peer reviewed websites

Navigation group

Home banner.

Where scientists empower society

Creating solutions for healthy lives on a healthy planet.

most-cited publisher

largest publisher

2.5 billion

article views and downloads

Main Content

• Editors and reviewers
• Collaborators

Find a journal

We have a home for your research. Our community led journals cover more than 1,500 academic disciplines and are some of the largest and most cited in their fields.

Submit your research

Start your submission and get more impact for your research by publishing with us.

Author guidelines

Ready to publish? Check our author guidelines for everything you need to know about submitting, from choosing a journal and section to preparing your manuscript.

Peer review

Our efficient collaborative peer review means you’ll get a decision on your manuscript in an average of 61 days.

Article publishing charges (APCs) apply to articles that are accepted for publication by our external and independent editorial boards

Press office

Visit our press office for key media contact information, as well as Frontiers’ media kit, including our embargo policy, logos, key facts, leadership bios, and imagery.

Institutional partnerships

Join more than 555 institutions around the world already benefiting from an institutional membership with Frontiers, including CERN, Max Planck Society, and the University of Oxford.

Publishing partnerships

Partner with Frontiers and make your society’s transition to open access a reality with our custom-built platform and publishing expertise.

Policy Labs

Connecting experts from business, science, and policy to strengthen the dialogue between scientific research and informed policymaking.

How we publish

All Frontiers journals are community-run and fully open access, so every research article we publish is immediately and permanently free to read.

Editor guidelines

Reviewing a manuscript? See our guidelines for everything you need to know about our peer review process.

Become an editor

Apply to join an editorial board and collaborate with an international team of carefully selected independent researchers.

My assignments

It’s easy to find and track your editorial assignments with our platform, 'My Frontiers' – saving you time to spend on your own research.

Experts call for global genetic warning system to combat the next pandemic and antimicrobial resistance

Scientists champion global genomic surveillance using latest technologies and a “One Health” approach to protect against novel pathogens like avian influenza and antimicrobial resistance, catching epidemics before they start.

Safeguarding peer review to ensure quality at scale

Making scientific research open has never been more important. But for research to be trusted, it must be of the highest quality. Facing an industry-wide rise in fraudulent science, Frontiers has increased its focus on safeguarding quality.

Scientists call for urgent action to prevent immune-mediated illnesses caused by climate change and biodiversity loss

Climate change, pollution, and collapsing biodiversity are damaging our immune systems, but improving the environment offers effective and fast-acting protection.

Baby sharks prefer being closer to shore, show scientists

marine scientists have shown for the first time that juvenile great white sharks select warm and shallow waters to aggregate within one kilometer from the shore.

Puzzling link between depression and cardiovascular disease explained at last

It’s long been known that depression and cardiovascular disease are somehow related, though exactly how remained a puzzle. Now, researchers have identified a ‘gene module’ which is part of the developmental program of both diseases.

Air pollution could increase the risk of neurological disorders: Here are five Frontiers articles you won’t want to miss this Earth Day

At Frontiers, we bring some of the world’s best research to a global audience. But with tens of thousands of articles published each year, it’s impossible to cover all of them. Here are just five amazing papers you may have missed.

Opening health for all: 7 Research Topics shaping a healthier world

We have picked 7 Research Topics that tackle some of the world's toughest healthcare challenges. These topics champion everyone's access to healthcare, life-limiting illness as a public health challenge, and the ethical challenges in digital public health.

Get the latest research updates, subscribe to our newsletter

Explore millions of high-quality primary sources and images from around the world, including artworks, maps, photographs, and more.

Explore migration issues through a variety of media types

• Part of The Streets are Talking: Public Forms of Creative Expression from Around the World
• Part of The Journal of Economic Perspectives, Vol. 34, No. 1 (Winter 2020)
• Part of Cato Institute (Aug. 3, 2021)
• Part of University of California Press
• Part of Open: Smithsonian National Museum of African American History & Culture
• Part of Indiana Journal of Global Legal Studies, Vol. 19, No. 1 (Winter 2012)
• Part of R Street Institute (Nov. 1, 2020)
• Part of Leuven University Press
• Part of UN Secretary-General Papers: Ban Ki-moon (2007-2016)
• Part of Perspectives on Terrorism, Vol. 12, No. 4 (August 2018)
• Part of Leveraging Lives: Serbia and Illegal Tunisian Migration to Europe, Carnegie Endowment for International Peace (Mar. 1, 2023)
• Part of UCL Press

Harness the power of visual materials—explore more than 3 million images now on JSTOR.

Enhance your scholarly research with underground newspapers, magazines, and journals.

Explore collections in the arts, sciences, and literature from the world’s leading museums, archives, and scholars.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Trending Articles

• Global disparities in surgeons' workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study. Podda M, et al. Updates Surg. 2024. PMID: 38684574
• The miR-200 family is increased in dysplastic lesions in ulcerative colitis patients. Lewis A, et al. PLoS One. 2017. PMID: 28288169 Free PMC article.
• CS incapacitant spray. Southward RD. J Accid Emerg Med. 2000. PMID: 10659007 Free PMC article. No abstract available.
• Left paraduodenal hernia accompanying chylous ascites. Yu DY, et al. Ann Surg Treat Res. 2015. PMID: 26576408 Free PMC article.
• Vitamin D regulates microbiome-dependent cancer immunity. Giampazolias E, et al. Science. 2024. PMID: 38662827

Latest Literature

• Am Heart J (3)
• Am J Clin Nutr (2)
• Am J Sports Med (1)
• Am J Surg Pathol (2)
• Arch Phys Med Rehabil (1)
• J Biol Chem (10)
• J Clin Endocrinol Metab (2)
• Pediatrics (1)

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

University Library, University of Illinois at Urbana-Champaign

Peer Review: An Introduction: Where to Find Peer Reviewed Sources

• Why not just use Google or Wikipedia?
• Where to Find Peer Reviewed Sources
• Where to Get More Help

Need More Help?

Have more questions? Contact Scholarly Communication and Publishing at [email protected]   for more information and guidance.

Ask a Librarian

The Ask a Librarian service for general reference is available during all of the hours when the Main Library is open. Visit the  Ask a Librarian  page to chat with a librarian.

Why is it so hard to find Peer-Reviewed Sources?

It isn't hard to find peer-reviewed sources: you just need to know where to look!  If you start in the right place, you can usually find a relevant, peer-reviewed source for your research in as few clicks as a Google search, and you can even use many of the search techniques you use in Google and Wikipedia.

The easiest way to find a peer-reviewed article is by using one of the Library's numerous databases. All of the Library's databases are listed in the Online Journals and Databases index. The databases are divided by name and discipline.

Departmental libraries and library subject guides have created subject-focused lists of electronic and print research resources that are useful for their disciplines. You can search the library directory  for links to the departmental libraries at the University of Illinois Library, or search library websites by college  if you're not sure which departmental library serves your subject.

Peer-Reviewed Resources for Disciplinary Topics

There are numerous print and digital resources for specific disciplines, areas of study, and specialist fields.  To find research resources and databases for your area, consult the comprehensive directory of LibGuides , the websites of specialist libraries, and above all, contact a librarian for help !

Here are a few major databases for finding peer-reviewed research sources in the humanities, social sciences, and sciences:

• MLA International Bibliography This link opens in a new window Indexes critical materials on literature, languages, linguistics, and folklore. Proved access to citations from worldwide publications, including periodicals, books, essay collections, working papers, proceedings, dissertations and bibliographies. more... less... Alternate Access Link
• Web of Science (Core Collection) This link opens in a new window Web of Science indexes core journal articles, conference proceedings, data sets, and other resources in the sciences, social sciences, arts, and humanities.
• Academic Search Ultimate This link opens in a new window A scholarly, multidisciplinary database providing indexing and abstracts for over 10,000 publications, including monographs, reports, conference proceedings, and others. Also includes full-text access to over 5,000 journals. Offers coverage of many areas of academic study including: archaeology, area studies, astronomy, biology, chemistry, civil engineering, electrical engineering, ethnic & multicultural studies, food science & technology, general science, geography, geology, law, mathematics, mechanical engineering, music, physics, psychology, religion & theology, women's studies, and other fields. more... less... Alternate Access Link
• IEEE Xplore This link opens in a new window Provides full-text access to IEEE transactions, IEEE and IEE journals, magazines, and conference proceedings published since 1988, and all current IEEE standards; brings additional search and access features to IEEE/IEE digital library users. Browsable by books & e-books, conference publications, education and learning, journals and magazines, standards and by topic. Also provides links to IEEE standards, IEEE spectrum and other sites.
• Scopus This link opens in a new window Scopus is the largest abstract and citation database including peer-reviewed titles from international publishers, Open Access journals, conference proceedings, trade publications and quality web sources. Subject coverage includes: Chemistry, Physics, Mathematics and Engineering; Life and Health Sciences; Social Sciences, Psychology and Economics; Biological, Agricultural and Environmental Sciences.
• Business Source Ultimate This link opens in a new window Provides bibliographic and full text content, including indexing and abstracts for scholarly business journals back as far as 1886 and full text journal articles in all disciplines of business, including marketing, management, MIS, POM, accounting, finance and economics. The database full text content includes financial data, books, monographs, major reference works, book digests, conference proceedings, case studies, investment research reports, industry reports, market research reports, country reports, company profiles, SWOT analyses and more. more... less... Alternate Access Link
• << Previous: Why not just use Google or Wikipedia?
• Next: Where to Get More Help >>
• Last Updated: Nov 9, 2023 11:15 AM
• URL: https://guides.library.illinois.edu/peerreview

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

PubMed Central (PMC) Home Page

PubMed Central ® (PMC) is a free full-text archive of biomedical and life sciences journal literature at the U.S. National Institutes of Health's National Library of Medicine (NIH/NLM)

Discover a digital archive of scholarly articles, spanning centuries of scientific research.

Learn how to find and read articles of interest to you.

Collections

Browse the PMC Journal List or learn about some of PMC's unique collections.

For Authors

Navigate the PMC submission methods to comply with a funder mandate, expand access, and ensure preservation.

For Publishers

Learn about deposit options for journals and publishers and the PMC selection process.

For Developers

Find tools for bulk download, text mining, and other machine analysis.

9.9 MILLION articles are archived in PMC.

Content provided in part by:, full participation journals.

Journals deposit the complete contents of each issue or volume.

NIH Portfolio Journals

Journals deposit all NIH-funded articles as defined by the NIH Public Access Policy.

Selective Deposit Programs

Publisher deposits a subset of articles from a collection of journals.

March 21, 2024

Preview upcoming improvements to pmc.

We are pleased to announce the availability of a preview of improvements planned for the PMC website. These…

Dec. 15, 2023

Update on pubreader format.

The PubReader format was added to PMC in 2012 to make it easier to read full text articles on tablet, mobile, and oth…

We are pleased to announce the availability of a preview of improvements planned for the PMC website. These improvements will become the default in October 2024.

Research with impact

The home of 500 peer-reviewed journals published by Oxford University Press and learned societies from around the world.

Publish open access

Read and publish agreements can provide you with transparent, flexible, and inclusive options for open access publishing in OUP journals.

Look up your institution

Black Studies

Explore research in the field of Black Studies, including Caribbean English varieties, Rihanna as a global beauty mogul, and African American Women's Welfare Rights.

Explore the collection

Celebrating Women in Science

From research and major discoveries to advocacy and outreach, we shine a spotlight on the representation of women in scientific fields and the gains that have been made.

Take a look

Sensus Impact

A community initiative that delivers standardized and shared infrastructure to report the impact of funded research publications.

Find out more

Information

• About Oxford Academic
• What we publish
• Institutional account management
• Get help with access
• Open research
• Using the content
• Legal and policy
• Advertising
• Media enquiries

New to Oxford Academic in 2024

Latest in Arts and Humanities

Latest in Law

Latest in Medicine and Health

Latest in Science and Mathematics

Latest in Social Sciences

• Mailing List

Affiliations

• Copyright © 2024
• Publish journals with us
• University press partners
• New features  
• Open access
• Rights and permissions
• Accessibility
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

April 25, 2024

Ecological drift and symbiont colonization

Why do specialized host-microbe symbioses show greater diversity than expected? Jason Chen, Zeeyong Kwong, Nicole Gerardo and Nic Vega study squash bug colonization by bacterial symbionts to reveal that heterogeneity and strain diversity in symbiotic microbial communities, both within and between insect hosts, can be simply explained by stochastic colonization.

Image credit: Jason Z Chen

PLOS Biologue

Community blog for plos biology, plos genetics and plos computational biology..

Research Article

Viral movement without viral movement proteins

The spread of viral genomes into adjacent cells and the plant vascular system is typically enabled by viral movement proteins. Xiaobao Ying, Sayanta Bera, Anne Simon and co-workers show that umbravirus-like RNA viruses can spread systemically without encoding any movement proteins, via the interaction of viral replication and capsid proteins with host protein PHLOEM PROTEIN 2.

Image credit: pbio.3002600

Recently Published Articles

• Multiple checkpoints ensure ribosomes have the correct end
• A network-based modeling framework reveals the core signal transduction network underlying high carbon dioxide-induced stomatal closure in guard cells
• Key residues in the VDAC2-BAK complex can be targeted to modulate apoptosis

Current Issue April 2024

Barley genotype tailors the subterranean microbiome

Plants secrete root exudates into the rhizosphere to attract beneficial microbes. Alba Pacheco-Moreno, Jacob Malone and colleagues show that barley genotype exerts multi-level selective pressure on the soil Pseudomonas population, affecting overall abundance, genotype and individual genetic features as well as expression of specific genes. Also read the accompanying Primer by Maggie Wagner.

Image credit: US National Arboretum via Wikimedia Commons

Short Reports

Bacterial thiosulfate uptake

YeeE is a bacterial membrane protein that mediates thiosulfate uptake, but whether it acts alone it is unclear. Mai Ikei, Ryoji Miyazaki, Muneyoshi Ichikawa, Tomoya Tsukazaki and co-authors identify YeeD as a necessary partner of YeeE, characterizing the cooperation of the two proteins (which is based on the thiosulfate ion decomposition activity of YeeD) at both structural and functional levels.

Image credit: pbio.3002601

Optogenetic manipulation of lysosomes

Lysosomes are cellular degradation centers, critical for maintaining homeostasis. Selective modulation of lysosomal activity has remained a challenge to date, but Wenping Zeng, Canjun Li, Ge Shan, Lili Qu, Chunlei Cang and colleagues describe the development of lysosome-targeted optogenetic tools for the light-inducible manipulation of lysosomal physiology in cells and in C. elegans .

Image credit: pbio.3002591

Bacteriophages affect human respiratory cells

Phage therapy is being explored to treat multidrug-resistant bacterial infections, but the possible direct effects of phages on the human host are less well understood. Paula Zamora, Jennifer Bomberger and co-workers show that therapeutic phages can be detected by epithelial cells of the human respiratory tract, eliciting proinflammatory responses that depend on specific phage properties and the airway microenvironment.

Image credit: pbio.3002566

Role for Hsp40 chaperone in long-term memory

Orb2, the Drosophila homolog of CPEB, forms prion-like oligomers that play a crucial role in the maintenance of long-term memory. Meghal Desai, Hemant, Tania Bose, Amitabha Majumdar and colleagues identify the Hsp40 family chaperone Mrj as a regulator of Orb2 oligomerization and its association with translating ribosomes.

Image credit: Prathamesh Dhamale & Amitabha Majumdar

Unsolved Mystery

How do endosymbionts work with so few genes?

This Unsolved Mystery article explores how genome reduction alters endosymbiont biology and highlights a ‘tipping point’ where the loss of the ability to build a cell envelope coincides with a marked erosion of translation-related genes.

Image credit: pbio.3002577

Symbiosis: In search of a deeper understanding

Thomas Richards and Nancy Moran discuss our new collection of articles exploring emerging themes in symbiosis research, as researchers exploit modern research tools and new models to unravel how symbiotic interactions function and evolve.

Image credit: Estelle Kilias

Perspective

Fungal holobionts to inform synthetic endosymbioses

Rhizopus microsporus is a fungal holobiont, harboring bacterial and viral endosymbionts. Laila Partida-Martínez explores how these microbial allies increase pathogenicity and defense and control reproduction in the fungus.

Image credit: pbio.3002587

Fitness trade-offs and the origins of endosymbiosis

Endosymbiosis is common and has played an important role in the evolution of complex life. Michael Brockhurst, Duncan Cameron and Andrew Beckerman explore the theory and experimental evidence for trade-offs in the early-stage evolution of endosymbiosis.

Image credit: pbio.3002580

Symbiosis across the tree of life

Symbiosis research has become a holistic and pervasive field with a mature theoretical basis. This collection showcases symbiotic relationships across the tree of life, exploring their evolutionary basis and underlying mechanisms.

PLOS Biology 20th Anniversary

PLOS Biology is 20 and we are celebrating with a collection that contains articles that look back at landmark studies that we published, others that look past and future, and others discussing how publishing and open science have evolved and what is to come.

Engineering plants for a changing climate

This collection explores engineering strategies to help us adapt plants to a changing climate, including breeding techniques, genome engineering, synthetic biology and microbiome engineering.

Going for green

The green collection explores biological solutions that could be applied to reduce CO2 emissions, get rid of non-degradable plastics, produce food in a sustainable manner or generate energy.

Ocean solutions for a sustainable, healthy and inclusive future

This collection explores potential solutions to mitigate the impacts of human activity on ocean ecosystems to minimize or reverse degradation.

RS: Vaccines and antimicrobial resistance: from science to policy

April 29 - 30

Virtually meet Magazine Editor Joanna Clarke (jclarkeplos.org)

Drug Discovery, Delivery and Therapeutics

Meet Senior Editor Richard Hodge ([email protected])

GRC: Enhancing Public Health, Food Security and Biodiversity

May 19 - 24

Meet Editor in Chief Nonia Pariente ([email protected])

CSHL: Brain Body Physiology

May 29 - Jun 2

Meet Senior Editor Luke Smith ([email protected])

Publish with PLOS

Submit Your Manuscript

Connect with Us

• PLOS Biology on Twitter
• PLOS on Facebook

Get new content from PLOS Biology in your inbox

Thank you you have successfully subscribed to the plos biology newsletter., sorry, an error occurred while sending your subscription. please try again later..

• Customer Services
• African History
• American History
• Anthropology
• Asian History
• Business and Management
• Classical Studies
• Climate Science
• Communication
• Criminology and Criminal Justice
• Economics and Finance
• Environmental Science
• Food Studies
• Global Public Health
• International Studies
• Latin American History
• Linguistics
• Natural Hazard Science
• Neuroscience
• Planetary Science
• Social Work

Welcome to Oxford Research Encyclopedias

• Current, peer-reviewed trustworthy research, read in 30 minutes or less across 25 encyclopedias .
• Includes the  Encyclopedia of Social Work and the Oxford Classical Dictionary

Perspectives From Coastal Ecosystems Through the Lens of Climate Change

"Climate change impacts coastal ecosystems and the humans who live and work in these regions. The coastal ecosystem, or the coastal zone, is defined as the margin between land, air, and ocean where complex interactions occur between living and nonliving parts of the system. ..." – By Kristy A. Lewis, Giovanna McClenachan, Kristin DeMarco, Jennifer Salerno and Katherine Thompson

The Geopolitics of Infotainment

"Although there is a lack of consensus among political communication scholars on the standard conceptualization of infotainment, scholarship converges on the idea that infotainment describes an admixture of information and entertainment...." – By Lindsay H. Hoffman and Gilbert K. Rotich 

April 2024 Update

What's new to the ores.

 In April 2024, 102 full new articles and 4 revised articles, spread across 23 subjects, have been published on the  Oxford Research Encyclopedias  platform.

Find out more about the newest discipline to be added: the Oxford Research Encyclopedia of Food Studies .

One More Encyclopedia Available via Subscription and Perpetual Access

On January 30, after a successful free period during development, the Oxford Research Encyclopedia of Physics has been made available via subscription and perpetual access to libraries and institutions worldwide.

Browse all ORE physics articles

Why the Oxford Research Encyclopedia?

With today’s overabundance of information, and misinformation, students and researchers alike can be overwhelmed in identifying what’s trustworthy, what’s up-to-date, and what’s accurate.

Explore by Discipline

Working with international communities of scholars across all fields of study, we are developing new comprehensive collections of in-depth, peer-reviewed summaries on an ever-growing range of topics.

For Librarians

Oxford University Press offers a variety of tools to help you promote your access to the Oxford Research Encyclopedias and get the most out of these resources.

Recently Published

Browse recently published articles by month, including summaries and previews of forthcoming full-text articles.

Latest blog articles

• Seven women who changed social work forever
• Black lives matter in prisons too
• How ancient Christians responded to pandemics
• Stress management in the work place [infographic]
• How academics can leave the university but stay in academia

APRIL 17, 2024

What’s new: april 2024.

In April 2024, 102 full new articles and 4 revised articles, spread across 23 subjects, have been published on the Oxford Research Encylopedias platform.

MARCH 20, 2024

What’s new: march 2024.

In March 2024, 81 full new articles, 1 revised, and 4 summary articles, spread across 20 subjects, have been published on the  Oxford Research Encyclopedias  platform.

FEBRUARY 27, 2024

What’s new: february 2024.

In February 2024, 52 full new articles, 6 revised, and 3 summary articles, spread across 19 subjects, have been published on the Oxford Research Encyclopedias platform.

date: 07 May 2024

• Cookie Policy
• Privacy Policy
• Legal Notice
• Accessibility
• [66.249.64.20|81.177.182.154]
• 81.177.182.154

Finding Scholarly Articles: Home

What's a Scholarly Article?

Your professor has specified that you are to use scholarly (or primary research or peer-reviewed or refereed or academic) articles only in your paper. What does that mean?

Scholarly or primary research articles are peer-reviewed , which means that they have gone through the process of being read by reviewers or referees  before being accepted for publication. When a scholar submits an article to a scholarly journal, the manuscript is sent to experts in that field to read and decide if the research is valid and the article should be published. Typically the reviewers indicate to the journal editors whether they think the article should be accepted, sent back for revisions, or rejected.

To decide whether an article is a primary research article, look for the following:

• The author’s (or authors') credentials and academic affiliation(s) should be given;
• There should be an abstract summarizing the research;
• The methods and materials used should be given, often in a separate section;
• There are citations within the text or footnotes referencing sources used;
• Results of the research are given;
• There should be discussion   and  conclusion ;
• With a bibliography or list of references at the end.

Caution: even though a journal may be peer-reviewed, not all the items in it will be. For instance, there might be editorials, book reviews, news reports, etc. Check for the parts of the article to be sure.   

You can limit your search results to primary research, peer-reviewed or refereed articles in many databases. To search for scholarly articles in  HOLLIS , type your keywords in the box at the top, and select  Catalog&Articles  from the choices that appear next.   On the search results screen, look for the  Show Only section on the right and click on  Peer-reviewed articles . (Make sure to  login in with your HarvardKey to get full-text of the articles that Harvard has purchased.)

Many of the databases that Harvard offers have similar features to limit to peer-reviewed or scholarly articles.  For example in Academic Search Premier , click on the box for Scholarly (Peer Reviewed) Journals  on the search screen.

Review articles are another great way to find scholarly primary research articles.   Review articles are not considered "primary research", but they pull together primary research articles on a topic, summarize and analyze them.  In Google Scholar , click on Review Articles  at the left of the search results screen. Ask your professor whether review articles can be cited for an assignment.

A note about Google searching.  A regular Google search turns up a broad variety of results, which can include scholarly articles but Google results also contain commercial and popular sources which may be misleading, outdated, etc.  Use Google Scholar  through the Harvard Library instead.

About Wikipedia .  W ikipedia is not considered scholarly, and should not be cited, but it frequently includes references to scholarly articles. Before using those references for an assignment, double check by finding them in Hollis or a more specific subject  database .

Still not sure about a source? Consult the course syllabus for guidance, contact your professor or teaching fellow, or use the Ask A Librarian service.

• Last Updated: Oct 3, 2023 3:37 PM
• URL: https://guides.library.harvard.edu/FindingScholarlyArticles

Harvard University Digital Accessibility Policy

Editor's Choice: AI Could Mean Better Mental Health for All

• Mortality Among US Youth, Parents May 4, 2024 Original Investigation Racial and Ethnic Disparities in All-Cause and Cause-Specific Mortality Among US Youth Elizabeth R. Wolf, MD, MPH; Frederick P. Rivara, MD, MPH; Colin J. Orr, MD, MPH; et al
• Editorial Injury Prevention Science and Firearm Injury in Pediatric Health Patrick M. Carter, MD; Laura Seewald, MD; Marc Zimmerman, PhD
• Original Investigation Youth Experiencing Parental Death Due to Drug Poisoning and Firearm Violence in the US, 1999-2020 Benjamin-Samuel Schlüter, PhD; Diego Alburez-Gutierrez, PhD; Kirsten Bibbins-Domingo, PhD, MD, MAS; et al
• Audio Racial and Ethnic Disparities in All-Cause and Cause-Specific Mortality Among US Youth Steven H. Woolf, MD, MPH, with host JAMA Associate Editor Tracy A. Lieu, MD, MPH

Just Published

• Associations of Milestone Ratings and Certification Examination Scores With Patient Outcomes Bradley M. Gray, PhD; et al. Original Investigation online first Bradley M. Gray, PhD; et al.
• Substances in Counterfeit Prescription Pills Seized by Law Enforcement, 2017-2022 Rachel S. Wightman, MD; et al. Research Letter online first Rachel S. Wightman, MD; et al.
• Youth Parental Death Due to Drug Poisoning and Firearm Violence in the US Benjamin-Samuel Schlüter, PhD; et al. Original Investigation online first free access Benjamin-Samuel Schlüter, PhD; et al.
• Racial and Ethnic Disparities in All-Cause and Cause-Specific Mortality Among US Youth Elizabeth R. Wolf, MD, MPH; et al. Original Investigation online first free access has multimedia Elizabeth R. Wolf, MD, MPH; et al. Editorial
• Varenicline or Nicotine Replacement After Initial Treatment Failure Paul M. Cinciripini, PhD; et al. Original Investigation online first has active quiz has multimedia Paul M. Cinciripini, PhD; et al.
• Risks of Harm in Alzheimer Disease by Amyloid Lowering Madhav Thambisetty, MD, PhD; et al. Viewpoint online first Madhav Thambisetty, MD, PhD; et al.
• Injury Prevention Science and Firearm Injury in Pediatric Health Patrick M. Carter, MD; et al. Editorial online first free access has multimedia Patrick M. Carter, MD; et al.
• Urgent Need for Regulatory Oversight of Human Cellular/Tissue–Based Products Robert P. Dickson, MD; et al. Viewpoint online first Robert P. Dickson, MD; et al.
• My Digital Refuge Anna Wexler, PhD A Piece of My Mind online first Anna Wexler, PhD
• The FDA and Gene Therapy for Duchenne Muscular Dystrophy David M. Rind, MD Viewpoint online first David M. Rind, MD
• The Women’s Health Initiative Randomized Trials and Clinical Practice JoAnn E. Manson, MD, DrPH; et al. Review online first free access has active quiz JoAnn E. Manson, MD, DrPH; et al.
• Lower Gastrointestinal Hemorrhage Hira Imran, MD; et al. JAMA Clinical Guidelines Synopsis online first has active quiz Hira Imran, MD; et al.
• Interstitial Lung Disease Toby M. Maher, MD, MSc, PhD Review online first has active quiz has multimedia Toby M. Maher, MD, MSc, PhD
• A Patient with Diabetes Mellitus and Acute Rhinosinusitis Francisco J. Machiavello Roman, MD; et al. JAMA Clinical Challenge online first has active quiz Francisco J. Machiavello Roman, MD; et al.
• Does This Infant Have a Dislocated Hip? Abhinav Singh, BMBS, MSc; et al. The Rational Clinical Examination online first has active quiz has multimedia Abhinav Singh, BMBS, MSc; et al.

Latest from the USPSTF

• USPSTF Recommendation: Screening for Breast Cancer
• USPSTF Recommendation: Primary Care Interventions to Prevent Child Maltreatment
• USPSTF Recommendation: Screening for Speech and Language Delay and Disorders
• 36,591 Views Prostate-Specific Antigen Screening and 15-Year Prostate Cancer Mortality
• 35,352 Views Acetaminophen Use During Pregnancy and Children’s Risk of Autism, ADHD, and Intellectual Disability
• 30,650 Views USPSTF Recommendation: Screening for Breast Cancer
• 30,648 Views Effect of Tirzepatide on Maintenance of Weight Reduction
• 29,115 Views Systemic Lupus Erythematosus
• 24,348 Views Clinical Benefit and Regulatory Outcomes of Cancer Drugs Receiving Accelerated Approval
• 23,978 Views Interstitial Lung Disease
• 21,302 Views Good Enough
• 19,217 Views Stewardship Prompts to Improve Antibiotic Selection for Pneumonia
• 18,485 Views A Pragmatic Approach to Prostate Cancer Screening
• 723 Citations Antibody Response to 2-Dose SARS-CoV-2 mRNA Vaccine Series in Solid Organ Transplant Recipients
• 693 Citations Strengthening the Reporting of Observational Studies in Epidemiology Using Mendelian Randomization
• 626 Citations Pancreatic Cancer
• 621 Citations USPSTF Recommendation: Screening for Colorectal Cancer
• 619 Citations Updated Guidance on the Reporting of Race and Ethnicity in Medical and Science Journals
• 520 Citations Effect of 2 Inactivated SARS-CoV-2 Vaccines on Symptomatic COVID-19 Infection in Adults
• 460 Citations The Leading Causes of Death in the US for 2020
• 447 Citations Association Between IL-6 Antagonists and Mortality Among Patients Hospitalized for COVID-19
• 412 Citations Association Between 3 Doses of mRNA COVID-19 Vaccine and Symptomatic Infection Caused by Omicron and Delta Variants
• 383 Citations Cerebral Venous Sinus Thrombosis With Thrombocytopenia After Ad26.COV2.S Vaccination
• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

• Systematic Review
• Open access
• Published: 01 May 2024

Addressing loneliness and social isolation in 52 countries: a scoping review of National policies

• Nina Goldman   ORCID: orcid.org/0000-0002-3058-1251 1 , 2   na1 ,
• Devi Khanna   ORCID: orcid.org/0000-0002-9254-0869 1   na1 ,
• Marie Line El Asmar   ORCID: orcid.org/0000-0002-0733-3911 3 ,
• Pamela Qualter   ORCID: orcid.org/0000-0001-6114-3820 1 &
• Austen El-Osta   ORCID: orcid.org/0000-0002-8772-4938 2  

BMC Public Health volume  24 , Article number:  1207 ( 2024 ) Cite this article

521 Accesses

5 Altmetric

Metrics details

Even prior to the advent of the COVID-19 pandemic, there was ample evidence that loneliness and social isolation negatively impacted physical and mental health, employability, and are a financial burden on the state. In response, there has been significant policy-level attention on tackling loneliness. The objective of this scoping review was to conduct a loneliness policy landscape analysis across 52 countries of the UN European country groups. Our policy analysis sought to highlight commonalities and differences between the different national approaches to manage loneliness, with the goal to provide actionable recommendations for the consideration of policymakers wishing to develop, expand or review existing loneliness policies.

We searched governmental websites using the Google search engine for publicly available documents related to loneliness and social isolation. Seventy-eight documents were identified in total, from which 23 documents were retained. Exclusion of documents was based on predetermined criteria. A structured content analysis approach was used to capture key information from the policy documents. Contextual data were captured in a configuration matrix to highlight common and unique themes.

We could show that most policies describe loneliness as a phenomenon that was addressed to varying degrees in different domains such as social, health, geographical, economic and political. Limited evidence was found regarding funding for suggested interventions. We synthesised actionable recommendations for the consideration of policy makers focusing on the use of language, prioritisation of interventions, revisiting previous campaigns, sharing best practice across borders, setting out a vision, evaluating interventions, and the need for the rapid and sustainable scalability of interventions.

Conclusions

Our study provides the first overview of the national loneliness policy landscape, highlighting the increasing prioritisation of loneliness and social isolation as a major public health and societal issue. Our findings suggest that policymakers can sustain this momentum and strengthen their strategies by incorporating rigorous, evidence-based intervention evaluations and fostering international collaborations for knowledge sharing. We believe that policymakers can more effectively address loneliness by directing funds to develop and implement interventions that impact the individual, the community and society.

Peer Review reports

Introduction

The significant increase in research on loneliness and social isolation over the last decade, and especially following the advent of the COVID-19 pandemic [ 1 , 2 , 3 ] highlighted the detrimental consequences of loneliness to individuals, society and governments worldwide. For older adults, the pandemic led to feelings of loneliness due to a lack of companionship and connections, which can negatively impact cognition, and mental health [ 4 ]. The paradox of social distancing, intended to protect older adults, further isolated them and exacerbated the negative effects of loneliness [ 5 ]. A longitudinal study on adolescents showed that they also experienced social isolation from peers, and that resulted in increases of loneliness due to COVID-related school closures [ 6 ]. Evidence shows that a lack of social connection impacts physical and mental health [ 7 ], employability opportunities [ 8 ], and how it is related to social disparities [ 1 , 9 ]. In response, there has been significant policy-level attention on loneliness, with, for example, the United Kingdom of Great Britain and Northern Ireland (GB) [ 10 ] and Japan [ 11 ] both appointing a Minister for Loneliness in 2018 (GB) and 2021 (Japan) respectively. In a joint press statement, both an EU Commissioner and the Japanese Loneliness Minister agreed that “loneliness and social isolation pose crucial challenges to the cohesion, economy and mental and physical health in 21st century societies across the world” [ 12 ]. In November 2023, the World Health Organization highlighted the importance of social connection, recognising the significant and often underestimated impact of loneliness and isolation on our health and well-being. This recognition led to the launch of its Commission on Social Connection (2024–2026), which aims to address this issue as a public health concern [ 13 ]. However, little is known about the extent that loneliness is currently included in national strategies and policies across the world.

Loneliness is often defined in psychological terms as an unpleasant feeling that people experience when they perceive their social relationships to be qualitatively or quantitatively inadequate [ 14 ]. The quality, rather than the quantity, of social relationships plays a greater role in loneliness [ 15 ]. While temporary loneliness is a natural human experience, chronic loneliness has serious negative consequences for health and life expectancy. There are three main types of loneliness: intimate (also known as emotional) loneliness, relational (also known as social) loneliness and collective loneliness, first identified by McWhirter (1990) [ 16 ], and empirically validated by Hawkley et al. (2005) [ 17 ] and Panayiotou et al. (2023) [ 18 ]. Loneliness is distinct from social isolation, which Nicholson Jr. (2009) [ 19 ] defines as “a state in which the individual lacks a sense of belonging socially, lacks engagement with others, has a minimal number of social contacts, and they are deficient in fulfilling and quality relationships” (p. 1346). This does not mean that socially isolated individuals necessarily feel lonely and vice versa.

There are different scales to measure loneliness and social isolation. The most commonly used instruments for measuring loneliness are the indirect measures from De Jong Gierveld Loneliness Scale [ 20 ] and the full UCLA Loneliness Scale [ 21 ], as well as the direct measure from the UK Office for National Statistics [ 22 ]. However, what these definitions fail to measure is the “intensity, frequency and duration of loneliness. Loneliness can be acute (i.e., transient) or chronic (i.e., enduring), and it can be mild to severe in its intensity” [ 23 , p.2]. There are also a variety of scales to measure social isolation, but there is no consensus on which should be used [ 24 ]. Some common scales include the Lubben Social Network Scale [ 25 ], the Cudjoe social isolation typology [ 26 ] or a social isolation index used by Shankar et al. [ 27 ].

Our study contributes to existing literature by presenting an overview of current governmental documents that address loneliness and social isolation. Our intention is that the scoping review would be used by federal agencies or local communities who want to develop their own strategies to address loneliness and social isolation, or by researchers to gain an overview of the policy landscape.

The aim of this study was to characterise the policy landscape relevant to tackling loneliness and social isolation across the UN European country groups to identify commonalities and differences between national approaches to loneliness. A secondary aim was to provide actionable recommendations including their implications based on the scoping review for the consideration of policy makers to help promote the rapid and widescale adoption and diffusion of sustainable, scalable and evidence-based interventions to manage loneliness.

We conducted a scoping review based on Mak and Thomas’ recommendations (2022) [ 28 ] to identify (i) how loneliness and social isolation are defined, (ii) the common characteristics between loneliness policies across countries, (iii) which population groups were targeted, and (iv) whether there was an identifiable commitment to action and funding. We contextualised findings using five domains (geographic, social, health, economic, political) that all affect or are affected by experiences of loneliness and social isolation. We have taken every step to make the scoping review as clear and reproducible as possible, following the PRISMA-ScR guidelines [ 29 ] [see file: Supplementary Material _PRISMA-ScR-Checklist].

Eligibility criteria

A multi-method review approach inspired by Schnable et al. (2021) [ 30 ], including a qualitative policy analysis, was used to identify and describe the characteristics of a collection of national-level government documents with reference to loneliness and social isolation. As national policy documents and commissioned governmental strategies and action plans are not available on a central database, a systematic review was not feasible.

We retrieved and reviewed policy documents that address loneliness or social isolation from a total of 52 countries from the UN European Country Groups: Albania (AL), Andorra (AD), Armenia (AM), Australia (AU), Austria (AT), Azerbaijan (AZ), Belarus (BY), Belgium (BE), Bosnia and Herzegovina (BA), Bulgaria (BG), Canada (CA), Croatia (HR), Czechia (CZ), Denmark (DK), Estonia (EE), Finland (FI), France (FR), Georgia (GE), Germany (DE), Greece (GR), Hungary (HU), Iceland (IS), Ireland (IE), Israel (IL), Italy (IT), Latvia (LV), Liechtenstein (LI), Lithuania (LT), Luxembourg (LU), Malta (MT), Monaco (MC), Montenegro (ME), Netherlands (NL), New Zealand (NZ), North Macedonia (MK), Norway (NO), Poland (PL), Portugal (PT), Republic of Moldova (MD), Romania (RO), Russian Federation (RU), San Marino (SM), Serbia (RS), Slovakia (SK), Slovenia (SI), Spain (ES), Sweden (SE), Switzerland (CH), Türkiye (TR), Ukraine (UA), United Kingdom of Great Britain and Northern Ireland (GB), and United States of America (US). We chose this geographic focus of Europe because the European Union was the first supranational union of states to put loneliness on its agenda with a policy brief published in 2018 [ 31 ]. To ensure comprehensive coverage of European nations, we chose the UN European country groups, recognising that they include some members beyond the continent’s geographical borders.

Articles including policies, reports, strategies and policy briefs were included in the analysis if they were (i) from the two UN country groups under study, (ii) officially published or commissioned by a national government, (iii) publicly available, (iv) published between 1 January 2003 and 1 July 2023, (v) related directly to loneliness and social isolation or indirectly by using other language such as social connection, (vi) published in any language.

Information sources

The main information sources were governmental websites of relevant ministries and departments of the 52 selected countries. Additionally, we used the Google search engine for all publicly available national policies related to loneliness and social isolation.

We conducted desktop research using the key terms “loneliness” and “social isolation” for all publicly available national policies, including a review of government websites to generate an asset map of key policy documents and white papers from each country. Online searches were conducted between 1st February 2023 and 1st July 2023.

Internet searches, using the Google search engine, included the following keywords: [(“loneliness” OR “social isolation” OR “social connection”)] and [(“policy” OR “strategy” OR “actions” OR “reports”) and “Country”]. If this did not yield any results for a specific country, we searched for the government website of that country using primary (loneliness and social isolation) and secondary (strategy/policy) terms to determine if governments published documents on loneliness and social isolation. The Google website translator was used to navigate non-English governmental websites.

Selection of sources of evidence

The documents were not limited to policies, but also included national strategies, technical reports, brochures and webpages published by government agencies, studies commissioned by a government agency, governmental press releases, and parliamentary enquiries from politicians to federal ministers or councillor regarding data on loneliness in their respective countries. If multiple strategies/policies from the same government were found, the most recently published one was included. We focused on national level documents only (excluding any regional strategies).

Where documents retrieved were not in English, they were translated into English using a paid (subscription) version of DeepL Pro, a powerful and sophisticated online translator. For reasons of pragmatism, no attempt was made to quality assure the translation with native speakers.

We excluded 40 documents after a first round of reviews where there was no disagreement between the researchers. For 20 documents there was no consensus, so a third researcher reviewed the documents. After reviewing each document, consensus was reached to exclude 16 of the 20 documents. Documents were excluded for the following reasons: (i) loneliness and social isolation were only mentioned in passing and did not elaborated on the issue of loneliness, or loneliness was not part of a proposed intervention, (ii) highlighted or acknowledged loneliness as a problem but we could not identify any detail or strategies or commitments on how to address it, (iii) short news piece or press releases that did not specifically touch on loneliness or social isolation, (iv) documented queries raised by political representatives addressed to parliament, (v) research articles not commissioned by the government, (vi) local focus, not national, (vii) NGO reports not commissioned by a government and (viii) older versions of included documents.

Data charting process

The principal investigator (NG) developed a coding matrix using Excel based on the study objectives and considerations from Braun and Clarke (2006) [ 32 ]. This matrix was first tested on the British documents (NG, DK, MLEA), as we knew these to be extensively detailed. In an iterative process this matrix was reviewed and adapted after testing it on a random selection of five sources of evidence (NG, DK, MLEA, PQ). After a final round of reviewing and adapting, all authors agreed by consensus that they have captured all desired variables needed to address the study objectives. Each policy document was coded independently by at least two investigators (NG, DK, MLEA) to minimise human error in information extraction.

The configuration matrix was completed for all sources of evidence containing information on: (i) document overview (title, publisher, year of publication, original language of publication), (ii) recommended measurement tool for loneliness, (iii) definitions for loneliness, social isolation and other language around social connection, (iv) target group of policy, (v) proposed or suggested actions by government (raising awareness, funding pledge, call for a development of a loneliness measure, proposed interventions or actions, type of evidence cited, commitment to work with specific charities), and (vi) five key domains (geographic, social, health, economic, political) that affect or are affected by experiences of loneliness and social isolation. We also coded whether the documents referred to five domains (geographic, social, health, economic, political) that have been shown to affect or are affected by experiences of loneliness and social isolation.

Synthesis of results

The data of the configuration matrix were consolidated and are presented as Table  1 , Supplementary Table A [see file: Supplementary Material_Table   A ], and within the text where a presentation in table format was not deemed useful (for data items 3–5 as detailed above). We used the document analysis as proposed by [ 33 ] to analyse all the included documents. This approach is based on an iterative processes of qualitative content analysis [ 34 ], with a specific thematic analysis [ 32 ]. The configuration matrix captured all extracted data from which the authors (NG, DK, MLEA) could identify emerging sub-themes within these broad pre-defined domains of loneliness (geographic, social, health, economic and political domain) using thematic analysis [ 32 ]. To create recommendations, two authors (NG, PQ) reviewed the extracted data, with the team revisiting the sources of evidence where needed.

Our scoping review identified 79 sources of evidence that discussed loneliness and social isolation from across 32 countries in both UN European country groups. We excluded a total of 56 documents after two review rounds for reasons shown in the PRISMA flowchart Fig.  1 . This yielded a subset of 23 documents that were included in our final analysis.

PRISMA flow chart based on [ 24 ]

Wider awareness of loneliness and social isolation in our study area

Here, we delve into the sources of evidence that were excluded from our study, but which are nonetheless noteworthy because they illustrate the momentum of the international conversations around loneliness. In some countries (AT, CH), we found parliamentary enquiries asking about data on loneliness in their respective countries, and whether there were any strategies in place to alleviate loneliness. DE does not have a loneliness strategy, but the governmental Committee for Family Affairs, Senior Citizens, Women and Youth has partially funded the organisation (the Competence Network on Loneliness (KNE)) which looks at the causes and consequences of loneliness and promotes the development and exchange of possible prevention and intervention measures in DE. NZ is a good example where there was no specific policy, despite there being great public awareness. They have an established nationwide trust called “Loneliness New Zealand Charitable Trust”. While some countries had excellent resources targeted at policy makers (e.g. CA), they have not yet been translated into a nationwide policy to address loneliness and social isolation. In countries where there was no national strategy, some cities have designed their own regional strategies or organisations, e.g. Barcelona [ 57 ], Helsinki [ 58 ], or Vancouver [ 59 ]. A map highlighting the loneliness policy development landscape across 52 countries of the UN European Country Groups is shown in Fig.  2 .

Current state of the loneliness policy landscape across the study area. Map created with [ 28 ]

It is important to note that for many countries in the study area we could not identify any resources that met the inclusion criteria. It is difficult to assess why loneliness and social isolation are not on the policy agenda of more national governments. Connel and t’ Hart [ 60 ] have developed a typology of policy inaction. Three of the five types may apply to our context: Type I: Calculated inaction. Governments may make a strategic decision not to act, or not to act now, because they believe that the costs of action outweigh the perceived benefits, or because they want to see a stronger evidence base on an issue. Type II: Ideological inaction. Government inaction as a product of ideology, where governments rely on non-governmental and not-for-profit organisations to address the issue of loneliness. The strong third or social-economy sector in the European Union [ 61 ], which includes more volunteers than paid employees, could give the impression that loneliness and social isolation can be managed without government policies. Type IV: Reluctant inaction. Governments do not act because they perceive an absolute or relative lack of resources to fund loneliness and social isolation policies. This may be the case for the less economically strong countries in our study area that do not have policies in place.

Characteristics of sources of evidence

Table  1 gives an overview of the 23 documents that we included in our analysis. Half the documents were published after 2020. Seven documents had to be translated into English. Certain countries released documents in conjunction with one another. For instance, Denmark published a National Strategy and an Action Plan simultaneously in 2023 that were complementary. Similarly, GB’s 2021 Action Plan builds on the GB Loneliness Strategy published in 2018.

Results of individual sources of evidence

For each of the included sources of evidence, we extracted information with our configuration matrix presented in the section Data items . We believe that presenting the results this way will better suit our study objectives, i.e., to highlight common and unique themes.

Target group of policies

Eight documents (from AL, CA, IT, MT, US) were targeted specifically at the older adult population, often classified as age 65 + years. Definitions, causes and proposed interventions for loneliness and social isolation in those documents were contextualised within the framework of old age. The other documents addressed the general population, often highlighting that there are specific groups that are more vulnerable to becoming lonely or socially isolated. Five of the documents identified target groups at increased risk of loneliness (AU, IE, CH, GB, DK). For instance, children (IE), young adults ages 18–25 years (AU, DK, IE, GB), older adults ages 65 + years (AU, CH, IE, GB), people with disabilities & special needs (AU, DK), people suffering from mental illness (CH), those with long-term illness (GB), migrants and refugees (AU, CH, GB), lower income households (AU), and people living alone (AU, CH), people with lower levels of schooling (CH), single parents (CH), young single men (CH), care leaver (GB), victims of domestic violence (US), LGBTQ + individuals (US) and minorities (DK, US).

Defining loneliness and social isolation

Of the 23 documents included in the review, 11 documents from seven countries (AU, AT, CA, DE, NL, GB, US) provided specific definitions of loneliness and social isolation. Those definitions were based on academic sources, explicitly referenced and cited, except for AT which based their definition on general “experts” rather than a specific source. Peplau and Perlman (1982)’s widely used framework is drawn upon in multiple documents, and some countries (AU, DE, NL, GB) go further in their definitions to distinguish between different types of loneliness, (e.g., social, emotional, and existential loneliness in the NL document).

The 11 documents that used a specific definition of loneliness used the Peplau and Perlman (1982) definition that highlights differences between loneliness and social isolation. Documents noted social isolation as an objective lack of social relationships, while loneliness is considered to be the subjective feelings as a result of that social isolation.

Across all the documents included in our review, both with and without specific definitions of loneliness, other language used around social connection can be classified as follows:

Inclusion in wider society, which includes the terms social inclusion (CZ, DK, IE, MT), social integration (CA) and social participation (DE, NL, CH).

Connecting with others, which includes the terms social networks (CA, DK, DE), social support (CH, US), social connection (AU, US), and social contacts (AT, DE, NL, GB).

Existing resources, which includes the terms social resources (CH), social capital (CH, CA), and social skills (CA, NL).

Covering a deficit, which includes the terms social exclusion (AL, CZ, CA), social vulnerability (IT, CA) and social recovery (AU).

Relationship between loneliness and mental health, which includes the term social wellbeing (GB), and discussions of social prescribing (GB) and the contribution of loneliness to poor mental health (IE).

Mental health, which includes the term social wellbeing (GB), and discussions of social prescribing (GB) and the contribution of loneliness to poor mental health (IE).

Funding pledges

Despite the governmental strategies and action plans to reduce loneliness and social isolation, we found little evidence of a commitment to funding. We identified concrete funding pledges or already provided funding for AL (0.75 m USD for 5 years), DK (145 m USD for 2014–2025), GB (24.8 m USD in 2018; 44.5 m USD in 2020), and NL (10.7 m USD per year for 2022–2025; 5.5 m USD 2018–2022) governments. DK provided a detailed overview of initiatives that can be achieved within the already approved budget, initiatives that could be delivered within existing financial frameworks and over 80 initiatives that should be advanced but required additional funding. The Australian government has not yet made a funding pledge but has received a specific budget and initiative proposal for funding from an alliance of three different national organisations. Other government strategies either stated that different ministries are to ensure the necessary financial and human resources for initiatives that fall under their respective jurisdiction (MT) or did not specify funding pledges, merely stating that adequate funding needs to be identified (IT). We identified that some governments (DE, SE) are (partially) funding research on loneliness to gather scientific evidence to help them build their own policy.

Interventions and partnerships

Strategies, policies and action plans proposed a variety of interventions, while technical reports focused on reviewing existing evidence. We have provided many intervention examples across various domains in the policy landscape analysis section below. Of those countries and documents included in our analysis, only AU and GB have committed to work with specific charities, organisations or initiatives to address loneliness and social isolation. Other governments (CA, IE, IT, MT) stated their intention to work with NGOs and local services, but did not mention any specific organisations.

Development of a loneliness and social isolation measure

None of the documents called for the development of new tools to measure loneliness or social isolation. US, DK and GB reviewed existing measures of loneliness for use in possible interventions and strategies. Notably, GB described its own use of a consistent and direct measure of loneliness, developed by the Office of National Statistics (ONS) in 2018. The Direct Measure of Loneliness is a single item measure developed by the ONS that should be used in conjunction with three questions from the University of California Los Angeles (UCLA) Loneliness Scale. A US documents considered multiple ways in which loneliness and social isolation should be measured in research and recommended the appropriate choice of measures in targeted interventions and in major health strategies. The US did not call for the creation of a new measure, but rather recommended the use of existing validated tools tailored to the purpose of proposed interventions. DK’s national strategy considered the applicability of adult measures to adolescents and children.

Policy landscape analysis

This section highlights the wider policy context of the loneliness debate. All 14 countries that have published documents on loneliness are aware that loneliness touches many different dimensions (geographical, health, social, economic, and political; see Table  2 for a brief overview). In 91% ( n  = 21) of the analysed documents, the social and health dimension was most prominent, highlighting the impact of loneliness on various aspects of people’s lives and across age groups, as well as the health implications. However, not all dimensions were addressed with the same level of detail. An extensive overview of the different dimensions touched upon in every document can be found in the Supplementary Table A . For each of the five dimensions, we have identified themes that recur across the documents. We have also added some intervention examples to show how loneliness could be addressed in this dimension from a policy perspective.

Geographic dimension

Most documents (74%, n  = 17) touched on various geographic dimensions that influence or are influenced by loneliness. Four governments observed geographical variation in loneliness prevalence within their country (AU, CA, DE, GB). Only one document suggested reforming the digital environment (US). Within the geographic dimension the following themes were most often mentioned as being influential regarding loneliness and social isolation in the context of geography: (i) place or residence and housing, (ii) public transport, (iii) community services, and (iv) urban planning.

Place of residence and housing

Four governments (AU, CA, DE, GB) reported that the place of residence (urban or rural) significantly influences loneliness. Loneliness levels were also considered to vary due to population changes (AT, DE) but acknowledged that regional distribution was complex and cannot be solely attributed to urban-rural differences. Relocating to a new place was also reported to lead to feelings of being disconnected from familiar social networks and support systems. Additionally, insufficient affordable and suitable housing contributed to social isolation. Living conditions were mostly mentioned in connection with older adults where the effect of the type of housing was mentioned to affect social interactions and feelings of loneliness (CA, DK). Intervention examples to manage loneliness as a result of a change in residence, or loss of housing include working within local municipal authorities’ strategies on housing policies and reform plans (IT, DK, NL), creating models of apartments that foster community life (AL, DK), creating flexible housing solutions to support life transitions, e.g. homes that can be adjusted in size or adapted to changing needs (DK).

Public transport

The impact of public transport, especially access and affordability, was mentioned as a key issue for social integration, especially for older people (AL, CA). The place of residence (especially if rural) was recognised as a barrier to public transport use. Intervention examples that were put in place to address this issue include an increase of public transport access for the poorer older adults by subsidising the costs locally (AL, DK), and further strengthening accessible transport for communities in residential areas specifically (DK, GB).

Community services

Limited awareness of or access to community services contributed to loneliness. Financial support and grants for rural projects are needed to promote social inclusion. GB, DK and NL documents highlight the importance of the central government working together with local authorities, as the latter play a key role in actively supporting local transport, voluntary groups and initiatives that promote social cohesion and reduce isolation. Intervention examples included subsidies for community work to promote social inclusion specifically in rural areas (CZ), expanding the services in and of community centres (AL), and promoting the use of tailored community-based services (US).

Urban planning

There was general awareness that the physical environment can pose challenges to social participation, especially for the more vulnerable groups, e.g. older adults (CA), in terms of access to public toilets or walkability. Intervention examples included cultivating a sense of belonging that should be considered by urban planners (CA, IT), ensuring proximity to public services (IT), access to public toilets (CA), establishment of healthy and active movement paths (IT) aimed at encouraging walking groups (IT, CH), maximising the use of underutilised community spaces (GB), and use of participatory design in the development of child-friendly neighbourhoods in local environments (CH).

Social dimension

Most documents (90.9%, n  = 20) highlighted a range of interrelated social factors associated with loneliness; the social determinants covered various aspects of people’s lives that shape experiences of loneliness across age groups. Throughout these documents were notes on groups more vulnerable to loneliness as well as everyday life transitions and triggers. Some risk factors for loneliness such as lacking contact with family and friends, the negative impact of unemployment, and inadequate income support were also prominently highlighted.

Groups vulnerable to loneliness

Many governments identified groups more vulnerable to loneliness and social isolation, in line with research findings (AL, CA, IT, MT, NL, CH, GB, US). The following groups were identified as more vulnerable to becoming lonely or socially isolated: single parents, widows, newly retirees, single households, those living in changing family structures, immigrants with language barriers or low socioeconomic status, individuals dealing with addiction, those from the LGBTIQ + community, young adults (around 18 to 29), older adults (above 80), individuals that experience bullying or harassment, and individuals with criminal records. The importance of cultivating inclusive communities and establishing safe spaces for individuals, particularly for groups like migrants, single parents, and older adults was emphasized. Interventions were often tailored to specific groups. For example, community-led interventions targeted older adults who were homebound or in residential long-term care (MT). Others strengthened the resources of older people caring for relatives (CH), invested in a Carers Action Plan (GB), levelled up the volunteering infrastructure through collaboration of the voluntary sector and the government especially for those out-of-work (GB), developed social prescribing pilots and peer support groups (GB, US), facilitated befriending and socializing (AU), and linked vulnerable groups of people in the form of self-help and enabled them to help each other (CH). Here are some examples of targeted interventions for specific groups:

Women: language classes for women who do not speak the local language with crèche facilities alongside the classes (GB), Mitigate the risks of lifelong gender inequalities that result in female old-age poverty and gender pension gaps by ensuring adequate levels of income security for older women (MT).

Men: increase offers for older (single) men such as Men’s Meeting Places or Men’s Communities (DK), active aging centres to mitigate against the tendency of older men to experience difficulties in seeking help and talking about loneliness (MT).

Young people: Strengthen detection of loneliness in day care, primary schools and educational institutions (DK), provide education courses as a source of mitigating loneliness among children (DK), create more binding communities for young people without education and jobs (DK).

Older adults and low-income households: offer free local cultural and leisure activities (CH), increase public transport access (AL), guaranteeing the living minimum and gradual improvement of lowest pensions (AL), activation of computer literacy paths (IT).

Everyday life

The impact of events like the pandemic on individuals and communities was noted, with reference to mental well-being and social interactions, including potential changes in post-pandemic work patterns that might limit personal engagement. The absence of support or opportunities within society, communities, and workplaces is discussed as hindering social integration and fosters loneliness. The role of technology and social media as both a potential mitigating and exacerbating factor was recognized. Intervention examples include enhancement of popular traditions by developing new forms of technologically-oriented interactions, while still including cultural heritage (IT), expansion of existing community interventions (MT) including specific funding allocated to national, local, and community levels (AU), development of national and community awareness or anti-stigma campaigns (AU, CA, DK, DE, IE, NL, GB, US), and awareness spreading specifically towards politicians, administrations, managers, health care providers and others who work on loneliness (DK, US).

Health dimension

The health dimension of loneliness was very prominent in most documents (91%, n  = 21), often noting that socially isolated individuals faced an increased risk of engaging in negative health behaviours. The evidence of interconnection between chronic illnesses, mental health and social isolation was also highlighted. Overlapping with recommendations identified in the social domain, the need for policy development to prioritize social function among older individuals, aiming to enhance their overall health and well-being, was mentioned by (AT, DE, IE).

Institutional intervention examples included the development of an integrated health and social system on a community basis (AL, DK), national training for health practitioners and community care services to systematically identify, monitor and direct people experiencing loneliness (AU, DK, MT, US), linking healthcare practitioners with researchers to further evaluate and use loneliness assessment tools in clinal settings (US), and the inclusion of loneliness and social isolation in electronic health records (AU, US).

Physical health

Documents noted the evidence that individuals with higher levels of chronic diseases, geriatric syndromes, reduced mobility, chronic pain, frailty, hearing and sight impairment, urinary incontinence, or other health issues necessitating long-term care were more susceptible to loneliness. Governments acknowledged these links, often targeting interventions to support disabled people. Intervention examples included the provision of sensory impairment guides for those whose social lives are impacted by a change in their senses due to accidents or disabilities (GB), strengthening bridge-building for civil society and other actors was recommended in the context of in-system transitions and among high-risk groups (DK), the establishment of mobility centres to help people stay mobile or provide information on alternative modes of transport (GB), increased focus on digital inclusion of older and disabled to reduce loneliness as they face reduced mobility (GB), and the advancement of physical activity interventions, especially promising for improving the health outcomes of older adults (US).

Mental health

The policy documents showed empirical evidence that individuals experiencing depression, mental health problems and addiction were at risk of social exclusion. Depression and anxiety are specifically mentioned as significant factors in the context of loneliness; the consequences of loneliness are also discussed, with reference to the increased risk of depression, suicide, anxiety disorders, dementia, and reduced cognitive abilities. Intervention examples included the introduction of community care for people with mental health problems (CZ), while others focused attention on cognitive behavioural therapy, interpersonal psychotherapy and mindfulness (US). The reduction of addictive substances in populations at risk of social exclusion was targeted (CZ); mental health literacy programs were also discussed (DE, IE), specifically in reference to school education initiatives such as social emotional learning programs for use in preschool, school, and youth settings (IE); mental health literacy campaigns were also highlighted (DE, IE).

Economic dimension

Economic factors relating to loneliness were also addressed most documents (74%, n  = 17). In line with research evidence, documents noted that unemployment, receiving income support, and dissatisfaction with financial situation contribute to loneliness. The need for allocating more resources to combat poverty and address the loneliness experienced by older individuals was emphasised, with reference to the fact that it plays a crucial role in enhancing their overall well-being and quality of life. The following themes were prominent within this dimension.

Economic poverty stemming from insufficient income was identified as a key concern for the older adult population. Notably, social exclusion and family poverty were found to be directly linked, posing a risk to children as well. One document (AU) noted that men ages 25–44 years with high incomes and women of all ages with low incomes have been to be more susceptible to loneliness, revealing a discrepancy based on gender. The economic burden of loneliness extended to health service utilization costs, especially for mental health services. Intervention examples included allocating more resources to combat poverty and address the loneliness of older people specifically (IT), guaranteeing dignified living conditions through the adoption of the minimum pension and the gradual improvement of the lowest pensions by offering sustainable support for the poorer elderly was also suggested within the economic domain (AL), early support interventions for children from disadvantaged families, including support for their parents (CH), and more widely to reduce risk of social exclusion due to over-indebtedness (CZ).

Unemployment

Lack of affordable and suitable housing and care options was noted as being linked to social isolation. Loneliness and lack of social support could lead to reduced community participation, hindering employment prospects and workplace progress. This can result in reduced productivity, lower job satisfaction, increased absenteeism, and longer recovery times due to stress and health issues, which in turn negatively affects the economy. Intervention examples included facilitation of the integration of vulnerable individuals into the workforce (CZ, DK), prevention of loneliness among the unemployed through volunteerism and community initiatives (GB, DK), focus on ensuring a smooth transition from work to retirement (DK), working in collaboration with job centres (GB), and creating a cultural shift in work environments for employees at risk of social exclusion (CZ).

Political dimension

Political factors pertaining to loneliness and social isolation were only identified in few documents (30%, n  = 7), indicating less governmental awareness of the political implications of loneliness. Instances of elderly individuals being denied many rights were observed to be associated with loneliness (AL). Additionally, the effects of COVID-19 lockdown policies were connected to the loneliness because of social isolation. DE mentioned the political relevance of loneliness as it correlates with decreased political engagement of individuals. Thus, it was stated that implementing political measures at the federal level is imperative to effectively foster a more socially connected society (DE). One of the documents mentioned the need for the government to establish a comprehensive national strategy targeting loneliness, accompanied by the allocation of sufficient funding, with active engagement from regions and municipalities, especially when it comes to implementation (DK). Furthermore, the same document underscored the contribution of various other key stakeholders, including research institutions, foundations, employers, and civil society, in combating loneliness (DK). Multiple countries acknowledged the relevance of working across government bodies and levels in combatting loneliness (AU, DE, NL, GB). One document highlighted the need for a “connection-in-all-Policies” [ 62 , p.49] approach as social connection, an antidote to loneliness and social isolation, is relevant in all sectors (US).

To our knowledge, this is the first study to characterise the loneliness policy landscape across the UN European country groups (52 countries). The scoping review provided comprehensive coverage of how countries address loneliness and social isolation on a national level, allowing for a much clearer understanding of the diversity in country-level strategies and better coordination across countries in tackling loneliness. This is particularly important because loneliness and social isolation have been increasingly identified as a public health concern [ 63 , 64 ]. The findings of this review can be used by a wide range of stakeholders including federal agencies and local community groups who want to develop their own strategies to address loneliness and social isolation, or by researchers to gain an overview of the policy landscape.

Summary of principal findings

While not all governments (14 of 52 countries; 27%) had official documents that addressed loneliness, the vast number of documents we identified (79 documents) highlight the growing momentum in the loneliness discourse in the study area. The inclusion of research findings in the vision and strategy documents from different nations suggests widespread evidence-to-policy across the world and calls for a cross-disciplinary approach to addressing loneliness, including efforts to leverage asset-based community development and place-based approaches to tackling loneliness [ 65 ].

All 14 countries that published documents on loneliness demonstrated an awareness that loneliness impacted various dimensions including geography (through place of residence and housing, public transport, community services, urban planning), social (some groups are more vulnerable to loneliness than others, social support, technology), health (physical and mental), economics (income, unemployment) or politics (effects of COVID policies, political engagement, working across sectors to address loneliness). Notably, none of the documents reviewed acknowledged that (i) most research on physical health and loneliness is cross-sectional, where the researcher measures both the outcome and the exposures of the study participants at the same time, and thus, the findings of these studies cannot be used to make causal inferences, and (ii) such work does not control for other predictors of health, including, for example, socioeconomic status and actual health conditions. These are important considerations because (a) we cannot be certain that healthy individuals are more likely to get sick if they experience loneliness compared to other healthy individuals who do not experience loneliness, and (b) whether the link between loneliness and health is actually driven by structural inequalities that determine our physical and social environments. We have also found that the documents rarely mention the transient nature of loneliness and the discourse often seems to frame loneliness like an illness that can be treated. The documents also did not address the cultural context (i.e. beliefs, values, religion) that can shape expectations of relationships and the welfare regime.

Policy targets proposed in the documents

Most countries in our sample showed some attempt at raising public awareness about loneliness (AL, AU, CA, DK, DE, IE, IT, MT, NL, CH, UK, US). Such policies are often informative, but there appeared to be a lack of deadlines and appropriate funding. That means the strategy cannot be evaluated. Another point of concern is the perception that loneliness is something that only affects older adults. Some documents lacked information about how to address loneliness, probably because here is limited evidence of what works and for whom. Also absent was a commitment to evaluation of interventions, which is crucial to verify the effects of any intervention and any risks related to action.

Recommendations for policy makers

Despite the adoption of an evidence-to-policy approach to loneliness, given the issues noted above, we encourage policymakers to be cautious in making claims in relation to loneliness, and to ensure that part of their strategy includes the funding of research that fill the gaps in knowledge. Policymakers should also ensure that the work they quote includes study populations that are well-represented in all relevant demographics and that the research is able to make causal claims about how loneliness impacts health. The World Health Organisation (WHO) and the European Union have identified the limits of their own knowledge and skills in this field, commissioning experts to write evidence gap reports [ 66 , 67 ] or GB and DK for example have had loneliness researchers help write their vision and strategy.

Policymakers should also adopt a similar approach in relation to interventions that address loneliness. A recent meta-analytic review [ 68 ] suggested that in order for interventions designed to reduce loneliness to be effective, matching the intervention to the loneliness type is essential, whereas a one size fits all will not be effective. For example, social support interventions and social and emotional skills training are all promising interventions for reducing loneliness, albeit they are usually only appropriate for loneliness that is linked to the perceived absence of a close friend or partner and perceived lack social encounters and acquaintances respectively. Such an understanding of the nuances surrounding loneliness interventions is absent from the documents we evaluated, and policymakers will want to fill that gap in their knowledge so that appropriate decisions about intervention work, and suitable funding, can be provided. The effects of current interventions have been shown to be only moderate, highlighting the need for funding for rigorous and systematically developed interventions that are also appropriately evaluated.

Based on our scoping review and underlying evidence we propose a list of actionable recommendations for national and regional governments wishing to establish or incorporate loneliness into their policy documents (Table  3 ). In sum, we believe that revisiting previous national and local campaigns to identify connection points for loneliness interventions is an effective way to include loneliness into the policy agenda. For example, a walkability campaign that focuses on making cities more pedestrian friendly will benefit individuals in terms of physical health and mental health but it also increases the likelihood of social encounters when walkability is higher [ 69 ]. We also believe that sharing best-practice approaches internationally and accessible to everyone ensures the development of a strong knowledge base. The EU has taken the lead as the first supranational union to address loneliness amongst its member states by recently organizing various roundtables and conferences around loneliness [ 70 ]. Globally, WHO has recently published an evidence gap report on in-person interventions for reducing social isolation and loneliness [ 67 ]. Lastly, we argue that policies would be meaningless if there are no concrete funding streams allocated towards evidence generation, intervention design and implementation and the evaluation thereof. Because our review could not identify clear funding streams for all countries, we strongly encourage policy makers to make the funding streams transparent within their loneliness policies.

Limitations

The primary limitation of our scoping review was concerned with identifying documents from countries that did not provide information in English. That limitation was partially overcome by the use of Google’s website translator. Another limitation is the reliance on machine translation for the identified documents. Documents were translated into English from German, Danish, Finnish, French, Dutch and Norwegian using DeepL. For German and French, the quality of the translation was checked by the author team and considered sufficient to meet our study aim. The cross-sectional design of our scoping review also does not account for how a country’s policy may have changed over time. This is a general issue in policy evaluation. That limitation can be overcome by conducting this review every two to four years. Another challenge with our study is that the data reflect the existence of policies and not the effectiveness of their implementation. Further, only funding that was explicitly allocated to reducing loneliness and social isolation was considered. We acknowledge that other initiatives that received governmental funding pledges, such as establishing community centres for older adults, might also reduce feelings of loneliness. However, it is beyond the scope of the current paper to identify which initiatives specifically reduce loneliness and how much funding has been allocated to them, especially as evidence on which interventions have proven successful are scarce. Additionally, there may be other funding streams we are not aware of or that might have been part of other documents (e.g., state budgets) not included in this analysis.

More work is needed to assess if the various proposed interventions are implemented and successful. Evaluating interventions is crucial if we want to effectively use the pledged funding, to identify what tools (online or other) are being developed to promote loneliness interventions on national and regional levels and to map out the role of the emerging national loneliness networks.

Our study provides the first comprehensive overview of the national loneliness policy landscape across 52 countries, highlighting the increasing prioritisation of loneliness and social isolation as significant public health and societal issues. While the momentum in addressing loneliness is evident, with most policies being informed by scientific evidence, gaps remain, particularly around intervention strategies and their effectiveness. Our findings urge policymakers to not only sustain this momentum but to also strengthen their strategies by incorporating rigorous, evidence-based intervention evaluations and fostering international collaborations for knowledge sharing. This approach can enhance the understanding and addressing of loneliness, ensuring interventions are well-targeted, effective, and scalable. By addressing these issues, policymakers can more effectively manage loneliness by directing funds to develop and implement interventions that impact the individual (e.g. through therapy or befriending services, thereby improving public health outcomes) and the community and society by making them genuinely inclusive, thereby increasing social cohesion.

Availability of data and materials

The references to the documents supporting the conclusions of this article are provided in Table  1 . Should a link have expired, contact the corresponding author for a pdf version of the translated and original document in question.

El-Osta A, Alaa A, Webber I, Sasco ER, Bagkeris E, Millar H, et al. How is the COVID-19 lockdown impacting the mental health of parents of school-age children in the UK? A cross-sectional online survey. BMJ Open. 2021;11(5): e043397.

Article   PubMed   Google Scholar  

Zhen R, Li L, Li G, Zhou X. Social Isolation, Loneliness, and Mobile Phone Dependence among Adolescents During the COVID-19 Pandemic: Roles of Parent–Child Communication Patterns. Int J Ment Health Addict. 2021. Available from: https://link.springer.com/10.1007/s11469-021-00700-1 . Cited 2022 Nov 23.

Van Beek M, Patulny R. The threat is in all of us’: perceptions of loneliness and divided communities in urban and rural areas during COVID-19. J Community Psychol. 2022;50(3):1531–48.

Okechukwu C. The impact of loneliness on physical and mental health among older adults in the era of coronavirus disease 2019 pandemic. Apollo Med. 2021;18(1):19–32.

Google Scholar  

Tyrrell CJ, Williams KN. The paradox of social distancing: implications for older adults in the context of COVID-19. Psychol Trauma Theory Res Pract Policy. 2020;12(S1):S214–216.

Article   Google Scholar  

Houghton S, Kyron M, Hunter SC, Lawrence D, Hattie J, Carroll A, et al. Adolescents’ longitudinal trajectories of mental health and loneliness: the impact of COVID-19 school closures. J Adolesc. 2022;94(2):191–205.

Article   PubMed   PubMed Central   Google Scholar  

Pai N, Vella SL. The physical and mental health consequences of social isolation and loneliness in the context of COVID-19. Curr Opin Psychiatry. 2022;35(5):305.

Matthews T, Odgers CL, Danese A, Fisher HL, Newbury JB, Caspi A, et al. Loneliness and Neighborhood characteristics: a multi-informant, nationally representative study of young adults. Psychol Sci. 2019;30(5):765–75.

Barreto M, Qualter P, Doyle D. Loneliness Inequalities Evidence Review. Wales Centre for Public Policy (WCPP); 2023. Available from: https://www.wcpp.org.uk/publication/loneliness-inequalities-evidence-review/ . Cited 2023 Sep 21.

HM Government. Loneliness Annual Report January 2020. Loneliness Annual Report January 2020. 2020. Available from: https://www.gov.uk/government/publications/loneliness-annual-report-the-first-year/loneliness-annual-report-january-2020--2 . Cited 2023 May 15.

Noda S. Policies on loneliness and isolation in Japan. 2021;15.

European Commission. Delegation of the European Union to Japan. EU-Japan Joint Press Statement: EU-Japan exchange of views on loneliness and social isolation | EEAS. 2021. Available from: https://www.eeas.europa.eu/delegations/japan/eu-japan-joint-press-statement-eu-japan-exchange-views-loneliness-and-social_en?s=169 . Cited 2023 May 15.

WHO Commission on Social Connection. Available from: https://www.who.int/groups/commission-on-social-connection . Cited 2024 Mar 1.

Perlman D, Peplau L. Toward a social psychology of loneliness. In: Gilmour R, Duck S, editors. Personal relationships in disorder. Academic; 1981. p. 31–56.

Hawkley LC, Hughes ME, Waite LJ, Masi CM, Thisted RA, Cacioppo JT. From Social Structural factors to perceptions of relationship quality and loneliness: the Chicago health, aging, and social relations study. J Gerontol B Psychol Sci Soc Sci. 2008;63(6):S375–384.

McWhirter BT. Factor analysis of the revised UCLA loneliness scale. Curr Psychol. 1990;9(1):56–68.

Hawkley LC, Browne MW, Cacioppo JT. How can I connect with thee? Let me count the ways. Psychol Sci. 2005;16(10):798–804.

Panayiotou M, Badcock JC, Lim MH, Banissy MJ, Qualter P. Measuring loneliness in different age groups: the Measurement Invariance of the UCLA loneliness scale. Assessment. 2023;30(5):1688–715.

Nicholson NR Jr. Social isolation in older adults: an evolutionary concept analysis. J Adv Nurs. 2009;65(6):1342–52.

Gierveld JDJ, Tilburg TV. A 6-Item scale for overall, emotional, and social loneliness: confirmatory tests on survey Data. Res Aging. 2006;28(5):582–98.

Pontinen HM, Swails JA. UCLA Loneliness Scale. In: Zeigler-Hill V, Shackelford TK, editors. Encyclopedia of personality and individual differences. Cham: Springer International Publishing; 2018. p. 1–3. https://doi.org/10.1007/978-3-319-28099-8_95-1 . (Cited 2023 Sep 25).

Chapter   Google Scholar  

Office for National Statistics. National measurement of loneliness. 2018. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/compendium/nationalmeasurementofloneliness/2018 . Cited 2023 Sep 25.

Prohaska T, Burholt V, Burns A, Golden J, Hawkley L, Lawlor B, et al. Consensus statement: loneliness in older adults, the 21st century social determinant of health? BMJ Open. 2020;10(8): e034967.

Pomeroy ML, Mehrabi F, Jenkins E, O’Sullivan R, Lubben J, Cudjoe TKM. Reflections on measures of social isolation among older adults. Nat Aging. 2023;3(12):1463–4.

Lubben J, Blozik E, Gillmann G, Iliffe S, Von Renteln Kruse W, Beck JC, et al. Performance of an abbreviated version of the Lubben social network scale among three European community-dwelling older adult populations. Gerontologist. 2006;46(4):503–13.

Cudjoe TKM, Roth DL, Szanton SL, Wolff JL, Boyd CM, Thorpe RJ. The epidemiology of social isolation: national health and aging trends study. J Gerontol B Psychol Sci Soc Sci. 2020;75(1):107–13.

Shankar A, McMunn A, Banks J, Steptoe A. Loneliness, social isolation, and behavioral and biological health indicators in older adults. Health Psychol. 2011;30(4):377–85.

Mak S, Thomas A. Steps for conducting a scoping review. J Grad Med Educ. 2022;14(5):565–7.

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73.

Schnable A, DeMattee AJ, Robinson RS, Brass JN, Longhofer W. The Multi-method Comprehensive Review: Synthesis and Analysis when Scholarship is International, Interdisciplinary, and Immense. Volunt Int J Volunt Nonprofit Organ. 2021. Available from: https://link.springer.com/10.1007/s11266-021-00388-w . Cited 2022 Sep 29.

d’Hombres B, Schnepf S, Barjaková M, Teixeira F. Loneliness – an unequally shared burden in Europe. Policy brief. Joint Research Centre; 2018. Available from: https://knowledge4policy.ec.europa.eu/sites/default/files/fairness_pb2018_loneliness_jrc_i1.pdf . Cited 2023 Dec 12.

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.

Bowen GA. Document analysis as a qualitative research method. Qual Res J. 2009;9(2):27–40.

Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–15.

Beckers A, Buecker S, Casabianca EJ, Nurminen M. Effectiveness of interventions tackling loneliness: a literature reviewMinistry of Health & Social Protection. The National Action Plan on Aging 2020-2024 [Internet]. Ministry of Health & Social Protection, Albania; 2019 [cited 2023 Oct 5]. Available from: https://acpd.org.al/wp-content/uploads/2021/01/PLANI-KOMB%C3%8BTAR-I-VEPRIMIT-MBI-MOSHIMIN-Anglisht.pdf

Ending Loneliness Together, R U OK?, Australian Psychological Society. A National Strategy to Address Loneliness and Social Isolation [Internet]. Treasury of the Australian Government; 2021 [cited 2023 Oct 5] p. 20. Available from: https://treasury.gov.au/sites/default/files/2021-05/171663_ending_loneliness_together.pdf

Strawa C. Australian Institute of Family Studies. 2022 [cited 2023 Oct 5]. Understanding and defining loneliness and social isolation. Available from: https://aifs.gov.au/resources/resource-sheets/understanding-and-defining-loneliness-and-social-isolation

Gesundheitsportal. Gesundheitsportal. 2023 [cited 2023 Oct 5]. Einsamkeit überwinden. Available from: https://www.gesundheit.gv.at/leben/lebenswelt/soziale-netzwerke/soziale-beziehungen/einsamkeit-ursachen-bewaeltigung.html

Keefe J, Andrew M, Fancey P, Hall M. Final Report - A profile of Social Isolation in Canada. Working Group on Social Isolation; 2006.

The National Seniors Council. National Seniors Council – Report on the Social Isolation of Seniors, 2013-2014 [Internet]. 2016 Jul [cited 2023 Oct 5]. Available from: https://www.canada.ca/en/national-seniors-council/programs/publications-reports/2014/social-isolation-seniors.html

Ministry of Labour & Social Affairs. Social Inclusion Strategy 2021–2030 [Internet]. Ministry of Labour & Social Affairs, Czechia; 2019 [cited 2023 Oct 5] p. 122. Available from: https://www.mpsv.cz/documents/20142/225517/Social+Inclusion+Strategy+2021%E2%80%932030_roz%C5%A1%C3%AD%C5%99en%C3%AD+2021.pdf/276ce086-941a-a976-6412-eda9488aaa34

Hent national strategi mod ensomhed [Internet]. Sammen Mod Ensomhed; 2023 [cited 2023 Oct 5]. Available from: https://sammenmodensomhed.dk/

Hent handlingsplan mod ensomhed [Internet]. Sammen Mod Ensomhed; 2023 [cited 2023 Oct 5]. Available from: https://sammenmodensomhed.dk/

Bücker S. Einsamkeit – Erkennen, evaluieren und entschlossen entgegentreten [Internet]. Deutscher Bundestag, Ausschuss für Familie, Senioren, Frauen und Jugend; 2021 p. 13. Report No.: BT-Drs. 19/25249. Available from: https://www.bundestag.de/resource/blob/833538/3db278c99cb6df3362456fefbb6d84aa/19-13-135dneu-data.pdf

Doherty A, Sheridan A, de Brun C, Chambers D. HSE Mental Health Promotion Plan [Internet]. Health Service Executive, Ireland; 2022. Available from: https://www.hse.ie/eng/about/who/healthwellbeing/our-priority-programmes/mental-health-and-wellbeing/hse-mental-health-promotion-plan.pdf

Lucantoni D, Aversa ML, Barbabella F, Checcucci P, D’Agostino L, Damiano G, et al. Policies for active ageing in Italy: what are the possible objectives? Italy: Family Department; 2022

Ministry for Active Ageing. National Strategic Policy for Active Ageing 2023-2030 [Internet]. Ministry for Active Ageing; 2022 [cited 2023 Oct 5] p. 120. Available from: https://activeageing.gov.mt/wp-content/uploads/2023/04/NSPActiveAgeing2023-30.pdf

Ministry of Health, Welfare and Sport. One against loneliness. Action programme 2022-2025. (=Eén tegen eenzaamheid. Actieprogramma 2022-2025) [Internet]. Netherlands; 2022 [cited 2023 Oct 5] p. 28. Available from: https://open.overheid.nl/documenten/ronl-056852de24cfc57b55dd6528f76937b99d3704e7/pdf

Bachmann N. Soziale Ressourcen als Gesundheitsschutz: Wirkungsweise und Verbreitung in der Schweizer Bevölkerung und in Europa [Internet]. Neuchâtel; 2014 p. 109. Report No.: Obsan Dossier 27. Available from: https://www.obsan.admin.ch/en/node/3290

Bachmann N. Social resources: Promotion of social resources as an important contribution to mental health, health and a high quality of life [Internet]. Health Promotion Switzerland; 2020 [cited 2023 Oct 5]. Report No.: 02.0325.DE 06.2020. Available from: https://gesundheitsfoerderung.ch/sites/default/files/migration/documents/Broschuere_GFCH_2020-06_-_Soziale_Ressourcen.pdf

Department for Digital, Culture, Media and Sport. Emerging Together: The Tackling Loneliness Network Action Plan [Internet]. UK; 2021 [cited 2023 Oct 5]. Available from: https://www.gov.uk/government/publications/emerging-together-the-tackling-loneliness-network-action-plan/emerging-together-the-tackling-loneliness-network-action-plan

Department for Digital, Culture, Media and Sport. A connected society. A strategy for tackling loneliness [Internet]. UK: Department for Digital, Culture, Media and Sport; 2018 [cited 2023 Oct 5] p. 84. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/936725/6.4882_DCMS_Loneliness_Strategy_web_Update_V2.pdf

PfG Analytics, Northern Ireland Statistics and Research Agency. Wellbeing in Northern Ireland [Internet]. The Executive Office North Ireland; 2022 p. 37. Available from: https://www.executiveoffice-ni.gov.uk/sites/default/files/publications/execoffice/wellbeing-ni-report-2021-22.pdf

National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System [Internet]. Washington, D.C.: National Academies Press; 2020 [cited 2022 Nov 23]. Available from: https://www.nap.edu/catalog/25663

Veazie S, Gilbert J, Winchell K, Paynter R, Guise JM. Addressing Social Isolation To Improve the Health of Older Adults: A Rapid Review [Internet]. Agency for Healthcare Research and Quality (AHRQ); 2019 Feb [cited 2023 Oct 6]. Available from: https://effectivehealthcare.ahrq.gov/topics/social-isolation/rapid-product

Office of the Surgeon General. Our Epidemic of Loneliness and Isolation: The U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community [Internet]. Washington (DC): US Department of Health and Human Services; 2023. Available from: https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf

Ajuntament de Barcelona. Barcelona against loneliness. Municipal strategy against loneliness 2020–2030. Ajuntament de Barcelona; 2021. Available from: https://ajuntament.barcelona.cat/dretssocials/sites/default/files/arxius-documents/barcelona_loneliness_strategy_2020_2030.pdf . Cited 2023 Sep 5.

Helsinki Missio. Helsinki Missio. Helsinki Missio. 2023. Available from: https://www.helsinkimissio.fi/en/ . Cited 2023 Sep 5.

Elmer EM. Social isolation and loneliness among seniors in Vancouver: strategies for reduction and prevention. 2018;192.

McConnell A, ’t Hart P. Inaction and public policy: understanding why policymakers ‘do nothing.’ Policy Sci. 2019;52(4):645–61.

Salamon LM, Sokolowski W. The Size and Composition of the European Third Sector. In: Enjolras B, Salamon LM, Sivesind KH, Zimmer A, editors. The third sector as a renewable resource for Europe: concepts, impacts, challenges and opportunities. Cham: Springer International Publishing; 2018. p. 49–94. https://doi.org/10.1007/978-3-319-71473-8_3 . (Cited 2024 Feb 29).

Office of the Surgeon General. Our Epidemic of Loneliness and Isolation: The U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community. Washington: US Department of Health and Human Services. 2023. Available from: https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf .

Gerst-Emerson K, Jayawardhana J. Loneliness as a public health issue: the impact of loneliness on health care utilization among older adults. Am J Public Health. 2015;105(5):1013–9.

Holt-Lunstad J. The potential public health relevance of social isolation and loneliness: prevalence, epidemiology, and risk factors. Public Policy Aging Rep. 2017;27(4):127–30.

Pang H, Bakhet M, Gnani S, Majeed A, El-Osta A. Leveraging community assets to tackle social isolation and loneliness: a needs assessment of the london borough of Hammersmith & Fulham. J Contrib. 2020. Available from: http://hdl.handle.net/10044/1/80602 . Cited 2023 Nov 22.

European Commission. Joint Research Centre. Effectiveness of interventions tackling loneliness: a literature review. LU: Publications Office. 2022. Available from: https://data.europa.eu/doi/10.2760/277109 . Cited 2023 Sep 25.

Welch V, Tanjong Ghogomu E, Dowling S, Choo WY, Yunus RM, Mohd TAMT, et al. PROTOCOL: In-person interventions to reduce social isolation and loneliness: an evidence and gap map. Campbell Syst Rev. 2023;19(3):e1340.

Lasgaard M, Løvschall C, Qualter P, Laustsen L, Lim M, Maindal H, et al. Are loneliness interventions effective in reducing loneliness? A meta-analytic review of 128 studies. Eur J Public Health. 2022;32(Supplement3):ckac129266.

Leyden KM. Social capital and the built environment: the importance of walkable neighborhoods. Am J Public Health. 2003;93(9):1546–51.

Beckers A, Buecker S, Casabianca EJ, Nurminen M. Effectiveness of interventions tackling loneliness: a literature review. ean Commission. Joint Research Centre (European Commission), editor. LU: Publications Office of the European Union; 2022. https://data.europa.eu/doi/10.2760/277109 . Cited 2023 Sep 25.

Zarling A, Kim J, Russell D, Cutrona C. Online acceptance and commitment therapy as treatment for loneliness among older adults: Report of a pilot study. J Am Geriatr Soc. 2023;71(8):2557–63.

Fischer R, Hartle L. Effective interventions to reduce loneliness in big cities. Curr Opin Psychiatry. 2023;36(3):206–12.

Download references

Acknowledgements

The authors thank the following students for assisting with compiling the dataset of government documents: Selma Akbas and Laura Baldini. The authors also thank the following students for assisting with the first round of document coding: Kim Aleppo, Izma Ahmed, Angela Benson, Emma Marchong, Sathana Sivanantham, Keyi Le, Yaxuan Shi, Ruifeng Ding and Yiming Bi. The authors would also like to thank Mahmoud M M Al Ammouri for creating the map displayed as Fig.  2 . The lead author also thanks Claudia Kessler from Public Health Services based in Switzerland for insightful discussions on the Danish and Dutch national loneliness policies.

This research was unfunded. Nina Goldman is supported by the Swiss National Science Foundation (SNSF), Bern (Grant #: 214225). Austen El-Osta is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) Northwest London. The views expressed are those of the authors and not necessarily those of the SNSF, NHS, NIHR or the Department of Health and Social Care. AEO is the guarantor.

Author information

Nina Goldman, Devi Khanna and Marie Line El Asmar contributed equally to this work.

Authors and Affiliations

Manchester Institute of Education, University of Manchester, Ellen Wilkinson Building, Devas Street, Manchester, M13 9PL, United Kingdom

Nina Goldman, Devi Khanna & Pamela Qualter

School of Public Heath, Faculty of Medicine, Imperial College London, Charing Cross Hospital, Reynolds Building, St Dunstan’s Road, London, W6 8RF, United Kingdom

Nina Goldman & Austen El-Osta

North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, United Kingdom

Marie Line El Asmar

You can also search for this author in PubMed   Google Scholar

Contributions

All authors contributed substantially to this study: Conception (N.G., A.EO.) and design of the work (N.G., A.EO., P.Q.); Data collection (N.G.); Data analysis and interpretation (N.G., D.K., M.L.EA.); Drafting the article (N.G., D.K., M.L.EA.); Critical revision of the article (P.Q., A.EO.); Final approval of the version to be submitted (N.G., D.K., M.L.EA., A.EO., P.Q.)

Authors' information

The authors span multiple nationalities and levels of seniority. All authors are based at three UK institutions (University of Manchester, Imperial College London and Hampshire Hospitals NHS Foundation Trust). The lead author is a human geographer researching loneliness from a spatial perspective, the second author has a background in international social and public policy, the third author is a medical doctor conducting mixed methods research in the area of public health, the fourth author is the UK's leading scientific expert on child and adolescent loneliness and the last author is a mixed methods public health researcher and is principal investigator of the Measuring Loneliness in the UK (INTERACT) study.

Corresponding authors

Correspondence to Nina Goldman or Devi Khanna .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

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

Supplementary Information

Supplementary material 1., supplementary material 2., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Goldman, N., Khanna, D., El Asmar, M.L. et al. Addressing loneliness and social isolation in 52 countries: a scoping review of National policies. BMC Public Health 24 , 1207 (2024). https://doi.org/10.1186/s12889-024-18370-8

Download citation

Received : 06 December 2023

Accepted : 17 March 2024

Published : 01 May 2024

DOI : https://doi.org/10.1186/s12889-024-18370-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Social isolation
• Policy analysis
• Policy recommendation

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• NATURE INDEX
• 01 May 2024

Plagiarism in peer-review reports could be the ‘tip of the iceberg’

• Jackson Ryan 0

Jackson Ryan is a freelance science journalist in Sydney, Australia.

You can also search for this author in PubMed   Google Scholar

Time pressures and a lack of confidence could be prompting reviewers to plagiarize text in their reports. Credit: Thomas Reimer/Zoonar via Alamy

Mikołaj Piniewski is a researcher to whom PhD students and collaborators turn when they need to revise or refine a manuscript. The hydrologist, at the Warsaw University of Life Sciences, has a keen eye for problems in text — a skill that came in handy last year when he encountered some suspicious writing in peer-review reports of his own paper.

Last May, when Piniewski was reading the peer-review feedback that he and his co-authors had received for a manuscript they’d submitted to an environmental-science journal, alarm bells started ringing in his head. Comments by two of the three reviewers were vague and lacked substance, so Piniewski decided to run a Google search, looking at specific phrases and quotes the reviewers had used.

To his surprise, he found the comments were identical to those that were already available on the Internet, in multiple open-access review reports from publishers such as MDPI and PLOS. “I was speechless,” says Piniewski. The revelation caused him to go back to another manuscript that he had submitted a few months earlier, and dig out the peer-review reports he received for that. He found more plagiarized text. After e-mailing several collaborators, he assembled a team to dig deeper.

Meet this super-spotter of duplicated images in science papers

The team published the results of its investigation in Scientometrics in February 1 , examining dozens of cases of apparent plagiarism in peer-review reports, identifying the use of identical phrases across reports prepared for 19 journals. The team discovered exact quotes duplicated across 50 publications, saying that the findings are just “the tip of the iceberg” when it comes to misconduct in the peer-review system.

Dorothy Bishop, a former neuroscientist at the University of Oxford, UK, who has turned her attention to investigating research misconduct, was “favourably impressed” by the team’s analysis. “I felt the way they approached it was quite useful and might be a guide for other people trying to pin this stuff down,” she says.

Peer review under review

Piniewski and his colleagues conducted three analyses. First, they uploaded five peer-review reports from the two manuscripts that his laboratory had submitted to a rudimentary online plagiarism-detection tool . The reports had 44–100% similarity to previously published online content. Links were provided to the sources in which duplications were found.

The researchers drilled down further. They broke one of the suspicious peer-review reports down to fragments of one to three sentences each and searched for them on Google. In seconds, the search engine returned a number of hits: the exact phrases appeared in 22 open peer-review reports, published between 2021 and 2023.

The final analysis provided the most worrying results. They took a single quote — 43 words long and featuring multiple language errors, including incorrect capitalization — and pasted it into Google. The search revealed that the quote, or variants of it, had been used in 50 peer-review reports.

Predominantly, these reports were from journals published by MDPI, PLOS and Elsevier, and the team found that the amount of duplication increased year-on-year between 2021 and 2023. Whether this is because of an increase in the number of open-access peer-review reports during this time or an indication of a growing problem is unclear — but Piniewski thinks that it could be a little bit of both.

Why would a peer reviewer use plagiarized text in their report? The team says that some might be attempting to save time , whereas others could be motivated by a lack of confidence in their writing ability, for example, if they aren’t fluent in English.

The team notes that there are instances that might not represent misconduct. “A tolerable rephrasing of your own words from a different review? I think that’s fine,” says Piniewski. “But I imagine that most of these cases we found are actually something else.”

The source of the problem

Duplication and manipulation of peer-review reports is not a new phenomenon. “I think it’s now increasingly recognized that the manipulation of the peer-review process, which was recognized around 2010, was probably an indication of paper mills operating at that point,” says Jennifer Byrne, director of biobanking at New South Wales Health in Sydney, Australia, who also studies research integrity in scientific literature.

Paper mills — organizations that churn out fake research papers and sell authorships to turn a profit — have been known to tamper with reviews to push manuscripts through to publication, says Byrne.

The fight against fake-paper factories that churn out sham science

However, when Bishop looked at Piniewski’s case, she could not find any overt evidence of paper-mill activity. Rather, she suspects that journal editors might be involved in cases of peer-review-report duplication and suggests studying the track records of those who’ve allowed inadequate or plagiarized reports to proliferate.

Piniewski’s team is also concerned about the rise of duplications as generative artificial intelligence (AI) becomes easier to access . Although his team didn’t look for signs of AI use, its ability to quickly ingest and rephrase large swathes of text is seen as an emerging issue.

A preprint posted in March 2 showed evidence of researchers using AI chatbots to assist with peer review, identifying specific adjectives that could be hallmarks of AI-written text in peer-review reports .

Bishop isn’t as concerned as Piniewski about AI-generated reports, saying that it’s easy to distinguish between AI-generated text and legitimate reviewer commentary. “The beautiful thing about peer review,” she says, is that it is “one thing you couldn’t do a credible job with AI”.

Preventing plagiarism

Publishers seem to be taking action. Bethany Baker, a media-relations manager at PLOS, who is based in Cambridge, UK, told Nature Index that the PLOS Publication Ethics team “is investigating the concerns raised in the Scientometrics article about potential plagiarism in peer reviews”.

How big is science’s fake-paper problem?

An Elsevier representative told Nature Index that the publisher “can confirm that this matter has been brought to our attention and we are conducting an investigation”.

In a statement, the MDPI Research Integrity and Publication Ethics Team said that it has been made aware of potential misconduct by reviewers in its journals and is “actively addressing and investigating this issue”. It did not confirm whether this was related to the Scientometrics article.

One proposed solution to the problem is ensuring that all submitted reviews are checked using plagiarism-detection software. In 2022, exploratory work by Adam Day, a data scientist at Sage Publications, based in Thousand Oaks, California, identified duplicated text in peer-review reports that might be suggestive of paper-mill activity. Day offered a similar solution of using anti-plagiarism software , such as Turnitin.

Piniewski expects the problem to get worse in the coming years, but he hasn’t received any unusual peer-review reports since those that originally sparked his research. Still, he says that he’s now even more vigilant. “If something unusual occurs, I will spot it.”

doi: https://doi.org/10.1038/d41586-024-01312-0

Piniewski, M., Jarić, I., Koutsoyiannis, D. & Kundzewicz, Z. W. Scientometrics https://doi.org/10.1007/s11192-024-04960-1 (2024).

Article   Google Scholar  

Liang, W. et al. Preprint at arXiv https://doi.org/10.48550/arXiv.2403.07183 (2024).

Download references

Related Articles

• Peer review
• Research management

Algorithm ranks peer reviewers by reputation — but critics warn of bias

Nature Index 25 APR 24

Researchers want a ‘nutrition label’ for academic-paper facts

Nature Index 17 APR 24

Rwanda 30 years on: understanding the horror of genocide

Editorial 09 APR 24

Structure peer review to make it more robust

World View 16 APR 24

Is ChatGPT corrupting peer review? Telltale words hint at AI use

News 10 APR 24

Mount Etna’s spectacular smoke rings and more — April’s best science images

News 03 MAY 24

How reliable is this research? Tool flags papers discussed on PubPeer

News 29 APR 24

Young talents in the fields of natural science and engineering technology

Apply for the 2024 Science Fund Program for Distinguished Young Scholars of the National Natural Science Foundation of China (Overseas).

Shenyang, Liaoning, China

Northeastern University, China

Calling for Application! Tsinghua Shenzhen International Graduate School Global Recruitment

To reshape graduate education as well as research and development to better serve local, national, regional, and global sustainable development.

Shenzhen, Guangdong, China

Tsinghua Shenzhen International Graduate School

Chief Editor, Physical Review X

The Chief Editor of PRX, you will build on this reputation and shape the journal’s scope and direction for the future.

United States (US) - Remote

American Physical Society

Assistant/Associate Professor, New York University Grossman School of Medicine

The Department of Biochemistry and Molecular Pharmacology at the NYUGSoM in Manhattan invite applications for tenure-track positions.

New York (US)

NYU Langone Health

Deputy Director. OSP

The NIH Office of Science Policy (OSP) is seeking an expert candidate to be its next Deputy Director. OSP is the agency’s central policy office an...

Bethesda, Maryland (US)

National Institutes of Health/Office of Science Policy (OSP)

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• Instructions for Authors
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 14, Issue e1
• Advance care plans for vulnerable and disadvantaged adults: systematic review and narrative synthesis
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• http://orcid.org/0000-0003-0792-8963 Samantha Jane Brean 1 , 2 ,
• http://orcid.org/0000-0002-0992-6809 Katrina Recoche 2 ,
• Leeroy William 3 , 4 ,
• Ali Lakhani 5 ,
• http://orcid.org/0000-0002-1372-7669 Yaping Zhong 2 and
• Kaori Shimoinaba 2
• 1 Advance Care Planning , Eastern Health , Wantirna , Victoria , Australia
• 2 Monash University, School of Nursing and Midwifery Peninsula Campus , Frankston , Victoria , Australia
• 3 Supportive and Palliative Care Service , Eastern Health , Wantirna , Victoria , Australia
• 4 Monash University, Eastern Health Clinical School , Box Hill , Victoria , Australia
• 5 La Trobe University, School of Psychology and Public Health , Melbourne , Victoria , Australia
• Correspondence to Samantha Jane Brean, Advance Care Planning, Eastern Health, Wantirna, VIC 3128, Australia; sam.brean{at}easternhealth.org.au

Background Evidence suggests that there is a gap in advance care planning (ACP) completion between vulnerable and disadvantaged populations compared with the general population. This review seeks to identify tools, guidelines or frameworks that have been used to support ACP interventions with vulnerable and disadvantaged adult populations as well as their experiences and outcomes with them. The findings will inform practice in ACP programmes.

Methods A systematic search of six databases from 1 January 2010 to 30 March 2022 was conducted to identify original peer-reviewed research that used ACP interventions via tools, guidelines or frameworks with vulnerable and disadvantaged adult populations and reported qualitative findings. A narrative synthesis was conducted.

Results Eighteen studies met the inclusion criteria. Relatives, caregivers or substitute decision-makers were included in eight studies. Settings: hospital outpatient clinics (N=7), community settings (N=7), nursing homes (N=2), prison (N=1) and hospital (N=1). A variety of ACP tools, guidelines or frameworks were identified; however, the facilitator’s skills and approach in delivering the intervention appeared to be as important as the intervention itself. Participants indicated mixed experiences, some positive, some negative and four themes emerged: uncertainty, trust, culture and decision-making behaviour. The most common descriptors relating to these themes were prognosis uncertainty, poor end-of-life communication and the importance of building trust.

Conclusion The findings indicate that ACP communication could be improved. ACP conversations should incorporate a holistic and personalised approach to optimise efficacy. Facilitators should be equipped with the necessary skills, tools and information needed to assist ACP decision-making.

• Communication
• Quality of life

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/spcare-2023-004162

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

WHAT IS ALREADY KNOWN ON THIS TOPIC

Vulnerable and disadvantaged populations have higher rates of disease, hospitalisation and death.

Vulnerable and disadvantaged adults undertake advance care planning (ACP) less than the general population.

WHAT THIS STUDY ADDS

Highlights the experiences of vulnerable and disadvantaged populations with ACP.

Recommends a holistic approach to ACP communication.

Identifies how an ACP intervention is delivered appears as important as the intervention itself.

Emphasises that when discussing ACP, no single ACP intervention can meet the diversity of populations or individuals within populations.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Recommend that healthcare professionals or lay persons have a diverse range of visual, written and verbal resources to assist in patient-centred ACP discussions.

Training for healthcare professionals on how to provide a holistic approach to ACP communication and different ACP interventions to enable individualised information and support may be beneficial.

Additional research is needed to explore the metrics used to evaluate ACP communication and perspectives of people with disabilities, Indigenous people, people with religious beliefs and gender minority groups.

The skills of the ACP facilitator, the impact of their life circumstances and the methods used to carry out the interventions appeared to be as important as the intervention itself. Further research is required to explore these domains.

Based upon the available evidence, policymakers could support a holistic approach to ACP communication.

Introduction

The WHO 1 reports advance care planning (ACP) to be an important indicator of palliative care, but only 14% of people worldwide who require palliative care at the end of life actually recieve it. In the literature, definitions of end-of-life-care (EOLC) vary, including care provided up to, and including the last 12 months of life. 2 It is important to highlight that ACP is voluntary, including for those people who require or receive palliative care. An international Delphi panel provided a consensus definition for ACP, stating that its goal is to support people to discuss their health and well-being, in order to receive medical care that reflects their values and preferences during a chronic, acute or life-threatening illness. If an individual is unable to make his or her own medical decisions, this process may include selecting another trusted person or persons to make those decisions. 3 ACP encourages shared decision-making by the individual, their family (if applicable) and the clinicians involved in their care. 4 People have a human right to be able to freely discuss their current or future healthcare and to make their own health and well-being decisions. 5 Some people, however, are unable, hesitant or afraid to discuss their current or future healthcare, particularly EOLC. 6

Studies on the barriers to ACP from the perspective of patients and their families have identified a lack of trust in the organisation or healthcare professionals as well as the timing, inaccurate and confusing terminology and philosophy for the ACP discussion. 7 8 The philosophy is relevant to the context of the interaction, such as a clinical need, a healthcare professional seeking direction on potential treatment options and/or limits or a family member seeking advice on what to say or do on their behalf. As a result, the ACP discussion’s philosophy may serve the interests of others rather than the individuals concerned. According to Scott et al , 9 lack of understanding, discussion timing, social and personal taboos against addressing death and healthcare professionals’ avoidance of the subject are all factors that contribute to avoidance of the topic and low uptake of ACP. Rather than relying on statutory advance care directives, specifying medical treatment consented to, or refused in specific circumstances, the importance of discussing values and preferences for care as well as the need for substitute decision-makers (SDM) to be more informed of illnesses, has been described in the literature. 10 11

Vulnerable and disadvantaged populations are more likely to have or develop chronic conditions as well as poor health, disability, frailty or an inability to protect themselves from harm. 12 13 When compared with the general population, all may experience health inequalities and poorer health outcomes because of social and environmental factors, socioeconomic disadvantage, isolation, illness and/or cultural factors. 14 15 The literature on discussing ACP with vulnerable and disadvantaged populations’ remains fragmented. Therefore, a systematic review was conducted with the aims of first identifying ACP tools, frameworks or guidelines available to assist vulnerable and disadvantaged adult populations; second, investigating ACP intervention experiences, including how they were delivered; and third, assessing the effectiveness of ACP interventions based on any reported outcomes among vulnerable and disadvantaged populations, their SDM, carers or families. The findings from the review also aim to inform practice in ACP programmes.

Study design

A systematic review with narrative synthesis was conducted. A narrative synthesis, was selected as according to Popay et al , 16 it encourages and supports storytelling, which is required for addressing the research question and synthesising the evidence on how and why an ACP intervention might be successful or not in various circumstances. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach was used in two searches. 17 A second search was undertaken to meet requirements for journal submission. This review could not be registered with PROSPERO due to submission restrictions during COVID-19 pandemic.

Eligibility criteria

Inclusion criteria.

Studies were included if:

They used original qualitative research methods to explore adult vulnerable and disadvantage populations’ experiences and outcomes with ACP interventions using tools, guidelines or frameworks as well as their SDM, carers or families. This included bereaved SDM, families or carers

This review used the validated PROGRESS-Plus criteria to capture different possible characteristics of vulnerable and disadvantaged populations as developed by Campbell and Cochrane Equity Methods Group and described in the study by Grossman et al , 18 see table 1 Inclusion and exclusion criteria ( online supplemental table1 ).

They used a mixed-methods approach, with qualitative data recorded separately and easily extracted.

They were published in English and full text available:

We were unable to review other languages due to language availabilities of the research team members.

Published between January 2020 and March 2022

Initially no year limits were set, yielding large volumes of potential studies. We reconsidered the criteria, and for the purpose of reviewing the more recent literature, a year limit beginning in 2010 was established. Importantly, in 2010, the inaugural worldwide ACP conference was held, marking a significant milestone.

Supplemental material

• View inline

Inclusion and exclusion criteria

Exclusion criteria

Studies were excluded if:

They were not original research, including opinion papers, editorials, books, study protocols, systematic reviews, conference abstracts, dissertations, comments, letters and grey literature as they would not be able to answer the research question.

Participants were under 18 years of age.

Search strategy

We conducted a systematic search of Ovid MEDLINE, Embase via Ovid, CINAHL Plus, Scopus, the Cochrane Library and PsyINFO for research published between January 2010 and March 2022. To guide the research strategy, SJB conducted a preliminary search of published literature on the topic, using the ‘snowballing’ technique to look for additional cited works, keywords and terms in titles and abstracts. 19 Ovid MEDLINE was then searched with the key terms, ‘advance care planning’, ‘vulnerable/disadvantaged’ and ‘tools’ to identify relevant medical subject headings terms. The Cochrane Library was used to capture broad descriptors to ensure that all related terminologies were included. The OVID Medline search strategy was adapted for the other five databases ( online supplemental appendix 1 ).

Study selection

The identified titles and abstracts from database searches were exported into EndNote V.X9. 20 Articles were then imported into Covidence, and duplicates were removed. 21 For titles and abstracts that met the inclusion criteria, full text was retrieved and reviewed independently by two reviewers, with any disagreements resolved through discussion with a third reviewer. There were 25 titles and abstracts that appeared to be conference posters or abstracts. Authors were contacted, five responded, three studies were published and full-text review was completed. There was no additional hand searching of the reference lists of the included studies.

Data extraction

We evaluated each study using the PROGRESS-Plus Eligibility Criteria, which includes 13 data points of characteristics of vulnerable and disadvantaged populations ( online supplemental table 2 ). Furthermore, the study, aims, setting, participants, size, age, sex, ACP intervention, data collection, outcomes and participant quotes were extracted. A synopsis of the study objectives, population, outcomes and conclusion was prepared during data extraction (SJB). Two reviewers (KS and KR) independently checked the data extracted from each study for completeness and accuracy. If findings were from a specific population group, they were categorised and synthesised accordingly. The findings were first coded by SJB, reviewed with KS, KR, LW and AL and any differences of opinion were resolved with discussion.

Quality assessment

The methodological quality of studies meeting inclusion criteria was evaluated as part of the full-text screening process. This is determined by the study design, the use of the appropriate quality assessment instrument and assessment of the risk of bias. 22 Three reviewers independently assessed the methodological quality of studies that meet the inclusion criteria using either the JBI Qualitative Assessment and Review Instrument, the JBI Randomised Control Trial checklist 23 or a Mixed Methods Appraisal Tool. 24 All questions within the applicable tool must be answered with an yes/no, unsure/can not tell, not applicable, include/exclude/require assistance. Any disagreements about the quality appraisal were discussed and, if necessary, resolved by a fourth reviewer.

A narrative synthesis was conducted according to the JBI manual for evidence synthesis. 25 We began by reviewing the data from each study that reported on ACP interventions using tools, frameworks or guidelines, participant experiences and outcomes with adult vulnerable and disadvantaged populations. Characteristics and key findings of each study’s type and mode of delivery of ACP interventions as well as an exploration of experiences with the interventions and any outcomes ( online supplemental table 2 ). The above findings were organised first by ACP intervention type, then within and across studies to look for commonalities and data relationships. If findings were from a specific population group, they were categorised and synthesised accordingly. The findings were first coded by SJB, reviewed with KS, KR, LW and AL and any differences of opinion were resolved with discussion.

These initial findings were then further analysed by identifying themes within the data. These themes were further organised into related groups. By grouping or clustering the findings into themes that best explained the findings, the synthesis was broadened. Because interventions were delivered by healthcare professionals or healthcare workers who had been trained for the intervention, the term facilitator was used. Members of the research team discussed any differences in finding comparisons until consensus was reached.

After removing 1076 duplicates, the database searches yielded 13 033 potential studies. Following a review of the titles and abstracts, a total of 12 506 papers were excluded due to the exclusion date being moved forward to 2010, the wrong study population, the lack of ACP intervention or the incorrect study design. Of the 527 remaining studies, 18 met criteria ( figure 1 ).

• Download figure
• Open in new tab
• Download powerpoint

Preferred Reporting Items for Systematic Reviews and Meta-analyses flowchart of study selection process. 17 ACP, advance care planning.

Characteristics of included studies

The 18 included studies were conducted in eight countries: single studies in Canada, 26 Netherlands, 27 Northern Ireland, 28 Norway, 29 Singapore, 30 South Korea 31 and Switzerland 32 and 11 studies in the USA 33–43 ( online supplemental table 3 ). There were eight qualitative studies, eight mixed methods studies and two randomised controlled trials that reported qualitative data separately. Study interventions were delivered across a variety of settings, hospital outpatient clinics (N=7), community settings (N=7), nursing homes (N=2), prison (N=1) and a hospital in-patient setting (N=1). The 18 studies involved a total of 1944 participants, including 538 men, 1347 women and 293 relatives or SDM. Across all studies that provided a mean age, the mean of this mean was 69 years. Participants ages ranged from 18 to 100 years.

In addition to living with or dying from chronic conditions, participants faced additional challenges such as low socioeconomic status, limited schooling, unemployment, gender minority status or social marginalisation. Nearly half of all studies, seven studies, recruited participants from low socioeconomic areas, and six studies, recruited participants with limited schooling, or from race/ethnicity minorities. Participants in five studies were either unemployed or retired, and five recruited participants who lived in public or urban housing, nursing homes or prison. Participants in two studies included participants with low traditional health or technology literacy, one of which also included participants with low numeracy or graph literacy and low patient engagement or participation ( online supplemental table 2 ).

Participants with neurological conditions with, or without, caregivers/relatives were recruited for five studies. This included one study with bereaved SDMs. Participants over the age of 65 years were recruited in three studies with or without family members. There were nine studies involving participants with liver cirrhosis, advanced cancer, dialysis patients with or without end-stage renal disease, chronically ill male prisoners, seriously ill veterans, underserved African Americans, hospitalised patients, nursing home residents and relatives, and bereaved lesbian, gay, bisexual older women.

Identified ACP interventions

We identified 17 ACP tools, guidelines or frameworks ( online supplemental table 3 ). Written information in the form of booklets (including disease and culturally specific), DVD and video (providing visual information including scenarios), local ACP and goals of care (GOC) form, interactive iPad (enabling individuals to make video declarations) and verbal activity/conversation guides (game, focus groups or semistructured interviews). One study embedded ACP into routine clinical practice, 27 and another used all modalities, written, visual and verbal to provide ACP information. 26 Three studies used or adapted a Respecting Choices ACP model 30 34 36 ( online supplemental table 3 ).

The ACP interventions explored individual’s preferences for life-prolonging treatments, cardiopulmonary resuscitation, mechanical ventilation, feeding tubes, EOLC preferences, experiences of making EOLC decisions for a family member, EOLC decision-making styles and cultural or spiritual needs. Outcomes were measured at various time points, ranging from immediately after the intervention to a few days, months or up to 2 years post death.

Health literacy considerations

All of the studies considered health literacy and recognised that ACP information needs to be provided in ways that take low health literacy into account. In the Australian context, data from 2014 identified that 60% of adult Australians have low or poor health literacy. 44 Because of additional possible psychosocial, economic, language and/or environmental factors, the relationship between health literacy and vulnerable and disadvantaged populations is complex. These elements can have an impact on a person’s ability to obtain and use health information. 45 Studies used a variety of strategies to provide ACP information and support in ways that were accessible and tailored to the needs of participants, including providing an ACP intervention in prison 34 and an EOL game in community venues. 38 Two studies offered ACP interventions in Spanish and English 37 39 ( online supplemental table 3 ).

Quality appraisal of included studies

All of the studies included were of high quality, had a low risk of bias and were evaluated independently ( online supplemental tables 4-6 ). However, seven of the eight qualitative studies lacked a statement identifying the theoretical and/or cultural context for the research. 26 27 29 30 33–35 The cultural context of qualitative research is increasingly recognised as important because it influences not only the individual behaviour of the researcher and participants but also their potential interactions within the context of the research methodology. 46

Identification of themes and interventions

Multiple themes emerged from the data analysis. The dominant themes were uncertainty, trust, culture and decision-making behaviour. Some participants’ experiences varied within populations, indicating the presence of more than one theme. When this occurred, there were insufficient findings to change themes within the individual study.

Uncertainty

Participants unsure what ACP was, or how to use it or felt unable to plan ahead and/or could not remember if they had previously made an ACP. Unknown or unsure prognosis.

Participant quote: I was in the hospital, in and out over two weeks at the holidays. One doctor would say this, one doctor would say that, nobody could tell me a straight answer, and I was like, to hell with that, I'm not doing this anymore (low social economic status ACP4). 26

Regardless of the study design, ACP tool, guideline or framework or population, seven studies found that participants were unsure about pre-emptive treatment decisions and EOL planning during or after ACP interventions. 26 28 30 32 33 40 43 In contrast, in a randomised controlled trial of a guide for caregivers called, comfort care at the EOL for persons with dementia, significantly reduced decision-making uncertainty in the intervention. 28 The intervention had no discernible effect on the psychological distress of family caregivers, the number of completed Do Not Resuscitate orders, hospitalisation or hospital deaths. Bereaved lesbian, gay and bisexual older women reported feeling uncertain about prognosis, EOL and ACP communication from healthcare professionals, which resulted in a lack of knowledge of palliative and EOLC. 43 Poor communication caused distress and missed opportunities to discuss EOLC with their children as a couple or as a family. Better consistent communication with spouse/partner, according to participants, is required to improve EOL experiences. 43 Patients with liver cirrhosis received an ACP intervention that included a local written ACP guide and visual materials demonstrating GOC designation. 26 Participants expressed different preferences for receiving ACP information but still expressed uncertainty about disease progression, GOC discussions, the role of the SDM and ACP. However, the majority of the 17 participants, 14 of them, had designated an SDM. 26 A study with bereaved African-American SDMs of a relative who died from dementia reflected on their EOL decision-making, which ranged from congruence with deceased relatives wishes to satisfaction or regret. 33 Participants expressed uncertainty about EOL and palliative care services because of a lack of information, emphasising the importance of clear and culturally appropriate SDM role preparation, including emotional and decision-making support throughout dementia disease progression. 33

Involvement of the patient or family in care, including respect for their knowledge of the individual. Distrust of the organisation.

Participant quote: It helped me, quite confused as I was at that time, to learn that there was a team that would help me, support me, people with a plan… and, of course, knowledge about the disease (interview patient 13). 27

Three qualitative and one mixed methods study identified that it is important for participants to establish trust and rapport with healthcare professionals before discussing their values or preferences for care. 27 29 34 36 Furthermore, during the Last Steps Respecting Choices ACP intervention, prisoners expressed a desire to feel safe and establish rapport before discussing their treatment preferences and EOLC. 34 Prisoners expressed gratitude for being given time to discuss their care and expressed a desire to continue treatments. 34 A study explored the perspectives of an ACP intervention embedded in routine practice with adult patients living with amyotrophic lateral sclerosis or progressive muscular atrophy. 27 Participants talked about how, as their condition progressed, ACP conversations became more common in their care. Participants could discuss EOLC at any time, and after being diagnosed, one participant discussed euthanasia with his doctor. 27 A study of nursing home residents and family members who used an ACP intervention with prescripted questions revealed residents’ interconnectedness and trust as well as the importance of family presence. 29 The study identified how residents and relatives share their experiences with dying and death, and their involvement and participation in ACP-conversations is critical for learning about what matters most to the residents for their care, including EOLC. Participants in a 12-month study with lay community health workers who provided home care to elderly adults with chronic conditions and were trained in the Respecting Choices ACP intervention concluded that the study was successful because the lay community health workers could be trusted. 36 However, 188 participants (46%) had no idea where their ACP documents were. The study emphasised the importance of the patient–caregiver relationship in supporting both parties to discuss ACP as well as in informing the participant about the location of their ACP documents.

Strategies to provide culturally respectful ACP information for specific populations, such as culturally and linguistically diverse (CALD) populations, in order to improve opportunity to engage in ACP discussions.

Participant quotes: You cannot go against what God has already decided. God was ultimately the one who decided when your life was over. Another stated, They at least have to try the chest compressions. That’s part of their job so it’s not really up to us. 37

Culturally specific ACP interventions were explored in four studies with different vulnerable, disadvantaged CALD populations. 31 37–39 The importance of faith and the church in EOL decisions was identified in two studies. 37 39 The relationship between culture and faith appears to be interconnected, with one potentially influencing the other. 47 In one, the ACP intervention used focus groups and semistructured interviews in Spanish and English to investigate treatment preferences and EOLC. Rather than specifying whether treatments were wanted, participants debated the acceptability of invasive versus natural procedures as well as the role of God and the doctor’s duty of care. Other observations included the importance of planning a traditional funeral and ensuring that funeral costs were prepaid, but many participants had not given ACP much thought because they believed that their health was God’s will. 37 ACP-I Plan was an ACP intervention used with older Latinos with chronic illness, which included counselling/emotional support, cultural influences with interactive ACP treatment decisional support and ACD documentation in both Spanish and English. 39 This study not only discovered a similar finding about the importance of faith but also included chaplains or their church pastor in the ACP discussions to provide emotional and spiritual support. Participants were mostly pleased with the ACP-I Plan intervention, but they did not elaborate on what that meant. Communicating and listening to our senior voice about EOL, also known as ‘the Hanoljigi’ (in Korean), is an ACP information booklet for older adults with chronic conditions and their surrogates. 31 Even though it was useful to 75% of the participants (17 patients and 15 surrogates), two surrogates expressed reservations about discussing EOLC. They expressed particular sadness, for having differing opinions on, and even disagreeing with, the preferences of their parents or spouses. Some patients reported that starting an EOL conversation with their families was difficult, but they appreciated the opportunity. In two studies, participants emphasised the importance of making time for ACP discussions because the conversations can be emotional and raise fears, including fear of dying. 31 39 African Americans from community hospice organisations who were underserved reported that the culturally appropriate EOL communication game ‘hello’ was enjoyable and educational because learning about ACP was empowering and emotionally beneficial. 38 There was a verbal pre-ACP explanation before the game began.

Decision-making behaviour

The elements that influence a person’s decision-making (or lack thereof) or the organisations approach to decision-making behaviour.

Participant quotes: ‘I decide’ ‘Let others decide’ ‘It’s my choice’ or ‘Others can choose’ 35

Three studies reported on participants' decision-making behaviour when discussing values and preferences for care; identifying critical factors such as motivation, decision-making time, and spirituality or religiosity. 35 41 42 Participants in a multiracial focus group of seriously ill veterans were asked guided questions about ACP-expressed decision-making behaviour ranging from ‘it’s my choice’ to fatalistic or planned to avoid decision-making. 35 Following a prepreparation EOL scenario video, a single study with hospitalised patients used iPad ACP declarations. 42 Participants videotaped themselves, but instead of making specific treatment declarations, many chose to talk about psychosocial needs, religion, spiritual well-being, dignity and legacy. The majority of participants reported the video declaration as helpful, and they would recommend it to others. However, 9 of the 15 participants, the ACP iPad declarations relating to life prolonging treatment, treatment limitations and comfort care were deemed unclear. 42 The researchers hypothesised that the reason declarations were unclear might be because participants were not aware of their options for treatment (with the exception of CPR and intubation, which were generally known), or they were not sure how to express their wishes clearly.

The ACT-Plan ACP intervention included group sessions with five to nine participants and discussed the knowledge, storytelling and behaviours required to make EOL decisions for another person with carers of a relative with dementia. At the post-test, 23 of the 35 ACT-Plan participants (66%) changed one or more of their decisions, while 10 of the 33 (30%) control group subjects did not. 41 In comparison to the attention control group, the findings indicated that the ACT-Plan education intervention showed positive changes, in participants’ knowledge and self-efficacy, and qualitative data suggested that the intervention was well received.

This systematic review examined 18 studies that reported on participant experiences and outcomes of ACP tools, guidelines or frameworks used to support ACP interventions with vulnerable and disadvantaged adult populations. The included studies recruited participants from eight countries. Four themes were identified: uncertainty, trust, culture and decision-making behaviour. The findings revealed that when participants discussed ACP within and across populations, they had mixed experiences, some positive and negative. This finding is consistent with experiences of health interventions with vulnerable and disadvantaged populations as described by Luchenski et al 48 All studies agreed that ACP information needs to be provided in ways that take into account particularly, people’s poor health literacy. This review found no evidence that a single ACP intervention met the needs of participants. However, it appeared that the facilitator’s skills and approach in delivering an intervention were just as important as the intervention itself. This implies that the ACP tool, guideline or framework is a method, but how, when, and who delivers the ACP intervention is equally important. As a result, of the experiences of participants in this review, a holistic framework for discussing ACP is proposed ( figure 2 ) as a strategy to support ACP communication and experiences. It is suggested that ACP training programmes incorporate a holistic individualised communication approach ( figure 2 ). This framework is adapted from the EOL decision-making process EOL. 49

Holistic Framework for Advance Care Planning Discussions. Adapted from EOL decision-making process diagram. 48 ACP, advance care planning; EOL, end-of-life.

Some participants from different populations reported discomfort when discussing ACP and EOLC as well as having negative experiences with healthcare professional communication. 31 32 34 42 43 It is also important to note that ACP is entirely voluntary, and some participants with early cognitive impairment reported that ACP was irrelevant or unnecessary. 30 Perhaps this is due to the taboo nature of discussing death and dying in many social and cultural settings as well as healthcare professionals’ discomfort and avoidance of discussing EOLC. 9 However, how healthcare professionals, patients, SDM, carers and/or families are supported to have these discussions is less clear. Tracy et al 50 raise that Australia is lagging behind many other countries in healthcare professional education, training, policies and resources in shared decision-making. A randomised controlled trial with family carers following a dementia-specific ACP intervention found that the ACP intervention did not increase anxiety/depression. 28 Suggesting an ACP intervention tailored to the participants’ needs may help with communication between the carers and healthcare professionals. In contrast, a study with people with early dementia (PWED) and their relatives, which encountered multiple challenges with the feasibility of the study, prompting the authors to emphasise the importance of developing an ACP tool that does not burden PWED and their relatives. 32

Because participants identified uncertainty, it suggests that reassurance and validation of uncertainty are important for effective ACP communication. 26 28 30 32 33 39 43 When someone is unsure what to do or needs to learn more about their health, how can they make a treatment decision? ACP communication does not always lead to medical treatment decisions or clinical outcomes, which raises the question of what metrics are used to assess ACP. Sudore et al 3 recognised that the ACP discussion focuses on the person’s concerns as well as their values, beliefs and preferences, including how they would like to obtain information.

Participants highlighted the importance of psychosocial (family structure), spiritual/religious needs, dignity, legacy and addressing physical symptoms in ACP communication. 27 37 38 40 42 43 Two studies with bereaved relatives/SDM highlighted lack of knowledge of palliative care services and EOLC options caused regret and missed opportunities for communication and support. 33 43 When discussing ACP, some participants across cultures emphasised the value of consulting a religious leader. 37 39 Additionally, ACP interventions for CALD communities required diversity in not only languages for information but also in formats used to provide the information. 51

Participants who had a positive experience emphasised the importance of taking the time to build trust in order to discuss their values and preferences for care 27 29 36 39 or that ACP was beneficial when included as a routine component of care as their disease progressed. 27 This could be because the more participants interacted with the ACP intervention, the more satisfied they were with the process, although more time and interaction may not result in the development of rapport or ACP communication outcomes.

The concept of vulnerability and disadvantage is complex, and while this review provides a definition, it is important to highlight the variety of health inequalities that exist as well as the need for healthcare professionals to be clear about the criteria used to determine health disparity. 52 In the broadest sense, vulnerability and disadvantage may be more widespread and influence anyone, regardless of illness stage, emotional, psychological, socioeconomic status, gender, cultural or spiritual needs.

Strengths and limitations

The review’s strength is that it described different vulnerable and disadvantaged populations’ experiences and outcomes with ACP; it includes bereaved carers and/or partners and includes both positive and negative experiences. Three researchers independently appraised the quality of each study, which strengthened the findings. However, there are some limitations. Only 18 studies met the inclusion criteria, highlighting the lack of ACP research focus in these populations. There was a scarcity of ACP-focused peer-reviewed publications undertaken with disability, Indigenous and minority religious groups. The review was restricted to studies published in English only, between 2010 and 2022, which introduced a selection bias; however, studies from eight countries were included, which is a strength.

There were difficulties with this review. Because the terms vulnerable and disadvantaged are complex, we used a validated measure. Many studies, however, did not meet the inclusion criteria because the study population was vulnerable but did not meet the disadvantaged criteria or did not include qualitative findings. Another difficulty was classifying an ACP tool, guideline or framework because some studies discussed intervention preparation or enablers rather than intervention implementation and evaluation.

This review synthesised evidence on the experiences and outcomes of ACP interventions via tools, guidelines or frameworks with vulnerable and disadvantaged adult populations. The most common experiences were uncertainty about prognosis, poor EOL communication, confusing ACP terminology and the importance of building trust when discussing ACP. A variety of ACP tools, guidelines or frameworks were identified, demonstrating that there is no one-size-fits-all solution. The skills and approach of the ACP facilitator in delivering the intervention appeared to be as important as the ACP tool, guideline or framework used. Understanding the needs and perspectives of vulnerable and disadvantaged adult populations who experience higher rates of illness and health inequities is key to providing holistic care that is consistent with their beliefs, values and preferences. Exploring a person’s motivation, past experience, current needs, awareness of their disease progression and obtaining permission before discussing ACP demonstrates respect for the individual and may play an important role in engaging and creating trust. It is recommended that healthcare professionals or lay persons have access to a wide range of visual, written and verbal resources to help with ACP discussions as well as training on a holistic individualised approach to ACP communication. Further research is recommended to explore metrics used to evaluate ACP communication, ACP facilitators’ impact on how an ACP intervention is delivered.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Acknowledgments.

The authors wish to thank Claire Johnson and Sharon Liqurish for their support in conceptualising this research.

• World Health Organization
• Rawlings D ,
• Sudore RL ,
• You JJ , et al
• Sulistio M ,
• Vo A , et al
• ↵ Charter of human rights and responsibilities act (2006) (Vic) (Austl) . Available : https://www.legislation.vic.gov.au/in-force/acts/charter-human-rights-and-responsibilities-act-2006/015
• Australian Commission on Safety and Quality in Health Care
• Hilliard TS ,
• Washington T ,
• Hines C , et al
• Tilburgs B ,
• Vernooij-Dassen M ,
• Koopmans R , et al
• Mitchell GK ,
• Reymond EJ , et al
• McMahan RD ,
• Morrison RS ,
• ↵ Australia’s health series No.17 cat. No.AUS 232 . In : Australia’s health 2020: in brief . Canberra : AIHW , 2020 . Available : https://www.aihw.gov.au/getmedia/2aa9f51b-dbd6-4d56-8dd4-06a10ba7cae8/aihw-aus-232.pdf.aspx?inline=true
• Australian Health Ministers’ Advisory Council (AHMAC)
• LoPresti MA ,
• Pereira-Salgado A ,
• Roberts H ,
• Sowden A , et al
• Shamseer L ,
• Clarke M , et al
• Grossman LV ,
• Masterson Creber RM ,
• Benda NC , et al
• ↵ The EndNote Team. EndNote (Version X9) Clarivate Analytics . 2018 Available : https://endnote.com/
• Covidence systematic review software
• Lockwood C ,
• Munn Z , et al
• Tufanaru C ,
• Aromataris E , et al
• Gonzalez-Reyes A ,
• Aromataris E ,
• Carbonneau M ,
• Davyduke T ,
• Spiers J , et al
• Seeber AA ,
• Hijdra A , et al
• Cardwell C , et al
• Thoresen L ,
• Lillemoen L
• Goh J , et al
• Park E-J , et al
• Bosisio F ,
• Sterie A-C ,
• Rubli Truchard E , et al
• Matthews AK ,
• Arslanian-Engoren C , et al
• Sanders S ,
• Stensland M ,
• Ford ME , et al
• Litzelman DK ,
• Griffin WJ , et al
• Gonzalez K ,
• Moreno G , et al
• Van Scoy LJ ,
• Witt P , et al
• Nedjat-Haiem FR ,
• Carrion IV ,
• Gonzalez K , et al
• Bakitas M ,
• Dionne-Odom JN ,
• Jackson L , et al
• Bonner GJ ,
• Wilkie DJ , et al
• Quintiliani LM ,
• Murphy JE ,
• Buitron de la Vega P , et al
• Valenti KG ,
• Janssen LM ,
• Enguidanos S , et al
• Pelzang R ,
• Hutchinson AM
• Permana I ,
• Ormandy P ,
• Luchenski S ,
• Maguire N ,
• Aldridge RW , et al
• Wallhagen MI ,
• Thompson R ,
• Muscat DM , et al
• Detering KM , et al
• Williams E ,
• Babalola G , et al

Contributors KS, KR and LW supervised the study. SJB, KS, KR and LW were responsible for planning the study, design, article screening and quality assessment. AL guided research methodology. YZ: article screening. SB drafted manuscript. KS, KR, LW and AL reviewed draft manuscript and made critical revisions. SJB is the guarantor and is responsible for the overall content.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Read the full text or download the PDF:

Chinese government website security is often worryingly bad, say Chinese researchers

Bad configurations, insecure versions of jquery, and crummy cookies are some of myriad problems.

Exclusive   Five Chinese researchers examined the configurations of nearly 14,000 government websites across the country and found worrying lapses that could lead to malicious attacks, according to a not-yet-peer-reviewed study released last week.…

The authors, all from the Harbin Institute of Technology, described the study as scrutinizing "the security and dependency challenges besieging China's governmental web infrastructure." They claim to have revealed "substantial vulnerabilities and dependencies that could impede the digital efficacy and safety of governmental web systems."

The researchers considered domain name resolution, utilization of third-party libraries, Certificate Authority (CA) services, Content Delivery Network (CDN) services, Internet Service Providers (ISP), the adoption of HTTPS, IPv6 integration, Domain Name System Security Extensions (DNSSEC) implementation, and website performance.

The paper found plenty of problems.

Over a quarter of domain names used by Chinese government websites were found not to have name server (NS) records – meaning it’s possible they lack effective DNS configuration and could be unreliable or inaccessible.

Another finding was a "notable dependence" on five DNS service providers – a lack of diversity that could open the network infrastructure to single points of failure.

"In the event of a technical issue, cyber attack, or regulatory action affecting one of these major providers, a significant portion of the DNS infrastructure could be compromised, impacting accessibility and security across a wide area," wrote the researchers.

Furthermore, 4250 of the systems used versions of the jQuery JavaScript library that are vulnerable to CVE-2020-23064 – meaning they were open to a remote attack that has been a known problem for around four years.

And although ISPs used by government websites were found to have a geographical spread that was moderately distributed, the researchers suggested that server redundancy fell short of what is required for optimal security and reliability.

"Among the ISPs, China Mobile, China Telecom, China Unicom, and Alibaba Cloud occupy 98.29 percent of the market," found the team, which explained that "if one of the ISPs experiences a failure or attack, the entire network could be affected, causing widespread service outages."

The researchers also found a slate of unsigned DNSSEC signatures – even though 101 subdomain records were found to have RRSIG (Resource Record Signature) records.

"This discrepancy suggests that while specific DNS records may have been signed, such signatures might not be accurately represented in the whois database, or alternatively, the signing may be limited to certain subdomains rather than encompassing the entire domain," explained the authors.

And finally, a Zed Attack Proxy (ZAP) analysis found:

The researchers concluded the investigation has uncovered "pressing security and dependency issues" that may not have a quick fix.

"Despite thorough analyses, practical solutions to bolster the security of these systems remain elusive," wrote the researchers. "Their susceptibility to cyber attacks, which could facilitate the spread of malicious content or malware, underscores the urgent need for real-time monitoring and malicious activity detection."

The study also highlights the need for "stringent vetting and regular updates" of third-party libraries and advocates "a diversified distribution of network nodes, which could substantially augment system resilience and performance."

The study will likely not go down well in Beijing, as China's government has urged improvements to government digital services and apps often issues edicts about improving cybersecurity. ®

Clyde Staffing

Photos & videos, you might also consider.

Prime Worx Partners

Prime worx partners go the extra mile for our clients no task to big or to small read more

in Business Consulting

Silver Med Healthcare

Providing subacute respiratory care can be challenging, but Silver Med Healthcare can help. We provide staff, equipment, supplies and consulting services for respiratory departments at organizations providing health care and senior… read more

in Employment Agencies, Financial Advising, Life Insurance

J Squared Communications

15.2 miles away from Clyde Staffing

Full service marketing agency specializing in strategy, content development + sales copy. We produce SEO blog + web content as well as ebooks, white papers, email sequences and social media for established businesses. read more

in Advertising, Marketing, Web Design

Location & Hours

Suggest an edit

Los Angeles, CA 90001

Florence-Firestone

Recommended Reviews

• 1 star rating Not good
• 2 star rating Could’ve been better
• 3 star rating OK
• 4 star rating Good
• 5 star rating Great

Select your rating

Overall rating

TLDR - Ultimately an impersonal, undiplomatic and unresponsive 'staffing' agency with strange business practices. Candidate experience is not equally prioritized and agency does not adhere to their own commitments on feedback provision after asking you prematurely (and in some cases unnecessarily) for quite a few documents & headshot (!?). Despite the few press releases announcing the agency's launch, no thorough reviews can be found anywhere, other than a sprinkling of Reddit and TikTok commentary that also speaks to poor candidate experiences. In a world of Anna Delvey's and Elizabeth Holmes', I am not sure if this is a legitimate agency. ----- Founded by former career assistant to high profile clientele, Meghan Grimm, Clyde Staffing was created with the intention of 'identifying, developing and placing exceptional assistant candidates with top talent, while providing a peer-based community.' The company hopes to execute this by doing the following: -Allowing 3 weeks for the review of your application & resume -Providing feedback to help you improve your candidacy -Offer training tools & resources to qualified candidates, while allowing them mentorship with their assistant community. One would think that because Meghan herself has been through the process of being staffed as a 'sidekick', her company would understand the sensitivity and importance of making the process of the job search/placement for qualified assistants, a streamlined and straight forward one, as I am sure the agency undoubtedly does for it's 'high profile clientele'. Unfortunately, this is not the case. Unlike other staffing agencies, Clyde follows up post resume submission with requests for certain documents prematurely, never even initiating a short screening call with the candidate of supposed interest. After resume submission, you are asked to provide a HEADSHOT, COVER LETTER, REFERENCES and a request to fill out their IN HOUSE APPLICATION, a thrown together Word doc that attempts to get addtl. info on your personal and professional background & preferences. No one introduces themselves or signs their emails, so you don't know who you are talking to or how to address them, which further makes the process incredibly impersonal and strange. The HEADSHOTS are an EXTREMELY bewildering ask and there is no disclosure as to why they need it or why it is relevant to the application process. This ultimately could lend itself to DISCRIMINATORY PRACTICES and should be revised immediately. No legitimate staffing agency asks for headshots. This is NOT a casting agency. While the Clyde Staffing site does not list job opportunities like their competitors, they post opportunities on sites that aggregate entertainment roles looking to be staffed. How they ARE similar to some staffing agencies is, upon application to the role of interest, they make no mention of it, which ultimately leads you to believe that you have fallen victim to the ol' BAIT & SWITCH. Either the role has been 'staffed' or perhaps it did not exist at all. Some tips: -If you are overwhelmed by applicant volume, you should be thoughtfully parsing through applications thoughtfully to organize them in a way to do proper outreach and followup if in fact interested. Candidates don't want to do any unnecessary homework' of providing addtl documentation if you do not plan on moving forward with them as an an applicant. You should be able to tell by the initial resume submission whether the candidate is a good fit for your business. -Do not say you will provide addtl feedback in a month's time if that is not your plan. -If a candidate is respectfully following up with you, there is a diplomatic way of letting them know that you need them to be patient, etc., rather than being unresponsive. It shouldn't need to be said, but it's unprofessional. All in all, perhaps the agency does not have the clientele to keep up with the influx of candidates seeking employment opportunities. Who knows? However, looking for new employment is already sometimes such a demoralizing experience...why add to that.? There is definite room for growth.

I had a similar experience as others reviewing here. Jumped through numerous hoops (I have over 20 years of celebrity PA experience) only to be ghosted by these former "assistants" who if they are who they say they are, should know how to be more professional. This team is as phony as they come.

Very unprofessional. Requiring a headshot for a professional position is grounds for malpractice. Requires so much paperwork without even disclosing the person you are applying for. Appears as a scammy agency and impersonal which is not beneficial for the client or people interviewed.

D-Kode Technology

10.9 miles away from Clyde Staffing

We are a full scale digital marketing firm doing website design, search engine optimization, inbound marketing along with mobile app and software development. We are located in the Bay Area and Daniel Kodam, one of our owners and… read more

in Web Design, Marketing, Software Development

Los Angeles Permit Expeditors

4.9 miles away from Clyde Staffing

We are a local permit expediting firm. We deal with highly complex projects in the toughest jurisdictions. Some of the services we have to offer are: Preliminary research, Entitlements, Planning approval, Building/MEP approval,… read more

in Professional Services

Browse Nearby

Things to Do

Restaurants

Typing Certificate

Other Employment Agencies Nearby

Find more Employment Agencies near Clyde Staffing

Related Cost Guides

Advertising

Internet Service Providers

Music Production Services

Personal Assistants

Product Design

Software Development

Video/Film Production

• 5 More Cost Guides

People Also Viewed

Comar Agency

Christopher Baker Staffing

Rose’s Agency

A-Z Staff Solutions

Stivers Staffing Services

The Grapevine Agency

Career Group Companies

Executive Temps

Pocketbook Agency

Bennett Gaynor Sustainable Staffing