health education literature review

Research article
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Published: 25 January 2012

Health literacy and public health: A systematic review and integration of definitions and models

Kristine Sørensen 1 ,
Stephan Van den Broucke 2 ,
James Fullam 3 ,
Gerardine Doyle 3 ,
Jürgen Pelikan 4 ,
Zofia Slonska 5 ,
Helmut Brand 1 &

(HLS-EU) Consortium Health Literacy Project European

BMC Public Health volume 12 , Article number: 80 ( 2012 ) Cite this article

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Health literacy concerns the knowledge and competences of persons to meet the complex demands of health in modern society. Although its importance is increasingly recognised, there is no consensus about the definition of health literacy or about its conceptual dimensions, which limits the possibilities for measurement and comparison. The aim of the study is to review definitions and models on health literacy to develop an integrated definition and conceptual model capturing the most comprehensive evidence-based dimensions of health literacy.

A systematic literature review was performed to identify definitions and conceptual frameworks of health literacy. A content analysis of the definitions and conceptual frameworks was carried out to identify the central dimensions of health literacy and develop an integrated model.

The review resulted in 17 definitions of health literacy and 12 conceptual models. Based on the content analysis, an integrative conceptual model was developed containing 12 dimensions referring to the knowledge, motivation and competencies of accessing, understanding, appraising and applying health-related information within the healthcare, disease prevention and health promotion setting, respectively.

Conclusions

Based upon this review, a model is proposed integrating medical and public health views of health literacy. The model can serve as a basis for developing health literacy enhancing interventions and provide a conceptual basis for the development and validation of measurement tools, capturing the different dimensions of health literacy within the healthcare, disease prevention and health promotion settings.

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Health literacy is a term introduced in the 1970s [ 1 ] and of increasing importance in public health and healthcare. It is concerned with the capacities of people to meet the complex demands of health in a modern society [ 2 ]. Health literate means placing one's own health and that of one's family and community into context, understanding which factors are influencing it, and knowing how to address them. An individual with an adequate level of health literacy has the ability to take responsibility for one's own health as well as one's family health and community health [ 3 ].

It is important to distinguish health literacy from literacy in general. According to the United Nation Education, Science and Culture Organization (UNESCO) during its history in English, the word 'literate' mostly meant to be 'familiar with literature' or in general terms 'well educated, learned'. While maintaining its broader meaning of being knowledgeable or educated in a particular area, during the late nineteenth century it has also come to refer to the abilities to read and write text. In recent years four understandings of literacy have appeared from the debate of the notion: 1) Literacy as an autonomous set of skills; 2) literacy as applied, practiced and situated; 3) literacy as a learning process; and 4) literacy as text. The focus is furthermore broadening so that literacy is not only referring to individual transformation, but also to contextual and societal transformation in terms of linking health literacy to economic growth and socio-cultural and political change [ 4 ].

The same development can be traced in the realm of health literacy. For some time most emphasis was given to health literacy as the ability to handle words and numbers in a medical context, and in recent years the concept is broadening to also understanding health literacy as involving the simultaneous use of a more complex and interconnected set of abilities, such as reading and acting upon written health information, communicating needs to health professionals, and understanding health instructions [ 5 ]. American studies in the 1990s linked literacy to health, showing an association between low literacy and decreased medication adherence, knowledge of disease and self-care management skills [ 6 ]. The 2003 National Assessment of Adult Literacy (NAAL), which measured the English literacy of American adults (people age 16 and older) included questions related to health, and revealed the consequences of limited literacy on health and healthcare [ 7 ].

A report from the Institute of Medicine indicates that nearly half of the American adult population may have difficulties in acting on health information [ 8 ]. This finding has been referred to as the "health literacy epidemic" [ 9 ]. In response, measures have been taken to ensure better health communication through establishing health literacy guidelines [ 10 ], and a trans-disciplinary approach has been encouraged to improve health literacy [ 11 ]. To support this approach, the American Medical Association recommends four areas for research: health literacy screening; improving communication with low-literacy patients; costs and outcomes of poor health literacy; and causal pathways of how poor health literacy influences health [ 12 , 13 ]. The research literature on health literacy has expanded exponentially, with nearly 5,000 PubMed-listed publications to date (Primo November 2011), the majority of which have been published since 2005 [ 5 , 14 ] and is evident that health literacy is being explored within different disciplines and with different approaches, e.g. looking at the role of health educators in promoting health literacy [ 15 ]; public health literacy for lawyers [ 16 ], health communication [ 17 ], the prevalence of limited health literacy [ 18 ], and health literacy as an empowerment tool for low-income mothers [ 19 ].

While until recently the interest in health literacy was mainly concentrated in the United States and Canada, it has become more internationalized over the past decade [ 20 ]. Research on health literacy has taken place in e.g. Australia [ 21 , 22 ], Korea [ 23 ], Japan [ 24 ], the UK [ 25 ], the Netherlands [ 26 ], and Switzerland [ 27 ]. Although the EU produced less than a third of the global research on health literacy between 1991 and 2005 [ 28 , 29 ], the importance of the issue is increasingly recognized in European health policies. As a case in point, health literacy is explicitly mentioned as an area of priority action in the European Commission's Health Strategy 2008-2013 [ 30 ]. It is linked to the core value of citizen empowerment, and the priority actions proposed by the European Commission include the promotion of health literacy programs for different age groups.

However, with the proliferation of health literacy research and policy measures, it becomes clear that there is no unanimously accepted definition of the concept. Moreover, the constituent dimensions of health literacy remain disputed, and attempts to operationalize the concept vary widely in scope, method and quality. As a result, it is very difficult to compare findings with regard to health literacy emerging from research in different countries.

The current article aims to address this issue by offering a systematic review of existing definitions and concepts of health literacy as reported in the international literature, by identifying the central health literacy dimensions, the target group as well as antecedents and consequences if explained. in order to develop an integrated definition and conceptual model capturing the most comprehensive evidence-based dimensions of health literacy.

A systematic review in Medline, Pubmed and Web of Science was performed by two independent research teams in autumn 2009 and spring 2010 and the results compared and combined to obtain information regarding two research questions: (1) How is health literacy defined? and (2) How can health literacy be conceptualized? To retrieve studies, 17 keywords (definition, model, concept, dimension, framework, conceptual framework, theory, analysis, qualitative, quantitative, competence, skill, "public health", communication, information, functional, critical) were combined (using the Boolean operator and ) with the search terms "health literacy", "health competence", and health competence (without quotes). Combinations of the keywords with health literacy (without quotes) produced a list of studies that was too wide for the purpose of this study, and therefore not used for the review. From the resulting list, studies were selected for inclusion in the review on the basis of their abstracts. Eligible studies were included which met the following inclusion criteria: (1) written in English; (2) concerned with health literacy in a developed country; and (3) offering relevant content with regard to the definition or conceptualization of health literacy, or a combination of these issues.

The eligible literature was scanned for definitions, and a content analysis was performed in three steps: Firstly, the definitions were coded and condensed by two research teams working independently. Secondly the analysis was discussed with a panel of health experts from the European Health Literacy Consortium. In a third step, the feedback was elaborated by the original research team and integrated in a final analysis yielding a condensed 'all-inclusive' definition of health literacy capturing the different meanings and dimensions presented in the literature. In addition, an overview of all models from the eligible literature was conducted, the models were compared according to dimensions, target groups and antecedents as well as consequences if explained, and as a result a new conceptual model was drafted capturing the most comprehensive core dimensions of health literacy identified as well as its antecedents and consequences.

The combination of the key words with the three search terms resulted in the initial identification of 170 publications. Additional publications were found by reference tracking and included in the review. Based on the application of the inclusion criteria to the abstracts, 19 publications were retrieved which explicitly dealt with the definition of health literacy, and 12 with conceptual frameworks of health literacy.

Definitions of health literacy

From the 19 publications focusing specifically on definitions of health literacy 17 explicit definitions could be derived (Table 1 ). Of these definitions, the ones by the American Medical Association [ 12 ], the Institute of Medicine [ 8 ] and WHO [ 31 ] are cited most frequently in the eligible literature. A shared characteristic of these definitions is their focus on individual skills to obtain, process and understand health information and services necessary to make appropriate health decisions. However, recent discussions on the role of health literacy highlight the importance of moving beyond an individual focus, and of considering health literacy as an interaction between the demands of health systems and the skills of individuals. In fact the Institute of Medicine report already alluded that "health literacy is a shared function of social and individual factors, which emerges from the interaction of the skills of individuals and the demands of social systems" [ 8 ]. More recently, Kwan [ 32 ] and Pleasant [ 33 ] underscored the importance of skills and abilities on the part of all parties involved in communication and decisions about health, including patients, providers, health educators, and lay people. This broader view is presented in the definition proposed by Zarcadoolas, Pleasant and Greer [ 34 ], who state that a health literate person is able to apply health concepts and information to novel situations, and to participate in ongoing public and private dialogues about health, medicine, scientific knowledge, and cultural beliefs. Freedman and her collegues [ 35 ] argue that the medical perspective on factors influencing people's health should be shifted towards a societal level, and that a distinction must be made between public and individual health literacy. Public health literacy can be found when the conceptual foundations of health literacy are in place in a group or community.

The content analysis on the definitions yielded six clusters representing: (1) competence, skills, abilities; (2) actions; (3) information and resources; (4) objective; (5) context; and (6) time as outlined in Table 2 . Accordingly each cluster was carefully examined, discussed and condensed by the research team and the resulting chosen terms and notions were combined to yield a new 'all inclusive' comprehensive definition capturing the essence of the 17 definitions identified in the literature:

Health literacy is linked to literacy and entails people's knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course .

This definition encompasses the public health perspective and can easily be specified to accommodate an individual approach by substituting the three domains of health "healthcare, disease prevention and health promotion" with "being ill, being at risk and staying healthy".

Concepts of health literacy

Table 3 lists the publications which provide a conceptual model of health literacy. From this overview, two issues become apparent. Firstly, health literacy is a multidimensional concept and consists of different components. Secondly, most conceptual models not only consider the key components of health literacy, but also identify the individual and system-level factors that influence a person's level of health literacy, as well as the pathways that link health literacy to health outcomes.

Dimensions of health literacy

The distinction between medical and public health literacy [ 35 ] is reflected in the identification of different dimensions. Within the definition of health literacy as individual capacities, the Institute of Medicine [ 8 ] consider cultural and conceptual knowledge, listening, speaking, arithmetical, writing, and reading skills as the main components of health literacy. Speros [ 48 ] also identifies reading and numeracy skills as the defining attributes, but adds comprehension, the capacity to use health information in decision making, and successful functioning in the role of healthcare consumer as dimensions. Baker [ 49 ] divides health literacy into health related print literacy and health related oral literacy, while Paashe-Orlow and Wolf [ 40 ] distinguish between listening, verbal fluency, memory span and navigation. Lee et al. [ 47 ] identify four interrelated factors: (1) disease and self-care knowledge; (2) health risk behavior; (3) preventive care and physician visits; and (4) compliance with medication. While these defining elements of health literacy vary considerably they all concern cognitive capabilities, skills and behaviors which reflect an individual's capacity to function in the role of a patient within the healthcare system.

Proponents of the population health literacy view, on the other hand, extend the concept to include dimensions which go beyond individual competences and the medical context. The prototypical model is that of Nutbeam [ 36 ], which distinguishes between three typologies of health literacy: (1) Functional health literacy refers to the basic skills in reading and writing that are necessary to function effectively in everyday situations, broadly comparable with the content of "medical" health literacy referred to above; (2) Interactive health literacy refers to more advanced cognitive and literacy skills which, together with social skills, can be used to actively participate in everyday situations, extract information and derive meaning from different forms of communication, and apply this to changing circumstance; and (3) Critical health literacy refers to more advanced cognitive skills which, together with social skills, can be applied to critically analyze information and use this to exert greater control over life events and situations. The different typologies represent levels of knowledge and skills that progressively support greater autonomy and personal empowerment in health related decision-making, as well as engagement with a wider range of health knowledge that extends from personal health management to the social determinants of health [ 52 ]. Manganello [ 50 ] adds media literacy as the ability to critically evaluate media messages. Zarcadoolas et al. [ 38 ] distinguish between fundamental literacy (skills and strategies involved in reading, speaking, writing and interpreting numbers); science literacy (the levels of competence with science and technology); civic literacy (abilities that enable citizens to become aware of public issues and become involved in the decision-making process); and cultural literacy (the ability to recognize and use collective beliefs, customs, world-view and social identity in order to interpret and act on health information). In a similar vein, Freedman et al. [ 35 ] identify three dimensions of public health literacy, each of which involves corresponding competences: (1) Conceptual foundations includes the basic knowledge and information needed to understand and take action on public health concerns; individuals and groups should be able to discuss core public health concepts, public health constructs and ecologic perspectives. (2) Critical skills relates to the skills necessary to obtain, process, evaluate, and act upon information that is needed to make public health decisions that benefit the community; an individual or group should be able to obtain, evaluate, and utilize public health information, identify public health aspects of personal and community concerns, and access who is naming and framing public health problems and solutions. (3) Civic orientation includes the skills and resources necessary to address health concerns through civic engagement; an individual or group should be able to articulate the uneven distribution of burdens and benefits of the society, evaluate who benefits and who is harmed by public health efforts, communicate current public health problems, and address public health problems through civic action, leadership, and dialogue. Mancuso [ 43 ] emphasizes that health literacy is a process that evolves over a person's lifetime and identify the attributes of health literacy to be capacity, comprehension and communication. (1) The Capacity skills related to health literacy include gathering, analyzing, and evaluating health information for credibility and quality, working together, managing resources, seeking guidance and support, developing and expressing a sense of self, creating and pursuing a vision and goals, and keeping pace with change. Oral language skills are also considered essential. Social skills and credentials such as reading, listening, analytical, decision-making, and numerical abilities are important as well to advocate for oneself, to act on health information, and to negotiate and navigate within the health-care system. (2) Comprehension is a complex process based on the effective interaction of logic, language, and experience and is crucial to the accurate interpretation of a myriad of information that is provided to the modern patient, such as discharge instructions, consent forms, patient education materials, and medication directions. (3) Communication is how thoughts, messages or information are exchanged through speech, signals, writing or behavior. Communication involves inputs, decoding, encoding output, and feedback. Essential communication skills are reading with understanding, conveying ideas in writing, speaking so others can understand, listening actively, and observing critically.

In conclusion, the range of factors that are considered as key components of health literacy is extensive, and there is a wide variation between conceptual models. However, this diversity of views can to a large extent be reduced to two dimensions, notably the core qualities of health literacy (e.g., basic or functional, interactive, and critical health literacy), and its scope and area of application (e.g., as a patient in healthcare, as a consumer at the market, as a citizen in the political arena, or as a member of the audience in relation to the media).

Antecedents and consequences of health literacy

Apart from the dimensions of health literacy, the conceptual models summarized in Table 3 also give the main antecedents and consequences of health literacy outlined in the literature.

For the antecedents , most authors refer to demographic, psychosocial, and cultural factors, as well as to more proximal factors such as general literacy, individual characteristics and prior experience with illness and the healthcare system. Among the demographic and social factors which impact on health literacy one notes socioeconomic status, occupation, employment, income, social support, culture and language [ 40 ], environmental and political forces [ 35 ], and media use [ 50 ]. In addition, peer and parental influences may impact on the health literacy of adolescents. In terms of personal characteristics, health literacy is predicted by age, race, gender and cultural background [ 50 ]; as well as by competences such as vision, hearing, verbal ability, memory and reasoning [ 40 ], physical abilities and social skills [ 50 ], and meta-cognitive skills associated with reading, comprehension, and numeracy [ 4 , 48 , 50 ]. The latter refers to the level of overall literacy, defined as the capacity to use printed and written information to function in society, achieve one's goals, and develop one's knowledge and potential. Finally, Nutbeam [ 36 ] points out that health literacy is also a result of health promotion actions such as education, social mobilization and advocacy.

In terms of the consequences , a number of researchers pointed out that health literacy leads to improved self-reported health status, lower healthcare costs, increased health knowledge, shorter hospitalization, and less frequent use of healthcare services [ 43 , 48 , 50 , 53 ]. According to Baker [ 49 ], these better health outcomes are caused by the acquisition of new knowledge, more positive attitudes, greater self-efficacy, and positive health behaviors associated with higher health literacy. Paashe-Orlow and Wolf [ 40 ] posit that health literacy influences three main factors which in turn have an impact on health outcomes: (1) navigation skills, self-efficacy and perceived barriers influence the access and utilization of healthcare; (2) knowledge, beliefs and participation in decision-making influence patient/provider interactions; and (3) motivation, problem-solving, self-efficacy, and knowledge and skills influence self care. The relationship of health literacy to health outcomes according to these authors must be conceived as a step function with a threshold effect, rather than in a simple linear fashion. People generally exist within a web of social relationships; and below a certain level of function, much of the day-to-day detail of chronic disease management often needs to be facilitated by others. While the interaction between health literacy and social support is likely to have complicated and subtle implications, the health impact of social effects has not been fully elucidated in the context of health literacy [ 54 ].

Nutbeam [ 36 ] distinguishes between individual and community or social benefits of health literacy. In terms of individual benefits, functional health literacy leads to an improved knowledge of risks and health services, and compliance with prescribed actions; interactive health literacy to an improved capacity to act independently, an improved motivation and more self-confidence; and critical health literacy to improved individual resilience to social and economic adversity. In terms of community and social benefits, functional health literacy increases the participation in population health programs; interactive health literacy enhances the capacity to influence social norms and interact with social groups; and critical health literacy improves community empowerment and enhances the capacity to act on social and economic determinants of health. Nutbeam's conceptual framework has been applied in case studies focusing on topics of diarrhea [ 55 ], self-management in diabetes [ 56 ] and health promoting schools [ 57 ].

Ratzan [ 58 ] links health literacy in the community to the concept of social capital, arguing that health literate people live longer and have stronger incentives to invest in developing their own and their children's knowledge and skills. Healthier populations tend to have higher labor market productivity contributing to, rather than withdrawing from, pension schemes. Similarly, healthier people use the health system less, and coupled with education and cognitive function, appropriately demand fewer health services.

An integrated conceptual model of health literacy

Whereas a number of conceptual models of health literacy have been presented in the literature, none of these can be regarded as sufficiently comprehensive to line up with the evolving health literacy definitions and with the competencies they imply [ 59 ]. This is probably due to the fact that attempts to conceptualize health literacy have thus far failed to integrate the existing knowledge encompassing different perspectives on health literacy. Firstly, most of the existing conceptual models are not sufficiently grounded in theory in terms of the notions and concepts included. Secondly, very few models have integrated the components included in "medical" and "public health" literacy models. The only models which explicitly try to bridge the difference between both views are Nutbeam's [ 36 ] and Manganello's [ 50 ], whose dimension of functional literacy corresponds with the cognitive skills of medical health literacy. Thirdly, while acknowledging that health literacy entails different dimensions, the majority of the existing models are rather static and do not explicitly account for the fact that health literacy is also a process, which involves the consecutive steps of accessing, understanding, processing and communicating information. Fourthly, while most conceptual models identify the factors that influence health literacy and mention its impact on health service use, health costs and health outcomes, the pathways linking health literacy to its antecedents and consequences are not very clear. Researchers could link conceptual models of health literacy more explicitly to established health promotion theories and models [ 59 ]. Finally, very few conceptual models of health literacy have been empirically validated. To address these shortcomings, we propose an integrated model of health literacy which captures the main dimensions of the existing conceptual models reviewed above (Figure 1 ).

Integrated model of health literacy--see separate file .

The model combines the qualities of a conceptual model outlining the main dimensions of health literacy (represented in the concentric oval shape in the middle of Figure 1 ), and of a logical model showing the proximal and distal factors which impact on health literacy, as well as the pathways linking health literacy to health outcomes.

The core of the model shows the competencies related to the process of accessing, understanding, appraising and applying health-related information. According to the 'all inclusive' definition this process requires four types of competencies: (1) Access refers to the ability to seek, find and obtain health information; (2) Understand refers to the ability to comprehend the health information that is accessed; (3) Appraise describes the ability to interpret, filter, judge and evaluate the health information that has been accessed; and (4) Apply refers to the ability to communicate and use the information to make a decision to maintain and improve health. Each of these competences represents a crucial dimension of health literacy, requires specific cognitive qualities and depends on the quality of the information provided [ 60 ]: obtaining and accessing health information depends on understanding, timing and trustworthiness; understanding the information depends on expectations, perceived utility, individualization of outcomes, and interpretation of causalities; processing and appraisal of the information depends on the complexity, jargon and partial understandings of the information; and effective communication depends on comprehension. The competences also incorporate the qualities of functional, interactive and critical health literacy as proposed by Nutbeam [ 36 ].

This process generates knowledge and skills which enable a person to navigate three domains of the health continuum: being ill or as a patient in the healthcare setting, as a person at risk of disease in the disease prevention system, and as a citizen in relation to the health promotion efforts in the community, the work place, the educational system, the political arena and the market place. Going through the steps of the health literacy process in each of these three domains equips people to take control over their health by applying their general literacy and numerical skills as well as their specific health literacy skills to acquire the necessary information, understanding this information, critically analyzing and appraising it, and acting independently to engage in actions overcoming personal, structural, social and economical barriers to health. As contextual demands change over time, and the capacity to navigate the health system depends on cognitive and psychosocial development as well as on previous and current experiences, the skills and competencies of health literacy develop during the life course and are linked to life long learning.

The frameworks associated with the three domains represent a progression from an individual towards a population perspective. As such, the model integrates the "medical" conceptualization of health literacy with the broader "public health" perspective. Placing greater emphasis on heath literacy outside of healthcare settings has the potential to impact on preventative health and reduce pressures on health systems.

The combination of the four dimensions referring to health information processing with the three levels of domains yields a matrix with 12 dimensions of health literacy as illustrated in Table 4 .

Four dimensions of health literacy in the domain of healthcare , i.e., the ability to access information on medical or clinical issues, to understand medical information, to interpret and evaluate medical information, and to make informed decisions on medical issues and comply with medical advice.

Four dimensions of health literacy in the domain of disease prevention , notably the ability to access information on risk factors for health, to understand information on risk factors and derive meaning, to interpret and evaluate information on risk factors, and to make informed decisions on risk factors for health.

Four dimensions in the domain of health promotion , notably the ability to regularly update oneself on determinants of health in the social and physical environment, to comprehend information on determinants of health in the social and physical environment and derive meaning, to interpret and evaluate information on determinants, of health in the social and physical environment, and the ability to make informed decisions on health determinants in the social and physical environment.

Health literacy is in our understanding regarded an asset for improving people's empowerment within the domains of healthcare, disease prevention and health promotion.

In addition to the components of health literacy proper, the model in Figure 1 also shows the main antecedents and consequences of health literacy. Among the factors which impact on health literacy, a distinction is made between more distal factors, including societal and environmental determinants (e.g., demographic situation, culture, language, political forces, societal systems), and proximal factors, which are more concerned with personal determinants (e.g., age, gender, race, socioeconomic status, education, occupation, employment, income, literacy) and situational determinants (e.g. social support, family and peer influences, media use and physical environment). Health literacy is strongly associated with educational attainment [ 50 ], as well as with overall literacy [ 34 , 38 , 39 ]. Fundamental literacy affects a wide range of cognitive, behavioral, and societal skills and abilities. It should be distinguished from other specific literacy, such as science literacy (i.e., the ability to comprehend technical complexity, understanding of common technology, and an understanding that scientific uncertainty is to be expected), cultural literacy (i.e., recognizing and using collective beliefs, customs, world-views, and social identity relationships) and civic literacy (i.e., knowledge about sources of information and about agendas and how to interpret them, enabling citizens to engage in dialogue and decision-making). According to Mancuso [ 43 ], an individual must have certain skills and abilities to obtain competence in health literacy, and identifies six dimensions that are considered as necessary antecedents of health literacy, namely operational, interactive, autonomous, informational, contextual, and cultural competence.

Health literacy in turn influences health behavior and the use of health services, and thereby will also impact on health outcomes and on the health costs in society. At an individual level, ineffective communication due to poor health literacy will result in errors, poor quality, and risks to patient safety of the healthcare services [ 61 ]. At a population level, health literate persons are able to participate in the ongoing public and private dialogues about health, medicine, scientific knowledge and cultural beliefs. Thus, the benefits of health literacy impact the full range of life's activities--home, work, society and culture [ 34 , 38 , 39 ]. Advancing health literacy will progressively allow for greater autonomy and personal empowerment, and the process of health literacy can be seen as a part of an individual's development towards improved quality of life. In the population, it may also lead to more equity and sustainability of changes in public health. Consequently, low health literacy can be addressed by educating persons to become more resourceful (i.e., increasing their personal health literacy), and by making the task or situation less demanding, (i.e., improving the "readability of the system").

In this article we have we have presented a working definition of health literacy which represents the essence of the definitions of this concept as given in the literature. Furthermore a new conceptual model has been developed as a result of the review of existing health literacy concepts. While the literature indicates that health literacy refers to the competences of people to meet the complex demands of health in modern society [ 2 , 3 , 62 ] the exact nature of these competences is still debated. One perspective is that they refer to a series of individual cognitive skills and abilities applied in a medical context; the other perspective sees a broader range of competencies applied in the social realm. The first is referred to as "medical health literacy" [ 5 ], "patient health literacy" [ 14 ], or "clinical health literacy" [ 63 ]; the second as "public health literacy" [ 35 ]. Nutbeam [ 52 ] refers to the opposing medical and public health views on health literacy as respectively a "clinical risk", and a "personal asset" approach, and points out that they are rooted in the different traditions of clinical care, and adult learning and health promotion, respectively. As both perspectives are important and useful to enable a better understanding of health communication processes in clinical and community settings, any definition of health literacy needs to integrate both views. The proposed 'all inclusive' definition is adaptable and includes the public health perspective as well as the individual perspective.

While originating from the study of the reading and numerical skills that are necessary to function adequately in the healthcare environment, the concept of health literacy has expanded in meaning to include information-seeking, decision-making, problem-solving, critical thinking, and communication, along with a multitude of social, personal, and cognitive skills that are imperative to function in the health-system [ 49 , 52 , 59 ]. It has now diffused into the realm of culture, context, and language [ 49 , 52 , 59 ]. Although some authors have argued that health literacy is merely "new wine in old bottles", and is basically the repackaging of concepts central to the ideological theory and practice of health promotion [ 64 ], enhancing health literacy is increasingly recognized as a public health goal and a determinant of health. As new health literacy frameworks have emerged to clarify the deeper meaning of health literacy, its contribution to health, and the social, environmental, and cultural factors that influence health literacy skills in a variety of populations, there is a need for an integration of diverging definitions, conceptual frameworks and models of health literacy.

The conceptual framework presented in this paper provides this integration in the form of a comprehensive model. Based on a systematic review of existing definitions and conceptualizations of health literacy, it combines the qualities of a conceptual model outlining the most comprehensive dimensions of health literacy, and of a logical model, showing the proximal and distal factors which impact on health literacy as well as the pathways linking health literacy to health outcomes. Specifically, the model identifies 12 dimensions of health literacy, referring to the competencies related to accessing, understanding, appraising and applying health information in the domains of healthcare, disease prevention and health promotion, respectively.

By integrating existing definitions and conceptualizations of health literacy into an encompassing model outlining the main dimensions of health literacy as well as its determinants and the pathways to health outcomes, this model has a heuristic value in its own right. More importantly, however, it can also support the practice of healthcare, disease prevention and health promotion by serving as a conceptual basis to develop health literacy enhancing interventions. Moreover, it can contribute to the empirical work on health literacy by serving as a basis for the development of measurement tools. As currently available tools to measure health literacy do not capture all aspects of the concept as discussed in the literature, there is a need to develop new tools to assess health literacy, reflecting health literacy definitions and accompanying conceptual models for public health. By following a concept validation approach, scales can be developed to assess the dimensions outlined in the conceptual model presented in this paper. This will not only produce a comprehensive measure of health literacy, reflecting the state of the art of the field and applicable for social research and in public health practice, but also serve to validate the conceptual model and thus contribute to the understanding of health literacy.

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The authors thank all partners in the HLS-EU consortium for contributing to the development of the conceptual model and the content of this article.

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Maastricht University, the Netherlands: Helmut Brand, Stephan van den Broucke and Kristine Sørensen

National School of Public Health, Greece: Demosthenes Agrafiodis, Elizabeth Ioannidis and Barbara Kondilis

University College of Dublin, National University of Ireland: Gerardine Doyle, James Fullam and Kenneth Cafferkey

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Medical University - Sofia, Bulgaria: Kancho Tchamov and Alex Zhekov

National Institute of Public Health and the Environment, The Netherlands: Mariël Droomers, Jantine Schuit, Iris van der Heide and Ellen Uiters

NRW Centre for Health, Germany: Gudula Ward and Monika Mensing

The HLS-EU project and related research are supported by grant 2007-113 from the European Commission.

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Background: KS, SVDB, JF, GD. Methodology: KS, SVDB, JF. Results: KS, SVDB, HB, JF, GD, ZS and JP. Discussion: KS, SVDB, HB, JF, GD, ZS and JP. Conclusion: KS, SVDB, JF and GD. All authors read and approved the final manuscript.

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Sørensen, K., Van den Broucke, S., Fullam, J. et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 12 , 80 (2012). https://doi.org/10.1186/1471-2458-12-80

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Problem-based learning in academic health education. A systematic literature review

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1 Department of Restorative Dentistry and Periodontology, Dublin Dental School & Hospital, Dublin, Ireland. [email protected]
PMID: 20070800
DOI: 10.1111/j.1600-0579.2009.00593.x

Problem based learning (PBL) arguably represents the most significant development in education over the past five decades. It has been promoted as the curriculum of choice, and since its introduction in the 1960's, has been widely adopted by many medical and dental schools. PBL has been the subject of much published literature but ironically, very little high quality evidence exists to advocate its efficacy and subsequently justify the widespread curriculum change. The purpose of this review is to classify and interpret the available evidence and extract relevant conclusions. In addition, it is the intent to propose recommendations regarding the relative benefits of PBL compared with conventional teaching. The literature was searched using PubMed, ERIC and PsycLIT. Further articles were retrieved from the reference lists of selected papers. Articles were chosen and included according to specific selection criteria. Studies were further classified as randomised controlled trials (RCTs) or comparative studies. These studies were then analysed according to intervention type: whole curricula comparisons and single educational interventions of shorter duration. At the level of RCTs and comparative studies (whole curricula), no clear difference was observed between PBL and conventional teaching. Paradoxically, it was only comparative studies of single PBL intervention in a traditional curriculum that yielded results that were consistently in favour of PBL. Further research is needed to investigate the possibility that multiple PBL interventions in a traditional curriculum could be more effective than an exclusively PBL programme. In addition, it is important to address the potential benefits of PBL in relation to life-long learning of health care professionals.

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Problem-based learning interventions in a traditional curriculum are an effective learning tool. Townsend G. Townsend G. Evid Based Dent. 2011 Dec;12(4):115-6. doi: 10.1038/sj.ebd.6400829. Evid Based Dent. 2011. PMID: 22193657

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Published: 22 December 2010

Global health competencies and approaches in medical education: a literature review

Robert Battat 1 ,
Gillian Seidman 1 ,
Nicholas Chadi 1 ,
Mohammed Y Chanda 1 ,
Jessica Nehme 1 ,
Jennifer Hulme 1 ,
Annie Li 1 ,
Nazlie Faridi 1 &
Timothy F Brewer 1

BMC Medical Education volume 10 , Article number: 94 ( 2010 ) Cite this article

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Physicians today are increasingly faced with healthcare challenges that require an understanding of global health trends and practices, yet little is known about what constitutes appropriate global health training.

A literature review was undertaken to identify competencies and educational approaches for teaching global health in medical schools.

Using a pre-defined search strategy, 32 articles were identified; 11 articles describing 15 global health competencies for undergraduate medical training were found. The most frequently mentioned competencies included an understanding of: the global burden of disease, travel medicine, healthcare disparities between countries, immigrant health, primary care within diverse cultural settings and skills to better interface with different populations, cultures and healthcare systems. However, no consensus on global health competencies for medical students was apparent. Didactics and experiential learning were the most common educational methods used, mentioned in 12 and 13 articles respectively. Of the 11 articles discussing competencies, 8 linked competencies directly to educational approaches.

Conclusions

This review highlights the imperative to document global health educational competencies and approaches used in medical schools and the need to facilitate greater consensus amongst medical educators on appropriate global health training for future physicians.

Peer Review reports

Health issues are increasingly transnational and in recent years the concept of global health has emerged to address these issues. Global health is the study and practice of improving health and health equity for all people worldwide through international and interdisciplinary collaboration [ 1 ]. Factors such as increasing international travel, the globalization of food supplies and commerce and the occurrence of multinational epidemics including the 2009 Influenza A pandemic have heightened awareness of global health issues. This awareness has influenced health practices and medical education locally and globally. Internationally, large-scale multinational public health programs such as the UN Millennium Development Goals, the Global Fund and the US President's Emergency Plan for AIDS relief have been created and funded with billions of dollars [ 2 ]. More locally, medical schools increasingly are offering international elective opportunities; almost one-third of recently graduated US and Canadian medical students participated in a global health experience [ 3 ]. However, despite growing interest in and the importance of global health, there exists little agreement on what constitutes appropriate global health training for medical students [ 4 ].

It has been argued that all medical students should have some exposure to global health issues, and groups are addressing this perceived gap in medical education by proposing global health competencies for undergraduate medical education [ 2 , 5 , 6 ]. In order to develop initial guidance in this area, this study reviewed existing literature to identify competencies and educational approaches recommended for teaching global health components in medical curricula. Using this information, a consensus was sought in order to further solidify this conceptual framework.

Data Sources and Searches

Relevant articles on global health competencies and teaching approaches were identified by applying similar search strategies to two databases, Ovid MEDLINE ® and Web of Science. Also, previously identified articles were obtained from the McGill Global Health Programs files. The Ovid MEDLINE ® search terms "world health" and "international educational exchange" were combined using the Boolean operator "OR" for the publication years 1996 to the 4 th week of January 2009. The initial search used the terms "global health" and "international health"; however, these terms mapped to the subject heading "world health" in the Ovid MEDLINE ® database. This procedure was repeated using the search terms "education, medical" and "education, medical, undergraduate", which was then cross-referenced with the search term "competencies". The resulting "education, medical"/"curriculum" set was combined with the resulting "world health"/"international educational exchange" set using the Boolean operator "AND". The results of the search were limited to humans and English. The Web of Science search cross-referenced the terms "medical education", "curriculum" and "global health" as topics for the publication years "all years" i.e. from 1900-1914 to January 2009. A research team comprised of all authors in this study, as well as the Liaison Librarian in the Life Sciences Library at McGill University, agreed upon these terms with the aim of avoiding researcher bias when selecting the articles. References from retrieved articles were reviewed to identify additional applicable publications.

Study Selection

Titles and abstracts of articles obtained from database searches were reviewed to identify those describing competencies or educational approaches currently used in global health components of medical school curricula. Articles not pertaining to contemporary global health medical educational practices or competencies were not further considered.

Data Extraction and Synthesis

Information relating to competencies and educational approaches was extracted from the retained articles. Information discussing the theoretical knowledge or practical skills authors believed medical students needed to obtain was categorized as a competency. Descriptions of specific programs or teaching methods were categorized as educational approaches.

The results of the search strategy on global health competencies and educational approaches are summarized in Figure 1 . The Ovid database search strategy yielded forty-five articles. The Web of Science search yielded two additional articles not found in the Ovid database[ 7 , 8 ]. Twelve more articles were found through reviewing references from retrieved articles[ 6 , 9 – 19 ]. Four other articles were obtained from the McGill Global Health Programs files[ 20 – 23 ]. Combining all of the search efforts and removing duplications, 63 articles were available for consideration. After reviewing titles and abstracts, 47 were retained for further consideration. Following a full review of the remaining articles, 32 articles were felt to contain relevant information and were included in the review.

Search strategy for retrieving literature on global health competencies and educational approaches .

The percentage of articles recommending a particular competency topic, the type of competency and the suggested method of implementation are summarized in Table 1 . Fifteen unique global health competencies for training medical students from 11 articles (34.4%) were identified in the literature [ 7 , 10 , 17 – 19 , 24 – 29 ]. Most competencies were concerned with increasing medical students' knowledge, though some addressed physician behaviour, physical examination abilities and other clinical skills. Competencies mentioned in more than one article included: an understanding of the global burden of disease; travel medicine; healthcare disparities between countries; immigrant health; primary care within diverse cultural settings; and skills to better interface with different populations, cultures and healthcare systems. All other competencies were mentioned only by a single article.

Global health educational approaches were described in 18 of 32 (56.3%) identified articles [ 6 , 7 , 9 , 10 , 13 , 15 – 17 , 19 , 22 , 24 , 26 , 28 – 33 ]. The percentage of articles recommending a particular educational approach, and the suggested methods for implementing that approach, are summarized in Table 2 .

The most common recommended educational approaches for teaching global health topics were didactics and experiential learning. However, there was substantial variability across described programs in the educational approach to global health as well as the methods used to implement these approaches. No commonly applied didactic method for teaching global health to medical students was apparent from this literature review. Moreover, descriptions of educational approaches often did not provide a tangible picture of what occurred in these programs.

Competencies and educational approaches were linked in 8 (25.0%) articles [ 7 , 10 , 17 , 19 , 24 , 26 , 28 , 29 ]. Eleven articles (34.4%) mentioned global health educational approaches or competencies for medical students, but did not provide sufficient detail to be used further [ 5 , 8 , 11 , 12 , 14 , 20 , 21 , 23 , 34 – 36 ]. Although these articles met search criteria, they tended to discuss international partnerships and suggestions for future endeavors rather than specifics regarding contemporary program competencies or educational approaches.

Interest in global health has grown dramatically among medical students in the past decade, and medical schools are grappling to define the skill sets and knowledge needed to ensure that graduates are appropriately prepared to work in this emerging field. Successful global health educational programs exist, and we explored the medical literature to identify competencies and educational approaches that might serve as potential resources for medical schools developing their own training programs. This literature review found no clear consensus on which global health competencies are relevant for most or all medical graduates to be able to draw on as future physicians. There also was little guidance regarding educational approaches for teaching global health competencies beyond the traditional methods of didactics and experiential learning.

Fifteen competencies were mentioned in the literature. The most commonly discussed ones included an understanding of the global burden of disease; travel medicine; healthcare disparities between countries; immigrant health; primary care within diverse cultural settings; and skills to better interface with different populations, cultures and healthcare systems. Although these competencies were mentioned in more than one article, no single topic area was covered in more than 16% of identified articles, suggesting a lack of consensus on the importance assigned to any particular subject. It is not possible from this review to determine why a lack of consensus exists; one possibility may be that medical schools developed their global health curricula independent of each other. Such an approach may foster innovation, but also means that the quality of resulting programs is likely to vary widely as was found in a review of global health programs [ 4 ]. Developing consensus on global health competencies would help ensure that all medical students were exposed to similar basic levels of training.

An alternative explanation for the lack of consensus in the retrieved articles is that published literature does not reflect common practice. Despite the tremendous growth in global health programs, only 11 articles were identified that addressed competencies. Furthermore, competencies were rarely the main focus of retrieved articles, giving little information on which to draw conclusions. A general consensus may exist among global health experts not reflected by the published literature.

The most common educational approaches for teaching global health were didactics and experiential learning. However, the implementation of these approaches varied considerably in the literature. Our review was hampered by the limited descriptions of educational approaches present in identified articles that may not have provided a complete picture of these programs. More detailed documentation of global health educational approaches is needed if the literature is to serve as a resource for medical schools developing new programs.

Of the 11 articles addressing competencies, 8 (72.7%) linked them to an educational approach. Conversely, educational approaches were mentioned in a majority of articles, but less than half of these linked these approaches to a competency. Competency-based descriptions of training give a more complete picture of global health education in medical curricula; schools looking to build global health educational activities should begin by defining the desired competencies, followed by enumerating the educational approaches to be used to teach them.

Over one-third of retrieved articles did not provide specific details regarding global health educational approaches or competencies despite the search strategy used. These articles often focused on the creation of international institutional partnerships to improve the quality and pace of global health curriculum development. However, establishing learning objectives and corresponding educational approaches should be prerequisites for undertaking activities such as international global health partnerships. This review highlights another potential weakness in existing global health training; medical schools may be pursuing secondary activities before establishing basic program components such as competencies and educational approaches. Without well thought-out competencies and educational approaches, medical students may lack the foundation necessary to participate in international global health programs.

Steps are underway to build consensus among global health experts regarding basic global health training for medical students. For example, the Global Health Education Consortium (GHEC) and the Association of Faculties of Medicine of Canada (AFMC) Resource Group on Global Health have created a joint committee to propose consensus global health core competencies for medical students [ 2 ]. Recently, a number of leading university-based global health programs came together to form the Consortium of Universities for Global Health (CUGH). CUGH is another potential forum for sharing global health program development information across schools. Locally, we have used the results of this review to add global burden of disease and travel-associated health topic areas to our curriculum. We suggest that medical schools use a competency based approach when developing global health programs. Educational approaches can then be linked to the learning objectives they are designed to teach. Documenting this information in the literature will facilitate the ability of medical schools to compare competencies and educational approaches being used across programs, and may stimulate consensus on appropriate global health training for medical students. Comparative studies also should be undertaken to measure how global health training affects clinical practice. Helping medical schools build appropriate global health components into their curricula should make physicians more informed and better equipped to care for patients in this increasingly globalized world.

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Acknowledgements

The authors acknowledge the work of the AFMC Resource Group on Global Health/GHEC joint committee in developing the proposed competency guidelines. Committee members include: Kelly Anderson, Timothy Brewer (Chair), Thuy Bui, Veronic Clair, Thomas Hall, Laura Janneck, Renee King, Ann McCarthy, Neal Nathanson, Sujal Parikh, Calvin Wilson and Karen Yeates. Also we would like to thank Jill Boruff for assistance with the search strategy.

This research was partially funded by a grant from the Donner Canadian Foundation. The funder did not play any role in the design and conduct of the study, the collection, management, analysis, and interpretation of the data, or the preparation, review, or approval of the manuscript.

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RB designed the study, coordinated the research team, designed the search strategy, conducted the literature search, organized and analyzed data, and was the primary author of the manuscript. RB read and approved the final manuscript. GS conducted the literature search, organized and analyzed data, and was the secondary author of the manuscript. GS read and approved the final manuscript. NC conducted the literature search, analyzed data, and edited the manuscript. NC read and approved the final manuscript. MYC conducted the literature search and analyzed data. MYC read and approved the final manuscript. JN contributed to the design of the search strategy, conducted the literature search and analyzed data. JN read and approved the final manuscript. JH conducted the literature search, analyzed data, and edited the manuscript. JH read and approved the final manuscript. AL conducted the literature search and analyzed data. AL read and approved the final manuscript. NF conducted the literature search and analyzed data. NF read and approved the final manuscript. TB conceived and designed the study, oversaw data analysis, secured funding, and edited the final manuscript. TB read and approved the final manuscript.

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Battat, R., Seidman, G., Chadi, N. et al. Global health competencies and approaches in medical education: a literature review. BMC Med Educ 10 , 94 (2010). https://doi.org/10.1186/1472-6920-10-94

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PsycINFO, produced by the American Psychological Association, is a collection of electronically stored bibliographic references--most with abstracts or content summaries. It contains citations that PsycINFO has created in electronic form. Although the references themselves are all written in English, the covered literature includes material published in over 45 countries and written in 30 languages.Coverage: 1872-present

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Published: 21 June 2024

Effects of different types of exercise intensity on improving health-related physical fitness in children and adolescents: a systematic review

Xianxian Zhou 1 ,
Jiayu Li 1 &
Xiaoping Jiang 1

Scientific Reports volume 14 , Article number: 14301 ( 2024 ) Cite this article

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A substantial body of empirical evidence reveals that physical activity is associated with a wide range of positive physical and mental health outcomes. However, an absence of comprehensive syntheses is observed concerning the varying effects of different exercise intensities on the improvement of physical health among children and adolescents. The aim of this review is to systematically investigate the effects of different exercise intensities on the physical fitness of children and adolescents, to analyses the optimal exercise intensities for improving physical fitness, and to provide a relevant theoretical basis for optimizing school physical education curricula. A systematic search strategy was used in this study in four online databases (PubMed, Scopus, EBSCO and Web of Science). Intervention studies that met the inclusion criteria underwent a thorough screening process, and their methodological quality was assessed utilizing the PEDro scale. The selected literature was systematically analyzed and evaluated through induction, summary, analysis, and evaluation. These findings indicate that high-intensity exercise training exerts significant positive effects on body composition, cardiopulmonary function and muscle fitness in children and adolescents. Therefore, we suggest that schools should focus on high-intensity sports in their physical education curriculum, which can further improve the student's PHYSICAL FITNESS.

Introduction

Overweight and obesity in children and adolescents have become a global public health problem 1 . The prevalence of obesity in children and adolescents has been reported to have increased from 0.7% to 5.6% 2 . The persistence of overweight and obesity into adulthood has the potential to lead to chronic diseases, including type 2 diabetes, cardiometabolic disorders, and a range of psychosocial problems 3 , 4 , 5 , 6 , Numerous studies have shown that physical activity is one of the most important interventions to reduce physical health and psychological problems in adolescents 7 , 8 , 9 . WHO recommends that children and adolescents should engage in an average of 60 min of moderate to high-intensity physical activity (MVPA) per day to obtain health benefits 10 , however, more than 80%of adolescents fail to reach the minimum recommended amount of physical activity 11 . Given that adolescents have difficulty starting and following recommended guidelines for 30–60 min of moderate-intensity training per day 12 , 13 , there is a need to explore and develop engaging alternatives for youth to achieve the many health benefits of regular physical activity. Traditionally, moderate-intensity continuous training (MICT) has been the most common type of exercise recommended to improve body composition and cardiorespiratory fitness (CRF) 14 , 15 . However, in recent years, a growing body of laboratory evidence has shown that high-intensity exercise training is less time-consuming than MICT in improving body composition and other health indicators in obese children and adolescents 16 , 17 , 18 . Whether high-intensity or low-intensity exercise training is more beneficial to the PHYSICAL FITNESS of children and adolescents is still highly debated. Therefore, there is a need to further explore differences in the effectiveness of different exercise intensity interventions in improving PHYSICAL FITNESS in children and adolescents.

PHYSICAL FITNESS is a multidimensional state of being. PHYSICAL FITNESS is the body’s ability to function efficiently and effectively. It is a state of being that consists of at least FIVE HEALTH-RELATED and SIX SKILL-RELATED PHYSICAL FITNESS COMPONENTS, each of which contributes to total quality of life. The five components of health-related PHYSICAL FITNESS are BODY COMPOSITION, CARDIOVASCULAR FITNESS, FLEXIBILITY, MUSCULAR ENDURANCE, AND STRENGTH 19 . A recent narrative and meta-analysis of 20 studies evaluated the efficacy of HIIT for improving HEALTH-RELATED FITNESS (ie, cardiorespiratory fitness, muscular fitness, body composition and flexibility). The results indicated significant improvements in cardiorespiratory fitness and body composition through HIIT, with notable effects observed in these areas 13 . Previous meta-analyses have weakened the interpretation of findings due to small sample sizes. Furthermore, there is less research on exercise interventions to treat PHYSICAL FITNESS in children and adolescents than in adults, particularly in terms of exploring exercise-related variables (intensity and duration).

Therefore, this systematic review aims to systematically summarized the effects of different exercise intensities on health-related fitness in children and adolescents and to analyze which exercise intensity is more conducive to improving health-related fitness in children and adolescents.

This review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines 20 , and the Cochrane Handbook for systematic review 21 . The PRISMA checklist is presented in Additional File 1.

Search strategy

A comprehensive search was done systematically through PubMed, Scopus, EBSCO, and Web of Science up to the 5 of June 2024. Searching terms were based on adapted PICO questions to search through the aforementioned databases to access all the important articles. Free text words and medical subject heading (MeSH) terms were used. (1) children OR childhood OR pre*schooler OR schoolchildren OR preadolescent OR adolescent OR adolescence OR youth;(2) physical*activity OR physical*education OR exercise OR fitness OR sport;(3) strength OR flexibility OR motor OR endurance OR agility OR body composition OR anthropometry OR body mass index OR waist circumference OR overall adiposity OR central adiposity OR overweight OR obesity OR risk factors OR risk score cardiovascular disease OR metabolic syndrome OR blood glucose OR glucose tolerance OR insulin resistance OR insulin sensitivity OR blood lipids OR dyslipidemia OR diabetes OR blood pressure OR hypertension OR inflammatory markers OR bone mineral OR bone mineral content;(4) random OR random*controlled trial OR controlled trial OR trial. (The search strategy used for each database is provided in the supplementary material (table S2). At the same time, the reference lists of included articles and relevant reviews were retrospectively included to supplement the missing literature in the computer search. The systematic search process was conducted by XXZ and JYL. Any disagreement of an included/excluded study was resolved by the author PXJ.

Eligibility criteria of the selected studies

The inclusion criteria for articles were determined using the PICOS (Participants/Interventions/Comparisons/Outcomes/Study Design) principles, as follows. Participants (P): Children and adolescents (individuals in the 10–19 year age group 22 , including samples of overweight/obese children, but excluding samples of children with medical conditions); Interventions (I):interventions in the form of exercise, High-intensity aerobic exercise, Low-intensity aerobic training (LIT), Endurance training (ET), High-intensity interval exercise (HIIE), Moderate-intensity exercise (MIE),HIIT, moderate-intensity continuous (MICT); Comparisons (C): control group performed low to moderate intensity physical activity or no artificially designed physical exercise; Outcomes (O): assessment of at least one of the following indicators (i.e., body composition, cardiorespiratory fitness, muscular fitness, strength, flexibility, motor, endurance, agility, body composition, anthropometry, body mass index, waist circumference, overall adiposity , central adiposity , overweight , obesity ,risk factors , risk score cardiovascular disease, metabolic syndrome, blood glucose, glucose tolerance, insulin resistance, insulin sensitivity, blood lipids, dyslipidemia, diabetes, blood pressure, hypertension, inflammatory markers, bone mineral, bone mineral content); Study Design (S): controlled trial.

Exclusion criteria: (1) studies not related to the topic (non-physical activity, physical activity); (2) non-intervention studies (observational studies, systematic reviews) and studies that did not provide sufficient comparisons to compare; (3) Exclude other age groups other than 3–19 years old. The title, abstract and full text were independently assessed by two authors for eligibility. Finally, randomized controlled trials were limited to articles published in English.

Data extraction

Data extraction from the included studies was independently performed by two authors (XXZ and JYL). For each study, data were extracted for the characteristics of the study population. These include (1) first author’s surname; (2) year of publication; (3) purpose; (4) results; (5) the characteristics, sample size and age of the participants; (6) sampling type; (7) type of research; (8) Characteristics of physical exercise (type, frequency and duration). Any disagreement in data extraction was resolved by the third author PXJ (Table 1 ).

Quality assessment

Papers that met the inclusion criteria were independently assessed by two authors (XXZ and JYL). This review assessed the included literature using the Physiotherapy Evidence Database (PEDro) scale, a credit rating scale developed by the Australian Centre for Evidence-Based Practice. The PEDro scale is a valid measure of the methodological quality of clinical trial 23 . The scale consisted of randomized grouping (2 items), blinding (3 item), data reporting (3 item), data analysis (1 item), and follow-up (1 item), with a total of 10 criteria. Each item was recorded as 1 point when it appeared in the article and 0 points when it was not reflected, for a total score of 0 to 10 points. To avoid subjective opinions, two reviewers assessed the opinions, and the third judged the differences. It classifies papers into three levels: high quality above 8, medium quality 4–7, and low quality below 4 points. Disagreements were solved by a third party (PXJ) (Table 2 ).

Data synthesis and analysis

Due to the heterogeneity of the studies, no meta-analysis was performed. Instead, intervention characteristics for each study were summarized and analyzed and then recorded in a standardized form created by the authors. The effectiveness of the intervention was calculated using the formula: number of effective trials (post-intervention scores significantly higher than pre-intervention or control scores)/total number of trials. Data analysis was performed by the first author XXZ and then validated by the second author JYL.

Literature screening process and results

A preliminary search of the database yielded 10,030 relevant studies. We first imported the documents into the document management software Endnote, and after removing duplicate documents and screening titles and abstracts, we excluded 9990 articles. Of the remaining 40 articles, 30 articles were obtained after screening and checking the full text, and the irrelevant articles were eliminated. The reasons for the exclusion based on the full text were: (1) no intervention studies (3 articles); (2) The age does not meet (3 articles); (3) non-full text (2 articles); (4) non-English articles (2 articles). The PRISMA flowchart is shown in Fig. 1 .

Flow chart of literature retrieval.

The systematic search of relevant literature published as of 5 June 2024 found 30 relevant articles, the earliest of which was published in 1999. The study included 30 related papers from the United States, Canada, Brazil, Denmark, Spain, China, Australia, the United Kingdom, Singapore, France, Portugal, Colombia, and Switzerland.

Study characteristics were summarized in Table 1 , and the final analysis included 6494 children and adolescents with participants ranging in age from 5 to 18 years, with most studies including healthy children and adolescents, but nine studies including overweight or obese children. Study sizes ranged from 10 to 2166. Physical activity interventions mainly included HIIT (8/30; 27%), aerobic training (5/30; 17%), resistance training (2/30; 7%), physical education (1/30; 3%), endurance training (1/30; 3%), acute exercise (1/30; 3%) and other interventions. Outcome measures: body mass index, waist circumference, body fat, cardiorespiratory fitness, and muscle fitness (muscular endurance, muscle strength and muscular flexibility). Quality scores for 30 studies are shown in Table 2 . The studies ranged in their scores from 3 to 10. Only two studies achieved high-quality scores (≥ 8) (Table 2 ). One study scored below 4. Blinding techniques ranged from 0 to 3 in this study, with only one study scoring 3 and four scoring 1; Fifteen studies scored 0.

Effects of different exercise intensity on BODY COMPOSITION in children and adolescents

A total of 11 studies in this study assessed the effects of different exercise intensities on body composition (weight, BMI, body fat, waist circumference, fat-free mass, and other relevant indicators), of which 9 showed that high-intensity exercise interventions had a positive effect on overweight or obese children and adolescents, but 2 had no positive effect.

Weight, BMI and body fat

A total of 8 of the 11 studies assessed changes in body weight, BMI, adiposity, or percentage of body fat measured. Six of the eight studies, reported positive effects of high-intensity exercise interventions on body weight, BMI, or body fat in overweight and obese child adolescents. However, 2 studies showed moderate or no positive effects of high-intensity exercise interventions on BMI, and body fat in overweight or obese children and adolescents.

Tadiotto et al. conducted a 12-week HIIT and MIIT intervention study and found significant reductions in (body mass index) BMI-z, (waist-to-height ratio) WHtR, and LDL-c in HIIT 28 . Benson et al. compared the effects of high-intensity progressive resistance training (PRT) on body composition in obese children and showed that an 8-week PRT intervention resulted in significant improvements in adiposity, percentage body fat, and body mass index 34 . Recent findings have shown that after 12 weeks of HIIT and MICT interventions, there was a significant reduction in BMI and body fat mass in the HIIT group compared to the control group, as well as a significant reduction in visceral adipose tissue (− 53 g vs. − 17 g, p < 0.01), LDL cholesterol was reduced only in the HIIT group, whereas in MICT only the body fat percentage was significantly reduced (− 17.2%, p < 0.05) 31 . In addition, Winn et al. compared the effects of HIIT on adolescents over a 6-month period and showed that after a 6-month school HIIT intervention, BMI was maintained in the HIIT group and significantly increased in the control group, and that HIIT was an effective tool for maintaining BMI 47 .

In a study assessing the effect of different exercise intensities on energy expenditure for spontaneous physical activity in adolescents, Paravidino et al. found that the mean energy expenditure was 82, 286 and 343 kcal in the control, moderate and vigorous exercise groups, respectively ( p < 0.001), and the results suggest that high intensities are more conducive to an increase in energy expenditure, and thus to weight loss 27 . Saidi et al. studied the effect of vigorous exercise on subsequent dietary intake in obese adolescent girls and showed a significant reduction in adiposity in the exercise group compared to the control group ( p < 0.02) 45 .

In the present study, 2 studies reported no significant effects of different intensities of exercise on body composition in overweight or obese children and adolescents. Gomes et al. compared the effects of different aerobic training intensities over a period of 12 on the body composition of obese adolescents, and showed a decrease in body weight, BMI, and body fat in both the intervention and control groups after a 12-week intervention ( p < 0.001), but these results could not be attributed solely to aerobic training intensity due to the multidisciplinary intervention 40 . In another study, Costigan et al. conducted an 8-week study of aerobic training (AEP) and resistance and aerobic programming (RAP) with 68 secondary school students, and the results showed a moderate effect of the BMI intervention for participants in the AEP and RAP groups. It may be related to the small sample size 43 .

Waist circumference

Three randomized controlled trials assessed changes in waist circumference and all found beneficial effects. (Insert literature), a study conducted by Farah et al., showed that after 6 months of high-intensity aerobic training (HIT) and low-intensity aerobic training (LIT), significant beneficial changes in waist circumference were found only in the HIT group 24 . Benson et al. investigated the effects of 8 weeks of high-intensity progressive resistance training (PRT) on body composition in obese children and compared the effects between the experimental and control groups, showing that significant changes in waist circumference were obtained in the intervention group after 8 weeks of PRT training 34 . Costigan et al. conducted an 8-week study of aerobic training (AEP), resistance and aerobic programming (RAP) with 68 secondary school students and showed that participants in the AEP and RAP groups had significant changes in waist circumference ( p = 0.024) 43 .

Fat-free mass

Only 1 study evaluated the effect of different exercise intensities on fat-free mass. Leppanen et al. investigated the effect of physical activity intensity and sedentary behaviours (ST) on body composition in 4 years old children. The results showed that the higher the intensity of moderate-to-vigorous exercise, the lower the percentage of fat (%FM, p = 0.015), the VPA (high intensity) and MVPA (moderate-to-vigorous exercise intensity) the higher the fat-free mass index (FFMI, p = 0.002 and p = 0.011) Time spent on VPA was associated with higher FFMI 38 .

Effects of different exercise intensities on CARDIOPULMONARY FUNCTION (CRF) in children and adolescents

A total of 16 studies investigated the effects of different exercise intensity interventions on cardiorespiratory fitness, and positive effects were found in all studies. In general, cardiorespiratory fitness improved with high-intensity exercise interventions. The included studies assessed vascularity, heart rate, lipids, insulin sensitivity, inflammatory markers, diabetes, and other relevant indicators.

Blood vessels

A total of 4 out of 16 studies investigated the effects of exercise intensity interventions on blood vessels in children and adolescents. Four studies demonstrated that high-intensity training interventions had a positive effect on blood vessels.

Bond et al. investigated the effect of exercise intensity on protecting the vascular system from high-fat diets in adolescents study by intervening with high-intensity interval exercise (HIIE) and moderate-intensity exercise (MIE) in 20 adolescents, and showed that exercise intensity plays an important role in protecting the vascular system from the deleterious effects of HFM, and that in the adolescent population, performing HIIE may be more effective than MIE in Provides better vascular benefits 26 . In a study examining the effects of sprint interval exercise on post-exercise metabolism and blood pressure in adolescents, it was shown that acute sprint interval exercise leads to an increase in short-term oxygen uptake and a decrease in blood pressure in adolescents 37 . Farpour-Lambert et al. investigated the effect of physical activity on systemic blood pressure in adolescent obese children, and after a 3-month intervention, significant changes in systolic and diastolic blood pressure were obtained in the intervention group compared to the control group 51 . Buchan et al. investigated whether a high-intensity training (HIT) intervention could improve the CVD risk profile of adolescents in a time-effective manner, and after a 7-week HIT intervention, a significant reduction in systolic blood pressure was obtained in the intervention group compared to the control group 41 .

Insulin sensitivity

Of the 16 studies, only 2 randomized controlled trials assessed the effect of exercise intensity on insulin sensitivity. Only one study showed that a high-intensity exercise intervention could have a positive effect on insulin sensitivity. In the first randomized controlled trial, the Davis study found that after the intervention, the high-dose aerobic training group had a greater reduction in insulin (AUC), which could be effective in reducing metabolic risk 36 . However, in another randomized trial of 106 overweight and obese adolescents who underwent high-intensity endurance training (ET) and moderate-intensity (ET) for 6 months, the results showed that ET significantly improved cardiorespiratory fitness in obese adolescents, but the effect of exercise intensity on insulin sensitivity and triglycerides remained unclear due to lack of compliance 25 .

Inflammation

A total of 3 out of 16 studies assessed the effect of exercise intensity interventions on inflammation, with only 2 showing a positive effect of high-intensity exercise interventions on the prevention of inflammation. The results of the study by Ramirez-Velez et al. suggest the utility of high-intensity aerobic and resistance training as a means of modulating the levels of certain pro-inflammatory interleukins in adolescent subjects, thereby playing an important role in the prevention of diseases associated with low-grade inflammation, such as cardiovascular disease and type 2 diabetes 30 . A study by Tadiotto et al. found that C-reactive protein (CRP) was significantly reduced in the HIIT group, promoting beneficial changes in obesity and inflammatory processes 28 . However, in a study conducted by Buchan et al. with 89 adolescent students to assess whether the HIIT intervention could improve the cardiovascular disease risk profile of secondary school students in a time-effective manner, after a 7-week intervention, the results showed no significant differences between groups for any of the nine biochemical risk markers for cardiovascular disease, but significantly improved cardiorespiratory fitness 41 .

Two of the 16 studies showed that high-intensity exercise interventions had a positive effect on heart rate. In one study examining the effect of exercise intensity on blood pressure and heart rate in obese adolescents, after a 6-month period of HIT and LIT, beneficial changes in HR and HRV occurred only in the HIT group 24 . In a randomized controlled trial, Ketelhut et al. assessed the effect of implementing school-specific HIIT in a physical education curriculum on various hemodynamics parameters and heart rate variability, and after a 12-week intervention, the results showed that significant changes in heart rate were obtained in the intervention group ( p = 0.010) 52 .

In addition, five other studies have all demonstrated the beneficial effects of high-intensity exercise interventions on cardiorespiratory fitness. Grasten et al. examined the effects of moderate-to-vigorous physical activity and ST with cardiorespiratory fitness in schoolchildren from 2017 to 2020, assessing accelerometer based MVPA by using waist-worn activity monitors and CRFs at four measurement points using the 20-m shuttle run test and ST, which showed a positive correlation between MVPA and CRF, and a negative correlation between ST and CRF 42 . Taber et al. conducted a moderate and vigorous exercise intervention with 1,029 eighth-grade girls and measured cardiorespiratory fitness using the Modified Physical Exercise Capacity Test (MPCT), which showed that vigorous exercise was positively associated with cardiorespiratory fitness 35 . Dias et al. showed that after 12 weeks of HIIT and MICT interventions, the HIIT group had a significant increase in relative peak VO2 compared to MICT, which was very effective in improving cardiorespiratory fitness 32 . Both studies by Gerber et al. and Leppanen et al. showed that higher levels of MVPA were associated with higher CRF scores 39 .

Effects of different exercise intensities on FLEXIBILITY in children and adolescents

Only two studies assessed changes in flexibility and no effects were found. The first study, conducted by Buchan et al., showed that after a 7-week period of high-intensity interval exercise, the intervention group showed an increase in vertical performance, and 10-m sprint speed ( p < = 0.05), while the control group showed a significant decrease in both flexibility and vertical performance 41 . The most recent study, conducted by Juric et al. investigated the effects of a HIIT intervention lasting 12 weeks on balance, coordination, speed, flexibility, strength, and agility in 10- to 15-year-old students, and showed no significant effects. This may be because short-term HIIT interventions of only two 10-min sessions per week do not provide sufficient stimulation for fitness (muscular strength, muscular endurance, power, speed, flexibility, and balance) enhancement 50 .

Effects of different exercise intensities on MUSCLE FITNESS in children and adolescents

Five studies assessed changes in muscle fitness, and four showed that high-intensity exercise interventions had a positive impact on muscle fitness in children and adolescents. Larsen et al. explored whether the musculoskeletal fitness of 8–10 year old schoolchildren is affected by frequent high-intensity physical education classes, and showed that after a 10-month intervention of varying intensities, the intervention group had higher scores for changes in bone mineral content (BMC) and bone mineral density (aBMD) change scores were higher, suggesting that well organized high-intensity physical education sessions can promote the development of musculoskeletal fitness in young children 29 . A study of the effects of different resistance training programs on the development of muscular strength and endurance in children found a significant increase in leg extension muscular endurance with low repetition-heavy loads and high repetition-heavy loads, with high repetition-medium loads being significantly greater than low repetition-heavy loads training, and in the chest press exercise only the high repetition-medium loads exercise group had significantly greater muscular strength and muscular endurance than the control group 33 . Benson et al. found that an 8-week PRT (two sets of high-intensity exercises targeting major muscle groups) intervention resulted in significant increases in upper body strength and lower body strength compared to a control group 34 . Leppanen et al. investigated the effect of physical activity intensity on PHYSICAL FITNESS in children by using the PREFIT PHYSICAL FITNESS test to measure PHYSICAL FITNESS (that is, cardiorespiratory fitness, lower and upper body muscular strength and motor fitness), and the results showed that replacing sedentary, low- or moderate-intensity exercise with 5 min of high-intensity exercise per day promoted an increase in muscle strength 38 .

However, Videira-Silva et al. showed no significant improvement in muscular endurance in participants in the 12-week HIIT group 49 . That's because the study, which only had two 10-min short-term high-intensity interval exercise sessions per week, failed to provide enough stimulation for fitness enhancement. Therefore, long-term, high-intensity training may be necessary to effectively improve muscle fitness in children and adolescents.

This review aimed to summarize the effects of physical activity of different exercise intensities on the PHYSICAL FITNESS of children and adolescents. The analysis included 30 interventional studies from 15 countries. 30 studies were assessed as above average, with good reason to believe that different exercise intensities had different effects on PHYSICAL FITNESS in children and adolescents. Based on strict restrictions on the nature of the intervention included in the studies, the studies included in the study span the years 1999 to 2024 (Table 1 ). It can be guessed that since 1999, researchers have gradually found differences in improving the PHYSICAL FITNESS of adolescents with different exercise intensities. In addition, from the perspective of regions and countries where the literature is published, relevant research is mainly concentrated in developed countries and some developing countries. This may be because, with the increase in material wealth, the PHYSICAL FITNESS of children and adolescents has received a high level of attention. Judging from the number of relevant published literature, there is still a lack of research on the effects of different exercise intensities on the PHYSICAL FITNESS of children and adolescents internationally. Therefore, this study aims to draw the attention of more draw the attention of more researchers from different regions and countries to this topic and encourage the conduction of controlled trials with high-quality evidence to further demonstrate the positive effects of different exercise intensities.

This study shows that high intensity exercise training has significant effects in improving body composition. It was mainly more effective in reducing visceral fat. These results align with a previous review by Batacan et al., which synthesized 65 studies and showed that HIIT can significantly improve waist circumference and body fat percentage in people who are overweight or obese 54 . A meta-analysis of adolescents found that exercise interventions of different intensities were differentially effective in reducing body weight and body mass index, and that high-intensity aerobic exercise and high-intensity aerobic exercise combined with high-intensity resistance training were more effective than low- and moderate-intensity exercise interventions 55 . We suspect that this may be due to the fact that high-intensity exercise leads to excessive post-exercise oxygen consumption and the substrate for this energy oxidation is fat, during high-intensity exercise the body needs to secrete more adrenaline and noradrenaline to control the muscles, and in addition the body has to maintain high metabolic levels for a longer period of time even after exercise. All of these effects lead to an increase in the body's resting metabolic levels, which further stimulates fat burning and leads to weight loss 56 , 57 . It is also interesting to note that Buchan and Kargarfard, when exploring the effects of HIIT on body composition in normal and obese adolescents, did not find any good changes in body composition or waist circumference in the intervention group. Both studies claimed that the lack of effect on body composition was due to the short duration of the training (duration of 7 and 8 weeks) 58 , 59 . Therefore, we suggest that relevant scholars pay more attention to the optimal training time when high-intensity exercise training can effectively improve the body composition of children and adolescents, and provide more effective training programs to reduce the obesity rate of children and adolescents at home and abroad.

This study showed that both high-intensity exercise training and moderate to low-level exercise training can improve cardiorespiratory fitness in children and adolescents, but high-intensity exercise training has a more significant effect on cardiorespiratory function. This finding coincides with previous conclusions 60 , 61 , 62 . A meta-analysis of adolescents aged 11–17 years found that high-intensity exercise training has a significant effect on improving cardiorespiratory fitness in adolescents compared to moderate-intensity exercise 60 , which is consistent with our findings. The mechanism by which this occurs may be due to the fact that high-intensity training increases the oxidative capacity of skeletal muscle more efficiently than conventional training methods. For example, in terms of the molecular adaptive mechanisms of skeletal muscle oxidative capacity, high-intensity exercise activates the activity of AMPK and MAPK exercise-responsive kinases 63 , 64 , while increasing the amount of mRNA for PGC-qα, a transcription factor that regulates the oxidative function of mitochondria. With the activation of the joints leading to increased transcription of mitochondrial substances, this allows the body's aerobic and anaerobic capacity to be enhanced, leading to improved cardiorespiratory fitness 65 . We therefore recommend that schools should incorporate high-intensity program in their physical education curricula so as to improve the cardiorespiratory fitness of children and adolescents and to reduce the probability of children and adolescents suffering from cardiovascular diseases in adulthood.

Muscle fitness is widely recognized as a key fitness component for maintaining overall health and is negatively correlated with obesity 66 .In this review, five studies confirmed the effects of different exercise intensities on muscle fitness function in children and adolescents. A systematic study of school-age children and adolescents suggests that high-intensity physical activity is more beneficial in building muscle 67 . Our findings are supported by Smith et al.'s study, where strenuous physical activity was positively associated with muscle fitness in children and adolescents 68 . In addition, only 1 study in this study showed that high-intensity training was effective in improving muscle flexibility. Muscle flexibility can be expressed as the normal physiological range of joint motion 69 . If adequate flexibility is lacking, daily activities will become difficult. In addition, reduced flexibility can also lead to musculoskeletal injuries 70 . Therefore, maintaining (or increasing) flexibility is essential as it maintains normal joint motion, thereby reducing the risk of injury 71 . A study of adolescents aged 14–17 years found that a 12-week, high-intensity training intervention resulted in adolescents displaying greater flexibility 72 , which is consistent with our findings. Furthermore, in the literature included in this review, only 1 study showed that high-intensity training improves muscle flexibility, but there was insufficient evidence that muscle flexibility is associated with high-intensity training. We speculate that on the one hand, this may be related to limitations in the assessment of muscle flexibility. The currently commonly used methods of assessing muscle flexibility (sitting and stretching) are unable to detect a lack of function due to muscle laxity 73 ; the other side of the coin is that most of the current research on muscle flexibility has focused on the elderly population, with less attention paid to children and adolescents. This is due to the fact that muscle flexibility decreases with age, leading to increased joint stiffness and progressive loss of balance, which increases the risk of falls in older adults 73 . Overall, appropriate levels of flexibility have positive implications for the PHYSICAL FITNESS of children and adolescents, and exploring scientifically sound methods of assessing flexibility and research on flexibility in children and adolescents should receive more attention.

Research limitations and prospects

Although this review discusses the effects of different exercise intensities on the PHYSICAL FITNESS of children and adolescents from four aspects, its limitations should be properly examined. This review provides direction for further research on the effects of different exercise intensities on the PHYSICAL FITNESS of children and adolescents. Although an extensive literature search was conducted, including articles published before 2024, it is possible that some relevant literature may have been overlooked due to variations in keywords used in this study. Additionally, we conducted an extensive literature search in four major databases, but some published non-English foreign studies may have been missed in this review as our search was limited to English-language journal articles.

Despite these limitations, this review systematically collated the literature reports on the different effects of different exercise intensities on the PHYSICAL FITNESS of children and adolescents. Future research could explore higher-quality randomize controlled trials to provide more convincing evidence for optimal exercise intensity to improve the health of children and adolescents. Future research should also focus on the effect of different exercise intensities on muscle flexibility. At the same time, more comprehensive exercise evaluation is needed to support high-intensity exercise training as an effective exercise program to improve the PHYSICAL FITNESS of children and adolescents.

Conclusions

This systematic review demonstrates a positive association between high-intensity exercise training and PHYSICAL FITNESS in children and adolescents. High-intensity exercise training yields notable improvement in body composition (reduced body mass index, waist circumference, and body fat), cardiopulmonary function, and muscle strength in children and adolescents. Furthermore, the high-intensity training group outperforms both the moderate-intensity group and the control group in terms of improving physical fitness. Specifically, participation in HIIT exhibits a more significant effect on improving PHYSICAL FITNESS in children and adolescents. Based on the findings, we recommend that schools optimize their physical education programs by incorporating more high-intensity physical activities, thereby promoting the healthy growth of children and adolescents through effective exercise.

Moreover, the study highlights that the effects of high-intensity physical activity on the PHYSICAL FITNESS of children and adolescents may be influenced by factors such as average age, overweight or obesity of participants. Therefore, further refinement of the study design is necessary, along with additional high-quality research, particularly randomized controlled trials, to ensure the long-term reliability of the results. Additionally, in terms of measurement of related indicators, this study primarily relies on manual measurement and automated equipment, which may introduce measurement errors. Subsequent studies could consider using more advanced instruments to assess relevant indicators of the PHYSICAL FITNESS of children and adolescents.

Data availability

Data is provided within the manuscript or supplementary information files.

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Zhou, X., Li, J. & Jiang, X. Effects of different types of exercise intensity on improving health-related physical fitness in children and adolescents: a systematic review. Sci Rep 14 , 14301 (2024). https://doi.org/10.1038/s41598-024-64830-x

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A systematic review of peer-reviewed gender literature in sustainability science

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Elisabeth Frank 1 ,
Rike Mühlhaus 2 ,
Katinka Malena Mustelin 3 ,
Esther Lara Trilken 4 ,
Noemi Katalin Kreuz 5 ,
Linda Catharine Bowes 6 ,
Lina Marie Backer 7 &
Henrik von Wehrden 8

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We conducted a systematic review of the available peer-reviewed literature that specifically focuses on the combination of sustainability and gender. We analyzed the existing peer-reviewed research regarding the extent to which gender plays a role in the empirical literature, how this is methodologically collected and what understanding of gender is applied in those articles. Our aim is to provide an overview of the current most common fields of research and thus show in which areas gender is already being included in the sustainability sciences and to what extent and in which areas this inclusion has not yet taken place or has only taken place to a limited extent. We identified 1054 papers that matched our criteria and conducted research on at least one sustainable development goal and gender research. Within these papers (i), the overall number of countries where lead authors were located was very high (91 countries). While the majority of lead authors were located in the Global North, less than a third of the articles were led by authors located in the Global South. Furthermore, gender is often just used as a category of empirical analysis rather than a research focus. We were able to identify (ii) a lack in coherent framing of relevant terms. Often no definition of sustainability was given, and only the sustainability goals (SDGs or MDGs) were used as a framework to refer to sustainability. Both gender and sustainability were often used as key words without being specifically addressed. Concerning the knowledge types of sustainability, our expectation that system knowledge dominates the literature was confirmed. While a problem orientation dominates much of the discourse, only a few papers focus on normative or transformative knowledge. (iii) Furthermore, the investigated literature was mainly contributing to few SDGs, with SDG 5 ‘Gender Equality’ accounting for 83% of all contributions, followed by SDG 8 ‘Decent Work and Economic Growth’ (21%), SDG 3 ‘Good Health and Well-being’ (15%) and SDG 4 ‘Quality Education’ (12%). We were additionally able to identify seven research clusters in the landscape of gender in sustainability science. (iv) A broad range of diverse methods was utilized that allow us to approximate different forms of knowledge. Yet within different research clusters, the spectrum of methodologies is rather homogeneous. (v) Overall, in most papers gender is conceptualized in binary terms. In most cases, the research is explicitly about women, running the risk that gender research in sustainability sciences grows into a synonym for women's studies.

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Environmental-, social-, and governance-related factors for business investment and sustainability: a scientometric review of global trends

Climate change effects on vulnerable populations in the Global South: a systematic review

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Introduction

The progression of climate change and further environmental degradation have direct ecological and social consequences that affect and will affect people differently according to different structures of social inequality (Kaijser and Kronsell 2014 ; Johnson et al. 2022 ; Thompson-Hall et al. 2016 ). This insight is important insofar as it sheds light on the fact that environmental problems and climate change will not have the same effects globally, but are context specific and related to power and domination structures (see contextualized vulnerability O’Brien et al. 2007 ) and must therefore be analyzed accordingly (Hackfort 2015 ; Johnson et al. 2022 ). However, sustainability science is not only dedicated to analyzing the problems that we will face as a result of ecological exploitation in ecological, social and economic terms, but also attempts to develop solution-oriented strategies and provide policy advice (von Wehrden et al. 2017 ). Therefore, it is equally important to reflect this power and domination-critical perspective in the search for solution options and to include different stakeholders (Malin and Ryder 2018 ). One specific issue that should be analyzed in connection with sustainability science problems and solution development is gender. As many studies have already shown, the effects of climate change and other problems resulting from the exploitation of natural resources have a gender-specific (Dankelman 2010 ; Denton 2002 ; MacGregor 2010 ) or intersectional impact (Kaijser and Kronsell 2014 ; Johnson et al. 2022 ; Thompson-Hall et al. 2016 ). Even though the unequal impacts of, e.g., climate change in terms of gender have been researched empirically in many areas such as agriculture (Agarwal 1998 ; Alston and Whittenbury 2013 ; Glazebrook et al. 2020 ), migration (Chindarkar 2012 ; Lama et al. 2021 ) and natural disasters (Enarson and Chakrabarty 2009 ; Neumayer and Plümper 2007 ), to date there has been no systematic recording of the research field of gender in the sustainability sciences. Our focus in this review is to give a broad overview of the current state of art regarding the topic of gender in sustainability science. We analyze the existing research regarding the extent to which gender plays a role in the empirical literature, how this is methodologically collected and what understanding of gender is applied in those articles. Our aim is to provide an overview of the currently most common fields of research and thus show in which areas gender is already being included in the sustainability sciences and to what extent and in which areas this inclusion has not yet taken place or has only taken place to a limited extent. Before describing our research focus in more detail, we first define our two main concepts, namely sustainability and gender.

We refer to sustainability based on the widely quoted definition by the Brundtland report from 1987 as meeting present needs without compromising the ability to compromise the needs of future generations (Brundtland 1987 ). Furthermore, our sustainability understanding includes an integrational perspective, also referred to as nested circles model, meaning that sustainability builds on economic, social and ecological dimensions that are interdependent and interconnected (Lozano 2008 ; Odrowaz-Coates 2021 ). In this framework in opposition to others, the economic and social pillars are not independent from the environmental dimension, but instead depend on it (Mebratu 1998 ).

Sustainability science addresses the challenges that threaten the long-term security of societal development conditions by distinguishing three levels that need to be researched: the systemic level to create system knowledge, the normative level to map out target knowledge and the operative level that aims to develop transformative knowledge (Brandt et al. 2013 ; Grunwald 2007 ; Michelsen and Adomßent 2014 ). System knowledge aims at describing and understanding a given social and/or ecological system via descriptive analysis. This often is disciplinary empirical research to analyze the dynamics, root causes and underlying mechanisms of the identified problem or system. System knowledge tries to reflect the current state of a system and its ability to change (Brandt et al. 2013 ; Grunwald 2007 ; von Wehrden et al. 2017 ; Wiek and Lang 2016 ). After identifying a problem and being able to describe it, target or normative knowledge is important to indicate the perception and direction of change. By asking what a desirable future situation could look like, target knowledge provides an orientation and an aim toward the development of solution options. This knowledge is normative since it asks which values are important when developing solutions to the identified problem (Grunwald 2007 ; von Wehrden et al. 2017 ). To then be able to address real-world place-based problems, transformative or action-oriented knowledge is necessary. By developing evidence-supported solutions, transformative knowledge offers possible transition paths from the current to the desirable situation (Grunwald 2007 ; von Wehrden et al. 2017 ; Wiek and Lang 2016 ). This action-oriented knowledge which aims at solving and mitigating the identified context-specific problem represents the main gap to this day (von Wehrden et al. 2017 ). While there are diverse and multi-faceted approaches in sustainability science (Clark and Harley 2019 ), we use the sustainable development goals as a lens of analysis. We agree that the conceptual foundation of sustainability is very diverse, and have mentioned the root literature above. However, the sustainable development goals can be seen as a main policy basis that currently attempts to shift the world toward a more sustainable development. While we agree that many conceptual foundations exist to this end, we focus on the SDGs since these contain a diversity of topical focuses, including gender.

Within the domain of sustainability, this review focuses on the diverse scientific literature published under the term of ‘gender’. We refer to gender as a historical construct consisting of attributes, norms, roles, opportunities, responsibilities and expectations that are socially, culturally and institutionally embedded and produce certain gender identities and social constructs (Arevalo 2020 ; Lieu et al. 2020 ; Mechlenborg and Gram-Hanssen 2020 ). Consequently, gender is not ‘given’ but learned and therefore dynamic and changing across a diverse and fluid spectrum (Curth and Evans 2011 ; Moyo and Dhliwayo 2019 ). Furthermore, we acknowledge the ‘intersectional’ nature of gender, i.e., the idea that one’s gendered experience of life overlaps and interacts with other axes of identity and systems of oppression (Richardson 2015 ).

Gender and environment

Now that we have defined the two core concepts of this article, sustainability and gender, we proceed to briefly summarize the state of research on gender in environmental and sustainability sciences. Before sustainability was declared a central part of international development in the 1990s and gender issues were incorporated in those development frameworks from the early 2000s, activists and researchers drew attention to the links between environmental degradation and gender inequality as early as the 1970s, with a particular focus on the disadvantages faced by women (Levy 1992 ; Mehta 2016 ). This early field of research called ecofeminism postulated an intrinsic relationship between women and nature based on their shared reproductive capacity (Majumdar 2019 ). Ecofeminism unites many currents and movements. Some of these take up an essentialist and biologistic understanding of gender, e.g., Shiva ( 1988 ), Mies and Shiva ( 1995 ), Agarwal ( 1992 ), Hackfort ( 2015 ). Women are understood as caring and nurturing by nature and at the same time suppressed by patriarchy as always being inferior and dominated by men (Agarwal 1992 ). Ecofeminists identified that the exploitation of women as well as of nature occurs in similar patterns, which is why it was assumed that "all women would have the same kind of sympathies and understandings of environmental change as a consequence of their close connection to nature [as well as their shared experience in exploitation]" (Majumdar 2019 , p. 72). Politically, these arguments and claims were taken up by the Women in Development (WID) approach which was adopted by many development agencies and NGOs in the 1970s. They argued that because of women's unique relationship with the environment as well as their particular affection by the effects of environmental degradation, women should receive special attention in global economic development (Levy 1992 ; Mehta 2016 ; Sasser 2018 ). Over the years, the arguments and theories of the essentialist view of ecofeminism outlined above have been widely criticized (e.g., Agarwal 1992 ). Many feminist researchers have pointed out that concepts of nature and gender are socially and historically constructed and not biologically determined (Agarwal 1992 ; Gottschlich et al. 2022 ; Levy 1992 ). Furthermore, the depiction of women as a unitary was declared insufficient, as gender must be considered and analyzed in combination with other forms of oppression such as race, class, caste and so on (Agarwal 1992 ; Häusler 1997 ; Levy 1992 ).

What is disputed, however, is not that the oppressive relationship between gender and nature exists, but how it is justified and how it should be responded to Gottschlich et al. ( 2022 ). One of the most recited critiques stems from the Indian economist Bina Agarwal ( 1992 ), who, instead of an essentialist derived connection between nature and gender, adopts a materialist perspective to describe the link between Indian women and the environment (Agarwal 1992 ; Gottschlich et al. 2022 ). Agarwal points out that a gendered and class-based organization of production, reproduction and distribution results in differential access to natural resources and ecological processes (Agarwal 1992 ). For example, women’s responsibility for certain natural resources is based on the gendered division of labor as well as class-specific ownership and property relations. This ascription can also be seen as dependence of women on these natural resources to make a living, which often entails a greater sensitivity to the respective ecological processes (Agarwal 1992 ; Gottschlich et al. 2022 ; Sasser 2018 ). Agarwal terms this research perspective ‘feminist environmentalism’ (Agarwal 1992 ). As a further development of feminist environmentalism, feminist political ecology (FPE) emerged in the 1990s, which takes a more holistic, intersectional perspective regarding gender on the connections between gender and nature (see for example Rocheleau et al. 1996 ; Gottschlich et al. 2022 ; Sasser 2018 ). FPE focuses explicitly on gender-specific power relations, which are considered in their historical, political and economic contexts, as well as across a range of scales (Gottschlich et al. 2022 ; Mehta 2016 ). Possible research foci include, for example, gender-specific access to natural resources and an intersectional and decolonial approach to environmental degradation and ecological change, as well as ecological conservation and sustainable development (Gottschlich et al. 2022 ; Mehta 2016 ; Sasser 2018 ). FPE questions the so far dominating victimizing narratives and stereotypes of women often from the Global South and emphasize instead their agency in, for example, highlighting their resistance practices and activism (MacGregor 2020 ). As research from feminist environmentalism and feminist political ecology has broadened the perspective on the connections between gender and the environment, new approaches have also been sought at the international political level. The focus and programs now shifted toward gender and development (GAD) which addresses all genders. GAD approaches also acknowledge socially constructed gender roles as the cause for gender inequality and aim at creating different forms of empowerment from a grassroots, bottom-up perspective that includes, for example, women as active participants in development from the beginning (Sasser 2018 ). The last concept which we want to highlight is queer ecology that was developed from the 2010s onward, e.g., Mortimer-Sandilands and Erickson ( 2010 ). Queer ecology analyzes and critically reflects the dominant human–environment relationships in terms of the underlying heteronormative order of the gender binary. The queer perspective expands feminist political ecology by deconstructing the 'naturalness' of heterosexual desire and the associated heteronormative relations of reproduction and production. The queer theoretical perspective questions the heterosexual nuclear family as the basic economic unit of the household and instead expands the view of social re-production by focusing on queer care relationships (Bauhardt 2022 ; Hofmeister et al. 2012 ).

Gender and sustainability

Research integrating gender as well as insights and theories from gender studies into sustainability science is relatively new and as we will see is not yet an established cornerstone in this research field. Nevertheless, scholars so far have already presented some important aspects as to why and how gendered perspectives should be integrated into sustainability science. Both gender studies and sustainability science are inherently normative sciences. They aim both at system knowledge about existing inequalities and unsustainable structures and their causes, but at the same time also gaining transformational knowledge about how inequalities can be reduced and resolved to create a more just world (Hofmeister et al. 2012 ). Both research fields position themselves as inter- and transdisciplinary and furthermore conduct their research across different scales, spatial as well as temporal (Bürkner 2012 ; Jerneck et al. 2011 ; Martens 2006 ; Rodenberg 2009 ). Feminist analyses and the integration of gender into sustainability science can however help integrate social and historical contexts more comprehensively in the analysis of socio-ecological systems as well as contribute to the development of suitable policy instruments for reducing gender inequalities and expanding adaptive capacities by contributing a social science perspective (Hackfort 2015 ; Hofmeister et al. 2012 ; Littig 2002 ). Feminist scholarship especially enhances sustainability science research by including analysis of power relations. Research interests within sustainability science should uncover the prevalent power relations in nature–society relationships and deconstruct them at various levels (Hackfort 2015 ; Hofmeister et al. 2012 ). Furthermore, feminist analysis critiques the claims of objective, universal and (gender) neutral scientific research and instead emphasizes the generation of situated knowledge that adopts partial perspectives which cannot be understood in isolation from its context (Hofmeister et al. 2012 ).

While the concept of gender is already explored within some research areas of sustainability science literature (Eger et al. 2022 ; Khalikova et al. 2021 ; Meinzen-Dick et al. 2014 ), the current state of the art remains widely unclear (Gottschlich et al. 2022 ; Hackfort 2015 ).

Research interests

Thus, in this paper, we explore the heterogeneous research area of gender in sustainability science by means of a systematic literature review of the peer-reviewed literature to identify prevalent research foci, trends and gaps. We focus on five research interests outlined in the following.

Bibliometric indicators

Firstly, we create a bibliometric overview of the scientific literature on gender in sustainability, thereby giving an account of the geographic origins, contexts and affiliations of authors as well as geographic tendencies concerning both authorships and study locations. Moreover, we closely examine definitions and perceptions of gender within the given research. Here, we differentiate between two applications: (1) gender as a specific empirical category and (2) gender as the general research topic. We focus on analyzing whether articles use gender as one of several variables in their empirical research or focus on gender as a central research topic. Our aim here is to examine whether research to date has addressed gender in a rather superficial way or whether and in which cases deeper analyses of gender and sustainability are taking place.

Sustainability definitions

Our second research interest centers around specific definitions of sustainability, which we acknowledge to be diverse and often incoherent within the available literature. We examine which sustainability concepts are predominantly used in the reviewed articles as well as if and how sustainability is defined. By identifying the diverse understandings of sustainability within gender research, we explore the different ways that specific concepts of sustainability and gender are intertwined. In addition, we link these notions to the three knowledge types we described above, system, target and transformative knowledge. These different types of knowledge are all important when conducting transdisciplinary research as is done in sustainability science (Wiek and Lang 2016 ). They all fulfill important steps when approaching wicked problems such as climate change or gender equality and build the basis for a comprehensive understanding which is needed when dealing with multifaceted and complex problems (von Wehrden et al. 2017 ). Our research interest is to analyze what kind of knowledge there is already in regard to gender in sustainability science and to present a state of the art which knowledge types are prevalent and which need more attention in the future. To this end, we assume that systemic, descriptive knowledge (Brandt et al. 2013 ; CASS et al. 1997 ) is decreasing over time, yet still expect to find overall less papers creating target or transformative knowledge.

Sustainable development goals and gender equality

Thirdly, we focus our scope of research on articles linked to at least one of the sustainable development goals (SDGs) (United Nations 2015 ). Building on and extending the Millennium Development Goals, the SDGs provide an umbrella of sectors which the examined research articles can be attributed to and/or associate themselves with. The SDGs were agreed on by the United Nations as “a comprehensive, far-reaching and people-centered set of universal and transformative Goals and targets” (United Nations 2015 ). Applying the lens of the SDGs allows us to narrow down the range of articles related to sustainability, while acknowledging they do not provide an ultimate, but a prominent framework. In view of the SDGs as forming an entity of interlinked targets which are aimed at fostering simultaneous, overarching developments (Toth et al. 2022 ), we want to find out whether the papers are equally distributed to the SDGs or whether a few SDGs are dominating the discourse. This approach makes it possible to compare the number of research articles on gender associated with individual goals as well as to highlight clusters of SDGs which are prevalently mentioned together. By deriving research areas which are represented in a smaller share, we identify possible future areas to focus on.

In the fourth research interest, we concentrate on the methods used in the reviewed articles. Research within gender studies and feminist research are dominated by qualitative methods. Many scholars investigate their research interests regarding gender and gender equality by applying qualitative methods which document the subjects’ experiences and perspectives in their own terms (Gaybor 2022 ; Harcourt and Argüello Calle 2022 ). We determine clusters of methods used and how these connect to the knowledge types of sustainability and also to the respective SDGs that each article targets. Based on that, we are able to specify certain research clusters which can be grouped according to their generated knowledge and applied methods as well as thematic focus. This gives us information about which methods dominate in which research fields, to what extent they differ and which methods have not been used much to date.

Definition and understanding of gender

Finally, we aim to draw conclusions on definitions and understandings of gender in sustainability science and how these have changed over time. There cannot be a general historical account of the understanding of gender as it must always be specific to societies, cultures and regions of the world. For instance, the Western academic understanding of gender has undergone certain fundamental changes in the past century (Haig 2004 ; Muehlenhard and Peterson 2011 ). In this paper, we focus on two changes, namely (i) the constructivist turn which conceptualizes gender as not biologically determined in a binary of man and woman, but instead socially constructed (Fenstermaker 2013 ; West and Zimmerman 1987 ) and (ii) the acknowledgment of the ‘intersectional’ nature of gender (Bürkner 2012 ), i.e., the idea that one’s gendered experience of life overlaps and interacts with other axes of identity and systems of oppression (Crenshaw 1989 ; Richardson 2015 ). We explore if these important developments in the understanding of gender are reflected in the temporal distribution of the reviewed literature. Moreover, we detect correlations between (non-)binary, (non-)intersectional understandings of gender and research clusters/fields of sustainability.

In this review, we attempt to systematize a complex and heterogeneous field of research, which is why we are aware that this aim entails the risk of uncovering inconsistencies, renewing them or even creating them. We do not claim that our research interests and choice of methods are the ‘correct’ ones to systematically assess the topic of gender in sustainability science, but rather to provide an overview of which topics and methods have dominated the field of research to date, how these can be located in light of sustainability science concepts such as knowledge types or the SDGs as well as how individual international contributions can be used constructively for the further development of the subject area.

The paper is organized as follows. In section two, we describe the methods used, followed by the presentation of our results in section three. In section four, we discuss these results and give an account of their methodological limitations. Finally, we conclude by reflecting upon the results of this review and postulate future research implications.

Our systematic literature review was based on a quantitative bibliometric content analysis of the available literature. We thus created a broad overview of the state of the literature, with a particular focus on the key interests named in the introduction.

We identified articles via the Scopus database (Elsevier B.V 2020 ). Scopus was chosen as it contains natural science as well as social science articles. Additionally, Scopus allows for the search and preview of abstracts, which was helpful for conducting the systematic review.

We applied a search string containing the two words ‘gender AND sustainab*’. The initial search resulted in 5993 papers for the period of 1991–2021. We restricted our search to this time period because hardly any literature was available before, and most journals have no online record before. We excluded books, conference papers and book chapters and limited the review to articles that were published in English.

Inductively we created the following criteria: the included articles must

be able to be assigned to at least one SDG and

have gender as a research focus, and not only as a category of analysis.

Since the review focuses on gender in sustainability science, we needed at least two criteria for the inclusion of the articles. For one, the paper should make a clear link to sustainability, since this term is often used as a buzzword and we tried to exclude any literature that mentioned the concept only vaguely or in passing, such as in the first part of the introduction of the latter parts of the discussion. Regarding the first exclusion criteria, we decided to use the SDGs as one possible framework that reflects our understanding of sustainability science topics, and that can be seen as the current policy baseline. For our analysis, this meant in practical terms that we checked whether the topic of an article could be assigned to at least one SDG and, if so, which one. The extent to which the article addresses the SDGs themselves did not play a role here.

The second criterion to include a paper in the full-text analysis refers to the realization of gender. When conducting a pre-test with a random sample of articles, we realized that many articles just used gender as one of many variables in their empirical research and that the focus of the research question lay upon something completely different, where gender was a mere building block or one of many variables. To be able to narrow down our sample, we decided to only include articles that focus on gender as a central research interest. Therefore, we always read the respective abstracts to be able to determine whether a thorough research focus on gender was given or not.

Based on these criteria, we excluded 4959 articles. The remaining 1054 papers were coded according to the following five questions:

Does the article create system knowledge, target knowledge and/or transformative knowledge? The definitions for the three individual types of knowledge were extracted and applied from various articles, as already detailed in the introduction (see: Brandt et al. 2013 ; Grunwald 2007 ; Michelsen and Adomßent 2014 ).

Which SDGs can be assigned to the article? Which sustainability concepts and definitions were named?

Which methods were used in the article? We inductively grouped the respective methods into categories.

Does the article conceptualize gender as binary, as non-binary and/or as social constructs?

Does the article consider gender as the only category of analysis? Were further social categories addressed as well or is there an intersectional approach? Other social categories were specified in such cases.

A team of seven coders worked on the literature review in an iterative process. We coded the papers separately as well as together and clarified possible pitfalls in the criteria to minimize ambiguities. The respective categories were then summarized in a table which was the basis of all statistical analysis of the content.

Furthermore, we are interested in investigating whether there are specific research clusters within the domain of gender in sustainability science. Our aim is to identify the dominant fields of research that deal with gender and sustainability and to characterize these in more detail on the basis of the above-mentioned research interests. To derive groups out of the reviewed papers, we used a linguistic approach that classifies all papers into groups based on their word abundance. Within this analysis, we compiled all words in a document containing all papers, and the respective x–y table was clustered into groups according to Ward ( 1963 ). To visualize the respective groups, we used a detrended correspondence analysis (Abson et al. 2014 ), which allows for a descriptive analysis of the linguistic patterns of the literature. The groups were illustrated by significant indicator words that we identified by an indicator species analysis. Based on this multivariate linguistic approach, we derived seven unbiased groups of the reviewed literature, which are solemnly based on the word abundance of the papers. All statistical analyses were conducted with the R Statistical Software (v4.2.2; R Core Team 2022 ).

We identified a total of 1054 papers, out of which almost half were published after 2017 (48%) (Fig. 1 ).

Total numbers of papers published per year

While some journals contain a relatively high proportion of papers (e.g., Sustainability 65 articles, Gender and Development 31 articles, World Development 21 articles, Gender, Place and Culture 14 articles, Corporate Social Responsibility and Environmental Management 14 articles), there is no dominating journal, and articles are published in a total of 566 journals. Lead authors originate mainly from the USA (19.9%), UK (11.5%), Australia (5.8%), Canada (4.6%), India (4.5%), South Africa (4.4%), Spain (4.3%) and Germany (4.2%). Lead authors from Sweden, Netherlands, Nigeria, Italy, China, Austria, Indonesia, South Korea, Denmark, Turkey, Norway and Switzerland published more than 1%, but less than 4% of the papers. All other countries have less than 1% of the lead authors in proportion (see online appendix 1). These numbers must be interpreted particularly in the aspect that only English articles were included in the analysis.

The vast majority of the papers (844) are empirical, and 113 papers utilize gender as a category within the empirical analysis. Roughly, a third of all the articles analyze gender in combination with other social categories. The most researched intersection is between gender and class (also specified as income differences), followed by the intersection between gender and race. Concerning the utilization of the SDGs, 83% of all papers research on Gender Equality (SDG 5). Decent Work and Economic Growth (SDG 8) is included in 20% of all papers. Good Health and Well-being (SDG 3) and Quality Education (SDG 4) are mentioned by about 15% of all papers. All other SDGs are mentioned by less than 10% of the papers (Table 1 ).

The majority of concrete definitions regarding sustainability built on the SDGs (137); the Millennium Goals are mentioned by some 40 papers, the Brundtland report by 23, Agenda 21 by 16, while all other frameworks such as the Kyoto protocol (2), national strategies (2), Rio declaration (2), IPCC (1), the Three Pillar Framework (1), Corporate Sustainability (1) and Club of Rome (1) are mentioned less often. Concerning the knowledge types, system knowledge clearly dominates, with stronger ties to normative knowledge and slightly weaker ties to transformative knowledge. All three types of knowledge are only achieved by few (31) papers (Fig. 2 ).

Distribution of knowledge types

Concerning the use of scientific methods, the most abundantly applied methods are literature reviews (22.5%), closely followed by interviews (22%). Statistical approaches are used by 12,7% of the papers, closely followed by methods of participatory research (10.4%), case study approaches (10.6%) and surveys (9.8%). Other methods are less abundantly used, including ethnographic approaches (3.6%), discourse or content analysis (2.7%) or systematic literature review (2.7%) (Fig. 3 ).

Percentage of papers using certain scientific methods

The majority of papers consider a binary gender understanding. While there was an increase in the absolute total number of papers that considered a socially constructed gender understanding overall, the proportion of papers falling into this category did decrease.

In the following section, we introduce the different groups derived from multivariate analysis, and present key characteristics of the individual groups (Fig. 4 ).

Research clusters with number of relevant contributions and the five most significant words that statistically indicate the research clusters

Cluster 1: gender equality and institutions

The first cluster, which contains 207 papers, emerged first in 1991 and is thus the oldest cluster. The proportion of articles displays a diverse activity, having peaked in 2020. The research focuses on the institutional commitment toward gender equality (Hennebry et al. 2019 ; Kalpazidou Schmidt et al. 2020 ; Larasatie et al. 2020 ). The topical focus encompasses entrepreneurship (Kamberidou 2020 ; Kravets et al. 2020 ; Vershinina et al. 2020 ), especially concerning the empowerment of women in social enterprises (Allen et al. 2019 ; Benítez et al. 2020 ; Green 2019 ), yet also research regarding peace building (Adjei 2019 ; Kim 2020 ; Turner 2020 ), foreign policy (Agius and Mundkur 2020 ; Cohn and Duncanson 2020 ) and security (Curth and Evans 2011 ; Mahadevia and Lathia 2019 ; Rothermel 2020 ) is conducted. These focal points are reflected in the usage of the most mentioned SDGs, 8 (decent work), 10 (reduced inequalities), and 16 (peace, justice and strong institutions). About one-quarter of the articles channel sustainability through SDGs and MDGs or the Brundtland report as well as the Agenda 21. The research questions of nearly all articles aim at generating system knowledge, yet more than half of them also create normative knowledge. Besides gender, half of the papers include other social categories in their analysis, mostly focusing on class, race, sexuality and ethnicity. A binary gender framing is mainly used, yet one-quarter of the articles acknowledge gender to be a social construct. Most of the papers are qualitative case studies utilizing interviews or ethnographic approaches.

Cluster 2: gender in health and well-being

The second cluster, consisting of 165 papers, emerged in 2003 and is closely related to the first and the 6th cluster. The topical focus of this cluster is on health equity and the impacts of gender on health services (Manandhar et al. 2018 ; Scheer et al. 2016 ; Thresia 2018 ), for instance concerning the evaluation or assessment of health programs (Friedson-Ridenour et al. 2019 ; Williams et al. 2009 ). Next to barrier identification (Kennedy et al. 2020 ; Sawade 2014 ; Sciortino 2020 ) and empowerment strategy assessment (Maluka et al. 2020 ; Plouffe et al. 2020 ; Yount et al. 2020 ), system knowledge is created through qualitative assessment strategies such as methods of participatory research and interviews. A considerable number of papers discussed health equity also in terms of motherhood, especially maternal health and maternal mortality rates were covered often (Klugman et al. 2019 ; Morgan et al. 2017 ). One-quarter of the articles reference sustainability through SDGs and MDGs. About one-third of the articles also apply other social categories in their analysis, mostly adding the concept of class but also ethnicity, race and religion. While the papers in this cluster widely build on a binary gender framework, many concern gender inequalities, especially aiming at low- and middle-income countries and communities.

Cluster 3: gendered access to resources

Cluster number three, which contains 244 papers, started to emerge in 1995, with the majority of papers being published between 2017 and 2020. According to the word abundance analysis, this cluster partly overlaps with cluster number two and six. On the one hand, the papers in this cluster focus on the assessment of inequalities and gender-specific barriers. Specifically, they examine the structural discrimination as well as underrepresentation of women in certain areas (Crockett and Cooper 2016 ; Ennaji 2016 ; Lama et al. 2017 ; Woodroffe 2015 ). Two areas that are analyzed most often are the limited access to specific natural resources respective institutions such as water (Andajani-Sutjahjo et al. 2015 ; Pandya and Shukla 2018 ; Singh and Singh 2015 ), energy (Burney et al. 2017 ), education (Ansong et al. 2018 ) and healthcare (Rivillas et al. 2018 ; Theobald et al. 2017 ). Secondly, the limited and ineffective opportunities to participate in decision-making processes, for example, in politics (Dyer 2018 ; Lama et al. 2017 ; Sindhuja and Murugan 2018 ), agriculture (Azanaw and Tassew 2017 ) and at the workplace (Limuwa and Synnevåg 2018 ; Rohe et al. 2018 ). The identification of different challenges which women face in regard to participation and representation clash with the fact that the women in these cases often bear the responsibility for survival and sustainability of the respective community (Belahsen et al. 2017 ; Garutsa and Nekhwevha 2016 ; Limuwa and Synnevåg 2018 ; Rohe et al. 2018 ). Apart from this problem-oriented focus creating system knowledge, quite many articles in this cluster offer evidence-based recommendations and solution strategies on how to improve those inequalities by suggesting possible areas of intervention such as enforcing legislation, mentorship, quotas, financial inclusion, etc. (Ansong et al. 2018 ; Appiah 2015 ; Burney et al. 2017 ; Mello and Schmink 2017 ; Saviano et al. 2017 ). The authors emphasize that adaptation strategies and policy-making must be gender sensitive and critically reflect gender-specific circumstances, vulnerabilities and experiences (Garai 2016 ; Rakib et al. 2017 ; Rivillas et al. 2018 ; Shanthi et al. 2017 ; Theobald et al. 2017 ). Some papers channel sustainability through SDGs and MDGs or the Brundtland report as well as the Agenda 21. About 50 papers focus on class or caste, race, ethnicity and religion as categories apart from gender. A binary gender framing is mostly used, and studies are predominantly qualitative case studies utilizing interviews, surveys or methods of participatory research.

Cluster 4: gender inequality in public infrastructure

Cluster four contains 191 papers with first publications in 1997 and the majority of the papers being published between 2017 and 2020. The thematic focus of this cluster lies upon gender inequality in public infrastructure. The articles mainly apply a problem-oriented lens while addressing different areas of gender discrimination in which safe, affordable and sustainable access to certain institutions of public infrastructure is not given. Three areas are analyzed most often: gendered mobility investigates gender differences in travel patterns and modal split (Abasahl et al. 2018 ; Winslott Hiselius et al. 2019 ; Kawgan-Kagan 2020 ; Le et al. 2019 ; Mitra and Nash 2019 ; Polk 2003 ), gendered barriers in public transportation (Al-Rashid et al. 2020 ; Malik et al. 2020 ; Montoya-Robledo and Escovar-Álvarez 2020 ) as well as gender discrimination within transport planning and policy-making (Kronsell et al. 2016 , 2020 ; Wallhagen et al. 2018 ). The second area discusses gendered access to healthcare, mostly referring to services providing counseling and treatment for victims of gender-based violence (Betron et al. 2020 ; Minckas et al. 2020 ; Prego-Meleiro et al. 2020 ), sexual and reproductive health rights (Bosmans et al. 2008 ; Lince-Deroche et al. 2019 ; Loganathan et al. 2020 ) and HIV prevention as well as treatment (Gómez 2011 ; Ssewamala et al. 2019 ). The third area analyzes gendered access to education (Burridge et al. 2016 ; Islam and Siddiqui 2020 ). The majority of the papers create systemic knowledge. Notably, many papers are published in the journal ‘Sustainability’ and several articles contain ‘women’ in the papers’ title. A few articles reference sustainability by mentioning the SDGs and the Brundtland report. About 40 papers mention interlinkages with other types of social categories and do not solely focus on gender in their analysis. The gender framing is mostly binary. The methodology in this cluster utilizes most often literature reviews or case studies conducting interviews or surveys.

Cluster 5: gender inequalities in agricultural systems

This cluster consists of 102 papers, and dates back to 1995. Since 2017, its contribution is slowly increasing. The research within this cluster can be grouped into four aspects and widely generates system knowledge. The majority of the research focuses on gender roles and how these influence interactions with(in) local systems such as forestry (Benjamin et al. 2018 ; Nhem and Lee 2019 ; Stiem and Krause 2016 ), agriculture (Drafor et al. 2005 ; Ergas 2014 ; Fischer et al. 2017 ), fisheries (Tejeda and Townsend 2006 ; Szymkowiak and Rhodes-Reese 2020 ; Torell et al. 2019 ), water (Imburgia 2019 ; Singh 2006 , 2008 ) and the energy sector (Buechler et al. 2020 ; Stock 2021 ; Wiese 2020 ). One topical focus is about participation of women in decision-making and planning processes (Ihalainen et al. 2020 ; Mulema et al. 2019 ; Pena et al. 2020 ). Another focus aims at gender differences in climate adaptation and conservation strategies (Abdelali-Martini et al. 2008 ; Rao et al. 2020 ; Wekesah et al. 2019 ). Furthermore, many papers investigate challenges women face in (agricultural) resource control and management (Badstue et al. 2020 ; Pehou et al. 2020 ) as well as in the access to markets and the distribution of land (Holden and Tilahun 2020 ; Meinzen-Dick et al. 1997 ). Lastly, a considerable number of papers discuss gendered climate vulnerabilities and risk management (Friedman et al. 2019 ; Yadav and Lal 2018 ; Ylipaa et al. 2019 ). These research interests are also reflected in the mentioned SDGs, which are 15 (life on land), 8 (decent work), 2 (zero hunger) and 1 (no poverty). Only very few papers channel sustainability through SDGs and MDGs. About one-third of the articles also include other social categories in their research, mostly adding the concept of class but also religion, age, race and ethnicity. Regarding the understanding of gender about 10% perceive gender to be a social and cultural construct and only one mentions a non-binary understanding of gender. The majority of the papers conduct qualitative case studies, often combined with interviews, surveys or methods of participatory research. Papers within this cluster mostly report about local projects conducted in low- and middle-income countries of the Global South.

Cluster 6: inclusion of gender equality in sustainable development

Cluster six contains 45 articles and emerged in 1992. The number of published papers within this cluster fluctuated widely over the years, yet since 2019 the proportional contribution is slowly increasing. In contrast to the other clusters, the papers in this group are not centered around a certain topic, but rather focus on a general discussion regarding the inclusion of gender issues in research on sustainable development, yet here scholars mainly apply problem-oriented empirical research on gender inequalities, discrimination and biases often on a national scale. Those gender inequalities are often referred to as gender gap and focus mostly on political representation (Azmi 2020 ; Kreile 2005 ; Purwanti et al. 2018 ; von Dach 2002 ), access to education (Assoumou-ella 2019 ; Cortina 2010 ; Cheng and Ghajarieh 2011 ; Suvarna et al. 2019 ) and participation in natural resource management (Sasaki and Chopin 2002 ; Valdivia and Gilles 2001 ; Yadav and Sharma 2017 ). These topical areas also overlap with the mentioned SDGs, 4 (quality education), 8 (decent work), 3 (good health and well-being) and 16 (peace, justice and strong institutions). Gender equality is thus highlighted as one of the most important tasks in sustainable development. A few articles reference sustainability by mentioning the SDGs and the Brundtland report. About 20% of the articles also add further social categories apart from gender when analyzing inequalities in sustainable development. Besides gender, most of these focus on race and class. While a mere half of the papers in this cluster are conceptual, the rest conduct mainly qualitative case studies utilizing interviews, surveys and methods of participatory research. Studies range across the global and the country or local level.

Cluster 7: gender diversity and corporate performance

The last cluster is a recently emerging research area with contributions starting from the year 2016 onward. The 44 contributions in this cluster focus on human resource characteristics, primarily the gender diversity of boards (Orazalin and Baydauletov 2020 ; Romano et al. 2020 ; Xie et al. 2020 ) and the sustainable performance of firms or other organizations (Burkhardt et al. 2020 ; Mungai et al. 2020 ; Ozordi et al. 2020 ). The cluster as such is very homogenous with many contributions sharing similarly phrased research questions and a local approach that is reflected in either the focus on organizations in a certain geographic region or of a specific economic sector. This is also reflected in the most often mentioned SDG 8 (decent work and economic growth). Nevertheless, two research angles can be differentiated within this cluster which both contribute to create system knowledge: one angle investigates the relationship between gender representation and indicators of corporate social responsibility (CSR) (Tapver et al. 2020 ; Valls et al. 2020 ; Yarram and Adapa 2021 ), corporate environmental performance or specific sustainable policies (Birindelli et al. 2019 ; Elmagrhi et al. 2018 ; García Martín and Herrero 2020 ), while another more economic angle investigates the relationship between gender representation and the limitation of risks for ‘sustainable’ i.e., continuous growth (Gudjonsson et al. 2020 ; Loukil et al. 2019 ; Suciu et al. 2020 ). In their findings, most papers tend to highlight gender-(binary-)based differences in morality or ethics. There is no intersectional approach or other social categories in the articles, as well as nearly no sustainability references. The majority of the papers conducted quantitative research utilizing statistics.

In the introduction, we set out five research interests for this systematic literature review. Based on the research clusters, we revisit these focal points and embed our findings into the current debate.

(i) Regarding bibliometric data, while the overall number of countries with lead authors is very high with 91 countries, there is a tendency that the majority of lead authors are from the Global North, and less than a third of the articles are led by authors located in the Global South. This depicts an overall determined imbalance of publication origins as shown by Blicharska et al. ( 2017 ), Collyer ( 2018 ), Jeffery ( 2014 ), Karlsson et al. ( 2007 ) and Rokaya et al. ( 2017 ). Previous accounts found a domination of SDG-related publications from European regions (Sweileh 2020 ). Within our analysis, all of the countries from which most lead authors come are listed OECD countries and can thus be described as belonging widely to the Global North (Blicharska et al. 2017 ), underlining the data gap between the Global North and the Global South (Karlsson et al. 2007 ). A comparable imbalance was found regarding the countries most affected by climate change which are equally underrepresented in environmental science (Blicharska et al. 2017 ). This is even more pronounced since researchers from the Global North tend to hold higher posts within research teams, compared to those from the Global South (Jeffery 2014 ). Such power imbalances can, however, be tackled by a higher contextual transparency in the research conduct (Maina-Okori et al. 2018 ), and other SDG-aimed research reviews show a similar bias toward the European regions (Sweileh 2020 ), while for instance SDG 5 was least researched in the Western Pacific regions. Deeper contextual information is often omitted in research papers due to the demand in brevity; there are counterexamples that incorporate the author's background into the research context (Maina-Okori et al. 2018 ).

The proportion of papers that utilizes gender as a research focus was less than 10% and thus relatively low. Based on the word-driven analysis, we identify clear groups differentiated based on the topical focus, methodological approaches and theoretical foundation. The literature ranges from rather qualitative and discourse-oriented approaches to more survey and interview-driven literature. A second gradient in the literature ranges across different systems, for instance from agricultural systems to different organizations and their development.

(ii) Concerning our second research interest, we identify a lack in coherent framing of relevant terms. Often no definition of sustainability is given, and only the sustainability goals (SDGs or MDGs) are used as a framework to refer to sustainability. With other diverse sources such as the Brundtland report and the WCED 1987 as well as the Agenda 21 and the Rio Conference 1992 being cited to define the sustainability understanding of the respective paper, it is clear that a coherent and uniting framing of sustainability science is still lacking in this specific scientific literature. After all, these sources are quite old, and much has been published since (e.g., Clark 2007 , etc.). One article we want to highlight that situates itself both within sustainability science and includes a gendered perspective is by Ong et al. ( 2020 ). They classified their research on queer identities within tourism and leisure research as social sustainability, arguing that social sustainability advocates equal opportunities and human rights for both individual and social well-being (Ong et al. 2020 ). Another paper which we want to mention is that by Maina-Okori et al. ( 2018 ) because it argues from a perspective that was taken up very little by the analyzed articles. They call for the inclusion of Black feminist thought and Indigenous knowledge in sustainability science research as well as the reflection on colonial history, which is not given enough attention in research on climate protection, education for sustainable development or land use rights. Concerning the knowledge types of sustainability (systemic, normative and transformative), our expectation that system knowledge widely dominates the literature was confirmed, with a combination of systemic and normative as well as systemic and transformative knowledge being also abundantly published. We cautiously interpret this as a reflection of the research we investigated on partial knowledge, while an overarching integration of knowledge types is needed for many of the sustainability challenges we face, including the ones associated with gender. While a problem orientation dominates much of the discourse, only few papers focus on normative or transformative knowledge. In their paper on environmental justice in urban mobility decision-making, for instance, Chavez-Rodriguez et al. ( 2020 ) combined all three knowledge types. First, they dismantled how discourses and narratives on urban mobility are often socially exclusionary and reproduce patterns of marginalization (systemic knowledge). They then argued that environmental justice as an intersectional system must include mobility justice (normative knowledge). In the end, they proposed a framework definition of ‘queering the city’ which shall help to create a more emancipatory narrative on urban mobility (transformative knowledge) (Chavez-Rodriguez et al. 2020 ). However, the small proportion of papers doing this indicates a lack of an overarching perspective when it comes to the diverse knowledge types, which can be considered relevant to overcome the problems we face globally.

(iii) Concerning the third research interest, the investigated literature mainly contributed to few SDGs, with SDG 5 ‘Gender Equality’, SDG 8 ‘Decent Work and Economic Growth’, SDG 3 ‘Good Health and Well-being’ and SDG 4 ‘Quality Education’ being in the main focus. All other SDGs were mentioned by less than 10% of the papers. This underlines that most scientific papers are rather focused than holistic when viewed through an SDG perspective. While no research can meaningfully engage with all SDGs, we would propose that a wider coverage of other SDGs to be engaging more in gender research would be beneficial.

Furthermore, SDGs are often mentioned as a boundary framework while missing the chance to deeply engage with the conceptual foundation or purpose of the SDG framework. Within the vast majority of papers, the SDGs are referred to as a means to the end of positioning the research within a current discourse. In other words, many papers do not work with the SDGs to contribute toward its strategies and solutions, but instead to simply be affiliated to the broad movement of sustainable development. This reference often takes place in the introduction or conclusion of the paper and is of no importance in the actual research. This gives the impression that the popularity of the SDGs, which goes beyond the discourse of sustainability science, is used to categorize or identify one's own research within the light of sustainability.

However, there are many constructive contributions toward a critical perspective on the integration of the Sustainable Development Goals. Ong et al. ( 2020 ) highlight that queer identities are not included within the SDGs, yet they relate their research to several SDGs such as SDG 5, 10, 11 and 16. They argued that “these goals demonstrate the centrality of inclusivity to the development of sustainable communities'' (Ong et al. 2020 , p. 1477). Poku et al. ( 2017 ) went one step further and postulated the need to queer the SDGs by linking opportunities for addressing social exclusion for LGBTI in Africa to the SDGs.

(iv) Based on the set of the literature we analyzed, all in all, gender and sustainability research utilize a broad range of methods that allow for different forms of knowledge (Spangenberg 2011 ). However, we find strong links between specific methods and certain areas of sustainability within the emerging groups within the identified literature. For example, nearly all research in cluster seven, which focuses on corporations and economy, uses a quantitative statistical approach, while other clusters are defined by qualitative methods and lack quantitative ones. This methodological homogeneity within certain research clusters highlights already established preferences for certain methods in specific fields of research, disciplines and focal topics where some methods are more adequate than others. Due to the interdisciplinary nature of gender and sustainability, however, we critically regard these links as they often emerge from previously existing research traditions and thus lack methodological plurality.

(v) Within the examined literature, the two investigated understandings of gender, namely non-binarity and intersectionality, are differently acknowledged and incorporated in the reviewed literature. Very few authors challenge the gender binary approaches within the considered scientific articles, where less than a fifth of the papers considered gender to be socially constructed (14%) or non-binary (5%). While the vast majority of papers do not explicitly state that they build on a binary understanding of gender, they nevertheless replicate or suggest a binarity in their focus and/or empirical categorization that clearly indicates a binary division. Moreover, some papers put forward ethical or moral differences in men and women when it comes to sustainability. For example, some researchers are led by gender assumptions which often originate from the field of eco-feminism such as women being more caring of the environment, since they have a natural disposition to care and to being a mother (Brough et al. 2016 ; Lau et al. 2021 ). When such proposals do not pay attention to gender norms and power imbalances, they run the risk of further naturalizing the gender binarity as ‘immutable biological differences’ (Lau et al. 2021 ). Lastly, we find that gender differences are nearly always illustrated on behalf of women. While an explicit focus on women’s lives in research can be useful and necessary, it should not be limited to it. A narrow focus on women excludes many other genders from research and can furthermore evoke the assumption that gender equality and sustainability are ‘women’s issues’ (Lau et al. 2021 ).

No pattern regarding the temporal increase or decrease of non-binary or socially constructed gender understanding can be found in the body of literature examined by us, in absolute numbers or in proportions.

In summary, theories and findings from gender studies like the constructivist turn and queer theory as well as intersectionality are yet to permeate the field of sustainability research.

Within the examined research, there is clearly a limited acknowledgment of intersectionality, with less than a third of all articles using other social categories apart from gender in their analysis or applying even an intersectional approach. Intersectionality was thus applied in diverse research cluster groups underlining the importance for a diverse methodological approach to investigate intersectionality (Rice et al 2019 ). Intersectionality is most frequently addressed in the research cluster focusing on gender and institutions, meaning that this literature named and utilized the concept. We refrained from making a deeper analysis of whether more than one social category was analyzed, which would demand a deeper text analysis. We refrained from such interpretation, because due to the short form of peer-reviewed papers such information is often omitted or not coherently reported. However, intersectionality often is hardly mentioned in the analyzed papers, neither as a word nor as a concept. Instead, different identity categories than gender are merely used to further characterize the research subject(s). For instance, Theobald et al. ( 2017 ) referred to intersectionality in their research regarding gender mainstreaming within health and neglected tropical diseases, highlighting the impact of gender on health issues while acknowledging the intersection of gender with other axes of inequality. They illustrated how dimensions of gender interact with poverty, (dis)ability, occupation, power, geography and other individual positionalities in shaping impacts on health and care programs (Theobald et al. 2017 ).

The concept of intersectionality is applied on a diversity of topics. As Rice et al. ( 2019 ) point out, there is also “no single method for undertaking intersectional research. It can be used with many methods and approaches, quantitative and qualitative” (Rice et al. 2019 , p. 418). In addition to previously mentioned example papers from our analysis focusing on tourism as well as sustainability education, there are suggestions to match the SDGs with an intersectional conceptualization (Stephens et al. 2018 ; Zamora et al. 2018 ). Similarly, attempts to integrate intersectionality to other long standing policy communities such as global health exist (Theobald et al. 2017 ). Hardy et al. ( 2020 ) integrate the concept into research on indigenous youth. Such papers showcase the strong connectivity of the concept to many different branches of research. By integrating diverse voices, showcasing how injustices are intertwined and that different reasons for injustices amplify each other, intersectionality can serve as a strong foundational concept within sustainability science (Maina-Okori et al. 2018 ). Our review showcases that the majority of papers focusing on gender do not utilize the concept. Within the analyzed literature, overall citation rates are comparably low and the most highly cited papers do not utilize the concept. In summary, intersectionality has not fully reached the sustainability science community as of yet.

Before we come to our final conclusions, we would like to again reflect upon our positionality as scholars researching this topic. We recognize that we as scholars have a highly privileged position in academia as well as the world, both regarding resources and the institutions at which we are working in that make our voices heard. We would like to use this position to address the existing power dynamics within sustainability science to other equally privileged scholars. We hope to reflect upon and challenge the deeply embedded power structures within Western academic knowledge production as well as considering the role gender inclusive and intersectional approaches can play in addressing sustainability problems. This paper is a mere attempt to grasp the research that has so far been conducted upon gender in sustainability science, and from our end a definitive work in progress. Yet, this is then also the ultimate goal in writing this paper, to progress, even if it is only one step at a time.

Finally, we would like to give an outlook on what findings have been published in the period following our research period. For this purpose, we again entered our search string in the Scopus database and searched for articles on gender in sustainability science for the period January 2021 to October 2022. This search yielded a further 2.304 articles after applying our exclusion criteria. To narrow the analysis, we sorted these results by citation and looked at the articles with the highest citations. This cursory scan reveals that many papers consider gender only as an empirical category of analysis, and that these are thematically related to the field of economics and health, for example, with regard to the COVID-19 pandemic. Only a few focus on gender as a central research interest. These results also largely coincide with the results of this review. As a perspective, we would like to highlight the COVID-19 pandemic once again, because the analyses and studies that have been conducted in connection with gender can shed new light on the role of gender during global crises and are therefore an important contribution to sustainability science.

We have systematically examined the development and state of research focusing on gender in sustainability science by means of a quantitative analysis of 1054 peer-reviewed papers published between 1991 and 2021. Our analysis clearly illustrates that while a diverse body of literature on gender exists within sustainability science, several research clusters with different focal points are emerging. As all these branches of the literature utilize diverse methodological approaches and different conceptual foundations; there is a lack of a more holistic integration of the topic within the broader literature. While the word “holistic” is a clearly big claim, we can underline based on our review that conceptual foundations, definitions and agreement on the most simple terms and procedures are lacking to this day, while at the same time the problems of gender issues are mounting.

It is highly likely that the recent surge in literature will increase. Thus, we put forward five tangible suggestions on how the research community could further evolve below.

Although a research focus on gender will not solve the prevalent problem of postcolonial research structures, an increasing diversity of voices with different backgrounds would bring forth new and diverse knowledge. At this point, we would like to draw particular attention to the theories and bodies of knowledge of Black feminists, as well as Indigenous knowledge and decolonial approaches.

We advise the research community to build on distinct definitions of sustainability as well as to put a strong focus on the contribution toward solutions for sustainability challenges. The creation of descriptive-analytical system knowledge which outlines the current status quo of gender equality with regards to sustainability and points out many current problems is a necessary and helpful first step. Yet, knowing the mechanics and causes of a problem does not translate into knowing how to approach and move toward a state of more equality. We therefore urge scholars to also apply a solution-oriented perspective in their research regarding gender in sustainability science.

Moreover, although there is seemingly much research that discusses gender issues, only a low proportion of those papers actively engage with gender on an empirical level. To achieve the goal of a world with less inequalities, more research should enable deep normative understandings of diverse and inclusive recognitions of gender identities and associated social, economic and cultural consequences as well as investigate pathways of transformation and sustainable change. While such normative claims may facilitate ethical evaluations, more work is needed to enable an inclusive understanding of the context of such evaluations.

All in all, the emerging research clusters showcase that there are engaged researchers that focus on gender within sustainability science. However, there are gaps between the clusters where for example a recognition of intersectionality would hold benefits for more researchers, and a higher methodological plurality may benefit knowledge production, to name two examples. What is clear is that within sustainability science, gender issues are widely ignored to this day, and based on the systematic review we conducted, we can encourage more research on gender issues and diversity.

When gender is integrated as an analytical foundation or a concept associated with gender is being utilized within sustainability science, the critical perspective that the academic field of gender studies has developed over the past decades is seldom integrated, e.g., theories on the social construction of gender, queer theory and Black feminist theory. The concept of intersectionality should especially be further acknowledged, as it may shed a stronger light on perceived and endured injustices and give hope for a greater involvement of researchers not only to investigate these issues, but also to help to overcome them.

While our review only focuses on peer-reviewed literature and thus can only offer a specific perspective, we hope yet to offer a contribution to the bigger picture, thereby creating a link between gender and sustainability.

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Textbox definitions

Intersectionality.

The concept of intersectionality describes the ways in which systems of inequality intersect, or interlock, to create unique dynamics and effects. Popularized by Crenshaw ( 1989 ), this idea was expressed one of the first times by the Combahee River Collective in 1977. The collective pinned down how their identity as queer, middle-class, Black women led to a specific and distinct experience of oppression and exclusion, resulting in the need to develop an “integrated analysis and practice based upon the fact that the major systems of oppression are interlocking” (Combahee River Collective 1977/ 2018 ). Even though the historical focus of intersectionality was on gender, race and class, the concept is not limited to these axes of social difference, but can and should include many more items such as, for example, disability or sexuality (Bührmann 2009 ; Butler 1990 ; Lutz 2002 ; Nash 2008 ).

We refer to gender as a historical construct consisting of attributes, norms, roles, opportunities, responsibilities and expectations that are socially, culturally and institutionally embedded and produce certain gender identities and social constructs (Arevalo 2020 ; Lieu et al. 2020 ; Mechlenborg and Gram-Hanssen 2020 ). Consequently, gender is not ‘given’ but learned and therefore dynamic and changing across a diverse and fluid spectrum (Curth and Evans 2011 ; Moyo and Dhliwayo 2019 ). In this paper, we focus on two important aspects, namely (i) the idea that gender is not biologically determined in a binary of man and woman but instead socially constructed and (ii) the acknowledgment of the ‘intersectional’ nature of gender, i.e., the idea that one’s gendered experience of life overlaps and interacts with other axes of identity and systems of oppression (Richardson 2015 ).

Sustainability

We refer to sustainability based on the widely quoted definition by the Brundtland report from 1987 as meeting present needs without compromising the ability to compromise the needs of future generations (Brundtland 1987 ). Furthermore, our sustainability understanding includes an integrational perspective, also referred to as nested circles model, meaning that sustainability builds on economic, social and ecological dimensions that are interdependent and interconnected (Lozano 2008 ; Odrowaz-Coates 2021 ). In this framework, in opposition to others, the economic and social pillars are not independent from the environmental dimension, but instead depend on it (Mebratu 1998 ).

Global North/Global South

Since there is no agreed definition of these terms, we use the definition by Martins ( 2020 ) as well as Odeh ( 2010 ). The distinction between Global North and Global South is not a mere geographical one, but has its roots in colonialism and imperialism. It is important to mention that neither the North nor the South are homogeneous. The global South refers broadly to a grouping of countries that are agrarian based and experience economic and political marginalization within the global system. Global South countries often have a shared history of colonization and exploitation. The global North refers to regions traditionally referred to as ‘the West’ such as Europe, North America and Australia, among others. These countries are wealthy, technologically advanced, politically stable and aging as well as dominate the Global South in international trade (Martins 2020 ; Odeh 2010 ).

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Hochschule für Bildende Künste Dresden, Dresden, Germany

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Frank, E., Mühlhaus, R., Mustelin, K.M. et al. A systematic review of peer-reviewed gender literature in sustainability science. Sustain Sci (2024). https://doi.org/10.1007/s11625-024-01514-5

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The relationship between education and health: reducing disparities through a contextual approach

Anna zajacova.

Western University

Elizabeth M. Lawrence

University of North Carolina

Adults with higher educational attainment live healthier and longer lives compared to their less educated peers. The disparities are large and widening. We posit that understanding the educational and macro-level contexts in which this association occurs is key to reducing health disparities and improving population health. In this paper, we briefly review and critically assess the current state of research on the relationship between education and health in the United States. We then outline three directions for further research: We extend the conceptualization of education beyond attainment and demonstrate the centrality of the schooling process to health; We highlight the dual role of education a driver of opportunity but also a reproducer of inequality; We explain the central role of specific historical socio-political contexts in which the education-health association is embedded. This research agenda can inform policies and effective interventions to reduce health disparities and improve health of all Americans.

URGENT NEED FOR NEW DIRECTIONS IN EDUCATION-HEALTH RESEARCH

Americans have worse health than people in other high-income countries, and have been falling further behind in recent decades ( 137 ). This is partially due to the large health inequalities and poor health of adults with low education ( 84 ). Understanding the health benefits of education is thus integral to reducing health disparities and improving the well-being of 21 st century populations. Despite tremendous prior research, critical questions about the education-health relationship remain unanswered, in part because education and health are intertwined over the lifespans within and across generations and are inextricably embedded in the broader social context.

We posit that to effectively inform future educational and heath policy, we need to capture education ‘in action’ as it generates and constrains opportunity during the early lifespans of today’s cohorts. First, we need to expand our operationalization of education beyond attainment to consider the long-term educational process that precedes the attainment and its effect on health. Second, we need to re-conceptualize education as not only a vehicle for social success, valuable resources, and good health, but also as an institution that reproduces inequality across generations. And third, we argue that investigators need to bring historical, social and policy contexts into the heart of analyses: how does the education-health association vary across place and time, and how do political forces influence that variation?

During the past several generations, education has become the principal pathway to financial security, stable employment, and social success ( 8 ). At the same time, American youth have experienced increasingly unequal educational opportunities that depend on the schools they attend, the neighborhoods they live in, the color of their skin, and the financial resources of their family. The decline in manufacturing and rise of globalization have eroded the middle class, while the increasing returns to higher education magnified the economic gaps among working adults and families ( 107 ). In addition to these dramatic structural changes, policies that protected the welfare of vulnerable groups have been gradually eroded or dismantled ( 129 ). Together, these changes triggered a precipitous growth of economic and social inequalities in the American society ( 17 ; 106 ).

Unsurprisingly, health disparities grew hand in hand with the socio-economic inequalities. Although the average health of the US population improved over the past decades ( 67 ; 85 ), the gains largely went to the most educated groups. Inequalities in health ( 53 ; 77 ; 99 ) and mortality ( 86 ; 115 ) increased steadily, to a point where we now see an unprecedented pattern: health and longevity are deteriorating among those with less education ( 92 ; 99 ; 121 ; 143 ). With the current focus of the media, policymakers, and the public on the worrisome health patterns among less-educated Americans ( 28 ; 29 ), as well as the growing recognition of the importance of education for health ( 84 ), research on the health returns to education is at a critical juncture. A comprehensive research program is needed to understand how education and health are related, in order to identify effective points of intervention to improve population health and reduce disparities.

The article is organized in two parts. First, we review the current state of research on the relationship between education and health. In broad strokes, we summarize the theoretical and empirical foundations of the education-health relationship and critically assess the literature on the mechanisms and causal influence of education on health. In the second part, we highlight gaps in extant research and propose new directions for innovative research that will fill these gaps. The enormous breadth of the literature on education and health necessarily limits the scope of the review in terms of place and time; we focus on the United States and on findings generated during the rapid expansion of the education-health research in the past 10–15 years. The terms “education” and “schooling” are used interchangeably. Unless we state otherwise, both refer to attained education, whether measured in completed years or credentials. For references, we include prior review articles where available, seminal papers, and recent studies as the best starting points for further reading.

THE ASSOCIATION BETWEEN EDUCATION AND HEALTH

Conceptual toolbox for examining the association.

Researchers have generally drawn from three broad theoretical perspectives to hypothesize the relationship between education and health. Much of the education-health research over the past two decades has been grounded in the Fundamental Cause Theory ( 75 ). The FCT posits that social factors such as education are ‘fundamental’ causes of health and disease because they determine access to a multitude of material and non-material resources such as income, safe neighborhoods, or healthier lifestyles, all of which protect or enhance health. The multiplicity of pathways means that even as some mechanisms change or become less important, other mechanisms will continue to channel the fundamental dis/advantages into differential health ( 48 ). The Human Capital Theory (HCT), borrowed from econometrics, conceptualizes education as an investment that yields returns via increased productivity ( 12 ). Education improves individuals’ knowledge, skills, reasoning, effectiveness, and a broad range of other abilities, which can be utilized to produce health ( 93 ). The third approach, the Signaling or Credentialing perspective ( 34 ; 125 ) has been used to explain the observed large discontinuities in health at 12 or 16 years of schooling, typically associated with the receipt of a high school and college degrees, respectively. This perspective views earned credentials as a potent signal about one’s skills and abilities, and emphasizes the economic and social returns to such signals. Thus all three perspectives postulate a causal relationship between education and health and identify numerous mechanisms through which education influences health. The HCT specifies the mechanisms as embodied skills and abilities, FCT emphasizes the dynamism and flexibility of mechanisms, and credentialism identifies social responses to educational attainment. All three theoretical approaches, however, operationalize the complex process of schooling solely in terms of attainment and thus do not focus on differences in educational quality, type, or other institutional factors that might independently influence health. They also focus on individual-level factors: individual attainment, attainment effects, and mechanisms, and leave out the social context in which the education and health processes are embedded.

Observed associations between education and health

Empirically, hundreds of studies have documented “the gradient” whereby more schooling is linked with better health and longer life. A seminal 1973 book by Kitagawa and Hauser powerfully described large differences in mortality by education in the United States ( 71 ), a finding that has since been corroborated in numerous studies ( 31 ; 42 ; 46 ; 109 ; 124 ). In the following decades, nearly all health outcomes were also found strongly patterned by education. Less educated adults report worse general health ( 94 ; 141 ), more chronic conditions ( 68 ; 108 ), and more functional limitations and disability ( 118 ; 119 ; 130 ; 143 ). Objective measures of health, such as biological risk levels, are similarly correlated with educational attainment ( 35 ; 90 ; 140 ), showing that the gradient is not a function of differential reporting or knowledge.

The gradient is evident in men and women ( 139 ) and among all race/ethnic groups ( 36 ). However, meaningful group differences exist ( 60 ; 62 ; 91 ). In particular, education appears to have stronger health effects for women than men ( 111 ) and stronger effects for non-Hispanic whites than minority adults ( 134 ; 135 ) even if the differences are modest for some health outcomes ( 36 ). The observed variations may reflect systematic social differences in the educational process such as quality of schooling, content, or institutional type, as well as different returns to educational attainment in the labor market across population groups ( 26 ). At the same time, the groups share a common macro-level social context, which may underlie the gradient observed for all.

To illustrate the gradient, we analyzed 2002–2016 waves of the National Health Interview Survey (NHIS) data from adults aged 25–64. Figure 1 shows the levels of three health outcomes across educational attainment levels in six major demographic groups predicted at age 45. Three observations are noteworthy. First, the gradient is evident for all outcomes and in all race/ethnic/gender groups. Self-rated health exemplifies the staggering magnitude of the inequalities: White men and women without a high school diploma have about 57% chance of reporting fair or poor health, compared to just 9% for college graduates. Second, there are major group differences as well, both in the predicted levels of health problems, as well as in the education effects. The latter are not necessarily visible in the figures but the education effects are stronger for women and weaker for non-white adults as prior studies showed (table with regression model results underlying the prior statement is available from the authors). Third, an intriguing exception pertains to adults with “some college,” whose health is similar to high school graduates’ in health outcomes other than general health, despite their investment in and exposure to postsecondary education. We discuss this anomaly below.

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Predicted Probability of Health Problems

Source: 2002–2016 NHIS Survey, Adults Age 25–64

Pathways through which education impacts health

What explains the improved health and longevity of more educated adults? The most prominent mediating mechanisms can be grouped into four categories: economic, health-behavioral, social-psychological, and access to health care. Education leads to better, more stable jobs that pay higher income and allow families to accumulate wealth that can be used to improve health ( 93 ). The economic factors are an important link between schooling and health, estimated to account for about 30% of the correlation ( 36 ). Health behaviors are undoubtedly an important proximal determinant of health but they only explain a part of the effect of schooling on health: adults with less education are more likely to smoke, have an unhealthy diet, and lack exercise ( 37 ; 73 ; 105 ; 117 ). Social-psychological pathways include successful long-term marriages and other sources of social support to help cope with stressors and daily hassles ( 128 ; 131 ). Interestingly, access to health care, while important to individual and population health overall, has a modest role in explaining health inequalities by education ( 61 ; 112 ; 133 ), highlighting the need to look upstream beyond the health care system toward social factors that underlie social disparities in health. Beyond these four groups of mechanisms that have received the most attention by investigators, many others have been examined, such as stress, cognitive and noncognitive skills, or environmental exposures ( 11 ; 43 ). Several excellent reviews further discuss mechanisms ( 2 ; 36 ; 66 ; 70 ; 93 ).

Causal interpretation of the education-health association

A burgeoning number of studies used innovative approaches such as natural experiments and twin design to test whether and how education causally affects health. These analyses are essential because recommendations for educational policies, programs, and interventions seeking to improve population health hinge on the causal impact of schooling on health outcomes. Overall, this literature shows that attainment, measured mostly in completed years of schooling, has a causal impact on health across numerous (though not all) contexts and outcomes.

Natural experiments take advantage of external changes that affect attainment but are unrelated to health, such as compulsory education reforms that raise the minimum years of schooling within a given population. A seminal 2005 study focused on increases in compulsory education between 1915 and 1939 across US states and found that a year of schooling reduced mortality by 3.6% ( 78 ). A re-analysis of the data indicated that taking into account state-level mortality trends rendered the mortality effects null but it also identified a significant and large causal effect on general health ( 88 ). A recent study of a large sample of older Americans reported a similar pattern: a substantial causal effect of education for self-rated health but not for mortality ( 47 ). School reform studies outside the US have reported compelling ( 122 ) or modest but significant ( 32 ) effects of schooling on health, although some studies have found nonsignificant ( 4 ), or even negative effects ( 7 ) for a range of health outcomes.

Twin design studies compare the health of twins with different levels of education. This design minimizes the influence of family resources and genetic differences in skills and health, especially for monozygotic twins, and thus serves to isolate the effect of schooling. In the US, studies using this design generated robust evidence of a causal effect of education on self-rated health ( 79 ), although some research has identified only modest ( 49 ) or not significant ( 3 ; 55 ) effects for other physical and mental health outcomes. Studies drawing on the large twin samples outside of the US have similarly found strong causal effects for mortality ( 80 ) and health ( 14 ; 16 ; 51 ) but again some analyses yielded no causal effects on health ( 13 ; 83 ) or health behaviors ( 14 ). Beyond our brief overview, readers may wish consult additional comprehensive reviews of the causal studies ( 40 ; 45 ; 89 ).

The causal studies add valuable evidence that educational attainment impacts adult health and mortality, even considering some limitations to their internal validity ( 15 ; 88 ). To improve population health and reduce health disparities, however, they should be viewed as a starting point to further research. First, the findings do not show how to improve the quality of schooling or its quantity for in the aggregate population, or how to overcome systematic intergenerational and social differences in educational opportunities. Second, their findings do take into account contexts and conditions in which educational attainment might be particularly important for health. In fact, the variability in the findings may be attributable to the stark differences in contexts across the studies, which include countries characterized by different political systems, different population groups, and birth cohorts ranging from the late 19 th to late 20 th centuries that were exposed to education at very different stages of the educational expansion process ( 9 ).

TOWARD A SOCIALLY-EMBEDDED UNDERSTANDING OF THE EDUCATION-HEALTH RELATIONSHIP

To date, the extensive research we briefly reviewed above has identified substantial health benefits of educational attainment in most contexts in today’s high-income countries. Still, many important questions remain unanswered. We outline three critical directions to gain a deeper understanding of the education-health relationship with particular relevance for policy development. All three directions shift the education-health paradigm to consider how education and health are embedded in life course and social contexts.

First, nearly universally, the education-health literature conceptualizes and operationalizes education in terms of attainment, as years of schooling or completed credentials. However, attainment is only the endpoint, although undoubtedly important, of an extended and extensive process of formal schooling, where institutional quality, type, content, peers, teachers, and many other individual, institutional, and interpersonal factors shape lifecourse trajectories of schooling and health. Understanding the role of the schooling process in health outcome is relevant for policy because it can show whether interventions should be aimed at increasing attainment, or whether it is more important to increase quality, change content, or otherwise improve the educational process at earlier stages for maximum health returns. Second, most studies have implicitly or explicitly treated educational attainment as an exogenous starting point, a driver of opportunities in adulthood. However, education also functions to reproduce inequality across generations. The explicit recognition of the dual function of education is critical to developing education policies that would avoid unintended consequence of increasing inequalities. And third, the review above indicates substantial variation in the education-health association across different historical and social contexts. Education and health are inextricably embedded in these contexts and analyses should therefore include them as fundamental influences on the education-health association. Research on contextual variation has the potential to identify contextual characteristics and even specific policies that exacerbate or reduce educational disparities in health.

We illustrate the key conceptual components of future research into the education-health relationship in Figure 2 . Important intergenerational and individual socio-demographic factors shape educational opportunities and educational trajectories, which are directly related to and captured in measures of educational attainment. This longitudinal and life course process culminates in educational disparities in adult health and mortality. Importantly, the macro-level context underlies every step of this process, shaping each of the concepts and their relationships.

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Enriching the conceptualization of educational attainment

In most studies of the education-health associations, educational attainment is modeled using years of schooling, typically specified as a continuous covariate, effectively constraining each additional year to have the same impact. A growing body of research has substituted earned credentials for years. Few studies, however, have considered how the impact of additional schooling is likely to differ across the educational attainment spectrum. For example, one additional year of education compared to zero years may be life-changing by imparting basic literacy and numeracy skills. The completion of 14 rather than 13 years (without the completion of associated degree) could be associated with better health through the accumulation of additional knowledge and skills as well, or perhaps could be without health returns, if it is associated with poor grades, stigma linked to dropping out of college, or accumulated debt ( 63 ; 76 ). Examining the functional form of the education-health association can shed light on how and why education is beneficial for health ( 70 ). For instance, studies found that mortality gradually declines with years of schooling at low levels of educational attainment, with large discontinuities at high school and college degree attainment ( 56 ; 98 ). Such findings can point to the importance of completing a degree, not just increasing the quantity (years) of education. Examining mortality, however, implicitly focused on cohorts who went to school 50–60 years ago, within very different educational and social contexts. For findings relevant to current education policies, we need to focus on examining more recent birth cohorts.

A particularly provocative and noteworthy aspect of the functional form is the attainment group often identified as “some college:” adults who attended college but did not graduate with a four-year degree. Postsecondary educational experiences are increasingly central to the lives of American adults ( 27 ) and college completion has become the minimum requirement for entry into middle class ( 65 ; 87 ). Among high school graduates, over 70% enroll in college ( 22 ) but the majority never earn a four-year degree ( 113 ). In fact,, the largest education-attainment group among non-elderly US adults comprises the 54 million adults (29% of total) with some college or associate’s degree ( 113 ). However, as in Figure 1 , this group often defies the standard gradient in health. Several recent studies have found that the health returns to their postsecondary investments are marginal at best ( 110 ; 123 ; 142 ; 144 ). This finding should spur new research to understand the outcomes of this large population group, and to glean insights into the health returns to the postsecondary schooling process. For instance, in the absence of earning a degree, is greater exposure to college education in terms of semesters or earned credits associated with better health or not? How do the returns to postsecondary schooling differ across the heterogeneous institutions ranging from selective 4-year to for-profit community colleges? How does accumulated college debt influence both dropout and later health? Can we identify circumstances under which some college education is beneficial for health? Understanding the health outcomes for this attainment group can shed light on the aspects of education that are most important for improving health.

A related point pertains to the reliability and validity of self-reported educational attainment. If a respondent reports 16 completed years of education, for example, are they carefully counting the number of years of enrollment, or is 16 shorthand for “completed college”? And, is 16 years the best indicator of college completion in the current context when the median time to earn a four-year degree exceeds 5 years ( 30 )? And, is longer time in college given a degree beneficial for health or does it signify delayed or disrupted educational pathways linked to weaker health benefits ( 132 )? How should we measure part-time enrollment? As studies begin to adjudicate between the health effects of years versus credentials ( 74 ) in the changing landscape of increasingly ‘nontraditional’ pathways through college ( 132 ), this measurement work will be necessary for unbiased and meaningful analyses. An in-depth understanding may necessitate primary data collection and qualitative studies. A feasible direction available with existing data such as the National Longitudinal Survey of Youth 1997 (NLSY97) is to assess earned college credits and grades rather than years of education beyond high school.

As indicated in Figure 2 , beyond a more in-depth usage of the attainment information, we argue that more effective conceptualization of the education-health relationship as a developmental life course process will lead to important findings. For instance, two studies published in 2016 used the NLSY97 data to model how gradual increases in education predict within-individual changes in health ( 39 ; 81 ). Both research teams found that gradual accumulation of schooling quantity over time was not associated with gradual improvements in health. The investigators interpreted the null findings as an absence of causal effects of education on health, especially once they included important confounders (defined as cognitive and noncognitive skills and social background). Alternatively, perhaps the within-individual models did not register health because education is a long-term, developing trajectory that cannot be reduced to point-in-time changes in exposure. Criticisms about the technical aspects of theses studies notwithstanding ( 59 ), we believe that these studies and others like them, which wrestle with the question of how to capture education as a long-term process grounded in the broader social context, and how this process is linked to adult health, are desirable and necessary.

Education as (re)producer of inequality

The predominant theoretical framework for studying education and health focuses on how education increases skills, improves problem-solving, enhances employment prospects, and thus opens access to other resources. In sociology, however, education is viewed not (only) as increasing human capital but as a “sieve more than a ladder” ( 126 ), an institution that reproduces inequality across generations ( 54 ; 65 ; 103 ; 114 ). The mechanisms of the reproduction of inequality are multifarious, encompassing systematic differences in school resources, quality of instruction, academic opportunities, peer influences, or teacher expectations ( 54 ; 114 ; 132 ). The dual role of education, both engendering and constraining social opportunities, has been recognized from the discipline’s inception ( 52 ) and has remained the dominant perspective in sociology of education ( 18 ; 126 ). Health disparities research, which has largely dismissed the this perspective as “specious” ( 93 ), could benefit from pivoting toward this complex sociological paradigm.

As demonstrated in Figure 2 , parental SES and other background characteristics are key social determinants that set the stage for one’s educational experiences ( 20 ; 120 ). These characteristics, however, shape not just attainment, but the entire educational and social trajectories that drive and result in particular attainment ( 21 ; 69 ). Their effects range from the differential quality and experiences in daycare or preschool settings ( 6 ), K-12 education ( 24 ; 136 ), as well as postsecondary schooling ( 5 ; 127 ). As a result of systematically different experiences of schooling over the early life course stratified by parental SES, children of low educated parents are unlikely to complete higher education: over half of individuals with college degrees by age 24 came from families in the top quartile of family income compared to just 10% in the bottom quartile ( 23 ).

Unfortunately, prior research has generally operationalized the differences in educational opportunities as confounders of the education-health association or as “selection bias” to be statistically controlled, or best as a moderating influence ( 10 ; 19 ). Rather than remove the important life course effects from the equation, studies that seek to understand how educational and health differences unfold over the life course, and even across generations could yield greater insight ( 50 ; 70 ). A life course, multigenerational approach can provide important recommendations for interventions seeking to avoid the unintended consequence of increasing disparities. Insofar as socially advantaged individuals are generally better positioned to take advantage of interventions, research findings can be used to ensure that policies and programs result in decreasing, rather than unintentionally widening, educational and health disparities.

Education and health in social context

Finally, perhaps the most important and policy-relevant emerging direction to improving our understanding of the education-health relationship is to view both as inextricably embedded within the broad social context. As we highlight in Figure 2 , this context underlies every feature of the development of educational disparities in health. In contrast to the voluminous literature focusing on individual-level schooling and health, there has been a “startling lack of attention to the social/political/economic context” in which the relationships are grounded ( 33 ). By context, we mean the structure of a society that varies across time and place, encompassing all major institutions, policy environments, as well as gender, race/ethnicity, age, and socioeconomic stratification. Under what circumstances, conditions, and policies are the associations between education and health stronger or weaker?

Within the United States, the most relevant units of geo-political boundaries generating distinct policy contexts are states, although smaller geographic units are also pertinent ( 44 ; 100 ). Since the 1980s, the federal government has devolved an increasing range of key socioeconomic, political, and health-care decisions to states. This decentralization has resulted in increasing diversity across states in conditions for a healthy life ( 96 ; 101 ). A recent study demonstrates how different environments across US states yield vastly different health returns to education ( 100 ). State-level characteristics had little impact on adults with high education, whose disability levels were similarly low regardless of their state of residence. In contrast, disability levels of low-educated adults were not only high but also varied substantially across states: disability was particularly high in states that have invested less in the social welfare of its residents, such as Mississippi, Kentucky, and West Virginia. Highly-educated adults, particularly white adults and men who can convert education into other resources most readily, use personal resources to protect their health like a ‘personal firewall’ ( 97 ). Their less-educated peers, meanwhile, are vulnerable without social safety nets. Demonstrating the potential for informing policy in this area, the findings directly identify state policies that influence the extent to which educational attainment matters for health and longevity. These include economic policies including state income tax structures and education expenditures per capita, as well as policies influencing social cohesion in a state, such as income inequality and unemployment rates. Beyond the US, investigators can leverage differences in political systems across countries to assess the impact of different welfare regimes on the education-health associations, as some European researchers began generating ( 41 ; 82 ).

Similar to variation across geo-political boundaries, research on variation across time can highlight policies and conditions that mitigate or inflate health disparities. How has the education-health association changed over time? In recent decades, the association has become increasingly strong, with widening disparities in health outcomes across education ( 53 ; 77 ; 86 ; 116 ; 143 ). These increases started in the 1980s ( 17 ) at the same time that social inequality began rising with the political embrace of pro-market neoliberal policies ( 33 ). Since then, the United States has been increasingly marked by plummeting economic wellbeing (except for the wealthiest Americans), growing economic segregation, emerging mass incarceration, downward social mobility, and despair in many working-class communities ( 17 ; 95 ; 129 ). Conversely, in the two decades prior (1960s and 70s), social disparities in health were decreasing ( 1 ; 72 ). During those decades, many pro-social policies such as Civil rights legislation, War on Poverty programs, and racial desegregation were improving social inequalities. Macro-level political forces, clearly, can influence not only social but also health inequalities ( 104 ). Two facts follow: growing disparities are not inevitable and changes in the education-health relationship may be strongly linked to social policies. While some of the growth in educational inequalities may be attributable to changes in educational composition of the population with increasingly negatively select groups of adults at the lowest levels of schooling, these compositional changes likely play only a minor role in the overall trends ( 38 ; 58 ). Linking education and health to the broader social context brings to the forefront the ways in which we, as individuals and a collective society, produce and maintain health disparities.

Implications for Policy and Practice

Reducing macro-level inequalities in health will require macro-level interventions. Technological progress and educational expansion over the past several decades have not decreased disparities; on the contrary, educational disparities in health and mortality have grown in the US. Moreover, the consistent, durable relationship between education and health and the multitude of mechanisms linking them suggests that programs targeting individual behaviors will have limited impact to counteract disparities. Thus, we argue that future findings from the new research directions proposed here can be used to intervene at the level of social contexts to alter educational trajectories from an early age, with the ultimate goal of reducing health disparities. We note two promising avenues for policy development.

One potential solution may focus on universal federal and state-level investment in the education and well-being of children early in the life course to disrupt the reproduction of social inequalities and change subsequent educational trajectories. Several experimental early-education programs such as the Perry Preschool Project and Carolina Abecedarian Project have demonstrated substantial, lasting, and wide-ranging benefits, including improved adult health ( 25 ; 57 ; 102 ). These programs provided intensive, exceptionally high-quality, and diverse services to children, and it is these characteristics that appear central to their success ( 138 ). Further research on the qualitative and social dimensions of education and their effects on health can inform future model educational programs and interventions across all ages.

Another important issue for both researchers and policymakers pertains to postsecondary enrollment and attrition, and their effects on health. Educational expansion in the college-for-all era has yielded high post-secondary enrollment, but also unacceptable dropout rates with multiple detrimental consequences, including high rates of student debt ( 64 ) and stigma ( 76 ), which may negatively affect health. Emerging studies found that college dropouts fail to benefit from their postsecondary investments. Next we need to understand under what circumstances college goers do reap health benefits, or how their postsecondary experience can be modified to improve their health.

For both of these avenues, effective implementation will need further research on the specific institutional characteristics and social contexts that shape the schooling effects. However, in designing interventions and policies, we need to be aware of the dual role of education as a drive and reproducer of inequality. Individuals from advantaged backgrounds may be better positioned to take advantage of new educational opportunities, and thus any interventions and programs need to ensure that marginalized populations have equal or greater access in order to avoid the unintended consequence of further intensifying disparities. Finally, researchers and policymakers should engage in a dialogue such that researchers effectively communicate their insights and recommendations to policymakers, and policymakers convey the needs and challenges of their practices to researchers.

Education and health are central to individual and population well-being. They are also inextricably embedded in the social context and structure. Future research needs to expand beyond the individual-focused analyses and hypothesize upstream ( 96 ), taking a contextual approach to understanding education and health. Such an approach will require interdisciplinary collaborations, innovations in conceptual models, and rich data sources. The three directions for further research on health returns to education we outlined above can help generate findings that will inform effective educational and health policies and interventions to reduce disparities. During this critical time when health differences are widening and less educated Americans are experiencing social and health declines, research and policy has the opportunity to make a difference and improve the health and well-being of our population.

Contributor Information

Anna Zajacova, Western University.

Elizabeth M. Lawrence, University of North Carolina.

Open access
Published: 15 June 2024

Interventions that have potential to help older adults living with social frailty: a systematic scoping review

Monika Kastner 1 , 2 , 3 ,
Isabella Herrington 1 ,
Julie Makarski 1 ,
Krystle Amog 2 ,
Tejia Bain 1 ,
Vianca Evangelista 1 ,
Leigh Hayden 1 ,
Alexa Gruber 1 ,
Justin Sutherland 1 ,
Amy Sirkin 1 ,
Laure Perrier 2 ,
Ian D. Graham 4 ,
Michelle Greiver 1 , 3 ,
Joan Honsberger 1 ,
Mary Hynes 1 ,
Charlie Macfarlane 1 ,
Leela Prasaud 1 ,
Barbara Sklar 1 ,
Margo Twohig 1 ,
Barbara Liu 5 ,
Sarah Munce 2 , 6 ,
Sharon Marr 7 ,
Braden O’Neill 8 ,
Alexandra Papaioannou 7 ,
Bianca Seaton 1 ,
Sharon E. Straus 8 , 9 ,
Katie Dainty 1 , 2 &
Jayna Holroyd-Leduc 10

BMC Geriatrics volume 24 , Article number: 521 ( 2024 ) Cite this article

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The impact of social frailty on older adults is profound including mortality risk, functional decline, falls, and disability. However, effective strategies that respond to the needs of socially frail older adults are lacking and few studies have unpacked how social determinants operate or how interventions can be adapted during periods requiring social distancing and isolation such as the COVID-19 pandemic. To address these gaps, we conducted a scoping review using JBI methodology to identify interventions that have the best potential to help socially frail older adults (age ≥65 years).

We searched MEDLINE, CINAHL (EPSCO), EMBASE and COVID-19 databases and the grey literature. Eligibility criteria were developed using the PICOS framework. Our results were summarized descriptively according to study, patient, intervention and outcome characteristics. Data synthesis involved charting and categorizing identified interventions using a social frailty framework.

Of 263 included studies, we identified 495 interventions involving ~124,498 older adults who were mostly female. The largest proportion of older adults (40.5%) had a mean age range of 70-79 years. The 495 interventions were spread across four social frailty domains: social resource (40%), self-management (32%), social behavioural activity (28%), and general resource (0.4%). Of these, 189 interventions were effective for improving loneliness, social and health and wellbeing outcomes across psychological self-management, self-management education, leisure activity, physical activity, Information Communication Technology and socially assistive robot interventions. Sixty-three interventions were identified as feasible to be adapted during infectious disease outbreaks (e.g., COVID-19, flu) to help socially frail older adults.

Conclusions

Our scoping review identified promising interventions with the best potential to help older adults living with social frailty.

Peer Review reports

By the year 2050, two billion people worldwide will be 60 years of age and older [ 1 , 2 ]. In Canada, the prevalence of frailty in those age 65+ years is almost twice that of those age 50-64 years [ 3 ]. The association of older age with increased prevalence of frailty may be due to the accumulation of multiple risk factors over time [ 3 ] and includes physical, psychological and social dimensions [ 4 , 5 , 6 ]. As such, frailty is considered “ a syndrome that affects biological, psychological, and social processes of a person’s life and leads to increased vulnerability and adverse outcomes in old age ” [ 7 , 8 ]. Frailty has traditionally been conceptualized as a physiological phenomenon, and related assessment tools often emphasize physical qualities such as multimorbidity, nutrition, and functional independence [ 9 ]. In social frailty, it is a person’s social activities, social supports, social networks, loneliness and whether they are living alone that are involved [ 10 ]. Social frailty has been identified as a risk to healthy aging and defined as: “a continuum of being at risk of losing, or having lost, social and general resources, activities or abilities that are important for fulfilling one or more basic social needs during the life span” [ 11 ]. Social frailty is associated with other related and overlapping concepts [ 12 , 13 , 14 , 15 ] such as loneliness, social isolation, social vulnerability and resilience, which highlights that we cannot investigate social frailty in isolation. We need to understand not only how these social frailty concepts operate within a person’s physical and psychological health state, but what strategies are the most helpful during stressful periods when this population becomes more vulnerable (e.g., COVID-19 or other infectious disease outbreaks such as the flu).

As adults get older, their physical and cognitive capacity can decrease [ 16 ], which can progressively decrease their social activities, social circles, and increase the likelihood of living alone [ 17 ] – all these factors can lead to social isolation and social frailty [ 17 ]. The prevalence of social frailty varies widely and estimated to be between 7.7% to 47% (socially frail), and between 25% to 32.1% (pre-socially frail) [ 18 , 19 , 20 ]. During the first three years of the COVID-19 pandemic (2020-2022), social frailty prevalence rose to 18-25% among community-dwelling older adults [ 20 , 21 ] and 47.3% in hospital [ 20 ], which was largely attributed to lockdown measures and quarantine leading to increased social isolation and loneliness among older adults. The impact of social frailty on older adults is profound. It is associated with the risk of all-cause mortality [ 22 ], physical and cognitive decline [ 18 ] including the onset of Alzheimer’s disease [ 23 ], reduced social and psychological well-being [ 17 ], depression and anxiety [ 24 ], moderate hearing loss [ 25 ], and decreased quality of life [ 26 ]. As such, social frailty represents one of the greatest challenges to the care for older adults and the health care system today. However, very little is known about effective strategies that can address social frailty.

Many existing knowledge syntheses focus on the clinical aspects of frailty (i.e., physical and psychological) or only on social isolation, vulnerability or loneliness [ 27 , 28 , 29 , 30 ]. Very few studies consider how social factors intersect with physical or psychological frailty [ 31 , 32 ] (Fig. 1 ). Increasingly, the physical, social and cognitive problems experienced by older adults are being considered as part of psychological frailty, but their differences and associations are not well understood in the context of overall frailty [ 31 ].

Domains of frailty and existing gaps

Existing reviews also have not identified how interventions can address social frailty or related concepts (e.g., social isolation, loneliness, resilience; poverty risk; housing; physical safety; and social roles, networks, and relationships). Furthermore, little is known about which social frailty interventions have potential to be adapted for use during social distancing and isolation measures due to infectious disease outbreaks such as the COVID-19 pandemic. The pandemic response had indirect consequences on older adults as these measures led to an even greater risk of morbidity and mortality and reduced physical, mental and social wellbeing [ 33 , 34 , 35 ]. To address these gaps, our objectives were to:

generate knowledge about which interventions have the best potential to help older adults (age ≥65 years) living with or at risk for social frailty or related concepts (e.g., social isolation, loneliness); and

to identify interventions that may be the most helpful (and can be adapted) during infectious disease outbreaks requiring isolation (e.g., the COVID-19 pandemic, flu) when older adults are at even greater risk to become social frail.

Study design

We conducted a scoping review using the JBI methodology [ 36 ]. Our protocol was registered with the Open Science Framework (OSF) (registration: https://doi.org/10.17605/OSF.IO/2MDQF ). We used the PRISMA extension for scoping reviews (PRISMA-ScR) [ 37 ] to prepare this manuscript. Our integrated knowledge translation (IKT) team contributed to the design and conduct of our scoping review. Our IKT team included knowledge users with expertise in social frailty (clinicians), scoping review methods (clinicians, researchers), patient partners with lived experience of social frailty and their caregivers. Our patient partners contributed to refining our research objectives, provided feedback on our data gathering tools, screened articles and helped to interpret findings.

Search strategy

An experienced information specialist (librarian) developed the search strategy, and a second information specialist appraised this strategy using the Peer Review of Electronic Search Strategies (PRESS) checklist [ 38 ]. We searched MEDLINE, CINAHL (EPSCO), EMBASE and COVID-19 databases (medRxiv and LitCovid) in English from 2000 to October 29, 2023, using a validated, age-specific search filter [ 39 ] to focus our search on studies on the older adult population (Supplement file 1). The search strategy utilized a combination of controlled vocabulary (e.g., “Social Isolation”, “Loneliness”, “Social Alienation”) and keywords (e.g., “connectedness”, “social vulnerability”, “aloneness”). We also searched the grey literature using the Canadian Agency for Drugs and Technologies in Health (CADTH) Grey Matter approach [ 40 ], including the sources of the Centre for Evidence-Based Medicine, Oxford COVID-19 Evidence Service.

Eligibility criteria

Our draft eligibility criteria were defined by our IKT team (including our patient partners) and developed using the PICOS framework [ 41 ]: Population : Community-dwelling older adults (age ≥ 65 years) at risk for or living with social frailty with or without concurrent disease(s) (e.g., diabetes). We excluded interventions targeting older adults living in long-term care homes (i.e., nursing home) or admitted to the hospital. Intervention: Any intervention addressing social frailty or related concepts (loneliness, social isolation, social vulnerability). Interventions that focused only on physical or psychological frailty were excluded. Outcomes: Social frailty or related concepts as reported by included studies (e.g., social support, social participation, social networks, social frailty index, loneliness score). We also considered quality of life (QOL), functional status (social), and general well-being (overall, social) outcomes. Study design : Any qualitative, quantitative, mixed-methods, multi-methods studies and systematic knowledge syntheses and excluded opinion driven reports (e.g., commentaries, editorials).

Article selection and extraction

Experienced reviewer pairs (IH, JH, JM, JS, KA, LH, LP, MM, MK) screened all potentially eligible records in duplicate for title and abstract screening and a verification process for full-text screening (one reviewer screened articles, and another verified 10% of these records). Reviewer pairs were calibrated at each screening level to ensure screening reliability (i.e., screening the same 10% set of articles by all reviewers until they reached ≥80% agreement, after which they screened independently). Our patient partners were also invited to screen articles. Any disagreements were resolved through team discussions.

Data charting

We developed and pilot tested a standardized data abstraction form, which was iteratively revised until data abstractor pairs reached consensus on data items. Experienced reviewer pairs (IH, JS, KA, MK, JH, LP, LH, MH) abstracted data and second reviewers checked a 10% random sample of data on key study characteristics (study design, journal, year and country of conduct), population characteristics (age, sex, gender, race) and intervention characteristics: type, mode of delivery (in-person, virtual), level of interaction with the intervention (one-to-one, group-based, self-directed, pair-based or mixed); and outcomes. Although not recommended by the JBI guide [ 42 ], abstracting outcome results was relevant for this review to identify interventions that could support knowledge user decision making about social frailty interventions, and how they might be adapted during infectious disease outbreaks. We also wanted to identify which intervention should be investigated in a future systematic review.

Data analysis and synthesis

Our results were summarized descriptively according to study, patient and intervention characteristics using tables and appendices. In our data analysis and reporting, all data was disaggregated by sex and gender if reported in included studies. To organize and categorize identified interventions, we used Bunt et al ’s social frailty framework [ 11 ], which highlights that the concept of social frailty needs to include not only the absence (or threat) of general and social resources that are needed to fulfill basic social needs but also the absence (or threat) of social behaviours and social activities as well as self-management abilities [ 11 ]. As such, we categorized identified interventions according to Bunt et al ’s four broad domains of social frailty: (i) General resource related (“ Resources that are beneficial generally, indirectly contributing to social need fulfilment ” such as education, financial status, housing, living environment, basic activities of daily living, cognition, lifestyle, life events); (ii) Social resource related (“ Resources that are likely to directly contribute to the fulfilment of one of more social needs “such as marital status, family ties, living children, social network size, care or help from others) [ 43 ]; (iii) Self-management (to improve an individual’s ability to manage their behaviours and emotions to benefit their overall health [ 44 ]); and (iv) Social behavioural activities ( “social behaviours or activities that are performed towards social need fulfilment” such as maintenance of close relationships, social participation, volunteerism, religiosity, occupation, neighborhood involvement) [ 43 ]. The intervention categorization process involved three reviewers (IH, KA, MK), iteratively developing a codebook and definitions using content analysis [ 45 ]. If interventions were represented by overlapping domains, we categorized interventions based on the predominant component via team discussion. We used a similar procedure to organize an expected large volume of outcomes and outcome categories from our studies. If reported, we also considered differences between participants of included studies in their social frailty risk (sex, gender, advanced age, low educational level and socioeconomic status and housing) as well as how they experience social frailty [ 10 ]. To classify loneliness, social and health and well-being outcomes in identified interventions, reviewer pairs (IH, JM, KA, MK) iteratively created a codebook using content analysis [ 45 ]. Our patient partners (BL, CM, JH, LP, MH, MT) had opportunities to review and provide feedback on these documents. Interventions were classified as “effective” if they reported outcome(s) as “effective” or “statistically significant”. We used the following effect direction definitions to classify all intervention result statements: “+*” = statistically significant positive impact; “-*” = statistically significant negative impact; “+” = positive direction in impact; “-“ = negative direction in impact; “+/-“ = mixed impact; NC = no change; NA = not applicable. One reviewer (IH) applied the effect direction classification scheme, and another reviewer (MK) audited a 10% random sample of classifications. We also identified effective interventions that may be helpful during infectious disease outbreaks such as the COVID-19 pandemic. This was based on whether interventions required participants to have any physical contact or in-person interaction with another individual (i.e., whether the intervention was feasible to be delivered virtually or remotely).

Literature search

Of 31,339 records that were identified by our search strategy, we screened 20,709 titles and abstracts and 928 full-text articles. Of these, 263 studies plus 3 companion reports met the eligibility criteria and were included in our scoping review (Fig. 2 ).

PRISMA Flowchart

Study characteristics

Table 1 includes the study characteristics. Of the 263 included studies, 57% were published between 2021 and 2023 followed by 31%, which were published between 2016-2020 with the earliest published in 2000. Most studies were conducted in North America (38%), followed by Europe (31%), Asia (19%%) and Australia (8%) (Fig. 3 ). The study designs of included studies were quasi-experimental (23%), qualitative (19%), experimental (19%) including 43 randomized controlled trials (16%), knowledge synthesis (19%), mixed- or multi-methods (16%), cross-sectional (2.7%), observational (1.5%) and cost or economic analysis (0.4%).

Country and continent of conduct*. *Percentages may not total to 100 due to rounding

Population characteristics

A total of ~124,498 older adults were included among our 263 included studies representing 90% of the 495 identified interventions. Table 1 includes the participant characteristics. Of the interventions that reported on age ( N =385; 78%), the largest proportion of older adults ( N= 156; 40.5%) had a mean age range of 70-79 years. Of 115 interventions that reported on participant sex (62%), 273 interventions (88%) included mostly female participants. Two interventions reported on gender (0.4%) and 83 interventions reported on race or ethnicity (17%). Of these, the largest proportion of interventions reported racial groups that self-identified as white (59 of 83 interventions; 71%), black (44 of 83 interventions; 53%), Latinx (28 of 83 interventions; 34%) or Asian including east, southeast and south Asian (23 of 83 interventions; 28%).

Intervention characteristics

Table 1 includes the intervention characteristics. Most of the 495 identified interventions were represented by three of the four social frailty domains [ 11 ]: 196 social resource related (40%), 157 self-management (32%), and 140 social behavioural activity interventions (28%); 2 interventions were identified from the general resource related domain (0.4 %). The largest proportion of interventions sub-categories were self-management education (21%), physical activity (9.7%) and leisure (9.7%) interventions followed by psychological self-management interventions (8.7%) and Information Communication Technology (ICT) (8.3%). The details of these intervention categories and sub-categories are in Supplement file 2. The most common mode of intervention delivery was in-person (59.5%) or virtual (35%). Participants most often interacted with interventions via group-based (48.5%) or one-to-one (27%) strategies. Intervention settings were mostly at home (47.5%) or in the community (20%).

Outcome characteristics

We identified 10 categories of outcomes (Supplement file 3): Loneliness outcomes were investigated by the largest proportion of interventions ( n= 312; 63%) followed by Social cohesion and connectedness ( n= 120; 24%), Quantity of social relationships ( n= 98; 20%), Social capital ( n= 95; 19%), Health and Wellbeing ( n= 83; 17%), Social engagement ( n= 78; 16%), Social isolation ( n= 75; 15%),

Social functioning and skills ( n= 37; 7.5%), Quality of life ( n= 54; 11%), and Frailty ( n= 5; 1%) outcomes. The highest concentration of effective interventions was found to be among loneliness outcomes ( n= 275), which was spread in similar proportion across the three social frailty domains: social behavioural activity (47%), self-management (43%) and social resource-related (42%).

Narrative synthesis of results

The detailed description of identified interventions and their impact across four social frailty domains are in Tables 2 , 3 and 4 .

Social resource-related interventions ( n =196) (Table 2 )

ICT-based ( n= 43), intergenerational ( n= 33), aging in place ( n= 31), socially assistive robots and computer agents ( n= 29), befriending ( n= 27), peer support group ( n= 23), mentorship, and mentorship ( n= 11) interventions.

ICT-based interventions included social networking platforms/apps ( n= 30), device-mediated communication strategies ( n= 9) or a combination of the two ( n= 2). Most of the social networking platforms/apps (70%) and device-mediated communication strategies (71%) showed non-significant improvements in social outcomes. Findings for loneliness outcomes were mixed with mostly non-significant improvement (70%) or no change (50%) for social networking platforms/apps, and non-significant improvement (71%), mixed findings (43%) or no change (14%) for device-mediated communication strategies. Intergenerational interventions included five types: strategies designed to promote or build social connections and engagement ( n= 12), to share experiences and memories including reminiscence therapy ( n= 7); community-based ( n= 6) or general ( n= 4) intergenerational programs; and interventions that promote socialization through activities and skills training ( n= 4). Most interventions from these five intergenerational intervention categories (range 67%-100%) significantly reduced loneliness outcomes. Similarly, most interventions across four of the five intervention categories (range 50%-100%) significantly improved health and wellbeing outcomes. Social outcomes across the five intervention categories mostly improved (range 50%-80%), but these were not significant. Aging in place interventions included home visit interventions ( n= 14), day care/seniors centres ( n= 8), telehealth interventions ( n= 7), and meal delivery interventions ( n= 4). Loneliness outcomes significantly improved in 40% of day care/seniors centre interventions, 40% of telehealth interventions, and 75% of meal delivery interventions; and no change was observed among 57% of home visit interventions. Among social outcomes, day care/seniors centres showed significant (50%) and non-significant (50%) improvement; and 44% of home visit interventions and 40% of telehealth interventions found non-significant improvement. Among health and wellbeing outcomes, most home visit or day care/seniors centre interventions (67% for both) showed significant improvement; one telehealth intervention showed non-significant improvement and meal delivery showed no change among the two interventions that investigated this outcome. Socially assistive robots (n=16) and computer agent (n=14) interventions. Among robot interventions, most reduced loneliness (67%), social (100%) and health and wellbeing (67%) outcomes non-significantly. Most computer agent interventions non-significantly improved social (83%) and wellbeing (67%) outcomes and of nine interventions that investigated loneliness outcomes, 44% significantly and 44% non-significantly showed improvement. Befriending interventions included technology mediated ( n= 14) and non-technology mediated ( n= 10) befriending interventions, and a combination of the two ( n= 2). None of the befriending interventions improved outcomes significantly, but most showed positive impact on loneliness (range 60%-80%), social (89%-100%) or health and wellbeing (40%-67%) outcomes regardless of whether they were mediated by technology or not. Peer support group interventions included those that were delivered in-person ( n= 16) or virtually ( n= 6). Half of in-person peer support interventions significantly reduced loneliness and health and wellbeing outcomes, and most (82%) non-significantly improved social outcomes. Most virtual peer support interventions (67%) improved social outcomes and half improved health and wellbeing outcomes but not significantly. Mentorship interventions included in-person delivered ( n= 8) or a combination of in-person and/or virtually delivered ( n= 3). Most in-person mentorship interventions (67%) significantly reduced loneliness outcomes. Of interventions that investigated social outcomes ( n= 3), most (75%) showed non-significant positive impact. When mentorship interventions were delivered in-person and/or virtually, findings were mixed with half of interventions finding significant improvement and half finding no change in loneliness, social or health and wellbeing outcomes.

Self-management-related interventions ( n =157) (Table 3 )

Self-management education ( n= 106), psychological self-management interventions ( n= 43), and social prescribing or asset-based ( n= 8).

Self-management education interventions included social health training ( n= 30), general health training ( n= 23), combination of technology device and Internet training ( n= 21), technology device training ( n= 16), caregiver support education ( n= 7), peer-based self-management education ( n= 5), and self-management skills training ( n= 4). Among social health training interventions, 70% significantly reduced loneliness and 40% significantly improved wellness outcomes, and most interventions (79%) non-significantly improved social outcomes. General health training interventions had mixed results with a third showing significant impact and 31%-40% showing no change in loneliness and social outcomes; wellness outcomes non-significantly improved in 57% of interventions. Most technology device training interventions had no change in loneliness (63%) or wellness (60%) outcomes but showed a non-significant improvement in social outcomes among 63% of interventions. 40% of caregiver support education interventions significantly reduced loneliness but showed mixed results for social and health and wellness outcomes. Among peer-based self-management education interventions, 60% non-significantly improved social outcomes and the two interventions that investigated health and wellness outcomes showed significant improvement. Most self-management skills training interventions (67%) improved social outcomes significantly but found mixed results for loneliness outcomes. Psychological self-management interventions included behavioural activation and cognitive behavioural therapy (CBT) interventions ( n= 22); a combination of different psychological interventions (e.g., CBT + mindfulness; music + reminiscence) ( n= 11), psychosocial interventions ( n= 5) and reminiscence therapy ( n= 5). Most behavioural activation or CBT interventions significantly reduced loneliness (63%) and improved health and wellbeing (67%) outcomes and half non-significantly improved social outcomes. Of interventions that included a combination of different psychological strategies, most showed positive impact for loneliness (67%) and social (60%) outcomes, but these were not significant. Among psychosocial interventions, none of the interventions showed impact in loneliness outcomes, 75% also showed no change in social outcomes but there was a non-significant improvement in health and wellbeing outcomes in two interventions. Among reminiscence therapy interventions, most (67%) significantly reduced loneliness outcomes, all interventions non-significantly improved social outcomes, and none of the three interventions that investigated health and wellness outcomes showed impact. Social prescribing or asset-based interventions included eight interventions, most of which (80%) significantly reduced loneliness and half significantly improved social outcomes; none investigated health and wellbeing outcomes.

Social behavioural activity interventions ( n =140) (Table 4 )

Physical activity ( n= 48) leisure activity ( n= 48), arts-based ( n= 27), mind-body ( n= 14), and spiritual ( n= 3) interventions.

Physical activity interventions : Among 16 technology-mediated physical activity interventions (including seven exergaming interventions), results were mixed for loneliness outcomes as 43% of interventions showed significant reduction in loneliness and 43% showed no change. For social outcomes, many interventions showed significant (40%) and non-significantly improvement, while 75% of interventions that investigated health and wellness outcomes found no change. Among physical activity interventions that were not technology mediated, some interventions investigating loneliness outcomes showed significant (36%) and non-significant (45%) improvement. Social outcomes improved non-significantly among 57% of interventions; and many interventions showed significant (50%) and non-significantly (67%) improvement in health and wellbeing outcomes. Leisure activity interventions : included group-based ( n= 19), self-directed ( n= 10), one-to-one ( n= 6) or mixed level of interaction ( n= 8) interventions. Many leisure activity interventions significantly reduced loneliness and improved health and wellbeing outcomes with group-based (43% and 55%, respectively) or self-directed (44% and 50%, respectively) interaction with the intervention. Results were mixed for strategies that were one-to-one or mixed level of interaction for loneliness and health and wellness outcomes. Social outcomes were non-significantly improved for most leisure interventions regardless of the type of interaction participants had with the intervention: group-based (55%), self-directed (50%), one-to-one (75%), mixed (71%). Arts-based interventions : included direct engagement ( n= 21), receptive engagement ( n= 3) or a combination of the two ( n= 2). Many arts-based interventions significantly reduced loneliness regardless of whether they were direct or receptive engagement strategies (44% and 50%, respectively). Most direct engagement in the arts strategies also improved social (71%) and health and wellbeing (75%) outcomes, but these were not significant. All the two arts-based interventions that included both direct and receptive engagement showed positive, non-significant reduction in loneliness and social outcomes. Mind-body interventions : Whether delivered in-person ( n= 11) or virtually ( n= 3), most mind-body intervention significantly reduced loneliness outcomes (44% and 67%, respectively). Among in-person strategies, most (75%) significantly improved social outcomes, and the two interventions that investigated health and wellbeing outcomes, also showed significant improvement. Spiritual interventions: Of three spiritual interventions, two significantly reduced loneliness. Social and health and wellness outcomes were mixed as one intervention significantly improved social outcomes while another showed no change in health and wellness outcomes.

General resource interventions ( n =2) (Supplement Table 2)

Two interventions were identified: A single mixed method environmental study showed that renovating the neighborhood open spaces had some positive effects on social participation. The second intervention involving a hearing aid and hearing diary showed a nonsignificant decrease in loneliness from baseline to 6-month follow-up.

Interventions with potential to help older adults during isolation measures due to infectious disease outbreaks

Of the 495 interventions that were identified in our scoping review, 189 (38%) reported at least one effective loneliness, social or health and wellbeing outcome across the three social frailty domains. Of these, we identified 63 interventions (33%) that may be considered to address social frailty in older adults during infectious disease outbreaks requiring social distancing and isolation (i.e., interventions that don’t require physical contact with a person) (Table 5 ). Effective interventions were clustered within six intervention categories across three social frailty domains: (i) psychological self-management ( n= 11) and (ii) self-management education ( n= 9) within the self-management domain; (iii) leisure activity ( n= 11) and (iv) physical activity ( n= 8) interventions within the social behavioural activities domain; and (v) ICT ( n= 10) and (vi) socially assistive robots and computer agents ( n= 5) within the social resource domain. Loneliness outcomes were the most frequently investigated across the six intervention categories. Additionally, the highest proportion of effective interventions were those that reduced loneliness outcomes (70-100%) compared with the proportion of interventions that improved social (range 18-60%) or health and wellbeing outcomes (range 11-38%). There were two interventions categories (self-management education, leisure activity) that included interventions that had significant impact across all three outcome categories: loneliness (89% and 73% respectively), social (44% and 45%, respectively), and health and wellbeing (11%, 27%). Among 10 effective ICT-based interventions, 70% reduced loneliness outcomes and 60% improved social outcomes. Among 11 psychological self-management interventions, 82% reduced loneliness outcomes, and 18% improved social outcomes. Among five effective computer agent or robot interventions, all reduced loneliness and one improved self-rated health.

Our scoping review identified 495 interventions across four broad domains of social frailty: social resource-, self-management-, social behaviour- and general resource-related [ 11 ] (Supplement file 2). The spread of effective interventions was nearly equal among social behaviour activity (44%) and self-management (41%) domains, followed by the social resource-related domain (33%). None of the interventions in the general resource related domain were effective. This was expected given that this category within Bunt et al ’s social frailty model represents “non-specific or general resources” that fulfill social needs more indirectly and which tend to be contextual or an unmodifiable resource (e.g., educational level, income) [ 11 , 43 ].

The most promising interventions were clustered around the behavioural activity and self-management domains of social frailty. Social behavioural activity interventions promote social behaviours or activities with the goal of fulfilling social needs (e.g., maintaining relationships, social participation) [ 43 ]. Most of the effective interventions in this domain were in the leisure activity ( n= 11) and physical activity ( n= 8) intervention categories. Effective leisure activities included horticulture therapy, volunteering and socializing, letter writing, and lifestyle engagement. Effective physical activities included technology-mediated (e.g., via computer, exergames) or non-technology-mediated (e.g., walking, outdoor park). Overall, both intervention categories had the greatest impact on loneliness outcomes (64% of leisure activity and 88% of physical activity interventions).

Interventions among the self-management domain aim to improve an individual’s ability to manage their behaviours, emotions and lifestyle toward improving overall health [ 44 ]. Most of the effective interventions in the self-management domain clustered within the psychological self-management ( n= 11) and self-management education ( n= 9) categories. Psychological self-management interventions included behavioural activation and CBT strategies. Self-management education interventions included skills training in general health, self-management, technology device and Internet use; and caregiver support education. Self-management strategies also had the greatest impact on loneliness outcomes as 82% of psychological and 89% of self-management education interventions significantly reduced loneliness. The positive impact of self-management interventions is not surprising given that a person’s ability to self-manage in general but particularly their social lives and activities is an important determinant of loneliness [ 46 ] and may also support healthy aging among community-dwelling older adults [ 47 ]. A person with stronger self-efficacy is more likely to do activities and to put in the effort to reach their goals [ 48 , 49 , 50 ]. Those who have higher coping self-efficacy (i.e., “a measure of self-confidence in one’s ability to effectively manage challenges using skills in problem-solving, emotional regulation, and coping through social support” ) have significantly lower odds of loneliness [ 51 ]. These suggest that we need to incorporate self-efficacy skills development and as an important component of a future social frailty intervention.

We also identified several effective interventions that may be considered during isolation measures due to infectious disease outbreaks such as the COVID-19 pandemic (i.e., physical activity, leisure activity, psychological self-management, ICT, self-management education). Most of these were delivered virtually via a computer or smart device (tablet, smartphone). Although ICT and digital communication technologies offer opportunities for older adults to remain socially connected and reinforce their existing or new social connections and relationships [ 52 ], their impact has generally been mixed [ 27 ], which is consistent with our findings. Reasons for this may be that few high-quality studies investigating ICT-based interventions exist, and many ignore confounding factors such as sociodemographic data [ 53 ]. Digital technologies have become a prominent part of social contact, interactions, and communication in society, and digital social media in particular, can expedite personal interactions and contactless communication [ 54 ]. However, digital inequities among older adults can occur on multiple levels, particularly if they are economically disadvantaged. Many older adults are excluded from social networks and online connectivity because they cannot easily access the internet either because they don’t have access to computers and smart devices, or they don’t have internet connection [ 54 , 55 ]. Furthermore, older adults may have differing knowledge, capacity, digital literacy, motivation and competence to access and engage with technology [ 55 ]. The COVID-19 pandemic further highlighted the depth of inequities among vulnerable populations related to gender, race, socioeconomic status, newcomer status, education social network quality and health literacy [ 55 , 56 , 57 ]. Older adults can only benefit from virtually delivered effective interventions if they have access to and can afford the technology (including the internet) and have digital literacy to benefit from services and resources, which are often only available via online government and other organization websites.

Considerations for future work in social frailty

Our scoping review results have several important considerations for future work in social frailty. First, we must ensure that a future social frailty innovation is usable, affordable, and accessible by all older adults by considering all possible inequities that they may experience. Second, a future social frailty intervention should target elements from all social frailty domains: the social resources of older adults (e.g., friendships or care from family members), their personal activities or social behaviours (e.g., social participation), as well as their self-management ability to gain or maintain their social resources and activities (e.g., their ability to make and maintain friends or to initiate social participation). Social frailty is a multidimensional concept because it’s not just about the absence of social resources or restrictions but the absence of social behaviours and social activities (e.g., maintaining cohesive relationships or social participation) as well as the absence of self-management abilities (e.g., feeling empowered or having the ability to make decision) [ 11 ]. Another important consideration is that the overall wellbeing of older adults is dependent on fulfilling needs according to their individual and personal circumstances, social resources, activities and capabilities [ 11 , 58 ]. Third, we should consider social prescribing alongside self-management as these strategies can be particularly helpful for more vulnerable populations such as those with social frailty. These strategies can support self-management by connecting older adults to non-clinical supports in their communities [ 59 ]. Of the eight social prescribing interventions that we identified, 80% significantly reduced loneliness and 50% significantly reduced social outcomes. Lastly, social frailty is an important risk factor for developing physical frailty in non-frail older adults [ 60 ]. As older adults increasingly rely on their informal social relationships for well-being (e.g., family and friends), it may be more prudent to address social frailty directly, which has the potential to improve outcomes across other frailty types (e.g., physical and psychological) in addition to the overall frailty state [ 61 ]. People with stronger compared with weaker social relationships have a 50% increased likelihood of survival [ 62 ], and as the number and types of social activities increases, so does social participation and positive self-perceived health [ 63 ]. This means that social frailty doesn’t have to be an inevitable part of aging.

Strengths and limitations

Our study used rigorous scoping review methods adhering to JBI guidelines [ 36 ]. We identified 189 social frailty interventions from 263 included studies that were reported as effective, and a subset of 63 interventions that may be feasible to be adapted during infectious disease outbreaks requiring further social isolation and distancing (Table 5 ). To our knowledge, this is the first scoping review of social frailty interventions grounded in theory [ 11 ]. Existing reviews focus on investigating the prevalence of social frailty [ 20 ] or focusing only on technology-based interventions [ 29 , 52 , 64 ] or on specific aspects of social frailty outcomes (loneliness, social isolation or vulnerability [ 27 , 28 , 30 ]. An important gap was that none of the 495 identified interventions were designed for social frailty and only one intervention measured social frailty as an outcome [ 65 ]. Our study also had some limitations. We identified a large number of interventions with considerable heterogeneity in the type of identified interventions and outcomes. It was also challenging to organize outcomes because they were inconsistently defined (e.g., social participation, social isolation, social vulnerability, social connectivity). To overcome this challenge, reviewer pairs (IH, JM, KA, MK) iteratively created a codebook for classifying outcomes using qualitative content analysis [ 45 ] (Supplement file 3).

Our scoping review identified promising interventions for socially frail older adults with self-management- and social behavioural activity-related strategies showing the highest rates of significantly positive impacts on loneliness, social, health and wellbeing outcomes. We also identified that psychological self-management, self-management education, leisure activity, physical activity, ICT and socially assistive robots and computer agent interventions delivered mostly virtually would be most feasible to help older adults during isolation measures due to infectious disease outbreaks such as the COVID-19 pandemic.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Abbreviations

Open Science Framework

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews

Canadian Agency for Drugs and Technologies in Health

Population, Intervention, Comparator/Context, Outcomes, Study design

Joanna Briggs Institute

Information Communication Technology

Randomized Controlled Trial

Cognitive Behavioural Therapy

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Acknowledgements

The authors would like to thank Divya Mathura for her assistance in updating the scoping review.

The authors received funding for this work from the Canadian Institutes of Health Research grant (#:172657).

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The study was designed by MK, JHL, SS. Articles were screened by IH, JH, JM, JS, KA, LH, LP, MM, MK, data charted by IH, JS, KA, MK, JH, LP, LH, MH, data analyzed and synthesized by IH, KA, MK, BL, CM, JH, LP, MH, MT and tables and figures prepared by MK, IH and JM. All authors contributed to the interpretation of findings, and contributed to and approved the final manuscript.

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Kastner, M., Herrington, I., Makarski, J. et al. Interventions that have potential to help older adults living with social frailty: a systematic scoping review. BMC Geriatr 24 , 521 (2024). https://doi.org/10.1186/s12877-024-05096-w

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Families’ importance in nursing care–families’ opinions: a cross-sectional survey study in the homecare setting

Josien M. Woldring 1 , 2 ,
Wolter Paans 1 , 3 ,
Reinold Gans 2 ,
Laura Dorland 4 &
Marie Louise Luttik 1

Archives of Public Health volume 82 , Article number: 87 ( 2024 ) Cite this article

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Informal care is an essential part of support provided in the homecare setting. To ensure effective healthcare provision, good communication and collaboration between informal and formal care providers are crucial. To achieve this aim, it is necessary to have a clear understanding of the perspectives of all stakeholders. In the scientific literature, limited knowledge is available regarding family members’ opinions about their involvement in care. To date, no instruments have been developed that accurately measure these opinions. This study aims to elucidate the opinions of family members about their involvement in nursing care.

A cross-sectional survey approach was employed. The methodological steps in this study were (1) convert the Families’ Importance in Nursing Care–Nurses’ Attitudes (FINC-NA) from a nurses’ perspective to a family perspective and thus develop the Families’ Importance in Nursing Care–Families’ Opinions (FINC-FO) and (2) measure families’ opinions regarding their involvement in home nursing care. The questionnaire was sent to 3,800 patients with activated patient portals, which accounts for about 17% of the total patient base. Responses were received from 1,339 family members, a response rate of 35%.

The developed FINC-FO questionnaire showed homogeneity and internal consistency. The results of the questionnaire indicate that family members consider it important to be involved in care and that they wish to be acknowledged as participants in discussions about care (planning) but are less inclined to actively participate in the provision of care by nurses. Family members expressed less explicit opinions about their own support needs. Factors such as level of education, type of partnership, and amount of care provided are seemingly associated with these opinions.

Conclusions

Family members in the homecare setting wish to be involved in discussions about care (planning). The transition in care from primarily formal to more informal care necessitates an awareness and clear definition—on part of both healthcare professionals and families—of their respective roles in the provision of care. Communication about wishes, expectations, and the need for support in care is essential to ensure quality of care and that the family can sustain caregiving.

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• Limited knowledge is available regarding family members’ opinions about their involvement in care, and to date, no instruments have been developed that accurately measure these opinions.
• The developed FINC-FO seems to be a feasible questionnaire to measure families’ opinions about their involvement in nursing care in the home setting.
• This study offers insight into family members’ opinions on their involvement in caregiving and the influencing factors. It underscores the importance for both healthcare professionals and families to cultivate awareness and establish clear definitions of their respective roles in providing care.

Informal family care is an essential aspect of healthcare that involves the provision of support to family members who are ill, disabled, or vulnerable [ 1 ]. Family caregivers (e.g., partner, child, neighbor, friend) are vital for patients’ support and informal care [ 2 , 3 ]. In recent years, the need for support from family caregivers at home has increased due to societal changes, such as the aging population and the decreasing availability of institutionalized professional care for daily support. As a result, vulnerable, dependent elderly people continue to live at home for longer periods but are less able to rely on professional care. These societal changes necessitate an appropriate transition from primarily formal to more informal care. Informal care provided by family benefits patients’ wellbeing; however, it is also associated with a range of practical, physical, and emotional challenges for family members [ 4 , 5 ].

To make this transition of care successful, a need exists for targeted, effective communication that facilitates collaboration between healthcare professionals and informal family caregivers. Healthcare professionals should view family caregivers as partners in the care process to meet patient and family needs [ 6 ]. Earlier research indicates that preparedness for caregiving depends on the support that families receive from healthcare professionals [ 7 ]. To achieve good communication and collaboration between healthcare professionals and family caregivers, it is important to know both families’ and healthcare professionals’ opinions regarding the role of family members in caring for patients. Earlier research further indicates that nurses who generally have positive attitudes toward involving families as partners in patient care are more likely to communicate and collaborate with families [ 8 ]. With the increasing importance of family caregivers at home, it is implicitly expected that in general, family members wish to be involved in care. However, limited research has been conducted on families’ opinions regarding their involvement in direct nursing care and, subsequently, how they prefer to communicate and collaborate with nurses [ 9 ]. Involvement in the care for a family member is likely to be imagined differently by and between family members, which may differ from what is expected by nurses [ 10 , 11 ]. It is thus crucial to understand the opinions of family members regarding their involvement in nursing care and determine whether families’ wishes and expectations align with the principles of care envisioned by nurses. As such, this study aims to explore family members’ opinions regarding their involvement in nursing care for relatives in a homecare setting.

Instruments exploring family members’ opinions regarding their involvement in nursing care are currently lacking. As such, we have adapted the widely used Families’ Importance in Nursing Care–Nurses’ Attitudes (FINC-NA) from a nursing to a family perspective.

The methodological steps employed in this study were to (1) convert FINC-NA from a nursing to a family perspective and thus develop the Families’ Importance in Nursing Care–Families’ Opinions (FINC-FO) and (2) measure families’ opinions regarding their involvement in nursing care at home. A cross-sectional survey approach adhering to the “Strengthening the Reporting of Observational Studies in Epidemiology” guidelines for articles reporting cross-sectional studies was employed [ 12 ].

FINC-NA, a widely used instrument to measure nurses’ attitudes toward the importance of involving families in nursing care [ 13 , 14 ], is based on family systems nursing theory and has been validated in different healthcare settings and countries [ 15 , 16 ]. The study of Hagedoorn et al. (2018) provides an overview of countries that have validated the FINC-NA. Examples of nurses and care settings described in this study are registered nurses in Sweden, psychiatric nurses in Iceland and Taiwan, primary healthcare nurses in Portugal and hospital nurses in Portugal and Australia [ 16 ]. In educational attainment, there are slight variations, but al nurses maintain an educational level comparable to registered nurses.

The FINC-NA comprises four subscales: family as a resource in nursing care , referring to a positive attitude toward families’ presence in nursing care; family as a conversational partner , referring to the acknowledgment of patients’ families as conversational partners; family as a burden , referring to statements of experiencing family as a burden; and family as its own resource , referring to families’ own resources for coping [ 17 ]. Other instruments exist that measure families’ perspectives toward family involvement, but these typically involve a specific context and focus on families’ experiences with care, rather than their opinions about how they want to be involved. As such, we have adapted FINC-NA from a nursing to a family perspective.

Converting the survey items

The FINC-NA questionnaire has undergone translation into Dutch and subsequent psychometric testing. Hagedoorn et al. (2018) details this linguistic validation process, which involved translating the original Swedish questionnaire to Dutch [ 16 ]. This Dutch version of FINC-NA, comprising 26 statements utilizing a 5-point Likert scale, was converted from a nursing to a family perspective, resulting in the Dutch FINC-FO. To remain as close as possible to the original statements of the validated list, initially, only the concept of “nurse” was converted to that of “family” (or vice versa). The statements were subsequently evaluated and adjusted by two researchers (MLL and LD) with expertise in family care, who aimed to maintain the intention of the statements while ensuring that they were also easily understandable and applicable from a family perspective. Most of the adjustments involved the addition of the words “I consider it important…”. Only one item from FINC-NA, on the subscale family as resource in nursing care (“The presence of families gives me a feeling of security”), could not be transferred to a family perspective. As this statement relates to nurses’ emotions and perceptions, it was not considered something that the family could express an opinion on.

The content validity of the FINC-FO items was established by homecare patients and experienced informal caregivers (4 in total) who were members of an official customer council within a homecare organization. The FINC-FO was sent to the council by e-mail. Members of the council were asked to review all 26 statements for clarity and relevance and provided written feedback to the research team. Some statements were assessed as unclear, which could subsequently be resolved by changes in word-order or word-choice. All experts agreed that the statements in the final version of FINC-FO were clear and relevant to examine families’ opinions about their involvement in care at home.

The converted questionnaire resulted in an FINC-FO list comprising 25 statements exploring the four subscales using a 5-point Likert scale (1 = strongly disagree–5 = strongly agree) aligning with the original FINC-NA. Items were presented per subscale, starting with family as a resource in nursing care , with nine items, followed by family as a conversational partner , with eight items, then family as a burden , with four items, and finally family as its own resource , also comprising four items [ 12 ].

Reliability and construct validity

An item-total correlation correcting for overlap was conducted to evaluate the homogeneity and discrimination ability of the items. This correlation should be higher than 0.30 [ 18 ]. Cronbach’s alpha was used as a measure of the internal consistency or reliability of FINC-FO and its subscales. An alpha value of 0.70 or higher is generally considered acceptable, while values of 0.80 or higher are considered excellent [ 18 ]. To analyze the questionnaire’s construct validity, a confirmatory factor analysis was used. Since FINC-FO is based on the theory of FINC-NA, a deductive theory-based approach with the original, pre-specified factor structure of the four constructs was tested. A one-factor analysis per subscale was used to investigate the size of loadings (i.e., the items’ degree of association with the latent factor). Stevens (2002) recommends interpreting factor loadings with absolute values above 0.40 as sufficient [ 19 ].

Sample and setting

FINC-FO was distributed among the family members of patients receiving care from three home healthcare organizations in the northern region of the Netherlands. In the Dutch research context, homecare institutions are defined as organizations that deliver varying levels of care within individuals’ homes, serving to different levels of complexity. These organizations match the complexity of care required with the training and competency level of the healthcare professional, typically categorized by nursing levels. This coordination is facilitated through a nursing assessment performed by registered nurses. This model of healthcare organization is generally analogous to home healthcare organization in other European countries and North America.

As the FINC-FO questionnaire was made available exclusively through the electronic health record system’s patient portal (Caren-Nedap), only family members admitted to the patient portal were able to participate. The questionnaire was sent to 3,800 patients with activated patient portals, which accounts for about 17% of the total patient base. Responses were received from 1,339 family members, a response rate of 35%.

Data collection

In April 2022, FINC-FO was administered to family caregivers through the patients’ electronic health record system. The questionnaire was accessible via a link within the patient’s care file, visible to both patients and their families. Demographic characteristics such as age, gender, level of education, type of relationship with the patient, number of hours of caregiving, and working status were subsequently collected. The entire data collection process took 4 weeks.

Data analysis

Only completed questionnaires were included in the data analysis. Of the 1,339 questionnaires, 64 were excluded due to incomplete responses, resulting in 1,275 questionnaires for data analysis. As in FINC-NA, items on the subscale family as a burden were reverse scored, so the scores on this scale were recoded before analysis. Education level was categorized as high (tertiary education), middle (secondary education), or low (primary education), and the categories of relationship to the patient were merged into three: spouse, parent/child, and other. Data were analyzed using SPSS for Windows (release 28.0.1.1), and descriptive statistics were used to describe the study population and the responses to the FINC-FO questionnaire on item levels. Higher scores indicate more positive opinions. An independent t-test and an ANOVA were used to compare differences in attitudes related to background variables. For these analyses, the continuous variables age and caregiving hours were dichotomized. Mean or median was used as the cut-off point for the distribution. Multivariable linear regression analyses were performed to determine the individual contribution of each background variable to the FINC-FO and subscale scores. The significance level was set at p ≤ 0.05.

FINC-FO questionnaire

The questionnaire was completed by 1,275 respondents. Table 1 illustrates the subscales, with the associated FINC-FO items. Subscales and items are shown in the same order as they appear in the questionnaire. All items on the subscales have been translated from Dutch to English by a certified translation agency with the original English FINC-NA terminology serving as a reference. They are expressed in truncated sentences to save space. Table 1 shows the homogeneity of the total FINC-FO scale with item-total correlations, internal consistency with the Cronbach’s alpha, and factor loadings per subscale.

The total FINC-FO questionnaire and the subscales family as a resource in nursing care , family as a conversation partner , and family as its own resource demonstrated strong internal consistency, with Cronbach’s alpha scores exceeding 0.80 across these scales. Most item-total correlations surpassed 0.40, with the exception of two items (RCN-1 and CP-5), which exhibited lower correlations. These two items also displayed inadequate factor loadings, below 0.40. Excluding them resulted in a slight improved Cronbach’s alpha. The Cronbach’s alpha for the subscale family as a burden was moderate, with one item showing a negative item-total correlation and the remaining items falling below 0.30.

Additionally, these FINC-FO score seem comparable to the Dutch FINC-NA questionnaire [ 16 ] which demonstrated similar reliability, with Cronbach’s alpha of 0.88 and 0.82 for the total score of the FINC-NA and subscale family as a resource in nursing care , respectively. However, the subscales family as a conversational partner and family as its own resource exhibited slightly lower Cronbach’s alpha values (0.74 and 0.73, respectively) compared to their counterparts in the FINC-FO. Conversely, the subscale family as a burden demonstrated slightly higher Cronbach’s alpha in the FINC-NA compared to the FINC-FO [ 16 ].

Measuring families’ opinions

Study population.

Table 2 illustrates the characteristics of the 1,275 respondents who completed the questionnaire. The average age of respondents was 60.7 years, and over 90% were between 40 and 80 years old. Over 70% were female, and more than half (57%) reported having paid employment. On average, these respondents worked 28 h a week, with 30% working 32 h a week or more. More than half of the respondents (59%) spent 8 h or less on caregiving tasks (ranging from 0 to 168 h), with 11.5% reporting spending at least 35 h on caregiving and 6.5% providing caregiving tasks 24 h a day.

Scores on FINC-FO

The total score of 92.3 (SD 11.5; range 25–125), as well as the scores on the subscales of the FINC-FO questionnaire, represented approximately 70% of the maximum possible score (see Table 3). Table 1 illustrates the response percentages per category.

Family as a resource in nursing care

Almost all respondents indicated that a good relationship with nurses gives them a positive feeling (95%), and most (75%) indicated having valuable knowledge that can be useful in caring for the patient or their family members. About half of the respondents indicated that their presence in care at home was meaningful (54%), made the work of a nurse easier (43%), and gave them a sense of purpose (52%). Family members also considered it important to actively participate in discussions about care (planning) and for nurses to allocate time for them. Fewer family members (19%) found it important to be present during actual care moments.

Family as a conversational partner

Of the family members, 87% found it important that nurses identify those who belong to the family, while less than half (43%) indicated that this had occurred in their situation. Most respondents (86%) considered it important to be invited for a conversation at the start of care provision, and 72% of respondents believed that this would save time. They also wished to be engaged in conversation at the end of care provision (77%), during changes (95%), or to regularly discuss progress (68%). Less than half (42%) found it important to be actively invited to participate in care provision.

Family as a burden

Most respondents (86%) did not believe that they hindered nurses in their work. Additionally, 67% did not feel that nurses found it difficult when family was present during care provision. Approximately 10% felt that they needed to monitor care provision to ensure that everything went well.

Family as its own resource

Nearly two-thirds (64%) of the respondents considered it important for nurses to view them as collaborative partners, while 10% did not find this important. Almost half of the respondents (46%) found it important to be asked how they could be supported, while 51% wanted support from nurses in coping with the situation. One-third (36%) found it important to be encouraged to cope with the situation as best as possible, while 19% did not find it important, and 45% had no opinion.

Differences according to background variables

Table 4 shows the scores for both the total FINC-FO questionnaire and the subscales related to the background variables.

A significant difference was found in the scores between the age groups. Older (> 60 years) family members scored higher compared to younger family members on the overall FINC-FO and on the three subscales family as a resource in nursing care , family as a burden , and family as its own resource ( p ≤ 0.005).

Gender showed no significant difference in scores, except on the subscale family as a resource in nursing care. On this subscale, male family members scored higher than female family members ( p = 0.03).

Education level

Family members with low education levels showed a significant higher score on the overall FINC-FO compared to middle and high education levels ( p < 0.001). This difference was also observed on the subscale family as its own resource . The subscale family as a resource in nursing care showed a statistically significant difference among family members of all education levels ( p < 0.001).

Relationship to the patient

Spouses of patients scored significantly higher compared to other relationships on the total FINC-FO and on the three subscales family as a resource in nursing care , family as a burden , and family as its own resource ( p < 0.001).

Paid employment

Family members who had paid employment scored significantly lower than family members who were unemployed or doing volunteer work on the total score of FINC-FO ( p < 0.001) as well as on the three subscales family as a resource in nursing care , family as a burden , and family as its own resource ( p ≤ 0.03).

Caregiving hours

The more care hours were provided by family members, the higher the scores on FINC-FO. Significant higher scores were seen in the total score of FINC-FO and on the subscales family as a resource in nursing care , family as a conversational partner , and family as its own resource ( p < 0.001).

Multiple linear regression

To determine the unique contribution of each background variable (see Table 4), multivariable linear regression models were performed for the FINC-FO questionnaire and its subscales (see Table 5). The number of caregiving hours made the greatest contribution for all subscales except family as a burden , and more caregiving hours resulted in a higher total FINC-FO score (β = 0.18; p < 0.001). The family relationship of spouses made the same contribution as caregiving hours on the subscale family as a resource in nursing care (β = 0.15; p < 0.001). Spouses made a significant contribution to the overall FINC-FO score (β = 0.09; p = 0.03), and on all subscales except family as a conversational partner . Low education level also contributed to the total FINC-FO score (β = 0.06; p = 0.04), as well as the subscales family as a resource in nursing care (β = 0.07; p = 0.02) and family as its own resource (β = 0.08; p = 0.02). Families with low education levels scored higher than those with middle education levels. For the subscale family as a burden , age made the greatest contribution (β = 0.10; p = 0.01).

Table 5 shows that only 2–9% is explained by the selected background variables.

In this study, we gained insight into families’ opinions regarding their involvement in nursing care at home using the developed FINC-FO questionnaire. The results specifically reveal that family members consider it important to be acknowledged as participants in discussions about care and care planning and that they wish for their knowledge and input to be appreciated. Family members seem less inclined to actively participate in care and express less explicit opinions about their own support needs. Overall, FINC-FO seems to be a feasible questionnaire to capture families’ opinions regarding their involvement in nursing care in the home setting.

Our study indicates that primarily, level of education, type of relationship, and amount of care provided are associated with opinions regarding involvement in care. In particular, spouses, family caregivers with a relative low level of education compared to middle and high level educated family members, and family caregivers providing more than eight hours of care express the wish to be involved in care for their relatives. As demonstrated in previous studies, the influences of these background characteristics often interconnect [ 20 ]. It seems obvious that spouses, who spend more time with patients, have the opportunity to provide more informal care. Also, people with lower resources in terms of education and income more often provide informal care because they are less inclined to utilize professional care and often have smaller social networks to assist with caregiving, and as a result, bear the burden of care themselves [ 21 , 22 , 23 , 24 ]. Healthcare professionals must be aware of these associations and the impact of these variables, as the desire for a high involvement in care and the inability to mobilize other resources to organize care might eventually contribute to the overloading of family members, which often happens gradually and when it becomes apparent it will become a crisis [ 25 ]. Prevention necessitates an approach that considers the entire care situation. Regular communication between patients, families, and healthcare professionals about collaborative caregiving and the division of roles and tasks is essential to ensure quality care in the long term and the sustainability of family caregiving.

Background variables discussed above explain only up to 9% of the variance regarding family involvement in care. This suggests that several other unidentified factors influence family members’ opinions and highlights the need for further research on this topic.

Although family members express a desire to be acknowledged as participants in discussions about care and care planning, they seem less inclined to be actively involved in actual care provision by nurses. Before healthcare professionals become involved, family members frequently perform myriad caregiving tasks. However, these responsibilities seem to shift when healthcare professionals become involved and take over the provision of care [ 26 ]. With the need for a transition from primarily formal care to a higher level of involvement of informal care, healthcare professionals should consider what care is already being provided by a family and discuss which additional aspects of care the family is willing and able to deliver by discussing the possibilities, wishes, and expectations in the provision of care with the family. This necessitates an awareness—on the part of both healthcare professionals and family members—of their respective roles and tasks in the provision of care [ 8 ]. In addition, it seems desirable that healthcare professionals and family members harmonize their principles, values, and mutual expectations regarding the provision of care for the patient. Such conversations will promote better collaboration and coordination based on mutual understanding.

Family members responded more neutrally on the subscale family as its own resource , which suggests that family members are focused primarily on the patient and less on themselves and their needs as family caregivers. Family members may be unaware of their need for support or expect nurses to be primarily dedicated to the patient, not to family members. However, from the perspective of family systems nursing, the focus of nurses should not be solely on the patient but on the care situation as a whole and the family as the unit of care [ 27 ]. Considering the transition from formal to more informal care, the awareness that families may need support seems relevant among healthcare professionals, and among the patients and families themselves [ 28 ].

Strengths and limitations

The FINC-FO questionnaire was distributed via an electronic health record system, so it reached not the entire population of family members within the organization but only those who utilized the electronic patient portal. As a result, a possibility of bias in the results exists; family members who use the electronic patient portal may be more closely involved than those who do not. The sample size of 1275 allowed us to perform psychometric testing of the FINC-FO, indicating that the FINC-FO seems to be a feasible questionnaire to capture families’ opinions regarding their involvement in nursing care in the home setting. However, with a final response rate representing 35% of the total population, only cautious conclusions can be drawn about the population of family members of patients receiving homecare using the electronic patient portal. Further research is needed, employing alternative strategies to engage more respondents, in order to be able to generalize findings to a broader family population.

In this study, a questionnaire that has not yet demonstrated validity was employed. Nevertheless, the FINC-FO offer a sufficiently reliable and differentiated picture of family members’ opinions regarding their involvement in nursing care in the home setting, which suggests that this instrument can be recommend for use in future studies. However, it should be noted that the psychometric test conducted in this study indicates that the subscale family as a burden had moderate internal consistency as a subscale and a low item-total correlation with the total questionnaire. Depending on the primary questions in such studies, consideration may be given to adjusting or removing the subscale family as a burden ; this domain seems to answer a nurse related topic as it concerns the perception of families toward nurses and is not related to family involvement. Therefore this subscale seems not to contribute meaningfully to the research question we posed as the starting point in our study. The internal consistency of the three other subscales had good reliability but could potentially be improved by removing two specific items (RNC-1: Having a good relationship with nurses gives me a good feeling ; CP-5: The nurses found out who the family members are ). These items also had the lowest factor loadings of the subscales, so removing or reformulating these items should be considered. RNC-1 seems to be more associated with generating positive emotions than functioning as a resource, while C-5 is not an opinion item. It asks about specific experiences, which does not fit in this questionnaire.

Further research will be needed to examine the performance of the FINC-FO questionnaire following further psychometric refinement and suitability in different (institutional) healthcare settings.

While many studies have investigated the perspective of nurses with regarding the role of family members in patient care, this study investigated how family members perceive their own role in patient care. Exploring how family members experience the involvement of nurses in the care for their loved-one, could also be an interesting lens to study in future research since nurses, at some point, enter the existing family system that initially takes up the care of the patient.

Despite the limit sample size in this study, it is vital to prioritize policy implications surrounding awareness among healthcare professionals and families regarding their caregiving roles. Interventions should be developed and implemented to enhance communication and fostering collaboration between healthcare providers and families. Healthcare education should emphasize the important of communication and implementation regarding the division of roles between nurses and family members in caregiving.

In general, the family members of homecare patients want to be involved in nursing care. They wish to be acknowledged in discussions about care and care planning as participants with valuable knowledge. Family members are less inclined to actively participate in the care provided by nurses and are less explicit in their opinions about their own support needs.

The transition from primarily formal to more informal care necessitates an awareness on the part of both healthcare professionals and families of their respective roles in the provision of care. Communication about wishes, expectations, and the need for support in care is essential to ensuring quality care and that family members can sustain caregiving. With some suggestions for adjustment and improvement, FINC-FO is a feasible questionnaire to capture families’ opinions about their involvement in care.

Data availability

The FINC-FO questionnaire, meta data and The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines used to support the findings of this study has been deposited in the Dataverse repository. Available at : https://doi.org/10.34894/OYDOU4.

Abbreviations

Families’ Importance in Nursing Care–Nurses’ Attitudes

Families’ Importance in Nursing Care–Families’ Opinions

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Acknowledgements

The authors would like to thank Sabine van der Ham, library specialist, for supporting in data storage and nursing students Anna van der Heide and Lisa Oolders for their contribution in data collection.

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Contributions

Conceptualization, Methodology, Validation: All authors; Formal analysis: JW, WP, MLL and LD; Investigation: JW and LD; Resources: JW, MLL and LD; Data curation, Writing original draft, Supervision and project administration : JW Writing-reviewing and editing: WP, RG, MLL and LD.

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Correspondence to Josien M. Woldring .

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Ethics approval and consent to participate.

The study was approved by the ethical committee of Hanze University Groningen (heac.T2023.028). Patients and family members were informed about the aim of the study, and the participation of family members was voluntary. Family members were asked for informed consent before beginning the online FINC-FO questionnaire. The researchers received anonymized responses, and answers could not be tracked to individuals.

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Woldring, J.M., Paans, W., Gans, R. et al. Families’ importance in nursing care–families’ opinions: a cross-sectional survey study in the homecare setting. Arch Public Health 82 , 87 (2024). https://doi.org/10.1186/s13690-024-01314-4

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Collaboration
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Informal care
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Help patients understand the hazards of vaping to the eyes

e-cigarettes and vaping: Person vaping with glasses on

It seems like ever since vaping was introduced in the U.S. market almost two decades ago, health care providers and researchers have been trying to smoke out whether vaping is indeed a “safe” alternative to combustible cigarettes.

In “The Impact of Vaping on the Ocular Surface: A Systematic Review of the Literature,” published April 28, 2024, in the Journal of Clinical Medicine, researchers found “significant risks”—from non-intended and intended exposures, though they note that more research is needed.

“The impact of vaping on the ocular surface is not benign,” the review’s authors say. “There are significant risks that vaping can pose to the ocular surface.

“Hence, it is necessary to develop appropriate risk communication tools given the increasing popularity of this activity.”

Among the conclusions, from intended and non-intended exposure to vapes’ aerosol mist, in the review:

E-cigs may reduce the quality and stability of the tear film, thereby impacting the ocular surface. The tear film acts as protection, lubricant and refraction for the cornea.
E-cigs/vaping products may contribute potentially to dry eye, a multifactorial disease.
E-cig users should be educated on the potential effects that vaping can have on their ocular surface, as well as potential dangers from non-intended exposure.
Policymakers should consider passing legislation that reduces the potential for ocular harm caused by e-cigs/vaping products, such as restricting e-liquid containers.

AOA members Pamela Lowe, O.D., FAAO, Dipl. ABO, who practices in Illinois, and Daniel Bintz, O.D., who practices in Oklahoma, comment on the literature review and about the role of doctors of optometry in protecting patients’ eye health from vaping.

What is your view on the conclusions in the literature review?

Dr. Lowe: Continued studies, along with a review of current studies, on the side effects of vaping are important to shed light on the potential ocular and physical complications optometrists need to be aware of to properly educate patients. This review of the current literature outlines the implications vaping has on tear film stability, which directly impacts visual and ocular comfort. The review of literature also addresses the well-known addictive nature of tobacco use and its long-term potential for systemic disease.

Dr. Bintz: It’s a good starting place. We know that any additive to the air we are exposed to may have a negative effect on the ocular surface and other external and internal tissues. So, it makes sense to study this new form of smoking. They keep repeating that studies are in their infancy and that more research is needed, but that initial studies are having mixed results, with most pointing to e-cig use as being an ocular surface irritant and possibly long-term effects of damaging the anatomy of the lids that helps produce tear film.

Do you converse with your patients about their vaping and/or tobacco use and potential harm to their eye health and vision?

Dr. Lowe: In many cases, the only health care provider patients see is their optometrist; this puts the responsibility on doctors of optometry to address the potential ocular and systemic diseases for which a patient is at risk. Addressing strategies to reduce these risks is essential for every patient’s follow-up and treatment plan.

Dr. Bintz: Yes, we all try to keep pushing the message, but with having to increase patient loads due to low reimbursement from vision care plans, our conversations sometimes do not happen or are quite brief.

How are you communicating with your patients on the subject?

Dr. Lowe: Along with giving patients information and resources on smoking cessation and the risks of topical tobacco use with popular products like Zyn, our office refers patients back to their primary care general physician to coordinate care. Especially due to the increased systemic risks of cancer, heart disease, stroke and cardiovascular disease.

Dr. Bintz: It’s part of the social history the techs take during pretesting and health history review, which I review during the exam. In our practice, we also have a poster in each pre-test room, one about vaping and the other about tobacco use. We also have materials from 1-800-QUIT NOW.

What role does patient education have in discouraging e-cigs/tobacco use?

Dr. Lowe: We are most certainly educating ALL patients who use tobacco products on the potential health risks and the direct relationship to tear film stability and increased risks for sight-threatening conditions such as glaucoma and age-related macular degeneration.

Dr. Bintz: I think most patients know they would be better off not using e-cigs but many think of it as the lesser of two evils, compared to tobacco use. Again, we try to educate them as to the risks of tobacco use, starting with contact lens training, as many new contact lens wearers are at the age where experimenting with vaping and tobacco use occurs. Scaring them with talk of blindness and lung cancer may not be as effective as telling them the immediate downsides such as bad smelling breath, hair, clothing, yellow teeth, reduced athletic performance. etc.

Go to AOA Marketplace to view the patient education pamphlet, " Contact Lenses, Smoking and Vaping ."

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Background and Objectives. Scholarship on the health of family caregivers to older adults continues to expand. Although existing research suggests that many family caregivers experience pain, which impacts their ability to perform caregiving tasks and is associated with care recipients' unmet needs, the scope of research on family caregivers' pain remains poorly characterized.
The relationship between education and health: reducing disparities
The enormous breadth of the literature on education and health necessarily limits the scope of the review in terms of place and time; we focus on the United States and on findings generated during the rapid expansion of the education-health research in the past 10-15 years. The terms "education" and "schooling" are used interchangeably.
Interventions that have potential to help older adults living with
By the year 2050, two billion people worldwide will be 60 years of age and older [1, 2].In Canada, the prevalence of frailty in those age 65+ years is almost twice that of those age 50-64 years [].The association of older age with increased prevalence of frailty may be due to the accumulation of multiple risk factors over time [] and includes physical, psychological and social dimensions [4,5,6].
Families' importance in nursing care-families' opinions: a cross
Informal care is an essential part of support provided in the homecare setting. To ensure effective healthcare provision, good communication and collaboration between informal and formal care providers are crucial. To achieve this aim, it is necessary to have a clear understanding of the perspectives of all stakeholders. In the scientific literature, limited knowledge is available regarding ...
Help patients understand the hazards of vaping to the eyes
This review of the current literature outlines the implications vaping has on tear film stability, which directly impacts visual and ocular comfort. The review of literature also addresses the well-known addictive nature of tobacco use and its long-term potential for systemic disease. Dr. Bintz: It's a good starting place. We know that any ...

Health literacy and public health: A systematic review and integration of definitions and models

(HLS-EU) Consortium Health Literacy Project European

Conclusions

Definitions of health literacy

Concepts of health literacy

Dimensions of health literacy

Antecedents and consequences of health literacy

An integrated conceptual model of health literacy

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Problem-based learning in academic health education. A systematic literature review

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Global health competencies and approaches in medical education: a literature review

Conclusions

Data Sources and Searches

Study Selection

Data Extraction and Synthesis

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Step 1: Frame Your Research Question(s)

Step 2: Contact Experts to Get Answers or for Guidance to Relevant Publications

Step 3: Read Secondary Sources to Gain a Broad Overview of the Literature Related to Your Research Area

Step 4: Select Preliminary Sources that Index Relevant Research Literature

Step 5: Identify Subject Terms, or Descriptors, and Use Them to Search Preliminary Sources

Step 6: Read and Evaluate Primary Sources Discovered Through Indexes

Step 7: Classify the Publications You Have Reviewed into Meaningful Categories

Step 8: Prepare Your Literature Review Report

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Effects of different types of exercise intensity on improving health-related physical fitness in children and adolescents: a systematic review

Introduction

Search strategy

Eligibility criteria of the selected studies

Data extraction

Quality assessment

Data synthesis and analysis

Literature screening process and results

Effects of different exercise intensity on BODY COMPOSITION in children and adolescents

Weight, BMI and body fat

Waist circumference

Fat-free mass

Effects of different exercise intensities on CARDIOPULMONARY FUNCTION (CRF) in children and adolescents

Blood vessels

Insulin sensitivity

Inflammation

Effects of different exercise intensities on FLEXIBILITY in children and adolescents

Effects of different exercise intensities on MUSCLE FITNESS in children and adolescents