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Chapter 4: Theoretical frameworks for qualitative research

Tess Tsindos

Learning outcomes

Upon completion of this chapter, you should be able to:

• Describe qualitative frameworks.
• Explain why frameworks are used in qualitative research.
• Identify various frameworks used in qualitative research.

What is a Framework?

A framework is a set of broad concepts or principles used to guide research.  As described by Varpio and colleagues 1 , a framework is a logically developed and connected set of concepts and premises – developed from one or more theories – that a researcher uses as a scaffold for their study. The researcher must define any concepts and theories that will provide the grounding for the research and link them through logical connections, and must relate these concepts to the study that is being carried out. In using a particular theory to guide their study, the researcher needs to ensure that the theoretical framework is reflected in the work in which they are engaged.

It is important to acknowledge that the terms ‘theories’ ( see Chapter 3 ), ‘frameworks’ and ‘paradigms’ are sometimes used interchangeably. However, there are differences between these concepts. To complicate matters further, theoretical frameworks and conceptual frameworks are also used. In addition, quantitative and qualitative researchers usually start from different standpoints in terms of theories and frameworks.

A diagram by Varpio and colleagues demonstrates the similarities and differences between theories and frameworks, and how they influence research approaches. 1(p991) The diagram displays the objectivist or deductive approach to research on the left-hand side. Note how the conceptual framework is first finalised before any research is commenced, and it involves the articulation of hypotheses that are to be tested using the data collected. This is often referred to as a top-down approach and/or a general (theory or framework) to a specific (data) approach.

The diagram displays the subjectivist or inductive approach to research on the right-hand side. Note how data is collected first, and through data analysis, a tentative framework is proposed. The framework is then firmed up as new insights are gained from the data analysis. This is referred to as a specific (data) to general (theory and framework) approach .

Why d o w e u se f rameworks?

A framework helps guide the questions used to elicit your data collection. A framework is not prescriptive, but it needs to be suitable for the research question(s), setting and participants. Therefore, the researcher might use different frameworks to guide different research studies.

A framework informs the study’s recruitment and sampling, and informs, guides or structures how data is collected and analysed. For example, a framework concerned with health systems will assist the researcher to analyse the data in a certain way, while a framework concerned with psychological development will have very different ways of approaching the analysis of data. This is due to the differences underpinning the concepts and premises concerned with investigating health systems, compared to the study of psychological development. The framework adopted also guides emerging interpretations of the data and helps in comparing and contrasting data across participants, cases and studies.

Some examples of foundational frameworks used to guide qualitative research in health services and public health:

• The Behaviour Change Wheel 2
• Consolidated Framework for Implementation Research (CFIR) 3
• Theoretical framework of acceptability 4
• Normalization Process Theory 5
• Candidacy Framework 6
• Aboriginal social determinants of health 7(p8)
• Social determinants of health 8
• Social model of health 9,10
• Systems theory 11
• Biopsychosocial model 12
• Discipline-specific models
• Disease-specific frameworks

E xamples of f rameworks

In Table 4.1, citations of published papers are included to demonstrate how the particular framework helps to ‘frame’ the research question and the interpretation of results.

Table 4.1. Frameworks and references

As discussed in Chapter 3, qualitative research is not an absolute science. While not all research may need a framework or theory (particularly descriptive studies, outlined in Chapter 5), the use of a framework or theory can help to position the research questions, research processes and conclusions and implications within the relevant research paradigm. Theories and frameworks also help to bring to focus areas of the research problem that may not have been considered.

• Varpio L, Paradis E, Uijtdehaage S, Young M. The distinctions between theory, theoretical framework, and conceptual framework. Acad Med . 2020;95(7):989-994. doi:10.1097/ACM.0000000000003075
• Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci .  2011;6:42. doi:10.1186/1748-5908-6-42
• CFIR Research Team. Consolidated Framework for Implementation Research (CFIR). Center for Clinical Management Research. 2023. Accessed February 15, 2023. https://cfirguide.org/
• Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res . 2017;17:88. doi:10.1186/s12913-017-2031-8
• Murray E, Treweek S, Pope C, et al. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med .  2010;8:63. doi:10.1186/1741-7015-8-63
• Tookey S, Renzi C, Waller J, von Wagner C, Whitaker KL. Using the candidacy framework to understand how doctor-patient interactions influence perceived eligibility to seek help for cancer alarm symptoms: a qualitative interview study. BMC Health Serv Res . 2018;18(1):937. doi:10.1186/s12913-018-3730-5
• Lyon P. Aboriginal Health in Aboriginal Hands: Community-Controlled Comprehensive Primary Health Care @ Central Australian Aboriginal Congress; 2016. Accessed February 15, 2023. https://nacchocommunique.com/wp-content/uploads/2017/09/cphc-congress-final-report.pdf
• Solar O., Irwin A. A Conceptual Framework for Action on the Social Determinants of Health:   Social Determinants of Health Discussion Paper 2 (Policy and Practice); 2010. Accessed February 22, 2023. https://www.who.int/publications/i/item/9789241500852
• Yuill C, Crinson I, Duncan E. Key Concepts in Health Studies . SAGE Publications; 2010.
• Germov J. Imagining health problems as social issues. In: Germov J, ed. Second Opinion: An Introduction to Health Sociology . Oxford University Press; 2014.
• Laszlo A, Krippner S. Systems theories: their origins, foundations, and development. In: Jordan JS, ed. Advances in Psychology . Science Direct; 1998:47-74.
• Engel GL. From biomedical to biopsychosocial: being scientific in the human domain. Psychosomatics . 1997;38(6):521-528. doi:10.1016/S0033-3182(97)71396-3
• Schmidtke KA, Drinkwater KG. A cross-sectional survey assessing the influence of theoretically informed behavioural factors on hand hygiene across seven countries during the COVID-19 pandemic. BMC Public Health . 2021;21:1432. doi:10.1186/s12889-021-11491-4
• Graham-Wisener L, Nelson A, Byrne A, et al. Understanding public attitudes to death talk and advance care planning in Northern Ireland using health behaviour change theory: a qualitative study. BMC Public Health . 2022;22:906. doi:10.1186/s12889-022-13319-1
• Walker R, Quong S, Olivier P, Wu L, Xie J, Boyle J. Empowerment for behaviour change through social connections: a qualitative exploration of women’s preferences in preconception health promotion in the state of Victoria, Australia. BMC Public Health . 2022;22:1642. doi:10.1186/s12889-022-14028-5
• Ayton DR, Barker AL, Morello RT, et al. Barriers and enablers to the implementation of the 6-PACK falls prevention program: a pre-implementation study in hospitals participating in a cluster randomised controlled trial. PLOS ONE . 2017;12(2):e0171932. doi:10.1371/journal.pone.0171932
• Pratt R, Xiong S, Kmiecik A, et al. The implementation of a smoking cessation and alcohol abstinence intervention for people experiencing homelessness. BMC Public Health . 2022;22:1260. doi:10.1186/s12889-022-13563-5
• Bossert J, Mahler C, Boltenhagen U, et al. Protocol for the process evaluation of a counselling intervention designed to educate cancer patients on complementary and integrative health care and promote interprofessional collaboration in this area (the CCC-Integrativ study). PLOS ONE . 2022;17(5):e0268091. doi:10.1371/journal.pone.0268091
• Lwin KS, Bhandari AKC, Nguyen PT, et al. Factors influencing implementation of health-promoting interventions at workplaces: protocol for a scoping review. PLOS ONE . 2022;17(10):e0275887. doi:10.1371/journal.pone.0275887
• Wilhelm AK, Schwedhelm M, Bigelow M, et al. Evaluation of a school-based participatory intervention to improve school environments using the Consolidated Framework for Implementation Research. BMC Public Health . 2021;21:1615. doi:10.1186/s12889-021-11644-5
• Timm L, Annerstedt KS, Ahlgren JÁ, et al. Application of the Theoretical Framework of Acceptability to assess a telephone-facilitated health coaching intervention for the prevention and management of type 2 diabetes. PLOS ONE . 2022;17(10):e0275576. doi:10.1371/journal.pone.0275576
• Laing L, Salema N-E, Jeffries M, et al. Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: a qualitative exploration using the Theoretical Framework of Acceptability. PLOS ONE . 2022;17(10):e0275633. doi:10.1371/journal.pone.0275633
• Renko E, Knittle K, Palsola M, Lintunen T, Hankonen N. Acceptability, reach and implementation of a training to enhance teachers’ skills in physical activity promotion. BMC Public Health . 2020;20:1568. doi:10.1186/s12889-020-09653-x
• Alexander SM, Agaba A, Campbell JI, et al. A qualitative study of the acceptability of remote electronic bednet use monitoring in Uganda. BMC Public Health . 2022;22:1010. doi:10.1186/s12889-022-13393
• May C, Rapley T, Mair FS, et al. Normalization Process Theory On-line Users’ Manual, Toolkit and NoMAD instrument. 2015. Accessed February 15, 2023. https://normalization-process-theory.northumbria.ac.uk/
• Davis S. Ready for prime time? Using Normalization Process Theory to evaluate implementation success of personal health records designed for decision making. Front Digit  Health . 2020;2:575951. doi:10.3389/fdgth.2020.575951
• Durand M-A, Lamouroux A, Redmond NM, et al. Impact of a health literacy intervention combining general practitioner training and a consumer facing intervention to improve colorectal cancer screening in underserved areas: protocol for a multicentric cluster randomized controlled trial. BMC Public Health . 2021;21:1684. doi:10.1186/s12889-021-11565
• Jones SE, Hamilton S, Bell R, Araújo-Soares V, White M. Acceptability of a cessation intervention for pregnant smokers: a qualitative study guided by Normalization Process Theory. BMC Public Health . 2020;20:1512. doi:10.1186/s12889-020-09608-2
• Ziegler E, Valaitis R, Yost J, Carter N, Risdon C. “Primary care is primary care”: use of Normalization Process Theory to explore the implementation of primary care services for transgender individuals in Ontario. PLOS ONE . 2019;14(4):e0215873. doi:10.1371/journal.pone.0215873
• Mackenzie M, Conway E, Hastings A, Munro M, O’Donnell C. Is ‘candidacy’ a useful concept for understanding journeys through public services? A critical interpretive literature synthesis. Soc Policy Adm . 2013;47(7):806-825. doi:10.1111/j.1467-9515.2012.00864.x
• Adeagbo O, Herbst C, Blandford A, et al. Exploring people’s candidacy for mobile health–supported HIV testing and care services in rural KwaZulu-Natal, South Africa: qualitative study. J Med Internet Res . 2019;21(11):e15681. doi:10.2196/15681
• Mackenzie M, Turner F, Platt S, et al. What is the ‘problem’ that outreach work seeks to address and how might it be tackled? Seeking theory in a primary health prevention programme. BMC Health Serv Res . 2011;11:350. doi:10.1186/1472-6963-11-350
• Liberati E, Richards N, Parker J, et al. Qualitative study of candidacy and access to secondary mental health services during the COVID-19 pandemic. Soc Sci Med. 2022;296:114711. doi:10.1016/j.socscimed.2022.114711
• Pearson O, Schwartzkopff K, Dawson A, et al. Aboriginal community controlled health organisations address health equity through action on the social determinants of health of Aboriginal and Torres Strait Islander peoples in Australia. BMC Public Health . 2020;20:1859. doi:10.1186/s12889-020-09943-4
• Freeman T, Baum F, Lawless A, et al. Revisiting the ability of Australian primary healthcare services to respond to health inequity. Aust J Prim  Health . 2016;22(4):332-338. doi:10.1071/PY14180
• Couzos S. Towards a National Primary Health Care Strategy: Fulfilling Aboriginal Peoples Aspirations to Close the Gap . National Aboriginal Community Controlled Health Organisation. 2009. Accessed February 15, 2023. https://researchonline.jcu.edu.au/35080/
• Napier AD, Ancarno C, Butler B, et al. Culture and health. Lancet . 2014;384(9954):1607-1639. doi:10.1016/S0140-6736(14)61603-2
• WHO. COVID-19 and the Social Determinants of Health and Health Equity: Evidence Brief . 2021. Accessed February 15, 2023. https://www.who.int/publications/i/item/9789240038387
• WHO. Social Determinants of Health . 2023. Accessed February 15, 2023. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
• McCrae JS, Robinson JAL, Spain AK, Byers K, Axelrod JL. The Mitigating Toxic Stress study design: approaches to developmental evaluation of pediatric health care innovations addressing social determinants of health and toxic stress. BMC Health Serv Res . 2021;21:71. doi:10.1186/s12913-021-06057-4
• Hosseinpoor AR, Stewart Williams J, Jann B, et al. Social determinants of sex differences in disability among older adults: a multi-country decomposition analysis using the World Health Survey. Int J  Equity   Health . 2012;11:52. doi:10.1186/1475-9276-11-52
• Kabore A, Afriyie-Gyawu E, Awua J, et al. Social ecological factors affecting substance abuse in Ghana (West Africa) using photovoice. Pan Afr Med J . 2019;34:214. doi:10.11604/pamj.2019.34.214.12851
• Bíró É, Vincze F, Mátyás G, Kósa K. Recursive path model for health literacy: the effect of social support and geographical residence. Front Public Health . 2021;9. doi:10.3389/fpubh.2021.724995
• Yuan B, Zhang T, Li J. Family support and transport cost: understanding health service among older people from the perspective of social-ecological model. Arch Public Health . 2022;80:173. doi:10.1186/s13690-022-00923-1
• Mahmoodi Z, Karimlou M, Sajjadi H, Dejman M, Vameghi M, Dolatian M. A communicative model of mothers’ lifestyles during pregnancy with low birth weight based on social determinants of health: a path analysis. Oman Med J . 2017 ;32(4):306-314. doi:10.5001/omj.2017.59
• Vella SA, Schweickle MJ, Sutcliffe J, Liddelow C, Swann C. A systems theory of mental health in recreational sport. Int J Environ Res Public Health . 2022;19(21):14244. doi:10.3390/ijerph192114244
• Henning S. The wellness of airline cabin attendants: A systems theory perspective. African Journal of Hospitality, Tourism and Leisure . 2015;4(1):1-11. Accessed February 15, 2023. http://www.ajhtl.com/archive.html
• Sutphin ST, McDonough S, Schrenkel A. The role of formal theory in social work research: formalizing family systems theory. Adv Soc Work . 2013;14(2):501-517. doi:10.18060/7942
• Colla R, Williams P, Oades LG, Camacho-Morles J. “A new hope” for positive psychology: a dynamic systems reconceptualization of hope theory. Front Psychol .  2022;13. doi:10.3389/fpsyg.2022.809053
• Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129–136. doi:10.1126/science.847460
• Wade DT, HalliganPW. The biopsychosocial model of illness: a model whose time has come. Clin Rehabi l. 2017;31(8):995–1004. doi:10.1177/0269215517709890
• Ip L, Smith A, Papachristou I, Tolani E. 3 Dimensions for Long Term Conditions – creating a sustainable bio-psycho-social approach to healthcare.  J Integr Care . 2019;19(4):5. doi:10.5334/ijic.s3005
• FrameWorks Institute. A Matter of Life and Death: Explaining the Wider Determinants of Health in the UK . FrameWorks Institute; 2022. Accessed February 15, 2023. https://www.frameworksinstitute.org/wp-content/uploads/2022/03/FWI-30-uk-health-brief-v3a.pdf
• Zemed A, Nigussie Chala K, Azeze Eriku G, Yalew Aschalew A. Health-related quality of life and associated factors among patients with stroke at tertiary level hospitals in Ethiopia. PLOS ONE . 2021;16(3):e0248481. doi:10.1371/journal.pone.0248481
• Finch E, Foster M, Cruwys T, et al. Meeting unmet needs following minor stroke: the SUN randomised controlled trial protocol. BMC Health Serv Res . 2019;19:894. doi:10.1186/s12913-019-4746-1

Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Tess Tsindos is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Theoretical Frameworks in Qualitative Research

• Vincent A. Anfara, Jr. - University of Tennessee, Knoxville, USA
• Norma T. Mertz - University of Tennessee, Knoxville, USA
• Description

The Second Edition of Theoretical Frameworks in Qualitative Research brings together some of today’s leading qualitative researchers to discuss the frameworks behind their published qualitative studies. They share how they found and chose a theoretical framework, from what discipline the framework was drawn, what the framework posits, and how it influenced their study. Both novice and experienced qualitative researchers are able to learn first-hand from various contributors as they reflect on the process and decisions involved in completing their study. The book also provides background for beginning researchers about the nature of theoretical frameworks and their importance in qualitative research; about differences in perspective about the role of theoretical frameworks; and about how to find and use a theoretical framework.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

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Committee decision because of the depth of the qualitative information.

Not the right fit for analysis course

useful for all types of health care professions

NEW TO THIS EDITION:

• Abstracts added to the beginning of each contributed chapter highlight what can be learned about the chapter’s theoretical frameworks.
• The contributing author’s published study is now displayed prominently after the abstract for easy access.
• A broader range of theoretical frameworks is presented and examined through three entirely new chapters, and a chapter that combines two chapters from the first edition, showing how to use multiple frameworks.
• New brief pieces in Chapter 12 by doctoral students show how they arrived at the frameworks used in their dissertations.
• Enhanced discussions cover the lessons to be learned from the contributing authors and further explain how to find a theoretical framework.

KEY FEATURES:

• A comprehensive examination of the role and influence of theoretical frameworks in qualitative research helps readers plan for their own qualitative research studies.
• A wide variety of distinctive, sometimes unusual, theoretical frameworks drawn from a number of disciplines are included.
• In-depth reflections on the use of a range of frameworks employed in accessible published studies help readers learn to use and understand theory.
• Real-world examples are detailed and explained by some of today's leading qualitative researchers.
• Expert and insightful guidance helps readers find a theoretical framework appropriate to their own study and also helps readers understand how to integrate the complexities of their frameworks into solid research designs.

Sample Materials & Chapters

For instructors, select a purchasing option.

The Ultimate Guide to Qualitative Research - Part 1: The Basics

• Introduction and overview
• What is qualitative research?
• What is qualitative data?
• Examples of qualitative data
• Qualitative vs. quantitative research
• Mixed methods
• Qualitative research preparation
• Theoretical perspective
• Introduction

Strategies for developing the theoretical framework

• Literature reviews
• Research question
• Conceptual framework
• Conceptual vs. theoretical framework
• Data collection
• Qualitative research methods
• Focus groups
• Observational research
• Case studies
• Ethnographical research
• Ethical considerations
• Confidentiality and privacy
• Power dynamics
• Reflexivity

Theoretical framework

The theoretical perspective provides the broader lens or orientation through which the researcher views the research topic and guides their overall understanding and approach. The theoretical framework, on the other hand, is a more specific and focused framework that connects the theoretical perspective to the data analysis strategy through pre-established theory.

A useful theoretical framework provides a structure for organizing and interpreting the data collected during the research study. Theoretical frameworks provide a specific lens through which the data is examined, allowing the researcher to identify recurring patterns, themes, and categories related to your research inquiry based on relevant theory.

Let's explore the idea of the theoretical framework in greater detail by exploring its place in qualitative research, particularly how it is generated and how it contributes to and guides your research study.

Theoretical framework vs. theoretical perspective

While these two terms may sound similar, they play very distinct roles in qualitative research . A theoretical perspective refers to the philosophical stance informing the methodology and thus provides a context for the research process. These perspectives could be rooted in various schools of thought like postmodernism, constructivism, or positivism, which fundamentally shape how researchers perceive reality and construct knowledge.

On the other hand, the theoretical framework represents the structure that can hold or support a theory of a research study. It presents a logical structure of connected concepts that help the researcher understand, explain, and predict how phenomena are interrelated. The theoretical framework can pull together various theories or ideas from different perspectives to provide a comprehensive approach to addressing the research problem.

Moreover, theoretical frameworks provide useful guidance as to which research methods are appropriate for your research project. If the theoretical framework you employ is relevant to individual perspectives and beliefs, then interviews may be more suitable for your research. On the other hand, if you are utilizing an existing theory about a certain social behavior, then ethnographic observations can help you more ably capture data from social interactions.

Later in this guide, we will also discuss conceptual frameworks , which help you visualize the essential concepts and data points in the context you are studying. For now, it is important to emphasize that these are all related but ultimately different ideas.

Example of a theoretical framework

Let's look at a simple example of a theoretical framework used to address a social science research problem. Consider a study examining the impact of social media on body image among adolescents. The theoretical perspective might be rooted in social constructivism, based on the assumption that our understanding of reality is shaped by social interactions and cultural context.

The theoretical framework, then, could draw on one or several theories to provide a comprehensive structure for examining this issue. For instance, it might combine elements of "social comparison theory" (which suggests that individuals determine their own social and personal worth based on how they stack up against others), "self-perception theory" (which posits that individuals develop their attitudes by observing their own behavior and concluding what attitudes must have caused it), and "cultivation theory" (which suggests that long-term immersion in a media environment leads to "cultivation", or adopting the attitudes and beliefs portrayed in the media).

This framework would provide the structure to understand how social media exposure influences adolescents' perceptions of their bodies, how they compare themselves to images seen on social media, and how these influences may shape their attitudes toward their own bodies.

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Other examples of theoretical frameworks

Let's briefly look at examples in other fields to put the idea of "theoretical framework" in greater context.

Political science

In a study investigating the influence of lobbying on legislative decisions, the theoretical framework could be rooted in the "pluralist theory" and "elite theory".

Pluralist theory views politics as a competition among groups, each one pressing for its preferred policies, while elite theory suggests that a small, cohesive elite group makes the most important decisions in society. The framework could combine these theories to examine the power dynamics in legislative decisions and the role of lobbying groups in influencing these outcomes.

Educational research

An educational research study aiming to understand the impact of parental involvement on children's academic success could employ a theoretical framework based on Bronfenbrenner's ecological systems theory and Epstein's theory of overlapping spheres of influence.

The ecological systems theory emphasizes the importance of multiple environmental systems on child development, while Epstein's theory focuses on the partnership between family, school, and community. The intersection of these theories allows for a comprehensive examination of parental involvement both in and outside of the school context.

Health services research

In a health services study exploring factors affecting patient adherence to medication regimes, the theoretical framework could draw from the health belief model and social cognitive theory.

The health belief model posits that people's beliefs about health problems, perceived benefits of action and barriers to action, and self-efficacy explain engagement in health-promoting behavior.

The social cognitive theory emphasizes the role of observational learning, social experience, and reciprocal determinism in behavior change. The framework combining these theories provides a holistic understanding of both personal and social influences on patient medication adherence.

Developing a theoretical framework involves a multi-step process that begins with a thorough literature review . This allows you to understand the existing theories and research related to your topic and identify gaps or unresolved puzzles that your study can address.

1. Identify key concepts: These might be the phenomena you are studying, the attributes of these phenomena, or the relationships between them. Identifying these can help you define the relevant data points to analyze.

2. Find relevant theories: Conduct a literature review to search for existing theories in academic research papers that relate to your key concepts. These theories might explain the phenomena you are studying, provide context for it, or suggest how the phenomena might be related. You can build off of one theory or multiple theories, but what is most important is that the theory is aligned with the concepts and research problem you are studying.

3. Map relationships: Outline how the theories you have found relate to one another and to your key concepts. This might involve drawing a diagram or writing a narrative that explains these relationships.

4. Refine the framework: As you conduct your research, refine your theoretical framework. This might involve adding new concepts or theories, removing concepts or theories that do not fit your data, or changing how you conceptualize the relationships between theories.

Remember, the theoretical framework is not set in stone. At the same time, it may start with existing knowledge, it is important to develop your own framework as you gather more data and gain a deeper understanding of your research topic and context.

In the end, a good theoretical framework guides your research question and methods so that you can ultimately generate new knowledge and theory that meaningfully contributes to the existing conversation around a topic.

Visualize your theories and analysis with ATLAS.ti

From literature review to research paper, ATLAS.ti makes the research process easier and more efficient. See how with a free trial.

Use of theoretical and conceptual frameworks in qualitative research

Affiliation.

• 1 University of Leeds, UK.
• PMID: 25059086
• DOI: 10.7748/nr.21.6.34.e1252

Aim: To debate the definition and use of theoretical and conceptual frameworks in qualitative research.

Background: There is a paucity of literature to help the novice researcher to understand what theoretical and conceptual frameworks are and how they should be used. This paper acknowledges the interchangeable usage of these terms and researchers' confusion about the differences between the two. It discusses how researchers have used theoretical and conceptual frameworks and the notion of conceptual models. Detail is given about how one researcher incorporated a conceptual framework throughout a research project, the purpose for doing so and how this led to a resultant conceptual model.

Review methods: Concepts from Abbott (1988) and Witz ( 1992 ) were used to provide a framework for research involving two case study sites. The framework was used to determine research questions and give direction to interviews and discussions to focus the research.

Discussion: Some research methods do not overtly use a theoretical framework or conceptual framework in their design, but this is implicit and underpins the method design, for example in grounded theory. Other qualitative methods use one or the other to frame the design of a research project or to explain the outcomes. An example is given of how a conceptual framework was used throughout a research project.

Conclusion: Theoretical and conceptual frameworks are terms that are regularly used in research but rarely explained. Textbooks should discuss what they are and how they can be used, so novice researchers understand how they can help with research design.

Implications for practice/research: Theoretical and conceptual frameworks need to be more clearly understood by researchers and correct terminology used to ensure clarity for novice researchers.

Keywords: Theoretical framework; case study; case study research.; conceptual framework; conceptual model; qualitative research; research design.

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• Research Design

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Literature Reviews, Theoretical Frameworks, and Conceptual Frameworks: An Introduction for New Biology Education Researchers

Julie a. luft.

† Department of Mathematics, Social Studies, and Science Education, Mary Frances Early College of Education, University of Georgia, Athens, GA 30602-7124

Sophia Jeong

‡ Department of Teaching & Learning, College of Education & Human Ecology, Ohio State University, Columbus, OH 43210

Robert Idsardi

§ Department of Biology, Eastern Washington University, Cheney, WA 99004

Grant Gardner

∥ Department of Biology, Middle Tennessee State University, Murfreesboro, TN 37132

Associated Data

To frame their work, biology education researchers need to consider the role of literature reviews, theoretical frameworks, and conceptual frameworks as critical elements of the research and writing process. However, these elements can be confusing for scholars new to education research. This Research Methods article is designed to provide an overview of each of these elements and delineate the purpose of each in the educational research process. We describe what biology education researchers should consider as they conduct literature reviews, identify theoretical frameworks, and construct conceptual frameworks. Clarifying these different components of educational research studies can be helpful to new biology education researchers and the biology education research community at large in situating their work in the broader scholarly literature.

INTRODUCTION

Discipline-based education research (DBER) involves the purposeful and situated study of teaching and learning in specific disciplinary areas ( Singer et al. , 2012 ). Studies in DBER are guided by research questions that reflect disciplines’ priorities and worldviews. Researchers can use quantitative data, qualitative data, or both to answer these research questions through a variety of methodological traditions. Across all methodologies, there are different methods associated with planning and conducting educational research studies that include the use of surveys, interviews, observations, artifacts, or instruments. Ensuring the coherence of these elements to the discipline’s perspective also involves situating the work in the broader scholarly literature. The tools for doing this include literature reviews, theoretical frameworks, and conceptual frameworks. However, the purpose and function of each of these elements is often confusing to new education researchers. The goal of this article is to introduce new biology education researchers to these three important elements important in DBER scholarship and the broader educational literature.

The first element we discuss is a review of research (literature reviews), which highlights the need for a specific research question, study problem, or topic of investigation. Literature reviews situate the relevance of the study within a topic and a field. The process may seem familiar to science researchers entering DBER fields, but new researchers may still struggle in conducting the review. Booth et al. (2016b) highlight some of the challenges novice education researchers face when conducting a review of literature. They point out that novice researchers struggle in deciding how to focus the review, determining the scope of articles needed in the review, and knowing how to be critical of the articles in the review. Overcoming these challenges (and others) can help novice researchers construct a sound literature review that can inform the design of the study and help ensure the work makes a contribution to the field.

The second and third highlighted elements are theoretical and conceptual frameworks. These guide biology education research (BER) studies, and may be less familiar to science researchers. These elements are important in shaping the construction of new knowledge. Theoretical frameworks offer a way to explain and interpret the studied phenomenon, while conceptual frameworks clarify assumptions about the studied phenomenon. Despite the importance of these constructs in educational research, biology educational researchers have noted the limited use of theoretical or conceptual frameworks in published work ( DeHaan, 2011 ; Dirks, 2011 ; Lo et al. , 2019 ). In reviewing articles published in CBE—Life Sciences Education ( LSE ) between 2015 and 2019, we found that fewer than 25% of the research articles had a theoretical or conceptual framework (see the Supplemental Information), and at times there was an inconsistent use of theoretical and conceptual frameworks. Clearly, these frameworks are challenging for published biology education researchers, which suggests the importance of providing some initial guidance to new biology education researchers.

Fortunately, educational researchers have increased their explicit use of these frameworks over time, and this is influencing educational research in science, technology, engineering, and mathematics (STEM) fields. For instance, a quick search for theoretical or conceptual frameworks in the abstracts of articles in Educational Research Complete (a common database for educational research) in STEM fields demonstrates a dramatic change over the last 20 years: from only 778 articles published between 2000 and 2010 to 5703 articles published between 2010 and 2020, a more than sevenfold increase. Greater recognition of the importance of these frameworks is contributing to DBER authors being more explicit about such frameworks in their studies.

Collectively, literature reviews, theoretical frameworks, and conceptual frameworks work to guide methodological decisions and the elucidation of important findings. Each offers a different perspective on the problem of study and is an essential element in all forms of educational research. As new researchers seek to learn about these elements, they will find different resources, a variety of perspectives, and many suggestions about the construction and use of these elements. The wide range of available information can overwhelm the new researcher who just wants to learn the distinction between these elements or how to craft them adequately.

Our goal in writing this paper is not to offer specific advice about how to write these sections in scholarly work. Instead, we wanted to introduce these elements to those who are new to BER and who are interested in better distinguishing one from the other. In this paper, we share the purpose of each element in BER scholarship, along with important points on its construction. We also provide references for additional resources that may be beneficial to better understanding each element. Table 1 summarizes the key distinctions among these elements.

Comparison of literature reviews, theoretical frameworks, and conceptual reviews

This article is written for the new biology education researcher who is just learning about these different elements or for scientists looking to become more involved in BER. It is a result of our own work as science education and biology education researchers, whether as graduate students and postdoctoral scholars or newly hired and established faculty members. This is the article we wish had been available as we started to learn about these elements or discussed them with new educational researchers in biology.

LITERATURE REVIEWS

Purpose of a literature review.

A literature review is foundational to any research study in education or science. In education, a well-conceptualized and well-executed review provides a summary of the research that has already been done on a specific topic and identifies questions that remain to be answered, thus illustrating the current research project’s potential contribution to the field and the reasoning behind the methodological approach selected for the study ( Maxwell, 2012 ). BER is an evolving disciplinary area that is redefining areas of conceptual emphasis as well as orientations toward teaching and learning (e.g., Labov et al. , 2010 ; American Association for the Advancement of Science, 2011 ; Nehm, 2019 ). As a result, building comprehensive, critical, purposeful, and concise literature reviews can be a challenge for new biology education researchers.

Building Literature Reviews

There are different ways to approach and construct a literature review. Booth et al. (2016a) provide an overview that includes, for example, scoping reviews, which are focused only on notable studies and use a basic method of analysis, and integrative reviews, which are the result of exhaustive literature searches across different genres. Underlying each of these different review processes are attention to the s earch process, a ppraisa l of articles, s ynthesis of the literature, and a nalysis: SALSA ( Booth et al. , 2016a ). This useful acronym can help the researcher focus on the process while building a specific type of review.

However, new educational researchers often have questions about literature reviews that are foundational to SALSA or other approaches. Common questions concern determining which literature pertains to the topic of study or the role of the literature review in the design of the study. This section addresses such questions broadly while providing general guidance for writing a narrative literature review that evaluates the most pertinent studies.

The literature review process should begin before the research is conducted. As Boote and Beile (2005 , p. 3) suggested, researchers should be “scholars before researchers.” They point out that having a good working knowledge of the proposed topic helps illuminate avenues of study. Some subject areas have a deep body of work to read and reflect upon, providing a strong foundation for developing the research question(s). For instance, the teaching and learning of evolution is an area of long-standing interest in the BER community, generating many studies (e.g., Perry et al. , 2008 ; Barnes and Brownell, 2016 ) and reviews of research (e.g., Sickel and Friedrichsen, 2013 ; Ziadie and Andrews, 2018 ). Emerging areas of BER include the affective domain, issues of transfer, and metacognition ( Singer et al. , 2012 ). Many studies in these areas are transdisciplinary and not always specific to biology education (e.g., Rodrigo-Peiris et al. , 2018 ; Kolpikova et al. , 2019 ). These newer areas may require reading outside BER; fortunately, summaries of some of these topics can be found in the Current Insights section of the LSE website.

In focusing on a specific problem within a broader research strand, a new researcher will likely need to examine research outside BER. Depending upon the area of study, the expanded reading list might involve a mix of BER, DBER, and educational research studies. Determining the scope of the reading is not always straightforward. A simple way to focus one’s reading is to create a “summary phrase” or “research nugget,” which is a very brief descriptive statement about the study. It should focus on the essence of the study, for example, “first-year nonmajor students’ understanding of evolution,” “metacognitive prompts to enhance learning during biochemistry,” or “instructors’ inquiry-based instructional practices after professional development programming.” This type of phrase should help a new researcher identify two or more areas to review that pertain to the study. Focusing on recent research in the last 5 years is a good first step. Additional studies can be identified by reading relevant works referenced in those articles. It is also important to read seminal studies that are more than 5 years old. Reading a range of studies should give the researcher the necessary command of the subject in order to suggest a research question.

Given that the research question(s) arise from the literature review, the review should also substantiate the selected methodological approach. The review and research question(s) guide the researcher in determining how to collect and analyze data. Often the methodological approach used in a study is selected to contribute knowledge that expands upon what has been published previously about the topic (see Institute of Education Sciences and National Science Foundation, 2013 ). An emerging topic of study may need an exploratory approach that allows for a description of the phenomenon and development of a potential theory. This could, but not necessarily, require a methodological approach that uses interviews, observations, surveys, or other instruments. An extensively studied topic may call for the additional understanding of specific factors or variables; this type of study would be well suited to a verification or a causal research design. These could entail a methodological approach that uses valid and reliable instruments, observations, or interviews to determine an effect in the studied event. In either of these examples, the researcher(s) may use a qualitative, quantitative, or mixed methods methodological approach.

Even with a good research question, there is still more reading to be done. The complexity and focus of the research question dictates the depth and breadth of the literature to be examined. Questions that connect multiple topics can require broad literature reviews. For instance, a study that explores the impact of a biology faculty learning community on the inquiry instruction of faculty could have the following review areas: learning communities among biology faculty, inquiry instruction among biology faculty, and inquiry instruction among biology faculty as a result of professional learning. Biology education researchers need to consider whether their literature review requires studies from different disciplines within or outside DBER. For the example given, it would be fruitful to look at research focused on learning communities with faculty in STEM fields or in general education fields that result in instructional change. It is important not to be too narrow or too broad when reading. When the conclusions of articles start to sound similar or no new insights are gained, the researcher likely has a good foundation for a literature review. This level of reading should allow the researcher to demonstrate a mastery in understanding the researched topic, explain the suitability of the proposed research approach, and point to the need for the refined research question(s).

The literature review should include the researcher’s evaluation and critique of the selected studies. A researcher may have a large collection of studies, but not all of the studies will follow standards important in the reporting of empirical work in the social sciences. The American Educational Research Association ( Duran et al. , 2006 ), for example, offers a general discussion about standards for such work: an adequate review of research informing the study, the existence of sound and appropriate data collection and analysis methods, and appropriate conclusions that do not overstep or underexplore the analyzed data. The Institute of Education Sciences and National Science Foundation (2013) also offer Common Guidelines for Education Research and Development that can be used to evaluate collected studies.

Because not all journals adhere to such standards, it is important that a researcher review each study to determine the quality of published research, per the guidelines suggested earlier. In some instances, the research may be fatally flawed. Examples of such flaws include data that do not pertain to the question, a lack of discussion about the data collection, poorly constructed instruments, or an inadequate analysis. These types of errors result in studies that are incomplete, error-laden, or inaccurate and should be excluded from the review. Most studies have limitations, and the author(s) often make them explicit. For instance, there may be an instructor effect, recognized bias in the analysis, or issues with the sample population. Limitations are usually addressed by the research team in some way to ensure a sound and acceptable research process. Occasionally, the limitations associated with the study can be significant and not addressed adequately, which leaves a consequential decision in the hands of the researcher. Providing critiques of studies in the literature review process gives the reader confidence that the researcher has carefully examined relevant work in preparation for the study and, ultimately, the manuscript.

A solid literature review clearly anchors the proposed study in the field and connects the research question(s), the methodological approach, and the discussion. Reviewing extant research leads to research questions that will contribute to what is known in the field. By summarizing what is known, the literature review points to what needs to be known, which in turn guides decisions about methodology. Finally, notable findings of the new study are discussed in reference to those described in the literature review.

Within published BER studies, literature reviews can be placed in different locations in an article. When included in the introductory section of the study, the first few paragraphs of the manuscript set the stage, with the literature review following the opening paragraphs. Cooper et al. (2019) illustrate this approach in their study of course-based undergraduate research experiences (CUREs). An introduction discussing the potential of CURES is followed by an analysis of the existing literature relevant to the design of CUREs that allows for novel student discoveries. Within this review, the authors point out contradictory findings among research on novel student discoveries. This clarifies the need for their study, which is described and highlighted through specific research aims.

A literature reviews can also make up a separate section in a paper. For example, the introduction to Todd et al. (2019) illustrates the need for their research topic by highlighting the potential of learning progressions (LPs) and suggesting that LPs may help mitigate learning loss in genetics. At the end of the introduction, the authors state their specific research questions. The review of literature following this opening section comprises two subsections. One focuses on learning loss in general and examines a variety of studies and meta-analyses from the disciplines of medical education, mathematics, and reading. The second section focuses specifically on LPs in genetics and highlights student learning in the midst of LPs. These separate reviews provide insights into the stated research question.

Suggestions and Advice

A well-conceptualized, comprehensive, and critical literature review reveals the understanding of the topic that the researcher brings to the study. Literature reviews should not be so big that there is no clear area of focus; nor should they be so narrow that no real research question arises. The task for a researcher is to craft an efficient literature review that offers a critical analysis of published work, articulates the need for the study, guides the methodological approach to the topic of study, and provides an adequate foundation for the discussion of the findings.

In our own writing of literature reviews, there are often many drafts. An early draft may seem well suited to the study because the need for and approach to the study are well described. However, as the results of the study are analyzed and findings begin to emerge, the existing literature review may be inadequate and need revision. The need for an expanded discussion about the research area can result in the inclusion of new studies that support the explanation of a potential finding. The literature review may also prove to be too broad. Refocusing on a specific area allows for more contemplation of a finding.

It should be noted that there are different types of literature reviews, and many books and articles have been written about the different ways to embark on these types of reviews. Among these different resources, the following may be helpful in considering how to refine the review process for scholarly journals:

• Booth, A., Sutton, A., & Papaioannou, D. (2016a). Systemic approaches to a successful literature review (2nd ed.). Los Angeles, CA: Sage. This book addresses different types of literature reviews and offers important suggestions pertaining to defining the scope of the literature review and assessing extant studies.
• Booth, W. C., Colomb, G. G., Williams, J. M., Bizup, J., & Fitzgerald, W. T. (2016b). The craft of research (4th ed.). Chicago: University of Chicago Press. This book can help the novice consider how to make the case for an area of study. While this book is not specifically about literature reviews, it offers suggestions about making the case for your study.
• Galvan, J. L., & Galvan, M. C. (2017). Writing literature reviews: A guide for students of the social and behavioral sciences (7th ed.). Routledge. This book offers guidance on writing different types of literature reviews. For the novice researcher, there are useful suggestions for creating coherent literature reviews.

THEORETICAL FRAMEWORKS

Purpose of theoretical frameworks.

As new education researchers may be less familiar with theoretical frameworks than with literature reviews, this discussion begins with an analogy. Envision a biologist, chemist, and physicist examining together the dramatic effect of a fog tsunami over the ocean. A biologist gazing at this phenomenon may be concerned with the effect of fog on various species. A chemist may be interested in the chemical composition of the fog as water vapor condenses around bits of salt. A physicist may be focused on the refraction of light to make fog appear to be “sitting” above the ocean. While observing the same “objective event,” the scientists are operating under different theoretical frameworks that provide a particular perspective or “lens” for the interpretation of the phenomenon. Each of these scientists brings specialized knowledge, experiences, and values to this phenomenon, and these influence the interpretation of the phenomenon. The scientists’ theoretical frameworks influence how they design and carry out their studies and interpret their data.

Within an educational study, a theoretical framework helps to explain a phenomenon through a particular lens and challenges and extends existing knowledge within the limitations of that lens. Theoretical frameworks are explicitly stated by an educational researcher in the paper’s framework, theory, or relevant literature section. The framework shapes the types of questions asked, guides the method by which data are collected and analyzed, and informs the discussion of the results of the study. It also reveals the researcher’s subjectivities, for example, values, social experience, and viewpoint ( Allen, 2017 ). It is essential that a novice researcher learn to explicitly state a theoretical framework, because all research questions are being asked from the researcher’s implicit or explicit assumptions of a phenomenon of interest ( Schwandt, 2000 ).

Selecting Theoretical Frameworks

Theoretical frameworks are one of the most contemplated elements in our work in educational research. In this section, we share three important considerations for new scholars selecting a theoretical framework.

The first step in identifying a theoretical framework involves reflecting on the phenomenon within the study and the assumptions aligned with the phenomenon. The phenomenon involves the studied event. There are many possibilities, for example, student learning, instructional approach, or group organization. A researcher holds assumptions about how the phenomenon will be effected, influenced, changed, or portrayed. It is ultimately the researcher’s assumption(s) about the phenomenon that aligns with a theoretical framework. An example can help illustrate how a researcher’s reflection on the phenomenon and acknowledgment of assumptions can result in the identification of a theoretical framework.

In our example, a biology education researcher may be interested in exploring how students’ learning of difficult biological concepts can be supported by the interactions of group members. The phenomenon of interest is the interactions among the peers, and the researcher assumes that more knowledgeable students are important in supporting the learning of the group. As a result, the researcher may draw on Vygotsky’s (1978) sociocultural theory of learning and development that is focused on the phenomenon of student learning in a social setting. This theory posits the critical nature of interactions among students and between students and teachers in the process of building knowledge. A researcher drawing upon this framework holds the assumption that learning is a dynamic social process involving questions and explanations among students in the classroom and that more knowledgeable peers play an important part in the process of building conceptual knowledge.

It is important to state at this point that there are many different theoretical frameworks. Some frameworks focus on learning and knowing, while other theoretical frameworks focus on equity, empowerment, or discourse. Some frameworks are well articulated, and others are still being refined. For a new researcher, it can be challenging to find a theoretical framework. Two of the best ways to look for theoretical frameworks is through published works that highlight different frameworks.

When a theoretical framework is selected, it should clearly connect to all parts of the study. The framework should augment the study by adding a perspective that provides greater insights into the phenomenon. It should clearly align with the studies described in the literature review. For instance, a framework focused on learning would correspond to research that reported different learning outcomes for similar studies. The methods for data collection and analysis should also correspond to the framework. For instance, a study about instructional interventions could use a theoretical framework concerned with learning and could collect data about the effect of the intervention on what is learned. When the data are analyzed, the theoretical framework should provide added meaning to the findings, and the findings should align with the theoretical framework.

A study by Jensen and Lawson (2011) provides an example of how a theoretical framework connects different parts of the study. They compared undergraduate biology students in heterogeneous and homogeneous groups over the course of a semester. Jensen and Lawson (2011) assumed that learning involved collaboration and more knowledgeable peers, which made Vygotsky’s (1978) theory a good fit for their study. They predicted that students in heterogeneous groups would experience greater improvement in their reasoning abilities and science achievements with much of the learning guided by the more knowledgeable peers.

In the enactment of the study, they collected data about the instruction in traditional and inquiry-oriented classes, while the students worked in homogeneous or heterogeneous groups. To determine the effect of working in groups, the authors also measured students’ reasoning abilities and achievement. Each data-collection and analysis decision connected to understanding the influence of collaborative work.

Their findings highlighted aspects of Vygotsky’s (1978) theory of learning. One finding, for instance, posited that inquiry instruction, as a whole, resulted in reasoning and achievement gains. This links to Vygotsky (1978) , because inquiry instruction involves interactions among group members. A more nuanced finding was that group composition had a conditional effect. Heterogeneous groups performed better with more traditional and didactic instruction, regardless of the reasoning ability of the group members. Homogeneous groups worked better during interaction-rich activities for students with low reasoning ability. The authors attributed the variation to the different types of helping behaviors of students. High-performing students provided the answers, while students with low reasoning ability had to work collectively through the material. In terms of Vygotsky (1978) , this finding provided new insights into the learning context in which productive interactions can occur for students.

Another consideration in the selection and use of a theoretical framework pertains to its orientation to the study. This can result in the theoretical framework prioritizing individuals, institutions, and/or policies ( Anfara and Mertz, 2014 ). Frameworks that connect to individuals, for instance, could contribute to understanding their actions, learning, or knowledge. Institutional frameworks, on the other hand, offer insights into how institutions, organizations, or groups can influence individuals or materials. Policy theories provide ways to understand how national or local policies can dictate an emphasis on outcomes or instructional design. These different types of frameworks highlight different aspects in an educational setting, which influences the design of the study and the collection of data. In addition, these different frameworks offer a way to make sense of the data. Aligning the data collection and analysis with the framework ensures that a study is coherent and can contribute to the field.

New understandings emerge when different theoretical frameworks are used. For instance, Ebert-May et al. (2015) prioritized the individual level within conceptual change theory (see Posner et al. , 1982 ). In this theory, an individual’s knowledge changes when it no longer fits the phenomenon. Ebert-May et al. (2015) designed a professional development program challenging biology postdoctoral scholars’ existing conceptions of teaching. The authors reported that the biology postdoctoral scholars’ teaching practices became more student-centered as they were challenged to explain their instructional decision making. According to the theory, the biology postdoctoral scholars’ dissatisfaction in their descriptions of teaching and learning initiated change in their knowledge and instruction. These results reveal how conceptual change theory can explain the learning of participants and guide the design of professional development programming.

The communities of practice (CoP) theoretical framework ( Lave, 1988 ; Wenger, 1998 ) prioritizes the institutional level , suggesting that learning occurs when individuals learn from and contribute to the communities in which they reside. Grounded in the assumption of community learning, the literature on CoP suggests that, as individuals interact regularly with the other members of their group, they learn about the rules, roles, and goals of the community ( Allee, 2000 ). A study conducted by Gehrke and Kezar (2017) used the CoP framework to understand organizational change by examining the involvement of individual faculty engaged in a cross-institutional CoP focused on changing the instructional practice of faculty at each institution. In the CoP, faculty members were involved in enhancing instructional materials within their department, which aligned with an overarching goal of instituting instruction that embraced active learning. Not surprisingly, Gehrke and Kezar (2017) revealed that faculty who perceived the community culture as important in their work cultivated institutional change. Furthermore, they found that institutional change was sustained when key leaders served as mentors and provided support for faculty, and as faculty themselves developed into leaders. This study reveals the complexity of individual roles in a COP in order to support institutional instructional change.

It is important to explicitly state the theoretical framework used in a study, but elucidating a theoretical framework can be challenging for a new educational researcher. The literature review can help to identify an applicable theoretical framework. Focal areas of the review or central terms often connect to assumptions and assertions associated with the framework that pertain to the phenomenon of interest. Another way to identify a theoretical framework is self-reflection by the researcher on personal beliefs and understandings about the nature of knowledge the researcher brings to the study ( Lysaght, 2011 ). In stating one’s beliefs and understandings related to the study (e.g., students construct their knowledge, instructional materials support learning), an orientation becomes evident that will suggest a particular theoretical framework. Theoretical frameworks are not arbitrary , but purposefully selected.

With experience, a researcher may find expanded roles for theoretical frameworks. Researchers may revise an existing framework that has limited explanatory power, or they may decide there is a need to develop a new theoretical framework. These frameworks can emerge from a current study or the need to explain a phenomenon in a new way. Researchers may also find that multiple theoretical frameworks are necessary to frame and explore a problem, as different frameworks can provide different insights into a problem.

Finally, it is important to recognize that choosing “x” theoretical framework does not necessarily mean a researcher chooses “y” methodology and so on, nor is there a clear-cut, linear process in selecting a theoretical framework for one’s study. In part, the nonlinear process of identifying a theoretical framework is what makes understanding and using theoretical frameworks challenging. For the novice scholar, contemplating and understanding theoretical frameworks is essential. Fortunately, there are articles and books that can help:

• Creswell, J. W. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). Los Angeles, CA: Sage. This book provides an overview of theoretical frameworks in general educational research.
• Ding, L. (2019). Theoretical perspectives of quantitative physics education research. Physical Review Physics Education Research , 15 (2), 020101-1–020101-13. This paper illustrates how a DBER field can use theoretical frameworks.
• Nehm, R. (2019). Biology education research: Building integrative frameworks for teaching and learning about living systems. Disciplinary and Interdisciplinary Science Education Research , 1 , ar15. https://doi.org/10.1186/s43031-019-0017-6 . This paper articulates the need for studies in BER to explicitly state theoretical frameworks and provides examples of potential studies.
• Patton, M. Q. (2015). Qualitative research & evaluation methods: Integrating theory and practice . Sage. This book also provides an overview of theoretical frameworks, but for both research and evaluation.

CONCEPTUAL FRAMEWORKS

Purpose of a conceptual framework.

A conceptual framework is a description of the way a researcher understands the factors and/or variables that are involved in the study and their relationships to one another. The purpose of a conceptual framework is to articulate the concepts under study using relevant literature ( Rocco and Plakhotnik, 2009 ) and to clarify the presumed relationships among those concepts ( Rocco and Plakhotnik, 2009 ; Anfara and Mertz, 2014 ). Conceptual frameworks are different from theoretical frameworks in both their breadth and grounding in established findings. Whereas a theoretical framework articulates the lens through which a researcher views the work, the conceptual framework is often more mechanistic and malleable.

Conceptual frameworks are broader, encompassing both established theories (i.e., theoretical frameworks) and the researchers’ own emergent ideas. Emergent ideas, for example, may be rooted in informal and/or unpublished observations from experience. These emergent ideas would not be considered a “theory” if they are not yet tested, supported by systematically collected evidence, and peer reviewed. However, they do still play an important role in the way researchers approach their studies. The conceptual framework allows authors to clearly describe their emergent ideas so that connections among ideas in the study and the significance of the study are apparent to readers.

Constructing Conceptual Frameworks

Including a conceptual framework in a research study is important, but researchers often opt to include either a conceptual or a theoretical framework. Either may be adequate, but both provide greater insight into the research approach. For instance, a research team plans to test a novel component of an existing theory. In their study, they describe the existing theoretical framework that informs their work and then present their own conceptual framework. Within this conceptual framework, specific topics portray emergent ideas that are related to the theory. Describing both frameworks allows readers to better understand the researchers’ assumptions, orientations, and understanding of concepts being investigated. For example, Connolly et al. (2018) included a conceptual framework that described how they applied a theoretical framework of social cognitive career theory (SCCT) to their study on teaching programs for doctoral students. In their conceptual framework, the authors described SCCT, explained how it applied to the investigation, and drew upon results from previous studies to justify the proposed connections between the theory and their emergent ideas.

In some cases, authors may be able to sufficiently describe their conceptualization of the phenomenon under study in an introduction alone, without a separate conceptual framework section. However, incomplete descriptions of how the researchers conceptualize the components of the study may limit the significance of the study by making the research less intelligible to readers. This is especially problematic when studying topics in which researchers use the same terms for different constructs or different terms for similar and overlapping constructs (e.g., inquiry, teacher beliefs, pedagogical content knowledge, or active learning). Authors must describe their conceptualization of a construct if the research is to be understandable and useful.

There are some key areas to consider regarding the inclusion of a conceptual framework in a study. To begin with, it is important to recognize that conceptual frameworks are constructed by the researchers conducting the study ( Rocco and Plakhotnik, 2009 ; Maxwell, 2012 ). This is different from theoretical frameworks that are often taken from established literature. Researchers should bring together ideas from the literature, but they may be influenced by their own experiences as a student and/or instructor, the shared experiences of others, or thought experiments as they construct a description, model, or representation of their understanding of the phenomenon under study. This is an exercise in intellectual organization and clarity that often considers what is learned, known, and experienced. The conceptual framework makes these constructs explicitly visible to readers, who may have different understandings of the phenomenon based on their prior knowledge and experience. There is no single method to go about this intellectual work.

Reeves et al. (2016) is an example of an article that proposed a conceptual framework about graduate teaching assistant professional development evaluation and research. The authors used existing literature to create a novel framework that filled a gap in current research and practice related to the training of graduate teaching assistants. This conceptual framework can guide the systematic collection of data by other researchers because the framework describes the relationships among various factors that influence teaching and learning. The Reeves et al. (2016) conceptual framework may be modified as additional data are collected and analyzed by other researchers. This is not uncommon, as conceptual frameworks can serve as catalysts for concerted research efforts that systematically explore a phenomenon (e.g., Reynolds et al. , 2012 ; Brownell and Kloser, 2015 ).

Sabel et al. (2017) used a conceptual framework in their exploration of how scaffolds, an external factor, interact with internal factors to support student learning. Their conceptual framework integrated principles from two theoretical frameworks, self-regulated learning and metacognition, to illustrate how the research team conceptualized students’ use of scaffolds in their learning ( Figure 1 ). Sabel et al. (2017) created this model using their interpretations of these two frameworks in the context of their teaching.

Conceptual framework from Sabel et al. (2017) .

A conceptual framework should describe the relationship among components of the investigation ( Anfara and Mertz, 2014 ). These relationships should guide the researcher’s methods of approaching the study ( Miles et al. , 2014 ) and inform both the data to be collected and how those data should be analyzed. Explicitly describing the connections among the ideas allows the researcher to justify the importance of the study and the rigor of the research design. Just as importantly, these frameworks help readers understand why certain components of a system were not explored in the study. This is a challenge in education research, which is rooted in complex environments with many variables that are difficult to control.

For example, Sabel et al. (2017) stated: “Scaffolds, such as enhanced answer keys and reflection questions, can help students and instructors bridge the external and internal factors and support learning” (p. 3). They connected the scaffolds in the study to the three dimensions of metacognition and the eventual transformation of existing ideas into new or revised ideas. Their framework provides a rationale for focusing on how students use two different scaffolds, and not on other factors that may influence a student’s success (self-efficacy, use of active learning, exam format, etc.).

In constructing conceptual frameworks, researchers should address needed areas of study and/or contradictions discovered in literature reviews. By attending to these areas, researchers can strengthen their arguments for the importance of a study. For instance, conceptual frameworks can address how the current study will fill gaps in the research, resolve contradictions in existing literature, or suggest a new area of study. While a literature review describes what is known and not known about the phenomenon, the conceptual framework leverages these gaps in describing the current study ( Maxwell, 2012 ). In the example of Sabel et al. (2017) , the authors indicated there was a gap in the literature regarding how scaffolds engage students in metacognition to promote learning in large classes. Their study helps fill that gap by describing how scaffolds can support students in the three dimensions of metacognition: intelligibility, plausibility, and wide applicability. In another example, Lane (2016) integrated research from science identity, the ethic of care, the sense of belonging, and an expertise model of student success to form a conceptual framework that addressed the critiques of other frameworks. In a more recent example, Sbeglia et al. (2021) illustrated how a conceptual framework influences the methodological choices and inferences in studies by educational researchers.

Sometimes researchers draw upon the conceptual frameworks of other researchers. When a researcher’s conceptual framework closely aligns with an existing framework, the discussion may be brief. For example, Ghee et al. (2016) referred to portions of SCCT as their conceptual framework to explain the significance of their work on students’ self-efficacy and career interests. Because the authors’ conceptualization of this phenomenon aligned with a previously described framework, they briefly mentioned the conceptual framework and provided additional citations that provided more detail for the readers.

Within both the BER and the broader DBER communities, conceptual frameworks have been used to describe different constructs. For example, some researchers have used the term “conceptual framework” to describe students’ conceptual understandings of a biological phenomenon. This is distinct from a researcher’s conceptual framework of the educational phenomenon under investigation, which may also need to be explicitly described in the article. Other studies have presented a research logic model or flowchart of the research design as a conceptual framework. These constructions can be quite valuable in helping readers understand the data-collection and analysis process. However, a model depicting the study design does not serve the same role as a conceptual framework. Researchers need to avoid conflating these constructs by differentiating the researchers’ conceptual framework that guides the study from the research design, when applicable.

Explicitly describing conceptual frameworks is essential in depicting the focus of the study. We have found that being explicit in a conceptual framework means using accepted terminology, referencing prior work, and clearly noting connections between terms. This description can also highlight gaps in the literature or suggest potential contributions to the field of study. A well-elucidated conceptual framework can suggest additional studies that may be warranted. This can also spur other researchers to consider how they would approach the examination of a phenomenon and could result in a revised conceptual framework.

It can be challenging to create conceptual frameworks, but they are important. Below are two resources that could be helpful in constructing and presenting conceptual frameworks in educational research:

• Maxwell, J. A. (2012). Qualitative research design: An interactive approach (3rd ed.). Los Angeles, CA: Sage. Chapter 3 in this book describes how to construct conceptual frameworks.
• Ravitch, S. M., & Riggan, M. (2016). Reason & rigor: How conceptual frameworks guide research . Los Angeles, CA: Sage. This book explains how conceptual frameworks guide the research questions, data collection, data analyses, and interpretation of results.

CONCLUDING THOUGHTS

Literature reviews, theoretical frameworks, and conceptual frameworks are all important in DBER and BER. Robust literature reviews reinforce the importance of a study. Theoretical frameworks connect the study to the base of knowledge in educational theory and specify the researcher’s assumptions. Conceptual frameworks allow researchers to explicitly describe their conceptualization of the relationships among the components of the phenomenon under study. Table 1 provides a general overview of these components in order to assist biology education researchers in thinking about these elements.

It is important to emphasize that these different elements are intertwined. When these elements are aligned and complement one another, the study is coherent, and the study findings contribute to knowledge in the field. When literature reviews, theoretical frameworks, and conceptual frameworks are disconnected from one another, the study suffers. The point of the study is lost, suggested findings are unsupported, or important conclusions are invisible to the researcher. In addition, this misalignment may be costly in terms of time and money.

Conducting a literature review, selecting a theoretical framework, and building a conceptual framework are some of the most difficult elements of a research study. It takes time to understand the relevant research, identify a theoretical framework that provides important insights into the study, and formulate a conceptual framework that organizes the finding. In the research process, there is often a constant back and forth among these elements as the study evolves. With an ongoing refinement of the review of literature, clarification of the theoretical framework, and articulation of a conceptual framework, a sound study can emerge that makes a contribution to the field. This is the goal of BER and education research.

Supplementary Material

• Allee, V. (2000). Knowledge networks and communities of learning . OD Practitioner , 32 ( 4 ), 4–13. [ Google Scholar ]
• Allen, M. (2017). The Sage encyclopedia of communication research methods (Vols. 1–4 ). Los Angeles, CA: Sage. 10.4135/9781483381411 [ CrossRef ] [ Google Scholar ]
• American Association for the Advancement of Science. (2011). Vision and change in undergraduate biology education: A call to action . Washington, DC. [ Google Scholar ]
• Anfara, V. A., Mertz, N. T. (2014). Setting the stage . In Anfara, V. A., Mertz, N. T. (eds.), Theoretical frameworks in qualitative research (pp. 1–22). Sage. [ Google Scholar ]
• Barnes, M. E., Brownell, S. E. (2016). Practices and perspectives of college instructors on addressing religious beliefs when teaching evolution . CBE—Life Sciences Education , 15 ( 2 ), ar18. https://doi.org/10.1187/cbe.15-11-0243 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Boote, D. N., Beile, P. (2005). Scholars before researchers: On the centrality of the dissertation literature review in research preparation . Educational Researcher , 34 ( 6 ), 3–15. 10.3102/0013189x034006003 [ CrossRef ] [ Google Scholar ]
• Booth, A., Sutton, A., Papaioannou, D. (2016a). Systemic approaches to a successful literature review (2nd ed.). Los Angeles, CA: Sage. [ Google Scholar ]
• Booth, W. C., Colomb, G. G., Williams, J. M., Bizup, J., Fitzgerald, W. T. (2016b). The craft of research (4th ed.). Chicago, IL: University of Chicago Press. [ Google Scholar ]
• Brownell, S. E., Kloser, M. J. (2015). Toward a conceptual framework for measuring the effectiveness of course-based undergraduate research experiences in undergraduate biology . Studies in Higher Education , 40 ( 3 ), 525–544. https://doi.org/10.1080/03075079.2015.1004234 [ Google Scholar ]
• Connolly, M. R., Lee, Y. G., Savoy, J. N. (2018). The effects of doctoral teaching development on early-career STEM scholars’ college teaching self-efficacy . CBE—Life Sciences Education , 17 ( 1 ), ar14. https://doi.org/10.1187/cbe.17-02-0039 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Cooper, K. M., Blattman, J. N., Hendrix, T., Brownell, S. E. (2019). The impact of broadly relevant novel discoveries on student project ownership in a traditional lab course turned CURE . CBE—Life Sciences Education , 18 ( 4 ), ar57. https://doi.org/10.1187/cbe.19-06-0113 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Creswell, J. W. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). Los Angeles, CA: Sage. [ Google Scholar ]
• DeHaan, R. L. (2011). Education research in the biological sciences: A nine decade review (Paper commissioned by the NAS/NRC Committee on the Status, Contributions, and Future Directions of Discipline Based Education Research) . Washington, DC: National Academies Press. Retrieved May 20, 2022, from www7.nationalacademies.org/bose/DBER_Mee ting2_commissioned_papers_page.html [ Google Scholar ]
• Ding, L. (2019). Theoretical perspectives of quantitative physics education research . Physical Review Physics Education Research , 15 ( 2 ), 020101. [ Google Scholar ]
• Dirks, C. (2011). The current status and future direction of biology education research . Paper presented at: Second Committee Meeting on the Status, Contributions, and Future Directions of Discipline-Based Education Research, 18–19 October (Washington, DC). Retrieved May 20, 2022, from http://sites.nationalacademies.org/DBASSE/BOSE/DBASSE_071087 [ Google Scholar ]
• Duran, R. P., Eisenhart, M. A., Erickson, F. D., Grant, C. A., Green, J. L., Hedges, L. V., Schneider, B. L. (2006). Standards for reporting on empirical social science research in AERA publications: American Educational Research Association . Educational Researcher , 35 ( 6 ), 33–40. [ Google Scholar ]
• Ebert-May, D., Derting, T. L., Henkel, T. P., Middlemis Maher, J., Momsen, J. L., Arnold, B., Passmore, H. A. (2015). Breaking the cycle: Future faculty begin teaching with learner-centered strategies after professional development . CBE—Life Sciences Education , 14 ( 2 ), ar22. https://doi.org/10.1187/cbe.14-12-0222 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Galvan, J. L., Galvan, M. C. (2017). Writing literature reviews: A guide for students of the social and behavioral sciences (7th ed.). New York, NY: Routledge. https://doi.org/10.4324/9781315229386 [ Google Scholar ]
• Gehrke, S., Kezar, A. (2017). The roles of STEM faculty communities of practice in institutional and departmental reform in higher education . American Educational Research Journal , 54 ( 5 ), 803–833. https://doi.org/10.3102/0002831217706736 [ Google Scholar ]
• Ghee, M., Keels, M., Collins, D., Neal-Spence, C., Baker, E. (2016). Fine-tuning summer research programs to promote underrepresented students’ persistence in the STEM pathway . CBE—Life Sciences Education , 15 ( 3 ), ar28. https://doi.org/10.1187/cbe.16-01-0046 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Institute of Education Sciences & National Science Foundation. (2013). Common guidelines for education research and development . Retrieved May 20, 2022, from www.nsf.gov/pubs/2013/nsf13126/nsf13126.pdf
• Jensen, J. L., Lawson, A. (2011). Effects of collaborative group composition and inquiry instruction on reasoning gains and achievement in undergraduate biology . CBE—Life Sciences Education , 10 ( 1 ), 64–73. https://doi.org/10.1187/cbe.19-05-0098 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Kolpikova, E. P., Chen, D. C., Doherty, J. H. (2019). Does the format of preclass reading quizzes matter? An evaluation of traditional and gamified, adaptive preclass reading quizzes . CBE—Life Sciences Education , 18 ( 4 ), ar52. https://doi.org/10.1187/cbe.19-05-0098 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Labov, J. B., Reid, A. H., Yamamoto, K. R. (2010). Integrated biology and undergraduate science education: A new biology education for the twenty-first century? CBE—Life Sciences Education , 9 ( 1 ), 10–16. https://doi.org/10.1187/cbe.09-12-0092 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Lane, T. B. (2016). Beyond academic and social integration: Understanding the impact of a STEM enrichment program on the retention and degree attainment of underrepresented students . CBE—Life Sciences Education , 15 ( 3 ), ar39. https://doi.org/10.1187/cbe.16-01-0070 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Lave, J. (1988). Cognition in practice: Mind, mathematics and culture in everyday life . New York, NY: Cambridge University Press. [ Google Scholar ]
• Lo, S. M., Gardner, G. E., Reid, J., Napoleon-Fanis, V., Carroll, P., Smith, E., Sato, B. K. (2019). Prevailing questions and methodologies in biology education research: A longitudinal analysis of research in CBE — Life Sciences Education and at the Society for the Advancement of Biology Education Research . CBE—Life Sciences Education , 18 ( 1 ), ar9. https://doi.org/10.1187/cbe.18-08-0164 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Lysaght, Z. (2011). Epistemological and paradigmatic ecumenism in “Pasteur’s quadrant:” Tales from doctoral research . In Official Conference Proceedings of the Third Asian Conference on Education in Osaka, Japan . Retrieved May 20, 2022, from http://iafor.org/ace2011_offprint/ACE2011_offprint_0254.pdf
• Maxwell, J. A. (2012). Qualitative research design: An interactive approach (3rd ed.). Los Angeles, CA: Sage. [ Google Scholar ]
• Miles, M. B., Huberman, A. M., Saldaña, J. (2014). Qualitative data analysis (3rd ed.). Los Angeles, CA: Sage. [ Google Scholar ]
• Nehm, R. (2019). Biology education research: Building integrative frameworks for teaching and learning about living systems . Disciplinary and Interdisciplinary Science Education Research , 1 , ar15. https://doi.org/10.1186/s43031-019-0017-6 [ Google Scholar ]
• Patton, M. Q. (2015). Qualitative research & evaluation methods: Integrating theory and practice . Los Angeles, CA: Sage. [ Google Scholar ]
• Perry, J., Meir, E., Herron, J. C., Maruca, S., Stal, D. (2008). Evaluating two approaches to helping college students understand evolutionary trees through diagramming tasks . CBE—Life Sciences Education , 7 ( 2 ), 193–201. https://doi.org/10.1187/cbe.07-01-0007 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Posner, G. J., Strike, K. A., Hewson, P. W., Gertzog, W. A. (1982). Accommodation of a scientific conception: Toward a theory of conceptual change . Science Education , 66 ( 2 ), 211–227. [ Google Scholar ]
• Ravitch, S. M., Riggan, M. (2016). Reason & rigor: How conceptual frameworks guide research . Los Angeles, CA: Sage. [ Google Scholar ]
• Reeves, T. D., Marbach-Ad, G., Miller, K. R., Ridgway, J., Gardner, G. E., Schussler, E. E., Wischusen, E. W. (2016). A conceptual framework for graduate teaching assistant professional development evaluation and research . CBE—Life Sciences Education , 15 ( 2 ), es2. https://doi.org/10.1187/cbe.15-10-0225 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Reynolds, J. A., Thaiss, C., Katkin, W., Thompson, R. J. Jr. (2012). Writing-to-learn in undergraduate science education: A community-based, conceptually driven approach . CBE—Life Sciences Education , 11 ( 1 ), 17–25. https://doi.org/10.1187/cbe.11-08-0064 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Rocco, T. S., Plakhotnik, M. S. (2009). Literature reviews, conceptual frameworks, and theoretical frameworks: Terms, functions, and distinctions . Human Resource Development Review , 8 ( 1 ), 120–130. https://doi.org/10.1177/1534484309332617 [ Google Scholar ]
• Rodrigo-Peiris, T., Xiang, L., Cassone, V. M. (2018). A low-intensity, hybrid design between a “traditional” and a “course-based” research experience yields positive outcomes for science undergraduate freshmen and shows potential for large-scale application . CBE—Life Sciences Education , 17 ( 4 ), ar53. https://doi.org/10.1187/cbe.17-11-0248 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Sabel, J. L., Dauer, J. T., Forbes, C. T. (2017). Introductory biology students’ use of enhanced answer keys and reflection questions to engage in metacognition and enhance understanding . CBE—Life Sciences Education , 16 ( 3 ), ar40. https://doi.org/10.1187/cbe.16-10-0298 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Sbeglia, G. C., Goodridge, J. A., Gordon, L. H., Nehm, R. H. (2021). Are faculty changing? How reform frameworks, sampling intensities, and instrument measures impact inferences about student-centered teaching practices . CBE—Life Sciences Education , 20 ( 3 ), ar39. https://doi.org/10.1187/cbe.20-11-0259 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Schwandt, T. A. (2000). Three epistemological stances for qualitative inquiry: Interpretivism, hermeneutics, and social constructionism . In Denzin, N. K., Lincoln, Y. S. (Eds.), Handbook of qualitative research (2nd ed., pp. 189–213). Los Angeles, CA: Sage. [ Google Scholar ]
• Sickel, A. J., Friedrichsen, P. (2013). Examining the evolution education literature with a focus on teachers: Major findings, goals for teacher preparation, and directions for future research . Evolution: Education and Outreach , 6 ( 1 ), 23. https://doi.org/10.1186/1936-6434-6-23 [ Google Scholar ]
• Singer, S. R., Nielsen, N. R., Schweingruber, H. A. (2012). Discipline-based education research: Understanding and improving learning in undergraduate science and engineering . Washington, DC: National Academies Press. [ Google Scholar ]
• Todd, A., Romine, W. L., Correa-Menendez, J. (2019). Modeling the transition from a phenotypic to genotypic conceptualization of genetics in a university-level introductory biology context . Research in Science Education , 49 ( 2 ), 569–589. https://doi.org/10.1007/s11165-017-9626-2 [ Google Scholar ]
• Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes . Cambridge, MA: Harvard University Press. [ Google Scholar ]
• Wenger, E. (1998). Communities of practice: Learning as a social system . Systems Thinker , 9 ( 5 ), 2–3. [ Google Scholar ]
• Ziadie, M. A., Andrews, T. C. (2018). Moving evolution education forward: A systematic analysis of literature to identify gaps in collective knowledge for teaching . CBE—Life Sciences Education , 17 ( 1 ), ar11. https://doi.org/10.1187/cbe.17-08-0190 [ PMC free article ] [ PubMed ] [ Google Scholar ]

• Open access
• Published: 06 May 2024

Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers

• Benjamin Schüz 1 ,
• Oliver Scholle 2 ,
• Ulrike Haug 2 , 3 ,
• Roland Tillmann 4 &
• Christopher Jones 1 , 5  

BMC Health Services Research volume  24 , Article number:  589 ( 2024 ) Cite this article

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Previous studies have identified substantial regional variations in outpatient antibiotic prescribing in Germany, both in the paediatric and adult population. This indicates inappropriate antibiotic prescribing in some regions, which should be avoided to reduce antimicrobial resistance and potential side effects. The reasons for regional variations in outpatient antibiotic prescribing are not yet completely understood; socioeconomic and health care density differences between regions do not fully explain such differences. Here, we apply a behavioural perspective by adapting the Theoretical Domains Framework (TDF) to examine regional factors deemed relevant for outpatient antibiotic prescriptions by paediatricians and general practitioners.

Qualitative study with guideline-based telephone interviews of 40 prescribers (paediatricians and general practitioners) in outpatient settings from regions with high and low rates of antibiotic prescriptions, stratified by urbanity. TDF domains formed the basis of an interview guide to assess region-level resources and barriers to rational antibiotic prescription behaviour. Interviews lasted 30–61 min (M = 45 min). Thematic analysis was used to identify thematic clusters, and relationships between themes were explored through proximity estimation.

Both paediatricians and general practitioners in low-prescribing regions reported supporting contextual factors (in particular good collegial networks, good collaboration with laboratories) and social factors (collegial support and low patient demand for antibiotics) as important resources. In high-prescribing regions, poor coordination between in-patient and ambulatory health services, lack of region-level information on antimicrobial resistance, few professional development opportunities, and regional variations in patient expectations were identified as barriers to rational prescribing behaviour.

Conclusions

Interventions targeting professional development, better collaboration structures with laboratories and clearer and user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates.

Peer Review reports

Antimicrobial resistance is a major threat to global health systems [ 1 ]. Despite improvements in international surveillance programs [ 2 ], for example in the WHO European region in 2019 alone, around 541,000 deaths were associated with and 133,000 deaths were directly attributable to antimicrobial resistance [ 3 ]. One of the key drivers of antimicrobial resistance in humans is previous exposure to antibiotics [ 4 ]. To reduce the development of antimicrobial resistance, improving rational antibiotic prescription practices (i.e. avoiding unnecessary prescriptions) is crucial [ 5 , 6 ]. Most antibiotic prescriptions in outpatient settings in Europe are for respiratory and urinary tract infections [ 7 , 8 ]. In Germany, the setting of this study, most outpatient prescriptions for antibiotics are issued by general practitioners and paediatricians [ 8 , 9 ].

Germany consistently ranks among the European countries with the lowest community consumption of antibiotics, for example, in the 2021 surveillance report of the European Centre for Disease Prevention and Control [ 10 ], Germany has the 3rd lowest community consumption of antibiotics for systemic use. Still, there is considerable regional variation in outpatient prescription rates across regions in Germany [ 11 ]. International research suggests that such regional differences in outpatient prescriptions cannot be fully explained by regional differences in infectious disease prevalence [ 12 ]. Instead, socioeconomic, demographic and cultural differences have been highlighted as additional key determinants [ 13 ].

A recent small-area analysis based on health insurance claims data [ 11 ], breaking down differences between the 401 administrative districts in Germany, found up to 4-fold differences in outpatient prescription rates for children (between 188 and 710 age- and sex-standardized outpatient prescriptions per 1000 persons/year), and more than 2-fold differences in adults (between 300 and 693 prescriptions per 1000 persons/year). These substantial regional variations in prescription rates continue to raise concern about the appropriateness of antibiotic prescribing practices in Germany [ 8 ].

At the same time, reasons for the observed regional differences in outpatient antibiotic prescription rates are not fully understood. On the one hand, urban-rural differences in prescription patterns might be due to differences in health care access and socioeconomic differences in populations such as age or deprivation status [ 14 ]. Proximity to animal breeding or fattening farms has also been associated with variations in antibiotic prescriptions [ 15 ]. Further regional differences exist in the quality and accessibility of out-of-hours emergency primary care settings, which have both been associated with an increase in antibiotic prescriptions [ 16 ].

On the other hand, non-clinical factors such as demographic and socioeconomic differences [ 13 ], or differences in patient demand and prescription practices have been suggested to underlie regional variations [ 17 ], and the influence of patient demand on inappropriate antibiotic prescriptions is well documented [ 18 , 19 ]. Supporting small-area differences, calls have been made to take into account small-area regional factors in devising targeted interventions to support rational prescription practices [ 20 ].

Together, this suggests that a better understanding of the reasons underlying regional variations in outpatient antibiotic prescriptions is vital, especially for the development and implementation of better interventions to avoid inappropriate antibiotic prescriptions. The present study is based on a mixed methods research project commissioned by the German Federal Ministry of Health (SARA; “Studie zur Analyse der Regionalen Unterschiede bei der Antibiotika-Verordnung” [Study to analyse regional variations in antibiotic prescriptions]). Previous publications from this research project include the abovementioned small-area analysis of health insurance claims data [ 11 ] and a conference presentation containing some of the present data [ 21 ]. The current study focuses on the qualitative part of the project and reports results from interviews with prescribers in outpatient settings.

To this end, it builds on the patterns of regional differences identified in the previous quantitative study [ 11 ] to better understand the drivers of these regional differences in prescription behaviour based on perceptions of prescribers (general practitioners and paediatricians) in districts differing by outpatient antibiotic prescription rates.

In order to do so, an established framework of determinants of health care professional behaviours, the Theoretical Domains Framework (TDF; [ 22 , 23 ]) was used to guide qualitative interviews with prescribers.

The TDF is a psychological model developed for healthcare and behaviour change research and is based on comprehensive reviews of behavioural theories [ 22 , 24 ]. It comprises 14 key individual, social and contextual domains influencing human behaviour: knowledge, skills, social/professional role/identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, goals, memory/attention/decision processes, environmental context/resources, social influences, emotion, and behavioural regulation. Both main effects of and interactions between domains are possible.

The TDF has been instrumental in examining individual determinants of antibiotic prescribing behaviour [ 25 , 26 , 27 , 28 ], and most studies show the domain of environmental context and resources to be influential for antibiotic prescriptions. However, which contextual aspects are particularly relevant is poorly understood to date.

The degree to which contextual resources and barriers as well as their interactions are specific to small-area districts and regions is vital to understand the observed variations in prescription rates and improve future intervention efforts. This study will therefore apply the TDF to understand differences in contextual determinants of antibiotic prescriptions and map these onto established small-area differences in paediatricians and general practitioners in Germany.

Participants and procedure

To identify region-level determinants of differences in outpatient antibiotic prescribing, semi-structured interviews were conducted with general practitioners and paediatricians working in outpatient settings. The protocol for this study was approved by the University of Bremen Ethics committee (AZ 2021-03).

Data collection materials

An interview guide (supplementary file 1 ) based on the Theoretical Domains Framework (TDF) [ 22 , 23 ] and previous studies using the TDF in antibiotic prescription contexts [ 25 , 28 ] was designed with input from a paediatrician (RT) and pharmacoepidemiologists (UH, OS) and was pilot-tested with GP representatives known to the researchers. The interview guide started with informing participants about the status of their district as high-or low-prescribing and subsequently asked an open question on prescribers’ ideas on reasons for this. Following this, we asked prescribers for their perceptions on regional levels of TDF domains relevant for prescribing antibiotics [ 25 , 28 ]; (i) knowledge, (ii) social support, (iii) environmental context and resources (and perceived differences to other districts), (iv) social and professional role, (v) social influences (patients), (vi) goals, (vii) beliefs about capabilities (patient expectation management), (viii) beliefs about consequences, (ix) optimism, (x) intentions, (xi) memory and attention processes.

Recruitment

We employed purposive sampling and stratified potential participants based on our previous quantitative analysis of regional differences in medical claims data of outpatient antimicrobial prescriptions in Germany [ 11 ]. Here, differences in prescriptions were compared between administrative districts (“Landkreise” or “kreisfreie Städte”; Nomenclature of Territorial Units for Statistics NUTS level-3 subdivision [ 29 ]).

In order to compare and contrast health care providers’ perspectives on regional differences, we selected, separately for paediatricians and GPs, 5 districts each that were within the 5% highest antibiotic prescription rates per 1,000 insured persons, and 5 districts that were within the 5% lowest antibiotic prescription rates. Within each district group, we further selected rural and urban districts (classification based on official regional statistics in Germany; [ 30 ]) to account for potential differences in settlement structure.

Contact information for paediatrician and GP practices in the respective districts were obtained through the regional representations of the respective medical councils, and were contacted through email and phone calls. Snowball recruitment was used during which participants recommended further colleagues within the respective districts, and a total of 1,444 contact attempts were made. Participants received €75 (approximately US$80) for their participation.

Prescribers who had expressed interest in the study were emailed a participant information sheet and were asked to suggest a date and time for a phone interview. Semi-structured telephone interviews were subsequently conducted by experienced female and male qualitative researchers (CJ, BS, PK), audio recorded and were transcribed verbatim. Interviews lasted a mean of 45 min (range 30–61 min) and started with an introduction, brief overview of the study goals, and verbal informed consent was obtained prior to interview commencement. The interviewed prescribers had no personal or professional connection to the researchers before the interviews.

Data analysis

Starting with the TDF domains in the interview guide, data analysis utilized an deductive approach and was based on thematic analysis [ 31 ]. Two researchers (CJ, BS) independently coded the material using MaxQDA data management software. Initial codes were reviewed between the two researchers, and saturation was achieved with both the paediatrician and GP interviews. All codes were mapped onto at least one of the TDF domains. Relationships between codes were examined looking at code overlaps in coded segments and analysing the relative proximity of coded segments in the transcribed text. The more frequently two codes appear in the same segment or in relative proximity, the more substantial overlaps between the codes are assumed. The relative positions of codes in this two-dimensional space were operationalized using multidimensional scaling implemented in MaxQDA. Here, a solution is estimated which replicates the distance between elements in the two-dimensional space between codes as well as possible relationships. Assigning of a code to a cluster of codes is estimated using the Unweighted Average Linkage method [ 32 ]. Disagreements were resolved through discussion between the researchers.

Results of the thematic analyses are presented separately for GPs and paediatricians.

Participants

A total of 40 interviews (17 paediatricians; 10 from high-prescription and 7 from low-prescription districts, 23 GPs; 10 from high-prescription and 13 from low-prescription districts) were conducted. Participants had between 1 and 35 years of experience in their current positions (mean 13.4 years, SD 9.9 years). Interviews lasted an average of 44.8 min (SD 7.1 min, range 30–61 min).

Paediatricians

TDF domains on region levels mentioned as influencing paediatricians’ prescribing behaviour (Fig.  1 ) included context and resources (86 mentions), social influences (56 mentions), knowledge (36 mentions), skills (22 mentions), social/professional role (15 mentions), beliefs about consequences (15 mentions), beliefs about capabilities (9 mentions), goals (9 mentions), behavioural regulation (6 mentions), optimism (3 mentions) and emotions (2 mentions).

TDF domains mentioned as barriers (red) or resources (blue) by paediatricians

Context and resources

Regional context and resources can affect prescribing behaviour through multiple, direct and indirect pathways, according to the participating paediatricians. The distinction between contextual (i.e., factors specific to the region) and composition effects (i.e., factors resulting from the composition of the population within a region; [ 33 ]) is particularly relevant.

Paediatricians mainly mentioned contextual factors, e.g., air pollution as a risk factor:

This area here is a former working-class area, air quality is poor, and this means we have more respiratory illnesses which are the most frequent reasons for antimicrobial prescriptions.

(A, paediatrician, urban area, high prescription rate)

Similar direct contextual effects are evident in the density of paediatricians:

…This means service provision for children in an emergency is limited, and they are rather seen by GPs. And the GPs are fantastic, […], but they don’t have our special training and might be a bit more anxious if they see a child with a high fever….

(B, paediatrician, rural area, high prescription rate)

This low density then results in overload of the paediatricians, which in turn can increase antimicrobial prescriptions:

I mean on a Monday in February I have seen about 200 children, or thereabouts. And then I can’t start discussing for ages, this just doesn’t work.

(C, paediatrician, rural area, high prescription rates)

Suboptimal transition from in-patient to out-patient care were also seen to increase antimicrobial prescriptions in districts with higher prescription rates:

…in the hospitals, they prescribe broad-spectrum antibiotics. And I have to say, after we have sat down together a year ago and have talked about outpatient antibiotic therapies, we had agreed on not prescribing some particular antibiotics. And now I see that these exact antibiotics are still being used in the hospital.

(D, paediatrician, rural area, high prescription rates)

Contextual effects however also can constitute resources for lower prescription rates, for example in high-quality laboratories and quick turnaround times:

This means we can get samples to them three or four times a day and are not dependent on pickups once a day like in the practices out there. This really is a resource I think .

(E, paediatrician, rural area, low prescription rates)

Social influences

Social influences have been mentioned frequently, both as social influences through patients and through other health care providers. In particular where patient characteristics are being discussed, such influences could also be classified as compositional context resources (see above). However, as most of the quotes illustrate, these compositional factors also contain social influences.

Social influences as factors affecting high prescription rates are mainly located on patient level, illustrated in the following quote referring to patients with Middle-Eastern migration history:

This is a totally different culture, also affecting ideas about illnesses. Their ideas are totally different, and antibiotics are seen as miracle drugs – they are over the moon if they can get an antibiotic.

(F, paediatrician, urban area, high prescription rates)

However, the demand by patients is also being attributed to context effects such as dominating agricultural influences:

I think that there are lots of expectations for antibiotics by patients. For example, I do have a mother who generally insists on getting an antibiotic for her child, and I wouldn’t prescribe it. And I tell you how she says it: ‘I also give this to my pigs, so it can’t be bad for my kids’. So I think that antibiotic practices in the farms around here, I think that this means they (antibiotics) are applied liberally and happily, and the parents have experience and want them for their kids as well.

At the same time, social influences are seen as malleable influences, in particular in combination with skills and knowledge which can then contribute to improvements in prescription practice:

It has become much better, yes. They (patients) now understand it, they have gotten used to it. And now we have, when the doctor says, you don’t need an antimicrobial, then more than half of them don’t go and see another doctor immediately and say ‘I need an antibiotic’.

(G, paediatrician, urban area, low prescription rates)

Knowledge included both information on current recommendations for antimicrobial prescribing, information on local resistance prevalence, information on local and personal prescription rates, and training content relevant to prescribing antimicrobials.

Participants from low-prescription districts mentioned knowledge on current recommendations as a resource and linked this knowledge to lower prescription rates within their districts:

We feel quite well informed. And everyone builds on that through individual research, further training and talking to colleagues. And I think, else we wouldn’t see these numbers.

(H, paediatrician, rural area, low prescription rates)

In contrast, paediatricians from high-prescription areas mentioned increased effort in obtaining relevant information:

[…] There is no information in the district, you always have to look after this yourself.

(I, paediatrician, rural area, high prescription rates).

In districts that had employed a paediatrician-initiated education programme (AnTiB; [ 34 ]), this programme was mentioned as an explicit resource:

We used to have this little informal guideline here in (city), which is also lying around in out-of-hours paediatric services and which every paediatrician here is likely to have in their practice. It is very useful and if you are doing emergency shifts, you pull it out of the drawer, look at the dosage and then prescribe.

(J, paediatrician, urban area, low prescription rate).

In contrast, the lack of specific knowledge in paediatric emergency services is seen as a barrier to effective prescribing:

We live in one of the areas with the most children in Germany, and, you can’t make this stuff up, we don’t have a paediatric out-of-hours service. This means out-of-hours is staffed by colleagues, e.g., urologists who have no clue, who start googling first – and then quickly prescribe an antibiotic.

Skills as mentioned by the paediatricians include both discipline-specific and generic skills such as language skills or interpersonal skills.

Lack of specific treatment skills are mentioned as barriers to lower prescription rates by paediatricians in high-prescribing districts:

Perhaps the experience that as a urologist, you might not have that much experience with these really high fever temperatures in toddlers under two years.

(K, paediatrician, rural area, high prescription rate).

Similarly, a lack of language skills both on the side of the prescribers and patients is being seen as a barrier, both to non-prescribing and to instructing parents to monitor their children’s health:

… there is such a large language barrier which prevents you from explaining what the parents have to look out for, what are the signs of deteriorations, when do they need to come back, well, that this is a problem overall.

(L, paediatrician, urban area, high prescription rate)

Social and professional role

Social and professional role are mainly seen as a resource for low prescription rates. The main effects are seen to be indirect, via social norms and better professional networks. In some areas, this professional role is a relevant part of paediatricians’ identity which is used to be a role model to other paediatricians.

I think there are these lighthouse or role model practices here, the bigger ones. And they do this on purpose, to set standards and blaze a trail, and the younger colleagues or others then orient themselves on them.

(M, paediatrician, urban area, low prescription rates)

In addition, the social influence through networks is being seen as strengthened through social and professional roles and identity:

So we do have quite a number of colleagues who are really well connected. They always participate in our quality groups, participate very reliably, and have good contact amongst themselves.

Beliefs about consequences

Beliefs about consequences tend to be related to contextual and environmental resources or barriers as well as regional outcomes. A particularly strong motive seems to be using antibiotics to prevent potential risks.

Paediatricians from districts with high prescription rates discuss avoiding consequences in particular with regards to patient overload:

My personal record in winter was 209 children a day. […] I have briefly checked them and then prescribed an antibiotic, because even if most of it is viral, you have children with whooping cough and I tend to be generous, because the hospitals are full of pneumonia.

Paediatricians from districts with low prescription rates on the other hand discuss low beliefs about negative consequences such as patients changing doctors due to low competition pressure:

So we don’t really have a competitive mindset here, because changes from one paediatrician to the other are really, really rare.

Interestingly, beliefs about consequences in terms of developing resistant microbes differ between paediatricians from low- and high-prescribing districts. Whereas those from high-prescribing districts argue that the responsibility for resistances is mainly located in the agricultural sector:

I think that resistant microbes develop if the farms in the area use lots of antibiotics […] So the kids who have MRSA here, they are all from farms. So they didn’t get MRSA because we gave them antibiotics but because the farms at home use lots of antibiotics.

(C, paediatrician, rural area, high prescription rates),

Those from low-prescription districts tend to attribute resistance development to health care professional behaviour:

The less antibiotics one prescribes, and if this happens everywhere, then we can expect, that the development of resistances will be less bad than elsewhere.

Beliefs about competences

Beliefs about competences mainly revolved around perceptions of competence to influence local resistance developments and largely mirror those exemplified in the beliefs about consequences section.

Both paediatricians from low- and high-prescribing districts explicitly mentioned goals to prescribe less antimicrobials, and mention that these goals are also shared by colleagues in the respective districts. Differences exist in the context within goals are mentioned – paediatricians from low-prescription districts mention the goal of lower prescriptions as part of a combinations of goals (e.g., optimal therapy or limiting resistance development), paediatricians from high-prescription districts concentrate on potentially more relevant goals than lower prescription rates:

…I think I can speak for most of my colleagues here, one tries to prescribe as little as possible. But if they really all read the reports, do they change their prescription behaviour, I doubt that. There are quite some other problems here that need solving as well.

Behavioural regulation

Behavioural regulation had only six mentions, but these were mainly together with contextual factors in districts with high prescription prevalence to highlight that contextual factors can pose barriers which also affect the low likelihood to change through impeding behavioural regulation:

And I think that these are basically deeply rooted, historic, ritualized prescription patterns, which then manifest regionally such that it is really difficult to change this.

General Practitioners (GPs)

TDF domains on district level that affected GP prescribing behaviour (Fig.  2 ) included context and resources (159 mentions), social influence (60 mentions), knowledge (41 mentions), beliefs about consequences (29 mentions), social/professional role (16 mentions), skills (16 mentions), goals (6 mentions), and behavioural regulation (4 mentions).

TDF domains mentioned as barriers (red) or resources (blue) by GPs

Similar to the paediatric participants, GPs reported on a range of regional contextual factors that influenced prescribing behaviour. These can also be differentiated along contextual and compositional factors [ 33 ].

A combination of contextual (main industry in the region) and compositional (migrant workers in the main industry) is a good example for these influences:

With the (migrant) workers in the meat industry, we do have a lot of people who might have potentially problems in dental hygiene, infections due to cuts for example. This happens a lot, and then increases the prescription of (antimicrobials).

(N, GP, rural area, high prescription rates).

GPs also report on regional differences in the influence of pharmaceutical representatives in their practices. For example, a GP from a low-prescription rural district mentioned that their local quality circles “will not invite pharmaceutical representatives if possible”.

Social influence

Social influences differ between districts, according to GP participants, and similar to paediatricians, these influences come through colleagues and patients.

One example for a local social influence could be long established GPs who influence local quality circles:

…as a young and newly arrived doctor, I quit going to the quality circles because the old guard was so present and influenced communication, work and thinking about practices. However, we do have now a new generation of GPs and things change.

(O, GP, rural area, low prescription rates)

Patient-level influences are also perceived to differ between districts, with some of the differences in expectations to be prescribed antibiotics being attributed to cultural factors:

There is a group of patients who are really eager to get antibiotics and who are incredibly demanding. Germans from the former Soviet Republics, and we do have many of them in this district. For them, it (not being prescribed antibiotics) is not a real therapy, even if it is viral….

(P, GP, rural area, high prescription rates)

Similar to cultural factors, the age distribution in a district is perceived to affect prescription, with more older adults in a district being associated with higher antibiotic demand.

Similar to this influence on higher prescriptions, specific regional social influences are also perceived as being influential for low prescription rates:

I mean, (city) is a very special city. It’s an administrative centre, a big university city, so I think there are a lot of people with a relatively high educational attainment, relatively little industry and I guess it’s also related to the fact that people have a bit of a different attitude. .

(Q, GP, urban area, low prescription rates)

Similar to the results in paediatricians, knowledge about current recommendations, information on local resistance, and training content relevant to prescribing antimicrobials were seen as relevant resources. One particular additional factor was that in one of the participating districts, the local university was seen as influential for particularly rational prescribing behaviour:

I think that this is due to the fact that here in (city) there are many doctors who have studied in (city). And I remember from my studies that antibiotic prescriptions were an important topic, and that in microbiology et cetera we were always being reminded that one does not just prescribe antibiotics but needs to justify this really well.

(R, GP, rural area, low prescription rates)

At the same time, similar to the paediatricians, a lack of knowledge in out-of-hours services is seen as a relevant factor for high prescription rates:

But there are many colleagues working in the out-of-hours primary care and doing GP tasks who have for example an anesthesia background, or something else from the hospital, they don’t know it any better.

(N, GP, rural area, high prescription rates)

These knowledge factors interact with resources and barriers on context level.

Similar to paediatricians, beliefs about consequences include beliefs about having to avoid liabilities, which are often mentioned in combination with structural and contextual factors:

And if something does go wrong, and that’s always a problem in outpatient settings, you are the one who screwed it up. That’s what all the colleagues are afraid of. So the fear of making a mistake and not prescribing the antibiotic is always bigger than the fear of damaging something with the antibiotic.

(S, GP, rural area, high prescription rates)

Losing patients to other practices in situations with strong competition was a strong belief about consequences in districts with high prescriptions:

You can say, No I am not going to prescribe this, but then you lose the patient, they are just going somewhere else.

(T, GP, urban area, high prescription rates).

At the same time, a lack of such perceived consequences has been perceived as a resource for lower prescriptions:

…at least we don’t have to bow to patient demands too much. It is very different here compared to (city) where I was before, in the inner city, where there was a lot of competition due to too many GPs. You are much more likely to give in to irrational demands then.

(U, GP, rural area, low prescription rates)

Social / professional role

Specific regional ideas on the professional roles are perceived to influence prescription behaviour, in particular in combination with specific aspects of rurality that could affect the composition of the local GP structure:

I just see what kind of colleagues – to say it cautiously – are coming to this region, who take over old practices or establish new ones. They are not necessarily the most committed doctors.

(V, GP, rural area, high prescription rates)

In districts with low prescription rates, skills were mainly being mentioned with regards to interpersonal skills regarding expectation management with patients, which were perceived to be higher in the respective districts:

…in fact, skills training in multiple areas. General communication skills, difficult patients, bad prognosis, diagnosis, or making the patients understand why a particular therapy is indicated – these are all key skills and have always been emphasized during our studies.

Similar to paediatricians, GPs from both low- and high-prescription districts mention the goal of low prescription rates, and assume that their colleagues in the district have similar goals. GPs in low-prescription districts mention this goal as part of multiple goals (ideal therapy, avoid resistance) in low-prescription districts, GPs in high-prescription districts mention this goal as having lower priority compared to competing demands.

Similar to the paediatricians, a lack of behavioural regulation in combination with contextual measures such as relatively old GPs in the district was seen as a risk factor for higher prescriptions:

Prescription behaviour by older colleagues plays a role I think. You can see this when you look at the age structure of the GPs here. They tend to prescribe antibiotics quickly whenever there are respiratory infections.

(W, GP, rural area, high prescription rates)

This study examined prescribers’ perceptions of region-specific drivers of outpatient antibiotic prescriptions. We conducted 40 interviews in districts stratified by antibiotic prescription rates, and mapped these perceptions on dimensions of the Theoretical Domains Framework [ 22 , 23 ]. A total of 11 domains were identified, and these served as, partially interacting, barriers against and resources for low antibiotic prescription rates. Most barriers and facilitators were similar between paediatricians and GPs. However, while GPs mentioned the age and workforce structure in districts as additional barrier, paediatricians emphasized a lack of skills and knowledge of GP colleagues treating young children as a barrier in districts with only few paediatricians.

We could link differences in the perception of TDF domains and their interactions to differences in prescribing behaviour in the districts to identify overarching barriers and resources for appropriate prescription practices.

Overarching barriers to low prescription rates

Both paediatric and GPs mentioned a lack of knowledge on district-level resistance developments as particular barrier to rational prescribing. This knowledge factor overlaps with a lack of contextual and environmental resources which could provide this information such as routine information flows between laboratories and health care providers.

Similarly, a lack of collaboration and coordination of knowledge in out-of-hours services was perceived to be associated with higher prescription rates – partly also due to a perception to avoid liabilities if prescribing antibiotics.

Lower health care provider density as contextual factor has been associated with higher prescription rates in previous international studies [ 35 , 36 ]. In the present study, lower prescriber density has only indirectly been associated with higher prescription rates – in the cases where lower density correlates with suboptimal emergency services prescription guidelines [ 16 ].

Participants also associated specific regional industries in rural districts (pig farming and meat factories) with higher patient demands due to either antibiotic practices in farming [ 15 ] or an increased demand for antibiotics by migrant workers and due to cuts in meat factories.

Social influences included culture-specific expectations about the effectiveness of antibiotics leading to higher patient demand for antibiotics, which together with time pressure from high patient load increased pressure on prescribers during consultations. This finding replicates findings from other European studies on antibiotic prescribing behaviour [ 18 , 19 ].

Overarching resources for low prescription rates

Overarching resources for low prescription rates that were mentioned by both paediatricians and GPs included environmental context and resources . Here in particular existing local networks supporting quality control were perceived as supportive of appropriate prescribing, both through the provision of information, best-practice examples and social norms. This replicates an earlier study suggesting that well-functioning local or regional primary care networks in Germany are associated with more appropriate antibiotic prescribing [ 37 ]. In addition, laboratories routinely providing information on local resistance data were perceived as resources for rational prescribing, which is in line with previous studies in Germany outlining the lack of local resistance information as a barrier to appropriate prescribing [ 38 ] and, similarly, showing that practitioners perceive information on local resistance as beneficial [ 39 ]. Low local population demand for antibiotics was also perceived as resource, as participants reported this to positively impact their prescription practice.

Implications

Most barriers and resources to rational outpatient prescribing in this study were contextual factors. However, contextual factors such as the local population, the main local branches of industry or (at least in Germany), or the free choice of practitioners to open practices anywhere within a district are not directly modifiable. This means that interventions should in particular target local collaboration structures and the availability of locally adapted guidelines.

If collaborations between local medical councils and laboratories can be improved to routinely provide local antimicrobial resistance data to prescribers, this information can readily be included into the prescription decision-making process [ 39 ]. In particular since both German and international studies [ 40 ] show that there is substantial variation in the degree to which individual practices take local resistance data into consideration, routine approaches are warranted. Germany has implemented a standardized surveillance program for multiresistant microbes such as MSRA [ 2 ], but the degree to which these surveillance findings are broken down locally and are available to practices varies considerably between districts, suggesting policies to standardise practice. If these findings are then included into local prescription guidelines such as the AnTiB guidelines [ 34 ], local prescription practices can be improved.

Routine antibiotic stewardship programmes that support paediatric and general practices could also help facilitating such closer collaborations and in turn build on some of the networking aspects mentioned as resources in the interviews. At the moment, antibiotic stewardship programs for outpatient settings in Germany are supported through national professional and scientific associations and are eligible for training credits, but implementation depends on local initiatives [ 5 ]. National policies to mandate such programmes would help to reduce the current regional disparities in antibiotic prescription practices, and the current antibiotic strategy of the German government DART 2030 [ 41 ] plans to explore compulsory training.

In terms of knowledge resources, participants mentioned that easy-to-use recommendations for emergency practice services are an important resource in particular if there is no paediatric emergency service, and children are seen by non-paediatrician practitioners. In Germany, initiatives such as Antibiotic Therapy in Bielefeld (AnTiB; [ 34 ]) provide such guidelines, but a systems-wide implementation of easy-to-follow guidelines such as e.g., NICE guidelines for upper respiratory tract infections [ 42 ] is currently lacking and would likely improve prescription practices in Germany.

Patient information such as leaflets might lead to increased patient knowledge about the role of antibiotics in managing infections and lower patient demand [ 43 ] without increased reconsultations [ 44 ]. At the same time, the role of involving audiences in the design of such leaflets and ensuring their understandability is crucial [ 45 ].

Strengths and limitations

A particular strength of the study lies in using the TDF to examine district-level differences in prescription behaviour, which allowed us to identify and interpret the impact of the factors mentioned by GPs and paediatricians. This deductive approach allowed mapping key themes on an established framework, which can in turn be used to determine and develop potential intervention applications. Our study complements previous work applying the TDF to understand antibiotic prescribing behaviour [ 25 ] by extending the perspective of the TDF on individual determinants onto characteristics of the district.

At the same time, the perceptions of participants regarding district-level TDF-based characteristics are subjective perceptions and do not necessarily correspond to the actual level of resources and barriers in the districts. Compared to face-to-face interviews, telephone interviews miss out on nonverbal information, but have allowed us to accommodate prescribers’ schedules. Due to the self-report nature of interviews, demand characteristics might affect responses such that participants exaggerate or downplay relevant factors.

Saturation in that no new codes emerged was achieved in all study cells (defined by practitioner group, urban/rural practice site and prescription rates) apart from GPs from high-prescribing urban areas, where only one interview could be realised. It is thus possible that additional interviews could have provided additional barriers and resources.

Substantial district-level differences in outpatient antibiotic prescriptions in paediatric and general practices can be mapped on differences in prescriber perceptions of district-level barriers and resources to rational prescribing. Given the regional variation in underlying reasons for inappropriate prescribing of antibiotics, similar qualitative studies in all districts in Germany with high prescription rates could be a promising approach to design targeted interventions. According to the results of interviews conducted in this study, routine provision of local antibiotic resistance data, better and clearer guidelines for paediatric patients in ambulatory emergency services, patient information and a wider implementation of standardised antibiotic stewardship programs could be promising targets for interventions.

Data availability

The qualitative data collected for this study was de-identified before analysis. Consent was not obtained to use or publish individual-level data from the participants and therefore may not be shared publicly. The de-identified (German) data can be obtained from the corresponding author upon reasonable request.

Change history

09 may 2024.

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World Health Organisation. Antimicrobial resistance. https://www.who.int/health-topics/antimicrobial-resistance . Accessed 6 Oct 2023.

Baede VO, David MZ, Andrasevic AT, Blanc DS, Borg M, Brennan G, et al. MRSA surveillance programmes worldwide: moving towards a harmonised international approach. Int J Antimicrob Agents. 2022;59:106538.

Article   CAS   PubMed   Google Scholar  

European Antimicrobial Resistance Collaborators. The burden of bacterial antimicrobial resistance in the WHO European region in 2019: a cross-country systematic analysis. Lancet Public Health. 2022;7:e897–913.

Article   Google Scholar  

Chatterjee A, Modarai M, Naylor NR, Boyd SE, Atun R, Barlow J, et al. Quantifying drivers of antibiotic resistance in humans: a systematic review. Lancet Infect Dis. 2018;18:e368–78.

Kern WV. Rationale Antibiotikaverordnung in Der Humanmedizin. Bundesgesundheitsbl. 2018;61:580–8.

O’Neill J. Tackling drug-resistant infections globally: final report and recommendations. 2016. https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf . Accessed 6 Oct 2023.

Goossens H, Ferech M, Stichele RV, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005;365:579–87.

Article   PubMed   Google Scholar  

Zweigner J, Meyer E, Gastmeier P, Schwab F. Rate of antibiotic prescriptions in German outpatient care - are the guidelines followed or are they still exceeded? GMS Hyg Infect Control. 2018;13:Doc04.

PubMed   PubMed Central   Google Scholar  

Poss-Doering R, Kronsteiner D, Kamradt M, Andres E, Kaufmann-Kolle P, Wensing M, et al. Antibiotic prescribing for acute, non-complicated infections in primary care in Germany: baseline assessment in the cluster randomized trial ARena. BMC Infect Dis. 2021;21:877.

Article   PubMed   PubMed Central   Google Scholar  

European Centre for Disease Prevention and Control. Antimicrobial consumption in the EU/EEA (ESAC-Net) - Annual Epidemiological Report for 2021. Stockholm: European Centre for Disease Prevention and Control; 2022.

Google Scholar  

Scholle O, Asendorf M, Buck C, Grill S, Jones C, Kollhorst B et al. Regional variations in Outpatient Antibiotic Prescribing in Germany: a small area analysis based on Claims Data. Antibiotics. 2022;11.

Zhang Y, Steinman MA, Kaplan CM. Geographic Variation in Outpatient Antibiotic Prescribing among older adults. Arch Intern Med. 2012;172:1465–71.

Filippini M, Masiero G, Moschetti K. Socioeconomic determinants of regional differences in outpatient antibiotic consumption: evidence from Switzerland. Health Policy. 2006;78:77–92.

Devine P, O’Kane M, Bucholc M. Trends, Variation, and factors influencing antibiotic prescribing: a longitudinal study in primary care using a Multilevel Modelling Approach. Antibiot (Basel). 2021;11:17.

van der Roof I, Oude Boerrigter L, Wielders CCH, Smit LAM. Use of antibiotics among residents living close to Poultry or Goat farms: a nationwide analysis in the Netherlands. Antibiot (Basel). 2021;10:1346.

Article   CAS   Google Scholar  

Huibers L, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB. Variation of GP antibiotic prescribing tendency for contacts with out-of-hours primary care in Denmark - a cross-sectional register-based study. Scand J Prim Health Care. 2022;40:227–36.

Bizune D, Tsay S, Palms D, King L, Bartoces M, Link-Gelles R, et al. Regional Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Tract infections in a commercially insured Population, United States, 2017. Open Forum Infect Dis. 2023;10:ofac584.

Sijbom M, Büchner FL, Saadah NH, Numans ME, de Boer MGJ. Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers: a systematic review and construction of a framework. BMJ Open. 2023;13:e065006.

Lescure DLA, van Oorschot W, van der Brouwer R, Tjon-A-Tsien AML, Bonnema IV, et al. Providing antibiotics to immigrants: a qualitative study of general practitioners’ and pharmacists’ experiences. BMC Prim Care. 2022;23:100.

Szymczak JE, Linder JA. Cultural Variation in Antibiotic Prescribing: have Regional differences had their day? Open Forum Infect Dis. 2023;10:ofad025.

Schüz B, Jones C, Scholle O, Haug U. Regional variations in antibiotic prescribing in Germany: understanding differences through an adapted theoretical domains Framework. Health psychology for all: Equity, Inclusiveness and Transformation. Bremen, Germany: European Health Psychology Society; 2023. p. 280.

Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.

Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the theoretical domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12:77.

Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14:26–33.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Courtenay M, Rowbotham S, Lim R, Peters S, Yates K, Chater A. Examining influences on antibiotic prescribing by nurse and pharmacist prescribers: a qualitative study using the theoretical domains Framework and COM-B. BMJ Open. 2019;9:e029177.

Bursey K, Hall A, Pike A, Etchegary H, Aubrey-Bassler K, Patey AM, et al. Physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care: protocol for a systematic review and synthesis of qualitative studies using the theoretical domains Framework. BMJ Open. 2022;12:e066681.

Talkhan H, Stewart D, McIntosh T, Ziglam H, Abdulrouf PV, Al-Hail M, et al. Investigating clinicians’ determinants of antimicrobial prescribing behaviour using the theoretical domains Framework. J Hosp Infect. 2022;122:72–83.

Sargent L, McCullough A, Del Mar C, Lowe J. Using theory to explore facilitators and barriers to delayed prescribing in Australia: a qualitative study using the theoretical domains Framework and the Behaviour Change Wheel. BMC Fam Pract. 2017;18:20.

Commission Regulation (EU). 2016/2066 of 21 November 2016 amending the annexes to Regulation (EC) No 1059/2003 of the European Parliament and of the Council on the establishment of a common classification of territorial units for statistics (NUTS). 2016.

Laufende Raumbeobachtung - Raumabgrenzungen. BBSR. https://www.bbsr.bund.de/BBSR/DE/forschung/raumbeobachtung/Raumabgrenzungen/deutschland/kreise/siedlungsstrukturelle-kreistypen/kreistypen.html . Accessed 2 Oct 2023.

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3:77–101.

Kuckartz U, Rädiker S. Analyzing qualitative data with MAXQDA: text, Audio, and video. Cham: Springer International Publishing; 2019.

Book   Google Scholar  

Leyland AH, Groenewegen PP, Context. Composition and how their influences vary. In: Leyland AH, Groenewegen PP, editors. Multilevel Modelling for Public Health and Health Services Research: Health in Context. Cham: Springer International Publishing; 2020. pp. 107–22.

Chapter   Google Scholar  

Bornemann R, Tillmann R. [Antibiotic therapy in Bielefeld (AnTiB)-a local project for the promotion of rational antibiotic prescribing in the outpatient paediatric sector]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2019;62:952–9.

Stedman M, Lunt M, Davies M, Fulton-McAlister E, Hussain A, van Staa T, et al. Controlling antibiotic usage—A national analysis of General Practitioner/Family Doctor practices links overall antibiotic levels to demography, geography, comorbidity factors with local discretionary prescribing choices. Int J Clin Pract. 2020;74:e13515.

Simon M, Thilly N, Pereira O, Pulcini C. Factors associated with the appropriateness of antibiotics prescribed in French general practice: a cross-sectional study using reimbursement databases. Clinical Microbiology and Infection. 2022;28:609.e1-609.e6.

Poss-Doering R, Kamradt M, Glassen K, Andres E, Kaufmann-Kolle P, Wensing M. Promoting rational antibiotic prescribing for non-complicated infections: understanding social influence in primary care networks in Germany. BMC Fam Pract. 2020;21:51.

Neugebauer M, Ebert M, Vogelmann R. [Lack of information and provision of information at the workplace as potential reasons for inappropriate antibiotic therapy in Germany]. Z Evid Fortbild Qual Gesundhwes. 2019;144–145:35–41.

Petruschke I, Stichling K, Greser A, Gagyor I, Bleidorn J. [The general practitioner perspective of a multimodal intervention for the adequate use of antibiotics in urinary tract infection - a qualitative interview study]. Z Evid Fortbild Qual Gesundhwes. 2022;170:1–6.

McKay R, Law M, McGrail K, Balshaw R, Reyes R, Patrick DM. What can we learn by examining variations in the use of urine culture in the management of acute cystitis? A retrospective cohort study with linked administrative data in British Columbia, Canada, 2005–2011. PLoS One. 2019;14:e0213534.

Bundesministerium für Gesundheit. DART 2030 - Deutsche Antibiotika-Resistenzstrategie. https://www.bundesgesundheitsministerium.de/themen/praevention/antibiotika-resistenzen/dart-2030 . Accessed 1 Mar 2024.

Kim NN, Marikar D. Antibiotic prescribing for upper respiratory tract infections: NICE guidelines. Archives Disease Child - Educ Pract. 2020;105:104–6.

de Bont EGPM, Alink M, Falkenberg FCJ, Dinant G-J, Cals JWL. Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: a systematic review. BMJ Open. 2015;5:e007612.

O’Sullivan JW, Harvey RT, Glasziou PP, McCullough A. Written information for patients (or parents of child patients) to reduce the use of antibiotics for acute upper respiratory tract infections in primary care. Cochrane Database Syst Rev. 2016;11:CD011360.

PubMed   Google Scholar  

Biezen R, Ciavarella S, Manski-Nankervis J-A, Monaghan T, Buising K. Addressing Antimicrobial stewardship in primary care-developing patient information sheets using Co-design Methodology. Antibiot (Basel). 2023;12:458.

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Acknowledgements

The support of Paula Kinzel during data assessment is gratefully acknowledged.

Open Access funding enabled and organized by Projekt DEAL.

The SARA project—on which this publication is based—was commissioned by the Federal Ministry of Health (grant number ZMVI1-2519FSB115).

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Benjamin Schüz & Christopher Jones

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Praxis für Kinder- und Jugendmedizin Roland Tillmann, Ärztenetz Bielefeld, Bielefeld, Germany

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Contributions

BS conceived of the study, analysed and interpreted data and wrote the first draft of the manuscript. OS contributed to design of the study, interpretation of data. UH contributed to acquisition, concept and design of the study as well as interpretation of data. RT contributed to design and acquisition of the study as well as interpretation of data. CJ contributed to design and concept of the study as well as assessment, analysis and interpretation of the data. All authors critically reviewed the manuscript.

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Correspondence to Benjamin Schüz .

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Ethics approval was obtained through the University of Bremen ethics committee (AZ 2021-03). All methods and procedures were performed in accordance with the relevant guidelines. All participants provided informed consent including before being interviewed for this study.

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Competing interests

OS and UH are working at an independent, non-profit research institute, the Leibniz Institute for Prevention Research and Epidemiology – BIPS. Unrelated to this study, BIPS occasionally conducts studies financed by the pharmaceutical industry. These are post-authorization safety studies (PASS) requested by health authorities. The design and conduct of these studies as well as the interpretation and publication are not influenced by the pharmaceutical industry. The study presented was not funded by the pharmaceutical industry. The Federal Ministry of Health specified the research question and the main content of the study concept and regularly participated in discussions on the implementation of the study. The authors were independent in the specific design, execution, interpretation, and writing of the study. The Federal Ministry of Health has authorized the publication of the results. BS, RT and CJ declare no conflicts of interest.

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Nature of child abuse in war-torn districts in Ethiopia: the case of Amhara Region, Chenna and Maikadra

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• Published: 13 May 2024

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• Aleminew A. Mekonen   ORCID: orcid.org/0000-0002-0354-2425 1 ,
• Getachew G. Tadese   ORCID: orcid.org/0000-0003-1448-4109 1 ,
• Shambel D. Gashaw 1 &
• Wassie K. Redda   ORCID: orcid.org/0000-0001-7944-9078 2  

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Since 2019, the war in Ethiopia between the Federal Government and the Tigrean People’s Liberation Front (TPLF) has severely impacted civilians, including children. Although children have been affected in many of the war-torn regions of the country, the study targeted two specific locations, Maikadra and Chenna, in Amhara National Regional State, where civilians were massacred because of their ethnicity. The focus of the study was to understand the acute and complex child abuse that occurred in the midst of the war. A qualitative method with a descriptive case study design was employed to collect and analyze data. Twenty-four individuals were purposely selected and participated in the interviews. From Maikadra, the participants included seven children, two parents, two school principals, one eyewitness woman in the community, and one Kebele administrator. Similarly, from Chenna, five children, three parents, two school principals, and one Kebele administrator participated in the interviews. We applied in-depth interviews and systematic observation to gather primary data. Using social ecology as a theoretical framework, the result revealed that at the micro level, community members (particularly children) experienced witnessing killings, experience rape and verbal abuse, intimidation, and the destruction of the family unit. At the mezzo level, the study documented communities’ experiences related to displacement and the destruction of schools and community networks. Further, at the exo level, the study revealed experiences of hunger, starvation, and the emergence of child-headed families. Finally, at the macro community level, the study revealed loss of future aspirations and the development of negative attitudes toward cultural values. All these forms of child abuse, as reported by study participants, are crimes deliberately committed by the TPLF rebel groups. This study suggests multiple interventions at all levels are required.

This qualitative case study, conducted in war-torn areas of Ethiopia, sheds light on the various contexts in which children were subjected to abuse.

The war resulted in child abuse that can be explained at micro, mezzo, exo, and macro system levels.

Children were directly targeted and witnessed ethnic-based atrocities. They lost their parents, took on family responsibilities, became orphaned, saw their schools turned into burial sites and were no longer attending school. Their future aspirations have been compromised.

War actors from the TPLF perpetuated negative attitudes towards the Amhara cultural values.

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Adamu, A. (2013). Causes of ethnic tensions and conflicts on campus among University Students in Ethiopia. Conference Paper Series, No. EDU2013-0644 .

Akresh, R., Lucchetti, L., & Thirumurthy, H. (2012). Wars and child health: Evidence from the Eritrean–Ethiopian conflict. Journal of Development Economics , 99 (2), 330–340. https://doi.org/10.1016/j.jdeveco.2012.04.001 .

Article   PubMed   PubMed Central   Google Scholar  

Anning, C., Denselow, J., Fylkes, K. G., & Kirollos, M. (2018). The War on Children: Time to end grave violations against children in conflict . https://resourcecentre.savethechildren.net/pdf/war_on_children-web.pdf/ .

Belay, F. Y. (2016). Conceptualizations and Impacts of Multiculturalism in the Ethiopian Education System [Ph.D., University of Toronto (Canada)]. https://www.proquest.com/docview/1819297605/abstract/32A3AB024E8C4BE7PQ/1 .

Betancourt, T. S., Keegan, K., Farrar, J., & Brennan, R. T. (2020). The intergenerational impact of war on mental health and psychosocial wellbeing: Lessons from the longitudinal study of war-affected youth in Sierra Leone. Conflict and Health , 14 (1), 62. https://doi.org/10.1186/s13031-020-00308-7 .

Biset, G., Goshiye G., Gedamu, S., & Tsehay, M. (2023). The effects of conflict on child and adolescent health in Amhara region, Ethiopia: Cross-sectional study. BMC Pediatrics , 1–7. https://doi.org/10.1186/s12887-023-04282-w .

Blanchard, L. P. (2021). Ethiopia’s Transition and the Tigray Conflict (R46905; p. 32). https://crsreports.congress.gov .

Blanchet-Cohen, N., Denov, M., Fraser, S., & Bilotta, N. (2017). The nexus of war, resettlement, and education: War-affected youth’s perspectives and responses to the Quebec education system. International Journal of Intercultural Relations , 60 , 160–168. https://doi.org/10.1016/j.ijintrel.2017.04.016 .

Article   Google Scholar  

Bookchin, M. (1996). The philosophy of social ecology (2°). Black Rose books. http://gen.lib.rus.ec/book/index.php?md5=DF2E6D94D5EECF10F7C4135D77B446C2 .

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology , 3 (2), 77–101. https://doi.org/10.1191/1478088706qp063oa .

Bronfenbrenner, U. (1981). The Ecology of Human Development: Experiments by Nature and Design . http://gen.lib.rus.ec/book/index.php?md5=60ae6590e0d4ca0d3b51fbc9902b0c44 .

Campbell, D. T., & Yin, R. K. (2018). Case study research and applications: Design and methods (Sixth edition.). SAGE Publications. http://gen.lib.rus.ec/book/index.php?md5=e82418db120c171268b08ba825136799 .

Coady, N., & Lehmann, P. (2007). Theoretical Perspectives for Direct Social Work Practice: A Generalist-Eclectic Approach . Springer Publishing Company.

Chukwu, E. N., & Aronu, I. N. (2018). Impacts of War on the family and marriage: A case study the Nigerian-Biafra war (1967-1970). A paper presented at the 2018 Women and the Nigeria-Biafra War International conference in commemoration of the 50th Anniversary of the war.

Cohen, D. K. (2013). Explaining Rape during Civil War: Cross-National Evidence (1980–2009). American Political Science Review , 107 (3), 461–477. https://doi.org/10.1017/S0003055413000221 .

Collier, P., Elliott, V. L., Hegre, H., Hoeffler, A., Reynal-Querol, M., & Sambanis, N. (2003). Breaking the Conflict Trap: Civil War and Development Policy . World Bank. https://doi.org/10.1596/978-0-8213-5481-0 .

Creswell, J. W. (2007). Qualitative inquiry & research design: Choosing among five approaches (2nd ed.) . (Sage Publications.

Google Scholar  

Deleersnyder, A.-E. (2021). Ethiopia’s Tigray conflict: Exposing the limits of EU and AU early warning mechanisms . Ground News. https://ground.news/article/ethiopias-tigray-conflict-exposing-the-limits-of-eu-and-au-early-warning-mechanisms .

Denov, M., & Shevell, M. C. (2019). Social work practice with war-affected children and families: The importance of family, culture, arts, and participatory approaches. Journal of Family Social Work , 22 (1), 1–16. https://doi.org/10.1080/10522158.2019.1546809 .

Duman, N. (2016). Importance of School Social Work in War and Conflicts Zone. European Journal of Social Science Education and Research , 3 (2), 191–194. https://doi.org/10.26417/ejser.v6i2.p191-194 .

EHRC. (2020). Rapid Investigation into Grave Human Rights Violation Maikadra—Preliminary Findings . https://ehrc.org/ethiopian-human-rights-commission-rapid-investigation-into-grave-human-rights-violation-maikadra-preliminary-findings/ .

EHRC. (2021). Amhara Region: Discovery of bodies in Dabat Woreda . https://ehrc.org/amhara-region-discovery-of-bodies-in-dabat-woreda/ .

Evans, H. N. (2019). Genocide and Severe Past Persecution: Child Survivors of Genocide as Per Se Refugees. Harvard Human Rights Journal , 32 , 189.

Fisseha, G., Gebrehiwot, T. G., Gebremichael, M. W., Wahdey, S., Meles, G. G., Gezae, K. E., … & Mulugeta, A. (2023). War-related sexual and gender-based violence in Tigray, Northern Ethiopia: a community-based study. BMJ global health, 8 (7), e010270.

Gebru, D. A. (2012). Ethnocentrism and Ethnic-Based Peer Preferences in Higher Education Institutions: Challenges and Implications for Ethiopia. International Journal of Educational Reform , 21 (1), 47–61. https://doi.org/10.1177/105678791202100104 .

Geoghegan, T. (2019). Global Childhood Report 2019: Changing lives in our lifetime . Save the Children’s Resource Centre. https://resourcecentre.savethechildren.net/pdf/global_childhood_report_2019_english.pdf/ .

Gutema, G., Kaba, M., Birhanu, Z., Diribi, J., & Elemo, I. (2023). Impact of armed conflicts on public health infrastructure and services in Oromia, Ethiopia. Cureus , 15 ( 6 ). https://doi.org/10.7759/cureus.40653 .

Holmes, D. G. A. (2020). Researcher positionality-A consideration of its influence and place in qualitative research: A new research guide. International Journal of Education , 8 (4), 1–10. https://doi.org/10.34293/education.v8i4.3232 .

Jones, N., Abebe, W., Emirie, G., Gebeyehu, Y., Gezahegn, K., Tilahun, K., Workneh, F., Vintges, J. (2022). Disrupted educational pathways: The effects of conflict on adolescent educational access and learning in war-torn Ethiopia. Frontiers in Education , https://doi.org/10.3389/feduc.2022.963415 .

Kaplan, S. (2013). Child Survivors of the 1994 Rwandan Genocide and trauma-related affect. Journal of Social Issues , 69 (1), 92–110. https://doi.org/10.1111/josi.12005 .

Kien, L., & My, N. (2020). The impacts of armed conflict on child health: Evidence from 56 developing countries, MPRA paper 109896 . Germany: University Library of Munich. https://mpra.ub.uni-muenchen.de/109896/1/MPRA_paper_109896.pdf .

Madoro, D., Mengistu, N., & Molla, W. (2021). Association of Conflict-Affected Environment on Ethiopian Students’ Mental Health and Its Correlates During COVID-19 Era. Neuropsychiatric Disease and Treatment , 17, 3283–3292. https://doi.org/10.2147/NDT.S338073 .

Marshall, M. N. (1996). The key informant technique. Family Practice , 13 (1), 92–97. https://doi.org/10.1093/fampra/13.1.92 .

Article   PubMed   Google Scholar  

Matthews, B., & Ross, L. (2010). Research methods: A practical guide for the social sciences . Longman. http://gen.lib.rus.ec/book/index.php?md5=3fd1ac295dce6f75e9450aed8effa860 .

McElroy, E., Hyland, P. Shevlin, M., Karatzias, T., Valliéres, F., Ben-Ezra, M., Vang, L.M., Lorberg, B., & Martsenkovsky. (2023). Change in child mental health during the Ukraine war: Evidence from a large sample of parents. European Child & Adolescent Psychiatry , https://doi.org/10.1007/s00787-023-02255-z .

Ritchie, J. B., Lewis, J., Nicholls, C. M., & Ormston, R. (2013). Qualitative Research Practice: A Guide for Social Science Students and Researchers (2nd ed.) . Sage Publications Ltd. http://gen.lib.rus.ec/book/index.php?md5=32A48F06B4742F834E01A247B156A38F .

Santa Barbara, J. (2006). Impact of War on Children and Imperative to End War. Croatian Medical Journal , 47 (6), 891–894. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080482/ .

PubMed   PubMed Central   Google Scholar  

Swenson, C. C., & Chaffin, M. (2006). Beyond psychotherapy: Treating abused children by changing their social ecology. Aggression and Violent Behavior , 11 (2), 120–137. https://doi.org/10.1016/j.avb.2005.07.004 .

Triplehorn, C. (2001). EDUCATION – Care & Protection of Children in Emergencies. A Field Guide . Save the Children’s Resource Centre. https://resourcecentre.savethechildren.net/pdf/2388.pdf/ .

Tsadik, M., Gebretnsae, H., Ayalew, A., Asgedom, A.A., Gebreyesus, A., Hagos, T., Abrha, M., Weldegerima, K., Abrha, B., Gebre, G., Hagos, M., Esayas, R., Gebregeorgis, M., Gesesew, A.H., & Mulugeta, A. (2023). Child health services and armed conflict in Tigray, North Ethiopia:A community-based study. Conflict and Health . https://doi.org/10.1186/s13031-023-00545-6 .

UNHCR Global Report (2021). UNHCR Operational Data Portal (ODP). Retrieved July 28, 2023, from https://data.unhcr.org/en/documents/details/93861 .

UNICEF. (2009a). Machel Study 10-year Strategic Review: Children and Conflict in a Changing World . UNICEF.

UNICEF. (2009b). Machel Study 10-year Strategic Review: Children and Conflict in a Changing World . UNICEF.

Walliman, N. (2006). Social Research Methods (SAGE Course Companions) . Sage Publications Ltd. http://gen.lib.rus.ec/book/index.php?md5=952369b8be113f9642247dcefe572ac5 .

Werner, E. E. (2012). Children and war: Risk, resilience, and recovery. Development and Psychopathology , 24 (2), 553–558. https://doi.org/10.1017/S0954579412000156 .

Wessells, M., & Kostelny, K. (2012). Everyday distress: Psychosocial and economic impact of forced migration on children and families. The Oxford Handbook of Poverty and Child Development . https://doi.org/10.1093/oxfordhb/9780199769100.013.0035 .

Yin, R. K. (2003). Applications of case study research (2nd.) . Sage Publications. http://gen.lib.rus.ec/book/index.php?md5=69f85b330fad266a385ece9e3c2acf11 .

Zainal, Z. (2007). Case Study As a Research Method. Jurnal Kemanusiaan , 5 (1), 1. https://jurnalkemanusiaan.utm.my/index.php/kemanusiaan/article/view/165 .

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The document has been fully edited with the discussion of Pamela Craven. She is a professional English language editor and translator. She is the language support teacher for the first two authors at Queen’s University School of English in Canada. We are thankful to Pamela for her contribution to editing the language of this paper. Email: [email protected].

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Mekonen, A.A., Tadese, G.G., Gashaw, S.D. et al. Nature of child abuse in war-torn districts in Ethiopia: the case of Amhara Region, Chenna and Maikadra . J Child Fam Stud (2024). https://doi.org/10.1007/s10826-024-02837-8

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How do labour market conditions explain the development of mental health over the life-course? a conceptual integration of the ecological model with life-course epidemiology in an integrative review of results from the Northern Swedish Cohort

• Anne Hammarström 1 , 2 ,
• Hugo Westerlund 3 ,
• Urban Janlert 2 ,
• Pekka Virtanen 4 ,
• Shirin Ziaei 1 &
• Per-Olof Östergren 5  

BMC Public Health volume  24 , Article number:  1315 ( 2024 ) Cite this article

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The aim of this study was to contribute to the theoretical development within the field of labour market effects on mental health during life by integrating Bronfenbrenner’s ecological model with mainly earlier theoretical work on life-course theory.

An integrative review was performed of all 52 publications about labour market conditions in relation to mental health from the longitudinal Northern Swedish Cohort study. Inductive and deductive qualitative content analysis were performed in relation to Bronfenbrenner’s ecological framework combined with life-course theories.

The following nine themes were identified: 1. Macroeconomic recession impairs mental health among young people. 2. The mental health effects on individuals of youth unemployment seem rather insensitive to recession. 3. Small but consistent negative effect of neighbourhood unemployment and other work-related disadvantaged on individuals’ mental health over life. 4. Youth unemployment becomes embodied as scars of mental ill-health over life. 5. Weak labour market attachment impairs mental health over life. 6. Bidirectional relations between health and weak labour market attachment over life. 7. Macrolevel structures are of importance for how labour market position cause poor health. 8. Unequal gender relations at work impacts negatively on mental health. 9. The agency to improve health over life in dyadic relations. Unemployment in society permeates from the macrolevel into the exolevel, defined by Bronfenbrenner as for example the labour market of parents or partners or the neighbourhood into the settings closest to the individual (the micro- and mesolevel) and affects the relations between the work, family, and leisure spheres of the individual. Neighbourhood unemployment leads to poor health among those who live there, independent of their employment status. Individuals’ exposure to unemployment and temporary employment leads to poorer mental health over the life-course. Temporal dimensions were identified and combined with Bronfenbrenner levels into a contextual life-course model

Combining the ecosocial theory with life-course theories provides a framework for understanding the embodiment of work-related mental health over life. The labour market conditions surrounding the individual are of crucial importance for the embodiment of mental health over life, at the same time as individual agency can be health promoting. Mental health can be improved by societal efforts in regulations of the labour market.

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An integrated understanding of how work-related factors influence mental health over life is lacking. In this integrative review we perform qualitative analyses of publications about the labour market effects on mental health during life and develop a contextualised life-course model about the embodiment of mental health during life.

To get a more holistic understanding of the impact of working conditions on mental health during life, this study will integrate main theoretical frameworks like the life-course model [ 1 ] with the theory of embodiment [ 2 ] and the ecosocial theory [ 2 ] in order to underline the concrete interplay between body and environment over the life-course of an individual. Urie Bronfenbrenner [ 3 ], stands out as one of the most influential contributors to ecological thinking in mental health research [ 2 ]. We suggest that Bronfenbrenner’s Ecological Systems Theory could serve as device for integrating a life course approach with the theory of embodiment, since it provides a multilevel systemic representation of exposures which relate to the axis of time for the individual.

Meta-analyses and systematic reviews have demonstrated that single work-related factors, such as lack of decision latitude, job strain and bullying, increase the risk of depressive symptoms [ 4 ]. The work-stress research has mainly focused on single measurements during life, and therefore loose the effect of intraindividual changes of working and employment conditions over time [ 5 ]. A life-course perspective is needed to capture exposures to various positions on the labour market during working life. During recent decades, the labour market has gone through rapid changes with increased insecurity for many workers. Globalization has led to new patterns of production, which have changed the working-life world-wide. These changes include increased polarisation between high- and low-paid jobs in relation to e.g., income. The demand for a more flexible workforce has led to a variety of non-standard work arrangements (e.g., short-term contracts, on call jobs, ‘platform gigs’, etc.) with increased levels of unemployment and widespread job insecurity as a result [ 6 ]. Employees in high-skill jobs have achieved increased autonomy and expanded their opportunities, while those in low-skill jobs have faced an increasingly insecure work situation with poorer employment relations and working conditions. During the last two decades, the number of fixed-term contracts has almost doubled among short time educated in Sweden [ 7 ]. So, while previous generations have worked with quite stable labour market position during life, those in working age of today have been exposed to rapid changes with increased risk for frequent transitions between various types of employment contracts, or jobs without a contract, and periods of unemployment, labour market measures or studies in-between. Therefore, a more holistic understanding is needed of the complex relations during life between health and work -related exposures in terms of both processes of exposures and processes of health-related selection which may influence individual’s’ vulnerability to poor work conditions [ 8 ].

To increase the understanding of these complex relations, there is a need for theoretical development in the field. So far, some models have been developed to understand how single work-related exposures influence health. The two most influential models in public health research used to analyse the role of psychosocial work environment in explaining health development are the demand, control, support model [ 9 ] and the effort-reward imbalance model [ 10 ]. A few older theories try to explain the health consequences of unemployment. According to Marie Jahoda’s theoretical framework [ 11 ], unemployment impairs health through the loss of both manifest (income) and latent (time structures, social networks, social identity, self-realisation, activity, and participation in collective effort) functions of employment. In stress theory, psychosocial threats (such as precarious employment or unemployment) together with psychobiological programming (including effects of earlier environmental and genetic factors) elicit metabolic and mental health responses [ 12 , 13 ]. Other aspects of the working life include labour market attachment which has been conceptualized as a centre periphery structure with those with most secure attachment in the centre, while those with the most unsecure attachment are found in the periphery [ 14 ]. The core-periphery model aims to capture this heterogeneity by regarding the permanent employees as the ‘core work force’ with favourable working conditions and temporary employees as the ‘periphery work force’ with increasing insecurity and reduced benefits the longer in the periphery they are positioned.

The social context surrounding an individual has been emphasised to be of particular importance for understanding the development of mental health [ 3 ]. The concept of embodiment and the ecosocial truth theory has been added by Krieger to underline the concrete interplay between body and environment over the life-course of an individual [ 2 ].

To get a more holistic understanding of the impact of working conditions on mental health during life, this study will integrate life-course theories with a social ecological model developed by Bronfenbrenner, which recognises the effect of multiple and inter-related settings on various contextual levels on mental health. An ecosocial perspective offers a way to simultaneously emphasise both the individual and the context and the relations between them. However, the ecosocial model does not extensively elaborate the complexity of differential exposure across different life periods. An understanding of how work-related factors influence mental health over life, which integrates main theoretical frameworks like the life course model [ 1 ] and the theory of embodiment [ 2 ] is lacking. In this integrative review we develop a contextualised interpretation of the findings utilizing these frameworks. Mental health will be defined as self-reported symptoms of mainly depressiveness, anxiety and functional somatic symptoms.

The life-course of an individual is shaped by historical times, places, and processes in which an individual is embedded during life. The theoretical ground in life-course research was laid by the sociologist Glen Elder [1 by defining the following four principles (1) historical time and place mean that the life-course of individuals is embedded in and shaped by the historical times and places they experience over life (2) Timing in lives states that the developmental impact of events is contingent on when they occur in a person’s life. (3) Linked lives means that lives are lived interdependently, and social and historical influences are expressed through this network of shared relationships. (4) Agency states that individuals construct their own life-course through the choices and actions they take within the opportunities and constraints of history and social circumstances. The principles also should direct the research in the domain of life-course epidemiology.

The contextual approach and mixed method design emphasised by Elder has however, gradually been replaced by a quite narrow and descriptive focus on individual characteristics in the field of life-course epidemiology of today. Life-course epidemiology investigates how exposures earlier in life can explain later development of diseases, with a focus on how biological, behavioural, and psychosocial processes operate across the life span [ 15 ]. The main conceptual models are accumulation of exposures, social chain of risks and critic or sensitive periods, implying increased sensitivity in a particular stage of the individual’s life when a certain exposure has the strongest detrimental effect.

The main limitation of life-course epidemiology of today is its failure to take a contextual approach into account, for example work-life [ 16 ]. The lack of contextualisation could be one reason why life-course epidemiology is much rarer in research on work life than e.g., in epidemiologic research on the impact of early individual risk factors. As a criticism of the fragmented research in the field, Amick et al. [ 16 ] conceptualised also work as life-course processes depending on place and time, with focus on labour market transitions and trajectories that various groups face during working life. They emphasize the need to understand the role of various contextual levels in shaping labour market and health trajectories to identify relevant policies and interventions. The relations between work and health are further complicated by the healthy worker effect, i.e., healthier employees are more likely to gain stable employments. Thus, health selection must be considered when analysing work-related exposures (e.g [ 8 ])..

To overcome the lack of context in life-course epidemiology we will contribute to theoretical development of the working life-course by integrating Elder’s [ 1 ] life-course theory with Urie Bronfenbrenner’s [ 3 ] Ecological Systems Theory of human development, which is of special importance from a life-course perspective since Bronfenbrenner’s theory can be used to understand how mental health develops from young age in close interplay with the larger social context. A central proposition in this theory is that people make choices and act in their social contacts as responses to emotional, cognitive, and behavioural elements of such interactions, and that these processes interact between settings on different ecological levels, conceived as a set of nested structures, each inside the next like a set of Russian dolls. Closest to the individual is the microlevel (the immediate settings including the family, the friends, the workplace, work conditions) followed by the mesolevel (the interconnections among several settings at the microlevel) and its extension called the exolevel, i.e., social structures which the person is not always actively involved in, or even present, but which are of major importance for their development, such as the neighbourhood. How society is organized on a “high” level is labelled the macrolevel (the overarching institutional patterns of gender relations, social class structure as well as the political, economic, legal, and social frameworks). The macrolevel permeates all the other levels. through different causal pathways, which is of key importance for the living conditions surrounding the individual.

Last, the chronolevel encompasses the temporal dimension and the gradual and often discrete changes of the context that occur over time, as well as the individual life history. This was the last level which Bronfenbrenner added to his model and has been least developed in research, even if time is implicit in all the processes described at the other levels of the model. Thus, the complexity of differential exposures across time and different life periods needs to be problematized. Incorporating an ecological approach into life-course epidemiology can provide a tool to analyse how determinants in various settings and ecological levels can interact and differ in extent, expression, and impact across the lifespan.

The aim of this study is to contribute to the theoretical development within the field of labour market effects on mental health by integrating Bronfenbrenner’s ecological model [ 3 ] with earlier theoretical work on life-course theory [ 1 ]. An integrative review will be performed, based on qualitative analyses of earlier published papers in the field of labour market and mental health in the Northern Swedish Cohort (NoSCo) in order to develop a contextualised life-course model. The research question is: How do labour market conditions explain the development of mental health over the life-course?

Methodological and conceptual issues

The work of this paper has been performed within a large research programme called “Mental health in adolescence and the paths ahead. An ecological life-course approach to mental health development into adulthood”. We have performed an empirical analysis of all earlier publications about labour market conditions and mental health during life within the rich database of the Northern Swedish Cohort (NoSCo) [ 17 ]. The cohort had, at the time of the research programme, been followed over 27 years. For this qualitative metasynthesis, we chose all international publications in referee-judged international journals based on NoSCo about how mental health was related to labour market conditions (labour market attachment, work environment, school environment, students’ situation etc.). In total 52 papers were available and all of them were included in the analyse. Another integrative review of all papers about exposures outside paid work has been published from the same research programme [ 18 ].

NoSCo consists of all pupils in the last year of compulsory school in the municipality of Luleå during Spring term in 1981 ( n  = 1083). The cohort had at the time of the study been followed with questionnaires and health examinations at ages 16, 18, 21, 30 and 43. The participation rate has been extremely high– 94.3% of those alive at age 43 ( n  = 1071) participated. The cohort has been shown to be representative of the country in relation to socio-demographics and socioeconomic factors as well as in relation to health status and health behaviour. All young people who became unemployed directly after leaving compulsory school ( n  = 20) were included in an interview group and have been followed with personal interviews during the follow-up [ 17 ].

To analyse the health impact of the macrolevel, a so-called younger NoSCo was constructed [ 19 ]. The cohort population consists of all pupils in the last year of compulsory school in Luleå in 1989. They were first followed-up at age 21 (in the deep recession of 1994) and later at age 39 (in 2012). The response rate at age 39 was 85.6% of those still alive ( n  = 686). The comparison of the cohorts at age 21 indicate the impact of macroeconomic recession on young people’s health, as compared to the financial boom when the older group was 21 in 1986.

Two additional register-based populations were included in this paper. For each cohort participant, neighbourhood measures were collected in accordance with Statistics Sweden’s small-area market statistics (SAMS) [ 20 ]. SAMS is a small-scale geographic division constructed as polygons, using demographic distinctions (such as roads, buildings etc.) to demarcate neighbourhoods. In this study the SAMS areas were composed on 31 December in 1980, 1986, 1995 and 2007, consisting of at least one cohort member and on average 1000 individuals from the neighbourhood. The number of neighbourhoods increased from 72 in 1980 to 374 in 2007, due to the cohort members’ moving pattern.

Information was retrieved from Statistics Sweden for all residents living in each area. Unemployment was defined broadly as having the main source of annual income from unemployment benefits, health-related benefits and early retirement.

Register data for all cohort participants who worked at a workplace in Sweden at age 42 ( n  = 837) were collected. For each participant, register data about gender, salary, education, parental leave, temporary parental leave and age for all employees in each workplace ( n  = 135 398) was collected from Statistics Sweden [ 21 ].

Luleå is a medium-sized (with about 70,000 inhabitants) industrial town in Northern Sweden. The town is representative of medium-sized industrial towns in Sweden as regards the sociodemographic factors and labour market conditions except for doubled rate of youth unemployment during the early 1980ies as compared to the country as a whole. The labour market is dominated by manufacturing and mineral extraction, with a steel company and a large harbour. Other major empl:oyers are the public sector and a technical university. At the time of the start of the study in 1981, unemployment in the town was twice as high rate as in the rest of Sweden and there was more workforce immigration from Finland [ 22 ].

Dependent variable: mental health

There are inherent methodological challenges in the measurement of mental health problems in longitudinal research. There is constant development in definitions, taxonomies and demands concerning the properties of mental health measurements. We have tested the properties of the mental health measures (mostly single items) used when NoSCo was initiated in the early 1980ies in relation to the standards of today and conclude that composite measures of mental health problems can be constructed from single items which are more than 30 years old [ 23 ]. These measures seem to have the same factorial structure and internal consistency across a significant part of the life course.

Most papers in this metasynthesis used the composite measures of mental health described above consisting of depressive symptoms, anxiety symptoms and functional somatic symptoms (FSS). Depressive symptom score was based on six symptoms (sleeplessness, poor appetite, fatigue, concentration difficulties, feeling down or sad, and feeling downhearted about the future). The measure of functional somatic symptoms was constructed as a score of symptoms: headache or migraine, stomach ache (other than heartburn, gastritis or gastric ulcer), nausea, backache, hip pain or sciatica, general tiredness, breathlessness, dizziness, overstrain, sleeping problems, and palpitations. The measure of anxiety symptoms included five symptoms; restlessness, concentration difficulties, worries/anxiety, palpitations and spanic (for details of the variable construction, see Hammarström et al. [ 23 ]). Similar composite measures of mental health have been used in papers published before the validation paper. As externalised symptom, excessive alcohol consumption was used. A single measure of self-rated health is used in some papers and included as measures of depressiveness and anxiety has been shown to strongly contribute to self-rated health [ 24 ]. One paper used cortisol awakening response [ 58 ] as a measure of physiological stress.

Independent variable: labour market position

From 1983, matrices were developed in the questionnaires to measure various labour market positions (unemployment, labour market measures, temporary employment, studies etc.) each half-year period from the latest follow-up. Between age 16 and age 18, accumulated time in various labour market positions (studies, employment, unemployment respectively labour market measures),

Register data about yearly accumulated time in unemployment and labour market measures was available from 1992 and onwards.

Conceptual model and integrative review

The theoretical development during our research programme inspired us to develop a conceptual model which is here used for analysing and synthesising our material.

To obtain broader and more holistic knowledge regarding the mental health effects of working-life conditions over life, we have conducted a qualitative metasynthesis using the method of integrative review of papers about labour market conditions from NoSCo by adapting the Whittemore and Knafl’s framework [ 25 ].

Schick-Makaroff et al. [ 26 ]. have identified integrative reviews as one of several broad categories of research synthesis methodology. Integrative. reviews “reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated” , and “ultimately present the “state of the art” of knowledge” [ 26 , page 198].

Integrative reviews summarize past empirical and theoretical studies and enables inclusion of studies with diverse methodologies. They can be used to address mature topics to re-conceptualize the expanding and diverse literature on the topic and to review new topics in need of preliminary conceptualization.

Whittemore and Knaufl [ 25 ] identified five steps in order to enhance rigour in integrative reviews: problem identification, literature search, data evaluation, data analyses and presentation. Problem identification was made in our large research programme with the aim of theory development and identification of how settings like labour market conditions explain the development of mental health over the life-course. Literature search was easily performed in relation to all international, referee judged publications about mental health and labour market conditions of NoSCo. The papers (including references) are presented in Tables  1 and 2 . The final sample for this integrative review included both empirical (quantitative and qualitative) data and theoretical texts. The empirical data included were derived from a wide variety of methods: cross-sectional, various longitudinal quantitative methods, trajectory analyses, content analyses and theoretical development. Due to this diverse representation of primary sources, the publications were graded in the third step (data evaluation) according to methodological rigour as high or low. Five papers were coded as low rigour due to cross-sectional design [ 29 , 31 , 34 , 50 ] and due to overadjustment [ 55 ]. No paper was excluded based on this evaluation, but these five papers contributed less to the analytic process.

Section 3comes here:Data analyses

Data analyses

The fourth step, data analyses of all included papers, was performed in the following way.

way. First, a deductive content analysis was performed of all papers in relation to Bronfenbrenner’s Ecological Systems Theory model [ 3 ]. Deductive implies that the analysed data was applied to a model and thus each paper was coded in relation to Bronfenbrenner’s ecological levels. Deductive approach represents a move from theory to data or from a more abstract and general to a more concrete and specific level. The main strength is that the theory that is used can be further developed and to some extent validated [ 27 ]. Each publication was coded with qualitative content analyses [ 28 ] in relation to the ecological levels of the model (see Tables  1 and 2 ). The statistical analyses in the various papers are controlled for baseline symptoms of mental health, i.e., for reversed causation, except in some of the early analyses (as stated in the paragraph above). These are stated to not control for baseline status in Table  1 .

Each paper was coded into meaning units, i.e., condensed sentences in which the original content is preserved. Thereafter, the meaning units were sorted into descriptive categories, which answer the question ‘what’. Finally, categories with similar meanings were conceptualised into themes, which answer the question ‘how’.

Second, inductive qualitative content analyses [ 28 ] were performed. We coded how each paper captured the temporal dimensions, as any of the traditional life-course models or as other models. This coding resulted in several new time related concepts.

The meaning units, categories, and themes as well as the life-course pathways of each paper are shown in Table  1 (all quantitative papers) and in Table  2 (all qualitative papers). The results were ordered according to the Bronfenbrenner levels, beginning with the macrolevel and ending with the microlevel. The last two themes consist of results related to more than one level. In the fifth step (presentation), we present our findings in Tables  1 and 2 and developed a contextualized life-course model based on mainly the themes from these tables (see figure below).

In developing our model, we used the levels suggested by Bronfenbrenner [ 3 ] and allocated them with our empirical findings (see Tables  1 and 2 ). We filled the time dimension (the chronolevel) with time related processes from both predefined life-course models [ 15 ] and with processes derived from the inductive part of our analysis. Our main contribution was combining Bronfenbrenner’s model and life-course epidemiology and thereby adding empirical data to the settings on various levels and new processes to the temporal dimension.

The trustworthiness of our findings was achieved according to scientific tradition in qualitative research [ 27 ]. Credibility of our research findings deals with how well themes and meaning units cover data, In the analyses of the included papers, no relevant data have been systematically excluded or irrelevant data included. To increase the trustworthiness of the study, the interpretations and formulations of themes were discussed and negotiated among the authors during the process of analyses. All meaning units were covered in each theme, which increases the trustworthiness. In order to ensure transferability, the setting of the study has been described in detail in both the Method and the Results and Reflection settings.

Results and reflections

The findings are presented in detail in Tables in relation to each Bronfenbrenner level as well as in relation to predominant life-course pathways. Below we concentrate on making a more holistic view on the results. Some themes permeate several levels while others are mainly situated on the microlevel.

First, the Bronfenbrenner model is described in more detail [ 3 ]. The macrolevel can be defined as how society is organized on a high level including structural relations (in relation to class, gender, ethnicity etc.), laws, institutions, policymaking as well as functional and normative elements (e.g., religiose norms, prejudices) [ 3 ]. Is the result of various policy making processes). Structures and processes on the macrolevel permeate all the other levels of the ecosocial system and are finally embodied through the effect of specific individual experiences resulting from those structures and processes, ultimately leading to different health outcomes. These embodied experiences are incorporated into the body from past time into the present in terms of susceptibility or resilience in relation to “exposures” on various level.

The exolevel e mbraces major arenas of society—such as the world of working life and the neighbourhood. These social arenas do not themselves contain the developing person but affect the immediate settings in which that person is found, and as such influence what is going on in these settings [ 3 ]. The mesolevel constitutes the interconnections among the settings at the microlevel, while the microlevel includes the settings where the individual directly interacts with others, such as the family, the friends, the workplace. The microlevel consists of the contexts where an individual interacts directly with other individuals, e.g., family, workplace, network of friends, etc.

Second, the results on and reflections about all nine themes of the qualitative analyses (Tables  1 and 2 ) are presented. The last two themes consist of results related to more than one ecological level.

Macroeconomic recession impairs young people’s mental health

During the 1980s the unemployment rates were high in Northern Sweden as compared to the rest of the country [ 22 ]. Local policies were developed to tackle the problem, by incentivising the unemployed in this region to move south [ 29 ]. The sudden recession in the early 1990s hit the whole country hard, with sharply increased levels of unemployment in the country at large [ 19 ]. Men-dominated workplaces, such as manufacturing industries, were affected first, followed in the mid-decade by cutdowns in the women-dominated public sector [ 19 ]. After the recession of the 1990s, the levels of unemployment decreased in the country, but never to earlier levels. The so-called great recession 2007–2009, by comparison, was relatively mild in Sweden.

Comparing mental health among 21 years old in relation to labour market position (excluding long-term unemployed) in boom and recession we found more symptoms among students during recession but otherwise no differences among young men [ 30 ]. Young women in work and in labour market measures had worse mental health during recession than during boom [ 30 ]. An explanation could be that in women-dominated, as compared to men-dominated, sectors, the workload cannot necessarily be reduced when cut-downs in the staff are made [ 31 ]. Thus, the work environment becomes more strained, when fewer staff are expected to produce the same or even larger volume of work in health care, social care, and education.

The business cycle-related differences in mental health among 21-year-old students did not last until adult age [ 30 ]. During life the mental health of those who were students during recession may have improved thanks to their ’forced’ studies: the education could have started a positive chain of possibilities, leading to more qualified jobs with better salaries and improved work environment, compared to those who entered the labour market [ 30 ].

The health effects of youth unemployment on individuals do not differ due to the trade cycle

The long-term consequences of youth unemployment on adult alcohol consumption [ 32 ]. and mental health [ 33 ] (scarring) were insensitive to the trade cycle. In other words, it seemed to be just as bad for mental health among 21-years old to be unemployed in boom as in recession [ 34 ].

Small but consistent negative effect of neighbourhood unemployment and other work-related disadvantages over life on individuals’ mental health

Several publications dealt with the negative impact of neighbourhood disadvantage on inhabitants’ mental health [ 20 , 32 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ]. During the 1990s recession, the exo-level phenomena of high rates of unemployment in the neighbourhood were related to impaired mental health, independently of the individual’s own labour market status [ 35 ]. High area unemployment could indicate high degree of marginalization among inhabitants and an environment, characterized by deprivation in infrastructure, educational and labour market opportunities, availability of healthy foods at affordable prices, increased stress, and lack of social support. Living in deprived areas could therefore increase individual strain, independent of a person’s own position in the labour market [ 35 ]. In addition, cumulative neighbourhood disadvantage (defined as not working, low income, lack of wealth, housing allowance and low socioeconomic status) during life was related to biological wear and tear among men [ 36 ] and poor mental health among both genders [ 37 ]. Neighbourhood disadvantage seems to have its greatest importance for mental health in young age [ 38 ]. Neighbourhood disadvantage in adolescence increases the risk for later alcohol consumption [ 39 ].

One of our studies analysed possible predictors of adult neighbourhood disadvantage. Adolescent neighbourhood disadvantage, family, and school circumstances but not health nor health behaviour were independently predictive of the socioeconomic character of one’s neighbourhood of residence in mid-adulthood. Thus, no health selection into neighbourhood disadvantage was found [ 20 ].

Youth unemployment becomes embodied as scars of mental ill-health over life

Several publications analyse the scarring effect of youth unemployment on mental health over life. In this context, scarring means that, while youth unemployment has well-known direct effects on health (“wounds”), these wounds remain as scars in adult age (measured in relation to alcohol consumption and various measures of mental health) [ 33 ]. Scarring thus denotes adversities due to individual exposure to unemployment that remain - or become - ‘visible’ when the individual has passed the actual unemployment episode. In other words, the health effects that remain after the exposure to unemployment has ended [ 33 ].

While mental health and alcohol scarring was consistently shown for youth unemployment [ 33 , 39 , 42 , 43 , 44 , 45 , 46 ], no such scarring was found from participating in Youth opportunities programmes [ 47 ].

Weak labour market attachment over life impacts on mental health

The direct negative health effects of exposure to accumulated unemployment, especially in young, but also in adult age, have been widely documented in our data in relation to symptoms of mental health [ 17 , 19 , 22 , 29 , 34 , 45 , 49 , 50 , 51 , 52 ] as well as to excessive alcohol consumption [ 53 ]. Cumulative exposure to unemployment (as little as 12 weeks between ages 16 and 18 years [ 29 ], and 6 months between ages 16 and 21 years [ 44 ] is related to impaired health and health behaviours in young age. The longer time of exposure to unemployment, the worse the health outcome [ 49 , 52 ]. Men and women are equally hit by the health consequences of unemployment, although the health expressions may differ [ 51 ].

The research also shows that having temporary employment contracts in young adulthood impacts negatively on mental health in adulthood [ 51 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 ]. The findings could be mediated via poor financial situation and job insecurity [ 54 ]. Moreover, the health effects of non-permanent employment depend on the socio-economic status of the employees, being more adverse in those with short education [ 59 ].

Transition from an unstable labor market position to permanent employment is related to improved mental health [ 60 ]. Being unemployed or out of the labour market at age 30 could explain the relation between poor school situation and adult depressiveness [ 63 ].

Locked-in on the labour market (having permanent contract in a non-preferable workplace or job) may be regarded as a kind of weak position on the labour market and is related to deteriorated mental health [ 64 ]. Getting locked-in increased mental symptoms over a ten-year period, while getting out of such situation improved mental health.

Bidirectional relations between health/behaviour and weak labour market attachment over life

The possible bidirectional relations between health/ health behaviour and later labour market attachment were analysed in almost all papers, by controlling for health/ health behaviour before exposure to the labour market. As it is well known that poor health and unfavourable health behaviours increase the risk of weak position on the labour market (so-called health-related selection), Several of our papers focused on the exposure effects, controlling for health selections [ 62 , 65 , 66 , 67 , 68 , 69 , 70 ].

An interesting finding is the almost lack of or weak effect of health selection -especially in young age– into later unemployment [ 52 , 65 ]. In fact, some of our research shows that the effects of exposure to unemployment in young age are stronger than the health-related selection [ 53 ].

Even with follow-ups until age 43, depressive symptoms in youth were not related to life-course trajectories (measured as sequence analyses) of weak labour market attachment [ 66 ].

Later in life, in young adulthood there is health-related selection into both unemployment [ 67 ] and temporary employment contracts [ 68 ], irrespective of exposure earlier in life. The findings may be interpreted as an indication of discrimination against those with mental health problems in the labour market.

The combination of macro- and other levels are of importance for how labour market position cause poor health

The theme includes macrolevel structures of major importance for how the labour market position can cause poor mental health over life. These structures include the construction of social class, which stratifies individuals into hierarchal social positions in relation to education, income, and occupation. These structures are powerful determinants of individuals life chances and health status during life [ 71 ].

Unfavourable school environment (rather than health) was a consistent determinant of negative inter- and intragenerational mobility between social classes [ 72 ]. Growing up in an unfavourable socioeconomic circumstance can cause a chain of risk of adverse living condition, which in turn affects adult mental health [ 73 ].

Accumulated unemployment as well as physical heavy work could explain the socio-economic gradient in self-rated health in young adulthood [ 74 ]. Early social adversities modify the relation between job characteristics and biological stress [ 75 ]. Thus, early disadvantages can have a long-term impact on vulnerability to work stress.

Macrolevel policies for facilitating the transition of unemployed into the labour market programmes have been in focus in our research. We conclude that there is a lack of research in the field, but a considered and consistent active labour market policy directed at youths could potentially reduce the short- and long-term mental health costs of youth unemployment [ 29 , 47 ].

Being in youth programmes between age 16 and 18 seem to be health promoting, compared to being unemployed. During the two-year follow-up, especially girls (and in relation to health behaviour also boys) in youth opportunity programmes improved their mental and health behaviour while mental health was impaired among boys and girls in unemployment [ 29 ]. Thus, youth opportunity programmes during this period of life seems to be health promotive.

Unequal gender relations at various levels impacts negatively on mental health

The societal gender order, constructed by multiple ideas about what is seen as feminine or masculine in a certain historical and societal context, is useful for understanding the gendered working conditions and its importance for health over life [ 77 ]. The gender order is built up by unequal gender relations, which permeates from the macro- to all other levels and creates the gender-segregated labour market, which divides men and women into different sectors and occupations as well as into gendered hierarchies.

The importance of gender equality at workplaces has been analysed on the exolevel in adulthood [ 21 ]. All employees at the workplaces, in which one or more participants worked, were included in the analyses. Register data was available, so a measure of gender equality was constructed (based on the proportion of men respectively women and the gender gradient in education, income, sick-leave, and parental leave), and analysed in relation to each workplace in which at least one participant in NoSCo worked. A cluster analysis resulted in six distinctive clusters with different patterns of gender equality at the workplaces that were associated to psychological distress among women [ 21 ]. For women the highest odds of psychological distress were found on traditionally gender unequal workplaces. The lowest psychological distress was found on the most gender equal workplaces, for both men and women. Thus, workplace gender equality was related to good mental health among both men and women.

The agency to improve health over life in dyadic relations in various microlevel settings

Agency refers to how individuals act within (or despite) social settings [ 78 ]. Thus, individuals can use agency to negotiate, challenge and transform their contexts and the surrounding intersecting power-structures, related to for example gender and social class.

The qualitative papers (see Table  2 ) illustrate how the participants constructed gender and developed agency in relation to their health over life.

A model of agency within structures was useful for analysing disposition to act and to capture the will and intentions of early unemployed men in relation to health [ 79 ]. The hardworking masculinity type of men developed agency by striving to fulfil the masculine ideal of working-class men in society by accepting all available jobs, despite hazardous work environments in jobs that were available for uneducated men on the labour market. Workplace accidents were common. In contrast, less agency was found in relation to the disconnected masculinity, which was related to development of pessimism and meaninglessness, as part of the young men’s lack of belief in having a future due to their marginalized position on the labour market. This masculine position could also be expressed by criminality or drug abuse. A more agentic and health-promoting masculine position was identified as connected masculinity, of caring and protection through hard work, in line with the collectively oriented welfare state ideas about responsibility for those unable to take care of themselves [ 79 ].

Among early unemployed women, we identified gender relations as ‘constructing respectability from disfavoured social positions’ [ 80 ]. Within this position, framed by dominant norms of patriarchal femininity, we explored the constructs of the agentic and health promoting normative and altruistic femininity as compared to the norm-breaking and risk-taking femininity related to health and health behaviours that became deteriorated.

Dyadic and complex relations were identified between unemployed persons and others in various settings at the microlevels, such as employment officers, employers, parents, and partners [ 81 ]. The macrolevel policies of moving to the South of Sweden influenced the relations between the unemployed youth and the employment officers. The young unemployed and their parents were upset about the advice for a 16-year-old to move alone far away and alone to a large city.

Relations with employers could be negative in terms of rejected job applications, getting insecure job contracts or no prolongation of contract [ 81 ]. The relations could also be very positive. Getting a job was felt as becoming a valuable citizen, given the possibilities of doing something valuable. A job could mean belonging to a team at the workplace, to be treated with respect and expected to be a capable worker. Having a job also lead to restricting late nights out drinking.

The macrolevel gender order shape relations in family so that the girls, but not the boys, were expected to do domestic duties while unemployed. Gendered caring responsibilities meant that becoming a mother was experienced as being a respectable position in society [ 80 ]. In addition, unemployed young men described how a girlfriend could be an important support for calming down after having lived a risk-taking life in relation to alcohol [ 79 ]. A girlfriend was described as important because you could talk to her; she gave hope to your life and could make you feel less restless. No similar stories about the positive impact of a boyfriend were told by the unemployed young women [ 79 ].

For young unemployed, relations to parents could be ambivalent [ 81 ]. They could be economic dependent on parents. But parents could also helpful. The young unemployed men could experience support from parents, e.g., help to find a job, financial support or to live with parents to avoid living a dangerous life.

A qualitative paper identified what macrolevel unemployment can mean for young people in work. “Living in the shadow of unemployment– an unhealthy life situation” implies that all young people may be influenced by the high rates of unemployment in society [ 81 ]. You may be forced to study as there are no jobs available. Also, the situation as employed is also coloured by the rate of unemployment in society. Due to lack of jobs and job insecurity you must take any job available despite poor work conditions and lack of safety regulations.

The paper also explored which possible mechanisms could explain how high levels of societal labour market processes could permeate down to the microlevel and cause scarring in the individual [ 81 ]. Negative feelings related to unemployment in young age– such as disappointment, dependence, distrust, and resignation– could become embedded in the mind and in the patterns of reactions to stressful life-events later in life rather than stir an active engagement against injustice and disappointments in life. Such negative feelings are closely embedded in depressive states and may be a key to our understanding of unemployment scarring.

Temporal dimensions

The life-course was mainly analysed according to the model of accumulation of exposure and, in relation to scarring also as models of sensitive periods [ 15 ]. Scarring per se can also be viewed as a temporal dimension, viewing the past being present as a permanent functional structure in the individual. Our use of trajectory analyses are also temporal methodological dimensions from past to present.

We developed the concept “lifetime analyses, controlled for earlier mental health” based on studies with mainly cross-sectional analyses, controlling for earlier health.

In the qualitative analyses, we identified a novel temporal dimension in relation to agency. The concept of agency is strongly linked to time because it represents a process that evolves over time. For example, if you lose your job, it takes time to respond to this in an agentic manner. It takes even longer time for the effect of the executed agency to manifest itself on the mental health of the individual for example when being employed again. The possible latitude of an individual’s agency is determined by several factors in the ecological system that may restrict it, such as macrolevel factors like inequality due to gender, social class and ethnicity that permeate all levels of the system. Factors which could facilitate agency include legislation or interventions in different social arenas such as labour market policies with the purpose of countering the mentioned agency-restricting phenomena. These circumstances further support the need of a complex integrative theoretical framework based on a system approach and with a strong notion of time as a fundamental element.

Concluding remarks

Mental health over life is shaped by the macrolevel structures of society defined by Bronfenbrenner and the labour market context surrounding the individual on both close and more distant levels. Neighbourhood disadvantages have a small but consistent negative impact on the individual’s health, especially in young age. Weak labour market attachment negatively impacts the mental health of the individual over life, in addition to bidirectional processes like health selection. Unemployment has the same negative health effects in both boom and recession. Those in other labour market positions (studies, work) have impaired health during recession, but without long-term effects. Macrolevel structures of importance for how labour market position caused poor health, include class and gender structures and processes, as well as labour market policies which were beneficial for health.

Our contextual life-course model, which integrates Bronfenbrenner’s Ecological Systems Theory model [ 3 ] with various temporal dimensions (see Fig.  1 ) is fruitful for providing a deeper understanding of how labour market conditions in various contexts influence mental health over life. As suggested by Elder [ 1 ], a mixed-method design, combining quantitative and qualitative methods, contributed to further development of the temporal dimensions and to new themes such as the impact of agency to improve mental health over life in dyadic relations at various microlevel settings.

A contextual life-course model. Conceptualization of the Bronfenbrenner model on various societal levels and the models of life-course epidemiology in relation to our empirical findings in the integrative review

According to Bronfenbrenner, research on the ecological system of human development should preferably include experiments involving the systems mentioned [ 3 ]. However, experiments performed in a laboratory lacking a minimum of context, proved to be a problematic approach heavily criticized by himself. Instead, he suggested that ‘natural experiments’ represented by implementation of changes in relevant policies, could be a fruitful approach if they could be operationalized in a clever mode. The huge and unexpected financial crisis of the early 1990s can be regarded as such a macrolevel experiment, which hit human beings differently depending on which developmental phase and which context they were in. This “experiment” is part of our metasynthesis. Other experiments, which are also part of our paper, consist of labour market policies and our analyses indicate their possible health promoting effects.

Our development of the contextual life-course model is of special importance to understand the health consequences of the rapidly developing labour market. Another framework for understanding the process of the gradual deterioration of the social rights components of the standard employment contract between employer and employee in a developed welfare state– i.e., full-time employment with income and employment security, paid vacation and pension rights, health insurance, functioning work safety measures and workplace democracy – has been proposed by Guy Standing [ 82 ].

Theoretical models are needed to further develop life-course epidemiology in relation to the rapidly changing labour market, as frameworks can help to structure ideas as well as explain disease distribution and causal relations between exposures and outcomes.

Our overall conclusion is that the labour market conditions surrounding the individual are of crucial importance for the embodiment of mental health over life, at the same time as individual agency can be health promoting. Mental health can be improved by societal efforts in regulations of the labour market.

Data availability

The datasets analysed during the current study are not publicly available due to the Swedish Act (SFS 2003:460) on ethical review of research involving humans, which does not permit sensitive data on humans to be freely shared. Parts of the datasets are available after ethical permission and after request to the PI (AH).

Elder GH. The Life Course as Developmental Theory. Child Dev. 1998;69(1):1–12.

Article   PubMed   Google Scholar  

Krieger N. Ecosocial Theory, embodied truths, and the people’s Health. Oxford: Oxford University Press; 2021.

Book   Google Scholar  

Bronfenbrenner U. The ecology of human development. Cambridge, MA: Harvard University Press; 1979.

Theorell T, et al. A systematic review including meta-analysis of work environment and depressive symptoms. BMC Public Health. 2015;15(1):738.

Article   PubMed   PubMed Central   Google Scholar  

Wahrendorf M, et al. Adverse employment histories and allostatic load: associations over the working life. J Epidemiol Community Health. 2022;76(4):374–81.

ILO. Non-standard employment around the world: Understanding challenges, shaping prospects. Geneva: International Labour Office 2016.

Bodin T et al. Trends in Precarious Employment in Sweden 1992–2017: A Social Determinant of Health. Int J Environ Res Public Health. 2022;19(19):12797. https://doi.org/10.3390/ijerph191912797

Benach J, Vives A, Amable M, Vanroelen C, Tarafa G, Muntaner C. Precarious employment: understanding an emerging social determinant of health. Annu Rev Public Health. 2014;35(1):229–53.

Article   CAS   PubMed   Google Scholar  

Karasek RA, Theorell T. Healthy work: stress, productivity and the reconstruction of working life. New York: Basic Books; 1990.

Google Scholar  

Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol. 1996;1:27–41.

Jahoda M. Employment and unemployment. Cambridge, England: University; 1982.

Brunner E. Socioeconomic determinants of health: stress and the biology of inequality. BMJ. 1997;314:1472.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Schneiderman N, Ironson G, Siegel SD. Stress and health: psychological, behavioral, and Biological determinants. Ann Rev Clin Psychol. 2004;1:607–28.

Article   Google Scholar  

Aronsson G, Gustafsson K, Dallner M. Work environment and health in different types of temporary jobs. Eur J Work Organizational Psychol. 2002;11(2):151–75.

Kuh D, Ben-Shlomo Y. A life course approach to chronic disease epidemiology. Oxford Univ. Press. 2004.

Amick BC, McLeod CB, Bültmann U. Labor markets and health: an integrated life course perspective. Scand J Work Environ Health. 2016;42(4):346– 53

Hammarström A, Janlert U. Cohort profile: the Northern Swedish Cohort. Int J Epidemiol. 2012;41(6):1545–52.

Ziaei S, Hammarström A. What social determinants outside paid work are related to development of mental health during life? An integrative review of results from the Northern Swedish Cohort. BMC Public Health. 2021;21(1):2190.

Novo M. Young and unemployed - does the trade cycle matter for health? A study of young men and women during times of prosperity and times of recession. Umeå, Umeå University; 2000.

Gustafsson PE, San Sebastian M, Janlert U, Theorell T, Westerlund H, Hammarström A. Residential selection across the life course: adolescent contextual and individual determinants of neighborhood disadvantage in mid-adulthood. PLoS ONE. 2013;8(11):e80241.

Elwer S, Harryson L, Bolin M, Hammarström A. Patterns of gender Equality at workplaces and Psychological Distress. PLoS ONE. 2013;8(1).

Hammarström A. Youth unemployment and ill-health. Results from a two-year follow-up study (thesis, monograph). Solna and Sundbyberg: Karolinska Institute, The National Institute of Psychosocial Factors and Health and the Department of Social Medicine Kronan, 1986.

Hammarström A, et al. Addressing challenges of validity and internal consistency of mental health measures in a 27- year longitudinal cohort study - the Northern Swedish Cohort study. BMC Med Res Methodol. 2016;16:4. https://doi.org/10.1186/s12874-015-0099-6 .

Singh-Manoux A, Martikainen P, Ferrie J, Zins M, Marmot M, Goldberg M. What does self rated health measure? Results from the British Whitehall II and French Gazel cohort studies. J Epidemiol Community Health. 2006;60(4):364–72.

Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546–53.

Schick-Makaroff K, Macdonald M, Plummer M, Burgess J, Neander W, Lundman B. What synthesis methodology should I use? A Review and Analysis of Approaches to Research Synthesis. AIMS Public Health 2016;3(1)172-15.

Graneheim UH, Lindgren B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurs Educ Today. 2004;24(2):105– 12.

Graneheim UH, Lindgren BM, Lundman B. Methodological challenges in qualitative content analysis: a discussion paper. Nurse Educ Today. 2017;56:29–34.

Hammarström A, Janlert U, Theorell T. Youth unemployment and ill health: results from a 2-year follow-up study. Soc Sci Med. 1988;26(10):1025–33.

Hammarström A, Virtanen P. The importance of financial recession for mental health among students: short- and long-term analyses from an ecosocial perspective. J Public Health Res. 2019;8(2):1504.

Novo M, Hammarström A, Janlert U. Do high levels of unemployment influence the health of those who are not unemployed? A gendered comparison of young men and women during boom and recession. Soc Sci Med. 2001;53(3):293–303.

Berg N, Virtanen P, Bean C, Lintonen T, Nummi T, Hammarström A. The relevance of macroeconomic conditions on concurrent and subsequent alcohol use– results from two northern Swedish cohorts. Addict Res &Theory. 2020;28(6):501–9.

Virtanen P, Hammarström A, Janlert U. Children of boom and recession and the scars to the mental health–a comparative study on the long-term effects of youth unemployment. Int J Equity Health. 2016;15:14.

Novo M, Hammarström A, Janlert U. Health hazards of unemployment–only a boom phenomenon? A study of young men and women during times of prosperity and times of recession. Public Health. 2000;114(1):25–9.

Brydsten A, Gustafsson PE, Hammarström A, San Sebastian M. Does contextual unemployment matter for health status across the life course? A longitudinal multilevel study exploring the link between neighborhood unemployment and functional somatic symptoms. Health Place. 2017;43:113–20.

Gustafsson PE, San Sebastian M, Janlert U, Theorell T, Westerlund H, Hammarström A. Life-course accumulation of neighborhood disadvantage and allostatic load: empirical integration of three social determinants of health frameworks. Am J Public Health. 2014;104(5):904–10.

Gustafsson PE, San Sebastian M. When does hardship matter for health? Neighbourhood and individual disadvantages and functional somatic symptoms from adolescence to mid-life in the Northern Swedish Cohort. PLoS ONE. 2014;9(6):e99558.

Gustafsson PE, Hammarström A, San Sebastian M. Cumulative contextual and individual disadvantages over the life course and adult functional somatic symptoms in Sweden. Eur J Public Health. 2015;25(4):592–7.

Johansson K, San Sebastian M, Hammarström A, Gustafsson PE. Neighbourhood disadvantage and individual adversities in adolescence and total alcohol consumption up to mid-life-results from the Northern Swedish Cohort. Health Place. 2015;33:187–94.

Gustafsson PE, Bozorgmehr K, Hammarström A, Sebastian MS. What role does adolescent neighborhood play for adult health? A cross-classified multilevel analysis of life course models in Northern Sweden. Health Place. 2017;46:137–44.

Jonsson F, San Sebastian M, Hammarström A, Gustafsson P. Are neighbourhood inequalities in adult health explained by socio-economic and psychosocial determinants in adolescence and the subsequent life course in northern Sweden? A decomposition analysis. Health Place. 2018;52:127–34.

Strandh M, Winefield A, Nilsson K, Hammarström A. Unemployment and mental health scarring during the life course. Eur J Public Health. 2014;24(3):440–5.

Brydsten A, Hammarström A, Strandh M, Johansson K. Youth unemployment and functional somatic symptoms in adulthood: results from the Northern Swedish cohort. Eur J Public Health. 2015;25(5):796–800.

Hammarström A, Janlert U. Early unemployment can contribute to adult health problems: results from a longitudinal study of school leavers. J Epidemiol Community Health. 2002;56(8):624–30.

Norström F, Janlert U, Hammarström A. Is unemployment in young adulthood related to self-rated health later in life? Results from the Northern Swedish Cohort. BMC Public Health. 2017;17(1):529.

Virtanen P, Lintonen T, Westerlund H, Nummi T, Janlert U, Hammarström A. Unemployment in the teens and trajectories of alcohol consumption in adulthood. BMJ Open. 2016;6(3):e006430.

Strandh M, Nilsson K, Nordlund M, Hammarström A. Do open youth unemployment and youth programs leave the same mental health scars? - evidence from a Swedish 27-year cohort study. BMC Public Health. 2015;15.

Hammarström A. Health consequences of youth unemployment. Public Health. 1994;108:403–12.

Janlert U, Winefield AH, Hammarström A. Length of unemployment and health-related outcomes: a life-course analysis. Eur J Public Health. 2015;25(4):662–7.

Reine I, Novo M, Hammarström A. Does the association between ill health and unemployment differ between young people and adults? Results from a 14-year follow-up study with a focus on psychological health and smoking. Public Health. 2004;118(5):337–45.

Hammarström A, Gustafsson PE, Strandh M, Virtanen P, Janlert U. It’s no surprise! Men are not hit more than women by the health consequences of unemployment in the Northern Swedish Cohort. Scand J Public Health. 2011;39(2):187–93.

Hammarström A, Janlert U. Nervous and depressive symptoms in a longitudinal study of youth unemployment–selection or exposure? J Adolesc. 1997;20(3):293–305.

Janlert U, Hammarström A. Alcohol consumption among unemployed youths: results from a prospective study. Br J Addict. 1992;87(5):703–14.

Waenerlund AK, Virtanen P, Hammarström A. Is temporary employment related to health status? Analysis of the Northern Swedish Cohort. Scand J Public Health. 2011;39(5):533–9.

Waenerlund AK, Gustafsson PE, Virtanen P, Hammarström A. Is the core-periphery labour market structure related to perceived health? Findings of the Northern Swedish Cohort. BMC Public Health. 2011;11:956.

Virtanen P, Janlert U, Hammarström A. Exposure to nonpermanent employment and health: analysis of the associations with 12 health indicators. J Occup Environ Med. 2011;53(6):653–7.

Waenerlund AK, Gustafsson PE, Hammarström A, Virtanen P. The Northern Swedish Cohort. History of labour market attachment as a determinant of health status: a 12-year follow-up of the Northern Swedish Cohort. BMJ Open. 2014;4(2):e004053.

Gustafsson PE, Janlert U, Virtanen P, Hammarström A. The association between long-term accumulation of temporary employment, the cortisol awakening response and circadian cortisol levels. Psychoneuroendocrinology. 2012;37(6):789–800.

Hammarström A, Virtanen P, Janlert U. Are the health consequences of temporary employment worse among low educated than among high educated? Eur J Public Health. 2011;21(6):756–61.

Reine I, Novo M, Hammarström A. Does transition from an unstable labour market position to permanent employment protect mental health? Results from a 14-year follow-up of scool-leavers. BMC Public Health. 2008;8:159.

Samuelsson A, Houkes I, Verdonk P, Hammarström A. Types of employment and their associations with work characteristics and health in Swedish women and men. Scand J Public Health. 2012;40(2):183–90.

Virtanen P, Janlert U, Hammarström A. Exposure to temporary employment and job insecurity: a longitudinal study of the health effects. Occup Environ Med. 2011;68(8):570–4.

Nyberg A, Rajaleid K, Westerlund H, Hammarström A. Does social and professional establishment at age 30 mediate the association between school connectedness and family climate at age 16 and mental health symptoms at age 43? J Affect Disord. 2018;246:52–61.

Virtanen P, Hammarström A, Janlert U. Locked in Permanent Employment-Longitudinal associations with depressive and functional somatic symptoms. J Occup Environ Med. 2021;63(7):588–93.

Hammarström A, Janlert U. Do early unemployment and health status among young men and women affect their chances of later employment? Scand J Public Health. 2000;28(1):10–5.

PubMed   Google Scholar  

Landstedt E, Brydsten A, Hammarström A, Virtanen P, Almquist Brännström Y. The role of social background and mental health in adolescence for life-course trajectories of education and work: a cohort study. BMC Public Health. 2016;16(1):1169.

Virtanen P, Janlert U, Hammarström A. Health status and health behaviour as predictors of the occurrence of unemployment and prolonged unemployment. Public Health. 2013;127(1):46–52.

Virtanen P, Janlert U, Hammarström A. Suboptimal health as a predictor of non-permanent employment in middle age: a 12-year follow-up study of the Northern Swedish Cohort. Int Arch Occ Env Hea. 2013;86(2):139–45.

Berg N, Kiviruusu O, Huurre T, Lintonen T, Virtanen P, Hammarström A. Associations between unemployment and heavy episodic drinking from adolescence to midlife in Sweden and Finland. Eur J Public Health. 2018;28(2):258–63.

Veldman K, Pingel R, Hallqvist J, Bean C, Hammarström A. How does social support shape the association between depressive symptoms and labour market participation: a four-way decomposition. Eur J Public Health. 2022;32(1):8–13.

Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661–9.

Novak M, Ahlgren C, Hammarström A. Social and health related correlates of inter-generational and intra-generational social mobility among Swedish men and women. Public Health. 2012;126(4):349–57.

Khatun M, Ahlgren C, Hammarström A. The influence of factors identified in adolescence and early adulthood on social class inequities of musculoskeletal disorders at age 30: a prospective population-based cohort study. Int J Epidemiol. 2004;33(6):1353–60.

Jonsson F, San Sebastian M, Strömsten LM, Hammarström A, Gustafsson PE. Life Course pathways of adversities linking adolescent socioeconomic circumstances and functional somatic symptoms in Mid-adulthood: a path analysis study. PLoS ONE. 2016;11(5):e0155963.

Hammarström A, Stenlund H, Janlert U. Mechanisms for the social gradient in health - results from a 14-year follow-up of the Northern Sweden Cohort. Public Health. 2011;125(9):567–76.

Westerlund H, Gustafsson PE, Theorell T, Janlert U, Hammarström A. Social Adversity in Adolescence increases the physiological vulnerability to job strain in Adulthood: a prospective Population-based study. PLoS ONE. 2012;7(4).

Connell R. Gender in a world perspective. Cambridge: Polity; 2009.

Boyadjieva P, Ilieva-Trichkova P. (Un)realized agency in a situation of early job insecurity: patterns of young people’s agency regarding employment. In: Hvinden B, Hyggen C, Schoyen MA, Sirovátka T, editors. Youth unemployment and job insecurity in Europe: problems, risk factors and policies. Cheltenham: Edward Elgar Publishing; 2019. pp. 117–36.

Hammarström A, Lundman B, Ahlgren C, Wiklund M. Health and Masculinities shaped by Agency within structures among Young Unemployed men in a Northern Swedish Context. PLoS ONE. 2015;10(5):e0124785.

Wiklund M, Ahlgren C, Hammarström A. Constructing respectability from disfavoured social positions: exploring young femininities and health as shaped by marginalisation and social context. A qualitative study in Northern Sweden. Glob Health Action. 2018;11(sup3):1519960.

Hammarström A, Ahlgren C. Living in the shadow of unemployment -an unhealthy life situation: a qualitative study of young people from leaving school until early adult life. BMC Public Health. 2019;19(1):1661.

Standing G. The precariat. The new dangerous class. London: Bloomsbury Academic; 2011.

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Acknowledgements

The authors would like to thank the participants of the Northern Swedish Cohorts and the Department of Epidemiology and Global Health at Umeå University for collaboration regarding the use of the database. We would also like to thank all co-authors of the analysed publications for theoretical and empirical contributions.

Open access funding provided by Karolinska Institute. The work was supported by grants from The Swedish Research Council Formas (grant number 259–2012-37).

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Anne Hammarström & Shirin Ziaei

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Anne Hammarström & Urban Janlert

Stress Research Institute, Stockholm University, Stockholm, Sweden

Hugo Westerlund

Faculty of Social Sciences, Tampere University, Tampere, Finland

Pekka Virtanen

Social Medicine and Global Health, Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden

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AH designed the study in discussion with all co-authors. AH was main responsible for all data collections of the Northern Sweden Cohorts. AH and SZ made the qualitative analyses. All authors read and contributed to all parts of the paper. All authors approved the final version.

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Hammarström, A., Westerlund, H., Janlert, U. et al. How do labour market conditions explain the development of mental health over the life-course? a conceptual integration of the ecological model with life-course epidemiology in an integrative review of results from the Northern Swedish Cohort. BMC Public Health 24 , 1315 (2024). https://doi.org/10.1186/s12889-024-18461-6

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Sacred space: a qualitative interpretive meta-synthesis of women’s experiences of supportive birthing environments

• December Maxwell 1 ,
• Sarah R. Leat 2 ,
• Toni Gallegos 3 &
• Regina T. Praetorius 3  

BMC Pregnancy and Childbirth volume  24 , Article number:  372 ( 2024 ) Cite this article

Metrics details

In the United States there are roughly three million births a year, ranging from cesarean to natural births. A major aspect of the birthing process is related to the healing environment, and how that helps or harms healing for the mother and child. Using the theoretical framework, Theory of Supportive Care Settings (TSCS), this study aimed to explore what is necessary to have a safe and sacred healing environment for mothers.

This study utilized an updated Qualitative Interpretive Meta-synthesis (QIMS) design called QIMS-DTT [deductive theory testing] to answer the research question, What are mother’s experiences of environmental factors contributing to a supportive birthing environment within healthcare settings?

Key terms were run through multiple databases, which resulted in 5,688 articles. After title and abstract screening, 43 were left for full-text, 12 were excluded, leaving 31 to be included in the final QIMS. Five main themes emerged from analysis: 1) Service in the environment, 2) Recognizing oneself within the birthing space, 3) Creating connections with support systems, 4) Being welcomed into the birthing space, and 5) Feeling safe within the birthing environment.

Conclusions

Providing a warm and welcoming birth space is crucial for people who give birth to have positive experiences. Providing spaces where the person can feel safe and supported allows them to find empowerment in the situation where they have limited control.

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Introduction

In 2021, there were 3,664,292 births in the United States. Of those birth, 98.3% took place in hospitals [ 1 ]. In hospital settings, medical interventions such as induction of labor, cesarean sections, and the use of instruments like forceps or vacuum extractors may be more common [ 2 ]. These interventions can carry risks such as increased likelihood of complications for both the birthing person and the baby [ 2 , 3 ]. Some women may feel stressed or anxious in a hospital setting, which could potentially slow down labor or lead to other complications. This stress can be due to various factors such as unfamiliar surroundings, medical procedures, or concerns about interventions [ 2 ]. In a hospital setting, decisions about the birth process may be influenced by hospital policies, medical protocols, and the preferences of healthcare providers, potentially leading to a loss of autonomy for the birthing person in decision-making about their own birth experience [ 4 ]. The experience of giving birth in a hospital, especially if it involves unexpected interventions or complications, can contribute to postpartum depression or anxiety in some women [ 5 ]. Hospital routines and policies may not always be conducive to establishing breastfeeding immediately after birth, which can lead to challenges in breastfeeding initiation and continuation [ 6 ].

Birthing requires healing and a supportive environment at every stage of the birthing process, consisting of holistic support and agency [ 7 ]. This involves “constant emotional, physical, spiritual, and psychosocial” support [ 8 ]. Experiencing birthing trauma has shown to result in postpartum post-traumatic stress disorder (P-PTSD) and postpartum depression (PPD) [ 9 , 10 , 11 ]. Likewise, disempowering births can have long term impacts of maternal self-esteem [ 12 , 13 ]. Maternal mental health issues have resulted in numerous public health concerns, specifically regarding the decreased safety and negative health outcomes that the infant faces [ 14 , 15 ]. Postpartum mental health disorders can also have lasting impacts on family outcomes [ 16 , 17 ]. As such, understanding how to improve the birth experience has the potential to reduce postpartum mental health issues, as well as reduce maternal morbidities, which can improve outcomes for both mother and child.

Of note is the influence of the built environment on healing. Given that thoughtfully designed healthcare facilities can influence the amount of privacy and control a patient perceives [ 18 ], the built environment plays an integral part in healing. Ample daylight, thermal comfort, color, and noise control all contribute to environmental healing within a hospital [ 19 ]. Furthermore, patient health outcomes have been linked to the built environment of hospitals in multiple studies [ 13 , 20 , 21 ]. More specific to birthing, women have indicated that perceived hominess and control in the environment relate to their birthing experience [ 20 , 22 , 23 ].

Control over the birthing environment, including comfort and perceived healing also have mental health impacts for birthing mothers, and the birth environment can have an impact on the mother’s perception of the birth which in turn can influence maternal mental health outcomes [ 24 , 25 ]. Given that approximately 1 in 7 mothers will experience postpartum depression (PPD) in the United States [ 26 , 27 ] and 0.05%-60% of mothers will experience PPD globally [ 28 , 29 ], understanding the impact of birthing environment on maternal morbidities and mental health can create holistic approaches to birthing environment design.

Given the impacts of the birthing environment on maternal mental health, learning what is necessary to have a safe and sacred healing environment for mothers is an important endeavor and the purpose of this qualitative interpretive meta-synthesis (QIMS). A QIMS is a method that is specific to the social work field. It was created to review and analyze qualitative data to identify and synthesize themes surrounding different phenomena found in existing qualitative research [ 30 ]. QIMS has previously been used to synthesize existing data regarding social justice concerns around minority police encounters [ 31 ] and children’s exposure to intimate partner violence [ 32 ]. Concerning the topic of birthing and motherhood, one QIMS explored marginalized women’s experiences of postpartum depression [ 33 ] and another explored the experience of suicidality postpartum [ 34 ]. To date, no QIMS has considered the experiences of the birth environment for birthing mothers and the impact on maternal mental health. A synthesis of the literature qualitatively evaluating women’s perspectives on what is necessary to have a safe and sacred healing environment for mothers could bolster understanding of how hospitals could better support birthing mothers. As such, this study uses QIMS to answer the following research question: what is necessary to have a safe and sacred healing environment for mothers?

Theoretical framework

This study sought to understand how birthing mothers experienced the birthing environment and which environmental factors contributed to a safe and sacred healing environment for mothers. As such, the Theory of Supportive Care Settings (TSCS) was used to frame this synthesis [ 35 ].

Theory of supportive care settings

Theory of Supportive Care Settings (TSCS) was created through research to have a theoretical understanding of which “processes supported a supportive care setting” [ 35 ]. TSCS was developed using three different care settings–a hospice, geriatric, and acute care ward, through qualitative interviews with patients, significant others, and care staff’s experiences. Although TSCS was not developed within the birthing environment, given the raise of childbirth induced P-PTSD, it is appropriate to apply the concepts to the birthing environment. One aspect of this synthesis is to assess the utility of the application of TSCS to the birthing environment using it as the main theoretical approach. There are five main processes the theory addresses as creating a supportive care environment: experiencing welcoming in the environment, recognizing oneself in the environment, creating and maintaining social relations in the environment, experiencing a willingness to serve in the environment, and experiencing safety in the environment. An applied theoretical framework was created (Fig.  1 ).

Framework of theory of supportive birth settings

Experiencing welcoming in the environment

Experiencing welcoming in the environment has three properties which are intensely experienced when the patient first enters the healthcare setting [ 35 ]. Being expected is the first property that involves the care setting knowing the patient is coming. This happens by having the patient’s name displayed and knowing pertinent information about the person before the beginning of care [ 35 ]. Being seen entails a warm welcome upon entering the care setting, having personal introductions, and care staff showing an interest [ 35 ]. Lastly, being invited consists of being shown around the care setting for the patient to become familiar with the environment and the people within [ 35 ].

Certainly, experiencing welcoming in a care setting, such as a hospital, heightens mood among patients and increases their satisfaction with their experience of the care setting [ 36 ]. Within a birthing environment, there is also evidence that being believed and welcomed upon arrival to the hospital increases the satisfaction of mothers as well as enhances their birthing experience [ 37 ].

Recognizing oneself in the environment

Within TSCS, recognizing oneself in the environment encapsulates the intensity of which patients recognize themselves within the care environment [ 35 ]. For example, environments that are perceived as too sterile do not allow the patient to recognize themselves in the environment. Being able to recognize oneself in the care setting includes being in a familiar and calm environment [ 35 ]. A familiar environment includes objects that are familiar to the patients, as well as beauty in the environment that includes windows and warm colors [ 35 ]. Further, a calm environment has minimal loud noises from machines, phones, and patients are allowed to move freely [ 35 ]. Features of familiarity in the birthing environment can reduce the length of labor and reduce pain intensity [ 38 ].

Creating and maintaining social relations in the environment

Creating and maintaining social relations in the environment within TSCS describes the social relations a patient develops that create ease within the environment [ 35 ]. Within this concept, there are two processes: staying in contact with social relations and creating new social relations. Staying in contact entails the patient’s ability to stay in contact with those in their social circles while undergoing care and can include environmental factors that facilitate this such as access to a personal phone and privacy to visit with social relations while in care. Creating new social relations explains the way patients can create new social relationships through positive interactions such as those that include laughter and support from care staff or others in the care setting. The process further includes the structural environment and facilitation of such connections, including openness of concept, support places, and comfortable furniture in private and common areas of the care setting [ 35 ].

This process of TSCS is again supported in literature regarding birthing environments. Availability of social support is integral to the birthing experience and increased access to social support creates better birthing outcomes and perceptions of birth [ 39 ]. Similarly, those supporting the birth need to feel welcomed and included in the birth environment, and there are specific aspects of the built environment that facilitate increased support during birth such as familial alcoves in birthing rooms and increased attempts at including the supporter by care setting providers [ 40 ].

Experiencing a willingness to serve in the environment

The willingness to serve in the environment from TCSC involves both care staff and patients. In TSCS doing a little extra and receiving a little extra are the processes that promote a willingness to serve. To the patients, seeing the care staff demonstrate thoughtful actions shows the staff’s willingness to serve. These actions can include things like remembering a patient’s preferences for their pillow or water temperature or arranging food in an appealing way. The willingness to serve can also come from patients though; some patients reaching out to other patients to give support or even just showing caring attitudes towards either nurses or other patients. For patients, an environment which demonstrates the willingness to serve is one when care staff do things without being asked, are intuitive in their approaches, and do not make the patient feel like a burden [ 35 ].

Within the birthing environment, willingness to serve can look like staff providing welcome distractions from the birthing process through music or aromatherapy, dimming lights, changing ambient temperature, and ensuring loud sounds are minimal. Further, care staff can exhibit willingness to serve by advocating for the birthing mother to have less people in the room, creating a familiar space, and providing comfort [ 38 ].

Experiencing safety in the environment

TSCA defines safety in the birthing environment as the safe feelings that arise from knowing what is happening, feeling informed, being comforted, and feeling trustful of care providers. Understanding what is happening includes, knowing what is happening, having information in an accessible language, and being aware of the course of events. For the patient, being is safe hands means having trust in the providers through honest conversations, knowing that their needs and requests are honored, and that the physical environment is clean, organized, and aesthetically pleasing rather than chaotic and messy [ 35 ].

The safety in the birthing environment often ties honest conversations and knowing needs and requests will be met to feel in control over the birth and the experience. Feeling in control of the birth environment can also include creating a familiar, homey space by being allowed to personalize the space with music, design elements like personal photos, pillows, or plants, and controlling the temperature and lighting [ 40 ]. In addition, knowing that healthcare providers are respecting the birth plan as much as possible and supporting freedom to move and move through the birth process in their own way [ 38 ]. Furthermore, machinery that ties the mother down, inhibiting freedom to move, can be distracting and reduce the time midwives or nurses spend in the birthing room, diminishing the birthing mother’s trust in care providers [ 41 ].

Despite the lack of use of TCSC in birthing environment literature, all five concepts from TCSC are found within the existing literature to be recommended for use in birthing environments. That said, there is not a synthesis to date utilizing the framework to evaluate qualitative perspectives of the birthing environment. This review aims to organize the existing qualitative literature within TCSC to provide a roadmap for birthing space design that aligns with a supportive care environment, with the hopes of creating more functional birthing spaces which may reduce the rates of maternal mental health challenges following the birth of a child.

Ethics, consent for publication, availability of data and materials

The data used in this study are derived from publicly available, published research articles and thus, in the public domain. Similarly, Institutional Review Board approval was not required since all data used were in the public domain in publicly available, published research articles. Informed consent was not required as no participants were recruited to participate in this study. There is no identifiable information of participants used in this method nor do we as consumers of previously published qualitative research have access to the original data.

QIMS is a method that lets researchers find a deeper understanding of a phenomenon or shared experience using qualitative journal articles as secondary data. QIMS is focused on researchers synthesizing previously published qualitative findings on a topic across the literature to reveal insights of participants’ experiences with a phenomenon [ 30 ]. This process includes creating a research question, conducting a systematic search of existing literature, and finally analyzing identified articles through theme extraction, synthesis, and triangulation [ 30 ].

QIMS has a set analysis process that involves reviewing the original authors’ published themes, as well as the participant's quotations in the manuscript. Themes and quotations are extracted and compiled into a new dataset to capture participants’ experiences of shared phenomenon across literature, providing a larger, more diverse sample size.

Sometimes, the analysis ends with a methodological reduction as well. Methodological reduction is an accepted method within phenomenological inquiry that permits researchers to understand the phenomena being observed through a new contextual lens allowing for further abstraction [ 42 ]. That said, due to the paucity of research evaluating what is necessary to have a safe and sacred healing environment for mothers, this study utilized a rare approach to QIMS wherein the theoretical framework was provided at the outset of the study to guide the entirety of the synthesis. This deviates from the more inductive approach of traditional QIMS, but this deductive approach allows for a more pointed answer to a specific research question that seeks to operationalize a construct within a distinctive context or population and has been used previously [ 30 ]. Essentially, this analysis approach used a combination of both QIMS and theory-testing deductive analysis methods. The theory guides each step of the QIMS process, and specific steps have been applied (see Fig.  2 ). This combined approach is formalized here and is called QIMS-DTT [deductive theory testing].

Associations of birthing environment to Theory of Supportive Care Settings 

First, in line with theory-testing deductive analysis [ 43 ], a qualitative question was posed with a specific theoretical lens in mind, in this case, Edvardsson’s Theory of Supportive Care Setting. Then, following QIMS, a systematic search of the literature was conducted using PRISMA guidelines [ 44 ]. The keywords for the initial search included “birth or childbirth or labour or labor or delivery or birthing” as subject terms. The key terms “experiences or experience” and “qualitative” were added to “in abstract” as well as “birthing experiences” and “birthing perceptions.” Key terms were searched within the following databases: ERIC, Academic Search Complete, APA PsycInfo, CINAHL Complete, Family Studies Abstracts, MedicLatina, MEDLINE, Psychology and Behavioral Sciences Collection, Alt HealthWatch. This initial search yielded 5,688 articles. After duplicates were removed 5,167 articles remained. The title and abstract screened for content relating to the desired topic, and inclusion and exclusion criteria were applied.

Inclusion criteria were that the studies were U.S. based only, included pregnant women’s experiences of hospital or birthing center birth, and were qualitative research with quotations presented in the article. Inclusion was limited to U.S. based studies given that birthing practices differ vastly across the world; focusing on the U.S. provides homogeneity of context for understanding the birthing environment impact. Furthermore, even though the U.S. is a high resource country, the perinatal care system is considered unique as requires private pay insurance and not every woman has access to Medicaid or Medicare federal and state funded health insurance programs [ 45 ]. Furthermore, among 11 high resourced countries, the U.S. has the highest maternal mortality rate, which some scholars attribute to how the U.S. has the lowest supply of obstetricians and heavily lacks midwives and insurance coverage for midwifery care [ 46 ]. Theory was incorporated here as well as an inclusion criterion, and the results were filtered through the operationalization of Edvardsson’s Theory of Supportive Care Setting used for this study. Using the five constructs of the theory that were operationalized for this study, the articles were included if authors discussed at least one construct from the theory (the constructs that articles discussed can be found in Table  1 ). Articles not discussing at least one of the five constructs of the theory were excluded. In addition, other exclusion criteria included articles discussing future births or expectations about future births, choice of location for birth, mode of delivery, labor pain, healthcare providers’ perspectives, existing reviews or syntheses, and articles discussing techniques of or towards birthing [e.g., acupuncture, Lamaze, education]. After title and abstract screening, 3,178 articles were excluded, leaving 43 articles to be screened full text. During the full-text screen, 12 articles were excluded, leaving 31 total articles to be included in the QIMS.

Following this approach (inclusive of both QIMS and theory-testing deductive analysis) we have formalized within this study, the original themes (Table  2 ) from the articles were organized by one researcher into appropriate theoretical assumptions that most aligned with the constructs of TSCS (See Table  1 –providing theoretical triangulation). Then, the quotations from each article were extracted and uploaded to qualitative software, atlas.ti (v.8.1). The quotations were coded deductively by the first two authors using the theoretical framework as a guide for thematic development. The themes were then aligned with each of the five theoretical constructs by unanimous rating. This process provided a layer of analyst triangulation additional to the triangulation inherent in QIMS design resulting from triangulation in the individual studies prior to the QIMS.

Instrumentation

In addition to the analysis process, it is also important for researchers to bracket, or disclose, their experiences with a phenomenon to increase the trustworthiness of the synthesis. The authors are the main instruments of this study, as is frequently the case in qualitative research. To further lend credibility and transparency to the QIMS process, brief descriptions of the authors can be found in Table  3 . The authors purposefully include two mothers–one who experienced Postpartum Mood and Anxiety Disorders (PMADs) and one who did not, and two women who were not mothers at the time of this writing. This intentionally focused toward balancing any biases the two mothers might have brought to the analyses given their experiences further explained in Table  3 .

The final sample included 30 qualitative studies giving ear to the voices of 1,802 postpartum mothers. These mothers ranged in age from 12 to 71 and represented a wide range of races and ethnicities. For more demographic information including data collection methods and settings, see Table  4 .

Using a theory-testing deductive analysis process in conjunction with QIMS, the analysis results in five themes with various subthemes. The supporting quotations can be found in Table  5 . In addition, thematic constructs of TSCS were found across the included articles and the theoretical deduction was sound. Evidence of theoretical constructs can be found in Table  1 .

Theme 1: service in the environment

The first theme consists of ways that participants experienced service within the birthing environment. This service can be either from the healthcare team or the woman themselves and can be expressed in ways more encompassing than just direct labor. Participants described providers who exhibited exceptional care as a memorable part of their birthing experience. This aspect of service within the environment contributed to warm feelings towards their providers and allowed them to feel important and cared for. Many described how taking time out of their busy schedules to focus on the woman one-on-one, accommodating disabilities or medical conditions without being asked, and going out of their way to encourage and empower women was how a provider demonstrated “above and beyond” care.

Theme 2: recognizing oneself within the birthing space

The second theme described how birthing persons saw themselves within the birthing space. This included their personhood being acknowledged and their maternal role being validated by providers.

Subtheme 2A: acknowledging personhood

Recognizing oneself within the environment should be facilitated by feeling acknowledged as persons with dignity. For participants in these studies, this was expressed in their experiences of not having their personhood acknowledged and valued during the birthing process. One participant was not allowed to walk to the bathroom and was also not clearly told why. Her dignity was wounded, and the situation introduced emotional trauma into her birth story. Other women had a similarly emotionally traumatic experience that compromised their dignity and devalued their personhood.

Subtheme 2B: validating maternal role

Validation in becoming a mother is an important step in a woman’s transition into motherhood. The birth is an experience that will forever impact how the person views their maternal role. Many participants felt that their role as mother was overlooked by providers or not validated in a way that made them feel unequipped to mother their children. Often, participants described how providers made decisions for their newborns for them without consulting or trusting them to make such decisions.

Theme 3: creating connections with support systems

The third theme describes the ability of participants to forge or maintain social connection while experiencing birth. This could be availability of social support through communication from providers or through inclusion of support persons. Furthermore, disrespect hampered the formation of social connections.

Subtheme 3A: communication is key

This subtheme revolved around the necessity of communication to forge a strong, trusting social connection between provider and women. This communication included informing the women of medically necessary interventions and allowing them to understand the necessity of them before consenting when medically possible. Communication also included introducing themselves and accepting a patient introduction genuinely through learning womens’ names and making eye contact and gathering consent before touching the client. When providers communicated in this fashion, the participants indicated that they felt a stronger social bond to the providers and their trust and satisfaction with them was increased.

Subtheme 3B: team effort among providers

Relationships required a team effort, which meant that multiple providers needed to be on the same page and operating in good communication with one another to support mothers. Participants in the included studies described how both providers and the birthing person, as well as their support people could work together to ensure the birthing process was a positive one. Others explained that when providers did not work together or communicate among each other the birthing process felt chaotic and disjointed, leaving them feeling unsatisfied and unsafe.

Subtheme 3C: respect forges social connection

This sub theme describes how care providers can forge social connection with their patients through respecting the wishes of the birthing person. Examples included respecting their birthing plan even when it was not medically necessary, allowing the birthing person to make choices about pain interventions, and not respecting the minimal birthing requests that were not related to medical interventions. Conversely, not hearing or respecting the birthing person created a negative experience which was detrimental to social connection in the birthing space.

Theme 4: being welcomed into the birthing space

The fourth theme that emerged encompassed participants’ desires to be welcomed into the birthing space. This involved experiences of being admitted into the maternity ward or birthing suite upon arrival at the hospital and being made to feel comfortable in the space.

Subtheme 4A: being believed and admitted

Participants within the included articles discussed the importance of being believe when they presented to the hospital in what they perceived as active labor. Participants described being unsure if the sensations they were feeling were in labor and expressed anxiety as to whether they would be admitted into the maternity ward. Participants worried that if they arrived at the hospital too early, they would be treated poorly for “over-reacting” and be sent home, even though they were in pain. Participants also described the feeling of being rejected as failure. Being admitted into the birthing space was crucial for participants in the included articles to feel supported and validated.

Subtheme 4B: comfortable birthing space

In addition to being admitted, having the birthing space be comfortable was also necessary for participants to feel welcomed. Participants described spaces that had enough room for all their family members, single-occupancy rooms that allowed the birthing mother to have the whole room to herself, and rooms that had calming items present to be the most comfortable. In addition, participants in the included articles described experiences of uncomfortable spaces. Several participants expressed discomfort at having to be moved to multiple locations within the hospital. Participants also found hospitals challenging to navigate which caused stress on the family and the laboring mothering. Some participants described how the temperature of the space affected them as well, with the ability to control the temperature helping them to feel comfortable, both themselves and their families.

Theme 5: feeling safe within the birthing environment

The fifth theme encompasses various ways birthing persons felt or did not feel safety in the birthing environment. Either through consent in procedures, being able to follow birth plans, having freedom to move, and having trust and confidence in the healthcare team, there were many ways participants expressed their perceptions of safety in the birthing environment.

Subtheme 5A: interpersonal safety

This theme described how interpersonal relationships contributed to feeling safety in the birthing environment. Participants in the original studies talked about how they took action to ensure they had interpersonal safety through choosing obstetricians that felt safe to them, either due to gender or validation tactics. Others described how having continuity of care when possible created safe feeling interpersonal relationships, such as having the same nurse throughout or when they did change shifts- the outgoing nurse took extra steps to introduce the new nurse and supported the forging of an interpersonal relationship between birthing person and new nurse. Having a familiar face consistently throughout the birthing process was comforting. In addition, many quotations described how a provider could focus on the woman in a way that was comforting and forged and interpersonal connection by ensuring they knew they were being heard and supported.

Subtheme 5B: Confidence in the healthcare team

Feeling safe in the birthing environment was also influenced by how much confidence the women had in their healthcare team. Some participants in the original study described how they trust doctors because they know better through education, while others felt like their care providers were not listening to their concerns, eroding their trust and making them feel unsafe. Others explained actions the healthcare team took to ruin the trust between them, either by not sharing the full truth of the current process or by giving false information. When the providers were not honest with their patients, the birthing person was less likely to feel safe and therefore it tainted their birthing experience with anxious feelings.

Subtheme 5C: Feeling in control of the birth

Participants also described feeling in control of the space allowed them to feel safe within the birthing space. Participants who were given the ability to make decisions about positions, movements, and even presented with a way to watch the birth felt in control and supported by staff. Conversely, participants who were restricted in their movement felt trapped.

The findings of this QIMS-DTT highlight what is necessary to have a safe and sacred healing environment for mothers. Filtered through the adapted Theory of Supportive Care Settings, the findings of this deductive theory-testing study found multiple overlaps with the theoretical approach and as such, propose the importance of utilizing a Theory of Supportive Birthing Environments when evaluating birthing care environments. The five main components of Edvardsson’s theory can be found across all included articles and in the findings of this QIMS-DTT, making the findings unique in the application of the theory as a framework to approach environmental birth design.

For instance, a novel finding was the participant-described need for a welcoming birthing environment, including their initial admission to the hospital, being believed, and validated about their labor process, and the birthing environment itself being welcoming to them and their support persons. The initial moments upon arrival at the birthing facility or the presence of the healthcare team can significantly impact the birthing person's emotional well-being, comfort, and sense of security. Indeed, research does indicate that a warm welcome can help alleviate these feelings by making the birthing person feel valued, respected, and cared for from the moment they arrive. A positive and supportive atmosphere can contribute to a more relaxed state of mind [ 47 ]. Although the findings illuminate that a warm welcome into the birthing environment is critically important as it sets the tone for the entire childbirth experience, there is scant literature on this phenomenon as an attribute of the birth environment experience. A warm welcome also fosters trust and rapport between the birthing person and the healthcare team [ 46 ] which is essential for effective communication and cooperation throughout labor and childbirth. When trust is established early on, it can lead to a more collaborative and positive birthing experience. Beyond alleviating stress, feeling welcomed and respected empowers the birthing person to actively engage in their care and decision-making [ 47 ]. When they are treated with kindness and dignity, they are more likely to voice their preferences, concerns, and questions, leading to informed decision-making [ 47 , 77 ]. As many participants shared, the birthing environment itself was responsible for the welcoming feeling and contributed to a positive and comfortable birthing environment. In this study, this included friendly greetings, a clean and inviting room, soft lighting, and soothing sounds. Such an environment can promote relaxation and facilitate a smoother labor and birth [ 77 ].

The findings also illuminate the importance of social connection within the birthing space, through feeling respected and heard, clear communication, and acknowledgment and validation. Social relationships, including those with partners, family members, friends, and healthcare providers, offer emotional support during a time that can be physically and emotionally challenging. Previous literature has supported these findings, indicating that when there are people who care about the birthing person's well-being and provide comfort and encouragement, it can reduce stress and anxiety for the birthing person [ 40 ]. Trust is a critical component of any healthcare relationship, especially during childbirth [ 52 ]. Unique within these findings, however, is the importance of social connection between the women and providers on the recounting of birth stories and satisfaction with the birth environment. Furthermore, although support by providers is well documented, the findings here offer a unique approach as establishing these relationships as a facet of the birth environment. Establishing trust with healthcare providers and support staff is essential for effective communication, which, in turn, leads to better decision-making and a more positive birthing experience.

Safety in the environment was a salient finding of this study, and with good reason. Participants expressed that having interpersonal safety, seeing a good team effort among healthcare providers, and confidence in that healthcare team all contributed to their perceptions of safety in the birthing environment. Creating feelings of safety in the birthing environment is of paramount importance for several reasons. A safe and supportive birthing environment not only ensures the physical well-being of the birthing person and baby but also has a profound impact on the overall childbirth experience. Feelings of safety help reduce stress and anxiety during labor and childbirth [ 78 ]. Perceived safety benefits medical providers as well- when the birthing environment is perceived as safe, it can facilitate the release of endorphins, the body's natural pain relief hormones, and contribute to a smoother labor and birth process without unnecessary medical interventions [ 79 ].

Another important, but already substantiated, finding within safety in the environment was the element of control and agency within the birthing environment that was necessary to have positive birth experiences. Participants engaged in self-advocacy and described the importance of feeling in control over the birthing process to their well-being. Agency and control in the birthing environment are documented crucial aspects of the childbirth experience, as they can significantly impact the physical and emotional well-being of the birthing person and their overall satisfaction with the process [ 45 ]. When birthing people have a sense of agency and control over their birth experience, they report higher levels of satisfaction with the process, regardless of whether their birth unfolds as planned or not [ 45 ]. Agency and control also empower the birthing person to make informed decisions about their birth plan and medical interventions and endorse their maternal role. Informed decision-making allows individuals to choose the options that align with their values, preferences, and health needs. Notably, the findings in this study indicate that when birthing persons do not feel in control of their birth, they had poor retrospective memories about their birth and sometimes felt shame or anger about it. Indeed, a lack of agency and control during childbirth can sometimes lead to feelings of trauma or dissatisfaction [ 80 ]. Although this phenomenon is well documented, the findings from this review contextualize the need for agency and control within the theoretical approach and creates a more comprehensive look at birth environment attributes.

Implications for providers and research

The findings of this study illuminate numerous implications for providers and researchers. For providers, the knowledge that a warm welcome extends beyond them to the entire birthing team, including nurses, midwives, doulas, and support persons. A cohesive and supportive team that welcomes the birthing person with open arms can enhance the overall birthing experience. Furthermore, welcoming includes initial contact and the way a birthing person is received and treated upon arrival can significantly influence their overall perception of their birth experience. A warm welcome contributes to positive birth memories and can have long-lasting emotional and psychological benefits [ 47 ].

Empowering birthing people to have control over their experience can help reduce the risk of trauma. Establishing trust and effective communication between the birthing person, their support team, and healthcare providers is essential for maintaining agency and control. When there is open dialogue and mutual respect, the birthing person is more likely to feel comfortable expressing their preferences and concerns. In some cases, having control over the birthing environment can lead to better physical outcomes. For example, a birthing person who can move freely, choose their birthing position, and have access to comfort measures may experience shorter labor and fewer complications [ 77 ]. In addition, providers should recognize that every birthing experience is unique and respecting cultural and individual differences is essential for promoting agency and control. What one person values or finds empowering in their birthing experience may differ from another, and healthcare providers should strive to accommodate these variations. More research may be needed to understand the prevalence of agency and control better quantitatively in the birthing environment and its relationship to maternal mental health outcomes using measurements surveying the birth environment that combine the attributes of the framework presented in the findings.

Building social relationships in the birthing environment can create a supportive and celebratory atmosphere. The birthing person, their partner, and their support network can share in the joy and excitement of welcoming a new life into the world, enhancing the overall experience.

Social relationships formed during childbirth can extend into the postpartum period, providing ongoing emotional support, advice, and assistance as the birthing person navigates the challenges of early parenthood. Social relationships in the birthing environment can also be a source of valuable information and education. Healthcare providers and support persons can share knowledge about the birthing process, available options, and potential interventions, empowering the birthing person to make informed decisions.

Another implication for providers is building a culture of safety within the environment. When the birthing environment feels unsafe or traumatic, it can have long-lasting negative effects on the birthing person's mental and emotional well-being. Feelings of trauma during childbirth can lead to post-traumatic stress disorder [PTSD] and have a significant impact on future pregnancies [ 80 , 81 ]. Safety also includes trust. Trust is a cornerstone of the birthing experience and when the birthing person trusts their healthcare providers and the birthing environment, they are more likely to follow recommendations, cooperate with care plans, and have a positive overall experience. More research is needed to better understand how women experience trust in the birthing environment specifically, including better understanding of the frequencies of agency, consent, and control over their environments. In addition, research surveying the use of interdisciplinary communication and communication mechanisms with women regarding birth plans might illuminate fragmented communication in the birth environment.

Limitations

Within this study there were some primary limitations related to sampling of studies. When identifying studies through databases and services such as GoogleScholar, embargoes and artificial intelligence interference [e.g., search algorithms] create challenges in replicating and updating searches. For this study, the search was initially conducted then redone to ensure all studies were identified since sufficient time had passed since the initial search. Although exact keywords and procedures were followed from search one to search two, algorithms and embargoes may have led to some key studies not emerging in the search. A second limitation is that given the breadth of birthing environments and cultural orientations to birthing, despite the number of studies analyzed, it is likely that some experiences are not represented in this study.

While the experiences of the participants appeared to range, the scope of the search did not include birthing person experiences outside of the US. Consequently, this leaves the results of this study to only be applicable to what is needed in the small context of the US. Problems that are faced by participants in this study may not be seen as harmful to others. Likewise, since QIMS-DTT is a social work focused method, it can limit how the researchers approached the material from the participants. This can be related to the complex nature of constraints that are often faced in the health-care field. Furthermore, there is a limitation related to the relevancy of applying the TSCS to the birthing space. A key difference between the concept of service in birthing space is that mothers only spend an average of 24 to 48 h in the birthing space, whereas those in nursing care, the environmental in which TSCS originated, could spend an extended period of time in the environment.

In conclusion, a new framework using the Theory of Supportive Care Settings can be applied to evaluate a sacred and healing birthing experience. This new framework includes a balance of already documented phenomenon such as agency and control during birth, as well as integrates new findings, such as the necessity of a warm welcome into the birthing environment to promote trust, comfort, and empowerment. Indeed, the importance of a welcoming environment cannot be overstated. It sets the initial tone for the birthing experience, influencing the individual's stress levels and emotional state, which, in turn, can affect the physiological aspects of childbirth. This study supports the hypothesis from applying TSCS to the birth environment that when individuals feel welcomed, they are more likely to experience a sense of calm and readiness for birth, which can lead to more positive outcomes.

Our study contributes to the growing body of literature that underscores the significance of the birth environment in shaping birth experiences. It calls for a reevaluation of current practices and environments in which childbirth takes place, advocating for a more holistic approach that encompasses emotional, psychological, and physical well-being. The implications of our findings extend beyond the individual, suggesting that by improving birth experiences, we can foster better early bonding experiences, potentially leading to long-term benefits for both the mother and child.

Authors’contributions

Authors DM and SL contributed to the initial design and concept. DM, SL, RT, and TG all performed data collection, data analysis, interpretation of results, and drafting of the article. All authors made substantial contributions to the initial and revised manuscript. All authors have read and approved the final version and are accountable for all aspects of the work.

Availability of data and materials

The data used in this study are from publicly available existing literature, therefore the data is available within this article from the data tables.

Grünebaum A, Bornstein E, McLeod-Sordjan R, Lewis T, Wasden S, Combs A, et al. The impact of birth settings on pregnancy outcomes in the United States. Am J Obstet Gynecol. 2023;228(5):S965–76.

Article   PubMed   Google Scholar  

Çalik KY, Karabulutlu Ö, Yavuz C. First do no harm - interventions during labor and maternal satisfaction: a descriptive cross-sectional study. BMC Pregnancy Childbirth. 2018;18(1):415.

Article   PubMed   PubMed Central   Google Scholar  

Lothian JA. Healthy birth practice #4: avoid interventions unless they are medically necessary. J Perinat Educ. 2014;23(4):198–206.

Zolkefli ZHH, Mumin KHA, Idris DR. Autonomy and its impact on midwifery practice. Br J Midwifery. 2020;28(2):120–9.

Article   Google Scholar  

Ahmadpour P, Faroughi F, Mirghafourvand M. The relationship of childbirth experience with postpartum depression and anxiety: a cross-sectional study. BMC Psychol. 2023;11(1):58. https://doi.org/10.1186/s40359-023-01105-6 .

George EK. Birth Center Breastfeeding Rates. MCNAm J Matern Child Nurs. 2022;47(6):310–7.

Parratt J, Fahy K. Creating a ‘safe’ place for birth: an empirically grounded theory. New Zealand College Midwives J. 2004;30. [cited 2020 Apr 17]. Available from: https://epubs.scu.edu.au/hahs_pubs/1657

Akbaş P, ÖzkanŞat S, Yaman SŞ. The effect of holistic birth support strategies on coping with labor pain, birth satisfaction, and fear of childbirth: a randomized, triple-blind. Controlled Trial Clin Nurs Res. 2022;31(7):1352–61.

Soet JE, Brack GA, DiIorio C. Prevalence and Predictors of Women’s Experience of Psychological Trauma During Childbirth. Birth. 2003;30(1):36–46. https://doi.org/10.1046/j.1523-536X.2003.00215.x . [cited 2017 Sep 7].

Moran Vozar TE, Van Arsdale A, Gross LA, Hoff E, Pinch S. The elephant in the delivery room: Enhancing awareness of the current literature and recommendations for perinatal PTSD. Pract Innov. 2021;6(1):1–16.

Orovou E, Eskitzis P, Mrvoljak-Theodoropoulou I, Tzitiridou-Chatzopoulou M, Dagla M, Arampatzi C, et al. The Relation between Neonatal Intensive Care Units and Postpartum Post-Traumatic Stress Disorder after Cesarean Section. Healthcare. 2023;11(13):1877.

Forssén ASK. Lifelong significance of disempowering experiences in prenatal and maternity care. Qual Health Res. 2012;22(11):1535–46.

Olwanda E, Opondo K, Oluoch D, Croke K, Maluni J, Jepkosgei J, et al. Women’s autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study. BMC Womens Health. 2024;24(1):181.

Letourneau NL, Dennis CL, Benzies K, Duffett-Leger L, Stewart M, Tryphonopoulos PD, et al. Postpartum depression is a family affair: addressing the impact on mothers, fathers, and children. Issues Ment Health Nurs. 2012;33(7):445–57.

Tripathy P. A public health approach to perinatal mental health: Improving health and wellbeing of mothers and babies. J Gynecol Obstet Hum Reprod. 2020;49(6).

VanderKruik R, Barreix M, Chou D, Allen T, Say L, Cohen LS, et al. The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry. 2017;17(1):272. [cited 2017 Sep 7]. Available from:  http://www.ncbi.nlm.nih.gov/pubmed/28754094 .

Walker AL, Peters PH, de Rooij SR, Henrichs J, Witteveen AB, Verhoeven CJM, et al. The long-term impact of maternal anxiety and depression postpartum and in early childhood on child and paternal mental health at 11–12 years follow-up. Front Psychiatry. 2020;15:11.

Google Scholar  

Huisman ERCM, Morales E, van Hoof J, Kort HSM. Healing environment: A review of the impact of physical environmental factors on users. Build Environ. 2012;1(58):70–80.

Simonsen T, Sturge J, Duff C. Healing Architecture in Healthcare: A Scoping Review. HERD: Health Environ Res Design J. 2022;15(3):315–28.

Asadi Z, Shahcheraghi A, Zare L, Gharehbaglou M. The effect of supportive care environment on the treatment process in hospitals: a qualitative study. Crescent J Med Biol Sci. 2023;10(2):81–92.

Nielsen JH, Overgaard C. Healing architecture and Snoezelen in delivery room design: a qualitative study of women’s birth experiences and patient-centeredness of care. BMC Pregnancy Childbirth. 2020;20(1):283.

Shin JH. Hospital Birthing Room Design: A Study Of Mothers’ Perception Of Hominess. J Inter Des. 2004;30(1):23–36. [cited 2020 Apr 17] Available from: https://doi.org/10.1111/j.1939-1668.2004.tb00397.x

Kuipers YJ, Thomson G, Goberna-Tricas J, Zurera A, Hresanová E, Temesgenová N, et al. The social conception of space of birth narrated by women with negative and traumatic birth experiences. Women and Birth. 2023;36(1):e78–85.

Borquez HA, Wiegers TA. A comparison of labour and birth experiences of women delivering in a birthing centre and at home in the Netherlands. Midwifery. 2006;22[4]:339–47. [cited 2019 Feb 21]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16647170

Preis H, Lobel M, Benyamini Y. Between Expectancy and Experience. Psychol Women Q. 2018;036168431877953. [cited 2019 Jan 19].  https://doi.org/10.1177/0361684318779537

Ko JY, Rockhill KM, Tong VT, Morrow B, Farr SL. Trends in Postpartum Depressive Symptoms — 27 States, 2004, 2008, and 2012. MMWR Morb Mortal Wkly Rep. 2017;66(6):153–8. [cited 2019 May 14] Available from: http://www.cdc.gov/mmwr/volumes/66/wr/mm6606a1.htm

Mughal S, Azhar Y, Siddiqui W. Postpartum Depression. 2024.

Abdollahi F, Lye MS, Zain AM, Ghazali SS, Zarghami M. Postnatal depression and its associated factors in women from different cultures. Iran J Psychiatry Behav Sci. Kowsar Medical Publishing Company; 2011;5(2):5–11.

Abenova M, Myssayev A, Kanya L, Turliuc MN, Jamedinova U. Prevalence of postpartum depression and its associated factors within a year after birth in Semey, Kazakhstan: A cross sectional study. Clin Epidemiol Glob Health. 2022;16:101103.

Aguirre RT, Bolton KW. Qualitative interpretive meta-synthesis in social work research: Uncharted territory. J Soc Work. 2014;14(3):279–94. [cited 2019 Jan 14].  https://doi.org/10.1177/1468017313476797

Nordberg A, Marcus Crawford BR, Regina Praetorius BT, Smith Hatcher S. Exploring Minority Youths’ Police Encounters: A Qualitative Interpretive Meta-synthesis. Adolescent Soc Work J. 2016;33(2):137–49. [cited 2018 Feb 20]. Available from: https://search-proquest-com.ezproxy.uta.edu/docview/1772422660?pq-origsite=summon

Ravi KE, Casolaro TE. Children’s Exposure to Intimate Partner Violence: A Qualitative Interpretive Meta-synthesis. Child Adolescent Soc Work J. 2017;1–13. [cited 2018 Feb 20]. https://doi.org/10.1007/s10560-017-0525-1

Maxwell D, Robinson SR, Rogers K. “I keep it to myself”: a qualitative meta-interpretive synthesis of experiences of postpartum depression among marginalised women. Health Soc Care Community. 2019;27(3):e23–6.

Praetorius R, Maxwell D, Alam K. Wearing a happy mask: mother’s expressions of suicidality with postpartum depression. Soc Work Ment Health. 2020;18(4):429–59.

Edvardsson JD, Sandman PO, Rasmussen BH. Sensing an atmosphere of ease: A tentative theory of supportive care settings. Scand J Caring Sci. 2005;19(4):344–53. [cited 2021 May 27]. Available from: https://pubmed.ncbi.nlm.nih.gov/16324058/

Leather P, Beale D, Santos A, Watts J, Lee L. Outcomes of environmental appraisal of different hospital waiting areas. Environ Behav. 2003;35(6):842–69.

Vedam S, Stoll K, Khemet Taiwo T, Rubashkin N, Cheyney M, Strauss N, et al. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health. 2019;16(1):77. [cited 2020 May 4]. Available from: https://doi.org/10.1186/s12978-019-0729-2

Nilsson C, Wijk H, Höglund L, Sjöblom H, Hessman E, Berg M. Effects of birthing room design on maternal and neonate outcomes: a systematic review. HERD. SAGE Publications Inc.; 2020;13(3):198–214.

Reid KM, Taylor MG. Social support, stress, and maternal postpartum depression: A comparison of supportive relationships. Soc Sci Res. 2015;54:246–62.

Harte JD, Sheehan A, Stewart SC, Foureur M. Childbirth supporters’ experiences in a built hospital birth environment: exploring inhibiting and facilitating factors in negotiating the supporter role. Health Environ Res Design J. 2016;9(3):135–61.

Hodnett E, Stremler R, Weston J, McKeever P. Re-conceptualizing the hospital labor room: the PLACE [Pregnant and Laboring in an Ambient Clinical Environment] pilot trial. Birth. 2009;36(2):159–66.

Van Maanen J. Ethnography as work: some rules of engagement. J Manage Stud. 2011;48(1):218–34.

Vargas-Bianchi L. Qualitative theory testing by deductive design and pattern matching analysis. SocArxiv. https://doi.org/10.31235/osf.io/w4gxe . Published online July 30, 2020.

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;29: n71.

Scrimshaw SC, Backes EP, editors. Birth Settings in America. Washington, D.C.: National Academies Press; 2020.

Admon LK, Dalton VK, Kolenic GE, et al. Trends in suicidality 1 year before and after birth among commercially insured childbearing individuals in the United States, 2006–2017. JAMA Psychiatry. Published online November 18, 2020. https://doi.org/10.1001/jamapsychiatry.2020.3550

Attanasio LB, McPherson ME, Kozhimannil KB. Positive childbirth experiences in US hospitals: a mixed methods analysis. Matern Child Health J. 2014;18(5):1280–90.

Beebe KR, Humphreys J. Expectations, perceptions, and management of labor in nulliparas prior to hospitalization. J Midwifery Womens Health. 2006;51(5):347–53.

Bernhard C, Zielinski R, Ackerson K, English J. Home birth after hospital birth: women’s choices and reflections. J Midwifery Womens Health. 2014;59(2):160–6.

Boucher D, Bennett C, McFarlin B, Freeze R. Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health. 2009;54(2):119–26.

Brooks JL, Holdtich-Davis D, Docherty SL, Theodorou CS. Birthing and parenting a premature infant in a cultural context. Qual Health Res. 2016;26(3):387–98.

Fair CD, Morrison T. “I felt part of the decision-making process”: a qualitative study on techniques used to enhance maternal control during labor and delivery. Int J Childbirth Educ. 2011;26(3):21–5.

Finn JM. Culture care of euro-american women during childbirth: using leininger’s theory. J Transcult Nurs. 1994;5(2):25–37.

Article   CAS   PubMed   Google Scholar  

Fowles ER. Labor concerns of women two months after delivery. Birth. 1998;25(4):235–40.

Gardner M, Suplee PD, Bloch J, Lecks K. Exploratory study of childbearing experiences of women with asperger syndrome. Nurs Womens Health. 2016;20(1):28–37.

Hall PJ, Foster JW, Yount KM, Jennings BM. Keeping it together and falling apart: Women’s dynamic experience of birth. Midwifery. 2018;58:130–6.

Hill N, Hunt E, Hyrkäs K. Somali immigrant women’s health care experiences and beliefs regarding pregnancy and birth in the United States. J Transcult Nurs. 2012;23(1):72–81.

Lipson JG, Rogers J. Pregnancy, birth, and disability: women’s health care experiences. Health Care Women Int. 2000;21(1):11–26.

Low LK, Martin K, Sampselle C, Guthrie B, Oakley D. Adolescents’ experiences of childbirth: contrasts with adults 1, 2 . J Midwifery Womens Health. 2003;48(3):192–8.

Low LK, Moffat A. Every Labor is Unique. MCN Am J Matern Child Nurs. 2006;31(5):307???312.

Lynch TA, Cheyney M, Chan M, Walia J, Burcher P. Temporal themes in periviable birth: a qualitative analysis of patient experiences. Matern Child Health J. 2019;23(3):422–30.

Lyndon A, Malana J, Hedli LC, Sherman J, Lee HC. Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth. J Obstet Gynecol Neonatal Nurs. 2018;47(3):324–32.

McKinney D. A Qualitative Study of the Bradley Method of Childbirth Education. International Journal of Childbirth Education. 2006;21(3).

Qureshi R, Pacquiao DF. Ethnographic study of experiences of Pakistani women immigrants with pregnancy, birthing, and postpartum care in the United States and Pakistan. J Transcult Nurs. 2013;24(4):355–62.

Raines DA, Morgan Z. Culturally sensitive care during childbirth. Appl Nurs Res. 2000;13(4):167–72.

Sauls DJ. Promoting a positive childbirth experience for adolescents. J Obstet Gynecol Neonatal Nurs. 2010;39(6):703–12.

Seo JY, Kim W, Dickerson SS. Korean immigrant women’s lived experience of childbirth in the United States. J Obstet Gynecol Neonatal Nurs. 2014;43(3):305–17.

Sheffield SM, Liddell JL. “If I Had a Choice, I’d Do It Natural”: Gulf South indigenous women’s preferences and experiences in childbirth. Int J Childbirth. 2023;13(1):23–36.

Smeltzer SC, Wint AJ, Ecker JL, Iezzoni LI. Labor, delivery, and anesthesia experiences of women with physical disability. Birth. 2017;44(4):315–24.

Taniguchi H, Baruffi G. Childbirth overseas: The experience of Japanese women in Hawaii. Nurs Health Sci. 2007;9(2):90–5.

Tiedje LB, Price E, You M. Childbirth Is Changing What Now? MCN Am J Matern Child Nurs. 2008;33(3):144–50.

VandeVusse L. Decision making in analyses of women’s birth stories. Birth. 1999;26(1):43–50.

Yeo S, Fetters M, Maeda Y. Japanese couples’ childbirth experiences in michigan: implications for care. Birth. 2000;27(3):191–8.

LoGiudice JA, Beck CT. The lived experience of childbearing from survivors of sexual abuse: “It Was the Best of Times, It Was the Worst of Times.” J Midwifery Womens Health. 2016;61(4):474–81.

Mackey MC. Women’s evaluation of the labor and delivery experience. Nursingconnections. 1998;11(3):19–32.

CAS   PubMed   Google Scholar  

Matthews R, Callister LC. Childbearing women’s perceptions of nursing care that promotes dignity. J Obstet Gynecol Neonatal Nurs. 2004;33(4):498–507.

Ayerle GM, Schäfers R, Mattern E, Striebich S, Haastert B, Vomhof M, et al. Effects of the birthing room environment on vaginal births and client-centred outcomes for women at term planning a vaginal birth: BE-UP, a multicentre randomised controlled trial. Trials. 2018 Nov 19;19(1):NA-NA.

Hollins Martin C, Fleming V. The birth satisfaction scale. Int J Health Care Qual Assur. 2011;24(2):124–35.

Uvnäs-Moberg K. The physiology and pharmacology of oxytocin in labor and in the peripartum period. Am J Obstet Gynecol. 2024;230(3):S740–58.

Tatano BC. A metaethnography of traumatic childbirth and its aftermath: amplifying causal looping. Qual Health Res. 2011;21(3):301–11.

Beck CT. Birth trauma and its sequelae. J Trauma Dissociation. 2009;10(2):189–203.

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Maxwell, D., Leat, S.R., Gallegos, T. et al. Sacred space: a qualitative interpretive meta-synthesis of women’s experiences of supportive birthing environments. BMC Pregnancy Childbirth 24 , 372 (2024). https://doi.org/10.1186/s12884-024-06544-6

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From isolation to revival: trade recovery amid global health crises

• Lijuan Yang   ORCID: orcid.org/0000-0003-2042-6431 1  

Globalization and Health volume  20 , Article number:  38 ( 2024 ) Cite this article

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The COVID-19 pandemic has highlighted the importance of designing effective trade recovery measures in response to global health events (GHEs). This study combines international trade risk management theory and multi-case comparative analysis of past GHEs to present a theoretical framework for designing national trade recovery measures for future events.

The research finds that during GHEs, trade risks shift to fundamental uncertainty, requiring spatial–temporal-subject dimension recovery measures. The study suggests changing the focus of trade recovery policy design from emergency-oriented and single-dimension measures to reserve-oriented and enduring-effect measures of comprehensive dimensions at micro- and macroeconomic levels.

The study contributes to the debate on managing trade risks in times of crisis, where there is a need to develop effective trade recovery measures that account for the complexities of global trade and the unique challenges of GHEs. The findings provide practical guidance for trade officials and policymakers to design measures in response to GHEs to improve a country’s overall trade recovery.

Global health events (GHEs), defined as pandemics or crises that widely influence people’s health, have major repercussions. Countries affected by GHEs Footnote 1 need to implement trade recovery measures to resume trade [ 1 ]. Footnote 2 These measures are crucial for mitigating the risks of capital, trade, and supply chain disruptions caused by disasters, reducing the burden of epidemics, and boosting national and global economies. Current research on GHEs is concentrated on medicine and public health issues, and only a few economic studies have been conducted [ 2 , 3 , 4 , 5 ]. Even this limited research has tended to peak alongside health events and bottom out when they end. The process of recovering from GHEs by taking comprehensive measures has rarely been discussed. Therefore, by applying international trade risk management theory and multi-case studies, this study examines the design of national trade recovery measures and offers countermeasures for GHEs.

Fifteen GHEs have occurred since the 1990s (Table  1 ), highlighting that their economic impact exceeds their immediate health consequences and regional spread [ 6 ]. Geographically distant health events can potentially reverberate to unaffected countries through international trade [ 7 ]. GHEs adversely affect the country of origin, trade partners, and the global economy [ 8 ]. Globalization has further exacerbated this negative impact. Footnote 3 GHEs affect foreign trade. Footnote 4 The transfer effects of trade bans can drastically harm welfare [ 9 , 10 ], leading to structural fractures in imports and exports [ 11 ]. Moreover, biosecurity measures during disease outbreaks [ 12 ] can indirectly influence technical trade measures that affect emerging countries’ exports to developed countries.

Scholars advocate the following strategies to respond to GHEs. (1) Conducting response measures. Once a global health emergency is under control, it enters the international trade recovery stage. The countries involved in the event must renegotiate trade agreements with their trading partners, strengthen consumer expectations and confidence, and evaluate response measures [ 13 , 14 ]. (2) Planning and sequencing measures. The international trade recovery must transcend the risk model to plan and prioritize trade recovery measures based on the interdependence between public health and trade [ 15 , 16 ]. The affected areas must take pre- and post-prevention and mitigation measures after the disaster outbreak [ 17 ]. (3) Implementing regional measures. The United States (US) adopted regional measures to manage the highly pathogenic avian influenza pandemic and to resume and maintain trade. Trading partner countries accepted the regional recommendations and allowed poultry and poultry product imports from US regions without the disease [ 18 ].

Furthermore, countries must address factors influencing trade recovery, as various factors determine the extent of adverse effects on trade and the duration of recovery. Emerging countries need to follow and strictly enforce the standards of the World Health Organization (WHO) [ 19 ] and deal with dynamic changes in trade and supply chain nodes during GHEs [ 20 , 21 , 22 , 23 , 24 ]. These efforts should include modeling and scenario simulation based on epidemiology and economic theory [ 25 , 26 ], risk rating of GHEs [ 27 ], and artificial intelligence modeling for potential risks [ 28 ]. The models under continuous development must reflect the dynamic landscape of emergent situations [ 29 ].

Although the WHO and multilateral institutions do not recommend interrupting international trade following a GHE, limited research has provided targeted suggestions for countries to adopt an appropriate course of action [ 30 , 31 ]. The interconnectedness of global health and the global economy highlights the need for such a policy and the relevance of health security efforts [ 7 ] to mitigate immediate health risks and long-term economic disruption. Including economic policies as part of GHE policies leads to collaboration between epidemiologists and economists in an economy-wide pandemic or public health crisis modeling, thereby demonstrating potential benefits [ 32 , 33 ].

This study posits that trade recovery is a dynamic process; hence, designing appropriate trade recovery measures should consider spatiotemporal dimensions and specific stakeholders at various subject levels. Research on developing trade recovery measures covers the spatial dimension but overlooks the time dimension. Lee et al. [ 34 ] established spatiotemporal modeling but did not distinguish different subject levels. Combining the spatiotemporal dimension and specific subject levels in trade recovery measures is essential for their success, ensuring adaptability and coverage across diverse economies. Additionally, comparative studies on countries’ trade recovery after different GHEs are limited, and research on trade recovery measures remains restricted to a single dimension. A clear framework for countermeasures is yet to be developed.

This study investigates trade recovery measures in countries affected by GHEs. The method includes a theoretical analysis based on international trade risk management with comparative multi-case studies. This methodology was developed by scholars such as Stake [ 35 ] and Yin [ 36 ], who formalized the approach as a tool for conducting in-depth explorations within real-life contexts. This qualitative research method enables the examination of complex phenomena within their specific settings, making it particularly suitable for understanding the nuanced implications of trade recovery measures across different geopolitical and socio-economic landscapes.

We construct a time–space-subject recovery measure framework, combining cases from the trade recovery measures adopted by Mexico, the US following the outbreak of influenza A H1N1, Japan following nuclear leakage triggered by a tsunami, three West African countries (Guinea, Liberia, and Sierra Leone) following the outbreak of Ebola, and South Korea following the outbreak of the Middle East Respiratory Syndrome (MERS). The framework is to design trade recovery measures for possible future events and for countries that are yet to recover from the COVID-19 pandemic.

Historically, the case method has been leveraged in public health and international policy research [ 6 , 12 , 37 ], offering insights into policy development and implementation. Its adoption in this study, rather than more quantitative methods, allows for a deep, contextual analysis of policy effectiveness and adaptability in diverse scenarios, thereby enhancing our understanding of trade recovery strategies. The application of this framework also supports the synthesis of cross-sector policies, combining health imperatives with economic resilience to devise trade recovery roadmaps for both immediate and long-term strategic planning.

This study’s theoretical and practical contributions are as follows. (1) Exploration of spatiotemporal dimensions and subject-specific levels enriches the design of trade recovery measures, expanding extant research in international trade risk management theory by integrating contextual analysis into risk assessment and mitigation strategies. (2) A comparative analysis of consistency and heterogeneity in trade recovery measures across developed and emerging countries reveals gaps in public health emergency response mechanisms related to international trade, deepening the need for tailored strategies targeting specific economic vulnerabilities. (3) Insights obtained offer references for shaping national trade recovery policies in response to GHEs. Given the post-disaster recovery’s uncertainty, governments must enforce transformative measures [ 37 ], which are both adaptive and robust, to ensure economic stability and resilience.

Theoretical framework for designing trade recovery measures in GHE-affected countries

According to the international trade risk management theory [ 14 , 38 ], the health event emergency management system includes four stages: early warning, preventing spread, controlling or eliminating the event’s impact, and recovery. The emergency’s containment initiates the recovery phase. Countries and regions have a low proportion of recovery work in the health emergency management system, which must be fully developed for trade recovery from GHEs [ 14 ]. During the international trade recovery stage, the affected country must renegotiate trade agreements with its partners, enhance expectations, disseminate information to consumers, and evaluate the implementation effect of the trade recovery measures. Promptly identifying international trade risks and employing risk management measures can prevent and mitigate risks and ensure the smooth progression of trade.

During GHEs, trade policy, market demand, and competition vary; exchange rates between a country and its main trading partners fluctuate; or fixed rates are maintained at a significant cost, leading to objective risks. Although trade subjects cannot eliminate objective risks, they can actively prevent them. GHEs expand the scope of restrictions on the movement of people and goods, with continuously increasing uncertainty within the affected country’s trade environment. The subjective risk of decision-making errors and improper measures increases sharply as governments, organizations, and people face multiple pressures [ 39 ] and emergent behaviors.

GHE-initiated international trade risks are multidimensional, featuring a spatiotemporal evolution. Measured in time, an epidemic’s early, middle, and late stages face short- and medium-term risks. The risk extends from the epidemic’s origin to neighboring countries and major trading partners. With aggravating uncertainties and risk factors, the potential impact of GHEs on trade expands beyond short-term scales and localities, further increasing the complexity of trade recovery.

Subject levels, including international, national, industrial, enterprise, and consumer, simultaneously face systematic risks caused by GHEs. The cognitive prediction of events leads to pressure superposition, unbalanced considerations, and decision-making errors, thereby increasing the risk of improper measures. These risks are intertwined throughout GHEs, making it more difficult for affected countries to recover their normal trade levels [ 14 , 15 , 16 ]. Recovering from health events through only one type of measure is infeasible.

To address the international trade risks triggered by GHEs, the trade recovery countermeasures of affected countries must be strengthened in their spatiotemporal dimensions and include international, national, industrial, enterprise, and consumer groups for different subject levels. Efforts should include tracking the epidemic’s evolutionary stage and identifying its regional characteristics, as shown in [ 18 , 40 ], which highlighted the effectiveness of region-specific trade policies during the Ebola outbreak. Moreover, it is necessary establish a national trade recovery countermeasure repository featuring adequacy, flexibility, and completeness. These measures are essential to shift from an emergency single-trade recovery measure design to a comprehensive, long-term trade recovery measure design (Fig.  1 ).

Trend of goods exports in countries with GHEs, 1995–2018 (current price, USD 10 billion) . Source: Author’s analysis based on data from the World Bank Database

Comparative case study on trade recovery measures after GHEs

This study comparatively analyzed the trade recovery measures of relevant countries in the aftermath of four GHEs: the H1N1 influenza that developed in Mexico in 2009 and spread to the US, affecting both countries and their major trading partners; the 2011 Fukushima nuclear leak; the 2014 Ebola virus outbreak that spread rapidly in West Africa; and the 2015 MERS outbreak introduced to South Korea by international travelers. Despite their sudden onset, these GHEs triggered various national trade recovery measures because of differences in their nature.

A comparative case study methodology, conducive to exploring the characteristics of national trade recovery measures and the specifics of the events [ 41 ], supported by Yin [ 36 ] for its effective analysis of complex phenomena within realities, was applied. This method involves a systematic collection, comparison, and analysis of case data to identify patterns, test theories, and derive insights that are not apparent through singular case analyses. In implementing this methodology, this study meticulously documented the sequence of trade policy adjustments, timing (spatiotemporal dimensions), and targeted entities (subject dimensions) for each GHE case. This approach enabled the identification of overarching strategies that successfully mitigated trade disruptions, as well as frequent challenges across varied geopolitical and economic contexts. The analytical process involved detailed case descriptions to highlight similarities and differences in GHE impacts and trade response effectiveness. This structured analysis underscored the necessity of incorporating spatiotemporal and subject-specific considerations in formulating trade policies in response to GHEs. This leads to the argument for a nuanced, multidimensional approach to trade recovery policy-making.

Four GHEs this century

The 2009 h1n1 influenza pandemic.

The H1N1 influenza emerged in March 2009 in Mexico and the US. On June 11, 2009, the WHO declared it a global public health emergency of international concern [ 42 ], with the pandemic alert level peaking on this date [ 43 ]. The WHO declared the end of the pandemic in August 2010. In 18 months, it caused more than 18,000 deaths and affected more than 200 countries [ 44 ].

The 2011 Fukushima nuclear leak

On March 11, 2011, an earthquake struck the Pacific Ocean, causing a tsunami that triggered a nuclear leak [ 45 ]. The US announced an import ban on Japanese food from radiation-affected areas. Additionally, South Korea and the European Union issued trade bans, while China, Thailand, and Vietnam required radiation inspection certificates for food produced in Japan.

The 2014 Ebola epidemic

In March 2014, the Ebola epidemic broke out in Guinea, Sierra Leone, and Liberia in West Africa. In August 2014, the WHO declared it a GHE. The official report on October 15 revealed 8,997 cases and 4,493 deaths [ 46 ]. The WHO announced the end of the epidemic in Sierra Leone, Guinea, and Liberia in November 2015, December 2015, and January 2016, respectively.

The 2015 MERS epidemic

In May 2015, the first MERS case was diagnosed in South Korea, with the disease spreading in medical institutions. Thirty-six patients died, and 186 were infected [ 47 ]. As the disease did not exhibit sustained human-to-human transmission, it was not classified as an international public health emergency. In December 2015, the WHO declared the end of the outbreak.

Comparison of the four GHEs with national trade recovery

Similarities.

The H1N1 flu occurred in the wake of the 2008 global financial crisis, further slowing the recovery of the affected countries. Owing to travel restrictions and trade embargoes, the tourism industry lost USD 2.8 billion, with the trade deficit in pork and pork products’ reaching USD 27 million. Mexico’s exports fell by 26% in the first quarter of 2009 [ 48 ]. The US economy was struggling and reached a nadir after the subprime crisis. The Dow Jones Industrial Average closed at 6763.29 on March 2, 2009, the lowest since April 1997 [ 49 ]. The H1N1 outbreak in April 2009 significantly decreased US GDP, retail sales, and exports of pork and pork products.

As the Japanese government could not provide on-time tests for all trade partners, Japan’s agricultural products and food exports to these countries stagnated. In the first quarter of 2011, Japan’s economy contracted at an annual rate of 3.7% [ 50 ]. In the aftermath of the earthquake, tsunami, and nuclear leakage, the economy continued to shrink over the next 6 months (GDP fell 0.9% from January to March), and private consumption fell by 0.6%. In September 2012, the government announced that the country was entering a recession [ 50 ].

The Ebola epidemic affected transportation, tourism, agriculture, and mining. Trading countries and airlines issued travel restrictions to affected areas [ 46 ]. Agricultural production was affected, with the epidemic limiting the transport of agricultural products to consumer areas, raising product prices. Conakry’s governor banned Eid celebrations on October 2, 2014 [ 51 ]. Travel bans implemented by national authorities and airline flight suspensions [ 46 ] cut off trade among West African countries and their partners for about 6 months until August 31, 2014. The loss of workers and travel restrictions reduced mining activity. The US government sent USD 2.89 billion in foreign aid to West Africa, focusing its efforts on Liberia [ 51 ].

The MERS outbreak reduced the number of tourists visiting South Korea by 2.1 million, resulting in a loss of USD 2.6 billion in tourism revenue. Additionally, the accommodation, catering service, and transportation sectors suffered losses of USD 542 million, USD 359 million, and USD 106 million, respectively [ 52 ]. This pushed the transportation sector’s service index below the expected levels in June 2015 and the accommodation and catering industries’ service indexes below the expected levels in June and July 2015.

Heterogeneities

H1N1 flu was a pandemic caused by viral variants. The Fukushima event was a technological disaster triggered by a strong earthquake but mainly caused by industrialization [ 53 ]. The Ebola virus was a highly infectious and destructive disease; the widespread nature of the West African outbreak relates to the highly mobile communities and densely populated regions affected in the early stages [ 51 ]. South Korean cases of the MERS virus, which originated in Saudi Arabia, were introduced through international travel.

Duration and influence areas

The H1N1 flu lasted approximately 1 year, affecting Mexico and the US. Following the nuclear accident, some countries prohibited agri-food product imports from Japan’s irradiated areas from 2011 to the present (e.g., the US and China). Footnote 5 The Ebola epidemic lasted 2 years, primarily affecting African countries. More than 13,000 confirmed cases were reported globally, with 4,951 deaths and a 36% mortality rate by October 2014. Although the outbreak involved only three countries, there was widespread and intense transmission in the West African region, and four nations (Nigeria, Senegal, Spain, and the US) reported initial cases or localized transmission. The MERS epidemic was challenging for South Korea’s medical system for more than 7 months.

Event outcomes

After the H1N1 outbreak, countries restricted travel and banned the imports of pork products, which affected their trade with Mexico, the US, and the rest of the global economy. Unwarranted concerns based on inappropriate designations also led to official and unofficial bans by 17 countries on US pork and pork product imports, with China maintaining its ban until mid-December 2009 [ 54 ]. The Fukushima nuclear accident primarily affected Japan’s agricultural product exports because its trade partners were concerned about radioactive contamination [ 55 ], while the Ebola epidemic endangered Guinea, Sierra Leone, and Liberia’s economic growth, leading to trade stagnation, foreign investment withdrawal, and a food crisis. MERS negatively affected South Korea’s tourism industry.

Evidence for these event outcomes is as follows.

Impact of GHEs on export volumes

In 2009, Mexico and US export volumes decreased by 21.13% and 17.97%, respectively, over the previous year (Fig.  2 ). Japan’s commodity export volume increased by 6.94% in 2011 over 2010, with a limited share of the Fukushima agricultural food export in Japan’s total foreign trade. Guinea’s commodity exports increased by 10% in 2014 over 2013 but decreased by 13.79% in 2015 over 2014, indicating the Ebola epidemic’s lagging effect on Guinea’s exports. In 2014, Liberia’s and Sierra Leone’s merchandise exports decreased by 54.7% and 19.04%, respectively, over 2013. South Korea’s merchandise exports decreased by 8.02% in 2015 over 2014.

Trends in international tourism revenue changes in GHEs-affected countries, 1995–2018 (current price, USD 10 billion). Data for Guinea and Liberia are missing from the World Bank Database. Source: Author’s analysis based on data from the World Bank Database

International tourism income changes in countries affected by GHEs

Mexican and US revenues decreased by 14.83% and 11.36%, respectively, in 2009 over 2008, and Japan’s revenues decreased by 18.38% in 2012 over 2011. In Sierra Leone, revenues decreased by 46.97% in 2014 over 2013, and in South Korea, by 16.43% in 2015 over 2014 (Fig.  3 ). Income from trade and transport fell because of the closure policy adopted during the Ebola outbreak, which also disrupted other business activities [ 56 ].

Theoretical framework for the design of trade recovery measures for GHE-affected countries. Source: Author’s analysis

Trade recovery

Developed countries (i.e., the US, Canada, and South Korea) have relatively robust health systems, sound economic foundations, and short trade recovery periods. The H1N1 epidemic lasted a year, after which exports from Mexico and the US returned to pre-pandemic levels. As an emerging economy, Mexico maintained its trade with the US during the outbreak; thus, trade recovered rapidly. In 2010, Mexico and US tourism revenues exceeded the level achieved in the 2009 pandemic year.

The impact of the Fukushima nuclear leakage on Japan’s export trade and tourism industry was limited, especially within Fukushima prefecture. Although Japan’s international tourism revenue declined in early 2011, the number of foreign tourists to Japan returned to 70% of that year by September 2012. By contrast, it took more than a decade to eliminate the consequences of the Fukushima disaster on the agricultural product trade. Agriculture production and trade resumed when decontamination was confirmed, which took a long time. In 2017, trade levels improved, and international tourism numbers recovered, exceeding pre-GHE levels [ 57 ].

Even before the Ebola outbreak, West African countries were impoverished and pursuing economic development. Guinea, Sierra Leone, and Liberia recovered their export levels within 2 years of the outbreak, but the economic recovery time was long. Guinea’s export recovery was notable; its export trade increased in 2015 over 2014 before decreasing in 2016, although it remained above the pre-outbreak level. In 2015, Liberia’s export volume decreased by 20.57% and did not return to its pre-epidemic level until 2018. Sierra Leone’s exports declined slowly from 2015 until they increased in 2018; however, these are yet to achieve their pre-epidemic level. International tourism income increased by USD 2 million in 2015 over 2014 before fluctuating upward (Figs.  1 and 2 ).

Comparison of trade recovery measures in GHE-affected countries

The common points of the affected countries’ trade recovery measures include countries that chose active fiscal and monetary policies to achieve trade recovery. Consumers, enterprises, and significantly damaged industries were crucial areas for trade recovery.

Mexico and the US

In May 2009, Mexico implemented a tax rate reduction and funding aimed at small and midsize enterprises in the tourism and transportation industries. Furthermore, it reduced its interbank interest rate and announced a financing plan to inject funds into the economy through institutions (i.e., the National Financial Development Bank) to support small and medium enterprises. The Mexican government revived its economy by introducing rules/regulations to facilitate mergers and acquisitions that promoted the development of the southeast economy within Mexico.

During the H1N1 outbreak, the US economy faced a slowdown in an unstable policy environment following the 2008 financial crisis. The country passed a law to support economic recovery and encourage reinvestment. The Federal Reserve cut interest rates to save financial institutions and enterprises on the brink of bankruptcy and help families with excessive debt. On July 12, 2009, the U.S. Department of Health announced the allocation of an additional USD 1 billion to fight A H1N1 influenza. Footnote 6 Despite reductions in US–Mexico air routes, trade between the two countries continued.

In March 2011, Japan launched a post-disaster recovery and reconstruction program, and the Reconstruction Agency was established in 2012. The timeframe included the Intensive Reconstruction Period (2011–2015), with USD 250 billion allocated, and the Reconstruction and Revitalization Period (2016–2020), with USD 65 billion. Japan also established a comprehensive environmental monitoring system. Footnote 7 To accelerate the resumption of normal business operations, the government supported the establishment of temporary stores, increased investment in support funds, and repaired damaged buildings.

Special financial support to reduce enterprises’ burden included establishing a Japanese financial company specialized in recovery and loans intended for reconstruction after the earthquake. The interest rate was slashed, and separate loan limits, extended loans, and repayment terms were established. The interest rate was reduced to almost zero for small and midsize enterprises whose office facilities were destroyed during the earthquake, and the government improved its management and financing. Tourism and other affected industries were supported, and entertainment and consumer destinations, such as Tokyo Disneyland, reopened to revitalize the local economy and restore international confidence after the disaster.

West Africa

Guinea, Liberia, and Sierra Leone introduced short-term response policies to ensure the health systems and economic sectors’ timely recovery. The Guinean government formulated a USD 2-billion post-Ebola recovery plan, with 63% allocated to improving nutrition, health, education, and children’s services and promoting socioeconomic recovery [ 43 ]. It emphasized that the disease’s spread was enhanced by poverty and illiteracy, while noting that the epidemic presented an opportunity to strengthen the country’s economic, social, and institutional resilience. Sierra Leone prioritized the implementation of universal health insurance, whereas Liberia focused on improving post-outbreak areas such as health staffing, infrastructure, monitoring, and response.

The outbreak of a large-scale epidemic in Africa attracted attention from the international community. The United Nations, World Bank, IMF, and US launched a series of epidemic prevention and financial support policies to assist the West African countries in combatting the outbreak. These policies included initial funding of USD 200 million from the US National Institutes of Health to foster cooperation between academic institutions in the US, Liberia, and Sierra Leone on virus research, including vaccine development and new testing and treatment methods. The World Bank approved a USD 110 million IDA assistance to help West Africa establish and expand disease surveillance systems [ 43 ].

South Korea

In June 2015, the central bank of South Korea cut its interest rate to 1.5% [ 58 ], issued special financing support, and promoted structural reforms in public utilities, finance, education, and labor sectors. The Korean government provided special insurance for visitors to Korea, covering all medical and MERS-related expenses. The government concurrently introduced supportive policies to reduce consumption taxes on automobiles and large household appliances, offering discounts and organizing shopping festivals. Commercial enterprises offered discounts on commodities and services to stimulate domestic demand and launched the Black Friday Shopping Festival. To accommodate the peak summer vacation from late July to early August and absorb the demand for popular products flowing overseas during the epidemic, Korean enterprises actively supported tourism recovery and extended the discount season from winter until August to attract consumers.

The main measures of trade recovery

After the GHEs, the affected governments implemented internal countermeasures to recover. Korean commercial enterprises also participated in the recovery process through marketing measures. Conversely, although the three West African countries implemented internal trade recovery measures, given their economic development and medical infrastructure level, they required additional support from the international community to recover.

Emphasis on trade recovery

Most countries strengthened entry-exit control and ensured strict isolation to prevent an epidemic. International flights were reduced, with some countries isolated. Mexico and the US, however, maintained trade ties during the H1N1 influenza pandemic. After controlling the pandemic, the countries used fiscal and monetary policies to manage the affected tourism and agricultural trade. The Japanese government’s trade recovery was based on environmental monitoring measures. When the affected region’s government officials pushed for and promoted marketing measures, it mitigated the nuclear accident’s adverse psychological effects on foreign consumers, thereby advancing the recovery of agricultural exports. The three West African countries’ trade recovery measures are nested in a broader socioeconomic promotion plan. Countries with adequate trade recovery considered the epidemic would opportunistically promote domestic economic development and improve medical facilities with the international community’s support. South Korean commercial enterprises focused on stimulating local demand.

Trade recovery measures differ between developed and emerging economies

During the MERS outbreak, South Korea implemented an economic stimulus plan to assist domestic enterprises. Developed economies, such as the US and Japan, also developed support measures for small and midsize enterprises. During the Ebola epidemic, however, West African countries could not provide such resources, and international organizations, such as the World Bank, United Nations Children’s Fund, and WHO, came to their rescue (Table  2 ).

Comparing the cases with the theoretical framework

This study enhances the theoretical framework using case study evidence. Combining the theoretical framework in " Results " section , trade recovery measures in the time dimension of these countries require further clarification, especially when the event was under control and during the trade recovery stage. In the time dimension (Fig.  3 ), after the GHE was under control (especially after the warning and outbreak), the countries embarked on the process of trade recovery (including early, middle, and late stages).

Implementing the foundations of trade recovery can enhance governments’ timely responses to GHEs. Robust trade recovery infrastructures significantly improve response times during health crises [ 13 , 37 , 50 ]. Trade recovery measures differ based on cities, regions, and domestic countries, with urban centers often rebounding more rapidly owing to better resource allocation [ 59 , 60 ]. International cooperation is critical for trade recovery, especially for emerging countries, as exemplified by the joint efforts during the 2014 Ebola crisis that facilitated regional trade resumption [ 61 ]. The trade recovery measures of developed countries are more comprehensive than those of emerging countries, helping to shorten their recovery time, with the OECD highlighting the correlation between recovery measures and reduced economic downtime [ 62 ]. Countries can classify and enrich trade recovery measures by applying the time–space-subject three-dimensional framework analyzed earlier and establishing a countermeasure repository (see Table 3  in " Comparative case study on trade recovery measures after GHEs " section) to recover from GHEs

Each GHE revealed areas for improvement in trade recovery measures. The responses to the nuclear leakage accident and the H1N1 influenza epidemic suffered from a lack of timely action and resource allocation [ 53 , 59 ]. Management of the MERS and Ebola outbreaks has been criticized for insufficient coordination and resource deployment [ 34 ]. The outbreak of GHEs has exposed the weaknesses in global governance, manifesting in uncoordinated public health and economic systems, and the failure to manage these events to achieve a better balance among health, economic, and trade shocks. This lack of synergy exacerbates the severity of health, economic, and trade shocks during these crises. Establishing joint committees of the WHO, WTO, and potentially other international organizations, such as the International Monetary Fund and United Nations, could provide a comprehensive approach to managing these conflicts. The effectiveness of such collaborative efforts has been documented in the joint WHO–WTO response to the SARS and H1N1 outbreak, which enhanced global preparedness and response capabilities [ 63 ]. Such joint committees could create a real-time data repository for cross-border information sharing, outline a tiered protocol for trade actions, manage a dedicated emergency fund, and conduct bi-annual stress tests. This would not only inform member nations’ preparedness for future GHEs as recommended by the WHO, WIPO, and WTO but also renew their commitment to supporting integrated solutions for global health challenges [ 64 ].

Moreover, implementing trade recovery measures in countries affected by GHEs will generate short-term impacts on trade and investment with a delayed effect. According to the Center on Budget and Policy Priorities [ 65 ], recovery measures typically result in initial disruptions that are offset by longer-term gains in efficiency and market access. During GHEs, the successive implementation of trade recovery measures influences current economic activities; however, these measures have a delayed and long-term impact. UNCTAD [ 66 ] revealed that the full benefits of the trade recovery measures from the pandemic were not realized until several years post-crisis, underscoring the need for patient capital and sustained policy support. Improving the effects of trade recovery measures requires evaluating the implementation effects of the affected country’s measures in response to GHEs, as demonstrated by the World Bank’s analysis of response strategies during the 2014–2015 Ebola outbreak. This provides crucial insights into the effectiveness of regional trade policies [ 61 ].

The following countermeasure repository clarifying the time–space-subject dimensions is chosen for countries experiencing GHEs (Table 3 ). Measures in the time dimension are differentiated in the short, medium, and long terms. Measures in the space dimension strengthen the choices of different geographic areas in the various affected levels (the degree to which an area has been affected by GHEs). The subject dimension highlights the heterogeneity of measures at the international, regional, national, industrial, and consumer levels. Countries experiencing a GHE can choose measures from this repository to address their specific needs.

Early stage of trade recovery

Countries should implement short-term policies with an open, transparent, and timely response. These policies should include the following.

Adopting short-term fiscal and monetary policies

Short-term policies were the primary measures employed by all four countries during the early stages of trade recovery. The availability of open and transparent information helps the government evaluate and control the situation. Timely isolation is significant in controlling an epidemic’s spread, thereby reducing infection and mortality rates. Short-term fiscal spending, income reduction, and credit policies (e.g., tax and reduction of property and insurance fees) can target the most impacted industries. The business cycle prefers a moderately loose monetary policy. Short-term policies should minimize the socioeconomic burden of people affected [ 67 ]. For emerging countries, countermeasures to reduce the economic burden are essential for mitigating the adverse effects rather than increasing employment and economic output [ 33 ].

Implementing trade policies to maintain open trade

During a GHE, neighboring countries and major trading partners fear the epidemic spread through trade channels, triggering trade bans and interruptions. Flight controls and border closures affect countries beyond those implementing the measures [ 46 ]. During the Ebola outbreak, West African countries closed their borders, disrupting regional trade and threatening the essential supply and livelihood of the host countries [ 30 , 31 ]. The affected countries and trading partners should keep trade as open as possible to secure an adequate supply of necessities. During the early stages of trade recovery, reducing trade costs (government-imposed trade costs such as tariffs and quotas) can help protect trade and economic openness. At the international, national, and industrial levels, timely trade policies should be implemented to avoid trade bans and actively respond to technical barriers to trade (TBTs) imposed by other countries. At the national level, affected countries must promptly reduce their short-term trade barriers. Footnote 8 The increased trade barriers during the COVID-19 pandemic further destroyed trade (i.e., the global food system) [ 68 ].

Middle and later stages of trade recovery

Rapid control of spreading diseases or radioactive substances poses challenges and leads to long-term lag effect on national trade recovery. While quantifying total trade losses from epidemics and nuclear radiation remains difficult, prioritizing national trade recovery is essential for normalizing trade. Measures taken during GHEs should be adjusted based on the overall trade recovery progress to prevent trade friction and expedite the normalization of trade and economic policies. The policy package aimed at ensuring timely trade normalization should incorporate the following three elements.

Highlighting macroeconomy-tolerant fiscal and monetary policies

The GHEs significantly disrupted total consumer spending during the middle and later periods of trade recovery. Policy interventions to maintain economic growth are therefore preferable. During GHEs, governments must coordinate their efforts to manage working time arrangements and determine the optimal level of public debt based on production technology and disease characteristics to effectively implement fiscal policy [ 69 ]. Simultaneously, medium- and long-term structural policies must be launched while establishing epidemic risk assessment tools. Measures include improving monitoring systems and raising public awareness of prevention and control measures. Pharmaceutical companies should be incentivized to develop new antiviral drugs and vaccines and enhance their production capacity. Footnote 9 Measures to increase medical reserves, such as adopting advanced technologies and medical infrastructure, should be pursued.

Supporting key industries and enterprises at medium and micro levels

Efforts include implementing targeted policies for industries significantly affected by the GHE to protect the interests of small and midsize enterprises, particularly those engaged in import and export businesses directly affected. Measures should target preferential policies and subsidies for small and midsize enterprises and prevent unemployment. Enterprises should continue to pay wages and facilitate employee benefit claims despite economic uncertainty. Global manufacturers and retailers can improve e-commerce for shopping channels, develop trust and confidence among e-commerce participants, and promote compatibility with international norms [ 70 ].

Attracting investment

GHEs can reduce or cause a withdrawal of foreign direct investment from affected countries. When the health event is controlled, implementing tax relief can help reduce losses promptly and promote major investing countries’ and trading partners’ investment plans. For example, foreign investment was withdrawn or withheld during West Africa’s Ebola outbreak. Even after the epidemic was under control, the withdrawn foreign capital slowed the economic recovery of the most affected countries. Weak investment was the primary restraint on trade recovery, accounting for approximately 80% of the decline in goods trade between 2012 and 2016 and between 2003 and 2007 [ 71 ]. Countries should actively maintain a stable financial system and encourage foreign direct investment inflows during the middle and later recovery periods.

Conclusions

This study investigated the impact of GHEs and designed countermeasures to address trade recovery based on theoretical and case analysis. The following conclusions are drawn. First, the unexpected and unique nature of GHEs complicates trade recovery. There were differences in the types of GHEs, their transmission times, and diffusion regions across the four health events. Regardless of the home country’s coping strategy or the experience gained from these events, the trade recovery capability of these countries warrants improvement. Second, the trade recovery measures for the four GHEs were heterogeneous in their focus and effectiveness among developed and emerging economies. Fiscal and monetary policies were more commonly used, followed by recovery measures for specific regions and industries. Enterprises must actively stimulate demand (i.e., marketing, e-commerce). Third, trade recovery measures should be implemented from a spatiotemporal perspective, considering specific subject levels. Short-term policies were the primary focus for affected countries during the early stages of trade recovery. Medium- and long-term policies were crucial for ensuring open trade and trade normalization in the middle and late stages.

The results indicate that trade recovery measures should operate in the space–time-subject dimension. Expedient short-term policies should be adopted during the early stages of recovery (i.e., tax relief and trade subsidies) to stabilize the affected economies rapidly. As recovery progresses, medium- and long-term financial, monetary, and trade policies (i.e., bilateral trade agreements and currency stabilization) should be preferred in the middle and later stages to sustain and bolster economic recovery. Designing trade recovery policies at the international, national, industrial, enterprise, and consumer levels should shift from emergency actions to comprehensive, reserve-oriented, and enduring-effects measures. These policies should address needs at different levels, such as permanent trade corridors to facilitate uninterrupted trade flows and consumer loyalty programs in sustaining market demands.

Our study acknowledges the comprehensive WTO trade measures during the COVID-19 pandemic, which documented diverse practices of trade facilitation and restriction across member states. According to the WTO’s report [ 72 ] and further detailed trade policy discussions [ 73 ], these measures significantly influenced the economic landscape globally, highlighting the need for adaptable tailor-made trade policies to specific country contexts. Building on these findings, we suggest that future trade recovery strategies should leverage both the resilience measures and lessons learned during the pandemic. Specifically, effective temporary trade measures identified by the WTO can serve as models for swift deployment in future global health emergencies, aiming to minimize disruptions to trade flows.

Limitations and future research

This study proposed that trade recovery countermeasures designed for countries with GHEs should distinguish between spatiotemporal dimensions and specific subject levels. Different trade recovery countermeasures inevitably produce overlapping effects (i.e., fiscal and easy monetary policies can promote trade recovery). However, this study did not fully explore the interactive or cumulative impacts of these overlapping countermeasures, leaving room for determining the most effective policy combinations. Further research is needed on the superimposed effects of trade promotion and combined policies. For example, clarifying these mechanisms requires analyzing the channels and results of various trade recovery countermeasures affecting trade recovery, collecting quarterly, monthly, even daily, and real-time data from countries with GHEs, and applying difference-in-difference, breakpoint regression models, as well as propensity score matching to identify the mechanism and countermeasures’ effects. This approach can provide insight into the overlapping effects of multiple trade recovery policies.

Availability of data and materials

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

GHEs affect the long-run evolution of the economy. This study assumes that countries experiencing GHEs will enter a new stage of development and show a long-run economic evolution.

The economy evolves endogenously. A GHE always affects/changes the economy, altering its evolutionary path. Therefore, countries affected by GHEs try to resume or recover trade by implementing trade recovery measures.

This causation runs both ways.

This research focuses on the impact of GHEs on trade; however, since forever, the relationship has run both ways.

The US Food and Drug Administration response to the Fukushima Daiichi nuclear power facility incident (May 14, 2023). https://www.fda.gov/news-events/public-health-focus/fda-response-fukushima-daiichi-nuclear-power-facility-incident Scholars also focus on the motivations/interests of the US agricultural community before and after the event—for example, the nuclear event was just an excuse to prohibit imports. This is also an interesting future topic.

US $1 billion to fight against influenza A (H1N1), China News Report , October 10, 2022. https://news.ifeng.com/c/7fYidCErT3J

Efforts toward reconstruction of Tohoku, Reconstruction Agency of Japan, May 14, 2023. https://www.reconstruction.go.jp/english/index.html

Facing COVID-19, the affected countries did the opposite. These activities clearly exposed the weakness of the current recovery measures taken by the countries. Enhancing trade barriers are emergency-oriented measures taken by countries facing multiple uncertainties, while reducing trade barriers are reserve-oriented and enduring-effect measures that benefit countries affected by GHEs.

Incentivizing pharmaceutical companies is challenging while recognizing their right to make a profit and the public’s opposing rights and interests. Governments need to play a role in avoiding their monopoly on meeting private interests while encouraging their progress, innovation, and social responsibility.

Abbreviations

• Global health events

Middle East respiratory syndrome

World Health Organization

World Trade Organization

United States

Artificial intelligence

Technical barriers to trade

Pike J, Bogich T, Elwood S, Finnoff DC, Daszak P. Economic optimization of a global strategy to address the pandemic threat. Proc Natl Acad Sci. 2014;111:18519–23. https://doi.org/10.1073/pnas.1412661112 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Elshabrawy HA, Erickson TB, Prabhakar BS. Ebola virus outbreak: updates on current therapeutic strategies. Rev Med Virol. 2015;25:241–53. https://doi.org/10.1002/rmv.1841 .

Article   PubMed   PubMed Central   Google Scholar  

Fang H, Wang L, Yang Y. Human mobility restrictions and the spread of the novel coronavirus (2019-nCoV) in China. J Pub Econ. 2020;191: 104272. https://doi.org/10.1016/j.jpubeco.2020.104272 .

Article   Google Scholar  

Hayakawa K, Keola S. How is the Asian economy recovering from covid-19? Evidence from the emissions of air pollutants. J Asian Econ. 2021;77: 101375. https://doi.org/10.1016/j.asieco.2021.101375 .

Maconachie R, Hilson G. Ebola and alluvial diamond mining in West Africa: initial reflections and priority areas for research. Extr Ind Soc. 2015;2:397–400. https://doi.org/10.1016/j.exis.2015.04.005 .

Lee J-W, McKibbin WJ. Globalization and disease: the case of SARS. Asian Econ Pap. 2004;3:113–31. https://doi.org/10.1162/1535351041747932 .

Kostova D, Cassell CH, Redd JT, Williams DE, Singh T, Martel LD, et al. long-distance effects of epidemics: assessing the link between the 2014 West Africa Ebola outbreak and U.S. exports and employment. Health Econ. 2019;28:1248–61. https://doi.org/10.1002/hec.3938 .

Mărcuță L, Dorobanțu DM, Popescu A, Tindeche C, Mărcuță A. The influence of epidemics on tourism under the conditions of globalization. AgroLife Sci J. 2020;9:214–20. https://www.cabdirect.org/globalhealth/abstract/20203375699 .

Hall C. Impact of Avian influenza on U.S. poultry trade relations-2002: H5 or H7 low pathogenic Avian influenza. Ann NY Acad Sci. 2004;1026:47–53. https://doi.org/10.1196/annals.1307.006 .

Wieck C, Schlüter SW, Britz W. Assessment of the impact of Avian influenza-related regulatory policies on poultry meat trade and welfare. World Econ. 2012;35:1037–52. https://doi.org/10.1111/j.1467-9701.2012.01461.x .

Davis CG, Dyck J. Shocks to a trading system: Northeast Asia poultry trade and Avian influenza. Int Food Agribusiness Manag Rev. 2015;18:1–16. https://doi.org/10.22004/ag.econ.207005 .

Fournié G, Tripodi A, Nguyen TTT, Nguyen VT, Tran TT, Bisson A, et al. Investigating poultry trade patterns to guide avian influenza surveillance and control: a case study in Vietnam. Sci Rep. 2016;6:29463. https://doi.org/10.1038/srep29463 .

Bowman QP, Arnoldi JM. Management of animal health emergencies in North America: prevention, preparedness, response and recovery. Rev Sci Tech (Int Off Epizoot). 1999;18(1):76–103. https://doi.org/10.20506/rst.18.1.1149 .

Article   CAS   Google Scholar  

Torres A, David MJ, Bowman QP. Risk management of international trade: emergency preparedness. Rev SciTech (Int Off Epizoot). 2002;21:493–8. https://doi.org/10.20506/rst.21.3.1344 .

Suk JE, Cangh TV, Beauté J, Bartels C, Tsolova S, Pharris A, et al. The interconnected and cross-border nature of risks posed by infectious diseases. Glob Health Action. 2014;7:25287. https://doi.org/10.3402/gha.v7.25287 .

Article   PubMed   Google Scholar  

Suk JE, Vaughan EC, Cook RG, Semenza JC. Natural disasters and infectious disease in Europe: a literature review to identify cascading risk pathways. Eur J Public Health. 2020;30:928–35. https://doi.org/10.1093/eurpub/ckz111 .

Mavrouli M, Mavroulis S, Lekkas E, Tsakris A. Infectious diseases associated with hydrometeorological hazards in europe: disaster risk reduction in the context of the climate crisis and the ongoing COVID-19 pandemic. Int J Environ Res Public Health. 2022;19:10206. https://doi.org/10.3390/ijerph191610206 .

Swayne DE, Hill RE, Clifford J. Safe application of regionalization for trade in poultry and poultry products during highly pathogenic Avian influenza outbreaks in the USA. Avian Pathol. 2017;46:125–30. https://doi.org/10.1080/03079457.2016.1257775 .

Wu T, Perrings C. The live poultry trade and the spread of highly pathogenic Avian influenza: regional differences between Europe, West Africa, and Southeast Asia. PLoS ONE. 2018;13: e0208197. https://doi.org/10.1371/journal.pone.0208197 .

Meyer A, Dinh TX, Han TA, Do DV, Nhu TV, Pham LT, et al. Trade patterns facilitating highly pathogenic Avian influenza virus dissemination in the free-grazing layer duck system in Vietnam. Transbound Emerg Dis. 2018;65:408–19. https://doi.org/10.1111/tbed.12697 .

Article   CAS   PubMed   Google Scholar  

Molia S, Boly IS, Duboz R, Coulibaly B, Guitian J, Grosbois V, et al. Live bird markets characterization and trading network analysis in Mali: implications for the surveillance and control of Avian influenza and Newcastle disease. Acta Trop. 2016;155:77–88. https://doi.org/10.1016/j.actatropica.2015.12.003 .

Poolkhet C, Chairatanayuth P, Thongratsakul S, Yatbantoong N, Kasemsuwan S, Damchoey D, et al. Social network analysis for assessment of Avian influenza spread and trading patterns of backyard chickens in Nakhon Pathom, Suphan Buri and Ratchaburi. Thailand Zoonoses Public Health. 2013;60:448–55. https://doi.org/10.1111/zph.12022 .

Sealy JE, Fournie G, Trang PH, Dang NH, Sadeyen J-R, Thanh TL, et al. Poultry trading behaviours in Vietnamese live bird markets as risk factors for Avian influenza infection in chickens. Transbound Emerg Dis. 2019;66:2507–16. https://doi.org/10.1111/tbed.13308 .

Wilasang C, Wiratsudakul A, Chadsuthi S. The dynamics of Avian influenza: individual-based model with intervention strategies in traditional trade networks in Phitsanulok province, Thailand. Comput Math Methods Med. 2016;2016:6832573. https://doi.org/10.1155/2016/6832573 .

Backer JA, van Roermund HJW, Fischer EAJ, van Asseldonk MAPM, Bergevoet RHM. Controlling highly pathogenic Avian influenza outbreaks: an epidemiological and economic model analysis. Prev Vet Med. 2015;121:142–50. https://doi.org/10.1016/j.prevetmed.2015.06.006 .

Schlüter H. Effective animal disease control – an epidemiological and financial point of view. Tierärztl Umsch. 2004;59:655–60.

Google Scholar  

O’Brien EC, Taft R, Geary K, Ciotti M, Suk JE. Best practices in ranking communicable disease threats: a literature review, 2015. Eurosurveill. 2016;21:30–40. https://doi.org/10.2807/1560-7917.ES.2016.21.17.30212 .

Yousefi Naghani SY, Dara R, Poljak Z, Sharif S. A review of knowledge discovery process in control and mitigation of Avian influenza. Anim Health Res Rev. 2019;20:61–71. https://doi.org/10.1017/S1466252319000033 .

Gaythorpe KAM, Fitzjohn RG, Hinsley W, Imai N, Knock ES, Guzman PNP, et al. Data pipelines in a public health emergency: the human in the machine. Epidemics. 2023;43: 100676. https://doi.org/10.1016/j.epidem.2023.100676 .

Buseh AG, Stevens PE, Bromberg M, Kelber ST. The Ebola epidemic in West Africa: challenges, opportunities, and policy priority areas. Nurs Outlook. 2015;63:30–40. https://doi.org/10.1016/j.outlook.2014.12.013 .

Moon S, Sridhar D, Pate MA, Jha AK, Clinton C, Delaunay S, et al. Will Ebola change the game? Ten essential reforms before the next pandemic: the report of the Harvard-LSHTM independent panel on the global response to Ebola. Lancet. 2015;386:2204–21. https://doi.org/10.1016/S0140-6736(15)00946-0 .

Darden ME, Dowdy D, Gardner L, Hamilton BH, Kopecky K, Marx M, et al. Modeling to inform economy-wide pandemic policy: bringing epidemiologists and economists together. Health Econ. 2022;31:1291–5. https://doi.org/10.1002/hec.4527 .

Stephens AR. The need for emergency economic policy options to mitigate the economic impacts of epidemics: Ebola in West Africa and MERS in South Korea. Reg Econ Policies. 2017;2017:1–11. https://www.researchgate.net/profile/Aaron-Stephens-2/publication/326423363_The_Need_for_Emergency_Economic_Policy_Options_to_Mitigate_the_Economic_Impacts_of_Epidemics_Ebola_in_West_Africa_and_MERS_in_South_Korea/links/5b4cad2ca6fdcc8dae224487/The-Need-f .

Lee J, Ko Y, Jung E. Effective control measures considering spatial heterogeneity to mitigate the 2016–2017 Avian influenza epidemic in the Republic of Korea. PLoS ONE. 2019;14: e0218202. https://doi.org/10.1371/journal.pone.0218202 .

Stake RE. The art of case study research. California: Sage Publications; 1995. https://www.mencap.org.uk/sites/default/files/2021-05/pdf-the-art-of-case-study-research-robert-e-stake-pdf-download-free-book-eeac09f.pdf .

Yin RK. Case study research: Design and methods. 4th ed. California: Sage Publications; 2009. https://books.google.com/books?id=FzawIAdilHkC&lr=&source=gbs_navlinks_s .

Kondo T, Takemoto S. Scenario planning approach to pre-event planning for post-disaster recovery: the case of the future mega-tsunami striking Kushimoto. Japan J Disaster Res. 2022;17:541–5. https://doi.org/10.20965/jdr.2022.p0541 .

Hillberry R, Karabay B, Tan SW. Risk Management in Border Inspection. J Dev Econ. 2022;154: 102748. https://doi.org/10.1016/j.jdeveco.2021.102748 .

Krause NM, Freiling I, Beets B, Brossard D. Fact-checking as risk communication: the multi-layered risk of misinformation in times of COVID-19. J Risk Res. 2020;23(7–8):1052–9. https://doi.org/10.1080/13669877.2020.1756385 .

Green A. West African countries focus on post-Ebola recovery plans. Lancet. 2016;388:2463–5. https://doi.org/10.1016/S0140-6736(16)32219-X .

Eisenhardt KM, Graebner ME. Theory building from cases: opportunities and challenges. Acad Manage J. 2007;50:2532. https://doi.org/10.5465/amj.2007.24160888 .

Sparke M, Anguelov D. H1N1, globalization and the epidemiology of inequality. Health Place. 2012;18:726–36. https://doi.org/10.1016/j.healthplace.2011.09.001 .

Zarocostas J. World health organization declares a (H1N1) influenza pandemic. BMJ. 2009;338:b2425–b2425. https://doi.org/10.1136/bmj.b2425 .

Bashynska I, Sokhatska O, Stepanova T, Malanchuk M, Rybianets S, Oksana S. Modelling the risks of international trade contracts. Int J Innov Tech Explor Eng. 2019;8:2815–20. https://doi.org/10.35940/ijitee.K2313.0981119 .

Akabayashi A, Hayashi Y. Mandatory evacuation of residents during the Fukushima nuclear disaster: an ethical analysis. J Public Health. 2012;34:348–51. https://doi.org/10.1093/pubmed/fdr114 .

Poletto C, Gomes MF, Piontti APy, Rossi L, Bioglio L, Chao DL, et al. Assessing the impact of travel restrictions on international spread of the 2014 West African Ebola epidemic. Eurosurveill. 2014;19:20936. https://doi.org/10.2807/1560-7917.ES2014.19.42.20936 .

Ha K-M. A lesson learned from the MERS outbreak in South Korea in 2015. J Hosp Infect. 2016;92:232–4. https://doi.org/10.1016/j.jhin.2015.10.004 .

Rassy D, Smith RD. The economic impact of H1N1 on Mexico’s tourist and pork sectors. Health Econ. 2013;22:824–34. https://doi.org/10.1002/hec.2862 .

Matt E. Dow jones industrial average closes. Cable News Network Business. 2009. https://money.cnn.com/2009/03/02/markets/markets_newyork/index.htm . Accessed 3 Apr 2023.

Ilie G. The effects of the natural disaster on Japan’s economy and few measures to economic recovery. Euromentor J. 2011;2:1–9. http://www.euromentor.ucdc.ro/euromentor/theeffectsofthenaturaldisasteronjapangeorgetailie_6.pdf .

Coltart CEM, Lindsey B, Ghinai I, Johnson AM, Heymann DL. The Ebola outbreak, 2013–2016: old Lessons for new epidemics. Philos Trans R Soc B, Biol Sci. 2017;372:20160297. https://doi.org/10.1098/rstb.2016.0297 .

Joo H, Maskery BA, Berro AD, Rotz LD, Lee Y-K, Brown CM. Economic impact of the 2015 MERS outbreak on the Republic of Korea’s tourism-related industries. Health Secur. 2019;17:100–8. https://doi.org/10.1089/hs.2018.0115 .

Khaji A, Larijani B, Ghodsi SM, Mohagheghi MA, Khankeh HR, Saadat S, et al. Ethical issues in technological disaster: a systematic review of literature. Arch Bone Jt Surg. 2018;6:269–76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110427/ .

Pappaioanou M, Gramer M. Lessons from pandemic H1N1 2009 to improve prevention, detection, and response to influenza pandemics from a one health perspective. ILAR J. 2010;51:268–80. https://doi.org/10.1093/ilar.51.3.268 .

Hong G-J. Export strategies against decreasing demand of Fukushima’s agricultural products. Asia Pac J Bus. 2018;9:105–21. https://doi.org/10.32599/apjb.9.2.201806.105 .

World Bank Group: The economic impact of the 2014 Ebola epidemic: short-and medium-term estimates of West Africa. 2014. https://www.worldbank.org/en/region/afr/publication/the-economic-impact-of-the-2014-ebola-epidemic-short-and-medium-term-estimates-for-west-africa#:~:text=In%20the%20%E2%80%9CLow%20Ebola%E2%80%9D%20scenario,some%20spread%20to%20other%20countries . Accessed 3 Apr 2023.

Zhang H, Dolan C, Jing SM, Uyimleshi J, Dodd P. Bounce forward: economic recovery in post-disaster Fukushima. Sustainability. 2019;11:6736. https://doi.org/10.3390/su11236736 .

Greenberg A. Bank of Korea cuts key interest rate to stave off economic fallout from MERS. Time. 2015. https://time.com/3917278/mers-south-korea-interest-rate-economy/ .

Sharifi A. The COVID-19 pandemic: lessons for urban resilience. In COVID-19: systemic risk and resilience. Cham: Springer International Publishing; 2021.p. 285–297. https://doi.org/10.1007/978-3-030-71587-8_16

Glaeser EL. Urban resilience. Urban Stud. 2022;59:3–35. https://doi.org/10.1177/00420980211052230 .

World Bank: 2014–2015 West Africa Ebola Crisis: Impact Update. 2021.  https://www.worldbank.org/en/topic/macroeconomics/publication/2014-2015-west-africa-ebola-crisis-impact-update . Accessed 3 Apr 2023.

OECD: Economic Outlook for Southeast Asia, China and India 2023 Reviving tourism post-pandemic. 2023.  https://www.oecd.org/dev/asia-pacific/economic-outlook/Final%20Overview_ebook.pdf . Accessed 27 Dec 2023.

Mackey TK, Liang BA. Lessons from SARS and H1N1/A: employing a WHO–WTO forum to promote optimal economic-public health pandemic response. J Public Health Policy. 2012;33:119–30. https://doi.org/10.1057/jphp.2011.51 .

WHO: WHO, WIPO, WTO renew commitment to support integrated solutions to global health challenges. 2023.  https://www.who.int/news/item/13-09-2023-who--wipo--wto-renew-commitment-to-support-integrated-solutions-to-global-health-challenges . Accessed 27 Dec 2023.

Center on Budget and Policy Priorities: Chart Book: Tracking the Recovery from the Pandemic Recession. 2024.  https://www.cbpp.org/research/economy/tracking-the-recovery-from-the-pandemic-recession . Accessed 17 Apr 2024.

UNCTAD. Global trade’s recovery from COVID-19 crisis hits record high. 2021.  https://unctad.org/news/global-trades-recovery-covid-19-crisis-hits-record-high . Accessed 17 Apr 2024.

Kim Y-W, Yoon S-J, Oh I-H. The economic burden of the 2009 pandemic H1N1 influenza in Korea. Scand J Infect Dis. 2013;45:390–6. https://doi.org/10.3109/00365548.2012.749423 .

Chen KZ, Mao R. Fire lines as fault lines: increased trade barriers during the COVID-19 pandemic further shatter the global food system. Food Secur. 2020;12:735–8. https://doi.org/10.1007/s12571-020-01075-2 .

Pang Y. A theory of fiscal policy response to an epidemic. Health Econ. 2022;31:2050–71. https://doi.org/10.1002/hec.4564 .

Jung H, Park M, Hong K, Hyun E. The impact of an epidemic outbreak on consumer expenditures: an empirical assessment for MERS Korea. Sustainability. 2016;8:454. https://doi.org/10.3390/su8050454 .

Aslam A, Boz E, Cerutti E, Poplawski-Ribeiro M, Topalova P. The slowdown in global trade: a symptom of a weak recovery? IMF Econ Rev. 2018;66:440–79. https://doi.org/10.1057/s41308-018-0063-7 .

World Trade Organization (WTO): World Trade Report 2021 Economic resilience and trade. Geneva. Accessed 3 Apr 2023.

World Trade Organization (WTO): Overview of discussions in the committee on technical barriers to trade relating to COVID-19. Accessed 3 Apr 2023.

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Post-funded project of the National Social Science Fund of China, “Research on academic frontier theory and policy of the economics of standards” [Grant No. 21FJLB039]; Soft Science Special Project of Gansu Basic Research Plan, “Research on promoting trade development between Gansu and countries along the Silk Road through harmonization of standards” [Grant No. 23JRZA385]; The China Association of Trade in Services project, “Research on the Impact of Digital Trade on Manufacturing Production Efficiency”[Grant No. FWMYKT-202429].

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LY has a Ph.D. from Fudan University and is an associate professor and vice-director of the Department of International Economy and Trade, School of Economics, Lanzhou University, Lanzhou, China.

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Yang, L. From isolation to revival: trade recovery amid global health crises. Global Health 20 , 38 (2024). https://doi.org/10.1186/s12992-024-01048-6

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Received : 25 September 2023

Accepted : 25 April 2024

Published : 06 May 2024

DOI : https://doi.org/10.1186/s12992-024-01048-6

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