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Covid-19 hotlines, helplines and call centers: a systematic review of characteristics, challenges and lessons learned

During the Covid-19 pandemic, a number of hotlines/helplines/call centers was implemented to provide remote services and support public health. The objective of this study was to investigate the characteristic...

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Supportive and non-supportive social experiences following suicide loss: a qualitative study

Suicide bereavement entails profound social stressors, including stigma and communication barriers, which can impair social support for suicide loss survivors (SLS). Despite recognized benefits of empathetic i...

Vitamin A supplementation coverage and associated factors for children aged 6 to 59 months in integrated and campaign-based delivery systems in four sub-Saharan African countries

Vitamin A deficiency (VAD) is a leading contributor to the poor health and nutrition of young children in sub-Saharan Africa. Funding constraints are compelling many countries to shift from longstanding campai...

Mortality burden of cardiovascular disease attributable to ambient PM 2.5 exposure in Portugal, 2011 to 2021

Exposure to high levels of environmental air pollution causes several health outcomes and has been associated with increased mortality, premature mortality, and morbidity. Ambient exposure to PM 2.5 is currently c...

Thriving from work questionnaire: Spanish translation and validation

Thriving from Work is a construct that has been highlighted as an important integrative positive worker well-being indicator that can be used in both research and practice. Recent public discourse emphasizes t...

Relative and absolute inequalities in cerebrovascular disease mortality rates: exploring the influence of socioeconomic status and urbanization levels in Taiwan

Limited evidence exists regarding the socioeconomic inequalities in cerebrovascular disease (CBD) mortality at different urbanization levels. Therefore, this study was conducted to assess the socioeconomic ine...

Trends in HIV prevalence and risk factors among men who have sex with men in Mozambique: implications for targeted interventions and public health strategies

Men who have sex with Men (MSM) are known to contribute to increased HIV prevalence as an integral part of key populations with high vulnerability to HIV/AIDS due to their sexual behaviours. Mozambique conduct...

The effect of retirement on physical and mental health in China: a nonparametric fuzzy regression discontinuity study

With the rapid aging of the domestic population, China has a strong incentive to increase the statutory retirement age. How retirement affects the health of the elderly is crucial to this policymaking. The hea...

Randomised pilot and feasibility trial of a group intervention for men who perpetrate intimate partner violence against women

There is a need for robust evidence on the effectiveness and cost-effectiveness of domestic abuse perpetrator programmes in reducing abusive behaviour and improving wellbeing for victim/survivors. While any ra...

Does health literacy mediate the relationship between socioeconomic status and health related outcomes in the Belgian adult population?

Health literacy (HL) has been put forward as a potential mediator through which socioeconomic status (SES) affects health. This study explores whether HL mediates the relation between SES and a selection of he...

Risk factors for low back pain in the Chinese population: a systematic review and meta-analysis

In China, the world’s largest developing country, low back pain (LBP) is a common public health issue affecting workability. This meta-analysis aimed to systematically assess the risk factors of LBP in the Chi...

The risk of contact between visitors and Borrelia burgdorferi -infected ticks is associated with fine-scale landscape features in a southeastern Canadian nature park

Infectious diseases are emerging across temperate regions of the world, and, for some, links have been made between landscapes and emergence dynamics. For tick-borne diseases, public parks may be important exp...

The prevalence of preterm and low birth weight infants among migrant women in the Pearl River Delta region, China: a population-based birth cohort study

The existing literature evaluating the association between neonatal morbidity and migrant status presents contradictory results. The purpose of this study was to compare the risk of preterm birth (PTB) and low...

Health and health behaviours in adolescence as predictors of education and socioeconomic status in adulthood – a longitudinal study

The positive association of health with education level and socioeconomic status (SES) is well-established. Two theoretical frameworks have been delineated to understand main mechanisms leading to socioeconomi...

Asbestos ban policies and mesothelioma mortality in Greece

Malignant mesothelioma is a rare form of cancer that mostly affects the pleura and has a strong link to asbestos exposure. Greece banned the use of asbestos in 2005, however, the public was already aware of th...

Examining the association between perceived stigma, its correlates, and restrictions in participation among persons with disabilities in Nepal: a cross-sectional study

Disability stigma in low- and middle-income countries is one of the most persistent and complex barriers limiting persons with disabilities (PwDs) from enjoying their rights and opportunities. Perceived stigma...

A new neonatal BCG vaccination pathway in England: a mixed methods evaluation of its implementation

The introduction of a national evaluation of newborn screening for Severe Combined Immunodeficiency (SCID) in England triggered a change to the selective Bacillus Calmette-Guerin (BCG) vaccination programme de...

Using propensity score matching analysis to compare between cardiometabolic risk factors and physical activity type in Korean adults: findings from a nationwide population-based survey

We aimed to assess the effects of different exercise modalities on cardiometabolic risk factors within a comprehensive, representative sample of the Korean population.

Changes in adolescents’ daily-life solitary experiences during the COVID-19 pandemic: an experience sampling study

Adolescent solitude was drastically impacted by the COVID-19 pandemic. As solitude is crucial for adolescent development through its association with both positive and negative developmental outcomes, it is cr...

The impact of quality-adjusted life years on evaluating COVID-19 mitigation strategies: lessons from age-specific vaccination roll-out and variants of concern in Belgium (2020-2022)

When formulating and evaluating COVID-19 vaccination strategies, an emphasis has been placed on preventing severe disease that overburdens healthcare systems and leads to mortality. However, more conventional ...

Association between movement behavior patterns and cardiovascular risk among Chinese adults aged 40–75: a sex-specific latent class analysis

Cardiovascular disease (CVD) is a major global health threat, particularly in China, contributing to over 40% of deaths. While sleep behaviors, sedentary behaviors, and physical activities are recognized as in...

Impact of home quarantine on physical fitness of school-aged children in Xi’an during COVID-19 lockdown: a cross-sectional study

The emergence of the COVID-19 pandemic has sparked unprecedented global challenges. This study intends to investigate changes in the physical fitness of students aged 6–22 during the COVID-19 pandemic and to a...

Uncovering the extent of dementia prevalence in Iran: a comprehensive systematic review and meta-analysis

Dementia is one of the major causes of disability and dependency among older people worldwide. The formation of an aging population in Iran can be associated with societal problems, including age-related disor...

The good, the bad and the ugly – a Swedish qualitative interview study about the landscape of meaning-imbued, exercise-related physical pain, as experienced by ‘normal’ gym-users

The gym is a well-known place for health promoting or rehabilitating exercise whose availability to all is regarded significant for people’s personal health work and the public’s health. In this context, physi...

Prevalence of and factors associated with suboptimal glycemic control among patients with type 2 diabetes mellitus attending public hospitals in the Greater Male’ Region, Maldives: a hospital-based cross-sectional study

Suboptimal glycemic control of type 2 diabetes mellitus (T2DM) which is defined as having HbA1c greater than 7% is a major public health problem in several countries, including the Maldives. The study aimed to...

Risk factors for smoking in adolescence: evidence from a cross-sectional survey in Switzerland

Cigarette smoking during adolescence is a major public health concern with far-reaching health implications. Adolescents who smoke are at an increased risk of developing long-term health problems and are more ...

Financial scarcity, psychological well-being and perceptions: an evaluation of the Nigerian currency redesign policy outcomes

The relationship between insufficient financial resources and psychological health has been extensively studied and established in various contexts. However, there remains uncertainty regarding the potential i...

The relationship between COVID-19 stress and test anxiety in art students: the chain mediating roles of intolerance of uncertainty and sleep quality

The global spread of COVID-19 has brought immense physiological and psychological distress to students, such as test anxiety and poor sleep quality. This study aims to explore the relationship between COVID-19...

The dynamic risk factors of cardiovascular disease among people living with HIV: a real-world data study

This study aims to investigate the incidence and dynamic risk factors for cardiovascular diseases (CVD) among people living with HIV (PLWH).

A machine learning screening model for identifying the risk of high-frequency hearing impairment in a general population

Hearing impairment (HI) has become a major public health issue in China. Currently, due to the limitations of primary health care, the gold standard for HI diagnosis (pure-tone hearing test) is not suitable fo...

Involuntary displacement and self-reported health in a cross-sectional survey of people experiencing homelessness in Denver, Colorado, 2018–2019

The number of people experiencing unsheltered homelessness in the U.S. is increasing. Municipalities have responded with punitive responses such as involuntary displacement (i.e., encampment sweeps, move along...

The association between waist circumference and adult asthma attack using nationally representative samples

This study aims to explore the relationship between waist circumference and asthma attack in adults.

Socio-economic inequities in mental health problems and wellbeing among women working in the apparel and floriculture sectors: testing the mediating role of psychological capital, social support and tangible assets

It is still unknown whether the mechanisms proposed by the Reserve Capacity Model (RCM) explaining socio-economic health and wellbeing inequities in high income countries can be applied to low-income countries...

A scoping review of academic and grey literature on migrant health research conducted in Scotland

Migration to Scotland has increased since 2002 with an increase in European residents and participation in the Asylum dispersal scheme. Scotland has become more ethnically diverse, and 10% of the current popul...

Food diversity: its relation to children’s health and consequent economic burden

This study investigates the impact of low food diversity on the health status of children using the Dietary Diversity Score (DDS) and Dietary Serving Score (DSS) in a sub-district with the highest percentage o...

Is economic growth enough to propel rehabilitation expenditures? An empirical analysis of country panel data and policy implications

Rehabilitation is a set of services designed to increase functioning and improve wellbeing across the life course. Despite being a core part of Universal Health Coverage, rehabilitation services often receive ...

Social determinants of health and emergency department visits among older adults with multimorbidity: insight from 2010 to 2018 National Health Interview Survey

Multimorbidity is prevalent among older adults and is associated with adverse health outcomes, including high emergency department (ED) utilization. Social determinants of health (SDoH) are associated with man...

Development and validation of Malaysian one stop crisis center service quality instrument (OSCC-Qual) for domestic violence management

One Stop Crisis Center (OSCC) is a multi-sectorial center aimed to provide medical, social, legal, police and shelter services to survivors of domestic violence, rape, sexual assault, sodomy and child abuse. A...

Comparing PrEP initiation rates by service delivery models among high risk adolescent boys and young men in KwaZulu-Natal, South Africa: findings from a population-based prospective study

Pre-exposure prophylaxis (PrEP) is an HIV prevention strategy that can reduce the risk of HIV acquisition by more than 90% if taken consistently. Although South Africa has been implementing PrEP since 2016, in...

Assessment of the integrated disease surveillance and response system implementation in health zones at risk for viral hemorrhagic fever outbreaks in North Kivu, Democratic Republic of the Congo, following a major Ebola outbreak, 2021

The Democratic Republic of the Congo (DRC) experienced its largest Ebola Virus Disease Outbreak in 2018–2020. As a result of the outbreak, significant funding and international support were provided to Eastern...

Anthropometric failures and its predictors among under five children in Ethiopia: multilevel logistic regression model using 2019 Ethiopian demographic and health survey data

Composite Index of Anthropometric Failure (CIAF) combines all three forms of anthropometric failures to assess undernutrition status of children. There is no study on CIAF to identify the real and severe form ...

1 plus 1 is more than 2: mental health problems, financial difficulties, and social exclusion in a cross-sectional study of 28,047 general-population adults

Mental health problems and financial difficulties each increase the risk of social exclusion. However, few large studies representing a broad age range have investigated the combined social effect of having bo...

Access to family planning services and associated factors among young people in Lira city northern Uganda

Access to family planning services among young people is crucial for reproductive health. This study explores the access and associated factors among young people in Lira City, Northern Uganda.

Exploring the practice of Iranian adolescent females during menstruation and related beliefs: a qualitative study

Menstruation is a natural occurrence that women experience during their reproductive years and may encounter many years throughout their lifespan. Many adolescent females lack accurate knowledge about menstrua...

Bayesian modeling of quantiles of body mass index among under-five children in Ethiopia

Body Mass Index (BMI) is a measurement of nutritional status, which is a vital pre-condition for good health. The prevalence of childhood malnutrition and the potential long-term health risks associated with o...

Acceptability of Tele-mental Health Services Among Users: A Systematic Review and Meta-analysis

Mental disorders are currently a global public health concern, particularly after the coronavirus disease 2019 (COVID-19) pandemic. Mental health services gradually transitioned to teleservices, employing vari...

A large, multi-center survey assessing health, social support, literacy, and self-management resources in patients with heart failure

Most patients with heart failure (HF) have multimorbidity which may cause difficulties with self-management. Understanding the resources patients draw upon to effectively manage their health is fundamental to ...

Exploring information needs among family caregivers of children with intellectual disability in a rural area of South Africa: a qualitative study

Globally, families experience challenges caring for and raising children with intellectual disability (ID). Family caregivers in rural states are mostly known for lacking support resources, including informati...

Housing and health for people from refugee and asylum-seeking backgrounds: findings from an Australian qualitative longitudinal study

For people from asylum-seeking and refugee backgrounds, housing and the re-establishment of home are key social determinants of health. Research highlights the inequities faced by asylum seekers and refugees i...

Living with type 1 diabetes and schooling among young people in Ghana: a truism of health selection, inadequate support, or artefactual explanation of educational inequalities?

Type 1 diabetes mellitus (T1DM) is mostly diagnosed among young people. Despite the evidence that T1DM is disruptive, and affects individuals’ health and cognitive ability, there is dearth of knowledge on the ...

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Correction: UN peacekeeper health and risk factors --- a systematic scoping review

The original article was published in Global Health Research and Policy 2024 9 :13

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UN peacekeeper health and risk factors --- a systematic scoping review

Conflicts, natural disasters, and complex emergencies present substantial health challenges to United Nations (UN) peacekeepers deployed in mission areas. This scoping review aims at summarizing previous resea...

The Correction to this article has been published in Global Health Research and Policy 2024 9 :14

Access to essential medicines for diabetes care: availability, price, and affordability in central Ethiopia

Diabetes is a major global public health burden. Effective diabetes management is highly dependent on the availability of affordable and quality-assured essential medicines (EMs) which is a challenge especiall...

Development of the China’s list of ambulatory care sensitive conditions (ACSCs): a study protocol

The hospitalization rate of ambulatory care sensitive conditions (ACSCs) has been recognized as an essential indicator reflective of the overall performance of healthcare system. At present, ACSCs has been wid...

Government responses to the COVID-19 pandemic of the Gulf Cooperation Council countries: good practices and lessons for future preparedness

The COVID-19 pandemic has dramatically threatened the Gulf Cooperation Council (GCC) countries which have a large proportion of foreign workers. The governments of GCC countries have proactively implemented a ...

Association of pre-migration socioeconomic status and post-migration mental health in Syrian refugees in Lebanon: a descriptive sex-stratified cross-sectional analysis

Refugee populations present with high levels of psychological distress, which may vary among sociodemographic characteristics. Understanding the distribution across these characteristics is crucial to subseque...

Access, interest and equity considerations for virtual global health activities during the COVID-19 pandemic: a cross-sectional study

Global health activities (GHAs) reduce health disparities by promoting medical education, professional development, and resource sharing between high- and low- to middle-income countries (HICs and LMICs). Virt...

Development assistance, donor–recipient dynamic, and domestic policy: a case study of two health interventions supported by World Bank–UK and Global Fund in China

This study views sustainability after the exit of development assistance for health (DAH) as a shared responsibility between donors and recipients and sees transitioning DAH-supported interventions into domest...

The effects of social networks on HIV risk behaviors among Vietnamese female sex workers: a qualitative study

Female sex workers (FSWs) experience heightened vulnerability to HIV and other health harms, and cross-border FSWs face additional challenges due to language issues, higher mobility, and weaker negotiation ski...

Assessing the impact of comorbid type 2 diabetes mellitus on the disease burden of chronic hepatitis B virus infection and its complications in China from 2006 to 2030: a modeling study

China bears a high burden of both hepatitis B virus (HBV) infection and type 2 diabetes mellitus (T2DM). T2DM accelerates the progression of liver disease among individuals infected with HBV. This study aims t...

Mapping of health technology assessment in China: a comparative study between 2016 and 2021

Health Technology Assessment (HTA) in China has recently expanded from purely academic research to include policy or decision-oriented practice, especially after HTA evidence was used to update the National Re...

Reimagining gendered community interventions: the case of family planning programs in rural Bangladesh

Family planning programs in Bangladesh have been successfully operating for over half a century, achieving phenomenal reductions in fertility rates. Acknowledging restrictions on women’s freedoms, much of the ...

Building a resilient health system for universal health coverage and health security: a systematic review

Resilient health system (RHS) is crucial to achieving universal health coverage (UHC) and health security. However, little is known about strategies towards RHS to improve UHC and health security. This systema...

Integrated health reporting within the UN architecture: learning from maternal, newborn and child health

Despite a proliferation of the United Nations General Assembly high-level meetings on a range of health issues and developmental challenges, global funding continues to flow disproportionately to HIV and mater...

Correction: Strengthening the primary health care for non-communicable disease prevention and control in the post-pandemic period: a perspective from China

The original article was published in Global Health Research and Policy 2023 8 :49

Building quality primary health care development in the new era towards universal health coverage: a Beijing initiative

Primary health care (PHC) is the most effective way to improve people's health and well-being, and primary care services should act as the cornerstone of a resilient health system and the foundation of univers...

Human trafficking risk factors, health impacts, and opportunities for intervention in Uganda: a qualitative analysis

Human trafficking is a global public health issue that is associated with serious short- and long-term morbidity. To address and prevent human trafficking, vulnerabilities to human trafficking and forces susta...

Economic costs of alcohol consumption in Thailand, 2021

Alcohol is one of the leading risk factors contributing to avoidable economic loss worldwide. Estimates from the economic cost of alcohol consumption studies play an important role in prioritizing healthcare r...

Childhood immunization uptake determinants in Kinshasa, Democratic Republic of the Congo: ordered regressions to assess timely infant vaccines administered at birth and 6-weeks

Despite global efforts to reduce preventable childhood illness by distributing infant vaccines, immunization coverage in sub-Saharan African settings remains low. Further, timely administration of vaccines at ...

Strengthening the primary health care for non-communicable disease prevention and control in the post-pandemic period: a perspective from China

Non-communicable diseases (NCDs) have become the leading cause of deaths in China and many other countries worldwide. To call for actions in strengthening primary health care (PHC) and accelerate NCD preventio...

The Correction to this article has been published in Global Health Research and Policy 2023 8 :54

Global health collaborative research: beyond mandatory collaboration to mandatory authorship

Collaborative research between the global north and global south is common and growing in number. Due to inability of local governments to fund research, global north actors provide the bulk of research fundin...

Awareness of and participation in mass drug administration programs used for onchocerciasis control in the Atwima Nwabiagya North District, Ghana

Studies on Mass drug administration (MDA) in Ghana targeting various diseases, have mostly focused on factors that affect coverage and compliance to MDA with limited focus on evidence regarding awareness and c...

Adaptation of the CUGH global health competency framework in the Chinese context: a mixed-methods study

In 2014, the Consortium of Universities for Global Health (CUGH) developed a global health competency framework and called for its validation. Given China's increasing engagement in global health over the past...

Factors associated with the utilization of diagnostic tools among countries with different income levels during the COVID-19 pandemic

Disparities in the utilization of essential medical products are a key factor contributing to inequality in health outcomes. We aimed to analyze the trends and influencing factors in using Coronavirus disease ...

Belt and road initiative and healthy silk road: an alternative path for Pacific island countries to participate in global public health governance

Pacific island countries (PICs) located in a region with relatively insufficient capacity to respond to public health emergencies, establishing reliable public health cooperation is conducive to maintaining se...

Depression and health-related quality of life of patients with type 2 diabetes attending tertiary level hospitals in Dhaka, Bangladesh

Type 2 diabetes mellitus (T2DM) and depression are closely linked. People with T2DM are at increased risk of developing depression and vice versa. T2DM and depression comorbid conditions adversely affect Healt...

The development and application of a two-step surveillance process for Healthy China Initiative based on wide coverage interagency data

Healthy China is a nationwide health strategy aiming at improving health from diverse dimensions, and strengthening high-quality assessment is essential for its stimulation. However, there is limited evidence in ...

Household satisfaction and associated factors with community-based health insurance scheme in Ethiopia: systematic review and meta-analysis

Community-based health insurance (CBHI) schemes are crucial for households to avoid financial hardship, improve healthcare quality, and engage in health policies. Household satisfaction is a key indicator for ...

Malaria rapid diagnostic tests in community pharmacies in Rwanda: availability, knowledge of community pharmacists, advantages, and disadvantages of licensing their use

Presumptive treatment of malaria is often practiced in community pharmacies across sub-Saharan Africa (SSA).To address this issue, the World Health Organization (WHO) recommends that malaria Rapid Diagnostic T...

A mixed method analysis of the Botswana schistosomiasis control policy and plans using the policy triangle framework

The present goal of the World Health Organization (WHO) 2021–2030 roadmap for Neglected Tropical Diseases is to eliminate schistosomiasis as a public health problem, and reduce its prevalence of heavy infectio...

Infectious disease control: from health security strengthening to health systems improvement at global level

Since the twenty first century, the outbreaks of global infectious diseases have caused several public health emergencies of international concern, imposing an enormous impact on population health, the economy...

Geriatric assessment for older people with cancer: policy recommendations

Most cancers occur in older people and the burden in this age group is increasing. Over the past two decades the evidence on how best to treat this population has increased rapidly. However, implementation of ...

The priority areas and possible pathways for health cooperation in BRICS countries

As one of the largest alliances of middle-income countries, the BRICS, known as an acronym for five countries including “Brazil, Russia, India, China, and South Africa”, represents half of the global populatio...

Mental health around retirement: evidence of Ashenfelter’s dip

Mental health issues among retirees have become increasingly concerning because the aging population presents a significant challenge globally, particularly in Western countries. Previous studies on this issue...

Correction: Cost of diabetes and its complications: results from a STEPS survey in Punjab, India

The original article was published in Global Health Research and Policy 2023 8 :11

Effect of workplace violence on health workers injuries and workplace absenteeism in Bangladesh

Workplace violence (WPV) is an emerging problem for health workers (HWs) and a global concern in health systems. Scientific literatures infer that WPV against HWs is often attributed to workplace injuries and ...

A life course health development model of HIV vulnerabilities and resiliencies in young transgender women in Peru

Globally transgender women (TW) are at heightened vulnerability for HIV infection. In Lima Peru, sharp increases in HIV prevalence are seen among TW ages 25 years and older highlighting the need for early HIV ...

High performing primary health care organizations from patient perspective: a qualitative study in China

There is a global call to build people-centred primary health care (PHC) systems. Previous evidence suggests that without organization-level reform efforts, the full potential of policy reforms may be limited....

Addressing neglected tropical diseases in Africa: a health equity perspective

Africa accounts for over one-third of the global burden of neglected tropical diseases (NTDs). Although continental efforts have been made to combat these diseases, there still exists a significant gap in the ...

Optimized segmented regression models for the transition period of intervention effects

The interrupted time series (ITS) design is a widely used approach to examine the effects of interventions. However, the classic segmented regression (CSR) method, the most popular statistical technique for an...

Oral health of adolescents in West Africa: prioritizing its social determinants

Oral health is a major public health issue in West Africa, yet it has gotten little attention. Individual and group disparities in health status are influenced by social determinants of health (SDH), which als...

Population health and sociodemographic variables as predictors of access to cardiac medicine and surgery in Haiti

In Haiti, cardiovascular disease is a leading cause of morbidity and mortality, with congenital and rheumatic heart disease comprising a large portion of disease burden. However, domestic disparities in cardia...

Evolving market-shaping strategies to boost access to essential medical products in developing countries with HIV self-testing as a case study

The COVID-19 pandemic has exacerbated health inequities among countries in the Global South with limited access to essential medical products, leading to a higher infection and mortality rate, especially among...

Prevalence and trends of polypharmacy in U.S. adults, 1999–2018

Polypharmacy is one of the most important health issues for its potential impacts on disease burden and healthcare costs. The aim of this study was to update a comprehensive picture of prevalence and trends in...

Patient views of the good doctor in primary care: a qualitative study in six provinces in China

China has been striving to train primary care doctors capable of delivering high-quality service through general practitioner training programs and family doctor team reforms, but these initiatives have not ad...

Down the brain drain: a rapid review exploring physician emigration from West Africa

The emigration of physicians from low- and middle-income countries (LMICs) to high-income countries (HICs), colloquially referred to as the “brain drain”, has been a topic of discussion in global health sphere...

Incidence and mortality trends of neglected tropical diseases and malaria in China and ASEAN countries from 1990 to 2019 and its association with the socio-demographic index

People in China and the countries in the Association of Southeast Asian Nations (ASEAN) are affected by neglected tropical diseases and malaria (NTDM). In this study, we aimed to assess the current status and ...

Transnational public and global health education in China

Transnational public and global health programs in China have rapidly expanded over the past 20 years, and have potential to make important contributions to China’s global health workforce. However, there has ...

Finding the fragments: community-based epidemic surveillance in Sudan

Sudan faces inter-sectional health risks posed by escalating violent conflict, natural hazards and epidemics. Epidemics are frequent and overlapping, particularly resurgent seasonal outbreaks of diseases such ...

Impact of federalization for health financing and workforce in Nepal

The adoption of its 2015 constitution has converted Nepal to a federal government while simultaneously resulted in significant reforms of the health system in Nepal in terms of both structure and commitment. I...

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Global Health Research and Policy

ISSN: 2397-0642

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Article Contents

Cardiovascular and associated metabolic disease.

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Physical activity and health: current issues and research needs

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Adrianne E Hardman, Physical activity and health: current issues and research needs, International Journal of Epidemiology , Volume 30, Issue 5, October 2001, Pages 1193–1197, https://doi.org/10.1093/ije/30.5.1193

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A substantial body of evidence now demonstrates the burden of ill-health attributable to sedentary living. This is most compelling for coronary heart disease (CHD) and, combined with the high prevalence of inactivity, 1 provides the rationale for Professor Morris's claim that exercise is 'today's best buy in public health'. 2 Besides a reduced risk of CHD, evidence is secure for many other health gains from physical activity; these include a reduced risk of stroke, 3, 4 type II diabetes, 5, 6 colon cancer, 7, 8 and hip fracture. 9, 10 There is evidence enough to justify the further development of public health policies to promote physical activity. The difficulty is with the specifics of what to promote and prescribe.

This paper is concerned with future contributions by research to an evidence-based rationale for exercise recommendations—both to the public at large and to individuals. It is clear that physically active people have a lower disease risk than sedentary individuals but the components of activity which determine particular health gains are poorly understood. Thus the 'dose-response' relationships for physical activity are the subject of current research interest. Intuitively, these will not be the same for different health outcomes and this is one reason why further study of the associated mechanisms is important. Understanding the underlying mechanisms will clarify the relative importance of intensity, frequency, duration and mode of exercise for specified health gains. It will also help us to distinguish the effects of exercise per se from those of co-existing behaviours and to identify stages of life during which levels of particular types of activity are critical for given health outcomes. This paper presents a personal view of research needs.

How important is intensity?

The rate of energy expenditure (in oxygen uptake units) of common physical activities is expressed in METS. One MET is equivalent to the resting metabolic rate, assumed to be 3.5 ml oxygen per kg of body mass per minute.

Oxygen uptake reserve is obtained by subtracting one MET (3.5 ml . kg .–1 min –1 ) from the maximal oxygen uptake.

Its importance in the epidemiology of physical activity is evidenced by data from British civil servants. 12 Whereas only frequent vigorous exercise (defined as liable to entail peaks of energy expenditure of ≥7.5 kcal.min –1 [31.5 kJ.min –1 ]) was associated with protection against heart attack in men aged 45–54 at entry, there was a dose-response relationship for a lesser degree of such exercise (either <2 sessions per week or not so intense, e.g. 'fairly brisk' walking for >30 min. per day) among older men aged 55–64 at entry. Thus, for example, older men reporting moderately intense activity such as 'much stair climbing' (not judged sufficiently vigorous to be included in the 'vigorous aerobic' cluster of activities) showed a coronary rate which was significantly lower than that in less active men. Protection among younger men was limited to those reporting frequent vigorous aerobic exercise. This finding suggests that the key features of cardio-protective exercise include its intensity relative to individual capacity. V • O 2 max declines, on average, by about 10% per decade in middle-aged and older people, 13 so exercise of a given MET value represents a higher relative intensity for older people. Where the number of individuals surveyed permit, one approach 14 may be to express the MET value of the activity in relation to age-related average values for oxygen uptake reserve.

Frequency of exercise

Recent recommendations 15, 16 are for exercise on '… most, preferably all, days of the week', underlining the importance of frequent exercise. This notion reflects increasing recognition of the acute effects of exercise, i.e. altered physiological or metabolic responses lasting between several hours and a few days after a session of exercise. These include a decrease in blood pressure, 17 improved insulin sensitivity 18 and decreases in plasma triglycerides. 19 The time-courses over which they disappear are poorly understood, however. Some information is available, for example the attenuation of the postprandial rise in plasma triglycerides following a standard high-fat meal has been reported to disappear within 60 hours of an exercise session. 20 Improved insulin sensitivity may persist for a little longer. 21 More information is required, however, as the duration of these effects dictates the frequency with which exercise sessions must be taken if favourable postprandial responses are to be maintained. Similarly, the determinants of the magnitude of acute effects of exercise need to be elucidated. Theoretically, this may be enhanced by training 22 because training permits more frequent and longer exercise sessions to be accomplished without fatigue. To the author's knowledge, this proposition has seldom been tested. 23

Pattern of exercise

Epidemiological studies have found an inverse relationship between the total energy expended in leisure time physical activity and health outcomes. These include a lower risk of all-cause mortality, 24 cardiovascular morbidity and mortality, 24, 25 type II diabetes, 6 hypertension, 26 and site-specific cancers. 27, 28 Some activities contributing to high totals of energy expenditure seem likely to have been performed at least partly on an intermittent basis, for example walking, 29 climbing stairs, 25, 30 gardening, 29 and repair work. 24 Survey evidence therefore suggests that several short sessions of moderate physical activity during the day influence health outcomes in a positive manner, at least when they contribute to a high total energy expenditure.

Scientific evidence for the efficacy of this pattern of exercise as a means of eliciting chronic (training) effects is limited however, both in the number of randomly controlled trials (three to the author's knowledge) and scope (the only common outcome measure was fitness). 31 Evidence is limited to scientific studies with outcome measures primarily of fitness and/or fatness. Only one study reported the effect of exercise pattern on acute health-related responses. This found similar reductions in plasma triglycerides with three, 10-minute bouts of brisk walking at intervals during the day and one, 30-minute bout in sedentary people consuming normal meals. 32

Further research is clearly required before the principle of accumulating exercise in short bouts throughout the day can be endorsed with confidence.

Energy expenditure and energy turnover

The product of intensity, frequency and duration of exercise—sometimes described as the total 'volume' of exercise (a difficult term)—yields the total gross energy expenditure. Some evidence points to this as an important determinant of health gains. In addition to the surveys referred to above, this includes the finding from the US Runners' Health Study that running mileage was six times more important in predicting high density lipoprotein cholesterol concentration than running speed. 33 This was not the case for associations with blood pressure or waist circumference, however, where running speed was the more important determinant. 33 Total energy expenditure may also be the main determinant of some acute effects of exercise. Two examples are relevant. First, the increase in glucose disposal rate was similar following exercise at 50% or 75% V • O 2 max when the total energy expended was held constant. 34 Second, the attenuation of postprandial plasma triglycerides by prior exercise was strikingly similar following a long bout of low intensity exercise and a shorter bout of moderate exercise expending the same energy. 35 This topic, again under-researched, is related to that of the accumulation of exercise (referred to above) because that enshrines the notion that the total energy expenditure is all-important.

Of course, in free-living people, an increased level of physical activity is invariably associated with an increase in energy intake so that energy turnover is increased. Speculatively, a higher energy turnover may constitute a metabolically desirable state because of effects on the pathways concerned with the disposition, storage and degradation of muscle energy substrates. Evidence for the health gains from such a state include the finding that men who were classified as obese by body mass index (BMI) but who had a high level of physical fitness had lower cardiovascular and total mortality rates than lean men who were unfit. 36 Similarly, although both high BMI and a high energy intake were associated with increased risk of colon cancer among inactive people, this was not the case among physically active individuals. 8 This finding suggests that a high energy intake does not confer increased risk of this cancer in the presence of a high expenditure.

The suggestion that a high energy turnover is metabolically advantageous is not new. The term 'metabolic fitness' was introduced by Després and Lamarche, 37 on the basis of a series of studies showing that change to plasma lipoprotein lipids and body fatness were achieved through high-volume, low intensity training in the absence of increases in V • O 2 max. Efforts to test this hypothesis through comparing the effects of 'lifestyle' activity with those of traditional exercise programmes have recently been reported 38– 40 but information is needed for a variety of health outcomes in different populations.

Over the last decade, epidemiological data on physical activity (a behaviour) has been complemented by findings based on physical fitness (a set of attributes related to the ability to perform exercise). These studies show a dose-response relationship so that, although men in the highest fitness groups consistently show the lowest coronary attack and total mortality rates, moderate levels of fitness also confer a statistically significant and clinically important reduction in risk. 41, 42 Physical fitness, because it is probably a more objective measure than physical activity is an attractive outcome measure. Its use could be extended of course if it could be measured satisfactorily outside the laboratory. A low-cost, rapid, non-intimidating method for this would allow large surveys with the statistical power to detect, for example, effects in sub-groups and effects of specific activities. Walking tests such as the UKK Institute's 2 km protocol 43 are attractive for both practical and theoretical reasons. Performance on these tests measures not only functional capacity (V • O 2 max, the most frequently used laboratory measure), but also endurance. This is defined as the capability to sustain aerobic exercise using a high proportion of V • O 2 max. Endurance is more sensitive to changes in physical activity level than V • O 2 max and, because it derives largely from metabolic adaptations in muscle, may be a more important determinant of related health gains.

As mentioned, epidemiological studies show associations between fitness and a variety of health outcomes. The need to elucidate the relationships between the 'dose' and pattern of activity and the health outcome has been mentioned above. Fitness (particularly endurance) is labile and so rather easily changed through short-term interventions. It therefore offers a means of studying these dose-response relations indirectly (but inexpensively), serving a link between the behaviour and health outcomes.

Most epidemiological studies have classified physical activities according to estimated energy expenditure—either totals or threshold rates. Recommendations to the public (whether direct or via health professionals), however, need to promote activities rather than energy expenditures. Walking is an obvious example. It is popular, inexpensive and carries a low risk of injury. It is often the most commonly reported activity, particularly among women 44 and older men. 12 Some landmark studies, including those by Professor Morris's group, 12 have published separate analyses for walking. 25 In British civil servants brisk walking accounted for over half of the exercise which was protective against heart attack in 55–64-year-old men. 12 Protection from attack among fairly brisk walkers was not significantly affected by controlling for participation in sports and cycling or for a lot of other CHD predictive factors. In recent years more data has become available, however. In the US Nurses Health Study, for example, walking was inversely associated with coronary events; women in the highest quintile group for walking (≥3 h per week at a brisk pace) had a multivariate relative risk of 0.65 (95% CI : 0.47–0.91). 45 Similarly, healthy older men in the Honolulu Heart Study who walked >1.5 miles per day had half the coronary risk of those who walked <0.25 miles per day. 46 Walking has also been reported to be associated with a lower risk of type II diabetes 47 (independently of participation in vigorous activity).

These observations are consistent with reports that moderate levels of fitness, associated with a reduction in all-cause mortality, are attainable through brisk or fast walking. 48, 49 Bearing in mind that sedentary people seldom exert themselves at more than 30–35% of V • O 2 max, 50 such walking is sufficiently vigorous to improve fitness in a majority of people whose health is at risk because of their inactivity.

Walking is especially suitable for older people and the functional gains it elicits will likely improve quality of life. It is plainly acceptable for them, and carries a low risk of injury. In 13 weeks of training by walking, only one injury was sustained among 57 healthy men and women their 70s. 51 Among older people, regular walking has been associated with lower rates of hospitalization, 52 lower plasma triglycerides and higher bone mineral density. 53

Because it is accessible to all but the very frail, more information on the specific benefits from walking—according to pace and distance—is sorely needed.

Studies of the associations between physical activity habits and disease outcomes must be complemented by research into the underlying mechanisms. Not only does this increase confidence that such associations may be causal but it helps us to understand the relative importance of the different components of exercise as mediators of specified health gains. For cardiovascular disease much is known of the potential contribution from exercise-induced changes to blood lipids, with recent information about considerable effects on the dynamic postprandial phase. Other mechanisms must be involved, however, because patients with CHD get improved myocardial perfusion (and decreased risk of further episodes) without net regression. 54

Recent findings suggest effects on the acute phases of the disease. (This would be concordant with observations that only continuing, current exercise confers a lower risk; past exercise has no effect. 12, 55 ) These include improved flow-mediated dilatation. 56 There may be links here with lipoprotein metabolism because flow-mediated dilatation is impaired by high plasma triglycerides, in proportion to concentration. 57

Mechanisms need elucidating in other areas, for instance skeletal health. Is the lower risk of hip fracture among physically active older women due to a decreased risk of falling and/or to an effect on bone mineral density? Is physical activity level particularly important during the years when bone formation predominates? The relationship between physical activity and a reduced risk of colon cancer is among the most consistent finding in the epidemiological literature. Is the mechanism systemic (reduced growth-promoting milieu) or local (increased colonic peristalsis)? Women who regularly engage in exercise may have a lower risk of breast cancer. 58 Speculation on potential mechanisms has involved endocrine factors and/or improved weight maintenance. Depending on the answers to such questions, some forms and regimens of exercise may be more effective than others in the achievement of particular objectives.

Physical inactivity is a waste of human potential for health and well-being and its high prevalence is a cause for concern. Its potential contribution to positive health (not merely the absence of disease but associated with a capacity to enjoy life and to withstand challenges 16 ) is considerable. So much is known—yet we need to understand much more. The effective 'dose' of exercise needed to elicit effects likely to be of clinical importance must be defined and this information translated into practical advice readily understood by the population at risk. Ten years after Professor Morris's plea for 'physiology and epidemiology to get together', 12 the need for co-operative efforts from these disciplines is even more urgent.

'Thank you'

I thank Professor Morris for posing thought-provoking questions and for stimulating discussion of these. His contributions—to research, to the National Fitness Survey for England, and to the development of public health policies—are valued by so many. It continues to be an education and a privilege to work with him.

National Fitness Survey: Main Findings. London: Sports Council and Health Education Authority, 1992.

Morris JN. Exercise in the prevention of coronary heart disease: today's best buy in public health. Med Sci Sports Exerc 1994 ; 26 : 807 –14.

Wannamethee G, Shaper AG. Physical activity and stroke in British middle-aged men. Br Med J 1992 ; 304 : 597 –601.

Lee I-M, Paffenbarger RS. Physical activity and stroke incidence. The Harvard Alumni Health Study. Stroke 1998 ; 29 : 2049 –54.

Haapanen N, Miilunpalo S, Vuori I, Oja P, Pasanen M. Association of leisure time physical activity with the risk of coronary heart disease, hypertension and diabetes in middle-aged men and women. Int J Epidemiol 1997 ; 26 : 739 –47.

Helmrich SP, Ragland DR, Leung RW, Paffenbarger RS. Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus. N Engl J Med 1991 ; 325 : 147 –52.

Giovannucci E, Ascherio A, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Physical activity, obesity, and risk for colon cancer and adenoma in men. Ann Int Med 1995 ; 122 : 327 –34.

Slattery ML, Potter J, Caan B et al . Energy balance and colon cancer—beyond physical activity. Cancer Res 1997 ; 57 : 75 –80.

Cummings SR, Nevitt MC, Browner WS et al . Risk factors for hip fracture in white women. N Engl J Med 1995 ; 332 : 767 –73.

Dargen-Molina P, Favier F, Grandjean H et al . Fall-related factors and risk of hip fracture: the EPIDOS prospective study. Lancet 1996 ; 348 : 145 –49.

Swain DP, Leutholtz BC. Heart rate reserve is equivalent to %V • O 2 Reserve, not to %V • O 2max . Med Sci Sports Exerc 1997 ; 29 : 410 –14.

Morris JN, Clayton DG, Everitt MG, Semmence AM, Burgess EH. Exercise in leisure time: coronary attack and death rates. Br Heart J 1990 ; 63 : 325 –34.

Hagberg JM. Effect of training on the decline of V • O 2max with aging. Fed Proc 1987 ; 46 : 1830 –33.

Howley ET. Type of activity: resistance, aerobic, anaerobic and leisure-time versus occupational physical activity. Med Sci Sports Exerc 2001 (in press).

More People, More Active, More Often . Report of Physical Activity Task Force. London: Department of Health, 1995.

Physical Activity and Health. A Report of the Surgeon General . US Departments of Health and Human Services. Centers for Disease Control and Prevention. Atlanta, GA, 1996.

Pescatello LS, Fargo AE, Leach CN, Scherzer HH. Short-term effect of dynamic exercsie on arterial blood pressure. Circulation 1991 ; 83 : 1557 –61.

Dela F, Mikines KJ, von Linstow M, Secher NH, Galbo H. Effect of training on insulin-mediated glucose uptake in human muscle. Am J Physiol 1992 ; 263 : E1134 –43.

Tsetsonis NV, Hardman AE, Mastana SS. Acute effects of exercise on postprandial lipemia: a comparative study in trained and untrained middle-aged women. Am J Clin Nutr 1997 ; 65 : 525 –33.

Hardman AE, Lawrence JEM, Herd SL. Postprandial lipemia in endurance-trained people during a short interruption to training. J Appl Physiol 1998 ; 84 : 1895 –901.

King DS, Baldus RJ, Sharp RL, Kesl LD, Feltmeyer TL, Riddle MS. Time course for exercise-induced alterations in insulin action and glucose tolerance in middle-aged people. J Appl Physiol 1995 ; 78 : 17 –22.

Haskell WL. Health consequences of physical activity: understanding and challenges regarding dose-response. Med Sci Sports Exerc 1994 ; 26 : 649 –60.

Crouse SF, O'Brien BC, Grandjean PW, Lowe RC, Rohack JJ, Green JS. Effects of training and a single session of exercise on lipids and apolipoproteins in hypercholesterolemic men. J Appl Physiol 1997 ; 83 : 2019 –28.

Haapanen N, Miilunpalo S, Vuori I, Oja P, Pasanen M. Characteristics of leisure time physical activity associated with decreased risk of premature all-cause and cardiovascular disease mortality in middle-aged men. Am J Epidemiol 1996 ; 143 : 870 –80.

Paffenbarger RS, Hyde RT, Wing AL, Hsieh C-C. Physical activity, all-cause mortality, and longevity of college alumni. N Engl J Med 1986 ; 314 : 605 –13.

Paffenbarger RS, Wing AL, Hyde RT, Jung DL. Physical activity and incidence of hypertension in college alumni. Am J Epidemiol 1983 ; 117 : 247 –57.

Thune I, Lund E. Physical activity and risk of colorectal cancer in men and women. Br J Cancer 1996 ; 73 : 1134 –40.

Thune I, Brenn T, Lund E, Gaard M. Physical activity and the risk of breast cancer. N Engl J Med 1997 ; 336 : 1269 –75.

Magnus K, Matroos A, Strackee J. Walking, cycling, or gardening, with or without seasonal interruption, in relation to coronary events. Am J Epidemiol 1979 ; 110 : 724 –33.

Paffenbarger RS, Hyde RT, Wing AL, Lee I-M, Jung DL, Kampert JB. The association of changes in physical activity level and other lifestyle characteristics with mortality among men. N Engl J Med 1993 ; 328 : 538 –45.

Hardman AE. Issues of fractionalization (intermittent versus continuous exercise). Med Sci Sports Exerc 2001 ; 33 (6Suppl.): S421 –27.

Murphy MH, Nevill AM, Hardman AE. Different patterns of brisk walking are equally effective in decreasing postprandial lipaemia. Int J Obesity 2000 ; 24 : 1303 –09.

Williams PT. Relationships of heart disease risk factors to exercise quantity and intensity. Arch Int Med 1998 ; 158 : 237 –45.

Braun B, Zimmermann MB, Kretchmer N. Effects of exercise intensity on insulin sensitivity in women with non-insulin-dependent diabetes mellitus. J Appl Physiol 1995 ; 78 : 300 –06.

Tsetsonis NV, Hardman AE. Reduction in postprandial lipemia after walking: influence of exercise intensity. Med Sci Sports Exerc 1996 ; 28 : 1235 –42.

Wei M, Kampert JB, Barlow CE et al . Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. J Am Med Assoc 1999 ; 282 : 1547 –53.

Després J-P, Lamarche B. Low-intensity endurance exercise training, plasma lipoproteins and the risk of coronary heart disease. J Int Med 1994 ; 236 : 7 –22.

Andersen RE. Effects of lifestyle activity vs structured aerobic exercise in obese women. A randomized trial. J Am Med Assoc 1999 ; 281 : 335 –40.

Jakicic JM, Winters C, Lang W, Wing RR. Effects of intermittent exercise and use of home exercise equipment on adherence, weight loss, and fitness in overweight women. A randomized trial. J Am Med Assoc 1999 ; 282 : 1554 –60.

Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW, Blair SN. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness. J Am Med Assoc 1999 ; 281 : 327 –34.

Lakka TA, Venäläinen JM, Raurama R, Salonen R, Tuomilehto J, Salonen JT. Relation of leisure-time physical activity and cardiorespiratory fitness to the risk of acute myocardial infarction in men. N Engl J Med 1994 ; 330 : 1549 –54.

Blair SN, Kampert JB, Kohl HW et al . Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. J Am Med Assoc 1996 ; 276 : 205 –10.

Oja P, Laukkanen R, Pasanen M, Tyry T, Vuori I. A 2-km walking test for assessing cardiorespiratory fitness in healthy adults. Int J Sports Med 1991 ; 12 : 356 –62.

Lemaitre RN, Heckbert SR, Psaty BM, Siscovick DS. Leisure-time physical activity and the risk of nonfatal myocardial infarction in postmenopausal women. Arch Int Med 1995 ; 155 : 2302 –08.

Manson J, Hu FB, Rich-Edwards JW et al . A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. N Engl J Med 1999 ; 341 : 650 –58.

Hakim AA, Curb JD, Petrovitch H et al . Effects of walking on coronary heart disease in elderly men. The Honolulu Heart Program. Circulation 1999 ; 100 : 9 –13.

Hu FB, Sigal RJ, Rich-Edwards JW et al . Walking compared with vigorous physical activity and risk of type 2 diabetes in women. J Am Med Assoc 1999 ; 282 : 1433 –39.

Stensel DJ, Brooke-Wavell K, Hardman AE, Jones PRM, Norgan NG. The influence of a one year programme of brisk walking on endurance fitness and body composition in previously sedentary men aged 42–59 years. Eur J Appl Physiol 1994 ; 68 : 531 –37.

Hardman AE, Jones PRM, Norgan NG, Hudson A. Brisk walking improves endurance fitness without changing body fatness in previously sedentary women. Eur J Appl Physiol 1992 ; 65 : 354 –59.

Franklin BA, Blair SN, Haskell WL, Thompson PD, Van Camp SP. Exercise and cardiac complications. Do the benefits outweigh the risks? Physician Sportsmed 1994 ; 22 : 56 –68.

Pollock ML, Carroll JF, Graves JE et al . Injuries and adherence to walk/jog and resistance training programs in the elderly. Med Sci Sports Exerc 1991 ; 23 : 1194 –200.

LaCroiz AZ, Leveille SG, Hecht JA, Grothaus LC, Wagner EH. Does walking decrease the risk of cardiovascular disease hospitalizations and death in older adults? J Am Geriatr Soc 1996 ; 44 : 113 –20.

Frändin K, Grimby G, Mellström D, Svanborg D. Walking habits and health-related factors in a 70-year-old population. Gerontology 1991 ; 37 : 281 –88.

Schuler G, Hambrecht R, Schlierf G et al . Regular physical exercise and low-fat diet: effects on the progression of coronary artery disease. Circulation 1992 ; 86 : 1 –11.

Paffenbarger RS, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol 1978 ; 108 : 161 –75.

Hambrecht R, Wolf A, Gielen S et al . Effect of exercise on coronary endothelial function in patients with coronary artery disease. N Engl J Med 2000 ; 342 : 454 –60.

Vogel RA, Corretti MC, Plotnick GD. Effect of a single high-fat meal on endothelial function in healthy subjects. Am J Cardiol 1997 ; 79 : 350 –54.

Bernstein L, Henderson BE, Hanisch R, Sullivan-Halley J, Ross RK. Physical exercise and reduced risk of breast cancer in young women. J Natl Cancer Inst 1994 ; 86 : 1403 –08.

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Research Topics & Ideas: Healthcare

100+ Healthcare Research Topic Ideas To Fast-Track Your Project

Finding and choosing a strong research topic is the critical first step when it comes to crafting a high-quality dissertation, thesis or research project. If you’ve landed on this post, chances are you’re looking for a healthcare-related research topic , but aren’t sure where to start. Here, we’ll explore a variety of healthcare-related research ideas and topic thought-starters across a range of healthcare fields, including allopathic and alternative medicine, dentistry, physical therapy, optometry, pharmacology and public health.

NB – This is just the start…

The topic ideation and evaluation process has multiple steps . In this post, we’ll kickstart the process by sharing some research topic ideas within the healthcare domain. This is the starting point, but to develop a well-defined research topic, you’ll need to identify a clear and convincing research gap , along with a well-justified plan of action to fill that gap.

If you’re new to the oftentimes perplexing world of research, or if this is your first time undertaking a formal academic research project, be sure to check out our free dissertation mini-course. In it, we cover the process of writing a dissertation or thesis from start to end. Be sure to also sign up for our free webinar that explores how to find a high-quality research topic.

Overview: Healthcare Research Topics

• Allopathic medicine
• Alternative /complementary medicine
• Veterinary medicine
• Physical therapy/ rehab
• Optometry and ophthalmology
• Pharmacy and pharmacology
• Public health
• Examples of healthcare-related dissertations

Allopathic (Conventional) Medicine

• The effectiveness of telemedicine in remote elderly patient care
• The impact of stress on the immune system of cancer patients
• The effects of a plant-based diet on chronic diseases such as diabetes
• The use of AI in early cancer diagnosis and treatment
• The role of the gut microbiome in mental health conditions such as depression and anxiety
• The efficacy of mindfulness meditation in reducing chronic pain: A systematic review
• The benefits and drawbacks of electronic health records in a developing country
• The effects of environmental pollution on breast milk quality
• The use of personalized medicine in treating genetic disorders
• The impact of social determinants of health on chronic diseases in Asia
• The role of high-intensity interval training in improving cardiovascular health
• The efficacy of using probiotics for gut health in pregnant women
• The impact of poor sleep on the treatment of chronic illnesses
• The role of inflammation in the development of chronic diseases such as lupus
• The effectiveness of physiotherapy in pain control post-surgery

Topics & Ideas: Alternative Medicine

• The benefits of herbal medicine in treating young asthma patients
• The use of acupuncture in treating infertility in women over 40 years of age
• The effectiveness of homoeopathy in treating mental health disorders: A systematic review
• The role of aromatherapy in reducing stress and anxiety post-surgery
• The impact of mindfulness meditation on reducing high blood pressure
• The use of chiropractic therapy in treating back pain of pregnant women
• The efficacy of traditional Chinese medicine such as Shun-Qi-Tong-Xie (SQTX) in treating digestive disorders in China
• The impact of yoga on physical and mental health in adolescents
• The benefits of hydrotherapy in treating musculoskeletal disorders such as tendinitis
• The role of Reiki in promoting healing and relaxation post birth
• The effectiveness of naturopathy in treating skin conditions such as eczema
• The use of deep tissue massage therapy in reducing chronic pain in amputees
• The impact of tai chi on the treatment of anxiety and depression
• The benefits of reflexology in treating stress, anxiety and chronic fatigue
• The role of acupuncture in the prophylactic management of headaches and migraines

Topics & Ideas: Dentistry

• The impact of sugar consumption on the oral health of infants
• The use of digital dentistry in improving patient care: A systematic review
• The efficacy of orthodontic treatments in correcting bite problems in adults
• The role of dental hygiene in preventing gum disease in patients with dental bridges
• The impact of smoking on oral health and tobacco cessation support from UK dentists
• The benefits of dental implants in restoring missing teeth in adolescents
• The use of lasers in dental procedures such as root canals
• The efficacy of root canal treatment using high-frequency electric pulses in saving infected teeth
• The role of fluoride in promoting remineralization and slowing down demineralization
• The impact of stress-induced reflux on oral health
• The benefits of dental crowns in restoring damaged teeth in elderly patients
• The use of sedation dentistry in managing dental anxiety in children
• The efficacy of teeth whitening treatments in improving dental aesthetics in patients with braces
• The role of orthodontic appliances in improving well-being
• The impact of periodontal disease on overall health and chronic illnesses

Tops & Ideas: Veterinary Medicine

• The impact of nutrition on broiler chicken production
• The role of vaccines in disease prevention in horses
• The importance of parasite control in animal health in piggeries
• The impact of animal behaviour on welfare in the dairy industry
• The effects of environmental pollution on the health of cattle
• The role of veterinary technology such as MRI in animal care
• The importance of pain management in post-surgery health outcomes
• The impact of genetics on animal health and disease in layer chickens
• The effectiveness of alternative therapies in veterinary medicine: A systematic review
• The role of veterinary medicine in public health: A case study of the COVID-19 pandemic
• The impact of climate change on animal health and infectious diseases in animals
• The importance of animal welfare in veterinary medicine and sustainable agriculture
• The effects of the human-animal bond on canine health
• The role of veterinary medicine in conservation efforts: A case study of Rhinoceros poaching in Africa
• The impact of veterinary research of new vaccines on animal health

Topics & Ideas: Physical Therapy/Rehab

• The efficacy of aquatic therapy in improving joint mobility and strength in polio patients
• The impact of telerehabilitation on patient outcomes in Germany
• The effect of kinesiotaping on reducing knee pain and improving function in individuals with chronic pain
• A comparison of manual therapy and yoga exercise therapy in the management of low back pain
• The use of wearable technology in physical rehabilitation and the impact on patient adherence to a rehabilitation plan
• The impact of mindfulness-based interventions in physical therapy in adolescents
• The effects of resistance training on individuals with Parkinson’s disease
• The role of hydrotherapy in the management of fibromyalgia
• The impact of cognitive-behavioural therapy in physical rehabilitation for individuals with chronic pain
• The use of virtual reality in physical rehabilitation of sports injuries
• The effects of electrical stimulation on muscle function and strength in athletes
• The role of physical therapy in the management of stroke recovery: A systematic review
• The impact of pilates on mental health in individuals with depression
• The use of thermal modalities in physical therapy and its effectiveness in reducing pain and inflammation
• The effect of strength training on balance and gait in elderly patients

Topics & Ideas: Optometry & Opthalmology

• The impact of screen time on the vision and ocular health of children under the age of 5
• The effects of blue light exposure from digital devices on ocular health
• The role of dietary interventions, such as the intake of whole grains, in the management of age-related macular degeneration
• The use of telemedicine in optometry and ophthalmology in the UK
• The impact of myopia control interventions on African American children’s vision
• The use of contact lenses in the management of dry eye syndrome: different treatment options
• The effects of visual rehabilitation in individuals with traumatic brain injury
• The role of low vision rehabilitation in individuals with age-related vision loss: challenges and solutions
• The impact of environmental air pollution on ocular health
• The effectiveness of orthokeratology in myopia control compared to contact lenses
• The role of dietary supplements, such as omega-3 fatty acids, in ocular health
• The effects of ultraviolet radiation exposure from tanning beds on ocular health
• The impact of computer vision syndrome on long-term visual function
• The use of novel diagnostic tools in optometry and ophthalmology in developing countries
• The effects of virtual reality on visual perception and ocular health: an examination of dry eye syndrome and neurologic symptoms

Topics & Ideas: Pharmacy & Pharmacology

• The impact of medication adherence on patient outcomes in cystic fibrosis
• The use of personalized medicine in the management of chronic diseases such as Alzheimer’s disease
• The effects of pharmacogenomics on drug response and toxicity in cancer patients
• The role of pharmacists in the management of chronic pain in primary care
• The impact of drug-drug interactions on patient mental health outcomes
• The use of telepharmacy in healthcare: Present status and future potential
• The effects of herbal and dietary supplements on drug efficacy and toxicity
• The role of pharmacists in the management of type 1 diabetes
• The impact of medication errors on patient outcomes and satisfaction
• The use of technology in medication management in the USA
• The effects of smoking on drug metabolism and pharmacokinetics: A case study of clozapine
• Leveraging the role of pharmacists in preventing and managing opioid use disorder
• The impact of the opioid epidemic on public health in a developing country
• The use of biosimilars in the management of the skin condition psoriasis
• The effects of the Affordable Care Act on medication utilization and patient outcomes in African Americans

Topics & Ideas: Public Health

• The impact of the built environment and urbanisation on physical activity and obesity
• The effects of food insecurity on health outcomes in Zimbabwe
• The role of community-based participatory research in addressing health disparities
• The impact of social determinants of health, such as racism, on population health
• The effects of heat waves on public health
• The role of telehealth in addressing healthcare access and equity in South America
• The impact of gun violence on public health in South Africa
• The effects of chlorofluorocarbons air pollution on respiratory health
• The role of public health interventions in reducing health disparities in the USA
• The impact of the United States Affordable Care Act on access to healthcare and health outcomes
• The effects of water insecurity on health outcomes in the Middle East
• The role of community health workers in addressing healthcare access and equity in low-income countries
• The impact of mass incarceration on public health and behavioural health of a community
• The effects of floods on public health and healthcare systems
• The role of social media in public health communication and behaviour change in adolescents

Examples: Healthcare Dissertation & Theses

While the ideas we’ve presented above are a decent starting point for finding a healthcare-related research topic, they are fairly generic and non-specific. So, it helps to look at actual dissertations and theses to see how this all comes together.

Below, we’ve included a selection of research projects from various healthcare-related degree programs to help refine your thinking. These are actual dissertations and theses, written as part of Master’s and PhD-level programs, so they can provide some useful insight as to what a research topic looks like in practice.

• Improving Follow-Up Care for Homeless Populations in North County San Diego (Sanchez, 2021)
• On the Incentives of Medicare’s Hospital Reimbursement and an Examination of Exchangeability (Elzinga, 2016)
• Managing the healthcare crisis: the career narratives of nurses (Krueger, 2021)
• Methods for preventing central line-associated bloodstream infection in pediatric haematology-oncology patients: A systematic literature review (Balkan, 2020)
• Farms in Healthcare: Enhancing Knowledge, Sharing, and Collaboration (Garramone, 2019)
• When machine learning meets healthcare: towards knowledge incorporation in multimodal healthcare analytics (Yuan, 2020)
• Integrated behavioural healthcare: The future of rural mental health (Fox, 2019)
• Healthcare service use patterns among autistic adults: A systematic review with narrative synthesis (Gilmore, 2021)
• Mindfulness-Based Interventions: Combatting Burnout and Compassionate Fatigue among Mental Health Caregivers (Lundquist, 2022)
• Transgender and gender-diverse people’s perceptions of gender-inclusive healthcare access and associated hope for the future (Wille, 2021)
• Efficient Neural Network Synthesis and Its Application in Smart Healthcare (Hassantabar, 2022)
• The Experience of Female Veterans and Health-Seeking Behaviors (Switzer, 2022)
• Machine learning applications towards risk prediction and cost forecasting in healthcare (Singh, 2022)
• Does Variation in the Nursing Home Inspection Process Explain Disparity in Regulatory Outcomes? (Fox, 2020)

Looking at these titles, you can probably pick up that the research topics here are quite specific and narrowly-focused , compared to the generic ones presented earlier. This is an important thing to keep in mind as you develop your own research topic. That is to say, to create a top-notch research topic, you must be precise and target a specific context with specific variables of interest . In other words, you need to identify a clear, well-justified research gap.

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ORIGINAL RESEARCH article

The relationship between health-promoting behaviors and negative emotions in college freshmen: a cross-lagged analysis.

• 1 College of Physical Education, Southwest University, Chongqing, China
• 2 Department of Rehabilitation Sciences Institute, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China

Background: The prevalence of mental health issues has been gradually increasing among college students in recent years. Improvements in mental health can be achieved through changes in daily behavior and the use of psychological counseling. This study aims to investigate the relationship between health-promoting behaviors and negative emotions among college freshmen as they enter the university. It also examines the impact of various sub-dimensions of health-promoting behaviors and other factors on the negative emotions (stress, anxiety, and depression) experienced by college freshmen.

Methods: Using the Negative Emotion and Health-Promoting Behavior scales, a 7-month longitudinal study was conducted on 4,252 college freshmen, with collection of data at two time points (T1: November 12, 2021; T2: June 17, 2022). Out of this longitudinal study, 3,632 valid samples were obtained. This research aimed to explore the association and impact between negative emotions and the level of health-promoting behaviors among college students during their time at the university.

Results: ① There were significant differences in the levels of health-promoting behaviors and negative emotions over the course of 7 months ( P < 0.05). Health-promoting behaviors were found to have a significant negative correlation with negative emotions ( P < 0.05). ② Negative emotions at T1 significantly negatively predicted health-promoting behaviors at T2 ( β = −0.11, P < 0.01), while health-promoting behaviors at T1 significantly negatively predicted negative emotions at T2 ( β = −0.12, P < 0.001). ③ Stress management ( β = −0.104, P < 0.05; β = −0.087, P < 0.05), self-actualization ( β = −0.282, P < 0.01; β = −0.260, P < 0.05), health responsibility ( β = −0.057, P < 0.05; β = −0.088, P < 0.05), and interpersonal relations ( β = 0.068, P < 0.01; β = 0.138, P < 0.05) were important components in improving stress and anxiety. Self-actualization ( β = −0.437, P < 0.001), exercise ( β = 0.048, P < 0.001), nutrition ( β = 0.044, P < 0.001), and interpersonal relations ( β = 0.065, P < 0.001) were important components in improving depression. ④ Gender, place of household registration, and whether the individual is the only child were significant factors affecting negative emotions in college freshmen.

Conclusion: The level of health-promoting behaviors is an important indicator for assessing the negative emotional states of college freshmen. Enhancing health-promoting behaviors across various dimensions can help alleviate different types of negative emotions. Gender, place of household registration, and being the only child are significant factors that influence negative emotions.

1 Introduction

In recent years, the college student population has been experiencing severe mental health issues, which is rising and attributable to unfamiliar living environments, intense academic pressures, and complex job market trends. As a result, there has been a spurt in research focusing on the psychological health issues faced by college students ( 1 ). According to statistics from the World Health Organization (WHO), over one billion people worldwide suffer from mental disorders as of June 2023, with more than one-eighth of the affected population comprising adults and adolescents. The current level of mental health services are vastly inadequate to meet the steadily increasing mental health needs. In high-income countries, only 70% of those in need can access mental health services, whereas in low-income countries, a mere 12% of the population is able to receive psychiatric treatment ( 2 ).

According to reports, the incidence of psychological disorders among Chinese university students has been rising annually and is higher than that of the general population in China. Moreover, psychological issues among Chinese students are showing a continuously increasing trend ( 3 , 4 ). Although relatively severe social safety issues may occur infrequently within this group, the level of psychological problems continues to escalate ( 5 ). Chinese university students represent a unique demographic, particularly those in their 1st year, as they are at a pivotal stage transitioning from adolescence to adulthood. They encounter learning methods distinct from their high-school experiences, along with changes in diet, exercise, academic pressure in university, social interactions with peers, and uncertainties about the future. All these factors may contribute to the accumulation and even eruption of mental health issues within this group ( 6 – 9 ). Research indicates that negative emotions are significant indicators of mental health, primarily manifesting as a combination of anxiety, depression, and stress. However, the accumulation of negative emotions may also become a major risk factor for physical health ( 10 ). For instance, the isolation resulting from pandemic control measures has led to more severe negative emotions among college students compared to non-lockdown periods. Studies have found that during the pandemic, 22.4% of college students reported symptoms of anxiety, 35.1% reported symptoms of depression ( 11 ), and 7.2% exhibited suicidal tendencies ( 12 ). In light of these findings, given the gradual increase in the level of negative emotions among college freshmen and the significant challenge such a trend poses to public safety, it is imperative to promptly address the mental health concerns and negative emotional states of this particular group. If their psychological issues continue to be overlooked, allowing them to accumulate, it could lead to unpredictable and potentially severe consequences.

At the same time, some studies suggest that there is an extremely close relationship between the level of negative emotions in the college student population and their health-promoting behaviors ( 13 , 14 ), although the specific effects are not clear. Health-promoting behaviors refer to an individual's lifestyle choices that promote health, which includes various actions such as exercise, nutrition, and others, and can be defined as “multi-dimensional, self-initiated continuous, daily activity undertaken with the deliberate aim of maintaining or enhancing the level of an individual's health, wellbeing, and self-actualization.” Research has found that college students with higher levels of physical activity tend to have lower levels of anxiety and depression ( 15 , 16 ). Additionally, a higher quality of interpersonal relationships can lead to lower levels of anxiety and stress ( 17 ). Furthermore, longitudinal studies have found that the level of interpersonal relationships among college students can directly predict their levels of depression ( 18 , 19 ). Additionally, there is evidence to suggest a link between diet and negative emotions. Studies have shown that poor dietary habits among college students are associated with increased levels of depression and anxiety ( 20 , 21 ). This evidence underscores the potential role of health-promoting behaviors in the early prevention of mental health issues and the management of negative emotions among college students. Therefore, it is important to conduct research into the relationship between health-promoting behaviors and negative emotions to determine how different levels and aspects of these behaviors impact anxiety, depression, and stress. Such research is essential for enhancing the psychological wellbeing of college students.

With this context in mind, the primary aim of this study is to explore the relationship between negative emotions (namely, depression, anxiety, and stress) and health-promoting behaviors and its impact among new university students in China through two longitudinal surveys of freshmen (T1: November 12, 2021; T2: June 17, 2022) as they acclimate to campus life. Compared to existing research on negative emotions and mental health among college students, this study aims to longitudinally analyze the predictive impact of health-promoting behaviors on college students' negative emotions using a cross-lagged panel model. Concurrently, by employing cross-sectional regression models, it will analyze the protective factors and improvement effects of demographic variables and health-promoting behaviors, along with their subdimensions, on college students' negative emotions. This approach is intended to provide ample evidence and a theoretical basis for reducing the levels of negative emotions and improving mental health issues among college students. Building on previous research findings, this study hypothesizes that as college freshmen enhance their sense of agency, health consciousness, and health capabilities during their time at the university, their levels of health-promoting behaviors will increase, which in turn will alleviate the negative emotions associated with college life. The results of this study are expected to have significance for the prevention and improvement of psychological issues among college students and aid in exploring pathways for the prevention and treatment of mental health issues in this population.

2 Objects/data sources and methods

2.1 objects/data sources.

This study focuses on freshmen at Southwest University in Chongqing, China. Through simple random sampling, a questionnaire survey was conducted on a randomly selected sample of 4,252 freshmen from this university. The questionnaire consisted of three parts: demographic information (such as gender, age, etc.), health-promoting behaviors, and a negative emotion scale. The specific survey details are as follows: the randomly selected students completed two rounds of questionnaire surveys at the Physical Fitness Test Center of Southwest University, with a 7-month interval between the two surveys (T1: November 12, 2021; T2: June 17, 2022). The same questionnaire was used and the same batch of participants were involved in both the surveys. Based on the sample size formula, which is 20 times the number of questionnaire items (80 questions) plus 10% for invalid questionnaires, the minimum sample size for this survey was 1,760. After the test concluded, a total of 4,252 samples were obtained, which meets the minimum sample size requirement for this survey. To ensure the authenticity and reliability of the data, this study filtered the obtained data from 4,252 participants. The inclusion criteria were: (1) the questionnaire was completed in 5–15 min and (2) the participants took part in both rounds of the complete test and their student ID and name matched in both the surveys. After filtering and matching the samples, a total of 3,632 valid samples were obtained, with a sample loss of 620, resulting in an effectiveness rate of 85.42%. Among the valid samples, there were 1,340 men (36.8%) and 2,292 women (63.1%); 1,550 were the only child in the family (42.68%) and 2,082 were not the only child in the family (57.32%); 1,823 urban residents (50.19%) and 1,809 rural residents (49.81%). After screening, the average age of the students was 18.92 ± 0.50 years. This experiment was approved by the Ethics Committee of Southwest University (Approval No.: SWH202011281421), and all participants signed an informed consent form before the experiment.

2.2 Methods

2.2.1 negative emotion scale.

The Chinese version of the Depression Anxiety Stress Scales (DASS-21) was originally developed by Lovibond et al. ( 22 ) and has since been translated into multiple languages. It is now widely used in China and has proven to be effective in measuring levels of negative emotions and its various dimensions. The Chinese version of the DASS has good reliability and validity, with the internal consistency coefficients (Cronbach's alpha) for the depression, anxiety, and stress subscales being 0.83, 0.80, and 0.82, respectively, and 0.92 for the total DASS score ( 23 – 25 ). The scale consists of three dimensions: anxiety, depression, and stress. Each of them have seven items, making it a total of 21 items. The questionnaire adopts a four-point scoring: “0” represents “never;” “1” represents “sometimes;” “2” represents “often;” and “3” represents “almost always.” The higher the scale score, the more serious the negative emotions. The scoring criteria are as follows: for the depression dimension, 0–9 is “normal;” 10–13 is “mild;” 14–20 is “moderate;” 21–27 is “severe;” and 28+ is “extremely severe;” for the anxiety dimension, 0–7 is “normal;” 8–9 is “mild;” 10–14 is “moderate;” 15–19 is “severe,” and 20+ is “extremely severe;” for the stress dimension, 0–14 is “normal;” 15–18 is “mild;” 19–25 is “moderate;” 26–33 is “severe;” and 34+ is “extremely severe.” In this study, the Cronbach's α-values of the two tests were 0.895 and 0.935, respectively.

2.2.2 Health promotion behavior scale

The Health-Promoting Lifestyle Profile II (HPLP-II) scale was developed by Walker et al. ( 26 ), based on Pender's Health Promotion Model, and is designed to effectively measure health-promoting behaviors and their various dimensions. The Chinese version of the HPLP-II has demonstrated good reliability and validity and has been widely used for evaluating the lifestyle of university students. The Cronbach's alpha coefficients for the subscales of the questionnaire are as follows: self-actualization (0.904), health responsibility (0.814), physical activity (0.809), nutrition (0.757), interpersonal support (0.800), stress management (0.702), and for the overall Health-Promoting Lifestyle Profile (HPLP) (0.922) ( 26 – 28 ). The scale was a relatively mature health behavior assessment instrument at home and abroad, including self-actualization (nine items), health responsibility (nine items), physical activity (eight items), nutrition (nine items), interpersonal relations (nine items), and stress management (eight items), making it a total of 52 items. The Likert four-level scoring method (1 = never, 2 = sometimes, 3 = often, 4 = routinely) is adopted for this measure, with scores ranging from 52 to 208. The scoring is done as follows: “poor” for a score of 52–90, “general” for a score of 91–129, “good” for a score of 130–168 for, and “excellent” for a score of 169–208 for. Higher scores represented higher levels of health behavior, and each dimension within the scale could be employed independently of the other dimensions. In this study, the Cronbach's α values of the two tests were 0.932 and 0.955, respectively.

2.3 Statistical processing

Statistical data analysis was conducted using SPSS 25.0 and Amos 24.0 software. Initially, the data was subjected to a normality test and a common method bias test. Subsequently, a one-way analysis of variance (ANOVA) was utilized to examine if there were differences in the levels of negative emotions and health-promoting behaviors between the two measurement points. The effect size, variance among groups, and significance level were represented by η p2, F , and p -values, respectively. Additionally, correlation analysis was employed to investigate the relationship between negative emotions and health-promoting behaviors across the different time points.

A structural equation model was constructed using Amos24.0 to analyze and verify the cross-lagged model. The χ 2 statistical index and the root mean square error of approximation (RMSEA) were utilized as the absolute fitting measures. Incremental fit index (IFI), Tucker–Lewis index (TLI), and goodness of fit index (GFI) were used as incremental fit indexes. χ 2 /df < 5, RMSEA < 0.08, IFI, TLI, and GFI values > 0.9 indicated that the model fitted well. Finally, a generalized linear regression model was established with depression, anxiety, and stress symptoms as the dependent variables and health behavior factors significantly related to one or more symptoms as independent variables. The data were presented in the form of mean plus or minus standard deviation (M ± SD). The significance level of statistical analysis was set as p < 0.05 for statistical difference, p < 0.01 for significant statistical difference, and p < 0.001 for the extremely significant statistical difference.

3.1 Sample randomization test and common method bias

Due to the use of questionnaire surveys to assess the levels of negative emotions and health-promoting behaviors among college freshmen, the selected sample may have errors compared to the original sample. Therefore, through the analysis and testing of the sample, it was found that there were no significant differences between the selected sample and the original sample in terms of the levels of negative emotions and health-promoting behaviors, as well as their demographic factors ( P > 0.05). As this study adopted self-reported data, there may be common method bias. This study took advantage of confirmatory factor analysis in Amos to test the common method bias of all self-evaluation items. The results showed that the model fitting was poor (χ 2 /df = 407.03, CFI = 0.441, GFI = 0.424, AGFI = 0.270, NFI = 0.440, RMSEA = 0.263). The original model was χ 2 /df = 43.78, CFI = 0.943, GFI = 0.884, AGFI = 0.848, NFI = 0.942, RMSEA = 0.085, so there was no common method bias in the study.

3.2 Correlation analysis of negative emotions and health behavior among college students

Correlation analysis between negative emotions and health-promoting behaviors across the two measurements is presented in Table 1 . The results of the two measurements indicated that health-promoting behaviors and negative emotions were correlated with each other. The correlation for negative emotions was significant with r = 0.316 ( p < 0.001), and for health-promoting behaviors, it was also significant, with r = 0.295 ( p < 0.001). Health-promoting behaviors were negatively correlated with negative emotions, with significant correlations at T1 and T2 for negative emotions and health behaviors at r = −0.032 ( p < 0.001) and r = −0.371 ( p < 0.001), respectively. The correlation between negative emotions at T1 and health-promoting behaviors at T2 was significant at r = −0.108 ( p < 0.001), and the correlation between negative emotions at T2 and health-promoting behaviors at T1 was significant at r = −0.136 ( p < 0.001). The correlation between negative emotions and health behaviors was significant, meeting the prerequisite conditions for cross-lagged analysis.

Table 1 . Correlation analysis of negative emotions and health behavior.

3.3 Differences in negative emotions and health behavior among college students at T1 and T2

In this study, negative emotions and three dimensions, health behavior and six dimensions, and gender were used as dependent variables, and measurement time T1 and T2 were used as the factors. One-way analysis of variance was performed on the data at two measurement time points. The results showed that the total scores of negative emotions ( F = 21.18, P < 0.001), anxiety ( F = 43.13, P < 0.001), depression ( F = 31.68, P < 0.001), stress ( F = 33.91, P < 0.001), health promotion behavior ( F = 14.36, P < 0.001), self-realization ( F = 13.64, P < 0.001), physical activity ( F = 14.64, P < 0.001), nutrition ( F = 13.84, P < 0.001), interpersonal relations ( F = 13.61, P < 0.001), stress management ( F = 19.11, P < 0.001), and health responsibility ( F = 5.43, P < 0.001) had significant main effects on time (see Table 2 ). The above results indicated that college students showed distinct differences in their total and individual dimension scores of negative emotions and health behavior in both tests during the pandemic period when controls were in place. Specific analysis of each dimension showed a significant improvement in overall negative emotions (Δ = −1.02) over time and a sharp decrease in both anxiety (Δ = −1.12) and stress (Δ = −0.1), but an increasing tendency for depression instead (Δ = 0.18). The overall health behavior (Δ = −1.31) decreased significantly, with noteworthy decreases in the dimensions of self-actualization (Δ = −0.98), interpersonal relations (−0.97), and stress management (−0.09) and an increasing trend in the dimensions of nutrition (Δ = 0.03) and health responsibility (Δ = 0.72).

Table 2 . One-way ANOVA ( M ± SD ) analysis for each dimension of negative emotions and health behavior.

3.4 The relationship between negative emotions and health behavior

After establishing a significant correlation between negative emotions and health behaviors, this study used a cross-lagged model to analyze the data from two assessments within a year, examining if there is a bidirectional effect between negative emotions and health-promoting behaviors. The model was constructed using the three dimensions of negative emotions—stress, depression, and anxiety—and the six dimensions of the health-promoting behaviors scale—stress management, nutrition, exercise, self-actualization, interpersonal relationships, and health responsibility—as manifest variables. Before conducting the cross-lagged panel model analysis, autoregressive and single cross-lagged models were established to verify the stability of the cross-lagged model. Specific path coefficients and their significance are shown in Table 3 , and all paths' fit indices met the standards (χ 2 /df < 5, RMSEA < 0.08, IFI, TLI, and GFI values > 0.9). After validating the autoregressive and single cross-lagged models, a double cross-lagged model was established. The specific model is shown in Figure 1 . To simplify the model, latent variable residuals and predictive paths between latent variables are not displayed in the figure. The model was constructed using Amos 24.0 and examined for fit using maximum likelihood estimation. The results indicated that the fit indices for each indicator were good (χ 2 /df = 4.010, CFI = 0.995, NFI = 0.993, TLI = 0.991, RFI = 0.989, RMSEA = 0.023). From the cross-lagged path diagram, it can be seen that the autoregressive coefficients for negative emotions and health-promoting behaviors at the two measurement time points were stable and highly significant, with β = 0.43 ( P < 0.001) and β = 0.36 ( P < 0.001), respectively. At both T1 ( β = −0.04, P < 0.05) and T2 ( β = −0.30, P < 0.001) time points, there was a negative correlation between negative emotions and health-promoting behaviors. After controlling for the autoregression of negative emotions and health behaviors, as well as the correlation between the two variables at the same measurement time point, the results showed that negative emotions measured at T1 significantly negatively predicted health-promoting behaviors at T2 ( β = −0.11, P < 0.01). Similarly, health-promoting behaviors measured at T1 significantly negatively predicted negative emotions at T2 ( β = −0.12, P < 0.001). The results indicate that there is a mutual negative influence between negative emotions and health-promoting behaviors.

Table 3 . Overview of the standardized stability and cross-lagged coefficients.

Figure 1 . The cross-lagged analysis of negative emotions and health behavior. * P < 0.05, ** P < 0.01, *** P < 0.001.

3.5 Protective factors for college students to reduce negative emotions

As indicated in Table 4 , generalized linear regression analysis was performed after including demographic factors such as gender, age, place of household registration, and being the only child as covariates. This analysis aimed to assess the impact of the subdimensions of health-promoting behaviors (self-actualization, health responsibility, exercise, nutrition, interpersonal relations, and stress management) on the levels of anxiety, depression, and stress among college freshmen. The results indicated that stress management, self-actualization, and health responsibility all had a negative effect on the stress and anxiety levels of college freshmen, while interpersonal relations had a positive effect on these levels. Specifically, higher levels of stress management ( β = −0.104, P < 0.05; β = −0.087, P < 0.05), self-actualization ( β = −0.282, P < 0.01; β = −0.260, P < 0.05), and health responsibility ( β = −0.057, P < 0.05; β = −0.088, P < 0.05) were associated with lower levels of stress and anxiety among college freshmen. On the other hand, a higher level of interpersonal relations ( β = 0.068, P < 0.01; β = 0.138, P < 0.05) was associated with higher levels of stress and anxiety. Furthermore, self-actualization was found to negatively impact the depression levels of college freshmen. In contrast, exercise, nutrition, and interpersonal relations were found to positively affect these levels. Specifically, higher self-actualization scores ( β = −0.437, P < 0.001) were associated with lower levels of depression among college freshmen. Conversely, higher levels of exercise ( β = 0.048, P < 0.001), nutrition ( β = 0.044, P < 0.001), and interpersonal relations ( β = 0.065, P < 0.001) were associated with higher levels of depression. In summary, stress management, self-actualization, health responsibility, and interpersonal relations are important predictive factors affecting the stress and anxiety levels of college freshmen, while self-actualization, exercise, nutrition, and interpersonal relations are important protective factors influencing their depression levels. Additionally, the results for demographic covariates indicated that gender, place of household registration, and whether one is the only child are also major factors influencing the stress, anxiety, and depression levels of college freshmen.

Table 4 . Generalized linear model analysis of negative emotions and health behavior.

4 Discussion

This study examined the longitudinal predictive relationship between negative emotions and health-promoting behaviors among college freshmen, as well as the cross-sectional impact of health-promoting behaviors and demographic factors on negative emotions, by employing cross-lagged and generalized linear models. The main findings revealed that over the course of 7 months, there were significant changes in the levels of negative emotions and health-promoting behaviors and their subdimensions. Specifically, the assessed levels of negative emotions and their anxiety dimension, as well as health-promoting behaviors and their subdimensions of self-actualization, interpersonal relationships, and stress management, significantly decreased. The results of the cross-lagged model indicated that there is a negative longitudinal bidirectional relationship between college freshmen's negative emotions and their levels of health-promoting behaviors. The generalized linear regression results demonstrated that within health-promoting behaviors, stress management, self-actualization, health responsibility, and interpersonal relations, as well as demographic factors such as gender, place of household registration, and whether one is the only child, are all significant predictive factors for stress and anxiety in college freshmen. Furthermore, self-actualization, exercise, nutrition, interpersonal relations, and demographic factors such as gender, place of household registration, and only-child status are also significant protective factors against depression in college freshmen.

Our research found that there were significant differences in the levels of negative emotions and health-promoting behaviors, as well as their subdimensions, among college students at T1 and T2, with both levels decreasing over time. It should be noted that as time progresses, one of the potential factors contributing to the reduction in negative emotions among college freshmen could be their growing familiarity with college life. However, this is not the only influencing factor, as during this period, no interventions were conducted on the participants. The analysis was based on the assessment of the levels of health behavior factors. Therefore, it is likely that other exposure factors, such as sleep quality, could have an impact on negative emotions. It is important to note that the complexity of human emotions and behaviors is influenced by a multifaceted array of factors, not just those measured or observed in a given study. During the second measurement of negative emotions among college freshmen, it was observed that only the level of depressive emotions showed a significant increase. This suggests that within the spectrum of negative emotions experienced by college freshmen, particular attention should be paid to the level of depression. The inference drawn from the second assessment of college freshmen suggests that the increase in the level of depression may be associated with a decrease in the levels of interpersonal relations, self-actualization, and stress management. This implies that these factors could potentially be key areas for intervention to mitigate depression among college students. To further explore the factors influencing the level of depressive emotions, this study also conducted a related analysis using generalized linear regression. The research found that self-actualization, exercise, nutrition, interpersonal relations, gender, place of household registration, and whether one is the only child are all significant protective factors against depression in college freshmen. This substantiates the previous inference and aligns with existing research, indicating that the level of depression among college students is associated with communication with peers and teachers, setting goals for self-actualization ( 29 , 30 ), and self-management of academic stress ( 31 – 33 ). This suggests that, compared to other negative emotions and mental health issues (such as anxiety and stress) experienced by college freshmen, depression appears to be a more severe issue and requires more attention. Concurrently, the results from the correlational analysis revealed a significant negative relationship between negative emotions and the level of health-promoting behaviors. This finding is consistent with the majority of results from previous studies ( 34 – 36 ), which indicate that certain health behaviors (such as exercise and nutrition) are negatively correlated with negative emotions. This suggests that engaging in healthy behaviors can potentially reduce the occurrence or intensity of negative emotions such as depression, anxiety, and stress among college students.

In previous research, studies investigating the impact of health-promoting behaviors on the levels of negative emotions among college students have been relatively scarce. To further explore the longitudinal predictive relationship between these two major factors, a cross-lagged model was employed for analysis. The results showed that there is a bidirectional negative predictive relationship between negative emotions and health-promoting behaviors in college freshmen. This is consistent with the findings from researchers like Liu et al., Cao et al., and Zhang et al. ( 9 , 36 , 37 ). They found that higher levels of self-efficacy, physical activity, and self-control contribute to reducing the accumulation of negative emotions such as depression, releasing stress, and stabilizing mood. In addition, our study identified important protective factors for improving stress, depression, and anxiety, providing significant evidence for predicting mental health levels in college freshmen. The research has revealed that if negative emotions among current college freshmen are not alleviated and addressed in a timely manner, they will continue to accumulate, leading to a reduction in health-promoting behaviors, which in turn can cause a further accumulation of more severe negative emotions. However, since an increase in health-promoting behaviors can improve negative emotions in college freshmen, maintaining a certain level of such behaviors can serve as a preventative measure against emotional outbursts and reduce the buildup of negative emotions. In fact, there have been studies based on the health promotion model that explain the connection with negative emotions, suggesting that when people engage in behaviors that are detrimental to their health, it could lead to the onset of psychological issues, while the converse could contribute to the improvement of such issues ( 30 , 38 , 39 ). Building on this theoretical foundation, our study explored the relationship between the psychology and daily behaviors (health-promoting behaviors) of college freshmen and further analyzed the protective factors against negative emotions.

Through the analysis using a generalized linear regression model, it was observed that within the subdimensions of health-promoting behaviors, lower levels of stress management, self-actualization, and health responsibility behaviors were associated with higher levels of stress and anxiety. Conversely, an increase in interpersonal relationship behaviors was found to help reduce stress and anxiety. In the study of depression, it was observed that more self-actualization behaviors could increase depressive emotions. However, an increase in nutrition, exercise, and interpersonal relationship behaviors could effectively reduce depression. This is similar to previous studies which suggested that adequate nutrition, exercise, and interpersonal relationships are one of the effective ways to improve and protect students' mental health ( 16 , 36 ). However, the difference lies in that these studies seemed to focus only on individual factors, such as the impact of physical activity, diet, or mindfulness, with only a few discussing the interactive effects of these factors on negative emotions. Among demographic factors, gender, household registration location (urban vs. rural), and whether an individual is the only child were identified as significant factors affecting negative emotions, with large regression coefficients. This is consistent with existing research which indicates that being women, from a rural area, and not being the only child can lead to higher levels of negative emotions ( 12 , 40 , 41 ).

In summary, this study analyzed the negative predictive relationship between negative emotions and health-promoting behaviors among college freshmen through both longitudinal and cross-sectional research. It also delved into the effects of subdimensions of health-promoting behaviors and demographic factors on the stress, anxiety, and depression experienced by college freshmen. This research has practical significance for the prevention and improvement of negative emotions among college students. At the school and societal levels, the role of healthy behaviors in moderating the emotions of college freshmen can be further emphasized to help students understand the practical importance of health-promoting behaviors, encouraging and monitoring the increase of such behaviors to alleviate negative emotions and prevent significant public safety issues. From a government macro-control perspective, reducing the rural–urban divide, advocating for gender equality, and liberalizing birth policies may help to reduce levels of stress, anxiety, and depression among the college student population.

5 Advantages and limitations

This study assessed the health-promoting behaviors and levels of negative emotions among college freshmen using the Health-Promoting Lifestyle Profile II (HPLP-II) and Depression Anxiety Stress Scales (DASS-21) scales. A cross-lagged model was employed to explore the impact of health-promoting behaviors and their subdimensions on negative emotions. Additionally, a generalized linear model was used to investigate the protective factors of health-promoting behaviors and their subdimensions against negative emotions. The goal was to identify predictive factors of daily health behavior suitable for reducing negative emotions and alleviating mental health issues among college freshmen. These findings play an important role in protecting and preventing psychological health issues in this population.

In addition to its strengths, this study also has some limitations. For instance, while health-promoting behaviors encompass most aspects of college freshmen's lives, and we have accounted for the regression impact of demographic variables on negative emotions through covariates, it is important to acknowledge that there are many other exposure factors that may affect negative emotions. These include family stress, financial pressure, friendly relationships between the sexes, and even factors such as weather, all of which require extensive research to infer and analyze their impact on negative emotions. Secondly, this study only included two time points, and the 7-month period may not be representative of the entire academic life of 1st-year college students (although this possibility is small). Future studies could consider including more measurement time points and shorter intervals, which would likely reduce research errors. Finally, the sample of over 3,000 students in this study may not be perfectly representative of the national population, which could introduce a certain degree of error in terms of representativeness. Based on this, future research will require more studies from different regions to validate these results.

6 Conclusions

College freshmen's negative emotions and health-promoting behaviors are significantly negatively correlated. The longitudinal analysis indicates that initial negative emotions and health-promoting behaviors can significantly negatively predict subsequent levels of negative emotions. Within health-promoting behaviors, stress management, self-actualization, health responsibility, and interpersonal relationship dimensions are significant protective factors against stress and anxiety. Self-actualization, exercise, nutrition, and interpersonal relationships are significant protective factors against depressive emotions. Gender, household registration location, and whether one is the only child are significant factors affecting the negative emotions of college freshmen.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by Ethics Review Committee of Southwest University Hospital, Chongqing, China. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

YT: Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. JW: Data curation, Writing – review & editing. KZ: Supervision, Writing – review & editing. LH: Conceptualization, Data curation, Supervision, Writing – review & editing. HL: Data curation, Supervision, Writing – review & editing. HT: Data curation, Supervision, Writing – review & editing. LP: Funding acquisition, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This research primarily received funding from the China National Social Science Fund Project. Identifier: 21BTY092. Project Title: Research on the Community-Integrated Healthcare Model for Promoting Healthy Behaviors in Chronic Patients. It also received additional funding from Chongqing Natural Science Foundation. Identifier: cstc2020jcyj-msxmX1025. Project Title: Investigation of Gut Microbiota Mechanisms in Type 2 Diabetes through Exercise Intervention; and Southwest University graduate research innovation project. Identifier: SWUS23036.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

1. Beiter R, Nash R, McCrady M, Rhoades D, Linscomb M, Clarahan M, et al. The prevalence and correlates of depression, anxiety, and stress in a sample of college students. J Affect Disord. (2015) 173:90–6. doi: 10.1016/j.jad.2014.10.054

PubMed Abstract | Crossref Full Text | Google Scholar

2. Cuijpers P, Javed A, Bhui K. The WHO World Mental Health Report: a call for action. Br J Psychiatr. (2023) 222:227–9. doi: 10.1192/bjp.2023.9

3. Jin Z, Cao W, Wang K, Meng X, Shen J, Guo Y, et al. Mental health and risky sexual behaviors among Chinese college students: a large cross-sectional study. J Affect Disord. (2021) 287:293–300. doi: 10.1016/j.jad.2021.03.067

4. Zhang H, Zhao H. Changes in Chinese adolescent college students' psychological security during 2004-2020: a cross-temporal meta-analysis. J Adolesc. (2023) 95:631–46. doi: 10.1002/jad.12147

5. Liu X, Zhang Y, Luo Y. Does subjective well-being improve self-rated health from undergraduate studies to three years after graduation in China? Healthcare. (2023) 11:2813. doi: 10.3390/healthcare11212813

6. Guo C, Cui Y, Xia Z, Hu J, Xue Y, Huang X, et al. Association between health literacy, depressive symptoms, and suicide-related outcomes in adolescents: a longitudinal study. J Affect Disord. (2023) 327:15–22. doi: 10.1016/j.jad.2023.01.054

7. Cheng S, An D, Yao Z, Liu JJ, Ning X, Wong JP, et al. Association between mental health knowledge level and depressive symptoms among Chinese College Students. Int J Environ Res Public Health. (2021) 18:1850. doi: 10.3390/ijerph18041850

8. Liu X, Zhang Y, Gao W, Gao X. Developmental trajectories of depression, anxiety, and stress among college students: a piecewise growth mixture model analysis. Human Soc Sci Commun. (2023) 10:1–10. doi: 10.1057/s41599-023-02252-2

Crossref Full Text | Google Scholar

9. Liu X, Li Y, Cao X. Bidirectional reduction effects of perceived stress and general self-efficacy among college students: a cross-lagged study. Human Soc Sci Commun. (2024) 11:1–8. doi: 10.1057/s41599-024-02785-0

10. Puustinen PJ. Screening for Psychological Distress . (2012). Available online at: http://www.researchgate.net/publication/286847943_Screening_for_psychological_distress (accessed March 18, 2024).

Google Scholar

11. Kalkbrenner MT, Flinn RE, Sullivan DK, Arteaga LEE. A mental health literacy approach to supporting first-generation community college student mental health: the REDFLAGS model. Commun Coll Rev. (2021) 49:243–61. doi: 10.1177/00915521211002893

12. Chen R-N, Liang S-W, Peng Y, Li X-G, Chen J-B, Tang S-Y, et al. Mental health status and change in living rhythms among college students in China during the COVID-19 pandemic: a large-scale survey. J Psychosom Res. (2020) 137:110219. doi: 10.1016/j.jpsychores.2020.110219

13. Lee RLT, Loke AJTY. Health-promoting behaviors and psychosocial wellbeing of university students in Hong Kong. Publ Health Nurs. (2005) 22:209–20. doi: 10.1111/j.0737-1209.2005.220304.x

14. Cao X, Ji S. Bidirectional relationship between self-rated health and the big five personality traits among Chinese adolescents: a two-wave cross-lagged study. Human Soc Sci Commun. (2024) 11:1–11. doi: 10.1057/s41599-024-02699-x

15. Deforche B, Van Dyck D, Deliens T, De Bourdeaudhuij I. Changes in weight, physical activity, sedentary behaviour and dietary intake during the transition to higher education: a prospective study. Int J Behav Nutr Phys Act. (2015) 12:16. doi: 10.1186/s12966-015-0173-9

16. Chi G, Wang L. The association of sports participation with depressive symptoms and anxiety disorder in adolescents. Front Publ Health. (2022) 10:860994. doi: 10.3389/fpubh.2022.860994

17. Meng T, He Y, Zhang Q, Yu F, Zhao L, Zhang S, et al. Analysis of features of social anxiety and exploring the relationship between childhood major adverse experiences and social anxiety in early adulthood among Chinese college students. J Affect Disord. (2021) 292:614–22. doi: 10.1016/j.jad.2021.05.105

18. Wang W, Xu H, Li S, Jiang Z, Sun Y, Wan Y. The impact of problematic mobile phone use and the number of close friends on depression and anxiety symptoms among college students. Front Psychiatry. (2023) 14:1281847. doi: 10.3389/fpsyt.2023.1281847

19. Frazier P, Liu Y, Asplund A, Meredith L, Nguyen-Feng VN. US college student mental health and COVID-19: comparing pre-pandemic and pandemic timepoints. J Am Coll Health. (2023) 71:2686–96. doi: 10.1080/07448481.2021.1987247

20. Keck MM, Vivier H, Cassisi JE, Dvorak RD, Dunn ME, Neer SM, et al. Examining the role of anxiety and depression in dietary choices among college students. Nutrients. (2020) 12:2061. doi: 10.3390/nu12072061

21. Chi X, Liang K, Chen S-T, Huang Q, Huang L, Yu Q, et al. Mental health problems among Chinese adolescents during the COVID-19: The importance of nutrition and physical activity. Int J Clin Health Psychol. (2021) 21:100218. doi: 10.1016/j.ijchp.2020.100218

22. Lovibond SH, Lovibond PF. Depression anxiety stress scales. Psychol Asses . (1995). doi: 10.1037/t01004-000

23. Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales . (2002). Available online at: http://www.mendeley.com/catalog/manual-depression-anxiety-stress-scales/ (accessed March 18, 2024).

24. Nanthakumar S, Bucks RS, Skinner TC, Starkstein S, Hillman D, James A, et al. Assessment of the Depression, Anxiety, and Stress Scale (DASS-21) in untreated obstructive sleep apnea (OSA). Psychol Assess . (2017) 29:401. doi: 10.1037/pas0000401

25. Chan RCK, Xu T, Huang J, Wang Y, Zhao Q, Shum DHK, et al. Extending the utility of the Depression Anxiety Stress scale by examining its psychometric properties in Chinese settings. Psychiatry Res. (2012) 200:879–83. doi: 10.1016/j.psychres.2012.06.041

26. Walker SN, Sechrist KR, Pender NJ. The health-promoting lifestyle profile: development and psychometric characteristics. Nurs Res. (1987) 36:76–81. doi: 10.1097/00006199-198703000-00002

27. Scholten S, Velten J, Bieda A, Zhang XC, Margraf J. Testing measurement invariance of the Depression, Anxiety, and Stress Scales (DASS-21) across four countries. Psychol Assess . (2017) 29:440. doi: 10.1037/pas0000440

28. Wang K, Shi HS, Geng FL, Zou LQ, Tan SP, Wang Y, et al. Cross-cultural validation of the Depression Anxiety Stress Scale-21 in China. Psychol Assess. (2015) 28:e88. doi: 10.1037/pas0000207

29. Kalpidou M, Costin D, Morris J. The relationship between Facebook and the wellbeing of undergraduate college students. Cyberpsychol Behav Soc Netstudy. (2011) 14:183–9. doi: 10.1089/cyber.2010.0061

30. Shi X, Wang A, Zhu Y. Longitudinal associations among smartphone addiction, loneliness, and depressive symptoms in college students: disentangling between- and within-person associations. Addict Behav. (2023) 142:107676. doi: 10.1016/j.addbeh.2023.107676

31. Yeh PM, Moxham L, Patterson C, Antoniou C, Liou JC. A comparison of psychological well-being, coping strategies, and emotional problems between Taiwanese and Australian Nursing Students. J Nurs Res. (2023) 31:e264. doi: 10.1097/jnr.0000000000000543

32. Yang SY, Fu SH, Chen KL, Hsieh PL, Lin PH. Relationships between depression, health-related behaviors, and internet addiction in men women junior college students. PLoS ONE. (2019) 14:e0220784. doi: 10.1371/journal.pone.0220784

33. Steinhardt M, Dolbier C. Evaluation of a resilience intervention to enhance coping strategies and protective factors and decrease symptomatology. J Am Coll Health. (2008) 56:445–53. doi: 10.3200/JACH.56.44.445-454

34. Hou T, Xie Y, Mao X, Liu Y, Zhang J, Wen J, et al. The mediating role of loneliness between social support and depressive symptoms among Chinese rural adolescents during COVID-19 outbreak: a comparative study between left-behind and non-left-behind students. Front Psychiatry. (2021) 12:740094. doi: 10.3389/fpsyt.2021.740094

35. Rezapour M. Factors associated with subjective state of health in college students. Front Psychol. (2022) 13:985982. doi: 10.3389/fpsyg.2022.985982

36. Cao X, Zhang Q, Liu X. Cross-lagged relationship between physical activity time, openness and depression symptoms among adolescents: evidence from China. Int J Mental Health Promot. (2023) 25:1009–18. doi: 10.32604/ijmhp.2023.029365

37. Zhang Q, Wang X, Miao L, He L, Wang H. The effect of chronotype on risk-taking behavior: the chain mediation role of self-control and emotional stability. Int J Environ Res Public Health. (2022) 19:16068. doi: 10.3390/ijerph192316068

38. Copeland W E, Mcginnis E, Bai Y, Adams Z, Nardone H, Devadanam V, et al. Impact of COVID-19 pandemic on college student mental health and wellness. J Am Acad Child Adolesc Psychiatr . (2021) 60:134–41.e2. doi: 10.1016/j.jaac.2020.08.466

39. Zhang X, Shi X, Wang Y, Jing H, Zhai Q, Li K, et al. Risk factors of psychological responses of Chinese university students during the COVID-19 outbreak: cross-sectional web-based survey study. J Med Internet Res. (2021) 23:e29312. doi: 10.2196/29312

40. Lin J, Zou L, Lin W, Becker B, Yeung A, Cuijpers P, et al. Does gender role explain a high risk of depression? A meta-analytic review of 40 years of evidence. J Affect Disord. (2021) 294:261–78. doi: 10.1016/j.jad.2021.07.018

41. Chen J. Hysteresis effects and emotional suffering: Chinese rural students' first encounters with the urban university. Sociol Res Onl. (2022) 27:101–17. doi: 10.1177/1360780420949884

Keywords: psychology, cross-lagged analysis, health-promoting behaviors, negative emotions, college students

Citation: Tao Y, Wu J, Huang L, Zheng K, Liu H, Tian H and Peng L (2024) The relationship between health-promoting behaviors and negative emotions in college freshmen: a cross-lagged analysis. Front. Public Health 12:1348416. doi: 10.3389/fpubh.2024.1348416

Received: 02 December 2023; Accepted: 02 April 2024; Published: 26 April 2024.

Reviewed by:

Copyright © 2024 Tao, Wu, Huang, Zheng, Liu, Tian and Peng. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Li Peng, 804455169@qq.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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This paper is in the following e-collection/theme issue:

Published on 26.4.2024 in Vol 26 (2024)

Patients’ Representations of Perceived Distance and Proximity to Telehealth in France: Qualitative Study

Authors of this article:

Original Paper

• Amélie Loriot 1 * , MSc   ; 
• Fabrice Larceneux 1 * , PhD   ; 
• Valérie Guillard 1 * , PhD   ; 
• Jean-Philippe Bertocchio 2, 3 * , MD, PhD  

1 Paris Dauphine–PSL (Paris Sciences & Lettres) University, Paris, France

2 Service Thyroïde – Tumeurs Endocrines, Hôpital de la Pitié-Salpêtrière, Assistance Publique – Hôpitaux de Paris, Paris, France

3 SKEZI, Annecy, France

*all authors contributed equally

Corresponding Author:

Amélie Loriot, MSc

Paris Dauphine–PSL (Paris Sciences & Lettres) University

Place du Maréchal de Lattre de Tassigny

Paris, 75116

Phone: 33 144054405

Email: [email protected]

Background: In the last 2 decades, new technologies have emerged in health care. The COVID-19 pandemic further accelerated the adoption of technology by both health care professionals and patients. These technologies create remote care practices that bring several benefits to the health care system: easier access to care, improved communication with physicians, and greater continuity of care. However, disparities in the acceptance and use of telehealth tools still exist among patients. These tools also disrupt conventional medical practices and prompt a new reassessment of the perceptions of distance and proximity as physical (ie, time and space dimensions) and nonphysical (ie, behavioral dimensions) concepts. The reasons why patients do or do not adopt telehealth tools for their care and therefore their perspectives on telehealth remain unanswered questions.

Objective: We explored the barriers as well as the motivations for patients to adopt telehealth tools. We specifically focused on the social representations of telehealth to establish a comprehensive conceptual framework to get a better understanding of how telehealth is perceived by patients.

Methods: This study uses a qualitative design through in-depth individual interviews. Participants were recruited using a convenience sampling method with balanced consideration of gender, age, location (urban/rural), and socioeconomic background. After collecting informed consent, interviews were transcribed and analyzed using the thematic analysis methodology.

Results: We conducted 14 interviews, with which data saturation was reached. The 2 main opposed dimensions, perceived proximity and distance, emerged as an essential structure for understanding the social representations of telehealth. A logic of engagement versus hostility emerged as the main tension in adopting telehealth, almost ideological. Interestingly, practical issues emerged regarding the adoption of telehealth: A logic of integration was opposed to a logic of constraints. Altogether, those dimensions enabled us to conceptualize a semiotic square, providing 4 categories with a coherent body of social representations. Due to the dynamic nature of these representations, we proposed 2 “paths” through which adherence to telehealth may improve.

Conclusions: Our semiotic square illustrating patients’ adherence to telehealth differentiates socially beneficial versus socially dangerous considerations and pragmatic from ideological postures. It shows how crucial it is to consider perceived distance and proximity to better understand barriers and motivations to adopting telehealth. These representations can also be considered as leverage that could be modified to encourage the step-by-step adhesion process. Even if reducing the perceived temporal distance to in-person meeting and enhancing the perceived proximity of access to care may be seen as efficient ways to adopt telehealth tools, telehealth can also be perceived as a care practice that threatens the patient-physician relationship. The patient-oriented perceived value turns out to be critical in the future development of and adherence to telehealth tools.

Introduction

Telehealth, a subset of ehealth still ongoing.

Many technologies have been developed in eHealth in recent years. Defined as the “use of information and communication technologies in support of health and health-related fields, including health care services, health monitoring, health literature, and health education, knowledge and research” [ 1 ], eHealth covers a wide range of practices. First, mobile apps and connected devices are referred to as mobile health (mHealth). Second, telehealth (ie, the practice of medicine using information and communication technologies) covers 5 practices: teleconsultation, teleexpertise, medical regulation, remote medical monitoring, and remote medical assistance.

Recent research focusing on remote care has indicated some confusion regarding the wording used to refer to health-related technologies [ 2 ]. For instance, the terms “telemedicine” and “telehealth” are often used interchangeably [ 3 ]. However, some researchers highlight a difference between these 2 concepts. Whereas telemedicine is limited to remote clinical services, telehealth is broader and refers to remote clinical services as well as remote nonclinical services, like administrative meetings [ 4 ]. Thus, telehealth has been defined as “the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration” [ 5 ].

eHealth is expected to lead to significant changes in the delivery of care and medical practices [ 6 ]. Because of (1) disparities in access to health care, (2) the aging population, and (3) budget constraints limiting public policies, the development of eHealth devices can be seen as a solution to the future challenges faced by the health system in many high-income countries [ 7 ]. Before the COVID-19 crisis, there were significant disparities in the use of eHealth tools between European countries [ 8 ]. A global shift occurred during the pandemic: The use of many eHealth tools became necessary, democratizing their use in terms of communication, monitoring, or care delivery, and the use of technology to provide health services has accelerated [ 9 , 10 ]. Telehealth may now concern everyone.

Benefits and Barriers of Telehealth

The practice of telehealth presents many benefits for patients, including (1) better access to health care services, in particular in isolated regions like rural areas; (2) improved continuity of care; (3) increased availability of health information [ 11 ]; and (4) empowerment of patients [ 12 ]. As such, telehealth is supposed to increase efficiency and quality of care [ 10 ] and favors patient-centered care by enabling better communication between patients and health care professionals [ 13 ].

However, researchers have pointed out that many barriers exist that limit health equity for all patients. Significant disparities remain regarding the access to, adherence to, and use of telehealth tools [ 14 , 15 ]. In particular, little is known about the role of digital health literacy [ 13 , 15 , 16 ] (ie, “the ability to search for, find, understand and evaluate health information from electronic sources and to apply knowledge acquired to solve a health problem” [ 17 ]). Among individuals in rural areas, low levels of education are associated with lower use of digital health tools [ 18 ]. Some scholars argue that online interactions are impersonal and dangerous because of the lack of a physical examination [ 10 ] and that telehealth may threaten the quality of the relationship between physicians and patients [ 19 ].

Studies among health care professionals have also shown a reluctance to adopt these technologies because of a fear of “dehumanization” by virtualizing patients and care [ 20 ]. This feeling of dehumanization of care could explain negative attitudes toward telehealth [ 21 ].

Patients tend to attribute significant importance to health care professionals’ physical and emotional presence [ 22 ] and direct interactions with them [ 7 ]. However, the digitalization of health is transforming these relationships [ 23 ]: Telehealth disrupts medical practices and reduces physical interactions between patients and physicians. However, it leads to reconsidering notions of distance and proximity [ 23 ], including physical and nonphysical dimensions (ie, cognitive or relational aspects that are perceived by individuals) [ 24 - 26 ]. Physical proximity and perceived proximity are not necessarily aligned. Indeed, individuals can feel themselves close to an element that is physically far but also to perceive it far when it is physically close [ 26 ]. Perceived proximity has a cognitive dimension that refers to “a mental assessment of how distant someone else seems” and an affective component, since these representations are subject to emotions rather than rational thought [ 26 , 27 ]. In health care, Talbot et al [ 28 ] investigated the perceptions French physicians may have about telehealth using the conceptual framework of proximity of Boschma [ 25 ] that includes the following 5 dimensions of proximity: cognitive, organizational, social, institutional, and geographical. However, how patients react to these changes in care delivery and the representations of these practices remain unanswered questions. Therefore, exploring patient’s representations of telehealth is important to better understand psychological mechanisms underlying the adherence to telehealth. The theory of social representations is fruitful in overcoming this limitation.

The Social Representations Theory

The theoretical background of social representations provides a framework for understanding how new concepts become common knowledge. Defined as a collective elaboration “of a social object by the community for the purpose of behaving and communicating” [ 29 ], social representations consist of a system of values, ideas, and practices that enable individuals to orient themselves in their material and social world as well as to master it and provide a code for social exchange [ 30 ]. Therefore, social representations provide people with a common frame of communication that is built in everyday interactions. More precisely, a social representation corresponds to thoughts and feelings being expressed in verbal and overt behavior of actors that constitutes an object for a social group [ 31 ].

Although social representations are commonly shared, some may be more polemical, reflecting oppositions between social groups in society [ 32 ]. In addition, social representations have a dynamic nature across and within social groups of people, and societal practices, communication, and the process of knowledge are strongly connected, particularly in the health field, which has been one of the leading research areas for this theory [ 33 - 35 ].

Interestingly, social representations constitute a structure explaining behaviors that result not only from an individual cognitive process but also from social and cultural representations and that are shared collectively [ 36 , 37 ]. Social representations have been shown to be a significant indicator of attitudes [ 38 , 39 ]. However, social representations of patients have never been studied in the context of telehealth specifically. A qualitative study is well suited to understand these representations. The objective of our qualitative research was to establish a comprehensive conceptual framework to gain a better understanding of how telehealth influences perceived proximity or distance for patients and therefore, to better apprehend their barriers as well as their motivations to adopting telehealth tools.

Study Design

A qualitative study was conducted with an interpretative approach to explore patients’ representations of telehealth and their perception of proximity toward it. We adopted an inductive, constructivist perspective, assuming that people construct their life-worlds through their representations and interpretations of telehealth as a social fact to which they attribute specific terms and meanings.

Setting and Sample

Qualitative in-depth individual interviews were set up using a semistructured thematic interview guide. Convenience sampling was used to recruit participants. Variation sampling was sought [ 40 ] with consideration of gender, age, location (urban/rural), and socioeconomic background ( Multimedia Appendix 1 ). We used the saturation criterion to stop recruitment. This criterion is the point at which gathering more data about a theoretical construct reveals no new properties nor yields any further theoretical insights [ 41 ]. This saturation point is usually reached with 9 to 17 interviews [ 42 ].

Data Collection

After obtaining informed consent, patients were contacted, and an appointment for an interview was set. Interviews lasted from 45 minutes to 75 minutes and were performed directly inside the family home or conducted through the digital platform Microsoft Teams because of the geographical distance between the researcher and the participant. The study took place in May 2022. A total of 14 interviews were gathered: 8 participants were female, 6 were male, and their mean age was 52 (range 23-83) years. Of the interviews, 11 interviews were run face to face, and 4 were online.

The interview guide explored various aspects of how health and telehealth are perceived; including defining what constitutes perceived good health; understanding respondents’ relationship with their own health; examining how they seek health-related information; discussing challenges in accessing care as related to geographical, temporal, and perceived distances; and evaluating respondents’ overall and specific relationships with technology within the context of health care. This comprehensive approach aimed to gain insights into how individuals perceive telehealth and their level of engagement with it.

During each interview, we wrote down our impressions that could possibly impact the interpretation of results. Interviews were digitally audio-recorded with permission, and verbatims were transcribed.

Ethical Considerations

At the beginning of each interview, potential participants were given comprehensive information about the context, objectives, and methods of the study. The interviewees were informed that they could withdraw from this study at any time. After allowing enough time for any questions or clarification they may have required, all the participants gave their informed consent. The study design was reviewed and approved by the Research Ethics Committee of Paris Dauphine–PSL (Paris Sciences & Lettres) University (20231128/01). Additionally, following national legislation, data were pseudonymized during the transcription process in a way that no participant could be directly identified: A number was assigned to each participant with no record of any directly identifying data. Participants received no compensation for participating in this research.

Data Analysis

First, we conducted a vertical analysis and read the transcripts to get an impression of the whole data set. Second, transcribed data were analyzed using a horizontal thematic analysis to develop a narrative of the findings through a categorical approach using qualitative software (NVivo Version 12). We followed the grounded theory approach to code verbatim [ 43 ]: Each transcript was coded inductively by manually marking central key words that could represent a code. The codes were then grouped under themes that emerged through the analysis process. Finally, we categorized the data by collapsing codes that conveyed similar meanings. Multimedia Appendix 2 presents an example of our analysis process.

After the first step of the analysis of social representations, which was to record all the dimensions that emerged from the participants, we used the semiotic square method to map semantic categories highlighting opposing and complementary concepts [ 44 ]. This structure enables the understanding of the tension among symbolic meanings and the elements by which meaning is being expressed [ 45 ]. The semiotic square has been often applied in consumer research [ 46 ] and specifically to explore consumers’ relationships with technology ideology [ 47 ].

First, a specific definition of telehealth emerged from the patient perspective. If researchers define telehealth broadly, the interview analysis revealed that telehealth is associated with teleconsultation for a large majority of patients and rarely with other practices. It concerns mainly remote care and is associated with questions about the quality of interactions with the physician.

Second, the content analysis revealed 4 main types of social representations of telehealth: the expected opposition between engagement and hostility and a more subtle distinction between integration and constraint.

Representations of Proximity: the Logic of Engagement

Our analysis of interviews revealed the first category of very positive social representations related to telehealth that led to a logic of engagement and adherence to this practice. This commitment is based on the idea of optimization of health services. The strong proximity with its practice is explained by a feeling of comfort and a perception of convenience. Telehealth is considered an easy, practical tool. Participant 4 (P4) mentioned:

I found it practical and comfortable.

Perceived practicality and convenience underline the actual benefits of adopting telehealth. Indeed, this practice enables a reduction of the perceived temporal distance to the consultation, leading to representations of efficiency and effectiveness (P13) on one hand and allowing reinforcement of access to care, which creates a feeling of personal usefulness (P8), on the other hand. Participant 13 (P13) mentioned:

Now that everything is overbooked in their appointments, (...), we are at about 15 days/3 weeks for getting any new appointment, both by phone or by Doctolib, in video, it is a little faster.

In addition, participant 8 (P8) said:

It is so quick, it makes everyday life easier!

From this perspective, the main issue behind social representations of proximity is related to an improvement of the functional proximity to telehealth.

Representations of Distance: the Logic of Hostility

At the opposite end to that of the first category, the second category of social representations follows a logic of hostility toward telehealth. It reveals a strong rejection of its development. Although adherence follows a view of functional proximity, rejection is explained by a lack of perceived relational proximity caused by telehealth. These representations of perceived distance reveal a profound fear of the dehumanization of medicine. Telehealth is seen as a dehumanizing practice that is destructive of human interaction by virtualizing both patients and care, as Kaplan [ 20 ] mentioned. This was confirmed by participant 6 (P6), who stated:

It kills the human contact, which is really important to me. I definitely prefer having the secretary over the phone to tell me there is an appointment in three weeks.

The major component of this category is the perceived deterioration of the relationship with the physician. Great importance is given to the human dimension in care. However, the interviews revealed these representations are based on a feeling of detachment from the caregiver caused by telehealth. This emphasizes the impersonal nature of the relationship. Participant 2 (P2) stated:

We dematerialize everything. It brings detachment from the caregiver.

From this perspective, the development of a relationship with perceived proximity and trust seems incompatible with distant and remote care. The virtual nature of this link is intrinsically considered as the opposite of human interaction. Participant 1 (P1) stated:

I do not like it. I like to see the person right in front of me.

Here, social representations of telehealth found an increase of perceived distance between the patient and physician. The perception of actual proximity to the physician tends to disappear with telehealth, which reinforces emotional and affective distance [ 48 ]. These representations finally highlight the fact that telehealth cannot replace an in-person consultation. For instance, participant 5 (P5) stated:

I would not make [a remote physician] my referring physician. There need to be a close relationship with him. I must be able to give him my trust. I am not sure that I will always have the same doctor when using teleconsultation.

Altogether, these depictions of distance nurture the perception that telehealth has a detrimental or potentially harmful impact on society, as it undermines the interpersonal nature of care.

In addition to these 2 opposite categories of representations, proximity versus distance, more nuanced types of social representations also emerged within the verbatims. We labelled them “nondistance” and “nonproximity” representations.

Representations of Nondistance: the Logic of Integration

The third category of social representations reflects “nondistance” to telehealth, as these representations are related neither to total adherence nor to rejection but rather follow a logic of integration: Participants highlighted the actual possibility to choose to use (or not) telehealth tools. Representations do not reflect a full engagement with this practice but rather a nonrejection of telehealth.

First, these representations of nondistance highlight the functional aspects of this practice. In this context, developing a relational proximity with the physician was not judged as necessary. For instance, participant 4 (P4) stated:

I felt more like I was with a teleoperator than a physician. It felt like there was a script behind it, but why not, that is not necessarily a bad thing.

This situation is not seen as a problem; the efficient and nonrelational aspect of the consultation is valued here. Thus, this representation shows a greater emphasis on the functional proximity rather than on the relational proximity [ 24 ].

The importance given to the functional aspects of telehealth was also revealed through the way specific health practices are elicited. For instance, telehealth was mainly seen as a backup or emergency solution, leading to occasional use according to the situation. Participant 5 (P5) stated:

It can be a first step to detect an emergency. For example, if you cannot get a doctor during the weekend, we have remote visits (...) So, to me, it is an emergency solution.

Because it is convenient, patients do not reject telehealth, especially when there is no need to be seen in person, for example for a prescription renewal, as suggested by participant 4 (P4):

It depends on what you are looking for in the consultation. If it is for a medication renewal, yes, I would recommend it.

Thus, these representations of nondistance do not refer to hostility nor engagement toward telehealth but rather to tolerance. The practice is adopted but not entirely accepted. Indeed, the use of telehealth should remain occasional. Participant 11 (P11) said:

If I were starting using a teleconsultation system, I would say to myself ‘no more than three times in a row.’ The fourth time, you still have to go, once every two years for a check-up, I would tend to say that.

Tolerance comes also with some reluctance about the reliability of this practice. Telehealth was perceived as less reliable than a physical consultation because there is no physical contact and no auscultation, which seems to lead to mistrust, as suggested by participants 10 (P10) and 14 (P14).

Auscultation is one of the first things you learn in medicine, like touching the patient. Try to get an auscultation from a machine, to put its hands on the belly. [P10]

When I had my operation, I had a consultation with the anesthesiologist by teleconsultation. It was silly, he told me to pull my tongue out (...) No, for me this is ridiculous! [P14]

Overall, social representations related to nondistance reveal nonrejection of telehealth under conditions of efficiency and reliability. The choice of using telehealth tools is made under specific circumstances and leads to occasional use, based on high value placed on simplicity and functional aspects.

Representations of Nonproximity: the Logic of Constraint

Within the fourth category, social representations are related to “nonproximity,” a label that reflects a logic of constraint. Whereas representations of proximity highlight engagement and active behavior toward telehealth, representations of nonproximity depict situations of the use of telehealth when there is no other choice, as participant 10 (P10) mentioned:

Is telehealth a good thing? Like everyone else, I use it because I am left with no alternative option.

Patients come to telehealth whenever they have no or few alternatives, considering telehealth as a last option, such as during a lockdown for example, as explained by participant 3 (P3):

If I had to use it, it would really be out of obligation, like during a lockdown, and because I do not have the possibility to move around.

In this perspective, telehealth tools are not really accepted and should remain a second option to physical in-person consultations, mainly because telehealth requires digital literacy. Participant 7 (P7) explained:

For the elderly, it is a problem! I have to schedule their appointments from my own mobile phone because they do not have access to the internet.

Thus, like the representations of perceived distance, the representations of nonproximity are also mostly negative. However, they do not reflect a total rejection of the practice of telehealth but rather a nonadherence as patients come to it when they have no other option.

Finally, our qualitative analysis allowed us to structure a semiotic square ( Figure 1 ) with 2 main categories of social representations of telehealth (ie, perceived proximity and perceived distance) as well as subsequent tensions in the discourse. The negation of these 2 terms forms 2 other categories illustrating 4 distinctive classes of meanings highlighting nuanced representations of perceived proximity and distance to telehealth and the opposite and complementary relationships [ 49 ]. The main components of the 4 categories are summarized in Figure 1 . Interestingly, 2 additional analyses of the semiotic square improve our vision of social representations of telehealth, one based on a vertical reading and the other based on a horizontal reading.

Telehealth: Socially Beneficial Versus Socially Dangerous

From a vertical reading of the relationships between the categories, there are 2 structuring representations of telehealth. In the left part of the semiotic square ( Figure 1 ), the complementary relationship, linking proximity and nondistance, refers to favorable representations as well as to discourse encouraging the development of telehealth. These tools are perceived as socially beneficial for all stakeholders, but there is room for improvement in generalizing their use.

Within these favorable representations of telehealth, adherence and nonrejection are based on 2 main drivers. First, trust in the physician is crucial as he or she is considered a legitimate expert, as suggested by participant 4 (P4):

I feel that doctors are experts (...), I trust them entirely because to me they seem to be experts.

Consequently, positive representations of telehealth seem to be linked to the perceived relational proximity with the health care professional. Second, these representations stem from familiarity with the tool. Being familiar with the term “telehealth” and knowing what it means generate a feeling of closeness toward it. Participant 5 (P5) stated:

I heard [about telehealth] because in my profession—I work with pharmacies—we talk about it.

In the right part of the square is the complementary relationship combining perceived distance and nonproximity. This underlines representations of hostility and skepticism toward telehealth, which are considered socially harmful or even dangerous for society. Rejection and nonadherence seem to be explained mainly by insufficient digital literacy as well as difficulties accessing the Internet and telehealth tools, as suggested by participant 9 (P9):

No, I do not use the Internet at all! (...) There are surely many things to do but I do not know how to do them...

This revealed a substantial cognitive distance to telehealth and ultimately making care practices feel more complex. The ancestral role of auscultation in medical consultation and the importance given to touching patients are noted, showing that the lack of perceived physical proximity between the patient and physician tends to reinforce the psychological distance toward telehealth and ultimately the rejection of its practice. Participant 4 (P4) said:

The ability itself of performing an actual auscultation by touching people and listening to them using a stethoscope is being lost at the expense of the care to improve the development of technology.

Telehealth: Ideological Versus Pragmatic Postures

A horizontal reading highlights the similarity of the logics of engagement and hostility, both based on ideological postures: pros and cons of the practice of telehealth depending on whether it seems to belong to the “good” versus “bad” for the society. More efficiencies appear to be pros, and less of a human relationship appears to be a con. Conversely, the logics of integration and constrain reflect pragmatic postures: how to deal with the tool and on what occasion. Sometimes, it appears to be accepted because it is convenient and adapted to specific situations, sometimes because there is no other choice. Interestingly, ideological postures tend to separate opposite groups, while the pragmatic views tend to rebuild a link between the nondistance and nonproximity groups. These nuanced, more balanced perceptions invite us to think about the practical implications, elaborating “paths” of social representations to drive patients toward less rejection of and more adherence to telehealth.

Main Findings

Using qualitative methods, our findings suggest a new conceptual framework to apprehend telehealth from patients’ perspectives based on 4 categories of social representations. First, perceived proximity was associated with social representations reflecting the idea that telehealth is intrinsically an efficient, practical, and effective solution. This logic of engagement is in line with a strong belief in progress and technological tools to face the challenges of the health care system, namely the issue of access to care. On the opposite side, social representations were more related to a feeling of distance from telehealth, enforcing an unfavorable attitude and leading to a rejection of these tools. This logic of hostility is mainly anchored in a fear of dehumanization of society. Telehealth is blamed for compromising the quality of the relations and for accelerating the loss of human contact between patients and physicians. This perceived distance from telehealth highlights a situation of exclusion, especially for patients who do not have access to digital technology or who do not have sufficient digital literacy. Aside from these 2 categories, 2 more nuanced types of representations emerged. First, from a logic of integration, social representations revealed that telehealth is appealing but showed worries and fears about its reliability. This practice can be conditionally accepted according to a situational approach. Second, a logic of constraint reflected social representations based on skepticism but leading to acceptance when there are no alternatives.

From a theoretical point of view, our results, based on a semiotic square, bring new elements to the literature of perceived proximity. We have shown that telehealth leads to reconsidering proximity through several dimensions. Although not diminishing the geographical or physical gap between the patient and the health care provider, technological tools, such as a teleconsultation from home, can enhance accessibility to health care. The relational dimension of proximity, already identified by Boschma [ 25 ], seems to also be impacted by telehealth. Indeed, many social representations have shown that this perception of proximity with the caregiver is reduced by telehealth and revealed a fear of dehumanization in the relationship. In addition, we showed that perceived functional proximity to telehealth leads to increased adherence and a favorable attitude to its development, which should encourage policymakers to strengthen this aspect in communication strategies for telehealth. These findings also constitute a societal contribution. In addition, this research has revealed 2 major oppositions embedded in the social representations. The first one consists of “good,” or a socially beneficial position, versus “bad,” or a socially dangerous position. The second one highlights the posture, rather “ideological” or “pragmatic,” leading to contributions to public policy aiming to foster adherence to eHealth tools.

Building a semiotic square also revealed potential changes in people’s representations of telehealth and thus the potential to contribute to change attitudes toward these tools. They may be adapted to patients’ concerns and aspects that patients value in the practice of consultation. Our qualitative material brings insight to how these representations can be obstacles to the adoption of telehealth, as well as elements that can foster adherence. We propose considering paths through which patients’ representations could evolve. Mobilizing the social representations along these paths could first alleviate the perception of distance to the health care professional then enable the perceived proximity to telehealth. Our analysis emphasized some risks in how telehealth is implemented. If telehealth is developed without considering representations expressing reluctancy, individuals who are subjected to the use of telehealth may remain hostile to its development, may gradually feel a distance to it, and may finally totally reject this practice (coming from nonproximity to distance). To avoid such a vicious circle, 2 paths ( Figure 2 ) may create an increased feeling of proximity to telehealth.

The first path consists of transforming representations related to a perceived nondistance into a perceived proximity to telehealth. This pathway adopts a functional approach to consultation. The challenge is to dispel fears about the technological feasibility of using digital health tools to eliminate skepticism and reinforce favorable representations. It would then be necessary to reassure patients about the importance of any human contact during medical consultations. Highlighting the regular and immediate exchanges with physicians that telehealth allows would be perceived as helpful. Developing remote auscultation solutions and increasing communication about them by highlighting the accuracy and reliability of these technologies would help to alleviate these concerns and encourage adherence to these tools. Finally, reinforcing the benefits in terms of efficiency, time optimization, and practicality would contribute to (1) reducing the perceived temporal distance of access to care and (2) increasing the perceived functional proximity to telehealth.

The second path consists of (1) transforming representations related to a perceived distance into a feeling of nonproximity and subsequently (2) fostering the perceived proximity to telehealth. This path is mainly aimed at individuals who attach great importance to the relational and human dimension of care. The first challenge would be to strengthen trust in the health care system because representations and attitudes toward telehealth are intrinsically linked to the relationship patients develop with the health care system and physicians. It is also necessary to improve access to digital technology to reduce the cognitive distance and to increase their perception of proximity. Finally, highlighting and communicating about the strengthening of relational and affective proximity, allowed by telehealth when facilitating contact between patients and physicians, could lead to favorable representations and attitudes. Therefore, conceiving a system of medical support with a health care professional in telehealth booths could be an effective solution.

Limitations and Research Avenues

This study has some limitations. First, our sample did not include patients with a broad range of diseases: Very few of them had chronic diseases. Due to the sample size, we could not cover all medical specialties: For instance, ophthalmology and the need for emergency surgery may bring specific representations of telehealth for patients. It could also be interesting to interview people from other rural areas known as “medical deserts” (ie, regions with inadequate access to health care). In addition, we interviewed patients who do not practice as health care professionals. To broaden our research findings, we could incorporate additional insights by examining the perceptions of telehealth among other groups, particularly caregivers.

The development of telehealth tools leads to new challenges in medical practice. The social representations telehealth brings go beyond the perception of proximity and distance, are multifaceted, and include postures and attitudes. The social representations revealed by the semiotic square on perceived proximity to telehealth underscore the importance of designing health care strategies based on a patient-centric approach in the implementation of digital health tools.

Acknowledgments

The authors would like to thank all the participants in this study.

Data Availability

The data sets generated and analyzed during this study are available upon reasonable request from the corresponding author.

Authors' Contributions

This study was carried out by all authors working collaboratively. AL initiated the proposal. AL and FL conceived the study, collected the data, and performed the qualitative analysis. AL wrote the first draft of the manuscript. FL, VG, and JPB participated in data interpretation and revised the manuscript. All authors approved the final version of the manuscript.

Conflicts of Interest

JPB is a physician and works at SKEZI, a company that develops digital tools in health. The remaining authors have no conflicts of interest to declare.

Characteristics of patients.

Example of the qualitative analysis process used in this research.

• 58th World Health assembly report. World Health Organization. 2005. URL: https://apps.who.int/gb/ebwha/pdf_files/WHA58-REC1/english/A58_2005_REC1-en.pdf [accessed 2024-04-12]
• Queirós A, Alvarelhão J, Cerqueira M, Silva A, Santos M, Pacheco Rocha N. Remote care technology: a systematic review of reviews and meta-analyses. Technologies. Feb 10, 2018;6(1):22. [ CrossRef ]
• Fatehi F, Wootton R. Telemedicine, telehealth or e-health? A bibliometric analysis of the trends in the use of these terms. J Telemed Telecare. Dec 01, 2012;18(8):460-464. [ CrossRef ] [ Medline ]
• Bitar H, Alismail S. The role of eHealth, telehealth, and telemedicine for chronic disease patients during COVID-19 pandemic: A rapid systematic review. Digit Health. Apr 19, 2021;7:20552076211009396. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Telemedicine and Telehealth. The Office of the National Coordinator for Health Information Technology (ONC). URL: https://www.healthit.gov/topic/health-it-health-care-settings/telemedicine-and-telehealth [accessed 2024-04-12]
• Meskó B, Drobni Z, Bényei É, Gergely B, Győrffy Z. Digital health is a cultural transformation of traditional healthcare. Mhealth. Sep 2017;3:38-38. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Lindberg J, Bhatt R, Ferm A. Older people and rural eHealth: perceptions of caring relations and their effects on engagement in digital primary health care. Scand J Caring Sci. Dec 14, 2021;35(4):1322-1331. [ FREE Full text ] [ CrossRef ] [ Medline ]
• From innovation to implementation: eHealth in the WHO European Region. World Health Organization. 2016. URL: https://apps.who.int/iris/handle/10665/326317 [accessed 2024-04-12]
• Wang W, Sun L, Liu T, Lai T. The use of E-health during the COVID-19 pandemic: a case study in China's Hubei province. Health Sociol Rev. Nov 23, 2022;31(3):215-231. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Gajarawala SN, Pelkowski JN. Telehealth benefits and barriers. J Nurse Pract. Feb 2021;17(2):218-221. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Gagnon M, Duplantie J, Fortin J, Landry R. Implementing telehealth to support medical practice in rural/remote regions: what are the conditions for success? Implement Sci. Aug 24, 2006;1(1):18. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Clemensen J. Patient empowerment and new citizen roles through telehealth technologies - The early stage. Proceedings of The Third International Conference on eHealth, Telemedicine, and Social Medicine. 2011.:114-119. [ FREE Full text ]
• Goodridge D, Marciniuk D. Rural and remote care: Overcoming the challenges of distance. Chron Respir Dis. May 21, 2016;13(2):192-203. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Smith B, Magnani JW. New technologies, new disparities: The intersection of electronic health and digital health literacy. Int J Cardiol. Oct 01, 2019;292:280-282. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Reiners F, Sturm J, Bouw LJ, Wouters EJ. Sociodemographic factors influencing the use of eHealth in people with chronic diseases. Int J Environ Res Public Health. Feb 21, 2019;16(4):645. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Dunn P, Hazzard E. Technology approaches to digital health literacy. Int J Cardiol. Oct 15, 2019;293:294-296. [ CrossRef ] [ Medline ]
• First meeting of WHO GCM/NCD Working Group on health education and health literacy for noncommunicable diseases. Geneva Global Health Hub. Feb 17, 2017. URL: https:/​/g2h2.​org/​posts/​event/​first-meeting-of-who-gcmncd-working-group-on-health-education-and-health-literacy-for-noncommunicable-diseases/​ [accessed 2024-04-12]
• Salemink K, Strijker D, Bosworth G. Rural development in the digital age: A systematic literature review on unequal ICT availability, adoption, and use in rural areas. Journal of Rural Studies. Aug 2017;54:360-371. [ CrossRef ]
• Hjelm NM. Benefits and drawbacks of telemedicine. J Telemed Telecare. Jun 24, 2005;11(2):60-70. [ CrossRef ] [ Medline ]
• Kaplan B. Revisiting health information technology ethical, legal, and social issues and evaluation: telehealth/telemedicine and COVID-19. Int J Med Inform. Nov 2020;143:104239. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Huryk L. Factors influencing nurses' attitudes towards healthcare information technology. J Nurs Manag. Jul 2010;18(5):606-612. [ CrossRef ] [ Medline ]
• Rørtveit K, Sætre Hansen B, Leiknes I, Joa I, Testad I, Severinsson E. Patients’ experiences of trust in the patient-nurse relationship—a systematic review of qualitative studies. Open Journal of Nursing. 2015;05(03):195-209. [ FREE Full text ] [ CrossRef ]
• Oudshoorn N. Physical and digital proximity: emerging ways of health care in face-to-face and telemonitoring of heart-failure patients. Sociol Health Illn. Apr 2009;31(3):390-405. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Torre A, Rallet A. Proximity and localization. Regional Studies. Feb 2005;39(1):47-59. [ CrossRef ]
• Boschma R. Proximity and innovation: a critical assessment. Regional Studies. Feb 2005;39(1):61-74. [ CrossRef ]
• Wilson JM, Boyer O'Leary M, Metiu A, Jett QR. Perceived proximity in virtual work: explaining the paradox of far-but-close. Organization Studies. May 20, 2008;29(7):979-1002. [ CrossRef ]
• van Zoonen W, Sivunen A, Rice RE, Treem JW. Organizational information and communication technologies and their influence on communication visibility and perceived proximity. International Journal of Business Communication. Oct 06, 2021;60(4):1267-1289. [ CrossRef ]
• Talbot D, Charreire Petit S, Pokrovsky A. La proximité comme perception de la distance. Le cas de la télémédecine. Rev. Fr. Gest. Nov 11, 2020;46(289):51-74. [ CrossRef ]
• Moscovici S. Attitudes and opinions. Annu Rev Psychol. Jan 1963;14(1):231-260. [ CrossRef ] [ Medline ]
• Moscovici S. Foreword. In: Herzlich C, editor. Health and illness A social psychological analysis. London, England. Academic Press; 1973;IX-XIV.
• Wagner W, Duveen G, Farr R, Jovchelovitch S, Lorenzi‐Cioldi F, Marková I, et al. Theory and method of social representations. Asian J of Social Psycho. Dec 18, 2002;2(1):95-125. [ CrossRef ]
• Manuti A, Mininni G. Social representations of medically assisted fecundation a study on the discursive construction of “media texts”. Psychology. 2010;01(05):337-348. [ FREE Full text ] [ CrossRef ]
• de Rosa AS, Wagner W. The social representations of mental illness in children and adults. In: Doise W, Moscovici S, editors. Current issues in European Social Psychology. Cambridge, United Kingdom. Cambridge University Press; 1987;47-138.
• de Rosa AS, Bocci E. Resisting cognitive polyphasia in social representations of madness. In: de Rosa AS, editor. Social Representations in the 'Social Arena'. Abingdon, United Kingdom. Routledge; 2012;310.
• de Rosa AS, Mannarini T. The “Invisible Other”: social representations of COVID-19 pandemic in media and institutional discourse. Papers on Social Representations. 2020;29(2):1-35. [ FREE Full text ]
• Moliner P, Tafani E. Attitudes and social representations: a theoretical and experimental approach. European Journal of Social Psychology. Dec 04, 1998;27(6):687-702. [ CrossRef ]
• Bidjari AF. Attitude and social representation. Procedia - Social and Behavioral Sciences. 2011;30:1593-1597. [ CrossRef ]
• Monterrubio JC, Andriotis K. Social representations and community attitudes towards spring breakers. Tourism Geographies. Mar 03, 2014;16(2):288-302. [ CrossRef ]
• Schultes M, Kollmayer M, Mejeh M, Spiel C. Attitudes toward evaluation: An exploratory study of students' and stakeholders' social representations. Eval Program Plann. Oct 2018;70:44-50. [ CrossRef ] [ Medline ]
• Patton MQ. Qualitative Research & Evaluation Methods. Thousand Oaks, CA. SAGE Publications, Inc; 2002.
• Bryant A, Charmaz K. The SAGE Handbook of Grounded Theory. Thousand Oaks, CA. SAGE Publications Ltd; 2007.
• Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Soc Sci Med. Jan 2022;292:114523. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Strauss A, Corbin JM. Grounded Theory in Practice. Thousand Oaks, CA. SAGE Publications, Inc; 1997.
• Greimas AJ. Structural semantics: An attempt at a method. Lincoln, NE. University of Nebraska Press; 1983.
• Signori P, Flint DJ. Revealing the unique blend of meanings in corporate identity: An application of the semiotic square. Journal of Marketing Theory and Practice. Nov 20, 2019;28(1):26-42. [ CrossRef ]
• Floch J. The contribution of structural semiotics to the design of a hypermarket. International Journal of Research in Marketing. Jan 1988;4(3):233-252. [ CrossRef ]
• Kozinets RV. Technology/ideology: how ideological fields influence consumers' technology narratives. Journal of Consumer Research. 2008;34(6):865-881. [ CrossRef ]
• Fiedler K. Construal level theory as an integrative framework for behavioral decision‐making research and consumer psychology. J Consum Psychol. Jan 22, 2008;17(2):101-106. [ CrossRef ]
• Greimas AJ, Rastier F. The interaction of semiotic constraints. Yale French Studies. 1968;(41):86. [ CrossRef ]

Abbreviations

Edited by A Mavragani; submitted 13.01.23; peer-reviewed by S Tubeuf, H Yu; comments to author 13.03.23; revised version received 08.05.23; accepted 19.12.23; published 26.04.24.

©Amélie Loriot, Fabrice Larceneux, Valérie Guillard, Jean-Philippe Bertocchio. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.04.2024.

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

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Roberts group publishes synthetic chemistry research in Science

MINNEAPOLIS / ST. PAUL (04/25/2024) – The Roberts group recently published a new paper in  Science that explores enabling the use of a previously inaccessible functional group for N-heteroaromatic compounds.  Science – the flagship journal for the American Association for the Advancement of Science (AAAS) – publishes groundbreaking research across the spectrum of scientific fields. 

N-Heteroaromatic are an important class of molecules which are key to elements of pharmaceutical, agrochemicals and materials. Efficient and innovative methods to make functionalized heteroarenes are needed to make these critical molecules more readily available. One attractive method for the synthesis of N-heteroaromatic compounds would be the use of a N-heteroaryne – an aromatic ring containing a nitrogen atom and a triple bond. N-heteroarynes within 6-membered rings have been used as key intermediates for synthetic chemists, however after 120 years of aryne research the use of 5-membered N-heteroarynes has remained elusive. Notably, a computational model has predicted these 5-membered N-heteroarynes to be “inaccessible”, meaning they cannot be accessed synthetically due to the excessive strain associated with forming a triple bond within a small 5-membered ring.

The Roberts group hypothesized by applying principles of organometallic chemistry, forming 5-membered N-heteroarynes at a metal center would alleviate strain through back-bonding and allow access to this previously inaccessible functional group.  In a report which was published in  Science , the Roberts group achieved the first synthesis of 7-azaindole-2,3-yne complexes using phosphine-ligated nickel complexes. The complexes were characterized by X-ray crystallography and spectroscopy. Additionally, the complexes showed ambiphilic reactivity, meaning they react with both nucleophiles and electrophiles, making them an exceptionally versatile tool for the synthesis of N-heteroaromatic compounds. This exciting research breakthrough will have important applications in expanding the “chemist’s toolbox” for developing new pharmaceuticals, agrochemicals, and materials, and also provide fundamental insights on accessing synthetically useful strained intermediates.

This new work from the Roberts group was enabled by the National Institutes of Health, and by a multitude of fellowships held by the paper’s collaborators. Fifth-year PhD candidate Erin Plasek is supported by the UMN Doctoral Dissertation Fellowship;  fifth-year student Jenna Humke is supported by the National Science Foundation Graduate Research Fellowship Program; both Plasek and Humke are supported by Department of Chemistry Fourth-Year Excellence Fellowships; and third-year graduate student Sallu Kargbo was supported by the Gleysteen Departmental First Year Fellowship. For leadership excellence of her research program, Courtney Roberts has been awarded the 3M Alumni Professorship, the McKnight Land-Grant Professorship, the Amgen Young Investigator Award, and the Thieme Chemistry Journal Award in the past year alone.

“It is incredibly exciting to see this work, which started out as a few lines in my initial job proposals, come to fruition because of the exceptional team of students and postdocs behind it. We are delighted to finally share this new functional group for 5-membered N-heterocycles with the synthetic community,” Roberts writes.

Founded in 2019, the Roberts group uses inorganic and organometallic chemistry and catalysis to solve fundamental problems in synthetic organic chemistry related to pharmaceuticals, agrochemicals and materials. They have published work related to early transition metal catalysis, photochemical reactions, and inducing regioselectivity in metal-mediated aryne reactions. The group now consists of 14 graduate students, two postdoctoral associates, and one undergraduate researcher from a range of organic and inorganic backgrounds, which allows the team to take a multidisciplinary approach to solving research problems. They value diversity, collaboration, inclusivity, and radical candor in everything they do.

Roberts Group Website

Science Vol. 384 Issue 6694

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Mental Health Prevention and Promotion—A Narrative Review

Associated data.

Extant literature has established the effectiveness of various mental health promotion and prevention strategies, including novel interventions. However, comprehensive literature encompassing all these aspects and challenges and opportunities in implementing such interventions in different settings is still lacking. Therefore, in the current review, we aimed to synthesize existing literature on various mental health promotion and prevention interventions and their effectiveness. Additionally, we intend to highlight various novel approaches to mental health care and their implications across different resource settings and provide future directions. The review highlights the (1) concept of preventive psychiatry, including various mental health promotions and prevention approaches, (2) current level of evidence of various mental health preventive interventions, including the novel interventions, and (3) challenges and opportunities in implementing concepts of preventive psychiatry and related interventions across the settings. Although preventive psychiatry is a well-known concept, it is a poorly utilized public health strategy to address the population's mental health needs. It has wide-ranging implications for the wellbeing of society and individuals, including those suffering from chronic medical problems. The researchers and policymakers are increasingly realizing the potential of preventive psychiatry; however, its implementation is poor in low-resource settings. Utilizing novel interventions, such as mobile-and-internet-based interventions and blended and stepped-care models of care can address the vast mental health need of the population. Additionally, it provides mental health services in a less-stigmatizing and easily accessible, and flexible manner. Furthermore, employing decision support systems/algorithms for patient management and personalized care and utilizing the digital platform for the non-specialists' training in mental health care are valuable additions to the existing mental health support system. However, more research concerning this is required worldwide, especially in the low-and-middle-income countries.

Introduction

Mental disorder has been recognized as a significant public health concern and one of the leading causes of disability worldwide, particularly with the loss of productive years of the sufferer's life ( 1 ). The Global Burden of Disease report (2019) highlights an increase, from around 80 million to over 125 million, in the worldwide number of Disability-Adjusted Life Years (DALYs) attributable to mental disorders. With this surge, mental disorders have moved into the top 10 significant causes of DALYs worldwide over the last three decades ( 2 ). Furthermore, this data does not include substance use disorders (SUDs), which, if included, would increase the estimated burden manifolds. Moreover, if the caregiver-related burden is accounted for, this figure would be much higher. Individual, social, cultural, political, and economic issues are critical mental wellbeing determinants. An increasing burden of mental diseases can, in turn, contribute to deterioration in physical health and poorer social and economic growth of a country ( 3 ). Mental health expenditure is roughly 3–4% of their Gross Domestic Products (GDPs) in developed regions of the world; however, the figure is abysmally low in low-and-middle-income countries (LMICs) ( 4 ). Untreated mental health and behavioral problems in childhood and adolescents, in particular, have profound long-term social and economic adverse consequences, including increased contact with the criminal justice system, lower employment rate and lesser wages among those employed, and interpersonal difficulties ( 5 – 8 ).

Need for Mental Health (MH) Prevention

Longitudinal studies suggest that individuals with a lower level of positive wellbeing are more likely to acquire mental illness ( 9 ). Conversely, factors that promote positive wellbeing and resilience among individuals are critical in preventing mental illnesses and better outcomes among those with mental illness ( 10 , 11 ). For example, in patients with depressive disorders, higher premorbid resilience is associated with earlier responses ( 12 ). On the contrary, patients with bipolar affective- and recurrent depressive disorders who have a lower premorbid quality of life are at higher risk of relapses ( 13 ).

Recently there has been an increased emphasis on the need to promote wellbeing and positive mental health in preventing the development of mental disorders, for poor mental health has significant social and economic implications ( 14 – 16 ). Research also suggests that mental health promotion and preventative measures are cost-effective in preventing or reducing mental illness-related morbidity, both at the society and individual level ( 17 ).

Although the World Health Organization (WHO) defines health as “a state of complete physical, mental, and social wellbeing and not merely an absence of disease or infirmity,” there has been little effort at the global level or stagnation in implementing effective mental health services ( 18 ). Moreover, when it comes to the research on mental health (vis-a-viz physical health), promotive and preventive mental health aspects have received less attention vis-a-viz physical health. Instead, greater emphasis has been given to the illness aspect, such as research on psychopathology, mental disorders, and treatment ( 19 , 20 ). Often, physicians and psychiatrists are unfamiliar with various concepts, approaches, and interventions directed toward mental health promotion and prevention ( 11 , 21 ).

Prevention and promotion of mental health are essential, notably in reducing the growing magnitude of mental illnesses. However, while health promotion and disease prevention are universally regarded concepts in public health, their strategic application for mental health promotion and prevention are often elusive. Furthermore, given the evidence of substantial links between psychological and physical health, the non-incorporation of preventive mental health services is deplorable and has serious ramifications. Therefore, policymakers and health practitioners must be sensitized about linkages between mental- and physical health to effectively implement various mental health promotive and preventive interventions, including in individuals with chronic physical illnesses ( 18 ).

The magnitude of the mental health problems can be gauged by the fact that about 10–20% of young individuals worldwide experience depression ( 22 ). As described above, poor mental health during childhood is associated with adverse health (e.g., substance use and abuse), social (e.g., delinquency), academic (e.g., school failure), and economic (high risk of poverty) adverse outcomes in adulthood ( 23 ). Childhood and adolescence are critical periods for setting the ground for physical growth and mental wellbeing ( 22 ). Therefore, interventions promoting positive psychology empower youth with the life skills and opportunities to reach their full potential and cope with life's challenges. Comprehensive mental health interventions involving families, schools, and communities have resulted in positive physical and psychological health outcomes. However, the data is limited to high-income countries (HICs) ( 24 – 28 ).

In contrast, in low and middle-income countries (LMICs) that bear the greatest brunt of mental health problems, including massive, coupled with a high treatment gap, such interventions remained neglected in public health ( 29 , 30 ). This issue warrants prompt attention, particularly when global development strategies such as Millennium Development Goals (MDGs) realize the importance of mental health ( 31 ). Furthermore, studies have consistently reported that people with socioeconomic disadvantages are at a higher risk of mental illness and associated adverse outcomes; partly, it is attributed to the inequitable distribution of mental health services ( 32 – 35 ).

Scope of Mental Health Promotion and Prevention in the Current Situation

Literature provides considerable evidence on the effectiveness of various preventive mental health interventions targeting risk and protective factors for various mental illnesses ( 18 , 36 – 42 ). There is also modest evidence of the effectiveness of programs focusing on early identification and intervention for severe mental diseases (e.g., schizophrenia and psychotic illness, and bipolar affective disorders) as well as common mental disorders (e.g., anxiety, depression, stress-related disorders) ( 43 – 46 ). These preventive measures have also been evaluated for their cost-effectiveness with promising findings. In addition, novel interventions such as digital-based interventions and novel therapies (e.g., adventure therapy, community pharmacy program, and Home-based Nurse family partnership program) to address the mental health problems have yielded positive results. Likewise, data is emerging from LMICs, showing at least moderate evidence of mental health promotion intervention effectiveness. However, most of the available literature and intervention is restricted mainly to the HICs ( 47 ). Therefore, their replicability in LMICs needs to be established and, also, there is a need to develop locally suited interventions.

Fortunately, there has been considerable progress in preventive psychiatry over recent decades, including research on it. In the light of these advances, there is an accelerated interest among researchers, clinicians, governments, and policymakers to harness the potentialities of the preventive strategies to improve the availability, accessibility, and utility of such services for the community.

The Concept of Preventive Psychiatry

Origins of preventive psychiatry.

The history of preventive psychiatry can be traced back to the early 1900's with the foundation of the national mental health association (erstwhile mental health association), the committee on mental hygiene in New York, and the mental health hygiene movement ( 48 ). The latter emphasized the need for physicians to develop empathy and recognize and treat mental illness early, leading to greater awareness about mental health prevention ( 49 ). Despite that, preventive psychiatry remained an alien concept for many, including mental health professionals, particularly when the etiology of most psychiatric disorders was either unknown or poorly understood. However, recent advances in our understanding of the phenomena underlying psychiatric disorders and availability of the neuroimaging and electrophysiological techniques concerning mental illness and its prognosis has again brought the preventive psychiatry in the forefront ( 1 ).

Levels of Prevention

The literal meaning of “prevention” is “the act of preventing something from happening” ( 50 ); the entity being prevented can range from the risk factors of the development of the illness, the onset of illness, or the recurrence of the illness or associated disability. The concept of prevention emerged primarily from infectious diseases; measures like mass vaccination and sanitation promotion have helped prevent the development of the diseases and subsequent fatalities. The original preventive model proposed by the Commission on Chronic Illness in 1957 included primary, secondary, and tertiary preventions ( 48 ).

The Concept of Primary, Secondary, and Tertiary Prevention

The stages of prevention target distinct aspects of the illness's natural course; the primary prevention acts at the stage of pre-pathogenesis, that is, when the disease is yet to occur, whereas the secondary and tertiary prevention target the phase after the onset of the disease ( 51 ). Primary prevention includes health promotion and specific protection, while secondary and tertairy preventions include early diagnosis and treatment and measures to decrease disability and rehabilitation, respectively ( 51 ) ( Figure 1 ).

The concept of primary and secondary prevention [adopted from prevention: Primary, Secondary, Tertiary by Bauman et al. ( 51 )].

The primary prevention targets those individuals vulnerable to developing mental disorders and their consequences because of their bio-psycho-social attributes. Therefore, it can be viewed as an intervention to prevent an illness, thereby preventing mental health morbidity and potential social and economic adversities. The preventive strategies under it usually target the general population or individuals at risk. Secondary and tertiary prevention targets those who have already developed the illness, aiming to reduce impairment and morbidity as soon as possible. However, these measures usually occur in a person who has already developed an illness, therefore facing related suffering, hence may not always be successful in curing or managing the illness. Thus, secondary and tertiary prevention measures target the already exposed or diagnosed individuals.

The Concept of Universal, Selective, and Indicated Prevention

The classification of health prevention based on primary/secondary/tertiary prevention is limited in being highly centered on the etiology of the illness; it does not consider the interaction between underlying etiology and risk factors of an illness. Gordon proposed another model of prevention that focuses on the degree of risk an individual is at, and accordingly, the intensity of intervention is determined. He has classified it into universal, selective, and indicated prevention. A universal preventive strategy targets the whole population irrespective of individual risk (e.g., maintaining healthy, psychoactive substance-free lifestyles); selective prevention is targeted to those at a higher risk than the general population (socio-economically disadvantaged population, e.g., migrants, a victim of a disaster, destitute, etc.). The indicated prevention aims at those who have established risk factors and are at a high risk of getting the disease (e.g., family history of psychiatric illness, history of substance use, certain personality types, etc.). Nevertheless, on the other hand, these two classifications (the primary, secondary, and tertiary prevention; and universal, selective, and indicated prevention) have been intended for and are more appropriate for physical illnesses with a clear etiology or risk factors ( 48 ).

In 1994, the Institute of Medicine (IOM) Committee on Prevention of Mental Disorders proposed a new paradigm that classified primary preventive measures for mental illnesses into three categories. These are indicated, selected, and universal preventive interventions (refer Figure 2 ). According to this paradigm, primary prevention was limited to interventions done before the onset of the mental illness ( 48 ). In contrast, secondary and tertiary prevention encompasses treatment and maintenance measures ( Figure 2 ).

The interventions for mental illness as classified by the Institute of Medicine (IOM) Committee on Prevention of Mental Disorders [adopted from Mrazek and Haggerty ( 48 )].

Although the boundaries between prevention and treatment are often more overlapping than being exclusive, the new paradigm can be used to avoid confusion stemming from the common belief that prevention can take place at all parts of mental health management ( 48 ). The onset of mental illnesses can be prevented by risk reduction interventions, which can involve reducing risk factors in an individual and strengthening protective elements in them. It aims to target modifiable factors, both risk, and protective factors, associated with the development of the illness through various general and specific interventions. These interventions can work across the lifespan. The benefits are not restricted to reduction or delay in the onset of illness but also in terms of severity or duration of illness ( 48 ).On the spectrum of mental health interventions, universal preventive interventions are directed at the whole population without identifiable risk factors. The interventions are beneficial for the general population or sub-groups. Prenatal care and childhood vaccination are examples of preventative measures that have benefited both physical and mental health. Selective preventive mental health interventions are directed at people or a subgroup with a significantly higher risk of developing mental disorders than the general population. Risk groups are those who, because of their vulnerabilities, are at higher risk of developing mental illnesses, e.g., infants with low-birth-weight (LBW), vulnerable children with learning difficulties or victims of maltreatment, elderlies, etc. Specific interventions are home visits and new-born day care facilities for LBW infants, preschool programs for all children living in resource-deprived areas, support groups for vulnerable elderlies, etc. Indicated preventive interventions focus on high-risk individuals who have developed minor but observable signs or symptoms of mental disorder or genetic risk factors for mental illness. However, they have not fulfilled the criteria of a diagnosable mental disorder. For instance, the parent-child interaction training program is an indicated prevention strategy that offers support to children whose parents have recognized them as having behavioral difficulties.

The overall objective of mental health promotion and prevention is to reduce the incidence of new cases, additionally delaying the emergence of mental illness. However, promotion and prevention in mental health complement each other rather than being mutually exclusive. Moreover, combining these two within the overall public health framework reduces stigma, increases cost-effectiveness, and provides multiple positive outcomes ( 18 ).

How Prevention in Psychiatry Differs From Other Medical Disorders

Compared to physical illnesses, diagnosing a mental illness is more challenging, particularly when there is still a lack of objective assessment methods, including diagnostic tools and biomarkers. Therefore, the diagnosis of mental disorders is heavily influenced by the assessors' theoretical perspectives and subjectivity. Moreover, mental illnesses can still be considered despite an individual not fulfilling the proper diagnostic criteria led down in classificatory systems, but there is detectable dysfunction. Furthermore, the precise timing of disorder initiation or transition from subclinical to clinical condition is often uncertain and inconclusive ( 48 ). Therefore, prevention strategies are well-delineated and clear in the case of physical disorders while it's still less prevalent in mental health parlance.

Terms, Definitions, and Concepts

The terms mental health, health promotion, and prevention have been differently defined and interpreted. It is further complicated by overlapping boundaries of the concept of promotion and prevention. Some commonly used terms in mental health prevention have been tabulated ( Table 1 ) ( 18 ).

Commonly used terms in mental health prevention.

Mental Health Promotion and Protection

The term “mental health promotion” also has definitional challenges as it signifies different things to different individuals. For some, it means the treatment of mental illness; for others, it means preventing the occurrence of mental illness; while for others, it means increasing the ability to manage frustration, stress, and difficulties by strengthening one's resilience and coping abilities ( 54 ). It involves promoting the value of mental health and improving the coping capacities of individuals rather than amelioration of symptoms and deficits.

Mental health promotion is a broad concept that encompasses the entire population, and it advocates for a strengths-based approach and tries to address the broader determinants of mental health. The objective is to eliminate health inequalities via empowerment, collaboration, and participation. There is mounting evidence that mental health promotion interventions improve mental health, lower the risk of developing mental disorders ( 48 , 55 , 56 ) and have socioeconomic benefits ( 24 ). In addition, it strives to increase an individual's capacity for psychosocial wellbeing and adversity adaptation ( 11 ).

However, the concepts of mental health promotion, protection, and prevention are intrinsically linked and intertwined. Furthermore, most mental diseases result from complex interaction risk and protective factors instead of a definite etiology. Facilitating the development and timely attainment of developmental milestones across an individual's lifespan is critical for positive mental health ( 57 ). Although mental health promotion and prevention are essential aspects of public health with wide-ranging benefits, their feasibility and implementation are marred by financial and resource constraints. The lack of cost-effectiveness studies, particularly from the LMICs, further restricts its full realization ( 47 , 58 , 59 ).

Despite the significance of the topic and a considerable amount of literature on it, a comprehensive review is still lacking that would cover the concept of mental health promotion and prevention and simultaneously discusses various interventions, including the novel techniques delivered across the lifespan, in different settings, and level of prevention. Therefore, this review aims to analyze the existing literature on various mental health promotion and prevention-based interventions and their effectiveness. Furthermore, its attempts to highlight the implications of such intervention in low-resource settings and provides future directions. Such literature would add to the existing literature on mental health promotion and prevention research and provide key insights into the effectiveness of such interventions and their feasibility and replicability in various settings.

Methodology

For the current review, key terms like “mental health promotion,” OR “protection,” OR “prevention,” OR “mitigation” were used to search relevant literature on Google Scholar, PubMed, and Cochrane library databases, considering a time period between 2000 to 2019 ( Supplementary Material 1 ). However, we have restricted our search till 2019 for non-original articles (reviews, commentaries, viewpoints, etc.), assuming that it would also cover most of the original articles published until then. Additionally, we included original papers from the last 5 years (2016–2021) so that they do not get missed out if not covered under any published review. The time restriction of 2019 for non-original articles was applied to exclude papers published during the Coronavirus disease (COVID-19) pandemic as the latter was a significant event, bringing about substantial change and hence, it warranted a different approach to cater to the MH needs of the population, including MH prevention measures. Moreover, the COVID-19 pandemic resulted in the flooding of novel interventions for mental health prevention and promotion, specifically targeting the pandemic and its consequences, which, if included, could have biased the findings of the current review on various MH promotion and prevention interventions.

A time frame of about 20 years was taken to see the effectiveness of various MH promotion and protection interventions as it would take substantial time to be appreciated in real-world situations. Therefore, the current paper has put greater reliance on the review articles published during the last two decades, assuming that it would cover most of the original articles published until then.

The above search yielded 320 records: 225 articles from Google scholar, 59 articles from PubMed, and 36 articles from the Cochrane database flow-diagram of records screening. All the records were title/abstract screened by all the authors to establish the suitability of those records for the current review; a bibliographic- and gray literature search was also performed. In case of any doubts or differences in opinion, it was resolved by mutual discussion. Only those articles directly related to mental health promotion, primary prevention, and related interventions were included in the current review. In contrast, records that discussed any specific conditions/disorders (post-traumatic stress disorders, suicide, depression, etc.), specific intervention (e.g., specific suicide prevention intervention) that too for a particular population (e.g., disaster victims) lack generalizability in terms of mental health promotion or prevention, those not available in the English language, and whose full text was unavailable were excluded. The findings of the review were described narratively.

Interventions for Mental Health Promotion and Prevention and Their Evidence

Various interventions have been designed for mental health promotion and prevention. They are delivered and evaluated across the regions (high-income countries to low-resource settings, including disaster-affiliated regions of the world), settings (community-based, school-based, family-based, or individualized); utilized different psychological constructs and therapies (cognitive behavioral therapy, behavioral interventions, coping skills training, interpersonal therapies, general health education, etc.); and delivered by different professionals/facilitators (school-teachers, mental health professionals or paraprofessionals, peers, etc.). The details of the studies, interventions used, and outcomes have been provided in Supplementary Table 1 . Below we provide the synthesized findings of the available research.

The majority of the available studies were quantitative and experimental. Randomized controlled trials comprised a sizeable proportion of the studies; others were quasi-experimental studies and, a few, qualitative studies. The studies primarily focussed on school students or the younger population, while others were explicitly concerned with the mental health of young females ( 60 ). Newer data is emerging on mental health promotion and prevention interventions for elderlies (e.g., dementia) ( 61 ). The majority of the research had taken a broad approach to mental health promotion ( 62 ). However, some studies have focused on universal prevention ( 63 , 64 ) or selective prevention ( 65 – 68 ). For instance, the Resourceful Adolescent Program (RAPA) was implemented across the schools and has utilized cognitive-behavioral and interpersonal therapies and reported a significant improvement in depressive symptoms. Some of the interventions were directed at enhancing an individual's characteristics like resilience, behavior regulation, and coping skills (ZIPPY's Friends) ( 69 ), while others have focused on the promotion of social and emotional competencies among the school children and attempted to reduce the gap in such competencies across the socio-economic classes (“Up” program) ( 70 ) or utilized expressive abilities of the war-affected children (Writing for Recover (WfR) intervention) ( 71 ) to bring about an improvement in their psychological problems (a type of selective prevention) ( 62 ) or harnessing the potential of Art, in the community-based intervention, to improve self-efficacy, thus preventing mental disorders (MAD about Art program) ( 72 ). Yet, others have focused on strengthening family ( 60 , 73 ), community relationships ( 62 ), and targeting modifiable risk factors across the life course to prevent dementia among the elderlies and also to support the carers of such patients ( 61 ).

Furthermore, more of the studies were conducted and evaluated in the developed parts of the world, while emerging economies, as anticipated, far lagged in such interventions or related research. The interventions that are specifically adapted for local resources, such as school-based programs involving paraprofessionals and teachers in the delivery of mental health interventions, were shown to be more effective ( 62 , 74 ). Likewise, tailored approaches for low-resource settings such as LMICs may also be more effective ( 63 ). Some of these studies also highlight the beneficial role of a multi-dimensional approach ( 68 , 75 ) and interventions targeting early lifespan ( 76 , 77 ).

Newer Insights: How to Harness Digital Technology and Novel Methods of MH Promotion and Protection

With the advent of digital technology and simultaneous traction on mental health promotion and prevention interventions, preventive psychiatrists and public health experts have developed novel techniques to deliver mental health promotive and preventive interventions. These encompass different settings (e.g., school, home, workplace, the community at large, etc.) and levels of prevention (universal, selective, indicated) ( 78 – 80 ).

The advanced technologies and novel interventions have broadened the scope of MH promotion and prevention, such as addressing the mental health issues of individuals with chronic medical illness ( 81 , 82 ), severe mental disorders ( 83 ), children and adolescents with mental health problems, and geriatric population ( 78 ). Further, it has increased the accessibility and acceptability of such interventions in a non-stigmatizing and tailored manner. Moreover, they can be integrated into the routine life of the individuals.

For instance, Internet-and Mobile-based interventions (IMIs) have been utilized to monitor health behavior as a form of MH prevention and a stand-alone self-help intervention. Moreover, the blended approach has expanded the scope of MH promotive and preventive interventions such as face-to-face interventions coupled with remote therapies. Simultaneously, it has given way to the stepped-care (step down or step-up care) approach of treatment and its continuation ( 79 ). Also, being more interactive and engaging is particularly useful for the youth.

The blended model of care has utilized IMIs to a varying degree and at various stages of the psychological interventions. This includes IMIs as a supplementary approach to the face-to-face-interventions (FTFI), FTFI augmented by behavior intervention technologies (BITs), BITs augmented by remote human support, and fully automated BITs ( 84 ).

The stepped care model of mental health promotion and prevention strategies includes a stepped-up approach, wherein BITs are utilized to manage the prodromal symptoms, thereby preventing the onset of the full-blown episode. In the Stepped-down approach, the more intensive treatments (in-patient or out-patient based interventions) are followed and supplemented with the BITs to prevent relapse of the mental illness, such as for previously admitted patients with depression or substance use disorders ( 85 , 86 ).

Similarly, the latest research has developed newer interventions for strengthening the psychological resilience of the public or at-risk individuals, which can be delivered at the level of the home, such as, e.g., nurse family partnership program (to provide support to the young and vulnerable mothers and prevent childhood maltreatment) ( 87 ); family healing together program aimed at improving the mental health of the family members living with persons with mental illness (PwMI) ( 88 ). In addition, various novel interventions for MH promotion and prevention have been highlighted in the Table 2 .

Depiction of various novel mental health promotion and prevention strategies.

a/w, associated with; A-V, audio-visual; b/w, between; CBT, Cognitive Behavioral Therapy; CES-Dep., Center for Epidemiologic Studies-Depression scale; CG, control group; FU, follow-up; GAD, generalized anxiety disorders-7; IA, intervention arm; HCWs, Health Care Workers; LMIC, low and middle-income countries; MDD, major depressive disorders; mgt, management; MH, mental health; MHP, mental health professional; MINI, mini neuropsychiatric interview; NNT, number needed to treat; PHQ-9, patient health questionnaire; TAU, treatment as usual .

Furthermore, school/educational institutes-based interventions such as school-Mental Health Magazines to increase mental health literacy among the teachers and students have been developed ( 80 ). In addition, workplace mental health promotional activities have targeted the administrators, e.g., guided “e-learning” for the managers that have shown to decrease the mental health problems of the employees ( 102 ).

Likewise, digital technologies have also been harnessed in strengthening community mental health promotive/preventive services, such as the mental health first aid (MHFA) Books on Prescription initiative in New Zealand provided information and self-help tools through library networks and trained book “prescribers,” particularly in rural and remote areas ( 103 ).

Apart from the common mental disorders such as depression, anxiety, and behavioral disorders in the childhood/adolescents, novel interventions have been utilized to prevent the development of or management of medical, including preventing premature mortality and psychological issues among the individuals with severe mental illnesses (SMIs), e.g., Lets' talk about tobacco-web based intervention and motivational interviewing to prevent tobacco use, weight reduction measures, and promotion of healthy lifestyles (exercise, sleep, and balanced diets) through individualized devices, thereby reducing the risk of cardiovascular disorders ( 83 ). Similarly, efforts have been made to improve such individuals' coping skills and employment chances through the WorkingWell mobile application in the US ( 104 ).

Apart from the digital-based interventions, newer, non-digital-based interventions have also been utilized to promote mental health and prevent mental disorders among individuals with chronic medical conditions. One such approach in adventure therapy aims to support and strengthen the multi-dimensional aspects of self. It includes the physical, emotional or cognitive, social, spiritual, psychological, or developmental rehabilitation of the children and adolescents with cancer. Moreover, it is delivered in the natural environment outside the hospital premises, shifting the focus from the illness model to the wellness model ( 81 ). Another strength of this intervention is it can be delivered by the nurses and facilitate peer support and teamwork.

Another novel approach to MH prevention is gut-microbiota and dietary interventions. Such interventions have been explored with promising results for the early developmental disorders (Attention deficit hyperactive disorder, Autism spectrum disorders, etc.) ( 105 ). It works under the framework of the shared vulnerability model for common mental disorders and other non-communicable diseases and harnesses the neuroplasticity potential of the developing brain. Dietary and lifestyle modifications have been recommended for major depressive disorders by the Clinical Practice Guidelines in Australia ( 106 ). As most childhood mental and physical disorders are determined at the level of the in-utero and early after the birth period, targeting maternal nutrition is another vital strategy. The utility has been expanded from maternal nutrition to women of childbearing age. The various novel mental health promotion and prevention strategies are shown in Table 2 .

Newer research is emerging that has utilized the digital platform for training non-specialists in diagnosis and managing individuals with mental health problems, such as Atmiyata Intervention and The SMART MH Project in India, and The Allillanchu Project in Peru, to name a few ( 99 ). Such frameworks facilitate task-sharing by the non-specialist and help in reducing the treatment gap in these countries. Likewise, digital algorithms or decision support systems have been developed to make mental health services more transparent, personalized, outcome-driven, collaborative, and integrative; one such example is DocuMental, a clinical decision support system (DSS). Similarly, frameworks like i-PROACH, a cloud-based intelligent platform for research outcome assessment and care in mental health, have expanded the scope of the mental health support system, including promoting research in mental health ( 100 ). In addition, COVID-19 pandemic has resulted in wider dissemination of the applications based on the evidence-based psycho-social interventions such as National Health Service's (NHS's) Mind app and Headspace (teaching meditation via a website or a phone application) that have utilized mindfulness-based practices to address the psychological problems of the population ( 101 ).

Challenges in Implementing Novel MH Promotion and Prevention Strategies

Although novel interventions, particularly internet and mobile-based interventions (IMIs), are effective models for MH promotion and prevention, their cost-effectiveness requires further exploration. Moreover, their feasibility and acceptability in LMICs could be challenging. Some of these could be attributed to poor digital literacy, digital/network-related limitations, privacy issues, and society's preparedness to implement these interventions.

These interventions need to be customized and adapted according to local needs and context, for which implementation and evaluative research are warranted. In addition, the infusion of more human and financial resources for such activities is required. Some reports highlight that many of these interventions do not align with the preferences and use the pattern of the service utilizers. For instance, one explorative research on mental health app-based interventions targeting youth found that despite the burgeoning applications, they are not aligned with the youth's media preferences and learning patterns. They are less interactive, have fewer audio-visual displays, are not youth-specific, are less dynamic, and are a single touch app ( 107 ).

Furthermore, such novel interventions usually come with high costs. In low-resource settings where service utilizers have limited finances, their willingness to use such services may be doubtful. Moreover, insurance companies, including those in high-income countries (HICs), may not be willing to fund such novel interventions, which restricts the accessibility and availability of interventions.

Research points to the feasibility and effectiveness of incorporating such novel interventions in routine services such as school, community, primary care, or settings, e.g., in low-resource settings, the resource persons like teachers, community health workers, and primary care physicians are already overburdened. Therefore, their willingness to take up additional tasks may raise skepticism. Moreover, the attitudinal barrier to moving from the traditional service delivery model to the novel methods may also impede.

Considering the low MH budget and less priority on the MH prevention and promotion activities in most low-resource settings, the uptake of such interventions in the public health framework may be lesser despite the latter's proven high cost-effectiveness. In contrast, policymakers may be more inclined to invest in the therapeutic aspects of MH.

Such interventions open avenues for personalized and precision medicine/health care vs. the traditional model of MH promotion and preventive interventions ( 108 , 109 ). For instance, multivariate prediction algorithms with methods of machine learning and incorporating biological research, such as genetics, may help in devising tailored, particularly for selected and indicated prevention, interventions for depression, suicide, relapse prevention, etc. ( 79 ). Therefore, more research in this area is warranted.

To be more clinically relevant, greater biological research in MH prevention is required to identify those at higher risk of developing given mental disorders due to the existing risk factors/prominent stress ( 110 ). For instance, researchers have utilized the transcriptional approach to identify a biological fingerprint for susceptibility (denoting abnormal early stress response) to develop post-traumatic stress disorders among the psychological trauma survivors by analyzing the expression of the Peripheral blood mononuclear cell gene expression profiles ( 111 ). Identifying such biological markers would help target at-risk individuals through tailored and intensive interventions as a form of selected prevention.

Similarly, such novel interventions can help in targeting the underlying risk such as substance use, poor stress management, family history, personality traits, etc. and protective factors, e.g., positive coping techniques, social support, resilience, etc., that influences the given MH outcome ( 79 ). Therefore, again, it opens the scope of tailored interventions rather than a one-size-fits-all model of selective and indicated prevention for various MH conditions.

Furthermore, such interventions can be more accessible for the hard-to-reach populations and those with significant mental health stigma. Finally, they play a huge role in ensuring the continuity of care, particularly when community-based MH services are either limited or not available. For instance, IMIs can maintain the improvement of symptoms among individuals previously managed in-patient, such as for suicide, SUDs, etc., or receive intensive treatment like cognitive behavior therapy (CBT) for depression or anxiety, thereby helping relapse prevention ( 86 , 112 ). Hence, such modules need to be developed and tested in low-resource settings.

IMIs (and other novel interventions) being less stigmatizing and easily accessible, provide a platform to engage individuals with chronic medical problems, e.g., epilepsy, cancer, cardiovascular diseases, etc., and non-mental health professionals, thereby making it more relevant and appealing for them.

Lastly, research on prevention-interventions needs to be more robust to adjust for the pre-intervention matching, high attrition rate, studying the characteristics of treatment completers vs. dropouts, and utilizing the intention-to-treat analysis to gauge the effect of such novel interventions ( 78 ).

Recommendations for Low-and-Middle-Income Countries

Although there is growing research on the effectiveness and utility of mental health promotion/prevention interventions across the lifespan and settings, low-resource settings suffer from specific limitations that restrict the full realization of such public health strategies, including implementing the novel intervention. To overcome these challenges, some of the potential solutions/recommendations are as follows:

• The mental health literacy of the population should be enhanced through information, education, and communication (IEC) activities. In addition, these activities should reduce stigma related to mental problems, early identification, and help-seeking for mental health-related issues.
• Involving teachers, workplace managers, community leaders, non-mental health professionals, and allied health staff in mental health promotion and prevention is crucial.
• Mental health concepts and related promotion and prevention should be incorporated into the education curriculum, particularly at the medical undergraduate level.
• Training non-specialists such as community health workers on mental health-related issues across an individual's life course and intervening would be an effective strategy.
• Collaborating with specialists from other disciplines, including complementary and alternative medicines, would be crucial. A provision of an integrated health system would help in increasing awareness, early identification, and prompt intervention for at-risk individuals.
• Low-resource settings need to develop mental health promotion interventions such as community-and school-based interventions, as these would be more culturally relevant, acceptable, and scalable.
• Utilizing a digital platform for scaling mental health services (e.g., telepsychiatry services to at-risk populations) and training the key individuals in the community would be a cost-effective framework that must be explored.
• Infusion of higher financial and human resources in this area would be a critical step, as, without adequate resources, research, service development, and implementation would be challenging.
• It would also be helpful to identify vulnerable populations and intervene in them to prevent the development of clinical psychiatric disorders.
• Lastly, involving individuals with lived experiences at the level of mental health planning, intervention development, and delivery would be cost-effective.

Clinicians, researchers, public health experts, and policymakers have increasingly realized mental health promotion and prevention. Investment in Preventive psychiatry appears to be essential considering the substantial burden of mental and neurological disorders and the significant treatment gap. Literature suggests that MH promotive and preventive interventions are feasible and effective across the lifespan and settings. Moreover, various novel interventions (e.g., internet-and mobile-based interventions, new therapies) have been developed worldwide and proven effective for mental health promotion and prevention; such interventions are limited mainly to HICs.

Despite the significance of preventive psychiatry in the current world and having a wide-ranging implication for the wellbeing of society and individuals, including those suffering from chronic medical problems, it is a poorly utilized public health field to address the population's mental health needs. Lately, researchers and policymakers have realized the untapped potentialities of preventive psychiatry. However, its implementation in low-resource settings is still in infancy and marred by several challenges. The utilization of novel interventions, such as digital-based interventions, and blended and stepped-care models of care, can address the enormous mental health need of the population. Additionally, it provides mental health services in a less-stigmatizing and easily accessible, and flexible manner. More research concerning this is required from the LMICs.

Author Contributions

VS, AK, and SG: methodology, literature search, manuscript preparation, and manuscript review. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.898009/full#supplementary-material