This systematic review on non-instrumental clinical assessment in adult oropharyngeal dysphagia (OD) provides an overview of published measures with reported reliability and validity. In alignment with PRISMA, four databases  were searched, resulting in a total of 16 measures and 32 psychometric studies included. The included measures assessed any aspect of swallowing, consisted of at least one specific subscale relating to swallowing, were developed by clinical observation, targeted adults, and were developed in English. The included psychometric studies focused on adults, reported on measures for OD-related conditions, described non-instrumental clinical assessments, reported on validity or reliability, and were published in English. Methodological quality was assessed using the standard quality assessment QualSyst. Most measures targeted only restricted subdomains within the conceptual framework of non-instrumental clinical assessments. Across the 16 measures, hypothesis testing and reliability were the most reported psychometrics, whilst structural validity and content validity were the least reported. Overall, data on the reliability and validity of the included measures proved incomplete and frequently did not meet current psychometric standards. Future research should focus on the development of comprehensive non-instrumental clinical assessments for adults with OD using contemporary psychometric research methods. Oropharyngeal dysphagia (OD) is a symptom or a collection of symptoms of one or more underlying anatomical abnormalities or impairments and disorders in cognitive, sensory, and motor acts involved with transferring food and liquids from the mouth to the stomach . OD may The first step in the management of OD is screening to identify people at risk of dysphagia. Next, those patients who fail screening are referred for further clinical assessment, for example, to identify possible causes of the swallowing problems, estimate the efficacy and safety of swallowing including the risk of aspiration, support decisions on oral or alternative feeding routes, and establish baseline data for future reference when determining the effects of interventions or the impact of a disease over time . ClinicaNon-instrumental clinical assessment by dysphagia experts refers to an alternative method of evaluation after failed screening comprising a large variety of assessments, each of which may describe different aspects of OD given that it is a multidimensional phenomenon . In the literature, different combinations of non-instrumental clinical assessments can be found, typically including measures of cognition and communication; evaluation of the oral, laryngeal, and pharyngeal anatomy, physiology, and function ; oral intake, nutritional status, and mealtime observations; and intervention trials  ,6.In 2022, the European Society for Swallowing Disorders (ESSD) published recommendations on how to select the best evidence-based screening and non-instrumental assessments for use in clinical practice targeting different constructs, subject populations, and respondents, based on criteria for diagnostic performance, psychometric properties , and feasibility . The ESSThe purpose of this systematic review was to (a) summarise the characteristics of the identified non-instrumental clinical assessments for adults with OD (excluding patient self-report), (b) determine which psychometric properties related to reliability and validity were reported, and (c) construct a conceptual map of the identified measures to determine how comprehensive existing non-instrumental clinical assessments are in measuring all the underlying constructs. The reporting on the psychometric properties of measures was based on the terminology and definitions as defined in the COSMIN  taxonomy ,16. RespThis systematic review was conducted and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement and checklist . The PRIA systematic literature search was performed across four electronic databases: CINAHL, Embase, PsycINFO, and PubMed. All publication dates up to 14 February 2022 were included. Both subject headings and free text terms related to dysphagia, non-instrumental clinical assessment, and psychometrics were used to capture all relevant literature. The eligibility of individual measures was determined through the following inclusion and exclusion criteria: (1) Measures assessed any aspect of swallowing , with measures investigating eating disorders or Gastro-Esophageal Reflux Disease (GERD) excluded; (2) at least one specific subscale or a minimum of 50% of the total number of items of the measures related to swallowing; (3) measures were developed for assessment by clinical observation or eliciting clinical information by questionnaire, with all instrumental assessments, screening tools, and self-reporting questionnaires excluded; (4) measures targeted adults ; and (5) measures needed to be developed originally in English, excluding translated versions of these measures.Psychometric studies included in the systematic review met the following inclusion and exclusion criteria: (1) Studies focused on adult populations (18 years old and above); (2) studies reported on measures for conditions related to OD or swallowing difficulties, whilst any studies related to psychogenic swallowing difficulties or eating disorders  were excluded; (3) studies described a non-instrumental clinical assessment, so any study that focused on instrumental assessment  was excluded; (4) studies reported on psychometrics—either validity or reliability—of the included measures as defined by the COSMIN taxonomy , thus exTwo reviewers worked independently evaluating the abstracts and titles of the records returned from the initial database search against the eligibility criteria. Abstracts were reviewed separately by the two reviewers to ensure accuracy in study selection. Any disagreements between the reviewers were discussed and, where consensus could not be reached, a third reviewer was consulted to assist in finding a resolution. None of the three reviewers had any affiliations with any of the authors of the included studies or measures. The selection process was completed according to the PRISMA guidelines and flow diagram , thus noFollowing the initial database search, a further set of searches was performed including the names and acronyms of the included measures, with the aim of locating all eligible and relevant psychometric studies. The same procedure was followed to ensure the accuracy of the selection process. A separate search was undertaken to identify potential measures and studies that met the inclusion criteria from the reference lists of the included studies.Following the selection process of both the studies and the measures, data from the remaining articles were extracted using comprehensive data extraction forms. Data were extracted under the following categories: (1) Measure characteristics  and (2) psychometric properties reported within the available studies. The use of a data extraction table ensured that the same data characteristics were extracted from all included papers . One revThe standard quality assessment , as described by Kmet et al., 2004 , was perTo construct a conceptual map of the identified measures, this systematic review utilised OD non-instrumental clinical assessment theory and definitions to inform a deductive thematic analysis of the findings. Following thematic synthesis of the scales and subscales of the included measures by the first and second authors, domains, sub-domains, and elements were subsequently identified, resulting in a conceptual framework of non-instrumental clinical assessment of OD.From the initial search, 1430 records were retrieved from the four separate electronic databases: 277 from CINAHL, 579 from Embase, 40 from PsycINFO, and 534 from PubMed. Of these, 301 duplicates were removed. From the measure-specific search, 2513 records were retrieved from the four separate electronic databases: 312 from CINAHL, 1201 from Embase, 316 from PsycINFO, and 684 from PubMed. Of these, 478 duplicates were removed, leaving a combined 3164 articles to be reviewed. Descriptions and characteristics of the included measures are presented in The systematic review utilised OD non-instrumental clinical assessment theory and definitions to inform a deductive thematic analysis of the findings . Based oThe content of the included measures—subscales and their items—varied and covered three domains : (1) SkiThe second domain ‘Making Adjustments to Facilitate Eating and Drinking’ includes two subdomains: Modified aspects related to the environment , adjustment of food and drink intake , and feeding support ), and modified aspects related to a person ).The third domain ‘Swallowing Act’ refers to two subdomains: Safety of swallowing and efficiency of swallowing. Safety of swallowing includes four elements , pain and discomfort , pharyngeal or laryngeal clearance , and trache . The efficacy of swallowing consists of three elements , speed , and direction ).The validity properties of the measures—content validity, criterion validity (where applicable), and construct validity )—are summarised in Content validity was reported for 11 of 16 (69%) of the measures: DSRS , EDACS , EDSQ 3, FOIS 2, IDDSI-FThe most commonly reported aspect of construct validity reported within the included studies was hypothesis testing—the degree to which the results produced evidence that was consistent with hypotheses based on the assumption that the instrument validly measures the construct to be measured ,16—with The reliability domain properties of the measures—internal consistency, reliability , and measurement error—are outlined in Data on the reliability measurement property were reported for all but two measures. Inter-rater agreement was determined for 12 of the 16 (75%) measures, with Intraclass Correlation Coefficient (ICC) and Kappa coefficient being the most commonly reported. ICC was reported for eight measures (50%), with values ranging from “moderate” (ICC = 0.68) to “excellent” (ICC = 1.00) . The KapSkills Related to Eating and Drinking’, ‘Making Adjustments to Facilitate Eating and Drinking’, and ‘Swallowing Act’  includewith DDS  and DMSSwith DDS  includinwith DDS , IDDSI-Fwith DDS , MASA [2with DDS , MASA-C with DDS , M-MASA with DDS , Swallowwith DDS , and SPEwith DDS —includedth EDACS  includinth EDACS  and TOMAth EDACS  each onlOverall, only seven of the sixteen measures included at least one item specific to each of the three domains, though thirteen of the sixteen included at least one item specific to two of the three domains. Three measures targeted a single domain only. The mean number of elements per measure was six . MASA  and MASAThis systematic review, in line with the PRISMA guidelines , aimed tAn important finding is that very few measures were identified in the literature that comprehensively measure the construct of non-instrumental clinical assessment, with seven measures (43.8%) consisting of a single scale covering only single aspects of OD. Based on the conceptual framework of non-instrumental clinical measures as introduced in this review, the identified measures collectively demonstrated great variety across a number of domains, subdomains, and elements. The number of elements for each measure ranged between one, demonstrating a very narrow focus, and twelve, demonstrating a very broad focus. On average, measures consisted of six elements. Even measures targeting all three domains as defined in our conceptual framework—skills related to eating and drinking, making adjustments to facilitate eating and drinking, and swallowing act—would still exclude several subdomains and elements from the assessment of people with OD. Therefore, since OD is a multidimensional phenomenon  and mostThe conceptual framework also highlighted the importance of a multidisciplinary approach in the assessment of OD. Different professional healthcare workers may add value to ensure comprehensive evaluation across OD assessment domains. By combining expertise from different disciplines , OD can be evaluated in all its multidimensional aspects. Consequently, experts from all relevant disciplines should be involved at the onset of instrument development to ensure good content validity .This current review is a first step towards optimising non-instrumental clinical assessment of OD. Although this review was based on the terminology and definitions used in the COSMIN taxonomy ,16, it iFuture research should focus on developing more comprehensive non-instrumental clinical assessments that can be used to capture OD as a multidimensional phenomenon, using contemporary psychometric standards and methods such as item response theory and classic test theory. All psychometric properties should be determined and reported on to allow for validity, reliability, and responsiveness to be established. Finally, before implementing newly developed measures in research and clinical practice, feasibility aspects should be taken into consideration such as time constraints and accessibility. Non-instrumental clinical measures with robust psychometric properties could be of critical value, especially in those health settings where access to instrumental assessment is not possible or where availability is restricted.Although the reporting of this review followed the PRISMA guidelines to reduce bias, some limitations are inherent to this study. As only studies and measures published in English were included, some measures may have been excluded based on language criteria. According to the COSMIN framework ,16, nineThis systematic review following PRISMA guidelines and terminology as defined by the COSMIN framework summarised the reliability and validity of non-instrumental clinical assessments for adults with OD excluding patient self-report. Only 16 measures were identified with reported psychometric characteristics. Even though OD is considered a multidimensional phenomenon, most measures only captured restricted subdomains within the conceptual framework of non-instrumental clinical assessments. Further, data on the reliability and validity of included measures proved incomplete and did not always meet current psychometric standards. Future research should focus on the development of comprehensive non-instrumental clinical assessments for adults with OD using contemporary psychometric research methods.


Recent research has increasingly focused on positive factors and supports for LGBTQ youth. This scoping review explores existing social support for LGBTQ youth in schools through the Ecological Systems Theory to respond to the following four objectives: (1) define social support systems in schools, (2) identify current research on outcomes for LGBTQ youth, (3) identify barriers to support LGBTQ youth in schools, and (4) identify areas for future research for LGBTQ youth and social support in schools. A systematic search :19–32, 2005) between 2007 through 2021 resulted in 94 articles. This review gave rise to an organizational framework to consolidate various systems of social support for LGBTQ youth in schools. Social support consisted of seven social support systems  that are positively associated with the promotion of positive socioemotional, behavioural, and educational outcomes for LGBTQ youth. Though the literature has been clear surrounding the risks associated with LGBTQ youth, this scoping review provides a positive outlook on LGBTQ youth’s school experiences and how these systems of social support allow for LGBTQ youth to act as active participants to foster a positive school climate and sense of safety.The online version contains supplementary material available at 10.1007/s44217-022-00016-9. Lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth spend most of their lives in schools, navigating through the difficult and threatening space , 80. SchMany studies have indicated that LGBTQ youth experience numerous socioemotional, educational, and health risks at school due to LGBTQ-specific prejudice and victimization. This includes isolation from peers, low social support, low school engagement, low academic success, school dropout, stress, anxiety, depressive symptoms, and suicidal ideation and attempts , 47, 60.LGBTQ youth experiences have been increasingly explored in a variety of settings: family, community, and school settings. One approach to organize the LGBTQ youth literature is through a broader, systemic lens. Bronfenbrenner’s –16 EcoloTaken together, this scoping review attempts to explore existing social support for LGBTQ youth in schools through the Ecological Systems Theory. An ecological systems approach in understanding the existing literature on social support for LGBTQ youth can provide an organizational framework necessary to consolidate the comprehensive literature of social support for LGBTQ youth in schools. As the scoping review attempts an initial exploration and organization of existing social support for LGBTQ youth in schools, a deeper exploration on the relationship between the systems will be explored in a separate review.American Psychological Association  publisheAs literature in this field typically examine systems of social support in isolation , this scoping review aims to provide a more comprehensive search strategy in consolidating the research on the available social support systems for LGBTQ youth in schools. This scoping review attempts to bring together the literature across multiple systems of social support for LGBTQ youth to develop a systemic definition of social support for LGBTQ youth, identify current research across all systems of social support, identify barriers and difficulties experienced by LGBTQ youth in schools, and identify areas for future research in understanding the social support systems for LGBTQ youth.Results from the 2015 Youth Risk Behavior Survey (YRBS) indicate that over 60% of LGB youth experienced prolonged feelings of hopelessness compared to only 25% of heterosexual youth. In a national survey of LGBTQ youth , 67% heaPresent data highlights that LGBTQ youth are at a heightened risk for numerous health and educational concerns. Such concerns can be attributed to a lack of connection with their teachers and school staff , a lack While efforts have been made to support LGBTQ youth in schools, literature is diffuse and show mixed results , 109. SuThis study seeks to respond to the following question:How does social support in elementary and secondary education relate to outcomes for LGBTQ youth?Define what it means to have social support in schools,Identify and describe the current research on outcomes for LGBTQ youth given the implementation of these social support systems,Identify barriers and difficulties to support LGBTQ youth in an educational setting, andIdentify areas for future research for LGBTQ youth and social support in schools.with the following objectives:This study follows the methodologically rigorous scoping review approach designed by Arksey and O’Malley  and condA set of inclusion and exclusion criteria were established a priori to provide guidance for the systematic search strategy. Inclusion criteria included: (a) empirical articles that were published in peer-reviewed journals between 2007 and 2021; (b) non-empirical literature including books, book chapters, case reports, reviews between 2007 and 2021; (c) written in the English language; (d) LGBTQ individuals; (e) school environment-specific ; (f) all geographical locations; and (g) social support outcomes for students. Exclusion criteria included: (a) non-LGBTQ specific; (b) unrelated to school environment; (c) social support outcomes not for students .The search used the following databases: PsycINFO, ERIC, Genderwatch, ProQuest Dissertation and Thesis, Web of Science, Cochrane Database of Systematic Reviews, and Campbell Systematic Review. A description of keywords can be seen in Supplementary Table 1 and a visual for the search and data collection process in Supplementary Figure 1.A social science librarian was consulted to ensure the scoping review was conducted in a systematic procedure. The five databases were cross-checked with an expert in the field of LGBTQ studies to ensure a comprehensive collection of databases. After databases were confirmed, key concepts were brainstormed and cross-checked with the second and third author, the expert in the field of LGBTQ research (April 2017), and the librarian (May 2017). Keywords were broken down into three sections. The first column consists of LGBTQ terms . The second column consists of school terms . The last column consists of social support terms . Refer to Supplementary Table 1 for a full list of search terms. All keywords in each column were combined. After a collaborative process between the authors, librarians, and expert, all keywords and related terms were included in each database.n2017 = 364; n2021 = 199). After deduplications were removed, 533 articles remained .Data were collected during June 2017 and revised in February 2021 to ensure consistency between the searches. Throughout the collection process, the authors engaged in an iterative process to discuss obstacles that arose during the screening phase. As depicted in the flow chart , the initial data collection yielded 565 articles  study characteristics , (2) group demographics , (3) social support factors, and (4) key findings.The resulting 54 articles from the full-text screening were broken into three blocks of 18. Each author independently read two of the three blocks of articles and extracted relevant data . After independent data extraction, the two reviewers for each corresponding block resolved any differences.N2017+2021 = 184). Replicating phase two, the first and fourth author conducted independent full-text screening on the 56 articles, resulting in 40 articles with an inter-rater reliability (IRR) of 75.00% (N2017+2021 = 94). Following phase three, the resulting 40 articles from the full-text screening were broken into two blocks of 20. Each author independently read one block of articles and extracted relevant data. After independent data extraction, the two authors checked and resolved any differences in the other block.A revised data collection was addended since the 2007 through 2017 phase. Another round of data collection, abstract, and full-text screening was conducted from 2017 through 2021. The update in data collection was done in 2021 to account for the many changes happening in society related to LGBTQ populations  as the After data abstraction, quantitative data was collected on the following categories (see Supplementary Table 2): (1) research design, (2) participant sample size range, (3) LGBTQ acronym, (4) school setting, (5) number of schools, (6) number of students, and (7) the types of social support. Initial IRR of 94 articles was 76.60% and discrepancies were discussed and resolved through an iterative process between the first through fourth authors.Subsequent thematic analysis , 36, 117Data analysis involved both quantitative  and qualitative  methods, resulting in a multi-layered synthesis process that allowed for the identification of existing gaps in the literature and revealed potential topics for conducting future systematic or novel reviews.Refer to Supplementary Table 2 for a tabulation of characteristics across the 94 articles.Out of the 94 articles, there were 48 (51.06%) quantitative studies, 43 (45.74%) qualitative studies, and three (3.19%) mixed-methods studies.n = 40; 39.22%), LGBT/GLBT , sexual minority/SMY , LGBQ , LGB/GLB , transgender/trans* , SSA , GSM/GSD , LGBTQQ , gender-variant , GM , LGBTQ2S , LGBTQ+ , queer , MSMY , bisexual/pansexual , TGD .As each article used several LGBTQ acronyms interchangeably, there are a total of 102 acronym frequencies across 94 articles. Acronyms include LGBTQ/GLBTQ , grades seven through 12 , grades eight through 12 , grades 10 through 12 , and grades six through 12 . 40 studies did not provide specific age or grade range of students and only included the educational institution broadly: high school , middle and high school , high school and college , middle school , elementary school , college , elementary and high school . The remaining 12 studies included adult staff or parent participants  or did not specify .Across 94 articles, 42 studies provided specific age or grade ranges of the participants. Participants ranged from students in grades nine through 13 , middle and high school , private schools , elementary through high school , elementary school , catholic schools , middle school , college , alternative schools , community center , democratic school , and independent school . Six studies (5.56%) did not specify the type of school setting.As each study recruited school settings that were different in type  and in developmental age , there was a total of 108 counts of school settings across the 94 articles. School settings included high school , peer support , parental support , and community support . School support was further broken to include gay-straight alliances , supportive non-teaching staff , supportive teachers , positive school climate , programs and policies , school-wide approaches , and curriculum .Each study reported more than one type of social support related to LGBTQ students, resulting in a total of 188 counts of social support types. Social support was organized into four categories: school support . As geographical information was not extracted, findings are generalized and may not accurately represent specific geographically contextualized policies and environments.narticles = 12), (2) family/caregiver support was not consistently adequate to buffer the negative emotional, behavioral, and educational outcomes (narticles = 3), and sex differences within family experiences highlighted complexities of family/caregiver support (narticles = 3).Three distinct themes were constructed from the literature: (1) high actual or perceived family/caregiver support buffered many negative socioemotional or educational outcomes (When family (or caregiver) support was low, LGBTQ youths’ level of emotional and behavioural distress was high , 90, 124Studies showed that family (or caregiver) support did not consistently buffer the negative outcomes that happens at school , 90. ThoThree unique studies found differences present for (1) boys and girls and (2) mothers and fathers. Pearson and Wilkinson  found thnarticles = 6), (2) LGBTQ-inclusive curriculum led to decreased victimization and negative socioemotional outcomes and increased sense of safety (narticles = 5), (3) a hidden, heteronormative curriculum exists behind the official academic curriculum that impedes LGBTQ youth support and engagement (narticles = 4), and (4) a need for teachers to feel supported to teach LGBTQ-inclusive curriculum effectively (narticles = 4).Four distinct themes were constructed from the literature: (1) LGBTQ-inclusive curriculum was most often taught in social sciences, humanities, and health classes, fostering authenticity with students and creating an inclusive classroom . IThis theme expands on the hidden, heteronormative curriculum that exists behind the official academic curriculum. Castro and Sujak  mentioneThough LGBTQ-inclusive curricula can be a pillar of social support for LGBTQ youth, teachers often miss teachable moments conducive to inclusive curriculum , 103. Tenarticles = 24), (2) GSAs created opportunities for connection for LGBTQ youth in their community (narticles = 13), (3) GSAs allowed for engagement and youth involvement in schools (narticles = 11), (4) GSAs had varying functions (narticles = 7), (5) GSAs encountered challenges in delivering positive outcomes (narticles = 15), and (6) school-based interventions (non-GSAs) were effective in supporting LGBTQ youth (narticles = 6). Note that most of the articles referred to GSAs as gay-straight alliances. One article referred to them as gender-sexuality alliances.Six distinct themes were constructed from the literature: (1) gay-straight alliances (GSAs) fostered a space for empowerment and change, creating a safe space and climate for LGBTQ youth  advocacy, education, and social support; (2) literature to reflect on the lives and experiences of LGBTQ youth; and (3) developing skillsets to assist students in fostering inclusion and acceptance . AdvisorAlthough GSAs were found to be effective in supporting LGBTQ youth in schools, only 19.1% of youth reported an existence of a GSA in their high school . ProgramThere is a need to employ a pragmatic approach and focus on student safety to gain administrative support to conduct interventions , 69, 94.narticles = 13), and (2) inconsistencies in the effectiveness of peer support for diverse LGBTQ youth (narticles = 4).Two distinct themes were constructed from the literature: (1) peer support and acceptance were related to lower levels of emotional and behavioural distress and fostered positive outcomes , (2) high level of within-school adult support reduced negative outcomes (narticles = 10), (3) teachers and school staff were ineffective and inconsistent in supporting LGBTQ students (narticles = 7), and (4) school staff perceived external support as key to ensure coordination of inclusivity for LGBTQ students (narticles = 4).Four distinct themes were constructed from the literature: (1) high level of within-school adult support resulted in positive benefits . LGBTQ youth mentioned the need to observe school staff acting and having a presence explicitly taking a stance against bigotry, emphasizing the importance of behavioural management to establish a safe classroom space –71, 84. LGBTQ youth perceptions of greater adult support  at school was linked to lower levels of victimization, school avoidance, substance use, suicidal behaviour, and other mental health risks , (2) implementation of inclusive and anti-discriminatory policies were effective in fostering a safer school space for LGBTQ students (narticles = 5), and (3) school policy and community support showed challenges in fostering positive outcomes (narticles = 4).Three distinct themes were constructed from the literature: (1) socio-political values of the wider community beyond the school impacted school policies and staff attitudes  to be accepted, subsequently fostering community connection and support for LGBTQ youth , 106. HoReframing the support for LGBTQ youth as systematic inclusion to meet the needs of all students may be a method to circumvent the restrictions and pressures from the larger community environment. Reframing support for LGBTQ youth to general support for all students can reduce the hesitance school staff have to support LGBTQ youth , 71, 106Schools with higher reported implementation of inclusive and anti-discriminatory policies had lower levels of discrimination against LGBTQ youth , fosteriBullying policies did not consistently predict LGBTQ safety and victimization , 28. Ratnarticles = 4), (2) a positive school climate fostered positive psychosocial and educational outcomes (narticles = 11), and (3) a whole school effort is required to foster a positive school climate (narticles = 10).Three distinct themes were constructed from the literature: (1) a positive school climate reduced negative emotional-behavioural outcomes  can promote tolerance, respect and inclusion for LGBTQ youth , 72, 121Creating and maintaining a positive and safe school climate for LGBTQ youth can foster positive outcomes for all students. This effort requires constant vigilance from all relevant stakeholders: students, teachers, administration, and community members . EffectiThe first objective of this review is to define what social support in schools mean for LGBTQ youth. Prior to understanding how social support in elementary and high school education relate to outcomes for LGBTQ youth, the scope of social support needs to be defined to create a systemic framework that can map how different social support systems are associated with LGBTQ youth outcomes in school.Organized through the Ecological Systems Theory, social support can be defined as support that is provided across various systems related to LGBTQ youth. This scoping review brought forth how social support in schools for LGBTQ youth can span across systems: (1) family, (2) curriculum, (3) GSAs (and other school programs), (4) peers, (5) school administrators and teachers, (6) school policies, and (7) school climate.The seven systems that were constructed from the review indicated that they impact LGBTQ youth and their experiences in school. The parental system was constructed from the review as a form of social support that is associated with LGBTQ youth outcomes in schools. Parents or caregivers who supported their LGBTQ youth through advocacy, open communication, trust, closeness, and acceptance minimized many negative educational outcomes  and promoted wellbeing, academic success, physical and emotional safety among other outcomes. The curricular system was constructed to show how influential LGBTQ-inclusive curriculum can be for LGBTQ youth. LGBTQ-inclusive curriculum provided LGBTQ youth the opportunity to explore their LGBTQ identity, make authentic connections, challenge oppression, and acquire knowledge inclusive of LGBTQ people and issues. When a LGBTQ-inclusive curriculum is introduced in classrooms, LGBTQ youth reported feeling safer, more accepted in their classroom, and lower victimization incidents. GSAs and other school-based programs were social support systems that were constructed based on the robust data related to how GSAs can provide space for empowerment and change, creating a safe space and climate for LGBTQ youth. This, in turn, can promote many positive outcomes in schools  and decrease substance use, victimization, and psychological distress among other risks. Supportive and accepting peers were a system of social support that fostered higher levels of school belongingness, school engagement, academic success, sense of safety, and minimized levels of depression and school victimization for LGBTQ youth. School administrators and teachers were another system of support for LGBTQ youth. The higher the number of safe adults that were identified at school, the greater the school engagement for LGBTQ youth. Supportive adults at school, through the knowledge, resources, and connections they have about LGBTQ issues, acted against bigotry and victimization incidents at school, and fostered a positive student–teacher relationship for LGBTQ youth. Subsequently, they perceived a safer and accepting classroom environment, increased sense of school belonging, academic success, and wellbeing. School policies were constructed as a system influential to LGBTQ youth outcomes in schools. Schools with LGBTQ-inclusive policies reported lower levels of victimization, and increased sense of safety and opportunities for LGBTQ youth to act towards an empowering climate. School climate arose as an overarching system where the other systems  interacted to foster a safer and accepting climate for LGBTQ youth, promoting tolerance, respect, academic success, wellbeing, and school connectedness.Based on the seven systems of social support for LGBTQ youth in schools, social support in schools can be defined as an understanding of systemic interactions amongst the seven systems  and how each system, uniquely and in overlap, can both positively promote academic, socioemotional, and behavioural outcomes, and moderate the health and psychological risks typically associated with LGBTQ youth in schools. Studies that did not align through the lens of ecological systems focused on specific definitions of social support. For example, Day and others  conceptuThe second objective of this review was to identify current research on outcomes for LGBTQ youth given the implementation of the social support systems. Identifying current research shed light to understand how social support provided across the social support systems are associated with LGBTQ youth outcomes. The current research on social support outcomes for LGBTQ youth sheds light on the multifaceted nature of social support systems shown to influence LGBTQ youth outcomes in schools.The current research on family systems focuses on fostering positive connections between parents and LGBTQ youth. More specifically, current research expands beyond family acceptance and closeness as family support. Family support also entails the active support through advocacy, allyship, and communication. This finding was replicated in other social support systems where providing social support for LGBTQ youth entails the act of standing up, advocating, and challenging the LGBTQ-related issues present in schools and community.Current research on curriculum support highlights variance in the implementation of LGBTQ-inclusive curriculum. LGBTQ-inclusive curriculum was most often incorporated in social sciences, humanities, and health classes where students were able to make authentic connections between their lives and LGBTQ-relevant social events . Moving towards a systematic implementation of LGBTQ-inclusive curriculum that expands beyond social sciences, humanities, and health classes is an important step to provide safety for LGBTQ youth in schools. A heteronormative curriculum excludes LGBTQ youth from making authentic connections with their own lives, subsequently influencing their interest and engagement in classrooms. Increasingly incorporating LGBTQ-inclusive curriculum in education can move towards the vision for LGBTQ youth to foster authentic connections between their identity and their curriculum. This can result in improvements in their learning, wellbeing, identity exploration, and foster a supportive school and classroom climate. Like the family system, pushing for a LGBTQ-inclusive curriculum moves the system to actively challenge and disrupt the homophobia and injustice that is present in schools. Based on the findings from both systems, it appears that activism, advocacy, and this shift towards criticality against an injustice educational system is common in the literature reviewed from 2017 through 2021.Current research on GSAs and other school programs were effective in creating a safe space for empowerment and change for LGBTQ youth. Though GSAs had different functions based on the schools’ needs and context, two of GSAs’ functions were to act as a space for advocacy and education, and acquire coping skills and resources to support their mental health. Similar to the previous systems, GSAs are moving towards providing LGBTQ youth the skills and opportunities necessary to be active participants in fostering a LGBTQ-inclusive school environment and make connections to the wider community for support.Current research on peer support similarly highlights the importance of peers as active participants in schools to foster a sense of safety and positive classroom environment for LGBTQ youth. Beyond peers as allies, the act of peer education and intervention where peers take an active role to support their LGBTQ peers in schools led to increased sense of safety and positive classroom experiences for LGBTQ youth. Positive friendships, also known as ‘thick’ friendships, pushed LGBTQ youth to question their sexualities, reflect, and consider how their LGBTQ identity emerges in their lives. This form of close relationship with friends helped LGBTQ youth take an active role in self-reflection of their LGBTQ identity and disruption against existing oppression in schools.Current research on school administrators and teachers focused on school staffs’ LGBTQ-inclusive knowledge, relationships with students, and opportunities for students to open the space for discussion on inclusion and diversity. School administrators and teachers have the power to create opportunities for students to foster awareness of LGBTQ issues in their schools through community events . This shows the importance for school administrators and teachers to have the knowledge and skills to create opportunities for students to be active participants in critical dialogue and reflection, subsequently promoting safety and acceptance in the classroom.Like the interaction between GSAs and the community system surrounding the school, school policies were also impacted by the socio-political values of the wider community. Inclusive school policies allowed students to have opportunities to create change in schools, such as the creation of LGBTQ-inclusive events like Pride Prom and the Day of Silence to acknowledge and promote awareness of LGBTQ issues and inclusivity. Recent research further emphasized the importance of a school-wide approach to effect change in schools and incorporate inclusive policies. The research on school policies as a social support system emphasizes social support as an interaction of systems where the larger context and values can impact both the inclusivity of school policies for LGBTQ youth and the level of supportiveness from school administrators and teachers, family, and peers.School climate, the last social support system, highlights the interrelatedness between all systems. Many articles indicated the robustness of a positive school climate and the academic, socio-emotional, and behavioural benefits for LGBTQ youth. To achieve a positive school climate, each social support system is relevant to provide social support for LGBTQ youth. Each social support system can influence each other in their effectiveness to provide the necessary space and opportunity for LGBTQ youth to act and challenge their school environment.In sum, the current research on social support for LGBTQ youth has moved beyond understanding LGBTQ youth as passive recipients of education to recognizing LGBTQ youth as active co-creators of supportive spaces and opportunities that promote inclusive school climates that foster a sense of belongingness and safety. Other reviews exploring the impact of positive school climate on LGBTQ youth similarly emphasized the importance of a positive school climate for LGBTQ youth. Ancheta and others  found thThe third objective of this review was to identify barriers and inconsistencies to support LGBTQ youth in schools. Though seven social support systems were identified to foster positive socioemotional, behavioural, and educational outcomes, barriers, and inconsistencies to support LGBTQ youth were identified in each system.Family support did not consistently buffer negative emotional, behavioural, and educational outcomes. Rather, general parental support was associated with peer victimization, self-harm, and poorer academic success , 90, 96.Several studies indicated the barriers of incorporating LGBTQ-inclusive curriculum in an effective manner in schools. One aspect includes the need to understand the hidden curriculum that exists beyond the formal, academic curriculum. The social relationships and school spaces can convey heteronormativity, adversely affecting LGBTQ youth and their sense of safety and engagement in schools. Additionally, there is a need for administration to provide support for teachers to effectively incorporate LGBTQ-inclusive curriculum. Oftentimes, teachers miss teachable moments that is conducive to inclusive curriculum due to the rigid curriculum of high stakes testing and fear of parental backlash. There is indication where GSAs can be spaces used to insert LGBTQ-inclusive curriculum in an informal space to compensate the barriers that exist in classrooms . Therefore, school administrators act as key members to ensure a LGBTQ-inclusive curriculum can be incorporated effectively in classrooms.GSAs also demonstrated barriers and difficulties in delivering positive outcomes for LGBTQ youth. Schools restricted GSA activities and presence because of sociopolitical reasons , limiting activism for LGBTQ youth. There is a need to negotiate between GSA advisors and administration for LGBTQ spaces in schools. Beyond macro-level barriers, GSAs also encountered difficulties in program implementation because of a lack of staff training to discuss sensitive topics  in schools. There were inconsistent results in the benefits of having a GSA in schools. Possible barriers may be due to the larger school and geographic context as being involved in GSAs in more hostile or unsafe environments that place LGBTQ youth at risk. In schools and geographical areas that is more hostile, the presence and involvement of GSA-related activities is associated with increased risks of safety and decreased positive outcomes.Peers were inconsistent in their support for LGBTQ youth. Victimized LGBTQ youth who had peers to confide to and discuss problems performed worse academically, had lower self-esteem, and had increased suicidal ideation. For racialized LGBTQ youth, peer support did not moderate perceived discrimination in schools and had no association with school performance. In addition, the lack of association for racialized LGBTQ youth suggests how peer support may be overshadowed by other (non)-LGBTQ concerns .School administrators and teachers were met with barriers to effectively support their LGBTQ youth in schools. Many LGBTQ youth reported not reaching out to school adults for support. The barrier appears to lie on the onus of LGBTQ youth to reach out to school staff for support. This can be due to a lack of trust or belief that teachers or administrators can effectively help them. LGBTQ youth reported teachers not knowing how to intervene in situations of harassment or teachers not feeling prepared to teach inclusive content and answer LGBTQ-related questions. LGBTQ students reported the need for teachers to increase their responsibility in teaching and conveying LGBTQ-inclusive material as the burden lies on students to provide education to their peers. From the perspective of school staff, they perceived the need for external support to coordinate support for teachers for curricular efforts, activities, and actions to reduce harassment towards LGBTQ youth and foster a greater sense of safety. Having an external coordinator as the point person to organize efforts to push the school for LGBTQ inclusion can increase LGBTQ acceptance in schools.The wider sociopolitical context that surrounds the school has an influence on the availability of LGBTQ-inclusive school policies. The sociopolitical context act as barriers limiting the schools’ abilities to have GSAs and school staff to show support for their LGBTQ youth. However, there has been mixed evidence showing an inverse relationship between an increase of inclusive school policies and a decrease in perceptions of safety. Though there may be inclusive policies put in place in schools, such policies may not be consistently enforced by school staff, lending to the ineffectiveness of inclusive policies. Consistent implementation of inclusive school policies will require dedicated school staff to monitor the progress of policy implementation. In this review, school administrators and teachers have mentioned the need to have an external staff coordinator to monitor consistent implementation of inclusive school policies due to the lack of time and energy. School principals also played a major role in the implementation of inclusive school policies as top-down administrative support is needed to send a message to school staff that they are supported by administration should they receive family or community backlash. Compared to the findings in this review, Russell and others  similarlThe fourth objective of this review was to identify areas for future research for the seven social support systems and their associations with LGBTQ youth outcomes in schools. The barriers and inconsistencies found to support LGBTQ youth across each system merits further research to explore the nuances in each system and their relationships to LGBTQ youth outcomes in school.Within family support, there is a nuance that lie between fathers and mothers, and LGBTQ boys and girls, indicating a need to understand the complex nature of family relationships and reasons why certain family members may provide more effective social support towards LGBTQ boys or girls. For GSAs, there needs to be further exploration to understand effective methods to overcome problems in discussing gender and sexuality in school settings due in part to the lack of school staff training and student sensitivity towards LGBTQ issues. Different aspects of a GSA  have shown different social support outcomes for LGBTQ youth. In schools that are hostile and unsafe, positive outcomes from GSA presence and engagement dissipate, highlighting the interaction between the school climate and GSAs’ ability to be considered as an effective social support system. Mixed findings demonstrated an inverse relationship between GSA presence and lower sense of safety by LGBTQ youth. Lastly, though GSAs were primarily conceptualized as gay-straight alliances, an exploration of gender-sexuality alliances can provide insight in the nuances between experiences of students from diverse sexualities and diverse genders.For peer systems, it is necessary to further explore reasons why peer support is either positively associated with more behavioural and emotional risks or have a lack of association. This can be due to the nature of peer support. As peer rumination can lead to further issues in schools rather than problem-solving discussions, the nature in how peers support LGBTQ peers in schools can shed light why there may be such an association. Another avenue of future research is the intersection of ethnicity among LGBTQ youth. The lack of association between peer support and positive social outcomes for racialized LGBTQ youth may be a result of the interplay of other identities that require other forms of support. For example, LGBTQ Asian youth may have an increased emphasis on the importance of family and familial piety, the need for racialized youth to bring pride to their family and minimize shame . PerhapsAn area of future research involves an exploration of methods to circumvent the larger sociopolitical context that limits the provision of LGBTQ support via inclusive policies. One possible avenue to provide LGBTQ support can be under the guise of Universal Design for Learning (UDL). This framework suggests the need to support all students, focusing LGBTQ support under the need to support diverse students. Another avenue of research involves exploring an explanation for inclusive policies predicting lower perceptions of safety. This may be due to the inclusive policies setting up motion to create change towards an inclusive school environment. Creating change, however, can still lead to decreased sense of safety and increased harassment issues for LGBTQ youth.One of the specific populations highlighted to be a key support system for LGBTQ youths were educators. One constructed theme involved the inconsistency in showing support through their actions. Several of the themes highlighted how students perceived their school staff members  as being hesitant to discuss LGBTQ issues. By being hesitant and uncomfortable to teach LGBTQ issues, a norm of LGBTQ silence exists in the school environment. Attitudes and beliefs where educators believed that homosexuality and other LGBTQ topics should not be discussed in school can lead to students perceiving their school staff as uncaring and exclusive towards LGBTQ youth. Therefore, educators and other school staff members need to be comfortable and foster an inclusive attitude and belief that they are supportive of all students, as shown through their actions. Effective actions students have mentioned include consistent intervention against LGBTQ-specific harassment, and opening dialogue on the importance of inclusion and acceptance . When students heard LGBTQ-inclusive topics in their classes, they felt an increased sense of safety. It is therefore important to have teachers be comfortable and open to teach LGBTQ-inclusive curriculum to increase LGBTQ youths’ sense of safety.The findings of this scoping review indicate three primary implications for future research and application. First, a whole school approach was emphasized by the themes as one of the most effective ways to provide social support for LGBTQ youths. Studies that focused on specific domains of support such as peer support or family support have similarly shown their effectiveness in supporting LGBTQ youth. However, having all relevant stakeholders involved in the process of supporting LGBTQ youth, such as a whole school approach, was evidently the most effective. Notwithstanding, a collaborative, whole school approach may be overly idealistic and an unrealistic approach for schools embedded in a larger, more conservative environment. A middle ground between realism and idealism could be attained by auctioning the GSA as a physical, supportive space where students can feel safe (within the club). This would be contrasted to having GSAs be a space for education and activism towards an increasingly LGBTQ-inclusive environment. In some cases, the inclusion of GSA spaces within schools may mean that, generally, the larger school spaces are unsafe for LGBTQ youth, influencing the concrete actions that educational stakeholders can take to provide support and opportunities for their students.Second, there were differences in perceived support and outcomes depending on the subpopulation of LGBTQ youth, highlighting the issues of generalizing the LGBTQ youth population as a homogenous population. For example, there were different perceptions of safety and struggles between sexual orientation minority youth and gender identity minority youth. For example, there were unique issues of gender nonconformity for youth who did not conform to their assigned gender at birth, whereas LGBQ youth were faced with victimization due to their sexual orientation. Of note, there have been a recent trend for studies reviewed between 2017 through 2021 to include trans and gender non-conforming (TGNC) youth as the focus, beyond the LGBTQ general identities. As several key findings foregrounded sexual identities over gender identities, future inquiries of LGBTQ youth should take into consideration the specific LGBTQ subgroups to be studied by researchers. Particularly, intersectionality should be taken into consideration as issues of gender, class, and ability may influence how specific LGBTQ students experience school supports. By doing so, researchers can be aware of the various intersecting sexual orientation and gender identities that LGBTQ youth manage and to be inclusive of programs, interventions, and strategies that are intended to support LGBTQ youth as a whole. Though the seven social support systems have been shown to effectively support LGBTQ youth, the inconsistencies that some articles brought up shed light with the interaction of these social support systems and their intersectional identities.Third, there were differences in perceived support and outcomes depending on the ethnicity and race of the youths. For example, LGBTQ Eurocentric youths experienced increasing emotional and behavioral distress due to LGBTQ-specific victimization, whereas LGBTQ racial and ethnic minority youths experienced less distress. A hypothesis explaining the difference may be linked to the coping skills and resilience that the racial and ethnic minority LGBTQ youths have already learned to cope in the face of racial and ethnic-specific victimization. This results in more frequent use of their coping skills and a higher resilience and grit in the face of LGBTQ-specific victimization and being in a school environment that is perceived to be less safe. Therefore, future inquiry should consider the multiple, intersecting minority identities LGBTQ youths may have had to juggle and its effect on their perceived safety and support in their school environment. Particularly, critically thinking through race and its impacts on the experience of school supports for LGBTQ youth should be a priority for future research. Based on their intersectional identities and experiences in schools, the seven social support systems found in this review may vary in effectiveness based on their other identities.This scoping review attempts to consolidate material from 2007 through early 2021, organize, and respond to the four research questions of defining social support, identifying the current social support outcomes for LGBTQ youth, the barriers and inconsistencies encountered by the social support systems, and the areas for further research because of the barriers and inconsistencies found in the literature. Due to the scope of the review, the literature search strategy was broad and resulted in a larger volume of articles. Though the search strategy was comprehensive, consulting various experts to ensure rigidity and confidence of the search strategy, a scoping review search strategy utilizes a less defined search compared to a full systematic review. Additionally, difficulty in consolidating a comprehensive search term strategy can lead to an increasingly narrow understanding of LGBTQ individuals. For example, no articles explored nonbinary parents or children. The search strategy did not account for an intersectional understanding of LGBTQ+ identities, particularly Two-spirit (2S) identities. As the initial search strategy was executed in 2017, Two-spirit identities were uncommon and, subsequently, not taken into consideration. Future reviews should include the search strategy to account for an intersectional approach to the 2SLGBTQ+ community. Further, search strategies for LGBTQ+ terms are difficult to standardize and capture comprehensively. Even though various experts were consulted to ensure confidence in the search strategy, the rigidity of keywords and subheadings in article search engines can be barriers in capturing the nuances inherent to the 2SLGBTQ+ community. Particularly, transgender and non-binary (TGNC) terms were limited. Moving forward, it would be important to implement the University of Minnesota’s search hedges (tested and standardized search strategies to retrieve articles on specific concepts) for TGNC terms . As wellThere have been many studies replicating the risks that LGBTQ youth experience in schools: socioemotional , behavioural , and educational . However, literature exploring the positive or protective factors for LGBTQ youth has been steadily increasing in the field of youth and LGBTQ studies. As it is still an emerging perspective to explore the protective factors for LGBTQ youth through positive youth development lens, this review consolidated literature and gave rise to an organizational framework to consolidate the various systems of social support for LGBTQ youth in schools. From the review, social support consists of seven social support systems  that, both uniquely and in overlap, are positively associated with the promotion of positive socioemotional, behavioural, and educational outcomes, as well as the moderation of the risks typically associated with LGBTQ youth in schools. Though the literature consistently revealed the benefits of ensuring that these seven systems are present to positively support LGBTQ youth’s development, inconsistencies and barriers in providing positive outcomes for LGBTQ youth was a result of (1) a lack of training and support for school administrators and teachers to enforce LGBTQ-inclusive policies and curriculum, (2) a larger sociopolitical context impeding or preventing LGBTQ activism and support in schools, and (3) unique differences within the subgroups of LGBTQ youth including ethnicity, sex, and gender identity and expression. Future research should explore the gaps present in this review to address the barriers and inconsistencies found to effectively provide social support for LGBTQ youth across these seven systems. This review highlights a positive outlook towards the available systems of social support to promote positive development for LGBTQ youth. Though the literature has been clear surrounding the risks associated with LGBTQ youth, this scoping review endeavored to provide a positive outlook on LGBTQ youth’s school experiences by highlighting how these systems of social support allow LGBTQ youth to act as active participants in the promotion of a positive and safe school climate.Supplementary file1 (DOCX 65 KB)Below is the link to the electronic supplementary material.


The COVID-19 pandemic revealed the importance of the health workforce for health system resilience. This study aims to explore whether and how healthcare system in Europe have responded to new emergent needs and transformed their health workforce policies.A qualitative comparative approach is applied, based on multi-level governance theory and a rapid assessment of three areas of health workforce policy: mental health, gender equality, and public health competencies. We consider two years of the pandemic with a focus on recent waves, October 2021-January 2022. Denmark, Germany, Portugal, Romania and Switzerland are selected for comparison, representing different health systems, health workforce conditions and COVID-19 indicators in the European Union and European Economic Area.Across countries the pandemic has highlighted mental health needs, persisting gender inequalities and demand for public health competencies. Our comparison reveals similar weaknesses and governance gaps. (1) Mental health needs of healthcare workers are increasingly recognised (more strongly in Denmark and less in Romania with the other countries clustering in-between); however, health workers’ perceptions are not used as guidance and effective programmes are lacking. (2) The situation is worst in relation to gender equality goals that are largely ignored in pandemic policy and recovery plans. (3) Public health competences are more advanced and integrated in the NHS systems in Denmark and Portugal, but no country has taken action to innovate health workforce education and strengthen public health.The comparative assessment highlights that health systems failed to adequately respond to health workforce needs and the COVID-19 challenges. Action has to be taken to implement participatory governance and step up efforts towards more responsive and resilient health workforce policy.


Prioritisation of clinical trials ensures that the research conducted meets the needs of stakeholders, makes the best use of resources and avoids duplication. The aim of this review was to identify and critically appraise approaches to research prioritisation applicable to clinical trials, to inform best practice guidelines for clinical trial networks and funders.A scoping review of English-language published literature and research organisation websites (January 2000 to January 2020) was undertaken to identify primary studies, approaches and criteria for research prioritisation. Data were extracted and tabulated, and a narrative synthesis was employed.Seventy-eight primary studies and 18 websites were included. The majority of research prioritisation occurred in oncology and neurology disciplines. The main reasons for prioritisation were to address a knowledge gap (51 of 78 studies [65%]) and to define patient-important topics . In addition, research organisations prioritised in order to support their institution’s mission, invest strategically, and identify best return on investment. Fifty-seven of 78 (73%) studies used interpretative prioritisation approaches ; six studies used quantitative approaches (8%) such as prospective payback or value of information (VOI) analyses; and 14 studies used blended approaches (18%) such as nominal group technique and Child Health Nutritional Research Initiative. Main criteria for prioritisation included relevance, appropriateness, significance, feasibility and cost-effectiveness.Current research prioritisation approaches for groups conducting and funding clinical trials are largely interpretative. There is an opportunity to improve the transparency of prioritisation through the inclusion of quantitative approaches. Example CTNs in Europe include the European Society of Anaesthesiology and Intensive Care  and in the USA include the HIV Prevention Trials Network (HPTN https://www.hptn.org/). However, with limited available resources including trained research personnel, trial participants and funds, decisions need to be made about which trials are a priority. The desired result of successful prioritisation is funded trials that generate important information, help inform clinical and policy decision-making and improve health outcomes. In reality, research prioritisation is not easy, and many organisations wrestle with competing criteria and the multiple interests of stakeholder groups.Clinical trials networks (CTNs) conduct investigator-initiated research and public good trials, largely funded by charities, universities and governments. Examples of CTNs in Australia include the Australian Kidney Trials Network  and Delphi surveys , 2. ThesThe aim of this scoping review was to identify approaches for priority setting in health and medical research useful to clinical trial networks (CTNs) in Australia and internationally and research funders. Specifically to answer the following research questions: what models, approaches or methods are used by CTNs to prioritise clinical trials; how have these models, approaches or methods been developed and validated; and what is the best practice for prioritising clinical trials? The findings will then be used to develop best practice guidance for CTNs and research funders.A scoping review of published literature and working documents, as well as websites from research funding organisations and CTNs, was undertaken to identify research prioritisation tools and criteria. Digital databases including Ovid MEDLINE, Embase and the WHO library database (WHOLIS) were searched for publications about guidelines for prioritising research questions relevant to CTNs. Search terms included . The search was limited to studies in English published from year 2000 onwards. The search was updated on 30 January 2020.Titles and abstracts were screened, and eligible studies were selected by a single reviewer (VBN) for the following inclusion criteria: original studies, systematic reviews, guidelines, recommendations, and tools for research prioritisation. Both qualitative and quantitative methods of prioritisation were accepted. Studies not relevant to CTNs, duplicate publications, guidelines written from the perspective of funders, opinion articles, letters to editors and abstracts only were excluded. A manual search of key references cited in the retrieved papers and reports was also undertaken to identify additional publications not encountered by the electronic searches. A second reviewer (RLM) was consulted when in doubt regarding study selection, and any discrepancies were resolved by consensus with a third reviewer (MC).A second search of key Australian and international CTNs/clinical disciplines/clinical specialties websites was then undertaken. Organisations were selected by the author team as likely to provide guidance on prioritisation and selection of clinical trials, and websites were searched by two authors . Searched websites are listed in the The following types of documents were selected for inclusion: guidance on prioritisation; case studies or examples of prioritisation exercises that reported the methods used; guidance on criteria for the assessment, selection or prioritization of clinical trials (e.g. for funding purposes). Documents that did not constitute current guidance or were superseded by later versions of current guidance (e.g. prioritisation processes to inform past priorities or strategic plans or discussion documents that appeared to be older than current guidance), were excluded. Documents with URLs that were no longer accessible in January 2020 were also excluded.Data from studies and websites were extracted and tabulated into an Excel file according to a predefined codebook. Data extraction variables comprised author name, author group , clinical discipline, country, year of publication, participants or stakeholders in the prioritisation process , intended audience , brief reason for prioritisation , type of research , research prioritisation tools , prioritisation method , research prioritisation criteria  and theThe results of the literature search and study selection process are depicted in Fig. n = 32; 41%) or North America ; six prioritisation studies (8%) originated in Australia and New Zealand. Two studies were conducted in South Asia , one in South-East Asia (1%), one in Africa (1%) and 11 studies were international (14%). Included studies were published between 2000 and 2019 , neurology , paediatrics , maternal and child health , infectious diseases and HIV/AIDS , nephrology , respiratory medicine , mental health  and ophthalmology .Most research prioritisation exercises were conducted either in Europe n = 3; 41% or n = 65 studies; 83.3%), patients and carers/consumers , researchers , policy or decision makers , and funders , ascertaining what was important to patients in 28 studies (36%), assessing the feasibility of a particular prioritisation methodology in 12 studies (15%) and estimating a return on investment in 10 studies , researchers in 34 studies (44%), government or policymakers in 13 studies (17%), clinicians in 12 studies (15%), CTNs in 11 studies (14%), the general public in 4 studies (5.1%) and not stated in 20 studies . Six studies used weighted scores (8%) and five studies used monetary value (6%). One study each used Agency for Healthcare Research and Quality (AHRQ) criteria, Dotmocracy, forced ranking, red-amber-green light and no prioritisation (1%).A table of the prioritisation approaches is presented in Table n=53, 68%) did not describe any formal prioritisation criteria. In those that did describe prioritisation criteria, multiple criteria were mentioned. Relevance  was cited in 14 of the 78 included studies (18%). Seven studies (9%) cited criteria related to appropriateness (i.e. should we do it? including scientific rigour and suitability to answer the research question); 17 studies (22%) considered criteria related to significance of research outcomes ; 12 studies (15%) cited feasibility among their prioritisation criteria . Cost-effectiveness was considered by fifteen studies (19%). Five studies cited other prioritisation criteria (6%).Over two-thirds of the identified studies  followed by health professionals  and policy/decision makers . Six organisations mentioned the reason for the priority-setting exercise was to support their vision and mission or to invest strategically and in a balanced way (33%) and five organisations wanted to find the best return on investment , followed by “wanting to know what was important to patients” , followed by the researchers , the government and policymakers  and clinicians or funders , one used the JLA tool, one used payback (VOI) and one used MCDA (6%). Five organisations used other tools  and seven did not describe the tool used (39%). In general, few details were provided in organisational websites to further describe the prioritisation approaches undertaken.The prioritisation criteria included relevance on 16 occasions (89%), appropriateness on 10 occasions (56%), significance on 14 occasions (78%), feasibility on 9 occasions (50%) and cost-effectiveness on 4 occasions (22%). Two websites did not state any prioritisation criteria ; a small proportion used a quantitative approach (e.g. prospective payback); and one fifth used a blended approach combining qualitative and quantitative methods (e.g. CHNRI). The most common criteria for prioritisation were significance, relevance and cost-effectiveness.The rationale for prioritisation of trials on the basis of generating new knowledge to improve clinical decision-making is not surprising, as efficacy and effectiveness trials are designed to answer important questions in patient management , 50, 88.The infrequent use of pure quantitative approaches for prioritisation of trials including burden of disease or value for money is likely due to few standardised methods to view competing claims side by side, or knowing how to weight such criteria. It may also be related to low technical knowledge or expertise within the trials community to generate this information. For example, many clinical trial funders suggest the relevance of the problem to be stated, which is typically reported as burden of disease, incidence or prevalence. When different metrics are used across trial proposals they become difficult to compare, which may lead to grant reviewers considering whether the criterion is satisfied , rather than comparing those burdens. Sometimes, the burden is presented as disability-adjusted life years (DALYs), and sometimes, the disease burden is monetized to provide an overview of health system or societal costs. While this provides a common metric on which trial applications can be compared, these estimates are limited to quantifying the current situation; they do not provide insight into the value of the proposed trial in reducing that burden (i.e. the significance), otherwise known as the impact or net benefit.Value of information (VOI) analysis has emerged as a new framework for quantifying the net benefit of proposed randomised trials. VOI uses a cost-effectiveness modelling approach and takes into account the cost of running the trial and the value of the new trial information to reduce uncertainty with the current clinical decision. The benefit of the health outcomes for the better decision (e.g. using drug A over drug B) is then multiplied across the population at risk using assumptions about post-trial implementation. A VOI analysis can be undertaken for most randomised trials enabling studies in a given portfolio to be ranked from most to least value. This requires capacity building in the health economics and statistics workforce. Efficient methods to calculate VOI are currently underway , 92.An encouraging sign from this review was the emphasis placed on patient-important topics through consumer-generated questions and topic ranking, from both published literature and organisational websites. This ensures that not only are questions important and of interest to clinicians or trialists, but that they also address issues, problems or concerns that are bothering those with the disease and/or undergoing specific treatments. This is especially important for government and non-profit charity funders where the funding for research originates from the general public (i.e. tax-payers), or donors.The strengths of this review include the dual searching of published and unpublished literature, including organisational websites of international clinical trial networks and trial funders. This approach was likely to identify prioritisation processes that were operational, yet had not been formally described in the peer-reviewed literature. It is a strength that we were able to locate and extract research prioritisation approaches and methods as well as the prioritisation criteria used, as this provides sufficient detail for clinical trials networks and funders to replicate. Our scoping review was limited to studies and websites published in English and therefore may omit relevant studies published in other languages. It was not a systematic review and therefore may not have identified all studies of research prioritisation in the published literature. In addition, we could only tabulate methods where they were clearly described.Further research consulting consumers, researchers and policy-makers is now needed to develop specific criteria weights for clinical trials networks and coordinating centre members of the Australian Clinical Trials Alliance (ACTA), of international CTNs and funders of clinical trials. Development of tools to aid clinicians and researchers in using quantitative approaches is also needed. Following implementation of a formalised prioritisation process, clinical trials networks and funders will need to then evaluate the process and assess whether the “best” trials are subsequently funded and deliver on their expected benefits .Research prioritisation approaches for groups conducting and funding clinical trials are predominantly interpretative. Given the strengths of a blended approach to prioritisation, there is an opportunity to improve the transparency of process through the inclusion of quantitative techniques.


This study explored questions of (1) whether certain areas of South Korea experienced inequal accessibility to public health centers, private hospitals/clinics, and general hospitals by car and public transportation using gaussian mixture models (GMM) and (2) whether socially disadvantaged socioeconomic groups faced disproportionate burdens on accessibility to the multi-tier healthcare services employing ordinary least square regression models (OLS). This study used nationwide accessibility indicators in South Korea measured by Korea Transport Institute in 2019. The main findings were as follows: First, the results of the GMM indicate that the degree of accessibility to healthcare services was significantly lower in rural, mountainous, and seaside locations compared to metropolitan areas. Second, there was more considerable inequality in public transportation accessibility than car accessibility. Third, the findings of the OLS reveal a significant relationship between accessibility indicators and socioeconomic variables, such as age, gender, disability, and residential location, which indicates socioeconomic inequality in accessibility in South Korea. This study contributes to shedding light on understanding the spatial and socioeconomic inequality in accessibility across the nation and offering policy implications. Accessibility to healthcare services is a critical component  since eaThe empirical research that lies at the intersection of accessibility and equity has been thriving ,10 sinceThis study identified and filled the following research gaps: (1) few existing studies have conducted a nationwide analysis, (2) few have comprehensively explored spatial and socioeconomic-based inequality in accessibility to different types of healthcare services, (3) few have studied inequal accessibility to healthcare services in the South Korea context, and (4) few have focused on accessibility by both private car and public transportation. Therefore, the research aims to fill the gaps and answer two lines of questions. Thus, this study aims to answer two research questions. The first line of question is whether there were spatial variations of accessibility to healthcare services by car and public transportation across South Korea. The second line of questions concerns whether marginalized population groups in South Korea  significantly took longer to access multi-tier healthcare services. This study employed gaussian mixture models (GMM) to answer the first research question and ordinary least square regression models (OLS) to explore the remaining question using the nationwide accessibility matrix measured by Korea Transport Institute in 2019. This research has three objectives: (1) shedding light on the knowledge of spatial and socioeconomic disparities in accessibility across the country, (2) identifying certain areas and socioeconomic groups that require accessibility improvements, and (3) drawing policymakers’ attention and providing policy implications.The procedure of this study is as follows. First, this study chose South Korea as a case study area and gathered relevant data. Second, this study employed GMM to address the first research question by classifying and visualizing healthcare service accessibility by car and public transportation throughout South Korea. Third, this study developed OLS to examine the associations between accessibility and socioeconomic features. Each stage is described in depth in the following subsections.2. Eight provinces, seven metropolitan regions , and one special self-governing city  make up the major administrative divisions in South Korea. Administratively, South Korea can be divided at the further finer levels, including Eup/Myeon/Dong (EMDs). According to the Healthcare Bigdata Hub, there were around 94,865 hospitals in South Korea in 2019. This number included approximately 350 general hospitals, approximately 52,000 private hospitals, and clinics, and approximately 3500 public health facilities.The study area of the paper was the whole country of South Korea, with a population of approximately 51 million persons in an area of around 100,000 kmThis study used the accessibility indicator across the country measured by Korea Transport Institute in 2019. The accessibility indicator used in this study was the average travel time from the centroid of a EMD by weight based on the total floor area of buildings to healthcare services within the EMD boundary. It is important to note that the accessibility measure employed a relatively straightforward approach, although a body of previous literature has developed quantitative measures of accessibility . For insThis study benefits from using the data set for the following reasons. First, the accessibility was significantly improved by applying additional nuances according to the type of healthcare service, the time of travel, and the transportation modes. Specifically, it considered various types of healthcare services, which were (1) general hospitals, (2) private hospitals and clinics, and (3) public health centers. The laws and regulations were used to classify the various types of healthcare services based on diverse factors, such as the purpose of the services, size, and facilities, an example of each category is presented in This study employed two methods to answer the two research questions adequately: (1) GMM and (2) OLS. Subsections present details on the analytic methods.This study used GMM for the following reasons. First, it helps find hidden patterns in the dataset and then classify instances into a certain number of clusters ,30. In tThis study developed two GMM algorithms to explore spatial clusters that differed in accessibility by two modes of transportation  since accessibility by car and public transportation generally differ from one another . Thus, tThis study developed 18 OLS models. This study used each accessibility indicator listed in The final model specifications include seven independent variables see  gatheredThe dependent and independent variables used the log transformation, which overcomes issues due to their skewed distributions and offers estimates of the constant elasticity effect of independent variables on the dependent variable .This section first presents the spatial inequality in healthcare accessibility by car and public transportation in South Korea using GMM, and then it demonstrates socioeconomic inequality in accessibility to healthcare services employing OLS.p-values of the ANOVA tests. Specifically, Cluster A showed the highest accessibility to healthcare services, which was concentrated in Metropolitan areas, including Seoul, Incheon, Daejeon, Daegu, and Busan. Higher healthcare accessibility by car and public transportation was also clustered in Cluster B immediately surrounding Cluster A. However, accessibility levels considerably decreased in the rural, mountainous, and coastal areas, identified as Cluster D and E. Specifically, residents in Cluster E generally encountered considerable burdens in terms of travel time to the three types of healthcare services. For instance, they take around 80 to 90 min to access general hospitals by car, while those in Cluster A take less than 10 min.Two major findings are as follows. First, the results in Second, This study conducted further analyses to explore the ways in which the spatial layout aspects of accessibility to healthcare services related to the socioeconomic factors of EMDs. Thus, this study used OLS to capture the association between the degree of accessibility to multi-tier healthcare services, including general hospitals, private hospitals, and public health centers, and the socio-economic factors that represent transportation disadvantages. The results of the 18 OLS models are displayed in First, the findings of The socioeconomic inequality in accessibility to the three types of healthcare services via public transportation in South Korea is outlined in With the clustering (GMM) and regression analyses (OLS) taken together, the empirical findings of this study revealed spatial and socioeconomic inequality in accessibility to three types of healthcare services  by car and public transportation throughout South Korea. Several key findings were as follows. First, the results of GMM reveal that the accessibility level significantly decreased in the rural, mountainous, and seaside areas, identified as Cluster D and E. Residents in Cluster E generally faced considerable burdens in travel time to the three types of healthcare services; for instance, they take around 90 min to access general hospitals by car, while those in Cluster A take less than 10 min. Second, the spatial variation was considerably different between car and public transportation; more precisely, it is evident that there was a more prevalent disparity in public transportation accessibility in South Korea. Third, the findings of OLS confirmed socioeconomic inequality in accessibility to the three types of healthcare services, although not all transport disadvantages did have a significant and positive association with inaccessibility to the three types of healthcare services in South Korea. For instance, EMDs with a higher elderly population density had significantly lower accessibility to general hospitals and private hospitals/clinics by both car and public transportation. Furthermore, immigrants experienced inequal accessibility by not car but public transportation to the upper-tier healthcare service  in South Korea. Additionally, people with disability and females were still part of systemic social inequality in terms of the accessibility to public health centers by car. Moreover, persons in rural areas had considerably limited accessibility to general hospitals and private hospitals, whereas accessibility to public health centers was better in rural areasThis study offers policy implications based on the findings. The first step in addressing the accessibility issue should be to establish some guiding principles. A robust ethical foundation supports this since freedom of movement and equal accessibility access to essential destinations are basic universal human rights . FurtherFurthermore, accessibility is a major concern in healthcare policy  due to iMoreover, several strategies in transportation planning are worth enhancing accessibility. For instance, areas with a higher density of transport disadvantages should have access to a variety of means of transportation, including local access initiatives, community transport, and a paratransit system . Beyond This study acknowledges several limitations. First, this study used a relatively simple accessibility measure, although various sophisticated formulations of accessibility have been proposed . Second,Furthermore, this study outlines several potential avenues for further investigation. Given accessibility is a crucial element of the quality of life , future This paper explored spatial and socioeconomic inequality in accessibility to multi-tier healthcare services, including general hospitals, private hospitals/clinics, and public health centers, by car and public transportation in South Korea. Using nationwide data set offered by Korea Transport Institute in 2019, this study employed two analytic methods: (1) GMM to classify and visualize inequal and spatial accessibility to healthcare services for car and public transportation across South Korea and (2) OLS to examine whether certain socioeconomic population groups in South Korea  experienced inequal accessibility to multi-tier healthcare services. The contributions of this study are three-fold. First, it sheds light on understanding the spatial and socioeconomic inequality in healthcare accessibility throughout South Korea using the nationwide analysis. Second, this study pinpoints geographic areas as well as subsets of the population groups that require additional accessibility enhancements in the healthcare system. Third, the findings of this research will garner significant attention and offer policy implications.


Adolescent pregnancy is a major health and social concern in South Asia. The aim of this study is to systematically review evidence on the factors associated with adolescent pregnancy in South Asia. This study was conducted using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. Four electronic databases: EMBASE, PubMed, CINAHL, and Scopus were searched for relevant studies on factors associated with adolescent pregnancy in South Asia published in English between January 2000 and July 2022. The quality of the included studies was assessed using 12 criteria from The National Institute of Health (NIH) Study Quality Assessment Tools for observational studies. Of the 166 articles retrieved, only 15 studies met the eligibility criteria and were included in the final analysis. Consistent factors associated with adolescent pregnancy in South Asia were low maternal education, low socioeconomic status, rural residency, and ethnic minorities. To prevent adolescent pregnancy in South Asia, concerted effort towards promoting health equity by addressing the predisposing factors associated with adolescent pregnancy is essential. This systematic review was registered with PROSPERO [CRD42022340344]. According to the World Health Organisation (WHO), adolescent pregnancy  is pregnancy in women aged 10–19 years . FurtherSouth Asia has one of the highest rates of adolescent pregnancy globally . Within There has been a significant global and regional effort aimed at reducing adolescent pregnancy. WHO, in collaboration with the United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), and United Nations Women and Family Planning 2020, had rolled out programs to end child marriage and reduce adolescent childbearing . To reduThere have been individual studies reporting the burden and factors associated with adolescent pregnancy in various countries within South Asia ,12,14,15The outcome variable for this review is adolescent pregnancy, defined as pregnancy in women aged 10–19 years [The modified World Health Organisation (WHO) conceptual framework  for sociFactor* OR determinant* OR predictor* OR risk*ANDTeenage pregnanc* OR adolescent pregnanc*ANDSouth Asia OR India OR Nepal OR Bangladesh OR Afghanistan OR Sri Lanka OR Bhutan OR Maldives OR Pakistan.This review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines . To idenTo identify any additional relevant studies that might have been missed, a search of the bibliographic references of all retrieved articles that met the inclusion criteria, complemented by citation tracking using Google Scholar, was conducted.Studies were included if they (i) assessed factor/s associated with adolescent pregnancy; (ii) were conducted in South Asia including Nepal, India, Bangladesh, Sri Lanka, Bhutan, Afghanistan, Pakistan and Maldives; (iii) were published between January 2000 and July 2022; (iv) were observational studies ; (v) were published in a peer-reviewed journal ; and (vi) were written in English. The year 2000 was used as a baseline for this review due to the significant effort South Asia has employed to prevent child marriage and promote reproductive health among adolescents. In addition, following the end of the millennium development goals (MDGs) and the introduction of the sustainable development goals (SDGs), adolescent health in South Asia has become an important public health action agenda.All retrieved studies were exported into an EndNote library, and duplicate records were removed. This was followed by an initial screening phase, with articles screened based on their titles and abstracts. In the final screening phase, full texts of retrieved articles were read for relevance and articles which met the inclusion criteria were retained. Data extraction and appraisal were independently conducted by two reviewers, and all disagreements between the reviewers were resolved through discussion and consensus. The summary of the selected studies was recorded including author, year, country, study design, sample size, factors associated with adolescent pregnancy, limitation and quality assessment score .The National Institute of Health (NIH) Study Quality Assessment Tools for observational studies  was usedA total of 166 articles were retrieved from four bibliographic databases and Google Scholar. After the entire screening process, 15 studies were retained for the final analysis as shown in The level of education attainment was found to be the most consistent factor associated with adolescent pregnancy. Studies conducted in Nepal ,24,25,27Eight studies conducted in Bangladesh ,19,20,21Studies conducted in Bangladesh ,18 and NThis systematic review highlights important factors associated with adolescent pregnancy in South Asia. The most consistent factors associated with adolescent pregnancy in South Asia include low education attainment, poor economic status, rural residence and women from a Muslim religious background.A lower education level of adolescent women as well as their male counterparts was reported as one of the most consistent factors associated with adolescent pregnancy across the countries in South Asia. Previous research suggested that educated men and women are better informed about protective sexual intercourse particularly contraception as well as the adverse effects of teenage childbearing and its consequences in family and community ,31,32. DLow economic status was reported to be associated with adolescent pregnancy in South Asia. Socio-economic factors including access to education, occupation and income generating programs are very essential to ensure health and wellbeing of adolescent girls. This could assist girls with avoiding early pregnancy or make them better equipped to manage if they do become pregnant . With soIn this review, women residing in rural areas were found to be more susceptible to adolescent pregnancy. In addition, predominantly rural divisions/provinces with adolescents of low economic status in Bangladesh and Pakistan reported a greater rate of adolescent pregnancy. Consistent with our findings are similar studies conducted in Africa  and otheReligion in South Asia is a medium for socialization which shapes the ideology within the community by impacting health, mainly women’s health, in many ways. In South Asia, the most common religions are Hinduism, Islam, Buddhism and Christianity with each religion having unique values and beliefs. Research has shown an association between Muslim religion and early marriage ,43,44, wFrom a study conducted in South Africa, it was inferred that not only are young woman reluctant to use contraceptives to prove their relationship commitment to their male counterparts, but they are also pressured or have their pills thrown out by their partners, which was indicative of power dynamics within relationships, and thus get exposed to untimely pregnancies . In addiThis review is a comprehensive search of literature which followed PRISMA guidelines, and the quality appraisal of reviewed articles was conducted using NIH study quality assessment tools for observational studies to ensure the methodological rigor. Furthermore, predefined MeSH words and sub-headings of keywords applied into four electronic databases along with a thorough screening of identified studies by two authors increased robustness in search strategy and the study selection process. However, this review did not conduct a meta-analysis to estimate the burden and factors associated with adolescent pregnancy in South Asia, and the conclusion was drawn based on narrative synthesis. This was mainly due to the discrepancy in definition used for adolescent pregnancy for which the estimation from the meta-analyses would be subject to bias. This review did not find studies from India, Afghanistan, Bhutan and the Maldives that met the inclusion criteria. Future research on adolescent pregnancy in these countries is recommended to fully understand its associated factors within the region.This systematic review identified important factors associated with adolescent pregnancy in South Asia. The findings suggest that the most common factors associated with adolescent pregnancy in South Asia include low education attainment, poor economic status and rural residence, belonging to ethnic minorities and those having a Muslim religious background.To prevent adolescent pregnancy in South Asia, there is a need for regional effort towards promoting girl child education, mainly focusing on rural locations and ethnic minorities. The implementation of effective policies around girls’ education and income generating vocational initiatives would aid in reducing pregnancies among adolescents with low socioeconomic background and subsequently assist the region with achieving the Sustainable Development Goal targets around the prevention of maternal death, and the promotion of free, equitable and quality primary and secondary education for girls.


Less than one percent of studies on the link between race and health have focused on structural racism. Empirical research on how structural racism affects health in later life is especially rare. Moreover, the conceptualization of structural racism in the race theory literature has often differed from the measurement strategies used in aging and health research. This study advances the field by 1) utilizing a novel, theory-informed latent measure of structural racism in states across multiple domains, including political participation, education, economics, housing, and the judicial system, 2) mapping structural racism across states, and 3) quantifying the association between structural racism and mental health outcomes  among Black and White older adults. We use administrative data measuring state-level racial stratification linked to geocoded individual-level demographic and health data from the HRS  and the BRFSS . Results show that, whereas structural racism is consistently associated with worse mental health for Black people, it is either unrelated to health or predictive of better health among Whites. Findings highlight the utility of rigorously conceptualizing and measuring structural racism and its impact on health among older adults.