secretion, which ultimately results in the appearance of GI inflammatory diseases (Collins, 2001[ 18 ]). This process can reactivate previous silent colitis (Million et al., 1999[ 76 ]; Qiu et al., 1999[ 85 ]). Mast cells play a crucial role in stress-induced effects on the GI system, because they cause neurotransmitters and other chemical factors to be released that affect the function of the GI system (Konturek et al., 2011[ 55 ]).

Stress can also alter the functional physiology of the intestine (Kiliaan et al., 1998[ 52 ]). Many inflammatory diseases, such as Crohn's disease and other ulcerative-based diseases of the GI tract, are associated with stress (Hommes et al., 2002[ 42 ]). It has been suggested that even childhood stress can lead to these diseases in adulthood (Schwartz and Schwartz, 1983[ 106 ]). Irritable bowel syndrome, which is a disease with an inflammatory origin, is highly related to stress (Gonsalkorale et al., 2003[ 33 ]). Studies on various animals suggest the existence of inflammatory GI diseases following induction of severe stress (Qiu et al., 1999[ 85 ]; Collins et al., 1996[ 19 ]). Additionally, pharmacological interventions, in an attempt to decrease the response of CRH to stress, have been shown to result in an increase in GI diseases in rats (Million et al., 1999[ 76 ]).

Altering the permeability of the mucosal membrane by perturbing the functions of mucosal mast cells may be another way that stress causes its effects on the GI system, since this is a normal process by which harmful and toxic substances are removed from the intestinal lumen (Söderholm and Perdue, 2001[ 112 ]). Also, stress can both decrease the removal of water from the lumen, as well as induce sodium and chloride secretion into the lumen. This most likely occurs by increasing the activity of the parasympathetic nervous system (Barclay and Turnberg, 1987[ 3 ]). Moreover, physical stress, such as trauma or surgery, can increase luminal permeability (Söderholm and Perdue, 2001[ 112 ]) (Table 2 (Tab. 2) ; References in Table 2: Halataei et al., 2011[ 37 ]; Ranjbaran et al., 2013[ 86 ]; Mönnikes et al., 2001[ 77 ]; Collins, 2001[ 18 ]; Nabavizadeh et al., 2011[ 79 ]; Barclay and Turnberg, 1987[ 3 ]; Million et al., 1999[ 76 ]; Gonsalkorale et al., 2003[ 33 ]).

Stress also affects movement of the GI tract. In this way, it prevents stomach emptying and accelerates colonic motility (Mönnikes et al., 2001[ 77 ]). In the case of irritable bowel syndrome, stress increases the movement (contractility and motility) of the large intestine (Mönnikes et al., 2001[ 77 ]). Previous studies have revealed that CRH increases movement in the terminal sections of the GI tract and decreases the movements in the proximal sections of the GI tract (Mönnikes et al., 2001[ 77 ]). A delay in stomach emptying is likely accomplished through CRH-2 receptors, while type 1 receptors affect the colon (Mönnikes et al., 2001[ 77 ]). The effects produced by CRH are so prominent that CRH is now considered an ideal candidate for the treatment of irritable bowel syndrome (Martinez and Taché, 2006[ 69 ]). When serotonin is released in response to stress (Chaouloff, 2000[ 14 ]), it leads to an increase in the motility of the colon by stimulating 5HT-3 receptors (Mönnikes et al., 2001[ 77 ]). Moreover, it has also been suggested that stress, especially mental and emotional types of stress, increase visceral sensitivity and activate mucosal mast cells (Mönnikes et al., 2001[ 77 ]). Stimulation of the CNS by stress has a direct effect on GI-specific nervous system ( i.e. , the myenteric system or plexus) and causes the above mentioned changes in the movements of the GI tract (Bhatia and Tandon, 2005[ 5 ]). In fact, stress has a direct effect on the brain-bowel axis (Konturek et al., 2011[ 55 ]). Various clinical studies have suggested a direct effect of stress on irritable bowel syndrome, intestinal inflammation, and peptic ulcers (Konturek et al., 2011[ 55 ]).

In conclusion, the effects of stress on the GI system can be classified into six different actions: GI tract movement disorders, increased visceral irritability, altered rate and extent of various GI secretions, modified permeability of the intestinal barrier, negative effects on blood flow to the GI tract, and increased intestinal bacteria counts (Konturek et al., 2011[ 55 ]).

Stress and the Endocrine System

There is a broad and mutual relationship between stress and the endocrine system. On one hand, stress has many subtle and complex effects on the activity of the endocrine system (Sapolsky, 2002[ 97 ]; Charmandari et al., 2005[ 15 ]), while on the other hand, the endocrine system has many effects on the response to stress (Ulrich-Lai and Herman, 2009[ 117 ]; Selye, 1956[ 110 ]). Stress can either activate, or change the activity of, many endocrine processes associated with the hypothalamus, pituitary and adrenal glands, the adrenergic system, gonads, thyroid, and the pancreas (Tilbrook et al., 2000[ 116 ]; Brown-Grant et al., 1954[ 11 ]; Thierry et al., 1968[ 115 ]; Lupien and McEwen, 1997[ 64 ]). In fact, it has been suggested that it is impossible to separate the response to stress from the functions of the endocrine system. This premise has been advanced due to the fact that even a minimal amount of stress can activate the hypothalamic-pituitary-adrenal axis, which itself is intricately involved with the activation of several different hormone secreting systems (Sapolsky, 2002[ 97 ]). In different locations throughout this article, we have already discussed the effects of stress on hormones and various endocrine factors and, thus, they will not be further addressed.

Altogether, stress may induce both beneficial and harmful effects. The beneficial effects of stress involve preserving homeostasis of cells/species, which leads to continued survival. However, in many cases, the harmful effects of stress may receive more attention or recognition by an individual due to their role in various pathological conditions and diseases. As has been discussed in this review, various factors, for example, hormones, neuroendocrine mediators, peptides, and neurotransmitters are involved in the body's response to stress. Many disorders originate from stress, especially if the stress is severe and prolonged. The medical community needs to have a greater appreciation for the significant role that stress may play in various diseases and then treat the patient accordingly using both pharmacological (medications and/or nutraceuticals) and non-pharmacological (change in lifestyle, daily exercise, healthy nutrition, and stress reduction programs) therapeutic interventions. Important for the physician providing treatment for stress is the fact that all individuals vary in their response to stress, so a particular treatment strategy or intervention appropriate for one patient may not be suitable or optimal for a different patient.

Yunes Panahi and Amirhossein Sahebkar (Department of Medical Biotechnology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran, P.O. Box: 91779-48564, Iran; Tel: 985118002288, Fax: 985118002287, E-mail: [email protected], [email protected]) contributed equally as corresponding authors.

Conflict of interest

The authors declare that have no conflict of interest in this study.

Acknowledgement

The authors would like to thank the "Neurosciences Research Center of Baqiyatallah University of Medical Sciences" and the “Clinical Research Development Center of Baqiyatallah (a.s.) Hospital” for providing technical supports.

AI + Machine Learning , Announcements , Azure AI , Azure AI Studio

Introducing Phi-3: Redefining what’s possible with SLMs

By Misha Bilenko Corporate Vice President, Microsoft GenAI

Posted on April 23, 2024 4 min read

• Tag: Copilot
• Tag: Generative AI

We are excited to introduce Phi-3, a family of open AI models developed by Microsoft. Phi-3 models are the most capable and cost-effective small language models (SLMs) available, outperforming models of the same size and next size up across a variety of language, reasoning, coding, and math benchmarks. This release expands the selection of high-quality models for customers, offering more practical choices as they compose and build generative AI applications.

Starting today, Phi-3-mini , a 3.8B language model is available on Microsoft Azure AI Studio , Hugging Face , and Ollama . 

• Phi-3-mini is available in two context-length variants—4K and 128K tokens. It is the first model in its class to support a context window of up to 128K tokens, with little impact on quality.
• It is instruction-tuned, meaning that it’s trained to follow different types of instructions reflecting how people normally communicate. This ensures the model is ready to use out-of-the-box.
• It is available on Azure AI to take advantage of the deploy-eval-finetune toolchain, and is available on Ollama for developers to run locally on their laptops.
• It has been optimized for ONNX Runtime with support for Windows DirectML along with cross-platform support across graphics processing unit (GPU), CPU, and even mobile hardware.
• It is also available as an NVIDIA NIM microservice with a standard API interface that can be deployed anywhere. And has been optimized for NVIDIA GPUs . 

In the coming weeks, additional models will be added to Phi-3 family to offer customers even more flexibility across the quality-cost curve. Phi-3-small (7B) and Phi-3-medium (14B) will be available in the Azure AI model catalog and other model gardens shortly.   

Microsoft continues to offer the best models across the quality-cost curve and today’s Phi-3 release expands the selection of models with state-of-the-art small models.

Azure AI Studio

Phi-3-mini is now available

Groundbreaking performance at a small size

Phi-3 models significantly outperform language models of the same and larger sizes on key benchmarks (see benchmark numbers below, higher is better). Phi-3-mini does better than models twice its size, and Phi-3-small and Phi-3-medium outperform much larger models, including GPT-3.5T.  

All reported numbers are produced with the same pipeline to ensure that the numbers are comparable. As a result, these numbers may differ from other published numbers due to slight differences in the evaluation methodology. More details on benchmarks are provided in our technical paper . 

Note: Phi-3 models do not perform as well on factual knowledge benchmarks (such as TriviaQA) as the smaller model size results in less capacity to retain facts.  

Safety-first model design

Responsible ai principles

Phi-3 models were developed in accordance with the Microsoft Responsible AI Standard , which is a company-wide set of requirements based on the following six principles: accountability, transparency, fairness, reliability and safety, privacy and security, and inclusiveness. Phi-3 models underwent rigorous safety measurement and evaluation, red-teaming, sensitive use review, and adherence to security guidance to help ensure that these models are responsibly developed, tested, and deployed in alignment with Microsoft’s standards and best practices.  

Building on our prior work with Phi models (“ Textbooks Are All You Need ”), Phi-3 models are also trained using high-quality data. They were further improved with extensive safety post-training, including reinforcement learning from human feedback (RLHF), automated testing and evaluations across dozens of harm categories, and manual red-teaming. Our approach to safety training and evaluations are detailed in our technical paper , and we outline recommended uses and limitations in the model cards. See the model card collection .  

Unlocking new capabilities

Microsoft’s experience shipping copilots and enabling customers to transform their businesses with generative AI using Azure AI has highlighted the growing need for different-size models across the quality-cost curve for different tasks. Small language models, like Phi-3, are especially great for: 

• Resource constrained environments including on-device and offline inference scenarios.
• Latency bound scenarios where fast response times are critical.
• Cost constrained use cases, particularly those with simpler tasks.

For more on small language models, see our Microsoft Source Blog .

Thanks to their smaller size, Phi-3 models can be used in compute-limited inference environments. Phi-3-mini, in particular, can be used on-device, especially when further optimized with ONNX Runtime for cross-platform availability. The smaller size of Phi-3 models also makes fine-tuning or customization easier and more affordable. In addition, their lower computational needs make them a lower cost option with much better latency. The longer context window enables taking in and reasoning over large text content—documents, web pages, code, and more. Phi-3-mini demonstrates strong reasoning and logic capabilities, making it a good candidate for analytical tasks. 

Customers are already building solutions with Phi-3. One example where Phi-3 is already demonstrating value is in agriculture, where internet might not be readily accessible. Powerful small models like Phi-3 along with Microsoft copilot templates are available to farmers at the point of need and provide the additional benefit of running at reduced cost, making AI technologies even more accessible.  

ITC, a leading business conglomerate based in India, is leveraging Phi-3 as part of their continued collaboration with Microsoft on the copilot for Krishi Mitra, a farmer-facing app that reaches over a million farmers.

“ Our goal with the Krishi Mitra copilot is to improve efficiency while maintaining the accuracy of a large language model. We are excited to partner with Microsoft on using fine-tuned versions of Phi-3 to meet both our goals—efficiency and accuracy! ”    Saif Naik, Head of Technology, ITCMAARS

Originating in Microsoft Research, Phi models have been broadly used, with Phi-2 downloaded over 2 million times. The Phi series of models have achieved remarkable performance with strategic data curation and innovative scaling. Starting with Phi-1, a model used for Python coding, to Phi-1.5, enhancing reasoning and understanding, and then to Phi-2, a 2.7 billion-parameter model outperforming those up to 25 times its size in language comprehension. 1 Each iteration has leveraged high-quality training data and knowledge transfer techniques to challenge conventional scaling laws. 

Get started today

To experience Phi-3 for yourself, start with playing with the model on Azure AI Playground . You can also find the model on the Hugging Chat playground . Start building with and customizing Phi-3 for your scenarios using the  Azure AI Studio . Join us to learn more about Phi-3 during a special  live stream of the AI Show.  

1 Microsoft Research Blog, Phi-2: The surprising power of small language models, December 12, 2023 .

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PM in Riyadh to attend WEF moot

RECORDER REPORT Islamabad: Prime Minister Shehbaz Sharif reached Riyadh, Saudi Arabia on Saturday to attend the World Economic Forum (WEF) Special Meeting on Global Collaboration, Growth and Energy being held from 28-29 April 2024. The invitation has been extended by Muhammad bin Salman bin Abdulaziz Al-Saud, Crown Prince and Prime Minister of the Kingdom of Saudi Arabia and Professor Klaus Schwab, the Founder and Executive Chairman of the World Economic Forum, Foreign Office said. Prime Minister is accompanied by a high level delegation including Foreign Minister Ishaq Dar and Finance Minister Muhammad Aurangzeb. The Prime Minister and the Ministers will participate in WEF discussions on issues related to trade and investment measures, new investment frameworks, restructuring of supply chains, sustainable growth, and the energy landscape. The high level participation in the Forum will afford an important opportunity to present Pakistan’s priorities specifically in global health architecture, inclusive growth, revitalizing regional collaboration and the need for striking a balance between promoting growth and energy consumption. On the margins of the main event, the Prime Minister and his delegation will hold bilateral meetings with world leaders, including the Saudi leadership, heads of international organizations, and other prominent figures participating in the event.

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Israel’s war on gaza, uk ship sets sail to help building of gaza aid jetty, mobile phones, govt forms body for psm revival, efforts to outsource airports get good response, dar calls for enhancing ‘economic diplomacy’.

This paper is in the following e-collection/theme issue:

Published on 29.4.2024 in Vol 26 (2024)

Effectiveness of a Smartphone App–Based Intervention With Bluetooth-Connected Monitoring Devices and a Feedback System in Heart Failure (SMART-HF Trial): Randomized Controlled Trial

Authors of this article:

Original Paper

• Minjae Yoon 1 , MD   ; 
• Seonhwa Lee 2 , MD   ; 
• Jah Yeon Choi 3 , MD, PhD   ; 
• Mi-Hyang Jung 4 , MD, PhD   ; 
• Jong-Chan Youn 4 , MD, PhD   ; 
• Chi Young Shim 5 , MD, PhD   ; 
• Jin-Oh Choi 6 , MD, PhD   ; 
• Eung Ju Kim 3 , MD, PhD   ; 
• Hyungseop Kim 2 , MD, PhD   ; 
• Byung-Su Yoo 7 , MD, PhD   ; 
• Yeon Joo Son 8 , BS   ; 
• Dong-Ju Choi 1 , MD, PhD  

1 Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seognam, Republic of Korea

2 Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea

3 Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea

4 Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

5 Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

6 Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea

7 Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Woonju, Republic of Korea

8 Healthcare Business Department, AI/DX Convergence Business Group, KT, Seoul, Republic of Korea

Corresponding Author:

Dong-Ju Choi, MD, PhD

Division of Cardiology, Department of Internal Medicine

Seoul National University Bundang Hospital, Seoul National University College of Medicine

82, Gumi-ro 173 Beon-gil, Bundang-gu

Seognam, 13620

Republic of Korea

Phone: 82 317877007

Fax:82 317877041

Email: [email protected]

Background: Current heart failure (HF) guidelines recommend a multidisciplinary approach, discharge education, and self-management for HF. However, the recommendations are challenging to implement in real-world clinical settings.

Objective: We developed a mobile health (mHealth) platform for HF self-care to evaluate whether a smartphone app–based intervention with Bluetooth-connected monitoring devices and a feedback system can help improve HF symptoms.

Methods: In this prospective, randomized, multicenter study, we enrolled patients 20 years of age and older, hospitalized for acute HF, and who could use a smartphone from 7 tertiary hospitals in South Korea. In the intervention group (n=39), the apps were automatically paired with Bluetooth-connected monitoring devices. The patients could enter information on vital signs, HF symptoms, diet, medications, and exercise regimen into the app daily and receive feedback or alerts on their input. In the control group (n=38), patients could only enter their blood pressure, heart rate, and weight using conventional, non-Bluetooth devices and could not receive any feedback or alerts from the app. The primary end point was the change in dyspnea symptom scores from baseline to 4 weeks, assessed using a questionnaire.

Results: At 4 weeks, the change in dyspnea symptom score from baseline was significantly greater in the intervention group than in the control group (mean –1.3, SD 2.1 vs mean –0.3, SD 2.3; P =.048). A significant reduction was found in body water composition from baseline to the final measurement in the intervention group (baseline level mean 7.4, SD 2.5 vs final level mean 6.6, SD 2.5; P =.003). App adherence, which was assessed based on log-in or the percentage of days when symptoms were first observed, was higher in the intervention group than in the control group. Composite end points, including death, rehospitalization, and urgent HF visits, were not significantly different between the 2 groups.

Conclusions: The mobile-based health platform with Bluetooth-connected monitoring devices and a feedback system demonstrated improvement in dyspnea symptoms in patients with HF. This study provides evidence and rationale for implementing mobile app–based self-care strategies and feedback for patients with HF.

Trial Registration: ClinicalTrials.gov NCT05668000; https://clinicaltrials.gov/study/NCT05668000

Introduction

Heart failure (HF) is a rapidly growing public health problem, with an estimated prevalence of 64 million people globally [ 1 - 5 ]. Although outcomes of HF have recently improved with the development of medications, a high rate of readmission remains after initial hospitalization for acute HF [ 6 - 10 ]. Recent studies have shown that 18%-23% of patients with acute HF were readmitted within 1 month, and these numbers have not decreased recently [ 6 , 11 , 12 ]. Therefore, the postdischarge management of patients with HF is important. In particular, multidisciplinary interventions, in addition to pharmacotherapy and discharge education, are known to improve quality of life and reduce hospitalizations [ 13 - 16 ]. A recent meta-analysis has shown that self-management interventions, including symptom and sign monitoring, education, and enhancement of drug adherence, improve outcomes of HF-related hospitalization and all-cause death, despite heterogeneity in the interventions [ 17 ]. Thus, current HF guidelines recommend multidisciplinary management, specific discharge education, and support to facilitate HF self-care [ 18 - 20 ].

Although encouraging self-care and providing feedback from health care providers are the most effective means, they are difficult to implement in a real-world clinical setting. These are also associated with higher costs and require more infrastructure and manpower. Smartphones are currently available to most of the general population at an affordable cost. The advent of mobile health (mHealth) technology and advances in artificial intelligence (AI) have enabled patient self-care, symptom, and sign monitoring, as well as mobile-based feedback via smartphone apps. Recent studies using smartphone apps for the self-management of cardiovascular disease demonstrated that this intervention led to better outcomes than the control groups [ 21 - 23 ]. Additionally, some recent studies and meta-analyses regarding mHealth apps have supported self-care among patients with HF [ 24 - 30 ]. However, these previous studies had a small number of participants and limited app functionality. Self-monitoring and feedback are particularly important, and the lack of these critical features limits the interpretation of the effectiveness of HF apps. Furthermore, functions provided in previous mobile-based interventions for HF were heterogeneous and varied between studies, which may lead to inconsistent results.

Given the uncertainty regarding the benefits of mobile apps for HF and their diverse functionality, we developed a mHealth platform to provide self-management interventions for patients with HF. This study aimed to evaluate whether this smartphone app–based intervention with Bluetooth-connected monitoring devices and a feedback system could improve the symptoms and clinical outcomes of HF.

Study Design and Population

The self-monitoring using a mobile app to improve symptoms and reduce rehospitalization and mortality in heart failure (SMART-HF) study is a prospective, multicenter, randomized, open-label trial to evaluate the efficacy of smartphone apps in improving the symptoms and outcomes of HF. A total of 7 tertiary university hospitals in South Korea participated in this study. The study design was registered at ClinicalTrials.gov (NCT05668000).

We enrolled patients aged older than 20 years who were hospitalized for acute HF with obvious symptoms or signs of HF at admission. Patients with N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels ≥400 pg/mL or brain natriuretic peptide levels ≥100 pg/mL were enrolled. Since smartphone use was essential in this study, participants should be able to use Android smartphones well and be capable of following instructions on how to use apps. Patients with a baseline systolic blood pressure (BP) of <90 mm Hg or a resting heart rate (HR) of <50 beats per minute were excluded from this study. Additionally, patients were excluded if they had a cardiac [ 30 ] implantable electronic device that could interfere with body water analysis. Patients who were expected to have a prolonged hospital stay owing to medical problems other than HF were also excluded. The detailed inclusion and exclusion criteria are presented in Table S1 in Multimedia Appendix 1 .

Ethical Considerations

This clinical trial was approved by the institutional review boards of Seoul National University Bundang Hospital (B-2211-795-304) and other hospitals. The study was conducted in accordance with the Declaration of Helsinki, and all study data were deidentified. All patients provided written informed consent upon enrollment.

Patient Recruitment and Randomization

After a comprehensive interview, eligible participants were asked to provide written informed consent before being discharged from the hospital. At baseline (visit 1), all participants were assessed for sex, age, demographics, vital signs, comorbidities, laboratory data, and medication use. Eligible participants were randomized 1:1 to either the intervention group (app with Bluetooth-connected monitoring devices and feedback) or the control group (app only) using a web-based central randomization service ( Figure 1 A). Due to the nature of the intervention, the study participants and investigators interacting with the patients were not blinded to the group allocation.

Intervention and Follow-Up

We developed a mobile app and operating platform to improve the symptoms and outcomes of patients with HF. The app and platform comprised three parts: (1) a smartphone app for patients, (2) a dashboard system for physicians, and (3) a clinical decision support system (CDSS) on the platform ( Figure 1 B and Figures S1 and S2 in Multimedia Appendix 1 ).

The smartphone app comprised 4 menu screens ( Figure 2 ), and the detailed functions of the app are described in Table S2 in Multimedia Appendix 1 . In the “Today” menu, patients can enter their information, including body water, weight, BP, HR, symptom diary, medications, diet, and exercise. Patients can input their symptoms of HF, including dyspnea, fatigue, ankle edema, and palpitations, daily. Symptoms were scored as 0 (no symptoms), 1 (mild symptoms), 2 (moderate symptoms), and 3 (severe symptoms; Table S3 in Multimedia Appendix 1 ). Moreover, they could enter their daily diet or physical activity into the apps, and the amount of sodium in their diet was assessed through a camera image using AI (Figure S3 in Multimedia Appendix 1 ). Additionally, the BP, HR, weight, and body water could be entered into the app by the patients (intervention + control group) or automatically paired using Bluetooth-connected monitoring devices (intervention group only). In the “Records” menu, patients can access and review their historical data entered by date, as well as receive feedback regarding medication adherence, dietary habits, and exercise. Furthermore, the app can analyze and evaluate a patient’s symptom scores or measured vital signs and subsequently generate alerts based on a predefined algorithm (Tables S3 and S4 in Multimedia Appendix 1 ) using the CDSS. In the event of rapid changes in a patient’s symptoms or vital signs, the app prompts the patient to provide information regarding medication adherence, symptom severity, and any other concerns. Upon perceiving significant changes, it sends a message to the patients, advising them to contact their health care provider. In the “Contents” menu, the app can provide patients with information about HF, including symptoms, treatment, dietary guidelines, and exercise recommendations using chatbots.

The dashboard system was designed to present stored information to physicians (Figure S4 in Multimedia Appendix 1 ). This information included BP, HR, body weight, body water composition, HF symptom score, medications, diet, exercise, and any data entered by the patient. Physicians could easily observe the vital sign trends (daily, weekly, and monthly) of the participants. The CDSS analyzes the input data and generates recommendations for users using AI and algorithms. For example, it aggregates data and information from the patient and sends necessary messaging alerts to the patient’s app and, if needed, to the health care provider’s dashboard during office visits.

After randomization, both groups installed the study app on their Android smartphones, which the research nurse provided. Only the intervention group had full access to all functions of the app, and the apps were automatically paired with Bluetooth-connected monitoring devices, including a BP monitor, weight scale, and body water analyzer. The intervention group received feedback and alerts from the app. In the control group, patients could enter their BP, HR, and weight into the app using conventional non-Bluetooth devices only. Additionally, they received no feedback or alerts from the app. The “Contents” menu providing information about HF was available in both groups. The study aimed to evaluate the improvement in HF symptoms based on the functionality of the mobile app between the intervention and control groups, with a particular focus on Bluetooth-connected monitoring devices and the feedback function of the app.

We used a Bluetooth-enabled BP monitor BP170 (InBody Co). Bioimpedance analysis was performed using a portable multifrequency bioimpedance device (BWA ON; InBody Co) to analyze body water composition. Bioimpedance analysis has recently proven its efficacy in patients with acute HF with dyspnea [ 31 ], and the device can estimate body fluid status using extracellular water divided by total body water of the 4 limbs and trunk. The parameters of extracellular water divided by total body water <0.390, 0.390-0.400, and >0.400 were considered to be “normal,” “slightly over,” and “over,” respectively (Table S5 in Multimedia Appendix 1 ). The device classifies body water levels from levels 1 to 16.

Follow-up visits were scheduled at 2 (visit 2, optional) and 4 (visit 3) weeks after randomization. Both groups received standard care according to the current HF guidelines [ 20 , 32 ], and HF medication could be modified at the discretion of the treating physicians.

Study Outcomes

The primary end point of the study was the change in dyspnea symptom scores from baseline to 4 weeks, which was assessed using a questionnaire. We used a visual analog scale and a numerical rating scale for dyspnea ranging from 0 to 10 based on previous studies [ 33 , 34 ] (Figure S5 in Multimedia Appendix 1 ).

There were two secondary end points: (1) a composite outcome, including death, rehospitalization, and urgent visit for HF and (2) the change in body water composition from baseline to the last measurement in the intervention group. The exploratory clinical outcome was adherence to the app, which was calculated using either log-in access logs or the percentage of days when symptoms were entered into the app. App adherence was defined as follows:

We also compared app satisfaction scores at 4 weeks through a questionnaire, ranging from 0 to 10, between the intervention and control groups. If patients could not attend the scheduled study date, the outcome measures were assessed telephonically.

Sample Size and Statistical Analysis

Due to the absence of previous research and the pioneering nature of our intervention, our study adopts an exploratory approach. The primary objective was not to test a specific hypothesis regarding efficacy but rather to collect preliminary data and assess feasibility in preparation for a larger-scale study. Consequently, a sample size calculation was not conducted at this preliminary stage. Since this was a pilot study to explore the benefits of mobile apps for HF, we enrolled a total of 84 participants across 7 institutes, considering the duration of the study and the number of participating hospitals.

Categorical variables are reported as frequencies (percentages), and continuous variables are expressed as means (SD) or medians with IQR. Categorical variables were compared using the Pearson chi-square test or Fisher exact test, and continuous variables were compared using the Student t test or the Mann-Whitney U test. The change in body water composition from baseline to the last measurement after randomization was analyzed using the paired t test.

The intention-to-treat analysis included all randomized patients. The efficacy end points were primarily analyzed using the full analysis set, which included randomized participants who used the mobile app at least once. We also performed a per-protocol sensitivity analysis, including patients who completed the study protocol. For patients who dropped out before the end of the trial or had missing data, we used the latest available records for analysis, namely, the last observation carried forward method.

All tests were 2-tailed, and a P value <.05 was considered statistically significant. Statistical analyses were performed by using R (version 4.2.0; R Core Team).

Patient Enrollment and Clinical Characteristics

From October 2022 to January 2023, 132 patients from 7 centers were screened for eligibility, and 84 were randomly assigned to the intervention (n=43) or control (n=41) group ( Figure 3 and CONSORT [Consolidated Standards of Reporting Trials] checklist in Multimedia Appendix 2 ). After allocation, 7 patients (4 and 3 in the intervention and control groups, respectively) were excluded because they did not use the app at least once; thus, 77 patients (39 and 38 in the intervention and control groups, respectively) were included in the full analysis set.

The baseline characteristics of the groups are presented in Table 1 . The mean age of the total population was 62.1 (SD 14.7) years; 62% were male, 61% had de novo HF, and 30% had HF of an ischemic etiology. The median left ventricular ejection fraction was 38.7% (IQR 28%-58%) and the median NT-proBN P value was 2572 (IQR 1211-6651) pg/mL. The baseline characteristics, including age, sex, demographic data, laboratory values, and comorbidities, were well balanced between the 2 groups, except for diastolic BP. Additionally, the medication use at discharge was not significantly different between the 2 groups.

a HF: heart failure.

b NYHA: New York Heart Association.

c LVEF: left ventricular ejection fraction.

d eGFR: estimated glomerular filtration rate.

e NT-proBNP: N-terminal pro-B-type natriuretic peptide.

f RAS: renin-angiotensin system.

g SGLT2: sodium-glucose cotransporter 2.

Dyspnea Symptom Score

The dyspnea symptom scores assessed using the questionnaire are presented in Table 2 and Figure 4 . The baseline dyspnea symptom scores were not significantly different between the 2 groups (intervention vs control: mean 2.4, SD 2.8 vs mean 2.0, SD 2.0; P =.46). Regarding the primary end point, change in dyspnea symptom score from baseline to 4 weeks was significantly greater in the intervention group than in the control group (mean –1.3, SD 2.1 vs mean –0.3, SD 2.3; P =.048).

Secondary End Points

Secondary composite end points, including death, rehospitalization, and urgent visit for HF, were not significantly different between the 2 groups (3/39 vs 3/38; P >.99). A significant reduction was found in the level of body water composition from baseline to the last measurement in the intervention group (baseline level mean 7.4, SD 2.5 vs final level mean 6.6, SD 2.5; P =.003; Figure 5 ).

App Adherence and Patient Satisfaction

The distribution of app adherence among the treatment and control groups is presented in Figure 6 . App adherence, which was assessed based on log-in access logs was higher in the intervention group than in the control group (80.0%, IQR 45.0%-96.8% vs 39.3%, IQR 20.6%-77.4%; P =.003). Additionally, the app adherence evaluated based on the percentage of days when symptom was entered into the app was significantly higher in the intervention group than in the control group (58.6%, IQR 19.2%-79.5% vs 30.6%, IQR 9.1%-64.3%; P =.046).

We also analyzed differences in app adherence according to age. Patients aged 65 years and older showed lower app adherence, as indicated by log-in access logs than those aged younger than 65 years in the overall population (45.9%, IQR 8.9%-79.2% vs 74.9%, IQR 35.7%-95.5%; P =.02). The intervention group showed similar results (61.4%, IQR 13.5%-89.5% vs 92.9%, IQR 64.2%-98.5%; P =.04); however, in the control group, no significant difference was found in app adherence according to the age cutoff of 65 years (39.4%, IQR 5.7%-76.7% vs 39.3%, IQR 27.8%-74.6%; P =.40).

App satisfaction scores at 4 weeks tended to be higher in the intervention group than in the control group; however, the difference was not statistically significant (mean 7.1, SD 2.6 vs mean 6.2, SD 2.9; P =.15).

Sensitivity Analysis

Overall, 74 patients (37 in the intervention group and 37 in the control group) completed the trial over 4 weeks (per-protocol analysis; Figure 3 ). Table S6 and Figure S6 in Multimedia Appendix 1 show the results of sensitivity analyses of the per-protocol population. There was a trend toward a greater reduction in dyspnea symptom scores from baseline to 4 weeks in the intervention group than in the control group, similar to the primary analyses (mean –1.4, SD 2.1 vs mean –0.5, SD 2.1; P =.08). Regarding body water composition, the intervention group showed a greater reduction in the level of body water composition from baseline to last measurement, consistent with the main analysis (baseline level mean 7.4, SD 2.5 vs final level mean 6.6, SD 2.6; P =.006).

Principal Results

We developed a smartphone app and mHealth platform for patients with HF. The main findings of this study are (1) a mobile-based health platform with Bluetooth-connected monitoring devices and feedback improved dyspnea symptoms compared with the control group and (2) this app-based intervention led to an improvement in the level of body water composition and higher adherence to the app. We believe that the findings of this prospective, randomized study will help in formulating public health strategies to improve HF outcomes using smartphones.

Support for facilitating self-care is crucial for patients with HF [ 18 - 20 ]. However, proper patient self-care and delivery of health care provider feedback are challenging to implement in a real-world clinical setting because of the required time, financial, and human resources. It is challenging for patients to know how to respond to changes in their symptoms or vital signs. It is also impossible for medical staff to quickly check patient information or provide feedback 24 hours a day, 7 days a week. These disadvantages can be overcome by self-management interventions via smartphones, including self-care, symptom and sign monitoring, and mobile-based feedback, which are easily accessible anytime, anywhere. Considering these advantages of a smartphone app–based intervention, including cost-effective and accessible methods, our group has previously developed mobile app platforms for patients with atrial fibrillation [ 35 , 36 ] or hypertension [ 37 ]. Therefore, we planned to develop an app for patients with HF.

Our mobile app for HF provides diverse functions using the concept of mHealth platforms for personalized interventions. Vital signs and body water can be paired with Bluetooth-connected devices, and patients can enter their HF symptoms into the apps. Patients can also receive feedback or alerts from the app based on the information they have entered. Additionally, patients can obtain information about HF using chatbots. Although direct interaction between patients and health care providers may be an ideal situation, it may not be feasible owing to rising costs and a shortage of medical staff. Our app-based monitoring and feedback system had the advantage of being accessible and quick for patients to receive feedback promptly on their changes without high personnel or cost. Although patients in the control group had access to the smartphone app for HF self-care, the improvement in dyspnea symptoms was more pronounced in the intervention group than in the control group. Patients in the control group could only use the limited functionality of the app, were unable to use Bluetooth devices, and could not receive any feedback or alerts. Therefore, our study suggests that the comprehensive functionality of apps, especially in the monitoring and feedback system, is particularly important for their role.

Comparison With Prior Work

Some previous studies have focused on mHealth apps for HF [ 24 - 30 ]. However, these studies were limited by the small number of participants and limited app functionality. Additionally, previous mobile apps have heterogeneous functions and platforms [ 24 , 25 ], and this diversity might have influenced the benefits of mobile apps in HF. Considering the inconsistent benefits of mobile apps in HF [ 25 ], we developed a mobile app with multiple functions in collaboration with 1 of the largest high-tech information technology companies in Korea (KT). In our opinion, this app has a considerably wider range of features and is more efficiently organized than other existing apps [ 28 - 30 ]. Our app has the advantage of keeping patients engaged in their condition and self-management after leaving the hospital. Not only does this provide psychological reassurance, but it also serves the patient’s best interests by keeping a close eye on any changes in their clinical presentation or symptoms. Patients can assess their symptoms more frequently, make lifestyle changes, or contact health care providers earlier. The dashboard system also enables health care professionals to identify changes in a patient’s condition quickly. Furthermore, the app contains elements that may be of interest to patients, including sodium analysis in food using AI and various HF information. Overall, we assumed that the monitoring and feedback function and app adherence are especially important for the mobile app’s role in HF and believe that the benefits of our app could improve the symptoms of HF.

Increasing app adherence has been a common challenge in many studies. For example, a recent study showed that only approximately 30% of patients actively used the HF app, underscoring the importance of caution regarding the enrollment of critically ill, postacute, and older patients [ 30 ]. In our study, median adherence to apps based on log-in access logs was 80% and 39% in the intervention and control groups, respectively, which we believe should be further improved. In the intervention group, we believe that a more comprehensive functionality of apps, including Bluetooth-connected monitoring devices and a feedback system, may lead to higher adherence to apps than in the control group. Additionally, this disparity in app functionality may be associated with a higher trend in app satisfaction scores within the intervention group.

Particularly, as a large proportion of patients with HF tend to be older and app adherence appears to decline in those aged 65 years and older in our study, increasing adherence to apps for HF is crucial; this can be achieved by improving the platform to make it more user-friendly for older patients. Interestingly, at the cutoff age of 65 years, a difference was observed in app adherence according to age category in the intervention group but not in the control group, probably due to overall higher app adherence in the intervention group. In the subgroup analysis, no difference was found in the change of dyspnea symptom scores between the intervention and control groups according to an app adherence cutoff of 50%. This is probably due to the small sample size. Therefore, further research with larger study populations is warranted to confirm whether the frequency of app usage directly affects the outcomes.

Limitations and Strengths

This study had some limitations. First, our results are limited by the small sample size of the study. Second, we only enrolled patients who had smartphones and could use them; therefore, the results of our trial may not be applicable to patients who cannot use smartphones, such as very old adults. Since a large proportion of patients with HF are older and have difficulty using smartphones, excluding them from participation may lead to bias and study limitations. Third, the true engagement and use frequency of the apps and the real responses of participants to feedback could not be analyzed. There is a lack of clarity on exactly how the frequency of app use affects clinical outcomes. Additionally, there was a relatively large number of older patients, and adherence to the app declined toward the end of the study. These limitations are commonly observed in studies that use mobile apps. Fourth, we evaluated the dyspnea symptom score using a visual analog scale and a numerical rating scale ranging from 0 to 10. However, at baseline, the average of these scores was <3 points, suggesting that this study was conducted on patients who already had achieved significant improvement in their dyspnea, which limits surveying on a scale of 0-10 over 4 weeks. Fifth, the HF medications could be modified at the discretion of each physician, which could be a confounding factor. Sixth, baseline diastolic BP was higher in the intervention group than in the control group, while patients in the intervention group tended to be younger. This difference in baseline characteristics may limit the generalizability of our conclusions. Seventh, the follow-up period in our studies was only 4 weeks, which was shorter than that in a similar study [ 29 ]; therefore, the effect of mobile apps on patients’ symptoms for a long-term follow-up period was unknown. Furthermore, secondary clinical outcomes, including death, rehospitalization, and urgent visits for HF, were not significantly different between the 2 groups in this study, although a similar study using apps [ 28 ] for HF showed reduced hospitalization for HF by mobile app. Finally, we tested a single app, and our results may not be generalizable to other smartphone-based apps for patients with HF.

Despite these limitations, the major strength of this study is the use of a mobile app with various functions developed in collaboration with a cutting-edge technology company. We believe that the features of our app can be effective solutions for improving self-care in patients with HF.

Conclusions

The smartphone app–based intervention with Bluetooth-connected monitoring devices and feedback improved dyspnea symptoms among patients with HF compared with the control group. Considering the high cost of classical patient-provider interventions, self-care, and feedback through mobile apps are promising alternatives. Therefore, our study provides evidence and rationale for mobile app–based self-care and feedback for patients with HF.

Acknowledgments

The app used in this study was developed in collaboration between the Digital Health Council (DHC) from the Korean Society of Heart Failure and KT Corporation. This research was supported by KT’s Internalization of Digital Therapeutics Business project. This research was supported by a grant from the Korea Health Technology Research & Development Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (HI21C1074).

Data Availability

The data sets generated and analyzed during this study are available from the corresponding author upon reasonable request.

Conflicts of Interest

None declared.

App characteristics and functionalities, and participants’ clinical characteristics and outcomes.

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Abbreviations

Edited by A Mavragani; submitted 22.08.23; peer-reviewed by O El-Gayar, P Athilingam; comments to author 18.10.23; revised version received 07.11.23; accepted 12.03.24; published 29.04.24.

©Minjae Yoon, Seonhwa Lee, Jah Yeon Choi, Mi-Hyang Jung, Jong-Chan Youn, Chi Young Shim, Jin-Oh Choi, Eung Ju Kim, Hyungseop Kim, Byung-Su Yoo, Yeon Joo Son, Dong-Ju Choi. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 29.04.2024.

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