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What is a literature review?

Systematic reviews vs literature reviews, literature reviews - articles, writing literature reviews, frequently used journal article databases.

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The literature review is the qualitative summary of evidence on a topic using informal or subjective methods to collect and interpret studies.The literature review can inform a particular research project or can result in a review article publication.

• Aaron L. Writing a literature review article. Radiol Technol. 2008 Nov-Dec; 80(12): 185-6.
• Gasparyan AY, Ayvazyan L, Blackmore H, Kitas GD. Writing a narrative biomedical review: considerations for authors, peer reviewers, and editors. Rheumatol Int. 2011 Nov; 31(11): 1409-17.
• Matharu GS, Buckley CD. Performing a literature review: a necessary skill for any doctor. Student BMJ. 2012; 20:e404. Requires FREE site registration
• Literature Reviews The Writing Center at University of North Carolina at Chapel Hill has created a succinct handout that explains what a literature review is and offer insights into the form and construction of a literature review in the humanities, social sciences, and sciences.
• Review Articles (Health Sciences) Guide Identifies the difference between a systematic review and a literature review. Connects to tools for research, writing, and publishing.

• Systematic Approaches to a Successful Literature Review by Andrew Booth; Diana Papaioannou; Anthea Sutton Call Number: Norris Medical Library, Upper Level, LB 1047.3 B725s 2012
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Performing a literature review

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• Gulraj S Matharu , academic foundation doctor ,
• Christopher D Buckley , Arthritis Research UK professor of rheumatology
• 1 Institute of Biomedical Research, College of Medical and Dental Sciences, School of Immunity and Infection, University of Birmingham, UK

A necessary skill for any doctor

What causes disease, which drug is best, does this patient need surgery, and what is the prognosis? Although experience helps in answering these questions, ultimately they are best answered by evidence based medicine. But how do you assess the evidence? As a medical student, and throughout your career as a doctor, critical appraisal of published literature is an important skill to develop and refine. At medical school you will repeatedly appraise published literature and write literature reviews. These activities are commonly part of a special study module, research project for an intercalated degree, or another type of essay based assignment.

Formulating a question

Literature reviews are most commonly performed to help answer a particular question. While you are at medical school, there will usually be some choice regarding the area you are going to review.

Once you have identified a subject area for review, the next step is to formulate a specific research question. This is arguably the most important step because a clear question needs to be defined from the outset, which you aim to answer by doing the review. The clearer the question, the more likely it is that the answer will be clear too. It is important to have discussions with your supervisor when formulating a research question as his or her input will be invaluable. The research question must be objective and concise because it is easier to search through the evidence with a clear question. The question also needs to be feasible. What is the point in having a question for which no published evidence exists? Your supervisor’s input will ensure you are not trying to answer an unrealistic question. Finally, is the research question clinically important? There are many research questions that may be answered, but not all of them will be relevant to clinical practice. The research question we will use as an example to work through in this article is, “What is the evidence for using angiotensin converting enzyme (ACE) inhibitors in patients with hypertension?”

Collecting the evidence

After formulating a specific research question for your literature review, the next step is to collect the evidence. Your supervisor will initially point you in the right direction by highlighting some of the more relevant papers published. Before doing the literature search it is important to agree a list of keywords with your supervisor. A source of useful keywords can be obtained by reading Cochrane reviews or other systematic reviews, such as those published in the BMJ . 1 2 A relevant Cochrane review for our research question on ACE inhibitors in hypertension is that by Heran and colleagues. 3 Appropriate keywords to search for the evidence include the words used in your research question (“angiotensin converting enzyme inhibitor,” “hypertension,” “blood pressure”), details of the types of study you are looking for (“randomised controlled trial,” “case control,” “cohort”), and the specific drugs you are interested in (that is, the various ACE inhibitors such as “ramipril,” “perindopril,” and “lisinopril”).

Once keywords have been agreed it is time to search for the evidence using the various electronic medical databases (such as PubMed, Medline, and EMBASE). PubMed is the largest of these databases and contains online information and tutorials on how to do literature searches with worked examples. Searching the databases and obtaining the articles are usually free of charge through the subscription that your university pays. Early consultation with a medical librarian is important as it will help you perform your literature search in an impartial manner, and librarians can train you to do these searches for yourself.

Literature searches can be broad or tailored to be more specific. With our example, a broad search would entail searching all articles that contain the words “blood pressure” or “ACE inhibitor.” This provides a comprehensive list of all the literature, but there are likely to be thousands of articles to review subsequently (fig 1). ⇓ In contrast, various search restrictions can be applied on the electronic databases to filter out papers that may not be relevant to your review. Figure 2 gives an example of a specific search. ⇓ The search terms used in this case were “angiotensin converting enzyme inhibitor” and “hypertension.” The limits applied to this search were all randomised controlled trials carried out in humans, published in the English language over the last 10 years, with the search terms appearing in the title of the study only. Thus the more specific the search strategy, the more manageable the number of articles to review (fig 3), and this will save you time. ⇓ However, this method risks your not identifying all the evidence in the particular field. Striking a balance between a broad and a specific search strategy is therefore important. This will come with experience and consultation with your supervisor. It is important to note that evidence is continually becoming available on these electronic databases and therefore repeating the same search at a later date can provide new evidence relevant to your review.

Fig 1 Results from a broad literature search using the term “angiotensin converting enzyme inhibitor”

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Fig 2 Example of a specific literature search. The search terms used were “angiotensin converting enzyme inhibitor” and “hypertension.” The limits applied to this search were all randomised controlled trials carried out in humans, published in English over the past 10 years, with the search terms appearing in the title of the study only

Fig 3 Results from a specific literature search (using the search terms and limits from figure 2)

Reading the abstracts (study summary) of the articles identified in your search may help you decide whether the study is applicable for your review—for example, the work may have been carried out using an animal model rather than in humans. After excluding any inappropriate articles, you need to obtain the full articles of studies you have identified. Additional relevant articles that may not have come up in your original search can also be found by searching the reference lists of the articles you have already obtained. Once again, you may find that some articles are still not applicable for your review, and these can also be excluded at this stage. It is important to explain in your final review what criteria you used to exclude articles as well as those criteria used for inclusion.

The National Institute for Health and Clinical Excellence (NICE) publishes evidence based guidelines for the United Kingdom and therefore provides an additional resource for identifying the relevant literature in a particular field. 4 NICE critically appraises the published literature with recommendations for best clinical practice proposed and graded based on the quality of evidence available. Similarly, there are internationally published evidence based guidelines, such as those produced by the European Society of Cardiology and the American College of Chest Physicians, which can be useful when collecting the literature in a particular field. 5 6

Appraising the evidence

Once you have collected the evidence, you need to critically appraise the published material. Box 1 gives definitions of terms you will encounter when reading the literature. A brief guide of how to critically appraise a study is presented; however, it is advisable to consult the references cited for further details.

Box 1: Definitions of common terms in the literature 7

Prospective—collecting data in real time after the study is designed

Retrospective—analysis of data that have already been collected to determine associations between exposure and outcome

Hypothesis—proposed association between exposure and outcome. If presented in the negative it is called the null hypothesis

Variable—a quantity or quality that changes during the study and can be measured

Single blind—subjects are unaware of their treatment, but clinicians are aware

Double blind—both subjects and clinicians are unaware of treatment given

Placebo—a simulated medical intervention, with subjects not receiving the specific intervention or treatment being studied

Outcome measure/endpoint—clinical variable or variables measured in a study subsequently used to make conclusions about the original interventions or treatments administered

Bias—difference between reported results and true results. Many types exist (such as selection, allocation, and reporting biases)

Probability (P) value—number between 0 and 1 providing the likelihood the reported results occurred by chance. A P value of 0.05 means there is a 5% likelihood that the reported result occurred by chance

Confidence intervals—provides a range between two numbers within which one can be certain the results lie. A confidence interval of 95% means one can be 95% certain the actual results lie within the reported range

The study authors should clearly define their research question and ideally the hypothesis to be tested. If the hypothesis is presented in the negative, it is called the null hypothesis. An example of a null hypothesis is smoking does not cause lung cancer. The study is then performed to assess the significance of the exposure (smoking) on outcome (lung cancer).

A major part of the critical appraisal process is to focus on study methodology, with your key task being an assessment of the extent to which a study was susceptible to bias (the discrepancy between the reported results and the true results). It should be clear from the methods what type of study was performed (box 2).

Box 2: Different study types 7

Systematic review/meta-analysis—comprehensive review of published literature using predefined methodology. Meta-analyses combine results from various studies to give numerical data for the overall association between variables

Randomised controlled trial—random allocation of patients to one of two or more groups. Used to test a new drug or procedure

Cohort study—two or more groups followed up over a long period, with one group exposed to a certain agent (drug or environmental agent) and the other not exposed, with various outcomes compared. An example would be following up a group of smokers and a group of non-smokers with the outcome measure being the development of lung cancer

Case-control study—cases (those with a particular outcome) are matched as closely as possible (for age, sex, ethnicity) with controls (those without the particular outcome). Retrospective data analysis is performed to determine any factors associated with developing the particular outcomes

Cross sectional study—looks at a specific group of patients at a single point in time. Effectively a survey. An example is asking a group of people how many of them drink alcohol

Case report—detailed reports concerning single patients. Useful in highlighting adverse drug reactions

There are many different types of bias, which depend on the particular type of study performed, and it is important to look for these biases. Several published checklists are available that provide excellent resources to help you work through the various studies and identify sources of bias. The CONSORT statement (which stands for CONsolidated Standards Of Reporting Trials) provides a minimum set of recommendations for reporting randomised controlled trials and comprises a rigorous 25 item checklist, with variations available for other study types. 8 9 As would be expected, most (17 of 25) of the items focus on questions relating to the methods and results of the randomised trial. The remaining items relate to the title, abstract, introduction, and discussion of the study, in addition to questions on trial registration, protocol, and funding.

Jadad scoring provides a simple and validated system to assess the methodological quality of a randomised clinical trial using three questions. 10 The score ranges from zero to five, with one point given for a “yes” in each of the following questions. (1) Was the study described as randomised? (2) Was the study described as double blind? (3) Were there details of subject withdrawals, exclusions, and dropouts? A further point is given if (1) the method of randomisation was appropriate, and (2) the method of blinding was appropriate.

In addition, the Critical Appraisal Skills Programme provides excellent tools for assessing the evidence in all study types (box 2). 11 The Oxford Centre for Evidence-Based Medicine levels of evidence is yet another useful resource for assessing the methodological quality of all studies. 12

Ensure all patients have been accounted for and any exclusions, for whatever reason, are reported. Knowing the baseline demographic (age, sex, ethnicity) and clinical characteristics of the population is important. Results are usually reported as probability values or confidence intervals (box 1).

This should explain the major study findings, put the results in the context of the published literature, and attempt to account for any variations from previous work. Study limitations and sources of bias should be discussed. Authors’ conclusions should be supported by the study results and not unnecessarily extrapolated. For example, a treatment shown to be effective in animals does not necessarily mean it will work in humans.

The format for writing up the literature review usually consists of an abstract (short structured summary of the review), the introduction or background, methods, results, and discussion with conclusions. There are a number of good examples of how to structure a literature review and these can be used as an outline when writing your review. 13 14

The introduction should identify the specific research question you intend to address and briefly put this into the context of the published literature. As you have now probably realised, the methods used for the review must be clear to the reader and provide the necessary detail for someone to be able to reproduce the search. The search strategy needs to include a list of keywords used, which databases were searched, and the specific search limits or filters applied. Any grading of methodological quality, such as the CONSORT statement or Jadad scoring, must be explained in addition to any study inclusion or exclusion criteria. 6 7 8 The methods also need to include a section on the data collected from each of the studies, the specific outcomes of interest, and any statistical analysis used. The latter point is usually relevant only when performing meta-analyses.

The results section must clearly show the process of filtering down from the articles obtained from the original search to the final studies included in the review—that is, accounting for all excluded studies. A flowchart is usually best to illustrate this. Next should follow a brief description of what was done in the main studies, the number of participants, the relevant results, and any potential sources of bias. It is useful to group similar studies together as it allows comparisons to be made by the reader and saves repetition in your write-up. Boxes and figures should be used appropriately to illustrate important findings from the various studies.

Finally, in the discussion you need to consider the study findings in light of the methodological quality—that is, the extent of potential bias in each study that may have affected the study results. Using the evidence, you need to make conclusions in your review, and highlight any important gaps in the evidence base, which need to be dealt with in future studies. Working through drafts of the literature review with your supervisor will help refine your critical appraisal skills and the ability to present information concisely in a structured review article. Remember, if the work is good it may get published.

Originally published as: Student BMJ 2012;20:e404

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

• ↵ The Cochrane Library. www3.interscience.wiley.com/cgibin/mrwhome/106568753/HOME?CRETRY=1&SRETRY=0 .
• ↵ British Medical Journal . www.bmj.com/ .
• ↵ Heran BS, Wong MMY, Heran IK, Wright JM. Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension. Cochrane Database Syst Rev 2008 ; 4 : CD003823 , doi: 10.1002/14651858.CD003823.pub2. OpenUrl PubMed
• ↵ National Institute for Health and Clinical Excellence. www.nice.org.uk .
• ↵ European Society of Cardiology. www.escardio.org/guidelines .
• ↵ Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed). Chest 2008 ; 133 : 381 -453S. OpenUrl CrossRef
• ↵ Wikipedia. http://en.wikipedia.org/wiki .
• ↵ Moher D, Schulz KF, Altman DG, Egger M, Davidoff F, Elbourne D, et al. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 2001 ; 357 : 1191 -4. OpenUrl CrossRef PubMed Web of Science
• ↵ The CONSORT statement. www.consort-statement.org/ .
• ↵ Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996 ; 17 : 1 -12. OpenUrl CrossRef PubMed Web of Science
• ↵ Critical Appraisal Skills Programme (CASP). www.sph.nhs.uk/what-we-do/public-health-workforce/resources/critical-appraisals-skills-programme .
• ↵ Oxford Centre for Evidence-based Medicine—Levels of Evidence. www.cebm.net .
• ↵ Van den Bruel A, Thompson MJ, Haj-Hassan T, Stevens R, Moll H, Lakhanpaul M, et al . Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ 2011 ; 342 : d3082 . OpenUrl Abstract / FREE Full Text
• ↵ Awopetu AI, Moxey P, Hinchliffe RJ, Jones KG, Thompson MM, Holt PJ. Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery. Br J Surg 2010 ; 97 : 797 -803. OpenUrl CrossRef PubMed

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• Meeting the review family: exploring review types and associated information retrieval requirements | Health Information and Libraries Journal, 2019
• A typology of reviews: an analysis of 14 review types and associated methodologies | Health Information and Libraries Journal, 2009
• Conceptual recommendations for selecting the most appropriate knowledge synthesis method to answer research questions related to complex evidence | Journal of Clinical Epidemiology, 2016
• Methods for knowledge synthesis: an overview | Heart & Lung: The Journal of Critical Care, 2014
• Not sure what type of review to conduct? Brief descriptions of each type plus tools to help you decide

• Ten simple rules for writing a literature review | PLoS Computational Biology, 2013
• The Purpose, Process, and Methods of Writing a Literature Review | AORN Journal. 2016
• Why, When, Who, What, How, and Where for Trainees Writing Literature Review Articles. | Annals of Biomed Engineering, 2019
• So You Want to Write a Narrative Review Article? | Journal of Cardiothoracic and Anesthesia, 2021
• An Introduction to Writing Narrative and Systematic Reviews - Tasks, Tips and Traps for Aspiring Authors | Heart, Lung, and Circulation, 2018

• The Literature Review: A Foundation for High-Quality Medical Education Research | Journal of Graduate Medical Education, 2016
• Writing an effective literature review : Part I: Mapping the gap | Perspectives on Medical Education, 2018
• Writing an effective literature review : Part II: Citation technique | Perspectives on Medical Education, 2018
• Last Updated: Mar 7, 2024 6:43 AM
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Home » Office of Curriculum » Medical Student Scholarship » III Scholarship Start Here » Scholarship of Integration » Key Steps in a Literature Review

Key Steps in a Literature Review

The 5 key steps  below are most relevant to narrative reviews. Systematic reviews include the additional step of using a standardized scoring system to assess the quality of each article. More information on  Step 1 can be found  here  and Step 5  here .

• Consider the purpose and rationale of a review
• Clearly articulate the components of the question
• The research question and purpose of your review should guide the development of your search strategy (i.e. which databases to search and which search terms to use)
• Justify any limitations you create for your search,
• Determine inclusion and exclusion criteria.
• Start by reviewing abstracts for relevant articles. Once this is complete, then begin a full text review of the remaining articles.
• Develop a data-charting form to extract data from each article. Update this form as needed if you find there is more information worth collecting.
• The resulting forms will serve as a summary of each article that will facilitate the process of synthesizing your results (i.e. the selected articles).
• In your analysis, include a numerical summary of studies included, an evidence table summarizing included articles, and a qualitative summary of the results.
• Report the results in the context of the overall purpose or research question.
• Consider the meaning of your results. Discuss limitations and implications for future research, practice, and/or policy.

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Literature review

Literature reviews are a way of identifying what is already known about a research area and what the gaps are. To do a literature review, you will need to identify relevant literature, often through searching academic databases, and then review existing literature. Most often, you will do the literature review at the beginning of your research project, but it is iterative, so you may choose to change the literature review as you move through your project.

Searching the literature

The University of Melbourne Library has some resources about searching the literature. Leonie spoke about how she met with a librarian about searching the literature. You may also want to meet face-to-face with a librarian or attend a class at the library to learn more about literature searching. When you search the literature, you may find journal articles, reports, books and other materials.

Filing, categorising and managing literature

In order to manage the literature you have identified through searches, you may choose to use a reference manager. The University of Melbourne has access to RefWorks and Endnote. Further information about accessing this software is available through the University of Melbourne Library .

Writing a literature review

The purpose of the literature review is to identify what is already known about a particular research area and critically analyse prior studies. It will also help you to identify any gaps in the research and situate your research in what is already known about a particular topic.

• Aveyard, H. (2010). Doing a literature review in health and social care: A practical guide . London, UK: McGraw-Hill Education. Retrieved from Proquest https://ebookcentral.proquest.com/lib/unimelb/detail.action?docID=771406
• Reeves, S., Koppel, I., Barr, H., Freeth, D., Hammick, M. (2002). Twelve tips for undertaking a systematic review. Medical Teacher . 24(4), 358-363 .
• Grant, M.J. and Booth, A. (2009). A typology of reviews: an analysis of 14 review types and associated methodologies. Health Information & Libraries Journal .
• Jesson, J., & Lacey, F. (2006). How to do (or not to do) a critical literature review. Pharmacy Education , 6(2), 139-148 .
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The use of drugs and medical students: a literature review

Affiliations.

• 1 4Th-year Medical Students fo the State University of Ponta Grossa (PR), Brazil.
• 2 Master in Science and Technology Teaching; Associate Professor of the Medical Program of the State University of Ponta Grossa (PR), Brazil.
• 3 PhD in Internal Medicine; Adjunct Professor of Medicine at the Ponta Grossa State University (UEPG), Ponta Grossa (PR), Brazil.
• PMID: 30304147
• DOI: 10.1590/1806-9282.64.05.462

Introduction: The consumption and abuse of alcohol and other drugs are increasingly present in the lives of university students and may already be considered a public health problem because of the direct impacts on the physical and mental health of these individuals. The requirements of the medical program play a vital role in the increasing rate of drug users.

Objectives: To carry out a systematic review of the literature on the use of drugs, licit or not, in Brazilian medical students.

Methods: A descriptive-exploratory study, in which the SciELO and MEDLINE databases were used. A total of 99 articles were found, of which 16 were selected for this review.

Results: Alcohol and tobacco were the most frequently used licit drugs among medical students. The most consumed illicit drugs were marijuana, solvents, "lança-perfume" (ether spray), and anxiolytics. The male genre presented a tendency of consuming more significant amounts of all kinds of drugs, with the exception of tranquilizers. It was found an increasing prevalence of drug consumption in medical students, as the program progressed, which may result from the intrinsic stress from medical school activities. Students who do not use psychoactive drugs are more likely to live with their parents, to disapprove drugs consumption, to practice religious beliefs and to be employed.

Conclusion: The prevalence of licit and illicit drug use among medical students is high, even though they understand the injuries it may cause.

Publication types

• Systematic Review
• Alcohol Drinking / epidemiology
• Brazil / epidemiology
• Illicit Drugs
• Marijuana Smoking / epidemiology
• Sex Factors
• Smoking / epidemiology
• Students, Medical / psychology*
• Substance-Related Disorders / epidemiology*

• Open access
• Published: 28 March 2024

Medical student wellbeing during COVID-19: a qualitative study of challenges, coping strategies, and sources of support

• Helen M West   ORCID: orcid.org/0000-0001-8712-5890 1 ,
• Luke Flain   ORCID: orcid.org/0000-0001-7296-6304 2 ,
• Rowan M Davies 3 , 4 ,
• Benjamin Shelley 3 , 5 &
• Oscar T Edginton   ORCID: orcid.org/0000-0001-5298-9402 3 , 6  

BMC Psychology volume  12 , Article number:  179 ( 2024 ) Cite this article

Metrics details

Medical students face challenges to their mental wellbeing and have a high prevalence of mental health problems. During training, they are expected to develop strategies for dealing with stress. This study investigated factors medical students perceived as draining and replenishing during COVID-19, using the ‘coping reservoir’ model of wellbeing.

In synchronous interactive pre-recorded webinars, 78 fourth-year medical students in the UK responded to reflective prompts. Participants wrote open-text comments on a Padlet site. Responses were analysed using reflexive thematic analysis.

Analysis identified five themes. COVID-19 exacerbated academic pressures, while reducing the strategies available to cope with stress. Relational connections with family and friends were affected by the pandemic, leading to isolation and reliance on housemates for informal support. Relationships with patients were adversely affected by masks and telephone consultations, however attending placement was protective for some students’ wellbeing. Experiences of formal support were generally positive, but some students experienced attitudinal and practical barriers.

Conclusions

This study used a novel methodology to elicit medical students’ reflections on their mental wellbeing during COVID-19. Our findings reinforce and extend the ‘coping reservoir’ model, increasing our understanding of factors that contribute to resilience or burnout. Many stressors that medical students typically face were exacerbated during COVID-19, and their access to coping strategies and support were restricted. The changes to relationships with family, friends, patients, and staff resulted in reduced support and isolation. Recognising the importance of relational connections upon medical students’ mental wellbeing can inform future support.

Peer Review reports

Medical students are known to experience high levels of stress, anxiety, depression and burnout due to the nature, intensity and length of their course [ 1 ]. Medical students are apprehensive about seeking support for their mental wellbeing due to perceived stigma and concerns about facing fitness to practice proceedings [ 2 ], increasing their vulnerability to poor mental health.

Research has identified that the stressors medical students experience include a demanding workload, maintaining work–life balance, relationships, personal life events, pressure to succeed, finances, administrative issues, career uncertainty, pressure around assessments, ethical concerns, and exposure to patient death [ 3 , 4 ]. In March 2020, the COVID-19 pandemic introduced additional stressors into medical students’ lives. These included sudden alterations to clinical placements, the delivery of online teaching, uncertainty around exams and progression, ambiguity regarding adequate Personal Protective Equipment (PPE), fear of infection, and increased exposure to death and dying [ 5 , 6 ]. Systematic reviews have reported elevated levels of anxiety, depression and stress among medical students during COVID-19 [ 7 ] and that the prevalence of depression and anxiety during COVID-19 was higher among medical students than in the general population or healthcare workers [ 8 ].

While training, medical students are expected to develop awareness of personal mental wellbeing and learn healthy coping strategies for dealing with stress [ 9 ]. Developing adaptive methods of self-care and stress reduction is beneficial both while studying medicine, and in a doctor’s future career. Protecting and promoting psychological wellbeing has the potential to improve medical students’ academic attainment, as well as their physical and mental wellbeing [ 10 ], and it is therefore important for medical educators to consider how mental wellbeing is fostered. Feeling emotionally supported while at medical school reduces the risk of psychological distress and burnout, and is related to whether students contemplate dropping out of medical training [ 11 ]. In their systematic narrative review of support systems for medical students during COVID-19, Ardekani et al. [ 12 ] propose a framework incorporating four levels: policies that promote a supportive culture and environment, active support for students at higher risk of mental health problems, screening for support needs, and provision for students wishing to access support. This emphasis on preventative strategies aligns with discussions of trauma-informed approaches to medical education, which aim to support student learning and prevent harm to mental wellbeing [ 13 ]. Dunn et al. [ 14 ] proposed a ‘coping reservoir’ model to conceptualise the factors that deplete and restore medical students’ mental wellbeing (Fig.  1 ). This reservoir is drained and filled repeatedly, as a student faces demands for their time, energy, and cognitive and emotional resources. This dynamic process leads to positive or negative outcomes such as resilience or burnout.

Coping reservoir model– adapted from Dunn et al. [ 14 ], with permission from the authors and Springer Nature

At present we have limited evidence to indicate why medical students’ mental wellbeing was so profoundly affected by COVID-19 and whether students developed coping strategies that enhanced their resilience, as suggested by Kelly et al. [ 15 ]. This study therefore sought to conceptualise the challenges medical students experienced during COVID-19, the coping strategies they developed in response to these stressors, and the supportive measures they valued. The ‘coping reservoir’ model [ 14 ] was chosen as the conceptual framework for this study because it includes both restorative and depleting influences. Understanding the factors that mediate medical students’ mental wellbeing will enable the development of interventions and support that are effective during crises such as the pandemic and more generally.

Methodology

This research study is based on a critical realist paradigm, recognising that our experience of reality is socially located [ 16 ]. Participant responses were understood to represent a shared understanding of that reality, acknowledging the social constructivist position that subjective meanings are formed through social norms and interactions with others, including while participating in this study. It also draws on hermeneutic phenomenology in aiming to interpret everyday experienced meanings for medical students during COVID-19 [ 17 ]. The use of an e-learning environment demonstrates an application of connectivism [ 18 ], a learning theory in which students participate in technological enabled networks. We recognise that meaning is co-constructed by the webinar content, prompts, ‘coping reservoir’ framework and through the process of analysis.

The multidisciplinary research team included a psychologist working in medical education, two medical students, and two Foundation level doctors. The team’s direct experience of the phenomenon studied was an important resource throughout the research process, and the researchers regularly reflected on how their subjective experiences and beliefs informed their interpretation of the data. Reflexive thematic analysis was chosen because it provides access to a socially contextualised reality, encompasses both deductive and inductive orientations so that analysis could be informed by the ‘coping reservoir’ while also generating unanticipated insights, and enables actionable outcomes to be produced [ 19 ].

Ethical approval

Approval was granted by the University of Liverpool Institute of Population Health Research Ethics Committee (Reference: 8365).

Participants

Fourth-year medical students at the University of Liverpool were invited to participate in the study during an online webinar in their Palliative Medicine placement. During six webinars between November 2020 and June 2021, 78 out of 113 eligible students participated, giving a response rate of 69%. This was a convenience sample of medical students who had a timetabled session on mental wellbeing. At the time, these medical students were attending clinical placements, however COVID-19 measures in the United Kingdom meant that academic teaching and support was conducted online, travel was limited, and contact with family and friends was restricted.

Students were informed about the study prior to the synchronous interactive pre-recorded webinar and had an opportunity to ask questions. Those who consented to participate accessed a Padlet ( www.padlet.com ) site during the webinar that provided teaching on mental wellbeing, self-care and resilience in the context of palliative medicine. Padlet is a collaborative online platform that hosts customisable virtual bulletin boards. During this recording, participants were asked to write anonymous open-text responses to reflective prompts developed from reviewing the literature (Appendix 1 ), and post these on Padlet. The Padlet board contained an Introduction to the webinar, sections for each prompt, links to references, and signposting to relevant support services. Data files were downloaded to Excel and stored securely, in line with the University of Liverpool Research Data Management Policy.

The research team used the six steps of reflexive thematic analysis to analyse the dataset. This process is described in Table  1 , and the four criteria for trustworthiness in qualitative research proposed by Lincoln and Guba [ 20 ] are outlined in Table  2 . We have used the purposeful approach to reporting thematic analysis recommended by Nowell et al. [ 21 ] and SRQR reporting standards [ 22 ] (Appendix 2 ).

Five themes were identified from the analysis:

COVID-19 exacerbated academic pressures.

COVID-19 affected students’ lifestyles and reduced their ability to cope with stress.

COVID-19 changed relationships with family and friends, which affected mental wellbeing.

COVID-19 changed interactions with patients, with positive and negative effects.

Formal support was valued but seeking it was perceived as more difficult during COVID-19.

COVID-19 exacerbated academic pressures

‘Every day feels the same, it’s hard to find motivation to do anything.’

Many participants reported feeling under chronic academic pressure due to studying medicine. Specific stressors reported were exams, revision, deadlines, workload, specific course requirements, timetables, online learning, placement, and communication from University. Some participants also reported negative effects on their mental wellbeing from feelings of comparison and competition, feeling unproductive, and overthinking.

Massive amounts of work load that feels unachievable.

COVID-19 exacerbated these academic stresses, with online learning and monotony identified as particularly draining. However, other students found online learning beneficial, due to reduced travelling.

I miss being able to see people face to face and zoom is becoming exhausting. My mental wellbeing hasn’t been great recently and I think the effects of the pandemic are slowly beginning to affect me.

I also prefer zoom as it is less tiring than travelling to campus/placement.

Clinical placements provided routine and social interaction. However, with few social interactions outside placement, this became monotonous. A reduction in other commitments helped some students to focus on their academic requirements.

Most social activity only taking place on placement has made every day feel the same.

Some students placed high value on continuing to be productive and achieve academically despite the disruption of a pandemic, potentially to the detriment of their mental wellbeing. Time that felt unproductive was frustrating and draining.

Having a productive day i.e. going for a run and a good amount of work completed in the day.

Unproductive days of revision or on placement.

COVID-19 affected students’ lifestyles and reduced their ability to cope with stress

‘Everyone’s mental well-being decreased as things they used for mental health were no longer available’.

Students often found it difficult to sustain motivation for academic work without the respite of their usual restorative activities challenging.

Not being able to balance work and social life to the same extent makes you resent work and placement more.

The competing demands medical students encounter for their time and energy were repeatedly reported by participants.

Sometimes having to go to placement + travel + study + look after myself is really tough to juggle!

However, removing some of the boundaries around academic contact and structure of extracurricular activities heightened the impact of stressors. Many participants focused on organising and managing their time to cope with this. Students were aware that setting time aside for relaxation, enjoyment, creativity, and entertainment would be beneficial for their wellbeing.

Taking time off on the weekends to watch movies.

However, they found it difficult to prioritise these without feeling guilty or believing they needed to ‘earn’ them, and academic commitments were prioritised over mental wellbeing.

Try to stop feeling guilty for doing something that isn’t medicine. Would like to say I’d do more to increase my mental wellbeing but finals are approaching and that will probably have to take priority for the next few months.

Medical students were generally aware that multiple factors such as physical activity, time with loved ones, spiritual care, nourishment and hobbies had a positive impact on their mental wellbeing. During COVID-19, many of the coping strategies that students had previously found helpful were unavailable.

Initially it improved my mental well-being as I found time to care for myself, but with time I think everyone’s mental well-being decreased as things they used for mental health were no longer available e.g. gym, counselling, seeing friends.

Participants adapted to use coping strategies that remained available during the pandemic. These included walks and time spent outdoors, exercise, journaling, reflection, nutrition, and sleep.

'Running’. ‘Yoga’. ‘Fresh air and walks'.

A few students also reported that they tried to avoid unhelpful coping strategies, such as social media and alcohol.

Not reading the news, not using social media.

Avoiding alcohol as it leads to poor sleep and time wasted.

Many participants commented on increased loneliness, anxiety, low mood, frustration, and somatic symptoms.

Everyone is worn out and demotivated. Feel that as I am feeling low I don’t want to bring others down. ‘Feel a lot more anxious than is normal and also easily annoyed and irritable.’

However, not all students reported that COVID-19 had a negative effect on wellbeing. A small minority responded that their wellbeing had improved in some way.

I think covid-19 has actually helped me become more self reliant in terms of well-being.

COVID-19 changed relationships with family and friends, which affected mental wellbeing

‘Family are a huge support for me and I miss seeing them and the lack of human contact.’

Feeling emotionally supported by family and friends was important for medical students to maintain good mental wellbeing. However, COVID-19 predominantly had a negative impact on these relationships. Restrictions, such as being unable to socialise or travel during lockdowns, led to isolation and poor mental wellbeing.

Not being able to see friends or travel back home to see friends/family there.

Participants frequently reported that spending too much time with people, feeling socially isolated, being unable to see people, or having negative social experiences had an adverse effect on their mental wellbeing. Relationships with housemates were a key source of support for some students. However, the increased intensity in housemate relationships caused tension in some cases, which had a particularly negative effect.

Much more difficult to have relationships with peers and began feeling very isolated. Talk about some of the experiences I’ve had on placement with my housemates. Added strain on my housemates to be the only ones to support me.

Knowing that their peers were experiencing similar stressors helped to normalise common difficulties. The awareness that personal contacts were also struggling sometimes curtailed seeking informal support to avoid being a burden.

Actually discussing difficulties with friends has been most helpful, as it can sometimes feel like you’re the only one struggling, when actually most people are finding this year really difficult. Family and friends, but also don’t want to burden them as I know I can feel overwhelmed if people are always coming to me for negative conversations.

COVID-19 changed interactions with patients, with positive and negative effects

‘With patients there has been limited contact and I miss speaking to patients.’

Some students reported positive effects on relationships with patients, and feeling a sense of purpose in talking to patients when their families were not allowed to visit. Medical students felt a moral responsibility to protect patients and other vulnerable people from infection, which contributed to a reduction in socialising even when not constrained by lockdown.

Talking to patients who can’t get visitors has actually made me feel more useful. Anxiety over giving COVID-19 to patients or elderly relatives.

Students occasionally reported that wearing PPE made interactions with patients more challenging. Students’ contact with patients changed on some placements due to COVID-19, for example replacing in-person appointments with telephone consultations, and they found this challenging and disappointing.

Masks are an impediment to meaningful connections with new people. GP block when I saw no patients due to it all being on the telephone.

Formal support was valued but seeking it was perceived as more difficult during COVID-19

‘Feel a burden on academic and clinical staff/in the way/annoying so tend to just keep to myself.’

Many participants emphasised the primary importance of support from family and friends, and their responses indicated that most had not sought formal support. While staff remained available and created opportunities for students to seek support, factors such as online learning and increased clinical workloads meant that some students found it harder to build supportive relationships with academic and placement staff and felt disconnected from them, which was detrimental for wellbeing and engagement.

Staff have been really helpful on placement but it was clear that in some cases, staff were overwhelmed with the workload created by COVID. Even though academic staff are available having to arrange meetings over zoom rather than face to face to discuss any problem is off putting.

A few students described difficulty knowing what support was available, and identifying when they needed it.

It’s difficult to access support when you’re not sure what is available. Also you may feel your problems aren’t as serious as other people’s so hold off on seeking support.

Formal support provided within the University included meetings with Academic Advisors, the School of Medicine wellbeing team, and University counselling service and mental health advisory team. It was also available from NHS services, such as GPs and psychological therapies. Those who had accessed formal support mostly described positive experiences with services. However, barriers to seeking formal support, such as perceived stigma, practicalities, waiting times for certain services, and concern that it may impact their future career were reported by some participants.

It is good that some services offer appointments that are after 5pm- this makes it more accessible to healthcare students. Had good experience with GPs about mental health personally. Admitting you need help or asking for help would make you look weak. Reassurance should be provided to medical students that accessing the wellbeing team is not detrimental to their degree. If anything it should be marketed as a professional and responsible thing to do.

Some students preferred the convenience of remote access, others found phone or video impersonal and preferred in-person contact.

Students expressed that it was helpful when wellbeing support was integrated with academic systems, for example Academic Advisors or placement supervisors.

My CCT [primary-care led small group teaching] makes sure to ask how we are getting on and how our placements are going, so I think small groups of people with more contact with someone are more useful then large groups over zoom. Someone to speak to on palliative care placement, individual time with supervisor to check how we are doing (wellbeing, mental health) - would be a nice quick checkup.

Participants typically felt able to share openly in an anonymous forum. Reading peers’ comments helped them to see that other students were having similar experiences and challenged unhealthy comparisons.

I definitely shared more than I would have done on a zoom call. I loved this session as it makes you feel like you’re not alone. Reassuring to know that there are others going through similar things as you.

Our findings demonstrate that the COVID-19 pandemic exacerbated the stressors medical students experience, and removed some rewarding elements of learning, while reducing access to pre-existing coping strategies. The results support many aspects of the ‘coping reservoir’ framework [ 14 ]. Findings corroborate the restorative effects of psychosocial support and social/healthy activities such as sleep and physical activity, and the depletion of wellbeing due to time and energy demands, stress, and disruptions relating to the pandemic such as online teaching and limited social interaction. Feeling a sense of purpose, from continuing studying or interactions with patients for example, was restorative for wellbeing. Mentorship and intellectual stimulation were present in the responses, but received less attention than psychosocial support and social/healthy activities. Internal conflict is primarily characterised by Dunn et al. [ 14 ] as ambivalence about pursuing a career in medicine, which was not expressed by participants during the study. However, participants identified that their wellbeing was reduced by feeling unproductive and lacking purpose, feeling guilty about taking time for self-care, competing priorities, and comparison with peers, all of which could be described as forms of internal conflict. Different restorative and draining factors appeared to not be equally weighted by the participants responding to the prompts: some appear to be valued more highly, or rely on other needs being met. Possible explanations are that students may be less likely to find intellectual stimulation and mentorship beneficial if they are experiencing reduced social support or having difficulty sleeping, and internal conflict about pursuing a career in medicine might be overshadowed by more immediate concerns, for example about the pandemic. This prioritisation resembles the relationship between physiological and psychological needs being met and academic success [ 23 ], based on Maslow’s hierarchy of needs [ 24 ]. A revised ‘coping reservoir’ model is shown in Fig.  2 .

Coping reservoir model - the effects of COVID-19 on restorative and depleting factors for medical students, adapted from Dunn et al. [ 14 ], with permission from the authors and Springer Nature

Relational connections with family, friends, patients, and staff were protective factors for mental wellbeing. Feeling emotionally supported by family and friends is considered especially important for medical students to maintain good mental wellbeing [ 11 ]. These relationships usually mitigate the challenges of medical education [ 25 ], however they were fundamentally affected by the pandemic. Restrictions affecting support from family and friends, and changes to contact with patients on placement, had a negative effect on many participants’ mental wellbeing. Wellbeing support changed during the pandemic, with in-person support temporarily replaced by online consultations due to Government guidelines. Barriers to seeking formal support, such as perceived stigma, practicalities, and concern that it may impact their future career were reported by participants, reflecting previous research [ 26 ]. Despite initiatives to increase and publicise formal support, some students perceived that this was less available and accessible during COVID-19, due to online learning and awareness of the increased workload of clinicians, as described by Rich et al. [ 27 ]. These findings provide further support for the job demand-resources theory [ 28 , 29 ] where key relationships and support provide a protective buffer against the negative effects of challenging work.

In line with previous research, many participants reported feeling under chronic academic pressure while studying medicine [ 3 ]. Our findings indicate that medical students often continued to focus on achievement, productivity and competitiveness, despite the additional pressures of the pandemic. Remaining productive in their studies might have protected some students’ mental wellbeing by providing structure and purpose, however students’ responses primarily reflected the adverse effect this mindset had upon their wellbeing. Some students felt guilty taking time away from studying to relax, which contributes to burnout [ 30 ] , and explicitly prioritised academic achievement over their mental wellbeing.

Students were aware of the factors that have a positive impact on their mental wellbeing, such as physical activity, time with loved ones, spiritual care, nourishment and hobbies [ 31 ]. However, COVID-19 restrictions affected many replenishing factors, such as socialising, team sports, and gyms, and intensified draining factors, such as academic stressors. Students found ways to adapt to the removal of most coping strategies, for example doing home workouts instead of going to the gym, showing how they developed coping strategies that enhanced their resilience [ 15 ]. However, they found it more difficult to mitigate the effect of restrictions on relational connections with peers, patients and staff, and this appears to have had a particularly negative impact on mental wellbeing. While clinical placements provided helpful routine, social interaction and a sense of purpose, some students reported that having few social interactions outside placement became monotonous.

Our findings show that medical students often felt disconnected from peers and academic staff, and reported loneliness, isolation and decreased wellbeing during COVID-19. This corresponds with evidence that many medical students felt isolated [ 32 ], and students in general were at higher risk of loneliness than the general population during COVID-19 lockdowns [ 33 ]. Just as ‘belongingness’ mediates subjective wellbeing among University students [ 34 ], feeling connected and supported acts as a protective buffer for medical students’ psychological wellbeing [ 25 ].

Translation into practice

Based on the themes identified in this study, specific interventions can be recommended to support medical students’ mental wellbeing, summarised in Table  3 . This study provides evidence to support the development of interventions that increase relational connections between medical students, as a method of promoting mental wellbeing and preventing burnout. Our findings highlight the importance of interpersonal relationships and informal support mechanisms, and indicate that medical student wellbeing could be improved by strengthening these. Possible ways to do this include encouraging collaboration over competition, providing sufficient time off to visit family, having a peer mentor network, events that encourage students to meet each other, and wellbeing sessions that combine socialising with learning relaxation and mindfulness techniques. Students could be supported in their interactions with patients and peers by embedding reflective practice such as placement debrief sessions, Schwartz rounds [ 35 ] or Balint groups [ 36 ], and simulated communication workshops for difficult situations.

Experiencing guilt [ 30 ] and competition [ 4 ] while studying medicine are consistently recognised as contributing to distress and burnout, so interventions targeting these could improve mental wellbeing. Based on the responses from students, curriculum-based measures to protect mental wellbeing include manageable workloads, supportive learning environments, cultivating students’ sense of purpose, and encouraging taking breaks from studying without guilt. Normalising sharing of difficulties and regularly including content within the curriculum on self-care and stress reduction would improve mental wellbeing.

In aiming to reduce psychological distress among medical students, it is important that promotion of individual self-care is accompanied by reducing institutional stressors [ 11 , 29 ]. While the exploration of individual factors is important, such as promoting healthy lifestyle habits, reflection, time management, and mindset changes, this should not detract from addressing factors within the culture, learning and work environment that diminish mental wellbeing [ 37 ]. Heath et al. [ 38 ] propose a pro-active, multi-faceted approach, incorporating preventative strategies, organisational justice, individual strategies and organisational strategies to support resilience in healthcare workers. Similarly, trauma-informed medical education practices [ 13 ] involve individual and institutional strategies to promote student wellbeing.

Students favoured formal support that was responsive, individualised, and accessible. For example, integrating conversations about wellbeing into routine academic systems, and accommodating in-person and remote access to support. There has been increased awareness of the wellbeing needs of medical students in recent years, especially since the start of the pandemic, which has led to improvements in many of these areas, as reported in reviews by Ardekani et al. [ 12 ] and Klein and McCarthy [ 39 ]. Continuing to address stigma around mental health difficulties and embedding discussions around wellbeing in the curriculum are crucial for medical students to be able to seek appropriate support.

Strengths & limitations

By using qualitative open-text responses, rather than enforcing preconceived categories, this study captured students’ lived experience and priorities [ 4 , 31 ]. This increased the salience and depth of responses and generated categories of responses beyond the existing evidence, which is particularly important given the unprecedented experiences of COVID-19. Several strategies were used to establish rigour and trustworthiness, based on the four criteria proposed by Lincoln and Guba [ 20 ] (Table  2 ). These included the active involvement of medical students and recent medical graduates in data analysis and the development of themes, increasing the credibility of the research findings.

Potential limitations of the study are that participants may have been primed to think about certain aspects of wellbeing due to data being collected during a webinar delivered by medical educators including the lead author at the start of their palliative medicine placement, and the choice of prompts. Data was collected during the COVID-19 pandemic, and therefore represents fourth year medical students’ views in specific and unusual circumstances. Information on this context is provided to enable the reader to evaluate whether the findings have transferability to their setting. Responses were visible to others in the group, so participants may have influenced each other to give socially acceptable responses. This process of forming subjective meanings through social interactions is recognised as part of the construction of a shared understanding of reality, and we therefore view it as an inherent feature of this methodology rather than a hindrance. Feedback on the webinar indicated that students benefitted from this process of collective meaning-making. Similarly, researcher subjectivity is viewed as a contextual resource for knowledge generation in reflexive thematic analysis, rather than a limitation to be managed [ 19 ]. The study design meant that different demographic groups could not be compared.

Padlet provided a novel and acceptable method of data collection, offering researchers and educators the potential benefits of an anonymous forum in which students can see their peers’ responses. The use of an interactive webinar demonstrated a potential application of connectivist pedagogical principles [ 18 ]. Researchers are increasingly using content from online forums for qualitative research [ 40 ], and Padlet has been extensively used as an educational tool. However, to the authors’ knowledge, Padlet has not previously been used as a data collection platform for qualitative research. Allowing anonymity carried the risk of students posting comments that were inappropriate or unprofessional. However, with appropriate guidance it appeared to engender honesty and reflection, provided a safe and collaborative learning environment, and student feedback was overwhelmingly positive. It would be useful to evaluate the effects of this reflective webinar on medical students’ mental wellbeing, given that it acted as an intervention in addition to a teaching session and research study.

Students were prompted to plan what they would do following the webinar to improve their mental wellbeing. A longitudinal study to determine how students enacted these plans would allow a more detailed investigation of students’ self-care behaviour.

While we hope that the stressors of COVID-19 will not be repeated, this study provides valuable insight into medical students’ mental wellbeing, which can inform support beyond this exceptional time. The lasting impact of the pandemic upon medical education and mental wellbeing remains to be seen. Nevertheless, our findings reinforce and extend the coping reservoir model proposed by Dunn et al. [ 14 ], adding to our understanding of the factors that contribute to resilience or burnout. In particular, it provides evidence for the development of interventions that increase experiences of relational connectedness and belonging, which are likely to act as a buffer against emotional distress among medical students.

Data availability

The datasets generated and analysed during the study are available from the corresponding author on reasonable request.

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Acknowledgements

We would like to thank Dr P Byrne for providing guidance, Mrs A Threlfall and Professor VCT Goddard-Fuller for commenting on drafts, and the medical students who participated in the webinars.

This study was unfunded.

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Helen M West

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School of Medicine, University of Liverpool, Liverpool, UK

Rowan M Davies, Benjamin Shelley & Oscar T Edginton

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Calderdale and Huddersfield NHS Foundation Trust, West Yorkshire, UK

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Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK

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HMW conceptualised the study and collected the data. HMW, LF, RMD, BS and OTE conducted data analysis. HMW, LF, RMD and OTE wrote the manuscript. All authors reviewed the manuscript.

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Correspondence to Helen M West .

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Approval was granted by the University of Liverpool Institute of Population Health Research Ethics Committee (Reference: 8365). Students were fully informed about the study prior to the workshop and had an opportunity to ask questions. Participants provided informed consent, completing an electronic consent form before responding to prompts. The study was conducted in accordance with relevant guidelines and regulations, including the University of Liverpool Research Ethics and Research Data Management Policies, and the Declaration of Helsinki.

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West, H.M., Flain, L., Davies, R.M. et al. Medical student wellbeing during COVID-19: a qualitative study of challenges, coping strategies, and sources of support. BMC Psychol 12 , 179 (2024). https://doi.org/10.1186/s40359-024-01618-8

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What motivates medical students to select medical studies: a systematic literature review

1 School of Public Health, PGIMER, Sector-12, Chandigarh, 160012 India

Federica Angeli

2 Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

3 Department of Organization Studies, School of Social and Behavioural Sciences, Tilburg University, Tilburg, the Netherlands

Nonita Dhirar

Neetu singla, dirk ruwaard.

4 Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

Associated Data

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

There is a significant shortage of health workers across and within countries. It is of utmost importance to determine the factors that motivate students to opt for medical studies. The objective of this study is to group and review all the studies that investigated the motivational factors that underpin students’ selection of medical study in recent years.

The literature search was carried out by two researchers independently in PubMed, Google Scholar, Wiley and IndMED databases for articles published from year 2006 till 2016. A total of 38 combinations of MeSH words were used for search purpose. Studies related to medical students and interns have been included. The application of inclusion and exclusion criteria and PRISMA guidelines for reporting systematic review led to the final selection of 24 articles.

The majority of the studies ( n  = 16; 66.6%) were from high-income countries followed by an equal number from upper-middle and lower-middle income countries ( n  = 4,16.7%). None of the studies were from low-income countries. All of the studies were cross-sectional in nature. The main motivating factors that emerged were scientific (interest in science / medicine, social interest and academia, flexible work hours and work independence), societal (prestige, job security, financial security) and humanitarian (serving the poor and under priviledged) in high-, upper-middle and lower-middle income countries, respectively. The findings were comparable to Maslow’s hierarchy of needs theory of motivation.

This systematic review identifies the motivational factors influencing students to join medical studies in different parts of the globe. These factors vary per country depending on the level of income. This study offers cues to policy makers and educators to formulate policy in order to tackle the shortage of health workers, i.e. medical doctors. However, more research is needed to translate health policy into concrete and effective measures.

The world is currently facing a dual problem of shortage and inequitable distribution of health workers, especially in middle- and low-income countries [ 1 ]. The World Health Organization (WHO) estimated a need for an additional 4.3 million health workers in 57 countries to fulfill the Millennium Development Goals [ 2 ]. In addition, 83 countries (44.6%) do not currently meet the 2006 World Health Report threshold of 22.8 skilled health professionals per 10,000 population [ 3 ]. Among many, the main reasons cited for shortage of health workers in rural areas include poor working conditions, lack of accommodation, lack of transport, poor pay structure, overburden with additional administrative responsibility and political interference [ 4 ]. In middle- and low-income countries, the situation is more critical because of migration of doctors to high-income (developed) countries whereas inequitable distribution of health workers between urban and rural areas is primarily due to poor motivation of health workers to work in rural areas [ 5 ].

The choice of medical study depends upon various factors such as interest in the medical field, good job opportunities, a desire to serve others, medical background of the parents and many more [ 6 , 7 ]. In literature, no review has been conducted in the last ten years about motivation factors of students to select medical studies. The existing reviews have either been conducted before ten years or with different objectives [ 8 , 9 ]. One review by Puertas et al. [ 8 ] published in 2013 was conducted to review the factors influencing medical student’s choice in primary care while another one by Brissette and Howes [ 9 ] published in 2010 was conducted on the articles available till 2008. Brisstte and Howes identified that motivation to take up medical studies lies in addressing learner’s needs for competence, autonomy, and relatedness. Providing optimal challenge and positive performance feedback, choice and opportunity for self-direction, and a sense of belongingness and connection to the medical profession can all be focused on to address the above mentioned motivators [ 9 ]. The review has given points for educators to act upon.The lacunae left by the previous review studies need to be addressed in a finer manner in context with the current challenge of the global workforce.

In last few years, human resources for health has attracted substantial scholarly attention. Over the last decade, there have been advancement in different fields of medical sciences, from prevention, patient care to laboratory workup and management of severe diseases and palliation. With the growing population and improving health care owing to better technologies, it is gravely important to improve the medical workforce, mostly doctors.

Globally, several health-related goals and programs are giving priority to human resource development in the health sector. The major health related initiatives like Sustainable Development Goals [ 10 ] and WHO’s six building blocks [ 11 ] focus on human resource development for achieving universal health coverage. The National health programs, like the National Health Mission in India, focuses on increasing human resources to upbring the health care services in the country.

The prospective medical students form a significant pool of health care workers that can help overcome the shortage globally. Therefore, understanding the current common motivational factors is essential and a summary of the factors through a review of these studies would derive a clearer picture. A strong predictor for any student to take up a career in any field is the motivation or drive from within. Motivation is defined as the process that initiates, guides, and maintains goal-oriented behaviors. It involves the biological, emotional, social, and cognitive forces that activate behavior. Fulfillment of needs results in some type of behavior, which can be either intrinsic or extrinsic [ 7 ]. Understanding motivation is very important in the medical sector because a motivated individual is willing to exert and maintain an effort to provide good-quality health services.

The objective of this study is to group and review all the studies that investigated the motivational factors that underpin students’ selection of medical study in recent years.

Search strategy

The literature search was carried out with the purpose to identify the perceptions of medical students to enter medical studies. The search was carried out by two researchers (NS and ND) independently in PubMed, Google Scholar, Wiley and IndMED databases for original studies conducted from 2006 to 2016. This time frame was chosen as many studies were done during this period to identify the motivational factors. MeSH and free-text terms “(Motivat*) AND (select* OR choice OR choose) AND (medical student* OR medical school* OR interns) have been used. Internship in the period of practical application of theoretical (mostly) knowledge of the previous medical school years, hence interns were also made a part of the search strategy. Search terms and keywords were altered as per specification of individual databases. A total of 38 combinations were used for search purpose.

An initial search identified thousands of related records from the Google scholar, PubMed, Ind Med and Wiley online library databases. The articles which were not related to motivation were excluded at the first step. Then search results were imported to Microsoft Excel and duplications were removed by sorting the titles of articles. The selected studies were then screened by reading the title and abstract resulting in shortlisting 91 articles. Of these, 62 articles were excluded based on eligibility criteria. The remaining 29 full-text articles were further assessed, and five were excluded because the articles were in Korean, Spanish and Chinese. A total of 24 studies were selected. Any differences of opinion were debated and consensus was reached. Further differences were resolved by the third researcher (SG). PRISMA guidelines were strictly followed during the study. Figure  1 represents the flow chart leading to sample selection.

Flow chart of selection and exclusion of studies for the systematic review

Selection criteria and sample

All studies carried out and published from year 2006 till 2016 were included in the review. Inclusion criteria were studies describing motivation to study medicine, conducted among medical students and interns and available in English language. Exclusion criteria were those studies done before 2006, published in languages other than English, and those not related to motivation or medical students and interns.

Data analysis

A thematic analysis of selected papers was performed, wherein two research assistants coded the papers independently and reached consensus on relevant themes [ 12 ]. They also extracted details of the final articles using a standardized abstraction form that collected information on: the author, the journal, the year of publication, location, study objectives, study design, major findings, limitations, and observations. In this paper, we systematically review the literature related to medical education with the goal of identifying the motivating factors influencing the medical students to join medical studies.

The results of the studies’ review were categorized under different heads viz. scientific factors, social factors and humanitarian factors based upon criteria devised by Goel S et al. in their study on development and validation of the motivations for selection of medical study in India [ 13 ]. In this study a ‘Motivation of Selection of Medical Study (MSMS)’ tool was developed using extensive literature review followed by Delphi technique. The three domains and the issues that emerged are shown in Table  1 .

Domains and issues that emerge as main motivational factors

Ethical considerations

The study was granted ethical approval from the Institute’s Ethical Committee, PGIMER, Chandigarh (PGI/IEC/2012/810–1 P-154). Since the study is a systematic review of studies and individual level data is neither obtained nor presented, the consent.

The characteristics of the studies included in the systematic review are shown in Table  2 . The assessment of factors of motivations for medical students to select medical studies was based on the World Bank categorization of low-, middle- and high-income countries [ 14 ].The low-income, lower middle-income, upper middle-income and high-income economies are defined as those with a Gross National Income (GNI) per capita of $1005 or less, between $1006 and $3955, between $3956 and $12,235 and $12,236 or more, respectively in the year 2016. The majority of the studies ( n  = 16, 66.6%) were from high-income countries followed by an equal number from upper middle and lower middle income countries ( n  = 4,16.7%). None of the studies were from low-income countries. All of the studies were cross sectional in nature ( n  = 24). Figure  2 shows the geographic distribution of the different studies.

Characteristics of the studies included in the systematic review ( n  = 24)

Geographical distribution of the different studies across the globe (used a web page https://mapchart.net which is free of cost and specifically designed for making customised maps)

Predominance of motivating factors according to income group

Results reported for motivation to select medicine by medical students changes in the context of place (see Fig.  3 and Table  3 ). The choice of medical study among students differs between students in high-income countries, and those in upper-middle and lower–middle-income countries. The individual motivation factors that emerged are presented in Table  4 .

Categorization of motivation factors across different income country groups

Factors affecting motivations of medical students to select medicine across different country income groups

Most commonly cited motivational factors among all the studies analyzed ( N  = 24)

High-income countries

In most of the high-income counties, scientific and humanitarian factors were described as the main motivators to select medicine by medical students [ 15 – 29 ]. Most of the high income countries including Spain, Croatia, Poland, UK, Hungary, Germany and South Korea reported similar type of motivators to motivate the medical students for choosing medicine: interest in science/medicine, social interest, flexible work hours and work independence. Results reported by Kim et al.(2016) [ 16 ], Becker et al. (2015) [ 29 ], Wouters (2014) [ 19 ] emphasized on the scientific factors. Societal factors were also reported in most of these studies but fell lower in hierarchy.

Uppermiddle income countries

The main motivators to select medicine by medical students of upper-middle income countries include the societal and scientific factors [ 30 – 33 ]. A study by Kavousipour et al. (2015) [ 30 ] conducted in Iran explains that the factors which were most significant to motivate the students were family attitudes, getting good jobs in future, respect for themselves, the ability to learn, believing their role in victory and defeat and the tendency toward optimism about themselves. Pagnin et al. (2013) [ 32 ] also concluded similar findings. Social and professional status of the job, healthcare-people factor, others’ recommendation and advices, personal interest and nature of occupation, occupational experience and personal life had been identified as main factors of motivation. The findings reported by Korkmaz et al. (2013) [ 31 ] also found societal and scientific factors to be more significant motivators.

Lower-middle -income

In low-middle income countries, students have mixed responses for the choice of medical studies. [ 34 – 37 ]. Humanitarian and societal factors had been reported as main influences to join medicine.

Few studies conducted in various parts of India had reported almost similar results. A study conducted in Madhya Pradesh, India by Diwan et al. (2013) [ 35 ] concluded that reasons for entering medical education included personal ambition, parental desire, prestigious profession, altruistic reasons and pecuniary incentives. Similar to these findings were those reported by Kuriakose (2015) [ 34 ], Seetharaman et al. (2012) [ 36 ] and Lal et al. in 2007 [ 37 ]. The main reasons that motivate the medical students were to serve the sick and society and having a high status in society.

To our knowledge, this is the first systematic review of motivational factors for choosing medical studies by medical students globally. Earlier reviews were related to factors influencing student rating in undergraduate medical education course evaluations and factors that influence a career choice in primary care among medical students from high-, middle- and low-income countries [ 8 ]. The present systematic review, which has analyzed 24 studies in detail, is important as it identifies the motivational factors influencing the medical students to join medical studies in different parts of the globe along with the variations among the factors in lower-middle, upper-middle and high-income countries. As such, it provides essential insights into how students could be motivated, and how this varies across countries. No study was found from low-income countries. The limited research on this topic in low-income countries could be related to the lack of interest in this particular area, or to an overall deficit in research in developing nations, or both. These countries could identify the issues and intervene according to the research done in lower-middle and upper-middle income countries.

Several theories of motivation have been described in relation to career choice among student including intrinsic and extrinsic factors as described by Brissette and Howe [ 9 ] and by Maslow [ 38 ],. Taylor, McClelland and Herzberg [ 39 ]. However, Maslow’s theory remains to be the most detailed and frequently used theory [ 38 ]. The Maslow’s hierarchy of needs describes motivational factors under five broad segments: the physiological needs, the needs for safety and security, the needs for love and belonging, the needs for esteem, and the need to actualize the self, in that order [ 38 ]. Physiological needs are the basic needs required by an individual, such as food, water, sleep, etc. Once these needs are met, the second segment of needs comes into picture making safety, stability, protection the prime concerns. Following these factors the third segment consists of desires to marry, have a family, become a part of their community etc. The fourth segment of esteem has two versions as described by Maslow. The need for respect, prestige, prominence, magnificence, appreciation, attention, status, self-esteem, and dominance forms the lower version while the higher form involves the need for self-respect which includes feelings as self-confidence, capability, accomplishment, mastery, and freedom. The last segment is the phase of self-actualization which is a desire for self-fulfillment [ 38 ].

In low-middle income countries, students are still striving to fulfill primary basic needs and safety and security of employment, family, health. They fall under the first two segments of the pyramid comprising of basic needs, safety stability and protection and hence the predominant motivational factors are humanitarian in this group. In some areas where these needs are fulfilled, the higher segment of self-esteem also come into picture, hence societal factors are also seen in lower-middle income countries. The prime reasons for selecting medical studies among students in low-income countries were parental desire, respected profession and economic incentives, respect in society, high societal status and to serve the sick. The desire to serve the poor is deeply ingrained in this society. Most of the students belong to lower or middle socio-economic groups and understand the miseries of poor well and these factors lead them to serve the humanity and poor people. Here medical students are more sensitive to the social needs of population. The very reasons identified to take up medical career in these countries can be used to encourage students to take up medical studies. Mainly, the respect and feeling of altruism, followed by the monetary and social benefits are a driving force that can be used to attract the students into medical profession, hence improving the workforce. As the motivational factors are mostly innate, their further interest in medical studies and serving the nation will remain significant.

In the upper-middle income countries the factors as described by the middle zone in the Maslow’s hierarchy of needs pyramid were identified. The majority of studies identified societal factors as better predictors as compared to humanitarian and scientific factors. The main motivators to select medicine by medical students of upper-middle income countries are job security, social status, and parental wish. The reason behind this is that, to become a doctor is one of the highest ambition of many school-going students and their parents in middle- and low-income countries, along with the fact that the medical profession is preferred by the students due to its high prospect of financial security and high social status. Being a respected profession with high social status and higher salaries has been found to be motivating factor for students. The students in these countries have mostly met their basic needs and are more attracted towards a better lifestyle and income. Security in all fronts is a strong predictor for picking medical studies, and this can help enroll more students into this career. Excelling in their medical education may act as a strong target as their competition decides their future prospects.

The motivational factors commonly reported by most of the studies in high-income countries were the third and fourth segments of the Maslow’s hierarchy of needs pyramid. The scientific factors were the main motivators to select medicine by students. This may be due to the fact that the students in high-income countries chose medicine or science, who have prime interest in these subjects. The interest in science is usually developed during their school times to become medical school academics in a well-developed education system and with advanced technologies (modern laboratory facilities). The availability of good technologies and advanced education helps in developing specialized skills through the medical school years and beyond. In addition, the ability to earn well, pay their debts and live comfortably are strong motivators as well.

There are various strengths of the study. Firstly, the review was done on a sizeable number of 24 studies across the globe, hence generating stronger evidence. Secondly, the study relates the motivational factors across different countries with the Maslow’s hierarchy of needs theory [ 38 ]. This helps to understand the motivational factors of medical students to work in rural areas with respect to the innate motivational factors of a human being.

This review has a few limitations. Despite our efforts to identify all relevant studies by searching four different databases and using a fairly large number of search terms, we might have missed relevant studies. Additionally, unpublished studies from low- and middle-income countries were not represented (publication bias). The exclusion of articles published before 2006 may have omitted literature that could have provided valuable information. However, our review supplement two existing reviews published earlier [ 8 , 9 ].

In conclusion, this systematic review investigated the reasons that affect students’ decisions to join medical profession. The motivational factors are being classified in scientific factors (e.g. ‘interest in medicine’), societal factors (e.g. ‘respect/prestige’) and humanitarian factors (e.g.‘desire to help others’). The predominance of factors varied among students in high-, upper-middle and lower-middle income countries. Hence, this study offers cues to policy makers and educators in different countries to understand the motivational factors as a first step to formulate policy in order to tackle the shortage of health workers to improve the status of human resources across nations. However, more research on the subject would assist in promoting as well as translating health policy into concrete and effective measures at the local, national, regional and global levels in low- and middle- income countries.

Acknowledgements

This study did not receive any funding.

Availability of data and materials

Abbreviations, authors’ contributions.

Conceptualization: SG FA. Data curation: SG ND NS. Formal analysis: SG ND NS. Funding acquisition: SG. Investigation: SG. Methodology: SG FA DR. Project administration: SG. Resources: SG. Software: NS, ND. Supervision: SG. Validation: SG ND. Writing original draft: ND NS. Writing review & editing: SG FA DR. All authors have read and approved the final version of the manuscript.

Ethics approval and consent to participate

The study was granted ethical approval from the Institute’s Ethical Committee, PGIMER, Chandigarh (PGI/IEC/2012/810–1 P-154). The anonymity and confidentiality of participants in the studies were ensured. Since the study is a systematic review of studies and individual level data is not obtained, the consent was not required.

Consent for publication

Since individual level data is not presented, the consent for publication of data was not required.

Competing interests

The authors declare that they have no competing interests.

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Contributor Information

Sonu Goel, Phone: 0172-2755215, Email: ni.oc.oohay@700leogunos .

Federica Angeli, Email: [email protected] , Email: [email protected] .

Nonita Dhirar, Email: moc.oohay@381atinon .

Neetu Singla, Email: [email protected] .

Dirk Ruwaard, Email: [email protected] .

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Active Student Participation in Whole-School Interventions in Secondary School. A Systematic Literature Review

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• Published: 04 May 2023
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This review presents a reasoned synthesis of whole-school interventions seeking to improve the overall school environment by fostering active student participation (ASP) in school activities and decision-making processes. The aims are to describe the selected programs, assess their methodological quality, and analyze the activities soliciting ASP. Among the 205 publications initially provided by the literature search in the academic databases PsycINFO and Education Research Complete, 22 reports met the inclusion criteria of presenting whole-school interventions that solicit ASP in secondary schools, and were thus included in the review. Such publications referred to 13 different whole-school programs, whose implemented activities were distinguished on a 5-point scale of ASP levels, ranging from Very high ASP , when students were involved in a decision-making role, to Very low ASP , when students were the passive recipients of content provided by adults. This review contributes to the literature by proposing an organizing structure based on different levels of ASP, which provides clarity and a common ground for future studies on student participation. Overall, the in-depth description of activities offers a framework to researchers and practitioners for planning interventions aimed at improving the learning environment and contributing meaningfully to the far-reaching goal of encouraging student participation in school life.

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Introduction

Research in educational psychology is consistent in showing that the quality of the school environment largely affects student well-being. Indeed, students’ experiences of a supportive school context have a significant impact on positive behaviors, such as academic achievement (Brand et al., 2008 ; Hoy, 2012 ) and good relationships among students and between students and staff (Cohen et al., 2009 ; Thapa et al., 2013 ). Conversely, the poor quality of the learning environment predicts negative outcomes, such as substance use (Weatherson et al., 2018 ) or bullying (Låftman et al., 2017 ).

In view of this, schools need to face the challenge of implementing interventions aimed at changing and improving the learning environment in the direction of promoting positive behaviors and reducing negative outcomes. One of the most promising directions in this regard is based on the adoption of whole-school approaches whose key features are the focus on overall school systems instead of on specific problems (Bonell et al., 2018 ).

The literature on whole-school interventions is broad (see, for example, Charlton et al., 2021 , for an extensive review on whole-school interventions focused on school climate), but it suffers from two major gaps. First, it relies primarily on programs applicable to elementary schools, while studies on high school populations are rarer, presumably because of the multiple challenges derived from the implementation of programs in such complex contexts (Estrapala et al., 2021 ; Vancel et al., 2016 ). Second, despite the importance generally attributed to the active involvement of students in the programs, to our knowledge, no previous reviews have specifically investigated the degree and the characteristics of student participation in such interventions. To address these limitations, in this article, we present a systematic literature review on whole-school interventions carried out in secondary schools and based on programs that envisage students’ active participation and involvement.

Whole-School Interventions for Improving the Learning Environment

In educational research, some reviews and meta-analyses (Charlton et al., 2021 ; Merrell et al., 2008 ; Voight & Nation, 2016 ) have critically synthesized and discussed studies on school interventions aimed at improving the learning environment. These programs have considered different outcomes of improvement, ranging from a general focus on school climate dimensions—e.g., relational aspects, institutional organization, and safety—to more specific aspects, such as bullying, violence, or substance use. However, the degree of effectiveness of such programs remains controversial. For example, a meta-analysis by Ttofi et al. ( 2008 ) indicated that school-based bullying prevention programs were able to bring about positive results, while another meta-analysis on the same topic (Merrel et al., 2008 ) concluded that evidence in this direction was only modest.

More positive results concerning the effectiveness of interventions were reported by Allen ( 2010 ) with reference to programs conducted by means of a whole-school approach. In her literature overview of studies designed to reduce bullying and victimization, the author concluded that whole-school interventions generally showed at least marginal evidence of improvement. Despite these encouraging findings, the studies conducted with a whole-school approach in secondary education contexts were rare. Among these, a well-established framework of whole-school interventions mostly implemented in middle schools is the School-Wide Positive Behavior Support program (for reviews, see Gage et al., 2018 ; Noltemeyer et al., 2019 ), which is a multi-tiered framework engaging students, school staff, and families for the delivery of evidence-based behavioral support aligned to students’ needs (Horner et al., 2004 ). By and large, the study results in this framework are again promising in suggesting a connection between such programs and school improvement, although the evidence is generally moderate and only regards a few of the considered outcome measures.

The mixed or weak results reported in the cited reviews solicit further exploration of the specific characteristics of whole-school interventions. In particular, a major limitation of the literature is the lack of an in-depth analysis of the types of activities proposed to students in each program, especially as far as their direct involvement is concerned. Given the importance attributed to student engagement in school life (Markham & Aveyard, 2003 ), this is a relevant area of inquiry that can inform researchers and practitioners willing to design and conduct whole-school interventions calling for students’ involvement.

Student Involvement in School Intervention

The importance of students’ involvement and participation finds a theoretical ground in the self-determination theory (see Ryan & Deci, 2017 ), according to which people who are self-determined perceive themselves as causal agents in life experiences, being proactive and engaged in the social environment. Studies examining such human disposition in adolescence supported the relevance of self-determination for quality of life and identity development (Griffin et al., 2017 ; Nota et al., 2011 ) and as a full mediator in the negative association between stress and school engagement (Raufelder et al., 2014 ).

In the light of these assumptions, educational and school psychologists have launched scientific and professional debates on the ways in which schools can implement favorable conditions for students to feel active and co-responsible for their educational and academic pathways (Carpenter & Pease, 2013 ; Helker & Wosnitza, 2016 ; Schweisfurth, 2015 ). These debates have reached consensus across-the-board on the recognition that school change and improvement are best fostered by intervention programs in which students are offered opportunities to get actively involved in school life (Baeten et al., 2016 ; Voight & Nation, 2016 ). For this goal to be achieved, all educational agencies are called upon to promote interventions capable of supporting activities that require student involvement and participation (Antoniou & Kyriakides, 2013 ).

The importance of students’ active participation in the school environment has also been confirmed by a substantial amount of literature investigating over time the association between high student involvement and positive learning environments. Mitchell ( 1967 ) reported that school climate is related to the extent of student participation and interaction during school life. Epstein and McPartland ( 1976 ) showed that student opportunities for school involvement were related to satisfactory outcomes. In a 1982 review published, Anderson claimed that “the type and extent of student interaction that is possible within a school appears to be a significant climate variable” (Anderson, 1982 ; p.401). A few years later, Power et al. ( 1989 ) described a program implemented in several contexts and characterized by high student involvement, whose results showed that a high rate of student participation led to their capacity to take on responsibility for building an effective learning environment and positive climate. More recent studies (Vieno et al., 2005 ) have confirmed that democratic school practices, such as student participation in decision-making processes, play a significant role in the development of a sense of community at individual, class, and school levels. The review by Thapa et al. ( 2013 ) confirmed the importance of student classroom participation as a variable affecting school climate and academic achievement.

On these theoretical and empirical grounds, providing space to student voices in decision-making and school change emerges as a powerful strategy for improving school environments and enforcing the success of programs (Mitra, 2004 ). The construct of student agency fits in well with this approach, as it refers to the students’ willingness and skill to act upon activities and circumstances in their school lives (Lipponen & Kumpulainen, 2011 ). Representing adolescents’ authentic, proactive, and transformative contributions to school life (Grazia et al., 2021 ), agency is fostered by school environments capable of soliciting and valorizing students’ active participation in educational practices and school decisions (Makitalo, 2016 ) and encouraging them to feel co-responsible with teachers and staff for their school lives (Mameli et al., 2019 ). The value of agency has been confirmed by research showing its positive associations with motivation and the fulfilment of basic psychological needs (Jang et al., 2012 ) as well as with the perception of supportive teaching (Matos et al., 2018 ).

Despite the agreement on student participation as a crucial feature for the success of programs capable of improving students’ school life, to our knowledge, previous literature reviews on school interventions have not focused specifically on the extent and way in which students are given a voice and are involved in the programs. In view of this, in the present work, we set out to search, in the existing literature, for interventions specifically based on activities in which students were not just the recipients of activities but rather took on an active and decision-making role. For our purposes, we use the notion of active student participation (ASP) to include the variety of ways in which students are given the opportunity to participate actively in school activities and decisions that will shape their own lives and those of their peers.

Review’s Aims

Previous reviews (Charlton et al., 2021 ; Estrapala et al., 2021 ; Voight & Nation, 2016 ) have provided extensive descriptions of whole-school interventions aimed at improving school environments or reducing school problems, suggesting their effectiveness. Moreover, a growing amount of literature has found that students’ active involvement in their school life is a crucial feature for improvement. Our general goal was to move forward by conducting an in-depth examination of existing whole-school interventions based on activities promoting ASP in secondary schools, by providing a reasoned synthesis of their characteristics and implementation. The choice to focus on secondary schools was driven by the evidence that this developmental stage has so far received less attention in whole-school intervention research (Estrapala et al., 2021 ; Vancel et al., 2016 ).

Given the large heterogeneity of existing intervention programs, both in terms of participants (specific subgroups vs general student population) and targets of improvement (specific abilities vs general school environment), it was essential to set clear boundaries for the study selection. As this was a novel undertaking, we chose to focus on whole-school interventions directed to the overall student population and aimed at improving the school climate as a whole. This allowed us to select a reasonably homogeneous sample of studies, with the confidence that future reviews will advance our knowledge by considering more specific fields and populations.

The review’s aims were (a) to describe the selected programs on the basis of their focus, country, duration, age of participants, and research design; (b) to assess the soundness of the research design and methodologies adopted in each study in order to provide evidence of the methodological quality of the selected programs; and (c) to differentiate among various levels of ASP in the program’s activities and, for each of these levels, to describe methods and activities carried out in the programs.

The present review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 updated statement (PRISMA 2020; Page et al., 2021 ). In line with the terminology proposed by the authors, in the following sections, we use the term study for every investigation that includes a well-defined group of participants and one or more interventions and outcomes, report for every document supplying information about a particular study (a single study might have multiple reports), and record for the title and/or abstract of a report indexed in a database. In addition, for the specific purposes of the present review, we use the term program when referring to an implemented whole-school intervention that has specific characteristics and is usually named, since more than one study may be conducted with the same program.

Eligibility Criteria

Studies were eligible for inclusion in the review if they were (i) written in English language; (ii) published in peer-reviewed academic journals; and (iii) aimed at assessing psychological effects of whole-school interventions that solicit ASP in secondary schools; thus, studies in which students were involved solely as recipients of activities delivered by adults were excluded. Moreover, in line with the review’s aims described above, studies were excluded from the review if they were (i) focused on specific subgroups of students (e.g., ethnical minorities or LGBTQ students); (ii) solely aimed at improving specific skills (e.g., literacy or mathematics); and (iii) solely focused on physical health (e.g., nutrition or physical activity).

Information Sources and Search Strategy

A literature search was conducted via EBSCO, including the academic databases PsycINFO and Education Research Complete, last consulted on April 9, 2022. The entered search terms were school-wide interventions OR whole-school interventions OR school-wide programs OR whole-school programs OR school-wide trainings OR whole-school trainings AND secondary school OR high school OR secondary education. By means of the software’s automated procedure, we searched these terms in the abstracts and filtered the results according to the first two inclusion criteria, selecting articles in English and published in peer-reviewed academic journals.

Selection and Data Collection Process

The records of each study were screened by two researchers, and the potentially relevant studies were further assessed for eligibility by three researchers, who read the full text independently. Moreover, some records relevant to the purposes of the research were identified through the references of the included documents ( forward snowballing ; Wohlin, 2014 ). Data from each included report were searched by two researchers, who worked independently to extrapolate the information relevant to the review, which were (a) the study characteristics; (b) the indicators of methodological quality; and (c) the program activities.

Detailed information about the selection process is provided in the PRISMA flow diagram (Fig.  1 ). The literature search provided 205 total records, and reduced to 169 after the automatic deduplication provided by EBSCO. After the application of our inclusion and exclusion criteria, 62 records were selected for full text reading. Of the 107 excluded records, 37 did not report interventions (e.g., they presented only school surveys), 25 were informative papers on initiatives and/or interventions without assessments, 15 focused only on academic skills attainment, 11 referred to primary schools, 10 focused on minorities, 6 were reviews of books or DVDs, and 3 only evaluated physical health as an outcome. After the full text reading of the 62 selected reports, 48 were excluded as they only discussed aspects related to implementation (e.g., feasibility or fidelity) without assessing the psychological effects of the intervention on students ( n  = 23) or did not solicit ASP during the intervention ( n  = 25). Thus, 14 reports were included in the sample. In addition, 10 reports were identified by sifting through the references of the selected documents ( forward snowballing ; Wohlin, 2014 ). After the full text reading, two of them were excluded as they did not assess the effects of the intervention. At the end of the selection process, the final sample of the present review included 22 reports, which referred to 16 studies and 13 programs.

PRISMA flow diagram

Study Characteristics

The main information about each study is reported in Table 1 . As for the focus of the interventions, three macro-areas were identified: (a) prevention of violence (nine studies and twelve reports), including programs for less bullying, cyberbullying, dating violence, sexual violence, and aggression; (b) promotion of mental health (five studies and seven reports), including programs for addressing depression and suicide risk and for promoting general psychological health; (c) promotion of positive emotional and relational school climate (two studies and three reports), including programs for enhancing school connectedness and school climate.

Within each macro-area, in Table 1 , the programs are listed following the alphabetical order of the program name. Out of the studies focused on preventing violence, three referred to unnamed anti-bullying programs, which in the present review were labeled Anti-bullying_1 , Anti-bullying_2 , and Anti-bullying_3 ; the other studies on the topic referred to an anti-cyberbullying program named Cyber Friendly School ; an anti-bullying program named Friendly School ; a bystander program aimed at preventing dating violence and sexual violence, named Green Dots ; a program aimed at preventing bullying and aggression, named Learning Together ; and an anti-bullying program named STAC , which stands for Stealing the show, Turning it over, Accompanying others, Coaching compassion. The studies focused on promoting mental health comprised a school research initiative aimed at preventing depression, named Beyond blue ; an intervention aimed at promoting mental health, named Gatehouse Project ; and a program to prevent suicide risk, named Sources of Strengths . Out of the studies focused on promoting positive emotional and relational school climate, one referred to the Restorative Justice program, aimed at promoting healthy and trusting relationships within the school, and the other referred to a program aimed at the promotion of a good school climate, named SEHER , which stands for Strengthening Evidence base on scHool-based intErventions for pRomoting adolescent health.

A large majority of the studies were conducted in the USA, some were carried out in Australia and the UK, and a few studies in India and China. The studies varied in duration, ranging from one to seven school years, and the number of schools involved in the intervention, ranging from 1 to 75. About half of the studies involved students from all grades while the other half was targeted only for some grades. Lastly, the reports varied in its research design: the majority conducted experimental group comparisons (EGC), but also other quantitative research designs (O) were present along with some qualitative designs (QUAL). To make text and tables more readable, the 13 included programs were renamed with a program ID consisting of the initials of the program name. Similarly, the 22 included reports were renamed with a report ID , consisting in the program ID followed by the surname of the first author and the publication year, all separated by underscores. Report ID and Program ID are reported in Table 1 .

Assessment of Methodological Quality

To assess each report’s methodological quality, we searched in the literature for a rigorous and comprehensive set of indicators and eventually decided to use as a reference the standards for evidence-based practices identified by the Council for Exceptional Children (CEC, 2014 ), which include indicators on setting and program description, fidelity, and reliability of outcome measures. Although the standards were originally recommended for the specific field of special education, they are considered appropriate to evaluate studies in all educational settings and were previously used by Charlton et al. ( 2021 ) in a systematic review studying the effects of school-wide interventions on school climate perceptions. Given that our aim was not to identify evidence-based practices but more generally to assess the methodological quality of the reports included in the review, some of the identified indicators were not applicable to our material. For this reason, among all the indicators described in the document (CEC, 2014), we selected those that provided a general overview of each report’s methodological quality. The selected indicators, their corresponding number in the CEC document, and a short description for each are reported in Table 2 .

In more detail, we applied a more extensive set of indicators to reports which fit the CEC definition of experimental group comparison design (EGC, as reported in Table 1 ), where participants were divided into two or more groups, both randomly and non-randomly, to test the effects of the interventions. For reports based on qualitative analyses and on quantitative analyses not consistent with the EGC design (QUAL and O, as reported in Table 1 ), we used a more limited set of indicators (indicators 1 to 6, as described in Table 2 ) and included a brief description of the research aims and methods. In the assessment of methodological quality, interrater reliability was achieved as three independent researchers read each report in detail, and the attribution of each indicator was discussed and agreed upon.

The assessment of methodological quality for the EGC reports is summarized in Table 3 . The findings show that most studies were strong in contextualizing the research, clearly describing the intervention program (either directly or with references to previous work) and conducting quality analyses. Weak points emerged to be related to the assessment of fidelity implementation (indicators 4 and 5 in Table 3 ), both with reference to adherence to the intervention program and to the dosage received by participants. Results for studies with qualitative analyses or quantitative analyses not EGC are reported in Table 4 . Like the ECG reports, most of these studies appeared strong in contextualizing the research and describing the intervention program, while fidelity of implementation received less attention (indicators 4 and 5 in Table 4 ).

Levels of Active Student Participation

As required by our inclusion criteria, all the selected programs were based on interventions that solicited ASP. However, from the careful analysis of the studies, we realized that the program activities promoted very different forms of ASP. Three independent researchers thus considered in detail each activity described in the programs and eventually agreed to score it on a 5-point scale (see Table 5 ), distinguishing among activities that solicit various levels of ASP. The scale partly followed the school participation scale of the HBSC questionnaire as defined by De Róiste et al. ( 2012 ). It ranged from Very high levels of ASP, attributed to activities in which students were given a fully decision-making role, to Very low levels of ASP, given to activities in which students were just the recipients of activities delivered by adults. In line with our inclusion criteria, in no programs, students were involved solely as recipients of activities delivered by adults (Very low ASP). Moreover, levels were not mutually exclusive, so that each program might include different levels of ASP.

In Table 5 , we report all the considered ASP levels, with the specifically related activities, and the coding of each program. It should be specified that the distribution of activities in the various levels was based on a qualitative accurate analysis of the role attributed to students and not on the number of students involved in each program’s activities, which varied to a great extent. In more detail, Very high ASP was attributed to interventions in which students were involved in processes with a direct organizational impact on school roles, curricula, and policies; this included two types of activities, i.e., student involvement in decision-making processes and the formation of school action teams comprising students. High ASP was recognized when students were still involved in organizational activities, but their role was limited to the implementation of activities and did not directly impact on school curricula and policies; it consisted of three activities, i.e., presentation of students’ works, leading of activities for peers, and leading of activities for adults. Moderate ASP was attributed when students were asked to express their viewpoints and opinions, without having a decision-making power, however; it comprised activities in which students were called to express their points of view on various school issues, either by the provision of platforms to share ideas, concerns, or suggestions, or by the organization of interactive school assemblies, or by their involvement in surveys based on data collection (e.g., by means of questionnaires) on specific aspects of their school life. Low ASP was attributed when the students’ activation was limited to a specific task required within a structured format designed by other people, including training for student leaders, interactive group activities, and individual activities. Finally, activities were coded as Very low ASP when students were involved as the passive recipients of contents provided by adults, through lecture-style lessons, viewing of videos, or distribution of didactic material. The activities provided for in each program are described at length in the following paragraphs, considering activities scored in every specific level of ASP.

For the sake of completeness, in Table 5 , we added a final column in which we indicated additional program activities that involved the staff. They comprised the formation of school action teams made up of adults, training, and the provision of materials for the staff. As the description of these activities goes beyond the scope of our investigation, we will not describe them in detail.

Very High ASP: Making School Rules

As can be seen in Table 5 , activities implying involvement of students in decision-making processes were identified in six programs. In AB3, during a school assembly, students were invited to develop a whole-school anti-bullying policy, while in later activities, they were asked to identify strategies to be implemented in the school to prevent bullying. In CFS, school staff and student leaders conducted whole-school activities helping students to review school policies to promote a positive use of technology. In FS, the intervention aimed to help the transition between primary and secondary school was co‐developed with students who had already made such a transition. In GP, the use of peer support and leadership was encouraged to increase opportunities and skills for students to participate in decision-making processes within the school; in addition, at a classroom level, rules were negotiated by teachers and students and displayed in each classroom. In RJ, during the first year of implementation, staff and students developed a plan for pathways of primary, secondary, and tertiary restorative interventions; in the following years, students’ leadership roles and collective decision-making activities increased, so that students themselves were able to advance whole-school initiatives and activities, to map out course goals and determine which projects they would embrace. Finally, in SE, some health policies were discussed with the principal, teachers, and students before being finalized in a school action team meeting and disseminated at whole-school level.

Activities consisting in the creation of school action teams (or school action groups) including students and teachers were identified in three programs (see Table 5 ). In AB2, a school action group with both students and staff was formed to define action plans and training for staff on restorative practices at whole-school level and to implement a new school curriculum focusing on social and emotional skills. In LT, a school action group comprising around six students and six staff was formed to lay down school policies and coordinate interventions, based on the feedback from the student data collection. In SE, a school health promotion committee, consisting of representatives from the school board, parents, teachers, and students, was formed to discuss issues submitted by the students and to plan the activities for the future years based on the feedback from the activities already carried out. In addition, a peer group of 10 and 15 students from each class discussed health topics and student concerns with adult facilitators, in order to develop an action plan and to help in organizing various activities, such as contests and school assemblies.

High ASP: Organizing School Events

Three types of activities were included in this level of ASP. As reported in Table 5 , five programs solicited the creation of different student artifacts . AB1 included a student-made video on bullying to be presented to all the students. In GP, student artifacts were presented to audiences such as parents, other students, teachers, and members of the community. In SS, student leaders made presentations for peers to share personal examples of using the strengths provided by the program. In RJ, students engaged in collaborative, interactive writing activities based on analytical reflection for the realization of a rubric co-developed by students. SE included the contribution of all the students, teachers, and the principal in the realization of works like write-ups, poems, pictures, or artwork, on specific topics for a monthly wall magazine publication. SE also envisaged contests among students, such as poster-making and essay writing, linked to the monthly topic of the wall magazine.

Activities regarding the organization of student-led activities for peers were found in four programs (see Table 5 ). In CFS, student leaders (four to six in each intervention school) conducted at least three important whole-school activities to promote students’ positive use of technology for raising students’ awareness of their rights and responsibilities online; they also provided cyberbullying prevention trainings for peers. In SS, student leaders (up to six in the school) conducted activities aimed at raising awareness of Sources of Strengths , generating conversations with other students, providing presentations about the strengths proposed by the program, and engaging peers to identify their own trusted adults. RJ included student-led restorative circles with students, workshops for students, and peer-to-peer mentorship on restorative practices. In SE, student leaders (between 10 and 15 in each class) conducted peer group meetings to discuss on relevant health topics.

In two programs, student-led activities for adults were organized (see Table 5 ). In CFS, student-led activities provided information to the teaching staff about the technologies used by students and cyberbullying prevention training given to parents. In RJ, circles and workshops on restorative practices were implemented by the students for the staff.

Moderate ASP: Expressing Personal Views

Three types of activities were included in this level of ASP. As can be seen in Table 5 , two programs provided platforms where students could express their personal views on various topics. In BB, students, families, and school staff were provided with platforms to share information and communication on mental health issues. In SE, platforms were used to raise concerns, make complaints, and give suggestions, either anonymously or by self-identifying, on the intervention topics.

Interactive assemblies for students to discuss on the main intervention topics were organized in three programs (see Table 5 ). AB1 provided a first interactive school assembly to discuss respect and bullying, and later assemblies at class level to further discuss the themes emerged during the whole-school assembly. Similarly, AB3 included a school assembly where students were encouraged to get involved in the development of a whole-school anti-bullying policy, followed by three lessons during which the class teacher facilitated a discussion in each class aimed to raise awareness about bullying and to think about school-based solutions. SE included group discussions for generating awareness about health issues, to be discussed during the school assemblies that took place four times a month.

In six programs, students were given a voice by data collections to be used in the process of school changes (see Table 5 ). AB1 included a bullying report form that students, in addition to staff and parents, filled in to report bullying incidents. AB3 provided feedback from student data collection during the school assembly as a basis for discussing whole-school anti-bullying strategies. In LT, annual reports on students’ needs, drawing from student surveys in relation to bullying, aggression, and school experiences, guided the action teams to define school policies and coordinate interventions. In BB, summaries of student and staff data on current school structures, policies, programs, and practices related to student well-being, collected annually, were used by the team to create an “action plan” for changes across the school, both at the classroom and whole-school level. In GP, the profile emerging from the student surveys on school environment guided school teams in the definition of priority areas and strategies within each school, both by coordinating existing health promotional work and introducing new strategies that met the needs of a specific school. In SE, the school action team planned school activities based on reports and discussions on issues presented by the students.

Low ASP: Trainings

A low level of ASP was identified in three types of activities. As can be seen in Table 5 , four programs included trainings for student peer leaders . CFS provided a 10-h training for peer leaders to lead whole-school activities on the positive use of technology. GD provided a 5-h bystander training for student leaders to recognize situations and behaviors that could lead to violence or abuse and to identify active bystander behaviors to be performed either individually or collectively to reduce the risk or effect of violence. ST provided a 90-min training session and two 15-min booster sessions on bullying, which included icebreaker exercises, hands-on activities, and role plays. SS provided a 4-h interactive training for peer leaders aimed at developing protective resources in themselves and encouraging peers to grow such resources as well.

Eight programs included interactive group activities (see Table 5 ). In AB3, students worked in small groups to identify the types of bullying in the school and to discuss strategies to prevent bullying, with the support of bullying scenarios with discussion questions. In CFS, interactive activities included problem-solving, quizzes, and case studies on the use of technology to prevent cyberbullying. LT included various interactive activities aimed at preventing violence, ranging from informal practice, for example, using “affective” statements to communicate feelings, to formal practices, for example hosting a restorative “circle” where participants were encouraged to express emotions and create emotional bonds after problematic or disruptive behavior. BB provided a range of interactive teaching methods, such as small-group exercises, role plays, and quizzes, for reflecting on mental health issues. GP provided activities as small group work and class discussion, by also implementing interactive teaching strategies, such as using questions to kindle discussions and emphasizing the importance to consider different perspectives on a topic, encourage challenges, and debate ideas. SS included peer-to-peer messages and activities wherein student leaders shared examples of strengths that have helped them to overcome personal challenges and invited their peers to participate in interactive tasks. RJ included many interactive practices, such as restorative circles, interactive writing activities, and peer-to-peer mentorship to broaden the impact of restorative practices. SE included monthly contests for students, such as elocution, debates, and quiz games.

Finally, in BB program, some individual activities , in addition to group tasks, were conducted (see Table 5 ). Such activities consisted of individual writings and self-reflection on specific topics, aimed at building or enhancing sense of self-worth, belonging, control, purpose, future, and humor, which were considered to protect against mental health problems.

Very Low ASP: Students as Recipients

Activities in which student’s role was overall that of the recipients of actions taken from adults were of three types. As can be seen in Table 5 , six programs included lecture-style lessons . AB1 included the speech by a nationally known speaker about respect and bullying and the presentation of the Social Support System to students by their English teachers. AB3 included the presentation of summary feedback from the pre-test questionnaires during a school assembly and three lessons, delivered by the class teachers, on school bullying. CFS included lessons led by class teachers, aimed at improving online social skills, focusing, in particular, on positive communication, resilience, self-management, conflict resolution, and social responsibility. GD included a 50-min persuasive lesson led by adults focused on violence victimization, perpetration, and prosocial behaviors. LT included adult-led lessons on social and emotional skills. SE organized workshops led by teachers or program facilitators on effective study skills, such as time management, learning style, note-taking, reading comprehension, memorization techniques, and concentration techniques.

Three programs included the viewing of videos during the implementation (see Table 5 ). AB1 and AB3 provided a video on school bullying for all the students. BB provided video or DVD materials on mental health issues.

Finally, three programs provided students with informative materials (see Table 5 ). AB1 provided a form with several responses for intervening against bullying, which offered alternatives to the traditional method of apportioning blame and punishing bullies. Similarly, AB3 provided a worksheet on possible responses to bullying. FS provided educational magazines on bullying issues. BB provided many materials, such as individual student workbooks, a review poster, master copies of resources for all activities, and homework worksheets.

The aim of this systematic review was to provide a reasoned synthesis of whole-school interventions in secondary school capable of improving the school environment by assigning an active role to students. The first result that warrants consideration regards the number of publications that met our eligibility criteria to select whole-school interventions based on activities soliciting ASP in secondary schools. Despite the wide interest of researchers on the topic of whole-school interventions in general (see Bonell et al., 2018 ; Charlton et al., 2021 ), our selection and data collection process eventually provided only 22 reports referring to 16 studies that fostered ASP during the intervention. This result calls for further work in the field. Based on the emphasis given by educational and political agendas about the importance of empowering students in their role as active participants in schools, first of all, and in societies, subsequently, research should not overlook the question of how to improve their participatory skills by involving them in school activities and decisions (Markham & Aveyard, 2003 ). More investment in this direction is needed to evaluate the consistency and efficacy of the existing programs, to eventually reach consensus on the intervention protocols that schools can implement to improve their learning environment. Results related to each of our specific aims will be discussed in the following paragraphs.

Characteristics of the Selected Programs

As for the first aim of the review, concerning the description of the identified literature, several reflections arise from our results. Considering the year of publication, we found growing interest by researchers in the field, as most reports were published in the last few years, i.e., from 2018 to 2021. This may be considered positive indication that research has identified student participation in school interventions as a crucial topic on which to invest for future works. As for the focus of the selected literature, most of the included studies concerned the reduction of violent behaviors, referring for the most part to bullying, while the promotion of a more general positive emotional and relational school climate is the less investigated topic. Notwithstanding the overall need to fill in this limitation of research, these results suggest that future studies should address the issue of how it is possible to create better school environments for students starting from their own involvement and decision-making roles. This is consistent with the direction indicated by Bonell et al. ( 2018 ), who upheld the importance of focusing more on overall school systems rather than on specific problems. The implementation of a larger number of programs fostering ASP in order to improve school climate and learning environments would thus be important to understand how to support students in dealing with the variety of non-specific problems that can arise during school life. Indeed, as confirmed by the literature, a positive school climate is related to higher academic achievement (Berkowitz et al., 2017 ; Kutsyuruba et al., 2015 ) and fewer problematic behaviors, violence (Reaves et al., 2018 ), and psychological malaise at school (Aldridge and McChesney, 2018 ). Finally, looking at the country of the selected program implementation, most of the studies were conducted in the USA, some in Australia and the UK, and a few in India and China. To our knowledge, with the exception of the two anti-bullying programs carried out in the UK and included in the current review, no other studies were conducted in European countries. With caution, as in many other countries researchers may have developed programs that could not be included in this review due to the inclusion criteria, we consider this as a gap in the literature that future work should fill, especially considering that school policies and organizations are very different between continents. In this regard, it would be interesting both to replicate existing programs and to develop revisited or new interventions specifically adapted to the context of the country’s school system, a work that would also fulfil the aim to increase the ecological validity of the proposed activities.

Methodological Quality of the Selected Reports

The second aim of the review was to assess the soundness of the research design and methodologies adopted in the selected studies. In this regard, we found that the considered reports were robust overall, as they met most of the considered indicators of methodological quality. In particular, most of the studies, based both on EGC or on other designs, described and contextualized the intervention and provided adequate analyses. Beyond the generally good methodological quality of the included studies, consistently with previous examinations of intervention programs (Charlton et al., 2021 ), we found a weakness concerning the fidelity of implementation, as this indicator was observed in only about half of the considered programs. Given that fidelity is a fundamental aspect for the evaluation of the intervention efficacy (O’Donnell, 2008 ), future studies should consider this important factor, by adding it to the evaluation of the programs for providing adequate monitoring tools that include qualitative and process indicators. Overall, however, the literature on the interventions meeting the criteria for our review, albeit limited, relies on methodologically sound grounds that allow us to draw some conclusions on programs and activities actively involving students and to offer suggestions for researchers and practitioners in the field.

Program Activities and Levels of ASP

As for the third and last aim of the review, i.e., concerning the analysis and description of ASP activities proposed in the various programs, our results offer material for an innovative way to look at the programs and points the way to future research in the field. In particular, some points should be highlighted. First, we were able to show that a variety of ASP activities can be used in interventions, from those requiring students to directly act on school programs and policies to those in which students are merely involved as recipients of contents delivered by school staff. From the careful and independently conducted analysis of all program activities, we were also able to grade such activities on a scale ranging from very high to very low levels of ASP. This may be a useful tool for researchers, as it advances a way to develop and organize interventions fostering different levels of ASP activities, to be selected on the basis of the research focus and aims. The effort to identify different levels of ASP also has the merit of introducing some degree of clarity and order in the great variability of program activities. While the importance of student involvement and participation was generally recognized in the literature (Baeten et al., 2016 ; Schweisfurth, 2015 ), our in-depth description shows that not all forms of participation are equal, and thus offers a tool to differentiate between them. This advances our understanding of the concept of student participation both on a theoretical and methodological level.

Beyond this general picture of ASP activities, our findings show that the interventions based on the highest levels of ASP are those aimed at generally improving the school environment, i.e., the Restorative Justice and SEHER programs. These programs included all but one of the activities defined as Very High ASP or High ASP , while all other programs usually provided only one or two of them. This result can offer interesting insights if taken together with the above-reported considerations on the importance to promote overall school improvement, and not to restrict the focus on one or few specific problems. On the basis of this result, we tentatively advance that when the study scope is broad and the theoretical approach is systemic, interventions are more directly centered on lending a voice to students and assigning to them a decision-making role. This again supports the importance of promoting whole-school interventions targeted toward the general learning environment.

Limitations and Conclusion

We are aware that the findings of the present literature review should be considered in the light of certain limitations. First of all, our choice to include only studies published in peer-reviewed journals in English requires some caution. While this selection criteria allowed us to provide a picture of the international literature, this might entail the loss of programs published in other languages that nonetheless contribute to the issue and deserve to be explored in future reviews. Secondly, in the present work, we did not address the issue of cross-cultural similarities and differences in schooling and education, which may influence the way ASP is conceived and valorized in the school context. However, the levels of ASP activities we proposed have the strength of resulting from the analysis of programs from several countries and may thus offer a basis for future discussions on the cross-cultural validity of practices fostering ASP. Furthermore, the present review has focused only on secondary school programs. While this choice was needed for guaranteeing clear references and boundaries to our findings, it also leaves to be explored whether our proposed classification of ASP activities could also be applied to younger students. Given the developmental and organizational differences between primary and secondary levels of education, this issue certainly merits further exploration in future reviews.

As the aim of our review was to provide an in-depth and reasoned description of existing studies based on ASP and of the activities adopted to promote the active role of students, testing the efficacy of these studies was beyond the scope of the present work. While future research may advance this line of inquiry, based on the evidence that different outcomes are considered in such a small number of studies, it seems premature to move toward extensive efficacy testing such as meta-analyses. Rather, at present, it is probably more feasible and desirable to have an increasing amount of literature focusing on ASP in whole-school interventions, to collect further evidence of robust programs and activities, especially with regard to high ASP. As a possible further research question in this direction, we suggest it would also be useful to assess whether the ways of actively involving students may change depending on the intervention target outcomes or on the number of students taking part in the activities. Lastly, while this is true for any review of the literature, it should nonetheless be acknowledged that our syntheses and reflections are dependent upon the choices made in the article selection process. For example, our inclusion and exclusion criteria (i.e., focusing on general participants and targets of intervention) may have restricted our sample. With this in mind, we followed closely the PRISMA guidelines and detailed each step of the process, so that readers can be well informed and future research may build as seamlessly as possible from our work.

Despite the mentioned limitations, this review provides a literature advance in its in-depth examination of existing whole-school interventions that include active student participation in secondary school. Their description and reasoned synthesis make available to researchers and practitioners an overview of specific programs and activities that are being used to actively involve students in processes of change. This in turn can inform reflections and experimentations as to how to integrate and improve the existing provision. In this direction, the major effort and contribution of the present review is the proposal of an organizing structure based on different levels of ASP for analyzing interventions, which allows to classify the specific activities included in each program. Such an effort provides a common ground for reflections and future studies on active student participation, as a shared classification can be instrumental for planning new interventions or evaluating the actual degree of students’ active involvement in the implemented programs. Overall, this work significantly contributes to the far-reaching goal of encouraging student participation in school life, and more specifically in the transformation of their learning environment, so that they can be empowered in shaping it to be increasingly responsive to their insights, ideas, and needs.

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All the authors contributed to the study conception and design. Literature search was conducted by Sara Berti; assessment of methodological quality was supervised by Valentina Grazia; draft of the introduction and overall supervision were performed by Luisa Molinari. All the authors contributed to data analyses, draft of the manuscript, and critical revisions of the work and they eventually approved the final manuscript.

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Berti, S., Grazia, V. & Molinari, L. Active Student Participation in Whole-School Interventions in Secondary School. A Systematic Literature Review. Educ Psychol Rev 35 , 52 (2023). https://doi.org/10.1007/s10648-023-09773-x

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Factors affecting Saudi medical students’ engagement during synchronous and asynchronous eLearning and their impacts on the students’ academic achievement: a national survey

• Amal A. Alghamdi 1 ,
• Ghada F. Alyousif 1 ,
• Amani M. AlQarni 1 ,
• Fatma H. Amer 1 ,
• Taghreed O. Alfadhel 2 ,
• Rawan N. Almutairi 3 ,
• Shatha M. Almutairi 3 ,
• Anwar D. Almutairi 3 ,
• Nouf A. Hakami 4 &
• Kholoud. Al Ghamdi 5  

BMC Medical Education volume  24 , Article number:  358 ( 2024 ) Cite this article

Metrics details

Nowadays, especially after the COVID-19 pandemic, electronic learning (eLearning) has become a necessity in education. eLearning can be either synchronous, where classes are conducted in real-time, or asynchronous, where students can access the class material at any time. Student-instructor interaction has become essential to the educational process. In the literature, most studies have focused on the preferred methods of eLearning and the barriers to interaction in eLearning. Thus, this study aimed to investigate the factors that affect students’ interactions during eLearning and their impacts on students’ academic achievements.

A national cross-sectional study was conducted among clinical and pre-clinical medical students who were attending universities in five regions of the Kingdom of Saudi Arabia. Data were collected using a bespoke online self-administered questionnaire covering sociodemographic features, eLearning barriers, preferences, and the impact of eLearning on students’ performance and understanding.

This study involved 1371 medical students, of whom 52.37% were male and 51.13% were in their pre-clinical years of medical college. Of the participants, 59.88% ( n  = 821) preferred synchronous modalities of eLearning, and 33.33% ( n  = 457) avoided interaction during synchronous lectures. The main predictors of avoiding interaction during online lectures were being male in the clinical years of medical studies, being in a quiet atmosphere, having difficulties using the eLearning platform, having a poor internet connection, having a visual learning style, being insecure, and the presence of opposite-sex students and facilitators. In addition, 12.25% students ( n  = 168) reported a lower grade point average (GPA), whereas 11.96% ( n  = 164) reported an improved GPA after eLearning compared with in-person/onsite learning sessions. The GPA fluctuation was related to gender, personality type, learning style, interaction, and eLearning modality preference. Moreover, the students’ understanding was enhanced by recorded lectures ( n  = 1,093, 79.72%) and supportive multimedia ( n  = 1,037, 75.64%), and the easy to use platform ( n  = 1037, 75.64%).

The synchronous modality of eLearning was the preferred teaching method among the medical students. However, multiple individual, technical, and environmental factors affected their interaction, performance, and understanding during these sessions. Hence, future interventional research is recommended to overcome interaction barriers and enhance student performance and understanding of eLearning.

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eLearning refers to the use of technology in the educational process [ 1 ]. Online lecture teaching modalities can be classified into synchronous and asynchronous [ 2 ]. Synchronous eLearning involves live broadcasting in the educational session and possibly live interactions, whereas asynchronous eLearning is when the academic session is recorded [ 2 ]. Synchronous eLearning simulates the traditional classroom by allowing teacher-student interaction, encouraging students to ask questions, and preventing students from feeling isolated [ 3 ].

The new advancement in technology and the production of various software programmes, especially video conference software, have facilitated the development of synchronous modalities of eLearning and encouraged student interaction [ 4 ]. Peer interaction is essential during the educational process; however, teacher-student interaction is considered the pillar of the educational process [ 5 ]. Each learning modality has its advantages in facilitating the teacher-student interaction. For example, the synchronous teaching method could be used for illustrating complex matters and supporting students while assigning them class work, whereas the asynchronous learning method can be used as a platform for instructors to provide feedback to students while reflecting on their performances or following up with them especially when a synchronous teaching modality cannot take place [ 3 ]. Today, the educational process has shifted from teacher-instructed learning to student-centred learning [ 6 ].

A previous study found that student-content interaction and engagement matters for the persistence of the educational process [ 7 ]. However, students’ motivation for eLearning and course engagement is the main challenge that might affect the continuity and success of eLearning [ 8 ]. In the literature, student engagement and interaction have been assessed using various methods such as evaluating interaction in discussions [ 9 ] and students’ clicking on the various activities in their learning platform [ 8 ]. It might be easier to assess student motivation and understand the barriers to engagement during online lectures with one-to-one or small-group mentoring [ 8 ].

During the COVID-19 pandemic restrictions, medical colleges in the Kingdom of Saudi Arabia shifted almost all their educational platforms, especially lectures, to online teaching from 2020 till the end of 2021. This shift might have affected medical students’ learning process and interaction and lowered their academic achievements. However, limited research has investigated interaction barriers and described the impacts of limited interaction and engagement on students’ academic achievements. In this study, we suggest that students’ interaction and engagement might be affected by internal factors, including students’ eLearning modality preferences, personality types, learning styles, and socio-demographic features. In addition, we assumed that motivation and engagement might be affected by external factors, including household, technical, and social factors. Thus, in this study, we aimed to identify which of these suggested factors might have influenced medical students’ eLearning engagement. We also aimed to understand the impact of students’ eLearning engagement on their academic performance as measured by their GPA fluctuation, exam performance, and subject understanding.

This cross-sectional study covered the five regions of Saudi Arabia: North, South, West, East, and Middle. One study author from each region approached at least one university. Data were collected using a self-administered online questionnaire technique. This online data collection was chosen because of the COVID-19 pandemic restrictions, which made it difficult for the authors to approach participants for recruitment personally. For sampling, we first stratified the kingdom into various regions and approached data collectors from various universities within these regions. Data collectors approached students from the same university through a convenient sampling approach using the students’ WhatsApp accounts. This was done to expand the reach and accessibility of the questionnaires and obtain a representative sample while minimising the risk of using convenient sampling, as this approach would provide us with a balanced number of participants with various sociodemographic features, especially regarding sex, academic level, and universities. The data collectors were supervised by one of the authors to make sure they approached students as planned and encouraged them with frequent reminders to improve the response rate. The data collection process lasted 2 months, from July to August 2021. The minimum accepted sample size was estimated to be 341 using the Epi Info software (version 7.2.4.0), considering a 95% confidence interval, 5% margin of error, and 50% engagement rate of eLearning among the participants.

The used questionnaire was a bespoke English questionnaire, and its items were designed based on the literature and expert opinion. The questionnaire aimed to measure specific aspects of online teaching and interaction. Each item was used individually rather than creating a global score to assess the overall level of engagement. A small pilot study was conducted to examine its face validity and clarity before running this study. The collected data included sociodemographic features (sex, academic year, region, marital status, socioeconomic status, and grade point average (GPA) before and after enrolment in an online teaching modality), technology-related data (type of device, platform atmosphere, internet connection, internet-handling skills, and setting atmosphere), personal and social factors (personality, the feeling of safety during interactions with others, the feeling of being threatened by peers’ negative comments, and the presence of opposite-sex students), instructor-related factors (the instructor’s ability to answer immediately and judgment, and an instructor of the opposite sex). In addition, we included data related to subjective descriptions of the participants’ personality types (shy or outgoing) and their learning style (visual, audio, or sensory). Furthermore, data were collected to measure the avoidance of engagement in online lectures (yes or no), mode of teacher-student interaction (unidirectional or bidirectional), preference for eLearning teaching modality (synchronous or asynchronous), changes in accumulative GPA and online exam performance (decreased, increased, or the same), and the level of subject understanding (poor or good).

Ethical approval was received from the Imam Abdulrahman bin Faisal University (IAU) Institutional Review Board (IRB) committee (IRB-2023-01-051). In addition, all participants were informed regarding the purpose and methods of the study and voluntarily provided written consent before filling out the questionnaire. All methods were performed in accordance with the relevant guidelines and regulations of the IAU ethical board committee. Data were analysed using the STATA 17 software. The chi-square and Fisher exact tests were used to assess significant differences in the distribution of determinants between the study groups. Unadjusted and adjusted logistic regression models were used to estimate the odds of interaction avoidance. In addition, multinomial logistic regression models were used to estimate the relative risk ratio for a change in GPA before and after the implementation of the online lecture modality in medical teaching. The regression models that estimated the risk of GPA fluctuation were adjusted by including the two main epidemiological confounders that are gender and academic year. However, GPA was added later to the adjustment of the logistic models that estimated the risk of interaction avoidance.

The total number of participants was 1371 students from the included universities and colleges (Table  1 ). Most participants were from governmental universities ( n  = 976, 71.19%) and the central region ( n  = 50.91%). The distribution of the participants among the universities were as follows: Imam Abdulrahman bin Faisal University ( n  = 188, 18.18%), Qassim University ( n  = 149, 14.41%), Jazan University ( n  = 110, 10.64%), Unaizah College of Medicine ( n  = 97, 9.38%), Majmah University ( n  = 89, 8.61%), King Faisal University ( n  = 57, 5.51%), King Saud bin Abdulaziz University for Health Sciences ( n  = 28, 2.71%). Significant differences in eLearning and interaction methods were found among the universities in the different kingdom regions. In the absence of standardisation of teaching methods among the Saudi universities, the synchronous method of eLearning was the most commonly used ( n  = 862, 62.87%). However, recorded lectures were not always available amongst 50.40% ( n  = 691) of the included universities. The student interaction with the instructor during live lecture was bidirectional in 52.15% of the respondents ( n  = 467). After the lecture, the main method of interaction was via email ( n  = 554, 40.41%). Most participants were male ( n  = 718, 52.37%), senior-level students ( n  = 701, 51.13%), from the middle region of the Kingdom ( n  = 698, 50.91%), unmarried ( n  = 958, 69.88%), and of middle socioeconomic class ( n  = 990, 72.21%), and had a GPA of A or B ( n  = 1310, 95.55%; Table  2 ).

The main reason for unsatisfaction with the eLearning experience was the inability to interact during the online lecture ( n  = 100, 33.33%), followed by the inability to download online materials ( n  = 47, 15.67%), the inability to open the website or program ( n  = 46, 15.33%), unclear font or text ( n  = 43, 14.33%), the inability to play multimedia materials on the platform ( n  = 38, 12.67%), and other unspecified reasons ( n  = 26, 8.67%). In addition, 37.86% of the participants used their universities’ Blackboard platform account to access online materials ( n  = 519). The remaining participants used live conference software such as Zoom and Microsoft Teams. Amongst the participants, 32.24% reported poor internet connection ( n  = 442), and only 7.88% reported poor internet skills ( n  = 186).

The internal factors that might have affected the participants’ engagement in relation to their preference for online teaching modalities are summarised in Table  2 . Most participants preferred synchronous teaching ( n  = 821, 59.88%). Amongst the participants who preferred the asynchronous method, most were male ( n  = 405,73.64%), in their senior academic years ( n  = 389, 70.73%), unmarried ( n  = 512, 93.09%), and had an excellent GPA score ( n  = 350, 63.64%). The three main reasons mentioned for preferring asynchronous learning modalities were time flexibility ( n  = 438, 79.63%), the ability to replay the lecture to study it ( n  = 212, 38.54%), and the possibility of facing internet connection problems with synchronous online lectures ( n  = 60, 10.91%). Regarding technology, most participants ( n  = 1071, 78.12%) used their computers ( n  = 906, 66.08%) to access their online lessons, and almost three-quarters of them were satisfied with the devices they used.

Concerning the students’ online engagement and teacher-student interaction during synchronous teaching, around a quarter of the participants reported that the primary method of interaction during lectures was unidirectional ( n  = 350), which means that the facilitator was the one asking questions. On the other hand, approximately one-third of the participants reported that the primary method of interaction was bidirectional ( n  = 539), which means that both the students and facilitators asked and answered questions. Statistically significantly more males ( n  = 339,74.18%), senior students ( n  = 299, 65.43%), and students with a high GPA ( n  = 278, 60.83%; Table  3 ) preferred synchronous modalities but avoided interaction ( n  = 449, 98.25%).

Concerning the estimated risk of avoiding interaction during online lectures, the odds of avoiding was at least two times higher amongst the participants who reported unsatisfaction with the provided platform atmosphere (adjusted OR = 6.27, 95% confidence interval [CI] = 4.79–8.21), the instructor’s slow response (adjusted OR = 6.84, 95% CI = 5.09–9.20), not feeling safe during interaction (adjusted OR = 4.41, 95% CI = 3.21–6.04), the presence of opposite-sex students during online lectures (adjusted OR = 2.05, 95% CI = 1.55–2.71), poor internet connection (adjusted OR = 2.24, 95% CI = 1.74–2.89), and the feeling of being threatened by other students’ negative comments (adjusted OR = 2.05, 95% CI = 1.55–2.71; for further details, please refer to Table  4 ).

Regarding exam performance and subject understanding, almost half ( n  = 477, 54.33%) of the participants were generally satisfied with their online exam performance. In the comparisons of onsite teaching and assessment scores, a small percentage reported lower and higher GPAscompared to their scores before the online lectures’ modality, (12.25% and 11.96%, respectively). Figure  1 shows that the major reported difficulty concerning the online exams was the limited allocated time for each exam ( n  = 308, 22.47%). On the other hand, few participants ( n  = 53, 3.87%) reported that the source of difficulty was the noisy or uncomfortable setting during the online exam. Concerning the improvement of the students’ understanding of the online learning process, 79.72% ( n  = 1,093) of the students reported that the recorded lecture material enhanced their understanding of the subject. Moreover, three-quarters ( n  = 1,037, 75.64%) of the participants found that the use of multimedia (e.g. educational videos, animated pictures, and audios clips) enhanced their understanding and that the type of platform used played an essential role in improving their understanding of the subject. Regarding the participants’ performances and effect of online teaching, 12.25% of the participants reported a decrease and 11.96% reported an improvement in accumulative GPA. The odds of the decline in GPA was greater amongst the senior students (adjusted OR = 3.25, 95% CI = 2.14–4.96), the participants with a GPA of B (adjusted OR = 2.08, 95% CI = 1.42–3.05), and the participants with a shy personality (adjusted OR = 1.50, 95% CI = 1.03–2.18). On the other hand, the odds of improving the accumulative GPA was associated with a preference for asynchronous teaching (adjusted OR = 1.55, 95% CI = 1.08–2.24) and avoidance of engagement in online interaction (adjusted OR = 1.55, 95% CI = 1.06–2.17; Tables  5 and 6 ).

Shows the distribution of the factors that influence the difficulty of taking an online exam

The main aim of our study was to identify factors that influence student interaction and academic achievement when using eLearning modalities. This study shows that more than half of the medical students preferred the synchronous modality of online teaching, and almost one-third did not engage in the class, most of whom were senior male students. Khalil et al. (2020) recently reported that Saudi medical students were satisfied with the synchronous eLearning modality during the COVID-19 pandemic and that there is an urgent need to shift to eLearning [ 2 ]. However, the main reasons that some of our participants preferred recorded lectures during online teaching were the time flexibility, ability to replay the lessons, and possibility of internet problems interfering with synchronous online instruction and sessions. These reasons highlight the importance of the use of cutting-edge technologies in online education and the need for offline teaching materials to refer to after the online sessions. In addition, the challenges in the use of technology in eLearning are frequently encountered in urban areas where limited access to the internet might affect the synchronisation process of eLearning [ 10 ]. Hence, demand is higher for providing asynchronous eLearning modality as a solution for students who might have problems accessing their synchronous classes. On the contrary, many studies have claimed that asynchronous education was superior to synchronous education in terms of flexibility in time and place, higher student independence, and self-monitoring [ 11 , 12 , 13 ]. However, these findings were poorly studied owing to methodological limitations such as unconsidered confounders and the inconsistency in the used technologies [ 11 ].

In addition, one main factor reported in the literature regarding successful eLearning implementation was related to students’ efficacy and belief in their abilities to practice eLearning, as these motivate them to learn and develop their technical skills [ 12 ]. Conversely, the main barriers reported were related to administrative issues such as complexity and cost- and payment-related issues [ 1 ]. Furthermore, difficulty in using the platform and difficulty of interaction due to the platform atmosphere were also critical factors for users to refrain from using online services, especially when they could shift to another provider [ 1 ]. In addition, technical issues such as internet problems and unequal online learning opportunities were considered the major contributing factors to complicated online learning [ 14 ]. Nevertheless, other eLearning barriers related to teachers were reported, including a lack of knowledge of the online teaching environment, the facilitator’s lack of skills, and the difficulty in assessment and evaluation [ 1 , 15 ]. Furthermore, the other reported eLearning barriers were related to the given curriculum, including ambiguity, quality of resources, assessment methods, teaching process, and the colleges themselves, such as organisational and physical structural factors not aligned with online learning and the lack of adequate resources [ 15 ]. Regarding these barriers, the students showed interest in eLearning when the eLearning process was well structured, of high quality, and supported by blended traditional learning and tutorials [ 16 ]. Baticulon et al. (2021) reported in their national survey in the Philippines that only 41% of students engaged mentally and physically in online learning activities during the COVID-19 pandemic. The most frequently reported barriers were poor communication with facilitators, the need for more facilitator direction, and home responsibilities [ 17 ]. The lack of student interaction and engagement and effective facilitator-student communication might be considered the main barriers to transition from a physical to an online environment; thus, careful consideration should be given to solve this matter [ 18 ].

In our study, most participants who avoided interaction were male, were at the senior level, and had a higher GPA. In the literature, the risk of avoiding interaction was higher in the following student categories: those who were not satisfied with their teaching platform, those who had slow-responding instructors, those who had mixed male and female sessions, those with a poor internet connection, and those who felt threatened by other students’ comments. Moreover, personal characteristics were found to play a role in students’ engagement during online teaching [ 19 ]. Emotional factors such as anxiety and enjoyment are essential in determining student engagement [ 11 ]. In addition, gender directly influences the educational learning process, especially in cultures with gender boundaries [ 12 ]. Similarly, the role of trust and privacy among learners might enhance or limit students’ interactions in their classes [ 1 ]. Learning style also played a role in avoiding interaction. The students in this study who described their learning style as visual showed a higher risk of avoiding interaction during online sessions. The literature recommends that online courses should be designed to accommodate the various learning styles and needs of students to enhance their engagement and academic achievement [ 20 ]. A previous study suggested that with the advancement in information and communication technology, eLearning strategies could be enhanced to become ‘adaptive’ to learners’ varied learning needs [ 21 ]. Many researchers have implemented artificial intelligence to recognise students’ learning styles and create ‘adaptive’ eLearning platforms and resources. Most of our students interacted during their sessions using a unidirectional method. A Bidirectional teacher-student interactions are well known to strengthen the role of student engagement during online sessions and improve student understanding by asking questions. The main contents of teacher-student interactions were asking about illustrations or content, planning work tasks and organising responsibilities, and providing emotional support and guidance [ 3 ]. However, online teaching could limit student interaction, as most students reported little interaction with their instructors [ 20 ]. However, technological advancements, especially faster internet speed and video conference software, might enhance student interaction [ 4 ].

Our study assessed the effect of student interaction and engagement in various eLearning modalities by assessing exam performance satisfaction, GPA fluctuations, and subject understanding. Satisfaction with online exam performance might reflect the success of the eLearning process, especially in the absence of other interfering environmental or technical factors. Approximately half of our students were satisfied with their exam performance. The main reasons for dissatisfaction were the limited allocated time, challenging questions, technical difficulties, stress, and uncomfortable or noisy online exam setting. Khalaf et al. (2020) reported that online exam satisfaction mainly depends on the availability of technology that is easy for students to use and allows them to navigate exam questions without difficulties or interruption. They also reported that online exam timing should consider the variation in technological skills amongst students (e.g. typing skills), internet speed and quality, revision time, and question backtracking [ 21 ]. However, designing online exams to accommodate these factors should not influence situations that could facilitate cheating. The literature has identified the presence of an ‘opportunity to cheat’, which could result from the design and delivery of the exam, as one of the most important reasons to cheat during the online exam. Interventions such as remote proctoring, introducing codes of conduct during examinations to the students before the exam, substituting individual assignments for group assignments, and using open-book exams could be adapted to reduce the incidence of cheating [ 13 ].

Student satisfaction with their eLearning was an essential factor of learning persistence, which pertains to students’ enthusiasm to accomplish their learning goals and overcome learning difficulties and challenges [ 7 ]. One factor that enhanced student satisfaction, motivation, and course score was technology self-efficacy [ 22 ]. This suggests the need to improve students’ technological skills while simultaneously enhancing their learning skills. In our study, the students believed that synchronous lectures enhanced their understanding mainly when multimedia (e.g. educational videos, animated pictures, and audios clips) and uncomplicated platforms were used for their eLearning. A systematic review of randomised control trials that included 6750 participants found that knowledge gained through eLearning did not differ from knowledge gained through traditional learning. On some occasions, eLearning was superior to traditional education, especially when eLearning was blended with traditional learning [ 23 ]. The study also reported that different eLearning modalities did not affect the amount of knowledge gained [ 23 ]. One main challenge in obtaining eLearning educational outcomes is that these are mainly learner dependent, influenced by students’ commitment, self-motivation, and self-monitoring [ 13 ]. Students’ loyalty to eLearning statistically significantly correlated with the overall eLearning service quality [ 24 ]. In our study, the risk of decreased GPA was higher amongst the senior students, students with an average GPA, and students with shy personalities. On the other hand, the GPA improved in the students who preferred asynchronous teaching. This might be attributed to the fact that asynchronous modalities allowed participants to replay recorded lectures and refer to educational materials as needed at their own appropriate time, giving them more flexibility. In addition, the participants described themselves as shy and were worried about their peers’ and instructors’ responses if they interacted during synchronous lessons. Hence, individualised eLearning educational plans should be recommended depending on the student’s demands and needs. eLearning outcomes significantly moderately correlated with the course design and the teacher-student interaction [ 25 ], illustrating the need for better online course designs and considering the students’ personalities.

Strengths and limitations

A significant strength of this study is that it is a multi-university study with participants from all regions of Saudi Arabia. It also highlights students’ perceptions regarding their preferences for eLearning modalities and the barriers to their engagement in such modalities. One limitation of this study is its use of online survey methods, which might have subjected the data to bias. However, we made a great effort to ensure that students with various sociodemographic and academic characteristics had sufficient access to the questionnaires. We used a systematic questionnaire distribution and asked data collectors from each university to distribute the questionnaire. Another limitation of this study is the use of a cross-sectional design, which might have limited the understanding of the risk factors for poor interaction and performance due to the lack of temporal sequences and the risk of unadjusted or latent unmeasured confounders. Furthermore, the use of unvalidated questionnaire that measured retrospective events might have led to measurement errors due to recall bias, especially considering the absence of a proper validation study. Finally, the subjective assessment of some study variables such as GPA, level of interaction, and exam performance might have led to measurement errors and recall biases being inherited into the study estimates.

This study sheds light on students’ perceptions of their engagement during online educational process. As part of their engagement and teacher interaction, a large percentage of the students preferred synchronous online lecture modalities. However, students who preferred the asynchronous teaching modality showed better GPAs and were more satisfied with their online exam performance. This reflects that the students’ engagement and academic benefit from eLearning do not solely depend on synchronous teacher-student interactions. Other factors were identified to affect students’ engagement during their eLearning process, including having an outgoing personality, learning style, and the availability of fundamental technology (e.g. diverse multimedia, good internet connection, and easy interactive platforms). Finally, both synchronous and asynchronous eLearning are a promising tool in education and complement each other to achieve better academic performance. Keeping students engaged and motivated to attend such online classes is a challenge, but success in keeping them engaged affects their academic achievement and satisfaction.

Data availability

The datasets generated and/or analysed during the present study are not publicly available owing to the ethical confidentiality agreement but are available from the corresponding author upon reasonable request.

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Acknowledgements

We thank the data collectors for their help in collecting data from various universities in the Kingdom. Additionally, we sincerely thank the educational institutions for their generous support and facilitation of data collection throughout this research.

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Amal A. Alghamdi, Ghada F. Alyousif, Amani M. AlQarni & Fatma H. Amer

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A. A. Alghamdi; G. F. Alyousif; A.M. AlQarni; and K. S. Al Ghamdi conceptualized the work and supervised and revised the final draft. T. O Alfadhel; R. N. Almutairi; S. M. Almutairi; A. D. Almutairi; and Nouf A. Hakami wrote the proposal, did the data collection, managed the literature, revised the final draft. A. A. Alghamdi wrote the first draft and did the analysis.

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Alghamdi, A.A., Alyousif, G.F., AlQarni, A.M. et al. Factors affecting Saudi medical students’ engagement during synchronous and asynchronous eLearning and their impacts on the students’ academic achievement: a national survey. BMC Med Educ 24 , 358 (2024). https://doi.org/10.1186/s12909-024-05323-3

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Received : 14 June 2023

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DOI : https://doi.org/10.1186/s12909-024-05323-3

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