research & reviews journal of educational studies

Research & Reviews: Journal of Educational Studies

• +447389646377
• Journal h-index : 7
• Journal cite score : 1.14
• Journal impact factor : 1.89
• Average acceptance to publication time (5-7 days)
• Average article processing time (30 - 45 days) Less than 5 volumes 30 days 8 - 9 volumes 40 days 10 and more volumes 45 days

Welcome to the Journal

About the journal.

Education in a broad sense is a system of learning where knowledge, values, beliefs, abilities, habits of a group are conveyed from one generation to the other by various modes of learning. Educational studies promote the analytical, critical and logical aspects of learning thereby leading to overall growth and development of an individual.

It enlightens the teaching fraternity to share the current educational practices, types of methodology, validations, examinations etc. This journal is a platform for students, teachers, research scholars and academicians to exchange their ideas.

To Submit manuscript, authors can use our Online Manuscript Submission or send us an e-mail attachment to the Editorial Office at [email protected]

The submission of manuscript would be considered under the specific branches of Education:

• Educational practices

• Examinations of new procedures

• Validations

• Administrations, counselors, supervisors, curriculum planners

• Literacy

• Methodology

• Sociology

• Trainings

• Debates

This is an open access journal where one can find scientific research as in form of research articles, review articles, case reports, special issues and short communications where it undergoes a series of steps to attain a standard and a unique scientific piece of research.

The Journal of Educational Studies is published biannually (Online and Print version) emphasizing on various educational studies, thereby providing an insight and wisdom to both the students as well as teachers. We invite researchers, academicians and worldwide scientists to share their research for the global enlightenment and benefit of academic community on an open access platform for one and all.

Fast Editorial Execution and Review Process (FEE-Review Process):

Research & Reviews: Journal of Educational Studies is participating in the Fast Editorial Execution and Review Process (FEE-Review Process) with an additional prepayment of $99 apart from the regular article processing fee. Fast Editorial Execution and Review Process is a special service for the article that enables it to get a faster response in the pre-review stage from the handling editor as well as a review from the reviewer. An author can get a faster response of pre-review maximum in 3 days since submission, and a review process by the reviewer maximum in 5 days, followed by revision/publication in 2 days. If the article gets notified for revision by the handling editor, then it will take another 5 days for external review by the previous reviewer or alternative reviewer.

Acceptance of manuscripts is driven entirely by handling editorial team considerations and independent peer-review, ensuring the highest standards are maintained no matter the route to regular peer-reviewed publication or a fast editorial review process. The handling editor and the article contributor are responsible for adhering to scientific standards. The article FEE-Review process of $99 will not be refunded even if the article is rejected or withdrawn for publication.

The corresponding author or institution/organization is responsible for making the manuscript FEE-Review Process payment. The additional FEE-Review Process payment covers the fast review processing and quick editorial decisions, and regular article publication covers the preparation in various formats for online publication, securing full-text inclusion in a number of permanent archives like HTML, XML, and PDF, and feeding to different indexing agencies.

Sociology of Education

It is mostly concerned with the public schooling systems of modern industrial societies, including the expansion of higher, further, adult, and continuing education. It is the study of how public institutions and individual experiences affect education and its outcomes. It is relatively a new branch and two great sociologists Émile Durkheim and Max Weber were the father of sociology of education.

Cross-Cultural Education

Cross-Cultural Education (CCE) places the student in an unfamiliar context through various educational settings including, but not limited to, academic and theological coursework, independent study and immersion encounters. Scholarly and theological pursuit of cross-cultural competencies is a critical aspect of a cross-cultural education, but so too is real-world encounter with diverse cultural locations and the people who live, work and worship there.

Educational Leadership

This term is often used synonymously with school leadership. It involves working with and guiding teachers towards improving educational processes in elementary, secondary and post secondary institutions. Education leaders work to improve educational programming. They are trained to advance and improve educational systems and create and enact policies.

Educational Evaluation

Educational evaluation is also a professional activity that individual educators need to undertake if they intend to continuously review and enhance the learning they are endeavouring to facilitate. There are two common purposes in educational evaluation which are, at times, in conflict with one another. It is the evaluation process of characterizing and appraising some aspects of an educational process.

Urban Education

Urban schools are at an extreme disadvantage, especially to the children who are attending these schools. Inequalities in education exist from the textbooks provided to the teacher qualification which in turn affects the quality of education that inner-city children are receiving. Neighbourhoods are being segregated by social class and the impoverished population is not getting the same educational opportunities as the suburban population.

Gender and Education

Gender-based discrimination in education is both a cause and a consequence of deep-rooted disparities in society. Poverty, geographical isolation, ethnic background, disability, traditional attitudes about their status and role all undermine the ability of women and girls to exercise their rights. Harmful practices such as early marriage and pregnancy, gender-based violence, and discriminatory education laws, policies, contents and practices still prevent millions of girls from enrolling, completing and benefitting from education. Gender must therefore be integrated at all levels of education, from early childhood to higher education, in formal and non-formal settings and from planning infrastructure to training teachers.

Educational Psychology

Educational psychology is concerned with children and young people in educational and early year’s settings. Educational psychologists tackle challenges such as learning difficulties, social and emotional problems and issues around disability as well as more complex developmental disorders. Educational psychology involves the study of how people learn, including topics such as student outcomes, the instructional process, individual differences in learning, gifted learners and learning disabilities.

Education Development

Development education in youth work aims to support young people to increase their awareness and intellect of the slavish trust and unequal world in which we live, through a process of interactive learning, debate, action and reflection. It involves justice perspective, linking local and global issues, nurturing imagination, using participative methodologies and empowerment through action.

Educational Technology

Improving global education through technology solutions. It is the effective use of technological tools in learning. It is not restricted to high technology. Educational technology includes numerous types of media that deliver text, audio, images, animation, and streaming video, and includes technology applications and processes such as audio or video tape, satellite TV, CD-ROM, and computer-based learning, as well as local intranet/extranet and web-based learning.

Education Policy

Education Policy is collection of laws and rules that govern the operation of education system. These are the principles and government policy-making in educational sphere. Education policy analysis is the scholarly study of education policy. It seeks to answer questions about the purpose of education, the objectives (societal and personal) that it is designed to attain, the methods for attaining them and the tools for measuring their success or failure.

*2023 Journal impact factor was established by dividing the number of articles published in 2021 and 2022 with the number of times they are cited in 2023 based on Google Scholar Citation Index database. If 'X' is the total number of articles published in 2021 and 2022, and 'Y' is the number of times these articles were cited in indexed journals during 2023 then, impact factor = Y/X

Articles published in Research & Reviews: Journal of Educational Studies have been cited by esteemed scholars and scientists all around the world. Research & Reviews: Journal of Educational Studies has got h-index 7 , which means every article in Research & Reviews: Journal of Educational Studies has got 7 average citations.

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Journal highlights, google scholar citation report, citations : 185.

Research & Reviews: Journal of Educational Studies received 185 citations as per Google Scholar report

Research & Reviews: Journal of Educational Studies peer review process verified at publons

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On The Site

Harvard educational review.

Edited by Maya Alkateb-Chami, Jane Choi, Jeannette Garcia Coppersmith, Ron Grady, Phoebe A. Grant-Robinson, Pennie M. Gregory, Jennifer Ha, Woohee Kim, Catherine E. Pitcher, Elizabeth Salinas, Caroline Tucker, Kemeyawi Q. Wahpepah

Individuals

Institutions.

• Read the journal here

Journal Information

• ISSN: 0017-8055
• eISSN: 1943-5045
• Keywords: scholarly journal, education research
• First Issue: 1930
• Frequency: Quarterly

Description

The Harvard Educational Review (HER) is a scholarly journal of opinion and research in education. The Editorial Board aims to publish pieces from interdisciplinary and wide-ranging fields that advance our understanding of educational theory, equity, and practice. HER encourages submissions from established and emerging scholars, as well as from practitioners working in the field of education. Since its founding in 1930, HER has been central to elevating pieces and debates that tackle various dimensions of educational justice, with circulation to researchers, policymakers, teachers, and administrators.

Our Editorial Board is composed entirely of doctoral students from the Harvard Graduate School of Education who review all manuscripts considered for publication. For more information on the current Editorial Board, please see here.

A subscription to the Review includes access to the full-text electronic archives at our Subscribers-Only-Website .

Editorial Board

2023-2024 Harvard Educational Review Editorial Board Members

Maya Alkateb-Chami Development and Partnerships Editor, 2023-2024 Editor, 2022-2024 [email protected]

Maya Alkateb-Chami is a PhD student at the Harvard Graduate School of Education. Her research focuses on the role of schooling in fostering just futures—specifically in relation to language of instruction policies in multilingual contexts and with a focus on epistemic injustice. Prior to starting doctoral studies, she was the Managing Director of Columbia University’s Human Rights Institute, where she supported and co-led a team of lawyers working to advance human rights through research, education, and advocacy. Prior to that, she was the Executive Director of Jusoor, a nonprofit organization that helps conflict-affected Syrian youth and children pursue their education in four countries. Alkateb-Chami is a Fulbright Scholar and UNESCO cultural heritage expert. She holds an MEd in Language and Literacy from Harvard University; an MSc in Education from Indiana University, Bloomington; and a BA in Political Science from Damascus University, and her research on arts-based youth empowerment won the annual Master’s Thesis Award of the U.S. Society for Education Through Art.

Jane Choi Editor, 2023-2025

Jane Choi is a second-year PhD student in Sociology with broad interests in culture, education, and inequality. Her research examines intra-racial and interracial boundaries in US educational contexts. She has researched legacy and first-generation students at Ivy League colleges, families served by Head Start and Early Head Start programs, and parents of pre-K and kindergarten-age children in the New York City School District. Previously, Jane worked as a Research Assistant in the Family Well-Being and Children’s Development policy area at MDRC and received a BA in Sociology from Columbia University.

Jeannette Garcia Coppersmith Content Editor, 2023-2024 Editor, 2022-2024 [email protected]

Jeannette Garcia Coppersmith is a fourth-year Education PhD student in the Human Development, Learning and Teaching concentration at the Harvard Graduate School of Education. A former public middle and high school mathematics teacher and department chair, she is interested in understanding the mechanisms that contribute to disparities in secondary mathematics education, particularly how teacher beliefs and biases intersect with the social-psychological processes and pedagogical choices involved in math teaching. Jeannette holds an EdM in Learning and Teaching from the Harvard Graduate School of Education where she studied as an Urban Scholar and a BA in Environmental Sciences from the University of California, Berkeley.

Ron Grady Editor, 2023-2025

Ron Grady is a second-year doctoral student in the Human Development, Learning, and Teaching concentration at the Harvard Graduate School of Education. His central curiosities involve the social worlds and peer cultures of young children, wondering how lived experience is both constructed within and revealed throughout play, the creation of art and narrative, and through interaction with/production of visual artifacts such as photography and film. Ron also works extensively with educators interested in developing and deepening practices rooted in reflection on, inquiry into, and translation of the social, emotional, and aesthetic aspects of their classroom ecosystems. Prior to his doctoral studies, Ron worked as a preschool teacher in New Orleans. He holds a MS in Early Childhood Education from the Erikson Institute and a BA in Psychology with Honors in Education from Stanford University.

Phoebe A. Grant-Robinson Editor, 2023-2024

Phoebe A. Grant-Robinson is a first year student in the Doctor of Education Leadership(EdLD) program at the Harvard Graduate School of Education. Her ultimate quest is to position all students as drivers of their destiny. Phoebe is passionate about early learning and literacy. She is committed to ensuring that districts and school leaders, have the necessary tools to create equitable learning organizations that facilitate the academic and social well-being of all students. Phoebe is particularly interested in the intersection of homeless students and literacy. Prior to her doctoral studies, Phoebe was a Special Education Instructional Specialist. Supporting a portfolio of more than thirty schools, she facilitated the rollout of New York City’s Special Education Reform. Phoebe also served as an elementary school principal. She holds a BS in Inclusive Education from Syracuse University, and an MS in Curriculum and Instruction from Pace University.

Pennie M. Gregory Editor, 2023-2024

Pennie M. Gregory is a second-year student in the Doctor of Education Leadership (EdLD) program at the Harvard Graduate School of Education. Pennie was born in Incheon, South Korea and raised in Gary, Indiana. She has decades of experience leading efforts to improve outcomes for students with disabilities first as a special education teacher and then as a school district special education administrator. Prior to her doctoral studies, Pennie helped to create Indiana’s first Aspiring Special Education Leadership Institute (ASELI) and served as its Director. She was also the Capacity Events Director for MelanatED Leaders, an organization created to support educational leaders of color in Indianapolis. Pennie has a unique perspective, having worked with members of the school community, with advocacy organizations, and supporting state special education leaders. Pennie holds an EdM in Education Leadership from Marian University.

Jennifer Ha Editor, 2023-2025

Jen Ha is a second-year PhD student in the Culture, Institutions, and Society concentration at the Harvard Graduate School of Education. Her research explores how high school students learn to write personal narratives for school applications, scholarships, and professional opportunities amidst changing landscapes in college access and admissions. Prior to doctoral studies, Jen served as the Coordinator of Public Humanities at Bard Graduate Center and worked in several roles organizing academic enrichment opportunities and supporting postsecondary planning for students in New Haven and New York City. Jen holds a BA in Humanities from Yale University, where she was an Education Studies Scholar.

Woohee Kim Editor, 2023-2025

Woohee Kim is a PhD student studying youth activists’ civic and pedagogical practices. She is a scholar-activist dedicated to creating spaces for pedagogies of resistance and transformative possibilities. Shaped by her activism and research across South Korea, the US, and the UK, Woohee seeks to interrogate how educational spaces are shaped as cultural and political sites and reshaped by activists as sites of struggle. She hopes to continue exploring the intersections of education, knowledge, power, and resistance.

Catherine E. Pitcher Editor, 2023-2025

Catherine is a second-year doctoral student at Harvard Graduate School of Education in the Culture, Institutions, and Society program. She has over 10 years of experience in education in the US in roles that range from special education teacher to instructional coach to department head to educational game designer. She started working in Palestine in 2017, first teaching, and then designing and implementing educational programming. Currently, she is working on research to understand how Palestinian youth think about and build their futures and continues to lead programming in the West Bank, Gaza, and East Jerusalem. She holds an EdM from Harvard in International Education Policy.

Elizabeth Salinas Editor, 2023-2025

Elizabeth Salinas is a doctoral student in the Education Policy and Program Evaluation concentration at HGSE. She is interested in the intersection of higher education and the social safety net and hopes to examine policies that address basic needs insecurity among college students. Before her doctoral studies, Liz was a research director at a public policy consulting firm. There, she supported government, education, and philanthropy leaders by conducting and translating research into clear and actionable information. Previously, Liz served as a high school physics teacher in her hometown in Texas and as a STEM outreach program director at her alma mater. She currently sits on the Board of Directors at Leadership Enterprise for a Diverse America, a nonprofit organization working to diversify the leadership pipeline in the United States. Liz holds a bachelor’s degree in civil engineering from the Massachusetts Institute of Technology and a master’s degree in higher education from the Harvard Graduate School of Education.

Caroline Tucker Co-Chair, 2023-2024 Editor, 2022-2024 [email protected]

Caroline Tucker is a fourth-year doctoral student in the Culture, Institutions, and Society concentration at the Harvard Graduate School of Education. Her research focuses on the history and organizational dynamics of women’s colleges as women gained entry into the professions and coeducation took root in the United States. She is also a research assistant for the Harvard and the Legacy of Slavery Initiative’s Subcommittee on Curriculum and the editorial assistant for Into Practice, the pedagogy newsletter distributed by Harvard University’s Office of the Vice Provost for Advances in Learning. Prior to her doctoral studies, Caroline served as an American politics and English teaching fellow in London and worked in college advising. Caroline holds a BA in History from Princeton University, an MA in the Social Sciences from the University of Chicago, and an EdM in Higher Education from the Harvard Graduate School of Education.

Kemeyawi Q. Wahpepah Co-Chair, 2023-2024 Editor, 2022-2024 [email protected]

Kemeyawi Q. Wahpepah (Kickapoo, Sac & Fox) is a fourth-year doctoral student in the Culture, Institutions, and Society concentration at the Harvard Graduate School of Education. Their research explores how settler colonialism is addressed in K-12 history and social studies classrooms in the United States. Prior to their doctoral studies, Kemeyawi taught middle and high school English and history for eleven years in Boston and New York City. They hold an MS in Middle Childhood Education from Hunter College and an AB in Social Studies from Harvard University.

Submission Information

Click here to view submission guidelines .

Contact Information

Click here to view contact information for the editorial board and customer service .

Subscriber Support

Individual subscriptions must have an individual name in the given address for shipment. Individual copies are not for multiple readers or libraries. Individual accounts come with a personal username and password for access to online archives. Online access instructions will be attached to your order confirmation e-mail.

Institutional rates apply to libraries and organizations with multiple readers. Institutions receive digital access to content on Meridian from IP addresses via theIPregistry.org (by sending HER your PSI Org ID).

Online access instructions will be attached to your order confirmation e-mail. If you have questions about using theIPregistry.org you may find the answers in their FAQs. Otherwise please let us know at [email protected] .

How to Subscribe

To order online via credit card, please use the subscribe button at the top of this page.

To order by phone, please call 888-437-1437.

Checks can be mailed to Harvard Educational Review C/O Fulco, 30 Broad Street, Suite 6, Denville, NJ 07834. (Please include reference to your subscriber number if you are renewing. Institutions must include their PSI Org ID or follow up with this information via email to [email protected] .)

Permissions

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Article Submission FAQ

Submissions, question: “what manuscripts are a good fit for her ”.

Answer: As a generalist scholarly journal, HER publishes on a wide range of topics within the field of education and related disciplines. We receive many articles that deserve publication, but due to the restrictions of print publication, we are only able to publish very few in the journal. The originality and import of the findings, as well as the accessibility of a piece to HER’s interdisciplinary, international audience which includes education practitioners, are key criteria in determining if an article will be selected for publication.

We strongly recommend that prospective authors review the current and past issues of HER to see the types of articles we have published recently. If you are unsure whether your manuscript is a good fit, please reach out to the Content Editor at [email protected] .

Question: “What makes HER a developmental journal?”

Answer: Supporting the development of high-quality education research is a key tenet of HER’s mission. HER promotes this development through offering comprehensive feedback to authors. All manuscripts that pass the first stage of our review process (see below) receive detailed feedback. For accepted manuscripts, HER also has a unique feedback process called casting whereby two editors carefully read a manuscript and offer overarching suggestions to strengthen and clarify the argument.

Question: “What is a Voices piece and how does it differ from an essay?”

Answer: Voices pieces are first-person reflections about an education-related topic rather than empirical or theoretical essays. Our strongest pieces have often come from educators and policy makers who draw on their personal experiences in the education field. Although they may not present data or generate theory, Voices pieces should still advance a cogent argument, drawing on appropriate literature to support any claims asserted. For examples of Voices pieces, please see Alvarez et al. (2021) and Snow (2021).

Question: “Does HER accept Book Note or book review submissions?”

Answer: No, all Book Notes are written internally by members of the Editorial Board.

Question: “If I want to submit a book for review consideration, who do I contact?”

Answer: Please send details about your book to the Content Editor at [email protected].

Manuscript Formatting

Question: “the submission guidelines state that manuscripts should be a maximum of 9,000 words – including abstract, appendices, and references. is this applicable only for research articles, or should the word count limit be followed for other manuscripts, such as essays”.

Answer: The 9,000-word limit is the same for all categories of manuscripts.

Question: “We are trying to figure out the best way to mask our names in the references. Is it OK if we do not cite any of our references in the reference list? Our names have been removed in the in-text citations. We just cite Author (date).”

Answer: Any references that identify the author/s in the text must be masked or made anonymous (e.g., instead of citing “Field & Bloom, 2007,” cite “Author/s, 2007”). For the reference list, place the citations alphabetically as “Author/s. (2007)” You can also indicate that details are omitted for blind review. Articles can also be blinded effectively by use of the third person in the manuscript. For example, rather than “in an earlier article, we showed that” substitute something like “as has been shown in Field & Bloom, 2007.” In this case, there is no need to mask the reference in the list. Please do not submit a title page as part of your manuscript. We will capture the contact information and any author statement about the fit and scope of the work in the submission form. Finally, please save the uploaded manuscript as the title of the manuscript and do not include the author/s name/s.

Invitations

Question: “can i be invited to submit a manuscript how”.

Answer: If you think your manuscript is a strong fit for HER, we welcome a request for invitation. Invited manuscripts receive one round of feedback from Editors before the piece enters the formal review process. To submit information about your manuscript, please complete the Invitation Request Form . Please provide as many details as possible. The decision to invite a manuscript largely depends on the capacity of current Board members and on how closely the proposed manuscript reflects HER publication scope and criteria. Once you submit the form, We hope to update you in about 2–3 weeks, and will let you know whether there are Editors who are available to invite the manuscript.

Review Timeline

Question: “who reviews manuscripts”.

Answer: All manuscripts are reviewed by the Editorial Board composed of doctoral students at Harvard University.

Question: “What is the HER evaluation process as a student-run journal?”

Answer: HER does not utilize the traditional external peer review process and instead has an internal, two-stage review procedure.

Upon submission, every manuscript receives a preliminary assessment by the Content Editor to confirm that the formatting requirements have been carefully followed in preparation of the manuscript, and that the manuscript is in accord with the scope and aim of the journal. The manuscript then formally enters the review process.

In the first stage of review, all manuscripts are read by a minimum of two Editorial Board members. During the second stage of review, manuscripts are read by the full Editorial Board at a weekly meeting.

Question: “How long after submission can I expect a decision on my manuscript?”

Answer: It usually takes 6 to 10 weeks for a manuscript to complete the first stage of review and an additional 12 weeks for a manuscript to complete the second stage. Due to time constraints and the large volume of manuscripts received, HER only provides detailed comments on manuscripts that complete the second stage of review.

Question: “How soon are accepted pieces published?”

Answer: The date of publication depends entirely on how many manuscripts are already in the queue for an issue. Typically, however, it takes about 6 months post-acceptance for a piece to be published.

Submission Process

Question: “how do i submit a manuscript for publication in her”.

Answer: Manuscripts are submitted through HER’s Submittable platform, accessible here. All first-time submitters must create an account to access the platform. You can find details on our submission guidelines on our Submissions page.

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Review of Educational Research

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• Description
• Aims and Scope
• Editorial Board
• Abstracting / Indexing
• Submission Guidelines

The Review of Educational Research ( RER , quarterly, begun in 1931; approximately 640 pp./volume year) publishes critical, integrative reviews of research literature bearing on education. Such reviews should include conceptualizations, interpretations, and syntheses of literature and scholarly work in a field broadly relevant to education and educational research. RER encourages the submission of research relevant to education from any discipline, such as reviews of research in psychology, sociology, history, philosophy, political science, economics, computer science, statistics, anthropology, and biology, provided that the review bears on educational issues. RER does not publish original empirical research unless it is incorporated in a broader integrative review. RER will occasionally publish solicited, but carefully refereed, analytic reviews of special topics, particularly from disciplines infrequently represented.

The Review of Educational Research publishes critical, integrative reviews of research literature bearing on education. Such reviews should include conceptualizations, interpretations, and syntheses of literature and scholarly work in a field broadly relevant to education and educational research. RER encourages the submission of research relevant to education from any discipline, such as reviews of research in psychology, sociology, history, philosophy, political science, economics, computer science, statistics, anthropology, and biology, provided that the review bears on educational issues. RER does not publish original empirical research, and all analyses should be incorporated in a broader integrative review. RER will occasionally publish solicited, but carefully refereed, analytic reviews of special topics, particularly from disciplines infrequently represented. The following types of manuscripts fall within the journal’s purview:

Integrative reviews pull together the existing work on an educational topic and work to understand trends in that body of scholarship. In such a review, the author describes how the issue is conceptualized within the literature, how research methods and theories have shaped the outcomes of scholarship, and what the strengths and weaknesses of the literature are. Meta-analyses are of particular interest when they are accompanied by an interpretive framework that takes the article beyond the reporting of effect sizes and the bibliographic outcome of a computer search.

Theoretical reviews should explore how theory shapes research. To the extent that research is cited and interpreted, it is in the service of the specification, explication, and illumination of a theory. Theoretical reviews and integrative reviews have many similarities, but the former are primarily about how a theory is employed to frame research and our understandings, and refer to the research as it relates to the theory.

Methodological reviews are descriptions of research design, methods, and procedures that can be employed in literature reviews or research in general. The articles should highlight the strengths and weaknesses of methodological tools and explore how methods constrain or open up opportunities for learning about educational problems. They should be written in a style that is accessible to researchers in education rather than methodologists.

Historical reviews provide analyses that situate literature in historical contexts. Within these reviews, explanations for educational phenomena are framed within the historical forces that shape language and understanding.

Commissioned reviews and thematic issues. The editors may commission and solicit authors to review areas of literature. In all other respects, commissioned reviews are subject to the same review process as submitted reviews. The editors also encourage readers to propose thematic topics for special issues and, as potential guest editors, to submit plans for such issues.

In addition to review articles, RER will occasionally publish notes and responses which are short pieces of no more than 1,200 words on any topic that would be of use to reviewers of research. Typically, they point out shortcomings and differences in interpretation in RER articles and policy.

The standards and criteria for review articles in RER are the following:

1. Quality of the Literature. Standards used to determine quality of literature in education vary greatly. Any review needs to take into account the quality of the literature and its impact on findings. Authors should attempt to review all relevant literature on a topic (e.g., international literature, cross-disciplinary work, etc.).

2. Quality of Analysis. The review should go beyond description to include analysis and critiques of theories, methods, and conclusions represented in the literature. This analysis should also examine the issue of access—which perspectives are included or excluded in a body of work? Finally, the analysis should be reflexive—how does the scholars’ framework constrain what can be known in this review?

3. Significance of the Topic. The review should seek to inform and/or illuminate questions important to the field of education. While these questions may be broad-based, they should have implications for the educational problems and issues affecting our national and global societies.

4. Impact of the Article. The review should be seen as an important contribution and tool for the many different educators dealing with the educational problems and issues confronting society.

5. Advancement of the Field. The review should validate or inform the knowledge of researchers and guide and improve the quality of their research and scholarship.

6. Style. The review must be well written and conform to style of the Publication Manual of the American Psychological Association (6th edition). Authors should avoid the use of unexplained jargon and parochialism.

7. Balance and Fairness. The review should be careful not to misrepresent the positions taken by others, or be disrespectful of contrary positions.

8. Purpose. Any review should be accessible to the broad readership of RER. The purpose of any article should be to connect the particular problem addressed by the researcher(s) to a larger context of education.

We also encourage all authors interested in submitting a manuscript to RER to read our Editorial Vision for more information on our publication aims.

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1. Publication Standards 2. Submission Preparation Checklist 3. How to Get Help With the Quality of English in Your Submission 4. Copyright Information 5. For authors who use figures or other materials for which they do not own copyright 6. Right of Reply 7. Sage Choice and Open Access

The Review of Educational Research (RER) publishes comprehensive reviews of literature related to education and does not publish new empirical work, except in the context of meta-analytic reviews of an area. Please check the journal’s Aims and Scope to see if your manuscript is appropriate to submit to RER.

All manuscripts should be submitted electronically to the editorial team at http://mc.manuscriptcentral.com/rer . For questions or inquiries about manuscripts, email us at [email protected] . Manuscripts may not be submitted via e-mail.

Publication Standards

Researchers who intend to submit studies for publication should consult the Standards for Research Conduct adopted by the AERA Council. We also recommend consulting (a) the Guidelines for Reviewers , which outline the criteria under which manuscripts are reviewed for publication by AERA and (b) recent previous editions of the journal. Individuals submitting systematic reviews or meta-analyses should also consult The PRISMA Statement ( http://www.prisma-statement.org ) as well the article on “Reporting Standards for Research in Psychology” in American Psychologist, 63 , 839 – 851 (doi:10.1037/0003-066X.63.9.839).

Submission Preparation Checklist

When you upload your initial submission, upload (1) a separate title page that is not anonymized. Please format the title page as described by the 7th edition of the APA Manual and (2) the main manuscript, which includes an ANONYMIZED title page, an abstract with keywords at the bottom, and the rest of the document including tables and figures, and finally (c) Author Bios.

Please ensure that your manuscript complies with the “ RER Formatting Requirements and Common Formatting Errors ” (see PDF on the RER website). If your submission does not meet these requirements, it will be returned to you.

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a Adjusted for age, sex, study center (random effect), body mass index, educational level, smoking status, physical activity, alcohol intake, urban vs rural location, history of diabetes, cardiovascular disease, cancer, use of statin or antihypertension medication, and intake of fruit, vegetables, red meat, poultry, dairy, and total energy.

Data are adjusted for age, sex, study center (random effect), body mass index, educational level, smoking status, physical activity, alcohol intake, history of diabetes, cardiovascular disease (CVD), cancer, use of statin or antihypertension medication, and intake of fruit, vegetables, red meat, poultry, and dairy. Fish with highest ω-3 levels included herring, mackerel, sable, salmon, tuna (steak), and sardine. Other fish with high ω-3 levels included anchovy, bluefish, oyster, tuna (can), salmon (can), and trout. Fish with lowest ω-3 levels included bass, barramundi, bream, flathead, flounder, perch, snapper, octopus, sword fish, tile fish, and shark. Shellfish included crab, lobster, scallop, and mussel. 30 HR represents hazard ratio.

Data adjusted for age, sex, study center (random effect), body mass index, educational level, smoking status, physical activity, alcohol intake, urban vs rural location, history of diabetes, cardiovascular disease, cancer, use of statin or antihypertension medication, and intake of fruit, vegetables, red meat, poultry, dairy, and total energy. LDL-C represents low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol.

eAppendix 1. Methods

eReferences.

eFigure 1. PURE Participants Included in These Analyses

eFigure 2. Median Fish Consumption (Grams per Week) by Geographic Region in PURE

eFigure 3. Mean Values of Other Cardiovascular Risk Markers by Level of Fish Intake in PURE

eFigure 4. Fish Intake and Mortality

eFigure 5. Fish Intake and Major Cardiovascular Disease

eTable 1. Fish Intake and Risk Markers in the ONTARGET/TRANSCEND and ORIGIN studies

eTable 2. Sensitivity Analyses of Associations of Fish Intake vs Composite of Death or Major CVD

eTable 3. Comparison of the Associations of Initial and Repeat Fish Intake Measures at 2-years vs Composite of Death or Major CVD Events in the ORIGIN Study

eTable 4. PURE Country Institution Names

• Error in Author Affiliation JAMA Internal Medicine Correction May 1, 2021
• Fishing for an Association With Sudden Cardiac Death—Reply JAMA Internal Medicine Comment & Response August 1, 2021 Andrew Mente, PhD; Mahshid Dehghan, PhD; Salim Yusuf, DPhil, FRCPC, FRSC
• Fishing for an Association With Sudden Cardiac Death JAMA Internal Medicine Comment & Response August 1, 2021 Emily R. Siegel, BS; Zian H. Tseng, MD, MAS
• Fish, Cardiovascular Disease, and Mortality JAMA Internal Medicine Invited Commentary May 1, 2021 Dariush Mozaffarian, MD, DrPH

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Mohan D , Mente A , Dehghan M, et al. Associations of Fish Consumption With Risk of Cardiovascular Disease and Mortality Among Individuals With or Without Vascular Disease From 58 Countries. JAMA Intern Med. 2021;181(5):631–649. doi:10.1001/jamainternmed.2021.0036

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Associations of Fish Consumption With Risk of Cardiovascular Disease and Mortality Among Individuals With or Without Vascular Disease From 58 Countries

• 1 Madras Diabetes Research Foundation and Dr. Mohan’s Diabetes Specialities Centre, Chennai, India
• 2 Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
• 3 Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
• 4 Department of Medicine, McMaster University, Hamilton, Ontario, Canada;
• 5 HRB-Clinical Research Facility, NUI Galway, Ireland
• 6 Université Laval Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada, G1V 4G5
• 7 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
• 8 Faculty of Health Sciences, and Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Vancouver, British Columbia, Canada
• 9 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
• 10 Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina
• 11 International Research Centre, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil, Universidade Santo Amaro (UNISA), Sao Paulo, SP Brazil
• 12 Masira Research Institute, Medical School, Santander University (UDES), Colombia
• 13 Universidad de La Frontera, Francisco Salazar, Temuco, Chile
• 14 St John’s Research Institute, Koramangala, Bangalore, India
• 15 School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
• 16 Health Action by People, Amrita Institute of Medical Sciences, Trivandrum, Kerala, India
• 17 Eternal Heart Care Centre and Research Institute, Rajasthan University of Health Sciences, Jaipur, India
• 18 Wroclaw Medical University, Department of Internal Medicine, 4th Military Hospital, Wroclaw, Poland
• 19 Department of Community Health Sciences and Medicine, Aga Khan University, Karachi Pakistan
• 20 Independent University, Bangladesh, Bashundhara, Dhaka, Bangladesh
• 21 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
• 22 Institute for Community and Public Health, Birzeit University, Birzeit, Palestine
• 23 Advocate Research Institute, Advocate Health Care, Chicago, Illinois
• 24 Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia, UCSI University, Cheras, Selangor, Malaysia
• 25 Cardiology Department, Ankara University Medical School, Ankara, Turkey
• 26 Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
• 27 Hatta Hospital, Dubai Health Authority, Dubai Medical University, Dubai, United Arab Emirates
• 28 Centre of Excellence for Nutrition, Faculty of Health Sciences, Potchefstroom, South Africa
• 29 Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
• 30 University of the Philippines, Ermita, Manila, Philippines
• 31 Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
• 32 Department of Medicine, Etherington Hall, Queen's University, Kingston, Ontario, Canada
• Invited Commentary Fish, Cardiovascular Disease, and Mortality Dariush Mozaffarian, MD, DrPH JAMA Internal Medicine
• Correction Error in Author Affiliation JAMA Internal Medicine
• Comment & Response Fishing for an Association With Sudden Cardiac Death—Reply Andrew Mente, PhD; Mahshid Dehghan, PhD; Salim Yusuf, DPhil, FRCPC, FRSC JAMA Internal Medicine
• Comment & Response Fishing for an Association With Sudden Cardiac Death Emily R. Siegel, BS; Zian H. Tseng, MD, MAS JAMA Internal Medicine

Question   Is there a difference in the association of fish consumption with risk of cardiovascular disease (CVD) or of mortality between individuals with and individuals without vascular disease?

Findings   In this analysis of 4 international cohort studies of 191 558 people from 58 countries on 6 continents, a lower risk of major CVD and total mortality was associated with higher fish intake of at least 175 g (2 servings) weekly among high-risk individuals or patients with vascular disease, but not in general populations without vascular disease; a similar pattern of results was observed for sudden cardiac death. Oily fish but not other types of fish were associated with greater benefits.

Meaning   Study findings suggest that fish intake of at least 175 g (2 servings) weekly is associated with lower risk of major CVD and mortality among patients with prior CVD, but not in the general population.

Importance   Cohort studies report inconsistent associations between fish consumption, a major source of long-chain ω-3 fatty acids, and risk of cardiovascular disease (CVD) and mortality. Whether the associations vary between those with and those without vascular disease is unknown.

Objective   To examine whether the associations of fish consumption with risk of CVD or of mortality differ between individuals with and individuals without vascular disease.

Design, Setting, and Participants   This pooled analysis of individual participant data involved 191 558 individuals from 4 cohort studies—147 645 individuals (139 827 without CVD and 7818 with CVD) from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study and 43 413 patients with vascular disease in 3 prospective studies from 40 countries. Adjusted hazard ratios (HRs) were calculated by multilevel Cox regression separately within each study and then pooled using random-effects meta-analysis. This analysis was conducted from January to June 2020.

Exposures   Fish consumption was recorded using validated food frequency questionnaires. In 1 of the cohorts with vascular disease, a separate qualitative food frequency questionnaire was used to assess intake of individual types of fish.

Main Outcomes and Measures   Mortality and major CVD events (including myocardial infarction, stroke, congestive heart failure, or sudden death).

Results   Overall, 191 558 participants with a mean (SD) age of 54.1 (8.0) years (91 666 [47.9%] male) were included in the present analysis. During 9.1 years of follow-up in PURE, compared with little or no fish intake (≤50 g/mo), an intake of 350 g/wk or more was not associated with risk of major CVD (HR, 0.95; 95% CI, 0.86-1.04) or total mortality (HR, 0.96; 0.88-1.05). By contrast, in the 3 cohorts of patients with vascular disease, the HR for risk of major CVD (HR, 0.84; 95% CI, 0.73-0.96) and total mortality (HR, 0.82; 95% CI, 0.74-0.91) was lowest with intakes of at least 175 g/wk (or approximately 2 servings/wk) compared with 50 g/mo or lower, with no further apparent decrease in HR with consumption of 350 g/wk or higher. Fish with higher amounts of ω-3 fatty acids were strongly associated with a lower risk of CVD (HR, 0.94; 95% CI, 0.92-0.97 per 5-g increment of intake), whereas other fish were neutral (collected in 1 cohort of patients with vascular disease). The association between fish intake and each outcome varied by CVD status, with a lower risk found among patients with vascular disease but not in general populations (for major CVD, I 2  = 82.6 [ P  = .02]; for death, I 2  = 90.8 [ P  = .001]).

Conclusions and Relevance   Findings of this pooled analysis of 4 cohort studies indicated that a minimal fish intake of 175 g (approximately 2 servings) weekly is associated with lower risk of major CVD and mortality among patients with prior CVD but not in general populations. The consumption of fish (especially oily fish) should be evaluated in randomized trials of clinical outcomes among people with vascular disease.

Dietary guidelines recommend at least 2 servings of fish per week for the prevention of cardiovascular disease (CVD). 1 , 2 Fish is a major source of the long-chain ω-3 fatty acids docosahexaenoic acid and eicosapentaenoic acid, which have been suggested to have beneficial effects on cardiovascular health. 3 - 5 In interventional studies, fish and ω-3 consumption have been shown to improve some cardiovascular risk markers, including triglycerides and blood pressure, especially in people with triglycerides of 500 mg/dL or greater (to convert to millimoles per liter, multiply by 0.0113). 6 , 7 Two recent meta-analyses of randomized trials in high-risk individuals showed that ω-3 supplementation (typically approximately 1 g/d) was not associated with risk of cardiovascular events, coronary heart deaths, coronary heart disease events, stroke, heart irregularities, or all-cause mortality. 8 , 9 By contrast, another recent meta-analysis 10 that included 3 new trials 11 - 13 showed that ω-3 supplementation was associated with significant benefit against risk of CVD outcomes (summary relative risk of 0.92; 95% CI, 0.86-0.98), 10 even after excluding a recent trial of patients with elevated triglyceride levels that used a much higher dose of fish oil (4 g daily). 13 Observational cohorts of participants without diagnosed vascular disease have found modest protective associations of moderate fish consumption (approximately ≥2 servings/wk) with fatal coronary heart disease (ie, summary relative risks in multiple meta-analyses ranging from 2% to 15% lower risk) and, usually less strongly, with total CVD. 14 To date, most cohort studies evaluating fish consumption and CVD events have been conducted in Europe, North America, Japan, and China, with little information from other world regions, where varying amounts and types of fish are consumed. Furthermore, whether the associations of fish consumption with CVD events vary between those with and those without vascular disease is unclear.

Because increasing fish intake may improve blood lipid levels, especially among high-risk individuals, 6 , 7 we hypothesized that there would be differences in the association between fish intake and major CVD outcomes and mortality among individuals with vascular disease compared with those without vascular disease. In the present pooled analysis, we studied 191 558 people (51 731 with vascular disease and 139 827 generally healthy individuals) from 58 countries who had been included as participants in 4 large prospective studies.

Details of the studies’ designs and population characteristics have been published before and are described in the eAppendix in the Supplement .

In brief, the Prospective Urban Rural Epidemiology (PURE) study 15 - 19 is an ongoing large-scale epidemiologic cohort study that has enrolled 166 762 individuals, 35 to 70 years of age, in 21 low-, middle-, and high-income countries on 5 continents. For the present analysis, we included 147 645 participants (including 7818 [5.3%] with a history of CVD) with complete information on their diet (eFigure 1 in the Supplement ). We included all outcome events known until July 31, 2019.

The Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial (ONTARGET) is a randomized clinical trial of antihypertension medication (ramipril, telmisartan, and their combination) for 25 620 patients aged 55 years or older with vascular disease or diabetes. 20 The Telmisartan Randomized Assessment Study in ACE Intolerant Subjects With Cardiovascular Disease (TRANSCEND) was a randomized clinical trial of telmisartan vs placebo for 5926 participants. 21 For the present analysis, we included 31 491 participants from ONTARGET and TRANSCEND with dietary assessments in 40 countries on 6 continents.

The Outcome Reduction With Initial Glargine Intervention (ORIGIN) trial was a randomized clinical trial of insulin glargine therapy or standard care and ω-3 fatty acid or placebo supplementation (2 × 2 factorial design) that included 12 537 people (mean [SD] age, 63.5 [7.8] years) with cardiovascular risk factors plus impaired fasting glucose or diabetes. 22 , 23 For the present analysis, we included 12 422 participants from ORIGIN with dietary assessments in 40 countries on 5 continents. We collected information on the type of fish consumed in ORIGIN but not in other studies. All studies were coordinated by the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.

The information about the study variables was collected with similar approaches and data collection forms in each of the studies. Information about demographic factors, lifestyle, health history, and medication use was recorded. Physical assessments included weight, height, waist and hip circumferences, and blood pressure.

In PURE, participants’ habitual food intake was recorded using country-specific validated food frequency questionnaires (FFQs; eAppendix in the Supplement ). 24 , 25 In ONTARGET and TRANSCEND, dietary information was obtained using a 19-item qualitative FFQ. 20 , 21 In ORIGIN, a 25-item qualitative FFQ was used to obtain information on individual foods or food groups, except for fish. 22 , 23 A separate 28-item qualitative FFQ was used to assess fish intake (24 types of fish and 4 types of shellfish) (eAppendix in the Supplement ).

Standardized case report forms were used to capture clinical data and to record major CVD events and death during follow-up in each study. Major cardiovascular events and deaths during follow-up were recorded and adjudicated centrally in each country using standard definitions. Events were classified according to the definitions used in each study, but these definitions were broadly similar.

Median fish intake was calculated overall and according to geographic region and country, with adjustment for age and sex. For all 3 cohorts, participants were grouped according to fish consumption into lower than 50 g/mo, 50 g/mo to lower than 175 g/wk, 175 to lower than 350 g/wk, and 350 g/wk or higher (ie, equivalent to fixed increments of about 25 g/d); the lowest intake group was used as the reference. Analysis of covariance was performed to calculate mean blood lipid levels and blood pressure levels among fish intake groups, adjusting for covariates.

We used a 2-stage individual participant data meta-analysis. 26 First, we assessed the associations between fish intake and events in each cohort separately. For the PURE cohort, estimates were obtained overall and separately for 2 subcohorts of people with or without CVD (the other 3 cohort studies were composed entirely of patients with vascular disease). Second, the cohort-specific hazard ratios (HRs) and 95% CIs were pooled (separately by cohort of people with or without CVD) in a random-effects meta-analysis. 27 The proportionality assumption was tested using the global goodness-of-fit test with Schoenfeld residuals in each cohort. No evidence of a violation was found. Tests of heterogeneity were conducted using the I 2 statistic.

In the PURE study, Cox frailty models with random effects (to account for clustering within study centers) were used to assess the association between fish intake and the outcomes. 28 In a minimally adjusted model, we adjusted for age, sex, and study center (as a random effect). The primary model adjusted for age, sex, study center (as a random effect), body mass index, educational level, wealth index, smoking status, urban or rural location, physical activity, history of diabetes, use of statin or antihypertension medication, and fruit, vegetables, red meat, poultry, dairy, and total energy intake, as in articles previously published by members of our group. 24 , 25 , 29 To test for linear trends, we used the median fish intake value in each of the categories of fish intake and included the variable as a quantitative risk factor. In ONTARGET and TRANSCEND, because the entry criteria and study conduct were similar for the 2 trials, we pooled the data from both studies in our analysis. As in the PURE analyses, in ONTARGET/TRANSCEND and in ORIGIN, we used Cox frailty models with similar adjustment models, but additionally adjusted for treatment allocation.

In sensitivity analyses for each study, estimates were assessed in the primary models after removing potential associated factors (body mass index, waist to hip ratio, diabetes, and hypertension). In addition, we assessed whether the association of fish intake varied by geographic region using tests of interaction. All statistical analyses were conducted using SAS, version 9.4 (SAS Institute Inc). A 2-sided P  < .05 was considered statistically significant. The present analysis was conducted from January to June 2020.

Participant characteristics from each study are provided in Table 1 . 15 , 19 Overall, 191 558 participants with a mean (SD) age of 54.1 (8.0) years (91 666 [47.9%] males) were included in the present analysis. The median duration of follow-up was 7.5 years (interquartile range [IQR], 4.9-9.4 years), with follow-up completed for 96% of the participants. The median follow-up in PURE was 9.1 years (IQR, 6.8-10.4 years), 4.5 years (IQR, 4.4-5.0 years) in ONTARGET and TRANSCEND, and 6.2 years (IQR, 5.8-6.7 years) in ORIGIN.

Overall, there were 8949 deaths (6.4%) among individuals without prior CVD and 6763 (13.1%) among individuals with prior CVD. There were 6825 (4.9%) major CVD events among individuals without prior CVD and 8565 (16.6%) among individuals with prior CVD.

Median fish intake ranged from 4.2 g/wk in South Asia to 468.3 g/wk in Southeast Asia (eFigure 2 in the Supplement ). By country, fish intake was lowest in Argentina (0.7 g/wk) and India (1.4 g/wk) and highest in Malaysia (452.2 g/wk), Philippines (522.9 g/wk), and United Arab Emirates (1350 g/wk).

In PURE, no significant association between fish intake and any health outcome was found, after adjustment for known confounders. Compared with little or no fish intake (≤50 g/mo; reference category), an intake of 350 g/wk or more (approximately 4 servings) was not significantly associated with risk of major CVD (HR, 0.95; 95% CI, 0.86-1.04), CVD mortality (HR, 0.94; 95% CI, 0.80-1.10), non-CVD mortality (HR, 1.00; 95% CI, 0.90-1.12), or total mortality (HR, 0.96; 95% CI, 0.88-1.05) ( Table 2 ; Figure 1 ). The association between fish intake and outcome events did not differ significantly by history of CVD status within PURE ( Figure 1 ; eFigure 5 in the Supplement ).

By contrast, in 2 cohorts of patients with vascular diseases (ONTARGET and TRANSCEND study, 40 countries, and 6 continents), a higher fish intake of at least 175 g/wk (approximately 2 servings/wk) was associated with lower risk of major CVD (HR, 0.89; 95% CI, 0.80-1.00), CVD mortality (HR, 0.87; 95% CI, 0.74-1.02), non-CVD mortality (HR, 0.83; 95% CI, 0.68-1.01), and total mortality (HR, 0.86; 95% CI, 0.76-0.98) compared with 50 g/mo or lower, with no further apparent decrease in HR with consumption of 350 g/wk or higher ( Table 2 ; eFigure 4 in the Supplement ).

In the ORIGIN study of patients with vascular dieases (40 countries, 5 continents), a higher fish intake of at least 175 g/wk (approximately 2 servings/wk) was associated with lower risk of major CVD (HR, 0.77; 95% CI, 0.66-0.89), CVD mortality (HR, 0.66; 95% CI, 0.54-0.80), and total mortality (HR, 0.77; 95% CI, 0.66-0.90) compared with 50 g/mo or lower, with no further apparent decrease in HR with consumption of 350 g/wk or higher ( Table 2 ; eFigure 4 in the Supplement ).

Collectively, in the 3 cohorts of patients with vascular disease, a minimal fish intake of 175 g/wk (approximately 2 servings/wk) was associated with lower major CVD (HR, 0.84; 95% CI, 0.73-0.96) and total mortality (HR, 0.82; 95% CI, 0.74-0.91) compared with 50 g/mo or lower, with no additional benefit with consumption of 350 g/wk or more.

Similar results were found when waist to hip ratio replaced body mass index in the multivariable models and also when waist to hip ratio, body mass index, hypertension, and diabetes were dropped from the models (eTable 2 in the Supplement ). Lastly, when participants with an event in the first 2 years were excluded, the findings were unchanged (eTable 2 in the Supplement ).

In the ORIGIN study, types of fish with higher amounts of ω-3 fats were strongly associated with a lower risk of major CVD events (HR, 0.94; 95% CI, 0.92-0.97 per 5-g increment of intake), whereas other types of fish were neutral ( Figure 2 ). 30 Similar protective associations of high ω-3 fish were found for sudden cardiac death (HR, 0.91; 95% CI, 0.86-0.96 per 5-g increment of intake; P  < .001), whereas other types of fish were found to be neutral (HR, 0.98; 95% CI, 0.88-1.09; P  = .69).

The association of fish intake with major CVD and CVD death varied significantly by history of CVD status (for major CVD, I 2  = 82.6 [ P  = .02]; for death, I 2  = 90.8 [ P  = .001]; for composite of death or CVD, I 2  = 87.6 [ P  = .004]) ( Figure 1 ; eFigure 4 in the Supplement ).

Among high-risk individuals or patients with existing vascular disease, a minimal fish intake of 175 g/week (approximately 2 servings/week) was associated with lower risk of major CVD (compared with ≤50 g/month; HR, 0.84; 95% CI, 0.77-0.92; P  = .008), total mortality (HR, 0.83; 95% CI, 0.76-0.91; P  < .001), and the composite of death or major CVD (HR, 0.86; 95% CI, 0.80-0.92; P  = .002), after adjustment for known confounders ( Figure 1 ; eFigure 4 in the Supplement ), with no further apparent decrease in HR with consumption of 350 g/week or higher. No significant heterogeneity in the associations with the composite outcome was found across regions.

By contrast, in general populations without vascular disease, a higher fish intake was not significantly associated with major CVD (comparing ≥350 g/wk vs ≤50 g/mo; HR, 0.97; 95% CI, 0.88-1.08; P  = .24), total mortality (HR, 0.97; 95% CI, 0.88-1.06; P  = .48), or the composite of death or major CVD (HR, 0.97; 95% CI, 0.90-1.04; P  = .18) ( Figure 1 ; eFigure 4 in the Supplement ).

Similarly, among high-risk individuals or patients with existing vascular disease, a higher fish intake was associated with lower risk of sudden cardiac death (comparing ≥350 g/wk with ≤50 g/mo; HR, 0.79; 95% CI, 0.63-0.99; P  = .04). By contrast, in general populations without vascular disease, a higher fish intake was not significantly associated with these events (HR, 1.10; 95% CI, 0.64-1.89; P  = .91).

In PURE, higher fish intake appeared to be associated with a lower risk of composite events in China and Africa but appeared to be neutral in other regions. For patients with vascular disease, similar associations were found across regions.

Higher fish intake was associated with lower triglyceride levels both among people with or without vascular disease ( Figure 3 ; eTable 1 in the Supplement ). However, no beneficial associations were found with other risk markers, and there were higher levels of low-density lipoprotein cholesterol (LDL-C) ( Figure 3 ; eFigure 3 in the Supplement ).

In this analysis of 4 international prospective cohort studies with 15 390 major CVD events and 15 712 deaths, among 191 558 people from 58 countries in 6 continents, we noted significant heterogeneity in the association between fish intake and major CVD events by history of CVD status. Lower risk of major CVD, total mortality, and their composite was found with higher fish intake of at least 175 g/wk (approximately 2 servings) among high-risk individuals or patients with vascular disease, but not in general populations without vascular disease. A similar pattern of results was found for sudden cardiac death, with significant protective associations observed among patients with vascular disease, but neutral in general populations without vascular disease. Furthermore, the data available from 1 study on types of fish suggested that oily fish but not other types of fish were associated with greater benefits.

Dietary guidelines generally encourage consumption of a variety of fish, preferably oily types (eg, salmon, sardines, tuna, and mackerel), at least twice a week for CVD prevention. 1 , 2 , 31 - 33 High-dose fish oil has been shown to lower triglyceride levels in people with severe hypertriglyceridemia. 6 , 7 Furthermore, short-term trials showed that 2 servings of fatty fish per week (roughly 112 g [4 oz] each) decreased triglyceride levels by 11.4% but also slightly increased LDL-C levels compared with the control diet. 34 , 35 Our findings are consistent with this information, both among people with and among persons without vascular disease (8% decrease in triglyceride level with approximately 2 standard servings of fish per week but with slightly higher LDL-C level). The increase in LDL-C level associated with fish intake may not suggest an increased CVD risk because this risk may be offset by the positive effects on lipoproteins. 36 Our finding of higher blood glucose levels associated with higher fish intake is consistent with some trial data for patients with diabetes, 37 but other trials of fish or fish oil consumption have been neutral regarding this factor. 38 Cohort studies of fish intake and incident diabetes have shown variable results. 39 , 40 Cooking methods, mercury levels, and the presence of polychlorinated biphenyls or other environmental contaminants in fish are potential factors associated with the different findings across studies, 41 but further work is needed in this area. Given that there are associations with CVD risk markers, some of which may be protective and others harmful, and that some fish may contain contaminants, 42 , 43 studying the association of fish intake with outcome events is essential to inform recommendations for populations.

To our knowledge, there are no primary prevention trials on fish intake and CVD outcomes. Some prospective cohort studies among mostly healthy people have found an inverse association between fish intake and CVD mortality, whereas others do not. 44 A recent umbrella review of cohort studies found modest protective associations of fish consumption with fatal coronary heart disease (ie, summary relative risks ranging from 2% to 15% lower risk). 14 Compared with fatal cardiac events, fish consumption has weaker associations with nonfatal cardiac events and stroke. 14 , 44 However, those meta-analyses were not based on combining individual data from each study and thus were not able to fully adjust for all potential confounders. In PURE, which covers fish intake in numerous world regions in which various amounts and types of fish are consumed, we found no significant association of fish intake with outcome events. In analyses by geographic region, we found considerable heterogeneity across geographic regions, but associations were neutral in most regions except for China and Africa, where protective associations between fish intake and composite events were detected. Taken together, the results suggest that higher fish consumption may be modestly associated with CVD outcomes or mortality in generally healthy populations.

Our findings of favorable associations of fish intake with CVD events and mortality among patients with vascular disease are consistent with the DART-1 (Diet and Reinfarction) trial, 45 but not the DART 2 study 46 or 2 recent meta-analyses of randomized clinical trials of fish oil supplementation for high-risk individuals, which showed that fish oil (approximately 1 g/d) had no association with CVD outcomes or total mortality. 8 , 9 More recently, in 2018, 2 trials of a 1-g/d ω-3 formulation found no significant effect of supplementation on major CVD, but there was significant lowering of fatal myocardial infarction, total coronary heart disease, 12 and fatal CVD. 11 In a 2019 meta-analysis 10 that included those new trials, 11 , 12 individuals who received ω-3 supplementation had significantly better CVD outcomes, even after excluding the recent REDUCE-IT randomized clinical trial of patients with elevated triglyceride levels that used a much higher dose of fish oil (4 g daily). 13 In our study, CVD risk was lowest with a moderate amount of fish (ie, at least 175 g/wk, or approximately 2 servings/wk), with no further apparent decrease in risk with higher fish intake (ie, >350 g/wk, or >3-4 servings/wk). Similarly, previous cohort studies of mostly generally healthy populations showed that approximately 2 or more servings/wk (150 g/wk) is associated with the lowest CVD risk. 14 , 44 On this basis, 2 servings of fish per week may be the minimal amount of fish needed to reach maximum benefit (an amount consistent with current recommendations for CVD prevention), 1 , 2 , 31 - 33 with little additional benefit with higher intakes among patients with vascular disease. As expected in ORIGIN, for which we collected information on types of fish, consumption of fish with higher amounts of ω-3 fats was strongly associated with a lower risk of major CVD, whereas consumption of other types of fish was found to be neutral. These findings are compatible with trials showing favorable effects of oily fish intake on CVD risk markers. 6 In addition, fish may have selective antiarrhythmic effects and accompanying protection against sudden cardiac death. 3 , 4 , 8 Some 47 but not all 48 , 49 trials of patients with vascular disease found that fish oil use results in a lower risk of sudden cardiac death. In our cohorts of patients with vascular disease, we found protective associations of fish intake (mainly from high ω-3 fish) with sudden death (HR, 0.79; 95% CI, 0.63-0.99, comparing >350 g/wk vs <50 g/mo). Collectively, a possible modest cardiovascular benefit (ie, approximately 10%-15% risk lowering) was found to be associated with consuming an equivalent of at least 175 g (2 servings) of fish weekly and with similar protection for more than 350 g (approximately 4 servings) weekly for secondary prevention. However, our findings require confirmation from randomized clinical trials evaluating the effects of increasing fish consumption (especially oily fish) on the clinical outcomes of people with vascular disease.

The first potential limitation of this study is that diet was self-reported, and variations in reporting may lead to random errors that could dilute real associations between fish intake and clinical outcomes. Second, we were not able to consider cooking methods, how the fish was consumed (with sauces, smoked, salted, etc), or contaminants in fish, which may also affect the results. Furthermore, we were not able to conduct a separate assessment of oily fish in PURE, which could at least partly explain the overall null findings. Third, in observational studies, the possibility of residual confounding cannot be completely ruled out (eg, fish intake may be a proxy for poverty or access to health care). However, our results persisted despite extensive adjustments for all known confounders, including the use of 4 markers of socioeconomic status (educational level, wealth, urban vs rural location, and geographic location). In addition, we adjusted for study center as a random effect, which takes into account socioeconomic factors and clustering by community, leading to comparisons within countries (eAppendix in the Supplement ). Lastly, some misclassification of fish intake cannot be ruled out because we did not have repeated measures of diet in all studies, and a full-length FFQ was used only in PURE. However, the ORIGIN study, in which we conducted repeated diet assessments at 2 years, showed similar results based on the first vs second diet assessments, indicating that misclassification of fish intake during follow-up was not a major factor in our findings (eTable 3 in the Supplement ).

In summary, this study found that a minimal fish intake of 175 g (approximately 2 servings) weekly was associated with lower risk of major CVD events and total mortality among high-risk individuals or patients with existing vascular disease but not in the general population.

Accepted for Publication: December 18, 2020.

Published Online: March 8, 2021. doi:10.1001/jamainternmed.2021.0036

Correction: This article was corrected on May 3, 2021, to fix an error in an author affiliation.

Corresponding Author: Andrew Mente, PhD, Population Health Research Institute, Hamilton Health Sciences and McMaster University, Second Floor, Room C2-105, 237 Barton St East, Hamilton, ON L8L 2X2, Canada ( [email protected] ).

Author Contributions: Drs D. Mohan and Mente are co–first authors. Drs D. Mohan and Mente had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Mente, Dehghan, O’Donnell, V. Mohan, Khatib, Chifamba, Dans, S. Yusuf.

Acquisition, analysis, or interpretation of data: D. Mohan, Mente, Rangarajan, O’Donnell, Hu, Dagenais, Wielgosz, Lear, Wei, Diaz, Avezum, Lopez-Jaramillo, Lanas, Swaminathan, Kaur, Krishnapillai, Gupta, Szuba, Iqbal, R. Yusuf, Mohammadifard, Khatib, Yusoff, Gulec, Rosengren, Yusufali, Wentzel-Viljoen, Alhabib, Yeates, Teo, Gerstein, S. Yusuf.

Drafting of the manuscript: D. Mohan, Mente, Dehghan, Dans.

Critical revision of the manuscript for important intellectual content: Rangarajan, O’Donnell, Hu, Dagenais, Wielgosz, Lear, Wei, Diaz, Avezum, Lopez-Jaramillo, Lanas, Swaminathan, Kaur, Krishnapillai, V. Mohan, Gupta, Szuba, Iqbal, R. Yusuf, Mohammadifard, Khatib, Yusoff, Gulec, Rosengren, Yusufali, Wentzel-Viljoen, Chifamba, Alhabib, Yeates, Teo, Gerstein, S. Yusuf.

Statistical analysis: Mente, Dehghan, Hu, Wei, Khatib.

Obtained funding: O’Donnell, Lear, Lanas, Rosengren, Yusufali, Alhabib, Yeates.

Administrative, technical, or material support: Rangarajan, Dagenais, Wielgosz, Diaz, Lanas, Swaminathan, Krishnapillai, Gupta, Yusoff, Gulec, Yusufali, Wentzel-Viljoen, Alhabib, S. Yusuf.

Supervision: Rangarajan, Wielgosz, Diaz, Kaur, V. Mohan, Gupta, Szuba, Iqbal, R. Yusuf, Khatib, Yusufali, Chifamba, Alhabib, Yeates, Teo, S. Yusuf.

Conflict of Interest Disclosures: Dr Diaz reported receiving grants from Amgen and Sanofi; recieiving personal fees from Sanofi; and receiving grants from Amarin outside the submitted work. Dr Szuba reported receiving grants from the Polish Ministry of Science and Higher Education and from the Population Health Research Institute during the conduct of the study. Dr Gulec reported receiving personal fees from Amgen, Astra Zeneca, Boehringer Ingelheim, Daichii Sankyo, Menarini, Pfizer, and Recordati outside the submitted work. Dr Yusufali reported receiving grants from Sheikh Hamdan bin Rashid AlMakhtoum Medical Research Award during the conduct of the study. Dr Gertstein reported recieving grants from Sanofi during the conduct of the study; grants and personal fees from AstraZeneca, Lilly, Novo Nordisk and Sanofi; and receiving personal fees from Abbot, Boehringer Ingelheim, Kowa Pharmaceuticals America Inc, and Merck & Co outside the submitted work. Dr S. Yusuf reported recieving support from the Mary W Burke endowed chair of the Heart and Stroke Foundation of Ontario. No other disclosures were reported.

Funding/Support: Dr S. Yusuf is supported by the Marion W Burke endowed chair of the Heart and Stroke Foundation of Ontario. The PURE study is an investigator-initiated study that is funded by the Population Health Research Institute, Hamilton Health Sciences Research Institute (HHSRI), the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Support from Canadian Institutes of Health Research’s Strategy for Patient Oriented Research, through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies (with major contributions from AstraZeneca [Canada], Sanofi-Aventis [France and Canada], Boehringer Ingelheim [Germany and Canada], Servier, and GlaxoSmithKline), and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries. These include: Argentina: Fundacion ECLA (Estudios Clínicos Latino America) ; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: This study was supported by an unrestricted grant from Dairy Farmers of Canada and the National Dairy Council (US), Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de La Frontera [DI13-PE11]; China: National Center for Cardiovascular Diseases and ThinkTank Research Center for Health Development; Colombia: Colciencias (grant 6566-04-18062 and grant 6517-777-58228); India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia (grants 100-IRDC/BIOTEK 16/6/21 [13/2007] and 07-05-IFN-BPH 010), Ministry of Higher Education of Malaysia (grant 600-RMI/LRGS/5/3 [2/2011]), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the United Nations Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research and Development; Poland: Polish Ministry of Science and Higher Education (grant 290/W-PURE/2008/0), Wroclaw Medical University; Saudi Arabia: Saudi Heart Association, Dr.Mohammad Alfagih Hospital, The Deanship of Scientific Research at King Saud University (Research group RG -1436-013), Riyadh; Saleh Hamza Serafi Chair for Research of Coronary Heart Disease, Umm AlQura University, Makkah, Saudi Arabia; South Africa: The North-West University, SA and Netherlands Programme for Alternative Development, National Research Foundation, Medical Research Council of South Africa, The South Africa Sugar Association, Faculty of Community and Health Sciences; Sweden: Grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemason’s Foundation, AFA Insurance; Turkey: Metabolic Syndrome Society, AstraZeneca, Sanofi Aventis; United Arab Emirates: Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The PURE, ONTARGET, TRANSCEND, and ORIGIN investigators are as follows. An asterisk denotes a national coordinator, and a hashtag denotes deceased person. PURE Project Office Staff, National Coordinators, Investigators, and Key Staff: Project office (Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada): S. Yusuf* (Principal Investigator), S. Rangarajan (Program Manager); K.K. Teo, S.S. Anand, C.K. Chow, M. O’Donnell, A. Mente, D. Leong, A. Smyth, P. Joseph, M. Duong, R. D’Souza, M. Walli-Attaei, S. Islam (Statistician), W. Hu (Statistician), C. Ramasundarahettige (Statistician), P. Sheridan (Statistician), S. Bangdiwala, L. Dyal, B. Liu (Biometric Programmer), C. Tang (Biometric Programmer), X. Yang (Biometric Programmer), R. Zhao (Biometric Programmer), L. Farago (ICT), M. Zarate (ICT), J. Godreault (ICT), M. Haskins (ICT), M. Jethva (ICT), G. Rigitano (ICT), A. Vaghela (ICT), M. Dehghan (Nutrition Epidemiologist), A. Aliberti, A. Reyes, A. Zaki, B. Connolly, B. Zhang, D. Agapay, D. Krol, E. McNeice, E. Ramezani, F. Shifaly, G. McAlpine, I. Kay, J. Rimac, J. Swallow, M. Di Marino, M. Jakymyshyn, M(a). Mushtaha, M(o). Mushtaha, M. Trottier, N. Aoucheva, N. Kandy, P. Mackie, R. Buthool, R. Patel, R. Solano, S. Gopal, S. Ramacham, S. Trottier. Core Laboratories : G. Pare, M. McQueen, S. Lamers, J. Keys (Hamilton), X. Wang (Beijing, China), A. Devanath (Bangalore, India). Argentina: R. Diaz*, A. Orlandini, P. Lamelas, M.L. Diaz, A. Pascual, M. Salvador, C. Chacon; Bangladesh: O. Rahman*, R. Yusuf*, S.A.K.S. Ahmed, T. Choudhury, M. Sintaha, A. Khan, O. Alam, N. Nayeem, S.N. Mitra, S. Islam, F. Pasha; Brazil: A. Avezum*, C.S. Marcilio, A.C. Mattos, G.B. Oliveira; Canada: K. Teo *, S. Yusuf * , Sumathy Rangarajan, A. Arshad, B. Bideri, I. Kay, J. Rimac, R. Buthool, S. Trottier, G. Dagenais, P. Poirier, G. Turbide, A.S. Bourlaud, A. LeBlanc De Bluts, M. Cayer, I. Tardif, M. Pettigrew, S. Lear, V. de Jong, A.N. Saidy, V. Kandola, E. Corber, I. Vukmirovich, D. Gasevic, A. Wielgosz, A. Pipe, A. Lefebvre, A. Pepe, A. Auclair, A. Prémont, A.S. Bourlaud; Chile: F. Lanas*, P. Serón, M.J. Oliveros, F. Cazor, Y. Palacios; China: Liu Lisheng*, Li Wei*, Chen Chunming # , Zhao Wenhua. Hu Bo, Yin Lu, Zhu Jun, Liang Yan, Sun Yi, Wang Yang, Deng Qing, Jia Xuan, He Xinye, Zhang Hongye, Bo Jian, Wang Xingyu, Liu Xu, Gao Nan, Bai Xiulin, Yao Chenrui, Cheng Xiaoru, Wang Chuangshi, Li Sidong, Liu Weida, Lang Xinyue, Liu Xiaoyun, Zhu Yibing, Xie Liya, Liu Zhiguang, Ren Yingjuan, Dai Xi, Gao Liuning, Wang Liping, Su yuxuan, Han Guoliang, Song Rui, Cao Zhuangni, Sun Yaya, Li Xiangrong, Wang Jing, Wang Li, Peng Ya, Li Xiaoqing, Li Ling, Wang Jia, Zou Jianmei, Gao Fan, Tian Shaofang, Liu Lifu, Li Yongmei, Bi Yanhui, Li Xin, Zhang Anran, Wu Dandan, Cheng ying, Xiao Yize, Lu Fanghong, Li Yindong, Hou Yan, Zhang Liangqing, Guo Baoxia, Liao Xiaoyang, Chen Di, Zhang Peng, Li Ning, Ma Xiaolan, Lei Rensheng, Fu Minfan, Liu Yu, Xing Xiaojie, Yang Youzhu, Zhao Shenghu, Xiang Quanyong, Tang Jinhua, Liu Zhengrong, Qiang Deren, Li Xiaoxia, Xu Zhengting, Aideeraili.Ayoupu, Zhao Qian; Colombia: P. Lopez-Jaramillo*, P.A. Camacho-Lopez, M. Perez, J. Otero-Wandurraga, D. I Molina, C. Cure-Cure, J.L. Accini, E. Hernandez, E. Arcos, C. Narvaez, A. Sotomayor, F. Manzur, H. Garcia, G. Sanchez, F. Cotes, A. Rico, M. Duran, C. Torres; India: Bangalore - P. Mony *, M. Vaz*, S. Swaminathan, A.V. Bharathi, K. Shankar, A. V. Kurpad, K.G. Jayachitra, H.A.L. Hospital, A.R. Raju, S. Niramala, V. Hemalatha, K. Murali, C. Balaji, A. Janaki, K. Amaranadh, P. Vijayalakshmi, Chennai - V. Mohan*, R.M. Anjana, M. Deepa, K. Parthiban, L. Dhanasekaran, S.K. Sundaram, M. Rajalakshmi, P. Rajaneesh, K. Munusamy, M. Anitha, S. Hemavathy, T. Rahulashankiruthiyayan, D. Anitha, R. Dhanasekar, S. Sureshkumar, D. Anitha, K. Sridevi, Jaipur - R. Gupta, R.B. Panwar, I. Mohan, P. Rastogi, S. Rastogi, R. Bhargava, M. Sharma, D. Sharma, Trivandrum - V. Raman Kutty, K. Vijayakumar, S. Nair, Kamala R., Manu M.S., Arunlal A.R., Veena A., Sandeep P. Kumar, Leena Kumari, Tessi R., Jith S., K. Ajayan, G. Rajasree, A.R. Renjini, A. Deepu, B. Sandhya, S. Asha, H.S. Soumya, Chandigarh - R. Kumar, M. Kaur, P.V.M. Lakshmi, V. Sagar J.S. Thakur, B. Patro, R. Mahajan, A. Josh, G. Singh, K. Sharma, P. Chaudary, Iran: R. Kelishadi*, A. Bahonar, N. Mohammadifard, H. Heidari, Kazakhstan: K. Davletov*, B. Assembekov, B. Amirov; Kyrgyzstan: E. Mirrakhimov*, S. Abilova, U. Zakirov, U. Toktomamatov; Malaysia: UiTM - K. Yusoff*, T.S. Ismail, K. Ng, A. Devi, N. Mat-Nasir, A.S. Ramli, M.N.K. Nor-Ashikin, R. Dasiman, M.Y. Mazapuspavina, F. Ariffin, M. Miskan, H. Abdul-Hamid, S. Abdul-Razak, N. Baharudin, N.M.N. Mohd-Nasir, S.F. Badlishah-Sham, M.S. Mohamed-Yassin, M. Kaur, M. Koshy, F.A. Majid, N.A. Bakar, N. Zainon, R. Salleh, S.R. Norlizan, N.M. Ghazali, M. Baharom, H. Zulkifli, R. Razali, S. Ali, C.W.J.C.W. Hafar, F. Basir; UKM - Noorhassim Ismail, M.J. Hasni, M.T. Azmi, M.I. Zaleha, R. Ismail, K.Y. Hazdi, N. Saian, A. Jusoh, N. Nasir, A. Ayub, N. Mohamed, A. Jamaludin, Z. Rahim; Occupied Palestinian Territory: R. Khatib*, U. Khammash, R. Giacaman; Pakistan: R. Iqbal*, R. Khawaja, I. Azam, K. Kazmi; Peru: J. Miranda*, A. Bernabe Ortiz, W. Checkley, R.H. Gilman, L. Smeeth, R.M. Carrillo, M. de los Angeles, C. Tarazona Meza ; Philippines: A. Dans*, H.U. Co, J.T. Sanchez, L. Pudol, C. Zamora-Pudol, L.A. M Palileo-Villanueva, M.R. Aquino, C. Abaquin, S.L. Pudol, K. Manguiat, S. Malayang; Poland: W. Zatonski*, A. Szuba, K. Zatonska, R. Ilow # , M. Ferus, B. Regulska-Ilow, D. Różańska, M. Wolyniec; Saudi Arabia: K.F. AlHabib*, M. Alshamiri, H.B. Altaradi, O. Alnobani, N. Alkamel, M. Ali, M. Abdulrahman, R. Nouri; South Africa: L. Kruger * , A. Kruger # , P. Bestra, H. Voster, A.E. Schutte, E. Wentzel-Viljoen, F.C. Eloff, H. de Ridder, H. Moss, J. Potgieter, A. Roux, M. Watson, G. de Wet, A. Olckers, J.C. Jerling, M. Pieters, T. Hoekstra, T. Puoane, R. Swart*, E. Igumbor, L. Tsolekile, K. Ndayi, D. Sanders, P. Naidoo, N. Steyn, N. Peer, B. Mayosi # , B. Rayner, V. Lambert, N. Levitt, T. Kolbe-Alexander, L. Ntyintyane, G. Hughes, J. Fourie, M. Muzigaba, S. Xapa, N. Gobile, K. Ndayi, B. Jwili, K. Ndibaza, B. Egbujie; Sweden A. Rosengren*, K. Bengtsson Boström, A. Rawshani, A. Gustavsson, M. Andreasson, L. Wirdemann; Tanzania: K. Yeates*, M. Oresto, N. West Turkey: A. Oguz*, N. Imeryuz, Y. Altuntas, S. Gulec, A. Temizhan, K. Karsidag, K.B.T. Calik, A.K. Akalin, O.T. Caklili, M.V. Keskinler, K. Yildiz; United Arab Emirates: A.H. Yusufali, F. Hussain, M.H.S. Abdelmotagali, D.F. Youssef, O.Z.S. Ahmad, F.H.M. Hashem, T.M. Mamdouh, F.M. AbdRabbou, S.H. Ahmed, M.A. AlOmairi, H.M. Swidan, M. Omran, N.A. Monsef; Zimbabwe: J. Chifamba*, T. Ncube, B. Ncube, C. Chimhete, G.K. Neya, T. Manenji, L. Gwaunza, V. Mapara, G. Terera, C. Mahachi, P. Murambiwa, R. Mapanga, A. Chinhara. ONTARGET/TRANSCEND Office Staff, National Coordinators, Investigators, and Key Staff: Current members of the Operations Committee are denoted by an asterisk. Previous members of the Operations Committee are denoted by a dagger. NC denotes National Coordinator, and NL National Leader. Steering Committee: S. Yusuf (Chair and Principal Investigator),* P. Sleight,* C. Anderson,* K. Teo,* I. Copland,* B. Ramos,† L. Richardson,* J. Murphy,* M. Haehl,* L. Hilbrich,† R.Svaerd,* K. Martin,† D. Murwin,* T. Meinicke,† A. Schlosser,* G. Schmidt,† R. Creek,* H. Schumacher,* M. Distel,† B. Aubert, J.Pogue, L. Dyal, R. Schmieder, T. Unger, R. Asmar, G. Mancia, R. Diaz, E. Paolasso, L. Piegas, A. Avezum, G. Dagenais, E. Cardona Munoz, J. Probstfield, M. Weber, J. Young, R. Fagard, P. Jansky, J. Mallion, J. Mann, M. Böhm, B. Eber, N.B. Karatzas, M. Keltai, B.Trimarco, P. Verdecchia, A. Maggioni, F.W.A. Verheugt, N.J. Holwerda, L. Ceremuzynski, A. Budaj, R. Ferreira, I. Chazova, L. Rydén, T.L. Svendsen, K. Metsärinne, K. Dickstein, G. Fodor, P. Commerford, J. Redon, T.R. Luescher, A. Oto, A. Binbrek, A. Parkhomenko, G. Jennings, L.S. Liu, C.M. Yu, A.L. Dans, R. Shah, J.-H. Kim, J.-H. Chen, S. Chaithiraphan. Data and Safety Monitoring Board: J. Cairns (Chair), L. Wilhelmsen, J. Chalmers, J. Wittes, M. Gent, C.H. Hennekens. Adjudication Committee: G. Dagenais (Chair), N. Anderson, A. Avezum, A. Budaj, G. Fodor, M. Keltai, A. Maggioni, J. Mann, A. Parkhomenko, K. Yusoff, P. Auger, V. Bernstein, E. Lonn, A. Panju, I. Anand, J.T. Bigger, P. Linz, J. Healey, C. Held, C. McGorrian, M. Rokoss, J. Villar. Substudies/Publication Committee: P. Sleight (Chair), C. Anderson, R. Creek, A. Dans, R. Diaz, R. Fagard, J. Probstfield, R. Svaerd, K. Teo, T. Unger, S. Yusuf. Coordinating Centers: Hamilton: K. Teo, I. Copland, B. Ramos, A. McDonald, J. Pogue, L. Dyal, R. Afzal, F. Zhao, S. Yusuf; Oxford: P. Sleight, L. Richardson; Auckland: C. Anderson, J. Murphy. Sites and Principal Investigators by Country: Argentina : R. Diaz (NC), E. Paolasso (NL), R.A. Ahuad Guerrero, M. Amuchastegui, H.P. Baglivo, M. Bendersky, J. Bono, B. Bustos, A. Caccavo, L.R. Cartasegna, C.R. Castellanos, M.A. Cipullo, P. Crunger, C.A. Cuneo, M. Focaccia, J.J. Fuselli, E. Hasbani, M.A. Hominal, J. Humphreys, F. Inserra, C.R. Killinger, E. Kuschnir, C.R. Majul, O.D. Manuale, G. Martinez, E.M. Marzetti, R. Nordaby, A.D. Orlandini, J.C. Pomposiello, G.M. Rodríguez, J. Salas, O.A. Salomone, R.A. Sanchez, C. Serra, M.L. Vico; Australia : G.L.R. Jennings (NC), J.V. Amerena, L.F. Arnolda, G.M. Aroney, P.E. Aylward, C.F. Bladin, J.C. Bridgeman, B.R. Chambers, A.J. Corbett, D.S. Crimmins, D.B. Cross, L. Davies, S.M. Davis, G.A. Donnan, D.S. Eccleston, J.H. Frayne, R. Hendriks, G.K. Herkes, A.T. Hill, I.M. Jeffery, J.A. Karrasch, G. Koshy, T.H. Marwick, D.A. Owensby, M.W. Parsons, D.M. Rees, A. Russell, R. Schwartz, B. Singh, P.L. Thompson, J.H. Waites, W.F. Walsh, D.L. Walters, R.W. Watts, A.P. Whelan; Austria : M. Böhm (NC), B.E. Eber (NL), J.B. Bonelli, P. Dolliner, J.H. Hohenecker, G.S. Steurer, W.W. Weihs; Belgium: R. Fagard (NC), I. Bekaert, C. Brohet, P. Chaumont, P. Cheron, V. Crasset, J.-P. Degaute, P. Dendale, K. Dujardin, S. Elshot, S. Hellemans, M. Herssens, G. Heyndrickx, P. Laloux, H. Lesseliers, P. Noyens, M. Quinonez, F. Stammen, H. Striekwold, J. Thoeng, W. Van Mieghem, G. Vanhooren, G. Vervoort, M. Vrolix, B. Wollaert; Brazil : L. Piegas (NC), A. Avezum (NL), J.A.M. Abrantes, D. Armaganijan, J.C. Ayoub, L.C. Bodanese, A.C. Carvalho, M. Coutinho, J.P. Esteves, R.J.S. Franco, P.C.B.V. Jardim, J.F. Kerr Saraiva, P.E. Leães, L.N. Maia, J.A. Marin-Neto, R.L. Marino, D. Mion, Jr., J.R. Moreira, Jr., W. Oigman, R.C. Pedrosa, E.A. Pelloso, F.L. Plavnik, C.A. Polanczyk, Á. Rabelo, Jr., S. Rassi, G. Reis, A.B. Ribeiro, J.M. Ribeiro, J.C. Rocha, P.R.F. Rossi, R.D. Santos, J.C.E. Tarastchuk, M.N. Villalón; Canada : K. Teo (NC), G. Dagenais (NC), B. Abramson, M. Arnold, T. Ashton, P. Auger, I. Bata, K. Bayly, J. Beauchef, A. Bélanger, V. Bernstein, R. Bhargava, A.W. Booth, S. Bose, M. Boulianne, M. Cameron, Y.K. Chan, C. Constance, P. Costi, D. Dion, J. Douketis, D. Fell, J.P. Giannoccaro, A. Glanz, G. Gosselin, D. Gould, S. Goulet, F. Grondin, M. Gupta, G. Gyenes, J.W. Heath, V.A. Heath, A. Hess, J.G. Hiscock, G. Hoag, G. Honos, J. Imrie, R. Kuritzky, C. Lai, A. Lalani, A. Lamy, P. LeBouthillier, H. Lochnan, E. Lonn, B. Lubelsky, A. Mackey, M. Meunier, A. Milot, L.B. Mitchell, S. Nawaz, M. Omichinski, A. Panju, C. Pilon, D. Pilon, P. Polasek, G. Proulx, T. Rebane, A.J. Ricci, D.W. Rupka, É. Sabbah, D. Savard, N.K. Sharma, D. Shu, R. St. Hilaire, F. St. Maurice, R. Starra, B. Sussex, T. Szaky, P. Talbot, K.-W. Tan, T.B. To, S. Tobe, R. Tytus, R. Vexler, P. Whitsitt, V. Woo; China : L. Liu (NC), X. Bai, X. Chen, J. Feng, S. Fu, Y. Ge, L. Gong, Z. He, J. Huang, Y. Jiang, L. Li, Q.H. Li, Y. Liao, Z. Lu, F. Lu, S. Ma, F. Niu, C. Pan, F. Qian, X. Shi, N. Sun, M. Sun, G. Sun, J. Wang, S. Wang, Y. Wang, Z. Wu, X. Yan, X. Yang, H. Yang, X. Ye, S. Yuan, T. Zhang, C. Zhang, F. Zhang, S. Zhang, D. Zhao, B. Zheng, H.Y. Zhou, S. Zhou, J. Zhu; Czech Republic : P. Janský (NC), V. Dedek, J. Dvorák, R. Holaj, J. Kotouš, E. Pederzoliová, M. Polák, J. Povolný, K. Smetana, J. Špác; Denmark : T.L. Svendsen (NC), L. Götzsche, H.F. Juhl, K. Koelendorf, P. Lund, F. Pedersen, O.L. Perdersen, T. Pindborg, L.H. Rasmussen, S.L. Rasmussen, K. Thygesen, C. Tuxen; Finland : K. Metsärinne (NL), R. Antikainen, M. Jääskivi, I. Kantola, M. Kastarinen, P. Kohonen-Jalonen, A. Koistinen, E. Lehmus, R. Nuuttila, M.-L. Tuominen, H. Ylihärsilä; France: J. Mallion (NC), N. Abenhaim, J. Allix, L. Boucher, M. Bourgoin, A. Boye, N. Breton, D. Cadinot, A. Campagne, J. Churet, G. Constantin, E. De Sainte Lorette, A. El Sawy, G. Etchegarray, S. Farhat, F. Lacoin, T. Latte, C. Magnani, D. Pineau-Valenciennes, M. Pithon, A. Quéguiner, J. Sicard, G. Sorbe, D. Taminau, H. Vilarem, J.Y. Vogel; Germany : H.H. Ebert, S. Genth-Zotz, N. Hermanns, C. Holzer, J. Minnich, D. Schimkus, M. Boehm (NC), J. Mann (NC), B. Brado, G. Claus, U. Dietz, R. Griebenow, T. Haak, K. Hahn, R. Hampel, H. Heitzer, G. Holle, T. Horacek, J. Jordan, C. Klein, R. Kolloch, S. Ludewig, W. Motz, T. Muenzel, H.P. Nast, M. Nauck, H. Nebelsieck, K. Rybak, H. Samer, T. Schaefer, J. Scholze, B. Schulze, Schleppinghoff, R. Schmieder, B. Schwaab, U. Sechtem, W. Sehnert, E. Steinhagen-Thiessen, G. Stenzel, P. Trenkwalder, B. Wedler, J. Zippel; Greece : N. Karatzas (NC), A. Achimastos, E. Diamantopoulos, A. Efstratopoulos, M. Elisaf, H. Karvounis, D. Mentzikof, D. Mytas, D. Papadogiannis, V. Pyrgakis, C. Stefanadis, D. Symeonidis, A. Tsoukas, I. Vogiatzis, S. Voyaki, C. Zamboulis; Hong Kong : C.-M. Yu (NC), C.K.H. Chan, L. Lam, Y.K. Lau, J. Sanderson, J. Wong, E.B. Wu, C.S. Yue; Hungary: M. Keltai (NC), I. Czuriga, I. Édes, C.S. Farsang, Á. Kalina, K. Karlócai, K. Keltai, M. Kozma, Z. László, V. Nagy, A. Papp, G.Y. Polák, I. Préda, A. Rónaszéki, M. Sereg, K. Simon, S. Sonkodi, J. Szegedi, S. Timár, K. Tóth, G.Y. Vándorfi, A. Vértes; Ireland: J. Feely, V.M.G. Maher, A.V. Stanton, P. Sullivan; Italy : B. Trimarco (NC), P. Verdecchia (NC), A. Maggioni (NL), E. Agabiti Rosei, G.B. Ambrosio, M. Bentivoglio, A. Branzi, P. Cavallo Perin, M. Chiariello, V. Cirrincione, R. Ferrari, R. Gattobigio, E. Giovannini, D. Giugliano, A. Lacchè, R. Lauro, G. Lembo, G. Marchetti, L. Moretti, L. Pancaldi, L. Partemi, S. Pede, G. Pettinati, G. Reboldi, R. Ricci, G. Rosiello, F. Rozza, M.G. Sardone, E.V. Scabbia, G. Selvetella, L. Tavazzi, P. Terrosu, A. Venco, A. Vetrano, M. Volpe, G. Zilio; Malaysia: T. Ismail, R.P. Shah, M. Singaraveloo, W.A. Wan Ahmad, Z. Yusof, K. Yusoff, I. Zainal Abidin, R. Zambahari; Mexico : E. Cardona Munoz (NC), L. Alcocer Diaz, S. Pascoe-Gonzalez, R. Arriaga Nava, G. De La Peña Topete, L.A. Elizondo Sifuentes, H.R. Hernández García, J. Illescas-Diaz, M.A. Macías Islas, J.A. Noriega Arellano, R. Olvera Ruiz, J.Z. Parra Carrillo, G. Velasco Sánchez, M. Vidrio Velásquez; the Netherlands : F.W.A. Verheugt (NC), N.J. Holwerda (NL), D.C.G. Basart, A.J.M. Boermans, H.A. Bosker, K.P. Bouter, C.P. Buiks, W.A. de Backer, J. J. de Graaf, J.H.M. Deppenbroek, F.D. Eefting, F.C.N.M. Gunneweg, H.R. Michels, D. Poldermans, G. Schrijver, M.I. Sedney, T. Slagboom, J.G. Smilde, G.E.M.G. Storms, R.M. Tjon, P.F.M.M. van Bergen, G.J.M. van Doesburg, L.H.J. van Kempen, H.F.C.M. van Mierlo, A. Veerman, F.A.A.M. Vermetten, A. Wester; New Zealand : W. Bagg, J. Benatar, R.J. Coxon, R.N. Doughty, D.H. Friedlander, R.A. Luke, P.L. Nairn, Y. Ratnasabapathy, A.M. Richards, G.P. Singh, R.A.H. Stewart, R.W. Troughton, H.D. White, M. Williams, S.P. Wong; Norway: K. Dickstein (NL), N. Bogale, J.O. Lier, J.E. Otterstad, P.K. Rønnevik, S. Skeie, P.O. Walle; Philippines : A.L. Dans (NC), M.T.B. Abola, J.C. Añonuevo, J.M. Jaro, D.R. Marañon, V.L. Mendoza, D.R. Morales, E.P. Pacheco, E.B. Reyes, A.A. Roxas, M.B. Sedurante; Poland : L. Ceremuzynski (NC), A. Budaj (NC), Z. Binio, M. Bronisz, P. Buszman, T. Czerski, M. Dalkowski, J. Gessek, A. Gieroba, K. Janik, M. Janion, T. Kawka-Urbanek, R. Klabisz, M. Krauze-Wielicka, S. Malinowski, P. Miekus, J. Mormul, M. Ogorek, G. Opolski, M. Skura, M. Szpajer, M. Tendera, T. Waszyrowski, M. Wierzchowiecki, B. Zalska; Portugal : R. Ferreira (NC), R. Capucho, C. Correia, L. Cunha, J.M. Ferro, V. Gama Ribeiro, V. Gil, P. Marques da Silva, M. Oliveira Carrageta, R. Sebra Gomes, M. Veloso Gomes; Russia : I. Chazova (NC), F. Ageev, Y. Belenkov, A. Ivleva, Y. Karpov, M. Shestakova, E. Shlyakhto, S. Shustov, B. Sidorenko; Singapore: H.M. Chang, B. Kwok; Slovakia : G. Fodor (NC), A. Dukát, J. Gonsorcík, M. Hranai, J. Lietava, D. Pella, R. Rybar, L. Ruffini; South Africa: P. Commerford (NC), F. Bonnici, B. Brown, A.J. Dalby, G.J. Gibson, L. Herbst, J. King, E. Klug, M. Middle, D. P. Naidoo, M. Pretorius, G. Podgorski, N. Ranjith, K. Silwa-Hahnle, H. Theron; South Korea : J.H. Kim (NC), S.C. Chae, N.S. Chung, K.P. Hong, M.H. Jeong, H.J. Kang, J.J. Kim, M.H. Kim, H.S. Seo, E.K. Shin; Spain : J. Redón (NC), J. Abellán, P. Aranda, V. Barrios, C. Calvo, M. De La Figuera, E. De Teresa, R. Durá, F. Escobar, F. Fernandez-Cruz, E. Galve, J. Garcia-Puig, B. Gil-Extremera, R. Gomis, O. Gonzalez-Albarran, J.R. González-Juanatey, A. Llacer, L. López-Bescós, J. Oliván, A. Picó, A. Pose, A. Roca-Cusachs, L.M. Ruilope; Sweden : L. Rydén (NC), A. Alvång, P.-Å. Boström, M. Dellborg, U.-B. Ericsson, J. Herlitz, T. Juhlin, K. Pedersen, B. Sträng, B. Sundqvist, B.-O. Tengmark, G. Ulvenstam, B. Westerdahl, L. Winberg; Switzerland : T.R. Luescher (NC), I. Baumgartner, P. Dubach, A. Gallino, T. Moccetti, G. Noll, A. Nordmann, H. Rickli, H. Schläpfer, K. Weber; Taiwan : J.-H. Chen (NC), T.H. Chao, C.Y. Chen, J.J. Cheng, H.C. Chiou, C.C. Fu, M. Fu, W.T. Lai, Y.H. Li, L.M. Lien, C.D. Tsai, J.H. Wang, P.S. Yeh; Thailand : S. Chaithiraphan (NC), T. Chantadansuwan, K. Jirasirirojanakorn, R. Krittayaphong, P. Laothavorn, N. Mahanonda, S. Sitthisook, S. Tanomsup, S. Tansuphaswadikul, P. Tatsanavivat, S. Yamwong; Turkey : A. Oto (NC), M. Akin, N.T. Caglar, A. Ergin, H. Müderrisoglu, A. Oguz, Z. Ongen, V. Sansoy, T. Tetiker, A. Uysal; Ukraine : A. Parkhomenko (NC), E. Amosova, O. Cherkasova, Y. Dykun, G. Dzyak, A. Galystska, O. Grishyna, O. Jaremenko, L. Kononenko, E. Koval, V. Kovalenko, V. Netyazhenko, T. Pertseva, A. Prokhorov, G. Radchenko, Y.U. Rudyk, Y. Sirenko, A. Skarzhevsky; United Arab Emirates: A.S. Binbrek (NC), A.A.R. Al Hajiri, E. Al Hatou, A.A.S. Al-Sousi, M. Alomairi, I. Maqsood Wajib; United Kingdom: P. Sleight (NC), A.A.J. Adgey, R. Andrews, S.G. Ball, D.H. Barer, A.H. Barnett, A.B. Bridges, V. Bryson, A.S. Cowie, A.J. De Belder, R. Donnelly, C.M. Francis, J. Furnace, S.K. Glen, N. Gough, A.M. Heagerty, P.R. Jackson, S.H.D. Jackson, E. Joyce, D.J. McEneaney, A.J. Moriarty, D.L. Murdoch, J.P. O’Hare, W.J. Penny, C.J. Reid, J. Tilley, J.P. Vora, J. Webster, B. Williams; United States: J. Probstfield (NC), M. Weber (NC), J. Young (NC), I. Ahmed, I.S. Anand, J.L. Anderson, J.S. Aponte Pagán, J. Barzilay, J.N. Basile, P.F. Bass III, S.S. Blumenthal, W.J. Bommer, D.F. Brautigam, C.D. Brown, N. Brown, J.D. Byrum, A.A. Carr, J. Chinn, D. Chiu, N.R. Cho, J.O. Ciocon, P.J. Colón-Ortíz, J.B. Cruz, W.D. Dachman, G.M. Dolson, S.G. Dorfman, W. Drummond, C. East, F. Eelani, H.S. Ellison, J.V. Felicetta, M.H. Fishbach, R.W. Force, S.J. Giddings, M.C. Goldberg, S. Goldman, R. Gomez Adrover, S.L. Goss, S.P. Graham, C.B. Granger, M.M. Greenspan, R.H. Grimm, G.B. Habib, M.R. Hagen, P.D. Hart, T.J. Hartney, M.A. Henriquez, J.J. Holland, B.J. Hoogwerf, M. Hossfeld, A.K. Jacobson, M.J. Jelley, T.V. Jones, R.A. Kaplan, D.G. Karalis, L.A. Katz, D.J. Kereiakes, M. Khan, R.M. Kipperman, M.J. Kozinn, J.G. Kozlowski, E.W. Lader, C. Landau, J.S. Landzberg, D. Laughrun, S.J. Lewis, C.S. Liang, M.C. Limacher, P.E. Linz, T.S. Lo, F. Lopez-Arostegui, R.R. Maddox, P.R. Mahrer, M.S. Maurer, D.K. McGuire, A.D. Mercando, J.H. Mersey, M. Meyer, A.N. Mooss, P. Narayan, S. Oparil, D.N. Padhiar, A.L. Phillips, M. Prisant, N. Qureshi, M.P. Raghuwanshi, R.R. Randall, T.M. Retta, R.E. Ringrose, A.A. Rizvi, M.D. Rizvi, M.G. Saklayen, S. Sastrasinh, I.K. Savani, A. Schlau, H.S. Schultz, M.J. Schweiger, R.D. Smith, M. Sosa-Padilla, D. Streja, T.P. Stuver, D.C. Subich, F.C. Sulak, W.A. Swagler III, M. Taitano, J.A. Tavarez-Valle, E.M. Taylor, M.L. Tuck, W.B. White, W.J. Wickemeyer, T.B. Wiegmann, P.A. Zee, X.Q. Zhao. ORIGIN Office Staff, National Coordinators, Investigators, and Key Staff: Operations committee: H. Gerstein (Co-chair and Co-PI), S. Yusuf (Co-chair and Co-PI), L. Rydén (European Co-chair), J. Bosch (Project Director), L. Richardson (European Project Office), G. Dagenais, R. Diaz, P Johnston, A. Maggioni, J Probstfield, A. Ramachandran, M. Riddle, R. Vige. Steering committee: H. Gerstein (Co-chair and Co-PI), S. Yusuf (co-chair and co-PI), L. Rydén (European co-chair), K. Birkeland, J. Bosch (project director), A. Budaj, E. Cardona, I. Chazova, P. Commerford, G. Dagenais, R. Diaz, L. Danilova, M. Davies, R. Fernando, G. Fodor, R. Gilbert, R. Gomis, N. Hâncu, M. Hanefeld, P. Hildebrandt, P. Johnston, G. Kacerovsky-Bielesz, M. Keltai, J.H. Kim, H. Krum, H. Kültürsay, F. Lanas, B.S. Lewis, E. Lonn, P. López-Jaramillo, A. Maggioni, J. Marin-Neto, M. Marre, R McKelvie, M. McQueen, I. Mendoza, C. Morillo, C. Pan, V. Pīrāgs, J. Probstfield, V. Profozic, A. Ramachandran, R. Ratner, M. Riddle, L. Richardson (European Project Office), J. Rosenstock, G.A. Spinas, S. Sreenan, I. Stoel, M. Syvänne, R. Vige, J.F. Yale. Event adjudication committee: G. Dagenais (chair), R. McKelvie (co-chair), A. Avezum, M.C. Bahit, P. Bogaty, L. Bordeleau, C. Chacόn, M. Corson, G. Fodor, W.L. Harper, D. Halon, P. Hildebrandt, P Magloire, J. Mann, C. Morillo, V. Pavlova, Z. Punthakee, J. Silva, M. Syvänne, B. Tsang, N. Yakubovich. Substudy and publications committee: A. Maggioni (co-chair), J. Probstfield (co-chair), P. Commerford, M. Davies, R. Gilbert, P. Johnston, J. Marin-Neto, M. McQueen; Glycemia management committee: H. Gerstein, M. Hanefeld, P. Johnston, A. Ramachandran, R. Ratner, M. Riddle, J. Rosenstock, J.F. Yale; Global project office: A. Abdallah, S. Ahmad, J. Bosch, J. Chandra, R. Chandra, T. Cukierman-Yaffee, L. Dyal, H. Gerstein, H. Jung, L. Joldersma, L. MacRae, S. MacRae, S. Malik, A. Mead, F. Pasha, J. Pazmino-Canizares, J. Pogue, K. Pohl, L. Richardson, A. Sakalas, J. Tyrwhitt, S. Yusuf. Site investigators by country: Argentina : R. Diaz, R. Ahuad Guerrero, A. Alebuena, N. Alvarez, M. Alzogaray, M. Amuchastegui, M. Andres, M. Angos, H. Baglivo, M. Barbieri, F. Bassi, F. Bello, J. Bono, M. Bustamante Labarta, B. Bustos, A. Caccavo, M. Calveira, A. Camino, M. Cantero, M. Capozzi, M. Cardone, L. Cartasegna, A. Cassetari, R. Castellanos, R. Chavez Caballero, M. Cipullo, A. Contreras, J. Coria, F. Corinaldesi, G. Costa, C. Crespo, M. Cruz, J. Cuello, C. Cuneo, I. Del Corro, R. Diez, C. Dituro, A. Dominguez, A. Facta, C. Faingold, M. Farah, A. Fares Taie, A. Fernandez, A. Ferrari, N. Ferrari, C. Garcia Monteverde, M. Garrido, C. Giachello, M. Gonzalez, N. Gutierrez, L. Guzman, P. Guzman, E. Hasbani, R. Henquin, A. Hershon, A. Hirschon Alvarez Prado, M. Hominal, A. Hrabar, H. Imposti, M. La Grutta, P. Lanchiotti, L. Lobo Marquez, R. Lopez Santi, J. Lowenstein, M. Lugo, M. Luqueci, S. Mainini, C. Majul, R. Manzano, S. Manzur, G. Marcucci, M. Marino, F. Massari, N. Mendez, M. Molina, O. Montaña, M. Mulazzi, L. Nardone, I. Odetto, A. Orlandini, A. Oviedo, O. Paez, A. Parnas, F. Risso Patron, C. Pedernera, M. Pelagagge, M. Plastino, P. Polari, J. Pomposiello, A. Porta, A. Prado, M. Quiroz, A. Ramirez, C. Rodriguez, M. Rodriguez, R. Ronderos, L. Sago, A. Sanchez, R. Sanchez, A. Sandrin, P. Schygiel, V. Sernia, I. Sinay, T. Smith Casabella, A. Sosa Liprandi, M. Sosa Liprandi, L. Soso, G. Sposetti, D. Stisman, P. Streitenberger, G. Suarez, H. Tonin, M. Ulla, J. Valdez, M. Vico, A. Villamil, A. Villarino, A. Viscaya Castro, V. Visco, D. Vogel, F. Waisman, C. Zaidman; Australia : H. Krum, J. Amerena, A. Applebe, P. Aylward, M. Binnekamp, I. Bruce, C. Burdeniuk, R. Burnet, P. Colman, D. Colquhoun, S. Davis, F. De Looze, C. De Pasquale, M. D'Emden, H. Eaton, A. Farshid, S. Foulanos, J. Galanos, G. Gordon, M. Guhu, J. Ho, I. Jeffery, G. Jerums, M. Kwan, J. Lefkovits, S. Luu, R. MacIsaac, J. Marjason, V. Mohabbati, A. Nankervis, D. O'Neal, N. Perera, A. Poynten, A. Rahman, S. Razak, T. Roberts, M. Sebastian, R. Simpson, G. Soldatos, D. Sullivan, H. Teede, F. Tiong, D. Topliss, D. Torpy, K. Waddell-Smith, J. Waites, J. Wenman, A. Whelan, L. Williams, B. Yeap, W. Yeow, G. Yong; Austria : G. Kacerovsky-Bielesz, S. Aczel, N. Azimy, P. Bertha, J. Blocher, C. Bohnel, H. Brath, J. Breuss, A. De Campo, H. Drexel, Y. Ettmuller, A. Feder, C. Feinboeck, E. Gulz, M. Hofmann, F. Hoppichler, H. Jahnel, V. Jankovic, T. Kann, T. Kathrein, T. Kotter, E. Kratz, E. Kreuzwieser, C. Loreck, B. Ludvik, T. Marte, K. Mellitzer, S. Nistler, G. Placher-Sorko, R. Prager, P. Rein, M. Riedl, C. Säly, G. Schernthaner, E. Schichka, C. Seidlhofer, M. Sonnenfeld, H. Stefan, K. Steiner, B. Thomas, H. Toplak, K. Urstoger, B. Vetter, A. Vonbank, W. Waldschutz, F. Wallner, F. Winkler; Belarus : L. Danilova, D. Goncharik, I. Lazareva, N. Lichorad, A. Mrochek, N. Murashko, D. Radyuk, A. Ramanovski, S. Sudzhaeva, V. Sujayeva, N. Yarashevich; Bermuda : G. Campbell, S. Marshall, A. West; Brazil : J. Marin-Neto, F. Abreu, M. Alves, J. Ayoub-Aidar, M. Barros, J. Barros-Silveira, M. Blacher, E. Costa, F. Costa, C. Daltro, J. Delana, F. Eliaschewitz, C. Facanha, G. Feitosa, J. Figueiredo, A. Forti, D. Franco, M. Franken, F. Freire, V. Garcia, A. Gouvea-Neto, S. Grofallo, N. Kanedlai, J. Kerr-Saraiva, R. Ladeira, P. Leaes, M. Lemos, F. Lima, M. Lima Filho, L. Macedo, E. Manenti, J. Marin-Neto, O. Monte, A. Mossman, F. Mothe, O. Mouco, M. Moyses Golbert, L. Nasser Hissa, M. Nasser-Hissa, J. Nicolau, L. Nigro Maia, T. Ninno, C. Nunes, C. Oliveira, O. Oliveira, R. Passos da Silva, J. Pericles-Esteves, L. Rabelo, A. Rabelo-Alves Jr., S. Rassi, R. Rech, F. Roldan, J. Salles, C. Sampaio, A. Seabra, N. Sealissi, A. Seixas, R. Sena, I. Shehadeh, M. Teixeira, H. Turin, C. Vicente Serrano Jr., M. Vidigal, M. Vilela, B. Wajchenberg; Canada : G. Dagenais, E. Lonn, C. Abbott, A. Abu-Bakare, J. Ardilouze, E. Auersperg, A. Bailey, G. Bailey, J. Baillargeon, C. Beaurivage, J. Belair, A. Belanger, D. Bellabarba, J. Berlingieri, F. Bernier, R. Bhargava, T. Bhesania, W. Booth, S. Bose, M. Boulianne, S. Bourgeois, D. Breton, R. Brossoit, J. Buithieu, J. Campeau, B. Carlson, A. Carpentier, R. Cavalcanti, J. Cha, P. Chagnon, Y. Chan, C. Chessex, J. Chiasson, S. Chouinard, D. Clayton, J. Conway, J. Crepeau, D. Cudmore, G. D'Ignazio, G. Doig, M. Dominguez, F. Dube, R. Dumas, R. Dupuis, I. Dyrda, D. Eddy, D. Eiley, H. Fox, S. Fratesi, S. Gallant, C. Garceau, N. Garfield, C. Germain, S. Glazer, G. Gosselin, D. Gould, G. Grills, J. Halle, P. Hardin, W. Harper, J. Heath, V. Heath, M. Hivert, K. Ho, G. Houde, I. Hramiak, A. Hutchinson, T. Huynh, R. Ilie-Haynes, S. Imran, A. Islam, M. Iwanochko, C. Jones, C. Joyce, I. Kirouac, R. Kumar, M. Lamothe, M. Langlois, C. Lauzon, M. Lavoie, R. Leader, S. Lecours, S. Lepage, H. Lochnan, P. Ma, S. Malik, A. McLean, S. Mecci, P. Mehta, M. Mercier, D. Miller, A. Morisset, S. Nawaz, W. Nisker, G. Nyomba, D. O'Keefe, J. Palardy, P. Parekh, T. Paul, P. Perron, M. Pesant, R. Phillips, G. Pruneau, I. Quintin, K. Raby, C. Richard, G. Rosenfeld, D. Saulnier, J. Shaban, A. Shah, D. Shu, R. Sigal, M. Silverman, J. Singh, W. Sivucha, A. Skamene, D. Sliwowicz, R. Smith, R. St. Hilaire, D. Steinson, B. Sussex, K. Tan, R. Tannous, A. Telner, P. Theroux, C. Tsoukas, G. Tsoukas, J. van Buuren, N. Van Rossum, R. Vexler, S. Vizel, W. Warnica, M. Weingert, R. Wilson, R. Wilson, W. Wong, V. Woo, J. Yale; Chile : F. Lanas, M. Acevedo, C. Alwyn, E. Baier, S. Baier, R. Galloso, R. Lahsen, G. Lorenas, A. Montecinos, M. Montecinos, P. Pineda, F. Pollak, J. Sapunar, V. Serrano, B. Stockins, P. Varleta, J. Yovanovich, F. Zambra; China : C. Pan, J. Ba, Y. Bao, Y. Bi, S. Bu, B. Chen, H. Chen, H. Chen, J. Chen, L. Chen, L. Chen, M. Chen, Y. Chen, Y. Chen, J. Cui, M. Dong, P. Feng, Z. Feng, C. Gao, F. Gao, X. Gao, Z. Gao, Y. Gong, L. Guang, X. Guo, F. Han, X. Han, X. Hou, R. Hu, L. JI, J. Jia, W. Jia, X. Jiao, X. Jin, J. Kuang, M. Li, Q. Li, X. Li, Y. Li, Y. Ling, F. Liu, Z. Liu, B. Lu, J. Lu, Z. Lu, X. Lv, G. Ning, Y. Peng, Y. Ren, Y. Shao, Y. Shi, X. Shu, H. Sun, L. Sun, X. Sun, K. Tang, H. Tian, H. Tian, C. Wang, F. Wang, L. Wang, Q. Wang, W. Wang, X. Wang, Y. Wang, Y. Wang, J. Wen, C. Wu, H. Wu, H. Wu, J. Wu, M. Wu, X. Xing, Y. Xue, L. Yan, S. Yan, H. Yang, N. Yang, W. Yang, Z. Yang, J. Yao, J. Yao, L. Yao, D. Yu, H. Yu, M. Yu, X. Yu, L. Yuan, M. Yuan, S. Yuan, W. Yuan, Y. Yuan, Z. Yuan, T. Zeng, J. Zhang, R. Zhang, X. Zhang, X. Zhang, L. Zhao, B. Zheng, J. Zheng, J. Zheng, W. Zhou, N. Zhu, Y. Zhu, D. Zou, J. Zou; Colombia : P. Lopez-Jaramillo, C. Morillo, J.L. Accini, R. Bohorquez, R. Botero, C. Cure, M. Figueredo, E. Hernandez, W. Kattah, A. Llamas, L. Orozco, L. Pava, M. Perez, M. Pineda, A. Quintero, R. Quiros, M. Urina, S. Velez: Croatia : V. Profozic, V. Altabas, I. Baotic, M. Berkovic, V. Goldoni, T. Kerum, G. Mirosevic, D. Tarle, I Vidovic, V. Zjacic-Rotkvic; Denmark : P. Hildebrandt, R. Abbas, H. Andersen, S. Auscher, L. Baumbach, H. Brockstedt, P. Christensen, M. Christiansen, K. Clemmensen, K. Egstrup, G. Gislason, D. Haar, K. Hansen, P. Heden Andersen, K. Helleberg, K. Hermansen, J. Holmer, J. Jeppesen, I. Klausen, T. Koustrup-Sonder, T. Krarup, S. Lerche, H. Lervang, B. Linde, P. Lund, S. Lund, S. Madsbed, J. Molvig, C. Orskov, O. Ostergaaard, H. Perrild, A. Pietraszek, N. Ralfkjaer, H. Roenne, J. Rokkedal Nielsen, M. Seibaek, H. Soendergaard, L. Sorensen, L. Sundahl Mortensen, C. Torp-Pedersen, C. Tuxen, S. Urhammer, E. Vadstrup; Estonia : V. Pirags, A. Ambos, A. Janson, P. Rudenko, L. Viitas; Finland : M. Syvänne, S. Aranko, M. Badeau, J. Eriksson, H. Haapamäki, O. Kajander, A. Kuusisto, S. Luukkonen, J. Mäkelä, S. Nieminen, L. Niskanen, J. Ripatti, S. Ruotsalainen, J. Saltevo, K. Sävelä, J. Strand, T. Valle, A. Virkamäki; France : M. Marre, E. Aboud, L. Alavoine, A. Bekherraz, P. Bohme, H. Bourezane, B. Catargi, G. Charpentier, A. Clergeot, J. Courreges, T. Delmas, F. Duengler, C. Feknous, D. Gendre, B. Guerci, S. Hadjadj, V. Kerlan, N. Laguerre, J. Le Potier, F. Lombardo, E. Malville, R. Marechaud, C. Mattei, J. Moreira, A. Penfornis, C. Petit, J. Pinel, X. Piquel, D. Raccah, Y. Reznik, A. Rod, N. Roudaut, E. Rousseau, F. Schillo, B. Schmitt, E. Sonnet, F. Torremocha, F. Travert, C. Vanhoute, M. Vimeux; Germany : M. Hanefeld, R. Abdollahnia, A. Adamidou, S. Arslan, B. Bach-Kliegel, B. Bartusch, N. Bauer, T. Bieler, H. Blankenfeld, U. Boeckmann, K. Busch, R. Butzer, M. Chenchanna-Merzhaeuser, R. Denger, C. Deutsch, S. Diessel, I. Donati-Hirsch, M. Dornisch, K. Enghofer, T. Fleig, T. Forst, M. Frommherz, K. Goeller, J. Habbig, S. Hadziselimovic, A. Hamann, T. Hampel, S. Heger, C. Helmes, C. Hoffman, C. Hohberg, P. Humpert, A. Kamke, W. Kamke, P. Kindermann, C. Klein, D. Klein, A. Koehler, A. Kuehn, K. Langer, S. Limmer, A. Loew, A. Maimer, C. Marck, G. Meier, M. Methner-Friederich, W. Metzler, K. Meyer, N. Miftari, J. Milde, J. Minnich, M. Molkewehrum, M. Morcos, C. Mueller-Hoff, M. Nguyen, M. Nishwitz, J. Oldenburg, P. Ott, K. Pauli, B. Pauly, A. Pfeiffer, A. Pfuetzner, U. Pischa, R. Radke, P. Reismann, M. Riemer, H. Rochlitz, G. Rudofsky, S. Ruhla, A. Sammler, F. Schaper, K. Schiemenz, G. Scholz, P. Schumm-Draeger, T. Segiet, A. Segner, J. Seissler, S. Spahn, U. Stier, G. Tonon, S. von Amelunxen, C. von Schacky, B. Wilhelm, K. Wilhelm, K. Witt, S. Wuechner-Hofmann; Hungary : M. Keltai, M. Baranyai, Z. Birkus, I. Foldesi, Z. Gaal, E. Harcsa, K. Hati, Z. Hohmann, I. Istenes, I. Jozsef, E. Juhasz, P. Kempler, B. Keresztes, K. Keresztes, P. Kis-Gombos, I. Kovacs, T. Kozma, Z. Laszlo, E. Noori, G. Nyirati, Z. Papp, J. Patkay, F. Poor, P. Pusztai, Z. Putz, E. Rigo, M. Sereg, K. Simon, A. Somogyi, J. Sumegi, A. Szabo, J. Szabo, S. Szigeti, D. Szilveszter, M. Tarko, C. Varga, L. Varga Szabo, P. Voros; India : A. Ramachandran, Arathi, S. Aravind, M. Badgandi, M. Balaji, V. Balaji, S. Chamukuttan, Devi Manduva, S. Fatima, B. Ganapathy, O. George, P. George, M. Jaffar, P. Jain, P. Kamath, V. Karthik, G. Koshy, L. Krishnan, H. Kumar, P. Lal, A. Mithal, S. Modi, V. Mohan, V. Moses, R. Oomen, P. Pais, P. Pati, S. Pendsey, P. Rai, R. Rajagopal, M. Ramu, U. Ranjit, P. Rao, V. Senthil, V. Seshaiah, B. Sethi, P. Shah, R. Sharma, S. Shetty, A. Shobha, R. Siddharth, G. Sridhar, K. Sudeep, C. Sunil, S. Sunitha, S. Suresh, N. Thomas, A. Vageesh; Ireland : S. Sreenan, Z. Anwer, J. Barton, L. Behan, M. Bell, M. Cullen, S. Dineen, M. Draman Yusof, F. Dunne, J. Gibney, T. Hussain, M. Khan, B. Kinsley, P. Kyithar, F. Lavin, A. McGowan, C. McGurk, A. Mirza, B. Mohammadi, T. O'Brien, J. O'Connell, D. O'Halloran, D. O'Shea, G. Roberts, G. Tomkin, W. Wan Mahmood; Israel : B.S. Lewis, R. Abramod-Ness, F. Adawi, B. Aharon, M. Backer, A. Beniashvili, A. Berliner, L. Bloch, D. Bugelman, A. Butnaru, O. Cohen, Y. Cohen, M. Frenkel, M. Glant, B. Gustava, H. Guttman, S. Halabi, D. Halon, I. Harman-Boehm, J. Ilany, B. Karkabi, N. Khader, A. Khaskia, Y. Khudyak, E. Klainman, N. Kogan, D. Lender, I. Levin, T. Mardi, A. Marmor, M. Mosseri, D. Nabriski, M. Omary, S. Orlovsky, D. Peres, M. Quasim, I. Raz, M. Remesnik, O. Rogowski, I. Rozenfeld, D. Scharr, I. Shnifer, T. Shuster, R. Solomon, H. Steiner, D. Tzivoni, N. Wolfson, Z. Yossef, D. Zahger, D. Zeltser, R. Zimlichman; Italy : A. Maggioni, Aina, C. Ariatti, R. Bonetti, F. Cacciatore, F. Calcinaro, G. Corona, P. De Maria, S. Del Prato, G. Derosa, G. Di Pasquale, A. Falorni, R. Fanelli, D. Fedele, G. Filorizzo, R. Fogari, G. Furgi, A. Ghio, C. Giorda, G. Gregori, G. Iannuzzi, A. Lapolla, B. Luciano, P. Lucotti, A. Maggi, L. Marafetti, T. Marchese, G. Martino, S. Marzotti, R. Miccoli, L.D. Monti, L. Moretti, M. Palvarini, R. Petacchi, F. Piarulli, P.M. Piatti, S. Rudi, F. Santeusanio, G. Sesti, E. Setola, A. Sforza, E. Shehaj, M. Veniani, G. Viviani, E. Zigoura; Korea : J.H. Kim, S. Chae, D. Cho, E. Cho, Y. Cho, Y. Choi, M. Chung, E. Hong, Y. Hong, M. Jeong, B. Kim, D. Kim, H. Kim, I. Kim, J. Kim, J. Kim, P. Kim, S. Kim, S. Kim, B. Koo, S. Kwok, H. Kwon, J. Lee, J. Lee, J. Lim, S. Oh, J. Ohn, C. Park, H. Park, K. Park, K. Seung, H. Son, J. Woo, K. Yoon; Latvia : V. Pirags, B. Ansmite, I. Balcere, A. Bumbure, K. Ducena, A. Lejnieks, I. Rasa, R. Ritenberga, M. Romanova, I. Salmina, S. Steina; Lithuania : V. Pirags, J. Badariene, S. Gailiuniene, S. Grigonis, R. Juskiene, Z. Petrulioniene, G. Sakalyte, T. Stasiunas, M. Sulskiene, B. Urbonaite, R. Zarankiene, R Ziukaite; Mexico : E. Cardona, R. Arechavaleta, T. Beltran-Jaramillo, C. Calvo-Vargas, C. Campillo-Cardenas, D. Cardona, J. Carmona-Huerta, M. Cedano-Limon, M. Comellas-De Armas, C. Dominguez, J. Gomez-Cruz, R. Gonzalez-Perez, J. Illescas, S. Jimenez-Ramos, A. Lopez-Alvarado, E. Marquez-Rodriguez, G. Martinez, S. Pascoe, O. Plascencia Vazquez, H. Rodriguez, M. Ruiz-Cornejo, G. Velasco-Sanchez, M. Vidrio-Velazquez, E. Villeda-Espinosa; Netherlands : I. Stoel, E. Badings, G. Bartels, P. Bruggink-Andre de la Porte, E. Bruijns, J. Cornel, P. De Milliano, M. De Mulder, J. De Swart, A. Derks, A. Dirkali, J. Droste, M. Galjee, R. Hautvast, W. Hermans, N. Holwerda, B. Ilmer, M. Kofflard, J. Kooistra-Huizer, M. Kurvers, J. Langerveld, C. Leenders, A. Liem, D. Lok, D. Neumann, P. Nierop, K. Plomp, J. Posma, C. Reichert, H. Roeters Van Lennep, E. Ronner, S. Said, L. Takens, V. Umans, A.A. Van der Sluis, C. Van der Zwaan, J. Van Dobbenburgh, A. Van Es, M. Van Hessen, R. Van Mechelen, A. Van Miltenburg-Van Zijl, L. Van Zeijl, M. Veerhoek, E. Viergever, E.E. Weijers, F. Willems; Norway : K. Birkeland, I. Blix, J. Cooper, A. Debowska, K. Erichsen, J. Fossum, E. Gjertsen, V. Grill, S. Gudnason, K. Hoye, H. Istad, J. Winther, R. Joakimsen, R. Jorde, I. Larsen, B. Mella, J. Otterstad, K. Risberg, K. Skare, S. Skeie, L. Sommervoll, A. Tandberg, R. Whitfield, C. Wium; Philippines : R. Fernando, E. Cunanan, E. Fernando-Catindig, M. Gomez, C. Jaring, F. Lantion-Ang, M. Licaros, J. Lim, M. Lim-Abrahan, E. Madronio, A. Panelo, J. Raboca, G. Ramos, S. Tugna; Poland : A. Budaj, E. Aksamit-Bialoszewska, E. Bandurska-Stankiewicz, M. Baranska, A. Bronisz, M. Bronisz, W. Chrustowski, B. Cieslak, L. Czupryniak, B. Drazkowicz-Gozdzik, A. Galuszka-Bilinska, M. Gmytrasiewicz, K. Janik, K. Jedynasty, G. Kania, T. Kawka-Urbanek, I. Kinalska, K. Kincel, U. Kleszczewska, J. Kruszewski, J. Loba, J. Malicka, M. Mielecka-Kincel, A. Milczarczyk, D. Milosz, A. Mrowczynska, M. Mytnik, A. Nowakowski, P. Nowakowski, L. Oleskowska, E. Omelanczuk-Wiech, M. Pawlowski, A. Poplawska, M. Rucinska, M. Rucinski, J. Rutkowska, M. Saryusz-Wolska, K. Siewko, M. Sikora-Frac, J. Stecka-Wierzbicka, M. Swiatkowski, R. Swierczynski, M. Szpajer, K. Szymkowiak, J. Tarach, U. Tarasiewicz, D. Wiatr, P. Wojewoda, H. Woszczak-Marcinkowska, J. Zadrozny; Romania : N. Hancu, A. Albota, C. Bala, D. Barbonta, G. Botnariu, O. Bradescu, M. Busegeanu, M. Bzduch, D. Catrinoiu, R. Caziuc, A. Cerghizan, D. Cheta, A. Cif, D. Ciomos, D. Cosma, G. Creteanu, I. Crisan, R. Danciulescu, C. Dobjanschi, R. Dodan, L. Duma, I. Ferariu, T. Ghenes, G. Ghise, M. Graur, M. Ilinca, R. Marton, N. Mindrescu, A. Morosanu, M. Morosanu, M. Mota, V. Nafornita, G. Negrisan, S. Nicodim, A. Nicolau, C. Nita, A. Onaca, C. Panus, N. Pletea, C. Pop, L. Pop, B. Popa, G. Roman, M. Rosu, N. Sandu, V. Serban, A. Sima, L. Stamoran, M. Strugariu, G. Suciu, I. Szilagyi, G. Vacaru, I. Veresiu, A. Vlad; Russia : I. Chazova, T. Adasheva, F. Ageev, N. Akhmedganov, A. Akinina, A. Alexandrov, L. Ambatiello, A. Ametov, A. Ausheva, L. Babaeva, A. Babenko, E. Balyasnikova, B. Bart, J. Belova, L. Berstein, I. Bondarenko, E. Bondarev, O. Bulkina, N. Chernikova, B. Chumak, T. Deeva, O. Demicheva, T. Demidova, E. Doskina, A. Duganova, N. Dzhaiani, I. Egorova, O. Ettinger, S. Feofanova, T. Fofanova, P. Galaktionov, N. Gavrilova, S. Gilyarevsky, N. Gnidkina, A. Golubev, N. Gornyakova, S. Grigorova, E. Grineva, V. Gurevich, N. Irtuganov, L. Ivanova, N. Jaiani, M. Kalashnikova, Y. Karpov, Y. Khalimov, G. Khorocheva, E. Kirillova, J. Kistner, Z. Kobalava, I. Kochergina, T. Kravchenko, K. Krylov P. Kulkova, I. Kuparev, E. Kurbanova, T. Lysenko, A. Markovich, I. Martyanova, T. Martynyuk, M. Masiinvets, E. Mavlyavieva, E. Maychuk, G. Melnichenko, M. Mikhailusova, A. Mkrtumyan, V. Mychka, D. Nebieridze, E. Nesterova, V. Orlov, V. Orlova, Y. Orlova, F. Papov, I. Patroucherva, N. Petunina, S. Pirozhinskaya, S. Podachina, S. Postnikova, O. Pshikova, L. Rogova, B. Romashevskiy, N. Runikhina, I. Sadulayeva, A. Safaryan, E. Sakovich, T. Saprikina, V. Sargsyan, O. Semikozova, E. Shkolnik, A. Shubina, S. Shustov, I. Sinitsina, E. Solovyeva, G. Storogakov, O. Stovpyuk, A. Sussekov, M. Telnova, A. Temirov, V. Terekhov, S. Tereschenko, T. Tiourina, V. Tolkacheva, U. Tsoy, S. Urazgyldeeva, Y. Vasyuk, N. Vinnitskay, E. Voevodina, A. Volkova, V. Zadionchenko, A. Zalevskaya, T. Zhelninova, N. Zhukova, A. Zilov; Slovakia : G. Fodor, J. Bernatova, T. Duris, I. Markova, E. Martinka, L. Michalova, P. Minarik, L. Peter, K. Raslova, D. Silvia, M. Subadova, J. Tisonova, B. Vohnout; South Africa : P. Commerford, M. Adam, A. Badat, A. Bester, F. Bester, L. Blacking, D. Bouwer, B. Brice, S. Cassimjee, T. Cronje, J. Deftereos, L. Distiller, G. Ellis, O. Forster, M. Fulat, M. Gani, G. Gibson, S. Hansa, N. Hendricks, L. Herbst, J. Hitzeroth, B. Joffe, C. Kelbe, D. Kelbe, J. King, B. Kramer, S. Landau, N. Levitt, S. Meyer-Nell, R. Moore, D. Muller, H. Nell, M. Omar, H. Randeree, M. Seeber, Seedat, D. Segynu, M. Siebert, E. Van Den Berg, P. Van Der Walt, C. Van Dyk, F. Van Niekerk, L. Van Zyl, H. Wellman Spain : R. Gomis, V. Bertomeu, M. Botella, M. Buño, A. Calle, J. Cano Perez, M. Coves, J.G. Juanatey, R. Garcia-Mayor, S. Gaztambide, A. Gippini, I. Goikolea, J. Gonzalez, N. Hillman, V. Lopez Garcia Aranda, I. Magueda, J. Mato, P. Mazon, P. Morillas, A. Novials, L. Pallardo, L. Perez, J. Rodriguez, L. Romero, E. Sagarra, L. Shamagian, A. Soto, H. Torrealday, R. Valero; Sweden : L. Rydén, S. Agergaard, S. Agewall, K. Andersson, O. Bergstrom, M. Bjornstedt Bennermo, J. Blomgren, K. Boman, G. Brohall, C. Cherfan, C. Dahlen, A. Dotevall, P. Enander, U. Ericsson, P. Hallgren, A. Hansson, L. Henareh, P. Henriksson, J. Herlitz, J. Holmqvist, G. Jarevi, C. Linderfalk, L. Jonasson, S. Jovinge, J. Kalen, M. Kilstrup, M. Leosdotir, J. Leppert, B. Linde, J. Ljungberg, B. Löfdahl, P. Lundman, C. LysellBergstrom, U. Mathiesen, L. Mellbin, S. Mörner, D. Nathanson, L. Nilsson, M. Peterson, S. Quittenbaum, A. Rosengren, B. Ryttberg, S. Scheel, K. 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Papademetriou, M. Pilar Solano, R. Ratner, J. Rosenstock, L. Sameshima, V. Savarese, J. Schnure, D. Schuster, J. Shin, A. Taylor, P. Thomson, M. Ting-Ryan, D. Trence, A. Vo, K. Weiland, K. Wells, P. Wu, M. Zimering, R. Zimmerman Venezuela : I. Mendoza, P. Ascanio, I. Brajkovich, E. Carrillo, J. Coll, K. Gonzalez, N. Gonzalez, E. Jimenez, R. Lopez, D. Marante, I. Morr, M. Paolillo, D. Perche, M. Portillo, H. Valbuena, M. Velarde, G. Vergara.

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A Systematic Literature Review on Types of Augmented Reality (AR) Technologies and Learning Strategies for Problem-Solving

Augmented reality (AR) technology has gained popularity among educators over the past decade in line with the development of Industrial Revolution 4.0 and the 21st century learning concept. Previous studies have provided evidence that students’ engagement in AR, in general, facilitates the development of problem-solving skills required in the field of education. However, there has been a lack of systematic research on the correlation between AR technologies and learning strategies, as well as the problem-solving methods utilized. Therefore, this study aimed to examine types of AR technologies utilized and their integration with learning strategies and problem-solving methods employed in education. The methodology of this study involved employing the preferred reporting items for systematic reviews and meta?analyses (PRISMA) approach, based on references from reputable online databases, namely Web of Science, Scopus, and ScienceDirect. The study analyzed publications from 2018 to 2023, with a total of 14 selected articles (N = 14). The findings show that the most popular type of AR technology was marker-based AR. In addition, the most dominant learning strategy was problem-based learning (PBL), with the specific problem-solving approach being the computational thinking approach. In conclusion, these findings will provide guidance regarding the types of AR technologies that have been integrated with learning strategies and problem-solving methods. By identifying the limitations of the analyzed AR technologies and learning strategies, new research opportunities can emerge, focusing on integrating emerging AR technologies with problem-solving methods that may be more effective in the learning process.

https://doi.org/10.26803/ijlter.23.5.4

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Pracademia—Role Modelling HyFlex Digital Pedagogies in Youth Work Education

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• Published: 01 June 2024

Cite this article

• Hayley Douglas   ORCID: orcid.org/0000-0002-2789-621X 1 ,
• Jess Achilleos   ORCID: orcid.org/0000-0003-1936-5774 1 ,
• Yasmin Washbrook   ORCID: orcid.org/0000-0002-5692-7142 1 &
• Mandy Robbins   ORCID: orcid.org/0000-0003-0834-4126 2  

This research evaluates the experience of educators and students engaging in HyFlex learning experiences on a university Youth Work programme during the Covid-19 pandemic. Adopting a mixed methods approach, the research identifies challenges, opportunities, and possibilities of HyFlex learning. The research explores how digital skills gained in the classroom supported students to be more confident in role modelling these to deliver Digital Youth Work and support them in a post-Covid-19 environment. HyFlex pedagogies supported the development of pracademics, creating opportunities for learning in the classroom and translating this into real-world practice. Themes of time, technology, accessibility, and communities of practice (COP) are also discussed. Recommendations are made for future Higher Education practice which can be applied beyond Youth Work programmes.

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Data Availability

The data that support the findings of this study are available from the corresponding author, Jess Achilleos, upon reasonable request.

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Hayley Douglas: literature review, lead researcher, final editing; Jess Achilleos: qualitative data analysis, findings and discussion, deputy lead researcher, editing; Yasmin Washbrook: methodology, reference editing; Mandy Robbins: quantitative data analysis.

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Douglas, H., Achilleos, J., Washbrook, Y. et al. Pracademia—Role Modelling HyFlex Digital Pedagogies in Youth Work Education. JAYS (2024). https://doi.org/10.1007/s43151-024-00128-z

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Differential attainment in assessment of postgraduate surgical trainees: a scoping review

• Rebecca L. Jones 1 , 2 ,
• Suwimol Prusmetikul 1 , 3 &
• Sarah Whitehorn 1  

BMC Medical Education volume  24 , Article number:  597 ( 2024 ) Cite this article

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Introduction

Solving disparities in assessments is crucial to a successful surgical training programme. The first step in levelling these inequalities is recognising in what contexts they occur, and what protected characteristics are potentially implicated.

This scoping review was based on Arksey & O’Malley’s guiding principles. OVID and Embase were used to identify articles, which were then screened by three reviewers.

From an initial 358 articles, 53 reported on the presence of differential attainment in postgraduate surgical assessments. The majority were quantitative studies (77.4%), using retrospective designs. 11.3% were qualitative. Differential attainment affects a varied range of protected characteristics. The characteristics most likely to be investigated were gender (85%), ethnicity (37%) and socioeconomic background (7.5%). Evidence of inequalities are present in many types of assessment, including: academic achievements, assessments of progression in training, workplace-based assessments, logs of surgical experience and tests of technical skills.

Attainment gaps have been demonstrated in many types of assessment, including supposedly “objective” written assessments and at revalidation. Further research is necessary to delineate the most effective methods to eliminate bias in higher surgical training. Surgical curriculum providers should be informed by the available literature on inequalities in surgical training, as well as other neighbouring specialties such as medicine or general practice, when designing assessments and considering how to mitigate for potential causes of differential attainment.

Peer Review reports

Diversity in the surgical workforce has been a hot topic for the last 10 years, increasing in traction following the BlackLivesMatter movement in 2016 [ 1 ]. In the UK this culminated in publication of the Kennedy report in 2021 [ 2 ]. Before this the focus was principally on gender imbalance in surgery, with the 2010 Surgical Workforce report only reporting gender percentages by speciality, with no comment on racial profile, sexuality distribution, disability occurrence, or socioeconomic background [ 3 ].

Gender is not the only protected characteristic deserving of equity in surgery; many groups find themselves at a disadvantage during postgraduate surgical examinations [ 4 ] and at revalidation [ 5 ]. This phenomenon is termed ‘differential attainment’ (DA), in which disparities in educational outcomes, progression rates, or achievements between groups with protected characteristics occur [ 4 ]. This may be due to the assessors’ subconscious bias, or a deficit in training and education before assessment.

One of the four pillars of medical ethics is “justice”, emphasising that healthcare should be provided in a fair, equitable, and ethical manner, benefiting all individuals and promoting the well-being of society as a whole. This applies not only to our patients but also to our colleagues; training should be provided in a fair, equitable, and ethical manner, benefiting all. By applying the principle of justice to surgical trainees, we can create an environment that is supportive, inclusive, and conducive to professional growth and well-being.

A diverse consultant body is crucial for providing high-quality healthcare to a diverse patient population. It has been shown that patients are happier when cared for by a doctor with the same ethnic background [ 6 ]. Takeshita et al. [ 6 ] proposed this is due to a greater likelihood of mutual understanding of cultural values, beliefs, and preferences and is therefore more likely to cultivate a trusting relationship, leading to accurate diagnosis, treatment adherence and improved patient understanding. As such, ensuring that all trainees are justly educated and assessed throughout their training may contribute to improving patient care by diversifying the consultant body.

Surgery is well known to have its own specific culture, language, and social rules which are unique even within the world of medicine [ 7 , 8 ]. Through training, graduates develop into surgeons, distinct from other physicians and practitioners [ 9 ]. As such, research conducted in other medical domains is not automatically applicable to surgery, and behavioural interventions focused on reducing or eliminating bias in training need to be tailored specifically to surgical settings.

Consequently, it’s important that the surgical community asks the questions:

Does DA exist in postgraduate surgical training, and to what extent?

Why does DA occur?

What groups or assessments are under-researched?

How can we apply this knowledge, or acquire new knowledge, to provide equity for trainees?

The following scoping review hopes to provide the surgical community with robust answers for future of surgical training.

Aims and research question

The aim of this scoping review is to understand the breadth of research about the presence of DA in postgraduate surgical education and to determine themes pertaining to causes of inequalities. A scoping review was chosen to provide a means to map the available literature, including published peer-reviewed primary research and grey literature.

Following the methodological framework set out by Arksey and O’Malley [ 10 ], our research was intended to characterise the literature addressing DA in HST, including Ophthalmology, Obstetrics & Gynaecology (O&G). We included literature from English-language speaking countries, including the UK and USA.

Search strategy

We used search terms tailored to our target population characteristics (e.g., gender, ethnicity), concept (i.e., DA) and context (i.e., assessment in postgraduate surgical education). Medline and Embase were searched with the assistance of a research librarian, with addition of synonyms. This was conducted in May 2023, and was exported to Microsoft Excel for further review. The reference lists of included articles were also searched to find any relevant data sources that had yet to be considered. In addition, to identify grey literature, a search was performed for the term “differential attainment” and “disparity” on the relevant stakeholders’ websites (See supplemental Table 1 for full listing). Stakeholders were included on the basis of their involvement in governance or training of surgical trainees.

Study selection

To start we excluded conference abstracts that were subsequently published as full papers to avoid duplications ( n  = 337). After an initial screen by title to exclude obviously irrelevant articles, articles were filtered to meet our inclusion and exclusion criteria (Table  1 ). The remaining articles ( n  = 47) were then reviewed in their entirety, with the addition of five reports found in grey literature. Following the screening process, 45 studies were recruited for scoping review (Fig.  1 ).

Charting the data

The extracted data included literature title, authors, year of publication, country of study, study design, population characteristic, case number, context, type of assessment, research question and main findings (Appendix 1). Extraction was performed initially by a single author and then subsequently by a second author to ensure thorough review. Group discussion was conducted in case of any disagreements. As charting occurred, papers were discovered within reference lists of included studies which were eligible for inclusion; these were assimilated into the data charting table and included in the data extraction ( n  = 8).

Collating, summarizing and reporting the results

The included studies were not formally assessed in their quality or risk of bias, consistent with a scoping review approach [ 10 ]. However, group discussion was conducted during charting to aid argumentation and identify themes and trends.

We conducted a descriptive numerical summary to describe the characteristics of included studies. Then thematic analysis was implemented to examine key details and organise the attainment quality and population characteristics based on their description. The coding of themes was an iterative process and involved discussion between authors, to identify and refine codes to group into themes.

We categorised the main themes as gender, ethnicity, country of graduation, individual and family background in education, socioeconomic background, age, and disability. The number of articles in each theme is demonstrated in Table  2 . Data was reviewed and organised into subtopics based on assessment types included: academic achievement (e.g., MRCS, FRCS), assessments for progression (e.g., ARCP), workplace-based assessment (e.g., EPA, feedback), surgical experience (e.g., case volume), and technical skills (e.g., visuo-spatial tasks).

PRISMA flow diagram

44 articles defined the number of included participants (89,399 participants in total; range of participants across individual studies 16–34,755). Two articles reported the number of included studies for their meta-analysis (18 and 63 included articles respectively). Two reports from grey literature did not define the number of participants they included in their analysis. The characteristics of the included articles are displayed in Table  2 .

Growth in published literature on differential attainment over the past 40 years

Academic achievement

In the American Board of Surgery Certifying Exam (ABSCE), Maker [ 11 ] found there to be no significant differences in terms of gender when comparing those who passed on their first attempt and those who did not in general surgery training, a finding supported by Ong et al. [ 12 ]. Pico et al. [ 13 ] reported that in Orthopaedic training, Orthopaedic In-Training Examination (OITE) and American Board of Orthopaedic Surgery (ABOS) Part 1 scores were similar between genders, but that female trainees took more attempts in order to pass. In the UK, two studies reported significantly lower Membership of the Royal College of Surgeons (MRCS) pass rates for female trainees compared to males [ 4 , 14 ]. However, Robinson et al. [ 15 ] presented no significant gender differences in MRCS success rates. A study assessing Fellowship of the Royal College of Surgeons (FRCS) examination results found no significant gender disparities in pass rates [ 16 ]. In MRCOG examination, no significant gender differences were found in Part 1 scores, but women had higher pass rates and scores in Part 2 [ 17 ].

Assessment for Progression

ARCP is the annual process of revalidation that UK doctors must perform to progress through training. A satisfactory progress outcome (“outcome 1”) allows trainees to advance through to the next training year, whereas non-satisfactory outcomes (“2–5”) suggest inadequate progress and recommends solutions, such as further time in training or being released from the training programme. Two studies reported that women received 60% more non-satisfactory outcomes than men [ 16 , 18 ]. In contrast, in O&G men had higher non-satisfactory ARCP outcomes without explicit reasons for this given [ 19 ].

Regarding Milestone evaluations based from the US Accreditation Council for Graduate Medical Education (ACGME), Anderson et al. [ 20 ] reported men had higher ratings of knowledge of diseases at postgraduate year 5 (PGY-5), while women had lower mean score achievements. This was similar to another study finding that men and women had similar competencies at PGY-1 to 3, and that it was only at PGY-5 that women were evaluated lower than men [ 21 ]. However, Kwasny et al. [ 22 ] found no difference in trainers’ ratings between genders, but women self-rated themselves lower. Salles et al. [ 23 ] demonstrated significant improvement in scoring in women following a value-affirmation intervention, while this intervention did not affect men.

Workplace-based Assessment

Galvin et al. [ 24 ] reported better evaluation scores from nurses for PGY-2 male trainees, while females received fewer positive and more negative comments. Gerull et al. [ 25 ] demonstrated men received compliments with superlatives or standout words, whereas women were more likely to receive compliments with mitigating phrases (e.g., excellent vs. quite competent).

Hayward et al. [ 26 ] investigated assessment of attributes of clinical performance (ethics, judgement, technical skills, knowledge and interpersonal skills) and found similar scoring between genders.

Several authors have studied autonomy given to trainees in theatre [ 27 , 28 , 29 , 30 , 31 ]. Two groups found no difference in level of granted autonomy between genders but that women rated lower perceived autonomy on self-evaluation [ 27 , 28 ]. Other studies found that assessors consistently gave female trainees lower autonomy ratings, but only in one paper was this replicated in lower performance scores [ 29 , 30 , 31 ].

Padilla et al. [ 32 ] reported no difference in entrustable professional activity assessment (EPA) levels between genders, yet women rated themselves much lower, which they regarded as evidence of imposter syndrome amongst female trainees. Cooney et al. [ 33 ] found that male trainers scored EPAs for women significantly lower than men, while female trainers rated both genders similarly. Conversely, Roshan et al. [ 34 ] found that male assessors were more positive in feedback comments to female trainees than male trainees, whereas they also found that comments from female assessors were comparable for each gender.

Surgical Experience

Gong et al. [ 35 ] found significantly fewer cataract operations were performed by women in ophthalmology residency programmes, which they suggested could be due to trainers being more likely to give cases to male trainees. Female trainees also participated in fewer robotic colorectal procedures, with less operative time on the robotic console afforded [ 36 ]. Similarly, a systematic review highlighted female trainees in various specialties performed fewer cases per week and potentially had limited access to training facilities [ 37 ]. Eruchalu et al. [ 38 ] found that female trainees performed fewer cases, that is, until gender parity was reached, after which case logs were equivalent.

Technical skills

Antonoff et al. [ 39 ] found higher scores for men in coronary anastomosis skills, with women receiving more “fail” assessments. Dill-Macky et al. [ 40 ] analysed laparoscopic skill assessment using blinded videos of trainees and unblinded assessments. While there was no difference in blinded scores between genders, when comparing blinded and unblinded scores individually, assessors were less likely to agree on the scores of women compared to men. However, another study about laparoscopic skills by Skjold-Ødegaard et al. [ 41 ] reported higher performance scores in female residents, particularly when rated by women. The lowest score was shown in male trainees rated by men. While some studies showed disparities in assessment, several studies reported no difference in technical skill assessments (arthroscopic, knot tying, and suturing skills) between genders [ 42 , 43 , 44 , 45 , 46 ].

Several studies investigated trainees’ abilities to complete isolated tasks associated with surgical skills. In laparoscopic tasks, men were initially more skilful in peg transfer and intracorporeal knot tying than women. Following training, the performance was not different between genders [ 47 ]. A study on microsurgical skills reported better initial visual-spatial and perceptual ability in men, while women had better fine motor psychomotor ability. However, these differences were not significant, and all trainees improved significantly after training [ 48 ]. A study by Milam et al. [ 49 ] revealed men performed better in mental rotation tasks and women outperformed in working memory. They hypothesised that female trainees would experience stereotype threat, fear of being reduced to a stereotype, which would impair their performance. They found no evidence of stereotype threat influencing female performance, disproving their hypothesis, a finding supported by Myers et al. [ 50 ].

Ethnicity and country of graduation

Most papers reported ethnicity and country of graduation concurrently, for example grouping trainees as White UK graduates (WUKG), Black and minority ethnicity UK graduates (BME UKG), and international medical graduates (IMG). Therefore, these areas will be addressed together in the following section.

When assessing the likelihood of passing American Board of Surgery (ABS) examinations on first attempt, Yeo et al. [ 51 ] found that White trainees were more likely than non-White. They found that the influence of ethnicity was more significant in the end-of-training certifying exam than in the start-of-training qualifying exam. This finding was corroborated in a study of both the OITE and ABOS certifying exam, suggesting widening inequalities during training [ 52 ].

Two UK-based studies reported significantly higher MRCS pass rates in White trainees compared to BMEs [ 4 , 14 ]. BMEs were less likely to pass MRCS Part A and B, though this was not true for Part A when variations in socioeconomic background were corrected for [ 14 ]. However, Robinson et al. [ 53 ] found no difference in MRCS pass rates based on ethnicity. Another study by Robinson et al. [ 15 ] demonstrated similar pass rates between WUKGs and BME UKGs, but IMGs had significantly lower pass rates than all UKGs. The FRCS pass rates of WUKGs, BME UKGs and IMGs were 76.9%, 52.9%, and 53.9%, respectively, though these percentages were not statistically significantly different [ 16 ].

There was no difference in MRCOG results based on ethnicity, but higher success rates were found in UKGs [ 19 ]. In FRCOphth, WUKGs had a pass rate of 70%, higher than other groups of trainees, with a pass rate of only 45% for White IMGs [ 52 ].

By gathering data from training programmes reporting little to no DA due to ethnicity, Roe et al. [ 54 ] were able to provide a list of factors they felt were protective against DA, such as having supportive supervisors and developing peer networks.

Assessment for progression

RCOphth [ 55 ] found higher rates of satisfactory ARCP outcomes for WUKGs compared to BME UKGs, followed by IMGs. RCOG [ 19 ] discovered higher rates of non-satisfactory ARCP outcomes from non-UK graduates, particularly amongst BMEs and those from the European Economic Area (EEA). Tiffin et al. [ 56 ] considered the difference in experience between UK graduates and UK nationals whose primary medical qualification was gained outside of the UK, and found that the latter were more likely to receive a non-satisfactory ARCP outcome, even when compared to non-UK nationals.

Woolf et al. [ 57 ] explored reasons behind DA by conducting interview studies with trainees. They investigated trainees’ perceptions of fairness in evaluation and found that trainees felt relationships developed with colleagues who gave feedback could affect ARCP results, and might be challenging for BME UKGs and IMGs who have less in common with their trainers.

Workplace-based assessment

Brooks et al. [ 58 ] surveyed the prevalence of microaggressions against Black orthopaedic surgeons during assessment and found 87% of participants experienced some level of racial discrimination during workplace-based performance feedback. Black women reported having more racially focused and devaluing statements from their seniors than men.

Surgical experience

Eruchalu et al. [ 38 ] found that white trainees performed more major surgical cases and more cases as a supervisor than did their BME counterparts.

Dill-Macky et al. [ 40 ] reported no significant difference in laparoscopic surgery assessments between ethnicities.

Individual and family background in education

Two studies [ 4 , 16 ] concentrated on educational background, considering factors such as parental occupation and attendance of a fee-paying school. MRCS part A pass rate was significantly higher for trainees for whom Medicine was their first Degree, those with university-educated parents, higher POLAR (Participation In Local Areas classification group) quintile, and those from fee-paying schools. Higher part B pass rate was associated with graduating from non-Graduate Entry Medicine programmes and parents with managerial or professional occupations [ 4 ]. Trainees with higher degrees were associated with an almost fivefold increase in FRCS success and seven times more scientific publications than their counterparts [ 16 ].

Socioeconomic background

Two studies used Index of Multiple Deprivation quintile, the official measure of relative deprivation in England based on geographical areas for grading socioeconomic level. The area was defined at the time of medical school application. Deprivation quintiles (DQ) were calculated, ranging from DQ1 (most deprived) to DQ5 (least deprived) [ 4 , 14 ].

Trainees with history of less deprivation were associated with higher MRCS part A pass rate. More success in part B was associated with history of no requirement for income support and less deprived areas [ 4 ]. Trainees from DQ1 and DQ2 had lower pass rates and higher number of attempts to pass [ 14 ]. A general trend of better outcomes in examination was found from O&G trainees in less deprived quintiles [ 19 ].

Trainees from DQ1 and DQ2 received significantly more non-satisfactory ARCP outcomes (24.4%) than DQ4 and DQ5 (14.2%) [ 14 ].

Trainees who graduated at age less than 29 years old were more likely to pass MRCS than their counterparts [ 4 ].

Authors [ 18 , 56 ] found that older trainees received more non-satisfactory ARCP outcomes. Likewise, there was higher percentage of non-satisfactory ARCP outcomes in O&G trainees aged over 45 compared with those aged 25–29 regardless of gender [ 19 ].

Trainees with disability had significantly lower pass rates in MRCS part A compared to candidates without disability. However, the difference was not significant for part B [ 59 ].

What have we learnt from the literature?

It is heartening to note the recent increase in interest in DA (27 studies in the last 4 years, compared to 26 in the preceding 40) (Fig.  2 ). The vast majority (77%) of studies are quantitative, based in the US or UK (89%), focus on gender (85%) and relate to clinical assessments (51%) rather than examination results. Therefore, the surgical community has invested primarily in researching the experience of women in the USA and UK.

Interestingly, a report by RCOG [ 19 ] showed that men were more likely to receive non-satisfactory ARCP outcomes than women, and a study by Rushd et al. [ 17 ] found that women were more likely to pass part 2 of MRCOG than men. This may be because within O&G men are the “out-group” (a social group or category characterised by marginalisation or exclusion by the dominant cultural group) as 75% of O&G trainees are female [ 60 ].

This contrasts with other specialities in which men are the in-group and women are seen to underperform. Outside of O&G, in comparison to men, women are less likely to pass MRCS [ 4 , 14 ], receive satisfactory ARCP outcome [ 16 , 18 ], or receive positive feedback [ 24 ], whilst not performing the same number of procedures as men [ 34 , 35 ]. This often leads to poor self-confidence in women [ 32 ], which can then worsen performance [ 21 ].

It proves difficult to comment on DA for many groups due to a lack of evidence. The current research suggests that being older, having a disability, graduate entry to medicine, low parental education, and living in a lower socioeconomic area at the time of entering medical school are all associated with lower MRCS pass rates. Being older and having a lower socioeconomic background are also associated with non-satisfactory ARCP outcomes, slowing progression through training.

These characteristics may provide a compounding negative effect – for example having a previous degree will automatically make a trainee older, and living in a lower socioeconomic area makes it more likely their parents will have a non-professional job and not hold a higher degree. When multiple protected characteristics interact to produce a compounded negative effect for a person, it is often referred to as “intersectional discrimination” or “intersectionality” [ 61 ]. This is a concept which remains underrepresented in the current literature.

The literature is not yet in agreement over the presence of DA due to ethnicity. There are many studies that report perceived discrimination, however the data for exam and clinical assessment outcomes is equivocal. This may be due to the fluctuating nature of in-groups and out-groups, and multiple intersecting characteristics. Despite this, the lived experience of BME surgeons should not be ignored and requires further investigation.

What are the gaps in the literature?

The overwhelming majority of literature exploring DA addresses issues of gender, ethnicity or country of medical qualification. Whilst bias related to these characteristics is crucial to recognise, studies into other protected characteristics are few and far between. The only paper on disability reported striking differences in attainment between disabled and non-disabled registrars [ 59 ]. There has also been increased awareness about neurodiversity amongst doctors and yet an exploration into the experience of neurodiverse surgeons and their progress through training has yet to be published [ 62 ].

The implications of being LGBTQ + in surgical training have not been recognised nor formally addressed in the literature. Promisingly, the experiences of LGBTQ + medical students have been recognised at an undergraduate level, so one can hope that this will be translated into postgraduate education [ 63 , 64 ]. While this is deeply entwined with experiences of gender discrimination, it is an important characteristic that the surgical community would benefit from addressing, along with disability. To a lesser extent, the effect of socioeconomic background and age have also been overlooked.

Characterising trainees for the purpose of research

Ethnicity is deeply personal, self-defined, and may change over time as personal identity evolves, and therefore arbitrarily grouping diverse ethnic backgrounds is unlikely to capture an accurate representation of experiences. There are levels of discrimination even within minority groups; colourism in India means dark-skinned Indians will experience more discrimination than light-skinned Indians, even from those within in their own ethnic group [ 65 ]. Therefore, although the studies included in the scoping review accepted self-definitions of ethnicity, this is likely not enough to fully capture the nuances of bias and discrimination present in society. For example, Ellis et al. [ 4 ] grouped participants as “White”, “Mixed”, “Asian”, “Black” and “Other”, however they could have also assigned a skin tone value such as the NIS Skin Colour Scale [ 66 ], thus providing more detail.

Ethnicity is more than genetic heritage; it is also cultural expression. The experience of an IMG in UK postgraduate training will differ from that of a UKG, an Indian UKG who grew up in India, and an Indian UKG who grew up in the UK. These are important distinctions which are noted in the literature (e.g. by Woolf et al., 2016 [ 57 ]) however some do not distinguish between ethnicity and graduate status [ 15 ] and none delve into an individual’s cultural expression (e.g., clothing choice) and how this affects the perception of their assessors.

Reasons for DA

Despite the recognition of inequalities in all specialties of surgery, there is a paucity of data explicitly addressing why DA occurs. Reasons behind the phenomenon must be explored to enable change and eliminate biases. Qualitative research is more attuned to capturing the complexities of DA through observation or interview-based studies. Currently most published data is quantitative, and relies on performance metrics to demonstrate the presence of DA while ignoring the causes. Promisingly, there are a gradually increasing number of qualitative, predominantly interview-based, studies (Fig.  2 ).

To create a map of DA in all its guises, an analysis of the themes reported to be contributory to its development is helpful. In our review of the literature, four themes have been identified:

Training culture

In higher surgical training, for there to be equality in outcomes, there needs to be equity in opportunities. Ellis et al. [ 4 ] recognised that variation in training experiences, such as accessibility of supportive peers and senior role models, can have implications on attainment. Trainees would benefit from targeted support at times of transition, such as induction or at examinations, and it may be that currently the needs of certain groups are being met before others, reinforcing differential attainment [ 4 ].

Experience of assessment

Most literature in DA relates to the presence (or lack of) an attainment gap in assessments, such as ARCP or MRCS. It is assumed that these assessments of trainee development are objective and free of bias, and indeed several authors have described a lack of bias in these high-stakes examinations (e.g., Ong et al., 2019 [ 12 ]; Robinson et al., 2019 [ 53 ]). However, in some populations, such as disabled trainees, there are differences in attainment [ 59 ]. This is demonstrated despite legislation requiring professional bodies to make reasonable adjustments to examinations for disabled candidates, such as additional time, text formatting amendments, or wheelchair-accessible venues [ 67 ]. Therefore it would be beneficial to investigate the implementation of these adjustments across higher surgical examinations and identify any deficits.

Social networks

Relationships between colleagues may influence DA in multiple ways. Several studies identified that a lack of a relatable and inspiring mentor may explain why female or BME doctors fail to excel in surgery [ 4 , 55 ]. Certain groups may receive preferential treatment due to their perceived familiarity to seniors [ 35 ]. Robinson et al. [ 15 ] recognised that peer-to-peer relationships were also implicated in professional development, and the lack thereof could lead to poor learning outcomes. Therefore, a non-discriminatory culture and inclusion of trainees within the social network of training is posited as beneficial.

Personal characteristics

Finally, personal factors directly related to protected characteristics have been suggested as a cause of DA. For example, IMGs may perform worse in examinations due to language barriers, and those from disadvantaged backgrounds may have less opportunity to attend expensive courses [ 14 , 16 ]. Although it is impossible to exclude these innate deficits from training, we may mitigate their influence by recognising their presence and providing solutions.

The causes of DA may also be grouped into three levels, as described by Regan de Bere et al. [ 68 ]: macro (the implications of high-level policy), meso (focusing on institutional or working environments) and micro (the influence of individual factors). This can intersect with the four themes identified above, as training culture can be enshrined at both an institutional and individual level, influencing decisions that relate to opportunities for trainees, or at a macro level, such as in the decisions made on nationwide recruitment processes. These three levels can be used to more deeply explore each of the four themes to enrich the discovery of causes of DA.

Discussions outside of surgery

Authors in General Practice (e.g., Unwin et al., 2019 [ 69 ]; Pattinson et al., 2019 [ 70 ]), postgraduate medical training (e.g., Andrews, Chartash, and Hay, 2021 [ 71 ]), and undergraduate medical education (e.g., Yeates et al., 2017 [ 72 ]; Woolf et al., 2013 [ 73 ]) have published more extensively in the aetiology of DA. A study by Hope et al. [ 74 ] evaluating the bias present in MRCP exams used differential item functioning to identify individual questions which demonstrated an attainment gap between male and female and Caucasian and non-Caucasian medical trainees. Conclusions drawn about MRCP Part 1 examinations may be generalisable to MRCS Part A or FRCOphth Part 1: they are all multiple-choice examinations testing applied basic science and usually taken within the first few years of postgraduate training. Therefore it is advisable that differential item functioning should also be applied to these examinations. However, it is possible that findings in some subspecialities may not be generalisable to others, as training environments can vary profoundly. The RCOphth [ 55 ] reported that in 2021, 53% of ophthalmic trainees identified as male, whereas in Orthopaedics 85% identified as male, suggesting different training environments [ 5 ]. It is useful to identify commonalities of DA between surgical specialties and in the wider scope of medical training.

Limitations of our paper

Firstly, whilst aiming to provide a review focussed on the experience of surgical trainees, four papers contained data about either non-surgical trainees or medical students. It is difficult to draw out the surgeons from this data and therefore it is possible that there are issues with generalisability. Furthermore, we did not consider the background of each paper’s authors, as their own lived experience of attainment gap could form the lens through which they commented on surgical education, colouring their interpretation. Despite intending to include as many protected characteristics as possible, inevitably there will be lived experiences missed. Lastly, the experience of surgical trainees outside of the English-speaking world were omitted. No studies were found that originated outside of Europe or North America and therefore the presence or characteristics of DA outside of this area cannot be assumed.

Experiences of inequality in surgical assessment are prevalent in all surgical subspecialities. In order to further investigate DA, researchers should ensure all protected characteristics are considered - and how these interact - to gain insight into intersectionality. Given the paucity of current evidence, particular focus should be given to the implications of disability, and specifically neurodiversity, in progress through training as they are yet to be explored in depth. In defining protected characteristics, future authors should be explicit and should avoid generalisation of cultural backgrounds to allow authentic appreciation of attainment gap. Few authors have considered the driving forces between bias in assessment and DA, and therefore qualitative studies should be prioritised to uncover causes for and protective factors against DA. Once these influences have been identified, educational designers can develop new assessment methods that ensure equity across surgical trainees.

Data availability

All data provided during this study are included in the supplementary information files.

Abbreviations

Accreditation Council for Graduate Medical Education

American Board of Orthopaedic Surgery

American Board of Surgery

American Board of Surgery Certifying Exam

Annual Review of Competence Progression

Black, Asian, and Minority Ethnicity

Council on Resident Education in Obstetrics and Gynecology

Differential Attainment

Deprivation Quintile

European Economic Area

Entrustable Professional Activities

Fellowship of The Royal College of Ophthalmologists

Fellow of the Royal College of Surgeons

General Medical Council

Higher Surgical Training

International Medical Graduate

In-Training Evaluation Report

Member of the Royal College of Obstetricians and Gynaecologists

Member of the Royal College of Physicians

Member of the Royal College of Surgeons

Obstetrics and Gynaecology

Orthopaedic In-Training Examination

Participation In Local Areas

Postgraduate Year

The Royal College of Ophthalmologists

The Royal College of Obstetricians and Gynaecologists

The Royal College of Surgeons of England

United Kingdom Graduate

White United Kingdom Graduate

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Rebecca L. Jones, Suwimol Prusmetikul & Sarah Whitehorn

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RJ, SP and SW conceived the study. RJ carried out the search. RJ, SP and SW reviewed and appraised articles. RJ, SP and SW extracted data and synthesized results from articles. RJ, SP and SW prepared the original draft of the manuscript. RJ and SP prepared Figs. 1 and 2. All authors reviewed and edited the manuscript and agreed to the final version.

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Jones, R.L., Prusmetikul, S. & Whitehorn, S. Differential attainment in assessment of postgraduate surgical trainees: a scoping review. BMC Med Educ 24 , 597 (2024). https://doi.org/10.1186/s12909-024-05580-2

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Barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with psychosis: a scoping review protocol

• Cláudia C. Gonçalves   ORCID: orcid.org/0000-0001-6767-0920 1 ,
• Zoe Waters 2 ,
• Shae E. Quirk 1 ,
• Peter M. Haddad 1 , 3 ,
• Ashleigh Lin 4 ,
• Lana J. Williams 1 &
• Alison R. Yung 1 , 5  

Systematic Reviews volume  13 , Article number:  143 ( 2024 ) Cite this article

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The prevalence of psychosis has been shown to be disproportionately high amongst sexual and gender minority individuals. However, there is currently little consideration of the unique needs of this population in mental health treatment, with LGBTQA+ individuals facing barriers in accessing timely and non-stigmatising support for psychotic experiences. This issue deserves attention as delays to help-seeking and poor engagement with treatment predict worsened clinical and functional outcomes for people with psychosis. The present protocol describes the methodology for a scoping review which will aim to identify barriers and facilitators faced by LGBTQA+ individuals across the psychosis spectrum in help-seeking and accessing mental health support.

A comprehensive search strategy will be used to search Medline, PsycINFO, Embase, Scopus, LGBTQ+ Source, and grey literature. Original studies of any design, setting, and publication date will be included if they discuss barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with experiences of psychosis. Two reviewers will independently screen titles/abstracts and full-text articles for inclusion in the review. Both reviewers will then extract the relevant data according to pre-determined criteria, and study quality will be assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Key data from included studies will be synthesised in narrative form according to the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews.

The results of this review will provide a comprehensive account of the current and historical barriers and facilitators to mental healthcare faced by LGBTQA+ people with psychotic symptoms and experiences. It is anticipated that the findings from this review will be relevant to clinical and community services and inform future research. Findings will be disseminated through publication in a peer-reviewed journal and presented at conferences.

Scoping review registration

This protocol is registered in Open Science Framework Registries ( https://doi.org/10.17605/OSF.IO/AT6FC ).

Peer Review reports

The prevalence of psychotic disorders in the general population has been estimated to be around 0.27–0.75% [ 1 , 2 ], with the lifetime prevalence of ever having a psychotic experience being estimated at 5.8% [ 3 ]. However, rates of psychotic symptoms and experiences are disproportionately high amongst LGBTQA+ populations, with non-heterosexual individuals estimated to be 1.99–3.75 times more likely to experience psychosis than their heterosexual peers [ 4 , 5 , 6 , 7 ]. Additionally, it has been estimated that transgender or gender non-conforming (henceforth trans) individuals are 2.46–49.7 times more likely than their cisgender peers (i.e. individuals whose gender identity is the same as their birth registered sex) to receive a psychotic disorder diagnosis [ 8 , 9 ]. The increased rates of psychotic experiences noted amongst gender and sexual minorities may be explained by evidence indicating that LGBTQA+ people are also exposed to risk factors for psychosis at a far greater rate than members of the general population, such as childhood adversity [ 10 , 11 , 12 ], minority stress [ 13 ], discrimination [ 14 ], and stigma [ 15 , 16 ]. Furthermore, there is added potential for diagnostic biases leading to over-diagnosing psychosis in gender diverse individuals, whose gender expression and dysphoria may be pathologized by mental health service providers [ 8 ].

Despite these concerning statistics, there is very little research examining the experiences of LGBTQA+ people with psychosis, and limited consideration of the unique needs these individuals may have in accessing and engaging with mental health services. While timely access to treatment has consistently been associated with better symptomatic and functional outcomes for people with psychosis [ 17 , 18 ], there are often delays to treatment initiation which are worsened for LGBTQA+ individuals [ 19 , 20 ]. These individuals face additional barriers to accessing adequate mental health support compared to cisgender/heterosexual people [ 19 ] and may need to experiment with several mental health services before finding culturally competent care [ 20 ]. This in turn may lead to longer duration of untreated psychosis. Additionally, there seems to be a lack of targeted support for this population from healthcare providers, with LGBTQA+ individuals with serious mental health concerns reporting higher rates of dissatisfaction with psychiatric services than their cisgender and heterosexual counterparts [ 7 , 14 , 21 ]. However, the extent of these differences varies across contexts [ 22 ], potentially due to improved education around stigma and LGBTQA+ issues within a subset of mental health services.

Nonetheless, stigma remains one of the highest cited barriers to help-seeking for mental health problems, particularly with regard to concerns around disclosure [ 23 ], which can be particularly challenging for people experiencing psychosis [ 24 , 25 ]. Stigma stress in young people at risk for psychosis is associated with less positive attitudes towards help-seeking regarding both psychiatric medication and psychotherapy [ 26 ], potentially partly due to fears of judgement and being treated differently by service providers [ 27 ]. This issue may be compounded for people who also belong to minoritized groups [ 23 , 28 ], particularly as LGBTQA+ individuals have reported experiencing frequent stigma and encountering uninformed staff when accessing mental healthcare [ 7 , 29 ]. Furthermore, stigma-fuelled hesitance to access services may be heightened for trans people [ 30 ] whose identities have historically been pathologized and conflated with experiences of psychosis [ 31 ].

Even when individuals manage to overcome barriers to access support, there are added challenges to maintaining adequate treatment engagement. In a large online study, half of trans and nearly one third of LGB participants reported having stopped using mental health services in the past because of negative experiences related to their gender identity or sexuality [ 20 ]. This can be particularly problematic as experiences of stigma predict poorer medication adherence in psychosis [ 32 ] which subsequently multiplies the risk for relapse and suicide [ 33 ]. While no research to date has explored non-adherence rates in people with psychosis who are LGBTQA+, concerns around suicidality are heightened for individuals who are gender and sexuality diverse [ 34 , 35 , 36 ].

Generally, there is rising demand for mental healthcare that specifically addresses the needs of gender and sexual minority individuals and promotes respect for diversity, equity, and inclusion [ 29 , 37 ]. This is particularly salient as positive relationships with staff are associated with better medication adherence for people with psychosis [ 38 ] and healthcare providers with LGBTQA+-specific mandates have demonstrated higher satisfaction rates for LGBTQA+ individuals [ 20 ]. Mental health services need to adapt treatment options to acknowledge minority stress factors for those with stigmatised identities and, perhaps more importantly, how these intersect and interact to increase inequalities in people from minoritized groups accessing and benefiting from treatment [ 37 , 39 ].

Additionally, gender affirming care needs to be recognised as an important facet of mental health treatment for many trans individuals, as it is associated with positive outcomes such as improvements in quality of life and psychological functioning [ 40 , 41 , 42 ] and reductions in psychiatric symptom severity and need for subsequent mental health treatment [ 8 , 43 ]. While there are additional barriers in access to gender affirming care for individuals with psychosis, this treatment has shown success in parallel with treatment to address psychosis symptom stabilisation [ 19 , 44 ]. The importance of affirmation is echoed by the finding that many negative experiences of LGBTQA+ participants with mental health services could be avoided simply by respecting people’s pronouns and using gender-neutral language [ 20 ].

To ensure timely access to appropriate treatment for LGBTQA+ people with psychosis, there is a need for improved understanding of the factors which challenge and facilitate help-seeking and engagement with mental health support. A preliminary search of Google Scholar, Medline, the Cochrane Database of Systematic Reviews, and PROSPERO was conducted and revealed no existing or planned reviews exploring benefits and/or obstacles to mental health treatment specific to this population. Therefore, the proposed review seeks to comprehensively search and appraise the existing literature to identify and summarise a range of barriers and facilitators to adequate mental health support faced by LGBTQA+ people with experiences of psychosis. This will allow for the mapping of the types of evidence available and identification of any knowledge gaps. Moreover, we hope to guide future decision-making in mental healthcare to improve service accessibility for LGBTQA+ individuals with psychosis and to set the foundations for future research that centres this marginalised population. Based on published guidance [ 45 , 46 , 47 ], a scoping review methodology was identified as the most appropriate approach to address these aims.

Selection criteria

This scoping review protocol has been developed in compliance with the JBI Manual for Evidence Synthesis [ 48 ] and, where relevant, the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist [ 49 ] (see Additional file 1). In the event of protocol amendments, the date, justification, and description for each amendment will be provided.

Due to the limited literature around the topic of this review, any primary original study design, setting, and publication date will be considered for inclusion. Publications written in English will be included, and articles in other languages may be considered pending time and cost constraints around translation. Publications will be excluded if the full text is not available upon request from authors.

The PCC (Population, Concept, Context) framework was used to develop the inclusion criteria for this scoping review:

This review will include individuals of any age who are LGBTQA+ and have had experiences of psychosis. For the purposes of this review, ‘LGBTQA+ individuals’ will be broadly defined as any individual that is not heterosexual and/or cisgender or anyone who engages in same-gender sexual behaviour. Studies may include participants who are cisgender and heterosexual if they separately report outcomes for LGBTQA+ individuals. Within this review, the term ‘psychosis’ includes (i) any diagnosis of a psychotic disorder, such as schizophrenia spectrum disorders, mood disorders with psychotic features, delusional disorders, and drug-induced psychotic disorders, (ii) sub-threshold psychotic symptoms, such as those present in ultra-high risk (UHR), clinical high risk (CHR), or at risk mental state (ARMS) individuals, and (iii) any psychotic-like symptoms or experiences. Studies may include participants with multiple diagnoses if they separately report outcomes for individuals on the psychosis spectrum.

This review will include publications which discuss potential barriers and/or facilitators to mental health help-seeking and/or engagement with mental health treatment. ‘Barriers’ will be operationalised as any factors which may delay or prevent individuals from accessing and engaging with appropriate mental health support. These may include lack of mental health education, experienced or internalised stigma, experiences of discrimination from health services, and lack of inclusivity in health services. ‘Facilitators’ will be operationalised as any factors which may promote timely help-seeking and engagement with sources of support. These may include improved access to mental health education, positive sources of social support, and welcoming and inclusive services. Mental health help-seeking will be broadly defined as any attempt to seek and access formal or informal support to address a mental health concern related to experiences of psychosis (e.g. making an initial appointment with a service provider, seeking help from a friend). Mental health treatment engagement will be broadly defined as adherence and active participation in the treatment that is offered by a source of support (e.g. attending scheduled appointments, taking medication as prescribed, openly communicating with service providers).

This review may include research encompassing any setting in which mental healthcare is provided. This is likely to include formal healthcare settings such as community mental health teams or inpatient clinics as well as informal settings such as LGBTQA+ spaces or informal peer support. Studies will be excluded if they focus exclusively on physical health treatment.

Search strategy

Database searches will be conducted in Medline, PsycINFO, Embase, Scopus, and LGBTQ+ Source. The full search strategy for this protocol is available (see Additional file 2). This strategy has been collaboratively developed and evaluated by a scholarly services health librarian. Searches will include subject headings relevant to each database and title/abstract keywords relating to three main concepts: (i) LGBTQA+ identity, (ii) experiences of psychosis, and (iii) mental health treatment. Keywords for each concept will be combined using the Boolean operator ‘OR’, and the three concepts will be combined using ‘AND’. This search strategy was appropriately translated for each of the selected databases. There will be no limitations on language or publication date at this stage to maximise the breadth of the literature captured. Publications returned from these searches will be exported to EndNote. Searches will be re-run prior to the final analysis to capture any newly published studies.

The database searches will be supplemented by searching the grey literature as per the eligibility criteria detailed above. These may include theses and dissertations, conference proceedings, reports from mental health services, and policy documents from LGBTQA+ groups. Google and Google Scholar will be searched using a combination of clauses for psychosis (Psychosis OR psychotic OR schizophrenia OR schizoaffective), treatment (treatment or “help-seeking”), and queer identity. The latter concept will have three clauses for three separate searches, with one including broad queer identity (LGBT), one specific to non-heterosexual individuals (gay OR lesbian OR homosexual OR bisexual OR queer OR asexual), and one specific to trans individuals (transgender OR transsexual OR transexual OR “non-binary” OR “gender minority”). Additionally, reference lists and citing literature will be manually searched for each paper included in the review to capture any articles and policy documents not previously identified.

Data selection

Search results will be imported into Covidence using EndNote, and duplicates will be eliminated. Titles and abstracts will be screened by the first and second authors according to pre-defined screening criteria, which will be discussed by the authors and piloted prior to screening. These criteria will consider whether the articles included LGBTQA+ participants with experiences of psychosis (as operationalised above) in relation to mental health help-seeking and/or treatment. Full texts of relevant articles will then be obtained and screened by the first and second reviewer in accordance with the full inclusion and exclusion criteria after initial piloting to maximise inter-rater reliability. Decisions on inclusion and exclusion will be blinded and recorded on Covidence. Potential discrepancies will be resolved through discussion, and when consensus cannot be reached, these will be resolved by the supervising author. The process of study selection will be documented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram [ 50 ].

Data extraction

Data extraction will be performed independently by two reviewers using Covidence. Prior to beginning final extraction, both reviewers will independently pilot the extraction tool using a sample of five included studies and discuss any necessary changes. Information extracted is planned to include the following: title, author name(s), year of publication, country in which the study was conducted, study design, sample size, population of focus (i.e. sexual minorities, gender minorities, or both), sample demographics (i.e. age, gender identity, and sexual orientation), setting (e.g. early intervention service, community mental health team, etc.), psychosis characteristics (e.g. diagnoses included, severity of symptoms, etc.), type of treatment (e.g. cognitive behavioural therapy, antipsychotic medication, etc.), and any barriers and/or facilitators identified according to the aforementioned operationalised definitions. Disagreements will be resolved through discussion between the two reviewers and, when necessary, final decisions will be made by a senior supervisor. Once extracted, information will be recorded in Excel. Lead authors of papers will be contacted by the primary review author in cases where there is missing or insufficient data.

Quality assessment

Due to the expected heterogeneity in the types of studies that may be included in this review (e.g. qualitative studies, randomised controlled trials, case control studies, case reports), the relevant revised Joanna Briggs Institute (JBI) critical appraisal checklists [ 51 ] will be used to assess risk of bias and study quality for each study design. Two reviewers will independently use these checklists to assess each paper that is included following the full-text screening. If there are discrepancies in article ratings, these will be resolved through discussion between the two authors. If no consensus is reached, discrepancies will be resolved by a senior supervisor. In line with the scoping nature of this review, low-quality studies will not be excluded from the synthesis.

Evidence synthesis

Data from included studies will be synthesised using a narrative synthesis approach in accordance with the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews [ 52 ]. A preliminary descriptive synthesis will be conducted by tabulating the extracted data elements from each study alongside quality assessment results and developing an initial description of the barriers and facilitators to (1) accessing and (2) engaging with mental health support that are identified in the literature. This initial synthesis will then be interrogated and refined to contextualise these barriers and facilitators in the setting, population, and methodology of each study to form the basis for an interpretative synthesis.

This review will not use a pre-existing thematic framework to categorise barriers and facilitators as it is expected that the factors identified will not neatly fit into existing criteria. Instead, these will be conceptualised according to overarching themes as interrelated factors, so that potentially complex interactions between barriers and facilitators within and across relevant studies may be explored through concept mapping. If most of the studies included are qualitative, there may also be scope for a partial meta-synthesis. To avoid oversimplifying the concept of ‘barriers and facilitators’ (see criticism by Bach-Mortensen & Verboom [ 53 ]), this data synthesis will be followed by a critical reflection of the findings through the lens of the socio-political contexts which may give rise to the barriers and facilitators identified, exploring the complexities necessary for any changes to be implemented in mental health services.

If the extracted data indicate that gender minority and sexual minority individuals experience unique or different barriers and/or facilitators to each other, these population groups will be analysed separately as opposed to findings being generalised across the LGBTQA+ spectrum. Furthermore, if there is scope to do so, analyses may be conducted to investigate how perceived barriers and facilitators for this population may have changed over time (i.e. according to publication date) as definitions of psychosis evolve and LGBTQA+ individuals gain visibility in clinical services.

The proposed review will add to the literature around mental health treatment for LGBTQA+ people with psychosis. It will provide a thorough account of the barriers and facilitators to accessing and engaging with support faced by this population and may inform future research and clinical practice.

In terms of limitations, this review will be constrained by the existing literature and may therefore not be sufficiently comprehensive in reflecting the barriers and facilitators experienced by subgroups within the broader LGBTQA+ community. Additionally, although broad inclusion criteria are necessary to capture the full breadth of research conducted in this topic, included studies are likely to be heterogeneous and varied in terms of their methodology and population which may complicate data synthesis.

Nonetheless, it is anticipated that the findings from this review will provide the most comprehensive synthesis to date of the issues driving low help-seeking and treatment engagement in people across the psychosis spectrum who are LGBTQA+. This review will likely also identify gaps in the literature which may inform avenues for future research, and the factors identified in this review will be considered in subsequent research by the authors.

Additionally, findings will be relevant to healthcare providers that offer support to people with psychosis who may have intersecting LGBTQA+ identities as well as LGBTQA+ organisations which offer support to LGBTQA+ people who may be experiencing distressing psychotic experiences. These services are likely to benefit from an increased awareness of the factors which may improve or hinder accessibility for these subsets of their target populations. Therefore, results from this review may inform decision-making around the implementation of service-wide policy changes.

The findings of this review will be disseminated through the publication of an article in a peer-reviewed journal and presented at relevant conferences in Australia and/or internationally. Additionally, the completed review will form part of the lead author’s doctoral thesis.

Availability of data and materials

Not applicable for this protocol.

Abbreviations

• At risk mental state

Clinical high risk for psychosis

Joanna Briggs Institute

Lesbian, gay, and bisexual

Lesbian, gay, bisexual, transgender, queer or questioning, asexual or aromantic, and more

Population, Concept, Context

Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols

Ultra-high risk for psychosis

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Acknowledgements

The authors would like to acknowledge the support of Ms Olivia Larobina, Scholarly Services Librarian (STEMM) at Deakin University, in the development of the search strategy.

CCG is funded by a Deakin University Postgraduate Research (DUPR) Scholarship. ZW is funded by a University of Western Australia Research Training Program (RTP) Scholarship. AL is supported by a National Health and Medical Research Council (NHMRC) Emerging Leaders Fellowship (2010063). LJW is supported by a NHMRC Emerging Leaders Fellowship (1174060). ARY is supported by a NHMRC Principal Research Fellowship (1136829). The funding providers had no role in the design and conduct of the study, or in the preparation, review, or approval of this manuscript.

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Cláudia C. Gonçalves, Shae E. Quirk, Peter M. Haddad, Lana J. Williams & Alison R. Yung

Telethon Kids Institute, University of Western Australia, Perth, WA, 6009, Australia

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CCG is the guarantor. CCG conceptualised the review, developed the study design, and drafted the manuscript. CCG, ZW, and SQ collaborated with OL (Scholarly Services Librarian) to develop the search strategy. All authors critically reviewed the manuscript. All authors read and approved the final manuscript.

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In the last 3 years, PMH has received honoraria for lecturing from Janssen, NewBridge Pharmaceuticals, and Otsuka and royalties from edited textbooks (Cambridge University Press, Oxford University Press).

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Additional file 1. prisma-p 2015 checklist. completed prisma-p checklist for this systematic review protocol., 13643_2024_2566_moesm2_esm.docx.

Additional file 2. Search Strategy. Detailed search strategy for this systematic review, including search terms and relevant controlled vocabulary terms for each included database.

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Gonçalves, C.C., Waters, Z., Quirk, S.E. et al. Barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with psychosis: a scoping review protocol. Syst Rev 13 , 143 (2024). https://doi.org/10.1186/s13643-024-02566-5

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DOI : https://doi.org/10.1186/s13643-024-02566-5

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