Success Factors of Medical Crowdfunding Campaigns: Systematic Review

Background: Medical crowdfunding provides opportunities for individuals who lack financial resources to access the health services that they need. Despite the popularity of medical crowdfunding, the current understanding of the success of medical crowdfunding campaigns is fragmented and inadequate. Objective: We aimed to comprehensively investigate which factors lead to the success of medical crowdfunding campaigns. Methods: A search was conducted in PubMed, PsycINFO, Web of Science, ACM Digital Library, and ScienceDirect from 2010 to June 2020. Papers directly and indirectly related to the success of medical crowdfunding campaigns were included. Two reviewers independently extracted information on the success of medical crowdfunding campaigns. Results: Our search yielded 441 articles, of which 13 met the inclusion criteria. Medical crowdfunding is increasingly attracting academic attention, and most studies leverage text analysis as their research methods; however, there is a lack of consensus on the definition of medical crowdfunding among researchers. Four categories of factors that affect the success of medical crowdfunding were identified: platforms, raisers, donors, and campaigns. Conclusions: Although some limitations exist in our systematic review, our study captured and mapped literatures of the success of medical crowdfunding campaigns systematically, which can be used as the basis for future research on this topic.


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Introduction
Crowdfunding has a massive impact on how people access health care services [1].Due to the low requirement and easy set-up of crowdfunding websites, the usage of crowdfunding platforms for health-related fundraising is getting increasingly popular.Crowdfunding platforms like GoFundMe, Kickstarter, and FundRazr are highly utilized for raising funds for a variety of causes, especially medical needs [2].Some of the crowdfunding websites report that medical campaigns rank as their top-grossing category of crowdfunding campaigns [3].The usage of crowdfunding websites for medical expenses is expected to increase by 25% per year [3].Online medical crowdfunding emerged in the post-2008 economic context, during which the economic crunch led to an equally enthusiastic increase in the use and accessibility of social media platforms [4].Medical crowdfunding is donations-based crowdfunding and dedicated to raise money for those who need for medical related costs.Medical crowdfunding could be people's response towards the gaps of national health payment systems [5].Many health needs which are not met by health systems with national insurance coverage are reflected in medical crowdfunding platforms [5][6][7].The lower national insurance coverage is, the greater number of medical crowdfunding projects will appear [8].The benefits of medical crowdfunding include expanding funder participation in health market, improving the access to financial support, drawing funding to neglected health issues and improving social engagement, etc [9].Medical crowdfunding also has been shown to cut down personal bankruptcy numbers [10].Therefore, it is becoming an important make up way to deal with medical financial issues.
Generally, the success of a medical crowdfunding campaign could be defined as the degree which the medical crowdfunding campaign achieve or exceed the goals which are set by fundraisers.
However, despite the convenience and popularity of medical crowdfunding websites, the success rate of medical crowdfunding campaigns on various platforms varies dramatically.For example, in China, campaigns have been reported to achieve just 18% of their goals [11], whereas, in the United States, medical crowdfunding campaigns have achieved over 40% of their goals on average [4].
Overall, only 10% of the medical crowdfunding campaigns have been reported to have reached their fundraising amount targets [4].Some campaigns have reached their fundraising target within a short time, while others have struggled to raise their target amount.Success factors of medical crowdfunding campaigns are factors which lead the campaigns achieve or exceed the goals which are set by fundraisers [12].Thus, they could help improve the success rate of medical crowdfunding campaign, then solving raisers' financial problems related to medical difficulties.Therefore, it is necessary to identify the success factors of medical crowdfunding.
Medical crowdfunding can not only make up for the deficiency of medical security system, but also deal with the problems of limited financing channels and low utilization rate of private capital [1,13,14].Meanwhile, negative consequences of medical crowdfunding have also been increasing and become visible [3,[15][16][17].Factors including low entry barriers to launch and donate to campaigns, the separation between raisers and donators, and anonymity could increase the risk of fraud in medical crowdfunding campaigns [18,19].Therefore, the importance and potential issues of medical crowdfunding has stimulated the interest of academic researchers [20].However, current understanding of medical crowdfunding, especially the success factors is defective.Previous literatures have considered the success factors of medical crowdfunding campaigns, but they all examine the factors from different perspectives by using samples from different countries.For example, Durand et al.only considered textual features as the success factors [12].Thus, current literature on the success factors of medical crowdfunding campaigns is segment and few of them give a holistic understanding of the factors.Therefore, we take a systematic review which systematically search, critically appraise, and synthesize studies, to explore the success factors of medical crowdfunding campaigns [21].The reasons why we use the systematic review, rather than other methods, are as follows: First, the systematic review could provide a comprehensive understanding concerning the success factors of medical crowdfunding campaigns.The comprehensive understanding could be the solid basis for further studies of this topic.Second, the systematic review could limit bias in identifying and rejecting bias by using explicit methods.Third, conclusions of the systematic review could be more reliable and accurate because it summarizes previous literatures systematically.Forth, the systematic review could reduce the delay between scientific discoveries and implementation.At last, the generalizability of findings could be established by the comparison among studies in the systematic review [22].In a word, this study aims to provide a comprehensive investigation into the factors leading to the success of medical crowdfunding campaigns by reviewing previous literature systematically.

Literature search
Five databases including PubMed, PsycINFO, Web of Science, ACM Digital Library, and ScienceDirect were used to search the relevant literature.These databases were chosen because they cover most disciplines that study medical crowdfunding, namely, medicine, information, psychology, global health, computer science, and business economics.For this review, medical crowdfunding was broadly defined.The search terms were "crowdfunding or crowd funding" and "health or disease or illness or medical or hospital or treatment."The database search was conducted on June 8, 2020, and the results were exported to Zotero and organized into folders based on the databases.Then, the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework to document the review process was used.Keywords, synonyms used in this search revolved around two concepts -crowdfunding, and health (see Table 1).The literature retrieval was mainly conducted by two of authors: one had the degree of Doctor of Philosophy and majored in Library and Information Science, while the other author is a master student who also majored in Library and Information Science.They are both the experts of performing the literature search.

Inclusion/exclusion criteria
Articles would be included for analysis when they met the following criteria:

Quality assessment
To ensure the quality of the articles, they were all rated for quality.The McGill Mixed Methods Appraisal Tool (MMAT -Version 2018), designed for complex systematic reviews and suitable for the quality assessment of qualitative, quantitative, or mixed methods, was used to perform the quality rating [23].Since published in 2009, the MMAT has verified its internal reliability, usability, and content validity in several studies.It would judge articles from category of study designs (qualitative research, quantitative research, mixed method research) and methodological (such as randomized controlled, non-randomized and descriptive studies) quality criteria with a series of items.Taking quantitative descriptive studies for example, the items included: (1) Is the sampling strategy relevant to address the quantitative research question?(2) Is the sample representative of the population understudy?(3) Are measurements appropriate?(4) Is there an acceptable response rate?For studies selected for a systematic review, the methodological quality can then be evaluated using the above four criteria.Since the full mark of quality evaluation is 100% (meeting all four criteria), we refer to previous studies and use the evaluation level of 75% (meeting at least three criteria) [24].Lowquality articles (75% or less based on MMAT ratings) were excluded.

Data analysis
The metadata of the articles was extracted and listed in Microsoft Excel including the author region, publication date, data sources, research questions, data collection settings, methods the results, discussions, conclusions and bibliographies.The details of search results and in different stages are presented in following section.To interpret our findings, all the authors discussed how to present our findings systematically.Since the conception of medical crowdfunding is dynamic, we discuss the conception at first.Then we summarize the bibliographic and study information of all included articles.Besides the summary of articles information, we tried to categorize the success factors according to the contextual structures of medical crowdfunding.Since there are three main actors which include platforms, raisers, and donors in medical crowdfunding and they interact with each other based on specific campaigns [25], we could categorize the success factors into four categories: platforms, raisers, donors and campaigns.Because of the heterogeneity of outcome measures adopted in our included studies, it was impracticable to conduct a meta-analysis.Therefore, findings were qualitatively grouped by the four categories.

Search results
According to PRISMA, we document the result of review process in this section.A total of 441 articles were identified from the five databases.After removing duplicate articles, a total of 395 related articles were screened out.Titles and abstracts were screened by two authors separately; however, when a different opinion was given, a third author would be involved to mediate the discussion and reach an agreement.After screening and based on the inclusion/exclusion criteria, a total of 27 potentially relevant articles were chosen for full-text review.In the full-text review, we excluded the articles which do not discuss or examine specific success factors of medical Hou et al crowdfunding campaigns.After full-text review was performed, 19 papers were selected for more indepth analysis.Finally, after all the stages of quality assessment, 13 articles were chosen for this review.The whole process is shown in Figure 1.

Description of the studies
Table 2 summarizes the features and discoveries for each of the 13 studies included.9 out of the 13 studies relied entirely on crowdfunding websites such as GoFundMe.There were four main analytical methods used: text analysis, regression analysis, semi-structured interviews, and exploratory spatial analysis.Of all the research methods, text analysis is the most used one, with 4 studies using only text analysis and two studies using text analysis partially.Of the 13 included studies, 6 studies are directly related to the success of medical crowdfunding, with the remaining 7 being indirectly related.The number of publications is steadily increasing over time, which indicates that this field is getting more and more attention from scholars and practitioners because of the particularity of medical crowdfunding.Most studies included in this review are from developed countries, with the largest source of articles being the United States from which almost half of the articles included in this review, followed by Canada.

Platforms
For platforms, the factors influencing the success of medical crowdfunding campaigns can be divided into two aspects: technical and social.The details of success factors related to platforms are summarized in Table 3.
The technical aspect of platforms reflects the functionality of medical crowdfunding platform in terms of platform audit, platform availability, platform types and platform design.Platform audit is reviewing the campaigns by platforms and could impact donor's decision on donation.The review of the campaigns by crowdfunding platforms is closely related to the eventual success of the crowdfunding campaigns [2].Besides, platform availability is the degree to which medical crowdfunding platform is available to their users.The availability of the platform will positively affect the donor's incentive, and thus the project funding results [35].In addition, the types of platform could also have impacts on fundraising.Platforms with more extensive publicity are more popular than specialized, smaller platforms [8].Finally, the design of the platform would decide donors' experience of using the medical crowdfunding, then their supportive behaviors and word of mouth behaviors which would help fundraisers attract the attention of potential donors [35].
The social aspect of crowdfunding platforms reflects the social interaction inside and outside the platforms in terms of total campaign number, total fundraising amount, total donor number and total and partnership with traditional media.The more categories and campaigns the platform contain, the more potential donors it attracts, and then the greater the probability of receiving donations will be [36].Meanwhile, if the total amount of fundraising on the platform is higher, fundraisers who publish campaigns on the platform would have more confidence to raise money they want [30].
Moreover, the total number of donors can represent the amount which could be raised to some extent [37].The number of registered institutions in the platform also reflects the platform's position within the industry and accessible resources for campaigns in the platform [3].Finally, the partnership with traditional media would make the campaigns have opportunities to access mass media and their audiences, then increase the number of potential donors.More interactions could help build more social capital and have higher fundraising possibilities [38].The larger potential donor base is, the higher possibility of accomplishing the target amount of campaigns is [9].

The review of campaigns by crowdfunding platforms
would affect donor's decision.

Platform availability
The degree to which the platform is available to users.
The availability of the platform would affect donor incentives and thus campaign funding results.

Aleksina et al. [30] Platform types
Whether the platform is specialized or general.
Platforms with more extensive publicity are more popular than specialized, smaller platforms.

Bassani et al. [8]
Aleksina et al. [30] Platform design The design elements of the platform including search engine, lists, webpage, etc.
Platform design would determine donors' experience, then their donation behavior.The more categories and number of projects, the more potential donors would visit the platform.

Aleksina et al. [30]
Total fundraising amount The total money raised in the platform.
The more total amount raised on the platform represents the higher recognition and acceptance of the platform.

Aleksina et al. [30]
Total donor number Total number of donors appears in the platform.
The more donors in the platform, the more possibility to get fundraising.

Aleksina et al. [30]
Barcelos and Budge [34] Partnership with traditional media The platform collaborates with traditional media to disseminate the information of its campaigns.
Traditional media could help medical crowdfunding campaigns get more donors.

Raisers
The influencing factors from raisers can be analyzed in terms of three aspects: demographic, individual characteristics, and social.The details of success factors related to raisers are summarized in Table 4.It should be noted that the raisers refer to the beneficiary.
The demographic characteristics of the raisers include age, nationality, and geographical locations, etc.It is shown that younger individuals were more likely to succeed in health crowdfunding [34].Meanwhile, the geographical locations of raisers are also an important factor affecting the success rate of campaigns.Raisers in remote areas are less successful in raising money, while raisers in affluent areas where there are more social resources are more likely to succeed in raising money [36].Moreover, raisers with higher education level and higher income are shown to be more likely to attract the attention of potential donors and thus get donations [27].
As to individual characteristics, prior literature has showed that the campaigners of successful crowdfunding campaigns had better media literacy and medical literacy [4].Raisers with high media literacy are more likely to spread their message across social media platforms and attract potential donors.Raisers with higher medical literacy are more likely to deliver accurate disease-related and healthcare information [4].In addition, once raisers are perceived to be deservingness to be donated, their campaigns would attract many donors and succeed in raising funds [35].
Social factors related to raisers contain personal connections, stakeholder support, professional organization support and individual prestige.Raisers' personal connections establish social networks and could share links of medical crowdfunding campaigns in their social networks, which allowed more potential donors to see the information of the campaigns, thus obtaining more funds.
Meanwhile, gaining the support of stakeholders and professional organizations makes it easier to successfully raise funds for medical crowdfunding campaigns [33].Finally, if raisers have high individual prestige, they are more likely to gain trust and support from donors in social networks [32].The prestige of raisers could serve as the signal of the credibility and success of their campaigns.

Donors
The determinants of the donors' intention to donate can be mainly divided into the demographic and individual characteristics.The details of success factors related to donors are summarized in Table 5.
Prior literature has examined the effect of demographics of donors and found that donors' gender [39,40], age [31], education level [31], income [31]and geographical location [30] had significant effects on donation behavior.Younger donors have more willingness to donate [34].
Besides, other studies also indicated that people with higher education and income level were more likely to donate [41].Meanwhile, donors were more willing to contribute to crowdfunding campaigns in or near their own regions in medical crowdfunding platforms [30].Therefore, there exists geographic inequity which are compounded by the social, technological, cultural issues.[4].
Individual characteristics studied include cognitive state and social returns.Cognitive state is donors' state invoked by reading campaigns' description [12].If donors may feel threatened by reading the negative campaign descriptions, they would hesitate to donate.While when donors aware the importance and urgency of the raiser's medical crowdfunding campaigns, they would have high willingness to donate [42].Besides, the social return is a major intrinsic motivation for individuals or groups to donate to medical crowdfunding campaigns [4].Relevant studies have demonstrated that people with prosocial values, participate more in charitable activities, and donate more willingly [43].Donors with this intrinsic motivation would have high willingness to donate.Durand et al. [12] Social returns The intrinsic motivation of donors to give back to society The more returns to the society from the donation, the more possibility donors would donate.

Campaigns
For campaigns, the success factors can be divided into two aspects: the format and the content.
The details of success factors related to donors are summarized in Table 6.
As to format, related factors of medical crowdfunding campaigns include goal amount, campaign description length, third-person description and social media sharing.Towards goal amount, studies have found that when a campaign was close to its fundraising goal, it would stimulate donors' donation behavior and increase the possibility of project success [39,44].
Meanwhile, longer campaign description length and higher goal amount were significantly associated with amount raised [12].In addition, third-person description perspective can convey a patient's positive qualities which would be not acceptable in the first person perspective due to the testimonial effect [12].Finally, it is critical for successful crowdfunding campaigns to leverage social media [30].The amount raised was strongly correlated with updates and shares in social media [12].
One additional tweet or retweet with more personal comments could enhance the probability of success of crowdfunding campaigns [30].
Regarding content aspect, success factors about campaigns contain the narrative strategy, authenticity, credibility, easy-to understand message, giving back, and depth of need.Illness narrative represents the personal story and illness experience that patients are sharing verbally or in writing [28].The narration style is found that not only affected the efficiency of the dissemination of health information, but also impacted heavily on the campaigners' cognitions, attitudes, and behaviors [28].
Authenticity which could be conveyed by pictures of raisers who depicts their medical conditions would increase the possibility of donation behaviors.Meanwhile, it has been shown that funding would be more accessible when the presented narratives of campaigns were credible [45].To demonstrate the credibility of campaigns, many methods could be used including collective endorsements, presenting details of external financial support, displaying off-site verification details (of ailment, incident, & treatment), fundraiser and beneficiary identity verification, and using a popular and trusted platform within a large scale [29].
Besides, easy-to-understand information in the campaign description gives potential donors who read the information a clear picture of the campaign [33].In addition, portraying the beneficiary as someone who selflessly gives back to society will not only help establish the positive image of raisers, but also inspire the donors themselves [32].Finally, it has shown that a patient who is in urgent need of funds because of disease or treatment will help to obtain donations from potential donors [32].The objective amount of money the campaign plan to raise.
Goal amount has a positive impact on campaign success.

Durand et al. [12]
Aleksina et al. [30] Campaign description length The length of the medical crowdfunding campaign description.
Campaign escription length has a positive impact on campaign success Durand et al. [12] Third-person description perspective The narrative perspective of the campaign is the third person.
The third person perspective makes the story more objective and realistic, which makes it more convincing.
Durand et al. [12] Social media sharing The number of shares and likes of campaigns in social media which connect to the platform.
The more shares and likes potential donors see, the more likely they are to donate.

Barcelos
and Budge [34] Content Narrative strategy The way that raisers describe their illness and ask for donations.Easy-to understand message The degree to which the message is easily understood.
Easy-to-understand information helps potential donors get a sense of the raisers' intention, which in turn helps donors make decisions.

Koole et al. [33]
Giving back Portraying the raisers as someone who selflessly gives back to society.
The past efforts of the raisers on behalf of others were used as a rationale for the potential donors to contribute to the crowdfunding campaign.

Snyder et al. [32]
Deep of need Campaign content reflects the urgent need of funds to solve health problems.
The urgency of need for help would determine the success of raising money.

Principle findings
By investigating 13 studies included, the key factors of successful medical crowdfunding campaigns were extracted.On this basis, we conducted a more in-depth review and provide a comprehensive understanding of the factors that influence successful campaigns.We find the success factors of medical crowdfunding campaigns could be divided into four categories: platforms, raisers, donors and campaigns based on included 13 studies.The success factors involve the main actors in the whole medical crowdfunding campaigns.Towards the four factor categories, we find campaign factors are more frequently studied than other factors.At the same time, the platform factors also play an important role in medical crowdfunding than other factors [46].This implies that platforms are important in linking donors and raisers [47].In addition, among the four categories of success factors of medical crowdfunding, there are relatively few studies related to donors and future studies could pay more attention to this area.Despite the widespread use of medical crowdfunding, to the best of our knowledge, this is the first systematic review that examines the factors that lead to successful medical crowdfunding campaigns.This review provides a summary of the conception of medical crowdfunding and successful factors of campaigns.

Implications
Our review reveals the research trends of the success of medical crowdfunding campaigns.
According to our review, more studies with more diverse methods and theoretical backgrounds about the success of medical crowdfunding campaigns would be published.The proposed categories of literatures provide a useful framework to understand the success of medical crowdfunding campaigns.The four categories: platforms, raisers, donors, campaigns could be the four research perspectives to understand the success of medical crowdfunding campaigns.However, several research opportunities are uncovered by our systematical review.For example, interactive effects of the four categories could be an opportunity to better understand the success of medical crowdfunding campaigns.
The four categories of successful factors that are actors in medical crowdfunding can interact with each other [7,48,49].First, raisers register in the platforms to initiate campaigns to raise money for medical expenses with illness narratives, which include fundraising goals, fundraising time and fundraising events, etc.Secondly, the medical crowdfunding platforms do a preliminary review and then release those campaigns to the platforms.Third, managers of the platforms give the fund raised from the public to the campaigners after the relevant processing charges are collected.Finally, a crowdfunding campaign is a success after all the above processes are were successfully implemented.
In addition, our study also provides some empirical implications.First, theoretical perspectives could be applied or built for understanding the success factors of medical crowdfunding.Few of included articles take strong theoretical perspective to help analyze, explain and predict the success factors of medical crowdfunding and convey few theoretical implications.Therefore, it is necessary to apply more theories to better understand this topic.Second, more methods or mixed methods could be employed to investigate this topic.Although text analysis dominates current included articles, more insights could be explored by applied other methods or mixed methods which possess different advantages to study the success factors of medical crowdfunding campaigns.Third, data could be collected from multi-sources.In current literature, data was collected from single sources which may make method suffer from inherent biases.Therefore, collecting data from multi-sources could provide multiple validation to our research models and methods.

( 1 )
Articles must have been published within conference proceedings or journals.Articles without details of research designs and results were excluded; (2) Articles should focus on the success of medical crowdfunding and/or included other factors related to the success of crowdfunding (e.g., narrative strategies and ethical factors of medical crowdfunding); (3) Articles must be written in English and published between 2010 and 2020 because medical crowdfunding emerged in the post-2008.Articles which do not meet above criteria were excluded.

Figure 1
Figure 1 Summary of literature search and study selection process The conceptions of medical crowdfunding Through the evaluation of the included articles, the factors affecting the success of medical crowdfunding campaigns can be summarized into four categories according to actors in the medical crowdfunding context: (a) platforms; (b) raisers; (c) donors; (d) campaigns.The influencing factors for the success of medical crowdfunding campaigns are discussed in detail with reference to the following four aspects.
literatures included in our review contain information from different sources about medical crowdfunding, quality of our review results may be impacted.Future research could ensure the quality by developing some guidelines of documentation.At last, other categories of success factors of medical crowdfunding campaigns could be considered.Besides the four categories of success factors discussed in our review, other categories of factors like health systems or national economic status could be considered.Conclusion This review explores the factors involved in successful medical crowdfunding campaigns by examining four categories: (a) platforms; (b) raisers; (c) donors; (d) campaigns.This review has contributed to the literature on medical crowdfunding by summarizing successful factors of medical crowdfunding systematically.This review could be the basis for both future research and medical crowdfunding campaigns.With the development of medical crowdfunding, more studies about different factors within and without the four categories are expected in the future.

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Table 3
Factors influencing the success of medical crowdfunding campaigns from the platforms

Table 4
Factors influencing the success of medical crowdfunding campaigns from the raisers

Table 5
Factors influencing the success of medical crowdfunding campaigns from donors

Table 6
Factors influencing the success of medical crowdfunding campaigns from campaigns