literature review social psych

PSYC 321--Social Psychology: Literature Review

Getting Started
Tests and Measurements
Literature Review
Citing Sources--APA Style

Methods for Synthesizing Qualitative Reviews

Ruth Garside, PhD, Senior Lecturer in Evidence Synthesis at the Medical School, University of Exeter

Check out PRISMA to guide your review: especially the checklist for your review and the flow diagram to develop your protocol.

The PRISMA Statement:

Anybody writing a systematic literature review should be familiar with the PRISMA statement . The PRISMA Statement is a document that consists of a 27-item checklist and a flow diagram and aims to guide authors on how to develop a systematic review protocol and what to include when writing the review.

A protocol ideally includes the following:

Databases to be searched and additional sources (particularly for grey literature)

Keywords to be used in the search strategy

Limits applied to the search.

Screening process

Data to be extracted

Summary of data to be reported

From Majumbder, K. (2015). A young researcher's guide to a systematic review. Editage Insights. Retrieved from https://www.editage.com/insights/a-young-researchers-guide-to-a-systematic-review#

Systematic Literature Review

Here are a couple of articles found in Sage Research Methods Online which give good definitions of what a Systematic Literature Review is and how to do one:

Dempster, M. (2003). Systematic review . In Robert L. Miller, & John D. Brewer

(Eds.), The A-Z of Social Research. (pp. 312-317). London, England: SAGE

Publications, Ltd. doi: http://dx.doi.org/10.4135/9780857020024.n110

Crisp, B.R. (2015). Systematic reviews: a social work perspective . Australian

Social Work, 68 (3): 284-295. http://dx.doi.org/10.1080/0312407X.2015.102426

Schick-Makaroff, K., MacDonald, M. Plummer, M., Burgess, J., & Neander, W. (2016).

What Synthesis Methodology Should I Use? A Review and Analysis of Approaches to

Research Synthesis . AIMS Public Health, 3 (1). 172-215.

doi: 10.3934/publichealth.2016.1.172

http://dspace.library.uvic.ca:8080/handle/1828/7464

Inclusion/Exclusion Criteria

Veale, T.Search concept tools. Retrieved from //medhealth.leeds.ac.uk/info/639/information_specialists/1500/search_concept_tools Describes various structures for developing criteria: PICO, PICOS, SPIDER, SPICE, etc.

Support for Systematic Reviews

Systematic Review Search Strategies Worksheet Organize your review by topic, database, search string, and criteria
Evaluation of Sources Questions to ask of primary source articles (both qualitative and quantitative) when evaluating their quality
Software for Organizing Systematic Reviews From Columbia University Medical Center's Library
Evidence-Based Practice
Meta-Ethnography
Qualitative Evidence Synthesis

Examples of Systematic Reviews

Prospero: International Prospective Register of Systematic Reviews

This web site collects systematic reviews in process. By reviewing them, you can see what is included in a systematic review.

Campbell Systematic Reviews

This Monograph series is an open access collection of peer-reviewed systematic reviews. "Campbell systematic reviews follow structured guidelines and standards for summarizing the international research evidence on the effects of interventions in crime and justice, education, international development, and social welfare." Registration and protocols are available from the Campbell Collaboration Library of Systematic Reviews .

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> The Cambridge Handbook of Research Methods and Statistics for the Social and Behavioral Sciences
> Literature Review

Book contents

The Cambridge Handbook of Research Methods and Statistics for the Social and Behavioral Sciences
Cambridge Handbooks in Psychology
Copyright page
Contributors
Part I From Idea to Reality: The Basics of Research
1 Promises and Pitfalls of Theory
2 Research Ethics for the Social and Behavioral Sciences
3 Getting Good Ideas and Making the Most of Them
4 Literature Review
5 Choosing a Research Design
6 Building the Study
7 Analyzing Data
8 Writing the Paper
Part II The Building Blocks of a Study
Part III Data Collection
Part IV Statistical Approaches
Part V Tips for a Successful Research Career

4 - Literature Review

from Part I - From Idea to Reality: The Basics of Research

Published online by Cambridge University Press: 25 May 2023

A literature review is a survey of scholarly sources that establishes familiarity with and an understanding of current research in a particular field. It includes a critical analysis of the relationship among different works, seeking a synthesis and an explanation of gaps, while relating findings to the project at hand. It also serves as a foundational aspect of a well-grounded thesis or dissertation, reveals gaps in a specific field, and establishes credibility and need for those applying for a grant. The enormous amount of textual information necessitates the development of tools to help researchers effectively and efficiently process huge amounts of data and quickly search, classify, and assess their relevance. This chapter presents an assessable guide to writing a comprehensive review of literature. It begins with a discussion of the purpose of the literature review and then presents steps to conduct an organized, relevant review.

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Literature Review
By Rachel Adams Goertel
Edited by Austin Lee Nichols , Central European University, Vienna , John Edlund , Rochester Institute of Technology, New York
Book: The Cambridge Handbook of Research Methods and Statistics for the Social and Behavioral Sciences
Online publication: 25 May 2023
Chapter DOI: https://doi.org/10.1017/9781009010054.005

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What is a Literature Review?

Description.

A literature review, also called a review article or review of literature, surveys the existing research on a topic. The term "literature" in this context refers to published research or scholarship in a particular discipline, rather than "fiction" (like American Literature) or an individual work of literature. In general, literature reviews are most common in the sciences and social sciences.

Literature reviews may be written as standalone works, or as part of a scholarly article or research paper. In either case, the purpose of the review is to summarize and synthesize the key scholarly work that has already been done on the topic at hand. The literature review may also include some analysis and interpretation. A literature review is not a summary of every piece of scholarly research on a topic.

Why are literature reviews useful?

Literature reviews can be very helpful for newer researchers or those unfamiliar with a field by synthesizing the existing research on a given topic, providing the reader with connections and relationships among previous scholarship. Reviews can also be useful to veteran researchers by identifying potentials gaps in the research or steering future research questions toward unexplored areas. If a literature review is part of a scholarly article, it should include an explanation of how the current article adds to the conversation. (From: https://researchguides.drake.edu/englit/criticism)

How is a literature review different from a research article?

Research articles: "are empirical articles that describe one or several related studies on a specific, quantitative, testable research question....they are typically organized into four text sections: Introduction, Methods, Results, Discussion." Source: https://psych.uw.edu/storage/writing_center/litrev.pdf)

Steps for Writing a Literature Review

1. Identify and define the topic that you will be reviewing.

The topic, which is commonly a research question (or problem) of some kind, needs to be identified and defined as clearly as possible. You need to have an idea of what you will be reviewing in order to effectively search for references and to write a coherent summary of the research on it. At this stage it can be helpful to write down a description of the research question, area, or topic that you will be reviewing, as well as to identify any keywords that you will be using to search for relevant research.

2. Conduct a Literature Search

Use a range of keywords to search databases such as PsycINFO and any others that may contain relevant articles. You should focus on peer-reviewed, scholarly articles . In SuperSearch and most databases, you may find it helpful to select the Advanced Search mode and include "literature review" or "review of the literature" in addition to your other search terms. Published books may also be helpful, but keep in mind that peer-reviewed articles are widely considered to be the “gold standard” of scientific research. Read through titles and abstracts, select and obtain articles (that is, download, copy, or print them out), and save your searches as needed. Most of the databases you will need are linked to from the Cowles Library Psychology Research guide .

3. Read through the research that you have found and take notes.

Absorb as much information as you can. Read through the articles and books that you have found, and as you do, take notes. The notes should include anything that will be helpful in advancing your own thinking about the topic and in helping you write the literature review (such as key points, ideas, or even page numbers that index key information). Some references may turn out to be more helpful than others; you may notice patterns or striking contrasts between different sources; and some sources may refer to yet other sources of potential interest. This is often the most time-consuming part of the review process. However, it is also where you get to learn about the topic in great detail. You may want to use a Citation Manager to help you keep track of the citations you have found.

4. Organize your notes and thoughts; create an outline.

At this stage, you are close to writing the review itself. However, it is often helpful to first reflect on all the reading that you have done. What patterns stand out? Do the different sources converge on a consensus? Or not? What unresolved questions still remain? You should look over your notes (it may also be helpful to reorganize them), and as you do, to think about how you will present this research in your literature review. Are you going to summarize or critically evaluate? Are you going to use a chronological or other type of organizational structure? It can also be helpful to create an outline of how your literature review will be structured.

5. Write the literature review itself and edit and revise as needed.

The final stage involves writing. When writing, keep in mind that literature reviews are generally characterized by a summary style in which prior research is described sufficiently to explain critical findings but does not include a high level of detail (if readers want to learn about all the specific details of a study, then they can look up the references that you cite and read the original articles themselves). However, the degree of emphasis that is given to individual studies may vary (more or less detail may be warranted depending on how critical or unique a given study was). After you have written a first draft, you should read it carefully and then edit and revise as needed. You may need to repeat this process more than once. It may be helpful to have another person read through your draft(s) and provide feedback.

6. Incorporate the literature review into your research paper draft. (note: this step is only if you are using the literature review to write a research paper. Many times the literature review is an end unto itself).

After the literature review is complete, you should incorporate it into your research paper (if you are writing the review as one component of a larger paper). Depending on the stage at which your paper is at, this may involve merging your literature review into a partially complete Introduction section, writing the rest of the paper around the literature review, or other processes.

These steps were taken from: https://psychology.ucsd.edu/undergraduate-program/undergraduate-resources/academic-writing-resources/writing-research-papers/writing-lit-review.html#6.-Incorporate-the-literature-r

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Social Psychology Research Topics

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Emily is a board-certified science editor who has worked with top digital publishing brands like Voices for Biodiversity, Study.com, GoodTherapy, Vox, and Verywell.

Choosing topics for social psychology research papers or projects for class can be challenging. It is a broad and fascinating field, which can make it challenging to figure out what you want to investigate in your research.

Social psychology explores how individual thoughts, feelings, and behaviors are affected by social influences. It explores how each person's behavior is affected by their social environment.

This article explores a few different social psychology topics and research questions you might want to study in greater depth. It covers how to start your search for a topic as well as specific ideas you might choose to explore.

How to Find a Social Psychology Research Topic

As you begin your search, think about the questions that you have. What topics interest you? Following your own interests and curiosities can often inspire great research questions.

Choose a Sub-Topic

Social psychologists are interested in all aspects of social behavior. Some of the main areas of interest within the field include social cognition, social influence, and social relationships investigating subtopics such as conformity, groupthink, attitude formation, obedience, prejudice, and so on.

Social cognition : How do we process and use information about social experiences? What kinds of biases influence how we engage with other people?
Social influence: What are the key social factors that influence our attitudes and behavior? What are group dynamics and how do we understand patterns of behavior in groups?
Social relationships : What are the different types of social relationships? How do they develop and change over time?

To help ensure that you select a topic that is specific enough, it can be helpful to start by confining your search to one of these main areas.

Browse Through Past Research

After narrowing down your choices, consider what questions you might have. Are there questions that haven't been fully answered by previous studies? At this point, it can be helpful to spend some time browsing through journal articles or books to see some examples of past findings and identify gaps in the literature.

You can also find inspiration and learn more about a topic by searching for keywords related to your topic in psychological databases such as PsycINFO or browsing through some professional psychology journals.

Narrow Down Your Specific Topic

Once you have a general topic, you'll need to narrow down your research. The goal is to choose a research question that is specific, measurable, and testable. Let's say you want to study conformity; An example of a good research question might be, “Are people more likely to conform when they are in a small group or a large group?” In this case, the specific topic of your paper would be how group size influences social conformity .

Review the Literature on Your Chosen Topic

After choosing a specific social psychology topic to research, the next step is to do a literature review. A literature review involves reading through the existing research findings related to a specific topic.

You are likely to encounter a great deal of information on your topic, which can seem overwhelming at times. You may find it helpful to start by reading review articles or meta-analysis studies. These are summaries of previous research on your topic or studies that incorporate a large pool of past research on the topic.

Talk to Your Instructor

Even if you are really excited to dive right in and start working on your project, there are some important preliminary steps you need to take.

Before you decide to tackle a project for your social psychology class, you should always clear your idea with your instructor. This initial step can save you a lot of time and hassle later on.

Your instructor can offer clear feedback on things you should and should not do while conducting your research and might be able to offer some helpful tips. Also, if you plan to implement your own social experiment, your school might require you to present to and gain permission from an institutional review board.

Thinking about the questions you have about social psychology can be a great way to discover topics for your own research. Once you have a general idea, explore the literature and refine your research question to make sure it is specific enough.

Examples of Social Psychology Research Topics

The following are some specific examples of different subjects you might want to investigate further as part of a social psychology research paper, experiment, or project:

Implicit Attitudes

How do implicit attitudes influence how people respond to others? This can involve exploring how people's attitudes towards different groups of people (e.g., men, women, ethnic minorities) influence their interactions with those groups. For example, one study found that 75% of people perceive men to be more intelligent than women .

In your own project, you might explore how implicit attitudes impact perceptions of qualities such as kindness, intelligence, leadership skills, or attractiveness.

Prosocial Behavior

You might also choose to focus on prosocial behavior in your research. This can involve investigating the reasons why people help others. Some questions you could explore further include:

What motivates people to help others?
When are people most likely to help others?
How does helping others cause people to feel?
What are the benefits of helping other people?

How do people change their attitudes in response to persuasion? What are the different techniques that can be used to persuade someone? What factors make some people more susceptible to persuasion than others?

One way to investigate this could be through collecting a wide variety of print advertisements and analyzing how persuasion is used. What types of cognitive and affective techniques are utilized? Do certain types of advertisements tend to use specific kinds of persuasive techniques ?

Another area of social psychology that you might research is aggression and violence. This can involve exploring the factors that lead to aggression and violence and the consequences of these behaviors. Some questions you might explore further include:

When is violence most likely to occur?
What factors influence violent behavior?
Do traumatic experiences in childhood lead to more aggressive behavior in adulthood?
Does viewing violent media content contribute to increased aggressive behavior in real life?

Prejudice and discrimination are areas that present a range of research opportunities. This can involve studying the different forms that prejudice takes (e.g., sexism, racism, ageism ), as well as the psychological effects of prejudice and discrimination. You might also want to investigate topics related to how prejudices form or strategies that can be used to reduce such discrimination.

Nonverbal Behavior

How do people respond when nonverbal communication does not match up to verbal behavior (for example, saying you feel great when your facial expressions and tone of voice indicate otherwise). Which signal do people respond to most strongly?

How good are people at detecting lies ? Have participants tell a group of people about themselves, but make sure some of the things are true while others are not. Ask members of the group which statements they thought were true and which they thought were false.

Social Norms

How do people react when social norms are violated? This might involve acting in a way that is outside the norm in a particular situation or enlisting friends to act out the behaviors while you observe.

Some examples that you might try include wearing unusual clothing, applauding inappropriately at the end of a class lecture, cutting in line in front of other people, or some other mildly inappropriate behavior. Keep track of your own thoughts as you perform the experiment and observe how people around you respond.

Online Social Behavior

Does online social networking make people more or less likely to interact with people in face-to-face or other offline settings? To investigate this further, you could create a questionnaire to assess how often people participate in social networking versus how much time they spend interacting with their friends in real-world settings.

Social Perception

How does our appearance impact how people respond to us? Ask some friends to help you by having two people dress up in dramatically different ways, one in a professional manner and one in a less conventional manner. Have each person engage in a particular action, then observe how they are treated and how other people's responses differ.

Social psychologists have found that attractiveness can produce what is known as a halo effect . Essentially, we tend to assume that people who are physically attractive are also friendly, intelligent, pleasant, and likable.

To investigate this topic, you could set up an experiment where you have participants look at photographs of people of varying degrees of physical attractiveness, and then ask them to rate each person based on a variety of traits, including social competence, kindness, intellect, and overall likability.

Think about how this might affect a variety of social situations, including how employees are selected or how jurors in a criminal case might respond.

Social psychology is a broad field, so there are many different subtopics you might choose to explore in your research. Implicit attitudes, prosocial behavior, aggression, prejudice, and social perception are just a few areas you might want to consider.

A Word From Verywell

Social psychology topics can provide a great deal of inspiration for further research, whether you are writing a research paper or conducting your own experiment. In addition to some of the social psychology topics above, you can also draw inspiration from your own curiosity about social behavior or examine social issues that you see taking place in the world around you.

American Psychological Association. Frequently asked questions about institutional review boards .

Storage D, Charlesworth TES, Banaji M, Cimpian A. Adults and children implicitly associate brilliance with men more than women . J Exp Soc Psychol . 2012;90:104020. doi:10.1016/j.jesp.2020.104020

Talamas SN, Mavor KI, Perrett DI. Blinded by beauty: Attractiveness bias and accurate perceptions of academic performance . PLoS ONE . 2016;11(2):e0148284. doi:10.1371/journal.pone.0148284

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

Give a new interpretation of old material or combine new with old interpretations,
Trace the intellectual progression of the field, including major debates,
Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

Given this, the purpose of a literature review is to:

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

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

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

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

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

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

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

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

NOTE: Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews." Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I. Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
An explanation of how each work is similar to and how it varies from the others,
Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
Persuasiveness -- which of the author's theses are most convincing or least convincing?
Validity -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II. Development of the Literature Review

Four Basic Stages of Writing 1. Problem formulation -- which topic or field is being examined and what are its component issues? 2. Literature search -- finding materials relevant to the subject being explored. 3. Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4. Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1. Roughly how many sources would be appropriate to include? 2. What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3. Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4. Should I evaluate the sources in any way beyond evaluating how they relate to understanding the research problem? 5. Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read, such as required readings in the course syllabus, are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make the act of reviewing easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for recent books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III. Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] A thematic literature review is the most common approach to summarizing prior research in the social and behavioral sciences. Thematic reviews are organized around a topic or issue, rather than the progression of time, although the progression of time may still be incorporated into a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it would still be organized chronologically reflecting technological developments in media. The difference in this example between a "chronological" and a "thematic" approach is what is emphasized the most: themes related to the role of the Internet in presidential politics. Note that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point being made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. However, only include what is necessary for the reader to locate your study within the larger scholarship about the research problem.

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

Current Situation : Information necessary to understand the current topic or focus of the literature review.
Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
Standards : Description of the way in which you present your information.
Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV. Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information, but that are not key to understanding the research problem, can be included in a list of further readings . Use Quotes Sparingly Some short quotes are appropriate if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, is not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for using your own words in reviewing the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work and the work of others. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V. Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

Sources in your literature review do not clearly relate to the research problem;
You do not take sufficient time to define and identify the most relevant sources to use in the literature review related to the research problem;
Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
Does not describe the search procedures that were used in identifying the literature to review;
Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout. Online Writing Center. Liberty University; Literature Reviews. The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation. vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It. University College Writing Centre. University of Toronto; Writing a Literature Review. Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

How are they organizing their ideas?
What methods have they used to study the problem?
What theories have been used to explain, predict, or understand their research problem?
What sources have they cited to support their conclusions?
How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research? Does it forge a new path? Or, does is merely add more of the same thing being said?
Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
Search Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review [see next sub-tab]. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

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Last Updated: Jun 12, 2024 8:53 AM
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Writing Research Papers

Writing a Literature Review

When writing a research paper on a specific topic, you will often need to include an overview of any prior research that has been conducted on that topic. For example, if your research paper is describing an experiment on fear conditioning, then you will probably need to provide an overview of prior research on fear conditioning. That overview is typically known as a literature review.

Please note that a full-length literature review article may be suitable for fulfilling the requirements for the Psychology B.S. Degree Research Paper . For further details, please check with your faculty advisor.

Different Types of Literature Reviews

Literature reviews come in many forms. They can be part of a research paper, for example as part of the Introduction section. They can be one chapter of a doctoral dissertation. Literature reviews can also “stand alone” as separate articles by themselves. For instance, some journals such as Annual Review of Psychology , Psychological Bulletin , and others typically publish full-length review articles. Similarly, in courses at UCSD, you may be asked to write a research paper that is itself a literature review (such as, with an instructor’s permission, in fulfillment of the B.S. Degree Research Paper requirement). Alternatively, you may be expected to include a literature review as part of a larger research paper (such as part of an Honors Thesis).

Literature reviews can be written using a variety of different styles. These may differ in the way prior research is reviewed as well as the way in which the literature review is organized. Examples of stylistic variations in literature reviews include:

Summarization of prior work vs. critical evaluation. In some cases, prior research is simply described and summarized; in other cases, the writer compares, contrasts, and may even critique prior research (for example, discusses their strengths and weaknesses).
Chronological vs. categorical and other types of organization. In some cases, the literature review begins with the oldest research and advances until it concludes with the latest research. In other cases, research is discussed by category (such as in groupings of closely related studies) without regard for chronological order. In yet other cases, research is discussed in terms of opposing views (such as when different research studies or researchers disagree with one another).

Overall, all literature reviews, whether they are written as a part of a larger work or as separate articles unto themselves, have a common feature: they do not present new research; rather, they provide an overview of prior research on a specific topic .

How to Write a Literature Review

When writing a literature review, it can be helpful to rely on the following steps. Please note that these procedures are not necessarily only for writing a literature review that becomes part of a larger article; they can also be used for writing a full-length article that is itself a literature review (although such reviews are typically more detailed and exhaustive; for more information please refer to the Further Resources section of this page).

Steps for Writing a Literature Review

1. Identify and define the topic that you will be reviewing.

2. Conduct a literature search.

Use a range of keywords to search databases such as PsycINFO and any others that may contain relevant articles. You should focus on peer-reviewed, scholarly articles. Published books may also be helpful, but keep in mind that peer-reviewed articles are widely considered to be the “gold standard” of scientific research. Read through titles and abstracts, select and obtain articles (that is, download, copy, or print them out), and save your searches as needed. For more information about this step, please see the Using Databases and Finding Scholarly References section of this website.

3. Read through the research that you have found and take notes.

Absorb as much information as you can. Read through the articles and books that you have found, and as you do, take notes. The notes should include anything that will be helpful in advancing your own thinking about the topic and in helping you write the literature review (such as key points, ideas, or even page numbers that index key information). Some references may turn out to be more helpful than others; you may notice patterns or striking contrasts between different sources ; and some sources may refer to yet other sources of potential interest. This is often the most time-consuming part of the review process. However, it is also where you get to learn about the topic in great detail. For more details about taking notes, please see the “Reading Sources and Taking Notes” section of the Finding Scholarly References page of this website.

4. Organize your notes and thoughts; create an outline.

5. Write the literature review itself and edit and revise as needed.

6. Incorporate the literature review into your research paper draft.

Further Tips for Writing a Literature Review

Full-length literature reviews

Many full-length literature review articles use a three-part structure: Introduction (where the topic is identified and any trends or major problems in the literature are introduced), Body (where the studies that comprise the literature on that topic are discussed), and Discussion or Conclusion (where major patterns and points are discussed and the general state of what is known about the topic is summarized)

Literature reviews as part of a larger paper

An “express method” of writing a literature review for a research paper is as follows: first, write a one paragraph description of each article that you read. Second, choose how you will order all the paragraphs and combine them in one document. Third, add transitions between the paragraphs, as well as an introductory and concluding paragraph. 1
A literature review that is part of a larger research paper typically does not have to be exhaustive. Rather, it should contain most or all of the significant studies about a research topic but not tangential or loosely related ones. 2 Generally, literature reviews should be sufficient for the reader to understand the major issues and key findings about a research topic. You may however need to confer with your instructor or editor to determine how comprehensive you need to be.

Benefits of Literature Reviews

By summarizing prior research on a topic, literature reviews have multiple benefits. These include:

Literature reviews help readers understand what is known about a topic without having to find and read through multiple sources.
Literature reviews help “set the stage” for later reading about new research on a given topic (such as if they are placed in the Introduction of a larger research paper). In other words, they provide helpful background and context.
Literature reviews can also help the writer learn about a given topic while in the process of preparing the review itself. In the act of research and writing the literature review, the writer gains expertise on the topic .

Downloadable Resources

How to Write APA Style Research Papers (a comprehensive guide) [ PDF ]
Tips for Writing APA Style Research Papers (a brief summary) [ PDF ]
Example APA Style Research Paper (for B.S. Degree – literature review) [ PDF ]

Further Resources

How-To Videos

Writing Research Paper Videos
UCSD Library Psychology Research Guide: Literature Reviews

External Resources

Developing and Writing a Literature Review from N Carolina A&T State University
Example of a Short Literature Review from York College CUNY
How to Write a Review of Literature from UW-Madison
Writing a Literature Review from UC Santa Cruz
Pautasso, M. (2013). Ten Simple Rules for Writing a Literature Review. PLoS Computational Biology, 9 (7), e1003149. doi : 1371/journal.pcbi.1003149

1 Ashton, W. Writing a short literature review . [PDF]

2 carver, l. (2014). writing the research paper [workshop]. , prepared by s. c. pan for ucsd psychology.

Research Paper Structure
Formatting Research Papers
Using Databases and Finding References
What Types of References Are Appropriate?
Evaluating References and Taking Notes
Citing References
Writing Process and Revising
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Writing Research Papers Videos

Purdue Online Writing Lab Purdue OWL® College of Liberal Arts

Social Work Literature Review Guidelines

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Copyright ©1995-2018 by The Writing Lab & The OWL at Purdue and Purdue University. All rights reserved. This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission. Use of this site constitutes acceptance of our terms and conditions of fair use.

Literature reviews are designed to do two things: 1) give your readers an overview of sources you have explored while researching a particular topic or idea and 2) demonstrate how your research fits into the larger field of study, in this case, social work.

Unlike annotated bibliographies which are lists of references arranged alphabetically that include the bibliographic citation and a paragraph summary and critique for each source, literature reviews can be incorporated into a research paper or manuscript. You may quote or paraphrase from the sources, and all references to sources should include in-text parenthetical citations with a reference list at the end of the document. Sometimes, however, an instructor may require a separate literature review document and will have specific instructions for completing the assignment.

Below you will find general guidelines to consider when developing a literature review in the field of social work. Because social work is a social science field, you will most likely be required to use APA style. Please see our APA materials for information on creating parenthetical citations and reference lists.

1. Choose a variety of articles that relate to your subject, even if they do not directly answer your research question. You may find articles that loosely relate to the topic, rather than articles that you find using an exact keyword search. At first, you may need to cast a wide net when searching for sources.

For example: If your research question focuses on how people with chronic illnesses are treated in the workplace, you may be able to find some articles that address this specific question. You may also find literature regarding public perception of people with chronic illnesses or analyses of current laws affecting workplace discrimination.

2. Select the most relevant information from the articles as it pertains to your subject and your purpose. Remember, the purpose of the literature review is to demonstrate how your research question fits into a larger field of study.

3. Critically examine the articles. Look at methodology, statistics, results, theoretical framework, the author's purpose, etc. Include controversies when they appear in the articles.

For example: You should look for the strengths and weaknesses of how the author conducted the study. You can also decide whether or not the study is generalizable to other settings or whether the findings relate only to the specific setting of the study. Ask yourself why the author conducted the study and what he/she hoped to gain from the study. Look for inconsistencies in the results, as well.

4. Organize your information in the way that makes most sense. Some literature reviews may begin with a definition or general overview of the topic. Others may focus on another aspect of your topic. Look for themes in the literature or organize by types of study.

For example: Group case studies together, especially if all the case studies have related findings, research questions, or other similarities.

5. Make sure the information relates to your research question/thesis. You may need to explicitly show how the literature relates to the research question; don't assume that the connection is obvious.

6. Check to see that you have done more than simply summarize your sources. Your literature review should include a critical assessment of those sources. For more information, read the Experimental Psychology - Writing a Literature Review handout for questions to think about when reading sources.

7. Be sure to develop questions for further research. Again, you are not simply regurgitating information, but you are assessing and leading your reader to questions of your own, questions and ideas that haven't been explored yet or haven't been addressed in detail by the literature in the field.

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Article Contents

Introduction, conclusions, recommendations and limitations of the study, supplementary data, data availability.

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A systematic review of literature examining the application of a social model of health and wellbeing

Article contents
Figures & tables
Supplementary Data

Rachel Rahman, Caitlin Reid, Philip Kloer, Anna Henchie, Andrew Thomas, Reyer Zwiggelaar, A systematic review of literature examining the application of a social model of health and wellbeing, European Journal of Public Health , Volume 34, Issue 3, June 2024, Pages 467–472, https://doi.org/10.1093/eurpub/ckae008

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Following years of sustained pressure on the UK health service, there is recognition amongst health professionals and stakeholders that current models of healthcare are likely to be inadequate going forward. Therefore, a fundamental review of existing social models of healthcare is needed to ascertain current thinking in this area, and whether there is a need to change perspective on current thinking.

Through a systematic research review, this paper seeks to address how previous literature has conceptualized a social model of healthcare and, how implementation of the models has been evaluated. Analysis and data were extracted from 222 publications and explored the country of origin, methodological approach, and the health and social care contexts which they were set.

The publications predominantly drawn from the USA, UK, Australia, Canada and Europe identified five themes namely: the lack of a clear and unified definition of a social model of health and wellbeing; the need to understand context; the need for cultural change; improved integration and collaboration towards a holistic and person-centred approach; measuring and evaluating the performance of a social model of health.

The review identified a need for a clear definition of a social model of health and wellbeing. Furthermore, consideration is needed on how a model integrates with current models and whether it will act as a descriptive framework or, will be developed into an operational model. The review highlights the importance of engagement with users and partner organizations in the co-creation of a model of healthcare.

Following years of sustained and increasing pressure brought about through inadequate planning and chronic under-resourcing including the unprecedented challenges of the Covid-19 pandemic, the UK NHS is at crisis point. 1 The incidents of chronic disease continue to increase alongside an ageing population who have more complex health and wellbeing needs, whilst recruitment and retention of staff continue to be insufficient to meet these increased demands. 1 Furthermore, the Covid-19 pandemic has only served to exacerbate pressures, resulting in delays in; patient presentation, 2 poor public mental health 3 strain and burnout amongst workforce. 4 However, preceding the pandemic there was already recognition of a need for a change to the current biomedical model of care to better prevent and treat the needs of the population. 5

While it is recognized that demands on the healthcare system are increasing rapidly, the biomedical model used to deal with these issues (which is the current model of healthcare provision in the UK) has largely remained unchanged over the years. The biomedical model takes the perspective that ill-health stems from biological factors and operates on the theory that good health and wellbeing is merely the absence of illness. Application of the model therefore focuses treatment on the management of symptoms and cure of disease from a biological perspective. This suggests that the biomedical approach is mainly reactive in nature and whilst rapid advancements in technology such as diagnostics and robotics have significantly improved patient outcomes and identification of early onset of disease, it does not fully extend into managing the social determinants that can play an important role in the prevention of disease. Therefore, despite its contribution in advancing many areas of biological and health research, the biomedical model has come under increasing scrutiny. 6 This is in part due to the growing recognition of the impact of those wider social determinants on health, ill-health and wellbeing including physical, mental and social wellbeing which moves the focus beyond individual physical abilities or dysfunction. 7–9 In order to address these determinants, action needs to be taken through developing policies in a range of non-medical areas such as social, economic and environment so that they regulate the commercial and corporate determinants. In this sense, we can quickly see that the traditional biological model rapidly becomes inadequate. With the current model, health care and clinical staff can do little to affect these determinants and as such can do little to assist the individual patient or society. The efficiency and effectiveness of clinical work will undoubtedly improve if staff have the ability to observe and understand the wider social determinants and consequences of the individual patients’ condition. Therefore, in order to provide a basis for understanding the determinants of disease and arriving at rational treatments and patterns of health care, a medical model must also take into account the patient, the social context in which they live, and a system devised by society to deal with the disruptive effects of illness, that is, the physician’s role and that of the health care system. Models such as Engel’s biopsychosocial model, 9 , 10 the social model of disability, social–ecological models of health 10 , 11 including the World Health Organisation’s framework for action on social determinants of health 8 , 9 are all proposed as attempting to integrate these wider social determinants.

However, the ability of health systems to effectively transition away from a dominant biomedical model to the adoption of a social model of health and care have yet to be fully developed. Responsibility for taking action on these social determinants will need to come from other sectors and policy areas and so future health policy will need to evolve into a more comprehensive and holistic social model of health and wellbeing. Wales’ flagship Wellbeing of Future Generations Act 12 for instance outlines ways of working towards sustainable development and includes the need to collaborate with society and communities in developing and achieving wellbeing goals. However, developing and implementing an effective operational model that allows multi-stakeholder integration will prove far more difficult to achieve than creating the polices. Furthermore, if the implementation of a robust model of social health is achievable, it’s efficiency, effectiveness and ability to deliver has yet to be proven. Therefore, any future model will need to extend past its conceptual development and provide an ability to manage the complex interactions that will exist between the stakeholders and polices.

Therefore, the use of the term ‘model’ poses its own challenges and debates. Different disciplines attribute differing parameters to what constitutes a model and this in turn may influence the interpretations or expectations surrounding what a model should comprise of or deliver. 13 According to numerous authors, a model has no ontological category and as such anything from physical entities, theoretical concepts, descriptive frameworks or equations can feasibly be considered a model. 14 It appears therefore, that much discussion has focussed on the move towards a ‘descriptive’ Social Model of Health and Wellbeing in an attempt to view health more holistically and identify a wider range of determinants that can impact on the health of the population. However, in defining an operational social model of health that can facilitate organizational change, there may be a need to consider a more systems- or process-based approach.

As a result, this review seeks to systematically explore the academic literature in order to better understand how a social model of health and wellbeing is conceptualized, implemented, operationalized and evaluated in health and social care.

The review seeks to address the research questions:

How is ‘a social model of health and wellbeing’ conceptualized?

How have social models of health and wellbeing been implemented and evaluated?

A systematic search of the literature was carried out between 6 January 2022 and 20 January 2022. Using the search terms shown in table 1 , a systematic search was carried out using online databases PsycINFO, ASSIA, IBSS, Medline, Web of Science, CINHAL and SCOPUS. English language and peer-reviewed journals were selected as limiters.

Search terms

Selection and extraction criteria

The search strategy considered research that explicitly included, framed, or adopted a ‘social model of health and wellbeing’. Each paper was checked for relevance and screened. The authors reviewed the literature using the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) method using the updated guidelines from 2020. 15 Figure 1 represents the process followed.

PRISMA flow chart.

Data extraction and analysis

A systematic search of the literature identified 222 eligible papers for inclusion in the final review. A data extraction table was used to extract information regarding location of the research, type of paper (e.g. review, empirical), service of interest and key findings. Quantitative studies were explored with a view to conducting a quantitative meta-analysis; however, given the disparate nature of the outcome measures, and research designs, this was deemed unfeasible. All included papers were coded using NVivo software with the identified research questions in mind, and re-analysed using Thematic Analysis 16 to explore common themes of relevance.

The majority of papers were from the USA (34%), with the UK (28%), Australia (16%), Canada (6%) and wider Europe (10%) also contributing to the field. The ‘other’ category (6%) was made up of single papers from other countries. Papers ranged in date from 1983 to 2021 with no noticeable temporal patterns in country of origin, health context or model definition. However, the volume of papers published relating to the social model for healthcare in each decade increased significantly, thus suggesting the increasing research interest towards the social model of healthcare. Table 2 shows the number of publications per decade that were identified from this study.

Publications identifying social models of healthcare.

Year of publication .	Number of publications identifying social models of healthcare .
1980s	5
1990s	11
2000	70
2010	87
2020–22	49

Year of publication .	Number of publications identifying social models of healthcare .
1980s	5
1990s	11
2000	70
2010	87
2020–22	49

Most of the papers were narrative reviews ( n = 90) with a smaller number of systematic reviews ( n = 9) and empirical research studies including qualitative ( n = 47), quantitative ( n = 39) and mixed methods ( n = 14) research. The remaining papers ( n = 23) comprised small samples of, for example, clinical commentaries, cost effectiveness analysis, discussion papers and impact assessment development papers. The qualitative meta-analysis identified five overarching themes in relation to the research questions, some with underlying sub-themes, which are outlined in figure 2 .

Overview of meta-synthesis themes.

The lack of a clear and unified definition of a social model of health and wellbeing

There was common recognition amongst the papers that a key aim of applying a social model of health and wellbeing was to better address the social determinants of health. Papers identified and reviewed relevant frameworks and models, which they later used to conceptualize or frame their approach when attempting to apply a social model of health. Amongst the most commonly referenced was the WHO’s framework. 17 Engel’s biopsychosocial model 9 which was referred to as a seminal framework by many of the researchers. However, once criticism of the biopsychosocial model was its inability to fully address social needs. As a result, a number of papers reported the development of new or enhanced models that used the biopsychosocial model as their underpinning ‘social model’ 18 , 19 but then extended their work by including a wider set of social elements in their resulting models. 20 The Social ecological model, 11 the Society-Behaviour-Biology Nexus, 21 and the Environmental Affordances Model are such examples. 22 Further examples of ‘Social Models’ included the Model of Social Determinants of Health 23 which framed specific determinants of interest (namely social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food and transport). Similarly, Dahlgren and Whitehead’s ‘social model’ 10 illustrates social determinants via a range of influential factors from the individual to the wider cultural and socioeconomic influences. However, none of these papers formally developed a working ‘definition’ of a social model of health and wellbeing, instead applying guiding principles and philosophies associated with a social model to their discussions or interventions. 24 , 25

The need to understand context

Numerous articles highlight that in order to move towards a social model of health and wellbeing, it is important to understand the context of the environment in which the model will need to operate. This includes balancing the needs of the individual with the resulting model to have been co-created, developed and implemented within the community whilst ensuring that the complexity of interaction between the social determinants of health and their influence on health and wellbeing outcomes are delivered effectively and efficiently.

The literature identified the complex multi-disciplinary nature of a variety of conditions or situations involving medical care. These included issues such as, but not exclusively, chronic pain, 26 cancer, 27 older adult care 28 and dementia, 29 thus indicating the complex arrangement of medical issues that a model will need to address and, where many authors acknowledged that the frequently used biomedical models failed to fully capture the holistic nature and need of patients. Papers outlined some of the key social determinants of health affecting the specific population of interest in their own context, highlighting the interactions between wider socioeconomic and cultural factors such as poverty, housing, isolation and transport and health and wellbeing outcomes. Interventions that had successfully addressed individual needs and successful embedded services in communities reported improved outcomes for end users and staff in the form of empowerment, agency, education and belonging. 30 There was also recognition that the transition to more community-based care could be challenging for health and social care providers who were having to work outside of their traditional models of care and accept a certain level of risk.

The need for cultural change

A number of papers referred to the need for a ‘culture change’ or ‘cultural shift’ in order to move towards a social model of health and wellbeing. Papers identified how ‘culture change models’ were implemented as a way of adapting to a social model. It was recognized that for culture change models to be effective, staff and the general public needed to be fully engaged with the entire move towards a social model, informing and shaping the mechanisms for the cultural shift as well as the application of the model itself.

Integration and collaboration towards a holistic and person-centred approach

The importance of integration and collaboration between health professionals, (which includes public, private and third sector organizations), services users and patients were emphasized in the ambition to achieve best practice when applying a social model of health and wellbeing. Papers identified the reported benefits of improved collaboration between, and integration of services which included improved continuity of care throughout complex pathways, 31 improved return to home or other setting on discharge, 25 and social connectedness. 32 Numerous papers discussed the importance of multi-disciplinary teams who were able to support individuals beyond the medicalized model.

A number of papers suggested specific professional roles or structures that would be ideal to act as champions or integrators of collaborative services and communities. 25 , 33 These could act as a link between secondary, primary and community level care helping to identify patient needs and supporting the integration of relevant services.

Measuring and evaluating a social model of health

Individual papers applying and evaluating interventions based on a social model used a variety of methods to evaluate success. Amongst these, some of the most common outcome measures included; general self-report measures of outcomes such as mental health and perceptions of safety, 34 wellbeing, 35 life satisfaction and health social networks and support 19 Some included condition specific self-report outcomes relevant to the condition in question (e.g. pregnancy, anxiety) and pain inventories. 36 Other papers considered the in-depth experiences of users or service implementers through qualitative techniques such as in-person interviews. 37 , 38

However, the complexity of developing effective methods to evaluate social models of health were recognized. The need to consider the complex interactions between social determinants, and health, wellbeing, economic and societal outcomes posed particular challenges in developing consistency across evaluations that would enable a conclusive evaluation of the benefits of social models to wider health systems and societal health. Some criticized the over-reliance of quantitative and evidence-based practice methods of evaluation highlighting how these could fail to fully capture the complexity of human behaviour and the manner in which their lives could be affected.

The aim of this systematic review was to better understand how a social model of health and wellbeing is conceptualized, implemented and evaluated in health and social care. The review sought to address the research questions identified in the ‘Introduction’ section of this paper.

With regards to the conceptualization of a social model of health and wellbeing, analysis of the literature suggests that whilst the ethos, values and aspirations of achieving a unified model appears to have consensus. However, a fundamental weakness exists in that there is no single unified definition or operational model of a social model of health and wellbeing applied to the health and social care sector. The decision about how best to conceptualize a ‘social model’ is important both in terms of its operational value but also the implication of the associated semantics. However, without a single or unified definition then implementation or further, operationalization of any model will be almost impossible to develop. Furthermore, use of the term ‘social model’ arguably loses site of the biological factors that are clearly relevant in many elements of clinical medicine. Furthermore, there is no clarification in the literature about what would ‘not’ be considered a social model of health and wellbeing, potentially leading to confusion within health and social care sectors when addressing their wider social remit. This raises questions and requires decisions about whether implementation of a social model of health and wellbeing will need to work alongside or replace the existing biomedical approach.

Authors have advocated that a social model provides a way of ‘thinking’ or articulating an organization’s values and culture. 24 Common elements of the values associated with a social model amongst the papers reviewed included recognition and awareness of the social determinants of health, increased focus on preventative rather than reactive care, and similarly the importance of quality of ‘life’ as opposed to a focus on quality of ‘care’. However, whilst this approach enables individual services to consider how well their own practices align with a social model, the authors suggest that this does not provide large organizations such as the NHS, with multifaceted services and complex internal and external connections and networks, sufficient guidance to enable large scale evaluation or transition to a widespread operational model of a social model of health and wellbeing. This raises questions about what the model should be: whether its function is to support communication of a complex ethos to encourage reflection and engagement of its staff and end users, or to develop the current illustrative framework into a predictive model that can be utilized as an evaluative tool to inform and measure the success of widespread systems change.

Regarding the potential implementation of a future social model of health and wellbeing, none of the papers evaluated the complex widespread organizational implementation of a social model, instead focusing on specific organizational contexts of services such as long-term care in care homes, etc. Despite this, common elements of successful implementation did emerge from the synthesis. This included the need to wholeheartedly engage and be inclusive of end users in policy and practice change to fully understand the complexity of their social worlds and to ensure that changes to practice and policy were ‘developed with’, as opposed to ‘create for’, the wider public. This also involved ensuring that health, social care and wider multi-disciplinary teams were actively included in the process of culture change from an early stage.

Implications for future research

The analysis identifies that a significant change of mindset and removal of perceived and actual hierarchical structures (that are historically embedded in health and social care structures) amongst both staff and public is needed although, eradicating socially embedded hierarchies will pose significant challenges in practice. Furthermore, the study revealed that many of the models proposed were conceptually underdeveloped and lacked the capability to be operationalized which in turn compromised their ability to be empirically tested. Therefore, in order that a future ‘implementable and operational’ model of social care and wellbeing can be created, further research into organizational behaviours, organizational learning and stakeholder theory (amongst others) applied to the social care and health environment is needed.

Towards defining a social model of health and wellbeing

In attempting to conceptualize a definition for a social model of health and wellbeing, it is important to note that the model needs to be sufficiently broad in scope in order to include the prevailing biomedical while also including the need to draw in the social determinants that provide a view and future trajectory towards social health and wellbeing. Therefore, the authors suggest that the ‘preventative’ approach brought by the improvements in the social health determinants (social, cultural, political, environmental ) need to be balanced effectively with the ‘remedial/preventative’ focus of the biomedical model (and the associated advancements in diagnostics, technology, vaccines, etc), ensuring that a future model drives cultural change; improved integration and collaboration towards a holistic and person-centred approach whilst ensuring engagement with citizens, users, multi-disciplinary teams and partner organizations to ensure that transition towards a social model of health and wellbeing is undertaken.

Through a comprehensive literature analysis, this paper has provided evidence that advocates a move towards a social model of health and wellbeing. However, the study has predominantly considered mainly literature from the USA, UK, Canada and Australia and therefore is limited in scope at this stage. The authors are aware of the need to consider research undertaken in non-English speaking countries where a considerable body of knowledge also exists and which will add to further discussion about how that work dovetails into this body of literature and, how it aligns with the biomedical perspective. There is a need for complex organizations such as the NHS and allied organizations to agree a working definition of their model of health and wellbeing, whether that be a social model of health and wellbeing, a biopsychosocial model, a combined model, or indeed a new or revised perspective. 39

One limitation seen of the models within this study is that at a systems level, most models were conceptual models that characterized current systems or conditions and interventions to the current system that result in localized improvements in systems’ performance. However, for meaningful change to occur, a ‘future state’ model may need to focus on a behavioural systems approach allowing modelling of the complete system to take place in order to understand how the elements within the model 40 behave under different external conditions and how these behaviours affect overall system performance.

Furthermore, considerable work will be required to engage on a more equal footing with the public, health and social care staff as well as wider supporting organizations in developing workable principles and processes that fully embrace the equality of a social model and challenging the ‘power’ imbalances of the current biomedical model.

Supplementary data are available at EURPUB online.

This research was funded/commissioned by Hywel Dda University Health Board. The research was funded in two phases.

Conflicts of interest: None declared.

The datasets generated and/or analysed during the current study are available in the Data Archive at Aberystwyth University and have been included in the supplementary file attached to this submission. A full table of references for studies included in the review will be provided as a supplementary document. The references below refer to citations in the report which are in addition to the included studies of the synthesis.

The review identified five themes namely: the lack of a clear definition of a social model of health and wellbeing; the need to understand context; the need for cultural change; improved integration and collaboration towards a holistic and person-centred approach; measuring and evaluating the performance of a social model of health.

The review identified a need for organizations to decide on how a social model is to be defined especially at the interfaces between partner organizations and communities.

The implications for public policy in this paper highlights the importance of engagement with citizens, users, multi-disciplinary teams and partner organizations to ensure that transition towards a social model of health and wellbeing is undertaken with holistic needs as a central value.

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Once you have refined your topic into a proper research question, you can begin your search for your literature review. The first step in this process is deciding where is the best place for you to search to find the information that you need. The following video explains the difference between what you can find with Google and what you can find in the libraries' research databases.

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Parenting as a Moderator of the Relation Between Child Inhibited Temperament and Anxiety in Western Contexts: A Systematic Review

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Published: 16 June 2024

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Elizabeth M. Aaron ORCID: orcid.org/0000-0003-3386-7498 1 ,
Emma Caley 1 &
Elizabeth J. Kiel ORCID: orcid.org/0000-0001-5922-8999 1

The literature on the role of parenting in the relation between child inhibited temperament and child anxiety is inconsistent, with some literature supporting a moderating role and some literature supporting alternative (e.g., mediating) roles. A systematic review of the evidence that parenting moderates the longitudinal relation between child inhibited temperament and child anxiety is needed. A systematic review of the literature was conducted in February and March of 2022 and repeated in January of 2024. Ten articles met criteria for inclusion, with 39 moderation analyses of interest among them. All included studies were conducted in Western contexts with predominately White, middle-class families. Thus, the current review can only be generalized to this population. Despite inconsistent findings, some evidence indicated that avoidance-promoting parenting behaviors such as overprotection and overinvolvement moderate the relation between child inhibited temperament and social anxiety symptoms, in particular. There was a lack of evidence that parenting behaviors moderate the relation between child inhibited temperament and anxiety disorders, and that affect-related parenting behaviors (e.g., negativity) moderate the relation between child inhibited temperament and non-social anxiety symptoms. There was mixed evidence regarding the moderating role of control-related parenting behaviors in the relation between child inhibited temperament and non-social anxiety symptoms, with some evidence that encouraging behaviors moderate this relation. Future research is needed to clarify these inconsistent and nuanced findings and investigate this moderation in non-Western, non-White, and low-income populations.

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Introduction

Inhibited temperament, or behavioral inhibition, is a temperamental dimension defined by withdrawal and hesitancy in novel environments (Kagan et al., 1984 ). Children with more inhibited temperaments have a higher likelihood of developing anxiety (Dyson et al., 2011 ; Sandstrom et al., 2020 ). Further, child inhibited temperament is most strongly linked to the development of social anxiety, specifically (Biederman et al., 2001 ; Chronis-Tuscano et al., 2009 ; Clauss & Blackford, 2012 ). Although many studies have found a relation between inhibited temperament and child anxiety, some studies have found that this relation only occurs in certain contexts (Crockenberg & Leerkes, 2006 ; White et al., 2017 ). One context that has been widely studied is that of the parenting environment. Certain parenting behaviors have been linked to child anxiety, including control-related parenting behaviors (e.g., overcontrol, overprotection, encouragement, intrusion; Edwards et al., 2010a ) and negative affect-related parenting behaviors (e.g., expressed anxiety, negativity, criticism; McLeod et al., 2007 ). There is research to suggest that control- and affect-related parenting behaviors moderate the relation between inhibited temperament and child anxiety, such that children who have more inhibited temperaments are more likely to develop anxiety only in the context of receiving high levels of these parenting behaviors (Lewis-Morrarty et al., 2012 ; Lorenzo et al., 2022 ). In other words, children who exhibit more fearfulness and withdrawal in novel situations in the context of receiving parenting that criticizes or reinforces these behaviors are more likely to develop child anxiety.

The moderating role of parenting in the relation between inhibited temperament and anxiety has been a major focus within the field, and yet it has not been reviewed systematically. Without a systematic review of the literature, the strength of research evidence for this moderating effect is unknown. Indeed, some research has not found evidence of parenting moderating the relation between inhibited temperament and anxiety (Hudson et al., 2011 ; Muris et al., 2011 ). Further, research suggests that parenting may have a different role than as a moderator in this relation. A recent literature review provided support for a relation between inhibited temperament and child anxiety, and then proposed a model of the developmental pathways from inhibited temperament to anxiety that included parenting as both a moderator and a mediator (Liu & Pérez-Edgar, 2019 ). Given the emerging research on parenting serving alternative roles, it is important to determine if there is sufficient evidence to continue modeling parenting as a moderator. The current review builds on the foundation of Liu and Pérez-Edgar ( 2019 ) by systematically investigating the previous research on parenting serving as a moderator.

Inhibited Temperament and Child Anxiety

Temperament is defined as a relatively stable biologically based dimension reflecting individuals’ typical emotional, physiological, attentional, and regulatory responses to their environment (Goldsmith et al., 1987 ; Shiner et al., 2012 ). Inhibited temperament (also referred to as behavioral inhibition or fearful temperament) is characterized by fearful, shy, and withdrawn responses to new stimuli and environments (Kagan et al., 1984 ). Behavioral inhibition is assessed both dichotomously (including children with extreme inhibited vs. uninhibited behavior only) and dimensionally (assessing all children’s varying levels of inhibition). Children with high inhibited temperament are more physiologically reactive to their environments, have more attentional bias toward novelty, have more difficulty shifting their attention away from threat, and are more likely to interpret ambiguous environmental stimuli as threatening (Pérez-Edgar & Guyer, 2014 ). An infant with a high inhibited temperament may move away from a stranger or an unknown toy or cry in response to these stimuli. These inhibited behaviors mirror behaviors seen in later child anxiety, when children exhibit fear and withdrawal in the presence of anxiety-provoking stimuli. Indeed, previous research has demonstrated that inhibited temperament is the strongest predictor of later child anxiety (Biederman et al., 2001 ; Buss et al., 2021 ; Clauss & Blackford, 2012 ; Liu & Pérez-Edgar, 2019 ). Inhibited temperament is most strongly linked to child social anxiety (Biederman et al., 2001 ; Buss et al., 2021 ; Clauss & Blackford, 2012 ). However, it is also related to other anxiety disorders such as generalized anxiety disorder and specific phobia (Sandstrom et al., 2020 ). These differing relations may be explained by the context in which inhibited temperament is measured, with measurement in social environments mapping more onto social anxiety symptoms and measurement in non-social environments relating more to other anxiety symptoms (Dyson et al., 2011 ; Tan et al., 2024 ).

The relation between inhibited temperament and anxiety is consistent with theories of anxiety development which posit that biological vulnerabilities, such as inhibited temperament, serve as predisposing risk factors for the development of anxiety (Barlow, 2000 ; Muris, 2006 ). These theories also acknowledge the important role of a child’s environment in the development of later psychopathology, considering environmental factors such as parenting as predisposing factors that interact with child temperament (Muris, 2006 ). Therefore, it is important to consider the role of the environment in the development of child anxiety.

Parenting and Child Anxiety

Parents and caregivers are integral to children’s development, and often regulate the manner in which children engage with their environments. Indeed, family systems theory indicates that the way in which family members interact with one another influences the development of individual family members and the family system itself. Within the realm of parenting, family systems theory suggests an anxious-coercive cycle in which children with high inhibited temperaments elicit overprotective and overcontrolling behaviors from their caregivers, which then serve to reinforce the child’s inhibition (Dadds & Roth, 2001 ). When a caregiver provides a child with high amounts of comfort and reassurance or seeks to control children’s behavior when faced with low-threat environmental stimuli, such as a friendly stranger or safe toy, this behavior can communicate to the child that they need their caregiver to help them navigate these stimuli.

Overprotective behaviors such as comfort and reassurance hinder child engagement with novel stimuli, and thus can be categorized as control-related behaviors that promote child avoidance. In other words, when parents comfort their children and attempt to protect them from unfamiliar environments, it reinforces children’s withdrawal and prevents them from engaging with the environment. It is well documented that anxiety is reinforced by avoidance of feared stimuli, and treated through exposure to feared stimuli (Peris et al., 2017 ; Whiteside et al., 2013 , 2020 ). Thus, when parents promote avoidance and limit exposure to these stimuli, they feed an anxious cycle for their inhibited children.

Alternatively, overcontrolling behaviors such as intrusive directives seek to control children’s engagement with unfamiliar stimuli, and thus can be categorized as control-related behaviors that excessively promote approach. When parents dictate how children should engage with their environments, children’s autonomy is reduced. Behaviors within both of these control-related categories contribute to children feeling less in control of their environments. When children have low self-efficacy regarding their ability to independently manage their environments, they are more likely to develop anxiety (Chorpita & Barlow, 1998 ).

Other parenting behaviors have been linked to child anxiety as well, including affect-related parenting behaviors such as negativity, dismissiveness, and criticism, which are characterized by negative affect and rejection (Gouze et al., 2017 ; McLeod et al., 2007 ). When caregivers respond to their children with high amounts of negative affect, these responses may limit children’s beliefs in their own capabilities, engendering the same feeling of a lack of control that is theorized to relate to child anxiety (Chorpita & Barlow, 1998 ; Gouze et al., 2017 ). Additionally, when caregivers respond to their children with criticism, it may cause their children to perceive social interactions as more threatening due to an expectation of further criticism, which then perpetuates anxiety (Garcia et al., 2021 ). Although the anxious-coercive cycle focuses on avoidance-promoting and rejecting parenting behaviors, the potential impact of negativity and criticism on children’s self-efficacy beliefs may create a similar cycle that maintains both the child temperamental risk for anxiety and the anxiogenic parenting risk for anxiety (Dadds & Roth, 2001 ). The anxious-coercive cycle highlights the joint role of parent and child factors in child anxiety development, and the way in which overcontrolling parenting behaviors engender child anxiety, both of which will be investigated in the current review. Previous research also suggests that parenting may serve as a contextual factor in the development of child social anxiety and other types of child anxiety.

Parenting as a Moderator

The trajectory of child anxiety development is influenced by child inhibited temperament and parenting behavior (Biederman et al., 2001 ; Edwards et al., 2010a ). Previous research has investigated the interaction between these variables in the development of child anxiety. It has been posited that children with high levels of inhibited temperament only go on to develop childhood social withdrawal and anxiety when their parents engage in high levels of anxiogenic parenting behaviors, such as overcontrolling and critical parenting (Liu & Pérez-Edgar, 2019 ; Rubin et al., 2009 ). This theory has been supported by previous research that has investigated numerous parenting behaviors as moderators and both social and non-social anxiety as outcomes (Kiel et al., 2016 ; Lewis-Morrarty et al., 2012 ; Lorenzo et al., 2022 ). For example, Lewis-Morrarty et al. ( 2012 ) found that stable childhood behavioral inhibition only predicted adolescent social anxiety within the context of mothers’ high levels of overcontrol. However, there are some studies that have failed to find a significant moderating effect of parenting behavior in this relation (Hudson et al., 2011 ; Muris et al., 2011 ). Hudson et al. ( 2011 ) found that children with behavioral inhibition (dichotomously assigned) were more likely to have a diagnosis of social phobia and generalized anxiety disorder, and that parenting did not moderate this relation.

Only some of these previous moderation studies used rigorous prospective designs to assess parenting as a moderator within the directional relation from child inhibited temperament to child anxiety. Some of the previous research was conducted concurrently, which limits the interpretability of these moderation results. Given the mixed findings and the inconsistent methodological rigor in the previous literature, it is important to conduct a systematic review to elucidate whether there is substantial evidence of parenting serving as a moderator of the relation between child inhibited temperament and child anxiety. Notably, the presence of moderation can be evaluated by assessing either parenting or inhibited temperament as the moderator (and the other variable as the predictor). The current review will include articles that assess this interaction, no matter the assignment of roles.

It is also important to note the various theoretical frameworks in which this moderation can be assessed. The interaction between child inhibited temperament and parenting can be conceptualized within a diathesis-stress model, a vantage-sensitivity model, or a differential susceptibility model. Within a diathesis-stress framework, child inhibited temperament would be considered a risk factor, and anxiogenic parenting behavior would be considered a stressor that, in interaction with inhibited temperament, predicts anxiety outcomes (Zuckerman, 1999 ). Within a differential susceptibility framework, children with high inhibited temperaments would be expected to be more negatively impacted by anxiogenic parenting and more positively impacted by adaptive parenting in comparison to children with moderate or low levels of inhibited temperament (Belsky & Pluess, 2009 ). Lastly, within a vantage-sensitivity framework, children with higher inhibited temperaments would have less anxiety within the context of adaptive parenting behaviors as compared to children with moderate or low levels of inhibited temperament (Pluess & Belsky, 2013 ). The current review will assess the foundational models used in the included articles. The paper will not weigh the evidence for each of these models, but instead will discuss how these theoretical frameworks may impact the moderation findings in the literature.

Objectives of the Review

The current state of the research on inhibited temperament and child anxiety indicates that it is time to examine whether there is sufficient research evidence to assert that parenting serves a moderating role in the relation between inhibited temperament and child anxiety. The current paper will systematically review the previous literature, assess the methodological rigor and quality of the included studies, and lastly, evaluate and integrate the included studies’ findings to elucidate the strength of the evidence for parenting moderating the relation between child inhibited temperament and child anxiety, considering both type of anxiety (social or other type) and the type of parenting assessed.

Literature Review

A systematic review of the literature was conducted in February and March of 2022, and then repeated in January of 2024. PsycINFO, MedLine, and PubMed were searched in February 2022 and January 2024 to find relevant articles. The following search terms were used: (moderat* or interact*) AND (parenting or mother–child relations or parent–child relations or child rearing or family) AND (inhibited temperament or inhibit* or fearful temperament or behavioral inhibit* or dysregulated fear) AND (anxi* or wariness or withdrawal or reticence or internaliz*) NOT (mice or rat or rodent* or mouse or autis* or asd or pharmac*). Only academic journal articles written in English were included in the search results. For MedLine and PsycINFO, the search was expanded to the full-text for the terms (moderat* or interact*). For all of the PubMed search terms and the rest of the MedLine and PsycINFO search terms, the detailed record was searched (i.e., title, abstract, keywords, subject headings). Once these searches were completed, the articles were exported to Zotero and duplicates were merged. Next, the first author screened the titles of all articles and removed articles with titles that did not refer to at least one of the pertinent review topics (i.e., temperament, parenting, and anxiety). Next, the first author screened the remaining abstracts and removed articles that did not mention all of the following topics: temperament, environment/parenting, and anxiety/anxiety-relevant domain. Lastly, the first and second authors screened the remaining full-text articles to determine which articles met the review inclusion criteria. The inter-rater reliability of the eligibility decisions made by the authors was κ = 0.64, which is considered moderate reliability (McHugh, 2012 ). Discrepancies were discussed and consensus was reached to finalize the list of included articles. Lastly, the first author screened the reference sections of included articles. Full-text articles identified in the reference sections were screened for eligibility and added to the list of included articles if they met all criteria.

Inclusion and Exclusion Criteria

Articles were included in the review if they met the following inclusion criteria: based in a laboratory context; assessed child inhibited temperament or a related temperamental dimension such as fearful temperament or behavioral inhibition when children were 6 years of age or younger; assessed child (children ages 17 years and younger) anxiety at least 6 months after temperament was assessed; assessed parenting behavior; examined the moderating role of parenting in the prospective relation between inhibited temperament and child anxiety or the moderating role of inhibited temperament in the prospective relation between parenting and child anxiety. Articles were excluded from the review if they were not written in English, were dissertations, or focused on children with autism spectrum disorder, other developmental disabilities, or chronic health conditions.

Study Selection

Ten articles including eight samples were identified for inclusion in the current review. The articles were published between 2011 and 2021. Details of the articles reviewed at each screening stage are located in Fig. 1 . One hundred and eight full-text articles were assessed for eligibility, 95 from databases and 13 from citation searches. The primary reasons for exclusion during the full-text review were that the moderation of interest was not assessed, child anxiety was not assessed at least 6 months following the assessment of child inhibited temperament, and that child anxiety was not assessed. Other reasons for exclusion are found in Fig. 1 . Three of the articles included in the review (Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ) used the same sample of participants with the same baseline data. However, each article used a different timepoint for measuring child anxiety at time 2, thus providing unique longitudinal results regarding the study question. Thus, all three articles were included in the present review. See Table 1 for a description of the included studies.

Search strategy and results

Sample Characteristics

The eight samples included in the current review were relatively racially and ethnically homogenous, with all samples comprised of a majority of White, non-Hispanic participants. There was minimal diversity in the geographic location of the eight samples, as well, including the United States ( n = 3), the Netherlands ( n = 2), the United Kingdom ( n = 2), and Australia ( n = 1). Given that all of these studies had Western samples with primarily White, non-Hispanic participants, this review will only reflect the evidence for moderation in Western contexts. Most samples were majority middle-to-upper class. All study samples were recruited from the community. One sample pre-screened community children for high and low levels of inhibited temperament for inclusion (Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ). One sample pre-screened community children for high positive and high negative reactivity to novelty as infants, and oversampled these infants for inclusion (Lorenzo et al., 2022 ). One sample pre-screened community mothers, and included mothers who met criteria for generalized anxiety disorder or social anxiety disorder and mothers who did not meet criteria for either disorder (Lawrence et al., 2020 ). One sample pre-screened pregnant mothers, and included mothers who met criteria for social anxiety disorder and mothers who did not meet criteria for social anxiety disorder or generalized anxiety disorder (Murray et al., 2014 ). One sample recruited first-time parents (Majdandžić et al., 2018 ). All other samples recruited community families with no pre-screening conducted for inclusion. All study samples had an approximately equal breakdown in binary designations of child sex or gender (no studies reported separate demographics for sex and gender, and no studies included children with non-binary identities). Samples ranged in size from 117 to 291 families.

Across the samples, child inhibited temperament was first assessed when children were between the ages of 4 months and 6 years. Three samples (Lawrence et al., 2020 ; Majdandžić et al., 2018 ; Murray et al., 2014 ) assessed inhibited temperament when children were infants (0–15 months), one sample (Kiel et al., 2016 ) assessed inhibited temperament when children were toddlers (16–35 months), three samples (Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ; Lorenzo et al., 2022 ; Vreeke et al., 2013 ) assessed inhibited temperament when children were pre-school or school-aged (3–6 years), and one sample created a longitudinal inhibited temperament profile using assessments from when children were 14 months, 24 months, 4 years, and 7 years (Lewis-Morrarty et al., 2012 ). Parenting behaviors were first assessed when children were between the ages of 10 months and 6 years. One sample (Lawrence et al., 2020 ) assessed parenting when children were infants (0–15 months), one sample (Kiel et al., 2016 ) assessed parenting when children were toddlers (16–35 months), one sample assessed parenting when children were infants and toddlers (at 1 and 2.5 years old; Majdandžić et al., 2018 ), and five samples (Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ; Lewis-Morrarty et al., 2012 ; Lorenzo et al., 2022 ; Murray et al., 2014 ; Vreeke et al., 2013 ) assessed parenting when children were pre-school or school-aged (3–7 years). Child anxiety was assessed as the outcome when children were between the ages of 3 and 17 years. Because each article by Hudson and colleagues assessed child anxiety at a different age, this sample will be broken down by article. Most articles ( n = 7; Hudson & Dodd, 2012 ; Hudson et al., 2011 ; Kiel et al., 2016 ; Lawrence et al., 2020 ; Majdandžić et al., 2018 ; Murray et al., 2014 ; Vreeke et al., 2013 ) assessed anxiety when children were in early to middle childhood (2–9 years). Two articles (Hudson et al., 2019 ; Lorenzo et al., 2022 ) assessed anxiety over time from early to middle childhood (3–9 years) through adolescence (12–15 years) and one article (Lewis-Morrarty et al., 2012 ) assessed anxiety in adolescence (14–17 years). The time between the measure of inhibited temperament and the measure of anxiety ranged from 1 to 16 years, with most studies assessing them 1–5 years apart ( n = 7; Hudson & Dodd, 2012 ; Hudson et al., 2011 ; Kiel et al., 2016 ; Lawrence et al., 2020 ; Majdandžić et al., 2018 ; Murray et al., 2014 ; Vreeke et al., 2013 ).

Method Characteristics

Measures of inhibited temperament.

Inhibited temperament was measured in a variety of ways across the study samples. Inhibited temperament was measured dimensionally in five samples (Kiel et al., 2016 ; Lewis-Morrarty et al., 2012 ; Lorenzo et al., 2022 ; Majdandžić et al., 2018 ; Vreeke et al., 2013 ) and dichotomously in three samples (Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ; Lawrence et al., 2020 ; Murray et al., 2014 ). Most samples used an observational measure ( n = 7; Kiel et al., 2016 ; Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ; Lawrence et al., 2020 ; Lewis-Morrarty et al., 2012 ; Lorenzo et al., 2022 ; Majdandžić et al., 2018 ; Murray et al., 2014 ), with two of these samples also using a parent-report measure. One sample used only a parent-report measure (Vreeke et al., 2013 ). All seven samples with observational measures used standardized procedures (from Aktar et al., 2013 ; Calkins et al., 1996 ; Fox et al., 2001 ; Kagan et al., 1987 ; Kagan & Snidman, 1991 ; Rubin, 2001 ) in which infants and children interacted with novel stimuli, such as unknown toys and people, and were coded for inhibited and fearful behaviors, such as distress vocalizations and proximity to caregiver.

The three samples that utilized parent-report measures of temperament all used different scales. The Hudson and colleagues sample (Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ) used the approach scale of the Short Temperament Scale for Children, using one standard deviation or more below the mean to represent uninhibited temperament and one standard deviation or more above the mean to represent inhibited temperament (Sanson et al., 1994 ). Lewis-Morrarty et al. ( 2012 ) used the Social Fearfulness scale of the Toddler Behavior Assessment Questionnaire (Goldsmith, 1996 ) in addition to the Shyness/Sociability subscale of the Colorado Children's Temperament Inventory (Buss & Plomin, 1984 ; Rowe & Plomin, 1977 ). Vreeke et al. ( 2013 ) used the short version of the Behavioral Inhibition Questionnaire (Bishop et al., 2003 ; Edwards, 2007 ).

Four of the eight study samples used more than one measure of inhibited temperament. The Hudson and colleagues sample (Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ) used the Short Temperament Scale for Children (Sanson et al., 1994 ) for their main analyses. Then, they re-ran their analyses with the behaviorally inhibited group only including children who met the cutoff for inhibition on both the observational and parent-report measures. Lewis-Morrarty et al. ( 2012 ) conducted a latent profile analysis using data from all of their parent-report and observational measures in order to create a continuous variable of the probability that each child would belong to the high behavioral inhibition profile. Lawrence et al. ( 2020 ) used a dichotomous measure of stability in inhibited temperament through identifying children who were categorized as negatively reactive at time 1 and behaviorally inhibited at time 2. Majdandžić et al. ( 2018 ) used both time 1 and time 2 assessments of fearful temperament in their analyses.

Measures of Parenting

Various parenting dimensions related to control and negative affect were examined in the included articles. Most of the studies assessed parenting behaviors that fell along the parenting dimension of control, with some articles measuring overcontrolling parenting behaviors that promote child avoidance (e.g., overprotection, n = 6), some articles measuring appropriate levels of parental control and encouragement (e.g., challenging, n = 3), and some articles measuring overcontrolling behaviors that excessively promote child approach (e.g., intrusiveness, n = 2). The remaining articles assessed dimensions related to negative and anxious affect ( n = 4). All parenting variables were continuous except for “attribution of threat to the environment” in Murray et al. ( 2014 ), which was dichotomous. As with the temperament variables, all but one of the samples used an observation of parenting. Vreeke et al. ( 2013 ) used a self-report measure, only. Additionally, the Hudson and colleagues sample used a self-report measure in addition to an observational measure. Many articles measured more than one parenting dimension.

Three samples observed parenting behaviors during tasks in which children and parents were presented with novel stimuli (maternal encouragement to approach novelty, Kiel et al., 2016 ; maternal encouragement, expressed anxiety, and intrusiveness, Lawrence et al., 2020 ; parental dismissive, task directive, and supportive behaviors, Lorenzo et al., 2022 ). Two samples observed parenting behaviors during numerous structured tasks and unstructured free play (maternal overcontrol, Lewis-Morrarty et al., 2012 ; parental overprotective and challenging behavior, Majdandžić et al., 2018 ). Murray et al. ( 2014 ) observed maternal encouragement and threat attribution while reading a book about starting school. Hudson and colleagues observed maternal overinvolvement and negativity during the preparation and delivery of a speech, and had parents complete the Control scale of the Parent Protection Scale (Thomasgard et al., 1995 ). Vreeke et al. ( 2013 ) used the Parental Overprotection Measure, a self-report survey (Edwards, 2007 ). Most of the samples ( n = 5) used more than one parenting variable, as described above. In each sample, these variables were assessed in separate moderation analyses. See Table 2 for more detail on how each article measured and defined their parenting variable, in addition to how these constructs are categorized in the current review.

Measures of Child Anxiety

Child anxiety was assessed via clinical interviews and parent- and self-report measures across the articles. Because each Hudson and colleagues article used a different timepoint for their child anxiety measure, this sample will be broken down by article. Seven of the ten articles used a clinical interview administered by a trained researcher or clinician. Five of these seven articles also used a parent-report or child self-report measure. The remaining three articles used parent- and child-report measures only.

Five of the ten articles administered the Anxiety Disorders Interview Schedule for DSM-IV parent version (ADIS-P, Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ; Lawrence et al., 2020 ; Murray et al., 2014 ; Silverman & Albano, 1996 ). In all of these articles, the ADIS-P was used to create a dichotomous value for the presence or absence of a diagnosis. Hudson and Dodd ( 2012 ) and Hudson et al. ( 2011 ) also used the ADIS-P to generate a continuous measure of number of diagnoses. Lewis-Morrarty et al. ( 2012 ) used the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL, Kaufman et al., 1997 ) with supplemental questions pulled from the Anxiety Disorder Interview Schedule for Children (Silverman & Albano, 1996 ) to dichotomously measure the presence or absence of a diagnosis, interviewing both adolescents and their parents separately.

Four articles used the Preschool Anxiety Scale (PAS; Spence et al., 2001 ) or the Preschool Anxiety Scale-Revised (PAS-R; Edwards et al., 2010b ), a parent-report measure (PAS: Hudson et al., 2011 , 2019 ; PAS-R: Majdandžić et al., 2018 ; Vreeke et al., 2013 ). Hudson et al. ( 2019 ) also used the Spence Children’s Anxiety Scale (Spence, 1998 ). Two articles (Lawrence et al., 2020 ; Lorenzo et al., 2022 ) used the Anxiety Problems scale of the parent-reported Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2000 ). Lorenzo et al. ( 2022 ) also used the social anxiety subscale of the Screen for Child Anxiety Related Emotional Disorders (SCARED, Birmaher et al., 1997 ), a child-report measure. Lewis-Morrarty et al. ( 2012 ) used the social anxiety subscale of the SCARED, as well, with both parents and children reporting child anxiety. Kiel et al. ( 2016 ) used the separation distress subscale of the Infant Toddler Social-Emotional Assessment—Revised (ITSEA, Carter & Briggs-Gowan, 2000 ), a parent-report measure. All of the parent and child-report measures were continuous variables.

Five of the articles used more than one measure of child anxiety. Lorenzo et al. ( 2022 ) used the CBCL to control for earlier anxiety symptoms and the SCARED to create an unconditional growth curve model of social anxiety over time, which was used as the outcome. Hudson et al. ( 2019 ) used the PAS and the Spence Children’s Anxiety Scale to create a growth curve of anxiety over time for one analysis, and used the ADIS-IV as the outcome in a separate analysis. The remaining three articles used each of their anxiety measures as outcomes in separate analyses (Hudson et al., 2011 ; Lawrence et al., 2020 ; Lewis-Morrarty et al., 2012 ).

Quality Assessment

The current review coded the included articles to assess their risk of bias using an adaptation of the Quality in Prognosis Studies (QUIPS) tool developed by Hayden et al. ( 2013 ). The QUIPS tool assesses bias in the areas of study participation, study attrition, prognostic factor measurement, outcome measurement, study confounding, and statistical analysis and reporting. A quality assessment tool was developed for the current review that assigned 0 (no risk of bias) or 1 (risk of bias) to 21 codes. See Table 3 for a complete description of the adapted scale.

The first and second authors each coded all of the articles. Initial agreement was calculated via kappa and percent agreement. Quality code kappas ranged from 0.78 to 1.00 across the 21 codes, indicating moderate to strong agreement (κ mean = 0.96). When either coder assigned only 0s across an entire code, kappa could not be calculated. In these nine cases, percent agreement was calculated. Percent agreement of these nine codes ranged from 80 to 100% with a mean percent agreement of 95%. After coding was completed separately, the first and second author met to reach consensus on the quality codes. The 21 codes were then summed for each article to create one composite code capturing the overall risk of bias. Articles were assigned composite quality codes between 3 and 11 with a mean quality score of 5.6. Articles with scores below the mean are considered to have a low risk of bias, and articles with scores above the mean are considered to have a higher risk of bias. Findings from articles with lower risk of bias will be given greater weight given their higher quality and rigor. See Table 4 for a summary of findings.

Social Anxiety Symptoms

Three of the articles assessed the interaction between parenting and child inhibited temperament in the prediction of social anxiety symptoms. One of these articles included three different parenting dimensions and assessed social anxiety at one timepoint and over time. Another article reported separate results by ethnicity. Therefore, nine moderation analyses were evaluated.

Control-Related Parenting

The majority of the moderation analyses assessing social anxiety symptoms measured a parenting dimension related to control ( n = 7, 78%). The two analyses that assessed control-related behavior that excessively promoted child approach (e.g., intrusiveness) did not find evidence for moderation (Lorenzo et al., 2022 ). However, there was some evidence that control-related parenting behaviors that promote child avoidance, such as overprotection and overly supportive parenting, moderate the relation between child inhibited temperament and child social anxiety symptoms. Four of five analyses (80%) found significant moderation, with small to medium effect sizes across the analyses. Three of these four significant analyses found that the positive relation between child inhibited temperament and social anxiety symptoms was strengthened within the context of avoidance-promoting parenting behaviors (Lewis-Morrarty et al., 2012 ; Lorenzo et al., 2022 ; Vreeke et al., 2013 ). However, one analysis found that high child inhibited temperament predicted a sharper reduction in social anxiety symptoms over time within the context of high avoidance-promoting parenting behaviors (Lorenzo et al., 2022 ). Thus, the impact of these parenting behaviors may be nuanced based on whether anxiety is assessed at one time point (or as change between time points) versus as a trajectory over time. Notably, the one sample with a rigorous design and low risk of bias (Lewis-Morrarty et al., 2012 ; quality code = 3) found overcontrol to be a significant moderator of medium effect size.

The control-related parenting moderation findings were supported by analyses with varying methods for measuring temperament, parenting, and anxiety (parent-report, observation) and varying child ages at anxiety measurement (childhood through adolescence). Almost all of the studies included parent–child dyads and did not recruit mothers or fathers in particular, except for Lewis-Morrarty et al. ( 2012 ), who only recruited mothers. Further, all of the control-related parenting analyses strengthened the rigor of their moderation by noting that child inhibited temperament did not significantly relate to parenting behavior.

Affect-Related Parenting

There was not enough evidence in the literature to determine whether affect-related parenting moderates the relation between child inhibited temperament and child social anxiety symptoms, with only one study with two analyses in the review (Lorenzo et al., 2022 ). One of these analyses found that dismissive parenting moderated the relation between child inhibited temperament and change in social anxiety symptoms over time, with high dismissive parenting strengthening the relation between high inhibited temperament and stability in social anxiety symptoms. However, there was no evidence of moderation when social anxiety was assessed at one timepoint.

Other Anxiety Symptoms

Across the six articles that investigated other anxiety symptoms, such as total anxiety, separation anxiety, and non-social anxiety symptoms, there was a different pattern of findings. Four of these articles included more than one parenting dimension (Hudson et al., 2011 , 2019 ; Lawrence et al., 2020 ; Majdandžić et al., 2018 ), one article divided the sample based on ethnicity (Vreeke et al., 2013 ), one article assessed anxiety both at one timepoint and over time (Hudson et al., 2019 ), and one article divided their analyses between mothers and fathers (Majdandžić et al., 2018 ). Therefore, sixteen moderation analyses were reviewed.

The majority of moderation analyses assessing other anxiety symptoms as the outcome measured a parenting dimension related to control ( n = 12, 75%), altogether yielding mixed evidence. One analysis assessed parenting behavior that excessively promoted child approach, and found no evidence of moderation (Lawrence et al., 2020 ). However, there was mixed evidence for parenting behaviors that promote child avoidance. Six of the seven analyses (86%) that assessed parenting behaviors that promote child avoidance found non-significant results (Hudson et al., 2011 , 2019 ; Majdandžić et al., 2018 ; Vreeke et al., 2013 ). However, when only high-quality studies were reviewed (Hudson et al., 2011 , 2019 ), there was one significant finding and two non-significant findings. Notably, Hudson et al. ( 2019 ) was the only analysis with overprotection that assessed child through adolescent anxiety as the outcome in addition to child anxiety at one timepoint. Given that Hudson et al. ( 2019 ) was also the only study to find a significant moderation, it is possible that avoidance-promoting parenting behaviors only moderate the relation between inhibited temperament and the trajectory of child anxiety symptoms over time.

There was some evidence for parental encouragement moderating the relation between inhibited temperament and early childhood anxiety symptoms. Two of four analyses (50%) found that parental encouragement moderated the relation between inhibited temperament and other anxiety symptoms (Kiel et al., 2016 ; Lawrence et al., 2020 ). However, the directionality of this effect differed. Lawrence et al. ( 2020 ) found that encouraging parenting was an adaptive parenting behavior that led to better anxiety outcomes within the context of stable inhibited temperament. Conversely, Kiel et al. ( 2016 ), a high-quality study (quality score = 3) found that encouragement served as an adaptive parenting behavior that led to better separation anxiety outcomes in children with low inhibited temperament, but served as a maladaptive parenting behavior that led to worse separation anxiety outcomes in children with very high inhibited temperament. There were no notable differences in measurement, sample, type of anxiety measured (separation anxiety vs. total anxiety), and child age between the significant and non-significant analyses. All of the studies assessed child anxiety in early childhood (age 2–5 years). Further research is needed to clarify whether encouraging parenting contextualizes a positive or negative relation between child inhibited temperament and child anxiety.

There was a lack of evidence that affect-related parenting, namely negativity and expressed anxiety, moderates the relation between inhibited temperament and non-social anxiety symptoms. Three articles assessed affective parenting behaviors as a moderator with a total of four analyses. All four analyses (100%) had non-significant results (Hudson et al., 2011 , 2019 ; Lawrence et al., 2020 ). Notably, all three of these studies recruited parents and children from the community and pre-screened them for inclusion based on particular characteristics (e.g., children with high and low levels of behavioral inhibition, mothers with and without anxiety disorders). Thus, more research is needed in community samples without pre-screening inclusion criteria. However, the consistent lack of evidence found for this moderation across these analyses suggests that negative and anxious parenting behaviors do not moderate the relation between child inhibited temperament and child anxiety symptoms.

Anxiety Disorders

There was a consistent lack of evidence that parenting behaviors moderate the relation between child inhibited temperament and child anxiety disorders. Six studies investigated parenting as a moderator of the relation between child inhibited temperament and child anxiety disorders. One study assessed for the presence of an anxiety disorder diagnosis and the number of anxiety disorder diagnoses (Hudson & Dodd, 2012 ). Five studies assessed more than one parenting behavior (Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ; Lawrence et al., 2020 ; Murray et al., 2014 ). Therefore, fourteen moderation analyses were reviewed. Eight analyses (57%) assessed anxiety disorders generally (Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ) and six analyses (43%) assessed social anxiety disorder in particular (Lawrence et al., 2020 ; Lewis-Morrarty et al., 2012 ; Murray et al., 2014 ).

Thirteen of the fourteen included analyses (93%) yielded non-significant findings (Hudson & Dodd, 2012 ; Hudson et al., 2011 , 2019 ; Lawrence et al., 2020 ; Murray et al., 2014 ). The one other analysis, conducted by Lewis-Morrarty et al. ( 2012 ), found that maternal overcontrol only marginally moderated the relation between child inhibited temperament and lifetime social anxiety disorder diagnoses, and therefore, the interaction was not probed for simple effects. These fourteen analyses included assessment of the current or lifetime presence of social anxiety disorder and the presence and number of any current anxiety disorders. The analyses also varied in how temperament, parenting, and anxiety disorders were assessed, the type of parenting measure used, and the age of children when the disorders were assessed. Overall, these findings indicate that no parenting behaviors moderate the relation between child inhibited temperament and anxiety disorders.

The current review systematically assessed the previous literature to determine whether there is adequate evidence that parenting moderates the relation between child inhibited temperament and child anxiety. Ten articles were identified in the literature, with 39 moderation analyses among them. All of these studies took place in Western contexts with predominately non-Hispanic, White, middle-class families. Therefore, this review only reflects the moderating role of parenting in predominately White and middle-class families in Western regions, and thus may not be generalizable to all racial and ethnic groups and non-Western contexts. The current review assessed numerous characteristics of the included analyses, most notably the type of anxiety measured and the type of parenting measured. Evidence for the moderation of interest differed across the different types of anxiety and parenting assessed.

Summary of Findings

The current review revealed that avoidance-promoting parenting behaviors such as overprotection moderate the relation between child inhibited temperament and social anxiety symptoms such that higher child inhibited temperament predicts greater social anxiety symptoms within the context of high levels of avoidance-promoting parenting behaviors. This research evidence supports developmental psychopathology theories of anxiety development that posit that children’s environments (e.g., parenting) interact with their predisposing characteristics (e.g., inhibited temperaments) to predict anxiety outcomes (Muris et al., 2011 ; Vasey & Dadds, 2001 ). Notably, the current review did not find substantial evidence for avoidance-promoting parenting behaviors moderating the relation between child inhibited temperament and other anxiety symptoms, such as total anxiety symptoms and separation anxiety symptoms. The stronger evidence for parenting moderating the relation between inhibited temperament and social anxiety, in particular, is in line with previous theory and research that links inhibited temperament to social anxiety specifically (Pérez-Edgar & Guyer, 2014 ).

Further, inhibited temperament captures withdrawal and hesitancy in various novel environments and contexts, some of which are social (e.g., unfamiliar person) and some of which are non-social (e.g., unfamiliar toy). There is evidence that inhibited temperament assessed in social contexts (i.e., social behavioral inhibition) relates differently to anxiety outcomes than inhibited temperament assessed in non-social contexts (i.e., non-social behavioral inhibition; Dyson et al., 2011 ; Tan et al., 2024 ). It may be that social inhibition in particular is driving the relation between inhibited temperament and anxiety, thus explaining the unique relation between inhibition and social anxiety that is further strengthened in the presence of anxiogenic parenting behaviors. It may also be that parenting that promotes child avoidance plays a role in the development of social anxiety, specifically. When parents engage in protective and overly supportive parenting, children with higher inhibited temperament are encouraged to avoid rather than engage with novel social environments, reinforcing the use of social withdrawal as a coping strategy and strengthening the belief that they cannot independently navigate the social world.

The finding that avoidance-promoting parenting behaviors are particularly important risk factors when combined with child inhibited temperament supports the anxious-coercive family systems theory that emphasizes the role of overcontrolling and overprotective parenting in particular in anxiety development (Dadds & Roth, 2001 ). As suggested by the anxious-coercive cycle, there may be a direct relation between temperament and parenting in which inhibited children elicit overprotective parenting behaviors. However, the current review indicates that when examining anxiety outcomes over time, avoidance-promoting parenting appears to moderate this relation. Further research is needed to tease apart the interaction between avoidance-promoting parenting and inhibited temperament in the prediction of social anxiety in particular to determine why this specificity exists.

When considering non-social anxiety, the current review revealed some evidence that encouraging parenting behaviors moderate the relation between child inhibited temperament and other anxiety symptoms; however, the direction of this relation within the context of encouraging parenting remains unclear. The way in which encouragement was measured in the included studies may have impacted the difference in the directionality of this effect. Lawrence et al. ( 2020 ) assessed gentle and enthusiastic encouragement only, whereas Kiel et al. ( 2016 ) assessed a continuum of encouragement with low values representing excessive comforting, middle values representing gentle encouragement, and high values representing excessive encouragement and intrusiveness. It may be that gentle encouragement is adaptive for children with high inhibited temperaments, whereas excessive encouragement is maladaptive for these children. Further research assessing various levels and types of encouragement will be helpful for elucidating this moderating effect.

Study findings indicated that parenting defined by negative affect does not moderate the relation between child inhibited temperament and other anxiety symptoms. The lack of evidence for parenting defined by negative affect moderating the relation between inhibition and anxiety is consistent with theory that focuses on the role of control-related parenting behaviors specifically in anxiety development (Chorpita & Barlow, 1998 ; Dadds & Roth, 2001 ). It may also be that affect-related parenting behavior predicts anxiety development across levels of child temperament, instead of interacting with inhibition to predict anxiety outcomes. Further research is needed to clarify whether parenting defined by negative affect moderates the relation between child inhibited temperament and social anxiety symptoms, given the limited research assessing this interaction with social anxiety specifically as the outcome.

Lastly, the current review revealed that no parenting behaviors moderated the relation between child inhibited temperament and whether or not children were diagnosed with anxiety disorders. The consistent lack of evidence for this moderation may be due to various factors. First, it is more difficult to find significant effects for dichotomous outcomes and outcome measures with low variance. Thus, it was statistically more difficult to find an effect when outcomes were the presence or absence of an anxiety disorder or the number of anxiety disorders as compared to when outcomes were anxiety symptoms. Second, anxiety diagnoses are given based on meeting a certain amount of specific diagnostic criteria, thus creating a cutoff for anxiety symptoms. It may be that there were many children with subclinical symptoms in the non-anxiety disorder groups and many children with low levels of clinical symptoms in the anxiety disorder groups that were not qualitatively distinct from one another, and actually had similar levels of anxiety symptoms. Therefore, it may be that these diagnostic cutoffs masked potential moderating effects. Lastly, it may be that the relation between inhibition and anxiety disorder diagnoses is indeed not impacted by the contextual role of parenting, and operates independently of the parenting children receive.

Clinical Implications

The current review found some evidence that overcontrolling and overprotective parenting behaviors moderate the relation between child inhibited temperament and child social anxiety with a small to medium effect size. This finding suggests that prevention and intervention efforts should focus on decreasing parenting behaviors that promote child avoidance, in particular. Additionally, these interventions may be most important for children with high inhibited temperaments. There are numerous parenting interventions for child anxiety that are efficacious (Comer et al., 2019 ; Lebowitz et al., 2020 ; Smith et al., 2014 ), some of which target children with high inhibited temperament in particular (Bayer et al., 2011 ; Rapee, 2013 ). The current review provides support for implementing these interventions that target parenting behaviors, given evidence that without these avoidance-promoting behaviors, the positive relation between inhibited temperament and social anxiety symptoms may be weakened.

Limitations of the Literature and Future Directions

There are various limitations of the current literature that highlight necessary future directions for the field. Primarily, the literature that prospectively assesses parenting as a moderator solely exists in Western countries with predominately White and middle-class samples. Therefore, the findings from the literature cannot be generalized to non-White or low-income individuals, and does not apply to non-Western contexts. Substantial research is needed in these samples in order to provide insight into how child temperament and parenting interact in the trajectory to anxiety development in these populations. Further, culture is complex and nuanced and cannot be captured in its entirety by quantitative measures of demographic characteristics such as race, ethnicity, or socioeconomic status. For instance, a child’s neighborhood, school, peers, and family environment all play a role in their cultural values, beliefs, and context. Future quantitative and qualitative research investigating specific cultural factors and their relation to this moderation are needed.

There were also methodological limitations to the literature. The studies in the current review had decent sample sizes ranging from 117 to 293 participants. However, it is difficult to find significant effects in longitudinal studies, and even more difficult to find significant interaction effects longitudinally. Therefore, it may be that many of these studies did not have sufficient power to detect an interaction effect. Further research with larger sample sizes will strengthen the evidence for this moderation and help determine the size of its effect. It is also important to consider the methodological rigor and the quality of included studies. Half of the included studies were considered high quality with low risk of bias across the areas of participants, measures, statistics, and reporting, whereas the other half were considered to have a higher risk of bias and lower quality. It may be that the findings of the current review would differ if there were more studies with low risk of bias. For example, the findings for control-related parenting behaviors moderating the relation between inhibition and other anxiety symptoms became more ambiguous when only high-quality studies were considered. Therefore, further high-quality studies with rigorous methodology and reporting are needed to further elucidate this moderation. Some considerations for improving the quality and rigor of studies include reporting the correlation between child temperament and parenting behavior and assessing for differences between participants who were retained and those who were lost to follow-up. Four of the ten included articles in the current review did not report these correlations, and therefore, it cannot be confirmed that their analyses conformed to the typical assumption of moderation analyses. Additionally, four of the ten included articles did not assess for differences between these participants.

The literature is also limited by the way in which parenting is measured. Most of the included articles only assessed parenting at one time point using one method (i.e., observation only, self-report only). Additionally, many of the observational measures were brief in nature (e.g., 3 min). Multimethod assessment for longer periods of time and at multiple timepoints might better capture caregivers’ parenting behaviors. Further, there is minimal research on the stability of parenting behaviors across child development (Verhoeven et al., 2007 ). If parenting behaviors change across development, then results regarding parenting as a moderator of the relation between inhibited temperament and child anxiety may also differ if parenting is measured over time versus at one timepoint. Future research would benefit from more comprehensive, longitudinal assessments of parenting behavior.

An additional limitation in the current literature is a primary focus on mothers. Seven of the ten included articles assessed maternal parenting behavior only. Although mothers are important caregivers to investigate, there are many other caregivers who have an important impact on child development. Future research should assess the moderation of interest in alternative caregivers, such as fathers, grandparents, and foster parents to elucidate the trajectory to child anxiety development in these families.

Another limitation of the literature is an emphasis on a diathesis-stress framework for understanding the roles of child inhibited temperament and parenting behavior. Most of the articles in the current review (nine out of ten) studied the moderation analysis within the context of a diathesis-stress model. In other words, these nine studies considered inhibited temperament to be a risk factor for worse anxiety outcomes when in the presence of maladaptive parenting behaviors. Only one study, Majdandžić et al. ( 2018 ), also considered that inhibited temperament may function within alternative moderation models in addition to a diathesis-stress model, such as a vantage-sensitivity or differential susceptibility model. Notably, Majdandžić et al. ( 2018 ) were one of only three articles that assessed a form of parental encouragement, which has been shown to serve an adaptive function for children with high inhibited temperaments (McLeod et al., 2007 ). Given that most of the articles in this review operated within a diathesis-stress framework, the potential role of child inhibited temperament as a protective or susceptibility factor may have been overlooked and thus not adequately assessed. Future research should consider these alternative models and assess the moderating role of adaptive parenting behaviors, in addition to maladaptive parenting behaviors, in the relation between child inhibited temperament and child anxiety.

The literature would also benefit from more comprehensive models of the developmental pathway to child anxiety, including other known correlates of inhibited temperament and anxiogenic parenting behavior, such as parental anxiety and cognitions (Borelli et al., 2015 ; Feinberg et al., 2018 ; Jones et al., 2021 ). Research has indicated that mothers with higher anxiety engage in more overprotective parenting behavior (Jones et al., 2021 ) and that parental negative beliefs about child anxiety relate to anxiogenic parenting behavior (Feinberg et al., 2018 ). Further, anxious parents are more likely to have children with anxiety, suggesting genetic and biological correlates that may influence the developmental pathway to child anxiety (Perlman et al., 2022 ). Future research with larger samples could examine a larger model in which child inhibited temperament and parental anxiety, beliefs, and behaviors are all included as contributors to child anxiety development.

The final limitation in the current literature is the relatively small number of studies that assess parenting as a moderator in the longitudinal relation between inhibited temperament and child anxiety. The current review assessed all relevant research, and only ten articles met criteria for inclusion in the review. Further research assessing affect- and control-related parenting behaviors as moderators in the relation between inhibited temperament and anxiety is needed to confirm the findings of the current review and expand upon the current understanding of this moderation.

Limitations of the Current Review

The current review is impacted by various limitations. First, the current review only assessed published journal articles, and thus did not include dissertations or unpublished results. Given the publication bias toward significant findings, the evidence found for avoidance-promoting parenting behaviors moderating the relation between child inhibited temperament and child social anxiety with a small to medium effect may be weaker than suggested in the current review. Second, the current review solely assessed study findings qualitatively. Future meta-analytic research may provide more quantitative insight into the strength of this moderation effect and how the effect differs across various demographic and sample characteristics. Third, the current review included three articles that used the same sample. Thus, this sample was overrepresented, and it is possible that there are unique characteristics of this sample that were overrepresented in the findings of the current review.

The current review systematically assessed the strength of the evidence for parenting moderating the relation between child inhibited temperament and child anxiety. There was some evidence that overprotective and overcontrolling parenting behaviors moderate the relation between child inhibited temperament and child social anxiety symptoms with a small to medium effect size. There was a consistent lack of evidence that parenting moderated the relation between child inhibited temperament and anxiety disorders and that parental negativity and expressed anxiety moderated the relation between child inhibited temperament and non-social anxiety symptoms. There was mixed evidence regarding the moderating role of control-related parenting behaviors in the relation between child inhibited temperament and non-social anxiety symptoms. Future research is needed to clarify these nuanced and inconsistent findings.

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Published: 13 June 2024

Effectiveness of home treatment in children and adolescents with psychiatric disorders—systematic review and meta-analysis

Daniel Graf 1 ,
Christine Sigrist 2 ,
Isabel Boege 3 ,
Marialuisa Cavelti 1 ,
Julian Koenig 2 &
Michael Kaess 1 , 4

BMC Medicine volume 22 , Article number: 241 ( 2024 ) Cite this article

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Home treatment in child and adolescent psychiatry offers an alternative to conventional inpatient treatment by involving the patient’s family, school, and peers more directly in therapy. Although several reviews have summarised existing home treatment programmes, evidence of their effectiveness remains limited and data synthesis is lacking.

We conducted a meta-analysis on the effectiveness of home treatment compared with inpatient treatment in child and adolescent psychiatry, based on a systematic search of four databases (PubMed, CINAHL, PsychINFO, Embase). Primary outcomes were psychosocial functioning and psychopathology. Additional outcomes included treatment satisfaction, duration, costs, and readmission rates. Group differences were expressed as standardised mean differences (SMD) in change scores. We used three-level random-effects meta-analysis and meta-regression and conducted both superiority and non-inferiority testing.

We included 30 studies from 13 non-overlapping samples, providing data from 1795 individuals (mean age: 11.95 ± 2.33 years; 42.5% female). We found no significant differences between home and inpatient treatment for postline psychosocial functioning (SMD = 0.05 [− 0.18; 0.30], p = 0.68, I 2 = 98.0%) and psychopathology (SMD = 0.10 [− 0.17; 0.37], p = 0.44, I 2 = 98.3%). Similar results were observed from follow-up data and non-inferiority testing. Meta-regression showed better outcomes for patient groups with higher levels of psychopathology at baseline and favoured home treatment over inpatient treatment when only randomised controlled trials were considered.

Conclusions

This meta-analysis found no evidence that home treatment is less effective than conventional inpatient treatment, highlighting its potential as an effective alternative in child and adolescent psychiatry. The generalisability of these findings is reduced by limitations in the existing literature, and further research is needed to better understand which patients benefit most from home treatment.

Trial registration

Registered at PROSPERO (CRD42020177558), July 5, 2020.

Peer Review reports

Most mental disorders have their onset in childhood or adolescence [ 1 , 2 ], with global point prevalence estimates at nearly 14% in this young population [ 3 ]. Recent research suggests that the global COVID-19 pandemic in early 2020 has contributed to an increase in the prevalence of affective, eating, and anxiety disorders, as well as in emergencies involving self-harm [ 4 , 5 , 6 , 7 ]. Simultaneously, the pandemic has increased the media presence of mental health in young people, reducing the stigma associated with mental disorders [ 8 ] and promoting more positive attitudes toward seeking professional help [ 9 ]. Both of these factors contribute to growing waiting lists for admission to inpatient treatment (IT) [ 10 , 11 , 12 ], exacerbating a long-standing problem in child and adolescent psychiatry [ 13 , 14 ].

Home treatment (HT) is not new to the field of child and adolescent psychiatry but is becoming increasingly important to address these challenges promising a possible alternative to IT that can be more rapidly implemented and scaled up. Different to IT, the young patients remain in their home environment and are visited on a frequent and regular basis by a multi-professional treatment team, including child and adolescent psychiatrists and psychotherapists, social workers, and nursing staff. The close involvement of the patient’s family, school, and the broader social environment (e.g. peers) in therapy allows problems to be observed and addressed where they arise, holding the potential to increase sustainability of treatment effects and reduced readmission rates [ 15 , 16 ]. Furthermore, HT has been suggested to be more cost-effective than IT [ 17 ], supported by two studies in the general child and adolescent psychiatry using acceptability curves based on QALYs [ 18 ] and the incremental cost-effectiveness ratios (ICER) based on changes in the psychosocial functioning [ 19 ]. Consequently, HT could allow treatment to be offered to a greater number of patients at the same cost.

These considerations of HT, its rationale, and implementation in general psychiatry date back to the 1960s [ 20 ]. In child and adolescent psychiatry, HT programmes were implemented as early as the 1970s and 1980s in the USA [ 21 ] and Europe [ 22 ]. Further clinical trials followed over the last four decades and several reviews were published, providing an overview of the consistently growing body of literature [ 23 , 24 , 25 , 26 , 27 , 28 ]. These reviews highlight the potential of HT as a promising alternative to IT; however, their conclusions are limited by the sparse underlying evidence and the small study samples. In addition, to the best of our knowledge, no meta-analysis of trials examining the effectiveness of HT in child and adolescent psychiatry has been conducted, as done previously for adult psychiatry [ 29 , 30 ].

To close this gap, we updated the most recent literature searches on this topic in 2020 [ 23 , 27 ] and conducted a meta-analysis to investigate the effectiveness of HT as an alternative to IT for children and adolescents with mental disorders. In addition, we sought to explore patient subgroups that are more likely to benefit from HT, taking into account various demographic and contextual variables.

This systematic review and meta-analysis followed the PRISMA guidelines [ 31 ] (checklist in Additional file 1, pp. 2–4). The study protocol was registered at PROSPERO (registration CRD42020177558).

Search strategy and selection criteria

We systematically searched PubMed, CINAHL, PsychINFO, and Embase for relevant articles in April 2020, with two updates in December 2022 and December 2023 (search strategy detailed in Additional file 1, Table S2). Additionally, we performed manual backward and forward snowballing of the reference lists of included articles and contacted the authors of all included studies to inquire about other potential HT trials or experts in the field. We did not search grey literature or trial registries. One rater (DG) screened titles and abstracts for inclusion/exclusion criteria, followed by full-text screening, using the Rayyan web application for systematic reviews [ 32 ]. To test robustness of the screening process, a random 10% sample of identified records was screened by a second rater (SE). The decisions for inclusion or exclusion were in complete agreement. Full texts were obtained online, through interlibrary loan [ 33 ], and from antiquarian bookshops [ 22 , 34 ]. The inclusion criteria were as follows: empirical clinical trials published in English- or German-language journals or books; intervention: HT equivalent to IT and presence of a control group receiving IT or equivalent care; population: patients with psychiatric diagnoses; mean age ≤ 21 years. Non-randomised controlled trials (nRCTs) were included due to the previously reported paucity of randomised controlled trials (RCTs) in this research area [ 24 ] and concerns about the generalisability of RCTs to real-world contexts [ 30 ].

Experimental and control treatment

Although recent literature provides more clarity and consensus regarding the nature and scope of intensive community care services [ 35 ], “home treatment” was often used in the past (and still is used) as an umbrella term for treatments delivered in a home-based setting, including supported discharge service (SDS) [ 36 ], Home-Based Crisis Intervention (HBCI) [ 37 ], Multisystemic Therapy (MST) [ 38 ], and others [ 30 ]. In the present study, we defined HT as an intensive psychiatric treatment delivered in a home-based setting that was intended to entirely replace or shorten an inpatient stay (“equivalent” to IT) [ 30 , 39 ]. Treatment programmes with different names that met the above criteria were considered HT (e.g. MST as an alternative to hospitalisation) [ 38 ]. The key element of all HT programmes was that they offered treatment outside of the clinic, which would have been the alternative treatment. Therapy sessions were primarily conducted at the patient’s home but additional options such as school visits or assistance with daily activities like using public transport or grocery shopping were often available. Presence of day services such as day clinic or group therapy carried out in the clinic was no criterion for excluding a HT programme, provided the majority of the treatment took place in the home environment. We defined IT as treatment delivered in a hospital ward or similar institutional setting, including residential care [ 40 ].

Choice of primary and secondary outcome

The primary outcomes were psychosocial functioning and psychopathology. These outcomes are considered relevant for daily life functioning, also from the perspective of youth with lived experience [ 41 ], and sensitive to changes over the course of treatment. Secondary outcomes included treatment cost, duration, and satisfaction. Where appropriate, we combined similar outcome measures from different instruments and studies (e.g. different instruments assessing “psychosocial functioning”). Details on the grouping of instruments are provided in the Additional file 1 (pp. 5–7). Outcome measures were categorised according to their source of information (clinician-rated, self-rated, parent-rated).

Data extraction and processing

Two reviewers (DG and SO) independently extracted information about the treatments (description, duration, intensity), study population (sample size, dropouts, age and sex distribution, primary psychiatric diagnoses), study design (randomisation, timing of endpoints), and outcome measures for each group and time of assessment (i.e. n , M , SD/var ). If relevant data was not reported in the studies, we contacted the authors to obtain the information (response rate: 50%) or derived it by calculation of other data reported in the article (Additional file 1, p. 8).

Risk of bias assessment

We assessed the methodological risk of bias using the “Cochrane Collaboration Risk of Bias 2.0” (ROB2) [ 42 ] for RCTs and the “Risk Of Bias In Non-randomised Studies—of Interventions” (ROBINS-I) [ 43 ] for nRCTs. RCTs were categorised as having low, medium, or high risk of bias based on the following criteria: randomisation process, deviations from planned interventions, missing outcome data, outcome measurement, and selection of reported outcomes. nRCTs were classified as having low, moderate, serious, or critical risk of bias based on the following criteria: confounding, selection of study participants, classification of interventions, deviations from planned interventions, missing data, measurement of outcomes, and selection of reported results.

Calculation of effect size measures

We calculated the standardised mean difference (SMD) for each outcome as the effect size measure, comparing HT to IT based on the difference between baseline and (a) postline values or (b) follow-up values, if available. For RCT studies, we employed formulas proposed by Becker [ 44 ] and Carlson and Schmidt [ 45 ] as described in Morris [ 46 ] to estimate SMD ( d ppc ). Due to the common scenario of unknown correlation between pre- and post-treatment measures in meta-analysis, we assumed ρ = 0.50. For nRCT studies, meta-analytic procedures were adjusted to account for the precision of effect sizes. For each study, the difference between the sample means at post-treatment or follow-up was divided by the pooled standard deviation at baseline and corrected for small-sample bias [ 47 ]. The exact formulas were used in this calculation of Hedges’ g and corresponding standard errors [ 48 ]. Readmission rates reported as percentages were translated to a 2 × 2 frequency table, based on which respective log odds ratios were calculated [ 49 , 50 ]. For studies reporting mean readmissions, SMDs were calculated and converted into log odds ratios (e.g. [ 51 , 52 , 53 , 54 ]), which were back-transformed into regular odds ratios (OR) for better interpretability after data synthesis. An OR above 1 indicated a higher rate of readmission after IT compared to HT, whereas an OR below 1 indicated the opposite.

Data synthesis

In most cases, effect sizes were nested within clusters of individual study samples based on rater perspective and time of assessment. That is, separate meta-analyses were conducted for post-treatment and follow-up effects. Clustering was specified for rater perspective for primary outcomes and treatment satisfaction, and for time of measurement for treatment costs. Three-level random-effects meta-analytical models [ 55 ], which allow effect sizes to vary between participants (level 1), outcomes (level 2), and studies (level 3) [ 56 ], were used to synthesise the cluster effects. We used inverse variance weighting and a restricted maximum likelihood estimator (REML) to estimate level 2 and level 3 τ 2 values. Heterogeneity was assessed using a generalised/weighted least squares extension of Cochran’s test [ 57 ]. For the synthesis of the treatment duration data, a conventional (two-level) meta-analytical model was used given the lack of clustering in these data. Inverse variance weighting and REML were used to estimate level 2 τ 2 . Confidence intervals for individual studies and tests of individual coefficients and confidence intervals were calculated based on a t -distribution (with degrees of freedom), such that the omnibus test used an F -distribution [ 58 ]. Forest plots were used to visualise meta-analytical summary models for outcome, and funnel plots were used to visually explore asymmetry. We conducted data analysis using the R-packages “meta” and “metafor” [ 57 , 59 ].

Moderator analyses

Meta-regression analyses were conducted to separately examine the potentially moderating effects of various factors on the effectiveness of HT compared with IT, including mean age (in years), sex (% female), mean duration of treatment (in days), study design (RCT vs. nRCT), type of HT (adjunctive to IT vs. substitute for IT), and presence of day services (provided during HT vs. not provided). Baseline scores of the primary outcomes were considered both as pooled mean scores to test whether generally higher or lower levels influenced post-treatment outcomes and as the difference in means (Δ = M HT − M IT ) to account for differences between groups at the onset of treatment, which can be expected particularly in nRCTs. Multivariate meta-analytical models tested continuous and categorical moderators using an omnibus test ( QM test) [ 57 ]. If a particular moderator was missing, the corresponding study was excluded from the meta-regression analyses. It is important to note that the meta-regression analyses are exploratory in nature and that the results should be interpreted with caution due to the potential for overfitting when the number of studies per covariate examined is small [ 60 ]. For the same reason, meta-regression analysis was conducted only for the primary outcomes of psychosocial functioning and psychopathology.

Objective non-inferiority assessment of primary outcomes

Considering that HT as a “novel” treatment is unlikely to be superior to IT from a real-world clinical perspective, we additionally conducted non-inferiority testing in the meta-analyses of primary outcomes as proposed by Trone et al. [ 61 ]. Non-inferiority testing evaluates whether a novel treatment is not worse than the comparator by the degree of “acceptable inferiority”, defined by the non-inferiority margin (∆) based on the reported effect of the active comparator. First, the effect size and corresponding 95% confidence interval (CI) of the active comparator versus an untreated control group (SMD Inptr ) were determined. Given the lack of evidence in the literature (i.e. no existing meta-analysis examined the efficacy of IT vs. untreated control), we performed an additional systematic search (detailed in Additional file 1, pp. 9–10) to obtain the effect size (95% CI) of IT for each primary outcome. We defined 50% and 95% as the percentage (alpha) of the effect of IT to test whether the effect was maintained with HT. ∆ was calculated using SMD Inptr and the upper bound of the 95% CI of SMD Inptr , respectively (with the latter being the more conservative approach to calculating an objective non-inferiority margin). After calculating ∆, we compared the 95% CI of the summary effect size of HT versus IT for primary outcomes obtained from meta-analysis of the respective RCTs, with the non-inferiority margin (∆). To demonstrate non-inferiority, the 95% CI of the HT vs. IT comparison should fall entirely on the left (negative) side of ∆.

Our search strategy yielded a total of 4072 unique records from the original search (04/2020) and 1735 additional from two literature update (12/2022 and 12/2023). The PRISMA flowchart in Fig. 1 summarises the selection procedure, which resulted in the inclusion of 28 articles and two books. These 30 publications reported relevant data from 13 non-overlapping samples comprising 1795 individuals (average baseline age: 11.95 ± 2.33 years; 42.5% female).

PRISMA flowchart of the systematic search

All included trials are summarised in Table 1 . They were conducted in Europe ( k = 8, 61.5%), the USA ( k = 3, 23.1%), and Canada ( k = 2, 15.4%). The majority of the trials used HT to entirely replace IT ( k = 9, 69.2%) and assigned patients randomly to the treatment groups ( k = 8, 61.5%). Risk of bias assessments showed moderate-to-high risk for most RCTs and all nRCTs (Additional file 1, Figures S2 and S3).

Psychosocial functioning

For the primary outcome of psychosocial functioning, we excluded one study [ 21 ] from the analysis, because the outcomes for the two treatment groups were assessed by two independent rater groups that differed substantially in their ratings. The forest plot in Fig. 2 shows the individual and summary effect size estimates. The final pooled effect size of postline assessments ( n = 9 studies, k = 15 estimates, N = 1722) was SMD = 0.02 [95% CI, − 0.20 to 0.25], p = 0.83. Overall heterogeneity was substantial, with I 2 = 98.1% ([95% CI, 97.6% to 98.5%], Q 14 = 751.48, p < 0.001). Visual inspection of the corresponding funnel plots (Additional file 1, Figure S4) suggested the presence of small study bias and one clear outlier [ 16 ]. The meta-regression analyses did not identify any significant moderators (Additional file 1, Table S7).

Differences in pre- to post-treatment effects in psychosocial functioning scores. SMD, standardised mean difference; CAFAS, Child and Adolescent Functioning Assessment Scale; CBCL, Child Behaviour Checklist; CGAS, Children’s Global Assessment Scale; CIS, Columbia Impairment Scale; RPC, rating of psychosocial competency; SGKJ, global assessment scale for children and adolescents (“Skala zur Gesamtbeurteilung von Kindern und Jugendlichen”); SSRS, Social Skills Rating System; YSR, Youth Self-Report

For follow-up assessments ( n = 5 studies, k = 7 estimates, N = 516), the pooled effect size was SMD = − 0.15 [95% CI, − 0.39 to 0.09], p = 0.23 (Additional file 1, Figure S5). Overall heterogeneity was substantial, with I 2 = 95.0% ([95% CI, 91.9% to 96.9%], Q 6 = 119.75, p < 0.001). Sensitivity analyses by type of design did not alter these results (Additional file 1, Figures S6–S8).

Psychopathology

Regarding the primary outcome of psychopathology, we excluded one study [ 78 ] from the data synthesis, because the data from this study was compared to that of another study conducted years earlier with a different sample [ 79 ]. Prior to the exclusion of this study, overall quality/risk of bias was identified as a significant moderator of the summary effect size, which was no longer the case after this study was excluded, suggesting that it introduced bias into the respective meta-analysis. The forest plot in Fig. 3 illustrates the individual and summary effect size estimates. The resulting pooled effect size of postline assessments ( n = 10 studies, k = 19 estimates, N = 1629) was SMD = 0.01 [95% CI, − 0.17 to 0.37], p = 0.48. Overall heterogeneity was substantial, with I 2 = 98.3% ([95% CI, 98.0% to 98.6%], Q 19 = 1083.61, p < 0.001). Visual inspection of the corresponding funnel plots (Additional file 1, Figure S4) suggested no clear study bias, but the presence of one outlier [ 21 ].

Differences in pre- to post-treatment effects in psychopathology. SMD, standardised mean difference; AFS, anxiety questionnaire for pupils (“Angstfragebogen für Schüler”); BRS, Conners Behaviour Rating Scale; CBCL, Child Behaviour Checklist; CGI-I, Clinical Global Impression—Improvement scale; GSI-BSI, Global Severity Index of the Brief Symptom Inventory; HoNOSCA, Health of the Nations Outcome Scale for children and adolescent; MEI, Mannheim Parents Interview (“Mannheimer Eltern Interview”); MSS, Marburg Symptom Scale; SCIS, Standardised Client Information System; SDQ, Strength and Difficulties Questionnaire; TRF, Teacher Report Form

Meta-regression analyses showed that differences in mean scores at baseline ( k = 19, β = − 0.10, [95% CI, − 0.16 to − 0.05], SE = 0.03, p < 0.001) and the study design ( k = 19, β = − 0.64, [95% CI, − 1.21 to − 0.07], SE = 0.29, p = 0.03) significantly moderated the individual effect size estimates. On average, effect sizes increased for patient groups with higher levels of psychopathology at baseline (relative to the other group, see Fig. 4 ) and tended to favour HT over IT when only RCTs were considered (Additional file 1, Table S7).

Meta-regression scatterplot showing the association between baseline differences in means in psychopathology and standardised mean differences (SMD) at postline. Positive delta scores indicate higher baseline psychopathology in the HT group compared to the IT group; negative SMD favour HT at postline

For follow-up assessments, the pooled effect size ( n = 7 studies, k = 9 estimates, N = 749) was SMD = 0.05 [95% CI, − 0.18 to 0.27], p = 0.69 (Additional file 1, Figure S9). Overall heterogeneity was substantial, with I 2 = 95.8% ([95% CI, 93.8% to 97.2%], Q 8 = 192.09, p < 0.001).

Notably, one study [ 37 ] compared HT with another alternative for IT (“Crisis Case Management”), which met the formal inclusion criteria but differed substantially from the control condition we intended for comparison as no inpatient or residential care was involved. A sensitivity analysis excluding this study showed negligible differences from the overall meta-analysis (Additional file 1, Figures S10 and S11), as did a sensitivity analysis considering only RCTs (Additional file 1, Figures S12 and S13). When considering only nRCTs, the resulting pooled effect size of postline assessments ( n = 2 studies, k = 3 estimates, N = 304) was SMD = 0.62 [95% CI, 0.29 to 0.96], p = 0.002 ( I 2 = 90.7%, [95% CI, 75.7% to 96.5%], Q 2 = 21.55, p < 0.001; see Additional file 1, Figure S14); the result for follow-up outcomes did not change (Additional file 1, Figure S15).

Secondary outcomes

Regarding the treatment satisfaction, the pooled effect size ( n = 4 studies, k = 7 estimates, N = 529) was SMD = 0.08 [95% CI, − 0.70 to 0.86], p = 0.84. Overall heterogeneity was substantial, with I 2 = 99.0% ([95% CI, 98.7% to 99.3%], Q 6 = 606.61, p < 0.001).

For treatment duration, the pooled effect size ( n = 5 studies, N = 491) was SMD = − 1.73 [95% CI, − 3.92 to 0.46], p = 0 . 12. Overall heterogeneity was substantial, with I 2 = 99.7% ([95% CI, 99.6% to 99.8%], Q 4 = 1356.38, p < 0.001).

Regarding treatment costs, the pooled effect size ( n = 2 studies, k = 3 estimates, N = 290, one study [ 68 ] was not considered due to inconsistent reporting) was SMD = − 1.55 [95% CI, − 4.56 to 1.46], p = 0.313. Overall heterogeneity was substantial, with I 2 = 99.9% ([95% CI, 99.8% to 99.9%], Q 4 = 1559.47, p < 0.001).

For readmission rates, the pooled effect size ( n = 3 studies, k = 3 estimates) was OR = 1.27 (95% CI, 0.74 to 2.18, p = 0.39) with no significant heterogeneity observed ( I 2 < 0.01%, Q 2 = 1.60, p = 0.45). Forest plots for all secondary outcomes are provided in Additional file 1, Figures S16–S19.

Non-inferiority testing

The systematic search for the efficacy of conventional IT for youth with mental disorders yielded two studies [ 82 , 83 ]. The resulting SMD was 0.64 [95% CI, 0.60 to 0.68] for psychosocial functioning ( n = 1 study, k = 1 estimate, N = 150) and 0.27 [95% CI, 0.08 to 0.46] for psychopathology ( n = 1 study, k = 2 estimates, N = 132). The calculated objective non-inferiority margins for each primary outcome are shown in Table 2 , along with the SMD between HT and IT for each primary outcome based on RCT studies.

Evidence of non-inferiority of HT was obtained for both primary outcomes of psychosocial functioning and psychopathology. First, conventional IT resulted in a significant improvement in the primary outcomes compared with no treatment (waitlist controls). Second, regardless of the non-inferiority margin used (i.e. 50% or 95%; based on SMD Inptr or the respective upper bound of the 95% CI), HT appeared to be non-inferior to conventional IT. Figure S20 in Additional file 1 illustrates the results of the non-inferiority assessment and Figures S21 and S22 show the forest plots based on the non-inferiority analysis.

The aim of this meta-analysis was to synthesise the existing data on the effectiveness of HT as an alternative to IT for youth with mental disorders. Based on a comprehensive synthesis of 30 articles (18 providing relevant data) derived from 13 non-overlapping samples with a total of 1795 individuals, we examined differences in treatment outcomes including potential moderators.

Our analyses for both superiority and non-inferiority testing showed no significant postline differences between patients who received HT and those who received IT with respect to the primary outcomes psychosocial functioning and psychopathology. This finding is consistent with conclusions drawn in several previous reviews of the existing data, suggesting that HT is generally not less effective than conventional IT [ 24 , 27 , 28 ].

The mean difference between groups at baseline was identified as a significant moderator of post-treatment psychopathology: on average, patient groups with higher levels of psychopathology at baseline (relative to the other group) showed greater improvements in the postline outcome (expressed as a higher SMD). Both IT and HT appear to be particularly effective for patients with severe psychopathological burden, for whom both services are designed. Alternatively, this effect may also reflect a regression to the mean as patients presenting with higher levels of psychopathology at baseline presumably had greater potential for improvement during treatment compared to those with lower baseline levels. Study design moderated post-treatment psychopathology, with effect sizes favouring HT over IT when only RCTs were considered and sensitivity analysis with only nRCTs showed significantly better psychopathology outcomes at postline for IT. This emphasises the importance of using rigorous methodological approaches in evaluation studies. In RCTs, treatments are usually delivered according to a strict protocol, ensuring high treatment fidelity. HT, as implemented in RCTs, might be more standardised and thus more effective compared to more variable programmes in less controlled study designs. Besides, patients who participated in RCTs may have hoped to be assigned to the HT group. Their disappointment when randomised to the control group may have affected their expectations of treatment, which has been associated with negative treatment outcome [ 84 ]. However, given the modest number of studies included in the meta-regression analyses and their exploratory nature, these findings should be considered indicative rather than conclusive and should be interpreted with caution, highlighting areas where further research is needed to support them. Despite the expectation that HT would be less expensive because of the reduced reliance on clinic infrastructure and staff, we found no significant difference in treatment costs between HT and IT. Possible explanations include the hospitalisation of some patients during the course of the HT and the fact that certain HT programmes compensated for lower intensity with longer treatment duration. However, the total duration of treatment was not significantly different between the two modalities. Furthermore, and contrary to expectations, readmission rates after discharge did not differ significantly between the two treatment settings. These findings do not support the expectation that HT is a cheaper alternative and leads to fewer readmissions due to a better transfer of treatment gains after discharge in HT.

However, the conclusions drawn from these findings are limited by the small sample sizes, with only two studies included in the meta-analysis of treatment costs [ 18 , 19 ] and three studies in the meta-analysis of readmission rates [ 65 , 71 , 78 ]. A direct comparison of the overall cost-effectiveness of the two treatments was not possible due to insufficient data.

This meta-analysis adheres to several aspects of good practice, including the pre-registration of a review protocol, considerable effort to obtain all available data (including contacting interlibrary loan, antiquarian booksellers, and authors of all studies), double‐rated data extraction by two independent reviewers, and the use of objective non-inferiority testing for primary outcomes.

However, our findings should be viewed in the context of several limitations, concerning both our methodology and the existing body of literature. We found considerable statistical heterogeneity in all results, reflecting our broad interpretation of the term “home treatment”. In nine studies, HT completely replaced hospitalisation [ 16 , 21 , 22 , 37 , 38 , 40 , 70 , 77 , 80 ], while in the other four, it only reduced the length of hospital stay [ 18 , 62 , 78 , 81 ]. Moreover, while most studies strictly separated the home and clinical environments, some provided additional day services during HT. These included distinct treatment elements such as structured daily routines, group therapy and opportunities for bonding with other patients, which have also been reported as important in the treatment of children and adolescents with psychiatric disorders [ 85 , 86 ]. The intensity of HT also varied widely, ranging from a maximum of 12 h per week [ 80 ] to a minimum of one visit per month [ 81 ], and while most programmes addressed general psychopathology, two targeted specific diagnoses [ 33 , 78 ]. Inconsistencies between studies in the selected outcomes and the instruments used to measure them may have introduced additional heterogeneity into the results, as may the combination of RCTs and nRCTs, which could also have affected the overall null effect. Although we conducted sensitivity analyses by types of design, these results should be interpreted with caution due to the small number of studies per subgroup. Besides, the generally small number of individual studies for the meta-regression analyses should also be noted. Meta-regression models can be overfitted when the number of studies per covariate examined is small, which may lead to spurious associations between covariates and treatment effect due to data idiosyncrasies [ 60 ]. Thus, these analyses need to be considered exploratory and interpreted with caution. For psychosocial functioning, only nine studies were included, which is below the minimum of 10 as suggested in the Cochrane Handbook [ 87 ]. However, there is also evidence that the required number of observations per covariate in ordinary least squares linear regression might be considerably lower than 10 [ 60 ]. We chose to explore potential moderators for effect size in this outcome, as such analyses can provide important information about directions for future research.

In terms of the search strategy, restricting our search to PubMed, CINAHL, PsychINFO, and Embase may have led to the omission of some relevant studies. The search results were screened by a single rater only with a second-rater screening for a random 10% sample to test the robustness of the process. The decision for inclusion or exclusion was in complete agreement; however, this approach leaves an increased risk of overlooking relevant studies in the remaining search results.

Regarding the available evidence, the small number of eligible studies, many of which used small samples, limited the statistical power, especially for secondary outcomes not reported in all studies. This made it impossible to further specify the treatment characteristics of the included HT to reduce heterogeneity. The moderate to high risk of bias in twelve out of thirteen studies indicates an overall low study quality. Additionally, the diversity of the studies, spanning four decades and six countries (all located in Europe and North America) with different legal and financial frameworks, as well as varying IT quality, limits the generalisability of our findings to other healthcare systems. Most studies did not explore potential mechanisms underlying the effectiveness of HT, such as the involvement of the whole (family) system, and left open the question of which family situations and diagnostic patterns are more likely to benefit from HT.

To address these limitations and replicate the current findings, further research on HT in child and adolescent psychiatry, as well as meta-analysis of its results as more studies are published, is urgently needed. Future studies should consider some important aspects: to ensure standardised treatment designs in future studies, it is advisable to refer to current guidelines, such as the agreed minimum requirements proposed by Keiller et al. [ 35 ]. Moreover, we suggest focusing on a set of key constructs including psychosocial functioning, psychiatric symptoms, quality of life, family functioning, and patient satisfaction to streamline the diversity in outcome measures. For consistent and comparative measurement, researchers may consult current reviews of widely used, reliable and validated instruments (e.g. Kwan and Rickwood [ 88 ] or the International Consortium for Health Outcomes Measurements [ 89 ]). Cost-effectiveness of new programmes should not only consider direct treatment costs, but also subsequent psychiatric care, such as inpatient readmissions, emergency department visits, medication, and outpatient treatments post-discharge. Quantifying the contacts with patients, families, peers, and schools during the HT could help understanding the potential mechanisms underlying its effectiveness and to explore the influence of systemic and individual factors in presenting disorders. Our study also highlights the importance of stringent methodological designs in treatment evaluation. This involves the use of randomised control groups and assessments at multiple time points (pre-, post-treatment, and follow-up), executed by trained and blinded researchers. If randomisation is difficult to realise due to health economic factors like imbalances in treatment group capacities, adaptive randomisation plans might be considered.

However, adhering to these methodological standards often requires additional resources, such as research staff or strategies for handling patient allocation disparities. Therefore, we call upon policymakers to not only endorse future HT projects in clinical practice but also support their scientific evaluation.

In this meta-analysis, we found no evidence that HT is generally less effective than conventional IT. Both treatments appear to be particularly effective in patients with a high psychopathological burden, highlighting the potential of HT as an effective alternative to IT in child and adolescent psychiatry. However, the generalisability of these findings is restricted by various limitations in the existing literature, and several unanswered questions remain. Further research is needed to identify patients who are more likely to benefit from HT based on their family situation and diagnosis patterns.

Availability of data and materials

The underlying dataset and analysis code used in this article [ 90 ] are available without restrictions on the Open Science Framework (osf.io) and can be found here: https://doi.org/10.17605/OSF.IO/TFD2Q .

Abbreviations

Confidence interval

Home treatment

Home-based crisis intervention

Inpatient treatment

Multisystemic therapy

Non-randomised controlled trial

Preferred reporting items for systematic reviews and meta-analyses

Randomised controlled trial

Restricted maximum likelihood estimator

Cochrane collaboration risk of bias 2.0

Risk of bias in non-randomised studies – of interventions

Standard error

Standardized mean difference

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Acknowledgements

We wish to thank Roman Vifian, Sarah Oberli, Sarah Eggenschwiler (all B.Sc., University of Bern), and Amelie Graf (B.Sc., University of Ulm) for their assistance with the screening and data extraction process. Roxana Rothe (University Hospital Cologne) was a great help in screening the results of the systematic search for literature on the efficiency of inpatient treatment. All received compensation for their work. Additional thanks go to Dr Isabell Boege, Dr Dennis Ougrin, Dr Daniel Stahl, and Dr Beate Herpertz-Dahlmann for providing raw or missing data and to Dr Marlis Reimer and Dr Katja Becker for their effort in searching missing data to support this meta-analysis.

Open Access funding enabled and organized by Projekt DEAL. Marialuisa Cavelti is supported by a grant from the Swiss National Science Foundation (PZ00P1_193279/1). Open Access funding enabled and organized by Projekt DEAL.

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MK, JK, and DG conceptualised the study. CS, JK, and DG designed the methodology. DG collected the data. CS did the data analysis. DG prepared the original draft of the manuscript with the input of CS, MC, and IB and with supervision of MK and JK. All authors edited and reviewed the final manuscript. DG and CS had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors read and approved the final manuscript and had responsibility for the decision to submit for publication.

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12916_2024_3448_moesm1_esm.docx.

Supplementary Material 1: Table S1. PRISMA 2020 Checklist. Table S2. Detailed search strategy. Table S3-S5. Grouping of different instruments. Table S6. Listing of all data derived by calculation. Figure S1. Additional systematic search on the efficacy of Inpatient Treatment. Figure S2 & S3. Summary of the risk of bias of RCTs and nRCTs. Figure S4. Funnel plots of individual observed effect sizes. Table S7. Meta-regression results. Figure S5. Follow-up effects in psychosocial functioning. Figure S6-S8. Sensitivity analyses for psychosocial functioning, including only RCTs or nRCTs. Figure S9. Follow-up effects in psychopathology. Figure S10 & S11. Sensitivity analyses for psychopathology excluding the study of Evans et al. (2003). Figure S12-S15. Sensitivity analyses for psychopathology, including only RCTs or nRCTs. Figure S16-S19. Meta-analyses of secondary outcomes. Figure S20-S22. Meta-analyses based on non-inferiority assessments.

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Graf, D., Sigrist, C., Boege, I. et al. Effectiveness of home treatment in children and adolescents with psychiatric disorders—systematic review and meta-analysis. BMC Med 22 , 241 (2024). https://doi.org/10.1186/s12916-024-03448-2

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The psychological impact, risk factors and coping strategies to COVID-19 pandemic on healthcare workers in the sub-Saharan Africa: a narrative review of existing literature

Freddy Wathum Drinkwater Oyat 1 ,
Johnson Nyeko Oloya 1 , 2 ,
Pamela Atim 1 , 3 ,
Eric Nzirakaindi Ikoona 4 ,
Judith Aloyo 1 , 5 &
David Lagoro Kitara ORCID: orcid.org/0000-0001-7282-5026 1 , 6 , 7

BMC Psychology volume 10 , Article number: 284 ( 2022 ) Cite this article

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The ongoing COVID-19 pandemic has significantly impacted the physical and mental health of the general population worldwide, with healthcare workers at particular risk. The pandemic's effect on healthcare workers' mental well-being has been characterized by depression, anxiety, work-related stress, sleep disturbances, and post-traumatic stress disorder. Hence, protecting the mental well-being of healthcare workers (HCWs) is a considerable priority. This review aimed to determine risk factors for adverse mental health outcomes and protective or coping measures to mitigate the harmful effects of the COVID-19 crisis among HCWs in sub-Saharan Africa.

We performed a literature search using PubMed, Google Scholar, Cochrane Library, and Embase for relevant materials. We obtained all articles published between March 2020 and April 2022 relevant to the subject of review and met pre-defined eligibility criteria. We selected 23 articles for initial screening and included 12 in the final review.

A total of 5,323 participants in twelve studies, predominantly from Ethiopia (eight studies), one from Uganda, Cameroon, Mali, and Togo, fulfilled the eligibility criteria. Investigators found 16.3–71.9% of HCWs with depressive symptoms, 21.9–73.5% with anxiety symptoms, 15.5–63.7% experienced work-related stress symptoms, 12.4–77% experienced sleep disturbances, and 51.6–56.8% reported PTSD symptoms. Healthcare workers, working in emergency, intensive care units, pharmacies, and laboratories were at higher risk of adverse mental health impacts. HCWs had deep fear, anxious and stressed with the high transmission rate of the virus, high death rates, and lived in fear of infecting themselves and families. Other sources of fear and work-related stress were the lack of PPEs, availability of treatment and vaccines to protect themselves against the virus. HCWs faced stigma, abuse, financial problems, and lack of support from employers and communities.

The prevalence of depression, anxiety, insomnia, and PTSD in HCWs in sub-Saharan Africa during the COVID-19 pandemic has been high. Several organizational, community, and work-related challenges and interventions were identified, including improvement of workplace infrastructures, adoption of correct and shared infection control measures, provision of PPEs, social support, and implementation of resilience training programs. Setting up permanent multidisciplinary mental health teams at regional and national levels to deal with mental health and providing psychological support to HCWs, supported with long-term surveillance, are recommended.

Peer Review reports

Introduction

When coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020, healthcare workers (HCWs) globally and in sub-Saharan Africa (SSA) were unprepared for the scale of the physical and mental health devastation that was to follow [ 1 ]. The impact of the COVID-19 pandemic on healthcare workers has been profound, characterized by death, disability, and untenable burden on mental health and well-being [ 2 ]. Factors impacting their mental health include high risks of exposure and infection, financial insecurity, separation from loved ones, stigma, difficult triage decisions, stressful work environment, scarcity of supplies including personal protective equipment (PPEs), exhaustion, traumatic experiences due to regular witnessing of deaths among patients and colleagues [ 2 , 3 ]. Greenberg et al. [ 4 ] observed that the COVID-19 pandemic put healthcare professionals worldwide in an unprecedented situation, making difficult decisions to provide care for many severely ill patients with constrained or inadequate resources.

In almost all WHO regions, data indicates that infection rates among healthcare workers are higher than in the general population [ 5 ]. Scholars suggest that the end of the COVID-19 pandemic is not yet in sight. Neither are they sure about the virulence of the following variant when it appears as caseloads are still rising, with more than 621 million infections and 6.5 million deaths reported worldwide by 19th October 2022 [ 6 ]; mainly driven by the newer omicron variants. However, recently in October 2022, we received with gratitude a reassuring message from US President Biden declaring the end of the COVID-19 pandemic in the United States of America.

Meanwhile, previous studies found high levels of depression, anxiety, and PTSD in survivors among the general population and healthcare workers (HCWs) one-to-three years after the control of the SARS epidemic [ 7 ] and the 2014–2016 Ebola epidemic in West Africa [ 8 ]. In addition, recent surveys [ 9 , 10 , 11 , 12 , 13 , 14 ], reviews, and meta-analyses [ 15 , 16 , 17 , 18 ] are pointing to early evidence that a considerable proportion of healthcare workers have experienced stress, anxiety, depression, and sleep disturbances during the COVID-19 pandemic, raising concerns about risks to their long-term mental health.

Studies from the global north countries [ 19 , 20 ], UK [ 21 ], USA [ 22 ], and in India [ 23 ], and China [ 24 , 25 ] have shed light on the vulnerability that characterizes frontline healthcare workers during this pandemic, especially regarding their mental health and well-being. However, evidence in sub-Saharan Africa is scanty, and the pattern and prevalence of psychological disorders are not well understood.

Evidence from a systematic review by Pappa S et al. on 33,062 Chinese HCWs in April 2020 found a pooled prevalence rate of mental health problems among respondents; anxiety 23.2%, depression 22.8%, and insomnia 38.9% [ 26 ]. Similarly, Singapore study, Tan et al . [ 27 ], Li et al . [ 28 ], BMA [ 29 ] and in China [ 31 ] found high levels of psychological disorders among health workers.

Since the beginning of the pandemic, we found one systematic review involving 919 frontline HCWs, 3928 general HCWs, and 2979 medical students conducted in Africa from December 2019 to April 2020 [ 31 ]. The study by Chen J et al . reported a high prevalence of depression, anxiety, and insomnia among frontline HCWs in sub-Saharan Africa (SSA) at 45%, 51%, and 28%, respectively. In comparison, the prevalence of depression, anxiety, and insomnia among the general population was much lower at 30%, 31%, and 24%, respectively [ 31 ]. Furthermore, we found that only a few studies investigated protective and coping measures, given the many uncertainties surrounding the evolution of the COVID-19 pandemic [ 32 ]. Adequate data are needed to equip frontline HCWs and healthcare managers in sub-Saharan Africa to mitigate the medium and long-term adverse effects of the COVID-19 pandemic [ 33 ].

This review aimed to answer three questions (1) What is the psychological impact of the COVID-19 pandemic on HCWs in Sub-Saharan Africa?

(2) What are the associated risk factors during the COVID-19 pandemic?

(3) What interventions (mitigating and coping strategies) protect and support the mental health and well-being of HCWs during the ongoing crises and after the pandemic?

Methodology

Search methodology and article selection.

This current article is a mixed-method narrative review of existing literature on mental health disorders, risk factors, and interventions relevant to the COVID-19 pandemic on HCWs in sub-Saharan. A search on the PubMed electronic database was undertaken using the search terms "novel coronavirus", "COVID-19", "nCoV", "mental health", "psychiatry", "psychology", "anxiety", "depression" and "stress" in various permutations and combinations.

Search processes

We conducted a comprehensive literature search on original articles published from March 2020 to 30 April 2022 in electronic databases of Embase, PubMed, Google Scholar, and the daily updated WHO COVID-19 database. Our search terms included but were not limited to ('COVID-19'/exp OR COVID-19 OR 'coronavirus'/exp OR coronavirus) AND ('psychological'/exp OR psychological OR 'mental'/exp OR mental OR 'stress'/exp OR stress OR 'anxiety' OR anxiety OR 'depression' OR depression OR 'post-traumatic' OR 'post-traumatic'/exp OR 'trauma' OR 'trauma'/exp) OR Health care workers, medical workers of health care professionals, sub-Saharan Africa, for Embase. ("COVID-19" [All Fields] OR "coronavirus" [All Fields]) AND ("Stress, Psychological" [Mesh] OR "mental" OR "anxiety" OR "depression" OR "stress" OR "post-traumatic" OR "trauma") for PubMed, for the WHO COVID-19 database, and ("COVID-19" OR "coronavirus") AND ("Psychological" OR "mental" OR "anxiety" OR "depression" OR "stress" OR "post-traumatic" OR "trauma") for Google Scholar. On reviewing the above citations, twelve articles met the inclusion criteria relevant for this review and are in Table 1 . All twelve articles were cross-sectional, with one qualitative and the others quantitative observational studies.

Eligibility criteria

We included original qualitative and quantitative studies examining the risk factors, psychological impact of COVID-19 and coping strategies of healthcare workers (HCWs) in sub-Saharan Africa during the COVID-19 pandemic. We excluded studies if they were.

1. Not reported in the English language 2. Studies which were not primary research 3. Studies that had not been published in a peer-reviewed journal 4. Studies that did not include data on HCWs’ mental health or psychological well-being 5. Duplicate studies 6. not using validated instruments to measure the risks and psychological impact.

FWDO performed the search of articles. DLK reviewed the articles involving screening of titles, followed by examination of abstracts. The potential articles identified were further reviewed in full text to examine their eligibility. In addition, four of the authors independently reviewed the full articles to abstract the relevant data required for the review. Thereafter, a meeting to harmonise findings were done and presented in a report.

Data extraction and appraisal of the study

We extracted information from each study, including author, study population, year of publication, country, socio-demographic characteristics, sample size, response rate, gender proportion, age, and study time, areas assessed, the validated instrument used and the prevalence. The appraisal involved assessing the research design, recruitment of respondents, inclusion and exclusion criteria, reliability of outcome determination, statistical analyses, ethical compliance, strengths, limitations, and clinical implications of the articles.

Our review protocol was not registered on PROSPERO because of the significant variation in the methodologies of the articles used in the review. The results precluded using a meta-analytic approach and made a narrative review the most suitable for this work. In addition, we did not use the Cochrane Collaboration GRADE method to assess the quality of evidence of outcomes included in this narrative review. Instead, we used the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) 22 items checklist to gauge the quality of the twelve articles included in this review. We qualitatively validated the articles based on additional considerations namely study design, sample sizes, sampling procedures, response rates, statistical methods used, measures taken by the authors to deal with bias and confounding factors and ethical consideration.

Definition of healthcare worker (HCW)

For this narrative review, we adhered to the Centres for Disease Control and Prevention (CDC) definition of HCWs, which includes physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, pharmacists, hospital volunteers, and administrative staff [ 34 ].

Search results

The search found twenty-three studies of interest. Full texts of potentially relevant studies underwent eligibility assessment, and twelve articles met the inclusion criteria for this narrative review.

Study characteristics

The twelve articles comprised eleven quantitative and one qualitative study. The common mental health conditions assessed were depression, anxiety, perceived stress, and post-traumatic stress disorder (PTSD). The coping strategy, perceived health status, health distress (including burnout), insomnia, and perceived stigma were also assessed [ 35 , 36 ]. The total number of respondents in these studies was 5,323. The qualitative study had fifty respondents [ 35 ], while the most significant number of participants, 420 was recorded in one of the quantitative studies from Ethiopia [ 37 ]. The questionnaire response rates varied between 90%-100%, with most studies dominated by male respondents at 51.9%-69.2% [ 38 ]. Nurses were the commonest study population, followed by doctors, pharmacists, and laboratory technicians, and no study involved non-HCWs of facilities. Most papers utilized probability sampling procedures, and four quantitative studies used non-random sampling procedures limiting generalizability of their findings and increasing the risk of selection bias. Eight studies were from Ethiopia, and one was from Cameroon, Uganda, Mali, and Togo, respectively (Table 1 ). Most studies were conducted in urban tertiary public hospitals, university teaching hospitals, and rural and urban general hospitals, including primary care facilities operated by Non-Governmental Organizations (NGOs) for example in Mali [ 39 ]. Several validated tools assessed depression, anxiety, insomnia, stress, and PTSD (Table 1 ).

Table 1 provides an overview of the studies selected and validated instruments used to measure psychological disorders.

Table 2 provides comparisons with studies conducted outside of sub-Saharan Africa.

Table 3 provides information on studies showing the classification of psychological outcomes.

Table 4 are studies showing risk factors associated with psychological disorders.

Table 5 are studies that identified protective factors for psychological disorders.

Risks of bias and confounding factors

Most articles selected were cross-sectional studies that employed probability sampling procedures (Table 1 ). Cross-sectional study design minimized selection biases, but many used structured questionnaires, including online self-administered questionnaires, which increased bias due to social desirability. It was not clear how confounding variables were controlled in five papers reviewed [ 38 , 39 , 40 , 43 , 45 ] leading to excessive and perhaps inappropriate determination of associations.

Socio-demographic factors

In this review, the mean age of the respondents ranged between 23 and 35 years, and predominantly males. Age was associated with anxiety, and stress symptoms in 6(50%) of all the studies reviewed [ 35 , 37 , 40 , 41 , 42 , 44 ]. An age of over 40 years was associated with moderate to severe symptoms of PTSD. Two studies concluded that respondents aged over 40 years were more likely to develop PTSD symptoms than their younger counterparts [ 37 , 41 ].

Female gender was significantly associated with depression, anxiety, and stress symptoms among HCWs in seven studies reviewed [ 36 , 37 , 38 , 41 , 42 , 43 ]. Many studies found that being female, married, and a nurse were independent predictors of stress symptoms. Moreover, sex, age, marital status, type of profession, and working environment were significant factors for PTSD symptoms [ 37 , 41 ]. However, one study in Ethiopia found that the odds of depression were twice higher among male healthcare providers than among female healthcare providers [ 35 ].

Psychological impact on healthcare workers

Most studies reviewed directly assessed the prevalence of depression, anxiety, stress, insomnia, and PTSD in HCWs. Common causes of anxiety, fear, or psychological distress that health professionals reported were: lack of access to PPEs and other equipment, being exposed to COVID-19 at work and taking the infection home to their families, uncertainties that their organization will support/take care of their personal and family needs if they got infection, long working hours, death of colleagues, lack of social support, stigmatization, high rates of transmission and poor income [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. However, the prevalence of mental health symptoms exhibited great variations for example depressive symptoms were examined in nine studies [ 35 , 36 , 37 , 39 , 43 , 44 , 45 , 46 ], and varied between 16.3% and 71.9% among HCWs [ 38 , 39 ].

In addition, nine other studies reported high prevalence of anxiety symptoms among HCWs [ 35 , 36 , 37 , 40 , 43 , 44 , 45 , 46 , 47 ] which varied between 21.9% and 73.5% [ 36 , 39 ]. Five studies investigated HCWs' perceived stress during the pandemic; 15.5%-63.7% of HCWs reported high levels of work-related stress [ 35 , 36 , 37 , 43 , 45 ]. Three studies reported 12.4–77% of HCWs experienced sleep disturbances during the COVID-19 pandemic [ 37 , 39 , 40 ].

Post-traumatic stress disorder (PTSD) was in three studies [ 38 , 41 , 42 ], and the prevalence of PTSD-like symptoms varied between 51.6 and 56.8% in HCWs [ 38 , 41 ]. A qualitative study from Uganda reported high symptoms of depression, anxiety, and PTSD among HCWs [ 35 ]. Additionally, factors that increased the risk of PTSD symptoms were for example, working in emergency units and being frontline workers. Furthermore, many studies found that frontline HCWs had increased symptoms of mental disorders and being a frontline worker was an independent risk factor for depression, anxiety, and PTSD [ 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ].

Risk factors associated with adverse mental health outcomes

The qualitative study from Uganda reported the factors associated with mental disorder symptoms among HCWs. These were long working hours, lack of equipment (PPEs, testing kits), lack of sleep, exhaustion, high death rates, death of colleagues, and a high COVID-19 transmission rate among HCWs [ 35 ]. Lack of equipment (PPEs, ventilators, and testing kits), overworking, and lack of logistic support were in Ethiopian studies [ 36 , 37 , 38 , 39 , 40 , 41 , 42 , 45 ]. Most studies identified several risk factors for adverse mental health outcomes among respondents for example those with medical and mental illnesses, contacts with confirmed COVID-19 patients, and poor social support which were significantly associated with depression [ 42 , 43 ]. Other factors were females, nurses, married, frontline workers, ICU, emergency units, living alone, and lack of social support [ 35 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. Too, participants’ families with chronic illnesses, had contacts with confirmed COVID-19 cases, and poor social support were significantly associated with anxiety. Other risk factors associated with anxiety include exhaustion, long working hours, frontline workers, emergencies, nurses, pharmacists, laboratory technicians, married, older, younger, living alone, being female, working at general and referral hospitals, and perceived stigma. In addition, participants’ families with chronic illnesses, those who had contacts with confirmed COVID-19 cases, and those with poor social support were predictors of stress during the COVID-19 pandemic [ 37 , 38 , 40 , 41 , 42 , 43 , 45 ]. Other stress symptoms include having a medical illness, a mental illness, being a frontline worker, married, nurse, female, pharmacist, laboratory technician, physician, older age, lack of standardized PPE supply, low incomes, and living with a family [ 36 , 37 , 40 , 41 , 42 , 43 , 44 , 45 ]. Healthcare providers with low monthly incomes were significantly more likely to develop stress than those with high monthly incomes [ 38 ]. In addition, participants living alone, living with a family, and being married were associated with symptoms of psychological disorders among HCWs [ 36 , 37 , 38 , 45 ]. Overall, the risk factors for adverse psychological impacts are categorized in three thematic areas (i) occupational, (ii) psychosocial, and (iii) environmental aspects.

Occupational factors

Most studies showed that frontline HCWs, nurses, doctors, pharmacists, and laboratory technicians had significantly higher levels of mental health risks compared to non-frontline HCWs [ 35 , 36 , 37 , 38 , 40 , 42 , 43 , 45 ]. They experienced higher frequency of insomnia, anxiety, depression, and somatization than non-frontline medical HCWs. In contrast, Mali [ 39 ] and Cameroon [ 46 ] studies found a higher prevalence of depression, anxiety, and PTSD in non-frontline HCWs [ 39 , 46 ]. However, among HCWs, physicians were 20% less likely to develop mental health disorders than nurses, pharmacists, and laboratory technicians [ 39 ]. In addition, healthcare workers with low monthly incomes had higher symptoms of depression, anxiety, stress, and insomnia [ 37 ].

Healthcare groups

Five studies found that being a nurse was associated with worse mental disorders than doctors [ 36 , 37 , 40 , 44 , 45 ].

Frontline staff with direct contact with COVID-19

Most papers in the review found that being in a “frontline” position or having direct contact with COVID-19 patients was associated with higher level of psychological distress [ 35 , 36 , 37 , 38 , 40 , 42 , 43 , 45 ]. In addition, studies found that contact with COVID-19 patients was independently associated with an increased risk of sleep disturbances [ 40 , 46 ]. Moreover, HCWs who had contact with confirmed COVID-19 cases were more likely to develop depression, anxiety, and stress symptoms than those who had no contact with COVID-19 patients [ 36 , 37 , 38 , 43 , 45 ].

Lack of personal protective equipment (PPEs)

Most studies reported that the lack of PPEs was associated with higher symptoms of depression, anxiety, stress, and insomnia, while its availability was associated with fewer mental disorder symptoms [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ]. In Mali, workers from centres that provided facemasks were 51% less likely to suffer from depression, 62% less likely to develop anxiety, and 45% less likely to develop insomnia [ 39 ]. In Ethiopia, the odds of developing post-traumatic stress disorder were much higher among HCWs who did not receive standardized PPEs supplies than those who had [ 38 , 41 , 42 ]. In Uganda, the lack of PPEs was associated with depression, anxiety, and PTSD [ 35 ].

Heavy workload

Longer working hours, increased work intensity, increased patient load, and exhaustion were risk factors in Ugandan [ 35 ] and Ethiopian studies [ 36 ].

Psychosocial factors: perceived stigma and fear of infection

The fear of infection was in the qualitative study from Uganda [ 35 ], one quantitative study from Cameroon [ 47 ] and seven cross-sectional studies from Ethiopia [ 36 , 37 , 38 , 41 , 42 , 43 , 44 ]. Poor social support was associated with PTSD symptoms, depression, anxiety, and stress [ 35 , 36 , 37 , 38 , 42 , 43 ]. Two studies reported that HCWs with perceived stigmatization were more likely to suffer from depression, anxiety, stress, and PTSD [ 37 , 42 ].

family concerns

This came up as one of the main risk factors of stress in almost all studies, especially among those HCWs in direct contact with confirmed COVID-19 cases [ 35 , 36 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 45 ]. A family member suffering from COVID-19 was associated with poor mental health outcomes in HCWs [ 36 , 37 ].

Protective psychosocial factors

Two studies suggest a reduction of perceived stigma can be achieved by sensitization of communities about COVID-19 [ 37 , 42 ], and four studies recommend solid social support [ 36 , 37 , 42 , 43 ].

Safety of family

Family safety had the most significant impact in reducing stress. Safety from COVID-19 infection and financial protection of families were essential coping strategies for HCWs [ 35 , 36 ].

Underlying illnesses

We found three studies that reported an underlying medical and mental illness as an independent risk factor for poor psychological outcomes [ 42 , 43 , 45 ].

Protective factors against adverse mental health outcomes

The review identified protective factors to adverse mental health outcomes during COVID-19. The qualitative study from Uganda and four quantitative cross-sectional studies from Ethiopia identified some protective factors [ 35 , 38 , 41 , 42 , 45 ]. The protective factors are grouped under three thematic areas (i) occupational, (ii) psychosocial, and (iii) environmental aspects.

The qualitative study identified many social coping strategies among respondents, including family networks, community networks, help from family, responsibility to society, assistance from community members, availability of assistance from strangers, and the symbiotic nature of assistance in the community [ 35 ].

Protective occupational factors

Studies suggest that physicians suffered fewer mental health disorders partly because of their experience with previous epidemics [ 37 , 42 , 45 ].

Some necessary coping measures include good hospital guidance and ongoing training of frontline HCWs [ 37 , 42 , 45 ].

Adequate supply of PPEs

As mentioned above, PPE was a protective factor when adequate and a risk factor for poor mental health outcomes when deemed inadequate [ 35 , 36 , 37 , 42 , 43 ].

The COVID-19 pandemic has been an ongoing global public health emergency that has burdened healthcare workers' physical and mental well-being (HCWs) [ 1 , 5 ]. Our review confirms the enormous magnitude of mental health impact of COVID-19 on healthcare workers in sub-Saharan Africa, and it is widespread, with significant levels of depression, anxiety, distress, and insomnia; especially those working directly with COVID-19 patients at particular risk [ 34 , 35 , 36 , 37 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. Out of the twelve articles reviewed, eight studies (66%) came from Ethiopia, and this has implications on the results (Table 1 ). This finding indicates few research published to date on the psychological impact of the pandemic on the mental health of HCWs in sub-Saharan Africa; a subregion that the COVID-19 pandemic has severely impacted.

Overview of the study sites

Studies in this review were conducted predominantly in hospital settings. We found only one study relating to primary healthcare workers or facilities [ 38 ]. This finding is of concern, as there is increasing evidence that many non-frontline HCWs continue to suffer psychological symptoms long after the conclusion of infectious disease epidemics [ 7 , 8 ]. In addition, a significant mortality due to COVID-19 was due to excess morbidity, some of which were from primary care facilities. Given that this study is the first narrative review in sub-Saharan Africa, it would be helpful to briefly compare our findings with some published reviews and surveys from other regions (Table 2 ).

High prevalence of psychological disorders among participants

Investigators in this review found 16.3–71.9% HCWs with depressive symptoms, 21.9–73.5% had anxiety symptoms, 15.5–63.7% experienced work-related stress symptoms, 12.4–77% experienced sleep disturbances, and 51.6–56.8% PTSD symptoms [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. This high prevalence of mental health symptoms among HCWs in our review is consistent with previous reviews conducted early in the pandemic in sub-Saharan Africa [ 31 ], Asia [ 17 , 18 , 26 , 28 ], USA & Europe [ 15 , 16 ], and supported by a batch of cross-sectional studies globally [ 11 , 12 , 13 , 14 , 19 , 27 , 30 ]. We found mixed results with significant variations within and among regions and countries, as depicted in Tables 1 and 2 .

Risk factors of psychological disorders among participants

Studies established that HCWs responding to the COVID-19 pandemic in sub-Saharan Africa were exposed to long working hours, overworking, exhaustion, high risk of infection, and shortage of personal protective equipment (Tables 3 and 4 ). In addition, HCWs had deep fear, were anxious and stressed with the high transmission rate of the virus among themselves, high death rates among themselves and their patients, and lived under constant fear of infecting themselves and their families with obvious consequences [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. Some HCWs were deeply worried about the lack of standardized PPEs, known treatments and vaccines to protect against the virus. Many health workers had financial problems, lacked support from families and employers if they contracted the virus [ 34 , 35 , 36 , 37 , 39 , 40 , 41 , 42 , 44 ]. An additional source of fear and anxiety was the perceived stigma attached to being infected with COVID-19 by the public [ 36 , 41 ]. Studies found that HCWs, especially those working in emergency, intensive care units, infectious disease wards, pharmacies, and laboratories, were at higher risk of developing adverse mental health impacts compared to others [ 34 , 35 , 36 , 37 , 39 , 40 , 41 , 42 , 43 , 44 ]. This is supported by previous reviews [ 15 , 16 , 17 , 18 , 26 , 28 ] and cross-sectional studies [ 10 , 11 , 12 , 13 , 14 , 20 , 21 , 23 , 25 , 30 ]. However, findings were inconsistent on the impact of COVID-19 on frontline health workers, with ten studies [ 35 , 36 , 37 , 39 , 40 , 41 , 42 , 44 , 45 ] suggesting they are at higher risk than peers and two studies showing no significant difference in psychological disorders relating to the departments [ 38 , 43 ].

The Mali’s study was conducted exclusively in primary care facilities among HCWs not involved in treating COVID-19 cases but still registered a very high prevalence of depression 71.9%, anxiety 73.6%, and insomnia 77.0% [ 39 ]. In contrast, two studies conducted among HCWs at COVID-19 treatment facilities in Ethiopia [ 36 , 38 ] registered much lower prevalence of depression 20.2%, anxiety 21.0%, and insomnia12.4% [ 36 ], and 16.3%, 30.7% and 15.9% respectively, in the second study [ 38 ]. These findings show that not only frontline HCWs experienced mental health disorders during this pandemic but highlight the need for direct interventions for all HCWs regardless of occupation or workstation during this and future pandemics. The significant disparity in the studies could be due to structural, occupational, and environmental issues for example challenges faced by Mali's healthcare systems, characterized by acute equipment shortages, lack of PPEs, human resources, lack of trained and experienced HCWs, ongoing nationwide insecurity, and terrorism compared to Ethiopia. Therefore, local context needs to be considered as contributing factor to mental health disorders among HCWs.

Regional variations of psychological disorders

Tan et al . found a higher prevalence of anxiety among non-medical HCWs in Singapore [ 27 ]. As previously noted, the prevalence of poor psychological outcomes varied between countries. Compared to sub-Saharan Africa and China, data from India [ 23 ] and Singapore [ 27 ] revealed an overall lower prevalence of anxiety and depression than similar cross-sectional data from sub-Saharan Africa [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ] and China [ 9 , 25 , 30 ]. This finding suggests that different contexts and cultures may reveal different psychological findings and that, it is possible that being at different countries’ outbreak curve may play a part, as there is evidence that it is influential.

Tan et al . suggests that medical HCWs in Singapore had experienced a SARS outbreak and thus were well prepared for COVID-19 psychologically and infection control measures [ 27 ]. What can be deduced is that context and cultural factors play a role, not just the cadre or role of healthcare workers [ 16 ]. It also highlights the importance of reviewing evidence regularly as more data emerge from other countries.

One hospital in Ethiopia found that the thought of resignation was associated with higher chances of mental health disorders and that pharmacists and laboratory technicians who did not receive prior training exhibited higher symptoms of mental health disorders compared to others [ 36 ]. Work shift arrangement, considering a dangerous atmosphere presented by working in COVID-19 wards, was one which exacerbated or relieved mental health symptoms among HCWs, with shorter exposure periods being most beneficial [ 36 ]. Meanwhile, studies found that financial worries caused by severe lockdowns and erratic payment of salaries and allowances were also major stressors [ 35 ]. This finding is like studies in Pakistan [ 13 ] and China [ 30 , 32 ].

In this review, HCWs who had contact with confirmed COVID-19 patients were more affected by depression, anxiety, and stress than their counterparts who had not [ 35 , 36 , 37 , 40 , 41 , 43 , 45 ]. This finding is like previous reviews [ 15 , 16 , 17 , 18 , 26 , 28 , 31 ] and cross-sectional studies [ 9 , 10 , 11 , 12 , 13 , 14 , 21 , 23 , 24 , 25 , 27 , 30 ], which reported higher depression, anxiety, and psychological symptoms of distress in HCWs who were in direct contact with confirmed or suspected COVID-19 patients.

A study in Pakistan showed that 80% of participants expected the provision of PPE from authority [ 13 ], and 86% were anxious. Some respondents alluded to forced deployment, while in Mali, 73.3% were anxious, with the majority worrying about the shortage of nurses [ 39 ]. Therefore, prospects of being deployed at a workstation where one had not been trained or oriented contributed to fear among health workers. In the sub-Saharan African context, this scenario can best be represented in HCWs involved in internship who must endure hard work during their training. Tan et al . found that junior doctors were more stressed than nurses in Singapore [ 27 ].

Socio-demographic characteristics

Nearly all studies in our review suggest that socio-demographic variables for example age, gender, marital status, and living alone or with families contribute to the high mental disorder symptoms [ 35 , 36 , 37 , 39 , 40 , 41 , 42 , 43 , 44 ]. We, the authors suggest that these observations are handled cautiously as several investigators of these reviewed articles did not entirely control the influence of confounding variables. An alternative explanation for this study's findings may be the more significant risks of frontline exposure amongst women and junior HCWs, predominantly employed in lower-status roles, many of whom lacked experience and appropriate training within healthcare system globally. It is also important to note that respondents to all studies, when disaggregated by gender, and age, were predominantly younger or female, which may have impacted the outcomes of these findings [ 16 ]. In addition, the consistently higher mortality rates, and risk of severe COVID-19 disease amongst men would suggest that the complete picture regarding gender and mental health during this pandemic is still incomplete [ 16 ]. Moreover, in several studies, both younger and older age groups were equally affected by mental health symptoms but for different reasons. Cai et al . [ 32 ] in a Chinese study on HCWs for example observed that irrespective of age, colleagues' safety, self and families' safety, the lack of treatment for COVID-19 was a factor that induced stress in HCWs. Similarly, in our review, the lack of PPEs, high infection transmission rates, high death rates among HCWs, and the fear of infecting their families were the factors that induced stress in all HCWs [ 34 , 35 , 36 , 37 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ].

We, the authors propose that paying close attention to concerns of HCWs by employers would greatly relieve some stressors and contribute to increased mental well-being of participants. Compared with physicians, our review showed that nurses were more likely to suffer from depression, anxiety, insomnia, PTSD, and stress [ 35 , 37 , 39 , 40 , 41 , 44 , 45 ]. Workloads and night shifts in healthcare facilities, as well as contacts with risky patients, enhanced nurses' mental distress risks [ 15 , 16 , 17 , 18 , 26 , 27 , 28 ]. In addition, nursing staff have more extended physical contacts and closer interactions with patients than other professionals, providing round-the-clock care required by patients with COVID-19 and thus the increased risk [ 15 ]. On the one hand, we posit that most senior physicians are experienced and always keep well-informed with emerging medical emergencies. The majority become aware of emerging epidemic early and actively protect themselves from infections through regular scientific literature updates compared to their junior counterparts. Senior physicians also spend less time in emergency wards unless there is a need to conduct specific procedures which cannot be undertaken by senior housemen or general medical officers. Cai et al . [ 32 ] concluded that it is essential to have a high level of training and professional experience for healthcare workers engaging in public health emergencies, especially for the new staff. As a result, these findings highlight the importance of focusing on all the frontline HCWs sacrificing to contain the COVID-19 pandemic.

Regular monitoring of high-risk groups

There is a need to continue monitoring the high-at-risk groups, including nursing staff, interns, support staff, and all deployed in emergency wards. These high-at-risk groups should be encouraged to undertake screening, treatment, and vaccination to avoid the medium and long-term consequences of such epidemics [ 15 , 16 , 35 , 37 , 40 , 44 ].

Social support and coping mechanisms

The effect of social support and coping measures is in the qualitative study [ 34 ] and three other quantitative studies [ 36 , 41 , 42 ] which concluded that respondents with good social support were less likely to suffer from severe depression, anxiety, work-related stress, and PTSD. The qualitative study identified several coping measures, including community and organizational support, family, and community networks, help from family, responsibility to society, and assistance from community members and strangers, including the symbiotic nature of assistance in the community [ 35 ]. Other measures include providing accommodation and food to employees [ 35 ].

Interestingly, no study examined the association of resilience and self-efficacy with sleep quality, degrees of anxiety, depression, PTSD, and stress. However, a Chinese study by Cai et al. [ 32 ] suggests that the social support given to HCWs causes a reduction in anxiety and stress levels and increases their self-efficacy. In divergence, Xiao et al . [ 46 ] found no relationship between social support and sleep quality.

Only two studies in our review examined the effects of stigma on the mental health of HCWs [ 36 , 41 ] and found that HCWs with perceived stigma were more likely to be depressed, anxious, stressed, and prone to poor sleep quality [ 36 , 41 ]. We, the authors suggest that better community sensitization by creating public awareness involving appropriate local community structures and networks are essential. The broader community in sub-Saharan Africa may have suffered severely from infodemics with severe consequences on their mental health, especially during the difficult lockdowns. In addition, removing discrimination/inequalities at the workplace based on race and other social standings have a powerful influence on the mental health outcomes of HCWs. Also, because emotional exhaustion is long associated with depression, anxiety, and sleep disturbances, none of the studies in our review examined burnout as an essential component of mental health disorders in HCWs in sub-Saharan Africa.

Protective and coping measures

In this review we have provided evidence about personal, occupational, and environmental factors that were important protective and coping measures against psychological disorders. Based on these factors we suggest some protective and coping measures which can help to reduce the negative effects of the pandemic on mental health of HCWs in sub-Saharan Africa. Organizations and healthcare managers need to be aware that primary prevention is key to any successful interventions to contain and control any epidemic. This should take the form of planned regular training, orientation and continuing medical education grounded on proven infection control measures. These measures need to be backed up by timely provision of protective equipment, drugs, testing facilities, vaccines, isolation facilities, clinical and mental health support, and personal welfare of HCWs [ 35 , 36 , 37 , 42 , 45 ]. The effect of community and organizational support and coping measures was shown by the qualitative study [ 35 ] and five other quantitative studies [ 36 , 37 , 41 , 42 , 43 ] indicating that respondents who had good social and organizational support were less likely to suffer from severe depression, anxiety, work related stress and PTSD. Prior experience with comparable pandemics and training are suggested as beneficial coping strategies for healthcare workers during this pandemic but also local social structural and geopolitical conditions appear to determine the pattern and evolution of mental health symptoms among HCWs [ 14 , 15 , 31 , 32 , 47 ]. In our case the high prevalence of all mental health symptoms in non-frontline primary health care facilities in Mali [ 39 ] which was already plagued with instability and weak healthcare systems prior to the pandemic is a case in point. Results are particularly consistent in showing that provision of PPEs, testing kits, orientation training of workers, work shift arrangements, provision of online counselling, provision of food and accommodation and prompt payment of allowances by employers were important protective measures [ 35 , 36 , 37 , 38 , 39 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ]. The feeling of being protected is associated with higher work motivation with implication for staff turnover [ 35 , 38 , 43 , 45 ]. Hence, physical protective materials [ 14 ], together with frequent provision of information, should be the cornerstone of any interventions to prevent deterioration in mental health of HCWs (Table 5 ). Finally, provision of rest rooms, online consultation with psychologists/psychiatrists, protection from financial hardships, access to social amenities and religious activities are some important coping measures [ 35 , 36 , 38 , 42 , 45 ]. In this era of digital health care with plentiful internet and smartphones, organization can conduct online trainings, online mental health education, online psychological counselling services, and online psychological self-help intervention tailored to the needs of their HCWs [ 35 , 37 , 42 ]. In addition, it is essential to understand and address the sources of anxiety among healthcare professionals during this COVID-19 pandemic, as this has been one of the most experienced mental health symptoms [ 48 ]. Adequate protective equipment provided by health facilities is one of the most important motivational factors for encouraging continuation of work in future outbreaks. Furthermore, availability of strict infection control guidelines, specialized equipment, recognition of their efforts by facility management, government, and reduction in reported cases of COVID-19 provide psychological benefits [ 15 , 32 ]. Finally, we call upon Governments (the largest employers of HCWs) in sub-Saharan Africa to do what it takes to improve investments in the mental health of HCWs and plan proactively in anticipation of managing infectious disease epidemics, including other expected and unexpected disasters.

Future research direction

There was no study that examined the association of resilience and self-efficacy with sleep quality, degrees of anxiety, depression, PTSD, and stress. Although emotional exhaustion has long been associated with depression, anxiety, and sleep disturbances, no study in our review examined burnout as an important component of mental health disorders in HCWs in sub-Saharan Africa. The impacts of infodemics, stringent lockdown measures, discrimination/inequalities at workplaces based on race, and other social standings on mental health outcomes of HCWs need to be investigated.

Future studies are needed on the above including other critical areas like suicidality, suicidal ideations, and substance abuse during the COVID-19 pandemic. In addition, there is a significant variation of related literature calling for more rigorous research in future. More systematic studies will be required to clarify the full impact of the pandemic so that meaningful interventions can be planned and executed at institutional and national levels in the Sub-Saharan Africa.

Limitations of this study

There are some limitations to this study. First, most of the studies are from one country, limiting the generalizability of the results to the whole African continent. Second, all the studies were cross-sectional and only looked at associations and correlations. There is a need for prospective or retrospective cohort or case–control studies on this subject matter. Longitudinal research studies on the prevalence of mental disorders in the COVID-19 pandemic in the sub-Saharan Africa are urgently required. Third, most studies reviewed did not adequately examine protective factors or coping measures of the health workers in their settings. In addition, most studies did not pay strict attention to confounding variables which could have led to inappropriate results and conclusions. Fourth, most sample sizes were small and unlikely representative of the population and yet larger sample sizes would better identify the extent of mental health problems among health workers in the region. Fifth, depression, anxiety, and stress were assessed solely through self-administered questionnaires rather than face-to-face psychiatric interviews. Sixth, these studies employed various instruments and different cut-off thresholds to assess severity. Notably, the magnitude and severity of reported mental health outcomes may vary based on the validity and sensitivity of the measurement tools. Seventh, there was no mention of mental baseline information among the studied population and therefore it was unknown if the studied population had pre-existing mental health illnesses that decompensated during the pandemic crisis. Eight, investigators did not give much attention to stigma, burnout, resilience, and self-efficacy among study participants.

Furthermore, our review did not employ systematic reviews or meta-analyses methods for the information generated. This narrative review paper precluded deeper insight into the quality of reviewed articles for this paper. Still, our observation was that investigators did not consider the strict lockdown measures, quarantine, and isolation imposed by many countries in sub-Saharan Africa as possible risk factors for mental health disorders among HCWs.

Based on the articles reviewed, the prevalence of depression, anxiety, insomnia, and PTSD in HCWs in the sub-Saharan Africa during the COVID-19 pandemic is high. We implore health authorities to consider setting up permanent multidisciplinary mental health teams at regional and national levels to deal with mental health issues and provide psychological support to patients and HCWs, always supported with sufficient budgetary allocations.

Long-term surveillance is essential to keep track of insidiously rising mental health crises among community members. There is a significant variation of related literature thus calling for more rigorous research in the future. More systematic studies will be needed to clarify the full impact of the pandemic so that meaningful interventions can be planned better and executed at institutional and national levels in sub-Saharan Africa.

Availability of data and materials

Datasets analysed in the current study are available from the corresponding author at a reasonable request.

Abbreviations

Coronavirus disease 2019

Healthcare workers.

Mental health

Public health emergency

Personal protective equipment

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Acknowledgements

We thank Uganda Medical Association Acholi-branch members for the financial assistance which enabled the team to conduct this study successfully.

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Freddy Wathum Drinkwater Oyat, Johnson Nyeko Oloya, Pamela Atim, Judith Aloyo & David Lagoro Kitara

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Oyat, F.W.D., Oloya, J.N., Atim, P. et al. The psychological impact, risk factors and coping strategies to COVID-19 pandemic on healthcare workers in the sub-Saharan Africa: a narrative review of existing literature. BMC Psychol 10 , 284 (2022). https://doi.org/10.1186/s40359-022-00998-z

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Included studies comprised three narrative case studies [29,30,31] a randomised control trial []; a narrative review [] a practitioners' guidance document []; and a naturalistic study [].Critical appraisal of the evidence (Table 1) demonstrates that caution must be exercised when considering the findings.The main strength of the included studies is the voice of young people through verbatim ...
Parenting as a Moderator of the Relation Between Child ...
The literature on the role of parenting in the relation between child inhibited temperament and child anxiety is inconsistent, with some literature supporting a moderating role and some literature supporting alternative (e.g., mediating) roles. A systematic review of the evidence that parenting moderates the longitudinal relation between child inhibited temperament and child anxiety is needed ...
Culture, sex and social context influence brain-to-brain synchrony: an
Background Unique interpersonal synchrony occurs during every social interaction, and is shaped by characteristics of participating individuals in these social contexts. Additionally, depending on context demands, interpersonal synchrony is also altered. The study therefore aims to investigate culture, sex, and social context effects simultaneously in a novel role-play paradigm. Additionally ...
Effectiveness of home treatment in children and adolescents with
Effectiveness of home treatment in children and adolescents with psychiatric disorders—systematic review and meta-analysis ... social workers, and nursing staff. The close involvement of the patient's family, school, and the broader social environment (e ... a systematic review of the literature. Clin Child Psychol Psychiatry. 2022;27:35 ...
The psychological impact, risk factors and coping strategies to COVID
This review aimed to determine risk factors for adverse mental health outcomes and protective or coping measures to mitigate the harmful effects of the COVID-19 crisis among HCWs in sub-Saharan Africa. We performed a literature search using PubMed, Google Scholar, Cochrane Library, and Embase for relevant materials.
Practical recommendations for addressing the psychological needs of
Given the inconsistencies in the provision of psychological interventions identified in the literature and through reports, this report aimed to (1) review existing recommendations on psychosocial interventions to address UASC mental health needs, (2) examine the current mental health provision within health and social care in England from service providers' perspectives, and (3) synthesise ...