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If it were not for Sci-Hub – I wouldn't be able to do my thesis in Materials Science (research related to the structure formation in aluminum alloys)

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We fight inequality in knowledge access across the world. The scientific knowledge should be available for every person regardless of their income, social status, geographical location and etc.

Our mission is to remove any barrier which impeding the widest possible distribution of knowledge in human society!

We advocate for cancellation of intellectual property , or copyright laws, for scientific and educational resources.

Copyright laws render the operation of most online libraries illegal. Hence many people are deprived from knowledge, while at the same time allowing rightholders to have a huge benefits from this. The copyright fosters increase of both informational and economical inequality.

The Sci-Hub project supports Open Access movement in science. Research should be published in open access, i.e. be free to read.

The Open Access is a new and advanced form of scientific communication, which is going to replace outdated subscription models. We stand against unfair gain that publishers collect by creating limits to knowledge distribution.

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Oa.mg is a search engine for academic papers, specialising in open access. we have over 250 million papers in our index..

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14 Websites to Download Research Paper for Free – 2024

Download Research Paper for Free

Table of contents

2. z-library, 3. library genesis, 4. unpaywall, 5. gettheresearch.org, 6. directory of open access journals (doaj), 7. researcher, 8. science open, 10. internet archive scholar, 11. citationsy archives, 13. dimensions, 14. paperpanda – download research papers for free.

Collecting and reading relevant research articles to one’s research areas is important for PhD scholars. However, for any research scholar, downloading a research paper is one of the most difficult tasks. You must pay for access to high-quality research materials or subscribe to the journal or publication. In this article, ilovephd lists the top 14 websites to download free research papers, journals, books, datasets, patents, and conference proceedings downloads.

Download Research Paper for Free – 2024

14 best free websites to download research papers are listed below:

Sci-Hub is a website link with over 64.5 million academic papers and articles available for direct download. It bypasses publisher paywalls by allowing access through educational institution proxies.  To download papers Sci-Hub  stores papers in its repository, this storage is called Library Genesis (LibGen) or library genesis proxy 2024.

Visit: Working Sci-Hub Proxy Links – 2024

Z-Library is a clone of Library Genesis, a shadow library project that allows users to share scholarly journal articles, academic texts, and general-interest books via file sharing (some of which are pirated). The majority of its books come from Library Genesis, however, some are posted directly to the site by individuals.

Individuals can also donate to the website’s repository to make literature more widely available. Z-library claims to have more than  10,139,382 Books  and  84,837,646 Articles  articles as of April 25, 2024.

It promises to be “the world’s largest e-book library” as well as “the world’s largest scientific papers repository,” according to the project’s page for academic publications (at booksc.org). Z-library also describes itself as a donation-based non-profit organization.

Visit: Z-Library – You can Download 70,000,000+ scientific articles for free

The Library Genesis aggregator is a community aiming at collecting and cataloging item descriptions for the most part of scientific, scientific, and technical directions, as well as file metadata. In addition to the descriptions, the aggregator contains only links to third-party resources hosted by users. All information posted on the website is collected from publicly available public Internet resources and is intended solely for informational purposes.

Visit: libgen.li

Unpaywall harvests Open Access content from over 50,000 publishers and repositories, and makes it easy to find, track, and use. It is integrated into thousands of library systems, search platforms, and other information products worldwide. In fact, if you’re involved in scholarly communication, there’s a good chance you’ve already used Unpaywall data.

Unpaywall is run by OurResearch, a nonprofit dedicated to making scholarships more accessible to everyone. Open is our passion. So it’s only natural our source code is open, too.

Visit: unpaywall.org

GetTheResearch.org is an  Artificial Intelligence(AI)  powered search engine for search and understand  scientific articles  for researchers and scientists. It was developed as a part of the  Unpaywall  project. Unpaywall is a database of 23,329,737 free scholarly Open Access(OA) articles from over 50,000 publishers and repositories, and make it easy to find, track, and use.

Visit: Find and Understand 25 Million Peer-Reviewed Research Papers for Free

DOAJ (Directory of Open Access Journals) was launched in 2003 with 300 open-access journals. Today, this independent index contains almost 17 500 peer-reviewed, open-access journals covering all areas of science, technology, medicine, social sciences, arts, and humanities. Open-access journals from all countries and in all languages are accepted for indexing.

DOAJ is financially supported by many libraries, publishers, and other like-minded organizations. Supporting DOAJ demonstrates a firm commitment to open access and the infrastructure that supports it.

Visit: doaj.org

The researcher is a free journal-finding mobile application that helps you to read new journal papers every day that are relevant to your research. It is the most popular mobile application used by more than 3 million scientists and researchers to keep themselves updated with the latest academic literature.

Visit: 10 Best Apps for Graduate Students 

ScienceOpen  is a discovery platform with interactive features for scholars to enhance their research in the open, make an impact, and receive credit for it. It provides context-building services for publishers, to bring researchers closer to the content than ever before. These advanced search and discovery functions, combined with post-publication peer review, recommendation, social sharing, and collection-building features make  ScienceOpen  the only research platform you’ll ever need.

Visit: scienceopen.com

OA.mg is a search engine for academic papers. Whether you are looking for a specific paper, or for research from a field, or all of an author’s works – OA.mg is the place to find it.

Visit: oa.mg

Internet Archive Scholar (IAS) is a full-text search index that includes over 25 million research articles and other scholarly documents preserved in the Internet Archive. The collection spans from digitized copies of eighteenth-century journals through the latest Open Access conference proceedings and pre-prints crawled from the World Wide Web.

Visit: Sci hub Alternative – Internet Archive Scholar

Citationsy was founded in 2017 after the reference manager Cenk was using at the time, RefMe, was shut down. It was immediately obvious that the reason people loved RefMe — a clean interface, speed, no ads, simplicity of use — did not apply to CiteThisForMe. It turned out to be easier than anticipated to get a rough prototype up.

Visit: citationsy.com

CORE is the world’s largest aggregator of open-access research papers from repositories and journals. It is a not-for-profit service dedicated to the open-access mission. We serve the global network of repositories and journals by increasing the discoverability and reuse of open-access content.

It provides solutions for content management, discovery, and scalable machine access to research. Our services support a wide range of stakeholders, specifically researchers, the general public, academic institutions, developers, funders, and companies from a diverse range of sectors including but not limited to innovators, AI technology companies, digital library solutions, and pharma.

Visit: core.ac.uk

Dimensions cover millions of research publications connected by more than 1.6 billion citations, supporting grants, datasets, clinical trials, patents, and policy documents.

Dimensions is the most comprehensive research grants database that links grants to millions of resulting publications, clinical trials, and patents. It

provides up-to-the-minute online attention data via Altmetric, showing you how often publications and clinical trials are discussed around the world. 226m Altmetric mentions with 17m links to publications.

Dimensions include datasets from repositories such as Figshare, Dryad, Zenodo, Pangaea, and many more. It hosts millions of patents with links to other citing patents as well as to publications and supporting grants.

Visit: dimensions.ai

PaperPanda is a Chrome extension that uses some clever logic and the Panda’s detective skills to find you the research paper PDFs you need. Essentially, when you activate PaperPanda it finds the DOI of the paper from the current page, and then goes and searches for it. It starts by querying various Open Access repositories like OpenAccessButton, OaDoi, SemanticScholar, Core, ArXiV, and the Internet Archive. You can also set your university library’s domain in the settings (this feature is in the works and coming soon). PaperPanda will then automatically search for the paper through your library. You can also set a different custom domain in the settings.

Visit: PaperPanda

I hope, this article will help you to know some of the best websites to download research papers and journals for free.

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Z-library is legal you can download 70,000,000+ scientific articles for free, top scopus indexed journals in aviation and aerospace engineering.

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How To Download Research Papers For Free: Sci-hub, LibGen, etc.

One of the biggest problems about accessing research papers is the cost. At times, you may have encountered the right papers for your research, only to be frustrated that it needs to be paid for. 

There are many ways to download research papers for free, using websites like Oa.mg, LibGen, and more. This post will talk about these platforms, so you can go try it out yourself.

Open Access vs Paywalled Research Papers

There may be many research papers around, but there are some that remain behind paywalls. While the demand for open access to research is undeniable, certain factors contribute to the persistence of paywalled content.

Publishing Companies Need The Funds

Publishers like Elsevier and Wiley operate on a model where subscription fees and paywalls helps to pay for costs such as:

• peer review,
• typesetting, and
• maintaining digital platforms.

This economic structure ensures the sustainability of publishing houses but limits access to those without the means to pay. 

Protect Copyright Laws

Copyright laws further entrench the paywall system. Publishers hold the rights to the vast majority of journal articles, making it illegal to distribute copyrighted material without consent.

This legal framework underpins the operation of paywalls, despite the ethical debate surrounding access to publicly funded research.

In response, platforms like PaperPanda and Unpaywall have emerged, utilizing clever logic and browser extensions to find open access versions of papers, leveraging repositories like the Directory of Open Access Journals.

Paid Papers Seem To Have Higher Value

The perceived value of peer-reviewed journal articles also plays a role. Academic institutions and researchers place high regard on published work, often equating it with career advancement and credibility.

This prestige associated with peer-reviewed publications incentivizes researchers to publish in traditional journals, despite their papers going to be behind a paywall.

Open access platforms and repositories strive to balance this by offering peer-reviewed articles for free, challenging the traditional valuation of scholarly work.

Despite these challenges, the landscape is shifting. Open access initiatives are gaining traction, challenging the traditional publishing model and advocating for free access to research.

As the academic community and the public demand more equitable access to knowledge, the future might see a paradigm shift towards a more open and accessible repository of human understanding.

Best Websites To Download Research Papers For Free

If you are looking to dive into the vast ocean of academic knowledge without hitting a paywall, certain websites are akin to hidden treasures.

These platforms offer free access to millions of research papers and journal articles, covering various areas of science and beyond.

Often dubbed as the “Pirate Bay” of scientific articles, Sci-Hub breaks down the barriers to knowledge by providing free access to research papers that are otherwise locked behind paywalls.

Founded by Alexandra Elbakyan in 2011, this website uses donated institutional logins to bypass publisher restrictions, offering a direct download button for the paper you’re after.

It’s a controversial but popular choice to download papers, with a repository that includes articles from nearly every field of research. Users simply need to find the DOI (Digital Object Identifier) of the paper they want, and Sci-Hub does the rest.

Library Genesis (LibGen)

This is more than just a repository for scientific papers; it’s a comprehensive database of:

• academic books,
• comics, and

Library Genesis offers a wide range of academic and non-academic content, making it a versatile resource for researchers, students, and the general public alike. 

The platform operates on the principle of sharing knowledge freely, and you can easily find and download PDFs of the research papers you need.

This is a free browser extension for Chrome and Firefox that provides legal access to millions of open access research papers.

When you stumble upon a paper online, Unpaywall’s clever logic checks various open access repositories and finds you a legal, freely available copy. 

It’s like having a digital detective at your disposal, dedicated to finding open-access versions of paywalled articles.

Directory of Open Access Journals (DOAJ)

The DOAJ is an online directory that indexes and provides access to high-quality, open access, peer-reviewed journals.

It covers all subjects and languages, making it an invaluable tool for researchers worldwide.

The directory is meticulously curated, ensuring that all listed journals adhere to a stringent open access policy. For those seeking reputable sources, this is a go-to place to find open access research papers across disciplines.

OA.mg is a tool designed to facilitate free access to scientific papers that are otherwise behind paywalls.

It operates by leveraging the open access movement’s resources, indexing millions of freely available research papers.

To obtain a paper, you typically need the DOI (Digital Object Identifier) of the desired article. By entering this DOI into OA.mg, the platform searches through various open access repositories and databases to find a legally accessible version of the paper.

This service simplifies the process of finding open access versions of research papers, making academic literature more accessible to everyone.

Utilizing some of the most advanced search algorithms, PaperPanda operates by querying various open access repositories to find you the research paper pdfs you need.

It’s especially useful for those who don’t have the DOI of a paper, as PaperPanda’s search capabilities can locate papers based on:

• author names, or

The platform aims to democratize access to scientific literature by making it as straightforward as possible to find and download research papers for free.

Download Research Papers For Free

Each of these websites plays a crucial role in the ongoing push towards open access, ensuring that scientific knowledge is available to anyone curious enough to seek it out.

Whether you’re conducting a literature review, working on a thesis, or simply indulging in a personal quest for knowledge, these platforms can provide you with the resources you need, free of charge.

Dr Andrew Stapleton has a Masters and PhD in Chemistry from the UK and Australia. He has many years of research experience and has worked as a Postdoctoral Fellow and Associate at a number of Universities. Although having secured funding for his own research, he left academia to help others with his YouTube channel all about the inner workings of academia and how to make it work for you.

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Download Research Papers and Scientific Articles for free (Sci-Hub and Library Genesis links updated August 2022)

Many students and researchers need to find a paper for their research, to complete the review of an article, or while writing their thesis. Many papers can be found through your university library, but for those that you may not have access to through your institution, we take a look at the three largest open access sites, as well as sci hub and Library Genesis .

Unpaywall Unpaywall is a website built by Impactstory, a nonprofit working to make science more open and reusable online. They are supported by grants from the National Science Foundation and the Alfred P. Sloan Foundation. What they do is gather all the articles they can from all the open-access repositories on the internet. These are papers that have been provided by the authors or publishers for free, and thus Unpaywall is completely legal. They say they have about 50-85% of all scientific articles available in their archive. Works with Chrome or Firefox.

PaperPanda PaperPanda is a free browser extension for Chrome that gives you one-click access to papers and journal articles. When you find a paper on the publisher’s site, just click the PaperPanda icon and the panda goes and finds the PDF for you.

Open Access Button The Open Access Button  does something very similar to Unpaywall, with some major differences. They search thousands of public repositories, and if the article is not in any of them they send a request to the author to make the paper publicly available with them. The more people try to find an article through them, the more requests an author gets. You can search for articles/papers directly from their page, or download their browser extension.

Library Genesis Library Genesis is a database of over 5 million (yes, million) free papers, articles, entire journals, and non-fiction books. They also have comics, fiction books, and books in many non-english languages. They are also known as LibGen or Genesis Library. Many of the papers on Library Genesis are the same as sci hub, but what sets them apart is that Library Genesis has books as well.

OAmg OAmg lets you search for journal articles and papers, download them, and of course cite them in your Citationsy projects. After entering a query it searches through all published papers in the world and shows you the matches. You can then click a result to see more details and read a summary. It will also let you download the paper through a couple different, completely legal open access services. www.oa.mg

Sci-Hub (link updated August 2022) Finally, there’s Sci Hub . Science-Hub works in a completely different way than the other two: researchers, students, and other academics donate their institutional login to Schi-Hub, and when you search for a paper they download it through that account. After the articles has been downloaded they store a copy of it on their own servers. You can basically download 99% of all scientific articles and papers on SciHub. Just enter the DOI to download the papers you need for free from scihub. Shihub was launched by the researcher Alexandra Elbakyan in 2011 with the goal of providing free access to research to everyone, not only those who have the money to pay for journals. Many in the scientific community praise hub-sci / sciencehub for furthering the knowledge of humankind and helping academics from all over the world. shi hub has been sued many times by publishers like Elsevier but it is still accessible, for example by using a sci hub proxy.

You can find links to Sci-Hub on Wikipedia ( https://en.wikipedia.org/wiki/Sci-Hub ) or WikiData ( https://www.wikidata.org/wiki/Q21980377#P856 ).

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Top 11 Websites for Free Research Paper Downloads

For PhD researchers, it’s critical to gather and read research publications that are pertinent to their areas of study. However, downloading a research paper is one of the most challenging chores for any research scholar. To gain access to high-quality research resources, one needs to pay a fee or subscribe to a journal or publication. In this post, We have shown you how to get a research paper for free.

Sci-Hub was originally launched by Alexandra Elbakyan, a Kazakhstani graduate student, in 2011. It is a website known for providing access to various academic articles and papers using educational institution access and its own collection of downloaded articles and papers. In fact, you can download almost 99% of all scientific papers and articles in existence on Sci-Hub.

Many internet service providers (especially in developed countries) have blocked it at present.  Sci-Hub’s own statistics show that the chances of a request for download being successful are 99%. It processes more than 200,000 requests every day.

How to use Sci-Hub?

• Visit https://sci-hub.se/ (Use a VPN to access it if blocked.) You can also checkout Visit: Working Sci-Hub Proxy Links – 2022 ( https://www.ilovephd.com/working-sci-hub-proxy-links-updated/ )
• Enter the full name of the DOI, URL, or URL in the paper that you would like to download.
• Select”Open” or click the “Open” click.

2. Library Genesis

Library Genesis (Libgen) is a file-sharing based shadow library website for scholarly journal articles, academic and general-interest books, images, comics, audiobooks, and magazines. The site enables free access to content that is otherwise paywalled or not digitized elsewhere. This website was threatened with legal action by Elsevier one of the largest publishing companies of technical, scientific medical and scientific research papers in the year 2015.

You can find a research paper or book on Library Genesis by following the steps given below:

• Visit Library Genesis’ official website (libgen.li).
• Type the name of whatever you’re looking for into the search field, and click the “search!” button.
• Click on the name of a book or research paper in the list of results, and choose one of the available mirrors.
• Proceed to download the book or research paper and save it to your device.

3. Z-Library

Z-Library is a clone of Library Genesis, a shadow library project that allows users to share scholarly journal articles, academic texts, and general-interest books via file sharing (some of which are pirated). The majority of its books come from Library Genesis, however, some are posted directly to the site by individuals.

Individuals can also donate to the website’s repository to make literature more widely available. Z-library claims to have more than 10,139,382 Books and 84,837,646 Articles articles as of April 25, 2022.

The steps to download Z-Library books for free are as follows:

Step 1: Go to the Z-Library website ( https://singlelogin.me/ )  and Sign In.

Step 2: Browse through the categories or use the search bar to find the book you want.

Step 3: Click on the book to open it.

Step 4: Click on the download button to download the book.

4. Unpaywall

This is a huge database that contains more than 21 million academic works from over fifty thousand content repositories as well as publishers. The content in the database is replicated from government resources so downloading them is legal. The authors claim they are able to access around 80-85 percent of all scientific papers accessible on their website. 

You can utilize Google’s Chrome extension to quickly get them at any time. 

In order to do this, you have to follow the instructions listed below:

• Visit https://unpaywall.org/products/extension
• Select on the “Add the Chrome” button. Chrome” option.
• Simply click “Add the store to Chrome” in the Chrome Web Store page in addition.
• Keep an eye on the extension until it is installed.
• After installing the extension, it will work automatically and will appear whenever you go to the site of a paywalled research paper in the database of Unpaywall’s open databases. All you have just click on the green Unpaywall button to allow the article to be displayed immediately.

5. Directory of Open Access Journals

A multidisciplinary, community-curated directory, the Directory of Open Access Journals (DOAJ) gives researchers access to high-quality peer-reviewed journals. It has archived more than two million articles from 17,193 journals, allowing you to either browse by subject or search by keyword.

The site was launched in 2003 with the aim of increasing the visibility of OA scholarly journals online. Content on the site covers subjects from science, to law, to fine arts, and everything in between. DOAJ has a commitment to “increase the visibility, accessibility, reputation, usage and impact of quality, peer-reviewed, OA scholarly research journals globally, regardless of discipline, geography or language.”

It can be used to search for and download research papers for free:

• Visit: https://doaj.org/
• Input your keywords in the search field , then hit enter.
• Choose the research paper you wish to download.
• Hit on the “Full Text” button that is located just below the abstract.

6.ScienceOpen

ScienceOpen offers a professional network platform for academics that gives access to more than 40 million research papers from all fields of science. Although you do need to register to view the full text of articles, registration is free. The advanced search function is highly detailed, allowing you to find exactly the research you’re looking for. You can also bookmark articles for later research. There are extensive networking options, including your Science Open profile, a forum for interacting with other researchers, the ability to track your usage and citations, and an interactive bibliography. Users have the ability to review articles and provide their knowledge and insight within the community.

To search for research papers with the help of Science open:

• Go to: http://about.scienceopen.com/ .
• Select on the “green “Search” button located in the upper right corner.
• Enter your search terms into the search box. In addition to the keywords, you can look up authors’ collections, journals publishers, as well as others.

OA.mg is a search engine for academic papers. Whether you are looking for a specific paper, or for research from a field, or all of an author’s works – OA.mg is the place to find it. Research papers can be found by using OA.mg by following these steps:

• Follow the link below: https://oa.mg
• You can enter your keywords or DOI number into the search field that is available there.
• Select on the “search” button, and wait for results to show up.
• In the search results Download any research document you require by clicking this link for download.

8.Citationsy Archives

Citationsy Archives allows you to look up journals and papers to download, download them, and (obviously) incorporate them into your work.It is important to note that you can access Citationsy Archives with or without an account. 

All you have to do is make a request, and it will then search for the exact phrase in all research papers around the world and show the pertinent matches to you. Click on each of them to view more information, and then access it directly from the search results. 

The platform also allows you to download the papers using a number of different and totally open access and legal options. 

Use Citationsy Archives from https://citationsy.com/archives/

CORE is the world’s largest aggregator of open access research papers from repositories and journals. It is a not-for-profit service dedicated to the open access mission. They serve the global network of repositories and journals by increasing the discoverability and reuse of open access content.

To find a research article using CORE:

• Visit: https://core.ac.uk/
• Enter your search terms into the search box.
• Hit the “Search” link.
• Select on the “Get PDF” button to download any research document you are looking for.

10. PaperPanda

PaperPanda is a Chrome extension that uses some clever logic and the Panda’s detective skills to find you the research paper PDFs you need. Essentially, when you activate PaperPanda it finds the DOI of the paper from the current page, and then goes and searches for it. It starts by querying various Open Access repositories like OpenAccessButton, OaDoi, SemanticScholar, Core, ArXiV, and the Internet Archive. You can also set your university libraries domain in the settings (this feature is in the works and coming soon). PaperPanda will then automatically search for the paper through your library. You can also set a different custom domain in the settings.

11.Dimensions

Dimensions covers millions of research publications connected by more than 1.6 billion citations, supporting grants, datasets, clinical trials, patents and policy documents. Dimensions is the most comprehensive research grants database which links grants to millions of resulting publications, clinical trials and patents.

Dimensions includes datasets from repositories such as Figshare, Dryad, Zenodo, Pangaea, and many more. It hosts millions of patents with links to other citing patents as well as to publications and supporting grants.

Visit: https://www.dimensions.ai/

https://www.scribendi.com/academy/articles/free_online_journal_and_research_databases.en.html

https://gauravtiwari.org/download-research-papers-for-free/

8 Sites to Download Research Papers for Free – 2020

https://microbiologynote.com/12-top-websites-to-download-research-papers-for-free/

14 Websites to Download Research Paper for Free – 2023

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Z-Library is legal? You can Download 70,000,000+ scientific articles for free

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access millions of research papers with Paper Panda

So easy to use, such a huge life saver in terms of research and assessments !! have not come across a article i can not, not read thanks to this :D so happy and has made life easier, thank you, thank you, thank you

One of the most useful web extensions I have ever used, Thank you to the girl on Tiktok that recommended it. I hope both sides of her pillow are cold everyday. Thank you to the developers as well. Huge thumbs up.

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Works great. Been using it only for a short while, but it didn’t fail yet. It’s also very quick. Downside is that it sometimes downloaded an early version of the paper, not the final published paper.

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“Paywall? What’s that?”

Paperpanda searches the web for pdf s so you don’t have to, i’m here to help, you’ve probably run into this problem – you want to read a paper, but it’s locked behind a paywall. maybe you have access to it through your library or university, maybe it’s available to download for free through an open access portal, maybe the author uploaded a pdf to a website somewhere – but how are you going to find it paperpanda is here to help just click the tiny panda in your toolbar and the panda will run off and find the paper for you., access research papers in one click, save time accessing full-text pdf s with the free paperpanda browser plugin, stop clicking and start reading, stop navigating paywalls, search engines, and logins. paperpanda helps you get that full-text pdf faster.

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What is a DOI? | Finding and Using Digital Object Identifiers

Published on December 19, 2018 by Courtney Gahan . Revised on February 24, 2023 by Raimo Streefkerk.

A DOI (Digital Object Identifier) is a unique and never-changing string assigned to online (journal) articles , books , and other works. DOIs make it easier to retrieve works, which is why citation styles, like APA and MLA Style , recommend including them in citations.

You may find DOIs formatted in various ways:

• doi:10.1080/02626667.2018.1560449
• https://doi.org/10.1111/hex.12487
• https://dx.doi.org/10.1080/02626667.2018.1560449
• https://doi.org/10.1016/j.jpsychires.2017.11.014

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How to find a doi, apa style guidelines for using dois, mla style guidelines for using dois, chicago style guidelines for using dois, frequently asked questions about dois.

The DOI will usually be clearly visible when you open a journal article on a database.

Examples of where to find DOIs

• Taylor and Francis Online
• SAGE journals

Note: JSTOR uses a different format, but their “stable URL” functions in the same way as a DOI.

What to do when you cannot find the DOI

If you cannot find the DOI for a journal article, you can also check Crossref . Simply paste the relevant information into the “Search Metadata” box to find the DOI. If the DOI does not exist here, the article most likely does not have one; in this case, use a URL instead.

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APA Style guidelines state that DOIs should be included whenever they’re available. In practice, almost all journal articles and most academic books have a DOI assigned to them.

You can find the DOI on the first page of the article or copyright page of a book. Omit the DOI from the APA citation if you cannot find it.

Formatting DOIs in APA Style

DOIs are included at the end of the APA reference entry . In the 6th edition of the APA publication manual, DOIs can be preceded by the label “doi:” or formatted as URLs. In the 7th edition , DOIs should be formatted as URLs with ‘https://doi.org/’ preceding the DOI.

• APA 6th edition: doi: 10.1177/0269881118806297 or https://doi.org/ 10.1177/0269881118806297
• APA 7th edition: https://doi.org/ 10.1177/0269881118806297

APA citation examples with DOI

• Fardouly, J., & Vartanian, L. R. (2016). Social media and body image concerns: Current research and future directions. Current Opinion in Psychology , 9 , 1–5. https://doi.org/10.1016/j.copsyc.2015.09.005
• Sustersic, M., Gauchet, A., Foote, A., & Bosson, J.-L. (2016). How best to use and evaluate Patient Information Leaflets given during a consultation: a systematic review of literature reviews. Health Expectations , 20 (4), 531–542. https://doi.org/10.1111/hex.12487

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MLA recommends using the format doi:10.1177/0269881118806297.

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In Chicago style , the format https://doi.org/10.1177/0269881118806297 is preferred.

Prevent plagiarism. Run a free check.

A DOI is a unique identifier for a digital document. DOIs are important in academic citation because they are more permanent than URLs, ensuring that your reader can reliably locate the source.

Journal articles and ebooks can often be found on multiple different websites and databases. The URL of the page where an article is hosted can be changed or removed over time, but a DOI is linked to the specific document and never changes.

The DOI is usually clearly visible when you open a journal article on an academic database. It is often listed near the publication date, and includes “doi.org” or “DOI:”. If the database has a “cite this article” button, this should also produce a citation with the DOI included.

If you can’t find the DOI, you can search on Crossref using information like the author, the article title, and the journal name.

Include the DOI at the very end of the APA reference entry . If you’re using the 6th edition APA guidelines, the DOI is preceded by the label “doi:”. In the 7th edition , the DOI is preceded by ‘https://doi.org/’.

• 6th edition: doi: 10.1177/0894439316660340
• 7th edition: https://doi.org/ 10.1177/0894439316660340

APA citation example (7th edition)

Hawi, N. S., & Samaha, M. (2016). The relations among social media addiction, self-esteem, and life satisfaction in university students. Social Science Computer Review , 35 (5), 576–586. https://doi.org/10.1177/0894439316660340

In an APA journal citation , if a DOI (digital object identifier) is available for an article, always include it.

If an article has no DOI, and you accessed it through a database or in print, just omit the DOI.

If an article has no DOI, and you accessed it through a website other than a database (for example, the journal’s own website), include a URL linking to the article.

In MLA style citations , format a DOI as a link, including “https://doi.org/” at the start and then the unique numerical code of the article.

DOIs are used mainly when citing journal articles in MLA .

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

Gahan, C. (2023, February 24). What is a DOI? | Finding and Using Digital Object Identifiers. Scribbr. Retrieved April 9, 2024, from https://www.scribbr.com/citing-sources/what-is-a-doi/

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• Published: 27 March 2024

Depleting myeloid-biased haematopoietic stem cells rejuvenates aged immunity

• Jason B. Ross   ORCID: orcid.org/0000-0002-0816-1314 1 , 2 , 3 , 4   na1 ,
• Lara M. Myers 5   na1 ,
• Joseph J. Noh 1 , 2 ,
• Madison M. Collins 5   nAff8 ,
• Aaron B. Carmody 6 ,
• Ronald J. Messer 5 ,
• Erica Dhuey   ORCID: orcid.org/0000-0002-5961-0722 1 , 2 ,
• Kim J. Hasenkrug   ORCID: orcid.org/0000-0001-8523-4911 5   na2 &
• Irving L. Weissman   ORCID: orcid.org/0000-0002-9077-7467 1 , 2 , 4 , 7   na2  

Nature volume  628 ,  pages 162–170 ( 2024 ) Cite this article

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• Haematopoietic stem cells
• Stem-cell research

Ageing of the immune system is characterized by decreased lymphopoiesis and adaptive immunity, and increased inflammation and myeloid pathologies 1 , 2 . Age-related changes in populations of self-renewing haematopoietic stem cells (HSCs) are thought to underlie these phenomena 3 . During youth, HSCs with balanced output of lymphoid and myeloid cells (bal-HSCs) predominate over HSCs with myeloid-biased output (my-HSCs), thereby promoting the lymphopoiesis required for initiating adaptive immune responses, while limiting the production of myeloid cells, which can be pro-inflammatory 4 . Ageing is associated with increased proportions of my-HSCs, resulting in decreased lymphopoiesis and increased myelopoiesis 3 , 5 , 6 . Transfer of bal-HSCs results in abundant lymphoid and myeloid cells, a stable phenotype that is retained after secondary transfer; my-HSCs also retain their patterns of production after secondary transfer 5 . The origin and potential interconversion of these two subsets is still unclear. If they are separate subsets postnatally, it might be possible to reverse the ageing phenotype by eliminating my-HSCs in aged mice. Here we demonstrate that antibody-mediated depletion of my-HSCs in aged mice restores characteristic features of a more youthful immune system, including increasing common lymphocyte progenitors, naive T cells and B cells, while decreasing age-related markers of immune decline. Depletion of my-HSCs in aged mice improves primary and secondary adaptive immune responses to viral infection. These findings may have relevance to the understanding and intervention of diseases exacerbated or caused by dominance of the haematopoietic system by my-HSCs.

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Data availability

Data for all graphical representations are provided as source data. RNA-seq data have been deposited at the GEO under accession code GSE252062 and the Sequence Read Archive (SRA) under BioProject PRJNA1054066 . The following publicly available datasets were used: GSE43729 (ref. 16 ), GSE39553 (ref. 24 ), GSE48893 (ref. 25 ), GSE109546 (ref. 26 ), GSE27686 (ref. 27 ), GSE44923 (ref. 28 ), GSE128050 (ref. 29 ), GSE47819 (ref. 30 ), GSE130504 (ref. 19 ), GSE112769 (ref. 22 ), E-MEXP-3935 (ref. 21 ), GSE32719 (ref. 3 ), GSE104406 (ref. 53 ), GSE69408 (ref. 54 ), GSE115348 (ref. 55 ), GSE107594 (ref. 104 ), GSE111410 (ref. 56 ), GSE55689 (ref. 57 ), GSE74246 (ref. 58 ), GSE132040 (ref. 108 ), GSE87633 (ref. 109 ) and GSE100428 (ref. 18 ).  Source data are provided with this paper.

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Acknowledgements

We thank the members of the Weissman and Hasenkrug laboratories for advice and discussions; A. McCarty, T. Naik, L. Quinn and T. Raveh for technical and logistical support; A. Banuelos, G. Blacker, B. George, G. Gulati, J. Liu, R. Sinha, M. Tal, N. Womack and Y. Yiu for general help, advice and experimental support; C. Carswell-Crumpton, C. Pan, J. Pasillas and the staff at the Stanford Institute for Stem Cell Biology and Regenerative Medicine FACS Core for flow cytometry assistance; H. Maecker and I. Herschmann of the Stanford Human Immune Monitoring Center (HIMC) for assistance with immunoassays; and the members of the Rocky Mountain Veterinary Branch (RMVB), especially T. Wiediger, for excellent care of the aged mice. This work was partially funded by the Intramural Research Program of the National Institute of Allergy and Infectious Diseases, National Institutes of Health, USA; the NIH/NCI Outstanding Investigator Award (R35CA220434 to I.L.W.); the NIH NIDDK (R01DK115600 to I.L.W.); the NIH NIAID (R01AI143889 to I.L.W.); and the Virginia and D.K. Ludwig Fund for Cancer Research (to I.L.W.). J.B.R. was supported by the Stanford Radiation Oncology Kaplan Research Fellowship, the RSNA Resident/Fellow Research Grant, and the Stanford Cancer Institute Fellowship Award and the Ellie Guardino Research Fund. This work was supported by the Stanford Cancer Institute, an NCI-designated Comprehensive Cancer Center. J.J.N. was supported by Stanford University Medical Scientist Training Program grant T32-GM007365 and T32-GM145402. E.D. was supported by grants from NIH NIDDK (5T32DK098132-09 and 1TL1DK139565-01). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. Some illustrations were created using BioRender.

Author information

Madison M. Collins

Present address: Department of Biological and Physical Sciences, Montana State University Billings, Billings, MT, USA

These authors contributed equally: Jason B. Ross, Lara M. Myers

These authors jointly supervised this work: Kim J. Hasenkrug, Irving L. Weissman

Authors and Affiliations

Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA

Jason B. Ross, Joseph J. Noh, Erica Dhuey & Irving L. Weissman

Ludwig Center for Cancer Stem Cell Research and Medicine, Stanford University School of Medicine, Stanford, CA, USA

Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA

Jason B. Ross

Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA

Jason B. Ross & Irving L. Weissman

Laboratory of Persistent Viral Diseases, Rocky Mountain Laboratories, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA

Lara M. Myers, Madison M. Collins, Ronald J. Messer & Kim J. Hasenkrug

Research Technologies Branch, Rocky Mountain Laboratories, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA

Aaron B. Carmody

Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA

Irving L. Weissman

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Contributions

J.B.R. and L.M.M. contributed equally to this work and they both have the right to be listed first in bibliographic documents. J.B.R. and L.M.M. conceived and performed experiments, analysed and interpreted all the data, and wrote the paper. J.J.N., M.M.C., A.B.C., R.J.M. and E.D. performed experiments and analysed data. L.M.M., M.M.C., A.B.C. and R.J.M. performed the Friend virus experiments. J.B.R. and E.D. designed and performed the RNA-seq and transplant experiments. I.L.W. and K.J.H. conceived experiments, supervised the research, interpreted results and wrote the paper. All of the authors reviewed, edited and approved the manuscript.

Corresponding authors

Correspondence to Kim J. Hasenkrug or Irving L. Weissman .

Ethics declarations

Competing interests.

I.L.W. is listed as an inventor on patents related to CD47 licensed to Gilead Sciences, but has no financial interests in Gilead; he is also a co-founder and equity holder of Bitterroot Bio, PHeast and 48 Bio; he is on the scientific advisory board of Appia. J.B.R. is a co-founder and equity holder of 48 Bio. I.L.W., K.J.H., J.B.R., L.M.M. and J.N.N. are listed as co-inventors on a pending patent application related to this work. The other authors declare no competing interests.

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Extended data figures and tables

Extended data fig. 1 expression of my-hsc markers in hspcs, mature cells, and tissues..

a - l , Expression of my-HSC candidate markers, Slamf1 (CD150) ( a ), Neo1 (NEO1) ( b ), Itga2b (CD41) ( c ), Selp (CD62p) ( d ), Cd38 (CD38) ( e ), Itgb3 (CD61) ( f ), Itgav (CD51) ( g ), Procr (CD201) ( h ), Tie2 ( i ), Esam ( j ), Eng (CD105) ( k ), Cd9 (CD9) ( l ), in HSC and HSPCs in normal mouse BM (top panels), and in young versus old bone marrow (bottom panels). Data and images from a – l generated and obtained directly from Gene Expression Commons 31 ; scale bars represent log2 Signal Intensity ( top ) and Gene Expression Activity ( bottom ) as defined by Gene Expression Commons 31 . m , Heatmap of relative RNA expression for CD150 ( Slamf1 ), NEO1 ( Neo1 ), CD62p ( Selp ), CD41 ( Itga2b ), CD38 ( Cd38 ), CD51 ( Itgav ), and CD61 ( Itgb3 ) in HSCs, MPPs, Progenitors, Myeloid, and Lymphoid cells. Processed data for 23 cell types were obtained directly from Gulati 19 Supplementary Table 1 . Fold-enrichment = [(average percentile of HSCs)/(average percentile of all other cell types)+100], as described in this publication. n – o , RNA expression of CD150 ( Slamf1 ), NEO1 ( Neo1 ), CD62p ( Selp ), and CD41 ( Itga2b ) in bulk mouse tissues from two independent datasets: Tabula Muris 108 ( n ) or Kadoki 109 ( o ). For n – o , Values are z-score normalized for each gene across all tissues.

Source Data

Extended Data Fig. 2 Gating strategy for total HSCs, my-HSCs, bal-HSCs, and HPCs.

a , Schematic to identify and validate my-HSC cell-surface antigens. The diagram was created using BioRender. b , Representative flow-cytometry gating of mouse BM to identify total HSC (Lin – cKIT + Sca1 + FLT3 – CD34 – CD150 + ), my-HSC (Lin – cKIT + Sca1 + FLT3 – CD34 – CD150 High ), bal-HSC (Lin – cKIT + Sca1 + FLT3 – CD34 – CD150 Low ), MPPs 115 [MPPa (Lin – cKIT + Sca1 + FLT3 – CD34 + CD150 + ), MPPb (Lin – cKIT + Sca1 + FLT3 – CD34 + CD150 – ), MPPc (Lin – cKIT + Sca1 + FLT3 + CD34 + CD150 – )], OPP (Lin – cKIT + Sca1 – ), CMP&GMP (Lin – cKIT + Sca1 – CD34 + CD41 – ), MkP (Lin – cKIT + Sca1 – CD34 + CD41 + ), MEP (Lin – cKIT + Sca1 – CD34 – CD41 + ), CLP (Lin – cKIT Lo Sca1 Lo IL7Ra + FLT3 + ). Panels are after excluding dead cells, doublets, and lineage-positive (CD3 + , or Ly-6G + /C + , or CD11b + , or CD45R + , or Ter-119 + ) cells. Used for Fig. 1b–k , Fig. 2a–f , Fig. 3b–d , Fig. 4a , Extended Data Fig. 2c–k , Extended Data Fig. 3a–l , Extended Data Fig. 4a–s , Extended Data Fig. 5c–s , Extended Data Fig. 6a Extended Data Fig. 8c–h . Illustration of Hematopoietic Stem and Progenitor Cell (HSPC) Tree Analysis. CMP is combined CMP&GMP. Gate to define my-HSC vs. bal-HSC was set as described previously 5 . c – f , Relative expression of CD41 ( c ), CD38 ( d ), CD51 ( e ), CD61 ( f ), on HSC and HSPCs. MFI values for each marker were obtained for each population and normalized from 0–1 based on the lowest to highest expression. g – h , Relative cell-surface levels ( g ) and percent-positive cells ( h ) for CD150, NEO1, CD62p, CD41, CD38, CD51, and CD61, on lineage-positive high and low cells, total HSCs, and HPCs in the BM. For cell-surface levels ( g ), MFI values for each marker were obtained for each population and normalized from 0–100 based on the lowest to highest expression. i , Percentage of total HSCs that are CD41 + (y-axis) vs. mouse age in weeks (x-axis); n  = 21 mice. j , Mouse age (x-axis) vs. the frequency of total HSCs (my-HSC+bal-HSC) as a percentage of live cells in the (i) total BM (left y-axis, red ) or (ii) cKIT-enriched BM (right y-axis, blue ) in untreated mice; n  = 13 mice. k , Percent-positive of my-HSCs vs. bal-HSCs for CD47 ( k , top) using independent anti-CD47 clones (MIAP301, left; MIAP410, right), and for cKIT ( k , bottom) using independent anti-cKIT clones (ACK2, left; 2B8, right). Mouse ages: 4–6 months ( b – i , k ), 3–23 months ( j ). For a – k , BM was cKIT-enriched prior to analysis. For j , total BM (non cKIT-enriched) was also examined. p -values and R values calculated with one-tailed Pearson correlation coefficient ( i – j ). n represents independent mice.

Extended Data Fig. 3 Anti-CD150 non-masking antibodies and FACS gating to isolate HSCs.

a , Schematic to identify anti-CD150 antibodies not masked by anti-CD150 antibody clone 1 (TC15), used in panels b – d ; BM cells were incubated with saturating concentrations of unlabelled anti-CD150 antibody clone 1 (TC15) and then stained with PE anti-CD150 clones 2, 3, 4 (Q38, 9D1, mShad150). b – d , Saturating concentrations of unlabelled anti-CD150 antibody clone TC15 blocks staining with PE anti-CD150 clone 4 (mShad150) ( d ), but does not block staining of PE anti-CD150 clones 2, 3 (Q38, 9D1) ( b – c ). e , Schematic to determine if anti-CD150 clones 2, 3, 4 (Q38, 9D1, mShad150) identify the same population as anti-CD150 clone 1 (TC15); used in panels f – h ; BM cells were incubated with PECy-7 anti-CD150 antibody clone 1 (TC15) and with PE anti-CD150 clones 2, 3, 4 (Q38, 9D1, mShad150). f – h , Co-staining with anti-CD150 clones 2, 3 (Q38, 9D1) identifies the same population as anti-CD150 antibody clone TC15 ( f – g ). Co-staining with anti-CD150 clone 4 (mShad150) and anti-CD150 antibody clone 1 (TC15) is mutually blocked ( h ). i , Schematic to identify anti-CD150 antibodies that are not blocked by anti-CD150 clone mShad150, used in panel j ; BM cells are incubated with saturating concentrations of unlabelled anti-CD150 antibody clone mShad150 and then stained with PE anti-CD150 clone 2 (Q38). j , Saturating concentrations of unlabelled anti-CD150 antibody clone mShad150 does not block staining of PE anti-CD150 clone 2 (Q38) ( j ). k , Schematic to determine if co-staining with anti-CD150 clone 2 (Q38) identifies the same population as anti-CD150 antibody clone mShad150; used in panel l ; BM cells are incubated with PECy-7 anti-CD150 antibody clone mShad150 and with PE anti-CD150 clone 2 (Q38). l , Co-staining with anti-CD150 clones 2 (Q38) identifies the same population as anti-CD150 antibody clone mShad150 ( l ). m – n , Representative FACS gating of mouse BM to sort total HSC (Lin – cKIT + Sca1 + FLT3 – CD34 – CD150 + ) from aged (11 months) control mice (Aged, A) or aged (11 months) mice with my-HSC depletion (Aged+Conditioning, A + C), used to sort HSCs for RNA-sequencing experiment presented in Fig. 2g, h , Extended Data Fig. 4x , and used to sort HSCs for transplant experiments presented in Fig. 2i–k , Extended Data Fig. 4t–v . My-HSC depletion was performed with anti-NEO1+anti-CD62p+anti-cKIT+CD47 and cells were collected at day 9 post-treatment; n  = 3 mice (A), n  = 3 mice (A + C). The diagrams ( a , e , i , k ) were created using BioRender. Mouse ages approximately: 3 months ( a – h ), 5–8 months ( i – l ), 11 months ( m – n ). For ( a – n ), BM was cKIT-enriched prior to FACS analysis or sorting. n represents independent mice.

Extended Data Fig. 4 Antibody-mediated depletion of my-HSCs in vivo.

a – d , Frequency (% live) ( a , c ) or absolute number ( b , d ) of my-HSCs and bal-HSCs ( a – b ) or of NEO1 + HSCs and NEO1 – HSCs ( c – d ) after anti-CD150 conditioning (anti-CD150, anti-CD150+anti-CD47, or anti-CD150+anti-CD47+anti-cKIT); n  = 3 mice per group. e , Total HSCs (my-HSCs+bal-HSCs) as percent-live in mice receiving anti-CD47; n  = 5 mice per group; P  = 0.3637. f , Percentage of total HSCs that are my-HSCs in mice receiving anti-CD47; n  = 5 mice per group; P  = 0.6628. g , Total HSCs (my-HSCs+bal-HSCs) as a percent-live, in mice receiving anti-CD47+anti-cKIT; n  = 4 mice per group; P  = 0.0973. h , Percentage of total HSCs that are my-HSCs in mice receiving anti-CD47+anti-cKIT; n  = 4 mice per group; P  = 0.2805. i , Percentage of total HSCs that are NEO1 + HSCs in mice receiving anti-CD150 (IgG2a)+anti-CD47+anti-cKIT (e.g., protocol CD150 v2 ); n  = 4 mice per group; * P  = 0.0353. j – n , Frequency (% live) of CLPs ( j ), IL7Ra + cells ( k ), CMPs&GMPs ( l ), MkPs ( m ), and MEPs ( n ), after anti-CD150, anti-CD62p, or anti-NEO1 conditioning protocols. Values relative to mean of untreated control mice and log2-transformed; n  = 3 mice per group (NEO1 v1 , NEO1 v2 , CD150 v1 ); n  = 4 mice per group (CD62p, CD150 v2 ). o , Ratio of frequency (% live) for Lymphoid to Myeloid Progenitors (CLP)/(CMP&GMP), after anti-CD150, anti-CD62p, or anti-NEO1 antibody protocols. Values relative to mean of untreated control mice and log2-transformed; n  = 3 mice per group (NEO1 v1 , NEO1 v2 , CD150 v1 ); n  = 4 mice per group (CD62p, CD150 v2 ). p , Frequency (% live) of my-HSCs, bal-HSCs, NEO1 + HSCs, and NEO1 - HSCs after treatment with anti-CD150, anti-CD62p, or anti-NEO1 protocols; n  = 3 mice per group (anti-CD150 v1 ); n  = 4 mice per group (anti-CD62p); n  = 3 control mice and n  = 6 treated mice (anti-NEO1, combined 90 ug & 200 ug protocols). Values relative to mean of control mice and log2-transformed. For j – p , values for treated mice (filled circles); values for control mice (unfilled circles). q , Correlation of fraction of live cells for my-HSCs vs. NEO1 + HSCs (left), and bal-HSCs vs. NEO1 - HSCs (right), of control mice and mice receiving anti-CD150, anti-CD62p, or anti-NEO1 protocols, in cKIT-enriched BM; n  = 3 mice (anti-CD150 v1 ); n  = 4 mice (anti-CD62p); n  = 3 control mice and n  = 6 treated mice (anti-NEO1, combined 90 ug & 200 ug protocols). r , Comparison of the absolute number of cells in total (non-cKIT-enriched) BM (y-axis) vs. frequency of cells as a percent-live (in cKIT-enriched) BM (x-axis), for my-HSCs, bal-HSCs, CLP, CMP&GMP, and MkP in control mice and mice receiving anti-CD150, anti-CD150+anti-CD47, or anti-CD150+anti-CD47+anti-cKIT; n  = 3 mice per condition. s , Comparison of the frequency of cells as a fraction of total (non-cKIT-enriched) BM (x-axis) vs. the frequency of cells as a fraction of cKIT-enriched BM (y-axis), for cell populations in control mice and mice receiving anti-CD150, anti-CD150+anti-CD47, or anti-CD150+anti-CD47+anti-cKIT; n  = 3 mice per condition. Data for q – s log10-transformed. t – v , HSC lineage potential 8-weeks after transplantation of 100 total HSCs FACS-sorted from CD45.2 aged mice without (A) or with my-HSC depletion (A + C) into CD45.1 recipients. Donor Myeloid to Lymphoid Ratio ( t , * P  = 0.0275) and Percent-Chimerism Ratio ( u , * P  = 0.0340). For each recipient (y-axis), % donor cells (bottom x-axis) that are Myeloid ( red bars) or Lymphoid ( blue bars) and the Myeloid/Lymphoid log2-ratio ( red circles) (top x-axis) ( v ); n  = 13 recipient mice (A), n  = 14 recipient mice (A + C). w , Donor Myeloid/Lymphoid Ratio 16-weeks after transplantation of 100 total HSCs FACS-sorted from CD45.2 aged mice without (A) or with my-HSC depletion (A + C) into CD45.1 recipients; n  = 12 recipient mice (A), n  = 14 recipient mice (A + C); * P  = 0.0232. x , Top 200 differentially expressed genes ranked by p-value for RNA-seq comparison between (A) vs. (A + C), based on Fragments Per Kilobase of transcript per Million mapped reads (FPKM); log2-transformed. Heatmap generated using Phantasus 110 (v1.21.5) with FPKM values as input and Limma 112 to define differentially expressed genes; n  = 3 mice (A), n  = 3 mice (A + C). Mouse ages approximately: 6-7 months ( a – d , r – s ), 7–9 months ( g – i ), 5–9 months ( j – q ), 11 months (donors, t – w ), 2 months (recipients, v ). For ( a , c , g – s ), BM was cKIT-enriched prior to analysis. For ( b , d , e – f , r – s ), total BM (non cKIT-enriched) was examined. P -values obtained by ordinary one-way ANOVA followed by one-tailed Dunnett’s multiple comparisons test with non-treated as control ( a – d ), unpaired parametric one-tailed t-test ( i - k , p , t – u ), unpaired non-parametric one-tailed t-test ( w ), or unpaired parametric two-tailed t-test ( e – h , l – o ). p -values and R values calculated with one-tailed Pearson correlation coefficient ( q – s ). CD150 v1 is rat IgG2b anti-CD150 protocol; CD150 v2 is rat IgG2a anti-CD150 protocol; NEO1 v2 includes mouse IgG2a anti-goat; α, anti-; ns, not significant. Bars indicate mean +/− s.e.m. n represents independent mice; * P  < 0.05, ** P  < 0.005, *** P  < 0.0005; Exact P -values provided as source data.

Extended Data Fig. 5 Optimization of NEO1 depletion protocol in vitro and in vivo.

a – b , Strategy to restore balanced lineage output by depleting my-HSCs. c – h , Anti-NEO1 antibody saturation curve ( c ) determined from in vitro antibody dilution series ( d – h ). i , Schematic of in vivo saturation experiments with anti-NEO1 antibody; used in panels j – m . j – m , Dose-dependent relationship between anti-NEO1 antibody dose (0 ug, 30 ug, 90 ug, 200 ug), when combined with anti-CD47 and anti-cKIT, on the relative depletion of NEO1 + HSCs ( j ), and increase in CLPs ( k ). Optimal concentration in yellow; n  = 3 mice per group. l , The increase in NEO1 – HSCs after anti-NEO1 dose escalation (0 ug, 30 ug, 90 ug, 200 ug) is correlated with the increase in CLPs. m , Impact on the ratio of Bal-HSCs/My-HSCs ( black ) and NEO1 – HSCs/NEO1 + HSCs ( blue ) as a percentage of live cells after anti-NEO1 antibody dose-escalation (0 ug, 30 ug, 90 ug, 200 ug), when combined with anti-CD47 and anti-cKIT; n  = 3 per group. Values relative to mean value of control (0 ug) mice and log2-transformed. n , Schematic of double-antibody strategy to target NEO1, whereby mouse IgG2a or IgG2b monoclonal anti-goat antibodies are administered 24 h after goat anti-NEO1 93 , 94 . o – p , Schematic ( o ) to demonstrate that saturating concentrations of mouse IgG2a or IgG2b anti-goat do not reduce ability of donkey anti-goat AF488 detect goat anti-NEO1 antibody ( p ). q – s , Schematic ( q ) of experiment demonstrating that mouse anti-goat IgG2a A555 ( r ) and IgG2b PE ( s ) antibodies identify the same population as donkey anti-goat AF488 by flow-cytometry. The diagrams ( a , b , i , n , o , q ) were created using BioRender. Mouse ages approximately: 5–7 months ( c – h , n – s ), 6–9 months ( i – m ). For ( c – s ), BM was cKIT-enriched prior to analysis. For correlation p -values, one-tailed Pearson correlation coefficient (R p ), and one-tailed Spearman correlation coefficient (R s ) were calculated ( l ). p -values obtained by ordinary one-way ANOVA followed by one-tailed Dunnett’s multiple comparisons test with 0ug condition as control ( m ). MaG, mouse-anti goat; DaG, donkey anti-goat. Bars indicate mean +/− s.e.m. n represents independent mice; * P  < 0.05, ** P  < 0.005, *** P  < 0.0005; Exact P -values provided as source data.

Extended Data Fig. 6 My-HSC depletion restores features of a youthful immune system.

a , Ratio of frequency of my-HSCs to bal-HSCs (% live) in aged (A), or aged+conditioning mice (A + C) after 8-weeks; n  = 4 (A), n  = 9 (A + C); P  = 0.0346. b – d , Statistical significance (y-axis, -log10p) vs. fold-change (x-axis, log2-FC) of plasma protein levels at week-8 for (A)/(Y) ( b ), (A)/(A + C) ( c ), or (A)/(Y & A + C) ( d ) comparisons. Grey bar (y = 1–1.3); values above grey bar p < 0.05; n  = 6 (Y, A), n  = 5 (A + C). e , Overlap of top 17% of plasma proteins, ranked by statistical significance, increased in (A)/(Y) and decreased in (A + C)/(A). f , Estimated plasma concentration of CXCL5 116 at week-8; n  = 6 (Y, A), n  = 5 (A + C). g , Relative plasma abundance of inflammatory proteins at week-8; n  = 6 (Y, A), n  = 5 (A + C). Values relative to the mean for (Y) and log2-transformed. h – i , Frequency of CD11b + Ly6G/C + ( h ) and CD11b + SIRPa + ( i ) mature myeloid cells in the blood approximately 1-week after antibody-conditioning; n  = 3 (A), n  = 4 (A, A + C). j – k , Frequency of mature B cells (B220 + CD19 + CD43 − CD93 − IgM + IgD + ) ( j ), and progenitor B cells (B220 + CD19 − B cells) ( k ), in the BM approximately 1-week after antibody-conditioning; n  = 5 (A), n  = 6 (A, A + C). Thymus weight ( l ) and frequency of thymic subsets 1–8 as defined by Akashi & Weissman 117 , as % of total CD45 + cells in the thymus ( n ), 8-weeks after antibody-conditioning; representative FACS ( m ); n  = 3 (Y, A), n  = 9 (A + C). Populations enriched for transitional intermediate cells (areas 3&4) 117 highlighted in box ( n ). Mouse ages: Y (3–6 months); A & A + C (18–24 months). For ( a ), BM was cKIT-enriched prior to analysis. p -values obtained by unpaired parametric one-tailed t-test ( a ), ordinary one-way ANOVA followed by one-tailed Dunnett’s multiple comparisons test using Aged as control ( f ), one-way ANOVA followed by Holm multiple comparisons test ( b – d , g ), ordinary one-way ANOVA followed by two-tailed Dunnett’s multiple comparisons test using Aged as control ( h – i , l , n ), or Brown-Forsythe and Welch ANOVA tests followed by Dunnett’s T3 multiple comparisons test using Aged as control ( j – k ). Bars indicate mean +/− s.e.m. n represents independent mice; * P  < 0.05, ** P  < 0.005, *** P  < 0.0005; Exact P -values provided as source data.

Extended Data Fig. 7 My-HSC depletion increases naïve T cells and B cells in aged mice.

a – c , Absolute numbers of ( a ) naïve (CD44 − CD62L + ); * P  = 0.0430, ( b ) central memory (CM: CD44 + CD62L + ); * P  = 0.0177, or ( c ) effector memory (EM: CD44 + CD62L − ); P  = 0.576, T cells (CD4 & CD8), per mL of blood, approximately 8-weeks post-treatment. Values log2-transformed; n  = 9 (A), n  = 14 (A + C), mice pooled from 2 independent experiments. d , Absolute numbers of mature B cells (IgM + IgD + ) per mL of blood, approximately 8-weeks post-treatment; * P  = 0.0498. Values log2-transformed; n  = 6 (A), n  = 5 (A + C). e , Absolute numbers of CD45+ cells per mL of blood, approximately 8-weeks post-treatment. Values log2-transformed; n  = 3 (A), n  = 9 (A + C); P  = 0.069. f – g , Percentage of CM ( f ) and EM ( g ) subsets per total T cells (CD4 & CD8), 8-weeks post-treatment; n  = 6 (Y, A), n  = 5 (A + C). h – j , Frequency relative to Aged mice of T cell (CD4 & CD8) subsets 8-weeks after antibody treatment ( h ). Naïve, CM, and EM subsets were defined by 12-marker cluster-based analysis ( i – j ); n  = 6 (Y, A), n  = 5 (A + C). Values relative to mean for Aged control mice and log2-transformed. Mouse ages: Y (3–6 months); A & A + C (18–24 months). p -values obtained by unpaired parametric one-tailed t-test ( a , d ), unpaired parametric two-tailed t-test ( b – c , e ), or ordinary one-way ANOVA followed by two-tailed ( f – g ) or one-tailed ( h ) Dunnett’s multiple comparisons test using Aged as control. Bars indicate mean +/− s.e.m. n represents independent mice; * P  < 0.05, ** P  < 0.005, *** P  < 0.0005; Exact P -values provided as source data.

Extended Data Fig. 8 Flow-cytometry gating strategy for T cells, B cells, and myeloid cells.

a – c , Gating strategy to identify: ( b ) naïve (CD44 – CD62L + ), central memory (CD44 + CD62L + ), and effector memory (CD44 + CD62L − ) T cells (combined CD4 & CD8), or ( c ) CD4 T cells that are PD1 + CD62L – or PD1 – CD62L + 41 in the blood, used for Fig. 3e,g , Extended Data Fig. 7a–c , Extended Data Fig. 7f–g . d – f , Gating strategy to identify: ( e ) mature B cells (CD19 + B220 + IgM + IgD + ) 118 , or ( f ) Aged B Cells ABCs 119 (CD19 + IgM + CD93 − CD43 − CD21/CD35 − CD23 − ) 42 in the blood, used for Fig. 3f,h , Extended Data Fig. 7d . g – i , Gating strategy to identify ( h ) progenitor B cells (B220 + CD19 − ), or ( i ) mature B cells (B220 + CD19 + CD43 − CD93 − IgM + IgD + ) in the bone-marrow, used for Extended Data Fig. 6j,k . j – l , Gating strategy to identify ( k ) CD11b + Ly6G/C + myeloid cells, or ( l ) CD11b + SIRPa + myeloid cells in the blood, used for Extended Data Fig. 6h,i .

Extended Data Fig. 9 Antibody-conditioning enhances functional immunity to infection.

a , Schematic of model to determine the impact of antibody-conditioning on functional immunity. The diagram was created using BioRender. b , Gating to identify Ter119 + cells (Ter119 + CD19 − CD3 − CD45 +/lo ) and antigen-infected cells (Ag34 + Ter119 + ) in mouse spleens, used for Extended Data Fig. 9i,j . c – h , My-HSC and NEO1 + HSC absolute numbers in total BM ( c , e ), or as percentage of total HSCs ( d , f ), with correlations ( h ), 10-weeks after anti-NEO1 v2 conditioning. Representative FACS on total HSCs ( g ). A and A + C mice received vaccination at Week 8; n  = 2 (Y), n  = 7 (A), n  = 10 (A + C). i , Total number of Ter119 + cells per mouse spleen in mice that were Naïve, Infected, or Vaccinated & Infected with FV. Representative FACS histograms for Ter119 expression, gated on all single cells. Each row represents an independent mouse. n  = 9 (Y, naïve), n  = 13 (Y, FV infected), n  = 13 (Y, vaccinated & FV infected), n  = 6 (A, naïve), n  = 10 (A, FV infected), n  = 8 (A, vaccinated & FV infected), n  = 5 (A + C, naïve), n  = 9 (A + C, vaccinated & FV infected). Data log10-transformed. j , Total number of antigen-infected (Ag34 + Ter119 + ) cells per spleen in mice that were: Infected, or Vaccinated & Infected with FV. Representative FACS histograms for Ag34 expression, gated on Ter119+ cells. Each row represents an independent mouse; n  = 13 (Y, FV infected), n  = 13 (Y, vaccinated & FV infected), n  = 10 (A, FV infected), n  = 8 (A, vaccinated & FV infected), n  = 9 (A + C, vaccinated & FV infected). Data log 10 (x + 1)-transformed. k , Correlation of Infectious virus levels (Infectious Centres; x -axis) vs. Dextramer + CD44 + cells (Percent of splenic CD8 + T cells; y -axis) in Vaccinated & FV-infected mice; n  = 8 (A, vaccinated & FV-infected), n  = 9 (A + C, vaccinated & FV-infected). Data log10-transformed. For i – k , data from experiments using the anti-NEO1 v1 protocol (open circles) or the anti-NEO1 v2 protocol (closed circles) were combined. Mouse ages: Y (3–6 months); A & A + C (21-22 months). For ( c – f ), BM was cKIT-enriched prior to analysis. For ( c , e , h ), total BM (non-cKIT-enriched) was also analysed to calculate total numbers of cells. p -values obtained by one-tailed unpaired parametric t-test ( c – f ), two-tailed Pearson correlation coefficient ( h , k ), or ordinary one-way ANOVA followed by Tukey’s multiple comparisons test ( i – j ). NEO1 v2 protocol is NEO1 v1 protocol (anti-NEO1+ anti-CD47+anti-cKIT)+mouse (IgG2a) anti-goat. Inf., FV infected without vaccination; Vacc. & Inf., FV infected with vaccination, Vacc. & Inf., FV infected with vaccination; LOD, limit of detection; n.s., not significant. n represents independent mice. Bars indicate mean +/− s.e.m. ( c – f ) or bars depict median ( i – j ). * P  < 0.05, ** P  < 0.005, *** P  < 0.0005; Exact P -values provided as source data.

Extended Data Fig. 10 Mouse my-HSC markers are enriched in aged human HSCs.

a , Relative mRNA expression of CD62p ( Selp , P  = 0.0243), CD41 ( Itga2b , P  = 0.0001), CD61 ( Itgb 3, P  = 0.0135), CD150 ( Slamf1 , P  = 0.179), and NEO1 ( Neo1 , P  = 0.433) in human HSCs isolated from young (age 20–26) and old (age >70) donors; data obtained from Nilsson 54 , GSE69408 . b , Relative mRNA expression of CD62p ( Selp , P  = 0.0001), CD41 ( Itga2b , P  = 0.0027), CD61 ( Itgb3 , P  = 0.0116), and NEO1 ( Neo1 , P  = 0.274) in human HSCs isolated from young (age 18–30) or old (age 65–75) donors; data obtained from Adelman 53 ( GSE104406 ). c – e , Correlation of relative mRNA expression of CD62p ( c ), CD41 ( d ), and CD61 ( e ) in human HSCs as compared to donor age; data obtained from Adelman 53 ( GSE104406 ). For a – e , values relative to mean of young samples. f , Heatmap depicting expression of candidate markers in independent datasets of human: HMGA2 + vs. HMGA2 – CD34 + cells ( e 104 ), MPN ( f 56 ) or MDS ( g 57 ) vs. normal HSCs, and Pre-AML vs. normal HSCs ( h 58 ). g – h , Representative FACS to identify human HSCs (Lin – CD34 + CD38 – CD45RA – CD90 + ) 59 , MPPs (Lin – CD34 + CD38 – CD45RA – CD90 – ) 59 , LMPPs (Lin – CD34 + CD38 – CD45RA + ) 120 , CMPs & MEPs (Lin – CD34 + CD38 + CD45RA – ) 121 , and GMPs (Lin – CD34 + CD38 + CD45RA + ) 121 in normal human BM 59 , used for Fig. 5f–i , Extended Data Fig. 10i–s . Samples are post CD34 + -enrichment. i – m , FACS of human HSCs depicting fluorescence-minus-one (FMO) control ( i ), anti-CD62p clone AK4 ( j ), anti-CD62p clone Psel.KO2.3 ( k ), anti-CD62p clone AC1.2 ( l ), and anti-CD150 ( m ); representative for n  = 3 donors ( j ); n  = 2 donors ( k – m ). n , Illustration of human Hematopoietic Stem and Progenitor Cell (HSPC) Tree Analysis ( n ). o – s , Relative expression of CD62p ( o ), CD150 ( p ), ESAM ( q ), and CD166 ( r ), on human HSPCs, with summary ( s ), showing percent positive HSCs, and normalized MFI for each marker on HSPCs. For o – s , FACS median fluorescent intensity (MFI) values for each marker were obtained for each population, divided by the MFI for the FMO control, and then normalized from 0–100 based on the lowest to highest expression. Red colour scale corresponds to normalized MFI values. Blue, purple, maroon scale corresponds to bins for HSC positivity (20–50%, 51–70%, and 71–100). t , Model to rejuvenate aged immune systems by depleting myeloid-biased hematopoietic stem cells. The diagram was created using BioRender. p -values obtained by unpaired parametric one-tailed t-test ( a – b ), or p -values and R values calculated with one-tailed Pearson correlation coefficient ( c – e ). MDS, myelodysplastic syndrome; MPN, myeloproliferative neoplasms. Bars indicate mean +/− s.e.m. * P  < 0.05, ** P  < 0.005, *** P  < 0.0005; Exact P -values provided as source data.

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Ross, J.B., Myers, L.M., Noh, J.J. et al. Depleting myeloid-biased haematopoietic stem cells rejuvenates aged immunity. Nature 628 , 162–170 (2024). https://doi.org/10.1038/s41586-024-07238-x

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Effectiveness of a Web-Based Individual Coping and Alcohol Intervention Program for Children of Parents With Alcohol Use Problems: Randomized Controlled Trial

Authors of this article:

Original Paper

• Håkan Wall 1 , PhD   ; 
• Helena Hansson 2 , PhD   ; 
• Ulla Zetterlind 3 , PhD   ; 
• Pia Kvillemo 1 , PhD   ; 
• Tobias H Elgán 1 , PhD  

1 Stockholm Prevents Alcohol and Drug Problems, Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden

2 School of Social Work, Faculty of Social Sciences, Lund University, Lund, Sweden

3 Clinical Health Promotion Centre, Department of Health Sciences, Lund University, Lund, Sweden

Corresponding Author:

Tobias H Elgán, PhD

Stockholm Prevents Alcohol and Drug Problems, Centre for Psychiatry Research

Department of Clinical Neuroscience

Karolinska Institutet, & Stockholm Health Care Services

Norra Stationsgatan 69

Stockholm, 11364

Phone: 46 700011003

Email: [email protected]

Background: Children whose parents have alcohol use problems are at an increased risk of several negative consequences, such as poor school performance, an earlier onset of substance use, and poor mental health. Many would benefit from support programs, but the figures reveal that only a small proportion is reached by existing support. Digital interventions can provide readily accessible support and potentially reach a large number of children. Research on digital interventions aimed at this target group is scarce. We have developed a novel digital therapist-assisted self-management intervention targeting adolescents whose parents had alcohol use problems. This program aims to strengthen coping behaviors, improve mental health, and decrease alcohol consumption in adolescents.

Objective: This study aims to examine the effectiveness of a novel web-based therapist-assisted self-management intervention for adolescents whose parents have alcohol use problems.

Methods: Participants were recruited on the internet from social media and websites containing health-related information about adolescents. Possible participants were screened using the short version of the Children of Alcoholics Screening Test-6. Eligible participants were randomly allocated to either the intervention group (n=101) or the waitlist control group (n=103), and they were unblinded to the condition. The assessments, all self-assessed, consisted of a baseline and 2 follow-ups after 2 and 6 months. The primary outcome was the Coping With Parents Abuse Questionnaire (CPAQ), and secondary outcomes were the Center for Epidemiological Studies Depression Scale, Alcohol Use Disorders Identification Test (AUDIT-C), and Ladder of Life (LoL).

Results: For the primary outcome, CPAQ, a small but inconclusive treatment effect was observed (Cohen d =–0.05 at both follow-up time points). The intervention group scored 38% and 46% lower than the control group on the continuous part of the AUDIT-C at the 2- and 6-month follow-up, respectively. All other between-group comparisons were inconclusive at either follow-up time point. Adherence was low, as only 24% (24/101) of the participants in the intervention group completed the intervention.

Conclusions: The findings were inconclusive for the primary outcome but demonstrate that a digital therapist-assisted self-management intervention may contribute to a reduction in alcohol consumption. These results highlight the potential for digital interventions to reach a vulnerable, hard-to-reach group of adolescents but underscore the need to develop more engaging support interventions to increase adherence.

Trial Registration: ISRCTN Registry ISRCTN41545712; https://www.isrctn.com/ISRCTN41545712?q=ISRCTN41545712

International Registered Report Identifier (IRRID): RR2-10.1186/1471-2458-12-35

Introduction

Children who grow up with parents who have substance use problems or disorders face extraordinary challenges. Approximately 20% of all children have parents with alcohol problems [ 1 - 5 ], while approximately 5% have parents with alcohol use disorders [ 4 , 6 , 7 ]. Children growing up with parental substance abuse are at an increased risk of several negative outcomes, such as psychiatric morbidity [ 8 - 12 ]; poor intellectual, cognitive, and academic achievement [ 13 - 15 ]; domestic physical abuse [ 16 ]; and early drinking onset and the development of substance use problems [ 9 , 17 , 18 ]. Thus, children exposed to parental substance abuse comprise a target group for selective interventions and prevention strategies [ 19 - 22 ].

In Sweden, municipalities account for most of the support offered to these children. An annual survey by the junior association of the Swedish branch of Movendi International (ie, an international temperance movement) reported that 97% of all municipalities provided support resources [ 23 ]. However, estimates from the same survey showed that approximately 2% of the children in the target group received support. Hence, an overwhelming majority never receives support, mainly because of difficulties in identifying and attracting them to intervention programs [ 22 , 24 ].

The internet has become an appealing way to reach and support a large number of people [ 25 , 26 ]. Web-based interventions seem particularly attractive to adolescents, as they generally use digital technology and social media. Furthermore, research has shown that adolescents regard the internet as inviting because it is a readily accessible, anonymous way of seeking help [ 27 ]. Web-based interventions can reduce the stigma associated with face-to-face consultations in health care settings [ 28 ], and young people appreciate the flexibility of completing web-based sessions to fit their own schedules [ 29 ]. The positive effects of web-based interventions have been detected across a broad range of conditions. A recent review by Hedman-Lagerlöf et al [ 30 ] concluded that therapist-supported internet-based cognitive behavioral therapy for adults yielded similar effects as face-to-face therapy. To date, most web-based interventions have been designed for adults. Although the number of web-based interventions targeting children or adolescents is increasing [ 25 , 31 - 33 ], the number of digital interventions aimed at children of substance-abusing parents is still scarce [ 22 , 34 - 38 ]. Those described in the literature, however, all have in common that they are quite extensive, with a duration over several weeks, and a brief digital intervention could complement these more extended interventions. For instance, our research group initiated a study on a web-based group chat for 15- to 25-year-old individuals who have parents with mental illness or substance use problems [ 35 ]. The duration of the program is 8 weeks, and it is a translated version of a program from the Netherlands [ 34 ], which has been shown to have inconclusive treatment effects [ 39 ]. In Sweden, 2 other programs with inconclusive treatment effects have been tested that target significant others and their children [ 37 , 38 ]. Finally, a digital intervention developed in Australia for 18- to 25-year-old individuals with parents with mental illness or substance use disorder [ 36 ] was tested in a pilot study demonstrating positive findings [ 40 ].

To meet the need for a brief, web-based intervention that targets adolescents having parents with alcohol problems and build on the evidence base of digital interventions targeting this vulnerable group, we developed a novel internet-delivered therapist-assisted self-management intervention called “Alcohol and Coping.” Our program originated from a manual-based face-to-face intervention called the “Individual Coping and Alcohol Intervention Program” (ICAIP) [ 41 , 42 ]. Previous studies on both the ICAIP, which aimed at college students having parents with alcohol problems, and a coping skills intervention program, which aimed at spouses of partners with alcohol dependency [ 43 ], have demonstrated positive effects regarding decreased alcohol consumption and improved mental health and coping behaviors [ 41 - 44 ]. Furthermore, the results from these studies underscore the importance of improving coping skills [ 42 , 44 ]. Among college students, those who received a combination of coping skills and an alcohol intervention program had better long-term outcomes [ 42 ].

The aim of this study was to test the effectiveness of Alcohol and Coping among a sample of adolescents aged 15-19 years with at least 1 parent with alcohol use problems. We hypothesized that the intervention group would be superior to the control group in improving coping skills. Secondary research questions concerned the participants’ improvement in (1) depression, (2) alcohol consumption, and (3) quality of life.

This study was a parallel-group randomized controlled trial in which participants were randomized to either the intervention or waitlist control group in a 1:1 allocation ratio. The trial design is illustrated in Figure 1 .

Recruitment and Screening

The participants were recruited from August 2012 to December 2013 through advertisements on social media (Facebook). The advertisements targeted individuals aged 15-19 years with Facebook accounts. Participants were recruited on the internet through advertisements on websites containing health-related information about adolescents. The advertisements included the text, “Do your parents drink too much? Participate in a study.” The advertisement contained an invitation to perform a web-based, self-assessed screening procedure. In addition to questions about age and sex, participants were screened for having parents with alcohol problems using the short version of the Children of Alcoholics Screening Test-6 (CAST-6), developed from a 30-item original version [ 45 ]. The CAST-6 is a 6-item true-false measure designed to assess whether participants perceive their parents’ alcohol consumption to be problematic. The CAST-6 has demonstrated high internal consistency ( r =0.92-0.94), test-retest reliability ( r =0.94), and high validity as compared to the 30-item version ( r =0.93) using the recommended threshold score of 3 or higher [ 45 , 46 ]. We previously translated the CAST-6 into Swedish and validated the translated version among 1450 adolescents, showing good internal consistency (α=.88), excellent test-retest reliability (intraclass correlation coefficient=0.93), and loading into 1 latent factor [ 47 ]. Additional inclusion criteria included having access to a computer and the internet and being sufficiently fluent in Swedish. Participants were excluded from the study and were referred to appropriate care if there were indications of either suicidal or self-inflicted harmful behaviors. Individuals eligible for inclusion received further information about the study and were asked to provide consent to participate by providing an email address.

Data Collection and Measures

All assessments were administered through email invitations containing a hyperlink to the web-based self-reported assessments. Up to 3 reminders were sent through email at 5, 10, and 15 days after the first invitation. A baseline assessment (t 0 ) was collected before randomization, and follow-up assessments were conducted at 2 and 6 months (t 1 and t 2 , respectively) after the initial assessment.

Participants were asked for age, sex, whether they lived with a parent (mother and father, mother or father, mother or father and stepparent, or alternate between mother and father), where their parents were born (Sweden or a Nordic country excluding Sweden or outside of the Nordic countries), parental status (employed, student, on parental leave, or unemployed), and any previous or present participation in support activities for children having parents with alcohol use problems. The primary outcome was coping, measured using the Coping With Parents Abuse Questionnaire (CPAQ) based on the Coping Behavior Scale developed by Orford et al [ 48 ]. Secondary outcomes were the Center for Epidemiological Studies Depression Scale (CES-DC) [ 49 ], the 3-question Alcohol Use Disorders Identification Test (AUDIT-C) [ 50 ], and the Ladder of Life (LoL), which measures the overall quality of life by asking about the participants’ past, present, and future ratings of their overall life satisfaction [ 50 ]. CPAQ has been shown to be reliable [ 41 , 42 ]. For this study, this scale was factor-analyzed to reduce the number of questions from 37 to 20. The resulting scale measures 6 coping typologies (discord, emotion, control, relationship, avoidance, and taking specific action) using a 4-point Likert scale, with a threshold score above 50 points (out of 80) indicating dysfunctional coping behavior. The CES-DC measures depressive symptoms during the past week using a 4-point Likert scale, where a higher total score indicates more depressive symptoms [ 49 ]. A cutoff score of ≥16 indicates symptoms of moderate depression, while a score of ≥30 indicates symptoms of severe depression [ 51 , 52 ]. The scale measures 4 dimensions of depression: depressed mood, tiredness, inability to concentrate, and feelings of being outside and lonely, and has positively stated items [ 52 ]. Additionally, this scale is a general measure of childhood psychopathology [ 53 ] and has been demonstrated to be reliable and valid among Swedish adolescents [ 52 ]. Alcohol consumption was measured using a modified AUDIT-C, which assesses the frequency of drinking, quantity consumed on a typical occasion, and frequency of heavy episodic drinking (ie, binge drinking) [ 50 ] using a 30-day perspective (as opposed to the original 12-month perspective). These questions have previously been translated into Swedish [ 54 ], and a score of ≥4 and ≥5 points for women and men, respectively, was used as a cutoff for risky drinking. This scale has been demonstrated to be reliable and valid for Swedish adolescents [ 55 ]. Furthermore, 2 questions were added concerning whether the participants had ever consumed alcohol to the point of intoxication and their age at the onset of drinking and intoxication. The original version of the LoL was designed for adults and asked the respondents to reflect on their, present, and future life status from a 5-year perspective on a 10-point Visual Analogue Scale representing life status from “worst” to “best” possible life imaginable [ 56 ]. A modified version for children, using a time frame of 1 year, has been used previously in Sweden [ 57 ] and was used in this study.

Randomization

After completing the baseline assessment, each participant was allocated to either the intervention or the control group. An external researcher generated an unrestricted random allocation sequence using random allocation software [ 58 ]. Neither the participants nor the researchers involved in the study were blinded to group allocation.

Based on the order in which participants were included in the study, they were allocated to 1 of the 2 study groups and informed of their allocation by email. Additionally, those who were randomized to the intervention group received a hyperlink to the Alcohol and Coping program, whereas the control group participants received information that they would gain access to Alcohol and Coping after the last follow-up assessment (ie, the waitlist control group). All participants were informed about other information and support available through web pages, notably drugsmart [ 59 ], which contains general information and facts about alcohol and drugs, in addition to more specific information about having substance-abusing parents. Telephone numbers and contact information for other organizations and primary health care facilities were also provided.

The Intervention

As noted previously, Alcohol and Coping is derived from the aforementioned manual-based face-to-face ICAIP intervention program [ 41 , 42 ]. The ICAIP consists of a combination of an alcohol intervention program, which is based on the short version of the Brief Alcohol Screening and Intervention for College Students program [ 60 ], and a coping intervention program developed for the purpose of the ICAIP [ 41 , 42 ]. Like the original ICAIP intervention, Alcohol and Coping builds on psychoeducational principles and includes components such as film-based lectures, various exercises, and both automated and therapist-assisted feedback. Briefly, once the participants logged into the Alcohol and Coping platform, they were introduced to the program, which followed the pattern of a board game ( Figure 2 ). Following the introduction, participants took part in 3 film-based lectures (between 8 and 15 minutes each, Figure 3 ) concerning alcohol problems within the family. The respective lectures included information about (1) dependency in general as well as the genetic and environmental risks for developing dependency, (2) family patterns and how the family adapts to the one having alcohol problems, and (3) attitudes toward alcohol and how they influence drinking and the physiological effects of alcohol. After completing the lectures, the participants were asked to answer 2 questions about their own alcohol consumption (ie, how often they drink and how often they drink to intoxication), followed by an automatic feedback message that depended on their answers. It was then suggested that the participants log out of the intervention for a 1- to 2-day break. The reason for this break was to give the participants a chance to digest all information and impressions. When they logged back into the intervention, they were asked to answer 20 questions about their coping strategies, which were also followed by automatic feedback. This feedback comprised a library covering all the prewritten feedback messages, each of which was tailored to the participants’ specific answers. The participants then participated in a 5-minute–long film-based lecture on emotion and problem-focused coping in relation to family alcohol problems ( Figure 3 ). This was followed by 4 exercises where the participants read through vignette-like stories from 4 fictional persons describing their everyday lives related to coping and alcohol problems in the family. The stories are presented by film-based introductions that are each 1-2 minutes long. Participants were then requested to respond to each story by describing how the fictive person could have coped with their situation. As a final exercise, participants were asked to reflect on their own family situation and how they cope with situations. The participants then had to take a break for a few days.

During the break, a therapist composed individual feedback that covered reflections and confirmation of the participant’s exercises and answers to questions and included suggestions on well-suited coping strategies. Additionally, the therapist encouraged the participants to talk to others in their surroundings, such as friends, teachers, or coaches, and seek further support elsewhere, such as from municipal social services, youth health care centers, or other organizations. Finally, the therapist reflected on the participants’ alcohol consumption patterns and reminded them of increased genetic and environmental risks. Those who revealed patterns of risky alcohol use were encouraged to look at 2 additional film-based lectures with more information about alcohol and intoxication (4 minutes) and alcohol use and dependency (5 minutes). Participants received this feedback once they logged back into the program, but they also had the opportunity to receive feedback through email. The total estimated effective time for completing the program was about 1 hour, but as described above, there was 1 required break when the individualized feedback was written. To keep track of the dose each participant received, each of the 15 components in the program ( Figure 1 ) is equal to completing 6.7% (1/15) of the program in total.

Sample Size

The trial was designed to detect a medium or large effect size corresponding to a standardized mean difference (Cohen d >0.5) [ 61 ]. An a priori calculation of the estimated sample size, using the software G*Power (G*Power Team) [ 62 ], revealed that a total of 128 participants (64 in each group) were required to enroll in the trial (power=0.80; α=.05; 2-tailed). However, to account for an estimated attrition rate of approximately 30% [ 34 ], it was necessary to enroll a minimum of 128/(1 – 0.3) = 183 participants in the trial. After a total of 204 individuals had been recruited and randomized into 2 study arms, recruitment was ended.

Statistical Analysis

Data were analyzed according to the intention-to-treat (ITT) principle, and all randomized participants were included, irrespective of whether they participated in the trial. The 4 research variables were depression (CES-DC), coping (CPAQ), alcohol use (AUDIT-C), and life status (LoL).

Data analysis consisted of comparing outcome measurements at t 1 and t 2 . The baseline measurement t 0 value was added as an adjustment variable in all models. The resulting data from CPAQ, CES-DC, and LoL were normally distributed and analyzed using linear mixed models. The resulting AUDIT-C scores were nonnormally distributed, with an excess of 0 values, and were analyzed using a 2-part model for longitudinal data. This model is sufficiently flexible to account for numerous 0 reports. This was achieved by combining a logistic generalized linear mixed model (GLMM) for the 0 parts and a skewed continuous GLMM for the non-0 alcohol consumption parts. R-package brms (Bayesian regression models using Stan; R Foundation for Statistical Computing) [ 63 ], a higher-level interface for the probabilistic programming language Stan [ 64 ], and a custom brms family for a marginalized 2-part lognormal distribution were used to fit the model [ 65 ]. The logistic part of the model represents the subject-specific effects on the odds of reporting no drinking. The continuous part was modeled using a gamma GLMM with a log link. The exponentiated treatment effect represents the subject-specific ratio of the total AUDIT-C scores between the treatment and waitlist control groups for those who reported drinking during the specific follow-up period.

Handling of Missing Data

GLMMs include all available data and provide unbiased ITT estimates under the assumption that data are missing at random, meaning that the missing data can be explained by existing data. However, it is impossible to determine whether the data are missing at random or whether the missing data are due to unobserved factors [ 66 ]. Therefore, we also assumed that data were not missing at random, and subsequent sensitivity analyses were performed [ 66 ]. We used the pattern mixture method, which assumes not missing at random, to compare those who completed the follow-up at 6 months (t 2 ) with those who did not (but completed the 2-month follow-up). The overall effect of this model is a combination of the effects of each subgroup. We also tested the robustness of the results by performing ANCOVAs at the 2-month follow-up, both using complete cases and with missing values imputed using multilevel multiple imputation.

The effect of the program was estimated using Cohen d , where a value of approximately 0.2 indicates a small effect size and values of approximately 0.5 and 0.8 indicate medium and large effect sizes, respectively [ 61 ].

Ethical Considerations

All procedures were performed in accordance with the ethical standards of the institutional or national research committees, the 1964 Helsinki Declaration and its later amendments, and comparable ethical standards. Informed consent was obtained from all the participants included in the study. This study was approved by the Swedish Ethical Review Authority (formerly the Regional Ethical Review Board in Stockholm, No. 2011/1648-31/5).

To enhance the response rates, participants received a cinema gift certificate corresponding to approximately EUR 11 (US $12) as compensation for completing each assessment. If a participant completed all assessments, an additional gift certificate was provided. The participants could subsequently receive 4 cinema gift certificates totaling EUR 44 (US $48).

The trial profile is depicted in Figure 1 and reveals that 2722 individuals who were aged between 15 and 19 years performed the screening procedure. A total of 1448 individuals did not fulfill the inclusion criteria and were excluded, leaving 1274 eligible participants. Another 1070 individuals were excluded because they did not provide informed consent or complete the baseline assessment, leaving 204 participants who were allocated to 1 of the 2 study groups. A total of 140 (69%) and 131 (64%) participants completed t 1 and t 2 assessments, respectively. Of the participants in the intervention group (n=101), 63% (n=64) registered an account on the Alcohol and Coping website, 35% (n=35) completed the alcohol intervention section, and 24% (n=24) completed both the alcohol and coping intervention sections.

Sample Characteristics

The mean age of the sample was 17.0 (SD 1.23) years, and the vast majority were female, with both parents born in Sweden and currently working ( Table 1 ). Approximately one-third of the participants reported living with both parents. The mean score on the CAST-6 was 5.33 (SD 0.87) out of a total of 6, and the majority of the sample (147/204, 72.1%) perceived their father to have alcohol problems. Approximately 12% (25/204) had never consumed alcohol, whereas approximately 70% (144/204) had consumed alcohol at a level of intoxication. The mean age at onset was 13.7 (SD 2.07) years and the age at first intoxication was 14.8 (SD 1.56) years. The proportion of participants with symptoms of at least moderate depression was 77.5% (158/204), of whom 55.1% (87/158) had symptoms of severe depression and 42.6% (87/204) had symptoms of dysfunctional coping behaviors. The percentage of participants who consumed alcohol at a risky level was 39.7% (81/204). Table 1 provides complete information regarding the study sample.

a Significance levels calculated by Pearson chi-square statistics for categorical variables and 2-tailed t tests for continuous variables.

Treatment Effects

For the primary outcome, coping behavior (CPAQ), we found a small but inconclusive treatment effect in favor of treatment at both 2 (t 1 ) and 6 (t 2 ) months (Cohen d =–0.05 at both t 1 and t 2 ). For the secondary outcome, alcohol use (AUDIT-C), we found a treatment effect in that the intervention group scored 38% less than the control group on the continuous part (ie, drinking when it occurred) at t 1 and 46% less at t 2 . Regarding depression (CES-DC) and life status (LoL), all between-group comparisons of treatment effects were inconclusive at both follow-up time points ( Table 2 ).

a CPAQ: Coping With Parents Abuse Questionnaire.

b CES-DC: Center for Epidemiological Studies Depression Scale.

c LoL: Ladder of Life.

d AUDIT-C: Alcohol Use Disorders Identification Test.

e N/A: not applicable.

Missing Data

In contrast to the ITT analyses, the sensitivity analyses showed that the treatment group, averaged over the levels of dropout, scored higher (ie, a negative effect) on the main outcome, coping behavior (CPAQ), at t 1 (2.44; P =.20). However, the results remain inconclusive.

Dose-Response Effects

We did not find any evidence for greater involvement in the program being linked to improved outcomes with regard to coping behavior.

We did not find any support for the primary hypothesis: the intervention was not superior to the control condition with regard to coping behavior. Inconclusive results with small effect sizes were observed at both follow-up time points. However, for the secondary outcomes, we found that those in the intervention group who drank alcohol drank approximately 40%-50% less than those in the control group at both follow-ups. These results corroborate previous findings on the precursor face-to-face ICAIP intervention program, demonstrating that participants who received a combined alcohol and coping intervention reported superior outcomes with regard to alcohol-related outcomes compared to participants in the other 2 study arms, who received only a coping or alcohol intervention [ 41 , 42 ]. In contrast to this study, Hansson et al [ 42 ] found that all groups improved their coping skills, although the between-group comparisons were inconclusive and the improvements were maintained over time. These differences could be explained by the different settings in which the precursor program was provided (ie, face-to-face to young adults in a university setting), whereas this study targeted young people (15-19 years of age) through a web-based digital intervention. Additionally, the poor adherence in this study may explain the absence of primary results favoring the intervention group. In a recent study, parents without alcohol problems were recruited to participate in a randomized trial evaluating the web-based SPARE (Supportive Parenting and Reinforcement) program to improve children’s mental health and reduce coparents’ alcohol use. In line with our study, the authors did not find the primary outcome of the SPARE program to be superior to that of the active control group (which received written psychoeducation); however, both groups reported decreased coparental alcohol consumption [ 38 ].

Considering that approximately 3600 children in 2022 participated in various forms of support provided by Swedish municipalities [ 23 ], our recruitment activities reached a large number of eligible individuals, pointing to the potential of finding these children on these platforms. There were unexpectedly high levels of depression among the participants in this study. Although the intervention did not target depressive symptoms per se , there was a trend for the intervention group to have decreased depression levels compared to the control group. A large proportion of participants had symptoms of severe depression, which may have aggravated their capacity for improvement at follow-up [ 28 , 67 ]. Targeting dysfunctional coping patterns could affect an individual’s perceived mental health, and studies have shown that healthy coping strategies positively affect depression and anxiety in a positive way [ 68 ]. Using dysfunctional coping strategies, such as negative self-talk and alcohol consumption, can lead to depressive symptoms [ 69 ]. Targeting these symptoms in the context of healthy and unhealthy coping strategies may be a viable route to fostering appropriate coping strategies that work in the long run. Given that the young people who were reached by the intervention in this study displayed high levels of depression, future interventions for this group should include programs targeting depressive symptoms.

Almost 37% (37/101) of the intervention group did not log into the intervention at all, and only 24% (24/101) of the intervention group participants completed all parts of the program. The fact that a high proportion of the participants had symptoms of severe depression could explain the low adherence. Another reason could be that the initial film-based lectures were too long to maintain the participants’ attention, as the lectures ranged from 8-15 minutes. Yet a final reason could be that we had a 1- to 2-day break built into the intervention, and for unknown reasons, some participants did not log back into the intervention. However, we did not find a dose-response relationship indicating favorable outcomes for those who completed more of the program content. High levels of attrition are not uncommon in self-directed programs such as the one in this study; for example, in a study on a smoking cessation intervention, 37% of the participants never logged into the platform [ 70 ], and in a self-directed intervention for problem gamblers, a majority dropped out after 1 week and none completed the entire program [ 71 ]. Increased intervention adherence is a priority when developing new digital interventions, particularly for young people. One method is to use more persuasive technologies, such as primary tasks, dialogue, and social support [ 72 ]. Considering children whose parents have mental disorders, Grové and Reupert [ 73 ] suggested that digital interventions should include components such as providing information about parental mental illness, access to health care, genetic risk, and suggestions for how children might initiate conversations with parents who have the illness. These suggestions should be considered in future studies on interventions for youths whose parents have substance use problems. Representatives of the target group and other relevant stakeholders should also be involved in coproducing new interventions to increase the probability of developing more engaging programs [ 74 ]. Moreover, one cannot expect study participants to return to the program more than once, and for the sake of adherence, briefer interventions should not encourage participants to log-out for a break. To keep adherence at an acceptable level, similar future interventions for this target group should also consider having symptoms of severe depression as an exclusion criterion [ 28 , 67 ]. Further, to improve adherence, strategies of coproduction could be used where all stakeholders, including the target group, are involved in intervention development [ 75 ]. Other important factors identified to improve adherence to digital interventions are to make the content relatable, useful, and even more interactive [ 76 ]. Those participants who have symptoms of severe depression should be referred to other appropriate health care. Finally, it is probably beneficial to develop shorter psychoeducative film-based lectures than ours, lasting up to 15 minutes. Future self-directed digital interventions targeting this population should, therefore, focus on a very brief and focused intervention, which, based on theory, has the potential to foster healthy coping behaviors that can lead to an increased quality of life and improved mental health for this group of young people.

Another concern for future projects would be to use a data-driven approach during the program development phase, where A/B testing can be used to test different setups of the program to highlight which setup works best. Another aspect that must be considered is the fast-changing world of technology, where young people are exposed to an infinite number of different apps that grab their attention, which also calls for interventions to be short and to the point. Furthermore, if the program is to spread and become generally available, one must consider that keeping the program alive for a longer period will require funding and staffing for both product management and technical support.

Strengths and Limitations

This study had several strengths. First, Alcohol and Coping is a web-based intervention program, and it appears as if the internet is a particularly promising way to provide support to adolescents growing up with parents with alcohol problems because it offers an anonymous means of communicating and makes intervention programs readily accessible [ 25 ]. Our recruitment strategies reached a considerable number of interested and eligible individuals, demonstrating the potential for recruiting through social media and other web platforms. Additionally, this program is one of the first brief web-based interventions aimed at adolescents with parents with alcohol-related problems. We used the CAST-6, which has been validated among Swedish adolescents [ 47 ], to screen eligible participants. Another strength is that the intervention program involved personalized, tailored feedback in the form of prewritten automatic messages and therapist-written personalized feedback, both of which have proven to be important components of web-based interventions aimed at adolescents [ 77 , 78 ]. Finally, this study evaluated the effectiveness of the Alcohol and Coping program using a randomized controlled trial design, which is considered the strongest experimental design with regard to allocation bias.

This study had some limitations. First, the design with a passive waitlist control group and an active intervention group, both unblinded to study allocation, may have resulted in biased estimates of treatment effects. Intervention adherence was low, and most of the study participants had symptoms of depression, where 55% (87/158) had symptoms of severe depression. This may have contributed to the small and overall inconclusive effects on the primary outcomes of this study. Many digital interventions have problems with low adherence, and in a review by Välimäki et al [ 79 ], some studies reported adherence rates as low as 10%. A vast proportion of the study participants were women, making the findings difficult to generalize to men. However, another limitation concerns selection bias and external validity. We recruited study participants through social media and other relevant websites containing health-related information, including information about parents with alcohol-related problems. It is, therefore, possible that the study population can be classified as “information-seeking” adolescents, who may have different personality traits relative to other adolescents in the same home situation. Additionally, as an inclusion criterion was having ready access to computers and the internet, it is possible that participants belonging to a lower socioeconomic class were underrepresented in the study. It should also be noted that the data presented here were collected approximately 10 years ago. However, we believe our findings make an important contribution to the field since, like our intervention, many recent web-based interventions use strategies of psychoeducation, films, exercises, questions, and feedback. Further, the number of web-based interventions for this target group remains scarce in the literature, which underscores the need for future research. Finally, the study was powered to detect a medium effect size. However, given the small effect sizes detected in this study, it is plausible that too few participants were recruited to detect differences between the groups.

Implications for Practice

Although growing up with parents who have alcohol problems per se is not sufficient for developing psychosocial disorders, many children need support to manage their situation. Therefore, it is difficult to recruit children to support these groups. In Sweden, not even 2% of all children growing up with parental alcohol problems attend face-to-face support groups provided by municipalities.

Offering support through web-based intervention programs seems particularly attractive to adolescents whose parents have alcohol-related problems. To date, evidence for such programs is scarce, and there is an urgent need to develop and evaluate digital interventions targeting this group of adolescents. This study makes important contributions to this novel field of research. The results provide insight into effective strategies for delivering intervention programs to children of parents with substance abuse issues, highlighting the potential for digital interventions to reach a vulnerable, hard-to-reach group of adolescents. Our findings underscore the need to develop more engaging interventions in coproduction with the target group.

Conclusions

We found that a digital therapist-assisted self-management intervention for adolescents whose parents have alcohol use problems contributed to a reduction in the adolescents’ own alcohol consumption. This result highlights the potential for digital interventions to reach a large, vulnerable, and hard-to-reach group of adolescents with support efforts. Findings were inconclusive for all other outcomes, which may be attributable to low adherence. This points to the need for future research on developing more engaging digital interventions to increase adherence among adolescents.

Acknowledgments

This work was undertaken on behalf of the Swedish Council for Information on Alcohol and Other Drugs (CAN) and was supported by grants from the Swedish National Institute of Public Health and the Swedish Council for Working Life and Social Research.

Conflicts of Interest

HH and UZ developed the study interventions. However, the parties did not derive direct financial income from these interventions. HW, PK, and THE declare no conflicts of interest.

CONSORT-eHEALTH checklist (V 1.6.1).

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Abbreviations

Edited by YH Lin; submitted 24.08.23; peer-reviewed by X Zhang, C Asuzu, D Liu; comments to author 28.01.24; revised version received 08.02.24; accepted 27.02.24; published 10.04.24.

©Håkan Wall, Helena Hansson, Ulla Zetterlind, Pia Kvillemo, Tobias H Elgán. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 10.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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Examining the role of community resilience and social capital on mental health in public health emergency and disaster response: a scoping review

• C. E. Hall 1 , 2 ,
• H. Wehling 1 ,
• J. Stansfield 3 ,
• J. South 3 ,
• S. K. Brooks 2 ,
• N. Greenberg 2 , 4 ,
• R. Amlôt 1 &
• D. Weston 1  

BMC Public Health volume  23 , Article number:  2482 ( 2023 ) Cite this article

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The ability of the public to remain psychologically resilient in the face of public health emergencies and disasters (such as the COVID-19 pandemic) is a key factor in the effectiveness of a national response to such events. Community resilience and social capital are often perceived as beneficial and ensuring that a community is socially and psychologically resilient may aid emergency response and recovery. This review presents a synthesis of literature which answers the following research questions: How are community resilience and social capital quantified in research?; What is the impact of community resilience on mental wellbeing?; What is the impact of infectious disease outbreaks, disasters and emergencies on community resilience and social capital?; and, What types of interventions enhance community resilience and social capital?

A scoping review procedure was followed. Searches were run across Medline, PsycInfo, and EMBASE, with search terms covering both community resilience and social capital, public health emergencies, and mental health. 26 papers met the inclusion criteria.

The majority of retained papers originated in the USA, used a survey methodology to collect data, and involved a natural disaster. There was no common method for measuring community resilience or social capital. The association between community resilience and social capital with mental health was regarded as positive in most cases. However, we found that community resilience, and social capital, were initially negatively impacted by public health emergencies and enhanced by social group activities.

Several key recommendations are proposed based on the outcomes from the review, which include: the need for a standardised and validated approach to measuring both community resilience and social capital; that there should be enhanced effort to improve preparedness to public health emergencies in communities by gauging current levels of community resilience and social capital; that community resilience and social capital should be bolstered if areas are at risk of disasters or public health emergencies; the need to ensure that suitable short-term support is provided to communities with high resilience in the immediate aftermath of a public health emergency or disaster; the importance of conducting robust evaluation of community resilience initiatives deployed during the COVID-19 pandemic.

Peer Review reports

For the general population, public health emergencies and disasters (e.g., natural disasters; infectious disease outbreaks; Chemical, Biological, Radiological or Nuclear incidents) can give rise to a plethora of negative outcomes relating to both health (e.g. increased mental health problems [ 1 , 2 , 3 , 4 ]) and the economy (e.g., increased unemployment and decreased levels of tourism [ 4 , 5 , 6 ]). COVID-19 is a current, and ongoing, example of a public health emergency which has affected over 421 million individuals worldwide [ 7 ]. The long term implications of COVID-19 are not yet known, but there are likely to be repercussions for physical health, mental health, and other non-health related outcomes for a substantial time to come [ 8 , 9 ]. As a result, it is critical to establish methods which may inform approaches to alleviate the longer-term negative consequences that are likely to emerge in the aftermath of both COVID-19 and any future public health emergency.

The definition of resilience often differs within the literature, but ultimately resilience is considered a dynamic process of adaptation. It is related to processes and capabilities at the individual, community and system level that result in good health and social outcomes, in spite of negative events, serious threats and hazards [ 10 ]. Furthermore, Ziglio [ 10 ] refers to four key types of resilience capacity: adaptive, the ability to withstand and adjust to unfavourable conditions and shocks; absorptive, the ability to withstand but also to recover and manage using available assets and skills; anticipatory, the ability to predict and minimize vulnerability; and transformative, transformative change so that systems better cope with new conditions.

There is no one settled definition of community resilience (CR). However, it generally relates to the ability of a community to withstand, adapt and permit growth in adverse circumstances due to social structures, networks and interdependencies within the community [ 11 ]. Social capital (SC) is considered a major determinant of CR [ 12 , 13 ], and reflects strength of a social network, community reciprocity, and trust in people and institutions [ 14 ]. These aspects of community are usually conceptualised primarily as protective factors that enable communities to cope and adapt collectively to threats. SC is often broken down into further categories [ 15 ], for example: cognitive SC (i.e. perceptions of community relations, such as trust, mutual help and attachment) and structural SC (i.e. what actually happens within the community, such as participation, socialising) [ 16 ]; or, bonding SC (i.e. connections among individuals who are emotionally close, and result in bonds to a particular group [ 17 ]) and bridging SC (i.e. acquaintances or individuals loosely connected that span different social groups [ 18 ]). Generally, CR is perceived to be primarily beneficial for multiple reasons (e.g. increased social support [ 18 , 19 ], protection of mental health [ 20 , 21 ]), and strengthening community resilience is a stated health goal of the World Health Organisation [ 22 ] when aiming to alleviate health inequalities and protect wellbeing. This is also reflected by organisations such as Public Health England (now split into the UK Health Security Agency and the Office for Health Improvement and Disparities) [ 23 ] and more recently, CR has been targeted through the endorsement of Community Champions (who are volunteers trained to support and to help improve health and wellbeing. Community Champions also reflect their local communities in terms of population demographics for example age, ethnicity and gender) as part of the COVID-19 response in the UK (e.g. [ 24 , 25 ]).

Despite the vested interest in bolstering communities, the research base establishing: how to understand and measure CR and SC; the effect of CR and SC, both during and following a public health emergency (such as the COVID-19 pandemic); and which types of CR or SC are the most effective to engage, is relatively small. Given the importance of ensuring resilience against, and swift recovery from, public health emergencies, it is critically important to establish and understand the evidence base for these approaches. As a result, the current review sought to answer the following research questions: (1) How are CR and SC quantified in research?; (2) What is the impact of community resilience on mental wellbeing?; (3) What is the impact of infectious disease outbreaks, disasters and emergencies on community resilience and social capital?; and, (4) What types of interventions enhance community resilience and social capital?

By collating research in order to answer these research questions, the authors have been able to propose several key recommendations that could be used to both enhance and evaluate CR and SC effectively to facilitate the long-term recovery from COVID-19, and also to inform the use of CR and SC in any future public health disasters and emergencies.

A scoping review methodology was followed due to the ease of summarising literature on a given topic for policy makers and practitioners [ 26 ], and is detailed in the following sections.

Identification of relevant studies

An initial search strategy was developed by authors CH and DW and included terms which related to: CR and SC, given the absence of a consistent definition of CR, and the link between CR and SC, the review focuses on both CR and SC to identify as much relevant literature as possible (adapted for purpose from Annex 1: [ 27 ], as well as through consultation with review commissioners); public health emergencies and disasters [ 28 , 29 , 30 , 31 ], and psychological wellbeing and recovery (derived a priori from literature). To ensure a focus on both public health and psychological research, the final search was carried across Medline, PsycInfo, and EMBASE using OVID. The final search took place on the 18th of May 2020, the search strategy used for all three databases can be found in Supplementary file 1 .

Selection criteria

The inclusion and exclusion criteria were developed alongside the search strategy. Initially the criteria were relatively inclusive and were subject to iterative development to reflect the authors’ familiarisation with the literature. For example, the decision was taken to exclude research which focused exclusively on social support and did not mention communities as an initial title/abstract search suggested that the majority of this literature did not meet the requirements of our research question.

The full and final inclusion and exclusion criteria used can be found in Supplementary file 2 . In summary, authors decided to focus on the general population (i.e., non-specialist, e.g. non-healthcare worker or government official) to allow the review to remain community focused. The research must also have assessed the impact of CR and/or SC on mental health and wellbeing, resilience, and recovery during and following public health emergencies and infectious disease outbreaks which affect communities (to ensure the research is relevant to the review aims), have conducted primary research, and have a full text available or provided by the first author when contacted.

Charting the data

All papers were first title and abstract screened by CH or DW. Papers then were full text reviewed by CH to ensure each paper met the required eligibility criteria, if unsure about a paper it was also full text reviewed by DW. All papers that were retained post full-text review were subjected to a standardised data extraction procedure. A table was made for the purpose of extracting the following data: title, authors, origin, year of publication, study design, aim, disaster type, sample size and characteristics, variables examined, results, restrictions/limitations, and recommendations. Supplementary file 3 details the charting the data process.

Analytical method

Data was synthesised using a Framework approach [ 32 ], a common method for analysing qualitative research. This method was chosen as it was originally used for large-scale social policy research [ 33 ] as it seeks to identify: what works, for whom, in what conditions, and why [ 34 ]. This approach is also useful for identifying commonalities and differences in qualitative data and potential relationships between different parts of the data [ 33 ]. An a priori framework was established by CH and DW. Extracted data was synthesised in relation to each research question, and the process was iterative to ensure maximum saturation using the available data.

Study selection

The final search strategy yielded 3584 records. Following the removal of duplicates, 2191 records remained and were included in title and abstract screening. A PRISMA flow diagram is presented in Fig.  1 .

PRISMA flow diagram

At the title and abstract screening stage, the process became more iterative as the inclusion criteria were developed and refined. For the first iteration of screening, CH or DW sorted all records into ‘include,’ ‘exclude,’ and ‘unsure’. All ‘unsure’ papers were re-assessed by CH, and a random selection of ~ 20% of these were also assessed by DW. Where there was disagreement between authors the records were retained, and full text screened. The remaining papers were reviewed by CH, and all records were categorised into ‘include’ and ‘exclude’. Following full-text screening, 26 papers were retained for use in the review.

Study characteristics

This section of the review addresses study characteristics of those which met the inclusion criteria, which comprises: date of publication, country of origin, study design, study location, disaster, and variables examined.

Date of publication

Publication dates across the 26 papers spanned from 2008 to 2020 (see Fig.  2 ). The number of papers published was relatively low and consistent across this timescale (i.e. 1–2 per year, except 2010 and 2013 when none were published) up until 2017 where the number of papers peaked at 5. From 2017 to 2020 there were 15 papers published in total. The amount of papers published in recent years suggests a shift in research and interest towards CR and SC in a disaster/ public health emergency context.

Graph to show retained papers date of publication

Country of origin

The locations of the first authors’ institutes at the time of publication were extracted to provide a geographical spread of the retained papers. The majority originated from the USA [ 35 , 36 , 37 , 38 , 39 , 40 , 41 ], followed by China [ 42 , 43 , 44 , 45 , 46 ], Japan [ 47 , 48 , 49 , 50 ], Australia [ 51 , 52 , 53 ], The Netherlands [ 54 , 55 ], New Zealand [ 56 ], Peru [ 57 ], Iran [ 58 ], Austria [ 59 ], and Croatia [ 60 ].

There were multiple methodological approaches carried out across retained papers. The most common formats included surveys or questionnaires [ 36 , 37 , 38 , 42 , 46 , 47 , 48 , 49 , 50 , 53 , 54 , 55 , 57 , 59 ], followed by interviews [ 39 , 40 , 43 , 51 , 52 , 60 ]. Four papers used both surveys and interviews [ 35 , 41 , 45 , 58 ], and two papers conducted data analysis (one using open access data from a Social Survey [ 44 ] and one using a Primary Health Organisations Register [ 56 ]).

Study location

The majority of the studies were carried out in Japan [ 36 , 42 , 44 , 47 , 48 , 49 , 50 ], followed by the USA [ 35 , 37 , 38 , 39 , 40 , 41 ], China [ 43 , 45 , 46 , 53 ], Australia [ 51 , 52 ], and the UK [ 54 , 55 ]. The remaining studies were carried out in Croatia [ 60 ], Peru [ 57 ], Austria [ 59 ], New Zealand [ 56 ] and Iran [ 58 ].

Multiple different types of disaster were researched across the retained papers. Earthquakes were the most common type of disaster examined [ 45 , 47 , 49 , 50 , 53 , 56 , 57 , 58 ], followed by research which assessed the impact of two disastrous events which had happened in the same area (e.g. Hurricane Katrina and the Deepwater Horizon oil spill in Mississippi, and the Great East Japan earthquake and Tsunami; [ 36 , 37 , 38 , 42 , 44 , 48 ]). Other disaster types included: flooding [ 51 , 54 , 55 , 59 , 60 ], hurricanes [ 35 , 39 , 41 ], infectious disease outbreaks [ 43 , 46 ], oil spillage [ 40 ], and drought [ 52 ].

Variables of interest examined

Across the 26 retained papers: eight referred to examining the impact of SC [ 35 , 37 , 39 , 41 , 46 , 49 , 55 , 60 ]; eight examined the impact of cognitive and structural SC as separate entities [ 40 , 42 , 45 , 48 , 50 , 54 , 57 , 59 ]; one examined bridging and bonding SC as separate entities [ 58 ]; two examined the impact of CR [ 38 , 56 ]; and two employed a qualitative methodology but drew findings in relation to bonding and bridging SC, and SC generally [ 51 , 52 ]. Additionally, five papers examined the impact of the following variables: ‘community social cohesion’ [ 36 ], ‘neighbourhood connectedness’ [ 44 ], ‘social support at the community level’ [ 47 ], ‘community connectedness’ [ 43 ] and ‘sense of community’ [ 53 ]. Table  1 provides additional details on this.

How is CR and SC measured or quantified in research?

The measures used to examine CR and SC are presented Table  1 . It is apparent that there is no uniformity in how SC or CR is measured across the research. Multiple measures are used throughout the retained studies, and nearly all are unique. Additionally, SC was examined at multiple different levels (e.g. cognitive and structural, bonding and bridging), and in multiple different forms (e.g. community connectedness, community cohesion).

What is the association between CR and SC on mental wellbeing?

To best compare research, the following section reports on CR, and facets of SC separately. Please see Supplementary file 4  for additional information on retained papers methods of measuring mental wellbeing.

• Community resilience

CR relates to the ability of a community to withstand, adapt and permit growth in adverse circumstances due to social structures, networks and interdependencies within the community [ 11 ].

The impact of CR on mental wellbeing was consistently positive. For example, research indicated that there was a positive association between CR and number of common mental health (i.e. anxiety and mood) treatments post-disaster [ 56 ]. Similarly, other research suggests that CR is positively related to psychological resilience, which is inversely related to depressive symptoms) [ 37 ]. The same research also concluded that CR is protective of psychological resilience and is therefore protective of depressive symptoms [ 37 ].

• Social capital

SC reflects the strength of a social network, community reciprocity, and trust in people and institutions [ 14 ]. These aspects of community are usually conceptualised primarily as protective factors that enable communities to cope and adapt collectively to threats.

There were inconsistencies across research which examined the impact of abstract SC (i.e. not refined into bonding/bridging or structural/cognitive) on mental wellbeing. However, for the majority of cases, research deems SC to be beneficial. For example, research has concluded that, SC is protective against post-traumatic stress disorder [ 55 ], anxiety [ 46 ], psychological distress [ 50 ], and stress [ 46 ]. Additionally, SC has been found to facilitate post-traumatic growth [ 38 ], and also to be useful to be drawn upon in times of stress [ 52 ], both of which could be protective of mental health. Similarly, research has also found that emotional recovery following a disaster is more difficult for those who report to have low levels of SC [ 51 ].

Conversely, however, research has also concluded that when other situational factors (e.g. personal resources) were controlled for, a positive relationship between community resources and life satisfaction was no longer significant [ 60 ]. Furthermore, some research has concluded that a high level of SC can result in a community facing greater stress immediately post disaster. Indeed, one retained paper found that high levels of SC correlate with higher levels of post-traumatic stress immediately following a disaster [ 39 ]. However, in the later stages following a disaster, this relationship can reverse, with SC subsequently providing an aid to recovery [ 41 ]. By way of explanation, some researchers have suggested that communities with stronger SC carry the greatest load in terms of helping others (i.e. family, friends and neighbours) as well as themselves immediately following the disaster, but then as time passes the communities recover at a faster rate as they are able to rely on their social networks for support [ 41 ].

Cognitive and structural social capital

Cognitive SC refers to perceptions of community relations, such as trust, mutual help and attachment, and structural SC refers to what actually happens within the community, such as participation, socialising [ 16 ].

Cognitive SC has been found to be protective [ 49 ] against PTSD [ 54 , 57 ], depression [ 40 , 54 ]) mild mood disorder; [ 48 ]), anxiety [ 48 , 54 ] and increase self-efficacy [ 59 ].

For structural SC, research is again inconsistent. On the one hand, structural SC has been found to: increase perceived self-efficacy, be protective of depression [ 40 ], buffer the impact of housing damage on cognitive decline [ 42 ] and provide support during disasters and over the recovery period [ 59 ]. However, on the other hand, it has been found to have no association with PTSD [ 54 , 57 ] or depression, and is also associated with a higher prevalence of anxiety [ 54 ]. Similarly, it is also suggested by additional research that structural SC can harm women’s mental health, either due to the pressure of expectations to help and support others or feelings of isolation [ 49 ].

Bonding and bridging social capital

Bonding SC refers to connections among individuals who are emotionally close, and result in bonds to a particular group [ 17 ], and bridging SC refers to acquaintances or individuals loosely connected that span different social groups [ 18 ].

One research study concluded that both bonding and bridging SC were protective against post-traumatic stress disorder symptoms [ 58 ]. Bridging capital was deemed to be around twice as effective in buffering against post-traumatic stress disorder than bonding SC [ 58 ].

Other community variables

Community social cohesion was significantly associated with a lower risk of post-traumatic stress disorder symptom development [ 35 ], and this was apparent even whilst controlling for depressive symptoms at baseline and disaster impact variables (e.g. loss of family member or housing damage) [ 36 ]. Similarly, sense of community, community connectedness, social support at the community level and neighbourhood connectedness all provided protective benefits for a range of mental health, wellbeing and recovery variables, including: depression [ 53 ], subjective wellbeing (in older adults only) [ 43 ], psychological distress [ 47 ], happiness [ 44 ] and life satisfaction [ 53 ].

Research has also concluded that community level social support is protective against mild mood and anxiety disorder, but only for individuals who have had no previous disaster experience [ 48 ]. Additionally, a study which separated SC into social cohesion and social participation concluded that at a community level, social cohesion is protective against depression [ 49 ] whereas social participation at community level is associated with an increased risk of depression amongst women [ 49 ].

What is the impact of Infectious disease outbreaks / disasters and emergencies on community resilience?

From a cross-sectional perspective, research has indicated that disasters and emergencies can have a negative effect on certain types of SC. Specifically, cognitive SC has been found to be impacted by disaster impact, whereas structural SC has gone unaffected [ 45 ]. Disaster impact has also been shown to have a negative effect on community relationships more generally [ 52 ].

Additionally, of the eight studies which collected data at multiple time points [ 35 , 36 , 41 , 42 , 47 , 49 , 56 , 60 ], three reported the effect of a disaster on the level of SC within a community [ 40 , 42 , 49 ]. All three of these studies concluded that disasters may have a negative impact on the levels of SC within a community. The first study found that the Deepwater Horizon oil spill had a negative effect on SC and social support, and this in turn explained an overall increase in the levels of depression within the community [ 40 ]. A possible explanation for the negative effect lays in ‘corrosive communities’, known for increased social conflict and reduced social support, that are sometimes created following oil spills [ 40 ]. It is proposed that corrosive communities often emerge due to a loss of natural resources that bring social groups together (e.g., for recreational activities), as well as social disparity (e.g., due to unequal distribution of economic impact) becoming apparent in the community following disaster [ 40 ]. The second study found that SC (in the form of social cohesion, informal socialising and social participation) decreased after the 2011 earthquake and tsunami in Japan; it was suggested that this change correlated with incidence of cognitive decline [ 42 ]. However, the third study reported more mixed effects based on physical circumstances of the communities’ natural environment: Following an earthquake, those who lived in mountainous areas with an initial high level of pre-community SC saw a decrease in SC post disaster [ 49 ]. However, communities in flat areas (which were home to younger residents and had a higher population density) saw an increase in SC [ 49 ]. It was proposed that this difference could be due to the need for those who lived in mountainous areas to seek prolonged refuge due to subsequent landslides [ 49 ].

What types of intervention enhance CR and SC and protect survivors?

There were mixed effects across the 26 retained papers when examining the effect of CR and SC on mental wellbeing. However, there is evidence that an increase in SC [ 56 , 57 ], with a focus on cognitive SC [ 57 ], namely by: building social networks [ 45 , 51 , 53 ], enhancing feelings of social cohesion [ 35 , 36 ] and promoting a sense of community [ 53 ], can result in an increase in CR and potentially protect survivors’ wellbeing and mental health following a disaster. An increase in SC may also aid in decreasing the need for individual psychological interventions in the aftermath of a disaster [ 55 ]. As a result, recommendations and suggested methods to bolster CR and SC from the retained papers have been extracted and separated into general methods, preparedness and policy level implementation.

General methods

Suggested methods to build SC included organising recreational activity-based groups [ 44 ] to broaden [ 51 , 53 ] and preserve current social networks [ 42 ], introducing initiatives to increase social cohesion and trust [ 51 ], and volunteering to increase the number of social ties between residents [ 59 ]. Research also notes that it is important to take a ‘no one left behind approach’ when organising recreational and social community events, as failure to do so could induce feelings of isolation for some members of the community [ 49 ]. Furthermore, gender differences should also be considered as research indicates that males and females may react differently to community level SC (as evidence suggests males are instead more impacted by individual level SC; in comparison to women who have larger and more diverse social networks [ 49 ]). Therefore, interventions which aim to raise community level social participation, with the aim of expanding social connections and gaining support, may be beneficial [ 42 , 47 ].

Preparedness

In order to prepare for disasters, it may be beneficial to introduce community-targeted methods or interventions to increase levels of SC and CR as these may aid in ameliorating the consequences of a public health emergency or disaster [ 57 ]. To indicate which communities have low levels of SC, one study suggests implementing a 3-item scale of social cohesion to map areas and target interventions [ 42 ].

It is important to consider that communities with a high level of SC may have a lower level of risk perception, due to the established connections and supportive network they have with those around them [ 61 ]. However, for the purpose of preparedness, this is not ideal as perception of risk is a key factor when seeking to encourage behavioural adherence. This could be overcome by introducing communication strategies which emphasise the necessity of social support, but also highlights the need for additional measures to reduce residual risk [ 59 ]. Furthermore, support in the form of financial assistance to foster current community initiatives may prove beneficial to rural areas, for example through the use of an asset-based community development framework [ 52 ].

Policy level

At a policy level, the included papers suggest a range of ways that CR and SC could be bolstered and used. These include: providing financial support for community initiatives and collective coping strategies, (e.g. using asset-based community development [ 52 ]); ensuring policies for long-term recovery focus on community sustainable development (e.g. community festival and community centre activities) [ 44 ]; and development of a network amongst cooperative corporations formed for reconstruction and to organise self-help recovery sessions among residents of adjacent areas [ 58 ].

This scoping review sought to synthesise literature concerning the role of SC and CR during public health emergencies and disasters. Specifically, in this review we have examined: the methods used to measure CR and SC; the impact of CR and SC on mental wellbeing during disasters and emergencies; the impact of disasters and emergencies on CR and SC; and the types of interventions which can be used to enhance CR. To do this, data was extracted from 26 peer-reviewed journal articles. From this synthesis, several key themes have been identified, which can be used to develop guidelines and recommendations for deploying CR and SC in a public health emergency or disaster context. These key themes and resulting recommendations are summarised below.

Firstly, this review established that there is no consistent or standardised approach to measuring CR or SC within the general population. This finding is consistent with a review conducted by the World Health Organization which concludes that despite there being a number of frameworks that contain indicators across different determinants of health, there is a lack of consensus on priority areas for measurement and no widely accepted indicator [ 27 ]. As a result, there are many measures of CR and SC apparent within the literature (e.g., [ 62 , 63 ]), an example of a developed and validated measure is provided by Sherrieb, Norris and Galea [ 64 ]. Similarly, the definitions of CR and SC differ widely between researchers, which created a barrier to comparing and summarising information. Therefore, future research could seek to compare various interpretations of CR and to identify any overlapping concepts. However, a previous systemic review conducted by Patel et al. (2017) concludes that there are nine core elements of CR (local knowledge, community networks and relationships, communication, health, governance and leadership, resources, economic investment, preparedness, and mental outlook), with 19 further sub-elements therein [ 30 ]. Therefore, as CR is a multi-dimensional construct, the implications from the findings are that multiple aspects of social infrastructure may need to be considered.

Secondly, our synthesis of research concerning the role of CR and SC for ensuring mental health and wellbeing during, or following, a public health emergency or disaster revealed mixed effects. Much of the research indicates either a generally protective effect on mental health and wellbeing, or no effect; however, the literature demonstrates some potential for a high level of CR/SC to backfire and result in a negative effect for populations during, or following, a public health emergency or disaster. Considered together, our synthesis indicates that cognitive SC is the only facet of SC which was perceived as universally protective across all retained papers. This is consistent with a systematic review which also concludes that: (a) community level cognitive SC is associated with a lower risk of common mental disorders, while; (b) community level structural SC had inconsistent effects [ 65 ].

Further examination of additional data extracted from studies which found that CR/SC had a negative effect on mental health and wellbeing revealed no commonalities that might explain these effects (Please see Supplementary file 5 for additional information)

One potential explanation may come from a retained paper which found that high levels of SC result in an increase in stress level immediately post disaster [ 41 ]. This was suggested to be due to individuals having greater burdens due to wishing to help and support their wide networks as well as themselves. However, as time passes the levels of SC allow the community to come together and recover at a faster rate [ 41 ]. As this was the only retained paper which produced this finding, it would be beneficial for future research to examine boundary conditions for the positive effects of CR/SC; that is, to explore circumstances under which CR/SC may be more likely to put communities at greater risk. This further research should also include additional longitudinal research to validate the conclusions drawn by [ 41 ] as resilience is a dynamic process of adaption.

Thirdly, disasters and emergencies were generally found to have a negative effect on levels of SC. One retained paper found a mixed effect of SC in relation to an earthquake, however this paper separated participants by area in which they lived (i.e., mountainous vs. flat), which explains this inconsistent effect [ 49 ]. Dangerous areas (i.e. mountainous) saw a decrease in community SC in comparison to safer areas following the earthquake (an effect the authors attributed to the need to seek prolonged refuge), whereas participants from the safer areas (which are home to younger residents with a higher population density) saw an increase in SC [ 49 ]. This is consistent with the idea that being able to participate socially is a key element of SC [ 12 ]. Overall, however, this was the only retained paper which produced a variable finding in relation to the effect of disaster on levels of CR/SC.

Finally, research identified through our synthesis promotes the idea of bolstering SC (particularly cognitive SC) and cohesion in communities likely to be affected by disaster to improve levels of CR. This finding provides further understanding of the relationship between CR and SC; an association that has been reported in various articles seeking to provide conceptual frameworks (e.g., [ 66 , 67 ]) as well as indicator/measurement frameworks [ 27 ]. Therefore, this could be done by creating and promoting initiatives which foster SC and create bonds within the community. Papers included in the current review suggest that recreational-based activity groups and volunteering are potential methods for fostering SC and creating community bonds [ 44 , 51 , 59 ]. Similarly, further research demonstrates that feelings of social cohesion are enhanced by general social activities (e.g. fairs and parades [ 18 ]). Also, actively encouraging activities, programs and interventions which enhance connectedness and SC have been reported to be desirable to increase CR [ 68 ]. This suggestion is supported by a recent scoping review of literature [ 67 ] examined community champion approaches for the COVID-19 pandemic response and recovery and established that creating and promoting SC focused initiatives within the community during pandemic response is highly beneficial [ 67 ]. In terms of preparedness, research states that it may be beneficial for levels of SC and CR in communities at risk to be assessed, to allow targeted interventions where the population may be at most risk following an incident [ 42 , 44 ]. Additionally, from a more critical perspective, we acknowledge that ‘resilience’ can often be perceived as a focus on individual capacity to adapt to adversity rather than changing or mitigating the causes of adverse conditions [ 69 , 70 ]. Therefore, CR requires an integrated system approach across individual, community and structural levels [ 17 ]. Also, it is important that community members are engaged in defining and agreeing how community resilience is measured [ 27 ] rather than it being imposed by system leads or decision-makers.

In the aftermath of the pandemic, is it expected that there will be long-term repercussions both from an economic [ 8 ] and a mental health perspective [ 71 ]. Furthermore, the findings from this review suggest that although those in areas with high levels of SC may be negatively affected in the acute stage, as time passes, they have potential to rebound at a faster rate than those with lower levels of SC. Ongoing evaluation of the effectiveness of current initiatives as the COVID-19 pandemic progresses into a recovery phase will be invaluable for supplementing the evidence base identified through this review.

• Recommendations

As a result of this review, a number of recommendations are suggested for policy and practice during public health emergencies and recovery.

Future research should seek to establish a standardised and validated approach to measuring and defining CR and SC within communities. There are ongoing efforts in this area, for example [ 72 ]. Additionally, community members should be involved in the process of defining how CR is measured.

There should be an enhanced effort to improve preparedness for public health emergencies and disasters in local communities by gauging current levels of SC and CR within communities using a standardised measure. This approach could support specific targeting of populations with low levels of CR/SC in case of a disaster or public health emergency, whilst also allowing for consideration of support for those with high levels of CR (as these populations can be heavily impacted initially following a disaster). By distinguishing levels of SC and CR, tailored community-centred approaches could be implemented, such as those listed in a guide released by PHE in 2015 [ 73 ].

CR and SC (specifically cognitive SC) should be bolstered if communities are at risk of experiencing a disaster or public health emergency. This can be achieved by using interventions which aim to increase a sense of community and create new social ties (e.g., recreational group activities, volunteering). Additionally, when aiming to achieve this, it is important to be mindful of the risk of increased levels of CR/SC to backfire, as well as seeking to advocate an integrated system approach across individual, community and structural levels.

It is necessary to be aware that although communities with high existing levels of resilience / SC may experience short-term negative consequences following a disaster, over time these communities might be able to recover at a faster rate. It is therefore important to ensure that suitable short-term support is provided to these communities in the immediate aftermath of a public health emergency or disaster.

Robust evaluation of the community resilience initiatives deployed during the COVID-19 pandemic response is essential to inform the evidence base concerning the effectiveness of CR/ SC. These evaluations should continue through the response phase and into the recovery phase to help develop our understanding of the long-term consequences of such interventions.

Limitations

Despite this review being the first in this specific topic area, there are limitations that must be considered. Firstly, it is necessary to note that communities are generally highly diverse and the term ‘community’ in academic literature is a subject of much debate (see: [ 74 ]), therefore this must be considered when comparing and collating research involving communities. Additionally, the measures of CR and SC differ substantially across research, including across the 26 retained papers used in the current review. This makes the act of comparing and collating research findings very difficult. This issue is highlighted as a key outcome from this review, and suggestions for how to overcome this in future research are provided. Additionally, we acknowledge that there will be a relationship between CR & SC even where studies measure only at individual or community level. A review [ 75 ] on articulating a hypothesis of the link to health inequalities suggests that wider structural determinants of health need to be accounted for. Secondly, despite the final search strategy encompassing terms for both CR and SC, only one retained paper directly measured CR; thus, making the research findings more relevant to SC. Future research could seek to focus on CR to allow for a comparison of findings. Thirdly, the review was conducted early in the COVID-19 pandemic and so does not include more recent publications focusing on resilience specifically in the context of COVID-19. Regardless of this fact, the synthesis of, and recommendations drawn from, the reviewed studies are agnostic to time and specific incident and contain critical elements necessary to address as the pandemic moves from response to recovery. Further research should review the effectiveness of specific interventions during the COVID-19 pandemic for collation in a subsequent update to this current paper. Fourthly, the current review synthesises findings from countries with individualistic and collectivistic cultures, which may account for some variation in the findings. Lastly, despite choosing a scoping review method for ease of synthesising a wide literature base for use by public health emergency researchers in a relatively tight timeframe, there are disadvantages of a scoping review approach to consider: (1) quality appraisal of retained studies was not carried out; (2) due to the broad nature of a scoping review, more refined and targeted reviews of literature (e.g., systematic reviews) may be able to provide more detailed research outcomes. Therefore, future research should seek to use alternative methods (e.g., empirical research, systematic reviews of literature) to add to the evidence base on CR and SC impact and use in public health practice.

This review sought to establish: (1) How CR and SC are quantified in research?; (2) The impact of community resilience on mental wellbeing?; (3) The impact of infectious disease outbreaks, disasters and emergencies on community resilience and social capital?; and, (4) What types of interventions enhance community resilience and social capital?. The chosen search strategy yielded 26 relevant papers from which we were able extract information relating to the aims of this review.

Results from the review revealed that CR and SC are not measured consistently across research. The impact of CR / SC on mental health and wellbeing during emergencies and disasters is mixed (with some potential for backlash), however the literature does identify cognitive SC as particularly protective. Although only a small number of papers compared CR or SC before and after a disaster, the findings were relatively consistent: SC or CR is negatively impacted by a disaster. Methods suggested to bolster SC in communities were centred around social activities, such as recreational group activities and volunteering. Recommendations for both research and practice (with a particular focus on the ongoing COVID-19 pandemic) are also presented.

Availability of data and materials

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

Abbreviations

Social Capital

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This study was supported by the National Institute for Health Research Research Unit (NIHR HPRU) in Emergency Preparedness and Response, a partnership between Public Health England, King’s College London and the University of East Anglia. The views expressed are those of the author(s) and not necessarily those of the NIHR, Public Health England, the UK Health Security Agency or the Department of Health and Social Care [Grant number: NIHR20008900]. Part of this work has been funded by the Office for Health Improvement and Disparities, Department of Health and Social Care, as part of a Collaborative Agreement with Leeds Beckett University.

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Hall, C.E., Wehling, H., Stansfield, J. et al. Examining the role of community resilience and social capital on mental health in public health emergency and disaster response: a scoping review. BMC Public Health 23 , 2482 (2023). https://doi.org/10.1186/s12889-023-17242-x

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