How to Write the Discussion Section of a Research Paper

The discussion section of a research paper analyzes and interprets the findings, provides context, compares them with previous studies, identifies limitations, and suggests future research directions.

Updated on September 15, 2023

researchers writing the discussion section of their research paper

Structure your discussion section right, and you’ll be cited more often while doing a greater service to the scientific community. So, what actually goes into the discussion section? And how do you write it?

The discussion section of your research paper is where you let the reader know how your study is positioned in the literature, what to take away from your paper, and how your work helps them. It can also include your conclusions and suggestions for future studies.

First, we’ll define all the parts of your discussion paper, and then look into how to write a strong, effective discussion section for your paper or manuscript.

Discussion section: what is it, what it does

The discussion section comes later in your paper, following the introduction, methods, and results. The discussion sets up your study’s conclusions. Its main goals are to present, interpret, and provide a context for your results.

What is it?

The discussion section provides an analysis and interpretation of the findings, compares them with previous studies, identifies limitations, and suggests future directions for research.

This section combines information from the preceding parts of your paper into a coherent story. By this point, the reader already knows why you did your study (introduction), how you did it (methods), and what happened (results). In the discussion, you’ll help the reader connect the ideas from these sections.

Why is it necessary?

The discussion provides context and interpretations for the results. It also answers the questions posed in the introduction. While the results section describes your findings, the discussion explains what they say. This is also where you can describe the impact or implications of your research.

Adds context for your results

Most research studies aim to answer a question, replicate a finding, or address limitations in the literature. These goals are first described in the introduction. However, in the discussion section, the author can refer back to them to explain how the study's objective was achieved. 

Shows what your results actually mean and real-world implications

The discussion can also describe the effect of your findings on research or practice. How are your results significant for readers, other researchers, or policymakers?

What to include in your discussion (in the correct order)

A complete and effective discussion section should at least touch on the points described below.

Summary of key findings

The discussion should begin with a brief factual summary of the results. Concisely overview the main results you obtained.

Begin with key findings with supporting evidence

Your results section described a list of findings, but what message do they send when you look at them all together?

Your findings were detailed in the results section, so there’s no need to repeat them here, but do provide at least a few highlights. This will help refresh the reader’s memory and help them focus on the big picture.

Read the first paragraph of the discussion section in this article (PDF) for an example of how to start this part of your paper. Notice how the authors break down their results and follow each description sentence with an explanation of why each finding is relevant. 

State clearly and concisely

Following a clear and direct writing style is especially important in the discussion section. After all, this is where you will make some of the most impactful points in your paper. While the results section often contains technical vocabulary, such as statistical terms, the discussion section lets you describe your findings more clearly. 

Interpretation of results

Once you’ve given your reader an overview of your results, you need to interpret those results. In other words, what do your results mean? Discuss the findings’ implications and significance in relation to your research question or hypothesis.

Analyze and interpret your findings

Look into your findings and explore what’s behind them or what may have caused them. If your introduction cited theories or studies that could explain your findings, use these sources as a basis to discuss your results.

For example, look at the second paragraph in the discussion section of this article on waggling honey bees. Here, the authors explore their results based on information from the literature.

Unexpected or contradictory results

Sometimes, your findings are not what you expect. Here’s where you describe this and try to find a reason for it. Could it be because of the method you used? Does it have something to do with the variables analyzed? Comparing your methods with those of other similar studies can help with this task.

Context and comparison with previous work

Refer to related studies to place your research in a larger context and the literature. Compare and contrast your findings with existing literature, highlighting similarities, differences, and/or contradictions.

How your work compares or contrasts with previous work

Studies with similar findings to yours can be cited to show the strength of your findings. Information from these studies can also be used to help explain your results. Differences between your findings and others in the literature can also be discussed here. 

How to divide this section into subsections

If you have more than one objective in your study or many key findings, you can dedicate a separate section to each of these. Here’s an example of this approach. You can see that the discussion section is divided into topics and even has a separate heading for each of them. 

Limitations

Many journals require you to include the limitations of your study in the discussion. Even if they don’t, there are good reasons to mention these in your paper.

Why limitations don’t have a negative connotation

A study’s limitations are points to be improved upon in future research. While some of these may be flaws in your method, many may be due to factors you couldn’t predict.

Examples include time constraints or small sample sizes. Pointing this out will help future researchers avoid or address these issues. This part of the discussion can also include any attempts you have made to reduce the impact of these limitations, as in this study .

How limitations add to a researcher's credibility

Pointing out the limitations of your study demonstrates transparency. It also shows that you know your methods well and can conduct a critical assessment of them.  

Implications and significance

The final paragraph of the discussion section should contain the take-home messages for your study. It can also cite the “strong points” of your study, to contrast with the limitations section.

Restate your hypothesis

Remind the reader what your hypothesis was before you conducted the study. 

How was it proven or disproven?

Identify your main findings and describe how they relate to your hypothesis.

How your results contribute to the literature

Were you able to answer your research question? Or address a gap in the literature?

Future implications of your research

Describe the impact that your results may have on the topic of study. Your results may show, for instance, that there are still limitations in the literature for future studies to address. There may be a need for studies that extend your findings in a specific way. You also may need additional research to corroborate your findings. 

Sample discussion section

This fictitious example covers all the aspects discussed above. Your actual discussion section will probably be much longer, but you can read this to get an idea of everything your discussion should cover.

Our results showed that the presence of cats in a household is associated with higher levels of perceived happiness by its human occupants. These findings support our hypothesis and demonstrate the association between pet ownership and well-being. 

The present findings align with those of Bao and Schreer (2016) and Hardie et al. (2023), who observed greater life satisfaction in pet owners relative to non-owners. Although the present study did not directly evaluate life satisfaction, this factor may explain the association between happiness and cat ownership observed in our sample.

Our findings must be interpreted in light of some limitations, such as the focus on cat ownership only rather than pets as a whole. This may limit the generalizability of our results.

Nevertheless, this study had several strengths. These include its strict exclusion criteria and use of a standardized assessment instrument to investigate the relationships between pets and owners. These attributes bolster the accuracy of our results and reduce the influence of confounding factors, increasing the strength of our conclusions. Future studies may examine the factors that mediate the association between pet ownership and happiness to better comprehend this phenomenon.

This brief discussion begins with a quick summary of the results and hypothesis. The next paragraph cites previous research and compares its findings to those of this study. Information from previous studies is also used to help interpret the findings. After discussing the results of the study, some limitations are pointed out. The paper also explains why these limitations may influence the interpretation of results. Then, final conclusions are drawn based on the study, and directions for future research are suggested.

How to make your discussion flow naturally

If you find writing in scientific English challenging, the discussion and conclusions are often the hardest parts of the paper to write. That’s because you’re not just listing up studies, methods, and outcomes. You’re actually expressing your thoughts and interpretations in words.

  • How formal should it be?
  • What words should you use, or not use?
  • How do you meet strict word limits, or make it longer and more informative?

Always give it your best, but sometimes a helping hand can, well, help. Getting a professional edit can help clarify your work’s importance while improving the English used to explain it. When readers know the value of your work, they’ll cite it. We’ll assign your study to an expert editor knowledgeable in your area of research. Their work will clarify your discussion, helping it to tell your story. Find out more about AJE Editing.

Adam Goulston, Science Marketing Consultant, PsyD, Human and Organizational Behavior, Scize

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Research Method

Home » Research Results Section – Writing Guide and Examples

Research Results Section – Writing Guide and Examples

Table of Contents

Research Results

Research Results

Research results refer to the findings and conclusions derived from a systematic investigation or study conducted to answer a specific question or hypothesis. These results are typically presented in a written report or paper and can include various forms of data such as numerical data, qualitative data, statistics, charts, graphs, and visual aids.

Results Section in Research

The results section of the research paper presents the findings of the study. It is the part of the paper where the researcher reports the data collected during the study and analyzes it to draw conclusions.

In the results section, the researcher should describe the data that was collected, the statistical analysis performed, and the findings of the study. It is important to be objective and not interpret the data in this section. Instead, the researcher should report the data as accurately and objectively as possible.

Structure of Research Results Section

The structure of the research results section can vary depending on the type of research conducted, but in general, it should contain the following components:

  • Introduction: The introduction should provide an overview of the study, its aims, and its research questions. It should also briefly explain the methodology used to conduct the study.
  • Data presentation : This section presents the data collected during the study. It may include tables, graphs, or other visual aids to help readers better understand the data. The data presented should be organized in a logical and coherent way, with headings and subheadings used to help guide the reader.
  • Data analysis: In this section, the data presented in the previous section are analyzed and interpreted. The statistical tests used to analyze the data should be clearly explained, and the results of the tests should be presented in a way that is easy to understand.
  • Discussion of results : This section should provide an interpretation of the results of the study, including a discussion of any unexpected findings. The discussion should also address the study’s research questions and explain how the results contribute to the field of study.
  • Limitations: This section should acknowledge any limitations of the study, such as sample size, data collection methods, or other factors that may have influenced the results.
  • Conclusions: The conclusions should summarize the main findings of the study and provide a final interpretation of the results. The conclusions should also address the study’s research questions and explain how the results contribute to the field of study.
  • Recommendations : This section may provide recommendations for future research based on the study’s findings. It may also suggest practical applications for the study’s results in real-world settings.

Outline of Research Results Section

The following is an outline of the key components typically included in the Results section:

I. Introduction

  • A brief overview of the research objectives and hypotheses
  • A statement of the research question

II. Descriptive statistics

  • Summary statistics (e.g., mean, standard deviation) for each variable analyzed
  • Frequencies and percentages for categorical variables

III. Inferential statistics

  • Results of statistical analyses, including tests of hypotheses
  • Tables or figures to display statistical results

IV. Effect sizes and confidence intervals

  • Effect sizes (e.g., Cohen’s d, odds ratio) to quantify the strength of the relationship between variables
  • Confidence intervals to estimate the range of plausible values for the effect size

V. Subgroup analyses

  • Results of analyses that examined differences between subgroups (e.g., by gender, age, treatment group)

VI. Limitations and assumptions

  • Discussion of any limitations of the study and potential sources of bias
  • Assumptions made in the statistical analyses

VII. Conclusions

  • A summary of the key findings and their implications
  • A statement of whether the hypotheses were supported or not
  • Suggestions for future research

Example of Research Results Section

An Example of a Research Results Section could be:

  • This study sought to examine the relationship between sleep quality and academic performance in college students.
  • Hypothesis : College students who report better sleep quality will have higher GPAs than those who report poor sleep quality.
  • Methodology : Participants completed a survey about their sleep habits and academic performance.

II. Participants

  • Participants were college students (N=200) from a mid-sized public university in the United States.
  • The sample was evenly split by gender (50% female, 50% male) and predominantly white (85%).
  • Participants were recruited through flyers and online advertisements.

III. Results

  • Participants who reported better sleep quality had significantly higher GPAs (M=3.5, SD=0.5) than those who reported poor sleep quality (M=2.9, SD=0.6).
  • See Table 1 for a summary of the results.
  • Participants who reported consistent sleep schedules had higher GPAs than those with irregular sleep schedules.

IV. Discussion

  • The results support the hypothesis that better sleep quality is associated with higher academic performance in college students.
  • These findings have implications for college students, as prioritizing sleep could lead to better academic outcomes.
  • Limitations of the study include self-reported data and the lack of control for other variables that could impact academic performance.

V. Conclusion

  • College students who prioritize sleep may see a positive impact on their academic performance.
  • These findings highlight the importance of sleep in academic success.
  • Future research could explore interventions to improve sleep quality in college students.

Example of Research Results in Research Paper :

Our study aimed to compare the performance of three different machine learning algorithms (Random Forest, Support Vector Machine, and Neural Network) in predicting customer churn in a telecommunications company. We collected a dataset of 10,000 customer records, with 20 predictor variables and a binary churn outcome variable.

Our analysis revealed that all three algorithms performed well in predicting customer churn, with an overall accuracy of 85%. However, the Random Forest algorithm showed the highest accuracy (88%), followed by the Support Vector Machine (86%) and the Neural Network (84%).

Furthermore, we found that the most important predictor variables for customer churn were monthly charges, contract type, and tenure. Random Forest identified monthly charges as the most important variable, while Support Vector Machine and Neural Network identified contract type as the most important.

Overall, our results suggest that machine learning algorithms can be effective in predicting customer churn in a telecommunications company, and that Random Forest is the most accurate algorithm for this task.

Example 3 :

Title : The Impact of Social Media on Body Image and Self-Esteem

Abstract : This study aimed to investigate the relationship between social media use, body image, and self-esteem among young adults. A total of 200 participants were recruited from a university and completed self-report measures of social media use, body image satisfaction, and self-esteem.

Results: The results showed that social media use was significantly associated with body image dissatisfaction and lower self-esteem. Specifically, participants who reported spending more time on social media platforms had lower levels of body image satisfaction and self-esteem compared to those who reported less social media use. Moreover, the study found that comparing oneself to others on social media was a significant predictor of body image dissatisfaction and lower self-esteem.

Conclusion : These results suggest that social media use can have negative effects on body image satisfaction and self-esteem among young adults. It is important for individuals to be mindful of their social media use and to recognize the potential negative impact it can have on their mental health. Furthermore, interventions aimed at promoting positive body image and self-esteem should take into account the role of social media in shaping these attitudes and behaviors.

Importance of Research Results

Research results are important for several reasons, including:

  • Advancing knowledge: Research results can contribute to the advancement of knowledge in a particular field, whether it be in science, technology, medicine, social sciences, or humanities.
  • Developing theories: Research results can help to develop or modify existing theories and create new ones.
  • Improving practices: Research results can inform and improve practices in various fields, such as education, healthcare, business, and public policy.
  • Identifying problems and solutions: Research results can identify problems and provide solutions to complex issues in society, including issues related to health, environment, social justice, and economics.
  • Validating claims : Research results can validate or refute claims made by individuals or groups in society, such as politicians, corporations, or activists.
  • Providing evidence: Research results can provide evidence to support decision-making, policy-making, and resource allocation in various fields.

How to Write Results in A Research Paper

Here are some general guidelines on how to write results in a research paper:

  • Organize the results section: Start by organizing the results section in a logical and coherent manner. Divide the section into subsections if necessary, based on the research questions or hypotheses.
  • Present the findings: Present the findings in a clear and concise manner. Use tables, graphs, and figures to illustrate the data and make the presentation more engaging.
  • Describe the data: Describe the data in detail, including the sample size, response rate, and any missing data. Provide relevant descriptive statistics such as means, standard deviations, and ranges.
  • Interpret the findings: Interpret the findings in light of the research questions or hypotheses. Discuss the implications of the findings and the extent to which they support or contradict existing theories or previous research.
  • Discuss the limitations : Discuss the limitations of the study, including any potential sources of bias or confounding factors that may have affected the results.
  • Compare the results : Compare the results with those of previous studies or theoretical predictions. Discuss any similarities, differences, or inconsistencies.
  • Avoid redundancy: Avoid repeating information that has already been presented in the introduction or methods sections. Instead, focus on presenting new and relevant information.
  • Be objective: Be objective in presenting the results, avoiding any personal biases or interpretations.

When to Write Research Results

Here are situations When to Write Research Results”

  • After conducting research on the chosen topic and obtaining relevant data, organize the findings in a structured format that accurately represents the information gathered.
  • Once the data has been analyzed and interpreted, and conclusions have been drawn, begin the writing process.
  • Before starting to write, ensure that the research results adhere to the guidelines and requirements of the intended audience, such as a scientific journal or academic conference.
  • Begin by writing an abstract that briefly summarizes the research question, methodology, findings, and conclusions.
  • Follow the abstract with an introduction that provides context for the research, explains its significance, and outlines the research question and objectives.
  • The next section should be a literature review that provides an overview of existing research on the topic and highlights the gaps in knowledge that the current research seeks to address.
  • The methodology section should provide a detailed explanation of the research design, including the sample size, data collection methods, and analytical techniques used.
  • Present the research results in a clear and concise manner, using graphs, tables, and figures to illustrate the findings.
  • Discuss the implications of the research results, including how they contribute to the existing body of knowledge on the topic and what further research is needed.
  • Conclude the paper by summarizing the main findings, reiterating the significance of the research, and offering suggestions for future research.

Purpose of Research Results

The purposes of Research Results are as follows:

  • Informing policy and practice: Research results can provide evidence-based information to inform policy decisions, such as in the fields of healthcare, education, and environmental regulation. They can also inform best practices in fields such as business, engineering, and social work.
  • Addressing societal problems : Research results can be used to help address societal problems, such as reducing poverty, improving public health, and promoting social justice.
  • Generating economic benefits : Research results can lead to the development of new products, services, and technologies that can create economic value and improve quality of life.
  • Supporting academic and professional development : Research results can be used to support academic and professional development by providing opportunities for students, researchers, and practitioners to learn about new findings and methodologies in their field.
  • Enhancing public understanding: Research results can help to educate the public about important issues and promote scientific literacy, leading to more informed decision-making and better public policy.
  • Evaluating interventions: Research results can be used to evaluate the effectiveness of interventions, such as treatments, educational programs, and social policies. This can help to identify areas where improvements are needed and guide future interventions.
  • Contributing to scientific progress: Research results can contribute to the advancement of science by providing new insights and discoveries that can lead to new theories, methods, and techniques.
  • Informing decision-making : Research results can provide decision-makers with the information they need to make informed decisions. This can include decision-making at the individual, organizational, or governmental levels.
  • Fostering collaboration : Research results can facilitate collaboration between researchers and practitioners, leading to new partnerships, interdisciplinary approaches, and innovative solutions to complex problems.

Advantages of Research Results

Some Advantages of Research Results are as follows:

  • Improved decision-making: Research results can help inform decision-making in various fields, including medicine, business, and government. For example, research on the effectiveness of different treatments for a particular disease can help doctors make informed decisions about the best course of treatment for their patients.
  • Innovation : Research results can lead to the development of new technologies, products, and services. For example, research on renewable energy sources can lead to the development of new and more efficient ways to harness renewable energy.
  • Economic benefits: Research results can stimulate economic growth by providing new opportunities for businesses and entrepreneurs. For example, research on new materials or manufacturing techniques can lead to the development of new products and processes that can create new jobs and boost economic activity.
  • Improved quality of life: Research results can contribute to improving the quality of life for individuals and society as a whole. For example, research on the causes of a particular disease can lead to the development of new treatments and cures, improving the health and well-being of millions of people.

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The results section is where you report the findings of your study based upon the methodology [or methodologies] you applied to gather information. The results section should state the findings of the research arranged in a logical sequence without bias or interpretation. A section describing results should be particularly detailed if your paper includes data generated from your own research.

Annesley, Thomas M. "Show Your Cards: The Results Section and the Poker Game." Clinical Chemistry 56 (July 2010): 1066-1070.

Importance of a Good Results Section

When formulating the results section, it's important to remember that the results of a study do not prove anything . Findings can only confirm or reject the hypothesis underpinning your study. However, the act of articulating the results helps you to understand the problem from within, to break it into pieces, and to view the research problem from various perspectives.

The page length of this section is set by the amount and types of data to be reported . Be concise. Use non-textual elements appropriately, such as figures and tables, to present findings more effectively. In deciding what data to describe in your results section, you must clearly distinguish information that would normally be included in a research paper from any raw data or other content that could be included as an appendix. In general, raw data that has not been summarized should not be included in the main text of your paper unless requested to do so by your professor.

Avoid providing data that is not critical to answering the research question . The background information you described in the introduction section should provide the reader with any additional context or explanation needed to understand the results. A good strategy is to always re-read the background section of your paper after you have written up your results to ensure that the reader has enough context to understand the results [and, later, how you interpreted the results in the discussion section of your paper that follows].

Bavdekar, Sandeep B. and Sneha Chandak. "Results: Unraveling the Findings." Journal of the Association of Physicians of India 63 (September 2015): 44-46; Brett, Paul. "A Genre Analysis of the Results Section of Sociology Articles." English for Specific Speakers 13 (1994): 47-59; Go to English for Specific Purposes on ScienceDirect;Burton, Neil et al. Doing Your Education Research Project . Los Angeles, CA: SAGE, 2008; Results. The Structure, Format, Content, and Style of a Journal-Style Scientific Paper. Department of Biology. Bates College; Kretchmer, Paul. Twelve Steps to Writing an Effective Results Section. San Francisco Edit; "Reporting Findings." In Making Sense of Social Research Malcolm Williams, editor. (London;: SAGE Publications, 2003) pp. 188-207.

Structure and Writing Style

I.  Organization and Approach

For most research papers in the social and behavioral sciences, there are two possible ways of organizing the results . Both approaches are appropriate in how you report your findings, but use only one approach.

  • Present a synopsis of the results followed by an explanation of key findings . This approach can be used to highlight important findings. For example, you may have noticed an unusual correlation between two variables during the analysis of your findings. It is appropriate to highlight this finding in the results section. However, speculating as to why this correlation exists and offering a hypothesis about what may be happening belongs in the discussion section of your paper.
  • Present a result and then explain it, before presenting the next result then explaining it, and so on, then end with an overall synopsis . This is the preferred approach if you have multiple results of equal significance. It is more common in longer papers because it helps the reader to better understand each finding. In this model, it is helpful to provide a brief conclusion that ties each of the findings together and provides a narrative bridge to the discussion section of the your paper.

NOTE :   Just as the literature review should be arranged under conceptual categories rather than systematically describing each source, you should also organize your findings under key themes related to addressing the research problem. This can be done under either format noted above [i.e., a thorough explanation of the key results or a sequential, thematic description and explanation of each finding].

II.  Content

In general, the content of your results section should include the following:

  • Introductory context for understanding the results by restating the research problem underpinning your study . This is useful in re-orientating the reader's focus back to the research problem after having read a review of the literature and your explanation of the methods used for gathering and analyzing information.
  • Inclusion of non-textual elements, such as, figures, charts, photos, maps, tables, etc. to further illustrate key findings, if appropriate . Rather than relying entirely on descriptive text, consider how your findings can be presented visually. This is a helpful way of condensing a lot of data into one place that can then be referred to in the text. Consider referring to appendices if there is a lot of non-textual elements.
  • A systematic description of your results, highlighting for the reader observations that are most relevant to the topic under investigation . Not all results that emerge from the methodology used to gather information may be related to answering the " So What? " question. Do not confuse observations with interpretations; observations in this context refers to highlighting important findings you discovered through a process of reviewing prior literature and gathering data.
  • The page length of your results section is guided by the amount and types of data to be reported . However, focus on findings that are important and related to addressing the research problem. It is not uncommon to have unanticipated results that are not relevant to answering the research question. This is not to say that you don't acknowledge tangential findings and, in fact, can be referred to as areas for further research in the conclusion of your paper. However, spending time in the results section describing tangential findings clutters your overall results section and distracts the reader.
  • A short paragraph that concludes the results section by synthesizing the key findings of the study . Highlight the most important findings you want readers to remember as they transition into the discussion section. This is particularly important if, for example, there are many results to report, the findings are complicated or unanticipated, or they are impactful or actionable in some way [i.e., able to be pursued in a feasible way applied to practice].

NOTE:   Always use the past tense when referring to your study's findings. Reference to findings should always be described as having already happened because the method used to gather the information has been completed.

III.  Problems to Avoid

When writing the results section, avoid doing the following :

  • Discussing or interpreting your results . Save this for the discussion section of your paper, although where appropriate, you should compare or contrast specific results to those found in other studies [e.g., "Similar to the work of Smith [1990], one of the findings of this study is the strong correlation between motivation and academic achievement...."].
  • Reporting background information or attempting to explain your findings. This should have been done in your introduction section, but don't panic! Often the results of a study point to the need for additional background information or to explain the topic further, so don't think you did something wrong. Writing up research is rarely a linear process. Always revise your introduction as needed.
  • Ignoring negative results . A negative result generally refers to a finding that does not support the underlying assumptions of your study. Do not ignore them. Document these findings and then state in your discussion section why you believe a negative result emerged from your study. Note that negative results, and how you handle them, can give you an opportunity to write a more engaging discussion section, therefore, don't be hesitant to highlight them.
  • Including raw data or intermediate calculations . Ask your professor if you need to include any raw data generated by your study, such as transcripts from interviews or data files. If raw data is to be included, place it in an appendix or set of appendices that are referred to in the text.
  • Be as factual and concise as possible in reporting your findings . Do not use phrases that are vague or non-specific, such as, "appeared to be greater than other variables..." or "demonstrates promising trends that...." Subjective modifiers should be explained in the discussion section of the paper [i.e., why did one variable appear greater? Or, how does the finding demonstrate a promising trend?].
  • Presenting the same data or repeating the same information more than once . If you want to highlight a particular finding, it is appropriate to do so in the results section. However, you should emphasize its significance in relation to addressing the research problem in the discussion section. Do not repeat it in your results section because you can do that in the conclusion of your paper.
  • Confusing figures with tables . Be sure to properly label any non-textual elements in your paper. Don't call a chart an illustration or a figure a table. If you are not sure, go here .

Annesley, Thomas M. "Show Your Cards: The Results Section and the Poker Game." Clinical Chemistry 56 (July 2010): 1066-1070; Bavdekar, Sandeep B. and Sneha Chandak. "Results: Unraveling the Findings." Journal of the Association of Physicians of India 63 (September 2015): 44-46; Burton, Neil et al. Doing Your Education Research Project . Los Angeles, CA: SAGE, 2008;  Caprette, David R. Writing Research Papers. Experimental Biosciences Resources. Rice University; Hancock, Dawson R. and Bob Algozzine. Doing Case Study Research: A Practical Guide for Beginning Researchers . 2nd ed. New York: Teachers College Press, 2011; Introduction to Nursing Research: Reporting Research Findings. Nursing Research: Open Access Nursing Research and Review Articles. (January 4, 2012); Kretchmer, Paul. Twelve Steps to Writing an Effective Results Section. San Francisco Edit ; Ng, K. H. and W. C. Peh. "Writing the Results." Singapore Medical Journal 49 (2008): 967-968; Reporting Research Findings. Wilder Research, in partnership with the Minnesota Department of Human Services. (February 2009); Results. The Structure, Format, Content, and Style of a Journal-Style Scientific Paper. Department of Biology. Bates College; Schafer, Mickey S. Writing the Results. Thesis Writing in the Sciences. Course Syllabus. University of Florida.

Writing Tip

Why Don't I Just Combine the Results Section with the Discussion Section?

It's not unusual to find articles in scholarly social science journals where the author(s) have combined a description of the findings with a discussion about their significance and implications. You could do this. However, if you are inexperienced writing research papers, consider creating two distinct sections for each section in your paper as a way to better organize your thoughts and, by extension, your paper. Think of the results section as the place where you report what your study found; think of the discussion section as the place where you interpret the information and answer the "So What?" question. As you become more skilled writing research papers, you can consider melding the results of your study with a discussion of its implications.

Driscoll, Dana Lynn and Aleksandra Kasztalska. Writing the Experimental Report: Methods, Results, and Discussion. The Writing Lab and The OWL. Purdue University.

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How to Write the Results/Findings Section in Research

example of results and discussion in research paper

What is the research paper Results section and what does it do?

The Results section of a scientific research paper represents the core findings of a study derived from the methods applied to gather and analyze information. It presents these findings in a logical sequence without bias or interpretation from the author, setting up the reader for later interpretation and evaluation in the Discussion section. A major purpose of the Results section is to break down the data into sentences that show its significance to the research question(s).

The Results section appears third in the section sequence in most scientific papers. It follows the presentation of the Methods and Materials and is presented before the Discussion section —although the Results and Discussion are presented together in many journals. This section answers the basic question “What did you find in your research?”

What is included in the Results section?

The Results section should include the findings of your study and ONLY the findings of your study. The findings include:

  • Data presented in tables, charts, graphs, and other figures (may be placed into the text or on separate pages at the end of the manuscript)
  • A contextual analysis of this data explaining its meaning in sentence form
  • All data that corresponds to the central research question(s)
  • All secondary findings (secondary outcomes, subgroup analyses, etc.)

If the scope of the study is broad, or if you studied a variety of variables, or if the methodology used yields a wide range of different results, the author should present only those results that are most relevant to the research question stated in the Introduction section .

As a general rule, any information that does not present the direct findings or outcome of the study should be left out of this section. Unless the journal requests that authors combine the Results and Discussion sections, explanations and interpretations should be omitted from the Results.

How are the results organized?

The best way to organize your Results section is “logically.” One logical and clear method of organizing research results is to provide them alongside the research questions—within each research question, present the type of data that addresses that research question.

Let’s look at an example. Your research question is based on a survey among patients who were treated at a hospital and received postoperative care. Let’s say your first research question is:

results section of a research paper, figures

“What do hospital patients over age 55 think about postoperative care?”

This can actually be represented as a heading within your Results section, though it might be presented as a statement rather than a question:

Attitudes towards postoperative care in patients over the age of 55

Now present the results that address this specific research question first. In this case, perhaps a table illustrating data from a survey. Likert items can be included in this example. Tables can also present standard deviations, probabilities, correlation matrices, etc.

Following this, present a content analysis, in words, of one end of the spectrum of the survey or data table. In our example case, start with the POSITIVE survey responses regarding postoperative care, using descriptive phrases. For example:

“Sixty-five percent of patients over 55 responded positively to the question “ Are you satisfied with your hospital’s postoperative care ?” (Fig. 2)

Include other results such as subcategory analyses. The amount of textual description used will depend on how much interpretation of tables and figures is necessary and how many examples the reader needs in order to understand the significance of your research findings.

Next, present a content analysis of another part of the spectrum of the same research question, perhaps the NEGATIVE or NEUTRAL responses to the survey. For instance:

  “As Figure 1 shows, 15 out of 60 patients in Group A responded negatively to Question 2.”

After you have assessed the data in one figure and explained it sufficiently, move on to your next research question. For example:

  “How does patient satisfaction correspond to in-hospital improvements made to postoperative care?”

results section of a research paper, figures

This kind of data may be presented through a figure or set of figures (for instance, a paired T-test table).

Explain the data you present, here in a table, with a concise content analysis:

“The p-value for the comparison between the before and after groups of patients was .03% (Fig. 2), indicating that the greater the dissatisfaction among patients, the more frequent the improvements that were made to postoperative care.”

Let’s examine another example of a Results section from a study on plant tolerance to heavy metal stress . In the Introduction section, the aims of the study are presented as “determining the physiological and morphological responses of Allium cepa L. towards increased cadmium toxicity” and “evaluating its potential to accumulate the metal and its associated environmental consequences.” The Results section presents data showing how these aims are achieved in tables alongside a content analysis, beginning with an overview of the findings:

“Cadmium caused inhibition of root and leave elongation, with increasing effects at higher exposure doses (Fig. 1a-c).”

The figure containing this data is cited in parentheses. Note that this author has combined three graphs into one single figure. Separating the data into separate graphs focusing on specific aspects makes it easier for the reader to assess the findings, and consolidating this information into one figure saves space and makes it easy to locate the most relevant results.

results section of a research paper, figures

Following this overall summary, the relevant data in the tables is broken down into greater detail in text form in the Results section.

  • “Results on the bio-accumulation of cadmium were found to be the highest (17.5 mg kgG1) in the bulb, when the concentration of cadmium in the solution was 1×10G2 M and lowest (0.11 mg kgG1) in the leaves when the concentration was 1×10G3 M.”

Captioning and Referencing Tables and Figures

Tables and figures are central components of your Results section and you need to carefully think about the most effective way to use graphs and tables to present your findings . Therefore, it is crucial to know how to write strong figure captions and to refer to them within the text of the Results section.

The most important advice one can give here as well as throughout the paper is to check the requirements and standards of the journal to which you are submitting your work. Every journal has its own design and layout standards, which you can find in the author instructions on the target journal’s website. Perusing a journal’s published articles will also give you an idea of the proper number, size, and complexity of your figures.

Regardless of which format you use, the figures should be placed in the order they are referenced in the Results section and be as clear and easy to understand as possible. If there are multiple variables being considered (within one or more research questions), it can be a good idea to split these up into separate figures. Subsequently, these can be referenced and analyzed under separate headings and paragraphs in the text.

To create a caption, consider the research question being asked and change it into a phrase. For instance, if one question is “Which color did participants choose?”, the caption might be “Color choice by participant group.” Or in our last research paper example, where the question was “What is the concentration of cadmium in different parts of the onion after 14 days?” the caption reads:

 “Fig. 1(a-c): Mean concentration of Cd determined in (a) bulbs, (b) leaves, and (c) roots of onions after a 14-day period.”

Steps for Composing the Results Section

Because each study is unique, there is no one-size-fits-all approach when it comes to designing a strategy for structuring and writing the section of a research paper where findings are presented. The content and layout of this section will be determined by the specific area of research, the design of the study and its particular methodologies, and the guidelines of the target journal and its editors. However, the following steps can be used to compose the results of most scientific research studies and are essential for researchers who are new to preparing a manuscript for publication or who need a reminder of how to construct the Results section.

Step 1 : Consult the guidelines or instructions that the target journal or publisher provides authors and read research papers it has published, especially those with similar topics, methods, or results to your study.

  • The guidelines will generally outline specific requirements for the results or findings section, and the published articles will provide sound examples of successful approaches.
  • Note length limitations on restrictions on content. For instance, while many journals require the Results and Discussion sections to be separate, others do not—qualitative research papers often include results and interpretations in the same section (“Results and Discussion”).
  • Reading the aims and scope in the journal’s “ guide for authors ” section and understanding the interests of its readers will be invaluable in preparing to write the Results section.

Step 2 : Consider your research results in relation to the journal’s requirements and catalogue your results.

  • Focus on experimental results and other findings that are especially relevant to your research questions and objectives and include them even if they are unexpected or do not support your ideas and hypotheses.
  • Catalogue your findings—use subheadings to streamline and clarify your report. This will help you avoid excessive and peripheral details as you write and also help your reader understand and remember your findings. Create appendices that might interest specialists but prove too long or distracting for other readers.
  • Decide how you will structure of your results. You might match the order of the research questions and hypotheses to your results, or you could arrange them according to the order presented in the Methods section. A chronological order or even a hierarchy of importance or meaningful grouping of main themes or categories might prove effective. Consider your audience, evidence, and most importantly, the objectives of your research when choosing a structure for presenting your findings.

Step 3 : Design figures and tables to present and illustrate your data.

  • Tables and figures should be numbered according to the order in which they are mentioned in the main text of the paper.
  • Information in figures should be relatively self-explanatory (with the aid of captions), and their design should include all definitions and other information necessary for readers to understand the findings without reading all of the text.
  • Use tables and figures as a focal point to tell a clear and informative story about your research and avoid repeating information. But remember that while figures clarify and enhance the text, they cannot replace it.

Step 4 : Draft your Results section using the findings and figures you have organized.

  • The goal is to communicate this complex information as clearly and precisely as possible; precise and compact phrases and sentences are most effective.
  • In the opening paragraph of this section, restate your research questions or aims to focus the reader’s attention to what the results are trying to show. It is also a good idea to summarize key findings at the end of this section to create a logical transition to the interpretation and discussion that follows.
  • Try to write in the past tense and the active voice to relay the findings since the research has already been done and the agent is usually clear. This will ensure that your explanations are also clear and logical.
  • Make sure that any specialized terminology or abbreviation you have used here has been defined and clarified in the  Introduction section .

Step 5 : Review your draft; edit and revise until it reports results exactly as you would like to have them reported to your readers.

  • Double-check the accuracy and consistency of all the data, as well as all of the visual elements included.
  • Read your draft aloud to catch language errors (grammar, spelling, and mechanics), awkward phrases, and missing transitions.
  • Ensure that your results are presented in the best order to focus on objectives and prepare readers for interpretations, valuations, and recommendations in the Discussion section . Look back over the paper’s Introduction and background while anticipating the Discussion and Conclusion sections to ensure that the presentation of your results is consistent and effective.
  • Consider seeking additional guidance on your paper. Find additional readers to look over your Results section and see if it can be improved in any way. Peers, professors, or qualified experts can provide valuable insights.

One excellent option is to use a professional English proofreading and editing service  such as Wordvice, including our paper editing service . With hundreds of qualified editors from dozens of scientific fields, Wordvice has helped thousands of authors revise their manuscripts and get accepted into their target journals. Read more about the  proofreading and editing process  before proceeding with getting academic editing services and manuscript editing services for your manuscript.

As the representation of your study’s data output, the Results section presents the core information in your research paper. By writing with clarity and conciseness and by highlighting and explaining the crucial findings of their study, authors increase the impact and effectiveness of their research manuscripts.

For more articles and videos on writing your research manuscript, visit Wordvice’s Resources page.

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At its core, a research paper aims to fill a gap in the research on a given topic. As a result, the results section of the paper, which describes the key findings of the study, is often considered the core of the paper. This is the section that gets the most attention from reviewers, peers, students, and any news organization reporting on your findings. Writing a clear, concise, and logical results section is, therefore, one of the most important parts of preparing your manuscript.

Difference between results and discussion

Before delving into how to write the results section, it is important to first understand the difference between the results and discussion sections. The results section needs to detail the findings of the study. The aim of this section is not to draw connections between the different findings or to compare it to previous findings in literature—that is the purview of the discussion section. Unlike the discussion section, which can touch upon the hypothetical, the results section needs to focus on the purely factual. In some cases, it may even be preferable to club these two sections together into a single section. For example, while writing  a review article, it can be worthwhile to club these two sections together, as the main results in this case are the conclusions that can be drawn from the literature.

Structure of the results section

Although the main purpose of the results section in a research paper is to report the findings, it is necessary to present an introduction and repeat the research question. This establishes a connection to the previous section of the paper and creates a smooth flow of information.

Next, the results section needs to communicate the findings of your research in a systematic manner. The section needs to be organized such that the primary research question is addressed first, then the secondary research questions. If the research addresses multiple questions, the results section must individually connect with each of the questions. This ensures clarity and minimizes confusion while reading.

Consider representing your results visually. For example, graphs, tables, and other figures can help illustrate the findings of your paper, especially if there is a large amount of data in the results.

Remember, an appealing results section can help peer reviewers better understand the merits of your research, thereby increasing your chances of publication.

Practical guidance for writing an effective results section for a research paper

  • Always use simple and clear language. Avoid the use of uncertain or out-of-focus expressions.
  • The findings of the study must be expressed in an objective and unbiased manner. While it is acceptable to correlate certain findings in the discussion section, it is best to avoid overinterpreting the results.
  • If the research addresses more than one hypothesis, use sub-sections to describe the results. This prevents confusion and promotes understanding.
  • Ensure that negative results are included in this section, even if they do not support the research hypothesis.
  • Wherever possible, use illustrations like tables, figures, charts, or other visual representations to showcase the results of your research paper. Mention these illustrations in the text, but do not repeat the information that they convey.
  • For statistical data, it is adequate to highlight the tests and explain their results. The initial or raw data should not be mentioned in the results section of a research paper.

The results section of a research paper is usually the most impactful section because it draws the greatest attention. Regardless of the subject of your research paper, a well-written results section is capable of generating interest in your research.

For detailed information and assistance on writing the results of a research paper, refer to Elsevier Author Services.

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  • How to Write a Discussion Section | Tips & Examples

How to Write a Discussion Section | Tips & Examples

Published on 21 August 2022 by Shona McCombes . Revised on 25 October 2022.

Discussion section flow chart

The discussion section is where you delve into the meaning, importance, and relevance of your results .

It should focus on explaining and evaluating what you found, showing how it relates to your literature review , and making an argument in support of your overall conclusion . It should not be a second results section .

There are different ways to write this section, but you can focus your writing around these key elements:

  • Summary: A brief recap of your key results
  • Interpretations: What do your results mean?
  • Implications: Why do your results matter?
  • Limitations: What can’t your results tell us?
  • Recommendations: Avenues for further studies or analyses

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What not to include in your discussion section, step 1: summarise your key findings, step 2: give your interpretations, step 3: discuss the implications, step 4: acknowledge the limitations, step 5: share your recommendations, discussion section example.

There are a few common mistakes to avoid when writing the discussion section of your paper.

  • Don’t introduce new results: You should only discuss the data that you have already reported in your results section .
  • Don’t make inflated claims: Avoid overinterpretation and speculation that isn’t directly supported by your data.
  • Don’t undermine your research: The discussion of limitations should aim to strengthen your credibility, not emphasise weaknesses or failures.

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Start this section by reiterating your research problem  and concisely summarising your major findings. Don’t just repeat all the data you have already reported – aim for a clear statement of the overall result that directly answers your main  research question . This should be no more than one paragraph.

Many students struggle with the differences between a discussion section and a results section . The crux of the matter is that your results sections should present your results, and your discussion section should subjectively evaluate them. Try not to blend elements of these two sections, in order to keep your paper sharp.

  • The results indicate that …
  • The study demonstrates a correlation between …
  • This analysis supports the theory that …
  • The data suggest  that …

The meaning of your results may seem obvious to you, but it’s important to spell out their significance for your reader, showing exactly how they answer your research question.

The form of your interpretations will depend on the type of research, but some typical approaches to interpreting the data include:

  • Identifying correlations , patterns, and relationships among the data
  • Discussing whether the results met your expectations or supported your hypotheses
  • Contextualising your findings within previous research and theory
  • Explaining unexpected results and evaluating their significance
  • Considering possible alternative explanations and making an argument for your position

You can organise your discussion around key themes, hypotheses, or research questions, following the same structure as your results section. Alternatively, you can also begin by highlighting the most significant or unexpected results.

  • In line with the hypothesis …
  • Contrary to the hypothesised association …
  • The results contradict the claims of Smith (2007) that …
  • The results might suggest that x . However, based on the findings of similar studies, a more plausible explanation is x .

As well as giving your own interpretations, make sure to relate your results back to the scholarly work that you surveyed in the literature review . The discussion should show how your findings fit with existing knowledge, what new insights they contribute, and what consequences they have for theory or practice.

Ask yourself these questions:

  • Do your results support or challenge existing theories? If they support existing theories, what new information do they contribute? If they challenge existing theories, why do you think that is?
  • Are there any practical implications?

Your overall aim is to show the reader exactly what your research has contributed, and why they should care.

  • These results build on existing evidence of …
  • The results do not fit with the theory that …
  • The experiment provides a new insight into the relationship between …
  • These results should be taken into account when considering how to …
  • The data contribute a clearer understanding of …
  • While previous research has focused on  x , these results demonstrate that y .

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Even the best research has its limitations. Acknowledging these is important to demonstrate your credibility. Limitations aren’t about listing your errors, but about providing an accurate picture of what can and cannot be concluded from your study.

Limitations might be due to your overall research design, specific methodological choices , or unanticipated obstacles that emerged during your research process.

Here are a few common possibilities:

  • If your sample size was small or limited to a specific group of people, explain how generalisability is limited.
  • If you encountered problems when gathering or analysing data, explain how these influenced the results.
  • If there are potential confounding variables that you were unable to control, acknowledge the effect these may have had.

After noting the limitations, you can reiterate why the results are nonetheless valid for the purpose of answering your research question.

  • The generalisability of the results is limited by …
  • The reliability of these data is impacted by …
  • Due to the lack of data on x , the results cannot confirm …
  • The methodological choices were constrained by …
  • It is beyond the scope of this study to …

Based on the discussion of your results, you can make recommendations for practical implementation or further research. Sometimes, the recommendations are saved for the conclusion .

Suggestions for further research can lead directly from the limitations. Don’t just state that more studies should be done – give concrete ideas for how future work can build on areas that your own research was unable to address.

  • Further research is needed to establish …
  • Future studies should take into account …
  • Avenues for future research include …

Discussion section example

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Writing a "good" discussion section

"discussion and conclusions checklist" from: how to write a good scientific paper. chris a. mack. spie. 2018., peer review.

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This is is usually the hardest section to write. You are trying to bring out the true meaning of your data without being too long. Do not use words to conceal your facts or reasoning. Also do not repeat your results, this is a discussion.

  • Present principles, relationships and generalizations shown by the results
  • Point out exceptions or lack of correlations. Define why you think this is so.
  • Show how your results agree or disagree with previously published works
  • Discuss the theoretical implications of your work as well as practical applications
  • State your conclusions clearly. Summarize your evidence for each conclusion.
  • Discuss the significance of the results
  •  Evidence does not explain itself; the results must be presented and then explained.
  • Typical stages in the discussion: summarizing the results, discussing whether results are expected or unexpected, comparing these results to previous work, interpreting and explaining the results (often by comparison to a theory or model), and hypothesizing about their generality.
  • Discuss any problems or shortcomings encountered during the course of the work.
  • Discuss possible alternate explanations for the results.
  • Avoid: presenting results that are never discussed; presenting discussion that does not relate to any of the results; presenting results and discussion in chronological order rather than logical order; ignoring results that do not support the conclusions; drawing conclusions from results without logical arguments to back them up. 

CONCLUSIONS

  • Provide a very brief summary of the Results and Discussion.
  • Emphasize the implications of the findings, explaining how the work is significant and providing the key message(s) the author wishes to convey.
  • Provide the most general claims that can be supported by the evidence.
  • Provide a future perspective on the work.
  • Avoid: repeating the abstract; repeating background information from the Introduction; introducing new evidence or new arguments not found in the Results and Discussion; repeating the arguments made in the Results and Discussion; failing to address all of the research questions set out in the Introduction. 

WHAT HAPPENS AFTER I COMPLETE MY PAPER?

 The peer review process is the quality control step in the publication of ideas.  Papers that are submitted to a journal for publication are sent out to several scientists (peers) who look carefully at the paper to see if it is "good science".  These reviewers then recommend to the editor of a journal whether or not a paper should be published. Most journals have publication guidelines. Ask for them and follow them exactly.    Peer reviewers examine the soundness of the materials and methods section.  Are the materials and methods used written clearly enough for another scientist to reproduce the experiment?  Other areas they look at are: originality of research, significance of research question studied, soundness of the discussion and interpretation, correct spelling and use of technical terms, and length of the article.

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how to write a discussion section

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The discussion section of a research paper is where the author analyzes and explains the importance of the study's results. It presents the conclusions drawn from the study, compares them to previous research, and addresses any potential limitations or weaknesses. The discussion section should also suggest areas for future research.

Everything is not that complicated if you know where to find the required information. We’ll tell you everything there is to know about writing your discussion. Our easy guide covers all important bits, including research questions and your research results. Do you know how all enumerated events are connected? Well, you will after reading this guide we’ve prepared for you!

What Is in the Discussion Section of a Research Paper

The discussion section of a research paper can be viewed as something similar to the conclusion of your paper. But not literal, of course. It’s an ultimate section where you can talk about the findings of your study. Think about these questions when writing:

  • Did you answer all of the promised research questions?
  • Did you mention why your work matters?
  • What are your findings, and why should anyone even care?
  • Does your study have a literature review?

So, answer your questions, provide proof, and don’t forget about your promises from the introduction. 

How to Write a Discussion Section in 5 Steps

How to write the discussion section of a research paper is something everyone googles eventually. It's just life. But why not make everything easier? In brief, this section we’re talking about must include all following parts:

  • Answers for research questions
  • Literature review
  • Results of the work
  • Limitations of one’s study
  • Overall conclusion

Indeed, all those parts may confuse anyone. So by looking at our guide, you'll save yourself some hassle.  P.S. All our steps are easy and explained in detail! But if you are looking for the most efficient solution, consider using professional help. Leave your “ write my research paper for me ” order at StudyCrumb and get a customized study tailored to your requirements.

Step 1. Start Strong: Discussion Section of a Research Paper

First and foremost, how to start the discussion section of a research paper? Here’s what you should definitely consider before settling down to start writing:

  • All essays or papers must begin strong. All readers will not wait for any writer to get to the point. We advise summarizing the paper's main findings.
  • Moreover, you should relate both discussion and literature review to what you have discovered. Mentioning that would be a plus too.
  • Make sure that an introduction or start per se is clear and concise. Word count might be needed for school. But any paper should be understandable and not too diluted.

Step 2. Answer the Questions in Your Discussion Section of a Research Paper

Writing the discussion section of a research paper also involves mentioning your questions. Remember that in your introduction, you have promised your readers to answer certain questions. Well, now it’s a perfect time to finally give the awaited answer. You need to explain all possible correlations between your findings, research questions, and literature proposed. You already had hypotheses. So were they correct, or maybe you want to propose certain corrections? Section’s main goal is to avoid open ends. It’s not a story or a fairytale with an intriguing ending. If you have several questions, you must answer them. As simple as that.

Step 3. Relate Your Results in a Discussion Section

Writing a discussion section of a research paper also requires any writer to explain their results. You will undoubtedly include an impactful literature review. However, your readers should not just try and struggle with understanding what are some specific relationships behind previous studies and your results.  Your results should sound something like: “This guy in their paper discovered that apples are green. Nevertheless, I have proven via experimentation and research that apples are actually red.” Please, don’t take these results directly. It’s just an initial hypothesis. But what you should definitely remember is any practical implications of your study. Why does it matter and how can anyone use it? That’s the most crucial question.

Step 4. Describe the Limitations in Your Discussion Section

Discussion section of a research paper isn’t limitless. What does that mean? Essentially, it means that you also have to discuss any limitations of your study. Maybe you had some methodological inconsistencies. Possibly, there are no particular theories or not enough information for you to be entirely confident in one’s conclusions.  You might say that an available source of literature you have studied does not focus on one’s issue. That’s why one’s main limitation is theoretical. However, keep in mind that your limitations must possess a certain degree of relevancy. You can just say that you haven’t found enough books. Your information must be truthful to research.

Step 5. Conclude Your Discussion Section With Recommendations

Your last step when you write a discussion section in a paper is its conclusion, like in any other academic work. Writer’s conclusion must be as strong as their starting point of the overall work. Check out our brief list of things to know about the conclusion in research paper :

  • It must present its scientific relevance and importance of your work.
  • It should include different implications of your research.
  • It should not, however, discuss anything new or things that you have not mentioned before.
  • Leave no open questions and carefully complete the work without them.

Discussion Section of a Research Paper Example

All the best example discussion sections of a research paper will be written according to our brief guide. Don’t forget that you need to state your findings and underline the importance of your work. An undoubtedly big part of one’s discussion will definitely be answering and explaining the research questions. In other words, you’ll already have all the knowledge you have so carefully gathered. Our last step for you is to recollect and wrap up your paper. But we’re sure you’ll succeed!

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How to Write a Discussion Section: Final Thoughts

Today we have covered how to write a discussion section. That was quite a brief journey, wasn’t it? Just to remind you to focus on these things:

  • Importance of your study.
  • Summary of the information you have gathered.
  • Main findings and conclusions.
  • Answers to all research questions without an open end.
  • Correlation between literature review and your results.

But, wait, this guide is not the only thing we can do. Looking for how to write an abstract for a research paper  for example? We have such a blog and much more on our platform.

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Our academic writing service is just a click away. We are proud to say that our writers are professionals in their fields. Buy a research paper and our experts can provide prompt solutions without compromising the quality.

Discussion Section of a Research Paper: Frequently Asked Questions

1. how long should the discussion section of a research paper be.

Our discussion section of a research paper should not be longer than other sections. So try to keep it short but as informative as possible. It usually contains around 6-7 paragraphs in length. It is enough to briefly summarize all the important data and not to drag it.

2. What's the difference between the discussion and the results?

The difference between discussion and results is very simple and easy to understand. The results only report your main findings. You stated what you have found and how you have done that. In contrast, one’s discussion mentions your findings and explains how they relate to other literature, research questions, and one’s hypothesis. Therefore, it is not only a report but an efficient as well as proper explanation.

3. What's the difference between a discussion and a conclusion?

The difference between discussion and conclusion is also quite easy. Conclusion is a brief summary of all the findings and results. Still, our favorite discussion section interprets and explains your main results. It is an important but more lengthy and wordy part. Besides, it uses extra literature for references.

4. What is the purpose of the discussion section?

The primary purpose of a discussion section is to interpret and describe all your interesting findings. Therefore, you should state what you have learned, whether your hypothesis was correct and how your results can be explained using other sources. If this section is clear to readers, our congratulations as you have succeeded.

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  • Open access
  • Published: 13 May 2024

What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review

  • Olivia R. Phillips 1 , 2   na1 ,
  • Cerian Harries 2 , 3   na1 ,
  • Jo Leonardi-Bee 1 , 2 , 4   na1 ,
  • Holly Knight 1 , 2 ,
  • Lauren B. Sherar 2 , 3 ,
  • Veronica Varela-Mato 2 , 3 &
  • Joanne R. Morling 1 , 2 , 5  

Research Involvement and Engagement volume  10 , Article number:  48 ( 2024 ) Cite this article

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There is increasing interest in using patient and public involvement (PPI) in research to improve the quality of healthcare. Ordinarily, traditional methods have been used such as interviews or focus groups. However, these methods tend to engage a similar demographic of people. Thus, creative methods are being developed to involve patients for whom traditional methods are inaccessible or non-engaging.

To determine the strengths and limitations to using creative PPI methods in health and social care research.

Electronic searches were conducted over five databases on 14th April 2023 (Web of Science, PubMed, ASSIA, CINAHL, Cochrane Library). Studies that involved traditional, non-creative PPI methods were excluded. Creative PPI methods were used to engage with people as research advisors, rather than study participants. Only primary data published in English from 2009 were accepted. Title, abstract and full text screening was undertaken by two independent reviewers before inductive thematic analysis was used to generate themes.

Twelve papers met the inclusion criteria. The creative methods used included songs, poems, drawings, photograph elicitation, drama performance, visualisations, social media, photography, prototype development, cultural animation, card sorting and persona development. Analysis identified four limitations and five strengths to the creative approaches. Limitations included the time and resource intensive nature of creative PPI, the lack of generalisation to wider populations and ethical issues. External factors, such as the lack of infrastructure to support creative PPI, also affected their implementation. Strengths included the disruption of power hierarchies and the creation of a safe space for people to express mundane or “taboo” topics. Creative methods are also engaging, inclusive of people who struggle to participate in traditional PPI and can also be cost and time efficient.

‘Creative PPI’ is an umbrella term encapsulating many different methods of engagement and there are strengths and limitations to each. The choice of which should be determined by the aims and requirements of the research, as well as the characteristics of the PPI group and practical limitations. Creative PPI can be advantageous over more traditional methods, however a hybrid approach could be considered to reap the benefits of both. Creative PPI methods are not widely used; however, this could change over time as PPI becomes embedded even more into research.

Plain English Summary

It is important that patients and public are included in the research process from initial brainstorming, through design to delivery. This is known as public and patient involvement (PPI). Their input means that research closely aligns with their wants and needs. Traditionally to get this input, interviews and group discussions are held, but this can exclude people who find these activities non-engaging or inaccessible, for example those with language challenges, learning disabilities or memory issues. Creative methods of PPI can overcome this. This is a broad term describing different (non-traditional) ways of engaging patients and public in research, such as through the use or art, animation or performance. This review investigated the reasons why creative approaches to PPI could be difficult (limitations) or helpful (strengths) in health and social care research. After searching 5 online databases, 12 studies were included in the review. PPI groups included adults, children and people with language and memory impairments. Creative methods included songs, poems, drawings, the use of photos and drama, visualisations, Facebook, creating prototypes, personas and card sorting. Limitations included the time, cost and effort associated with creative methods, the lack of application to other populations, ethical issues and buy-in from the wider research community. Strengths included the feeling of equality between academics and the public, creation of a safe space for people to express themselves, inclusivity, and that creative PPI can be cost and time efficient. Overall, this review suggests that creative PPI is worthwhile, however each method has its own strengths and limitations and the choice of which will depend on the research project, PPI group characteristics and other practical limitations, such as time and financial constraints.

Peer Review reports

Introduction

Patient and public involvement (PPI) is the term used to describe the partnership between patients (including caregivers, potential patients, healthcare users etc.) or the public (a community member with no known interest in the topic) with researchers. It describes research that is done “‘with’ or ‘by’ the public, rather than ‘to,’ ‘about’ or ‘for’ them” [ 1 ]. In 2009, it became a legislative requirement for certain health and social care organisations to include patients, families, carers and communities in not only the planning of health and social care services, but the commissioning, delivery and evaluation of them too [ 2 ]. For example, funding applications for the National Institute of Health and Care Research (NIHR), a UK funding body, mandates a demonstration of how researchers plan to include patients/service users, the public and carers at each stage of the project [ 3 ]. However, this should not simply be a tokenistic, tick-box exercise. PPI should help formulate initial ideas and should be an instrumental, continuous part of the research process. Input from PPI can provide unique insights not yet considered and can ensure that research and health services are closely aligned to the needs and requirements of service users PPI also generally makes research more relevant with clearer outcomes and impacts [ 4 ]. Although this review refers to both patients and the public using the umbrella term ‘PPI’, it is important to acknowledge that these are two different groups with different motivations, needs and interests when it comes to health research and service delivery [ 5 ].

Despite continuing recognition of the need of PPI to improve quality of healthcare, researchers have also recognised that there is no ‘one size fits all’ method for involving patients [ 4 ]. Traditionally, PPI methods invite people to take part in interviews or focus groups to facilitate discussion, or surveys and questionnaires. However, these can sometimes be inaccessible or non-engaging for certain populations. For example, someone with communication difficulties may find it difficult to engage in focus groups or interviews. If individuals lack the appropriate skills to interact in these types of scenarios, they cannot take advantage of the participation opportunities it can provide [ 6 ]. Creative methods, however, aim to resolve these issues. These are a relatively new concept whereby researchers use creative methods (e.g., artwork, animations, Lego), to make PPI more accessible and engaging for those whose voices would otherwise go unheard. They ensure that all populations can engage in research, regardless of their background or skills. Seminal work has previously been conducted in this area, which brought to light the use of creative methodologies in research. Leavy (2008) [ 7 ] discussed how traditional interviews had limits on what could be expressed due to their sterile, jargon-filled and formulaic structure, read by only a few specialised academics. It was this that called for more creative approaches, which included narrative enquiry, fiction-based research, poetry, music, dance, art, theatre, film and visual art. These practices, which can be used in any stage of the research cycle, supported greater empathy, self-reflection and longer-lasting learning experiences compared to interviews [ 7 ]. They also pushed traditional academic boundaries, which made the research accessible not only to researchers, but the public too. Leavy explains that there are similarities between arts-based approaches and scientific approaches: both attempts to investigate what it means to be human through exploration, and used together, these complimentary approaches can progress our understanding of the human experience [ 7 ]. Further, it is important to acknowledge the parallels and nuances between creative and inclusive methods of PPI. Although creative methods aim to be inclusive (this should underlie any PPI activity, whether creative or not), they do not incorporate all types of accessible, inclusive methodologies e.g., using sign language for people with hearing impairments or audio recordings for people who cannot read. Given that there was not enough scope to include an evaluation of all possible inclusive methodologies, this review will focus on creative methods of PPI only.

We aimed to conduct a qualitative systematic review to highlight the strengths of creative PPI in health and social care research, as well as the limitations, which might act as a barrier to their implementation. A qualitative systematic review “brings together research on a topic, systematically searching for research evidence from primary qualitative studies and drawing the findings together” [ 8 ]. This review can then advise researchers of the best practices when designing PPI.

Public involvement

The PHIRST-LIGHT Public Advisory Group (PAG) consists of a team of experienced public contributors with a diverse range of characteristics from across the UK. The PAG was involved in the initial question setting and study design for this review.

Search strategy

For the purpose of this review, the JBI approach for conducting qualitative systematic reviews was followed [ 9 ]. The search terms were (“creativ*” OR “innovat*” OR “authentic” OR “original” OR “inclu*”) AND (“public and patient involvement” OR “patient and public involvement” OR “public and patient involvement and engagement” OR “patient and public involvement and engagement” OR “PPI” OR “PPIE” OR “co-produc*” OR “co-creat*” OR “co-design*” OR “cooperat*” OR “co-operat*”). This search string was modified according to the requirements of each database. Papers were filtered by title, abstract and keywords (see Additional file 1 for search strings). The databases searched included Web of Science (WoS), PubMed, ASSIA and CINAHL. The Cochrane Library was also searched to identify relevant reviews which could lead to the identification of primary research. The search was conducted on 14/04/23. As our aim was to report on the use of creative PPI in research, rather than more generic public engagement, we used electronic databases of scholarly peer-reviewed literature, which represent a wide range of recognised databases. These identified studies published in general international journals (WoS, PubMed), those in social sciences journals (ASSIA), those in nursing and allied health journals (CINAHL), and trials of interventions (Cochrane Library).

Inclusion criteria

Only full-text, English language, primary research papers from 2009 to 2023 were included. This was the chosen timeframe as in 2009 the Health and Social Reform Act made it mandatory for certain Health and Social Care organisations to involve the public and patients in planning, delivering, and evaluating services [ 2 ]. Only creative methods of PPI were accepted, rather than traditional methods, such as interviews or focus groups. For the purposes of this paper, creative PPI included creative art or arts-based approaches (e.g., e.g. stories, songs, drama, drawing, painting, poetry, photography) to enhance engagement. Titles were related to health and social care and the creative PPI was used to engage with people as research advisors, not as study participants. Meta-analyses, conference abstracts, book chapters, commentaries and reviews were excluded. There were no limits concerning study location or the demographic characteristics of the PPI groups. Only qualitative data were accepted.

Quality appraisal

Quality appraisal using the Critical Appraisal Skills Programme (CASP) checklist [ 10 ] was conducted by the primary authors (ORP and CH). This was done independently, and discrepancies were discussed and resolved. If a consensus could not be reached, a third independent reviewer was consulted (JRM). The full list of quality appraisal questions can be found in Additional file 2 .

Data extraction

ORP extracted the study characteristics and a subset of these were checked by CH. Discrepancies were discussed and amendments made. Extracted data included author, title, location, year of publication, year study was carried out, research question/aim, creative methods used, number of participants, mean age, gender, ethnicity of participants, setting, limitations and strengths of creative PPI and main findings.

Data analysis

The included studies were analysed using inductive thematic analysis [ 11 ], where themes were determined by the data. The familiarisation stage took place during full-text reading of the included articles. Anything identified as a strength or limitation to creative PPI methods was extracted verbatim as an initial code and inputted into the data extraction Excel sheet. Similar codes were sorted into broader themes, either under ‘strengths’ or ‘limitations’ and reviewed. Themes were then assigned a name according to the codes.

The search yielded 9978 titles across the 5 databases: Web of Science (1480 results), PubMed (94 results), ASSIA (2454 results), CINAHL (5948 results) and Cochrane Library (2 results), resulting in 8553 different studies after deduplication. ORP and CH independently screened their titles and abstracts, excluding those that did not meet the criteria. After assessment, 12 studies were included (see Fig.  1 ).

figure 1

PRISMA flowchart of the study selection process

Study characteristics

The included studies were published between 2018 and 2022. Seven were conducted in the UK [ 12 , 14 , 15 , 17 , 18 , 19 , 23 ], two in Canada [ 21 , 22 ], one in Australia [ 13 ], one in Norway [ 16 ] and one in Ireland [ 20 ]. The PPI activities occurred across various settings, including a school [ 12 ], social club [ 12 ], hospital [ 17 ], university [ 22 ], theatre [ 19 ], hotel [ 20 ], or online [ 15 , 21 ], however this information was omitted in 5 studies [ 13 , 14 , 16 , 18 , 23 ]. The number of people attending the PPI sessions varied, ranging from 6 to 289, however the majority (ten studies) had less than 70 participants [ 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Seven studies did not provide information on the age or gender of the PPI groups. Of those that did, ages ranged from 8 to 76 and were mostly female. The ethnicities of the PPI group members were also rarely recorded (see Additional file 3 for data extraction table).

Types of creative methods

The type of creative methods used to engage the PPI groups were varied. These included songs, poems, drawings, photograph elicitation, drama performance, visualisations, Facebook, photography, prototype development, cultural animation, card sorting and creating personas (see Table  1 ). These were sometimes accompanied by traditional methods of PPI such as interviews and focus group discussions.

The 12 included studies were all deemed to be of good methodological quality, with scores ranging from 6/10 to 10/10 with the CASP critical appraisal tool [ 10 ] (Table  2 ).

Thematic analysis

Analysis identified four limitations and five strengths to creative PPI (see Fig.  2 ). Limitations included the time and resource intensity of creative PPI methods, its lack of generalisation, ethical issues and external factors. Strengths included the disruption of power hierarchies, the engaging and inclusive nature of the methods and their long-term cost and time efficiency. Creative PPI methods also allowed mundane and “taboo” topics to be discussed within a safe space.

figure 2

Theme map of strengths and limitations

Limitations of creative PPI

Creative ppi methods are time and resource intensive.

The time and resource intensive nature of creative PPI methods is a limitation, most notably for the persona-scenario methodology. Valaitis et al. [ 22 ] used 14 persona-scenario workshops with 70 participants to co-design a healthcare intervention, which aimed to promote optimal aging in Canada. Using the persona method, pairs composed of patients, healthcare providers, community service providers and volunteers developed a fictional character which they believed represented an ‘end-user’ of the healthcare intervention. Due to the depth and richness of the data produced the authors reported that it was time consuming to analyse. Further, they commented that the amount of information was difficult to disseminate to scientific leads and present at team meetings. Additionally, to ensure the production of high-quality data, to probe for details and lead group discussion there was a need for highly skilled facilitators. The resource intensive nature of the creative co-production was also noted in a study using the persona scenario and creative worksheets to develop a prototype decision support tool for individuals with malignant pleural effusion [ 17 ]. With approximately 50 people, this was also likely to yield a high volume of data to consider.

To prepare materials for populations who cannot engage in traditional methods of PPI was also timely. Kearns et al. [ 18 ] developed a feedback questionnaire for people with aphasia to evaluate ICT-delivered rehabilitation. To ensure people could participate effectively, the resources used during the workshops, such as PowerPoints, online images and photographs, had to be aphasia-accessible, which was labour and time intensive. The author warned that this time commitment should not be underestimated.

There are further practical limitations to implementing creative PPI, such as the costs of materials for activities as well as hiring a space for workshops. For example, the included studies in this review utilised pens, paper, worksheets, laptops, arts and craft supplies and magazines and took place in venues such as universities, a social club, and a hotel. Further, although not limited to creative PPI methods exclusively but rather most studies involving the public, a financial incentive was often offered for participation, as well as food, parking, transport and accommodation [ 21 , 22 ].

Creative PPI lacks generalisation

Another barrier to the use of creative PPI methods in health and social care research was the individual nature of its output. Those who participate, usually small in number, produce unique creative outputs specific to their own experiences, opinions and location. Craven et al. [ 13 ], used arts-based visualisations to develop a toolbox for adults with mental health difficulties. They commented, “such an approach might still not be worthwhile”, as the visualisations were individualised and highly personal. This indicates that the output may fail to meet the needs of its end-users. Further, these creative PPI groups were based in certain geographical regions such as Stoke-on-Trent [ 19 ] Sheffield [ 23 ], South Wales [ 12 ] or Ireland [ 20 ], which limits the extent the findings can be applied to wider populations, even within the same area due to individual nuances. Further, the study by Galler et al. [ 16 ], is specific to the Norwegian context and even then, maybe only a sub-group of the Norwegian population as the sample used was of higher socioeconomic status.

However, Grindell et al. [ 17 ], who used persona scenarios, creative worksheets and prototype development, pointed out that the purpose of this type of research is to improve a certain place, rather than apply findings across other populations and locations. Individualised output may, therefore, only be a limitation to research wanting to conduct PPI on a large scale.

If, however, greater generalisation within PPI is deemed necessary, then social media may offer a resolution. Fedorowicz et al. [ 15 ], used Facebook to gain feedback from the public on the use of video-recording methodology for an upcoming project. This had the benefit of including a more diverse range of people (289 people joined the closed group), who were spread geographically around the UK, as well as seven people from overseas.

Creative PPI has ethical issues

As with other research, ethical issues must be taken into consideration. Due to the nature of creative approaches, as well as the personal effort put into them, people often want to be recognised for their work. However, this compromises principles so heavily instilled in research such as anonymity and confidentiality. With the aim of exploring issues related to health and well-being in a town in South Wales, Byrne et al. [ 12 ], asked year 4/5 and year 10 pupils to create poems, songs, drawings and photographs. Community members also created a performance, mainly of monologues, to explore how poverty and inequalities are dealt with. Byrne noted the risks of these arts-based approaches, that being the possibility of over-disclosure and consequent emotional distress, as well as people’s desire to be named for their work. On one hand, the anonymity reduces the sense of ownership of the output as it does not portray a particular individual’s lived experience anymore. On the other hand, however, it could promote a more honest account of lived experience. Supporting this, Webber et al. [ 23 ], who used the persona method to co-design a back pain educational resource prototype, claimed that the anonymity provided by this creative technique allowed individuals to externalise and anonymise their own personal experience, thus creating a more authentic and genuine resource for future users. This implies that anonymity can be both a limitation and strength here.

The use of creative PPI methods is impeded by external factors

Despite the above limitations influencing the implementation of creative PPI techniques, perhaps the most influential is that creative methodologies are simply not mainstream [ 19 ]. This could be linked to the issues above, like time and resource intensity, generalisation and ethical issues but it is also likely to involve more systemic factors within the research community. Micsinszki et al. [ 21 ], who co-designed a hub for the health and well-being of vulnerable populations, commented that there is insufficient infrastructure to conduct meaningful co-design as well as a dominant medical model. Through a more holistic lens, there are “sociopolitical environments that privilege individualism over collectivism, self-sufficiency over collaboration, and scientific expertise over other ways of knowing based on lived experience” [ 21 ]. This, it could be suggested, renders creative co-design methodologies, which are based on the foundations of collectivism, collaboration and imagination an invalid technique in the research field, which is heavily dominated by more scientific methods offering reproducibility, objectivity and reliability.

Although we acknowledge that creative PPI techniques are not always appropriate, it may be that their main limitation is the lack of awareness of these methods or lack of willingness to use them. Further, there is always the risk that PPI, despite being a mandatory part of research, is used in a tokenistic or tick-box fashion [ 20 ], without considering the contribution that meaningful PPI could make to enhancing the research. It may be that PPI, let alone creative PPI, is not at the forefront of researchers’ minds when planning research.

Strengths of creative PPI

Creative ppi disrupts power hierarchies.

One of the main strengths of creative PPI techniques, cited most frequently in the included literature, was that they disrupt traditional power hierarchies [ 12 , 13 , 17 , 19 , 23 ]. For example, the use of theatre performance blurred the lines between professional and lay roles between the community and policy makers [ 12 ]. Individuals created a monologue to portray how poverty and inequality impact daily life and presented this to representatives of the National Assembly of Wales, Welsh Government, the Local Authority, Arts Council and Westminster. Byrne et al. [ 12 ], states how this medium allowed the community to engage with the people who make decisions about their lives in an environment of respect and understanding, where the hierarchies are not as visible as in other settings, e.g., political surgeries. Creative PPI methods have also removed traditional power hierarchies between researchers and adolescents. Cook et al. [ 13 ], used arts-based approaches to explore adolescents’ ideas about the “perfect” condom. They utilised the “Life Happens” resource, where adolescents drew and then decorated a person with their thoughts about sexual relationships, not too dissimilar from the persona-scenario method. This was then combined with hypothetical scenarios about sexuality. A condom-mapping exercise was then implemented, where groups shared the characteristics that make a condom “perfect” on large pieces of paper. Cook et al. [ 13 ], noted that usually power imbalances make it difficult to elicit information from adolescents, however these power imbalances were reduced due to the use of creative co-design techniques.

The same reduction in power hierarchies was noted by Grindell et al. [ 17 ], who used the person-scenario method and creative worksheets with individuals with malignant pleural effusion. This was with the aim of developing a prototype of a decision support tool for patients to help with treatment options. Although this process involved a variety of stakeholders, such as patients, carers and healthcare professionals, creative co-design was cited as a mechanism that worked to reduce power imbalances – a limitation of more traditional methods of research. Creative co-design blurred boundaries between end-users and clinical staff and enabled the sharing of ideas from multiple, valuable perspectives, meaning the prototype was able to suit user needs whilst addressing clinical problems.

Similarly, a specific creative method named cultural animation was also cited to dissolve hierarchies and encourage equal contributions from participants. Within this arts-based approach, Keleman et al. [ 19 ], explored the concept of “good health” with individuals from Stoke-on Trent. Members of the group created art installations using ribbons, buttons, cardboard and straws to depict their idea of a “healthy community”, which was accompanied by a poem. They also created a 3D Facebook page and produced another poem or song addressing the government to communicate their version of a “picture of health”. Public participants said that they found the process empowering, honest, democratic, valuable and practical.

This dissolving of hierarchies and levelling of power is beneficial as it increases the sense of ownership experienced by the creators/producers of the output [ 12 , 17 , 23 ]. This is advantageous as it has been suggested to improve its quality [ 23 ].

Creative PPI allows the unsayable to be said

Creative PPI fosters a safe space for mundane or taboo topics to be shared, which may be difficult to communicate using traditional methods of PPI. For example, the hypothetical nature of condom mapping and persona-scenarios meant that adolescents could discuss a personal topic without fear of discrimination, judgement or personal disclosure [ 13 ]. The safe space allowed a greater volume of ideas to be generated amongst peers where they might not have otherwise. Similarly, Webber et al. [ 23 ], , who used the persona method to co-design the prototype back pain educational resource, also noted how this method creates anonymity whilst allowing people the opportunity to externalise personal experiences, thoughts and feelings. Other creative methods were also used, such as drawing, collaging, role play and creating mood boards. A cardboard cube (labelled a “magic box”) was used to symbolise a physical representation of their final prototype. These creative methods levelled the playing field and made personal experiences accessible in a safe, open environment that fostered trust, as well as understanding from the researchers.

It is not only sensitive subjects that were made easier to articulate through creative PPI. The communication of mundane everyday experiences were also facilitated, which were deemed typically ‘unsayable’. This was specifically given in the context of describing intangible aspects of everyday health and wellbeing [ 11 ]. Graphic designers can also be used to visually represent the outputs of creative PPI. These captured the movement and fluidity of people and well as the relationships between them - things that cannot be spoken but can be depicted [ 21 ].

Creative PPI methods are inclusive

Another strength of creative PPI was that it is inclusive and accessible [ 17 , 19 , 21 ]. The safe space it fosters, as well as the dismantling of hierarchies, welcomed people from a diverse range of backgrounds and provided equal opportunities [ 21 ], especially for those with communication and memory difficulties who might be otherwise excluded from PPI. Kelemen et al. [ 19 ], who used creative methods to explore health and well-being in Stoke-on-Trent, discussed how people from different backgrounds came together and connected, discussed and reached a consensus over a topic which evoked strong emotions, that they all have in common. Individuals said that the techniques used “sets people to open up as they are not overwhelmed by words”. Similarly, creative activities, such as the persona method, have been stated to allow people to express themselves in an inclusive environment using a common language. Kearns et al. [ 18 ], who used aphasia-accessible material to develop a questionnaire with aphasic individuals, described how they felt comfortable in contributing to workshops (although this material was time-consuming to make, see ‘Limitations of creative PPI’ ).

Despite the general inclusivity of creative PPI, it can also be exclusive, particularly if online mediums are used. Fedorowicz et al. [ 15 ], used Facebook to create a PPI group, and although this may rectify previous drawbacks about lack of generalisation of creative methods (as Facebook can reach a greater number of people, globally), it excluded those who are not digitally active or have limited internet access or knowledge of technology. Online methods have other issues too. Maintaining the online group was cited as challenging and the volume of responses required researchers to interact outside of their working hours. Despite this, online methods like Facebook are very accessible for people who are physically disabled.

Creative PPI methods are engaging

The process of creative PPI is typically more engaging and produces more colourful data than traditional methods [ 13 ]. Individuals are permitted and encouraged to explore a creative self [ 19 ], which can lead to the exploration of new ideas and an overall increased enjoyment of the process. This increased engagement is particularly beneficial for younger PPI groups. For example, to involve children in the development of health food products, Galler et al. [ 16 ] asked 9-12-year-olds to take photos of their food and present it to other children in a “show and tell” fashion. They then created a newspaper article describing a new healthy snack. In this creative focus group, children were given lab coats to further their identity as inventors. Galler et al. [ 16 ], notes that the methods were highly engaging and facilitated teamwork and group learning. This collaborative nature of problem-solving was also observed in adults who used personas and creative worksheets to develop the resource for lower back pain [ 23 ]. Dementia patients too have been reported to enjoy the creative and informal approach to idea generation [ 20 ].

The use of cultural animation allowed people to connect with each other in a way that traditional methods do not [ 19 , 21 ]. These connections were held in place by boundary objects, such as ribbons, buttons, fabric and picture frames, which symbolised a shared meaning between people and an exchange of knowledge and emotion. Asking groups to create an art installation using these objects further fostered teamwork and collaboration, both at an individual and collective level. The exploration of a creative self increased energy levels and encouraged productive discussions and problem-solving [ 19 ]. Objects also encouraged a solution-focused approach and permitted people to think beyond their usual everyday scope [ 17 ]. They also allowed facilitators to probe deeper about the greater meanings carried by the object, which acted as a metaphor [ 21 ].

From the researcher’s point of view, co-creative methods gave rise to ideas they might not have initially considered. Valaitis et al. [ 22 ], found that over 40% of the creative outputs were novel ideas brought to light by patients, healthcare providers/community care providers, community service providers and volunteers. One researcher commented, “It [the creative methods] took me on a journey, in a way that when we do other pieces of research it can feel disconnected” [ 23 ]. Another researcher also stated they could not return to the way they used to do research, as they have learnt so much about their own health and community and how they are perceived [ 19 ]. This demonstrates that creative processes not only benefit the project outcomes and the PPI group, but also facilitators and researchers. However, although engaging, creative methods have been criticised for not demonstrating academic rigour [ 17 ]. Moreover, creative PPI may also be exclusive to people who do not like or enjoy creative activities.

Creative PPI methods are cost and time efficient

Creative PPI workshops can often produce output that is visible and tangible. This can save time and money in the long run as the output is either ready to be implemented in a healthcare setting or a first iteration has already been developed. This may also offset the time and costs it takes to implement creative PPI. For example, the prototype of the decision support tool for people with malignant pleural effusion was developed using personas and creative worksheets. The end result was two tangible prototypes to drive the initial idea forward as something to be used in practice [ 17 ]. The use of creative co-design in this case saved clinician time as well as the time it would take to develop this product without the help of its end-users. In the development of this particular prototype, analysis was iterative and informed the next stage of development, which again saved time. The same applies for the feedback questionnaire for the assessment of ICT delivered aphasia rehabilitation. The co-created questionnaire, designed with people with aphasia, was ready to be used in practice [ 18 ]. This suggests that to overcome time and resource barriers to creative PPI, researchers should aim for it to be engaging whilst also producing output.

That useable products are generated during creative workshops signals to participating patients and public members that they have been listened to and their thoughts and opinions acted upon [ 23 ]. For example, the development of the back pain resource based on patient experiences implies that their suggestions were valid and valuable. Further, those who participated in the cultural animation workshop reported that the process visualises change, and that it already feels as though the process of change has started [ 19 ].

The most cost and time efficient method of creative PPI in this review is most likely the use of Facebook to gather feedback on project methodology [ 15 ]. Although there were drawbacks to this, researchers could involve more people from a range of geographical areas at little to no cost. Feedback was instantaneous and no training was required. From the perspective of the PPI group, they could interact however much or little they wish with no time commitment.

This systematic review identified four limitations and five strengths to the use of creative PPI in health and social care research. Creative PPI is time and resource intensive, can raise ethical issues and lacks generalisability. It is also not accepted by the mainstream. These factors may act as barriers to the implementation of creative PPI. However, creative PPI disrupts traditional power hierarchies and creates a safe space for taboo or mundane topics. It is also engaging, inclusive and can be time and cost efficient in the long term.

Something that became apparent during data analysis was that these are not blanket strengths and limitations of creative PPI as a whole. The umbrella term ‘creative PPI’ is broad and encapsulates a wide range of activities, ranging from music and poems to prototype development and persona-scenarios, to more simplistic things like the use of sticky notes and ordering cards. Many different activities can be deemed ‘creative’ and the strengths and limitations of one does not necessarily apply to another. For example, cultural animation takes greater effort to prepare than the use of sticky notes and sorting cards, and the use of Facebook is cheaper and wider reaching than persona development. Researchers should use their discretion and weigh up the benefits and drawbacks of each method to decide on a technique which suits the project. What might be a limitation to creative PPI in one project may not be in another. In some cases, creative PPI may not be suitable at all.

Furthermore, the choice of creative PPI method also depends on the needs and characteristics of the PPI group. Children, adults and people living with dementia or language difficulties all have different engagement needs and capabilities. This indicates that creative PPI is not one size fits all and that the most appropriate method will change depending on the composition of the group. The choice of method will also be determined by the constraints of the research project, namely time, money and the research aim. For example, if there are time constraints, then a method which yields a lot of data and requires a lot of preparation may not be appropriate. If generalisation is important, then an online method is more suitable. Together this indicates that the choice of creative PPI method is highly individualised and dependent on multiple factors.

Although the limitations discussed in this review apply to creative PPI, they are not exclusive to creative PPI. Ethical issues are a consideration within general PPI research, especially when working with more vulnerable populations, such as children or adults living with a disability. It can also be the case that traditional PPI methods lack generalisability, as people who volunteer to be part of such a group are more likely be older, middle class and retired [ 24 ]. Most research is vulnerable to this type of bias, however, it is worth noting that generalisation is not always a goal and research remains valid and meaningful in its absence. Although online methods may somewhat combat issues related to generalisability, these methods still exclude people who do not have access to the internet/technology or who choose not to use it, implying that online PPI methods may not be wholly representative of the general population. Saying this, however, the accessibility of creative PPI techniques differs from person to person, and for some, online mediums may be more accessible (for example for those with a physical disability), and for others, this might be face-to-face. To combat this, a range of methods should be implemented. Planning multiple focus group and interviews for traditional PPI is also time and resource intensive, however the extra resources required to make this creative may be even greater. Although, the rich data provided may be worth the preparation and analysis time, which is also likely to depend on the number of participants and workshop sessions required. PPI, not just creative PPI, often requires the provision of a financial incentive, refreshments, parking and accommodation, which increase costs. These, however, are imperative and non-negotiable, as they increase the accessibility of research, especially to minority and lower-income groups less likely to participate. Adequate funding is also important for co-design studies where repeated engagement is required. One barrier to implementation, which appears to be exclusive to creative methods, however, is that creative methods are not mainstream. This cannot be said for traditional PPI as this is often a mandatory part of research applications.

Regarding the strengths of creative PPI, it could be argued that most appear to be exclusive to creative methodologies. These are inclusive by nature as multiple approaches can be taken to evoke ideas from different populations - approaches that do not necessarily rely on verbal or written communication like interviews and focus groups do. Given the anonymity provided by some creative methods, such as personas, people may be more likely to discuss their personal experiences under the guise of a general end-user, which might be more difficult to maintain when an interviewer is asking an individual questions directly. Additionally, creative methods are by nature more engaging and interactive than traditional methods, although this is a blanket statement and there may be people who find the question-and-answer/group discussion format more engaging. Creative methods have also been cited to eliminate power imbalances which exist in traditional research [ 12 , 13 , 17 , 19 , 23 ]. These imbalances exist between researchers and policy makers and adolescents, adults and the community. Lastly, although this may occur to a greater extent in creative methods like prototype development, it could be suggested that PPI in general – regardless of whether it is creative - is more time and cost efficient in the long-term than not using any PPI to guide or refine the research process. It must be noted that these are observations based on the literature. To be certain these differences exist between creative and traditional methods of PPI, direct empirical evaluation of both should be conducted.

To the best of our knowledge, this is the first review to identify the strengths and limitations to creative PPI, however, similar literature has identified barriers and facilitators to PPI in general. In the context of clinical trials, recruitment difficulties were cited as a barrier, as well as finding public contributors who were free during work/school hours. Trial managers reported finding group dynamics difficult to manage and the academic environment also made some public contributors feel nervous and lacking confidence to speak. Facilitators, however, included the shared ownership of the research – something that has been identified in the current review too. In addition, planning and the provision of knowledge, information and communication were also identified as facilitators [ 25 ]. Other research on the barriers to meaningful PPI in trial oversight committees included trialist confusion or scepticism over the PPI role and the difficulties in finding PPI members who had a basic understanding of research [ 26 ]. However, it could be argued that this is not representative of the average patient or public member. The formality of oversight meetings and the technical language used also acted as a barrier, which may imply that the informal nature of creative methods and its lack of dependency on literacy skills could overcome this. Further, a review of 42 reviews on PPI in health and social care identified financial compensation, resources, training and general support as necessary to conduct PPI, much like in the current review where the resource intensiveness of creative PPI was identified as a limitation. However, others were identified too, such as recruitment and representativeness of public contributors [ 27 ]. Like in the current review, power imbalances were also noted, however this was included as both a barrier and facilitator. Collaboration seemed to diminish hierarchies but not always, as sometimes these imbalances remained between public contributors and healthcare staff, described as a ‘them and us’ culture [ 27 ]. Although these studies compliment the findings of the current review, a direct comparison cannot be made as they do not concern creative methods. However, it does suggest that some strengths and weaknesses are shared between creative and traditional methods of PPI.

Strengths and limitations of this review

Although a general definition of creative PPI exists, it was up to our discretion to decide exactly which activities were deemed as such for this review. For example, we included sorting cards, the use of interactive whiteboards and sticky notes. Other researchers may have a more or less stringent criteria. However, two reviewers were involved in this decision which aids the reliability of the included articles. Further, it may be that some of the strengths and limitations cannot fully be attributed to the creative nature of the PPI process, but rather their co-created nature, however this is hard to disentangle as the included papers involved both these aspects.

During screening, it was difficult to decide whether the article was utilising creative qualitative methodology or creative PPI , as it was often not explicitly labelled as such. Regardless, both approaches involved the public/patients refining a healthcare product/service. This implies that if this review were to be replicated, others may do it differently. This may call for greater standardisation in the reporting of the public’s involvement in research. For example, the NIHR outlines different approaches to PPI, namely “consultation”, “collaboration”, “co-production” and “user-controlled”, which each signify an increased level of public power and influence [ 28 ]. Papers with elements of PPI could use these labels to clarify the extent of public involvement, or even explicitly state that there was no PPI. Further, given our decision to include only scholarly peer-reviewed literature, it is possible that data were missed within the grey literature. Similarly, the literature search will not have identified all papers relating to different types of accessible inclusion. However, the intent of the review was to focus solely on those within the definition of creative.

This review fills a gap in the literature and helps circulate and promote the concept of creative PPI. Each stage of this review, namely screening and quality appraisal, was conducted by two independent reviewers. However, four full texts could not be accessed during the full text reading stage, meaning there are missing data that could have altered or contributed to the findings of this review.

Research recommendations

Given that creative PPI can require effort to prepare, perform and analyse, sufficient time and funding should be allocated in the research protocol to enable meaningful and continuous PPI. This is worthwhile as PPI can significantly change the research output so that it aligns closely with the needs of the group it is to benefit. Researchers should also consider prototype development as a creative PPI activity as this might reduce future time/resource constraints. Shifting from a top-down approach within research to a bottom-up can be advantageous to all stakeholders and can help move creative PPI towards the mainstream. This, however, is the collective responsibility of funding bodies, universities and researchers, as well as committees who approve research bids.

A few of the included studies used creative techniques alongside traditional methods, such as interviews, which could also be used as a hybrid method of PPI, perhaps by researchers who are unfamiliar with creative techniques or to those who wish to reap the benefits of both. Often the characteristics of the PPI group were not included, including age, gender and ethnicity. It would be useful to include such information to assess how representative the PPI group is of the population of interest.

Creative PPI is a relatively novel approach of engaging the public and patients in research and it has both advantages and disadvantages compared to more traditional methods. There are many approaches to implementing creative PPI and the choice of technique will be unique to each piece of research and is reliant on several factors. These include the age and ability of the PPI group as well as the resource limitations of the project. Each method has benefits and drawbacks, which should be considered at the protocol-writing stage. However, given adequate funding, time and planning, creative PPI is a worthwhile and engaging method of generating ideas with end-users of research – ideas which may not be otherwise generated using traditional methods.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Critical Appraisal Skills Programme

The Joanna Briggs Institute

National Institute of Health and Care Research

Public Advisory Group

Public and Patient Involvement

Web of Science

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Acknowledgements

With thanks to the PHIRST-LIGHT public advisory group and consortium for their thoughts and contributions to the design of this work.

The research team is supported by a National Institute for Health and Care Research grant (PHIRST-LIGHT Reference NIHR 135190).

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Olivia R. Phillips and Cerian Harries share joint first authorship.

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Nottingham Centre for Public Health and Epidemiology, Lifespan and Population Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK

Olivia R. Phillips, Jo Leonardi-Bee, Holly Knight & Joanne R. Morling

National Institute for Health and Care Research (NIHR) PHIRST-LIGHT, Nottingham, UK

Olivia R. Phillips, Cerian Harries, Jo Leonardi-Bee, Holly Knight, Lauren B. Sherar, Veronica Varela-Mato & Joanne R. Morling

School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK

Cerian Harries, Lauren B. Sherar & Veronica Varela-Mato

Nottingham Centre for Evidence Based Healthcare, School of Medicine, University of Nottingham, Nottingham, UK

Jo Leonardi-Bee

NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, NG7 2UH, UK

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Author contributions: study design: ORP, CH, JRM, JLB, HK, LBS, VVM, literature searching and screening: ORP, CH, JRM, data curation: ORP, CH, analysis: ORP, CH, JRM, manuscript draft: ORP, CH, JRM, Plain English Summary: ORP, manuscript critical review and editing: ORP, CH, JRM, JLB, HK, LBS, VVM.

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Phillips, O.R., Harries, C., Leonardi-Bee, J. et al. What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review. Res Involv Engagem 10 , 48 (2024). https://doi.org/10.1186/s40900-024-00580-4

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Sexual and reproductive health implementation research in humanitarian contexts: a scoping review

  • Alexandra Norton 1 &
  • Hannah Tappis 2  

Reproductive Health volume  21 , Article number:  64 ( 2024 ) Cite this article

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Meeting the health needs of crisis-affected populations is a growing challenge, with 339 million people globally in need of humanitarian assistance in 2023. Given one in four people living in humanitarian contexts are women and girls of reproductive age, sexual and reproductive health care is considered as essential health service and minimum standard for humanitarian response. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on appropriate methods and analytical frameworks is limited.

A scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Peer-reviewed papers published from 2013 to 2022 were identified through relevant systematic reviews and a literature search of Pubmed, Embase, PsycInfo, CINAHL and Global Health databases. Papers that presented primary quantitative or qualitative data pertaining to a sexual and reproductive health intervention in a humanitarian setting were included.

Seven thousand thirty-six unique records were screened for inclusion, and 69 papers met inclusion criteria. Of these, six papers explicitly described the use of an implementation research framework, three citing use of the Consolidated Framework for Implementation Research. Three additional papers referenced other types of frameworks used in their evaluation. Factors cited across all included studies as helping the intervention in their presence or hindering in their absence were synthesized into the following Consolidated Framework for Implementation Research domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process.

This review found a wide range of methodologies and only six of 69 studies using an implementation research framework, highlighting an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

Plain English summary

Three hundred thirty-nine million people globally were in need of humanitarian assistance in 2023, and meeting the health needs of crisis-affected populations is a growing challenge. One in four people living in humanitarian contexts are women and girls of reproductive age, and provision of sexual and reproductive health care is considered to be essential within a humanitarian response. Implementation research can help to better understand how real-world contexts affect health improvement efforts. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on how best to do so is limited. This scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Of 69 papers that met inclusion criteria for the review, six of them explicitly described the use of an implementation research framework. Three used the Consolidated Framework for Implementation Research, a theory-based framework that can guide implementation research. Three additional papers referenced other types of frameworks used in their evaluation. This review summarizes how factors relevant to different aspects of implementation within the included papers could have been organized using the Consolidated Framework for Implementation Research. The findings from this review highlight an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

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Over the past few decades, the field of public health implementation research (IR) has grown as a means by which the real-world conditions affecting health improvement efforts can be better understood. Peters et al. put forward the following broad definition of IR for health: “IR is the scientific inquiry into questions concerning implementation – the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions)” [ 1 ].

As IR emphasizes real-world circumstances, the context within which a health intervention is delivered is a core consideration. However, much IR implemented to date has focused on higher-resource settings, with many proposed frameworks developed with particular utility for a higher-income setting [ 2 ]. In recognition of IR’s potential to increase evidence across a range of settings, there have been numerous reviews of the use of IR in lower-resource settings as well as calls for broader use [ 3 , 4 ]. There have also been more focused efforts to modify various approaches and frameworks to strengthen the relevance of IR to low- and middle-income country settings (LMICs), such as the work by Means et al. to adapt a specific IR framework for increased utility in LMICs [ 2 ].

Within LMIC settings, the centrality of context to a health intervention’s impact is of particular relevance in humanitarian settings, which present a set of distinct implementation challenges [ 5 ]. Humanitarian responses to crisis situations operate with limited resources, under potential security concerns, and often under pressure to relieve acute suffering and need [ 6 ]. Given these factors, successful implementation of a particular health intervention may require different qualities than those that optimize intervention impact under more stable circumstances [ 7 ]. Despite increasing recognition of the need for expanded evidence of health interventions in humanitarian settings, the evidence base remains limited [ 8 ]. Furthermore, despite its potential utility, there is not standardized guidance on IR in humanitarian settings, nor are there widely endorsed recommendations for the frameworks best suited to analyze implementation in these settings.

Sexual and reproductive health (SRH) is a core aspect of the health sector response in humanitarian settings [ 9 ]. Yet, progress in addressing SRH needs has lagged far behind other services because of challenges related to culture and ideology, financing constraints, lack of data and competing priorities [ 10 ]. The Minimum Initial Service Package (MISP) for SRH in Crisis Situations is the international standard for the minimum set of SRH services that should be implemented in all crisis situations [ 11 ]. However, as in other areas of health, there is need for expanded evidence for planning and implementation of SRH interventions in humanitarian settings. Recent systematic reviews of SRH in humanitarian settings have focused on the effectiveness of interventions and service delivery strategies, as well as factors affecting utilization, but have not detailed whether IR frameworks were used [ 12 , 13 , 14 , 15 ]. There have also been recent reviews examining IR frameworks used in various settings and research areas, but none have explicitly focused on humanitarian settings [ 2 , 16 ].

Given the need for an expanded evidence base for SRH interventions in humanitarian settings and the potential for IR to be used to expand the available evidence, a scoping review was undertaken. This scoping review sought to identify IR approaches that have been used in the last ten years to evaluate SRH interventions in humanitarian settings.

This review also sought to shed light on whether there is a need for a common framework to guide research design, analysis, and reporting for SRH interventions in humanitarian settings and if so, if there are any established frameworks already in use that would be fit-for-purpose or could be tailored to meet this need.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews was utilized to guide the elements of this review [ 17 ]. The review protocol was retrospectively registered with the Open Science Framework ( https://osf.io/b5qtz ).

Search strategy

A two-fold search strategy was undertaken for this review, which covered the last 10 years (2013–2022). First, recent systematic reviews pertaining to research or evaluation of SRH interventions in humanitarian settings were identified through keyword searches on PubMed and Google Scholar. Four relevant systematic reviews were identified [ 12 , 13 , 14 , 15 ] Table 1 .

Second, a literature search mirroring these reviews was conducted to identify relevant papers published since the completion of searches for the most recent review (April 2017). Additional file 1 includes the search terms that were used in the literature search [see Additional file 1 ].

The literature search was conducted for papers published from April 2017 to December 2022 in the databases that were searched in one or more of the systematic reviews: PubMed, Embase, PsycInfo, CINAHL and Global Health. Searches were completed in January 2023 Table 2 .

Two reviewers screened each identified study for alignment with inclusion criteria. Studies in the four systematic reviews identified were considered potentially eligible if published during the last 10 years. These papers then underwent full-text review to confirm satisfaction of all inclusion criteria, as inclusion criteria were similar but not fully aligned across the four reviews.

Literature search results were exported into a citation manager (Covidence), duplicates were removed, and a step-wise screening process for inclusion was applied. First, all papers underwent title and abstract screening. The remaining papers after abstract screening then underwent full-text review to confirm satisfaction of all inclusion criteria. Title and abstract screening as well as full-text review was conducted independently by both authors; disagreements after full-text review were resolved by consensus.

Data extraction and synthesis

The following content areas were summarized in Microsoft Excel for each paper that met inclusion criteria: publication details including author, year, country, setting [rural, urban, camp, settlement], population [refugees, internally displaced persons, general crisis-affected], crisis type [armed conflict, natural disaster], crisis stage [acute, chronic], study design, research methods, SRH intervention, and intervention target population [specific beneficiaries of the intervention within the broader population]; the use of an IR framework; details regarding the IR framework, how it was used, and any rationale given for the framework used; factors cited as impacting SRH interventions, either positively or negatively; and other key findings deemed relevant to this review.

As the focus of this review was on the approach taken for SRH intervention research and evaluation, the quality of the studies themselves was not assessed.

Twenty papers underwent full-text review due to their inclusion in one or more of the four systematic reviews and meeting publication date inclusion criteria. The literature search identified 7,016 unique papers. After full-text screening, 69 met all inclusion criteria and were included in the review. Figure  1 illustrates the search strategy and screening process.

figure 1

Flow chart of paper identification

Papers published in each of the 10 years of the review timeframe (2013–2022) were included. 29% of the papers originated from the first five years of the time frame considered for this review, with the remaining 71% papers coming from the second half. Characteristics of included publications, including geographic location, type of humanitarian crisis, and type of SRH intervention, are presented in Table  3 .

A wide range of study designs and methods were used across the papers, with both qualitative and quantitative studies well represented. Twenty-six papers were quantitative evaluations [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ], 17 were qualitative [ 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ], and 26 used mixed methods [ 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 ]. Within the quantitative evaluations, 15 were observational, while five were quasi-experimental, five were randomized controlled trials, and one was an economic evaluation. Study designs as classified by the authors of this review are summarized in Table  4 .

Six papers (9%) explicitly cited use of an IR framework. Three of these papers utilized the Consolidated Framework for Implementation Research (CFIR) [ 51 , 65 , 70 ]. The CFIR is a commonly used determinant framework that—in its originally proposed form in 2009—is comprised of five domains, each of which has constructs to further categorize factors that impact implementation. The CFIR domains were identified as core content areas influencing the effectiveness of implementation, and the constructs within each domain are intended to provide a range of options for researchers to select from to “guide diagnostic assessments of implementation context, evaluate implementation progress, and help explain findings.” [ 87 ] To allow for consistent terminology throughout this review, the original 2009 CFIR domains and constructs are used.

Guan et al. conducted a mixed methods study to assess the feasibility and effectiveness of a neonatal hepatitis B immunization program in a conflict-affected rural region of Myanmar. Guan et al. report mapping data onto the CFIR as a secondary analysis step. They describe that “CFIR was used as a comprehensive meta-theoretical framework to examine the implementation of the Hepatitis B Virus vaccination program,” and implementation themes from multiple study data sources (interviews, observations, examination of monitoring materials) were mapped onto CFIR constructs. They report their results in two phases – Pre-implementation training and community education, and Implementation – with both anchored in themes that they had mapped onto CFIR domains and constructs. All but six constructs were included in their analysis, with a majority summarized in a table and key themes explored further in the narrative text. They specify that most concerns were identified within the Outer Setting and Process domains, while elements identified within the Inner Setting domain provided strength to the intervention and helped mitigate against barriers [ 70 ].

Sarker et al. conducted a qualitative study to assess provision of maternal, newborn and child health services to Rohingya refugees residing in camps in Cox’s Bazar, Bangladesh. They cite using CFIR as a guide for thematic analysis, applying it after a process of inductive and deductive coding to index these codes into the CFIR domains. They utilized three of the five CFIR domains (Outer Setting, Inner Setting, and Process), stating that the remaining two domains (Intervention Characteristics and Characteristics of Individuals) were not relevant to their analysis. They then proposed two additional CFIR domains, Context and Security, for use in humanitarian contexts. In contrast to Guan et al., CFIR constructs are not used nor mentioned by Sarker et al., with content under each domain instead synthesized as challenges and potential solutions. Regarding the CFIR, Sarker et al. write, “The CFIR guided us for interpretative coding and creating the challenges and possible solutions into groups for further clarification of the issues related to program delivery in a humanitarian crisis setting.” [ 51 ]

Sami et al. conducted a mixed methods case study to assess the implementation of a package of neonatal interventions at health facilities within refugee and internally displaced persons camps in South Sudan. They reference use of the CFIR earlier in the study than Sarker et al., basing their guides for semi-structured focus group discussions on the CFIR framework. They similarly reference a general use of the CFIR framework as they conducted thematic analysis. Constructs are referenced once, but they do not specify whether their application of the CFIR framework included use of domains, constructs, or both. This may be in part because they then applied an additional framework, the World Health Organization (WHO) Health System Framework, to present their findings. They describe a nested approach to their use of these frameworks: “Exploring these [CFIR] constructs within the WHO Health Systems Framework can identify specific entry points to improve the implementation of newborn interventions at critical health system building blocks.” [ 65 ]

Three papers cite use of different IR frameworks. Bolan et al. utilized the Theoretical Domains Framework in their mixed methods feasibility study and pilot cluster randomized trial evaluating pilot use of the Safe Delivery App by maternal and newborn health workers providing basic emergency obstetric and newborn care in facilities in the conflict-affected Maniema province of the Democratic Republic of the Congo (DRC). They used the Theroetical Domains Framework in designing interview questions, and further used it as the coding framework for their analysis. Similar to the CFIR, the Theoretical Domains Framework is a determinant framework that consists of domains, each of which then includes constructs. Bolan et al. utilized the Theoretical Domains Framework at the construct level in interview question development and at the domain level in their analysis, mapping interview responses to eight of the 14 domains [ 83 ]. Berg et al. report using an “exploratory design guided by the principles of an evaluation framework” developed by the Medical Research Council to analyze the implementation process, mechanisms of impact, and outcomes of a three-pillar training intervention to improve maternal and neonatal healthcare in the conflict-affected South Kivu province of the DRC [ 67 , 88 ]. Select components of this evaluation framework were used to guide deductive analysis of focus group discussions and in-depth interviews [ 67 ]. In their study of health workers’ knowledge and attitudes toward newborn health interventions in South Sudan, before and after training and supply provision, Sami et al. report use of the Conceptual Framework of the Role of Attitudes in Evidence-Based Practice Implementation in their analysis process. The framework was used to group codes following initial inductive coding analysis of in-depth interviews [ 72 ].

Three other papers cite use of specific frameworks in their intervention evaluation [ 19 , 44 , 76 ]. As a characteristic of IR is the use of an explicit framework to guide the research, the use of the frameworks in these three papers meets the intention of IR and serves the purpose that an IR framework would have in strengthening the analytical rigor. Castle et al. cite use of their program’s theory of change as a framework for a mixed methods evaluation of the provision of family planning services and more specifically uptake of long-acting reversible contraception use in the DRC. They describe use of the theory of change to “enhance effectiveness of [long-acting reversible contraception] access and uptake.” [ 76 ] Thommesen et al. cite use of the AAAQ (Availability, Accessibility, Acceptability and Quality) framework in their qualitative study assessing midwifery services provided to pregnant women in Afghanistan. This framework is focused on the “underlying elements needed for attainment of optimum standard of health care,” but the authors used it in this paper to evaluate facilitators and barriers to women accessing midwifery services [ 44 ]. Jarrett et al. cite use of the Centers for Disease Control and Prevention’s (CDC) Guidelines for Evaluating Public Health Surveillance Systems to explore the characteristics of a population mobility, mortality and birth surveillance system in South Kivu, DRC. Use of these CDC guidelines is cited as one of four study objectives, and commentary is included in the Results section pertaining to each criteria within these guidelines, although more detail regarding use of these guidelines or the authors’ experience with their use in the study is not provided [ 19 ].

Overall, 22 of the 69 papers either explicitly or implicitly identified IR as relevant to their work. Nineteen papers include a focus on feasibility (seven of which did not otherwise identify the importance of exploring questions concerning implementation), touching on a common outcome of interest in implementation research [ 89 ].

While a majority of papers did not explicitly or implicitly use an IR framework to evaluate their SRH intervention of focus, most identified factors that facilitated implementation when they were present or served as a barrier when absent. Sixty cite factors that served as facilitators and 49 cite factors that served as barriers, with just three not citing either. Fifty-nine distinct factors were identified across the papers.

Three of the six studies that explicitly used an IR framework used the CFIR, and the CFIR is the only IR framework that was used by multiple studies. As previously mentioned, Means et al. put forth an adaptation of the CFIR to increase its relevance in LMIC settings, proposing a sixth domain (Characteristics of Systems) and 11 additional constructs [ 2 ]. Using the expanded domains and constructs as proposed by Means et al., the 59 factors cited by papers in this review were thematically grouped into the six domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process. Within each domain, alignment with CFIR constructs was assessed for, and alignment was found with 29 constructs: eight of Means et al.’s 11 constructs, and 21 of the 39 standard CFIR constructs. Three factors did not align with any construct (all fitting within the Outer Setting domain), and 14 aligned with a construct label but not the associated definition. Table 5 synthesizes the mapping of factors affecting SRH intervention implementation to CFIR domains and constructs, with the construct appearing in italics if it is considered to align with that factor by label but not by definition.

Table 6 lists the CFIR constructs that were not found to have alignment with any factor cited by the papers in this review.

This scoping review sought to assess how IR frameworks have been used to bolster the evidence base for SRH interventions in humanitarian settings, and it revealed that IR frameworks, or an explicit IR approach, are rarely used. All four of the systematic reviews identified with a focus on SRH in humanitarian settings articulate the need for more research examining the effectiveness of SRH interventions in humanitarian settings, with two specifically citing a need for implementation research/science [ 12 , 13 ]. The distribution of papers across the timeframe included in this review does suggest that more research on SRH interventions for crisis-affected populations is taking place, as a majority of relevant papers were published in the second half of the review period. The papers included a wide range of methodologies, which reflect the differing research questions and contexts being evaluated. However, it also invites the question of whether there should be more standardization of outcomes measured or frameworks used to guide analysis and to facilitate increased comparison, synthesis and application across settings.

Three of the six papers that used an IR framework utilized the CFIR. Guan et al. used the CFIR at both a domain and construct level, Sarker et al. used the CFIR at the domain level, and Sami et al. did not specify which CFIR elements were used in informing the focus group discussion guide [ 51 , 65 , 70 ]. It is challenging to draw strong conclusions about the applicability of CFIR in humanitarian settings based on the minimal use of CFIR and IR frameworks within the papers reviewed, although Guan et al. provides a helpful model for how analysis can be structured around CFIR domains and constructs. It is worth considering that the minimal use of IR frameworks, and more specifically CFIR constructs, could be in part because that level of prescriptive categorization does not allow for enough fluidity in humanitarian settings. It also raises questions about the appropriate degree of standardization to pursue for research done in these settings.

The mapping of factors affecting SRH intervention implementation provides an example of how a modified CFIR framework could be used for IR in humanitarian contexts. This mapping exercise found factors that mapped to all five of the original CFIR domains as well as the sixth domain proposed by Means et al. All factors fit well within the definition for the selected domain, indicating an appropriate degree of fit between these existing domains and the factors identified as impacting SRH interventions in humanitarian settings. On a construct level, however, the findings were more variable, with one-quarter of factors not fully aligning with any construct. Furthermore, over 40% of the CFIR constructs (including the additional constructs from Means et al.) were not found to align with any factors cited by the papers in this review, also demonstrating some disconnect between the parameters posed by the CFIR constructs and the factors cited as relevant in a humanitarian context.

It is worth noting that while the CFIR as proposed in 2009 was used in this assessment, as well as in the included papers which used the CFIR, an update was published in 2022. Following a review of CFIR use since its publication, the authors provide updates to construct names and definitions to “make the framework more applicable across a range of innovations and settings.” New constructs and subconstructs were also added, for a total of 48 constructs and 19 subconstructs across the five domains [ 90 ]. A CFIR Outcomes Addendum was also published in 2022, based on recommendations for the CFIR to add outcomes and intended to be used as a complement to the CFIR determinants framework [ 91 ]. These expansions to the CFIR framework may improve applicability of the CFIR in humanitarian settings. Several constructs added to the Outer Setting domain could be of particular utility – critical incidents, local attitudes, and local conditions, each of which could help account for unique challenges faced in contexts of crisis. Sub-constructs added within the Inner Setting domain that seek to clarify structural characteristics and available resources would also be of high utility based on mapping of the factors identified in this review to the original CFIR constructs. As outcomes were not formally included in the CFIR until the 2022 addendum, a separate assessment of implementation outcomes was not undertaken in this review. However, analysis of the factors cited by papers in this review as affecting implementation was derived from the full text of the papers and thus captures content relevant to implementation determinants that is contained within the outcomes.

Given the demonstrated need for additional flexibility within an IR framework for humanitarian contexts, while not a focus of this review, it is worth considering whether a different framework could provide a better fit than the CFIR. Other frameworks have differing points of emphasis that would create different opportunities for flexibility but that do not seem to resolve the challenges experienced in applying the CFIR to a humanitarian context. As one example, the EPIS (Exploration, Preparation, Implementation, Sustainment) Framework considers the impact of inner and outer context on each of four implementation phases; while the constructs within this framework are broader than the CFIR, an emphasis on the intervention characteristics is missing, a domain where stronger alignment within the CFIR is also needed [ 92 ]. Alternatively, the PRISM (Practical, Robust Implementation and Sustainability Model) framework is a determinant and evaluation framework that adds consideration of context factors to the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) outcomes framework. It has a stronger emphasis on intervention aspects, with sub-domains to account for both organization and patient perspectives within the intervention. While PRISM does include aspects of context, external environment considerations are less robust and intentionally less comprehensive in scope, which would not provide the degree of alignment possible between the Characteristics of Systems and Outer Setting CFIR domains for the considerations unique to humanitarian environments [ 93 ].

Reflecting on their experience with the CFIR, Sarker et al. indicate that it can be a “great asset” in both evaluating current work and developing future interventions. They also encourage future research of humanitarian health interventions to utilize the CFIR [ 51 ]. The other papers that used the CFIR do not specifically reflect on their experience utilizing it, referring more generally to having felt that it was a useful tool [ 65 , 70 ]. On their use of an evaluation framework, Berg et al. reflected that it lent useful structure and helped to identify aspects affecting implementation that otherwise would have gone un-noticed [ 67 ]. The remaining studies that utilized an IR framework did not specifically comment on their experience with its use [ 72 , 83 ]. While a formal IR framework was not engaged by other studies, a number cite a desire for IR to contribute further detail to their findings [ 21 , 37 ].

In their recommendations for strengthening the evidence base for humanitarian health interventions, Ager et al. speak to the need for “methodologic innovation” to develop methodologies with particular applicability in humanitarian settings [ 7 ]. As IR is not yet routinized for SRH interventions, this could be opportune timing for the use of a standardized IR framework to gauge its utility. Using an IR framework to assess factors influencing implementation of the MISP in initial stages of a humanitarian response, and interventions to support more comprehensive SRH service delivery in protracted crises, could lend further rigor and standardization to SRH evaluations, as well as inform strategies to improve MISP implementation over time. Based on categorizing factors identified by these papers as relevant for intervention evaluation, there does seem to be utility to a modified CFIR approach. Given the paucity of formal IR framework use within SRH literature, it would be worth conducting similar scoping exercises to assess for explicit use of IR frameworks within the evidence base for other health service delivery areas in humanitarian settings. In the interim, the recommended approach from this review for future IR on humanitarian health interventions would be a modified CFIR approach with domain-level standardization and flexibility for constructs that may standardize over time with more use. This would enable use of a common analytical framework and vocabulary at the domain level for stakeholders to describe interventions and the factors influencing the effectiveness of implementation, with constructs available to use and customize as most appropriate for specific contexts and interventions.

This review had a number of limitations. As this was a scoping review and a two-part search strategy was used, the papers summarized here may not be comprehensive of those written pertaining to SRH interventions over the past 10 years. Papers from 2013 to 2017 that would have met this scoping review’s inclusion criteria may have been omitted due to being excluded from the systematic reviews. The review was limited to papers available in English. Furthermore, this review did not assess the quality of the papers included or seek to assess the methodology used beyond examination of the use of an IR framework. It does, however, serve as a first step in assessing the extent to which calls for implementation research have been addressed, and identify entry points for strengthening the science and practice of SRH research in humanitarian settings.

With one in 23 people worldwide in need of humanitarian assistance, and financing required for response plans at an all-time high, the need for evidence to guide resource allocation and programming for SRH in humanitarian settings is as important as ever [ 94 ]. Recent research agenda setting initiatives and strategies to advance health in humanitarian settings call for increased investment in implementation research—with priorities ranging from research on effective strategies for expanding access to a full range of contraceptive options to integrating mental health and psychosocial support into SRH programming to capturing accurate and actionable data on maternal and perinatal mortality in a wide range of acute and protracted emergency contexts [ 95 , 96 ]. To truly advance guidance in these areas, implementation research will need to be conducted across diverse humanitarian settings, with clear and consistent documentation of both intervention characteristics and outcomes, as well as contextual and programmatic factors affecting implementation.

Conclusions

Implementation research has potential to increase impact of health interventions particularly in crisis-affected settings where flexibility, adaptability and context-responsive approaches are highlighted as cornerstones of effective programming. There remains significant opportunity for standardization of research in the humanitarian space, with one such opportunity occurring through increased utilization of IR frameworks such as a modified CFIR approach. Investing in more robust sexual and reproductive health research in humanitarian contexts can enrich insights available to guide programming and increase transferability of learning across settings.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Availability, Accessibility, Acceptability and Quality

Centers for Disease Control and Prevention

Consolidated Framework for Implementation Research

Democratic Republic of the Congo

Exploration, Preparation, Implementation, Sustainment

  • Implementation research

Low and middle income country

Minimum Initial Service Package

Practical, Robust Implementation and Sustainability Model

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Reach, Effectiveness, Adoption, Implementation, Maintenance

  • Sexual and reproductive health

World Health Organization

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Ethical guidance for conducting health research with online communities: A scoping review of existing guidance

Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom

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Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Roles Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

  • Jane Harris, 
  • Jennifer Germain, 
  • Ellie McCoy, 
  • Rosemary Schofield

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  • Published: May 17, 2024
  • https://doi.org/10.1371/journal.pone.0302924
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Table 1

Online research methods have grown in popularity due in part to the globalised and far-reaching nature of the internet but also linked to the Covid-19 pandemic whereby restrictions to travel and face to face contact necessitated a shift in methods of research recruitment and data collection. Ethical guidance exists to support researchers in conducting online research, however this is lacking within health fields. This scoping review aims to synthesise formal ethical guidance for applying online methods within health research as well as provide examples of where guidance has been used. A systematic search of literature was conducted, restricted to English language records between 2013 and 2022. Eligibility focused on whether the records were providing ethical guidance or recommendations, were situated or relevant to health disciplines, and involved the use or discussion of online research methods. Following exclusion of ineligible records and duplicate removal, three organisational ethical guidance and 24 research papers were charted and thematically analysed. Four key themes were identified within the guidance documents, 1) consent, 2) confidentiality and privacy, 3) protecting participants from harm and 4) protecting researchers from harm with the research papers describing additional context and understanding around these issues. The review identified that there are currently no specific guidelines aimed at health researchers, with the most cited guidance coming from broader methodological perspectives and disciplines or auxiliary fields. All guidance discussed each of the four key themes within the wider context of sensitive topics and vulnerable populations, areas and issues which are often prominent within health research thus highlighting the need for unifying guidance specific for health researchers. Further research should aim to understand better how online health studies apply ethical principles, to support in informing gaps across both research and guidance.

Citation: Harris J, Germain J, McCoy E, Schofield R (2024) Ethical guidance for conducting health research with online communities: A scoping review of existing guidance. PLoS ONE 19(5): e0302924. https://doi.org/10.1371/journal.pone.0302924

Editor: Ayush Anand, BP Koirala Institute of Health Sciences, NEPAL

Received: September 5, 2023; Accepted: April 15, 2024; Published: May 17, 2024

Copyright: © 2024 Harris et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Globally, there are 5.3 billion and 4.95 billion users of the internet and social media respectively [ 1 ], with these online spaces creating unprecedented research opportunities, particularly within health research and leading the internet to be coined ‘the laboratory for the social sciences’ [ 2 , 3 ]. Online methods are frequently used in health research to engage with populations who are hard to reach or seldom heard outside of online spaces, as well as those who are engaging in illicit or risky behaviours [ 4 ]. More recently, the Covid-19 pandemic restrictions necessitated a shift in methods of data collection and heightened interest in online methods [ 5 , 6 ]. Online research methods can range from recruiting participants online, e.g., advertising surveys online, through to online communities and social media becoming sources of data through data capture or scraping. It is this latter category where data is ‘taken’ from existing online spaces which often poses the most ethical questions, challenges and blurring of boundaries for researchers [ 7 ] who are working in spaces which are changing and adapting all the time as technology advances.

Ethical guidance exists to support researchers conducting online research and comes from both discipline specific fields such as psychology [ 8 ] and sociology [ 9 , 10 ], as well as more general guidance from cross disciplinary organisations [ 11 ]. This guidance applies offline ethical considerations to online methods, considering issues regarding consent, confidentiality and anonymity as well as protecting both participants and researchers from harm. Whilst these are standard ethical principles, their application can differ in online spaces and guidelines can often be interpreted differently or overlooked entirely within research and by researchers [ 12 ]. Furthermore, the study of online communities can present new ethical considerations such as whether these spaces can be considered public or private, a distinction which is difficult to navigate within the context of online platforms and where views are inconsistent even by those who inhabit such spaces [ 13 ]. Whilst online research has been used extensively within social sciences and particularly within health research, no guidance exists which is aimed specifically at health researchers. This coupled with complex ethical issues within an ever-changing online landscape can make conducting this research challenging. Therefore, this scoping review aims to synthesise current best ethical practice and guidance for online research and specifically for health researchers, consider the application of these sets of guidance within health research.

Due to a paucity in guidance specifically aimed at health researchers, this scoping review aimed to synthesise existing formal online ethical guidance within health research. Arksey and O’Malley’s [ 14 ] five-stage iterative process for scoping reviews was followed throughout, comprising the following 5 stages: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data and (5) collating, summarizing and reporting the results.

Research question

The review aimed to understand what ethical guidance is available for researchers conducting online research. The underpinning research question was ‘what guidance exists on the ethical considerations that should be taken by health researchers conducting research with or about online health communities’ which guided the systematic search strategy. The overarching review question allowed the reviewers to search a wide range of available literature to capture what guidance is already available in the public domain and collate and review recommendations developed from other studies.

Aims and objectives

Specifically, this study aimed to:

  • Map the available guidance on online ethics that is of relevance to health researchers
  • Thematically describe the key ethical considerations covered by this guidance (e.g., consent, protection from harm, preventing identification, verbatim quotes)
  • Highlight any areas of disagreement across the guidance
  • Identify any gaps or ethical grey areas in current guidance.

Identifying relevant studies

The search strategy was developed using search terms based on the PCC framework [ 15 , 16 ]; population of interest (health researchers), the concept (ethical guidance and considerations) and context (research with online health communities). JH and JG led the development of the search strategy and search terms focused on 1) online 2) research 3) ethics and 4) policy and guidance. Searches were conducted across Scopus, Web of Science, Medline and Psycinfo to locate publications over a 10-year timeframe between 2013 and 2022. A ten year timeframe was chosen due to rapidly evolving trends across social media and technology, with this time frame best reflecting the current online platform landscape. Manual searching of reference lists was undertaken and grey literature searched using Google Scholar, Google and websites of key health related research bodies and regulators (e.g., NIHR, BPS, Royal College of Physicians).

Searches identified 3,294 records which were imported into Rayan online reference manager and duplicates removed (n = 1,177). Study selection utilised a two-step process to screen titles and abstracts (n = 2,117) and then full paper screening (n = 189). All screening was undertaken by JH, JG, EMC and RS and following inclusion and exclusion criteria set out in Table 1 . Two reviewers each blind screened papers at both screening stages with conflicts resolved by group discussion and a third review where necessary. Research papers were selected for the review if they were conducting one of the forms of online research outlined in Table 1 in a health-related field and if their article made recommendations or guidance of their own for ethical practice as a result of their research experiences. Grey literature followed the same two-step process for screening. Twenty-seven articles and guidance were selected for data charting. All searches were conducted between February and June 2022, and were repeated in August 2023 however no new guidance was identified in these latter searches.

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Risk of bias

Whilst quality assessment is not a requirement of scoping reviews, assessing the methodological and other qualities of studies can support in contextualising findings and enable interpretation [ 15 ]. Therefore, the selected articles were assessed for quality and bias using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Text and Opinion [ 17 ]. The Text and Opinion checklist was considered most suitable as the scoping review had identified a range of different publications which made recommendations on ethical practice in online health research including organisational guidance documents, commentary and opinion pieces and methodological papers. As presented in Table 2 , the checklist criteria focused on whether the ethical recommendations made were clearly identified and logical, had standing in their field of expertise, were relevant to health researchers and had congruence with existing research. The quality of the papers and guidance was independently assessed by one of the four reviewers (JH, JG, EMC, RS) using the predetermined questions. The quality assessment of the papers can be viewed in Table 2 . The review papers largely met the criteria and after discussion, the decision was made to include all 27 papers in the final review.

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Data collection, summarisation and presentation of results

A data extraction form was developed in a Microsoft Excel Spreadsheet charting all relevant data including authors, year of publication, key ethical topics covered and, for research papers, which if any ethical organisational guidance had been followed. The data form was piloted independently by two authors (JH/JG) on 10% (n = 3) of papers, and the remainder of included studies split between the two reviewers. Data was charted across four key areas 1) consent , 2) confidentiality and privacy , 3) protecting participants from harm and 4) protecting researchers from harm . The areas where initially informed by the key subheading across all included ethical guidance and refined through discussions involving all members of the team. All data was systematically extracted and charting was conducted by two researchers (JH and JG) and checked for consistency. The researchers then made comparisons across the selected papers to identify common themes and gaps across the existing guidance. Once data extraction was complete, JH and JG discussed the findings to identify the key points of ethical consideration within each theme which were then synthesised to create a narrative account of the guidance.

Guidance from three organisations met the inclusion criteria for the review (See Fig 1 for PRISMA flow diagram): the British Psychological Society (BPS) [ 8 ], the Association of Internet Research (AoIR) [ 11 ] and the British Sociological Association (BSA) [ 9 , 10 ].

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Summaries of the guidance are included in Table 3 and our narrative is presented around four key themes: consent, confidentiality and privacy, protecting participants from harm and protecting researchers from harm ( Fig 2 ). Alongside these guidance documents, 24 research papers ( Table 4 ) were included to give a clearer understanding of which (if any) ethical guidance health researchers were following. The AoIR [ 11 ] was the most commonly cited guidance (n = 18), followed by the BPS [ 8 ] (n = 7), with the BSA [ 9 ] least cited (n = 1). Six papers did not cite any of the guidance documents, however, most papers were following the key guidance principles.

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All guidance discussed the complexities of obtaining informed participant consent in online research with BSA [ 9 ] and AOIR [ 11 ] noting particular difficulties for big data studies due to the sheer number of participants involved. According to the BSA, whilst informed consent is not legally required to obtain data from public online spaces, it cannot be overlooked from an ethical perspective [ 9 , 10 ], particularly when topics are sensitive in nature [ 10 ]. The BPS [ 8 ] assert that if data is not considered in the public domain and there is no scientific justification for undisclosed use, consent should always be gained. The AOIR [ 11 ] state that consent should consider environmental factors and expectations of the online communities and users under investigation. A number of practical difficulties were noted in obtaining consent including users having left online spaces and the potential disruption to online communities [ 10 ]. The BPS [ 8 ] outline the need to verify participant characteristics including vulnerability to coercion and ensure consent processes are not overly complicated and lengthy. BSA [ 9 ] advocate for a participatory approach of ongoing communication and recommend researchers consult forum moderators for permission (although they acknowledge moderators may not speak for all users) [ 10 ].

The majority of papers (n = 13) concurred that consent was more ambiguous in public online spaces [ 8 , 11 ] and was an ongoing process requiring continual reflection and communication with participants [ 4 , 18 , 19 , 23 , 25 , 27 , 30 , 32 , 33 , 35 , 36 , 38 – 40 ]. Eight papers repeated the BPS assertion that not seeking consent for public domain online data could be justified when the scientific and social value outweighed the associated risk [ 18 , 19 , 23 , 30 , 33 , 36 , 38 , 40 ]. Examples included data on non-sensitive health topics taken from large publicly accessible forums (for example Mumsnet) and blog or vlog data produced for a public audience [ 25 , 27 , 33 ]. Two studies [ 21 , 22 ] took a more extreme view that all online spaces are private, and consent should always be sought. However, in these instances both were discussing recruiting participants from online spaces to take part in conventional research.

In line with AoIR, seven papers gave attention to the expectations of online communities in relation to research [ 19 , 25 , 30 , 33 , 36 , 39 , 40 ]. For example, Burles et al [ 25 ] suggested that disrupting online illness support communities could cause members to change or reduce the support they provide to others. Three papers agreed with the BSA that consent should be sought from community moderators [ 40 ] using the examples of a private fathering forum [ 33 ], an online youth counselling platform [ 36 ] and closed Facebook groups [ 33 , 39 ]. However, seven papers acknowledged challenges of verifying age characteristics online [ 26 , 28 , 29 , 32 , 34 – 36 ] and the ability to give or capture informed consent online [ 36 ], and recommended consent processes relative to topic sensitivity [ 35 ] developed in consultation with clinical and subject experts [ 36 ]. Five papers acknowledged the challenges of ensuring participant information was read by participants [ 27 – 29 , 32 , 36 ] with solutions including FAQs [ 28 ], online quizzes [ 28 , 29 ] and multi-stage consent forms [ 32 ]. The scale of online datasets was also viewed as a barrier to seeking individual level consent [ 8 , 9 , 11 ]. Solutions proposed included seeking consent for quotes used in publications [ 11 , 27 ], as well as the posting of debriefing messages on the online communities or a dedicated study site [ 27 , 36 , 40 ]. Finally, three papers discussed the challenges of withdrawing consent in online research, for example when data included in a study is deleted by the user [ 4 , 36 ] or in prospective studies when the sensitive data has not yet been produced, with Clark et al [ 27 ] giving the example of using Twitter posts to predict post-natal depression.

Confidentiality/Privacy/Anonymity

As the guidance on consent indicates, all three guidance documents acknowledge that privacy is challenging to define in online spaces [ 8 , 9 , 11 ]. The BPS generally defines a public space as one where participants could reasonably be expected to be observed by strangers [ 8 ]. However, their internet mediated research guidance acknowledges this distinction is not so clear cut for online research because online interaction can simultaneously take place publicly (for example a public online forum) and privately (from the home) [ 8 ]. Where this ambiguity exists the BPS [ 8 ] and BSA [ 9 ] propose several practical steps to ensure participants are sufficiently protected from harm which are discussed in the section below. As the only international guidance included, the AoIR [ 11 ] gives a wider contextual outlook at differing perspectives between disciplines and across countries. They highlight the difference between deontological approaches to privacy (protecting the rights of autonomous individuals) in Europe versus the more utilitarian approaches (achieving a greater good for society) taken in the UK and US and advocate for “ ethical pluralism” which acknowledges these legitimate differences but develops shared norms and practices. The AoIR highlights several contextual factors which must be considered alongside the practical steps outlined by the BPS [ 8 ] and BSA [ 9 ]. This includes legal frameworks (e.g., GDPR), platform terms and conditions, management of data, adequate anonymisation of large data sets and reliance on companies giving access to their API which can favour certain countries, universities and researchers.

Twelve papers reflected on the blurred lines between public and private spaces online and users varying expectations of privacy in relation to research [ 4 , 21 , 23 – 27 , 29 – 33 , 36 ]. For example DeCamp [ 29 ] made recommendations which aligned well with the guidance, stating: 1) researchers should understand site Terms and Conditions regarding privacy and research participation, 2) if a site requires registration and moderator approval, there is some expectation of privacy, and 3) sites with express purpose of sharing individual health stories might have some expectation of privacy and researchers should engage with moderators and users before beginning the research. Two papers recommend the publication of a privacy statement via study or research group specific websites [ 18 , 32 , 35 ]. The issues highlighted by the AoIR in relation to different legal and cultural understandings of privacy internationally were rarely discussed, with only three papers providing any reflection on this [ 26 – 28 ].

Participant harm

The BSA [ 9 ] and BPS [ 8 ] both argue that online research should maximise benefits and minimise harm through values of protection, respect, dignity, and privacy [ 9 ] and gaining informed consent and anonymisation are vital to this. The BPS highlight social responsibility to respect the social structures of existing online groups and the consequences of undertaking research upon group cohesion and trust. Several practical steps are recommended to address this. These include: familiarisation with the online space of study to ascertain if participants perceive it to be public [ 9 ], discussions with group moderators on the best way to research their online groups [ 8 , 9 ], anonymisation of data through removal of personal information [ 8 , 9 ] including online pseudonyms [ 8 ], not including potentially embarrassing or sensitive information [ 9 ], paraphrasing or combining quotes [ 8 , 9 ], age verification and not naming online communities [ 8 ]. The guidance also note that these actions should be proportional to the risk of harm, for example sensitive topics and more vulnerable groups including children and young people, women, certain emotional states such as grieving and/or trauma, illnesses; and minorities such LGBTQ+ communities [ 8 , 11 ]. Research on sensitive topics where risks are high and the ability to control is low should be avoided and consideration must be given to researchers’ responsibility in reporting online users discussing negative well-being and criminal activity [ 8 ].

Sixteen of the studies recommended the anonymisation of data [ 4 , 19 , 23 – 28 , 30 – 33 , 35 – 37 , 40 ], achieved through removing online pseudonyms, sensitive health information, geolocation data and the names of sites from which data was collected. Benton et al [ 23 ] advise caution when linking data across multiple platforms as individual online personas could “out” sensitive health information. Ten studies recommended paraphrasing verbatim quotes [ 4 , 18 , 23 – 26 , 30 , 33 , 35 ], and this varied from changing minor words to prevent retrieval form a search engine, through to the fabrication of synthetic quotes based on participants’ words [ 23 , 25 ]. Eighteen papers felt potential harm was dependent on the sensitivity and anonymity of each online group and that vulnerability should be sensitively negotiated as the research progresses [ 4 , 18 , 19 , 21 – 24 , 26 – 32 , 34 – 36 ]. Three papers suggest this is addressed through familiarisation with site netiquette and potential impacts on cohesion and trust [ 29 , 31 , 33 ].

Researcher harm

Two of the three guidance discussed protecting researchers from harm [ 9 , 11 ]. This was considered particularly important for research relating to politically sensitive topics or where researchers hold identities (e.g., ethnicity, minority identity, sexual identity, political activism, etc.) that could trigger strong ideological reactions [ 11 ], placing them in publicly visible, vulnerable positions and at risk of abuse [ 9 ]. Both guidelines called for the support from individual institutions, stating that researchers should receive ethical approval prior to commencing research and continue to discuss challenges with the committee throughout [ 9 ]. Furthermore, institutions should develop policy detailing support procedures for researchers experiencing online threats or harassment related to their work [ 11 ]. The BPS [ 8 ] also highlight the challenges of ensuring integrity and scientific value when researchers have less control over who can participate, environmental conditions and responses during the research and variations in the research procedures caused by different hardware and software.

Seven papers considered the potential researcher harms from online research. Two papers noted that researchers should be cautious of putting themselves at risk of online abuse particularly if they were from groups vulnerable to harm [ 18 , 24 ]. Hunter et al [ 4 ], in line with AoIR [ 11 ], discuss the emotional impacts of exposure to sensitive or politically extreme information online, recommending clearly defined researcher roles and regular debriefs when exposed to content. Five papers reflect on the impacts upon research integrity raised by the BPS [ 8 , 26 , 30 , 33 , 36 ] with three papers suggesting that seeking approval from institutional research ethics committees is the best way to ensure methodologically and ethically sound research [ 30 , 33 , 36 ].

Our scoping review identified three online ethical guidance documents published within the last ten years which were relevant to researchers working across health-related disciplines: the Association of Internet Researchers (AoIR) [ 11 ], the British Psychological Society (BPS) [ 8 ], and the British Sociological Association (BSA) [ 9 ]. Whilst our review identified common thematic components across this guidance, it is also important to acknowledge that these guidance documents differ in scope and intention. The AoIR guidance promotes ethical pluralism, by highlighting key principles which are relevant to multidisciplinary researchers globally. In contrast, the BPS and BSA are country and discipline specific, presenting structured guidance on research practices. Our review identified a notable gap in formal guidance produced by international and national health organisations. As a result, a number of papers were identified which aimed to give advice to health researchers on conducting ethical online research and these papers drew on a combination of the existing guidance from other disciplines and research experience. Seventeen of the selected papers cited at least one of the three guidance documents, highlighting a clear will among health researchers to make use of guidance when designing their research. However, this also highlights a lack of standardisation of ethical approaches in health research with papers citing different or multiple ethical guidelines including those published prior to the last decade or from wider, less relevant disciplines such as marketing or education. This lack of uniform guidance for health research makes it challenging for researchers seeking to design online studies and for ethical review committees seeking to make consistent decisions about how such research should be conducted [ 41 – 44 ]. Previous reviews have also noted the variation in practices across social media research specifically and called for concrete guidelines on research ethics for social media research to be made available [ 45 ]. However, it should be noted that there has been an argument against a “one size fits all” approach to online research due to the diversity in online cultures, values, and platforms [ 46 ]. Whilst these complexities should not deter researchers from conducting online research they often instead require an individual assessment of the potential ethical issues [ 47 ]. However, the reflexive approach taken to online ethics by the BPS [ 8 ], BSA [ 9 ] and AoIR [ 11 ] (termed “ethical pluralism” by the AoIR [ 11 ]) and commonality in key themes, suggests that it is possible to develop research guidance which covers varying health research aims and approaches.

Broadly, the guidance documents covered four common thematic areas and recommended 1) decisions about seeking consent to use publicly available online data should balance the scientific value to the research with environmental factors relating to the online community including sensitivity of the research topic, vulnerability of populations and the potential for community disruption 2) there is ambiguity around which online spaces are public and private which can vary according to individual, online community, cultural and legal perceptions 3) researchers must therefore take active steps to protect participants from harm relative to the perceived risk, for example through anonymisation of data, and 4) researchers must also protect themselves from individual and reputational harm by seeking the correct ethical approvals for their research. Overall, there was good coverage of these principles within the selected papers with the principles of anonymity (n = 16) and perceptions of privacy (n = 12) most frequently included. Issues of consent (n = 7) and potential researcher harm (n = 7) were considered less often.

Notably across these themes, the guidance documents recommended decisions were made relative to the sensitivity of the research topic and vulnerability of the population under study. Examples of sensitive research areas included mental health [ 8 ], experiences of personal illness [ 9 ] and grief and trauma [ 11 ]. Vulnerable populations included women, children and young people, people in certain emotional states and LGBTQ+ people [ 8 , 11 ]. From our reading of this guidance, it was clear to us that a significant proportion of research undertaken in health-related disciplines could be considered sensitive by this definition as they involve the sharing of personal health experiences [ 48 ] or data, cover sensitive topics (such as mental health, chronic conditions, or substance use) and aim to include or target vulnerable populations [ 49 ]. This suggest that health researchers will be required to consider many of the more complex issues within the guidance as well as ethical safeguards around such issues as potential confidentiality breaches, the collection of sensitive data, or the unauthorised reuse of it [ 50 ]. Health research has a long- and well-established tradition of ethical guidance. In many countries, research taking place on healthcare premises or with patients is reviewed by separate institutional boards within healthcare organisations and there are many standardised expectations and procedures which govern how health related research can take place. For example, in the UK approval for research with National Health Service (NHS) patients must be granted by an NHS ethical committee and then individual approval provided by each hospital or healthcare trust where research will take place. Given the rigorous ethical requirements for health-related research in many countries, it is therefore quite surprising that guidance for online health research has not been produced by any official health organisations. This guidance would be valuable in assisting health researchers to reflexively design their studies to meet the ethical requirements in both health-related disciplines and the wider online research community.

Limitations

This scoping review only included studies which were of relevance to health-related researchers. Given the lack of guidance from health organisations, this may have excluded some broader ethics documents which are being used by health researchers to inform their studies. We limited our scoping review to guidance and papers published in the past 10 years to reflect the fast-changing nature of online communities and online research methodologies. It is possible this may have excluded some earlier guidance in health-related fields, although if these documents have not been updated then their relevance to current health related researchers may be limited. Our review also identified some emerging issues which were beyond the scope of this paper including the ethics of digital images [ 11 ] and the ethical impacts of big data in health, particularly prospective studies which predict sensitive health issues such as mental health or chronic conditions [ 27 , 51 ] which warrant further research. Similarly, we only included papers which presented some form of recommendation or guidance to other researchers on ethical online research practices. Further research could consider online health studies more generally to understand which key ethical principles are being applied, although the early stage of our review suggests that reporting of ethical practices in online research studies is inconsistent.

This scoping review aimed to synthesise current best ethical practice for online research in health -related fields. The review identified that there are currently no specific guidelines aimed at health researchers, with the most cited guidance coming from broader methodological perspectives (Franzke et al, 2020) or auxiliary fields [ 8 , 9 ]. As a consequence, many researchers had attempted to synthesise the recommendations from this guidance, their own research and previous studies to produce their own recommendations on ethical practice. Our review identified four key principles of ethical practice which were well cited in the online health research literature 1) a reflexive approach to seeking informed consent 2) protecting the privacy and anonymity of online participants 3) protecting participants from any harm associated with analysing their online data 4) preventing researchers from harm whilst undertaking online research. Across all the existing guidance, ethical decision making was framed in relation to the sensitivity of the research topic and vulnerability of the population. Given that much health research focuses on sensitive topics and populations, our review recommends unifying guidance specific for health researchers to help them design reflexive and ethical online research. Next steps should be focused on developing tailored health research guideline which draws on the experiences of health researchers working in this domain, as well as providing particular consideration to research across sensitive topics and with vulnerable groups.

Supporting information

S1 checklist. prisma 2020 checklist..

https://doi.org/10.1371/journal.pone.0302924.s001

https://doi.org/10.1371/journal.pone.0302924.s002

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  • 8. British Psychological Society. Ethics guidelines for internetmediated research. Leceister: BPS; 2020 2020.
  • 9. BSA (British Sociological Association). Ethics Guidelines and Collated Resources for Digital Research: British Sociological Association; 2017 2017.

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1. Introduction

2. results and discussion, 3. conclusions, 4. related literature, supporting information.

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Open Access

Analysis of COF-300 synthesis: probing degradation processes and 3D electron diffraction structure

a XStruct, Department of Chemistry, Ghent University, Krijgslaan 281–S3, 9000 Ghent, Belgium, b COMOC – Center for Ordered Materials, Organometallics and Catalysis – Department of Chemistry, Ghent University, Krijgslaan 281–S3, 9000 Ghent, Belgium, c Rigaku Corporation, Haijima, Tokyo, Japan, and d Rigaku Europe SE, Neu-Isenburg, Germany * Correspondence e-mail: [email protected]

Although COF-300 is often used as an example to study the synthesis and structure of (3D) covalent organic frameworks (COFs), knowledge of the underlying synthetic processes is still fragmented. Here, an optimized synthetic procedure based on a combination of linker protection and modulation was applied. Using this approach, the influence of time and temperature on the synthesis of COF-300 was studied. Synthesis times that were too short produced materials with limited crystallinity and porosity, lacking the typical pore flexibility associated with COF-300. On the other hand, synthesis times that were too long could be characterized by loss of crystallinity and pore order by degradation of the tetrakis(4-aminophenyl)methane (TAM) linker used. The presence of the degradation product was confirmed by visual inspection, Raman spectroscopy and X-ray photoelectron spectroscopy (XPS). As TAM is by far the most popular linker for the synthesis of 3D COFs, this degradation process might be one of the reasons why the development of 3D COFs is still lagging compared with 2D COFs. However, COF crystals obtained via an optimized procedure could be structurally probed using 3D electron diffraction (3DED). The 3DED analysis resulted in a full structure determination of COF-300 at atomic resolution with satisfying data parameters. Comparison of our 3DED-derived structural model with previously reported single-crystal X-ray diffraction data for this material, as well as parameters derived from the Cambridge Structural Database, demonstrates the high accuracy of the 3DED method for structure determination. This validation might accelerate the exploitation of 3DED as a structure determination technique for COFs and other porous materials.

Keywords: 3D electron diffraction ; 3DED ; microcrystal electron diffraction ; microED ; covalent organic frameworks ; Cambridge Structural Database ; porous organic solids ; crystallization and crystal growth .

CCDC reference: 2321626

In Figs. S6–S8, the effect of time on I 65°C (as discussed earlier) is compared with the effect on the other samples. Note that, as expected, I RT is slower to form a crystalline material compared with I 65°C due to the reduced error correction at room temperature, with reflections appearing after 1 d, and fully developed crystallinity after 5 d. However, the pore structure never fully establishes, as indicated by the broad, late and small second step in the N 2 -sorption isotherm. The appearance of crystallinity in C 65°C is even more delayed, with no crystalline reflections observed after 1 d of reaction time, indicating the superiority of the intermediate-assisted procedure. Here, maximal crystallinity is observed after 5 d, as peaks start to broaden significantly after 7 d. Surprisingly, the best N 2 -sorption behaviour was observed for the 7 d sample, indicating that the relationship between crystallinity and porosity is not always straightforward. Finally, using the conditions of C RT, we were unable to form any crystalline material, even after 7 d of reaction time. We also checked if the scale of the synthesis had any influence on the material. Therefore, a sample (I 65°C ×5) was prepared in an identical way to I 65°C but with every quantity used multiplied by 5. The resulting PXRD patterns and the N 2 -sorption isotherms are presented in Fig. S9 and show no significant influence on the crystallinity and a small decrease of porosity (with a BET surface area of 1180 m 2  g −1 and V p of 0.71 obtained for I 65°C ×5).

The response of COF-300 to an intermediate-assisted synthesis protocol was studied by careful evaluation of the evolution of both crystallinity and porosity as functions of reaction time and temperature. Kinetic studies among four different synthesis conditions revealed three distinct stages in the synthesis of COF-300, namely a network build-up phase at short synthetic times (≤1 d) with low crystallinity and no pore flexibility, followed by an optimal stage (3 d) characterized by high crystallinity and porosity before partial breakdown by TAM degradation (≥5 d). This degradation process could be confirmed in both control experiments as well as the obtained COF materials and can easily be estimated by the observation of magenta-coloured reaction mixtures. As a pronounced influence of this degradation reaction on both crystallinity and porosity was observed and most 3D COFs are based on the TAM linker, knowledge of TAM degradation in a acidic environment is of utmost importance for the synthesis of high-quality 3D COFs. Knowledge of this degradation process might help to increase the synthetic toolbox for 3D COFs (which are mainly based on the TAM linker), which is still lacking compared with 2D COFs. However, using the optimized conditions, a reliable crystal structure of COF-300 could be readily obtained via 3DED analysis, indicating single crystallinity of the synthesized materials. The structure model obtained showed high completeness and comparable resolution and R values. Comparison with an SCXRD structure model as well as with data for similar chemical functionalities in the CSD database showed no significant differences, supporting that 3DED is a reliable and fast technique for the structure solution of COFs. As SCXRD structure solution is hardly possible and PXRD models often show ambiguity in structure determination, 3DED might play an important role in the future of COFs with better accessibility of 3DED diffraction equipment and improving dynamic refinement algorithms.

Crystal structure: contains datablock 1. DOI: https://doi.org/10.1107/S2052252524003713/vq5005sup1.cif

Structure factors: contains datablock 1. DOI: https://doi.org/10.1107/S2052252524003713/vq5005sup2.hkl

Supporting Information - revised - highlighted. DOI: https://doi.org/10.1107/S2052252524003713/vq5005sup3.pdf

Acknowledgements

The authors thank Karen Leus for the XPS measurements and Dieter Buyst for the solid-state NMR measurements.

Funding information

LB acknowledges Ghent University (UGent) for funding. PVDV acknowledges financial support through UGent concerted action (grant No. 01G01017) and the Fonds Wetenschappelijk Onderzoek (FWO)–Vlaanderen project (grant Nos. 3G020521 awarded to PVDV; 1275221N awarded to SB and KVH). Gas sorption and powder X-ray diffraction were made possible through UGent (grant Nos. 01B00215; BOF20/BAS/015 awarded to PVDV). The spectrometer electronics, magnet and accessories used for solid-state NMR measurements, including the BBI and high-gradient diffusion probe, were funded by the Hercules foundation (grant No. AUGE/09/2006); the solid-state (CP-MAS) and HR-MAS expansion were made possible by FWO (grant No. I006920N).

This is an open-access article distributed under the terms of the Creative Commons Attribution (CC-BY) Licence , which permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are cited.

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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Main Article Content

There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole . Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus. [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

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[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research.  The New England journal of medicine ,  351 (3), 207–209. https://doi.org/10.1056/NEJMp048145 ; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos . The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos ; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy , 38 (2/3), 264–284. http://www.jstor.org/stable/24439776 ; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells.  The New England journal of medicine ,  351 (3), 209–211. https://doi.org/10.1056/NEJMp048147 ; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality.  Bosnian journal of basic medical sciences ,  4 (1), 5–14. https://doi.org/10.17305/bjbms.2004.3453

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[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa.  Stem Cell Res Ther   4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction.  Frontiers in pharmacology ,  13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

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[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan.  Curr Stem Cell Rep   1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned.  Accountability in research ,  13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

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Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

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Characterizing Community Forests in the United States

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Current affiliation: University of North Carolina Wilmington, Environmental Science, Wilmington, NC, USA

Current affiliation: US Department of the Interior, Office of Collaborative Action and Dispute Resolution Washington, DC, USA

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Reem Hajjar, Kathleen McGinley, Susan Charnley, Gregory E Frey, Meredith Hovis, Frederick W Cubbage, John Schelhas, Kailey Kornhauser, Characterizing Community Forests in the United States, Journal of Forestry , Volume 122, Issue 3, May 2024, Pages 273–284, https://doi.org/10.1093/jofore/fvad054

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Research on community forests (CFs), primarily governed and managed by local forest users in the United States, is limited, despite their growth in numbers over the past decade. We conducted a survey to inventory CFs in the United States and better understand their ownership and governance structures, management objectives, benefits, and financing. The ninety-eight CFs in our inventory are on private, public, and tribal lands. They had various ways of soliciting input from, or sharing decision-making authority with, local groups, organizations, and citizens. Recreation and environmental services were the most important management goals, but timber production occurred on more than two-thirds of CFs, contributing to income on many CFs, along with a diversity of other income sources to fund operations. We discuss the difficulties in creating a comprehensive CF inventory and typology given the diversity of models that exist, reflecting local social and environmental conditions and the bottom-up nature of community forestry in the United States.

Study Implications: Despite their small footprint in the United States, community forests are a rapidly developing model of forest ownership, governance, and management that helps protect forestlands and open space and demonstrates how market and nonmarket forest goods and services can be produced for broad and enduring community benefits. This study inventories and characterizes community forests in the United States to increase understanding of this model, its prevalence, and its potential. It provides a baseline of information that serves as a foundation for further exploration and research on the impacts and contributions of community forests.

Over the past few decades, many countries have increasingly promoted community forests (CFs) as a way to conserve forests, enhance rural livelihoods, and recognize the traditional and customary rights of local forest users to access, use, and manage forests ( Hajjar et al. 2021 ; Lund et al. 2018 ). CFs are delineated forest areas where community members have access to natural resources, are engaged in their governance, and receive indirect and direct benefits from their management ( Charnley and Poe 2007 ; McDermott and Schreckenberg 2009 ). Although CFs have existed in many forms across the globe for centuries, these more recent efforts are typically formal, government-sanctioned, and often government-sponsored. A total 14% of the world’s forests, and 28% of forests in low- and middle-income countries, are currently owned or managed by Indigenous peoples and local communities ( Rights and Resources Initiative 2018 ). Internationally, CF initiatives span a broad range of tenure regimes, institutional arrangements, relationships between communities and higher levels of government, activities, and outcomes that have evolved in line with local contexts, conditions, needs, and goals ( Charnley and Poe 2007 ; Hajjar and Molnar 2016 ).

In the United States, CFs have also existed in diverse forms for centuries ( Baker and Kusel 2003 ; McCullough 1995 ), although as elsewhere, formally designated community forests have been increasing in number since the 1990s. This relatively recent trend is likely driven by several factors. First, vertically integrated forest products companies nationwide have been divesting of their industrial timberlands since the late 1980s for economic reasons ( Zhang 2021 ), causing a large-scale shift in timberland ownership from industrial to institutional investors ( Zhang 2021 ). To prevent residential development, maintain access to local forests, conserve forest resources, and keep working forests working to provide economic opportunities for local residents, initiatives to acquire industrial timberland and manage it as CFs have proliferated ( Belsky 2008 ). Second, private family forest owners are aging; the average age of the primary decision-maker over family forestlands is 65 and, for about 20% of these ownerships, 75 or older ( Butler et al. 2021 ). Keeping their family forestland intact for future generations is a top concern for family forest owners ( Butler et al. 2021 ). If their descendants are uninterested or unable to keep this land in the family, community groups or municipalities may wish to acquire it as a CF to prevent its subdivision and fragmentation and provide community benefits.

Third, Indigenous peoples in the United States have regained greater control over ancestral lands, including forestlands, both on and off tribal trust lands over the past several decades ( McGinley et al. 2022 ). Some tribes have acquired forestland through fee simple purchase, including with funding designated for CF creation, and established CFs on those lands ( McGinley et al. 2022 ). Fourth, the 1990s saw a dramatic increase in citizen participation in decision-making about the management of public forestlands ( Baker and Kusel 2003 ; Charnley and Poe 2007 ). This trend has persisted, with community-based organizations, community members, forest collaborative groups, and other stakeholders playing a greater role in management decision-making and collaborative forest stewardship on federal lands ( Davis et al. 2020 ). In some cases, these arrangements may exhibit the characteristics of a CF.

Simultaneously, several programs providing funding for land acquisition to create CFs have arisen in the past two decades ( McGinley et al. 2022 ). Access to funding along with the emergence of supportive policies, organizations providing technical assistance, and practitioner networks have fostered a more favorable environment for CF creation since the 2000s ( Frey et al. forthcoming ). These trends have played out somewhat differently in different locations, but together they have contributed to a nationwide rise in CFs in the United States.

Unlike many other countries around the world with communal property systems, CFs in the United States do not exist as a distinct land tenure or ownership class. CFs have been established on a variety of public, private, and tribal lands and have diverse land tenure arrangements ( McGinley et al. 2022 ). Furthermore, there is no universally accepted definition of a CF in the United States ( Frey et al. forthcoming ). These two facts make studying CFs in the United States, as a distinct form of forest tenure, management, and governance, challenging. Literature on US CFs, most of it published since the 1990s, has primarily been descriptive in nature, relying on limited numbers of case studies to elaborate on the various motivations for creating CFs and the institutional and political context that pushed them forward ( Belsky 2015 ; McCarthy 2006 ); development of mechanisms and institutional arrangements for governance ( Abrams 2023 ; Abrams et al. 2015 ; Belsky and Barton 2018 ); and their potential benefits ( Christoffersen et al. 2008 ; Lyman et al. 2014 ). Belsky (2008) proposed a typology of CFs defined by who owns the CF—Indigenous groups, towns or municipalities, or community-based conservation organizations. A key message of the scientific literature is that a vast diversity of CFs exists in the United States, reflecting the diverse social, economic, and ecological contexts in which they occur.

To our knowledge, no prior research has attempted to document or characterize the full suite of CFs in the United States. Thus, the goals of this paper are to (1) identify, inventory, and characterize CFs in the United States; (2) enhance understanding of their ownership and governance structures, management objectives, and sources of income; (3) extend the discussion of the variability in forms of CFs and build on previous work to refine a CF typology; and (4) problematize how we recognize CFs in the United States (i.e., what is included, what is not, and why).

Defining CFs 1

A common but broad premise of CFs internationally is that place-based communities have some role in determining how local forests are to be managed for community benefit ( Hajjar et al. 2021 ). In the United States, communities associated with CFs are frequently not only place-based but also communities of interest and practice or some combination of these ( McGinley et al. 2022 ), complicating the notion of “community” and “local” (see Brosius et al. [2005 ] for a discussion). For purposes of deciding what to include in this study, we considered the following attributes of CFs, which are prevalent in the literature on US CFs (see Frey et al. forthcoming ): (1) ownership or tenure by a local governmental or nongovernmental organization (NGO) on behalf of the community; (2) communities are substantively involved in forest management and governance; (3) communities have secure rights to access and benefit from the forest; (4) social and economic benefits for local communities are a management priority; and (5) forest conservation values are permanently protected.

Creating a CF Inventory

To catalogue and characterize CFs in the United States, we first undertook an inventory of existing CFs, aiming to be as comprehensive as possible. Given the lack of a consistent definition or model of CFs, we used a hybrid approach to identify them ( Frey et al. forthcoming ). This meant first searching for entities that self-identify their property or initiative as a CF and for those that have participated in programs or policies related to CFs. Then we overlaid a series of inclusion criteria based on the attributes of CFs outlined above. Therefore, to be included in our study, local communities had to have rights of access and use and some form of management responsibility or decision-making authority (beyond consultation) over local forests. Additionally, these forests were managed to promote ecological sustainability and contribute to conservation while creating tangible local community benefits as a management priority.

We began by compiling a list of CFs and related information from a US Endowment for Forestry and Communities study ( Christoffersen et al. 2008 ) and a previous exploratory project ( Hovis et al. 2022 ). We then added to this list, drawing from CF lists provided by organizations that work with and support them, such as the Ford Foundation, the Northwest Community Forest Coalition, the Northern Forest Center, the Trust for Public Lands, the Open Space Institute, and the USDA Forest Service (Forest Service) Community Forest and Open Space Conservation Program. We also used Google Search Engine to identify any additional CFs not already included in our list. Search terms included: state name AND community forest OR community managed forest OR community-based forest OR town forest. We further consulted with various professionals in our networks involved with CFs (e.g., via the Northwest Community Forest Coalition annual meeting) to ensure the comprehensiveness of our list. Finally, we consulted with two project advisory committees that we set up at the start of the funded project under which this research was undertaken: one, a research advisory committee consisting of CF professionals across select government agencies, CF coalitions, and networks; the other, a tribal forestry advisory committee consisting of representatives of tribes with CFs and tribal natural resources networks.

We also used Google Search Engine to record any information on the identified CFs, usually landing on the websites of CF owners or their supporters. This information typically included the group name, forest location, acreage, landowner, governance, management objectives, history, URL, and contact information. Searches and consultations took place between 2019 and 2023, with more CFs identified and added continually as we heard of cases that were missed in our searches or that were being newly created. We examine the limitations of this approach in the Discussion section.

We initially located 136 possible CFs in the United States using these methods. Of these, thirty-two clearly did not meet our criteria, and we were unable to find additional information or contacts for eleven. To the remaining ninety-three CFs that met our inclusion criteria and for which we had contact information, we sent an internet-based survey using Qualtrics. We requested that a CF manager or other person familiar with the CF fill out the survey. The survey included questions about the CF, such as size, forest type, ownership, decision-making, who is involved in day-to-day management, management priorities, rules of access and use, and financing. Although most survey questions were designed to capture objective characteristics of the CF (i.e., size, ownership, etc.), we acknowledge that answers to a question asking about “management priorities” may not reflect the diversity of priorities a community may have for its forests. Rather, we expected that a CF manager responding to the survey would choose priorities that were being explicitly managed for, consistent with their management plan or mission statement.

To increase response rates ( Dillman et al. 2014 ), we followed up by sending reminder emails after 2 and 4 weeks and then through phone calls where phone numbers were available. Following this, for all nonresponses or cases where contact information could not be located, we filled out the survey ourselves to the extent possible using CF websites and other available resources. Not all survey questions had responses readily available from website sources, and so these surveys were not as complete. This resulted in some topic areas having smaller sample sizes, as displayed in the Results section. We also followed this protocol for newly identified CFs throughout the time period of the research (either newly created CFs or CFs discovered through our networks that met our criteria), for a combined total of ninety-eight CFs recorded up to April 2023. Survey responses were tabulated in SPSS, where descriptive statistics (frequencies and crosstabs) were used to show patterns across various CF characteristics.

We refer to three regions in discussing our results based on the Forest Service Resources Planning Act Assessment (RPA) regions: the West, combining the Pacific Coast and Rocky Mountain RPA regions, including CFs in Montana, Idaho, Washington, Oregon, California, and Arizona; the North, which includes CFs found in Maine, Vermont, New Hampshire, Massachusetts, New York, Connecticut, Michigan, and Wisconsin; and the South, which includes CFs in Georgia, North and South Carolina, Virginia, and Puerto Rico.

We collected data on ninety-eight CFs across the United States, constituting the sample used for this study ( SI Table 1 ). The survey response rate was 87% (eighty-five of ninety-eight); for the remaining thirteen survey nonresponses, we gathered information from internet sources. We expect the number of CFs to continue to grow in the coming years: after closing the survey in April 2023, we learned of at least four additional initiatives that were close to acquiring CF lands and nine that were seeking funds to purchase CF land. We believe that ninety-eight is close to the current total number of self-identifying CFs in the United States but acknowledge that it is likely an undercount of actual CFs that meet our inclusion criteria. We discuss the difficulties in accurately capturing all US CFs in the Discussion section. Rather than thinking of our sample as a complete inventory of all US CFs, we consider it sufficient for characterizing different types of CFs in the United States.

Location, Year Established, and Size

The greatest number of CFs per state were found in West Coast states ( figure 1 ; Washington, fourteen CFs; Oregon, twelve; California, nine); northeastern states (Maine, twelve CFs; Vermont, nine; New Hampshire, eight); and the upper midwestern states of Michigan and Wisconsin (five each). Fewer were located in southern states, with a handful spread across Georgia, North and South Carolina, and Virginia. The earliest recorded CFs in our sample were created in the 1930s and 1940s ( figure 2 ), mostly city and county forests in the northwestern United States (Montesano Community Forest, Hood River County Forest, Ashland Forestlands, Arcata Community Forest), and two town forests that self-describe as CFs in the Northeast (Gorham Town Forest, Mendon Town Forest). Most CFs in our sample were created after 2010 when there was a sharp increase in the number of CFs in all regions. This time period corresponded with new legislative support for CFs in some states (e.g., Washington State’s 2011 Community Forest Trust legislation) and at the federal level (e.g., the Forest Service's 2011 Community Forest Program), which have helped tribes, local governments, and nonprofit organizations acquire land at risk of development to establish CFs.

Location of CFs in our database. In this article, we refer to three regions in discussing our results: the West, which includes CFs found in Montana, Idaho, Washington, Oregon, California, and Arizona; the North, which includes Maine, Vermont, New Hampshire, Massachusetts, New York, Connecticut, Michigan, and Wisconsin; and the South, which includes Georgia, North and South Carolina, Virginia, and Puerto Rico.

Location of CFs in our database. In this article, we refer to three regions in discussing our results: the West, which includes CFs found in Montana, Idaho, Washington, Oregon, California, and Arizona; the North, which includes Maine, Vermont, New Hampshire, Massachusetts, New York, Connecticut, Michigan, and Wisconsin; and the South, which includes Georgia, North and South Carolina, Virginia, and Puerto Rico.

Number of CFs in the United States since 1930.

Number of CFs in the United States since 1930.

The total area covered by CFs in our inventory is 436,411 acres (ac). Of this total, 87% of CFs were smaller than 5,000 ac ( figure 3 ), and 63% were less than 1,000 ac. By region, median sizes of CFs were: 1,360 ac in the West, 375 ac in the North, and 334 ac in the South. Nine CFs in the West were 5,000 ac or larger, compared to four in the North and none in the South. The majority of CFs less than 1,000 ac (thirty-nine of sixty-one CFs) were located in the North, with over half of those being between 100 and 500 ac (twenty-five of thirty-nine CFs). A total of 76% of reporting CFs said their forests were located on one contiguous parcel and 24% were on multiple unconnected parcels (varying from two to seventeen parcels).

Acreage of CFs across regions.

Acreage of CFs across regions.

Ownership, Decision-Making Authority, and Management

As indicated in figure 4 , CFs in our sample were primarily owned by either a local government body (town, city, or county government) or by an NGO (e.g., a community-based organization, land trust, or other nonprofit). In the West, CFs were mostly purchased from private corporate owners (industrial timber companies, timber investment management organizations [TIMOs], or real estate investment trusts). In the North, CF lands were mostly acquired from private family forest owners. Ownership types included CFs of various sizes, although CFs larger than 1,000 ac tended to be held by a government body, whereas the majority of NGO-held CFs were smaller than 1,000 ac ( SI Table 2 ).

Ownership of CFs: (a) current landowner of forestlands designated as CFs and (b) previous landowners from whom the current landowner acquired the CF land. “Joint ownership” in (a) were parcels jointly owned by a local government body and a land trust (n = 3), a private utilities firm (n = 1), or a university (n = 1); a tribe and a conservancy (n = 1); and a land trust and private equity firm (n = 1). “Other” in (b) were parcels that were pieced together from multiple ownerships.

Ownership of CFs: (a) current landowner of forestlands designated as CFs and (b) previous landowners from whom the current landowner acquired the CF land. “Joint ownership” in (a) were parcels jointly owned by a local government body and a land trust ( n  = 3), a private utilities firm ( n  = 1), or a university ( n  = 1); a tribe and a conservancy ( n  = 1); and a land trust and private equity firm ( n  = 1). “Other” in (b) were parcels that were pieced together from multiple ownerships.

Land ownership largely corresponded with the entity with ultimate decision-making authority over management, access, and use of the CF ( SI Figure 1 ). Government agencies largely had authority over government-owned CFs, tribes over tribally owned CFs, and NGOs over the land they owned. These entities had various ways of soliciting input from, or sharing decision-making authority with, local groups, organizations, and citizens. In some cases, this was institutionalized through formal joint decision-making processes. For example, there were eleven cases of local government ownership (town, city, or county-owned forests) where decision-making authority was jointly held by both that government body and formal citizen councils or committees established for this purpose. In other cases, although respondents did not describe decision-making as “joint,” they involved community members through mechanisms such as advisory committees and boards made up of local citizens, formal community and public consultation processes (mostly for city or town government ownerships), or various events, regular meetings, and other formal and informal mechanisms that sought community input (mostly for NGO ownerships). Local groups and volunteers contributed to day-to-day management of CFs across most ownerships ( SI Figure 2 ). In particular, various recreation-related volunteer groups helped to maintain trail systems. Otherwise, in many cases, forest consultants or forestry professionals from government agencies or NGOs contributed to forest planning and stewardship.

Management Goals and Allowed Activities

Survey respondents were asked to select the top four goals, from a list of options, that the CF was managed for ( figure 5 ). Across the country, the vast majority of CFs stated that recreation was a top management goal (82% of ninety-five reporting CFs). Collectively, conservation-oriented goals (watershed, habitat or open space protection, biodiversity conservation and restoration, and carbon sequestration, totaling 98% of reporting CFs), as well as other nonextractive goals (education, recreation, and cultural heritage protection, totaling 93% of reporting CFs) were much more prominent than extraction-oriented goals (timber production, nontimber forest products (NTFPs) management, agroforestry, and livestock grazing, totaling 47% of reporting CFs). However, timber production was among the top four management goals reported across the sample as a whole.

Primary management goals. Respondents were asked to list top four management goals for their CF.

Primary management goals. Respondents were asked to list top four management goals for their CF.

There were few strong patterns between ownership type and management goals ( SI Table 3 ). Recreation was listed as one of the top management goals in over 75% of cases across CF ownership types, except for tribal (two of five CFs) and private corporate (one of two) owned CFs. All but two CFs owned by local governments listed a conservation-oriented goal. Half of local government-owned (twenty-two of forty-four CFs) and half of NGO-owned CFs (fifteen of thirty-two CFs) listed an extractive-oriented goal. Of the five tribal-owned CFs in our sample, only one listed an extractive-oriented goal (agroforestry) as a primary management goal and only one indicated that timber was produced but not as a primary goal. Local government and NGO-owned CFs reported slightly more often that producing timber was a primary goal (government: nineteen CFs listed it as a primary goal, twelve as a nonprimary goal, and twelve do not produce timber; NGO: thirteen, ten, and six, respectively).

Although timber production occurred on 70% of reporting CFs (sixty-five of ninety-three reporting CFs; figure 6A ), in almost half of those cases (twenty-eight of sixty-five cases) timber production was not one of the top four primary management goals of the CF. Geographically, no CFs in the southern region produced timber as a primary goal. In the North, slightly more CFs produced timber as a primary goal than not as a primary goal (twenty versus sixteen CFs), with only nine reporting no timber production. In the West, seventeen CFs reported producing timber as a primary goal, with ten producing but not primary and ten not producing. Timber production occurred across all acreages ( figure 6B ), including on almost two-thirds of the smallest CFs in our study (<1,000 ac) and on all CFs larger than 5,000 ac (although not always as a primary goal). Similarly, timber production occurred across all ownership types ( figure 6C ), whether as a primary goal or not. Of those engaged in timber production, a private consulting forester was used to oversee timber sales in 43% of fifty-one reporting cases, and internal staff from the CF owner in 26% of cases. Across ownerships, the entity that did the logging was most often a private contracting company (70% of fifty reporting cases). These entities were located at a place within 25 miles of the CF in 52% of forty-two reporting cases, or 26–50 miles in 33% of cases.

Status of timber production across CFs (a) by region, (b) CF size, and (c) ownership type.

Status of timber production across CFs (a) by region, (b) CF size, and (c) ownership type.

Community forests had a variety of rules related to which activities were allowed and whether permits from CF owners were needed if allowed ( SI Figure 3 ). Motorized recreation, camping, and commercial uses of firewood or NTFPs were only allowed in a handful of CFs, often with the requirement of a free or paid permit. Hunting and fishing, in accordance with state regulations, were allowed in more than half of the reporting cases (69% of sixty-five reporting cases and 78% of sixty reporting cases, respectively) and rarely required a permit from CF owners. Personal use of firewood and other NTFPs were allowed in 22% and 40% of sixty-three reporting cases, respectively, although firewood use often required a permit. Altogether, 85% of sixty-six reporting cases allowed some nontimber extractive activities for personal use (either firewood, other NTFPs, hunting, or fishing). Only one CF did not allow recreation and four allowed it only with a free permit. In almost all cases, the same rules applied to the local community as to the general public, except for a few instances where NTFP and firewood use were limited to local community members.

Income Generation and Budgetary Support

A number of CFs across ownerships generated revenue from forest products and services (80% of forty-nine reporting CFs), mostly from timber sales ( figure 7 ; SI Table 4 ), although two-thirds of those reporting revenue generation stated that timber contributed to less than 30% of their budget. The few instances of revenue from hunting leases and payments for ecosystem services (mainly carbon offsets) were mostly reported in CFs owned by private nonprofits, whereas grazing permits or agriculture revenue were only reported in three state or local government-owned CFs ( SI Table 4 ). Timber revenue was reported across all ownerships where timber harvest occurred, except for the two cases of state government ownership, where it is anticipated in the future, once the forest regains commercial value following harvest by the previous owner.

Main sources of revenue generated from forest activities in 48 reporting CFs by region.

Main sources of revenue generated from forest activities in 48 reporting CFs by region.

Grants from federal or state governments were the most frequently cited sources of annual budgetary support from 2018 to 2020, the period we asked about (70% of fifty-three reporting CFs; figure 8 ; SI Figure 4 ), although almost two-thirds of those CFs stated that grants contributed to less than 30% of their budget. Unsurprisingly, government-owned CFs more often reported (federal, state, or local) government sources for budgetary support. Local government-owned CFs were more reliant on local government funds: 71% of twenty-four reporting local government CFs stated they received funding from local governments (50% of them stating that they received more than 60% of their budget from this source), with only a handful of nongovernment owned CFs reporting support from this source. The NGO-owned CFs reported relying on donations from local community members and fundraiser events much more often than government-owned CFs (in three cases, community donations made up more than 60% of the budget). We did not track sources of funds used for acquiring forestlands in our survey.

Sources of budgetary support 2018–2020 by ownership type. Public ownership includes federal, state, and local governments, and private ownership includes both corporate and nonprofits. Polygons indicate largest differences between private and public ownerships.

Sources of budgetary support 2018–2020 by ownership type. Public ownership includes federal, state, and local governments, and private ownership includes both corporate and nonprofits. Polygons indicate largest differences between private and public ownerships.

As the results indicate, there are a variety of ownership and governance forms that CFs currently take in the United States, a variety of benefits that they provide, and a diversity of income sources that they rely on. As stated above, one goal of this study was to discuss the variability in CFs and develop a robust typology of them. Although Belsky (2008) proposed a CF typology based on ownership types, given the diversity of CFs we encountered in our survey (including within ownership types), we intended to develop a typology based on key characteristics, including ownership, decision-making, operational management, goals, size, and income sources. Two-step cluster analyses and Pearson’s χ 2 tests were performed to assess whether the CFs in our dataset could be empirically grouped according to various combinations of these characteristics. However, limited patterns emerged for creating definitive statistical typologies. Instead, we discuss here some emergent qualitative patterns based on the descriptive statistics reported in the Results section, reflect on the diversity of CFs in the United States, and propose a basic typology for practical purposes. Finally, we discuss the difficulties in creating a comprehensive CF inventory for the United States, given this diversity.

Ownership type emerged as a factor that seemed to shape some key functions of a CF—specifically, decision-making authority and sources of budgetary support. Publicly owned CFs (mostly by local city or town government) more often reported having either a government entity as ultimate decision-making authority or joint authority between local government and citizen councils or other local groups. They were also more reliant on government funding for budgetary support, either through federal or state grants, local government funds, or combinations of these. Privately owned CFs (mostly community-based organizations and local land trusts) more often reported having those same owners make decisions about the CF and less often reported that they formally engage in joint decision-making (although it is difficult to ascertain actual community participation in governance with our survey research design). They also more often reported relying on community donations and fundraiser events than local government funds. All five tribally owned CFs in our dataset were run by tribes themselves, including decision-making authority and operational management. Besides these basic characteristics, however, ownership type seems to have little influence on the size of CFs, management goals, allowed activities, timber production (equally present in public and private CFs), or earned income sources.

We saw moderate regional differences in ownership and size (more government ownership and larger sizes in the West), and who the CF owner bought their forestland from. Ownership history may help explain why the median size of CFs in the West was considerably larger than in the North. The majority of CF lands in the West were purchased from private corporate forest owners, whose holdings are often in the hundreds of thousands of acres ( Sass et al. 2021 ), and from TIMOs in particular, which typically sell land every 10 to 15 years ( Zhang 2021 ). In contrast, the majority of CF lands in the North were purchased from family forest owners; approximately 90% of these ownerships in the United States are under 50 ac ( Butler et al. 2021 ). Yet CFs larger than 5,000 ac occur in both the North and the West.

In both these regions, timber production often occurred across CFs of all sizes and was a primary management goal in roughly equal frequency, although not in our small sample of southern CFs. Timber production was not limited to any particular ownership type, or size class, of CF; rather, the potential to harvest timber as a management goal and source of revenue generation is likely influenced by the nature of the forest assets contained in a particular CF. Those with productive timberlands are presumably more likely than those lacking them to have timber production as a primary management goal. However, it may take years for this goal to be realized if the former owner recently harvested a substantial amount of commercial timber. All CFs across regions emphasized conservation goals, but forest restoration (phrased in the survey as “forest restoration, including wildfire management”) was cited more often in the West. Almost all CFs allowed public access for recreation and many for nontimber extractive activities for personal use. It is likely that some CFs regulate access more than others, but we could not capture this variation in our survey.

The difficulty in creating a typology of CFs is unsurprising given that, by definition, CFs reflect the values and priorities of the communities in which they are situated. Other historical, social, economic, and environmental factors also likely influence their characteristics. Additionally, policies and programs that provide funding opportunities to support CFs and their operations vary by state, influencing their sources of budgetary support. Investigating underlying factors that lead to the diversity in CF models and characteristics is a rich area for further research.

The second phase of our research (a larger project than reported here, aiming to better understand how CFs contribute to conservation and rural prosperity in the United States) uses a case-study sampling approach based on two characteristics that we postulated would be important distinguishing features of a typology: ownership of the CF and whether timber production is a primary management goal of the CF ( Table 1 ). We acknowledge that our survey results do not show that these two characteristics are statistically related to many other factors examined here but reasoned that ownership can influence CF governance and financing mechanisms, and that the role (or lack thereof) of timber production reflects the CF’s management goals, forest resources, financing mechanisms, and benefit streams. We recognize that CFs produce a host of benefits for communities beyond timber production. However, whether a CF prioritizes timber, harvests timber but does not prioritize it, or does not harvest timber emerged as an effective way to distinguish groups of CFs from each other in terms of their management priorities and resulting benefit streams. Otherwise, most CFs shared recreation and conservation-related goals.

A basic typology based on ownership and whether timber is a primary management goal of the CF. Percentages (in parentheses) reflect percentage of eighty-two CFs in our inventory that reported on timber status and ownership.

The diversity of CFs in the United States also reflects the grassroots nature of community forests across the country, making them somewhat unique relative to community forests globally. In many low- and middle-income countries, community forests are forests managed using a top-down model imposed and defined by national CF policies or land reforms and extensive financial and technical support from external donor organizations (e.g., national or international NGOs, multilateral/bilateral aid agencies), with communities receiving some rights and many responsibilities for forest management ( Charnley 2023 ; Hajjar et al. 2021 ; Ribot et al. 2006 ). In contrast, in the United States, CF establishment is typically driven from the bottom up, in most cases through local governments, locally based NGOs, or groups of citizens that come together to protect their local forests. There is no distinct CF tenure category at the national level and few national or state-level policies associated with community forests in the United States. Exceptions include Washington and New York states, where there are legislatively approved funding sources 2 to support CF acquisition and associated policy requirements once established, and the national-level Forest Service Community Forest and Open Space Conservation Program, which has supported the acquisition of numerous CFs in our inventory. This more grassroots approach results in a broad range of ownership, management, governance types, and rights and responsibilities among community members relative to many other countries. It also makes CFs somewhat hard to pinpoint in the United States, posing challenges for efforts to inventory them.

Stemming from this diversity in CFs, a key difficulty we faced in undertaking this inventory was determining what to include. Our approach to including CFs that self-identify as such or had participated in a program or policy related to CFs and met our criteria was naturally limiting. Although this approach was necessary to make an inventory possible, we acknowledge that many more CFs potentially exist than we included here, depending on how a CF is defined. In particular, our inventory captured many town forests and land trust forestlands, some tribal forests, and some state and federal forests. Yet these general ownership categories need further examination.

Town forests are local government-owned forests common across much of New England and the Northeast and in many cases may be considered CFs. They have long been established to generate income from timber and other resources for town budgets or specific projects and public services, to protect water, soil, and wildlife habitat, and to provide recreation and education opportunities for local community members and others ( Baker and Kusel 2003 ; Brown 1941 ; Hovis et al. 2022 ; McCullough 1995 ). The local ownership, management, and benefits of many town forests fulfill most of the criteria of CFs as laid out above. However, the acquisition and designation of a town forest does not guarantee its long-term protection from sale or development, and depending on how much the community participates in governance, it may or may not fulfil the governance criterion of CFs ( McGinley et al. 2022 ).

Similarly, many land trusts own forestlands that could be considered CFs, depending on how these forests are governed and managed, potentially increasing the number and extent of CFs in the United States. However, land trusts may not provide access for local communities or the general public to their forested land, may not provide for local community participation in decision-making, or may not manage their forests specifically for local benefits.

The extent to which tribal forests should be considered CFs is also complicated. Most tribal lands are trust lands, with about 56 million acres of land held in trust for tribes by the federal government (2.3% of US land area; DOI 2023 ). Although these lands are managed for the benefit of individual tribes, forest management activities take place under the direction of forest management and integrated resource management plans developed under the federal Bureau of Indian Affairs (BIA) guidelines and are subject to BIA approval. Since the passage of the Indian Self-Determination and Education Assistance Act of 1975 (Public Law 93-638), an increasing number of tribes have established contracts, known as 638 contracts, with the BIA by which tribal government forestry departments assume management responsibilities for forests on trust lands. These contracts are initiated by a formal request by a tribe to the BIA. By 2011, 112 tribes had taken advantage of these self-determination/self-governance opportunities for forest management, compared to 187 that relied on BIA to manage their lands directly ( Gordon et al. 2013 ). Given this complexity in governance, it is unclear to what extent the trust lands of individual tribes meet the criteria of CFs; such classification should be undertaken by tribes themselves. Tribes can also purchase and own fee lands to which they hold title. The five tribally owned CFs in our sample (they self-identify as such) were purchased this way from private landowners. Further research on tribal forests could explore the variations in ownership, benefits, and management of these forests on trust and fee lands.

Our inventory includes two CFs owned by Washington State and one that occurs on federal lands in California. These cases may appear to contradict our defining attributes of a CF, namely that they have local, long-term ownership or tenure, and that communities have significant decision-making authority. We included the state and federal CFs in our inventory primarily because they self-identified as CFs. However, they also display several attributes of a CF. The two state-owned CFs were acquired through Washington’s 2011 Community Forest Trust Program ( WA DNR, n.d. ). The legislation that created the program stipulated that CFs acquired with program funds (from state budget appropriations) be state-owned, and that state agencies have ultimate decision-making authority. But the legislation also stipulated that state-owned CFs have an advisory committee composed of roughly twenty members representing diverse stakeholder interests to inform those decisions and co-develop forest management plans with citizen input, and that CF management objectives should reflect the values of local communities ( WA Legislature 2011 ).

Regarding the federally owned case, Weaverville CF, the community manages the CF through a 10-year renewable cooperative stewardship agreement between the Forest Service and Bureau of Land Management (who own and administer different parts of the CF), and the local county resource conservation district (RCD) ( Frost 2014 ; Kelly 2018 ). The RCD is responsible for implementing forest management activities and is governed by a board of directors that oversees CF management, with input from a steering committee composed of ten to fifteen members, including local citizens and agency and RCD staff. Local residents have opportunities to provide input at community meetings that occur once or twice annually. The CF is managed to meet local community needs and priorities, such as wildfire risk reduction, habitat improvement for fish and wildlife, and recreation ( Frost 2014 ; Kelly 2018 ).

The question of whether CFs in the United States that self-identify as such should be considered CFs if they occur on land that is state- or federally owned—with the government retaining ultimate decision-making authority—deserves more attention and is a matter of debate among some practitioners and scholars (see Frey et al. forthcoming ). The international literature recognizes CFs that occur on national government-owned land where communities have concessions to manage the forests for a specified time period (e.g., several CFs in Canada [ Teitelbaum et al. 2006 ], Cameroon [ Piabuo et al. 2018 ], Guatemala [ Taylor 2010 ]); and CFs on national government land that are comanaged by the state and local communities (e.g., Tanzania; Blomley and Ramadhani, 2006 ). This highlights the importance of taking into account the governance criterion in defining CFs in the United States—the level of community involvement in decision-making—just as with town forests and land trusts, and opens the door for potential additional CFs on public lands that might fit the criteria but were not captured here.

The CFs we identified comprise less than 0.1% of all forests in the United States but are a rapidly developing model of forest ownership, governance, and management that provides local community benefits. They take a creative approach to funding and managing local forestlands through public, NGO, or tribal structures, generated income sources, and grant and donor fundraising. They have continued long-standing town and tribal forest ownership and management, helped protect forestlands and open space from imminent development, and offered innovative ways to form explicit community partnerships to manage existing public and private landscapes. As they solidify income sources and management capability, they also might serve as a new model of how market and nonmarket goods and services can be produced on forestlands for broad and enduring community benefits.

We have likely not included all individual CFs in the United States in this study and may have significant undercounts of certain types of CFs. Potential undercounts stem largely from ambiguity over which town, tribal, and private (e.g., land trust-held) forests meet our CF definition and criteria and lingering questions over whether CFs exist on federal lands. Nevertheless, the inventory will increase continually as communities develop proposals for CFs and obtain acquisition funding each year and new research is carried out. To help address this research limitation, we plan to create a centralized, publicly accessible repository that can serve as a living inventory to be updated as more CFs are either acknowledged as such or created. Although incomplete, our current inventory captures a fair representation of the variety of CF models in the United States, reflecting a diversity of ownerships, governance structures, management goals, benefit streams, and more.

This initial research to inventory and describe US CFs provides a sound base for further exploration. Future research could further explore levels of local participation in forest management and governance and when and how these variables would qualify a forest as a CF on public, private, or tribal lands. More in-depth research could also help refine our CF typology to include characteristics hard to ascertain from a survey instrument, such as level of community involvement or capacity and organizational development stage (e.g., incipient or mature). Furthermore, as more NGO-owned and town-owned forests self-identify with the label “community forest,” the consequences, advantages, and disadvantages of using that label will need further examination.

Future research could also compare CF models with traditional (noncommunity based) private and public forest ownerships to highlight their relative differences, advantages, and disadvantages. For example, some CF models share similarities but also have important differences with private family forest ownerships in terms of priority management objectives and timber production ( Butler et al. 2021 ; Shanafelt et al. 2023 ), warranting a systematic comparison of ownership types. Finally, we began this exercise of inventorying CFs in the United States to better understand their contributions to conservation and rural prosperity. Better understanding the ability of communities to capture CF monetary and nonmonetary benefits (and to do so equitably) can help inform the design of policies, programs, and actions to best support CFs.

Supplementary data are available at Journal of Forestry online.

This study was funded in part by the USDA National Institute of Food and Agriculture, Agriculture and Food Research Initiative (AFRI) Award number 2021-67023-34426. Partial funding was also provided by the USDA Forest Service’s Southern Research Station, Pacific Northwest Research Station, and International Institute of Tropical Forestry as well as Oregon State University and North Carolina State University.

The authors are developing a publicly accessible repository of community forests. In the meantime, the data used in this study will be made available upon reasonable request.

Abrams , Jesse. 2023 . Forest Policy and Governance in the United States . New York, NY : Routledge .

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Zhang , Daowei. 2021 . From Backwoods to Boardrooms: The Rise of Institutional Investment in Timberland . Corvallis, OR : Oregon State University Press .

Community forests, community forestry, and community-based forestry are terms that are often used interchangeably in the U.S. literature; however, see Frey et al. (forthcoming) and Belsky (2008) for a discussion of important differences.

The Washington State Community Forests Program was established by the state legislature in 2019 to provide grant funding for CF acquisition ( https://rco.wa.gov/grant/community-forests-program/ ). The New York Community Forest Conservation Grant program similarly funds municipal land acquisitions for community forests ( https://www.dec.ny.gov/lands/124345.html#:~:text=and%20contact%20information-,Program%20Overview,Leadership%20and%20Community%20Protection%20Act ).

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    Present the results of the paper, in logical order, using tables and graphs as necessary. Explain the results and show how they help to answer the research questions posed in the Introduction. Evidence does not explain itself; the results must be presented and then explained. Avoid: presenting results that are never discussed; presenting ...

  15. How to Write a Discussion Section for a Research Paper

    Begin the Discussion section by restating your statement of the problem and briefly summarizing the major results. Do not simply repeat your findings. Rather, try to create a concise statement of the main results that directly answer the central research question that you stated in the Introduction section.

  16. How to Write the Results/Findings Section in Research

    Step 1: Consult the guidelines or instructions that the target journal or publisher provides authors and read research papers it has published, especially those with similar topics, methods, or results to your study. The guidelines will generally outline specific requirements for the results or findings section, and the published articles will ...

  17. The Writing Center

    IMRaD Results Discussion. Results and Discussion Sections in Scientific Research Reports (IMRaD) After introducing the study and describing its methodology, an IMRaD* report presents and discusses the main findings of the study. In the results section, writers systematically report their findings, and in discussion, they interpret these findings.

  18. How to Write an Effective Discussion in a Research Paper; a Guide to

    Explaining the meaning of the results to the reader is the purpose of the discussion section of a research paper. There are elements of the discussion that should be included and other things that ...

  19. How to write the results section of a research paper

    Practical guidance for writing an effective results section for a research paper. Always use simple and clear language. Avoid the use of uncertain or out-of-focus expressions. The findings of the study must be expressed in an objective and unbiased manner. While it is acceptable to correlate certain findings in the discussion section, it is ...

  20. How to Write a Discussion Section

    What not to include in your discussion section. There are a few common mistakes to avoid when writing the discussion section of your paper. Don't introduce new results: You should only discuss the data that you have already reported in your results section. Don't make inflated claims: Avoid overinterpretation and speculation that isn't directly supported by your data.

  21. Research Guides: Writing a Scientific Paper: DISCUSSION

    DISCUSSION. Evidence does not explain itself; the results must be presented and then explained. Typical stages in the discussion: summarizing the results, discussing whether results are expected or unexpected, comparing these results to previous work, interpreting and explaining the results (often by comparison to a theory or model), and hypothesizing about their generality.

  22. Discussion Section of a Research Paper: Guide & Example

    The discussion section of a research paper is where the author analyzes and explains the importance of the study's results. It presents the conclusions drawn from the study, compares them to previous research, and addresses any potential limitations or weaknesses. The discussion section should also suggest areas for future research.

  23. What are the strengths and limitations to utilising creative methods in

    There is increasing interest in using patient and public involvement (PPI) in research to improve the quality of healthcare. Ordinarily, traditional methods have been used such as interviews or focus groups. However, these methods tend to engage a similar demographic of people. Thus, creative methods are being developed to involve patients for whom traditional methods are inaccessible or non ...

  24. Sexual and reproductive health implementation research in humanitarian

    Background Meeting the health needs of crisis-affected populations is a growing challenge, with 339 million people globally in need of humanitarian assistance in 2023. Given one in four people living in humanitarian contexts are women and girls of reproductive age, sexual and reproductive health care is considered as essential health service and minimum standard for humanitarian response ...

  25. Ethical guidance for conducting health research with online communities

    Online research methods have grown in popularity due in part to the globalised and far-reaching nature of the internet but also linked to the Covid-19 pandemic whereby restrictions to travel and face to face contact necessitated a shift in methods of research recruitment and data collection. Ethical guidance exists to support researchers in conducting online research, however this is lacking ...

  26. (IUCr) Analysis of COF-300 synthesis: probing degradation processes and

    Results and discussion Firstly, Int was prepared by simply combining equimolar quantities of terephthalaldehyde (TA) and aniline and refluxing in methanol for 4 h before filtering (Scheme S1). Subsequently, to test the potential of the method, synthesis of COF-300 via the conventional method and the intermediate-assisted synthesis were compared.

  27. Cultural Relativity and Acceptance of Embryonic Stem Cell Research

    Voices in Bioethics is currently seeking submissions on philosophical and practical topics, both current and timeless. Papers addressing access to healthcare, the bioethical implications of recent Supreme Court rulings, environmental ethics, data privacy, cybersecurity, law and bioethics, economics and bioethics, reproductive ethics, research ethics, and pediatric bioethics are sought.

  28. Characterizing Community Forests in the United States

    Location of CFs in our database. In this article, we refer to three regions in discussing our results: the West, which includes CFs found in Montana, Idaho, Washington, Oregon, California, and Arizona; the North, which includes Maine, Vermont, New Hampshire, Massachusetts, New York, Connecticut, Michigan, and Wisconsin; and the South, which includes Georgia, North and South Carolina, Virginia ...

  29. Untangling the environmental and tectonic drivers of the Noto ...

    Data and materials availability: All data needed to evaluate the conclusions in the paper are present in the paper and/or the Supplementary Materials. Hi-net seismic data required in the paper are available from the National Research Institute for Earth Science and Disaster Prevention (NIED; www.hinet.bosai.go.jp).