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Communication Theory: An Underrated Pillar on Which Strategic Communication Rests

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• https://doi.org/10.1080/1553118X.2018.1452240

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Communication theory, strategic communication defined, communication as a concept in strategic communication, strategy theory, communication theory for strategic communication.

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This article addresses the concept of “communication” in strategic communication, and proposes a new lens through which to view communication in order to deepen knowledge of strategic communication, as well as to significantly improve the alignment of strategic communication with the demands of today’s strategy development process. Looking at modern strategy theory, this article focuses on communication theory as an ongoing process of meaning construction. It posits that communication is a process that is interactive by nature and participatory at all levels. This process is not necessarily two-way but omnidirectional diachronic, with an emphasis on the external and internal arenas of continuous meaning presentations, negotiations, and constructions. Strategic communication, therefore, needs to be conceptualized as an agile management process in which the focus is on feeding these arenas for strategy building and implementation, and on testing strategic decisions by presenting and negotiating these in a continuous loop.

As a research field, strategic communication is said to examine how organizations use communication purposefully to fulfill their mission (Hallahan, Holtzhausen, van Ruler, Vercic, & Sriramesh, Citation 2007 ; Holtzhausen & Zerfass, Citation 2015 ). Because communication is an integral part of the field and the purpose of communication is essential to the concept of strategic communication, we should consider communication as the pillar on which the field rests. However, what is fundamentally meant by “communication” remains rather unclear, as do the metatheories or lenses through which the field views the concept. Unraveling the often rather implicit concept of communication that strategic communication scholars seem to employ, it is questionable whether the lens through which communication is viewed is appropriate for today’s demands of organizational life. In this article, I will elaborate on this issue and propose a lens with which to examine communication within the context of strategic communication, in such a way that fits modern forms of strategy development.

The term communication theory refers to the body of theories that constitute our understanding of the communication process (Littlejohn, Citation 1983 ). Theories represent various ways in which observers see their environment, and as Littlejohn claims ( Citation 1983 , p. 12), because theories are abstractions, every theory is partial. Each theory delineates a way of looking and, therefore, its truth value can only be measured in term of how well it is constructed. This is the reason why there is much disagreement about what constitutes an adequate theory of communication. The search for who is doing what in a communication process and with what effects, to paraphrase Lasswell ( Citation 1948 ), is the basic question of every communication theory, although it might be studied from different angles or by looking at different facets.

There has never been agreement on what “communication” or “to communicate” means. Even in classical Latin, communicare meant “to share with,” “to share out,” “to make generally accessible” or “to discuss together” (Glare, Citation 1968 , p. 369). Rosengren ( Citation 2000 ) suggests that, above all, communication concerns the process of meaning creation: questions concerning how people create meaning psychologically, socially, and culturally; how messages are understood intellectually; and how ambiguity arises and is resolved. For Littlejohn, “communication does not happen without meaning, and people create and use meaning in interpreting events” (Littlejohn, Citation 1992 , p. 378). Thus, the crucial question concerns our understanding of “meaning” and how the process of meaning creation works (for an overview of the concept of meaning, see Littlejohn, Citation 1983 , pp. 95–113).

In communication theory, there are at least three different lenses with which to view how this process works: communication as a one-way process of meaning construction, in which the sender attempts to construct or reconstruct the meaning developed by the receiver; communication as a two-way process of meaning construction, in which two or more people construct new meanings together; and communication as a omnidirectional diachronic process of meaning construction, in which the focus is on the continuous development of meaning itself.

Communication as a one-way process from sender to receiver

Early theories of mass communication were focused on communication as a one-way process in which a sender does something to one or more receivers. However, the identity of this something remained a matter of debate. Some theories viewed communication as a process of dissemination, a flow of information in which a sender disseminates a message to receivers by revealing its meaning within this message. In this case, the focus is on the flow of information, where this information is seen as objective , as in the mathematical communication theory developed by Shannon (Shannon & Weaver, Citation 1949 ). In this model, reaching the receiver is sufficient to make the communication successful. In relation to this one-way transmission perspective, other theories view communication as an attempt by a sender to produce a predefined attitudinal change in the receiver; that is, a change in the meaning of the situation as perceived by the receiver. One well-known theory of this type is Two-Step Flow (Lazersfeld, Berelson, & Gaudet, Citation 1948 ), which stipulates that the mass media informs certain people, who in turn influence the meanings perceived by others. There is also the personal influence model of Katz and Lazersfeld ( Citation 1955 ), which considers that responses to media messages are mediated by interpersonal communication between members of one’s own social environment. This theory uses a lens through which communication is seen as a process directed from a sender to one or more receivers, in which the meaning construction of the receivers is mediated by certain influential others, or by peers.

Although the one-way approach might be convincing in relation to information giving and persuasive communication, more recent approaches to the concept of communication view it as a fundamental two-way process that is interactive by nature and participatory at all levels (for an overview, see Servaes, Citation 1999 ). This involves the paradigmatic change from the sender/receiver orientation into an actor orientation, in which all actors may be active and take initiatives. This implies that sharing meaning is not so much seen from a perspective by which the receiver should be willing to share the meaning originally expressed by the sender, as is the case in the one-way perspective. The emphasis today is much more on communication as a process in which meanings are created and exchanged, or even shared, by the parties involved.

In the 1960s, Dance ( Citation 1967 , p. 294) discussed the issues that communication scholars had with Shannon’s rather simple one-way transmission approach. At the time, they wanted to replace this theory with a more circular model in which feedback became important or was at least not neglected. The concept of feedback stems from Wiener ( Citation 1961 ), who studied cybernetics from the early 1940s on. Cybernetics is interested in purposeful levels of behavior within systems. Wiener concluded that feedback mechanisms are essential in communication theory, whether in a machine or in an animal. All purposeful behavior requires feedback to be adjustable and therefore remain purposeful and have a particular effect. However, “adding a feedback loop to a linear process model does not make that model circular or dynamic – it is there to increase the effectiveness of the linear process” (O’Sullivan, Hartley, Saunders, & Fiske, Citation 1983 , p. 90). Thus, this feedback idea of interaction has nothing to do with a two-way lens on communication.

Communication as a two way process between actors

When looking through the two-way lens of communication, interaction is vital. However, there are different interpretations of what “interaction” means in this context. The term comes from Latin and not only means “direct reciprocal dialogue,” but also “to act upon each other and have influences on each other” (Neumann, Citation 2008 , p. 2307). Thus, the term may refer to feedback processes as well as to direct interaction between people, but it can also refer to a more abstract concept of interaction concerned with how people relate to other meanings in developing their own meanings.

In interpersonal communication theory, interaction is usually seen from the angle of person-to-person interaction or group interaction, as in Bales’ interaction process analysis or Fisher’s interaction analysis (for an overview, see Littlejohn, Citation 1983 , pp. 227–240), in which people respond to each other. This notion can also be found in relational communication theory as constructed by Bateson, who concluded that every interpersonal exchange bears a message that contains the substance or content of the communication, as well as a statement about the relationship itself. Watzlawick, Beavin, and Jackson ( Citation 1967 , pp. 48–51) called this latter part of the message “metacommunication.” Watzlawick et al. ( Citation 1967 ) also claimed that relationships emerge from the interaction between people, with many kinds of interaction rules being set that govern their communicative behaviors. By obeying the rules, the participants sanction the defined relationship. In these models, interaction is focused on how people engage in conversations with each other and literally converge in creating meaning. Thus, from this perspective on interaction, the focus is on interpersonal conversations, whether mediated or not. In some instances, the concept of dialogue is used, in this respect, to mean: focusing on the acts of turning toward the other, and listening to each other with respect to differences in order to enhance the quality of the communication (Broome, Citation 2009 , p. 305).

In strategic communication theory, the Communicative Constitution of Organizations (CCO) approach is becoming increasingly important as a lens through which to examine communication. According to Ashcraft, Kuhn, and Cooren ( Citation 2009 ), CCO thinking begins with the premise that communication is not just a peripheral epiphenomenon of human actions, but the primary model of explaining social reality (see also Schoeneborn & Blaschke, Citation 2014 , p. 302). This interpretation relies on the Chicago School of Urban Sociology (cf. Rogers, Citation 1997 , pp. 137–202) and has been popularized by Berger and Luckmann ( Citation 1966 ) in their explanation of reality as not “something out there,” but as something that human beings construct themselves. Typical of CCO and related approaches is the idea that this construction is achieved through interactive conversations between people.

Taylor and Van Every ( Citation 2000 ) constructed the Montreal CCO model based on speech theory and looked at communication from a co-orientation perspective. They focused on daily human interpersonal exchanges, by which, they argue, organization arises “through the laminated sense-making activities of members, endlessly renegotiated” (Taylor & Van Every, Citation 2000 , p. 33). They suggest that people orientate themselves toward each other, leading to moments of consensus, but this consensus is endlessly renegotiated. For Taylor and Every, co-orientation is an ongoing, emergent process of these interactions.

argues that what matters is not how a particular individual understands a communication but how a subsequent communication interprets the preceding communication it is connected to; only a communicative event can determine the particular way in which the immediately preceding communicative event is understood (Seidl in Schoeneborn & Blaschke, Citation 2014 , p. 290).

Here, co-orientation is also seen as an ongoing, emergent process.

Examining the CCO approach as a whole, it is obvious that emergence is an important concept: in communicating, the people within and around an organization order and build the organization by negotiating their meanings over and over again. Interaction is not so much a matter of how meanings converge, but how meanings are continuously created in this manner, and developed in this ongoing process of conversations.

Communication as an omnidirectional diachronic process of meaning development itself

There is yet another approach to communication. Through this lens of communication, interaction also plays a key role, but in a different way to the approach previously discussed. In two-way models, the notion of interaction is normally narrowed to a consideration of the concrete interactions of those who are literally engaged in conversations with each other. Through a lens of communication as omnidirectional diachronic process of meaning development itself, interaction is seen as a dynamic interplay between actors in their roles as senders and receivers, which influences the consequences of the communicative transactions at a fundamental level (for an overview, see Stappers, Reijnders, & Möller, Citation 1990 ). Through this lens, interaction is focused on the social acts of all those engaged in a relationship with the communicative process itself and not so much focused on their relationship with each other. This is to be seen as a virtual process occurring at the level of the interpretations made by senders and receivers, which influence the meanings they give to a message and consequently the effects of the message. Seen through this lens, actors are not necessarily related or in proximity to each other.

In his seminal book on the process of communication, Berlo ( Citation 1960 ) explained that a communication process is not a sequence of events, one following the other, but a continuous and simultaneous interaction of a large number of variables that are moving, changing, and affecting each other. Thus, interaction means that the sender plays a role in the interpretation of the receiver in the context and situation in which the communication is taking place but does not necessarily entail a conversation. This view is rooted in constructivism (Lindlof, Citation 2008 ) and echoes Thomas Theorem. As Lindlof argues, “if men define situations as real, they are real in their consequences,” which can be said to be a typical constructivist explanation. This perspective on communication considers that “communication is the chief means by which the social world is created, understood, and reproduced across time and space” (Lindlof, Citation 2008 , p. 947). For Burleson and Bodie ( Citation 2008 , p. 953), “constructivism assumes that humans actively interpret the world, construct meaningful understandings of it, and act in the world on the basis of their interpretations.” In this context, a distinction is made between “constructivism” and “constructionism,” where the focus is often more on how people construct meaning in their interactions. However, to avoid discussion about constructivism and constructionism, I prefer to call the approach under examination here an omnidirectional diachronic lens on communication.

The lens on communication as an omnidirectional diachronic process of meaning development itself can also be found in the ritual model of communication as developed by Carey ( Citation 1975 , Citation 2009 ). Influenced by theorists such as Dewey, Innis, and McLuhan, Carey made the distinction between transmission and ritual models of communication that occur in society. Transmission models are classic sender-receiver models, yet a ritual model sees communication as a symbolic process, whereby reality is produced, maintained, repaired, and transformed, over and over again, in a very dynamic and uncontrolled way. Carey’s ritual model reflects the diachronic view of communication, which, as Thayer ( Citation 1968 , Citation 1987 ) argued some years earlier, stipulates that communication can best be seen as an ongoing and complex process of learning in which meanings develop. By using the concept of the diachronic—which means developing over time—he focused on ongoing meaning-creation over time, instead of focusing on the transmission or the effectivity of messages, or on the interaction between actors as people involved in communicating.

does make the point that what and how one communicates has an effect that may alter future communication. The main shortcoming of the circular model is that if accurately understood, it also suggests that communication comes back, full-circle, to exactly the same point from which it started. … The helix gives geometrical testimony to the concept that communication while moving forward is at the same moment coming back upon itself and being affected by its past behavior, for the coming curve of the helix is fundamentally affected by the curve from which it emerges. (Dance, Citation 1967 , p. 294).

For this reason, he proposes to focus on the communication process as constantly moving forward and yet always to some degree dependent upon the past, which informs the present and the future (Dance, Citation 1967 , p. 295). This is also why this kind of lens on communication is sometimes called an evolutionary or transactional model (Stappers et al., Citation 1990 ). Consequently, we should talk about plural meanings creations , instead of meaning creation, and as an ongoing process that develops as it occurs and cannot be predicted. From this perspective, feedback is still an important concept but only as a formative monitoring tool to steer follow-up action.

Although at first sight, the helical model of Dance ( Citation 1970 ), the ritual model of Carey ( Citation 2009 ), and the ideas of Berlo ( Citation 1960 ) look similar to the CCO approach suggested by Taylor and Van Every ( Citation 2000 ), unlike the latter, Dance, Carey, and Berlo consider communication on a cultural, societal level, and look at meaning development as such. From their perspectives, the concept of interactivity is not understood as entailing interaction between two or more people. They look at the more abstract level of the interplay between social actors, acting as senders and receivers, related to each other only in the context of developing their own meanings continuously over time, thereby constructing society itself and, consequently, also constructing ideas about how organizations in society should behave.

Krippendorf ( Citation 1994 ) mentions the recursiveness of communication: it is an ongoing social process of de-constructing and reconstructing interpretations. This is not exclusively done in direct conversations, but is an ongoing process, insofar as people orient themselves toward others, and again, not necessarily toward their interaction partners (alone). This is why Faulstich ( Citation 1992 ) and other German mass communication scholars state that “ Öffentlichkeitsarbeit ” (which is often translated as “public relations” in the sense of organizational work with and for publics and in public, e.g., as a part of strategic communication, BvR) is not so much about interaction between individual human beings, but rather concerns societal action itself.

From my perspective, this is an interesting addition to the CCO approach, as it concentrates on meaning creation itself, and therefore on the role of the organization in society, as one of the actors in the arenas of ongoing meaning construction. Furthermore, it stipulates that people present and propagate their own meanings but do so in a reflective and evolutionary way.

It is by the means of reflexiveness—the turning back of the experience of the individual upon himself—that the whole social process is thus brought into the experience of the individuals involved in it; it is by such means, which enable the individual to take the attitude of the other toward himself, that the individual is able consciously to adjust himself to that process, and to modify the resultant process in any given social act in terms of his adjustment to it. (1934/1962, p. 134)

Reflexivity or reflectivity, which I prefer to use, is the counterpart of causality: it is an ongoing, interactive process, and not a discrete, linear one. Along these lines of thinking, reflectivity must be seen as the core concept of societal interaction because it provides a better explanation of what happens than causality. Human beings reflect upon themselves in relation to individual others and the social group as a whole, and as a result their knowledge is reflective. The question of which of these three lenses on communication is helpful for strategic communication depends on the question of what strategic communication actually is.

The concept of “strategic communication” suggests that not all communication can be seen as strategic. One definition that can currently be found on Wikipedia states that: “Communication is strategic when it is completely consistent with the organization mission, vision, values and when it is able to enhance the strategic positioning and competitiveness between their competitors” (retrieved 23rd March 2017). In this case, communication is only strategic when it has a certain quality. When attempting to define a field, this is problematic.

Like the unknown Wikipedia author, most known authors on strategic communication quote the seminal article by Hallahan et al. ( Citation 2007 ), who argued that the essence of strategic communication is being purposeful, in order to advance an organization’s mission through communicating (Hallahan et al., Citation 2007 , p. 3). When communication helps to move the organization’s mission forward in a purposeful way, we may speak of strategic communication. Therefore, only communication that has the intention to advance an organization’s mission can be defined as “strategic.” For these scholars, it is not the quality that makes communication strategic, but its purpose of enhancing the organization’s mission. Many other authors echo this definition.

The emphasis is on the strategic application of communication and how an organization functions as a social actor to advance its mission. … Whereas academic research on organizational communication broadly examines the various processes involved in how people interact in complex organizations, strategic communication focuses on how the organization itself presents and promotes itself through the intentional activities of its leaders, employees, and communication practitioners. (Hallahan et al., Citation 2007 , p. 7)

As a result, the authors focus on how an organization functions as a social actor, which suggests that strategic communication is only about the integration of external communication fields. In the explanation of this often-used definition, we can learn that what differentiates strategic communication is the fact that it is concerned with the intended communication that presents and promotes the organization in all its utterances to the outside world.

Thorson ( Citation 2013 ) provides another rationale: “The strength of the approach [of strategic communication, BvR] is its emphasis on strategy rather than on specific tactics as well as its focus on communications understood holistically.” In addition, Johnson and Scholes ( Citation 1999 , p. 17) called this the difference between “strategic” and “operational.” Thorson does not explain what she means by “holistically,” but we can assume that this aligns with the statement from Hallahan ( Citation 2004 ) on the integration of various forms of communication in and by the organization.

Thorson also states that the increasing complexity of a global, digital society has challenged the capacity for organizations to engage in long-term strategic planning. She claims that this is why organizations need strategic communication and strategic communication practitioners as a part of strategy formulation. This would suggest that strategic communication is not only a matter of presenting and promoting organizational strategy but also of building this. This idea has already resonated within the field. Argenti, Howel, and Beck ( Citation 2005 ) interviewed CEOs, SFOs, and CCOs and showed that the respondents indeed see strategic communication as making a difference for a business, and thus driving strategy development. The conclusion of Argenti et al. ( Citation 2005 ) is that even though the question of whether communication practitioners are part of strategy formulation might remain open, it is obvious that strategic communication is part of strategy formulation.

In summary, we may conclude that strategic communication is seen as strategic when it integrates all those communications that are associated with organizational goals and strategies. For some, strategic communication is focused on presenting and promoting goals and strategies; for others, it is also focused on driving its development. In other words, for some, strategy precedes strategic communication; for others, strategic communication also constitutes strategy. Surprisingly, there is not much debate over these differences. This might be because of the relative absence of a view of communication as a pillar on which strategic communication rests.

Human communication is, of course, as old as humankind, but theorizing about strategic communication is rather new. Paul ( Citation 2011 ), a professional and scholar in strategic communication in the military field, reviewed all of the definitions of strategic communication he could find and argued that strategic communication “should not be limited to formal messages, while actions also convey meaning and should, therefore, also be part of strategic communication. What we do is often more important than what we say” (Paul, Citation 2011 , p. 28). For Paul, strategic communication thus concerns what you say and what you do. Although he claims that he is cautious about seeing the “public” only as an audience, he retains the term “audience” but “means to include interaction with that audience that goes beyond ‘great megaphone’ broadcasting” (Paul, Citation 2011 , p. 28). A closer look at his ideas on interaction, however, reveals that he interprets interaction as equivalent to personal communication from the organization to an audience, rather than broadcasting messages mediated by mass media.

This is a rather uncommon interpretation of interaction because it remains pure one-way communication, namely what one says and does to present and promote the organizational goals to audiences directly. He also elaborates on the question of whether strategic communication should only inform people or might also be used to influence them. He concludes that communication is always a matter of influence, and that it is permissible to influence your public as long as it is not manipulation.

Although Paul does not define communication as such, he obviously sees it as a one-way process of information-provision that flows from a sender to a receiver and influences the receiver automatically. In other words, communication is a matter of utterances, and when you make an utterance it flows to your audience and has its effect. This is a rather prescientific “injection needle” kind of approach to communication, and it justifies the conclusion of Nothhaft and Schölzel ( Citation 2015 ) that communication consultants often conceptualize communication “along the lines of a paradigm of information flow, information transfer, information submission, or the like” (Nothhaft & Schölzel, Citation 2015 , p. 28).

As Nothhaft argues ( Citation 2016 , p. 71), a major problem is that there is no solid theoretical discussion, and very little convergence on the theoretical conceptions of strategic communication. Looking back over the last 10 years of issues of the only scholarly journal that is purely focused on strategic communication, the International Journal of Strategic Communication , communication theory seems to not be a concept that needs much attention. It is obvious that communication should not be seen as a simple flow from sender to receiver, as Paul ( Citation 2011 ) conceives it, but there has been little debate in the journal about how it should be seen. Only a few authors refer to communication theory, especially when they prefer to see communication as an interactive or conversational process. After the initial article by the founders of the journal in its first issue in 2007, which includes a review of some theories on how communication works, the journal has not published a literature review on the concept of communication, or any other article on how communication is or can be understood in the context of strategic communication.

In the opening chapter of the Routledge Handbook of Strategic Communication , Holtzhausen and Zerfass ( Citation 2015 , p. 4) state that: “The strategic communication process typically is a communication process that follows from an organization’s strategic plan and focuses on the role of communication in enabling the organization’s strategic goals and objectives.” Some years earlier, they specified this in another way and proposed: “Strategic communication is the practice of deliberate and purposive communication that a communication agent enacts in the public sphere on behalf of a communicative entity to reach set goals ” (Holtzhausen & Zerfass, Citation 2013 , p. 284; italics added). Thus, for these authors, organizational goals come first, and strategic communication is there to help realize these goals, especially in the outside world. Strategic communication is thus one of the instruments to successfully attain organizational goals, not to create or recreate them. In other words, strategic communication follows strategy, and strategic communication is the aid with which to attain set goals by influencing the public sphere to accept these set goals.

In their 2015 article, Holtzhausen and Zerfass posit that “the notion that communication can be controlled and regulated is now largely redundant” ( Citation 2015 , p. 7). This is why they reject the concept of linearity and argue that the question of “how do we get information from here to there?” remains a valid question, “but more important is the question ‘What happens to communication in that process and how is meaning shaped and co-created?’” They call upon a constitutive approach to communication to answer this question: “Whereas the transmission model focuses on how to get information from one point to another, constitutive communication focuses on the importance of communication to bring about actual change and action” ( Citation 2015 , p. 7).

The role of the practitioner is to send information that can act as the point of departure for meaning creation between a communicative entity and its stakeholders which can actually lead to social change and social action. Instead of transmitting information, with the underlying assumptions that one can control communication so transmitted, strategic communication increasingly focuses on the process of communication, which might take place over long periods of time and stretch over time long after a message has been transmitted. (Holtzhausen & Zerfass, Citation 2015 , p. 8)

Obviously, from their perspective, meaning construction is a constitutive process, but only among people in the audience after the organization, as initiator, has spread its message.

Holtzhausen and Zerfass also stipulate the role of the media, which acts as interpreter in this constituting meaning creation process. They alert their audience to the fact that media have a strong role in shaping social and cultural realities. They warn them not to see the media as mere channels, and audiences as mere receivers: “Strategic communicators need to consider how meaning is shaped in the interaction process involving stakeholders and the media practitioners and how stakeholders interpret and recreate media content in the process” (Holtzhausen & Zerfass, Citation 2015 , p. 8)

Holtzhausen and Zerfass, who are the editors of the Handbook and leading scholars in the field of strategic communication, do not give a definition of communication in their introduction to the Handbook , but I would like to call their approach an enlightened “one-way orientation” to communication – enlightened because they are aware that meaning is constructed over time and that people co-construct meaning. However, quite obviously, the organization does not play a role other than as the initiator of this constitutive process by providing messages. Thus, for them, strategic communication entails presenting and promoting organizational goals, not constructing or reconstructing them, yet strategic communication is seen as a kind of two-step flow process, in which media and audiences negotiate meaning together.

Aggerholm and Thomsen ( Citation 2015 ) have a different focus on strategic communication, more precisely on the role of strategic communication in decision making in organizations. They argue that the definition of strategic communication used by Hallahan et al. ( Citation 2007 ) comprises “a somewhat naive recipient and a rational and deliberate decision making process” (Aggerholm & Thomsen, Citation 2015 , p. 174). They question this definition and conclude that “all kinds of actors shape the organization through his or her (strategic) communication role in the organization.” They also criticize the communication theory of Hallahan et al. ( Citation 2007 ) as being a “simplistic idea of strategic communication as message exchange between sender and receiver” (Aggerholm & Thomsen, Citation 2015 , p. 175), referring to Shannon and Weaver ( Citation 1949 )—who did not speak of exchange but of a flow from sender to receiver—and thereby suggesting that Holtzhauzen and Zerfass maintain a simple Shannon-like transmission view of communication. Aggerholm and Thomson prefer to understand communication as a much more complex, multivocal process, whereby organizations are “constituted by complex webs of sense-making activities between groups and individuals whose understandings intersect, clash and interfere with each other” (Aggerholm & Thomsen, Citation 2015 , p. 175).

Whether we can see the lens of communication offered by Holtzhausen and Zerfass as an enlightened one-way orientation, as I proposed before, or from a transmission perspective as Aggerholm and Thomson do, the perspectives in these two articles on what strategic communication is about and how communication works in strategic communication are completely different.

The CCO approach is becoming important in strategic communication theory. Marchiori and Bilgarov ( Citation 2015 ) argue that a strategy process itself is a communication practice. For them, communication is always “a process of active participants, not of neutral receivers and passive observers” (Marchiori & Bilgarov, Citation 2015 , p. 191). Following the CCO approach of Taylor and Van Every ( Citation 2000 ), they conclude that a communicational practice, due to its procedural and interactive nature, constitutes strategic practice” (Marchiori & Bilgarov, Citation 2015 , p. 193). Thus, according to Marchiori and Bilgarov, strategic communication does not constitute the meanings of stakeholders, but of the strategic practice of the organization itself.

The scope of organizational communication broadens to include virtually everything an organization says and does, and everyone who is affected by the organization’s existence and activities. That is why nowadays not only everything is viewed as communication, but also as strategic communication. (Torp, Citation 2015 , p. 43)

Torp thus argues that the CCO approach is basically about the daily use of language, by which the organization is constituted, and on this basis finds this to imply that there is no difference between tactical and strategic communication – it is all strategic in nature. Using the concept of CCO to discuss strategic communication, all communication in and around the organization can be seen as part of strategic communication, Torp concludes. Moreover, not only messages or communicative interactions belong to strategic communication, but also the actions of people, because they also communicate, and consequently constitute organizational life as such and thus constitute strategy. Torp extends the scope of strategic communication quite a long way with this definition.

Obviously, we may conclude that strategic communication scholars have very different ideas of the role communication plays in the context of strategic communication and how it works. Some see it as a controlled one-way process of a sender, who is attempting to gain approval from the audience; for others, it is a constituting process in which decisions are made. This leads to a different approach to strategic communication as well: for some, strategic communication is there to help the organization to gain approval for its strategic choices; for others, the focus is on the constituting process by which strategy is built.

Are we looking at two completely different schools of thought; do we have to choose one of them? Considering the context in which strategic communication works (organizational strategy), I do not believe so. This makes it important to have a closer look at strategy theory and the role of communication within it.

The term “strategy” comes from the Greek verb, strategein , which literally means building roads ( stratos agein ) and since ancient times has also been used to mean “being the leader” as well as “using a ploy to win” (Muller, Citation 1920 ). As Mintzberg ( Citation 1994 ) and Whittington ( Citation 1993 ), and more recently, Koch ( Citation 2011 ) amongst others, describe, theoretical ideas about how to develop strategy have changed over time. Classical strategy theory is about rational long-term planning, and recent strategy theory is much more about continuous change and is much more emergent and incremental. Although these strategy theorists do not speak about strategic communication as such, we may assume that in rational long-term planning theory, strategic communication plays a role in presenting and promoting it, yet in emergent and incremental strategy development, strategic communication obviously plays a role in building strategy.

Unfortunately, in the professional strategic communication field, modern strategy theory has made little progress, and this might limit scholars to theorizing about the possible reach of strategic communication as only presenting and promoting the organizational strategy or reconstructing it. Strategy is more often considered part of a longer term strategic planning model or as planning itself. Torp ( Citation 2015 ), for example, claims that “in present day, strategy is often defined as a plan or action intended to accomplish specific goals.” In such a case, “strategy” is only another word for “plan.” A search for strategic communication planning models showed, indeed, that most models resemble the widely spread public relations planning model of Smith ( Citation 2013 ), in which planning is seen as a process that consist of some phases and a number of stages through which one must proceed.

The first phase is the analysis of the situation, the organization, and the publics involved. The second phase is called an action plan, including objectives and strategy, and consists of establishing goals and objectives, formulating action and response strategies and developing the message strategy. The third phase concerns tactics, which means first selecting communication tactics, and then implementing them, whereas the fourth phase involves the evaluation of the plan. All these models start with research, followed by the development of the strategy, a list of tactics/actions to be performed, preferably as detailed as possible, and conclude with an evaluation. Thus, in these planning models, strategy is the second phase and always defined as the outcome of the first phase, which concerns the analysis of the situation. These models fit the classic model of strategy development described by Whittington ( Citation 1993 ) as “rational long term planning” and by Mintzberg, Quinn, and Ghoshal ( Citation 1995 )–in their overview of schools of thought—as “deliberate strategy” development.

In a popular article in the Harvard Business Review , “The Big Lie of Strategic Planning,” Martin ( Citation 2014 ) argues that strategy is completely different from a plan, and may even be the opposite. “True strategy is about placing bets and making hard choices,” he claims, and adds that: “Planning typically isn’t explicit about what the organization chooses not to do and why. It does not question assumptions. And its dominant logic is affordability; the plan consists of whichever initiatives fit the company’s resources. Mistaking planning for strategy is a common trap.” For Martin, it is the opposite: “strategy making is uncomfortable; it’s about taking risks and facing the unknown.” Thus, here strategy implies movement from a present position to a desirable but uncertain future position. The choices made concern a series of linked hypotheses, no less but also no more. To avoid the traps, Martin advises that the strategy statement should be kept short and simple (far from a detailed plan) and that it should be recognized that strategy is not about perfection (SMART objectives) but about choices about the unknown (no more than just ambitions, a dot on the horizon). He also offers advice on how to make the logic explicit by focusing on choices, advises professionals to develop strategies not just to eliminate risk but to increase the odds of success, and suggests that—because choices have to be made about the unknown—it might be better to talk about choosing certain hypotheses.

Koch ( Citation 2011 ), Viki ( Citation 2015 ), and many others echo this statement. This implies that today strategy development is often seen as being based on assumptions to be tested, over and over again, and adjusted accordingly. Today’s theories of strategy development are much more oriented toward emergence than rational long-term planning.

Emergence versus planning

The public debate on how to develop strategy started in the 1980s. At that time, rational long-term planning was mainstream. Many scholars opposed it and argued that strategy development is or should be emergent (e.g., Johnson & Scholes, Citation 1999 ; and the overview by Mintzberg, Citation 1994 ). Deliberate strategy is a top-down approach in which management specifies the strategy and the actions based on an analysis of the situation (Viki, Citation 2015 ). Deliberate strategy assumes that the manager has near to complete control over how to allocate the internal and external resources and can thus manipulate the internal organization of the firm to better suit these objectives, with the focus being on the prediction of the future and control. Emergent strategy is the opposite; it is about learning what works in practice by testing. Emergent strategy evolves in response to changes in the environment; the more turbulent the environment is, the more adaptive the strategy should be, in order to respond to the evolving reality.

Since strategy has almost inevitably been conceived in terms of what the leaders of an organization ‘plan’ to do in the future, strategy formation has, not surprisingly, tended to be treated as an analytic process for establishing long-range goals and action plans for an organization; that is, as one of formulation followed by implementation. As important as this emphasis may be, we would argue that it is seriously limited, that the process needs to be viewed from a wider perspective so that the variety of ways in which strategies actually take shape can be considered. (Mintzberg & Waters, Citation 1985 , p. 257)

Mintzberg and Waters ( Citation 1985 ) argued that the pure concepts of both deliberate strategy and emergent strategy are very rarely applied in practice. Viki ( Citation 2015 ) confirmed this and claimed that this is because deliberate strategies mean no learning at all and emergent strategies mean no control at all, and both are not very realistic.

However, today’s strategy scholars go further than this balanced approach. Moore ( Citation 2011 ), a long-time colleague of Mintzberg, claimed that “today’s more volatile world no longer lends itself to deliberate strategy, especially when you’ve got to be faster and more agile than competitors. In such a world, and in these times, emergent strategy seems to be a better fit.” Emergent strategy entails the view that strategy emerges over time as intentions collide with, and accommodate, a changing reality. The term “emergent strategy” implies that an organization is learning what works in practice. Opposed to any idea of a rational long-term planning approach, Moore ( Citation 2011 , p. 1) claims that “given today’s world, I think emergent strategy is on the upswing.” In this case, strategy is seen as an ongoing process that needs to be reflected upon in order to adapt to internal and external emergent changes, and to determine whether one is still doing the right things in the right way. Continuous monitoring is essential as a means to gather data to gain insights required to make the necessary changes in the choices made.

Such an approach to strategy implies that in today’s organizations, strategy is presented and promoted by communication, but also rebuilt by it in a continuous and reflective way. It also emphasizes the importance of a strategy model of continuous learning. The notion of a learning organization (see, e.g., Argyris, Citation 1994 ; Quinn, Citation 1996 ; Senge, Citation 1990 ) is a common interpretation of how organizations can best cope with today’s environment, which favors emergent strategy over deliberate strategy, although it is not necessarily emergent strategy in its purest form. A learning organization is a continuously self-correcting system steered by reflectivity and based in or carried by communicative processes (Hatch, Citation 1997 , p. 371).

In addition to formulating their own communication strategies, communication practitioners are often asked to communicate to employees the vision and mission of the organization as set out by management. Although this remains the standard view of strategic communication, alternative perspectives on strategy formulation open up new directions for studying the role of communication in strategy formulation and execution … From this perspective, the notion of practice as part of the strategic process that influences society and in turn is influenced by society allows scholars, rather than studying communication practice as an organizational function, to study how communication practices transform both organizations and societies. ( Citation 2007 , p. 14)

Looking at the development of strategy theory we may conclude that the latter demarcation is now more realistic than ever. It can, therefore, no longer be seen as merely a subordinate clause, but as a normal part of strategic communication, and it must, consequently, also be included in the definition of the field.

As a result, we may conclude that modern strategy development theory sees strategy development as a more or less emergent and continuing developmental process. Moreover, recent strategy theory considers strategy as based in assumptions to be tested, continuously anew, and adjusted accordingly.

Although strategy theorists do not talk about communication, it is obvious that it plays an important role in this emergent and continuing process. In modern strategy theory, it is communication that constitutes strategy on a daily basis and new assumptions constitute follow-up communication processes, which on their part create input into the strategy-building process. All this is done in a continuous loop and is interactive and reflective in all its aspects and phases. Looking at modern strategy theory from a communication perspective, we must see strategy as an amalgam of continuous communication processes in order to build, define, present, realize, and rebuild strategy .

On this basis, we must admit that strategic communication is both: it presents strategy and it builds and rebuilds it. For this reason, I prefer to see strategic communication as the management of this amalgam of communication processes in the context of strategy making, presenting, realizing, and remaking, as a continuous, reflective learning loop. If so, we need a lens through which to view communication in which this continuous, reflective learning loop is emphasized.

Reading through the existing literature on strategic communication, it is possible to find references to communication theory, especially when a CCO view is being used, but it is difficult to find a profound explanation of communication theory—just as in the public relations literature (see van Ruler, Citation 2016 ). It is obviously not seen as a theoretical pillar on which the field of strategic communication rests. Exploring what the authors in The Routledge Handbook of Strategic Communication and in the International Journal of Strategic Communication implicitly or explicitly say about communication, as well as in other books and articles, different points of view are apparent, but these differences are little questioned, let alone deeply debated.

I consider communication as the constituting pillar of strategic communication, and strategy is the context in which strategic communication takes place. Consequently, we need a lens through which to view communication that aligns with modern approaches to strategy development, and which can help scholars delineate their research and assist practitioners to actually “do” strategic communication in a theoretically profound way.

If strategy can be seen as an amalgam of continuous communication processes, we need a communication lens through which this continuous, reflective learning loop is emphasized. It is obvious that one-way lenses on communication are insufficient for this. We need a more interactive lens. We might view CCO as a typical and interesting exponent of this approach. However, the problem with CCO is that it is focused on how organizational decisions are made in and through communication in general, and strategic communication is only focused on decisions in the context of organizational goals and strategy and is – moreover – also focused on how strategy is demonstrated, propagated, and realized. We could, of course, decide that CCO is the best communication lens for strategic communication and focus only on the strategy-building process in the organization. Strategic communication would then be merely a specific part of organizational communication.

I would prefer to see strategic communication as the management of the amalgam of communication processes in the context of continuous strategy development, and therefore include the presentation, promotion, and realization aspects as well as the building and rebuilding aspects of strategy and see this as a continuous loop. That is why I propose to build on the basic principles of CCO and expand them with a notion of communication as an omnidirectional, diachronic societal process of meaning development as such, as propagated by Carey, Dance, Berlo, and others. A constitutive view of communication with a focus on the social construction of meanings itself would then become the metatheory guiding our theorization and methodology.

This lens through which to view communication helps us to focus on the internal and external arenas in which meanings are presented, propagated, and negotiated in a continuous, nonlinear, and complex way. The ongoing and very complex processes of constantly moving presentations of and negotiations about meanings in these external and internal arenas regarding strategy thus constitute the playing field of strategic communication research.

In this reasoning, as a research field, strategic communication is still focused on how organizations use communication purposefully to fulfill their mission, but no longer as a one-way process to present, promote, and realize their strategy, nor as a conversational process through which it is built. Instead it focuses on the agile management of the amalgam of communication processes in the context of strategy making, presentation, realization, and remaking.

Considering modern strategy theory, we should no longer focus on strategic communication as a one-way process from the organization to audiences that presents, promotes and realizes organizational goals and strategy. I would prefer to focus on the amalgam of ongoing communication processes in the context of strategy building, presenting, realizing, negotiating and rebuilding. Consequently, we should not only leave the traditional definitions of strategic communication behind, but also leave the one-way focus on communication behind. In addition, two-way models that focus on conversations between participants in the communication process do not suffice. We have to embrace the idea that communication is a process that is interactive by nature and participatory at all levels. This does not necessarily make it a two-way conversational event, but instead omnidirectional and diachronic, with an emphasis on the internal and external arenas of meaning presentation, negotiation, construction, and reconstruction. As communication is the theoretical pillar on which strategic communication rests, we need to include this perspective in the definition of strategic communication. For this reason, I proposed here that strategic communication should be conceptualized as an agile management process in which the focus is on feeding the arenas in which meanings are presented, negotiated, constructed, or reconstructed for strategy building and strategy implementation, and on testing strategic decisions by presenting and negotiating these in a continuous loop.

1 Similarly to Holmström ( Citation 2000 ), I use “reflectivity” instead of “reflexivity,” for two reasons: First, because of the psychological behavioral connotations of the word “reflexivity” (which suggests a rather routine action: “reflex”), although here I refer to reflection as a conscious cognitive process; and second, related to the background of the word, “reflex” is the perfectum of the Latin verb “ reflecto .” “Reflexive,” therefore, refers more to a state, whereas “reflective” refers to an ongoing process.

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COMM 3020: Communication Research Methods

• Literature Reviews
• Identifying & Using Scholarly Articles
• Search Strategies
• Find Articles
• Find Statistics & Data

Library Help

What is a literature review.

While reviewing published literature on your topic, you may discover a "gap" in the research, such as little or no research focusing on a specific demographic or no research on a potential intervention for a problem. Finding a "gap" can help guide the direction of your research. It’s OK if you can’t find an article that exactly aligns with your proposal—that's actually a good thing, because it demonstrates a need for your own research and how you can contribute to the scholarly conversation surrounding your topic!

A good literature review in a research proposal will:

• Inform readers of the existing research surrounding your topic, including major concepts and trends they need to know to understand your work.
• Demonstrate why your own proposed research is needed.

Your literature review will primarily include scholarly articles published in peer-reviewed journals. Keep reading this guide to learn how to locate your articles, find tips for reading articles effectively, and find tools for formatting your citations. Literature review requirements can vary significantly, so be sure to review the guidelines for your assignment for length requirements and number of sources you need to include.

Examples of Literature Reviews

Literature reviews are often included in the intro of research articles, but they are also published as full-length, stand-alone articles. Systematic reviews are another type of full-length article that compile published literature on a topic and compare and analyze the results from the included studies. Looking at published literature reviews or systematic reviews can help you learn how to organize this type of work, and they can also be a gold mine of potential articles you could include in your own paper!

The following are examples of published literature reviews in communication. You can look for more in our databases by adding AND "literature review" or AND "systematic review" after your search terms. For example: family AND communication AND "literature review"

• Social Media Use and Offline Interpersonal Outcomes during Youth: A Systematic Literature Review
• Risk, Crisis, and Social Media: A Systematic Review of Seven Years' Research
• Understanding Conspiracy Theories

Organization Tips

Because literature reviews can require many sources, you might get a little overwhelmed by all the research you find. As you research, it's important to keep track of the citation information (authors, titles, journal titles, etc.) so that you can easily build your reference list later and to save copies of sources as you go—finding some sources a second time can be tricky.

Here are some ways to keep your sources organized:

• Keep good notes for each source, along with the source's citation information.
• Use folders to sort sources by sub-topic.
• Use online resources like the Citation Management tools on the Citations page of this guide.

Reading & Writing Tips

• Scan the Abstracts, Introductions, Discussions, and Conclusions. Highlight and make note of important findings, main ideas and arguments, and references to previous studies and theories.
• Keep track of research methods used in the Methods section—these may come in useful when designing your own research study!
• See the Identifying & Using Scholarly Articles page in this guide for more information on this step.
• Create an outline that organizes your sources into an order (topical, chronological, etc.) for you to follow in your review.
• Write a short introduction to your summary that lets your reader know what to expect.
• Write paragraphs that summarize the findings found in the literature. Each paragraph should address one major idea. Similar sources can be summarized together in statements like, "Most researchers agree that..." or "Current trends in the literature are..."
• Use transitions to show how different sources interact with each other. For example, you might write, "While earlier researchers thought X, new discoveries have led researchers to think Y." Or "Researcher applied W in new circumstances and found Z."
• Use direct quotations sparingly in your review—you should be summarizing and paraphrasing as much as possible. Remember to cite your sources using in-text citations when you refer to an idea from a specific source, whether you're paraphrasing or using a direct quotation. See the Citations page in this guide for help with this step.
• Write a short conclusion that sums up the major points from the literature. If you've noticed there are subjects that the literature hasn't tackled yet, you can point out that further research is needed.
• Only include sources in your references that you quoted, paraphrased, or mentioned in your paper. 

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SPCH U301 - Theories and Principles of Human Communication - Dr. Webber: Literature Review

• Communication Theory
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What is a Literature Review?

A Literature Review is a systematic and comprehensive analysis of books, scholarly articles, and other sources relevant to a specific topic providing a base of knowledge on a topic. Literature reviews are designed to identify and critique the existing literature on a topic to justify your research by exposing gaps in current research. This investigation should provide a description, summary, and critical evaluation of works related to the research problem and should also add to the overall knowledge of the topic as well as demonstrating how your research will fit within a larger field of study. A literature review should offer a critical analysis of the current research on a topic and that analysis should direct your research objective. This should not be confused with a book review or an annotated bibliography both research tools but very different in purpose and scope. A Literature Review can be a stand-alone element or part of a larger end product, know your assignment. The key to a good Literature Review is to document your process.

Literature Review LibGuide

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There is SO much more information on the full LibGuide for Literature Reviews Please make sure to click over to that LibGuide for more examples, explanations, and hints.

Elements in a Literature Review

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Process of a Literature Review

The process of writing a literature review is not necessarily a linear process, you will often have to loop back and refine your topic, try new searches and altar your plans. The info graphic above illustrates this process.  It also reminds you to continually keep track of your research by citing sources and creating a bibliography.

• Know what the review is for; each assignment will offer the purpose for the review.  For example, is it for “background”, or a “pro and con discussion”, "integration", “summarizing”, etc.
• Create a “search plan”, decide where you will search for information, what type of information you will need.
• Research   - Preform Searches; choose sources and collect information to use in your paper.  Make sure you cite the sources used.
• Think  - Analyze information in a systematic manner and begin your literature review (e.g., summarize, synthesize, etc.). Make sure you cite the sources used.
• Complete  - Write your paper, proof & revise and create your finished bibliography.

Literature Review Places to Look

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• Learn How to Write a Review of Literature - University of Wisconsin-Madison Writing Center Learn How to Write a Review of Literature - From the University of Wisconsin-Madison Writing Center.
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What is a literature review?

What are Literature Reviews?

Literature reviews examine scholarly literature surrounding a subject-area, topic, or historical event. Literature reviews typically synthesize popular academic arguments, spanning multiple viewpoints. They often explore common trends, themes, and arguments, examining how perceptions of an event have changed over time. However, literature reviews are more than historiographies. Literature reviews should evaluate sources, determining common argumentative flaws. They should also identify knowledge-gaps in the field. You should not make a new argument in your literature review. However, you should evaluate the legitimacy of current sources and arguments. 

An example literature review, from the University of West Florida, is attached below:

How Should I Write My Literature Review? 

• Literature reviews on your subject likely already exist. Before writing your literature review, you should examine pre-existing ones. This process will quickly familiarize you with prominent themes, arguments, and sources in your field.
• Once you are familiar with influential arguments and sources, you should begin organizing your literature review. Literature reviews are organized by ideas, not sources. You should align your sources to popular arguments, evaluating the similarities and differences between these arguments. Ideally, you should examine how the scholarly conversation has changed over time. What aspects of the conversation have become more important? What arguments have fallen out of favor? Why has this happened? 
• The introduction should briefly introduce common themes, and foreshadow your organizational strategy.
• The "body" of your literature review should analyze sources and arguments.
• Finally, the conclusion should identify gaps in the scholarly conversation, and summarize your findings. Where is further research needed?
• Like a research paper, your literature review should include a bibliography. 

For more information on literature reviews, including more tips on writing them, visit the link below:

Literature Review: Conducting & Writing  by the  University of West Florida Library

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COMM 300: Communication Research

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Why Write a Lit review?

• They can help you better understand your topic.
• They demonstrate to your audience that you know what you're talking about.
• They can help you develop new ideas or perspectives.

Guide to Literature Review

• Cook Library's Guide to Literature Reviews

What is a literature review?

A literature review is designed to summarize, synthesize, and discuss the current state of knowledge about a topic. You will survey information related to your research topic ito critically analyze prior research and how it will inform your  research question. A literature review is not an annotated bibliography. 

Organizing your research

Use the research resources page on this guide to find information to support your topic. One strategy to help organize your literature review by theme is to create a synthesis matrix. 

You can download the blank matrix template below to help organize your research.

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A literature review surveys scholarly articles, books and other sources relevant to a particular issue, area of research, or theory, and by so doing, providing a description, summary, and critical evaluation of these works. Literature reviews are designed to provide an overview of sources you have explored while researching a particular topic and to demonstrate to your readers how your research fits into the larger field of study.

All contect is from a Literature Review please refer to the sub-tab under The Literature Review created by Dr. Robert Larabee.

Importance of a Good Literature Review

A literature review may consist of simple a summary of key sources, but it usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

• give a new interpretation of old material or combine new with old interpretations,
• trace the intellectual progression of the field, including major debates,
• depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant, or
• usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

The purpose of a literature review is to:

• Place each work in the context of its contribution to the understanding of the research problem being studied,
• Describe the relationship of each work to the others under consideration,
• Identify new ways to interpret, and shed light on any gaps in previous research,
• Resolve conflicts amongst seemingly contradictory previous studies,
• Identify areas of prior scholarship to prevent duplication of effort,
• Point the way in fulfilling a need for additional research, and
• Locate your own research within the context of existing literature.

All contect is from The Literature Review created by Dr. Robert Larabee.

Types of Literature Reviews

As Kennedy (2007) notes*, it is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the original studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally that become part of the lore of field. In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews.

Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are several approaches to how they can be done, depending upon the type of analysis underpinning your study. Listed below are definitions of types of literature reviews:

Argumentative Review      This form examines literature selectively in order to support or refute an argument, deeply imbedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to to make summary claims of the sort found in systematic reviews.

Integrative Review      Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication.

Historical Review      Few things rest in isolation from historical precedent. Historical reviews are focused on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review      A review does not always focus on what someone said [content], but how they said it [method of analysis]. This approach provides a framework of understanding at different levels (i.e. those of theory, substantive fields, research approaches and data collection and analysis techniques), enables researchers to draw on a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection and data analysis, and helps highlight many ethical issues which we should be aware of and consider as we go through our study.

Systematic Review      This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyse data from the studies that are included in the review. Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?"

Theoretical Review      The purpose of this form is to concretely examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review help establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

* Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following :

• An overview of the subject, issue or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories (e.g. works that support of a particular position, those against, and those offering alternative approaches entirely),
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research

The critical evaluation of each work should consider :

• Provenance -- what are the author's credentials? Are the author's arguments supported by evidence (e.g. primary historical material, case studies, narratives, statistics, recent scientific findings)?
• Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness -- which of the author's theses are most/least convincing?
• Value -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  The Development of the Literature Review

Four stages : 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not very specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources should I include? 2.  What types of sources should I review (books, journal articles, websites)? 3.  Should I summarize, synthesize, or critique your sources by discussing a common theme or issue? 4.  Should I evaluate the sources? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature reviews. Read them to get a sense of the types of themes you might want to look for in your own research or ways to organize your final review. The bibliography or reference section of sources you've already read are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make your job easier if you first limit scope of the research problem. A good strategy is to begin by searching the HOMER catalog for books about the topic and review their contents for chapters that focus on more specific issues. You can also review the subject indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is very common in the sciences where research conducted only two years ago could be obsolete. However, when writing a review in the social sciences, a survey of the history of the literature may be what is needed because what is important is how perspectives have changed over the years or within a certain time period. Try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to consider what is consider by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronological of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression of revealed a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic (“conceptual categories”) Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it will still be organized chronologically reflecting technological developments in media. The only difference here between a "chronological" and a "thematic" approach is what is emphasized the most: the role of the Internet in presidential politics. Note however that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Interbnet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you but include only what is necessary for the reader to locate your study within the larger scholarship framework.

Here are examples of other sections you may need to include depending on the type of review you write:

• Current Situation : information necessary to understand the topic or focus of the literature review.
• History : the chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : the criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed articles and journals.
• Standards : the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Use Quotes Sparingly Some short quotes are okay if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Sometimes you may need to quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute your own summary and interpretation of the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to their own work. Keep Your Own Voice While the literature review presents others' ideas, your voice (the writer's) should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

The most common mistakes made in reviewing social science research literature are that the researcher:

• does not clearly relate the findings of the literature review to the research problem;
• does not take sufficient time to define and identify the most relevent sources to use in the literature review related to the research problem;
• relies exclusively on secondary analytical sources rather than including primary research studies or data;
• uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
• does not describe the search procedures that were used in the literature review;
• reports isolated statistical results rather than sythesizing them in chi-squared or meta-analytic methods; and,
• only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.
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• v.21(3); Fall 2022

Literature Reviews, Theoretical Frameworks, and Conceptual Frameworks: An Introduction for New Biology Education Researchers

Julie a. luft.

† Department of Mathematics, Social Studies, and Science Education, Mary Frances Early College of Education, University of Georgia, Athens, GA 30602-7124

Sophia Jeong

‡ Department of Teaching & Learning, College of Education & Human Ecology, Ohio State University, Columbus, OH 43210

Robert Idsardi

§ Department of Biology, Eastern Washington University, Cheney, WA 99004

Grant Gardner

∥ Department of Biology, Middle Tennessee State University, Murfreesboro, TN 37132

Associated Data

To frame their work, biology education researchers need to consider the role of literature reviews, theoretical frameworks, and conceptual frameworks as critical elements of the research and writing process. However, these elements can be confusing for scholars new to education research. This Research Methods article is designed to provide an overview of each of these elements and delineate the purpose of each in the educational research process. We describe what biology education researchers should consider as they conduct literature reviews, identify theoretical frameworks, and construct conceptual frameworks. Clarifying these different components of educational research studies can be helpful to new biology education researchers and the biology education research community at large in situating their work in the broader scholarly literature.

INTRODUCTION

Discipline-based education research (DBER) involves the purposeful and situated study of teaching and learning in specific disciplinary areas ( Singer et al. , 2012 ). Studies in DBER are guided by research questions that reflect disciplines’ priorities and worldviews. Researchers can use quantitative data, qualitative data, or both to answer these research questions through a variety of methodological traditions. Across all methodologies, there are different methods associated with planning and conducting educational research studies that include the use of surveys, interviews, observations, artifacts, or instruments. Ensuring the coherence of these elements to the discipline’s perspective also involves situating the work in the broader scholarly literature. The tools for doing this include literature reviews, theoretical frameworks, and conceptual frameworks. However, the purpose and function of each of these elements is often confusing to new education researchers. The goal of this article is to introduce new biology education researchers to these three important elements important in DBER scholarship and the broader educational literature.

The first element we discuss is a review of research (literature reviews), which highlights the need for a specific research question, study problem, or topic of investigation. Literature reviews situate the relevance of the study within a topic and a field. The process may seem familiar to science researchers entering DBER fields, but new researchers may still struggle in conducting the review. Booth et al. (2016b) highlight some of the challenges novice education researchers face when conducting a review of literature. They point out that novice researchers struggle in deciding how to focus the review, determining the scope of articles needed in the review, and knowing how to be critical of the articles in the review. Overcoming these challenges (and others) can help novice researchers construct a sound literature review that can inform the design of the study and help ensure the work makes a contribution to the field.

The second and third highlighted elements are theoretical and conceptual frameworks. These guide biology education research (BER) studies, and may be less familiar to science researchers. These elements are important in shaping the construction of new knowledge. Theoretical frameworks offer a way to explain and interpret the studied phenomenon, while conceptual frameworks clarify assumptions about the studied phenomenon. Despite the importance of these constructs in educational research, biology educational researchers have noted the limited use of theoretical or conceptual frameworks in published work ( DeHaan, 2011 ; Dirks, 2011 ; Lo et al. , 2019 ). In reviewing articles published in CBE—Life Sciences Education ( LSE ) between 2015 and 2019, we found that fewer than 25% of the research articles had a theoretical or conceptual framework (see the Supplemental Information), and at times there was an inconsistent use of theoretical and conceptual frameworks. Clearly, these frameworks are challenging for published biology education researchers, which suggests the importance of providing some initial guidance to new biology education researchers.

Fortunately, educational researchers have increased their explicit use of these frameworks over time, and this is influencing educational research in science, technology, engineering, and mathematics (STEM) fields. For instance, a quick search for theoretical or conceptual frameworks in the abstracts of articles in Educational Research Complete (a common database for educational research) in STEM fields demonstrates a dramatic change over the last 20 years: from only 778 articles published between 2000 and 2010 to 5703 articles published between 2010 and 2020, a more than sevenfold increase. Greater recognition of the importance of these frameworks is contributing to DBER authors being more explicit about such frameworks in their studies.

Collectively, literature reviews, theoretical frameworks, and conceptual frameworks work to guide methodological decisions and the elucidation of important findings. Each offers a different perspective on the problem of study and is an essential element in all forms of educational research. As new researchers seek to learn about these elements, they will find different resources, a variety of perspectives, and many suggestions about the construction and use of these elements. The wide range of available information can overwhelm the new researcher who just wants to learn the distinction between these elements or how to craft them adequately.

Our goal in writing this paper is not to offer specific advice about how to write these sections in scholarly work. Instead, we wanted to introduce these elements to those who are new to BER and who are interested in better distinguishing one from the other. In this paper, we share the purpose of each element in BER scholarship, along with important points on its construction. We also provide references for additional resources that may be beneficial to better understanding each element. Table 1 summarizes the key distinctions among these elements.

Comparison of literature reviews, theoretical frameworks, and conceptual reviews

This article is written for the new biology education researcher who is just learning about these different elements or for scientists looking to become more involved in BER. It is a result of our own work as science education and biology education researchers, whether as graduate students and postdoctoral scholars or newly hired and established faculty members. This is the article we wish had been available as we started to learn about these elements or discussed them with new educational researchers in biology.

LITERATURE REVIEWS

Purpose of a literature review.

A literature review is foundational to any research study in education or science. In education, a well-conceptualized and well-executed review provides a summary of the research that has already been done on a specific topic and identifies questions that remain to be answered, thus illustrating the current research project’s potential contribution to the field and the reasoning behind the methodological approach selected for the study ( Maxwell, 2012 ). BER is an evolving disciplinary area that is redefining areas of conceptual emphasis as well as orientations toward teaching and learning (e.g., Labov et al. , 2010 ; American Association for the Advancement of Science, 2011 ; Nehm, 2019 ). As a result, building comprehensive, critical, purposeful, and concise literature reviews can be a challenge for new biology education researchers.

Building Literature Reviews

There are different ways to approach and construct a literature review. Booth et al. (2016a) provide an overview that includes, for example, scoping reviews, which are focused only on notable studies and use a basic method of analysis, and integrative reviews, which are the result of exhaustive literature searches across different genres. Underlying each of these different review processes are attention to the s earch process, a ppraisa l of articles, s ynthesis of the literature, and a nalysis: SALSA ( Booth et al. , 2016a ). This useful acronym can help the researcher focus on the process while building a specific type of review.

However, new educational researchers often have questions about literature reviews that are foundational to SALSA or other approaches. Common questions concern determining which literature pertains to the topic of study or the role of the literature review in the design of the study. This section addresses such questions broadly while providing general guidance for writing a narrative literature review that evaluates the most pertinent studies.

The literature review process should begin before the research is conducted. As Boote and Beile (2005 , p. 3) suggested, researchers should be “scholars before researchers.” They point out that having a good working knowledge of the proposed topic helps illuminate avenues of study. Some subject areas have a deep body of work to read and reflect upon, providing a strong foundation for developing the research question(s). For instance, the teaching and learning of evolution is an area of long-standing interest in the BER community, generating many studies (e.g., Perry et al. , 2008 ; Barnes and Brownell, 2016 ) and reviews of research (e.g., Sickel and Friedrichsen, 2013 ; Ziadie and Andrews, 2018 ). Emerging areas of BER include the affective domain, issues of transfer, and metacognition ( Singer et al. , 2012 ). Many studies in these areas are transdisciplinary and not always specific to biology education (e.g., Rodrigo-Peiris et al. , 2018 ; Kolpikova et al. , 2019 ). These newer areas may require reading outside BER; fortunately, summaries of some of these topics can be found in the Current Insights section of the LSE website.

In focusing on a specific problem within a broader research strand, a new researcher will likely need to examine research outside BER. Depending upon the area of study, the expanded reading list might involve a mix of BER, DBER, and educational research studies. Determining the scope of the reading is not always straightforward. A simple way to focus one’s reading is to create a “summary phrase” or “research nugget,” which is a very brief descriptive statement about the study. It should focus on the essence of the study, for example, “first-year nonmajor students’ understanding of evolution,” “metacognitive prompts to enhance learning during biochemistry,” or “instructors’ inquiry-based instructional practices after professional development programming.” This type of phrase should help a new researcher identify two or more areas to review that pertain to the study. Focusing on recent research in the last 5 years is a good first step. Additional studies can be identified by reading relevant works referenced in those articles. It is also important to read seminal studies that are more than 5 years old. Reading a range of studies should give the researcher the necessary command of the subject in order to suggest a research question.

Given that the research question(s) arise from the literature review, the review should also substantiate the selected methodological approach. The review and research question(s) guide the researcher in determining how to collect and analyze data. Often the methodological approach used in a study is selected to contribute knowledge that expands upon what has been published previously about the topic (see Institute of Education Sciences and National Science Foundation, 2013 ). An emerging topic of study may need an exploratory approach that allows for a description of the phenomenon and development of a potential theory. This could, but not necessarily, require a methodological approach that uses interviews, observations, surveys, or other instruments. An extensively studied topic may call for the additional understanding of specific factors or variables; this type of study would be well suited to a verification or a causal research design. These could entail a methodological approach that uses valid and reliable instruments, observations, or interviews to determine an effect in the studied event. In either of these examples, the researcher(s) may use a qualitative, quantitative, or mixed methods methodological approach.

Even with a good research question, there is still more reading to be done. The complexity and focus of the research question dictates the depth and breadth of the literature to be examined. Questions that connect multiple topics can require broad literature reviews. For instance, a study that explores the impact of a biology faculty learning community on the inquiry instruction of faculty could have the following review areas: learning communities among biology faculty, inquiry instruction among biology faculty, and inquiry instruction among biology faculty as a result of professional learning. Biology education researchers need to consider whether their literature review requires studies from different disciplines within or outside DBER. For the example given, it would be fruitful to look at research focused on learning communities with faculty in STEM fields or in general education fields that result in instructional change. It is important not to be too narrow or too broad when reading. When the conclusions of articles start to sound similar or no new insights are gained, the researcher likely has a good foundation for a literature review. This level of reading should allow the researcher to demonstrate a mastery in understanding the researched topic, explain the suitability of the proposed research approach, and point to the need for the refined research question(s).

The literature review should include the researcher’s evaluation and critique of the selected studies. A researcher may have a large collection of studies, but not all of the studies will follow standards important in the reporting of empirical work in the social sciences. The American Educational Research Association ( Duran et al. , 2006 ), for example, offers a general discussion about standards for such work: an adequate review of research informing the study, the existence of sound and appropriate data collection and analysis methods, and appropriate conclusions that do not overstep or underexplore the analyzed data. The Institute of Education Sciences and National Science Foundation (2013) also offer Common Guidelines for Education Research and Development that can be used to evaluate collected studies.

Because not all journals adhere to such standards, it is important that a researcher review each study to determine the quality of published research, per the guidelines suggested earlier. In some instances, the research may be fatally flawed. Examples of such flaws include data that do not pertain to the question, a lack of discussion about the data collection, poorly constructed instruments, or an inadequate analysis. These types of errors result in studies that are incomplete, error-laden, or inaccurate and should be excluded from the review. Most studies have limitations, and the author(s) often make them explicit. For instance, there may be an instructor effect, recognized bias in the analysis, or issues with the sample population. Limitations are usually addressed by the research team in some way to ensure a sound and acceptable research process. Occasionally, the limitations associated with the study can be significant and not addressed adequately, which leaves a consequential decision in the hands of the researcher. Providing critiques of studies in the literature review process gives the reader confidence that the researcher has carefully examined relevant work in preparation for the study and, ultimately, the manuscript.

A solid literature review clearly anchors the proposed study in the field and connects the research question(s), the methodological approach, and the discussion. Reviewing extant research leads to research questions that will contribute to what is known in the field. By summarizing what is known, the literature review points to what needs to be known, which in turn guides decisions about methodology. Finally, notable findings of the new study are discussed in reference to those described in the literature review.

Within published BER studies, literature reviews can be placed in different locations in an article. When included in the introductory section of the study, the first few paragraphs of the manuscript set the stage, with the literature review following the opening paragraphs. Cooper et al. (2019) illustrate this approach in their study of course-based undergraduate research experiences (CUREs). An introduction discussing the potential of CURES is followed by an analysis of the existing literature relevant to the design of CUREs that allows for novel student discoveries. Within this review, the authors point out contradictory findings among research on novel student discoveries. This clarifies the need for their study, which is described and highlighted through specific research aims.

A literature reviews can also make up a separate section in a paper. For example, the introduction to Todd et al. (2019) illustrates the need for their research topic by highlighting the potential of learning progressions (LPs) and suggesting that LPs may help mitigate learning loss in genetics. At the end of the introduction, the authors state their specific research questions. The review of literature following this opening section comprises two subsections. One focuses on learning loss in general and examines a variety of studies and meta-analyses from the disciplines of medical education, mathematics, and reading. The second section focuses specifically on LPs in genetics and highlights student learning in the midst of LPs. These separate reviews provide insights into the stated research question.

Suggestions and Advice

A well-conceptualized, comprehensive, and critical literature review reveals the understanding of the topic that the researcher brings to the study. Literature reviews should not be so big that there is no clear area of focus; nor should they be so narrow that no real research question arises. The task for a researcher is to craft an efficient literature review that offers a critical analysis of published work, articulates the need for the study, guides the methodological approach to the topic of study, and provides an adequate foundation for the discussion of the findings.

In our own writing of literature reviews, there are often many drafts. An early draft may seem well suited to the study because the need for and approach to the study are well described. However, as the results of the study are analyzed and findings begin to emerge, the existing literature review may be inadequate and need revision. The need for an expanded discussion about the research area can result in the inclusion of new studies that support the explanation of a potential finding. The literature review may also prove to be too broad. Refocusing on a specific area allows for more contemplation of a finding.

It should be noted that there are different types of literature reviews, and many books and articles have been written about the different ways to embark on these types of reviews. Among these different resources, the following may be helpful in considering how to refine the review process for scholarly journals:

• Booth, A., Sutton, A., & Papaioannou, D. (2016a). Systemic approaches to a successful literature review (2nd ed.). Los Angeles, CA: Sage. This book addresses different types of literature reviews and offers important suggestions pertaining to defining the scope of the literature review and assessing extant studies.
• Booth, W. C., Colomb, G. G., Williams, J. M., Bizup, J., & Fitzgerald, W. T. (2016b). The craft of research (4th ed.). Chicago: University of Chicago Press. This book can help the novice consider how to make the case for an area of study. While this book is not specifically about literature reviews, it offers suggestions about making the case for your study.
• Galvan, J. L., & Galvan, M. C. (2017). Writing literature reviews: A guide for students of the social and behavioral sciences (7th ed.). Routledge. This book offers guidance on writing different types of literature reviews. For the novice researcher, there are useful suggestions for creating coherent literature reviews.

THEORETICAL FRAMEWORKS

Purpose of theoretical frameworks.

As new education researchers may be less familiar with theoretical frameworks than with literature reviews, this discussion begins with an analogy. Envision a biologist, chemist, and physicist examining together the dramatic effect of a fog tsunami over the ocean. A biologist gazing at this phenomenon may be concerned with the effect of fog on various species. A chemist may be interested in the chemical composition of the fog as water vapor condenses around bits of salt. A physicist may be focused on the refraction of light to make fog appear to be “sitting” above the ocean. While observing the same “objective event,” the scientists are operating under different theoretical frameworks that provide a particular perspective or “lens” for the interpretation of the phenomenon. Each of these scientists brings specialized knowledge, experiences, and values to this phenomenon, and these influence the interpretation of the phenomenon. The scientists’ theoretical frameworks influence how they design and carry out their studies and interpret their data.

Within an educational study, a theoretical framework helps to explain a phenomenon through a particular lens and challenges and extends existing knowledge within the limitations of that lens. Theoretical frameworks are explicitly stated by an educational researcher in the paper’s framework, theory, or relevant literature section. The framework shapes the types of questions asked, guides the method by which data are collected and analyzed, and informs the discussion of the results of the study. It also reveals the researcher’s subjectivities, for example, values, social experience, and viewpoint ( Allen, 2017 ). It is essential that a novice researcher learn to explicitly state a theoretical framework, because all research questions are being asked from the researcher’s implicit or explicit assumptions of a phenomenon of interest ( Schwandt, 2000 ).

Selecting Theoretical Frameworks

Theoretical frameworks are one of the most contemplated elements in our work in educational research. In this section, we share three important considerations for new scholars selecting a theoretical framework.

The first step in identifying a theoretical framework involves reflecting on the phenomenon within the study and the assumptions aligned with the phenomenon. The phenomenon involves the studied event. There are many possibilities, for example, student learning, instructional approach, or group organization. A researcher holds assumptions about how the phenomenon will be effected, influenced, changed, or portrayed. It is ultimately the researcher’s assumption(s) about the phenomenon that aligns with a theoretical framework. An example can help illustrate how a researcher’s reflection on the phenomenon and acknowledgment of assumptions can result in the identification of a theoretical framework.

In our example, a biology education researcher may be interested in exploring how students’ learning of difficult biological concepts can be supported by the interactions of group members. The phenomenon of interest is the interactions among the peers, and the researcher assumes that more knowledgeable students are important in supporting the learning of the group. As a result, the researcher may draw on Vygotsky’s (1978) sociocultural theory of learning and development that is focused on the phenomenon of student learning in a social setting. This theory posits the critical nature of interactions among students and between students and teachers in the process of building knowledge. A researcher drawing upon this framework holds the assumption that learning is a dynamic social process involving questions and explanations among students in the classroom and that more knowledgeable peers play an important part in the process of building conceptual knowledge.

It is important to state at this point that there are many different theoretical frameworks. Some frameworks focus on learning and knowing, while other theoretical frameworks focus on equity, empowerment, or discourse. Some frameworks are well articulated, and others are still being refined. For a new researcher, it can be challenging to find a theoretical framework. Two of the best ways to look for theoretical frameworks is through published works that highlight different frameworks.

When a theoretical framework is selected, it should clearly connect to all parts of the study. The framework should augment the study by adding a perspective that provides greater insights into the phenomenon. It should clearly align with the studies described in the literature review. For instance, a framework focused on learning would correspond to research that reported different learning outcomes for similar studies. The methods for data collection and analysis should also correspond to the framework. For instance, a study about instructional interventions could use a theoretical framework concerned with learning and could collect data about the effect of the intervention on what is learned. When the data are analyzed, the theoretical framework should provide added meaning to the findings, and the findings should align with the theoretical framework.

A study by Jensen and Lawson (2011) provides an example of how a theoretical framework connects different parts of the study. They compared undergraduate biology students in heterogeneous and homogeneous groups over the course of a semester. Jensen and Lawson (2011) assumed that learning involved collaboration and more knowledgeable peers, which made Vygotsky’s (1978) theory a good fit for their study. They predicted that students in heterogeneous groups would experience greater improvement in their reasoning abilities and science achievements with much of the learning guided by the more knowledgeable peers.

In the enactment of the study, they collected data about the instruction in traditional and inquiry-oriented classes, while the students worked in homogeneous or heterogeneous groups. To determine the effect of working in groups, the authors also measured students’ reasoning abilities and achievement. Each data-collection and analysis decision connected to understanding the influence of collaborative work.

Their findings highlighted aspects of Vygotsky’s (1978) theory of learning. One finding, for instance, posited that inquiry instruction, as a whole, resulted in reasoning and achievement gains. This links to Vygotsky (1978) , because inquiry instruction involves interactions among group members. A more nuanced finding was that group composition had a conditional effect. Heterogeneous groups performed better with more traditional and didactic instruction, regardless of the reasoning ability of the group members. Homogeneous groups worked better during interaction-rich activities for students with low reasoning ability. The authors attributed the variation to the different types of helping behaviors of students. High-performing students provided the answers, while students with low reasoning ability had to work collectively through the material. In terms of Vygotsky (1978) , this finding provided new insights into the learning context in which productive interactions can occur for students.

Another consideration in the selection and use of a theoretical framework pertains to its orientation to the study. This can result in the theoretical framework prioritizing individuals, institutions, and/or policies ( Anfara and Mertz, 2014 ). Frameworks that connect to individuals, for instance, could contribute to understanding their actions, learning, or knowledge. Institutional frameworks, on the other hand, offer insights into how institutions, organizations, or groups can influence individuals or materials. Policy theories provide ways to understand how national or local policies can dictate an emphasis on outcomes or instructional design. These different types of frameworks highlight different aspects in an educational setting, which influences the design of the study and the collection of data. In addition, these different frameworks offer a way to make sense of the data. Aligning the data collection and analysis with the framework ensures that a study is coherent and can contribute to the field.

New understandings emerge when different theoretical frameworks are used. For instance, Ebert-May et al. (2015) prioritized the individual level within conceptual change theory (see Posner et al. , 1982 ). In this theory, an individual’s knowledge changes when it no longer fits the phenomenon. Ebert-May et al. (2015) designed a professional development program challenging biology postdoctoral scholars’ existing conceptions of teaching. The authors reported that the biology postdoctoral scholars’ teaching practices became more student-centered as they were challenged to explain their instructional decision making. According to the theory, the biology postdoctoral scholars’ dissatisfaction in their descriptions of teaching and learning initiated change in their knowledge and instruction. These results reveal how conceptual change theory can explain the learning of participants and guide the design of professional development programming.

The communities of practice (CoP) theoretical framework ( Lave, 1988 ; Wenger, 1998 ) prioritizes the institutional level , suggesting that learning occurs when individuals learn from and contribute to the communities in which they reside. Grounded in the assumption of community learning, the literature on CoP suggests that, as individuals interact regularly with the other members of their group, they learn about the rules, roles, and goals of the community ( Allee, 2000 ). A study conducted by Gehrke and Kezar (2017) used the CoP framework to understand organizational change by examining the involvement of individual faculty engaged in a cross-institutional CoP focused on changing the instructional practice of faculty at each institution. In the CoP, faculty members were involved in enhancing instructional materials within their department, which aligned with an overarching goal of instituting instruction that embraced active learning. Not surprisingly, Gehrke and Kezar (2017) revealed that faculty who perceived the community culture as important in their work cultivated institutional change. Furthermore, they found that institutional change was sustained when key leaders served as mentors and provided support for faculty, and as faculty themselves developed into leaders. This study reveals the complexity of individual roles in a COP in order to support institutional instructional change.

It is important to explicitly state the theoretical framework used in a study, but elucidating a theoretical framework can be challenging for a new educational researcher. The literature review can help to identify an applicable theoretical framework. Focal areas of the review or central terms often connect to assumptions and assertions associated with the framework that pertain to the phenomenon of interest. Another way to identify a theoretical framework is self-reflection by the researcher on personal beliefs and understandings about the nature of knowledge the researcher brings to the study ( Lysaght, 2011 ). In stating one’s beliefs and understandings related to the study (e.g., students construct their knowledge, instructional materials support learning), an orientation becomes evident that will suggest a particular theoretical framework. Theoretical frameworks are not arbitrary , but purposefully selected.

With experience, a researcher may find expanded roles for theoretical frameworks. Researchers may revise an existing framework that has limited explanatory power, or they may decide there is a need to develop a new theoretical framework. These frameworks can emerge from a current study or the need to explain a phenomenon in a new way. Researchers may also find that multiple theoretical frameworks are necessary to frame and explore a problem, as different frameworks can provide different insights into a problem.

Finally, it is important to recognize that choosing “x” theoretical framework does not necessarily mean a researcher chooses “y” methodology and so on, nor is there a clear-cut, linear process in selecting a theoretical framework for one’s study. In part, the nonlinear process of identifying a theoretical framework is what makes understanding and using theoretical frameworks challenging. For the novice scholar, contemplating and understanding theoretical frameworks is essential. Fortunately, there are articles and books that can help:

• Creswell, J. W. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). Los Angeles, CA: Sage. This book provides an overview of theoretical frameworks in general educational research.
• Ding, L. (2019). Theoretical perspectives of quantitative physics education research. Physical Review Physics Education Research , 15 (2), 020101-1–020101-13. This paper illustrates how a DBER field can use theoretical frameworks.
• Nehm, R. (2019). Biology education research: Building integrative frameworks for teaching and learning about living systems. Disciplinary and Interdisciplinary Science Education Research , 1 , ar15. https://doi.org/10.1186/s43031-019-0017-6 . This paper articulates the need for studies in BER to explicitly state theoretical frameworks and provides examples of potential studies.
• Patton, M. Q. (2015). Qualitative research & evaluation methods: Integrating theory and practice . Sage. This book also provides an overview of theoretical frameworks, but for both research and evaluation.

CONCEPTUAL FRAMEWORKS

Purpose of a conceptual framework.

A conceptual framework is a description of the way a researcher understands the factors and/or variables that are involved in the study and their relationships to one another. The purpose of a conceptual framework is to articulate the concepts under study using relevant literature ( Rocco and Plakhotnik, 2009 ) and to clarify the presumed relationships among those concepts ( Rocco and Plakhotnik, 2009 ; Anfara and Mertz, 2014 ). Conceptual frameworks are different from theoretical frameworks in both their breadth and grounding in established findings. Whereas a theoretical framework articulates the lens through which a researcher views the work, the conceptual framework is often more mechanistic and malleable.

Conceptual frameworks are broader, encompassing both established theories (i.e., theoretical frameworks) and the researchers’ own emergent ideas. Emergent ideas, for example, may be rooted in informal and/or unpublished observations from experience. These emergent ideas would not be considered a “theory” if they are not yet tested, supported by systematically collected evidence, and peer reviewed. However, they do still play an important role in the way researchers approach their studies. The conceptual framework allows authors to clearly describe their emergent ideas so that connections among ideas in the study and the significance of the study are apparent to readers.

Constructing Conceptual Frameworks

Including a conceptual framework in a research study is important, but researchers often opt to include either a conceptual or a theoretical framework. Either may be adequate, but both provide greater insight into the research approach. For instance, a research team plans to test a novel component of an existing theory. In their study, they describe the existing theoretical framework that informs their work and then present their own conceptual framework. Within this conceptual framework, specific topics portray emergent ideas that are related to the theory. Describing both frameworks allows readers to better understand the researchers’ assumptions, orientations, and understanding of concepts being investigated. For example, Connolly et al. (2018) included a conceptual framework that described how they applied a theoretical framework of social cognitive career theory (SCCT) to their study on teaching programs for doctoral students. In their conceptual framework, the authors described SCCT, explained how it applied to the investigation, and drew upon results from previous studies to justify the proposed connections between the theory and their emergent ideas.

In some cases, authors may be able to sufficiently describe their conceptualization of the phenomenon under study in an introduction alone, without a separate conceptual framework section. However, incomplete descriptions of how the researchers conceptualize the components of the study may limit the significance of the study by making the research less intelligible to readers. This is especially problematic when studying topics in which researchers use the same terms for different constructs or different terms for similar and overlapping constructs (e.g., inquiry, teacher beliefs, pedagogical content knowledge, or active learning). Authors must describe their conceptualization of a construct if the research is to be understandable and useful.

There are some key areas to consider regarding the inclusion of a conceptual framework in a study. To begin with, it is important to recognize that conceptual frameworks are constructed by the researchers conducting the study ( Rocco and Plakhotnik, 2009 ; Maxwell, 2012 ). This is different from theoretical frameworks that are often taken from established literature. Researchers should bring together ideas from the literature, but they may be influenced by their own experiences as a student and/or instructor, the shared experiences of others, or thought experiments as they construct a description, model, or representation of their understanding of the phenomenon under study. This is an exercise in intellectual organization and clarity that often considers what is learned, known, and experienced. The conceptual framework makes these constructs explicitly visible to readers, who may have different understandings of the phenomenon based on their prior knowledge and experience. There is no single method to go about this intellectual work.

Reeves et al. (2016) is an example of an article that proposed a conceptual framework about graduate teaching assistant professional development evaluation and research. The authors used existing literature to create a novel framework that filled a gap in current research and practice related to the training of graduate teaching assistants. This conceptual framework can guide the systematic collection of data by other researchers because the framework describes the relationships among various factors that influence teaching and learning. The Reeves et al. (2016) conceptual framework may be modified as additional data are collected and analyzed by other researchers. This is not uncommon, as conceptual frameworks can serve as catalysts for concerted research efforts that systematically explore a phenomenon (e.g., Reynolds et al. , 2012 ; Brownell and Kloser, 2015 ).

Sabel et al. (2017) used a conceptual framework in their exploration of how scaffolds, an external factor, interact with internal factors to support student learning. Their conceptual framework integrated principles from two theoretical frameworks, self-regulated learning and metacognition, to illustrate how the research team conceptualized students’ use of scaffolds in their learning ( Figure 1 ). Sabel et al. (2017) created this model using their interpretations of these two frameworks in the context of their teaching.

Conceptual framework from Sabel et al. (2017) .

A conceptual framework should describe the relationship among components of the investigation ( Anfara and Mertz, 2014 ). These relationships should guide the researcher’s methods of approaching the study ( Miles et al. , 2014 ) and inform both the data to be collected and how those data should be analyzed. Explicitly describing the connections among the ideas allows the researcher to justify the importance of the study and the rigor of the research design. Just as importantly, these frameworks help readers understand why certain components of a system were not explored in the study. This is a challenge in education research, which is rooted in complex environments with many variables that are difficult to control.

For example, Sabel et al. (2017) stated: “Scaffolds, such as enhanced answer keys and reflection questions, can help students and instructors bridge the external and internal factors and support learning” (p. 3). They connected the scaffolds in the study to the three dimensions of metacognition and the eventual transformation of existing ideas into new or revised ideas. Their framework provides a rationale for focusing on how students use two different scaffolds, and not on other factors that may influence a student’s success (self-efficacy, use of active learning, exam format, etc.).

In constructing conceptual frameworks, researchers should address needed areas of study and/or contradictions discovered in literature reviews. By attending to these areas, researchers can strengthen their arguments for the importance of a study. For instance, conceptual frameworks can address how the current study will fill gaps in the research, resolve contradictions in existing literature, or suggest a new area of study. While a literature review describes what is known and not known about the phenomenon, the conceptual framework leverages these gaps in describing the current study ( Maxwell, 2012 ). In the example of Sabel et al. (2017) , the authors indicated there was a gap in the literature regarding how scaffolds engage students in metacognition to promote learning in large classes. Their study helps fill that gap by describing how scaffolds can support students in the three dimensions of metacognition: intelligibility, plausibility, and wide applicability. In another example, Lane (2016) integrated research from science identity, the ethic of care, the sense of belonging, and an expertise model of student success to form a conceptual framework that addressed the critiques of other frameworks. In a more recent example, Sbeglia et al. (2021) illustrated how a conceptual framework influences the methodological choices and inferences in studies by educational researchers.

Sometimes researchers draw upon the conceptual frameworks of other researchers. When a researcher’s conceptual framework closely aligns with an existing framework, the discussion may be brief. For example, Ghee et al. (2016) referred to portions of SCCT as their conceptual framework to explain the significance of their work on students’ self-efficacy and career interests. Because the authors’ conceptualization of this phenomenon aligned with a previously described framework, they briefly mentioned the conceptual framework and provided additional citations that provided more detail for the readers.

Within both the BER and the broader DBER communities, conceptual frameworks have been used to describe different constructs. For example, some researchers have used the term “conceptual framework” to describe students’ conceptual understandings of a biological phenomenon. This is distinct from a researcher’s conceptual framework of the educational phenomenon under investigation, which may also need to be explicitly described in the article. Other studies have presented a research logic model or flowchart of the research design as a conceptual framework. These constructions can be quite valuable in helping readers understand the data-collection and analysis process. However, a model depicting the study design does not serve the same role as a conceptual framework. Researchers need to avoid conflating these constructs by differentiating the researchers’ conceptual framework that guides the study from the research design, when applicable.

Explicitly describing conceptual frameworks is essential in depicting the focus of the study. We have found that being explicit in a conceptual framework means using accepted terminology, referencing prior work, and clearly noting connections between terms. This description can also highlight gaps in the literature or suggest potential contributions to the field of study. A well-elucidated conceptual framework can suggest additional studies that may be warranted. This can also spur other researchers to consider how they would approach the examination of a phenomenon and could result in a revised conceptual framework.

It can be challenging to create conceptual frameworks, but they are important. Below are two resources that could be helpful in constructing and presenting conceptual frameworks in educational research:

• Maxwell, J. A. (2012). Qualitative research design: An interactive approach (3rd ed.). Los Angeles, CA: Sage. Chapter 3 in this book describes how to construct conceptual frameworks.
• Ravitch, S. M., & Riggan, M. (2016). Reason & rigor: How conceptual frameworks guide research . Los Angeles, CA: Sage. This book explains how conceptual frameworks guide the research questions, data collection, data analyses, and interpretation of results.

CONCLUDING THOUGHTS

Literature reviews, theoretical frameworks, and conceptual frameworks are all important in DBER and BER. Robust literature reviews reinforce the importance of a study. Theoretical frameworks connect the study to the base of knowledge in educational theory and specify the researcher’s assumptions. Conceptual frameworks allow researchers to explicitly describe their conceptualization of the relationships among the components of the phenomenon under study. Table 1 provides a general overview of these components in order to assist biology education researchers in thinking about these elements.

It is important to emphasize that these different elements are intertwined. When these elements are aligned and complement one another, the study is coherent, and the study findings contribute to knowledge in the field. When literature reviews, theoretical frameworks, and conceptual frameworks are disconnected from one another, the study suffers. The point of the study is lost, suggested findings are unsupported, or important conclusions are invisible to the researcher. In addition, this misalignment may be costly in terms of time and money.

Conducting a literature review, selecting a theoretical framework, and building a conceptual framework are some of the most difficult elements of a research study. It takes time to understand the relevant research, identify a theoretical framework that provides important insights into the study, and formulate a conceptual framework that organizes the finding. In the research process, there is often a constant back and forth among these elements as the study evolves. With an ongoing refinement of the review of literature, clarification of the theoretical framework, and articulation of a conceptual framework, a sound study can emerge that makes a contribution to the field. This is the goal of BER and education research.

Supplementary Material

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• Open access
• Published: 27 September 2024

Narrative Medicine: theory, clinical practice and education - a scoping review

• Ilaria Palla 1 ,
• Giuseppe Turchetti 1 &
• Stefania Polvani 2 , 3  

BMC Health Services Research volume  24 , Article number:  1116 ( 2024 ) Cite this article

Metrics details

The origin of Narrative Medicine dates back to more than 20 years ago at an international level. Narrative Medicine is not an alternative to evidence-based medicine, however these two approaches are integrated. Narrative Medicine is a methodology based on specific communication skills where storytelling is a fundamental tool to acquire, understand and integrate several points of view related to persons involving in the disease and in the healthcare process. Narrative Medicine, henceforth NM, represents a union between disease and illness between the doctor’s clinical knowledge and the patient’s experience. According to Byron Good, “we cannot have direct access to the experience of others’ illness , not even through in-depth investigations: one of the ways in which we can learn more from the experience of others is to listen to the stories of what has happened to other people.” Several studies have been published on NM; however, to the best of our knowledge, no scoping review of the literature has been performed.

This paper aims to map and synthetize studies on NM according to theory, clinical practice and education/training.

The scoping review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist. A search was conducted in PubMed, APA PsycNet and Jstor. Two authors independently assessed the eligibility and methodological quality of the studies and extracted the data. This review refers to the period from 1998 to 2022.

A total of 843 abstracts were identified of which 274 papers were selected based on the title/abstract. A total of 152 papers in full text were evaluated and 76 were included in the review. Papers were classified according to three issues:

✘ Nineteen studies focused on the definition and concept of NM (Theoretical).

✘ Thirty-eight papers focused on the collection of stories, projects and case reports (Clinical practice).

✘ Nineteen papers focused on the implementation of the Narrative Medicine approach in the education and training of medical doctors (Education and training).

Conclusions

This scoping review presents an overview of the state of the art of the Narrative Medicine. It collect studies performed mainly in Italy and in the United States as these are the countries developing the Narrative Medicine approach in three identified areas, theoretical, clinical practice and education and training. This scoping review will help to promote the power of Narrative Medicine in all three areas supporting the development of methods to evaluate and to measure the Narrative Medicine approach using key performance indicators.

Peer Review reports

Introduction

The role and involvement of patients in healthcare have changed, as has their relationship with healthcare professionals. The patient is no longer a passive subject but part of the healthcare process. Over the years, many approaches to patients’ involvement in healthcare have been developed in the literature, with significant differences in terms of concept and significance.

NM represents a focus on the patient’s needs and the empowerment of their active participation in the healthcare process.

Narrative Medicine enables patients to share their stories with healthcare professionals so that the latter can gain the necessary skills to recognize, interpret and relate to patients [ 1 ]. Stories of illness have an important impact on patients and their caregivers, healthcare professionals and organisational systems [ 2 ].

Trisha Greenhalgh, an academic in primary healthcare who trained as a General Practitioner, and Brian Hurwitz, an Emeritus Professor of Medicine and The Arts at King’s College (London) [ 3 , 4 ], affirmed that the core clinical skills in terms of listening, questioning, outlining, collecting, explaining and interpreting can provide a way of navigating among the very different worlds of patients and health professionals. These tasks need to be performed well because they can affect disease outcomes from the patient’s perspective and the scientific aspects of diagnosis and treatment.

In 2013, Rita Charon, a general internist and professor at Columbia University (New York), and Brian Hurwitz promoted “a narrative future for healthcare” , the first global conference on Narrative Based Medicine (NBM). The global conference took place in London in June 2013, where experts in humanities, social sciences and professionals interested in shaping a narrative future for healthcare discussed several topics, such as increasing the visibility of narrative-based concepts and methods; developing strategies that can influence traditional clinical institutions; spreading appreciation for the role of creativity in caring for the sick; articulating the risks of narrative practices in health care; providing a space for Narrative Medicine in the context of other fields, including personalized medicine; and sharing goals for training, research, and clinical care. The conference was the first important opportunity to share different points of view and perspectives at the global level involving several stakeholders with different backgrounds [ 5 ].

In the early 2000s, the first Italian experience of Narrative Medicine occurred in Florence with NaMe, a project endorsed by the Local Health Authority aimed at diffusing the culture of patient-centered medicine and integrating strategies to improve doctor‒patient communication in clinical practice [ 6 ]. This project was inspired by the articles of Hurwitz and Greenhalgh [ 3 , 4 ]. In addition, significant input was derived from Arthur Kleinman [ 7 ] and Byron Good [ 8 ], psychiatrists and anthropologists who studied medicine as a cultural system, as a set of symbolic meanings involving the story of the sick person. Health and illness represent the subjective experience of the person.

Kleinmann [ 7 ] defines three dimensions to explain the illness using three different significances:

✘ Disease: “only as an alteration in biological structure or functioning” .

✘ Illness: the subjective experience of suffering and discomfort.

✘ Sickness: the social representation.

Narrative Medicine can be used in several areas such as prevention, diagnosis, treatment, and rehabilitation; adherence to treatment; organization of the care team; awareness of the professional role and the emotional world by health and social workers; prevention of the burnout of professionals and caregivers; promotion and implementation of Patient Care Pathways (PCPs); and prevention of legal disputes and defensive medicine.

The Italian guidelines established by the National Institute of Health in 2015 [ 9 ] represent a fundamental step in the process of diffusion and implementation of Narrative Medicine in Italy and currently represents the only document. The guidelines define Narrative Medicine as an intervention methodology based on specific communication skills. Storytelling is a fundamental instrument for acquiring, understanding and integrating the different perspectives of those involved in the disease and in the healthcare process. Storytelling represents a moment of contact between a healthcare professional and the patient’s world. The story told involves people, those who narrate and those who listen. Telling stories is a way of transferring knowledge and experience, connecting, reflecting and feeling emotions.

In the last few years, several studies have been carried out with different objectives and perspectives, but no literature review on Medicine Narrative has been performed. We founded the study of Rui et al. [ 10 ] performing a bibliometric analysis of the literature on medical narratives published from 2011 to 2021 showing that the field of narrative medicine is dominated by a few countries. Respect to 736 studies included in the review, 48% (369) are performed in US and 98 papers in Italy.

The objective of scoping review was to map and synthetize studies on NM according to theory, clinical practice and education/training, three settings where NM was developed.

The research questions formulated: (1) What is Narrative Medicine?; (2) How is Narrative Medicine implemented in clinical practice?; (3) What is the role of Narrative Medicine in education and training for medical doctors?

The study protocol follows the PRISMA-ScR checklist (PRISMA extension for Scoping Reviews) but it is not registered (Additional file 1).

We included peer-reviewed papers published from 1998 to December 2022 written in Italian or in English. We excluded papers written in other languages. We included articles according to one of these issues: studies on theory of Narrative Medicine, on clinical practice or education/training of Narrative Medicine. We excluded books, case reports, reviews. To identify potentially relevant studies, the following databases were searched from 1998 to December 2022: PubMed, APA PsycNet and Jstor. The search strategy can be founded in Additional file 2. A data charting form was developed by two reviewers to define which variables can be extracted. The reviewers independently charted the data and discussed the results. We grouped the studies by type of application related to the Narrative Medicine and summarized objective, methods and reflections/conclusions. The scoping review maps the evidence on Narrative Medicine according one of the three fields of diffusion and implementation (Fig.  1 ). Furthermore, the studies classified in “theoretical field “are grouped in subcategories to explain in best way the concepts and permit a clearer and more streamlined reading.

Categories of Narrative Medicine

Review process

After removing duplicates, 843 abstracts from PubMed, Jstor and APA PsycNet were screened. A total of 274 papers were screened based on the abstracts, of which 122 were excluded. A total of 152 full texts were evaluated, and 76 were included in the review (Fig.  2 ).

PRISMA Flow-chart

The studies included were classified into the three fields where the Narrative Medicine is implemented:

✘ Theoretical studies: 19.

✘ Clinical Practice: 38.

✘ Education and training: 19.

The scoping review did not present the results of papers included but the main objectives and the methods used as the aim of the scoping review was to map the studies performed in terms of theory, clinical practice and education/training. We have tried to organize the studies published so far, making it increasingly clear how Narrative Medicine has developed.

Theoretical studies

This section presents the 19 selected theoretical studies grouped into subcategories (Additional file 3).

Narrative Medicine: advantages

In this section, we present seven papers that highlight the benefits of narrative medicine.

Of the seven papers considered, four were performed by Rita Charon emphasizing the value of Narrative Medicine in four different contexts. In the first [ 11 ], the study by Goupy et al. evaluated a Narrative Medicine elective course at the Paris-Descartes School of Medicine. In the second [ 12 ], Charon rewrote a patient’s family illness to demonstrate how medicine that respects the narrative dimension of illness and care can improve the care of individual patients, their colleagues and effective medical practice. The third paper [ 13 ] describes a visit to the Rothko Room at the Tate Modern in London as a pretext to emphasize how for narrative medicine, creativity is at the heart of health care and that the care of the sick is a work of art.

In the fourth [ 14 ], Charon provides the elements of narrative theory through a careful reading of the form and content of an excerpt from a medical record. This is part of an audio-recorded interview with a medical student and a reflection on a short section of a modernist novel to show how to determine the significance of patients’ situations.

According to Abettan [ 15 ], Narrative Medicine can play a key role in the reform of current medical practice, although to date, there has been little focus on how and why it can deliver results and be cost-effective.

Cenci [ 16 ] underlines that the existential objective of the patient is fundamental to know the person’s life project and how they would like to live their future years.

Zaharias [ 17 ], whose main sources are Charon and Launer, has published three articles on NM as a valid approach that, if practiced more widely by general practitioners, could significantly benefit both patients and doctors. If the patient’s condition is central, the NM shifts the doctor’s focus from the need to solve the problem to the need to understand. Consequently, the patient‒physician relationship is strengthened, and patients’ needs and concerns are addressed more effectively and with better results.

Narrative Medicine: the role of digital technologies

This section includes 3 papers on the role of digital technologies in Narrative Medicine. Digital narrative medicine is diffusing in care relationship as presents an opportunity for the patient and the clinician. The patient has more time to reflect on his/her needs and communicate in best way with the healthcare professionals. The clinician can access to more information as quantitative and qualitative information and data provided by the patient. These information represent an instrument for the clinician to personalize the care and respond to patient’s unmet needs.

The use of digital technologies, particularly the digital health storymap tool described by Cenci [ 16 ], for obtaining a multidisciplinary understanding of the patient’s medical history facilitates communication between the patient and caregiver. According to Charon [ 18 ], the relentless specialization and technologization of medicine damages the therapeutic importance of recognizing the context of patients’ lives and witnessing their suffering.

Rosti [ 19 ] affirms that e-health technologies will build new bridges and permit professionals to have more time to use narrative techniques with patients.

The increased use of digital technologies could reduce the opportunity for narrative contact but provide a starting point for discussion through the use of electronically transmitted patient pain diaries.

Narrative Medicine: integration with evidence-based medicine

Greenhalgh’s [ 20 ] and Rosti’s [ 19 ] studies address one of the most significant issues, the integration of Narrative Medicine with Evidence Based Medicine. Narrative Medicine is not an alternative to Evidence Based Medicine, they coexist and can complement each other in clinical practice.

Greenhalgh’s work [ 20 ] clearly shows how NM and EBM can be integrated. EBM requires an interpretative paradigm in which the patient experiences the disease in a unique and contextual way and the clinician can draw on all aspects of the evidence and thus arrive at an integrated clinical judgement.

Rosti [ 19 ] believes that even “evidence-based” physicians sustain the importance of competence and clinical judgement. Clinicians also need to rely on patients’ narratives to integrate more objective clinical results. Clinical methods are not without their limitations, which Narrative Medicine can help to overcome. Lederman [ 21 ] enphatises the importance of social sciences to analyze the stories and to improve the care.

Narrative-based Medicine: insidious

Three papers in this section focus on the possible risks of the Narrative Medicine approach. It is needing a more awareness on role of Narrative Medicine as a robust methodology.

The study by Kalitzus [ 22 ] shows how a narrative approach in medicine will be successful only if it has a positive effect on daily clinical practice instead of merely increasing existing problems.

Complex narratives on diseases published in biographies or collected by social scientists are useful only for training and research purposes. NM requires time and effort and cannot be considered the only important issue in medicine. According to Abettan [ 15 ], Narrative Medicine can make the treatment more personalised for each patient, but it is not the only way.

Zaharias [ 17 ] affirms that Narrative Medicine is often described simplistically as listening to the patient’s story, whereas it is much more common and requires special communication skills. Perhaps for these reasons, and despite its advantages, NM is not as widely practiced as it could be. Narrative skills are an integral part of practice and learning them takes time. As the author also states, “the healing power of storytelling is repeatedly attested to while evidence of effectiveness is scarce”. Lanphier [ 23 ] underlines the need to explain the term "narrative medicine" to avoid misunderstandings and to analyze the use of narrative as a tool.

Narrative Medicine: training

Liao et al. [ 24 ] presented a study aimed at helping students improve their relationships with patients by listening to them. These results, similar to those described by Charon [ 25 ], suggest that Narrative Medicine is worth recommending in academic training. The essay by O’Mahony [ 26 ] aims to provoke a debate on how and what the medical humanities should teach. Narratology and narrative medicine are linked to empathy.

Narrative Medicine: clinician-patient communication

Papers included within this category focus on the relationship between the clinician and patient, which is important in the healthcare context.

American healthcare institutions recognize the use of the Narrative Medicine approach to develop quality patient care. As a gastroenterologist at a health centre in Minnesota (US), Rian [ 27 ] concluded that the practice of Narrative Medicine should not be kept on the fringes of medicine as a hobby or ancillary treatment for the benefit of the patients but should be considered key to the healthcare process. Improving doctor‒patient communication merits more attention.

According to Rosti [ 19 ], NM can be seen as a tool to promote better communication. Although time constraints are often mentioned as an obstacle, the time needed to listen to patients is not excessive, and all healthcare professionals should consider giving patients more freedom from time constraints during consultations by encouraging them to talk about their experiences. The use of NM may also be associated with better diagnosis and treatment of pain.

Zaharias [ 28 ] underlines that communication skills are crucial. General practitioners can further develop the strong communication skills they already possess by practicing NM through neutrality, circular questions and hypotheses, and reflective skills.

Narrative Medicine: bioethics in qualitative research

The use of qualitative research in bioethics and narrative approaches to conducting and analysing qualitative interviews are becoming increasingly widespread. As Roest [ 29 ] states, this approach enables more “diagnostic thinking”. It is about promoting listening skills and the careful reading of people and healthcare practices, as well as quality criteria for the ethical evaluation of research and training.

• Clinical practice

In this classification, we included case studies performed in clinical care. We focused on methods used to guide the patients’ stories or narratives written by healthcare professionals. We analysed how Narrative Medicine has been implemented in clinical healthcare practice.

The studies included (38) were performed in the following countries: Italy (28), USA (4), Australia (1), Canada (1), China (1), Colombia (1), Norway (1), and several European countries (1) (Table  1 ). The main methods used were semi-structured interviews that guided the patient’s and physician’s narration [ 30 , 31 , 32 , 33 ], narrative diaries written by patients [ 34 ], and paper parallel charts (an instrument to integrate the patients’ stories in clinical practice) written by clinicians [ 34 , 35 , 36 ].

The studies underlined the usefulness of narrative medicine not only in qualitative research but also in integration with quantitative analysis. Gargiulo et al. [ 45 ] highlighted the importance of integrating narrative medicine and evidence-based approaches to improve therapeutic effectiveness and organizational pathways. Cappuccio et al. [ 36 ] affirmed that narrative medicine can be effective in supporting clinicians in their relationships with patients and caregivers.

Narrative Medicine is an important instrument for patients, caregivers and healthcare professionals [ 63 ]. Suter et al. [ 60 ] affirmed that patients’ stories can help other patients with similar experiences. The studies performed by Cercato [ 39 , 40 ] and Zocher [ 67 ] highlighted the role of digital diaries in the care process from the perspective of healthcare professionals and patients. Sansone et al. [ 55 ] highlighted that the use of diaries in the intensive care unit is helpful in facilitating communication between healthcare professionals and the family.

Education and training

This section includes studies on the role of Narrative Medicine in the education and training of medical students and healthcare professionals. The studies discuss the experiences, roles and programmes of the Narrative Medicine programme in education and training. Nineteen studies were carried out, 10 of which were in the USA (Table  2 ). Only two studies were carried out in Europe, 4 in Taiwan, 1 in Canada, 1 in Iran and 1 in Israel. Seven studies focused on the role of narrative medicine for healthcare professionals [ 68 , 69 , 70 , 71 , 72 , 73 , 74 ], and 11 were aimed at medical students from different disciplines. All studies underlined the positive role of Narrative Medicine in training. Chou et al. [ 75 ] affirmed that the new model of narrative medicine training, “community-based participatory narrative medicine”, which focuses on shared narrative work between healthcare trainees and patients, facilitates the formation of therapeutic patient-clinician relationships but also creates new opportunities to evaluate those relationships. Darayazadeh et al. [ 70 ] underlined the effectiveness of Narrative Medicine in improving students’ reflections and empathy with patients. Additionally, Lam et al. [ 76 ] highlighted that Narrative Medicine could be a useful tool for improving clinical empathy skills. The studies used different approaches to implement the Narrative Medicine method. Arntfield et al. [ 77 ] proposed three tools at different steps of the study (survey, focus group and open-ended questions). Chou et al. [ 75 ] asked participants to write a personal narrative. DasGupta and Charon [ 78 ] used a reflective writing exercise to analyse personal experiences of illness.

In this scoping review we identified 76 studies addressing dissemination and implementation of Narrative Medicine across three settings between 1998 and 2022. The studies performed by Hurwitz [ 3 ] and Greenhalgh [ 4 ] provide a path towards the Narrative Medicine affirm that sickness episodes are important milestones in patient life stories. Not only we live through storytelling, but often, with our doctor or nurse as a witness, we get sick, we improve, we get worse, we are stable and finally we also die through the story. affirms that the stories are often evocative and memorable. They are image rich, action packed and laden with emotions. Most people recall them better than they recall lists, graphs or numbers. Stories can convey important elements of nuance, including mood, tone and urgency. We learn through stories because the story form allows our existing schemas to be modified in the light of emerging experiential knowledge. The stories can capture tacit knowledge: in healthcare organizations they can bridge the gap between explicit, codified and formal knowledge (job descriptions, guidelines and protocols) and informal, not codified knowledge (knowing how to get things done in a particular organization or team, sometimes referred to as knowing the ropes). The “story” is the focal point in the studies related to the clinical practice as these discuss about the patient’s experience, illness story thought tools as questionnaires, narrative diary, chart parallels. The patient is an expert patient able to interact with the healthcare professionals, he/she had not a passive role; the patient is part of the process with the other involved stakeholders. Also, the Italian guidelines on Narrative Medicine [ 9 ] considers the storytelling as a fundamental instrument to acquire, understand and integrate several points of view related to persons involving in the disease and in the healthcare process. Storytelling represents the interaction between a healthcare professional and the patient’s world. According to this perspective, it is useful to educate in Narrative Medicine the healthcare professionals from the University to provide instruments to communicate and interact with their patients. Charon [ 11 ] emphasizes the role of training in narrative skills as an important tool permitting to physicians and medical students to improve their care. Charon [ 24 ] underlines that narrative training permits to explore the clinician’s attention to patients and to establish a relationship with patients, colleagues, and the self. The study of Liao [ 22 ] underlines that Narrative Medicine is worth recommending for healthcare education as resource for interdisciplinary collaboration among students from different discipline.

John Launer in The Art of Medicine. Narrative medicine , narrative practice , and the creation of meaning (2023) [ 87 ] affirm that Narrative Medicine could be complemented by the skills and pedagogy of narrative practice. In addition to the creation and study of words on the page, learners could bring their spoken accounts of their experiences at work and interview each other using narrative practice techniques. He also affirms that narrative practice and narrative medicine could both do more to build alliances with advocacy groups.

We have performed a picture of Narrative Medicine from its origin to today hoping that it will help to promote the power of Narrative Medicine in all three areas becoming increasingly integrated.

Strengths and limitations

The scoping review does not present the results of studies included but objectives, methodology and conclusions/suggestions as it aims to map the evidence related to the Narrative Medicine using a classification defined for the review. This classification had permit to make even clearer the “world” of Narrative Medicine and present a mapping.

English- and Italian-language articles were included because, as seen from the preceding pages, most of the studies were carried out in the United States and Italy.

This could be a limitation, as we may have excluded papers written in other languages. However, the United States and Italy are the countries where Narrative Medicine has developed the most.

The scoping review presents an overview of the literature considering three settings in which Narrative Medicine has emerged from its origins until today highlighting evidence in terms of theory, clinical practice, and education. Currently, a methodology to “measure” Narrative Medicine with indicators, a method assessing the effectiveness and promoting a greater diffusion of Narrative Medicine using objective and measurable indicators, is not available. Furthermore, the literature analysis doesn’t show an integration across three settings. We hope that the review will be a first step towards future projects in which it will be possible to measure Narrative Medicine according to an integrated approach between clinical practice and education/training.

Availability of data and materials

Availability of data and materials: All data generated or analysed during this study are included in this published article.

Abbreviations

• Narrative Medicine

Narrative-Based Medicine

Evidence-Based Medicine

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Palla, I., Turchetti, G. & Polvani, S. Narrative Medicine: theory, clinical practice and education - a scoping review. BMC Health Serv Res 24 , 1116 (2024). https://doi.org/10.1186/s12913-024-11530-x

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Using best-worst scaling to inform policy decisions in Africa: a literature review

• Laura K. Beres 1 ,
• Nicola B. Campoamor 2 ,
• Rachael Hawthorn 3 ,
• Melissa L. Mugambi 4 ,
• Musunge Mulabe 5 ,
• Natlie Vhlakis 5 ,
• Michael Kabongo 5 ,
• Anne Schuster 2 &
• John F. P. Bridges 2  

BMC Public Health volume  24 , Article number:  2607 ( 2024 ) Cite this article

Metrics details

Stakeholder engagement in policy decision-making is critical to inform required trade-offs, especially in low-and-middle income settings, such as many African countries. Discrete-choice experiments are now commonly used to engage stakeholders in policy decisions, but other methods such as best-worst scaling (BWS), a theory-driven prioritization technique, could be equally important. We sought to document and explore applications of BWS to assess stakeholder priorities in the African context to bring attention to BWS as a method and to assess how and why it is being used to inform policy.

We conducted a literature review of published applications of BWS for prioritization in Africa.

Our study identified 35 studies, with the majority published in the past four years. BWS has most commonly been used in agriculture (43%) and health (34%), although its broad applicability is demonstrated through use in fields influencing social and economic determinants of health, including business, environment, and transportation. Published studies from eastern, western, southern, and northern Africa include a broad range of sample sizes, design choices, and analytical approaches. Most studies are of high quality and high policy relevance. Several studies cited benefits of using BWS, with many of those citing potential limitations rather than observed limitations in their study.

Conclusions

Growing use of the method across the African continent demonstrates its feasibility and utility, recommending it for consideration among researchers, program implementers, policy makers, and funders when conducting preference research to influence policy and improve health systems.

Registration

The review was registered on PROSPERO (CRD42020209745).

Peer Review reports

Introduction

Health policies govern both health systems hardware (e.g., human resources, finance, medicines and technologies) and software (e.g., values, norms, power dynamics) by constraining or facilitating individual, organizational, and community actions and experiences [ 1 , 2 , 3 ]. Additionally, healthcare workers take numerous discretionary decisions each day to translate policy into practice and to fill gaps between policy guidance and implementation realities [ 4 , 5 , 6 ]. When guided by evidence, health policies and clinical decision-making facilitate optimized health practices and outcomes [ 6 , 7 , 8 ]. However, policy and practice decisions are often made in an evidence void due to a lack of data or poor evidence access and translation, resulting in inefficient, ineffective, or harmful health system outcomes [ 9 , 10 , 11 ].

Evidence about the preferences of those affected by health decision-making is particularly limited, but greatly needed for policy and practice. Internationally recognized processes for developing health guidelines and recommendations include incorporating the values and preferences of affected parties, such as patients and healthcare workers, into decision-making [ 12 , 13 ]. Limited availability of preference-based evidence downgrades the strength of recommendations [ 13 , 14 ]. Additionally, the welcomed and growing call for person-centered healthcare explicitly requires integration of patient preferences and perspectives into health practice [ 15 , 16 ]. Across all settings, policy makers must trade off services implemented with available resources. Required trade-offs are often more common and more challenging in more resource-limited settings, such as low-and-middle-income countries. Expanded use of tools to understand and systematically incorporate evidence on the preferences of patients, healthcare workers, and other stakeholders into policies and practices is needed to improve health systems at every level [ 17 , 18 , 19 , 20 ].

Researchers and practitioners use multiple methods to understand preferences and priorities, including deliberative processes such as testimony or community meetings, qualitative processes such as focus group discussions and interviews, and mixed methods approaches such as human-centered participatory design processes, surveys, Likert scales, and community scorecards. Developing an even broader methodological toolkit allows for more influential data to facilitate policy and practice changes, as teams will be equipped to optimize the methods selected for the target audience and research question. Stated preference methods offer a theory-driven, structured approach to understanding preferences and priorities. They produce interpretable outcomes with clear relevance to the questions of interest. They have been used across various industries, including healthcare, transportation services, and grocery retailing demonstrating their versatility and potential for suitability. However, while a range of preference elicitation methods exist [ 21 , 22 , 23 ], discrete choice experiments (DCEs) predominate in published health literature [ 24 ]. Recent studies internationally have shown the potential utility and appropriateness of other, lesser known but valuable quantitative stated preference methods, such as best-worst scaling (BWS) [ 25 ]. Studies from eastern, western, southern, and northern Africa have demonstrated interesting advances [ 26 , 27 , 28 ], but have received less attention than BWS in other regions.

The goal of this study was to document and explore applications of BWS to assess stakeholder priorities in eastern, western, southern, and northern Africa to inform future preference assessment implementation. Such documentation of current BWS in the African setting is an important step in bringing attention to this increasingly important method and to stress that there are other theory-driven alternatives to DCEs – that are now commonly applied in Africa [ 24 ]. The review presents study design, methods, quality, and policy relevance from extant studies to enable preference researchers to consider the appropriateness of similar BWS applications in their work. While several international reviews have been conducted on BWS in health [ 25 , 29 ] and more generally [ 30 ], it is important to document how this method is being used in the African context, and what specific role it might have in informing policy there. Furthermore, there has been increased use of these methods in Africa since these previous reviews. It is important that contributions of African preference researchers are well-document to ensure their inclusion in international efforts around preference methods and the presented strengths and weaknesses of these methods are well understood [ 31 ].

Best-worst scaling (BWS) is a choice experiment that is aimed to assess how individiuals or groups prioritize concepts. It offers a theory-driven alternative to descriptive rating, ranking or Likert scale preference measurement, leveraging relative participant ease of selecting extremes compared to mid-range rankings. Several types of BWS exist; however, they all share the same underlying concept. BWS relies on the concept of individuals choosing the ‘best’ and ‘worst’ (or ‘most’ and ‘least’ important) items from a given sub-set of three or more items. Sub-sets of the items are shown repeatedly in different combinations requiring choices of ‘best’ and ‘worst’ within each sub-set. This results in a prioritization of the items. Even if all options are preferred, participants are forced to prioritize among the choices. The purpose is to determine the most and least preferred options of items existing on a subjective, latent value continuum. The application of BWS for prioritizing objects has also been referred to as MaxDiff, object scaling, BWS case 1, or BWS object case. Best-worst responses can also be used in other choice formats that are more similar to DCEs, which are not the focus of this paper [ 32 ].

BWS draws on random utility theory to identify perceived importance and priorities among a set of items (known as attributes) of a scenario based on repeat choices. It can estimate the likelihood of preference selection and heterogeneity of preferences between groups. BWS can be used with a relatively small sample size and analyzed with a range of methods including more simple count analyses or more complex probablistic models. The range of analysis approaches makes them particularly useful when working across a broad range of stakeholders, including policy makers, who would want and need to understand how conclusions were drawn. Compared to DCEs, where participants select which of two or more presented profiles (specific item combinations) are preferred, BWS offers more information per choice task (i.e., best and worst choices instead of only best), allowing for a more efficient design with either a smaller sample size or more information per task. BWS may have a lower cognitive burden for participants than DCEs [ 33 , 34 ]. We refer the reader to additional resources for more detail on the theory, methods, and application of BWS [ 35 , 36 ].

Our review of BWS for prioritization in published research from southern, eastern, western, and northern Africa drew from a broader database of BWS studies identified in previous reviews. While an earlier literature review on all types of BWS choice formats had previously been published [ 29 ], our team completed the first systematic review of BWS applications in health published prior to 2022 [ 25 ]. We then extended our review (PROSPERO: CRD42020209745) to include publications from any field (e.g., health, business, agriculture, etc.) published prior to 2023 [ 30 ]. We have continued to improve this database of articles, utilizing additional search strategies and including previously unidentified relevant articles directly sent to our team. Our database currently has 623 published studies from which we systematically extract data application, development, design, administration/analysis, quality, and policy relevance. The study reported in this paper leverages the most expanded database. Review methods were detailed in prior publications [ 25 ].

We included all studies from the database that focused exclusively on, or incorporated into a multi-country study, participants from eastern, western, southern, or northern Africa. We then accessed extracted data in the database for each study to characterize BWS application types, study methods, context, quality, and policy relevance. Specific fields included: study year, country, topic, objective, sample size, perspective (i.e., whose preferences are measured), terminology used to describe BWS type (e.g., object case, MaxDiff), mode of survey administration (e.g., in-person), time frame of prioritization scenario (i.e., past, present, or future), methods of instrument development (e.g., formative research, literature review to determine attributes and survey tool), time frame of prioritization scenario (i.e., past, present, or future), measurement scale, experimental design type, BWS anchor description (i.e., most/least, best/worst), directionality, total number of objects, number of objects per task, number of tasks in the experiment, number of tasks per respondent, analysis approach, and theoretical assumptions [ 25 ]. We re-classified database ‘topic’ for three studies from ‘agriculture’ to ‘business’ after reviewing study journal and conclusions. To understand study quality, we utilized the PREFS checklist quality assessment which measures quality and validity of preference studies on a 0–5 point scale, assigning one point for each of the following: p urpose of the study clearly defined; r espondents similar to non-respondents (sampling); e xplanation of preference assessment methods clear; f indings reported for all respondents; and significance testing done [ 37 ]. We also present the validated subjective quality (range: 1–10) and policy relevance (range: 1–10) scores adjudicated by the prior review.

Identified strengths and weaknesses of BWS were extracted from the studies. This information primarily came from the background, methods, and discussion portions of the studies, specifically when justifying the use of BWS and highlighting any study limitations. Seven domains of strengths and weaknesses were dervied and modified from exisiting best-practice documents for preference research [ 38 , 39 ].

To highlight the application of BWS and improve understanding of the method, we include a narrative case study description of two of the included manuscripts. We chose health-related studies selected for their high quality (≥ 4 PREFS score) and policy relevance (≥ 7) with illustrative diversity across other factors including country, perspective, design, instrument development, and analysis approach. While diversity in other points such as assumptions, directionality, and heterogeneity analysis are interesting, (See Tables  1 , 2 and 3 ) the selected articles offered rich contrast among the articles in this review.

The review identified 35 published studies using best-worst scaling for prioritization focused on (in full or in part) participants from Africa. As seen in Table  1 , studies originated from northern Africa ( N  = 1), eastern Africa ( N  = 7), southern Africa ( N  = 13), and western Africa ( N  = 14). This included 7 studies not identified by previous reviews. The majority of the papers (72%) from Africa were published between 2019 and 2023 [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 ] and referred to ‘Best Worst Scaling’ in their write-up (85%) [ 40 , 41 , 43 , 44 , 45 , 46 , 47 , 49 , 51 , 52 , 54 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ]. Of the 14 countries where research was conducted, South Africa produced the most studies (34%) [ 41 , 42 , 46 , 51 , 52 , 55 , 56 , 60 , 61 , 66 , 67 , 70 , 74 ]. Most papers presented results from empirical research (97%) [ 40 , 41 , 42 , 44 , 45 , 46 , 47 , 48 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 70 , 71 , 72 , 73 , 74 ]. Agriculture (43%) [ 41 , 43 , 44 , 45 , 47 , 49 , 50 , 51 , 54 , 59 , 60 , 63 , 64 , 65 , 69 , 70 , 71 ] and health (34%) [ 40 , 46 , 48 , 52 , 55 , 56 , 57 , 62 , 67 , 72 , 73 , 74 ] were the most common research topics. Most studies (51%) measured preferences from the perspective of the patient / consumer [ 41 , 42 , 46 , 49 , 51 , 54 , 55 , 57 , 60 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 72 ], with nearly a third measuring provider / producer preferences (37%) [ 40 , 43 , 44 , 45 , 47 , 48 , 50 , 56 , 58 , 59 , 62 , 71 , 74 ].

Study design

All identified studies articulated their approach to developing their BWS instrument. The vast majority, (74%), utilized a literature review [ 41 , 42 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 52 , 53 , 54 , 55 , 56 , 57 , 60 , 61 , 64 , 65 , 66 , 67 , 68 , 69 , 71 , 72 , 74 ] while less than a quarter conducted piloting (17%) [ 42 , 46 , 50 , 53 , 56 , 73 ] or pretesting (20%) [ 47 , 50 , 52 , 54 , 56 , 66 , 71 ] of the instrument prior to administration. Half of the studies reported utilizing formal qualitative methods during instrument development [ 40 , 42 , 43 , 46 , 48 , 50 , 53 , 56 , 57 , 60 , 62 , 67 , 68 , 69 , 73 , 74 ]. In-person, surveyor-administered was the most common mode of survey administration (66%) [ 40 , 43 , 44 , 45 , 46 , 47 , 48 , 50 , 52 , 53 , 54 , 55 , 58 , 59 , 61 , 62 , 64 , 65 , 66 , 67 , 68 , 69 , 72 ] with online (9%) [ 51 , 56 , 74 ] and self-administered (11%) [ 41 , 57 , 70 , 73 ] less frequently utilized. The time horizon used to contextualize the survey was present tense most frequently (89%) [ 40 , 41 , 42 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 74 ] with only four studies asking about the future (11%) [ 43 , 54 , 55 , 73 ] and no studies asking about the past. BWS most frequently measured importance (69%) [ 41 , 45 , 46 , 49 , 51 , 52 , 53 , 55 , 56 , 57 , 59 , 60 , 61 , 63 , 64 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ], followed by preferences motivating responses (17%) [ 40 , 43 , 44 , 48 , 54 , 65 ]. The most common phrasing to anchor the experiment was asking participants to choose the “most” and “least” [important/preferred/concerning] (86%) [ 40 , 41 , 42 , 44 , 45 , 46 , 47 , 48 , 49 , 51 , 52 , 54 , 55 , 56 , 57 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ], followed by asking participants to choose the “best” and “worst” (11%) [ 43 , 53 , 58 , 67 ]. The most common experimental design used was a Balanced Incomplete Block Design (BIBD) (69%) [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 48 , 49 , 50 , 51 , 53 , 54 , 56 , 58 , 59 , 60 , 64 , 65 , 67 , 70 , 71 , 72 , 73 ] with 14% using a design from Sawtooth software [ 47 , 57 , 66 , 68 , 69 ]. The mean total objects per experiment was 15.9 (standard deviation (sd): 9.1, min 6: max: 48). Experiments had a mean of 5.2 objects per task (sd: 3.5, min: 3 max: 24), 22.4 (sd: 38.4, min: 1 max: 210) choice tasks per experiment and a mean of 13.7 (sd: 8.2, min: 1 max: 51) choice tasks per respondent during their participation in the experiment (Table  2 ).

BWS administration and analysis

Median sample size was 282 participants (IQR: 150–451, min: 28, max: 1002) but only 17% of papers gave a formal sample size justification (Table  3 ) [ 40 , 47 , 48 , 57 , 62 , 66 ]. Stata was the most reported data analysis program utilized (14%) [ 46 , 50 , 53 , 67 , 73 ], followed by Excel [ 42 , 61 , 66 ], SAS [ 43 , 48 , 62 ], or SPSS (9% each) [ 47 , 66 , 69 ]. The remaining studies (60%) did not specify which statistical analysis program they used. Probability / ratio rescaling (43%) [ 40 , 42 , 43 , 45 , 48 , 49 , 51 , 54 , 59 , 60 , 64 , 65 , 67 , 68 , 71 ], counts (49%) [ 40 , 41 , 45 , 46 , 50 , 52 , 53 , 54 , 56 , 58 , 61 , 63 , 66 , 67 , 70 , 71 , 73 ], regression coefficients (43%) [ 43 , 44 , 48 , 49 , 52 , 53 , 55 , 63 , 64 , 65 , 68 , 69 , 71 , 72 , 73 ], and best-worst scores (46%) [ 41 , 42 , 45 , 46 , 47 , 52 , 54 , 58 , 59 , 60 , 61 , 64 , 66 , 70 , 71 , 73 ] were common analysis approaches. Approximately half of the studies (40%) effects coded their data [ 40 , 42 , 49 , 50 , 52 , 55 , 64 , 65 , 69 , 71 , 72 ] while fewer (17%) used an omitted variable [ 43 , 44 , 48 , 53 , 54 , 62 ]. Heterogeneity analyses were conducted by most studies (63%) [ 42 , 43 , 44 , 45 , 46 , 49 , 50 , 51 , 52 , 54 , 55 , 57 , 58 , 59 , 64 , 66 , 67 , 68 , 69 , 72 ], with stratification being the most common heterogeneity analysis approach (40%) [ 42 , 44 , 49 , 51 , 52 , 55 , 57 , 63 , 64 , 65 , 66 , 67 , 68 , 72 ] followed next by latent class analysis (20%) [ 45 , 46 , 50 , 54 , 58 , 59 , 69 ].

Study quality and policy relevance

Policy relevance of studies was high with 66% scoring 7 or above on the 10-point scale [ 40 , 41 , 42 , 44 , 46 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 57 , 59 , 64 , 65 , 67 , 68 , 70 , 71 , 72 , 73 ]. Most studies scored in the upper half of the PREFS scale [ 3 , 4 , 5 , 40 , 42 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 ].

Strengths and weaknesses of BWS

Strengths and weaknesses of using BWS were identified in most of the published studies from Africa. Most of these studies focused solely on strengths of using BWS, though some identified both strengths and weaknesses and a few focused solely on weaknesses. These strengths and weaknesses were categorized into seven domains: context, purpose, method, burden, results, comparisons, and bias (Table  4 ).

Strengths were noted across all seven domains. In the context domain, BWS was noted for eliciting priorities and preferences from populations with lower education levels [ 52 , 72 ] and lower income [ 72 , 73 ]. The purpose domain highlighted strengths such as engaging communities [ 42 ] and informing decision-making [ 55 ]. The method domain emphasized that BWS overcomes limitations of other ranking methods [ 41 , 42 , 59 , 61 , 71 ], including variations in interpretation related to Likert-type scales. The burden domain commonly cited that BWS reduces respondent burden [ 41 , 45 , 49 , 50 , 52 , 55 , 59 , 61 , 66 , 68 , 72 ]. The results domain stressed that BWS captures more information [ 49 , 59 , 64 , 66 , 68 , 72 ] and produces higher quality and more precise results than other methods [ 41 , 45 , 49 , 58 , 71 ]. The comparisons domain focused on the ability to discriminate between objects [ 45 , 49 , 59 , 65 , 68 , 73 ]. The bias domain noted a reduction of general bias [ 41 , 51 , 53 , 59 , 66 , 70 ].

Weaknesses or limitations of using BWS were provided for only five of the seven domains. In the context domain, it was suggested that BWS might be challenging to use in clinical practice as a decision-making tool [ 57 ] and, contrary to studies noting it as a strength, some identified it as, challenging for populations with lower education levels [ 52 ]. The method domain pointed out that BWS involves hypothetical scenarios that may not be realistic [ 64 ]. The burden domain cited possible respondent burden associated with completing a series of BWS tasks [ 52 , 59 , 66 ]. The comparisons domain highlighted potential difficulties in making comparisons between populations within the sample [ 68 , 69 ]. The bias domain noted the possibility of desirability bias, where respondents report socially acceptable factors rather than genuine preferences [ 72 ]. Most of these weaknesses were posed as possibilities, rather than observed limitations.

Case studies

Policy relevance : Ozawa et al. [ 72 ] used BWS scaling to inform message development and effective delivery strategies with the goal of improving childhood vaccination awareness and demand in Nahuche, Zamfara State northern Nigeria, a region with low vaccination uptake. Instrument development : The survey items were developed through a review of published literature from Nigeria and other low-and-middle income countries on factors that affect childhood vaccine demand and uptake. Identified factors were categorized into four groups and each written out as a negative or positive influence based on the literature (e.g., vaccines may harm a child (negative), trust the views of leaders about vaccines (positive)), balancing equal numbers of positive and negative statements. A local study advisory board reviewed the items. Population : The survey was administered in-person to parents with children under 5 years old during a household survey from a representative sample of households. Administration : The survey was translated into Hausa and presented as a pictorial questionnaire with both photographs and words used to represent each factor. Perspective and time scale : Participants were asked to select the most and least important factors to them (consumer/patient) when deciding whether to vaccinate a 1-year-old child (present). Design : The study utilized a BIBD where every participant was presented with 16 choice sets of 6 factors. The survey took approximately 1 h to complete. Analysis : They assumed sequential BWS and used conditional logistic regression with effects coding to determine factor rankings. Heterogeneity : They examined heterogeneity in the results by looking at different strata: male/female parent and by previous diphtheria, tetanus, and pertussis (DTaP) vaccination status (yes/no). Participation : 198 parents participated. Results : The most important motivating factor for vaccinating children was the perception that vaccination makes one a good parent. Trust and norms were found to be more important than benefits and risks in vaccination decisions. They identified differences in rankings between fathers and mothers and in families with and without prior DTaP vaccination.

Policy relevance : Yemeke et al. [ 52 ] compared the Uganda national budget resource allocations across 16 sectors to citizen preferences for such allocations. A particular emphasis was placed on understanding the health care sector as a funding priority. Instrument development : The sixteen survey factors represented each of the sixteen sector allocations within the Uganda national government’s budget. Results from a pre-test of the survey to assess respondent understanding were used to improve the instrument. Population : The survey was administered in-person to the head of household or spouse, of at least 18 years of age, in both rural and urban areas in the Mukono district in central Uganda. Administration : The survey was translated into Luganda and displayed accompanying pictorial representations (such as photographs or graphics) of the sectors. Descriptions of the sectors and their functions were also read aloud. Perspective and time scale : Respondents were asked to select the most and least important sectors for resource allocation for their community (present) in each choice task, offering societal perspective prioritization. Design : A main effects orthogonal design was used to generate 16 choice tasks, each with 4 sectors (factors). Analysis : Count analysis: Relative mean best-worse scores were calculated for each sector. Scores were transformed to a positive scale, anchored at zero, to calculate percentage preference relative to estimated cumulative sums. The preferred percentages were compared to the actual percentages allocated in the national budget. Assuming sequential BWS, the authors used McFadden’s conditional logistic regression with effects coding to regress a single dichotomous choice variable on all sectors to assess ranking of preferred sectors. Heterogeneity : They examined heterogeneity in the results across two strata (urban/rural). Participation : There were 432 respondents across two settings (217 urban respondents, 215 rural respondents). Results : The health sector was the highest ranked sector by a significant margin amongst both rural and urban respondents. This result was consistent in both the relative best-minus-worst score method and the regression analysis. This highlighted a clear disparity between citizen preferences and national budget al.location, where the health sector was ranked sixth.

Policy relevance : Nyarko et al. [ 48 ] used BWS to quantify the antimicrobial dispensing practices of medicine sales outlet staff. Understanding these practices can help to improve patient safety and care quality, as well as to serve as a guide for decision-making in the pharmaceutical sector. Instrument development : The initial list of survey items was identified through informant interviews with medicine sales experts and an extensive literature review. The list of items was condensed into eight objects through focus group discussions with medicine sales outlet staff. Population : The survey was conducted in-person through interviewer-questionnaire administration with medicine sales outlet staff over a two-month period. Staff were eligible for the study if they had dispensed microbials within the past year. Administration : Demographic information was collected at the start of the questionnaire, followed by questions regarding the staff’s prescribing and dispensing practices of antimicrobial medications. Perspective and time scale : Participants were asked to indicate which object regarding antimicrobial dispensing practices concerned them the most and least. Design : A BIBD was used, generating 8 tasks, each with 7 objects. Analysis : Assuming the respondent chose the items they most liked and disliked, a maximum difference model with effects coding was used to determine parameter estimates. The relative importance of each object was determined based on the parameter estimates, allowing the objects to be ranked by level of importance. Heterogeneity : Heterogeneity was examined by comparing antimicrobial dispensing practices with their associated objects. Participation : 200 staff participated. Results : The antimicrobial dispensing practice that concerned respondents most was the need to follow the drug act and avoid dispensing antimicrobials without a prescription. Dispensing antibiotics to poor patients who may not be able to afford medical bills was not a concern for respondents. Overall, the study suggests that staff are careful when dispensing antimicrobials.

Our study identified 35 studies from across Africa, with the majority published in the past four years. BWS has most commonly been used in agriculture and health, although its broad applicability is demonstrated through its use in fields including business, environment, and transportation. Published studies from eastern, western, southern, and northern Africa include a broad range of sample sizes, design choices, and analytical approaches. Consistent with other BWS reviews [ 25 ], the majority of studies are both of high quality and of high policy relevance. It is interesting to highlight that among articles classified as ‘multi-country,’ two articles included participants from at least one African country in their sample. However, we considered them ‘near misses’ and excluded them as neither disaggregated data by country to ensure review data came from Africa. Both had few participants from African countries relative to the overall sample.

The application of BWS for prioritization in the Africa context is an emerging practice as demonstrated by our findings that its use has increased dramatically over time. The quality of studies, as measured by PREFS, has remained consistently high over time [ 24 ]. As the method continues to be applied, guidelines exist that could further ensure researchers conduct high-quality studies and publish high-quality papers about them [ 38 , 39 , 75 ]. This includes the increased use of instrument development methods, especially formal qualitative work, pretesting with cognitive interviewing, and piloting [ 76 ]. Importantly, this also requires attentiveness to ensuring accuracy of conceptual translation which is often missed if focusing exclusively on linguistic translation for studies working across multiple language groups [ 77 ].

The use of BWS also draws attention to the notion of prioritization itself. Our findings highlight the relevance of the method to policy making; over three-quarters of the included studies received a policy relevance score of seven or more. Clearly expressed priorities may allow policy makers to shift away from informal decision-making heuristics to more formal, principled decision making practices. Certainly, the more recently observed integration of BWS into deliberative processes [ 78 ] such as the modified policy Delphi [ 79 ] and deliberative democracy [ 80 ] exemplifies other ways that priority and preference elicitation can help inform group deliberation to achieve consensus [ 81 , 82 ]. That said, there remain questions about aggregating individual priorities in group decision making [ 36 ] and is a topic that others have grappled with, including in health state valuation [ 83 ]. Finally, it is important to note that BWS is only one method to assess priorities, where other methods include deliberation [ 84 ], simple rating or ranking approaches alone or as a part of a Delphi approach [ 85 ], pick n of m tasks [ 86 ], or stated preference methods such as willingness to pay [ 87 ], DCEs, or conjoint analyses [ 88 ].

With only 34% of included studies in health, this shows an opportunity for greater application in the health field. The range of health-specific topics to which BWS was applied in this study demonstrates versatility across health areas. Various types of preference facilitation have proven successful in health-specific areas [ 25 , 89 ]. Additionally, as health systems are conceptualized more broadly to include social determinants of health such as transportation options, food systems, and the environment the other topical applications demonstrate direct relevance to health systems and decision-making. Similarly, its use in business may be applicable to business-based approaches to health such as social marketing strategies for behavior change. While patient-centered care may involve individual-level preference accommodation of individual patients (e.g., choosing a community-adherence group over fast-track appointments among HIV differentiated service delivery options), systematic understanding of trends in patient preferences at a broader level can inform efficient health system decision-making (e.g., the creation of differentiated service delivery options for HIV). The two studies including data from an African country that we nearly included but did not due to lack of geographic specificity both show successful implementation of multi-country BWS.

Our study is subject to publication bias, as the systematic review searched published literature. The review targeted object case BWS (also known as case 1, MaxDiff, and object scaling). Further research into other types of BWS would contribute to a more comprehensive understanding of BWS in Africa. While we introduce BWS, we do not offer guidance on methods or analysis. Multiple other peer reviewed papers, including some included in this review [ 42 ], and texts offer clear instruction on BWS implementation to aid researchers wishing to apply this method [ 36 ]. Further, we do not include assessments of BWS participation from the participant perspective, as literature on this topic is very limited [ 90 ]. The field would benefit from frameworks for participant assessment of BWS participation to better incorporate this into BWS findings, as have been developed for instrument development [ 76 ].

We need effective tools to measure preferences and priorities, including tools that suit those whose input is more traditionally sought in health decision making (e.g., providers) and those whose voice is critical, but often unheard (e.g., patients, consumers, and community members). BWS is one of those tools. BWS offers a versatile alternative to DCEs and other better-known methods of measuring preferences. Researchers can successfully employ BWS across a range of sample sizes, and using various analysis approaches and programs. Growing use of the method across the African continent demonstrates its feasibility and utility, recommending it for consideration among researchers, program implementers, policy makers, and funders when conducting preference research to influence policy and improve health systems. Further research can help to recommend specific applications, including further work to understand context-specific implications of the strengths and limitations of the methods alongside cognitive burden and population-specific recommendations.

Data availability

All study data are available upon request from the authors for the review registered on PROSPERO (CRD42020209745).

Abbreviations

Balanced incomplete block design

• Best-worst scaling

Discrete choice experiments

Diphtheria, tetanus, and pertussis

Purpose, responses, explanations, findings

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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John F.P. Bridges holds an Innovation in Regulatory Science Award from the Burroughs Wellcome Fund. Laura K Beres’ contributions were supported by National Institute of Mental Health 1K01MH130244-01A1. The contents included here are the responsibility of the authors and do not represent the official views of the National Institute of Mental Health.

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Beres, L.K., Campoamor, N.B., Hawthorn, R. et al. Using best-worst scaling to inform policy decisions in Africa: a literature review. BMC Public Health 24 , 2607 (2024). https://doi.org/10.1186/s12889-024-20068-w

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DOI : https://doi.org/10.1186/s12889-024-20068-w

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