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How to Write a Conclusion for Research Papers (with Examples)

The conclusion of a research paper is a crucial section that plays a significant role in the overall impact and effectiveness of your research paper. However, this is also the section that typically receives less attention compared to the introduction and the body of the paper. The conclusion serves to provide a concise summary of the key findings, their significance, their implications, and a sense of closure to the study. Discussing how can the findings be applied in real-world scenarios or inform policy, practice, or decision-making is especially valuable to practitioners and policymakers. The research paper conclusion also provides researchers with clear insights and valuable information for their own work, which they can then build on and contribute to the advancement of knowledge in the field.

The research paper conclusion should explain the significance of your findings within the broader context of your field. It restates how your results contribute to the existing body of knowledge and whether they confirm or challenge existing theories or hypotheses. Also, by identifying unanswered questions or areas requiring further investigation, your awareness of the broader research landscape can be demonstrated.

Remember to tailor the research paper conclusion to the specific needs and interests of your intended audience, which may include researchers, practitioners, policymakers, or a combination of these.

Table of Contents

What is a conclusion in a research paper, summarizing conclusion, editorial conclusion, externalizing conclusion, importance of a good research paper conclusion, how to write a conclusion for your research paper, research paper conclusion examples.

• How to write a research paper conclusion with Paperpal? 

Frequently Asked Questions

A conclusion in a research paper is the final section where you summarize and wrap up your research, presenting the key findings and insights derived from your study. The research paper conclusion is not the place to introduce new information or data that was not discussed in the main body of the paper. When working on how to conclude a research paper, remember to stick to summarizing and interpreting existing content. The research paper conclusion serves the following purposes: 1

• Warn readers of the possible consequences of not attending to the problem.
• Recommend specific course(s) of action.
• Restate key ideas to drive home the ultimate point of your research paper.
• Provide a “take-home” message that you want the readers to remember about your study.

Types of conclusions for research papers

In research papers, the conclusion provides closure to the reader. The type of research paper conclusion you choose depends on the nature of your study, your goals, and your target audience. I provide you with three common types of conclusions:

A summarizing conclusion is the most common type of conclusion in research papers. It involves summarizing the main points, reiterating the research question, and restating the significance of the findings. This common type of research paper conclusion is used across different disciplines.

An editorial conclusion is less common but can be used in research papers that are focused on proposing or advocating for a particular viewpoint or policy. It involves presenting a strong editorial or opinion based on the research findings and offering recommendations or calls to action.

An externalizing conclusion is a type of conclusion that extends the research beyond the scope of the paper by suggesting potential future research directions or discussing the broader implications of the findings. This type of conclusion is often used in more theoretical or exploratory research papers.

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The conclusion in a research paper serves several important purposes:

• Offers Implications and Recommendations : Your research paper conclusion is an excellent place to discuss the broader implications of your research and suggest potential areas for further study. It’s also an opportunity to offer practical recommendations based on your findings.
• Provides Closure : A good research paper conclusion provides a sense of closure to your paper. It should leave the reader with a feeling that they have reached the end of a well-structured and thought-provoking research project.
• Leaves a Lasting Impression : Writing a well-crafted research paper conclusion leaves a lasting impression on your readers. It’s your final opportunity to leave them with a new idea, a call to action, or a memorable quote.

Writing a strong conclusion for your research paper is essential to leave a lasting impression on your readers. Here’s a step-by-step process to help you create and know what to put in the conclusion of a research paper: 2

• Research Statement : Begin your research paper conclusion by restating your research statement. This reminds the reader of the main point you’ve been trying to prove throughout your paper. Keep it concise and clear.
• Key Points : Summarize the main arguments and key points you’ve made in your paper. Avoid introducing new information in the research paper conclusion. Instead, provide a concise overview of what you’ve discussed in the body of your paper.
• Address the Research Questions : If your research paper is based on specific research questions or hypotheses, briefly address whether you’ve answered them or achieved your research goals. Discuss the significance of your findings in this context.
• Significance : Highlight the importance of your research and its relevance in the broader context. Explain why your findings matter and how they contribute to the existing knowledge in your field.
• Implications : Explore the practical or theoretical implications of your research. How might your findings impact future research, policy, or real-world applications? Consider the “so what?” question.
• Future Research : Offer suggestions for future research in your area. What questions or aspects remain unanswered or warrant further investigation? This shows that your work opens the door for future exploration.
• Closing Thought : Conclude your research paper conclusion with a thought-provoking or memorable statement. This can leave a lasting impression on your readers and wrap up your paper effectively. Avoid introducing new information or arguments here.
• Proofread and Revise : Carefully proofread your conclusion for grammar, spelling, and clarity. Ensure that your ideas flow smoothly and that your conclusion is coherent and well-structured.

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Remember that a well-crafted research paper conclusion is a reflection of the strength of your research and your ability to communicate its significance effectively. It should leave a lasting impression on your readers and tie together all the threads of your paper. Now you know how to start the conclusion of a research paper and what elements to include to make it impactful, let’s look at a research paper conclusion sample.

How to write a research paper conclusion with Paperpal?

A research paper conclusion is not just a summary of your study, but a synthesis of the key findings that ties the research together and places it in a broader context. A research paper conclusion should be concise, typically around one paragraph in length. However, some complex topics may require a longer conclusion to ensure the reader is left with a clear understanding of the study’s significance. Paperpal, an AI writing assistant trusted by over 800,000 academics globally, can help you write a well-structured conclusion for your research paper. 

• Sign Up or Log In: Create a new Paperpal account or login with your details.  
• Navigate to Features : Once logged in, head over to the features’ side navigation pane. Click on Templates and you’ll find a suite of generative AI features to help you write better, faster.  
• Generate an outline: Under Templates, select ‘Outlines’. Choose ‘Research article’ as your document type.  
• Select your section: Since you’re focusing on the conclusion, select this section when prompted.  
• Choose your field of study: Identifying your field of study allows Paperpal to provide more targeted suggestions, ensuring the relevance of your conclusion to your specific area of research. 
• Provide a brief description of your study: Enter details about your research topic and findings. This information helps Paperpal generate a tailored outline that aligns with your paper’s content. 
• Generate the conclusion outline: After entering all necessary details, click on ‘generate’. Paperpal will then create a structured outline for your conclusion, to help you start writing and build upon the outline.  
• Write your conclusion: Use the generated outline to build your conclusion. The outline serves as a guide, ensuring you cover all critical aspects of a strong conclusion, from summarizing key findings to highlighting the research’s implications. 
• Refine and enhance: Paperpal’s ‘Make Academic’ feature can be particularly useful in the final stages. Select any paragraph of your conclusion and use this feature to elevate the academic tone, ensuring your writing is aligned to the academic journal standards. 

By following these steps, Paperpal not only simplifies the process of writing a research paper conclusion but also ensures it is impactful, concise, and aligned with academic standards. Sign up with Paperpal today and write your research paper conclusion 2x faster .  

The research paper conclusion is a crucial part of your paper as it provides the final opportunity to leave a strong impression on your readers. In the research paper conclusion, summarize the main points of your research paper by restating your research statement, highlighting the most important findings, addressing the research questions or objectives, explaining the broader context of the study, discussing the significance of your findings, providing recommendations if applicable, and emphasizing the takeaway message. The main purpose of the conclusion is to remind the reader of the main point or argument of your paper and to provide a clear and concise summary of the key findings and their implications. All these elements should feature on your list of what to put in the conclusion of a research paper to create a strong final statement for your work.

A strong conclusion is a critical component of a research paper, as it provides an opportunity to wrap up your arguments, reiterate your main points, and leave a lasting impression on your readers. Here are the key elements of a strong research paper conclusion: 1. Conciseness : A research paper conclusion should be concise and to the point. It should not introduce new information or ideas that were not discussed in the body of the paper. 2. Summarization : The research paper conclusion should be comprehensive enough to give the reader a clear understanding of the research’s main contributions. 3 . Relevance : Ensure that the information included in the research paper conclusion is directly relevant to the research paper’s main topic and objectives; avoid unnecessary details. 4 . Connection to the Introduction : A well-structured research paper conclusion often revisits the key points made in the introduction and shows how the research has addressed the initial questions or objectives. 5. Emphasis : Highlight the significance and implications of your research. Why is your study important? What are the broader implications or applications of your findings? 6 . Call to Action : Include a call to action or a recommendation for future research or action based on your findings.

The length of a research paper conclusion can vary depending on several factors, including the overall length of the paper, the complexity of the research, and the specific journal requirements. While there is no strict rule for the length of a conclusion, but it’s generally advisable to keep it relatively short. A typical research paper conclusion might be around 5-10% of the paper’s total length. For example, if your paper is 10 pages long, the conclusion might be roughly half a page to one page in length.

In general, you do not need to include citations in the research paper conclusion. Citations are typically reserved for the body of the paper to support your arguments and provide evidence for your claims. However, there may be some exceptions to this rule: 1. If you are drawing a direct quote or paraphrasing a specific source in your research paper conclusion, you should include a citation to give proper credit to the original author. 2. If your conclusion refers to or discusses specific research, data, or sources that are crucial to the overall argument, citations can be included to reinforce your conclusion’s validity.

The conclusion of a research paper serves several important purposes: 1. Summarize the Key Points 2. Reinforce the Main Argument 3. Provide Closure 4. Offer Insights or Implications 5. Engage the Reader. 6. Reflect on Limitations

Remember that the primary purpose of the research paper conclusion is to leave a lasting impression on the reader, reinforcing the key points and providing closure to your research. It’s often the last part of the paper that the reader will see, so it should be strong and well-crafted.

• Makar, G., Foltz, C., Lendner, M., & Vaccaro, A. R. (2018). How to write effective discussion and conclusion sections. Clinical spine surgery, 31(8), 345-346.
• Bunton, D. (2005). The structure of PhD conclusion chapters.  Journal of English for academic purposes ,  4 (3), 207-224.

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Organizing Your Social Sciences Research Paper

• 9. The Conclusion
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The conclusion is intended to help the reader understand why your research should matter to them after they have finished reading the paper. A conclusion is not merely a summary of the main topics covered or a re-statement of your research problem, but a synthesis of key points derived from the findings of your study and, if applicable, where you recommend new areas for future research. For most college-level research papers, two or three well-developed paragraphs is sufficient for a conclusion, although in some cases, more paragraphs may be required in describing the key findings and their significance.

Conclusions. The Writing Center. University of North Carolina; Conclusions. The Writing Lab and The OWL. Purdue University.

Importance of a Good Conclusion

A well-written conclusion provides you with important opportunities to demonstrate to the reader your understanding of the research problem. These include:

• Presenting the last word on the issues you raised in your paper . Just as the introduction gives a first impression to your reader, the conclusion offers a chance to leave a lasting impression. Do this, for example, by highlighting key findings in your analysis that advance new understanding about the research problem, that are unusual or unexpected, or that have important implications applied to practice.
• Summarizing your thoughts and conveying the larger significance of your study . The conclusion is an opportunity to succinctly re-emphasize  your answer to the "So What?" question by placing the study within the context of how your research advances past research about the topic.
• Identifying how a gap in the literature has been addressed . The conclusion can be where you describe how a previously identified gap in the literature [first identified in your literature review section] has been addressed by your research and why this contribution is significant.
• Demonstrating the importance of your ideas . Don't be shy. The conclusion offers an opportunity to elaborate on the impact and significance of your findings. This is particularly important if your study approached examining the research problem from an unusual or innovative perspective.
• Introducing possible new or expanded ways of thinking about the research problem . This does not refer to introducing new information [which should be avoided], but to offer new insight and creative approaches for framing or contextualizing the research problem based on the results of your study.

Bunton, David. “The Structure of PhD Conclusion Chapters.” Journal of English for Academic Purposes 4 (July 2005): 207–224; Conclusions. The Writing Center. University of North Carolina; Kretchmer, Paul. Twelve Steps to Writing an Effective Conclusion. San Francisco Edit, 2003-2008; Conclusions. The Writing Lab and The OWL. Purdue University; Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8.

Structure and Writing Style

I.  General Rules

The general function of your paper's conclusion is to restate the main argument . It reminds the reader of the strengths of your main argument(s) and reiterates the most important evidence supporting those argument(s). Do this by clearly summarizing the context, background, and necessity of pursuing the research problem you investigated in relation to an issue, controversy, or a gap found in the literature. However, make sure that your conclusion is not simply a repetitive summary of the findings. This reduces the impact of the argument(s) you have developed in your paper.

When writing the conclusion to your paper, follow these general rules:

• Present your conclusions in clear, concise language. Re-state the purpose of your study, then describe how your findings differ or support those of other studies and why [i.e., what were the unique, new, or crucial contributions your study made to the overall research about your topic?].
• Do not simply reiterate your findings or the discussion of your results. Provide a synthesis of arguments presented in the paper to show how these converge to address the research problem and the overall objectives of your study.
• Indicate opportunities for future research if you haven't already done so in the discussion section of your paper. Highlighting the need for further research provides the reader with evidence that you have an in-depth awareness of the research problem but that further investigations should take place beyond the scope of your investigation.

Consider the following points to help ensure your conclusion is presented well:

• If the argument or purpose of your paper is complex, you may need to summarize the argument for your reader.
• If, prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the end of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration that returns the topic to the context provided by the introduction or within a new context that emerges from the data [this is opposite of the introduction, which begins with general discussion of the context and ends with a detailed description of the research problem]. 

The conclusion also provides a place for you to persuasively and succinctly restate the research problem, given that the reader has now been presented with all the information about the topic . Depending on the discipline you are writing in, the concluding paragraph may contain your reflections on the evidence presented. However, the nature of being introspective about the research you have conducted will depend on the topic and whether your professor wants you to express your observations in this way. If asked to think introspectively about the topics, do not delve into idle speculation. Being introspective means looking within yourself as an author to try and understand an issue more deeply, not to guess at possible outcomes or make up scenarios not supported by the evidence.

II.  Developing a Compelling Conclusion

Although an effective conclusion needs to be clear and succinct, it does not need to be written passively or lack a compelling narrative. Strategies to help you move beyond merely summarizing the key points of your research paper may include any of the following:

• If your essay deals with a critical, contemporary problem, warn readers of the possible consequences of not attending to the problem proactively.
• Recommend a specific course or courses of action that, if adopted, could address a specific problem in practice or in the development of new knowledge leading to positive change.
• Cite a relevant quotation or expert opinion already noted in your paper in order to lend authority and support to the conclusion(s) you have reached [a good source would be from your literature review].
• Explain the consequences of your research in a way that elicits action or demonstrates urgency in seeking change.
• Restate a key statistic, fact, or visual image to emphasize the most important finding of your paper.
• If your discipline encourages personal reflection, illustrate your concluding point by drawing from your own life experiences.
• Return to an anecdote, an example, or a quotation that you presented in your introduction, but add further insight derived from the findings of your study; use your interpretation of results from your study to recast it in new or important ways.
• Provide a "take-home" message in the form of a succinct, declarative statement that you want the reader to remember about your study.

III. Problems to Avoid

Failure to be concise Your conclusion section should be concise and to the point. Conclusions that are too lengthy often have unnecessary information in them. The conclusion is not the place for details about your methodology or results. Although you should give a summary of what was learned from your research, this summary should be relatively brief, since the emphasis in the conclusion is on the implications, evaluations, insights, and other forms of analysis that you make. Strategies for writing concisely can be found here .

Failure to comment on larger, more significant issues In the introduction, your task was to move from the general [the field of study] to the specific [the research problem]. However, in the conclusion, your task is to move from a specific discussion [your research problem] back to a general discussion framed around the implications and significance of your findings [i.e., how your research contributes new understanding or fills an important gap in the literature]. In short, the conclusion is where you should place your research within a larger context [visualize your paper as an hourglass--start with a broad introduction and review of the literature, move to the specific analysis and discussion, conclude with a broad summary of the study's implications and significance].

Failure to reveal problems and negative results Negative aspects of the research process should never be ignored. These are problems, deficiencies, or challenges encountered during your study. They should be summarized as a way of qualifying your overall conclusions. If you encountered negative or unintended results [i.e., findings that are validated outside the research context in which they were generated], you must report them in the results section and discuss their implications in the discussion section of your paper. In the conclusion, use negative results as an opportunity to explain their possible significance and/or how they may form the basis for future research.

Failure to provide a clear summary of what was learned In order to be able to discuss how your research fits within your field of study [and possibly the world at large], you need to summarize briefly and succinctly how it contributes to new knowledge or a new understanding about the research problem. This element of your conclusion may be only a few sentences long.

Failure to match the objectives of your research Often research objectives in the social and behavioral sciences change while the research is being carried out. This is not a problem unless you forget to go back and refine the original objectives in your introduction. As these changes emerge they must be documented so that they accurately reflect what you were trying to accomplish in your research [not what you thought you might accomplish when you began].

Resist the urge to apologize If you've immersed yourself in studying the research problem, you presumably should know a good deal about it [perhaps even more than your professor!]. Nevertheless, by the time you have finished writing, you may be having some doubts about what you have produced. Repress those doubts! Don't undermine your authority as a researcher by saying something like, "This is just one approach to examining this problem; there may be other, much better approaches that...." The overall tone of your conclusion should convey confidence to the reader about the study's validity and realiability.

Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8; Concluding Paragraphs. College Writing Center at Meramec. St. Louis Community College; Conclusions. The Writing Center. University of North Carolina; Conclusions. The Writing Lab and The OWL. Purdue University; Freedman, Leora  and Jerry Plotnick. Introductions and Conclusions. The Lab Report. University College Writing Centre. University of Toronto; Leibensperger, Summer. Draft Your Conclusion. Academic Center, the University of Houston-Victoria, 2003; Make Your Last Words Count. The Writer’s Handbook. Writing Center. University of Wisconsin Madison; Miquel, Fuster-Marquez and Carmen Gregori-Signes. “Chapter Six: ‘Last but Not Least:’ Writing the Conclusion of Your Paper.” In Writing an Applied Linguistics Thesis or Dissertation: A Guide to Presenting Empirical Research . John Bitchener, editor. (Basingstoke,UK: Palgrave Macmillan, 2010), pp. 93-105; Tips for Writing a Good Conclusion. Writing@CSU. Colorado State University; Kretchmer, Paul. Twelve Steps to Writing an Effective Conclusion. San Francisco Edit, 2003-2008; Writing Conclusions. Writing Tutorial Services, Center for Innovative Teaching and Learning. Indiana University; Writing: Considering Structure and Organization. Institute for Writing Rhetoric. Dartmouth College.

Writing Tip

Don't Belabor the Obvious!

Avoid phrases like "in conclusion...," "in summary...," or "in closing...." These phrases can be useful, even welcome, in oral presentations. But readers can see by the tell-tale section heading and number of pages remaining that they are reaching the end of your paper. You'll irritate your readers if you belabor the obvious.

Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8.

Another Writing Tip

New Insight, Not New Information!

Don't surprise the reader with new information in your conclusion that was never referenced anywhere else in the paper. This why the conclusion rarely has citations to sources. If you have new information to present, add it to the discussion or other appropriate section of the paper. Note that, although no new information is introduced, the conclusion, along with the discussion section, is where you offer your most "original" contributions in the paper; the conclusion is where you describe the value of your research, demonstrate that you understand the material that you’ve presented, and position your findings within the larger context of scholarship on the topic, including describing how your research contributes new insights to that scholarship.

Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8; Conclusions. The Writing Center. University of North Carolina.

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Home » Research Paper Conclusion – Writing Guide and Examples

Research Paper Conclusion – Writing Guide and Examples

Table of Contents

Research Paper Conclusion

Definition:

A research paper conclusion is the final section of a research paper that summarizes the key findings, significance, and implications of the research. It is the writer’s opportunity to synthesize the information presented in the paper, draw conclusions, and make recommendations for future research or actions.

The conclusion should provide a clear and concise summary of the research paper, reiterating the research question or problem, the main results, and the significance of the findings. It should also discuss the limitations of the study and suggest areas for further research.

Parts of Research Paper Conclusion

The parts of a research paper conclusion typically include:

Restatement of the Thesis

The conclusion should begin by restating the thesis statement from the introduction in a different way. This helps to remind the reader of the main argument or purpose of the research.

Summary of Key Findings

The conclusion should summarize the main findings of the research, highlighting the most important results and conclusions. This section should be brief and to the point.

Implications and Significance

In this section, the researcher should explain the implications and significance of the research findings. This may include discussing the potential impact on the field or industry, highlighting new insights or knowledge gained, or pointing out areas for future research.

Limitations and Recommendations

It is important to acknowledge any limitations or weaknesses of the research and to make recommendations for how these could be addressed in future studies. This shows that the researcher is aware of the potential limitations of their work and is committed to improving the quality of research in their field.

Concluding Statement

The conclusion should end with a strong concluding statement that leaves a lasting impression on the reader. This could be a call to action, a recommendation for further research, or a final thought on the topic.

How to Write Research Paper Conclusion

Here are some steps you can follow to write an effective research paper conclusion:

• Restate the research problem or question: Begin by restating the research problem or question that you aimed to answer in your research. This will remind the reader of the purpose of your study.
• Summarize the main points: Summarize the key findings and results of your research. This can be done by highlighting the most important aspects of your research and the evidence that supports them.
• Discuss the implications: Discuss the implications of your findings for the research area and any potential applications of your research. You should also mention any limitations of your research that may affect the interpretation of your findings.
• Provide a conclusion : Provide a concise conclusion that summarizes the main points of your paper and emphasizes the significance of your research. This should be a strong and clear statement that leaves a lasting impression on the reader.
• Offer suggestions for future research: Lastly, offer suggestions for future research that could build on your findings and contribute to further advancements in the field.

Remember that the conclusion should be brief and to the point, while still effectively summarizing the key findings and implications of your research.

Example of Research Paper Conclusion

Here’s an example of a research paper conclusion:

Conclusion :

In conclusion, our study aimed to investigate the relationship between social media use and mental health among college students. Our findings suggest that there is a significant association between social media use and increased levels of anxiety and depression among college students. This highlights the need for increased awareness and education about the potential negative effects of social media use on mental health, particularly among college students.

Despite the limitations of our study, such as the small sample size and self-reported data, our findings have important implications for future research and practice. Future studies should aim to replicate our findings in larger, more diverse samples, and investigate the potential mechanisms underlying the association between social media use and mental health. In addition, interventions should be developed to promote healthy social media use among college students, such as mindfulness-based approaches and social media detox programs.

Overall, our study contributes to the growing body of research on the impact of social media on mental health, and highlights the importance of addressing this issue in the context of higher education. By raising awareness and promoting healthy social media use among college students, we can help to reduce the negative impact of social media on mental health and improve the well-being of young adults.

Purpose of Research Paper Conclusion

The purpose of a research paper conclusion is to provide a summary and synthesis of the key findings, significance, and implications of the research presented in the paper. The conclusion serves as the final opportunity for the writer to convey their message and leave a lasting impression on the reader.

The conclusion should restate the research problem or question, summarize the main results of the research, and explain their significance. It should also acknowledge the limitations of the study and suggest areas for future research or action.

Overall, the purpose of the conclusion is to provide a sense of closure to the research paper and to emphasize the importance of the research and its potential impact. It should leave the reader with a clear understanding of the main findings and why they matter. The conclusion serves as the writer’s opportunity to showcase their contribution to the field and to inspire further research and action.

When to Write Research Paper Conclusion

The conclusion of a research paper should be written after the body of the paper has been completed. It should not be written until the writer has thoroughly analyzed and interpreted their findings and has written a complete and cohesive discussion of the research.

Before writing the conclusion, the writer should review their research paper and consider the key points that they want to convey to the reader. They should also review the research question, hypotheses, and methodology to ensure that they have addressed all of the necessary components of the research.

Once the writer has a clear understanding of the main findings and their significance, they can begin writing the conclusion. The conclusion should be written in a clear and concise manner, and should reiterate the main points of the research while also providing insights and recommendations for future research or action.

Characteristics of Research Paper Conclusion

The characteristics of a research paper conclusion include:

• Clear and concise: The conclusion should be written in a clear and concise manner, summarizing the key findings and their significance.
• Comprehensive: The conclusion should address all of the main points of the research paper, including the research question or problem, the methodology, the main results, and their implications.
• Future-oriented : The conclusion should provide insights and recommendations for future research or action, based on the findings of the research.
• Impressive : The conclusion should leave a lasting impression on the reader, emphasizing the importance of the research and its potential impact.
• Objective : The conclusion should be based on the evidence presented in the research paper, and should avoid personal biases or opinions.
• Unique : The conclusion should be unique to the research paper and should not simply repeat information from the introduction or body of the paper.

Advantages of Research Paper Conclusion

The advantages of a research paper conclusion include:

• Summarizing the key findings : The conclusion provides a summary of the main findings of the research, making it easier for the reader to understand the key points of the study.
• Emphasizing the significance of the research: The conclusion emphasizes the importance of the research and its potential impact, making it more likely that readers will take the research seriously and consider its implications.
• Providing recommendations for future research or action : The conclusion suggests practical recommendations for future research or action, based on the findings of the study.
• Providing closure to the research paper : The conclusion provides a sense of closure to the research paper, tying together the different sections of the paper and leaving a lasting impression on the reader.
• Demonstrating the writer’s contribution to the field : The conclusion provides the writer with an opportunity to showcase their contribution to the field and to inspire further research and action.

Limitations of Research Paper Conclusion

While the conclusion of a research paper has many advantages, it also has some limitations that should be considered, including:

• I nability to address all aspects of the research: Due to the limited space available in the conclusion, it may not be possible to address all aspects of the research in detail.
• Subjectivity : While the conclusion should be objective, it may be influenced by the writer’s personal biases or opinions.
• Lack of new information: The conclusion should not introduce new information that has not been discussed in the body of the research paper.
• Lack of generalizability: The conclusions drawn from the research may not be applicable to other contexts or populations, limiting the generalizability of the study.
• Misinterpretation by the reader: The reader may misinterpret the conclusions drawn from the research, leading to a misunderstanding of the findings.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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• How to Write Discussions and Conclusions

The discussion section contains the results and outcomes of a study. An effective discussion informs readers what can be learned from your experiment and provides context for the results.

What makes an effective discussion?

When you’re ready to write your discussion, you’ve already introduced the purpose of your study and provided an in-depth description of the methodology. The discussion informs readers about the larger implications of your study based on the results. Highlighting these implications while not overstating the findings can be challenging, especially when you’re submitting to a journal that selects articles based on novelty or potential impact. Regardless of what journal you are submitting to, the discussion section always serves the same purpose: concluding what your study results actually mean.

A successful discussion section puts your findings in context. It should include:

• the results of your research,
• a discussion of related research, and
• a comparison between your results and initial hypothesis.

Tip: Not all journals share the same naming conventions.

You can apply the advice in this article to the conclusion, results or discussion sections of your manuscript.

Our Early Career Researcher community tells us that the conclusion is often considered the most difficult aspect of a manuscript to write. To help, this guide provides questions to ask yourself, a basic structure to model your discussion off of and examples from published manuscripts. 

Questions to ask yourself:

• Was my hypothesis correct?
• If my hypothesis is partially correct or entirely different, what can be learned from the results? 
• How do the conclusions reshape or add onto the existing knowledge in the field? What does previous research say about the topic? 
• Why are the results important or relevant to your audience? Do they add further evidence to a scientific consensus or disprove prior studies? 
• How can future research build on these observations? What are the key experiments that must be done? 
• What is the “take-home” message you want your reader to leave with?

How to structure a discussion

Trying to fit a complete discussion into a single paragraph can add unnecessary stress to the writing process. If possible, you’ll want to give yourself two or three paragraphs to give the reader a comprehensive understanding of your study as a whole. Here’s one way to structure an effective discussion:

Writing Tips

While the above sections can help you brainstorm and structure your discussion, there are many common mistakes that writers revert to when having difficulties with their paper. Writing a discussion can be a delicate balance between summarizing your results, providing proper context for your research and avoiding introducing new information. Remember that your paper should be both confident and honest about the results! 

• Read the journal’s guidelines on the discussion and conclusion sections. If possible, learn about the guidelines before writing the discussion to ensure you’re writing to meet their expectations. 
• Begin with a clear statement of the principal findings. This will reinforce the main take-away for the reader and set up the rest of the discussion. 
• Explain why the outcomes of your study are important to the reader. Discuss the implications of your findings realistically based on previous literature, highlighting both the strengths and limitations of the research. 
• State whether the results prove or disprove your hypothesis. If your hypothesis was disproved, what might be the reasons? 
• Introduce new or expanded ways to think about the research question. Indicate what next steps can be taken to further pursue any unresolved questions. 
• If dealing with a contemporary or ongoing problem, such as climate change, discuss possible consequences if the problem is avoided. 
• Be concise. Adding unnecessary detail can distract from the main findings. 

Don’t

• Rewrite your abstract. Statements with “we investigated” or “we studied” generally do not belong in the discussion. 
• Include new arguments or evidence not previously discussed. Necessary information and evidence should be introduced in the main body of the paper. 
• Apologize. Even if your research contains significant limitations, don’t undermine your authority by including statements that doubt your methodology or execution. 
• Shy away from speaking on limitations or negative results. Including limitations and negative results will give readers a complete understanding of the presented research. Potential limitations include sources of potential bias, threats to internal or external validity, barriers to implementing an intervention and other issues inherent to the study design. 
• Overstate the importance of your findings. Making grand statements about how a study will fully resolve large questions can lead readers to doubt the success of the research. 

Snippets of Effective Discussions:

Consumer-based actions to reduce plastic pollution in rivers: A multi-criteria decision analysis approach

Identifying reliable indicators of fitness in polar bears

• How to Write a Great Title
• How to Write an Abstract
• How to Write Your Methods
• How to Report Statistics
• How to Edit Your Work

The contents of the Peer Review Center are also available as a live, interactive training session, complete with slides, talking points, and activities. …

The contents of the Writing Center are also available as a live, interactive training session, complete with slides, talking points, and activities. …

There’s a lot to consider when deciding where to submit your work. Learn how to choose a journal that will help your study reach its audience, while reflecting your values as a researcher…

Organizing Academic Research Papers: 9. The Conclusion

• Purpose of Guide
• Design Flaws to Avoid
• Glossary of Research Terms
• Narrowing a Topic Idea
• Broadening a Topic Idea
• Extending the Timeliness of a Topic Idea
• Academic Writing Style
• Choosing a Title
• Making an Outline
• Paragraph Development
• Executive Summary
• Background Information
• The Research Problem/Question
• Theoretical Framework
• Citation Tracking
• Content Alert Services
• Evaluating Sources
• Primary Sources
• Secondary Sources
• Tertiary Sources
• What Is Scholarly vs. Popular?
• Qualitative Methods
• Quantitative Methods
• Using Non-Textual Elements
• Limitations of the Study
• Common Grammar Mistakes
• Avoiding Plagiarism
• Footnotes or Endnotes?
• Further Readings
• Annotated Bibliography
• Dealing with Nervousness
• Using Visual Aids
• Grading Someone Else's Paper
• How to Manage Group Projects
• Multiple Book Review Essay
• Reviewing Collected Essays
• About Informed Consent
• Writing Field Notes
• Writing a Policy Memo
• Writing a Research Proposal
• Acknowledgements

The conclusion is intended to help the reader understand why your research should matter to them after they have finished reading the paper. A conclusion is not merely a summary of your points or a re-statement of your research problem but a synthesis of key points. For most essays, one well-developed paragraph is sufficient for a conclusion, although in some cases, a two-or-three paragraph conclusion may be required.

Importance of a Good Conclusion

A well-written conclusion provides you with several important opportunities to demonstrate your overall understanding of the research problem to the reader. These include:

• Presenting the last word on the issues you raised in your paper . Just as the introduction gives a first impression to your reader, the conclusion offers a chance to leave a lasting impression. Do this, for example, by highlighting key points in your analysis or findings.
• Summarizing your thoughts and conveying the larger implications of your study . The conclusion is an opportunity to succinctly answer the "so what?" question by placing the study within the context of past research about the topic you've investigated.
• Demonstrating the importance of your ideas . Don't be shy. The conclusion offers you a chance to elaborate on the significance of your findings.
• Introducing possible new or expanded ways of thinking about the research problem . This does not refer to introducing new information [which should be avoided], but to offer new insight and creative approaches for framing/contextualizing the research problem based on the results of your study.

Conclusions . The Writing Center. University of North Carolina; Kretchmer, Paul. Twelve Steps to Writing an Effective Conclusion . San Francisco Edit, 2003-2008.

Structure and Writing Style

https://writing.wisc.edu/wp-content/uploads/sites/535/2018/07/conclusions_uwmadison_writingcenter_aug2012.pdf I.  General Rules

When writing the conclusion to your paper, follow these general rules:

• State your conclusions in clear, simple language.
• Do not simply reiterate your results or the discussion.
• Indicate opportunities for future research, as long as you haven't already done so in the discussion section of your paper.

The function of your paper's conclusion is to restate the main argument . It reminds the reader of the strengths of your main argument(s) and reiterates the most important evidence supporting those argument(s). Make sure, however, that your conclusion is not simply a repetitive summary of the findings because this reduces the impact of the argument(s) you have developed in your essay.

Consider the following points to help ensure your conclusion is appropriate:

• If the argument or point of your paper is complex, you may need to summarize the argument for your reader.
• If, prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the end of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration that returns the topic to the context provided by the introduction or within a new context that emerges from the data.

The conclusion also provides a place for you to persuasively and succinctly restate your research problem, given that the reader has now been presented with all the information about the topic . Depending on the discipline you are writing in, the concluding paragraph may contain your reflections on the evidence presented, or on the essay's central research problem. However, the nature of being introspective about the research you have done will depend on the topic and whether your professor wants you to express your observations in this way.

NOTE : Don't delve into idle speculation. Being introspective means looking within yourself as an author to try and understand an issue more deeply not to guess at possible outcomes.

II.  Developing a Compelling Conclusion

Strategies to help you move beyond merely summarizing the key points of your research paper may include any of the following.

• If your essay deals with a contemporary problem, warn readers of the possible consequences of not attending to the problem.
• Recommend a specific course or courses of action.
• Cite a relevant quotation or expert opinion to lend authority to the conclusion you have reached [a good place to look is research from your literature review].
• Restate a key statistic, fact, or visual image to drive home the ultimate point of your paper.
• If your discipline encourages personal reflection, illustrate your concluding point with a relevant narrative drawn from your own life experiences.
• Return to an anecdote, an example, or a quotation that you introduced in your introduction, but add further insight that is derived from the findings of your study; use your interpretation of results to reframe it in new ways.
• Provide a "take-home" message in the form of a strong, succient statement that you want the reader to remember about your study.

III. Problems to Avoid Failure to be concise The conclusion section should be concise and to the point. Conclusions that are too long often have unnecessary detail. The conclusion section is not the place for details about your methodology or results. Although you should give a summary of what was learned from your research, this summary should be relatively brief, since the emphasis in the conclusion is on the implications, evaluations, insights, etc. that you make. Failure to comment on larger, more significant issues In the introduction, your task was to move from general [the field of study] to specific [your research problem]. However, in the conclusion, your task is to move from specific [your research problem] back to general [your field, i.e., how your research contributes new understanding or fills an important gap in the literature]. In other words, the conclusion is where you place your research within a larger context. Failure to reveal problems and negative results Negative aspects of the research process should never be ignored. Problems, drawbacks, and challenges encountered during your study should be included as a way of qualifying your overall conclusions. If you encountered negative results [findings that are validated outside the research context in which they were generated], you must report them in the results section of your paper. In the conclusion, use the negative results as an opportunity to explain how they provide information on which future research can be based. Failure to provide a clear summary of what was learned In order to be able to discuss how your research fits back into your field of study [and possibly the world at large], you need to summarize it briefly and directly. Often this element of your conclusion is only a few sentences long. Failure to match the objectives of your research Often research objectives change while the research is being carried out. This is not a problem unless you forget to go back and refine your original objectives in your introduction, as these changes emerge they must be documented so that they accurately reflect what you were trying to accomplish in your research [not what you thought you might accomplish when you began].

Resist the urge to apologize If you've immersed yourself in studying the research problem, you now know a good deal about it, perhaps even more than your professor! Nevertheless, by the time you have finished writing, you may be having some doubts about what you have produced. Repress those doubts!  Don't undermine your authority by saying something like, "This is just one approach to examining this problem; there may be other, much better approaches...."

Concluding Paragraphs. College Writing Center at Meramec. St. Louis Community College; Conclusions . The Writing Center. University of North Carolina; Conclusions . The Writing Lab and The OWL. Purdue University; Freedman, Leora  and Jerry Plotnick. Introductions and Conclusions . The Lab Report. University College Writing Centre. University of Toronto; Leibensperger, Summer. Draft Your Conclusion. Academic Center, the University of Houston-Victoria, 2003; Make Your Last Words Count . The Writer’s Handbook. Writing Center. University of Wisconsin, Madison; Tips for Writing a Good Conclusion . Writing@CSU. Colorado State University; Kretchmer, Paul. Twelve Steps to Writing an Effective Conclusion . San Francisco Edit, 2003-2008; Writing Conclusions . Writing Tutorial Services, Center for Innovative Teaching and Learning. Indiana University; Writing: Considering Structure and Organization . Institute for Writing Rhetoric. Dartmouth College.

Writing Tip

Don't Belabor the Obvious!

Avoid phrases like "in conclusion...," "in summary...," or "in closing...." These phrases can be useful, even welcome, in oral presentations. But readers can see by the tell-tale section heading and number of pages remaining to read, when an essay is about to end. You'll irritate your readers if you belabor the obvious.

Another Writing Tip

New Insight, Not New Information!

Don't surprise the reader with new information in your Conclusion that was never referenced anywhere else in the paper. If you have new information to present, add it to the Discussion or other appropriate section of the paper.  Note that, although no actual new information is introduced, the conclusion is where you offer your most "original" contributions in the paper; it's where you describe the value of your research, demonstrate your understanding of the material that you’ve presented, and locate your findings within the larger context of scholarship on the topic.

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Research Implications & Recommendations

A Plain-Language Explainer With Examples + FREE Template

By: Derek Jansen (MBA) | Reviewers: Dr Eunice Rautenbach | May 2024

The research implications and recommendations are closely related but distinctly different concepts that often trip students up. Here, we’ll unpack them using plain language and loads of examples , so that you can approach your project with confidence.

Overview: Implications & Recommendations

• What are research implications ?
• What are research recommendations ?
• Examples of implications and recommendations
• The “ Big 3 ” categories
• How to write the implications and recommendations
• Template sentences for both sections
• Key takeaways

Implications & Recommendations 101

Let’s start with the basics and define our terms.

At the simplest level, research implications refer to the possible effects or outcomes of a study’s findings. More specifically, they answer the question, “ What do these findings mean?” . In other words, the implications section is where you discuss the broader impact of your study’s findings on theory, practice and future research.

This discussion leads us to the recommendations section , which is where you’ll propose specific actions based on your study’s findings and answer the question, “ What should be done next?” . In other words, the recommendations are practical steps that stakeholders can take to address the key issues identified by your study.

In a nutshell, then, the research implications discuss the broader impact and significance of a study’s findings, while recommendations provide specific actions to take, based on those findings. So, while both of these components are deeply rooted in the findings of the study, they serve different functions within the write up.

Need a helping hand?

Examples: Implications & Recommendations

The distinction between research implications and research recommendations might still feel a bit conceptual, so let’s look at one or two practical examples:

Let’s assume that your study finds that interactive learning methods significantly improve student engagement compared to traditional lectures. In this case, one of your recommendations could be that schools incorporate more interactive learning techniques into their curriculums to enhance student engagement.

Let’s imagine that your study finds that patients who receive personalised care plans have better health outcomes than those with standard care plans. One of your recommendations might be that healthcare providers develop and implement personalised care plans for their patients.

Now, these are admittedly quite simplistic examples, but they demonstrate the difference (and connection ) between the research implications and the recommendations. Simply put, the implications are about the impact of the findings, while the recommendations are about proposed actions, based on the findings.

The “Big 3” Categories

Now that we’ve defined our terms, let’s dig a little deeper into the implications – specifically, the different types or categories of research implications that exist.

Broadly speaking, implications can be divided into three categories – theoretical implications, practical implications and implications for future research .

Theoretical implications relate to how your study’s findings contribute to or challenge existing theories. For example, if a study on social behaviour uncovers new patterns, it might suggest that modifications to current psychological theories are necessary.

Practical implications , on the other hand, focus on how your study’s findings can be applied in real-world settings. For example, if your study demonstrated the effectiveness of a new teaching method, this would imply that educators should consider adopting this method to improve learning outcomes.

Practical implications can also involve policy reconsiderations . For example, if a study reveals significant health benefits from a particular diet, an implication might be that public health guidelines be re-evaluated.

Last but not least, there are the implications for future research . As the name suggests, this category of implications highlights the research gaps or new questions raised by your study. For example, if your study finds mixed results regarding a relationship between two variables, it might imply the need for further investigation to clarify these findings.

To recap then, the three types of implications are the theoretical, the practical and the implications on future research. Regardless of the category, these implications feed into and shape the recommendations , laying the foundation for the actions you’ll propose.

How To Write The  Sections

Now that we’ve laid the foundations, it’s time to explore how to write up the implications and recommendations sections respectively.

Let’s start with the “ where ” before digging into the “ how ”. Typically, the implications will feature in the discussion section of your document, while the recommendations will be located in the conclusion . That said, layouts can vary between disciplines and institutions, so be sure to check with your university what their preferences are.

For the implications section, a common approach is to structure the write-up based on the three categories we looked at earlier – theoretical, practical and future research implications. In practical terms, this discussion will usually follow a fairly formulaic sentence structure – for example:

This research provides new insights into [theoretical aspect], indicating that…

The study’s outcomes highlight the potential benefits of adopting [specific practice] in..

This study raises several questions that warrant further investigation, such as…

Moving onto the recommendations section, you could again structure your recommendations using the three categories. Alternatively, you could structure the discussion per stakeholder group – for example, policymakers, organisations, researchers, etc.

Again, you’ll likely use a fairly formulaic sentence structure for this section. Here are some examples for your inspiration: 

Based on the findings, [specific group] should consider adopting [new method] to improve…

To address the issues identified, it is recommended that legislation should be introduced to…

Researchers should consider examining [specific variable] to build on the current study’s findings.

Remember, you can grab a copy of our tried and tested templates for both the discussion and conclusion sections over on the Grad Coach blog. You can find the links to those, as well as loads of other free resources, in the description 🙂

FAQs: Implications & Recommendations

How do i determine the implications of my study.

To do this, you’ll need to consider how your findings address gaps in the existing literature, how they could influence theory, practice, or policy, and the potential societal or economic impacts.

When thinking about your findings, it’s also a good idea to revisit your introduction chapter, where you would have discussed the potential significance of your study more broadly. This section can help spark some additional ideas about what your findings mean in relation to your original research aims. 

Should I discuss both positive and negative implications?

Absolutely. You’ll need to discuss both the positive and negative implications to provide a balanced view of how your findings affect the field and any limitations or potential downsides.

Can my research implications be speculative?

Yes and no. While implications are somewhat more speculative than recommendations and can suggest potential future outcomes, they should be grounded in your data and analysis. So, be careful to avoid overly speculative claims.

How do I formulate recommendations?

Ideally, you should base your recommendations on the limitations and implications of your study’s findings. So, consider what further research is needed, how policies could be adapted, or how practices could be improved – and make proposals in this respect.

How specific should my recommendations be?

Your recommendations should be as specific as possible, providing clear guidance on what actions or research should be taken next. As mentioned earlier, the implications can be relatively broad, but the recommendations should be very specific and actionable. Ideally, you should apply the SMART framework to your recommendations.

Can I recommend future research in my recommendations?

Absolutely. Highlighting areas where further research is needed is a key aspect of the recommendations section. Naturally, these recommendations should link to the respective section of your implications (i.e., implications for future research).

Wrapping Up: Key Takeaways

We’ve covered quite a bit of ground here, so let’s quickly recap.

• Research implications refer to the possible effects or outcomes of a study’s findings.
• The recommendations section, on the other hand, is where you’ll propose specific actions based on those findings.
• You can structure your implications section based on the three overarching categories – theoretical, practical and future research implications.
• You can carry this structure through to the recommendations as well, or you can group your recommendations by stakeholder.

Remember to grab a copy of our tried and tested free dissertation template, which covers both the implications and recommendations sections. If you’d like 1:1 help with your research project, be sure to check out our private coaching service, where we hold your hand throughout the research journey, step by step.

Psst... there’s more!

This post was based on one of our popular Research Bootcamps . If you're working on a research project, you'll definitely want to check this out ...

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6.6: Formal Report—Conclusion, Recommendations, References, and Appendices

Learning objectives.

• Examine the remaining report sections: conclusion, recommendation, reference list, appendices

What Are the Remaining Report Sections?

Conclusions and recommendations.

The conclusions and recommendations section conveys the key results from the analysis in the discussion section. Up to this point, readers have carefully reviewed the data in the report; they are now logically prepared to read the report’s conclusions and recommendations.

According to OACETT (2021), “Conclusions are reasoned judgment and fact, not opinion. Conclusions consider all of the variables and relate cause and effect. Conclusions analyze, evaluate, and make comparisons and contrasts” (p. 7) and “Recommendation(s) (if applicable) suggest a course of action and are provided when there are additional areas for study, or if the reason for the Technology Report was to determine the best action going forward” (p. 7).

You may present the conclusions and recommendations in a numbered or bulleted list to enhance readability.

Reference Page

All formal reports should include a reference page; this page documents the sources cited within the report. The recipient(s) of the report can also refer to this page to locate sources for further research.

Documenting your information sources is all about establishing, maintaining, and protecting your credibility in the profession. You must cite (“document”) borrowed information regardless of the shape or form in which you present it. Whether you directly quote it, paraphrase it, or summarize it—it’s still borrowed information. Whether it comes from a book, article, a diagram, a table, a web page, a product brochure, an expert whom you interview in person—it’s still borrowed information.

Documentation systems vary according to professionals and fields. In ENGL 250, we follow  APA. Refer to a credible APA guide for support.

Appendices are those extra sections in a report that follow the conclusion. According to OACETT (2021), “Appendices can include detailed calculations, tables, drawings, specifications, and technical literature” (p. 7).

Anything that does not comfortably fit in the main part of the report but cannot be left out of the report altogether should go into the appendices. They are commonly used for large tables of data, big chunks of sample code, background that is too basic or too advanced for the body of the report, or large illustrations that just do not fit in the body of the report. Anything that you feel is too large for the main part of the report or that you think would be distracting and interrupt the flow of the report is a good candidate for an appendix.

References & Attributions

Blicq, R., & Moretto, L. (2012).  Technically write. (8th Canadian Ed.). Pearson Canada.

OACETT. (2021).  Technology report guidelines . https://www.oacett.org/getmedia/9f9623ac-73ab-4f99-acca-0d78dee161ab/TR_GUIDELINES_Final.pdf.aspx

Attributions

Content is adapted from Technical Writing by Allison Gross, Annemarie Hamlin, Billy Merck, Chris Rubio, Jodi Naas, Megan Savage, and Michele DeSilva, which is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

Writing in a Technical Environment (First Edition) Copyright © 2022 by Centennial College is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Quick answers, conclusions and recommendations, related terms.

Implications or Recommendations in Research: What's the Difference?

• Peer Review

High-quality research articles that get many citations contain both implications and recommendations. Implications are the impact your research makes, whereas recommendations are specific actions that can then be taken based on your findings, such as for more research or for policymaking.

Updated on August 23, 2022

That seems clear enough, but the two are commonly confused.

This confusion is especially true if you come from a so-called high-context culture in which information is often implied based on the situation, as in many Asian cultures. High-context cultures are different from low-context cultures where information is more direct and explicit (as in North America and many European cultures).

Let's set these two straight in a low-context way; i.e., we'll be specific and direct! This is the best way to be in English academic writing because you're writing for the world.

Implications and recommendations in a research article

The standard format of STEM research articles is what's called IMRaD:

• Introduction
• Discussion/conclusions

Some journals call for a separate conclusions section, while others have the conclusions as the last part of the discussion. You'll write these four (or five) sections in the same sequence, though, no matter the journal.

The discussion section is typically where you restate your results and how well they confirmed your hypotheses. Give readers the answer to the questions for which they're looking to you for an answer.

At this point, many researchers assume their paper is finished. After all, aren't the results the most important part? As you might have guessed, no, you're not quite done yet.

The discussion/conclusions section is where to say what happened and what should now happen

The discussion/conclusions section of every good scientific article should contain the implications and recommendations.

The implications, first of all, are the impact your results have on your specific field. A high-impact, highly cited article will also broaden the scope here and provide implications to other fields. This is what makes research cross-disciplinary.

Recommendations, however, are suggestions to improve your field based on your results.

These two aspects help the reader understand your broader content: How and why your work is important to the world. They also tell the reader what can be changed in the future based on your results.

These aspects are what editors are looking for when selecting papers for peer review.

Implications and recommendations are, thus, written at the end of the discussion section, and before the concluding paragraph. They help to “wrap up” your paper. Once your reader understands what you found, the next logical step is what those results mean and what should come next.

Then they can take the baton, in the form of your work, and run with it. That gets you cited and extends your impact!

The order of implications and recommendations also matters. Both are written after you've summarized your main findings in the discussion section. Then, those results are interpreted based on ongoing work in the field. After this, the implications are stated, followed by the recommendations.

Writing an academic research paper is a bit like running a race. Finish strong, with your most important conclusion (recommendation) at the end. Leave readers with an understanding of your work's importance. Avoid generic, obvious phrases like "more research is needed to fully address this issue." Be specific.

The main differences between implications and recommendations (table)

Now let's dig a bit deeper into actually how to write these parts.

What are implications?

Research implications tell us how and why your results are important for the field at large. They help answer the question of “what does it mean?” Implications tell us how your work contributes to your field and what it adds to it. They're used when you want to tell your peers why your research is important for ongoing theory, practice, policymaking, and for future research.

Crucially, your implications must be evidence-based. This means they must be derived from the results in the paper.

Implications are written after you've summarized your main findings in the discussion section. They come before the recommendations and before the concluding paragraph. There is no specific section dedicated to implications. They must be integrated into your discussion so that the reader understands why the results are meaningful and what they add to the field.

A good strategy is to separate your implications into types. Implications can be social, political, technological, related to policies, or others, depending on your topic. The most frequently used types are theoretical and practical. Theoretical implications relate to how your findings connect to other theories or ideas in your field, while practical implications are related to what we can do with the results.

Key features of implications

• State the impact your research makes
• Helps us understand why your results are important
• Must be evidence-based
• Written in the discussion, before recommendations
• Can be theoretical, practical, or other (social, political, etc.)

Examples of implications

Let's take a look at some examples of research results below with their implications.

The result : one study found that learning items over time improves memory more than cramming material in a bunch of information at once .

The implications : This result suggests memory is better when studying is spread out over time, which could be due to memory consolidation processes.

The result : an intervention study found that mindfulness helps improve mental health if you have anxiety.

The implications : This result has implications for the role of executive functions on anxiety.

The result : a study found that musical learning helps language learning in children .

The implications : these findings suggest that language and music may work together to aid development.

What are recommendations?

As noted above, explaining how your results contribute to the real world is an important part of a successful article.

Likewise, stating how your findings can be used to improve something in future research is equally important. This brings us to the recommendations.

Research recommendations are suggestions and solutions you give for certain situations based on your results. Once the reader understands what your results mean with the implications, the next question they need to know is "what's next?"

Recommendations are calls to action on ways certain things in the field can be improved in the future based on your results. Recommendations are used when you want to convey that something different should be done based on what your analyses revealed.

Similar to implications, recommendations are also evidence-based. This means that your recommendations to the field must be drawn directly from your results.

The goal of the recommendations is to make clear, specific, and realistic suggestions to future researchers before they conduct a similar experiment. No matter what area your research is in, there will always be further research to do. Try to think about what would be helpful for other researchers to know before starting their work.

Recommendations are also written in the discussion section. They come after the implications and before the concluding paragraphs. Similar to the implications, there is usually no specific section dedicated to the recommendations. However, depending on how many solutions you want to suggest to the field, they may be written as a subsection.

Key features of recommendations

• Statements about what can be done differently in the field based on your findings
• Must be realistic and specific
• Written in the discussion, after implications and before conclusions
• Related to both your field and, preferably, a wider context to the research

Examples of recommendations

Here are some research results and their recommendations.

A meta-analysis found that actively recalling material from your memory is better than simply re-reading it .

• The recommendation: Based on these findings, teachers and other educators should encourage students to practice active recall strategies.

A medical intervention found that daily exercise helps prevent cardiovascular disease .

• The recommendation: Based on these results, physicians are recommended to encourage patients to exercise and walk regularly. Also recommended is to encourage more walking through public health offices in communities.

A study found that many research articles do not contain the sample sizes needed to statistically confirm their findings .

The recommendation: To improve the current state of the field, researchers should consider doing power analysis based on their experiment's design.

What else is important about implications and recommendations?

When writing recommendations and implications, be careful not to overstate the impact of your results. It can be tempting for researchers to inflate the importance of their findings and make grandiose statements about what their work means.

Remember that implications and recommendations must be coming directly from your results. Therefore, they must be straightforward, realistic, and plausible.

Another good thing to remember is to make sure the implications and recommendations are stated clearly and separately. Do not attach them to the endings of other paragraphs just to add them in. Use similar example phrases as those listed in the table when starting your sentences to clearly indicate when it's an implication and when it's a recommendation.

When your peers, or brand-new readers, read your paper, they shouldn't have to hunt through your discussion to find the implications and recommendations. They should be clear, visible, and understandable on their own.

That'll get you cited more, and you'll make a greater contribution to your area of science while extending the life and impact of your work.

The AJE Team

See our "Privacy Policy"

• Differences between a finding, a conclusion, and a recommendation: examples
• Learning Center

Table of Contents

• Defining the Terms: What Is a Finding, a Conclusion, and a Recommendation in M&E?
• Why It Matters: Understanding the Importance of Differentiating between Findings, Conclusions, and Recommendations in M&E
• How to Identify and Distinguish between Findings, Conclusions, and Recommendations in M&E
• How to Communicate Findings, Conclusions, and Recommendations Effectively in M&E Reports
• The Benefits of Clear and Accurate Reporting of Findings, Conclusions, and Recommendations in M&E

1. Defining the Terms: What Is a Finding, a Conclusion, and a Recommendation in M&E?

Monitoring and Evaluation (M&E) is a critical process for assessing the effectiveness of development programs and policies. During the M&E process, evaluators collect and analyze data to draw conclusions and make recommendations for program improvement. In M&E, it is essential to differentiate between findings, conclusions, and recommendations to ensure that the evaluation report accurately reflects the program’s strengths, weaknesses, and potential areas for improvement.

In an evaluation report, a finding, a conclusion, and a recommendation serve different purposes and convey different information. Here are the differences between these three elements:

1.1 Finding

A finding is a factual statement that is based on evidence collected during the evaluation . It describes what was observed, heard, or experienced during the evaluation process. A finding should be objective, unbiased, and supported by data. Findings are typically presented in the form of a summary or a list of key points, and they provide the basis for the evaluation’s conclusions and recommendations.

Findings are an important part of the evaluation process, as they provide objective and unbiased information about what was observed, heard, or experienced during the evaluation. Findings are based on the evidence collected during the evaluation, and they should be supported by data and other relevant information. They are typically presented in a summary or list format, and they serve as the basis for the evaluation’s conclusions and recommendations. By presenting clear and accurate findings, evaluators can help stakeholders understand the strengths and weaknesses of the program or initiative being evaluated, and identify opportunities for improvement.

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1.2 Examples of Finding

Here are some examples of findings in M&E:

• “Program participants reported a high level of satisfaction with the quality of training provided, with 85% rating it as good or excellent.”
• “The program was successful in increasing the number of girls enrolled in secondary school, with a 25% increase observed in the target communities.”
• “Program beneficiaries reported improved access to healthcare services, with a 40% increase in the number of individuals accessing healthcare facilities in the program area.”
• “The program’s training curriculum was found to be outdated and ineffective, with only 30% of participants reporting that the training was useful.”
• “The program’s monitoring and evaluation system was found to be inadequate, with data quality issues and insufficient capacity among staff to carry out effective monitoring and evaluation activities.”

These findings represent objective, measurable results of the data collected during the M&E process, and can be used to inform program design and implementation, as well as to draw conclusions and make recommendations for improvement.

1.3 Conclusion

A conclusion is a judgment or interpretation of the findings based on the evidence collected during the evaluation. It is typically expressed in terms of what the findings mean or what can be inferred from them. Conclusions should be logical, evidence-based, and free from personal bias or opinion.

Conclusions often answer the evaluation questions or objectives, and they provide insights into the effectiveness or impact of the program, project, or intervention being evaluated. By synthesizing the findings into a cohesive narrative, evaluators can provide stakeholders with a clear and actionable understanding of the program or initiative being evaluated. Conclusions can also inform future planning and decision-making, by identifying areas for improvement and highlighting successful strategies or interventions. Overall, conclusions are a crucial component of the evaluation process, as they help stakeholders make informed decisions about the programs and initiatives they are involved in.

1.4 Examples of Conclusion

Here are some examples of conclusions in M&E:

• Based on the data collected, it can be concluded that the program was successful in achieving its objective of increasing access to clean water in the target communities.”
• “The data indicates that the program’s training curriculum is ineffective and in need of revision in order to better meet the needs of participants.”
• “It can be concluded that the program’s community mobilization efforts were successful in increasing community participation and ownership of the program.”
• “Based on the data collected, it is concluded that the program’s impact on improving maternal and child health outcomes is limited and further efforts are needed to address the underlying health system and infrastructure issues.”
• “The data collected indicates that the program’s impact on reducing poverty in the target area is modest, but still significant, and further investment in complementary programs may be needed to achieve more substantial reductions in poverty rates.”
• These conclusions are based on the evidence presented in the findings and represent the interpretation or explanation of the meaning of the findings. They help to provide insight into the impact and effectiveness of the program and can be used to make recommendations for improvement.

1.5 Recommendation

A recommendation is a specific action or set of actions proposed based on the findings and conclusions of the evaluation. Recommendations should be practical, feasible, and tailored to the needs of the stakeholders who will be implementing them. They should be supported by evidence and aligned with the goals of the program, project, or intervention being evaluated.

Recommendations often provide guidance on how to improve the effectiveness or efficiency of the program, project, or intervention, and they can help to inform decision-making and resource allocation. By presenting clear and actionable recommendations, evaluators can help stakeholders identify and prioritize areas for improvement, and develop strategies to address identified issues. Recommendations can also serve as a roadmap for future planning and implementation and can help to ensure that the program or initiative continues to achieve its intended outcomes over time.

Overall, recommendations are an essential component of the evaluation process, as they help to bridge the gap between evaluation findings and programmatic action. By proposing specific and evidence-based actions, evaluators can help to ensure that evaluation results are translated into meaningful improvements in program design, implementation, and outcomes.

1.6 Examples of Recommendation

Here are some examples of recommendations in M&E:

• “To improve the effectiveness of the program’s training, the curriculum should be revised to better meet the needs of participants, with a focus on practical, hands-on learning activities.”
• “To address the data quality issues identified in the monitoring and evaluation system, staff should receive additional training on data collection and management, and the system should be revised to incorporate additional quality control measures.”
• “To build on the success of the program’s community mobilization efforts, further investments should be made in strengthening community-based organizations and networks, and in promoting greater community participation in program planning and decision-making.”
• “To improve the program’s impact on maternal and child health outcomes, efforts should be made to address underlying health system and infrastructure issues, such as improving access to health facilities and training health workers.”
• “To achieve more substantial reductions in poverty rates in the target area, complementary programs should be implemented to address issues such as economic development, education, and social protection.”

These recommendations are specific actions that can be taken based on the findings and conclusions of the M&E process. They should be practical, feasible, and based on the evidence presented in the evaluation report. By implementing these recommendations, development practitioners can improve program effectiveness and impact, and better meet the needs of the target population.

2. Why It Matters: Understanding the Importance of Differentiating between Findings, Conclusions, and Recommendations in M&E

Differentiating between findings, conclusions, and recommendations is crucial in M&E for several reasons. First, it ensures accuracy and clarity in the evaluation report. Findings, conclusions, and recommendations are distinct components of an evaluation report, and they serve different purposes. By clearly defining and differentiating these components, evaluators can ensure that the report accurately reflects the program’s strengths and weaknesses, potential areas for improvement, and the evidence supporting the evaluation’s conclusions.

Second, differentiating between findings, conclusions, and recommendations helps to facilitate evidence-based decision-making. By clearly presenting the evidence supporting the evaluation’s findings and conclusions, and making recommendations based on that evidence, evaluators can help program managers and policymakers make informed decisions about program design, implementation, and resource allocation.

Finally, differentiating between findings, conclusions, and recommendations can help to increase the credibility and trustworthiness of the evaluation report. Clear and accurate reporting of findings, conclusions, and recommendations helps to ensure that stakeholders understand the evaluation’s results and recommendations, and can have confidence in the evaluation’s rigor and objectivity.

In summary, differentiating between findings, conclusions, and recommendations is essential in M&E to ensure accuracy and clarity in the evaluation report, facilitate evidence-based decision-making, and increase the credibility and trustworthiness of the evaluation.

3. How to Identify and Distinguish between Findings, Conclusions, and Recommendations in M&E

Identifying and distinguishing between findings, conclusions, and recommendations in M&E requires careful consideration of the evidence and the purpose of each component. Here are some tips for identifying and distinguishing between findings, conclusions, and recommendations in M&E:

• Findings: Findings are the results of the data analysis and should be objective and evidence-based. To identify findings, look for statements that summarize the data collected and analyzed during the evaluation. Findings should be specific, measurable, and clearly stated.
• Conclusions: Conclusions are interpretations of the findings and should be supported by the evidence. To distinguish conclusions from findings, look for statements that interpret or explain the meaning of the findings. Conclusions should be logical and clearly explained, and should take into account any limitations of the data or analysis.
• Recommendations: Recommendations are specific actions that can be taken based on the findings and conclusions. To distinguish recommendations from conclusions, look for statements that propose actions to address the issues identified in the evaluation. Recommendations should be practical, feasible, and clearly explained, and should be based on the evidence presented in the findings and conclusions.

It is also important to ensure that each component is clearly labeled and presented in a logical order in the evaluation report. Findings should be presented first, followed by conclusions and then recommendations.

In summary, identifying and distinguishing between findings, conclusions, and recommendations in M&E requires careful consideration of the evidence and the purpose of each component. By ensuring that each component is clearly labeled and presented in a logical order, evaluators can help to ensure that the evaluation report accurately reflects the program’s strengths, weaknesses, and potential areas for improvement, and facilitates evidence-based decision-making.

4. How to Communicate Findings, Conclusions, and Recommendations Effectively in M&E Reports

Communicating findings, conclusions, and recommendations effectively in M&E reports is critical to ensuring that stakeholders understand the evaluation’s results and recommendations and can use them to inform decision-making. Here are some tips for communicating findings, conclusions, and recommendations effectively in M&E reports:

• Use clear and concise language: Use clear, simple language to explain the findings, conclusions, and recommendations. Avoid technical jargon and use examples to illustrate key points.
• Present data visually: Use tables, graphs, and charts to present data visually, making it easier for stakeholders to understand and interpret the findings.
• Provide context: Provide context for the findings, conclusions, and recommendations by explaining the evaluation’s purpose, methodology, and limitations. This helps stakeholders understand the scope and significance of the evaluation’s results and recommendations.
• Highlight key points: Use headings, bullet points, and other formatting techniques to highlight key points, making it easier for stakeholders to identify and remember the most important findings, conclusions, and recommendations.
• Be objective: Present the findings, conclusions, and recommendations objectively and avoid bias. This helps to ensure that stakeholders have confidence in the evaluation’s rigor and objectivity.
• Tailor the report to the audience: Tailor the report to the audience by using language and examples that are relevant to their interests and needs. This helps to ensure that the report is accessible and useful to stakeholders.

In summary, communicating findings, conclusions, and recommendations effectively in M&E reports requires clear and concise language, visual presentation of data, contextualization, highlighting of key points, objectivity, and audience-tailoring. By following these tips, evaluators can help to ensure that stakeholders understand the evaluation’s results and recommendations and can use them to inform decision-making.

5. The Benefits of Clear and Accurate Reporting of Findings, Conclusions, and Recommendations in M&E

Clear and accurate reporting of M&E findings, conclusions, and recommendations has many benefits for development programs and policies. One of the most significant benefits is improved program design and implementation. By clearly identifying areas for improvement, program designers and implementers can make adjustments that lead to more effective and efficient programs that better meet the needs of the target population.

Another important benefit is evidence-based decision-making. When M&E findings, conclusions, and recommendations are reported accurately and clearly, decision-makers have access to reliable information on which to base their decisions. This can lead to more informed decisions about program design, implementation, and resource allocation.

Clear and accurate reporting of M&E findings, conclusions, and recommendations also supports accountability. By reporting transparently on program performance, development practitioners can build trust and support among stakeholders, including program beneficiaries, donors, and the general public.

M&E findings, conclusions, and recommendations also support continuous learning and improvement. By identifying best practices, lessons learned, and areas for improvement, development practitioners can use this information to improve future programming.

Finally, clear and accurate reporting of M&E findings, conclusions, and recommendations can increase program impact. By identifying areas for improvement and supporting evidence-based decision-making, development programs can have a greater positive impact on the communities they serve.

In summary, clear and accurate reporting of M&E findings, conclusions, and recommendations is critical for improving program design and implementation, supporting evidence-based decision-making, ensuring accountability, supporting continuous learning and improvement, and increasing program impact. By prioritizing clear and accurate reporting, development practitioners can ensure that their programs are effective, efficient, and have a positive impact on the communities they serve.

Very interesting reading which clearly explain the M&E finding, recommendation and conclusion, which sometimes the terms can be confusing

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Conducting Biosocial Surveys: Collecting, Storing, Accessing, and Protecting Biospecimens and Biodata (2010)

Chapter: 5 findings, conclusions, and recommendations, 5 findings, conclusions, and recommendations.

A s the preceding chapters have made clear, incorporating biological specimens into social science surveys holds great scientific potential, but also adds a variety of complications to the tasks of both individual researchers and institutions. These complications arise in a number of areas, including collecting, storing, using, and distributing biospecimens; sharing data while protecting privacy; obtaining informed consent from participants; and engaging with Institutional Review Boards (IRBs). Any effort to make such research easier and more effective will need to address the issues in these areas.

In considering its recommendations, the panel found it useful to think of two categories: (1) recommendations that apply to individual investigators, and (2) recommendations that are addressed to the National Institute on Aging (NIA) or other institutions, particularly funding agencies. Researchers who wish to collect biological specimens with social science data will need to develop new skills in a variety of areas, such as the logistics of specimen storage and management, the development of more diverse informed consent forms, and ways of dealing with the disclosure risks associated with sharing biogenetic data. At the same time, NIA and other funding agencies must provide researchers the tools they need to succeed. These tools include such things as biorepositories for maintaining and distributing specimens, better guidance on informed consent policies, and better ways to share data without risking confidentiality.

TAKING ADVANTAGE OF EXISTING EXPERTISE

Although working with biological specimens will be new and unfamiliar to many social scientists, it is an area in which biomedical researchers have a great deal of expertise and experience. Many existing documents describe recommended procedures and laboratory practices for the handling of biospecimens. These documents provide an excellent starting point for any social scientist who is interested in adding biospecimens to survey research.

Recommendation 1: Social scientists who are planning to add biological specimens to their survey research should familiarize themselves with existing best practices for the collection, storage, use, and distribution of biospecimens. First and foremost, the design of the protocol for collec tion must ensure the safety of both participants and survey staff (data and specimen collectors and handlers).

Although existing best-practice documents were not developed with social science surveys in mind, their guidelines have been field-tested and approved by numerous IRBs and ethical oversight committees. The most useful best-practice documents are updated frequently to reflect growing knowledge and changing opinions about the best ways to collect, store, use, and distribute biological specimens. At the same time, however, many issues arising from the inclusion of biospecimens in social science surveys are not fully addressed in the best-practice documents intended for biomedical researchers. For guidance on these issues, it will be necessary to seek out information aimed more specifically at researchers at the intersection of social science and biomedicine.

COLLECTING, STORING, USING, AND DISTRIBUTING BIOSPECIMENS

As described in Chapter 2 , the collection, storage, use, and distribution of biospecimens and biodata are tasks that are likely to be unfamiliar to many social scientists and that raise a number of issues with which even specialists are still grappling. For example, which biospecimens in a repository should be shared, given that in most cases the amount of each specimen is limited? And given that the available technology for cost-efficient analysis of biospecimens, particularly genetic analysis, is rapidly improving, how much of any specimen should be used for immediate research and analysis, and how much should be stored for analysis at a later date? Collecting, storing, using, and distributing biological specimens also present significant practical and financial challenges for social scientists. Many of the questions they must address, such as exactly what should be held, where it should be held, and what should be shared or distributed, have not yet been resolved.

Developing Data Sharing Plans

An important decision concerns who has access to any leftover biospecimens. This is a problem more for biospecimens than for biodata because in most cases, biospecimens can be exhausted. Should access be determined according to the principle of first funded, first served? Should there be a formal application process for reviewing the scientific merits of a particular investigation? For studies that involve international collaboration, should foreign investigators have access? And how exactly should these decisions be made? Recognizing that some proposed analyses may lie beyond the competence of the original investigators, as well as the possibility that principal investigators may have a conflict of interest in deciding how to use any remaining biospecimens, one option is for a principal investigator to assemble a small scientific committee to judge the merits of each application, including the relevance of the proposed study to the parent study and the capacities of the investigators. Such committees should publish their review criteria to help prospective applicants. A potential problem with such an approach, however, is that many projects may not have adequate funding to carry out such tasks.

Recommendation 2: Early in the planning process, principal investigators who will be collecting biospecimens as part of a social science survey should develop a complete data sharing plan.

This plan should spell out the criteria for allowing other researchers to use (and therefore deplete) the available stock of biospecimens, as well as to gain access to any data derived therefrom. To avoid any appearance of self-interest, a project might empower an external advisory board to make decisions about access to its data. The data sharing plan should also include provisions for the storage and retrieval of biospecimens and clarify how the succession of responsibility for and control of the biospecimens will be handled at the conclusion of the project.

Recommendation 3: NIA (or preferably the National Institutes of Health [NIH]) should publish guidelines for principal investigators containing a list of points that need to be considered for an acceptable data sharing plan. In addition to staff review, Scientific Review Panels should read and comment on all proposed data sharing plans. In much the same way as an unacceptable human subjects plan, an inadequate data sharing plan should hold up an otherwise acceptable proposal.

Supporting Social Scientists in the Storage of Biospecimens

The panel believes that many social scientists who decide to add the collection of biospecimens to their surveys may be ill equipped to provide for the storage and distribution of the specimens.

Conclusion: The issues related to the storage and distribution of biospecimens are too complex and involve too many hidden costs to assume that social scientists without suitable knowledge, experience, and resources can handle them without assistance.

Investigators should therefore have the option of delegating the storage and distribution of biospecimens collected as part of social science surveys to a centralized biorepository. Depending on the circumstances, a project might choose to utilize such a facility for immediate use, long-term or archival storage, or not at all.

Recommendation 4: NIA and other relevant funding agencies should support at least one central facility for the storage and distribution of biospecimens collected as part of the research they support.

PROTECTING PRIVACY AND CONFIDENTIALITY: SHARING DIGITAL REPRESENTATIONS OF BIOLOGICAL AND SOCIAL DATA

Several different types of data must be kept confidential: survey data, data derived from biospecimens, and all administrative and operational data. In the discussion of protecting confidentiality and privacy, this report has focused on biodata, but the panel believes it is important to protect all the data collected from survey participants. For many participants, for example, data on wealth, earnings, or sexual behavior can be as or more sensitive than genetic data.

Conclusion: Although biodata tend to receive more attention in discussions of privacy and confidentiality, social science and operational data can be sensitive in their own right and deserve similar attention in such discussions.

Protecting the participants in a social science survey that collects biospecimens requires securing the data, but data are most valuable when they are made available to researchers as widely as possible. Thus there is an inherent tension between the desire to protect the privacy of the participants and the desire to derive as much scientific value from the data as possible, particularly since the costs of data collection and analysis are so high. The following recommendations regarding confidentiality are made in the spirit of balancing these equally important needs.

Genomic data present a particular challenge. Several researchers have demonstrated that it is possible to identify individuals with even modest amounts of such data. When combined with social science data, genomic data may pose an even greater risk to confidentiality. It is difficult to know how much or which genomic data, when combined with social science data, could become critical identifiers in the future. Although the problem is most significant with genomic data, similar challenges can arise with other kinds of data derived from biospecimens.

Conclusion: Unrestricted distribution of genetic and other biodata risks violating promises of confidentiality made to research participants.

There are two basic approaches to protecting confidentiality: restricting data and restricting access. Restricting data—for example, by stripping individual and spatial identifiers and modifying the data to make it difficult or impossible to trace them back to their source—usually makes it possible to release social science data widely. In the case of biodata, however, there is no answer to how little data is required to make a participant uniquely identifiable. Consequently, any release of biodata must be carefully managed to protect confidentiality.

Recommendation 5: No individual-level data containing uniquely identify ing variables, such as genomic data, should be publicly released without explicit informed consent.

Recommendation 6: Genomic data and other individual-level data con taining uniquely identifying variables that are stored or in active use by investigators on their institutional or personal computers should be encrypted at all times.

Even if specific identifying variables, such as names and addresses, are stripped from data, it is still often possible to identify the individuals associated with the data by other means, such as using the variables that remain (age, sex, marital status, family income, etc.) to zero in on possible candidates. In the case of biodata that do not uniquely identify individuals and can change with time, such as blood pressure and physical measurements, it may be possible to share the data with no more protection than stripping identifying variables. Even these data, however, if known to intruders, can increase identification disclosure risk when combined with enough other data. With sufficient characteristics to match, intruders can uniquely identify individuals in shared data if given access to another data source that contains the same information plus identifiers.

Conclusion: Even nonunique biodata, if combined with social science data, may pose a serious risk of reidentification.

In the case of high-dimensional genomic data, standard disclosure limitation techniques, such as data perturbation, are not effective with respect to preserving the utility of the data because they involve such extreme alterations that they would severely distort analyses aimed at determining gene–gene and gene–environment interactions. Standard disclosure limitation methods could be used to generate public-use data sets that would enable low-dimensional analyses involving genes, for example, one gene at a time. However, with several such public releases, it may be possible for a key match to be used to construct a data set with higher-dimensional genomic data.

Conclusion: At present, no data restriction strategy has been demonstrated to protect confidentiality while preserving the usefulness of the data for drawing inferences involving high-dimensional interactions among genomic and social science variables, which are increasingly the target of research. Providing public-use genomic data requires such intense data masking to protect confidentiality that it would distort the high-dimensional analyses that could result in ground-breaking research progress.

Recommendation 7: Both rich genomic data acquired for research and sensitive and potentially identifiable social science data that do not change (or change very little) with time should be shared only under restricted circumstances, such as licensing and (actual or virtual) data enclaves.

As discussed in Chapter 3 , the four basic ways to restrict access to data are licensing, remote execution centers, data enclaves, and virtual data enclaves. Each has its advantages and disadvantages. 1 Licensing, for example, is the least restrictive for a researcher in terms of access to the data, but the licensing process itself can be lengthy and burdensome. Thus it would be useful if the licensing process could be facilitated.

Recommendation 8: NIA (or preferably NIH) should develop new stan dards and procedures for licensing confidential data in ways that will maximize timely access while maintaining security and that can be used by data repositories and by projects that distribute data.

Ways to improve the other approaches to restricted access are needed as well. For example, improving the convenience and availability of virtual data enclaves could increase the use of combined social science and biodata without

a significant increase in risk to confidentiality. The panel notes that much of the discussion of the confidentiality risk posed by the various approaches is theoretical; no one has a clear idea of just what disclosure risks are associated with the various ways of sharing data. It is important to learn more about these disclosure risks for a variety of reasons—determining how to minimize the risks, for instance, or knowing which approaches to sharing data pose the least risk. It would also be useful to be able to describe disclosure risks more accurately to survey participants.

Recommendation 9: NIA and other funding agencies should assess the strength of confidentiality protections through periodic expert audits of confidentiality and computer security. Willingness to participate in such audits should be a condition for receipt of NIA support. Beyond enforce ment, the purpose of such audits would be to identify challenges and solutions.

Evaluating risks and applying protection methods, whether they involve restricted access or restricted data, is a complex process requiring expertise in disclosure protection methods that exceeds what individual principal investigators and their institutions usually possess. Currently, not enough is known to be able to represent these risks either fully or accurately. The NIH requirement for data sharing necessitates a large investment of resources to anticipate which variables are potentially available to intruders and to alter data in ways that reduce disclosure risks while maintaining the utility of the data. Such resources are better spent by principal investigators on collecting and analyzing the data.

Recommendation 10: NIH should consider funding Centers of Excellence to explore new ways of protecting digital representations of data and to assist principal investigators wishing to share data with others. NIH should also support research on disclosure risks and limitations.

Principal investigators could send digital data to these centers, which would organize and manage any restricted access or restricted data policies or provide advisory services to investigators. NIH would maintain the authority to penalize those who violated any confidentiality agreements, for example, by denying them or their home institution NIH funding. Models for these centers include the Inter-university Consortium for Political and Social Research (ICPSR) and its projects supported by NIH and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the UK data sharing archive. The centers would alleviate the burden of data sharing as mandated of principal investigators by NIH and place it in expert hands. However, excellence in the design of data access and control systems

is likely to require intimate knowledge of each specific data resource, so data producers should be involved in the systems’ development.

INFORMED CONSENT

As described in Chapter 4 , informed consent is a complex subject involving many issues that are still being debated; the growing power of genetic analysis techniques and bioinformatics has only added to this complexity. Given the rapid pace of advances in scientific knowledge and in the technology used to analyze biological materials, it is impossible to predict what information might be gleaned from biological specimens just a few years hence; accordingly, it is impossible, even in theory, to talk about perfectly informed consent. The best one can hope for is relatively well-informed consent from a study’s participants, but knowing precisely what that means is difficult. Determining the scope of informed consent adds another layer of complexity. Will new analyses be covered under the existing consent, for example? There are no clear guidelines on such questions, yet specific details on the scope of consent will likely affect an IRB’s reaction to a study proposal.

What Individual Researchers Need to Know and Do Regarding Informed Consent

To be sure, there is a wide range of views about the practicality of providing adequate protection to participants while proceeding with the scientific enterprise, from assertions that it is simply not possible to provide adequate protection to offers of numerous procedural safeguards but no iron-clad guarantees. This report takes the latter position—that investigators should do their best to communicate adequately and accurately with participants, to provide procedural safeguards to the extent possible, and not to promise what is not possible. 2 Social science researchers need to know that adding the collection of biospecimens to social science surveys changes the nature of informed consent. Informed consent for a traditional social science survey may entail little more than reading a short script over the phone and asking whether the participant is willing to continue; obtaining informed consent for the collection and use of biospecimens and biodata is generally a much more involved process.

Conclusion: Social scientists should be made aware that the process of obtaining informed consent for the use of biospecimens and biodata typically differs from social science norms.

If participants are to provide truly informed consent to taking part in any study, they must be given a certain minimum amount of information. They should be told, for example, what the purpose of the study is, how it is to be carried out, and what participants’ roles are. In addition, because of the unique risks associated with providing biospecimens, participants in a social science survey that involves the collection of such specimens should be provided with other types of information as well. In particular, they should be given detail on the storage and use of the specimens that relates to those risks and can assist them in determining whether to take part in the study.

Recommendation 11: In designing a consent form for the collection of biospecimens, in addition to those elements that are common to social science and biomedical research, investigators should ensure that certain other information is provided to participants:

how long researchers intend to retain their biospecimens and the genomic and other biodata that may be derived from them;

both the risks associated with genomic data and the limits of what they can reveal;

which other researchers will have access to their specimens, to the data derived therefrom, and to information collected in a survey questionnaire;

the limits on researchers’ ability to maintain confidentiality;

any potential limits on participants’ ability to withdraw their speci mens or data from the research;

the penalties 3 that may be imposed on researchers for various types of breaches of confidentiality; and

what plans have been put in place to return to them any medically relevant findings.

Researchers who fail to properly plan for and handle all of these issues before proceeding with a study are in essence compromising assurances under informed consent. The literature on informed consent emphasizes the importance of ensuring that participants understand reasonably well what they are consenting to. This understanding cannot be taken for granted, particularly as it pertains to the use of biological specimens and the data derived therefrom.

While it is not possible to guarantee that participants have a complete understanding of the scientific uses of their specimens or all the possible risks of their participation, they should be able to make a relatively well-informed decision about whether to take part in the study. Thus the ability of various participants to understand the research and the informed consent process must be considered. Even impaired individuals may be able to participate in research if their interests are protected and they can do so only through proxy consent. 4

Recommendation 12: NIA should locate and publicize positive examples of the documentation of consent processes for the collection of biospeci mens. In particular, these examples should take into account the special needs of certain individuals, such as those with sensory problems and the cognitively impaired.

Participants in a biosocial survey are likely to have different levels of comfort concerning how their biospecimens and data will be used. Some may be willing to provide only answers to questions, for example, while others may both answer questions and provide specimens. Among those who provide specimens, some may be willing for the specimens to be used only for the current study, while others may consent to their use in future studies. One effective way to deal with these different comfort levels is to offer a tiered approach to consent that allows participants to determine just how their specimens and data will be used. Tiers might include participating in the survey, providing specimens for genetic and/or nongenetic analysis in a particular study, and allowing the specimens and data to be stored for future uses (genetic and/or nongenetic). For those participants who are willing to have their specimens and data used in future studies, researchers should tell them what sort of approval will be obtained for such use. For example, an IRB may demand reconsent, in which case participants may have to be contacted again before their specimens and data can be used. Ideally, researchers should design their consent forms to avoid the possibility that an IRB will demand a costly or infeasible reconsent process.

Recommendation 13: Researchers should consider adopting a tiered approach to obtaining consent. Participants who are willing to have their specimens and data used in future studies should be informed about the process that will be used to obtain approval for such uses.

What Institutions Should Do Regarding Informed Consent

Because the details of informed consent vary from study to study, individual investigators must bear ultimate responsibility for determining the details of informed consent for any particular study. Thus researchers must understand the various issues and concerns surrounding informed consent and be prepared to make decisions about the appropriate approach for their research in consultation with staff of survey organizations. These decisions should be addressed in the training of survey interviewers. As noted above, however, the issues surrounding informed consent are complex and not completely resolved, and researchers have few options for learning about informed consent as it applies to social science studies that collect biospecimens. Thus it makes sense for agencies funding this research, the Office for Human Research Protection (OHRP), or other appropriate organizations (for example, Public Responsibility in Medicine and Research [PRIM&R]) to provide opportunities for such learning, taking into account the fact that the issues arising in biosocial research do not arise in the standard informed consent situations encountered in social science research. It should also be made clear that the researchers’ institution is usually deemed (e.g., in the courts) to bear much of the responsibility for informed consent.

Recommendation 14: NIA, OHRP, and other appropriate organizations should sponsor training programs, create training modules, and hold informational workshops on informed consent for investigators, staff of survey organizations, including field staff, administrators, and mem bers of IRBs who oversee surveys that collect social science data and biospecimens.

The Return of Medically Relevant Information

An issue related to informed consent is how much information to provide to survey participants once their biological specimens have been analyzed and in particular, how to deal with medically relevant information that may arise from the analysis. What, for example, should a researcher do if a survey participant is found to have a genetic disease that does not appear until later in life? Should the participant be notified? Should participants be asked as part of the initial interview whether they wish to be notified about such a discovery? At this time, there are no generally agreed-upon answers to such questions, but researchers should expect to have to deal with these issues as they analyze the data derived from biological specimens.

Recommendation 15: NIH should direct investigators to formulate a plan in advance concerning the return of any medically relevant findings to

survey participants and to implement that plan in the design and conduct of their informed consent procedures.

INSTITUTIONAL REVIEW BOARDS

Investigators seeking IRB approval for biosocial research face a number of challenges. Few IRBs are familiar with both social and biological science; thus, investigators may find themselves trying to justify standard social science protocols to a biologically oriented IRB or explaining standard biological protocols to an IRB that is used to dealing with social science—or sometimes both. Researchers can expect these obstacles, which arise from the interdisciplinary nature of their work, to be exacerbated by a number of other factors that are characteristic of IRBs in general (see Chapter 4 ).

Recommendation 16: In institutions that have separate biomedical and social science IRBs, mechanisms should be created for sharing expertise during the review of biosocial protocols. 5

What Individual Researchers Need to Do Regarding IRBs

Because the collection of biospecimens as part of social science surveys is still relatively unfamiliar to many IRBs, researchers planning such a study can expect their interactions with the IRB overseeing the research to involve a certain learning curve. The IRB may need extra time to become familiar and comfortable with the proposed practices of the survey, and conversely, the researchers will need time to learn what the IRB will require. Thus it will be advantageous if researchers conducting such studies plan from the beginning to devote additional time to working with their IRBs.

Recommendation 17: Investigators considering collecting biospecimens as part of a social science survey should consult with their IRBs early and often.

What Research Agencies Should Do Regarding IRBs

One way to improve the IRB process would be to give members of IRBs an opportunity to learn more about biosocial research and the risks it entails.

This could be done by individual institutions, but it would be more effective if a national funding agency took the lead (see Recommendation 14).

It is the panel’s hope that its recommendations will support the incorporation of social science and biological data into empirical models, allowing researchers to better document the linkages among social, behavioral, and biological processes that affect health and other measures of well-being while avoiding or minimizing many of the challenges that may arise. Implementing these recommendations will require the combined efforts of both individual investigators and the agencies that support them.

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Recent years have seen a growing tendency for social scientists to collect biological specimens such as blood, urine, and saliva as part of large-scale household surveys. By combining biological and social data, scientists are opening up new fields of inquiry and are able for the first time to address many new questions and connections. But including biospecimens in social surveys also adds a great deal of complexity and cost to the investigator's task. Along with the usual concerns about informed consent, privacy issues, and the best ways to collect, store, and share data, researchers now face a variety of issues that are much less familiar or that appear in a new light.

In particular, collecting and storing human biological materials for use in social science research raises additional legal, ethical, and social issues, as well as practical issues related to the storage, retrieval, and sharing of data. For example, acquiring biological data and linking them to social science databases requires a more complex informed consent process, the development of a biorepository, the establishment of data sharing policies, and the creation of a process for deciding how the data are going to be shared and used for secondary analysis--all of which add cost to a survey and require additional time and attention from the investigators. These issues also are likely to be unfamiliar to social scientists who have not worked with biological specimens in the past. Adding to the attraction of collecting biospecimens but also to the complexity of sharing and protecting the data is the fact that this is an era of incredibly rapid gains in our understanding of complex biological and physiological phenomena. Thus the tradeoffs between the risks and opportunities of expanding access to research data are constantly changing.

Conducting Biosocial Surveys offers findings and recommendations concerning the best approaches to the collection, storage, use, and sharing of biospecimens gathered in social science surveys and the digital representations of biological data derived therefrom. It is aimed at researchers interested in carrying out such surveys, their institutions, and their funding agencies.

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Institute of Medicine (US) Committee on Serious and Complex Medical Conditions; Chrvala CA, Sharfstein S, editors. Definition of Serious and Complex Medical Conditions. Washington (DC): National Academies Press (US); 1999.

Definition of Serious and Complex Medical Conditions.

• Hardcopy Version at National Academies Press

3 Conclusions and Recommendations

• Introduction

Throughout the course of this study, the committee has been extremely aware of the fact that the topic addressed by this report concerns one of the most critical issues confronting HCFA, health care plans and providers, and patients today. The Medicare+Choice regulations focus on the most vulnerable populations in need of medical care and other services—those with serious or complex medical conditions. Caring for these highly vulnerable populations poses a number of challenges.

In the absence of a fully developed research and clinical knowledge base, combined with the time and resource constraints of this study, the committee chose what it believes is the most prudent and thoughtful approach to its charge. Specifically, the committee has chosen to provide guidance to HCFA and health care plans to support initial steps to address the major issues confronting health care plans and their beneficiaries with serious and complex medical conditions. This guidance is supported by presentation of possible strategies that might be used to screen enrollees for the presence of serious and complex medical conditions. Health care plans are encouraged to be innovative in their initial efforts to develop case-screening methodologies. As plans develop experience with different screening modalities, information can be shared nationally. It is the committee's intent that this will lead to the identification of best practices and subsequent standardized methods for ongoing screening of beneficiaries for serious and complex conditions. The committee also recommends strategies to ensure that the care offered to persons with serious and complex conditions is responsive to the diverse, multidisciplinary needs for services to address a full spectrum of medical, social, and mental health issues. Finally, the committee feels strongly that evaluation and research efforts must occur simultaneously with the implementation of the guidance and recommendations concerning screening and care of patients with serious and complex medical conditions. As HCFA and health care plans develop the necessary expertise and resources to provide comprehensive, multidisciplinary care to patients with serious and complex conditions, this knowledge can be generalized to address the needs of patients with serious but not complex and complex but not serious medical conditions. The following conclusions and recommendations are based on consideration of these diverse issues.

Recommendation 1: The establishment of an administrative definition for serious and complex medical conditions by the Health Care Financing Administration would be premature at this time.

It is the opinion of the committee that the current state of clinical and research literature does not support development of an operational definition for serious and complex medical conditions. There are a large number of potential ways to screen and identify patients with serious and complex medical conditions, although each has its own set of limitations. Disease classification systems such as diagnosis-related groups, diagnostic cost groups, and the International Classification of Diseases—Ninth Edition lack the sensitivity and specificity required to effectively distinguish between patients with acute care needs and those who need more extensive treatment and service arrays. The validity of patient classifications systems (e.g., diagnosis-related groups) and functional status definitions (e.g., Karnofsky and SF-36 scales) has not yet been determined. Efforts to develop case-mix-adjusted reimbursement systems to ensure cost-effectiveness and high-quality interventions for patients with serious and complex conditions are still in the early stages or are limited to only a single disease category. Similarly, efforts to develop standardized protocols for care coordination, continuity of care, care management strategies, and service reimbursement plans have met with varying degrees of success.

Clinical research relevant to defining patient populations as having serious and complex conditions and developing the most effective care protocols to respond to patient needs is evolving rapidly, but only preliminary results are available. For example, research in correlating patient volume with patient outcomes, differentiating access to services as a function of health plan benefits, and addressing variations in quality of care has just begun to yield meaningful results about particular groups of patients. The committee anticipates that this research will continue to evolve and will provide more definitive conclusions to guide the efforts of health plans to identify patients with serious and complex medical conditions and ensure appropriate levels of treatment and care management. As the science base is strengthened, so too will be the ability of HCFA and health plans to correctly identify patients with serious and complex medical conditions who would benefit from broad strategies of care management.

Recognizing these limitations, the committee recommends that plans first focus their attentions on patient populations with conditions that are serious AND complex. These conditions are described as persistent, substantially disabling or life threatening that require treatments and interventions across a broad scope of medical, social, and mental health services. Plans will require time to develop expertise and resources to develop methods of case finding and provision of an integrated care management approach for these patients. As such expertise is developed and resources are allocated, plans can then expand their efforts to include patients with serious but not complex conditions and those with complex but not serious conditions.

Recommendation 2: The committee recommends that the Health Care Financing Administration should provide guidance to health plans to assist their efforts to identify patients with serious and complex medical conditions. Specifically, the committee recommends the following language be used to facilitate efforts of plans to identify their enrollees with ''serious and complex conditions": "A serious and complex condition is one that is persistent and substantially disabling or life threatening that requires treatments and services across a variety of domains of care to ensure the best possible outcomes for each unique patient of member."

The committee recognizes the importance at this time of providing health plans with guidance to facilitate operationalization of their own definitions of serious and complex medical conditions. This guidance includes a description of a serious and complex medical condition as one that is persistent and substantially disabling or life threatening that requires treatments and services across a variety of domains of care. The committee reviewed a number of possible categories of conditions that might be considered serious and complex. These are discussed in Chapter 1 of this report and include, but are not limited to, life-threatening conditions, conditions that cause serious disability without necessarily being life threatening, conditions associated with severe consequences, conditions affecting multiple organ systems, conditions requiring coordination of management by multiple specialties, and conditions requiring treatments that carry a risk of serious complications.

Clinical research to identify patient populations with serious and complex medical conditions and develop the most effective care management strategies to respond to patient needs is evolving rapidly, with only preliminary results available. The current state of clinical and research literature does not adequately address all of the challenges and issues relevant to the identification and care of these patients. These issues include, but are not limited to, identification of methods and criteria that can be applied to screen enrollees for the presence of serious and complex conditions; development of strategies for proper care and management of the complex array of medical, social, and mental health problems confronting these patients; development of strategies to evaluate the effectiveness, efficacy, and efficiency of different strategies of care management; and ongoing research to ensure continuous improvements in the care of patients. Health care service research is only beginning to emerge with initial findings relevant to these issues.

The committee anticipates that this research will continue to evolve and provide more definitive conclusions to guide the efforts of health plans to identify patients with serious and complex medical conditions and help plans to provide appropriate levels of treatment and care management. The committee urges health care plans, in collaboration with federal agencies and research institutions, to support this ongoing research and facilitate a synthesis of emerging results. As the science base is strengthened, so too will be the ability of HCFA and health plans to correctly identify patients who would benefit from a broad care management strategy including those with serious but not complex or complex but not serious conditions.

Recommendation 3: The committee recommends that health plans develop a broad strategy for care management to enable patients and providers to achieve the best possible outcomes for each unique patient or member with a serious or complex medical condition.

This care management strategy should include, but not necessarily be limited to, case finding; screening and selection; problem assessment and identification of strengths; development of treatment or care plans; implementation of care plans with an emphasis on proactive interventions; and monitoring of care plan implementation and outcomes.

The treatments for individuals with serious and complex medical conditions will inevitably vary due to many factors, including characteristics of the individual patient and the patient's social situation, characteristics of individual providers, provider organizations, health plans, resources in the community, health plan benefits, and so forth. Although these factors will vary for all patients, they have less impact on preventive care (e.g., immunizations) and acute care (e.g., setting a broken arm) interventions. Successful outcomes for persons with serious and complex medical conditions will rely on a diverse mix of medical, social, functional, financial, and psychological factors, as well as on how these factors mesh with a community's health and social services resources. There is no single guideline that can prescribe the care or treatments for persons with serious and complex medical conditions.

The committee's recommendations concerning elements of the care management strategy have been derived, in part, from existing publications (Case Management Society of America, 1996; HMO Workgroup on Care Management, 1999). A brief explanation for each of the recommended steps in the care process is provided below.

Case finding refers to methods for identifying persons who may have a serious and complex medical condition. Utilization of the committee's recommended description for serious and complex conditions can facilitate efforts by health plans and providers to identify possible categories of patients for whom case finding should be conducted. Depending on the organization of a health plan and its provider group(s), case finding methods may include electronic searching of administrative databases; phone screening of new or existing members; referral by patient or family member; referral by a clinician or other professional; or notification by an emergency room, hospital, nursing home, or other provider organization.

Case screening and selection outline a process for deciding exactly which patients meet a plan's criteria for serious and complex medical conditions. These criteria should be established by each health plan with review by HCFA. Examples of selection criteria might include factors such as diagnostic codes, patient age, presence of comorbidities, severity of illness or disability, duration of a disability, and so forth. It is expected that patients meeting these criteria would benefit from coordinated care management.

The next step in the care process should involve an assessment of the patient's problems and strengths. This is a tool for gathering information about the patient's medical, social, functional, and financial status that will be used to further determine his or her need for care management and the resources available to access the necessary services.

Treatment or care planning is also recommended by the committee as an essential element of a care management strategy for patients with serious and complex medical conditions. Such planning supports the development of individualized, goal-focused care plans (based on assessment findings and drawing on evidence-based treatments when available) to provide a guide for delineating patient, provider, and plan responsibilities for accessing and coordinating needed services.

The care management strategy also demands that steps be taken to ensure the implementation of care plans. Execution of the care management plan includes strategies and tactics for providing or purchasing needed services, or for linking patients to covered services, services available in the community, or those for which the patient will have to pay. It also includes advocating for the provision of informal services by family, friends, and neighbors.

The final step of the care process is monitoring implementation and outcomes of the care management strategy. This can be based upon periodic reviews of a patient's status and treatments to determine whether goals are being achieved, whether interventions and treatments continue to be appropriate, whether there is a medical need for continued services, or whether proactive care is required to address potential or emerging new problems. This type of monitoring can also include measurements to assess the impact of care management and treatment on clinical, functional, cost, and satisfaction outcomes.

Throughout the entire care management strategy for persons with serious and complex medical conditions, three principles should be evident. First, the care management strategy should reflect a commitment to continuity and coordination of care, as described among the requirements for National Committee for Quality Assurance accreditation. This entails monitoring continuity and coordination activities, analyzing data to identify opportunities for improvement, and taking actions to bring about improvements, as indicated. Second, the care process should include multidisciplinary perspectives and treatments, as appropriate. The care of persons with serious and complex medical conditions may require the assessment and treatment expertise of primary care providers; medical and surgical specialists; nurses and nurse specialists; social workers; pharmacists; occupational, speech, and physical therapists; behavioral and mental health professionals; and community-based service providers and resources. Access to expertise from these various disciplines should be available as needed. Third, and perhaps most important, patients and their family members should be involved at every step so that the care process incorporates the patient's expectations and preferences and documents the patient's role in achieving treatment goals.

The committee's recommendations concerning the care management process for patients with serious and complex conditions assumes patient willingness to collaborate with a multidisciplinary team of providers in the development and implementation of that plan. In those instances where a patient or family member declines such participation, appropriate documentation should be entered into the patient record. The presence of such documentation should be considered by HCFA as evidence that a good faith effort has been made by the plan to involve the patient and family in the development of the case management plan.

Recommendation 4: The committee recommends that health plans design and implement strategies for routine screening and selection to identify those beneficiaries with serious and complex medical conditions. These strategies should be consistent with the guidance outlined in Recommendation 2 to determine which patients meet a plan's threshold for serious and complex medical conditions and would benefit from a coordinated care management strategy.

The committee recommends that health plans identify specific categories of patients or health conditions for which screening for the presence of serious and complex conditions should occur on a routine basis. Examples of such categories are provided in Chapter 1 . The committee is of the opinion that screening a health care plan's entire population of enrollees is not a feasible, cost-effective, or efficient method of identifying subpopulations with serious and complex medical conditions. The committee feels strongly, however, that early efforts to develop case-screening methodologies should not be prescriptive; rather, innovation should be encouraged. Documentation of locally derived methods by plans will result in extensive nationwide experience that can be assessed and can lead to the identification of best practices and subsequent standardized methods for ongoing routine screening of patient populations.

The appropriate application of resources by a health plan to patients with serious and complex medical conditions requires the identification of those individuals whose health outcomes would benefit by such designation. For the purposes of this report, the committee has not included patients suffering from acute conditions that might require coordinated delivery of sophisticated medical services to treat complications of acute decompensation. On the other hand, many patients who have endured prolonged hospitalization for an acute medical condition may subsequently need coordinated long-term care to maximize their rehabilitation potential; to treat persistent sequelae of the disease processes that resulted from the acute, severe illness; and to ensure that they receive proactive care to prevent further exacerbation of the illness or disability.

Conceptually, various methodologies could be applied to administrative databases that could produce relevant lists of patients with serious and complex medical conditions who would be likely to benefit from written care management plans. High-cost patients, for example, might merit designation as having serious and complex conditions. Some of these individuals, however, may have undergone a single event such as bypass surgery that is self-limited and not appropriate for such designation. In contrast, others will have conditions, such as organ transplants, disabling traumatic injury, and HIV/AIDS, that clearly require ongoing medical attention and resources to sustain or improve their health status. Aside from costs, certain diagnostic entities could be identified for designation as serious and complex medical conditions. Examples of such entities could include progressive, degenerative disorders, active collagen vascular disease, and metastatic cancers. The committee does not believe it is feasible at this time to create an all-encompassing list of diagnoses appropriate for designation as serious and complex conditions. Indeed, within any diagnostic label, there exists a continuum of disease and disability that requires varying degrees of medical and other health-related support.

Beneficiary survey tools could supplement the use of administrative data sets to identify appropriate patients. Questionnaires that quantify functional status could assist plans in capturing individuals who need special attention in the outpatient setting to improve or sustain functional capacity or physiological stability. Similarly, home health agencies or medical professionals could identify frail elderly patients who require care management to sustain homeostasis. These agents could refer patients' names to health plans for development of a formal management program for serious and complex medical conditions. Such patients could include those of advanced age (over 85) with several comorbid medical conditions such as congestive heart failure, chronic renal failure, and diabetes. These persistent conditions in concert with reduced cognitive functioning or physical capacity to sustain daily living activities produce a constellation of physiological deficits that require supportive health care services for the patient to maintain independent living in a community setting.

There are several reasons why it is essential to the care of persons with serious and complex medical conditions that screening and selection of a plan's designated patient categories or conditions occur on a routine basis. First, periodic screening allows the multidisciplinary care team to adjust the care management approach as patient needs change over time. Second, routine screening is necessary to identify new patients with serious and complex medical conditions. Third, it ensures that persons who are no longer considered to have a serious and complex condition will be identified and services adjusted accordingly, which could result in a cost benefit.

The committee believes that over time, the health care system will identify reliable, accurate screening techniques for populations of patients with serious and complex medical conditions. In many cases, timely identification will permit appropriate treatment at the level of the primary care provider. Nevertheless, even with robust methodologies in place, there will be patients and families who believe that they require additional resources or attention to adequately manage a persistent health condition. In instances in which a treatment plan is not mutually agreeable, individuals should be able to appeal to the medical director of the provider group or health plan. The review process should be timely and should allow for both internal and independent external review.

Recommendation 5: The committee recommends that health care plans develop a care management strategy that integrates the participation of all those involved in the care of the patient, including primary care physicians; medical and surgical specialists; nurses and nurse specialists; behavioral and mental health specialists; physical, occupational, and speech therapists; social workers; allied health professionals; and community-based service providers.

The development of a collaborative care management strategy involving all those who participate in providing care to the individual patient is critical to the treatment of patients with serious and complex conditions. The treatment plan serves several important functions within the care management strategy. First, it provides a road map and a guide to indicate direction of and demarcate landmarks in care management, making it easier to ensure that all providers involved in the patient's care share the same goals, and that these goals are accessible to the patient and the patient's family. Second, it provides a way to measure progress and the achievement of care goals, and it serves as a powerful communication and coordination tool among the participants involved in the care of the patient, avoiding overlapping or redundant efforts as well as gaps and inattention to components of care assumed to be the responsibility of others on the care team. Third, a treatment plan offers an opportunity to delineate which provider is taking responsibility for specific aspects of care.

Although there is currently no evidence to support the identification of a single format or model as superior to all others, the committee feels confident in recommending certain key components that should be part of any treatment plan for patients with serious and complex medical conditions. Specifically, the plan should involve the collaborative participation of all those taking part in the care of the patient, including primary care physicians; medical and surgical specialists; nurses and nurse specialists; physical, occupational, and speech therapists; rehabilitation specialists; behavioral and mental health specialists; social workers; allied health professionals; and community-based service providers and resources.

The perspectives, health beliefs, and values of the patient and the patient's family should be taken into consideration, and the care management plan should be constructed in a culturally appropriate manner. Elements of the care management plan should be appropriate both for the age or life phase of each patient as well as the stage or severity of the health condition. This will ensure selection of treatment options that are responsive to the unique needs of patients of different age groups and with conditions of varying severity. The patient should be involved in the development of the plan and should have access to the plan.

The plan should be linked to relevant clinical practice guidelines and should reflect the process of adapting population-based clinical practice guidelines to the unique care and service needs of the individual. The treatment plan should cross areas of expertise and should address the need for coordination of care across the continuum of care delivery settings. The plan should be longitudinal, with accommodations for proactive interventions to prevent potential problems from arising, and it should also enable longitudinal assessment of outcomes. The treatment plan should be a living document that is periodically reviewed, updated, and tested for continuing relevance to the patient's circumstances (e.g., the life phase) and clinical condition (e.g., the disease stage).

Recommendation 6: The committee recommends that health care plans have programs in place to monitor care management plans for both process and outcomes for patients with serious and complex conditions at the level of population, patient, provider, and best practices of care .

The Health Care Financing Administration should establish a formal mechanism to evaluate a Medicare+Choice provider organization's program to monitor the outcomes of care for patients with serious and complex medical conditions. The committee recognizes that the monitoring and evaluation programs will vary between health plans but recommends that all programs include population-based monitoring of the outcomes of care for patients with serious or complex conditions, as well as individual case monitoring, assessment of provider interventions, and evaluation of best practices of care.

Assessment of population-based measures may include, but not be limited to, review of plan-wide policies and procedures; application of working definitions of serious and complex conditions; adoption of evidence-based clinical guidelines; review of health outcomes survey, patient satisfaction and complaint data; and review of clinical outcomes data for patients with serious or complex medical conditions. Individual case monitoring may include, but not be limited to, analysis of complaint data, patient satisfaction, internal and external appeals of the care plan, and overturned denials. Evaluation and monitoring at the level of providers will include efforts to assess clinical quality of care, timeliness of care, and effectiveness of specific interventions. Best practices of care will be identified by data that describe clinical, functional, and patient satisfaction outcomes.

Recommendation 7: The committee recommends that the Health Care Financing Administration collaborate with federal, private, and voluntary agencies, organizations, and consumers to establish an ongoing process to address policy issues to ensure continuous improvements in the care of populations with serious and complex medical conditions .

Access to providers with the appropriate training and expertise is important, but other issues must be addressed to ensure that beneficiaries with serious and complex conditions achieve the best possible outcomes. The committee recognizes that a number of these issues supersede activities that can be accomplished at the level of individual health plans. Issues that must be addressed include, but are not limited to, the following:

• Payment.

The current Medicare capitated payment mechanisms for health plans are not risk adjusted and are derived from experience in the fee-for-service sector. These payment mechanisms may not provide adequate compensation to some health plans. Furthermore, health plans use a variety of methods to compensate individual providers and hospitals. Greater attention should be focused on the improved alignment of financial incentives at all levels to ensure appropriate payment for serious and complex cases through adequate funding and risk-adjusted payment systems.

• Benefits.

Improving the care of persons with serious and complex medical conditions can be supported by ensuring that Medicare beneficiaries can choose among different health plans. When beneficiaries have multiple affordable options, they can select based upon their own evaluations of quality. Where benefits are provided through multiple payment programs (i.e., Medicare and Medicaid dual eligibles), coordination of benefit packages and eligibility requirements is critical. The movement of patients with serious and complex conditions into managed care holds the promise of greater health for these patients and therefore reduced expenditures for Medicaid programs due to reduced nursing home use. Prescription coverage for these patients would result in a direct reduction in state Medicaid prescription coverage expenses. Medicare requirements for management of patients with serious and complex conditions may also serve as the future basis for Medicaid managed care contracts.

• Medicaid and Medicare Fee-for-Service Programs.

The committee was unable to address the third point of its charge with any degree of thoroughness. This is primarily due to the fact that the committee lacked sufficient information and time to conduct informed deliberations about the implications of alternative definitions for serious and complex medical conditions for Medicaid and commercial programs, especially when applied to Medicare beneficiaries who are dual eligible. The committee strongly recommends that HCFA, in collaboration with Medicare and Medicaid provider plans, establish this as a research priority. Resources and expertise should be allocated to conduct a study to define the relevant issues and generate possible approaches to address this question.

In the meantime, the committee suggests that the basic guidance provided in this report concerning the description of serious and complex medical conditions and recommendations concerning strategies for care management for this patient population should be extended to include Medicaid beneficiaries and those that are dual eligible. In addition, this guidance should apply to patients enrolled in fee-for-service Medicare programs. This should be a priority area for collaborative research on policy issues to ensure continuous improvements in the care of populations with serious and complex medical conditions covered by Medicaid and fee-for-service Medicare plans.

• Consumer Education and Participation.

Many patients, especially those with persistent and disabling conditions, are ready and able to become more active participants in the care delivery process. Attempts should be made to increase patient participation in clinical decision-making and caregiving processes consistent with improving clinical outcomes and satisfaction.

• Professional Training.

To serve persons with serious and complex medical conditions, an aggressive strategy must be developed to educate and train health professionals to provide appropriate care for this population. There is currently a great undersupply of persons trained in care management processes, multidisciplinary team care, geriatrics, patient education and self-management, and cultural competence.

• Information Technology.

More sophisticated information technology is required to provide high-quality, coordinated care to those with complex or serious medical conditions. More sophisticated information systems are needed to support efforts to monitor, analyze, and improve patient care. Continued development of electronic medical records will be an important factor in ensuring that all health care organizations and providers involved in the care of a patient have timely access to complete information on the patient's clinical conditions, diagnostic and therapeutic test results, and services received. Confidentiality protections must be respected throughout the process of technology development.

• Regulatory Framework.

Developing a regulatory approach for the Medicare+Choice program that affords adequate protections for beneficiaries with serious and complex medical conditions while encouraging innovation in a rapidly changing health care environment will be an ongoing challenge. Periodic evaluation and modification will be essential.

• Applied Research.

Research is needed to further inform the policy process and to identify best practices in the care of patients with serious and complex conditions. Attention should be focused on the following areas: effects of benefits coverage and payment methods on care delivery; determination and dissemination of best practices in the identification of patients with serious and complex conditions; efficacy, effectiveness, and efficiency of multidisciplinary teams; use of information technology to support care coordination and delivery; and development of innovative methods of designing, implementing, and coordinating medical, social, and other services.

These and related issues will require HCFA to actively collaborate with all types of payors, health care plans, providers, research organizations, and consumer and disability groups to develop strategies and solutions that will maximize the quality of health care and other services for patients with serious and complex medical conditions.

• Conclusions

The needs of patients with serious and complex medical conditions far exceed the boundaries of a single issue such as access to specialists for care. For health care delivery systems to provide high-quality, effective care for these patients, the systems must be responsive to a diverse array of clinical, social, mental, and functional health issues. The development of a health care delivery system that will provide quality and effective care for these patient populations must be responsive to a diverse group of clinical, social, mental, and functional health issues. The health care delivery system must also be capable of working effectively with other community and social support systems.

The questions raised by HCFA concerning implementation and regulations for the Medicare+Choice program apply broadly to include all health care delivery and payment systems, including fee-for-service care. This study is one of the first to address these complex and extremely important topics. Thus, the committee urges HCFA, health care plans, and consumer groups to view this report, and especially its conclusions and recommendations, as first steps in the effort to address the unique and complicated needs of persons with serious and complex medical conditions and to ensure that they receive the most cost-effective and best-quality care possible. The work of this committee is intended to support and provide direction for future work to be conducted by HCFA, in collaboration with all types of health care plans and consumer organizations, to design innovative strategies to ensure adequate reimbursement, access to broad care management, and the highest possible quality of treatment services required by patients with serious and complex medical conditions.

• Cite this Page Institute of Medicine (US) Committee on Serious and Complex Medical Conditions; Chrvala CA, Sharfstein S, editors. Definition of Serious and Complex Medical Conditions. Washington (DC): National Academies Press (US); 1999. 3, Conclusions and Recommendations.
• PDF version of this title (730K)

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Putin’s China Visit Highlights Military Ties That Worry the West

The Russian leader visited an institute in Harbin known for defense research. President Xi Jinping saw him off with a rare and seemingly deliberate embrace for the cameras.

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By David Pierson

President Vladimir V. Putin of Russia attended a trade fair on Friday in a northeastern Chinese city and toured a state-backed university famous for its cutting-edge defense research, highlighting how economic and military ties between the countries have grown despite, or perhaps because of, Western pressure.

Mr. Putin’s visit to Harbin, a Chinese city with a Russian past, is part of a trip aimed at demonstrating that he has powerful friends even as his war against Ukraine — a campaign that he is escalating — has isolated him from the West. The visit followed a day of talks between him and President Xi Jinping of China that seemed orchestrated to convey not only the strategic alignment of the two powerful, autocratic leaders against the West, but a personal connection.

State media showed Mr. Putin and Mr. Xi, neckties off after formal talks on Thursday, strolling under willow trees and sipping tea at a traditional pavilion on the sprawling grounds of Zhongnanhai, the walled leadership compound in Beijing, with only their interpreters. As Mr. Xi saw Mr. Putin off in the evening, he even initiated a hug — a rare expression of affection for the Chinese leader.

“Xi’s very deliberate embrace of Putin for the cameras wasn’t just to emphasize the closeness of the political relationship between the two countries and their leaders,” said Richard McGregor, a senior fellow for East Asia at the Lowy Institute in Sydney. “There was also a touch of disdain directed at Washington, which has been pressuring Beijing to withdraw support from Moscow. That clearly isn’t going to happen in any substantive fashion.”

The show of camaraderie was the final touch in talks that culminated in a joint statement that took aim at the United States, which Mr. Putin and Mr. Xi have accused of seeking to suppress their countries. The statement pledged that Russia and China would work more closely in critical sectors like energy, space and the military.

The large size of Russia’s delegation, which included Mr. Putin’s top security and energy officials, as well the length of the bilateral meetings, implied the seriousness with which both sides have approached the negotiations, said Alexander Gabuev, a China expert at the Carnegie Russia Eurasia Center in Berlin.

“It’s like an iceberg,” he said. “The public documents are symbolic and largely meaningless. But there’s an underwater part, which is likely to be much more significant.”

Still, Mr. Putin’s visit also showed the limits of the countries alliance. In China, Mr. Xi rolled out the red carpet for Mr. Putin, but the visit did not produce any public commitments to concrete new projects or investments between the two countries.

Specifically, Mr. Putin and Mr. Xi have not publicly reported any progress on a planned new gas pipeline from China into Russia, known as Power of Siberia 2. Russia urgently needs the pipeline to redirect the flow of its gas exports from the rapidly declining market in Europe.

Mr. Putin had no news to share about the pipeline’s progress when he was asked about it in a brief news conference at the end of his trip on Friday.

“I am not prepared to discuss any technical details, but the interest of both sides in realizing these projects has been confirmed,” Mr. Putin said, referring to Power of Siberia 2.

He also deflected a question about reports that Chinese banks are reducing transactions with Russian clients out of fear of Western sanctions, turning the conversation from China to the shortcomings of the U.S. financial system.

The growing security ties between the two nuclear-armed powers was a focal point of Mr. Putin’s visit to Harbin, and the Harbin Institute of Technology.

While China and Russia are not formal allies committed to defend each other with military support, their armed forces have worked together more closely in recent years. Their air forces and navies have held joint military exercises, including near Alaska and Taiwan, the de facto independent island claimed by Beijing. On Thursday, the two leaders issued words of support for their separate claims to Taiwan and Ukraine.

And while China has vowed not to provide Russia with lethal weapons, it has been the top supplier of components like semiconductors and machine tools that have both civilian and military uses.

While that is helpful, Mr. Putin still seeks access to more sophisticated tools. The Harbin institute is best known for its research of rockets, missiles and space technology — expertise that Russia would greatly benefit from as the war in Ukraine has revived its need for a more robust military-industrial complex. The institute also trained North Korean scientists who worked on Pyongyang’s nuclear weapons program, according to The Wall Street Journal and South Korean media.

Mr. Putin’s tour of the institute was steeped in symbolism. The 103-year-old institution recently opened a joint campus with St. Petersburg State University, Mr. Putin’s alma mater. And in something of a snub to Washington, the school belongs on the United States’ so-called entity list, barring it from accessing American technology and taking part in educational exchanges because of its links to the People’s Liberation Army.

“We should be less concerned about what particular technologies China might be sharing with Russia from Harbin or elsewhere, than the larger pattern and signal that this visit represents,” said Markus Garlauskas, a security expert at the Atlantic Council.

“China did not need to host Putin at Harbin in order to transfer technologies from there to Russia,” he added. “That this visit took place so openly is a visible and symbolic sign of Beijing being willing to provide directly military-applicable technology to support Russia’s war against Ukraine.”

Song Zhongping, a commentator in Beijing who is a former military officer, defended Mr. Putin’s visit to the institute, pointing to the school’s cooperation with Russia in education.

“Communication at the university level between China and Russia is consistent with the academic exchange and national interests of both countries,” Mr. Song said.

Mr. Garlauskas said the tour of the institute had echoes of when Mr. Putin hosted Kim Jong-un, the North Korean dictator, at a Russian spaceport last year before Pyongyang began supplying Moscow with ballistic missiles and other munitions to use in Ukraine.

“What China shares with Russia, Russia could easily then turn around and share with North Korea,” Mr. Garlauskas said.

Not long ago, it was China that drew greater benefits from access to Russian military technology. Starting in the 1990s, and peaking in the early 2000s, Beijing was a major buyer of Russian arms. Sales then began to slow after Moscow grew concerned about China reverse-engineering Russian weapons, said Elizabeth Wishnick, a senior research scientist at the Center for Naval Analyses in Virginia.

It wasn’t until about a decade ago that cooperation between the two sides returned, leading to China’s acquisition of more Russian jet engine technology and surface-to-air missile systems. Still, in a sign that there are limits to its cooperation with China, Russia is holding out sharing its silent submarine technology, a feature that makes the vessels especially hard to detect, Ms. Wishnick said.

Mr. Putin is also using his visit to Harbin, where he attended a trade fair, to promote the flow of goods between the countries.

China has given Russia an economic lifeline by buying huge amounts of Russian oil to circumvent the effects of its financial isolation from the West. Not only that, with many foreign consumer brands also leaving Russia, Chinese companies have stepped in to fill a vacuum for the likes of automobiles , smartphones and televisions. That contributed to a record $240 billion in two-way trade between the China and Russia in 2023, up from $190 billion in 2022, according to Chinese customs data.

Maintaining that growth in trade is a major focus in both countries, analysts said, now that Western pressure on Chinese banks to scale back transactions with Russian firms is believed to have led to the first year-on-year decline in trade in more than two years in March.

One solution would be to increase the amount of transactions settled in local currencies rather than dollars to avoid the risk of sanctions. Mr. Putin said on Thursday that more than 90 percent of commercial transactions conducted between Russia and China were now being cleared in rubles or renminbi.

“Protecting the financial assets of big banks in China is the top crucial interest of China,” said Shi Yinhong, an international relations professor at Renmin University in Beijing. He said China was trying to reduce its exposure to the dollar beyond just in Russia, but that the room to do so was “limited.”

Olivia Wang and Anatoly Kurmanaev contributed reporting.

David Pierson covers Chinese foreign policy and China’s economic and cultural engagement with the world. He has been a journalist for more than two decades. More about David Pierson

Our Coverage of the War in Ukraine

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Russia sent a pointed reminder that it could use battlefield nuclear weapons in Ukraine, releasing video of its forces beginning exercises  to practice their use.

As Russia’s war effort in Ukraine intensifies, it is increasingly clear that efforts by the West to squeeze Moscow’s oil revenues are faltering .

The United States and Europe are coalescing around a plan to use interest earned on frozen Russian central bank assets to provide Ukraine with a loan to be used for military and economic assistance .

Europe’s Defense Industry: Russia’s invasion of Ukraine jolted Europe out of complacency about military spending. But the challenges are about more than just money .

Putin’s Victory Narrative: The Russian leader’s message to his country appears to be taking hold : that Russia is fighting against the whole Western world — and winning.

A Boxing Win Offers Hope: The Ukrainian boxer Oleksandr Usyk became the world’s undisputed heavyweight champion, a victory that has lifted morale  in a country struggling to contain Russian advances.

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E-Cigarette Use Among Youth

What to know.

E-cigarettes are the most commonly used tobacco product among U.S. youth. No tobacco products, including e-cigarettes, are safe, especially for children, teens, and young adults. Learn more about e-cigarette use among youth.

• In the United States, youth use e-cigarettes, or vapes, more than any other tobacco product. 1
• No tobacco products, including e-cigarettes, are safe, especially for children, teens, and young adults. 2
• Most e-cigarettes contain nicotine, which is highly addictive. Nicotine can harm the parts of an adolescent's brain that control attention, learning, mood, and impulse control. 2
• E-cigarette marketing, the availability of flavored products, social influences, and the effects of nicotine can influence youth to start or continue vaping. 3 4
• Most middle and high school students who vape want to quit. 5
• Many people have an important role in protecting youth from vaping including parents and caregivers, educators and school administrators, health care providers, and community partners.
• States and local communities can implement evidence-based policies, programs, and services to reduce youth vaping.

E-cigarette use among U.S. youth

In 2023, e-cigarettes were the most commonly used tobacco product among middle and high school students in the United States. In 2023: 6

• 550,000 (4.6%) middle school students.
• 1.56 million (10.0%) high school students.
• Among students who had ever used e-cigarettes, 46.7% reported current e-cigarette use.
• 1 in 4 (25.2%) used an e-cigarette every day.
• 1 in 3 (34.7%) used an e-cigarette on at least 20 of the last 30 days.
• 9 in 10 (89.4%) used flavored e-cigarettes.
• Most often used disposable e-cigarettes (60.7%) followed by e-cigarettes with prefilled or refillable pods or cartridges (16.1%).
• Most commonly reported using the following brands: Elf Bar, Esco Bars, Vuse, JUUL, and Mr. Fog.

Most middle and high school students who vape want to quit and have tried to quit. 5 In 2020:

• 63.9% of students who currently used e-cigarettes reported wanting to quit.
• 67.4% of students who currently used e-cigarettes reported trying to quit in the last year.

Most tobacco use, including vaping, starts and is established during adolescence. There are many factors associated with youth tobacco product use . These include:

• Tobacco advertising that targets youth.
• Product accessibility.
• Availability of flavored products.
• Social influences.
• Adolescent brain sensitivity to nicotine.

Some groups of middle and high school students use e-cigarettes at a higher percentage than others. For example, in 2023: 6

• More females than males reported current e-cigarette use.
• Non-Hispanic multiracial students: 20.8%.
• Non-Hispanic White students: 18.4%.
• Hispanic or Latino students: 18.2%.
• Non-Hispanic American Indian and Alaska Native students: 15.4%.
• Non-Hispanic Black or African American students: 12.9%.

Many young people who vape also use other tobacco products, including cigarettes and cigars. 7 This is called dual use. In 2020: 8

• About one in three high school students (36.8%) who vaped also used other tobacco products.
• One in two middle school students (49.0%) who vaped also used other tobacco products.

E-cigarettes can also be used to deliver other substances, including cannabis. In 2016, nearly one in three (30.6%) of U.S. middle and high school students who had ever used an e-cigarette reported using marijuana in the device. 9

• Park-Lee E, Ren C, Cooper M, Cornelius M, Jamal A, Cullen KA. Tobacco product use among middle and high school students—United States, 2022 . MMWR Morb Mortal Wkly Rep. 2022;71:1429–1435.
• U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon General . Centers for Disease Control and Prevention; 2016. Accessed Feb 14, 2024.
• Apelberg BJ, Corey CG, Hoffman AC, et al. Symptoms of tobacco dependence among middle and high school tobacco users: results from the 2012 National Youth Tobacco Survey . Am J Prev Med. 2014;47(Suppl 1):S4–14.
• Gentzke AS, Wang TW, Cornelius M, et al. Tobacco product use and associated factors among middle and high school students—National Youth Tobacco Survey, United States, 2021 . MMWR Surveill Summ. 2022;71(No. SS-5):1–29.
• Zhang L, Gentzke A, Trivers KF, VanFrank B. Tobacco cessation behaviors among U.S. middle and high school students, 2020 . J Adolesc Health. 2022;70(1):147–154.
• Birdsey J, Cornelius M, Jamal A, et al. Tobacco product use among U.S. middle and high school students—National Youth Tobacco Survey, 2023 . MMWR Morb Mortal Wkly Rep. 2023;72:1173–1182.
• Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and associated factors among middle and high school students—United States, 2019 . MMWR Surveill Summ. 2019;68(No. SS-12):1–22.
• Wang TW, Gentzke AS, Neff LJ, et al. Characteristics of e-cigarette use behaviors among US youth, 2020 . JAMA Netw Open. 2021;4(6):e2111336.
• Trivers KF, Phillips E, Gentzke AS, Tynan MA, Neff LJ. Prevalence of cannabis use in electronic cigarettes among U.S. youth . JAMA Pediatr. 2018;172(11):1097–1099.

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