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Literature reviews, what is a literature review, learning more about how to do a literature review.

• Planning the Review
• The Research Question
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• Organizing the Review
• Writing the Review

A literature review is a review and synthesis of existing research on a topic or research question. A literature review is meant to analyze the scholarly literature, make connections across writings and identify strengths, weaknesses, trends, and missing conversations. A literature review should address different aspects of a topic as it relates to your research question. A literature review goes beyond a description or summary of the literature you have read. 

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Literature Reviews

• What is a literature review?
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What is a Literature Review?

A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

• Provide a comprehensive and updated review of the literature;
• Explain why this review has taken place;
• Articulate a position or hypothesis;
• Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

• Demonstrate how a study fills a gap in research
• Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

• Organizes or describes a topic
• Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

• It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
• It may be too focused. Some niche studies may miss the bigger picture.
• It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
• It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

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For help in other subject areas, please see the guide to library specialists by subject .

Periodically, UT Libraries runs a workshop covering the basics and library support for literature reviews. While we try to offer these once per academic year, we find providing the recording to be helpful to community members who have missed the session. Following is the most recent recording of the workshop, Conducting a Literature Review. To view the recording, a UT login is required.

• October 26, 2022 recording
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• UConn Library
• Literature Review: The What, Why and How-to Guide
• Introduction

Literature Review: The What, Why and How-to Guide — Introduction

• Getting Started
• How to Pick a Topic
• Strategies to Find Sources
• Evaluating Sources & Lit. Reviews
• Tips for Writing Literature Reviews
• Writing Literature Review: Useful Sites
• Citation Resources
• Other Academic Writings

What are Literature Reviews?

So, what is a literature review? "A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries." Taylor, D.  The literature review: A few tips on conducting it . University of Toronto Health Sciences Writing Centre.

Goals of Literature Reviews

What are the goals of creating a Literature Review?  A literature could be written to accomplish different aims:

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 

Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews .  Review of General Psychology , 1 (3), 311-320.

What kinds of sources require a Literature Review?

• A research paper assigned in a course
• A thesis or dissertation
• A grant proposal
• An article intended for publication in a journal

All these instances require you to collect what has been written about your research topic so that you can demonstrate how your own research sheds new light on the topic.

Types of Literature Reviews

What kinds of literature reviews are written?

Narrative review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.

• Example : Predictors and Outcomes of U.S. Quality Maternity Leave: A Review and Conceptual Framework:  10.1177/08948453211037398  

Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L. K. (2013). Research in Communication Sciences and Disorders . Plural Publishing.

• Example : The effect of leave policies on increasing fertility: a systematic review:  10.1057/s41599-022-01270-w

Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M. C., & Ilardi, S. S. (2003). Handbook of Research Methods in Clinical Psychology . Blackwell Publishing.

• Example : Employment Instability and Fertility in Europe: A Meta-Analysis:  10.1215/00703370-9164737

Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). Qualitative meta-synthesis: A question of dialoguing with texts .  Journal of Advanced Nursing , 53 (3), 311-318.

• Example : Women’s perspectives on career successes and barriers: A qualitative meta-synthesis:  10.1177/05390184221113735

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Peer Reviewed Literature

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

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

This Guide was created by Carolyn Swidrak (retired).

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

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

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

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

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

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

Peer-reviewed and refereed are identical terms.

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

Peer reviewed articles can include:

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

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

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

Government Agencies

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

Conference Proceedings

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

Dissertations

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

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

• Peer reviewed journal articles (although they are not identified as peer-reviewed)
• Unpublished scholarly articles (not peer-reviewed)
• Masters theses, doctoral dissertations and other degree publications (not peer-reviewed)
• Book citations and links to some books (not necessarily peer-reviewed)
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Peer-reviewed journals are also called “refereed” or “juried” journals. They are sometimes called "scholarly" or "academic" journals. The peer review process means that a manuscript is reviewed by others in the same field. These individuals (peers) read and review the manuscript, offering their comments and judgment as to its value. The process is intended to enhance the quality of the publications.

Note: You might find different terminology used to refer to peer-reviewed articles. A professor might ask you to find primary studies, primary research, scholarly articles or peer-reviewed articles. These are all generally referred as the same thing, however, if you need further help ask your professor or a librarian!

Below is an example of a peer-reviewed journal for Wildlife Management:

Characteristics of Peer Reviewed Journals

• Journal articles are written by experts in the field. 
• Journal articles are often intended for a person with knowledge in a specific discipline: a medical journal is written for doctors, a legal journal for attorneys, etc.
• The author of a journal article is always listed—usually, along with his or her qualifications or brief information about the author.
• Journal articles include a list of references. This allows you to see what the sources are and to check them if you wish, providing you with other possible resources.
• Scholarly journals are often published by a professional organization or society.
• Often, the word “journal” appears in the title. However, this is not always a good clue: Ladies Home Journal, for instance, is a popular magazine.
• Often, a journal article is preceded by an abstract, or summary of the content.
• Journals do not include advertisements.
• Titles of articles in journals are very revealing of content, not just clever or catchy, as is often the case with popular magazines.
• Scholarly journal articles often report on research; they may include theoretical assumptions, methodology, hypotheses, results, and conclusions. 

Example of a Peer-Reviewed Journal Article

Arizona State University. (n.d.). Anatomy of an Article. Retrieved from https://askabiologist.asu.edu/explore/anatomy-of-an-article

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Understanding peer review

The peer review process.

Peer review is a formal quality control process completed before an  academic work  is published. Not all academic literature is peer reviewed, but many academic journal articles and books will be. Peer-reviewed literature is sometimes also called “refereed literature”.

“Peer assessment”, where peers and colleagues give general feedback on your work, is sometimes also called peer review. However, “peer review” in published research refers specifically to the process described below.

Researchers who are experts in the same field review the submitted work to see if the research and arguments are sound, original, and of high enough quality to be published. Peer reviewers will provide feedback for the author to incorporate before the article is published, or they may advise that the work is not published at all. 

If the peer review process is conducted to a high standard by relevant, respected experts, it can improve the quality of published academic literature and encourage original, high-quality research. However, peer review takes time, which affects how quickly an article can be published. The quality of peer review processes can also vary across publishers and reviewers.           

Find peer-reviewed literature

In most cases, you can identify whether an academic work is peer reviewed by looking at the publisher’s website or using a “peer reviewed” filter when searching a database. 

Academic journals

Some journals require all research articles to be peer reviewed. You can look up the journal’s website to find out their peer review process. Be aware that other content in these journals, like reviews and editorial pieces, may not be peer reviewed. 

Another way to check if a journal has a peer review process is to look it up in a journal directory.

• Search a journal’s International Standard Serial Number (ISSN) or title ( not the article title) and see if it is listed with this black ”refereed” icon.  
• Click the journal title for more details and a link to the journal website.

Directory of Open Access Journals (DOAJ)

• Search for open access journals. Click the journal title in the search results to check for links to their peer review process.

Some academic journal databases will include an option to only search peer-reviewed journals. This option will appear either in their “advanced search” function or as a filter for their results page once you’ve searched. The  Library catalogue also has a “peer-reviewed journals” filter on its search results page.

Academic books 

Check the book publisher’s website for their review processes. University presses are highly likely to publish peer-reviewed academic books.

If the book is open access, check to see if it’s listed in the Directory of Open Access Books (DOAB) , which only includes scholarly, peer-reviewed books. 

Academic books are less likely than academic journals to be clearly identified as peer reviewed in databases. Searching an ebook collection that focuses on research will increase your chances of finding peer-reviewed books.

You can also search for a book’s title in the Library catalogue or an academic journal database to see if other researchers have reviewed it and commented on the book’s peer review process. 

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Scholarly Journals, Popular Magazine and Trade Publications

What is a Scholarly Journal?

Scholarly journals are generally published by and for experts. A publication is considered to be peer reviewed if its articles go through an official editorial process that involves review and approval by the author’s peers (people who are experts in the same subject area.) Articles in scholarly journals present new, previously unpublished research. Scholarly sources will almost always include:

• Bibliography and footnotes
• Author’s name and academic credentials

Use scholarly journals for highly focused original research.

Articles in popular magazines tend to be written by staff writers or freelance journalists and are geared towards a general audience . While most magazines adhere to editorial standards, articles do not go through a peer review process and rarely contain bibliographic citations. Popular magazines are periodicals that one typically finds at grocery stores, airport newsstands, or bookstores. Use popular magazines for a general overview of current news and opinions, or firsthand accounts of an event.

Trade publications focus on a specific profession or trade. Articles in trade magazines cover the interest of skilled laborers, technicians, and artisans. Professional magazines cover the interests of professors, librarians, and members of other fields that require advanced degrees. Subject magazines cover a topic of interest to one or more professions. Use trade magazines for overviews of news and research in a particular field .

What are the types of scholarly articles?

Scholarly articles usually fall into one of five major types: empirical studies, review articles theoretical articles, methodological or case studies. A typical article will have an abstract to summarize the article which follows. The article will introduce the problem, present a thesis statement followed by the body/methodology section.  If there is raw data, there will be a results section or if not, it could be a section called the findings section. A discussion section interprets the results in light of other studies. The last section is the conclusion which restates the thesis and suggest future research.

An empirical article contains original research. It can be either quantitative or qualitative. In format, it has an introduction (problem statement/purpose) followed by sections covering methods, results and discussion. Usually arranged chronologically.

Review articles evaluate existing published research and shows how current research relates to previous research. In the introduction, the article will define the problem of the research, then summarizes and evaluates previous research. The conclusion usually recommends possible next steps for inquiry.

Theoretical articles either advance a theory or critique a current theory.

Methodological articles either advances or modifies a methodological approach. Uses empirical data

Case studies use an individual or organzation as an illustration of a problem or solution

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

Jacalyn kelly.

1 Clinical Biochemistry, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada

Tara Sadeghieh

Khosrow adeli.

2 Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada

3 Chair, Communications and Publications Division (CPD), International Federation for Sick Clinical Chemistry (IFCC), Milan, Italy

The authors declare no conflicts of interest regarding publication of this article.

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

WHAT IS PEER REVIEW AND WHAT IS ITS PURPOSE?

Peer Review is defined as “a process of subjecting an author’s scholarly work, research or ideas to the scrutiny of others who are experts in the same field” ( 1 ). Peer review is intended to serve two primary purposes. Firstly, it acts as a filter to ensure that only high quality research is published, especially in reputable journals, by determining the validity, significance and originality of the study. Secondly, peer review is intended to improve the quality of manuscripts that are deemed suitable for publication. Peer reviewers provide suggestions to authors on how to improve the quality of their manuscripts, and also identify any errors that need correcting before publication.

HISTORY OF PEER REVIEW

The concept of peer review was developed long before the scholarly journal. In fact, the peer review process is thought to have been used as a method of evaluating written work since ancient Greece ( 2 ). The peer review process was first described by a physician named Ishaq bin Ali al-Rahwi of Syria, who lived from 854-931 CE, in his book Ethics of the Physician ( 2 ). There, he stated that physicians must take notes describing the state of their patients’ medical conditions upon each visit. Following treatment, the notes were scrutinized by a local medical council to determine whether the physician had met the required standards of medical care. If the medical council deemed that the appropriate standards were not met, the physician in question could receive a lawsuit from the maltreated patient ( 2 ).

The invention of the printing press in 1453 allowed written documents to be distributed to the general public ( 3 ). At this time, it became more important to regulate the quality of the written material that became publicly available, and editing by peers increased in prevalence. In 1620, Francis Bacon wrote the work Novum Organum, where he described what eventually became known as the first universal method for generating and assessing new science ( 3 ). His work was instrumental in shaping the Scientific Method ( 3 ). In 1665, the French Journal des sçavans and the English Philosophical Transactions of the Royal Society were the first scientific journals to systematically publish research results ( 4 ). Philosophical Transactions of the Royal Society is thought to be the first journal to formalize the peer review process in 1665 ( 5 ), however, it is important to note that peer review was initially introduced to help editors decide which manuscripts to publish in their journals, and at that time it did not serve to ensure the validity of the research ( 6 ). It did not take long for the peer review process to evolve, and shortly thereafter papers were distributed to reviewers with the intent of authenticating the integrity of the research study before publication. The Royal Society of Edinburgh adhered to the following peer review process, published in their Medical Essays and Observations in 1731: “Memoirs sent by correspondence are distributed according to the subject matter to those members who are most versed in these matters. The report of their identity is not known to the author.” ( 7 ). The Royal Society of London adopted this review procedure in 1752 and developed the “Committee on Papers” to review manuscripts before they were published in Philosophical Transactions ( 6 ).

Peer review in the systematized and institutionalized form has developed immensely since the Second World War, at least partly due to the large increase in scientific research during this period ( 7 ). It is now used not only to ensure that a scientific manuscript is experimentally and ethically sound, but also to determine which papers sufficiently meet the journal’s standards of quality and originality before publication. Peer review is now standard practice by most credible scientific journals, and is an essential part of determining the credibility and quality of work submitted.

IMPACT OF THE PEER REVIEW PROCESS

Peer review has become the foundation of the scholarly publication system because it effectively subjects an author’s work to the scrutiny of other experts in the field. Thus, it encourages authors to strive to produce high quality research that will advance the field. Peer review also supports and maintains integrity and authenticity in the advancement of science. A scientific hypothesis or statement is generally not accepted by the academic community unless it has been published in a peer-reviewed journal ( 8 ). The Institute for Scientific Information ( ISI ) only considers journals that are peer-reviewed as candidates to receive Impact Factors. Peer review is a well-established process which has been a formal part of scientific communication for over 300 years.

OVERVIEW OF THE PEER REVIEW PROCESS

The peer review process begins when a scientist completes a research study and writes a manuscript that describes the purpose, experimental design, results, and conclusions of the study. The scientist then submits this paper to a suitable journal that specializes in a relevant research field, a step referred to as pre-submission. The editors of the journal will review the paper to ensure that the subject matter is in line with that of the journal, and that it fits with the editorial platform. Very few papers pass this initial evaluation. If the journal editors feel the paper sufficiently meets these requirements and is written by a credible source, they will send the paper to accomplished researchers in the field for a formal peer review. Peer reviewers are also known as referees (this process is summarized in Figure 1 ). The role of the editor is to select the most appropriate manuscripts for the journal, and to implement and monitor the peer review process. Editors must ensure that peer reviews are conducted fairly, and in an effective and timely manner. They must also ensure that there are no conflicts of interest involved in the peer review process.

Overview of the review process

When a reviewer is provided with a paper, he or she reads it carefully and scrutinizes it to evaluate the validity of the science, the quality of the experimental design, and the appropriateness of the methods used. The reviewer also assesses the significance of the research, and judges whether the work will contribute to advancement in the field by evaluating the importance of the findings, and determining the originality of the research. Additionally, reviewers identify any scientific errors and references that are missing or incorrect. Peer reviewers give recommendations to the editor regarding whether the paper should be accepted, rejected, or improved before publication in the journal. The editor will mediate author-referee discussion in order to clarify the priority of certain referee requests, suggest areas that can be strengthened, and overrule reviewer recommendations that are beyond the study’s scope ( 9 ). If the paper is accepted, as per suggestion by the peer reviewer, the paper goes into the production stage, where it is tweaked and formatted by the editors, and finally published in the scientific journal. An overview of the review process is presented in Figure 1 .

WHO CONDUCTS REVIEWS?

Peer reviews are conducted by scientific experts with specialized knowledge on the content of the manuscript, as well as by scientists with a more general knowledge base. Peer reviewers can be anyone who has competence and expertise in the subject areas that the journal covers. Reviewers can range from young and up-and-coming researchers to old masters in the field. Often, the young reviewers are the most responsive and deliver the best quality reviews, though this is not always the case. On average, a reviewer will conduct approximately eight reviews per year, according to a study on peer review by the Publishing Research Consortium (PRC) ( 7 ). Journals will often have a pool of reviewers with diverse backgrounds to allow for many different perspectives. They will also keep a rather large reviewer bank, so that reviewers do not get burnt out, overwhelmed or time constrained from reviewing multiple articles simultaneously.

WHY DO REVIEWERS REVIEW?

Referees are typically not paid to conduct peer reviews and the process takes considerable effort, so the question is raised as to what incentive referees have to review at all. Some feel an academic duty to perform reviews, and are of the mentality that if their peers are expected to review their papers, then they should review the work of their peers as well. Reviewers may also have personal contacts with editors, and may want to assist as much as possible. Others review to keep up-to-date with the latest developments in their field, and reading new scientific papers is an effective way to do so. Some scientists use peer review as an opportunity to advance their own research as it stimulates new ideas and allows them to read about new experimental techniques. Other reviewers are keen on building associations with prestigious journals and editors and becoming part of their community, as sometimes reviewers who show dedication to the journal are later hired as editors. Some scientists see peer review as a chance to become aware of the latest research before their peers, and thus be first to develop new insights from the material. Finally, in terms of career development, peer reviewing can be desirable as it is often noted on one’s resume or CV. Many institutions consider a researcher’s involvement in peer review when assessing their performance for promotions ( 11 ). Peer reviewing can also be an effective way for a scientist to show their superiors that they are committed to their scientific field ( 5 ).

ARE REVIEWERS KEEN TO REVIEW?

A 2009 international survey of 4000 peer reviewers conducted by the charity Sense About Science at the British Science Festival at the University of Surrey, found that 90% of reviewers were keen to peer review ( 12 ). One third of respondents to the survey said they were happy to review up to five papers per year, and an additional one third of respondents were happy to review up to ten.

HOW LONG DOES IT TAKE TO REVIEW ONE PAPER?

On average, it takes approximately six hours to review one paper ( 12 ), however, this number may vary greatly depending on the content of the paper and the nature of the peer reviewer. One in every 100 participants in the “Sense About Science” survey claims to have taken more than 100 hours to review their last paper ( 12 ).

HOW TO DETERMINE IF A JOURNAL IS PEER REVIEWED

Ulrichsweb is a directory that provides information on over 300,000 periodicals, including information regarding which journals are peer reviewed ( 13 ). After logging into the system using an institutional login (eg. from the University of Toronto), search terms, journal titles or ISSN numbers can be entered into the search bar. The database provides the title, publisher, and country of origin of the journal, and indicates whether the journal is still actively publishing. The black book symbol (labelled ‘refereed’) reveals that the journal is peer reviewed.

THE EVALUATION CRITERIA FOR PEER REVIEW OF SCIENTIFIC PAPERS

As previously mentioned, when a reviewer receives a scientific manuscript, he/she will first determine if the subject matter is well suited for the content of the journal. The reviewer will then consider whether the research question is important and original, a process which may be aided by a literature scan of review articles.

Scientific papers submitted for peer review usually follow a specific structure that begins with the title, followed by the abstract, introduction, methodology, results, discussion, conclusions, and references. The title must be descriptive and include the concept and organism investigated, and potentially the variable manipulated and the systems used in the study. The peer reviewer evaluates if the title is descriptive enough, and ensures that it is clear and concise. A study by the National Association of Realtors (NAR) published by the Oxford University Press in 2006 indicated that the title of a manuscript plays a significant role in determining reader interest, as 72% of respondents said they could usually judge whether an article will be of interest to them based on the title and the author, while 13% of respondents claimed to always be able to do so ( 14 ).

The abstract is a summary of the paper, which briefly mentions the background or purpose, methods, key results, and major conclusions of the study. The peer reviewer assesses whether the abstract is sufficiently informative and if the content of the abstract is consistent with the rest of the paper. The NAR study indicated that 40% of respondents could determine whether an article would be of interest to them based on the abstract alone 60-80% of the time, while 32% could judge an article based on the abstract 80-100% of the time ( 14 ). This demonstrates that the abstract alone is often used to assess the value of an article.

The introduction of a scientific paper presents the research question in the context of what is already known about the topic, in order to identify why the question being studied is of interest to the scientific community, and what gap in knowledge the study aims to fill ( 15 ). The introduction identifies the study’s purpose and scope, briefly describes the general methods of investigation, and outlines the hypothesis and predictions ( 15 ). The peer reviewer determines whether the introduction provides sufficient background information on the research topic, and ensures that the research question and hypothesis are clearly identifiable.

The methods section describes the experimental procedures, and explains why each experiment was conducted. The methods section also includes the equipment and reagents used in the investigation. The methods section should be detailed enough that it can be used it to repeat the experiment ( 15 ). Methods are written in the past tense and in the active voice. The peer reviewer assesses whether the appropriate methods were used to answer the research question, and if they were written with sufficient detail. If information is missing from the methods section, it is the peer reviewer’s job to identify what details need to be added.

The results section is where the outcomes of the experiment and trends in the data are explained without judgement, bias or interpretation ( 15 ). This section can include statistical tests performed on the data, as well as figures and tables in addition to the text. The peer reviewer ensures that the results are described with sufficient detail, and determines their credibility. Reviewers also confirm that the text is consistent with the information presented in tables and figures, and that all figures and tables included are important and relevant ( 15 ). The peer reviewer will also make sure that table and figure captions are appropriate both contextually and in length, and that tables and figures present the data accurately.

The discussion section is where the data is analyzed. Here, the results are interpreted and related to past studies ( 15 ). The discussion describes the meaning and significance of the results in terms of the research question and hypothesis, and states whether the hypothesis was supported or rejected. This section may also provide possible explanations for unusual results and suggestions for future research ( 15 ). The discussion should end with a conclusions section that summarizes the major findings of the investigation. The peer reviewer determines whether the discussion is clear and focused, and whether the conclusions are an appropriate interpretation of the results. Reviewers also ensure that the discussion addresses the limitations of the study, any anomalies in the results, the relationship of the study to previous research, and the theoretical implications and practical applications of the study.

The references are found at the end of the paper, and list all of the information sources cited in the text to describe the background, methods, and/or interpret results. Depending on the citation method used, the references are listed in alphabetical order according to author last name, or numbered according to the order in which they appear in the paper. The peer reviewer ensures that references are used appropriately, cited accurately, formatted correctly, and that none are missing.

Finally, the peer reviewer determines whether the paper is clearly written and if the content seems logical. After thoroughly reading through the entire manuscript, they determine whether it meets the journal’s standards for publication,

and whether it falls within the top 25% of papers in its field ( 16 ) to determine priority for publication. An overview of what a peer reviewer looks for when evaluating a manuscript, in order of importance, is presented in Figure 2 .

How a peer review evaluates a manuscript

To increase the chance of success in the peer review process, the author must ensure that the paper fully complies with the journal guidelines before submission. The author must also be open to criticism and suggested revisions, and learn from mistakes made in previous submissions.

ADVANTAGES AND DISADVANTAGES OF THE DIFFERENT TYPES OF PEER REVIEW

The peer review process is generally conducted in one of three ways: open review, single-blind review, or double-blind review. In an open review, both the author of the paper and the peer reviewer know one another’s identity. Alternatively, in single-blind review, the reviewer’s identity is kept private, but the author’s identity is revealed to the reviewer. In double-blind review, the identities of both the reviewer and author are kept anonymous. Open peer review is advantageous in that it prevents the reviewer from leaving malicious comments, being careless, or procrastinating completion of the review ( 2 ). It encourages reviewers to be open and honest without being disrespectful. Open reviewing also discourages plagiarism amongst authors ( 2 ). On the other hand, open peer review can also prevent reviewers from being honest for fear of developing bad rapport with the author. The reviewer may withhold or tone down their criticisms in order to be polite ( 2 ). This is especially true when younger reviewers are given a more esteemed author’s work, in which case the reviewer may be hesitant to provide criticism for fear that it will damper their relationship with a superior ( 2 ). According to the Sense About Science survey, editors find that completely open reviewing decreases the number of people willing to participate, and leads to reviews of little value ( 12 ). In the aforementioned study by the PRC, only 23% of authors surveyed had experience with open peer review ( 7 ).

Single-blind peer review is by far the most common. In the PRC study, 85% of authors surveyed had experience with single-blind peer review ( 7 ). This method is advantageous as the reviewer is more likely to provide honest feedback when their identity is concealed ( 2 ). This allows the reviewer to make independent decisions without the influence of the author ( 2 ). The main disadvantage of reviewer anonymity, however, is that reviewers who receive manuscripts on subjects similar to their own research may be tempted to delay completing the review in order to publish their own data first ( 2 ).

Double-blind peer review is advantageous as it prevents the reviewer from being biased against the author based on their country of origin or previous work ( 2 ). This allows the paper to be judged based on the quality of the content, rather than the reputation of the author. The Sense About Science survey indicates that 76% of researchers think double-blind peer review is a good idea ( 12 ), and the PRC survey indicates that 45% of authors have had experience with double-blind peer review ( 7 ). The disadvantage of double-blind peer review is that, especially in niche areas of research, it can sometimes be easy for the reviewer to determine the identity of the author based on writing style, subject matter or self-citation, and thus, impart bias ( 2 ).

Masking the author’s identity from peer reviewers, as is the case in double-blind review, is generally thought to minimize bias and maintain review quality. A study by Justice et al. in 1998 investigated whether masking author identity affected the quality of the review ( 17 ). One hundred and eighteen manuscripts were randomized; 26 were peer reviewed as normal, and 92 were moved into the ‘intervention’ arm, where editor quality assessments were completed for 77 manuscripts and author quality assessments were completed for 40 manuscripts ( 17 ). There was no perceived difference in quality between the masked and unmasked reviews. Additionally, the masking itself was often unsuccessful, especially with well-known authors ( 17 ). However, a previous study conducted by McNutt et al. had different results ( 18 ). In this case, blinding was successful 73% of the time, and they found that when author identity was masked, the quality of review was slightly higher ( 18 ). Although Justice et al. argued that this difference was too small to be consequential, their study targeted only biomedical journals, and the results cannot be generalized to journals of a different subject matter ( 17 ). Additionally, there were problems masking the identities of well-known authors, introducing a flaw in the methods. Regardless, Justice et al. concluded that masking author identity from reviewers may not improve review quality ( 17 ).

In addition to open, single-blind and double-blind peer review, there are two experimental forms of peer review. In some cases, following publication, papers may be subjected to post-publication peer review. As many papers are now published online, the scientific community has the opportunity to comment on these papers, engage in online discussions and post a formal review. For example, online publishers PLOS and BioMed Central have enabled scientists to post comments on published papers if they are registered users of the site ( 10 ). Philica is another journal launched with this experimental form of peer review. Only 8% of authors surveyed in the PRC study had experience with post-publication review ( 7 ). Another experimental form of peer review called Dynamic Peer Review has also emerged. Dynamic peer review is conducted on websites such as Naboj, which allow scientists to conduct peer reviews on articles in the preprint media ( 19 ). The peer review is conducted on repositories and is a continuous process, which allows the public to see both the article and the reviews as the article is being developed ( 19 ). Dynamic peer review helps prevent plagiarism as the scientific community will already be familiar with the work before the peer reviewed version appears in print ( 19 ). Dynamic review also reduces the time lag between manuscript submission and publishing. An example of a preprint server is the ‘arXiv’ developed by Paul Ginsparg in 1991, which is used primarily by physicists ( 19 ). These alternative forms of peer review are still un-established and experimental. Traditional peer review is time-tested and still highly utilized. All methods of peer review have their advantages and deficiencies, and all are prone to error.

PEER REVIEW OF OPEN ACCESS JOURNALS

Open access (OA) journals are becoming increasingly popular as they allow the potential for widespread distribution of publications in a timely manner ( 20 ). Nevertheless, there can be issues regarding the peer review process of open access journals. In a study published in Science in 2013, John Bohannon submitted 304 slightly different versions of a fictional scientific paper (written by a fake author, working out of a non-existent institution) to a selected group of OA journals. This study was performed in order to determine whether papers submitted to OA journals are properly reviewed before publication in comparison to subscription-based journals. The journals in this study were selected from the Directory of Open Access Journals (DOAJ) and Biall’s List, a list of journals which are potentially predatory, and all required a fee for publishing ( 21 ). Of the 304 journals, 157 accepted a fake paper, suggesting that acceptance was based on financial interest rather than the quality of article itself, while 98 journals promptly rejected the fakes ( 21 ). Although this study highlights useful information on the problems associated with lower quality publishers that do not have an effective peer review system in place, the article also generalizes the study results to all OA journals, which can be detrimental to the general perception of OA journals. There were two limitations of the study that made it impossible to accurately determine the relationship between peer review and OA journals: 1) there was no control group (subscription-based journals), and 2) the fake papers were sent to a non-randomized selection of journals, resulting in bias.

JOURNAL ACCEPTANCE RATES

Based on a recent survey, the average acceptance rate for papers submitted to scientific journals is about 50% ( 7 ). Twenty percent of the submitted manuscripts that are not accepted are rejected prior to review, and 30% are rejected following review ( 7 ). Of the 50% accepted, 41% are accepted with the condition of revision, while only 9% are accepted without the request for revision ( 7 ).

SATISFACTION WITH THE PEER REVIEW SYSTEM

Based on a recent survey by the PRC, 64% of academics are satisfied with the current system of peer review, and only 12% claimed to be ‘dissatisfied’ ( 7 ). The large majority, 85%, agreed with the statement that ‘scientific communication is greatly helped by peer review’ ( 7 ). There was a similarly high level of support (83%) for the idea that peer review ‘provides control in scientific communication’ ( 7 ).

HOW TO PEER REVIEW EFFECTIVELY

The following are ten tips on how to be an effective peer reviewer as indicated by Brian Lucey, an expert on the subject ( 22 ):

1) Be professional

Peer review is a mutual responsibility among fellow scientists, and scientists are expected, as part of the academic community, to take part in peer review. If one is to expect others to review their work, they should commit to reviewing the work of others as well, and put effort into it.

2) Be pleasant

If the paper is of low quality, suggest that it be rejected, but do not leave ad hominem comments. There is no benefit to being ruthless.

3) Read the invite

When emailing a scientist to ask them to conduct a peer review, the majority of journals will provide a link to either accept or reject. Do not respond to the email, respond to the link.

4) Be helpful

Suggest how the authors can overcome the shortcomings in their paper. A review should guide the author on what is good and what needs work from the reviewer’s perspective.

5) Be scientific

The peer reviewer plays the role of a scientific peer, not an editor for proofreading or decision-making. Don’t fill a review with comments on editorial and typographic issues. Instead, focus on adding value with scientific knowledge and commenting on the credibility of the research conducted and conclusions drawn. If the paper has a lot of typographical errors, suggest that it be professionally proof edited as part of the review.

6) Be timely

Stick to the timeline given when conducting a peer review. Editors track who is reviewing what and when and will know if someone is late on completing a review. It is important to be timely both out of respect for the journal and the author, as well as to not develop a reputation of being late for review deadlines.

7) Be realistic

The peer reviewer must be realistic about the work presented, the changes they suggest and their role. Peer reviewers may set the bar too high for the paper they are editing by proposing changes that are too ambitious and editors must override them.

8) Be empathetic

Ensure that the review is scientific, helpful and courteous. Be sensitive and respectful with word choice and tone in a review.

Remember that both specialists and generalists can provide valuable insight when peer reviewing. Editors will try to get both specialised and general reviewers for any particular paper to allow for different perspectives. If someone is asked to review, the editor has determined they have a valid and useful role to play, even if the paper is not in their area of expertise.

10) Be organised

A review requires structure and logical flow. A reviewer should proofread their review before submitting it for structural, grammatical and spelling errors as well as for clarity. Most publishers provide short guides on structuring a peer review on their website. Begin with an overview of the proposed improvements; then provide feedback on the paper structure, the quality of data sources and methods of investigation used, the logical flow of argument, and the validity of conclusions drawn. Then provide feedback on style, voice and lexical concerns, with suggestions on how to improve.

In addition, the American Physiology Society (APS) recommends in its Peer Review 101 Handout that peer reviewers should put themselves in both the editor’s and author’s shoes to ensure that they provide what both the editor and the author need and expect ( 11 ). To please the editor, the reviewer should ensure that the peer review is completed on time, and that it provides clear explanations to back up recommendations. To be helpful to the author, the reviewer must ensure that their feedback is constructive. It is suggested that the reviewer take time to think about the paper; they should read it once, wait at least a day, and then re-read it before writing the review ( 11 ). The APS also suggests that Graduate students and researchers pay attention to how peer reviewers edit their work, as well as to what edits they find helpful, in order to learn how to peer review effectively ( 11 ). Additionally, it is suggested that Graduate students practice reviewing by editing their peers’ papers and asking a faculty member for feedback on their efforts. It is recommended that young scientists offer to peer review as often as possible in order to become skilled at the process ( 11 ). The majority of students, fellows and trainees do not get formal training in peer review, but rather learn by observing their mentors. According to the APS, one acquires experience through networking and referrals, and should therefore try to strengthen relationships with journal editors by offering to review manuscripts ( 11 ). The APS also suggests that experienced reviewers provide constructive feedback to students and junior colleagues on their peer review efforts, and encourages them to peer review to demonstrate the importance of this process in improving science ( 11 ).

The peer reviewer should only comment on areas of the manuscript that they are knowledgeable about ( 23 ). If there is any section of the manuscript they feel they are not qualified to review, they should mention this in their comments and not provide further feedback on that section. The peer reviewer is not permitted to share any part of the manuscript with a colleague (even if they may be more knowledgeable in the subject matter) without first obtaining permission from the editor ( 23 ). If a peer reviewer comes across something they are unsure of in the paper, they can consult the literature to try and gain insight. It is important for scientists to remember that if a paper can be improved by the expertise of one of their colleagues, the journal must be informed of the colleague’s help, and approval must be obtained for their colleague to read the protected document. Additionally, the colleague must be identified in the confidential comments to the editor, in order to ensure that he/she is appropriately credited for any contributions ( 23 ). It is the job of the reviewer to make sure that the colleague assisting is aware of the confidentiality of the peer review process ( 23 ). Once the review is complete, the manuscript must be destroyed and cannot be saved electronically by the reviewers ( 23 ).

COMMON ERRORS IN SCIENTIFIC PAPERS

When performing a peer review, there are some common scientific errors to look out for. Most of these errors are violations of logic and common sense: these may include contradicting statements, unwarranted conclusions, suggestion of causation when there is only support for correlation, inappropriate extrapolation, circular reasoning, or pursuit of a trivial question ( 24 ). It is also common for authors to suggest that two variables are different because the effects of one variable are statistically significant while the effects of the other variable are not, rather than directly comparing the two variables ( 24 ). Authors sometimes oversee a confounding variable and do not control for it, or forget to include important details on how their experiments were controlled or the physical state of the organisms studied ( 24 ). Another common fault is the author’s failure to define terms or use words with precision, as these practices can mislead readers ( 24 ). Jargon and/or misused terms can be a serious problem in papers. Inaccurate statements about specific citations are also a common occurrence ( 24 ). Additionally, many studies produce knowledge that can be applied to areas of science outside the scope of the original study, therefore it is better for reviewers to look at the novelty of the idea, conclusions, data, and methodology, rather than scrutinize whether or not the paper answered the specific question at hand ( 24 ). Although it is important to recognize these points, when performing a review it is generally better practice for the peer reviewer to not focus on a checklist of things that could be wrong, but rather carefully identify the problems specific to each paper and continuously ask themselves if anything is missing ( 24 ). An extremely detailed description of how to conduct peer review effectively is presented in the paper How I Review an Original Scientific Article written by Frederic G. Hoppin, Jr. It can be accessed through the American Physiological Society website under the Peer Review Resources section.

CRITICISM OF PEER REVIEW

A major criticism of peer review is that there is little evidence that the process actually works, that it is actually an effective screen for good quality scientific work, and that it actually improves the quality of scientific literature. As a 2002 study published in the Journal of the American Medical Association concluded, ‘Editorial peer review, although widely used, is largely untested and its effects are uncertain’ ( 25 ). Critics also argue that peer review is not effective at detecting errors. Highlighting this point, an experiment by Godlee et al. published in the British Medical Journal (BMJ) inserted eight deliberate errors into a paper that was nearly ready for publication, and then sent the paper to 420 potential reviewers ( 7 ). Of the 420 reviewers that received the paper, 221 (53%) responded, the average number of errors spotted by reviewers was two, no reviewer spotted more than five errors, and 35 reviewers (16%) did not spot any.

Another criticism of peer review is that the process is not conducted thoroughly by scientific conferences with the goal of obtaining large numbers of submitted papers. Such conferences often accept any paper sent in, regardless of its credibility or the prevalence of errors, because the more papers they accept, the more money they can make from author registration fees ( 26 ). This misconduct was exposed in 2014 by three MIT graduate students by the names of Jeremy Stribling, Dan Aguayo and Maxwell Krohn, who developed a simple computer program called SCIgen that generates nonsense papers and presents them as scientific papers ( 26 ). Subsequently, a nonsense SCIgen paper submitted to a conference was promptly accepted. Nature recently reported that French researcher Cyril Labbé discovered that sixteen SCIgen nonsense papers had been used by the German academic publisher Springer ( 26 ). Over 100 nonsense papers generated by SCIgen were published by the US Institute of Electrical and Electronic Engineers (IEEE) ( 26 ). Both organisations have been working to remove the papers. Labbé developed a program to detect SCIgen papers and has made it freely available to ensure publishers and conference organizers do not accept nonsense work in the future. It is available at this link: http://scigendetect.on.imag.fr/main.php ( 26 ).

Additionally, peer review is often criticized for being unable to accurately detect plagiarism. However, many believe that detecting plagiarism cannot practically be included as a component of peer review. As explained by Alice Tuff, development manager at Sense About Science, ‘The vast majority of authors and reviewers think peer review should detect plagiarism (81%) but only a minority (38%) think it is capable. The academic time involved in detecting plagiarism through peer review would cause the system to grind to a halt’ ( 27 ). Publishing house Elsevier began developing electronic plagiarism tools with the help of journal editors in 2009 to help improve this issue ( 27 ).

It has also been argued that peer review has lowered research quality by limiting creativity amongst researchers. Proponents of this view claim that peer review has repressed scientists from pursuing innovative research ideas and bold research questions that have the potential to make major advances and paradigm shifts in the field, as they believe that this work will likely be rejected by their peers upon review ( 28 ). Indeed, in some cases peer review may result in rejection of innovative research, as some studies may not seem particularly strong initially, yet may be capable of yielding very interesting and useful developments when examined under different circumstances, or in the light of new information ( 28 ). Scientists that do not believe in peer review argue that the process stifles the development of ingenious ideas, and thus the release of fresh knowledge and new developments into the scientific community.

Another issue that peer review is criticized for, is that there are a limited number of people that are competent to conduct peer review compared to the vast number of papers that need reviewing. An enormous number of papers published (1.3 million papers in 23,750 journals in 2006), but the number of competent peer reviewers available could not have reviewed them all ( 29 ). Thus, people who lack the required expertise to analyze the quality of a research paper are conducting reviews, and weak papers are being accepted as a result. It is now possible to publish any paper in an obscure journal that claims to be peer-reviewed, though the paper or journal itself could be substandard ( 29 ). On a similar note, the US National Library of Medicine indexes 39 journals that specialize in alternative medicine, and though they all identify themselves as “peer-reviewed”, they rarely publish any high quality research ( 29 ). This highlights the fact that peer review of more controversial or specialized work is typically performed by people who are interested and hold similar views or opinions as the author, which can cause bias in their review. For instance, a paper on homeopathy is likely to be reviewed by fellow practicing homeopaths, and thus is likely to be accepted as credible, though other scientists may find the paper to be nonsense ( 29 ). In some cases, papers are initially published, but their credibility is challenged at a later date and they are subsequently retracted. Retraction Watch is a website dedicated to revealing papers that have been retracted after publishing, potentially due to improper peer review ( 30 ).

Additionally, despite its many positive outcomes, peer review is also criticized for being a delay to the dissemination of new knowledge into the scientific community, and as an unpaid-activity that takes scientists’ time away from activities that they would otherwise prioritize, such as research and teaching, for which they are paid ( 31 ). As described by Eva Amsen, Outreach Director for F1000Research, peer review was originally developed as a means of helping editors choose which papers to publish when journals had to limit the number of papers they could print in one issue ( 32 ). However, nowadays most journals are available online, either exclusively or in addition to print, and many journals have very limited printing runs ( 32 ). Since there are no longer page limits to journals, any good work can and should be published. Consequently, being selective for the purpose of saving space in a journal is no longer a valid excuse that peer reviewers can use to reject a paper ( 32 ). However, some reviewers have used this excuse when they have personal ulterior motives, such as getting their own research published first.

RECENT INITIATIVES TOWARDS IMPROVING PEER REVIEW

F1000Research was launched in January 2013 by Faculty of 1000 as an open access journal that immediately publishes papers (after an initial check to ensure that the paper is in fact produced by a scientist and has not been plagiarised), and then conducts transparent post-publication peer review ( 32 ). F1000Research aims to prevent delays in new science reaching the academic community that are caused by prolonged publication times ( 32 ). It also aims to make peer reviewing more fair by eliminating any anonymity, which prevents reviewers from delaying the completion of a review so they can publish their own similar work first ( 32 ). F1000Research offers completely open peer review, where everything is published, including the name of the reviewers, their review reports, and the editorial decision letters ( 32 ).

PeerJ was founded by Jason Hoyt and Peter Binfield in June 2012 as an open access, peer reviewed scholarly journal for the Biological and Medical Sciences ( 33 ). PeerJ selects articles to publish based only on scientific and methodological soundness, not on subjective determinants of ‘impact ’, ‘novelty’ or ‘interest’ ( 34 ). It works on a “lifetime publishing plan” model which charges scientists for publishing plans that give them lifetime rights to publish with PeerJ, rather than charging them per publication ( 34 ). PeerJ also encourages open peer review, and authors are given the option to post the full peer review history of their submission with their published article ( 34 ). PeerJ also offers a pre-print review service called PeerJ Pre-prints, in which paper drafts are reviewed before being sent to PeerJ to publish ( 34 ).

Rubriq is an independent peer review service designed by Shashi Mudunuri and Keith Collier to improve the peer review system ( 35 ). Rubriq is intended to decrease redundancy in the peer review process so that the time lost in redundant reviewing can be put back into research ( 35 ). According to Keith Collier, over 15 million hours are lost each year to redundant peer review, as papers get rejected from one journal and are subsequently submitted to a less prestigious journal where they are reviewed again ( 35 ). Authors often have to submit their manuscript to multiple journals, and are often rejected multiple times before they find the right match. This process could take months or even years ( 35 ). Rubriq makes peer review portable in order to help authors choose the journal that is best suited for their manuscript from the beginning, thus reducing the time before their paper is published ( 35 ). Rubriq operates under an author-pay model, in which the author pays a fee and their manuscript undergoes double-blind peer review by three expert academic reviewers using a standardized scorecard ( 35 ). The majority of the author’s fee goes towards a reviewer honorarium ( 35 ). The papers are also screened for plagiarism using iThenticate ( 35 ). Once the manuscript has been reviewed by the three experts, the most appropriate journal for submission is determined based on the topic and quality of the paper ( 35 ). The paper is returned to the author in 1-2 weeks with the Rubriq Report ( 35 ). The author can then submit their paper to the suggested journal with the Rubriq Report attached. The Rubriq Report will give the journal editors a much stronger incentive to consider the paper as it shows that three experts have recommended the paper to them ( 35 ). Rubriq also has its benefits for reviewers; the Rubriq scorecard gives structure to the peer review process, and thus makes it consistent and efficient, which decreases time and stress for the reviewer. Reviewers also receive feedback on their reviews and most significantly, they are compensated for their time ( 35 ). Journals also benefit, as they receive pre-screened papers, reducing the number of papers sent to their own reviewers, which often end up rejected ( 35 ). This can reduce reviewer fatigue, and allow only higher-quality articles to be sent to their peer reviewers ( 35 ).

According to Eva Amsen, peer review and scientific publishing are moving in a new direction, in which all papers will be posted online, and a post-publication peer review will take place that is independent of specific journal criteria and solely focused on improving paper quality ( 32 ). Journals will then choose papers that they find relevant based on the peer reviews and publish those papers as a collection ( 32 ). In this process, peer review and individual journals are uncoupled ( 32 ). In Keith Collier’s opinion, post-publication peer review is likely to become more prevalent as a complement to pre-publication peer review, but not as a replacement ( 35 ). Post-publication peer review will not serve to identify errors and fraud but will provide an additional measurement of impact ( 35 ). Collier also believes that as journals and publishers consolidate into larger systems, there will be stronger potential for “cascading” and shared peer review ( 35 ).

CONCLUDING REMARKS

Peer review has become fundamental in assisting editors in selecting credible, high quality, novel and interesting research papers to publish in scientific journals and to ensure the correction of any errors or issues present in submitted papers. Though the peer review process still has some flaws and deficiencies, a more suitable screening method for scientific papers has not yet been proposed or developed. Researchers have begun and must continue to look for means of addressing the current issues with peer review to ensure that it is a full-proof system that ensures only quality research papers are released into the scientific community.

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• 16 April 2024

Structure peer review to make it more robust

• Mario Malički 0

Mario Malički is associate director of the Stanford Program on Research Rigor and Reproducibility (SPORR) and co-editor-in-chief of the Research Integrity and Peer Review journal.

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In February, I received two peer-review reports for a manuscript I’d submitted to a journal. One report contained 3 comments, the other 11. Apart from one point, all the feedback was different. It focused on expanding the discussion and some methodological details — there were no remarks about the study’s objectives, analyses or limitations.

My co-authors and I duly replied, working under two assumptions that are common in scholarly publishing: first, that anything the reviewers didn’t comment on they had found acceptable for publication; second, that they had the expertise to assess all aspects of our manuscript. But, as history has shown, those assumptions are not always accurate (see Lancet 396 , 1056; 2020 ). And through the cracks, inaccurate, sloppy and falsified research can slip.

As co-editor-in-chief of the journal Research Integrity and Peer Review (an open-access journal published by BMC, which is part of Springer Nature), I’m invested in ensuring that the scholarly peer-review system is as trustworthy as possible. And I think that to be robust, peer review needs to be more structured. By that, I mean that journals should provide reviewers with a transparent set of questions to answer that focus on methodological, analytical and interpretative aspects of a paper.

For example, editors might ask peer reviewers to consider whether the methods are described in sufficient detail to allow another researcher to reproduce the work, whether extra statistical analyses are needed, and whether the authors’ interpretation of the results is supported by the data and the study methods. Should a reviewer find anything unsatisfactory, they should provide constructive criticism to the authors. And if reviewers lack the expertise to assess any part of the manuscript, they should be asked to declare this.

Anonymizing peer review makes the process more just

Other aspects of a study, such as novelty, potential impact, language and formatting, should be handled by editors, journal staff or even machines, reducing the workload for reviewers.

The list of questions reviewers will be asked should be published on the journal’s website, allowing authors to prepare their manuscripts with this process in mind. And, as others have argued before, review reports should be published in full. This would allow readers to judge for themselves how a paper was assessed, and would enable researchers to study peer-review practices.

To see how this works in practice, since 2022 I’ve been working with the publisher Elsevier on a pilot study of structured peer review in 23 of its journals, covering the health, life, physical and social sciences. The preliminary results indicate that, when guided by the same questions, reviewers made the same initial recommendation about whether to accept, revise or reject a paper 41% of the time, compared with 31% before these journals implemented structured peer review. Moreover, reviewers’ comments were in agreement about specific parts of a manuscript up to 72% of the time ( M. Malički and B. Mehmani Preprint at bioRxiv https://doi.org/mrdv; 2024 ). In my opinion, reaching such agreement is important for science, which proceeds mainly through consensus.

Stop the peer-review treadmill. I want to get off

I invite editors and publishers to follow in our footsteps and experiment with structured peer reviews. Anyone can trial our template questions (see go.nature.com/4ab2ppc ), or tailor them to suit specific fields or study types. For instance, mathematics journals might also ask whether referees agree with the logic or completeness of a proof. Some journals might ask reviewers if they have checked the raw data or the study code. Publications that employ editors who are less embedded in the research they handle than are academics might need to include questions about a paper’s novelty or impact.

Scientists can also use these questions, either as a checklist when writing papers or when they are reviewing for journals that don’t apply structured peer review.

Some journals — including Proceedings of the National Academy of Sciences , the PLOS family of journals, F1000 journals and some Springer Nature journals — already have their own sets of structured questions for peer reviewers. But, in general, these journals do not disclose the questions they ask, and do not make their questions consistent. This means that core peer-review checks are still not standardized, and reviewers are tasked with different questions when working for different journals.

Some might argue that, because different journals have different thresholds for publication, they should adhere to different standards of quality control. I disagree. Not every study is groundbreaking, but scientists should view quality control of the scientific literature in the same way as quality control in other sectors: as a way to ensure that a product is safe for use by the public. People should be able to see what types of check were done, and when, before an aeroplane was approved as safe for flying. We should apply the same rigour to scientific research.

Ultimately, I hope for a future in which all journals use the same core set of questions for specific study types and make all of their review reports public. I fear that a lack of standard practice in this area is delaying the progress of science.

Nature 628 , 476 (2024)

doi: https://doi.org/10.1038/d41586-024-01101-9

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M.M. is co-editor-in-chief of the Research Integrity and Peer Review journal that publishes signed peer review reports alongside published articles. He is also the chair of the European Association of Science Editors Peer Review Committee.

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• Published: 15 April 2024

Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis

• Christopher J. Byrne 1 , 2 ,
• Fabio Sani 3 ,
• Donna Thain 2 ,
• Emma H. Fletcher 2 &
• Amy Malaguti 3 , 4  

Harm Reduction Journal volume  21 , Article number:  81 ( 2024 ) Cite this article

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Metrics details

Background and aims

Psychological and social status, and environmental context, may mediate the likelihood of experiencing overdose subsequent to illicit drug use. The aim of this systematic review was to identify and synthesise psychosocial factors associated with overdose among people who use drugs.

This review was registered on Prospero (CRD42021242495). Systematic record searches were undertaken in databases of peer-reviewed literature (Medline, Embase, PsycINFO, and Cinahl) and grey literature sources (Google Scholar) for work published up to and including 14 February 2023. Reference lists of selected full-text papers were searched for additional records. Studies were eligible if they included people who use drugs with a focus on relationships between psychosocial factors and overdose subsequent to illicit drug use. Results were tabulated and narratively synthesised.

Twenty-six studies were included in the review, with 150,625 participants: of those 3,383–4072 (3%) experienced overdose. Twenty-one (81%) studies were conducted in North America and 23 (89%) reported polydrug use. Psychosocial factors associated with risk of overdose ( n  = 103) were identified and thematically organised into ten groups. These were: income; housing instability; incarceration; traumatic experiences; overdose risk perception and past experience; healthcare experiences; perception of own drug use and injecting skills; injecting setting; conditions with physical environment; and social network traits.

Conclusions

Global rates of overdose continue to increase, and many guidelines recommend psychosocial interventions for dependent drug use. The factors identified here provide useful targets for practitioners to focus on at the individual level, but many identified will require wider policy changes to affect positive change. Future research should seek to develop and trial interventions targeting factors identified, whilst advocacy for key policy reforms to reduce harm must continue.

Introduction

People Who Use Drugs (PWUD) experience myriad harms which drive substantial morbidity and mortality [ 1 , 2 , 3 , 4 , 5 , 6 ]. In 2019, approximately 6% of the world’s population used illicit drugs at least once – including using illicitly obtained prescription medications in the context of polydrug use – and this is predicted to rise to 11% by 2030 [ 7 , 8 ]. Approximately 21% of PWUD are estimated to have experienced recent non-fatal overdose – known to precipitate future fatal overdose – equating to an estimated 3.2 million people, while approximately 42% have ever experienced overdose [ 2 ]. Internationally, approximately 500,000-600,000 fatalities are attributable to drug use annually, with close to 80% of these related to opioids and 25–30% directly induced by opioid overdose [ 7 , 9 ]. This can include illicit drugs, such as heroin, as well as use of illicitly obtained pharmaceutical opioids, such as morphine, fentanyl, and oxycodone [ 2 , 3 ]. The escalation in drug-related harms and mortality in recent decades has been attributed to a triple-wave epidemic, mediated by supply and demand side drivers, characterised by widespread opioid use; beginning with prescription opioid pills, transitioning through heroin use, and culminating in synthetic opioids – of variable quality and potency – including fentanyl variants, and nitazenes, often combined with or substituted for heroin [ 10 , 11 ].

In North America alone, nearly 600,000 people have died from an opioid-induced overdose in the last two decades with 1.2 million predicted to meet the same fate by 2029 if current trends persist. Elsewhere in the Americas substantial mortality rates have also been recorded [ 12 , 13 ]. In the UK and Western Europe, overdose and mortality rates associated with polydrug use are increasing year-on-year in some nations, with opioids involved in most fatalities [ 14 , 15 , 16 , 17 ]. In Australasia, an estimated 51% of PWUD are reported to have experienced non-fatal overdose, while this is estimated at approximately 34%, 45%, and 50%, in East & Southeast Asia, South Asia, and Central Asia, respectively [ 2 ]. Indeed, Asia, relative to North America, Europe, and Australia, has the highest crude mortality rates among PWUD, with many attributable to fatal overdose [ 3 ]. Although data from African settings is sparse, the available evidence suggests that overdose consequent to illicit drug use, fatal or non-fatal, is increasingly common worldwide, and constitutes a significant threat to public health. Beyond opioids, other central nervous system depressants – benzodiazepines, alcohol – play a critical role contributing to risk, usually in the context of polydrug use [ 17 ]. Similarly, stimulants like cocaine in different forms, and amphetamines, are commonly used together with opioids and elevate risk by artificially masking respiratory depression [ 17 , 18 ].

Responding to these alarming trends, many have endeavoured to improve surveillance and trial interventions to protect people who use drugs from harm. Some existing medicalised interventions include naloxone provision [ 19 , 20 , 21 , 22 ], opioid agonist therapy (OAT) [ 23 ], opioid antagonist therapy [ 24 ], supervised consumption sites [ 25 , 26 , 27 ], related healthcare engagement [ 28 ], detoxification [ 29 ], and integrated prevention activities [ 30 ]. Naloxone provision has gained particular salience due to its efficacy in rapidly reversing opioid-induced overdose symptoms [ 31 ]. Conventionally carried in medical and pre-hospital settings, evidence has shown high willingness among overdose bystanders to administer it [ 20 , 32 , 33 ]. Subsequently, several countries spanning Europe, Australia, and North America, have adopted legislative changes to enable provision without prescription, and protect bystanders who administer it from prosecution [ 34 , 35 , 36 ]. Beyond medicalised interventions, recovery-based approaches which prioritise empowerment, self-determination, and holistic wellbeing, have been widely adopted to underpin recovery journeys with senses of identity, belonging, purpose, and social connection [ 37 ]. Peer outreach and in-reach programmes for overdose reduction, as well as mutual help programmes, have also demonstrated efficacious impacts on recovery [ 38 , 39 , 40 , 41 ]. Such approaches acknowledge that recovery is an ongoing process that requires support, compassion, and dedication, which often extends beyond drug use alone to shifts in identity [ 42 , 43 , 44 ].

It is in the context of the varied approaches to overdose intervention, and the acknowledgement that experiences of drug effects are influenced by psychological characteristics and social processes, that we sought to evaluate the available evidence quantifying the risk of overdose among PWUD associated with psychosocial factors [ 45 , 46 ]. That is, features that pertain to the influence of social factors on an individual’s mind or behaviour, and to the interrelation of behavioural and social factors upon outcomes [ 47 ]. These may relate, for example, to social resources, like healthcare access or income source; psychological resources, such as risk perception; and psychological morbidity. Several guidelines on illicit drug use and dependence recommend psychosocial interventions, often targeting behaviour change through mindfulness, motivational interviewing, cognitive behavioural therapy (CBT) based interventions, and acceptance and commitment therapy [ 48 , 49 , 50 , 51 , 52 ]. These interventions are frequently positioned as adjuncts to overall treatment packages, as they are of uncertain benefit relative to medicalised therapies [ 53 , 54 , 55 ].

Over the years, many risk factors for overdose have been identified, for example: polydrug use; psychiatric comorbidity; unstable housing; witnessing overdose; substance use disorder; prescription of opioids; increasing pharmacy use; increasing opioid prescribers; vulnerability to socio-economic marginalisation; hepatitis C/HIV infection; male gender; rural residence; certain employment types/industries; incarceration; familial distress; disability; detoxification programme experience; the built environment; and suicidality as key factors [ 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 ]. However, despite this expansive evidence base, prior to this review, we were unable to identify any unified work that identified which psychosocial factors are associated with overdose, and therefore best to target with interventions found in prevailing guidelines.

Generating this information is critically important in the current era of increasingly limited public health resource and multiple competing public health priorities. Given their prevalence in clinical guidelines, and the uncertainty around their benefits, we sought to understand which psychosocial factors might impact on risk of overdose, to inform future intervention development and clinical practice. Accordingly, we undertook a systematic review with a narrative synthesis, which aimed to identify which, if any, psychosocial factors are associated with risk of overdose, whether fatal or non-fatal.

This review complied with the updated PRISMA statement checklist for reporting of systematic reviews and meta-analyses [ 68 ] and reporting guidelines for synthesis without meta-analysis in systematic reviews [ 69 ]. The review protocol with methods and inclusion criteria was registered in advance on PROSPERO (CRD42021242495).

Eligibility criteria

Only studies written in English were considered. The search (up to 14 February 2023) was completed with no limitations on publication dates and no geographic restrictions.

Participants

Studies were required to include PWUD as participants.

The exposure in this study was psychosocial factors which are associated with fatal and non-fatal overdose. Psychosocial was defined as pertaining to the influence of social factors on an individual’s mind or behaviour, and to the interrelation of behavioural and social factors on the outcome [ 47 ].

In studies where comparison was undertaken, PWUD who experienced overdose were compared to PWUD who did not.

The primary outcome was overdose (fatal or non-fatal) consequent to use of illicit, or illicitly obtained controlled, drugs. Intentional overdose was excluded where possible, as suicidality constitutes different behavioural characteristics to unintentional overdose. Where it was unclear whether intention was assessed or not, the study was included.

The review included observational studies (cross-sectional, cohort, case-control, and qualitative studies). Case series, case reports, and reviews, were excluded.

Information sources

The following databases were searched via OVID: Medline, Embase and PsycINFO. Cinhal was searched via EBSCOhost. Grey literature was explored by searching with Google Scholar. Reference lists of selected full-text studies were manually screened for further identification of relevant studies.

Search strategy

The search strategy was identical across databases, adjusting for database-specific search requirements. An example of the search strategy is provided in the Supplementary File. Reference lists for manuscripts eligible for full text review were searched manually for relevant titles; whilst Google Scholar was searched with ‘Psychosocial factors AND drug overdose’, and results screened manually. Screening stopped once 100 sequential results did not match search terms, given the results were ordered according to accuracy and relevance. Database searches were saved in an EBSCOhost or OVID account folder. Duplicates were removed.

Study selection and data extraction

Search results were exported from relevant databases into Microsoft Excel 365 spreadsheets for screening, with tables on study characteristics and psychosocial factors created using Microsoft Word 365. One reviewer (AM) screened titles for inclusion. Two reviewers (AM and CJB) screened all abstracts and full texts independently and a third reviewer (FS) arbitrated. Inter-rater agreement, calculated using Cohen’s kappa in Stata 17 BE, indicated high levels of agreement for both abstract (κ = 0.672 [0.565-0.780], p  < .001) and full-text (κ = 0.835 [0.697-0.974], p  < .001) screening. Data were extracted by two reviewers (AM and CJB), and separated into tables. First, data were extracted for study and sample characteristics: author, study design, location and location type, sample size, gender, age, ethnicity, population type, drugs (and other substances) reported, overdose definition, and number who experienced overdose. Second, psychosocial factors associated with overdose identified in each study along with comparators and the estimated effects/description of the association were extracted and tabulated.

Risk of bias assessment

Two reviewers independently assessed risk of bias for all included studies, discussing any discrepancies and mutually agreeing on final assessment; where required, arbitration was conducted by a third person to arrive at a final decision. The National Institutes of Health Study Quality Assessment Tools for quantitative studies, and the Critical Appraisal Skills Programme Qualitative studies checklist for qualitative studies, were used [ 70 , 71 ]. In brief, these prompt quality appraisal by considering clarity of research aims; definition of, and homogeneity of, study populations; participation rates; appropriateness of analytic approaches; clarity of outcomes measured; and ethical conduct.

Effect measures

Effect measures extracted from the studies were tabulated. Given the heterogeneous nature of the studies selected for the review, and the attendant factors examined, results were narratively synthesised; effects were not meta-analysed.

Synthesis procedure

Data were extracted manually and tabulated according to study characteristics and study findings (identified factor, author, effect size, and direction of effect). The tables were used to familiarise the reviewers with the data initially. Once data extraction was complete, the findings were reviewed, and relationships within the data and overlapping themes were annotated throughout the process of narratively synthesising individual data. The themes were discussed among three members of the research team (AM, CJB, FS) and a peer worker with lived experienced of drug use to ensure they were as accurate a reflection of the lived reality of drug use as could feasibly be achieved for a review. Themes were considered against the review question and full dataset to ensure they were focused and addressed the research question. Extracted data within each theme were then inspected to explore differences in effect direction and potential bias introduced by the different study designs included in the review. Where divergences existed, these were considered in light of study design and risk of bias. Following these steps, the manuscript was drafted, which continued the analytical, procedural, and conceptual thinking for the synthesis to be completed.

Study selection

The screening results are illustrated in Fig.  1 . During the search, 2,802 titles were screened: 2,408 were excluded, and 394 were selected for abstract review. After exclusion of duplicates, 187 remained. After further review, 61 were selected for full text assessment. Thirty-five studies were excluded with reason, whilst 26 were selected for quality appraisal and analysis.

Prisma flow chart summarising the screening process

Study characteristics

All studies focussed on overdose, fatal and non-fatal, consequent to illicit drug use as the primary outcome. This was often combined with use of legal substances (e.g. alcohol), and/or illicitly obtained controlled drugs, meaning the cohorts examined were often in the context of polydrug use. One study defined the outcome as death by unintentional overdose, according to post-mortem medical examination records [ 72 ], while one examined people hospitalised with ICD-9 codes for opioid-induced non-fatal overdose [ 73 ]. All other studies relied on self-reported non-fatal overdose disclosure, though outcome timeframes varied. In nine studies, participants self-reported ever experiencing overdose [ 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 ]. For nine other studies, the primary outcome was self-reported overdose in the last six months [ 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 ]. The primary outcome for three studies was experience of overdose in the past 12 months [ 92 , 93 , 94 ]. Riggs et al. defined the primary outcome as self-reported overdose in the last three years, while Argento et al. defined it as self-reported overdose during the study observation period (participants were sampled over nine years and follow-up varied) [ 95 , 96 ]. Lastly, for one study the primary outcome was self-reported overdose in the past five years [ 97 ]. Descriptive characteristics of each study are in Table  1 .

The total sample comprised 150,625 people. Of those, the number of participants who experienced overdose, according to the definitions reported, ranged from 3,383 to 4,072 (3%). A range is provided as one study did not report the number with sufficient clarity [ 87 ].

Most studies were conducted in North America ( n  = 21), three were in Asia, one was in Europe, and one in Australia. Participant ages ranged from 21 to 56 years. Six studies focussed on female and/or gender minority participants [ 75 , 77 , 84 , 88 , 90 , 96 ], and the remainder had a preponderance of male participants (Table  1 ). Twenty-three studies reported polydrug use and, of those, eight specified this was a mixture of prescription and illicit drugs. Three studies did not disclose the specific drugs used [ 73 , 74 , 88 ].

Methodological quality

No methodological concerns were identified which warranted removal of any of the included studies (Supplementary file 1 ).

Psychosocial factors

Factors associated with overdose ( n  = 103) were extracted from each study and structured into ten thematically similar groupings (Table  2 ; Fig.  2 ).

Thematic groups of factors found to impact on experience of overdose in reviewed studies ( n  = 103)

Note : N in each circle is the number of factors within that thematic group. Groups with smaller N are smaller circles, while groups with the same N are the same colour. Groups are randomly scattered as there is no inherent hierarchy or linearity to their impact

Eighteen studies reported odds ratios (OR) as the measure of the association between factors and exposure to overdose [ 73 , 75 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 90 , 91 , 93 , 94 , 95 ]. Two studies reported incidence rate ratios (IRR) [ 74 , 76 ], two reported relative risk (RR) [ 89 , 92 ], and two reported hazard ratios (HR) [ 72 , 96 ]. Two studies were qualitative, so no quantitative estimates were reported [ 77 , 97 ]. Given the heterogeneity of measures and study designs, summary statistics were not calculated, and meta-analysis was not performed [ 98 ]. Despite this heterogeneity, estimates of effects were considered and informed the narrative synthesis.

Eight studies explored the relationship between income source and/or unemployment and odds, or risk, of overdose [ 73 , 75 , 81 , 85 , 87 , 89 , 90 , 94 ]. Winter et al. demonstrated sustained unemployment prior to imprisonment was associated with four-to-five times higher risk of overdose following liberation. Mitra et al. also showed a four-fold increase in odds associated with unemployment. Similarly, Pabayo et al. found 40% and 70% higher odds of overdose among men and women respectively, in receipt of social welfare. Harris et al. showed recent engagement in sex work was associated with 60% higher odds of overdose, while Fairbairn et al. reported ever engaging in sex work was associated with twice the odds. El-Bassel et al. examined compounding effects of sex work and violence, with over ten years sex work experience also associated with twice the odds of overdose, and combined exposure to this with recent violence, including from intimate partners, increasing the odds four-fold. Analysis from Latkin et al. (2019) implied selling drugs in the past 30 days was associated with two-to-three times higher odds of overdose. Finally, work by Silva et al. found identifying as a lower socio-economic status growing up increased odds of overdose by 80%.

Homeless/housing instability

Eight studies explored this theme [ 73 , 81 , 87 , 88 , 89 , 90 , 91 , 95 ]. Unstable housing and lack of accommodation was consistently found to increase the odds and risk of overdose. Mitra et al. observed the largest effect, with housing insecurity increasing the odds of overdose seven-to-eight-fold. Thumath et al. found recent homelessness was associated with 60% higher odds, current homelessness increased odds by 30% according to Riggs et al., while being unhoused in the past six months was associated with 50–70% increased odds in a study by Harris et al. in an all-female sample, and 30% higher odds in Pabayo et al. in a restricted male-only analysis. The highest estimate among examinations of recent homelessness was by Silva et al, who showed past 90-day homelessness increased odds of overdose by close to three-fold, while Tomko et al. estimated a two-fold increase. Ever experiencing homelessness and ever living in a foster home were associated with five-fold and 60% increases in odds of overdose in work by Thumath et al. and Silva et al. respectively. Finally, Winter et al. found experience of unstable accommodation one month prior to incarceration increased risk of overdose three-fold among recently liberated prisoners.

Incarceration

Eight studies explored incarceration-related factors [ 72 , 75 , 77 , 79 , 81 , 86 , 89 ]. Winter et al. estimated any previous incarceration as an adult resulted in five-times higher risk of overdose, while Milloy et al. and El-Bassel et al. estimated a roughly four-fold increase in odds of overdose for participants with similar histories, and Silva et al. estimated a doubling of odds. Harris et al. and Lake et al. found incarceration in the past six months was also associated with twice the odds of overdose, with the effect enduring when adjusted for physical or emotional neglect in the work by Lake et al. El-Bassel et al. estimated a more pronounced effect among those with history of incarceration and intimate partner violence, who experienced five-times higher odds of overdose, with those who experienced non-partner violence having close to four-times higher odds. Recent liberation from prison, coupled with mental ill health, conferred a 50% higher hazard of overdose in work by Pizzicato et al. and Lamonica et al., in their qualitative study, also found that recent liberation from carceral settings increased risk of overdose in a suburban all-female cohort.

Traumatic experiences

Nine studies assessed traumatic experiences [ 75 , 77 , 84 , 86 , 88 , 89 , 90 , 91 , 96 ]. Lamonica et al. found emotional trauma, such as negative life events and consequent depressive states, increased risk of overdose. Various other traumatic experiences were examined, but multiple iterations of physical trauma pre-dominated. Thumath et al. found experience of intimate partner violence doubled the odds of overdose among marginalised women in Canada, Lake et al. found physical abuse and neglect increased odds of overdose by 40% and 30% respectively. Harris et al. found recent physical violence increased overdose odds by 80% in an all-female cohort, with that increasing to close to three-fold among sex workers and adjusted for confounders. Combined physical and sexual workplace violence was associated with twice the odds of overdose among sex workers in Goldenberg et al., while sexual abuse carried a 50% increase in odds in Lake et al., and any physical/sexual violence conferred a 90% increase in hazard in Argento et al. El-Bassel et al. examined multiple type of physical violence, imparted by intimate partners and others, and found consistently elevated odds of overdose, with severe physical violence conferring 30% increased odds in adjusted analysis.

Beyond physical trauma, Tomko et al. identified a 70% increase in odds of overdose among those who experience daily psychological pain in adjusted analysis. Separately, severe emotional abuse conferred a 50% increase in odds in adjusted analysis by Lake et al. Adverse childhood events, such as removal from family as a child, or removal from parental care, were associated with a four-fold increase in odds by Winter et al. and a doubling of odds by Thumath et al., respectively. Similarly, having a child removed from one’s care held a 60% increase in odds in adjusted analysis by Thumath et al., and child custody loss was linked with higher overdose risk in qualitative work by Lamonica et al. Finally, Thumath et al. found food insecurity drove a 90% increased in odds of overdose.

Overdose risk perception and past experience

Risk perception and past experiences with overdose were evaluated in six studies [ 74 , 77 , 80 , 81 , 92 , 95 ]. There were divergent effects between perceived severity of prior overdose experience and participants’ perception of their own susceptibility to overdosing in work by Bonar et al., where higher perceived severity was linked to 40% decreased incidence and higher perceived susceptibility was linked to 50% higher incidence. Vicarious experience, i.e. witnessing an overdose, was associated with two-fold higher odds of subsequent overdose experience in Riggs et al., while ever witnessing a family member overdose conferred 60% higher odds in adjusted analysis by Silva et al. Schiavon et al. estimated that the higher the number of times a participant witnessed another person overdose, odds of subsequent overdose experience increased by 40%, with odds increasing four-fold where the other person was identified as a friend. Prior experience of overdose was also linked to 70% higher risk of subsequent overdose in Grau et al. whereas, in qualitative work by Lamonica et al., being a ‘novice’ to drug use, which may include erroneous polydrug use, was linked to higher risk.

Healthcare experiences

Most healthcare experiences, across eight studies, focused on medicalised addictions treatment [ 76 , 80 , 81 , 84 , 86 , 89 , 91 , 94 ]. Ever experiencing addictions treatment was associated with a 60% increased incidence of overdose in Havens et al., while Latkin et al. estimated a 50% increase in odds. However, when examined by Silva et al., the increase in odds was two-fold, and ever receiving opioid substitution therapy conferred a three-fold increase in relative risk in Winter et al. Schiavon et al. estimated that with increasing number of treatment episodes, the odds of experiencing overdose increased by 60% in adjusted analysis. Conversely, Lake et al. found that being denied access to addictions treatment was associated with close to three-fold odds of overdose. Other studies examined healthcare need, with Goldenberg et al. identifying unmet healthcare need was associated with 70% higher odds of overdose, and Tomko et al. linking unmet mental health care need to a 40% increase in adjusted analysis.

Perception of own drug use and injecting skills

Three studies examined participants’ perceptions of their own drug use, two of which were qualitative [ 77 , 95 , 97 ]. In the quantitative work, Riggs et al. estimated that participants who perceived they had a drug ‘problem’ had five-fold higher odds of subsequent overdose in adjusted analysis. Lamonica et al. found participants who disclosed a lack of knowledge about drug use, a lack of control over the quality of the drugs they were using, or lack of knowledge of their tolerance of those drugs, had higher risk of experiencing overdose. Chang et al. termed similar types of knowledge as ‘opioid expertise’ – this also included perceived self-control over opioid use and one’s bodily response – and identified that participants who felt they possessed a high degree of opioid expertise had increased risk of overdose. Related to the sense of expertise and experience, low injecting skill was examined in two studies [ 86 , 87 ]. Both linked requiring assistance with injecting with increased odds of overdose. Lake et al. found requiring help to inject increased odds by 90%, with adjusted models for physical and sexual abuse yielding 70% higher odds, and adjusted models for physical and emotional neglect yielding 70% and 50% higher odds respectively. Likewise, Pabayo et al., found that, among men, requiring help injecting increased odds of overdose by 74%.

Injecting setting

Injecting setting was assessed in four studies [ 83 , 84 , 85 , 86 ]. Injecting in public spaces in the past six months was consistently linked with higher odds of overdose. Lake et al. found a close to three-fold increase in odds of overdose in a Canadian cohort, which attenuated to 90% when adjusted for experience of emotional abuse, and to 70% when adjusted for experience of emotional neglect. Fairbairn et al. estimated a more pronounced effect, with a close to five-fold increase in odds associated with injecting in public settings. Both cohorts were sampled in Vancouver, Canada. Conversely, these studies found diverging effects for injecting alone in the last six months. Lake et al. estimated an 80% increase in odds, while Fairbairn et al. found the odds of overdose decreased by 60%. Fear of police intervention while injecting in public spaces was associated with a two-fold increase in odds by Bazazi et al., including in adjusted analysis. While ‘rushed’ outdoor drug use in the last six months conferred a 30% increase in odds in work by Goldenberg et al.

Conditions within physical environment

In related analyses, specific conditions within the wider physical environment were found to mediate overdose likelihood in six studies that examined this [ 83 , 84 , 90 , 93 , 94 , 96 ]. Proximity to harm reduction provision was examined in three studies, with somewhat diverging outcomes. First, Bazazi et al., found that among those who reported that a needle and syringe provision (NSP) site was the main source of their injecting equipment acquisition, this was linked to a 60% reduction in odds of overdose. However, Latkin et al. (2019) found that among those who replaced syringes through such a service, there was a three-to-four-fold increase in odds. Vallance et al. also reported a similar finding, where participants that resided in areas of high harm reduction coverage had twice the odds of overdose in adjusted analysis. In further conflicting results, Goldenberg et al. identified police-related barriers to harm reduction access doubled odds of overdose in adjusted analysis.

Similarly, Argento et al., found the same parameter conferred a close to three-fold increase in hazard of overdose in adjusted analysis, while Harris et al. observed that, among women, being stopped, searched, detained, or assaulted by police conferred a 50% increase in odds. This increased to a doubling of odds when stratified for sex workers only. Meanwhile, living in an area characterised by criminalisation, marginalisation, and prevalence of drug use, was associated with 40% higher odds of overdose in the same paper. Somewhat similar to wider drug use prevalence in the area, residing in a neighbourhood with an increasing number of known settings in which to use drugs was associated with 30% increase in odds overdose in adjusted analysis by Latkin et al.

Social network traits

Finally, density of social networks and supports were examined in six studies [ 76 , 77 , 78 , 82 , 84 , 87 ]. Pabayo et al. found three or more social supports was associated with a 50% reduction in odds of overdose among women in adjusted analysis. While, in their study, Tobin et al. found density of social network at baseline, and increases in density reported during follow-up, were associated with 90% and 80% reductions in odds in adjusted analyses. However, among those who reported recent injection drug use, Tobin et al. found increasing density in social network conferred a 20% increase in overdose odds in adjusted analysis, while Latkin et al. (2004) identified that reporting increasing numbers of people who inject heroin in one’s social network was associated with 20% higher odds of past overdose, and 30% higher odds of recent overdose. Conversely, in the same study, increasing numbers of contacts who snort heroin, rather than inject, was associated with a 20% reduction in odds of overdose.

Conflicting somewhat with these findings, Tobin et al. also found that, among those who reported recent injection drug use, an increasing number of people who inject drugs in participants’ social networks was associated with 80% reduced odds of overdose in adjusted analysis. Similarly, Havens et al. found increasing numbers of support members in one’s social network was linked to a 20% increased in incidence of overdose in adjusted analysis. Latkin et al. found increasing levels of conflict within a participant’s social network conferred a 30% increase in odds, whilst other studies examined intimate partnerships. In their qualitative study, Lamonica et al., found being friends, or in an intimate partnership, with someone who uses drugs increased participants’ risk of overdose. Similarly, Goldenberg et al., reported that providing drugs for an intimate partner (who was male) was associated with a 40% increase in odds of overdose.

This review is the first to our knowledge which specifically evaluated psychosocial factors associated with unintentional overdose consequent to illicit drug use, with many reviewed studies documenting polydrug use. Prior research suggests the majority of serious overdoses are unintentional, implying our findings are pertinent to the experiences of many people who use drugs [ 99 ]. While existing review evidence has elucidated many important factors, as noted in the Introduction, none highlighted the important connections between sex work, violence, or social networks, and overdose risk that we identified [ 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 ]. Twenty-six studies from seven countries were reviewed, only two of which were qualitative, with the vast majority conducted in North America. Most participants were male, though several studies examined female-only cohorts. The overall proportion estimated to have experienced overdose was 3%, contrasting sharply with global estimates of 21% (15-26%) of PWUD reported to have recently experienced overdose [ 2 ]. Sample sizes varied widely, with two registry studies reporting disproportionately large samples relative to other reviewed studies, and low relative overdose prevalence [ 72 , 73 ]. Excluding these from the estimate would bring the overall prevalence closer to 16%. Thus we believe most studies reviewed are representative of the at-risk population.

Identified factors were structured into ten overarching groups, with some thematically similar correlates yielding conflicting results. Factors varied from the individual (e.g. risk perception) to the structural (e.g. housing) in a manner which illustrates the synergies between biological factors, psychological traits, and social processes, both at micro and macro levels, which influence an individual’s likelihood of experiencing overdose [ 45 , 46 , 100 , 101 ].

For example, income played an important role in mediating risk, with experience of sex work, unemployment, drug selling, social welfare receipt, and lower socio-economic status, all associated with increased reports of overdose. The relationship between income and health may be explained by subjective psychosocial experiences mediated by work environments and exposure to unemployment [ 102 , 103 ]. However, the correlates reported are characterised by socioeconomic marginalisation, which speaks to the economic and political frameworks which worsen health outcomes for people who use drugs within the model of interdiction which predominates globally. For instance, at the micro level, while the individual acts involved in drug use may have shaped sex worker/client interactions and were important in moderating overdose risk, the ultimate harm induced by that behaviour was enabled by the fact sex workers were reticent to report overdose due to criminalisation and structural stigmatisation, both of their drug use but also their method of income generation [ 104 ]. The risk environment for sex workers was elucidated further by El-Bassel et al. who demonstrated the compounding impact of violence and sex work on overdose risk [ 75 ]. The context may then be at least partially characterised by risky drug use and frequent violence at the micro level – a common experience among sex workers operating in a social environment of gendered norms and unequal power dynamics – which is enabled by public policy at the macro level which marginalises sex workers and leaves them vulnerable to harms related to drug use [ 105 , 106 ]. These findings speak to the urgent need to cease using criminal law to enforce morals upon income generation and strengthen the previously elucidated case for this as the best strategy to reduce harms experienced by sex workers [ 107 ].

At the individual level, there is little evidence to support the use of psychosocial interventions to improve health and well-being among sex workers, perhaps due to the structural factors at play [ 108 ]. Separate to this, unemployment was generally associated with higher risk than sex work and other income factors such as social welfare receipt, participation in the illicit drug trade, and lower socio-economic status, and it is important to note that the relationship between these factors and overdose may be mediated by social capital and isolation [ 59 , 62 , 109 ]. These, in turn, drive worse psychosocial outcomes, which are enabled by prevailing policies of state-imposed methods of control (social welfare) of non-conforming behaviour (non-participation in ‘normative’ modes of economic activity), and intentional criminalisation of drug use which erodes drug supply quality and increases overdose risk [ 10 ].

In a similar vein, housing instability was consistently linked with increased odds of overdose, similar to prior research which observed this [ 110 ]. Among vulnerable adults experiencing homelessness, psychological and social issues at the micro level, such as self-esteem, social support, coping mechanisms, and emotional distress, have been associated with increased substance use [ 111 ]. Further, people facing homelessness experience frequent stigmatisation which negatively impacts mental health and well-being, and wider social interactions. Whilst drug use in this context of unstable housing will be influenced by immediate social norms of the situation, there is an overarching synergy between housing and drug use which has driven opioid-overdose to be a leading cause of death among people experiencing it [ 112 , 113 , 114 ]. Research suggests this synergy confers 38% higher odds of overdose [ 115 ]. These issues are likely manifestations of both immediate social interactions in the context of insecure housing, and macro housing policy which inhibits the social environments which vulnerable individuals are enabled to access. Recent work has reported positive effects for psychosocial interventions in reducing psychological morbidity among people experiencing homelessness [ 116 ], but these will not negate the risks which require wider policy reform around housing programmes [ 112 ]. For example, many housing programmes restrict PWUD accessing their services as a matter of policy, despite housing being linked with harm reduction impacts and improved psychosocial measures which may facilitate recovery-based approaches [ 117 , 118 , 119 ]. The results illustrate a need for supportive and stable housing – a fundamental requirement to establish a sense of safety and stability – to be viewed as a critical intervention which policy makers and public health practitioners should seek to deliver to moderate prevalence of overdose.

The likelihood of becoming homeless may be mediated by history of incarceration [ 120 ]. Incarceration was consistently linked to higher risk of overdose in reviewed studies, and other work not reviewed here [ 115 ]. The circumstances surrounding the first two weeks post liberation have been demonstrated to induce an up to eight-fold increase in risk of fatal overdose relative to subsequent weeks and, furthermore, all-cause mortality is up to 12.7 times higher than that of the general population among those recently liberated, with most attributable to fatal overdose [ 121 , 122 ]. While mental health difficulties, victimisation, and feeling unsafe during incarceration, have been linked to poorer psychosocial adjustment upon liberation (which psychosocial interventions may help address), these findings emphasise the inadequacy of efforts by health and welfare services, and carceral establishments, to assist people in the vulnerable period following liberation with transitional social and medical supports [ 123 , 124 , 125 ].

Research has shown relapse to drug use in this window occurs in the context of poor social support, situational stressors (violence, poverty, isolation, availability), and decreased tolerance [ 125 ]. Conversely, exposure to factors which address these, such as housing, social supports (including avoiding old social networks), mutual help programmes, and spiritual services, have been cited as protective [ 125 ]. Overdose risk caused by liberation to environments that trigger drug use may be somewhat ameliorated by provision of take-home naloxone, but research has shown people in prison may not be receptive to training and carriage of naloxone, and motivation to carry it is complicated by desires to remain abstinent [ 126 , 127 ]. Beyond individual factors, useful conceptual frameworks have been posited to frame the multilevel nature of the determinants involved in overdose risk upon liberation, which suggest researchers shift the lens through which this issue framed from the individual to the socio-structural [ 128 , 129 ]. Our findings highlight the harms conferred by structural control mechanisms which reinforce criminalisation of drug use and compound inequalities experienced by people who use drugs in health outcomes.

There were additive effects for incarceration with physical neglect and recent experience of violence. Intimate partner violence (IPV) was among the traumatic experiences linked to higher risk, alongside multiple types of intimate partner and non-partner violence, including sexual abuse and neglect. It was unclear from the results whether IPV, abuse, and neglect experienced were reciprocal/bidirectional, however all but one study examining these experiences were in female cohorts. So the relationship between overdose risk and these factors may be understood as the confluence of the drug effects, the norms and boundaries concerning gender-based violence within the immediate social context, and wider cultural and systemic factors which perpetuate gender-based violence. At the individual level, psychosocial interventions, with advocacy and psychological components, can reduce depressive symptomology and post-traumatic stress among IPV survivors, which may ameliorate overdose risk [ 130 ]. However, they do not mitigate against re-experience and therefore policy changes which address the physical, social, and economic circumstances that manifest in the macro environment, and perpetuate gender-based violence, are critical to reducing risk, alongside individual interventions. One relevant example is the ongoing pilot of discreet payments to women availing of aid services in Scotland to abscond from circumstances of abuse [ 131 ].

In studies which examined experiences of healthcare, unmet needs and denied care were important in elevating overdose risk. PWUD are less likely to be able to avail of preventive healthcare to screen and manage conditions due to frequent experiences of stigma, distrust, and frustration in health environments; with those same people often blamed for the stigma they experience [ 132 , 133 , 134 , 135 , 136 ]. Unmet health needs have been linked to increased depression, with 29% (21-37%) of PWUD meeting the threshold for clinical depression diagnosis, and consequent self-harm and post-traumatic stress common [ 1 , 137 ]. There were also associations between experience of addictions treatment and overdose which were unexpected, given OAT is known to be protective against drug-related mortality [ 138 ]. This association may be explained by severity of dependence (and related suboptimal dosage); changes in tolerance whilst engaging with treatment; those who engaged with treatment having a higher likelihood of follow-up for overdose; those with past overdose experience being more likely to be referred for treatment; OAT discontinuity and re-entry; and transferring between OAT providers [ 139 , 140 ]. It should further be acknowledged that, though it is an established harm reduction tool, OAT can (and has) been interpreted as a mechanism of control through which moral discipline is inculcated in people who participate in drug use [ 141 , 142 ]. Through this lens, OAT engagement is necessitated only by ongoing interdiction and the intersecting inequalities and harms this produces. Safer supply and decriminalisation of drug use present reasonable (structural) approaches relative to individual interventions such as OAT, which may aid in mitigating overdose risk at the population level, whilst simultaneously mitigating against negative effects of interventions premised on ill-conceived moral frameworks [ 143 , 144 ].

Some environmental factors linked to overdose included experience of police-related interventions such as blocking access to harm reduction, stopping, arresting, and detaining people. All of which are more likely to occur in areas characterised by socio-economic marginalisation and prevalent drug use. Policing of drug use is characterised by violence which drives increased psychological distress among PWUD [ 145 , 146 ]. Similarly, rushed and public injecting, often accompanied by punitive policing, drove increased risk, as demonstrated in previous work [ 115 ]. Social-ecological frameworks have been proposed to articulate a means of addressing such factors, as it is unlikely individual-level interventions will modify these risks [ 147 , 148 ]. It is likely public health approaches which account for the societal, communal, and interpersonal factors, which drive these risks will be required to mitigate against the high likelihood of overdose they confer. These approaches require policy change – particularly regarding criminalisation of drug use and associated policing – while educational campaigns and clear service pathways to harm reduction are also critical.

At a more individual level, perception and social issues noted highlight the interconnectedness between drug use, individual psychology, and social processes. Social support systems impact psychological and physical wellbeing, and the interplay of social networks with environmental and individual factors can differentially impact upon psychological stressors [ 149 ]. This was apparent in the results, with contrasting effects observed. Higher density of social networks of varying degrees were protective against overdose in one study [ 82 ], while others which examined social networks characterised by conflict, ongoing injecting, and exposure to recent overdose among peers, signalled harmful impacts. Individually, peer social support may reduce psychological distress which in turn reduces overdose risk [ 150 , 151 ], and interventions which target social connectedness may be beneficial in this context [ 152 ]. More broadly, these results may be viewed through the Social Identity Model of Recovery, which proposes that recovery from drug use relies on a shift in identity wherein individuals reshape their social network to one wherein drug use is uncommon [ 43 , 44 , 153 ]. Reviewed studies which signalled harmful impacts studied social networks characterised by ongoing risks, whilst one might infer that those which examined network density where actually examining surrogates of networks wherein use of drugs was less prevalent. Where recovery from drug use is sought, peer support can be critical. One form which this takes is in mutual aid groups, which have been shown to catalyse changes in social networks, increase recovery capital, and enhance commitment to sobriety, through community reinforcement [ 154 , 155 ]. Additionally, alternative unstructured peer support strategies, such as recovery cafes, can also be enabling, whilst strategies like ‘spotting’ can help to enhance overdose response in the context of ongoing drug use [ 156 , 157 ].

Furthering the consideration of social context, witnessing overdose is deleterious to psychological wellbeing, causes post-traumatic stress, and can drive people to engage in risky drug use behaviours to manage feelings of bereavement and trauma [ 158 , 159 ]. Psychological distress has itself been independently associated with close to ten-times higher odds of overdose in young people [ 110 ]. Therefore trauma-informed psychosocial interventions for post-traumatic stress – which have been demonstrated as effective, particularly CBT-based therapies – may be important to integrate into existing harm reduction services [ 160 , 161 ]. Particularly when prefaced by safety and stabilisation work within a phased interventional model, to establish safety and create coping mechanisms before trauma reprocessing occurs [ 162 ]. However, an increase in psychological wellbeing may not mitigate against social factors such as requiring injecting assistance – shown previously to increase risk by approximately 58% – and risk conferred by one’s perception of their drug use [ 115 ]. Factors which implied low injecting skill were associated with increased risk – psychosocial interventions may improve injecting skills among PWUD [ 163 ] – alongside identifying as an expert in drug use. This contrasts with research among people who use new psychoactive substances, where expertise has been linked to higher risk perception and greater control in exposure to risk [ 164 ]. Individual-level interventions which assess and affect changes to psychological mechanisms that relate risk perception to overdose risk may therefore also be appropriate to explore.

Limitations

There are several limitations to this review. First, we did not undertake a meta-analysis due to the heterogeneity in effect estimates and study designs, instead opting for narrative review of the effects. Although appropriate for the heterogeneous study types and factors examined, this provides limited information for decision making relative to meta-analysis and risks emphasising the results of some studies erroneously and potentially misrepresenting the evidence [ 165 ]. Second, reviewed studies were concentrated in high-income countries, mostly in North America, significantly limiting the generalisability of the work. No work from African settings was identified, which is a critical limitation given the ongoing epidemic of extra-medical use of opioids (tramadol) and expansion of cocaine markets in recent years into African and Near and Middle Eastern settings, beyond conventional markets in Europe and North America [ 166 ]. This likely means PWUD in these settings will be disproportionately impacted by associated harms in coming years, with little representation in research. Third, our search strategy included terms for ‘psychosocial’, ‘psychological’, ‘social’, or ‘behavioural’, which was intended to be comprehensive. Nonetheless, some relevant research may have been omitted unintentionally due to the search design and/or interpretation of the results by the reviewers, given the broad scope and interpretability of the term ‘psychosocial’; we mitigated against this by referencing a recognised definition when interpreting and extracting results, and citing works thought to be relevant in the Discussion [ 47 ]. Finally, only two studies reviewed were qualitative in nature. This suggests the findings may omit relevant work documenting subjective experience, not captured in the quantitative studies. We suggest two reasons for this: our search strategy did not include terms for methodology like ‘quantitative’ or ‘qualitative’ which may have resulted in more results returned for relevant qualitative work; and much qualitative work proximal to overdose which we reviewed for inclusion concurrently examined factors which made them ineligible on the basis of our criteria (e.g. suicidal ideation; relationships).

Globally, rates of fatal and non-fatal overdose continue to increase, alongside many cognate harms, consequent to illicit drug use [ 1 , 2 , 167 ]. This review identified many psychosocial correlates of overdose which spoke to the interdependencies between drug use, psychological traits, and social processes, alongside the overlapping structural, societal, and environmental inequities which govern harms related to drug use, and therefore frame the risks related to overdose. Existing harm reduction interventions are insufficient to resolve the crisis of overdose and avoidable fatalities consequent to the opioid epidemic [ 168 ]. To date, many national drug policies are premised more on ideology than evidence, and our findings support the view that punitive approaches are not just ineffective in reducing prevalence of overdose, but actually contribute to the risk environment which increases it [ 144 ]. Where we believe this review adds value for the harm reduction movement is in elucidating several themes not previously identified in existing review evidence, which may be helpful in policy work concerning drug use, and clarifying the factors which practitioners may seek to engage at the individual level when exploring psychosocial interventions in harm reduction services, to facilitate therapeutic response. For example: mechanisms underlying risk perception, social connectedness, coping mechanisms, and screening and management of IPV [ 50 , 51 , 52 , 55 ].

Data availability

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Acknowledgements

We wish to acknowledge and thank Teresa Flynn, Tammie Brown, Ann Eriksen, Dr Jennifer Breen, and Dr Fiona Cowden, for their contributions to this review and our wider research programme.

This study was funded by the Scottish Drug Death Taskforce (grant number: DDTFRF16). The funder was not involved in collection, analysis, and/or interpretation of data, in the writing of the report, or in the decision to submit the manuscript for publication.

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Conceptualisation: AM. Methodology: AM, CJB, FS. Software: Not applicable. Validation: Not applicable. Formal analysis: AM, CJB, FS. Investigation: AM, CJB, FS. Resources: Not applicable. Data curation: AM, CJB, FS. Writing – Original Draft: CJB, AM. Writing – Review & Editing: All authors. Visualisation: AM, CJB. Supervision: AM, CJB. Project administration: AM. Funding acquisition: AM.

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CJB has received honoraria from the International Network for Health and Hepatitis in Substance Users (INHSU), and grant funding from the Scottish Society of Physicians, unrelated to the submitted work. FS received funding from the Scottish Drug Deaths Taskforce related to the submitted work. AM has received funding from the Scottish Drug Deaths Taskforce related to the submitted work, and funding from the British Psychological Society unrelated to the submitted work. EF and DT report no competing interests.

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Byrne, C.J., Sani, F., Thain, D. et al. Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis. Harm Reduct J 21 , 81 (2024). https://doi.org/10.1186/s12954-024-00999-8

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DOI : https://doi.org/10.1186/s12954-024-00999-8

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• Psychosocial
• Narrative synthesis
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• Drug-related death

Harm Reduction Journal

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Electronic Medical Records Management and Administration: Current Trends, Issues, Solutions, and Future Directions

• Review Article
• Published: 20 April 2024
• Volume 5 , article number  460 , ( 2024 )

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• Umar Abdulkadir   ORCID: orcid.org/0000-0002-8118-0626 1 ,
• Victor Onomza Waziri 1 ,
• John Kolo Alhassan   ORCID: orcid.org/0000-0002-9289-0404 2 &
• Idris Ismaila 1  

Electronic Medical Records (EMR) is often used to refer to as electronic personal health (EPH) records or electronic healthcare records (EHR). These are considered vivacious assets of health facilities and patients. The relevance of the EMRs has motivated diverse innovations in the collecting, organizing, managing and administering for purpose of treatment primarily and other reasons. There are various concerns raised about legitimate usages, reproducibility, accuracy, and privacy breaches of EMRs across majority of health and medical facilities globally. This phenomenon became popular due to its support of electronic devices, wireless links, transmission and storage of data in the cloud, and communication across a gateway (or central-point). Therefore, physicians and medical facilities were empowered to undertake virtual consultations to patients through telemedicine applications for the remote treatment and diagnosis. Internet of Things (IoT) systems, medical wearable objects, and sensors were the basic components that collect and transmit patient data on real-time basis to a base station or centralized servers managed by hospitals. However, there is the need to improve creation and adoption of EMRs not without understanding their roles and shortfalls as well possible means of improvement. Consequently, this study conducts a systematic literature review on electronic medical records management and administration under current trends, issues, solutions and future directions. To this end, eighty-one (81) peer-reviewed articles including conferences and journals papers were included in the final stage of the study after applying Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRIMA-P) methodology of records selection. The contributions of this study include: the recognition of the informed consent strategy as the best solution to illegitimate access to patient electronic records; the use of permissioned access strategies provided by blockchain technology as most recent attempt for privacy preservations; the use of lightweight cryptosystems with greater emphasis on Lattice systems; and the need to scale beyond theoretical frameworks to real-life implementations.

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Abdulkadir, U., Waziri, V.O., Alhassan, J.K. et al. Electronic Medical Records Management and Administration: Current Trends, Issues, Solutions, and Future Directions. SN COMPUT. SCI. 5 , 460 (2024). https://doi.org/10.1007/s42979-024-02803-7

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