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Chapter 14: completing ‘summary of findings’ tables and grading the certainty of the evidence.

Holger J Schünemann, Julian PT Higgins, Gunn E Vist, Paul Glasziou, Elie A Akl, Nicole Skoetz, Gordon H Guyatt; on behalf of the Cochrane GRADEing Methods Group (formerly Applicability and Recommendations Methods Group) and the Cochrane Statistical Methods Group

Key Points:

• A ‘Summary of findings’ table for a given comparison of interventions provides key information concerning the magnitudes of relative and absolute effects of the interventions examined, the amount of available evidence and the certainty (or quality) of available evidence.
• ‘Summary of findings’ tables include a row for each important outcome (up to a maximum of seven). Accepted formats of ‘Summary of findings’ tables and interactive ‘Summary of findings’ tables can be produced using GRADE’s software GRADEpro GDT.
• Cochrane has adopted the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) for assessing certainty (or quality) of a body of evidence.
• The GRADE approach specifies four levels of the certainty for a body of evidence for a given outcome: high, moderate, low and very low.
• GRADE assessments of certainty are determined through consideration of five domains: risk of bias, inconsistency, indirectness, imprecision and publication bias. For evidence from non-randomized studies and rarely randomized studies, assessments can then be upgraded through consideration of three further domains.

Cite this chapter as: Schünemann HJ, Higgins JPT, Vist GE, Glasziou P, Akl EA, Skoetz N, Guyatt GH. Chapter 14: Completing ‘Summary of findings’ tables and grading the certainty of the evidence. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane, 2023. Available from www.training.cochrane.org/handbook .

14.1 ‘Summary of findings’ tables

14.1.1 introduction to ‘summary of findings’ tables.

‘Summary of findings’ tables present the main findings of a review in a transparent, structured and simple tabular format. In particular, they provide key information concerning the certainty or quality of evidence (i.e. the confidence or certainty in the range of an effect estimate or an association), the magnitude of effect of the interventions examined, and the sum of available data on the main outcomes. Cochrane Reviews should incorporate ‘Summary of findings’ tables during planning and publication, and should have at least one key ‘Summary of findings’ table representing the most important comparisons. Some reviews may include more than one ‘Summary of findings’ table, for example if the review addresses more than one major comparison, or includes substantially different populations that require separate tables (e.g. because the effects differ or it is important to show results separately). In the Cochrane Database of Systematic Reviews (CDSR),  all ‘Summary of findings’ tables for a review appear at the beginning, before the Background section.

14.1.2 Selecting outcomes for ‘Summary of findings’ tables

Planning for the ‘Summary of findings’ table starts early in the systematic review, with the selection of the outcomes to be included in: (i) the review; and (ii) the ‘Summary of findings’ table. This is a crucial step, and one that review authors need to address carefully.

To ensure production of optimally useful information, Cochrane Reviews begin by developing a review question and by listing all main outcomes that are important to patients and other decision makers (see Chapter 2 and Chapter 3 ). The GRADE approach to assessing the certainty of the evidence (see Section 14.2 ) defines and operationalizes a rating process that helps separate outcomes into those that are critical, important or not important for decision making. Consultation and feedback on the review protocol, including from consumers and other decision makers, can enhance this process.

Critical outcomes are likely to include clearly important endpoints; typical examples include mortality and major morbidity (such as strokes and myocardial infarction). However, they may also represent frequent minor and rare major side effects, symptoms, quality of life, burdens associated with treatment, and resource issues (costs). Burdens represent the impact of healthcare workload on patient function and well-being, and include the demands of adhering to an intervention that patients or caregivers (e.g. family) may dislike, such as having to undergo more frequent tests, or the restrictions on lifestyle that certain interventions require (Spencer-Bonilla et al 2017).

Frequently, when formulating questions that include all patient-important outcomes for decision making, review authors will confront reports of studies that have not included all these outcomes. This is particularly true for adverse outcomes. For instance, randomized trials might contribute evidence on intended effects, and on frequent, relatively minor side effects, but not report on rare adverse outcomes such as suicide attempts. Chapter 19 discusses strategies for addressing adverse effects. To obtain data for all important outcomes it may be necessary to examine the results of non-randomized studies (see Chapter 24 ). Cochrane, in collaboration with others, has developed guidance for review authors to support their decision about when to look for and include non-randomized studies (Schünemann et al 2013).

If a review includes only randomized trials, these trials may not address all important outcomes and it may therefore not be possible to address these outcomes within the constraints of the review. Review authors should acknowledge these limitations and make them transparent to readers. Review authors are encouraged to include non-randomized studies to examine rare or long-term adverse effects that may not adequately be studied in randomized trials. This raises the possibility that harm outcomes may come from studies in which participants differ from those in studies used in the analysis of benefit. Review authors will then need to consider how much such differences are likely to impact on the findings, and this will influence the certainty of evidence because of concerns about indirectness related to the population (see Section 14.2.2 ).

Non-randomized studies can provide important information not only when randomized trials do not report on an outcome or randomized trials suffer from indirectness, but also when the evidence from randomized trials is rated as very low and non-randomized studies provide evidence of higher certainty. Further discussion of these issues appears also in Chapter 24 .

14.1.3 General template for ‘Summary of findings’ tables

Several alternative standard versions of ‘Summary of findings’ tables have been developed to ensure consistency and ease of use across reviews, inclusion of the most important information needed by decision makers, and optimal presentation (see examples at Figures 14.1.a and 14.1.b ). These formats are supported by research that focused on improved understanding of the information they intend to convey (Carrasco-Labra et al 2016, Langendam et al 2016, Santesso et al 2016). They are available through GRADE’s official software package developed to support the GRADE approach: GRADEpro GDT (www.gradepro.org).

Standard Cochrane ‘Summary of findings’ tables include the following elements using one of the accepted formats. Further guidance on each of these is provided in Section 14.1.6 .

• A brief description of the population and setting addressed by the available evidence (which may be slightly different to or narrower than those defined by the review question).
• A brief description of the comparison addressed in the ‘Summary of findings’ table, including both the experimental and comparison interventions.
• A list of the most critical and/or important health outcomes, both desirable and undesirable, limited to seven or fewer outcomes.
• A measure of the typical burden of each outcomes (e.g. illustrative risk, or illustrative mean, on comparator intervention).
• The absolute and relative magnitude of effect measured for each (if both are appropriate).
• The numbers of participants and studies contributing to the analysis of each outcomes.
• A GRADE assessment of the overall certainty of the body of evidence for each outcome (which may vary by outcome).
• Space for comments.
• Explanations (formerly known as footnotes).

Ideally, ‘Summary of findings’ tables are supported by more detailed tables (known as ‘evidence profiles’) to which the review may be linked, which provide more detailed explanations. Evidence profiles include the same important health outcomes, and provide greater detail than ‘Summary of findings’ tables of both of the individual considerations feeding into the grading of certainty and of the results of the studies (Guyatt et al 2011a). They ensure that a structured approach is used to rating the certainty of evidence. Although they are rarely published in Cochrane Reviews, evidence profiles are often used, for example, by guideline developers in considering the certainty of the evidence to support guideline recommendations. Review authors will find it easier to develop the ‘Summary of findings’ table by completing the rating of the certainty of evidence in the evidence profile first in GRADEpro GDT. They can then automatically convert this to one of the ‘Summary of findings’ formats in GRADEpro GDT, including an interactive ‘Summary of findings’ for publication.

As a measure of the magnitude of effect for dichotomous outcomes, the ‘Summary of findings’ table should provide a relative measure of effect (e.g. risk ratio, odds ratio, hazard) and measures of absolute risk. For other types of data, an absolute measure alone (such as a difference in means for continuous data) might be sufficient. It is important that the magnitude of effect is presented in a meaningful way, which may require some transformation of the result of a meta-analysis (see also Chapter 15, Section 15.4 and Section 15.5 ). Reviews with more than one main comparison should include a separate ‘Summary of findings’ table for each comparison.

Figure 14.1.a provides an example of a ‘Summary of findings’ table. Figure 15.1.b  provides an alternative format that may further facilitate users’ understanding and interpretation of the review’s findings. Evidence evaluating different formats suggests that the ‘Summary of findings’ table should include a risk difference as a measure of the absolute effect and authors should preferably use a format that includes a risk difference .

A detailed description of the contents of a ‘Summary of findings’ table appears in Section 14.1.6 .

Figure 14.1.a Example of a ‘Summary of findings’ table

Summary of findings (for interactive version click here )

a All the stockings in the nine studies included in this review were below-knee compression stockings. In four studies the compression strength was 20 mmHg to 30 mmHg at the ankle. It was 10 mmHg to 20 mmHg in the other four studies. Stockings come in different sizes. If a stocking is too tight around the knee it can prevent essential venous return causing the blood to pool around the knee. Compression stockings should be fitted properly. A stocking that is too tight could cut into the skin on a long flight and potentially cause ulceration and increased risk of DVT. Some stockings can be slightly thicker than normal leg covering and can be potentially restrictive with tight foot wear. It is a good idea to wear stockings around the house prior to travel to ensure a good, comfortable fit. Participants put their stockings on two to three hours before the flight in most of the studies. The availability and cost of stockings can vary.

b Two studies recruited high risk participants defined as those with previous episodes of DVT, coagulation disorders, severe obesity, limited mobility due to bone or joint problems, neoplastic disease within the previous two years, large varicose veins or, in one of the studies, participants taller than 190 cm and heavier than 90 kg. The incidence for the seven studies that excluded high risk participants was 1.45% and the incidence for the two studies that recruited high-risk participants (with at least one risk factor) was 2.43%. We have used 10 and 30 per 1000 to express different risk strata, respectively.

c The confidence interval crosses no difference and does not rule out a small increase.

d The measurement of oedema was not validated (indirectness of the outcome) or blinded to the intervention (risk of bias).

e If there are very few or no events and the number of participants is large, judgement about the certainty of evidence (particularly judgements about imprecision) may be based on the absolute effect. Here the certainty rating may be considered ‘high’ if the outcome was appropriately assessed and the event, in fact, did not occur in 2821 studied participants.

f None of the other studies reported adverse effects, apart from four cases of superficial vein thrombosis in varicose veins in the knee region that were compressed by the upper edge of the stocking in one study.

Figure 14.1.b Example of alternative ‘Summary of findings’ table

14.1.4 Producing ‘Summary of findings’ tables

The GRADE Working Group’s software, GRADEpro GDT ( www.gradepro.org ), including GRADE’s interactive handbook, is available to assist review authors in the preparation of ‘Summary of findings’ tables. GRADEpro can use data on the comparator group risk and the effect estimate (entered by the review authors or imported from files generated in RevMan) to produce the relative effects and absolute risks associated with experimental interventions. In addition, it leads the user through the process of a GRADE assessment, and produces a table that can be used as a standalone table in a review (including by direct import into software such as RevMan or integration with RevMan Web), or an interactive ‘Summary of findings’ table (see help resources in GRADEpro).

14.1.5 Statistical considerations in ‘Summary of findings’ tables

14.1.5.1 dichotomous outcomes.

‘Summary of findings’ tables should include both absolute and relative measures of effect for dichotomous outcomes. Risk ratios, odds ratios and risk differences are different ways of comparing two groups with dichotomous outcome data (see Chapter 6, Section 6.4.1 ). Furthermore, there are two distinct risk ratios, depending on which event (e.g. ‘yes’ or ‘no’) is the focus of the analysis (see Chapter 6, Section 6.4.1.5 ). In the presence of a non-zero intervention effect, any variation across studies in the comparator group risks (i.e. variation in the risk of the event occurring without the intervention of interest, for example in different populations) makes it impossible for more than one of these measures to be truly the same in every study.

It has long been assumed in epidemiology that relative measures of effect are more consistent than absolute measures of effect from one scenario to another. There is empirical evidence to support this assumption (Engels et al 2000, Deeks and Altman 2001, Furukawa et al 2002). For this reason, meta-analyses should generally use either a risk ratio or an odds ratio as a measure of effect (see Chapter 10, Section 10.4.3 ). Correspondingly, a single estimate of relative effect is likely to be a more appropriate summary than a single estimate of absolute effect. If a relative effect is indeed consistent across studies, then different comparator group risks will have different implications for absolute benefit. For instance, if the risk ratio is consistently 0.75, then the experimental intervention would reduce a comparator group risk of 80% to 60% in the intervention group (an absolute risk reduction of 20 percentage points), but would also reduce a comparator group risk of 20% to 15% in the intervention group (an absolute risk reduction of 5 percentage points).

‘Summary of findings’ tables are built around the assumption of a consistent relative effect. It is therefore important to consider the implications of this effect for different comparator group risks (these can be derived or estimated from a number of sources, see Section 14.1.6.3 ), which may require an assessment of the certainty of evidence for prognostic evidence (Spencer et al 2012, Iorio et al 2015). For any comparator group risk, it is possible to estimate a corresponding intervention group risk (i.e. the absolute risk with the intervention) from the meta-analytic risk ratio or odds ratio. Note that the numbers provided in the ‘Corresponding risk’ column are specific to the ‘risks’ in the adjacent column.

For the meta-analytic risk ratio (RR) and assumed comparator risk (ACR) the corresponding intervention risk is obtained as:

As an example, in Figure 14.1.a , the meta-analytic risk ratio for symptomless deep vein thrombosis (DVT) is RR = 0.10 (95% CI 0.04 to 0.26). Assuming a comparator risk of ACR = 10 per 1000 = 0.01, we obtain:

For the meta-analytic odds ratio (OR) and assumed comparator risk, ACR, the corresponding intervention risk is obtained as:

Upper and lower confidence limits for the corresponding intervention risk are obtained by replacing RR or OR by their upper and lower confidence limits, respectively (e.g. replacing 0.10 with 0.04, then with 0.26, in the example). Such confidence intervals do not incorporate uncertainty in the assumed comparator risks.

When dealing with risk ratios, it is critical that the same definition of ‘event’ is used as was used for the meta-analysis. For example, if the meta-analysis focused on ‘death’ (as opposed to survival) as the event, then corresponding risks in the ‘Summary of findings’ table must also refer to ‘death’.

In (rare) circumstances in which there is clear rationale to assume a consistent risk difference in the meta-analysis, in principle it is possible to present this for relevant ‘assumed risks’ and their corresponding risks, and to present the corresponding (different) relative effects for each assumed risk.

The risk difference expresses the difference between the ACR and the corresponding intervention risk (or the difference between the experimental and the comparator intervention).

For the meta-analytic risk ratio (RR) and assumed comparator risk (ACR) the corresponding risk difference is obtained as (note that risks can also be expressed using percentage or percentage points):

As an example, in Figure 14.1.b the meta-analytic risk ratio is 0.41 (95% CI 0.29 to 0.55) for diarrhoea in children less than 5 years of age. Assuming a comparator group risk of 22.3% we obtain:

For the meta-analytic odds ratio (OR) and assumed comparator risk (ACR) the absolute risk difference is obtained as (percentage points):

Upper and lower confidence limits for the absolute risk difference are obtained by re-running the calculation above while replacing RR or OR by their upper and lower confidence limits, respectively (e.g. replacing 0.41 with 0.28, then with 0.55, in the example). Such confidence intervals do not incorporate uncertainty in the assumed comparator risks.

14.1.5.2 Time-to-event outcomes

Time-to-event outcomes measure whether and when a particular event (e.g. death) occurs (van Dalen et al 2007). The impact of the experimental intervention relative to the comparison group on time-to-event outcomes is usually measured using a hazard ratio (HR) (see Chapter 6, Section 6.8.1 ).

A hazard ratio expresses a relative effect estimate. It may be used in various ways to obtain absolute risks and other interpretable quantities for a specific population. Here we describe how to re-express hazard ratios in terms of: (i) absolute risk of event-free survival within a particular period of time; (ii) absolute risk of an event within a particular period of time; and (iii) median time to the event. All methods are built on an assumption of consistent relative effects (i.e. that the hazard ratio does not vary over time).

(i) Absolute risk of event-free survival within a particular period of time Event-free survival (e.g. overall survival) is commonly reported by individual studies. To obtain absolute effects for time-to-event outcomes measured as event-free survival, the summary HR can be used in conjunction with an assumed proportion of patients who are event-free in the comparator group (Tierney et al 2007). This proportion of patients will be specific to a period of time of observation. However, it is not strictly necessary to specify this period of time. For instance, a proportion of 50% of event-free patients might apply to patients with a high event rate observed over 1 year, or to patients with a low event rate observed over 2 years.

As an example, suppose the meta-analytic hazard ratio is 0.42 (95% CI 0.25 to 0.72). Assuming a comparator group risk of event-free survival (e.g. for overall survival people being alive) at 2 years of ACR = 900 per 1000 = 0.9 we obtain:

so that that 956 per 1000 people will be alive with the experimental intervention at 2 years. The derivation of the risk should be explained in a comment or footnote.

(ii) Absolute risk of an event within a particular period of time To obtain this absolute effect, again the summary HR can be used (Tierney et al 2007):

In the example, suppose we assume a comparator group risk of events (e.g. for mortality, people being dead) at 2 years of ACR = 100 per 1000 = 0.1. We obtain:

so that that 44 per 1000 people will be dead with the experimental intervention at 2 years.

(iii) Median time to the event Instead of absolute numbers, the time to the event in the intervention and comparison groups can be expressed as median survival time in months or years. To obtain median survival time the pooled HR can be applied to an assumed median survival time in the comparator group (Tierney et al 2007):

In the example, assuming a comparator group median survival time of 80 months, we obtain:

For all three of these options for re-expressing results of time-to-event analyses, upper and lower confidence limits for the corresponding intervention risk are obtained by replacing HR by its upper and lower confidence limits, respectively (e.g. replacing 0.42 with 0.25, then with 0.72, in the example). Again, as for dichotomous outcomes, such confidence intervals do not incorporate uncertainty in the assumed comparator group risks. This is of special concern for long-term survival with a low or moderate mortality rate and a corresponding high number of censored patients (i.e. a low number of patients under risk and a high censoring rate).

14.1.6 Detailed contents of a ‘Summary of findings’ table

14.1.6.1 table title and header.

The title of each ‘Summary of findings’ table should specify the healthcare question, framed in terms of the population and making it clear exactly what comparison of interventions are made. In Figure 14.1.a , the population is people taking long aeroplane flights, the intervention is compression stockings, and the control is no compression stockings.

The first rows of each ‘Summary of findings’ table should provide the following ‘header’ information:

Patients or population This further clarifies the population (and possibly the subpopulations) of interest and ideally the magnitude of risk of the most crucial adverse outcome at which an intervention is directed. For instance, people on a long-haul flight may be at different risks for DVT; those using selective serotonin reuptake inhibitors (SSRIs) might be at different risk for side effects; while those with atrial fibrillation may be at low (< 1%), moderate (1% to 4%) or high (> 4%) yearly risk of stroke.

Setting This should state any specific characteristics of the settings of the healthcare question that might limit the applicability of the summary of findings to other settings (e.g. primary care in Europe and North America).

Intervention The experimental intervention.

Comparison The comparator intervention (including no specific intervention).

14.1.6.2 Outcomes

The rows of a ‘Summary of findings’ table should include all desirable and undesirable health outcomes (listed in order of importance) that are essential for decision making, up to a maximum of seven outcomes. If there are more outcomes in the review, review authors will need to omit the less important outcomes from the table, and the decision selecting which outcomes are critical or important to the review should be made during protocol development (see Chapter 3 ). Review authors should provide time frames for the measurement of the outcomes (e.g. 90 days or 12 months) and the type of instrument scores (e.g. ranging from 0 to 100).

Note that review authors should include the pre-specified critical and important outcomes in the table whether data are available or not. However, they should be alert to the possibility that the importance of an outcome (e.g. a serious adverse effect) may only become known after the protocol was written or the analysis was carried out, and should take appropriate actions to include these in the ‘Summary of findings’ table.

The ‘Summary of findings’ table can include effects in subgroups of the population for different comparator risks and effect sizes separately. For instance, in Figure 14.1.b effects are presented for children younger and older than 5 years separately. Review authors may also opt to produce separate ‘Summary of findings’ tables for different populations.

Review authors should include serious adverse events, but it might be possible to combine minor adverse events as a single outcome, and describe this in an explanatory footnote (note that it is not appropriate to add events together unless they are independent, that is, a participant who has experienced one adverse event has an unaffected chance of experiencing the other adverse event).

Outcomes measured at multiple time points represent a particular problem. In general, to keep the table simple, review authors should present multiple time points only for outcomes critical to decision making, where either the result or the decision made are likely to vary over time. The remainder should be presented at a common time point where possible.

Review authors can present continuous outcome measures in the ‘Summary of findings’ table and should endeavour to make these interpretable to the target audience. This requires that the units are clear and readily interpretable, for example, days of pain, or frequency of headache, and the name and scale of any measurement tools used should be stated (e.g. a Visual Analogue Scale, ranging from 0 to 100). However, many measurement instruments are not readily interpretable by non-specialist clinicians or patients, for example, points on a Beck Depression Inventory or quality of life score. For these, a more interpretable presentation might involve converting a continuous to a dichotomous outcome, such as >50% improvement (see Chapter 15, Section 15.5 ).

14.1.6.3 Best estimate of risk with comparator intervention

Review authors should provide up to three typical risks for participants receiving the comparator intervention. For dichotomous outcomes, we recommend that these be presented in the form of the number of people experiencing the event per 100 or 1000 people (natural frequency) depending on the frequency of the outcome. For continuous outcomes, this would be stated as a mean or median value of the outcome measured.

Estimated or assumed comparator intervention risks could be based on assessments of typical risks in different patient groups derived from the review itself, individual representative studies in the review, or risks derived from a systematic review of prognosis studies or other sources of evidence which may in turn require an assessment of the certainty for the prognostic evidence (Spencer et al 2012, Iorio et al 2015). Ideally, risks would reflect groups that clinicians can easily identify on the basis of their presenting features.

An explanatory footnote should specify the source or rationale for each comparator group risk, including the time period to which it corresponds where appropriate. In Figure 14.1.a , clinicians can easily differentiate individuals with risk factors for deep venous thrombosis from those without. If there is known to be little variation in baseline risk then review authors may use the median comparator group risk across studies. If typical risks are not known, an option is to choose the risk from the included studies, providing the second highest for a high and the second lowest for a low risk population.

14.1.6.4 Risk with intervention

For dichotomous outcomes, review authors should provide a corresponding absolute risk for each comparator group risk, along with a confidence interval. This absolute risk with the (experimental) intervention will usually be derived from the meta-analysis result presented in the relative effect column (see Section 14.1.6.6 ). Formulae are provided in Section 14.1.5 . Review authors should present the absolute effect in the same format as the risks with comparator intervention (see Section 14.1.6.3 ), for example as the number of people experiencing the event per 1000 people.

For continuous outcomes, a difference in means or standardized difference in means should be presented with its confidence interval. These will typically be obtained directly from a meta-analysis. Explanatory text should be used to clarify the meaning, as in Figures 14.1.a and 14.1.b .

14.1.6.5 Risk difference

For dichotomous outcomes, the risk difference can be provided using one of the ‘Summary of findings’ table formats as an additional option (see Figure 14.1.b ). This risk difference expresses the difference between the experimental and comparator intervention and will usually be derived from the meta-analysis result presented in the relative effect column (see Section 14.1.6.6 ). Formulae are provided in Section 14.1.5 . Review authors should present the risk difference in the same format as assumed and corresponding risks with comparator intervention (see Section 14.1.6.3 ); for example, as the number of people experiencing the event per 1000 people or as percentage points if the assumed and corresponding risks are expressed in percentage.

For continuous outcomes, if the ‘Summary of findings’ table includes this option, the mean difference can be presented here and the ‘corresponding risk’ column left blank (see Figure 14.1.b ).

14.1.6.6 Relative effect (95% CI)

The relative effect will typically be a risk ratio or odds ratio (or occasionally a hazard ratio) with its accompanying 95% confidence interval, obtained from a meta-analysis performed on the basis of the same effect measure. Risk ratios and odds ratios are similar when the comparator intervention risks are low and effects are small, but may differ considerably when comparator group risks increase. The meta-analysis may involve an assumption of either fixed or random effects, depending on what the review authors consider appropriate, and implying that the relative effect is either an estimate of the effect of the intervention, or an estimate of the average effect of the intervention across studies, respectively.

14.1.6.7 Number of participants (studies)

This column should include the number of participants assessed in the included studies for each outcome and the corresponding number of studies that contributed these participants.

14.1.6.8 Certainty of the evidence (GRADE)

Review authors should comment on the certainty of the evidence (also known as quality of the body of evidence or confidence in the effect estimates). Review authors should use the specific evidence grading system developed by the GRADE Working Group (Atkins et al 2004, Guyatt et al 2008, Guyatt et al 2011a), which is described in detail in Section 14.2 . The GRADE approach categorizes the certainty in a body of evidence as ‘high’, ‘moderate’, ‘low’ or ‘very low’ by outcome. This is a result of judgement, but the judgement process operates within a transparent structure. As an example, the certainty would be ‘high’ if the summary were of several randomized trials with low risk of bias, but the rating of certainty becomes lower if there are concerns about risk of bias, inconsistency, indirectness, imprecision or publication bias. Judgements other than of ‘high’ certainty should be made transparent using explanatory footnotes or the ‘Comments’ column in the ‘Summary of findings’ table (see Section 14.1.6.10 ).

14.1.6.9 Comments

The aim of the ‘Comments’ field is to help interpret the information or data identified in the row. For example, this may be on the validity of the outcome measure or the presence of variables that are associated with the magnitude of effect. Important caveats about the results should be flagged here. Not all rows will need comments, and it is best to leave a blank if there is nothing warranting a comment.

14.1.6.10 Explanations

Detailed explanations should be included as footnotes to support the judgements in the ‘Summary of findings’ table, such as the overall GRADE assessment. The explanations should describe the rationale for important aspects of the content. Table 14.1.a lists guidance for useful explanations. Explanations should be concise, informative, relevant, easy to understand and accurate. If explanations cannot be sufficiently described in footnotes, review authors should provide further details of the issues in the Results and Discussion sections of the review.

Table 14.1.a Guidance for providing useful explanations in ‘Summary of findings’ (SoF) tables. Adapted from Santesso et al (2016)

14.2 Assessing the certainty or quality of a body of evidence

14.2.1 the grade approach.

The Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE Working Group) has developed a system for grading the certainty of evidence (Schünemann et al 2003, Atkins et al 2004, Schünemann et al 2006, Guyatt et al 2008, Guyatt et al 2011a). Over 100 organizations including the World Health Organization (WHO), the American College of Physicians, the American Society of Hematology (ASH), the Canadian Agency for Drugs and Technology in Health (CADTH) and the National Institutes of Health and Clinical Excellence (NICE) in the UK have adopted the GRADE system ( www.gradeworkinggroup.org ).

Cochrane has also formally adopted this approach, and all Cochrane Reviews should use GRADE to evaluate the certainty of evidence for important outcomes (see MECIR Box 14.2.a ).

MECIR Box 14.2.a Relevant expectations for conduct of intervention reviews

For systematic reviews, the GRADE approach defines the certainty of a body of evidence as the extent to which one can be confident that an estimate of effect or association is close to the quantity of specific interest. Assessing the certainty of a body of evidence involves consideration of within- and across-study risk of bias (limitations in study design and execution or methodological quality), inconsistency (or heterogeneity), indirectness of evidence, imprecision of the effect estimates and risk of publication bias (see Section 14.2.2 ), as well as domains that may increase our confidence in the effect estimate (as described in Section 14.2.3 ). The GRADE system entails an assessment of the certainty of a body of evidence for each individual outcome. Judgements about the domains that determine the certainty of evidence should be described in the results or discussion section and as part of the ‘Summary of findings’ table.

The GRADE approach specifies four levels of certainty ( Figure 14.2.a ). For interventions, including diagnostic and other tests that are evaluated as interventions (Schünemann et al 2008b, Schünemann et al 2008a, Balshem et al 2011, Schünemann et al 2012), the starting point for rating the certainty of evidence is categorized into two types:

• randomized trials; and
• non-randomized studies of interventions (NRSI), including observational studies (including but not limited to cohort studies, and case-control studies, cross-sectional studies, case series and case reports, although not all of these designs are usually included in Cochrane Reviews).

There are many instances in which review authors rely on information from NRSI, in particular to evaluate potential harms (see Chapter 24 ). In addition, review authors can obtain relevant data from both randomized trials and NRSI, with each type of evidence complementing the other (Schünemann et al 2013).

In GRADE, a body of evidence from randomized trials begins with a high-certainty rating while a body of evidence from NRSI begins with a low-certainty rating. The lower rating with NRSI is the result of the potential bias induced by the lack of randomization (i.e. confounding and selection bias).

However, when using the new Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool (Sterne et al 2016), an assessment tool that covers the risk of bias due to lack of randomization, all studies may start as high certainty of the evidence (Schünemann et al 2018). The approach of starting all study designs (including NRSI) as high certainty does not conflict with the initial GRADE approach of starting the rating of NRSI as low certainty evidence. This is because a body of evidence from NRSI should generally be downgraded by two levels due to the inherent risk of bias associated with the lack of randomization, namely confounding and selection bias. Not downgrading NRSI from high to low certainty needs transparent and detailed justification for what mitigates concerns about confounding and selection bias (Schünemann et al 2018). Very few examples of where not rating down by two levels is appropriate currently exist.

The highest certainty rating is a body of evidence when there are no concerns in any of the GRADE factors listed in Figure 14.2.a . Review authors often downgrade evidence to moderate, low or even very low certainty evidence, depending on the presence of the five factors in Figure 14.2.a . Usually, certainty rating will fall by one level for each factor, up to a maximum of three levels for all factors. If there are very severe problems for any one domain (e.g. when assessing risk of bias, all studies were unconcealed, unblinded and lost over 50% of their patients to follow-up), evidence may fall by two levels due to that factor alone. It is not possible to rate lower than ‘very low certainty’ evidence.

Review authors will generally grade evidence from sound non-randomized studies as low certainty, even if ROBINS-I is used. If, however, such studies yield large effects and there is no obvious bias explaining those effects, review authors may rate the evidence as moderate or – if the effect is large enough – even as high certainty ( Figure 14.2.a ). The very low certainty level is appropriate for, but is not limited to, studies with critical problems and unsystematic clinical observations (e.g. case series or case reports).

Figure 14.2.a Levels of the certainty of a body of evidence in the GRADE approach. *Upgrading criteria are usually applicable to non-randomized studies only (but exceptions exist).

14.2.2 Domains that can lead to decreasing the certainty level of a body of evidence   

We now describe in more detail the five reasons (or domains) for downgrading the certainty of a body of evidence for a specific outcome. In each case, if no reason is found for downgrading the evidence, it should be classified as 'no limitation or not serious' (not important enough to warrant downgrading). If a reason is found for downgrading the evidence, it should be classified as 'serious' (downgrading the certainty rating by one level) or 'very serious' (downgrading the certainty grade by two levels). For non-randomized studies assessed with ROBINS-I, rating down by three levels should be classified as 'extremely' serious.

(1) Risk of bias or limitations in the detailed design and implementation

Our confidence in an estimate of effect decreases if studies suffer from major limitations that are likely to result in a biased assessment of the intervention effect. For randomized trials, these methodological limitations include failure to generate a random sequence, lack of allocation sequence concealment, lack of blinding (particularly with subjective outcomes that are highly susceptible to biased assessment), a large loss to follow-up or selective reporting of outcomes. Chapter 8 provides a discussion of study-level assessments of risk of bias in the context of a Cochrane Review, and proposes an approach to assessing the risk of bias for an outcome across studies as ‘Low’ risk of bias, ‘Some concerns’ and ‘High’ risk of bias for randomized trials. Levels of ‘Low’. ‘Moderate’, ‘Serious’ and ‘Critical’ risk of bias arise for non-randomized studies assessed with ROBINS-I ( Chapter 25 ). These assessments should feed directly into this GRADE domain. In particular, ‘Low’ risk of bias would indicate ‘no limitation’; ‘Some concerns’ would indicate either ‘no limitation’ or ‘serious limitation’; and ‘High’ risk of bias would indicate either ‘serious limitation’ or ‘very serious limitation’. ‘Critical’ risk of bias on ROBINS-I would indicate extremely serious limitations in GRADE. Review authors should use their judgement to decide between alternative categories, depending on the likely magnitude of the potential biases.

Every study addressing a particular outcome will differ, to some degree, in the risk of bias. Review authors should make an overall judgement on whether the certainty of evidence for an outcome warrants downgrading on the basis of study limitations. The assessment of study limitations should apply to the studies contributing to the results in the ‘Summary of findings’ table, rather than to all studies that could potentially be included in the analysis. We have argued in Chapter 7, Section 7.6.2 , that the primary analysis should be restricted to studies at low (or low and unclear) risk of bias where possible.

Table 14.2.a presents the judgements that must be made in going from assessments of the risk of bias to judgements about study limitations for each outcome included in a ‘Summary of findings’ table. A rating of high certainty evidence can be achieved only when most evidence comes from studies that met the criteria for low risk of bias. For example, of the 22 studies addressing the impact of beta-blockers on mortality in patients with heart failure, most probably or certainly used concealed allocation of the sequence, all blinded at least some key groups and follow-up of randomized patients was almost complete (Brophy et al 2001). The certainty of evidence might be downgraded by one level when most of the evidence comes from individual studies either with a crucial limitation for one item, or with some limitations for multiple items. An example of very serious limitations, warranting downgrading by two levels, is provided by evidence on surgery versus conservative treatment in the management of patients with lumbar disc prolapse (Gibson and Waddell 2007). We are uncertain of the benefit of surgery in reducing symptoms after one year or longer, because the one study included in the analysis had inadequate concealment of the allocation sequence and the outcome was assessed using a crude rating by the surgeon without blinding.

(2) Unexplained heterogeneity or inconsistency of results

When studies yield widely differing estimates of effect (heterogeneity or variability in results), investigators should look for robust explanations for that heterogeneity. For instance, drugs may have larger relative effects in sicker populations or when given in larger doses. A detailed discussion of heterogeneity and its investigation is provided in Chapter 10, Section 10.10 and Section 10.11 . If an important modifier exists, with good evidence that important outcomes are different in different subgroups (which would ideally be pre-specified), then a separate ‘Summary of findings’ table may be considered for a separate population. For instance, a separate ‘Summary of findings’ table would be used for carotid endarterectomy in symptomatic patients with high grade stenosis (70% to 99%) in which the intervention is, in the hands of the right surgeons, beneficial, and another (if review authors considered it relevant) for asymptomatic patients with low grade stenosis (less than 30%) in which surgery appears harmful (Orrapin and Rerkasem 2017). When heterogeneity exists and affects the interpretation of results, but review authors are unable to identify a plausible explanation with the data available, the certainty of the evidence decreases.

(3) Indirectness of evidence

Two types of indirectness are relevant. First, a review comparing the effectiveness of alternative interventions (say A and B) may find that randomized trials are available, but they have compared A with placebo and B with placebo. Thus, the evidence is restricted to indirect comparisons between A and B. Where indirect comparisons are undertaken within a network meta-analysis context, GRADE for network meta-analysis should be used (see Chapter 11, Section 11.5 ).

Second, a review may find randomized trials that meet eligibility criteria but address a restricted version of the main review question in terms of population, intervention, comparator or outcomes. For example, suppose that in a review addressing an intervention for secondary prevention of coronary heart disease, most identified studies happened to be in people who also had diabetes. Then the evidence may be regarded as indirect in relation to the broader question of interest because the population is primarily related to people with diabetes. The opposite scenario can equally apply: a review addressing the effect of a preventive strategy for coronary heart disease in people with diabetes may consider studies in people without diabetes to provide relevant, albeit indirect, evidence. This would be particularly likely if investigators had conducted few if any randomized trials in the target population (e.g. people with diabetes). Other sources of indirectness may arise from interventions studied (e.g. if in all included studies a technical intervention was implemented by expert, highly trained specialists in specialist centres, then evidence on the effects of the intervention outside these centres may be indirect), comparators used (e.g. if the comparator groups received an intervention that is less effective than standard treatment in most settings) and outcomes assessed (e.g. indirectness due to surrogate outcomes when data on patient-important outcomes are not available, or when investigators seek data on quality of life but only symptoms are reported). Review authors should make judgements transparent when they believe downgrading is justified, based on differences in anticipated effects in the group of primary interest. Review authors may be aided and increase transparency of their judgements about indirectness if they use Table 14.2.b available in the GRADEpro GDT software (Schünemann et al 2013).

(4) Imprecision of results

When studies include few participants or few events, and thus have wide confidence intervals, review authors can lower their rating of the certainty of the evidence. The confidence intervals included in the ‘Summary of findings’ table will provide readers with information that allows them to make, to some extent, their own rating of precision. Review authors can use a calculation of the optimal information size (OIS) or review information size (RIS), similar to sample size calculations, to make judgements about imprecision (Guyatt et al 2011b, Schünemann 2016). The OIS or RIS is calculated on the basis of the number of participants required for an adequately powered individual study. If the 95% confidence interval excludes a risk ratio (RR) of 1.0, and the total number of events or patients exceeds the OIS criterion, precision is adequate. If the 95% CI includes appreciable benefit or harm (an RR of under 0.75 or over 1.25 is often suggested as a very rough guide) downgrading for imprecision may be appropriate even if OIS criteria are met (Guyatt et al 2011b, Schünemann 2016).

(5) High probability of publication bias

The certainty of evidence level may be downgraded if investigators fail to report studies on the basis of results (typically those that show no effect: publication bias) or outcomes (typically those that may be harmful or for which no effect was observed: selective outcome non-reporting bias). Selective reporting of outcomes from among multiple outcomes measured is assessed at the study level as part of the assessment of risk of bias (see Chapter 8, Section 8.7 ), so for the studies contributing to the outcome in the ‘Summary of findings’ table this is addressed by domain 1 above (limitations in the design and implementation). If a large number of studies included in the review do not contribute to an outcome, or if there is evidence of publication bias, the certainty of the evidence may be downgraded. Chapter 13 provides a detailed discussion of reporting biases, including publication bias, and how it may be tackled in a Cochrane Review. A prototypical situation that may elicit suspicion of publication bias is when published evidence includes a number of small studies, all of which are industry-funded (Bhandari et al 2004). For example, 14 studies of flavanoids in patients with haemorrhoids have shown apparent large benefits, but enrolled a total of only 1432 patients (i.e. each study enrolled relatively few patients) (Alonso-Coello et al 2006). The heavy involvement of sponsors in most of these studies raises questions of whether unpublished studies that suggest no benefit exist (publication bias).

A particular body of evidence can suffer from problems associated with more than one of the five factors listed here, and the greater the problems, the lower the certainty of evidence rating that should result. One could imagine a situation in which randomized trials were available, but all or virtually all of these limitations would be present, and in serious form. A very low certainty of evidence rating would result.

Table 14.2.a Further guidelines for domain 1 (of 5) in a GRADE assessment: going from assessments of risk of bias in studies to judgements about study limitations for main outcomes across studies

Table 14.2.b Judgements about indirectness by outcome (available in GRADEpro GDT)

Intervention:

Comparator:

Direct comparison:

Final judgement about indirectness across domains:

14.2.3 Domains that may lead to increasing the certainty level of a body of evidence

Although NRSI and downgraded randomized trials will generally yield a low rating for certainty of evidence, there will be unusual circumstances in which review authors could ‘upgrade’ such evidence to moderate or even high certainty ( Table 14.3.a ).

• Large effects On rare occasions when methodologically well-done observational studies yield large, consistent and precise estimates of the magnitude of an intervention effect, one may be particularly confident in the results. A large estimated effect (e.g. RR >2 or RR <0.5) in the absence of plausible confounders, or a very large effect (e.g. RR >5 or RR <0.2) in studies with no major threats to validity, might qualify for this. In these situations, while the NRSI may possibly have provided an over-estimate of the true effect, the weak study design may not explain all of the apparent observed benefit. Thus, despite reservations based on the observational study design, review authors are confident that the effect exists. The magnitude of the effect in these studies may move the assigned certainty of evidence from low to moderate (if the effect is large in the absence of other methodological limitations). For example, a meta-analysis of observational studies showed that bicycle helmets reduce the risk of head injuries in cyclists by a large margin (odds ratio (OR) 0.31, 95% CI 0.26 to 0.37) (Thompson et al 2000). This large effect, in the absence of obvious bias that could create the association, suggests a rating of moderate-certainty evidence.  Note : GRADE guidance suggests the possibility of rating up one level for a large effect if the relative effect is greater than 2.0. However, if the point estimate of the relative effect is greater than 2.0, but the confidence interval is appreciably below 2.0, then some hesitation would be appropriate in the decision to rate up for a large effect. Another situation allows inference of a strong association without a formal comparative study. Consider the question of the impact of routine colonoscopy versus no screening for colon cancer on the rate of perforation associated with colonoscopy. Here, a large series of representative patients undergoing colonoscopy may provide high certainty evidence about the risk of perforation associated with colonoscopy. When the risk of the event among patients receiving the relevant comparator is known to be near 0 (i.e. we are certain that the incidence of spontaneous colon perforation in patients not undergoing colonoscopy is extremely low), case series or cohort studies of representative patients can provide high certainty evidence of adverse effects associated with an intervention, thereby allowing us to infer a strong association from even a limited number of events.
• Dose-response The presence of a dose-response gradient may increase our confidence in the findings of observational studies and thereby enhance the assigned certainty of evidence. For example, our confidence in the result of observational studies that show an increased risk of bleeding in patients who have supratherapeutic anticoagulation levels is increased by the observation that there is a dose-response gradient between the length of time needed for blood to clot (as measured by the international normalized ratio (INR)) and an increased risk of bleeding (Levine et al 2004). A systematic review of NRSI investigating the effect of cyclooxygenase-2 inhibitors on cardiovascular events found that the summary estimate (RR) with rofecoxib was 1.33 (95% CI 1.00 to 1.79) with doses less than 25mg/d, and 2.19 (95% CI 1.64 to 2.91) with doses more than 25mg/d. Although residual confounding is likely to exist in the NRSI that address this issue, the existence of a dose-response gradient and the large apparent effect of higher doses of rofecoxib markedly increase our strength of inference that the association cannot be explained by residual confounding, and is therefore likely to be both causal and, at high levels of exposure, substantial.  Note : GRADE guidance suggests the possibility of rating up one level for a large effect if the relative effect is greater than 2.0. Here, the fact that the point estimate of the relative effect is greater than 2.0, but the confidence interval is appreciably below 2.0 might make some hesitate in the decision to rate up for a large effect
• Plausible confounding On occasion, all plausible biases from randomized or non-randomized studies may be working to under-estimate an apparent intervention effect. For example, if only sicker patients receive an experimental intervention or exposure, yet they still fare better, it is likely that the actual intervention or exposure effect is larger than the data suggest. For instance, a rigorous systematic review of observational studies including a total of 38 million patients demonstrated higher death rates in private for-profit versus private not-for-profit hospitals (Devereaux et al 2002). One possible bias relates to different disease severity in patients in the two hospital types. It is likely, however, that patients in the not-for-profit hospitals were sicker than those in the for-profit hospitals. Thus, to the extent that residual confounding existed, it would bias results against the not-for-profit hospitals. The second likely bias was the possibility that higher numbers of patients with excellent private insurance coverage could lead to a hospital having more resources and a spill-over effect that would benefit those without such coverage. Since for-profit hospitals are likely to admit a larger proportion of such well-insured patients than not-for-profit hospitals, the bias is once again against the not-for-profit hospitals. Since the plausible biases would all diminish the demonstrated intervention effect, one might consider the evidence from these observational studies as moderate rather than low certainty. A parallel situation exists when observational studies have failed to demonstrate an association, but all plausible biases would have increased an intervention effect. This situation will usually arise in the exploration of apparent harmful effects. For example, because the hypoglycaemic drug phenformin causes lactic acidosis, the related agent metformin was under suspicion for the same toxicity. Nevertheless, very large observational studies have failed to demonstrate an association (Salpeter et al 2007). Given the likelihood that clinicians would be more alert to lactic acidosis in the presence of the agent and over-report its occurrence, one might consider this moderate, or even high certainty, evidence refuting a causal relationship between typical therapeutic doses of metformin and lactic acidosis.

14.3 Describing the assessment of the certainty of a body of evidence using the GRADE framework

Review authors should report the grading of the certainty of evidence in the Results section for each outcome for which this has been performed, providing the rationale for downgrading or upgrading the evidence, and referring to the ‘Summary of findings’ table where applicable.

Table 14.3.a provides a framework and examples for how review authors can justify their judgements about the certainty of evidence in each domain. These justifications should also be included in explanatory notes to the ‘Summary of Findings’ table (see Section 14.1.6.10 ).

Chapter 15, Section 15.6 , describes in more detail how the overall GRADE assessment across all domains can be used to draw conclusions about the effects of the intervention, as well as providing implications for future research.

Table 14.3.a Framework for describing the certainty of evidence and justifying downgrading or upgrading

14.4 Chapter information

Authors: Holger J Schünemann, Julian PT Higgins, Gunn E Vist, Paul Glasziou, Elie A Akl, Nicole Skoetz, Gordon H Guyatt; on behalf of the Cochrane GRADEing Methods Group (formerly Applicability and Recommendations Methods Group) and the Cochrane Statistical Methods Group

Acknowledgements: Andrew D Oxman contributed to earlier versions. Professor Penny Hawe contributed to the text on adverse effects in earlier versions. Jon Deeks provided helpful contributions on an earlier version of this chapter. For details of previous authors and editors of the Handbook , please refer to the Preface.

Funding: This work was in part supported by funding from the Michael G DeGroote Cochrane Canada Centre and the Ontario Ministry of Health.

14.5 References

Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, Mills E, Heels-Ansdell D, Johanson JF, Guyatt G. Meta-analysis of flavonoids for the treatment of haemorrhoids. British Journal of Surgery 2006; 93 : 909-920.

Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour RT, Haugh MC, Henry D, Hill S, Jaeschke R, Leng G, Liberati A, Magrini N, Mason J, Middleton P, Mrukowicz J, O'Connell D, Oxman AD, Phillips B, Schünemann HJ, Edejer TT, Varonen H, Vist GE, Williams JW, Jr., Zaza S. Grading quality of evidence and strength of recommendations. BMJ 2004; 328 : 1490.

Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris S, Guyatt GH. GRADE guidelines: 3. Rating the quality of evidence. Journal of Clinical Epidemiology 2011; 64 : 401-406.

Bhandari M, Busse JW, Jackowski D, Montori VM, Schünemann H, Sprague S, Mears D, Schemitsch EH, Heels-Ansdell D, Devereaux PJ. Association between industry funding and statistically significant pro-industry findings in medical and surgical randomized trials. Canadian Medical Association Journal 2004; 170 : 477-480.

Brophy JM, Joseph L, Rouleau JL. Beta-blockers in congestive heart failure. A Bayesian meta-analysis. Annals of Internal Medicine 2001; 134 : 550-560.

Carrasco-Labra A, Brignardello-Petersen R, Santesso N, Neumann I, Mustafa RA, Mbuagbaw L, Etxeandia Ikobaltzeta I, De Stio C, McCullagh LJ, Alonso-Coello P, Meerpohl JJ, Vandvik PO, Brozek JL, Akl EA, Bossuyt P, Churchill R, Glenton C, Rosenbaum S, Tugwell P, Welch V, Garner P, Guyatt G, Schünemann HJ. Improving GRADE evidence tables part 1: a randomized trial shows improved understanding of content in summary of findings tables with a new format. Journal of Clinical Epidemiology 2016; 74 : 7-18.

Deeks JJ, Altman DG. Effect measures for meta-analysis of trials with binary outcomes. In: Egger M, Davey Smith G, Altman DG, editors. Systematic Reviews in Health Care: Meta-analysis in Context . 2nd ed. London (UK): BMJ Publication Group; 2001. p. 313-335.

Devereaux PJ, Choi PT, Lacchetti C, Weaver B, Schünemann HJ, Haines T, Lavis JN, Grant BJ, Haslam DR, Bhandari M, Sullivan T, Cook DJ, Walter SD, Meade M, Khan H, Bhatnagar N, Guyatt GH. A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. Canadian Medical Association Journal 2002; 166 : 1399-1406.

Engels EA, Schmid CH, Terrin N, Olkin I, Lau J. Heterogeneity and statistical significance in meta-analysis: an empirical study of 125 meta-analyses. Statistics in Medicine 2000; 19 : 1707-1728.

Furukawa TA, Guyatt GH, Griffith LE. Can we individualize the 'number needed to treat'? An empirical study of summary effect measures in meta-analyses. International Journal of Epidemiology 2002; 31 : 72-76.

Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse: updated Cochrane Review. Spine 2007; 32 : 1735-1747.

Guyatt G, Oxman A, Vist G, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann H. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336 : 3.

Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, Jaeschke R, Rind D, Meerpohl J, Dahm P, Schünemann HJ. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. Journal of Clinical Epidemiology 2011a; 64 : 383-394.

Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, Devereaux PJ, Montori VM, Freyschuss B, Vist G, Jaeschke R, Williams JW, Jr., Murad MH, Sinclair D, Falck-Ytter Y, Meerpohl J, Whittington C, Thorlund K, Andrews J, Schünemann HJ. GRADE guidelines 6. Rating the quality of evidence--imprecision. Journal of Clinical Epidemiology 2011b; 64 : 1283-1293.

Iorio A, Spencer FA, Falavigna M, Alba C, Lang E, Burnand B, McGinn T, Hayden J, Williams K, Shea B, Wolff R, Kujpers T, Perel P, Vandvik PO, Glasziou P, Schünemann H, Guyatt G. Use of GRADE for assessment of evidence about prognosis: rating confidence in estimates of event rates in broad categories of patients. BMJ 2015; 350 : h870.

Langendam M, Carrasco-Labra A, Santesso N, Mustafa RA, Brignardello-Petersen R, Ventresca M, Heus P, Lasserson T, Moustgaard R, Brozek J, Schünemann HJ. Improving GRADE evidence tables part 2: a systematic survey of explanatory notes shows more guidance is needed. Journal of Clinical Epidemiology 2016; 74 : 19-27.

Levine MN, Raskob G, Landefeld S, Kearon C, Schulman S. Hemorrhagic complications of anticoagulant treatment: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 : 287S-310S.

Orrapin S, Rerkasem K. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database of Systematic Reviews 2017; 6 : CD001081.

Salpeter S, Greyber E, Pasternak G, Salpeter E. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2007; 4 : CD002967.

Santesso N, Carrasco-Labra A, Langendam M, Brignardello-Petersen R, Mustafa RA, Heus P, Lasserson T, Opiyo N, Kunnamo I, Sinclair D, Garner P, Treweek S, Tovey D, Akl EA, Tugwell P, Brozek JL, Guyatt G, Schünemann HJ. Improving GRADE evidence tables part 3: detailed guidance for explanatory footnotes supports creating and understanding GRADE certainty in the evidence judgments. Journal of Clinical Epidemiology 2016; 74 : 28-39.

Schünemann HJ, Best D, Vist G, Oxman AD, Group GW. Letters, numbers, symbols and words: how to communicate grades of evidence and recommendations. Canadian Medical Association Journal 2003; 169 : 677-680.

Schünemann HJ, Jaeschke R, Cook DJ, Bria WF, El-Solh AA, Ernst A, Fahy BF, Gould MK, Horan KL, Krishnan JA, Manthous CA, Maurer JR, McNicholas WT, Oxman AD, Rubenfeld G, Turino GM, Guyatt G. An official ATS statement: grading the quality of evidence and strength of recommendations in ATS guidelines and recommendations. American Journal of Respiratory and Critical Care Medicine 2006; 174 : 605-614.

Schünemann HJ, Oxman AD, Brozek J, Glasziou P, Jaeschke R, Vist GE, Williams JW, Jr., Kunz R, Craig J, Montori VM, Bossuyt P, Guyatt GH. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ 2008a; 336 : 1106-1110.

Schünemann HJ, Oxman AD, Brozek J, Glasziou P, Bossuyt P, Chang S, Muti P, Jaeschke R, Guyatt GH. GRADE: assessing the quality of evidence for diagnostic recommendations. ACP Journal Club 2008b; 149 : 2.

Schünemann HJ, Mustafa R, Brozek J. [Diagnostic accuracy and linked evidence--testing the chain]. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen 2012; 106 : 153-160.

Schünemann HJ, Tugwell P, Reeves BC, Akl EA, Santesso N, Spencer FA, Shea B, Wells G, Helfand M. Non-randomized studies as a source of complementary, sequential or replacement evidence for randomized controlled trials in systematic reviews on the effects of interventions. Research Synthesis Methods 2013; 4 : 49-62.

Schünemann HJ. Interpreting GRADE's levels of certainty or quality of the evidence: GRADE for statisticians, considering review information size or less emphasis on imprecision? Journal of Clinical Epidemiology 2016; 75 : 6-15.

Schünemann HJ, Cuello C, Akl EA, Mustafa RA, Meerpohl JJ, Thayer K, Morgan RL, Gartlehner G, Kunz R, Katikireddi SV, Sterne J, Higgins JPT, Guyatt G, Group GW. GRADE guidelines: 18. How ROBINS-I and other tools to assess risk of bias in nonrandomized studies should be used to rate the certainty of a body of evidence. Journal of Clinical Epidemiology 2018.

Spencer-Bonilla G, Quinones AR, Montori VM, International Minimally Disruptive Medicine W. Assessing the Burden of Treatment. Journal of General Internal Medicine 2017; 32 : 1141-1145.

Spencer FA, Iorio A, You J, Murad MH, Schünemann HJ, Vandvik PO, Crowther MA, Pottie K, Lang ES, Meerpohl JJ, Falck-Ytter Y, Alonso-Coello P, Guyatt GH. Uncertainties in baseline risk estimates and confidence in treatment effects. BMJ 2012; 345 : e7401.

Sterne JAC, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, Henry D, Altman DG, Ansari MT, Boutron I, Carpenter JR, Chan AW, Churchill R, Deeks JJ, Hróbjartsson A, Kirkham J, Jüni P, Loke YK, Pigott TD, Ramsay CR, Regidor D, Rothstein HR, Sandhu L, Santaguida PL, Schünemann HJ, Shea B, Shrier I, Tugwell P, Turner L, Valentine JC, Waddington H, Waters E, Wells GA, Whiting PF, Higgins JPT. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355 : i4919.

Thompson DC, Rivara FP, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews 2000; 2 : CD001855.

Tierney JF, Stewart LA, Ghersi D, Burdett S, Sydes MR. Practical methods for incorporating summary time-to-event data into meta-analysis. Trials 2007; 8 .

van Dalen EC, Tierney JF, Kremer LCM. Tips and tricks for understanding and using SR results. No. 7: time‐to‐event data. Evidence-Based Child Health 2007; 2 : 1089-1090.

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Research Summary – Structure, Examples and Writing Guide

Table of Contents

Research Summary

Definition:

A research summary is a brief and concise overview of a research project or study that highlights its key findings, main points, and conclusions. It typically includes a description of the research problem, the research methods used, the results obtained, and the implications or significance of the findings. It is often used as a tool to quickly communicate the main findings of a study to other researchers, stakeholders, or decision-makers.

Structure of Research Summary

The Structure of a Research Summary typically include:

• Introduction : This section provides a brief background of the research problem or question, explains the purpose of the study, and outlines the research objectives.
• Methodology : This section explains the research design, methods, and procedures used to conduct the study. It describes the sample size, data collection methods, and data analysis techniques.
• Results : This section presents the main findings of the study, including statistical analysis if applicable. It may include tables, charts, or graphs to visually represent the data.
• Discussion : This section interprets the results and explains their implications. It discusses the significance of the findings, compares them to previous research, and identifies any limitations or future directions for research.
• Conclusion : This section summarizes the main points of the research and provides a conclusion based on the findings. It may also suggest implications for future research or practical applications of the results.
• References : This section lists the sources cited in the research summary, following the appropriate citation style.

How to Write Research Summary

Here are the steps you can follow to write a research summary:

• Read the research article or study thoroughly: To write a summary, you must understand the research article or study you are summarizing. Therefore, read the article or study carefully to understand its purpose, research design, methodology, results, and conclusions.
• Identify the main points : Once you have read the research article or study, identify the main points, key findings, and research question. You can highlight or take notes of the essential points and findings to use as a reference when writing your summary.
• Write the introduction: Start your summary by introducing the research problem, research question, and purpose of the study. Briefly explain why the research is important and its significance.
• Summarize the methodology : In this section, summarize the research design, methods, and procedures used to conduct the study. Explain the sample size, data collection methods, and data analysis techniques.
• Present the results: Summarize the main findings of the study. Use tables, charts, or graphs to visually represent the data if necessary.
• Interpret the results: In this section, interpret the results and explain their implications. Discuss the significance of the findings, compare them to previous research, and identify any limitations or future directions for research.
• Conclude the summary : Summarize the main points of the research and provide a conclusion based on the findings. Suggest implications for future research or practical applications of the results.
• Revise and edit : Once you have written the summary, revise and edit it to ensure that it is clear, concise, and free of errors. Make sure that your summary accurately represents the research article or study.
• Add references: Include a list of references cited in the research summary, following the appropriate citation style.

Example of Research Summary

Here is an example of a research summary:

Title: The Effects of Yoga on Mental Health: A Meta-Analysis

Introduction: This meta-analysis examines the effects of yoga on mental health. The study aimed to investigate whether yoga practice can improve mental health outcomes such as anxiety, depression, stress, and quality of life.

Methodology : The study analyzed data from 14 randomized controlled trials that investigated the effects of yoga on mental health outcomes. The sample included a total of 862 participants. The yoga interventions varied in length and frequency, ranging from four to twelve weeks, with sessions lasting from 45 to 90 minutes.

Results : The meta-analysis found that yoga practice significantly improved mental health outcomes. Participants who practiced yoga showed a significant reduction in anxiety and depression symptoms, as well as stress levels. Quality of life also improved in those who practiced yoga.

Discussion : The findings of this study suggest that yoga can be an effective intervention for improving mental health outcomes. The study supports the growing body of evidence that suggests that yoga can have a positive impact on mental health. Limitations of the study include the variability of the yoga interventions, which may affect the generalizability of the findings.

Conclusion : Overall, the findings of this meta-analysis support the use of yoga as an effective intervention for improving mental health outcomes. Further research is needed to determine the optimal length and frequency of yoga interventions for different populations.

References :

• Cramer, H., Lauche, R., Langhorst, J., Dobos, G., & Berger, B. (2013). Yoga for depression: a systematic review and meta-analysis. Depression and anxiety, 30(11), 1068-1083.
• Khalsa, S. B. (2004). Yoga as a therapeutic intervention: a bibliometric analysis of published research studies. Indian journal of physiology and pharmacology, 48(3), 269-285.
• Ross, A., & Thomas, S. (2010). The health benefits of yoga and exercise: a review of comparison studies. The Journal of Alternative and Complementary Medicine, 16(1), 3-12.

Purpose of Research Summary

The purpose of a research summary is to provide a brief overview of a research project or study, including its main points, findings, and conclusions. The summary allows readers to quickly understand the essential aspects of the research without having to read the entire article or study.

Research summaries serve several purposes, including:

• Facilitating comprehension: A research summary allows readers to quickly understand the main points and findings of a research project or study without having to read the entire article or study. This makes it easier for readers to comprehend the research and its significance.
• Communicating research findings: Research summaries are often used to communicate research findings to a wider audience, such as policymakers, practitioners, or the general public. The summary presents the essential aspects of the research in a clear and concise manner, making it easier for non-experts to understand.
• Supporting decision-making: Research summaries can be used to support decision-making processes by providing a summary of the research evidence on a particular topic. This information can be used by policymakers or practitioners to make informed decisions about interventions, programs, or policies.
• Saving time: Research summaries save time for researchers, practitioners, policymakers, and other stakeholders who need to review multiple research studies. Rather than having to read the entire article or study, they can quickly review the summary to determine whether the research is relevant to their needs.

Characteristics of Research Summary

The following are some of the key characteristics of a research summary:

• Concise : A research summary should be brief and to the point, providing a clear and concise overview of the main points of the research.
• Objective : A research summary should be written in an objective tone, presenting the research findings without bias or personal opinion.
• Comprehensive : A research summary should cover all the essential aspects of the research, including the research question, methodology, results, and conclusions.
• Accurate : A research summary should accurately reflect the key findings and conclusions of the research.
• Clear and well-organized: A research summary should be easy to read and understand, with a clear structure and logical flow.
• Relevant : A research summary should focus on the most important and relevant aspects of the research, highlighting the key findings and their implications.
• Audience-specific: A research summary should be tailored to the intended audience, using language and terminology that is appropriate and accessible to the reader.
• Citations : A research summary should include citations to the original research articles or studies, allowing readers to access the full text of the research if desired.

When to write Research Summary

Here are some situations when it may be appropriate to write a research summary:

• Proposal stage: A research summary can be included in a research proposal to provide a brief overview of the research aims, objectives, methodology, and expected outcomes.
• Conference presentation: A research summary can be prepared for a conference presentation to summarize the main findings of a study or research project.
• Journal submission: Many academic journals require authors to submit a research summary along with their research article or study. The summary provides a brief overview of the study’s main points, findings, and conclusions and helps readers quickly understand the research.
• Funding application: A research summary can be included in a funding application to provide a brief summary of the research aims, objectives, and expected outcomes.
• Policy brief: A research summary can be prepared as a policy brief to communicate research findings to policymakers or stakeholders in a concise and accessible manner.

Advantages of Research Summary

Research summaries offer several advantages, including:

• Time-saving: A research summary saves time for readers who need to understand the key findings and conclusions of a research project quickly. Rather than reading the entire research article or study, readers can quickly review the summary to determine whether the research is relevant to their needs.
• Clarity and accessibility: A research summary provides a clear and accessible overview of the research project’s main points, making it easier for readers to understand the research without having to be experts in the field.
• Improved comprehension: A research summary helps readers comprehend the research by providing a brief and focused overview of the key findings and conclusions, making it easier to understand the research and its significance.
• Enhanced communication: Research summaries can be used to communicate research findings to a wider audience, such as policymakers, practitioners, or the general public, in a concise and accessible manner.
• Facilitated decision-making: Research summaries can support decision-making processes by providing a summary of the research evidence on a particular topic. Policymakers or practitioners can use this information to make informed decisions about interventions, programs, or policies.
• Increased dissemination: Research summaries can be easily shared and disseminated, allowing research findings to reach a wider audience.

Limitations of Research Summary

Limitations of the Research Summary are as follows:

• Limited scope: Research summaries provide a brief overview of the research project’s main points, findings, and conclusions, which can be limiting. They may not include all the details, nuances, and complexities of the research that readers may need to fully understand the study’s implications.
• Risk of oversimplification: Research summaries can be oversimplified, reducing the complexity of the research and potentially distorting the findings or conclusions.
• Lack of context: Research summaries may not provide sufficient context to fully understand the research findings, such as the research background, methodology, or limitations. This may lead to misunderstandings or misinterpretations of the research.
• Possible bias: Research summaries may be biased if they selectively emphasize certain findings or conclusions over others, potentially distorting the overall picture of the research.
• Format limitations: Research summaries may be constrained by the format or length requirements, making it challenging to fully convey the research’s main points, findings, and conclusions.
• Accessibility: Research summaries may not be accessible to all readers, particularly those with limited literacy skills, visual impairments, or language barriers.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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• How to Write Discussions and Conclusions

The discussion section contains the results and outcomes of a study. An effective discussion informs readers what can be learned from your experiment and provides context for the results.

What makes an effective discussion?

When you’re ready to write your discussion, you’ve already introduced the purpose of your study and provided an in-depth description of the methodology. The discussion informs readers about the larger implications of your study based on the results. Highlighting these implications while not overstating the findings can be challenging, especially when you’re submitting to a journal that selects articles based on novelty or potential impact. Regardless of what journal you are submitting to, the discussion section always serves the same purpose: concluding what your study results actually mean.

A successful discussion section puts your findings in context. It should include:

• the results of your research,
• a discussion of related research, and
• a comparison between your results and initial hypothesis.

Tip: Not all journals share the same naming conventions.

You can apply the advice in this article to the conclusion, results or discussion sections of your manuscript.

Our Early Career Researcher community tells us that the conclusion is often considered the most difficult aspect of a manuscript to write. To help, this guide provides questions to ask yourself, a basic structure to model your discussion off of and examples from published manuscripts. 

Questions to ask yourself:

• Was my hypothesis correct?
• If my hypothesis is partially correct or entirely different, what can be learned from the results? 
• How do the conclusions reshape or add onto the existing knowledge in the field? What does previous research say about the topic? 
• Why are the results important or relevant to your audience? Do they add further evidence to a scientific consensus or disprove prior studies? 
• How can future research build on these observations? What are the key experiments that must be done? 
• What is the “take-home” message you want your reader to leave with?

How to structure a discussion

Trying to fit a complete discussion into a single paragraph can add unnecessary stress to the writing process. If possible, you’ll want to give yourself two or three paragraphs to give the reader a comprehensive understanding of your study as a whole. Here’s one way to structure an effective discussion:

Writing Tips

While the above sections can help you brainstorm and structure your discussion, there are many common mistakes that writers revert to when having difficulties with their paper. Writing a discussion can be a delicate balance between summarizing your results, providing proper context for your research and avoiding introducing new information. Remember that your paper should be both confident and honest about the results! 

• Read the journal’s guidelines on the discussion and conclusion sections. If possible, learn about the guidelines before writing the discussion to ensure you’re writing to meet their expectations. 
• Begin with a clear statement of the principal findings. This will reinforce the main take-away for the reader and set up the rest of the discussion. 
• Explain why the outcomes of your study are important to the reader. Discuss the implications of your findings realistically based on previous literature, highlighting both the strengths and limitations of the research. 
• State whether the results prove or disprove your hypothesis. If your hypothesis was disproved, what might be the reasons? 
• Introduce new or expanded ways to think about the research question. Indicate what next steps can be taken to further pursue any unresolved questions. 
• If dealing with a contemporary or ongoing problem, such as climate change, discuss possible consequences if the problem is avoided. 
• Be concise. Adding unnecessary detail can distract from the main findings. 

Don’t

• Rewrite your abstract. Statements with “we investigated” or “we studied” generally do not belong in the discussion. 
• Include new arguments or evidence not previously discussed. Necessary information and evidence should be introduced in the main body of the paper. 
• Apologize. Even if your research contains significant limitations, don’t undermine your authority by including statements that doubt your methodology or execution. 
• Shy away from speaking on limitations or negative results. Including limitations and negative results will give readers a complete understanding of the presented research. Potential limitations include sources of potential bias, threats to internal or external validity, barriers to implementing an intervention and other issues inherent to the study design. 
• Overstate the importance of your findings. Making grand statements about how a study will fully resolve large questions can lead readers to doubt the success of the research. 

Snippets of Effective Discussions:

Consumer-based actions to reduce plastic pollution in rivers: A multi-criteria decision analysis approach

Identifying reliable indicators of fitness in polar bears

• How to Write a Great Title
• How to Write an Abstract
• How to Write Your Methods
• How to Report Statistics
• How to Edit Your Work

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The contents of the Writing Center are also available as a live, interactive training session, complete with slides, talking points, and activities. …

There’s a lot to consider when deciding where to submit your work. Learn how to choose a journal that will help your study reach its audience, while reflecting your values as a researcher…

Criteria for Good Qualitative Research: A Comprehensive Review

• Regular Article
• Open access
• Published: 18 September 2021
• Volume 31 , pages 679–689, ( 2022 )

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• Drishti Yadav   ORCID: orcid.org/0000-0002-2974-0323 1  

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Good Qualitative Research: Opening up the Debate

Beyond qualitative/quantitative structuralism: the positivist qualitative research and the paradigmatic disclaimer.

What is Qualitative in Research

Avoid common mistakes on your manuscript.

Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

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The Ultimate Guide to Crafting Impactful Recommendations in Research

Are you ready to take your research to the next level? Crafting impactful recommendations is the key to unlocking the full potential of your study. By providing clear, actionable suggestions based on your findings, you can bridge the gap between research and real-world application.

In this ultimate guide, we'll show you how to write recommendations that make a difference in your research report or paper.

You'll learn how to craft specific, actionable recommendations that connect seamlessly with your research findings. Whether you're a student, writer, teacher, or journalist, this guide will help you master the art of writing recommendations in research. Let's get started and make your research count!

Understanding the Purpose of Recommendations

Recommendations in research serve as a vital bridge between your findings and their real-world applications. They provide specific, action-oriented suggestions to guide future studies and decision-making processes. Let's dive into the key purposes of crafting effective recommendations:

Guiding Future Research

Research recommendations play a crucial role in steering scholars and researchers towards promising avenues of exploration. By highlighting gaps in current knowledge and proposing new research questions, recommendations help advance the field and drive innovation.

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Well-crafted recommendations have the power to shape policies, programs, and strategies across various domains, such as:

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By providing clear, evidence-based suggestions, recommendations facilitate informed decision-making and improve outcomes.

Connecting Research to Practice

Recommendations act as a conduit for transferring knowledge from researchers to practitioners, policymakers, and stakeholders. They bridge the gap between academic findings and their practical applications, ensuring that research insights are effectively translated into real-world solutions.

Enhancing Research Impact

By crafting impactful recommendations, you can amplify the reach and influence of your research, attracting attention from peers, funding agencies, and decision-makers.

Addressing Limitations

Recommendations provide an opportunity to acknowledge and address the limitations of your study. By suggesting concrete and actionable possibilities for future research, you demonstrate a thorough understanding of your work's scope and potential areas for improvement.

Identifying Areas for Future Research

Discovering research gaps is a crucial step in crafting impactful recommendations. It involves reviewing existing studies and identifying unanswered questions or problems that warrant further investigation. Here are some strategies to help you identify areas for future research:

Explore Research Limitations

Take a close look at the limitations section of relevant studies. These limitations often provide valuable insights into potential areas for future research. Consider how addressing these limitations could enhance our understanding of the topic at hand.

Critically Analyze Discussion and Future Research Sections

When reading articles, pay special attention to the discussion and future research sections. These sections often highlight gaps in the current knowledge base and propose avenues for further exploration. Take note of any recurring themes or unanswered questions that emerge across multiple studies.

Utilize Targeted Search Terms

To streamline your search for research gaps, use targeted search terms such as "literature gap" or "future research" in combination with your subject keywords. This approach can help you quickly identify articles that explicitly discuss areas for future investigation.

Seek Guidance from Experts

Don't hesitate to reach out to your research advisor or other experts in your field. Their wealth of knowledge and experience can provide valuable insights into potential research gaps and emerging trends.

By employing these strategies, you'll be well-equipped to identify research gaps and craft recommendations that push the boundaries of current knowledge. Remember, the goal is to refine your research questions and focus your efforts on areas where more understanding is needed.

Structuring Your Recommendations

When it comes to structuring your recommendations, it's essential to keep them concise, organized, and tailored to your audience. Here are some key tips to help you craft impactful recommendations:

Prioritize and Organize

• Limit your recommendations to the most relevant and targeted suggestions for your peers or colleagues in the field.
• Place your recommendations at the end of the report, as they are often top of mind for readers.
• Write your recommendations in order of priority, with the most important ones for decision-makers coming first.

Use a Clear and Actionable Format

• Write recommendations in a clear, concise manner using actionable words derived from the data analyzed in your research.
• Use bullet points instead of long paragraphs for clarity and readability.
• Ensure that your recommendations are specific, measurable, attainable, relevant, and timely (SMART).

Connect Recommendations to Research

By following this simple formula, you can ensure that your recommendations are directly connected to your research and supported by a clear rationale.

Tailor to Your Audience

• Consider the needs and interests of your target audience when crafting your recommendations.
• Explain how your recommendations can solve the issues explored in your research.
• Acknowledge any limitations or constraints of your study that may impact the implementation of your recommendations.

Avoid Common Pitfalls

• Don't undermine your own work by suggesting incomplete or unnecessary recommendations.
• Avoid using recommendations as a place for self-criticism or introducing new information not covered in your research.
• Ensure that your recommendations are achievable and comprehensive, offering practical solutions for the issues considered in your paper.

By structuring your recommendations effectively, you can enhance the reliability and validity of your research findings, provide valuable strategies and suggestions for future research, and deliver impactful solutions to real-world problems.

Crafting Actionable and Specific Recommendations

Crafting actionable and specific recommendations is the key to ensuring your research findings have a real-world impact. Here are some essential tips to keep in mind:

Embrace Flexibility and Feasibility

Your recommendations should be open to discussion and new information, rather than being set in stone. Consider the following:

• Be realistic and considerate of your team's capabilities when making recommendations.
• Prioritize recommendations based on impact and reach, but be prepared to adjust based on team effort levels.
• Focus on solutions that require the fewest changes first, adopting an MVP (Minimum Viable Product) approach.

Provide Detailed and Justified Recommendations

To avoid vagueness and misinterpretation, ensure your recommendations are:

• Detailed, including photos, videos, or screenshots whenever possible.
• Justified based on research findings, providing alternatives when findings don't align with expectations or business goals.

Use this formula when writing recommendations:

Observed problem/pain point/unmet need + consequence + potential solution

Adopt a Solution-Oriented Approach

Foster collaboration and participation.

• Promote staff education on current research and create strategies to encourage adoption of promising clinical protocols.
• Include representatives from the treatment community in the development of the research initiative and the review of proposals.
• Require active, early, and permanent participation of treatment staff in the development, implementation, and interpretation of the study.

Tailor Recommendations to the Opportunity

When writing recommendations for a specific opportunity or program:

• Highlight the strengths and qualifications of the researcher.
• Provide specific examples of their work and accomplishments.
• Explain how their research has contributed to the field.
• Emphasize the researcher's potential for future success and their unique contributions.

By following these guidelines, you'll craft actionable and specific recommendations that drive meaningful change and showcase the value of your research.

Connecting Recommendations with Research Findings

Connecting your recommendations with research findings is crucial for ensuring the credibility and impact of your suggestions. Here's how you can seamlessly link your recommendations to the evidence uncovered in your study:

Grounding Recommendations in Research

Your recommendations should be firmly rooted in the data and insights gathered during your research process. Avoid including measures or suggestions that were not discussed or supported by your study findings. This approach ensures that your recommendations are evidence-based and directly relevant to the research at hand.

Highlighting the Significance of Collaboration

Research collaborations offer a wealth of benefits that can enhance an agency's competitive position. Consider the following factors when discussing the importance of collaboration in your recommendations:

• Organizational Development: Participation in research collaborations depends on an agency's stage of development, compatibility with its mission and culture, and financial stability.
• Trust-Building: Long-term collaboration success often hinges on a history of increasing involvement and trust between partners.
• Infrastructure: A permanent infrastructure that facilitates long-term development is key to successful collaborative programs.

Emphasizing Commitment and Participation

Fostering quality improvement and organizational learning.

In your recommendations, highlight the importance of enhancing quality improvement strategies and fostering organizational learning. Show sensitivity to the needs and constraints of community-based programs, as this understanding is crucial for effective collaboration and implementation.

Addressing Limitations and Implications

If not already addressed in the discussion section, your recommendations should mention the limitations of the study and their implications. Examples of limitations include:

• Sample size or composition
• Participant attrition
• Study duration

By acknowledging these limitations, you demonstrate a comprehensive understanding of your research and its potential impact.

By connecting your recommendations with research findings, you provide a solid foundation for your suggestions, emphasize the significance of collaboration, and showcase the potential for future research and practical applications.

Crafting impactful recommendations is a vital skill for any researcher looking to bridge the gap between their findings and real-world applications. By understanding the purpose of recommendations, identifying areas for future research, structuring your suggestions effectively, and connecting them to your research findings, you can unlock the full potential of your study. Remember to prioritize actionable, specific, and evidence-based recommendations that foster collaboration and drive meaningful change.

As you embark on your research journey, embrace the power of well-crafted recommendations to amplify the impact of your work. By following the guidelines outlined in this ultimate guide, you'll be well-equipped to write recommendations that resonate with your audience, inspire further investigation, and contribute to the advancement of your field. So go forth, make your research count, and let your recommendations be the catalyst for positive change.

Q: What are the steps to formulating recommendations in research? A: To formulate recommendations in research, you should first gain a thorough understanding of the research question. Review the existing literature to inform your recommendations and consider the research methods that were used. Identify which data collection techniques were employed and propose suitable data analysis methods. It's also essential to consider any limitations and ethical considerations of your research. Justify your recommendations clearly and finally, provide a summary of your recommendations.

Q: Why are recommendations significant in research studies? A: Recommendations play a crucial role in research as they form a key part of the analysis phase. They provide specific suggestions for interventions or strategies that address the problems and limitations discovered during the study. Recommendations are a direct response to the main findings derived from data collection and analysis, and they can guide future actions or research.

Q: Can you outline the seven steps involved in writing a research paper? A: Certainly. The seven steps to writing an excellent research paper include:

• Allowing yourself sufficient time to complete the paper.
• Defining the scope of your essay and crafting a clear thesis statement.
• Conducting a thorough yet focused search for relevant research materials.
• Reading the research materials carefully and taking detailed notes.
• Writing your paper based on the information you've gathered and analyzed.
• Editing your paper to ensure clarity, coherence, and correctness.
• Submitting your paper following the guidelines provided.

Q: What tips can help make a research paper more effective? A: To enhance the effectiveness of a research paper, plan for the extensive process ahead and understand your audience. Decide on the structure your research writing will take and describe your methodology clearly. Write in a straightforward and clear manner, avoiding the use of clichés or overly complex language.

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O’Hara R, Johnson M, Hirst E, et al. A qualitative study of decision-making and safety in ambulance service transitions. Southampton (UK): NIHR Journals Library; 2014 Dec. (Health Services and Delivery Research, No. 2.56.)

A qualitative study of decision-making and safety in ambulance service transitions.

Chapter 8 conclusions and recommendations.

The aim of this study was to explore the range and nature of influences on safety in decision-making by ambulance service staff (paramedics). A qualitative approach was adopted using a range of complementary methods. The study has provided insights on the types of decisions that staff engage in on a day-to-day basis. It has also identified a range of system risk factors influencing decisions about patient care. Although this was a relatively small-scale exploratory study, confidence in the generalisability of the headline findings is enhanced by the high level of consistency in the findings, obtained using multiple methods, and the notable consensus among participants.

The seven predominant system influences identified should not be considered discrete but as overlapping and complementary issues. They also embody a range of subthemes that represent topics for future research and/or intervention.

The apparently high level of consistency across the participating trusts suggests that the issues identified may be generic and relevant to other ambulance service trusts.

In view of the remit of this study, aspects relating to system weaknesses and potential threats to patient safety dominate in the account of findings. However, it should be noted that respondent accounts also provided examples of systems that were said to be working well, for example specific care management pathways, local roles and ways of working and technological initiatives such as IBIS and the ePRF.

• Implications for health care

The NHS system within which the ambulance service operates is characterised in our study as fragmented and inconsistent. For ambulance service staff the extent of variation across the geographical areas in which they work is problematic in terms of knowing what services are available and being able to access them. The lack of standardisation in practice guidelines, pathways and protocols across services and between areas makes it particularly challenging for staff to keep up to date with requirements in different parts of their own trust locations and when crossing trust boundaries. Although a degree of consistency across the network is likely to improve the situation, it is also desirable to have sufficient flexibility to accommodate the needs of specific local populations. There was some concern over the potential for further fragmentation with the increased number of CCGs.

Ambulance services are increasingly under pressure to focus on reducing conveyance rates to A&E; this arguably intensifies the need to ensure that crews are appropriately skilled to be able to make effective decisions over the need to convey or not to convey if associated risks to patients are to be minimised. Our findings highlight the challenges of developing staff and ensuring that their skills are utilised where they are most needed within the context of organisational resource constraints and operational demands. Decisions over non-conveyance to A&E are moderated by the availability of alternative care pathways and providers. There were widespread claims of local variability in this respect. Staff training and development, and access to alternatives to A&E, were identified as priorities for attention by workshop attendees.

One of the difficulties for ambulance services is that they operate as a 24/7 service within a wider urgent and emergency care network that, beyond A&E, operates a more restricted working day. The study findings identify this as problematic for two reasons. First, it fuels demand for ambulance service care as a route to timely treatment, when alternatives may involve delay. Second, it contributes to inappropriate conveyance to A&E because more appropriate options are unavailable or limited during out-of-hours periods. Ultimately, this restricts the scope for ensuring that patients are getting the right level of care at the right time and place. Study participants identified some patient populations as particularly poorly served in terms of alternatives to A&E (e.g. those with mental health issues, those at the end of life, older patients and those with chronic conditions).

The effectiveness of the paramedic role in facilitating access to appropriate care pathways hinges on relationships with other care providers (e.g. primary care, acute care, mental health care, community health care). An important element relates to the cultural profile of paramedics in the NHS, specifically, the extent to which other health professionals and care providers consider the clinical judgements/decisions made by paramedics as credible and actionable. Staff identified this as a barrier to access where the ambulance service is still viewed primarily as a transport service. Consideration could be given to ways of improving effective teamworking and communication across service and professional boundaries.

Although paramedics acknowledged the difficulties of telephone triage, they also identified how the limitations of this system impact on them. Over-triage at the initial call-handling stage places considerable demands on both staff and vehicle resources. A related concern is the limited information conveyed to crews following triage. Initial triage was suggested as an area that warrants attention to improve resource allocation.

The findings highlight the challenges faced by front-line ambulance service staff. It was apparent that the extent and nature of the demand for ambulance conveyance represents a notable source of strain and tension for individuals and at an organisational level. For example, there were widespread claims that meeting operational demands for ambulance services limits the time available for training and professional development, with this potentially representing a risk for patients and for staff. Staff perceptions of risk relating to patient safety extend to issues of secondary risk management, that is, personal and institutional liabilities, in particular risks associated with loss of professional registration. The belief that they are more likely to be blamed than supported by their organisation in the event of an incident was cited by staff as a source of additional anxiety when making more complex decisions. This perceived vulnerability can provoke excessively risk-averse decisions. These issues merit further attention to examine the workforce implication of service delivery changes, including how to ensure that staff are appropriately equipped and supported to deal effectively with the demands of their role.

Paramedics identified a degree of progress in relation to the profile of patient safety within their organisations but the apparent desire within trusts to prioritise safety improvement was felt to be constrained by service demands and available resources. Attempts to prioritise patient safety appear to focus on ensuring that formal systems are in place (e.g. reporting and communication). Concerns were expressed over how well these systems function to support improvement, for example how incident reports are responded to and whether lessons learned are communicated to ambulance staff within and between trusts. Consideration could be given to identifying ways of supporting ambulance service trusts to develop the safety culture within their organisation.

Service users attributed the increased demand for ambulance services to difficulties in identifying and accessing alternatives. They were receptive to non-conveyance options but felt that lack of awareness of staff roles and skills may cause concern when patients expect conveyance to A&E.

• Recommendations for research

The workshop attendees identified a range of areas for attention in relation to intervention and research, which are provided in Chapter 6 (see Suggestions for potential interventions and research ). The following recommendations for research are based on the study findings:

• Limited and variable access to services in the wider health and social care system is a significant barrier to reducing inappropriate conveyance to A&E. More research is needed to identify effective ways of improving the delivery of care across service boundaries, particularly for patients with limited options at present (e.g. those with mental health issues, those at the end of life and older patients). Research should address structural and attitudinal barriers and how these might be overcome.
• Ambulance services are increasingly focused on reducing conveyance to A&E and they need to ensure that there is an appropriately skilled workforce to minimise the potential risk. The evidence points to at least two issues: (1) training and skills and (2) the cultural profile of paramedics in the NHS, that is, whether others view their decisions as credible. Research could explore the impact of enhanced skills on patient care and on staff, for example the impact of increased training in urgent rather than emergency care. This would also need to address potential cultural barriers to the effective use of new skills.
• Research to explore the impact of different aspects of safety culture on ambulance service staff and the delivery of patient care (e.g. incident reporting, communication, teamworking, and training) could include comparisons across different staff groups and the identification of areas for improvement, as well as interventions that could potentially be tested.
• The increased breadth of decision-making by ambulance service crews with advanced skills includes more diagnostics; therefore, there is a need to look at the diagnostic process and potential causes of error in this environment.
• There is a need to explore whether there are efficient and safe ways of improving telephone triage decisions to reduce over-triage, particularly in relation to calls requiring an 8-minute response. This could include examining training and staffing levels, a higher level of clinician involvement or other forms of decision support.
• There is a need to explore public awareness of, attitudes towards, beliefs about and expectations of the ambulance service and the wider urgent and emergency care network and the scope for behaviour change interventions, for example communication of information about access to and use of services; empowering the public through equipping them with the skills to directly access the services that best meet their needs; and informing the public about the self-management of chronic conditions.
• A number of performance measures were identified engendering perverse motivations leading to suboptimal resource utilisation. An ongoing NIHR Programme Grant for Applied Research (RP-PG-0609–10195; ‘Pre-hospital Outcomes for Evidence-Based Evaluation’) aims to develop new ways of measuring ambulance service performance. It is important that evaluations of new performance metrics or other innovations (e.g. Make Ready ambulances, potential telehealth technologies or decision-support tools) address their potential impact on patient safety.

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Improved Surface Drainage of Pavements: Final Report (1998)

Chapter: chapter 5 summary, findings, and recommendations.

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

CHAPIER 5 SI~MARY, FINDINGS, AND RECOMMENDATIONS SUGARY The primary objective of this research was to identify unproved methods for draining rainwater from the surface of multi-lane pavements and to develop guidelines for their use. The guidelines, along with details on the rationale for their development, are presented in a separate document' "Proposed Design Guidelines for Improving Pavement Surface Drainage" (2J. The guidelines support an interactive computer program, PAVDRN, that can be used by practicing engineers In the process of designing new pavements or rehabilitating old pavements' is outlined In figure 39. The intended audience for the guidelines is practicing highway design engineers that work for transportation agencies or consulting firms. Improved pavement surface drainage is needed for two reasons: (~) to minimize splash and spray and (2) to control the tendency for hydroplaning. Both issues are primary safety concerns. At the request of the advisory panel for the project, the main focus of this study was on ~mprov~g surface drainage to mammae the tendency for hydroplaning. In terms of reducing the tendency for hydroplaTuT g, the needed level of drainage is defined in terms of the thickness of the film of water on the pavement. Therefore, the guidelines were developed within the context of reducing the thickness of the water film on pavement surfaces to the extent that hydroplaning is unlikely at highway design speeds. Since hydroplaning is ~7

DESIGN CRITERIA Pavement Geometry Number of lanes Section type - Tangent - Horizontal curve - Transition - Vertical crest curve - Vertical sag curve Enviromnental oramaters Rainfall intensity ~ Temperature Pavement Tvpe Dense-graded asphalt Porous asphalt Portland cement concrete ~ Grooved Portland cement concrete Desion Soeed Allowable speed for onset of hydroplaning Recommend Desion Changes Alter geometry Alter pavement surface Add appurtenances Groove (Portland cement concrete) CALCULATIONS Lenoth of flow path Calculate on basis of pavement geometry IT Hydraulic Analvses .  No? Water film thickness Equation No. 10 Equation No.'s. 16-19 1 Hvdroolanino Analvsis Hydroplaning speed Equation No.'s 21-24 Rainfall Intensity Equation No. 25 -A I / Meet Design ~ \ Cntena? / \<es? Accent Desinn | Figure 39. Flow diagram representing PAVI)RN design process In "Proposed Guidelines for Improving Pavement Surface DrmT~age" (2). 118

controlled primarily by the thickness of the water film on the pavement surface, the design guidelines focus on the prediction and control of ache depth of water flowing across the pavement surface as a result of rainfall, often referred to as sheet flow. Water film thickness on highway pavements can be controlled In three fundamental ways, by: I. Minimizing the length of the longest flow path of the water over We pavement and thereby the distance over which the flow can develop; 2. Increasing the texture of the pavement surface; and 3. Removing water from the pavement's surface. In the process of using PAVDRN to implement the design guidelines, the designer is guided to (~) minimize the longest drainage path length of the section under design by altering the pavement geometry and (2) reduce the resultant water film thickness that will develop along that drainage path length by increasing the mean texture depth, choosing a surface that maximizes texture, or using permeable pavements, grooving, and appurtenances to remove water from the surface. Through the course of a typical design project, four key areas need to be considered in order to analyze and eventually reduce the potential for hydroplaning. These areas are: ~9

I. Environmental conditions: 2. Geometry of the roadway surface; 3. Pavement surface (texture) properties; and 4. Appurtenances. Each of these areas and their influence on the resulting hydroplaning speed of the designed section are discussed In detail In the guidelines (21. The environmental conditions considered are rainfall ~ntensibr and water temperature, which determines the kinematic viscosity of the water. The designer has no real control over these environmental factors but needs to select appropriate values when analyzing the effect of flow over the pavement surface and hydroplaning potential. Five section types, one for each of the basic geometric configurations used In highway design, are examined. These section are: 1. TaIlgent; 2. Superelevated curve; 3. Transition; 4. Vertical crest curve; and 5. Vertical sag curve. 120

Pavement properties that affect the water fihn thickness mclude surface characteristics, such as mean texture depth and grooving of Portland cement concrete surfaces, are considered In the process of applying PAVDRN. Porous asphalt pavement surfaces can also reduce He water film thickness and thereby contribute to the reduction of hydroplaning tendency and their presence can also be accounted for when using PAVDRN. Finally, PAVDRN also allows the design engineer to consider the effect of drainage appurtenances, such as slotted drain inlets. A complete description of the various elements that are considered In the PAVDRN program is illustrated In figure 40. A more complete description of the design process, the parameters used in the design process, and typical values for the parameters is presented In the "Proposed Design Guidelines for Improving Pavement Surface Drainage" (2) alla in Appendix A. fIN1)INGS The following findings are based on the research accomplished during the project, a survey of the literature, and a state-of-the-art survey of current practice. I. Model. The one~unensional mode} is adequate as a design tool. The simplicity and stability of the one~imensional mode} offsets any increased accuracy afforded by a two-d~mensional model. The one~mensional model as a predictor of water fiDn thickness and How path length was verified by using data from a previous study (11). 121

No. of Planes Length of Plane Grade Step Increment Wdth of Plane Cross Slope Section T,rne 1) Tangent 2) Honzontal Curare 3) Transition 4) Vertical Crest 5) Vertical Sag U=tS 1)U.S. 2) S. I. Rainfall Intenstity ~ , \ |Kinematic Viscosity |Design Speed Note: PC = Point of Curvature PI. = Point of Tangency PCC = Portland cement concrete WAC = Dense graded asphalt concrete 0GAC = 0pcn~raded asphalt concrete where OGAC includes all types of intentally draining asphalt surfaces GPCC = Grooved Ponland cement concrete Taneent Pavement Type Mean Texture Depth 1) PCC 2) DGAC 3) OGAC 4) GPCC Horizontal Cun~c  Grade Cross Slope Radius of Cunran~re Wdth Pavement Type _ 2) DGAC 3) OGAC 4) GPCC Mean Texture Depth Step Increment _ Transition Length of Plane Super Elevation Tangent Cross Slope Tangent Grade width of Curve Transition Width Pavement Type_ 1) PCC 3) OGAC 4) GPCC Mean Texture Depth Step Increment Horizontal Length Cross slope width PC Grade PI' Grade Elevation: Pr-PC Vertical Crest Flow Direction Step Increment Pavement Type 1) PC Side I 2) PI. Side | 1)PCC 2) DGAC 3) OGAC 4) GPCC Mean Tex~rc Depth _ _ ~ Figure 40. Factors considered in PAVDRN program. 122 ~1 r - . , Vertical Sad | Horizontal Length | Cross slope Wldth PC Grade PI Grade Elevation: PIE Flow Direction  Step Increment / Stored :_ ~ cats ~ 1) PC Side | 2) PI Side | . Pavement Typed 1) PCC 3) OGAC 14) GPCC Mean Texture Depth I I

~ Stored data V ~ 3 L IN1T For use with a second nut using data from the first run.) , 1 EPRINT (Echos input to output ) 1 CONVERT (Converts units to and from SI and English.) ~ , ADVP  (Advances Page of output.) KINW (Calculates Minning's n, Water Film Thickness (WEIR), and Hydroplaning Speed UPS).) , EDGE (Determines if flow has reached the edge of the pavement.) out roar Figure 40. Factors considered in PAVDRN program (continued). 123

2. Occurrence of Hydropl~r g. In general, based on the PAVDRN mode! and the assumptions inherent in its development, hydroplaning can be expected at speeds below roadway design speeds if the length of the flow path exceeds two lane widths. 3. Water Film Thickness. Hydroplaning is initiated primarily by the depth of the water film thickness. Therefore, the primary design objective when controlling hydroplaning must be to limit the depth of the water film. 4. Reducing Water Film Thickness. There are no simple means for controlling water John thickness, but a number of methods can effectively reduce water film thickness and consequently hydroplaning potential. These include: Optimizing pavement geometry, especially cross-slope. Providing some means of additional drainage, such as use of grooved surfaces (PCC) or porous mixtures (HMA). Including slotted drains within the roadway. 5. Tests Needed for Design. The design guidelines require an estimate of the surface texture (MTD) and the coefficient of permeability Porous asphalt only). The sand patch is an acceptable test method for measuring surface texture, except for the more open (20-percent air voids) porous asphalt mixes. In these cases, an estimate of the surface texture, based on tabulated data, is sufficient. As an alternative, 124

sand patch measurements can be made on cast replicas of the surface. For the open mixes, the glass beads flow into the voids within the mixture, giving an inaccurate measure of surface texture. Based on the measurements obtained In the laboratory, the coefficient of permeability for the open-graded asphalt concrete does not exhibit a wide range of values, and values of k may be selected for design purposes from tabulated design data (k versus air voids). Given the uncertainty of this property resulting from compaction under traffic and clogging from contaminants and anti-skid material, a direct measurement (e.g., drainage lag permeameter) of k is not warranted. Based on the previous discussion, no new test procedures are needed to adopt the design guidelines developed during this project. 6. Grooving. Grooving of PCC pavements provides a reservoir for surface water and can facilitate the removal of water if the grooves are placed parallel to the flow oath. Parallel orientation is generally not practical because the flow on highway pavements is typically not transverse to the pavement. Thus, the primary contribution offered by grooving is to provide a surface reservoir unless the grooves comlect with drainage at the edge of the pavement. Once the grooves are filled with water, the tops of the grooves are the datum for the Why and do not contribute to the reduction in the hydroplaning potential. 125

7. Porous Pavements. These mixtures can enhance the water removal and Hereby reduce water film tHch~ess. They merit more consideration by highway agencies In the United States, but they are not a panacea for eliminating hydroplaning. As with grooved PCC pavements, the internal voids do not contribute to the reduction of hydroplaning; based on the field tests done In this study. hv~ronImiina can be if, , , ~ expected on these mixtures given sufficient water fiLn thickness. Other than their ability to conduct water through internal flow, the large MTD offered by porous asphalt is the main contribution offered by the mixtures to the reduction of hydroplaning potential. The high-void ~ > 20 percent), modified binder mixes used In Europe merit further evaluation in the United States. They should be used In areas where damage from freezing water and the problems of black ice are not likely. 8. Slotted Drains. These fixtures, when installed between travel lanes, offer perhaps the most effective means of controlling water film thickness from a hydraulics standpoint. They have not been used extensively In the traveled lanes and questions remain unanswered with respect to their installation (especially in rehabilitation situations) and maintenance. The ability to support traffic loads and still maintain surface smoothness has not been demonstrated and they may be susceptible to clogging from roadway debris, ice, or snow. 126

RECOMMENDATIONS AND CONCLUSIONS The following recommendations are offered based on the work accomplished during this project and on the conclusions given previously: I. Implementation. The PAVDRN program and associated guidelines need to be field tested and revised as needed. The program and the guidelines are sufficiently complete so that they can be used in a design office. Some of the parameters and algorithms will I~ely need to be modified as experience is gained with the program. 2. Database of Material Properties. A database of material properties should be gathered to supplement the information contained in PAVDRN. This information should Include typical values for the permeability of porous asphalt and topical values for the surface texture (MTD) for different pavement surfaces to include toned Portland cement concrete surfaces. A series of photographs of typical pavement sections and their associated texture depths should be considered as an addition to the design guide (21. 3. Pavement Geometry. The AASHTO design guidelines (~) should be re-evaluated In terms of current design criteria to determine if they can be modified to enhance drainage without adversely affecting vehicle handling or safety. ~27

4. Use of appurtenances. Slotted drams should be evaluated In the field to determine if they are practical when Installed In the traveled way. Manufacturers should reconsider the design of slotted drains and their Installation recommendations currently In force to maximize them for use In multi-lane pavements and to determine if slotted drains are suitable for installations In the traveled right of way. 5. Porous Asphalt Mixtures. More use should be made of these mixtures, especially the modified high a~r-void mixtures as used In France. Field trials should be conducted to monitor HPS and the long-term effectiveness of these mixtures and to validate the MPS and WDT predicted by PAVDRN. 6. Two-D~mensional Model. Further work should be done with two~mensional models to determine if they improve accuracy of PAVDRN and to determine if they are practical from a computational standpoint. ADDITIONAL STUDIES On the basis of the work done during this study, a number of additional items warrant furler study. These Include: 1. Full-scale skid resistance studies to validate PAVDRN in general and the relationship between water film thickness and hydroplaning potential in particular are needed in light of the unexpectedly low hvdronlanin~ speeds predicted during 128 , . ~. , ~

this study. The effect of water infiltration into pavement cracks and loss of water by splash and spray need to be accounted for In the prediction of water fihn Sickness. Surface Irregularities, especially rutting, need to be considered in the prediction models. 2. Field trials are needed to confirm the effectiveness of alternative asphalt and Portland cement concrete surfaces. These include porous Portland cement concrete surfaces, porous asphalt concrete, and various asphalt m~cro-surfaces. 3. The permeability of porous surface mixtures needs to be confirmed with samples removed from the field, and the practicality of a simplified method for measuring in-situ permeability must be investigated and compared to alternative measurements, such as the outflow meter. 4. For measuring pavement texture, alternatives to the sand patch method should be investigated, especially for use with porous asphalt mixtures. 129

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• Published: 10 May 2024

The role of leisure activities in enhancing well-being in Saudi’s retired community: a mixed methods study

• Homoud Mohammed Nawi Alanazi 1  

Humanities and Social Sciences Communications volume  11 , Article number:  604 ( 2024 ) Cite this article

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This mixed-methods study delves into the impact of leisure activities on the well-being of retirees in Saudi Arabia, focusing on health, emotional balance, social integration, and self-fulfillment. In the quantitative phase, 545 retirees were selected through a snowball sampling, providing a diverse sample of age, gender, socio-economic status, and educational background. Data were collected using a structured questionnaire and analyzed using SPSS. The qualitative phase involved randomly selecting 23 participants from the initial cohort for semi-structured interviews, with the data subjected to thematic analysis for deeper insights. Findings revealed a moderate overall enhancement in well-being attributed to leisure activities, with health benefits being most significantly improved. Emotional and social well-being showed moderate enhancements, while self-fulfillment benefits were less pronounced. Demographic variations were evident, with gender, socio-economic status, and education level influencing the perceived benefits. Qualitatively, the importance of cultural alignment in leisure activities was highlighted, underscoring their role in social connectivity and personal development. The study underscores the need for culturally sensitive and accessible leisure programs tailored to the varied needs of the retired population in Saudi Arabia. It provides crucial insights for policymakers and community planners, emphasizing the importance of demographic considerations in leisure interventions to improve retirees’ quality of life. This research contributes significantly to understanding leisure’s role in enhancing post-retirement well-being, offering a comprehensive perspective for future leisure-related initiatives and policies.

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Introduction.

The transition to retirement is a significant event that impacts individuals’ daily lives, social dynamics, and personal aspirations. This topic acquires added importance in the Kingdom of Saudi Arabia due to the country’s unique socioeconomic changes and demographic trends toward an ageing population. Leisure activities are crucial for enhancing retirees’ well-being, addressing physical health, and self-actualization needs (Bashatah et al. 2023 ; Morse et al. 2021 ). This research is essential for scholars, policymakers, and practitioners focused on ageing, well-being, and cultural specificity in retirement planning.

Research has increasingly recognized the value of leisure activities in promoting retirees’ health, emotional balance, and social integration (Han et al. 2021 ; Lee et al. 2023 ; Michèle et al. 2019 ; Nielsen et al. 2021 ; Wheatley and Bickerton 2022 ). However, existing studies predominantly reflect Western contexts, leaving a noticeable gap in our understanding of retirement within the socio-cultural landscape of the Middle East, particularly Saudi Arabia. This gap is significant because cultural norms and societal changes profoundly influence retirement experiences, suggesting that findings from Western studies may not fully translate to the Saudi context. The absence of culturally tailored research highlights a critical need for empirical studies to inform culturally appropriate interventions and policies for enhancing retiree well-being in Saudi Arabia.

This study aims to fill the existing gap by examining the impact of leisure activities on the well-being of Saudi retirees through a mixed-methods approach. It will quantify the benefits of leisure activities across different well-being dimensions and explore how these perceptions vary across demographic groups within the retired population. Additionally, it will provide in-depth insights into retirees’ experiences and perceptions regarding leisure activities. This research seeks to fundamentally enhance our understanding of retiree well-being in the Saudi context by offering new theoretical perspectives and empirical evidence. The findings promise to challenge existing paradigms by incorporating the cultural subtleties of the Middle Eastern retirement experience, thus advancing the field and guiding the development of targeted culturally sensitive well-being interventions. Given this, the following questions are put under the lens:

What is the overall level of well-being enhancement attributed to leisure activity engagement among retirees in Saudi Arabia, as measured by comprehensive scores on the Leisure Benefits Scale?

Which domains, among health, emotional well-being, social integration, and self-fulfillment, are most significantly enhanced by leisure activities, according to the retired population in Saudi Arabia?

Are there identifiable differences in the perceived benefits of leisure activities across various demographic groups (age, gender, socio-economic status and educational level) within the retired population of Saudi Arabia?

How do retirees in Saudi Arabia perceive the role of leisure activities in enhancing their well-being, particularly in terms of health, emotional balance, social integration, and self-fulfillment, post-retirement?

Literature review

This literature review serves as the foundational piece of this research undertaking, thoroughly analyzing the intricate relationship between recreational activities and the welfare of the retired population. Amidst a period marked by significant demographic changes, including a growing elderly population, the welfare of retirees has emerged as a central topic of academic investigation and public interest. This academic article systematically examines the various complex aspects of recreational activities and their simultaneous effects on the health of retired individuals, emphasizing the importance of conducting this research in the unique sociocultural context of Saudi Arabia. This section explores the theoretical and empirical aspects of the relationship between leisure and well-being.

Theoretical framework

This study’s underpinning is rooted in an integrated theoretical framework synthesizing insights from Activity Theory, Socioemotional Selectivity Theory, Self-Determination Theory, and cultural adaptation theories. This amalgamation offers a sophisticated lens through which the dynamics of leisure activities and their consequential impact on retirees’ well-being in Saudi Arabia can be examined. The ensuing discourse delineates the contribution of each theoretical perspective to comprehending the relationship between leisure pursuits and the multifaceted construct of well-being in the context of retirement.

Activity theory asserts the imperative of active engagement across various physical, social, and cognitive dimensions for sustaining and augmenting well-being in later life stages (Teles and Ribeiro 2019 ). It posits that a retiree’s involvement in diverse leisure activities is pivotal for achieving enhanced health, life satisfaction, and purpose (Winstead et al. 2014 ). Within the Saudi Arabian milieu, this theory underscores the investigation into how a spectrum of leisure engagements contributes to retirees’ overall well-being, advocating for a proactive and enriched lifestyle during retirement

Socioemotional selectivity theory, propounded by Carstensen, elucidates the evolution of social motivations and preferences toward emotionally meaningful engagements as one advances in age (Carstensen 2021 ). This theoretical approach illuminates the predilections of the Saudi retiree population toward leisure activities that fulfill emotional needs, foster social connections, and enhance a sense of community belonging—critical aspects of well-being in the autumn years of life.

Self-determination theory emphasizes the centrality of satisfying fundamental psychological needs—autonomy, competence, and relatedness—for optimal well-being. It is proposed that leisure activities, which resonate with retirees’ intrinsic motivations and facilitate psychological need satisfaction, significantly uplift their life quality (Ryan and Vansteenkiste 2023 ). This study utilizes SDT to probe into how leisure engagements underpin the psychological well-being of the Saudi retired populace, aligning leisure pursuits with their inherent motivations and the broader social fabric.

Incorporating cultural adaptation theory allows for accommodating Saudi Arabia’s distinct sociocultural nuances. This theory aids in deciphering how cultural values, norms, and the transformative socio-economic landscape shape leisure preferences and practices among retirees (Elliott 2020 ). It facilitates exploring the interaction between traditional and contemporary leisure activities and their role in satisfying psychological needs and enhancing well-being against the backdrop of Saudi Arabia’s evolving society.

Grounded in Activity Theory, Socioemotional Selectivity Theory, Self-Determination Theory, and cultural adaptation insights, this framework lays a solid foundation for exploring how leisure activities influence well-being among Saudi retirees. Considering Saudi Arabia’s unique cultural context, these theoretical constructs collectively provide a nuanced approach to understanding the role of leisure in promoting well-being.

The Importance of well-being in retirement

The concept of “well-being” has been the subject of extensive scholarly discussion, giving rise to many definitions that span various fields of study and paradigms. Fundamentally, well-being encompasses balanced health, contentment, and affluence as an intermediary between the subjective perceptions and the objective facts of human life (Carruthers and Hood 2004 ). In retirement, well-being transforms, assuming a multifaceted nature that interweaves human existence’s material, mental, and interpersonal aspects (Trenberth 2005 ). Beyond the absence of illness or disability, it embodies favorable qualities, including a deep-seated sense of direction, independence, and proactive involvement with the fabric of existence (Morse et al. 2021 ).

The significance of well-being is particularly pronounced in retirement, a phase of life characterized by substantial changes. When individuals are no longer employed, they encounter changes in their daily routines, social responsibilities, and sense of self, making maintaining their health and wellness a critical concern (Michèle et al. 2019 ). There is empirical support for retirees who report greater well-being, are more inclined to lead physically active and satisfying lives and demonstrate superior health outcomes (Mansfield et al. 2020 ).

Well-being among retired individuals is a complex and multifaceted phenomenon. Life satisfaction, the preponderance of positive emotions, and the reduction of negative affective states are all indicators of psychological well-being (Nielsen et al. 2021 ). Social well-being is characterized by strong social networks, enduring support systems, and an ingrained sense of inclusion within the fabric of the community (George 2010 ). Physical well-being’s foundation is preserving health, capability, and independence (Capio et al. 2014 ). Each of these dimensions exerts an intricate influence on the others and is reciprocally impacted by them, creating an intricate mosaic of interdependencies (Anglim et al. 2020 ).

Leisure activities and well-being

Leisure activities—elective, intrinsically motivated engagements conducted during discretionary periods—are critical in enhancing well-being in the retirement landscape (Morse et al. 2021 ). These activities, which range from cultural immersion and artistic endeavors to physical activities and social engagements, provide a respite from necessary work and a setting for self-discovery and personal evolution (Kuykendall et al. 2020 ). The significance of leisure in the post-career phase is multifaceted; it serves as a critical tool for acclimating to the post-occupational epoch, encouraging continuous intellectual stimulation, experiential exploration, and the cultivation of both new and existing social connections (Michèle et al. 2019 ; Verma 2017 ).

Academic discourses advocate leisure as an essential component of a more prosperous existence, especially during the golden years of retirement. Individuals frequently confront an abundance of temporal resources at this juncture, which is juxtaposed with the task of infusing this time with activities that resonate with their transforming identities and proficiencies (Li et al. 2019 ; Wang 2023 ). In this sense, leisure activities provide a conduit for retirees to re-calibrate their sense of purpose and contact with their surroundings. They make it easier to pursue dormant hobbies, rekindle old passions, and learn new skills and avocations (Hakman et al. 2019 ).

Furthermore, leisure activities help to maintain physical and cognitive vigor, reducing the potential attrition associated with the ageing process. They also act as a hub for social integration, allowing retirees to form new associations, strengthen existing relationships, and contribute to their societal spheres (Chul-Ho et al. 2020 ). Fundamentally, leisure is necessary in the alchemy of a satisfying and vibrant retirement, endowing it with exhilaration, intentionality, and a deep sense of community.

Leisure benefits

The variety of benefits derived from leisure activities generates a complex mosaic that significantly impacts several well-being elements. Engaging in such activities offers retirees more than just a diversion; it serves as a springboard for all-encompassing personal growth and renewal. Empirical evidence suggests that retirees who are heavily involved in leisure activities generally experience significant increases in their physical endurance, mental clarity, emotional equilibrium, and social involvement (Eskiler et al. 2019 ). Trekking and swimming workouts improve cardiac health and muscle strength, and intellectually stimulating activities like strategic games and artistic creativity sharpen mental abilities and help prevent cognitive decline (Lee et al. 2023 ). On the emotional front, recreational activities provide a therapeutic refuge from daily tensions, generating a sense of peace and well-being (Ertekin 2021 ). Furthermore, these activities frequently serve as focal areas for social interaction, fostering strong and long-lasting bonds within social circles and communities. These aspects of leisure activity work together to improve seniors’ physical strength, cognitive capacities, emotional resilience, and social fiber, thus improving their overall quality of life.

Health benefits

Leisure activities provide many health advantages, from soothing, meditative practices to more active and demanding workouts. Tranquil exercises, such as tai chi and strolling, have various health benefits, including lower blood pressure, increased joint mobility, and improved mental tranquillity (Fancourt et al. 2021 ). Aerobics and trekking, on the other hand, not only energize the body but also provide considerable health benefits. These exercises have been linked to improved cardiovascular health, musculoskeletal strength, and metabolic efficiency (Han et al. 2021 ; Peel et al. 2021 ; Šabić et al. 2020 ). These physical activities have been scientifically linked to lowering the risk factors associated with numerous chronic ailments, potentially delaying the onset of age-related diseases, and even playing a role in life extension (Lackey et al. 2021 ). Furthermore, a regular schedule of various physical leisure activities fosters improved agility and balance, which is essential for fall prevention in older persons. Furthermore, such activities boost total functional fitness, providing retirees with the physical capability and autonomy required to tackle the numerous obstacles of everyday living with greater ease and self-sufficiency (Fancourt and Steptoe 2021 ).

Emotional benefits

Leisure activities go beyond ordinary recreation to become significant emotional repair and wellness conduits. These activities provide a break from the unrelenting pace of daily life, raising spirits and acting as bulwarks against the tides of stress, worry, and sadness (Chen et al. 2022 ). The creative process, whether represented in the deft strokes of a painting, the fluidity of dance, or the painstaking building of a handcrafted product, is a type of emotional release (Eskiler et al. 2019 ). Such activities assist people in negotiating their emotions, allowing them to relieve internal tensions and cultivate a state of conscious presence (Wheatley and Bickerton 2022 ). The calm gained from leisure activities such as gardening, or yoga has a contemplative character, grounding the individual in the present and reducing concerns. More energetic occupations, such as team sports or the performing arts, on the other hand, can induce a state of “flow”, a profound immersion in which the outer world recedes, leaving a potent sensation of fulfillment and elation (Brymer et al. 2021 ). These leisure activities, taken together, function as wellsprings of emotional fortitude, replenishing emotional reserves, cultivating resilience, and instilling a profound sense of inner tranquillity and balance (Mansfield et al. 2020 ).

Social benefits

Leisure activities are not only diversions from a social standpoint; they are fundamental to the fabric of community dynamics, interweaving individuals in a network of social cohesion and shared enjoyment (Li et al. 2021 ). These activities go beyond ordinary pastimes for retirees, serving as vital channels for connection and active social engagement. They promote meaningful contact with peers, encourage involvement in community events, and provide the framework for developing long-lasting friendships (Poscia et al. 2018 ). Structured group activities, such as intellectually challenging book clubs, harmonic dance classes, and collaborative gardening projects, provide common areas for interchange and connection. These connections can exchange wisdom, share life stories, and form profound bonds (Brajša-Žganec et al. 2011 ). The effects of these events frequently extend far beyond the activities themselves, spawning subsequent social meetings such as coffee conversations, cultural trips, and various communal participation. Such lively exchanges do more than enliven retirees’ social lives; they also strengthen their sense of belonging and identification within the more extraordinary communal fabric (Adams et al. 2010 ; Lindsay Smith et al. 2017 ). Finally, leisure activities work as a catalyst for weaving a tapestry of social connections, promoting a sense of communal belonging essential to a fulfilling and full retirement life.

Self-fulfillment interests

In the golden years of retirement, leisure activities emerge as powerful catalysts for self-discovery and personal growth. These endeavors allow retirees to delve deeply into long-held hobbies or start on new adventurous excursions, creating a sense of competence and self-assurance (Stebbins 2017 ). Mastering a musical instrument, for example, is cognitively engaging and a source of tremendous personal joy. Painting and writing, for example, become channels for introspection and creativity, providing a sense of success and personal pride (Li et al. 2021 ). Similarly, learning a new language improves communication abilities and broadens one’s perspective by embracing various cultures and beliefs. Such interactions frequently induce a state of “flow”, an immersive experience in which profound focus and satisfaction coincide, providing great intrinsic pleasure (Stebbins 2013 ). Beyond personal fulfillment, these activities pave the path for social appreciation and active participation, enhancing retirees’ self-worth and maintaining their identity. Finally, leisure interests in the fabric of retirement go beyond mere hobbies; they are critical in filling life with significance, vigor, and an enduring enthusiasm for learning and self-development (Shutenko 2015 ).

Primarily, the domain of leisure activities is a complete cornerstone underpinning retirement well-being. These hobbies, which span life’s physical, cognitive, emotional, and social components, create a tapestry that enriches and elevates the whole fabric of retired living (Adams et al. 2010 ). With a more nuanced understanding of leisure’s various benefits, the emphasis shifts to the subtle interplay between cultural and demographic influences and leisure pastimes. The following part will explore the complexity of how cultural contexts and demographic nuances impact the character and outcomes of leisure activities, influencing retiree well-being.

Cultural and demographic influences on leisure and well-being

Leisure preferences are delicately woven into the tapestry of a person’s cultural milieu. The complex web of cultural conventions, values, and collective ideas defines the leisure landscape, sketching what is acceptable or desirable. Hofstede’s foundational work on cultural factors, according to Roy ( 2020 ), elucidates the significant influence of conceptions such as individualism and collectivism on leisure behaviors. Collectivist societies often highly value leisure activities that strengthen community solidarity and familial bonds. On the other hand, leisure activities tend to emphasize personal expression and the attainment of individual accomplishments in societies that trend toward individualism (Newman et al. 2014 ). Cultural heritage threads are similarly important, weaving traditional pleasures and customs into leisure participation (Brajša-Žganec et al. 2011 ).

Demographic factors intimately intertwine within the sphere of leisure, with each strand considerably impacting the mosaic of activities that people participate in. Age is a significant predictor, significantly impacting leisure preferences (Adams et al. 2010 ). Younger retirees may seek out physically exciting pursuits, but their elderly counterparts may seek refuge in milder yet equally gratifying activities (Agahi et al. 2011 ). Gender, a critical demographic factor, also impacts leisure decisions, frequently repeating deeply ingrained societal roles and expectations. As a result, the leisure sector reveals distinct gender-based patterns shaped by past access inequities and established norms (Fernandez 2023 ).

Socioeconomic position is a double-edged sword in leisure, enabling and restricting. Affluence opens up many leisure possibilities; however, financial constraints can narrow the range of available activities (Beenackers et al. 2012 ). Furthermore, educational background has a subtle but considerable influence on leisure participation. Higher education degrees extend one’s perspectives, encouraging interest in intellectually enriching or culturally sophisticated leisure activities. Thus, educational achievements gently pervade leisure preferences, shaping them to reflect an individual’s intellectual breadth and cultural depth (Stalsbergm and Pedersen 2010 ).

The leisure world is painted with the twin hues of cherished traditions and emerging modernity within Saudi Arabia’s vivid cultural mosaic (Amin et al. 2012 ). This juxtaposition creates a captivating story of continuity and change, uniquely molding the leisure domain. At its core, the Kingdom’s rich cultural past casts a long shadow on retiree leisure habits. Time-honored practices like falconry, woven into the fabric of history and social prestige, continue to maintain weight, as do poetic gatherings that connect with the nation’s historic literary past, anchoring retirees to their cultural roots (Al-Otaibi 2013 ). At the same time, the Kingdom is on the verge of revolution, pushed by the ambitious Vision 2030. This roadmap for socioeconomic transformation is altering the leisure paradigm by presenting a diverse range of contemporary leisure expressions (Alkhalaf and Orams 2021 ). As Saudi Arabia moves closer to its vision of the future, retirees are navigating a rising leisure revolution. New types of leisure are gaining traction, ranging from digital entertainment and adventure sports to the appeal of international travel. This fusion of the ancestral and the avant-garde creates a new language of leisure in the Saudi narrative, blurring the distinctions between tradition and innovation (Al-Otaibi 2013 ).

The relationship between cultural context and demographic characteristics is complex and multi-layered, altering the landscape of leisure and its impact on well-being significantly. The mosaic of leisure is a reflection not just of cultural heritage but also of the several demographic threads—age, gender, socioeconomic level—that intertwine to produce a great diversity of leisure experiences (Iwasaki et al. 2014 ). This dynamic is fundamental in the Kingdom of Saudi Arabia, as the country is undergoing tremendous socioeconomic and cultural developments. The developing societal fabric, supported by programs such as Vision 2030, sheds a dynamic light on the intersectionality of culture and demographics, substantially altering leisure interests and their implications for well-being (Bashatah et al. 2023 ).

Finally, the interaction of cultural and demographic variables significantly impacts leisure pursuits and, as a result, the well-being of retirees. This interdependence is remarkable in the Saudi environment, characterized by rapid and dramatic transitions. The following section outlines the methodological framework used to investigate and understand these factors in the Saudi context.

Previous studies

The relationship between leisure activities and well-being has been the focus of scholarly investigation across various cultural terrains. A strong relationship between leisure activity and improved well-being in the retired population stands out in the corpus of Western academic studies. Amin et al. ( 2012 ) conducted a seminal study highlighting the significant importance of leisure activities to increase life satisfaction and psychological well-being among the elderly. This idea is supported by Poscia et al.’s ( 2018 ) research, which emphasizes the crucial function of leisure in catalyzing social connections and alleviating feelings of loneliness among the elderly. To support these findings, Li et al. ( 2021 ) outline the various benefits of leisure activities, which include physical health, cognitive agility, emotional stability, and social connectedness.

Stebbins ( 2017 ) investigated the idea of severe leisure and its implications for self-fulfillment and identity reformation in the retirement phase, broadening the investigational purview of the European environment. Zwart and Hines’ ( 2022 ) study emphasizes the social benefits of outdoor adventure recreation, which reflect the broader social and communal benefits of leisure activities. Their findings, which emphasize shared experiences and social participation, are consistent with the function that leisure plays in building social bonds and well-being, highlighting the importance of leisure in fostering community and interpersonal connections.

Regarding the Middle Eastern story, particularly within Saudi Arabia, the scholarly terrain looks relatively unexplored. Human resources, societal culture, facilities, financing, instruments, programs, and policies, according to Sayyd and Abuhassna ( 2023 ), are the seven significant variables promoting leisure-time physical activity among Saudi male university students. The study highlights the value of integrated sports facilities, financial incentives, and customized programs in boosting public health through leisure-time physical exercise. According to a study by Bashatah et al. ( 2023 ), many adults in Riyadh, Saudi Arabia, maintain sedentary lifestyles with little involvement in leisure and exercise activities. Nearly half reported exercising only 1–2 days per week, with a sizable proportion never exercising. Despite being aware of the health concerns, sedentary behavior during leisure time persists. The study implies that governmental measures are needed to encourage more active leisure lifestyles among Saudi citizens. These recent studies critically investigated evolving leisure preferences against Saudi Arabia’s socioeconomic transformations, as spurred by projects like Vision 2030. Although these studies shed light on the general leisure habits of the Kingdom, they fall short of offering a granular insight into the retired demographic’s unique experiences.

A significant study vacuum concerning the retired community in Saudi Arabia exists in gerontology and leisure studies. The Kingdom’s distinct socio-cultural and economic fabric, particularly in the middle of revolutionary programs such as Vision 2030, warrants an in-depth investigation of how leisure activities influence retirees’ well-being in this specific setting. Existing studies primarily employed either quantitative or qualitative approaches, frequently delving into isolated aspects of well-being and ignoring seniors’ multidimensional experiences. However, this study uses a mixed-methods approach to overcome this gap, capturing the intricate interplay between health, emotional well-being, social integration, and self-fulfillment among Saudi retirees. The research attempts to improve worldwide understanding of leisure and well-being through this holistic lens, customizing its discoveries to the particular Saudi cultural and socioeconomic environment.

Research method

Research design.

This study adopts a mixed-method research design, combining quantitative and qualitative methodologies to capitalize on each offer’s distinct advantages. Grounded in the comprehensive framework proposed by Guetterman et al. ( 2019 ), this methodological synergy is strategically chosen to encompass the breadth and depth required to explore the intricate dynamics between leisure activities and well-being among the retired population.

Quantitative methodologies are employed to systematically quantify the correlations between leisure engagements and well-being metrics, facilitating an empirical assessment of prevalent trends and patterns within this demographic. This aspect is informed by prior empirical research that has elucidated quantifiable aspects of retiree well-being, thus providing a solid benchmark for evaluating the impact of leisure activities (Bashatah et al. 2023 ; Li et al. 2021 ; Zwart and Hines 2022 ).

Conversely, the qualitative facet of this research delves into retirees’ narratives, perceptions, and lived experiences, offering a rich, contextual understanding of the statistical patterns observed. This approach is inspired by foundational qualitative studies in the field (Amin et al. 2012 ; Fancourt et al. 2021 ; Stebbins 2017 ; Verma 2017 ), highlighting the critical importance of capturing the subjective interpretations and meanings that retirees attribute to their leisure activities and their consequent influence on their well-being.

This dual approach ensures that the findings are statistically validated and deeply rooted in the authentic experiences of the study population, providing a comprehensive and nuanced view of the leisure-well-being nexus among retirees in Saudi Arabia. The selection of a mixed-methods design is a deliberate strategic choice aimed at producing findings that are empirically robust, contextually rich, and practically relevant for enhancing the well-being of retirees.

Participants

The study engaged 545 retirees for its quantitative analysis, comprising 268 women and 277 men. These individuals, now distanced from their roles in various public and private sector jobs, were selected through a snowball sampling method to ensure a diverse representation across socioeconomic, educational, and cultural backgrounds. Snowball sampling was employed due to its capacity to penetrate diverse retiree networks, ensuring a varied representation across socioeconomic and cultural strata, which is vital for examining the study’s questions. This technique complements our theoretical framework, enabling a comprehensive analysis of the relationship between leisure activities and well-being (Parker et al. 2019 ). The age range of these participants spanned from 55 years to those above 65 years of age, aiming to capture a broad spectrum of post-retirement experiences. In the subsequent qualitative phase of the research, a focused group of 23 retirees was strategically chosen from the initial quantitative pool. This selection was tailored to gain deeper insights and reflect the larger group’s heterogeneity. The qualitative interviews aimed to elaborate on themes and patterns that emerged from the quantitative data (Roulston and Choi 2018 ). Detailed demographic and background information for both segments of the study population are methodically outlined in Fig. 1 .

This figure presents a composite bar and line graph detailing the sample population’s demographics. The bars show the distribution of individuals across various economic statuses (low income to high income) and education levels (primary to tertiary education), while the line graph indicates the age distribution within the sample. Social status categories are separated into divorced, separated, married, and single. The final bars compare the number of males to females. Each bar is labeled with the number of respondents in that category.

In the demographic section of the survey, the income categories were delineated as follows: Earnings below 5000 Saudi Riyals are classified as “low income”; those between 5000 and 7999 Riyals are categorized as “middle income”; incomes ranging from 8000 to 10,999 Riyals are defined as “upper-middle income”; and a monthly income of 11,000 Riyals or more is designated as “high income”. This stratification facilitates a nuanced understanding of respondents’ economic statuses.

Instruments

To collect the quantitative data, the “Leisure Benefits Scale” by Li et al. ( 2021 ) was used to measure this research, assessing the multifaceted advantages of leisure pursuits among retirees. This scale has been widely used by several studies (Ertekin 2021 ; Geng et al. 2023 ; Li et al. 2021 ), underscoring its validity and reliability in measuring the constructs of interest across diverse contexts. It consists of four constructs, each focusing on the dimensions of leisure benefits. The scale includes four items dedicated to evaluating the health benefits and assessing the impact of leisure activities on physical well-being. Another four items explore the emotional benefits, identifying the psychological and emotional uplift that leisure can provide. The social benefits construct, also with four items, measures the extent of social engagement and community connection derived from leisure activities. Lastly, the construct of self-fulfillment interests comprises five items, which delve into the personal development and sense of achievement that retirees gain from their leisure pursuits. Each construct collectively contributes to a comprehensive assessment of the positive effects of leisure activities on retirees’ overall quality of life. Each item was evaluated using a five-point Likert scale, ranging from 1, denoting “strongly disagree”, to 5, signifying “strongly agree”. This scaling method was chosen to provide a nuanced measure of the respondents’ levels of agreement or disagreement with each statement. The selection of health, emotional, social, and self-fulfillment benefits constructs, as well as the utilization of a five-point Likert scale, are informed by prior literature emphasizing their relevance to retirees’ well-being (e.g., Mansfield et al. 2020 ; Geng et al. 2023 ; Li et al. 2021 ). This approach ensures the study’s methodological design is grounded in empirically validated concepts, offering a detailed examination of how leisure activities enhance life quality.

To gather the qualitative data, a set of three semi-structured, open-ended interview questions was formulated. These questions were strategically designed to prompt detailed responses and discussions, enabling participants to articulate their experiences and perspectives on how leisure activities have influenced their well-being. The flexibility of the semi-structured format allowed for a conversational depth that facilitated the emergence of rich, narrative data, capturing the complex and personal dimensions of leisure that quantitative measures might overlook (Roulston and Choi 2018 ). This approach complements the empirical data, providing a more textured understanding of the retirees’ engagement with leisure activities.

Instrumentation’s validity

A two-pronged approach was adopted to ensure the validity of the questionnaire employed in this study, encompassing both expert evaluation and empirical testing for internal consistency. Initially, the questionnaire underwent rigorous assessment through the jury panel method. The expert panel method was chosen for its effectiveness in leveraging specialized knowledge to enhance the validity and reliability of the assessment process (Almanasreh et al. 2019 ). The assessment process involved a thorough evaluation by a panel of eight esteemed experts, each with specialized recreation and leisure management expertise. Their insightful feedback and recommendations were incorporated to enhance the questionnaire’s relevance and accuracy. Subsequently, to further reinforce the questionnaire’s validity, a pilot study was conducted involving 41 participants. This research phase involved a quantitative evaluation of the questionnaire’s internal consistency. Advanced statistical methods were employed to calculate the correlation coefficients for each item concerning the total score of its respective dimension. This comprehensive process ensured that the questionnaire was theoretically sound, as vetted by experts, and empirically robust, meeting the standards of internal consistency. Table 1 provides a detailed depiction of these correlation coefficients, showcasing the relationship between each item’s score and the overall score of its corresponding dimension within the questionnaire.

Table 1 presents a comprehensive analysis of correlation coefficients across four critical dimensions in a survey: Health Benefits, Emotional Benefits, Social Benefits, and Self-fulfillment Interests. Each dimension undergoes a thorough evaluation for internal consistency, as indicated by the Dimension Correlation, and its congruence with the overarching framework of the questionnaire, denoted by the Overall Correlation. The coefficients, consistently marked with double asterisks to denote statistical significance, exhibit a spectrum from moderate to high across these dimensions. This trend evidences a robust internal coherence within each dimension and underscores their substantial congruity with the global objectives of the questionnaire. The persistent presence of the double asterisks (**) underscores the statistical robustness of these correlations, bolstering the reliability of the findings. These outcomes collectively attest to the questionnaire’s efficacy in precisely capturing the targeted constructs within each dimension, thereby ensuring that each query contributes effectively to the broader research objectives.

Factorial validity

Exploratory factor analysis (EFA) was conducted using the principal components method, where orthogonal rotation via the Varimax technique was applied. This was done to extract factors by selecting the items most heavily loaded on each factor after rotation, as demonstrated in Table 2 .

An examination of Table 2 reveals the presence of four distinct factors, onto which a total of seventeen items are substantially loaded. Cumulatively, these factors account for 66.387% of the total variance. In detail, the first factor encompasses four items and has an eigenvalue of 3.075, contributing to 18.09% of the total variance. Similarly, the second factor includes four items and possesses an eigenvalue of 2.809, explaining 16.524% of the total variance. The third factor, comprising four items, has an eigenvalue of 2.725, accounting for 16.029% of the total variance. The fourth factor, consisting of five items, has an eigenvalue of 2.676, representing 15.743% of the total variance. To corroborate the proposed item-factor alignments, Confirmatory Factor Analysis (CFA) was employed using the Maximum Likelihood Method, facilitated by the LISREL software. Figure 2 depicts the resultant factor structure, confirming the factor structure hypothesized for the scale.

This figure illustrates the confirmatory factor analysis of the scale’s factor structure. The diagram presents the path coefficients for the scale items, which range from 0.52 to 0.89, signifying statistical significance at p  ≤ 0.01. The Chi-square statistic ( χ 2 ) is 561.18 with 168 degrees of freedom, corresponding to a χ 2 /df ratio of 3.34, indicating a good model fit. Goodness-of-fit indices including RMSEA, GFI, AGFI, and NFI are within optimal ranges, thereby affirming the factorial validity of the scale and its suitability for this study.

The analysis revealed that the path coefficients for the items on the scale ranged from 0.52 to 0.89, all achieving statistical significance at a threshold of p  ≤ 0.01. The Chi-square ( χ 2 ) statistic was calculated to be 561.18, with 168 degrees of freedom and a highly significant level of p  ≤ 0.001. This resulted in a (χ 2 /df) ratio of 3.34, indicative of a favorable model fit to the data. Moreover, the indices assessing the model’s goodness-of-fit, including RMSEA, GFI, AGFI, and NFI, all fell within their respective optimal ranges. These findings collectively underscore the factorial validity of the scale, confirming its robustness and appropriateness for the study.

Instrumentation’s reliability

The questionnaire’s reliability was assessed by the computation of Cronbach’s alpha ( α ) coefficient. The outcomes of this assessment are systematically presented in Table 3 .

The analysis of Table 3 reveals that the questionnaire possesses a robust overall reliability coefficient, quantified at 0.85. The dimension-specific reliability indices, evaluated using Cronbach’s alpha for assessing internal consistency, vary between 0.75 and 0.81. Each of these indices surpasses the established minimum reliability threshold of 0.6, indicating a commendable level of consistency across the questionnaire’s dimensions. These findings collectively affirm the questionnaire’s high reliability, validating its appropriateness for implementation within the study’s sample.

Data collection

Data collection was an integral component of this research, aiming to capture a comprehensive snapshot of the leisure pursuits among retirees. The data collection process for this study was conducted methodically over a 3-month period, from the beginning of May to the end of July 2023, allowing for extensive participation and detailed data accumulation. The process began with identifying retiree groups active on social media platforms like WhatsApp, capitalizing on the widespread use of such networks for enhanced reach and engagement. Subsequent efforts to expand the participant base employed a snowball sampling technique, which effectively utilized existing study participants to recommend additional retirees, thus facilitating the inclusion of diverse individuals across varying demographics. The survey distribution was substantial, reaching out to 1243 retirees, a number designed to ensure a wide berth of data for robust analysis. This outreach garnered a substantial response, with 545 retirees contributing their insights.

To enrich the quantitative findings with qualitative depth, the study extended invitations to 35 retirees from the initial pool of 545 respondents for personal interviews. The selection criteria prioritized diversity in leisure activities and engagement levels with the preliminary survey. This targeted approach was designed to capture a broad spectrum of experiences, ensuring that the qualitative interviews offer a detailed and representative view of the leisure phenomenon among retirees. Of those invited, 23 retirees accepted, demonstrating interest and readiness to provide more granular insights into their leisure pursuits. This positive response underscored the value retirees placed on discussing their leisure experiences and the potential impact on their well-being. The interviews were set to provide a layered understanding of leisure activities, bringing to light the individual stories behind the data and offering a comprehensive view of the retirees’ lived experiences.

Data analysis

To analyze the quantitative data, a comprehensive statistical approach was adopted to ascertain the psychometric robustness of the study instrument. Pearson correlation coefficients and Cronbach’s alpha formula were employed to validate the tool’s reliability and consistency. Furthermore, the study incorporated both exploratory and confirmatory factor analysis methodologies to assess the structure of the data. Quantitative measures such as frequencies, percentages, arithmetic means, and standard deviations were calculated for detailed data analysis. Comparative statistical techniques, including the Independent sample T -test for contrasting two independent means and one-way ANOVA for variance analysis, were utilized. These were augmented with Scheffe’s method for conducting multiple comparison tests. The statistical analyses were methodically executed using advanced statistical software, namely SPSS and LISREL, ensuring precision and reliability in the results.

To analyze the qualitative phase of data from semi-structured interviews, thematic analysis was utilized, enabling the identification and interpretation of emergent themes within participant narratives. Thematic analysis stands out for its ability to delve into human experiences’ particulars, offering invaluable depth to qualitative investigations. Identifying and analyzing themes significantly enriches the understanding of complex phenomena, aligning closely with the nuanced objectives of behavioral and psychological research (Castleberry and Nolen 2018 ). This approach was selected for its proficiency in capturing the experiences of retirees engaging in leisure activities. Supplementing the quantitative findings, this method facilitates a detailed exploration of how leisure activities influence well-being, with themes meticulously correlated to the research aims.

Ethical considerations

The study was designed with transparent communication of its purpose and objectives. On the first page of the questionnaire, a clear statement outlined the study’s primary goal, which served as an implicit agreement and permission from participants who proceeded with the questionnaire. This upfront disclosure ensured that participants were fully informed about the nature and intentions of the research before contributing their data. This practice not only adhered to ethical standards of informed consent but also fostered trust between the researchers and participants, which is fundamental to the integrity of the research process.

The findings section of this study is structured into two segments: an initial analysis of the quantitative data, followed by a detailed examination of the qualitative data, providing a comprehensive view of the research outcomes.

Quantitative findings

To effectively respond to the research question regarding the overall level of well-being enhancement attributed to leisure activity participation among Saudi retirees, an analytical approach was employed. This involved calculating the arithmetic means and standard deviations for each item on the questionnaire. The results of these calculations are systematically presented in Table 4 . The focus of this analysis is to ascertain the aggregate scores on the Leisure Benefits Scale, thereby providing a quantified measure of the impact of leisure activities on the well-being of the retired population in Saudi Arabia.

The table analysis reveals that the perceived impact of leisure activities on the well-being of the Saudi retiree community is moderately significant. This observation is supported by an arithmetic mean of 2.96 and a notably low standard deviation of 0.28, under one. Such a minimal standard deviation indicates a remarkable consistency in the perceptions of the study’s participants regarding the contribution of leisure activities to the well-being of retirees in Saudi Arabia. This uniformity underscores a collective agreement among the sample population on the moderate yet noteworthy role of leisure activities in enhancing retirees’ quality of life.

To answer the second question, which aims to identify which among health, emotional well-being, social integration, and self-fulfillment are most substantially enhanced by leisure activities among Saudi Arabia’s retired population, a methodical approach was taken. This involved calculating the arithmetic means and standard deviations for each dimension within the questionnaire. The results of these calculations, essential for providing a clear understanding of the relative impact of leisure activities in these specific domains, are methodically presented in the subsequent Table 5 . This detailed analysis is instrumental in discerning the most positively affected domain among the retired demographic in the context of leisure activities.

The table’s analysis provides a clear ranking of the impact of leisure activities on various well-being dimensions among retirees in Saudi Arabia. It shows that Health Benefits is the most positively impacted domain, with a high average mean score of 3.50. Afterwards, Emotional Benefits rank second with a moderate average mean of 3.10. Social Benefits are also moderately enhanced, coming in third with an average score of 3.01. Lastly, despite being beneficial, Self-fulfillment Interests are less influenced by leisure activities compared to the other domains, as indicated by its lower average mean of 2.38, placing it in the fourth position. This hierarchy reflects the varying degrees to which different aspects of well-being are affected by leisure activities among the retired population.

In addressing the third research question, which aims to uncover potential disparities in how leisure activities are perceived to benefit various demographic groups (including gender, age, socio-economic status, and educational level) within Saudi Arabia’s retired community, the initial focus is on the gender demographic. This phase of the analysis entailed a comprehensive computation of arithmetic means and standard deviations for the responses of the study’s sample, segregated by gender. The independent sample T -test was applied to ascertain the statistical significance of the observed differences in these means. The findings of this rigorous analysis, which are systematically outlined in Table 6 , provide critical insights into the existence and extent of gender-specific differences in the perception of the benefits of leisure activities. This strategic approach offers a refined understanding of the influence of gender on the valuation of leisure benefits among the Saudi retired populace.

Analysis of the data presented in the table indicates the presence of statistically significant disparities, noted at the α  ≤ 0.05 significance level, in the study participants’ average responses when segmented by gender. Notably, these differences are in favor of female respondents. This finding highlights a gender-specific variation in the perception or experience of the studied phenomena, underscoring the nuanced impact of gender on the research outcomes.

Moving on to examine another critical demographic variable, Table 7 provides the outcomes of the one-way ANOVA test. This analysis was conducted to discern any statistically significant differences in the average responses of the study’s participants, explicitly focusing on the age variable. The results are systematically organized and presented to offer a clear understanding of how age influences the perceptions within the study’s scope.

The statistical analysis of age-based variations in the perception of leisure benefits among Saudi retirees, as reflected in Table 7 , reveals a tendency toward differences across age cohorts. However, these differences did not achieve statistical significance ( F  = 2.794, p  = 0.053). This outcome implies that, although there might be slight variations in the valuation of leisure activities among different age groups within the retired population, such differences are not markedly significant within this study’s dataset. Consequently, this analysis suggests a uniform perception of the benefits of leisure activities across the age spectrum among retirees in Saudi Arabia.

Table 8 presents the findings from the one-way analysis of variance (ANOVA) test, which was executed to ascertain any statistical disparities in the mean responses of the study’s sample population based on the variable of Social Status.

The analysis of Table 8 , detailing Social Status-based differences in leisure benefits among Saudi retirees, reveals significant statistical disparities ( F  = 11.642, p  = 0.000). This significant variation indicates that retirees’ social status notably influences their perception of leisure benefits, suggesting that access and attitudes toward leisure activities vary across different social strata within the retired population in Saudi Arabia. To determine the direction of the differences, the post hoc Scheffe test was used; Table 9 below illustrates the direction of these differences.

Table 9 , focusing on social status, reveals differences in how leisure activities’ benefits are perceived among Saudi retirees. Married individuals show a significant variation in their perception compared to divorced retirees, as indicated by the mean scores. This suggests that marital status, including being single, married, divorced, or separated, plays a role in shaping perceptions of leisure’s impact on well-being, with marital status particularly influencing these viewpoints.

Table 10 presents the outcomes from a one-way analysis of variance (ANOVA) conducted to ascertain the presence of statistical differences in the average responses of participants in the study. This analysis specifically focuses on understanding how perceptions of the role of leisure activities in enhancing well-being in Saudi’s retired community vary concerning the economic status of the respondents.

Table 10 , which focuses on the differences based on economic status, reveals pronounced statistical variations in how leisure activities are perceived to enhance well-being among Saudi retirees. The considerable F -statistic of 206.038 and a p value of 0.000 robustly indicate marked disparities in perceptions across varying economic groups. This significant variance underscores the pivotal influence of economic status in molding retirees’ perspectives regarding the benefits of leisure activities, highlighting economic factors as critical determinants in shaping the perceived efficacy of leisure in enhancing well-being. To determine the direction of these differences, the Scheffe post hoc test was utilized; Table 11 illustrates the direction of these differences.

Table 11 reveals notable disparities in the perception of leisure benefits across different economic statuses among Saudi retirees. High-income individuals perceive significantly more benefits from leisure activities than upper-middle, middle, and low-income groups. These findings suggest a clear relationship between economic status and the perceived impact of leisure on well-being, with higher income correlating with a greater appreciation of leisure benefits. This highlights the influence of economic factors on the perceived quality and effectiveness of leisure activities in enhancing well-being.

Table 12 features the one-way ANOVA results, evaluating statistical differences in how participants, segmented by educational background, perceive leisure activities’ impact on well-being among retired individuals in Saudi Arabia.

Table 12 demonstrates statistically significant variances in the perceptions of leisure activities’ role in enhancing well-being correlated with the educational levels of Saudi retirees. The pronounced F -value of 10.289 and the definitive p value of 0.000 prove that a retiree’s educational background markedly influences their perception of leisure benefits. This finding implies that the educational level is a crucial factor in forming retirees’ perspectives and experiences related to leisure, significantly affecting its perceived value and impact on overall well-being during retirement. To determine the direction of the differences, the Scheffe post hoc test was utilized. Table 13 illustrates the direction of these differences.

Table 13 , showcasing the results from the Scheffe post hoc analysis, indicates significant differences in perceptions of leisure benefits among Saudi retirees according to their educational levels. It highlights that retirees with tertiary education have markedly different perceptions than those with primary or secondary education, as evident in the distinct mean scores. This finding suggests a correlation between higher educational attainment and a unique understanding of leisure activities’ contribution to well-being in retirement.

Qualitative findings

This section outlines the qualitative findings, where the thematic analysis identified three main themes that reflect the retirees’ experiences and perspectives on leisure activities and their impact on well-being.

Holistic health and emotional well-being

The retirees’ narratives reveal a strong link between leisure activities and improved physical health, a finding particularly relevant in the Saudi context, where traditional lifestyles may have been more sedentary. “Since I began regular evening walks around our neighbourhood parks, I have noticed my blood pressure stabilizing,” one retiree shared, indicating the health benefits of accessible, low-impact physical activities. Another retiree’s experience with a more culturally traditional activity, such as falconry, underscores this, “Falconry is not just a sport for me; it is an engaging way to stay active, which I find beneficial for my health.”

The emotional benefits retirees associate with leisure activities are profound. “In our culture, family and social gatherings are significant. Organizing and participating in these brings me immense joy and a sense of belonging,” a participant noted, reflecting the social aspect of leisure that resonates strongly in the collectivist Saudi culture. Another retiree mentioned, “ Pursuing calligraphy, a cherished art form in our culture, has been incredibly soothing for me.”

The analysis shows that Saudi retirees’ leisure activities are often closely tied to their cultural heritage, enhancing their sense of identity and continuity. Activities such as gardening, calligraphy, or participating in community events offer physical and emotional benefits and help maintain a connection with their cultural roots.

In summary, the qualitative responses from Saudi retirees highlight that leisure activities contribute significantly to their well-being, with the benefits of these activities being amplified by their alignment with cultural practices and values. The findings suggest that integrating culturally relevant leisure activities into the daily routines of retirees could be vital to enhancing their overall health and emotional well-being.

Social integration and self-fulfillment

The qualitative data revealed that leisure activities enhance social integration among Saudi retirees. Participants frequently emphasized how these activities catalyzed social interaction and community bonding. A retiree articulated, “My involvement in a local walking group transcends physical health benefits; it has been instrumental in forging new connections with neighbours and creating a supportive community network.” The significance of participating in culturally resonant events was also noted, with another retiree stating, “My engagement in mosque gatherings and community volunteerism has deepened my sense of belonging and unity within my community.” These narratives highlight the intrinsic value of leisure activities as vehicles for social engagement, which is crucial in a societal context that places high importance on communal relationships and solidarity.

In the domain of self-fulfillment, retirees voiced how leisure pursuits were instrumental in providing a sense of personal achievement and identity. One participant reflected, “ Retirement has allowed me to immerse myself in painting, transforming it from a hobby to an integral part of my identity.” Another retiree’s experience acquiring new skills, such as digital photography, was cited as a source of personal accomplishment and cognitive stimulation. These insights underscore the significant role of leisure activities in promoting self-worth and ongoing personal development, particularly during retirement, which often prompts a reevaluation of personal identity and aspirations.

Within the Saudi cultural framework, where family and community relationships are central to social life, the dual aspects of social integration and self-fulfillment acquire heightened significance. Leisure activities provide a harmonious blend of traditional communal engagement and individual self-expression, reinforcing personal identities in the post-retirement phase.

In summary, the qualitative findings indicate that leisure activities in Saudi Arabia are far more than mere pastimes. They are integral to fostering meaningful social connections and achieving personal fulfillment. This dual role is especially pertinent in the Saudi context, where leisure bridges traditional communal values and the pursuit of individual interests, thereby enhancing retirees’ overall quality of life.

Cultural influence and barriers to leisure

The qualitative findings underscored the significant role of cultural ethos in shaping leisure activities among Saudi retirees. Participants frequently discussed how entrenched cultural norms and traditions underpin their approach to leisure. One retiree illustrated this: “Our leisure practices are deeply rooted in cultural values; they extend beyond personal amusement to embrace family traditions and communal gatherings.” Another participant elaborated, “Leisure choices in our Saudi society are invariably intertwined with our cultural and religious principles, guiding us towards socially appropriate and personally enriching activities.” These reflections reveal that in the Saudi context, leisure is not solely an individual pursuit but is inextricably linked to cultural identity, often reflecting collective values and societal expectations.

Several impediments to leisure engagement for Saudi retirees were reported. Recurring discussions centered on the inadequacy of leisure infrastructure and opportunities that cater to older adults’ needs and preferences. “Navigating the limited options for age-appropriate and accessible leisure activities presents a significant challenge,” expressed a respondent. Economic factors also emerged as substantial barriers, with a participant noting, “Economic constraints at times limit our participation in diverse leisure pursuits, particularly those requiring financial investment or travel.” Also, prevalent societal perceptions of ageing and activity levels were highlighted as deterrents. A retiree voiced, “There exists a societal notion that retirement should be a period of reduced activity, which can be disheartening for those of us eager to explore and engage more actively.” These barriers underscore the necessity for developing more inclusive leisure strategies and advocating a paradigm shift in societal attitudes toward aging to optimize the role of leisure in enhancing retirees’ well-being and life satisfaction.

To address the first research question concerning the extent to which leisure activity engagement enhances well-being among retirees in Saudi Arabia, this study revealed a moderate level of enhancement in well-being, as quantified by the scores on the Leisure Benefits Scale. The observed moderate enhancement in retirees’ well-being can be understood through unique Saudi cultural and socio-economic contexts. Predominantly, cultural norms in Saudi society, which prioritize family and communal activities over individual leisure pursuits, might have tempered the impact of leisure on individual well-being. Moreover, this cultural inclination toward communal leisure could suggest a detailed pathway through which leisure activities contribute to well-being, potentially emphasizing the value of social cohesion and familial bonds. Furthermore, the accessibility and diversity of leisure activities available to retirees are likely influenced by the country’s ongoing socio-economic changes, particularly those associated with the Vision 2030 reform plan. These reforms, aiming to diversify entertainment and leisure opportunities, may gradually alter the landscape of leisure activities available to retirees, influencing future well-being outcomes.

The study’s outcomes resonate with the observations made by Adams et al. ( 2010 ), who acknowledged the complexities inherent in correlating leisure activities with well-being enhancement in later life, particularly under varying contextual influences. Similarly, Agahi et al. ( 2011 ) underscore the importance of sustained engagement in leisure activities for augmented well-being, suggesting that the intensity and nature of leisure activities pursued by Saudi retirees might be pivotal in understanding the observed moderate enhancement. This emphasis on sustained engagement aligns with the notion that not just any leisure activity but those consistently engaged in and meaningful to the individual are likely to have the most significant impact on well-being.

Conversely, the findings slightly contradict Brajša-Žganec et al. ( 2011 ), who reported a more pronounced link between leisure activities and subjective well-being. This discrepancy might stem from the distinct socio-cultural milieu of Saudi Arabia, which potentially modulates retirees’ perceptions and participation in leisure activities. The cultural specificity of Saudi Arabia, including its values and norms, plays a critical role in shaping how leisure activities are perceived and engaged in, thereby influencing their impact on well-being. Furthermore, this research aligns with Li et al. ( 2021 ), who discuss the differential impacts of leisure activities across various dimensions of well-being in older adults. Therefore, the moderate enhancement observed in the Saudi context might reflect a variation in how leisure activities align with the retirees’ specific well-being needs and expectations. This suggests that the leisure activities most beneficial for well-being in Saudi Arabia may differ from those in cultures with different norms and values regarding leisure and retirement. The study reinforces that, as recognized globally, leisure activities are vital in enhancing retirees’ well-being. However, the specific context of Saudi Arabia, marked by its unique cultural and socio-economic landscape, significantly shapes the extent of this enhancement, highlighting the importance of contextual factors in designing and implementing policies and programs aimed at promoting retiree well-being through leisure.

Concerning the second research question regarding the domains most significantly enhanced by leisure activities among the retired population in Saudi Arabia, the study pinpointed health benefits as the foremost area of improvement. This prioritization of physical health mirrors broader global trends underscoring the critical role of physical well-being in later life. Within Saudi Arabia, such emphasis likely reflects a cultural and societal evolution toward valuing physical health during retirement, perhaps spurred by recent public health initiatives and a movement toward more active living.

The study also found moderate emotional and social well-being enhancements through leisure activities. These enhancements, while noteworthy, highlight a differential impact of leisure across well-being domains, with physical health seeing the most substantial benefits. This could be attributed to the cultural norms in Saudi Arabia, where leisure may often be experienced in communal settings, intertwining emotional and social benefits. Indeed, the communal nature of leisure in Saudi society may inherently bolster emotional and social well-being, yet distinguishing these effects from the broader context of health benefits presents an intriguing area for further investigation. Such a pattern indicates that emotional well-being and social integration through leisure are fostered within community and family-oriented activities, a characteristic feature of Saudi society. However, the area of self-fulfillment through leisure showed relatively lower enhancement. This observation suggests a potential area for policy intervention, aiming to broaden the scope and perception of leisure’s role in supporting comprehensive well-being, including personal growth.

Comparing these findings with existing literature, the emphasis on health benefits is consistent with the research of Lee et al. ( 2023 ), who highlighted the relationship between leisure activities and physical well-being in older adults. The moderate impact on emotional well-being parallels Chen et al. ( 2022 ), indicating that the influence of leisure on emotional health is subject to individual and contextual factors. For social benefits, the study’s findings align with Lindsay Smith et al. ( 2017 ), though the impact in Saudi Arabia may be nuanced by the society’s existing solid communal ties. In contrast, the lower emphasis on self-fulfillment aligns less with the observations of Ertekin ( 2021 ), who found a significant impact of leisure on personal growth among younger demographics, underscoring a potential generational divide in leisure’s contributions to well-being. Overall, the study affirms the beneficial role of leisure in enhancing various aspects of well-being among Saudi retirees. However, the variations in the degree of enhancement across different domains highlight the importance of cultural and societal factors in shaping retirees’ leisure experiences and their perceived benefits, pointing to the nuanced role leisure plays in the fabric of retirees’ lives, influenced by both individual preferences and the prevailing cultural ethos.

In exploring the third research question, which investigates the presence of demographic differences in how leisure activities are perceived to benefit retirees in Saudi Arabia, the study unveils distinct variations across gender, age, socio-economic status, and educational level. The research found that female retirees perceive a more significant benefit from leisure activities compared to their male counterparts. This difference underlines the impact of societal roles and cultural expectations on leisure engagement and its perceived value, suggesting that leisure activities offer a unique avenue for social and emotional fulfillment for women. This could be attributed to gender-specific roles and cultural norms, where women might find more value or solace in leisure activities, particularly those that foster social interaction or creativity. Moreover, these findings align with the broader discourse on gender and leisure, highlighting the need to consider gender dynamics when designing and promoting leisure activities for retirees. This gender distinction in leisure perception may also reflect broader societal dynamics, where leisure serves different psychosocial functions for men and women.

While initial data suggested variations in leisure benefits perceptions across age groups, these differences were not statistically significant. This lack of significant variation highlights a universal appreciation for leisure across the retirement spectrum, suggesting that leisure’s role in enhancing well-being is broadly recognized among the elderly in Saudi Arabia. This implies a consistency in the value placed on leisure activities among the elderly, regardless of age. Such findings challenge the notion that leisure’s importance diminishes with advancing age, reinforcing that leisure activities remain a crucial component of well-being for retirees. It indicates that, despite physiological and lifestyle changes that come with different stages of ageing, the perceived importance and benefits of leisure remain relatively stable among Saudi retirees.

The analysis highlights socio-economic and marital status as critical determinants in shaping retirees’ perceptions of leisure benefits. It was observed that retirees belonging to higher income groups reported a heightened perception of the benefits derived from leisure activities. This association points to the critical role of financial stability in enhancing leisure experiences, where economic resources expand access to diverse and potentially more fulfilling leisure options. This trend suggests that more significant economic resources, which enable access to a broader spectrum of leisure opportunities, significantly contribute to an enhanced sense of well-being from these activities. Concurrently, marital status emerged as a pivotal factor, with married retirees consistently reporting more favorable perceptions of leisure benefits than their unmarried peers. This finding highlights the importance of companionship and shared experiences in magnifying the positive impacts of leisure on well-being, suggesting that social connections are integral to the leisure experience. This variation can likely be ascribed to the added social and emotional support provided by marital relationships, which may amplify the enjoyment and overall satisfaction derived from leisure pursuits. Furthermore, the significant influence of educational level on leisure perceptions emphasizes the link between education and leisure engagement, where higher education fosters an enriched understanding and valuation of leisure’s benefits. These findings underscore the multifaceted nature of leisure benefits and their dependency on individual socio-economic and relational contexts. Ultimately, these insights call for a nuanced approach to promoting leisure among retirees, considering how socioeconomic status, marital status, and education level influence leisure’s perceived value and impact on well-being.

These findings align with various strands of existing research. The gender-based differences affirm the nuanced view of leisure engagement across genders, with women potentially valuing leisure differently due to societal roles and cultural expectations. The gender-based differences resonate with Fernandez’s ( 2023 ) exploration of gender dynamics in leisure activities. In contrast, the age-related findings present a different narrative from studies like Nielsen et al. ( 2021 ), which observed more pronounced age-based variations in leisure engagement. This discrepancy suggests that cultural and societal contexts, such as those in Saudi Arabia, may be crucial in moderating the relationship between age and leisure engagement. The impact of socio-economic status on leisure perceptions finds support in Beenackers et al. ( 2012 ), highlighting the role of economic factors in leisure activity participation. This emphasizes the importance of accessibility and the ability to engage in preferred leisure activities as key factors influencing well-being. Lastly, the influence of education aligns with Li et al. ( 2021 ), emphasizing the role of educational background in shaping leisure experiences and benefits. Educational attainment not only influences the types of leisure activities pursued but also affects the depth of engagement and the derived psychological benefits. These findings underscore the need for a nuanced understanding of leisure engagement among retirees, considering the diverse backgrounds and life experiences within this demographic. Such insights are vital for developing targeted interventions and policies that cater to retirees’ specific needs and preferences, ensuring leisure activities are accessible and meaningful across different segments of the retired population.

Regarding the fourth research question dealing with how retirees in Saudi Arabia perceive the role of leisure activities in enhancing their well-being, particularly in terms of health, emotional balance, social integration, and self-fulfillment, post-retirement, the qualitative findings provide in-depth insights. Interviews revealed that retirees associate significant health benefits with regular engagement in leisure activities, highlighting a shift from potentially sedentary lifestyles to more active pursuits. The study reveals a profound link between leisure activities and physical health improvement among retirees. Participants frequently mentioned activities like evening walks and gardening alongside culturally specific pursuits such as falconry, underscoring their dual benefits for physical health and emotional enrichment.

Retirees emphasize the emotional upliftment of leisure activities, especially those involving family and social interactions. These activities contribute to emotional well-being and echo the collectivist values inherent in Saudi society, reinforcing familial and social bonds. These activities are credited with bringing joy and fostering a deep sense of belonging, reflecting the collectivist nature of Saudi culture. Moreover, the findings indicate that leisure activities are crucial in promoting social integration. Retirees highlighted the role of leisure in expanding their social networks and maintaining active social lives, which is particularly valuable in the context of Saudi Arabia’s communal culture. For many retirees, these activities are pivotal in building and maintaining social connections, contributing significantly to their sense of community involvement and social life. Furthermore, participants viewed retirement as a unique opportunity for exploring new hobbies and interests, signifying leisure’s critical role in personal development and self-discovery. Retirement is seen as an opportunity for personal growth and identity development. Leisure pursuits are instrumental in this phase, allowing retirees to explore new skills and hobbies, enhancing their self-worth and personal accomplishment.

These qualitative insights corroborate and expand upon existing literature, providing a nuanced understanding of the multifaceted benefits of leisure among Saudi retirees. The study’s insights align with existing research in gerontology and leisure studies. The focus on health and emotional well-being through leisure resonates with the findings of Lee et al. ( 2023 ), who identified a strong correlation between leisure activities and physical well-being in older adults. Similarly, the emphasis on social integration through leisure activities finds support in the research of Lindsay Smith et al. ( 2017 ), who highlighted the importance of social support in leisure activities among older adults. Moreover, the narrative around leisure as a means for self-enhancement and identity reconstruction enriches the discourse on leisure’s transformative potential in the post-retirement phase. Besides, the significance of leisure in facilitating personal development and identity reconstruction is consistent with the observations made by Ertekin ( 2021 ), emphasizing leisure’s role in personal growth.

In summarizing this discourse, it becomes clear that this research not only addresses a significant gap but also advances our understanding of the impact of leisure activities on the well-being of retirees in Saudi Arabia. Through a nuanced examination of the effects across diverse demographic groups, this study unveils previously unrecognized aspects of how leisure contributes to post-retirement life. These insights challenge existing paradigms and enrich the academic dialogue surrounding gerontological well-being. The implications of this research extend beyond academic interest, providing a robust foundation for policy formulations that aim to cultivate a more inclusive and supportive leisure environment for retirees. This study’s contributions are mainly distinguished by its methodical analysis and culturally sensitive recommendations, which are pivotal for practitioners aiming to enhance retiree well-being through targeted leisure programs. This research offers a strategic roadmap for implementing culturally attuned leisure initiatives by explicitly detailing how these findings can influence policy and practice. Such contributions are vital for shaping future studies and encouraging the adoption of informed practices that optimize the quality of life for retirees in Saudi Arabia, marking a significant advancement in the field.

Implications

Drawing from this study’s key findings, significant theoretical and practical implications emerge, highlighting the multidimensional impact of leisure activities on retirees’ well-being.

Theoretical implications

This research substantially enriches the theoretical framework surrounding the impact of leisure activities on the well-being of retirees. It reaffirms the idea that leisure serves as a vital component in enhancing life quality, transcending the traditional view of it as a mere pastime, particularly in the context of retirement. This perspective aligns with the findings of Mansfield et al. ( 2020 ), who also emphasized leisure’s critical role in retirees’ quality of life. By doing so, this study extends beyond conventional leisure theories to highlight the multifaceted role of leisure in promoting comprehensive well-being among retirees, incorporating aspects such as physical health, emotional well-being, social integration, and self-fulfillment. A notable aspect of the study is its emphasis on the role of cultural context in shaping leisure experiences. This introduces a good perspective to leisure theories, suggesting that cultural dimensions are pivotal in influencing how leisure activities impact well-being, thereby calling for a broader, more culturally inclusive framework in future research, as supported by Poscia et al. ( 2018 ), who explored the cultural determinants of leisure activity. Furthermore, the study sheds light on the variations in perceived leisure benefits across different demographic segments, including gender, socio-economic status, and educational levels. These findings prompt reevaluating existing assumptions within the academic discourse on leisure and aging, advocating for a refined approach that better accommodates the diversity of retirees’ experiences and needs, echoing the work of Li et al. ( 2021 ), who highlighted demographic influences on leisure engagement.

Practical implications

Practically, the study offers critical insights for enhancing retirees’ well-being through leisure activities. Highlighting the importance of culturally sensitive and accessible leisure programs, it emphasizes the need for initiatives that cater to retirees’ physical capabilities and align with their cultural values and social preferences. This approach aligns with the findings of Adams et al. ( 2010 ), who demonstrated the positive impact of culturally tailored leisure programs on the well-being of diverse elderly populations. This calls for creating leisure opportunities that are not only physically accessible but also resonate deeply with the cultural and social fabric of the Saudi retired community. Moreover, identifying barriers to leisure engagement underscores the critical need for targeted interventions to remove obstacles related to economic constraints and infrastructural deficiencies. The importance of overcoming these barriers is echoed in the work of Beenackers et al. ( 2012 ), who explored the significant role of accessible leisure infrastructure in promoting active aging. The study also highlights the need to address prevalent barriers to leisure engagement, such as economic limitations and inadequate infrastructure. Therefore, policymakers and community developers are urged to prioritize the development of inclusive leisure environments that support the holistic well-being of the retired population. Lastly, the research points to the crucial role of societal perceptions regarding aging and retirement. It advocates for shifting societal narratives toward viewing retirement as a period of continued engagement and fulfillment, leveraging public campaigns and community programs to foster positive attitudes toward aging and active lifestyles among retirees. This recommendation aligns with the conclusions of Li et al. ( 2021 ), who highlighted the transformative potential of public narratives in shaping retirement experiences. Facilitating this societal change involves public awareness campaigns and community initiatives that support and celebrate the active participation of older individuals in diverse leisure and social activities, thereby fostering a more inclusive and supportive environment for retirees.

Limitations and recommendations for further research

This study identifies three primary limitations, each accompanied by a corresponding recommendation. First, the sample’s limited diversity may not fully capture the heterogeneity of Saudi Arabia’s retired population. To address this, future research should aim for a broader demographic reach, including more varied age groups, socio-economic statuses, and participants from urban and rural areas, ensuring inclusivity of various regions, socio-economic statuses, and cultural backgrounds. Second, the cultural specificity of the study, focused primarily on the Saudi context, limits the generalizability of findings to other cultural environments. It is recommended that subsequent studies incorporate comparative analyses with different cultural groups, such as retirees in Western, Asian, and other Middle Eastern contexts, to enhance the applicability of the research findings. Finally, the study’s cross-sectional nature constrains exploring longitudinal changes and causality in leisure activities’ impact on well-being. Future research should consider longitudinal designs to assess changes over time and identify causal relationships to observe how retirees’ perceptions and benefits of leisure evolve, providing a more dynamic understanding of the role of leisure in retirement life.

In summarizing this research, it is evident that the study significantly advances our understanding of how leisure activities contribute to the well-being of retirees in Saudi Arabia. It comprehensively delineates the multifaceted role of leisure—highlighting its profound influence on physical health, emotional well-being, social connectivity, and the pursuit of self-fulfillment among the elderly. The study elucidates that leisure activities, particularly those resonating with cultural traditions, transcend mere recreation to become pivotal in enhancing the quality of life for retirees. The investigation examines the impact of demographic variables, including gender, age, socio-economic status, and educational level, on how leisure benefits are perceived and experienced. It demonstrates that the positive effects of leisure on well-being are universally acknowledged yet vary in magnitude across different demographic segments. This variation underscores the necessity for customized leisure program designs that accommodate the diverse needs and preferences within the retired community. Beyond leisure and gerontology, the findings offer strategic insights for policymakers, urban planners, and healthcare professionals. The study advocates for establishing inclusive and culturally attuned leisure infrastructures and programs, ensuring broad accessibility for the entire spectrum of the retired population. Ultimately, this research contributes to our comprehension of leisure’s role in retirement, promoting its strategic integration into initiatives aimed at augmenting the life quality of the elderly. As Saudi Arabia navigates through ongoing demographic and cultural changes, the pertinence of such research becomes increasingly vital in informing policies and practices that foster a vibrant, engaged, and content retired community.

Data availability

The datasets generated and analyzed during this study are shared in an online Supplementary file with this published article.

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Acknowledgements

The authors extend their appreciation to the Deanship of Scientific Research at Northern Border University, Arar, KSA for funding this research work through the project number “NBU-FFR-2024-48-02”.

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Department of General Courses, College of Humanities and Social Sciences, Northern Border University, Arar, Saudi Arabia

Homoud Mohammed Nawi Alanazi

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As the sole author of this paper, I was responsible for all aspects of the research and manuscript preparation. This included interpreting the results, articulating the study’s implications, and drafting the manuscript’s key sections, including the “Introduction”, “Discussion”, and “Conclusion”. I also analyzed the statistical data, examining and interpreting the quantitative data collected. This all-encompassing role ensured a thorough and rigorous examination of the research topic.

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Correspondence to Homoud Mohammed Nawi Alanazi .

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The study was approved by the Permanent Committee for Research Ethics at Northern Border University (No. 16-7-24).

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The study guaranteed participant anonymity and data confidentiality, avoiding the collection of email or IP addresses. The survey’s introduction clearly stated the study’s purpose and reassured participants about the confidential treatment of their responses. Participation was entirely voluntary, and choosing to participate was considered as giving informed consent.

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Alanazi, H.M.N. The role of leisure activities in enhancing well-being in Saudi’s retired community: a mixed methods study. Humanit Soc Sci Commun 11 , 604 (2024). https://doi.org/10.1057/s41599-024-03126-x

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Received : 15 December 2023

Accepted : 24 April 2024

Published : 10 May 2024

DOI : https://doi.org/10.1057/s41599-024-03126-x

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