critical review of research article

How to Write Critical Reviews

When you are asked to write a critical review of a book or article, you will need to identify, summarize, and evaluate the ideas and information the author has presented. In other words, you will be examining another person’s thoughts on a topic from your point of view.

Your stand must go beyond your “gut reaction” to the work and be based on your knowledge (readings, lecture, experience) of the topic as well as on factors such as criteria stated in your assignment or discussed by you and your instructor.

Make your stand clear at the beginning of your review, in your evaluations of specific parts, and in your concluding commentary.

Remember that your goal should be to make a few key points about the book or article, not to discuss everything the author writes.

Understanding the Assignment

To write a good critical review, you will have to engage in the mental processes of analyzing (taking apart) the work–deciding what its major components are and determining how these parts (i.e., paragraphs, sections, or chapters) contribute to the work as a whole.

Analyzing the work will help you focus on how and why the author makes certain points and prevent you from merely summarizing what the author says. Assuming the role of an analytical reader will also help you to determine whether or not the author fulfills the stated purpose of the book or article and enhances your understanding or knowledge of a particular topic.

Be sure to read your assignment thoroughly before you read the article or book. Your instructor may have included specific guidelines for you to follow. Keeping these guidelines in mind as you read the article or book can really help you write your paper!

Also, note where the work connects with what you’ve studied in the course. You can make the most efficient use of your reading and notetaking time if you are an active reader; that is, keep relevant questions in mind and jot down page numbers as well as your responses to ideas that appear to be significant as you read.

Please note: The length of your introduction and overview, the number of points you choose to review, and the length of your conclusion should be proportionate to the page limit stated in your assignment and should reflect the complexity of the material being reviewed as well as the expectations of your reader.

Write the introduction

Below are a few guidelines to help you write the introduction to your critical review.

Introduce your review appropriately

Begin your review with an introduction appropriate to your assignment.

If your assignment asks you to review only one book and not to use outside sources, your introduction will focus on identifying the author, the title, the main topic or issue presented in the book, and the author’s purpose in writing the book.

If your assignment asks you to review the book as it relates to issues or themes discussed in the course, or to review two or more books on the same topic, your introduction must also encompass those expectations.

Explain relationships

For example, before you can review two books on a topic, you must explain to your reader in your introduction how they are related to one another.

Within this shared context (or under this “umbrella”) you can then review comparable aspects of both books, pointing out where the authors agree and differ.

In other words, the more complicated your assignment is, the more your introduction must accomplish.

Finally, the introduction to a book review is always the place for you to establish your position as the reviewer (your thesis about the author’s thesis).

As you write, consider the following questions:

• Is the book a memoir, a treatise, a collection of facts, an extended argument, etc.? Is the article a documentary, a write-up of primary research, a position paper, etc.?
• Who is the author? What does the preface or foreword tell you about the author’s purpose, background, and credentials? What is the author’s approach to the topic (as a journalist? a historian? a researcher?)?
• What is the main topic or problem addressed? How does the work relate to a discipline, to a profession, to a particular audience, or to other works on the topic?
• What is your critical evaluation of the work (your thesis)? Why have you taken that position? What criteria are you basing your position on?

Provide an overview

In your introduction, you will also want to provide an overview. An overview supplies your reader with certain general information not appropriate for including in the introduction but necessary to understanding the body of the review.

Generally, an overview describes your book’s division into chapters, sections, or points of discussion. An overview may also include background information about the topic, about your stand, or about the criteria you will use for evaluation.

The overview and the introduction work together to provide a comprehensive beginning for (a “springboard” into) your review.

• What are the author’s basic premises? What issues are raised, or what themes emerge? What situation (i.e., racism on college campuses) provides a basis for the author’s assertions?
• How informed is my reader? What background information is relevant to the entire book and should be placed here rather than in a body paragraph?

Write the body

The body is the center of your paper, where you draw out your main arguments. Below are some guidelines to help you write it.

Organize using a logical plan

Organize the body of your review according to a logical plan. Here are two options:

• First, summarize, in a series of paragraphs, those major points from the book that you plan to discuss; incorporating each major point into a topic sentence for a paragraph is an effective organizational strategy. Second, discuss and evaluate these points in a following group of paragraphs. (There are two dangers lurking in this pattern–you may allot too many paragraphs to summary and too few to evaluation, or you may re-summarize too many points from the book in your evaluation section.)
• Alternatively, you can summarize and evaluate the major points you have chosen from the book in a point-by-point schema. That means you will discuss and evaluate point one within the same paragraph (or in several if the point is significant and warrants extended discussion) before you summarize and evaluate point two, point three, etc., moving in a logical sequence from point to point to point. Here again, it is effective to use the topic sentence of each paragraph to identify the point from the book that you plan to summarize or evaluate.

Questions to keep in mind as you write

With either organizational pattern, consider the following questions:

• What are the author’s most important points? How do these relate to one another? (Make relationships clear by using transitions: “In contrast,” an equally strong argument,” “moreover,” “a final conclusion,” etc.).
• What types of evidence or information does the author present to support his or her points? Is this evidence convincing, controversial, factual, one-sided, etc.? (Consider the use of primary historical material, case studies, narratives, recent scientific findings, statistics.)
• Where does the author do a good job of conveying factual material as well as personal perspective? Where does the author fail to do so? If solutions to a problem are offered, are they believable, misguided, or promising?
• Which parts of the work (particular arguments, descriptions, chapters, etc.) are most effective and which parts are least effective? Why?
• Where (if at all) does the author convey personal prejudice, support illogical relationships, or present evidence out of its appropriate context?

Keep your opinions distinct and cite your sources

Remember, as you discuss the author’s major points, be sure to distinguish consistently between the author’s opinions and your own.

Keep the summary portions of your discussion concise, remembering that your task as a reviewer is to re-see the author’s work, not to re-tell it.

And, importantly, if you refer to ideas from other books and articles or from lecture and course materials, always document your sources, or else you might wander into the realm of plagiarism.

Include only that material which has relevance for your review and use direct quotations sparingly. The Writing Center has other handouts to help you paraphrase text and introduce quotations.

Write the conclusion

You will want to use the conclusion to state your overall critical evaluation.

You have already discussed the major points the author makes, examined how the author supports arguments, and evaluated the quality or effectiveness of specific aspects of the book or article.

Now you must make an evaluation of the work as a whole, determining such things as whether or not the author achieves the stated or implied purpose and if the work makes a significant contribution to an existing body of knowledge.

Consider the following questions:

• Is the work appropriately subjective or objective according to the author’s purpose?
• How well does the work maintain its stated or implied focus? Does the author present extraneous material? Does the author exclude or ignore relevant information?
• How well has the author achieved the overall purpose of the book or article? What contribution does the work make to an existing body of knowledge or to a specific group of readers? Can you justify the use of this work in a particular course?
• What is the most important final comment you wish to make about the book or article? Do you have any suggestions for the direction of future research in the area? What has reading this work done for you or demonstrated to you?

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Writing Critical Reviews

What is a Critical Review of a Journal Article?

A critical review of a journal article evaluates the strengths and weaknesses of an article's ideas and content. It provides description, analysis and interpretation that allow readers to assess the article's value.

Before You Read the Article

• What does the title lead you to expect about the article?
• Study any sub-headings to understand how the author organized the content.
• Read the abstract for a summary of the author's arguments.
• Study the list of references to determine what research contributed to the author's arguments. Are the references recent? Do they represent important work in the field?
• If possible, read about the author to learn what authority he or she has to write about the subject.
• Consult Web of Science to see if other writers have cited the author's work. (Please see 'How to use E-Indexes'.) Has the author made an important contribution to the field of study?

Reading the Article: Points to Consider

Read the article carefully. Record your impressions and note sections suitable for quoting.

• Who is the intended audience?
• What is the author's purpose? To survey and summarize research on a topic? To present an argument that builds on past research? To refute another writer's argument?
• Does the author define important terms?
• Is the information in the article fact or opinion? (Facts can be verified, while opinions arise from interpretations of facts.) Does the information seem well-researched or is it unsupported?
• What are the author's central arguments or conclusions? Are they clearly stated? Are they supported by evidence and analysis?
• If the article reports on an experiment or study, does the author clearly outline methodology and the expected result?
• Is the article lacking information or argumentation that you expected to find?
• Is the article organized logically and easy to follow?
• Does the writer's style suit the intended audience? Is the style stilted or unnecessarily complicated?
• Is the author's language objective or charged with emotion and bias?
• If illustrations or charts are used, are they effective in presenting information?

Prepare an Outline

Read over your notes. Choose a statement that expresses the central purpose or thesis of your review. When thinking of a thesis, consider the author's intentions and whether or not you think those intentions were successfully realized. Eliminate all notes that do not relate to your thesis. Organize your remaining points into separate groups such as points about structure, style, or argument. Devise a logical sequence for presenting these ideas. Remember that all of your ideas must support your central thesis.

Write the First Draft

The review should begin with a complete citation of the article. For example:

Platt, Kevin M.F. "History and Despotism, or: Hayden White vs. Ivan the Terrible  and Peter the Great." Rethinking History 3:3 (1999) : 247-269.

NOTE: Use the same bibliographic citation format as you would for any bibliography, works cited or reference list. It will follow a standard documentation style such as MLA or APA.

Be sure to ask your instructor which citation style to use. For frequently used style guides consult Queen's University Library's Citing Sources guide.

The first paragraph may contain:

• a statement of your thesis
• the author's purpose in writing the article
• comments on how the article relates to other work on the same subject
• information about the author's reputation or authority in the field

The body of the review should:

• state your arguments in support of your thesis
• follow the logical development of ideas that you mapped out in your outline
• include quotations from the article which illustrate your main ideas

The concluding paragraph may:

• summarize your review
• restate your thesis

Revise the First Draft

Ideally, you should leave your first draft for a day or two before revising. This allows you to gain a more objective perspective on your ideas. Check for the following when revising:

• grammar and punctuation errors
• organization, logical development and solid support of your thesis
• errors in quotations or in references

You may make major revisions in the organization or content of your review during the revision process. Revising can even lead to a radical change in your central thesis.

NOTE: Prepared by University of Toronto Mississauga Library, Hazel McCallion Academic Learning Centre.

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Additional Resources

Writing a Critical Review (Allyson Skene, The Writing Centre, U of Toronto at Scarborough)

The Book Review or Article Critique (Margaret Procter, Writing Support, University of Toronto)

Critical Reviews of Journal Articles (Herbert Coutts, University of Alberta)

Writing a Critical Review (The Writing Centre, Queen's University)

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Write a Critical Review of a Scientific Journal Article

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A scientific journal is a publication intended to further the progress of scientific discovery by reporting novel research. Scientific journals publish both original research articles and review articles.

A critical review is an assessment of an original research article.  Writing a critical review of a journal article can help you improve your research skills. By assessing the work of others, you develop skills as a critical reader and become familiar with the types of evaluation criteria that will be applied to research in your field.

You are expected to read the article carefully, analyze it, and evaluate the quality and originality of the research, as well as its relevance and presentation. You should assess its strengths and weaknesses, followed by its overall value.

• Do not be confused by the term critique: it does not mean that you only look at the negative aspects of what the researchers have done. You should address both the positive and negative aspects of the journal article.
• If your instructor has given you specific advice on how to write a critical review, follow that advice. If not, the following steps may help you. 

This guide is divided into two parts. The first part, "Analyzing the Text," outlines the steps involved in evaluating a research article. The second part, "Writing Your Critique," discusses two possible ways to structure your review.​

• Developing a Research Question + Worksheet Use this worksheet to develop, assess, and refine your research questions. There is also a downloadable PDF version.
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PSY290 - Research Methods

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Writing a Critical Review

Sample summaries, verbs to help you write the summary, how to read a scholarly article.

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A critical review is an academic appraisal of an article that offers both a summary and critical comment. They are useful in evaluating the relevance of a source to your academic needs. They demonstrate that you have understood the text and that you can analyze the main arguments or findings. It is not just a summary; it is an evaluation of what the author has said on a topic. It’s critical in that you thoughtfully consider the validity and accuracy of the author’s claims and that you identify other valid points of view.

An effective critical review has three parts:

• APA citation of article
• Clearly summarizes the purpose for the article and identifies the strengths and weaknesses of the research. (In your own words – no quotations.)
• Evaluates the contribution of the article to the discipline or broad subject area and how it relates to your own research.

Steps to Write a Critical Review:

• Create and APA style citation for the article you are reviewing.
• Skim the text: Read the title, abstract, introduction, and conclusion.
• Read the entire article in order to identify its main ideas and purpose.

Q. What were the authors investigating? What is their thesis? Q. What did the authors hope to discover?

        D. Pay close attention to the methods used by the authors to collection information.

Q. What are the characteristics of the participants? (e.g.) Age/gender/ethnicity

Q. What was the procedure or experimental method/surveys used?

Q. Are their any flaws in the design of their study?

  E. Review the main findings in the “Discussion” or “Conclusion” section. This will help you to evaluate the validity of their evidence, and the credibility of the authors.             Q.   Are their conclusions convincing?            Q.   Were their results significant? If so, describe how they were significant.  F. Evaluate the usefulness of the text to YOU in the context of your own research.

Q. How does this article assist you in your research?

Q. How does it enhance your understanding of this issue?

Q. What gaps in your research does it fill?

Good Summary:

Hock, S., & Rochford, R. A. (2010). A letter-writing campaign: linking academic success and civic engagement. Journal  of Community Engagement and Scholarship, 3 (2), 76-82.

Hock & Rochford (2010) describe how two classes of developmental writing students were engaged in a service-learning project to support the preservation of an on-campus historical site. The goal of the assignment was to help students to see how they have influence in their community by acting as engaged citizens, and to improve their scores on the ACT Writing Sample Assessment (WSA) exam. The authors report that students in developmental classes often feel disempowered, especially when English is not their first language. This assignment not only assisted them in elevating their written communication skills, but it also gave real-life significance to the assignment, and by extension made them feel like empowered members of the community. The advancement in student scores serves as evidence to support my research that when students are given assignments which permit local advocacy and active participation, their academic performance also improves.

Bad Summary:

Two ELL classes complete a service-learning project and improve their writing scores. This article was good because it provided me with lots of information I can use. The students learned a lot in their service-learning project and they passed the ACT exam.  

Remember you're describing what someone else has said. Use verbal cues to make this clear to your reader.  Here are some suggested verbs to use: 

* Adapted from: http://www.laspositascollege.edu/raw/summaries.php

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Structure of a Critical Review

Critical reviews, both short (one page) and long (four pages), usually have a similar structure. Check your assignment instructions for formatting and structural specifications. Headings are usually optional for longer reviews and can be helpful for the reader.

Introduction

The length of an introduction is usually one paragraph for a journal article review and two or three paragraphs for a longer book review. Include a few opening sentences that announce the author(s) and the title, and briefly explain the topic of the text. Present the aim of the text and summarise the main finding or key argument. Conclude the introduction with a brief statement of your evaluation of the text. This can be a positive or negative evaluation or, as is usually the case, a mixed response.

Present a summary of the key points along with a limited number of examples. You can also briefly explain the author’s purpose/intentions throughout the text and you may briefly describe how the text is organised. The summary should only make up about a third of the critical review.

The critique should be a balanced discussion and evaluation of the strengths, weakness and notable features of the text. Remember to base your discussion on specific criteria. Good reviews also include other sources to support your evaluation (remember to reference).

You can choose how to sequence your critique. Here are some examples to get you started:

• Most important to least important conclusions you make about the text.
• If your critique is more positive than negative, then present the negative points first and the positive last.
• If your critique is more negative than positive, then present the positive points first and the negative last.
• If there are both strengths and weakness for each criterion you use, you need to decide overall what your judgement is. For example, you may want to comment on a key idea in the text and have both positive and negative comments. You could begin by stating what is good about the idea and then concede and explain how it is limited in some way. While this example shows a mixed evaluation, overall you are probably being more negative than positive.
• In long reviews, you can address each criterion you choose in a paragraph, including both negative and positive points. For very short critical reviews (one page or less), where your comments will be briefer, include a paragraph of positive aspects  and another of negative.
• You can also include recommendations for how the text can be improved in terms of ideas, research approach; theories or frameworks used can also be included in the critique section.

Conclusion & References

This is usually a very short paragraph.

• Restate your overall opinion of the text.
• Briefly present recommendations.
• If necessary, some further qualification or explanation of your judgement can be included. This can help your critique sound fair and reasonable.

If you have used other sources in you review you should also include a list of references at the end of the review.

Summarising and paraphrasing for the critical review

The best way to summarise

• Scan the text. Look for information that can be deduced from the introduction, conclusion, title, and headings. What do these tell you about the main points of the article?
• Locate the topic sentences and highlight the main points as you read.
• Reread the text and make separate notes of the main points. Examples and evidence do not need to be included at this stage. Usually they are used selectively in your critique.

Paraphrasing means putting it into your own words. Paraphrasing offers an alternative to using direct quotations in your summary (and the critique) and can be an efficient way to integrate your summary notes.

The best way to paraphrase

• Review your summary notes
• Rewrite them in your own words and in complete sentences
• Use reporting verbs and phrases, e.g. 'The author describes…', 'Smith argues that …'.
• Use quotation marks if If you include unique or specialist phrases from the text.

  Next: Some general criteria for evaluating texts

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How to Write a Critical Review of an Article

Need to write a critical review but unsure of where to start? Don’t worry, it’s normal to feel stuck when writing a critical review.

So, how should you approach a critical review? Well, you need to consider the strengths and weaknesses of the article. But, more than this, you need to draw links between this article and other relevant papers. This is important if you want a first-class grade!

Critical reviews are difficult, but they can help you improve your research and selection skills. That said, let’s explore how to write a critical review of an article.

How to be ‘critical’

First and foremost, be clear on what it means to be ‘critical’. If you’ve read our guide on how to critically discuss , you’ll know that being critical isn’t just about being negative.

Being critical means weighing up the strengths and weaknesses of a particular piece of work and considering its implications and applications from various perspectives.

That said, in order to ‘be critical’ you must:

• Fully immerse yourself in the work(s) you are critiquing.
• Keep an open, balanced mind.

Why critically review an article?

Understanding why your tutor has set this piece of work can help you to feel more motivated to finish it. So, why would your tutor ask you to critically review an article?

Well, being able to critically appraise others’ work is considered essential to thrive as a student. This is especially true if you want to progress to master’s or PhD level study.

Writing a critical review can help you to become a more discerning researcher, because it teaches you how to appraise other people’s work.

If you can become good at critically appraising one paper, you can become good at appraising a bunch of papers. So, this means that when writing subsequent essays, you can accurately discern which research papers are worth including in your essays, and which are not.

Not to mention, an assignment like this also introduces you to the practice of peer-review; another practice that is central to UK academia.

What should I include?

The expectation of what a critical review should include will vary between subjects. As a rough guide, it should include the following:

A brief overview of the content

Generally, you should assume that your reader has not read the article, so you will need to include a brief description of its content. Remember to be brief in order to leave enough space for critique.

It’s up to you whether you write a short paragraph at the beginning of your review summarising the article, or whether you describe and critique the paper as you go along. The latter strategy can be more impressive, but it is more difficult to do.

Acknowledge (and critique) the author’s rationale

Ask yourself, why did the author(s) write this article? What problem or issue were they trying to solve? Ultimately, your review should say whether you agree that there was a problem to be solved, and whether you think this article has addressed this problem effectively.

So, for example, let’s say you need to review an article that tested whether putting stricter quotas on fishing can tackle the overfishing crisis.

First, ask yourself, is there enough evidence to confirm that we are facing an overfishing crisis? Use your response to this question to determine how ‘important’ you see this article to be.  Moreover, ask yourself, were the authors right to focus on stricter quotas as a potential solution, or could/should they have focused on something else?

Remember, you are not just critiquing the paper itself but the decisions (or rationale) that led the authors to formulate this type of paper in the first place.

Strengths and weaknesses of the methodology

Most critical reviews should discuss the strengths and weaknesses of the methodology, since the choice of methodology relates to issues like reliability and validity.

When critiquing the methodology, ask yourself why you think the author(s) chose this approach. For example, if they chose to conduct qualitative interviews rather than administer a quantitative questionnaire, why do you think they did this?

Tip: Most journal articles have a section at the end where the authors discuss the limitations of their paper (including the methodology), so this can give you some hints if you’re struggling to find any weaknesses with the methodology.

Research methods is a broad area of study, so we strongly recommend you take out a research methods textbook from your university library; this will introduce you to the basics of different research methods which will help you to critique the article confidently.

Applications and future directions

Remember we said that a critical review shouldn’t only be negative? Indeed, you should generally say positive things about the article, too.

One way to do this is to consider alternative applications of the author’s theory or argument. So, let’s say that the paper found that caffeine helps improve people’s memory. You might wonder whether caffeine could be an effective treatment for memory disorders and recommend this as a potential avenue for future research.

Remember, one of the aims of a critical review is to ‘fit it in’ to the wider literature. This will show off your ability to draw links between theories, concepts, and disciplines.

Language and tone

Depending on the type of article you are reviewing, you might also want to comment on the language skills of the authors.

Have they presented their ideas coherently? Is the argument easy to follow? If you had written the article, would you have approached it differently? Under this remit, you might also consider the quality of presentation.

Questions to ask yourself when critiquing an article

As mentioned, your tutor might have some quite unique requirements for what to include in your review. But, generally speaking, these are some good questions to get you started:

• Is this article convincing?
• What part of this article is most/least convincing to me?
• Does this article solve a problem?
• Does this article oversimplify (or exaggerate) a problem?
• How would I summarise this article in one sentence? (write it down)
• Does this article support or refute previous research?
• Did the author(s) formulate a specific hypothesis? If so, what was it?
• Were the findings largely in-line with the author(s) predictions or were they surprising?
• If another researcher replicated this study, are they likely to find similar results? (e.g., if this study was done in a different country, or using a different medium, what influence might this have on the results?)
• When was this article written? Is it still relevant?
• What have other commentators said about this article?
• Does this article feel biased or balanced?

Should I reference other papers?

Your tutor will be able to tell you whether your critical review should include other references.

However it is a good idea to include additional references because this shows you can ‘fit’ this article into the ‘bigger picture’ and draw links between different theorists’ ideas.

Moreover, when making an evaluative statement about a particular weakness within the paper, including a citation can help you to appear more authoritative.

For example, let’s say you write ‘The authors only included 12 participants so the sample size was very small; this means the findings cannot be generalised’ (Smith, 2010).

By including a reference to Smith (2010), you are showing that you have read up about sampling and the effects of using a small sample size. This demonstrates that you have thought carefully about various aspects of the article and done your own research to critique it confidently.

Tips for getting started

As with all academic papers, getting started is often the hardest part. That said, here are some tips to help you kickstart your critical review:

• Fully immerse yourself in the article – try to read the paper through at least three times so you fully understand it. If you’re finding it hard to focus, see if you can find an audio version of the article. If you can’t find an official audio version, copy-and-paste the content into Word, click the ‘Review’ tab and then click ‘Read Aloud’.
• Tell someone else about the article – This is a great way of testing your comprehension of the article and can help to increase your motivation for finishing the assignment.
• Check out the reference list – The reference list of the article can be useful for finding relevant sources for contextualising the article, e.g., some of these references will likely refer to the opposing side of the debate (you need to engage with these too).
• Make notes – Make notes as you go, and you will find it much easier to write up your critical review later.

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Narrative Reviews: Flexible, Rigorous, and Practical

Javeed sukhera.

Javeed Sukhera, MD, PhD, FRCPC , is Chair/Chief, Department of Psychiatry, Institute of Living and Hartford Hospital

Introduction

Narrative reviews are a type of knowledge synthesis grounded in a distinct research tradition. They are often framed as non-systematic, which implies that there is a hierarchy of evidence placing narrative reviews below other review forms. 1 However, narrative reviews are highly useful to medical educators and researchers. While a systematic review often focuses on a narrow question in a specific context, with a prespecified method to synthesize findings from similar studies, a narrative review can include a wide variety of studies and provide an overall summary, with interpretation and critique. 1 Examples of narrative review types include state-of-the-art, critical, and integrative reviews, among many others.

Foundations

Narrative reviews are situated within diverse disciplines in the social sciences and humanities. Most forms of narrative reviews align with subjectivist and interpretivist paradigms. These worldviews emphasize that reality is subjective and dynamic. They contrast with the positivist and post-positivist worldviews that are the foundations of systematic reviews: a single reality can be known through experimental research. Unlike systematic reviews, narrative reviews offer researchers the ability to synthesize multiple points of view and harness unique review team perspectives, which will shape the analysis. Therefore, insights gained from a narrative review will vary depending on the individual, organizational, or historical contexts in which the review was conducted. 1 - 5

Why Choose a Narrative Review?

Narrative reviews allow researchers to describe what is known on a topic while conducting a subjective examination and critique of an entire body of literature. Authors can describe the topic's current status while providing insights on advancing the field, new theories, or current evidence viewed from different or unusual perspectives. 3 Therefore, such reviews can be useful by exploring topics that are under-researched as well as for new insights or ways of thinking regarding well-developed, robustly researched fields.

Narrative reviews are often useful for topics that require a meaningful synthesis of research evidence that may be complex or broad and that require detailed, nuanced description and interpretation. 1 See Boxes 1 and 2 for resources on writing a narrative review as well as a case example of a program director's use of a narrative review for an interprofessional education experience. This Journal of Graduate Medical Education (JGME) special review series will continue to use the Case of Dr. Smith to consider the same question using different review methodologies.

Box 1 The Case of Dr. Smith

Dr. Smith, a program director, has been tasked to develop an interprofessional education (IPE) experience for the residency program. Dr. Smith decides that conducting a literature review would be a savvy way to examine the existing evidence and generate a publication useful to others. Using PubMed and a general subject search with “interprofessional education,” Dr. Smith identifies 24 000 matches. Dr. Smith begins to randomly sample the papers and notes the huge diversity of types and approaches: randomized trials, qualitative investigations, critical perspectives, and more.

Dr. Smith decides to do a meta-narrative review, because she notes that there are tensions and contradictions in the ways in which IPE is discussed by different health professions education communities, such as in nursing literature vs in medical journals.

Box 2 Resources

Ferrari R. Writing narrative style literature reviews. Med Writing . 2015;24(4):230-235. doi: 10.1179/2047480615Z.000000000329

Green BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. J Chiropr Med . 2006;5(3):101-117. doi: 10.1016/S0899-3467(07)60142-6

Gregory AT, Denniss AR. An introduction to writing narrative and systematic reviews—tasks, tips and traps for aspiring authors. Heart Lung Circ . 2018;27(7):893-898. doi: 10.1016/j.hlc.2018.03.027

Murphy CM. Writing an effective review article. J Med Toxicol . 2012;8(2):89-90. doi: 10.1007/s13181-012-0234-2

Process and Rigor

While each type of narrative review has its own associated markers of rigor, the following guidelines are broadly applicable to narrative reviews and can help readers critically appraise their quality. These principles may also guide researchers who wish to conduct narrative reviews. When engaging with a narrative review as a reader or a researcher, scholars are advised to be conversant with the following 5 foundational elements of narrative reviews.

Rationale for a Narrative Review

First, scholars should consider the framing of the research question. Does the topic being studied align with the type of knowledge synthesis performed through a narrative review? Authors should have a clear research question and a specific audience target. Authors should also provide a rationale for why a narrative review method was chosen. 6 The manuscript should include the initial research question as well as details about any iterative refinements to the question.

Clarity of Boundaries, Scope, and Definitions

Second, although narrative reviews do not typically involve strict predetermined inclusion or exclusion criteria, scholars should explicitly demarcate the boundaries and scope of their topic. They should also clearly define key terms related to the topic and research question and any definitions used. Authors should elaborate why they chose a particular definition if others were available. As narrative reviews are flexible, the initial scope may change through the review process. In such circumstances, authors should provide reasonable justification for the evolution of inclusion and exclusion criteria and a description of how this affected the literature search.

Justification for Inclusion and Exclusion Criteria

Third, authors of narrative reviews should explain which search terms and databases were included in the synthesis and why. For example, did authors include research studies from a particular database, time frame, or study design? Did they include commentaries or empirical articles? Did they include grey literature such as trade publications, reports, or digital media? Each of the authors' choices should be outlined with appropriate reasoning. 7 Narrative reviews tend to be iterative and involve multiple cycles of searching, analysis, and interpretation. High-quality narrative reviews usually include pivotal or seminal papers that address the phenomenon of interest and other manuscripts that are relevant to the research question.

Reflexivity and a Saturation/Sufficiency Statement

Fourth, narrative reviews should clearly specify any factors that may have shaped the authors' interpretations and analysis. One fundamental distinction between narrative and non-narrative reviews is that narrative reviews explicitly recognize that they may not include all relevant literature on a topic. Since narrative reviews do not aim to be inclusive of all literature addressing the phenomenon of interest, a justification for the selection of manuscripts must be included. Authors should carefully outline how researchers conducted analyses and how they determined that sufficient analysis and interpretation was achieved. This latter concept is similar to considerations of saturation or thematic sufficiency in primary qualitative research. 8

Details on Analysis and Interpretation

Lastly, since several different categories of reviews fall under the narrative review umbrella, the analysis conducted in a narrative review varies by type. Regardless of the type of narrative review carried out, authors should clearly describe how analyses were conducted and provide justification for their approach. Narrative reviews are enhanced when researchers are explicit about how their perspectives and experiences informed problem identification, interpretation, and analysis. Given that authors' unique perspectives shape the selection of literature and its interpretation, narrative reviews may be reproduced, but different authors will likely yield different insights and interpretations.

Distinctive Methods and Subtypes

The narrative review has been commonly framed as an umbrella term that includes several different subtypes of reviews. These narrative medicine subtypes share the goals of deepening an understanding of a topic, while describing why researchers chose to explore and analyze the topic in a specific way.

There are several subtypes of narrative reviews with distinctive methodologies; each offers a unique way of approaching the research question and analyzing and interpreting the literature. This article will describe some common narrative review types that will also be discussed in upcoming JGME special articles on reviews: state-of-the-art , meta-ethnographic , critical , and theory integration reviews.

A state-of-the-art review attempts to summarize the research concerning a specific topic along a timeline of significant changes in understanding or research orientations. By focusing on such turning points in the history of evolving understandings of a phenomenon, state-of-the-art reviews offer a summary of the current state of understanding, how such an understanding was developed, and an idea of future directions. A state-of-the art review seeks to offer a 3-part description: where are we now in our understanding, how did we get here, and where should we go next?

A meta-ethnographic review involves choosing and interpreting qualitative research evidence about a specific topic. Working exclusively with qualitative data, this type of knowledge synthesis aims to generate new insights or new conclusions about a topic. It draws together insights and analyses from existing publications of qualitative research to construct new knowledge that spans across these individual, and often small scale, studies.

A meta-narrative review seeks to explore and make sense of contradictions and tensions within the literature. A meta-narrative review maps how a certain topic is understood in distinct ways, conducts a focused search to describe and compare narratives, and then seeks to make sense of how such narratives are interpreted across different disciplines or historical contexts, as part of the analysis. 9

A critical review is a narrative synthesis of literature that brings an interpretative lens: the review is shaped by a theory, a critical point of view, or perspectives from other domains to inform the literature analysis. Critical reviews involve an interpretative process that combines the reviewer's theoretical premise with existing theories and models to allow for synthesis and interpretation of diverse studies. First, reviewers develop and outline their interpretive theoretical position, which is informed by individual knowledge and experience. Next, a noncomprehensive search is completed to capture and identify dominant themes focused on a research question. 8 , 10

An integrative review typically has 1 of 2 different orientations. Empirical integrative reviews analyze and synthesize publications of evidence-based studies with diverse methodologies. In contrast, theoretical integrative reviews conduct an analysis of the available theories addressing a phenomenon, critically appraise those theories, and propose an advancement in the development of those theories. Both types of integrative reviews follow a multistage approach including problem identification, searching, evaluation, analysis, and presentation. 11

Strengths and Weaknesses

Narrative reviews have many strengths. They are flexible and practical, and ideally provide a readable, relevant synthesis of a diverse literature. Narrative reviews are often helpful for teaching or learning about a topic because they deliver a general overview. They are also useful for setting the stage for future research, as they offer an interpretation of the literature, note gaps, and critique research to date.

Such reviews may be useful for providing general background; however, a more comprehensive form of review may be necessary. Narrative reviews do not offer an evidence-based synthesis for focused questions, nor do they offer definitive guideline statements. All types of narrative reviews offer interpretations that are open to critique and will vary depending on the author team or context of the review.

Conclusions

Well-done narrative reviews provide a readable, thoughtful, and practical synthesis on a topic. They allow review authors to advance new ideas while describing and interpreting literature in the field. Narrative reviews do not aim to be systematic syntheses that answer a specific, highly focused question; instead, they offer carefully thought out and rigorous interpretations of a body of knowledge. Such reviews will not provide an exhaustive, comprehensive review of the literature; however, they are useful for a rich and meaningful summary of a topic.

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• Critical Reviews

How to Write an Article Review (With Examples)

Last Updated: July 27, 2024 Fact Checked

Preparing to Write Your Review

Writing the article review, sample article reviews, expert q&a.

This article was co-authored by Jake Adams . Jake Adams is an academic tutor and the owner of Simplifi EDU, a Santa Monica, California based online tutoring business offering learning resources and online tutors for academic subjects K-College, SAT & ACT prep, and college admissions applications. With over 14 years of professional tutoring experience, Jake is dedicated to providing his clients the very best online tutoring experience and access to a network of excellent undergraduate and graduate-level tutors from top colleges all over the nation. Jake holds a BS in International Business and Marketing from Pepperdine University. There are 12 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 3,130,389 times.

An article review is both a summary and an evaluation of another writer's article. Teachers often assign article reviews to introduce students to the work of experts in the field. Experts also are often asked to review the work of other professionals. Understanding the main points and arguments of the article is essential for an accurate summation. Logical evaluation of the article's main theme, supporting arguments, and implications for further research is an important element of a review . Here are a few guidelines for writing an article review.

Education specialist Alexander Peterman recommends: "In the case of a review, your objective should be to reflect on the effectiveness of what has already been written, rather than writing to inform your audience about a subject."

Article Review 101

• Read the article very closely, and then take time to reflect on your evaluation. Consider whether the article effectively achieves what it set out to.
• Write out a full article review by completing your intro, summary, evaluation, and conclusion. Don't forget to add a title, too!
• Proofread your review for mistakes (like grammar and usage), while also cutting down on needless information.

• Article reviews present more than just an opinion. You will engage with the text to create a response to the scholarly writer's ideas. You will respond to and use ideas, theories, and research from your studies. Your critique of the article will be based on proof and your own thoughtful reasoning.
• An article review only responds to the author's research. It typically does not provide any new research. However, if you are correcting misleading or otherwise incorrect points, some new data may be presented.
• An article review both summarizes and evaluates the article.

• Summarize the article. Focus on the important points, claims, and information.
• Discuss the positive aspects of the article. Think about what the author does well, good points she makes, and insightful observations.
• Identify contradictions, gaps, and inconsistencies in the text. Determine if there is enough data or research included to support the author's claims. Find any unanswered questions left in the article.

• Make note of words or issues you don't understand and questions you have.
• Look up terms or concepts you are unfamiliar with, so you can fully understand the article. Read about concepts in-depth to make sure you understand their full context.

• Pay careful attention to the meaning of the article. Make sure you fully understand the article. The only way to write a good article review is to understand the article.

• With either method, make an outline of the main points made in the article and the supporting research or arguments. It is strictly a restatement of the main points of the article and does not include your opinions.
• After putting the article in your own words, decide which parts of the article you want to discuss in your review. You can focus on the theoretical approach, the content, the presentation or interpretation of evidence, or the style. You will always discuss the main issues of the article, but you can sometimes also focus on certain aspects. This comes in handy if you want to focus the review towards the content of a course.
• Review the summary outline to eliminate unnecessary items. Erase or cross out the less important arguments or supplemental information. Your revised summary can serve as the basis for the summary you provide at the beginning of your review.

• What does the article set out to do?
• What is the theoretical framework or assumptions?
• Are the central concepts clearly defined?
• How adequate is the evidence?
• How does the article fit into the literature and field?
• Does it advance the knowledge of the subject?
• How clear is the author's writing? Don't: include superficial opinions or your personal reaction. Do: pay attention to your biases, so you can overcome them.

• For example, in MLA , a citation may look like: Duvall, John N. "The (Super)Marketplace of Images: Television as Unmediated Mediation in DeLillo's White Noise ." Arizona Quarterly 50.3 (1994): 127-53. Print. [9] X Trustworthy Source Purdue Online Writing Lab Trusted resource for writing and citation guidelines Go to source

• For example: The article, "Condom use will increase the spread of AIDS," was written by Anthony Zimmerman, a Catholic priest.

• Your introduction should only be 10-25% of your review.
• End the introduction with your thesis. Your thesis should address the above issues. For example: Although the author has some good points, his article is biased and contains some misinterpretation of data from others’ analysis of the effectiveness of the condom.

• Use direct quotes from the author sparingly.
• Review the summary you have written. Read over your summary many times to ensure that your words are an accurate description of the author's article.

• Support your critique with evidence from the article or other texts.
• The summary portion is very important for your critique. You must make the author's argument clear in the summary section for your evaluation to make sense.
• Remember, this is not where you say if you liked the article or not. You are assessing the significance and relevance of the article.
• Use a topic sentence and supportive arguments for each opinion. For example, you might address a particular strength in the first sentence of the opinion section, followed by several sentences elaborating on the significance of the point.

• This should only be about 10% of your overall essay.
• For example: This critical review has evaluated the article "Condom use will increase the spread of AIDS" by Anthony Zimmerman. The arguments in the article show the presence of bias, prejudice, argumentative writing without supporting details, and misinformation. These points weaken the author’s arguments and reduce his credibility.

• Make sure you have identified and discussed the 3-4 key issues in the article.

You Might Also Like

• ↑ https://libguides.cmich.edu/writinghelp/articlereview
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548566/
• ↑ Jake Adams. Academic Tutor & Test Prep Specialist. Expert Interview. 24 July 2020.
• ↑ https://guides.library.queensu.ca/introduction-research/writing/critical
• ↑ https://www.iup.edu/writingcenter/writing-resources/organization-and-structure/creating-an-outline.html
• ↑ https://writing.umn.edu/sws/assets/pdf/quicktips/titles.pdf
• ↑ https://owl.purdue.edu/owl/research_and_citation/mla_style/mla_formatting_and_style_guide/mla_works_cited_periodicals.html
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548565/
• ↑ https://writingcenter.uconn.edu/wp-content/uploads/sites/593/2014/06/How_to_Summarize_a_Research_Article1.pdf
• ↑ https://www.uis.edu/learning-hub/writing-resources/handouts/learning-hub/how-to-review-a-journal-article
• ↑ https://writingcenter.unc.edu/tips-and-tools/editing-and-proofreading/

About This Article

If you have to write an article review, read through the original article closely, taking notes and highlighting important sections as you read. Next, rewrite the article in your own words, either in a long paragraph or as an outline. Open your article review by citing the article, then write an introduction which states the article’s thesis. Next, summarize the article, followed by your opinion about whether the article was clear, thorough, and useful. Finish with a paragraph that summarizes the main points of the article and your opinions. To learn more about what to include in your personal critique of the article, keep reading the article! Did this summary help you? Yes No

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• Writing an article SUMMARY
• Writing an article REVIEW

Writing an article CRITIQUE

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A critique asks you to evaluate an article and the author’s argument. You will need to look critically at what the author is claiming, evaluate the research methods, and look for possible problems with, or applications of, the researcher’s claims.

Introduction

Give an overview of the author’s main points and how the author supports those points. Explain what the author found and describe the process they used to arrive at this conclusion.

Body Paragraphs

Interpret the information from the article:

• Does the author review previous studies? Is current and relevant research used?
• What type of research was used – empirical studies, anecdotal material, or personal observations?
• Was the sample too small to generalize from?
• Was the participant group lacking in diversity (race, gender, age, education, socioeconomic status, etc.)
• For instance, volunteers gathered at a health food store might have different attitudes about nutrition than the population at large.
• How useful does this work seem to you? How does the author suggest the findings could be applied and how do you believe they could be applied?
• How could the study have been improved in your opinion?
• Does the author appear to have any biases (related to gender, race, class, or politics)?
• Is the writing clear and easy to follow? Does the author’s tone add to or detract from the article?
• How useful are the visuals (such as tables, charts, maps, photographs) included, if any? How do they help to illustrate the argument? Are they confusing or hard to read?
• What further research might be conducted on this subject?

Try to synthesize the pieces of your critique to emphasize your own main points about the author’s work, relating the researcher’s work to your own knowledge or to topics being discussed in your course.

From the Center for Academic Excellence (opens in a new window), University of Saint Joseph Connecticut

Additional Resources

All links open in a new window.

Writing an Article Critique (from The University of Arizona Global Campus Writing Center)

How to Critique an Article (from Essaypro.com)

How to Write an Article Critique (from EliteEditing.com.au)

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• Last Updated: Mar 15, 2024 9:32 AM
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How to Write a Research Proposal: (with Examples & Templates)

Table of Contents

Before conducting a study, a research proposal should be created that outlines researchers’ plans and methodology and is submitted to the concerned evaluating organization or person. Creating a research proposal is an important step to ensure that researchers are on track and are moving forward as intended. A research proposal can be defined as a detailed plan or blueprint for the proposed research that you intend to undertake. It provides readers with a snapshot of your project by describing what you will investigate, why it is needed, and how you will conduct the research.  

Your research proposal should aim to explain to the readers why your research is relevant and original, that you understand the context and current scenario in the field, have the appropriate resources to conduct the research, and that the research is feasible given the usual constraints.  

This article will describe in detail the purpose and typical structure of a research proposal , along with examples and templates to help you ace this step in your research journey.  

What is a Research Proposal ?  

A research proposal¹ ,²  can be defined as a formal report that describes your proposed research, its objectives, methodology, implications, and other important details. Research proposals are the framework of your research and are used to obtain approvals or grants to conduct the study from various committees or organizations. Consequently, research proposals should convince readers of your study’s credibility, accuracy, achievability, practicality, and reproducibility.   

With research proposals , researchers usually aim to persuade the readers, funding agencies, educational institutions, and supervisors to approve the proposal. To achieve this, the report should be well structured with the objectives written in clear, understandable language devoid of jargon. A well-organized research proposal conveys to the readers or evaluators that the writer has thought out the research plan meticulously and has the resources to ensure timely completion.  

Purpose of Research Proposals  

A research proposal is a sales pitch and therefore should be detailed enough to convince your readers, who could be supervisors, ethics committees, universities, etc., that what you’re proposing has merit and is feasible . Research proposals can help students discuss their dissertation with their faculty or fulfill course requirements and also help researchers obtain funding. A well-structured proposal instills confidence among readers about your ability to conduct and complete the study as proposed.  

Research proposals can be written for several reasons:³  

• To describe the importance of research in the specific topic  
• Address any potential challenges you may encounter  
• Showcase knowledge in the field and your ability to conduct a study  
• Apply for a role at a research institute  
• Convince a research supervisor or university that your research can satisfy the requirements of a degree program  
• Highlight the importance of your research to organizations that may sponsor your project  
• Identify implications of your project and how it can benefit the audience  

What Goes in a Research Proposal?    

Research proposals should aim to answer the three basic questions—what, why, and how.  

The What question should be answered by describing the specific subject being researched. It should typically include the objectives, the cohort details, and the location or setting.  

The Why question should be answered by describing the existing scenario of the subject, listing unanswered questions, identifying gaps in the existing research, and describing how your study can address these gaps, along with the implications and significance.  

The How question should be answered by describing the proposed research methodology, data analysis tools expected to be used, and other details to describe your proposed methodology.   

Research Proposal Example  

Here is a research proposal sample template (with examples) from the University of Rochester Medical Center. 4 The sections in all research proposals are essentially the same although different terminology and other specific sections may be used depending on the subject.  

Structure of a Research Proposal  

If you want to know how to make a research proposal impactful, include the following components:¹  

1. Introduction  

This section provides a background of the study, including the research topic, what is already known about it and the gaps, and the significance of the proposed research.  

2. Literature review  

This section contains descriptions of all the previous relevant studies pertaining to the research topic. Every study cited should be described in a few sentences, starting with the general studies to the more specific ones. This section builds on the understanding gained by readers in the Introduction section and supports it by citing relevant prior literature, indicating to readers that you have thoroughly researched your subject.  

3. Objectives  

Once the background and gaps in the research topic have been established, authors must now state the aims of the research clearly. Hypotheses should be mentioned here. This section further helps readers understand what your study’s specific goals are.  

4. Research design and methodology  

Here, authors should clearly describe the methods they intend to use to achieve their proposed objectives. Important components of this section include the population and sample size, data collection and analysis methods and duration, statistical analysis software, measures to avoid bias (randomization, blinding), etc.  

5. Ethical considerations  

This refers to the protection of participants’ rights, such as the right to privacy, right to confidentiality, etc. Researchers need to obtain informed consent and institutional review approval by the required authorities and mention this clearly for transparency.  

6. Budget/funding  

Researchers should prepare their budget and include all expected expenditures. An additional allowance for contingencies such as delays should also be factored in.  

7. Appendices  

This section typically includes information that supports the research proposal and may include informed consent forms, questionnaires, participant information, measurement tools, etc.  

8. Citations  

Important Tips for Writing a Research Proposal  

Writing a research proposal begins much before the actual task of writing. Planning the research proposal structure and content is an important stage, which if done efficiently, can help you seamlessly transition into the writing stage. 3,5  

The Planning Stage  

• Manage your time efficiently. Plan to have the draft version ready at least two weeks before your deadline and the final version at least two to three days before the deadline.
• What is the primary objective of your research?  
• Will your research address any existing gap?  
• What is the impact of your proposed research?  
• Do people outside your field find your research applicable in other areas?  
• If your research is unsuccessful, would there still be other useful research outcomes?  

  The Writing Stage  

• Create an outline with main section headings that are typically used.  
• Focus only on writing and getting your points across without worrying about the format of the research proposal , grammar, punctuation, etc. These can be fixed during the subsequent passes. Add details to each section heading you created in the beginning.   
• Ensure your sentences are concise and use plain language. A research proposal usually contains about 2,000 to 4,000 words or four to seven pages.  
• Don’t use too many technical terms and abbreviations assuming that the readers would know them. Define the abbreviations and technical terms.  
• Ensure that the entire content is readable. Avoid using long paragraphs because they affect the continuity in reading. Break them into shorter paragraphs and introduce some white space for readability.  
• Focus on only the major research issues and cite sources accordingly. Don’t include generic information or their sources in the literature review.  
• Proofread your final document to ensure there are no grammatical errors so readers can enjoy a seamless, uninterrupted read.  
• Use academic, scholarly language because it brings formality into a document.  
• Ensure that your title is created using the keywords in the document and is neither too long and specific nor too short and general.  
• Cite all sources appropriately to avoid plagiarism.  
• Make sure that you follow guidelines, if provided. This includes rules as simple as using a specific font or a hyphen or en dash between numerical ranges.  
• Ensure that you’ve answered all questions requested by the evaluating authority.  

Key Takeaways   

Here’s a summary of the main points about research proposals discussed in the previous sections:  

• A research proposal is a document that outlines the details of a proposed study and is created by researchers to submit to evaluators who could be research institutions, universities, faculty, etc.  
• Research proposals are usually about 2,000-4,000 words long, but this depends on the evaluating authority’s guidelines.  
• A good research proposal ensures that you’ve done your background research and assessed the feasibility of the research.  
• Research proposals have the following main sections—introduction, literature review, objectives, methodology, ethical considerations, and budget.  

Frequently Asked Questions  

Q1. How is a research proposal evaluated?  

A1. In general, most evaluators, including universities, broadly use the following criteria to evaluate research proposals . 6  

• Significance —Does the research address any important subject or issue, which may or may not be specific to the evaluator or university?  
• Content and design —Is the proposed methodology appropriate to answer the research question? Are the objectives clear and well aligned with the proposed methodology?  
• Sample size and selection —Is the target population or cohort size clearly mentioned? Is the sampling process used to select participants randomized, appropriate, and free of bias?  
• Timing —Are the proposed data collection dates mentioned clearly? Is the project feasible given the specified resources and timeline?  
• Data management and dissemination —Who will have access to the data? What is the plan for data analysis?  

Q2. What is the difference between the Introduction and Literature Review sections in a research proposal ?  

A2. The Introduction or Background section in a research proposal sets the context of the study by describing the current scenario of the subject and identifying the gaps and need for the research. A Literature Review, on the other hand, provides references to all prior relevant literature to help corroborate the gaps identified and the research need.  

Q3. How long should a research proposal be?  

A3. Research proposal lengths vary with the evaluating authority like universities or committees and also the subject. Here’s a table that lists the typical research proposal lengths for a few universities.  

Q4. What are the common mistakes to avoid in a research proposal ?  

A4. Here are a few common mistakes that you must avoid while writing a research proposal . 7  

• No clear objectives: Objectives should be clear, specific, and measurable for the easy understanding among readers.  
• Incomplete or unconvincing background research: Background research usually includes a review of the current scenario of the particular industry and also a review of the previous literature on the subject. This helps readers understand your reasons for undertaking this research because you identified gaps in the existing research.  
• Overlooking project feasibility: The project scope and estimates should be realistic considering the resources and time available.   
• Neglecting the impact and significance of the study: In a research proposal , readers and evaluators look for the implications or significance of your research and how it contributes to the existing research. This information should always be included.  
• Unstructured format of a research proposal : A well-structured document gives confidence to evaluators that you have read the guidelines carefully and are well organized in your approach, consequently affirming that you will be able to undertake the research as mentioned in your proposal.  
• Ineffective writing style: The language used should be formal and grammatically correct. If required, editors could be consulted, including AI-based tools such as Paperpal , to refine the research proposal structure and language.  

Thus, a research proposal is an essential document that can help you promote your research and secure funds and grants for conducting your research. Consequently, it should be well written in clear language and include all essential details to convince the evaluators of your ability to conduct the research as proposed.  

This article has described all the important components of a research proposal and has also provided tips to improve your writing style. We hope all these tips will help you write a well-structured research proposal to ensure receipt of grants or any other purpose.  

References  

• Sudheesh K, Duggappa DR, Nethra SS. How to write a research proposal? Indian J Anaesth. 2016;60(9):631-634. Accessed July 15, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5037942/  
• Writing research proposals. Harvard College Office of Undergraduate Research and Fellowships. Harvard University. Accessed July 14, 2024. https://uraf.harvard.edu/apply-opportunities/app-components/essays/research-proposals  
• What is a research proposal? Plus how to write one. Indeed website. Accessed July 17, 2024. https://www.indeed.com/career-advice/career-development/research-proposal  
• Research proposal template. University of Rochester Medical Center. Accessed July 16, 2024. https://www.urmc.rochester.edu/MediaLibraries/URMCMedia/pediatrics/research/documents/Research-proposal-Template.pdf  
• Tips for successful proposal writing. Johns Hopkins University. Accessed July 17, 2024. https://research.jhu.edu/wp-content/uploads/2018/09/Tips-for-Successful-Proposal-Writing.pdf  
• Formal review of research proposals. Cornell University. Accessed July 18, 2024. https://irp.dpb.cornell.edu/surveys/survey-assessment-review-group/research-proposals  
• 7 Mistakes you must avoid in your research proposal. Aveksana (via LinkedIn). Accessed July 17, 2024. https://www.linkedin.com/pulse/7-mistakes-you-must-avoid-your-research-proposal-aveksana-cmtwf/  

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Get accurate academic translations, rewriting support, grammar checks, vocabulary suggestions, and generative AI assistance that delivers human precision at machine speed. Try for free or upgrade to Paperpal Prime starting at US$19 a month to access premium features, including consistency, plagiarism, and 30+ submission readiness checks to help you succeed.  

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Bioenergy and Value-Added Chemicals Derived Through Electrocatalytic Upgradation of Biomass: a Critical Review

• Published: 16 August 2024

Cite this article

• Mudasir Akbar Shah   ORCID: orcid.org/0000-0002-6204-5242 1 ,
• Wasif Farooq 1 , 3 ,
• Tasrin Shahnaz 2 &
• Muthumariappan Akilarasan 3  

Electrocatalytic upgradation of biomass for chemicals and energy production is an emerging approach to address the environmental issues related to chemicals and energy production. If coupled with renewable energy, this approach will further enhance the sustainability goals for the future energy and chemical sector. This work critically reviews the progress on oxidative and reductive electrocatalytic upgrading of biomass-derived chemicals such as glycerol, sorbitol, levulinic acid, 5-hydroxymethylfurfural, furfural, and bio-oil to value-added products, including 2.5-dimethyl tetrahydrofuran, 2.5-dihydroxy methyl tetrahydro furan, 2-hydroxymethyl-5-(methyl amino methyl) furan, and 2,5-furan dicarboxylic acid with simulations production of hydrogen (H 2 ) energy. The role of the mediator in electrocatalytic upgradation serves as a high-efficiency catalytic platform for oxidation and reduction reactions. Pd and Ru exhibit promising attributes such as durability and superior electrocatalytic hydrogenation performance. Additionally, this review discusses various methods for enhancing biofuel through a multitude of approaches, such as hydrocracking, hydrotreatment, supercritical fluid processing, steam reforming, catalytic cracking, esterification, emulsification, hydrodeoxygenation, and electrocatalytic hydrogenation. Techno-economic assessment of electrocatalytic conversion of biomass to chemicals and energy are explored to identify the key contributing factors toward the economic viability of electrocatalytic upgradation of biomass for chemical and energy. Finally, research gaps are identified for further work along with economic assessment of electrocatalytic upgradation of biomass technology with and without integration of renewable energy.

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The authors would like to acknowledge the support provided by the Department of Chemical Engineering at King Fahd University of Petroleum and Minerals (KFUPM). Authors from KFUPM would like to acknowledge the funding from Interdisciplinary Research Center for Refining & Advanced Chemicals (IRC-CRAC), King Fahd University of Petroleum & Minerals (KFUPM), Dhahran, 31261, Saudi Arabia through Project Nos. INRC 2439.

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Shah, M.A., Farooq, W., Shahnaz, T. et al. Bioenergy and Value-Added Chemicals Derived Through Electrocatalytic Upgradation of Biomass: a Critical Review. Bioenerg. Res. (2024). https://doi.org/10.1007/s12155-024-10797-6

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Factors critical for the successful delivery of telehealth to rural populations: a descriptive qualitative study

• Rebecca Barry   ORCID: orcid.org/0000-0003-2272-4694 1 ,
• Elyce Green   ORCID: orcid.org/0000-0002-7291-6419 1 ,
• Kristy Robson   ORCID: orcid.org/0000-0002-8046-7940 1 &
• Melissa Nott   ORCID: orcid.org/0000-0001-7088-5826 1  

BMC Health Services Research volume  24 , Article number:  908 ( 2024 ) Cite this article

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The use of telehealth has proliferated to the point of being a common and accepted method of healthcare service delivery. Due to the rapidity of telehealth implementation, the evidence underpinning this approach to healthcare delivery is lagging, particularly when considering the uniqueness of some service users, such as those in rural areas. This research aimed to address the current gap in knowledge related to the factors critical for the successful delivery of telehealth to rural populations.

This research used a qualitative descriptive design to explore telehealth service provision in rural areas from the perspective of clinicians and describe factors critical to the effective delivery of telehealth in rural contexts. Semi-structured interviews were conducted with clinicians from allied health and nursing backgrounds working in child and family nursing, allied health services, and mental health services. A manifest content analysis was undertaken using the Framework approach.

Sixteen health professionals from nursing, clinical psychology, and social work were interviewed. Participants mostly identified as female (88%) and ranged in age from 26 to 65 years with a mean age of 47 years. Three overarching themes were identified: (1) Navigating the role of telehealth to support rural healthcare; (2) Preparing clinicians to engage in telehealth service delivery; and (3) Appreciating the complexities of telehealth implementation across services and environments.

Conclusions

This research suggests that successful delivery of telehealth to rural populations requires consideration of the context in which telehealth services are being delivered, particularly in rural and remote communities where there are challenges with resourcing and training to support health professionals. Rural populations, like all communities, need choice in healthcare service delivery and models to increase accessibility. Preparation and specific, intentional training for health professionals on how to transition to and maintain telehealth services is a critical factor for delivery of telehealth to rural populations. Future research should further investigate the training and supports required for telehealth service provision, including who, when and what training will equip health professionals with the appropriate skill set to deliver rural telehealth services.

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Introduction

Telehealth is a commonly utilised application in rural health settings due to its ability to augment service delivery across wide geographical areas. During the COVID-19 pandemic, the use of telehealth became prolific as it was rapidly adopted across many new fields of practice to allow for healthcare to continue despite requirements for physical distancing. In Australia, the Medicare Benefits Scheme (MBS) lists health services that are subsidised by the federal government. Telehealth items were extensively added to these services as part of the response to COVID-19 [ 1 ]. Although there are no longer requirements for physical distancing in Australia, many health providers have continued to offer services via telehealth, particularly in rural areas [ 2 , 3 ]. For the purpose of this research, telehealth was defined as a consultation with a healthcare provider by phone or video call [ 4 ]. Telehealth service provision in rural areas requires consideration of contextual factors such as access to reliable internet, community members’ means to finance this access [ 5 ], and the requirement for health professionals to function across a broad range of specialty skills. These factors present a case for considering the delivery of telehealth in rural areas as a unique approach, rather than one portion of the broader use of telehealth.

Research focused on rural telehealth has proliferated alongside the rapid implementation of this service mode. To date, there has been a focus on the impact of telehealth on areas such as client access and outcomes [ 2 ], client and health professional satisfaction with services and technology [ 6 ], direct and indirect costs to the patient (travel cost and time), healthcare service provider staffing, lower onsite healthcare resource utilisation, improved physician recruitment and retention, and improved client access to care and education [ 7 , 8 ]. In terms of service implementation, these elements are important but do not outline the broader implementation factors critical to the success of telehealth delivery in rural areas. One study by Sutarsa et al. explored the implications of telehealth as a replacement for face-to-face services from the perspectives of general practitioners and clients [ 9 ] and articulated that telehealth services are not a like-for-like service compared to face-to-face modes. Research has also highlighted the importance of understanding the experience of telehealth in rural Australia across different population groups, including Aboriginal and Torres Strait Islander peoples, and the need to consider culturally appropriate services [ 10 , 11 , 12 , 13 ].

Research is now required to determine what the critical implementation factors are for telehealth delivery in rural areas. This type of research would move towards answering calls for interdisciplinary, qualitative, place-based research [ 12 ] that explores factors required for the sustainability and usability of telehealth in rural areas. It would also contribute to the currently limited understanding of implementation factors required for telehealth delivery to rural populations [ 14 ]. There is a reasonable expectation that there is consistency in the way health services are delivered, particularly across geographical locations. Due to the rapid implementation of telehealth services, there was limited opportunity to proactively identify factors critical for successful telehealth delivery in rural areas and this has created a lag in policy, process, and training. This research aimed to address this gap in the literature by exploring and describing rural health professionals’ experiences providing telehealth services. For the purpose of this research, rural is inclusive of locations classified as rural or remote (MM3-6) using the Modified Monash Model which considers remoteness and population size in its categorisation [ 15 ].

This research study adopted a qualitative descriptive design as described by Sandelowski [ 16 ]. The purpose of a descriptive study is to document and describe a phenomenon of interest [ 17 ] and this method is useful when researchers seek to understand who was involved, what occurred, and the location of the phenomena of interest [ 18 ]. The phenomenon of interest for this research was the provision of telehealth services to rural communities by health professionals. In line with this, a purposive sampling technique was used to identify participants who have experience of this phenomenon [ 19 ]. This research is reported in line with the consolidated criteria for reporting qualitative research [ 20 ] to enhance transparency and trustworthiness of the research process and results [ 21 ].

Research aims

This research aimed to:

Explore telehealth service provision in rural areas from the perspective of clinicians.

Describe factors critical to the successful delivery of telehealth in rural contexts.

Participant recruitment and data collection

People eligible to participate in the research were allied health (using the definition provided by Allied Health Professions Australia [ 22 ]) or nursing staff who delivered telehealth services to people living in the geographical area covered by two rural local health districts in New South Wales, Australia (encompassing rural areas MM3-6). Health organisations providing telehealth service delivery in the southwestern and central western regions of New South Wales were identified through the research teams’ networks and invited to be part of the research.

Telehealth adoption in these organisations was intentionally variable to capture different experiences and ranged from newly established (prompted by COVID-19) to well established (> 10 years of telehealth use). Organisations included government, non-government, and not-for-profit health service providers offering child and family nursing, allied health services, and mental health services. Child and family nursing services were delivered by a government health service and a not-for-profit specialist service, providing health professional advice, education, and guidance to families with a baby or toddler. Child and family nurses were in the same geographical region as the families receiving telehealth. Transition to telehealth services was prompted by the COVID-19 pandemic. The participating allied health service was a large, non-government provider of allied health services to regional New South Wales. Allied health professionals were in the same region as the client receiving telehealth services. Use of telehealth in this organisation had commenced prior to the COVID-19 pandemic. Telehealth mental health services were delivered by an emergency mental health team, located at a large regional hospital to clients in another healthcare facility or location to which the health professional could not be physically present (typically a lower acuity health service in a rural location).

Once organisations agreed to disseminate the research invitation, a key contact person employed at each health organisation invited staff to participate via email. Staff were provided with contact details of the research team in the email invitation. All recruitment and consent processes were managed by the research team to minimise risk of real or perceived coercion between staff and the key contact person, who was often in a supervisory or managerial position within the organisation. Data were collected using semi-structured interviews using an online platform with only the interviewer and participant present. Interviews were conducted by a research team member with training in qualitative data collection during November and December 2021 and were transcribed verbatim by a professional transcribing service. All participants were offered the opportunity to review their transcript and provide feedback, however none opted to do so. Data saturation was not used as guidance for participant numbers, taking the view of Braun and Clarke [ 23 ] that meaning is generated through the analysis rather than reaching a point of saturation.

Data analysis

Researchers undertook a manifest content analysis of the data using the Framework approach developed by Ritchie and Spencer [ 24 ]. All four co-authors were involved in the data analysis process. Framework uses five stages for analysis including (1) familiarisation (2) identifying a thematic framework based on emergent overarching themes, (3) application of the coding framework to the interview transcripts [indexing], (4) reviewing and charting of themes and subthemes, and (5) mapping and interpretation [ 24 , p. 178]. The research team analysed a common interview initially, identified codes and themes, then independently applied these to the remaining interviews. Themes were centrally recorded, reviewed, and discussed by the research team prior to inclusion into the thematic framework. Final themes were confirmed via collaborative discussion and consensus. The iterative process used to review and code data was recorded into an Excel spreadsheet to ensure auditability and credibility, and to enhance the trustworthiness of the analysis process.

This study was approved by the Greater Western NSW Human Research Ethics Committee and Charles Sturt University Human Research Ethics Committee (approval numbers: 2021/ETH00088 and H21215). All participants provided written consent.

Eighteen health professionals consented to be interviewed. Two were lost to follow-up, therefore semi-structured interviews were conducted with 16 of these health professionals, the majority of which were from the discipline of nursing ( n  = 13, 81.3%). Participant demographics and their pseudonyms are shown in Table  1 .

Participants mostly identified as female ( n  = 14, 88%) and ranged in age from 26 to 65 years with a mean age of 47 years. Participants all delivered services to rural communities in the identified local health districts and resided within the geographical area they serviced. The participants resided in areas classified as MM3-6 but were most likely to reside in an area classified MM3 (81%). Average interview time was 38 min, and all interviews were conducted online via Zoom.

Three overarching themes were identified through the analysis of interview transcripts with health professionals. These themes were: (1) Navigating the role of telehealth to support rural healthcare; (2) Preparing clinicians to engage in telehealth service delivery; and (3) Appreciating the complexities of telehealth implementation across services and environments.

Theme 1: navigating the role of telehealth to support rural healthcare

The first theme described clinicians’ experiences of using telehealth to deliver healthcare to rural communities, including perceived benefits and challenges to acceptance, choice, and access. Interview participants identified several factors that impacted on or influenced the way they could deliver telehealth, and these were common across the different organisational structures. Clinicians highlighted the need to consider how to effectively navigate the role of telehealth in supporting their practice, including when it would enhance their practice, and when it might create barriers. The ability to improve rural service provision through greater access was commonly discussed by participants. In terms of factors important for telehealth delivery in rural contexts, the participants demonstrated that knowledge of why and how telehealth was used were important, including the broadened opportunity for healthcare access and an understanding of the benefits and challenges of providing these services.

Access to timely and specialist healthcare for rural communities

Participants described a range of benefits using telehealth to contact small, rural locations and facilitate greater access to services closer to home. This was particularly evident when there was lack of specialist support in these areas. These opportunities meant that rural people could receive timely care that they required, without the burden of travelling significant distances to access health services.

The obvious thing in an area like this, is that years ago, people were being transported three hours just to see us face to face. It’s obviously giving better, more timely access to services. (Patrick)

Staff access to specialist support was seen as an important aspect for rural healthcare by participants, because of the challenges associated with lack of staffing and resources within these areas which potentially increased the risks for staff in these locations, particularly when managing clients with acute mental illnesses.

Within the metro areas they’ve got so many staff and so many hospitals and they can manage mental health patients quite well within those facilities, but with us some of these hospitals will have one RN on overnight and it’s just crappy for them, and so having us able to do video link, it kind of takes the pressure off and we’re happy to make the decisions and the risky decisions for what that person needs. (Tracey)

Participants described how the option to use telehealth to provide specialised knowledge and expertise to support local health staff in rural hospitals likely led to more appropriate outcomes for clients wanting to be able to remain in their community. Conversely, Amber described the implications if telehealth was not available.

If there was some reason why the telehealth wasn’t available… quite often, I suppose the general process be down to putting the pressure on the nursing and the medical staff there to make a decision around that person, which is not a fair or appropriate thing for them to do. (Amber)

Benefits and challenges to providing telehealth in rural communities

Complementing the advantage of reduced travel time to access services, was the ability for clients to access additional support via telehealth, which was perceived as a benefit. For example, one participant described how telehealth was useful for troubleshooting client’s problems rather than waiting for their next scheduled appointment.

If a mum rings you with an issue, you can always say to them “are you happy to jump onto My Virtual Care with me now?” We can do that, do a consult over My Virtual Care. Then I can actually gauge how mum is. (Jade)

While accessibility was a benefit, participants highlighted that rural communities need to be provided with choice, rather than the assumption that telehealth be the preferred option for everyone, as many rural clients want face-to-face services.

They’d all prefer, I think, to be able to see someone in person. I think that’s generally what NSW rural [want] —’cause I’m from country towns as well—there’s no substitute, like I said, for face-to-face assessment. (Adam)

Other, more practical limitations of broad adoption of telehealth raised by the participants included issues with managing technology and variability in internet connectivity.

For many people in the rural areas, it’s still an issue having that regular [internet] connection that works all the time. I think it’s a great option but I still think it’s something that some rural people will always have some challenges with because it’s not—there’s so many black spots and so many issues still with the internet connection in rural areas. Even in town, there’s certain areas that are still having lots of problems. (Chloe)

Participants also identified barriers related to assumptions that all clients will have access to technology and have the necessary data to undertake a telehealth consultation, which wasn’t always the case, particularly with individuals experiencing socioeconomic disadvantage.

A lot of [Aboriginal] families don’t actually have access to telehealth services. Unless they use their phone. If they have the technology on their phones. I found that was a little bit of an issue to try and help those particular clients to get access to the internet, to have enough data on their phone to make that call. There was a lot of issues and a lot of things that we were putting in complaints about as they were going “we’re using up a lot of these peoples’ data and they don’t have internet in their home.” (Evelyn).

Other challenges identified by the participants were related to use of telehealth for clients that required additional support. Many participants talked about the complexities of using an interpreter during a telehealth consultation for culturally and linguistically diverse clients.

Having interpreters, that’s another element that’s really, really difficult because you’re doing video link, but then you’ve also got the phone on speaker and you’re having this three-way conversation. Even that, in itself, that added element on video link is really, really tough. It’s a really long process. (Tracey)

In summary, this theme described some of the benefits and constraints when using telehealth for the delivery of rural health services. The participants demonstrated the importance of understanding the needs and contexts of individual clients, and accounting for this when making decisions to incorporate telehealth into their service provision. Understanding how and why telehealth can be implemented in rural contexts was an important foundation for the delivery of these services.

Theme 2: preparing clinicians to engage in telehealth service delivery

The preparation required for clinicians to engage with telehealth service delivery was highlighted and the participants described the unique set of skills required to effectively build rapport, engage, and carry out assessments with clients. For many participants who had not routinely used telehealth prior to the COVID-19 pandemic, the transition to using telehealth had been rapid. The participants reflected on the implications of rapidly adopting these new practices and the skills they required to effectively deliver care using telehealth. These skills were critical for effective delivery of telehealth to rural communities.

Rapid adoption of new skills and ways of working

The rapid and often unsupported implementation of telehealth in response to the COVID-19 pandemic resulted in clinicians needing to learn and adapt to telehealth, often without being taught or with minimal instruction.

We had to do virtual, virtually overnight we were changed to, “Here you go. Do it this way,” without any real education. It was learned as we went because everybody was in the same boat. Everyone was scrabbling to try and work out how to do it. (Chloe)

In addition to telehealth services starting quickly, telehealth provision requires clinicians to use a unique set of skills. Therapeutic interventions and approaches were identified as being more challenging when seeing a client through a screen, compared to being physically present together in a room.

The body language is hidden a little bit when you’re on teleconference, whereas when you’re standing up face to face with someone, or standing side by side, the person can see the whole picture. When you’re on the video link, the patient actually can’t—you both can’t see each other wholly. That’s one big barrier. (Adam)

There was an emphasis on communication skills such as active listening and body language that were required when engaging with telehealth. These skills were seen as integral to building rapport and connection. The importance of language in an environment with limited visualisation of body language, is further demonstrated by one participant describing how they tuned into the timing and flow of the conversation to avoid interrupting and how these skills were pertinent for using telehealth.

In the beginning especially, we might do this thing where I think they’ve finished or there’s a bit of silence, so I go to speak and then they go to speak at the same time, and that’s different because normally in person you can really gauge that quite well if they’ve got more to say. I think those little things mean that you’ve got to work a bit harder and you’ve got to bring those things to the attention of the client often. (Robyn)

Preparing clinicians to engage in telehealth also required skills in sharing clear and consistent information with clients about the process of interacting via telehealth. This included information to reassure the client that the telehealth appointment was private as well as prepare them for potential interruptions due to connection issues.

I think being really explicitly clear about the fact that with our setups we have here, no one can dial in, no one else is in my room even watching you. We’re not recording, and there’s a lot of extra information, I think around that we could be doing better in terms of delivering to the person. (Amber)

Becoming accustomed to working through the ‘window’

Telehealth was often described as a window and not a view of the whole person which presented limitations for clinicians, such as seeing nuance of expression. Participants described the difficulties of assessing a client using telehealth when you cannot see the whole picture such as facial expressions, movement, behaviour, interactions with others, dress, and hygiene.

I found it was quite difficult because you couldn’t always see the actual child or the baby, especially if they just had their phone. You couldn’t pick up the body language. You couldn’t always see the facial expressions. You couldn’t see the child and how the child was responding. It did inhibit a lot of that side of our assessing. Quite often you’d have to just write, “Unable to view child.” You might be able to hear them but you couldn’t see them. (Chloe)

Due to the window view, the participants described how they needed to pay even greater attention to eye contact and tone of voice when engaging with clients via telehealth.

I think the eye contact is still a really important thing. Getting the flow of what they’re comfortable with a little bit too. It’s being really careful around the tone of voice as well too, because—again, that’s the same for face-to-face, but be particularly careful of it over telehealth. (Amber)

This theme demonstrates that there are unique and nuanced skills required by clinicians to effectively engage in provision of rural healthcare services via telehealth. Many clinicians described how the rapid uptake of telehealth required them to quickly adapt to providing telehealth services, and they had to modify their approach rather than replicate what they would do in face-to-face contexts. Appreciating the different skills sets required for telehealth practice was perceived as an important element in supporting clinicians to deliver quality healthcare.

Theme 3: appreciating the complexities of telehealth implementation across services and environments

It was commonly acknowledged that there needed to be an appreciation by clinicians of the multiple different environments that telehealth was being delivered in, as well as the types of consultations being undertaken. This was particularly important when well-resourced large regional settings were engaging with small rural services or when clinicians were undertaking consultations within a client’s home.

Working from a different location and context

One of the factors identified as important for the successful delivery of services via telehealth was an understanding of the location and context that was being linked into. Participants regularly talked about the challenges when undertaking a telehealth consultation with clients at home, which impacted the quality of the consultation as it was easy to “ lose focus” (Kelsey) and become distracted.

Instead of just coming in with one child, they had all the kids, all wanting their attention. I also found that babies and kids kept pressing the screen and would actually disconnect us regularly. (Chloe)

For participants located in larger regional locations delivering telehealth services to smaller rural hospitals, it was acknowledged that not all services had equivalent resources, skills, and experience with this type of healthcare approach.

They shouldn’t have to do—they’ve gotta double-click here, login there. They’re relying on speakers that don’t work. Sometimes they can’t get the cameras working. I think telehealth works as long as it’s really user friendly. I think nurses—as a nurse, we’re not supposed to be—I know IT’s in our job criteria, but not to the level where you’ve got to have a degree in technology to use it. (Adam)

Participants also recognised that supporting a client through a telehealth consultation adds workload stress as rural clinicians are often having pressures with caseloads and are juggling multiple other tasks while trying to trouble shoot technology issues associated with a telehealth consultation.

Most people are like me, not great with computers. Sometimes the nurse has got other things in the Emergency Department she’s trying to juggle. (Eleanor)

Considerations for safety, privacy, and confidentiality

Participants talked about the challenges that arose due to inconsistencies in where and how the telehealth consultation would be conducted. Concerns about online safety and information privacy were identified by participants.

There’s the privacy issue, particularly when we might see someone and they might be in a bed and they’ve got a laptop there, and they’re not given headphones, and we’re blaring through the speaker at them, and someone’s three meters away in another bed. That’s not good. That’s a bit of a problem. (Patrick)

When telehealth was offered as an option to clients at a remote healthcare site, clinicians noted that some clients were not provided with adequate support and were left to undertake the consultation by themselves which could cause safety risks for the client and an inability for the telehealth clinician to control the situation.

There were some issues with patients’ safety though. Where the telehealth was located was just in a standard consult room and there was actually a situation where somebody self-harmed with a needle that was in a used syringe box in that room. Then it was like, you just can’t see high risk—environment. (Eleanor)

Additionally, participants noted that they were often using their own office space to conduct telehealth consultations rather than a clinical room which meant there were other considerations to think about.

Now I always lock my room so nobody can enter. That’s a nice little lesson learnt. I had a consult with a mum and some other clinicians came into my room and I thought “oh my goodness. I forgot to lock.” I’m very mindful now that I lock. (Jade)

This theme highlights the complexities that exist when implementing telehealth across a range of rural healthcare settings and environments. It was noted by participants that there were variable skills and experience in using telehealth across staff located in smaller rural areas, which could impact on how effective the consultation was. Participants identified the importance of purposely considering the environment in which the telehealth consultation was being held, ensuring that privacy, safety, and distractibility concerns have been adequately addressed before the consultation begins. These factors were considered important for the successful implementation of telehealth in rural areas.

This study explored telehealth service delivery in various rural health contexts, with 16 allied health and nursing clinicians who had provided telehealth services to people living in rural communities prior to, and during the COVID-19 pandemic. Reflections gained from clinicians were analysed and reported thematically. Major themes identified were clinicians navigating the role of telehealth to support rural healthcare, the need to prepare clinicians to engage in telehealth service delivery and appreciating the complexities of telehealth implementation across services and environments.

The utilisation of telehealth for health service delivery has been promoted as a solution to resolve access and equity issues, particularly for rural communities who are often impacted by limited health services due to distance and isolation [ 6 ]. This study identified a range of perceived benefits for both clients and clinicians, such as improved access to services across large geographic distances, including specialist care, and reduced travel time to engage with a range of health services. These findings are largely supported by the broader literature, such as the systematic review undertaken by Tsou et al. [ 25 ] which found that telehealth can improve clinical outcomes and increase the timeliness to access services, including specialist knowledge. Clinicians in our study also noted the benefits of using telehealth for ad hoc clinical support outside of regular appointment times, which to date has not been commonly reported in the literature as a benefit. Further investigation into this aspect may be warranted.

The findings from this study identify a range of challenges that exist when delivering health services within a virtual context. It was common for participants to highlight that personal preference for face-to-face sessions could not always be accommodated when implementing telehealth services in rural areas. The perceived technological possibilities to improve access can have unintended consequences for community members which may contribute to lack of responsiveness to community needs [ 12 ]. It is therefore important to understand the client and their preferences for using telehealth rather than making assumptions on the appropriateness of this type of health service delivery [ 26 ]. As such, telehealth is likely to function best when there is a pre-established relationship between the client and clinician, with clients who have a good knowledge of their personal health and have access to and familiarity with digital technology [ 13 ]. Alternatively, it is appropriate to consider how telehealth can be a supplementary tool rather than a stand-alone service model replacing face-to-face interactions [ 13 ].

As identified in this study, managing technology and internet connectivity are commonly reported issues for rural communities engaging in telehealth services [ 27 , 28 ]. Additionally, it was highlighted that within some rural communities with higher socioeconomic disadvantage, limited access to an appropriate level of technology and the required data to undertake a telehealth consult was a deterrent to engage in these types of services. Mathew et al. [ 13 ] found in their study that bandwidth impacted video consultations, which was further compromised by weather conditions, and clients without smartphones had difficulty accessing relevant virtual consultation software.

The findings presented here indicate that while telehealth can be a useful model, it may not be suitable for all clients or client groups. For example, the use of interpreters in telehealth to support clients was a key challenge identified in this study. This is supported by Mathew et al. [ 13 ] who identified that language barriers affected the quality of telehealth consultations and accessing appropriate interpreters was often difficult. Consideration of health and digital literacy, access and availability of technology and internet, appropriate client selection, and facilitating client choice are all important drivers to enhance telehealth experiences [ 29 ]. Nelson et al. [ 6 ] acknowledged the barriers that exist with telehealth, suggesting that ‘it is not the groups that have difficulty engaging, it is that telehealth and digital services are hard to engage with’ (p. 8). There is a need for telehealth services to be delivered in a way that is inclusive of different groups, and this becomes more pertinent in rural areas where resources are not the same as metropolitan areas.

The findings of this research highlight the unique set of skills required for health professionals to translate their practice across a virtual medium. The participants described these modifications in relation to communication skills, the ability to build rapport, conduct healthcare assessments, and provide treatment while looking at a ‘window view’ of a person. Several other studies have reported similar skillsets that are required to effectively use telehealth. Uscher-Pines et al. [ 30 ] conducted research on the experiences of psychiatrists moving to telemedicine during the COVID-19 pandemic and noted challenges affecting the quality of provider-patient interactions and difficulty conducting assessment through the window of a screen. Henry et al. [ 31 ] documented a list of interpersonal skills considered essential for the use of telehealth encompassing attributes related to set-up, verbal and non-verbal communication, relationship building, and environmental considerations.

Despite the literature uniformly agreeing that telehealth requires a unique skill set there is no agreement on how, when and for whom education related to these skills should be provided. The skills required for health professionals to use telehealth have been treated as an add-on to health practice rather than as a specialty skill set requiring learning and assessment. This is reflected in research such as that by Nelson et al. [ 6 ] who found that 58% of mental health professionals using telehealth in rural areas were not trained to use it. This gap between training and practice is likely to have arisen from the rapid and widespread implementation of telehealth during the COVID-19 pandemic (i.e. the change in MBS item numbers [ 1 ]) but has not been addressed in subsequent years. For practice to remain in step with policy and funding changes, the factors required for successful implementation of telehealth in rural practice must be addressed.

The lack of clarity around who must undertake training in telehealth and how regularly, presents a challenge for rural health professionals whose skill set has been described as a specialist-generalist that covers a significant breadth of knowledge [ 32 ]. Maintaining knowledge currency across this breadth is integral and requires significant resources (time, travel, money) in an environment where access to education can be limited [ 33 ]. There is risk associated with continually adding skills on to the workload of rural health professionals without adequate guidance and provision for time to develop and maintain these skills.

While the education required to equip rural health professionals with the skills needed to effectively use telehealth in their practice is developing, until education requirements are uniformly understood and made accessible this is likely to continue to pose risk for rural health professionals and the community members accessing their services. Major investment in the education of all health professionals in telehealth service delivery, no matter the context, has been identified as critical [ 6 ].

This research highlights that the experience of using telehealth in rural communities is unique and thus a ‘one size fits all’ approach is not helpful and can overlook the individual needs of a community. Participants described experiences of using telehealth that were different between rural communities, particularly for smaller, more remote rural locations where resources and staff support and experience using telehealth were not always equivalent to larger rural locations. Research has indicated the need to invest in resourcing and education to support expansion of telehealth, noting this is particularly important in rural, regional, and remote areas [ 34 ]. Our study recognises that this is an ongoing need as rural communities continue to have diverse experiences of using telehealth services. Careful consideration of the context of individual rural health services, including the community needs, location, and resource availability on both ends of the consultation is required. Use of telehealth cannot have the same outcomes in every area. It is imperative that service providers and clinicians delivering telehealth from metropolitan areas to rural communities appreciate and understand the uniqueness of every community, so their approach is tailored and is helpful rather than hindering the experience for people in rural communities.

Limitations

There are a number of limitations inherent to the design of this study. Participants were recruited via their workplace and thus although steps were taken to ensure they understood the research would not affect their employment, it is possible some employees perceived an association between the research and their employment. Health professionals who had either very positive or very negative experiences with telehealth may have been more likely to participate, as they may be more likely to want to discuss their experiences. In addition to this, only health services that were already connected with the researchers’ networks were invited to participate. Other limitations include purposive sampling, noting that the opinions of the participants are not generalisable. The participant group also represented mostly nursing professionals whose experiences with telehealth may differ from other health disciplines. Finally, it is important to acknowledge that the opinions of the health professionals who participated in the study, may not represent, or align with the experience and opinions of service users.

This study illustrates that while telehealth has provided increased access to services for many rural communities, others have experienced barriers related to variability in connectivity and managing technology. The results demonstrated that telehealth may not be the preferred or appropriate option for some individuals in rural communities and it is important to provide choice. Consideration of the context in which telehealth services are being delivered, particularly in rural and remote communities where there are challenges with resourcing and training to support health professionals, is critical to the success of telehealth service provision. Another critical factor is preparation and specific, intentional training for health professionals on how to transition to manage and maintain telehealth services effectively. Telehealth interventions require a unique skill set and guidance pertaining to who, when and what training will equip health professionals with the appropriate skill set to deliver telehealth services is still to be determined.

Data availability

The qualitative data collected for this study was de-identified before analysis. Consent was not obtained to use or publish individual level identified data from the participants and hence cannot be shared publicly. The de-identified data can be obtained from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to acknowledge Georgina Luscombe, Julian Grant, Claire Seaman, Jennifer Cox, Sarah Redshaw and Jennifer Schwarz who contributed to various elements of the project.

The study authors are employed by Three Rivers Department of Rural Health. Three Rivers Department of Rural Health is funded by the Australian Government under the Rural Health Multidisciplinary Training (RHMT) Program.

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RB & EG contributed to the conceptualisation of the study and methodological design. RB & MN collected the research data. RB, EG, MN, KR contributed to analysis and interpretation of the research data. RB, EG, MN, KR drafted the manuscript. All authors provided feedback on the manuscript and approved the final submitted manuscript.

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Barry, R., Green, E., Robson, K. et al. Factors critical for the successful delivery of telehealth to rural populations: a descriptive qualitative study. BMC Health Serv Res 24 , 908 (2024). https://doi.org/10.1186/s12913-024-11233-3

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DOI : https://doi.org/10.1186/s12913-024-11233-3

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Two decades of advancements in cold supply chain logistics for reducing food waste: a review with focus on the meat industry.

1. Introduction

Objective and scope of study.

• What is the current state of the art on beef CSCL in terms of management, sustainability, network design, and the use of information technologies for red meat waste reduction?
• To provide an overview of the current state of the art and to identify the gaps and contemporary challenges to red meat waste reduction;
• To identify key research themes and their potential role and associated elements in mitigating red meat waste reduction, especially across the beef CSCL systems;
• To pinpoint the directions in each theme that warrant further research advancement.

2. Materials and Methods

2.1. literature retrieval and selection, 2.2. extracting the research themes, 3.1. the literature review identified themes and subjects, 3.2. the literature’s evolution and descriptive results, 3.3. management, 3.3.1. logistics management and chronological evolution, 3.3.2. management and regulations, 3.3.3. management and collaboration, 3.3.4. management and costs, 3.3.5. management and inventory, 3.3.6. management and decision-making, 3.3.7. management and risks, 3.3.8. management and waste reduction, 3.3.9. management and information, 3.3.10. management and cold chain deficiencies, 3.4. sustainability, 3.4.1. sustainability and closed-loop scs (clscs), 3.4.2. sustainability and business models, 3.4.3. sustainability and wastage hotspots, 3.4.4. sustainability and packing, 3.4.5. sustainability and information flow, 3.5. network design optimisation, 3.5.1. network design and decision levels, 3.5.2. network design and the location–inventory problem, 3.5.3. network design and routing-inventory problem, 3.5.4. network design and the location routing problem, 3.5.5. network design and the integrated location–inventory routing problem, 3.5.6. network design and sustainability, 3.5.7. network design and information flow, 3.6. information technologies, 3.6.1. it and meat sc transformation, 3.6.2. emerging information technologies and meat scs, technical instruments, technological systems, 4. discussion, 4.1. management, 4.2. sustainability, 4.3. network design, 4.4. information technology, 5. conclusions.

• Management: ◦ Effective management practices are crucial for addressing FLW in beef CSCL systems. ◦ There is a notable transition from LM to FLM and SFLM, with the potential for emerging technologies to create an “Intelligent Sustainable Food Logistics Management” phase. ◦ Suboptimal management practices continue to contribute significantly to FLW, underscoring the need for enhanced strategies and adherence to regulations and standards.
• Sustainability: ◦ Sustainability in beef CSCL involves addressing social, economic, and environmental benefits. ◦ Reducing FLW can lead to increased profits, improved customer satisfaction, public health, equity, and environmental conservation by minimising resource use and emissions. ◦ Comprehensive research integrating all sustainability dimensions is needed to fully understand and mitigate FLW. Current efforts often address only parts of sustainability. A more holistic approach is required to balance environmental, economic, and social dimensions effectively.
• Network Design: ◦ Effective network design and optimisation are pivotal in reducing FLW within beef CSCL systems. ◦ There is a necessity for integrating all three levels of management decisions in the logistics network design process. Decision levels in network design must be considered to understand trade-offs among sustainability components in this process. ◦ Future research should focus on integrating management decisions and network design, CSCL uncertainties, sustainability dimensions, and advanced technologies to enhance efficiency and reduce waste in beef CSCL systems.
• Information Technologies: ◦ Information technologies such as Digital Twins (DTs) and Blockchain (BC) play a significant role in improving efficiency and reducing FLW in beef CSCL. ◦ The integration of these technologies can enhance understanding of fluid dynamics, thermal exchange, and meat quality variations, optimising the cooling process and reducing energy usage. ◦ Challenges like data security and management efficiency need to be addressed to maximise the benefits of these technologies.

Author Contributions

Data availability statement, acknowledgments, conflicts of interest.

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Davoudi, S.; Stasinopoulos, P.; Shiwakoti, N. Two Decades of Advancements in Cold Supply Chain Logistics for Reducing Food Waste: A Review with Focus on the Meat Industry. Sustainability 2024 , 16 , 6986. https://doi.org/10.3390/su16166986

Davoudi S, Stasinopoulos P, Shiwakoti N. Two Decades of Advancements in Cold Supply Chain Logistics for Reducing Food Waste: A Review with Focus on the Meat Industry. Sustainability . 2024; 16(16):6986. https://doi.org/10.3390/su16166986

Davoudi, Sina, Peter Stasinopoulos, and Nirajan Shiwakoti. 2024. "Two Decades of Advancements in Cold Supply Chain Logistics for Reducing Food Waste: A Review with Focus on the Meat Industry" Sustainability 16, no. 16: 6986. https://doi.org/10.3390/su16166986

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REVIEW article

Nox4-reactive oxygen species axis: critical regulators of bone health and metabolism.

• 1 Laboratory of Molecular Physiology of Bone, Institute of Physiology of the Czech Academy of Sciences, Prague, Czechia
• 2 Faculty of Science, Charles University, Prague, Czechia
• 3 Translational Biology, Medicine, and Health, Virginia Tech, Roanoke, VA, United States
• 4 Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA, United States

Bone marrow stromal cells (BMSCs) play a significant role in bone metabolism as they can differentiate into osteoblasts, bone marrow adipocytes (BMAds), and chondrocytes. BMSCs chronically exposed to nutrient overload undergo adipogenic programming, resulting in bone marrow adipose tissue (BMAT) formation. BMAT is a fat depot transcriptionally, metabolically, and morphologically distinct from peripheral adipose depots. Reactive oxygen species (ROS) are elevated in obesity and serve as important signals directing BMSC fate. ROS produced by the NADPH oxidase (NOX) family of enzymes, such as NOX4, may be responsible for driving BMSC adipogenesis at the expense of osteogenic differentiation. The dual nature of ROS as both cellular signaling mediators and contributors to oxidative stress complicates their effects on bone metabolism. This review discusses the complex interplay between ROS and BMSC differentiation in the context of metabolic bone diseases.Special attention is paid to the role of NOX4-ROS in regulating cellular processes within the bone marrow microenvironment and potential target in metabolic bone diseases.

Introduction

Bone marrow (BM) is the heterogenous and multicellular tissue located within the medullary cavity of bones. The BM plays an essential role in many physiological and pathological processes, including hematopoiesis, bone remodeling, and even cardiovascular and metabolic diseases ( Benova and Tencerova, 2020 ). Although bone and BM are anatomically connected, they possess some specialized roles ( Del Fattore et al., 2010 ). Bones provide skeletal support and organ protection, store calcium and phosphorus, and regulate various organ systems via the release of bone-derived hormones (“osteokines”), whereas the BM serves as a specialized niche that facilitates the generation of multiple crucial cell types, including red blood cells, white blood cells, and platelets ( Del Fattore et al., 2010 ).

A significant stem cell population within the BM is hematopoietic stem cells (HSCs) (∼0.01%–0.1% of the total number of nuclear cells in BM aspirates) ( Pang et al., 2011 ; Rossi et al., 2011 ). HSCs are the source of immune cell progenitors and bone resorbing cells (osteoclasts), which serve to negatively remodel bone. Beyond HSCs, multiple other cell types promote BM homeostasis, such as those providing nutrient supply (endothelial cells), innervations (nerve cells), and bone matrix formation (osteoblasts, osteocytes) and their progenitors, known as BM stromal cells (BMSCs) ( Peci et al., 2022 ). BMSCs, though a rare population of cells within the BM (∼0.001%–0.01%) ( Bianco et al., 2001 ), play a crucial role in the BM microenvironment as they can differentiate into osteoblasts, BM adipocytes (BMAds), and chondrocytes (cartrilage forming cells) ( Dominici et al., 2006 ). The ability of BMSCs to differentiate into these different cell types is largely affected by physiological and pathophysiological conditions that result in the activation of different transcriptional programs and secreted factors ( Tencerova and Kassem, 2016 ; Lecka-Czernik et al., 2017 ).

Within the BM, bone cells and adipocytes exhibit cell-to-cell contact and communication ( Lanske and Rosen, 2017 ), to facilitate bone remodeling, hormonal regulation and nutrient exchange. BMAds collectively form BM adipose tissue (BMAT), a fat depot with unique molecular and physiological properties in comparison to peripheral adipose tissue (AT) ( Suchacki and Cawthorn, 2018 ). During aging, up to 70% of red BM (replete with HSCs) undergoes conversion to yellow BM filled with BMAds ( Kricun, 1985 ). This conversion occurs mainly in distal bones and does so centripetally (from peripheral skeleton to axial skeleton), possibly due to differences in temperature, vascularity, and oxygen tension in distal versus proximal bones ( Kricun, 1985 ). In addition to aging ( Farr et al., 2017 ), other metabolic diseases, such as obesity, diabetes and osteoporosis ( Tencerova and Kassem, 2016 ; Suchacki and Cawthorn, 2018 ) affect BMSC properties and shift BMSC differentiation towards higher BMAd formation in the BM. Increased BMAT is often associated with reduced bone mineral density (BMD) and higher fracture risk, indicating a potential role of BMAT in the pathogenesis of osteoporosis ( Shen et al., 2014 ; Beekman et al., 2023 ). Therefore, identifying the signals promoting BMAT accumulation in metabolic diseases could bring insight into the mechanisms affecting cell fate determination.

BMAT accumulation is accompanied with an increased production of reactive oxygen species (ROS), which contributes to a senescent BM microenvironment and increased bone fragility ( Tencerova et al., 2019a ). Traditionally, ROS were characterized simply as toxic by-products of aerobic metabolism that pathologically contributed to oxidative stress by damaging macromolecules such as lipids, proteins and nucleic acids ( Beckman and Ames, 1998 ). As oxidative stress can accelerate various cellular processes including apoptosis and senescence ( Jones, 2006 ), ROS production has been implicated in many disease processes. However, indiscriminate quenching of ROS can impair cell signaling as these molecules also can act as physiological signaling agents promoting health ( Rhee et al., 2000 ; Finkel, 2011 ). Due to the two unpaired electrons in its outer orbital, oxygen (O 2 ) is highly susceptible to the formation of ROS such as: O 2 ·− , hydroxyl radical (HO · ), H 2 O 2 , etc. ( Sies, 2020 ). These ROS are characterized by different half-lives, charges and abilities to cross biological membranes. H 2 O 2 is the most stable ROS as it has a significantly longer half-life and can cross biological membranes, enabling it to actively serve as a signaling molecule ( Chen et al., 2008 ). For instance, H 2 O 2 can directly react with cysteine residues of proteins involved in regulation of cell differentiation (e.g., Phosphatase and tensin homolog (PTEN), Akt2) ( Vieceli Dalla Sega et al., 2017 ; Sies, 2020 ).

The family of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX) enzymes is a major source of ROS production within the BM. It has been shown that NOX-ROS play an important role in cell proliferation, differentiation, homing, and senescence ( Schroder, 2019 ). Notably, NOX members are found to be differentially expressed based on cell type, and their activity responds to specific extra- and intracellular signals through generation of ROS, e.g., superoxide (O 2 ·− ) or hydrogen peroxide (H 2 O 2 ) ( Brown and Griendling, 2009 ). Interestingly, NOX4 is unique among the NOX family members as it does not require agonist-stimulated activation to produce ROS ( Martyn et al., 2006 ). A key structural property enabling NOX4 to facilitate essential cellular processes in its third extracystosolic loop (E loop). This loop allows NOX4 to produce H 2 O 2 over O 2 ·− ( Takac et al., 2011 ). Consequenly, NOX4-generated H 2 O 2 may play a significant role in signal transduction ( Finkel, 2011 ).

The role of NOX-ROS across different BM-resident cells in pathophysiological conditions is not well documented. Thus, this review provides an overview of the literature on elucidating the role of NOX-ROS in bone-fat metabolism. As NOX4 is important in BMSC differentiation ( Atashi et al., 2015 ), we will highlight the potential role of NOX4 in the regulation of BMAT expansion and BMSC properties, which may significantly contribute to alterations in bone homeostasis.

BMSCs and BMAT

The relationship between BMAT and metabolic diseases such as obesity and diabetes has recently attracted increased attention, even though BMAT was first described by anatomists in the late 19th century in histological sections of bone biopsies ( Stockman and Greig, 1898 ). As opposed to the well-studied white, brown, beige and pink AT ( Richard et al., 2000 ), the researchers have only recently begun to characterize the exact functions of BMAT. In the last decade, the BM adiposity literature has rapidly increased, leading to the recent understanding that BMAT acts as a unique fat depot that differs from peripheral AT not only anatomically but also developmentally, functionally, and metabolically ( Hardouin et al., 2016 ; Suchacki and Cawthorn, 2018 ; Tencerova et al., 2018 ).

BMAT supplies energy to neighboring BM cells, such as osteoblasts and HSCs ( Li et al., 2022 ; Alekos et al., 2023 ) during periods of increased energy demand, such as bone remodeling, haematopoiesis or cell proliferation ( Shafat et al., 2017 ; Tabe et al., 2017 ; Tencerova et al., 2018 ). Beyond the traditional role of AT as an energy reserve, BMAT can contribute to bone loss through the release of pro-inflammatory and pro-resorptive cytokines and adipokines (e.g., receptor activator of nuclear factor kappa-Β ligand (RANKL), macrophage colony-stimulating factor (M-CSF), dipeptidyl peptidase (DPP4), lipocalin 2 (LCN2), tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6), which negatively regulate bone metabolism) ( Herrmann, 2019 ; Tencerova et al., 2021 ). BMAT expansion results in compromised osteoblast differentiation, as BMAT originates from BMSCs ( Tencerova and Kassem, 2016 ). This reciprocal relationship is further highlighted by the fact that molecular pathways promoting osteogenesis typically inhibit adipogenesis and vice versa ( Li et al., 2013 ). This may be partially mediated by ROS-induced changes in redox-sensitive microRNAs that inhibit transcription factors such as Runt-related transcription factor 2 (RUNX2), impairing osteogenesis and augmenting adipogenesis in BMSCs through NF-κB signaling ( Liao et al., 2013 ; Wang et al., 2015 ).

In both osteoporosis and obesity, there is commonly an imbalance in the regulation of osteoblastic and adipogenic BMSC differentiation ( Sui et al., 2016 ). Several studies have shown a negative correlation between BMAT volume and BMD ( Yeung et al., 2005 ; Li et al., 2014 ), which may underpin elevated risk of bone fractures ( Woods et al., 2022 ; Guimaraes et al., 2023 ) ( Figure 1 ). In obesity, BMAT resists the development of insulin resistance and inflammation, unlike what is observed in peripheral tissues ( Tencerova et al., 2019a ). However, continuous recruitment of BMSCs to BMAT as seen in obesity exceeds this protective potential and instead drives progenitor cell exhaustion, reduced osteoblastic recruitment, and ultimately decreased bone formation ( Tencerova et al., 2018 ). Exposure of human BMSCs to sera isolated from overweight individuals increased adipocyte differentiation at the expense of osteogenic differentiation demonstrating that circulating factors are sufficient to skew the BMSC differentiation potential towards adipogenesis ( Di Bernardo et al., 2014 ). In fact, the BM contains BMSCs that are uniquely primed for adipogenesis, which readily proliferate under obesogenic conditions and significantly contribute to BMAT expansion ( Tencerova et al., 2019b ). Increased ROS levels in obesity are associated with adipogenic BMSCs that demonstrate a shift from glycolysis towards higher oxidative phosphorylation, enhanced insulin signaling, glucose transport, lipid metabolism, and senescence ( Guntur et al., 2018 ; Tencerova et al., 2019b ). This hypermetabolic phenotype of BMSCs may represent a mechanism by which obesity contributes to bone fragility ( Tencerova et al., 2019a ). Thus, one can hypothesize that ROS might mediate the adverse effects of metabolic diseases on bone and BM microenvironment.

Figure 1 . Bone homeostasis in normal and pathophysiological conditions. In physiological conditions, bone homeostasis represents a balance between bone formation (formed by OBs) and bone resorption (mediated by OCs). In homeostasis, BMSC differentiation favors OBs over BMAds. OCs, responsible for degrading bone, create lacunae that are subsequently filled with newly synthesized matrices by OBs. However, in pathophysiological conditions such as obesity, diabetes, or aging, this balance is disrupted. BMSC differentiation is shifted towards adipogenesis leading to the accumulation of BMAds within BM through increased PPARγ and insulin signaling. OB-mediated bone formation is diminished, while OC differentiation and activities, as well as subsequent bone resorption, are increased. This imbalance is facilitated directly or indirectly through increased production of RANKL and M-CSF, exacerbating the detrimental effects of oxidative stress on bone health and leading to a higher risk of fracture.

ROS in the BM compartment

Emerging evidence suggests that elevated ROS in metabolic bone diseases negatively impact bone homeostasis ( Table 1 ). ROS aid in mineralized matrix degradation and influence the behaviour of cells involved in this process ( Agidigbi and Kim, 2019 ). Osteoclasts located on the bone interface generate O 2 ·− and H 2 O 2 which regulates their differentiation and development ( Goettsch et al., 2013 ; Agidigbi and Kim, 2019 ). Furthermore, ROS released by neighboring cells stimulate osteoclast activity through ERK/NF-κB signaling and increased RANKL production ( Ha et al., 2004 ; Lorenzo, 2017 ). These signals result in the inhibition of osteoblast lifespan ( Deng et al., 2019 ), differentiation ( Bai et al., 2004 ; Chen et al., 2018 ), and decreased alkaline phosphatase (ALP) activity ( Luo et al., 2020 ). One of the key signaling pathways influenced by ROS is the Wingless/Int-1 (Wnt) signaling, important for BMSC fate, and homeostasis ( Houschyar et al., 2018 ), which is diminished by excess ROS causing increased BMAd expansion ( Atashi et al., 2015 ). ROS inhibition of Wnt occurs through the oxidation of key signaling molecules, such as β-catenin, which is crucial for Wnt signal transduction ( Kajla et al., 2012 ; Staehlke et al., 2020 ).Another pathway affected by ROS is the PI3K/Akt pathway, which is vital for cell survival and proliferation ( Liu et al., 2021 ). ROS can inhibit the activity of PTEN, a negative regulator of the PI3K/Akt pathway, leading to increased Akt signaling and altered cell survival and differentiation ( Koundouros and Poulogiannis, 2018 ; Liu et al., 2021 ). ROS can modulate the MAPK/ERK pathway, which is involved in the regulation of cell growth and differentiation.

Table 1 . Role of NOX-ROS in metsbolic bone diseases.

The role of ROS in driving BMSC differentiation to BMAT is further confirmed through the use of antioxidants where osteogenic potential was enhanced while adipogenic potential was reduced in mouse and human BMSCs in response to antioxidants such as the flavanol quercetin ( Wang et al., 2021 ), the fullerene-derivative fullerol ( Liu et al., 2013 ), the polyphenol resveratrol ( Ali et al., 2020 ), and the isoflavone formomentin ( Gautam et al., 2017 ). The mechanisms by which ROS quenching reduces BMAT are still being elucidated but have been shown to involve interactions between canonical factors like RUNX2, osterix (OSX), RANKL and osteoprotegerin (OPG), which are crucial in bone remodeling ( Wauquier et al., 2009 ; Ali et al., 2020 ).

In summary, ROS play a pivotal role in bone by both promoting osteoclastogenesis and inhibiting osteoblast differentiation in favor of adipogenesis ( Figure 2 ). While the role of ROS in bone remodeling and the impact on osteoclasts and osteoblasts are well-established, there is a critical need for comprehensive research to elucidate the specific ROS-producers and effects of ROS on BMSCs and, thus, BMAT. Unraveling the molecular mechanisms by which ROS are produced and may modulate BMSC fate decisions can provide valuable insights into the complex interplay between oxidative stress and BM homeostasis. This knowledge will not only contribute to a more nuanced understanding of bone physiology but may also unveil potential therapeutic targets for conditions characterized by altered bone homeostasis.

Figure 2 . ROS and its effect on bone homeostasis. ROS play a crucial role in modulating signaling pathways within bone cells. They contribute to bone loss by impairing osteoblastogenesis and promoting osteoclastogenesis and adipogenesis. ROS induction of bone resorption occurs either directly by mediating OC function through activation of the mitogen-activated protein kinase (MAPK) signaling pathways such as JNK, p38, and ERK1/2. In addition, they have an important roles in signal transduction that activate cellular responses to many types of stresses, but also control the proliferation, differentiation, and survival of osteoclasts. Indirect activation of OCs is achieved through the upregulation of RANKL expression within OBs. PKA and CREB are central to the cAMP signaling pathway that regulates the production of RANKL. PKA activation leads to CREB phosphorylation, which binds to the RANKL promoter to enhance its transcription. This mechanism underscores the critical role of OBs in this process. On the other hand, osteoblastogenesis, together with bone formation is impaired through inhibiton of Wnt signaling and ALP activity, which are crucial for maintaining bone homeostasis. The activation of PPARγ promotes adipogenic differentiation of BMSCs at the expense of osteoblastogenesis. The presence of BMAds within the BM negatively affects the differentiaton of BMSCs towards OBs by releasing pro-inflammatory and pro- resorptive cytokines and adipokines. Created with BioRender.com

NOX4-ROS signaling and its effect on BMSCs and BMAT function

The quenching of high levels of ROS via endogenous or exogenous antioxidants can prevent cell damage and attenuate BMSC apoptosis and loss of viability ( Balogh et al., 2016 ). Yet, as described above, ROS are not only harmful by-products of cell metabolism but also participate in signal transduction and are required for cellular functions such as differentiation ( Atashi et al., 2015 ). Therefore, it is critical to understand the sources and specify locations of ROS and their impacts on BMSC function. NOXs are considered a major source of ROS production within the BM. They are transmembrane proteins that transfer electrons across membranes to O 2 using NADPH as an electron donor ( Schroder, 2019 ). Among the NOX family members, research has highlighted the role of NOX2 and NOX4 in BM, demonstrating they contribute to bone loss, marrow adipogenesis, and osteoclastogenesis in mice ( Atashi et al., 2015 ; Rahman et al., 2018 ; Sun et al., 2021 ), As osteoclastogenesis is intricately linked to BMSC function, the role of NOX4 in this process is significant. NOX4 is a critical source of ROS in mouse HSCs ( Wang et al., 2010 ), human monocytes and human macrophages ( Lee et al., 2010 ), controlling their function and differentiation ( Yang et al., 2004 ). Notably, it has been reported that NOX4 limits bone mass by promoting osteoclastogenesis in an osteoporotic mouse model ( Goettsch et al., 2013 ) and it is involved in the regulation of osteoprogenitors in bone development ( Chen et al., 2022 ).

During differentiation, the major sources of ROS production include mitochondrial complexes I and III and NOX4 ( Mahadev et al., 2001 ; Furukawa et al., 2004 ). Interestingly, the relationship between mitochondria and NOX4 seems to be bidirectional. In cancer cells, mitochondrial ATP produced through oxidative phosphorylation limits NOX4 activity by binding to a specific ATP-binding motif in the C-terminal tail of NOX4 ( Shanmugasundaram et al., 2017 ), suggesting that NOX4 serves as an intracellular energy sensor. Indeed, NOX4 is required for mitochondrial biogenesis in the skeletal muscle following conditions of high energy demand like those in exercise ( Specht et al., 2021 ). On the other hand, NOX4 has been shown to repress mitochondrial biogenesis and Complex I activity in fibroblasts ( Bernard et al., 2017 ). As mitochondrial biogenesis increases during BMSC differentiation ( Yan et al., 2021 ), understanding the relationship between NOX4, mitochondrial metabolism and mitochondrial biogenesis in BMSCs may be a fruitful avenue of research.

NOX4-ROS and differential regulation on the peripheral AT and BM microenvironment in obesity

BMAT and peripheral AT are significantly different tissues ( Liu et al., 2011 ; Miggitsch et al., 2019 ). However, examining NOX4 and ROS in peripheral AT may reveal crucial insights into NOX4 function and impact on overall metabolic health. In peripheral AT, NOX4 signaling pathways are primarily centered around adipogenesis and metabolic regulation ( Den Hartigh et al., 2017 ). NOX4-ROS production stimulates the differentiation of preadipocytes to mature adipocytes ( Schroder et al., 2009 ). This process involves the activation of adipogenic transcription factors which are essential for adipocyte maturation and lipid accumulation such as peroxisome proliferator-activated receptor gamma (PPARγ) and CCAAT enhancer-binding protein alpha (C/EBPα) ( Schroder et al., 2009 ). In response to hypoxia, Nox4 silencing in adipose-derived stem cells led to reduced proliferation and cell migration, along with decreased phosphorylation of platelet-derived growth factor receptor-β, AKT serine/threonine kinase 1 or Protein kinase B (AKT), and ERK1/2 ( Kim et al., 2012 ). A common stressor to simulate obesogenic condition in vitro is high glucose. With obesity, NOX4 is upregulated in adipocytes ( Den Hartigh et al., 2017 ). Peripheral preadipocytes differentiated from mice lacking adipocyte NOX4 are resistant to high glucose and palmitate-induced inflammation ( Den Hartigh et al., 2017 ). This suggests that NOX4-ROS in AT participates in signaling cascades responsible for the early onset of insulin resistance and the inflammatory response in obesity ( Den Hartigh et al., 2017 ). BMAds were shown to overproduce ROS mediated through the enhanced NOX4 expression, causing increased intracellular ROS levels and downregulating the endogenous antioxidant systems following high glucose treatment ( Rharass and Lucas, 2019 ). Thus, BMAds are sensitive to both glucose and ROS levels, and these together influence their phenotype and functionality.

Comparing the transcriptome of BMAds and peripheral adipocytes demonstrates apparent differences between these two tissues ( Suchacki et al., 2020 ). However, such a comparison may lend insights into the difference in response to ROS and adipogenic priming in obesogenic conditions discussed above. For instance, BMAds demonstrate increased early adipogenic gene expression, and lower late adipogenic genes compared to epididymal adipocytes ( Liu et al., 2011 ). Furthermore, BMAds showed greater expression of pro-inflammatory genes ( Liu et al., 2011 ) and displayed an elevated production of ROS ( Miggitsch et al., 2019 ). These findings suggest that BMAds may be primed to receive maturation cues due to obesogenic stressors compared to peripheral adipocytes due to a comparably decreased antioxidant capacity. Therefore, NOX4-ROS may direct the maturation of BMSCs into BMAds within BM. Together, these data provide evidence that NOX4-ROS are important for activation, differentiation, and the response to metabolic stressors in the peripheral AT, which may also be relevant in the BM. Thus, these findings collectively indicate distinct responses of BMAds and peripheral adipocytes to metabolic stressors ( Figure 3 ).

Figure 3 . NOX4-ROS signaling in AT-MSCs and BMSCs. The impact of oxidative stress induced by obesogenic conditions on stem cells varies between adipose tissue-derived AT-MSCs and bone marrow-derived BMSCs. In AT-MSCs, NOX-ROS signaling pathways predominantly affect adipogenesis and metabolic regulation. In obesogenic conditions, the metabolism of AT-MSCs is characterized by compromised insulin response and increased inflammation caused by increased expression of NF-κB, leading to impaired adipogenesis and insulin resistance. On the other hand, BMSCs manifest a distinctive insulin response in obesogenic conditions defined in BM by the absence of inflammation, which leads to different insulin responsiveness and activation of AKT signaling compared to AT. Notably, unlike AT-MSCs, insulin signaling in BMSCs is enhanced in obesity. Obesogenic BMSCs exhibit a molecular phenotype shift towards committed adipocytic progenitors and inhibition of Wnt signaling, a critical factor for OB differentiation. Despite this, increased ROS contribute to an enhanced senescent phenotype in both cell types. Created with BioRender.com .

Differential responses between peripheral AT and BMAT may be due to NOX4 expression levels which alter downstream signaling. Transcriptomic profiling revealed that NOX4 is more highly expressed in AT compared to BM (data available from v23.0.proteinatlas.org ; https://www.proteinatlas.org/ENSG00000086991-NOX4/tissue#rna_expression ). This disparity may suggest regulation beyond the transcriptional level through varying activation and posttranslational modifications of proteins involved in downstream metabolic pathways between the two cell types ( Forrester et al., 2018 ). Further investigation is needed to unravel the distinct role of NOX4 expression in producing the distinct phenotype between these two tissues and to define the unique role of NOX4 in determining the pathophysiology of BM and bone metabolism in obesity.

Obesity is a significant risk factor for insulin resistance, a maladaptive metabolic state characterized by impaired insulin-mediated glucose uptake, changes in insulin secretion and dyslipidemia ( Czech, 2017 ). Importantly, increased NOX4-ROS in AT due to obesity promote the generation of dysregulated metabolism through increased production of adipokines such as plasminogen activator inhibitor 1 (PAI-1), IL-6, and monocyte chemotactic protein-1, and decreases the generation of the insulin-sensitizing factor, adiponectin ( Furukawa et al., 2004 ). Systemic inflammation is another hallmark of obesity linked to poor bone health ( Iantomasi et al., 2023 ). NOX4-ROS contributes to this low-grade inflammation in AT, where inflammation drives obesity-induced impairment of insulin signaling ( Den Hartigh et al., 2017 ). However, mixed findings surround the idea that inflammation caused by obesity disrupts insulin signaling in BMAT. These observations underscore the complexity of how systemic metabolism impacts BMAT homeostasis and expansion ( Pham et al., 2020 ). In obesity, the BM does not demonstrate a clear increase in the inflammatory response compared to the periphery ( Tencerova et al., 2018 ). This suggests the existence of a barrier within the BM, likely due to a distinct microenvironment that significantly influences the the stress response of BM cells ( Tencerova et al., 2018 ; Tencerova et al., 2019a ). Indeed, recent animal and clinical studies ( Tencerova et al., 2018 ; Pham et al., 2020 ) did not observe insulin resistance in obese BMSCs and BMAT, further supporting the hypothesis that significant metabolic and molecular differences exist in the BM compartment versus peripheral tissues. Another study reported that BMAT is capable of insulin-stimulated AKT S473 phosphorylation but lacks AKT T308 phosphorylation ( Suchacki et al., 2020 ). These data suggest a distinct mechanism for lipogenesis in BMAT, possibly less dependent on insulin than in peripheral AT. Thus, these findings offer potential mechanistic insight into the differential responses between BMAds and peripheral adipocytes to metabolic stress ( Figure 3 ). Recent studies using specific NOX4 inhibitors in osteoporotic animal models showed promising results in improvement of bone loss ( Woods et al., 2022 ). Thus, targeting NOX4 in obesity-induced bone fragility may be an interesting target for potential treatment in patients with metabolic bone diseases. However, further studies are needed to better understand the underlying mechanism in the regulation of cellular metabolism and inflammatory responses in BMAT in the context of obesity. While NOX4 generates ROS in both peripheral AT and BMAT, the ultimate impact of NOX4-ROS in metabolic bone diseases appears to depend on the distinct depot and microenvironments within these tissues.

Limitations of the current research studies

BMAT is heterogeneous: There are different types of BMAT (constitutive vs. regulated), present in different regions of the BM ( Li et al., 2018 ) exhibiting unique properties and responses to ROS. The studies might not account for this heterogeneity, potentially oversimplifying the conclusions.

In vivo models are lacking: The versatility of in vitro models has promoted significant gains in our understanding of the impact of ROS on BMSC differentiation and other instrumental properties of BM cells. However, they also demonstrate the need for in vivo validation due to the widely recognized microenvironmental nuances, the phenotypic heterogeneity and multifaceted roles of BMSCs within the BM niche. Very little in vivo research is available using cell-type-specific genetic modifications or target-specific molecules to elucidate the role of ROS on BMAT in osteoporosis and metabolic diseases.

Sexual dimorphism requires further exploration: Research on females and female-derived cells underrepresent the current knowledge of ROS and BMAT. Due to known sexual dimorphisms in BM adiposity, redox homeostasis, and BMSC properties, further investigation is necessary to understand these differences and their implications ( Malorni et al., 2007 ; Lecka-Czernik et al., 2017 ; Beekman et al., 2022 ).

Translation to human physiology: Findings from animal models and in vitro studies may not always translate directly to human physiology. Differences between species and the controlled experimental conditions can limit the applicability of the results to clinical settings.

Conclusion and perspectives

Taken together, the recent discoveries provide a strong rationale for closer exploration of NOX4-ROS signaling in BMSCs and BMAT, as well as its unique functions when compared to peripheral AT. The BM is rich in progenitors sensitive to cues for adipogenesis in response to stressors such as metabolic diseases and aging, perhaps mediated by NOX4-ROS. Increased evidence in the literature suggests that NOX4-ROS could drive bone fragility in obesity by influencing BMSC senescence, proliferation, and adipocyte differentiation, ultimately promoting the expansion of BMAT ( Figure 4 ). However, the exact signaling pathways and effects of NOX4 in BMAT are still being elucidated. They likely involve interactions with factors like RANKL and OPG, which are crucial in bone remodeling. More mechanistic and clinical studies investigating tissue-specific NOX4-ROS signaling may bring a better understanding of the role of NOX4 in the regulation of bone-fat metabolism and its potential use in the treatment of metabolic bone disease.

Figure 4 . Obesity-induced changes in AT and BM microenvironment via NOX4-ROS production. Obesity increases NOX4-ROS production in AT, which affects adipogenesis and AT inflammation. On the other hand, NOX4-ROS in BM microenvironment accelerates BMSC adipogenesis at the expense of osteogenic differentiation. Those changes lead to impaired glucose metabolism and increased bone fragility in obesity. Created with BioRender.com .

Author contributions

MD: Conceptualization, Data curation, Investigation, Methodology, Visualization, Writing–original draft. JB: Conceptualization, Data curation, Investigation, Writing–original draft. SC: Conceptualization, Funding acquisition, Supervision, Writing–review and editing. MT: Conceptualization, Funding acquisition, Supervision, Writing–review and editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This study was supported by START UP Research programme by IPHYS, the Czech Science Foundation (GACR 22-12243S; MT), EFSD/NovoNordisk foundation Future leaders award (NNF20SA0066174; MT), National Institute for Research of Metabolic and Cardiovascular Diseases (Program EXCELES, ID Project No. LX22NPO5104)—Funded by the European Union—Next Generation EU; MT), the Ministry of Health of the Czech Republic (NU23-01-00125; MT), the S. J. Ritchey HNFE Fund for Faculty Pilot Studies (SMC) and NIH K01AR073332 (SMC).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

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Keywords: bone marrow stromal cells, bone marrow adipose tissue, ROS, NADPH oxidase, bone fragility, obesity, senescence

Citation: Dzubanova M, Bond JM, Craige SM and Tencerova M (2024) NOX4-reactive oxygen species axis: critical regulators of bone health and metabolism. Front. Cell Dev. Biol. 12:1432668. doi: 10.3389/fcell.2024.1432668

Received: 14 May 2024; Accepted: 29 July 2024; Published: 12 August 2024.

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Copyright © 2024 Dzubanova, Bond, Craige and Tencerova. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Michaela Tencerova, [email protected]

† These authors have contributed equally to this work and share first authorship

‡ These authors have contributed equally to this work and share last authorship

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Sustainable Energy & Fuels

Metal-free and natural dye sensitized solar cells: recent advancement and future perspectives.

Currently, the predominant energy source utilized by humanity is fossil fuels. However, as demand surges and supplies wane, identifying alternative sources of energy becomes increasingly critical. Solar energy has emerged as a promising solution to this energy crisis, and dye-sensitized solar cells (DSSCs) represent a particularly viable technology. DSSCs are the most confident choice for a cost-effective and reliable substitute for other types of photovoltaic devices including organic, inorganic and hybrid solar cells. DSSCs help to convert light energy into electrical energy directly. DSSCs are simple to manufacture, require less energy to produce, and can be made from abundant and non-toxic materials. In addition, they can function effectively even in environments with low levels of lighting conditions, making them a versatile option for various applications. This review aims to provide an in-depth understanding of the operating principle, components, and progress of DSSCs. It begins by explaining the operational mechanics of DSSCs. Specifically, it highlights the process by which the cells convert solar energy into electrical energy via a photoelectrochemical mechanism. This report also delves into the various components of DSSCs, including the photoanode, counter electrode, and electrolyte, and their respective roles in the conversion process. This review investigates the recent advancements in the field of DSSC technology which encompasses novel approaches such as the utilization of new materials to enhance light harvesting efficiency and the development of efficient DSSCs. It also discusses the present state of development of DSSCs, including their commercial availability and widespread adoption. Finally, the review highlights the potential future prospects for DSSCs, such as their integration with other renewable energy sources and their use in building-integrated photovoltaics. By gaining a comprehensive understanding of the benefits and limitations of DSSCs, we can make informed decisions on how to optimally harness this technology to meet our energy requirements sustainably and efficiently.

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S. S. Malhotra, M. Ahmed, M. K. Gupta and A. Ansari, Sustainable Energy Fuels , 2024, Accepted Manuscript , DOI: 10.1039/D4SE00406J

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