is a scoping review a research article

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Scoping reviews: reinforcing and advancing the methodology and application

• Micah D. J. Peters 1 , 2 , 3 ,
• Casey Marnie 1 ,
• Heather Colquhoun 4 , 5 ,
• Chantelle M. Garritty 6 ,
• Susanne Hempel 7 ,
• Tanya Horsley 8 ,
• Etienne V. Langlois 9 ,
• Erin Lillie 10 ,
• Kelly K. O’Brien 5 , 11 , 12 ,
• Ӧzge Tunçalp 13 ,
• Michael G. Wilson 14 , 15 , 16 ,
• Wasifa Zarin 17 &
• Andrea C. Tricco   ORCID: orcid.org/0000-0002-4114-8971 17 , 18 , 19  

Systematic Reviews volume  10 , Article number:  263 ( 2021 ) Cite this article

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Scoping reviews are an increasingly common approach to evidence synthesis with a growing suite of methodological guidance and resources to assist review authors with their planning, conduct and reporting. The latest guidance for scoping reviews includes the JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses—Extension for Scoping Reviews. This paper provides readers with a brief update regarding ongoing work to enhance and improve the conduct and reporting of scoping reviews as well as information regarding the future steps in scoping review methods development. The purpose of this paper is to provide readers with a concise source of information regarding the difference between scoping reviews and other review types, the reasons for undertaking scoping reviews, and an update on methodological guidance for the conduct and reporting of scoping reviews.

Despite available guidance, some publications use the term ‘scoping review’ without clear consideration of available reporting and methodological tools. Selection of the most appropriate review type for the stated research objectives or questions, standardised use of methodological approaches and terminology in scoping reviews, clarity and consistency of reporting and ensuring that the reporting and presentation of the results clearly addresses the review’s objective(s) and question(s) are critical components for improving the rigour of scoping reviews.

Rigourous, high-quality scoping reviews should clearly follow up to date methodological guidance and reporting criteria. Stakeholder engagement is one area where further work could occur to enhance integration of consultation with the results of evidence syntheses and to support effective knowledge translation. Scoping review methodology is evolving as a policy and decision-making tool. Ensuring the integrity of scoping reviews by adherence to up-to-date reporting standards is integral to supporting well-informed decision-making.

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Introduction

Given the readily increasing access to evidence and data, methods of identifying, charting and reporting on information must be driven by new, user-friendly approaches. Since 2005, when the first framework for scoping reviews was published, several more detailed approaches (both methodological guidance and a reporting guideline) have been developed. Scoping reviews are an increasingly common approach to evidence synthesis which is very popular amongst end users [ 1 ]. Indeed, one scoping review of scoping reviews found that 53% (262/494) of scoping reviews had government authorities and policymakers as their target end-user audience [ 2 ]. Scoping reviews can provide end users with important insights into the characteristics of a body of evidence, the ways, concepts or terms have been used, and how a topic has been reported upon. Scoping reviews can provide overviews of either broad or specific research and policy fields, underpin research and policy agendas, highlight knowledge gaps and identify areas for subsequent evidence syntheses [ 3 ].

Despite or even potentially because of the range of different approaches to conducting and reporting scoping reviews that have emerged since Arksey and O’Malley’s first framework in 2005, it appears that lack of consistency in use of terminology, conduct and reporting persist [ 2 , 4 ]. There are many examples where manuscripts are titled ‘a scoping review’ without citing or appearing to follow any particular approach [ 5 , 6 , 7 , 8 , 9 ]. This is similar to how many reviews appear to misleadingly include ‘systematic’ in the title or purport to have adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement without doing so. Despite the publication of the PRISMA Extension for Scoping Reviews (PRISMA-ScR) and other recent guidance [ 4 , 10 , 11 , 12 , 13 , 14 ], many scoping reviews continue to be conducted and published without apparent (i.e. cited) consideration of these tools or only cursory reference to Arksey and O’Malley’s original framework. We can only speculate at this stage why many authors appear to be either unaware of or unwilling to adopt more recent methodological guidance and reporting items in their work. It could be that some authors are more familiar and comfortable with the older, less prescriptive framework and see no reason to change. It could be that more recent methodologies such as JBI’s guidance and the PRISMA-ScR appear more complicated and onerous to comply with and so may possibly be unfit for purpose from the perspective of some authors. In their 2005 publication, Arksey and O’Malley themselves called for scoping review (then scoping study) methodology to continue to be advanced and built upon by subsequent authors, so it is interesting to note a persistent resistance or lack of awareness from some authors. Whatever the reason or reasons, we contend that transparency and reproducibility are key markers of high-quality reporting of scoping reviews and that reporting a review’s conduct and results clearly and consistently in line with a recognised methodology or checklist is more likely than not to enhance rigour and utility. Scoping reviews should not be used as a synonym for an exploratory search or general review of the literature. Instead, it is critical that potential authors recognise the purpose and methodology of scoping reviews. In this editorial, we discuss the definition of scoping reviews, introduce contemporary methodological guidance and address the circumstances where scoping reviews may be conducted. Finally, we briefly consider where ongoing advances in the methodology are occurring.

What is a scoping review and how is it different from other evidence syntheses?

A scoping review is a type of evidence synthesis that has the objective of identifying and mapping relevant evidence that meets pre-determined inclusion criteria regarding the topic, field, context, concept or issue under review. The review question guiding a scoping review is typically broader than that of a traditional systematic review. Scoping reviews may include multiple types of evidence (i.e. different research methodologies, primary research, reviews, non-empirical evidence). Because scoping reviews seek to develop a comprehensive overview of the evidence rather than a quantitative or qualitative synthesis of data, it is not usually necessary to undertake methodological appraisal/risk of bias assessment of the sources included in a scoping review. Scoping reviews systematically identify and chart relevant literature that meet predetermined inclusion criteria available on a given topic to address specified objective(s) and review question(s) in relation to key concepts, theories, data and evidence gaps. Scoping reviews are unlike ‘evidence maps’ which can be defined as the figural or graphical presentation of the results of a broad and systematic search to identify gaps in knowledge and/or future research needs often using a searchable database [ 15 ]. Evidence maps can be underpinned by a scoping review or be used to present the results of a scoping review. Scoping reviews are similar to but distinct from other well-known forms of evidence synthesis of which there are many [ 16 ]. Whilst this paper’s purpose is not to go into depth regarding the similarities and differences between scoping reviews and the diverse range of other evidence synthesis approaches, Munn and colleagues recently discussed the key differences between scoping reviews and other common review types [ 3 ]. Like integrative reviews and narrative literature reviews, scoping reviews can include both research (i.e. empirical) and non-research evidence (grey literature) such as policy documents and online media [ 17 , 18 ]. Scoping reviews also address broader questions beyond the effectiveness of a given intervention typical of ‘traditional’ (i.e. Cochrane) systematic reviews or peoples’ experience of a particular phenomenon of interest (i.e. JBI systematic review of qualitative evidence). Scoping reviews typically identify, present and describe relevant characteristics of included sources of evidence rather than seeking to combine statistical or qualitative data from different sources to develop synthesised results.

Similar to systematic reviews, the conduct of scoping reviews should be based on well-defined methodological guidance and reporting standards that include an a priori protocol, eligibility criteria and comprehensive search strategy [ 11 , 12 ]. Unlike systematic reviews, however, scoping reviews may be iterative and flexible and whilst any deviations from the protocol should be transparently reported, adjustments to the questions, inclusion/exclusion criteria and search may be made during the conduct of the review [ 4 , 14 ]. Unlike systematic reviews where implications or recommendations for practice are a key feature, scoping reviews are not designed to underpin clinical practice decisions; hence, assessment of methodological quality or risk of bias of included studies (which is critical when reporting effect size estimates) is not a mandatory step and often does not occur [ 10 , 12 ]. Rapid reviews are another popular review type, but as yet have no consistent, best practice methodology [ 19 ]. Rapid reviews can be understood to be streamlined forms of other review types (i.e. systematic, integrative and scoping reviews) [ 20 ].

Guidance to improve the quality of reporting of scoping reviews

Since the first 2005 framework for scoping reviews (then termed ‘scoping studies’) [ 13 ], the popularity of this approach has grown, with numbers doubling between 2014 and 2017 [ 2 ]. The PRISMA-ScR is the most up-to-date and advanced approach for reporting scoping reviews which is largely based on the popular PRISMA statement and checklist, the JBI methodological guidance and other approaches for undertaking scoping reviews [ 11 ]. Experts in evidence synthesis including authors of earlier guidance for scoping reviews developed the PRISMA-ScR checklist and explanation using a robust and comprehensive approach. Enhancing transparency and uniformity of reporting scoping reviews using the PRISMA-ScR can help to improve the quality and value of a scoping review to readers and end users [ 21 ]. The PRISMA-ScR is not a methodological guideline for review conduct, but rather a complementary checklist to support comprehensive reporting of methods and findings that can be used alongside other methodological guidance [ 10 , 12 , 13 , 14 ]. For this reason, authors who are more familiar with or prefer Arksey and O’Malley’s framework; Levac, Colquhoun and O’Brien’s extension of that framework or JBI’s methodological guidance could each select their preferred methodological approach and report in accordance with the PRISMA-ScR checklist.

Reasons for conducting a scoping review

Whilst systematic reviews sit at the top of the evidence hierarchy, the types of research questions they address are not suitable for every application [ 3 ]. Many indications more appropriately require a scoping review. For example, to explore the extent and nature of a body of literature, the development of evidence maps and summaries; to inform future research and reviews and to identify evidence gaps [ 2 ]. Scoping reviews are particularly useful where evidence is extensive and widely dispersed (i.e. many different types of evidence), or emerging and not yet amenable to questions of effectiveness [ 22 ]. Because scoping reviews are agnostic in terms of the types of evidence they can draw upon, they can be used to bring together and report upon heterogeneous literature—including both empirical and non-empirical evidence—across disciplines within and beyond health [ 23 , 24 , 25 ].

When deciding between whether to conduct a systematic review or a scoping review, authors should have a strong understanding of their differences and be able to clearly identify their review’s precise research objective(s) and/or question(s). Munn and colleagues noted that a systematic review is likely the most suitable approach if reviewers intend to address questions regarding the feasibility, appropriateness, meaningfulness or effectiveness of a specified intervention [ 3 ]. There are also online resources for prospective authors [ 26 ]. A scoping review is probably best when research objectives or review questions involve exploring, identifying, mapping, reporting or discussing characteristics or concepts across a breadth of evidence sources.

Scoping reviews are increasingly used to respond to complex questions where comparing interventions may be neither relevant nor possible [ 27 ]. Often, cost, time, and resources are factors in decisions regarding review type. Whilst many scoping reviews can be quite large with numerous sources to screen and/or include, there is no expectation or possibility of statistical pooling, formal risk of bias rating, and quality of evidence assessment [ 28 , 29 ]. Topics where scoping reviews are necessary abound—for example, government organisations are often interested in the availability and applicability of tools to support health interventions, such as shared decision aids for pregnancy care [ 30 ]. Scoping reviews can also be applied to better understand complex issues related to the health workforce, such as how shift work impacts employee performance across diverse occupational sectors, which involves a diversity of evidence types as well as attention to knowledge gaps [ 31 ]. Another example is where more conceptual knowledge is required, for example, identifying and mapping existing tools [ 32 ]. Here, it is important to understand that scoping reviews are not the same as ‘realist reviews’ which can also be used to examine how interventions or programmes work. Realist reviews are typically designed to ellucide the theories that underpin a programme, examine evidence to reveal if and how those theories are relevant and explain how the given programme works (or not) [ 33 ].

Increased demand for scoping reviews to underpin high-quality knowledge translation across many disciplines within and beyond healthcare in turn fuels the need for consistency, clarity and rigour in reporting; hence, following recognised reporting guidelines is a streamlined and effective way of introducing these elements [ 34 ]. Standardisation and clarity of reporting (such as by using a published methodology and a reporting checklist—the PRISMA-ScR) can facilitate better understanding and uptake of the results of scoping reviews by end users who are able to more clearly understand the differences between systematic reviews, scoping reviews and literature reviews and how their findings can be applied to research, practice and policy.

Future directions in scoping reviews

The field of evidence synthesis is dynamic. Scoping review methodology continues to evolve to account for the changing needs and priorities of end users and the requirements of review authors for additional guidance regarding terminology, elements and steps of scoping reviews. Areas where ongoing research and development of scoping review guidance are occurring include inclusion of consultation with stakeholder groups such as end users and consumer representatives [ 35 ], clarity on when scoping reviews are the appropriate method over other synthesis approaches [ 3 ], approaches for mapping and presenting results in ways that clearly address the review’s research objective(s) and question(s) [ 29 ] and the assessment of the methodological quality of scoping reviews themselves [ 21 , 36 ]. The JBI Scoping Review Methodology group is currently working on this research agenda.

Consulting with end users, experts, or stakeholders has been a suggested but optional component of scoping reviews since 2005. Many of the subsequent approaches contained some reference to this useful activity. Stakeholder engagement is however often lost to the term ‘review’ in scoping reviews. Stakeholder engagement is important across all knowledge synthesis approaches to ensure relevance, contextualisation and uptake of research findings. In fact, it underlines the concept of integrated knowledge translation [ 37 , 38 ]. By including stakeholder consultation in the scoping review process, the utility and uptake of results may be enhanced making reviews more meaningful to end users. Stakeholder consultation can also support integrating knowledge translation efforts, facilitate identifying emerging priorities in the field not otherwise captured in the literature and may help build partnerships amongst stakeholder groups including consumers, researchers, funders and end users. Development in the field of evidence synthesis overall could be inspired by the incorporation of stakeholder consultation in scoping reviews and lead to better integration of consultation and engagement within projects utilising other synthesis methodologies. This highlights how further work could be conducted into establishing how and the extent to which scoping reviews have contributed to synthesising evidence and advancing scientific knowledge and understandings in a more general sense.

Currently, many methodological papers for scoping reviews are published in healthcare focussed journals and associated disciplines [ 6 , 39 , 40 , 41 , 42 , 43 ]. Another area where further work could also occur is to gain greater understanding on how scoping reviews and scoping review methodology is being used across disciplines beyond healthcare including how authors, reviewers and editors understand, recommend or utilise existing guidance for undertaking and reporting scoping reviews.

Whilst available guidance for the conduct and reporting of scoping review has evolved over recent years, opportunities remain to further enhance and progress the methodology, uptake and application. Despite existing guidance, some publications using the term ‘scoping review’ continue to be conducted without apparent consideration of available reporting and methodological tools. Because consistent and transparent reporting is widely recongised as important for supporting rigour, reproducibility and quality in research, we advocate for authors to use a stated scoping review methodology and to transparently report their conduct by using the PRISMA-ScR. Selection of the most appropriate review type for the stated research objectives or questions, standardising the use of methodological approaches and terminology in scoping reviews, clarity and consistency of reporting and ensuring that the reporting and presentation of the results clearly addresses the authors’ objective(s) and question(s) are also critical components for improving the rigour of scoping reviews. We contend that whilst the field of evidence synthesis and scoping reviews continues to evolve, use of the PRISMA-ScR is a valuable and practical tool for enhancing the quality of scoping reviews, particularly in combination with other methodological guidance [ 10 , 12 , 44 ]. Scoping review methodology is developing as a policy and decision-making tool, and so ensuring the integrity of these reviews by adhering to the most up-to-date reporting standards is integral to supporting well informed decision-making. As scoping review methodology continues to evolve alongside understandings regarding why authors do or do not use particular methodologies, we hope that future incarnations of scoping review methodology continues to provide useful, high-quality evidence to end users.

Availability of data and materials

All data and materials are available upon request.

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Acknowledgements

The authors would like to acknowledge the other members of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) working group as well as Shazia Siddiqui, a research assistant in the Knowledge Synthesis Team in the Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto.

The authors declare that no specific funding was received for this work. Author ACT declares that she is funded by a Tier 2 Canada Research Chair in Knowledge Synthesis. KKO is supported by a Canada Research Chair in Episodic Disability and Rehabilitation with the Canada Research Chairs Program.

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Micah D. J. Peters & Casey Marnie

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Micah D. J. Peters

The Centre for Evidence-based Practice South Australia (CEPSA): a Joanna Briggs Institute Centre of Excellence, Faculty of Health and Medical Sciences, The University of Adelaide, 5006, Adelaide, South Australia

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MDJP, CM, HC, CMG, SH, TH, EVL, EL, KKO, OT, MGW, WZ and AT all made substantial contributions to the conception, design and drafting of the work. MDJP and CM prepared the final version of the manuscript. All authors reviewed and approved the final version of the manuscript.

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Peters, M.D.J., Marnie, C., Colquhoun, H. et al. Scoping reviews: reinforcing and advancing the methodology and application. Syst Rev 10 , 263 (2021). https://doi.org/10.1186/s13643-021-01821-3

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Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach

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Scoping reviews are a relatively new approach to evidence synthesis and currently there exists little guidance regarding the decision to choose between a systematic review or scoping review approach when synthesising evidence. The purpose of this article is to clearly describe the differences in indications between scoping reviews and systematic reviews and to provide guidance for when a scoping review is (and is not) appropriate.

Researchers may conduct scoping reviews instead of systematic reviews where the purpose of the review is to identify knowledge gaps, scope a body of literature, clarify concepts or to investigate research conduct. While useful in their own right, scoping reviews may also be helpful precursors to systematic reviews and can be used to confirm the relevance of inclusion criteria and potential questions.

Conclusions

Scoping reviews are a useful tool in the ever increasing arsenal of evidence synthesis approaches. Although conducted for different purposes compared to systematic reviews, scoping reviews still require rigorous and transparent methods in their conduct to ensure that the results are trustworthy. Our hope is that with clear guidance available regarding whether to conduct a scoping review or a systematic review, there will be less scoping reviews being performed for inappropriate indications better served by a systematic review, and vice-versa.

Peer Review reports

Systematic reviews in healthcare began to appear in publication in the 1970s and 1980s [ 1 , 2 ]. With the emergence of groups such as Cochrane and the Joanna Briggs Institute (JBI) in the 1990s [ 3 ], reviews have exploded in popularity both in terms of the number conducted [ 1 ], and their uptake to inform policy and practice. Today, systematic reviews are conducted for a wide range of purposes across diverse fields of inquiry, different evidence types and for different questions [ 4 ]. More recently, the field of evidence synthesis has seen the emergence of scoping reviews, which are similar to systematic reviews in that they follow a structured process, however they are performed for different reasons and have some key methodological differences [ 5 , 6 , 7 , 8 ]. Scoping reviews are now seen as a valid approach in those circumstances where systematic reviews are unable to meet the necessary objectives or requirements of knowledge users. There now exists clear guidance regarding the definition of scoping reviews, how to conduct scoping reviews and the steps involved in the scoping review process [ 6 , 8 ]. However, the guidance regarding the key indications or reasons why reviewers may choose to follow a scoping review approach is not as straightforward, with scoping reviews often conducted for purposes that do not align with the original indications as proposed by Arksey and O’Malley [ 5 , 6 , 7 , 8 , 9 , 10 ]. As editors and peer reviewers for various journals we have noticed that there is inconsistency and confusion regarding the indications for scoping reviews and a lack of clarity for authors regarding when a scoping review should be performed as opposed to a systematic review. The purpose of this article is to provide practical guidance for reviewers on when to perform a systematic review or a scoping review, supported with some key examples.

Indications for systematic reviews

Systematic reviews can be broadly defined as a type of research synthesis that are conducted by review groups with specialized skills, who set out to identify and retrieve international evidence that is relevant to a particular question or questions and to appraise and synthesize the results of this search to inform practice, policy and in some cases, further research [ 11 , 12 , 13 ]. According to the Cochrane handbook, a systematic review ‘uses explicit, systematic methods that are selected with a view to minimizing bias, thus providing more reliable findings from which conclusions can be drawn and decisions made.’ [ 14 ] Systematic reviews follow a structured and pre-defined process that requires rigorous methods to ensure that the results are both reliable and meaningful to end users. These reviews may be considered the pillar of evidence-based healthcare [ 15 ] and are widely used to inform the development of trustworthy clinical guidelines [ 11 , 16 , 17 ].

A systematic review may be undertaken to confirm or refute whether or not current practice is based on relevant evidence, to establish the quality of that evidence, and to address any uncertainty or variation in practice that may be occurring. Such variations in practice may be due to conflicting evidence and undertaking a systematic review should (hopefully) resolve such conflicts. Conducting a systematic review may also identify gaps, deficiencies, and trends in the current evidence and can help underpin and inform future research in the area. Systematic reviews can be used to produce statements to guide clinical decision-making, the delivery of care, as well as policy development [ 12 ]. Broadly, indications for systematic reviews are as follows [ 4 ]:

Uncover the international evidence

Confirm current practice/ address any variation/ identify new practices

Identify and inform areas for future research

Identify and investigate conflicting results

Produce statements to guide decision-making

Despite the utility of systematic reviews to address the above indications, there are cases where systematic reviews are unable to meet the necessary objectives or requirements of knowledge users or where a methodologically robust and structured preliminary searching and scoping activity may be useful to inform the conduct of the systematic reviews. As such, scoping reviews (which are also sometimes called scoping exercises/scoping studies) [ 8 ] have emerged as a valid approach with rather different indications to those for systematic reviews. It is important to note here that other approaches to evidence synthesis have also emerged, including realist reviews, mixed methods reviews, concept analyses and others [ 4 , 18 , 19 , 20 ]. This article focuses specifically on the choice between a systematic review or scoping review approach.

Indications for scoping reviews

True to their name, scoping reviews are an ideal tool to determine the scope or coverage of a body of literature on a given topic and give clear indication of the volume of literature and studies available as well as an overview (broad or detailed) of its focus. Scoping reviews are useful for examining emerging evidence when it is still unclear what other, more specific questions can be posed and valuably addressed by a more precise systematic review [ 21 ]. They can report on the types of evidence that address and inform practice in the field and the way the research has been conducted.

The general purpose for conducting scoping reviews is to identify and map the available evidence [ 5 , 22 ]. Arskey and O’Malley, authors of the seminal paper describing a framework for scoping reviews, provided four specific reasons why a scoping review may be conducted [ 5 , 6 , 7 , 22 ]. Soon after, Levac, Colquhoun and O’Brien further clarified and extended this original framework [ 7 ]. These authors acknowledged that at the time, there was no universally recognized definition of scoping reviews nor a commonly acknowledged purpose or indication for conducting them. In 2015, a methodological working group of the JBI produced formal guidance for conducting scoping reviews [ 6 ]. However, we have not previously addressed and expanded upon the indications for scoping reviews. Below, we build upon previously described indications and suggest the following purposes for conducting a scoping review:

To identify the types of available evidence in a given field

To clarify key concepts/ definitions in the literature

To examine how research is conducted on a certain topic or field

To identify key characteristics or factors related to a concept

As a precursor to a systematic review.

To identify and analyse knowledge gaps

Deciding between a systematic review and a scoping review approach

Authors deciding between the systematic review or scoping review approach should carefully consider the indications discussed above for each synthesis type and determine exactly what question they are asking and what purpose they are trying to achieve with their review. We propose that the most important consideration is whether or not the authors wish to use the results of their review to answer a clinically meaningful question or provide evidence to inform practice. If the authors have a question addressing the feasibility, appropriateness, meaningfulness or effectiveness of a certain treatment or practice, then a systematic review is likely the most valid approach [ 11 , 23 ]. However, authors do not always wish to ask such single or precise questions, and may be more interested in the identification of certain characteristics/concepts in papers or studies, and in the mapping, reporting or discussion of these characteristics/concepts. In these cases, a scoping review is the better choice.

As scoping reviews do not aim to produce a critically appraised and synthesised result/answer to a particular question, and rather aim to provide an overview or map of the evidence. Due to this, an assessment of methodological limitations or risk of bias of the evidence included within a scoping review is generally not performed (unless there is a specific requirement due to the nature of the scoping review aim) [ 6 ]. Given this assessment of bias is not conducted, the implications for practice (from a clinical or policy making point of view) that arise from a scoping review are quite different compared to those of a systematic review. In some cases, there may be no need or impetus to make implications for practice and if there is a need to do so, these implications may be significantly limited in terms of providing concrete guidance from a clinical or policy making point of view. Conversely, when we compare this to systematic reviews, the provision of implications for practice is a key feature of systematic reviews and is recommended in reporting guidelines for systematic reviews [ 13 ].

Exemplars for different scoping review indications

In the following section, we elaborate on each of the indications listed for scoping reviews and provide a number of examples for authors considering a scoping review approach.

Scoping reviews that seek to identify the types of evidence in a given field share similarities with evidence mapping activities as explained by Bragge and colleagues in a paper on conducting scoping research in broad topic areas [ 24 ]. Chambers and colleagues [ 25 ] conducted a scoping review in order to identify current knowledge translation resources (and any evaluations of them) that use, adapt and present findings from systematic reviews to suit the needs of policy makers. Following a comprehensive search across a range of databases, organizational websites and conference abstract repositories based upon predetermined inclusion criteria, the authors identified 20 knowledge translation resources which they classified into three different types (overviews, summaries and policy briefs) as well as seven published and unpublished evaluations. The authors concluded that evidence synthesists produce a range of resources to assist policy makers to transfer and utilize the findings of systematic reviews and that focussed summaries are the most common. Similarly, a scoping review was conducted by Challen and colleagues [ 26 ] in order to determine the types of available evidence identifying the source and quality of publications and grey literature for emergency planning. A comprehensive set of databases and websites were investigated and 1603 relevant sources of evidence were identified mainly addressing emergency planning and response with fewer sources concerned with hazard analysis, mitigation and capability assessment. Based on the results of the review, the authors concluded that while there is a large body of evidence in the field, issues with its generalizability and validity are as yet largely unknown and that the exact type and form of evidence that would be valuable to knowledge users in the field is not yet understood.

To clarify key concepts/definitions in the literature

Scoping reviews are often performed to examine and clarify definitions that are used in the literature. A scoping review by Schaink and colleagues 27 was performed to investigate how the notion of “patient complexity” had been defined, classified, and understood in the existing literature. A systematic search of healthcare databases was conducted. Articles were assessed to determine whether they met the inclusion criteria and the findings of included articles were grouped into five health dimensions. An overview of how complexity has been described was presented, including the varying definitions and interpretations of the term. The results of the scoping review enabled the authors to then develop a complexity framework or model to assist in defining and understanding patient complexity [ 27 ].

Hines et al. [ 28 ] provide a further example where a scoping review has been conducted to define a concept, in this case the condition bronchopulmonary dysplasia. The authors revealed significant variation in how the condition was defined across the literature, prompting the authors to call for a ‘comprehensive and evidence-based definition’. [ 28 ]

To examine how research is conducted on a certain topic

Scoping reviews can be useful tools to investigate the design and conduct of research on a particular topic. A scoping review by Callary and colleagues 29 investigated the methodological design of studies assessing wear of a certain type of hip replacement (highly crosslinked polyethylene acetabular components) [ 29 ]. The aim of the scoping review was to survey the literature to determine how data pertinent to the measurement of hip replacement wear had been reported in primary studies and whether the methods were similar enough to allow for comparison across studies. The scoping review revealed that the methods to assess wear (radiostereometric analysis) varied significantly with many different approaches being employed amongst the investigators. The results of the scoping review led to the authors recommending enhanced standardization in measurements and methods for future research in this field [ 29 ].

There are other examples of scoping reviews investigating research methodology, with perhaps the most pertinent examples being two recent scoping reviews of scoping review methods [ 9 , 10 ]. Both of these scoping reviews investigated how scoping reviews had been reported and conducted, with both advocating for a need for clear guidance to improve standardization of methods [ 9 , 10 ]. Similarly, a scoping review investigating methodology was conducted by Tricco and colleagues 30 on rapid review methods that have been evaluated, compared, used or described in the literature. A variety of rapid review approaches were identified with many instances of poor reporting identified. The authors called for prospective studies to compare results presented by rapid reviews versus systematic reviews.

Scoping reviews can be conducted to identify and examine characteristics or factors related to a particular concept. Harfield and colleagues (2015) conducted a scoping review to identify the characteristics of indigenous primary healthcare service delivery models [ 30 , 31 , 32 ]. A systematic search was conducted, followed by screening and study selection. Once relevant studies had been identified, a process of data extraction commenced to extract characteristics referred to in the included papers. Over 1000 findings were eventually grouped into eight key factors (accessible health services, community participation, culturally appropriate and skilled workforce, culture, continuous quality improvement, flexible approaches to care, holistic health care, self-determination and empowerment). The results of this scoping review have been able to inform a best practice model for indigenous primary healthcare services.

Scoping reviews conducted as precursors to systematic reviews may enable authors to identify the nature of a broad field of evidence so that ensuing reviews can be assured of locating adequate numbers of relevant studies for inclusion. They also enable the relevant outcomes and target group or population for example for a particular intervention to be identified. This can have particular practical benefits for review teams undertaking reviews on less familiar topics and can assist the team to avoid undertaking an “empty” review [ 33 ]. Scoping reviews of this kind may help reviewers to develop and confirm their a priori inclusion criteria and ensure that the questions to be posed by their subsequent systematic review are able to be answered by available, relevant evidence. In this way, systematic reviews are able to be underpinned by a preliminary and evidence-based scoping stage.

A scoping review commissioned by the United Kingdom Department for International Development was undertaken to determine the scope and nature of literature on people’s experiences of microfinance. The results of this scoping review were used to inform the development of targeted systematic review questions that focussed upon areas of particular interest [ 34 ].

In their recent scoping review on the conduct and reporting of scoping reviews, Tricco and colleagues 10 reveal only 12% of scoping reviews contained recommendations for the development of ensuing systematic reviews, suggesting that the majority of scoping review authors do not conduct scoping reviews as a precursor to future systematic reviews.

To identify and analyze gaps in the knowledge base

Scoping reviews are rarely solely conducted to simply identify and analyze gaps present in a given knowledge base, as examination and presentation of what hasn’t been investigated or reported generally requires exhaustive examination of all of what is available. In any case, because scoping reviews tend to be a useful approach for reviewing evidence rapidly in emerging fields or topics, identification and analysis of knowledge gaps is a common and valuable indication for conducting a scoping review. A scoping review was recently conducted to review current research and identify knowledge gaps on the topic of “occupational balance”, or the balance of work, rest, sleep, and play [ 35 ]. Following a systematic search across a range of relevant databases, included studies were selected and in line with predetermined inclusion criteria, were described and mapped to provide both an overall picture of the current state of the evidence in the field and to identify and highlight knowledge gaps in the area. The results of the scoping review allowed the authors to illustrate several research ‘gaps’, including the absence of studies conducted outside of western societies, the lack of knowledge around peoples’ levels of occupational balance, as well as a dearth of evidence regarding how occupational balance may be enhanced. As with other scoping reviews focussed upon identifying and analyzing knowledge gaps, results such as these allow for the identification of future research initiatives.

Scoping reviews are now seen as a valid review approach for certain indications. A key difference between scoping reviews and systematic reviews is that in terms of a review question, a scoping review will have a broader “scope” than traditional systematic reviews with correspondingly more expansive inclusion criteria. In addition, scoping reviews differ from systematic reviews in their overriding purpose. We have previously recommended the use of the PCC mnemonic (Population, Concept and Context) to guide question development [ 36 ]. The importance of clearly defining the key questions and objectives of a scoping review has been discussed previously by one of the authors, as a lack of clarity can result in difficulties encountered later on in the review process [ 36 ].

Considering their differences from systematic reviews, scoping reviews should still not be confused with traditional literature reviews. Traditional literature reviews have been used as a means to summarise various publications or research on a particular topic for many years. In these traditional reviews, authors examine research reports in addition to conceptual or theoretical literature that focuses on the history, importance, and collective thinking around a topic, issue or concept. These types of reviews can be considered subjective, due to their substantial reliance on the author’s pre-exiting knowledge and experience and as they do not normally present an unbiased, exhaustive and systematic summary of a topic [ 12 ]. Regardless of some of these limitations, traditional literature reviews may still have some use in terms of providing an overview of a topic or issue. Scoping reviews provide a useful alternative to literature reviews when clarification around a concept or theory is required. If traditional literature reviews are contrasted with scoping reviews, the latter [ 6 ]:

Are informed by an a priori protocol

Are systematic and often include exhaustive searching for information

Aim to be transparent and reproducible

Include steps to reduce error and increase reliability (such as the inclusion of multiple reviewers)

Ensure data is extracted and presented in a structured way

Another approach to evidence synthesis that has emerged recently is the production of evidence maps [ 37 ]. The purpose of these evidence maps is similar to scoping reviews to identify and analyse gaps in the knowledge base [ 37 , 38 ]. In fact, most evidence mapping articles cite seminal scoping review guidance for their methods [ 38 ]. The two approaches therefore have many similarities, with perhaps the most prominent difference being the production of a visual database or schematic (i.e. map) which assists the user in interpreting where evidence exists and where there are gaps [ 38 ]. As Miake-Lye states, at this stage ‘it is difficult to determine where one method ends and the other begins.’ [ 38 ] Both approaches may be valid when the indication is for determining the extent of evidence on a particular topic, particularly when highlighting gaps in the research.

A further popular method to define and scope concepts, particularly in nursing, is through the conduct of a concept analysis [ 39 , 40 , 41 , 42 ]. Formal concept analysis is ‘a process whereby concepts are logically and systematically investigated to form clear and rigorously constructed conceptual definitions,’ [ 42 ] which is similar to scoping reviews where the indication is to clarify concepts in the literature. There is limited methodological guidance on how to conduct a concept analysis and recently they have been critiqued for having no impact on practice [ 39 ]. In our opinion, scoping reviews (where the purpose is to systematically investigate a concept in the literature) offer a methodologically rigorous alternative to concept analysis with their results perhaps being more useful to inform practice.

Comparing and contrasting the characteristics of traditional literature reviews, scoping reviews and systematic reviews may help clarify the true essence of these different types of reviews (see Table 1 ).

Rapid reviews are another emerging type of evidence synthesis and a substantial amount of literature have addressed these types of reviews [ 43 , 44 , 45 , 46 , 47 ]. There are various definitions for rapid reviews, and for simplification purposes, we define these review types as ‘systematic reviews with shortcuts.’ In this paper, we have not discussed the choice between a rapid or systematic review approach as we are of the opinion that perhaps the major consideration for conducting a rapid review (as compared to a systematic or scoping review) is not the purpose/question itself, but the feasibility of conducting a full review given financial/resource limitations and time pressures. As such, a rapid review could potentially be conducted for any of the indications listed above for the scoping or systematic review, whilst shortening or skipping entirely some steps in the standard systematic or scoping review process.

There is some overlap across the six listed purposes for conducting a scoping review described in this paper. For example, it is logical to presume that if a review group were aiming to identify the types of available evidence in a field they would also be interested in identifying and analysing gaps in the knowledge base. Other combinations of purposes for scoping reviews would also make sense for certain questions/aims. However, we have chosen to list them as discrete reasons in this paper in an effort to provide some much needed clarity on the appropriate purposes for conducting scoping reviews. As such, scoping review authors should not interpret our list of indications as a discrete list where only one purpose can be identified.

It is important to mention some potential abuses of scoping reviews. Reviewers may conduct a scoping review as an alternative to a systematic review in order to avoid the critical appraisal stage of the review and expedite the process, thinking that a scoping review may be easier than a systematic review to conduct. Other reviewers may conduct a scoping review in order to ‘map’ the literature when there is no obvious need for ‘mapping’ in this particular subject area. Others may conduct a scoping review with very broad questions as an alternative to investing the time and effort required to craft the necessary specific questions required for undertaking a systematic review. In these cases, scoping reviews are not appropriate and authors should refer to our guidance regarding whether they should be conducting a systematic review instead.

This article provides some clarification on when to conduct a scoping review as compared to a systematic review and clear guidance on the purposes for conducting a scoping review. We hope that this paper will provide a useful addition to this evolving methodology and encourage others to review, modify and build upon these indications as the approach matures. Further work in scoping review methods is required, with perhaps the most important advancement being the recent development of an extension to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for scoping reviews [ 48 ] and the development of software and training programs to support these reviews [ 49 , 50 ]. As the methodology advances, guidance for scoping reviews (such as that included in the Joanna Briggs Institute Reviewer’s Manual) will require revision, refining and updating.

Scoping reviews are a useful tool in the ever increasing arsenal of evidence synthesis approaches. Researchers may preference the conduct of a scoping review over a systematic review where the purpose of the review is to identify knowledge gaps, scope a body of literature, clarify concepts, investigate research conduct, or to inform a systematic review. Although conducted for different purposes compared to systematic reviews, scoping reviews still require rigorous and transparent methods in their conduct to ensure that the results are trustworthy. Our hope is that with clear guidance available regarding whether to conduct a scoping review or a systematic review, there will be less scoping reviews being performed for inappropriate indications better served by a systematic review, and vice-versa.

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ZM: Led the development of this paper and conceptualised the idea for a paper on indications for scoping reviews. Provided final approval for submission. MP: Contributed conceptually to the paper and wrote sections of the paper. Provided final approval for submission. CS: Contributed conceptually to the paper and wrote sections of the paper. Provided final approval for submission. CT: Contributed conceptually to the paper and wrote sections of the paper. Provided final approval for submission. AM: Contributed conceptually to the paper and reviewed and provided feedback on all drafts. Provided final approval for submission. EA: Contributed conceptually to the paper and reviewed and provided feedback on all drafts. Provided approval and encouragement for the work to proceed. Provided final approval for submission.

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Munn, Z., Peters, M.D.J., Stern, C. et al. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 18 , 143 (2018). https://doi.org/10.1186/s12874-018-0611-x

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DOI : https://doi.org/10.1186/s12874-018-0611-x

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• Systematic review
• Scoping review
• Evidence-based healthcare

BMC Medical Research Methodology

ISSN: 1471-2288

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• Research Guides
• Reviewing Research: Literature Reviews, Scoping Reviews, Systematic Reviews
• Differentiating the Three Review Types

Reviewing Research: Literature Reviews, Scoping Reviews, Systematic Reviews: Differentiating the Three Review Types

• Framework, Protocol, and Writing Steps
• Working with Keywords/Subject Headings
• Citing Research

The Differences in the Review Types

Grant, M.J. and Booth, A. (2009), A typology of reviews: an analysis of 14 review types and associated methodologies. H ealth Information & Libraries Journal , 26: 91-108. https://doi.org/10.1111/j.1471-1842.2009.00848.x   The objective of this study is to provide descriptive insight into the most common types of reviews, with illustrative examples from health and health information domains.

• What Type of Review is Right for you (Cornell University)

Literature Reviews

Literature Review: it is a product and a process.

As a product , it is a carefully written examination, interpretation, evaluation, and synthesis of the published literature related to your topic. It focuses on what is known about your topic and what methodologies, models, theories, and concepts have been applied to it by others.

The process is what is involved in conducting a review of the literature.

• It is ongoing
• It is iterative (repetitive)
• It involves searching for and finding relevant literature.
• It includes keeping track of your references and preparing and formatting them for the bibliography of your thesis

• Literature Reviews (University of North Carolina at Chapel Hill) This handout will explain what literature reviews are and offer insights into the form and construction of literature reviews in the humanities, social sciences, and sciences.

Scoping Reviews

Scoping reviews are a " preliminary assessment of potential size and scope of available research literature . Aims to identify nature and extent of research evidence (usually including ongoing research)." Grant and Booth (2009).

Scoping reviews are not mapping reviews: Scoping reviews are more topic based and mapping reviews are more question based.

• examining emerging evidence when specific questions are unclear - clarify definitions and conceptual boundaries
• identify and map the available evidence
• a scoping review is done prior to a systematic review
• to summarize and disseminate research findings in the research literature
• identify gaps with the intention of resolution by future publications

• Scoping review timeframe and limitations (Touro College of Pharmacy

Systematic Reviews

Many evidence-based disciplines use ‘systematic reviews," this type of review is a specific methodology that aims to comprehensively identify all relevant studies on a specific topic, and to select appropriate studies based on explicit criteria . ( https://cebma.org/faq/what-is-a-systematic-review/ )

• clearly defined search criteria
• an explicit reproducible methodology
• a systematic search of the literature with the defined criteria met
• assesses validity of the findings - no risk of bias
• a comprehensive report on the findings, apparent transparency in the results

• Better evidence for a better world Browsable collection of systematic reviews
• Systematic Reviews in the Health Sciences by Molly Maloney Last Updated Jan 8, 2024 360 views this year
• Next: Framework, Protocol, and Writing Steps >>

What is a Scoping Review?

• Peer Review

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Updated on August 24, 2022

Scoping reviews are similar to systematic reviews but are conducted for different reasons. Scoping reviews tend to focus on the nature, volume, or characteristics of studies rather than on the synthesis of published data.

Scoping reviews were developed in the early 2000s. Researchers saw the need for a review type that could be published that was less detailed than a systematic review but more detailed than a narrative (summary) review. These can be more speculative: Scoping a research area in order to highlight possible new research directions. These can also position researchers as potential "thought leaders" within areas and so are popular article types to write as they can garner high citation rates.

According to a research article on scoping reviews, "Researchers may conduct scoping reviews instead of systematic reviews where the purpose of the review is to identify knowledge gaps, scope a body of literature, clarify concepts or to investigate research conduct." (Munn, et al. 2018) .

To date, no set methods for scoping reviews have been established. General guidelines have been published and are detailed below. Despite the lack of rules, scoping reviews must contain valid, transparent research methods. As with all research studies, the methods above all must be reproducible by other authors.

A scoping review is a relatively new research methodology. However, when performed correctly, it can contribute greatly to a research field.

What is a scoping review?

Scoping reviews are similar to systematic reviews, but they tend to focus on the nature, volume, or characteristics of studies or gaps in knowledge. In contrast, systematic reviews evaluate and synthesize data on a particular subject or question.

Scoping reviews are performed to "scope" a broad topic in a research field.

Daudt et al. (2013) suggested the following definition of scoping studies: "Scoping studies aim to map the literature on a particular topic or research area and provide an opportunity to identify key concepts; gaps in the research; and types and sources of evidence to inform practice, policymaking, and research."

The purpose of a scoping review

According to Munn et al., 2018, "Scoping reviews are useful for examining emerging evidence when it is still unclear what other, more specific questions can be posed and valuably addressed by a more precise systematic review. They can report on the types of evidence that address and inform practice in the field and the way the research has been conducted."

You may perform a scoping review when there is little data on a topic or when data are heterogeneous. This may be when evidence is still emerging or unclear. Thus, scoping reviews can be performed prior to a detailed systematic review on a topic.

For example, many scoping reviews have been conducted on COVID-19. This is because COVID-19 is a relatively new disease and data are still being collected.

What level of evidence is a scoping review?

Systematic reviews have the highest level of evidence of all research types.

Scoping reviews do not contain the level of detail of systematic reviews. They may have a higher risk of bias due to higher heterogeneity. Thus, their level of evidence is considered only moderate.

The benefit of scoping reviews is that they help map the literature on a specific topic. Additionally, they can inform future research and systematic reviews on that topic.

How to conduct a scoping review

In 2005, Arksey and O'Malley published a scoping review framework. Their framework has been modified over the years, but the concepts remain the same.

They proposed an iterative six-stage process:

(1) identify the research question

(2) identify relevant studies

(3) select studies

(4) chart the data

(5) collect, summarize and report the results

(6 - optional) perform a consultation exercise

Over the years, this framework has been enhanced by researchers such as Daudt et al. (2013).

There is no consensus on the length of a scoping review. Reviews should be long enough to clearly present the results but should not contain irrelevant information.

Scoping review protocols

Several websites outlining the gold-standard reporting guidelines for scoping reviews exist. Additionally, a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist specifically for scoping reviews has been published. Click here to review the PRISMA checklist .

The general protocol for a scoping review is as follows:

• Introduction
• Definitions
• Review objective(s)
• Preliminary search details, if performed
• Explanation of the need for this review
• Eligibility criteria
• Sample search strategy
• Explanation of the search approach
• Black and gray literature that was searched
• Reasons for including the literature
• Study selection process,
• Include an explanation of how disagreements between reviewers will be resolved
• The table/form used for data extraction and an explanation of the form
• Presentation of results and data
• This may include text, tables, charts, figures, etc.

For additional information, Click here to see the Joanna Briggs Institute's website on scoping reviews .

Click here for an example of a published scoping review protocol .

Click here to review multiple scoping review preprints .

Scoping reviews versus other types of reviews

Many types of reviews exist. The most common are systematic reviews, scoping reviews, and narrative reviews. Narrative reviews are also called summary reviews. It can be hard to know which type of review to choose.

Systematic reviews

Systematic reviews are often accompanied by meta-analyses. The goal of a systematic review is to summarize existing data on a specific research question. For example, does nutritional status in infancy affect obesity risk in early childhood? Another way to think about this is researching research! Research studies included in a systematic review must meet specific criteria regarding methods, outcomes, sampling, etc.

Munn et al. (2018) notes that "According to the Cochrane handbook, a systematic review ‘uses explicit, systematic methods that are selected with a view to minimizing bias, thus providing more reliable findings from which conclusions can be drawn and decisions made.'"

Additionally, systematic reviews mostly focus on specific study types; for example, case-cohort studies, prospective studies, etc. Scoping reviews can summarize data from many different study types (Arksey and O'Malley, 2005).

Scoping reviews

Scoping reviews also aim to answer a research question. However, the question can be a bit more broad, and the inclusion criteria not as strict. For example, you can include multiple study types in a scoping review, while study types in systematic reviews are generally restricted. Scoping reviews still must use reproducible research methods, but the methodology is not as strict.

As noted in Munn et al. (2018), "Scoping reviews are similar to systematic reviews in that they follow a structured process, however they are performed for different reasons and have some key methodological differences."

Narrative reviews (summary reviews)

Narrative reviews do not aim to answer a research question. Rather, they aim to summarize the available data on a topic in a descriptive format. Narrative reviews are more similar to literature reviews or book chapters than research papers. Generally, no methods need to be followed because you are "telling the story" of a particular topic.

See below for a quick summary of the components of all three review types:

Final thoughts

While scoping reviews may not be as detailed as systematic reviews, they play a beneficial role in the research landscape. Scoping reviews can help summarize known and yet unknown data on a specific topic. This is especially true for new research topics, such as new diseases or technologies.

If your research interests involve new frontiers, consider publishing a scoping review.

To learn more about AJE's editing, pre-submission review, and scientific review services, visit our services page .

Catherine Zettel Nalen, MS

Academic Editor, Specialist, and Journal Recommendation Team Lead

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Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach

Affiliations.

• 1 The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005, South Australia. [email protected].
• 2 The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005, South Australia.
• PMID: 30453902
• PMCID: PMC6245623
• DOI: 10.1186/s12874-018-0611-x

Background: Scoping reviews are a relatively new approach to evidence synthesis and currently there exists little guidance regarding the decision to choose between a systematic review or scoping review approach when synthesising evidence. The purpose of this article is to clearly describe the differences in indications between scoping reviews and systematic reviews and to provide guidance for when a scoping review is (and is not) appropriate.

Results: Researchers may conduct scoping reviews instead of systematic reviews where the purpose of the review is to identify knowledge gaps, scope a body of literature, clarify concepts or to investigate research conduct. While useful in their own right, scoping reviews may also be helpful precursors to systematic reviews and can be used to confirm the relevance of inclusion criteria and potential questions.

Conclusions: Scoping reviews are a useful tool in the ever increasing arsenal of evidence synthesis approaches. Although conducted for different purposes compared to systematic reviews, scoping reviews still require rigorous and transparent methods in their conduct to ensure that the results are trustworthy. Our hope is that with clear guidance available regarding whether to conduct a scoping review or a systematic review, there will be less scoping reviews being performed for inappropriate indications better served by a systematic review, and vice-versa.

Keywords: Evidence-based healthcare; Scoping review; Systematic review.

• Choice Behavior* / physiology
• Decision Making / physiology
• Evidence-Based Medicine / methods
• Evidence-Based Medicine / standards
• Guidelines as Topic* / standards
• Publications / classification
• Publications / standards
• Research Design
• Research Personnel
• Review Literature as Topic*
• Systematic Reviews as Topic*

• Open access
• Published: 20 June 2022

Protocol for a scoping review to map patient engagement in scoping reviews

• Nebojša Oravec 1 ,
• Caroline Monnin 2 ,
• April Gregora 3 ,
• Brian Bjorklund 3 ,
• Mudra G. Dave 4 ,
• Annette S. H. Schultz 5 , 6 &
• Anna M. Chudyk 5 , 6  

Research Involvement and Engagement volume  8 , Article number:  27 ( 2022 ) Cite this article

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Scoping reviews of health research are increasing in popularity. However, only a minority of scoping reviews in this sector engage patients and caregivers as co-producers of the research. Despite developments in scoping review methodology, which insist that stakeholder consultation is essential, no guiding methods exist to instruct the conduct of this stage. Thus, it is necessary to understand how patients and caregivers have been engaged as part of scoping reviews, toward a unifying methodology.

We have developed a protocol for a scoping review of methods used to engage patients and caregivers in scoping reviews of health research. The search strategy will comprise two phases: the first will involve a secondary analysis of retrieved articles from a prior scoping review, and the second will identify articles that cite Levac et al.’s update to the original scoping review framework by Arksey and O’Malley. Titles and full texts of retrieved articles will be screened in duplicate. Inclusion will be limited to articles related to heath research that follow the six-stage scoping review framework by Arksey and O’Malley and that report patient engagement activities during at least one stage. The method of analysis of charted variables will be decided once data have been collected. Two patients will be engaged as collaborators throughout this review. We will also consult with patients, caregivers, and researchers upon completion of preliminary analyses.

We anticipate that our scoping review will provide guidance for researchers seeking to involve health care stakeholders as co-producers of scoping reviews.

Plain English summary

A “scoping review” is a type of study that collects and summarizes published and unpublished research reports to better understand the amount and types of information available on a particular topic. There is a well-known framework for how to conduct a scoping review, which involves six stages. The sixth stage is optional, and involves consulting with people who have an interest in the research results (i.e., people who the research is “about” or who it will affect the most). Very few scoping reviews actually include this stage, potentially due to a lack of practical guidance on how to perform it. For scoping reviews related to health research, it is important to consult or more widely engage patients and caregivers in the scoping review’s conduct because these individuals have a unique type of knowledge that comes from their experience of a health issue, which can yield valuable insights. Therefore, we have designed a scoping review that will identify the ways in which patients and caregivers have been engaged in scoping reviews of health research in the past. We hope to produce recommendations to make it easier for other researchers to engage patients and caregivers in scoping reviews.

Peer Review reports

A scoping review is a type of knowledge synthesis that aims to map the key concepts and knowledge gaps related to an exploratory research question, and the sources and types of evidence available [ 1 , 2 , 3 ]. Its popularity has skyrocketed over recent years [ 4 ]. Several approaches have been proposed for conducting scoping reviews [ 5 , 6 , 7 , 8 ], of which the framework by Arksey and O’Malley is one of the most common [ 8 ]. According to Arksey and O’Malley, a scoping review consists of six stages: (1) Identifying the research question, (2) Identifying relevant studies, (3) Study selection, (4) Charting (i.e., extracting) the data, (5) Collating, summarising, and reporting the results, and (6) Consultation. Of these stages, the sixth (consultation) was considered optional. Though Arksey and O’Malley discuss consultation as providing an additional source of knowledge, particularly on the relevance of data gathered from studies included in the scoping review, they do not offer advice on how to define or conduct the consultation, collect and organize the resultant information, nor how to integrate the results of consultation into the findings of the scoping review. Other barriers to consultation could be related to resources, skills and motivations, recruitment issues, and logistics [ 9 ]. Unsurprisingly, less than 50 percent of scoping reviews incorporate consultation within their methods [ 8 ].

Consultation has been conceptualized as an activity in which relevant stakeholders provide feedback to researchers, who may or may not incorporate this information in their subsequent decision-making [ 10 , 11 ]. Patient engagement is a research approach that involves the active engagement of patients and informal caregivers (e.g., friends and family) in the design, conduct, analysis, and/or dissemination of research—also referred to as “co-production” [ 12 ]. In this context, consultation is one mode along a “spectrum of engagement,” where each level across the spectrum is associated with a different degree of decision-making power among researchers and the public [ 10 ]. For example, patients have an advisory role in the level “involve,” whereas there is equal partnering in the level “collaborate,” and they have final decision-making power in the level “lead/support.” The moral imperative of engaging patients and caregivers in research through activities such as consultation, and its benefits for public funders, participants, healthcare users, academia, and industry, is becoming increasingly apparent [ 13 , 14 ]. Some of these benefits include the potential for increased uptake of research findings, results that are more generalizable, and increased satisfaction. In an update of the framework proposed by Arksey and O’Malley, Levac et al. argue that consultation should be a requirement [ 6 ]. Thus, failure to engage patients and caregivers in scoping reviews can be seen as a limitation, especially in the realm of health and medicine, which is the sector that publishes the majority of scoping reviews [ 8 ].

To support the uptake of consultation as a required component of scoping reviews, in this article we propose a protocol for a scoping review of methods to engage patients and caregivers in scoping reviews of health research. Since we conceptualize consultation as one component of a broader engagement spectrum that represents the different degrees to which patients and caregivers can be engaged in scoping reviews, we are not only interested in studies that “ consult ” patients and caregivers but also in the broader spectrum of engagement modes (i.e., involve, collaborate, lead/support). Further, as the spectrum of engagement provides limited practical guidance on the types of activities that can be used to engage patients and caregivers, we are interested in not only the levels at which patients and caregivers were engaged, but also the activities used to engage them. Through this proposed work, we hope to provide guidance on how patients and caregivers can be involved throughout the stages of a scoping review and thereby help facilitate the routine engagement of the stakeholders in this work. The results of the review will serve to emphasize consultation as a feature that distinguishes scoping reviews from other types of secondary research.

A scoping review approach was chosen due to the broad nature of our research question. Moreover, we anticipate heterogeneous methods for and ways of reporting patient engagement, primarily because the topic of engagement methods in context of health-related scoping reviews has not been extensively studied before.

Team composition and engagement of patients within our research team

Uniquely, our entire research team (including two patient co-researchers, also commonly referred to as "patient partners" or "research collaborators") has experience engaging patients as co-producers of prior scoping reviews. The two patient co-researchers (AG and BB) have lived experience as cardiac surgery patients, previous co-research experiences, and have co-authored other publications and knowledge translation products [ 15 , 16 ]. They collaborated on the development of this protocol through research team meetings and provided feedback on this resultant protocol submission. As we move forward on the scoping review, these patient co-researchers will continue to collaborate on the study as equal members of our research team. In this way, the study will serve as a working example of the benefits of co-production. We will formally establish their roles and responsibilities (along with those of the other research team members working on the study) through the co-development of a terms of reference at the outset of the scoping review. This living document will briefly explain all of the proposed stages of the scoping review, opening the door for informed conversations about the different opportunities for involvement across the entirety of the study. Based on early discussions, we anticipate that some of the patient co-researchers’ future roles and responsibilities may include engaging in team meetings aimed at: discussing challenges and uncertainties related to study selection and refining the search strategy and selection criteria if necessary, calibrating the study’s charting form based on a subset of extracted studies, deciding upon the best methods to analyze the charted variables, developing the instrument used in the study’s consultation phase, interpreting the collected data, helping plan the resultant manuscript and other related knowledge translation/dissemination products. In addition, patient co-researchers will provide feedback on the resultant scoping review manuscript and likely help create and present other knowledge translation/disseminations products. We will evaluate our study’s patient engagement activities and their impacts through a modified version of the Public and Patient Engagement Evaluation tool and regular reflexive check-ins focused on addressing the considerations related outlined in the Guidance for Reporting Involvement of Patients and the Public 2 (GRIPP2) checklist [ 17 , 18 ].

Reporting guidelines

The planning of this scoping review protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P, Additional file 1 ) and the PRISMA-ScR (Additional file 2 ) [ 19 ]. The reporting of patient engagement activities is in accordance with the GRIPP2 short form (Additional file 3 ) [ 18 ]. There has been no prospective registration in any database.

Scoping review methodology

This protocol describes a scoping review in keeping with the six-stage scoping review framework described by Arksey and O’Malley and with the revised recommendations by Levac et al. [ 5 , 6 ].

Stage 1: Identifying the research question

The research question was developed in accordance with the population, context, concept (PCC) framework (Table 1 ).

The research question

How have patients and caregivers been engaged in scoping reviews of health research guided by the methodology proposed by Arksey and O’Malley [ 5 ] and Levac et al. [ 6 ]?

Stage 2: Identifying relevant studies

Search methods.

The search strategy will comprise two phases that will be conducted and finished within approximately two weeks. Since Pham et al. conducted a comprehensive scoping review that identified all relevant scoping reviews published before 2013, our first phase will comprise a secondary analysis of the articles included in Pham et al.’s scoping review [ 8 ]. The authors’ search strategy identified all scoping reviews published in the following electronic databases within the associated timelines: Medline/PubMed (biomedical sciences, 1946–2012), SciVerse Scopus (multidisciplinary; 1823–2012), CINAHL/EBSCO (nursing and allied health; 1981–2012), Current Contents Connect/ISI Web of Knowledge (multidisciplinary current awareness; 1998–2012). Their strategy was also supplemented by a grey literature search and reference checking.

In the second phase, articles published subsequent to the last search date reported in Pham et al.’s review (October 1, 2012) will be identified through a search strategy designed to identify any scoping reviews citing Levac et al.’s 2010 update to the Arskey and O’Malley framework [ 6 ]. Scoping reviews citing Levac et al. will be identified from the following electronic databases: Medline (Ovid), Scopus, Web of Science, PsychINFO (Ovid), and the Joanna Briggs Institute. These databases were selected because of their relevancy to health research as well as their ability to track citations. Although Google Scholar can track citations, it was not selected due to its vast subject coverage. To locate grey literature, we will search ProQuest Theses & Dissertations and OSF Registries, using a similar search strategy of locating records that cite Levac et al. A sample search strategy is provided in Table 2 .

This two-phase search strategy was developed in an iterative process led by an expert health sciences librarian (CM) and validated by a second librarian using the Peer Review of Electronic Search Strategy (PRESS) checklist [ 22 ]. To maximize available resources, we focused our search strategy on scoping reviews that cite Levac et al.’s work, as they are often cited as supporting consultation as a required stage within Arksey and O’Malley’s framework. While we acknowledge that this decision could result in the omission of some relevant articles, through this approach, we aimed to balance comprehensiveness and feasibility in the context of our broad research question and a substantial increase in the number of scoping reviews published since the article by Pham et al. That is, although ideally we would wish to replicate the search conducted in Pham et al. with updated timelines, the growth of scoping reviews in the last 10 years makes it unfeasible to do so. For example, the Medline (Ovid) search conducted by Pham et al. in 2011 had 454 results, whereas the same search in Medline (Ovid) as of January 1, 2022 has 10,389 results. In addition, through hand-searching the literature, we have found that consultation methods are rarely mentioned in titles and abstracts, making it difficult to identify articles involving patient engagement using keyword search terms.

All resources will be exported to EndNote (version × 9), and the screening process will be conducted in the free, online systematic review management software, Covidence.

Inclusion and exclusion criteria

To be eligible for inclusion, a scoping review must be related to health research. Secondly, it must be guided by the Arksey and O’Malley framework for scoping reviews [ 5 ]. Even if not explicitly stated, if the scoping review comprises the same stages as those proposed by Arksey and O’Malley, it will be included. Finally, the scoping review must have engaged patients and/or caregivers (see Table 1 for definitions of these terms) in at least one of the stages of the scoping review, including and not limited to the formal consultation stage proposed by Arksey and O’Malley (i.e., Stage 6). Articles written in a language other than English will be excluded.

Stage 3: Study selection

We will select articles using a two-phase approach: first from the list of included articles in the paper by Pham et al., then from the articles identified through our search. For both phases, the (1) titles and abstracts and (2) full-texts of identified articles will be screened in duplicate by two independent reviewers. This is instead of the standard three-step workflow (i.e., titles, then abstracts, then full-texts) for study selection, which is not relevant for our purposes because some of our inclusion criteria are not consistently reported in abstracts (i.e., scoping review framework and the presence of patient engagement).To establish agreement and resolve discrepancies in applying study selection criteria, reviewers will screen a random subset of titles and abstracts (n = 100 articles) and full-texts (n = 5 articles) and meet with a third reviewer to go over their agreement and resolve any discrepancies. Further, at the beginning and end, and throughout the study selection stage, reviewers will meet with the study team to discuss challenges and uncertainties and refine the search strategy or selection criteria if necessary. A third reviewer will resolve discrepancies as necessary. In the event that it is unclear whether a study meets inclusion criteria, a designated reviewer will attempt to contact the study’s corresponding author for clarifying information. The flow of studies included in the scoping review will be reported in a modified PRISMA flowchart (Fig.  1 ).

PRISMA flowchart for study selection

Stage 4: Charting (i.e., extracting) the data

The charting form will include general information about the study and its design and more specific information about the methods of engagement (Table 3 ). Many of the engagement variables will be charted narratively (as opposed to nominal response choices) since there is no consensus on what elements of consultation (and more broadly, engagement) should be reported in a scoping review. The charting form will be calibrated by the research team using the first 5–10 studies to ensure consistency and may be modified in iterations based on increased familiarity with the included studies. Data will be charted in duplicate, and records will be stored and managed using Google Forms, Google Sheets, and Microsoft Excel. Inconsistencies will be resolved through conversation and/or consulting a third reviewer. To establish agreement and resolve discrepancies in how data are charted, at this stage’s outset, reviewers will chart a random subset (n = 5) of included studies and meet with a third reviewer to go over their agreement and resolve any discrepancies. To help minimize missing data, a designated reviewer will attempt to contact the corresponding author of any included study that is missing information relevant to the charting form.

Stage 5: Collating, summarizing, and reporting the results

The research team will decide the best method for analyzing the charted variables once the data have been collected. We anticipate using a qualitative thematic analysis to summarize narratively-collected information pertaining to engagement methods. This will be conducted using a qualitative coding software, and the specific approach will be decided at the time of analysis. Dichotomous or nominal variables will be summarized using descriptive statistics. The results may be presented using figures, concept maps, diagrams, or tables. Regular meetings and consensus discussions will aim to eliminate biases and strive to achieve a mutual interpretation of the review findings. During this stage, scoping reviews may be excluded from the final analyses if they do not provide sufficient detail about the methods used to engage patients and caregivers.

Stage 6: Consultation

Upon completion of preliminary analyses, we will also consult patients, caregivers, and researchers to gather additional data on methods used to engage patients and caregivers in scoping reviews and help make sense of study findings. We plan to do this by surveying corresponding authors of articles included in our review and patients, caregivers, and researchers recruited through personal (e.g., social media) and professional networks. The survey will re-phrase the review question to directly address respondents and contain items that aim to clarify and/or validate preliminary findings. The survey will also ask respondents to identify scoping reviews of health research that engaged patients and caregiver co-researchers, for consideration for inclusion in the review using the process outlined above. The specific survey questions will be decided once the preliminary analysis has been completed. To improve accessibility, respondents will also be given the option to complete the survey through other modes (e.g., phone call, Zoom) and engage in a follow-up discussion if they wish to build upon their survey responses.

The proposed scoping review will gather existing methods for engaging patients and caregivers in scoping reviews. Due to the limited availability of guiding methods, we expect our review findings to assist researchers in incorporating lived experience perspectives in their scoping reviews. For example, the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist extension for scoping reviews (PRISMA-ScR) contains a checklist for the reporting of essential and optional items for scoping reviews. Though the other elements of Arksey and O’Malley’s framework are represented in PRISMA-ScR, reporting of the goals, activities, and findings of stakeholder consultation are absent [ 19 ]. We hope that our study findings support the creation of a set of recommended reporting items related to consultation that could be added to the PRISMA-ScR checklist. Ultimately, we aim to advance and facilitate the inclusion of patient and caregiver perspectives in research so as to improve understanding of their conditions and healthcare experiences, and consequently, the provision of their health care.

We expect our review to show that the methods used to engage patients and caregivers in scoping reviews are heterogeneous, as is their reporting. We also anticipate more frequent consultation at the planning stages of research (i.e., Stage 1: Identifying the research question) and following data analysis, and less often in the actual conduct of the review (e.g., identifying studies, selection, charting, analysis). This is in keeping with other patient engagement research, which has shown that patients are often treated as consultants at key study points rather than partners or co-producers of the research product [ 23 ]. Another goal of our review will be to produce recommendations for co-producing scoping reviews with patients from start to finish. We acknowledge the scoping review protocol by Tischerning et al. [ 24 ], and systematic rapid review by Manafo et al. [ 10 ], which have some shared objectives, but without focus on engagement in the context of a scoping review study design. Our review findings will be disseminated in the form of a peer-reviewed publication, conference presentations, and non-traditional knowledge transitional activities, such as on our research group website ( http://www.patientengagementinresearch.ca ).

Availability of data and materials

All data generated or analyzed in this study will be included in the published scoping review article. Other resources can be made available upon request.

Abbreviations

Preferred reporting items for systematic review and meta-analysis scoping reviews

Preferred reporting items for systematic review and meta-analysis protocols

Guidance for reporting involvement of patients and the public 2

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Oravec, N., Monnin, C., Gregora, A. et al. Protocol for a scoping review to map patient engagement in scoping reviews. Res Involv Engagem 8 , 27 (2022). https://doi.org/10.1186/s40900-022-00361-x

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• Published: 12 March 2024

Mental health and psychosocial interventions in the context of climate change: a scoping review

• Siqi Xue 1 ,
• Alessandro Massazza 2 ,
• Samia C. Akhter-Khan 3 ,
• Britt Wray 4 ,
• M. Ishrat Husain 1 , 5 &
• Emma L. Lawrance 6 , 7 , 8  

npj Mental Health Research volume  3 , Article number:  10 ( 2024 ) Cite this article

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• Health care
• Planetary science

The evidence on the impacts of climate change on mental health and wellbeing is growing rapidly. The objective of this scoping review is to understand the extent and type of existing mental health and psychosocial interventions aimed at addressing the mental health and psychosocial impacts of climate change. A scoping review methodology was followed. MEDLINE, PsycINFO, and Web of Science databases were searched from inception to May 2022. Comprehensive gray literature search, including expert consultation, was conducted to identify interventions for which peer-reviewed academic literature may not yet be available. Data on intervention type, setting, climate stressor, mental health outcome, evaluation, and any other available details were extracted, and results were summarized narratively. Academic literature search identified 16 records and gray literature search identified a further 24 records. Altogether, 37 unique interventions or packages of interventions were identified. The interventions act at the levels of microsystem, mesosystem, exosystem, and macrosystem through diverse mechanisms. While most interventions have not been formally evaluated, promising preliminary results support interventions in low- and middle-income-country settings disproportionately affected by climate disasters. Interventions from multidisciplinary fields are emerging to reduce psychological distress and enhance mental health and wellbeing in the context of climate change. This scoping review details existing evidence on the interventions and summarizes intervention gaps and lessons learned to inform continued intervention development and scale-up interventions.

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Introduction

Climate change is increasingly recognized as a public health emergency 1 , 2 . Beyond its well-recognized physical health consequences, the crisis impacts mental health in profound ways 1 , 3 , 4 , 5 . Climate events have been associated with worsened psychiatric mortality outcomes, including depression, post-traumatic stress disorder (PTSD), and suicide 6 . Various population groups have been identified as being particularly at-risk, including children and youth, older adults, pregnant women, people living with chronic illnesses, and racialized communities 6 , 7 . Indigenous groups worldwide have described feelings of sadness, anger, grief, fear, and helplessness from climate change-related forced migration, disrupted cultural continuity, and historical and ongoing disempowerment 8 .

Researchers in the climate change and mental health space acknowledge the intricate tension between recognizing the detrimental mental health impacts of climate change while not pathologizing culture-specific, expected, and adaptive responses to ongoing and anticipated threats. To encapsulate the nuanced range of experiences, new vocabulary, such as climate emotions, eco-anxiety, and ecological grief, have been introduced to literature 4 , 7 . Academics and third-sector organizations have also begun to identify protective coping mechanisms, including “active hope” and “meaning-focused coping” that emphasize acting in line with values, developing positive framings, and creating hope through action and trust in societal actors 9 , 10 , 11 .

Despite the accumulating evidence on climate-related mental health and/or psychological responses and coping strategies, little is known about evidence-based interventions to mitigate the negative consequences and support individuals and their communities. Of the 120 original studies identified in a scoping review on climate change and mental health research, the vast majority were cross-sectional studies quantifying the impact of climate change exposure on mental health outcomes 6 . The 8 studies related to interventions were primarily proposals and did not contain conclusive evidence. In another review on interventions for eco-anxiety, only 2 studies involved an empirical evaluation component, with the rest being conceptual or reflection papers 12 . The most comprehensive review to date identified 23 studies 13 , but did not differentiate between interventions implemented for a climate-related event and those for other settings (e.g., armed conflicts) theoretically relevant to the climate change context. The review was further limited to academic literature and interventions for preventing or treating known psychiatric disorders. As the World Health Organization (WHO) defines mental health as not the mere absence of a disorder but an overall state of wellbeing 14 , a broader conceptual framework could be helpful to recognize interventions that promote psychological strengths and emotional resilience in the face of climate stressors.

As increasing numbers of mental health interventions are being formally or informally developed and implemented in the context of climate change, there is a strong need to map out this space to facilitate knowledge exchange and identify best practices to scale-up support. Indeed, one of the global research priorities identified in a recent consensus building exercise is to “assess the appropriateness, feasibility, effectiveness, and scalability of mental health and psychosocial interventions (clinical and non-clinical) in the context of climate change” 15 . The current review aims to address this need by (1) focusing on existing interventions aimed at promoting mental health or mitigating the impacts on mental health; (2) considering broad mental health and wellbeing outcomes, which are not limited to predefined psychiatric diagnoses or newly described psychological states; and (3) incorporating a formal gray literature search process to identify interventions that have not been studied academically but are being implemented. The exploratory and flexible nature of a scoping review represents, therefore, an ideal methodology. To our knowledge, this is the first scoping review that aims to identify all such mental health and psychosocial interventions that have been implemented in the context of climate change.

The scoping review was conducted in accordance with the JBI Manual for Evidence Synthesis 16 . The protocol was registered prospectively on March 9, 2022 and is available at: https://osf.io/dya94/ .

Inclusion criteria

The scoping review included records describing existing interventions that promote mental health or mitigate mental health impacts in the context of climate change. No restrictions were imposed on intervention target populations or geographical settings. All study designs were considered, given the a priori understanding that many interventions likely have not been formally evaluated through clinical trials. Further, given the interdisciplinary nature of the topic, records in the humanities and applied social sciences may not be easily categorizable into a study design conventional to medicine or public health.

Exclusion criteria

The scoping review excluded records describing interventions for humanitarian crises not directly related to climate change (e.g., earthquakes, nuclear disasters, acts of terrorism), or natural hazards (e.g., recurrent floods) not explicitly connected with climate change by the authors. Other ineligible records included general resources (e.g., videos, webinars, podcasts, newsletters, therapist directories) that do not have an active interventional or participatory component; private, stand-alone retreats or courses; and books or book chapters. Proposals and expert opinions on psychotherapeutic approaches, while valuable to inform intervention development, are not organized programs that have been expanded beyond the individual therapist’s practice or systematically evaluated or implemented; they were therefore excluded.

Academic literature search strategy

The academic literature search strategy combined three core constructs, “intervention”, “mental health” and “climate change”, the definitions of which are outlined in Table 1 . The search terms were first developed for MEDLINE (Supplementary File 1 ) and modified for other databases as required. MEDLINE, PsycINFO and Web of Science were carried out from inception to May 2, 2022. Reference lists of any included studies and relevant reviews were hand searched to identify additional articles.

Study selection

All identified citations were collated in EndNote X9 with duplicates removed, then uploaded into Rayyan.ai, an online tool for conducting systematic and scoping reviews 17 . Titles and abstracts were screened by one reviewer (SX), with a subset (10%) screened by a second reviewer (SAK). Full texts of potentially relevant studies were acquired and screened by SX, a subset (10%) of which was also screened by SAK. Any discrepancies in reviewer decisions were resolved via discussions with a third reviewer (EL/AM).

Gray literature search strategy

A comprehensive gray literature search was undertaken to capture interventions not published in peer-reviewed journals or evaluated in academic literature. The search strategy was informed by the methodology and best-practice guidelines by Godin et al. 18 and Pollock et al. 18 , 19 , and involved four distinct steps: (1) targeted database search; (2) Google search; (3) targeted website search; and (4) key stakeholder consultation. The first three steps were carried out in May 2022 and the consultations took place between June-July 2022. Details of the gray literature search strategy can be found in Supplementary File 2 .

Data extraction

For academic literature, data were collected concerning the records (authors, publication year, study design) and nature of the interventions (delivery country/location; target population; climate stressor; mental health and wellbeing outcomes; evaluation outcomes; and any other available details, such as theoretical framework, intervention length, cost, facilitator characteristics, delivery methods, and involvement of stakeholders in co-designing the intervention). Best efforts were made to extract the same categories of data from gray literature. As the content from organizations may be trademarked, direct quotations from websites were at times extracted to best reflect the intervention description as intended. Data were presented in tabular form and analyzed narratively in accordance with their relevance to the review objectives.

Data presentation

Results are presented by clustering interventions according to Bronfenbrenner’s ecological theory 20 , 21 . The theory describes one’s ecological environment at four levels: microsystem (individual and immediate home environment); mesosystem (peer groups and social networks); exosystem (institutions, the media, and local government), and the macrosystem (policies, laws, and overarching social structures). Bronfenbrenner’s theory has been widely applied in public mental health research given its embracing of the complex interplay between individual and contextual factors. We believe categorizing the interventions at the different levels would allow for a clear conceptual map of where work has been done and where more work is needed, and the presentation of most pertinent information to relevant stakeholders (e.g., policymakers).

Overview of academic literature findings

In total, 5126 unique records were identified (5107 from databases and 19 from backward citation hand search) (Fig. 1 ). Among the 194 records reviewed in full, 16 met inclusion criteria and were included in the review (Table 2 ). The 16 studies described 13 unique stand-alone interventions or packages of interventions across Asia, Europe, North America and the Caribbean, Oceania, and Sub-Saharan Africa. Among the studies, 7 (44%) were conducted in LMIC settings. All studies were published in or after 2009, with half (50%) having been published within the past 3 years (2019–2022).

PRISMA flow diagram.

Climate stressors included general climatic change, wildfires, droughts, cyclones, typhoons, and floods. Targeted mental health outcomes included psychological distress, psychiatric symptoms (depression, anxiety, PTSD), and broader psychological wellbeing measures such as emotional strength, emotional self-efficacy, confidence in the future, and general mental and spiritual wellness. Nine (56%) studies involved a type of design (e.g., RCT, quasi-experimental, pre-post) aimed to quantitatively evaluate the interventions, and 7 (44%) reported effectiveness results. Eleven (69%) studies mentioned a co-design process, during which local stakeholders were consulted for the needs assessment, intervention design, and/or cultural adaptation of the intervention.

Description of interventions from academic literature

Five microsystem interventions were identified that primarily focus on individual-level emotions, behaviors, and psycho-emotional resilience.

In Nigeria, where increasingly frequent floods are being attributed to climate change, an evaluation of a rational emotive behavior therapy (REBT) program was conducted 22 . REBT is a short-term therapy related to cognitive behavioral therapy (CBT) and encourages participants to actively dispute irrational beliefs after experiencing an undesirable triggering event. REBT was delivered over 20 sessions to 49 flood victims with clinical depression by professional therapists. In comparison to the waitlist control group, the intervention group was found to have significantly decreased depression symptoms as measured by the Hamilton Depression Scale ( F (1,97) = 208.935, p  = 0.001, ηp 2  = 0.69) and by the Goldberg’s Depression Scale ( F (1,97) = 34.842, p  = 0.001, ηp 2  = 0.27) and at 3-month follow-up.

In Haiti, a disaster-prone country susceptible to climate change effects, an integrated community intervention was developed to promote mental health and improve practical disaster preparedness 23 . The intervention was manualized and consisted of activities that promote mental health literacy and coping skills (e.g., progressive muscle relaxation), and increase household-level preparedness (e.g., developing emergency action plan, mapping community risks and resources). The intervention was delivered by local lay workers over 3 days to 144 individuals who recently experienced a hurricane and associated flooding. In comparison to the control group, intervention participants experienced fewer depression ( B  = −0.35, p  < 0.001), anxiety ( B  = 0.27, p  < 0.001), and PTSD ( B  = −0.46, p  < 0.001) symptoms, and increased mental health-focused help-giving intention ( B  = 2.62, p  < 0.001).

Several interventions identified themselves as resilience-building programs. In the Philippines, a six-module intervention Katatagan was developed in the aftermaths of the Super Typhoon Haiyan and evaluated in two settings 24 , 25 . In Tacloban City where trained paraprofessionals delivered the intervention, the 48 intervention participants experienced lower anxiety scores ( F (1,105) = 3.89, p  = 0.05, ηp 2  = 0.036), increased adaptive coping ( F (2.79,192.6) = 5.87, p  = 0.001, ηp 2  = 0.078), and increased individual resilience ( F (1,105) = 4.68, p  = 0.03, ηp 2  = 0.043) 24 in comparison to the control group. In the Samar Province, the intervention was delivered as part of a mission trip by Health Futures Incorporated (HFI). The 163 intervention participants improved in all self-efficacy domains, as measured by a locally constructed scale based on each Katatagan module, in comparison to the participants’ baseline. Reported effect sizes ranged from Cohen’s d  = 0.33 for Engaging in Positive Activities, Cohen’s d  = 0.51 for Managing Thoughts and Emotions, to Cohen’s d  = 0.83 for Seeking Solutions and Support 25 . Benefits were largest immediately post-intervention and decreased at six-month follow-up in both settings.

Skills for Life Adjustment and Resilience (SOLAR) is another resilience-building intervention that was piloted in Tuvalu, a small island developing state (SIDS) vulnerable to sea-level rise 26 . Forty-nine islanders impacted by Cyclone Pam and experiencing mental health symptoms participated in the lay-worker-delivered group intervention over 5 consecutive days. Module content included Skills for Healthy Living, Managing Strong Emotions, Getting Back into Life Following Disaster, Coming to Terms with Disaster, Managing Worry and Rumination, and Maintaining Healthy Relationships. In comparison to controls, participants experienced improvements in psychological distress (Glass’s d  = 1.106), PTSD symptoms (Glass’s d  = 1.575), and functional impairment (Glass’s d  = 1.316). Benefits were retained at six-month follow-up but were reduced compared to immediate post-intervention.

One review study narratively described an Environmental Health Clinic based at New York University 27 , 28 . Individuals concerned about environmental issues received “prescriptions” to participate in environmental projects, with the aim to channel anxiety to specific climate action. This intervention was used as an example of structured problem-based coping and no evaluation was available.

Four mesosystem interventions were identified that involve focuses beyond individual-level changes, and additionally target peer group relationships and local community identity and cohesion in relation to mental health and wellbeing.

Carbon Conversations is a UK-based third-sector initiative which allows individuals to reflect on difficult emotions around climate change, and in turn be better able to engage with carbon footprint reduction 29 . Groups of six to eight participants meet with two facilitators over six sessions and discuss themes pertaining to Climate Change and Low Carbon Futures, Energy in the Home, Travel and Transport, Food and Water, and Consumption and Waste. In an online survey to 113 group participants, 50% agreed or strongly agreed that taking part helped them “face their worries about climate change”. Semi-structured interviews further revealed themes that the intervention allowed participants a unique space to express and share difficult emotions around climate change, feel more empowered and in control, and engage with others with similar experiences.

In various parts of the world vulnerable to extreme weather and regional food security, multiple interventions involving community-level participatory activities have been developed. These include: (1) land restoration work and associated reflection exercises for youth living at the Arizona-Mexico border in the United States; (2) community garden hubs with tree-planting activities for low-income residents and people with chronic and mental health conditions in Australia; and (3) traditional fish camp activities and participatory research for indigenous youth of the Selkirk First Nation in Canada 30 , 31 , 32 . All interventions were designed in the context of climate change to improve psychological and/or spiritual wellbeing, and to promote connectedness among participants through shared identities. Internal program evaluations of the land restoration and community garden interventions both anecdotally suggest improved mental health outcomes among participants, though the specific evaluative methods and outcome measures were not reported.

Two packages of exosystem interventions were identified that involved the implementation of multi-pronged mental health services and mobilization of the media and local institutions.

In Sonoma County, California, the Sonoma Wildfire Mental Health Collaborative was established following the historic 2017 wildfires 33 , 34 . The Collective launched a package of interventions that included a trauma-informed yoga and meditation program, a mental health app targeting adolescent survivors, and a Skills for Psychological Recovery (SPR) training program for counselors and paraprofessionals. The package was coupled with a media campaign to raise post-disaster mental health awareness, destigmatize help-seeking, and promote available resources. Given small sample sizes, the evaluative study was unable to conclude the effects of the app or SPR training; a preliminary survey suggested that participants experienced short-term beneficial effects from the yoga and meditation program.

For the rural farming populations who face climate-related adversity in New South Wales, Australia, a government-funded Drought Mental Health Assistance Package (DMHAP) was implemented 35 , 36 . DMHAP consisted of mental health promotion (e.g., resource booklet development, community mental health forums, mental health first aid trainings) and early intervention (e.g., rural telephone support line, service network planning workshops). Following renewed funding, the extended Rural Adversity Mental Health Program (RAMHP) increased the number of dedicated drought mental health workers and introduced specific activities for priority groups, including women, youth, older farmers, and Aboriginal communities. The authors reported that given funding limitations, no formal outcome evaluation was carried out.

Two macrosystem interventions were identified that involved macro-level interventional components, primarily through poverty reduction to improve mental health and wellbeing outcomes.

In Bangladesh, a Red Cross Red Crescent humanitarian project was delivered to promote financial security and associated psychological benefits among river basin communities amidst the 2017 floods 37 . A forecast-based unconditional cash transfer of BDT 5000 (USD 60 equivalent) was distributed to 1039 poor households prior to a flood peak. Relative to the unassisted households, intervention households were less likely to have always felt anxiety and depression (43% vs 29%, p  = 0.015) and less likely to have always felt miserable or unhappy (61% vs 40%, p  < 0.01) since the flood. While these findings were triangulated with qualitative interviews, the authors noted that the intervention benefits were not sustained after a second flood peak in the same year.

In Ethiopia, a capacity-building intervention was developed for pastoral communities who face increasingly severe droughts, land changes, and food crises. The intervention included components to inspire motivation, build collective-action groups, and improve literacy and numeracy 38 . The macro-economic components specifically involved the promotion of microenterprises and distribution of donor grants for livestock trading. The study reported the creation of 59 primarily women-led collective-action groups, 11 of which received donor grants. Following a major drought, intervention participants who received both capacity building and donor grants in the Liben District scored much higher on study-defined mental health and wellbeing attributes than their peers. The attributes included better ability to recover from crisis (OR = 91.7, p  < 0.001), more confidence in the future (OR = 33.6, p  < 0.001), and better human health (OR = 19.2, p  < 0.001). The positive findings were replicated in the Moyale District with smaller effect sizes.

Overview of gray literature findings

Targeted database search, Google search, and targeted website search identified 14 records describing 14 organizations offering relevant stand-alone and/or packages of interventions. One of the interventions (Carbon Conversations) was already identified through academic literature. A list containing these interventions, along with the inclusion and exclusion criteria, was circulated to 30 international content experts for consultation; through snowballing, we were introduced to and contacted 6 additional experts. Of all individuals contacted, 26 (72%) responded to the gray literature search request, and 8 (31%) of the respondents were based in a LMIC setting. The content experts reviewed and confirmed the list of interventions and identified 11 additional records for inclusion (total records = 25; minus duplicate = 24) (Table 3 ).

All identified interventions are offered by an organization, and all but two were founded or based in a high-income country (HIC), primarily the US (46%) or the UK (33%). For the organizations that cited their founders, a large majority (11/12; 92%) of those founders are women.

The climate stressors addressed by interventions from the gray literature all involve general climatic changes and/or anticipated climate-related threats rather than specific climate-related disasters. Targeted mental health outcomes are independently defined by the organizations rather than by psychiatric diagnoses or standardized instruments, and many used emotion-based wordings such as “overwhelm”, “despair”, and “loneliness”. Five records (21%) described a co-design process involving local stakeholders.

Description of interventions from gray literature

The 24 interventions or packages of interventions acted at the levels of microsystem and mesosystem. No exosystem or macrosystem interventions were identified through gray literature. Of note, none of the interventions reported formal evaluation methods; a minority (12.5%) reported selected positive internal evaluation results.

Four microsystem interventions were identified that take a self-guided approach and support individuals to improve their own mental health and wellbeing in the context of climate change.

In the UK, a group of organizations, namely Climate Cares based at Imperial College London, Force of Nature and Common Vision worked with young people and environmental scientists to create a virtual intervention Hold This Space 39 . The interactive website guides youth to explore their feelings towards climate change, imagine the world they would like to see based on the latest science, and reflect on how to act on environmental issues most concerning to them. In consultation with youth advisors, mental health practitioners, and climate change professionals, Climate Cares also co-designed a 4-week activity-based physical journal 40 . The goal is to reduce the mental health impacts that can be associated with climate-related distress, build coping strategies, envision a desired future, and increase capability to take desired action. The Climate Journal Project based in the US is another intervention involving a journaling approach 41 . The organization created digital and printed journals and worksheets that target eco-anxiety and environmental grief. Individuals have the additional option of participating in virtually guided “journal circles”. Other self-guided activities and worksheets were identified through Eco-Anxious Stories, a Canada-based online platform 42 . In the “Sharing Our Stories” worksheet, individuals are prompted to answer questions such as “Where is eco-anxiety showing up in my life?” and “What does a meaningful response to this crisis look like and feel like?”

The rest of 20 gray literature records all acted at the level of the mesosystem and involve a group-based or outreach approach that harness the power of group dynamics and community building.

Many of the interventions function on the premise of offering a safe space for individuals to gather and make sense of their positive or negative climate emotions. As a quintessential example, Climate Cafés are decentralized, drop-in meetings for discussing the climate crisis and building collective psycho-emotional resilience – often over tea or coffee. The model of Climate Cafés is now adopted by many organizations globally with both in-person and virtual meetings available 43 , 44 , 45 . The Good Grief Network developed an intervention based on the 12-Step approach of Alcoholics Anonymous 46 . Trained peer facilitators deliver the 10-week group program for individuals interested in recognizing and exploring their eco-distress and being supported to move towards meaningful action. The Network’s website reports that over 90% of program participants feel more empowered and less alone, though the exact survey methods or number of surveyed participants are not available publicly. Other examples of facilitated discussions include All We Can Save Circles (10 structured sessions) 47 , Climate Emotions Conversations by Climate Awakening (3 available sessions per month) 48 , and The Rest of Activism (2 available sessions per week) 49 . A few interventions name their specific target audience: Conceivable Future “house parties” are intended for individuals who wish to discuss reproductive decisions and parenthood while facing an uncertain future 50 , and Globe and Psyche conversation meetings are intended for individuals working in psychotherapeutic and psycho-spiritual domains to reflect on professional identities and healings for others 51 .

Five identified organizations offer packages of interventions (e.g., facilitated workshops, events, trainings, online communities) under the same theoretical or philosophical premise. The Work That Reconnects (WTR) is a network based on Joanna Macy’s work, also known as Deep Ecology Work and Active Hope. The work’s philosophical premise follows a spiral sequence of four stages, “gratitude”, “honoring our pain for the world”, “seeing with fresh eyes”, and “going forth”, and is designed to be delivered in an interactive group setting 52 . The Deep Adaptation Forum is based on Jem Bendell’s work 53 , which recognizes the “breakdown” from climate change and aims to support individuals to prepare for and co-create a loving response to what Bendell describes as the “inevitable near term societal collapse”. The Resilient Activist is based on the “Five Essentials” principle (Reconnect to Nature, Respect All Life, Regreen Our Planet, Revamp Our Spending, and Replenish Our Resources) to maintain a healthy mindset and ease the emotional burden from climate change 45 . The Transition Network offers a variety of interventions (e.g., “Heart and Soul” groups) based on the Inner Transition principle, which posits that shifts in emotional and psychological dimensions are needed to make outer systemic changes towards healthier communities 54 . One Earth Sangha is a hub for spiritual-psychological participatory groups and events in response to climate change based on Buddhist teachings 55 .

Seven interventions involve outreach or capacity-building approaches to improve the participants’ mental health and wellbeing and/or that of their wider community. Force of Nature runs training programs for youth affected by eco-anxiety. The trained youth then have the opportunity to run group “anxiety-to-agency” workshops, and become speakers or consultants for businesses and educators on matters related to climate change 56 . The Resilience Project UK also offers a program for young people, who then become leaders of an 8-week Circle to co-design resilience-building programs for other youth 57 . Project InsideOut is an online hub with interactive tools and resources, allowing individuals who experience climate emotions to undergo an inner transformation before becoming “Guides” for others and leading climate action 58 . Eco-Anxious Stories, Climate Psychology Alliance, Circularity, and The Resource Innovation Group (TRIG) all list eco-anxiety outreach services (e.g., speaker hub, trainings, workshops, resource development) for schools, organizations, and communities 42 , 44 , 59 , 60 .

Only two identified interventions at this level are based in a LMIC setting. In Nigeria, The Eco-Anxiety in Africa Program (TEAP) is managed by Sustyvibes - a non-profit climate activism organization. Reported TEAP activities include the creation of virtual and physical spaces to stimulate dialogs on climate change and mental health (e.g., “Sustyparties” that use poetry and open mic settings to facilitate the sharing climate emotions) 61 . In Cameroon, the Ibanikom Climate Mental Health Literacy Project facilitated meetings for flood-affected communities, allowing participants to learn about the effects of climate change on mental health and co-develop local, small-scale culturally relevant integrated health and agriculture projects 62 .

The impact of climate change on mental health and wellbeing is a pressing global challenge. More information is critically needed to plan for the design, implementation, and scaleup of effective interventions that address the dual and interconnected crises of ecological breakdown and mental health and psychosocial wellbeing burden. The present scoping review represents one of the first comprehensive efforts to fulfill this research priority and identified a total of 40 records which describe 37 unique interventions across academic and gray literature. The interventions acted at the levels of individuals, groups, local media and institutions, and larger social structures, and involved diverse mechanisms of action including psychotherapy, resilience-building programs, nature-based activities, community strengthening networks, and climate activism projects (Fig. 2 ). The mental health and wellbeing targets included depression, anxiety, PTSD, emotional strength and resilience, and various climate emotions, stemming from both direct exposure to climate-related extreme events and awareness of climate change.

Identified interventions and their level of action based on Bronfenbrenner’s ecological theory as applied to public mental health research.

The academic literature search identified interventions implemented primarily in geographical areas at risk of extreme weather events, and the target populations were often residents of the areas. Interestingly, all studies that reported a formal evaluation methodology and intervention effectiveness results ( n  = 7) were conducted in a LMIC setting. Among these studies, 5 incorporated a co-design process, and all demonstrated promising initial results in reducing negative psychiatric symptoms and/or promoting positive mental health and wellbeing outcomes. It is well recognized that the climate crisis deepens pre-existing global inequities 63 ; it is therefore encouraging to see that current research efforts have been attentive to supporting the most disproportionately affected populations. However, several studies with a longitudinal evaluation component commented on reduced interventional effects at follow-up 24 , 25 , 26 . Furthermore, it is common for the LMIC-based interventions to be funded or run by international humanitarian organizations (e.g., Red Cross, HFI) rather than being integrated into the local system, and the potential for the sustainable implementation and scaleup of these interventions remain less certain.

In contrast to the academic literature findings, the gray literature search identified mostly interventions delivered by organizations founded or based in HICs. Few interventions commented on a theoretical framework for the mechanism of intervention. None were formally evaluated or have evaluative data publicly available, and therefore it is not possible to determine whether they are effective in addressing their targeted mental health and wellbeing outcomes or have any unintended impacts. It is further difficult to draw the line between non-profit and for-profit organizations, as various workshops and events depend on out-of-pocket payments from participants. This highlights additional sustainability and accessibility issues for individuals who are intersectionally disenfranchised by financial insecurity and mental health burden and may also limit their potential scalability to low-resource settings.

Overall, it appears that conceptual linkage for interventions at the intersection of climate change and mental health remains at a nascent stage, and most interventions are newly designed with scarce or anecdotal evidence. Most of the existing trials involve microsystem-level interventions (i.e., targeting individual emotions and behaviors) implemented in LMIC settings. Even then, the interventions are limited to a single study or country, and the findings have not been replicated. While there are many mesosystem-level interventions that leverage group dynamics, the overwhelming majority are based in HICs and have not been academically evaluated. There is a shortage of exo- and macrosystem interventions that mobilize local government and media or incorporate socioeconomic reforms and policy changes that may influence downstream mental health and wellbeing outcomes, though there is clear evidence for the potential co-benefits of climate policies for mental health and wellbeing 1 . There is, in general, also a lack of publicly available implementation information (e.g., training procedure of facilitators, implementation cost) for existing interventions, which would be key for scaleup.

Strengths and limitations

A strength of this review lies in its comprehensive conceptualization of mental health. To reflect that mental health is “an intrinsic part of our individual and collective health and wellbeing” 14 , the review included search terms such as “wellbeing”, “resilience” and “post-traumatic growth”. This open approach allowed us to identify interventions beyond the realms of clinical psychology or psychiatry and tap into fields such as international development, urban planning, and environmental public health. The resulting diverse findings suggest that climate mental health interventions are likely to require complex, multidisciplinary input. Another strength of this review is its incorporation of a rigorous gray literature review process, which involved a large panel of international content experts. The process allowed for the capturing of emerging interventions and those not formally evaluated. Moreover, the review sought to, beyond identifying interventions, determine which types of interventions are better supported by evidence, and where there are clear gaps for the evaluation of existing interventions and/or the design of new ones.

A limitation of the review is that the search terms were only in English, which likely influenced the outcome that all included academic literature articles were English-language ones. Potential relevant articles published in other languages describing local interventions may be omitted. Further, most of the identified gray literature interventions are based in HICs. While we purposively consulted content experts from LMICs, it is possible that the search was biased towards HIC-based content given the immediate professional network of the authors and given that HIC-based organizations are likely better resourced to host and publicize their interventions on websites. We recognize that there are likely many other local, grassroot initiatives that have not gained international traction, yet also provide safe, accessible, and community-relevant spaces for discussions and actions around climate change and mental health. Many Indigenous communities have historically and continue to implement cultural practices that care for the wellbeing of people and the non-human world. Additionally, without individually contacting the individual organizations, we cannot comment on whether the website information is accurate and up-to-date, or the scale of the intervention (e.g., how frequently the microsystem-level worksheets are being downloaded, how many individuals have participated in the mesosystem group interventions). Therefore, this review cannot claim to be an exhaustive search of all existing and active mental health and psychosocial interventions, but rather a best effort at describing and mapping out the present interventional space.

Recommendations for future research

Most of the existing evidence supports microsystem-level interventions in LMIC settings. For these interventions, studies using more robust study designs and involving more participants, as well as studies involving their adaptation to other geographical regions, would be helpful to better evaluate their larger-scale effectiveness and scalability. Implementation science would need to be applied to better assess the feasibility, acceptability, cost-effectiveness, and sustainability of the interventions. Ideally, the studies would also include a process evaluation component to better elicit why longitudinal effects may be reduced. This review further identified various mesosystem-level interventions in HIC settings, and there is potential for these interventional models to be studied using robust trial methodologies.

Regarding the development and piloting of new interventions, there is much room to explore exo- and macrosystem interventions in both LMICs and HICs. In our literature search, we identified three studies that may offer important insight. All were secondary analyses of the social impacts of climate interventions, which originally did not have a mental health focus (and hence did not meet our inclusion criteria and were not summarized narratively in our results). In one study based in Zimbabwe, it was found retrospectively that a biogas project contributed to community cohesion and empowerment 64 ; in another study based in China, planned relocation and sheltering was found to be protective against depression, anxiety, and PTSD symptoms among flood victims 65 . In contrast, a study conducted in six LMICs (Brazil, Cameroon, Indonesia, Peru, Tanzania, and Vietnam) concluded that the Reducing Emissions from Deforestation and Degradation (REDD+) initiative may have negatively impacted women’s wellbeing 66 . Suggested reasons for the wellbeing decline included unrealized expectations for REDD+ initiatives and limited advanced consideration of addressing gender inequality in REDD+ policies. The studies demonstrated that while macrosystem interventions aiming to improve social welfare and their larger environment likely offer additional psychological benefits, they may also have unintended consequences if mental health and wellbeing, and its relationship to factors such as participatory approaches and gender equity, is not considered at conception. The REDD+ study further highlighted the importance of involving underserved groups, such as women, in the intervention design, implementation, and decision-making stages, thereby empowering them with leadership roles and incorporating their own definitions and experiences of wellbeing. This point applies generally, and it is vital for the appropriateness and ultimately success of both the content and implementation of interventions that they are co-designed with the people for whom they are being created. Understandings of mental health and wellbeing, and the experiences of climate change vary across geographies and cultures, and it is important to not perpetuate colonial practices by imposing Western definitions and understandings universally 67 , 68 .

It has also been increasingly recognized that being in and feeling connected with nature is beneficial for human health, including mental health 69 , 70 , 71 . However, most of the existing studies are limited to cross-sectional assessments that outline the association between time spent in the natural environment and health benefits. Nature-based programs or eco-therapies, such as animal-assisted interventions, therapeutic horticulture, forest bathing, and social prescriptions that bring participants into nature do offer trial evidence, but many were developed or evaluated among specific populations (e.g., cancer patients, children), and have not yet been directly associated with climate change 72 , 73 , 74 , 75 , 76 . It would be of interest to further explore climate-informed nature engagement (e.g. “reciprocal restoration” or social prescribing interventions) 30 and their mental health and wellbeing outcomes.

Finally, disaster psychiatry offers much knowledge of interventions for individuals and communities surviving potentially traumatic events, and many lessons can be drawn regarding what works, where, and for whom. It is likely that climate change has contributed to the development of many natural hazards (e.g., Hurricane Katrina) which have been the object of study in disaster psychiatry 77 . However, as developed interventions typically have not factored in climate change - an unprecedented ongoing and growing crisis - they would likely need to be adapted to support individuals to cope with not only current but future stressors, and incorporate strategies such as proactive, forecast-based interventions, and disaster preparedness. The interventions would also likely benefit from collaborating across multiple bio-psychosocial fields to work preventatively and to address contextual factors.

Implications for policy and practice

Multiple studies identified in this review did not successfully carry out an evaluative component despite having the intent, primarily due to limited funding and/or resources to recruit a larger sample size. This reflects a need to invest in and better support the evaluation of mental health and psychosocial interventions in the context of climate change, such that resources can be channeled into best evidence-based practices. When these practices are identified, a streamlined process is needed for their integration into the local health and social care systems, particularly in low-resource settings using existing infrastructures such as community groups. Consideration of participation cost is crucial, such that individuals from all socioeconomic backgrounds can be included and benefit.

For the work that is being done informally or in a community-led manner, including the gray literature interventions identified here and emerging ones we are aware of anecdotally, should be convened, collated, and showcased in an accessible manner. For example, an “online hub” of currently available interventions and case studies of best practices could promote shared learning and evidence-based investment, while minimizing the likelihood of duplicated efforts 78 .

Conclusions

There is growing awareness of the detrimental effects of climate change on mental health and psychosocial wellbeing. In response to this evidence-base and lived experiences globally, interventions have been designed to promote mental health and wellbeing as well as to manage the detrimental impacts. This scoping review identified interventions acting at the microsystem, mesosystem, exosystem, and macrosystem levels. While most interventions have not been evaluated, existing studies, primarily on protecting mental health in the context of climate-related disasters in LMICs, show preliminary promising results. More evaluative studies using robust trial designs are needed, especially those involving implementation research. Future interventions are recommended to consider at conception the definition of wellbeing, the interests of underserved groups, co-design, equitable access, and sustainability.

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Acknowledgements

We would like to thank the following individuals who acted as expert consultants in the gray literature search stage: Kenneth Yongabi Anchang (Cameroon), John Aruta (Philippines), Helen Berry (Australia), Mike Campbell (Barbados), Fiona Charlson (Australia), Susan Clayton (USA), Julian Eaton (UK), Mohamed Elshazly (Egypt), Brandon Gray (Switzerland), Natalie Greaves (Barbados), Renzo Guinto (Philippines), Katie Hayes (Canada), Jo Hamilton (UK), Asha Hans (India), Zeinab Hijazi (USA), Juan Segundo Peña Loray (Spain), Raj Mariwala (India), Catriona Mellor (UK), Rebecca Nestor (UK), Sena Salcedo (Philippines), Jennifer Uchendu (Nigeria), and Sacha Wright (UK). We would like to thank Jura Augustinavicius for reviewing and providing comments for the protocol.

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Siqi Xue & M. Ishrat Husain

Centre for Global Mental Health, The London School of Hygiene & Tropical Medicine, London, UK

Alessandro Massazza

Department of Health Service & Population Research, Institute of Psychiatry, Psychology, & Neuroscience, King’s College London, London, UK

Samia C. Akhter-Khan

Department of Psychiatry and Behavioral Sciences of Stanford Medicine, Stanford, US

Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada

M. Ishrat Husain

Institute of Global Health Innovation, Imperial College London, London, UK

Emma L. Lawrance

Grantham Institute - Climate Change and the Environment, Imperial College London, London, UK

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Contributions

E.L. and A.M. conceptualized the study in discussion with S.X. S.X. conducted the literature review. S.A.K. acted as a second reviewer for a portion of the abstracts and full texts. B.W. contributed to the gray literature search, and E.L. and A.M. resolved any conflict decisions. S.X. conducted data analysis and wrote the original draft of the manuscript. All authors contributed to the review and editing of subsequent drafts. S.X. received supervision from E.L. (Imperial College London), A.M. (London School of Hygiene & Tropical Medicine) and M.I.H. (University of Toronto).

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Correspondence to Siqi Xue .

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Xue, S., Massazza, A., Akhter-Khan, S.C. et al. Mental health and psychosocial interventions in the context of climate change: a scoping review. npj Mental Health Res 3 , 10 (2024). https://doi.org/10.1038/s44184-024-00054-1

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Systematic Reviews & Other Review Types

• What is a Systematic Review?

What is a Scoping Review?

• What is a literature review?
• What is a Rapid Review?
• What is a Mixed Methods Review?
• What is a Network Meta-Analysis?
• What is an Overview of Reviews?
• What is a Meta-Syntheses?
• What is an Integrative Review?
• What is a Diagnostic Test Accuracy Review?
• What is a Living Systematic Review?

Scoping reviews are a "preliminary assessment of potential size and scope of available research literature.  Aims to identify nature and extent of research evidence (usually including ongoing research)."   Grant and Booth (2009).

Requires fewer data sources and doesn't require assessing individual studies for risk of bias. 

Often a scoping review is confused with a mapping review.  They are  not systematic reviews , but the methodology is closely related. 

Scoping Reviews are best:

"When a body of literature has not yet been comprehensively reviewed, or exhibits a large, complex, or heterogeneous nature not amenable to a more precise systematic review."

To map existing literature in terms of nature, features, volume

To clarify working definitions and conceptual boundaries of a topic or field

To identify gaps in existing literature/research

(Pete rs M, Godfrey C,  Khalil  H, et al)

How a Scoping Review Differs from a Systematic Review

Timeframe:  12+ months, (same amount of time as a systematic review or longer).

Question:  Answers broader questions beyond those related to the effectiveness of treatments or interventions.  A priori review protocol is recommended.

Sources and searches: Is still as comprehensive as a systematic review but much broader.  May involve multiple structured searches rather than a single structured search.  This will produce more results than a systematic review.  Must include a modified PRISMA flow diagram.

Selection:  Based on inclusion/exclusion criteria, due to the iterative nature of a scoping review some changes may be necessary.  May require more time spent screening articles due to the larger volume of results from broader questions.

Appraisal:  Not applicable for scoping reviews. 

Synthesis: The extraction of data for a scoping review may include a charting table or form.  Results may include a logical diagram or table or any descriptive form that aligns with the scope and objectives of the review.  May incorporate a numerical summary and qualitative thematic analysis.

Source: MDJ Peters et al. (2015), Levac et al. (2010)

Scoping Review Resources

• PRISMA SCR-Scoping Reviews Statement and Checklist
• Scoping studies: advancing the methodology
• Scoping Studies: Towards a Methodological Framework
• A scoping review of scoping reviews: advancing the approach and enhancing the consistency
• An Evidence-Based Approach to Scoping Reviews
• Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach
• CURRENT BEST PRACTICES FOR THE CONDUCT OF SCOPING REVIEWS
• Scoping reviews: establishing the role of the librarian
• Methodology for JBI Scoping Reviews

Limitations of a Scoping Review

• Is not easier than a systematic review.
• Is not faster than a systematic review, may take longer.
• More citations to screen
• Different screening criteria/process than a systematic review
• Often leads to a broader, less defined search.
• Requires multiple structured searches instead of one.
• Increased emphasis for hand searching the literature.
• May require larger teams because of larger volume of literature.
• Inconsistency in the conduct of scoping reviews.

Other names for a Scoping Review

Scoping Study, Systematic Scoping Review, Scoping Report, Scope of the Evidence, Rapid Scoping Review, Structured Literature Review, Scoping Project, Scoping Meta Review

Temple Attribution

Adapted with permission from Temple University Libraries. https://guides.temple.edu/systematicreviews

• Last Updated: Mar 13, 2024 4:27 PM
• URL: https://touromed.libguides.com/review_types

Using Covidence for Systematic and Scoping Reviews

Systematic vs. scoping reviews, review guides, databases commonly used for review searches, access covidence, hchhs librarian.

"A systematic review attempts to identify, appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria to answer a given research question. Researchers conducting systematic reviews use explicit methods aimed at minimizing bias, in order to produce more reliable findings that can be used to inform decision making” (Cochrane Library, n.d.).

" Scoping reviews , a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps” (Levac et al., 2010).

The table below shows the main differences between systematic and scoping reviews.

Sources: About Cochrane Reviews | Cochrane Library. (n.d.). Retrieved from https://www.cochranelibrary.com/about/about-cochrane-reviews

Levac, D., Colquhoun, H., & O’Brien, K. K. (2010). Scoping studies: Advancing the methodology. Implementation Science, 5(1), 69. https://doi.org/10.1186/1748-5908-5-69

The following databases are most commonly used to conduct systematic and scoping reviews. However, you should defer to the most common databases for your specific discipline.

• PubMed This link opens in a new window PubMed is a database with access to articles in biomedical and life science journals, many of which are full-text.
• MEDLINE Ultimate This link opens in a new window MEDLINE Ultimate offers access to evidence-based and peer-reviewed full-text content from top biomedical journals.
• Web of Science This link opens in a new window Web of Science is an academic citation index that covers the sciences, social sciences, arts, and humanities.
• Scopus This link opens in a new window Scopus is the largest abstract and citation database of peer-reviewed literature, including scientific journals, books, and conference proceedings.
• CINAHL Ultimate This link opens in a new window CINAHL Ultimate is the primary database for the nursing and allied health professions. It includes articles as well as standards of practice, practice acts, government publications, research instruments, and patient education materials.
• PsycINFO This link opens in a new window PsycINFO is the premier resource for finding articles in psychology, behavioral sciences, and related disciplines.
• Covidence This link opens in a new window Covidence is a resource for systematic and scoping review management. It is a cloud-based tool with the ability to perform title/abstract screening, full-text screening, data abstraction, and quality assessment all in one place.

Help! How do I access Covidence for the first time?

If you have never used Covidence before, visit the  NC A&T Covidence Sign-Up page  and enter your name and NC A&T email on the sign in page. You will then receive an email inviting you to Covidence. Follow the link in the email and click on "Create an Account." 

For help using Covidence, contact the Social Work & Sociology Librarian via the box on the left side of the page.

• Last Updated: Mar 19, 2024 9:49 PM
• URL: https://libguides.library.ncat.edu/covidence

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Scoping reviews: reinforcing and advancing the methodology and application

Micah d. j. peters.

1 University of South Australia, UniSA Clinical and Health Sciences, Rosemary Bryant AO Research Centre, Playford Building P4-27, City East Campus, North Terrace Adelaide, 5000 South Australia

2 Adelaide Nursing School, Faculty of Health and Medical Sciences, The University of Adelaide, 101 Currie St, Adelaide, 5001 South Australia

3 The Centre for Evidence-based Practice South Australia (CEPSA): a Joanna Briggs Institute Centre of Excellence, Faculty of Health and Medical Sciences, The University of Adelaide, 5006 Adelaide, South Australia

Casey Marnie

Heather colquhoun.

4 Department of Occupational Science and Occupational Therapy, University of Toronto, Terrence Donnelly Health Sciences Complex, 3359 Mississauga Rd, Toronto, Ontario L5L 1C6 Canada

5 Rehabilitation Sciences Institute (RSI), University of Toronto, St. George Campus, 160-500 University Avenue, Toronto, Ontario M5G 1V7 Canada

Chantelle M. Garritty

6 Knowledge Synthesis Group, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9 Canada

Susanne Hempel

7 Southern California Evidence Review Center, University of Southern California, Los Angeles, CA 90007 USA

Tanya Horsley

8 Royal College of Physicians and Surgeons of Canada, 774 Echo Drive, Ottawa, Ontario K1S 5N8 Canada

Etienne V. Langlois

9 Partnership for Maternal, Newborn and Child Health (PMNCH), World Health Organisation, Avenue Appia 20, 1211 Geneva, Switzerland

Erin Lillie

10 Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, Ontario M4N 3M5 Canada

Kelly K. O’Brien

11 Department of Physical Therapy, University of Toronto, St. George Campus, 160-500 University Avenue, Toronto, Ontario M5G 1V7 Canada

12 Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, St. George Campus, 155 College Street 4th Floor, Toronto, Ontario M5T 3M6 Canada

Ӧzge Tunçalp

13 UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organisation, Avenue Appia 20, 1211 Geneva, Switzerland

Michael G. Wilson

14 McMaster Health Forum, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8 Canada

15 Department of Health Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8 Canada

16 Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8 Canada

Wasifa Zarin

17 Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, Ontario M5B 1T8 Canada

Andrea C. Tricco

18 Epidemiology Division and Institute for Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St, Room 500, Toronto, Ontario M5T 3M7 Canada

19 Queen’s Collaboration for Health Care Quality Joanna Briggs Institute Centre of Excellence, School of Nursing, Queen’s University, 99 University Ave, Kingston, Ontario K7L 3N6 Canada

Associated Data

All data and materials are available upon request.

Scoping reviews are an increasingly common approach to evidence synthesis with a growing suite of methodological guidance and resources to assist review authors with their planning, conduct and reporting. The latest guidance for scoping reviews includes the JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses—Extension for Scoping Reviews. This paper provides readers with a brief update regarding ongoing work to enhance and improve the conduct and reporting of scoping reviews as well as information regarding the future steps in scoping review methods development. The purpose of this paper is to provide readers with a concise source of information regarding the difference between scoping reviews and other review types, the reasons for undertaking scoping reviews, and an update on methodological guidance for the conduct and reporting of scoping reviews.

Despite available guidance, some publications use the term ‘scoping review’ without clear consideration of available reporting and methodological tools. Selection of the most appropriate review type for the stated research objectives or questions, standardised use of methodological approaches and terminology in scoping reviews, clarity and consistency of reporting and ensuring that the reporting and presentation of the results clearly addresses the review’s objective(s) and question(s) are critical components for improving the rigour of scoping reviews.

Rigourous, high-quality scoping reviews should clearly follow up to date methodological guidance and reporting criteria. Stakeholder engagement is one area where further work could occur to enhance integration of consultation with the results of evidence syntheses and to support effective knowledge translation. Scoping review methodology is evolving as a policy and decision-making tool. Ensuring the integrity of scoping reviews by adherence to up-to-date reporting standards is integral to supporting well-informed decision-making.

Introduction

Given the readily increasing access to evidence and data, methods of identifying, charting and reporting on information must be driven by new, user-friendly approaches. Since 2005, when the first framework for scoping reviews was published, several more detailed approaches (both methodological guidance and a reporting guideline) have been developed. Scoping reviews are an increasingly common approach to evidence synthesis which is very popular amongst end users [ 1 ]. Indeed, one scoping review of scoping reviews found that 53% (262/494) of scoping reviews had government authorities and policymakers as their target end-user audience [ 2 ]. Scoping reviews can provide end users with important insights into the characteristics of a body of evidence, the ways, concepts or terms have been used, and how a topic has been reported upon. Scoping reviews can provide overviews of either broad or specific research and policy fields, underpin research and policy agendas, highlight knowledge gaps and identify areas for subsequent evidence syntheses [ 3 ].

Despite or even potentially because of the range of different approaches to conducting and reporting scoping reviews that have emerged since Arksey and O’Malley’s first framework in 2005, it appears that lack of consistency in use of terminology, conduct and reporting persist [ 2 , 4 ]. There are many examples where manuscripts are titled ‘a scoping review’ without citing or appearing to follow any particular approach [ 5 – 9 ]. This is similar to how many reviews appear to misleadingly include ‘systematic’ in the title or purport to have adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement without doing so. Despite the publication of the PRISMA Extension for Scoping Reviews (PRISMA-ScR) and other recent guidance [ 4 , 10 – 14 ], many scoping reviews continue to be conducted and published without apparent (i.e. cited) consideration of these tools or only cursory reference to Arksey and O’Malley’s original framework. We can only speculate at this stage why many authors appear to be either unaware of or unwilling to adopt more recent methodological guidance and reporting items in their work. It could be that some authors are more familiar and comfortable with the older, less prescriptive framework and see no reason to change. It could be that more recent methodologies such as JBI’s guidance and the PRISMA-ScR appear more complicated and onerous to comply with and so may possibly be unfit for purpose from the perspective of some authors. In their 2005 publication, Arksey and O’Malley themselves called for scoping review (then scoping study) methodology to continue to be advanced and built upon by subsequent authors, so it is interesting to note a persistent resistance or lack of awareness from some authors. Whatever the reason or reasons, we contend that transparency and reproducibility are key markers of high-quality reporting of scoping reviews and that reporting a review’s conduct and results clearly and consistently in line with a recognised methodology or checklist is more likely than not to enhance rigour and utility. Scoping reviews should not be used as a synonym for an exploratory search or general review of the literature. Instead, it is critical that potential authors recognise the purpose and methodology of scoping reviews. In this editorial, we discuss the definition of scoping reviews, introduce contemporary methodological guidance and address the circumstances where scoping reviews may be conducted. Finally, we briefly consider where ongoing advances in the methodology are occurring.

What is a scoping review and how is it different from other evidence syntheses?

A scoping review is a type of evidence synthesis that has the objective of identifying and mapping relevant evidence that meets pre-determined inclusion criteria regarding the topic, field, context, concept or issue under review. The review question guiding a scoping review is typically broader than that of a traditional systematic review. Scoping reviews may include multiple types of evidence (i.e. different research methodologies, primary research, reviews, non-empirical evidence). Because scoping reviews seek to develop a comprehensive overview of the evidence rather than a quantitative or qualitative synthesis of data, it is not usually necessary to undertake methodological appraisal/risk of bias assessment of the sources included in a scoping review. Scoping reviews systematically identify and chart relevant literature that meet predetermined inclusion criteria available on a given topic to address specified objective(s) and review question(s) in relation to key concepts, theories, data and evidence gaps. Scoping reviews are unlike ‘evidence maps’ which can be defined as the figural or graphical presentation of the results of a broad and systematic search to identify gaps in knowledge and/or future research needs often using a searchable database [ 15 ]. Evidence maps can be underpinned by a scoping review or be used to present the results of a scoping review. Scoping reviews are similar to but distinct from other well-known forms of evidence synthesis of which there are many [ 16 ]. Whilst this paper’s purpose is not to go into depth regarding the similarities and differences between scoping reviews and the diverse range of other evidence synthesis approaches, Munn and colleagues recently discussed the key differences between scoping reviews and other common review types [ 3 ]. Like integrative reviews and narrative literature reviews, scoping reviews can include both research (i.e. empirical) and non-research evidence (grey literature) such as policy documents and online media [ 17 , 18 ]. Scoping reviews also address broader questions beyond the effectiveness of a given intervention typical of ‘traditional’ (i.e. Cochrane) systematic reviews or peoples’ experience of a particular phenomenon of interest (i.e. JBI systematic review of qualitative evidence). Scoping reviews typically identify, present and describe relevant characteristics of included sources of evidence rather than seeking to combine statistical or qualitative data from different sources to develop synthesised results.

Similar to systematic reviews, the conduct of scoping reviews should be based on well-defined methodological guidance and reporting standards that include an a priori protocol, eligibility criteria and comprehensive search strategy [ 11 , 12 ]. Unlike systematic reviews, however, scoping reviews may be iterative and flexible and whilst any deviations from the protocol should be transparently reported, adjustments to the questions, inclusion/exclusion criteria and search may be made during the conduct of the review [ 4 , 14 ]. Unlike systematic reviews where implications or recommendations for practice are a key feature, scoping reviews are not designed to underpin clinical practice decisions; hence, assessment of methodological quality or risk of bias of included studies (which is critical when reporting effect size estimates) is not a mandatory step and often does not occur [ 10 , 12 ]. Rapid reviews are another popular review type, but as yet have no consistent, best practice methodology [ 19 ]. Rapid reviews can be understood to be streamlined forms of other review types (i.e. systematic, integrative and scoping reviews) [ 20 ].

Guidance to improve the quality of reporting of scoping reviews

Since the first 2005 framework for scoping reviews (then termed ‘scoping studies’) [ 13 ], the popularity of this approach has grown, with numbers doubling between 2014 and 2017 [ 2 ]. The PRISMA-ScR is the most up-to-date and advanced approach for reporting scoping reviews which is largely based on the popular PRISMA statement and checklist, the JBI methodological guidance and other approaches for undertaking scoping reviews [ 11 ]. Experts in evidence synthesis including authors of earlier guidance for scoping reviews developed the PRISMA-ScR checklist and explanation using a robust and comprehensive approach. Enhancing transparency and uniformity of reporting scoping reviews using the PRISMA-ScR can help to improve the quality and value of a scoping review to readers and end users [ 21 ]. The PRISMA-ScR is not a methodological guideline for review conduct, but rather a complementary checklist to support comprehensive reporting of methods and findings that can be used alongside other methodological guidance [ 10 , 12 – 14 ]. For this reason, authors who are more familiar with or prefer Arksey and O’Malley’s framework; Levac, Colquhoun and O’Brien’s extension of that framework or JBI’s methodological guidance could each select their preferred methodological approach and report in accordance with the PRISMA-ScR checklist.

Reasons for conducting a scoping review

Whilst systematic reviews sit at the top of the evidence hierarchy, the types of research questions they address are not suitable for every application [ 3 ]. Many indications more appropriately require a scoping review. For example, to explore the extent and nature of a body of literature, the development of evidence maps and summaries; to inform future research and reviews and to identify evidence gaps [ 2 ]. Scoping reviews are particularly useful where evidence is extensive and widely dispersed (i.e. many different types of evidence), or emerging and not yet amenable to questions of effectiveness [ 22 ]. Because scoping reviews are agnostic in terms of the types of evidence they can draw upon, they can be used to bring together and report upon heterogeneous literature—including both empirical and non-empirical evidence—across disciplines within and beyond health [ 23 – 25 ].

When deciding between whether to conduct a systematic review or a scoping review, authors should have a strong understanding of their differences and be able to clearly identify their review’s precise research objective(s) and/or question(s). Munn and colleagues noted that a systematic review is likely the most suitable approach if reviewers intend to address questions regarding the feasibility, appropriateness, meaningfulness or effectiveness of a specified intervention [ 3 ]. There are also online resources for prospective authors [ 26 ]. A scoping review is probably best when research objectives or review questions involve exploring, identifying, mapping, reporting or discussing characteristics or concepts across a breadth of evidence sources.

Scoping reviews are increasingly used to respond to complex questions where comparing interventions may be neither relevant nor possible [ 27 ]. Often, cost, time, and resources are factors in decisions regarding review type. Whilst many scoping reviews can be quite large with numerous sources to screen and/or include, there is no expectation or possibility of statistical pooling, formal risk of bias rating, and quality of evidence assessment [ 28 , 29 ]. Topics where scoping reviews are necessary abound—for example, government organisations are often interested in the availability and applicability of tools to support health interventions, such as shared decision aids for pregnancy care [ 30 ]. Scoping reviews can also be applied to better understand complex issues related to the health workforce, such as how shift work impacts employee performance across diverse occupational sectors, which involves a diversity of evidence types as well as attention to knowledge gaps [ 31 ]. Another example is where more conceptual knowledge is required, for example, identifying and mapping existing tools [ 32 ]. Here, it is important to understand that scoping reviews are not the same as ‘realist reviews’ which can also be used to examine how interventions or programmes work. Realist reviews are typically designed to ellucide the theories that underpin a programme, examine evidence to reveal if and how those theories are relevant and explain how the given programme works (or not) [ 33 ].

Increased demand for scoping reviews to underpin high-quality knowledge translation across many disciplines within and beyond healthcare in turn fuels the need for consistency, clarity and rigour in reporting; hence, following recognised reporting guidelines is a streamlined and effective way of introducing these elements [ 34 ]. Standardisation and clarity of reporting (such as by using a published methodology and a reporting checklist—the PRISMA-ScR) can facilitate better understanding and uptake of the results of scoping reviews by end users who are able to more clearly understand the differences between systematic reviews, scoping reviews and literature reviews and how their findings can be applied to research, practice and policy.

Future directions in scoping reviews

The field of evidence synthesis is dynamic. Scoping review methodology continues to evolve to account for the changing needs and priorities of end users and the requirements of review authors for additional guidance regarding terminology, elements and steps of scoping reviews. Areas where ongoing research and development of scoping review guidance are occurring include inclusion of consultation with stakeholder groups such as end users and consumer representatives [ 35 ], clarity on when scoping reviews are the appropriate method over other synthesis approaches [ 3 ], approaches for mapping and presenting results in ways that clearly address the review’s research objective(s) and question(s) [ 29 ] and the assessment of the methodological quality of scoping reviews themselves [ 21 , 36 ]. The JBI Scoping Review Methodology group is currently working on this research agenda.

Consulting with end users, experts, or stakeholders has been a suggested but optional component of scoping reviews since 2005. Many of the subsequent approaches contained some reference to this useful activity. Stakeholder engagement is however often lost to the term ‘review’ in scoping reviews. Stakeholder engagement is important across all knowledge synthesis approaches to ensure relevance, contextualisation and uptake of research findings. In fact, it underlines the concept of integrated knowledge translation [ 37 , 38 ]. By including stakeholder consultation in the scoping review process, the utility and uptake of results may be enhanced making reviews more meaningful to end users. Stakeholder consultation can also support integrating knowledge translation efforts, facilitate identifying emerging priorities in the field not otherwise captured in the literature and may help build partnerships amongst stakeholder groups including consumers, researchers, funders and end users. Development in the field of evidence synthesis overall could be inspired by the incorporation of stakeholder consultation in scoping reviews and lead to better integration of consultation and engagement within projects utilising other synthesis methodologies. This highlights how further work could be conducted into establishing how and the extent to which scoping reviews have contributed to synthesising evidence and advancing scientific knowledge and understandings in a more general sense.

Currently, many methodological papers for scoping reviews are published in healthcare focussed journals and associated disciplines [ 6 , 39 – 43 ]. Another area where further work could also occur is to gain greater understanding on how scoping reviews and scoping review methodology is being used across disciplines beyond healthcare including how authors, reviewers and editors understand, recommend or utilise existing guidance for undertaking and reporting scoping reviews.

Whilst available guidance for the conduct and reporting of scoping review has evolved over recent years, opportunities remain to further enhance and progress the methodology, uptake and application. Despite existing guidance, some publications using the term ‘scoping review’ continue to be conducted without apparent consideration of available reporting and methodological tools. Because consistent and transparent reporting is widely recongised as important for supporting rigour, reproducibility and quality in research, we advocate for authors to use a stated scoping review methodology and to transparently report their conduct by using the PRISMA-ScR. Selection of the most appropriate review type for the stated research objectives or questions, standardising the use of methodological approaches and terminology in scoping reviews, clarity and consistency of reporting and ensuring that the reporting and presentation of the results clearly addresses the authors’ objective(s) and question(s) are also critical components for improving the rigour of scoping reviews. We contend that whilst the field of evidence synthesis and scoping reviews continues to evolve, use of the PRISMA-ScR is a valuable and practical tool for enhancing the quality of scoping reviews, particularly in combination with other methodological guidance [ 10 , 12 , 44 ]. Scoping review methodology is developing as a policy and decision-making tool, and so ensuring the integrity of these reviews by adhering to the most up-to-date reporting standards is integral to supporting well informed decision-making. As scoping review methodology continues to evolve alongside understandings regarding why authors do or do not use particular methodologies, we hope that future incarnations of scoping review methodology continues to provide useful, high-quality evidence to end users.

Acknowledgements

The authors would like to acknowledge the other members of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) working group as well as Shazia Siddiqui, a research assistant in the Knowledge Synthesis Team in the Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto.

Authors’ contributions

MDJP, CM, HC, CMG, SH, TH, EVL, EL, KKO, OT, MGW, WZ and AT all made substantial contributions to the conception, design and drafting of the work. MDJP and CM prepared the final version of the manuscript. All authors reviewed and approved the final version of the manuscript.

The authors declare that no specific funding was received for this work. Author ACT declares that she is funded by a Tier 2 Canada Research Chair in Knowledge Synthesis. KKO is supported by a Canada Research Chair in Episodic Disability and Rehabilitation with the Canada Research Chairs Program.

Availability of data and materials

Declarations.

Not applicable.

Author ACT is an Associate Editor for the journal. All other authors declare no conflicts of interest.

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

Contributor Information

Micah D. J. Peters, Email: [email protected] .

Casey Marnie, Email: [email protected] .

Heather Colquhoun, Email: [email protected] .

Chantelle M. Garritty, Email: ac.irho@yttirragc .

Susanne Hempel, Email: ude.csu@hennasus .

Tanya Horsley, Email: ac.egelloclayor@yelsroht .

Etienne V. Langlois, Email: tni.ohw@esiolgnal .

Erin Lillie, Email: [email protected] .

Kelly K. O’Brien, Email: [email protected] .

Ӧzge Tunçalp, Email: tni.ohw@oplacnut .

Michael G. Wilson, Email: ac.retsamcm@2mosliw .

Wasifa Zarin, Email: [email protected] .

Andrea C. Tricco, Email: [email protected] .

• Open access
• Published: 03 October 2022

The partner’s experiences of childbirth in countries with a highly developed clinical setting: a scoping review

• Nadine Schmitt 1 ,
• Sabine Striebich 2 ,
• Gabriele Meyer 1 ,
• Almuth Berg 1 &
• Gertrud M. Ayerle 1  

BMC Pregnancy and Childbirth volume  22 , Article number:  742 ( 2022 ) Cite this article

3120 Accesses

6 Citations

4 Altmetric

Metrics details

In Western countries, it is common practice for a woman to be supported by a trusted person during childbirth, usually the other parent. Numerous studies have shown that this has a positive effect both on the woman’s satisfaction with the birth process and on physical outcomes. However, there is little research on the birth experience of partners and their wellbeing. The aim of this review is to summarise the existing literature on partner experience, consider its quality and identify the underlying themes.

Both a systematic literature search in three databases and a manual search were conducted, for qualitative, quantitative, and mixed-methods studies from Western countries examining the experiences of partners present at a birth.

A total of 35 studies were included. Only one study included same-sex partners (the other studies addressed fathers’ experiences only) and only one validated questionnaire examining partners’ birth experiences was identified. Four major themes were found to influence partners’ birth experiences: (1) intense feelings, (2) role of support, (3) staff support, and (4) becoming a father.

Conclusions

Partners may feel very vulnerable and stressed in this unfamiliar situation. They need emotional and informal support from staff, want to be actively involved, and play an important role for the birthing woman. To promote good attachment for parents, systematic exploration of the needs of partners is essential for a positive birth experience. Because of the diversity of family constellations, all partners should be included in further studies, especially same-sex partners.

Peer Review reports

Until the 1980’s, childbirth was considered “women’s business”. For this reason, as well as because of strict hygiene regulations, partners were not desired or encouraged to attend the birth [ 1 ]. It has only been in the last 40 years that support from a trusted person has been encouraged as part of family-oriented childbirth [ 2 ]. The partner’s presence at birth has increased significantly, at least in Western countries [ 3 ].

The majority of partners want to participate in the birth of their child and support the women [ 4 ]. Partners describe the birth of their child as a moment of realisation, a transformation into becoming a father [ 5 ]. Partners who participated in the birth feel they have “grown” into fatherhood [ 6 ] and report higher attachment scores than partners who did not participate in the birth [ 7 ]. The more involved the partner is during childbirth, the stronger the bond with the baby will be [ 8 ]. Gettler et al. suggest that birth represents a phase in which paternal psychobiology responds to fathers’ new experiences in interacting with their newborns [ 9 ]. They found that first-time fathers’ oxytocin levels were higher after holding their newborn for the first time than before. They also found that fathers played more with their infants after birth when their oxytocin levels increased and testosterone decreased. Thus, stronger attachment is associated with greater involvement. Fathers’ involvement during childhood has positive effects on children’s development, such as physical health and social skills [ 10 ]. Therefore, strong attachment is likely to have a lasting positive impact on the family and society as a whole [ 11 ].

In contrast to the body of knowledge outlined above, partners often receive little attention and are not always involved during childbirth [ 12 , 13 ]. They report feeling excluded and unsupported by the healthcare system during pregnancy and childbirth [ 14 ]. If the partner does not experience support and does not feel included, he or she will not be able to adequately support the woman [ 15 ].

Lack of communication between partners and medical staff and the feeling of exclusion can lead to a negative birth experience for the partner [ 16 ]. A negative birth experience can affect fathers’ mental health [ 17 ]. It is associated with an increased risk of postpartum depression, for example [ 18 ], and can even lead to symptoms of post-traumatic stress disorder (PTSD) [ 19 ]. A negative birth experience and PTSD can in turn lead to disrupted attachment between parent and child and be associated with negative parenting outcomes [ 18 ].

While in low-income countries very low caesarean section rates with a high maternal mortality risk are reported, in high-income countries caesarean section rates have risen sharply since the 1970s [ 20 ]. In many highly developed Western countries, an intervention-rich obstetric care is currently practised in hospitals, where excessive and non-evidence-based use of interventions can be observed [ 21 ]. A high degree of medicalisation and high rates of intervention, with one in three children born by caesarean section [ 22 ], characterise clinical obstetric care in Germany. It has been indicated that less than 10% of low-risk women birthing in hospital in Germany experience a natural birth without any invasive interventions [ 23 ]. Despite a lack of or inconclusive evidence regarding interventions, the physiological birth process is frequently intervened in [ 24 ]. This is countered by the fact that childbirth is one of the most important personal experiences in many women’s lives and it is important for many women to experience a physiologic birth process [ 25 ].

In 2018, the World Health Organization published a guideline with evidence-based recommendations for low-risk births [ 26 ]. The goal is to avoid unnecessary interventions and therefore promote physiological births. Social support during childbirth is an important component of a natural birth. A positive birth experience is related to the woman being accompanied by someone she knows and trusts [ 27 ]. The WHO clarifies that every woman has the right to have a companion of her choice present during childbirth [ 28 ]. A Cochrane review concludes that the presence of a companion has a positive effect on the birth process: Women who received continuous support were more likely to have a spontaneous vaginal birth and were less likely to require intrapartum analgesia, their labour was shorter, and they were more satisfied with the birth process [ 29 ].

The companionship of a close person has been shown to be important for birthing women [ 30 , 31 , 32 ]. Companions provide emotional, psychological and physical support during labour, which contributes to a more positive birth experience [ 27 , 32 , 33 , 34 ]. Specifically, the presence of a partner promotes trust and safety, can alleviate pain and feelings of loneliness, create emotional and physical wellbeing [ 35 ], contribute to self-confidence and strength in coping with childbirth [ 32 ], and promote women’s sense of control in labour [ 36 ].

Nowadays, in most Western countries, it is common for expectant fathers to be present in the birthing room and to actively participate in their partner’s labour and birth [ 32 ]. While the subjective feelings of the women giving birth are increasingly addressed, research on partners’ experiences of childbirth is still quite scarce [ 11 , 37 ]. Men are seen as companions during pregnancy and birth, but are not treated as individuals with their own needs [ 38 ]. If we want to promote secure attachment between both parents and their child, we need to create conditions that support the development of partners’ attachment hormones too. This includes a positive birth experience for the partner and an understanding of what partners need to achieve that. According to Nielsen & Overgaard, to support true family development involvement, the individual needs of the partner should be explored [ 39 ]. We also need to identify factors that lead to a negative birth experience so as to be able to preventively protect partners’ mental health.

This scoping review therefore aims to identify, review and synthesise the literature on the experiences of partners during childbirth in clinical settings in Western countries in order to identify the different themes and subthemes, which influence these experiences.

We used the design of a scoping review since it maps the key concepts underlying an area of research and the main sources and types of available evidence [ 40 ]. Scoping reviews typically address broad questions and may include a range of methods. This is in contrast to a systematic review, where the research question is narrowly defined and the included studies are critically appraised. For this study, a scoping review was deemed most appropriate for mapping the literature and identify the main themes related to partners’ birth experiences. This review follows the five steps of Arksey & O’Malley’s framework [ 40 ]: 1. Identifying the research question, 2. Identifying relevant studies, 3. Study selection, 4. Charting the data, 5. Collating, summarising and reporting the results. In addition to these five steps, the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA_ScR) Checklist was used to ensure completeness of the procedure (Additional File 1 ) [ 41 ]. To reflect the heterogeneity of the included studies and their methodological quality, we have included a critical appraisal of these studies in this scoping review.

Identifying the research question

What are the experiences of partners attending the birth of their child in clinical settings in Western countries?

Although heteronormative relationships are the most common type of relationship and thus the father is the most common companion, diverse constellations of relationships exist. For this reason, we searched for the experience of partners in general. However, with the exception of one study, we found only studies that examined the experiences of fathers. For this reason, we refer to fathers in this review.

Identifying relevant studies

The beginnings of partner birth attendance 1980s are not comparable to today`s birth attendance. For this reason, and due to societal changes regarding the inclusion of fathers and equal parenting, especially from the turn of the millennium onwards, we conducted a review of the literature published after 2000. Initial searches were conducted in Medline via PubMed and CINAHL and in the midwifery digest MIDIRS in May 2021. To find additional relevant studies, we manually searched the Internet and used citation tracking. Since this work is a preliminary work for the development of a German language questionnaire for partners during childbirth, we were strongly interested in what publications have appeared in Germany on this topic. For this reason we manually reviewed professional journals in the field of maternity care published in Germany via database Thieme publisher. The search terms (Table 1 ) were piloted (i.e., terms like ‘labour’ that yielded too many hits were searched in the title only) and adjusted according to the databases. To achieve efficient search results, we used truncations according to the requirements of the databases and MeSH terms for Medline. For example, the search string for PubMed was as follows:

(“labour companionship”[tiab] OR companion*[tiab] OR father*[tiab] OR husband*[tiab] OR “birth partner*”[tiab] OR “support person” OR spouse* OR spouses[MeSH]) AND (well-being[tiab] OR wellbeing[tiab] OR welfare[tiab] OR emotion*[tiab] OR affectiv*[tiab] OR psychologic*[tiab] OR experienc*[tiab]) AND (labour[ti] labor[ti] OR birth*[ti] OR childbirth[ti] OR parturition[ti] OR parturition[MeSH]).

Study selection

We considered as eligible all qualitative, quantitative and mixed-method studies which examined the birth experiences of partners in the clinical setting, whether or not it was their first attendance at a birth. Any published language was included. Table 2 lists the inclusion and exclusion criteria.

For comparability, studies were included from Western countries, covering Northern, Western and Southern European countries, Australia, New Zealand, and Canada (for a detailed list of related countries see: https://unstats.un.org/unsd/methodology/m49/ ). Since obstetric care in Eastern European countries and North and South America differs greatly from that in Germany, studies from these countries were not included, nor were studies from developing countries.

Charting the data

Two independent researchers (NSch and SStr) extracted the data. First, all titles and abstracts were checked for inclusion, and the included studies were then reviewed for relevance using the full text. Disagreements between researchers were resolved through discussion and consensus. If necessary, the opinion of a third researcher (GA) was obtained. Researchers extracted information on study characteristics using a piloted data extraction form. Data extraction included information about the authors and year, the country in which the study was conducted, a description of the participants, the birth modes included in the study, information about which method was used to examine the birth experience and a summary of the results found.

Collating, summarising and reporting the results

Due to heterogeneity in study design and quality, various birth experience themes were categorised and described. Some sources addressed experiences during pregnancy or postpartum in addition to the birth experience. Here, only evidence related to the birth experience was extracted. If both mothers and fathers were interviewed in the publication, we considered only the experiences of fathers, also in comparison to mothers, whenever possible.

In order to identify recurring themes regarding birth experiences, the main results of all included studies were first recorded in a comprehensive table. Then, similarities and differences in the data were systematically identified by rereading the studies’ main results. Obvious recurring themes were first colour coded. Subsequently, each main result was assigned to a theme. Four themes common across all studies were identified.

Because we combined qualitative, quantitative and mixed-methods studies, we used the Mixed Methods Appraisal Tool (MMAT) to assess the quality of the studies [ 42 ]. Screening questions were answered to determine the empirical nature of the study and to assess the key features of its methodology. The first author (NSch) assessed all studies, while co-authors (GA, AB, GM, SStr), acting as independent second reviewers, assessed a subset of studies each. Disagreements were resolved through discussion between the authors.

Search outcomes and study characteristics

The flow chart of the literature selection (Fig.  1 ) provides an overview of the search results. After removing duplicates, 1054 hits (1003 + 51) were identified in the Medline, CINAHL and MIDIRS databases and then screened. Citation tracking and other search sources (e.g., asking colleagues) yielded 11 additional hits. Of these, 61 abstracts related to fathers’ experiences. The scoping review includes 35 studies that met the inclusion criteria. 13 used a qualitative method approach, 18 used a quantitative approach and four a mixed-method approach. In some studies, participants were first-time fathers. In other studies, the experiences of fathers who did not have their first child but had another child were examined. Seven studies also examined the experiences of the women giving birth [ 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. Another examined the experiences of the mother and sisters of the women giving birth [ 50 ]. As mentioned above, only one study included same-sex partners in addition to fathers [ 44 ]. The time span of postpartum follow-up ranged from 24 h after birth to one year after birth. Some studies did not specify at what time after birth the data collection took place.

Literature selection flowchart

The majority of the qualitative studies used open or semi-structured interviews, two of them in combination with observation. In the included mixed-method studies, data were collected mainly through closed- and open-ended questions. Most quantitative studies were conducted with self-developed questionnaires. In one case the Salmon’s Item List was adapted to men [ 51 ], and in another, the rate of PTSD was measured using established instruments [ 52 ]. One study combined the results of their questionnaire with data collected using the State-Trait-Anxiety Inventory (STAI) during childbirth [ 11 ]. In the period from 2000 to 2021, only one validated questionnaire (the First-time Father Questionnaire) was found to measure birth experiences of partners, and two of the included studies referred to it [ 53 , 54 ]. Additional File 2 shows the assessment of methodological quality of the included studies. Here it can be seen that the majority of the qualitative studies have good validity. The quantitative studies, on the other hand, are only of moderate to low validity. This is mainly due to the fact that the studies used poorly validated questionnaires to investigate the birth experience of partners. Another issue that affects validity is that many quantitative studies contain incomplete outcome data.

Findings – thematic areas of birth experience

Four main themes relate to fathers’ experiences of clinical birth: Intense feelings, the role of support, staff support, and the becoming a father. Table 3 provides an overview of the included studies.

Intense feelings

Almost all included studies report intense feelings among fathers. The most commonly reported feelings are anxiety, ranging from worry to fear, and helplessness [ 49 , 53 , 54 , 55 , 60 , 67 , 70 , 71 , 74 , 75 ]. For fathers, dealing with women’s pain during birth is extremely challenging [ 49 , 51 , 55 , 59 , 66 , 69 , 72 ], especially when pain increases, something unexpected happens, and the couple is left alone [ 74 ]. Fathers worry about the health and life of both the woman and the baby [ 59 , 60 , 69 , 73 ]. The inability to help her or to share the pain is one of the overwhelming memories [ 64 ] and leads to helplessness [ 65 ]. This helplessness can lead to feelings of panic [ 46 , 56 ]. The greater the level of anxiety, the lower the satisfaction with the birth experience [ 11 ]. Higher levels of anxiety have been found to be associated with an unplanned pregnancy, feeling poorly prepared for labour and birth, a lower sense of control, and paternal history of mental health issues [ 52 ].

While some studies show that fathers who already have children are less fearful [ 60 ], Bradley et al. report higher levels of ‘intrusion’ and ‘avoidance’ (symptoms of PTSD) when fewer children and fewer births were experienced [ 52 ]. Regardless of the number of births experienced, Vischer et al. (2020) found that the PTSD symptom ‘intrusion’ was still prevalent in fathers six months after birth. The authors’ explanation is that the birth experience is still very present due to the memorable event. They did, however, find that not a single father met all the criteria for PTSD after experiencing the birth [ 75 ].

Fathers feel vulnerable and highly stressed in this unknown situation [ 63 , 67 ] and report a variety of emotions. Gawlik et al. describe the birth experience for fathers as a multidimensional process, similar to mothers’ [ 51 ]. Fathers are unsure of how to act [ 70 ] and struggle with emotional distress [ 48 , 74 ]. Feelings of lack of control [ 47 , 60 ] are described, as are feelings of tension or guilt [ 73 ]. Stress levels are particularly high among fathers who felt pressured to be present at birth [ 63 ]. Fathers sometimes report ambivalent feelings: they want to be there, but at the same time are afraid of what they might see [ 74 ], or even have the impulse to flee [ 73 ]. In two studies, some fathers expressed fears about negative effects on their sex lives [ 55 , 73 ]. While some studies report that fathers felt well prepared [ 45 ], in others all fathers stated that they were not really prepared for what was happening because they could not imagine it [ 67 , 74 ]. Some fathers talk about the discrepancy between their expectations and the actual duration of the birth, in both directions [ 65 , 66 ].

The environment also has an impact on fathers’ feelings. Men state that the unfamiliar environment in a hospital birthing room causes discomfort [ 64 ] or criticise the equipment, describing a lack of privacy and even seating [ 66 ]. Harte et al. conducted a single-case study to examine the influence of the hospital environment on the experiences of birth companions [ 50 ]. They found that support people felt disorientated, inhibited and hesitant in the environment, with the predominant feeling was ‘unbelonging’. They wanted to build a nest for the women, but felt foreign, uncomfortable and lacking in privacy. They felt that they had no control over the birthing room; the equipment frightened them and they found it disruptive.

Other factors affecting fathers’ feelings are the impacts of the birth process itself. Experiencing interventions or witnessing complications is perceived as stressful and difficult [ 65 , 72 ]. Men whose partners adopt an upright position are more likely to have a positive birth experience and feel more comfortable and powerful than those where a horizontal birth position is adopted [ 62 ]. There were conflicting results regarding the use of analgesia in labour. In one study, men whose partners received analgesia perceived their presence as more necessary, helpful and relaxing. They felt more involved, less anxious and stressed [ 11 ]. In contrast, in the study by Bélanger-Lévesque et al., the use of epidural analgesia is a significant predictor of lower satisfaction [ 44 ]. Different modes of birth also affect fathers’ feelings differently, although the data are also inconsistent. Premberg et al. found that fathers were more worried when the child was born by caesarean section or instrumental birth than when a spontaneous vaginal birth was possible [ 53 ]. Rosich-Medina & Shetty and Johansson & Hildingsson report more negative feelings about emergency caesarean sections and instrumental births in fathers, than in those who witness vaginal birth or elective caesarean section [ 61 , 71 ]. Bélanger-Lévesque et al. report lower satisfaction among fathers attending instrumental birth and primary caesarean section [ 44 ]. Chan & Paterson-Brown, however, report more negative feelings during a caesarean birth than during a normal or instrumental vaginal birth [ 45 ]. In contrast, Porrett et al. found no significant difference in fathers’ experiences between birth modes [ 69 ].

Despite these negative feelings, many of the included studies report positive overall experiences for fathers [ 44 , 45 , 46 , 47 , 48 , 49 , 51 , 58 ]. Most men report a desire to be present at a future birth and advise other men to attend [ 54 , 55 , 64 , 75 ].

The studies comparing the experiences of fathers and mothers all concluded that the overall experience was the same for both parents, but that they differed on individual subthemes [ 44 , 46 , 47 , 48 ]. While the fathers feel they were not supportive, mothers report the opposite. Women rate father involvement and support as more active and positive than men do [ 45 , 47 , 48 ]. Men hide their feelings from the woman giving birth so as not to worry her [ 70 ]. However, there are also findings that the fathers’ experiences are rated more negatively by mothers than by fathers themselves [ 45 ], which leads the authors to conclude that the men do not seem to have hidden their feelings from women.

The feelings reported by fathers also relate to the role they assumed during childbirth. Johnson report higher levels of stress in men who did not fulfil their expectations of the role [ 63 ].

Role of support

In five studies, the majority of men were found to have felt helpful and important in supporting the woman giving birth [ 49 , 55 , 67 , 69 , 75 ]. However, in four studies the opposite was found: men felt unable to meet the mother’s needs and did not believe that they had been supportive [ 47 , 62 , 63 , 68 ]. Partners aim to provide comfort and protection [ 43 , 50 ], for example, by withholding negative information or advocating for the woman during conflicts with staff [ 70 ]. They provide emotional support by being present and offering conversation, physical support by aiding different birthing positions or easing mobility, and informational support by mediating between staff and the woman [ 49 , 65 ]. They try to be part of the process [ 67 ], want to be seen as one half of the birthing couple [ 56 ], but are sometimes described as being on the edge of events [ 68 ]. It can be difficult for the father to find his role, regardless of factors such as environment or staff [ 68 ]. Sometimes the role of the father is described as ‘just being there’ [ 68 , 74 ]. Several studies report that men would like to be more involved [ 58 , 62 ] and some even report feeling they have no role or are in the way [ 50 , 63 , 64 ]. When fathers feel involved in the birth process, they also feel more useful [ 69 ]. In Krulis et al. the majority of the fathers were satisfied with the role they played [ 66 ].

It is typical for the man to put his own needs aside and to hide own feelings [ 70 ]. The role of the support person is described as highly variable [ 66 ], depending on personality [ 74 ], and an individual partner’s assumed role can change during the birth process [ 50 ]. Tarlazzi et al. describe fathers as more engaged and active in the second stage of labour when pain is described as more active [ 74 ].

Studies attempting to classify different roles describe, for example, an observer role (distant and disinterested, passive or vigilant active observer role), a carer role (providing comfort and emotional support), an intermediary role (facilitating information sharing) and an advocate role (representing the woman’s needs by advocating for her) [ 68 ].

The environment influences the role of support people by either providing a place to be present and responsive to the woman’s needs or by preventing closeness [ 50 ]. Technology influences this, as do the presence of staff and the woman’s expectations and encouragement [ 43 ].

Staff support

The behaviour and communication of medical staff are described as having a strong influence on partners’ feelings [ 65 ]. The fathers’ role in labour is also related to the support provided by the staff [ 56 , 70 ]. They need the midwife’s guidance to find their role [ 67 ]. Fathers’ needs are varied, but what seems to be the most important is information , especially about the birth process, particularly for those who are unmarried, have a lower education status, and for first-time fathers [ 57 ]. In Eggermont et al.’s study, formal information needs were given higher priority than involvement in the birth process, but midwives were found to overlook this or give unwanted information [ 57 ]. Hildingsson et al. also found information to be a high priority among fathers with more than one child. First-time fathers in this study, however, considered it more important for the midwife to be present and supportive [ 58 ]. Premberg et al. found that fathers whose child was born by caesarean section also rated the provision of information highly [ 53 ]. The information needed by fathers relates to what is happening and how they can help [ 56 , 65 , 66 , 70 ]. They need support in their ability to support the woman [ 59 ], for example, by the midwife showing the father how to be supportive or for the father to imitate the midwife [ 56 ]. They want to receive clear and appropriate information, and feel more confident when midwives know when and how to act as midwives themselves [ 62 ].

In addition to information, emotional support and acceptance are important factors [ 53 ]. Fathers want to feel that their presence is important [ 70 ], to be treated with respect and empathy, and to be actively involved in the decision-making process [ 59 , 60 ]. Whether fathers feel supported during childbirth depends on whether they feel included as one half of the birthing couple, or whether they feel marginalised [ 56 ]. The partner needs informative and emotional support to feel calm and find their role [ 50 ]. Men want to be treated as an important part, both as an individual and as part of the birthing couple [ 56 ]. They want to be involved but also have the option of not being involved [ 56 ]. When lack of importance and support are perceived this leads to helplessness and panic and makes their supportive role more difficult [ 56 ], or leads to a more passive role [ 43 ]. However, Longworth & Kingdon show that staff behaviour or language did not affect fathers’ feelings of being on the periphery of events during childbirth [ 68 ].

Fathers frequently report low professional support [ 47 , 54 , 56 , 57 , 58 , 76 ]. Fathers would have liked the midwife to be present more often and for more information about the birth process to have been provided [ 47 ]. There is a large discrepancy between the perceived reality of receiving enough information and the subjective importance of it [ 58 ]. Support options, such as holding the birthing woman were reportedly difficult to implement because of environmental factors, e.g., lack of space or convenient options [ 50 ].

In contrast, other studies report that midwifery care, opportunities for participation and decision-making were better than expected or needed [ 58 ]; staff care is overwhelmingly positively viewed [ 66 ], and the majority found staff helpful in answering questions and reducing anxiety [ 69 ]. The midwife’s competence, her calming manner, and communication with her were perceived as helpful [ 66 ]. Fathers do not express the need for emotional support, probably because, as mentioned above, they suppress their feelings [ 57 ].

Involvement in care, trustworthy and supportive staff [ 60 ], satisfaction with midwife presence and the provision of information are related to a positive birth experience [ 58 ]. Limited participation in the decision-making process, lack of support from staff, and lack of information are related to a negative birth experience [ 60 ]. The more informed fathers feel, the more they find that the birth was as they expected [ 69 ].

While some studies find no difference in fathers’ ages [ 58 , 69 ], other studies showed that younger fathers have a greater need for emotional support and acceptance [ 53 ].

Becoming a father

The moment of birth is described as a life-changing and overwhelming moment characterised by feelings of love and belonging [ 5 , 65 ]. The best moment of the birth experience is the physical appearance of the baby [ 55 , 72 ] followed by great feelings of relief [ 65 ]. Fathers want to hold the baby in their arms as soon as possible [ 59 ] and describe witnessing the birth of the child – along with supporting the woman – as the most important reason to accompany the birth [ 49 ]. Potential emotional disconnection during pregnancy and birth can now be reconnected [ 68 ]. Birth as the beginning of fatherhood is described as a transformation [ 5 ]. The cutting of the umbilical cord is referred to as a “rite of passage”, the physical separation of mother and baby [ 64 ], or the event that makes the baby an independent person [ 49 ]. The feelings are described as much stronger than expected, the greatest event in their lives [ 67 ], wonderful and different from anything else [ 5 ]. Fathers feel the bond with the child [ 68 ], but also feel the bond as a trio [ 5 ]. The birth experience can strengthen and enhance the relationship with the woman [ 45 , 73 ]. However, feelings of fear for the child and strangeness are also reported [ 73 ].

This scoping review presents the quantitative, qualitative and mixed-method findings on fathers’ birth experiences in the clinical setting. Four important themes were found to influence fathers’ birth experiences, enhance their well-being, and promote an active and thus more satisfying role. One theme deals with the intense feelings reported by the fathers after the birth. During the birth process, the fathers describe strong negative feelings, especially fear and being overwhelmed. The birth of the child, on the contrary, is described as the most beautiful event of their lives. Premberg et al. describe this essential meaning of the experience as an ‘interwoven process pendulating between euphoria and agony’ [ 70 ]. These positive feelings are part of a main theme in this review, the becoming a father . The remaining two themes are the role of support and staff support . These two are closely related, as staff support has a significant impact on the role of the support person.

Fenwick et al. found that the desire for support from staff was expressed in advance when men were asked about their expectations for the birth, as confirmed in this review [ 14 ]. Partners want to receive information, they want to be involved, and to be part of the process. They need trustworthy and professional staff to support them and an environment that is sensitive to their needs and supportive of their role. Men want to be treated with empathy and respect. They need support from staff to find their role. One finding from this review is that fathers put the woman’s well-being first, suppress their feelings in favour of the woman, and therefore do not ask for support from staff even when they need it. It is not yet clear exactly what partners need to be able to express their true feelings and needs, and how health professionals can be more inclusive of the father. A first step toward identifying partners’ needs and concerns has been taken with this review. Following this, a more in-depth study using validated instruments is needed to determine how staff can address these needs from the partners’ perspective.

If men do not receive support, they may take a very passive role, feel helpless and as a result not experience a positive birth. Women equally want an active partner to go through the birth process with them [ 39 ]. They need physical contact and intimacy [ 39 , 77 ] and want someone emotionally close to them who gives them a sense of familiarity [ 30 ]. Women can be distracted by the need to attend to their support person’s wellbeing, as they tend to be at least peripherally aware of their partner’s activities, comfort, and mood [ 50 ]. Nielsen & Overgaard show that women’s stress and anxiety levels are lower when they do not have to worry about their partner’s wellbeing [ 39 ].

Previous studies have reported that support people felt unprepared for the intensity of the unpredictable birth process and the resulting fears regarding the health and life of the partner and child [ 78 ]. In addition, feelings of discomfort and difficulties in dealing with the woman’s pain are reported [ 6 ]. These intense emotions, especially fear and feeling overwhelmed, were confirmed by the present review. Men are mainly afraid for the woman and child and are overwhelmed by the woman’s pain. We found few studies that used established and validated instruments to measure psychological outcomes, such as anxiety and stress, in fathers [ 11 , 52 ]. More research is needed if we want to prevent post-traumatic stress disorder and provide partners with a positive experience of birth care. However, this scoping review has also confirmed the positive feelings described earlier [ 6 ]. The majority of fathers report a great experience and would recommend other fathers attending the birth. Studies are required to investigate whether feelings of anxiety and overwhelm are part of the process, whether they are compensated for by the joy of having a child, or whether they are stressful and long-lasting. There is also a need for studies that investigate what key factors influence the experience of overwhelm and thus what differentiates the partners in their experience.

The evidence regarding different birth modes was inconsistent, particularly with respect to caesarean section. While in some studies caesarean section was found in general to lead to a more negative birth experience, others reported that elective caesarean section led to a positive birth experience. Many of the studies included here focussed on spontaneous vaginal births and excluded other birth modes from the outset. Studies focusing on the fathers’ experience with caesarean birth found that they want to receive information and be involved in the decision-making process [ 76 ]. What is clear from the studies included in this review is that being present at an instrumental birth leads to negative feelings and a negative birth experience for the father. A study by Hildingsson et al., focusing on couples’ experiences of instrumental birth, reports fathers feeling near panic when attending an instrumental vaginal birth [ 79 ]. Nevertheless, the extent to which partners’ needs differ across birth modes remains to be determined. Therefore, more comprehensive studies are warranted to determine the specific needs of partners in different birth processes and birth modes.

Studies focusing on a non-clinical setting were excluded from this scoping review. Fathers present during a home birth report different feelings, in particular greater active mental and physical involvement [ 80 ]. In Lindgren & Erlandsson, a father at home describes himself as an interpreter and provider of safety for the woman, whereas in a hospital birth he sees himself as a protector and guardian of the woman [ 81 ]. The home environment facilitates support, and the absence of unknown people gives the father a sense of security in supporting the woman [ 81 ]. Men find it much easier to find a supportive role at home because they can relax and engage with the woman’s needs. They feel they are in the role of host rather than guest [ 81 ]. This facilitation of the paternal role during birth is difficult to achieve in the highly medicalised obstetric setting. Studies which compare the wellbeing of fathers in the homebirth environment to that in conventional birthing rooms are needed. Studies should also find out what can be changed in the clinics so that the partner can take a confident supportive role as in home births.

The present review has some potential limitations. First, the methodological quality of the studies varied, which may have influenced the results presented here. For example, the sample size of most of the quantitative studies included was small and the questionnaires used to capture birth experiences of partners were often not validated. Second, although the focus was restricted to Western countries, comparability between different healthcare and obstetric systems is limited. Results should therefore be considered with caution. Third, some studies do not specify at what time after birth the data collection took place. Thus, no conclusion can be drawn about potential recall effects in these studies. Fourth, a number of the studies reviewed were Swedish, therefore the Swedish context may be overly represented. In Sweden, fathers’ involvement is generally considered a social ‘norm’ [ 82 ]. This may be one reason why typical male gender biases have not been addressed in the studies included in this review. Dolan & Coe suggest that men’s mental construction of appropriate support during childbirth is in conflict with traditional masculine values and men feel marginalised [ 12 ]. To compensate, men construct masculine identities during childbirth which allow them to embody a masculine form (e.g., by suppressing overwhelming feelings and hiding them from the woman giving birth and staff).

It is important to consider the woman, the partner and the couple as three separate and individual units. The active role of the support person should be encouraged, as they are more likely to feel useful and thus more satisfied with the birth process. To this end, the support person needs emotional and informal support from the staff. He or she needs information to reduce fears and anxieties and instruction on how to support the woman. Given the prevailing shortage of midwives and work overload of clinical staff, the wellbeing and role of the support person should be systematically studied and promoted. Results are sometimes inconsistent and studies with validated questionnaires are lacking. Systematic research should be conducted on what support people need to achieve a positive birth experience. Further, studies should be conducted which include all support people and do not focus exclusively on fathers.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Abbreviations

Post-traumatic stress disorder

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

Medical Literature Analysis and Retrieval System Online

Public Medicine

Cumulative Index to Nursing and Allied Health Literature

Midwives Information & Resource Service

Medical Subject Headings

State-Trait-Anxiety Inventory

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NSch formulated the research question and carried out the literature search. NSch and SStr sifted through the titles and abstracts of the published articles. NSch checked and summarised the literature and wrote the draft. GA consulted on the review of the articles and monitored the review process. AB gave advice on assessing the methodological quality of the studies. All authors were involved in the critical appraisal. SStr, GA and GM checked and made substantive improvements in the draft manuscript. All authors read and approved the final manuscript.

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Schmitt, N., Striebich, S., Meyer, G. et al. The partner’s experiences of childbirth in countries with a highly developed clinical setting: a scoping review. BMC Pregnancy Childbirth 22 , 742 (2022). https://doi.org/10.1186/s12884-022-05014-1

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Abstract 4791: Characterizing interventions to reduce disparities in lung-cancer screening uptake by state Medicaid expansion status: A scoping review

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Miranda J. Reid , Caretia Washington , Meghann Wheeler , Lauren Adkins , Dejana Braithwaite , Ramzi Salloum; Abstract 4791: Characterizing interventions to reduce disparities in lung-cancer screening uptake by state Medicaid expansion status: A scoping review. Cancer Res 15 March 2024; 84 (6_Supplement): 4791. https://doi.org/10.1158/1538-7445.AM2024-4791

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Background: Lung cancer is the leading cause of cancer-related deaths in the United States, and yet, lung cancer screening rates remain persistently low. Many interventions are being developed to address the low rates of lung cancer screening (LCS), including interventions that address the additional barriers faced by historically marginalized racial and ethnic populations as well as low-income and rural populations. However, the impact of Medicaid expansion on the types of interventions developed in non-expansion states and the efficacy of those interventions is not well understood.

Methods: A research librarian conducted searches in MEDLINE via PubMed, Web of Science, and Embase. Results were screened and evaluated for eligibility by three reviewers in Covidence. Data was extracted from included studies after full-text review and analyzed using both a thematic analysis and a descriptive numerical summary of studies. The chosen framework was based on scoping review guidelines by Levac et al. and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR).

Results: Of 4696 studies found through the initial search, 53 met inclusion criteria. This includes 34 studies in Medicaid expansion states (M) and 17 studies in non-Medicaid expansion states (NM). Two additional studies compared interventions implemented in a Medicaid expansion state to a similar intervention implemented in a non-expansion state. Studies in both groups were primarily focused on addressing disparities by race and ethnicity (M=74%; NM=65%), with fewer studies focusing on rurality (M=9%; NM=12%), income (M=9%; NM=0%), or multiple disparities (M=9%; NM=24%). In non-expansion states, the most common interventions were patient navigation (29%) and community outreach (24%). While in Medicaid expansion states, the most common interventions were EHR algorithms (24%) and decision aids (21%). The intervention setting for both Medicaid expansion and non-expansion states were most commonly in a hospital/health system (M=53%; NM=47%) or community setting (M=24%; NM=47%). Interventions in both groups typically showed some improvement in uptake of LCS, though the degree of impact was variable between studies.

Conclusion: Due to continued barriers to access posed by inadequate insurance coverage, there is a critical need for interventions to reduce disparities in lung cancer mortality in states that have not expanded Medicaid. Interventions focused on patient navigation and community outreach have been effective in multiple settings in these states and could fill that gap.

Citation Format: Miranda J. Reid, Caretia Washington, Meghann Wheeler, Lauren Adkins, Dejana Braithwaite, Ramzi Salloum. Characterizing interventions to reduce disparities in lung-cancer screening uptake by state Medicaid expansion status: A scoping review [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4791.

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• Published: 26 March 2022

Weight stigma in the COVID-19 pandemic: a scoping review

• Patricia Fortes Cavalcanti de Macêdo   ORCID: orcid.org/0000-0002-2728-0431 1 ,
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Journal of Eating Disorders volume  10 , Article number:  44 ( 2022 ) Cite this article

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Weight stigma is a phenomenon associated with adverse behavioural and psychological consequences. Although experts suggest that its increase during the COVID-19 pandemic may be associated with worse health outcomes for people with obesity, a thorough analysis of the main findings and gaps is still needed when relating to this subject.

We aim to answer three questions: (1) How does weight stigma manifest in the COVID-19 pandemic? (2) How can weight stigma affect people with overweight or obesity in times of COVID-19? (3) What are the perceptions and experiences of weight stigma during the pandemic in individuals who experience overweight or obesity?

We conducted a scoping review of studies addressing weight stigma and the COVID-19 pandemic in electronic databases (Medline/PubMed, CINAHL, Embase, PsycInfo, BVS/Lilacs, Scopus, Web of Science, Google Scholar, and OpenGrey) published until 10th August 2021. All relevant studies were reviewed in full by two researchers. In addition, a narrative synthesis of the data was performed.

The results included 35 studies out of 8,090 records and identified 14 original research publications, 15 text and opinion papers, and 6 narrative reviews. The results revealed the presence of weight stigma in the media, healthcare settings, interpersonal relationships, and public campaigns during the COVID-19 pandemic. The evidence of increasing weight stigma in the COVID-19 outbreak is limited, though. Many weight discrimination consequences were described during this time, such as impairment in accessing healthcare, worst COVID-19 outcomes, and maladaptive eating. However, only maladaptive behaviours and decline in mental health outcomes were demonstrated empirically in all age groups. This effect occurred regardless of body mass index, but people with high body weight were more likely to experience weight stigma. For some people with obesity, weight stigma in the pandemic has made activities of daily routine difficult.

Conclusions

The results suggest that weight stigma in the COVID-19 pandemic occurs in several settings; moreover, although weight discrimination impacts mental health, whether before or during the pandemic, this influence between the pandemic and pre-pandemic scenario is still unclear. Therefore, more research is required in this field while the pandemic lasts, especially with people with obesity.

Plain English summary

Overall, people with overweight or obesity are more vulnerable to weight stigma than individuals without overweight. In addition, weight stigma refers to discrimination or prejudice based on a person’s weight and relates to several consequences, for instance, poor healthcare treatment and mental health problems. In the COVID-19 outbreak, these weight stigma effects tend to become even more critical because they may be associated with unfavourable COVID-19 outcomes and eating disorder risks. Thus, it is crucial to investigate how weight stigma occurs during the pandemic and its impact on health, mainly for the most affected people.

We investigated 35 studies published between 2019 and 2021 to map and explore how weight stigma was manifested and the related consequences for people with overweight or obesity in the COVID-19 pandemic. Only about a third of them were quantitative or qualitative, limiting the evidence of weight stigma in the COVID-19 context. The available evidence suggests that weight stigma manifests in several settings such as media, healthcare, public campaigns, and is more common in people with excess weight. However, weight discrimination experiences before or during the pandemic were associated with adverse psychological and behavioural consequences across all age groups, regardless of body weight. For some people with obesity, for instance, weight stigma made it difficult to accomplish their activities of daily routine. Nevertheless, it remains unclear whether weight stigma has increased in the pandemic, thus, more studies are required, especially about people with overweight or obesity.

Introduction

The debate about weight stigma and its consequences for people with obesity has gained ground in the scientific community in recent years. In March 2020, experts published the first international consensus to combat weight stigma [ 1 ]. Furthermore, with the advent of the COVID-19 pandemic, the media, scientists, and the general public increased focus on body weight [ 2 , 3 ]. In this sense, the fact that obesity is considered a risk factor for the aggravation of the viral infection and the emergence of the widespread fear of gaining weight due to social distancing measures have become of concern for people living with obesity during the pandemic and reinforced the implications of weight stigma [ 3 , 4 , 5 , 6 ].

Weight stigma refers to people's devaluation and social depreciation due to excess weight [ 1 ], and its multidimensionality encompasses structural and individual forms of discrimination [ 7 ]. Structural stigma occurs when institutions as the media and the health sector, for example, issue stigmatizing messages and frame a group negatively [ 7 , 8 ]. Individual forms of discrimination include person-to-person weight stigma experiences and self-stigma (or internalized weight stigma) [ 7 , 8 ]. In addition, when high body weight converges with other forms of stigmatization (e.g., socioeconomic status), it can be incorporated into the concept of intersectional stigma [ 9 ]. Thus, weight stigma extends to multiple domains such as health services, education, work, family, public policy campaigns, media, and others [ 1 , 10 , 11 ].

In the COVID-19 pandemic, experts suggest increased vulnerability to weight stigma in the healthcare sector and the media [ 3 , 4 , 6 ]. Although these sectors already recognized weight stigma as pervasive in the pre-pandemic environment, it is believed that the increase in media and scientific coverage of obesity and COVID-19 can intensify weight discrimination in healthcare settings [ 4 ]. Furthermore, the "quarantine-15" hashtag, which alluded to the fear of gaining weight in the context of social isolation, helped identify the dissemination of stereotyped images of people with high body weight on social media [ 3 , 6 ].

This information regarding the manifestations of weight stigma in healthcare and the media in the pandemic is remarkably relevant considering that weight-based discrimination is associated with varied consequences. For example, structural stigmas, such as those linked to healthcare settings, are related to behavioural effects such as avoiding or delaying the search for health services [ 12 ]. Moreover, weight stigma experiences or internalization are associated with adverse psychological and behavioural outcomes, such as poor mental health [ 7 ] and disordered eating [ 13 ]. Therefore, in a context of health and economic crisis such as the pandemic, it is necessary to understand how the manifestations of weight stigma can impact health and well-being, especially of the most vulnerable, that is, people with overweight [ 14 ].

Experts consider that weight bias in the healthcare settings may be associated with worse outcomes of COVID-19 [ 4 , 5 ], especially in racial or ethnic minorities and socioeconomically disadvantaged groups affected by other forms of discrimination [ 5 ], and that exposure to fat-phobic content in the media could pose a greater risk for worsening eating disorders symptomatology (ED) in times of pandemic [ 6 ]. However, a narrative review with articles published in 2020 identified that more studies are required to investigate weight bias and the consequences of weight stigma experienced in the pandemic on health and well-being [ 15 ]. Although these results are essential, we believe that an updated review with systematic methodology is necessary to identify which scenarios manifested weight stigma, whether it has increased or not, and its consequences in the context of the COVID-19 outbreak.

Given that the COVID-19 pandemic implies a broad and rapidly developing literature base, a scoping review can provide evidence on the extent, nature, and consequences of weight stigma in that context. Furthermore, scoping reviews are helpful when one has complex and heterogeneous issues [ 16 , 17 ] and provide an overview of the available scientific literature [ 18 ]. Thus, we systematically reviewed the literature published from 2019 to 2021 to explore and map the evidence on weight stigma directed at people with overweight and obesity in the context of the COVID-19 pandemic. We proposed three research questions to meet the objective of this review: (1) How does weight stigma manifest in the COVID-19 pandemic? (2) How can weight stigma affect people with obesity in times of COVID-19? (3) What are the perceptions and experiences of weight stigma during the pandemic in individuals who experience overweight or obesity?

This scoping review was conducted following the Joanna Briggs Institute methodology [ 18 ] and adopted the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist extension for Scoping Reviews (PRISMA-ScR) [ 19 ]. The review protocol was previously registered ( https://osf.io/ujcbf ).

Eligibility criteria

The (PCC) framework guided the inclusion of studies in this review. The population (P) of interest was represented by all studies that addressed weight stigma towards people with overweight or obesity; weight stigma was the concept (C) underlying this work, and the Context (C) referred to the COVID-19 pandemic. For the definition of weight stigma in this review, we adopted the proposals by Rubino et al. [ 1 ], referring to this phenomenon as the social devaluation and denigration of people because of their excess weight, which can lead to negative attitudes, stereotypes, prejudice, and discrimination. Thus, studies needed to clearly emphasize weight stigma (the presence of the concept, or interchangeable terms, in the study full text). Inclusion criteria consisted of observational, qualitative, or mixed studies and text and opinion evidence. The research excluded in vitro intervention studies involving animals, theses, dissertations, and abstracts.

Information sources and search strategy

We searched without restrictions in February 2021 and last updated it in August 2021 to identify potentially relevant documents in the following databases: Medline/PubMed, CINAHL, Embase/Elsevier, PsycInfo, Regional Portal BVS/Lilacs, Scopus, and Web of Science, as well as Google Scholar (retained records from the first 15 pages) and OpenGrey (grey literature). Two authors (PFCM, EPM) elaborated the research strategy in three stages. First, an initial search was performed in MEDLINE/Pubmed and PsycInfo. Next, a second search with all keywords and indexed terms was conducted in all databases. Finally, the reference list of all included articles was manually searched to include additional studies. Search terms included “weight stigma” and “COVID-19” and their respective related terms using Boolean operators AND and OR. The final search strategy can be found in an Additional file 1 .

Selection of sources of evidence

After duplicates removal in EndNote®, three authors (PFCM, CMMN, LCL) independently selected studies using the Rayyan software [ 20 ]. During the screening, the titles and abstracts of the publications were read, followed by the complete reading and selection of eligible studies. Finally, a fourth reviewer’s (MLPS) decision resolved any discrepancy.

Data mapping process and data items

The first author (PFCM) extracted the required data from the selected studies by using the Joanna Briggs Institute's System for the Unified Management, Assessment and Review of Information (SUMARI), and two authors (NSS, VAOQ) reviewed the collected information. The extracted variables consisted of the type of study, country of publication, study methodology, the phenomenon of interest (weight stigma and related constructs), subjects (i.e., people with overweight or obesity), context, and relevant findings for the purpose(s) of the review. These variables were recorded as described in the studies or marked as not applicable.

Synthesis of results

A narrative synthesis reported the results of this review. The collected data were presented in tables or figures. To investigate weight stigma manifestation (question 1), we identified the terms used to refer to the concept, weight stigma dimensions (experienced, self-stigma, structural, intersectional), measurements of the concept (when applicable), and in which domains the phenomenon had occurred (when applicable). In addition, the research included all studies that proposed outcomes or consequences related to the phenomenon to analyse data on the consequences of weight stigma in the pandemic context (question 2), as psychological outcomes measured in primary studies or increased risk of mortality presented in texts and opinion articles. Similarly, to find out about perceptions and experiences of weight stigma in individuals who experienced overweight or obesity during the pandemic (question 3), we considered studies that related directly to the topic, through interviews in qualitative studies, for instance, or discussed the theme in text and opinion documents.

Selection and characteristics of sources of evidence

A total of 8090 records were retrieved from the databases. After duplicate records had been removed, 6264 studies were screened by title or abstract, and 40 were considered for full text-reading, resulting in 32 original studies [ 2 , 3 , 4 , 5 , 6 , 15 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 ] for inclusion (three studies had two published articles each) [ 26 , 32 , 38 , 43 , 48 , 49 ]. Later, the references of the studies included initially were searched, and four additional citations were considered for full text-reading, with three of them fulfilling inclusion criteria [ 4 , 23 , 41 ], totalling 35 included studies for this review. Overall, six unrelated studies to the phenomenon or context of interest were excluded. The selection process of this study is described in the PRISMA flowchart adapted from Page et al. [ 53 ] (Fig.  1 ).

Flow diagram of included studies

As for the characteristics of the studies, the majority corresponded to text and opinion documents (n = 15) [ 2 , 3 , 4 , 5 , 25 , 26 , 27 , 29 , 31 , 33 , 36 , 37 , 41 , 42 , 50 , 52 ] and narrative reviews (n = 6) [ 6 , 15 , 28 , 30 , 35 , 46 ]. Quantitative ( n  = 6) [ 24 , 26 , 32 , 38 , 39 , 43 , 47 , 48 , 49 ] and qualitative research studies ( n  = 8) [ 21 , 22 , 23 , 34 , 40 , 44 , 45 , 51 ] were retained. Of the quantitative studies, three were cross-sectional [ 24 , 39 , 47 ] and three were longitudinal [ 32 , 47 , 48 , 49 ]. And, among the qualitative studies, seven corresponded to content analysis of texts or images [ 21 , 22 , 23 , 40 , 44 , 45 , 51 ] and one to people with obesity interviews [ 34 ]. (Table 1 ).

Most studies were published in 2020 ( n  = 20) [ 2 , 3 , 4 , 5 , 6 , 21 , 28 , 29 , 31 , 34 , 36 , 37 , 41 , 44 , 45 , 46 , 47 , 48 ]. As shown in Fig.  2 , there were more opinion texts and narrative reviews than quantitative and qualitative studies in the first year of the pandemic. There was great variability related to weight stigma domains addressed by the studies. Thus, it is worth considering the focus of the respective document. Almost half of the studies [ 4 , 5 , 25 , 27 , 28 , 29 , 30 , 31 , 33 , 34 , 36 , 37 , 41 , 46 , 51 ] addressed weight stigma when evaluating aspects related to obesity in the pandemic context, and only six [ 24 , 26 , 32 , 38 , 39 , 43 , 47 , 48 , 49 ] directly measured variables related to weight stigma (Table 1 ).

The number of studies published by type of publication throughout the COVID-19 pandemic

Overall, studies were predominantly from Europe ( n  = 19) [ 2 , 4 , 22 , 23 , 24 , 28 , 29 , 30 , 31 , 33 , 34 , 37 , 38 , 41 , 42 , 43 , 46 , 47 , 54 ] and North America ( n  = 14) [ 3 , 5 , 6 , 15 , 21 , 25 , 36 , 38 , 39 , 40 , 43 , 45 , 47 , 48 , 49 , 51 ]. One opinion piece [ 4 ] and two reviews [ 6 , 30 ] included authors from different countries. And, one quantitative research used a multinational sample [ 38 , 43 ]. Figure  3 , elaborated via EviAtlas [ 54 ], shows a map of study locations and illustrates their concentrations.

Sources of evidence on weight stigma during the COVID-19 pandemic published by country. Note : red dots correspond to different studies ( n  = 31); grey, orange, and brown dots represent three studies and their repetitions stand for the countries of their respective authors; green dots correspond to the samples of a multinational study comprising six countries

Participants' characteristics

Six quantitative [ 24 , 26 , 32 , 38 , 39 , 43 , 47 , 48 , 49 ] and one qualitative study [ 34 ] assessed participants’ characteristics. All studies included both genders [ 24 , 26 , 32 , 34 , 38 , 39 , 43 , 47 , 48 , 49 ] with a sample size of 23 to 13,996. Of these studies, five included a sample of adults (age ≥ 18 years old) from the United States (the US) [ 38 , 43 , 47 , 48 , 49 ], Canada [ 38 , 43 ], Germany [ 38 , 43 ], France [ 38 , 43 ], Australia [ 38 , 43 ], the United Kingdom (the UK) [ 24 , 38 , 43 ] and Ireland [ 34 ]; the other two involved American adolescents (age < 18 years old) [ 39 ] and Chinese children (age 7–13 years old) [ 26 , 32 ]. In addition, two studies with adults included only participants with obesity [ 24 , 34 ].

Results from individual evidence sources

The following topics will describe the mapping related to the review questions (Table 2 ). Additional information is available in an Additional file 2 .

Weight stigma manifestations in the pandemic context

All thirty-five studies indicated weight stigma manifestations in the pandemic. Most studies used more than one nomenclature to address the same concept. Nevertheless, the predominant term was weight stigma ( n  = 18) [ 2 , 3 , 5 , 6 , 15 , 25 , 26 , 27 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 43 , 44 , 47 , 52 ]. Similarly, most documents addressed more than one dimension of the concept, highlighting a higher frequency in the category of structural weight stigma ( n  = 25) [ 2 , 3 , 4 , 5 , 6 , 15 , 21 , 22 , 23 , 25 , 29 , 30 , 31 , 33 , 36 , 37 , 39 , 40 , 41 , 42 , 44 , 45 , 46 , 50 , 52 ], comprising publications about stigmatizing messages disseminated in the media ( n  = 18) [ 2 , 3 , 4 , 6 , 15 , 21 , 23 , 27 , 30 , 31 , 35 , 37 , 39 , 40 , 42 , 44 , 45 , 52 ], public health campaigns ( n  = 5) [ 22 , 27 , 33 , 41 , 50 ] and healthcare ( n  = 13) [ 1 , 2 , 4 , 5 , 15 , 25 , 29 , 30 , 31 , 36 , 37 , 42 , 46 ] in the pandemic.

Ten studies reported the increase in weight stigma during the pandemic in the media [ 3 , 6 , 23 , 27 , 30 , 31 , 39 ], in healthcare [ 4 ], on public campaigns [ 22 ], expressed as a general vulnerability for people with elevated body weight [ 42 ] or related to perceived weight discrimination [ 39 ]. Most of these sources of evidence corresponded to expert opinion ( n  = 7). Only two studies observed that weight stigma empirically increased during the pandemic: one qualitative research about the UK’s mass media [ 23 ] and one quantitative research with American adolescents [ 39 ]. The former found that the British press had created rhetoric around obesity generating more stigma than usual. In the latter, 53% of the teenagers reported increased weight stigma on social media and 12.8% in their interpersonal relationships [ 39 ]. More details are described in sections " Media " and " Experienced and internalized weight stigma estimates ".

Six studies [ 24 , 26 , 32 , 38 , 39 , 43 , 47 , 48 , 49 ] used measures to assess weight stigma: five applied closed-ended questions (one to four items) to analyse weight stigma experiences [ 24 , 38 , 43 , 47 , 48 , 49 ] or weight stigma in media content exposure [ 39 ]; two studies used scales to assess weight stigma internalization [ 43 ] and perceived weight stigma [ 26 , 32 ]. In addition, a qualitative study [ 34 ] observed weight self-stigma through one of the interviews.

Weight stigma in the pandemic has been cited in domains such as the media, healthcare settings, public campaigns, related to perceived experiences and internalization, as mentioned above, in public opinions of people with obesity [ 51 ], and interpersonal relationships [ 25 , 39 ]. Therefore, the following session will feature the evidence on the concept in all respective domains.

We classified evidence on weight stigma in the media into two categories: coverage on obesity and COVID-19 and stigmatizing content on social media in the pandemic context.

Two opinion papers [ 2 , 42 ], one narrative review [ 15 ] and three qualitative studies [ 21 , 23 , 45 ] cited the coverage on obesity and COVID-19. Overall, the authors highlighted the narrative of individual responsibility for obesity in the media coverage by journalists [ 42 ], broadsheets [ 23 ], tabloids [ 23 ], television [ 2 ], online news media [ 21 , 45 ], and news stories [ 2 , 15 ]. The studies suggested that weight stigma in media coverage was either reinforced [ 2 , 21 ] or intensified [ 23 , 42 ] in the pandemic. The three qualitative studies identified an implicit anti-fat bias in Brazilian articles published on internet portals [ 45 ], Canadian news media [ 21 ], and British broadsheets and tabloids [ 23 ], but only one analysed pandemic and pre-pandemic periods. Brookes (2021) [ 23 ] compared the discourses of articles in British tabloids ( n  = 2000) and broadsheets ( n  = 2000) (published in March-July/2020) to articles on obesity from before the pandemic (August-December/2019). The author concluded that the COVID-19 pandemic produced more stigmatizing discourses than usual, holding people with obesity responsible for their health and the healthcare system's problems [ 23 ].

The stigmatizing content on social media during the pandemic was mentioned in seven opinion texts [ 3 , 4 , 27 , 31 , 37 , 42 , 52 ], four narrative reviews [ 6 , 15 , 30 , 35 ], two qualitative content analysis studies [ 40 , 44 ] and one quantitative paper [ 39 ]. The studies characterized weight stigma on social media as the spread of anti-fat memes and images [ 3 , 15 , 31 , 40 ] and messages [ 6 , 37 , 42 , 44 ] that mocked people with overweight [ 27 , 30 ] through jokes about weight gain, sedentary behaviour or overeating during the pandemic [ 6 , 39 , 52 ]. Eight documents mentioned posts on social media referring to "Quarantine 15" [ 3 , 6 , 15 , 27 , 40 , 42 , 44 , 52 ] characterized by weight-stigmatizing content due to fear or risk of weight gain during the period of COVID-19 social distancing. The two qualitative studies identified anti-fat attitudes on Instagram comments [ 44 ] and images [ 40 ], which identified posts that disliked higher-weight bodies (46.9%) through the “quarantine-15” hashtag [ 40 ]. In the quantitative study ( n  = 452) [ 32 ], the majority of adolescents (53%) reported increases in seeing jokes on social media about people eating food because they were stressed (45%) or memes about people gaining weight (37%) during the pandemic. Perceived weight stigma exposure on social media was approximately 10% higher in female adolescents and 20% greater in the girls with higher body weight [ 32 ].

Eight sources of evidence of text and opinion documents [ 2 , 4 , 5 , 29 , 31 , 36 , 37 , 42 ] and five narrative reviews [ 15 , 25 , 30 , 35 , 46 ] mentioned associations to weight stigma in healthcare settings in the COVID-19 pandemic. In addition, at least one dimension of weight stigma, such as experiences of stigma and weight bias, intersections of vulnerabilities during the pandemic, high stigma or perceived vulnerability in the pandemic, or systematic weight bias, was related to consequences for people with obesity in the health sector during the pandemic, such as the impediment or delay in accessing healthcare [ 2 , 4 , 5 , 15 , 27 , 29 , 31 , 36 , 37 , 46 ].

Public campaigns and public opinion towards people with obesity

Four texts and opinion papers [ 27 , 33 , 41 , 50 ] and one qualitative study [ 22 ] cited the possibility of further stigmatization of people with obesity through the message of public health campaigns that considered weight loss as a critical strategy to fight COVID-19. Four of these documents referred to the UK public health campaign [ 22 , 33 , 41 , 50 ]. In addition, the qualitative study [ 22 ] observed personal responsibility discourses directed at people with obesity and argued that the pandemic context itself might have intensified this stigmatization by motivating this new set of policies. Finally, one qualitative study [ 51 ] had investigated public opinion towards obesity of Americans living in the United States during the pandemic (May/2020) and observed a predominant narrative about obesity which said that "people are lazy."

Interpersonal sources of weight stigma

One quantitative study [ 39 ] and one text and opinion document [ 25 ] reported potential interpersonal sources of weight stigma. The quantitative study ( n  = 452) showed that part of adolescents perceived an increase in experiencing mistreatment due to body weight from parents and peers in the pandemic context, which was pronounced in people with higher body mass index and females (estimated prevalence in the section below). Moreover, the text and opinion paper [ 25 ] suggested that teasing and bullying in online education in the pandemic could also enable children to bully other children with obesity.

Experienced and internalized weight stigma estimates

Six studies evaluated measures of experienced weight stigma before or during the pandemic and internalized weight stigma [ 24 , 26 , 32 , 38 , 39 , 43 , 47 , 48 , 49 ]. Each study used a different open-ended question or scale and evaluated distinct aspects of the constructs. None of the samples was representative of the wider population including adults, adolescents, and children. In almost all of them [ 24 , 26 , 32 , 38 , 39 , 43 , 48 , 49 ], weight stigma before or during the pandemic was more prevalent or significantly associated with high body weight; the remaining study did not address this issue [ 49 ]. Four of these studies reported the prevalence or mean of weight stigma experienced or internalized in the period of the COVID-19 pandemic [ 24 , 26 , 32 , 39 , 43 ]. In adults with obesity ( n  = 543), the prevalence of weight stigma experienced during the pandemic was 16.7% [ 24 ]. Among adolescents ( n  = 452) [ 39 ], 12.8% and 3.8% reported an increase in weight-based mistreatment from parents and peers, respectively, which were almost twice as high in those with overweight [ 39 ]. Similarly, in the study with children ( n  = 1357) [ 26 ], those with overweight had higher means ( p  < 0.05) of perceived weight stigma scores in the pandemic compared to kids without overweight [ 26 ]. However, the children's mean perceived weight stigma scores were higher ( p  < 0.01) than the scores before the pandemic than in the social distancing and post-lockdown period [ 32 ]. Only one study investigated internalized weight stigma during the pandemic [ 43 ]. They evaluated adults ( n  = 13,996) from six countries enrolled in an international weight management program. This study highlights that the mean internalized weight stigma scores were significantly higher ( p  ≤ 0.001) in the UK, Australia, and France than in Germany, Canada, and the United States. Unfortunately, the authors did not compare the results to values before the pandemic.

Weight stigma and associated consequences in the pandemic

Twenty-five included studies reported weight stigma consequences in the pandemic: six quantitative studies [ 24 , 26 , 32 , 38 , 39 , 43 , 47 , 48 , 49 ], one qualitative paper [ 34 ], six narrative reviews [ 6 , 15 , 28 , 30 , 35 , 46 ] and twelve text and opinion documents [ 2 , 4 , 5 , 25 , 29 , 31 , 36 , 37 , 42 , 52 ].

The six quantitative studies [ 24 , 26 , 32 , 38 , 39 , 43 , 47 , 48 , 49 ] presented a relation between adverse behavioural and psychological outcomes in the pandemic and weight stigma in adults [ 24 , 38 , 43 , 47 , 48 , 49 ], adolescents [ 39 ], and children [ 26 , 32 ]. Additional information from these studies is available in an additional file [see Additional file 2 ].

Four studies, two cross-sectional and two cohorts, investigated weight stigma consequences in adults. The cross-sectional studies measured the association of history of weight stigma (i.e., had experienced weight stigma until May to July/2020) and psychological and behavioural outcomes in samples composed mostly for people with overweight or obesity [ 24 , 38 , 43 ]. For example, Brown et al. [ 24 ] assessed 543 people with obesity from the UK. They observed that participants with a history of weight stigma had lower well-being, more significant depression ( p  < 0.001) and more precautionary behaviours ( p  = 0.010) in the pandemic. The findings of this study accord with more large-scale research [ 38 , 43 ], in which the authors evaluated 13,996 individuals enrolled in an international weight management program from six countries (the UK, Australia, France, Germany, the US, and Canada). The large-scale research observed that history of weight stigma was also significantly ( p  ≤ 0.001) associated with worsened mental health and some maladaptive behaviours, such as gym avoidance and eating to cope, in the pandemic (May–July/2020) [ 38 ]. However, internalized weight stigma was significantly associated with many outcomes, including their effects across countries for poor body image, weight gain in the previous year, less eating and physical activity self-efficacy and lower physical health-related quality of life [ 43 ]. The authors also highlighted some differences between countries. For example, France showed slightly weaker effects of weight stigma internalized for some variables, like eating to cope, body image, and stress, when compared to all other countries in the study [ 43 ].

Longitudinal studies supported these results. The two cohort studies with adults investigated if pre-pandemic weight stigma experiences could predict psychological distress or behavioural outcomes during pandemic (March and April/2020) [ 47 , 48 , 49 ]. These studies sampled people living in the US ( n  = 584–2094) and included assessments before and after the pandemic. Sutin et al. [ 48 , 49 ] measured responses to the Coronavirus and the trajectory of psychological distress and well-being across the pandemic by BMI category and weight discrimination. Overall, this research observed that pre-pandemic weight stigma experiences were associated with more positive (e.g., engaging in more preventative behaviours) and negative (e.g., less trust in people) responses to the pandemic [ 48 ] and influenced the worsening of well-being across the outbreak [ 49 ]. The authors also showed that the distress trajectory did not vary by weight discrimination; however, those with pre-pandemic weight stigma experiences were at a twofold increased risk of incident depression [ 49 ]. The longitudinal influence of weight stigma on psychological well-being found in this study accords with the research findings of Puhl et al. [ 47 ]. These authors observed that pre-pandemic experiences of weight stigma predicted higher levels of depressive symptoms, stress, eating to cope, and an increased likelihood of binge eating (odds ratio = 2.88, p  < 0.001) [ 47 ]. However, nonsignificant associations emerged for depressive symptoms and stress after adjusting for their baseline levels. The authors suggested that the effects of weight stigma were attenuated for distress when considering their pre-pandemic levels [ 47 ]. In the two studies [ 47 , 49 ], the impact of weight stigma persisted regardless of the BMI.

In adolescents, a cross-sectional study with a crosstab analysis showed that increases in weight stigma experienced or in weight stigma exposure on social media by American teenagers ( n  = 542) during the pandemic (until December/2020) were aligned with increases in body dissatisfaction [ 39 ]. Furthermore, both weight stigma and body dissatisfaction increase in the pandemic were higher in youth with higher weight ( p  < 0.025) and among females ( p  < 0.001) [ 39 ].

Finally, in Chinese children ( n  = 1357), the cross-sectional analyses showed that high levels of perceived weight stigma in the COVID-19 pandemic (March/2020) were significantly associated with greater fear of COVID-19 infection and higher levels of stress, anxiety, and depression regardless of weight status [ 26 ]. In the longitudinal evaluation of the same study, ( n  = 489), perceived weight stigma before the pandemic (January/2020) or in subsequent waves (March and June/2020) was associated ( p  < 0.001) with problematic use of social media, depression, anxiety, and stress in all three waves [ 32 ]. The association between perceived weight stigma and psychological distress in children was more robust in the pandemic than in the pre-pandemic period [ 32 ].

A qualitative study [ 34 ] ( n  = 23) pointed out the difficulty of an Irish adult following up on obesity treatment due to self-stigmatization. And, finally, six narrative reviews [ 6 , 15 , 28 , 30 , 35 , 46 ] and twelve text and opinion documents [ 2 , 4 , 5 , 25 , 29 , 31 , 36 , 37 , 42 , 52 ] cited negative consequences associated with weight stigma in the pandemic context, in which they highlighted the impediment or delay to information or health services [ 2 , 4 , 5 , 15 , 27 , 29 , 31 , 36 , 37 , 46 ], worse COVID-19 outcomes [ 4 , 5 , 27 , 29 , 30 , 31 , 35 , 36 , 37 ] and increased susceptibility to disordered or maladaptive eating [ 2 , 6 , 15 , 25 , 28 , 41 , 52 ]. Some theoretical proposals explained these implications. For example, a position statement elaborated by the European Association for the Study of Obesity (AESO) [ 29 ] proposed a conceptual model where past experiences of weight stigma integrated social factors that link obesity with COVID-19 severity. Three opinion articles also suggested the impact of weight stigma associated with other forms of vulnerability in health inequalities and unsatisfactory COVID-19 results [ 5 , 35 , 36 ]. Also, a review [ 6 ] pointed out that the increase in fatphobic messaging on media (e.g., “Quarantine 15”) during pandemic integrated the risk factors for worsening symptomatology of individuals with ED. Todisco et al. [ 52 ] corroborates this framework and suggest that the weight stigmatizing social media posts in the pandemic may generate common weight-based stereotypes while promoting unrealistic thin ideals and extreme weight-management practices.

People with obesity (PwO) perceptions or experiences on weight stigma in the pandemic

Two studies described perceptions or experiences on weight stigma of people with overweight in the pandemic [ 34 , 37 ]. First, a qualitative study [ 34 ] carried out with Irish adult patients ( n  = 23) undergoing multimodal treatment for obesity observed the impact of weight self-stigmatization on the ability to engage in obesity treatment through the one participant’s report. Second, a text and opinion study [ 37 ] based on interviews with PwO from the UK showed that participants reported feelings of shame, a perception of being "less of a priority than any other condition" and a reluctance to seek help because of weight stigmatizing comments on social media. In this opinion paper [ 37 ], some of the people interviewed associated fear of weight gain during lockdown with stigma or shame, which prevented them from exercising or shopping for food.

Summary of evidence

The results pointed to four main settings or sources of weight stigma in the COVID-19 pandemic: media (18/35), healthcare (13/35), public campaigns (5/35), and interpersonal relationships (2/35). Weight stigma’s consequences varied according to the study type; quantitative studies (6/35) related weight stigma to behavioural and psychological outcomes in adults (4/6), adolescents (1/6), and children (1/6). Opinion papers and narrative reviews (21/35) suggested delay or impairment in accessing healthcare (10/21), worst COVID-19 outcomes (8/21), maladaptive eating (6/21), and others (3/21). Few studies (2/35) described experiences or perceptions of people with obesity. This work proposes to discuss, firstly, the question on weight stigma manifestations, second, the related consequence, and, thirdly, PwO perceptions and experiences.

Although weight stigma occurs in different sectors during the pandemic, some of these manifestations still need to be tested empirically. For example, although experts have widely mentioned the health sector as a possible source of stigmatization in the pandemic [ 2 , 4 , 5 , 29 , 31 , 36 , 37 , 42 ], no empirical studies have evaluated this issue. In addition, the scope found in the investigation regarding the different environments that manifested weight stigma in the pandemic partially demonstrates what is already pointed out in studies in the pre-pandemic period, that is, weight stigma is pervasive and manifests itself in multiple domains [ 1 , 14 , 55 ]. Our review also showed conceptual proposals that support the importance of assessing multiple forms of stigma (e.g., weight stigma and mistreatment based on race/ethnicity) [ 5 , 29 , 35 , 36 ]. However, the pre-pandemic scenario [ 56 ] lacks quantitative data on this issue, indicating a lack of investment in research independent of the outbreak.

What makes empirical evidence even more limited in this context is that only one epidemiologic study assessed weight stigma sources during the COVID-19 pandemic (media and interpersonal relationships) [ 39 ]. Besides, this research collected data from an unrepresentative sample of American adolescents, and used single-item assessments that had not previously been validated as instruments to evaluate weight stigma [ 39 ]. In any case, higher BMI was associated with weight stigma in the quantitative studies [ 24 , 26 , 32 , 38 , 39 , 43 , 47 , 48 , 49 ], which agrees with the literature conducted before the outbreak [ 14 ] and suggests the greatest vulnerability of this group. Only one quantitative study with children compared pandemic and pre-pandemic values of weight stigma [ 26 ]. The authors suggested that lower perceived weight stigma values during the pandemic may be related to decreased social interactions [ 26 ]. Given that the scale used in this research did not assess sources of experiences, we believe that instruments should include them to be more sensitive to understanding how changes in experiences of weight discrimination occurred in the pandemic compared to the previous scenario.

Regarding weight stigma consequences, the empirical evidence available on this subject comes from three cross-sectional papers and three longitudinal studies: the adult studies by Puhl et al. [ 47 ], Sutin et al. [ 48 , 49 ], Lessard et al., Pearl et al. [ 38 , 43 ] and Brown et al. [ 24 ]; the adolescent studies by Lessard and Puhl [ 39 ]; and the children's investigation by Chen et al. and Fung et al. [ 26 , 32 ]. Altogether, the data showed that experiencing weight stigma could lead to unfavourable psychological and behavioural outcomes in the pandemic in all age groups, regardless of body weight. However, some considerations are crucial to interpret these results. First, the research included a small number of studies, all with unrepresentative samples and some partly composed of people who mainly were overweight [ 24 , 38 , 43 ]. Second, although the relationship between weight stigma and worse mental health indicators and maladaptive behaviours in people with or without overweight agrees with previous literature [ 7 , 13 , 57 ], it is impossible to conclude whether this impact is different between the two groups in the pandemic. Third, the consequences for physical or mental health and whether a possible increase in weight stigma can result in worse health outcomes are unclear when stigma comes from different domains (e.g., interpersonal relationships  versus  media) or multiple sources in the outbreak.

Cross-sectional and longitudinal studies supported results on the consequences of weight stigma, particularly in studies with adults. In addition, previous studies demonstrate the relationship between weight stigma (experienced and internalized) with emotional distress and worse body image and symptoms of eating disorder (ED) [ 58 , 59 ]. Therefore, based on the data collected during this review, we suggest that this may be a pathway to increase the risk of eating disorders at the present. Furthermore, differences in the frequency and impact of weight stigma across countries may indicate that cultural issues mediate these relationships [ 38 , 43 ], and one should proceed with caution when comparing results. Furthermore, we believe that a more robust statistical analysis for repeated data can help to understand better the effect of weight stigma on distress throughout the pandemic. The increased weight stigma and body dissatisfaction in adolescents during the pandemic [ 39 ] indicate significant findings; however, the theme also demands more robust statistical analyses to confirm these results and their weight status and gender consequences. In children, the influence of weight discrimination on mental health appears to have been exacerbated throughout the pandemic [ 32 ]. Although a meta-analysis suggests that age is not a moderator of the effect of weight stigma on emotional distress in the pre-pandemic setting [ 7 ], children may be particularly susceptible to the adverse effects of the pandemic on mental health as they have limited coping strategies [ 60 ]. Therefore, weight stigma may be amplifying worse mental health outcomes in an already vulnerable group during the outbreak.

When these findings from quantitative studies are considered together with well demonstrated diminished mental health [ 7 ] and disordered eating association [ 13 ] in people who have suffered weight stigma, they support the importance of considering weight stigma in mental health and eating disorder (ED) risks in times of great stress, such as the pandemic. Furthermore, it is also essential to consider the susceptibility of gender and weight differences to increased exposure to weight stigma content and body dissatisfaction, which can be crucial in identifying vulnerable groups to ED in the current scenario.

Furthermore, several papers pointed out the implications of weight stigma during the pandemic in worse healthcare quality [ 4 , 29 , 30 , 36 , 37 , 42 ], mainly for people with obesity. Even though this evidence was taken from opinion papers, it is worth recognizing and evaluating whether weight stigma in the context of health crisis could imply worse outcomes related to COVID-19 and health disparities. Finally, despite obesity being a risk factor for COVID-19, studies have shown that media coverage and public policies have used this premise to reinforce or intensify anti-fat attitudes through weighty stigmatizing narratives and images [ 2 , 22 , 23 ]. However, no included study evaluated the influence of media coverage and public policies launched in the pandemic on the health and well-being of people with obesity. We believe that identifying groups vulnerable to COVID-19 is vital to establishing effective protective measures. Weight stigma can pose additional questions to people living with obesity, and therefore, its consequences need to be appropriately investigated.

According to studies based on interviews with people with obesity included in this review [ 34 , 37 ], the findings may also reflect possible challenges faced in the pandemic due to weight stigma, such as difficulty or reluctance to perform activities of daily living. Similarly, previous qualitative research published before the pandemic shows that weight stigma (experiences or self-stigmatization) contributed to depressive feelings [ 61 ] and avoidance behaviour towards situations in which individuals perceive that they could be stigmatized [ 62 ]. Although it is possible to consider that subjectivity does not just consist of the relationship with the body, it is necessary to assume that weight stigma is a constitutive part of people's personal experience. In this respect, this review did not identify any study that directly investigated qualitatively what people with obesity feel or perceive about weight stigma during the pandemic.

Knowledge gaps and proposals for future studies

The results of this review indicated the scarcity of primary studies that identified the frequency and impact of individual (experienced weight stigma or self-stigmatization), structural or intersectional dimensions of weight stigma assessed through scales, self-reports, interviews, focus groups, or reports during the pandemic. Thus, representing critical gaps in the evidence. Furthermore, interpersonal sources of weight stigma were measured only by one investigation with adolescents and mentioned in online teaching in a single opinion paper. Home confinement in the pandemic impacts relationships [ 63 , 64 ] and imposes novel dynamics (such as the new norm of increased telecommunication and distance learning) [ 65 ]. So, there is a need to investigate how people express weight stigma facing these matters. Identifying weight discrimination in different settings is crucial to designing effective interventions and politics.

No empirical study investigated extreme or unhealthy weight control behaviours regarding weight stigma consequences on the COVID-19 outbreak. Nevertheless, further research is required to better assess the fatphobic dynamics in the care of people with obesity during the pandemic since their negative impact on health and well-being. Moreover, fat activism has combatted normative beliefs that contribute to the pervasiveness of weight bias [ 66 ] and, therefore, needs scientific attention on the current scenario.

This lack of evidence is an indication that research on weight stigma in the pandemic needs more attention and more resources, as highlighted above [ 15 ]. Furthermore, it is crucial to understand how weight stigma occurs in the outbreak and its consequences to map its extent and nature. Therefore, clarifying research areas for effective implementation of strategies is particularly relevant in this pandemic context because weight stigma may be an additional factor to influence unfavourable health outcomes.

Strengths and limitations

According to the authors ' knowledge, this work is the first comprehensive scoping review to map and systematically explore weight stigma in the COVID-19 pandemic context. It is an important issue, though, as stigmatization has negative implications for weight-related health correlations and behaviours [ 7 , 55 , 57 , 67 , 68 ]. However, this scoping review has some limitations primarily because the availability of evidence limits it. We found basically opinion papers (specifically for the intersectional domain and healthcare implications), so the phenomenon was mainly described from researchers' and experts' perspectives, making it difficult to understand to what extent those data could extrapolate to the manifestations of the phenomenon in the pandemic. Furthermore, although there were studies from many countries, they may not apply to all demographic groups. There was a predominance of publications from European countries and the United States, so that it would require a better investigation on weight stigma characterization in other scenarios. Nevertheless, in literature, terms such as prejudice, discrimination, bias, and stigma are commonly used interchangeably within the concept proposed in this review, which may have hindered a more accurate understanding of the phenomenon's dimensions and its respective effects in the pandemic. Finally, we searched for sources of evidence for weight stigma during the COVID-19 outbreak at the end of 2021 with a range of time equivalent to more than a year of the pandemic, but the majority of the quantitative studies found in the present review collected data from March to July 2020, which restricts the understanding of the effects of weight stigma to the initial months of the pandemic.

In conclusion, weight stigma definitely manifested in the media, public campaigns, and interpersonal relationships during the pandemic. Nevertheless, the evidence of increased weight stigma in the COVID-19 outbreak is limited. Although weight stigma consequences are associated with implications for psychological well-being across all age groups regardless of body weight, people with high body weight were more likely to experience weight stigma before and during pandemic than those without overweight. The scarcity of studies measuring weight stigma in the pandemic context supports the need for high-quality research to identify and confirm weight stigma characterization. Besides, it reinforces the need to understand weight discrimination magnitude in different global contexts and its impacts on people with overweight or obesity, thereby contributing to the development of effective and inclusive public health policies and eating disorders prevention.

Availability of data and materials

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

Change history

04 may 2022.

A Correction to this paper has been published: https://doi.org/10.1186/s40337-022-00582-1

Abbreviations

Eating disorders

People with obesity

Body mass index

United States

United Kingdom

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Acknowledgements

The authors acknowledge the financial support provided by the Coordination for the Improvement of Higher Education Personnel (CAPES) and by the Foundation for Research Support of the State of Bahia (FAPESB).

This work was supported by two Brazilian Foundations by Postgraduate Scholarship to PFCM (CAPES) and EPM (FABESP).

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Patricia Fortes Cavalcanti de Macêdo, Nedja Silva dos Santos, Valterlinda Alves de Oliveira Queiroz, Emile Miranda Pereira, Lucineide da Conceição Leal, Lígia Amparo da Silva Santos, Poliana Cardoso Martins & Mônica Leila Portela de Santana

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de Macêdo, P.F.C., Nepomuceno, C.M.M., dos Santos, N.S. et al. Weight stigma in the COVID-19 pandemic: a scoping review. J Eat Disord 10 , 44 (2022). https://doi.org/10.1186/s40337-022-00563-4

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