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A network perspective on public sphere, communicative roles, objective conditions and subjective perception of the situation, selecting from the options for communicative action, echoes of communicative actions, network dynamics and implications for the public sphere.

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The public sphere as a dynamic network

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Thomas N Friemel, Christoph Neuberger, The public sphere as a dynamic network, Communication Theory , Volume 33, Issue 2-3, May-August 2023, Pages 92–101, https://doi.org/10.1093/ct/qtad003

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This article proposes to conceptualize the public sphere as a dynamic network of actors and contents that are linked with each other by communicative actions. This perspective allows us to theoretically derive and empirically describe the entire range of small to large network structures and their evolution over time. First, we will define the elements of these networks, which include the actors, content, communicative actions, and content relations. Based on these entities, four communicative roles (producer, recipient, curator, isolate) will be distinguished. Second, we will summarize how these actors perceive the communicative situation and how they select from behavioral options. Third, we will show how this combines with the network dynamics and outcomes that are discussed in the different lines of research. This provides not only the basis for understanding the link between the communicative actions on the micro-level and macro-level structures, but also new avenues for normative discussions.

Traditionally, the public sphere is described with metaphors such as “sphere,” “forum,” or “arena” ( Donges & Jarren, 2017 , pp. 75–76). This is associated with the idea of a shared, open space in which a multitude of participants can mutually observe and influence each other, as they are in the same place at the same time. The public sphere is conceptualized as a spatiotemporal unity in a face-to-face-situation. This idea was transferred to the societal macro-level. Here, the metaphors refer to the public sphere mediated by mass media ( Habermas, 1992 , 2008 ). Various functions, such as social self-observation and temporal synchronization, are assigned to this sphere ( Luhmann, 1996 ). However, this notion of the public sphere as a shared space of observation and influence has been challenged by the digitalization of public communication for three reasons: First, there has been intense debate and research on whether the public sphere is breaking down into echo chambers, relegating individuals to their own filter bubbles. While there is considerable empirical doubt that such decay is occurring ( Bruns, 2019 ), the selectivity of reception in a high-choice media environment ( Van Aelst et al., 2017 ) nevertheless reduces the proportion of the reception of the same content. Second, publics often no longer emerge only synchronously (as in television and radio) or in a very narrow temporal frame (as in newspaper and magazine) through the reception of linear or periodically distributed mass media, but also in a time-delayed manner as a viral effect through the diffusion of content. This diffusion may be very rapid or delayed by retrieval from online archives (additive public instead of co-present public). Furthermore, it is not limited to pure replication, but also includes translation and transformation ( Boullier, 2023 ). Third, the spatial metaphor is called into question because the boundaries between contexts become blurred, including the different arenas and levels of the public sphere ( Davis & Jurgenson, 2014 ). In sum, digitalization has increased the variability and dynamics of public communication, which is why the models of static, one-way linear, and one-to-many communication and the public sphere as the delimited, homogeneous, and shared space that these models created appear to be outdated. New models of the public sphere need to build on a flexible, relational, and dynamic understanding of public communication ( Keinert et al., 2021 ). Therefore, instead of a top-down view, we propose the opposite starting point of a bottom-up view. We locate the term “public” as an adjective on the micro-level of communicative actions and frame this attribute in terms of action theory: content is “public” as an option for action if it is objectively accessible to all ( Friemel & Neuberger, 2021 ).

The metaphor of the public sphere as a network has been proposed previously ( Habermas, 1992 , p. 436, 2008, pp. 158–159). We followed this metaphor but specified it conceptually by building on the literature of social network analysis for two reasons: First, using Habermas (1963, 1991 ) as a starting point, the normative perspective has dominated public sphere theory. Consequently, the normative ideal of a unified public sphere has determined theoretical reasoning and empirical investigation on the macro-level. While this approach has resulted in a rich and differentiated scholarly debate, it has remained reduced to the question of whether the Habermasian ideal has been fulfilled or not. This limited the development of alternative analytical approaches. Therefore, our approach has aimed to complement the literature by starting at the other end. We intend to fill the analytical gap before we try to evaluate the quality of public communication and its outcomes as measured by deliberative criteria. Second, conceptualizing the public sphere as a dynamic network of actors and contents that are linked to each other by communicative actions has allowed us to link the micro-level of individual actors with the macro-structures within society. Hereby, the reasoning may go in both directions: (1) The knowledge regarding the behavioral preferences and decisions of individual actors may help to predict emergent phenomena; and (2) The patterns on the macro-level may help to identify the prevalence of behavioral preferences. This article makes use of both directions of reasoning.

Network analysis and its aim for empirical investigation requires a radical formalization and reduction of complexity. Therefore, we elaborate a language for the description of networks and to detect the mechanisms for the explanation of network development. First, we will define the elements of these networks, which include the actors, contents, communicative actions, and content relations. Based on these entities, four communicative roles (producer, recipient, curator, isolate) are distinguished. Second, we will summarize how these actors perceive the communicative situation and how they select from the options for action. Third, we will discuss what is known about the selection of the communicative options by the different roles. Finally, we will discuss how these micro-level decisions shape the macro-level structure and dynamics of the public sphere. In combination, this approach follows the reasoning of the methodological individualism: We describe and explain the decisions of the actors to connect (or not) through communicative actions with other actors. At the same time, every communicative action changes the situation for other actors and their follow-up decisions. As a result, this network evolves step-by-step and the dynamic macro-effects result from the interlinking of many communicative actions.

In order to demonstrate the applicability and heuristic potential of our analytical tools for public sphere theory, we use as an example the much-debated and studied concept of the “echo chamber.” Echo chambers are defined as homogeneous, densely connected, and isolated clusters of actors who share the same political opinions ( Bruns, 2019 , p. 29). We will provide arguments for the plausibility of such effects under certain conditions and the reasons for the limited empirical evidence of it ( Bruns, 2019 ). Our considerations may help to resolve these inconclusive findings and open new avenues for normative discussions of the public sphere.

The technical infrastructure of the internet and the emergence of online networking platforms have triggered a multitude of theories and models regarding the networked public sphere (e.g., Benkler, 2006 , pp. 212–272; Friedland et al., 2006 ; Kaiser et al., 2017 ; Meraz & Papacharissi, 2013 ; Neuberger, 2014 , 2022 ; Simone, 2010 ). These share the idea that the public sphere consists of a multitude of actors that engage with each other. Following the literature on social network analysis, the public sphere can be defined by a set of nodes and ties ( Wasserman & Faust, 1994 ). The relevant nodes of the public sphere are the actors and contents. The relevant ties are their communicative actions (production, reception, and curation) and the references between the content elements.

Figure 1 illustrates the minimal constellation of communicative actions in the public sphere, including two actors (i, j), a content (k), and the two basal types of communicative actions (production as solid line and reception as dashed line). This communication is “public” if the content is potentially subject to the communicative actions of other actors (m). In contrast to private communication, the receptive access is not limited to certain (predefined) actors. Due to these communicative actions of further actors and the substantial ties to other content (n), a complex network can emerge (dotted lines) ( van Dijk, 2012 , p. 27). Furthermore, we will argue that “curation” can be defined by the further processing of the received content (n) by an actor (m) through the curative actions, such as selection, arrangement, aggregation, and redistribution of existing content (i.e., combining reception and production).

Network model of communicative actions in the public sphere.

To conceptualize the public sphere not only as a network but as a dynamic network it is necessary to consider the temporal dimension. Therefore, the public sphere may be defined by the nodes, ties, and time frame that are relevant. This can be done in a deductive manner by selecting the nodes and ties based on specific characteristics (e.g., citizens as relevant actors, political issues as relevant content, and communicative actions on a specific social media platform as relevant ties) and by choosing a specific timeframe (e.g., election campaign). In combination, this would allow the conceptualization of the part of the public sphere that is delineated with respect to an election. Alternatively, a network can be defined in an inductive manner by starting with a set of seed nodes from which the relevant communicative actions (e.g., use of specific modes of communication) and related nodes are identified. Depending on the number and types of communicative actions taken, a public sphere may result that may include a multitude of topics that link actors that would otherwise be assumed to be disconnected. In principle, both approaches may be used to specify small and narrowly defined networks or an all-encompassing global network without any constraints to nodes, ties, and time.

From a normative perspective, the academic discourse on the structure of the public sphere often alludes to the macro-level structure at a given timepoint (e.g., polarized) or the changes of this structure over time (e.g., polarization). This is often done in a decontextualized manner from the perspective of the producers, contents, or recipients. Regarding producers, the number of actors and their characteristics that contribute to the public sphere may be assessed. Hereby, it is repeatedly criticized from a normative perspective that the number of news publishers has decreased over the past decades ( Reese, 2021 ). While this market concentration may be criticized, it can also be argued that it is the plurality of the content that is crucial for the quality of a deliberative discourse ( Rössler, 2007 , pp. 503–504; Van Aelst et al., 2017 , p. 11). A third perspective takes the recipients into account. The rationale is that it is not the plurality of the content provided that is decisive, if the recipients do not make use of it. While these are relevant aspects of the overall picture, the focus on one aspect distracts from the others. The proposed network perspective on the public sphere not only suggests considering all elements (actors in different roles, contents, and communicative actions) and therefore integrating the previously separate fields of research in communication research, but also that this should be performed from a dynamic perspective. The subsequent sections will provide a more detailed description of these defining elements of a public sphere as a dynamic network (actors and content as nodes, communicative actions as ties) before we define the most important communicative roles, the context they are embedded in, and their behavioral preferences.

Actors and content as nodes

A network may include different types of nodes; our network model of the public sphere includes actors and contents as two distinct node types (defining a two-mode network) ( Wasserman & Faust, 1994 ). Both types may be further differentiated by various attributes. For actors, it may be relevant to distinguish between individual actors (e.g., politicians, journalists, citizens), collective actors (e.g., parties, news organizations), and artificial actors (e.g., algorithms, bots). Also, more specific characteristics, such as the sociodemographic variables of individual actors or the economic resources of collective actors, may be considered. With respect to content, the relevant attributes include the subject (ranging from broadly defined topics to very specific dimensions used in content analysis) and its modality (e.g., text, picture, sound). However, for the network structures and dynamics discussed in this article, most of these differences are negligible and it is more important to take their persistency into account (e.g., stable vs. ephemeral).

The number of nodes included in a network defines its size and the question regarding the inclusion or exclusion of nodes is a crucial decision for any theoretical or empirical model of the public sphere. As mentioned above, this may be done using two different approaches. The deductive approach requires certain knowledge regarding the universe of nodes that can be considered as being part of the public sphere. The spatial models mentioned in the introduction follow this top-down approach and include, for example, media organizations, depending on their distribution technology (e.g., press, radio, television, internet), or geographical and cultural attributes (e.g., country, language). However, in past decades these criteria have increasingly blurred and new actors have emerged, which complicates the delineation of a network of the public sphere.

Hence, an inductive approach may be more suitable to identify the relevant nodes. Hereby, a set of seed nodes (i.e., actors or contents) may be used as the starting point to identify all the (directly or indirectly) connected nodes that are relevant for the discourse on a specific topic or to understand in what context the actors are embedded. This approach allows the identification of the nodes that otherwise might have been excluded because they do not fulfill the deductive selection criteria. At the same time, this approach does not consider the nodes that are not tied to other nodes. Hence, a deductive approach needs to be inclusive in order not to miss the relevant nodes or should be combined with an inductive approach.

From a temporal perspective, the emergence of new nodes and the disappearance of existing nodes are two crucial network dynamics. These dynamics not only affect the size of a network but can have a crucial impact on the role of other actors, the relative importance of content (e.g., visibility), and the overall network structure. The same holds true for nodes that disappear. Furthermore, it needs to be considered that, with the exclusion of a node, the related ties disappear. At the same time, it can be argued that, in the public sphere, the legacy of vanished nodes may remain relevant. For example, actors may remember that there was another actor whose opinion was censored. Hence, a dynamic network model of the public sphere needs to consider that the role of an actor and the relevancy of a content is neither an attribute of the node itself nor is it stable over time.

Communicative actions and content relations as ties

In a network model of the public sphere, two sets of ties need to be distinguished: (1) the ties between actors and content; and (2) the ties among the content itself. The ties between actors and content are formed by the communicative actions of the actors with respect to content. Hereby, we distinguish three types of communicative actions: production, reception, and curation. Production is understood as any form of content creation. This may be an article in a newspaper, a movie on a video platform, a podcast, or any other form of public content. The complementary action is the reception of content. Hence, it is not the content that reaches passive recipients, but the recipient who performs the communicative action of reception. This also emphasizes that the reception of content may only be enabled by production but not enforced. Curation as a third communicative action depends on the prior reception of a content and describes its further processing by selecting, arranging, aggregating, and redistributing without changes to the content. This is a narrower understanding of curation compared to the definitions in the literature (e.g., Bhaskar, 2016 ). The reason for this is the need for a clear distinction between curation and production.

Production, reception, and curation as types of communicative action encompass the relations between actors and content. To clarify these references, the speech act theory can be used. A single speech act consists of two parts: the illocutionary act as a communicative action of producers (such as regulatives and constatives) and the propositional act as the content (topic) ( Searle, 1969 , pp. 23–24, 2010 , p. 69). Therefore, references are two-dimensional: they refer to a type of communicative action and a specific content. Based on a simplified form of speech act theory ( Searle, 1969 ), we distinguish two types of content production: evaluations and assertions. At this point, we follow Habermas’s revision of Searle’s speech act typology, who labeled them “regulatives” and “constatives” ( Habermas, 1984 , pp. 8–42). Their claim of validity is related to the “normative rightness” (regulatives) and “truth” (constatives) of speech acts. This is a common distinction, for example, in journalism, where a professional norm requires the separation of news and opinion. Evaluations (regulatives) can be positive or negative, while assertions (constatives) can be indicated as “true” or “false.” A subsequent speech act (of a former recipient who switches in the next act into the role of a producer) can confirm (“Yes, it is true!”) or deny (“No, it is wrong!”) the validity claim of a preceding speech act. Thus, with the help of speech act theory, the concatenation of communicative action can be observed. Besides production, reception, and curation, we acknowledge the absence of a subsequent tie, the interruption of communication after reception, as a fourth action, but will not elaborate in more detail on this.

The second set of ties in a network model of the public sphere includes the relations between the content elements (without consideration of the actors). On the one hand, these ties can be formal (explicit) references such as citations or links as a form of meta-communication ( Kleinberg, 1999 ). On the other hand, it is important to include the implicit ties between contents. This may be the case if they are not formally linked but address the same topic. In fact, the observation of no explicit tie may be as relevant for the understanding of the public sphere as the existence of other ties (e.g., if actors attempt to exclude certain information or arguments from the discourse).

Roles are “patterns of mutually adjusted expectations and orientations.” They are “the central instance of mediation between the totality of ‘society’ and the concrete actions of ‘individuals’” ( Esser, 2000 , pp. 141–142; translated by the authors). Roles can open or close institutionally determined options for action. Complementary roles, such as that of producer and recipient, depend on each other in order to result in a successful process of communication. In a network model, these expectations and orientations, as well as the actions, can be conceptualized as node attributes and ties. A relevant node attribute can be an exogenous (e.g., institutionally given) role, such as professional journalist. Alternatively, a role can endogenously arise from the interactions (ties) in the network itself. While most models of the public sphere rely on an exogenous attribution of the actors, the conceptualization of the public sphere as a network allows for an endogenous approach. This means that, in a network model of the public sphere, roles do not have to be determined a priori, but can emerge from the communicative actions of the actors involved and the repetition of certain types of action ( Friemel, 2008 ). This approach has the advantage that even unusual actions and relationship repertoires can be captured in the analysis. This is particularly appropriate in the case of online media, where traditional institutional roles such as “journalist” are supplemented by new roles such as “influencer,” or that of private persons who may reach even more recipients than an established media company.

Communication theories provide a wide spectrum of possibilities to define the roles in a network. This starts with such classic ideas as that of the “opinion leaders”: those persons who influence at least one other person ( Lazarsfeld et al., 1944 ) or those who are nominated by at least four persons as being relevant informants ( Merton, 1949 ). By considering several types of communicative actions at the same time, an infinite number of further roles can be defined, such as those of the “transmitters” and “carriers” proposed by Harary et al. (1965) or the “sycophants” and “brokers” described by Marsden (1992) . A further group of possible definitions is suggested by the literature on social network analysis ( Friemel, 2008 , 2015 ). Going beyond the dyadic and triadic perspective, these concepts often take the broader structure into account. This may be done using centrality measures ( Borgatti, 2005 ), structural and regular equivalence ( White et al., 1976 ), or symmetric-acyclic decomposition ( Doreian et al., 2000 ; Harary et al., 1965 ). Finally, it can be argued that communication roles are not discrete categories that allow an exclusive classification but should rather be considered as a value on a continuous scale ( Lin, 1973 ).

Given that there is no superior theoretical deductive or inductive empirical definition of the roles in a communication network, we propose to begin with a simple dyadic constellation of the communicative actions of an actor in relation to a content that includes four types of ties (production, reception, curation, and no action). Hence, four prototypical roles can be distinguished: producers, recipients, curators, and isolates. In a single dyad of an actor and a content, this definition is unambiguous. However, with respect to a multitude of actors and contents, this may become more blurred, because every node is necessarily involved in many dyads. In fact, it is unlikely to encounter exclusive roles of actors that are only producing, receiving, curating, or not participating in any communicative actions. For example, even a professional news organization is not limited to production, since they are dependent on perceiving the content to communicate about and monitoring the content of other actors to adjust their production. Nevertheless, in many cases, a distinction will be possible based on the role an actor most frequently takes. This endogenous identification of communicative roles may confirm the exogenous definitions such as those of the journalist and audience. However, they also provide leeway for changing roles or actors that play the functionally equivalent roles without a formal designation. Roles can be defined by not only one type of communicative action, but also by a mixture of different types.

The four prototypical roles of producers, recipients, curators, and isolate can be described as follows:

Producers are actors that (mainly) create content; the literature on the public sphere refers to these actors as the sources of journalism or the spokespersons pursuing their interests in the public. We suggest extending this understanding to include all the actors that produce content in a form that may subsequently be perceived or curated by other actors. These can be journalists who write an article or produce a TV segment, as well as any other actor producing publicly available content (e.g., on social media). Producers may be categorized according to their productivity (i.e., number of producing communicative actions, the amount of content they produce) or the success of their content among the recipients (i.e., number of receiving communicative actions by recipients). Newspapers of record or influencers on social media are examples of successful producers with respect to their reach. In addition to these dyadic (i.e., producer–content) and triadic perspectives (i.e., producer–content–recipient), the network perspective also allows the identification of actors that are crucial for the overall structure without being very active. For example, a whistleblower may only communicate once but the respective content is the starting point of many subsequent communicative actions by curators sharing it or by other producers that include it as an important piece of information in their own content production (e.g., when commenting on this).

Recipients are actors that (mainly) turn to the content provided by others. Theories on the public sphere typically refer to this role as the “audience” and emphasize that the number and identities of the recipients may not be restricted or controlled. If content may potentially be received by an undefined set of actors, the communication meets the criteria of public communication. The research on media use distinguishes among the different types of recipients according to the amount of content they perceive (e.g., heavy users), the overall pattern of content they use (e.g., media repertoire) ( Hasebrink & Domeyer, 2012 ), or the share of the news within their media menu (e.g., news deprived) ( Eisenegger et al., 2020 ).

Curators are actors that receive, select, arrange, aggregate, and redistribute the existing content produced by other actors. Compared to other definitions ( Bhaskar, 2016 ; Thorson & Wells, 2016 ), this understanding is more focused on how existing content is handled. In its pure form, this does not include the communicative actions, such as interpreting, commenting, and moderating, that are key for other definitions ( Neuberger, 2020 , pp. 137–141). In our network model, these would be the actions of production, with the specificity that the produced content is explicitly linked to another content (e.g., a commentary by an editor regarding the front-page articles or a comment accompanying a social media post). Nevertheless, even without producing content, curation can add value by filtering content and by arranging it in a specific way. In doing so, curators provide a service as intermediaries between producers and recipients. Not only journalistic media organizations (and foremost their editors), but also social media platforms such as Twitter, Facebook, Instagram, YouTube, and TikTok, are examples of institutional curators that (mostly algorithmically) influence the context and visibility of third-party content ( Gillespie, 2018 ). On the individual level, actors can curate sporadically as ordinary users (for example, when they recommend a content in their network as opinion leaders).

Isolates are actors that do not participate in communicative actions. In the context of an information society, this is unlikely to be found in its pure form. However, it may be the case for specific topics (e.g., a specific political issue) or a broader set of topics (e.g., politics). Furthermore, some people may be in this role against their will as a result of lack of access (e.g., digital inequality) ( Friemel et al., 2021 ).

Having characterized nodes and ties as basic elements of a network, we now turn to the question of how they combine to a network of the public sphere. We followed the basic model of sociological explanation by Hartmut Esser (1996 , pp. 91–102). According to this model, actors perceive various options for action (logic of the situation) in a situation and choose from these options (logic of selection); the concatenation of actions results in aggregative effects (logic of aggregation).

The logic of the situation is determined by the objectively offered options and their subjective perception ( Esser, 1999 , p. 36). The objective conditions for communicative options are first determined by the public context, which is an open, society-wide sphere of mutual observation and influence. The conditions also depend to a high degree on the respective media and their affordances that are technically and institutionally defined ( Evans et al., 2016 ). However, other factors beyond the specific media must be considered. For example, for journalists as institutionally embedded producers, five levels of influence can be distinguished: the individual level of journalists, the level of routines and practices in the newsroom, the organizational level (publishing house), the level of social institutions (professional norms, practices, roles), and the social system level ( Shoemaker & Vos, 2009 ). At the system level, the political, legal, economic, and cultural conditions of a media system must be taken into account ( Hallin & Mancini, 2004 ). Media reception is similarly socially influenced, such as in the gratifications sought by recipients ( Blumler, 1979 ). The objective conditions are also an expression of the distribution of power in a society. Therefore, the results of the public discourse depend not only on the quality of arguments, but also on power ( Foucault, 1980 , pp. 131–133). Besides the objectively proffered options of a situation, their subjective perception must be considered. Among others, this includes the perceived opportunities (e.g., when gaining attention and approval by other actors) and risks (e.g., when other actors disagree). These exogenous factors of the situation (whether objectively proffered or subjectively perceived) must be supplemented by the course of communication as an endogenous factor. Communicative actions are interrelated and the sequences of such actions build a path-dependency for following actions ( Burkart, 2019 , pp. 29–33; Luhmann, 1996 , p. 14). This aspect becomes especially important for the understanding of dynamic processes.

Digital transformation expands the spectrum of possibilities for communicative actions because more actors have the possibility to produce public content that is available for reception or curation. This results in a public sphere that is often referred to as a “high-choice media environment” ( Van Aelst et al., 2017 ). This implies that more variants of the producing, receiving, and curating actions are possible than before ( Costera Meijer & Kormelink, 2015 ). From the perspective of the individual actor, there are more possibilities for communicative actions in the public sphere, and from the macro-perspective, more complex networks result. Furthermore, digital media facilitate explicit relations among content, which has become a characteristic feature of most online media (e.g., hyperlink between websites or tags). In sum, this leads to the paradoxical situation in which content is accessible for more potential recipients over a longer period than ever before, but its visibility vanishes due to the increase in the amount of content (“information overload”).

Because the complexity of the situation increases, it is not plausible to assume that actors make their decisions based on the full information of the entire (“global”) network and all previous and potential future constellations. It is more likely that the perception of the situation is dominated by “local” factors such as the adjacent actors, related contents, and previous actions within a limited timeframe. In a digital high-choice media environment ( Van Aelst et al., 2017 ), the objective increase in options leads to an overload because actors only possess a limited capacity for processing. The options of reception are no longer compared, but only scanned ( Panek, 2016 ). The information on the global network and its previous and potential future structure must be generated actively (e.g., by researchers) and may provide only a rough and generic description, such as with the notion of echo chambers ( Bruns, 2019 ).

In the previous sections, we have argued that communicative actions are always embedded in the context of actors, contents, preceding communicative actions, and other factors that structure the set of possibilities in a given situation. In this section, we will turn to the logic of selecting a particular action from the available options.

Our model of the public sphere builds on the following assumptions for this selection of a distinct action: First, this selection is not at random, but follows specific preferences and models of decision-making that may differ among actors and over time. Schimank (2016 , pp. 44–185) distinguished among the rationally calculating, egoistic utility maximizer (“homo economicus”), the norm-guided “homo sociologicus,” the “emotional man” following his emotions, and the “identity assertor” who seeks to live up to his evaluative self-image. These preferences should not be considered as being deterministic but, rather, as a question of probability. In order to reduce the complexity of a decision-making situation, actors define situations with the aid of mental models that help to typify situations (frames) and to select a distinct action (script). According to the dual-process model, the degree of rationality and depth of processing varies ( Esser & Kroneberg, 2015 ). These considerations have been applied to curating in journalism (situation model for the explanation of news selection) ( Engelmann, 2012 , pp. 125–150) and reception (extended elaboration likelihood model; Ott et al., 2020 ).

Second, the relevant set of possibilities to choose from does not include the entire public sphere but rather a set of “local” options that are within the observational scope of an actor. We elaborated on this in the previous section (logic of situation).

Third, communicative actions depend on previous actions. This means that the production or reception of a specific content can be assumed to be dependent on other content that was already perceived or produced by that actor. In the simplest case, this results in a triadic setting including two contents and an actor. In this triad, one content is given and the actor must decide regarding the communicative action (producing, receiving, curating vs. no action) toward the second content. Equivalent to the second assumption, that only a “local” set of options is relevant, it can be assumed that this limitation also applies to the temporal dimension. More recent actions are likely to be more relevant for behavioral preferences than older actions. Therefore, communicative actions must be considered as part of a sequence of the preceding actions that refer to each other.

Table 1 summarizes the key concepts that we introduced and defined above. In sum, they represent the relevant building blocks to describe the public sphere and its dynamics from a network perspective.

Concepts for the analysis of the public sphere as dynamic network

The following paragraphs summarize what is known about and can plausibly be assumed to guide the selection of the communicative actions of producers, receivers, curators, and isolates. Mostly, these theories refer to these roles in the context of mass media and must be transferred to the context of the digital public sphere, in which the options for action largely overlap between the roles ( Arendt et al., 2016 ).

There is a variety of producers, including stakeholders from politics and business (public relations, advertising) and, as a result of platformization, ordinary participants who use social media for communication. Other content producers, such as authors and film producers, are financially dependent on the number of recipients and are in constant competition with other producers. In contrast to companies or political parties, they may not follow a substantial goal but simply focus on the number of receptive actions towards their content. Hence, they attempt to anticipate the selective actions of the recipients. Providing more of the content that was successful in the past appears to be a less costly and risky strategy.

The same holds true for curators. News values can be considered to be the most prominent and sophisticated line of research that addresses the respective selective process of journalistic curators. According to this, various news factors are assessed to anticipate the value of a content for the recipients and thereby maximize the likelihood of a respective communicative action (reception) ( Galtung & Ruge, 1965 ). However, the assessment of this news value requires substantial efforts and comes with uncertainties. Today, the most prominent institutional curators are the various social media platforms. In contrast to journalism, most platforms avoid taking responsibility for the content. In fact, they are radically indifferent to the quality of content ( Zuboff, 2019 ) to increase the number of recipients for a content and to increase the amount of content perceived by a recipient.

Similar to the producers and curators, a recipient may prefer content that is similar to content that was perceived before. The relevant theories and research traditions hereby are balance theory ( Newcomb, 1953 ) and selective exposure ( Stroud, 2010 ); they suggest the dominance of communicative actions that confirm previously perceived content. Furthermore, theoretical arguments and empirical findings suggest a co-orientation of media use among the members of a social setting ( Atkin, 1972 ; Friemel, 2021 ).

In sum, there are many arguments to assume that producers, curators, and recipients follow stable preferences over time to reduce the complexity of communicative actions. Hence, the communicative actions produce an echo that continues to resonate. Due to the different regulative and constative speech acts transferring opinion and knowledge, this dynamic is likely to be separated into multiple echo chambers. However, as with every echo, the repercussion decreases and is unlikely to persist over time. Furthermore, at some points, recipients actively challenge their balanced set of cognitions in order to cope with changing context. In addition, the novelty of a piece of information and its inconsistency with previous information may be a strong driver of reception and curation ( Vosoughi et al., 2018 ). Hence, echo chambers are not stable but may only buffer the dynamics within the networks of the public sphere.

Finally, isolates do not select any option from the other possible communicative actions. A classic explanation for choosing not to participate in communicative actions is in the avoidance of cognitive dissonance ( Festinger, 1957 ). This can result in the general avoidance of content regarding a specific domain (e.g., political news) or a more specific selection by avoiding content regarding a specific topic (e.g., climate change) or a specific position toward an issue (e.g., reducing CO 2 emissions). With respect to the digitalization of the public sphere and the chronic overload of available content and other negative side-effects, even more fundamental behavioral preferences, such as “digital detox” ( Radtke et al., 2022 ), “unfriending” on social media as a form of active isolating ( Neubaum et al., 2021 ), and even the request for a “right to disconnect” ( Karppi et al., 2020 ) have emerged in recent years. The fear of hate-speech or other negatively perceived actions may cause participants to withdraw and remain silent (a reaction called the “chilling effect” or “self-censorship”) ( Penney, 2022 ), even in journalism ( Springer & Troger, 2021 ), leaving only a loud, unanimous minority ( Hölig, 2018 ). This has raised the question of whether such intimidation and forced isolation restricts freedom of speech ( Wu, 2018 ).

In the previous sections we have focused on communicative roles and how an actor selects from the options for communicative actions, given the objective conditions and his/her subjective perceptions. Up to this point, we have only considered single communicative actions of the actors. However, for a discussion of communicative dynamics in the public sphere, we must consider multiple actors and their simultaneous, as well as subsequent actions. We argue that, among the theoretically infinite number of sequences and outcomes, some are more likely to emerge. This represents the uneven distribution of communicative actions, the structures along content characteristics, and the logic of aggregation. All three are inherently linked but are discussed in the literature using different terms and with different arguments. The proposed perspective of the public sphere as a dynamic network helps to clarify their similarities and differences.

Uneven distribution of communicative actions

The uneven distribution of (follow-up) communicative actions is well documented by the long tail distribution of attention that publicly available content and the providing actors receive (i.e., few contents receive the most attention, while the other content receives very little attention). This dynamic and structural outcome can be explained by the co-orientation process among actors ( Friemel, 2021 ) and the thereby informed algorithmic selection by social media platforms. Although, this so-called “Matthew effect” is not new to the digital age ( Merton, 1968 ; Salganik et al., 2006 ), the digitalization of communication seems to have aggravated this tendency instead of providing equal opportunities to gain attention (i.e., reception as communicative action)—a central normative criterion for the public discourse ( Habermas, 2006 ).

Structures along content characteristics

In addition to this uneven distribution of communicative actions, the public sphere is likely to be structured along content characteristics. Producers, curators, and recipients tend to prefer confirming (i.e., positive evaluation) over contradicting content in most communicative actions. Nevertheless, in the conflict mode of interaction, producers and curators may deviate from this and favor contradicting over confirming content. In combination, the two tendencies support the clustering effects of specific actors and contents. Confirming relations are bounded within the clusters, while contradicting relations exist between the clusters. The often-cited polarization of the U.S.–Twittersphere along Republican and Democrat partisanship lines ( Colleoni, 2014 ) can be seen as a prototypical example of what can be assumed to exist on other topics and in other settings of the public sphere. However, this dynamic is not limited to two poles but may lead to a fragmentation across multiple topics and social settings (see the notion of echo chambers discussed above). This network structure is often discussed as being problematic and against normative criteria. However, the increased opportunities for cooperation within the clusters should not be neglected.

Logic of aggregation

It is important to note that the described selection mechanisms may accumulate to significantly different network structures even if there are minor tendencies for the single decision (logic of aggregation). This is because every communicative action changes the situational condition for further communicative actions ( Friemel & Bixler, 2018 ; Luhmann, 1996 , p. 14). Therefore, the public sphere is not only the result of all actors, communicative actions, and content, but, at the same time, the situational condition for any further communicative action. Therefore, theoretical reasoning and empirical investigation need to be very sensitive to these decisive differences in behavioral preferences as a starting point of larger effects ( Slater, 2007 ). At the same time, it is likely that the dynamics do not perpetuate infinitely, but that there are points where decisive changes occur. This may be endogenous by means of a saturation effect or exogenous by means of regulation by an authority.

The academic discourse on the public sphere often begins at the macro-level of the public sphere and focuses on the performance of central actors (e.g., public service media, media companies, and regulators) to reach normative goals. In contrast to this top-down approach, this article began from the bottom up with a description of what can plausibly be assumed for individual actors in order to link these micro-behaviors to aggregated dynamics and structures. Given the multitude of possible communicative roles and situations, we focused on the most basic roles and behavioral preferences. This reasoning suggests the emergence of a public sphere that is characterized by specific network structures and the dominance by a limited number of actors and contents. In fact, this assumption is backed by empirical findings regarding the longtail distribution of content and network structures of the public discourse. Hence, the proposed conceptualization of the public sphere as a dynamic network (in which actors perform communicative actions) seems to provide a valid starting point to link the micro-level of individual actors to the macro-level of the public sphere.

Of course, more detailed theoretical discussions and empirical investigations of all aspects are necessary. With respect to the theoretical discussion, this includes the concept of “actor constellation” and the related modes of interaction. An actor constellation exists when at least two actors interact with each other ( Schimank, 2016 , p. 202) and are, therefore, in a “reciprocal relationship” ( Simmel, 1909 , p. 296). There are several ideal-typical patterns of interaction ( Neuberger, 2014 , 2022 ), such as cooperation and conflict. Cooperation is experienced if the communicative action serves a shared interest or the individual interest of the respective other ( Lewis, 2006 , pp. 201–204). In a conflict, opponents with differing interests or values interact directly and try to convince each other or the recipients. The distinction of interaction modes can provide new avenues for normative discussions. They can be assessed for their quality ( Neuberger, 2022 , p. 77), for example, in the case of conflicts involving criteria of deliberative quality ( Habermas, 1991 , 2008 ).

With respect to empirical research, the proposed concept allows three different research designs: First, future studies can advance our knowledge about the behavioral preferences and decisions of individual actors with respect to the four communicative actions and thereby inform agent-based modeling approaches ( Waldherr, 2014 ). Second, the analysis of structures on the macro-level may help to infer regarding the prevalence of the behavioral preferences of the actors. Third, longitudinal network data on communicative actions allow to merge the two perspectives and to test theoretically informed stochastic models regarding their ability to explain the observed dynamics ( Friemel, 2021 ; Snijders et al., 2010 ; Stadtfeld et al., 2017 ).

Conflicts of interest : None declared.

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Public Sphere by Hartmut Wessler , Rainer Freudenthaler LAST REVIEWED: 11 January 2018 LAST MODIFIED: 11 January 2018 DOI: 10.1093/obo/9780199756841-0030

The “public sphere” is generally conceived as the social space in which different opinions are expressed, problems of general concern are discussed, and collective solutions are developed communicatively. Thus, the public sphere is the central arena for societal communication. In large-scale societies, mass media and, more recently, online network media support and sustain communication in the public sphere. The English term “public sphere” is a translation of the German öffentlichkeit . The term translates into two related terms: “the public,” or the collective of speakers and listeners present in the public sphere, and “publicness,” or the state of being publicly visible and subject to scrutiny by the public. In communication studies, the concept of the public sphere has been applied to political as well as cultural communication. The term carries both a descriptive and a normative connotation. Normative theories of the public sphere usually specify ideal characteristics of public communication, as well as conditions conducive to their realization, and help to evaluate critically existing communication. The most prominent normative theorist of the public sphere is German social theorist Jürgen Habermas (born in 1929) whose work has inspired a long-lasting and controversial debate in communication studies and beyond.

Modern research on the public sphere was sparked by the German social theorist Jürgen Habermas’s seminal study, The Structural Transformation of the Public Sphere ( Habermas 1989 ), published in German in 1962 and translated into English, rather belatedly, in 1989. In this volume, Habermas put forward his now-famous argument about the alleged demise of the public sphere, as it sunk from the level of critical discourse in the 19th century to merely affirmative publicity in the 20th century. The reception of the study in the English-speaking world is reflected in Craig Calhoun’s Habermas and the Public Sphere ( Calhoun 1992 ), a collection of critical essays by leading US and UK authors. At the end of this volume, in his “Further Reflections on the Public Sphere,” Habermas offers far-reaching revisions of his original argument, acknowledging a number of his critics while holding on to his critical-normative perspective in looking at modern mediated communication. The edited collection Neidhardt 1994 integrates theoretical and empirical work on mediated political communication and social movements into a common research framework. This framework is explicated in Gerhards and Neidhardt 1993 . Gripsrud, et al. 2010 offers a comprehensive collection of key texts in public sphere theory from the Enlightenment era to the early 21st century. Butsch 2009 brings together contributions from US, European, and Asian scholars that explore how the media structure public spheres and how people use various media to participate in the public sphere. Breese 2011 introduces the distinction between civic public spheres oriented toward enhancing solidarity between citizens in their everyday life and political public spheres oriented toward influencing political decisions.

Breese, Elisabeth B. 2011. Mapping the variety of public spheres. Communication Theory 21.2: 130–149.

DOI: 10.1111/j.1468-2885.2011.01379.x

Breese argues for mapping public spheres along two continua: whether their orientation is toward civil society or the political system and whether they aim for face-to-face interaction or symbolic/mediated communication.

Butsch, Richard, ed. 2009. Media and public spheres . Basingstoke, UK: Palgrave Macmillan.

The contributions to this volume explore the role of mass and online network media for the constitution and maintenance of public spheres in various countries and settings, drawing on conceptions of the public sphere that mostly go beyond the idea of rational-critical discourse. First published in 2007.

Calhoun, Craig, ed. 1992. Habermas and the public sphere . Cambridge, MA: MIT.

Assembling contributions by Seyla Benhabib, Nancy Fraser, Moishe Postone, Nicholas Garnham, Michael Schudson, and many others, as well as a rejoinder by Jürgen Habermas, this volume reflects the Anglo-American reception of Habermas 1989 after its late translation into English.

Gerhards, Jürgen, and Friedhelm Neidhardt. 1993. Strukturen und funktionen moderner öffentlichkeit. In Politische kommunikation: Grundlagen, strukturen, prozesse . Edited by Wolfgang R. Langenbucher, 52–88. Vienna: Braumüller.

German sociologists Jürgen Gerhards and Friedhelm Neidhardt develop an empirical model of public communication that distinguishes three levels of the public sphere (encounters in everyday life, public meetings and protests, and political communication in the mass media) and specifies the input, throughput, and output functions of the political public sphere.

Gripsrud, Jostein, Hallvard Moe, Anders Molander, and Graham Murdock, eds. 2010. The idea of the public sphere: A reader . Lanham, MD: Lexington Books.

This collection of key texts traces the history of public sphere theory from Kant, Hegel, and John Stuart Mill through 20th-century debates, including those of Walter Lippmann and John Dewey, Hannah Arendt, Jürgen Habermas, Nancy Fraser, and John Rawls, to current challenges addressed, among others, in the works of Bernhard Peters, James Bohman, Chantal Mouffe, and Seyla Benhabib. Helpful for students and researchers alike.

Habermas, Jürgen. 1989. The structural transformation of the public sphere: An inquiry into a category of bourgeois society . Cambridge, MA: MIT.

In this “founding study” of modern public sphere research, Habermas traces the roots of public sphere theory in British, French, and German philosophy of the Enlightenment era and develops a critical argument about the commercialization and “refeudalization” of public communication in the early 1960s that is still partially rooted in Frankfurt school critical theory. First published in German in 1962.

Neidhardt, Friedhelm, ed. 1994. Öffentlichkeit, öffentliche Meinung, soziale Bewegungen . Opladen, Germany: Westdeutscher Verlag.

This collection of essays marks a turning point in public sphere research in that it confronts theoretical contributions, drawing on Jürgen Habermas as well as his counterpart in German sociology, Niklas Luhmann, with empirical contributions from political communication and social movement research, thus opening up new routes for the empirical investigation of public political communication under the conditions of media society.

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Publics and the public sphere.

• Andrew Graan Andrew Graan University of Helsinki
• https://doi.org/10.1093/acrefore/9780190854584.013.568
• Published online: 15 August 2022

Mass communication is a constitutive part of social life and experience across the world today, affecting how people work, practice religion, engage in politics, understand others, and so on. Indeed, in many world contexts, social actors interact with mass media on a daily basis. In doing so, they not only consume or produce media artifacts but also participate in publics. A public is a particular kind of social form that coalesces as discourse circulates among, and thereby creates, audiences of mutual attention. Through participants’ ongoing orientation to and engagement with circulation of texts and images, publics produce social arenas that link disparate persons into collectivities of shared interests, issues, and convictions. Some publics are large, general, and sustained, such as those centered on national news. Other publics focus on particular topics, such as those related to religious communities, political ideologies, marked social identities, professional worlds, or even hobby and fan cultures. Others still are relatively small scale, such as those formed among the diffuse groupings of friends and acquaintances connected on social media platforms. As venues constituted by the circulation of discourse, publics have wide-ranging social and political consequences. The interests and identities that they privilege and presuppose shape broader processes of social belonging, exclusion, and contestation. Publics ground claims to political authority through assertions of the public interest. Publics also mediate contemporary consumer capitalism, as when advertising targets particular networks of public circulation. In short, publics lie at the center of contemporary social formations and political economies.

The anthropology of publics and the public sphere examines how practices and structures of mass communication mediate and generate wider forms of social and political organization. How do publics normalize some identities while marginalizing others? Under what conditions can publics emerge as political actors? How do dominant public spheres shape political cultures? In taking on these questions, anthropologists attend to the regimes of publicity; that is, constellations of participation norms, social imaginaries, media infrastructures, language ideologies, and metadiscourses that organize publics. This analytic perspective illuminates both how normative publicity is reproduced and challenged and to what effect. In addition, in focusing on discursive circulation, scholarship on publics has pushed anthropologists to develop research methodologies that go beyond face-to-face, participant observation as a tool of data collection. The anthropology of publics and the public sphere has thus emerged as a theoretically generative and methodologically innovative field that endeavors to illuminate mass communication and its implications for social life. In doing so, it has generated novel theoretical understandings of mass media, power and affect, consumption and capitalism, identity, belonging and exclusion, and the bases and limits of democratic representation.

• the public sphere
• circulation
• consumption
• mass communication

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Public sphere in China: A Literature Review

Controversies have been longstanding around the application of the concept of public sphere to a Chinese context since China did not ever have the equivalent historical circumstances for the sprouting of public sphere as the eighteenth century Europe did. With a postmodern constructivist perspective, this paper combs a series of important academic works henceforth from the discussion of Chinese public sphere began in late 1980s and tries to unpack the trajectory of the development of public sphere in China as well as the discussions arising therefrom. It argues that the concept of public sphere can be extrapolated but with distinct manifestations taking root in its respective socio-political conditions. The paper echoes with some scholars' proposal that studying Chinese public sphere should break free of the conceptual constrains and establish the theoretical autonomy by examining it in social movements rather than in theoretical argumentation.

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The focus of this research is whether the Habermas’ ‘bourgeois public sphere’, which is characteristic of Western society, can be extended to China. My main contribution is to demonstrate that the concepts of ‘sentiment’ and ‘reason’ are central to any discussion of the public sphere in China. This is in sharp contrast to the West where rational discussion and the rule of law are the twin foundations of the classical discourse of the public sphere. China’s society is distinct from Western democracies the West in at least two fundamental ways. In the first place, the political system remains ‘communist’ with a single party controlling all of the media. As a result, the degree of freedom of thought and speech is extremely limited, and there is no obvious way in which the mass media can act directly as a forum for free and informed discussion of public policy. Secondly, whereas the rule of law is understood as a central element in Western democratic culture, it has a subordinate place ...

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With the 18th National Congress of the Communist Party of China concluded on 15th November 2012 and the birth of a new Politburo Standing Committee, the Party thus completed its second orderly hand-over of power in more than six decades of its rule over this most populous country in the world, and today, the world’s second largest economic entity. Nevertheless, also marking the year 2012 are various other poignant events that have further strained State-civil society relations in this vast country: the suicide of Zha Weilin, the mysterious death of Li Wangyang, the daring escape of Chen Guangcheng from captivity in Shandong, the intensification of public protests apparently emboldened by the encouraging solution to late 2011’s Siege of Wukan, and the continuing self-immolation of Tibetans since 2009. Among these, most undoubtedly epitomizing the contemporary sociopolitical dilemmas of the People’s Republic of China (PRC) is the proliferation of public protests mainly related to forced demolition and relocation, industrial pollution and official corruption, and related to this, State response to civil rights-defending weiquan activism and its treatment of such activists as part of the wider dissident community. The continued unfolding of this systemic crisis has, indeed, to be properly placed in the overall environmental context of the problem of increasingly acute socioeconomic inequality, including its ethnoregional dimension, which in many ways constitute the epitome as well as the root of China’s social ills resulted from her recent decades of continuous, astounding economic tour de force while having stagnated are the modernization and democratization of its political structure and sociopolitical power configuration. <https://www.dropbox.com/s/96bjjwjjmkb64av/IJCS-V3N3-yeoh-intro-280413.pdf>

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Jane Austen museum appeals to public for help deciphering brother’s memoir

Curators launch campaign after acquiring 78-page document that could hold new information about author

There may be gems about Jane Austen’s life and times buried in a memoir handwritten by her older brother – but it is proving difficult to decipher his tricky handwriting.

So museum curators at her old cottage in the Hampshire village of Chawton are asking Austen enthusiasts across the world if they can help transcribe the newly acquired 78-page document.

The head of collections, interpretation and engagement at Jane Austen’s House , Sophie Reynolds, said: “It’s really, really, rare to have new Austen family material come to light. It’s not fully known what is in there so that’s really exciting.”

As well as the unpublished handwritten biography, the museum has bought an album of watercolours and drawings Austen’s brother made during his career in the Royal Navy. Both have gone on display in an exhibition called Travels with Frank Austen – the name he was known by.

Anyone who wants to help can email the house to request a page to transcribe. Reynolds compared it to a citizen science project. “It’s genuinely useful, it’s a really valuable thing to do. Reading it is quite painstaking.”

The memoir is written in the third person and the pages towards the end of the book are particularly difficult to read as arthritis made the author’s handwriting go “spidery”.

Reynolds said: “Jane Austen left so little facts on her life. This is another piece of the puzzle that can go into the museum. Scholars will find it fascinating to pull things out. It’s about filling in some more of the details that sort of surrounded her. We can see the world a little bit as she would have done.”

Austen lived at Chawton for the last eight years of her life and wrote Pride and Prejudice, Sense and Sensibility, Mansfield Park, Emma, Northanger Abbey and Persuasion there.

Both the manuscript biography and the watercolour album came up for auction at Bonham’s in London last June and were acquired by Chawton with funding from Friends of the National Libraries, a charity that saves the nation’s written and printed heritage.

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• Open access
• Published: 08 November 2023

Policies to prevent zoonotic spillover: a systematic scoping review of evaluative evidence

• Chloe Clifford Astbury 1 , 2 , 3 ,
• Kirsten M. Lee 1 , 2 ,
• Ryan Mcleod 1 ,
• Raphael Aguiar 2 ,
• Asma Atique 1 ,
• Marilen Balolong 4 ,
• Janielle Clarke 1 ,
• Anastassia Demeshko 1 ,
• Ronald Labonté 5 ,
• Arne Ruckert 5 ,
• Priyanka Sibal 6 ,
• Kathleen Chelsea Togño 4 ,
• A. M. Viens 1 , 3 ,
• Mary Wiktorowicz 1 , 2 ,
• Marc K. Yambayamba 7 ,
• Amy Yau 8 &
• Tarra L. Penney 1 , 2 , 3  

Globalization and Health volume  19 , Article number:  82 ( 2023 ) Cite this article

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Emerging infectious diseases of zoonotic origin present a critical threat to global population health. As accelerating globalisation makes epidemics and pandemics more difficult to contain, there is a need for effective preventive interventions that reduce the risk of zoonotic spillover events. Public policies can play a key role in preventing spillover events. The aim of this review is to identify and describe evaluations of public policies that target the determinants of zoonotic spillover. Our approach is informed by a One Health perspective, acknowledging the inter-connectedness of human, animal and environmental health.

In this systematic scoping review, we searched Medline, SCOPUS, Web of Science and Global Health in May 2021 using search terms combining animal health and the animal-human interface, public policy, prevention and zoonoses. We screened titles and abstracts, extracted data and reported our process in line with PRISMA-ScR guidelines. We also searched relevant organisations’ websites for evaluations published in the grey literature. All evaluations of public policies aiming to prevent zoonotic spillover events were eligible for inclusion. We summarised key data from each study, mapping policies along the spillover pathway.

Our review found 95 publications evaluating 111 policies. We identified 27 unique policy options including habitat protection; trade regulations; border control and quarantine procedures; farm and market biosecurity measures; public information campaigns; and vaccination programmes, as well as multi-component programmes. These were implemented by many sectors, highlighting the cross-sectoral nature of zoonotic spillover prevention. Reports emphasised the importance of surveillance data in both guiding prevention efforts and enabling policy evaluation, as well as the importance of industry and private sector actors in implementing many of these policies. Thoughtful engagement with stakeholders ranging from subsistence hunters and farmers to industrial animal agriculture operations is key for policy success in this area.

This review outlines the state of the evaluative evidence around policies to prevent zoonotic spillover in order to guide policy decision-making and focus research efforts. Since we found that most of the existing policy evaluations target ‘downstream’ determinants, additional research could focus on evaluating policies targeting ‘upstream’ determinants of zoonotic spillover, such as land use change, and policies impacting infection intensity and pathogen shedding in animal populations, such as those targeting animal welfare.

The increasing incidence of zoonotic emerging infectious diseases (EIDs) has been attributed to behavioural practices and ecological and socioeconomic change, and is predicted to continue in the coming years [ 1 ]. Higher levels of anthropogenic activity, including agricultural intensification, urbanisation and other forms of land use change, have led to increased interactions between wildlife, humans and livestock, increasing the risk of cross-species transmission [ 2 , 3 , 4 ]. Meanwhile, accelerating rates of globalisation and urbanisation, leading to increased global movement of people and goods and more dense human settlements, have made outbreaks of disease in human populations more difficult to contain [ 5 ]. In response, a call has been issued by leading organisations and experts, including the United Nations Environment Programme, the International Livestock Research Institute and the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services, to complement reactive policy responses with policies that prevent zoonotic EIDs [ 1 , 6 , 7 , 8 , 9 , 10 ]. This approach, sometimes called deep prevention, would need to target upstream drivers to reduce the risk of outbreaks occuring [ 11 ].

Zoonotic spillover, defined as the transmission of a pathogen from an animal to a human, depends on the alignment of ecological, epidemiological and behavioural factors [ 12 ]. Zoonotic pathogens must be transmitted across a spillover pathway (Fig.  1 ) in order to induce infections in humans [ 12 , 13 ]. This involves meeting a series of conditions including appropriate density and distribution of reservoir hosts, pathogen prevalence, infection intensity and human exposure [ 12 ]. Across this pathway, a number of drivers of zoonotic spillover have been identified, including changes in wildlife and livestock populations [ 14 ]; deforestation, urbanisation and other forms of land use change [ 15 , 16 ]; bushmeat consumption [ 17 , 18 , 19 ]; and a variety of human practices including hunting, farming, animal husbandry, mining, keeping of exotic pets and trade [ 8 , 9 , 20 , 21 , 22 ]. These large-scale changes have repeatedly given rise to spillover events [ 2 , 15 , 23 ], sometimes involving pathogens with epidemic or pandemic potential [ 24 ].

Spillover pathway adapted from Plowright et al. [ 12 , 13 ]

The responsibility for addressing zoonotic disease frequently spans multiple sectors of governance due to its relevance for both animals and humans. A One Health perspective, which recognises the health of humans, animals and the environment as being closely linked and inter-dependent [ 25 ], can be useful in understanding the spillover pathway and drivers of spillover events, as well as informing policy and governance approaches to address this cross-sectoral problem. At the international level, the World Health Organization, the Food and Agriculture Organization, the World Organisation for Animal Health and the United Nations Environment Programme have endorsed a One Health approach to policymaking to respond to zoonotic infectious diseases, emphasising collaboration between agencies [ 26 ].

Operationalising a One Health approach to policy

While One Health is a promising approach to preventing zoonotic EIDs, operationalising this concept remains a challenge. Evaluative evidence exists around the effectiveness of interventions to prevent spillover events [ 13 , 27 , 28 , 29 ], however these have often been implemented as short- to medium-term programmes or academic investigations [ 8 ]. In some cases, zoonoses have re-emerged after successful programmes have ended [ 29 ]. As a result, experts have argued for the incorporation of successful interventions into policy frameworks, providing interventions with the sustainability required for long-term disease control [ 8 , 10 ].

Operationalising a One Health approach to policy involves understanding the policy options, identifying the stakeholders involved and developing insights into how to successfully implement and evaluate these policies. Although the longevity and scope of government actions may make policy an effective vehicle for prevention of emerging diseases, implementing policy is a complex process involving numerous actors with competing views and interests [ 30 ]. This context presents challenges for policy development and implementation. Where relevant policies are designed and implemented in isolation, opportunities for co-benefits may be missed and interventions may produce unintended consequences [ 31 ]. Finally, while evaluative evidence is key to informing future policy decisions, the complex systems in which policies are often implemented make evaluation challenging [ 32 ].

Aims and scope

To provide insights around how to use policy to successfully prevent zoonotic spillover events, it is necessary to synthesise the available evaluative evidence. A One Health perspective allows this evidence synthesis to incorporate a wide range of policy instruments and actors and to identify approaches to successfully implementing and evaluating policies in this complex, multi-sectoral context.

Approaches to managing epidemic and pandemic infectious pathogens when they have entered human populations have been systematically catalogued in the medical literature [ 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. These measures include hand washing, face masks, school closures, contact tracing, vaccination and case isolation. Further upstream, systematic reviews of interventions targeting the spillover pathway have predominantly focused on programmes rather than policies, and have been restricted by various characteristics such as geographic region [ 28 ] or pathogen type [ 29 ], or focused on programmes with an explicit endorsement of a One Health approach [ 27 ]. In consequence, a comprehensive understanding of what policies to prevent zoonotic spillover have been evaluated, what actors are involved, and how to successfully implement and evaluate them, is lacking. To address these research gaps, our objective was to synthesise the existing evaluative evidence around policies that target the determinants of zoonotic spillover.

Our approach to identifying and analysing this literature was informed by a One Health perspective, acknowledging the inter-connectedness of human, animal and environmental health.

We conducted a systematic scoping review of evaluations of policies aimed at preventing zoonotic spillover events, based on a previously published protocol [ 40 ]. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews [ 41 ]. The scoping review was conducted in line with guidelines published by Arksey and O’Malley and refined by Levac and colleagues [ 42 , 43 , 44 ], which emphasise an iterative approach suited to an exploratory research question.

The One Health perspective guided the development of the review methodology. This included the search strategy and inclusion criteria, which allow for the inclusion of policies focused on human, animal or environmental health (or any combination of these areas) and with leadership from one or more of these sectors, and the research questions, which seek to outline the policies and the range of sectors involved in implementation. While our focus on the spillover pathway meant we only included policies that had been evaluated in terms of their impacts on animal and human population distributions, health and interactions, we explicitly searched for environment-focused policies (e.g., protection of wetlands and other wildlife habitats) that might have been evaluated from this perspective. We also aimed to interrogate the One Health approach to governance, by assessing to what extent cross-sectoral collaboration – a key tenet of One Health practice [ 25 ] – emerged as a reason for policy success.

Stage 1: identifying the research question

Informed by our research objective, our research questions were:

What policies aimed at preventing zoonotic spillover (i.e., policies that target the determinants of zoonotic spillover included in the spillover pathway [ 12 ]: population distribution, health and interactions) have been evaluated?

What are the types of policies?

Which policy actors (single department, multi-sectoral, whole of government) are involved?

What are the reasons for policy success and failure, and the unintended consequences of implementing these policies?

How has evaluation of these policies been approached in the literature?

What are the methods or study designs used?

What are the outcomes?

What are the opportunities and challenges for evaluation?

Stage 2: identifying relevant studies

We systematically searched four electronic databases (Medline, Scopus, Web of Science, Global Health) in May 2021. The search strategy was organized by the main concepts in our research question: the spillover pathway; public policy; prevention; and zoonotic pathogens. The search strategy was developed iteratively, informed by existing systematic reviews focused on related concepts [ 28 , 45 , 46 , 47 , 48 , 49 ] and known indicator papers meeting inclusion criteria. We also searched the websites of 18 organisations involved in the prevention of zoonotic spillover to identify relevant grey literature. The choice of organisations was informed by an actor mapping exercise in which we identified key international organisations working on the prevention of emerging zoonoses using network sampling [ 50 ]. We searched the websites of a subset of these organisations, focusing on inter-governmental organisations and organisations whose main focus was zoonotic disease. See Supplementary File 1 for details of academic database and grey literature search strategies.

Stage 3: study selection

Studies were included if they met the following criteria:

Primary empirical study with an English-language abstract from any country or region (reviews were excluded);

Study reporting empirical findings from an evaluation of any sort; and.

Study focused on a policy implemented by government that targets the determinants of zoonotic spillover.

Academic records identified through the searches were collated and double screened using the online platform Covidence [ 51 ]. Two researchers (CCA and KML) initially screened titles and abstracts. Title and abstract screening of an initial set of 100 papers was undertaken by both researchers independently. Results were compared to ensure consistency in decisions around study eligibility, and discrepancies were resolved through consensus. This process was repeated until an acceptable level of agreement (> 90%) was reached. The remaining papers were then screened by one of the two reviewers. Full-text screening was undertaken by two independent researchers and discrepancies were resolved by consensus. Studies with full-texts in any language were eligible for inclusion if they include an English-language abstract. Full-text studies published in French, Spanish or Chinese were single-screened by a member of the research team fluent in that language (CCA or AY). Studies published in other languages were translated as necessary.

Grey literature was screened by one researcher (CCA) to determine whether it met the inclusion criteria. Publications were initially screened by looking at titles, tables of contents and executive summaries. Where these indicated that the publication might be eligible, documents were read in full to determine if inclusion criteria were met.

In line with published guidelines, the approach to study selection was refined iteratively when reviewing articles for inclusion [ 42 , 43 , 44 ].

Stage 4: charting the data

Data charting was conducted using a form designed to identify the information required to answer the research question and sub-research questions (see Supplementary File 2). Data charting focused on characteristics of the study, the policy, and the evaluation. For each policy, this included identifying which determinant of zoonotic spillover situated along the spillover pathway was being targeted. For the purpose of this study, we used a model of the spillover pathway adapted from Plowright et al.’s work [ 12 , 13 ], in which we differentiated between wildlife and domesticated animals (Fig.  1 ). This differentiation is important in the policy context, as the wildlife-domesticated animal interface is an important site for intervention, as well as the human-animal interface.

The data charting form was piloted with ten records to ensure that it was consistent with the research question, and revised iteratively [ 42 , 43 , 44 ]. Data charting was conducted by one researcher (CCA, RM, JC, AD or PS) and checked by a second researcher (CCA or KML). Discrepancies were resolved by consensus.

Stage 5: collating, summarising and reporting the results

Our protocol stated that we would use the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project [ 52 ] to assess study quality [ 40 ]. However, on reviewing the included studies we selected two tools that were more appropriate to their characteristics: (1) ROBINS-I [ 53 ] for quantitative outcome evaluations and (2) a tool developed by the authors of a previous review [ 54 ] – based on Dixon-Woods et al.’s approach to assessing study credibility and contribution [ 55 ] – for all other study types. Two researchers (CCA and KML) assessed study quality independently for an initial set of 10 studies, before comparing assessments and reaching agreement where discrepancies occurred. This process was repeated until an adequate level of agreement was reached (> 90%). The remaining studies were assessed by a single researcher (CCA or KML). Records were not excluded based on quality assessment. Instead, assessments were primarily used to help synthesize the literature on how policies were evaluated. Quality assessment was not performed on grey literature due to the wide variability in the format and comprehensiveness of included publications.

We analysed the charted data, presenting a numerical summary of the included studies in table form, allowing us to describe the range of policy interventions that have been evaluated, aspects of policy implementation and approaches to evaluation. Based on the charted data, we inductively grouped evaluated policies with similar characteristics into policy types and assigned a policy instrument to each policy type: communication/marketing, guidelines, fiscal, regulation, legislation, environmental/social planning or service provision. We mapped policy types onto the spillover pathway shown in Fig.  1 to outline the policies that have been used to target each of these determinants. Thematic analysis was conducted using the approach described by Braun and Clarke where the focus is guided by the researcher’s analytic interests [ 56 ], with five overarching themes chosen as an a priori coding framework: (1) reasons for policy success; (2) reasons for policy failure; (3) unintended consequences of policy implementation; (4) opportunities for policy evaluation; and (5) challenges for policy evaluation. We selected these themes based on our research questions and previous familiarisation with the included articles during the process of article selection, data extraction and quality assessment. Sub-themes were subsequently identified through close reading and coding of the included articles. Thematic analysis was conducted by one researcher (RM) using the qualitative data analysis software Dedoose [ 57 ] and reviewed by the lead author (CCA).

Study characteristics

After removing duplicates, our searches identified a total of 5064 academic records. After screening titles and abstracts, we considered 330 records for full-text review. We also identified 11 relevant publications through our grey literature search. Grey literature reports were published by five organisations: four organisations focused on health and disease, including an intergovernmental organisation (the World Organisation for Animal Health) and three non-governmental organisations (the One Health Commission, the Global Alliance for Rabies Control and EcoHealth Alliance); and one non-governmental organisation focused on wildlife trade (TRAFFIC). In total, we included 95 publications in this review (PRISMA diagram in Fig.  2 ) [ 58 ].

We excluded studies which assessed the unintended consequences of policies to prevent zoonotic spillover without evaluating their effectiveness. This included studies that looked exclusively at the mental health impacts of mandatory livestock culls on farm workers [ 59 ]; studies which focused on potentially relevant factors, such as the wildlife trade, but with no consideration of outcomes situated on the spillover pathway [ 60 ]; and studies which assessed the detection power of surveillance systems without assessing the impact of associated policy interventions [ 61 , 62 , 63 ].

Policy characteristics

The characteristics of the policies evaluated in the included studies are presented in Supplementary File 3 and summarised in Table  1 . Some studies evaluated more than one policy, particularly modelling studies which compared the impacts of several policy options and process evaluations focused on a range of activities undertaken by a single government. Therefore, the number of evaluated policies (n = 111) is greater than the number of included studies (n = 95).

Most policies were evaluated for their impact on human exposure (21%), pathogen prevalence in domesticated animals (18%), barriers within domesticated animals (15%), and pathogen survival and spread in domesticated animals (9%). There were also a number of multi-component policies studies across multiple stages of the spillover pathway (18%). Fewer studies focused on wildlife health and populations, and none of the included studies evaluated policies for their impact on infection intensity and pathogen release in either domesticated animals or wildlife.

Where the government department responsible for implementing a policy was identified in the paper, most policies were implemented by a single department (35%), although there were a number of multi-sectoral efforts (24%). The range of government sectors responsible for implementing policies to prevent zoonotic spillover included human health, animal health, food safety, agriculture, conservation, national parks, forestry, fisheries, environmental protection, border control and foreign affairs. Policies were predominantly intended to be implemented by private sector actors, including individuals and organisations working in trade, retail, hunting and animal agriculture. However, some policies were also implemented by public sector actors working in public health, veterinary public health and environmental conservation.

Most policies were situated in high-income (49%) and upper middle-income (28%) countries, with studies from East Asia and the Pacific (43%) and Europe and Central Asia (19%) dominating. Publications focused on policies targeting various zoonotic diseases, with the most common being avian influenza (50%), rabies (19%), brucellosis (11%) and Hendra virus (4%).

Most policies were evaluated using process (38%) or outcome (31%) evaluation. The most frequently used policy instrument was legislation (59%), particularly for managing pathogen spread in domesticated animals through measures such as mandatory vaccination, culls or disinfection protocols. Meanwhile, communication and marketing or service provision was more typically used to reduce risk in wildlife and human populations, for example by providing guidance around recommended hygiene protocol, by distributing oral vaccination in wildlife habitat or by offering vaccination to human populations.

PRISMA 2020 diagram [ 58 ]

What policies aimed at preventing zoonotic spillover have been evaluated?

Policy types targeted different determinants across the pathway to zoonotic spillover and used various approaches with different evidence of success (Table  2 ). We identified policy options including culling – both general and targeted – of wild and domesticated animals; habitat protection (limiting activities such as agriculture and animal husbandry in wildlife habitats); supplemental feeding to control wildlife movements; vaccination of both wildlife, domesticated animals and human populations with occupational exposure to animals; policies to improve biosecurity in sites where animals are kept, slaughtered and sold, including mandates and information campaigns; live animal market closures; and bans on hunting and selling wildlife. Where outcomes or impacts were evaluated, most policies saw some level of success (i.e., outcome measures were found to vary in a direction that indicated policy success), though relative effectiveness was not assessed due to variation in study design and outcome measure. Policies with consistent evidence of effectiveness – where outcome measures varied in a direction that indicated policy success in all studies included in the review – included culling and sterilisation of wildlife populations, habitat protection, vaccination in wildlife and domesticated animal populations and mandated disinfection protocols. Policies with equivocal evidence of success (i.e., outcome measures varied in different directions or studies had different findings, some indicating success and some indicating failure) included supplemental feeding of wildlife, pre-emptive livestock culls, live animal market closures and bans on wildlife hunting, trade and consumption. For many policies, there were no impact or outcome evaluations identified in this review.

What are the reasons for policy success?

The evidence from the identified impact and outcome evaluations suggests that most of the policies succeeded to some extent. A range of factors contributed to policy success. First, studies emphasized the importance of effective collaboration and coordination between various agencies, disciplines, and levels of government in the execution of policy directives [ 114 , 115 ], in line with a One Health approach to policy and governance. Policy success was attributed, in part, to strong working relationships that encouraged effective communication between various government agencies, and facilitated timely and appropriate policy responses [ 115 ]. Synergy between agencies responsible for surveillance and the execution of control strategies was also reported to be beneficial. For example, prompt communication and effective collaboration between laboratories testing samples and agencies implementing culls in the field was seen as important in the control of highly pathogenic avian influenza in Nigeria [ 116 ]. Similarly, authors also identified the importance of private-public relations and private sector contributions to implementing policies to prevent zoonotic spillover [ 112 ]. This included stronger government engagement with private veterinarians as a factor for success in reducing the spillover of Hendra virus in Queensland [ 109 ], and with farmers, poultry companies and national farming and poultry processing associations in Ghana as part of a successful campaign to reduce risk from highly pathogenic avian influenza [ 112 ]. Studies suggest that the inclusion of private sector stakeholders in the policy process has the potential to improve compliance through transparent dialogue around disease ecology, risk and risk mitigation [ 90 , 91 , 103 , 117 ]; and highlight the utility of participatory approaches in prompting behaviour changes [ 91 ].

Second, authors emphasised the significance of economic incentives, suggesting that policy impact is dependent on private actors’ appraisal of costs and benefits. Studies illustrated how incentives, including compensation, subsidies, rebates, and fines, have had varying degrees of success [ 91 , 97 , 112 , 115 ]. Compensation levels [ 104 , 114 ] and enforcement practices [ 92 ] were identified as salient factors for compliance and adherence. For example, fear of sanctions for bushmeat hunting while a ban was in place in some parts of West Africa were identified as a stronger incentive to avoid bushmeat hunting than the fear of contracting Ebola virus [ 97 ]. Culls were seen as particularly challenging in this regard: while the long-term benefits for farmers may outweigh the financial loss [ 104 ], authorities need to be conscientious of the substantial economic impacts when considering policies that mandate culling or safe disposal [ 95 ]. The direct losses related to compliance (time, labour and expenses) and indirect losses due to price fluctuations and decreases in trade volume, as well as losses to associated industries, are substantial [ 88 , 96 , 113 , 118 ].

Third, trust in government and public support for implemented policy were specified as critical factors influencing the effectiveness of disease control strategies, and research suggests that strategic engagement to facilitate compliance is a necessary step in the policy process [ 97 ]. Participatory approaches that attempt to identify and understand factors influencing compliance have been consistently used to overcome resistance to policy, as insights from engagement and consultation can lead to solutions that facilitate behaviour change at the population level [ 91 , 103 ]. For example, a World Health Organization initiative to reduce avian influenza transmission in poultry markets in Indonesia worked alongside market vendors to achieve its aims, carrying out repeated consultations with the vendors and implementing market infrastructure (such as energy and running water in the market) in collaboration with local authorities to support vendor behaviour change [ 91 ].

Fourth, studies also demonstrated the importance of public communication. The quality of information, as well as the volume, complexity and delivery of public health messages, were key factors [ 75 , 114 ]. Authors contend that communication strategies must understand the target audience and how they interpret and engage with messages [ 97 ], for example by building on relationships where there is exiting trust, such as between veterinarians advising animal vaccination and animal owners [ 117 ]. Homogenously delivered communication strategies were ineffectual: they limited opportunities for open discourse; discounted contradictory lived experiences and expressions of uncertainty; and ultimately contributed to scepticism surrounding implemented policies [ 97 , 117 ].

Finally, studies underscored the importance of surveillance infrastructure to inform intervention strategies. Surveillance programs with the ability to collect and operationalize relevant data were essential to the development of appropriate interventions that are responsive to each unique context [ 115 , 119 ]. Implementing effective surveillance programmes requires the appropriate evaluation tools [ 120 ] and trained personnel [ 81 ].

What are the reasons for policy failure?

Studies showed that perceptions of acceptability and appropriateness were crucial to the effectiveness of implemented policies [ 101 , 104 ]. Several factors were identified that negatively affected acceptability and appropriateness, including: additional expenses for private sector actors without sufficient support [ 75 , 100 , 104 , 112 , 114 ], particularly were culls were demanded but reimbursement for farmers was slow and inadequate, as in a brucellosis eradication campaign in Macedonia [ 81 ]; lack of affordable alternatives [ 97 ]; impracticality of implemented strategies [ 75 , 101 ]; lack of cultural understanding in designing policy interventions [ 97 , 100 ], for example the distribution of footwear to pig farmers in a Polynesian context where footwear was not traditionally worn [ 100 ]; lack of understanding of viral ecology [ 100 ]; as well as public scepticism and distrust [ 97 , 114 ].

Additionally, policy ineffectiveness was associated with poor planning and execution of intervention strategies, including lack of clear direction [ 114 ]; incomplete or inconsistent implementation of control measures (17); limited scope of intervention [ 114 ]; and poor enforcement [ 92 ]. A lack of adequate resources to implement strategies also contributed to policy failure [ 81 ]. Adequate financial resources were necessary to hire and train staff to run surveillance and control operations [ 81 ]. Financial resources were also necessary to fund compensation mechanisms that facilitate compliance. Willingness to adopt policy-prescribed disposal practices was found to be associated with compensation levels (incentives) as a proportion of production price, dependency on income from activities driving zoonotic risk, and contact with prevention staff [ 92 ].

What are the unintended consequences of implementing policies to prevent zoonotic spillover?

A small number of the included studies collected data on the unintended consequences of policies to prevent zoonotic spillover (n = 18). In some instances, unintended consequences were due to disease ecology or human behaviour as a result of policy failure. For example, a study assessing the impacts of the closure of a live poultry market found that, following the closure, vendors travelled to neighbouring markets to sell their animals [ 94 ]. As a result, while cases of avian influenza decreased in the area surrounding the closed market, cases increased in these neighbouring markets, leading to the wider geographic spread of the disease. In another study, elk were provided with supplementary feeding grounds to discourage them from coming into contact with the livestock who shared their range [ 65 ]. While this intervention had the intended consequence of reducing the transmission of brucellosis between elk and livestock, the spread of brucellosis between the elk using the supplementary feeding grounds – who were gathering in larger, tighter groups for longer periods, resulting in higher within-herd transmission – and other elk populations in the area increased. This resulted in an increasing prevalence of brucellosis among the elk, potentially increasing the risk of spillover to livestock. These examples illustrate the complexity of the social and ecological systems in which these policies are implemented, further suggesting the need for a One Health approach to policies to prevent zoonotic spillover.

A key unintended consequence can be attributed to the loss of profits and livelihoods sometimes associated with policies to prevent zoonotic spillover, as described above. The losses incurred by complying with regulations made farmers, hunters and other private sector actors reluctant to report potential infections, contributing to increased unauthorized or illegal activity, and unrestrained spread of disease [ 90 , 92 , 94 , 98 , 112 , 114 ]. Studies investigated the creative ways policy enforcement was circumvented, including hiding hunting equipment on the outskirts of towns or developing informal trade markets and networks [ 97 , 98 ]. Unintended consequences identified in the included evaluations emphasize an opportunity for policymakers to improve sector compliance through public education, levying the influence of consumer attitudes on industry standards [ 104 , 113 ].

A range of study designs were used to evaluate policies. Outcome evaluations (n = 33) used time series or repeat cross-sectional data to conduct evaluations of natural experiments, though most studies did not include a control group for comparison. Outcome evaluations also used case-control and modelling approaches to assess policy impact on an outcome of interest. Process evaluations (n = 30) used cross-sectional and qualitative approaches, as well as study designs combining multiple sources of data, to understand aspects of policy implementation such as the extent to which the policy was being implemented as designed, and the responses and attitudes of stakeholders involved in policy implementation. Economic evaluations (n = 11) included cost-benefit analyses, risk-benefit analyses and modelling studies. Formative evaluations (n = 17) used modelling approaches to estimate what the impacts of a proposed policy option would be in a specific context.

Outcome variables interpreted as indicators of policy success were also numerous and represented determinants along the spillover pathway. As expected, many studies assessed impact on disease transmission, including disease prevalence and incidence, disease eradication, case numbers, and basic reproduction number in human and animal populations, as well as evidence of disease in environmental samples, such as in live animal markets or at carcass disposal sites. Studies also assessed impacts on intermediate factors indicative of successful implementation of specific policies, such as the availability of wild species in markets where a trade ban had been implemented, or knowledge and practices of stakeholders in response to an educational or information campaign.

While most studies found a reduced risk of zoonotic spillover following policy implementation, comparing the magnitude of these impacts was challenging due to the variety of study designs and outcome measures used in the included studies. However, we identified several studies which used modelling to directly compare the impacts of policy options. These studies evaluated various policy scenarios: different combinations within multi-component policy interventions [ 121 ]; culling versus vaccinating wildlife [ 122 ] and livestock [ 84 , 85 ] populations; targeting strategies to humans exclusively versus targeting humans and livestock [ 108 ]; and altering the parameters for culling and vaccination strategies, for example by modelling different ranges for culling and vaccination near infected farms [ 85 ]. These studies often highlighted trade-offs between the effectiveness of policy measures and their cost. For example, estimates of the number of infected flocks were lower when incorporating a ring cull (cull of animals on farms surrounding an outbreak) into a multi-component control strategy for highly pathogenic avian influenza [ 121 ]. However, livestock vaccination was estimated to be a highly effective strategy, with one study findings livestock vaccination to be as or more effective than a pre-emptive cull for outbreak control purposes (depending on the extent of vaccination coverage), while minimising the number of animals culled [ 85 ]. One study jointly modelled costs and benefits of strategies, and found that livestock vaccination had a higher cost-benefit ratio than a wildlife cull [ 122 ]. A final study highlighted the potential of holistic approaches, with drug administration in humans and livestock having a lower cost per disability-adjusted life year averted than intervention in humans alone [ 108 ].

Study authors noted a number of challenges encountered while evaluating policies to prevent zoonotic spillover. One study noted the difficulty of determining the impact of policies aiming to reduce spillover events between wildlife, livestock and humans, as the number of spillover events is often relatively small [ 65 ]. This highlights the importance of considering upstream determinants and risk factors as outcome measures in attempting to evaluate these policies, particularly where spillover events may happen infrequently or not at all during the period of observation. Studying changes in risk factors for spillover can provide insight on the effectiveness of different policies in tackling spillover risk.

Lack of suitable data was a frequently cited barrier to policy evaluation. As policies to prevent zoonotic spillover are often reactive, being implemented in response to an outbreak in animal populations, accessing data from before a policy was implemented was challenging. Studies highlighted the value of routinely collected data, which was often the only data available and was frequently used for policy evaluation [ 65 , 66 , 94 , 115 , 119 , 123 ]. However, in many contexts routine data on animal health is not collected [ 80 ]. Routine testing data from livestock can sometimes be used for evaluation where it exists, but it does not always provide sufficient detail for examining the potential for a policy to prevent zoonotic spillover. For example, some tests do not differentiate between current and past infection, making it difficult to identify where and when spillover occurred [ 65 ], and animal health data may not be granular enough for policy evaluation, particularly in terms of evaluating local policies [ 94 ]. Studies also highlighted instances where the private sector may own data sets reporting disease prevalence and transmission, but may be reluctant to share the data for evaluation purposes [ 121 ]. In such instances, open communication and good relationships with the private sector may be facilitators to evaluation.

Beyond the lack of baseline data, studies highlighted the difficulty in collecting information about policy compliance. As failing to comply often puts farmers and hunters at risk of fines or imprisonment, they were reluctant to disclose information about non-compliance or participation in illegal trade and sale of animals [ 86 , 92 , 97 , 112 ]. This made it difficult to determine policy effectiveness.

Quality assessment

Of the 44 quantitative evaluations, 37 were evaluated as being at moderate or higher risk of bias (see Supplementary File 4), given the possibility of bias in the assessment of intervention impact due to the presence of confounding effects. A small number of studies were determined to be at serious (n = 6) or critical (n = 1) risk of bias, for two main reasons: only having data from after the intervention was implemented; or using a case-control study model without measuring and adjusting for important potential confounders, such as the prevalence of a targeted disease prior to policy implementation. These limitations may reflect the nature of zoonotic spillover events and policy responses, which can happen quickly and leave little time for baseline data collection. Many of the included studies relied on surveillance data, but where such data sets are not available, post-test and case-control study designs may be the only options.

The quality of studies assessed with the tool developed based on Dixon-Woods’ approach [ 55 ] was high overall (n = 41, see Supplementary file 5). Most studies were rated as high in terms of clearly and comprehensively presenting their results (n = 37), analysis (n = 34), research design (n = 33), aims (n = 32) and research process (n = 28). Most studies also had a high relevance to the research question (n = 31), indicating that the research was embedded in policy, being commissioned, co-designed or conducted in partnership with government stakeholders.

We identified a range of policies targeting different parts of the spillover pathway implemented by various policy and governance sectors, including some multi-sectoral initiatives. Policies tended to rely heavily on private sector actors (including actors ranging from small-scale farmers and hunters to larger commercial operations) for implementation, suggesting that open communication and collaboration with these actors was essential for successful policy implementation. Policy success was undermined by lack of collaboration between government agencies; lack of communication between surveillance and control operations; poor understanding of the context in which policies were implemented; and inadequate financial compensation for private sector actors who lost profits and incurred additional costs by complying with policies. Where policies were ineffective, this tended to be due to unintended consequences relating to complex dynamics within the social and ecological systems where policies were implemented. Lack of appropriate data was a key obstacle to policy evaluation, and studies emphasised the importance of robust surveillance infrastructure in evaluating policies that tended to be implemented reactively, in response to an outbreak of zoonotic disease in animal or human populations.

Implications for policy and practice

The key role that the private sector and industry actors play in implementing policies to prevent zoonotic spillover is an important consideration for policymakers. Our findings suggest that many of these policies must be complied with by farmers – from subsistence and smallholder farmers to large corporations – as well as by other actors, such as hunters. Lack of awareness as well as financial costs of compliance among these groups present key barriers to policy success in this area. This set of stakeholders is complex as some may make very marginal profits, if any, and may struggle to afford the additional costs of implementing preventive policies. However, powerful actors and profitable industries are also involved, including large-scale farms and primary resource extraction enterprises [ 22 ]. Acknowledging the differences across these stakeholder groups, and in particular assessing their capacity to bear some of the costs related to prevention, emerges as crucial in successful policy implementation.

Finally, our findings highlight the importance of disease surveillance in efforts to reduce the risk of spillover events. As well as acting as an early warning system, surveillance provides a source of data to evaluate the impact of preventive policies. We found the availability of surveillance data to be a key enabling factor in evaluating policies. In addition, close collaboration between agencies responsible for disease surveillance and control efforts was key to policy success. National surveillance efforts, as well as cross-country collaboration to support global efforts, such as the United States Agency for International Development’s PREDICT program supporting surveillance in areas at high risk for zoonotic disease outbreaks [ 124 ], must be sustained and expanded. In complex areas such as the prevention of zoonotic spillover, approaches to surveillance which encompass risk factors and transmission pathways [ 125 ], as well as One Health surveillance systems which harmonise and integrate data collection and analysis from across human, animal and environmental sectors [ 126 ], are promising approaches to developing surveillance systems that support risk. This context also involves a need to strengthen surveillance capacity in remote and rural locations, as communities living in these contexts may have exposure to numerous pathogens of wildlife origin. This will require strengthening clinical and diagnostic capacity in these settings, as well as engaging with stakeholders such as community human and animal health workers and wildlife or national park rangers [ 127 ].

Comparison with existing literature

This review sought to map the range of policies implemented to reduce the risk of zoonotic spillover, and the various approaches taken to evaluation, and identify factors behind the success and failure of policy implementation and evaluation. Due to this broad scope, comparing relative effectiveness of policy interventions was challenging. Existing systematic reviews with a more specific focus could apply meta-analysis to determine which interventions were most effective. For example, a review of market-level biosecurity measures aiming to reduce the transmission of avian influenza found that reducing market size, separating poultry species, cleaning and disinfecting premises, closing markets and banning overnight storage were highly effective interventions [ 45 ]. However, our findings suggest that studies focused on the control of avian influenza dominate the literature in this space (55 out of 111 evaluated policies), and many of these are focused on market-level measures. Systematic reviews focused on other approaches to reduce spillover risk, such as on-farm biosecurity [ 47 ]; biosecurity for backyard poultry rearing [ 46 ]; and community-based interventions [ 28 ] comment on the paucity of high-quality evidence around the impacts of such approaches. By taking a broad perspective, we hope our findings will provide policy options for consideration in a number of contexts, and guide researchers in focusing their efforts on areas where evidence is lacking.

Strengths and weaknesses of the study

To our knowledge, this is the first attempt to systematically identify and document evaluations of policies aiming to prevent the spillover of zoonotic pathogens into human populations. However, because of the complex drivers of spillover events, some potentially relevant policy evaluations may be excluded where their outcome measures are too far removed from zoonotic spillover. While relevant, such evaluations will be difficult to systematically identify as they make no reference to zoonotic disease.

In addition, this review focused on policy evaluations that have been reported in the peer-reviewed literature and the grey literature published by international agencies and organisations working on these topics. Policies that have been implemented but not evaluated, or evaluated but not published in these literatures, will therefore be excluded from this review. As a result, potentially effective and important policies in the prevention of zoonotic spillover events may not have been identified. However, we hope that the findings from this review will highlight these gaps in the evaluative evidence. We also hope that this review, by extracting practical dimensions, such as study design, outcome measures and the challenges encountered in the evaluation process, will support policymakers and researchers in carrying out further policy evaluations in this space.

Unanswered questions and future research

Our findings highlight several important gaps in the evidence. First, while observational evidence emphasises the importance of upstream determinants such as environmental and ecosystem health in the increasing rate of zoonotic spillover [ 1 , 15 ], we only identified a single evaluation of a policy attempting to target one of these upstream determinants: an evaluation carried out in China to assess the impact of the Ramstar wetland protection program on avian influenza in migratory waterfowl [ 66 ]. This study found that proximity to protected wetlands reduced outbreak risk. Authors hypothesised that this effect was due to the separation of wild waterfowl and poultry populations and the diversion of wild waterfowl away from human-dominated landscapes and toward protected natural habitats. Our findings support existing calls for more quantitative and mechanistic studies of the impact of interventions supporting environmental and ecosystem health on zoonotic spillover risk [ 128 ], as well as calls for greater integration of the environment into One Health research, policy and practice [ 31 ]. Further evaluations of environment and habitat protection policies would strengthen our understanding of this area. In addition, the impact of policies to reduce deforestation or expand forest coverage, such as China’s Grain-to-Green program [ 129 ], on the spillover pathway could be evaluated. Such evaluations might consider potential unintended consequences, as these policies could promote healthier wildlife populations with better disease resistance, but may also facilitate wildlife population growth and higher rates of wildlife-human encounters [ 130 ].

There is also a lack of evaluation of policies targeting infection intensity and pathogen release in either wildlife or domesticated animals. These could include approaches such as improving animal health and welfare to make these populations more resistant to disease [ 13 ]. While arguments have been made for strengthening legal structures supporting animal welfare in order to reduce the risk of zoonotic pathogen transmission [ 131 ], there is a need to evaluate policies that take this approach.

Our review found publications evaluating a wide range of policy interventions spanning the spillover pathway, including habitat protection; trade regulations; border control and quarantine procedures; farm and market biosecurity measures; public information campaigns; and vaccination programmes for wildlife and domesticated animals, as well as human populations with occupational exposure to animals. A wide range of governance sectors implemented these policies, highlighting the prevention of zoonotic spillover as a cross-sectoral issue, though most policies were implemented by a single sector. Our findings highlight the importance of industry and private actors in implementing policies to prevent zoonotic spillover, and the need for thoughtful and effective engagement with this wide range of actors, from subsistence hunters and farmers through to industrial animal agriculture operations to address their concerns through a range of incentives. We also identified the centrality of surveillance data in evaluating policies that are often implemented reactively, and effective collaboration between surveillance and control operations as a central factor in successful policy implementation.

Data Availability

All data generated or analysed during this study are included in this published article and its supplementary information files. Analysis code for descriptive characteristics of included policies is available on GitHub.

Abbreviations

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CCA, JC and TLP acknowledge internal research support from York University. MW and CCA acknowledge internal research support from the Dahdaleh Institute for Global Health Research. KML acknowledges funding from the Canadian Institutes of Health Research through a Health System Impact Fellowship. AY is funded by the BBSRC through the Mandala project (grant number BB/V004832/1). AMV acknowledges support from York University through a York Research Chair in Population Health Ethics & Law. This review was undertaken as part of a project funded by the Canadian Institutes of Health Research, Grant Reference Number VR5-172686. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Understanding the Public Sphere

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The public space is the place for a society’s internal discourse. Different subsystems such as politics, the economy, culture, or the organized civil society compete for discursive dominance among themselves and with each other and try to determine the public agenda. The performance of the community depends on whether the actors succeed in developing an understanding of each other’s language and logic of action and in finding common solutions. What is needed is politicization in the best sense of the sub-sectors of society, especially in view of the declining steering capacity of the state. As the boundary-dissolving forces of globalization and digitalization put pressure on the limited regulatory power of states and as citizens and consumers voice ever greater demands, all societal actors are called upon to contribute their political resources for the common good.

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Prevalence of metabolic syndrome and associated factors among patient with type 2 diabetes mellitus in Ethiopia, 2023: asystematic review and meta analysis

• Betelhem Mesfin Demissie 1 ,
• Fentaw Girmaw 2 ,
• Nimona Amena 3 &
• Getachew Ashagrie 2  

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Metabolic syndrome is a complex pathophysiologic state which characterized by abdominal obesity, insulin resistance, hypertension, and hyperlipidaemia. The Adult Treatment Panel III report (ATP III) of the National Cholesterol Education Programme identified the metabolic syndrome as a serious public health issue in the modern era. In Western and Asian nations, the frequency of metabolic syndrome is rising, especially in developing regions experiencing rapid socio-environmental changes, in Sub-Saharan Africa; metabolic syndrome may be present in more than 70% of people with type 2 diabetes mellitus. Therefore the objective of our study was to estimate the pooled prevalence of metabolic syndrome and associated factors among type II diabetes mellitus patient.

This systematic review and meta-analysis included original articles of cross sectional studies published in the English language. Searches were carried out in PubMed, Web of Science, Google Scholar, and grey literature Journals from 2013 to June 2023. A random-effects model was used to estimate the pooled prevalence of metabolic syndrome among type II Diabetes mellitus patient in Ethiopia. Heterogeneity was assessed using the I 2 statistic. Subgroup analysis was also conducted based on study area. Egger’s test was used to assess publication bias. Sensitivity analysis was also conducted.

Out of 300 potential articles, 8 cross sectional studies were included in this systematic review and meta-analysis study. The pooled prevalence of metabolic syndrome among patient with type II diabetes mellitus in Ethiopia was found to be 64.49% (95% CI: 62.39, 66.59) and 52.38% (95% CI: 50.05, 54.73) by using NCEP/ATP III and IDF criteria, respectively. The weighted pooled prevalence of metabolic syndrome among type II diabetes mellitus patients by sub group analysis based on the study region was 63.79% (95% CI: 56.48, 71.11) and 52.23% (95%CI: 47.37, 57.22) by using NCEP/ATP III and IDF criteria, respectively. Being female and increased body mass index were factors associated with metabolic syndrome among type II diabetes mellitus patients.

The prevalence of metabolic syndrome among type II patient is high. Therefore, policymakers, clinicians, and concerned stakeholders shall urge effective strategies in the control, prevention, and management of metabolic syndrome among type II diabetes mellitus.

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Introduction

The complicated pathophysiologic condition known as the metabolic syndrome is characterised by insulin resistance, hypertension, hyperlipidaemia, and abdominal obesity and which originate primarily from an imbalance between energy expenditure and calorie intake [ 1 ]. Even though the NCEP-ATPIII, IDF, and WHO criteria are the most often utilised clinical criteria for the diagnosis of metabolic syndrome, there are numerous similarities between them, there are also notable differences in the perspectives on the underlying causes of the metabolic syndrome [ 2 ]. The prevalence of metabolic syndrome is increasing in Western and Asian countries, particularly in emerging areas that are undergoing fast socio-environmental change. Numerous studies have demonstrated that metabolic syndrome is a major risk factor for type 2 diabetes mellitus, cardiovascular disease (CVD), and overall mortality [ 3 ].

Global estimates suggest that about one-third of the world’s population, primarily in developing countries, may have metabolic syndrome [ 4 ]. The National Cholesterol Education Programme’s Adult Treatment Panel III report (ATP III) recognised metabolic syndrome as a significant contemporary public health concern. It is a multiplex risk factor for cardiovascular disease (CVD) that requires more therapeutic care, and it also raises the risk of cancer, mental problems, renal illness, and early mortality [ 2 , 5 ].

Compared to those in Western countries, the urban population in several developing nations has a greater prevalence of metabolic syndrome. The two main causes of this disease’s growth are the increase in fast food consumption—high-calorie, low-fiber foods—and the decline in physical activity brought on by sedentary leisure activities and the use of automated transportation [ 1 ].

In Sub-Saharan Africa, metabolic syndrome may be present in more than 70% of people with type 2 diabetes mellitus. According to research which is done in two rural clinics of Ghana, the prevalence of metabolic syndrome among type II diabetes mellitus patients was 68.6% (95% CI: 64.0-72.8), and having diabetes for more than five years, being female, and being overweight are significantly associated with metabolic syndrome [ 4 ]. A study done by Lira Neto JCG et al., Stated that among 201 study participants, 50.7% were diagnosed with metabolic syndrome [ 5 ].

A cross sectional study conducted in Ethiopia reported that the prevalence of metabolic syndrome was 20.3% among 325 study participants [ 6 ]. A Systematic Review and Meta-analysis study conducted in Ethiopia stated that the pooled prevalence of metabolic syndrome in Ethiopia was found to be 34.89% (95% CI: 26.77, 43.01) and 27.92% (95% CI: 21.32, 34.51) by using NCEP/ATP III and IDF criteria, respectively. Subgroup analysis based on the study subjects using NCEP/ATP III showed that the weighted pooled prevalence was 63.78%(95% CI: 56.17, 71.40) among type 2 Diabetes Mellitus patients [ 7 ].

Even though this topic has been studied before, our work is unique since we look at aspects outside prevalence. Thus, our study’s goal was to analyse the pooled prevalence of metabolic syndrome and associated factors among patients with type II diabetes mellitus. How much is the prevalence of metabolic syndrome among Ethiopian patients with type II diabetes mellitus? And what variables are associated with metabolic syndrome patients with type II diabetes in Ethiopian?

Protocol and search strategy

The systematic review and meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guideline (Fig.  1 ). The study protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42023442704). An inclusive literature search was conducted to identify studies about the prevalence of metabolic syndrome among patients with type II diabetes mellitus reported among the Ethiopian population of various study subjects. Both electronic and gray literature searches were carried out systematically. PubMed, Web of Science, Google Scholar, and grey literature, were searched for material between 2013 and 2023. The search terms were used separately and in combination using Boolean operators like “OR” or “AND.” An example of keywords used in PubMed to select relevant studies was as follows: (((“Metabolic Syndrome“[Mesh] OR Metabolic syndrome*[tiab]) AND (“Diabetes Mellitus, Type 2“[Mesh] OR “Diabetes Mellitus, Type 2*“[tiab])) AND (“Prevalence“[Mesh] OR “Magnitude*“[tiab])) AND (“Ethiopia“[Mesh] OR “Ethiopia*“[tiab]). Moreover, each database’s specific search parameters were customized accordingly.

Study selection (inclusion and exclusion criteria)

Inclusion criteria.

Studies were selected according to the following criteria: study design, participants, exposures and condition or outcome(s) of interest. Eligible studies were only quantitative full- text, and observational studies (cross-sectional) reporting prevalence and associated factors in terms of the odds ratio. Only articles written in English were retrieved for review. We included studies involving only type II diabetes mellitus patients aged greater than 30.

The primary outcome was the prevalence of metabolic syndrome. We used author reported definitions (according ATP III &IDF) (Table  1 ). Secondary outcome was factors associated with metabolic syndrome among type 2 diabetes mellitus patients. We were used unpublished articles to identify any potential studies that might have been missed from our search.

Exclusion criteria

We excluded reviews, case reports, case series, qualitative studies, and opinion articles. We were exclude abstract-only papers.

Data extraction and quality assessment

Data extraction was done independently by the two reviewers in a pre-piloted data extraction form created in MS Excel. Any discrepancies in the extracted data were resolved by consensus or discussion with a third reviewer. The following details will be extracted from each study:- details of the study (first author’s last name, year of publication), study region, study design, sample size, Prevalence of metabolic syndrome, associated factors.

The Joanna Brigg Institute’s quality evaluation criteria’s (JBI) were used to evaluate the studies’ quality. We assessed each of the chosen publications using the JBI assessment checklist. Research with a quality score of at least 50% was deemed to be of high quality.

Data analysis

Version 17 of STATA was used to analyse the retrieved data after they were imported into Microsoft Excel. To get a general summary estimate of the prevalence across trials, a random-effects model was employed. We employed point estimate with a 95% confidence interval. Sensitivity analysis was used to evaluate each study’s contribution to the outcome by eliminating each one individually. Using Egger’s test, the existence of publication bias was evaluated. The Cochran’s Q statistic and I2 statistics were used to assess the heterogeneity of the studies. Moreover, meta-regression has been conducted that represents linear predictions for the metabolic syndrome among type 2 diabetes mellitus patients prevalence as a function of published year. Subgroup analysis was performed based on study region and study subjects since there was unexplained significant heterogeneity.

Publication bias

Funnel plot and Egger’s test was used to assess publication bias and a P-value of less than 0.05 was used to declare the publication bias. The included studies were assessed for potential publication bias and separate analyses were done based on IDF and NCEP/ATPIII criteria (p values were 0.58 and 0.88, respectively) which indicated the absence of publication bias (Figs.  2 and 3 ).

PRISMA flow diagram of study selection for systematic review and meta-analysis of prevalence of metabolic syndrome among type II Diabetes mellitus patients in Ethiopia [ 11 ]

Forest plot showing the pooled prevalence of metabolic syndrome among type II Diabetes mellitus patients in Ethiopia (according to NCEP ATP III Criteria)

Forest plot showing the pooled prevalence of metabolic syndrome among type II Diabetes mellitus patients in Ethiopia (according to IDF Criteria)

Characteristics of included studies

The title and abstract screening of 300 potential articles yielded 102 that were included relevant to the topic of interest; the full-text screening of 50 of these articles indicated their eligibility for full-text assessment; 8 of these articles, involving 2375 study participants, were found to be eligible for systematic review and meta-analysis. Based on the NCEP/ATPIII and IDF criteria, the prevalence of metabolic syndrome in patients with type 2 diabetes mellitus was assessed among the Ethiopian population of different study participants. Five studies reported the prevalence of metabolic syndrome among type 2 diabetes mellitus based on both IDF and NCEP/ATPIII criteria, whereas seven studies based on NCEP/ATPIII criteria only and six studies by IDF criteria only (Table  2 ).

Prevalence of metabolic syndrome among type 2 diabetes mellitus patients using IDF and NCEP ATP III Criteria

The random-effects model was applied since the heterogeneity index of the studies were significant. The pooled prevalence of metabolic syndrome was found to be 64.49% (95% CI: 62.39, 66.59) by using NCEP/ATP III (Figs.  4 ) and 52.38% (95% CI: 50.05, 54.73) by using IDF criteria (Fig.  5 ). Subgroup analysis based on the study region using NCEP/ ATP III showed that the weighted pooled prevalence was 63.79% (95% CI: 56.48, 71.11) among type 2 diabetes patients (Fig.  6 ). Using IDF criteria, subgroup analysis based on the study region showed that the weighted pooled prevalence was 52.23% (95%CI: 47.37, 57.22).

Sub group analysis based on study region using NCEP ATP III Criteria

the pooled odds ratio of the association between sex and prevalence of metabolic syndrome among type II diabetes mellitus patients

The pooled odds ratio of the association between BMI and prevalence of metabolic

Factors associated with metabolic syndrome among type II DM

Association between sex and prevalence of metabolic syndrome.

The association between being female and prevalence of metabolic syndrome was examined based on the finding from five studies ( 1 , 2 , 4 , 5 and 7 ). The pooled odds ratio (AOR: 0.5, 95% CI: -0.32-1.31) showed that prevalence of metabolic syndrome associated with being female. The studies showed very high heterogeneity (I²=86.3% and P  = 0.00) (Fig.  7 ). Hence, a random effects model was employed to do the final analysis.

Funnel plot for prevalence of metabolic syndrome according to NCE ATPIII

Association between BMI and prevalence of metabolic syndrome

The association between BMI and prevalence of metabolic syndrome was examined based on the finding from four studies ( 1 , 2 , 4 and 8 ). The pooled odds ratio (AOR: 3.86, 95% CI: 2.57–5.15) showed that prevalence of metabolic syndrome associated with BMI. The studies showed high heterogeneity (I²= 68.2% and P  = 0.034) (Fig.  8 ). Hence, a random effects model was employed to do the final analysis.

Funnel plot for prevalence of metabolic syndrome according to IDF

Sensitivity analysis

Sensitivity analysis was carried out by gradually removing each research from the analytic process according to the two provided diagnostic criteria (NCEP/ATP III and IDF) in order to evaluate the impact of each study on the pooled estimated prevalence of metabolic syndrome among type II diabetes mellitus patients. The result showed that excluded studies led to significant changes in the shared estimation of the prevalence of metabolic syndrome (Figs.  9 and 10 ).

Sensitivity analysis based on NCEP/ATP III diagnostic criteria

Sensitivity analysis based on IDF diagnostic criteria

This systematic review and meta- analysis study provides evidence of an estimated pooled prevalence of metabolic syndrome among type II diabetes mellitus patients of the Ethiopian population. According to this review, the combined pooled prevalence of Metabolic syndrome among type II diabetes mellitus patients were 64.49% (95% CI: 62.39, 66.59) and 52.38% (95% CI: 50.05, 54.73) by using NCEP/ATP III and IDF criteria, respectively.

The finding of this study similar with the study conducted in African populations, which reported that the prevalence of metabolic syndrome among type 2 diabetes mellitus was 66.9%(95%CI: 60.3–73.1) [ 9 ]. In addition, the study which was done in sub-Saharan African countries in line with this finding which reports that prevalence of metabolic syndrome among type II diabetes melituse patients were 64.8% (95% CI: 54.74, 74.86) and 57.15% by using NCEP/ATP III and IDF criteria, respectively.

Furture more, the study which was done in Sub-Saharan Africa reported that, among others sub-Saharan Africa countries the prevalence of metabolic syndrome was highest in Ethiopia, (61.14%, 95% CI: 51.74, 70.53), which is almost similar with our study findings [ 8 ].

Similarly the study conducted in Ethiopian population showed that the weighted pooled prevalence of metabolic syndrome among type II diabetes mellitus patient was 63.78% (95% CI: 56.17, 71.40) [ 7 ].

This study result supported by the fact that metabolic syndrome has been associated with type 2 diabetes due to its high prevalence worldwide since it is both related to the increase in obesity and a sedentary lifestyle. Several studies suggest that individuals with Metabolic syndrome are 5 times more likely to develop type 2 diabetes [ 10 ].

This meta-analysis assessed factors determining metabolic syndrome among type II diabetes mellitus patients. The current meta-analysis demonstrated that the prevalence rate of metabolic syndrome was higher in females compared to that in males. This has been shown in all the Middle Eastern countries, and the prevalence was much higher among women than men [ 6 ]. The prevalence rate of metabolic syndrome associated with the individual’s body mass index.

This study has implications for clinical practice. Determining the prevalence of metabolic syndrome among type 2 diabetic patients is critical to guide healthcare professionals to minimize the risk of metabolic syndrome by providing guidance to the patient who has undergone diabetic care follow up. Moreover, it gives information about the burden and public health impact of metabolic syndrome for possible consideration during routine diabetic patient care.

This meta-analysis study has its own limitations that should be considered in the future research. Few studies are included due to limited research in Ethiopia which makes it difficult to generalize the findings to all type 2 diabetic patients in the countery and which makes the discussion part more shallow.

In conclusion, according to this systematic review the prevalence of metabolic syndrome among type II patient is high in Ethiopia and recommends an urgent attention from both the clinical and public health viewpoint Therefore, policymakers, clinicians, and concerned stakeholders shall urge effective strategies in the control, prevention, and management of metabolic syndrome among type II diabetes mellitus. In addition country context-specific preventive strategies should be developed to reduce the burden of metabolic syndrome.

Data availability

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

Abbreviations

Cardiovascular Disease

National Cholesterol Education Program–Adult Treatment Panel III

International diabetes federation

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

World Health Organization

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“B.M involved in the entire work of the manuscript which is a design of the study, review of literature, and data analysis, “F.G.” was involved in, design of the study, review of the literature, data extraction, and statistical analysis. “N.A”. and “G.A” were involved in data analysis and interpretation and drafting of the manuscript. All authors critically revised the paper, and they agreed to be accountable for all aspects of the work.

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Demissie, B.M., Girmaw, F., Amena, N. et al. Prevalence of metabolic syndrome and associated factors among patient with type 2 diabetes mellitus in Ethiopia, 2023: asystematic review and meta analysis. BMC Public Health 24 , 1128 (2024). https://doi.org/10.1186/s12889-024-18580-0

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Received : 10 November 2023

Accepted : 12 April 2024

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DOI : https://doi.org/10.1186/s12889-024-18580-0

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