importance of conclusions in research

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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

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Conclusions

What this handout is about.

This handout will explain the functions of conclusions, offer strategies for writing effective ones, help you evaluate conclusions you’ve drafted, and suggest approaches to avoid.

About conclusions

Introductions and conclusions can be difficult to write, but they’re worth investing time in. They can have a significant influence on a reader’s experience of your paper.

Just as your introduction acts as a bridge that transports your readers from their own lives into the “place” of your analysis, your conclusion can provide a bridge to help your readers make the transition back to their daily lives. Such a conclusion will help them see why all your analysis and information should matter to them after they put the paper down.

Your conclusion is your chance to have the last word on the subject. The conclusion allows you to have the final say on the issues you have raised in your paper, to synthesize your thoughts, to demonstrate the importance of your ideas, and to propel your reader to a new view of the subject. It is also your opportunity to make a good final impression and to end on a positive note.

Your conclusion can go beyond the confines of the assignment. The conclusion pushes beyond the boundaries of the prompt and allows you to consider broader issues, make new connections, and elaborate on the significance of your findings.

Your conclusion should make your readers glad they read your paper. Your conclusion gives your reader something to take away that will help them see things differently or appreciate your topic in personally relevant ways. It can suggest broader implications that will not only interest your reader, but also enrich your reader’s life in some way. It is your gift to the reader.

Strategies for writing an effective conclusion

One or more of the following strategies may help you write an effective conclusion:

• Play the “So What” Game. If you’re stuck and feel like your conclusion isn’t saying anything new or interesting, ask a friend to read it with you. Whenever you make a statement from your conclusion, ask the friend to say, “So what?” or “Why should anybody care?” Then ponder that question and answer it. Here’s how it might go: You: Basically, I’m just saying that education was important to Douglass. Friend: So what? You: Well, it was important because it was a key to him feeling like a free and equal citizen. Friend: Why should anybody care? You: That’s important because plantation owners tried to keep slaves from being educated so that they could maintain control. When Douglass obtained an education, he undermined that control personally. You can also use this strategy on your own, asking yourself “So What?” as you develop your ideas or your draft.
• Return to the theme or themes in the introduction. This strategy brings the reader full circle. For example, if you begin by describing a scenario, you can end with the same scenario as proof that your essay is helpful in creating a new understanding. You may also refer to the introductory paragraph by using key words or parallel concepts and images that you also used in the introduction.
• Synthesize, don’t summarize. Include a brief summary of the paper’s main points, but don’t simply repeat things that were in your paper. Instead, show your reader how the points you made and the support and examples you used fit together. Pull it all together.
• Include a provocative insight or quotation from the research or reading you did for your paper.
• Propose a course of action, a solution to an issue, or questions for further study. This can redirect your reader’s thought process and help them to apply your info and ideas to their own life or to see the broader implications.
• Point to broader implications. For example, if your paper examines the Greensboro sit-ins or another event in the Civil Rights Movement, you could point out its impact on the Civil Rights Movement as a whole. A paper about the style of writer Virginia Woolf could point to her influence on other writers or on later feminists.

Strategies to avoid

• Beginning with an unnecessary, overused phrase such as “in conclusion,” “in summary,” or “in closing.” Although these phrases can work in speeches, they come across as wooden and trite in writing.
• Stating the thesis for the very first time in the conclusion.
• Introducing a new idea or subtopic in your conclusion.
• Ending with a rephrased thesis statement without any substantive changes.
• Making sentimental, emotional appeals that are out of character with the rest of an analytical paper.
• Including evidence (quotations, statistics, etc.) that should be in the body of the paper.

Four kinds of ineffective conclusions

• The “That’s My Story and I’m Sticking to It” Conclusion. This conclusion just restates the thesis and is usually painfully short. It does not push the ideas forward. People write this kind of conclusion when they can’t think of anything else to say. Example: In conclusion, Frederick Douglass was, as we have seen, a pioneer in American education, proving that education was a major force for social change with regard to slavery.
• The “Sherlock Holmes” Conclusion. Sometimes writers will state the thesis for the very first time in the conclusion. You might be tempted to use this strategy if you don’t want to give everything away too early in your paper. You may think it would be more dramatic to keep the reader in the dark until the end and then “wow” them with your main idea, as in a Sherlock Holmes mystery. The reader, however, does not expect a mystery, but an analytical discussion of your topic in an academic style, with the main argument (thesis) stated up front. Example: (After a paper that lists numerous incidents from the book but never says what these incidents reveal about Douglass and his views on education): So, as the evidence above demonstrates, Douglass saw education as a way to undermine the slaveholders’ power and also an important step toward freedom.
• The “America the Beautiful”/”I Am Woman”/”We Shall Overcome” Conclusion. This kind of conclusion usually draws on emotion to make its appeal, but while this emotion and even sentimentality may be very heartfelt, it is usually out of character with the rest of an analytical paper. A more sophisticated commentary, rather than emotional praise, would be a more fitting tribute to the topic. Example: Because of the efforts of fine Americans like Frederick Douglass, countless others have seen the shining beacon of light that is education. His example was a torch that lit the way for others. Frederick Douglass was truly an American hero.
• The “Grab Bag” Conclusion. This kind of conclusion includes extra information that the writer found or thought of but couldn’t integrate into the main paper. You may find it hard to leave out details that you discovered after hours of research and thought, but adding random facts and bits of evidence at the end of an otherwise-well-organized essay can just create confusion. Example: In addition to being an educational pioneer, Frederick Douglass provides an interesting case study for masculinity in the American South. He also offers historians an interesting glimpse into slave resistance when he confronts Covey, the overseer. His relationships with female relatives reveal the importance of family in the slave community.

Works consulted

We consulted these works while writing this handout. This is not a comprehensive list of resources on the handout’s topic, and we encourage you to do your own research to find additional publications. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. For guidance on formatting citations, please see the UNC Libraries citation tutorial . We revise these tips periodically and welcome feedback.

Douglass, Frederick. 1995. Narrative of the Life of Frederick Douglass, an American Slave, Written by Himself. New York: Dover.

Hamilton College. n.d. “Conclusions.” Writing Center. Accessed June 14, 2019. https://www.hamilton.edu//academics/centers/writing/writing-resources/conclusions .

Holewa, Randa. 2004. “Strategies for Writing a Conclusion.” LEO: Literacy Education Online. Last updated February 19, 2004. https://leo.stcloudstate.edu/acadwrite/conclude.html.

You may reproduce it for non-commercial use if you use the entire handout and attribute the source: The Writing Center, University of North Carolina at Chapel Hill

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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.

Align your conclusion’s tone with the rest of your research paper. Start Writing with Paperpal Now!  

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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In a short paper—even a research paper—you don’t need to provide an exhaustive summary as part of your conclusion. But you do need to make some kind of transition between your final body paragraph and your concluding paragraph. This may come in the form of a few sentences of summary. Or it may come in the form of a sentence that brings your readers back to your thesis or main idea and reminds your readers where you began and how far you have traveled.

So, for example, in a paper about the relationship between ADHD and rejection sensitivity, Vanessa Roser begins by introducing readers to the fact that researchers have studied the relationship between the two conditions and then provides her explanation of that relationship. Here’s her thesis: “While socialization may indeed be an important factor in RS, I argue that individuals with ADHD may also possess a neurological predisposition to RS that is exacerbated by the differing executive and emotional regulation characteristic of ADHD.”

In her final paragraph, Roser reminds us of where she started by echoing her thesis: “This literature demonstrates that, as with many other conditions, ADHD and RS share a delicately intertwined pattern of neurological similarities that is rooted in the innate biology of an individual’s mind, a connection that cannot be explained in full by the behavioral mediation hypothesis.”  

Highlight the “so what”  

At the beginning of your paper, you explain to your readers what’s at stake—why they should care about the argument you’re making. In your conclusion, you can bring readers back to those stakes by reminding them why your argument is important in the first place. You can also draft a few sentences that put those stakes into a new or broader context.

In the conclusion to her paper about ADHD and RS, Roser echoes the stakes she established in her introduction—that research into connections between ADHD and RS has led to contradictory results, raising questions about the “behavioral mediation hypothesis.”

She writes, “as with many other conditions, ADHD and RS share a delicately intertwined pattern of neurological similarities that is rooted in the innate biology of an individual’s mind, a connection that cannot be explained in full by the behavioral mediation hypothesis.”  

Leave your readers with the “now what”  

After the “what” and the “so what,” you should leave your reader with some final thoughts. If you have written a strong introduction, your readers will know why you have been arguing what you have been arguing—and why they should care. And if you’ve made a good case for your thesis, then your readers should be in a position to see things in a new way, understand new questions, or be ready for something that they weren’t ready for before they read your paper.

In her conclusion, Roser offers two “now what” statements. First, she explains that it is important to recognize that the flawed behavioral mediation hypothesis “seems to place a degree of fault on the individual. It implies that individuals with ADHD must have elicited such frequent or intense rejection by virtue of their inadequate social skills, erasing the possibility that they may simply possess a natural sensitivity to emotion.” She then highlights the broader implications for treatment of people with ADHD, noting that recognizing the actual connection between rejection sensitivity and ADHD “has profound implications for understanding how individuals with ADHD might best be treated in educational settings, by counselors, family, peers, or even society as a whole.”

To find your own “now what” for your essay’s conclusion, try asking yourself these questions:

• What can my readers now understand, see in a new light, or grapple with that they would not have understood in the same way before reading my paper? Are we a step closer to understanding a larger phenomenon or to understanding why what was at stake is so important?  
• What questions can I now raise that would not have made sense at the beginning of my paper? Questions for further research? Other ways that this topic could be approached?  
• Are there other applications for my research? Could my questions be asked about different data in a different context? Could I use my methods to answer a different question?  
• What action should be taken in light of this argument? What action do I predict will be taken or could lead to a solution?  
• What larger context might my argument be a part of?  

What to avoid in your conclusion  

• a complete restatement of all that you have said in your paper.  
• a substantial counterargument that you do not have space to refute; you should introduce counterarguments before your conclusion.  
• an apology for what you have not said. If you need to explain the scope of your paper, you should do this sooner—but don’t apologize for what you have not discussed in your paper.  
• fake transitions like “in conclusion” that are followed by sentences that aren’t actually conclusions. (“In conclusion, I have now demonstrated that my thesis is correct.”)
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Writing a Paper: Conclusions

Writing a conclusion.

A conclusion is an important part of the paper; it provides closure for the reader while reminding the reader of the contents and importance of the paper. It accomplishes this by stepping back from the specifics in order to view the bigger picture of the document. In other words, it is reminding the reader of the main argument. For most course papers, it is usually one paragraph that simply and succinctly restates the main ideas and arguments, pulling everything together to help clarify the thesis of the paper. A conclusion does not introduce new ideas; instead, it should clarify the intent and importance of the paper. It can also suggest possible future research on the topic.

An Easy Checklist for Writing a Conclusion

It is important to remind the reader of the thesis of the paper so he is reminded of the argument and solutions you proposed.

Think of the main points as puzzle pieces, and the conclusion is where they all fit together to create a bigger picture. The reader should walk away with the bigger picture in mind.

Make sure that the paper places its findings in the context of real social change.

Make sure the reader has a distinct sense that the paper has come to an end. It is important to not leave the reader hanging. (You don’t want her to have flip-the-page syndrome, where the reader turns the page, expecting the paper to continue. The paper should naturally come to an end.)

No new ideas should be introduced in the conclusion. It is simply a review of the material that is already present in the paper. The only new idea would be the suggesting of a direction for future research.

Conclusion Example

As addressed in my analysis of recent research, the advantages of a later starting time for high school students significantly outweigh the disadvantages. A later starting time would allow teens more time to sleep--something that is important for their physical and mental health--and ultimately improve their academic performance and behavior. The added transportation costs that result from this change can be absorbed through energy savings. The beneficial effects on the students’ academic performance and behavior validate this decision, but its effect on student motivation is still unknown. I would encourage an in-depth look at the reactions of students to such a change. This sort of study would help determine the actual effects of a later start time on the time management and sleep habits of students.

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How to write a strong conclusion for your research paper

Last updated

17 February 2024

Reviewed by

Writing a research paper is a chance to share your knowledge and hypothesis. It's an opportunity to demonstrate your many hours of research and prove your ability to write convincingly.

Ideally, by the end of your research paper, you'll have brought your readers on a journey to reach the conclusions you've pre-determined. However, if you don't stick the landing with a good conclusion, you'll risk losing your reader’s trust.

Writing a strong conclusion for your research paper involves a few important steps, including restating the thesis and summing up everything properly.

Find out what to include and what to avoid, so you can effectively demonstrate your understanding of the topic and prove your expertise.

• Why is a good conclusion important?

A good conclusion can cement your paper in the reader’s mind. Making a strong impression in your introduction can draw your readers in, but it's the conclusion that will inspire them.

• What to include in a research paper conclusion

There are a few specifics you should include in your research paper conclusion. Offer your readers some sense of urgency or consequence by pointing out why they should care about the topic you have covered. Discuss any common problems associated with your topic and provide suggestions as to how these problems can be solved or addressed.

The conclusion should include a restatement of your initial thesis. Thesis statements are strengthened after you’ve presented supporting evidence (as you will have done in the paper), so make a point to reintroduce it at the end.

Finally, recap the main points of your research paper, highlighting the key takeaways you want readers to remember. If you've made multiple points throughout the paper, refer to the ones with the strongest supporting evidence.

• Steps for writing a research paper conclusion

Many writers find the conclusion the most challenging part of any research project . By following these three steps, you'll be prepared to write a conclusion that is effective and concise.

• Step 1: Restate the problem

Always begin by restating the research problem in the conclusion of a research paper. This serves to remind the reader of your hypothesis and refresh them on the main point of the paper. 

When restating the problem, take care to avoid using exactly the same words you employed earlier in the paper.

• Step 2: Sum up the paper

After you've restated the problem, sum up the paper by revealing your overall findings. The method for this differs slightly, depending on whether you're crafting an argumentative paper or an empirical paper.

Argumentative paper: Restate your thesis and arguments

Argumentative papers involve introducing a thesis statement early on. In crafting the conclusion for an argumentative paper, always restate the thesis, outlining the way you've developed it throughout the entire paper.

It might be appropriate to mention any counterarguments in the conclusion, so you can demonstrate how your thesis is correct or how the data best supports your main points.

Empirical paper: Summarize research findings

Empirical papers break down a series of research questions. In your conclusion, discuss the findings your research revealed, including any information that surprised you.

Be clear about the conclusions you reached, and explain whether or not you expected to arrive at these particular ones.

• Step 3: Discuss the implications of your research

Argumentative papers and empirical papers also differ in this part of a research paper conclusion. Here are some tips on crafting conclusions for argumentative and empirical papers.

Argumentative paper: Powerful closing statement

In an argumentative paper, you'll have spent a great deal of time expressing the opinions you formed after doing a significant amount of research. Make a strong closing statement in your argumentative paper's conclusion to share the significance of your work.

You can outline the next steps through a bold call to action, or restate how powerful your ideas turned out to be.

Empirical paper: Directions for future research

Empirical papers are broader in scope. They usually cover a variety of aspects and can include several points of view.

To write a good conclusion for an empirical paper, suggest the type of research that could be done in the future, including methods for further investigation or outlining ways other researchers might proceed.

If you feel your research had any limitations, even if they were outside your control, you could mention these in your conclusion.

After you finish outlining your conclusion, ask someone to read it and offer feedback. In any research project you're especially close to, it can be hard to identify problem areas. Having a close friend or someone whose opinion you value read the research paper and provide honest feedback can be invaluable. Take note of any suggested edits and consider incorporating them into your paper if they make sense.

• Things to avoid in a research paper conclusion

Keep these aspects to avoid in mind as you're writing your conclusion and refer to them after you've created an outline.

Dry summary

Writing a memorable, succinct conclusion is arguably more important than a strong introduction. Take care to avoid just rephrasing your main points, and don't fall into the trap of repeating dry facts or citations.

You can provide a new perspective for your readers to think about or contextualize your research. Either way, make the conclusion vibrant and interesting, rather than a rote recitation of your research paper’s highlights.

Clichéd or generic phrasing

Your research paper conclusion should feel fresh and inspiring. Avoid generic phrases like "to sum up" or "in conclusion." These phrases tend to be overused, especially in an academic context and might turn your readers off.

The conclusion also isn't the time to introduce colloquial phrases or informal language. Retain a professional, confident tone consistent throughout your paper’s conclusion so it feels exciting and bold.

New data or evidence

While you should present strong data throughout your paper, the conclusion isn't the place to introduce new evidence. This is because readers are engaged in actively learning as they read through the body of your paper.

By the time they reach the conclusion, they will have formed an opinion one way or the other (hopefully in your favor!). Introducing new evidence in the conclusion will only serve to surprise or frustrate your reader.

Ignoring contradictory evidence

If your research reveals contradictory evidence, don't ignore it in the conclusion. This will damage your credibility as an expert and might even serve to highlight the contradictions.

Be as transparent as possible and admit to any shortcomings in your research, but don't dwell on them for too long.

Ambiguous or unclear resolutions

The point of a research paper conclusion is to provide closure and bring all your ideas together. You should wrap up any arguments you introduced in the paper and tie up any loose ends, while demonstrating why your research and data are strong.

Use direct language in your conclusion and avoid ambiguity. Even if some of the data and sources you cite are inconclusive or contradictory, note this in your conclusion to come across as confident and trustworthy.

• Examples of research paper conclusions

Your research paper should provide a compelling close to the paper as a whole, highlighting your research and hard work. While the conclusion should represent your unique style, these examples offer a starting point:

Ultimately, the data we examined all point to the same conclusion: Encouraging a good work-life balance improves employee productivity and benefits the company overall. The research suggests that when employees feel their personal lives are valued and respected by their employers, they are more likely to be productive when at work. In addition, company turnover tends to be reduced when employees have a balance between their personal and professional lives. While additional research is required to establish ways companies can support employees in creating a stronger work-life balance, it's clear the need is there.

Social media is a primary method of communication among young people. As we've seen in the data presented, most young people in high school use a variety of social media applications at least every hour, including Instagram and Facebook. While social media is an avenue for connection with peers, research increasingly suggests that social media use correlates with body image issues. Young girls with lower self-esteem tend to use social media more often than those who don't log onto social media apps every day. As new applications continue to gain popularity, and as more high school students are given smartphones, more research will be required to measure the effects of prolonged social media use.

What are the different kinds of research paper conclusions?

There are no formal types of research paper conclusions. Ultimately, the conclusion depends on the outline of your paper and the type of research you’re presenting. While some experts note that research papers can end with a new perspective or commentary, most papers should conclude with a combination of both. The most important aspect of a good research paper conclusion is that it accurately represents the body of the paper.

Can I present new arguments in my research paper conclusion?

Research paper conclusions are not the place to introduce new data or arguments. The body of your paper is where you should share research and insights, where the reader is actively absorbing the content. By the time a reader reaches the conclusion of the research paper, they should have formed their opinion. Introducing new arguments in the conclusion can take a reader by surprise, and not in a positive way. It might also serve to frustrate readers.

How long should a research paper conclusion be?

There's no set length for a research paper conclusion. However, it's a good idea not to run on too long, since conclusions are supposed to be succinct. A good rule of thumb is to keep your conclusion around 5 to 10 percent of the paper's total length. If your paper is 10 pages, try to keep your conclusion under one page.

What should I include in a research paper conclusion?

A good research paper conclusion should always include a sense of urgency, so the reader can see how and why the topic should matter to them. You can also note some recommended actions to help fix the problem and some obstacles they might encounter. A conclusion should also remind the reader of the thesis statement, along with the main points you covered in the paper. At the end of the conclusion, add a powerful closing statement that helps cement the paper in the mind of the reader.

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How to Write a Conclusion for a Research Paper

3-minute read

• 29th August 2023

If you’re writing a research paper, the conclusion is your opportunity to summarize your findings and leave a lasting impression on your readers. In this post, we’ll take you through how to write an effective conclusion for a research paper and how you can:

·   Reword your thesis statement

·   Highlight the significance of your research

·   Discuss limitations

·   Connect to the introduction

·   End with a thought-provoking statement

Rewording Your Thesis Statement

Begin your conclusion by restating your thesis statement in a way that is slightly different from the wording used in the introduction. Avoid presenting new information or evidence in your conclusion. Just summarize the main points and arguments of your essay and keep this part as concise as possible. Remember that you’ve already covered the in-depth analyses and investigations in the main body paragraphs of your essay, so it’s not necessary to restate these details in the conclusion.

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Highlighting the Significance of Your Research

The conclusion is a good place to emphasize the implications of your research . Avoid ambiguous or vague language such as “I think” or “maybe,” which could weaken your position. Clearly explain why your research is significant and how it contributes to the broader field of study.

Here’s an example from a (fictional) study on the impact of social media on mental health:

Discussing Limitations

Although it’s important to emphasize the significance of your study, you can also use the conclusion to briefly address any limitations you discovered while conducting your research, such as time constraints or a shortage of resources. Doing this demonstrates a balanced and honest approach to your research.

Connecting to the Introduction

In your conclusion, you can circle back to your introduction , perhaps by referring to a quote or anecdote you discussed earlier. If you end your paper on a similar note to how you began it, you will create a sense of cohesion for the reader and remind them of the meaning and significance of your research.

Ending With a Thought-Provoking Statement

Consider ending your paper with a thought-provoking and memorable statement that relates to the impact of your research questions or hypothesis. This statement can be a call to action, a philosophical question, or a prediction for the future (positive or negative). Here’s an example that uses the same topic as above (social media and mental health):

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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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• Last Updated: Jul 18, 2023 11:58 AM
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Writing Center

Strategic enrollment management and student success, conclusions and why they matter, a guide to what they are, how they work, and how to master them, conclusions vs. introductions.

Similarly to introductions, conclusions exist to guide readers. While introductions guide readers into essays, conclusions guide readers out. These functions are equally important in the structure of an essay. A conclusion is a paragraph (or set of paragraphs) that comes at the very end of an essay and it must restate the thesis (say what the essay has argued) and summarize the argument.

Think about a conclusion from the reader's point of view as the end of a conversation

Hey!   Don't hang up on me!

Sometimes it's hard to know what to say in a conclusion. after all, you've just written the essay, what else can possibly be left to say? A lot of writers feel this way. However, an essay without a conclusion is similar to hanging up the phone the instant after you've told your friend a great story - your friend is going to think about how rude you were rather than about your story. In a phone conversation, you've got to wrap things up and say goodbye, this is also true for an essay. Make sure to provide your reader with a summary.

• A summary:   Since good stories are complex and can't be learned by heart the first time, give your reader a device to help remember and master your story (your argument).
• A sense of relevance:   Help the reader understand the point of your story by explaining the relevance of it.

How conclusions work

What does it really mean to say that a conclusion resembles the end of a phone conversation?

• All things come to an end.   Of course, you can't keep talking on the phone forever; both you and your friend expect an end to your conversation. At the same time, a conversation is something produced by two people, meaning that its end must be agreed upon, and if you hang up without warning, then you've seized all control, which isn't friendly. Even though the conclusion of an essay may be just a repetition of ideas found elsewhere, a reader needs to be able to see that things are winding down.
• An end means a last look.   If you sound polite and cheerful in saying goodbye, your friend will be much more likely to recall the story you've told and to look forward to hearing from you in the future. Because the conclusion to an essay is a reader's last impression of a writer's work, the writer must maintain excellence up to the last sentence, not dash something off quickly or run out of steam.
• A last look is a kind of legacy.   While you probably wouldn't tell your friend a pointless story, or one with no relation to any shared experience, making the relevance clear helps your friend know how to think about your story. Similarly, an essay that leaves a reader with something to think about is an essay that is more likely to be judged favorably and even reread. Connecting the writing to the reader is central to succeeding in communicating the importance of your story.

Acing the conclusion

The strategies below can help you write a conclusion that leaves your reader satisfied and feeling like they've gotten closure on your ideas.

Remind and encapsulate

Remember that even though you are already familiar with your essay, your reader is not. Having a reader who wants to reread your work is great, but your reader shouldn't have to reread. Giving your reader a summary is similar to taking a snapshot of your whole essay. Looking at that snapshot reminds your reader of the main points that have come before. A snapshot is a lot easier to carry around than a thousand little details.

Acknowledge loose ends

Since issues are complex and often do not have a single, neat resolution, the topic of your essay doesn't need to either. What possible resolutions do you see for the issue you have presented? Is there even a resolution? In either case, say what you see. Don't present answers if you haven't found any. Just be honest.

Make connections

Show your reader the point of reading your essay. What did you learn from writing your essay? How might reading your essay be helpful to your reader? What does your essay contribute?

Don't get carried away

You don't have to revolutionize the world or say the absolute final world on an age-old debate. In fact, a grandiose conclusion may seem out of proportion in anything as short as an essay. Communicating an idea is enough.

Now let's apply these ideas to an example conclusion

The trend towards "good taste" in mass-market products draws into question the idea of good taste altogether   (Thesis) . Many things symbolizing high class living are in danger of losing their status simply because they can now be purchased at any Home Depot or Ikea;   (Summary 1: the first main point)   however, critics call décor and furniture exports such as Pier 1 Imports and Pottery Barn "cheap" not for offering sophisticated designs at bargain prices, but for offering them to all, even to mail-order costumers   (Summary 2: the second main point) . Worst of all, Martha Stewart is said to have reduced good taste to merely another brand name by creating a line of home wares for the suburban superstore K-Mart   (Summary 3: the third main point) . The implication is that a fine object loses its fineness as it gains wider appreciation, that beauty and elegance are qualities conferred by the elite and that an object's glow vanishes once too many have touched it, In other words, the wealthy and influential are not content with wealth and influence, but must have a world all to themselves; when others enter this world, they come to destroy   (Relevance 1: a synthesis of the main points that reveals their significance in a wider context) . Martha Stewart would have to disagree. Sconce lights might look out of place on a cattle ranch, but their popularity does not equate them with the neon signs that one sees in the windows of bars - quality is quality. If replacing the average household's melamine plates with porcelain makes some people insecure, then so be it   (Relevance 2: a stance that applies to readers) .

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How to Write a Research Paper Conclusion Section

What is a conclusion in a research paper?

The conclusion in a research paper is the final paragraph or two in a research paper. In scientific papers, the conclusion usually follows the Discussion section , summarizing the importance of the findings and reminding the reader why the work presented in the paper is relevant.

However, it can be a bit confusing to distinguish the conclusion section/paragraph from a summary or a repetition of your findings, your own opinion, or the statement of the implications of your work. In fact, the conclusion should contain a bit of all of these other parts but go beyond it—but not too far beyond! 

The structure and content of the conclusion section can also vary depending on whether you are writing a research manuscript or an essay. This article will explain how to write a good conclusion section, what exactly it should (and should not) contain, how it should be structured, and what you should avoid when writing it.  

Table of Contents:

What does a good conclusion section do, what to include in a research paper conclusion.

• Conclusion in an Essay
• Research Paper Conclusion 
• Conclusion Paragraph Outline and Example
• What Not to Do When Writing a Conclusion

The conclusion of a research paper has several key objectives. It should:

• Restate your research problem addressed in the introduction section
• Summarize your main arguments, important findings, and broader implications
• Synthesize key takeaways from your study

The specific content in the conclusion depends on whether your paper presents the results of original scientific research or constructs an argument through engagement with previously published sources.

You presented your general field of study to the reader in the introduction section, by moving from general information (the background of your work, often combined with a literature review ) to the rationale of your study and then to the specific problem or topic you addressed, formulated in the form of the statement of the problem in research or the thesis statement in an essay.

In the conclusion section, in contrast, your task is to move from your specific findings or arguments back to a more general depiction of how your research contributes to the readers’ understanding of a certain concept or helps solve a practical problem, or fills an important gap in the literature. The content of your conclusion section depends on the type of research you are doing and what type of paper you are writing. But whatever the outcome of your work is, the conclusion is where you briefly summarize it and place it within a larger context. It could be called the “take-home message” of the entire paper.

What to summarize in the conclusion

Your conclusion section needs to contain a very brief summary of your work , a very brief summary of the main findings of your work, and a mention of anything else that seems relevant when you now look at your work from a bigger perspective, even if it was not initially listed as one of your main research questions. This could be a limitation, for example, a problem with the design of your experiment that either needs to be considered when drawing any conclusions or that led you to ask a different question and therefore draw different conclusions at the end of your study (compared to when you started out).

Once you have reminded the reader of what you did and what you found, you need to go beyond that and also provide either your own opinion on why your work is relevant (and for whom, and how) or theoretical or practical implications of the study , or make a specific call for action if there is one to be made.   

How to Write an Essay Conclusion

Academic essays follow quite different structures than their counterparts in STEM and the natural sciences. Humanities papers often have conclusion sections that are much longer and contain more detail than scientific papers. There are three main types of academic essay conclusions.

Summarizing conclusion

The most typical conclusion at the end of an analytical/explanatory/argumentative essay is a summarizing conclusion . This is, as the name suggests, a clear summary of the main points of your topic and thesis. Since you might have gone through a number of different arguments or subtopics in the main part of your essay, you need to remind the reader again what those were, how they fit into each other, and how they helped you develop or corroborate your hypothesis.

For an essay that analyzes how recruiters can hire the best candidates in the shortest time or on “how starving yourself will increase your lifespan, according to science”, a summary of all the points you discussed might be all you need. Note that you should not exactly repeat what you said earlier, but rather highlight the essential details and present those to your reader in a different way. 

Externalizing conclusion

If you think that just reminding the reader of your main points is not enough, you can opt for an externalizing conclusion instead, that presents new points that were not presented in the paper so far. These new points can be additional facts and information or they can be ideas that are relevant to the topic and have not been mentioned before.

Such a conclusion can stimulate your readers to think about your topic or the implications of your analysis in a whole new way. For example, at the end of a historical analysis of a specific event or development, you could direct your reader’s attention to some current events that were not the topic of your essay but that provide a different context for your findings.

Editorial conclusion

In an editorial conclusion , another common type of conclusion that you will find at the end of papers and essays, you do not add new information but instead present your own experiences or opinions on the topic to round everything up. What makes this type of conclusion interesting is that you can choose to agree or disagree with the information you presented in your paper so far. For example, if you have collected and analyzed information on how a specific diet helps people lose weight, you can nevertheless have your doubts on the sustainability of that diet or its practicability in real life—if such arguments were not included in your original thesis and have therefore not been covered in the main part of your paper, the conclusion section is the place where you can get your opinion across.    

How to Conclude an Empirical Research Paper

An empirical research paper is usually more concise and succinct than an essay, because, if it is written well, it focuses on one specific question, describes the method that was used to answer that one question, describes and explains the results, and guides the reader in a logical way from the introduction to the discussion without going on tangents or digging into not absolutely relevant topics.

Summarize the findings

In a scientific paper, you should include a summary of the findings. Don’t go into great detail here (you will have presented your in-depth  results  and  discussion  already), but do clearly express the answers to the  research questions  you investigated.

Describe your main findings, even if they weren’t necessarily the ones anticipated, and explain the conclusion they led you to. Explain these findings in as few words as possible.

Instead of beginning with “ In conclusion, in this study, we investigated the effect of stress on the brain using fMRI …”, you should try to find a way to incorporate the repetition of the essential (and only the essential) details into the summary of the key points. “ The findings of this fMRI study on the effect of stress on the brain suggest that …” or “ While it has been known for a long time that stress has an effect on the brain, the findings of this fMRI study show that, surprisingly… ” would be better ways to start a conclusion. 

You should also not bring up new ideas or present new facts in the conclusion of a research paper, but stick to the background information you have presented earlier, to the findings you have already discussed, and the limitations and implications you have already described. The one thing you can add here is a practical recommendation that you haven’t clearly stated before—but even that one needs to follow logically from everything you have already discussed in the discussion section.

Discuss the implications

After summing up your key arguments or findings, conclude the paper by stating the broader implications of the research , whether in methods , approach, or findings. Express practical or theoretical takeaways from your paper. This often looks like a “call to action” or a final “sales pitch” that puts an exclamation point on your paper.

If your research topic is more theoretical in nature, your closing statement should express the significance of your argument—for example, in proposing a new understanding of a topic or laying the groundwork for future research.

Future research example

Future research into education standards should focus on establishing a more detailed picture of how novel pedagogical approaches impact young people’s ability to absorb new and difficult concepts. Moreover, observational studies are needed to gain more insight into how specific teaching models affect the retention of relationships and facts—for instance, how inquiry-based learning and its emphasis on lateral thinking can be used as a jumping-off point for more holistic classroom approaches.

Research Conclusion Example and Outline

Let’s revisit the study on the effect of stress on the brain we mentioned before and see what the common structure for a conclusion paragraph looks like, in three steps. Following these simple steps will make it easy for you to wrap everything up in one short paragraph that contains all the essential information: 

One: Short summary of what you did, but integrated into the summary of your findings:

While it has been known for a long time that stress has an effect on the brain, the findings of this fMRI study in 25 university students going through mid-term exams show that, surprisingly, one’s attitude to the experienced stress significantly modulates the brain’s response to it. 

Note that you don’t need to repeat any methodological or technical details here—the reader has been presented with all of these before, they have read your results section and the discussion of your results, and even (hopefully!) a discussion of the limitations and strengths of your paper. The only thing you need to remind them of here is the essential outcome of your work. 

Two: Add implications, and don’t forget to specify who this might be relevant for: 

Students could be considered a specific subsample of the general population, but earlier research shows that the effect that exam stress has on their physical and mental health is comparable to the effects of other types of stress on individuals of other ages and occupations. Further research into practical ways of modulating not only one’s mental stress response but potentially also one’s brain activity (e.g., via neurofeedback training) are warranted.

This is a “research implication”, and it is nicely combined with a mention of a potential limitation of the study (the student sample) that turns out not to be a limitation after all (because earlier research suggests we can generalize to other populations). If there already is a lot of research on neurofeedback for stress control, by the way, then this should have been discussed in your discussion section earlier and you wouldn’t say such studies are “warranted” here but rather specify how your findings could inspire specific future experiments or how they should be implemented in existing applications. 

Three: The most important thing is that your conclusion paragraph accurately reflects the content of your paper. Compare it to your research paper title , your research paper abstract , and to your journal submission cover letter , in case you already have one—if these do not all tell the same story, then you need to go back to your paper, start again from the introduction section, and find out where you lost the logical thread. As always, consistency is key.    

Problems to Avoid When Writing a Conclusion 

• Do not suddenly introduce new information that has never been mentioned before (unless you are writing an essay and opting for an externalizing conclusion, see above). The conclusion section is not where you want to surprise your readers, but the take-home message of what you have already presented.
• Do not simply copy your abstract, the conclusion section of your abstract, or the first sentence of your introduction, and put it at the end of the discussion section. Even if these parts of your paper cover the same points, they should not be identical.
• Do not start the conclusion with “In conclusion”. If it has its own section heading, that is redundant, and if it is the last paragraph of the discussion section, it is inelegant and also not really necessary. The reader expects you to wrap your work up in the last paragraph, so you don’t have to announce that. Just look at the above example to see how to start a conclusion in a natural way.
• Do not forget what your research objectives were and how you initially formulated the statement of the problem in your introduction section. If your story/approach/conclusions changed because of methodological issues or information you were not aware of when you started, then make sure you go back to the beginning and adapt your entire story (not just the ending). 

Consider Receiving Academic Editing Services

When you have arrived at the conclusion of your paper, you might want to head over to Wordvice AI’s AI Writing Assistant to receive a free grammar check for any academic content. 

After drafting, you can also receive English editing and proofreading services , including paper editing services for your journal manuscript. If you need advice on how to write the other parts of your research paper , or on how to make a research paper outline if you are struggling with putting everything you did together, then head over to the Wordvice academic resources pages , where we have a lot more articles and videos for you.

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Trikalinos TA, Dahabreh IJ, Lee J, et al. Defining an Optimal Format for Presenting Research Needs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Jun. (Methods Future Research Needs Reports, No. 3.)

Defining an Optimal Format for Presenting Research Needs [Internet].

Discussion and conclusions.

Future research needs recommendations are valuable inputs for researchers, funders, and advocates making decisions about avenues for future scientific exploration. We performed an empirical evaluation of the published literature to appreciate the variability in the presentation of information on future research needs. We found that most systematic reviews, meta-analyses, or economic analyses do not focus on future research needs, and any referral to future research is most often cursory. Systematic reviews and meta-analyses often call for additional randomized trials, while economic analyses are more diverse in their suggestions.

In qualitative discussions with experts, we identified a number of general themes. The discussions were quickly saturated, and while additional one-to-one interviews could have generated more themes, it is unclear whether these would have been of major importance for defining the optimal format for presenting future research needs. An unanticipated theme from the qualitative interviews was that specificity in the recommendations for future research is not universally and unconditionally viewed as a desirable attribute. The rationale is that specific descriptions could be perceived as too prescriptive or restrictive, and in the extreme they may have unintended consequences, such as opposing the paradigm of investigator-initiated research. Experts disagreed on the importance of this point. Nevertheless it is probably prudent to take this point into account when reporting assessments of future research needs, and all experts agreed that proper framing of the future research needs documents could address this concern. A survey of a large and representative sample of potential users of future research needs assessments would clarify whether such reactions are prevalent. If yes, it would be also interesting to understand why some users are prone to seeing even moderately specific recommendations with skepticism. Ideology, cultural norms, or professional self-interests may be explanations.

Several limitations need to be considered when interpreting our results. First, we only recruited four experts for our qualitative interviews; hence, our results should be considered hypothesis forming and not representative of all stakeholders. However, the purpose of the qualitative interviews was to identify general themes with respect to the way different stakeholders would approach a document presenting and discussing future research needs, and not necessarily to get a representative quantification of different opinions. The optimal research design to quantify the frequency of different opinions is a survey using a representative sampling scheme, rather than qualitative interviews or even focus groups.

Regarding our empirical assessment of secondary research manuscripts, we focused on high impact general journals (for systematic reviews) or highly specialized technical journals (for cost-effectiveness/utility analyses). Thus our empirical assessment of future research presentation is not be generalizable to all journals. If anything, because even in these “top-tier” journals the presentation of implications for future research was fairly cursory and informal, the situation is unlikely to be better in other research outlets. Further, determining future research needs is not the primary focus of systematic reviews and cost-effectiveness/utility analyses. Therefore it is doubtful that including a broader set of journals would change the essence of our conclusions.

The concept of a stand-alone document on future research needs is probably new to most of the individuals approached, and additional discussion is likely needed regarding potential uses prior to making very specific recommendations on the optimal presentation of future research needs documents. We outline the following preliminary recommendations for presenting future research needs documents, based on the results of the empirical assessment and the qualitative interviews:

• Provide succinct yet adequate description of methods and results, following guidelines for reporting of health care research (for example, reporting guidelines for qualitative research 8–11 and modeling 12–15 ). Aim for a level of detail similar to that found in papers addressed to a general medical audience.
• Be cognizant of the importance of the face validity of the process. Justify the selection of the stakeholders who participated in the identification or prioritization of research needs, and be clear about their degree of engagement.
• Consider reporting the results of the future research needs assessment at two levels of detail. A suggestion would be to first present general areas that merit future research without specifying research designs or specific details on, for example, PICO elements. A second set of results could elaborate further on potential research designs, details on PICO elements, or other details as applicable.
• Frame the more specific set of results as “examples” rather than strict recommendations.
• Avoid explicit prioritization of research needs when there are no clear differences in the perceived strength of alternative recommendations. A general prioritization of future research recommendations as of “high,” “medium,” or “low” importance may be more appropriate than an explicit numerical ranking. Consider a grouped presentation of future research needs by thematic entities.
• Clearly define how the feasibility of future research was assessed. It may be instructive to perform power analyses for specific research designs for a range of assumptions, and to compare the results with the size and type of existing studies in the field. For example, trials are typically more resource-intensive than secondary analyses of existing data.
• Cite this Page Trikalinos TA, Dahabreh IJ, Lee J, et al. Defining an Optimal Format for Presenting Research Needs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Jun. (Methods Future Research Needs Reports, No. 3.) Discussion and Conclusions.
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How to Write Effective Discussion and Conclusion Sections

Affiliations.

• 1 Cooper Medical School of Rowan University, Camden, NJ.
• 2 Rothman Institute, Philadelphia, PA.
• PMID: 29979216
• DOI: 10.1097/BSD.0000000000000687

With the exponential increase in research in the field of spine surgery, publishing peer-reviewed articles has become both more desirable and competitive in the past decade. Constructing an impactful manuscript has many important factors, one of which is a well-written Discussion section. A research study can ask a pressing question, have a meticulous methodology and report compelling results; however, without a thoughtful and well-informed analysis of the meaning of the study's findings and their potential influence on the field, the paper will be uninteresting and weak. Thus, formulating an effective Discussion section is crucial to improving the likelihood of the study's publication and its impact.

• Biomedical Research
• Guidelines as Topic
• Peer Review, Research*

Topic Guide - Developing Your Research Study

• Purpose of Guide
• Flaws to Avoid
• Independent and Dependent Variables
• Glossary of Research Terms
• Reading Research Effectively
• 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
• APA 7th Edition
• Executive Summary
• The C.A.R.S. Model
• Background Information
• The Research Problem/Question
• Theoretical Framework
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• Evaluating Sources
• Primary Sources
• Secondary Sources
• Tiertiary Sources
• What Is Scholarly vs. Popular?
• Qualitative Methods
• Quantitative Methods
• Using Non-Textual Elements
• Limitations of the Study

Importance of a Good Conclusion

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• Further Readings
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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 and, if applicable, where you recommend new areas for future research. For most college-level research papers, one or two well-developed paragraphs is sufficient for a conclusion, although in some cases, three or more paragraphs may be required.

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

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 or result section or by noting important or unexpected implications applied to practice.
• Summarizing your thoughts and conveying the larger significance of your study . The conclusion is an opportunity to succinctly answer [or in some cases, to re-emphasize]  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 [described in your literature review section] has been filled by your research.
• Demonstrating the importance of your ideas . Don't be shy. The conclusion offers you the opportunity to elaborate on the impact and 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 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.

I.  General Rules

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). Do this by stating clearly 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. Make sure, however, 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 essay.

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

• State your conclusions in clear, simple language. Re-state the purpose of your study then state how your findings differ or support those of other studies and why [i.e., what were the unique or new contributions your study made to the overall research about your topic?].
• Do not simply reiterate your results 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.

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.

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 : 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 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 strategies:

• 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 that, if adopted, could address a specific problem in practice or in the development of new knowledge.
• Cite a relevant quotation or expert opinion already noted in your paper in order to lend authority to the conclusion you have reached [a good place to look is research 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 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 presented in your introduction, but add further insight derived from the findings of your study; use your interpretation of results to recast it in new or important ways.
• Provide a "take-home" message in the form of a strong, succinct 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 [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. Problems, drawbacks, and challenges encountered during your study 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 your summary of the 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 back into 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 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 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.

Assan, Joseph. Writing the Conclusion Chapter: The Good, the Bad and the Missing . Department of Geography, University of Liverpool; 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.

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.

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, 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 locate your findings within the larger context of scholarship on the topic, including describing how your research contributes new insights or value to that scholarship.

Assan, Joseph. Writing the Conclusion Chapter: The Good, the Bad and the Missing . Department of Geography, University of Liverpool; Conclusions . The Writing Center. University of North Carolina.

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• The Importance of Conclusions and Recommendations in the Monitoring and Evaluation (M&E) Process
• Learning Center

Drawing conclusions and making recommendations are other important aspects of the monitoring and evaluation process . The conclusions and recommendations that are drawn from the evaluation findings can help to inform decision-making, improve program effectiveness, and promote learning and accountability.

Here are some key considerations when drawing conclusions and making recommendations in the monitoring and evaluation process.

Table of Contents

What are the conclusions?

Examples of conclusions in the monitoring and evaluation (m&e), what are the recommendations, examples of recommendations in the monitoring and evaluation (m&e), example of a conclusion and recommendation section from a monitoring and evaluation report, review the evaluation findings, consider the context, identify strengths and weaknesses, make actionable recommendations, communicate findings and recommendations.

Conclusions in the Monitoring and Evaluation (M&E) process refer to the key findings or results of the evaluation that provide insights into the effectiveness and efficiency of the program or intervention being evaluated. They are based on the analysis of data collected during the evaluation process and are used to determine the extent to which the program or intervention has achieved its intended objectives.

Conclusions in M&E typically include a summary of the evaluation results, highlighting what worked well and what did not work. They also provide an assessment of the program or intervention’s impact, sustainability, and scalability. Conclusions are an essential component of the M&E process as they provide decision-makers with evidence-based information that can be used to improve future programs or interventions.

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Here are some examples of conclusions in the Monitoring and Evaluation (M&E) process:

• Program effectiveness: The evaluation may conclude that the program was effective in achieving its intended objectives, based on the analysis of data collected during the evaluation process. For example, if a health education program was intended to increase knowledge of healthy eating habits and the evaluation found that the program achieved this goal, the conclusion would be that the program was effective.
• Program efficiency: The evaluation may conclude that the program was efficient in achieving its objectives, based on the resources used to implement the program. For example, if a job training program was implemented at a lower cost than similar programs and achieved similar outcomes, the conclusion would be that the program was efficient.
• Program impact: The evaluation may conclude that the program had a positive impact on the target population, based on the analysis of data collected during the evaluation process. For example, if a youth development program was intended to reduce delinquency rates and the evaluation found a significant reduction in delinquency rates among program participants, the conclusion would be that the program had a positive impact.
• Program scalability: The evaluation may conclude that the program can be scaled up to reach a larger population, based on the program’s success in achieving its intended objectives. For example, if a literacy program was implemented in one community and was successful in improving reading levels, the conclusion would be that the program could be scaled up to reach other communities.
• Program sustainability: The evaluation may conclude that the program is sustainable, based on the program’s ability to continue achieving its intended objectives over time. For example, if a community-based environmental program has been successful in reducing pollution levels and has secured long-term funding, the conclusion would be that the program is sustainable.

These are just a few examples of the types of conclusions that may be drawn from the M&E process. The specific conclusions will depend on the evaluation results and the program’s goals and objectives.

Recommendations in the Monitoring and Evaluation (M&E) process refer to suggestions or proposals for actions that should be taken based on the evaluation results. They are based on the analysis of data collected during the evaluation process and are used to improve the program or intervention being evaluated.

Recommendations in M&E typically include specific actions that should be taken to address the program’s weaknesses or to build on its strengths. They may also include suggestions for improving program design, implementation, monitoring, and evaluation. Recommendations may be directed towards program managers, stakeholders, funders, or policymakers, depending on the intended audience.

Recommendations are an essential component of the M&E process as they provide decision-makers with evidence-based information that can be used to improve the program’s effectiveness and efficiency. They help to ensure that future programs or interventions are designed and implemented in a way that maximizes their impact and achieves their intended objectives.

Related: Recommendations in Evaluation

Here are some examples of recommendations in the Monitoring and Evaluation (M&E) process:

• Improve program design: If the evaluation finds that the program design is not effective, the recommendation may be to redesign the program and its activities to ensure they are more relevant and appropriate to the target population’s needs.
• Enhance implementation: If the evaluation reveals implementation challenges, the recommendation may be to implement strategies to address these challenges, such as providing additional training to program staff, improving program management, or increasing community engagement.
• Strengthen monitoring and evaluation: If the evaluation finds that the monitoring and evaluation system is weak, the recommendation may be to improve the quality of data collected, increase the frequency of data collection, or develop a better system for data analysis and reporting.
• Expand program coverage: If the evaluation finds that the program has had a positive impact, the recommendation may be to expand the program’s coverage to reach more people in the target population.
• Increase program sustainability: If the evaluation reveals that the program’s sustainability is at risk, the recommendation may be to develop a sustainability plan that outlines strategies for long-term program funding and support.

These are just a few examples of the types of recommendations that may be made as a result of the M&E process. The specific recommendations will depend on the evaluation results and the program’s goals and objectives.

Related: Eval Rec’s – EVAL CAFE

Here is an example of a conclusion and recommendation section from a monitoring and evaluation report on a water supply project in rural Ethiopia:

The evaluation found that the water supply project has achieved its objectives of increasing access to safe and reliable water sources for 15,000 people in five rural communities in Ethiopia. The project has also contributed to improved health, hygiene, education, and livelihood outcomes for the beneficiaries, as well as enhanced social cohesion and gender equality. The project has demonstrated good practices in community participation, capacity building, sustainability, and innovation. However, the project also faced some challenges and limitations, such as delays in construction, technical issues with some water points, lack of adequate monitoring data, and insufficient coordination with other actors. The evaluation identified some areas for improvement and learning for future similar projects.

Recommendations

Based on the evaluation findings and conclusions, the following recommendations are proposed:

• To the project team: Conduct regular maintenance and repair of the water points to ensure their functionality and durability. Strengthen the monitoring system to collect more accurate and comprehensive data on the project outputs, outcomes, and impacts. Enhance the communication and collaboration with other stakeholders, such as local authorities, NGOs, and donors, to avoid duplication of efforts and to leverage synergies.
• To the community water committees: Continue to mobilize and educate the community members on the importance of water conservation, hygiene practices, and payment of water fees. Ensure that the water fees are collected transparently and used efficiently for the operation and maintenance of the water points. Promote the inclusion and empowerment of women and marginalized groups in the decision-making and management of water resources.
• To the donor: Provide continued financial and technical support to the project team and the community water committees to ensure the sustainability and scalability of the project. Share the evaluation findings and lessons learned with other relevant actors to disseminate good practices and to inform future policy and programming.

Related: How to write a good M&E report – guidelines & best practices – TolaData

Reviewing the evaluation findings is a crucial step in drawing conclusions and making recommendations in the monitoring and evaluation process. This involves a thorough examination and analys is of the data collected during the evaluation, including both quantitativ e and qualitative data.

Quantitative data may include numerical data such as statistics, percentages, and figures, while qualitative data may include non-numerical data such as narratives, descriptions, and observations. Both types of data need to be analyzed carefully to identify patterns, trends, and themes that can inform the evaluation conclusions and recommendations.

The analysis of the evaluation findings should also consider the limitations of the data, such as sample size, response rate, and potential biases, and how these limitations may affect the reliability and validity of the conclusions and recommendations.

In summary, reviewing the evaluation findings is a critical step in drawing conclusions and making recommendations, as it provides the evidence base for the evaluation and ensures that the conclusions and recommendations are grounded in the data.

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Context refers to the broader circumstances or environment in which the program operates, and it plays a crucial role in shaping the program’s outcomes and effectiveness.

To draw accurate conclusions and make relevant recommendations, it is essential to consider various contextual factors, including political, economic, social, and cultural dimensions. Political factors such as government policies, regulations, and political stability can significantly impact the success of a program. Economic factors such as funding, market trends, and economic growth can also influence the program’s outcomes.

Similarly, social and cultural factors such as social norms, cultural beliefs, and community attitudes can shape how the program is perceived and implemented. Therefore, it is critical to consider these contextual factors while evaluating the program’s goals and objectives to determine whether they align with the local context and to make recommendations accordingly.

Overall, taking into account the program’s goals and objectives in light of its contextual factors will help in drawing accurate conclusions and making informed recommendations that are relevant and effective in achieving the program’s intended outcomes.

Strengths and weaknesses analysis is a crucial component of program evaluation, and the statement rightly highlights its importance in drawing conclusions and informing future program planning and implementation.

Strengths analysis allows program evaluators to identify the program’s positive aspects, including its achievements, successes, and benefits. These strengths can help inform future program planning by highlighting successful strategies and practices that can be replicated or expanded to improve program effectiveness. Moreover, identifying strengths can also help to build on the program’s positive aspects, improving its overall impact.

On the other hand, weaknesses analysis helps identify areas of the program that require improvement or restructuring. These weaknesses can include issues related to program design, implementation, or outcomes. Identifying weaknesses is essential to inform future program planning and improve program effectiveness. Moreover, weaknesses analysis can also provide opportunities to learn from past mistakes, and it can help to avoid repeating them in the future.

Overall, identifying the strengths and weaknesses of a program is essential to draw accurate conclusions and inform future program planning and implementation. By recognizing the program’s positive and negative aspects, program evaluators can develop evidence-based recommendations to improve program effectiveness, ensuring that the program achieves its intended goals and objectives.

Making actionable recommendations ensures that the recommendations are relevant, feasible, and likely to lead to improvements in program performance.

To make actionable recommendations, it is crucial to base them on the evidence generated through program evaluation. The recommendations should address specific issues or challenges identified during the evaluation, and they should be specific, measurable, achievable, relevant, and time-bound ( SMART ).

• For example, a program evaluation may identify that the program’s target population is not adequately engaged, and this is affecting program outcomes. Based on this finding, the recommendation could be to enhance community outreach efforts to increase engagement among the target population. This recommendation is actionable, and specific, and provides a clear path forward for program managers to improve the program’s performance.

Moreover, recommendations may also include changes to program design or implementation, such as modifying the program’s goals or objectives, revising the program’s theory of change, or enhancing the program’s monitoring and evaluation framework. These recommendations should also be actionable, feasible, and backed by evidence to ensure that they are likely to result in program improvements.

Finally, recommendations may include suggestions for future research to address gaps in knowledge or evaluate the effectiveness of specific program components. These recommendations should also be actionable, specific, and feasible, providing a clear path forward for researchers to conduct further studies.

Overall, making actionable recommendations is essential to ensure that program evaluation leads to tangible improvements in program performance, and that the recommendations are feasible, relevant, and likely to lead to positive change.

Effective communication is essential to ensure that stakeholde rs understand the evaluation results, the rationale for the recommendations, and their implications for program planning and implementation.

• To communicate evaluation findings and recommendations effectively, it is essential to tailor the communication approach to the audience. For example, program managers may require a more detailed presentation of the evaluation results, including the methodology, data analysis, and limitations. In contrast, funders may require a concise summary of the evaluation results, including the key findings and recommendations.

In addition to tailoring the communication approach, it is also essential to use clear, concise, and jargon-free language to ensure that stakeholders understand the evaluation results and recommendations. Effective communication should also provide opportunities for stakeholders to ask questions, clarify doubts, and provide feedback on the evaluation results and recommendations.

Furthermore, effective communication should also highlight the benefits of the evaluation , such as identifying successful strategies, opportunities for program improvement, and lessons learned. This can help to build support for future evaluations and ensure that stakeholders understand the value of the monitoring and evaluation process .

Overall, effective communication of evaluation findings and recommendations is essential to ensure that stakeholders understand the evaluation results and can use them to inform future program planning and implementation. Effective communication can help build support for the evaluation process and ensure that stakeholders are engaged and invested in program improvement.

The importance of conclusions and recommendations in monitoring and evaluation practice cannot be overstated. Conclusions are the results of an evaluation study, which provide an analysis of the findings and an interpretation of their meaning. Recommendations, on the other hand, are suggestions for action that are based on the conclusions.

Effective monitoring and evaluation requires that conclusions and recommendations are well-thought-out and communicated clearly. It is important that the conclusions and recommendations are evidence-based, comprehensive, and practical. The conclusions and recommendations should be tailored to the needs of the stakeholders and communicated in a way that is easily understandable.

In addition, it is important to consider the limitations and constraints of the evaluation study when formulating conclusions and recommendations. The evaluation team should be transparent about the methods used, the data collected, and the conclusions drawn.

Overall, the conclusions and recommendations are critical components of any monitoring and evaluation exercise. They provide valuable insights into the effectiveness of programs, policies, and interventions and can guide decision-makers in making informed decisions about future actions.

Patrick Kapuot

Very informative, interesting and clearly said.

I suggest in future to include a sample report that have key traits in it that were applied in the report.

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• Methodology
• Open access
• Published: 20 September 2023

Co-producing principles to guide health research: an illustrative case study from an eating disorder research clinic

• Cat Papastavrou Brooks   ORCID: orcid.org/0000-0002-3055-5301 1 , 2 ,
• Eshika Kafle 2 ,
• Natali Butt 2 ,
• Dave Chawner 2 , 3 ,
• Anna Day 2 ,
• Chloë Elsby-Pearson   ORCID: orcid.org/0000-0002-2235-2379 2 ,
• Emily Elson 2 ,
• John Hammond 2 ,
• Penny Herbert 2 ,
• Catherine L. Jenkins 2 ,
• Zach Johnson 2 ,
• Sarah Helen Keith-Roach 2 ,
• Eirini Papasileka 2 , 4 ,
• Stella Reeves 2 , 5 ,
• Natasha Stewart 2 ,
• Nicola Gilbert 2 , 6 &
• Helen Startup 2  

Research Involvement and Engagement volume  9 , Article number:  84 ( 2023 ) Cite this article

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There is significant value in co-produced health research, however power-imbalances within research teams can pose a barrier to people with lived experience of an illness determining the direction of research in that area. This is especially true in eating disorder research, where the inclusion of co-production approaches lags other research areas. Appealing to principles or values can serve to ground collaborative working. Despite this, there has not been any prior attempt to co-produce principles to guide the work of a research group and serve as a basis for developing future projects.

The aim of this piece of work was to co-produce a set of principles to guide the conduct of research within our lived experience led research clinic, and to offer an illustrative case for the value of this as a novel co-production methodology. A lived experience panel were recruited to our eating disorder research group. Through an iterative series of workshops with the members of our research clinic (composed of a lived experience panel, clinicians, and researchers) we developed a set of principles which we agreed were important in ensuring both the direction of our research, and the way in which we wanted to work together.

Six key principles were developed using this process. They were that research should aim to be: 1) real world—offering a clear and concrete benefit to people with eating disorders, 2) tailored—suitable for marginalised groups and people with atypical diagnoses, 3) hopeful—ensuring that hope for recovery was centred in treatment, 4) experiential—privileging the ‘voice’ of people with eating disorders, 5) broad—encompassing non-standard therapeutic treatments and 6) democratic—co-produced by people with lived experience of eating disorders.

Conclusions

We reflect on some of the positives as well as limitations of the process, highlighting the importance of adequate funding for longer-term co-production approaches to be taken, and issues around ensuring representation of minority groups. We hope that other health research groups will see the value in co-producing principles to guide research in their own fields, and will adapt, develop, and refine this novel methodology.

Plain English summary

It important that when researchers are trying to understand illnesses they do this together with people who have experienced them. This can be difficult, because researchers often take over—even if everyone is meant to be working as a team. We are a group of people trying to understand eating disorders and help people who have them get better. In our group there are some people that have experienced an eating disorder, health workers and researchers.

We thought it might be helpful if we could start by working out what things were most important to us as a group, and then try to stick by them. We talked a lot together to come up with a list of principles.

The six principles we thought were the most important were that research should make a difference to people’s lives, see people as individuals, be hopeful, make sure that people have a voice, look at things that aren’t traditional therapies, and always work together as equals.

There are some issues with what we did; we found it hard to get a good mix of people in our group, and we were lucky in having enough money to pay people to do what we wanted to do, which is not always true. Despite this, we still hope that other teams might look at what we have done, and see if they could build on it, or change it, so it would work for them.

Peer Review reports

Co-production approaches

Co-production has been defined as the delivery of “public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbours” [ 21 ], placing a strong emphasis on the importance of citizens’ power and worth [ 26 ]. The initial emergence of co-production within health services stemmed from a critique of the limited power patients had to shape the service they received, and the failure of services to acknowledge and respond to patients’ often negative experiences [ 32 ]. Despite the argued importance of co-production in terms of its substantive, instrumental, normative and political value [ 94 ] there have been significant criticisms of what is typically described as ‘co-production’ in health services. This includes the claim that co-production rarely involves a transfer of power to patients [ 136 ], instead involving a co-option of people’s lived experience to be used for agendas which are foreign to them and their interests [ 102 ]. Genuine co-production is often impossible due to the reality of the power imbalances present in the psychiatric system [ 97 ], and—by masking and de-politicising these imbalances—it can serve to exacerbate them [ 124 ].

Within health research, co-production approaches come with their own associated set of difficulties [ 79 ]. Relationships within research often mirror those between patient and clinician and there can be a division between researchers who are seen as active, knowing and rational in contrast to the passive, known and irrational objects of health research—patients [ 66 ]. Although evidence-based practice is often reified as a values-neutral methodology [ 14 ], it involves the privileging a specific scientific or rationalistic voice, excluding ways of knowing which do not conform to this and often constituting a form of injustice against epistemically marginalized groups [ 30 , 37 ]. This critique is foundational to the emerging field of mad studies, which seeks not to just include mad people within mental health research by forcing them to assimilate within traditional methodological frameworks but demands instead substantial changes to the way we conceive of and conduct research [ 44 , 63 ]. Thus the aims of mad studies include both “showing that there is method in our madness; and on the other side, preserving madness in our method” [ 63 ].

In addition to these theoretical issues, co-producing research with patients can often have significant psychological and emotional costs for them, partially as a result of increased interpersonal conflict which often occurs [ 94 ]. Collaborating with patients on mental health research has been conceptualised as occurring on one of three distinct levels: consultation, collaboration, and user-controlled,Rose and Kalathil [ 105 ] argue that consultation is superficial and lacks value, and that collaboration only requires power imbalances to be hidden as opposed to abolished, meaning it inevitably collapses into consultation. On this model, methodologies like participatory action research—which centre around collaboration between researchers and participants [ 54 ] though do not challenge either the conceptual distinction or the power-relations between them typically fall under the category of collaboration. Only user-controlled research can preserve patients’ autonomy and ability to affect the research process without the risk of co-option [ 105 ].

Co-producing eating disorder research

Eating disorders (EDs) are a classification of disorders which involve feeding and eating disturbances which cause significant clinical distress [ 76 ]. An estimated 725,000 people in the UK are affected by EDs, at an estimated cost of 3.9–4.6 billion pounds annually to the NHS [ 15 ]. Anorexia Nervosa (AN) and Bulimia Nervosa (BN) are two eating disorders with high mortality rates, compared to the general population [ 11 , 128 ] with AN leading to the highest mortality rates compared to all other psychiatric illnesses [ 11 ].

Despite this, the strength of evidence for eating disorder treatments is modest [ 23 , 58 ] with no gold standard psychological interventions available for adult presentations of AN [ 83 ] or BN [ 96 ]. Systematic reviews of randomised control trials (RCTs) in eating disorders have found the evidence for psychological therapies for eating disorders inconclusive [ 24 , 58 ]. Therapies for eating disorders have a minimal evidence base, consisting of a very small number of studies [ 113 ], with and high impact factor journals publish significantly fewer papers on eating disorders than other psychiatric conditions [ 113 ]. This may be due, in part, to a deficit in funding for eating disorder research in comparison to the burden of illness [ 38 , 83 ], mirroring a lack of funding for clinical services [ 6 ].

However, another reason for the lack of effective evidence-based treatments for people with eating disorders could be comparative failings of integrating lived-experience perspectives into research in this area. Aspects of co-production have been incorporated into case-studies [ 4 , 5 , 19 ], the development of novel pathways such as FREED [ 7 ], within service delivery [ 75 ] and in research priority setting [ 9 , 92 ]. Feminist approaches within an eating disorder context have also been significant in challenging the politics and validity of diagnoses and power-imbalances within treatment, through drawing on women’s embodied and socially situated lived experience of having an eating disorder [ 72 ]. However, co-production within eating disorder research is not as established as service-user /survivor led research in other areas [ 44 , 104 ], where research teams and projects are either headed by or predominantly composed of lived-experience researchers.

Principles for co-production

A barrier to co-production in health research more generally, and eating disorder research specifically, might be that people with lived experience of an illness are often brought in to work on a specific research project, the parameters, aims and methodology of which have been set prior to their involvement. This contrasts with longer term work conducted by research teams including people with lived experience as key members—who might have the capacity to work together over a longer time-period to decide the direction they want their research to go in, and co-produce projects from the ground-up. Developing projects according to research principles has been found to be helpful in enabling this kind of longer-term collaboration, particularly around ideas of sharing power and building trust [ 31 ]. Many historically significant groups of mental patients advocating for their rights and to change mental health services have manifestos structured around shared values they collectively organize on the basis of CAPO [ 28 ], Mental Patients Union [ 81 ], MPU [ 82 ]. Within mental health services, there has been work carried on co-producing principles to guide the development and evaluation of peer worker roles [ 50 ], for best practice in school mental health [ 133 ] and within health research to develop principles for community-based research [ 107 ]. However, to our knowledge, there has not been an attempt to develop principles to form the basis for co-producing research between people with lived experience of a particular mental health issue and researchers, who though they might happen to have lived experience of what they are researching, are not employed in that capacity. Principles may help to guide the research process, facilitate collaborative working, and form the shared basis from which to derive research priorities. We believe that doing so could be an important way of preventing the collapse of collaboration into consultation [ 105 ].

The SPIRED research clinic

SPIRED (Sussex Partnership Innovation and Research in Eating Disorders) research clinic was founded in January 2021 and is composed of people with lived experience of eating disorders, researchers and clinicians working in the Sussex Eating Disorders Services within Sussex Partnership NHS Foundation Trust (SPFT). These identities are not mutually exclusive; many SPIRED clinic members will fall under two or more of these categories, and we aspire to be a team where clinicians and researchers are able to share their own experiences of mental health issues, regardless of their formal role [ 70 ].

To ensure those with lived experience had oversight in the research activities of the clinic, a lived experience panel was recruited in collaboration with SPFT’s Patient and Public Involvement (PPI) team [ 115 ]. The PPI team oversees the development of lived experience advisory panels (LEAPs) to ensure that those with lived experience can provide insight into the research conducted within SPFT. An advert was circulated on social media, within SPFT and with partner organisations to recruit individuals with diverse experiences of eating disorders and eating disorder treatment and was also circulated to patients within the trust eating disorder service who were at point of discharge. Sixteen individuals were recruited to the lived experience panel, and consequently SPIRED. The criteria for recruitment were that they had to identify as having experienced an eating disorder, regardless of whether that had been formally diagnosed. They were not required to reveal any information about their eating disorder. Since the eating disorder service SPIRED is connected to is for adults, all SPIRED lived experience panel members are over eighteen. Although these individuals were specifically recruited for a lived experience role, some of them also had clinical experience within the NHS, as well as research expertise. A co-production approach is followed in research conducted by SPIRED [ 32 ], echoing the rhetoric 'no decision about me without me' [ 41 ]. Within SPIRED, those with lived experience of EDs contribute to developing ideas, overseeing projects and conducting research.

To co-produce a set of principles to guide research, within an eating disorder research clinic composed of people with lived experience of an eating disorder, clinicians, and other researchers.

To provide an illustrative case for our approach as a novel co-production methodology, by demonstrating how co-producing developing principles can lead to a clear and defined research agenda.

Development of principles

Prior to the first SPIRED team meeting, the lived experience panel and SPIRED team members were invited to complete a questionnaire. The questionnaire was developed by the SPIRED clinic research assistant, a Service User and Carer Involvement Coordinator from the SPFT PPI team, and a member of the lived experience panel.

The questionnaire consisted of four open ended questions, and asked members to share whatever they felt comfortable sharing: their experience of eating disorders and eating disorder services, their view of what lived experience involvement in research meant, what they wanted to contribute to SPIRED aside from their lived experience of an eating disorder, and what they felt should be the key priorities for eating disorder research.

Responses were loosely summarised by theme and presented at the first SPIRED clinic meeting (facilitated over an online platform), where seventeen members were present, including eleven members of the lived experience panel. Small group discussions were held in break-out rooms to develop key principles, followed by feedback and a discussion with the whole group. Extensive notes were taken of all these discussions.

These notes formed the starting point of a smaller working group, with three lived experience panel members and two other SPIRED clinic members. A consensus-based decision making methodology [ 56 ] was used to derive core principles from the discussions of the wider SPIRED group. All the key principles derived from the initial meeting were discussed individually, with each working group member holding veto-power for any decision around a particular principle (whether that was to include or to exclude it). This then halted the decision, and the principle was then re-discussed and modified until consensus could be reached [ 56 ]. Following agreement about which principles to include, this consensus-based process was used for decision-making around which of the principles could be synthesized.

A group facilitator chaired the meeting and made notes on ongoing discussions to enable further reflection. The lead author then wrote up the main sections of this paper, which were then circulated to all SPIRED clinic members for comments and feedback, following which extensive changes were made to this paper.

Reflexivity

Everyone who has contributed to this paper at any stage has been invited to co-author (including the lived experience panel). Although we felt it was vital to highlight the extent of the contribution of the lived experience panel in the co-production of these principles, we did not want to force any individual to identify themselves as someone with lived experience of an eating disorder. Therefore, all authors are listed solely as SPIRED clinic members.

The SPIRED clinic consists of individuals with a range of experiences of different eating disorders, eating disorder services, clinicians, and researchers. We aimed to ensure representation from neurodivergent people, LGBTIA people, men, and people of colour (POC), all of which are often marginalised within eating disorder treatment. However, we recognise that POC are particularly underrepresented on our lived experience panel, which may have impacted on the principles that our research team chose to prioritise.

The SPFT Research Governance department confirmed that ethical approval was not necessary for this project, as there were no participants.

Because of the increased sensitivity of sharing personal information about mental health, co-authors who were lived experience panel members also signed a consent form to be anonymously quoted in this paper.

As a result of the process outlined above, the following six principles were determined to be fundamental in guiding our research. We believe in eating disorder research which is: real world, tailored, hopeful, experiential, broad and democratic (see Fig.  1 ).

Overview of SPIRED principles

We have chosen in this section to integrate the ‘results’ of our decision-making with existing literature, as this best reflects both our aims in doing this work and the process through which the principles came about. Traditional qualitative research results focus solely on ‘participant data’, viewing people experiences, viewpoints, and theorizing as data-points to be analysed by a researcher, and then contextualized within the discussion section of a paper. However, our lived experience panel (along with other clinic members) are not participants, but researchers, and drew on both their own individual experiences but also their understanding and critical assessment of the research literature during this process. This demonstrates the capacity of lived-experience led research to create new forms of knowing outside traditional research binaries, such as those between researcher and researched [ 63 ]. Because our discussions as a group, both in the meetings, and over email, involved sharing and reflecting on research findings, this structure has been mirrored in our write-up. The point of this work was to create a set of principles that would be foundational for our work together and could be shared with others. Although this paper describes the process by which we developed these principles, we consider the below results section not the output of a novel co-production process, but also an argument for change [ 16 ].

Given the paucity of research on efficacy and acceptability of ED treatments, there is an urgent need for research which is ‘real world’ and makes an immediate, practical impact on the lives of people with eating disorders. Within SPIRED, this could include developing and evaluating novel interventions for eating disorders [ 93 ], evaluating, improving and developing ED service provision [ 109 ] or engaging with policymaking to ensure it is evidence-based.

Current research does not seem to consistently meet the needs of those with EDs. Although recent research has established connections between the presence of an ED and brain structure and functioning [ 42 , 117 ], translating findings on neurofeedback and biofeedback into effective treatment has proven difficult, with current therapeutic options proving too invasive and costly [ 126 ].

Due to the high mortality rate of EDs and current lack of evidence-based treatment, we call for urgent prioritisation of funding for well-targeted research that can be translated into concrete and immediate changes in service provision [ 55 ].

Where evidence-based treatments do exist, researchers have often been slow to adapt them effectively for marginalised groups [ 2 ]. We believe that eating disorder treatments and services should adopt an intersectional approach [ 25 ], recognising that people have differing identities, such as race, class, gender and sexuality, which interact and result in differing experiences of oppression [ 36 ]. Consequently, ED research should offer evidence-based ways of tailoring existing interventions to include minority groups and acknowledge the systemic factors which may create inequalities in accessing ED treatment [ 17 ].

Within ED research, particular groups have been excluded from treatment development, and treatment and service provision, so are often missing in the dialogue within eating disorder research. These include: people with other comorbid mental health issues [ 10 , 17 , 69 , 137 ], autistic spectrum conditions [ 3 , 22 , 40 , 62 , 118 , 121 ], people with binge-eating disorder, EDNOS/OSFED or ARFID [ 11 , 13 , 106 ], men [ 103 , 112 , 120 , 134 , 138 , 140 ], racially minoritized groups [ 1 , 20 , 52 , 53 , 77 , 114 , 119 , 139 ] and LGBTIA people [ 8 , 27 , 51 , 80 , 85 , 95 , 98 ].

Whilst acknowledging the issues within current ED research is important, it is vital to hold an optimistic and forward-thinking stance on treatment for EDs. Individuals with eating disorders often experience high levels of hopelessness [ 116 ], and as a result interventions which target “hope” and forward looking thinking have been found to be effective in facilitating recovery [ 64 , 116 ]. Empathy and the provision of hope have been repeatedly found to be the most important features in health professionals working with patients with eating disorders [ 43 , 46 , 65 , 135 ].

Evidence suggests that peer support can provide the support and connection necessary to increase people’s sense of hope for recovery, as a key mechanism of change [ 29 , 48 , 86 , 101 , 110 ].

Interventions which harness peer support have included online discussion forums [ 67 , 86 ], formal mentoring programmes [ 57 , 99 , 100 ] and clinicians use of their own personal recovery in the treatment of eating disorders [ 34 , 131 ].

Experiential

Eating disorder research often focuses on quantitative outcomes such as BMI to evaluate interventions [ 12 , 24 ]. However solely focusing on BMI as an indicator of recovery is not recommended by NICE guidelines [ 90 ]. This narrow focus on BMI can cause iatrogenic harm to patients [ 88 ], and marginalise patients with diagnoses aside from AN [ 130 ].

The importance placed on measuring people with eating disorders bodies, over listening to their experience, can be understood utilizing the philosophical concept of epistemic injustice; whereby patients’ knowledge about their own condition is disregarded, and they are reduced to passive ‘objects’ to be measured, instead of active and knowing subjects [ 37 ].

A significant part of recovery from eating disorders can involve developing a “recovery” voice separate from the illness [ 18 ], with effective therapeutic interventions utilising creative ways of developing this [ 59 , 60 ]. The current focus on BMI as an indicator of recovery does not take patients own knowledge and understanding of their illness into account and overlooks the subjective experiences of those with EDs receiving treatment.

We feel there is a need for an increase in qualitative research which explores the perspectives of ED sufferers and aims to understand their experiences. This may be key for developing more effective interventions in this area [ 35 ].

Although traditional therapies for EDs can form an important part of ED recovery, they do not address all the factors which have the capacity to have a positive impact of the lives of those with EDs. It is well established in the literature that carers play an important role in recovery [ 108 , 123 ], as well as peers [ 57 ]. Despite acknowledgment that carers might struggle in these roles [ 33 ], research exploring which factors impact carer wellbeing, and what support they might benefit from, is still a comparatively new field [ 122 ].

There is an emerging evidence base on the impact of holistic therapies on EDs, including art therapy [ 47 , 61 ], dance [ 71 ] and comedy [ 78 ]. This is consistent with an understanding that ED recovery involves rebuilding a life outside the ED [ 135 ] beyond simply managing the illness [ 39 , 74 , 111 ].

We believe that it is important to broaden out the research focus from the development and evaluation of therapies, to consider provision of support to all parts of the ‘system’ (family members, carers, peers, clinicians) as well as focusing on the development of novel and creative interventions.

Despite the importance of involving patients and carers in eating disorder research and service provision there is often limited ‘co-production in this area’ [ 87 ], with inclusion of lived-experience perspectives “scarce to date” [ 84 ].

It is our belief that many of the current issues we have highlighted in eating disorder research are the result of not including the perspectives and expertise of people who have experience of eating disorders. Co-production in eating disorder research is particularly important in determining how to define and evaluate recovery in eating disorders (moving away from narrow outcomes like BMI) [ 68 , 125 ] and towards a richer understanding of the recovery process [ 135 ].

We advocate an approach to research that involves service-users/survivors and clinicians working in partnership with other researchers, in all aspects of eating disorder research. This could include setting research priorities, designing research projects, conducting all aspects of research, and disseminating research and engaging the public.

We wanted to trial a ‘principles-first’ approach in developing research projects within our eating disorder research clinic (SPIRED), as we hoped that it would give us a direction and mandate for our work stemming from all members of the clinic. Through a series of workshops, we co-produced a set of principles to guide the direction and process of our work together, agreeing that the eating disorder research we conducted would be real world, tailored, hopeful, experiential, broad, and democratic.

In this section we first offer some reflections on the process from clinic members, highlighting strengths and weaknesses of the approach we took, before setting these in the context of the broader literature.

Reflections

Members of the SPIRED research clinic wrote reflections on their experience of co-producing principles to guide our research and collaborating on this paper. We present these in their individuality and diversity, instead of coming to a single reflexive position (as authors) on the strengths and limitations of the process we took.

There was consensus that any division between members of the lived experience panel and other researchers and clinicians was not only artificial (as members had a multiplicity of roles and identities in their lives), but also undermined the democratic way we aimed to work together. People are identified here by whether they are a professional member or a lived experience panel member within the SPIRED clinic, however we wanted to emphasize that they will have other identities and areas of expertise. We identified people in this way as we thought it was important to acknowledge the power imbalances that exist between lived experience panel members, and those employed by the trust in a more permanent capacity.

“[Contrasting lived experience perspectives with clinicians and researchers] creates an artificial binary where our ED defines us—instead of recognising multiple identities. I fit into each of these 'categories’, but the research process runs the risk of reinforcing power differentials and that we ARE the ED. An ED can silence our sense of self and other aspects of identity—the research process shouldn't replay this.” -Lived Experience Panel Member

"I was looking forward to contributing as someone with Lived Experience, because I work as a research student in my day job, so I wear two hats and have seen first-hand the value in incorporating Lived Experience perspectives.” -Lived Experience Panel Member

“As a clinician and researcher who has also had experiences of being on the other side of service provision, I was acutely aware of the ‘us and them’ divisions that play out in both clinical and research settings, and how these divisions can make it harder for people to open up and express fully their views about any care they might or might not have received. We are then missing important information around how to develop interventions and improve care delivery.” -Professional Member

One of the most significant things about the process for many SPIRED members was that the initial meeting was one of the first times they were able to be open about, integrate and use their multiple identities. This meeting was felt by many as cathartic, hopeful and powerful, as well as providing a solid foundation for collaboration.

“As a mental health professional, who was sharing my experiences of being a service user for the first time in front of other professionals, I felt scared and shy at first. Everyone was supportive and reassuring, and I never felt “less than” for sharing my lived experience.” -Lived Experience Panel Member

“I was keen that the LEAP was a place that welcomed all perspectives and we put a lot of thought into the initial meetings to create a psychologically safe arena for people to know they could be open and honest. An example of this was me sharing that I had not had good experiences of service use, to help others feel that all perspectives were welcome and to counter the us and them divide.” -Professional Member

“There was such a really open atmosphere in that first meeting—I shared things about my mental illness for the first time in a work context. I think this was such a respectful and trusting basis for the later consensus-based decision-making work we did together in developing the principles.” -Professional Member

Part of why the process of co-producing principles was felt to be successful, was because everyone shared similar motivations for wanting to be part of the SPIRED research clinic. These included a motivation to improve eating disorder treatment, alongside a commitment to genuine co-production, as opposed to lived experience involvement just having a ‘rubber-stamping’ function.

“Having been denied help because of a “normal BMI”, deteriorating and then being on a waiting list for months I felt the need to do something- just anything to take this disappointment and anger towards services and turn it into something a bit positive.” -Lived Experience Panel Member

“I think my main motivations for helping out are guilt, being bluntly honest. I had amazing treatment—the best. Not everyone is so lucky. So, I want to pay that forward and try in any meagre way to give back.” -Lived Experience Panel Member

“I really wanted to work at SPIRED because the people who set it up were so clear about how much they valued co-production as core to the way they worked.” -Professional Member

“I was happy that everyone seemed to be on the same page and have a shared passion for improving lives for people with eating disorders.” -Lived Experience Panel Member

All the co-authors of this paper except two, were present for the initial meeting and subsequent discussions. However even those who joined the process later, felt aligned with what had already been done.

“I have been struck by the paucity of research focused on ED interventions, particularly the lack of research which is co-produced with those with lived experience. Despite not being involved in the discussions in which SPIRED principles emerged, I believe the research priorities outlined by SPIRED are incredibly important and reflective of my own values.” -Professional Member

“As I was reading through, I couldn’t believe how aligned they were with my own personal views on co-production and the importance of lived experience perspectives in research […]. This is such a hopeful piece of work.” -Professional Member

Those responsible for facilitating the initial meeting, and supporting the lived experience panel going forward, were keen to reduce the burden on them from engaging in this work.

“I was also aware that speaking about your own difficult experiences can be exhausting, triggering and recovery is not neat; people can relapse and struggle. I didn’t want there to be only a couple of people who were relied on excessively for contributions, so there was an idea that people could dip in and out depending on capacity and interest.” -Professional Member

However, despite the shared wish to make lived experience work core to the SPIRED clinic, structural inequalities between the clinic members were a significant barrier to democratic working. Clinicians and researchers were employed on a substantive basis, whereas the lived experience panel were employed on a casualized basis, occasionally doing work—but with limited funding. This meant that often they were not able to lead on aspects of the research.

“Although I do have lived experience of mental illness (including disordered eating) I’m not one of the Lived Experience Panel members for SPIRED, and it should have been one or many of them that wrote up this paper—which they would have been much better placed to do than me. However sadly we didn’t have a permanently employed lived experience researcher, or enough in our PPI budget to pay for this work to be done on a casualised basis.” -Professional Member

Some people felt that this led to differences between how lived experience panel members and other SPIRED clinic members were treated, though others didn’t share this view.

“[There was a] 'distance' between the researchers and those assigned a 'lived experience' identity in having limited communications from the project.” -Lived Experience Panel Member

"Every communication I had from the PPI team felt like they were talking to an equal member of the team. Same for the paper- I didn’t feel like my thoughts and comments counted less because I was a LEAP member and not a researcher." -Lived Experience Panel Member

In general, people felt pride in what we’d achieved together and positive about the personal benefits of creating this paper.

“I remember feeling very proud of having contributed on that piece of collective work.” -Lived Experience Panel Member

“Lived Experience contributors don't often have a "career pathway" or professional development opportunities, so helping to shape an academic paper—and this was before I had published anything in my own field, as a student—was a really valuable experience.” -Lived Experience Panel Member

Our work in context

We set-up our lived experience led research clinic due to a belief that ED research was not currently adequately meeting the needs of the population it aimed to serve.

It is our view current issues in ED research are partially due to the distinct absence of the voices of those with lived experience of EDs and a lack of co-production in ED research.

We wanted to address the absence or superficiality of co-production in ED research by co-producing a set of principles which would be a mandate for our work together and ensure that it was grounded in what we cared about as a team. Although it initially seemed unlikely that a consensus-based decision-making methodology [ 56 ] would be successful, given the range of people with different backgrounds and experiences and priorities in our initial clinical meeting, this has not been our experience. Even the initial questionnaires that were completed by all clinic members — prior to meeting —s howed significant overlap in which principles people wanted to prioritize, and discussions further solidified these shared understandings and commitment. There was debate at all stages of the process of developing the principles, from initial workshops through to comments on drafts of the paper. These issues were resolved through discussion (during meetings as well as via email),this resolution tended to occur by describing the principles in a nuanced way that incorporated critical feedback from clinic members. All members enthusiastically agreed with the way the principles were framed in the final draft of this paper.

We were fortunate as a research clinic in having funding allocated to us for about 60 h of PPI time annually, as well as a dedicated PPI co-ordinator for our clinic, and a broader PPI team within our NHS trust who were able to advise on issues. This enabled us to take a longer-term strategy for PPI, as opposed to only having funding tied to specific research projects — where the aims and the method of the project had already been determined. Even though UK funders often include a requirement for PPI to have occurred at the project development stage [ 91 ], meaning that research institutions often have funding available for this specific purpose, it is rarer that PPI funding is allocated to a research team to spend in any way they think appropriate. However, this was essential to the kind of approach we were able to take. Additional funding would have allowed us time and research capacity to use a wider variety of methodological approaches to co-produce principles,we would love to see the work outlined in this paper built on and added to by other researchers trialling different and more systematic approaches for doing so. We believe that it is important to have more substantive lived-experience positions in research, something that we would like to see in our research clinic.

We recruited our PPI panel from social media, as well as patients who were at the point of discharge. As outlined above, POC are not adequately represented on our lived experience advisory panel, something that is a significant issue with many cases of co-production and PPI within research [ 49 ]. Developing ongoing collaborations with organisations focused on health research specific to POC, as well as putting systems in place to enhance recruitment of POC to senior positions within research teams [ 45 ] are both strategies that could improve these issues. However, neither of these constitutes a ‘quick fix’, and we were keen to work to address the underlying issue causing under-presentation of POC on our LEAP, as opposed to just advertising specifically for more POC which we felt was tokenistic.

We wanted to ensure that the research funding that we applied for corresponded to our research agenda — which was derived directly from our principles. However, in trying to develop competitive funding applications which fell under the ‘broad’ principle (i.e., developing and evaluating non-standard therapeutic treatments, including peer-support) it became clear that fewer health research funding sources would consider these kinds of treatments, as opposed to more traditional therapies. It appears that currently, ED research priorities can be guided by funders [ 38 ], rather than those with lived experience of EDs, who can provide valuable insight into where research efforts need to be urgently directed.

Priorities and principles and developed as a result of co-production approaches such as that one taken in this paper are often critical in approach and conflict with existing recommendations for eating disorder treatments [ 89 ], as approaches which seek to elevate the voices of service users have found in other areas [ 129 ]. However, we feel that this conflict has arisen because of the historic marginalization of lived experience voices within mental health research, and the lack of power people with lived experience still have in collaborating on research projects [ 73 ]. Given the evidence that research priorities determined by ED service-users produce better interventions and outcomes [ 132 ], and the ineffectiveness of current ED treatments [ 58 ], we believe it time for a new approach—led by those with lived-experience of eating disorders.

To our knowledge, we are the first health research group to have co-produced principles as the basis for our work together—putting us more in line with grassroots campaigning organisations [ 81 , 82 ]. However, these historic organizations rarely outline the process by which they produce their manifestos, which makes it hard to replicated and develop their methodology. There are several limitations to this piece of work, however we hope that other researchers will both build upon and refine the approach outlined in this paper and develop new methodologies for enhancing co-production within health research through the creation of principles to guide their collaborative work. More broadly, we wanted to provide an illustrative case for the value and generative potential of co-producing principles to guide health research and enable long-term collaboration between people with lived experience of an illness, and other researchers [ 127 ].

Following the development of SPIRED principles they were included in an All-Party parliamentary group report on eating disorders led by BEAT [ 16 ], as an example of how "a relatively small investment can make a big impact in building local research capacity and supporting the application of research findings into clinical practice."

Availability of data and materials

Not applicable.

Abbreviations

• Anorexia nervosa
• Bulimia nervosa

Eating disorder

Patient and public involvement (in research)

Sussex Partnership NHS Foundation Trust

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Papastavrou Brooks, C., Kafle, E., Butt, N. et al. Co-producing principles to guide health research: an illustrative case study from an eating disorder research clinic. Res Involv Engagem 9 , 84 (2023). https://doi.org/10.1186/s40900-023-00460-3

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Practice Standards in International Medical Departments of Public Academic Hospitals in China: Cross-Sectional Study

Authors of this article:

Original Paper

• Yaxu Zhou 1 * , MPH   ; 
• Ying Zhou 2 * , MPH   ; 
• Di Xu 3 , MPH   ; 
• Jie Min 3 , MPH   ; 
• Yu Du 3 , MPH   ; 
• Qi Duan 3 , MPH   ; 
• Wen Bao 3 , MPH   ; 
• Yingying Sun 3 , MPH   ; 
• Huiqin Xi 4 , RN   ; 
• Chunming Wang 2 , Prof Dr   ; 
• Evelyne Bischof 5, 6 , Prof Dr  

1 Finance Department, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China

2 Smart Hospital Development Department, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China

3 International Medical Service, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China

4 Nursing Department, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China

5 Department of Oncology and Clinical Cancer Center, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Shanghai, China

6 Department of Oncology, Reni Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China

*these authors contributed equally

Corresponding Author:

Chunming Wang, Prof Dr

Smart Hospital Development Department

Renji Hospital

Shanghai Jiaotong University School of Medicine

No160 Pujian Road

Shanghai, 200127

Phone: 86 2168383408

Email: [email protected]

Background: Improving health care in cities with a diverse, international population is crucial for ensuring health equity, particularly for foreigners facing challenges due to cultural and language barriers. This situation is especially relevant in China, a major destination for expatriates and travelers, where optimizing health care services and incorporating international standards in the public sector are vital. Achieving this involves understanding the operational details, cultural and linguistic nuances, and advancing medical digitalization. A strategic approach focusing on cultural competence and awareness of health care systems is essential for effectively navigating health care for foreigners and expatriates in China.

Objective: The aim of this study was to perform an in-depth analysis of the subjective and objective experiences of local and international patients in public hospitals in China to provide a basis for enhancing the medical experience of all patients.

Methods: A structured questionnaire was provided to patients at an international outpatient service of a top-tier university hospital in China. Qualitative analysis of the survey responses was performed to methodically categorize and analyze medical treatment, focusing on patient demand and satisfaction across four main category elements (“high demand, high satisfaction”; “high demand, low satisfaction”; “low demand, high satisfaction”; and “low demand, low satisfaction”), enabling a detailed cross-sectional analysis to identify areas for improvement.

Results: Elements falling under “high demand, high satisfaction” for both Chinese and international patients were primarily in the realms of medical quality and treatment processes. In contrast, elements identified as “high demand, low satisfaction” were significantly different between the two patient groups.

Conclusions: The findings highlight the importance of systematic, objective research in advancing the quality of international health care services within China’s leading academic medical centers. Key to this improvement is rigorous quality control involving both patients and providers. This study highlights the necessity of certifying such centers and emphasizes the role of digital platforms in disseminating information about medical services. This strategy is expected to cater to diverse patient needs, enhancing the overall patient experience. Furthermore, by developing comprehensive diagnosis and treatment services and highlighting the superior quality and costs associated with international health care, these efforts aim to foster a sense of belonging among international patients and increase the attractiveness of China’s medical services for this demographic.

Introduction

Improving health care processes to ensure equality in international metropoles has recently become a widely discussed challenge [ 1 ]. For foreigners living or traveling abroad, navigating the health care system presents unique challenges, especially when there are significant cultural and language differences. Given China’s substantial role as a global hub for expatriates and travelers, optimizing health care and establishing international service in the public sector are essential. This process requires a high-level understanding of operational intricacies, cultural and linguistic skills, as well as a great extent of medical digitalization [ 1 - 3 ]. These factors collectively necessitate a strategic approach to health care navigation for foreigners in China, underscoring the importance of cultural competence and systemic awareness in international medical settings [ 4 ].

Medical tourism represents a dynamic and growing sector within the global tourism and health care industries, characterized by individuals traveling across international borders to access medical treatments that may be unavailable, more costly, or have longer waiting times in their home countries [ 5 ]. In China, the medical tourism landscape is distinguished by its integration of traditional Chinese medicine (TCM) with modern health care services, offering a unique proposition to medical tourists [ 6 ]. China has seen significant growth in this sector, facilitated by its advancements in medical technology, the global reputation of its health care institutions, and government support for health care development [ 7 ]. The presence of high-quality health care services at relatively lower costs compared to those available in Western countries makes China an attractive destination for medical tourists seeking both conventional treatments and TCM therapies, leading to a significant growth in the number of foreign patients in hospitals [ 7 ]. Moreover, China’s status as a host for a large expatriate population adds another dimension to its medical tourism sector. Expatriates, alongside international tourists, contribute to the demand for high-quality and culturally sensitive health care services. This necessitates the adjustment of treatment offerings and health care service quality to cater to the diverse preferences and expectations of both medical tourists and the expatriate community residing in China. Ensuring the provision of health care that aligns with international standards and cultural sensitivities is crucial for maintaining China’s competitiveness as a preferred destination for medical tourism, as well as for fostering inclusivity for the expatriates.

In China, grade-3A hospitals represent the highest level within the three-tier hospital classification system, characterized by their extensive capacity for specialist health services, medical education, and scientific research [ 7 ]. Public hospitals, as the backbone of the Chinese health care system, integrate the best global practices and advanced digital infrastructures. Shanghai’s foreigner-oriented medical service institutions can be divided into three categories: an international medical service in a public hospital, a fully independent general hospital or clinic, or a “special medical care” sector in public hospitals [ 6 , 8 ]. The high quality of treatment for international patients in public hospitals, as evidenced by their increasing numbers, emphasizes accessibility, quality, and multidisciplinary expertise. In Shanghai, 61.6% of all foreign patients were treated in public hospitals between 2016 and 2018 [ 9 , 10 ].

International medical services in Shanghai public 3A-class hospitals have become the preferred choice for both Chinese and foreign patients because of the multidisciplinary excellence in clinical, educational, and scientific resources [ 11 ].

The Shanghai Renji University Hospital (hereafter referred to as Renji Hospital), one of the top three public hospitals in Shanghai, officially opened an international outpatient service in October 2015. This is the first international outpatient service platform in China that has passed the world-renowned international certification, assessment, and risk management Det Norske Veritas (DNV) certification for 3 consecutive years. Therefore, we selected Renji Hospital as a case study for a comprehensive cross-sectional analysis of the strategies employed and the outcomes achieved to enhance Shanghai’s global health care brand and, by extension, China’s international medical services framework.

Through a commitment to providing high-quality health care services to international patients, focused on understanding and meeting their specific needs and expectations, Chinese medical services embrace the importance of cultural sensitivity and cross-cultural communication. In 2022, the “14th Five-Year Plan” for Shanghai’s Health and Health Development was officially released, aiming at transforming Shanghai into an Asian “Medical City of Health” [ 12 ]. The strategy involves improving the health care service level, building a high-quality medical system, and incorporating an integrated and intelligent medical service that will ultimately transform the national public health system. At the same time, these efforts will increase the attraction of patients from neighboring countries and regions to come to Shanghai for medical treatment and enhance its international image [ 12 ].

Research Objective

This study was designed to evaluate and assess patient demands and satisfaction across various medical service elements. The aim of the study was to identify key areas of patient demand and satisfaction, particularly focusing on the international medical outpatient services. Analysis of the survey responses can help to provide guidelines on improving the medical experience for both local and international patients. Furthermore, these guidelines will serve as a tool for enhancing Shanghai’s quality of international patent care, thereby contributing to the city’s growth as China’s medical tourism hub.

The study was conducted in the international outpatient service of Renji Hospital. Recruitment for the study occurred over a 6-week period from February to March 2020. The selection process involved a stratified random sampling technique to ensure a representative sample of the international outpatient population attending the international outpatient service. Patients were approached by trained research coordinators who were fluent in both Mandarin and English, allowing for clear communication regarding the purpose of the study and the nature of the questionnaire. Inclusion criteria stipulated that participants must be international outpatients 18 years or older who had visited the international outpatient service within the past year.

Upon agreeing to participate, individuals were provided with the questionnaire in either English or Mandarin, based on their preference. To mitigate the potential for selection bias and to ensure privacy, questionnaires were completed anonymously in a designated area within the international outpatient service waiting room, with research coordinators available to assist with any queries.

Ethical Considerations

The Ethical Committee of Renji Hospital exempted this study from the requirement of official approval since it was survey-based with voluntary participation. Patients were informed that participation was voluntary, with no incentives offered, and that their care would not be affected by their decision of whether to participate. The questionnaires were anonymous. The participants were informed about the nature of the research. This process highlighted that they could withdraw at any time without any consequences. The participants were not financially compensated for their participation.

Questionnaire Design

Questionnaires were distributed before the medical treatment. The first section asked the patients to provide basic sociodemographic and general information, including customer category (first or return visit), sex, nationality, age, education level, payment method, and residence history in Shanghai.

To measure patients’ expectations (demand) and satisfaction from the medical service, an expert consortium designed a questionnaire drawing upon validated surveys from both local and international contexts related to hospital evaluation and patient satisfaction [ 13 , 14 ], as well as studies on the medical needs and satisfaction of foreign or commercially insured patients [ 15 , 16 ]. The questionnaire focused on five critical dimensions of health care provision: medical quality, physical environment, quality service, medical treatment process, and institutional qualification. Each dimension was further broken down into a total of 30 specific medical treatment aspects (eg, safety and efficiency), labeled Y1-Y30, to ensure a thorough evaluation.

The same questionnaire was distributed to the patients twice: before and after the visit. Before the visit, patients were asked to attribute their subjective importance to each of the categories showcasing their expectations (demand). After the visit, the patients were provided the questionnaire again, asking for the extent to which their demands were met (satisfaction).

The respondents’ demand scores for the 30 medical elements were compiled using the Likert 5-level scale method. Cronbach α was used for assessment of content validity to test the reliability and validity of the questionnaire. The Cronbach α coefficient was 0.964, confirming good structural reliability of the questionnaire.

Response Rate

Of the 200 questionnaires distributed, 180 were retrieved, yielding a high return rate of 90%. The responses underwent a preliminary screening to validate the completeness and consistency of the data, resulting in 171 questionnaires deemed valid for analysis. This led to an effective response rate of 94.4%, indicating robust engagement and reliability of the data collected. The high response rate may be reflective of the strong patient engagement and satisfaction with the services at the international outpatient service, which is consistent with the facility’s patient-centered approach to health care delivery.

Sociodemographic and Core Characteristics of the Respondents

The basic information of the respondents is summarized in Table 1 . Among the total 171 respondents, there were 92 Chinese patients and 79 foreign patients. The respondents were mainly patients seeking a second opinion, accounting for more than 60% of the sample. The proportion of men and women was similar, with 72.6% of the respondents under the age of 50 years. Overall, 91.3% of the respondents had received undergraduate education or above. Commercial insurance direct payment was the main payment method, accounting for 68.4% of the sample, and 75.4% of the respondents had been living in Shanghai for more than 3 years.

Demand Scores of Chinese and Foreign Patients

The average score of the respondents’ demand for each element was 4.61 out of 5, with the highest score found for medical quality (4.74), followed by medical treatment process (4.66), physical environment (4.59), institutional qualification (4.58), and quality service (4.47). Through single-factor analysis at an α level of .05, the difference in the scores of demand degree of patients of different nationalities in each dimension was found to be statistically significant. The scores of each item are shown in Table 2 .

Satisfaction Scores of Chinese and Foreign Patients

The average score of respondents’ satisfaction with each element was 4.50 out of 5, with the highest scores obtained for medical treatment process (4.56), followed by medical quality (4.55), institutional qualification (4.54), physical environment (4.48), and quality service (4.34). Through single-factor analysis at an α level of .05, there were statistically significant differences in the satisfaction scores between groups. The scores of each item are shown in Table 3 .

Cross-Sectional Analysis of Patients’ Demands and Satisfaction

To visualize the relations between patients, demand, and satisfaction, scatterplot charts were plotted ( Figures 1 - 2 ), where the x-axis represents the demand score and the y-axis represents the satisfaction score. The scatter chart was divided into four quadrants by taking the average satisfaction and demand scores as the boundary (as shown in the orange lines in Figures 1 - 2 ). The quadrants are as follows: Q1, “high demand, high satisfaction”; Q2, “high demand, low satisfaction”; “Q3, low demand, high satisfaction”; and Q4, “low demand, low satisfaction.”

Demands and Satisfaction of Chinese Patients

For Chinese patients, medical treatment process and physical environment are perceived as equally important given that they were the most abundant categories in Q2 (high demand, low satisfaction). Institutional qualification scored the lowest, as Chinese patients’ high demands were not met for this category. The medical quality received outperformed Chinese patients’ demands, being the most abundant category in Q3 (low demand, high satisfaction). Regarding Q4 (low demand, low satisfaction), the quality service category was the most abundant, suggesting that Chinese patients did not expect and were not satisfied with the nonmedical services ( Table 4 ).

a See Tables 2 and 3 for a description of each element Y1-Y30.

b N/A: not applicable.

Demands and Satisfaction of Foreign Patients

For the foreign patients, the medical treatment process category performed the best as it had the most elements in Q1 (high demand, high satisfaction), suggesting that the high demands of international patients were met. However, Q1 had the most questions of all categories (13 questions), suggesting that foreign patients seek a comprehensive health care experience. Institutional qualification performed the most poorly, as it was the most abundant category in Q2 (high demand, low satisfaction), suggesting that the needs of foreign patients were not met. Quality service appears to have positively surprised foreign patients as it was the most abundant category in Q3 (low demand, high satisfaction). The question distribution in Q4 was uniform and the interpretation is inconclusive ( Table 5 ).

Comparison of “High Demand, High Satisfaction” Points Between Chinese and Foreign Patients

The Chinese and foreign patients exhibited similar preferences and satisfaction levels regarding aspects categorized under “high demand, high satisfaction.” This suggests that certain aspects of health care services that are highly sought after and meet expectations well are relatively consistent across both patient groups.

In Q1, the scores to 9 questions overlapped between Chinese and foreign patients: attention paid to patient safety, effective clinical diagnosis and treatment, convenient visit process, convenient and fast appointment, convenience payment, complete medical equipment, comfortable treatment environment, complete emergency facilities, and attaches importance to informed consent. This suggests that both groups have high expectations regarding the quality of medical procedures and care inherent to standard health care; thus, both groups ranked these demands as being met with high satisfaction.

The high score of patients’ feelings regarding the prediagnosis appointment and postdiagnosis payment is likely due to the construction of Renji’s public hospital as an internet hospital and the implementation of mobile payment [ 17 ].

In Q1, there were 4 questions unique to foreign patients: multinational language service, conform to the medical care standards, hospital specialist ranking, and postdiagnosis follow-up service. The difference in demand for a multinational language service represents a reasonable distinction between Chinese and foreign patients given that its existence is tailored to foreign patients only and therefore there was no need for this category to be among the high demands of Chinese patients.

The unique questions for Chinese patients in Q1 included attention paid to customer participation, smooth connection of referral, and convenient and fast parking.

Both groups marked “hospital specialists ranking” as a high-demand point, but only foreign patients marked it as both high demand and high satisfaction, suggesting that international patients are more satisfied with the doctors’ rankings.

Complete medical equipment/emergency facilities refer to facilities having the necessary infrastructure for high-quality medical services [ 18 , 19 ]. Hospital brand reputation/hospital specialist ranking is the externalization of high medical quality [ 20 ]. Therefore, the core medical demand of Chinese and foreign patients in international clinics is medical quality. Based on medical quality, the demand for service provider equipment and specialist reputation is extended. It is suggested that the international medical service entities in the public context must consolidate the bottom line of medical quality, improve medical facilities and equipment, highlight the brand publicity centered on medical quality, and demonstrate the image and concept of “effective and safe” to patients.

Comparison of “High Demand, Low Satisfaction” Points Between Chinese and Foreign Patients

In Q2, only two of the questions (insurance network hospital and international certification) overlapped between Chinese and foreign patients, which both belong to the institutional qualification category.

The aspects for which foreign patients had high demands and these expectations were not met included hospital infection management, attention paid to customer participation, efficient and convenient transportation, and nature of hospital organization. The high demands of Chinese patients were not met in the following aspects: guided and accompanied services, hospital brand reputation, hospital specialist ranking, and conform to the medical care standards. Interestingly, 4 out of 6 of these questions fall under the institutional qualification category.

To address areas of “high demand, low satisfaction,” it is crucial for international medical services to accelerate investment, develop strategies, and implement targeted improvements.

Comparison of “Low Demand, High Satisfaction” Points Between Chinese and Foreign Patients

In Q3, two questions (carries out health education and reasonable medical expenses) overlapped between the Chinese and foreign patients; the low demand and high satisfaction for these aspects suggest that the services outperformed the expectations for both groups. This overlap suggests that both groups were positively surprised by the extent of health education and affordable prices at Renji Hospital.

The unique items in this quadrant for Chinese patients were attention paid to customer feedback, postdiagnosis follow-up service, and organization size. The unique items for the foreign patients were convenient and fast parking and adequate information disclosure.

It can be assumed that Chinese patients did not demand for their feedback to be heard (Y5), but they were positively surprised that they were asked for it, whereas the responses to this question for the foreign patients landed in Q4 (low demand, low satisfaction). By contrast, foreign patients were positively surprised by the adequate information disclosure, whereas Chinese patients’ scores for this item landed in Q4.

Both groups were highly satisfied with the fast and convenient parking at the hospital; however, only the Chinese patients had a demand for this aspect of service.

Comparison of “Low Demand, Low Satisfaction” Points Between Chinese and Foreign Patients

In Q4, only two questions overlapped between Chinese and foreign patients: protect customer privacy and respect for religious beliefs, suggesting that both groups see the hospital setting as a public space and their feelings of privacy should be enhanced.

The unique items in Q4 for the foreign patients were attention paid to customer feedback, smooth connection of referral, guided and accompanied services, hospital brand reputation, and organization size.

Both Chinese and foreign patients had low demand for the organization size; however, only the Chinese patients marked this item with high satisfaction scores. In addition, only the Chinese group had a high demand for guided accompany services, although both groups rated this item as a low-satisfaction category. Both groups rated hospital brand reputation as a low-satisfaction item, whereas this was only indicated as a high-demand item for the Chinese patient group.

The unique items in Q4 for Chinese patients were infection management, efficient and convenient transportation, nature of hospital organization, and adequate information disclosure.

Principal Findings

This study represents the first comprehensive cross-sectional analysis of patient needs and satisfaction in an international outpatient service center at a top-tier academic hospital. Through cross-sectional analysis, 30 elements were divided into four categories: “high demand, high satisfaction”; “high demand, low satisfaction”; “low demand, low satisfaction”; and “low demand, high satisfaction.”

The analysis investigated a practical experience from the construction of the international outpatient service within a large top-tier academic Chinese public hospital. The findings provide valuable insights for the construction and enhancement of the international medical service model in Shanghai and are also applicable to the broader context of public health care in China.

Considering the limitations of public hospital resources, based on these findings, we can propose various strategies for continuous optimization and key improvement of the international outpatient experience.

Strategies for Improving the Medical Experience of International Outpatients

Rely on the advantages of public medical quality with third-party international certification to deliver a progressive patient experience.

International medical service entities in the public context should take the traditional advantages of the medical quality management of public hospitals into consideration, combine the characteristics of international medical services, benchmark the international medical care standards, take the third-party international certification as the starting point, promote reform through evaluation, continue to consolidate the quality of medical services, and improve the sense of access of international outpatients to the elements of medical quality. Through the third-party international certification, the international outpatient service of Renji Hospital has established the organizational structure, system process, evaluation method, and continuous improvement measures of foreign-related medical quality and safety that are suitable for the framework of Chinese public hospitals. Accordingly, the medical quality and safety standards of the international outpatient service can become the benchmark of the quality of foreign-related medical service in China and can be used to further improve the diversified service quality and medical experience of large public hospitals.

Digitalization and Use of International Media Platforms

Internet platforms play a crucial role in hospitals’ information disclosure efforts [ 21 , 22 ]. For international medical entities operating in the public sphere, it is vital to establish distinct foreign-related medical service information platforms tailored to patient needs. These platforms should offer multilingual or bilingual Chinese-to-English options to ensure a high-quality and informed medical experience for international patients. However, despite the bilingual online system, it is still critical for the medical personnel and doctors to communicate effectively in foreign languages, as language barriers have been highlighted as a key deterrent for foreign patients seeking medical care in Shanghai [ 12 , 23 ].

The platforms should include comprehensive content covering qualification certification, specialty strengths, treatment processes, expert profiles, facility background, additional services, and pricing details. Timely updates on medical treatment guidance, international medical care schedules, insurance partnerships, and patient feedback channels are essential [ 24 ]. Additionally, disclosing hospital social responsibility information such as patient satisfaction and safety measures will enhance transparency and build patient trust. Renji Hospital exemplifies this practice by developing a bilingual internet platform for foreign-related medical services, elevating the online and offline medical experience, and meeting diverse health needs effectively.

Build the Service Chain of the Whole Diagnosis and Treatment Cycle

Providing high-quality medical care at an affordable price is a crucial characteristic of international medical services, especially within the public health care context. To prioritize patient satisfaction, it is important for international medical entities to not only fulfill basic diagnostic and treatment needs but to also offer a quality service and improve the nonmedical efficiency to enhance patients’ overall experience. Based on the findings of this study, the following measures are recommended.

First, it is necessary to establish a comprehensive service chain that covers the entire diagnosis and treatment cycle, including prediagnosis appointments, inpatient care, and postdiagnosis follow-up [ 25 ]. To achieve this, internet hospital platforms can be used to facilitate preappointment guidance and improve the information and visual guidance systems. Accompanying and guidance services should be provided to enhance interaction and improve efficiency. Various channels can be implemented for postdiagnosis follow-up, such as telephone, email, and internet hospital, to extend the service chain and foster patient engagement.

Second, it is essential to respect patients’ right to privacy [ 26 ]. This can be achieved by ensuring that each patient has access to a private consultation room and, if spatial constraints exist in the examination area, to use curtain screens or other methods to create separation. Staff should provide reassurance and clear explanations to make patients feel respected. In addition, the training and supervision of medical personnel should be enhanced, integrating the protection of patient privacy into their daily behaviors during diagnosis, treatment, and communication.

Third, it is necessary to maintain a comfortable and tidy international medical reception and treatment area [ 27 ]. This should be done in a manner that emphasizes the harmony and unity of both the physical environment and the decor. In addition, the area should be regularly maintained and cleaned, while guiding staff members to maintain a positive and professional attitude.

Implementing these measures will contribute to creating a favorable environment for international medical services, ensuring a balance between high-quality care and affordability while enhancing the overall patient experience.

Foster Inclusivity, Integration, and Internationality

Finally, a conducive environment for foreign-related medical services is one that combines local training and foreign expertise. First, it is crucial to enhance language training for staff to overcome language barriers. Implementing a comprehensive foreign-language training and assessment plan is recommended, ensuring that staff can proficiently master English expressions and medical terminology, pronounce the words accurately, respond promptly, and communicate effectively with foreign patients [ 28 ]. Second, there is a need to cultivate exceptional general practitioners and develop a medical service model that prioritizes “general practice before specialty,” aligning with the medical preferences of foreign patients [ 29 ]. It is advisable to explore and implement training, educational, and exchange programs for high-quality general practitioners, fostering practitioners with international medical attributes [ 30 ]. In this model, general practitioners would conduct initial diagnosis and treatment, accurately referring patients requiring further diagnosis and specialized treatment to relevant specialists based on professional judgment. This approach is better suited to the medical preferences of foreign patients and enhances their sense of belonging. Third, the introduction of renowned foreign experts can significantly contribute to improving services at an international hospital. Renji Hospital has established and improved standardized systems and processes for the practice registration, diagnosis, and treatment of foreign clinicians, gradually establishing a well-regulated management system. The hospital has successfully recruited two full-time doctors from the United States and Italy, as well as five part-time doctors from the United States, Canada, Germany, and Singapore, fostering a favorable practice of receiving foreign patients.

Strengths and Limitations

The novelty of this study lies in the utilization of management tools to conduct a cross-sectional analysis of patient needs and satisfaction regarding medical treatment elements, leading to the accurate classification of 30 key elements. This approach enables practitioners and researchers involved in international medical service construction to identify crucial areas, implement targeted policies, enhance the efficiency of international medical services, and improve the overall patient experience.

However, it is important to acknowledge some limitations of this study. First, to emphasize key points, the strategies proposed may not encompass all aspects comprehensively. Second, the terms “low demand” and “low satisfaction” refer to relative values rather than absolute levels. In practical application, regular assessments of patients’ medical needs and satisfaction should be conducted, allowing for dynamic adjustments in focus areas. Third, the study was restricted to a single hospital’s international outpatient service and there is potential for response bias, as the participants who chose to respond may have different perspectives from those who did not participate. Additionally, the study period coincides with the onset of the COVID-19 pandemic, which may have influenced patient expectations and satisfaction levels.

Conclusions

The findings from this study have broad implications for the improvement of international outpatient services within public hospitals. The results suggest that such entities must not only reinforce the foundation of medical quality but also enhance the visibility and accessibility of their services through better medical facilities, equipment, and brand communication. The study advocates for an increase in investment in areas of “high demand, low satisfaction,” such as language services and privacy protection, to provide targeted improvements. Emphasizing the importance of digital platforms for information dissemination and adopting a comprehensive approach to the diagnosis and treatment service chain can significantly improve patient experiences. As public hospitals continue to navigate the demands of a global patient base, these findings offer valuable insights for developing services that are not only of high quality but also culturally sensitive and patient-centered.

Acknowledgments

The authors would like to express their gratitude to Dominika Wilczok of Duke and Duke Kunshan University for her contributions to scientific conciseness, articulating rebuttal, and valuable input in the structural review process. This research was supported in part by the National Natural Science Foundation of China (grant 72031006) and the Chenxing Young Scholars Administrator Program of Shanghai Jiao Tong University.

Data Availability

The data sets generated during and/or analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

Ying Zhou, EB, Yaxu Zhou, CW, DX, JM, YD, QD, WB, YS, and HX contributed to conceptualization and data curation. Ying Zhou and Yaxu Zhou performed the formal analysis. Ying Zhou, EB, and Yaxu Zhou wrote the original draft of the manuscript. CW and EB reviewed and edited the manuscript. All authors reviewed the results and approved the final version of the manuscript.

Conflicts of Interest

None declared.

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Abbreviations

Edited by A Mavragani; submitted 24.10.23; peer-reviewed by M Avdagovska; comments to author 11.12.23; revised version received 07.03.24; accepted 14.03.24; published 13.05.24.

©Yaxu Zhou, Ying Zhou, Di Xu, Jie Min, Yu Du, Qi Duan, Wen Bao, Yingying Sun, Huiqin Xi, Chunming Wang, Evelyne Bischof. Originally published in JMIR Formative Research (https://formative.jmir.org), 13.05.2024.

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• Review Article
• Published: 07 May 2024

Design principles for strong and tough hydrogels

• Xueyu Li   ORCID: orcid.org/0000-0002-3056-1509 1 &
• Jian Ping Gong   ORCID: orcid.org/0000-0003-2228-2750 1 , 2  

Nature Reviews Materials ( 2024 ) Cite this article

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• Gels and hydrogels

Hydrogels are crosslinked polymer networks swollen with water. Owing to their soft and water-containing nature, hydrogels are promising materials for applications in many fields, such as biomedical engineering, soft robotics and environmental studies. One of the main obstacles to the practical application of hydrogels is their low mechanical strength and toughness. Since the 2000s, many breakthroughs in the development of mechanically strong and tough hydrogels have led to enormous advances in the study of soft materials and our understanding of their failure mechanisms. Research has also been conducted on long-term mechanical stability — that is, the cyclic fatigue resistance and self-strengthening properties of hydrogels — to enable their application as load-bearing materials. This Review provides a comprehensive overview of the design principles for tough hydrogels. Strategies to obtain self-growing and reinforced hydrogels that can adapt to their surrounding mechanical environment are also presented.

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Acknowledgements

This work was supported by JSPS KAKENHI (grant nos. JP22H04968, JP22K21342, JP22K20521 and JP23K13796).

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Li, X., Gong, J.P. Design principles for strong and tough hydrogels. Nat Rev Mater (2024). https://doi.org/10.1038/s41578-024-00672-3

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United States Provider Experiences with Telemedicine for Hepatitis C Treatment: A Nationwide Survey

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Background: Hepatitis C virus (HCV) elimination requires treatment access expansion, especially for underserved populations. Telehealth has the potential to improve HCV treatment access, although data are limited on its incorporation into standard clinical practice. Methods: We conducted a cross-sectional, e-mail survey of 598 US HCV treatment providers who had valid email addresses and 1) were located in urban areas and had written >20 prescriptions for HCV treatment to US Medicare beneficiaries in 2019-20 or 2) were located in non-urban areas and wrote any HCV prescriptions in 2019-20. Through email, we notified providers of a self-administered electronic 28-item survey of clinical strategies and attitudes about telemedicine for HCV. Results: We received 86 responses (14% response rate), of which 75 used telemedicine for HCV in 2022. Of those 75, 24% were gastroenterologists/hepatologists, 23% general medicine, 17% infectious diseases, and 32% non-physicians. Most (82%) referred patients to commercial laboratories, and 85% had medications delivered directly to patients. Overwhelmingly, respondents (92%) felt that telehealth increases healthcare access, and 76% reported that it promotes or is neutral for treatment completion. Factors believed to be "extremely" or "very" important for telehealth use included patient access to technology (86%); patients' internet access (74%); laboratory access (76%); reimbursement for video visits (74%) and audio-only visits (66%). Non-physician licensing and liability statutes were rated "extremely" or "very" important by 43% and 44%, respectively. Conclusions: Providers felt that telehealth increases HCV treatment access. Major limitations were technological requirements, reimbursement, and access to ancillary services. These findings support the importance of digital equity and literacy to achieve HCV elimination goals.

Competing Interest Statement

Dr Kapadia reports grants to his institution from Gilead Sciences Inc unrelated to the current study. Dr. Patel is part of the Speakers Bureau for Gilead Sciences. Dr. Talal reports grants to his institution from Gilead Sciences, Merck, and Abbott Laboratories. He has also served on advisory committees and as an advisor to Gilead Sciences, Novo Nordisk, and AbbVie. All other authors report no conflicts of interest.

Funding Statement

This work was supported in part by R01 DK123205 (to MS, MTW, EW, AHT), K01 DA048172 (to SNK), a Patient-Centered Outcomes Research Institute (PCORI) Award (IHS-1507-31640) (to AHT) and the Troup Fund of the Kaleida Health Foundation (to AHT). The opinions expressed in this work are those of the authors, and do not necessarily reflect the views of the funding agencies or the US Government.

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The IRB of the Biomedical Research Alliance of New York (BRANY) gave ethical approval for this work.

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Multi-omics analysis reveals key regulatory defense pathways and genes involved in salt tolerance of rose plants

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Haoran Ren, Wenjing Yang, Weikun Jing, Muhammad Owais Shahid, Yuming Liu, Xianhan Qiu, Patrick Choisy, Tao Xu, Nan Ma, Junping Gao, Xiaofeng Zhou, Multi-omics analysis reveals key regulatory defense pathways and genes involved in salt tolerance of rose plants, Horticulture Research , Volume 11, Issue 5, May 2024, uhae068, https://doi.org/10.1093/hr/uhae068

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Salinity stress causes serious damage to crops worldwide, limiting plant production. However, the metabolic and molecular mechanisms underlying the response to salt stress in rose ( Rosa spp.) remain poorly studied. We therefore performed a multi-omics investigation of Rosa hybrida cv. Jardin de Granville (JDG) and Rosa damascena Mill. (DMS) under salt stress to determine the mechanisms underlying rose adaptability to salinity stress. Salt treatment of both JDG and DMS led to the buildup of reactive oxygen species (H 2 O 2 ). Palisade tissue was more severely damaged in DMS than in JDG, while the relative electrolyte permeability was lower and the soluble protein content was higher in JDG than in DMS. Metabolome profiling revealed significant alterations in phenolic acid, lipids, and flavonoid metabolite levels in JDG and DMS under salt stress. Proteome analysis identified enrichment of flavone and flavonol pathways in JDG under salt stress. RNA sequencing showed that salt stress influenced primary metabolism in DMS, whereas it substantially affected secondary metabolism in JDG. Integrating these datasets revealed that the phenylpropane pathway, especially the flavonoid pathway, is strongly enhanced in rose under salt stress. Consistent with this, weighted gene coexpression network analysis (WGCNA) identified the key regulatory gene chalcone synthase 1 ( CHS1 ), which is important in the phenylpropane pathway. Moreover, luciferase assays indicated that the bHLH74 transcription factor binds to the CHS1 promoter to block its transcription. These results clarify the role of the phenylpropane pathway, especially flavonoid and flavonol metabolism, in the response to salt stress in rose.

Rose ( Rosa spp.) is a popular ornamental crop that is also used in the cosmetics, perfume and medicine. Rose plants contains various bioactive substances, including flavonoids, fragrant components, and hydrolysable and condensed tannins, which have high value and market potential [ 1 ]. However, soil salinization is common in many rose-growing regions, and high salt concentrations in soil can severely inhibit rose plant growth, reduce flower quality, and cause significant economic losses [ 2 ]. Additionally, salt stress can enhance the secondary metabolites of roses such as citronellol, geraniol, and phenyl ethyl alcohol [ 3 , 4 ]. Such alterations in secondary metabolites may help to regulate the salt tolerance of rose. Research on roses has focused mainly on flower quality, petal development, and flower bloom [ 5–7 ], and there are limited data available regarding signaling pathways linking plant development and secondary metabolites associated with salt stress.

In plants, salt stress induces osmotic imbalances, which lead to the closure of leaf stomata, limit photosynthesis, and affect plant growth and metabolism [ 8 ]. To alleviate osmotic stress and protect themselves from its adverse effects, plants accumulate numerous compatible solutes (such as soluble proteins, soluble sugars, and proline), known collectively as osmoprotectants [ 9 ]. Moreover, plants generate reactive oxygen species (ROS) to cope with salt stress [ 10 ]. Nevertheless, excessive ROS accumulation can lead to oxidative DNA damage, affect protein biosynthesis, and ultimately result in cell damage and death [ 11 , 12 ]. Plant cells utilize both enzymatic and nonenzymatic antioxidant mechanisms to diminish ROS levels and prevent oxidative damage. Superoxide dismutase (SOD), peroxidase (POD), ascorbate peroxidase (APX), catalase (CAT), and glutathione peroxidase (GPX) are antioxidant enzymes that work as O 2− and H 2 O 2 scavengers [ 13 , 14 ]. Nonenzymatic antioxidants, such as ascorbate, glutathione, phenols, and flavonoids, also play vital roles in ROS scavenging [ 15 , 16 ].

Flavonoids are naturally occurring bioactive substances found in fruits, vegetables, tea, and medicinal plants [ 17 ]. Flavonoids comprise more than 9000 compounds and constitute a substantial category of plant secondary metabolites [ 18 ]. They have diverse biological functions in the growth and development of plants, including improving pollen fertility, imparting color, and influencing seed dormancy and germination [ 19 , 20 ]. In addition, flavonoids have protective roles against biotic and abiotic stresses, such as pathogen infections, ultraviolet (UV)-B, cold, drought, and salinity [ 21–23 ]. Flavonoids have also received widespread attention due to their possible benefits for human health [ 24 ].

The molecular mechanism of flavonoid biosynthesis has been elucidated in many plants [ 25 ]. Chalcone synthase (CHS) mediates the first step in flavonoid production, catalyzing the formation of naringenin chalcone from three molecules of malonyl CoA and one molecule of 4-coumaroyl CoA. Chalcone isomerase (CHI) then quickly converts naringenin chalcone into naringenin (flavanone), which is further biosynthesized into different flavonoids by the subsequent enzymes in this pathway [ 26 ]. Although the biosynthesis of flavonoids has attracted increasing attention from scholars, current research does not fully explain the effects of regulatory factors on the transcription and activity of the major enzymes in flavonoid metabolism. Therefore, further research on the signaling molecules and regulatory pathways associated with flavonoids, as well as their regulatory mechanisms, is needed to elucidate the physiological activity of flavonoids.

Rosa hybrida cv. Jardin de Granville (JDG) is a new hybrid rose developed by 'Les Roses Anciennes André Eve' for the Prestige range of Christian Dior skin care products. JDG possesses twice the vitality of a traditional rose and grows and blooms vigorously in the salty air and harsh winds of coastal climates. JDG is also rich in beneficial bioactive substances that are mainly used in cosmetics and anti-aging skin care creams [ 27 , 28 ]. Rosa damascena Mill. (DMS) is one of the most common fragrant roses in the Rosaceae family. Its essential oils and aromatic compounds are used extensively in the cosmetic and food industries worldwide [ 29 ]. DMS is considered an excellent rose throughout the world due to its high resistance to abiotic stress and abundance of beneficial secondary metabolites [ 30 ].

Here, we conducted an integrated analysis on the transcriptomes, proteomes, and metabolomes of JDG and DMS to explore the relationship between plant development and secondary metabolites of rose under salt stress. We used WGCNA and Cytoscape software to decipher the similarities and differences in the complex metabolic pathways and regulatory genes of JDG and DMS under salt stress. These results provide comprehensive information on the metabolic and molecular mechanisms of the response to salt stress in rose, promoting the cultivation of excellent new rose varieties that are both salt tolerant and rich in beneficial secondary metabolites.

JDG is more tolerant than DMS to salt stress

To explore the salt tolerance of rose, plants of JDG and DMS were treated with 400 mM NaCl for 2 weeks. DMS plants showed typical damage with yellowing and death of leaves, while JDG leaves only exhibited slight wilting ( Fig. 1A ). Additionally, detached rose leaves were treated with salt for 4 days; DMS leaves showed significantly more necrosis than JDG leaves ( Fig. 1B ). In order to quickly observe the response of rose cultivars to salt stress and convenience sampling, subsequent experiments mainly used detached rose leaves. To examine the overall anatomy and morphology of leaves treated for 2 days with NaCl, we stained treated and control leaves with toluidine blue and prepared thin sections. Palisade tissue damage in response to salt treatment was more severe in DMS than in JDG (indicated by red arrowheads in Fig. 1C ). To investigate ROS accumulation in response to salt stress, we performed 3, 3'-diaminobenzidine (DAB) staining. DMS leaves accumulated substantially more ROS (deeper staining) than JDG plants after salt stress, whereas there was no difference in ROS content between these two cultivars under normal conditions ( Fig. 1D, E ). Soluble protein content was higher in JDG leaves after 4 days of salt stress than after 2 days of salt stress, while the soluble protein content of DMS leaves was much higher than that of before treatment leaves after 2 days and decreased by 4 days of salt treatment ( Fig. 1F ). The relative electrolyte permeability of JDG leaves was increased slightly after 2 days of salt treatment and more substantially after 4 days of treatment, while relative electrolyte permeability was much higher in DMS than in JDG on both days after salt treatment ( Fig. 1G ). Phenotypic and physiological analyses indicated that JDG is more salt tolerant than DMS.

Phenotypes of JDG and DMS under salt stress. (A) Phenotypes of JDG and DMS plants after 2 weeks of treatment with 400 mM NaCl. Left, phenotype of the whole plant; right, enlarged image of the protruding part indicated by the red circle. Bars, 3 cm. (B) Detached leaves of rose on different days after onset of salt stress (400 mM NaCl). (C) Anatomical analysis of leaves in (B). Red arrowheads represent the palisade tissue. Mock (0 mM NaCl); NaCl (400 mM NaCl). Bars, 50 μm. (D) Tissue staining of rose leaves under salt stress using DAB. (E) Quantitative statistics of the relative staining intensity in (D). Brown staining area and total leaf area were measured using ImageJ software, their ratio is the relative staining intensity. (F) Soluble protein content of rose leaves at different days under salt treatment. (G) Relative electrolyte permeability of rose leaves at different days under salt treatment. Data are based on the mean ± SE of at least three repeated biological experiments.

Flavonoid metabolites play an important role in the salinity tolerance of rose

To better understand how salt stress affects rose metabolites, we performed a comprehensive untargeted analysis of metabolites using ultra-performance liquid chromatography/mass spectrometry (UPLC/MS). Fig. S1A shows the different metabolites detected, and Fig. S1B shows the curves of the quality control samples, indicating that the mass spectral data were highly reproducible and reliable. Principal component analysis (PCA) was used to reduce the data dimensions and clarify the relationships among the samples. The two principal components PC1, and PC2 could explain 50.07% and 23.36% of the variance, respectively. Moreover, PC1 revealed variance in genotypes, while PC2 revealed differences in time of exposure to salt stress. Thus, the metabolite-based PCA revealed obvious differences in salt tolerance between the two cultivars ( Fig. S2A ).

Our screening for differentially accumulated metabolites (DAMs) identified hundreds of metabolites with significantly altered accumulation under salt stress ( Fig. 2A , Table S1 ). Preliminary analysis indicated that DAMs included amino acids and their derivatives, nucleotides and their derivatives, phenolic acids, flavonoids, lipids, tannins, lignans and coumarins, organic acids, alkaloids, and terpenoids, and most of the DAMs were upregulated under salt stress ( Fig. 2B ). Phenolic acids, lipids, and flavonoid metabolites showed significantly altered accumulation under salt stress in both JDG and DMS. Compared with their levels in DMS, flavonoid metabolites, phenolic acid metabolites, and lipids were differentially accumulated in JDG leaves under both control conditions and salt stress ( Table S1 ). These results indicate that flavonoid metabolites, phenolic acid metabolites, and lipids may play important roles in the salt tolerance of rose.

Metabolomic analysis of JDG and DMS under salt stress. (A) Number of DAMs in different comparison groups. (B) Classification of DAMs in each comparison. (C) Classification of DAMs upregulated in both JDG and DMS under salt treatment. (D) Classification of DAMs upregulated in JDG compared with DMS under both control and salt treatments. (E, F) KEGG pathway enrichment of DAMs under salt stress: (E) JDG-NaCl vs JDG-Mock and (F) DMS-NaCl vs DMS-Mock.

To determine how metabolites differ between JDG and DMS, we summarized the differences in metabolite accumulation in the different comparison groups using Venn diagrams. Groups JDG-NaCl vs JDG-Mock and DMS-NaCl vs DMS-Mock shared 109 of the same metabolite changes, of which 79 were increases and 15 were decreases. Among the upregulated metabolites, phenolic acids and flavonoids accounted for 21.52% and 7.59%, respectively. These metabolites included ferulic acid, coniferaldehyde, pinocembrin (dihydrochrysin), naringin, eucalyptin (5-hydroxy-7,4'-dimethoxy-6,8-dimethylflavone), patuletin (quercetagetin-6-methyl ether), naringenin-7- O -rutinoside-4'- O -glucoside, naringin (naringenin-7- O -neohesperidoside), and sudachitin ( Fig. 2C , Fig. S2B–D , Table S1 ). Notably, 5,7,8,4'-tetramethoxyflavone, vanillic acid-4- O -glucoside, and 3',4',5',5,7-pentamethoxyflavone were upregulated in JDG and downregulated in DMS under salt stress, while kaempferol-3- O -arabinoside-7- O -rhamnoside was upregulated in DMS and downregulated in JDG. Groups JDG-Mock vs DMS-Mock and JDG-NaCl vs DMS-NaCl shared 408 metabolites showing the same tendency in alteration, of which accumulation of 188 was increased and 202 was decreased. Among the upregulated metabolites, phenolic acids and flavonoids accounted for 29.26% and 33.51%, respectively ( Fig. 2D ). Notably, the genkwanin (apigenin 7-methyl ether) content was 12.74-fold higher, the 5,7-dihydroxy-6,3′,4′,5′-tetramethoxyflavone (arteanoflavone) content was 15.64-fold higher, the naringenin-4′,7-dimethyl ether content was 13-fold higher, and the naringin dihydrochalcone content was 13.30-fold in JDG compared with DMS under control conditions; all of these are flavonoid metabolites. Venn analysis also showed that many metabolites displaying changes under salt stress were genotype specific, indicating that the cultivars have different mechanisms of response to salinity. There were 77 metabolites that specifically accumulated in JDG under salt stress, which may represent the major metabolites in the salt stress response of JDG. Notably, four metabolites—ethylsalicylate (a phenolic acid), salidroside (a phenolic acid), L-ornithine (amino acids and derivatives), and epiafzelechin (a flavonoid)—accumulated specifically in JDG after salt treatment and were also highly accumulated under control conditions in JDG compared with DMS ( Fig. S2B–D , Table S1 ).

All DAMs were analyzed using Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment ( Fig. 2E, F , Fig. S3A, B ). In JDG (JDG-NaCl vs JDG-Mock group), salt stress induced changes in metabolites mainly involved 'purine metabolism,' 'phenylpropanoid biosynthesis,' 'linoleic acid metabolism,' and 'alpha-linolenic acid metabolism' ( Fig. 2E ). In DMS (DMS-NaCl vs DMS-Mock group), the DAMs in leaves under salt stress were mainly associated with 'phenylpropanoid biosynthesis,' 'alpha-linolenic acid metabolism,' 'linoleic acid metabolism,' and 'pentose and glucuronate interconversions' ( Fig. 2F ). In the JDG-Mock vs DMS-Mock group, DAMs between leaves of DMS and JDG were mostly associated with 'flavonoid biosynthesis,' 'flavone and flavonol biosynthesis,' and 'phenylpropanoid biosynthesis' ( Fig. S3A ). Meanwhile, in the JDG-NaCl vs DMS-NaCl group, DAMs were largely involved in 'flavonoid biosynthesis,' 'flavone and flavonol biosynthesis,' and 'linoleic acid metabolism' ( Fig. S3B ). KEGG enrichment analysis showed that 'linolenic acid/α-linolenic acid metabolism' and 'phenylpropanoid biosynthesis' were significantly enriched under salt stress in both cultivars, indicating that these two pathways play important roles under salt stress in rose. Regardless of the presence of salt stress, DAMs between DMS and JDG were concentrated in the flavone, flavonoid, and flavonol biosynthetic pathways, indicating that differential accumulation of these metabolites may be the main reason for different salt sensitivities among rose cultivars. Notably, 'caffeine metabolism' was enriched in JDG, while 'starch and sucrose metabolism' was significantly increased in DMS.

Salt stress causes dynamic changes in distinct sets of proteins

To delve deeper into the molecular mechanisms of the salt stress response in rose plants, we performed a proteome profiling analysis under the same salt treatment and control conditions as the metabolome analysis and characterized proteins on the basis of fold changes in their accumulation level. We identified 119 (87 upregulated and 32 downregulated) and 163 (83 downregulated and 80 upregulated) proteins with significantly differential accumulation under salt stress in JDG and DMS, respectively ( Fig. 3A, B ). Only 18 differentially accumulated proteins (DAPs) overlapped between the two cultivars, of which 13 were upregulated and 4 were downregulated in both JDG and DMS, while one DUF1279 domain–containing protein was upregulated in JDG and downregulated in DMS. Moreover, 101 DAPs were unique to JDG, whereas 145 DAPs were unique to DMS ( Table S2 ).

Proteomic analysis of rose under salt stress. (A) Number of DAPs in JDG and DMS. (B) Venn diagram of the DAPs in JDG and DMS. (C) Localizations of DAPs identified in JDG. (D) Functional categorization of DAPs unique to JDG. (E, F) KEGG enrichment analysis of DAPs in JDG (upregulated, E) and DMS (upregulated, F).

We predicted that most of the DAPs are located in chloroplasts in rose, according to the WoLFPSORT database ( Fig. 3C , Fig. S4A ). Gene Ontology (GO) and KEGG analyses were performed to analyze and annotate protein functions. The 20 most highly enriched GO terms associated with the DAPs are depicted in a circle diagram ( Fig. S5A, B , Table S2 ). Among them, GO:0046658 (anchored component of plasma membrane), GO:0051554 (flavonol metabolic process), GO:0047893 (flavonol 3- O -glucosyltransferase activity), and GO:0051555 (flavonol biosynthetic process) were highly enriched in JDG under salt stress. In DMS, GO:0006720 (isoprenoid catabolic process), GO:0005764 (lysosome), and GO:0004602 (glutathione peroxidase activity) were the most enriched among all GO terms. In addition, the GO data indicated that the DAPs specific to JDG were highly involved in the 'icosanoid metabolic process,' 'diterpenoid metabolic process,' and 'diterpenoid biosynthetic process' ( Fig. 3D ), whereas the DAPs specific to DMS were enriched in 'cellular hyperosmotic salinity response,' 'monocarboxylic acid catabolic process,' 'terpenoid catabolic process,' 'sesquiterpenoid catabolic process,' and 'apocarotenoid catabolic process' functions ( Fig. S4B ). DAPs shared by JDG and DMS included Q2VA35 (xyloglucan endotransglucosylase/hydrolase) and A0A2P6P708 (glutathione peroxidase), which are present only in extracellular regions ( Table S2 ). The DAPs in different comparison groups were classified and then clustered according to enrichment of their associated GO terms ( Fig. S4C ). We determined that salinity mainly influences flavone and flavonol metabolism pathways in JDG. Flavones and flavonols are antioxidants and bioactive reagents [ 24 ]. In DMS, salt mainly influences the osmotic response, water stimulus response, and salt stress response pathways, most of which are stress related [ 31 ]. We used KEGG enrichment to determine the metabolic pathways associated with the DAPs in JDG and DMS under salt stress ( Fig. 3E, F ). Many DAPs in JDG were associated with phenylpropanoid biosynthesis and alpha-linolenic acid metabolism, with examples including lipoxygenase (A0A2P6S713), 12-oxophytodienoate reductase (A0A2P6PFD8), peroxidase (A0A2P6R8H8), and flavone 3′- O -methyltransferase (A0A2P6RK21). The DAPs upregulated in DMS under salt stress were frequently associated with alpha-linolenic acid metabolism and glutathione metabolism, whereas the DAPs that were downregulated were associated with ribosomes ( Table S2 ). Notably, alpha-linolenic acid metabolism was significantly upregulated in both JDG and DMS under salt stress. Collectively, the GO and KEGG enrichment results show that salt stress causes dynamic changes in distinct sets of proteins in rose.

Salt stress differentially alters the transcriptomes of JDG and DMS

To identify the genes involved in salt stress and explore the molecular mechanisms of salt tolerance in DMS and JDG, we sequenced the transcriptomes of JDG and DMS leaves by RNA sequencing (RNA-seq). We obtained high-quality reads for transcriptome analysis ( Table S3 ). PCA showed a distinct difference between the two cultivars along PC1, and PC2 separated the treatment from the control. The three biological replicates in the ordination space were mostly clustered together, suggesting an acceptable correlation between replicates ( Fig. 4A ).

Transcriptomic analysis of JDG and DMS under salt stress. (A) PCA score plot of transcriptomic profiles from different cultivars. (B) Number of DEGs in JDG and DMS. (C–E) Venn diagrams of DEGs in JDG and DMS: (C) total DEGs, (D) upregulated DEGs, and (E) downregulated DEGs. (F, G) KEGG enrichment analysis of DEGs in JDG (F) and DMS (G).

Correlation analysis of transcriptome, proteome, and metabolomics data. (A, B) KEGG enrichment analysis of combined transcriptome, proteome, and metabolome data: (A) JDG-NaCl vs JDG-Mock, and (B) DMS-NaCl vs DMS-Mock. The x-axis shows the enrichment factor of the pathway in different omics, and the y-axis shows the name of the KEGG pathway; the color from red to green represents the significance of enrichment from high to low (indicated by the P value). The size of bubbles indicates the number of DEGs, DAPs, or DAMs; the larger the number, the larger the symbol. The shape of bubbles illustrates the various omics: circles represent genes omics, triangles represent metabolites omics, and squares represent proteins omics. (C) Co-expression network of major genes, proteins, and metabolites in the phenylpropanoid pathway. Different colors indicate the value of log 2 Fold Change (NaCl/Mock), with red for upregulated and blue for downregulated genes, proteins, or metabolites.

We analyzed differentially expressed genes (DEGs) in JDG and DMS under control and salt stress conditions. We detected 10,662 DEGs in DMS under salt stress, of which 4651 were upregulated and 6011 were downregulated. However, only 1990 genes were differentially expressed in JDG: 1102 upregulated and 888 downregulated ( Fig. 4B ). The smaller number of DEGs in JDG than in DMS under salt stress implies that JDG is less affected by salt stress. We used a Venn diagram to display the differences between various genes in DMS and JDG under salt stress. Group DMS-NaCl vs DMS-Mock and group JDG-NaCl vs JDG-Mock shared 1120 DEGs under salt stress, with 577 upregulated genes and 433 downregulated genes ( Fig. 4C–E ).

Next, we performed GO analysis of DEGs in the categories cellular component (CC), biological process (BP), and molecular function (MF). The top 21 most enriched GO terms associated with DEGs of JDG-NaCl vs JDG-Mock and DMS-NaCl vs DMS-Mock are presented in circle diagrams ( Fig. S6 , Table S4 ). Seven GO terms associated with the JDG-NaCl vs JDG-Mock group were highly involved in the BP category, among which GO:0016052 (carbohydrate catabolic process), GO:0009813 (flavonoid biosynthetic process), and GO:0009812 (flavonoid metabolic process) contained the most DEGs (43, 26, and 27, respectively), and most of these enriched genes were upregulated. Thirteen GO terms were highly involved in the MF category, among which GO:0010427 (abscisic acid binding), GO:0016832 (aldehyde-lyase activity), and GO:0019840 (isoprenoid binding) were highly significant. One GO term was highly involved in the CC category: GO:0031226 (intrinsic component of plasma membrane). Moreover, 19 GO terms associated with the DMS-NaCl vs DMS-Mock group were enriched in the BP category, among which GO:0036294 (cellular response to decreased oxygen levels), GO:0048511 (rhythmic process), and GO:0048585 (negative regulation of response to stimulus) contained the most DEGs (85, 95, and 146, respectively), and most of these enriched genes were downregulated. One GO term was enriched in the MF category: GO:0016854 (racemase and epimerase activity). Similarly, one GO term was enriched in the CC category: GO:0009501 (amyloplast). KEGG pathway enrichment analysis for JDG-NaCl vs JDG-Mock revealed that the DEGs were mainly involved in metabolic pathways, plant hormone signal transduction, biosynthesis of secondary metabolites, and glycolysis/gluconeogenesis ( Fig. 4F , Table S4 ). In the DMS-NaCl vs DMS-Mock group, the DEGs were chiefly enriched in metabolic pathways, plant hormone signal transduction, the MAPK signaling pathway, biosynthesis of cofactors, and ubiquitin-mediated proteolysis ( Fig. 4G , Table S4 ). These findings indicate that the biosynthesis of secondary metabolites is substantially enhanced under salt stress in JDG, but not in DMS. However, the biosynthesis of cofactors associated with primary metabolism is enhanced under salt stress in DMS. Therefore, we speculate that salinity results in large changes in primary metabolism in DMS, while it influences secondary metabolism in JDG.

Transcription factors (TFs) are essential for regulating the expression of stress response genes. Among the DEGs, we identified 114 TFs in JDG and 491 TFs in DMS, covering 39 TF families ( Table S4 ). The most abundant genes belonged to the AP2/ERF-ERF, MYB, NAC, bHLH, and C2C2 families ( Fig. S7A, B ). Moreover, 64 TFs were differentially expressed in both cultivars in response to salinity. We speculate that these TFs form a highly complex transcriptional regulatory network and could perform critical functions in the mechanism of salt tolerance in rose.

Expression of phenylpropanoid-related genes is correlated with proteins and metabolites affected by salt stress

Integrated analysis of multi-omics data provides a powerful tool for identifying significantly different pathways and crucial metabolites in biological processes. Here, we integrated our transcriptome, proteome, and metabolome data to determine the performance of the two rose cultivars under salt stress. Pathways associated with alpha-linolenic acid metabolism, phenylpropanoid biosynthesis, and starch and sucrose metabolism were significantly enriched in JDG under salt stress ( Fig. 5A ), while the pathways enriched in DMS were involved in starch and sucrose metabolism, cyanoamino acid metabolism, and phenylpropanoid biosynthesis ( Fig. 5B ). Starch and sucrose metabolism represent primary metabolic functions common to different cultivars [ 32 ], while alpha-linolenic acid metabolism is related to the biosynthesis of jasmonic acid, which is a phytohormone involved in fungal invasion and senescence [ 7 ]. The phenylpropanoid biosynthesis pathway comprises multiple secondary metabolites, which confer a range of colors, flavors, nutritional components, and bioactivities in plants. Flavonoids are an important type of phenylpropanoid that play key roles in resistance against biotic and abiotic stresses [ 24 ]. Thus, we focused on the phenylpropanoid pathway.

Gene–protein–metabolite correlation networks can be used to elucidate functional relationships and identify regulatory factors. Therefore, we analyzed the regulatory networks of the DEGs, DAPs, and DAMs related to phenylpropanoid metabolism. We identified 14 DEGs that were strongly correlated with one DAP and six DAMs in JDG under salt stress. Similarly, 25 DEGs were strongly correlated with one DAP and eight DAMs in DMS under salt stress ( Table S5 ). For example, in JDG, there was a strong correlation between the expression of one gene (RchiOBHmChr4g0430951) and the abundance of one protein (A0A2P6PM56) and two metabolites [coniferyl alcohol (mws0093) and sinapyl alcohol (mws0853)]. Epiafzelechin (mws1422) was also significantly associated with the expression of the gene RchiOBHmChr2g0092641. In DMS, there was a close association between the expression of three genes (RchiOBHmChr2g0092671, RchiOBHmChr3g0480401, and RchiOBHmChr5g0041231) and the abundance of one protein (A0A2P6QM41) and one metabolite [L-tyrosine (mws0250)]. The strong association of particular genes with phenylpropanoid proteins or metabolites suggests that these genes play a major role in phenylpropanoid biosynthesis under salt stress.

We selected 20 important genes in the biosynthetic pathway of phenylpropanoid and compared their expression between rose cultivars ( Table S6 ). The transcript levels of many genes ( 4CL1 , CCR1 , HCT1 , HCT2 , HCT3 , HCT4 , CHS1 , CHS2 , CHI , DFR , F3H , and ANR ) were higher in JDG than in DMS, which may be valuable for salt tolerance by stimulating JDG to produce more flavonoids. Our multi-omics analysis revealed that ferulic acid, sinapic acid, and coniferaldehyde accumulated to high levels in JDG under salt stress ( Fig. 5C , Table S1 ). We also compared the flavonoid compounds in the two cultivars. Quercetin-3,3′-dimethyl ether, 5,7-dihydroxy-6,3′,4′,5′-tetramethoxyflavone (arteanoflavone), naringenin-4′,7-dimethyl ether, naringin dihydrochalcone, genkwanin (apigenin 7-methyl ether), and mearnsetin accumulated to greater levels in JDG than in DMS under control conditions. Correspondingly, the flavonoids brickellin, 3- O -methylquercetin, 5,2′,5′-trihydroxy-3,7,4′-trimethoxyflavone-2′- O -glucoside, and kaempferol-3- O -(6′′-acetyl)glucosyl-(1→3)-galactoside were more abundant in JDG than in DMS under salt stress. By contrast, naringenin-4′,7-dimethyl ether, aromadendrin (dihydrokaempferol), pinocembrin-7- O -(6′′- O -malonyl)glucoside, Quercetin-3- O -(2”- O -glucosyl)glucuronide, were specifically accumulated in DMS. Moreover, 3′,4′,5′,5,7-pentamethoxyflavone, 3,5,7,3′4′-pentamethoxyflavone, and 5,7,8,4′-tetramethoxyflavone were abundant in JDG under salt stress but were decreased in DMS ( Table S7 ). Overall, the integration of the three omics datasets indicated that the phenylpropane pathway, especially the flavonoid pathway, is strongly enhanced under salinity conditions and that this contributes to salt tolerance in roses, especially in the JDG genotype.

Networks of co-expressed genes associated with phenylpropanoid biosynthesis are involved in the salt stress response

To identify candidate genes associated with phenylpropanoid biosynthesis, we constructed co-expression gene network modules via weighted gene correlation network analysis (WGCNA). We constructed a cluster tree based on correlation between expression levels (indicated by fragments per kilobase of script per million fragments mapped, FPKM), which partitioned the genes into 11 different gene modules ( Fig. 6A, B ). To identify candidate genes that play significant roles within the gene networks, we extracted annotation information for all these genes from the Rosa chinensis 'Old Blush' reference genome annotation database. We selected 16 genes contributing to phenylpropanoid biosynthesis and four genes associated with flavonoid biosynthesis. Table S8 lists the annotated genes participating in flavonoid-related pathways in JDG. Among the 11 modules, the green module contained 10 of these genes: CHS1 , CHS2 , CCR1 , HCT3 , HCT4 , CCoAOMT , F3H , DFR , ANR , and CHI . The turquoise module contained three genes: CCR2 , HCT1 , and CAD2 . The blue module contained three genes: PRDX1 , 4CL1 , and ANS . The red, yellow, brown, and black modules each contained one gene: CAD1 , PRDX2 , HCT2 , and 4CL2 , respectively ( Table S8 ). After combining certain genes in modules and comparing them with the DEGs, we checked and confirmed these results using reverse-transcription quantitative PCR (RT-qPCR). The expression trends of eight DEGs from phenylpropanoid and flavonoid biosynthesis pathways matched the results of RNA-seq ( Fig. S8 ).

Co-expression network related to flavonoid biosynthesis. (A) Clustering tree based on the correlation between gene expression levels. (B) Module–sample relationships. Each row represents a gene module, with the same color in as (A); each column represents a sample; the boxes within the chart contain corresponding correlations and P values. (C–E) Networks built from correlations among structural genes and TFs. Circles represent genes, and the size of the circle represents the number of relationships between genes in the network and surrounding genes. Lines represent regulatory relationships between genes, and different colored lines represent different connection strengths: red, strong connections; green, weak connections. (F) Heat map depicting the expression profiles of 15 TF genes. The scale bar denotes the Fold change/(mean expression levels across the three treatment groups). The color indicates relative levels of gene expression, horizontal rows represent the different treatments in JDG, and vertical columns show the TFs. (G) Representative images of transient expression of bHLH74 and LUC driven by the CHS1 promoter in Nicotiana benthamiana leaves. The color scale represents the signal level. High represents a strong signal, and low represents a weak signal. (H) Relative value of LUC/REN. Data are based on the mean ± SE of at least three repeated biological experiments. Significance determined using Student’s t -test ( ** P < 0.01).

To determine the regulatory genes involved in phenylpropanoid biosynthesis in JDG, we constructed three subnetworks from the different modules using the 20 phenylpropanoid biosynthesis–related DEGs as the nodes ( Table S9 ). In the regulatory networks of phenylpropanoid biosynthesis, we identified 15 TF genes from seven TF families: AP2/ERF-ERF (5 unigenes), bHLH (3 unigenes), MYB (3 unigenes), Alfin-like (1 unigene), SBP (1 unigene), C2C2-GATA (1 unigene), and TCP (1 unigene). bHLH62 and bHLH74 were strongly associated with CHS1 , CHS2 , CHI , CCR1 , and F3H ; ERF81 was strongly associated with 4CL1 ; and ERF110 and MYB-related were strongly associated with 4CL2 ( Fig. 6C–E ), indicating that CHS and 4CL are the major target genes in phenylpropanoid biosynthesis. Therefore, we speculated that the abundance of flavonoids is increased by enhancing the expression of upstream flavonoid biosynthesis genes. Fig. 6F shows a heat map of expression of the 15 TF genes after NaCl treatment. The green module contained a substantial number of phenylpropanoid biosynthesis genes, among which CHS1 was closely related to the TFs bHLH74 and bHLH62. Therefore, dual-luciferase reporter assays were conducted to determine their regulatory relationship ( Fig. 6G, H ). We used bHLH74 and bHLH62 driven by the CaMV35S promoter as effectors in a transient expression system, with the CHS1 promoter fused with LUC as a reporter. When we cotransformed Nicotiana benthamiana leaves with the effectors and the reporter, the LUC/REN ratio of CHS1 was 0.3/1, which was drastically lower than those of the controls ( Fig. 6G, H , Fig. S9A, B ). These results indicate that bHLH74, but not bHLH62, inhibits the expression of CHS1 .

Salt stress damages the structure and osmotic potential of rose leaves

Roses belong to the Rosaceae family and are one of the most important commercial flower crops. Extracts from various parts of the rose plant have also been shown to have excellent biological activity and are used in industries such as cosmetics, perfume and medicine [ 1 ]. Meanwhile, an increasing number of wild rose varieties with significant health benefits are being domesticated and brought into mainstream cultivation [ 33 ]. Salt stress is one of the most widespread abiotic constraints for rose cultivation. Salt stress threatens plant survival and growth but can stimulate an increase in the biosynthesis of secondary metabolites [ 34 ]. Previous studies have shown that optimal coordination between leaf structure and photosynthetic processes is essential for enabling plants to tolerate salt stress [ 35 ]. When exposed to salt treatment, leaves become thicker and smaller while the palisade tissue and spongy tissue become loose and jumbled and the intercellular space of the mesophyll becomes thinner [ 36–39 ]. We observed that the palisade tissue of DMS was loose, disordered, and severely damaged compared with that in JDG under salt stress ( Fig. 1C ). This indicates that DMS is more sensitive to salt stress than JDG. Typically, excessive ROS accumulate under stress conditions, which can lead to membrane oxidative damage (lipid peroxidation) [ 40 ]. Silencing of the gene GmNAC06 in soybean ( Glycine max ) leads to accumulation of ROS under salt stress, which in turn leads to significant losses in soybean production [ 41 ]. In Arabidopsis , the sibp1 mutant accumulates more ROS than wild-type plants or AtSIBP1-overexpressing plants, resulting in a lower survival rate under salt treatment [ 42 ]. In this study, salinity led to a greater accumulation of ROS in DMS compared with JDG, as detected by DAB staining ( Fig. 1D, E ). This indicates that DMS suffers greater damage under salinity stress. Excessive accumulation of ROS in cells can lead to membrane oxidative damage and trigger the production of enzyme systems or non-enzyme free radical scavengers to cope with oxidative damage [ 10 ]. Here, antioxidant enzyme activities such as peroxidase (A0A2P6R8H8) and glutathione peroxidase (A0A2P6P708) were upregulated in roses under salt treatment ( Table S2 ). This suggests that rose plants maintain lower ROS levels by upregulating the activity of antioxidant enzymes, thereby protecting photosynthetic mechanisms and maintaining plant growth under salt stress. Among the nonenzymatic antioxidants, phenols and flavonoids accumulate in various tissues and contribute to free radical scavenging that enhances plant salt tolerance [ 43 ]. Indeed, we identified significant differences in the contents of phenolic acids, lipids, and flavonoid metabolites in JDG and DMS under control and salt stress conditions ( Table S1 ). Moreover, our transcriptomic and proteomic analysis revealed the activation of genes and proteins within the phenylpropanoid and flavonol pathways. This activation results in the accumulation of various phenolic compounds, potentially enhancing their capacity for scavenging ROS.

Flavonoids are beneficial for improving salt stress in rose

Phenolic compounds, such as flavonoids, are among the most widespread secondary metabolites observed throughout the plant kingdom [ 44 ]. These compounds fulfill various biochemical and molecular functions within plants, encompassing roles in plant defense, signal transduction, antioxidant action, and the scavenging of free radicals [ 45 ]. Environmental changes commonly trigger the flavonoid pathway, which aids in shielding plants from the harmful effects of ultraviolet radiation, salt, heat, and drought [ 23 , 46 , 47 ]. Moreover, flavonoids demonstrate potent biological activity and serve as significant antioxidants [ 48 ]. Recently, researchers and consumers have been interested in plant-based polyphenols and flavonoids for their antioxidant potential, their dietary accessibility, and their role in preventing fatal diseases such as cardiovascular disease and cancer [ 49 ]. Our transcriptomics analysis showed that salinity causes significant alterations in the secondary metabolism of JDG, while affecting the primary metabolism of DMS. Proteomics showed that phenylpropanoid biosynthesis is significantly enhanced in JDG under salt stress, especially through the flavonoid pathway. In DMS, glutathione metabolism is significantly enhanced under salt stress, indicating differences in salt tolerance pathways between the two cultivars. Our metabolome data indicated that the abundance of phenolic acid and flavonoid metabolites was significantly altered in both JDG and DMS under salt stress. Furthermore, by comparing their contents in leaves under salt stress and control conditions, we found that more flavonoids accumulated in DMS than in JDG under salt stress. This evidence suggests that DMS requires an increased presence of flavones to withstand the damage caused by salinity. By contrast, salinity stress did not trigger a substantial buildup of flavonoids in JDG, possibly due to the adequate levels of flavonoids already present under normal conditions, which provided ample tolerance to salt-induced stress. This observation could also explain the higher tolerance of JDG to salt stress ( Table S1 ). When we compared the flavonoid metabolites of the phenylpropanoid pathway to identify flavonoid metabolites associated with salt tolerance, we found that 17 phenolic acid metabolites and 6 flavonoid metabolites were significantly differentially accumulated in both genotypes. Of these compounds, ferulic acid serves as a free radical scavenger, while simultaneously serving as an inhibitor for enzymes engaged in generating free radicals and boosting the activity of scavenger enzymes [ 49 ]. Sinapic acid is a bioactive phenolic acid with anti-inflammatory and anti-anxiety effects [ 50 ]. Pinocembrin, a naturally occurring flavonoid found in fruits, vegetables, nuts, seeds, flowers, and tea, is an anti-inflammatory, antimicrobial, and antioxidant agent [ 51 ]. This indicates that these two rose cultivars contain beneficial metabolites with some economic value. We investigated the possible effects of these metabolites in conferring salt tolerance in rose by comparing specific DAMs between JDG and DMS. Among these DAMs, eight metabolites were upregulated and six metabolites were downregulated under salt treatment in JDG compared to DMS. Among these eight upregulated DAMs, the contents of 3- O -methylquercetin, brickellin, 5,2′,5′-trihydroxy-3,7,4′-trimethoxyflavone-2′- O -glucoside, and kaempferol-3- O -(6′′-acetyl)glucosyl-(1→3)-galactoside accumulated significantly with salinity ( Table S7 ). These metabolites have important functions. For example, 3- O -methylquercetin has potent anticancer, antioxidant, antiallergy, and antimicrobial activities and shows strong antiviral activity against tomato ringspot virus [ 52 ]. Kaempferol, a biologically active compound found in numerous fruits, vegetables, and herbs, demonstrates various pharmacological benefits, such as antimicrobial, antioxidant, and anticancer properties [ 53 ]. This indicates that JDG is an excellent rose cultivar that is both salt tolerant and rich in beneficial bioactive substances.

bHLHL74 regulates flavonoid biosynthesis

The biosynthesis of flavonoids is initiated from the amino acid phenylalanine, giving rise to phenylpropanoids that subsequently enter the flavonoid-anthocyanin pathway [ 25 ]. The CHS enzyme is situated at a crucial regulatory position preceding the flavonoid biosynthetic pathway, directing the flow of the phenylpropanoid pathway towards flavonoid production, which has been extensively documented in many plant species [ 54 , 55 ]. In rice ( Oryza sativa ), defects in the flavonoid biosynthesis gene CHS can alter the distribution of flavonoids and lignin [ 56 ]. In eggplant ( Solanum melongena L.), CHS regulates the content of anthocyanins in eggplant skin under heat stress [ 57 ]. In apple ( Malus domestica ), overexpression of CHS increases the accumulation of flavonoids and enhances nitrogen absorption [ 58 ]. We identified a positive correlation between flavonoid accumulation and the expression of CHS genes, in agreement with previous reports. The bHLH TFs involved in regulating flavonoid biosynthesis work in a MYB-dependent or -independent manner. For example, DvIVS, a bHLH transcription factor in dahlia ( Dahlia variabilis ), activates flavonoid biosynthesis by regulating the expression of Chalcone synthase 1 ( CHS1 ) [ 59 ]. The Arabidopsis bHLH proteins TRANSPARENT TESTA 8 (AtTT8) and ENHANCER OF GLABRA 3 (AtEGL3) are all involved in the biosynthesis of various flavonoids [ 60–62 ]. In Chrysanthemum ( Chrysanthemum morifolium ), CmbHLH2 significantly activates CmDFR transcription, leading to anthocyanin accumulation, especially when in coordination with CmMYB6 [ 63 ]. In blueberry ( Vaccinium sect. Cyanococcus ), the bHLH25 and bHLH74 TFs potentially engage with MYB or directly hinder the expression of genes responsible for flavonoid biosynthesis, thereby regulating flavonoid accumulation [ 64 ]. In apple ( Malus domestica ), expression of bHLH62, bHLH74, and bHLH162 is significantly negatively correlated with anthocyanin content and has been shown to inhibit anthocyanin biosynthesis [ 65 ]. In apple fruit skin, hypermethylation of bHLH74 in the mCG context leads to transcriptional inhibition of downstream anthocyanin biosynthesis genes [ 66 ]. In rose, our co-expression network revealed a strong correlation between CHS and genes encoding TFs such as bHLH74 and bHLH62 in the key gene network. bHLH proteins can bind to the promoter regions of pivotal genes encoding enzymes, playing important roles in regulating DAMs under salt stress. Dual-luciferase reporter assays showed that LUC bioluminescence was suppressed well below background levels in Nicotiana benthamiana leaves infiltrated with pCHS1:LUC plus 35S:bHLH74, but not 35S:bHLH62 ( Fig. 6G, H , Fig. S9A, B ). Thus, we conclude that bHLHL74 TFs negatively regulate flavonoid biosynthesis by directly inhibiting the expression of CHS1 , which is involved in the flavonoid biosynthetic pathway.

We examined the morphological phenotypes, transcriptomes, proteomes, and widely targeted metabolomes of JDG and DMS under salt stress. Multi-omics analysis revealed that the phenylpropane pathway, especially the flavonoid pathway, contributes strongly to salt tolerance in rose, particularly JDG. Meanwhile, the bHLHL74 TF negatively regulates flavonoid biosynthesis by repressing the expression of the CHS1 gene involved in the flavonoid biosynthetic pathway. This research facilitates our understanding of the regulatory mechanisms of plant development and secondary metabolites underlying salt stress responses in rose, offering valuable insights that could be used to develop new strategies for improving plant tolerance to salinity.

Plant materials and growth conditions

Rosa hybrida cv. Jardin de Granville (JDG) and Rosa damascena Mill. (DMS) were planted in the Science and Technology Park of China Agricultural University (40°03′N, 116°29′E). Rose plants were propagated by cutting culture. Rose shoots with at least two nodes and approximately 6 cm in length were used as cuttings and inserted into square flowerpots (diameter 8 cm) containing a mixture of vermiculite and peat soil [1:1 (v/v)]. Cuttings were soaked in 0.15% (v/v) indole-3-butytric acid (IBA) before insertion into pots and then grown in a growth chamber at 25°C with 50% relative humidity and a cycle of 8 hours of darkness/16 hours of light for 1 month until rooting [ 67 ].

Nicotiana benthamiana plants were used for measurement of transient expression. Seeds were sown in square flowerpots (diameter 8 cm); after 1 week, seedlings were transplanted into different pots. The soil and cultivation conditions for N. benthamiana cultivation were the same as those for roses.

Salt treatment

Twenty JDG and 20 DMS rose cuttings displaying good rooting and uniform appearance were selected for salt treatment experiments. JDG or DMS plants were randomly divided into two groups watered with either 0 or 400 mM NaCl. Phenotypes were recorded after 2 weeks. This process was repeated three times [ 68 ].

Salt treatment of rose leaves was described previously [ 68 ]. Thirty JDG and 30 DMS rose cuttings with good rooting and uniform appearance were selected, and mature leaves of similar size were collected. The leaves were divided into two treatment groups, each containing 30 leaves: group A, immersed in deionized water treatment, and group B, immersed in 400 mM NaCl treatment. Phenotypes were observed after 0, 2, and 4 days. On the second day of treatment, leaves showed obvious differences. By the fourth day of treatment, the leaves had become soft or had died. Therefore, sequencing data from the second day were used. Three independent biological replicates were assayed.

Relative electrolyte permeability

Determination of relative electrolyte permeability was as previously reported [ 69 ] with the following modifications. Salt-treated leaves (0.1 g) were weighed, placed in a 50-ml centrifuge tube, and covered with 20 ml deionized water. The conductivity of the distilled water was measured and defined as EC0. After shaking for 20 minutes at 60 rpm on an orbital shaker, the conductivity at room temperature was measured and defined as EC1. The centrifuge tube was then placed in boiling water for 10 minutes and cooled to room temperature, and the conductivity of the solution was measured as EC2. The relative permeability of the electrolytes (as a percentage) was determined as (EC1-EC0) / (EC2-EC0) × 100%.

Soluble protein content

Soluble protein content was determined following the method of Bradford (1976) [ 70 ]. Leaf samples (0.5 g) were placed in a mortar with 8 ml distilled water and a small amount of quartz sand, crushed thoroughly, and incubated at room temperature for 0.5 hours. After centrifugation at 3,000 g for 20 minutes at 4 °C, the supernatant was transferred to a 10-ml volumetric flask and the volume was adjusted to 10 ml with distilled water. Two 1.0-ml aliquots of this sample extraction solution (or distilled water as a control) were transferred to clean test tubes, 5 ml of Coomassie Brilliant Blue reagent was added, and the tubes were shaken well. After 2 minutes, when the reaction was complete, the absorbance and chromaticity at 595 nm were measured, and the protein content was determined using a standard curve.

Leaf anatomical structure

Paraffin sections were prepared as described previously with some modifications [ 71 ]. Leaves from the control and NaCl treatments were collected, washed slowly with deionized water at normal room temperature, and stored at 4°C until further use. A 3-mm × 5-mm sample was cut from the same part of each leaf, and these leaf samples were fixed in 2.5% (v/v) glutaraldehyde. Samples were dehydrated using acetone through a concentration gradient of 30%, 50%, 70%, 80%, 95%, and 100% (v/v) and then embedded in paraffin. The embedded tissues (3-μm sections) were sectioned using a Leica RM2265 rotary slicer (Leica Microsystems, Wetzlar, Germany). Slides were stained with 0.02% (v/v) toluidine blue for 5 minutes, and the residual toluidine blue was removed using distilled water. Slides were allowed to dry and then observed under a microscope (OLYMPUS BH-2, Tokyo, Japan). Three independent biological replicates were examined.

DAB (3,3′-diaminobenzidine) staining for H 2 O 2

H 2 O 2 content was detected using the DAB staining method [ 72 ]. Leaves treated with NaCl or control leaves were rinsed clean with distilled water, immersed in DAB solution (1 mg/ml, pH 3.8), and placed under vacuum at approximately 0.8 Mpa for 5 minutes; this process was repeated three to six times until the leaves were completely infiltrated. Leaves were then incubated in a box in the dark for 8 hours until a brown sediment was observed. Chlorophyll was removed by repeatedly washing with eluent (ethanol:lactic acid:glycerol, 3:1:1, v/v/v). Decolorized leaves were photographed to record their phenotypes. ImageJ was used to quantify the stained areas.

UPLC-QQQ-based widely targeted metabolome analysis

Metabolomics analysis was performed on four groups of samples: JDG-Mock, JDG-NaCl, DMS-Mock, and DMS-NaCl. Extraction and determination of metabolites were performed with the assistance of Wuhan Metware Biotechnology Co., Ltd. Samples were crushed using a stirrer containing zirconia beads (MM 400, Retsch). Freeze-dried samples (0.1 g) were incubated overnight with 1.2 ml 70% (v/v) methanol solution at 4 °C, then centrifuged at 13,400 g for 10 minutes. The extracts were filtered and subjected to LC-MS/MS analysis [ 73 ]. A previously described procedure [ 74 ] was followed for analyzing the conditions and quantifying metabolites using an LC-ESI-Q TRAP-MS/MS in multi-reaction monitoring (MRM) mode. The prcomp function was used for PCA, significantly different metabolites were determined by |log 2 Fold Change| ≥ 1, and annotated metabolites were mapped to the KEGG pathway database ( http://www.kegg.jp/kegg/pathway.html ). Comparisons are described as follows: e.g., JDG-NaCl vs JDG-Mock, indicating that the treated sample is being compared with the untreated sample and that metabolites are upregulated or downregulated in the NaCl sample compared with the Mock sample.

Tandem mass tag-based proteomic analysis

Experiments were carried out with the assistance of Hangzhou Jingjie Biotechnology Co., Ltd. Samples were thoroughly ground into powder using liquid nitrogen, and protein extraction was performed using the phenol extraction method. The protein was added to trypsin for enzymolysis overnight, and then the peptide segments were labeled with TMT tags. LC-MS/MS analysis was performed using an EASY-nLC 1200 UPLC system (ThermoFisher Scientific) and a Q Active TM HF-X (ThermoFisher Scientific) [ 75 ]. An absolute value of 1.3 was used as the threshold for significant changes. GO ( http://www.ebi.ac.uk/GOA/ ) and KEGG categories were used to annotate DAPs; WoLFPSORT software was used to predict subcellular localization ( https://wolfpsort.hgc.jp/ ).

Transcriptome sequencing

We constructed 12 cDNA libraries (three biological replicates for each of JDG and DMS under each treatment) for RNA-seq. Transcriptome sequencing was completed at Wuhan Metware Biotechnology Co., Ltd. RNA purity and RNA integrity were determined using a nanophotometer spectrophotometer and an Agilent 2100 bioanalyzer, respectively. The RNA library was then sequenced on the Illumina Hiseq platform. Raw data were filtered using fastp v 0.19.3 and compared with the reference genome ( https://lipm-browsers.toulouse.inra.fr/pub/RchiOBHm-V2/ ). FPKM (fragments per kilobase of script per million fragments mapped) was used as an indicator to measure gene expression levels, with the threshold for significant differential expression being an absolute |log 2 Fold Change| ≥ 1 and False Discovery Rate < 0.05. GO and KEGG categories were used to annotate DEGs [ 76 ].

To identify modules with high gene correlation, co-expression network analysis was performed using the R-based WGCNA package (v.1.69) with default parameters [ 77 ]. The varFilter function of the R language genefilter package was used to remove genes with low or stable expression levels in all samples. Modules based on the correlation between gene expression levels were identified, and a correlation matrix between each module and the sample was calculated using the R-based WGCNA software package. The module network was visualized using Cytoscape software (v.3.7.2).

RT-qPCR was performed on eight DEGs in the phenylpropanoid pathway to verify the accuracy of the data obtained from high-throughput sequencing. Total RNA was extracted using the hot borate method [ 72 ] and reverse transcribed using HiScript III All-in-one RT SuperMix (R333-01, Vazyme Biotech Co., Ltd., Nanjing, China). Subsequently, 2 × ChamQ SYBR qPCR Master Mix (Q331, Vazyme Biotech Co., Ltd., Nanjing, China) was used for quantitative detection of gene expression. The relative expression of genes was calculated using the 2 −ΔΔCt method [ 76 ]. GAPDH was used as an endogenous control, and primers for RT-qPCR are listed in Table S10 .

Dual-LUC reporter assay

A transactivation assay was designed to evaluate the effect of BHLH74/BHLH62 on the CHS1 promoter using methods described previously [ 78 ]. Initially, a 2000-bp segment of the CHS1 promoter was cloned into the pGreenII 0800-LUC vector, generating the ProCHS1:LUC reporter plasmid. Concurrently, the coding sequences of BHLH74/BHLH62 were inserted into the pGreenII0029 62-SK vector, resulting in the construction of Pro35S: BHLH74/BHLH62 effector plasmids. pGreenII 0800-LUC vector containing REN under control of the 35S promoter was used as a positive control.

Following plasmid construction, these constructs were introduced into Agrobacterium tumefaciens strain GV3101, which harbored the pSoup plasmid. Subsequently, A. tumefaciens containing different combinations of effector and reporter plasmids was infiltrated into N. benthamiana plants with six to eight young leaves. After a 3-day incubation period, the ratios of LUC to REN were quantified using the Bio-Lite Luciferase Assay System (DD1201, Vazyme Biotech Co., Ltd., Nanjing, China). Images capturing LUC signals were acquired using a CCD camera (Night Shade LB 985, Germany). Primer sequences are listed in Table S10 .

Statistical analysis

Statistical analyses of data were conducted using IBM SPSS Statistics, while graphical representations were created using GraphPad Prism 8.0.1. Paired data comparisons were assessed through Student's t -tests ( * P < 0.05, ** P < 0.01, *** P < 0.001). Each experiment was performed using a minimum of three biological replicates, and error bars depicted on graphs denote the standard error (SE) of the mean value. The NetWare Cloud platform ( https://cloud.metware.cn ) and OmicShare tools ( https://www.chiplot.online/ ) were used for bioinformatics analyses and mapping.

This work was supported by the Consult of Flower Industry of Jinning District (202204BI090022), General Project of Shenzhen Science and Technology and Innovation Commission (Grant No. 6020330006K0).

ZX, MN conceived and designed the experiments. RH and YW conducted the experiments. RH, YW, ZX analyzed the data. LY, JW, QX, CP, XT, GJ and MN performed the research. RH, SM and ZX wrote the manuscript. All authors read and approved the manuscript. RH and YW contributed equally to this work.

The datasets generated and analyzed during the current study are available in the Biological Research Project Data (BioProject), National Center for Biotechnology Information (NCBI) repository, accession: PRJNA1030783.

The authors declare that they have no competing interests.

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A GIS-based catastrophe approach for optimal site selection for installation of solar power plants, East Azerbaijan province case study, Iran

• Research Article
• Published: 14 May 2024

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• Marziyeh Esmaeilpour 1 &
• Mansour Kheirizadeh Arouq 2  

Due to depletion of fossil fuels and environmental issues, renewable energy consumption is increasingly growing. Solar energy as the most abundant renewable energy source available is becoming more popular around the world. In the current study, the optimal sites for solar photovoltaic power plants in East Azerbaijan province, Northwest Iran, were investigated. A total of 17 variables were categorized into four groups: climatic, geomorphological, environmental, and access-economic. In order to integrate the variables, a model based on catastrophe theory in the context of GIS was applied. The relative importance and weight of the criteria are computed based on the internal mechanism of the catastrophic system, thus greatly reducing subjectivism and uncertainties of the decision-making process. Five optimal sites located in the western part of the province within the counties of Malekan, Bonab, Ajabshir, Shabestar, and Tabriz were identified as suitable sites for the construction of solar photovoltaic power plants, where there are ideal conditions in terms of many environmental-human variables such as high potential of solar energy, high sunshine hours, low relative humidity, suitable slope, poor vegetation, distance to protected areas, proximity to the population centers, excellent access to the roads and to the main power lines.

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This paper is published as part of a research project supported by University of Maragheh Research Affairs Office, grant number 98/d/3390.

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Department of Geography and Urban Planning, University of Maragheh, Maragheh, Iran

Marziyeh Esmaeilpour

Geomorphology From University of Tabriz, Tabriz, Iran

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Marziyeh Esmaeilpour: visualization, software, formal analysis, writing—original draft preparation, writing—review and editing, funding acquisition, conceptualization, analysis and interpretation of results. Mansour Kheirizadeh: data curation, resources, formal analysis, methodology, writing—review and editing, investigation. All authors reviewed the results and approved the final version of the manuscript.

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Esmaeilpour, M., Kheirizadeh Arouq, M. A GIS-based catastrophe approach for optimal site selection for installation of solar power plants, East Azerbaijan province case study, Iran. Environ Sci Pollut Res (2024). https://doi.org/10.1007/s11356-024-33639-6

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Received : 23 December 2022

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DOI : https://doi.org/10.1007/s11356-024-33639-6

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