systematic review health education programs

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• Published: 23 May 2024

Effectiveness of school oral health programs in children and adolescents: an umbrella review

• Upendra Singh Bhadauria 1 ,
• Harsh Priya 2 ,
• Bharathi Purohit 1 &
• Ankur Singh 3  

Evidence-Based Dentistry ( 2024 ) Cite this article

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To evaluate the systematic reviews assessing the effectiveness of any type of school-based oral health programs in children and adolescents.

Methodology

A two-staged search strategy comprising electronic databases and registries based on systematic reviews was employed to evaluate the effectiveness of school-based interventions. The quality assessment of the systematic reviews was carried out using the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2) tool. The Corrected Covered Area was used to evaluate the degree of overlap.

Nine reviews were included in this umbrella review. The Critical Covered Area reported moderate overlap (5.70%) among the primary studies. The assessment of risk of bias revealed one study with a high level confidence; one with moderate whereas all other studies with critically low confidence. Inconclusive evidence related to improvements in dental caries and gingival status was reported whereas, plaque status improved in a major proportion of the reviews. Knowledge, attitude, and behavior significantly increased in students receiving educational interventions when compared to those receiving usual care.

Conclusions

The evidence points to the positive impact of these interventions in behavioral changes and clinical outcomes only on a short term basis. There is a need for long-term follow-up studies to substantiate the outcomes of these interventions.

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Upendra Singh Bhadauria & Bharathi Purohit

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Harsh Priya

Australian Research Council DECRA Senior Research Fellow, The University of Melbourne, Parkville, Victoria, Australia

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Bhadauria, U.S., Priya, H., Purohit, B. et al. Effectiveness of school oral health programs in children and adolescents: an umbrella review. Evid Based Dent (2024). https://doi.org/10.1038/s41432-024-01013-7

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• Published: 18 September 2020

Effective educational interventions for the promotion of sexual and reproductive health and rights for school-age children in low- and middle-income countries: a systematic review protocol

• Arone Wondwossen Fantaye 1   na1 ,
• Amos Wung Buh 1   na1 ,
• Dina Idriss-Wheeler 1 ,
• Karine Fournier 2 &
• Sanni Yaya   ORCID: orcid.org/0000-0002-4876-6043 3 , 4  

Systematic Reviews volume  9 , Article number:  216 ( 2020 ) Cite this article

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Biological changes underlying the sexual and reproductive maturation of school-age children are linked with various sexual and reproductive health and rights risks. SRHR risks are predictors of poor SRHR outcomes, such as poor knowledge of sexually transmitted diseases and early sexual initiation occurring predominantly among school-age children. The aim of this proposed review, therefore, is to identify educational interventions that have proven to be effective in promoting or supporting the sexual and reproductive health and rights of school-aged children in low- and middle-income countries.

A systematic review of studies on the strategies promoting the SRHR of school-aged children shall be conducted. Electronic searches will be conducted from January 2000 onwards on the following databases: MEDLINE(R) ALL (Ovid), Embase (Ovid), CINAHL (EBSCOHost), APA PsycInfo (Ovid), ERIC (Ovid), Cochrane Central Register of Controlled Trials (Ovid), Education Source (EBSCOHost), Web of Science (Clarivate Analytics), SciELO Citation Index (Clarivate Analytics), Global Health (Ovid), and Sociological Abstract (Proquest). Studies eligible for inclusion will be randomized control trials (RCTs), non-randomized trials, quasi-experimental studies (e.g., pre-post tests), and observational studies (cross-sectional and cohort studies). Peer-reviewed studies published in English and/or French and involving school-aged children 5–10 years old will be included. The primary outcomes of interest will include knowledge, awareness, or attitudes about SRHR topics. The secondary outcomes of interest will include sexual and reproductive behaviors. Two reviewers will independently screen all citations, abstract data, and full-text articles, and the methodological quality of each study will be appraised using JBI critical appraisal tools. A narrative synthesis of extracted data will be conducted.

The systematic review will synthesize the evidence on existing educational interventions targeting SRHR outcomes of school-aged children in low- and middle-income countries. It will identify which interventions have proven to be effective, and which interventions have not proven to be effective in promoting or supporting their SRHR. Review findings will provide a useful reference for policy-makers, program developers, global health leaders, and decision makers who wish to support the SRHR of school-age children.

Systematic review registration

The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO CRD42020173158).

Peer Review reports

Middle childhood is a critical developmental period of vast physical, social, behavioral, and cognitive changes that can have a significant influence on one’s health status later in the life course [ 1 ]. It is also a period when children develop curiosity about reproduction and anatomy, experience initial physical changes (puberty) related to sexual and reproductive development, develop foundational capacities to build social relationships with the opposite sex, and experience their first sexual and romantic attractions [ 2 , 3 ].

Middle-aged children learn about sexuality and reproduction, and form perceptions, attitudes, and behaviors related to what they have absorbed [ 4 ]. Their resulting perceptions, attitudes, and behaviors may contribute to healthy or unhealthy sexual and reproductive values, preferences, and decisions in subsequent life stages. Given that these decisions influence outcomes, including morbidity and poor quality of life, or death, in adolescence and adulthood, it is crucial to build a foundation for healthy and positive sexual and reproductive health outcomes in middle-aged children before they enter full sexual and reproductive maturity and activity [ 2 ].

In low- and middle-income countries (LMICs), middle childhood aligns with school-age children, which generally range from 5 to 12 years of age [ 1 , 5 , 6 ]. Developmental changes underlying the sexual and reproductive maturation of school-age children are linked with various sexual and reproductive health and rights risks (SRHR) [ 1 ]. SRHR risks are predictors of poor SRHR outcomes, which can include unsafe sexual practices, underage marriage, unplanned pregnancy, early childbearing, gender-based violence, sexually transmitted infections, maternity complications, and potentially death [ 1 , 7 , 8 ]. A review of Demographic and Health Surveys data from 55 LMICs identified insubstantial progress in delaying marriage and pregnancy, reducing unwanted pregnancies, or reducing gender inequities [ 9 ]. The United Nations Population Fund estimates that about 50 million girls in developing countries are at risk of early marriage by age 15 [ 10 ]. In 2016, early adolescent girls between the ages of 10 to 14 years had approximately 777,000 births, with 58% occurring in Africa, 28% in Asia, and 14% in Central and South America [ 11 ]. In addition, nearly a third of births by mothers under 15 years of age are unintended and unplanned [ 10 , 11 ]. This is unsurprising as school-age girls entering early adolescence in LMICs are often expected to start taking on the traditional roles of women in the household, including early marriage and childbearing [ 12 ]. Child brides are still being forced into early sexual debuts and childbearing, irrespective of the adverse health risks and poor social and economic outcomes [ 13 ]. School-age boys, on the other hand, can be pressured onto a path of early and unprotected sexual activity or displays of male dominance, including sexual violence on middle-aged children or early adolescent girls [ 12 ]. Boys’ stereotypical masculinity norms and gender attitudes towards sexuality are shaped and reinforced by stereotypical masculine attributes and behaviors. These norms are often shaped by unregulated and unaccredited information, such as from peers, TV shows, and movies [ 12 ]. Gender-based violence targeting children is another rampant issue in LMICs [ 14 ]. Victims of child sexual assault tend to be school-aged children between the ages of 7 to 12 years. Given their incomplete cognitive, moral, and social development, school-aged children do not have the foundational capacity to comprehend whether they are being sexually assaulted nor can they provide informed consent [ 14 ].

Despite increasing global commitments and efforts to improve the SRHR of school-age children over the past three decades, there are still countless unmet SRHR challenges and needs for this population. Poor education and the corresponding lack of knowledge and awareness are one of the major unmet SRHR challenges and needs today [ 15 , 16 , 17 ]. Many school-age children in LMICs start sexual activity and reproductive maturity with only limited access to timely and adequate SRHR education and information [ 15 , 16 ]. A lack of education can create barriers to accessing, receiving, and making informed decisions pertaining to SRHR, thereby increasing the likelihood of poor SRHR outcomes. These barriers can include the lack of awareness of available services, fear of privacy, and confidentiality breach to family or peers, lack of decision-making power, negative health provider attitudes, gender-based inequities, harmful sociocultural norms, as well as stigmas and taboos surrounding sexuality [ 10 , 15 , 18 , 19 ]. Vast research evidence suggests that early educational attainment related to SRHR needs is a strong predictor of positive SRHR outcomes, including delays in sexual initiation, marriage, and pregnancy [ 20 , 21 , 22 ].

Developmental changes in the brain and behaviors of school-aged children, before their sexual initiation and reproductive maturation, present clear opportunities to introduce educational interventions promoting healthy and positive SHRH outcomes. There is existing systematic evidence on the effectiveness of SRHR interventions, including educational programs, targeting adolescents and young adults between ages 10 and 25 in LMICs [ 17 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ]. One manuscript in particular has reviewed the evidence on the effectiveness of sexual abuse prevention programs for school-aged children in developing countries [ 37 ]. However, it did not adhere to a specific, structured method of synthesis. There is therefore a need for a comprehensive synthesis of the evidence on the effectiveness of existing educational interventions targeting positive SRHR outcomes among school-aged children in LMICs. It is imperative to note that school-age children are a diverse group with various emerging needs. Identifying evidence-based, developmentally appropriate, and proven educational interventions on sexual and reproductive health, as well as sexual and reproductive rights, will help to address the neglected and unmet educational needs of school-age children in LMICs. While these children transition through the subsequent developmental stages, having the information and knowledge needed to make informed sexual and reproductive decisions will increase their likelihood of positive SRHR outcomes in adolescence and adulthood. Ultimately, the review findings will inform global efforts aiming to ensure access to effective SRHR information and services and aiming to reduce future risks of morbidity and mortality of school-age children.

The objective of this study will be to conduct a systematic review of published studies that have assessed educational interventions used for promoting or supporting positive sexual and reproductive health and rights among 5 to 10 years old school-aged children in low- and middle-income countries.

Research question

Which educational interventions have proven to be effective in promoting or supporting the sexual and reproductive health and rights of 5-10 years old school-age children in low- and middle-income countries?

Patient and public involvement statement

Patients were not involved in the development of this protocol.

Protocol registration and reporting

This systematic review protocol is being reported in accordance with the reporting guidance provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) criteria (see Additional file 1 ) [ 38 ]. The review protocol has been registered within the International Prospective Register of Systematic Reviews (PROSPERO)—registration number CRD42020173158.

Inclusion criteria

The review will include studies that assessed educational interventions on school-aged children in LMICs. Middle childhood starts at about age five, aligning with the expected age range for school-age children. Several developmental changes, including physical and biological changes related to pubertal processes, link middle childhood to early adolescence. Health risks in middle childhood also tend to carry on into early adolescence, further connecting the two stages. Accordingly, interventional studies often aggregate middle-aged children and early adolescents into a single age range. As a result, this systematic review will likely include studies that assessed educational interventions on an age range composed of middle-aged children (5–10) and early adolescents (10–14). However, given the evidence gap, the focus will be on the 5–10 years age range. In consort, studies that solely focused on early adolescents and older (≥ 11), and that have not included children ≤ 10 years, will be excluded. The included studies must have a disaggregated age range of 5–10 years or a mean age of participants that falls between 5 and 10 years.

Interventions

Any educational intervention aiming to improve knowledge, awareness, attitudes, sexual behaviors, or reproductive behaviors that are relevant to the review objectives will be eligible. The review will consider studies that quantitatively evaluate the effects of educational interventions aiming to promote or support the sexual and reproductive health and rights of school-aged children in LMICs through a range of delivery channels. The educational intervention channels may include school-based interventions, conventional health services, community and outreach-based interventions, and digital media-based interventions. Interventions will be categorized by type (e.g., abstinence-only programs, comprehensive sex education programs, peer-led education), setting, and modes of delivery. Specific examples of educational interventions may include educational workshops about HIV infection, curriculum-based lessons about child sexual abuse, information about contraception access and use through social media posts, parent-led counselling about early sexual debuts and pregnancy, among others. Studies with comprehensive, composite interventions that aggregate educational interventions and non-educational interventions will be excluded if the educational intervention and its effects on an SRHR outcome are not clearly disaggregated.

The review will include studies that compared the target educational intervention group(s) to no intervention groups or other intervention groups.

The review will consider studies that measure the following SRHR primary and secondary outcomes selected based on select previous work completed in the field [ 23 , 24 , 25 , 26 , 27 , 28 , 37 , 39 ]:

Primary outcomes will include knowledge, awareness, and attitudes about SRHR topics regarding HIV infection and gender-based violence (FGC, rape, assault). Examples of outcome variables include intentions to postpone sexual activity (as measured by Intentions to Postpone Sexual Activity Scale), sexual abstinence behavior skills (as measured by Sexual Abstinence Behavior Skills Scale), knowledge scores and affirmative attitude scores regarding HIV/AIDS prevention, knowledge regarding child abuse (as measured by Children’s Knowledge of Abuse Questionnaire-Revised III), self-efficacy, and curriculum specific questionnaires on personal safety or HIV/AIDS.

Secondary outcomes will include, but are not limited to, data collected in the studies that report the following: sexual initiation, number of sexual partners, prevalence or timing of adolescent pregnancy, unintended/unplanned pregnancies, child marriages, contraceptive use/safe-sex practices, gender-based violence, and sexually transmitted infections.

Effects will be considered positive if they lead to a statistically significant increase in knowledge, awareness, or attitudes, or statistically significant effects on sexual and/or reproductive behavior. The rationale for including knowledge, attitudes, and behaviors as the primary outcomes is based on the age range of the cohort (5–10 years old) for whom the primary goal of an intervention is to educate and promote positive SRHR attitudes and decisions in subsequent years when sexual activity begins [ 20 , 21 , 22 ].

Types of studies to be included

The review will include experimental and quasi-experimental studies with controlled interventions that have evaluated the effects of educational programs designed to promote or support the SRHR of school-aged children. This will include randomized control trials (RCTs), non-randomized controlled trials, quasi-randomized controlled trials, pre-post and interrupted time-series trials, and a controlled before/after comparison. Studies without a comparison group (e.g. a control intervention group) will be excluded, unless they are observational studies. Observational studies (cross-sectional and longitudinal) that examine the effectiveness of educational interventions targeting improvements in knowledge, awareness, or attitudes related to an SRHR outcome will also be included. Articles that merely indicate the prevalence of an SRHR outcome or investigate factors that influence an SRHR outcome, without implementing and testing intervention effect, will be excluded. Only studies conducted in LMICs [ 40 ] and published in peer-reviewed journals will be included in the review. In terms of language, only studies conducted in English and French will be included in the review.

Information sources and search strategy

Electronic searches will be performed by an information specialist (KF) in the following databases: MEDLINE(R) ALL (Ovid), Embase (Ovid), CINAHL (EBSCOHost), APA PsycInfo (Ovid), ERIC (Ovid), Cochrane Central Register of Controlled Trials (Ovid), Education Source (EBSCOHost), Web of Science (Clarivate Analytics), SciELO Citation Index (Clarivate Analytics), Global Health (Ovid), and Sociological Abstract (Proquest). Studies will be identified using a combination of each of the databases’ unique subject headings and keywords (when applicable). Concepts pertaining to age (e.g., children), sexual health and rights, educational programs, and LMICs were developed for MEDLINE (see Additional file 2 for MEDLINE’s search strategy). The Cochrane LMICs filter [ 41 ] was modified to reflect the current list of LMICs identified by the World Bank [ 40 ]. The search filters for randomized controlled trials and observational studies developed by the Scottish Intercollegiate Guidelines Network (SIGN) were used and modified to include quasi-experimental designs as well [ 42 ]. All peer-reviewed publications from January 2000 onwards will be retrieved. This period accounts for a new wave and focus of studies on primary level education following the release of the Millennium Development Goals at the turn of the century.

Screening and selection process

All the database results will be sent to Covidence (Veritas Health Innovation Ltd.), where duplicate records will be removed automatically. The articles will then be sent to the screening phase. One reviewer will independently screen all titles and abstracts, while two other reviewers will each independently screen a split of the titles and abstracts. This method will ensure that each article gets screened by two reviewers within a reasonable time frame. AWB will resolve conflicts between AWF and DIW, while DIW will resolve conflicts between AWF and AWB. The same procedure shall be repeated in screening the full-text of articles that are retained after the title and abstract screening phase. Following full-text screening, one reviewer will peruse articles relevant to the review’s objective from Prevention Science and Child Abuse and Neglect. In addition, the reference lists of included (selected) studies will be manually perused to identify additional relevant articles. Finally, articles that have cited the included (selected) full-text articles will be searched using the database Scopus to ensure the identification of additional relevant articles that may not have been identified through the database searching.

Assessment of methodological quality

Two reviewers will independently assess the methodological quality (risk of bias) in the studies that will be selected for retrieval following full-text screening. The assessments will be done using Joanna Briggs Institute (JBI) critical appraisal tools for randomized controlled trials, quasi-experimental (non-randomized) studies, and observational studies [ 43 ] (see Additional file 3 ). All studies will be included in the review and weaved into the narrative description. The quality of the studies and outcome-specific evidence will be reported (as “low,” “moderate,” or “high quality”) based on the percentage of criteria met or not met. Any disagreements between the two reviewers will be settled by a third reviewer.

Data extraction

Two reviewers will independently extract data from all included studies to minimize potential biases. Disagreements will be resolved through discussion, or a third reviewer if required. Extraction will be carried out using a standardized data extraction tool—the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review instrument (JBI-MASARI) (see Additional file 4 ). The extracted data will include specific details about the study characteristics, participant characteristics, study methods, interventions (including name, type, description, timing of evaluation), outcome measures, and study results related to the review question and objectives. In the event of any missing or ambiguous data from a study, the corresponding author of the study will be contacted to retrieve missing or additional data.

Data synthesis

We anticipate that a meta-analysis will not be appropriate given the expected heterogeneity between the studies. In particular, the studies are expected to use various designs, and to measure or report outcomes diversely, which would make it unfeasible to pool data and generate a single effect estimate. As a result, we believe a narrative summary of the effects of interventions across different studies will be the most appropriate. Following Popay’s guidance on the conduct of a narrative synthesis, the review will include a narrative synthesis of the interventional studies targeting improvements in a SRHR outcome [ 44 ]. The review will also use the synthesis without meta-analysis (SWiM) reporting guideline to help guide the reporting of the narrative synthesis [ 45 ]. The guideline has been developed to guide reviews of interventions that conduct a narrative synthesis of intervention effects.

The narrative synthesis method is ideal for synthesizing evidence from a wide range of research paradigms and study designs. The review will synthesize the evidence on the quantitatively determined effects of the various types of educational interventions using textual summaries and tabulations. Structured textual summaries will be developed for each of the individual studies, reporting the same information in a consistent manner [ 44 ]. The summaries will contextualize the extracted data and include details about the educational intervention(s), implementation strategy, and outcomes. The textual summaries will be accompanied with tables where needed. The tables will provide details of setting, study design, population characteristics, intervention, implementation strategy, outcome measures (including direction of intervention effect), and quality assessment scores. The direction of intervention effects will be categorized as one of the following: positive, statistically significant evidence of improvement on an outcome; negative, statistically significant evidence of worsening; or null, statistically non significant effect. Contrary to the more constructivist methods, the narrative synthesis does not require new, layered constructs of the evidence beyond the original data. It is thereby ideal for developing recommendations directly applicable to policy-makers, and for providing implications for future research.

Subgroup synthesis

If a sufficient number of studies are identified, reviewers plan to examine the variability in settings (e.g. Africa vs Central/South America), study populations (e.g. boys vs girls), interventions (curriculum led vs parent led), and intervention implementation strategies (e.g., digital media vs school-based lessons). The subgroup synthesis will enable the reviewers to identify patterns within and between studies and their results. The patterns can uncover factors that may explain any differences in the effects of interventions across the individual studies [ 44 ].

Confidence in review evidence

The review will assess the confidence and certainty of the review evidence for each outcome using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach [ 46 ]. The overall GRADE certainty of evidence score for each outcome will be classified as “high,” “moderate,” “low,” or “very low.” The overall scores will be based on judgements of five key GRADE domains: methodological limitations, indirectness, imprecision, inconsistency, and the likelihood of publication bias [ 47 ]. Two reviewers will independently rate the certainty of evidence for the outcomes, and discrepancies will be resolved by consensus or with input from a third reviewer. The review findings will be discussed in the context of evidence certainty, strengths, and limitations of findings, along with their implications for policy initiatives, programmatic actions, and future research.

This systematic review will synthesize the evidence on existing educational interventions that have proven to be effective or ineffective in promoting or supporting the sexual and reproductive health and rights of school-age children. Review findings will help to form direct recommendations and inform the design or amendments to programs and policy initiatives related to children’s SRHR in LMICs. Review findings will also help to identify gaps in the existing research evidence and formulate future directions for research. Given the size of the project and the number of reviewers, we anticipate timeline-related challenges. In addition, given COVID-19 restrictions, the review team will be forced to collaborate virtually. Any amendments made to this protocol when conducting the study will be outlined in PROSPERO and in the final manuscript.

There are some potential limitations to the proposed systematic review. Firstly, since some studies will not directly use the terms “educational,” we may miss some interventions relevant to the review objectives. To mitigate this limitation, the search strategies were made to be highly comprehensive and sensitive. In addition, additional searching methods will be undertaken, such as perusing all articles that cite the included studies. Secondly, the reporting of potentially complex, multi-interventional studies that combine an educational intervention with non-educational interventions could be a limitation. To mitigate this limitation, studies that do not clearly disaggregate the educational intervention and its effects on an SRHR outcome will be excluded. Given the focus on school-age children and the potential lack of adequate educational intervention studies with comparison groups, the review may only retrieve a few eligible experimental and quasi-experimental studies. Another limitation is that observational studies assessing an intervention effect can be susceptible to major confounding biases. The review is intended for publication in a peer-reviewed journal.

Availability of data and materials

Not applicable

Abbreviations

Sexual and Reproductive Health and Rights

Low- and Middle-Income Countries

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols

International Prospective Register of Systematic Reviews

Scottish Intercollegiate Guidelines Network

Joanna Briggs Institute

Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review instrument

Grading of Recommendations Assessment, Development and Evaluation

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Acknowledgements

This work was carried out with the aid of a grant from the Innovating for Maternal and Child Health in Africa initiative—a partnership of Global Affairs Canada (GAC), the Canadian Institutes of Health Research (CIHR), and Canada’s International Development Research Centre (IDRC). The authors would like to acknowledge the SickKids Centre for Global Child Health for their continued dedication to improve child health outcomes and well-being.

The review is funded by the International Development Research Centre (IDRC).

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Arone Wondwossen Fantaye and Amos Wung Buh are joint first authors.

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Interdisciplinary School of Health Sciences, University of Ottawa, 25 University Private, Ottawa, ON, K1N 7K4, Canada

Arone Wondwossen Fantaye, Amos Wung Buh & Dina Idriss-Wheeler

Health Sciences Library, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada

Karine Fournier

School of International Development and Global Studies, University of Ottawa, 120 University Private, Ottawa, ON, K1N 6N5, Canada

The George Institute for Global Health, Oxford University, Oxford, UK

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AWF, AWB, DIW, and KF drafted the review protocol. SY conceived the study, led and coordinated the entire protocol process. SY had final responsibility to submit for publication. All authors were responsible for revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

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Additional file 1..

PRISMA-P 2015 Checklist.

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MEDLINE search strategy.

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JBI Critical Appraisal Checklists.

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JBI Extraction Tool.

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Fantaye, A.W., Buh, A.W., Idriss-Wheeler, D. et al. Effective educational interventions for the promotion of sexual and reproductive health and rights for school-age children in low- and middle-income countries: a systematic review protocol. Syst Rev 9 , 216 (2020). https://doi.org/10.1186/s13643-020-01464-w

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Oral Health Education and Promotion Activities by Early Head Start Programs in the United States: A systematic review

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Purpose: Dental caries is a non-communicable, preventable disease that disproportionately affects low-income children in the United States (US). The purpose of this systematic review was to describe oral health education and promotion activities designed to prevent early childhood caries (ECC) provided by Early Head Start (EHS) programs in the United States.

Methods: Five databases were searched including CINAHL, Dentistry & Oral Sciences Source through EBSCO, PubMed, Google Scholar, and the Wiley Online Library, to identify peer-reviewed quantitative studies published in English on oral health education and promotion activities within EHS programs from 2000 to 2019. Studies were assessed for eligibility using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram (PRISMA). Two researchers independently evaluated the included studies.

Results: The initial search yielded a total of 363 articles. Following the screening process, five studies met the inclusion criteria (observational, n=2; quasi-experimental, n=3). The main outcome measures included oral health knowledge, attitudes and behaviors, oral health education, oral health promotion, and oral health activities. Three studies investigated the effectiveness of oral health education and promotion interventions among EHS staff and parents. Two studies examined oral health activities such as education, toothbrushing instructions, toothpaste use, dietary education, and dental assessment.

Conclusion: Studies that focused on increasing pediatric oral health knowledge and practice behaviors among both EHS staff members and parents reflected positive outcomes. Ongoing research is needed to examine the effectiveness of oral health education and promotion activities as they relate to the oral health outcomes of children enrolled in EHS programs.

• early childhood caries
• health promotion
• oral health prevention
• public health
• systematic review
• Introduction

Early childhood education programs in the United States (US) are supported with grants and services, such as educational planning, development, evaluation, and quality assurance from the US Department of Education in partnership with the US Department of Health and Human Services. 1 Early childhood prevention programs, such as Head Start (HS), Early Head Start (EHS), Women, Infants, and Children (WIC), and home visiting provide a variety of oral health promotion and education activities for families and children, and provide assistance in navigating health and dental services. 2 , 3 In addition, HS/EHS programs introduce children to school through the implementation of a goal oriented approach to enhance positive outcomes for children and families. 4 Head Start programs are federally funded and provide education, health, and family well-being services for low-income children age 4 to 5 years. 5 Children from birth to age 3 years and pregnant women from low-income families are served by EHS programs. 6 In the year 2000, there were 1700 HS/EHS programs that provided services via the HS center-base, home-base, or family child care model. 5

Oral health policies and standards for the HS/EHS programs are provided through the US Department of Health and Human Services, Office of Head Start, with the assistance of partnerships from professional oral health organizations. 6 Oral health performance standards include regulations related to tooth brushing, feeding practices, fluoride use, first dental visit, and oral health education and promotion activities. 6 In 2018-2019, a total of 166,693 children were enrolled in EHS programs across the US. 7 Data collected from an inner-city childcare center in New York (2004-2006) showed that 43% of the children enrolled in EHS (n=162) had at least one carious lesion. 8 Further, data collected during 2011-2014 showed that 9.14% of children in the US aged 0-5 years had untreated dental caries. 9 In general, children enrolled in EHS programs 8 and those from families with parental poverty and low health literacy, tend to have a higher risk for dental caries. 10

Dental caries is a preventable disease that disproportionately affects low-income children. 10 , 11 Specifically, early childhood caries (ECC) involves children <6 years old with a dental caries experience. 11 Organizations such as the American Academy of Pediatrics (AAP), American Academy of Pediatric Dentistry (AAPD), American Dental Association (ADA), and American Dental Hygienists’ Association (ADHA) emphasize the importance of oral health education to improve oral health status and overall quality of life for children. 12 - 15 It is important to understand the oral health education and promotion activities EHS programs are implementing resulting from the recommended oral health standards. Examples of oral health education may include incorporating learning activities within the classroom and providing oral health information to parents and caregivers. Oral health promotion activities may include integrating toothbrushing and dental screenings within EHS programs. 6 Early Head Start staff members have been shown to value children’s oral health and exhibit interest in providing learning activities; however, inadequate oral health knowledge has been shown to minimize their confidence to develop preventive activities. 16 , 17 The purpose of this systematic review was to address the question, “What oral health education and promotion activities are performed in EHS programs for staff, children, and caregivers in the United States?”

Search strategy

An initial search was conducted February 2019 by the primary investigator using five data bases: CINAHL Plus with Full Text, Dentistry & Oral Sciences Source through EBSCO, Medline through PubMed, Google Scholar, and the Wiley Online Library. Various combinations of keywords were used in the search. Search terms included: [oral health OR dental health OR oral hygiene OR dental hygiene AND education OR promotion OR activities OR tooth brushing AND Early Head Start AND Early Childhood Caries OR dental caries OR tooth decay OR cavities]. Other keywords included specific oral health activities for children, among them: “mouth cleaning, fluoride use, bottle use, first dental visit, and dental referral.” The specific population reference words included: “staff, directors, children, and parents.” Once the database search was completed, an individual search was performed utilizing the reference lists of the included studies. After the search was conducted, a second investigator screened the list of search terms and article returns based on the research question. A reference management software program (Mendeley version 1.19.3; London, UK) was used to identify duplicates, and to organize abstracts.

Eligibility criteria

Inclusion criteria for the systematic review were quantitative peer-reviewed experimental and observational studies, conducted in the US, and written in English between 2000-2019. Specifically, studies that examined oral health activities, oral health education, and oral health promotion in Early Head Start programs were included in the search strategy. Studies were excluded if they were qualitative, letters to the editor, case reports, personal communications, or narrative reviews.

Study selection

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart was used for the systematic review. 18 In the first step, duplicate studies were removed, and the remaining studies were screened by titles and abstracts independently by the primary and secondary reviewers. Second, full text articles were assessed for eligibility. Lastly, articles that met the inclusion criteria were reviewed by the primary reviewer followed by the second reviewer.

Risk of bias in individual studies

The quality of included studies was assessed by two reviewers, who independently evaluated the quality of studies using the Effective Public Health Practice Project’s Quality Assessment Tool. 19 The tool consists of eight components that evaluate selection bias, study design, confounding variables, blinding, data collection methods, withdrawals and dropouts, intervention integrity, and analyses. 19 Each of the eight components have questions with multiple choice answers that are scored according to a specific criteria and described as good, fair, or poor. Next, an overall global rating was developed for each component to include strong, moderate, and weak. At the end of the article review, a rating was determined for the overall quality of the study. Rating criteria were strong (the article received no weak ratings), moderate (one weak rating), or weak (two or more weak ratings). If there was a discrepancy with an article rating due to an oversight or differences in interpretation of criteria, the reviewers discussed the article to reach a consensus. The five articles were summarized according to the author and year, study location, research design, population, outcome measure, and significant results.

A total of 363 search results were obtained from the electronic database search. After duplicates were removed, 155 articles remained and of those, 93 were excluded based on the titles, 17 were excluded after screening the abstracts. The remaining 45 articles were included in full-text screenings; of these, 40 were removed based on the exclusion criteria. A total of five articles met the inclusion criteria for this review. Ratings for the five articles were as follows: high (n=1), moderate (n=3) and weak (n=1). The PRISMA flow-chart is shown in Figure 1 .

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Four-phase preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow-chart of identified articles18 (n=266)

Study characteristics

The five articles included were observational studies (cross-sectional, n=2; quasi-experimental n=3). Two studies were conducted in North Carolina, one in New York, one on the Hawaiian island of O’ahu, and one in Wisconsin. Study participants included EHS directors, teachers, and health coordinators (n= 485), 17 Migrant and Migrant Seasonal Head Start Program (MSHS) staff (n=401), 20 and EHS staff members who interacted directly with children and parents (n=71), 21 parents of children enrolled in EHS programs (n= 91), 23 and EHS home visitors (n=118). 22 Outcome measures used within the five studies included: oral health knowledge and attitudes, oral health activities, self-efficacy, readiness to perform oral health promotion, and promotion of dental care use. For this systematic review, the outcome measures were organized into three categories: oral health knowledge, oral health promotion, and oral health activities. A summary of the included studies is shown in Table I .

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Summary and characteristics of included studies (n=5)

Oral health knowledge

Glatt et al., 22 Kranz et al., 17 , 20 and Wilson et al. 23 examined oral health knowledge of EHS home visitors, parents, and staff members (program directors, teachers, and health coordinators) using self-administered questionnaires. Two of these studies used interventions, educational videos and motivational interviewing, with the aim to increase knowledge of the participants. 22 , 23 Glatt et al. demonstrated improvement in oral health knowledge of EHS staff members, 22 while Kranz et al. noted a gap in the oral health knowledge of EHS teachers. 17 , 20 Wilson et al. revealed improved knowledge among parents after receiving oral health education videos intervention, as demonstrated by increased correct answers from baseline (72%) to posttest (81%). 23

Glatt et al. focused on home visitors (n=118) who received a 3 hour educational session including a video that provided motivational interviewing techniques. 22 The short-term impacts of the intervention increased home visitors’ oral health knowledge by 7-29% on 5 out of 14 questions (p <0.05 ) . 22 Kranz et al. examined pediatric oral health knowledge and activities of EHS staff members (e.g. directors, teachers, and health coordinators) in two studies. 17 , 20 A dental visit for children by age one is emphasized by the Head Start Early Childhood Learning and Knowledge resource center. 24 However, 47.69% of EHS teachers (n=260) reported knowing about the recommended dental visit by age one compared to 61.11% of EHS program directors (n=18), and over 50% of health coordinators (n=18). 17 Over 80% of EHS teachers reported knowing that low-income children have an increased risk for tooth decay. 17 Kranz et al. (2012) compared oral health knowledge and activities of EHS and Migrant and Seasonal Head Start (MSHS) programs staff members. 20 Of these, 79.6% of EHS teachers (n=329) and 70.8% of MSHS teachers (n=72) reported knowing that low-income children have an increased risk for tooth decay. 20

Unlike the previous studies that focused on EHS staff members, Wilson et al. focused on the oral health knowledge of parents (n=91). 23 The researchers used two intervention approaches and randomly assigned parents and caregivers to one or two video groups: didactic in a lecture format or family-centered in a personal interview format. 23 Participants’ overall mean oral health knowledge score increased significantly by 1.79 points (before intervention M=15.19, SD=3.43; after intervention M=16.98, SD=3.42). 23 However, there was no statistically significant difference between the groups in post-test knowledge scores based on the type of video received (didactic versus family centered). 23

Oral health activities

Of all the studies reviewed, only two examined oral health activities in EHS program. 17 , 20 These studies assessed the numbers of oral health activities performed by EHS and MSHS teachers, using self-administered questionnaires. 17 , 20 Activities were divided into two categories, according to whether they were directed towards children or parents. 17 , 20 Children activities included toothbrushing, toothpaste use, and classroom education. 17 , 20 Parents’ activities included oral health education and promotion in addition to assessing children’s’ dental needs and parents’ oral health. 17 , 20 The studies also assessed perceived oral health self-efficacy and barriers to performing oral health activities by staff members. 17 , 20

One study compared oral health activities performed by EHS teachers with those performed by MSHS teachers. 20 Fewer than half of EHS teachers (n = 260) were engaged in parent-focused activities as compared to more than 60% of MSHS teachers (n=72). 20 Children-focused activities were highly reported for both EHS and MSHS programs with higher percentages of brushing related activities in MSHS program compared to EHS program. 17 , 20 Both EHS and MSHS teachers were more likely to report the children brushing their teeth independently compared to assisting the children with toothbrushing. 20 The results also indicated that 74% of MSHS teachers provided classroom oral health education compared to 45.2% of EHS teachers. 20

Among barriers cited for performing parent activities, EHS teachers demonstrated the highest lack of knowledge regarding fluoride use. 17 The most frequent barriers reported by EHS teachers for performing children activities included inadequate oral health education resources and knowledge regarding oral health activities. 17 For EHS directors and health coordinators, difficulty in locating dental professionals willing to provide dental services for children younger than three and accepting Medicaid insurance reimbursement, were the most frequently cited barriers for performing oral health activities. 17

Oral health promotion

Chinn evaluated the effectiveness of an oral health promotion intervention program on oral health knowledge and confidence of HS/EHS staff using a self-administered survey before and after the implementation of the Columbia Head Start Oral Health Program (C-HSOHP). 21 The intervention program consisted of oral health education and training to include dental screenings and assistance with referrals to dental services. 21 Chinn found that a majority of the staff members (n=61) believed that oral health training and dental screenings were effective in improving children’s oral health. 21 In addition, HS/EHS staff members’ perceived self-confidence in communicating with parents and oral health professionals regarding children’s oral health both increased from pre- to post- surveys by 15% and 20%, respectively. 21 Furthermore, dental referrals among staff members improved after the C-HSOHP by 20%, however there were no significant differences in identifying oral health issues, dental pain, and the overall oral health status of children. 21

Early Head Start children are considered high risk for developing ECC due to familial and environmental factors. 10 Preventive oral health activities within EHS programs can be beneficial in providing education and promoting healthy oral habits for children and their families. 25 Effective oral health education programs that target children, parents, and caregivers have improved oral health knowledge and reduced the disease prevalence among children. 26 Literature demonstrates that it is more effective to provide oral health education through promotional activities for preventing oral diseases. 25 , 26

To the best of the authors’ knowledge, this is the first systematic review to examine oral health education and promotion activities within EHS programs. The review revealed only five studies that examined oral health education and promotion activities in EHS programs and these studies were observational or quasi-experimental. 17 , 20 - 23 Three of the five studies focused on evaluating oral health education and promotion interventions, 21 - 23 while two studies directly assessed oral health activities in EHS. 17 , 20 In most studies, researchers controlled for confounders, such as participants’ level of education and oral health knowledge. 17 , 20 - 23

Evidence on the effectiveness of oral health education interventions was demonstrated in two studies that received a strong or moderate overall quality scores by the raters. 22 , 23 In spite of the limitations with these studies, including small sample sizes and lack of follow-up of long-term effects, the results revealed that oral health education interventions in EHS are effective in increasing pediatric oral health knowledge among both staff and parents. 22 , 23 Oral health activities were assessed in two studies with moderate overall quality scores and revealed a low number of oral health activities within EHS programs. 17 , 20 In the Head Start Oral Health Project evaluation report of 2001 – 2008, it was recommended that more oral health educational resources be made available to all HS programs and more importantly that collaboration with dental hygienists is needed to support oral health activities within EHS. 25

Oral health promotion was investigated in one study that utilized a community oral health training grant program in HS/EHS to improve pediatric oral health knowledge of staff members and parents. 21 In addition, the program provided children with dental screenings and assisted with dental referrals. 21 Although, the results demonstrated significant differences in pediatric oral health knowledge and competence among HS/EHS staff members, data was not presented on the children’s oral health before and after the intervention program. 21 The study received a weak overall quality score due to insufficient control of confounders, social desirability bias, and unclear validity of data collection instrument. 21

Limitations of this systematic review include a small number of studies that met the inclusion criteria and there were no randomized control designs identified. Furthermore, none of the included studies provided data on children’s oral health outcomes resulting from the interventions implemented among EHS program directors, teachers, health coordinators, and parents. 17 , 20 - 23 Despite these limitations, this review provides information on oral health education and promotion activities within EHS programs that resulted in improved oral health knowledge among parents, and EHS directors, teachers, and staff members. These studies can be used as a framework to develop and evaluate future oral health education and promotion activities for EHS programs. Furthermore, the need is recognized for investigating and reporting oral health outcomes of EHS enrolled children as a future research direction. 21

Dental hygiene implications

The American Dental Hygienists’ Association (ADHA) encourages the promotion of oral health among low-income children and families through expanding the dental hygiene scope of practice to include their participation in community oral health programs. 27 Head start and EHS programs provide an opportunity for oral health care professionals to conduct education programs and promote interventions in to reduce the risk of ECC among young children. 23 Results of the studies included in this literature review revealed improved oral health knowledge of EHS staff members, parents and caregivers resulting from oral health education and promotion interventions. 22 , 23 Dental hygienists have a key role to play in promoting oral health and preventing ECC among children participating in EHS. 2 The Dental Hygienist Liaison Project (DHL), a partnership between the National Center on Early Childhood Health and Wellness and the ADHA, was formed to promote oral health among HS enrolled children, parents and staff members. 29 The project provides oral health education and increases children’s access to dental services by connecting the HS community with dental hygiene education programs and dental professionals. 29 However, only a limited number of dental hygiene education programs have partnered with HS/EHS to provide dental hygiene services for children. 30 , 31 Dental hygiene education programs that have collaborated with HS/EHS programs have provided dental screenings and prophylaxis for children in addition to oral health education for children and parents. 30 , 31

In addition to working with HS/EHS programs, there are opportunities for dental hygiene students to provide oral health education and dental hygiene care for pre-school aged children through community outreach and service-learning endeavors. Claiborne et al. implemented an innovative, collaborative service-learning activity that was provided by dental hygiene and primary care nurse practitioner students, with a focus on oral health education and dental screenings for pre-school aged children. 32 The program demonstrated a positive experience for the pre-school aged children and provided an interprofessional education experience for dental hygiene and primary care nurse practitioner students. 32 Dental hygiene education programs and practicing professionals who collaborate with HS/EHS programs can provide essential dental hygiene services to children and increase access to oral health care. 30 , 31

A limited number of studies have examined oral health education and promotion activities for EHS staff members and parents. Studies that focused on increasing pediatric oral health knowledge and practice behaviors among EHS staff members and parents revealed improved oral health knowledge and behaviors. Ongoing studies are needed to examine the effectiveness of oral health education and promotion interventions within EHS programs. Impacts of oral health education and promotion interventions on children’s oral health also warrant examination in EHS programs. Collaboration with dental hygienists and dental hygiene education programs can support the oral health education and promotion activities of EHS programs and positively impact pediatric oral health and access to oral care.

This manuscript supports the NDHRA priority area, Population level: Health services (Community health interventions).

• Received August 17, 2020.
• Accepted January 29, 2021.
• Copyright © 2021 The American Dental Hygienists’ Association
• 1. ↵ Programs that support early learning [Internet] . Washington, DC : U.S. Department of Education ; 2011 Jul [cited 2021 Aug 4]. Available from: https://www.ed.gov/early-learning/programs .
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The effectiveness of sleep education programs in improving sleep hygiene knowledge, sleep behavior practices and/or sleep quality of college students: a systematic review protocol

Dietrich, Shellene K; Francis-Jimenez, Coleen M; Knibbs, Melida Delcina; Umali, Ismael L; Truglio-Londrigan, Marie

1 College of Health Professions, Pace University, New York, NY, USA

2 The Northeast Institute for Evidence Synthesis and Translation (NEST): a Collaborating Center of the Joanna Briggs Institute

Corresponding author : Marie Truglio-Londrigan [email protected]

Review question/objective

What is the effectiveness of sleep education programs in improving sleep hygiene knowledge, sleep behavior practices and/or sleep quality of college students?

The review objective is to identify, appraise and synthesize the best available evidence on the effectiveness of sleep education programs in improving sleep hygiene knowledge, sleep behavior practices, and/or sleep quality versus traditional strategies.

Sleep is a physiological state occurring in alternation with wakefulness, and its duration and quality are equally important for the quality of life of an individual. 1 The World Health Organization (WHO) along with other organizations have realized the importance of sleep and its direct correlation to health. 2 According to WHO, one-third of the lifespan is spent asleep, a state that is crucial for physical, mental and emotional well-being. 2 The WHO and the National Sleep Foundation, a nonprofit organization dedicated to improve sleep via sleep education based in the United States (US), recommend that adults should be receiving an average of seven to nine hours of sleep per night. 1,3 A reduction in sleep hours and sleep quality has a direct effect on lifestyle. 1,3

Poor sleep health can have severe consequences for the individual as well as society. 3,4 Sleep health is essential for overall health, quality of life and safety. The Institute of Medicine (IOM), an independent nonprofit organization dedicated to provide advice and answers about health in the U.S., reports that approximately 20% of automobile accidents are caused by drivers' drowsiness. 5 Healthy People 2020, a US based initiative aimed at improving the nation's health, recognize that drowsy driving causes vehicular crashes and its objective is to reduce the rate of vehicular crashes per 100 million miles traveled that are due to drowsy driving. 3,4 Sleepiness from any cause can compromise memory, grades, perception of effort and driving performance. 6,7,8 The individual can experience a poorly functioning immune system, emotional instability, memory deficits and poor concentration. 3 Approximately half of the world's population is at risk for some kind of sleep disorder and the cost to society is over $18 billion from a loss in productivity and mass transportation accidents. 2 The National Center on Sleep Disorder Research (NCSDR) estimates that 70 million Americans suffer from sleep problems, and nearly 60 percent have a chronic disorder. 9 Satisfactory sleep is comprised of numerous aspects, such as sleep quality and quantity. 6 These factors are affected by, but are not limited to, the following: consumption of alcohol, caffeine and drugs, establishing a regular relaxing bedtime routine, reducing lighting, the use of technology and being aware of environmental noise. 6

For the past 20 years, researchers have found a reduction in the average number of hours of sleep among college students. 10 College students are notorious for sacrificing sleep to study, socializing during the week, and then sleeping long hours on weekends along with the consumption of alcohol, drugs and caffeine. 5,7,10,11 Many of these behaviors are not reflective of sleep hygiene practices that facilitate sleep health. 7 Sleep hygiene is “…a variety of different practices that are necessary to have normal, quality nighttime sleep and full daytime alertness”. 12(p1) Sleep practices are behaviors that an individual carries out to facilitate sleep health. These practices include: maintaining regular sleep wake times, limited alcohol, caffeine and nicotine use prior to bed time, regular sleep wake schedules, and sleep environments conducive to sleep. 3 In 2000, a study found that 68.3% of college students reported poor sleep health as a result of inappropriate sleep behaviors that do not reflect sleep hygiene practices. 7,8 Among college students, 50% reported daytime sleepiness while 70% experienced insufficient sleep. 6 Poor sleep has been ranked the third most common impediment among college students and has been associated with deficit in attention, reduction in academic performance, impaired driving, risk-taking behavior, depression, impaired social relationships and poorer health. 8,11,13 College students may have limited knowledge about sleep health and sleep hygiene practices that supports sleep health. This limited knowledge may lead to poor sleep behavior practices ultimately leading to poor sleep health resulting in diminished quantity and quality of sleep.

Efforts to improve the overall health status of college students in the United States (US) began with Healthy Campuses in 2007. Healthy Campuses is closely aligned with Healthy People 2020 using Healthy People as a guiding framework. 14 Healthy Campus 2020 is an initiative that reflects the work of higher education professionals representing numerous organizations and disciplines. The vision of Healthy Campus 2020 is to promote campus communities in which all members live long, healthy lives. 15 Overarching goals guide the work of the Healthy Campus initiative 15 and specific health objectives have been developed to track and measure successful attainment of these goals. 16 One of the major student objectives pertaining to sleep health is Health Impediments to Academic Performance. 17 Under this objective there is a series of sub-objectives. Sub-objective 1.2 states: “reduce the proportion of students who report that their academic performance was adversely affected by sleep difficulties in the past 12 months”. 17(p1)

Sleep health is important not only for health, quality of life and safety but also for optimal academic performance in college students. 10 Gilbert and Weaver described how sleep deprived college students performed poorly academically. These students had poor concentration, often missed classes due to sleepiness and as a result had lower grade point averages, and more course incompletes, drops and withdrawals than participants with little sleep deprivation and good sleep quality. 10 Furthermore, without interventions that promote sleep hygiene practices and sleep health, there is the potential for later diagnosis of sleep disorders such as delayed sleep phase disorder and insomnia, both common to the population of college students. 8 Hershner and Chervin 6 found that there was a significant link between lack of sleep and academic performance. They hypothesized that effective interventions which focus on improving sleep behavior and disseminating sleep knowledge could help to improve academic performance among this population. 5–8,10,11,18,19

Studies that have looked at sleep education programs have demonstrated positive outcomes. For example, a sleep 101 program for college students described improved sleep hygiene knowledge, reduced maladaptive beliefs about sleep, and a decrease in sleep disturbances. 20 Other studies have also revealed the potential benefits of formal sleep education with a curriculum based on sleep hygiene practices versus informal advice delivered via verbal prompts from school staff and professionals. 5,7,8,16,17 Formal sleep education programs on sleep, sleep health, and sleep hygiene practices developed for the college student population may increase this population's knowledge on sleep and sleep hygiene practices. 17 The implementation of formal health promoting sleep education programs that focus on sleep hygiene practices is a strategy that has the potential to facilitate sleep health. 7,10,13,16,20–24

A search of the Cochrane Library of Systematic Reviews, Medline, CINAHL and the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports found no systematic review on the effectiveness of sleep education programs on sleep hygiene knowledge, sleep behavior practices, and/or sleep quality in college students or in any other specific population. A systematic review on sleep education is necessary in providing valuable, evidenced based information concerning the impact of sleep education on college students.

Inclusion criteria

Types of participants.

This review will consider studies that include all undergraduate or graduate college students, male or female, and of all ages, cultures and ethnicities. All undergraduate and graduate college students will be considered for inclusion due to pre-existing behaviors and circumstances that occur when a student enters into the college environment, for example, late night sleep patterns due to studies and socializing as previously discussed in Background. Pre-existing knowledge on sleep hygiene practices, diagnoses and treatments are not considered in this systematic review as confounding variables as the entire population is exposed to the contexts and risks for poor sleep health.

Types of intervention(s)

This review will consider studies that evaluate formal sleep education programs that include a curriculum on sleep hygiene practices that is designed to facilitate sleep health including but not limited to: maintaining regular sleep wake times, limited alcohol, caffeine and nicotine use prior to bed time, regular sleep wake schedules, and sleep environments conducive to sleep. 3 Formal educational delivery will include, for example: college courses/seminars that are delivered face-to-face, web-based computer programs, and/or a combination of these delivery methods. The formal sleep education program may be delivered any time throughout the participants' college experience.

Comparator intervention

This review will consider as a comparator no sleep hygiene education as an intervention.

Types of outcomes

This review will consider studies that include the following primary outcome measures:

Sleep hygiene knowledge - measured by tools such as the Sleep Hygiene Awareness and Practices Scale (SHAPS). The SHAPS contains three sections: sleep hygiene awareness and knowledge, sleep hygiene practices and caffeine. The first section has 13 items to measure participants' knowledge of activities that disrupt sleep. The second section assesses caffeine knowledge and has 19 items to measure participants' awareness of food, beverages or drugs that disrupt sleep. The final practice section of this instrument contains an additional 19 items asking participants how many nights per week where they engage in activities that promote or inhibit sleep. 7,20,25

Sleep hygiene behavior - measured by tools such as the Sleep Hygiene Awareness and Practices Scale (SHAPS) and the Sleep Habits Surveys (SHS). The Sleep Habits Surveys consists of 10 fill-in-the-blank items that ask for estimates of respondents' sleep habits, such as bed times, rise times and total sleep times for both weeknights and weekends. 25

Sleep quality - measured by tools such as the Pittsburg Sleep Quality Index (PSQI). The Pittsburg Sleep Quality Index (PSQI) measures and assesses sleep patterns. It is a self-rated instrument with 19 items designed to assess sleep and sleep disturbances over a period of one month. 7,10,11,20,25

Types of studies

This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials and quasi-experimental studies. In the absence of the above other designs will be considered for inclusion, including before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Non-English studies will be excluded due to limited language proficiency of the review team. Studies published from the year 1980 will be considered for inclusion in this review. This year was identified as the target start date as it has been noted that the trend of poor sleep among college students began in the 1980s. Hicks, Fernandez and Pellegrini conducted surveys and noted a trend of reported sleep problems beginning in the late 70s and 80's in which “24% of the respondents were dissatisfied with their sleep and in 1988, 53% were dissatisfied with their sleep”. 23(p660)

The databases to be searched include:

CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Academic Search Complete, PsycINFO, Healthsource Nursing/Academic edition, ProQuest Central, and PubMed and ERIC.

The search for unpublished studies will include:

New York Academy of Medicine, ProQuest Dissertations and Thesis, Google Scholar Advance, Virginia Henderson Library of Sigma Theta Tau, Robert Wood Johnson Institute

Initial keywords to be used will be:

college students, sleep, sleep education programs, sleep hygiene, sleep practices, sleep quality

Assessment of methodological quality

Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) ( Appendix I ). Any disagreements that arise between the reviewers will be resolved through discussion until consensus is reached, or with a third reviewer.

Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI ( Appendix II ). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Additionally, attempts will be made to obtain data missing from the study report(s) by contacting the appropriate author(s).

Data synthesis

Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Conflicts of interest

The authors have no conflict of interest to declare.

Acknowledgements

We would like to thank Jennifer Rosenstein MLS, MA for her input and guidance with the construction of this protocol.

We would like to thank Noreen McGuire MLS, MA, Assistant University Librarian for Collection Development, for her guidance and extensive assistance with literature searches and databases.

This review will partially fulfill degree requirements for successful completion of the Doctor of Nursing Practice Program at Pace University, College of Health Professions, New York, NY, for SD, CF-J, MK and IU.

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Appendix I: Appraisal instruments

MAStARI appraisal instrument

Appendix II: Data extraction instruments

MAStARI data extraction instrument

sleep; sleep education; sleep hygiene; sleep hygiene knowledge; sleep quality; sleep behavior practices; Healthy People 2020; Healthy Campus 2020

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Effectiveness of sleep education programs to improve sleep hygiene and/or sleep ....

• Open access
• Published: 30 July 2024

Transforming healthcare: A pilot study to improve primary healthcare professionals’ self-management support behaviour through blended learning

• Lotte Timmermans   ORCID: orcid.org/0000-0003-1447-2562 1 ,
• Peter Decat   ORCID: orcid.org/0000-0001-8948-6040 2 ,
• Veerle Foulon   ORCID: orcid.org/0000-0002-4053-3915 3 ,
• Ann Van Hecke   ORCID: orcid.org/0000-0003-3576-7159 4 , 5 ,
• Mieke Vermandere   ORCID: orcid.org/0000-0002-0437-6633 1 ,
• Birgitte Schoenmakers   ORCID: orcid.org/0000-0003-1909-9613 1 on behalf of

the Primary Care Academy

BMC Medical Education volume  24 , Article number:  823 ( 2024 ) Cite this article

54 Accesses

Metrics details

Self-management of a chronic condition is a complex but increasingly important issue. However, a supportive attitude and behaviour among healthcare professionals is hampered by a lack of awareness, knowledge and motivation. In addition, the role of professionals in supporting self-management seems unclear.

A blended learning program for primary healthcare professionals was developed to strengthen self-management support in primary care. The program was piloted in community health centres and multidisciplinary medical practices in Flanders. Using the Kirkpatrick model, the impact on healthcare professionals’ reaction, learning and behaviour regarding self-management support was evaluated.

A total of 60 healthcare professionals registered for the educational program. Post-learning questionnaires and verbal feedback showed a positive response, with professionals highly appreciating the innovative blended learning approach. In terms of learning, participants showed a good understanding of self-management support, although nuances were observed in the application of acquired knowledge to practice scenarios. Finally, preliminary insights into behavioural change were explored, revealing a positive impact of the intervention on participants’ supportive self-management behaviours in healthcare practice.

Conclusions

Our study provides preliminary insights into the outcomes of a blended learning program designed to increase awareness and knowledge of self-management support among professionals. The program needs to be refined for general implementation in primary care.

Peer Review reports

Worldwide, our healthcare systems are undergoing continuous and fundamental changes in response to various challenges, particularly to the increasing number of people with chronic conditions [ 1 , 2 ]. One of the key components of this changing healthcare landscape is the emphasis on self-management support as an essential aspect of healthcare delivery [ 3 ]. This focus is not only driven by international policy, as evidenced by WHO recommendations [ 4 ]. Self-management support is also receiving increasing attention at national level, in Belgium [ 5 ].

Self-management of a chronic condition is defined as “the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition” [ 3 ]. Engaging patients in self-managing their chronic condition is beneficial for both health and quality of life [ 6 , 7 , 8 ]. Healthcare professionals play a crucial role here [ 9 ]. Despite the clear benefits of self-management support, its successful integration into healthcare practice remains a challenge [ 10 , 11 ]. Barriers include limited awareness and knowledge of the role of healthcare professionals, the persistence of traditional consultation models, the lack of clear guidelines and models, and the limited accessibility and applicability of supportive interventions [ 12 , 13 , 14 ]. As the role of the primary healthcare professionals is often underestimated, it is essential to empower this group by focussing on their attitudes and behaviour towards self-management support to achieve effective support in practice [ 15 ].

Therefore, our research group conducted an in-depth analysis of professionals’ behaviour regarding self-management support in primary care practices. Using Michie’s behaviour change wheel (BCW) [ 16 ], we concluded that to achieve supportive behaviour, there should be a focus on ‘education’ and ‘enablement’ of professionals. Indeed, these two components emerged as the key intervention functions from the behavioural analysis. To integrate both education and enablement, we developed an interactive blended learning intervention.

Blended learning, defined as a mixture of traditional face-to-face and asynchronous or synchronous online learning methods [ 17 ], has been shown to increase the effectiveness and flexibility of educational programs. Previous research on blended learning and educational approaches in healthcare has demonstrated its potential to improve the delivery of self-management support by healthcare professionals [ 18 , 19 ]. Also, recent research shows that blended learning methods, particularly applied to healthcare professionals, are more efficient and lead to greater participant engagement and understanding [ 20 , 21 , 22 ]. Moreover, there is a growing need for new online e-learning approaches to meet the demand for high levels of interactivity, reflection, practice and application for healthcare professionals learning to provide effective self-management support, particularly in the context of chronic conditions [ 19 ]. Our choice was additionally influenced by the advantages of synchronous and asynchronous learning, giving professionals the flexibility to adapt their learning pace to individual needs and time constraints [ 18 , 23 ].

Based on these literature findings and on our own behavioural analysis, we developed a high-quality, theory-based intervention called MEnToSS (“More Encouragement Towards Self-management Support”). It’s a blended learning intervention targeted at all types of healthcare professionals and created with input from different stakeholders (patients, informal and formal caregivers, representatives of patient organisations, policy makers, etc.). Detailed information on the intervention is provided in the methodology section.

This paper reports on preliminary insights into the outcomes of the MEnToSS intervention regarding the attitudes and behaviours of healthcare professionals to support self-management. The research question addressed in this paper is: What is the impact of the MEnToSS learning program on healthcare professionals’ attitudes and behaviours to support self-management?

Study design

The present study is a pilot study because of its preliminary nature, involving small-scale testing of a completely new intervention. Using a mixed-methods design, the study integrates both quantitative and qualitative research methods to provide an in-depth understanding of the outcomes of the MEnToSS learning intervention. Ethical approval was obtained from the Ethical Committee Research of UZ/KU Leuven (S63890). To ensure transparent reporting, this study follows the CRISP (Consensus Reporting Items for Studies in Primary Care) reporting guideline [ 24 ], chosen for their relevance to the primary care context of our study (Supplementary file A).

Participants

The intervention is tailored for primary healthcare professionals, both health and welfare, in multidisciplinary practices or community health centres. These professionals provide care to a vulnerable population of chronic patients with moderate complex care needs, as defined by Iglesias (2018) [ 25 ]. These include people with multimorbidity, medication complexity, increased post-hospital care needs, socio-economic challenges, low health literacy, etc. Participation was limited to teams consisting of a minimum of four healthcare professionals, each of whom represented at least two different healthcare disciplines. Information materials, such as leaflets and a video, were used and distributed through our organisation (i.e., the Primary Care Academy—PCA) to recruit participants. In addition, e-mail invitations were sent to various health- and welfare organisations. The study sought to enrol of at least six centres, comprising minimally 24 healthcare professionals.

MEnToSS intervention

Intervention.

The intervention consisted of a blended learning program that combined asynchronous and synchronous learning. The aim was to educate and enable healthcare professionals to more effectively support self-management in primary care practice. This includes providing professionals with the motivation, knowledge and insights needed to address barriers to supporting self-management in practice.

Learning objectives

The intervention was designed to help participants better understand the concept of self-management, the importance of self-management support and define their role as a healthcare professional in it. In addition, they were encouraged to think critically about their own actions in supporting self-management. These objectives contributed to the overall goal of increasing professionals’ knowledge, attitudes and perceived behaviour towards self-management support.

The learning program was developed by researchers from the PCA consortium according to Horton’s Absorb-Do-Connect (ADC) model [ 26 ], chosen for its emphasis on active engagement, practical application, and seamless integration into real-world contexts. The theoretical underpinnings included data from literature analysis [ 27 ], interviews [ 28 ], focus groups [ 29 ] and nominal group brainstorming sessions [ 30 ]. These diverse sources of empirical and theoretical material, which closely examined self-management support in primary healthcare, were systematically integrated in Michie’s behaviour change wheel framework [ 31 ]. This evidence-based approach consists of eight steps in three phases to develop sustainable interventions, taking into account input from all actors in the healthcare network (i.e.; patients, informal and formal caregivers, representatives of patient organisations, policy makers). This inclusive process ensured that the intervention was not only theoretically robust but also contextually relevant, focusing on the practical aspects of implementation tailored to specific contexts. The methodological rigour of the development process provided the intervention with a solid foundation for behaviour change.

Learning materials

The MEnToSS intervention offered three different learning materials. First, a written course provided an in-depth understanding of the topic of self-management, including its origins and significance and the crucial role that healthcare professionals play. In addition, there were informative short video clips that briefly addressed challenges and misconceptions related to self-management (support). Finally, the learning materials included podcasts with healthcare professionals that gave insights into the topic of self-management support.

Learning strategies

The learning intervention consisted of multiple steps, represented in Fig.  1 . Participants received a certificate after completion of the learning program.

Steps of the blended learning intervention. Template retrieved from ww.canva.com

The intervention was delivered via a Learning Management System (LMS) (password-protected) over a two-month period, from the starting point to the final workshop. The intervention was initiated at the kick-off and concluded during the final workshop by the main trainer (LT), a primary healthcare researcher and an expert in self-management support. Moreover, this person remained available online throughout the entire learning process to provide ongoing guidance and support. In addition, pedagogical support was received from an assistant trainer with teaching experience (i.e., platform guidance, practical issues, etc.).

It’s important to acknowledge that the main researcher (LT) also facilitated the intervention, acting as both researcher and facilitator/coach. While this dual role offers advantages in terms of research alignment and expert guidance, it also raises awareness of potential biases. Efforts were made to mitigate bias by ensuring that each step of the intervention was rigorously validated and cross-checked by the wider Primary Care Academy team. This collaborative approach helped to minimise bias and ensure the integrity and validity of the intervention.

Data collection

The evaluation of the MEnToSS self-management support intervention used a mixed-methods approach, incorporating the Kirkpatrick model to assess the levels of reaction, learning and behaviour [ 32 ]. This choice was based on previous successful and meaningful applications of the model in different healthcare settings, such as primary care. It allows for a holistic assessment of intervention outcomes, in line with our aim to capture both immediate impressions (learning/reaction) and long-term behavioural change.

Quantitative data were collected using electronic questionnaires (Qualtrics®) to assess program impact or change (Supplementary file B). Responses were evaluated using a 5 or 7-point Likert scale, with the possibility of making additional comments. To evaluate reaction, the Short version of the User Experience Questionnaire (UEQ-S) was distributed immediately after the intervention, complemented by questions on general satisfaction with blended learning (using a modified version of a validated Blended Learning Questionnaire [ 33 ]). More specifically, the UEQ-S provides a comprehensive assessment by measuring multiple dimensions of user experience and satisfaction [ 34 ]. In addition, the Blended Learning Questionnaire developed by Naaj et al. (2012) assesses learner satisfaction across different aspects of the blended learning experience, including instructor effectiveness, technology integration, and interaction quality [ 33 ].

In terms of learning, participants’ self-perceived knowledge and skills related to self-management support were assessed immediately after, with a specific focus on the SILCQ-fundamentals [ 28 ]. These fundamentals cover the essential professional tasks of Supporting, Involving, Listening, Coordinating, and asking Questions in primary care practice in order to guide patients towards more effective self-management. These questions, compiled by the research group, included both statements (ranging from strongly disagree to strongly agree) and validations (ranging from very unimportant to very important). Finally, participants’ self-reported behaviour was assessed using another researcher-made questionnaire. These data were collected three months after the intervention. Besides quantitative methods, qualitative verbal feedback was collected. More specifically, participants were invited to share their experiences of the learning trajectory, its impact on their healthcare practice, and any challenges and barriers they encountered in oral feedback sessions. These sessions were organised half an hour before the concluding workshop and were set up as roundtable discussions, using pre-defined questions to encourage in-depth interaction. Discussions were organised by practice/centre, with each group consisting of all participants from the same practice/centre. Although this set-up meant that direct feedback from the concluding workshop could not be included in the oral feedback sessions, this information was collected later through the questionnaires that participants filled in after the learning program. This gave us a full picture of how the intervention was received and allowed us to complete the evaluation.

Data analysis

Quantitative data from the questionnaires were analysed using SPSS (descriptive statistics). Medians and interquartile ranges were reported when there was noticeable variability and a lack of consistent agreement among respondents, ensuring a comprehensive understanding of professionals’ experiences. Chi-square tests were performed to assess relationships between variables. A p -value of 0.05 was considered as the level of significance. For qualitative data from the feedback sessions, thematic analysis was applied, following the approach described by Braun and Clarke (2006) [ 35 ]. Input was collected, coded and grouped into themes, which provided insights into participants’ experiences, how the intervention influenced their practice and identified obstacles. We integrated the quantitative and qualitative data using a convergent parallel design, as recommended by Pluye et al. (2018) [ 36 ]. This involved analysing the quantitative and qualitative data separately, then comparing and contrasting the findings to identify areas of convergence and divergence, providing a comprehensive understanding of the impact of the intervention.

A total of 60 healthcare professionals from eight multidisciplinary centres/practices registered for the intervention (Table  1 ). Of these, 56 participants fully completed the learning program, while four participants (from one centre) dropped out.

Quantitative user feedback

The first post-intervention feedback questionnaire, focusing on reaction and learning levels according to the Kirkpatrick model, was received from 25 participants. Of these, 72% were female respondents, 28% male respondents, with 64% general practitioners and 24% nurses, as the two largest groups. In terms of learning preference, 24% took an integrated approach to all materials, while 24% combined text with podcasts and 16% took a mix of text and videos. In terms of prior exposure, the initial post-intervention questionnaire revealed that 77% of the participants had previously been exposed to the concept of self-management support, albeit to a very limited extent. This exposure was mainly through formal education and training, focusing on goal-oriented care and positive health. The chi-square test showed no significant relationship between years of experience ( p  = 0.165) or professionals’ background ( p  = 0.829) and previous knowledge of self-management support.

The second feedback questionnaire, which assessed behavioural levels after three months, was completed by 17 participants. Gender and background remained comparable with the first round of feedback, with female respondents and mainly general practitioners or nurses as background.

Reaction to the learning materials and learning program

For the written learning materials (referred to as “text”), participants rated their experience on average as 5 out of 7 using the UEQ-S (Table  2 ).

The interquartile range (IQR) of the dataset was 1. Relatively high scores were given to the level of support (Median (Med) = 5, IQR = 1.5), convenience (Med = 5, IQR = 2), clarity (Med = 5, IQR = 2.5) and interest (Med = 5, IQR = 1). Opinions were divided on the level of efficiency (Med = 4.5, IQR = 2), inventiveness (Med = 4, IQR = 2) and novelty (Med = 4, IQR = 2) and excitement (Med = 4, IQR = 1). Similar results were found for the videos, but the scores were slightly higher. The median score for these visual learning materials was also 5 out of 7 for the UEQ-S (Table  3 ). The IQR of the dataset was 2.

High scores were recorded for the level of support (Med = 6, IQR = 3), convenience (Med = 6, IQR = 2 and clarity (Med = 6, IQR = 2). There was a positive trend for level of interest (Med = 4, IQR = 1). Opinions were moderately divided on the level of efficiency (Med = 5, IQR = 2) and strongly divided on inventiveness (Med = 4, IQR = 4) and novelty (Med = 5, IQR = 4).The majority rated the level of excitement as rather neutral (Med = 4, IQR = 2). Finally, the podcasts were rated by the UEQ-S with a median score of 4 out of 7 (Table  4 ). The IQR of the dataset was 3.

High scores were obtained for the level of support (Med = 5, IQR = 3), convenience (Med = 6, IQR = 2) and clarity (Med = 5, IQR = 1). There were different opinions on the level of interest (Med = 5, IQR = 5), inventiveness (Med = 4, IQR = 5) and novelty (Med = 4, IQR = 3). A slightly decreasing trend was observed in the level of efficiency (Med = 4.5, IQR = 2.5) and excitement (Med = 4, IQR = 4).

In terms of the learning program in general, the analysis of the modified blended learning questionnaire gave a mixed picture of participants’ experiences (Fig.  2 ). More specifically, opinions on the perceived effort in getting through the program were strongly divided (statement 1). However, most participants (strongly) agreed that they were satisfied with the level of effort (45%). In contrast, opinions about the collaborative methods during the learning process were positive, with a large majority of participants (strongly) agreeing that they were satisfied with the process of collaboration (59%) (statement 2). In addition, the quality of interaction between all parties involved was also reported as satisfactory by the majority of participants (64%) (statement 3). A mixed picture emerged regarding the use of blended learning technology (statement 4). Although the majority reported to be satisfied (54%), a few participants (strongly) disagreed that the blended technology encouraged them to learn independently (36%). The accessibility and availability of the learning program team was also rated positively by the majority (59%) (statement 5). Finally, opinions were divided on the willingness to recommend this learning program to others (statement 6).

Reaction outcomes post-program questionnaire using statements. X-axis: Agreement Level (Strongly Disagree to Strongly Agree) for statements 1–6. Y-axis: Percentage. Bars represent the distribution of respondents’ agreement levels, with percentages and absolute counts displayed on each bar for each of the six charts

Learning about self-management and self-management support

Learning outcomes were examined in the post-program questionnaire using statements and validations grouped into three main categories (Table  5 ): Relevance of the concepts, including the importance of the SILCQ fundamentals; Knowledge and understanding of the concepts, including being able to unravel misunderstandings; Transferability of knowledge. Medians and interquartile ranges are not presented for the levels of learning and behaviour because participants’ responses to the 5-point Likert scale were remarkably homogeneous. Clear consensus and consistent agreement were observed, resulting in minimal variability between respondents.

After participating in the learning program, healthcare professionals indicated that they recognised the importance of actively searching for ways to integrate disease and health into patients’ daily lives or the importance of supporting patients’ self-management (statements 7–8: 76% strongly agreed, 24% agreed). The relevance of the fundamentals of self-management support as described in the SILCQ-model was also widely recognised, with an emphasis on involving patients in decision making, listening to them and asking questions (validations 1–5: 30–65% important, 35–70% very important).

Participants in the MEnToSS intervention indicated that the learning program contributed significantly to their knowledge (statement 19: 52% agreed, 14% strongly agreed). Also, a significant percentage of participants reported having a good understanding of the concepts, with the vast majority agreeing that they know what self-management is, what self-management support is and what the SILCQ fundamentals are (statements 9, 11, 18: 48–76% agreed, 19–24% strongly agreed). This knowledge extended to insights into self-management and self-management support (statements 10 and 12: 76% agreed, 19% strongly agreed). Misunderstanding and misconceptions about self-management (support) were effectively debunked, with high percentages disagreeing or strongly disagreeing (statements 20, 21, 23 and 25), or agreeing or strongly agreeing in the reversed statements (22 and 24).

Transferability

Participants expressed confidence in applying and communicating their knowledge of self-management and self-management support (statements 13, 15–17: 62–76% agreed, 19–24% strongly agreed). They reported a good ability to provide examples from healthcare practice and to articulate specific ways in which they could contribute to self-management support.

Behaviour related to self-management support in practice

Three months after the MEnToSS learning program, the majority of respondents in the second questionnaire indicated that they were able to actively search for ways to integrate disease and health into their patients’ daily lives, referring to supporting self-management (statement 26: 82% agreed). In this supportive process, the majority of participants indicated that they were aware of their patients’ social environment (statement 27: 24% were neutral, 75% agreed). Most of them also reported being able to cooperate with this social environment (statement 28: 35% were neutral, 65% agreed). In addition to the informal network, professionals reported having knowledge of the formal health and welfare network around their patients (statement 29: 66% agreed). Collaboration with this network was reported to be more moderate (statement 30: 29% were neutral, 59% agreed).

The five specific self-management support behaviours from the SILCQ-model were also examined. Participants reported being able to provide patients with practical tools, resources and information in addition to medical support (statement 31: 76% agreed, 18% strongly agreed). They also reported being able to make care-related choices together with their patients (statement 32: 76% agreed). Furthermore, respondents indicated they could offer a listening ear in healthcare practice (statement 33: 41% agreed, 53% strongly agreed) and play an active role in coordinating care (statement 34: 76% agreed). Finally, they reported having the skills to actively ask their patients questions about what is going well, what is not going well and what their needs are (statement 35: 65% agreed, 29% strongly agreed). The behavioural results are represented in the appendices (Table  6 ).

Qualitative user feedback

All 56 participants who had completed the MEnToSS intervention provided oral feedback in the structured group discussions at the beginning of the concluding workshop. The intervention received mostly positive responses, with ratings influenced not only by the background of participants, but also by their personality traits, as everyone preferred different learning strategies and methods. The intervention’s emphasis on the person behind the patient was highly appreciated.

“The trajectory provides a fresh perspective, and I have gained more attention [for self-management support].” – Medical secretary

“I have learned to actively listen, observe the whole person, and not just the complaint.” – GP

However, participants with prior knowledge expressed a desire for more profound insights due to overlap with other learning programs. Nevertheless, participants indicated that the MEnToSS learning program added value on several levels. The flexible format of self-study through videos, podcasts and text was seen as a major strength. In particular, the flexibility of self-study allowed participants to progress at their own pace with the learning material that was most appropriate for each individual. As a result, participants indicated that the learning program provided a deeper understanding of the concept of self-management support and its fundamentals (i.e., SILCQ-model). However, the extensive platform also posed challenges, with participants calling for a stronger storyline, more structure and more case-based learning content.

“I open the platform, but if you only have a quarter of an hour, it is not structured enough to motivate you.” – GP

With regard to the learning materials, participants praised the usability and clarity of the podcasts, as well as the short and concise videos, which facilitated independent learning. A minority of participants found the videos too academic and the podcasts boring. To address this, participants suggested making summaries of these learning resources in advance. They wanted to know in advance what would be covered in each video or podcast to assess its relevance, and they also recommended shortening the length of podcast discussions for greater engagement.

“I found the videos concise and, therefore, useful.” – Nurse

The breakdown of self-management support in healthcare practice into five actions, referring to the SILCQ fundamentals, received positive feedback for its simplicity and clear structure. In addition, the assignments on these SILCQ actions, as part of the learning program, were well received. This short, powerful reflection after going through one or more learning materials was perceived as valuable.

“Breaking down the consultation into 5 actions makes it clear and manageable.” – GP

Finally, participants recognised that navigating through the learning program in such an accessible way increased their awareness of the concept and importance of self-management support. The inclusion of take-home messages was described as a possible beneficial added value in the future.

“This intervention opens our eyes to the importance of focusing on these concepts (self-management, self-management support, etc.)” – Nurse

This study aimed to investigate how a blended learning intervention, the MEnToSS intervention, influenced healthcare professionals’ reaction, learning and behaviour towards self-management support in primary care practice. At the reaction level (level 1), participants responded generally positive to the innovative approach of the educational program and recognised the importance of self-management support. The reaction was found to be dependent on several factors, including the learning materials consulted, the participant’s prior knowledge and individual learning style preferences. In general, watching the videos seemed more appealing and, based on the scores, was slightly better received than the other learning materials. Listening to podcasts, in turn, was described as a considerable effort, although those with prior knowledge found them a valuable addition and found more depth in them. This variability highlights the importance of providing varied learning materials and individually tailoring educational interventions to reach and satisfy a wide range of participants [ 37 ]. At learning level (level 2), results showed a good understanding of the concept of self-management (support). In addition, the SILCQ-model seemed well understood and was described as a useful tool to reflect on self-management support in practice. At behavioural level (level 3), participants’ confidence to apply the acquired knowledge in their healthcare practice were generally positive. Notably, comparisons between the levels of reaction, learning and behaviour reveals interesting patterns. While the majority had a positive response to the learning program and showed a good understanding of self-management support, responses on knowledge transfer to behaviour in practice showed variation, indicating a possible gap between theoretical knowledge and practical application. Future context analysis should focus on the mechanisms of knowledge transfer to gain deeper insights.

The results of our study are consistent with the conclusion of the systematic review by Collins et al. (2021), which examined the impact of primary care professional education on patient self-management in chronic diseases [ 18 ]. Although our study did not directly assess the impact on patients, we also evaluated a professional education program on self-management support. Similar findings emerge, highlighting the critical need for high quality research to investigate the optimal methods and conditions for training primary care professionals. This reinforces our study’s emphasis on nuanced educational approaches. Our learning program differs from previous interventions by using both asynchronous and synchronous learning approaches. We use a variety of learning materials and organise an interactive workshop in a real-life environment. This strategy has been shown to be effective and is in line with the findings of other studies, which show that interactive learning is effective because it reflects the challenges of real-life situations. It promotes deep learning and intrinsic motivation and can potentially bridge the gap between theory and practice [ 38 ]. Furthermore, our use of asynchronous components facilitated flexible learning and met participants’ preferences for learning at their own pace and independent of location. The blended strategy benefits from flexibility and self-directed learning and is in line with successful healthcare educational programs that focus on tailored, engaging approaches [ 37 ]. The variety of learning materials in our program, including both audio, visual and written materials, improved accessibility and engagement. According to the literature, offering different options accommodate different learning styles, making interventions more inclusive and appealing to a wider audience [ 39 ].

Some limitations should be mentioned. First, the use of self-reported outcomes limits the scope of information, preventing a direct translation of findings into practical implications. However, this strategy focuses specifically on the perspectives and experiences of professionals in supporting self-management. Understanding professionals’ perceptions is integral to improving patient self-management support and highlights the importance of their voices in shaping interventions. Secondly, there was no pre-program assessment, which meant that baseline knowledge or behaviour prior to the intervention was not measured. In our case, the decision not to conduct a pre-test was based on the results of an extensive literature review [ 27 ], which provided an overview of previous self-management support interventions worldwide. This analysis revealed that our intervention introduced novel approaches and content to self-management support. Consequently, participants’ prior knowledge was likely to be minimal to non-existent, making a pre-test insufficiently justified. In addition, our primary focus was on evaluating the impact of the intervention on real-world outcomes, rather than comparing and measuring improvements in participants’ skills or competencies. In addition, our study encountered a limitation in that we could not use solely standardised questionnaires for evaluation. Given the unique focus on SILCQ, a self-developed model, there were no existing validated customised questionnaires for this purpose. However, we addressed this limitation by using a combination of standardised questions and self-developed measures, with minimal modifications. Finally, it should be noted that the study may be subject to selection bias, as only a small subset of participants who had completed the intervention provided feedback in the questionnaires.

Above limitations highlight the need for cautious interpretation and point to areas for improvement for future evaluations. Therefore, we recommend examining our learning intervention over a longer period of time and with a larger sample size. In addition, future research should explore the nuances of implementation in different primary care contexts to refine and tailor recommendations for maximum impact. Finally, we recommend that future research should go beyond measuring effects on professionals’ self-management support behaviour. It would be valuable to assess the direct effect of our educational intervention in clinical practice by examining how the intervention affects patients’ self-management outcomes. This extension would provide more insight into the wider effects of the intervention and underline its value in practice.

The MEnToSS intervention not only generated very positive feedback and promoted knowledge acquisition, but also participants perceived the intervention as an opportunity to critically reflect on and more effectively apply the learning to real-life situations in healthcare settings. The success highlights the power of interactive educational programs not only to deliver information, but also to trigger truly transformative learning experiences. As a result, the use of the blended learning approach, with its flexibility and interactive components, suggests that there may be greater awareness of the concept of self-management support among healthcare professionals. This makes the intervention a promising step towards continuous improvement of self-management support in healthcare.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Behaviour Change Wheel

More Encouragement Towards Self-management Support

Consensus Reporting Items for Studies in Primary Care

Absorb-Do-Connect

Learning Management System

Short version of the User Experience Questionnaire

Supporting, Involving, Listening, Coordinating and Questioning

Statistical Package for the Social Sciences

General Practitioner

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Acknowledgements

Special thanks go to Anabel Wanzeele, education expert at UCLL University of Applied Sciences, who played a crucial role in the development, design and piloting of the intervention. Her expertise, guidance and commitment were instrumental in shaping the teaching materials and ensuring the success of the project. I would also like to express my sincere thanks to those who contributed to the development of the learning materials, including the podcast participants, and to UCLL for their podcast expertise and access to the video recording studio. Special thanks also go to the Leuven Institute for Media and Learning (LIMEL) for providing valuable resources and support for the recording of the podcasts. And, of course, my sincere thanks also go to all health professionals who participated in the intervention. Their involvement in the learning program and their valuable feedback greatly enriched the research process.

The PCA is funded by the Fund dr. Daniël De Coninck, which is managed by the King Baudouin Foundation (Belgium). This research paper received no additional external funding, and the funder was not involved in this research.

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LT and BS conceived and designed the pilot study. LT collected the data and analysed the data under the supervision of BS. LT drafted the manuscript. All authors read and approved the final version of the manuscript.

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Timmermans, L., Decat, P., Foulon, V. et al. Transforming healthcare: A pilot study to improve primary healthcare professionals’ self-management support behaviour through blended learning. BMC Med Educ 24 , 823 (2024). https://doi.org/10.1186/s12909-024-05799-z

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The Effect of Overdose Education and Naloxone Distribution: An Umbrella Review of Systematic Reviews

• PMID: 34464184
• PMCID: PMC8489639
• DOI: 10.2105/AJPH.2021.306306a

Background. Opioids contribute to more than 60 000 deaths annually in North America. While the expansion of overdose education and naloxone distribution (OEND) programs has been recommended in response to the opioid crisis, their effectiveness remains unclear. Objectives. To conduct an umbrella review of systematic reviews to provide a broad-based conceptual scheme of the effect and feasibility of OEND and to identify areas for possible optimization. Search Methods. We conducted the umbrella review of systematic reviews by searching PubMed, Embase, PsycINFO, Epistemonikos, the Cochrane Database of Systematic Reviews, and the reference lists of relevant articles. Briefly, an academic librarian used a 2-concept search, which included opioid subject headings and relevant keywords with a modified PubMed systematic review filter. Selection Criteria. Eligible systematic reviews described comprehensive search strategies and inclusion and exclusion criteria, evaluated the quality or risk of bias of included studies, were published in English or French, and reported data relevant to either the safety or effectiveness of OEND programs, or optimal strategies for the management of opioid overdose with naloxone in out-of-hospital settings. Data Collection and Analysis. Two reviewers independently extracted study characteristics and the quality of included reviews was assessed in duplicate with AMSTAR-2, a critical appraisal tool for systematic reviews. Review quality was rated critically low, low, moderate, or high based on 7 domains: protocol registration, literature search adequacy, exclusion criteria, risk of bias assessment, meta-analytical methods, result interpretation, and presence of publication bias. Summary tables were constructed, and confidence ratings were provided for each outcome by using a previously modified version of the Royal College of General Practitioners' clinical guidelines. Main Results. Six systematic reviews containing 87 unique studies were included. We found that OEND programs produce long-term knowledge improvement regarding opioid overdose, improve participants' attitudes toward naloxone, provide sufficient training for participants to safely and effectively manage overdoses, and effectively reduce opioid-related mortality. High-concentration intranasal naloxone (> 2 mg/mL) was as effective as intramuscular naloxone at the same dose, whereas lower-concentration intranasal naloxone was less effective. Evidence was limited for other naloxone formulations, as well as the need for hospital transport after overdose reversal. The preponderance of evidence pertained persons who use heroin. Author's Conclusions. Evidence suggests that OEND programs are effective for reducing opioid-related mortality; however, additional high-quality research is required to optimize program delivery. Public Health Implications. Community-based OEND programs should be implemented widely in high-risk populations.

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• Reducing Opioid Overdose Deaths by Expanding Naloxone Distribution and Addressing Structural Barriers to Care. Smart R, Davis CS. Smart R, et al. Am J Public Health. 2021 Aug;111(8):1382-1384. doi: 10.2105/AJPH.2021.306376. Am J Public Health. 2021. PMID: 34464185 Free PMC article. No abstract available.

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Open Access

Peer-reviewed

Research Article

Factors influencing the uptake of public health interventions delivery by community pharmacists: A systematic review of global evidence

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, Nairobi, Kenya

Roles Conceptualization, Methodology

Roles Conceptualization, Supervision, Writing – review & editing

Affiliations Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, Nairobi, Kenya, Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom

Roles Supervision

Affiliation Department of Health Services, Policy, Planning, Management, and Economics, School of Public Health, University for Development Studies, Tamale, Ghana

Roles Conceptualization, Supervision, Validation, Writing – review & editing

Affiliations Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, Nairobi, Kenya, Liverpool School of Tropical Medicine, Liverpool, United Kingdom

• Audrey Mumbi, 
• Peter Mugo, 
• Edwine Barasa, 
• Gilbert Abotisem Abiiro, 
• Jacinta Nzinga

• Published: August 1, 2024
• https://doi.org/10.1371/journal.pone.0298713
• Reader Comments

Community pharmacies are the first point of contact for most people seeking treatment for minor illnesses globally. In recent years, the role of community pharmacists has evolved, and they play a significant role in the delivery of public health interventions (PHIs) aimed at health promotion and prevention such as smoking cessation services, weight management services, HIV prevention, and vaccination. This review aims to explore the evidence on the factors that influence community pharmacists to take up the role of delivery of such interventions.

Three electronic databases namely, Embase (1947-December 2023), Medline (1975-December 2023), and Scopus (1823-December 2023) were searched for relevant literature from the inception of the database to December 2023. Reference lists of included articles were also searched for relevant articles. A total of 22 articles were included in the review based on our inclusion and exclusion criteria. The data were analyzed and synthesized using a thematic approach to identify the factors that influence the community pharmacist’s decision to take up the role of PHI delivery. Reporting of the findings was done according to the PRISMA checklist.

The search identified 10,927 articles of which 22 were included in the review. The main factors that drive the delivery of PHIs by community pharmacists were identified as; training and continuous education, remuneration and collaboration with other healthcare professionals. Other factors included structural and workflow adjustments and support from the government and regulatory bodies.

Conclusions

Evidence from this review indicates that the decision to expand the scope of practice of community pharmacists is influenced by various factors. Incorporating these factors into the design of policies and public health programs is critical for the successful integration of community pharmacists in the delivery of broader public health to meet the rising demand for health care across health systems.

Citation: Mumbi A, Mugo P, Barasa E, Abiiro GA, Nzinga J (2024) Factors influencing the uptake of public health interventions delivery by community pharmacists: A systematic review of global evidence. PLoS ONE 19(8): e0298713. https://doi.org/10.1371/journal.pone.0298713

Editor: Naeem Mubarak, Lahore Medical and Dental College, PAKISTAN

Received: January 29, 2024; Accepted: May 28, 2024; Published: August 1, 2024

Copyright: © 2024 Mumbi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its supporting information files.

Funding: This research was funded in whole, or in part by the Wellcome Trust 223658/Z/21/Z For the purpose of open access, the author has applied a CC BY public copyright license to any Author Accepted Manuscript version arising from this submission.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Community pharmacies are the first point of contact with the health system for most people seeking treatment for minor illnesses globally [ 1 – 3 ]. They are easily accessible, widely distributed, provide quicker services, open for longer hours, and are relatively cheaper than other private health facilities [ 4 – 6 ]. Additionally, they provide a more casual setting for individuals by offering services over the counter for those who do not wish to seek health services from health facilities [ 7 ].

The traditional role of community pharmacists has mainly been product-oriented. This entails dispensing prescription and non-prescription medicine, however, this role has evolved to include the provision of various Public Health Interventions (PHIs) due to the increased health demands of the population [ 1 ]. This evolution has been endorsed by the International Pharmaceutical Federation (FIP) and is recognized in several income high-income countries such as Australia, the United States, United Kingdom where it has been integrated into existing healthcare models [ 8 ]. Low and middle-income countries (LMICs) on the other hand are also recognizing the contribution of community pharmacists to public health however, this role is not well integrated into the broader health system.

Public health entails three main domains; health improvement, health protection, and health service delivery and community pharmacists provide PHIs which contribute greatly to all three domains [ 9 ]. These interventions include smoking cessation services such as Nicotine Replacement Therapy (NRT) and counselling services [ 10 ]; provision of interventions aimed at promoting health and well-being through changing lifestyle habits, healthy weight management services, advice on healthy living, and participation in health promotion campaigns [ 11 , 12 ]. In regards to health protection, community pharmacists offer disease control measures, screening for risk factors for non-communicable diseases such as Cardiovascular Disease (CVD) [ 13 , 14 ], Sexually Transmitted Infections (STIs) screening [ 15 ], Human Immune deficiency Virus (HIV) screening [ 16 ], provision of immunization services and communicating information on threats to health to patients and the public in general [ 9 ]. Health service quality entails the provision of innovative quality pharmacy services to improve health outcomes for instance through medication therapy management services and supporting the safe and effective use of medicine [ 9 ]. This review mainly focuses on public health interventions aimed at promoting health and preventing disease as the community pharmacists’ roles are clearly defined in literature.

The delivery of PHIs through community pharmacies not only leads to improved health outcomes but also reduces health inequalities. This is because they are accessible to individuals who lack the resources to access conventional healthcare providers [ 17 ]. It also reduces the burden on the health system in two folds; first, it reduces the burden on healthcare providers in facilities with a shortage of healthcare workers [ 18 ]. Second, by provision of vaccine and screening services, it reduces the burden of preventable disease in the health care system [ 19 ]. Furthermore, the provision of these interventions through community pharmacies leads to reduction of medical treatment costs which leads to savings in healthcare costs [ 20 ].

Despite the evidence of such benefits, there is a gap in knowledge on the factors driving community pharmacists to take up this role. Understanding the factors that influence their decision to take up the role is essential for the design of policies in a manner that aligns with their incentives and for the successful implementation of PHI programs. This review therefore aims to explore the factors that influence the community pharmacist’s decision to take up the extended role of PHI delivery.

Research question

What are the factors that influence community pharmacists’ decision to take up the role of PHI delivery?

The objective of this study was to systematically review available global evidence on the factors that influence community pharmacists’ decision to take up the role of delivery of Public Health Interventions.

A protocol for our review can be found in the Open Science Framework [ 21 ]. We conducted this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [ 22 ] and adhered to the PRISMA checklist S1 Checklist .

Search strategy

We searched the literature from July-December 2023 in 3 databases namely: Embase (1947-December 2023), Scopus (18230December 2023), and Medline (1975-December 2023) to identify relevant literature. Both Medical Subject Heading (Mesh) and keywords, Boolean and proximity (e.g. adj2) operators, truncations (*) were used in the search. The search terms used were: “Community Pharmacy” “Private pharmacy” OR “Retail pharmacy” AND “preventive health services” OR “public health services” OR “health promotion” OR “screening” OR “testing” OR “Case finding” AND “cardiovascular disease” OR “Diabetes” OR “Blood pressure” OR “drug use” OR “substance use” OR “mental health” OR “sexual health” OR “vaccination” OR “Immunization” OR “Family planning” OR “Contraception”. This search strategy and terms were modified for Embase and Scopus as appropriate. The search strategy was discussed with the librarian for inclusion sensitivity. Detailed search strategy can be found in the supplementary information S1 Table .

We also searched for relevant literature from reference lists of identified studies. The search results from each database were uploaded to End Note 2.0 reference software and duplicates were removed.

Study selection

Studies were eligible for inclusion if they: 1) reported on interventions delivered in community pharmacies, which are also referred to as private or retail pharmacies. Community pharmacies refer to generally small to medium-sized businesses providing typical pharmacy services such as filling of prescriptions, over-the-counter products, and point-of-care (POC) testing or self-testing kits for common diseases. We included studies conducted in both chain and independent pharmacies. 2) reported on factors that influence the uptake of the delivery of PHIs. 3) interventions were provided by registered pharmacists and/or pharmacy technicians (in some cases referred to as pharmacy assistants); 4) were published in the English language.

Studies were excluded if they: 1) reported on interventions delivered in pharmacies in hospitals, clinics and online pharmacies; 2) reported on interventions aimed at antimicrobial resistance as this is beyond the scope of the broader study, improving treatment and management of diseases, self-medication or management interventions without screening or diagnosis components; 3) Book chapters, reviews, commentaries, letters to the editor, and conference papers.

Data screening, extraction and analysis

Titles and abstracts were screened by AM in two steps. First, following the removal of duplicates, titles and abstracts were screened against the inclusion and exclusion criteria. Studies that did not meet the criteria were deemed to be irrelevant and excluded. Second, the full articles of the potentially relevant studies were retrieved, and a detailed screening was conducted based on the inclusion and exclusion criteria.

Relevant data from the selected articles were extracted into Ms. Excel by AM with accuracy checks performed on selected articles by JN and any conflict was resolved through discussion of the justification of the inclusion and exclusion criteria. We extracted information on the study title, first author, year of study, study country, PHI and factors influencing the uptake of PHI delivery.

The coding process was conducted manually in MS Excel. Data were analyzed using thematic analysis which entailed 4 phases [ 23 ]. Phase 1: familiarization with the identified articles through reading and re-reading, Phase 2: generation of initial codes that were used to develop the coding framework, Phase 3: coding the contents of the articles onto the coding framework, and Phase 4: generation of themes by identifying patterns and relationships across the identified codes. We used established themes to summarize the findings descriptively and summary tables.

Quality assessment

The studies were assessed for quality independently by AM using the Critical Appraisal Skills Programme (CASP) which uses a standardized checklist to assess the adequacy, trustworthiness, and relevance of the evidence reported in the articles [ 24 , 25 ]. The CASP checklist evaluates articles on methodological quality, participant recruitment, data collection and analysis, bias, ethical considerations, and the value of the research. For each of the studies a score of 1 (Response of Yes) or 0 (response of No/Can’t tell) was assigned to each of the items assessed, with a maximum score of 10. We classified studies as high (8–10) moderate (6–8) or low (4–6). Studies that scored 6 and above were included in the review. (See S1 Table for more information). The appraisal tool for Cross-Sectional Studies (AXIS tool) to assess for quality of cross-sectional studies [ 26 ]. AXIS task contains 20 Yes, No/Somewhat questions to assess the aims, methods, results, and conclusion reported in each study. A score greater than 75% is considered to be high quality, a score of 60%-70% is considered to be of moderate quality and a score less than 60% is considered to be of low quality. The information on quality assessment is in the supplementary files S1 File .

Our search yielded 10,927 articles from the three databases, of these 4,434 were duplicates, 6,436 were excluded after the screening of the title and abstracts,157 articles were included in the full-text review, and we included 22 studies in the final review. This selection process is demonstrated in Fig 1 .

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• TIFF original image

https://doi.org/10.1371/journal.pone.0298713.g001

Characteristics of the selected studies

Table 1 shows the characteristics of the studies included in the review. Twenty-two studies were selected for the review. Out of the 22, 4 studies were conducted in United Kingdom (UK), 2 in United States of America (USA), 3 in Australia, 4 in Canada, and 1 from Nigeria, Poland, Portugal, Austria, Lebanon, Malaysia, Pakistan, United Arab Emirates (UAE) and Qatar. The main public health interventions identified from the review were; vaccination services (6), healthy weight management (4), Emergency hormonal Contraceptives (EHC) (4), chlamydia screening (2), Cardiovascular screening (CVS) (2), HIV services (2), Health education (1), Pre-exposure prophylaxis screening (PrEP) (1), Diabetes screening (1).

https://doi.org/10.1371/journal.pone.0298713.t001

Quality of evidence

All the included studies had clear statements on the aims, methods used, research design and data collection procedures, data analysis and made significant contributions to existing knowledge and discussed the transferability of the findings to other contexts. However, the relationship between the researchers and participants was not adequately described in 14/16 articles. It was therefore difficult to determine how this relationship may have impacted the findings. For cross-sectional studies assessed using the AXIS tool, the studies met most of the criteria on the tool. However, 5/6 of the studies did not report on measures taken to address non-response bias.

Despite this, we decided to include all the studies in the review as they adequately met the inclusion criteria and contributed to our review objective. (The full details are in the S2 and S3 Tables in S1 File ).

Synthesis of results

We identified 6 major themes from this review: training and education (19/22), structural and organizational adjustments (11/22), remuneration (9/22), collaboration with other health care professionals (6/22), support from government and professional bodies (4/22).

Training and continuous education

Pharmacists are qualified to provide health care services, however, the reviewed literature suggests that they feel incompetent in taking up this role and would benefit from additional training on the provision of specific PHIs [ 27 , 29 – 35 , 37 – 47 ]. Pharmacists in the UK received training on how to deliver chlamydia testing by attending a sexual health learning training session and through the completion of an online learning module [ 27 ]. Elsewhere, Moore S et al found that 70% (21/30) of pharmacists acquired health promotion training in their undergraduate degree and informally through reading articles in professional journals rather than attending a formal training program [ 29 ]. In Canada, vaccination training was provided to pharmacists through online learning modules and live day training [ 41 ]. Almukdad et al, exploring the attitudes of pharmacists in the role of offering weight management services found that pharmacists would benefit from regular and structural training to promote their expertise [ 34 ]. Pharmacists in Malaysia reported they would prefer to have at least 1 or 2 days of short training workshops [ 35 ].

Pharmacists in Pakistan and Poland expressed a gap in formal training in the undergraduate curriculum and they recommended the inclusion of more practical training sessions in the curriculum [ 30 , 31 ]. They also expressed concern about the high fees of the courses, and they suggested the need for funding opportunities for free courses. Community pharmacists in Australia and Malaysia reported willingness to provide vaccination services after having received additional short training that covers aspects of needle size gauge and landmarking [ 41 ], vaccine storage, technique, and handling of emergency cases [ 35 ], with a 2 year renewal interval [ 43 ]. Training was suggested for both pharmacists and their assistants in 4 studies to facilitate task shifting of responsibilities [ 29 , 33 , 41 , 44 ].

Remuneration

The provision of PHIs was viewed as an additional workload on top of the dispensing and pharmaceutical-based services and remuneration is a pre-requisite for further activity [ 28 , 29 , 31 , 33 – 35 , 40 , 41 ]. Pharmacists in Poland expressed they would like to be compensated through an increase in salary to motivate them to take up the role of a health educator [ 31 ]. Elsewhere, pharmacists in the UK reported they would prefer to be compensated through a fee-for-service model by the Kingston & Richmond Family Health Service Authority (FHSA) [ 29 ]. Pharmacy assistants in Australia viewed remuneration as a tangible recognition for the provision of Chlamydia screening and participation in the training program, in addition to receiving a certificate [ 33 ]. None of the other studies reported on the modes of remuneration but there was consensus that remuneration was a means of motivating pharmacists. For instance, pharmacists in the UAE reported that remuneration would motivate them to screen more clients for STIs [ 28 ]. There was also an agreement among pharmacists in Australia and the UAE that screening services should be offered at minimal or no costs, funded through government subsidies [ 28 ].

Structural and workflow adjustments

Structural adjustments such as the establishment of a dedicated space for private consultation and as an enabler for the adoption of this role. This was indicated in 8 studies; [ 29 – 31 , 34 – 36 , 39 , 44 ]. For example, community pharmacists in Nigeria reported that having a designated space for offering patient counseling would encourage them to participate in more public health services [ 44 ], similar to findings by Almukdad et al where pharmacists proposed having a private area for counseling as an internal strategy to improve the provision of weight management services (WMS) [ 34 ]. The need for a designated space with proper equipment to measure obesity-related parameters for screening blood pressure, weight measurement and cholesterol measurement was reported in Pakistan [ 30 ]. For provision of vaccination services pharmacists expressed the need for a specified area for provision of the vaccine services and storage of vaccines under the right temperatures [ 35 , 41 ]. However, none of the studies detailed how this could be achieved.

Elsewhere organizational adjustments such as having a time dedicated time for delivery of PHIs to avoid disruption of the normal dispensing activities [ 29 , 31 , 35 , 36 , 40 ] was reported as an enabler for uptake of PHI delivery. Providing training to pharmacy assistants on how to handle pharmacy-based activities was reported as a strategy to free up time for pharmacists to be involved in the delivery of PHIs [ 31 , 44 ], as well as scheduling appointments for the PHIs [ 36 ].

Collaboration with other healthcare professionals

Pharmacists expressed that the provision of additional services (i.e. delivery of PHIs) would require a multidisciplinary approach [ 29 , 30 , 34 , 37 , 46 ], especially for cases that required referral and consultation with other health care professionals such as obesity cases [ 46 ]. Pharmacists reported they would prefer having multi-disciplinary training courses as a way of forming links between different professional groups [ 29 ]. Pharmacists in Canada expressed low awareness among general physicians on pharmacists’ capabilities in providing PHIS and suggested having a shared electronic medical record with physician to facilitate an integrated model of care [ 37 ]. Elsewhere in Qatar, pharmacists viewed offering Weight Management Services as complex and they highlighted the need for collaboration with dieticians and physicians for referral purposes [ 34 ]. However, the findings from these studies were mainly aspirational, and none reported on an existing collaboration model.

Support from the government and professional bodies

Support from governing bodies was identified as crucial in the implementation of public health programs in four studies [ 30 , 34 , 35 , 37 ]. For example, in Pakistan pharmacists reported there was low awareness of the role pharmacists play in public health and the government could play a role in promoting awareness to the public which in turn would enhance trust from the public [ 30 ]. These findings were similar in Canada where pharmacists expressed that professional associations could play a role in creating awareness of this role [ 37 ]. Pharmacists in Qatar expressed the need for the Ministry of Health to establish guidelines for pharmacists to facilitate the adoption of Weight Management Services (WMS) [ 34 ]. Elsewhere in Malaysia, pharmacists expressed that the government could support them in this role by offering free training and resources to facilitate the vaccination role and professional bodies by advocating for the roles of CPs to be included in vaccination programs [ 35 ].

To the best of our knowledge, this is the first review highlighting the factors that influence community pharmacists to expand their scope of practice and deliver PHIs from a global perspective. The findings from this review reaffirm that pharmacists are willing to expand their practice beyond dispensing and take up the role of PHI delivery.

The core finding of this review was that offering additional training to community pharmacists on the delivery of specific PHIs is a requirement to boost the uptake of this role. Training could augment pharmacists’ knowledge and skills as well as empower them to be more competent and confident in the delivery of PHI. The benefits of training pharmacists on PHI delivery include elevating their confidence and competence in service delivery and thus improved health outcomes [ 49 , 50 ] For instance community pharmacists who received training on provision of smoking cessation services in Thailand reported feeling more confident in offering such services in the future [ 51 , 52 ]. Similarly, community pharmacists in Australia reported feeling confident in screening clients for risk of cardiovascular disease after receiving training in their pharmacies [ 53 ]. Policymakers should therefore put efforts to ensure that community pharmacy providers are qualified and have access to regular training. There was no reported standardized model in place for training pharmacists on PHI delivery from the studies reviewed. Nevertheless, various training models have been adopted elsewhere although these differ by context and the PHI under consideration [ 54 – 57 ].

These training models include peer learning, which has the potential to influence the practitioner’s behaviour [ 54 ], learning at work [ 55 , 56 ], and formal certification to become specialists [ 57 ]. These trainings are delivered through different formats such as face-to-face learning (onsite/off-site), and online learning (webinars-learning modules and activities). Face-to-face training has been reported as the preferred mode of delivery by pharmacists in Ethiopia [ 55 ], UAE [ 58 ], and USA [ 59 ], as it offers an opportunity for quick feedback from the instructor, and provides an opportunity for peer networking, which could enhance collaboration with healthcare professionals in other fields. Online training on the other hand has been reported as a preferred mode of delivery by pharmacists in Australia [ 60 ], as it offers the convenience of pharmacists completing modules at their own pace and schedule. Blending diverse training methods and modes by pharmacists’ preferences is key to ensuring that pharmacists are well-equipped to take up the role of delivery of PHI. Additionally, modifications of the undergraduate curriculum to include public health modules is a starting point to improving professional skills and perceptions of pharmacists towards taking up this extended role [ 61 , 62 ].

Government support to community pharmacies is crucial in enhancing the uptake of PHI delivery. This can be through the provision of resources to facilitate the adoption of PHI delivery through, for example, the provision of materials to promote awareness and offering equipment at a subsidized price that is affordable to pharmacists [ 63 ]. The vital role that community pharmacies play in improving health indicators is recognized globally, however, their inclusion in the design of policies, countries’ health strategies, regulations and monitoring is minimal [ 64 ]. The government can therefore play a role by establishing clear guidelines, policies, and regulatory frameworks to guide the integration of this role into broader health systems tailored to the unique landscape of each country. For instance, in Saudi Arabia, MoH has developed specific guidelines on the provision of immunization services within community pharmacies [ 65 ]. Elsewhere in Kenya, MOH through the National AIDS and STI Control Programme (NASCOP) launched guidelines which advocated for the delivery of HIV-Self test kits in community pharmacies [ 66 ]. Furthermore, the government and professional bodies could promote national campaigns to create awareness of the crucial role that pharmacists play in public health.

Whilst integrating community pharmacist PHI delivery role into the broader health system, it’s important that they generally operate independently of other healthcare providers in a retail environment [ 67 ]. Therefore, training sessions could create an avenue to foster interprofessional collaborations between pharmacists and other healthcare professionals.

Interprofessional collaboration between physicians and pharmacists has resulted in improved patient outcomes and a reduction of health system inefficiencies and costs [ 68 , 69 ]. This has led to the establishment of Collaborative Practice Agreements (CPAs) in the USA where community pharmacists conduct screening for chronic infections in the pharmacies and hand off the reactive cases to general physicians. This helps to close the gap of loss to follow-up patients [ 70 ]. Elsewhere in UK general physicians have communication channels for referral of patients for a same day consultation with community pharmacists and vice versa [ 71 ]. Interprofessional collaboration has been described as an evolving process that progresses through a series of stages described by various collaboration models. For instance, a GP- pharmacist model by McDonough and Doucette [ 72 ] describes it as a progression in 4 main stages: stage 0- professional awareness, stage 1- professional recognition, stage 2- exploration and trial stage, stage 3- professional relationship expansion, stage 4- a commitment to the collaborative working relationship and is influenced by different factors such as proximity, time, clinical knowledge, communication, mutual interests and professional equality. Other models have been adopted for collaboration between pharmacists and GPs and are similar in that collaboration progresses from brief interactions to a clearly defined relationship where the roles of both cadres are well defined [ 73 , 74 ]. Role clarity has been shown to influence the adoption of role expectations and task performance [ 75 , 76 ].

Community pharmacies are private retail businesses operating within a competitive market and aim to maximize profits to survive in the market, it is therefore not surprising that remuneration influences the uptake of the additional role. Delivery of PHI is viewed as an additional role and pharmacists have few incentives to deliver the expanded services if the compensation is inadequate. Although the remuneration of community pharmacists has mainly been based on their retailing and dispensing functions, a few countries have introduced payment mechanism reforms as a means of encouraging the adoption of this role [ 77 ]. For instance, the fee-for-service model has been adopted to encourage pharmacists to provide smoking cessation services [ 78 ], influenza vaccination [ 79 ], and diabetes-related education, training and monitoring in the community settings [ 80 ] and was more preferred by pharmacists as it was easy to implement and integrate into the existing business model [ 81 ]. Pay-for-performance model has been used in a UK program, where pharmacies were renumerated based on the number of people who successfully quit smoking [ 82 ]. However, there is a gap in knowledge on the preferred payment model in various contexts. Understanding the payment model preferences of community pharmacists is a crucial knowledge gap as it has major implications on the implementation, adoption, and potential impact of pharmacists’ payment model.

Finally, structural and workflow adjustments such as having a designated space and having a dedicated time play a role in community pharmacists taking up the role of PHI. The importance of a private room has been stressed in several studies as a way of building trust and maintaining confidentiality for patients who want to discuss sensitive medical issues such as requests for EHC, screening for STIs, Prep, and HIV screening [ 83 , 84 ]. Evidence suggests that community pharmacists have a preference for having a private consultation room to provide services for diabetes management to preserve patients’ privacy and confidentiality [ 85 ]. This can be achieved through the establishment by development of policies and standards for the physical space of pharmacies such as having a designated space for conducting PHIs. For instance, having a private space has been incorporated as a requirement in Western Australia section 7 of Pharmacy Regulations 2010, which specifies that, “ The premises are to have an area in which a consultation conducted by a pharmacist is not reasonably likely to be overheard by a person not a party to the consultation” [ 86 ]. These guidelines are backed up by the professional body code of ethics as a means to ensure that the client’s right to privacy and confidentiality is maintained [ 87 ]. Workflow adjustments such as having time dedicated to PHIs would allow pharmacists to plan efficiently and allocate sufficient time to deliver high-quality services. However, evidence shows that community pharmacists have a general preference for being easily accessible to patients by taking walk-in clients [ 85 ].

Limitations

One limitation of this review was that most of the findings from were mainly aspirational and therefore minimal data on various mechanisms that have been applied to facilitate the role of PHI delivery by community pharmacists, however, this will be addressed by a broader study. Second, the findings from this review were mainly in studies conducted in high-income countries and therefore the findings may not be contextually replicable in low-income settings as factors vary across different contexts. To overcome these limitations, further empirical work in LMIC settings is required to determine the key drivers, policy, and practical considerations for delivery of PHIs. Finally, the studies included in this review were those published in English language and there is a likelihood that we might have missed some articles that may be relevant to our review. Despite these limitations, this manuscript provides crucial information that has great potential to inform the design of public health policies targeting community pharmacists.

Study implications

This review highlights the different factors that play a key role in influencing community pharmacists’ decision to take up the role of PHI delivery. However further research is needed to generate evidence on how these factors interact to influence implementation practices and sustainability. This research could entail identifying context specific barriers and facilitators of PHI delivery in community pharmacies particularly in LMICs. This information could inform the design of implementation strategies that can enhance sustainability of PHI programs adopted in community pharmacies. Such research is crucial for two reasons: first, it will ensure that policies are designed in a manner that incentivizes community pharmacists to take up this role. Second, it will facilitate the establishment of guidelines to standardize community pharmacy practice and integration of this role into broader health systems which will in turn enhance the contribution of community pharmacists to public health.

This review sheds light on the various factors that influence the decision of community pharmacists to expand the scope of practice and take up the role of delivery of public health interventions. Incorporating these factors into the design of policies and public health programs is crucial for the successful integration of community pharmacists into broader public health initiatives. However, these findings do not indicate the relative importance that is placed on each of the factors by community pharmacists. The findings from this review will inform the design of a discrete choice experiment to elicit context-specific preferences of community pharmacists for the identified factors, which will in turn contribute to the design of policies that will enhance the contribution of community pharmacists to public health.

Supporting information

S1 checklist. prisma 2020 checklist..

https://doi.org/10.1371/journal.pone.0298713.s001

S1 Table. Search strategy.

https://doi.org/10.1371/journal.pone.0298713.s002

S1 File. Quality assessment findings.

https://doi.org/10.1371/journal.pone.0298713.s003

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• Published: 01 August 2024

Knowledge and skill level among non-healthcare providers regarding cardiopulmonary resuscitation (CPR) training in the Middle East (Arab countries): a systematic review and meta-analysis

• Mohammed Alsabri Hussein Alsabri 1 , 2 ,
• Basel F. Alqeeq 3 ,
• Alaa Ahmed Elshanbary 4 ,
• Youssef Soliman 5 ,
• Mohamed Sayed Zaazouee 6 &
• Rebecca Yu 7  

BMC Public Health volume  24 , Article number:  2081 ( 2024 ) Cite this article

Metrics details

Effective education is considered by the American Heart Association (AHA) as a vital variable in improving outcomes of cardiac arrest. Studies have shown that the level of knowledge and attitude of non-healthcare providers towards resuscitation training varies widely across the globe. While some training methods and barriers to training have been discussed, the literature is still quite vague and unclear regarding resuscitation training, particularly in the Middle East. This study’s focus on the efficacy of resuscitation training in this region of the world may help dictate how to better implement education initiatives aimed towards non-healthcare providers in developing countries.

Methodology

A systematic review and meta-analysis were conducted on studies published from inception until March 2023. Observational studies assessing CPR knowledge and skills among non-healthcare workers in Arab countries were included. Data were extracted from PubMed, Cochrane Library, EMBASE, Web of Science, and Scopus. Data analysis was performed using Rstudio with a random effects model.

50 studies were included in this review and meta-analysis, revealing that 55% of participants had prior knowledge of CPR, while only 28% considered their knowledge sufficient. The majority (76%) supported mandatory CPR training, and 86% were willing to attend training if offered. This study found that prior knowledge of cardiopulmonary resuscitation (CPR) varied among populations. This meta-analysis also compiled results regarding CPR technique defined by correct compression to ventilation ratio, compression depth, compression rate, location of chest compression, and correct sequence. The overall results from this meta-analysis showed that, of these factors, compression rate and depth were the two factors that were most often administered incorrectly. In all, the results from this study demonstrated that CPR training in Arab countries was favorably viewed overall, with the majority of participants indicating both support for mandatory CPR training and general willingness to attend training if offered the opportunity.

Given the overall positive view and willingness to learn CPR skills, healthcare policy makers should adopt a more comprehensive focus on strategies that enhance the accessibility and opportunity for CPR training for non-healthcare populations in Arab countries. Future training programs should implement strategies to highlight the ideal combination of compression rates and depth to learners to ensure correct and efficacious delivery of CPR with increased focus on the practical portion during refresher courses to promote retention.

Peer Review reports

Worldwide, cardiovascular diseases are the number one cause of death, causing 32% of all global deaths according to the World Health Organization (WHO) [ 1 ]. Sequalae of cardiovascular diseases, such as respiratory failure and circulatory shock, are reversible, yet cause millions of deaths globally. There is a disproportionate number of such deaths in developing countries [ 2 ]. In fact, the American Heart Association (AHA) has noted that the administration of cardiopulmonary resuscitation (CPR) and defibrillation within the first three to five minutes of collapse can yield survival rates ranging from 49% to as high as 75% [ 3 , 4 ]. Not only that, CPR has also been shown to double or triple survival from the time of witnessed sudden cardiac arrest [ 4 ]. Implementation of effective resuscitation training is critical to improving survival rates and outcomes.

Effective education is considered by the AHA as a vital variable in improving outcomes of cardiac arrest [ 5 ]. Resuscitation training programs aim to provide evidence-based knowledge and skills to reduce the morbidity and mortality of reversible life-threatening conditions. Such training is necessary to allow for lay persons and healthcare providers alike to consistently apply this evidence-based approach [ 5 ]. It has been reported that resuscitation teams one or more members trained in advanced cardiovascular life support (ACLS) have better outcomes [ 5 ].

Although morbidity and mortality related to cardiovascular diseases have been decreasing, the prognosis of out-of-hospital cardiac arrest (OHCA) remains the same [ 6 ]. OHCA is defined as the cessation of cardiac mechanical activity that takes place outside hopitals. Importantly, OHCA is considered a potentially reversible event through the activation of chain of early CPR and proper care. The survival rate of OHCA could be two to three times higher if bystander CPR is performed in a timely manner. While healthcare professionals are expectedly aware of of CPR, adequate awareness of CPR among the general population is still lacking as many studies have reported poor knowledge among laypersons [ 7 ].

In Arab countries, first aid education and CPR training are often provided through schools, community centers, and healthcare institutions. However, the extent and quality of this training can vary widely. For example, in countries like Lebanon and the UAE, CPR training is integrated into school curricula, whereas in others, it is offered sporadically through community initiatives [ 8 , 9 ].

The rationale for this systemic review originates from the paucity of literature covering this specific topic. As discussed previously, cardiovascular diseases are a leading cause of death worldwide and its sequelae, such as respiratory failure and circulatory shock, can be reversible. The burden on the healthcare system increases dramatically due to increased morbidity and mortality that could have been mitigated with evidence-based application of resuscitation measures. While the awareness and knowledge of CPR among healthcare providers are a popular concern worldwide, awareness of CPR among the general public represents an equally crucial objective in order to enhance the prognosis of OHCA. The aim of this study is to systematically review and analyze the level of CPR knowledge and skills among non-healthcare providers in Arab countries, identifying key areas for improvement and providing recommendations for future training programs.

We followed the PRISMA statement guidelines when conducting this systematic review and meta-analysis [ 8 ]. All steps were done per the Cochrane Handbook of Systematic Reviews and Meta-analysis of Interventions [ 9 ]. Based on the PRISMA guidelines, investigators (MA and MSA) created the review protocol and the search strategy. Our research question was developed following the key elements of the PICO framework: Participants, Interventions, Comparison, and Outcomes [ 10 , 11 ]. The protocol (CRD42023399328) was registered in PROSPERO (International Prospective Register of Systematic Reviews) 2023.

Inclusion and selection criteria

Using predefined keywords, databases were searched from inception through August 2023 for studies that assessed the knowledge, attitude, and perceptions (KAP) towards Basic Life Support (BLS) among non-healthcare workers in Arab/Middle Eastern countries. In the case of studies which included both healthcare and non-healthcare workers, we included the study only when there were separable data for the non-healthcare workers eligible per our criteria; otherwise, we excluded the studies. In this meta-analysis, we included observational studies such as cross-sectional studies that assessed CPR knowledge and skills. For specific outcomes like previous knowledge, only cross-sectional studies were used to ensure consistency in the analysis. Reviews, abstracts, editorials, conference papers, and non-English studies were excluded. We removed the duplicates using Endnote 8 software. Then, we screened the titles and abstracts, followed by full-text screening to identify the relevant studies.

Information sources and search strategy

To identify studies to be included in this review, the databases PubMed, Cochrane Library, EMBASE, Web of Science, and Scopus were searched for keywords related to CPR, knowledge, skill, Middle East, Arab, Arabian Gulf (see Table 1. in appendix) from inception until August 2023. Additionally, we manually searched the references of the included studies, Google Scholar, and Research Gate for additional articles of interest.

Study selection

Following the database searches, all of the citations were imported into EndNote X9 Windows version. Duplicate references resulting from the overlap of database content were identified and removed. Two independent reviewers (MSZ and AAE) screened the titles and abstracts of all unique citations against the predefined inclusion and exclusion criteria. Any disagreements between the two reviewers at this stage were resolved through discussion; if necessary, a third reviewer (MA) was consulted. Studies that appeared to meet the inclusion criteria, or for which there was insufficient information in the title and abstract to make a clear decision, were advanced to full-text review. Again, two independent reviewers (MSZ and AAE) assessed each full-text article to determine its eligibility. Disagreements at this stage were resolved through consultation with a third reviewer (MA). The reference lists of all included studies were scanned to identify additional studies that might have been missed during the initial database searches. Any potentially relevant studies identified through this process were subjected to a full-text review and included if they met the criteria.

Data extraction and synthesis

The data analysis in this study was performed using Rstudio (Version 4.2.2). We performed subgroup analysis according to the study group (e.g., university students, parents, etc.). To calculate the pooled proportion along with its corresponding 95% confidence interval (CI) for all the analyzed outcomes, a random effects model was employed. This statistical approach was implemented using the “meta prop” function, which is a part of the “meta” library available within the Rstudio environment. We assessed the prevalence of the different indices of CPR knowledge among all studies with higher prevalence (percentage %) indicating higher number of participants being aware or proficient in each index. The assessment of heterogeneity among the included studies was a crucial aspect of this analysis. To quantify heterogeneity, the I^2 statistic was computed, and its associated p-value was determined. A p-value < 0.1 indicated statistically significant heterogeneity. The meta-analytical method utilized in this study involved the application of a random intercept logistic regression model, employing maximum-likelihood estimation to determine tau^2. To establish random effects confidence intervals, the t-distribution was utilized, and a logit transformation was applied to the data.

Quality assessment

We employed an adapted version of the Newcastle–Ottawa quality assessment scale (NOS) for cross-sectional studies. The scale has three main domains with seven items for quality assessment. We included the detailed guidelines for NOS risk of bias assessment in our supplementary material. While the maximum points a study can score is up to 9 points, studies were deemed to be of good quality if they scored 5 points or more [ 12 ].

To assess the quality of experimental and quasi-experimental studies, we used the AHA guideline’s definitions for the level of evidence and class of recommendation of the CPR training. The following are the definitions: ‘LOE A’ represents high-quality evidence based on two or more randomized controlled trials (RCTs); ‘LOE B’ is intermediate level of evidence based on one RCT or more; ‘LOE B-NR’ level is based on strong observational or nonrandomized studies; ‘LOE C-LD’ has evidence from weak or limited observational studies; ‘LOE C-EO’ is the weakest level of evidence which is based only on experts’ opinion [ 13 ].

In terms of class of recommendation (COR) in CPR training, the strength of training is stratified as follows:

When benefit is three-fold the risks of intervention A compared to intervention B, the training is considered “class I (strong).”

When benefit is two-fold the risks of intervention A compared to intervention B, the training is considered “class IIa (moderate).”

When benefit is thought to be equal or more than the risks of intervention A compared to intervention B, the training is considered “class IIb (weak).”

When benefit of intervention A equals intervention B, the training is considered “class III (no benefit/moderate).”

When intervention A has risks higher than those of intervention B the training is considered “class III (harm/strong).” [ 14 ].

Literature search

The initial search identified a total of 4573 records from five different databases. Following the removal of duplicates, 3705 records remained. Through the title and abstract screening, we excluded 3512 records. Moreover, following the full-text screening, there were 40 included studies. Additionally, we included 10 through manual screening (Fig.  1 ),

PRISMA flow diagram

Characteristics of the included studies and population

50 studies [ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 ] were included in the meta-analysis. A summary of the characteristics of the included studies is provided in Table  1 . Regarding the populations of included studies, 14 studies enrolled health colleges students, 12 studies enrolled university students, 5 studies enrolled teachers, 5 studies enrolled secondary school students and 14 studies enrolled patricipants of the general population. Our quantitative analysis included a total number of 30,308 participants. Subgroup analyses were performed on several groups of participants: health colleges students ( n  = 7,420), university students ( n  = 9,802), school students ( n  = 3,256), teaching staff ( n  = 1,389), and the general population ( n  = 8,441).

Previous knowledge

In the meta-analysis of 13 studies [ 19 , 20 , 21 , 22 , 26 , 29 , 31 , 37 , 38 , 43 , 45 , 57 , 58 ] on “Previous Knowledge” (9,343 observations, 5,226 events), 55% of participants were found to have previous knowledge regarding CPR (95% CI: 43% to 66%). Heterogeneity analysis showed substantial variability among the included studies, with an I^2 value of 98.7% ( p  < 0.01). Subgroup analysis demonstrated significant differences in previous knowledge among various groups of participants: secondary school students (47%, 95% CI: 33% to 61%), the general population (61%, 95% CI: 51% to 71%), health college students (59%, 95% CI: 30% to 83%), and teachers (11%, 95% CI: 9% to 13%). (Fig. 2  A). The meta-analysis revealed significant variations in CPR knowledge and skills. The prevalence of prior knowledge was 55%, while the correct compression rate was only 26%. Figures 2 and 3 illustrate the distribution of knowledge and skills, respectively.”

(A,B,C,D) A Forest plot of a previous knwladge ergarding CPR, B Forest plot of consider their Knwladge sufficient, C Forest plot of CPR training should be mandatory,  D  Forest plot of encountered a case that need CPR

(A,B,C,D) A Forest plot of willings to attend CPR training if offered, B Forest plot of ctivate an EMS when encountering an unresponsive person, D Forest plot of correct CPR ratio (Compression/Ventilation)

Consider their knowledge sufficient

The meta-analysis of 9 studies [ 18 , 19 , 22 , 25 , 31 , 33 , 40 , 52 , 60 ] (7,188 observations, 1,608 events) revealed that 28% of paricipants consider their knowledge sufficient (95% CI: 14% to 48%). Heterogeneity was substantial with an I^2 of 99.1% ( p  < 0.01). Subgroup analysis indicated differences among groups of participants regarding whether they consider their knowledge sufficient, including teachers (35%, 95% CI: 30% to 41%), secondary school students (13%, 95% CI: 1% to 62%), health college students (48%, 95% CI: 41% to 54%), university students (19%, 95% CI: 9% to 35%), and the general population (84%, 95% CI: 81% to 88%).(Fig. 2  B).

CPR training should be mandatory

The meta-analysis of 14 studies [ 18 , 19 , 20 , 25 , 26 , 28 , 30 , 31 , 39 , 40 , 50 , 59 , 60 , 61 ] (11,974 observations, 7,937 events) revealed that 76% of participants think that CPR training should be mandatory (95% CI: 62% to 86%). Heterogeneity was substantial with an I^2 of 99.3% ( p  < 0.01). Subgroup analysis revealed variations in responses among different groups of participants, including teachers (70%, 95% CI: 39% to 90%), secondary school students (38%, 95% CI: 25% to 54%), the general population (89%, 95% CI: 67% to 97%), university students (66%, 95% CI: 15% to 95%), and health college students (88%, 95% CI: 41% to 99%).(Fig.  2  C).

Encountered a case that needed CPR

The meta-analysis of 14 studies [ 19 , 26 , 29 , 31 , 32 , 33 , 38 , 40 , 42 , 52 , 53 , 57 , 60 , 64 ] (11,685 observations, 2,068 events) estimated that 18% of participants encountered a case that needed CPR (95% CI: 14% to 22%). Heterogeneity was substantial with an I^2 of 96.4% ( p  < 0.01). Subgroup analysis showed varying results concerning this question among different groups of participants, including secondary school students (14%, 95% CI: 0.5% to 84.7%), teachers (19%, 95% CI: 14.7% to 24.9%), the general population (18%, 95% CI: 10.7% to 28.7%), university students (17%, 95% CI: 9.8% to 29.1%), and health college students (26%, 95% CI: 23.8% to 28.7%).(Fig.  2  D).

Willingness to attend CPR training if offered

The meta-analysis of 13 studies [ 17 , 18 , 20 , 24 , 25 , 28 , 30 , 38 , 45 , 50 , 52 , 61 ] (7,622 observations, 6,396 events) estimated that 86% of participants ar willing to attend CPR training if offered (95% CI: 81% to 90%). Heterogeneity was present with an I^2 of 95.0% ( p  < 0.01). Subgroup analysis showed variations in responses to this question among different groups of participants, including teachers (85%, 95% CI: 49% to 97%), the general population (88%, 95% CI: 77% to 94%), university students (85%, 95% CI: 74% to 92%), and health college students (89%, 95% CI: 87% to 90%).( Fig.  3  A).

Activate emergency medical services (EMS) when encountering an unresponsive person

The meta-analysis of 7 studie [ 22 , 24 , 25 , 28 , 30 , 31 , 60 ] (3,321 observations, 1,020 events) estimated that 34% of patricipants would activate EMS when encountering an unresponsive person (95% CI: 15% to 60%). Heterogeneity was substantial with an I^2 of 99.0% ( p  < 0.01). Subgroup analysis revealed differences in responses among various groups of participants, including health college students (29%, 95% CI: 0% to 100%), university students (38%, 95% CI: 0% to 100%), teachers (55%, 95% CI: 49% to 60%), secondary school students (52%, 95% CI: 48% to 56%), and the general population (12%, 95% CI: 9% to 15%).( Fig.  3  B).

Awareness of EMS number

Meta-analysis across 10 studies [ 16 , 26 , 28 , 30 , 38 , 45 , 50 , 58 , 60 , 63 ] revealed that 66% of participants are aware of the EMS number (95% CI: 56% to 74%). Significant heterogeneity was observed (I^2 = 97.0%, p  < 0.0001). Subgroup analysis showed varying responses concerning the awareness of the EMS number among different groups of participants, with university students having the lowest awareness (48%, 95% CI: 31% to 66%), while health college students demonstrated the highest awareness (72%, 95% CI: 67% to 76%). (Fig.  3  C).

Correct CPR ratio (Compression to ventilation)

In the meta-analysis of 14 studies [ 23 , 30 , 31 , 32 , 33 , 39 , 44 , 45 , 50 , 53 , 55 , 58 , 59 , 63 ] 32% of participants were found to know the correct CPR ratio (95% CI: 22% to 43%). Substantial heterogeneity was observed (I^2 = 99.1%, p  < 0.0001). Subgroup analysis indicated significant variations among different groups of participants, with university students showing the lowest correct CPR ratio (35%, 95% CI: 6% to 82%) and health college students having the highest (36%, 95% CI: 20% to 56%). ( Fig.  3  D).

Correct compression rate for adults

Meta-analysis 11 studies [ 23 , 30 , 32 , 33 , 39 , 44 , 50 , 53 , 55 , 59 , 63 ] revealed that 26% of participants were found to know the correct compression rate for adults (95% CI: 19% to 35%). Considerable heterogeneity was observed (I^2 = 98.3%, p  < 0.0001). Subgroup analysis demonstrated variations among different groups of participants, with university students having the lowest correct compression rate (27%, 95% CI: 7% to 65%), while health college students exhibited the highest (25%, 95% CI: 14% to 40%). (Fig.  4  A).

(A,B,C,D,E) A Forest plot of compression rate, B Forest plot of compression depath of 5–6 cm, C forest plot of correct location for chest compression(Mid-Chest),  D Forest plot of abbreviation of BLS,  E Forest plot of correct sequence of CPR

Correct compression depth for adults

Meta-analysis across 10 studies [ 23 , 30 , 33 , 39 , 44 , 50 , 55 , 58 , 59 , 63 ] 34% of participants were found to know the correct compression depth for adults (95% CI: 22% to 47%). Significant heterogeneity was observed (I^2 = 98.9%, p  < 0.0001). Subgroup analysis revealed variations among different groups of participants, with university students showing the lowest correct compression depth (40%, 95% CI: 13% to 74%) and health college students having the highest (31%, 95% CI: 17% to 56%). (Fig.  4  B).

Correct location for chest compression

Meta-analysis of 13 studies [ 16 , 23 , 30 , 32 , 33 , 39 , 44 , 50 , 53 , 54 , 55 , 59 , 63 ] revealed that 50% of participants know the correct location for chest compression across (95% CI: 39% to 61%). Significant heterogeneity was observed (I^2 = 98.7%, p  < 0.0001). Subgroup analysis indicated variations among different groups of participants, with university students having the lowest prevelance (55%, 95% CI: 31% to 76%), while health college students exhibited the highest (44%, 95% CI: 27% to 63%). (Fig.  4  C).

Knowledge of what the abbreviation of BLS stands for

Meta-analysis of 4 studies [ 23 , 44 , 50 , 63 ] revealed that 69% of patricipants know what the abbreviation of BLS stands for (95% CI: 24% to 94%). Substantial heterogeneity was observed (I^2 = 99.5%, p  < 0.0001). Subgroup analysis showed variations among different groups of participants, with university students having a prevelance of 67% (95% CI: 0% to 100%), while health college students exhibited 70% (95% CI: 0% to 100%). (Fig.  4  D).

Correct sequence for CPR

Meta-analysis of 3 studies [ 38 , 55 , 58 ] showed that 54% of participants know the correct sequence for CPR (95% CI: 23% to 82%). Significant heterogeneity was observed (I^2 = 96.2%, p  < 0.0001). Subgroup analysis revealed variations among different groups of participants, with health college students having the highest prevelance (62%, 95% CI: 3% to 99%). (Fig.  4  E).

Quality assessment of included studies

Overall, the quality of cross-sectional questionnaire studies was good with score ranging between 5 and 8, with only two of them scoring 8 and twenty-two studies scoring 7. All studies, except for Al Harbi et al. [ 66 ], Alghamdi et al. [ 67 ], Aloraibi et al. [ 68 ], Alshehri et al. [ 69 ] and Awadallah et al. [ 70 ] scored zero in the ‘Non-Response Rate’ in the selection domain. Table 2 presents the details of the quality assessment thoroughly.

Furthermore, we stratified seven experimental and quasi-experimental studies according to the AHA level of evidence and class of recommendation classification as summarized in Table S2. Evidence level ‘LOE B-R’ was given to four studies, ‘LOE B-NR’ to two studies and ‘LOE C-LD’ to one study. Only Abbas et al. [ 65 ] Hassan et al. [ 71 ], Majid et al. [ 72 ] were considered to have moderate (class IIa) evidence, while the remainder of the studies were deemed to have weak (class IIb) evidence.

The results from this study demonstrated that CPR training in Arab countries was favorably viewed overall with the majority of participants indicating both support for mandatory CPR training and general willingness to attending training if offered the opportunity. Public awareness is of great importance as the success rate of BLS can be ameliorated when lay persons initiate life-saving techniques before arrival of healthcare professionals. Given the overall positive view and willingness to learn CPR skills, there should be increased focus on strategies that increase accessibility and opportunity for CPR training in Arab countries. One country that has recognized the importance of this notion is Lebanon, as evidenced by the position statement published by the Lebanese Society of Cardiology and the Lebanese Society of Emergency Medicine [ 15 ]. In this statement, the launching of a campaign raising public awareness of CPR and automated external defibrillator (AED) use through videos, messages, and educational material was recommended to demonstrate the importance of early recognition of signs of cardiac arrest and factors impacting survival outcomes. This statement also discussed mandating of CPR training including the use of AEDs in high schools, in addition to training of lay people in the community. In a Slovenian study on CPR training in school children, the youngest age group (12.5 years) made the most progress in CPR knowledge, thus highlighting the value of starting training and instilling a sense of social responsibility early [ 16 ]. This is comparable to several other countries such as Japan, Austria, Hong Kong, Singapore, and Norway where CPR and AED courses are integrated into secondary school curricula [ 17 ].

As expected, prior knowledge of CPR varied among populations. This can be explained by differing stages of life and variations in work, school, and living environments that result in different levels of exposure to information about CPR. Compared to the proportion of participants who reported prior knowledge of CPR, the proportion of those who considered their knowledge sufficient was roughly half; this is consistent with multiple studies. For instance, in a study conducted at a medical school in Oman, 53.6% and 64.5% of 304 medical students had insufficient knowledge and no previous BLS training, respectively [ 18 ]. In another observational study, comprised of 121 participants including nurses, dental personnel, and house officers, it was found that the average health care worker lacked sufficient BLS and CPR knowledge [ 19 ]. This may be remedied by providing initial training and refresher programs with strategies that promote knowledge retention. Recent studies have highlighted the importance of high-quality resuscitation training. For example, Dudziński et al. [ 20 ] analyzed the quality of CPR performed by firefighters and found significant insights into compression quality under physical strain. Leszczyński et al. [ 21 ] evaluated the use of virtual environments for CPR training, demonstrating the potential of multimedia methods. Sholokhova et al. [ 22 ] examined CPR knowledge among pedagogy students, providing valuable data on the effectiveness of training programs for non-healthcare professionals. A prospective study conducted in Slovenia on schoolchildren demonstrated a more marked drop in retention of practice CPR skills compared to theoretical knowledge; they recommended putting a greater emphasis on practical training combined with a quick theoretical overview on repeat courses [ 23 ]. This can be implemented to empower individuals following initial training to be able to initiate CPR measures as a bystander.

In our review, we found that 13 included studies have organized their questionnaires in line with the American Heart Association (AHA) guidelines and one study in line with the European Resuscitation Council (ERC) guidelines. While the AHA guidelines are often referenced due to their global influence, the ERC guidelines are also significant in this region. Studies have shown that the adoption of resuscitation guidelines in the Middle East can be influenced by regional collaborations and the availability of training resources [ 24 , 25 ].

Another finding in this meta-analysis was that 66% of participants over 10 studies reported knowledge of the EMS contact number, with only 34% over 7 studies activating EMS when encountering an unconscious person. One factor that may be contributing to this difference may be that participants simply had never found themselves in such a situation; for instance, in our study, only 18% of individuals over 14 studies had encountered a case requiring CPR. However, it is alarming that there is not a larger proportion of the population is aware of the EMS number. This is unfortunately consistent with other studies conducted in the area. A study in Saudi Arabia conducted on security personnel in shopping malls showed that more than half of the participants (54.1%) did know the correct EMS number in Saudi Arabia [ 17 ]. A study in Iran in non-institutionalized older adults demonstrated that 47% were not familiar with the EMS system and thus, how to implement it [ 26 ]. They cited a low public awareness and high rate of illiteracy as contributing factors. Given that recognition and subsequent activation of the emergency response system is the first step of the chain of survival, knowledge of the EMS number and how to activate the response is imperative. Future endeavors should focus on increasing public awareness of the role, availability, and contact of local EMS.

Several studies have discussed the outcomes and modifying factors of OHCA in Middle Eastern countries. Ethnicity has been evaluated by Awad et al. [ 27 ] in a Qatari population as a possible influencing factor on the prognosis of OHCA cases and they found that North African patients had lower risk factors, more favorable rhythms and better survival rates as they were more likely to receive advanced cardiac life support (ACLS) interventions. On the other hand, another study found sex-based difference in the outcomes of OHCA cases with lower incidence of OHCA in public places among female patients; moreover, female patients were less likely to receive bystander CPR compared to male patients [ 28 ]. Alqahtani et al. [ 29 ] performed a prospective observational study of OHCA cases that were treated by the ambulance services in United Arab Emirates; they reported low bystander response rate -with only half of OHCA cases being recognized- and low AED usage rate.

This meta-analysis compiled results regarding CPR technique defined by correct compression to ventilation ratio, compression depth, compression rate, location of chest compression, and correct sequence. The overall results from this meta-analysis showed that, of these factors, compression rate and depth were the two factors that were most often administered incorrectly. This is supported by a study conducted in Saudi Arabia in which participants’ most common misconceptions included the adult compression rate (90.8%) and the compression depth (84.5%) [ 17 ]. This represents an area for improvement as these two factors, when within target ranges, are correlated with recovery with good neurologic function after OHCA [ 30 ]. The AHA recommends a target compression rate of 100–120 per minute and a depth of at least 5 cm for adult patients [ 31 ]. However, it is important to note that these factors affect one another; for instance, a faster compression rate can compromise the compression depth. Furthermore, it has been postulated that the recommended depth is too high and that maximal survival is at a depth of 45.6 mm [ 32 ]. A study in 2019 sought to find an ideal combination target for these two factors and recommended a combination of 107 compressions per minute and a depth of 4.7 cm [ 30 ]. In a prospective study on school children examining retention of CPR skills, hand location was well adapted as were the depth and release of the compressions, but compression rate was noted to be most out of the desired range, too slow on average [ 16 ]. With this information in mind, future training programs should implement strategies to highlight the ideal combination of compression rates and depth to learners to ensure correct and efficacious delivery of CPR.

Limitations

This study has several limitations. Many included studies were cross-sectional and relied on self-reported data, which may introduce bias as individuals may not accurately report their own knowledge and proficiency in CPR. The exclusion of studies without separable data for non-healthcare workers might limit the comprehensiveness of our analysis. Additionally, the variations in first aid education programs across different countries may impact the generalizability of our findings. Future studies should aim to include a broader range of data sources and consider longitudinal designs to better assess the impact of CPR training over time [ 33 , 34 ]. Another limitation may stem from the fact that all the studies included in this meta-analysis were conducted in Arab countries; as such, this may limit the generalizability of the results to the rest of the world, given that several cultural and demographic factors might influence the results.

Future direction

We are encourage future studies to assess the knowledge, awareness, and perception (KAP) before and after CPR training, including long-term follow-up, and to investigate possible associated factors that impact BLS KAP and CPR performance. This information will aid in identifying lapses and areas for improvement to ensure better performance – and outcomes – following CPR training. In addition to this, we are shedding a spotlight on the importance of adoption of national policies that should prioritize the quality and accessibility of BLS education, not only to healthcare providers, but to the general population.

As expected, prior knowledge of CPR varied between different groups of participants. This can be explained by differing stages of life and variations in work, school, and living environments that result in different levels of exposure to information about CPR. This meta-analysis also compiled results with regards to CPR technique defined by correct compression to ventilation ratio, compression depth, compression rate, location of chest compression, and correct sequence. The overall results from this meta-analysis showed that, of these factors, compression rate and depth were the two factors that were most often administered incorrectly. future training programs should implement strategies to highlight the ideal combination of compression rates and depth to learners to ensure correct and efficacious delivery of CPR with increased focus on the practical portion during refresher courses to promote retention. In all, the results from this study demonstrated that CPR training in Arab countries was favorably viewed overall with the majority of non-healthcare participants indicating both support for mandatory CPR training and general willingness to attending training if offered the opportunity. Given the overall positive view and willingness to learn CPR skills, healthcare policy makers should adopt a more comprehensive focus on strategies that enhance the accessibility and opportunity for CPR training for non-healthcare populations in Arab countries.

Availability of data and materials

The datasets generated or analyzed in this manuscript are provided either in the main text of the article or the supplementary file.

Abbreviations

Cardiopulmonary resuscitation

American Heart Association

Advanced cardiovascular life support

Knowledge, attitude, and perceptions

Basic Life Support

Newcastle–Ottawa quality assessment scale

Confidence interval

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Mohammed Alsabri Hussein Alsabri

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Mohammed Alsabri Hussein (MA) along with Basel F. Alqeeq (BA) are considered as the first authors as they participated in the screening and the selection of the studies, contributed to the conception, formulation, drafting of the article, reviewed and revised the manuscript. MA* is the corresponding author who proposed the project and wrote the study protocol. Mohamed Sayed Zaazouee (MSZ) assisted with writing the protocol, conducted the literature search, and helped with data analysis. MSZ and Alaa Ahmed Elshanbary (AAE) participated in the screening of the studies. BA and YS (Youssef Soliman) helped with the data extraction, quality assessment of the included studies, and critical revision. YS conducted the data analysis, and participated in writing and revison the final manuscript. Rebecca Yu (RY) participated in writing and revision of the final manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Alsabri, M.A.H., Alqeeq, B.F., Elshanbary, A.A. et al. Knowledge and skill level among non-healthcare providers regarding cardiopulmonary resuscitation (CPR) training in the Middle East (Arab countries): a systematic review and meta-analysis. BMC Public Health 24 , 2081 (2024). https://doi.org/10.1186/s12889-024-19575-7

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Navigating New Territories: A Systematic Review of the Transition Experiences of International Medical Graduates in English-Speaking Countries

• Published: 30 July 2024

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• Yoshito Nishimura   ORCID: orcid.org/0000-0003-0224-7501 1 , 2 ,
• Arvin Tan 1 ,
• Bryan Brown 1 ,
• Masayuki Nogi 1 ,
• Travis Watai 1 ,
• Richard T. Kasuya 1 &
• Christina Chong 1  

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To summarize the evidence related to the experiences and challenges of International Medical Graduates (IMGs) in healthcare systems of English-speaking countries.

Following the PRISMA statement, we searched MEDLINE and EMBASE for all peer-reviewed articles using keywords including “international medical graduates,” “foreign medical graduates,” or “transition,” from their inception to December 21st, 2022.

In this review, we included 20 articles, comprising 17 descriptive studies and three quasi-experimental studies. These studies highlight the challenges centered around communication skills and languages including the use and meaning of slang, health system differences, cultural distinctions such as varying patient expectations, and the prevalence of biases and preconceived notions about IMGs.

This systematic review summarizes the current evidence related to IMGs’ transition into healthcare systems in English-speaking countries. Despite the limited quality of available studies, several common issues were identified, including communication skills and language proficiency, cultural understanding, and system-related themes. To improve the experiences of IMGs and the quality of patient care, clinical educators, and residency program leaders may need to provide targeted needs assessments, focused orientations, and year-round programs.

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Nishimura, Y., Tan, A., Brown, B. et al. Navigating New Territories: A Systematic Review of the Transition Experiences of International Medical Graduates in English-Speaking Countries. Med.Sci.Educ. (2024). https://doi.org/10.1007/s40670-024-02126-5

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Abstract: Background: Cancer disparities persist in the United States, with significant variations in incidence, mortality, and survival rates across different population groups. This systematic review aims to synthesize current evidence on the relationship between social determinants of health and cancer disparities, and to identify effective interventions for promoting equitable cancer prevention and control. Methods: We conducted a systematic search of PubMed, Embase, and Cochrane Library databases for peer-reviewed articles published between 2010 and 2024. Studies were included if they examined the association between social determinants (e.g., socioeconomic status, race/ethnicity, education, healthcare access) and cancer outcomes, or evaluated interventions addressing these factors. Two independent reviewers screened articles, extracted data, and assessed study quality using standardized tools. Results: Of 3,247 initially identified studies, 142 met inclusion criteria. The review found strong evidence linking various social determinants to cancer disparities, particularly in screening rates, stage at diagnosis, and survival outcomes. Socioeconomic status and healthcare access were the most frequently studied determinants. Effective interventions identified included patient navigation programs, community-based education initiatives, and policy changes to expand insurance coverage. However, the quality and long-term impact of many interventions were limited by short follow-up periods and small sample sizes. Conclusion: This systematic review confirms the significant role of social determinants in perpetuating cancer disparities and highlights promising strategies for addressing these inequities. Future research should focus on developing and evaluating multilevel interventions that target both individual and structural determinants. Policy makers and healthcare providers should prioritize evidence-based approaches to reduce social barriers and promote equitable cancer prevention and control.

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A reflection on the value of participating in a journal club: Early findings from a transition to practice program

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Effectiveness of school-based health promotion interventions prioritized by stakeholders from health and education sectors: A systematic review and meta-analysis

Julia dabravolskaj.

a School of Public Health, University of Alberta, Edmonton, Canada

Genevieve Montemurro

John paul ekwaru, kate storey, sandra campbell.

b John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada

Paul J. Veugelers

Arto ohinmaa, associated data.

Childhood obesity and associated modifiable risk factors exert significant burden on the health care system. The goal of this systematic review and meta-analysis was to examine the effectiveness of school-based intervention types perceived by Canadian stakeholders in health and education as feasible, acceptable and sustainable in terms of improving physical activity (PA), fruit and vegetable intake, and body weight. We searched multiple databases for studies that evaluated school-based interventions to prevent obesity and associated risk factors (i.e., unhealthy diet, physical inactivity, sedentary behaviour) in children aged 4–18 years from January 1, 2012 to January 28, 2020. From 10,871 identified records, we included 83 and 80 studies in our systematic review and meta-analysis, respectively. Comprehensive School Health (CSH) and interventions which focused on modifications to school nutrition policies showed statistically significant positive effects on fruit intake of 0.13 (95% CI: 0.04, 0.23) and 0.30 (95% CI: 0.1, 0.51) servings per day, respectively. No intervention types showed statistically significant effect on vegetable intake. CSH, modifications to physical education (PE) curriculum, and multicomponent interventions showed statistically significant difference in BMI of −0.26 (95% CI: −0.40, −0.12), −0.16 (95% CI: −0.3, −0.02), and −0.18 (95% CI: −0.29, −0.07), respectively. CSH interventions showed positive effect on step-count per day, but no other types of interventions showed significant effect on any of PA outcome measures. Thus, the results of this systematic review and meta-analysis suggest that decision-makers should carefully consider CSH, multicomponent interventions, modifications to PE curricula and school nutrition policies to prevent childhood obesity.

1. Introduction

Physical inactivity and unhealthy diet are established risk factors that increase the odds of childhood overweight and obesity 3.5- ( McGavock et al., 2009 ) and 2-fold ( Dubois et al., 2007 ). As a result of more than 80% of adolescents worldwide being inactive ( World Health Organization, 2018 ) and only a negligible minority of them consuming the recommended intake of vegetables and fruits ( World Health Organization, 2003 ), over 340 million children and adolescents aged 5–19 had overweight or obesity in 2016 ( World Health Organization, 2018 ). In developed countries, the prevalence of overweight and obesity has increased substantially over the past three decades: from 16.9% in boys and 16.2% in girls in 1980 to 23.8% and 22.6%, respectively, in 2013 ( Ng et al., 2014 ). Due to its prevalence and deleterious consequences in later life, childhood obesity and associated modifiable risk factors exert significant burden on the health care system ( Tremmel et al., 2017 ).

To improve diet and physical activity (PA) and curb rising obesity rates among children, various jurisdictions have focused efforts and resources on school-based health promotion interventions which have been lauded as an effective approach since they reach a wide range of children over a prolonged period of time ( Fung et al., 2012 ). Previous systematic reviews focused on evaluating school-based interventions in terms of their effectiveness ( Wang et al., 2015 , Harris et al., 2009 , Hynynen et al., 2016 , Brown and Summerbell, 2009 , Katz et al., 2008 , Safron et al., 2011 , da Silveira et al., 2013 ). A systematic review of 139 obesity prevention interventions showed significant effects on both body mass index (BMI) z scores and BMI, with interventions that involve multiple components appearing more promising ( Wang et al., 2015 ). For example, Harris et al. (2009) found that interventions targeting only physical activity (PA) failed to improve BMI in children. Katz et al. (2008) previously reached the same conclusion and showed a significant positive effect on body weight reduction of interventions combining PA and healthy diet.

Despite the valuable contribution of these knowledge syntheses to our understanding of efficacy and effectiveness of such interventions, they lack information about feasibility, acceptability, sustainability, cost-effectiveness, and return on investment of these interventions. To circumvent this gap and to equip decision-makers with relevant and actionable information, we took a novel approach to conducting a systematic review. We facilitated focus group discussions with stakeholders in health and education sectors to determine which school-based health promotion intervention types were perceived as the most feasible, acceptable, and sustainable in the Canadian context ( Montemurro et al., 2018 ). The goal of the present systematic review and meta-analysis was to examine the effectiveness of interventions that belonged to the prioritized types, for specific outcomes (i.e., PA, fruit and vegetable [FV] intake, and adiposity) that were selected to guide the future step: assessing cost-effectiveness and return on investment of these interventions to fully inform decision makers.

2.1. Identification of priority areas through facilitated focus groups

We used participatory qualitative research methods to convene a group of 45 Canadian stakeholders with expertise and prolonged engagement in school health. They included practitioners working directly with school communities (e.g., educators, administrators), government employees within health and education ministries, and researchers in education, public health, nutrition, and kinesiology, sport and recreation. Participants were led through facilitated discussions to review and define all responses, and build group consensus on the most important key considerations to inform prioritization of the intervention types, such as research/evidence based, sustainability, acceptability, feasibility, and whole-school/comprehensive. Stakeholders identified and prioritized through a cumulative voting exercise the following 7 school-based intervention types (in rank order) ( Montemurro et al., 2018 ):

• • Interventions based on the comprehensive school health (CSH) approach with a focus on increasing PA, decreasing sedentary behaviour, and promoting healthy eating through changes to the whole school community;
• • Interventions based on modifications of school nutrition policies (e.g., implementation of competitive food policies);
• • Universal school food program interventions that promote involvement of children in food production (e.g., school gardens), preparation (e.g., school kitchens), and waste management;
• • Interventions that increase provision of healthy foods in schools with the active involvement of food suppliers and food service staff to ensure the availability and appeal of healthy food choices;
• • Interventions involving modifications of the existing physical education (PE) classes delivered by PE specialists, in terms of their duration and/or quality;
• • Promotion of PA outside of PE classes (e.g., changing the school environment to increase active and/or unstructured play);
• • Interventions changing foods/drinks sold and/or served in schools through installment of water fountains, banning unhealthy foods and beverages, and changing options offered by vending machines.

2.2. Search strategy

In partnership with a librarian, we executed a search in PROSPERO, OVID Medline, OVID EMBASE, OVID PsycINFO, OVID ERIC, Cochrane Database of Systematic Reviews <2005>, EBSCO CINAHL, Proquest Dissertations and Theses Global databases, using controlled vocabulary (e.g., MeSH, Emtree) and key words representing the concepts “obesity” and “school based interventions”. Studies situated in daycares and other out-of-school programs were excluded. Searches were limited to January 1, 2012 to January 28, 2020, since a comprehensive review on school-based obesity prevention programmes from inception to April 2013 was previously conducted by Wang et al. (2015) Articles considered by Wang et al. (2015) were included at the abstract review stage if they reported on dietary, PA, or adiposity outcome measures, and were school-based intervention studies. No other limits were applied. The search strategy syntax adapted for all databases is available in Supplementary Table 1A. Database of researcher-identified literature and trial Registries ( https://.clinicaltrials.gov and http://www.who.int/ictrp/en/ ) were also searched for relevant grey literature.

2.3. Eligibility criteria

The search focused on comparative studies that evaluated school-based interventions to prevent obesity and associated risk factors (i.e., unhealthy diet, physical inactivity, sedentary behaviour) in school-aged children (4–18 years old). Non-comparative studies and those interventions that targeted children who were overweight or obese at baseline were excluded. To ensure that identified studies were appropriate to the Canadian context, we included only those conducted in countries with human development index of 0.80 or greater ( United Nations Development Programme, 2017 ). Additionally, the identified interventions had to include outcome assessment at least 6 months following the baseline assessment and had to include information on the following outcomes: FV intake (servings or times per day), PA (minutes of moderate to vigorous physical activity [MVPA] and step counts), and/or adiposity (BMI, BMI z-score, BMI percentile, % overweight and/or obese).

2.4. Data abstraction and management

Articles were uploaded into systematic review data management software Covidence (Veritas Health Innovation Ltd.). Following duplicate removal, two research assistants independently reviewed titles and abstracts; any discrepancies were resolved by a third reviewer. Research assistants followed an exclusion criteria decision tree to define the exclusion reason for studies (Supplementary Table 1B). During full text review, reviewers independently tagged articles relevant to the 7 prioritized types to be considered for data extraction. Interventions with 1 or more of the 7 prioritized types of interventions and/or additional intervention components were considered multicomponent .

Four research assistants were involved (at different points in time) in extracting the following data: program/policy type; authors; title; country; study design; study duration; intervention setting and description of delivery; sample size and characteristics; and detailed results on the aforementioned outcome measures. The accuracy of the extracted data was then checked by two other research assistants.

2.5. Quality assessment

We assessed the methodological quality of included studies using the Downs and Black checklist ( Downs and Black, 1998 ). Similar to Wang et al. (2015) we included 7 questions in our assessment: 1) Is the hypothesis/aim/objective of the study clearly described? 2) Are the main outcomes to be measured clearly described in the introduction or methods? 3) Are the characteristics of the study subjects clearly described? 4) Are the interventions of interest clearly described? 5) Are the main findings of the study clearly described? 6) Were study subjects randomized to intervention groups? 7) Was the randomized intervention assignment concealed from both subjects and those conducting the study until recruitment was complete and irrevocable?

Papers were considered of low methodological quality if they did not do or describe more than 3 of the above items and were excluded from further analysis. Additional questions were used to assess the validity and reliability of each outcome measure. Measures of FV intake were considered valid and reliable if studies cited sources demonstrating the accuracy of the outcome measure; and PA and adiposity outcomes—if they described the use of objective instruments.

2.6. Data synthesis

For each included study, we collected the following information: first author, year of publication, area/country, program name, settings, study designs, duration of the intervention and follow-up time points, sample size, age group targeted by the intervention, and criteria used for subgroup analysis (if conducted). We examined randomized controlled trial (RCT) studies to obtain information about the unit of randomization and the number of intervention and control groups. In addition, we extracted data on effectiveness of interventions in terms of the outcomes of our interest. The effect measures included mean differences for continuous outcomes and odds ratios for categorical outcomes and the 95% confidence intervals.

We carried out meta-analysis using valid and reliable effect measures for each of the prioritized intervention types and did not attempt to combine effects across intervention types. Within each intervention type, we aggregated any 2 or more effects on the same outcome and same effect measure. All meta-analyses were done using a random effects model. For FV consumption, we combined studies that reported effects in terms of servings. To transform intake in grams and times per day, we used assumptions that each serving is 80 g ( World Health Organization, 2004 ) and servings per day and times per day are used interchangeably. The Cochrane Q and I 2 statistic were used to test the degree of heterogeneity. Publication bias was assessed by visual inspection of funnel plots and regression-based Egger test for small-study effects. The results were statistically significant when two-sided p values were less than 5%. All analyses were conducted in STATA v. 14 (Stata Corporation, College Station, Texas, USA). The review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines (Supplementary Table 1C).

3.1. Search results

A total of 10,301 records were identified through database searching and 570 additional records were identified through other sources (e.g., articles included and excluded by Wang et al. (2015) researcher identified studies), see PRISMA flow chart in Supplementary Fig. S1. The 83 studies included in final data extraction ( Table 1 ) were published between 2001 and 2020; 80 studies were included in meta-analysis. Studies represented 66 different school-based interventions implemented in 18 countries. Most studies were conducted in the United States (n = 17), followed by ten in Australia, eight in Canada, seven each in Denmark and Spain, six each in the United Kingdom (UK) and Norway, and New Zealand, four in Germany, two each in Ireland, Italy, Switzerland and France, and one in Belgium, Sweden, South Korea, and Israel.

Characteristics of included studies, grouped by stakeholders’ prioritized type.

a Considering the heterogeneity of reporting in the selected papers, we present all available information.

b Please note that the duration of the study was 3 years.

c Socioeconomic status (SES).

d Not included in the analysis.

3.2. Description of the included studies

Study numbers by prioritized intervention type were as follows: CSH approach (n = 18), modifications of school nutrition policies (n = 1), universal school food program (n = 2), provision of healthy foods in schools (n = 4), modifications of the existing PE curriculum (n = 18), promotion of PA outside of PE classes (n = 8), changing foods/drinks sold and/or served in schools (n = 3), and multicomponent interventions (n = 29). Risk of bias summary is shown in Table 2 . The sample size varied from 82 ( Harman, 2014 ) to 1,065,562 ( Schwartz et al., 2016 ) students. RCT design was employed in 56 studies, with school being the unit of randomization in 50 studies ( Table 3 ). The duration of the interventions ranged from three months ( Damsgaard et al., 2014 ) to seven years ( Rush et al., 2014 , Tarp et al., 2018 ). Most of the interventions (n = 35) lasted approximately 1 academic year and out of these intervention, 28 assessed only short-term impacts (e.g., at the end of the intervention as the latest time point), while only 3 studies included a follow-up period of 1 year ( Nogueira et al., 2017 , Farmer et al., 2017 , Dewar et al., 2013 ), and one each included a follow-up of 3 ( Meyer et al., 2014 ); 4 ( Hobin et al., 2017 ), and 7 ( Bere et al., 2014 ) years post-intervention. Forty-four papers reported subgroup analysis based on age group, sex, race/ethnicity, parental education, socioeconomic status, weight status, rurality, activity group, intervention school, school vs. non-school days and hours, and semesters.

Risk of bias summary.

Characteristics of the included RCTs.

FV intake outcomes of interest were reported in 18 studies; PA outcomes of interest in 28 studies (step-counts, n = 19, and MVPA, n = 19). The following adiposity outcomes were measured in 70 studies: BMI (n = 41), BMI z score (n = 35), BMI percentile (n = 7), and % obesity and/or overweight (n = 27).

Based on the statistical testing reported in the included studies, positive effect of the interventions on vegetable or fruit intake was noted in seven studies (five ( Waters et al., 2018 , Bjelland et al., 2015 , Alaimo et al., 2013 , Perry et al., 2004 , Llargues et al., 2011 ) and two ( Sahota et al., 2001 , Damsgaard et al., 2014 ) on fruit and vegetable intake, respectively, Table 4 ). Positive effect of the interventions on one of the PA outcome measures was noted in eight studies ( Bell et al., 2017 , Benden et al., 2014 , Donnelly et al., 2009 , Grydeland et al., 2013 , Kriemler et al., 2010 , Spencer et al., 2014 , Sutherland et al., 2016 , Vander Ploeg et al., 2014 ); two studies that reported no change for the total sample observed positive long-term effect ( Farmer et al., 2017 ) and effect in girls ( Grydeland et al., 2013 ). Positive effect of the interventions on at least one of the adiposity outcomes of interest was reported in 27 studies ( Ekwaru et al., 2017 , Millar et al., 2011 , Lazaar et al., 2007 , Sacchetti et al., 2013 , Azevedo et al., 2014 , Jansen et al., 2011 , Kriemler et al., 2010 , Hollis et al., 2016 , Story et al., 2012 , Marcus et al., 2009 , Aperman-Itzhak et al., 2018 , Bartelink et al., 2019 , Lubans et al., 2012 , Yang et al., 2017 , Ariza et al., 2019 , Scherr et al., 2017 , Fetter et al., 2018 , Erfle and Gamble, 2015 , Reed et al., 2013 , Klakk et al., 2013 , Learmonth et al., 2019, , Schwartz et al., 2016 , Muckelbauer et al., 2009 , Llargues et al., 2011 , Recasens et al., 2019 , Llargués et al., 2012 , Llargués et al., 2017 ); ten studies reported no changes for the total sample, but showed positive effect among girls ( Grydeland et al., 2014 ), boys ( Breheny et al., 2020 , Yang et al., 2017 ), low socioeconomic status (SES) groups ( De Coen et al., 2012 ), long-term ( Bere et al., 2014 , Bugge et al., 2012 , Hollis et al., 2016 , Adab et al., 2018 , Ickovics et al., 2019 ), incidence and prevalence of overweight (as opposed to obesity) ( Foster et al., 2008 ).

Effectiveness of the interventions in terms of adiposity, PA, and fruit and vegetable consumption outcomes as reported by the authors of the included studies.

“+” denotes positive effect on outcome; “ns” denotes non-significant effect on outcome; blank cells indicate outcome data was not measured or did not meet criteria.

a Increase in vegetable consumption according to the 24 h diary but not 3-day diary.

b ns for the total sample; + for girls.

c ns for the total sample; + for girls.

d ns for the total sample; + for girls.

e + overall; ns for boys.

f ns overall; + for the low-SES community.

g +in younger/ ns in older students.

h + for the HSAT and MSBE interventions; ns for SNAK team.

i ns for incidence and prevalence of overweight/obesity at T1 and T2; negative results for prevalence of obesity at T2 in the intervention group.

j ns at T1; negative results at T2 (i.e., statistically significant increase and decrease in BMI z-scores were observed in the intervention and control groups, respectively).

k ns at the 4-year follow-up; + at 8-year follow-up.

l ns differences for the change between groups; statistically significant positive changes within groups.

m + for elementary school girls; ns for elementary school boys and middle school students.

n + in total sample of overweight and normal weight kids; ns in both groups when stratified by sex.

o ns changes in BMI from baseline to postintervention; + change from baseline to follow up.

p ns for boys; negative trend in girls.

q ns difference between T1-T2 and T2-T3 (results for T1-T3 not presented).

r ns in the 1st year; + in the second year.

s ns in the total sample and boys; + in girls.

t + in the likelihood of being overweight; ns in being obese.

u + on the incidence and prevalence of overweight; ns for the incidence, prevalence, and remission of obesity and remission of overweight.

v ns at 12 months; + at 24 months follow-up.

w + for overweight; ns for obesity.

x ns at 15- and 30-month follow-up, but + at 39-month follow-up.

y + for T1 and T2 for Partial HPSF vs control, for T2 for Full HPSF vs. control; ns for T1 for Full HPSF vs. control.

z ns for Year 1 and + for Year 2 and 3 post-intervention (nutrition intervention); ns at Year 1, 2, and 3 post-intervention (physical activity intervention).

*+ in the total sample, normal weight children, boys, and elementary school students; ns in overweight and obese, girls, and middle school students.

** the outcome of interest was cumulative incidence rate of obesity.

3.3. CSH approach (n = 18)

From seven studies ( Sahota et al., 2001 , Waters et al., 2018 , Merrotsy et al., 2019 , Bjelland et al., 2015 , Malakellis et al., 2017 , Millar et al., 2011 , De Coen et al., 2012 ) which reported on FV consumption, positive changes were reported in two studies on fruit ( Waters et al., 2018 , Bjelland et al., 2015 ) and one study on vegetable ( Sahota et al., 2001 ) intake. Five studies ( Vander Ploeg et al., 2014 , Ofosu et al., 2018 , Grydeland et al., 2013 , O’Leary et al., 2019 , Toftager et al., 2014 ) reported on PA outcomes: one study ( Vander Ploeg et al., 2014 ) reported positive effect on step-counts; the other study ( Grydeland et al., 2013 ) reported improvement in step-counts in boys, no changes in MVPA in the total sample but positive changes in girls. Among the 14 studies ( Reed et al., 2008 , Ekwaru et al., 2017 , Ekwaru et al., 2017 , Ofosu et al., 2018 , Sahota et al., 2001 , Waters et al., 2018 , Grydeland et al., 2014 , Malakellis et al., 2017 , Millar et al., 2011 , De Coen et al., 2012 , Rush et al., 2012 , Rush et al., 2014 , Martínez-Vizcaíno et al., 2020 , O’Leary et al., 2019 , Merrotsy et al., 2019 ) that used one or more adiposity outcome measures, three ( Ekwaru et al., 2017 , Ekwaru et al., 2017 , Millar et al., 2011 , Rush et al., 2014 ) found a significant positive effect on at least one of the measures; nine ( Reed et al., 2008 , Malakellis et al., 2017 , Rush et al., 2012 , Ofosu et al., 2018 , Sahota et al., 2001 , Waters et al., 2018 , Martínez-Vizcaíno et al., 2020 , O’Leary et al., 2019 , Merrotsy et al., 2019 ) reported non-significant effects; and two ( Grydeland et al., 2014 , De Coen et al., 2012 ) reported mixed results with no changes in the total sample and positive changes in female students ( Grydeland et al., 2014 ) and those of low SES ( De Coen et al., 2012 ). No studies used BMI percentile as an outcome measure.

When combined, these interventions showed statistically significant difference in BMI of −0.26 (95% confidence interval [CI]: −0.4, −0.12), fruit intake of 0.13 servings/times per day (95% CI: 0.04, 0.23), and step-count per day (1155.76, 95% CI 449.77, 1861.75) ( Table 5 , Fig. S2). However, no statistically significant difference was found in BMI z score (−0.02, 95% CI: −0.04, 0.01), odds of being overweight (0.89, 95% CI: 0.58, 1.38) and obese (0.84, 95% CI: 0.64, 1.12) or overweight/obese (0.85, 95% CI: 0.71, 1.01), vegetable intake (0.12, 95% CI: −0.01, 0.25), step-count per minute (20.7, 95% CI: −46.23, 87.63) and MVPA (−0.67, 95% CI: −4.39, 3.05).

Summary results of the meta-analysis for the intervention effect by outcomes and the type of interventions.

Note: Subgroups that did not have at least 2 effect estimates are not shown.

§ Effect sizes are listed for the following outcomes (units of measures are listed in brackets): BMI (kg/m 2 , z score, percentile), overweight and obesity (odds for overweight, obesity, or both), step counts (per day, per minute), MVPA (minutes per day), fruit (servings or times per day), and vegetables (servings or times per day).

3.4. Modifications of school nutrition policies (n = 1)

A study by Alaimo et al. (2013 ) aimed to test the effectiveness of several interventions based on the Healthy School Action Tools (i.e., HSAT) on FV intake, but no data was available for PA and obesity outcomes of interest. This study reported significant positive effect on fruit intake in two intervention arms (i.e., HSAT only, and Michigan State Board of Education Nutrition policy), but not in the third one (i.e., School Nutrition Advances Kids Team). Increase in vegetable consumption was not significant. Meta-analysis of the three arms showed significant increase in the number of servings of fruits per day (0.30, 95% CI: 0.01, 0.51), but not vegetables (−0.02, 95% CI: −0.10, 0.06).

3.5. Universal school food program (n = 2)

Only interventions in two studies ( Polonsky et al., 2019 , Vik et al., 2019 ) were categorized as universal school food programs. None of the studies included FV intake or PA outcomes of interest. While both studies reported non-significant changes in BMI z scores and prevalence of overweight/obese in the total samples, Polonsky et al. (2019 ) and Vik et al. (2019 ) reported negative results for prevalence of obese in the intervention group BMI z score 12 months following the beginning of the intervention respectively.

Meta-analysis showed no significant difference between intervention and control groups in terms of BMI z score (0.05, 95% CI: −0.05, 0.15), odds of obesity (1.25, 95% CI: 0.94, 1.66) and overweight/obesity (1.21, 95% CI: 0.95, 1.55).

3.6. Provision of healthy foods in schools (n = 4)

Three ( Perry et al., 2004 , Bere et al., 2014 , Scherr et al., 2017 ) out of four ( Perry et al., 2004 , Bere et al., 2014 , Scherr et al., 2017 , Fetter et al., 2018 ) studies reported on FV consumption, but only one ( Perry et al., 2004 ) showed a statistically significant positive effect on fruit intake. Three studies reported on adiposity outcome measures: one ( Bere et al., 2014 ) showed no effect on BMI and prevalence of overweight/obese (with positive effect noted in long-term follow-up), while another study ( Scherr et al., 2017 ) found significant positive effects on BMI z scores, and two ( Scherr et al., 2017 , Fetter et al., 2018 ) studies showed positive effect on BMI percentile. Only one ( Fetter et al., 2018 ) study measured and reported non-significant changes in MVPA.

One ( Bere et al., 2014 ) study measured effect of the intervention on BMI score at two time points; aggregate effect measures of BMI (−0.33, 95% CI: −0.94, 0.28) were not significant, while effect measures were significantly different in terms of BMI percentile (−7.92, 95% CI: −16.53, 0.7). No data on PA or FV intake were pooled in the meta-analysis.

3.7. Modifications of existing PE curriculum (n = 18)

No studies reported on FV outcomes. None of the four studies ( Tarp et al., 2018 , Bugge et al., 2012 , Hobin et al., 2017 , Ten Hoor et al., 2018 ) reporting on PA outcomes showed a significant effect. Fifteen studies ( Lucertini et al., 2013 , Nogueira et al., 2017 , Erfle and Gamble, 2015 , Walther et al., 2009 , Müller et al., 2016 , Reed et al., 2013 , Klakk et al., 2013 , Learmonth et al., 2019, , Bugge et al., 2012 , Resaland et al., 2011 , Lazaar et al., 2007 , Thivel et al., 2011 , Weeks and Beck, 2012 , Sacchetti et al., 2013 , Hart, 2014 ) reported on adiposity outcomes of interest. Two studies ( Erfle and Gamble, 2015 , Sacchetti et al., 2013 ) showed positive effect on BMI and another study ( Bugge et al., 2012 ) reported positive long-term changes (as opposed to no short-term effect). One study ( Weeks and Beck, 2012 ) reported no changes in BMI for the total sample, but negative changes for girls. Positive changes on BMI percentile were noted in one study ( Reed et al., 2013 ) in female elementary school students (no effect for male elementary school students and male and female middle school students). One study ( Lazaar et al., 2007 ) showed positive effects on BMI z scores, and two studies ( Klakk et al., 2013 , Learmonth et al., 2019, ) showed positive effects on % overweight/obese, with no significant changes when stratified by sex ( Learmonth et al., 2019 ).

Meta-analysis showed statistically significant difference in BMI of −0.16 (95% CI: −0.3, −0.02) and odds of overweight/obesity 0.41 (95% CI: 0.23, 0.73), as opposed to no difference in BMI z score (0.0, 95% CI: −0.06, 0.06), BMI percentile (−0.68, 95% CI: −1.42, 0.06), odds of being obese (0.85, 95% CI: 0.51, 1.41), step-count per minute (10.5, 95% CI: −63.81, 84.81) and MVPA minutes per day (−1.47, 95% CI: −3.4, 0.46).

3.8. Promotion of PA outside of PE classes (n = 8)

Six studies ( Donnelly et al., 2009 , Ford et al., 2013 , Have et al., 2018 , Azevedo et al., 2014 , Farmer et al., 2017 , Benden et al., 2014 ) reported on PA outcomes: one study ( Donnelly et al., 2009 ) demonstrated positive effect on both PA outcomes and one study ( Farmer et al., 2017 ) demonstrated mixed results with positive effects noted one year after the end of the intervention but not immediately following the intervention. One study ( Azevedo et al., 2014 ) reported negative effects on total PA. From seven ( Breheny et al., 2020 , Have et al., 2018 , Donnelly et al., 2009 , Ford et al., 2013 , Harman, 2014 , Azevedo et al., 2014 , Farmer et al., 2017 ) studies reporting on adiposity outcomes, two studies reported statistically significant positive effect on BMI in the total sample ( Azevedo et al., 2014 ) and boys ( Breheny et al., 2020 ).

The studies included in meta-analysis showed no overall mean difference in any of the outcomes of interest: BMI (−0.18, 95% CI: −0.39, 0.04), BMI z score (0.01, 95% CI: −0.04, 0.02), step counts per minute (1.24, 95% CI: −1.62, 4.09), and MVPA (2.16, 95% CI: −3.91, 8.23).

3.9. Changing foods/drinks sold and/or served in schools (n = 3)

No studies reported on PA outcomes of interest. Only one study ( Damsgaard et al., 2014 ) measured FV intake, with positive effects reported only on vegetable intake. Two studies ( Schwartz et al., 2016 , Muckelbauer et al., 2009 ) reported significant changes in adiposity outcomes, and one study ( Schwartz et al., 2016 ) reported mixed results on prevalence of overweight and/or obese.

Meta-analysis showed no overall difference of this type of intervention on BMI z score (−0.01, 95% CI: −0.02, 0.01) and odds of being obese (0.96, 95%CI: 0.88, 1.05) or overweight/obese (0.96, 95% CI: 0.86, 1.06). Data on FV intake was not enough to pool in the meta-analysis.

3.10. Multicomponent interventions (n = 29)

Six studies ( Llargues et al., 2011 , Foster et al., 2008 , Story et al., 2012 , Bell et al., 2017 , Adab et al., 2018 , Ariza et al., 2019 ) evaluated FV intake, and only one ( Llargues et al., 2011 ) found significant positive effect on fruit intake. Two studies ( Foster et al., 2008 , Adab et al., 2018 ) reported no significant effect on combined FV consumption. Four ( Sutherland et al., 2016 ) out of twelve studies showed significant positive effect on PA outcomes. Twelve ( Jansen et al., 2011 , Kriemler et al., 2010 , Hollis et al., 2016 , Marcus et al., 2009 , Aperman-Itzhak et al., 2018 , Bartelink et al., 2019 , Lubans et al., 2012 , Yang et al., 2017 , Llargues et al., 2011 , Recasens et al., 2019 , Llargués et al., 2012 , Llargués et al., 2017 ) of 25 studies measuring adiposity outcomes reported significant positive effects, and three studies ( Foster et al., 2008 , Hollis et al., 2016 , Yang et al., 2017 ) reported mixed results based on the subgroup analysis.

Multicomponent interventions showed significant difference in BMI (−0.18, 95% CI: −0.29, −0.07), odds of being overweight (0.65, 95% CI: 0.49, 0.86), BMI z score (−0.04, 95% CI: −0.06, −0.01), BMI percentile (−0.8, 95% CI: −1.49, −0.1), but no difference in the odds of being obese (0.79, 95%CI: 0.51, 1.22) or overweight/obese (0.84, 95% CI: 0.65, 1.08), step-counts per day (−0.06, 95% CI: −1.02, 0.9) and per minute (0.27, 95% CI: −0.41, 0.95), and MVPA (0.18, 95% CI: −0.51, 0.87). Data was insufficient to perform meta-analysis on FV intake.

3.11. Publication bias

Based on the results of visual inspection of funnel plots and the regression-based Egger test for small-study effects (Supplementary Fig. S3), there is evidence suggesting potential publication bias for vegetable intake (p = 0.043) and odds of overweight and obesity (p = 0.006). However, we could not perform “trim and fill” analysis due to a small number of studies within each group of interventions, and therefore the pooled estimates obtained for these outcomes should be interpreted with caution.

4. Discussion

This systematic review with meta-analysis of effectiveness of school-based interventions focusing on preventing obesity and underlying lifestyle risk factors, was informed by facilitated group discussions among knowledgeable stakeholders who identified intervention types perceived as feasible, acceptable and sustainable in the Canadian context ( Montemurro et al., 2018 ). Among the 83 selected papers, the three most common types of interventions were those utilizing a CSH approach, modifications to existing PE curricula, and those with multiple components. While stakeholders identified universal school food programs and modifications of school nutrition policies as top priority interventions, very few studies fulfilling the inclusion criteria with extractable data were found. This finding illustrates the discrepancy between available evidence and evidence required to guide decision-making. To facilitate policy decisions related to school-based interventions, we encourage local policy-makers and stakeholders to engage with researchers when identifying, implementing, and evaluating interventions.

The CSH interventions and modifications of school nutrition policies had sufficient data on FV intake, allowing meta-analysis. Both interventions showed statistically significant positive effects on fruit intake, as opposed to not statistically significant effect on vegetable intake. This finding aligns with available evidence demonstrating preference for fruits ( Perry et al., 2004 ) and the practicality of eating fruits as snacks ( Bjelland et al., 2015 ).

CSH interventions showed statistically significant effect on step-count per day, but not on step-count per minute. None of the other three types of interventions showed statistically significant effect on PA outcome measures . Potential explanations related to the measurement of PA include social desirability bias if questionnaires are used; non-compliance with wearing devices ( Meyer et al., 2014 ) and considerable drop out due to data collection fatigue ( Spencer et al., 2014 ); and the inability of certain devices to accurately measure specific activities (e.g., free play activities ( Farmer et al., 2017 ). Moreover, there could be seasonal variations in PA patterns ( Santos et al., 2014 1 ) and comparatively high PA in the study sample at baseline ( Farmer et al., 2017 ). Potential explanations may include the lack of engagement of students and teachers at the intervention design stage, with subsequent implementation challenges. For example, similarly to Breheny et al. (2020 ) and Griffiths and Griffiths (2019 ), a recent study in 53 primary schools in the UK showed no significant effects of the intervention combining healthy eating and PA on any of the anthropometric, dietary, physical activity and psychological outcomes due to the fidelity of the program being compromised by a considerable lack of both compliance to the intervention protocol and teachers involvement due to competing demands ( Adab et al., 2018 ).

Meta-analysis showed that multicomponent, CSH approach-based, and modifications of the PE curricula are effective in improving obesity outcomes . These intervention types usually require approval and support of school system leaders promoting school-wide changes that may be better embedded, and in the case of PE curricula, often compulsory ( Connelly et al., 2007 ). However, as Hollis et al. (2016 ) noted, changes in adiposity outcomes might not be clinically significant at the individual level, but can still produce health benefits at the population level. In fact, even small changes in BMI z scores can point to a change in the increasing BMI trend typical for children and youth ( Bartelink et al., 2019 ), and slowing this trend is critically important for prevention of obesity later in life ( Goldschmidt et al., 2013 ).

There are certain limitations of the included studies that warrant discussion. While the majority of the studies utilized a cluster RCT design with comparatively large number of students, most often the number of schools that were randomized into each arm was small ( Sahota et al., 2001 ), which could result in the overestimation of the intervention effect ( Waters et al., 2018 ). Allocation concealment and masking of participants and assessors were impossible in all but one study ( Thivel et al., 2011 ), considering that interventions were too “obvious” ( Jansen et al., 2011 ). Control schools could not be forbidden to implement any interventions due to ethical concerns ( De Coen et al., 2012 , Alaimo et al., 2013 ), and intervention schools could modify interventions, leading to heterogeneity of intervention activities and their delivery and different levels of intervention dose ( Millar et al., 2011 , Breheny et al., 2020 ). Moreover, as was mentioned above, effectiveness of interventions when implemented in the real-world setting is often less than efficacy shown in RCTs, where interventions are often delivered by knowledgeable and skilled experts ( McCrabb et al., 2019 ). Quasi-experimental studies were prone to selection bias: underrepresented children tended to be overweight and obese ( Grydeland et al., 2014 , Millar et al., 2011 ), with migrant background ( Meyer et al., 2014 ), and with low SES ( De Coen et al., 2012 ). Most of the studies assessed effectiveness shortly or right after the end of the intervention. However, interventions might “serve as ‘catalyst’ to prolonged habitual changes” ( Maziekas et al., 2003 ) and significant long-term, despite non-significant short-term, effects were observed in several studies ( Bere et al., 2014 , Bugge et al., 2012 , Farmer et al., 2017 , Hollis et al., 2016 ).

While we focused on particular outcomes with the overarching goal to inform future economic modelling, the selected outcomes had certain pitfalls. For example, dietary assessment in children, especially when completed by parents who might not be aware of what their children eat at school ( De Coen et al., 2012 ), appears imprecise. De Coen et al. (2012) hypothesized that eating behaviours could have changed for the better during school hours, and therefore were not captured and assessed using parental questionnaires. Use of parental questionnaires to assess PA might also be subjective and prone to bias ( Vander Ploeg et al., 2014 ), just as well as measuring PA only during the school day ( Spencer et al., 2014 ). BMI as the primary measure for adiposity in children has also been criticized as it cannot change significantly over short periods of time ( Sahota et al., 2001 ) and depends on weight and height with no regard for the distribution of fat mass ( Weeks and Beck, 2012 ). Similarly, BMI z scores have low specificity, particularly in obese children and youth: in fact, Freedman et al. (2017) showed that BMI z score values could differ by more than one standard deviation simply because of differences in age or sex. A recent longitudinal observational study in 515 obese children corroborated findings of low specificity (42%) of BMI z score for predicting a decrease in % body fat, thus highlighting the limitations of using BMI z scores alone to monitor changes in adiposity ( Vanderwall et al., 2018 ). Despite this criticism, BMI for age is the most established diagnostic measure for childhood obesity. As Reilly (2006) noted, most of the currently used cutoffs appear adequate for using BMI in clinical practice and research. BMI is an inexpensive and easy-to-perform measure that correlates directly with body fat measurements ( Reed et al., 2013 ) and appears to be the most feasible screening tool in the multifaceted approach to childhood obesity prevention ( Parsons et al., 2014 ). The use of alternative BMI metrics, such as distance and % distance from median (including that on a log scale), has recently been proposed as those suitable for assessing BMI in all children, including overweight and obese ( Freedman ).

Several strengths and limitations need to be acknowledged. We conducted a comprehensive search of both peer-reviewed and grey literature. However, we focused on specific outcomes to keep the meta-analysis feasible. Further, some heterogeneity remained, which was particularly pronounced in multicomponent interventions that could contain any combination of intervention components, as long as at least one of them was prioritized. Hence, random-effects models were used to pull the results of the interventions together. Finally, it needs to be highlighted that, despite an innovative approach we took, the focus of this systematic review was on the effectiveness of school-based intervention types, prioritized by the perceived feasibility, acceptability and sustainability that emerged in facilitated discussions rather than detailed evaluation. While some may consider this a limitation, we view it as an innovative strategy to overcome the gaps in literature: future studies should include process evaluation measures to complement assessment of intervention effectiveness. Prioritization was guided by the Canadian context, and therefore generalization of our findings beyond Canada should proceed with caution. Nevertheless, our approach of identifying prioritized interventions can be freely adopted to other countries.

5. Conclusion

Among the papers identified in the review, only two were classified as universal food programs and one as modifications of school nutrition policies, thus highlighting the mismatch between the available research and required evidence to inform decision-making. Interventions based on the CSH approach and modifications of school nutrition policies showed positive effect on fruit intake, but not on vegetable intake. CSH interventions showed statistically significant positive effect on step-count per day, but not per minute; none of the other interventions appeared beneficial in terms of their effect on PA outcome measures. CSH-based, multicomponent, and interventions that consisted of modifications of the PE curricula appear effective in improving obesity outcomes.

This research was funded by an Alberta Innovates Collaborative Research and Innovative Opportunities Team grant.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

The present work was supported by an Alberta Innovates Collaborative Research and Innovation Opportunities (CRIO) Team grant (grant number 201300671) led by PJV and AO. PJV holds a Canada Research Chair in Population Health, an Alberta Research Chair in Nutrition and Disease Prevention, and an Alberta Innovates Health Scholarship. KS is a Distinguished Researcher, Stollery Children’s Hospital Foundation and member, Women and Children’s Health Research Institute.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.pmedr.2020.101138 .

Appendix A. Supplementary data

The following are the Supplementary data to this article:

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What’s the impact of safety footwear on workers concerning foot-related problems a systematic review.

1. Introduction

2. materials and methods, 2.1. search strategy and selection criteria, 2.2. study selection and data collection, 2.3. quality assessment, 2.4. data synthesis and analysis, 3.1. quality assessment, 3.2. population, 3.3. discomfort, 3.5. foot skin lesion, 3.6. safety footwear type and foot problems, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Arceri, A.; Mazzotti, A.; Liosi, S.G.; Zielli, S.O.; Artioli, E.; Golinelli, D.; Brognara, L.; Faldini, C. What’s the Impact of Safety Footwear on Workers Concerning Foot-Related Problems? A Systematic Review. Healthcare 2024 , 12 , 1522. https://doi.org/10.3390/healthcare12151522

Arceri A, Mazzotti A, Liosi SG, Zielli SO, Artioli E, Golinelli D, Brognara L, Faldini C. What’s the Impact of Safety Footwear on Workers Concerning Foot-Related Problems? A Systematic Review. Healthcare . 2024; 12(15):1522. https://doi.org/10.3390/healthcare12151522

Arceri, Alberto, Antonio Mazzotti, Sofia Gaia Liosi, Simone Ottavio Zielli, Elena Artioli, Davide Golinelli, Lorenzo Brognara, and Cesare Faldini. 2024. "What’s the Impact of Safety Footwear on Workers Concerning Foot-Related Problems? A Systematic Review" Healthcare 12, no. 15: 1522. https://doi.org/10.3390/healthcare12151522

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THE BEST Elektrostal Art Museums

Art museums in elektrostal.

• Art Museums
• Specialty Museums
• History Museums

1. Electrostal History and Art Museum

40 Facts About Elektrostal

Written by Lanette Mayes

Modified & Updated: 01 Jun 2024

Reviewed by Jessica Corbett

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

• Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
• With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy , materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes , offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development .

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy , with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

Elektrostal's fascinating history, vibrant culture, and promising future make it a city worth exploring. For more captivating facts about cities around the world, discover the unique characteristics that define each city . Uncover the hidden gems of Moscow Oblast through our in-depth look at Kolomna. Lastly, dive into the rich industrial heritage of Teesside, a thriving industrial center with its own story to tell.

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