what is a literature review in public health

The Sheridan Libraries

• Public Health
• Sheridan Libraries
• Literature Reviews + Annotating
• How to Access Full Text
• Background Information
• Books, E-books, Dissertations
• Articles, News, Who Cited This, More
• Google Scholar and Google Books
• PUBMED and EMBASE
• Statistics -- United States
• Statistics -- Worldwide
• Avoiding Plagiarism
• Citing Sources This link opens in a new window
• Copyright This link opens in a new window
• Evaluating Information This link opens in a new window
• RefWorks Guide and Help This link opens in a new window
• Epidemic Proportions
• Environment and Your Health, AS 280.335, Spring 2024
• Honors in Public Health, AS280.495, Fall 23-Spr 2024
• Intro to Public Health, AS280.101, Spring 2024
• Research Methods in Public Health, AS280.240, Spring 2024
• Social+Behavioral Determinants of Health, AS280.355, Spring 2024
• Feedback (for class use only)

Literature Reviews

• Organizing/Synthesizing
• Peer Review
• Ulrich's -- One More Way To Find Peer-reviewed Papers

"Literature review," "systematic literature review," "integrative literature review" -- these are terms used in different disciplines for basically the same thing -- a rigorous examination of the scholarly literature about a topic (at different levels of rigor, and with some different emphases).  

1. Our library's guide to Writing a Literature Review

2. Other helpful sites

• Writing Center at UNC (Chapel Hill) -- A very good guide about lit reviews and how to write them
• Literature Review: Synthesizing Multiple Sources (LSU, June 2011 but good; PDF) -- Planning, writing, and tips for revising your paper

3. Welch Library's list of the types of expert reviews

Doing a good job of organizing your information makes writing about it a lot easier.

You can organize your sources using a citation manager, such as refworks , or use a matrix (if you only have a few references):.

• Use Google Sheets, Word, Excel, or whatever you prefer to create a table
• The column headings should include the citation information, and the main points that you want to track, as shown

Synthesizing your information is not just summarizing it. Here are processes and examples about how to combine your sources into a good piece of writing:

• Purdue OWL's Synthesizing Sources
• Synthesizing Sources (California State University, Northridge)

Annotated Bibliography  

An "annotation" is a note or comment. An "annotated bibliography" is a "list of citations to books, articles, and [other items]. Each citation is followed by a brief...descriptive and evaluative paragraph, [whose purpose is] to inform the reader of the relevance, accuracy, and quality of the sources cited."*

• Sage Research Methods (database) --> Empirical Research and Writing (ebook) -- Chapter 3: Doing Pre-research  
• Purdue's OWL (Online Writing Lab) includes definitions and samples of annotations  
• Cornell's guide * to writing annotated bibliographies  

* Thank you to Olin Library Reference, Research & Learning Services, Cornell University Library, Ithaca, NY, USA https://guides.library.cornell.edu/annotatedbibliography

What does "peer-reviewed" mean?

• If an article has been peer-reviewed before being published, it means that the article has been read by other people in the same field of study ("peers").
• The author's reviewers have commented on the article, not only noting typos and possible errors, but also giving a judgment about whether or not the article should be published by the journal to which it was submitted.

How do I find "peer-reviewed" materials?

• Most of the the research articles in scholarly journals are peer-reviewed.
• Many databases allow you to check a box that says "peer-reviewed," or to see which results in your list of results are from peer-reviewed sources. Some of the databases that provide this are Academic Search Ultimate, CINAHL, PsycINFO, and Sociological Abstracts.

What kinds of materials are *not* peer-reviewed?

• open web pages
• most newspapers, newsletters, and news items in journals
• letters to the editor
• press releases
• columns and blogs
• book reviews
• anything in a popular magazine (e.g., Time, Newsweek, Glamour, Men's Health)

If a piece of information wasn't peer-reviewed, does that mean that I can't trust it at all?

No; sometimes you can. For example, the preprints submitted to well-known sites such as  arXiv  (mainly covering physics) and  CiteSeerX (mainly covering computer science) are probably trustworthy, as are the databases and web pages produced by entities such as the National Library of Medicine, the Smithsonian Institution, and the American Cancer Society.

Is this paper peer-reviewed? Ulrichsweb will tell you.

1) On the library home page , choose "Articles and Databases" --> "Databases" --> Ulrichsweb

2) Put in the title of the JOURNAL (not the article), in quotation marks so all the words are next to each other

3) Mouse over the black icon, and you'll see that it means "refereed" (which means peer-reviewed, because it's been looked at by referees or reviewers). This journal is not peer-reviewed, because none of the formats have a black icon next to it:

• << Previous: Evaluating Information
• Next: RefWorks Guide and Help >>
• Last Updated: May 13, 2024 10:04 AM
• URL: https://guides.library.jhu.edu/public-health

Public Health

• COVID-19 Resources This link opens in a new window
• Define Your Topic
• Searching Strategies
• Types of Resources
• Other Types of Scholarly Articles
• Finding Op-Eds

Literature Review

• Qualitative Research
• Web Resources
• LibX This link opens in a new window
• Reload Button
• Virtual Private Network (VPN)
• Google Scholar Settings
• Articles & Databases
• Data & Statistics This link opens in a new window
• Data Visualization Tools This link opens in a new window
• Films and videos
• Infographics This link opens in a new window
• Systematic Reviews This link opens in a new window
• Stay Current with Research
• Tenure and Promotion Resources This link opens in a new window
• Theses & Dissertations This link opens in a new window
• Bills, Laws and Public Policies
• Biostatistics
• Complementary & Alternative Medicine
• Consumer Health
• Epidemiology
• Evidence-Based Medicine
• Environmental Health Law
• Fact-checking resources
• Family Science
• Government Information
• Health Behavior Theory
• History of Medicine
• Infectious Diseases
• Kinesiology
• Patient Protection and Affordable Care Act
• Statistics This link opens in a new window
• Tests and Measurement Instruments
• Citation Styles
• Citation Managers
• Academic Integrity
• Books on different types of professional writing
• Health Sciences Libraries in DC area
• Library Award for Undergraduate Research
• For faculty
• Class materials
• What is a literature review?
• Tutorial - text and video
• Tips for better writing

What exactly is a Literature Review?

A literature review describes, summarizes and analyzes previously published literature in a field. What you want to do is demonstrate your knowledge and understanding of what the "conversation" about this topic is, identify gaps in the literature, present research pertinent to your ideas and how your research fits in with, changes, elaborates on, etc., the present conversation.

BOOKS - Literature Review and how to write it

BOOKS - Research Methods

Research Methods at a Glance

This information on basic business research methods is in part adapted from the book Field Guide to Nonprofit Program Design, Marketing and Evaluation by Carter McNamara (Call number: HD62.6 .M36). 

Research Methods in General

Research Methods in Public Health

• The Literature Review: A Research Journey This guide from the Harvard School of Education is an introduction to the basics of conducting a literature review.

• How to cite effectively and improve readability of your paper?

Improve your writing

The Academic Phrasebank is a general resource for academic writers. It aims to provide you with examples of some of the phraseological ‘nuts and bolts’ of writing organized according to the main sections of a research paper or dissertation:

• Introducing work  - e.g Evidence suggests that X is among the most important factors for …
• Referring to sources  - e.g. A number of authors have considered the effects of … (Smith, 2003; Jones, 2004).
• Describing methods - e.g. Different methods have been proposed to classify … (Johnson, 2021; Petersen, 2019; Appel, 2017).
• Reporting results - e.g. Interestingly, the X was observed to …
• Discussing findings  - e.g. A strong relationship between X and Y has been reported in the literature.
• Writing conclusions  - e.g. One of the more significant findings to emerge from this study is that …

Additional  examples from Academic Phrasebank are below:

Before explaining these theories, it is necessary to …

In a similar case in America, Smith (2021) identified …

This is exemplified in the work undertaken by Smith (2021) ...

Recent cases reported by Smith  et al . (2021) also support the hypothesis that …

This section has reviewed the three key aspects of …

In summary, it has been shown from this review that …

• << Previous: Finding Op-Eds
• Next: Qualitative Research >>
• Last Updated: May 14, 2024 12:14 PM
• URL: https://lib.guides.umd.edu/PublicHealth

Systematic Reviews

Describes what is involved with conducting a systematic review of the literature for evidence-based public health and how the librarian is a partner in the process.

Several CDC librarians have special training in conducting literature searches for systematic reviews.  Literature searches for systematic reviews can take a few weeks to several months from planning to delivery.

Fill out a search request form here  or contact the Stephen B. Thacker CDC Library by email  [email protected] or telephone 404-639-1717.

Campbell Collaboration

Cochrane Collaboration

Eppi Centre

Joanna Briggs Institute

McMaster University

PRISMA Statement

Systematic Reviews – CRD’s Guide

Systematic Reviews of Health Promotion and Public Health Interventions

The Guide to Community Preventive Services

Look for systematic reviews that have already been published. 

• To ensure that the work has not already been done.
• To provides examples of search strategies for your topic

Look in PROSPERO for registered systematic reviews.

Search Cochrane and CRD-York for systematic reviews.

Search filter for finding systematic reviews in PubMed

Other search filters to locate systematic reviews

A systematic review attempts to collect and analyze all evidence that answers a specific question.  The question must be clearly defined and have inclusion and exclusion criteria. A broad and thorough search of the literature is performed and a critical analysis of the search results is reported and ultimately provides a current evidence-based answer  to the specific question.

Time:  According to Cochrane , it takes 18 months on average to complete a Systematic Review.

The average systematic review from beginning to end requires 18 months of work. “…to find out about a healthcare intervention it is worth searching research literature thoroughly to see if the answer is already known. This may require considerable work over many months…” ( Cochrane Collaboration )

Review Team: Team Members at minimum…

• Content expert
• 2 reviewers
• 1 tie breaker
• 1 statistician (meta-analysis)
• 1 economist if conducting an economic analysis
• *1 librarian (expert searcher) trained in systematic reviews

“Expert searchers are an important part of the systematic review team, crucial throughout the review process-from the development of the proposal and research question to publication.” ( McGowan & Sampson, 2005 )

*Ask your librarian to write a methods section regarding the search methods and to give them co-authorship. You may also want to consider providing a copy of one or all of the search strategies used in an appendix.

The Question to Be Answered: A clearly defined and specific question or questions with inclusion and exclusion criteria.

Written Protocol: Outline the study method, rationale, key questions, inclusion and exclusion criteria, literature searches, data abstraction and data management, analysis of quality of the individual studies, synthesis of data, and grading of the evidience for each key question.

Literature Searches:  Search for any systematic reviews that may already answer the key question(s).  Next, choose appropriate databases and conduct very broad, comprehensive searches.  Search strategies must be documented so that they can be duplicated.  The librarian is integral to this step of the process. Before your librarian creates a search strategy and starts searching in earnest you should write a detailed PICO question , determine the inclusion and exclusion criteria for your study, run a preliminary search, and have 2-4 articles that already fit the criteria for your review.

What is searched depends on the topic of the review but should include…

• At least 3 standard medical databases like PubMed/Medline, CINAHL, Embase, etc..
• At least 2 grey literature resources like Clinicaltrials.gov, COS Conference Papers Index, Grey Literature Report,  etc…

Citation Management: EndNote is a bibliographic management tools that assist researchers in managing citations.  The Stephen B. Thacker CDC Library oversees the site license for EndNote.

To request installation:   The library provides EndNote  to CDC staff under a site-wide license. Please use the ITSO Software Request Tool (SRT) and submit a request for the latest version (or upgraded version) of EndNote. Please be sure to include the computer name for the workstation where you would like to have the software installed.

EndNote Training:   CDC Library offers training on EndNote on a regular basis – both a basic and advanced course. To view the course descriptions and upcoming training dates, please visit the CDC Library training page .

For assistance with EndNote software, please contact [email protected]

Vendor Support and Services:   EndNote – Support and Services (Thomson Reuters)  EndNote – Tutorials and Live Online Classes (Thomson Reuters)

Getting Articles:

Articles can be obtained using DocExpress or by searching the electronic journals at the Stephen B. Thacker CDC Library.

IOM Standards for Systematic Reviews: Standard 3.1: Conduct a comprehensive systematic search for evidence

The goal of a systematic review search is to maximize recall and precision while keeping results manageable. Recall (sensitivity) is defined as the number of relevant reports identified divided by the total number of relevant reports in existence. Precision (specificity) is defined as the number of relevant reports identified divided by the total number of reports identified.

Issues to consider when creating a systematic review search:   

• All concepts are included in the strategy
• All appropriate subject headings are used
• Appropriate use of explosion
• Appropriate use of subheadings and floating subheadings
• Use of natural language (text words) in addition to controlled vocabulary terms
• Use of appropriate synonyms, acronyms, etc.
• Truncation and spelling variation as appropriate
• Appropriate use of limits such as language, years, etc.
• Field searching, publication type, author, etc.
• Boolean operators used appropriately
• Line errors: when searches are combined using line numbers, be sure the numbers refer to the searches intended
• Check indexing of relevant articles
• Search strategy adapted as needed for multiple databases
• Cochrane Handbook: Searching for Studies See Part 2, Chapter 6

A step-by-step guide to systematically identify all relevant animal studies

Materials listed in these guides are selected to provide awareness of quality public health literature and resources. A material’s inclusion does not necessarily represent the views of the U.S. Department of Health and Human Services (HHS), the Public Health Service (PHS), or the Centers for Disease Control and Prevention (CDC), nor does it imply endorsement of the material’s methods or findings. HHS, PHS, and CDC assume no responsibility for the factual accuracy of the items presented. The selection, omission, or content of items does not imply any endorsement or other position taken by HHS, PHS, and CDC. Opinion, findings, and conclusions expressed by the original authors of items included in these materials, or persons quoted therein, are strictly their own and are in no way meant to represent the opinion or views of HHS, PHS, or CDC. References to publications, news sources, and non-CDC Websites are provided solely for informational purposes and do not imply endorsement by HHS, PHS, or CDC.

Exit Notification / Disclaimer Policy

• The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
• Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
• You will be subject to the destination website's privacy policy when you follow the link.
• CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.

Global Public Health Research Guide: Literature Reviews

Literature reviews.

• Types of Research Articles
• Database Tutorials
• Medical Reference
• Interlibrary Loans
• Web Resources
• Exporting to PubMed & Web of Science
• RefWorks & Word
• Sharing and Collaborating

What is a Literature Review and Why Do one?

A literature review surveys books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have explored while researching a particular topic and to demonstrate to your readers how your research fits within a larger field of study.

The purpose of a literature review is to:

• Place each work in the context of its contribution to understanding the research problem being studied.
• Describe the relationship of each work to the others under consideration.
• Identify new ways to interpret prior research.
• Reveal any gaps that exist in the literature.
• Resolve conflicts amongst seemingly contradictory previous studies.
• Identify areas of prior scholarship to prevent duplication of effort.
• Point the way in fulfilling a need for additional research.
• Locate your own research within the context of existing literature [very important].

Different Approaches to Writing Literature Reviews

Argumentative Review This form examines literature selectively in order to support or refute an argument, deeply imbedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to make summary claims of the sort found in systematic reviews [see below].

Integrative Review Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses or research problems. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication. This is the most common form of review in the social sciences.

Historical Review Few things rest in isolation from historical precedent. Historical literature reviews focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review A review does not always focus on  what  someone said [findings], but  how  they came about saying what they say [method of analysis]. Reviewing methods of analysis provides a framework of understanding at different levels [i.e. those of theory, substantive fields, research approaches, and data collection and analysis techniques], how researchers draw upon a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection, and data analysis. This approach helps highlight ethical issues which you should be aware of and consider as you go through your own study.

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and  summarize scientifically all of the research about a clearly defined research problem . Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

Theoretical Review The purpose of this form is to examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review helps to establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

Adapted from:  https://writingcenter.unc.edu/tips-and-tools/literature-reviews/ ;  https://libguides.usc.edu/writingguide/literaturereview

What is a Literature Review?

This handout will explain what a literature review is and offer insights into the form and construction of a literature review in the humanities, social sciences, and sciences.

OK. You've got to write a literature review. You dust off a novel and a book of poetry, settle down in your chair, and get ready to issue a "thumbs up" or "thumbs down" as you leaf through the pages. "Literature review" done. Right?

Wrong! The "literature" of a literature review refers to any collection of materials on a topic, not necessarily the great literary texts of the world. "Literature" could be anything from a set of government pamphlets on British colonial methods in Africa to scholarly articles on the treatment of a torn ACL. And a review does not necessarily mean that your reader wants you to give your personal opinion on whether or not you liked these sources.

What is a literature review, then?

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period.

A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.

But how is a literature review different from an academic research paper?

The main focus of an academic research paper is to develop a new argument, and a research paper will contain a literature review as one of its parts. In a research paper, you use the literature as a foundation and as support for a new insight that you contribute. The focus of a literature review, however, is to summarize and synthesize the arguments and ideas of others without adding new contributions.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone. For professionals, they are useful reports that keep them up to date with what is current in the field. For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper's investigation. Comprehensive knowledge of the literature of the field is essential to most research papers.

Who writes these things, anyway?

Literature reviews are written occasionally in the humanities, but mostly in the sciences and social sciences; in experiment and lab reports, they constitute a section of the paper. Sometimes a literature review is written as a paper in itself.

If your assignment is not very specific, seek clarification from your instructor:

• Roughly how many sources should you include?
• What types of sources (books, journal articles, websites)?
• Should you summarize, synthesize, or critique your sources by discussing a common theme or issue?
• Should you evaluate your sources?
• Should you provide subheadings and other background information, such as definitions and/or a history?

Find models

Look for other literature reviews in your area of interest or in the discipline and read them to get a sense of the types of themes you might want to look for in your own research or ways to organize your final review. You can simply put the word "review" in your search engine along with your other topic terms to find articles of this type on the Internet or in an electronic database. The bibliography or reference section of sources you've already read are also excellent entry points into your own research.

Narrow your topic

There are hundreds or even thousands of articles and books on most areas of study. The narrower your topic, the easier it will be to limit the number of sources you need to read in order to get a good survey of the material. Your instructor will probably not expect you to read everything that's out there on the topic, but you'll make your job easier if you first limit your scope.

And don't forget to tap into your professor's (or other professors') knowledge in the field. Ask your professor questions such as: "If you had to read only one book from the 70's on topic X, what would it be?" Questions such as this help you to find and determine quickly the most seminal pieces in the field.

Consider whether your sources are current

Some disciplines require that you use information that is as current as possible. In the sciences, for instance, treatments for medical problems are constantly changing according to the latest studies. Information even two years old could be obsolete. However, if you are writing a review in the humanities, history, or social sciences, a survey of the history of the literature may be what is needed, because what is important is how perspectives have changed through the years or within a certain time period. Try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to consider what is currently of interest to scholars in this field and what is not.

Find a focus

A literature review, like a term paper, is usually organized around ideas, not the sources themselves as an annotated bibliography would be organized. This means that you will not just simply list your sources and go into detail about each one of them, one at a time. No. As you read widely but selectively in your topic area, consider instead what themes or issues connect your sources together. Do they present one or different solutions? Is there an aspect of the field that is missing? How well do they present the material and do they portray it according to an appropriate theory? Do they reveal a trend in the field? A raging debate? Pick one of these themes to focus the organization of your review.

Construct a working thesis statement

Then use the focus you've found to construct a thesis statement. Yes! Literature reviews have thesis statements as well! However, your thesis statement will not necessarily argue for a position or an opinion; rather it will argue for a particular perspective on the material. Some sample thesis statements for literature reviews are as follows:

The current trend in treatment for congestive heart failure combines surgery and medicine.

More and more cultural studies scholars are accepting popular media as a subject worthy of academic consideration.

Consider organization

You've got a focus, and you've narrowed it down to a thesis statement. Now what is the most effective way of presenting the information? What are the most important topics, subtopics, etc., that your review needs to include? And in what order should you present them? Develop an organization for your review at both a global and local level:

First, cover the basic categories Just like most academic papers, literature reviews also must contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper. Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern. Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each). Conclusions/Recommendations: Discuss what you have drawn from reviewing literature so far. Where might the discussion proceed? Organizing the body Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further. To help you come up with an overall organizational framework for your review, consider the following scenario and then three typical ways of organizing the sources into a review: You've decided to focus your literature review on materials dealing with sperm whales. This is because you've just finished reading Moby Dick , and you wonder if that whale's portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980's. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick , so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel. Chronological If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus. By publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies. By trend A better way to organize the above sources chronologically is to examine the sources under another trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Under this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.

Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a "chronological" and a "thematic" approach is what is emphasized the most: the development of the harpoon or the harpoon technology.

But more authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as "evil" in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.

Methodological

A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the "methods" of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Once you've decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

Current Situation : Information necessary to understand the topic or focus of the literature review.

History : The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.

Methods and/or Standards : The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

Once you've settled on a general pattern of organization, you're ready to write each section. There are a few guidelines you should follow during the writing stage as well. Here is a sample paragraph from a literature review about sexism and language to illuminate the following discussion:

However, other studies have shown that even gender-neutral antecedents are more likely to produce masculine images than feminine ones (Gastil, 1990). Hamilton (1988) asked students to complete sentences that required them to fill in pronouns that agreed with gender-neutral antecedents such as "writer," "pedestrian," and "persons." The students were asked to describe any image they had when writing the sentence. Hamilton found that people imagined 3.3 men to each woman in the masculine "generic" condition and 1.5 men per woman in the unbiased condition. Thus, while ambient sexism accounted for some of the masculine bias, sexist language amplified the effect. (Source: Erika Falk and Jordan Mills, "Why Sexist Language Affects Persuasion: The Role of Homophily, Intended Audience, and Offense," Women and Language19:2.

Use evidence

In the example above, the writers refer to several other sources when making their point. A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid.

Be selective

Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the review's focus, whether it is thematic, methodological, or chronological.

Use quotes sparingly

Falk and Mills do not use any direct quotes. That is because the survey nature of the literature review does not allow for in-depth discussion or detailed quotes from the text. Some short quotes here and there are okay, though, if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Notice that Falk and Mills do quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. But if you find yourself wanting to put in more quotes, check with your instructor.

Summarize and synthesize

Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. The authors here recapitulate important features of Hamilton's study, but then synthesize it by rephrasing the study's significance and relating it to their own work.

Keep your own voice

While the literature review presents others' ideas, your voice (the writer's) should remain front and center. Notice that Falk and Mills weave references to other sources into their own text, but they still maintain their own voice by starting and ending the paragraph with their own ideas and their own words. The sources support what Falk and Mills are saying.

Use caution when paraphrasing

When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. In the preceding example, Falk and Mills either directly refer in the text to the author of their source, such as Hamilton, or they provide ample notation in the text when the ideas they are mentioning are not their own, for example, Gastil's. 

Draft in hand? Now you're ready to revise. Spending a lot of time revising is a wise idea, because your main objective is to present the material, not the argument. So check over your review again to make sure it follows the assignment and/or your outline. Then, just as you would for most other academic forms of writing, rewrite or rework the language of your review so that you've presented your information in the most concise manner possible. Be sure to use terminology familiar to your audience; get rid of unnecessary jargon or slang. Finally, double check that you've documented your sources and formatted the review appropriately for your discipline. 

We consulted these works while writing the original version of this handout. This is not a comprehensive list of resources on the handout's topic, and we encourage you to do your own research to find the latest publications on this topic. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. 

Anson, Chris M. and Robert A. Schwegler, The Longman Handbook for Writers and Readers. Second edition. New York: Longman, 2000.

Jones, Robert, Patrick Bizzaro, and Cynthia Selfe. The Harcourt Brace Guide to Writing in the Disciplines. New York: Harcourt Brace, 1997.

Lamb, Sandra E. How to Write It: A Complete Guide to Everything You'll Ever Write. Berkeley, Calif.: Ten Speed Press, 1998.

Rosen, Leonard J. and Laurence Behrens. The Allyn and Bacon Handbook. Fourth edition. Boston: Allyn and Bacon, 2000.

Troyka, Lynn Quitman. Simon and Schuster Handbook for Writers. Upper Saddle River, N.J.: Prentice Hall, 2002.

Originally written and publised by the The Writing Center, University of North Carolina at Chapel Hill

• << Previous: Home
• Next: Types of Research Articles >>
• Last Updated: Oct 16, 2023 1:05 PM
• URL: https://libguides.dominican.edu/PublicHealth

• Reserve a study room
• Library Account
• Undergraduate Students
• Graduate Students
• Faculty & Staff

How to Conduct a Literature Review (Health Sciences and Beyond)

What is a literature review, traditional (narrative) literature review, integrative literature review, systematic reviews, meta-analysis, scoping review.

• Developing a Research Question
• Selection Criteria
• Database Search
• Documenting Your Search
• Organize Key Findings
• Reference Management

Ask Us! Health Sciences Library

The health sciences library.

Call toll-free:  (844) 352-7399 E-mail:   Ask Us More contact information

Related Guides

• Systematic Reviews by Roy Brown Last Updated Oct 17, 2023 513 views this year
• Write a Literature Review by John Glover Last Updated Oct 16, 2023 2721 views this year

A literature review provides an overview of what's been written about a specific topic. There are many different types of literature reviews. They vary in terms of comprehensiveness, types of study included, and purpose. 

The other pages in this guide will cover some basic steps to consider when conducting a traditional health sciences literature review. See below for a quick look at some of the more popular types of literature reviews.

For additional information on a variety of review methods, the following article provides an excellent overview.

Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009 Jun;26(2):91-108. doi: 10.1111/j.1471-1842.2009.00848.x. Review. PubMed PMID: 19490148.

• Next: Developing a Research Question >>
• Last Updated: Mar 15, 2024 12:22 PM
• URL: https://guides.library.vcu.edu/health-sciences-lit-review

News alert: UC Berkeley has announced its next university librarian

Secondary menu

• Log in to your Library account
• Hours and Maps
• Connect from Off Campus
• UC Berkeley Home

Search form

Searching the public health & medical literature more effectively: literature review help.

• Getting Started
• Articles: Searching PubMed This link opens in a new window
• More Sources: Databases, Systematic Reviews, Grey Literature
• Organize Citations & Search Strategies
• Literature Review Help
• Need More Help?

Writing Guides, Manuals, etc.

Literature Review Tips Handouts

Write about something you are passionate about!

• About Literature Reviews (pdf)
• Literature Review Workflow (pdf)
• Search Tips/Search Operators
• Quick Article Evaluation Worksheet (docx)
• Tips for the Literature Review Workflow
• Sample Outline for a Literature Review (docx)

Ten simple rules for writing a literature review . Pautasso M. PLoS Comput Biol. 2013;9(7):e1003149. doi:10.1371/journal.pcbi.1003149

Conducting the Literature Search . Chapter 4 of Chasan-Taber L. Writing Dissertation and Grant Proposals: Epidemiology, Preventive Medicine and Biostatistics. New York: Chapman and Hall/CRC, 2014.

A step-by-step guide to writing a research paper, from idea to full manuscript . Excellent and easy to follow blog post by Dr. Raul Pacheco-Vega.

Data Extraction

Data extraction answers the question “what do the studies tell us?”

At a minimum, consider the following when extracting data from the studies you are reviewing ( source ):

• Only use the data elements relevant to your question;
• Use a table, form, or tool (such as Covidence ) for data extraction;
• Test your methods and tool for missing data elements, redundancy, consistency, clarity.

Here is a table of data elements to consider for your data extraction. (From University of York, Centre for Reviews and Dissemination).

Critical Reading

As you read articles, write notes. You may wish to create a table, answering these questions:

• What is the hypothesis?
• What is the method? Rigorous? Appropriate sample size? Results support conclusions?
• What are the key findings?
• How does this paper support/contradict other work?
• How does it support/contradict your own approach?
• How significant is this research? What is its special contribution?
• Is this research repeating existing approaches or making a new contribution?
• What are its strengths?
• What are its weaknesses/limitations?

From: Kearns, H. & Finn, J. (2017) Supervising PhD Students: A Practical Guide and Toolkit . AU: Thinkwell, p. 103.

Submitting to a Journal? First Identify Journals That Publish on Your Topic

Through Scopus

• Visit the  Scopus database.
• Search for recent articles on your research topic.
• Above the results, click “Analyze search results."
• Click in the "Documents per year by source" box.
• On the left you will see the results listed by the number of articles published on your research topic per journal.

Through Web of Science

• Visit the Web of Science database.
• In the results, click "Analyze Results" on the right hand side.
• From the drop-down menu near the top left, choose "Publication Titles."
• Change the "Minimum record count (threshold)," if desired.
• Scroll down for a table of results by journal title.
• JANE (Journal/Author Name Estimator) Use JANE to help you discover and decide where to publish an article you have authored. Jane matches the abstract of your article to the articles in Medline to find the best matching journals (or authors, or articles).
• Jot (Journal Targeter) Jot uses Jane and other data to determine journals likely to publish your article (based on title, abstract, references) against the impact metric of those journals. From Yale University.
• EndNote Manuscript Matcher Using algorithms and data from the Web of Science and Journal Citation Reports, Manuscript Matcher identifies the most relevant and impactful journals to which one may wish to submit a manuscript. Access Manuscript Matcher via EndNote X9 or EndNote 20.
• DOAJ (Directory of Open Access Journals) Journal Lookup Look up a journal title on DOAJ and find information on publication fees, aims and scope, instructions for authors, submission to publication time, copyright, and more.

Writing Help @UCB

Here is a short list of sources of writing help available to UC Berkeley students, staff, and faculty:

• Purdue OWL Excellent collection of guides on writing, including citing/attribution, citation styles, grammar and punctuation, academic writing, and much more.
• Berkeley Writing: College Writing Programs "Our philosophy includes small class size, careful attention to building your critical reading and thinking skills along with your writing, personalized attention, and a great deal of practice writing and revising." Website has a Writing Resources Database .
• Graduate Writing Center, Berkeley Graduate Division Assists graduate students in the development of academic skills necessary to successfully complete their programs and prepare for future positions. Workshops and online consultations are offered on topics such as academic writing, grant writing, dissertation writing , thesis writing , editing, and preparing articles for publication, in addition to writing groups and individual consultations.
• Nature Masterclass on Scientific Writing and Publishing For Postdocs, Visiting Scholars, and Visiting Student Researchers with active, approved appointments, and current UC Berkeley graduate students who are new to publishing or wish to refresh their skills. Part 1: Writing a Research Paper; Part 2: Publishing a Research Paper; Part 3: Writing and Publishing a Review Paper. Offered by Visiting Researcher Scholar and Postdoc Affairs (VSPA) program; complete this form to gain access.

Alternative Publishing Formats

Here is some information and tips on getting your research to a broader, or to a specialized, audience

• Creating One-Page Reports One-page reports are a great way to provide a snapshot of a project’s activities and impact to stakeholders. Summarizing key facts in a format that is easily and quickly digestible engages the busy reader and can make your project stand out. From EvaluATE .
• How to write an Op-ed (Webinar) Strategies on how to write sharp op-eds for broader consumption, one of the most important ways to ensure your analysis and research is shared in the public sphere. From the Institute for Research on Public Policy .
• 10 tips for commentary writers From UC Berkeley Media Relations’ 2017 Op-Ed writing workshop.
• Journal of Science Policy and Governance JSPG publishes policy memos, op-eds, position papers, and similar items created by students.
• Writing Persuasive Policy Briefs Presentation slides from a UCB Science Policy Group session.
• 3 Essential Steps to Share Research With Popular Audiences (Inside Higher Ed) How to broaden the reach and increase the impact of your academic writing. Popular writing isn’t a distraction from core research!

The Politics of Citation

"One of the feminist practices key to my teaching and research is a feminist practice of citation."

From The Digital Feminist Collective , this blog post emphasizes the power of citing.

"Acknowledging and establishing feminist genealogies is part of the work of producing more just forms of knowledge and intellectual practice."

Here's an exercise (docx) to help you in determining how inclusive you are when citing.

Additional Resources for Inclusive Citation Practices :

• BIPOC Scientists Citation guide (Rockefeller Univ.).
• Conducting Research through an Anti-Racism Lens (Univ. of Minnesota Libraries).
• cleanBib (Code to probabilistically assign gender and race proportions of first/last authors pairs in bibliography entries).
• Balanced Citer (Python script guesses the race and gender of the first and last authors for papers in your citation list and compares your list to expected distributions based on a model that accounts for paper characteristics).
• Read Black women's work;
• Integrate Black women into the CORE of your syllabus (in life & in the classroom);
• Acknowledge Black women's intellectual production;
• Make space for Black women to speak;
• Give Black women the space and time to breathe.
• CiteASista .
• << Previous: Organize Citations & Search Strategies
• Next: Need More Help? >>
• Last Updated: May 10, 2024 11:43 AM
• URL: https://guides.lib.berkeley.edu/publichealth/litsearch

Library Guides

Public Health, Health Management and Health & Social Care

• Journals, databases and critical thinking

What is a literature review?

Choosing a topic, developing your search strategy, carrying out your search, saving and documenting your search, formulating a research question, critical appraisal tools.

• Go to LibrarySearch This link opens in a new window

So you have been asked to complete a literature review, but what is a literature review?

A literature review is a piece of research which aims to address a specific research question. It is a comprehensive summary and analysis of existing literature. The literature itself should be the main topic of discussion in your review. You want the results and themes to speak for themselves to avoid any bias.

The first step is to decide on a topic. Here are some elements to consider when deciding upon a topic:

• Choose a topic which you are interested in, you will be looking at a lot of research surrounding that area so you want to ensure it is something that interests you. 
• Draw on your own experiences, think about your placement or your workplace.
• Think about why the topic is worth investigating.  

Once you have decided on a topic, it is a good practice to carry out an initial scoping search.

This requires you to do a quick search using  LibrarySearch  or  Google Scholar  to ensure that there is research on your topic. This is a preliminary step to your search to check what literature is available before deciding on your question. 

The research question framework elements can also be used as keywords.

• Think about who the population/ sample group. Are you looking for a particular age group, ethnicity, cultural background, gender, health issue etc.
• What is the intervention/issue you want to know more about? This could be a particular type of medication, education, therapeutic technique etc. 
• Do you have a particular context in mind? This could relate to a community setting, hospital, ward etc. 

It is important to remember that databases will only ever search for the exact term you put in, so don't panic if you are not getting the results you hoped for. Think about alternative words that could be used for each keyword to build upon your search. 

Build your search by thinking about about synonyms, specialist language, spellings, acronyms, abbreviations for each keyword that you have.

Inclusion & Exclusion Criteria

Your inclusion and exclusion criteria is also an important step in the literature review process. It allows you to be transparent in how you have  ended up with your final articles. 

Your inclusion/exclusion criteria is completely dependent on your chosen topic. Use your inclusion and exclusion criteria to select your articles, it is important not to cherry pick but to have a reason as to why you have selected that particular article. 

• Search Planning Template Use this template to plan your search strategy.

Once you have thought about your keywords and alternative keywords, it is time to think about how to combine them to form your search strategy. Boolean operators instruct the database how your terms should interact with one another. 

Boolean Operators

• OR can be used to combine your keywords and alternative terms. For example "Social Media OR Twitter". When using OR we are informing the database to bring articles continuing either of those terms as they are both relevant so we don't mind which appears in our article. 
• AND can be used to combine two or more concepts. For example "Social Media AND Anxiety". When using AND we are informing the database that we need both of the terms in our article in order for it to be relevant.
• Truncation can be used when there are multiple possible word endings. For example Nurs* will find Nurse, Nurses and Nursing. 
• Double quotation marks can be used to allow for phrase searching. This means that if you have two or more words that belong together as a phrase the database will search for that exact phrase rather than words separately.  For example "Social Media"

Don't forget the more ORs you use the broader your search becomes, the more ANDs you use the narrower your search becomes. 

One of the databases you will be using is EBSCOHost Research Databases. This is a platform which searches through multiple databases so allows for a comprehensive search. The short video below covers how to access and use EBSCO. 

A reference management software will save you a lot of time especially when you are looking at lots of different articles. 

We provide support for EndNote and Mendeley. The video below covers how to install and use Mendeley. 

Consider using a research question framework. A framework will ensure that your question is specific and answerable.

There are different frameworks available depending on what type of research you are interested in.

Population - Who is the question focussed on? This could relate to staff, patients, an age group, an ethnicity etc.

Intervention - What is the question focussed on? This could be a certain type of medication, therapeutic technique etc. 

Comparison/Context - This may be with our without the intervention or it may be concerned with the context for example where is the setting of your question? The hospital, ward, community etc?

Outcome - What do you hope to accomplish or improve etc.

Sample - as this is qualitative research sample is preferred over patient so that it is not generalised. 

Phenomenon of Interest - reasons for behaviour, attitudes, beliefs and decisions.

Design - the form of research used. 

Evaluation - the outcomes.

Research type -qualitative, quantitative or mixed methods.  

All frameworks help you to be specific, but don't worry if your question doesn't fit exactly into a framework. 

There are many critical appraisal tools or books you can use to assess the credibility of a research paper but these are a few we would recommend in the library. Your tutor may be able to advise you of others or some that are more suitable for your topic.

Critical Appraisal Skills Programme (CASP)

CASP is a well-known critical appraisal website that has checklists for a wide variety of study types. You will see it frequently used by practitioners.

Understanding Health Research

This is a brand-new, interactive resource that guides you through appraising a research paper, highlighting key areas you should consider when appraising evidence.

Greenhalgh, T. (2014) How to read a paper: The basics of evidence-based medicine . 5 th edn. Chichester: Wiley

Greenhalgh’s book is a classic in critical appraisal. Whilst you don’t need to read this book cover-to-cover, it can be useful to refer to its specific chapters on how to assess different types of research papers. We have copies available in the library!

• << Previous: Journals, databases and critical thinking
• Next: Go to LibrarySearch >>
• Last Updated: May 8, 2024 4:26 PM
• URL: https://libguides.gre.ac.uk/health

Library policies | Library Code of Conduct | IT Service Status | Portal © University of Greenwich | FOI | Privacy and cookies | Legal | Terms & conditions

University Library

Public health.

• Getting Started
• Finding Articles
• Find the full text PDF
• Finding Books

Lit Review Tips

Need help writing a literature review, what is a literature review.

• Not sure what 'peer review' means?
• Los Angeles Public Health Data and Statistics
• Health Statistics This link opens in a new window
• Paraphrasing Exercise

Search for the most recent articles that deal with your topic; many of them will summarize the prior literature in the area, saving you valuable time. Remember to attribute even if you paraphrase!

Literature reviews can be overwhelming. You can't find everything. Just find the literature that gets discussed the most or is most relevant to your topic.

The goal of the literature review is to show that you understand the 'bigger picture' and can put your research and recommendations in context of others working in the field.

The literature review: a step-by-step guide for students, by Dr. Diana Ridley

Library North 3rd Floor   LB2369 .R525 2012 

A literature review is an explanation of what has been published on a subject by recognized researchers. Occasionally you will be asked to write one as a separate assignment (sometimes in the form of an annotated bibliography--, but more often it is part of the introduction to a   research report, essay, thesis or dissertation. Critical literature reviews help to write your literature review more effectively: A literature review must do these things: a. be organized around and related directly to the thesis or research question you are developing b. synthesize results into a summary of what is and is not known c. identify areas of controversy in the literature d. formulate questions that need further research Before writing literature review ask yourself questions like these:

1. What is the specific thesis, problem, or research question that my review of literature helps to define?

2. What type of literature review am I conducting? Am I looking at issues of theory? methodology? policy? quantitative research (e.g. on the effectiveness of a new procedure)? qualitative research (e.g., studies )?

3. What is the scope of my literature review? What types of publications am I using (e.g., journals, books, government documents, popular media)? What discipline am I working in (e.g., management , organizational behavior, 

marketing)?

4. How good was my information seeking? Has my search been wide enough to ensure I've found all the relevant material? Has it been narrow enough to exclude irrelevant material? Is the number of sources I've used appropriate for the length of my paper?

5. Have I critically analyzed the literature I use? Do I follow through a set of concepts and questions, comparing items to each other in the ways they deal with them? Instead of just listing and summarizing items, do I assess them, discussing strengths and weaknesses?

6. Have I cited and discussed studies contrary to

my perspective?

7. Will the reader find my literature review relevant, appropriate, and useful?

Tips on writing a literature review (Hart 1998)

• << Previous: Finding Books
• Next: Not sure what 'peer review' means? >>
• Last Updated: Apr 5, 2024 3:09 PM
• URL: https://libguides.calstatela.edu/publichealth

• University of Detroit Mercy
• Health Professions

Health Services Administration

• Writing a Literature Review
• Find Articles (Databases)
• Evidence-based Practice
• eBooks & Articles
• General Writing Support
• Creating & Printing Posters
• Research Project Web Resources
• Statistics: Health / Medical
• Searching Tips
• Streaming Video
• Database & Library Help
• Medical Apps & Mobile Sites
• Faculty Publications

Literature Review Overview

What is a Literature Review? Why Are They Important?

A literature review is important because it presents the "state of the science" or accumulated knowledge on a specific topic. It summarizes, analyzes, and compares the available research, reporting study strengths and weaknesses, results, gaps in the research, conclusions, and authors’ interpretations.

Tips and techniques for conducting a literature review are described more fully in the subsequent boxes:

• Literature review steps
• Strategies for organizing the information for your review
• Literature reviews sections
• In-depth resources to assist in writing a literature review
• Templates to start your review
• Literature review examples

Literature Review Steps

Graphic used with permission: Torres, E. Librarian, Hawai'i Pacific University

1. Choose a topic and define your research question

• Try to choose a topic of interest. You will be working with this subject for several weeks to months.
• Ideas for topics can be found by scanning medical news sources (e.g MedPage Today), journals / magazines, work experiences, interesting patient cases, or family or personal health issues.
• Do a bit of background reading on topic ideas to familiarize yourself with terminology and issues. Note the words and terms that are used.
• Develop a focused research question using PICO(T) or other framework (FINER, SPICE, etc - there are many options) to help guide you.
• Run a few sample database searches to make sure your research question is not too broad or too narrow.
• If possible, discuss your topic with your professor. 

2. Determine the scope of your review

The scope of your review will be determined by your professor during your program. Check your assignment requirements for parameters for the Literature Review.

• How many studies will you need to include?
• How many years should it cover? (usually 5-7 depending on the professor)
• For the nurses, are you required to limit to nursing literature?

3. Develop a search plan

• Determine which databases to search. This will depend on your topic. If you are not sure, check your program specific library website (Physician Asst / Nursing / Health Services Admin) for recommendations.
• Create an initial search string using the main concepts from your research (PICO, etc) question. Include synonyms and related words connected by Boolean operators
• Contact your librarian for assistance, if needed.

4. Conduct searches and find relevant literature

• Keep notes as you search - tracking keywords and search strings used in each database in order to avoid wasting time duplicating a search that has already been tried
• Read abstracts and write down new terms to search as you find them
• Check MeSH or other subject headings listed in relevant articles for additional search terms
• Scan author provided keywords if available
• Check the references of relevant articles looking for other useful articles (ancestry searching)
• Check articles that have cited your relevant article for more useful articles (descendancy searching). Both PubMed and CINAHL offer Cited By links
• Revise the search to broaden or narrow your topic focus as you peruse the available literature
• Conducting a literature search is a repetitive process. Searches can be revised and re-run multiple times during the process.
• Track the citations for your relevant articles in a software citation manager such as RefWorks, Zotero, or Mendeley

5. Review the literature

• Read the full articles. Do not rely solely on the abstracts. Authors frequently cannot include all results within the confines of an abstract. Exclude articles that do not address your research question.
• While reading, note research findings relevant to your project and summarize. Are the findings conflicting? There are matrices available than can help with organization. See the Organizing Information box below.
• Critique / evaluate the quality of the articles, and record your findings in your matrix or summary table. Tools are available to prompt you what to look for. (See Resources for Appraising a Research Study box on the HSA, Nursing , and PA guides )
• You may need to revise your search and re-run it based on your findings.

6. Organize and synthesize

• Compile the findings and analysis from each resource into a single narrative.
• Using an outline can be helpful. Start broad, addressing the overall findings and then narrow, discussing each resource and how it relates to your question and to the other resources.
• Cite as you write to keep sources organized.
• Write in structured paragraphs using topic sentences and transition words to draw connections, comparisons, and contrasts.
• Don't present one study after another, but rather relate one study's findings to another. Speak to how the studies are connected and how they relate to your work.

Organizing Information

Options to assist in organizing sources and information :

1. Synthesis Matrix

• helps provide overview of the literature
• information from individual sources is entered into a grid to enable writers to discern patterns and themes
• article summary, analysis, or results
• thoughts, reflections, or issues
• each reference gets its own row
• mind maps, concept maps, flowcharts
• at top of page record PICO or research question
• record major concepts / themes from literature
• list concepts that branch out from major concepts underneath - keep going downward hierarchically, until most specific ideas are recorded
• enclose concepts in circles and connect the concept with lines - add brief explanation as needed

3. Summary Table

• information is recorded in a grid to help with recall and sorting information when writing
• allows comparing and contrasting individual studies easily
• purpose of study
• methodology (study population, data collection tool)

Efron, S. E., & Ravid, R. (2019). Writing the literature review : A practical guide . Guilford Press.

Literature Review Sections

• Lit reviews can be part of a larger paper / research study or they can be the focus of the paper
• Lit reviews focus on research studies to provide evidence
• New topics may not have much that has been published

* The sections included may depend on the purpose of the literature review (standalone paper or section within a research paper)

Standalone Literature Review (aka Narrative Review):

• presents your topic or PICO question
• includes the why of the literature review and your goals for the review.
• provides background for your the topic and previews the key points
• Narrative Reviews: tmay not have an explanation of methods.
• include where the search was conducted (which databases) what subject terms or keywords were used, and any limits or filters that were applied and why - this will help others re-create the search
• describe how studies were analyzed for inclusion or exclusion
• review the purpose and answer the research question
• thematically - using recurring themes in the literature
• chronologically - present the development of the topic over time
• methodological - compare and contrast findings based on various methodologies used to research the topic (e.g. qualitative vs quantitative, etc.)
• theoretical - organized content based on various theories
• provide an overview of the main points of each source then synthesize the findings into a coherent summary of the whole
• present common themes among the studies
• compare and contrast the various study results
• interpret the results and address the implications of the findings
• do the results support the original hypothesis or conflict with it
• provide your own analysis and interpretation (eg. discuss the significance of findings; evaluate the strengths and weaknesses of the studies, noting any problems)
• discuss common and unusual patterns and offer explanations
•  stay away from opinions, personal biases and unsupported recommendations
• summarize the key findings and relate them back to your PICO/research question
• note gaps in the research and suggest areas for further research
• this section should not contain "new" information that had not been previously discussed in one of the sections above
• provide a list of all the studies and other sources used in proper APA 7

Literature Review as Part of a Research Study Manuscript:

• Compares the study with other research and includes how a study fills a gap in the research.
• Focus on the body of the review which includes the synthesized Findings and Discussion

Literature Reviews vs Systematic Reviews

Systematic Reviews are NOT the same as a Literature Review:

Literature Reviews:

• Literature reviews may or may not follow strict systematic methods to find, select, and analyze articles, but rather they selectively and broadly review the literature on a topic
• Research included in a Literature Review can be "cherry-picked" and therefore, can be very subjective

Systematic Reviews:

• Systemic reviews are designed to provide a comprehensive summary of the evidence for a focused research question
• rigorous and strictly structured, using standardized reporting guidelines (e.g. PRISMA, see link below)
• uses exhaustive, systematic searches of all relevant databases
• best practice dictates search strategies are peer reviewed
• uses predetermined study inclusion and exclusion criteria in order to minimize bias
• aims to capture and synthesize all literature (including unpublished research - grey literature) that meet the predefined criteria on a focused topic resulting in high quality evidence

Literature Review Examples

• Breastfeeding initiation and support: A literature review of what women value and the impact of early discharge (2017). Women and Birth : Journal of the Australian College of Midwives
• Community-based participatory research to promote healthy diet and nutrition and prevent and control obesity among African-Americans: A literature review (2017). Journal of Racial and Ethnic Health Disparities

• Vitamin D deficiency in individuals with a spinal cord injury: A literature review (2017). Spinal Cord

Resources for Writing a Literature Review

These sources have been used in developing this guide.

Resources Used on This Page

Aveyard, H. (2010). Doing a literature review in health and social care : A practical guide . McGraw-Hill Education.

Purdue Online Writing Lab. (n.d.). Writing a literature review . Purdue University. https://owl.purdue.edu/owl/research_and_citation/conducting_research/writing_a_literature_review.html

Torres, E. (2021, October 21). Nursing - graduate studies research guide: Literature review. Hawai'i Pacific University Libraries. Retrieved January 27, 2022, from https://hpu.libguides.com/c.php?g=543891&p=3727230

• << Previous: General Writing Support
• Next: Creating & Printing Posters >>
• Last Updated: Apr 19, 2024 3:11 PM
• URL: https://udmercy.libguides.com/hsa

• Systematic Review
• Open access
• Published: 10 May 2023

What is public health? a scoping review

• Razieh Azari 1 &
• Bettina Borisch 1 , 2  

Archives of Public Health volume  81 , Article number:  86 ( 2023 ) Cite this article

6587 Accesses

3 Citations

21 Altmetric

Metrics details

during the last hundred years, several major public health issues have already afflicted humanity. Most frequently cited definitions of public health have stemmed from long-standing definitions, which raises several concerns including whether these definitions can respond to today’s public health challenges. The present study aimed to identify and review available public health definitions in the first place.

in this scoping review, we undertook an electronic search in four databases (PubMed, Web of Science, Embase, and EBSCOhost) from inception until June 06, 2022, and a grey literature search in Google Scholar. Moreover, reference lists of publications included in the scoping review were screened manually for additional relevant publications. All types of scientific publications, in English, that focused on the definition of public health and provided an original definition were included. Year, type, disciplinary fields of publications, objectives of publications, and public health definitions were extracted.

5651 publications were identified through the scoping search, of which five were subjected to full-text review. Of these publications, two were included. An additional nine publications were identified through the manual screening. A total 11 of publications were included in the scoping review. Of the 11 definitions included in this review, the latest original definitions date back to about two decades ago.

Conclusions

there is a noticeable lack of updated definitions of public health. Considering our findings and the ever-changing nature of public health issues, there is an urgent need for re-assessing and updating public health definitions.

Peer Review reports

What is public health? It is a challenging concept that perhaps no single definition will satisfy everyone [ 1 , 2 , 3 , 4 , 5 ]. A national telephone survey of 1234 registered voters conducted in the United States (US) in 1999 found that over half of the respondents misunderstood the term public health [ 6 ]. The efforts to define the term public health can be traced back to a century ago to Charles-Edward A. Winslow’s definition which later Sir Donald Acheson in 1988 built on it and put forward his definition as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” [ 7 , 8 ]. Winslow’s definition is considered one of the most commonly cited definitions of public health [ 9 ]. It is still considered valid today [ 2 ]. Winslow’s influence can still be seen in many contemporary definitions of public health [ 1 ]. In 2011, a concept paper of the World Health Organization (WHO) European Region which investigated several definitions of public health from a selection of key stakeholders concluded that Acheson’s definition can be a useful point of departure [ 8 , 10 ].

Several studies insisted on the important role of public health definition [ 9 , 10 ]. According to the Pan American Health Organization (PAHO), [ 9 ]. the definition of public health strengthens public health. “Operationalising activities, intelligence, systems, skills and competencies for public health is consequent on the definition of public health” [ 10 ]. A clear definition of public health helps people who work in, are served by, or study the system to sort out its components, understand it, and work to improve it [ 4 ].

During the last hundred years, several major epidemics and pandemics have afflicted humanity. Currently, the world has been confronting Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) causing Coronavirus disease 2019 (COVID-19). Since December 2019 when the first cases of COVID-19 have emerged in Wuhan, China, this novel infectious disease has spread to millions of people worldwide [ 11 ]. The outbreak of COVID-19 was characterized as a pandemic by WHO on 11 March 2020 [ 11 ]. In addition to these major public health issues, there are new phenomena such as atmospheric warming, sea level rise, mountain glacier loss, and ocean acidification [ 12 ]. These phenomena lead to extreme weather events such as storms, floods, droughts, heatwaves, fires, and many more, which threaten the lives of billions of people around the world [ 12 ]. Whether these new phenomena can be considered and called public health issues depends on the definition of public health [ 1 ]. Needless to say, by considering a phenomenon as a public health issue, attention is drawn to the fact that such an issue is common or increasing within a population [ 1 ]. Calling a phenomenon public health issue could highlight the fact that such an issue does not solely depend on individual actions but is influenced by other conditions including socio-economic situations [ 1 ]. When a phenomenon is considered a public health issue, it might trigger the idea that it should be treated differently, perhaps through collective or governmental rather than individual action [ 1 ]. Prioritisation and treatment with a particular urgency could be expected when a phenomenon is labelled as a public health issue [ 1 ]. These consequences are not exclusive and many more can be expected [ 1 ].

The concept of public health is not fixed and has been changing over time [ 9 , 13 ]. What is included in public health has been evolving in accordance with our understanding of reality and the instruments available for intervention [ 9 , 5 ]. Due to the complexity of public health in today’s world, it is a multifaceted concept in constant flux [ 9 ]. “All the different facets of this concept deserve to be examined carefully from all possible angles, as they manifest themselves through the many different ways in which they are defined and acted on” [ 9 ]. The ever-changing nature of public health requires a continuous need for reassessing and updating its definition [ 14 ]. Recently, Nutbeam and Muscat talked about Health Promotion Glossary 2021 which is the first full review and revision of the first Health Promotion Glossary commissioned by the WHO in 1986, fully revised in 1998 [ 15 , 16 , 17 ]. “This revision provides an updated overview of the many ideas and concepts which are central to contemporary health promotion” [ 15 ]. One of the definitions modified in this revision was public health [ 15 ]. However, this modified definition is taken from the Dictionary of Public Health published in 2007 [ 18 ].

This background leads us to a consideration of whether current definitions stemming from long-standing definitions can respond to today’s public health challenges. Before taking this point into consideration, we needed to identify and review available public health definitions, which was the objective of the current study. To achieve this objective, a scoping review of the literature was conducted, which is discussed in detail in the next section.

Search strategy and selection criteria

A scoping review of peer-reviewed and grey literature was conducted to identify available public health definitions. This review was prepared according to the framework of the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines [ 19 ].

In order to gain familiarity with the previous studies and aid with the identification of key concepts and words, several preliminary searches were conducted. Then, four databases including PubMed (from its inception until June 06, 2022), Web of Science (from its inception until June 06, 2022), EBSCOhost (from its inception until June 06, 2022), and Embase (from its inception until June 08, 2022) were searched to identify relevant literature. Grey literature was searched using Google Scholar (from its inception until June 06, 2022) and the first 100 search results sorted by relevance were compared against the inclusion criteria. Moreover, reference lists of publications included in the scoping review were screened manually for additional relevant publications. No language restriction was applied at this stage.

The search for the relevant literature was conducted using the following keywords in the title and abstract of the literature: “public”, “health”, “definition”, and “meaning”. The final search results were exported into an Excel spreadsheet, and duplicates were removed.

Publications were included if they satisfied all of the following eligibility criteria: (1) All types of scientific publications such as articles, editorials, viewpoints, guidelines, etc.; (2) English-language publications providing an original definition of public health.

The selection of relevant publications was conducted in three stages: (1) Screening of the title and abstract conducted by the first author (RA); (2) Full text screening completed independently by the first and second authors (RA and BB). Raised discrepancies resolved through discussion until consensus was reached; and (3) data extraction and collation. These stages were summarized in the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) flow diagram (see Fig.  1 ).

Flow diagram of the scoping review process (from inception until June 06, 2022) based on the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) [ 19 ]

Figure  1 : Flow diagram of the scoping review process (from inception until June 06, 2022) based on the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) [ 19 ]

Data analysis

Eligible publications were reviewed by RA and BB independently and the following data were extracted: Title, author(s), year of publication, country/region, type of publication, disciplinary fields of publications, aims and objectives of the publication, and public health definitions (see Table  1 ). Discrepancies were resolved through discussion until a consensus was reached.

The electronic searches conducted in the above-mentioned databases identified a total of 5651 publications, resulting in 3675 unique publications to be screened for inclusion following the removal of duplicates (see Fig.  1 ). Based on the eligibility criteria, the titles and abstracts were assessed for their relevance, resulting in five publications being retained. Of these, two publications were excluded as their abstracts and full texts were not available [ 20 , 21 ]. The full texts of the remaining publications, three publications, were obtained and after applying the eligibility criteria, one publication was excluded as it did not introduce a new definition of public health [ 22 ]. Therefore, two publications were included [ 14 , 23 ]. An additional nine publications were identified through the manual screening [ 4 , 7 , 8 , 9 , 24 , 25 , 26 , 27 , 28 ]. A total 11 of publications were included in the scoping review (see Fig.  1 ). Characteristics of the included publications are shown in Table  1 .

Of the 11 publications included in this review, six publications were original research articles published in 1920, 2001, 2002, and 2003 [ 7 , 26 , 27 , 28 , 14 , 23 ]. Four publications were books published in 1988, 1999, and 2002 [ 8 , 4 , 25 , 9 ]. One publication was a report published in 1998 [ 24 ]. All the publications were authored in North America and Europe mainly. Disciplinary fields of the publications included health, public health, medicine, law, ethics, bioethics, and human rights (see Table  1 ).

Of the 11 publications included in this review, only two publications set providing a new definition of public health as the aim and objective of their studies [ 14 , 23 ]. Formulating scopes and tendencies of modern public health, reviewing the future development of the public health function, analysing the public health situation in the US and presenting an action plan for a strong public health capability, providing expert assessments of the global health situation and projecting health trends, providing new health for all policy framework, investigating the use of research-based information in public health practice, providing a greater understanding of the related fields of public health, ethics, and human rights, providing a conceptual map of the terrain of public health ethics, and reflecting on public health in the context of Americas were stated as the aims and objectives of the other publications (see Table  1 ).

All the publications under review provided explicit definitions. All the definitions which are provided in Table  1 were formulated by their authors without any references to other definitions.

The publications under review reported several rationales for providing a new definition of public health. Winslow sought to provide a more inclusive definition [ 7 ]. “If the foregoing outline of the problems of public health be accepted as correct, it will be obvious that the field as thus visualized is no small and restricted one” [ 7 ] …. “If we are looking to the future we must conceive our subject in terms no smaller than those of the [provided] definition” [ 7 ]. Acheson looked for a wide definition of the term public health [ 8 ]. In the past, public health has been rather narrowly interpreted and associated with sanitary hygiene and epidemic disease control [ 8 ]. He preferred a broader definition which gives “as much weight to the importance of lifestyle as to environmental hygiene in the preservation and promotion of health” [ 8 ]. Institute of Medicine believed that understanding of public health should not be restricted to what health departments do [ 4 ]. A clear definition helps those who work in, are served by, or study the system to understand it and work to improve its performance [ 4 ]. The need for expanding and clarifying the meaning of public health based on public health challenges was another rationale stated by PAHO [ 9 ]. Traditional cornerstones of public health such as prevention and control of communicable diseases or environmental sanitation continue to be important; however, current definitions of public health should include much more [ 9 ]. Moreover, defining public health in terms of what the government does is no longer sufficient [ 9 ]. “Government should in fact play a central and fundamental role in public health today. However, not everything that government does in terms of health can be regarded as public health, just as public health cannot remain limited to government action” [ 9 ]. Rothstein sought to narrow the scope of public health definition and opposed using “the term “public health” as an open-ended descriptor of widely divergent efforts to improve the human condition” [ 14 ]. There is an ongoing need to reassess scientific, ethical, legal, and social underpinnings of public health as it evolves [ 15 ]. However, considering so many activities as public health just because they interfere with the health of individuals and populations does not mean that eliminating them is part of the mission of public health and can solve the problem of poor health [ 14 ]. Broad definition of public health will not eliminate forms of human privations to call them public health issues [ 14 ]. Heller and colleagues’ rationale was to offer a broader and more inclusive definition which helps public health professionals interpret their own roles [ 23 ]. They tried to provide a wider definition of public health by recognizing the centrality of the public [ 23 ]. “The practice of public health has been criticized as being too involved with a narrow, managerial agenda focused on health care rather than the wider horizons of public good” [ 23 ]. Moreover, they attempted to produce a clear definition that “meets the expectations of those who work in the discipline and the public to whom they are accountable” [ 23 ].

This scoping review was conducted to identify available public health definitions. While previous studies have emphasized the importance of re-assessing and updating definitions of public health, [ 1 , 10 ] the results of the present study indicated a noticeable lack of updated definitions. Of the 11 definitions included in this review, the latest original definitions date back to about 20 years ago. During the last two decades, the world has witnessed the emergence and reemergence of viral outbreaks of Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) in 2002, Influenza A virus subtype H1N1 (A/H1N1) in 2009, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in 2012, Ebola virus in 2013, and the SARS-CoV-2 in 2019 [ 29 , 30 ]. Findings of the study led us to a consideration of whether current definitions can fully respond to today’s public health challenges. The situation could be more challenging as public health is a “concept with shifting parameters and multiple interpretations” [ 10 ]. Scholars have insisted on the fact that public health is in constant flux [ 1 , 9 , 13 ]. Considering the findings of the study and the ever-changing nature of public health issues, it can be argued that there is an urgent need for re-assessing and updating public health definitions.

In the last twenty years, new phenomena, such as global warming and climate change, affect the health and well-being of billions of people around the world. Considering these phenomena as public health issues could lead to increased attention, prioritization, different treatment, and many more actions [ 1 ]. Whether these new phenomena can be considered and called public health issues depends on the definition of public health [ 1 ]. Therefore, it seems that updating public health definitions is needed.

The results indicated that the definition of public health plays a crucial role in reaching objectives such as analysing public health situations locally and globally, providing policies and action plans, and many more. This result was in accordance with what previous studies insisted on, which is the important role of public health definition in understanding, shaping, and strengthening public health [ 4 , 9 ]. It can be argued that updating public health definition is needed as an outdated definition might not be able to fulfil such an important role.

According to the findings of the study, a “narrow–broad distinction” [ 1 ] can be drawn between the identified public health definitions. One group of the definitions was provided to present a narrow approach, while the other group was provided to present a broad one. Narrow definitions focus more on health factors such as sanitation, infectious disease control, screening programmes, or health education [ 1 ]. Broad definitions deal with all of the factors that might affect health, including societal, cultural, and economic determinants of health [ 1 , 14 , 31 ]. Rickles called this distinction “local’ and ‘nonlocal’ since they concern factors that act directly on individuals in the former case and more indirectly in the latter case” [ 5 ].

According to the findings of the study, eight out of the 11 publications included in this review were authored in higher-income countries. In other words, the majority of available public health definitions were authored in higher-income countries, which may unevenly illustrate the interests and priorities of stakeholders from higher-income countries. The findings suggest a need for greater diversity and inclusion in providing definitions of public health.

Health, medicine, law, ethics, bioethics, and human rights were the disciplinary fields of the publications included in this review, which could be due to the fact that public health is a massively interdisciplinary field, incorporating epidemiology, biology, sociology, economics, psychology, and more [ 5 ].

The present study has the strength of being the first scoping review conducted to identify available public health definitions. However, the limitations of our study need to be considered. One limitation of our study is that only publications focused on definition of public health were included, which might lead to the absence of studies which provided a new definition of public health without focusing on the subject matter exclusively. Manual screening of reference lists of publications included in the scoping review was used to add relevant publications that had not been initially identified through database searching. This ensured that the review was exhaustive. However, it means that some conclusions may have been influenced by this manual search strategy. Despite not restricting the language of publication, only English keywords were searched, which could lead to the exclusion of non-English publications providing public health definitions. Another limitation is that only publications written in English were included. Future reviews should include non-English studies to have a better understanding of the situation.

Most frequently cited definitions of public health stemmed from long-standing definitions. Despite the emphasis on the importance of re-assessing and updating definitions of public health, there is a noticeable lack of updated definitions. This lack raises several concerns including responding to today’s public health challenges. Considering previous studies, the findings of this study, and the ever-changing nature of public health issues, there is an urgent need for re-assessing and updating public health definitions. Future studies could focus on providing new definitions that fit the present global society.

Data Availability

All data generated or analysed during this study are included in this published article.

Abbreviations

The United States

The World Health Organization

The Pan American Health Organization

Coronavirus disease 2019

Verweij M, Dawson A. The meaning of ‘public’ in ‘public health’. In: Dawson A, Verweij M, editors. Ethics, prevention, and public health. Oxford: Oxford University Press; 2007. pp. 13–29.

Google Scholar  

Schneider MJ, Schneider HS. Introduction to public health. 5th ed. Burlington, Massachusetts: Jones & Bartlett Learning; 2017.

Turnock BJ. Public health: what it is and how it works. 6th ed. Burlington, Massachusetts: Jones & Bartlett Learning; 2016.

Institute of Medicine (US) Committee for the Study of the Future of Public Health. The future of public health. Washington (DC): National Academies Press (US); 1988. https://www.ncbi.nlm.nih.gov/books/NBK218218/ . Accessed 11 April 2022.

Rickles D. Public health. Gifford F. Handbook of the philosophy of science, philosophy of medicine.North-Holland; 2011. 523–72.

Centers for Disease Control and Prevention (CDC). Public opinion about public health–United States, 1999. MMWR Morb Mortal Wkly Rep. 2000 Mar;31(12):258–60.

Winslow CEA. The untilled fields of public health. Sci 1920 Jan 9;51(1306):23–33.

Acheson D. Public health in England. The report of the committee of inquiry into the future development of the public health function. London: HMSO; 1988.

Pan-American Health Organization. Public health in the Americas: conceptual renewal, performance assessment, and bases for action. Washington, D.C; 2002.

Marks L, Hunter DJ, Alderslade R. Strengthening public health capacity and services in Europe: a concept paper. Copenhagen: WHO Regional Office for Europe; 2011.

World Health Organization: WHO Director-General’s opening remarks at the media briefing on COVID-19–11. March 2020. https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 (2020). Accessed 29 May 29, 2022.

IPCC. Summary for Policymakers. In: IPCC Special Report on the Ocean and Cryosphere in a Changing Climate [H- O Pörtner, Roberts DC, Masson-Delmotte V, Zhai P, Tignor M, Poloczanska E, Mintenbeck K, Nicolai M, Okem A, Petzold J, Rama B. N Weyer, eds.]; 2019. In press.

Mold A, Clark P, Millward G, Payling D. The public and public health. In: Placing the public in public health in post-war Britain, 1948–2012. Cham: Springer International Publishing; 2019. http://link.springer.com/ https://doi.org/10.1007/978-3-030-18685-2_2 Accessed 10 May 2022.

Rothstein MA. Rethinking the meaning of public health. J Law Med Ethics. 2002;30(2):144–9.

Article   PubMed   Google Scholar  

Nutbeam D, Muscat DM. Health promotion glossary 2021. Health Promot Int. 2021 Dec 23;36(6):1811–1811. doi: https://doi.org/10.1093/heapro/daab067 .

Nutbeam D. Health promotion glossary. Health Promot Int. 1986;1(1):113–27. https://doi.org/10.1093/heapro/1.1.113 .

Article   CAS   Google Scholar  

Nutbeam D. Health promotion glossary. Health Promot Int. 1998 Jan 1;13(4):349–64. doi: https://doi.org/10.1093/heapro/13.4.349 .

Last JM. Dictionary of public health. Oxford: Oxford University Press; 2007.

Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009 Jul;21(7):e1000097.

Ballabeni A. The definition of public health - where to shift the focus: prevention or population? Perspect Public Health. 2015 Jul;135(4):166.

Ellencweig AY, Yoshpe RB. Definition of public health. Public Health Rev. 1984;12:65–78.

CAS   PubMed   Google Scholar  

Kitaw Y, Assefa M, Bulto T, Kaba M, Yigzaw T, Worku S. Issues in the definition and philosophy of public health in relation to core competencies. Ethiop J Health Dev. 2020;34:34–8.

Heller RF, Heller TD, Pattison S. Putting the public back into public health. Part I. A re-definition of public health. Public Health. 2003 Jan;117(1):62–5.

World Health Organization. The World health report: 1998: life in the 21st century: a vision for all: report of the Director-General. Geneva: World Health Organization; 1998.

World Health Organization. Health21: the health for all policy framework for the WHO European Region. Copenhagen: World Health Organization, Regional Office for Europe; 1999.

Forsetlund L, Bjørndal A. The potential for research-based information in public health: identifying unrecognised information needs. BMC Public Health. 2001 Dec;1(1):1.

Gostin LO. Public health, ethics, and human rights: a tribute to the late Jonathan Mann. J Law Med Ethics. 2001;29(2):121–30.

Article   CAS   PubMed   Google Scholar  

Childress JF, Faden RR, Gaare RD, Gostin LO, Kahn J, Bonnie RJ, et al. Public Health Ethics: mapping the terrain. J Law Med Ethics. 2002;30(2):170–8.

Piret J, Boivin G. Pandemics throughout history. Front Microbiol 2021 Jan 15;11:631736.

Coltart CEM, Lindsey B, Ghinai I, Johnson AM, Heymann DL. The Ebola outbreak, 2013–2016: old lessons for new epidemics. Philos Trans R Soc Lond B Biol Sci. 2017 May;26(1721):20160297.

Cabaj JL, Musto R, Ghali WA. Public health: who, what, and why? Can J Public Health 2019 Jun 19;110(3):340–3.

Download references

Acknowledgements

Not applicable.

Open access funding provided by University of Geneva.

Author information

Authors and affiliations.

Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, 1202, Switzerland

Razieh Azari & Bettina Borisch

World Federation of Public Health Associations, WFPHA, Geneva, Switzerland

Bettina Borisch

You can also search for this author in PubMed   Google Scholar

Contributions

BB conceived the study aims. RA undertook the title and abstract screening. RA and BB undertook full-text screening, data extraction, and data analysis. RA drafted the initial manuscript and BB edited the initial draft. All authors interpreted the results and provided critical comments on the manuscript. All authors had full access to all the data in the study and had final responsibility for the decision to submit publication.“

Corresponding author

Correspondence to Razieh Azari .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Azari, R., Borisch, B. What is public health? a scoping review. Arch Public Health 81 , 86 (2023). https://doi.org/10.1186/s13690-023-01091-6

Download citation

Received : 09 November 2022

Accepted : 15 April 2023

Published : 10 May 2023

DOI : https://doi.org/10.1186/s13690-023-01091-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Public health
• Public health definition
• Public health meaning
• Scoping review

Archives of Public Health

ISSN: 2049-3258

• General enquiries: [email protected]

• Open access
• Published: 14 May 2024

Research outcomes informing the selection of public health interventions and strategies to implement them: A cross-sectional survey of Australian policy-maker and practitioner preferences

• Luke Wolfenden 1 , 2 , 3 ,
• Alix Hall 1 , 2 , 3 ,
• Adrian Bauman 1 , 4 , 5 ,
• Andrew Milat 6 , 7 ,
• Rebecca Hodder 1 , 2 , 3 ,
• Emily Webb 1 ,
• Kaitlin Mooney 1 ,
• Serene Yoong 1 , 2 , 3 , 8 , 9 ,
• Rachel Sutherland 1 , 2 , 3 &
• Sam McCrabb 1 , 2 , 3  

Health Research Policy and Systems volume  22 , Article number:  58 ( 2024 ) Cite this article

Metrics details

A key role of public health policy-makers and practitioners is to ensure beneficial interventions are implemented effectively enough to yield improvements in public health. The use of evidence to guide public health decision-making to achieve this is recommended. However, few studies have examined the relative value, as reported by policy-makers and practitioners, of different broad research outcomes (that is, measures of cost, acceptability, and effectiveness). To guide the conduct of research and better inform public health policy and practice, this study aimed at describing the research outcomes that Australian policy-makers and practitioners consider important for their decision-making when selecting: (a) public health interventions; (b) strategies to support their implementation; and (c) to assess the differences in research outcome preferences between policy-makers and practitioners.

An online value-weighting survey was conducted with Australian public health policy-makers and practitioners working in the field of non-communicable disease prevention. Participants were presented with a list of research outcomes and were asked to select up to five they considered most critical to their decision-making. They then allocated 100 points across these – allocating more points to outcomes perceived as more important. Outcome lists were derived from a review and consolidation of evaluation and outcome frameworks in the fields of public health knowledge translation and implementation. We used descriptive statistics to report relative preferences overall and for policy-makers and practitioners separately.

Of the 186 participants; 90 primarily identified as policy-makers and 96 as public health prevention practitioners. Overall, research outcomes of effectiveness, equity, feasibility, and sustainability were identified as the four most important outcomes when considering either interventions or strategies to implement them. Scores were similar for most outcomes between policy-makers and practitioners.

For Australian policy-makers and practitioners working in the field of non-communicable disease prevention, outcomes related to effectiveness, equity, feasibility, and sustainability appear particularly important to their decisions about the interventions they select and the strategies they employ to implement them. The findings suggest researchers should seek to meet these information needs and prioritize the inclusion of such outcomes in their research and dissemination activities. The extent to which these outcomes are critical to informing the decision of policy-makers and practitioners working in other jurisdictions or contexts warrants further investigation.

Peer Review reports

Research evidence has a key role in public health policy-making [ 1 ]. Consideration of research is important to maximize the potential impact of investments in health policies and services. Public health policy-makers and practitioners frequently seek out research to inform their professional decision-making [ 2 ]. However, they report that published research is not well aligned with their evidence needs [ 3 , 4 ]. Public health decision-making is a complex and dynamic process where evidence is used in a variety of ways, and for different purposes [ 3 , 5 , 6 ]. Ensuring research meets the evidence needs of public health policy-makers and practitioners is, therefore, an important strategy to improve its use in decision-making [ 7 , 8 , 9 , 10 ].

“Research outcomes” are broad domains or constructs measured to evaluate the impacts of health policies, practices or interventions, such as their effectiveness or acceptability. They are distinct from “outcome measures”, which are the measures selected to assess an outcome. Outcome measures require detailed specification of measurement parameters, including the measurement techniques and instrument, and consideration of the suitability of its properties (for example, validity) given the research question. The inclusion of research outcomes considered most relevant to public health policy-makers and practitioners is one way in which researchers can support evidence-informed decision-making.

Policy-makers are primarily responsible for developing public health policy and selecting and resourcing health programs. Practitioners are primarily responsible for supporting their implementation. As such, public health policy-makers and practitioners require research to: (i) help identify “what works” to guide the selection of interventions that will be beneficial for their community, for example, those that are effective in improving health, and acceptable to the target population and/or (ii) to help identify “how to implement” effective intervention, for example, strategies that are capable of achieving implementation at a level sufficient to accrue benefit, are affordable and reach the targeted population [ 6 , 11 ]. Research that includes outcomes relevant to these responsibilities facilitates evidence-informed decision-making by public health policy-makers and practitioners.

Initiatives such as the World Health Organization INTEGRATe Evidence (WHO INTEGRATE) framework [ 12 ], and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision framework [ 13 ] have been designed to support the selection of public health interventions. Application of these frameworks required the collation and synthesis of a range of scientific evidence including studies employing qualitative and quantitative research designs. Collectively, the frameworks suggest public health policy-makers and practitioners should consider, alongside research outcomes reporting the effectiveness of a public health intervention, other research outcomes such as cost–effectiveness, potential harms and acceptability of an intervention to patients or community.

Several authors have also sought to guide outcomes researchers should include in implementation studies [ 11 ]. Proctor and colleagues defined a range of implementation research outcomes [distinct from service or clinical (intervention) effectiveness outcomes] – including intervention adoption, appropriateness, feasibility, fidelity, cost, penetration and sustainability [ 14 ]. This work helped standardize how the field of implementation science defined, measured and reported implementation outcomes. More recently McKay and colleagues put forward measures of implementation “determinants” and “outcomes” and proposed a “minimum set” of such outcomes to include in implementation and scale-up studies. The implementation research outcomes proposed by both Proctor and McKay and colleagues were developed primarily from the input of researchers to improving the quality and consistency of reporting in implementation science. However, the relative value of these outcomes to the decision-making of public health policy-makers, and in particular practitioners, has largely been unexplored.

While several studies have explored policy-maker and practitioner research evidence preferences, these have focused on a small number of potential outcomes [ 15 , 16 , 17 ]. An appraisal of the potential value, and importance of a comprehensive range of research outcomes to public health policy-maker and practitioner decision-making, therefore, is warranted. In this study, we sought to quantify the relative importance of research outcomes from the perspective of Australian public health policy-makers and practitioners working in the field of non-communicable disease prevention (hereafter referred to as “prevention” policy-makers or practitioners). Specifically, using a value-weighting methodology to elicit relative preferences, the study aimed to describe: (a) research the outcomes prevention policy-makers and practitioners regard as important to their decision-making when selecting a public health intervention to address an identified health issue, (b), research the outcomes prevention policy-makers and practitioners regard as important to their decision-making when selecting a strategy to support the implementation of a public health intervention in the community and (c) assess the differences between prevention policy-makers and practitioners regarding their research outcome preferences.

Design and setting

An online cross-sectional value-weighting survey was conducted with Australian public health prevention policy-makers and practitioners. This study was undertaken as one step of a broader program of work to establish a core outcome set that has been prospectively registered on the Core Outcome Measures in Effectiveness Trials (COMET database; https://www.comet-initiative.org/Studies/Details/1791 ).

Participant eligibility

To be eligible, participants had to self-identify as having worked as a public health prevention policy-maker or practitioner at a government or non-government health organization within the past 5 years. While the term “policy-maker” has been used to describe legislators in US studies, in Australian research it has broadly been used to describe employees of government departments (or non-government agencies) involved in the development of public health policy [ 18 , 19 , 20 , 21 , 22 ]. Policy-makers are not typically involved in the direct implementation of policy or the delivery of health services. We defined a “policy-maker” as a professional who makes decisions, plans and actions that are undertaken to achieve specific public health prevention goals on behalf of a government or non-government organization [ 23 ]. Practitioners are typically employed by government or non-government organizations responsible for prevention service provision, and are directly involved in the implementation or supporting the implementation of public health policies or programs. Specifically, we defined a “practitioner” as a professional engaged in the delivery of public health prevention programs, implementing services or models of care in health and community settings (definition developed by research team). Research and evaluation are a core competency of the public health prevention workforce in Australia [ 24 ], as it is in other countries [ 25 ]. As such, participants may be engaged in research and have published research studies. Researchers, such as those employed by academic institutions only and without an explicit public health policy or practice role in a policy or practice organization, were excluded.

Recruitment

Comprehensive methods were used to recruit individuals through several agencies. First, email invitations were distributed to Australian government health agencies at local (for example, New South Wales Local Health District Population Health units), state (for example, departments or ministries of health) and national levels, as well as to non-government organizations (for example, Cancer Council) and professional societies (for example, Public Health Association Australia). Registered practitioners with the International Union for Health Promotion and Education (IUHPE) from Australia were contacted by public domain emails or on LinkedIn (where identified) with the study invitation. Authors who had published articles of relevant topics from 2018 to 2021 within three Australian public health journals [ Australian and New Zealand Journal of Public Health ( ANZJPH ), Health Promotion Journal of Australia ( HPJA ) and Public Health Research and Practice ( PHRP )] were invited to participate in the study. Invitation emails included links to the information statement for participants and the online survey. The online survey was also promoted on the social media account of a partnering organization [National Centre of Implementation Science (NCOIS)] as well as on Twitter and LinkedIn. From these social media accounts individuals could self-select to participate in the online survey. Reminder emails were sent to non-responders at approximately 2 and 4 weeks following the initial email invitation.

Data collection and measures

The online survey was kept on servers at the Hunter Medical Research Institute, New South Wales, Australia, and deployed using the REDCap software [ 26 ], a secured web-based application for building and managing online surveys and databases. The length of the survey was approximately 20–30 min in duration.

Professional characteristics

Participants completed brief items assessing their professional role (that is, practitioner or policy-maker), the number of years’ experience as policy-makers or practitioners, their professional qualifications and the prevention risk factors (for example, smoking, nutrition, physical activity, injury, sexual health, etc.) for which they had expertise.

Valued intervention and implementation outcomes

We sought to identify outcomes that may be valued by public health policy-makers and practitioners when making decisions about what policies and/or programs of interventions to implement and how implementation could best occur. We separated outcomes on this basis, consistent with recommendations of the evidence policy and practice [ 27 ], the effectiveness–implementation research typology [ 28 , 29 ] and trial conduct and reporting guidelines [ 30 ]. This is illustrated in a broad study logic model (Fig.  1 ).

Both effective interventions and effective implementation are required to improve health outcomes

The authors undertook a review of intervention- and implementation-relevant outcome frameworks to determine program and intervention outcomes that may be of interest to policy-makers and practitioners, including the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework [ 31 , 32 ], the Intervention Scalability Assessment Tool (ISAT) [ 18 ] and Proctor and colleagues’ implementation outcome definitions [ 14 ] as well as a series of publications on the topic [ 31 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. This was used to generate a comprehensive inventory of all possible outcomes (and outcome definitions) that may be of interest to public health policy-makers and practitioners. The outcome list was then reduced following grouping of outcomes addressing similar constructs or concepts. A panel of 16 public health policy-makers provided feedback on their perceived importance of each outcome for evidence-informed policy and practice decision-making, as well as the proposed outcome definition. This process occurred over two rounds until no further suggested improvements or clarifications were provided or requested, yielding a final list of 17 outcomes to inform the selection of public health intervention and 16 outcomes for the selection of implementation strategies (Additional file 1 : Table S1). Panel participants also pre-tested the survey instrument; however, they were not invited to participate in the value-weighting study.

Participating public health policy-makers and practitioners completed the value-weighting survey. Value-weighting surveys offer advantages over other methods to identify preferences (such as ranks or mean scores on a rating scale), as they provide an opportunity to quantify the relative preference or value of different dissemination strategies from the perspective of public health policy-makers or practitioners. Specifically, they were only presented with the list of outcomes and their definition, and were asked to select up to 5 of the 17 interventions “that they considered are critical to their decision-making when selecting a public health intervention to address an identified health issue” and 16 implementation outcomes “that they consider to be critical to their decision-making when selecting a strategy to support the implementation of a public health intervention in the community” in a decision-making context. Participants were then asked to value weight, allocating 100 points across their five (or less) intervention and implementation outcomes. A higher allocation of points represented a greater level of perceived importance. In this way, participants weight the allocation of points to outcomes based on preference. No statistical weights are applied in the analysis. Participants were asked to select up to five outcomes as this restriction forced a prioritization of the outcomes among participants. The identification of a small number of critical outcomes, rather than all relevant outcomes, is also recommended to facilitate research outcome harmonization [ 44 , 45 ].

Statistical analysis

All statistical analyses and data management were undertaken in SAS version 9.3. Descriptive statistics were used to describe the study sample. Similar to other value-weighting studies, we used descriptive analyses to identify the intervention and implementation outcomes ranked from highest to lowest importance [ 46 , 47 ]. Items not selected or allocated any points were assumed a score of 0, to reflect that they were not perceived as a high-priority outcome by the participant. Specifically, the mean points allocated to each of the individual outcomes were calculated and ranked in descending order. This was calculated overall for the entire participant sample, as well as separately by policy-makers and practitioners. As points were assigned in free-text fields, in instances where participants allocated more or less than 100 points across the individual items, the points they allocated were standardized to 100. Differences in the points allocated to each individual outcome by policy-maker/practitioner role were explored using Mann–Whitney U test. To examine any differences in the outcome preferences by participant risk factor expertise, we also examined and described outcome preferences among risk factor subgroups (with a combined sample of > 30 participants). These findings are discussed.

A total of 186 eligible participants completed the survey in part or in full.

Of the 186 participants, 90 primarily identified as policy-makers and 96 as public health prevention practitioners (Table  1 ). In all, 37% of participants (47% policy-makers, 27% practitioners) had over 15 years’ experience, and approximately one third (32% policy-makers, 36% practitioners) had a PhD. The most common areas of experience were nutrition and dietetics (38% policy-maker, 53% practitioner), physical activity or sedentary behaviour (46% policy-maker, 44% practitioner), obesity (49% policy-maker, 48% practitioner) and tobacco, alcohol or other drugs (51% policy-maker, 34% practitioner).

Valued outcomes

Intervention outcomes.

A total of 169 participants (83 policy-makers and 86 practitioners, with 7 and 10 missing, respectively) responded to the value-weighting questions for the 17 listed intervention outcomes. Table 2 (Fig.  2 ) reports the mean and standard deviation of points allocated by policy-makers and practitioners for each outcome, ranked in descending order to represent the most to least important. For policy-makers and practitioners combined, the effectiveness of an intervention, and its impact on equity, were clearly identified by participants as the leading two outcomes, with a mean allocation of 24.47 [standard deviation (SD) = 17.43] and 13.44(SD = 12.80), respectively. The mean scores for outcomes of feasibility (9.78) and sustainability (9.04) that ranked third and fourth, respectively, were similar; then scores dropped noticeably to 7.24 for acceptability and 5.81 for economic outcomes.

Line graph representing mean points allocated for the 17 intervention outcomes overall and by role

For most outcomes, average scores were similar for policy-makers and practitioners. However, practitioner scores for the outcome of acceptability (mean = 8.95, SD = 9.11), which ranked third most important for practitioners was significantly different than for policy-makers (mean = 5.48, SD = 9.62), where it was ranked seventh ( p  = 0.005). Economics/cost outcomes were ranked fifth by policy-makers (mean = 8.28, SD = 10.63), which significantly differed from practitioners (mean = 3.43, SD = 6.56), where it was ranked ninth ( p  = 0.002). For co-benefits, ranked eighth by policy-makers (mean = 4.37, SD = 7.78), scores were significantly different than for practitioners (mean = 2.27, SD = 6.49), where it was ranked thirteenth ( p  = 0.0215). Rankings for the top five outcomes were identical for those with expertise in nutrition and dietetics, physical activity or sedentary behaviour, obesity and tobacco, alcohol or other drugs (Additional file 1 : Table S2).

Implementation outcomes

A total of 153 participants (75 policy-makers and 78 practitioners, with 15 and 18 missing, respectively) responded to the value-weighting questions for the 16 listed implementation outcomes (Table  3 , Fig.  3 ). The effectiveness of an implementation strategy was clearly identified by participants as the most important intervention outcome, with a mean allocation of 19.82 (SD = 16.85) overall. The mean scores for the next three ranked outcomes namely equity (mean = 10.42, SD = 12.7), feasibility (mean = 10.2, SD = 12.91) and sustainability (mean = 10.08, SD = 10.58) were similar, and thereafter, scores noticeably dropped for measures of adoption (mean = 8.55, SD = 10.90), the fifth-ranked outcome.

Line graph representing mean points allocated for the 16 implementation outcomes overall and by role

For most implementation outcomes (Fig.  3 ) policy-makers and practitioners scores were similar. However, economics outcomes were ranked seventh for policy-makers with a mean = 5.58 (SD = 9.25), compared with practitioners who had a ranking of eleventh for this outcome (mean = 2.88, SD = 6.67). The difference in the points allocated were statistically significant between the two groups ( p  = 0.0439). Timeliness was ranked tenth most important for policy-makers, with a mean allocation of 4.03 (SD = 7.72), compared with practitioners who had a ranking of fourteenth for this outcome and a mean allocation of 2.05 (SD = 5.78). The difference in mean scores between policy-makers and practitioners on this outcome was not significant. Rankings and scores were similar for those with expertise in nutrition and dietetics, physical activity or sedentary behaviour, obesity and tobacco, alcohol or other drugs (Additional file 1 : Table S3).

Broadly, this study sought to better understand the information valued by public health policy-makers and practitioners to support their decisions regarding what and how interventions should be implemented in the community. The most valued research outcomes were the same regardless of whether policy-makers or practitioners were selecting interventions or implementation strategies. Namely outcomes regarding the effectiveness of interventions and implementation strategies. Following this, outcomes about equity, feasibility and sustainability also appeared to represent priorities. The study also found broad convergence among the most valued research outcomes, between policy-makers and practitioners, and across participants with expertise across different non-communicable disease (NCD) risk factors (for example, nutrition, obesity and tobacco). Such findings underscore the importance of research reporting these outcomes to support the translation of public health research into policy and practice.

For outcomes about decisions regarding intervention selection, the findings are broadly consistent with factors recommended by evidence-to-decision frameworks. For example, the top six ranked outcomes (effectiveness, equity, feasibility, sustainability, acceptability and economic), are also represented in both the WHO INTEGRATE framework [ 12 ] and the GRADE Evidence to Decision framework [ 13 ]. However, research outcomes about harms (adverse effects), which are included in both the WHO INTEGRATE and GRADE frameworks were ranked 13th by participants in this study. Such a finding was surprising given that potential benefits and harms of an intervention must be considered to appraise its net impact on patient or public health. Health professionals, however, do not have accurate expectations of the harms and benefits of therapeutic interventions. This appears particularly to be the case for public health professionals who acknowledge the potential for unintended consequences of policies [ 48 ] but consider these risks to be minimal [ 49 ]. The findings, therefore, may reflect the tendency of health professionals to overestimate the benefits of therapeutic interventions, and to a larger extent, underestimate harms [ 50 , 51 ]. In doing so, participants may have elevated their reported value of outcomes regarding the beneficial effectiveness of an intervention and discounted their value of outcomes reporting potential harms. Further research is warranted to substantiate this hypothesis, or explore whether other factors such as participant comprehension or misinterpretation of the outcome description may explain the finding. Nonetheless, the inclusion of measures of adverse effects (or harms) as trial outcomes is prudent to support evidence-informed public health decision-making, as is the use of strategies to facilitate risk communication to ensure the likelihood of such outcomes is understood by policy-makers and practitioners [ 52 , 53 , 54 ].

To our knowledge, this is the first study to examine the research evidence needs of public health policy-makers and practitioners when deciding on what strategies may be used to support policy or program implementation. Most of the eight implementation outcomes recommended by Proctor and colleagues [ 14 ] were ranked within the top eight by participants of this study. However, equity outcomes, ranked second by these participants, were not an outcome included in the list of outcomes defined by Proctor and colleagues. The findings may reflect public health values, which, as a discipline, has equity at its core [ 55 ]. It may also reflect the increasing attention to issues of health equity in implementation science [ 56 ].

Further, one of the eight Proctor outcomes, penetration – defined by Proctor and colleagues as the integration or saturation of an intervention within a service setting and its subsystems – was not ranked highly. Successful penetration implies a level of organization institutionalization of an intervention, which once achieved may continue to provide ongoing benefit to patients or populations. It may also suggest the capacity within the organization to expand implementation or adopt new interventions. Penetration outcomes, therefore, have been suggested to be particularly important to model and understand the potential impact of investment of scarce health resources in the implementation of public health policies and interventions [ 57 ].

At face value, such findings may suggest, at least from the perspective of public health policy-makers and practitioners, that penetration outcomes may not be particularly valued in terms of decision-making. However, it may also reflect a lack of familiarity with this term among public health policy-makers and practitioners, where related outcomes such as “reach” are more commonly used in the literature [ 14 , 58 ]. Alternatively it may be due to the conceptual similarity of this and other outcomes such as adoption, maintenance or sustainability. In other studies, for example, penetration has been operationalized to include the product of “reach”, “adoption” and “organizational maintenance” [ 58 ]. A lack of clear conceptual distinction may have led some participants to allocate points to related outcomes such as “adoption” rather than “penetration”.

The use of concept mapping techniques, consolidation of definitions of existing outcomes, and articulation of specific measures aligned to these outcomes may reduce some of these conceptual challenges. Indeed, best practice processes to develop core outcome sets for clinical trials suggest processes of engagement with end-users [ 45 ], stakeholders and researchers to articulate both broad outcomes and specific measures of these to support a shared understanding of important outcomes (and measures) to be included in such research. For example, there are many measures and economic methods to derive related to a broad outcome of “cost” (for example, absolute costs, cost–effectiveness, cost–benefit, cost–utility, and budget impact analysis) [ 59 ]. However, public health policy-makers’ preference or perceived value of these different measures to their decision-making will likely vary. While work in the field to map or align specific measures to broad outcomes is ongoing [ 57 , 58 , 60 ], extending this to empirically investigate end-user preferences for measures would be an important contribution to the field.

Broadly speaking, there was little variation in the outcomes valued between policy-makers and practitioners. However, economic evaluations were ranked as more important by policy-makers. The findings may reflect differences in the roles of Australian public health policy-makers and practitioners. That is, government policy-makers are often responsible for setting and financing the provision of public health programs, whereas health practitioners are responsible for directly supporting or undertaking their delivery. Economic considerations, therefore, may have greater primacy among policy-makers, who may be more likely to incur program costs [ 19 ]. Further research to explore and better understand these areas of divergence is warranted.

The study intended to provide information about outcomes that were generally of most use in public health policy and practice decision-making. However, such decisions are often highly contextual, and preferences may vary depending on the policy-maker or practitioner, the health issue to be addressed, the target population or broader decision-making circumstances [ 2 , 61 ]. As such, the extent to which the findings reported in this study generalize to other contexts, such as those working in different fields of public health, on different health issues or from countries or jurisdictions outside Australia is unknown. Future research examining the outcome preferences of public health policy-makers and practitioners in different contexts, therefore, is warranted.

The contextual nature of evidence needs of policy-makers and practitioners may explain, in part, the variability in outcome preferences. In many cases, for example, the mean of the outcome preference was less than its standard deviation. The interpretation of the study findings should consider this variability. That is, there is little distinguishing the mean preference ranks of many outcomes. However, the study findings at the extremes are unambiguous, suggesting clear preferences for the highest over the lowest ranking outcomes that did not differ markedly across policy-makers, practitioners or those with expertise in addressing different non-communicable disease risks such as nutrition, physical activity or tobacco or alcohol use.

Several study limitations are worth considering when interpreting the research findings. The initial inventory of outcomes was compiled from outcome frameworks, many of which were generic health or medical research outcomes that are uncommon in public health prevention research. There was considerable overlap in the outcomes included across frameworks, though how these were defined at times varied. Variability in outcome terminology has previously been identified as a problem for the field [ 62 ]. Despite being provided definitions for each, some participants may have responded to survey items based on their pre-existing understanding of these terms. Furthermore, following completion of the study, a programming error was identified whereby the definition of “Acceptability of the implementation strategy” was incorrectly assigned as “A measure of the uptake or reach of an implementation strategy”. The extent to which this may have influenced participant preferences is unclear, so sensitivity analysis was conducted by removing all participants who selected acceptability as a measure of interest. We conducted two analyses, one where the people who chose acceptability were removed but their other rankings remained and another where all their data were deleted. Results indicated that the top five outcomes did not differ after conducting the analysis, with only sustainability moving from fourth to second place in the second sensitivity analysis (Additional file 1 : Tables S4 and S5).

The pathway from research production to research in health policy or practice is complex. While a range of effective public health policies and interventions exist across a range of community settings [ 63 , 64 , 65 , 66 ], their implementation at a level capable of achieving population-level risk reductions remains elusive [ 67 , 68 , 69 , 70 ]. Nonetheless, undertaking research with end-use in mind, including reporting of outcomes valued by decision-makers, will likely facilitate the knowledge translation process [ 7 ]. In this study we found that outcomes related to effectiveness, equity, feasibility and sustainability appear important to decisions policy-makers and practitioners make about the interventions they select and the strategies they employ to implement public health prevention initiatives. Researchers interested in supporting evidence-informed decision-making should seek to provide for these information needs and prioritize such outcomes in dissemination activities to policy-makers and practitioners.

Contribution to the literature

It is essential to the research needs of policy-makers and practitioners to determine core outcomes to facilitate research use and knowledge translation.

Here we quantify the relative values of a variety of research outcomes commonly used in health research.

Findings suggest the primary outcomes of interest to public health prevention policy-makers and practitioners when making decisions about the selection of interventions and strategies to implement them are related to effectiveness, equity, feasibility and sustainability and that these do not differ markedly between public health prevention policy-makers and practitioners.

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

Australian and New Zealand Journal of Public Health

Health Promotion Journal of Australia

Intervention scalability assessment tool

Non-communicable disease

National Centre of Implementation Science

Public Health Research and Practice

World Health Organization

Campbell D, Moore G, Sax Institute. Increasing the use of research in policymaking. An Evidence Check rapid review brokered by the Sax Institute for the NSW Ministry of Health. 2017. https://www.health.nsw.gov.au/research/Documents/increasing-the-use-of-research.pdf .

Oliver KA, de Vocht F. Defining “evidence” in public health: a survey of policymakers’ uses and preferences. Eur J Public Health. 2017;27(2):112–7. https://doi.org/10.1093/eurpub/ckv082 .

Article   PubMed   Google Scholar  

Newson RS, Rychetnik L, King L, Milat AJ, Bauman AE. Looking for evidence of research impact and use: a qualitative study of an Australian research-policy system. Res Eval. 2021;30(4):458–69. https://doi.org/10.1093/reseval/rvab017 .

Article   Google Scholar  

van der Graaf P, Cheetham M, McCabe K, Rushmer R. Localising and tailoring research evidence helps public health decision making. Health Info Libr J. 2018;35(3):202–12. https://doi.org/10.1111/hir.12219 .

World Health Organization. Evidence, policy, impact: WHO guide for evidence-informed decision-making. World Health Organization; 2021.

Global Commission on Evidence to Address Societal Challenges. The Evidence Commission Report: a wake-up call and path forward for decisionmakers, evidence intermediaries, and impact-oriented evidence producers. 2022. https://www.mcmasterforum.org/networks/evidence-commission/report/english .

Wolfenden L, Mooney K, Gonzalez S, et al. Increased use of knowledge translation strategies is associated with greater research impact on public health policy and practice: an analysis of trials of nutrition, physical activity, sexual health, tobacco, alcohol and substance use interventions. Health Res Policy Syst. 2022;20(1):15. https://doi.org/10.1186/s12961-022-00817-2 .

Article   PubMed   PubMed Central   Google Scholar  

Kathy E, David G, Anne H, et al. Improving knowledge translation for increased engagement and impact in healthcare. BMJ Open Qual. 2020;9(3): e000983. https://doi.org/10.1136/bmjoq-2020-000983 .

Squires JE, Santos WJ, Graham ID, et al. Attributes and features of context relevant to knowledge translation in health settings: a response to recent commentaries. Int J Health Policy Management. 2023;12(1):1–4. https://doi.org/10.34172/ijhpm.2023.7908 .

Thomas A, Bussières A. Leveraging knowledge translation and implementation science in the pursuit of evidence informed health professions education. Adv Health Sci Educ Theory Pract. 2021;26(3):1157–71. https://doi.org/10.1007/s10459-020-10021-y .

Dobbins M, Jack S, Thomas H, Kothari A. Public health decision-makers’ informational needs and preferences for receiving research evidence. Worldviews Evid-Based Nurs. 2007;4(3):156–63. https://doi.org/10.1111/j.1741-6787.2007.00089.x .

Rehfuess EA, Stratil JM, Scheel IB, Portela A, Norris SL, Baltussen R. The WHO-INTEGRATE evidence to decision framework version 10: integrating WHO norms and values and a complexity perspective. BMJ Glob Health. 2019;4(Suppl 1):e000844. https://doi.org/10.1136/bmjgh-2018-000844 .

Moberg J, Oxman AD, Rosenbaum S, et al. The GRADE Evidence to Decision (EtD) framework for health system and public health decisions. Health Res Policy Syst. 2018;16(1):45. https://doi.org/10.1186/s12961-018-0320-2 .

Proctor E, Silmere H, Raghavan R, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65–76. https://doi.org/10.1007/s10488-010-0319-7 .

Dodson EA, Geary NA, Brownson RC. State legislators’ sources and use of information: bridging the gap between research and policy. Health Educ Res. 2015;30(6):840–8. https://doi.org/10.1093/her/cyv044 .

Morshed AB, Dodson EA, Tabak RG, Brownson RC. Comparison of research framing preferences and information use of state legislators and advocates involved in cancer control, United States, 2012–2013. Prev Chronic Dis. 2017;14:E10. https://doi.org/10.5888/pcd14.160292 .

Turon H, Wolfenden L, Finch M, et al. Dissemination of public health research to prevent non-communicable diseases: a scoping review. BMC Public Health. 2023;23(1):757. https://doi.org/10.1186/s12889-023-15622-x .

Milat A, Lee K, Conte K, et al. Intervention Scalability Assessment Tool: a decision support tool for health policy makers and implementers. Health Res Policy Syst. 2020;18(1):1–17.

Milat AJ, King L, Newson R, et al. Increasing the scale and adoption of population health interventions: experiences and perspectives of policy makers, practitioners, and researchers. Health Res Policy Syst. 2014;12(1):18. https://doi.org/10.1186/1478-4505-12-18 .

Cleland V, McNeilly B, Crawford D, Ball K. Obesity prevention programs and policies: practitioner and policy-maker perceptions of feasibility and effectiveness. Obesity. 2013;21(9):E448–55. https://doi.org/10.1002/oby.20172 .

Wolfenden L, Bolsewicz K, Grady A, et al. Optimisation: defining and exploring a concept to enhance the impact of public health initiatives. Health Res Policy Syst. 2019;17(1):108. https://doi.org/10.1186/s12961-019-0502-6 .

Purtle J, Dodson EA, Nelson K, Meisel ZF, Brownson RC. Legislators’ sources of behavioral health research and preferences for dissemination: variations by political party. Psychiatr Serv. 2018;69(10):1105–8. https://doi.org/10.1176/appi.ps.201800153 .

World Health Organization. WHO Health policy [Internet] 2019;

Australian Health Promotion Association Core competencies for health promotion practitioners. Maroochydore: University of the Sunshine Coast. 2009;

Barry MM, Battel-Kirk B, Dempsey C. The CompHP Core Competencies Framework for Health Promotion in Europe. Health Educ Behav. 2012;39(6):648–62. https://doi.org/10.1177/1090198112465620 .

Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. https://doi.org/10.1016/j.jbi.2008.08.010 .

Wolfenden L, Williams CM, Kingsland M, et al. Improving the impact of public health service delivery and research: a decision tree to aid evidence-based public health practice and research. Aust N Zeal J Public Health. 2020;44(5):331–2. https://doi.org/10.1111/1753-6405.13023 .

Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217–26. https://doi.org/10.1097/MLR.0b013e3182408812 .

Wolfenden L, Williams CM, Wiggers J, Nathan N, Yoong SL. Improving the translation of health promotion interventions using effectiveness–implementation hybrid designs in program evaluations. Health Promot J Austr. 2016;27(3):204–7. https://doi.org/10.1071/HE16056 .

Wolfenden L, Foy R, Presseau J, et al. Designing and undertaking randomised implementation trials: guide for researchers. Br Med J. 2021;372:m3721. https://doi.org/10.1136/bmj.m3721 .

Suhonen R, Papastavrou E, Efstathiou G, et al. Patient satisfaction as an outcome of individualised nursing care. Scand J Caring Sci. 2012;26(2):372–80. https://doi.org/10.1111/j.1471-6712.2011.00943.x .

Gaglio B, Shoup JA, Glasgow RE. The RE-AIM framework: a systematic review of use over time. Am J Public Health. 2013;103(6):e38-46. https://doi.org/10.2105/ajph.2013.301299 .

Rye M, Torres EM, Friborg O, Skre I, Aarons GA. The Evidence-based Practice Attitude Scale-36 (EBPAS-36): a brief and pragmatic measure of attitudes to evidence-based practice validated in US and Norwegian samples. Implement Sci. 2017;12(1):44. https://doi.org/10.1186/s13012-017-0573-0 .

Sansoni JE. Health outcomes: an overview from an Australian perspective. 2016;

Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17(1):88. https://doi.org/10.1186/s12913-017-2031-8 .

Weiner BJ, Lewis CC, Stanick C, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108. https://doi.org/10.1186/s13012-017-0635-3 .

Simoens S. Health economic assessment: a methodological primer. Int J Environ Res Public Health. 2009;6(12):2950–66. https://doi.org/10.3390/ijerph6122950 .

Lorgelly PK, Lawson KD, Fenwick EA, Briggs AH. Outcome measurement in economic evaluations of public health interventions: a role for the capability approach? Int J Environ Res Public Health. 2010;7(5):2274–89. https://doi.org/10.3390/ijerph7052274 .

Williams K, Sansoni J, Morris D, Grootemaat P, Thompson C. Patient-reported outcome measures: literature review. Sydney: Australian Commission on Safety and Quality in Health Care; 2016.

Google Scholar  

Zilberberg MD, Shorr AF. Understanding cost-effectiveness. Clin Microbiol Infect. 2010;16(12):1707–12. https://doi.org/10.1111/j.1469-0691.2010.03331.x .

Article   CAS   PubMed   Google Scholar  

Feeny DH, Eckstrom E, Whitlock EP, et al. A primer for systematic reviewers on the measurement of functional status and health-related quality of life in older adults [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013. Available from: https://www.ncbi.nlm.nih.gov/books/NBK169159/ .

Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–7. https://doi.org/10.2105/ajph.89.9.1322 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. National Academies Press (US); 2001.

Higgins JP, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions. John Wiley & Sons; 2019.

Book   Google Scholar  

Williamson PR, Altman DG, Bagley H, et al. The COMET Handbook: version 1.0. Trials. 2017;18(3):280. https://doi.org/10.1186/s13063-017-1978-4 .

Paul CL, Sanson-Fisher R, Douglas HE, Clinton-McHarg T, Williamson A, Barker D. Cutting the research pie: a value-weighting approach to explore perceptions about psychosocial research priorities for adults with haematological cancers. Eur J Cancer Care. 2011;20(3):345–53. https://doi.org/10.1111/j.1365-2354.2010.01188.x .

Article   CAS   Google Scholar  

Fradgley EA, Paul CL, Bryant J, Oldmeadow C. Getting right to the point: identifying Australian outpatients’ priorities and preferences for patient-centred quality improvement in chronic disease care. Int J Qual Health Care. 2016;28(4):470–7. https://doi.org/10.1093/intqhc/mzw049 .

Oliver K, Lorenc T, Tinkler J, Bonell C. Understanding the unintended consequences of public health policies: the views of policymakers and evaluators. BMC Public Health. 2019;19(1):1057. https://doi.org/10.1186/s12889-019-7389-6 .

Sally M, Mark P. Good intentions and received wisdom are not enough. J Epidemiol Community Health. 2000;54(11):802. https://doi.org/10.1136/jech.54.11.802 .

Hoffmann TC, Del Mar C. Clinicians’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2017;177(3):407–19. https://doi.org/10.1001/jamainternmed.2016.8254 .

Hanoch Y, Rolison J, Freund AM. Reaping the benefits and avoiding the risks: unrealistic optimism in the health domain. Risk Anal. 2019;39(4):792–804. https://doi.org/10.1111/risa.13204 .

Oakley GP Jr, Johnston RB Jr. Balancing benefits and harms in public health prevention programmes mandated by governments. Br Med J. 2004;329(7456):41–3. https://doi.org/10.1136/bmj.329.7456.41 .

Pitt AL, Goldhaber-Fiebert JD, Brandeau ML. Public health interventions with harms and benefits: a graphical framework for evaluating tradeoffs. Med Decis Making. 2020;40(8):978–89. https://doi.org/10.1177/0272989x20960458 .

McDowell M, Rebitschek FG, Gigerenzer G, Wegwarth O. A simple tool for communicating the benefits and harms of health interventions: a guide for creating a fact box. MDM Policy Pract. 2016;1(1):2381468316665365. https://doi.org/10.1177/2381468316665365 .

World Health Organization. Social determinants of health. 2022.

Brownson RC, Kumanyika SK, Kreuter MW, Haire-Joshu D. Implementation science should give higher priority to health equity. Implement Sci. 2021;16(1):28. https://doi.org/10.1186/s13012-021-01097-0 .

Brownson RC, Colditz GA, Proctor EK. Dissemination and implementation research in health: translating science to practice. Oxford University Press; 2017.

Reilly KL, Kennedy S, Porter G, Estabrooks P. Comparing, contrasting, and integrating dissemination and implementation outcomes included in the RE-AIM and implementation outcomes frameworks. Front Public Health. 2020;8:430. https://doi.org/10.3389/fpubh.2020.00430 .

Eisman AB, Kilbourne AM, Dopp AR, Saldana L, Eisenberg D. Economic evaluation in implementation science: making the business case for implementation strategies. Psychiatry Res. 2020;283:112433. https://doi.org/10.1016/j.psychres.2019.06.008 .

Allen P, Pilar M, Walsh-Bailey C, et al. Quantitative measures of health policy implementation determinants and outcomes: a systematic review. Implement Sci. 2020;15(1):47. https://doi.org/10.1186/s13012-020-01007-w .

Whitty JA, Lancsar E, Rixon K, Golenko X, Ratcliffe J. A systematic review of stated preference studies reporting public preferences for healthcare priority setting. Patient. 2014;7(4):365–86. https://doi.org/10.1007/s40271-014-0063-2 .

Smith PG MR, Ross DA, editors, Field trials of health interventions: a toolbox. 3rd edition. Chapter 12, Outcome measures and case definition. 2015.

Wolfenden L, Barnes C, Lane C, et al. Consolidating evidence on the effectiveness of interventions promoting fruit and vegetable consumption: an umbrella review. Int J Behav Nutr Phys Act. 2021;18(1):11. https://doi.org/10.1186/s12966-020-01046-y .

Nathan N, Hall A, McCarthy N, et al. Multi-strategy intervention increases school implementation and maintenance of a mandatory physical activity policy: outcomes of a cluster randomised controlled trial. Br J Sports Med. 2022;56(7):385–93. https://doi.org/10.1136/bjsports-2020-103764 .

Sutherland R, Brown A, Nathan N, et al. A multicomponent mHealth-based intervention (SWAP IT) to decrease the consumption of discretionary foods packed in school lunchboxes: type I effectiveness-implementation hybrid cluster randomized controlled trial. J Med Internet Res. 2021;23(6):e25256. https://doi.org/10.2196/25256 .

Breslin G, Shannon S, Cummings M, Leavey G. An updated systematic review of interventions to increase awareness of mental health and well-being in athletes, coaches, officials and parents. Syst Rev. 2022;11(1):99. https://doi.org/10.1186/s13643-022-01932-5 .

McCrabb S, Lane C, Hall A, et al. Scaling-up evidence-based obesity interventions: a systematic review assessing intervention adaptations and effectiveness and quantifying the scale-up penalty. Obesity Rev. 2019;20(7):964–82. https://doi.org/10.1111/obr.12845 .

Wolfenden L, McCrabb S, Barnes C, et al. Strategies for enhancing the implementation of school-based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use. Cochrane Database Syst Rev. 2022. https://doi.org/10.1002/14651858.CD011677.pub3 .

Wolfenden L, Barnes C, Jones J, et al. Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services. Cochrane Database Syst Rev. 2020. https://doi.org/10.1002/14651858.CD011779.pub3 .

Sutherland RL, Jackson JK, Lane C, et al. A systematic review of adaptations and effectiveness of scaled-up nutrition interventions. Nutr Rev. 2022;80(4):962–79. https://doi.org/10.1093/nutrit/nuab096 .

Download references

Acknowledgements

Not applicable.

This study was funded in part by a National Health and Medical Research Council (NHMRC) Centre for Research Excellence – National Centre of Implementation Science (NCOIS) Grant (APP1153479) and a New South Wales (NSW) Cancer Council Program Grant (G1500708). LW is supported by an NHMRC Investigator Grant (G1901360).

Author information

Authors and affiliations.

Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, 2318, Australia

Luke Wolfenden, Alix Hall, Adrian Bauman, Rebecca Hodder, Emily Webb, Kaitlin Mooney, Serene Yoong, Rachel Sutherland & Sam McCrabb

Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW, 2287, Australia

Luke Wolfenden, Alix Hall, Rebecca Hodder, Serene Yoong, Rachel Sutherland & Sam McCrabb

Hunter Medical Research Institute, Newcastle, NSW, 2305, Australia

Prevention Research Collaboration, Charles Perkins Centre, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia

Adrian Bauman

The Australian Prevention Partnership Centre, Sydney, NSW, Australia

School of Public Health, University of Sydney, Sydney, NSW, Australia

Andrew Milat

Centre for Epidemiology and Evidence, NSW Ministry of Health, Sydney, Australia

School of Health Sciences, Swinburne University of Technology, Melbourne, VIC, 3122, Australia

Serene Yoong

Global Nutrition and Preventive Health, Institute of Health Transformation, School of Health and Social Development, Deakin University, Burwood, VIC, Australia

You can also search for this author in PubMed   Google Scholar

Contributions

LW and SMc led the conception and design of the study, were closely involved in data analysis and interpretation and wrote the manuscript. AH, AB, AM and RH comprised the study advisory committee, reviewed the study’s methods and assisted with survey development. AH was responsible for data analysis. KM and EW assisted with survey development, data collection and preliminary analysis. AH, AB, AM, RH, SY and RS were involved in interpretation and revised the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Luke Wolfenden .

Ethics declarations

Ethics approval and consent to participate.

Ethics approval was provided by the University of Newcastle Human Research Ethics Committee (H-2014-0070). Implied consent was obtained from participants rather than explicit consent (that is, individuals were not required to expressly provide consent by checking a “I consent box”; rather, undertaking the survey provided implicit consent).

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1:.

Table S1. Mean point allocations for each of the 17 intervention outcomes overall and by area of expertise (where field of expertise n ≥ 30). Table S2. Mean point allocations for each of the 16 implementation outcomes overall and by area of expertise (where field of expertise n ≥ 30). Table S3. Mean points for implementation outcomes overall and by area of expertise (field of expertise n ≥ 30). Table S4. Sensitivity analysis, participants who selected ‘acceptability’ removed from the analysis, their other rankings remained. Table S5. Sensitivity analysis, participants who selected ‘acceptability’ whole data set removed from the analysis.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Wolfenden, L., Hall, A., Bauman, A. et al. Research outcomes informing the selection of public health interventions and strategies to implement them: A cross-sectional survey of Australian policy-maker and practitioner preferences. Health Res Policy Sys 22 , 58 (2024). https://doi.org/10.1186/s12961-024-01144-4

Download citation

Received : 12 July 2023

Accepted : 19 April 2024

Published : 14 May 2024

DOI : https://doi.org/10.1186/s12961-024-01144-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Health Research Policy and Systems

ISSN: 1478-4505

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

• Program Finder
• Admissions Services
• Course Directory
• Academic Calendar
• Hybrid Campus
• Lecture Series
• Convocation
• Strategy and Development
• Implementation and Impact
• Integrity and Oversight
• In the School
• In the Field
• In Baltimore
• Resources for Practitioners
• Articles & News Releases
• In The News
• Statements & Announcements
• At a Glance
• Student Life
• Strategic Priorities
• Inclusion, Diversity, Anti-Racism, and Equity (IDARE)
• What is Public Health?

research@BSPH

The School’s research endeavors aim to improve the public’s health in the U.S. and throughout the world.

• Funding Opportunities and Support
• Faculty Innovation Award Winners

Conducting Research That Addresses Public Health Issues Worldwide

Systematic and rigorous inquiry allows us to discover the fundamental mechanisms and causes of disease and disparities. At our Office of Research ( research@BSPH), we translate that knowledge to develop, evaluate, and disseminate treatment and prevention strategies and inform public health practice. Research along this entire spectrum represents a fundamental mission of the Johns Hopkins Bloomberg School of Public Health.

From laboratories at Baltimore’s Wolfe Street building, to Bangladesh maternity wards in densely   packed neighborhoods, to field studies in rural Botswana, Bloomberg School faculty lead research that directly addresses the most critical public health issues worldwide. Research spans from molecules to societies and relies on methodologies as diverse as bench science and epidemiology. That research is translated into impact, from discovering ways to eliminate malaria, increase healthy behavior, reduce the toll of chronic disease, improve the health of mothers and infants, or change the biology of aging.

120+ countries

engaged in research activity by BSPH faculty and teams.

of all federal grants and contracts awarded to schools of public health are awarded to BSPH. 

citations on  publications where BSPH was listed in the authors' affiliation in 2019-2023. 

 publications where BSPH was listed in the authors' affiliation in 2019-2023.

Departments

Our 10 departments offer faculty and students the flexibility to focus on a variety of public health disciplines

Centers and Institutes Directory

Our 80+ Centers and Institutes provide a unique combination of breadth and depth, and rich opportunities for collaboration

Institutional Review Board (IRB)

The Institutional Review Board (IRB) oversees two IRBs registered with the U.S. Office of Human Research Protections, IRB X and IRB FC, which meet weekly to review human subjects research applications for Bloomberg School faculty and students

Generosity helps our community think outside the traditional boundaries of public health, working across disciplines and industries, to translate research into innovative health interventions and practices

Introducing the research@BSPH Ecosystem

The   research@BSPH   ecosystem aims to foster an interdependent sense of community among faculty researchers, their research teams, administration, and staff that leverages knowledge and develops shared responses to challenges. The ultimate goal is to work collectively to reduce administrative and bureaucratic barriers related to conducting experiments, recruiting participants, analyzing data, hiring staff,   and more, so that faculty can focus on their core academic pursuits.

Research at the Bloomberg School is a team sport.

In order to provide  extensive guidance, infrastructure, and support in pursuit of its research mission,   research@BSPH  employs three core areas: strategy and development, implementation and impact, and integrity and oversight. Our exceptional research teams comprised of faculty, postdoctoral fellows, students, and committed staff are united in our collaborative, collegial, and entrepreneurial approach to problem solving. T he Bloomberg School ensures that our research is accomplished according to the highest ethical standards and complies with all regulatory requirements. In addition to our institutional review board (IRB) which provides oversight for human subjects research, basic science studies employee techniques to ensure the reproducibility of research. 

Research@BSPH in the News

Four bloomberg school faculty elected to national academy of medicine.

Considered one of the highest honors in the fields of health and medicine, NAM membership recognizes outstanding professional achievements and commitment to service.

The Maryland Maternal Health Innovation Program Grant Renewed with Johns Hopkins

Lerner center for public health advocacy announces inaugural sommer klag advocacy impact award winners.

Bloomberg School faculty Nadia Akseer and Cass Crifasi selected winners at Advocacy Impact Awards Pitch Competition

Nudging in Public Health Lifestyle Interventions: A Systematic Literature Review and Metasynthesis

Affiliation.

• 1 Aarhus University, Aarhus C, Denmark.
• PMID: 32517522
• DOI: 10.1177/1090198120931788

Nudging is increasingly used in public health interventions in Western societies to produced health-promoting behavior changes; however, there is lack of clarity as to what constitutes a nudge, scant knowledge of the effectiveness of nudging techniques in public health lifestyle interventions and a number of ethical and value-based concerns. The aim of this review is to address these research lacunae and identify the characteristics of nudges in empirical research on public health interventions intended to induce healthy lifestyle changes, including whether they are effective. We conducted systematic searches for relevant articles published between January 2008 and April 2019 in three databases, PubMed, CINAHL and PsycINFO, and combined this with a metasynthesis to construct interpretative explanations. A total of 66 original studies met the inclusion criteria. The findings of the systematic review showed that most nudging interventions involved diet/nutrition, most were carried out as single experiments, and the majority had the intended effects. Specific nudging techniques were identified with respect to the broader nudging categories of accessibility, presentation, using messages and pictures, technology-supported information, financial incentives, affecting the senses, and cognitive loading; several studies included more than one nudging technique. Although many nudging techniques had the intended effects, it is unclear whether they would work outside the study setting. The synthesis revealed that the studies lacked critical reflection on the assumptions about health that were implicit in nudging interventions, the cultural acceptability of nudges, the context-free assumptions of nudging theory, and the implications of these aspects for the public health context.

Keywords: general terms; health behavior; health communications; health promotion; literature review.

Publication types

• Research Support, Non-U.S. Gov't
• Systematic Review
• Healthy Lifestyle*
• Public Health*

• Open access
• Published: 11 May 2024

Does a perceptual gap lead to actions against digital misinformation? A third-person effect study among medical students

• Zongya Li   ORCID: orcid.org/0000-0002-4479-5971 1 &
• Jun Yan   ORCID: orcid.org/0000-0002-9539-8466 1  

BMC Public Health volume  24 , Article number:  1291 ( 2024 ) Cite this article

217 Accesses

12 Altmetric

Metrics details

We are making progress in the fight against health-related misinformation, but mass participation and active engagement are far from adequate. Focusing on pre-professional medical students with above-average medical knowledge, our study examined whether and how third-person perceptions (TPP), which hypothesize that people tend to perceive media messages as having a greater effect on others than on themselves, would motivate their actions against misinformation.

We collected the cross-sectional data through a self-administered paper-and-pencil survey of 1,500 medical students in China during April 2022.

Structural equation modeling (SEM) analysis, showed that TPP was negatively associated with medical students’ actions against digital misinformation, including rebuttal of misinformation and promotion of corrective information. However, self-efficacy and collectivism served as positive predictors of both actions. Additionally, we found professional identification failed to play a significant role in influencing TPP, while digital misinformation self-efficacy was found to broaden the third-person perceptual gap and collectivism tended to reduce the perceptual bias significantly.

Conclusions

Our study contributes both to theory and practice. It extends the third-person effect theory by moving beyond the examination of restrictive actions and toward the exploration of corrective and promotional actions in the context of misinformation., It also lends a new perspective to the current efforts to counter digital misinformation; involving pre-professionals (in this case, medical students) in the fight.

Peer Review reports

Introduction

The widespread persistence of misinformation in the social media environment calls for effective strategies to mitigate the threat to our society [ 1 ]. Misinformation has received substantial scholarly attention in recent years [ 2 ], and solution-oriented explorations have long been a focus but the subject remains underexplored [ 3 ].

Health professionals, particularly physicians and nurses, are highly expected to play a role in the fight against misinformation as they serve as the most trusted information sources regarding medical topics [ 4 ]. However, some barriers, such as limitations regarding time and digital skills, greatly hinder their efforts to tackle misinformation on social media [ 5 ].

Medical students (i.e., college students majoring in health/medical science), in contrast to medical faculty, have a greater potential to become the major force in dealing with digital misinformation as they are not only equipped with basic medical knowledge but generally possess greater social media skills than the former generation [ 6 ]. Few studies, to our knowledge, have tried to explore the potential of these pre-professionals in tackling misinformation. Our research thus fills the gap by specifically exploring how these pre-professionals can be motivated to fight against digital health-related misinformation.

The third-person perception (TPP), which states that people tend to perceive media messages as having a greater effect on others than on themselves [ 7 ], has been found to play an important role in influencing individuals’ coping strategies related to misinformation. But empirical exploration from this line of studies has yielded contradictory results. Some studies revealed that individuals who perceived a greater negative influence of misinformation on others than on themselves were more likely to take corrective actions to debunk misinformation [ 8 ]. In contrast, some research found that stronger TPP reduced individuals’ willingness to engage in misinformation correction [ 9 , 10 ]. Such conflicting findings impel us to examine the association between the third-person perception and medical students’ corrective actions in response to misinformation, thus attempting to unveil the underlying mechanisms that promote or inhibit these pre-professionals’ engagement with misinformation.

Researchers have also identified several perceptual factors that motivate individuals’ actions against misinformation, especially efficacy-related concepts (e.g., self-efficacy and health literacy) and normative variables (e.g., subjective norms and perceived responsibility) [ 3 , 8 , 9 ]. However, most studies devote attention to the general population; little is known about whether and how these factors affect medical students’ intentions to deal with misinformation. We recruited Chinese medical students in order to study a social group that is mutually influenced by cultural norms (collectivism in Chinese society) and professional norms. Meanwhile, systematic education and training equip medical students with abundant clinical knowledge and good levels of eHealth literacy [ 5 ], which enable them to have potential efficacy in tackling misinformation. Our study thus aims to examine how medical students’ self-efficacy, cultural norms (i.e., collectivism) and professional norms (i.e., professional identification) impact their actions against misinformation.

Previous research has found self-efficacy to be a reliable moderator of optimistic bias, the tendency for individuals to consider themselves as less likely to experience negative events but more likely to experience positive events as compared to others [ 11 , 12 , 13 ]. As TPP is thought to be a product of optimistic bias, accordingly, self-efficacy should have the potential to influence the magnitude of third-person perception [ 14 , 15 ]. Meanwhile, scholars also suggest that the magnitude of TPP is influenced by social distance corollary [ 16 , 17 ]. Simply put, individuals tend to perceive those who are more socially distant from them to be more susceptible to the influence of undesirable media than those who are socially proximal [ 18 , 19 , 20 ]. From a social identity perspective, collectivism and professional identification might moderate the relative distance between oneself and others while the directions of such effects differ [ 21 , 22 ]. For example, collectivists tend to perceive a smaller social distance between self and others as “they are less likely to view themselves as distinct or unique from others” [ 23 ]. In contrast, individuals who are highly identified with their professional community (i.e., medical community) are more likely to perceive a larger social distance between in-group members (including themselves) and out-group members [ 24 ]. In this way, collectivism and professional identification might exert different effects on TPP. On this basis, this study aims to examine whether and how medical students’ perceptions of professional identity, self-efficacy and collectivism influence the magnitude of TPP and in turn influence their actions against misinformation.

Our study builds a model that reflects the theoretical linkages among self-efficacy, collectivism, professional identity, TPP, and actions against misinformation. The model, which clarifies the key antecedents of TPP and examines the mediating role of TPP, contribute to the third-person effect literature and offer practical contributions to countering digital misinformation.

Context of the study

As pre-professionals equipped with specialized knowledge and skills, medical students have been involved in efforts in health communication and promotion during the pandemic. For instance, thousands of medical students have participated in various volunteering activities in the fight against COVID-19, such as case data visualization [ 25 ], psychological counseling [ 26 ], and providing online consultations [ 27 ]. Due to the shortage of medical personnel and the burden of work, some medical schools also encouraged their students to participate in health care assistance in hospitals during the pandemic [ 28 , 29 ].

The flood of COVID-19 related misinformation has posed an additional threat to and burden on public health. We have an opportunity to address this issue and respond to the general public’s call for guidance from the medical community about COVID-19 by engaging medical students as a main force in the fight against coronavirus related misinformation.

Literature review

The third-person effect in the misinformation context.

Originally proposed by Davison [ 7 ], the third-person effect hypothesizes that people tend to perceive a greater effect of mass media on others than on themselves. Specifically, the TPE consists of two key components: the perceptual and the behavioral [ 16 ]. The perceptual component centers on the perceptual gap where individuals tend to perceive that others are more influenced by media messages than themselves. The behavioral component refers to the behavioral outcomes of the self-other perceptual gap in which people act in accordance with such perceptual asymmetry.

According to Perloff [ 30 ], the TPE is contingent upon situations. For instance, one general finding suggests that when media messages are considered socially undesirable, nonbeneficial, or involving risks, the TPE will get amplified [ 16 ]. Misinformation characterized as inaccurate, misleading, and even false, is regarded as undesirable in nature [ 31 ]. Based on this line of reasoning, we anticipate that people will tend to perceive that others would be more influenced by misinformation than themselves.

Recent studies also provide empirical evidence of the TPE in the context of misinformation [ 32 ]. For instance, an online survey of 511 Chinese respondents conducted by Liu and Huang [ 33 ] revealed that individuals would perceive others to be more vulnerable to the negative influence of COVID-19 digital disinformation. An examination of the TPE within a pre-professional group – the medical students–will allow our study to examine the TPE scholarship in a particular population in the context of tackling misinformation.

Why TPE occurs among medical students: a social identity perspective

Of the works that have provided explanations for the TPE, the well-known ones include self-enhancement [ 34 ], attributional bias [ 35 ], self-categorization theory [ 36 ], and the exposure hypothesis [ 19 ]. In this study, we argue for a social identity perspective as being an important explanation for third-person effects of misinformation among medical students [ 36 , 37 ].

The social identity explanation suggests that people define themselves in terms of their group memberships and seek to maintain a positive self-image through favoring the members of their own groups over members of an outgroup, which is also known as downward comparison [ 38 , 39 ]. In intergroup settings, the tendency to evaluate their ingroups more positively than the outgroups will lead to an ingroup bias [ 40 ]. Such an ingroup bias is typically described as a trigger for the third-person effect as individuals consider themselves and their group members superior and less vulnerable to undesirable media messages than are others and outgroup members [ 20 ].

In the context of our study, medical students highly identified with the medical community tend to maintain a positive social identity through an intergroup comparison that favors the ingroup and derogates the outgroup (i.e., the general public). It is likely that medical students consider themselves belonging to the medical community and thus are more knowledgeable and smarter than the general public in health-related topics, leading them to perceive the general public as more vulnerable to health-related misinformation than themselves. Accordingly, we propose the following hypothesis:

H1: As medical students’ identification with the medical community increases, the TPP concerning digital misinformation will become larger.

What influences the magnitude of TPP

Previous studies have demonstrated that the magnitude of the third-person perception is influenced by a host of factors including efficacy beliefs [ 3 ] and cultural differences in self-construal [ 22 , 23 ]. Self-construal is defined as “a constellation of thoughts, feelings, and actions concerning the relationship of the self to others, and the self as distinct from others” [ 41 ]. Markus and Kitayama (1991) identified two dimensions of self-construal: Independent and interdependent. Generally, collectivists hold an interdependent view of the self that emphasizes harmony, relatedness, and places importance on belonging, whereas individualists tend to have an independent view of the self and thus view themselves as distinct and unique from others [ 42 ]. Accordingly, cultural values such as collectivism-individualism should also play a role in shaping third-person perception due to the adjustment that people make of the self-other social identity distance [ 22 ].

Set in a Chinese context aiming to explore the potential of individual-level approaches to deal with misinformation, this study examines whether collectivism (the prevailing cultural value in China) and self-efficacy (an important determinant of ones’ behavioral intentions) would affect the magnitude of TPP concerning misinformation and how such impact in turn would influence their actions against misinformation.

The impact of self-efficacy on TPP

Bandura [ 43 ] refers to self-efficacy as one’s perceived capability to perform a desired action required to overcome barriers or manage challenging situations. He also suggests understanding self-efficacy as “a differentiated set of self-beliefs linked to distinct realms of functioning” [ 44 ]. That is to say, self-efficacy should be specifically conceptualized and operationalized in accordance with specific contexts, activities, and tasks [ 45 ]. In the context of digital misinformation, this study defines self-efficacy as one’s belief in his/her abilities to identify and verify misinformation within an affordance-bounded social media environment [ 3 ].

Previous studies have found self-efficacy to be a reliable moderator of biased optimism, which indicates that the more efficacious individuals consider themselves, the greater biased optimism will be invoked [ 12 , 23 , 46 ]. Even if self-efficacy deals only with one’s assessment of self in performing a task, it can still create the other-self perceptual gap; individuals who perceive a higher self-efficacy tend to believe that they are more capable of controlling a stressful or challenging situation [ 12 , 14 ]. As such, they are likely to consider themselves less vulnerable to negative events than are others [ 23 ]. That is, individuals with higher levels of self-efficacy tend to underestimate the impact of harmful messages on themselves, thereby widening the other-self perceptual gap.

In the context of fake news, which is closely related to misinformation, scholars have confirmed that fake news efficacy (i.e., a belief in one’s capability to evaluate fake news [ 3 ]) may lead to a larger third-person perception. Based upon previous research evidence, we thus propose the following hypothesis:

H2: As medical students’ digital misinformation self-efficacy increases, the TPP concerning digital misinformation will become larger.

The influence of collectivism on TPP

Originally conceptualized as a societal-level construct [ 47 ], collectivism reflects a culture that highlights the importance of collective goals over individual goals, defines the self in relation to the group, and places great emphasis on conformity, harmony and interdependence [ 48 ]. Some scholars propose to also examine cultural values at the individual level as culture is embedded within every individual and could vary significantly among individuals, further exerting effects on their perceptions, attitudes, and behaviors [ 49 ]. Corresponding to the construct at the macro-cultural level, micro-psychometric collectivism which reflects personality tendencies is characterized by an interdependent view of the self, a strong sense of other-orientation, and a great concern for the public good [ 50 ].

A few prior studies have indicated that collectivism might influence the magnitude of TPP. For instance, Lee and Tamborini [ 23 ] found that collectivism had a significant negative effect on the magnitude of TPP concerning Internet pornography. Such an impact can be understood in terms of biased optimism and social distance. Collectivists tend to view themselves as an integral part of a greater social whole and consider themselves less differentiated from others [ 51 ]. Collectivism thus would mitigate the third-person perception due to a smaller perceived social distance between individuals and other social members and a lower level of comparative optimism [ 22 , 23 ]. Based on this line of reasoning, we thus propose the following hypothesis:

H3: As medical students’ collectivism increases, the TPP concerning digital misinformation will become smaller.

Behavioral consequences of TPE in the misinformation context

The behavioral consequences trigged by TPE have been classified into three categories: restrictive actions refer to support for censorship or regulation of socially undesirable content such as pornography or violence on television [ 52 ]; corrective action is a specific type of behavior where people seek to voice their own opinions and correct the perceived harmful or ambiguous messages [ 53 ]; promotional actions target at media content with desirable influence, such as advocating for public service announcements [ 24 ]. In a word, restriction, correction and promotion are potential behavioral outcomes of TPE concerning messages with varying valence of social desirability [ 16 ].

Restrictive action as an outcome of third-person perceptual bias (i.e., the perceptual component of TPE positing that people tend to perceive media messages to have a greater impact on others than on themselves) has received substantial scholarly attention in past decades; scholars thus suggest that TPE scholarship to go beyond this tradition and move toward the exploration of corrective and promotional behaviors [ 16 , 24 ]. Moreover, individual-level corrective and promotional actions deserve more investigation specifically in the context of countering misinformation, as efforts from networked citizens have been documented as an important supplement beyond institutional regulations (e.g., drafting policy initiatives to counter misinformation) and platform-based measures (e.g., improving platform algorithms for detecting misinformation) [ 8 ].

In this study, corrective action specifically refers to individuals’ reactive behaviors that seek to rectify misinformation; these include such actions as debunking online misinformation by commenting, flagging, or reporting it [ 3 , 54 ]. Promotional action involves advancing correct information online, including in response to misinformation that has already been disseminated to the public [ 55 ].

The impact of TPP on corrective and promotional actions

Either paternalism theory [ 56 ] or the protective motivation theory [ 57 ] can act as an explanatory framework for behavioral outcomes triggered by third-person perception. According to these theories, people act upon TPP as they think themselves to know better and feel obligated to protect those who are more vulnerable to negative media influence [ 58 ]. That is, corrective and promotional actions as behavioral consequences of TPP might be driven by a protective concern for others and a positive sense of themselves.

To date, several empirical studies across contexts have examined the link between TPP and corrective actions. Koo et al. [ 8 ], for instance, found TPP was not only positively related to respondents’ willingness to correct misinformation propagated by others, but also was positively associated with their self-correction. Other studies suggest that TPP motivates individuals to engage in both online and offline corrective political participation [ 59 ], give a thumbs down to a biased story [ 60 ], and implement corrective behaviors concerning “problematic” TV reality shows [ 16 ]. Based on previous research evidence, we thus propose the following hypothesis:

H4: Medical students with higher degrees of TPP will report greater intentions to correct digital misinformation.

Compared to correction, promotional behavior has received less attention in the TPE research. Promotion commonly occurs in a situation where harmful messages have already been disseminated to the public and others appear to have been influenced by these messages, and it serves as a remedial action to amplify messages with positive influence which may in turn mitigate the detrimental effects of harmful messages [ 16 ].

Within this line of studies, however, empirical studies provide mixed findings. Wei and Golan [ 24 ] found a positive association between TPP of desirable political ads and promotional social media activism such as posting or linking the ad on their social media accounts. Sun et al. [ 16 ] found a negative association between TPP regarding clarity and community-connection public service announcements (PSAs) and promotion behaviors such as advocating for airing more PSAs in TV shows.

As promotional action is still underexplored in the TPE research, and existing evidence for the link between TPP and promotion is indeed mixed, we thus propose an exploratory research question:

RQ1: What is the relationship between TPP and medical students’ intentions to promote corrective information?

The impact of self-efficacy and collectivism on actions against misinformation

According to social cognitive theory, people with higher levels of self-efficacy tend to believe they are competent and capable and are more likely to execute specific actions [ 43 ]. Within the context of digital misinformation, individuals might become more willing to engage in misinformation correction if they have enough knowledge and confidence to evaluate information, and possess sufficient skills to verify information through digital tools and services [ 61 ].

Accordingly, we assumed medical students with higher levels of digital misinformation self-efficacy would be likely to become more active in the fight against misinformation.

H5: Medical students with higher levels of digital misinformation self-efficacy will report greater intentions to (a) correct misinformation and (b) promote corrective information on social media.

Social actions of collectivists are strongly guided by prevailing social norms, collective responsibilities, and common interest, goals, and obligations [ 48 ]. Hence, highly collectivistic individuals are more likely to self-sacrifice for group interests and are more oriented toward pro-social behaviors, such as adopting pro-environmental behaviors [ 62 ], sharing knowledge [ 23 ], and providing help for people in need [ 63 ].

Fighting against misinformation is also considered to comprise altruism, especially self-engaged corrective and promotional actions, as such actions are costly to the actor (i.e., taking up time and energy) but could benefit the general public [ 61 ]. Accordingly, we assume collectivism might play a role in prompting people to engage in reactive behaviors against misinformation.

It is also noted that collectivist values are deeply rooted in Chinese society and were especially strongly advocated during the outbreak of COVID-19 with an attempt to motivate prosocial behaviors [ 63 ]. Accordingly, we expected that the more the medical students were oriented toward collectivist values, the more likely they would feel personally obliged and normatively motivated to engage in misinformation correction. However, as empirical evidence was quite limited, we proposed exploratory research questions:

RQ2: Will medical students with higher levels of collectivism report greater intentions to (a) correct misinformation and (b) promote corrective information on social media?

The theoretical model

To integrate both the antecedents and consequences of TPP, we proposed a theoretical model (as shown in Fig. 1 ) to examine how professional identification, self-efficacy and collectivism would influence the magnitude of TPP, and how such impact would in turn influence medical students’ intentions to correct digital misinformation and promote corrective information. Thus, RQ3 was proposed:

RQ3: Will the TPP mediate the impact of self-efficacy and collectivism on medical students’ intentions to (a) correct misinformation, and (b) promote corrective information on social media? Fig. 1 The proposed theoretical model. DMSE = Digital Misinformation Self-efficacy; PIMC = Professional Identification with Medical Community; ICDM = Intention to Correct Digital Misinformation; IPCI = Intention to Promote Corrective Information Full size image

To examine the proposed hypotheses, this study utilized cross-sectional survey data from medical students in Tongji Medical College (TJMC) of China. TJMC is one of the birthplaces of Chinese modern medical education and among the first universities and colleges that offer eight-year curricula on clinical medicine. Further, TJMC is located in Wuhan, the epicenter of the initial COVID-19 outbreaks, thus its students might find the pandemic especially relevant – and threatening – to them.

The survey instrument was pilot tested using a convenience sample of 58 respondents, leading to minor refinements to a few items. Upon approval from the university’s Institutional Research Board (IRB), the formal investigation was launched in TJMC during April 2022. Given the challenges of reaching the whole target population and acquiring an appropriate sampling frame, this study employed purposive and convenience sampling.

We first contacted four school counselors as survey administrators through email with a letter explaining the objective of the study and requesting cooperation. All survey administrators were trained by the principal investigator to help with the data collection in four majors (i.e., basic medicine, clinical medicine, nursing, and public health). Paper-and-pencil questionnaires were distributed to students on regular weekly departmental meetings of each major as students in all grades (including undergraduates, master students, and doctoral students) were required to attend the meeting. The projected time of completion of the survey was approximately 10–15 min. The survey administrators indicated to students that participation was voluntary, their responses would remain confidential and secure, and the data would be used only for academic purposes. Though a total of 1,500 participants took the survey, 17 responses were excluded from the analysis as they failed the attention filters. Ultimately, a total of 1,483 surveys were deemed valid for analysis.

Of the 1,483 respondents, 624 (42.10%) were men and 855 (57.70%) were women, and four did not identify gender. The average age of the sample was 22.00 ( SD  = 2.54, ranging from 17 to 40). Regarding the distribution of respondents’ majors, 387 (26.10%) were in basic medicine, 390 (26.30%) in clinical medicine, 307 (20.70%) in nursing, and 399 (26.90%) in public health. In terms of university class, 1,041 (70.40%) were undergraduates, 291 (19.70%) were working on their master degrees, 146 (9.90%) were doctoral students, and five did not identify their class data.

Measurement of key variables

Perceived effects of digital misinformation on oneself and on others.

Three modified items adapted from previous research [ 33 , 64 ] were employed to measure perceived effects of digital misinformation on oneself. Respondents were asked to indicate to what extent they agreed with the following: (1) I am frequently concerned that the information about COVID-19 I read on social media might be false; (2) Misinformation on social media might misguide my understanding of the coronavirus; (3) Misinformation on social media might influence my decisions regarding COVID-19. The response categories used a 7-point scale, where 1 meant “strongly disagree” and 7 meant “strongly agree.” The measure of perceived effects of digital misinformation on others consisted of four parallel items with the same statement except replacing “I” and “my” with “the general others” and “their”. The three “self” items were averaged to create a measure of “perceived effects on oneself” ( M  = 3.98, SD  = 1.49, α  = 0.87). The three “others” items were also added and averaged to form an index of “perceived effects on others” ( M  = 4.62, SD  = 1.32, α  = 0.87).

The perceived self-other disparity (TPP)

TPP was derived by subtracting perceived effects on oneself from perceived effects on others.

Professional identification with medical community

Professional identification was measured using a three item, 7-point Likert-type scale (1 =  strongly disagree , 7 =  strongly agree ) adapted from previous studies [ 65 , 66 ] by asking respondents to indicate to what extent they agreed with the following statements: (1) I would be proud to be a medical staff member in the future; (2) I am committed to my major; and (3) I will be in an occupation that matches my current major. The three items were thus averaged to create a composite measure of professional identification ( M  = 5.34, SD  = 1.37, α  = 0.88).

Digital misinformation self-efficacy

Modified from previous studies [ 3 ], self-efficacy was measured with three items. Respondents were asked to indicate on a 7-point Linkert scale from 1 (strongly disagree) to 7 (strongly agree) their agreement with the following: (1) I think I can identify misinformation relating to COVID-19 on social media by myself; (2) I know how to verify misinformation regarding COVID-19 by using digital tools such as Tencent Jiaozhen Footnote 1 and Piyao.org.cn Footnote 2 ; (3) I am confident in my ability to identify digital misinformation relating to COVID-19. A composite measure of self-efficacy was constructed by averaging the three items ( M  = 4.38, SD  = 1.14, α  = 0.77).

• Collectivism

Collectivism was measured using four items adapted from previous research [ 67 ], in which respondents were asked to indicate their agreement with the following statements on a 7-point scale, from 1 (strongly disagree) to 7 (strongly agree): (1) Individuals should sacrifice self-interest for the group; (2) Group welfare is more important than individual rewards; (3) Group success is more important than individual success; and (4) Group loyalty should be encouraged even if individual goals suffer. Therefore, the average of the four items was used to create a composite index of collectivism ( M  = 4.47, SD  = 1.30, α  = 0.89).

Intention to correct digital misinformation

We used three items adapted from past research [ 68 ] to measure respondents’ intention to correct misinformation on social media. All items were scored on a 7-point scale from 1 (very unlikely) to 7 (very likely): (1) I will post a comment saying that the information is wrong; (2) I will message the person who posts the misinformation to tell him/her the post is wrong; (3) I will track the progress of social media platforms in dealing with the wrong post (i.e., whether it’s deleted or corrected). A composite measure of “intention to correct digital misinformation” was constructed by adding the three items and dividing by three ( M  = 3.39, SD  = 1.43, α  = 0.81).

Intention to promote corrective information

On a 7-point scale ranging from 1 (very unlikely) to 7 (very likely), respondents were asked to indicate their intentions to (1) Retweet the corrective information about coronavirus on my social media account; (2) Share the corrective information about coronavirus with others through Social Networking Services. The two items were averaged to create a composite measure of “intention to promote corrective information” ( M  = 4.60, SD  = 1.68, r  = 0.77).

Control variables

We included gender, age, class (1 = undergraduate degree; 2 = master degree; 3 = doctoral degree), and clinical internship (0 = none; 1 = less than 0.5 year; 2 = 0.5 to 1.5 years; 3 = 1.5 to 3 years; 4 = more than 3 years) as control variables in the analyses. Additionally, coronavirus-related information exposure (i.e., how frequently they were exposed to information about COVID-19 on Weibo, WeChat, and QQ) and misinformation exposure on social media (i.e., how frequently they were exposed to misinformation about COVID-19 on Weibo, WeChat, and QQ) were also assessed as control variables because previous studies [ 69 , 70 ] had found them relevant to misinformation-related behaviors. Descriptive statistics and bivariate correlations between main variables were shown in Table 1 .

Statistical analysis

We ran confirmatory factor analysis (CFA) in Mplus (version 7.4, Muthén & Muthén, 1998) to ensure the construct validity of the scales. To examine the associations between variables and tested our hypotheses, we performed structural equation modeling (SEM). Mplus was chosen over other SEM statistical package mainly because the current data set included some missing data, and the Mplus has its strength in handling missing data using full-information maximum likelihood imputation, which enabled us to include all available data [ 71 , 72 ]. Meanwhile, Mplus also shows great flexibility in modelling when simultaneously handling continuous, categorical, observed, and latent variables in a variety of models. Further, Mplus provides a variety of useful information in a concise manner [ 73 ].

Table 2 shows the model fit information for the measurement and structural models. Five latent variables were specified in the measurement model. To test the measurement model, we examined the values of Cronbach’s alpha, composite reliability (CR), and average variance extracted (AVE) (Table 1 ). Cronbach’s alpha values ranged from 0.77 to 0.89. The CRs, which ranged from 0.78 to 0.91, exceeded the level of 0.70 recommended by Fornell (1982) and thus confirmed the internal consistency. The AVE estimates, which ranged from 0.54 to 0.78, exceeded the 0.50 lower limit recommended by Fornell and Larcker (1981), and thus supported convergent validity. All the square roots of AVE were greater than the off-diagonal correlations in the corresponding rows and columns [ 74 ]. Therefore, discriminant validity was assured. In a word, our measurement model showed sufficient convergence and discriminant validity.

Five model fit indices–the relative chi-square ratio (χ 2 / df ), the comparative fit index (CFI), the Tucker–Lewis index (TLI), the root mean square error of approximation (RMSEA), and the standardized root-mean-square residual (SRMR) were used to assess the model. Specifically, the normed chi-square between 1 and 5 is acceptable [ 75 ]. TLI and CFI over 0.95 are considered acceptable, SRMR value less than 0.08 and RMSEA value less than 0.06 indicate good fit [ 76 ]. Based on these criteria, the model was found to have an acceptable fit to the data.

Figure 2 presents the results of our hypothesized model. H1 was rejected as professional identification failed to predict TPP ( β  = 0.06, p  > 0.05). Self-efficacy was positively associated with TPP ( β  = 0.14, p  < 0.001) while collectivism was negatively related to TPP ( β  = -0.10, p  < 0.01), lending support to H2 and H3.

Note. N  = 1,483. The coefficients of relationships between latent variables are standardized beta coefficients. Significant paths are indicated by solid line; non-significant paths are indicated by dotted lines. * p  < .05, ** p  < .01; *** p  < .001. DMSE = Digital Misinformation Self-efficacy; PIMC = Professional Identification with Medical Community; ICDM = Intention to Correct Digital Misinformation; IPCI = Intention to Promote Corrective Information

H4 posited that medical students with higher degrees of TPP would report greater intentions to correct digital misinformation. However, we found a negative association between TPP and intentions to correct misinformation ( β  = -0.12, p  < 0.001). H4 was thus rejected. Regarding RQ1, results revealed that TPP was negatively associated with intentions to promote corrective information ( β  = -0.08, p  < 0.05).

Further, our results supported H5 as we found that self-efficacy had a significant positive relationship with corrective intentions ( β  = 0.18, p  < 0.001) and promotional intentions ( β  = 0.32, p  < 0.001). Collectivism was also positively associated with intentions to correct misinformation ( β  = 0.14, p  < 0.001) and promote corrective information ( β  = 0.20, p  < 0.001), which answered RQ2.

Regarding RQ3 (see Table 3 ), TPP significantly mediated the relationship between self-efficacy and intentions to correct misinformation ( β  = -0.016), as well as the relationship between self-efficacy and intentions to promote corrective information ( β  = -0.011). However, TPP failed to mediate either the association between collectivism and corrective intentions ( β  = 0.011, ns ) or the association between collectivism and promotional intentions ( β  = 0.007, ns ).

Recent research has highlighted the role of health professionals and scientists in the fight against misinformation as they are considered knowledgeable, ethical, and reliable [ 5 , 77 ]. This study moved a step further by exploring the great potential of pre-professional medical students to tackle digital misinformation. Drawing on TPE theory, we investigated how medical students perceived the impact of digital misinformation, the influence of professional identification, self-efficacy and collectivism on these perceptions, and how these perceptions would in turn affect their actions against digital misinformation.

In line with prior studies [ 3 , 63 ], this research revealed that self-efficacy and collectivism played a significant role in influencing the magnitude of third-person perception, while professional identification had no significant impact on TPP. As shown in Table 1 , professional identification was positively associated with perceived effects of misinformation on oneself ( r  = 0.14, p  < 0.001) and on others ( r  = 0.20, p  < 0.001) simultaneously, which might result in a diminished TPP. What explains a shared or joint influence of professional identification on self and others? A potential explanation is that even medical staff had poor knowledge about the novel coronavirus during the initial outbreak [ 78 ]. Accordingly, identification with the medical community was insufficient to create an optimistic bias concerning identifying misinformation about COVID-19.

Our findings indicated that TPP was negatively associated with medical students’ intentions to correct misinformation and promote corrective information, which contradicted our hypotheses but was consistent with some previous TPP research conducted in the context of perceived risk [ 10 , 79 , 80 , 81 ]. For instance, Stavrositu and Kim (2014) found that increased TPP regarding cancer risk was negatively associated with behavioral intentions to engage in further cancer information search/exchange, as well as to adopt preventive lifestyle changes. Similarly, Wei et al. (2008) found concerning avian flu news that TPP negatively predicted the likelihood of engaging in actions such as seeking relevant information and getting vaccinated. In contrast, the perceived effects of avian flu news on oneself emerged as a positive predictor of intentions to take protective behavior.

Our study shows a similar pattern as perceived effects of misinformation on oneself were positively associated with intentions to correct misinformation ( r  = 0.06, p  < 0.05) and promote corrective information ( r  = 0.10, p  < 0.001, See Table 1 ). While the reasons for the behavioral patterns are rather elusive, such findings are indicative of human nature. When people perceive misinformation-related risk to be highly personally relevant, they do not take chances. However, when they perceive others to be more vulnerable than themselves, a set of sociopsychological dynamics such as self-defense mechanism, positive illusion, optimistic bias, and social comparison provide a restraint on people’s intention to engage in corrective and promotional actions against misinformation [ 81 ].

In addition to the indirect effects via TPP, our study also revealed that self-efficacy and collectivism serve as direct and powerful drivers of corrective and promotive actions. Consistent with previous literature [ 61 , 68 ], individuals will be more willing to engage in social corrections of misinformation if they possess enough knowledge, skills, abilities, and resources to identify misinformation, as correcting misinformation is difficult and their effort would not necessarily yield positive outcomes. Collectivists are also more likely to engage in misinformation correction as they are concerned for the public good and social benefits, aiming to protect vulnerable people from being misguided by misinformation [ 82 ].

This study offers some theoretical advancements. First, our study extends the TPE theory by moving beyond the examination of restrictive actions and toward the exploration of corrective and promotional actions in the context of misinformation. This exploratory investigation suggests that self-other asymmetry biased perception concerning misinformation did influence individuals’ actions against misinformation, but in an unexpected direction. The results also suggest that using TPP alone to predict behavioral outcomes was deficient as it only “focuses on differences between ‘self’ and ‘other’ while ignoring situations in which the ‘self’ and ‘other’ are jointly influenced” [ 83 ]. Future research, therefore, could provide a more sophisticated understanding of third-person effects on behavior by comparing the difference of perceived effects on oneself, perceived effects on others, and the third-person perception in the pattern and strength of the effects on behavioral outcomes.

Moreover, institutionalized corrective solutions such as government and platform regulation are non-exhaustive [ 84 , 85 ]; it thus becomes critical to tap the great potential of the crowd to engage in the fight against misinformation [ 8 ] while so far, research on the motivations underlying users’ active countering of misinformation has been scarce. The current paper helps bridge this gap by exploring the role of self-efficacy and collectivism in predicting medical students’ intentions to correct misinformation and promote corrective information. We found a parallel impact of the self-ability-related factor and the collective-responsibility-related factor on intentions to correct misinformation and promote corrective information. That is, in a collectivist society like China, cultivating a sense of collective responsibility and obligation in tackling misinformation (i.e., a persuasive story told with an emphasis on collective interests of social corrections of misinformation), in parallel with systematic medical education and digital literacy training (particularly, handling various fact-checking tools, acquiring Internet skills for information seeking and verification) would be effective methods to encourage medical students to engage in active countering behaviors against misinformation. Moreover, such an effective means of encouraging social corrections of misinformation might also be applied to the general public.

In practical terms, this study lends new perspectives to the current efforts in dealing with digital misinformation by involving pre-professionals (in this case, medical students) into the fight against misinformation. As digital natives, medical students usually spend more time online, have developed sophisticated digital competencies and are equipped with basic medical knowledge, thus possessing great potential in tackling digital misinformation. This study further sheds light on how to motivate medical students to become active in thwarting digital misinformation, which can help guide strategies to enlist pre-professionals to reduce the spread and threat of misinformation. For example, collectivism education in parallel with digital literacy training would help increase medical students’ sense of responsibility for and confidence in tackling misinformation, thus encouraging them to engage in active countering behaviors.

This study also has its limitations. First, the cross-sectional survey study did not allow us to justify causal claims. Granted, the proposed direction of causality in this study is in line with extant theorizing, but there is still a possibility of reverse causal relationships. To establish causality, experimental research or longitudinal studies would be more appropriate. Our second limitation lies in the generalizability of our findings. With the focus set on medical students in Chinese society, one should be cautious in generalizing the findings to other populations and cultures. For example, the effects of collectivism on actions against misinformation might differ in Eastern and Western cultures. Further studies would benefit from replication in diverse contexts and with diverse populations to increase the overall generalizability of our findings.

Drawing on TPE theory, our study revealed that TPP failed to motivate medical students to correct misinformation and promote corrective information. However, self-efficacy and collectivism were found to serve as direct and powerful drivers of corrective and promotive actions. Accordingly, in a collectivist society such as China’s, cultivating a sense of collective responsibility in tackling misinformation, in parallel with efficient personal efficacy interventions, would be effective methods to encourage medical students, even the general public, to actively engage in countering behaviors against misinformation.

Availability of data and materials

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

Tencent Jiaozhen Fact-Checking Platform which comprises the Tencent information verification tool allow users to check information authenticity through keyword searching. The tool is updated on a daily basis and adopts a human-machine collaboration approach to discovering, verifying, and refuting rumors and false information. For refuting rumors, Tencent Jiaozhen publishes verified content on the homepage of Tencent's rumor-refuting platform, and uses algorithms to accurately push this content to users exposed to the relevant rumors through the WeChat dispelling assistant.

Piyao.org.cn is hosted by the Internet Illegal Information Reporting Center under the Office of the Central Cyberspace Affairs Commission and operated by Xinhuanet.com. The platform is a website that collects statements from Twitter-like services, news portals and China's biggest search engine, Baidu, to refute online rumors and expose the scams of phishing websites. It has integrated over 40 local rumor-refuting platforms and uses artificial intelligence to identify rumors.

Dhawan D, Bekalu M, Pinnamaneni R, McCloud R, Viswanath K. COVID-19 news and misinformation: do they matter for public health prevention? J Health Commun. 2021;26:799–808.

Article   PubMed   Google Scholar  

Janmohamed K, Walter N, Nyhan K, Khoshnood K, Tucker JD, Sangngam N, et al. Interventions to mitigate COVID-19 misinformation: a systematic review and meta-analysis. J Health Commun. 2021;26:846–57.

Cheng Y, Chen ZF. The influence of presumed fake news influence: examining public support for corporate corrective response, media literacy interventions, and governmental regulation. Mass Commun Soc. 2020;23:705–29.

Article   Google Scholar  

Earnshaw VA, Katz IT. Educate, amplify, and focus to address COVID-19 misinformation. JAMA Health Forum. 2020;1:e200460.

Bautista JR, Zhang Y, Gwizdka J. Healthcare professionals’ acts of correcting health misinformation on social media. Int J Med Inf. 2021;148:104375.

O’Doherty D, Lougheed J, Hannigan A, Last J, Dromey M, O’Tuathaigh C, et al. Internet skills of medical faculty and students: is there a difference? BMC Med Educ. 2019;19:39.

Article   PubMed   PubMed Central   Google Scholar  

Davison WP. The third-person effect in communication.

Koo AZ-X, Su M-H, Lee S, Ahn S-Y, Rojas H. What motivates people to correct misinformation? Examining the effects of third-person perceptions and perceived norms. J Broadcast Electron Media. 2021;65:111–34.

Oktavianus J, Bautista JR. Motivating healthcare professionals to correct online health misinformation: the roles of subjective norm, third-person perception, and channel differences. Comput Hum Behav. 2023;147:107839.

Tang S, Willnat L, Zhang H. Fake news, information overload, and the third-person effect in China. Glob Media China. 2021;6:492–507.

Chapin J. Third-person perception and facebook. Int J Cyber Behav Psychol Learn. 2014;4:34–44.

Wei R, Lo V-H, Lu H-Y. Reconsidering the relationship between the third-person perception and optimistic bias. Commun Res. 2007;34:665–84.

Weinstein ND. Unrealistic optimism about future life events. J Pers Soc Psychol. 1980;39:802–20.

Liu X. Media exposure and third-person perception: the mediating role of social realism and proxy efficacy. 2021.

Yang J, Tian Y. “Others are more vulnerable to fake news than I Am”: Third-person effect of COVID-19 fake news on social media users. Comput Hum Behav. 2021;125:106950.

Sun Ye, Shen L, Pan Z. On the behavioral component of the third-person effect. Commun Res. 2008;35:257–78.

Article   CAS   Google Scholar  

Wei R, Lo V-H. The third-person effects of political attack ads in the 2004 U.S. Presidential election. Media Psychol. 2007;9:367–88.

Duck JM, Hogg MA, Terry DJ. Social identity and perceptions of media persuasion: are we always less influenced than others? 1. J Appl Soc Psychol. 1999;29(9):1879–99.

Eveland WP, Nathanson AI, Detenber BH, McLEOD DM. Rethinking the social distance corollary: perceived likelihood of expsoure and the third-person perception. Commun Res. 1999;26:275–302.

Scharrer E. Third-person perception and television violence: the role of out-group stereotyping in perceptions of susceptibility to effects. Commun Res. 2002;29:681–704.

Brownlee K, Halverson G, Chassie A. Multiple relationships: maintaining professional identity in rural social work practice. J Compar Soc Work. 2012;7(1):81–91.

Hogg MA, Reid SA. Social identity, self-categorization, and the communication of group norms. Commun Theory. 2006;16:7–30.

Lee B, Tamborini R. Third-person effect and internet pornography: the influence of collectivism and internet self-efficacy. J Commun. 2005;55:292–310.

Wei R, Golan G. Political advertising on social media in the 2012 presidential election: exploring the perceptual and behavioral components of the third-person effect. Electron News. 2013;7:223–42.

Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020;20:533–4. 

Jun Z, Weili W, Xin Z, Wei Z. Recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in China: a model of West China Hospital. Precis Clin Med. 2020;3(1):3–8.

Shi Y, Zhang S, Fan L, Sun T. What motivates medical students to engage in volunteer behavior during the COVID-19 Outbreak? A large cross-sectional survey. Front Psychol. 2021;11:569765.

Passemard S, Faye A, Dubertret C, Peyre H, Vorms C, Boimare V, ... & Ricard JD. Covid-19 crisis impact on the next generation of physicians: a survey of 800 medical students. BMC Med Educ. 2021;21(1):1–13.

Tempski P, Arantes-Costa FM, Kobayasi R, Siqueira MA, Torsani MB, Amaro BQ, Martins MA. Medical students’ perceptions and motivations during the COVID-19 pandemic. PLoS ONE. 2021;16(3):e0248627.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Perloff RM. Third-person effect research 1983–1992: a review and synthesis. Int J Public Opin Res. 1993;5:167–84.

Chen L, Fu L. Let’s fight the infodemic: the third-person effect process of misinformation during public health emergencies. Internet Res. 2022;32:1357–77.

Lee T. How people perceive influence of fake news and why it matters. Commun Q. 2021;69:431–53.

Liu PL, Huang LV. Digital disinformation about COVID-19 and the third-person effect: examining the channel differences and negative emotional outcomes. Cyberpsychol Behav Soc Netw. 2020;23:789–93.

Gunther AC, Thorson E. Perceived persuasive effects of product commercials and public service announcements: third-person effects in new domains. Commun Res. 1992;19:574–96.

Gunther A. What we think others think: cause and consequence in the third-person effect. Commun Res. 1991;18:355–72.

Reid SA, Hogg MA. A self-categorization explanation for the third-person effect. Hum Commun Res. 2005;31:129–61.

Cao B, Chen Z, Huang Y, Lo WH. Conflict between Mainland Chinese and Hong Kongers: a social identity perspective in explaining the hostile media phenomenon and the third-person effect. J Appl J Media Stud. 2014;3:225–40.

Google Scholar  

Tajfel H. Experimental studies of intergroup behaviour. In: Cognitive analysis of social behavior: Proceedings of the NATO advanced study Institute on “The cognitive analysis of socio-psychological processes”, Aix-enProvence, France, July 12–31, 1981 Dordrecht: Springer Netherlands; 1982. p. 227–46.

Chapter   Google Scholar  

Tajfel H, Turner JC, Austin WG, Worchel S. An integrative theory of intergroup conflict. Organizational Identity. 1979;56(65):9780203505984–9780203505916.

Crocker J, Luhtanen R. Collective self-esteem and ingroup bias. J Pers Soc Psychol. 1990;58(1).

Singelis TM. The measurement of independent and interdependent self-construals. Pers Soc Psychol Bull. 1994;20(5):580–91.

Cho H, Lee JS. The influence of self-efficacy, subjective norms, and risk perception on behavioral intentions related to the H1N1 flu pandemic: a comparison between K orea and the US. Asian J Soc Psychol. 2015;18(4):311–24.

Bandura A, Freeman WH, Lightsey R. Self-efficacy: the exercise of control. J Cogn Psychother. 1999;13:158–66.

Bandura A, Guide for constructing self-efficacy scales. Self-efficacy beliefs of adolescents. 2006;5(1):307–37.

Pajares F. Self-efficacy beliefs in academic settings. Rev Educ Res. 1996;66:543–78.

Park JS, Ahn HY, Haley EJ. Optimistic bias, advertising skepticism, and consumer intentions for seeking information about the health risks of prescription medicine. Health Mark Q. 2017;34(2):81–96.

Hofstede GH. Culture’s consequences: comparing values, behaviors, institutions, and organizations across nations. 2nd ed. Thousand Oaks: Sage Publications; 2001.

Triandis HC. Individualism and Collectivism. 1st ed. New York: Routledge; 2018.

Wated G, Sanchez JI. Managerial tolerance of nepotism: the effects of individualism-collectivism in a Latin American Context. J Bus Ethics. 2015;130:45–57.

Markus HR, Kitayama S. Culture and the self."Implications for cognition, emotion, and motivation.

Sullivan D, Landau MJ, Kay AC, Rothschild ZK. Collectivism and the meaning of suffering. J Pers Soc Psychol. 2012;103:1023–39.

Lo V, Wei R. Third-person effect, gender, and pornography on the lnternet. J Broadcast Electron Media. 2002;46:13–33.

Barnidge M, Rojas H. Hostile media perceptions, presumed media influence, and political talk: expanding the corrective action hypothesis. Int J Public Opin Res. 2014;26:135–56.

Wintterlin F, Frischlich L, Boberg S, Schatto-Eckrodt T, Reer F, Quandt T. Corrective Actions in the information disorder. the role of presumed media influence and hostile media perceptions for the countering of distorted user-generated content. Polit Commun. 2021;38:773–91.

Wei R, Lo V-H, Lu H-Y, Hou H-Y. Examining multiple behavioral effects of third-person perception: evidence from the news about Fukushima nuclear crisis in Taiwan. Chin J Commun. 2015;8:95–111.

McLEOD DM, Eveland WP, Nathanson AI. Support for censorship of violent and misogynic rap lyrics: an analysis of the third-person effect. Commun Res. 1997;24:153–74.

Nathanson AI, Eveland WP Jr, Park H-S, Paul B. Perceived media influence and efficacy as predictors of caregivers’ protective behaviors. J Broadcast Electron Media. 2002;46:385–410.

McLeod DM, Detenber BH, Eveland WP. Behind the third-person effect: differentiating perceptual processes for self and other. J Commun. 2001;51:678–95.

Rojas H. “Corrective” Actions in the public sphere: how perceptions of media and media effects shape political behaviors. Int J Public Opin Res. 2010;22:343–63.

Chung M, Munno GJ, Moritz B. Triggering participation: exploring the effects of third-person and hostile media perceptions on online participation. Comput Hum Behav. 2015;53:452–61.

Zhao L, Yin J, Song Y. An exploration of rumor combating behavior on social media in the context of social crises. Comput Hum Behav. 2016;58:25–36.

Sherman DK, Updegraff JA, Handy MS, Eom K, Kim HS. Beliefs and social norms as precursors of environmental support: the joint influence of collectivism and socioeconomic status. Pers Soc Psychol Bull. 2022;48:463–77.

Zhu Y, Wei R, Lo V-H, Zhang M, Li Z. Collectivism and altruistic behavior: a third-person effect study of COVID-19 news among Wuhan residents. Glob Media China. 2021;6:476–91.

Yang F, Horning M. Reluctant to share: how third person perceptions of fake news discourage news readers from sharing “real news” on social media. Soc Media Soc. 2020;6:205630512095517.

Adams K, Hean S, Sturgis P, Clark JM. Investigating the factors influencing professional identity of first-year health and social care students. Learn Health Soc Care. 2006;5(2):55–68.

丁汉青, 王军. 冲突与协调: 传媒从业者后备军职业认同状况研究——以北京某高校新闻学院在校生为例. 国际新闻界, 2019;2 :113–131.

Yoo B, Donthu N, Lenartowicz T. Measuring Hofstede’s five dimensions of cultural values at the individual level: development and validation of. J Int Consum Mark. 2011;23(3-4):193-210.

Tandoc EC, Lim D, Ling R. Diffusion of disinformation: how social media users respond to fake news and why. Journalism. 2020;21:381–98.

Tan ASL, Lee C, Chae J. Exposure to health (Mis)Information: lagged effects on young adults’ health behaviors and potential pathways. J Commun. 2015.

Tully M, Bode L, Vraga EK. Mobilizing users: does exposure to misinformation and its correction affect users’ responses to a health misinformation post? Soc Media Soc. 2020;6:205630512097837.

Arbuckle JL. Full information estimation in the presence of in complete data. In: Marcoulides GA, Schumaker RE, editors. Advanced structural equation modeling: issues and techniques. Mahwah: Erlbaum; 1996. p. 243–77.

Narayanan A. A review of eight software packages for structural equation modeling. Am Stat. 2012;66(2):129–38.

Sakaria D, Maat SM, Mohd Matore MEE. Examining the optimal choice of SEM statistical software packages for sustainable mathematics education: a systematic review. Sustainability. 2023;15(4):3209.

Fornell C, Larcker DF. Evaluating structural equation models with unobservable variables and measurement error. J Mark Res. 1981;18(1):39–50.

Wheaton B, Muthen B, Alwin DF, Summers GF. Assessing reliability and stability in panel models. Sociol Methodol. 1977;8:84–136.

Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6(1):1–55.

Ho SS, Goh TJ, Leung YW. Let’s nab fake science news: predicting scientists’ support for interventions using the influence of presumed media influence model. Journalism. 2022;23:910–28.

Bhagavathula AS, Aldhaleei WA, Rahmani J, Mahabadi MA, Bandari DK. Knowledge and perceptions of COVID-19 among health care workers: cross-sectional study. JMIR Public Health Surveill. 2020;6(2):e19160.

Jung EH, Zhang L, Nekmat E. SNS usage and third-person effects in the risk perception of Zika virus among Singaporean Women. J Health Commun. 2020;25:736–44.

Stavrositu CD, Kim J. Social media metrics: third-person perceptions of health information. Comput Hum Behav. 2014;35:61–7.

Wei R, Lo VH, Lu HY. Third-person effects of health news: exploring the relationships among media exposure, presumed media influence, and behavioral intentions. Am Behav Sci. 2008;52:261–77.

Hong SC. Presumed effects of “fake news” on the global warming discussion in a cross-cultural context. Sustainability. 2020;12(5).

Neuwirth K, Frederick E. Extending the framework of third-, first-, and second-person effects. Mass Commun Soc. 2002;5:113–40.

Bastick Z. Would you notice if fake news changed your behavior? An experiment on the unconscious effects of disinformation. Comput Hum Behav. 2021;116.

Harff D, Bollen C, Schmuck D. Responses to social media influencers’ misinformation about COVID-19: a pre-registered multiple-exposure experiment. Media Psychol. 2022;25:831–50.

Download references

Acknowledgements

We thank all participants and staff working for the project.

This work was supported by Humanities and Social Sciences Youth Foundation of the Ministry of Education of China (Grant No. 21YJC860012).

Author information

Authors and affiliations.

Journalism and Information Communication School, Huazhong University of Science and Technology, Wuhan, Hubei, China

Zongya Li & Jun Yan

You can also search for this author in PubMed   Google Scholar

Contributions

Zongya Li wrote the main manuscript and Jun yan collected the data. All authors reviewed the manuscript.

Corresponding author

Correspondence to Jun Yan .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the Medical Ethics Committee of Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology (approval number: 2022S009). All the participants provided informed consent to engage in this research.

Consent for publication

The authors give their consent for the publication of identifiable details, which can include photograph(s) and/or videos and/or case history and/or details within the manuscript to be published in the BMC Public Health.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Li, Z., Yan, J. Does a perceptual gap lead to actions against digital misinformation? A third-person effect study among medical students. BMC Public Health 24 , 1291 (2024). https://doi.org/10.1186/s12889-024-18763-9

Download citation

Received : 08 December 2023

Accepted : 02 May 2024

Published : 11 May 2024

DOI : https://doi.org/10.1186/s12889-024-18763-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Digital misinformation
• Third-person perception
• Pre-professionals
• Professional identification

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]

• {{subColumn.name}}

AIMS Public Health

• {{newsColumn.name}}
• Share facebook twitter google linkedin

A systematic review of the literature: Gender-based violence in the construction and natural resources industry

• Joyce Lo 1 , 
• Sharan Jaswal 1 , 
• Matthew Yeung 1 , 
• Vijay Kumar Chattu 1,2,3 , 
• Ali Bani-Fatemi 1 , 
• Aaron Howe 1 , 
• Amin Yazdani 4 , 
• Basem Gohar 5,6 , 
• Douglas P. Gross 7 , 
• Behdin Nowrouzi-Kia 1,6 ,  , 
• 1. Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON M5G 1V7, Canada
• 2. Center for Global Health Research, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai 600077, India
• 3. Department of Community Medicine, Faculty of Medicine, Datta Meghe Institute of Medical Sciences, Wardha 442107, India
• 4. Canadian Institute for Safety, Wellness & Performance, School of Business, Conestoga College Institute of Technology and Advanced Learning, Kitchener, ON N2G 4M4, Canada
• 5. Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada
• 6. Centre for Research in Occupational Safety & Health, Laurentian University, Sudbury, ON P3E 2C6, Canada
• 7. Department of Physical Therapy, University of Alberta, Edmonton, AB, T6G 2G4, Canada
• Received: 08 February 2024 Revised: 09 April 2024 Accepted: 12 April 2024 Published: 08 May 2024
• Full Text(HTML)
• Download PDF

Supplements

Gender-based violence (GBV) poses a significant concern in the construction and natural resources industries, where women, due to lower social status and integration, are at heightened risk. This systematic review aimed to identify the prevalence and experience of GBV in the construction and natural resources industries. A systematic search across databases including PubMed, OVID, Scopus, Web of Science, and CINAHL was conducted. The Risk of Bias Instrument for Cross-sectional Surveys of Attitudes and Practices by McMaster University and the Critical Appraisal of Qualitative Studies by the Center for Evidence Based Medicine at the University of Oxford were used to assess the studies included in the review. Six articles were included after full-text analysis. GBV was reported in the construction, mining, urban forestry, and arboriculture sectors. Workplace GBV was measured differently across the studies, and all studies examined more than one form of GBV. The main forms of GBV discussed in these studies were discrimination, sexual harassment, and sexism. The studies provided some insight for demographic factors that may or may not be associated with GBV, such as age, region of work, and number of years working in the industry. The review also suggests that workplace GBV has a negative impact on mental health and well-being outcomes, such as higher levels of stress and lower job satisfaction. The current research has not established the effectiveness of interventions, tools, or policies in these workplaces. Thus, additional research should include intervention studies that aim to minimize or prevent GBV in male-dominated workplaces. The current study can bring awareness and acknowledgement towards GBV in the workplace and highlight the importance of addressing it as this review outlines the negative consequences of GBV on mental health and well-being in these male-dominated industries.

• construction ,
• gender-based violence ,
• natural resources ,
• systematic review ,

Citation: Joyce Lo, Sharan Jaswal, Matthew Yeung, Vijay Kumar Chattu, Ali Bani-Fatemi, Aaron Howe, Amin Yazdani, Basem Gohar, Douglas P. Gross, Behdin Nowrouzi-Kia. A systematic review of the literature: Gender-based violence in the construction and natural resources industry[J]. AIMS Public Health, 2024, 11(2): 654-666. doi: 10.3934/publichealth.2024033

Related Papers:

• This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0 ) -->

Access History

Reader comments.

• © 2024 the Author(s), licensee AIMS Press. This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0 )

通讯作者: 陈斌, [email protected]

沈阳化工大学材料科学与工程学院 沈阳 110142

Article views( 84 ) PDF downloads( 14 ) Cited by( 0 )

Figures and Tables

Figures( 1 )  /  Tables( 2 )

Associated material

Other articles by authors.

• Sharan Jaswal
• Matthew Yeung
• Vijay Kumar Chattu
• Ali Bani-Fatemi
• Amin Yazdani
• Basem Gohar
• Douglas P. Gross
• Behdin Nowrouzi-Kia

Related pages

• on Google Scholar
• Email to a friend
• Order reprints

Export File

• Figure 1.  The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) diagram

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Health Res Policy Syst

Defining and classifying public health systems: a critical interpretive synthesis

Tamika jarvis.

1 Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada

Fadi El-Jardali

2 Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon

Elizabeth Alvarez

Associated data.

All data generated or analysed during this study are included in this published article and its additional files.

The introduction of the determinants of health has caused a shift towards understanding health from a holistic perspective as well as increased recognition of public health’s contributions to the health of the population. Several frameworks exist to conceptualise healthcare systems, highlighting the stark contrast of frameworks unique to public health systems. The objectives of this study were to define public health systems and assess differences between healthcare systems and public health systems within established health systems frameworks.

A critical interpretive synthesis was conducted. Databases searched included EBSCOhost, OVID, Scholars Portal, Web of Science, Cochrane Library and Health Systems Evidence. Data extraction, coding and analysis followed a best-fit framework analysis method. Initial codes were based on a current leading health systems and policy classification scheme – health systems arrangements (governance, financial and delivery arrangements).

A total of 5933 unique documents were identified and 67 were included in the analysis. Definitions of public health and public health systems varied significantly as did their roles and functions across jurisdictions. Public health systems arrangements generally followed those of health systems, with the addition of partnerships (community and inter-sectoral) and communication playing a larger role in public health. A public health systems framework and conceptualisation of how public health currently fits within health systems are presented.

Conclusions

Public health systems are unique and vital entities within health systems. In addition to examining how public health and public health systems have been defined within the literature, this review suggests that establishing the scope of public health is crucial to understanding its role within the larger health system and adds to the discourse around the relationship between public health, healthcare and population health. More broadly, this study addresses an important gap in understanding public health systems and provides conceptual and practical contributions as well as areas for future research.

Public health is generally understood to engage in population rather than in individual health activities and to undertake a population health approach recognising that genetic, behavioural and socio-economic factors (e.g. housing, social networks, education) influence health and well-being [ 1 , 2 ]. The introduction of the determinants of health has caused a shift towards understanding health from a holistic perspective as well as increased recognition of public health’s contributions to the health of the population [ 3 ]. Outside of global public health emergencies, such as Ebola or Zika Virus, attention to the role that public health plays in the protection and advancement of health has often taken a backseat to discussions of healthcare reform [ 4 , 5 ]. For many, health and the health system equate to healthcare, namely clinics and hospitals. In the context of the United States and Canada, considering, for example, that medical care consumes the largest amounts of the health budget in Canada and the United States, it is unsurprising that there is generally little public or political interest in strengthening or investing in public health systems [ 6 , 7 ]. For example, amid concerns that public health across Canada continues to be weakened through budgetary cuts and lack of investment in public health infrastructure, there remains little evidence related to understanding public health systems or what is currently done in practice in a comparative fashion [ 6 , 8 ]. Most public health research has focused on the evaluation of programmes aimed at individual or population-level interventions and understanding the causes and patterns of risk of ill health and disease rather than informing broader questions about the organisation, delivery or funding mechanisms of public health systems [ 7 , 9 – 11 ]. Amid the current novel coronavirus disease (COVID-19) pandemic, understanding how public health and broader health systems function, is crucial.

Health services and system researchers have not adequately acknowledged public health as a vital component and contributor to health systems, and achievements made by public health activities, such as communicable and non-communicable disease control, are often attributed to the delivery of primary healthcare services and advances in biomedical interventions [ 12 ]. While multiple health systems frameworks identify the components, functions and goals of healthcare systems, no clear or consistent definition of public health systems exist [ 13 , 14 ].

Defining public health systems can help determine how to best design systems and deliver programmes and services to support public health within the larger health system and other key institutions and move discussions about the relationship between public health and healthcare forward. As a first step, this paper addresses a priority research area that called for the development of a framework describing the key elements of public health systems [ 3 , 15 , 16 ]. A qualitative synthesis of the current literature was completed to investigate how public health systems have been defined and classified as well as the differences between healthcare systems and public health systems within established conceptual frameworks for health systems.

This qualitative review adopted the critical interpretive synthesis (CIS) approach as the overarching methodology while using a second and complimentary qualitative strategy, the best-fit framework synthesis (BFF), to guide structured data extraction and analysis. CIS differs from traditional systematic reviews in several ways; namely, (1) it is an iterative process that explicitly allows for the critical re-interpretation of existing literature and filling of conceptual gaps, and (2) it prioritises the inclusion of papers based on relevance to the research question, including grey literature, increasing the likelihood of capturing relevant documents [ 17 – 19 ]. The BFF is used to test, refine and/or generate relevant frameworks, theories or conceptual models using systematically retrieved empirical data. For this study, BFF was determined to be useful for the organisation, extraction and analysis of large amounts of data, as a priori or pre-identified codes allows researchers to utilise and generate codes and interpret themes but not be restricted by an existing framework, model or theory [ 20 ]. This study conformed with the recommended PRISMA guidelines [ 21 ] and was registered in PROSPERO (CRD42016049967).

Search strategy

Following pilot testing, the databases searched included EBSCOhost, OVID, Scholars Portal, Web of Science, Cochrane Library and Health Systems Evidence. The final search was conducted on 25 October 2016. Studies were not limited to date, language or study design. Additional sources were identified through reviewing the references of included documents to find relevant material and through internet searching to fill conceptual gaps using non-systematic searching. The initial search strategy can be found in Additional file  1 . As public health systems have not been clearly defined, our search strategy sought to include terms that may be used interchangeably within the literature but warrant clear definitions. For the purpose of this study, we define a system as “ a set of inter-connected parts that have to function together to be effective ” [ 22 ], a framework as “ a basic conceptual structure ” [ 23 ], a model as “ a standard or example for imitation for comparison ” [ 24 ], and classification as “ an arrangement of people or things into groups based on ways that they are alike ” [ 25 ].

Study selection

Records identified were screened, duplicates were removed, and titles and abstracts were independently reviewed for exclusion by two reviewers. Records were excluded that (1) did not describe local, state/provincial/territorial, or national public health systems, frameworks or critical components, (2) addressed publicly funded healthcare systems, unless it also addressed the role of public health, and (3) were in languages other than English, French or Spanish. Records were not restricted by date or country as we wanted to obtain a general picture of public health systems globally. To help address the compass question and maximise the diversity of papers, potentially relevant documents were purposively sampled and prioritised for inclusion if they were clearly relevant to the research topic, offered conceptual insights about full frameworks, and were able to provide a cross section of different jurisdictions [ 19 , 26 ]. Full-text documents were retrieved and assessed for eligibility with additional documents found through reference chaining of all included studies or internet searches to help fill conceptual gaps.

Data abstraction

A data extraction tool was developed to organise the key themes of relevant documents and bibliographic information, including title of document, author(s), study type, context of study, key topic areas, and further relevant references from paper. Documents were imported into NVivo 11 software to facilitate the coding and organisation of data. Seven documents were randomly selected and coded independently by two reviewers to ensure consistency. Disagreements were resolved by consensus.

Data analysis and synthesis

A current leading health systems and policy classification scheme, the health systems arrangements framework (based on the three key building blocks of governance, financial and delivery arrangements), was used to form the initial a priori codes [ 27 ]. Originally developed as a taxonomy of health system topics to classify documents for Health Systems Evidence, this framework was chosen as the BFF theoretical framework because it is comprehensive (e.g. includes the essential components of WHO’s health system building blocks [ 22 ]), easy to understand, and has been used in various international contexts for health systems and policy research and applied work, for example, to develop health systems guidance documents and to contextualise research for evidence-based decision-making in Peru and Uganda [ 28 – 30 ]. Codes were added inductively from the data and were linked into themes. Data analysis continued until there was data saturation and conceptual gaps were addressed [ 31 ].

Search results and study selection

Electronic database searches identified 5933 unique citations, 338 of which met inclusion criteria after title and abstract exclusion; 81 of these documents were purposively sampled and full-text review excluded 23 records. Nine additional documents were attained through reference chaining and internet searches. In total, 67 documents were included (Fig.  1 ). A description of these documents can be found in Additional file  2 .

PRISMA flow chart for inclusion/exclusion of documents [ 21 ]

The results are presented in four sections – defining public health and public health systems; roles and functions of public health; public health systems; and public health within health systems. High-level findings are presented in the text and more details are provided in the Additional files.

Defining public health and public health systems

Most documents defined public health via its functions; therefore, separate sections were created for defining public health and public health systems and for describing the roles and functions of public health.

Public health

Seven definitions of public health were found (Additional file  3 ). Public health was described as a multidisciplinary area of practice, concept and set of values that engaged in a larger population health perspective. Eight documents used the definition of public health provided by WHO as an art and science whose organised efforts aim to prevent illness and disease as well as to protect and promote health within society [ 32 – 39 ]. Five other definitions expanded or emphasised various priorities within public health practice and included values of equity and equality.

Public health systems

Public health systems were defined in 20 documents, with 10 unique definitions identified (Additional file 3 ). Eleven documents defined public health systems as all levels of governmental and non-governmental entities which share in the responsibility for ensuring healthy social and physical environments, and consist of a variety of organisations that contribute to the core functions of public health to protect and promote health within the community [ 12 , 40 – 49 ]. Public health systems were also defined based on their composition, level of service, contributing actors, mission and activities, or a combination of these. Public health was largely seen as a governmental responsibility and included partnerships between formal (government) and informal (private sectors, volunteer) organisations.

Roles and functions of public health

Subsystem models of delivery, governance, finance, and roles and functions were identified, for example, Mays et al.’s [ 45 ] typology of public health delivery systems, but none provided a comprehensive public health system framework. Several frameworks identified essential public health functions (Additional file  4 ). The most frequent frameworks were the Institute of Medicine’s three ‘core’ public health functions of assessment, policy development and assurance [ 12 , 38 , 42 , 47 , 48 , 50 ] and the ‘Ten Essential Public Health Services’, which were developed to further refine the specific set of functions and services within public health systems in the United States but have been adapted elsewhere [ 40 , 42 , 44 , 48 , 51 – 56 ].

Roles and functions

Thirty-nine documents defined or highlighted what they identified as the ‘essential’ functions of public health. Additional file 4 provides a table as a way of organising what functions were found within the literature across a variety of countries, following the three core public health functions and 10 essential services. The following were listed as public health functions and services in more than half of the documents: health promotion ( n  = 30); health protection, which included air, water, and food quality and inspection as well as environmental and occupational health activities ( n  = 26); investigation and surveillance ( n  = 25); emergency planning, preparedness and response ( n  = 25); health assessment and monitoring ( n  = 24); injury and chronic disease prevention and management ( n  = 23); and linking with and providing personal clinical services, which included maternal and child health services, minority, rural, indigent, mental, clinical and community health improvement activities, to targeted and/or vulnerable populations ( n  = 22). Communicable disease control ( n  = 18); research ( n  = 16); regulation and enforcement ( n  = 16); resource and organisational management, including leadership, governance capacity, resource management and development of organisational structures ( n  = 14); establishment of partnerships and advocacy in communities ( n  = 13); evaluation of health services ( n  = 11); policy development and planning ( n  = 11); workforce strengthening ( n  = 9); programme implementation ( n  = 4); laboratory services ( n  = 3); hospital and long-term care facility licensing ( n  = 2); and vital statistics ( n  = 2) were also identified as being the responsibility of public health in various jurisdictions. Functions and services had to be interpreted and summarised, as there were different terms being used to represent the same activities between jurisdictions. For example, health protection and environmental health were both used to describe the responsibility for testing and monitoring the quality of air, food and water, and population health assessment was used to describe monitoring, surveillance or epidemiological activities.

It was found that public health system descriptions fit the health system arrangements framework well, with the addition of partnerships and communication, which affected each of the other parts of the system (Additional file  5 ). The health systems arrangements framework was refined to highlight differences between terms and components of public health systems (Table  1 ). While little to no evidence on certain features, such as commercial authority, remunerating providers and incentivising consumers, was available within the literature, these arrangements are still applicable to public health, and thus remain within the public health systems framework.

Public health system arrangements, adapted from health system arrangements framework

Governance arrangements

Policy authority.

Four levels of policy authority were identified within the public sector, namley international, national, state/provincial/territorial, and local. The degree of decentralisation within a country or state/province determined the responsibilities and structural organisation of agencies within public health systems [ 4 , 12 , 32 , 34 , 37 , 44 , 46 , 49 , 57 – 60 ]. Most national public health agencies were primarily responsible for providing guidance and acting as a source of expertise while giving states/provinces authority to organise public health [ 4 , 32 , 39 , 48 , 54 , 57 , 61 – 64 ]. Many state/provincial governments established overall priorities, strategic direction, policies, strategies, standards, and funding models for local public health agencies [ 4 , 34 ].

Organisational authority

Regional or local health units planned and implemented the majority of services, developed policies and communicated legislation [ 34 , 57 , 61 , 63 , 65 ].

Consumer and stakeholder involvement

In public health systems, consumers most often referred to targeted populations and communities rather than individuals, as is more common in healthcare systems. Stakeholders included other public sectors, communities, service providers in and outside of the health system, the private sector, and individuals [ 63 ]. Community partnerships and public engagement were identified as being important for individual and community health, accountability, and an influential factor in the operation of local public health agencies [ 33 , 41 , 47 , 56 , 61 , 63 , 66 , 67 ].

Delivery arrangements

In public health systems, the terms ‘programmes’ or ‘services’ seemed to better reflect the wide range of activities and roles of public health within the larger health system than the term ‘care’.

How are programmes and services designed to meet consumers’ needs

Public health functions were carried out by all levels of government, including federal, state/provincial/territorial and local, but most activities remained organised at the state/provincial level or locally in many countries [ 2 , 38 – 40 , 48 , 58 , 59 , 62 , 63 , 68 – 71 ]. Delivery of public health services often rested at the local level but, in some instances, were delivered at the state/provincial level or through separate government or private organisations [ 38 , 48 , 59 , 62 ]. In one United States-based example, although public health and healthcare were largely independent of one another, public health increasingly provided personal health services for pre-identified or vulnerable groups [ 72 ].

By whom are programmes and services provided

Most public health programmes/services were provided by public sector employees as part of a public health unit, as well as faith-based groups, private businesses, social services agencies, schools, workplaces and healthcare providers [ 46 , 73 ]. Healthcare and other sectors support public health in its missions by participating in surveillance, health protection and emergency planning activities [ 37 , 73 , 74 ]. Because of the diversity in the organisations and people involved in providing public health programmes and services, the size of a public health workforce is difficult to determine [ 5 , 57 , 63 , 73 , 75 ].

Where are programmes and services provided

Delivery of public health programmes and services occurs in multiple public and private settings, including schools, homes of private citizens, workplaces, clinics, public health laboratories, local public health agencies and offices, and various indoor and outdoor spaces within the community [ 57 , 61 ]. Partnerships and contracts with non-governmental and community organisations in public and private sectors have often been established to circumvent barriers to service provision (e.g. due to geographical location or size of jurisdictions) [ 40 , 49 , 71 ].

With what supports are programmes and services provided

Support was often referred to as capacity in human health resources [ 2 , 40 , 51 , 57 , 59 ] and information technology [ 62 , 75 ]. A few articles discussed the use of technology as a tool used to deliver and support public health activities and messaging, and included services such as eHealth, web portals, mobile phone applications and social media [ 66 ].

Financial arrangements

It was difficult to estimate the direct and indirect financial contributions by public and private sectors given the diversity in public health activities [ 39 ].

Financing systems

Several sources estimated that, on average, public health systems received between 3% and 8% of the national health budget [ 5 , 32 , 38 , 39 , 44 , 51 , 57 , 72 ]. Like healthcare, public and private funding sources existed in these systems, with many being publicly financed through general taxation, including federal, state/provincial and local taxes such as income, property and sales taxes [ 32 , 39 , 47 , 52 , 57 – 59 , 62 , 69 , 76 ]. Private sector financing included out-of-pocket service fees and for-profit and non-profit organisations [ 44 , 47 , 52 , 59 ]. A significant part of public health funding is derived from external donors, particularly for disease-specific initiatives, in low-income countries [ 58 ].

Funding organisations

Revenue transfers from national governments to state/provincial or local public health agencies, with funding being distributed to local health agencies to deliver services, were most prevalent. Funding was largely allocated by funding formulas; however, a combination of funding mechanisms, such as activity- and standard-specific funding and reimbursements, per capita allocations, competitive and needs-based grants, and performance-based funding were also reported [ 38 , 46 , 47 , 55 , 58 , 59 ]. Other sources of funding originated from other public sector partners and from collaborations between public and private sectors [ 39 , 47 , 59 , 65 ]. In some instances, external donors allocated funds to community-based organisations to target specific community health needs or provided informal funding for ‘non-essential’ public health programmes [ 4 , 12 , 39 , 47 , 63 , 65 ].

Purchasing products and services

Funding organisations and purchasing products and services were strongly linked. Many federal and state/provincial governments allocated funds for specific public health activities, which influenced the availability of services [ 38 , 46 , 47 , 58 , 59 ]. Generally, there was a trend towards a substantial portion of public health funding directed at individual clinical services (e.g. maternal and child health, mental health, prenatal visits, family planning) [ 12 , 60 ].

Partnerships and communication

Partnerships were identified as an essential way to extend the reach of programmes to target population health issues and to share expertise, information and resources [ 2 , 4 , 39 , 40 , 46 , 56 , 59 , 65 , 66 , 68 , 77 – 81 ]. Partners included other local, national and international government agencies, the healthcare system, academic centres, private sector businesses, faith groups, foundations, service organisations and communities [ 32 – 34 , 40 , 45 , 46 , 48 , 52 , 54 , 56 , 62 – 64 , 72 , 79 , 82 , 83 ]. Within governance arrangements, the goal of partnerships was identified as community empowerment and capacity-building for successful interventions [ 4 , 56 , 61 , 74 , 79 , 82 , 84 ]. Engagement within communities reportedly increased stakeholder involvement in policy and decision-making [ 82 , 84 ].

Public health is an information-dependent sector that requires constant information exchange in order to support public health functions, activities and policies, especially in emergency planning and response [ 2 , 58 ]. Communication not only improves surveillance and response systems between all levels of government and internationally but is necessary for effective knowledge translation activities [ 5 , 84 , 85 ]. Clear, consistent and timely communication is essential for delivering messages to the public, preventing mixed messages and encouraging public engagement. Current and evolving technology, such as the internet and other mass media sources, are tools that support this effort by improving health literacy and outreach [ 66 ] but can also spread misinformation.

Public health within health systems

In framing how public health is seen as part of a larger health system, the literature pointed to two related but separate concepts – that of system integration and the role of public health in promoting a population health approach.

Sofaer [ 79 ] states that the best way to judge how effective a health system is, is by how well it can improve the health of individuals and populations. Interest in integrating public health and healthcare systems is not new [ 34 , 48 , 76 ]. While definitions of integration vary, integration in this report is the relationship between public health and healthcare and the extent to which services are provided to promote and achieve health. Integration is believed to bring the two systems closer together to provide a seamless service delivery within the larger health system and better respond to the needs of both individuals and communities [ 33 , 65 ]. Potential benefits of integration include bringing a population health perspective to the healthcare system, increased access to care, and the reduction of direct and indirect healthcare costs [ 4 ]. However, the literature also points to various challenges regarding integration and what it might mean for the future of the public health system. These include the loss of public health authority and expertise, capacity and management of competing priorities, consequently linked to adverse health outcomes [ 58 ]. Over time, the diversion of public health resources to primary care, loss of positions in public health units, and loss of linkages to community partners and communities would hinder public health from being able to extend the reach of its activities and lead to fragmentation in programme delivery and in the services necessary to protect the health of the population such as community health assessments, programme planning, and disease control and surveillance [ 9 , 58 , 86 ].

From the literature, healthcare and public health are separate systems, often with their own aims and functions, governance and financial systems, and ways of delivering services, although significant overlap has been observed, particularly within delivery arrangements. The health system is separate from but influenced by the larger political and social systems. Health, within this health system, is determined by individual factors and access to and use of public health and healthcare services. Yet, the wider determinants of health recognise the importance of social and political factors on health. Figure  2 aims to organise how public health currently fits within a health system. It is important to note that public health is often equated to and touted as a steward of population health. Population health is the driving force behind public health. Its upstream focus, following an ecological model of health, is concerned with how individual, social and environmental determinants influence health outcomes [ 53 , 55 ]. A strength of the population health approach is that it recognises that people are not passive but are active participants in their own health outcomes. Individual health is supported by both public health and healthcare activities and by how individuals interact with these systems and their larger social environments. There is a constant exchange between individuals, healthcare, public health, and the political and social systems they are embedded in, with more resources, programmes and services targeted towards those identified as vulnerable to try and establish a level of equity in health outcomes. It could be argued that, while activities in public health are population based, the ultimate target of public health is still to support individual health within the larger community. For example, although health promotion messages and activities are delivered to the population, the goal of these activities is to encourage individuals within communities towards healthier lifestyles (e.g. tobacco cessation, vaccinations), whose health statistics are then tracked (e.g. surveillance) and regarded as the population’s health.

Conceptual fit of public health systems within current health systems

Population health is conceptualised as extending far beyond the health system to include the political and societal contexts. While policies outside of the public health system may not be implemented to directly impact population health, they often do. For example, taxes on carbon emissions have short- and long-term effects on population-level health outcomes. Similarly, public health systems affect, and are affected by, many sectors. As broader determinants of health are becoming increasingly recognised as influential, there has been an increased emphasis on holistic approaches to healthy public policies [ 9 ]. Recent work has focused on holistic approaches to health such as Health in All Policies and One Health. Health in All Policies refers to the intersectoral aim of integrating health considerations into the actions, interventions and policies outside of the health sector, and One Health refers to the approach that recognises that human health is influenced by both animal and environmental health [ 87 , 88 ]. Figure ​ Figure2 2 highlights the gaps that exist between what we currently have, at least in high-income countries, and paradigms of population health, Health in All Policies and, especially, One Health. For example, public health is often separate from healthcare and from the political process (i.e. healthy public policies). Population health spans further than public health’s reach and integration may need to be reconceptualised to align with a broader vision of health.

Main findings

The synthesis suggests that public health systems have not been clearly defined because (1) public health systems have been conceptualised in various ways and (2) there is overlap in terminology with publicly funded healthcare systems. One further potential reason for the lack of clarity regarding definitions and the change in the use of terms over time could be related to funder and publication preferences. No comprehensive public health system frameworks were identified within the literature although there was significant emphasis on defining the essential roles and functions of public health. These are broad and consensus on essential functions is often absent between jurisdictions, which made comparisons challenging. Services not provided by healthcare systems are often taken up by public health, increasing pressures on already limited budgets. In addition, response to health emergencies appears to have largely been adopted by public health systems because they are most likely to possess the capacity and expertise to organise and respond to large-scale events or threats to health. We found that, while many components of public health systems fit under the governance, delivery and financial arrangements of traditional healthcare systems, there are noted differences, specifically related to the role of partnerships and communication within public health. Partnerships provided the structure for multi-sectoral collaboration and facilitated communication and information exchange to accomplish the core functions of public health. A proposed framework for public health systems is presented in this paper.

The argument is made that public health and healthcare share the common goal of supporting the health of individuals within populations. Integration, the intersection of public health and healthcare, is believed to bring the two systems closer together to provide seamless service delivery within the broader health system that better responds to the needs of both individuals and communities [ 33 , 65 ]. The challenge with developing these integrated health systems is determining how to best align financial, governance and delivery arrangements, ensuring both complementarity and positive health outcomes. As population health extends beyond the health system to include the political, environmental and societal contexts, as such, it is important to understand these larger contexts within which health systems operate [ 89 ]. The conceptualisation of the current fit of public health systems within health systems has two important ramifications. The first being that integration of healthcare and public health will be difficult at best given that the aims, governance, finance and service delivery are not often aligned. There would have to be significant incentives for integration to happen and even with that, there may not be a shared vision of health to drive collaboration between these systems. The second ramification is that public health will not be able to inform healthy public policies unless they have a seat at the decision-making table for policies outside of the public health realm. There may be arguments on both sides as to whether this is practical or desired, but the case can be made that population health, encompassing the broader social determinants of health, will not occur within the current paradigm and structures.

Strengths and limitations

The flexibility of the CIS approach allows for a broad sampling frame and iterative filling of conceptual gaps. The BFF approach provides a structured approach to data analysis but also for change if a more applicable model is identified. The combination of these two qualitative approaches allowed for a broad research question in an area that is not well defined and helped bring a lot of data together in an efficient manner. The study was informed by a diverse team of experts in public health, health systems research and qualitative research methodology. The search strategy may not have captured all terms and concepts regarding public health systems. To try and mitigate this, a search string was developed with broad search terms to identify as much relevant literature as possible. Additionally, as the reviewed literature mainly covers the period from 2000 to 2016, the search strategy may not have captured all relevant documents such as recent institutional reports. While literature addressing health systems have origins before 2000, more recent documents were purposively sampled and prioritised in the document selection process as they would expectedly include earlier relevant works. This also presents an opportunity to review works after 2016, such as the 2018 report on the organisation and financing of public health services in Europe, and more recent documents that highlight the importance of improving population health through the Sustainable Development Goals (SDGs) [ 90 , 91 ]. CIS requires constant reflexive analysis by the principal investigator and results may vary if another person were to replicate this study; however, the use of a priori codes was used to increase transparency. Finally, although public health systems from various countries were reviewed, almost all documents were from high-income countries, mostly originating from the United States and Canada. While some of the results may be equally relevant to systems outside of these Western contexts, the findings highlight the need for future research outside of these jurisdictions, for example, in low- and middle-income countries, particularly in light of the SDGs.

Placing this work within the literature

This study is a first attempt at defining a holistic public health systems framework and highlighting the differences and similarities between public health and healthcare system arrangements. We have specifically addressed a priority research theme proposed by Canadian and United States federal agencies, such as the Canadian Institutes of Health Research Institute of Population and Public Health, the Centers for Disease Control and Prevention, and other stakeholders, to describe dimensions of public health systems and conceptualise a framework for public health systems.

Practice and policy implications

This study suggests five considerations for practice and policy. First, defining public health systems solidifies and challenges public health’s role to encourage political interest to secure the investment necessary to improve health system capacity. The COVID-19 pandemic has demonstrated the importance of understanding the role of public health within the larger health system, particularly with respect to the capacity to respond to public health crises efficiently and effectively. As was observed following the 2004 SARS pandemic, it is expected that there will be an increase in renewed calls and discussion around public health systems strengthening. Second, the discourse around establishing essential functions of public health is enhanced. Our synthesis has identified a growing concern that public health is currently filling gaps within the healthcare system by providing clinical services to targeted or vulnerable groups, consuming vast amounts of both human and financial resources from already under-resourced public health systems [ 5 , 60 , 69 ]. Thus, defining public health and the boundaries of public health systems could be an important step towards measuring performance and preventing public health systems from becoming too overburdened from the increasing scope of public health clinical activities [ 48 , 54 ]. Third, this study has reinforced the importance of partnerships in the work of public health. Partnerships have the potential to form and navigate systems in contexts challenged by limited resources. For example, the United Nations Millennium Development Goals, aimed to tackle societal issues influencing health, such as poverty, education, and gender equality and, while substantial progress was made, the state of many health systems revealed barriers to reaching specific targets and delivering services to the most vulnerable, particularly for those in many low- and middle-income countries. The SDGs, whose agenda is broader and more ambitious, explicitly recognise the broader determinants of health, by establishing social, economic and environmental objectives such as climate action, sustainable cities and communities, economic development, and social inclusion [ 92 ]. Defining public health systems serves as a building block for under-developed or transitioning public health systems and services, whereby determining roles and functions of public health systems allows practitioners to identify areas that require strengthening. Fourth, this synthesis suggests that the critical differences between public health and healthcare systems need to be acknowledged and negotiated for integration to be successful. The gaps that exist between the public health and healthcare subsystems have been highlighted. Lastly, the idea that public health is the champion of population health is presented as a challenge. Population health is influenced by political and social factors outside of the public health system. The idea of public health as the steward of population health requires serious consideration, especially if public health continues to be excluded from the decision-making process and its role in protecting and promoting health is relegated to the background.

Research implications

By developing a method that combined the best aspects of two qualitative systematic review methods, CIS and BFF, we were able to bring substantial amounts of data together in a timely manner, while simultaneously testing and refining a well-known framework in a critical way. The use of other frameworks, such as the performance-based conceptual framework by Handler et al. [ 42 ], or an assessment framework identified by Martin-Moreno et al. [ 53 ], provide other ways to examine public health systems and could be a way to validate the findings of this study or illustrate different health system ideas. The performance of public health systems cannot be measured if definitions, functions and key components are not well defined. The numerous variations in terminology make it difficult to perform a comparative analysis of public health systems across jurisdictions. Similarly, the differences in defined functions, or a lack thereof, limits our ability to monitor quality indicators between systems. Furthermore, the lack of research in public health and public health systems hampers both interest and investment in public health and limits the development of recommendations for evidence-based practice. Further research is required to determine what integration might look like and at what systems levels integration might work best. This presents additional opportunities for future research, particularly with respect to the gaps highlighted within financial arrangements such as remunerating providers and incentivising consumers. Lastly, this study is a first attempt at trying to understand how public health systems have been conceptualised. A public health systems framework (Table ​ (Table1) 1 ) and conceptualisation of how public health currently fits within the larger health system (Fig.  2 ) are proposed and can be applied and tested in real life settings as well as used to guide further research and practice in public health systems.

The aim of this paper was to examine the literature on how public health systems have been defined and classified and to illustrate how current public health systems align within established conceptual frameworks for health systems. Defining the scope of public health systems is crucial to solidify public health’s role as part of the larger health system and the degree to which public health and healthcare systems are different should be understood if public health is to be able to attend to its primary mandate within integrated health systems. While there is increased movement towards health systems focused on population health, specifically the increased focus on Health in All Policies and One Health, many gaps exist to reach those aims.

Supplementary information

Acknowledgements.

We would like to acknowledge Dr. Steven J. Hoffman for his input on an earlier version of this manuscript.

Abbreviations

Authors’ contributions.

T. Jarvis and E. Alvarez conceived and designed the presented study. E. Alvarez, F. Scott and F. El-Jardali verified the analytical methods. T. Jarvis extracted, analysed and interpreted the data. E. Alvarez supervised the findings of this work. All authors discussed the results and contributed to the final manuscript. The author(s) read and approved the final manuscript.

Authors’ information

This work was completed as part of a Master’s thesis and includes material from a thesis published on MacSphere: http://hdl.handle.net/11375/22170 .

Jarvis, T. (2017). Defining public health systems: A critical interpretive synthesis of how public health systems are defined and classified (Master’s dissertation).

Not applicable.

Availability of data and materials

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Fran Scott, Fadi El-Jardali and Elizabeth Alvarez contributed equally to this work.

Supplementary information accompanies this paper at 10.1186/s12961-020-00583-z.