Systematic vs. Scoping Reviews: Evidence Synthesis Architectures for African Healthcare

Levi Cheptora

Wed, 05 Nov 2025

I. Strategic Introduction to Evidence Synthesis

A. The Role of Reviews in Evidence-Informed Health Policy (EIHP) in Africa

Evidence synthesis serves as the critical mechanism for contextualizing and integrating the findings of individual research studies within the larger body of knowledge pertaining to a topic.1 In the African continent, where health challenges are often severe, multifaceted, and compounded by resource limitations, the strategic application of synthesized evidence is paramount for achieving efficiency and maximizing impact in public health interventions.2 Robust evidence synthesis methodologies, such as Systematic Reviews (SRs) and Scoping Reviews (SCRs), ensure that policy and practice decisions are grounded in reliable data. Both methods are forms of knowledge synthesis, demanding transparency and reproducible methods, whether quantitative, qualitative, or mixed.1

The effective generation and use of research evidence to inform health policy (EIHP) in West Africa, for example, necessitates a synergistic approach that builds capacity among both researchers and decision-makers.3 Identified strategies include the development of Communities of Practice, creation of repositories for Health Policy and Systems Research (HPSR) evidence, stakeholder mapping, and, crucially, presenting research results in a culturally sensitive manner that frames them as solutions to political problems.3 This highlights that the value of an evidence synthesis project extends beyond its methodological rigor to its practical utility and acceptance within the policy landscape.

B. Defining the Hierarchy of Evidence and the Place of SRs and SCRs

Systematic reviews (SRs), particularly when coupled with meta-analyses, are widely recognized as occupying the pinnacle of the evidence hierarchy in clinical medicine.4 These reviews are designed to identify, critically appraise, and synthesize empirical evidence to answer specific research questions, thereby driving advancements in clinical practice and informing the creation of trustworthy clinical guidelines.1 They are considered the "pillar of evidence-based healthcare".6

Scoping reviews (SCRs), by contrast, serve a distinct architectural function within the evidence landscape. Their primary goal is not to provide a definitive answer to a clinical question but to provide an overall map of the evidence base, regardless of study quality.7 SCRs clarify concepts, examine the extent and nature of research activity, and identify significant knowledge gaps.6 Consequently, an SCR typically precedes the traditional evidence hierarchy by defining the boundaries of the research field, setting the stage for more focused, quality-assessed systematic reviews to follow.8

C. Initial Decision Matrix: When Clarity Demands Specificity vs. Breadth

The choice between undertaking an SR or an SCR is fundamentally contingent upon the nature of the research question and the practical constraints, particularly concerning resources and time.1

When the aim is to answer a tightly defined, clinical question that will directly inform policy or clinical practice, a systematic review is the appropriate method.1 However, if the question is exploratory, seeking to map the scope of available literature, clarify heterogeneous concepts, or determine research gaps in an emerging field, a scoping review is the correct methodological choice.1

For researchers and policymakers operating in Low- and Middle-Income Countries (LMICs), particularly across Africa, this methodological choice involves strategic resource allocation. Systematic reviews are highly resource-intensive, often requiring 12 to 24 months to complete due to their exhaustive search and rigorous critical appraisal phases.11 Given the "limited capacity for conducting systematic reviews within LMICs," which poses a significant technical challenge to health systems advancement 12, prioritizing a quicker, gap-identifying SCR (typically 2 to 6 months) becomes a necessary strategic choice.11 The scoping review acts as a vital tool for feasibility assessment and risk mitigation, ensuring that scarce resources are not committed to a full systematic review prematurely, or on a question for which insufficient, or overly heterogeneous, evidence exists.8 Thus, in resource-constrained African settings, the selection between SR and SCR is often driven by strategic prudence rather than purely methodological ideals.

II. The Fundamental Distinction: Purpose, Scope, and Frameworks

A. Systematic Review: Answering the Focused Clinical Question

The systematic review aims to achieve depth and certainty regarding a specific inquiry. Its objective is to identify, appraise, and synthesize all empirical evidence that meets pre-specified eligibility criteria.1 The outcome is a synthesis of evidence that minimizes bias and produces reliable findings suitable for decision-making, policy development, and informing clinical guidelines.1 The scope of a systematic review is narrow, focused, and must aim to be exhaustive within its defined boundaries.10

The defining characteristic of the systematic review question is its structure, typically utilizing the PICO (Population, Intervention, Comparison, Outcomes) framework.11 This framework ensures the research team defines all key components prior to starting the review, leading to highly specific inclusion and exclusion criteria.13

B. Scoping Review: Mapping the Research Terrain and Identifying Gaps

The scoping review is fundamentally exploratory. It addresses broad questions aimed at mapping key concepts, determining the types of evidence available, and identifying gaps in research related to a defined area or field.1 Scoping reviews examine the extent, range, and nature of research activity.7 They are particularly valuable for exploring complex or emerging topics where the body of evidence may be diffuse or heterogeneous, and they provide an overall map of what evidence has been produced, irrespective of its quality.7

To accommodate this broader scope, scoping reviews utilize the PCC (Population, Concept, Context) framework.10 This structure allows the review to focus on an idea or field, rather than being confined to a specific clinical outcome and comparison.7 Furthermore, in the context of African public health and health systems research (HPSR), the inclusion of 'Context' in the PCC framework is methodologically superior. Health outcomes on the continent are profoundly influenced by historical, cultural, political, and systemic factors.15 By explicitly incorporating context, the scoping methodology provides the necessary dimension of contextual capture when exploring non-clinical topics such as service equity or the evolution of healthcare systems.16

C. Comprehensive Differentiation Table

The core differences between these two evidence synthesis methods lie in their methodological requirements, reflecting their distinct objectives. These contrasts are summarized below:

Comprehensive Differentiation of Systematic and Scoping Reviews

The SCR is not a "less rigorous" version of the SR; rather, it possesses a distinct methodological utility. It clarifies conceptual ambiguity and identifies research voids, providing the necessary precursor information for more tightly defined, subsequent SRs.8 In essence, the scoping review serves as the critical foundational phase for sophisticated evidence programs, preventing the waste of time and resources on premature or unfocused systematic reviews.

III. Rigor and Synthesis: The Systematic Review Deep Dive

The systematic review demands stringent methodological adherence at every stage to minimize bias and produce findings reliable enough to inform clinical decision-making.1 The following steps illustrate the required rigor of the SR methodology.

A. Step-by-Step Systematic Review Guide (SR)

Stage 1: Formulating the Review Question and Protocol Registration

The SR process initiates with the formulation of a highly specific research question, ideally using the PICO framework.4 Subsequently, a comprehensive protocol detailing the review plan must be developed. This protocol ensures transparency and reproducibility, outlining specific hypotheses, inclusion/exclusion criteria, and planned analysis methods. Crucially, systematic review protocols are formally registered in repositories like PROSPERO prior to the commencement of data collection.11

Stage 2: Comprehensive Search Strategy

The search strategy must be explicitly systematic and comprehensive, aiming to identify all available empirical evidence.1 This includes searching across multiple bibliographic databases (e.g., PubMed, Embase, Cochrane).4 To counteract inherent publication bias—a significant concern in LMICs where local studies or those with negative findings may not be indexed in major global databases 12—SRs focusing on African clinical interventions must deliberately incorporate extensive searches for 'grey literature,' such as government reports, theses, and regional journals.22 Tools like Covidence and EndNote are commonly used to streamline reference management and the initial screening of titles and abstracts.4

Stage 3: Study Selection and Data Extraction

The selection of studies involves a rigorous screening process against the pre-specified eligibility criteria, with the decisions documented transparently, usually via a PRISMA flow diagram.11 Data extraction is performed using standardized, piloted forms to ensure the consistent and accurate capture of specific data items, including study design, participant characteristics, interventions, and outcomes.4

Stage 4: Mandatory Critical Appraisal and Risk of Bias Assessment

A key differentiator and methodological imperative of the systematic review is the mandatory assessment of methodological quality, or Risk of Bias (RoB), for all included studies.5 This assessment is essential because the findings of an SR are entirely dependent on the validity of the studies it assesses.5 RoB assessment identifies systematic flaws or limitations in the design, conduct, or analysis of studies that could distort results.5

For systematic reviews designed to underpin clinical practice and develop guidelines, this step is non-negotiable.17 For high-stakes decisions within African health ministries—such as adopting a new national drug protocol or treatment guideline—the confidence in the policy relies directly on the rigor of the RoB assessment. Standardized tools are utilized, tailored to the study design, such as the Cochrane Risk of Bias Tool (RoB 2.0) for randomized trials, the Newcastle-Ottawa Scale (NOS) for non-randomized studies, and GRADE (Grading of Recommendations Assessment, Development, and Evaluation) for assessing the certainty of evidence.4

Stage 5: Data Analysis and Synthesis

The ultimate goal is to synthesize the evidence to provide a definitive, evidence-based answer.23 Where appropriate and when studies are sufficiently homogeneous, quantitative synthesis (meta-analysis) is employed.4 This statistical technique combines data from multiple studies to compute effect sizes and confidence intervals, using specialized software such as R or RevMan.4 Challenges such as heterogeneity and publication bias are statistically addressed through methods like sensitivity analyses and Egger regression.4 For qualitative data or highly heterogeneous quantitative data, qualitative synthesis methods are used to integrate findings.4

Stage 6: Dissemination and Reporting

The findings, which should be sufficiently reliable to inform clinical practice and policy 13, must be reported transparently. Systematic reviews adhere strictly to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines.11

The extensive time (12–24 months) and resources demanded by the SR methodology, requiring sustained, meticulous adherence to protocols, must be supported by robust institutional and financial capacity.11 The high methodological standard of SRs, while necessary for rigor, risks exacerbating challenges such as researcher burnout and intellectual exploitation if not adequately supported in LMICs.24

IV. Mapping and Exploration: The Scoping Review Deep Dive

The scoping review methodology, often guided by the established framework of Arksey and O'Malley (2005) with modern enhancements from the Joanna Briggs Institute (JBI) 7, is structured to provide a comprehensive map of the literature landscape.

A. Step-by-Step Scoping Review Guide (SCR)

Stage 1: Defining the Research Question (PCC Framework) and Protocol Development

Scoping reviews address broad, exploratory questions, often inquiring about the current state of knowledge or the range of outcomes examined in a specific area.26 The question is framed using the PCC (Population, Concept, Context) framework.10 A clear protocol is essential for transparency, defining objectives, inclusion criteria, search strategy, and data charting methods.10 This protocol is typically registered in the Open Science Framework (OSF).11

Stage 2: Iterative Search Strategy (Balancing Feasibility with Breadth)

The search aims to be comprehensive and systematic, but it is fundamentally designed to be inclusive rather than exhaustive, capturing a wide array of sources.7 Unlike SRs, the SCR process is often iterative, allowing researchers to reflexively revise search terms and research questions as familiarity with the literature increases.7 Crucially, the search strategy for SCRs often extends beyond standard peer-reviewed literature to include diverse sources such as policy briefs, organizational reports, and book chapters.14

Stage 3: Study Selection

Study selection involves screening titles, abstracts, and full texts against the established criteria, similar to SRs.26 The selection process benefits from an iterative team approach, which enhances consistency during the screening and data extraction stages.25

Stage 4: Data Charting and Descriptive Summarization

The core analytical step in a scoping review is known as data charting.19 Data charting involves the development and piloting of a form to record key descriptive information from each source, focusing on characteristics such as author, year, study setting, methodology used, and key concepts addressed.11 A crucial methodological difference is that SCRs generally do not extract specific results or assess the risk of bias of the included studies, focusing instead on describing the nature and extent of the evidence.7

When applied to the African context, this descriptive data charting takes on a strategic dimension. By recording details like geographic origin, target populations, and research approaches 27, the charting process functions as a vital research capacity mapping tool. This capability reveals which countries or institutions are leading research in a particular field, identifying institutional investment priorities and helping policymakers fill geographic research voids.

Stage 5: Collating, Summarizing, and Reporting Results

Synthesis in an SCR is primarily descriptive, focusing on summarizing the characteristics of the included studies and identifying thematic trends.6 Results typically include a numerical summary (e.g., volume of studies over time or by location) alongside qualitative thematic analysis.25 Reporting must comply with the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist.11

Stage 6: Consultation Exercise (JBI Recommendation)

The consultation stage, originally optional in early frameworks but highly recommended or effectively required by JBI guidance, involves actively engaging knowledge users or stakeholders.15 This engagement is vital for refining the findings, ensuring they are relevant to policy and practice, and developing actionable implications.25 In African health research protocols, where stakeholder acceptance is critical for implementation 2, this consultation stage should be considered mandatory. It translates the mapped research landscape into policy-relevant action plans, fostering acceptance and utilization of findings among decision-makers.3

V. Application in African Medical and Healthcare Settings (Scenarios and Case Studies)

The decision to conduct a Systematic Review or a Scoping Review in African healthcare is guided by the strategic goal—whether the intent is to define efficacy (SR, PICO) or map the landscape (SCR, PCC).

A. Application Frameworks: PICO (Systematic) vs. PCC (Scoping)

The choice of framework dictates the specificity of the search and the type of evidence synthesized:

Application Frameworks: PICO (Systematic) vs. PCC (Scoping)

B. Case Study 1 (Systematic Review): Determining Intervention Efficacy

Scenario: A Ministry of Health in Kenya is revising its national Tuberculosis (TB) treatment protocols. They need definitive, reliable evidence regarding the effectiveness of a new short-course regimen compared to the standard regimen in adult populations with drug-sensitive TB.

Question Type: Effectiveness/Clinical Efficacy.

Justification for SR: This question requires synthesizing the "best evidence available" to produce practice recommendations.6 A systematic review is mandatory because it requires a rigorous critical appraisal (Risk of Bias assessment) of Randomized Controlled Trials (RCTs) or high-quality observational studies to determine the reliable effect size and safety profile of the intervention. This rigor is necessary to provide the requisite level of confidence for policy adoption and national clinical guideline development.

PICO Example: (P) Adults with drug-sensitive TB in East Africa; (I) New 4-month short-course regimen; (C) Standard 6-month regimen; (O) Treatment success rates and incidence of adverse events.

C. Case Study 2 (Scoping Review): Mapping Research Gaps and Health System History

Scenario: The African Health Observatory (affiliated with WHO AFRO) is launching a major project to document and learn from the history of healthcare delivery on the continent to inform future policy. They need to identify all existing academic and grey literature on health practices and delivery systems from the precolonial era through the Sustainable Development Goals (SDG) era.15

Question Type: Exploratory/Mapping/Conceptual clarification.

Justification for SCR: The aim is explicitly to "identify existing literature" on a broad, complex topic ("African health histories") and map the extent, range, and nature of evidence.15 This goal is exploratory and gap-identifying, requiring the inclusion of diverse sources, including historical texts and reports, which are outside the scope of a typical SR focused on effectiveness. This approach allows the identification of historical factors (context) that have shaped current health outcomes, a necessary prerequisite for effective future planning.15

PCC Example: (P) Health practitioners/systems in Africa; (C) History of health practices and healthcare delivery; (C) From the precolonial era through to the SDG era.15

D. Case Study 3 (Scoping Review): Clarifying Policy Concepts

Scenario: Several African nations are developing unified strategies for Universal Health Coverage (UHC). Policymakers need to understand the various dimensions of inequality in service utilization across the continent, particularly how socioeconomic status, place of residence, and education influence access to reproductive, maternal, newborn, and child health (RMNCH) services.16

Question Type: Conceptual clarification and landscape analysis of inequality stratifiers.

Justification for SCR: The research objective is not to test the effectiveness of one intervention but to clarify how complex concepts—specifically, the dimensions of inequality in service coverage—have been assessed across various African settings.16 When the research focus shifts from 'clinical effectiveness' to 'health system equity or function,' the SCR becomes the preferred methodology because it accommodates the multi-dimensional, descriptive nature of the evidence required for systems change.16 The resulting mapping of evidence, categorized by inequality stratifiers like those in the PROGRESS-Plus framework, is a strategic document used to justify future resource investment and define context-relevant research agendas.15

PCC Example: (P) Populations in Africa; (C) Inequalities in RMNCH service coverage (using stratifiers); (C) Health systems in African countries.16

VI. Strategic Implications and Capacity Building for African Researchers

A. Navigating Resource Constraints: Strategic Choice based on Time and Rigor

The methodological differences between SRs and SCRs translate directly into strategic decisions for research teams in resource-constrained African settings.

The significant time disparity—12 to 24 months for an SR versus 2 to 6 months for an SCR 11—means that an SCR often represents the only viable option when policy formulation requires rapid input.1 If the policy goal is exploratory insight or landscape identification, the SCR is appropriate. Conversely, if the policy necessitates reliable effect sizes for large-scale implementation (high rigor), the SR is the only methodologically sound choice.6

Furthermore, the high methodological bar of SRs, while crucial for rigor, requires sustained institutional and financial capacity. This intersects critically with the realities faced by research staff in LMICs, including precarious employment conditions and inadequate remuneration.24 The long timeline of an SR, if not properly supported, can intensify challenges related to ethical strain and intellectual exploitation, demonstrating that the pursuit of the "gold standard" SR must be balanced against the practical constraints and well-being of the local research workforce.

B. Recommendations for Policy and Practice

1. Prioritize Methodologies Based on Decision Type

For African policymakers, the utility of evidence synthesis methods must be clearly stratified based on the type of decision required:

• Clinical Guidance (Intervention): SRs should be utilized for definitive clinical guidance, such as finalizing drug protocols or treatment regimens. Meticulously conducted SRs and meta-analyses, which undergo mandatory critical appraisal, provide the highest level of evidence required for clinical adoption and practice changes.4 For example, SRs were essential for reviewing key recommendations to improve the implementation of the revitalized Integrated Disease Surveillance and Response (IDSR) system in Africa.22
• System Strategy (Governance, History, Capacity): SCRs should be employed to set long-term research agendas, clarify complex policy concepts (e.g., health literacy, research barriers), and identify critical knowledge gaps for future funding.21 The output of an SCR is a strategic document that justifies resource investment and defines context-relevant research priorities for national and regional bodies.2

2. Mandate Contextual Engagement and Consultation

To maximize evidence uptake and relevance, researchers must adopt a "Knowledge Translation Plus" approach. This involves coupling methodological rigor (adherence to PRISMA/PRISMA-ScR) with strategic reporting designed to overcome local barriers.11 This means presenting results as solutions to political problems, using research for advocacy, and ensuring cultural considerations in presentation.3

Specifically, the consultation exercise (Stage 6 of the JBI-enhanced SCR framework) must be integrated into health policy development processes.25 This step ensures active engagement with knowledge users, guaranteeing that the mapped findings translate into actionable implications for policy or practice, thereby enhancing acceptance and utilization by decision-makers.2

3. Standardize Training and Institutional Support

Given the institutional necessity for both SRs and SCRs, capacity building must be invested in simultaneously at multiple levels, often supported by high-income countries with established skills.12 For African researchers focused on public health and policy relevance, methodologies guided by organizations like the Joanna Briggs Institute (JBI) provide a superior, integrated framework. JBI emphasizes both the rigorous synthesis of the SR and the policy translation goals of the SCR, offering greater institutional consistency than relying solely on disparate models.25 Training should cover the use of appropriate tools for bias assessment and meta-analysis (for SRs) alongside proficiency in the PCC framework and data charting (for SCRs).

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