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Harvard educational review.

Edited by Maya Alkateb-Chami, Jane Choi, Jeannette Garcia Coppersmith, Ron Grady, Phoebe A. Grant-Robinson, Pennie M. Gregory, Jennifer Ha, Woohee Kim, Catherine E. Pitcher, Elizabeth Salinas, Caroline Tucker, Kemeyawi Q. Wahpepah

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Journal Information

• ISSN: 0017-8055
• eISSN: 1943-5045
• Keywords: scholarly journal, education research
• First Issue: 1930
• Frequency: Quarterly

Description

The Harvard Educational Review (HER) is a scholarly journal of opinion and research in education. The Editorial Board aims to publish pieces from interdisciplinary and wide-ranging fields that advance our understanding of educational theory, equity, and practice. HER encourages submissions from established and emerging scholars, as well as from practitioners working in the field of education. Since its founding in 1930, HER has been central to elevating pieces and debates that tackle various dimensions of educational justice, with circulation to researchers, policymakers, teachers, and administrators.

Our Editorial Board is composed entirely of doctoral students from the Harvard Graduate School of Education who review all manuscripts considered for publication. For more information on the current Editorial Board, please see here.

A subscription to the Review includes access to the full-text electronic archives at our Subscribers-Only-Website .

Editorial Board

2023-2024 Harvard Educational Review Editorial Board Members

Maya Alkateb-Chami Development and Partnerships Editor, 2023-2024 Editor, 2022-2024 [email protected]

Maya Alkateb-Chami is a PhD student at the Harvard Graduate School of Education. Her research focuses on the role of schooling in fostering just futures—specifically in relation to language of instruction policies in multilingual contexts and with a focus on epistemic injustice. Prior to starting doctoral studies, she was the Managing Director of Columbia University’s Human Rights Institute, where she supported and co-led a team of lawyers working to advance human rights through research, education, and advocacy. Prior to that, she was the Executive Director of Jusoor, a nonprofit organization that helps conflict-affected Syrian youth and children pursue their education in four countries. Alkateb-Chami is a Fulbright Scholar and UNESCO cultural heritage expert. She holds an MEd in Language and Literacy from Harvard University; an MSc in Education from Indiana University, Bloomington; and a BA in Political Science from Damascus University, and her research on arts-based youth empowerment won the annual Master’s Thesis Award of the U.S. Society for Education Through Art.

Jane Choi Editor, 2023-2025

Jane Choi is a second-year PhD student in Sociology with broad interests in culture, education, and inequality. Her research examines intra-racial and interracial boundaries in US educational contexts. She has researched legacy and first-generation students at Ivy League colleges, families served by Head Start and Early Head Start programs, and parents of pre-K and kindergarten-age children in the New York City School District. Previously, Jane worked as a Research Assistant in the Family Well-Being and Children’s Development policy area at MDRC and received a BA in Sociology from Columbia University.

Jeannette Garcia Coppersmith Content Editor, 2023-2024 Editor, 2022-2024 [email protected]

Jeannette Garcia Coppersmith is a fourth-year Education PhD student in the Human Development, Learning and Teaching concentration at the Harvard Graduate School of Education. A former public middle and high school mathematics teacher and department chair, she is interested in understanding the mechanisms that contribute to disparities in secondary mathematics education, particularly how teacher beliefs and biases intersect with the social-psychological processes and pedagogical choices involved in math teaching. Jeannette holds an EdM in Learning and Teaching from the Harvard Graduate School of Education where she studied as an Urban Scholar and a BA in Environmental Sciences from the University of California, Berkeley.

Ron Grady Editor, 2023-2025

Ron Grady is a second-year doctoral student in the Human Development, Learning, and Teaching concentration at the Harvard Graduate School of Education. His central curiosities involve the social worlds and peer cultures of young children, wondering how lived experience is both constructed within and revealed throughout play, the creation of art and narrative, and through interaction with/production of visual artifacts such as photography and film. Ron also works extensively with educators interested in developing and deepening practices rooted in reflection on, inquiry into, and translation of the social, emotional, and aesthetic aspects of their classroom ecosystems. Prior to his doctoral studies, Ron worked as a preschool teacher in New Orleans. He holds a MS in Early Childhood Education from the Erikson Institute and a BA in Psychology with Honors in Education from Stanford University.

Phoebe A. Grant-Robinson Editor, 2023-2024

Phoebe A. Grant-Robinson is a first year student in the Doctor of Education Leadership(EdLD) program at the Harvard Graduate School of Education. Her ultimate quest is to position all students as drivers of their destiny. Phoebe is passionate about early learning and literacy. She is committed to ensuring that districts and school leaders, have the necessary tools to create equitable learning organizations that facilitate the academic and social well-being of all students. Phoebe is particularly interested in the intersection of homeless students and literacy. Prior to her doctoral studies, Phoebe was a Special Education Instructional Specialist. Supporting a portfolio of more than thirty schools, she facilitated the rollout of New York City’s Special Education Reform. Phoebe also served as an elementary school principal. She holds a BS in Inclusive Education from Syracuse University, and an MS in Curriculum and Instruction from Pace University.

Pennie M. Gregory Editor, 2023-2024

Pennie M. Gregory is a second-year student in the Doctor of Education Leadership (EdLD) program at the Harvard Graduate School of Education. Pennie was born in Incheon, South Korea and raised in Gary, Indiana. She has decades of experience leading efforts to improve outcomes for students with disabilities first as a special education teacher and then as a school district special education administrator. Prior to her doctoral studies, Pennie helped to create Indiana’s first Aspiring Special Education Leadership Institute (ASELI) and served as its Director. She was also the Capacity Events Director for MelanatED Leaders, an organization created to support educational leaders of color in Indianapolis. Pennie has a unique perspective, having worked with members of the school community, with advocacy organizations, and supporting state special education leaders. Pennie holds an EdM in Education Leadership from Marian University.

Jennifer Ha Editor, 2023-2025

Jen Ha is a second-year PhD student in the Culture, Institutions, and Society concentration at the Harvard Graduate School of Education. Her research explores how high school students learn to write personal narratives for school applications, scholarships, and professional opportunities amidst changing landscapes in college access and admissions. Prior to doctoral studies, Jen served as the Coordinator of Public Humanities at Bard Graduate Center and worked in several roles organizing academic enrichment opportunities and supporting postsecondary planning for students in New Haven and New York City. Jen holds a BA in Humanities from Yale University, where she was an Education Studies Scholar.

Woohee Kim Editor, 2023-2025

Woohee Kim is a PhD student studying youth activists’ civic and pedagogical practices. She is a scholar-activist dedicated to creating spaces for pedagogies of resistance and transformative possibilities. Shaped by her activism and research across South Korea, the US, and the UK, Woohee seeks to interrogate how educational spaces are shaped as cultural and political sites and reshaped by activists as sites of struggle. She hopes to continue exploring the intersections of education, knowledge, power, and resistance.

Catherine E. Pitcher Editor, 2023-2025

Catherine is a second-year doctoral student at Harvard Graduate School of Education in the Culture, Institutions, and Society program. She has over 10 years of experience in education in the US in roles that range from special education teacher to instructional coach to department head to educational game designer. She started working in Palestine in 2017, first teaching, and then designing and implementing educational programming. Currently, she is working on research to understand how Palestinian youth think about and build their futures and continues to lead programming in the West Bank, Gaza, and East Jerusalem. She holds an EdM from Harvard in International Education Policy.

Elizabeth Salinas Editor, 2023-2025

Elizabeth Salinas is a doctoral student in the Education Policy and Program Evaluation concentration at HGSE. She is interested in the intersection of higher education and the social safety net and hopes to examine policies that address basic needs insecurity among college students. Before her doctoral studies, Liz was a research director at a public policy consulting firm. There, she supported government, education, and philanthropy leaders by conducting and translating research into clear and actionable information. Previously, Liz served as a high school physics teacher in her hometown in Texas and as a STEM outreach program director at her alma mater. She currently sits on the Board of Directors at Leadership Enterprise for a Diverse America, a nonprofit organization working to diversify the leadership pipeline in the United States. Liz holds a bachelor’s degree in civil engineering from the Massachusetts Institute of Technology and a master’s degree in higher education from the Harvard Graduate School of Education.

Caroline Tucker Co-Chair, 2023-2024 Editor, 2022-2024 [email protected]

Caroline Tucker is a fourth-year doctoral student in the Culture, Institutions, and Society concentration at the Harvard Graduate School of Education. Her research focuses on the history and organizational dynamics of women’s colleges as women gained entry into the professions and coeducation took root in the United States. She is also a research assistant for the Harvard and the Legacy of Slavery Initiative’s Subcommittee on Curriculum and the editorial assistant for Into Practice, the pedagogy newsletter distributed by Harvard University’s Office of the Vice Provost for Advances in Learning. Prior to her doctoral studies, Caroline served as an American politics and English teaching fellow in London and worked in college advising. Caroline holds a BA in History from Princeton University, an MA in the Social Sciences from the University of Chicago, and an EdM in Higher Education from the Harvard Graduate School of Education.

Kemeyawi Q. Wahpepah Co-Chair, 2023-2024 Editor, 2022-2024 [email protected]

Kemeyawi Q. Wahpepah (Kickapoo, Sac & Fox) is a fourth-year doctoral student in the Culture, Institutions, and Society concentration at the Harvard Graduate School of Education. Their research explores how settler colonialism is addressed in K-12 history and social studies classrooms in the United States. Prior to their doctoral studies, Kemeyawi taught middle and high school English and history for eleven years in Boston and New York City. They hold an MS in Middle Childhood Education from Hunter College and an AB in Social Studies from Harvard University.

Submission Information

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Contact Information

Click here to view contact information for the editorial board and customer service .

Subscriber Support

Individual subscriptions must have an individual name in the given address for shipment. Individual copies are not for multiple readers or libraries. Individual accounts come with a personal username and password for access to online archives. Online access instructions will be attached to your order confirmation e-mail.

Institutional rates apply to libraries and organizations with multiple readers. Institutions receive digital access to content on Meridian from IP addresses via theIPregistry.org (by sending HER your PSI Org ID).

Online access instructions will be attached to your order confirmation e-mail. If you have questions about using theIPregistry.org you may find the answers in their FAQs. Otherwise please let us know at [email protected] .

How to Subscribe

To order online via credit card, please use the subscribe button at the top of this page.

To order by phone, please call 888-437-1437.

Checks can be mailed to Harvard Educational Review C/O Fulco, 30 Broad Street, Suite 6, Denville, NJ 07834. (Please include reference to your subscriber number if you are renewing. Institutions must include their PSI Org ID or follow up with this information via email to [email protected] .)

Permissions

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Article Submission FAQ

Submissions, question: “what manuscripts are a good fit for her ”.

Answer: As a generalist scholarly journal, HER publishes on a wide range of topics within the field of education and related disciplines. We receive many articles that deserve publication, but due to the restrictions of print publication, we are only able to publish very few in the journal. The originality and import of the findings, as well as the accessibility of a piece to HER’s interdisciplinary, international audience which includes education practitioners, are key criteria in determining if an article will be selected for publication.

We strongly recommend that prospective authors review the current and past issues of HER to see the types of articles we have published recently. If you are unsure whether your manuscript is a good fit, please reach out to the Content Editor at [email protected] .

Question: “What makes HER a developmental journal?”

Answer: Supporting the development of high-quality education research is a key tenet of HER’s mission. HER promotes this development through offering comprehensive feedback to authors. All manuscripts that pass the first stage of our review process (see below) receive detailed feedback. For accepted manuscripts, HER also has a unique feedback process called casting whereby two editors carefully read a manuscript and offer overarching suggestions to strengthen and clarify the argument.

Question: “What is a Voices piece and how does it differ from an essay?”

Answer: Voices pieces are first-person reflections about an education-related topic rather than empirical or theoretical essays. Our strongest pieces have often come from educators and policy makers who draw on their personal experiences in the education field. Although they may not present data or generate theory, Voices pieces should still advance a cogent argument, drawing on appropriate literature to support any claims asserted. For examples of Voices pieces, please see Alvarez et al. (2021) and Snow (2021).

Question: “Does HER accept Book Note or book review submissions?”

Answer: No, all Book Notes are written internally by members of the Editorial Board.

Question: “If I want to submit a book for review consideration, who do I contact?”

Answer: Please send details about your book to the Content Editor at [email protected].

Manuscript Formatting

Question: “the submission guidelines state that manuscripts should be a maximum of 9,000 words – including abstract, appendices, and references. is this applicable only for research articles, or should the word count limit be followed for other manuscripts, such as essays”.

Answer: The 9,000-word limit is the same for all categories of manuscripts.

Question: “We are trying to figure out the best way to mask our names in the references. Is it OK if we do not cite any of our references in the reference list? Our names have been removed in the in-text citations. We just cite Author (date).”

Answer: Any references that identify the author/s in the text must be masked or made anonymous (e.g., instead of citing “Field & Bloom, 2007,” cite “Author/s, 2007”). For the reference list, place the citations alphabetically as “Author/s. (2007)” You can also indicate that details are omitted for blind review. Articles can also be blinded effectively by use of the third person in the manuscript. For example, rather than “in an earlier article, we showed that” substitute something like “as has been shown in Field & Bloom, 2007.” In this case, there is no need to mask the reference in the list. Please do not submit a title page as part of your manuscript. We will capture the contact information and any author statement about the fit and scope of the work in the submission form. Finally, please save the uploaded manuscript as the title of the manuscript and do not include the author/s name/s.

Invitations

Question: “can i be invited to submit a manuscript how”.

Answer: If you think your manuscript is a strong fit for HER, we welcome a request for invitation. Invited manuscripts receive one round of feedback from Editors before the piece enters the formal review process. To submit information about your manuscript, please complete the Invitation Request Form . Please provide as many details as possible. The decision to invite a manuscript largely depends on the capacity of current Board members and on how closely the proposed manuscript reflects HER publication scope and criteria. Once you submit the form, We hope to update you in about 2–3 weeks, and will let you know whether there are Editors who are available to invite the manuscript.

Review Timeline

Question: “who reviews manuscripts”.

Answer: All manuscripts are reviewed by the Editorial Board composed of doctoral students at Harvard University.

Question: “What is the HER evaluation process as a student-run journal?”

Answer: HER does not utilize the traditional external peer review process and instead has an internal, two-stage review procedure.

Upon submission, every manuscript receives a preliminary assessment by the Content Editor to confirm that the formatting requirements have been carefully followed in preparation of the manuscript, and that the manuscript is in accord with the scope and aim of the journal. The manuscript then formally enters the review process.

In the first stage of review, all manuscripts are read by a minimum of two Editorial Board members. During the second stage of review, manuscripts are read by the full Editorial Board at a weekly meeting.

Question: “How long after submission can I expect a decision on my manuscript?”

Answer: It usually takes 6 to 10 weeks for a manuscript to complete the first stage of review and an additional 12 weeks for a manuscript to complete the second stage. Due to time constraints and the large volume of manuscripts received, HER only provides detailed comments on manuscripts that complete the second stage of review.

Question: “How soon are accepted pieces published?”

Answer: The date of publication depends entirely on how many manuscripts are already in the queue for an issue. Typically, however, it takes about 6 months post-acceptance for a piece to be published.

Submission Process

Question: “how do i submit a manuscript for publication in her”.

Answer: Manuscripts are submitted through HER’s Submittable platform, accessible here. All first-time submitters must create an account to access the platform. You can find details on our submission guidelines on our Submissions page.

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Review of Educational Research

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• Description
• Aims and Scope
• Editorial Board
• Abstracting / Indexing
• Submission Guidelines

The Review of Educational Research ( RER , quarterly, begun in 1931; approximately 640 pp./volume year) publishes critical, integrative reviews of research literature bearing on education. Such reviews should include conceptualizations, interpretations, and syntheses of literature and scholarly work in a field broadly relevant to education and educational research. RER encourages the submission of research relevant to education from any discipline, such as reviews of research in psychology, sociology, history, philosophy, political science, economics, computer science, statistics, anthropology, and biology, provided that the review bears on educational issues. RER does not publish original empirical research unless it is incorporated in a broader integrative review. RER will occasionally publish solicited, but carefully refereed, analytic reviews of special topics, particularly from disciplines infrequently represented.

The Review of Educational Research publishes critical, integrative reviews of research literature bearing on education. Such reviews should include conceptualizations, interpretations, and syntheses of literature and scholarly work in a field broadly relevant to education and educational research. RER encourages the submission of research relevant to education from any discipline, such as reviews of research in psychology, sociology, history, philosophy, political science, economics, computer science, statistics, anthropology, and biology, provided that the review bears on educational issues. RER does not publish original empirical research, and all analyses should be incorporated in a broader integrative review. RER will occasionally publish solicited, but carefully refereed, analytic reviews of special topics, particularly from disciplines infrequently represented. The following types of manuscripts fall within the journal’s purview:

Integrative reviews pull together the existing work on an educational topic and work to understand trends in that body of scholarship. In such a review, the author describes how the issue is conceptualized within the literature, how research methods and theories have shaped the outcomes of scholarship, and what the strengths and weaknesses of the literature are. Meta-analyses are of particular interest when they are accompanied by an interpretive framework that takes the article beyond the reporting of effect sizes and the bibliographic outcome of a computer search.

Theoretical reviews should explore how theory shapes research. To the extent that research is cited and interpreted, it is in the service of the specification, explication, and illumination of a theory. Theoretical reviews and integrative reviews have many similarities, but the former are primarily about how a theory is employed to frame research and our understandings, and refer to the research as it relates to the theory.

Methodological reviews are descriptions of research design, methods, and procedures that can be employed in literature reviews or research in general. The articles should highlight the strengths and weaknesses of methodological tools and explore how methods constrain or open up opportunities for learning about educational problems. They should be written in a style that is accessible to researchers in education rather than methodologists.

Historical reviews provide analyses that situate literature in historical contexts. Within these reviews, explanations for educational phenomena are framed within the historical forces that shape language and understanding.

Commissioned reviews and thematic issues. The editors may commission and solicit authors to review areas of literature. In all other respects, commissioned reviews are subject to the same review process as submitted reviews. The editors also encourage readers to propose thematic topics for special issues and, as potential guest editors, to submit plans for such issues.

In addition to review articles, RER will occasionally publish notes and responses which are short pieces of no more than 1,200 words on any topic that would be of use to reviewers of research. Typically, they point out shortcomings and differences in interpretation in RER articles and policy.

The standards and criteria for review articles in RER are the following:

1. Quality of the Literature. Standards used to determine quality of literature in education vary greatly. Any review needs to take into account the quality of the literature and its impact on findings. Authors should attempt to review all relevant literature on a topic (e.g., international literature, cross-disciplinary work, etc.).

2. Quality of Analysis. The review should go beyond description to include analysis and critiques of theories, methods, and conclusions represented in the literature. This analysis should also examine the issue of access—which perspectives are included or excluded in a body of work? Finally, the analysis should be reflexive—how does the scholars’ framework constrain what can be known in this review?

3. Significance of the Topic. The review should seek to inform and/or illuminate questions important to the field of education. While these questions may be broad-based, they should have implications for the educational problems and issues affecting our national and global societies.

4. Impact of the Article. The review should be seen as an important contribution and tool for the many different educators dealing with the educational problems and issues confronting society.

5. Advancement of the Field. The review should validate or inform the knowledge of researchers and guide and improve the quality of their research and scholarship.

6. Style. The review must be well written and conform to style of the Publication Manual of the American Psychological Association (6th edition). Authors should avoid the use of unexplained jargon and parochialism.

7. Balance and Fairness. The review should be careful not to misrepresent the positions taken by others, or be disrespectful of contrary positions.

8. Purpose. Any review should be accessible to the broad readership of RER. The purpose of any article should be to connect the particular problem addressed by the researcher(s) to a larger context of education.

We also encourage all authors interested in submitting a manuscript to RER to read our Editorial Vision for more information on our publication aims.

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1. Publication Standards 2. Submission Preparation Checklist 3. How to Get Help With the Quality of English in Your Submission 4. Copyright Information 5. For authors who use figures or other materials for which they do not own copyright 6. Right of Reply 7. Sage Choice and Open Access

The Review of Educational Research (RER) publishes comprehensive reviews of literature related to education and does not publish new empirical work, except in the context of meta-analytic reviews of an area. Please check the journal’s Aims and Scope to see if your manuscript is appropriate to submit to RER.

All manuscripts should be submitted electronically to the editorial team at http://mc.manuscriptcentral.com/rer . For questions or inquiries about manuscripts, email us at [email protected] . Manuscripts may not be submitted via e-mail.

Publication Standards

Researchers who intend to submit studies for publication should consult the Standards for Research Conduct adopted by the AERA Council. We also recommend consulting (a) the Guidelines for Reviewers , which outline the criteria under which manuscripts are reviewed for publication by AERA and (b) recent previous editions of the journal. Individuals submitting systematic reviews or meta-analyses should also consult The PRISMA Statement ( http://www.prisma-statement.org ) as well the article on “Reporting Standards for Research in Psychology” in American Psychologist, 63 , 839 – 851 (doi:10.1037/0003-066X.63.9.839).

Submission Preparation Checklist

When you upload your initial submission, upload (1) a separate title page that is not anonymized. Please format the title page as described by the 7th edition of the APA Manual and (2) the main manuscript, which includes an ANONYMIZED title page, an abstract with keywords at the bottom, and the rest of the document including tables and figures, and finally (c) Author Bios.

Please ensure that your manuscript complies with the “ RER Formatting Requirements and Common Formatting Errors ” (see PDF on the RER website). If your submission does not meet these requirements, it will be returned to you.

Additionally, your submission should meet the following guidelines:

1. The submission has not been previously published and is not under consideration for publication elsewhere; or an explanation has been provided in the Cover Letter. Authors should indicate in the Author Note on the separate title page if sections of the manuscript have been published in other venues.

2. THE MANUSCRIPT CONTAINS NO IDENTIFYING INFORMATION, EVEN ON THE ANONYMIZED TITLE PAGE. Please anonymize any work of limited circulation (e.g., in press papers, manuscripts under submission) that would point to the author, both in the body of the manuscript and the reference list. More information on anonymizing is described subsequently. Please double check that the author’s name has been removed from the document’s Properties, which in Microsoft Word is found in the File menu (select “File,” “Properties,” “Summary,” and remove the author’s name; select “OK” to save).

3. The text conforms to APA style (currently the 7th ed.). Consult the guidelines spelled out under “Manuscript Style, Length, and Format” on this webpage and in the RER Formatting Requirements PDF included on our website.

4. The submission must be in Microsoft Word format (.doc or .docx), which will be converted into a PDF file. Please do not upload PDF files, or they will be returned to you.

5. All URL addresses and DOIs in the manuscript (e.g., http://www.aera.net ) should be activated and ready to click.

6. An abstract of 150 words maximum is included (both separately and on the second page of the main document after the ANONYMIZED title page). Please also include three to five keywords—the terms that researchers will use to find your article in indexes and databases.

Manuscript Style, Length, and Format

The style guide for the Review of Educational Research and all AERA journals is the Publication Manual of the American Psychological Association, 7th ed., 2020. The manual is available for purchase here . Guidelines are also available on the APA website .

Manuscripts should NOT exceed 65 pages (or 15,000 words), including tables, figures, appendices, notes, and references, but excluding anonymized title page, abstract, and any supplementary files. Pages should be numbered consecutively in the top right-hand corner, with a fully capitalized running head in the top-left corner. All manuscripts should begin with the anonymized title page (p.1). Manuscripts should be typed for 8½” x 11” paper, in upper and lower case, with 1-inch margins on all sides. Manuscripts should be typed in 12-point Times New Roman font. Manuscripts that exceed 65 pages may be returned without review.

All text, from the title page to the end of the manuscript should be double-spaced , including the abstract, block quotations, bulleted text, and the reference list. Single-spacing is allowed in tables when it is useful in making the table clearer. Do not leave blank lines after paragraphs or before sub-headings. However, if a heading or subheading is the last line on a page, use a page break to move it to the top of the next page. The Abstract, Introduction (beginning with the title), the References, and all tables and figures begin on new pages.

Please use the five subheadings as appropriate based on the 7th edition of the APA style manual. In addition to being on the title page, the title should also be placed at the beginning of the Introduction (in lieu of the word, “Introduction,” which should not appear) and the title at the beginning of the Introduction should be a Level 1 heading.

Tables and figures are to be placed after the references—all tables precede all figures—and should not be included in the body of the text. Each figure and table should begin on a separate page. Do NOT use the “Place Table 5 here” or “Place Figure 1 here” convention. The tables and figures will be placed nearest to where they are mentioned as appropriate when copyediting is done.

Figures and tables should present data to the reader in a clear and unambiguous manner, and should be referred to in the text. If the illustration/table/figure and text are redundant, eliminate the illustration or reduce the amount of detail provided in text. The use of lines in tables is limited (please consult the APA style manual for formatting guidelines ). Figure captions should be placed at the bottom of the figure. One high-quality electronic version of each figure must be submitted with the manuscript. Tables will be typeset. Note that any figures and tables uploaded separately from the main manuscript will still count toward the total 65-page limit.

Italics can be used for emphasis or contrast in special situations but should be used sparingly. Ideally, sentence structure should be used for these issues. All words to be set in italics (e.g., book titles, journal names) should be typed in italics. There should be no underlined text . Abbreviations and acronyms should be spelled out the first time they are mentioned unless they are found as entries in their abbreviated form in Merriam-Webster’s Collegiate Dictionary , 11th ed., 2003 (e.g., “IQ” can be used without being spelled out). Mathematical symbols and symbols for vectors should be clearly formatted in italics and boldface, respectively.

You can use the footnote or endnote feature of Microsoft Word. However, notes are only for explanations or amplifications of textual material that cannot be incorporated into the regular text; they are not for reference information. Moreover, notes are distracting to readers and expensive to produce and should be used sparingly and avoided whenever possible.

The reference list should contain only references that are cited in the text. Its accuracy and completeness are the responsibility of the authors. Reference each publicly available dataset with its title, author, date, and a persistent Web identifier such as a digital object identifier (doi), a handle, or a uniform resource name (URN). If necessary, this last element may be replaced by a web address. Additionally, any references that were included in the analysis but not cited in-text in the main manuscript can be included in a separate reference list that is uploaded as a Supplementary File for Review (this may assist in meeting the page limit).

Authors should anonymize their manuscripts for review . Anonymizing does not mean removing all self-citations. Authors should only anonymize citations of limited circulation (e.g., forthcoming, in press, unpublished) that point to the author. Publications already in the extant literature (e.g., books, book chapters, journal articles) should be cited normally, but authors should include self-citations judiciously . When anonymizing, please use “Author” or “Authors” as in the examples below and place this alphabetically in the reference list and not where the author’s actual name would typically appear.

For examples of common types of references, consult the APA 7th edition manual, or visit the webpage here: https://apastyle.apa.org/style-grammar-guidelines/references

How to Get Help with the Quality of English in Your Submission

Authors who would like to refine the use of English in their manuscripts might consider using the services of a professional English-language editing company. We highlight some of these companies at  https://languageservices.sagepub.com/en/ .

Please be aware that Sage has no affiliation with these companies and makes no endorsement of them. An author's use of these services in no way guarantees that his or her submission will ultimately be accepted. Any arrangement an author enters into will be exclusively between the author and the particular company, and any costs incurred are the sole responsibility of the author.

Copyright Information Accepted authors will be asked to  assign copyright  to AERA, in return for which AERA grants several rights to authors.

Permission to reproduce your own published material

No written or oral permission is necessary to reproduce a table, a figure, or an excerpt of fewer than 500 words from this journal, or to make photocopies for classroom use. Authors are granted permission, without fee, to photocopy their own material or make printouts from the final pdf of their article. Copies must include a full and accurate bibliographic citation and the following credit line: “Copyright [year] by the American Educational Research Association; reproduced with permission from the publisher.” Written permission must be obtained to reproduce or reprint material in circumstances other than those just described. Please review Sage Publishing’s  Journal Permissions  for further information on policies and fees.

Permission to submit material for which you do not own copyright

Authors who wish to use material, such as figures or tables, for which they do not own the copyright must obtain written permission from the copyright holder (usually the publisher) and submit it along with their manuscript. However, no written or oral permission is necessary to reproduce a table, a figure, or an excerpt of fewer than 500 words from an AERA journal.

Copyright transfer agreements for accepted works with more than one author

This journal uses a transfer of copyright agreement that requires just one author (the corresponding author) to sign on behalf of all authors. Please identify the corresponding author for your work when submitting your manuscript for review. The corresponding author will be responsible for the following:

1. Ensuring that all authors are identified on the copyright agreement, and notifying the editorial office of any changes in the authorship.

2. Securing written permission (by letter or e-mail) from each co-author to sign the copyright agreement on the co-author’s behalf.

3. Warranting and indemnifying the journal owner and publisher on behalf of all co-authors. Although such instances are very rare, you should be aware that in the event that a co-author has included content in his or her portion of the article that infringes the copyright of another or is otherwise in violation of any other warranty listed in the agreement, you will be the sole author indemnifying the publisher and the editor of the journal against such violation.

Please contact the publications office at  AERA  if you have questions or if you prefer to use a copyright agreement for all coauthors to sign.

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If an article is accepted for publication in an AERA journal that, in the judgment of the editor, has as its main theme or thrust a critique of a specific piece of work or a specific line of work associated with an individual or program of research, then the individual or representative of the research program whose work is critiqued should be notified in advance about the upcoming publication and given the opportunity to reply, ideally in the same issue. The author of the original article should also be notified. Normal guidelines for length and review of the reply and publication of a rejoinder by the original article’s author(s) should be followed. Articles in the format “an open letter to …” may constitute prototypical exemplars of the category defined here, but other formats may well be used, and would be included under the qualifications for response prescribed here (Council, January 2002).

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If you or your funder wish your article to be freely available online to nonsubscribers immediately upon publication (gold open access), you can opt for it to be included in Sage Choice, subject to payment of a publication fee. The manuscript submission and peer review procedure is unchanged. On acceptance of your article, you will be asked to let Sage know directly if you are choosing Sage Choice. To check journal eligibility and the publication fee, please visit  Sage Choice . For more information on open access options and compliance at Sage, including self author archiving deposits (green open access) visit  Sage Publishing Policies  on our Journal Author Gateway.

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The Review of Higher Education

Penny A. Pasque, The Ohio State University; Thomas F. Nelson Laird, Indiana University, Bloomington

Journal Details

The Review of Higher Education  is interested in empirical research studies, empirically-based historical and theoretical articles, and scholarly reviews and essays that move the study of colleges and universities forward. The most central aspect of  RHE  is the saliency of the subject matter to other scholars in the field as well as its usefulness to academic leaders and public policymakers. Manuscripts submitted for  RHE  need to extend the literature in the field of higher education and may connect across fields and disciplines when relevant. Selection of articles for publication is based solely on the merits of the manuscripts with regards to conceptual or theoretical frameworks, methodological accurateness and suitability, and/or the clarity of ideas and gathered facts presented. Additionally, our publications center around issues within US Higher Education and any manuscript that we send for review must have clear implications for US Higher Education. 

Guidelines for Contributors

Manuscripts should be typed, serif or san serif text as recommended by APA 7th edition (e.g., 11-point Calibri, 11-point Arial, and 10-point Lucida Sans Unicode, 12-point Times New Roman, 11-point Georgia, 10-point Computer Modern) double-spaced throughout, including block quotes and references. Each page should be numbered on the top right side of the page consecutively and include a running head. Please supply the title of your submission, an abstract of 100 or fewer words, and keywords as the first page of your manuscript submission (this page does not count towards your page limit). The names, institutional affiliations, addresses, phone numbers, email addresses and a short biography of authors should appear on a separate cover page to aid proper masking during the review process. Initial and revised submissions should not run more than 32 pages (excluding abstract, keywords, and references; including tables, figures and appendices). Authors should follow instructions in the 7th edition Publication Manual of the American Psychological Association; any manuscripts not following all APA guidelines will not be reviewed. Please do not change fonts, spacing, or margins or use style formatting features at any point in the manuscript except for tables. All tables should be submitted in a mutable format (i.e. not a fixed image). Please upload your manuscript as a word document. All supporting materials (i.e., tables, figures, appendices) should be editable in the manuscript or a separate word document (i.e., do not embedded tables or figures). For a fixed image, please upload a separate high-resolution JPEG.

Authors should use their best judgment when masking citations. Masking some or all citations that include an author’s name can help prevent reviewers from knowing the identities of the authors. However, in certain circumstances masking citations is unnecessary or could itself reveal the identities of manuscript authors. Because authors are in the best position to know when masking citations will be effective, the editorial team will generally defer to them for these decisions.

Manuscripts are to be submitted in Word online at  mc.manuscriptcentral.com/rhe . (If you have not previously registered on this website, click on the “Register here” link to create a new account.) Once you log on, click on the “Author Center” link and then follow the printed instructions to submit your manuscript.

The term “conflict of interest” means any financial or other interest which conflicts with the work of the individual because it (1) could significantly impair the individual’s objectivity or (2) could create an unfair advantage for any person or organization. We recommend all authors review and adhere to the ASHE Conflict of Interest Policy before submitting any and all work. Please refer to the policy at  ashe.ws/ashe_coi

Please note that  The Review of Higher Education  does not require potential contributors to pay an article submission fee in order to be considered for publication.  Any other website that purports to be affiliated with the Journal and that requires you to pay an article submission fee is fraudulent. Do not provide payment information. Instead, we ask that you contact the  RHE  editorial office at  [email protected]  or William Breichner the Journals Publisher at the Johns Hopkins University Press  [email protected] .

Author Checklist for New Submissions

Page Limit.  Manuscripts should not go over 32 pages (excluding abstract, keywords, and references; including tables, figures and appendices.)

Masked Review.  All author information (i.e., name, affiliation, email, phone number, address) should appear on a separate cover page of the manuscript. The manuscript should have no indication of authorship. Any indication of authorship will result in your manuscript being unsubmitted.

Formatting.  Manuscripts should be typed, serif or san serif text as recommended by APA 7th edition (e.g., 11-point Calibri, 11-point Arial, and 10-point Lucida Sans Unicode, 12-point Times New Roman, 11-point Georgia, 10-point Computer Modern), double-spaced throughout, including block quotes and references, and each page should be numbered on the top right side of the page consecutively. Authors should follow instructions in the 7th edition Publication Manual of the American Psychological Association; this includes running heads, heading levels, spacing, margins, etc.. Any manuscripts not following APA 7th edition will be unsubmitted. [Please note, the  RHE  editorial team recommends 12-pt Times New Roman font to ensure proper format conversion within the ScholarOne system.]

Abstract.  All manuscripts must include an abstract of 100 words or fewer, and keywords as the first page of your manuscript submission (this page does not count towards your page limit).

Author Note.  An Author’s note may include Land Acknowledgments, Disclosure Statement (i.e., funding sources), or other acknowledgments. This should appear on your title page (not in the masked manuscript).  

Tables.  All tables should be editable. Tables may be uploaded in the manuscript itself or in a separate word document. All tables must be interpretable by readers without the reference to the manuscript. Do not duplicate information from the manuscript into tables. Tables must present additional information from what has already been stated in the manuscript.

Figures.  Figures should be editable in the manuscript or a separate word document (i.e., no embedded tables). For fixed images, please upload high-resolution JPEGs separately.

References.  The reference page should follow 7th edition APA guidelines and be double spaced throughout (reference pages do not count toward your page limit). 

Appendices.  Appendices should generally run no more than 3 manuscript pages. 

Additional Checklist for Revised Submissions

Revised manuscripts should follow the checklist above, with the following additional notes: 

Page Limit.  Revised manuscripts should stay within the page limit for new submissions (32 pages). However, we do realize that this is not always possible, and we may allow for a couple of extra pages for your revisions. Extensions to your page length will be subject to editor approval upon resubmission, but may not exceed 35 pages (excluding abstract, keywords, and references).

• Author Response to Reviewer Comments.  At the beginning of your revised manuscript file, please include a separate masked statement that indicates fully [1] all changes that have been made in response to the reviewer and editor suggestions and the pages on which those changes may be found in the revised manuscript and [2] those reviewer and editor suggestions that are not addressed in the revised manuscript and a rationale for why you think such revisions are not necessary. This can be in the form of a table or text paragraphs and must appear at the front of your revised manuscript document. Your response to reviewer and editor comments will not count toward your manuscript page limit. Please note that, because you will be adding your response to the reviewer and editor feedback to the beginning of your submission, this may change the page numbers of your document unless you change the pagination and start your manuscript itself on page 1. The choice is yours but either way, please ensure that you reference the appropriate page numbers within your manuscript in these responses. Additionally, when you submit your revised manuscript, there will be a submission box labeled “Author Response to Decision Letter”. You are not required to duplicate information already provided in the manuscript, but instead may use this to send a note to the reviewer team (e.g., an anonymous cover letter or note of appreciation for feedback). Please maintain anonymity throughout the review process by NOT including your name or by masking any potentially identifying information when providing your response to the reviewer's feedback (both in documents and the ScholarOne system).

Editorial Correspondence

Please address all correspondence about submitting articles (no subscriptions, please) to one or both of the following editors:

Dr. Penny A. Pasque, PhD Editor, Review of Higher Education 341 C Ramseyer Hall 29 W. Woodruff Avenue The Ohio State University Columbus, OH 43210 email:  [email protected]

Dr. Thomas F. Nelson Laird, PhD Editor, Review of Higher Education 201 North Rose Avenue Indiana University School of Education Bloomington, IN 47405-100 email:  [email protected]

Submission Policy

RHE publishes original works that are not available elsewhere. We ask that all manuscripts submitted to our journal for review are not published, in press or submitted to other journals while under our review. Additionally, reprints and translations of previously published articles will not be accepted.

Type of Preliminary Review

RHE utilizes a collaborative review process that requires several members of the editorial team to ensure that submitted manuscripts are suitable before being sent out for masked peer-review. Members of this team include a Editor, Associate Editor and Managing Editors. Managing Editors complete an initial review of manuscripts to ensure authors meet RHE ’s Author Guidelines and work with submitting authors to address preliminary issues and concerns (i.e., APA formatting). Editors and Associate Editors work together to decide whether it should be sent out for review and select appropriate reviewers for the manuscript.

Type of Review

When a manuscript is determined as suitable for review by the collaborative decision of the editorial team, Editors and/or Associate Editors will assign reviewers. Both the authors’ and reviewers’ are masked throughout the review and decision process.

Criteria for Review

Criteria for review include, but are not limited to, the significance of the topic to higher education, completeness of the literature review, appropriateness of the research methods or historical analysis, and the quality of the discussion concerning the implications of the findings for theory, research, and practice. In addition, we look for the congruence of thought and approach throughout the manuscript components.

Type of Revisions Process

Some authors will receive a “Major Revision” or “Minor Revision” decision. Authors who receive such decisions are encouraged to carefully attend to reviewer’s comments and recommendations and resubmit their revised manuscripts for another round of reviews. When submitting their revised manuscripts, authors are asked to include a response letter and indicate how they have responded to reviewer comments and recommendations. In some instances, authors may be asked to revise and resubmit a manuscript more than once.

Review Process Once Revised

Revised manuscripts are sent to the reviewers who originally made comments and recommendations regarding the manuscript, whenever possible. We rely on our editorial board and ad-hoc reviewers who volunteer their time and we give those reviewers a month to provide thorough feedback. Please see attached pdf for a visual representation of the RHE workflow .

Timetable (approx.)

• Managing Editor Technical Checks – 1-3 days
• Editor reviews and assigns manuscript to Associate Editors – 3-5 days
• Associate Editor reviews and invites reviewers – 3-5 days
• Reviewer comments due – 30 days provided for reviews
• Associate Editor makes a recommendation –  5-7 days
• Editor makes decision – 5-7 days
• If R&R, authors revise and resubmit manuscript – 90 days provided for revisions
• Repeat process above until manuscript is accepted or rejected -

Type of review for book reviews

Book reviews are the responsibility of the associate editor of book reviews. Decisions about acceptance of a book review are made by that associate editor.

The Hopkins Press Journals Ethics and Malpractice Statement can be found at the ethics-and-malpractice  page.

The Review of Higher Education expects all authors to review and adhere to ASHE’s Conflict of Interest Policy before submitting any and all work. The term “conflict of interest” means any financial or other interest which conflicts with the work of the individual because it (1) could significantly impair the individual’s objectivity or (2) could create an unfair advantage for any person or organization. Please refer to the policy at ashe.ws/ashe_coi .

Guidelines for Book Reviews

RHE publishes book reviews of original research, summaries of research, or scholarly thinking in book form. We do not publish reviews of books or media that would be described as expert opinion or advice for practitioners.

The journal publishes reviews of current books, meaning books published no more than 12 months prior to submission to the associate editor in charge of book reviews.

If you want to know whether the RHE would consider a book review before writing it, you may email the associate editor responsible for book reviews with the citation for the book.

Reviewers should have scholarly expertise in the higher education research area they are reviewing.

Graduate students are welcome to co-author book reviews, but with faculty or seasoned research professionals as first authors.

Please email the review to the associate editor in charge of book reviews (Timothy Reese Cain, [email protected] ), who will work through necessary revisions with you if your submission is accepted for publishing.

In general, follow the APA Publication Manual, 7th edition.

Provide a brief but clear description and summary of the contents so that the reader has a good idea of the scope and organization of the book. This is especially important when reviewing anthologies that include multiple sections with multiple authors.

Provide an evaluation of the book, both positive and negative points. What has been done well? Not so well? For example the following are some questions that you can address (not exclusively), as appropriate:

What are the important contributions that this book makes?

What contributions could have been made, but were not made?

What arguments or claims were problematic, weak, etc.?

How is the book related to, how does it supplement, or how does it complicate current work on the topic?

To which audience(s) will this book be most helpful?

How well has the author achieved their stated goals?

Use quotations efficiently to provide a flavor of the writing style and/or statements that are particularly helpful in illustrating the author(s) points. 

If you cite any other published work, please provide a complete reference.

Please include a brief biographical statement immediately after your name, usually title and institution. Follow the same format for co authored reviews. The first author is the contact author.

Please follow this example for the headnote of the book(s) you are reviewing: Stefan M. Bradley. Upending the Ivory Tower: Civil Rights, Black Power, and the Ivy League. New York: New York University Press, 2018. 465 pp. $35. ISBN 97814798739999.

Our preferred length is 2,000–2,500 words in order for authors to provide a complete, analytical, review. Reviews of shorter books may not need to be of that length.

The term “conflict of interest” means any financial or other interest which conflicts with the work of the individual because it (1) could significantly impair the individual’s objectivity or (2) could create an unfair advantage for any person or organization. We recommend all book reviewers read and adhere to the ASHE Conflict of Interest Policy before submitting any and all work. Please refer to the policy at ashe.ws/ashe_coi

NOTE: If the Editor has sent a book to an author for review, but the author is unable to complete the review within a reasonable timeframe, we would appreciate the return of the book as soon as possible; thanks for your understanding.

Please send book review copies to the contact above. Review copies received by the Johns Hopkins University Press office will be discarded.

Penny A. Pasque,         The Ohio State University

Thomas F. Nelson Laird,         Indiana University-Bloomington

Associate Editors

Angela Boatman,         Boston College

Timothy Reese Cain (including Book Reviews),         University of Georgia

Milagros Castillo-Montoya,         University of Connecticut

Tania D. Mitchell,         University of Minnesota

Chrystal A. George Mwangi       George Mason University

Federick Ngo,        University of Nevada, Las Vegas

Managing Editors

Stephanie Nguyen,         Indiana University Bloomington

Monica Quezada Barrera,         The Ohio State University

Editorial Board

Sonja Ardoin,         Clemson University

Peter Riley Bahr,        University of Michigan

Vicki Baker,      Albion College

Allison BrckaLorenz,        Indiana University Bloomington

Nolan L. Cabrera,        The University of Arizona

Brendan Cantwell,        Michigan State University

Rozana Carducci,        Elon University

Deborah Faye Carter,         Claremont Graduate University

Ashley Clayton,         Louisiana State University

Regina Deil-Amen,         The University of Arizona 

Jennifer A. Delaney,     University of Illinois Urbana Champaign

Erin E. Doran,    Iowa State University

Antonio Duran,   Arizona State University 

Michelle M. Espino,        University of Maryland 

Claudia García-Louis,        University of Texas, San Antonio

Deryl Hatch-Tocaimaza,        University of Nebraska-Lincoln

Nicholas Hillman,        University of Wisconsin-Madison

Cindy Ann Kilgo,        Indiana University-Bloomington

Judy Marquez Kiyama,  University of Arizona

Román Liera,        Montclair State University

Angela Locks,        California State University, Long Beach

Demetri L. Morgan,  Loyola University Chicago

Rebecca Natow,         Hofstra University 

Z Nicolazzo,        The University of Arizona

Elizabeth Niehaus,        University of Nebraska-Lincoln

Robert T. Palmer,        Howard University

Rosemary Perez,        University of Michigan

OiYan Poon,         Spencer Foundation 

Kelly Rosinger,        The Pennsylvania State University

Vanessa Sansone,         The University of Texas at San Antonio

Tricia Seifert,        Montana State University

Barrett Taylor,         University of North Texas 

Annemarie Vaccaro,  University of Rhode Island

Xueli Wang,        University of Wisconsin-Madison

Stephanie Waterman,         University of Toronto 

Rachelle Winkle-Wagner,         University of Wisconsin-Madison

Association for the Study of Higher Education Board of Directors

The Review of Higher Education is the journal of Association for the Study Higher Education (ASHE) and follows the ASHE Bylaws and Statement on Diversity. 

ASHE Board of Directors

Abstracting & Indexing Databases

• Current Contents
• Web of Science
• Dietrich's Index Philosophicus
• IBZ - Internationale Bibliographie der Geistes- und Sozialwissenschaftlichen Zeitschriftenliteratur
• Internationale Bibliographie der Rezensionen Geistes- und Sozialwissenschaftlicher Literatur
• Academic Search Alumni Edition, 9/1/2003-
• Academic Search Complete, 9/1/2003-
• Academic Search Elite, 9/1/2003-
• Academic Search Premier, 9/1/2003-
• Current Abstracts, 9/1/2003-
• Education Research Complete, 3/1/1997-
• Education Research Index, Sep.2003-
• Education Source, 3/1/1997-
• Educational Administration Abstracts, 3/1/1991-
• ERIC (Education Resources Information Center), 1977-
• MLA International Bibliography (Modern Language Association)
• Poetry & Short Story Reference Center, 3/1/1997-
• PsycINFO, 2001-, dropped
• Russian Academy of Sciences Bibliographies
• TOC Premier (Table of Contents), 9/1/2003-
• Scopus, 1996-
• Gale Academic OneFile
• Gale OneFile: Educator's Reference Complete, 12/2001-
• Higher Education Abstracts (Online)
• ArticleFirst, vol.15, no.3, 1992-vol.35, no.2, 2011
• Electronic Collections Online, vol.20, no.1, 1996-vol.35, no.2, 2011
• Periodical Abstracts, v.26, n.4, 2003-v.33, n.3, 2010
• PsycFIRST, vol.24, no.3, 2001-vol.33, no.1, 2009
• Personal Alert (E-mail)
• Education Collection, 7/1/2003-
• Education Database, 7/1/2003-
• Health Research Premium Collection, 7/1/2003-
• Hospital Premium Collection, 7/1/2003-
• Periodicals Index Online, 1/1/1981-7/1/2000
• Professional ProQuest Central, 07/01/2003-
• ProQuest 5000, 07/01/2003-
• ProQuest 5000 International, 07/01/2003-
• ProQuest Central, 07/01/2003-
• Psychology Database, 7/1/2003-
• Research Library, 07/01/2003-
• Social Science Premium Collection, 07/01/2003-
• Educational Research Abstracts Online
• Research into Higher Education Abstracts (Online)
• Studies on Women and Gender Abstracts (Online)

Abstracting & Indexing Sources

• Contents Pages in Education   (Ceased)  (Print)
• Family Index   (Ceased)  (Print)
• Psychological Abstracts   (Ceased)  (Print)

Source: Ulrichsweb Global Serials Directory.

1.8 (2022) 3.2 (Five-Year Impact Factor) 0.00195 (Eigenfactor™ Score) Rank in Category (by Journal Impact Factor): 185 of 269 journals, in “Education & Educational Research”

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Readers include: Scholars, academic leaders, administrators, public policy makers involved in higher education, and all members of the Association for the Study of Higher Education (ASHE)

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Also of Interest

Vasti Torres, Indiana University

Patti Duncan, Oregon State University

Georgia L. Irby, College of William & Mary

Benjamin Fraser, The University of Arizona

Jeraldine Kraver, University of Northern Colorado; Peter Kratzke, University of Colorado, Boulder

Chrysogonus Siddha Malilang, Malmö University, Sweden

Carine Bourget, University of Arizona

Megan Corbin, West Chester University

Joseph Michael Sommers, Central Michigan University

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How can education systems improve? A systematic literature review

• Published: 07 April 2022
• Volume 24 , pages 479–499, ( 2023 )

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• Ignacio Barrenechea   ORCID: orcid.org/0000-0002-4673-3862 1 ,
• Jason Beech 2 &
• Axel Rivas 1  

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Understanding what contributes to improving a system will help us tackle the problems in education systems that usually fail disproportionately in providing quality education for all, especially for the most disadvantage sectors of the population. This paper presents the results of a qualitative systematic literature review aimed at providing a comprehensive overview of what education research can say about the factors that promote education systems’ improvement. This literature is emerging as a topic of empirical research that merges comparative education and school effectiveness studies as standardized assessments make it possible to compare results across systems and time. To examine and synthesize the papers included in this review we followed a thematic analysis approach. We identify, analyze, and report patterns in the papers included in this systematic review. From the coding process, four drivers for system improvement emerged: (1) system-wide approaches; (2) human capital; (3) governance and macro–micro level bridges; and (4) availability of resources.

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Barrenechea, I., Beech, J. & Rivas, A. How can education systems improve? A systematic literature review. J Educ Change 24 , 479–499 (2023). https://doi.org/10.1007/s10833-022-09453-7

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Montessori education: a review of the evidence base

• Chloë Marshall 1  

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The Montessori educational method has existed for over 100 years, but evaluations of its effectiveness are scarce. This review paper has three aims, namely to (1) identify some key elements of the method, (2) review existing evaluations of Montessori education, and (3) review studies that do not explicitly evaluate Montessori education but which evaluate the key elements identified in (1). The goal of the paper is therefore to provide a review of the evidence base for Montessori education, with the dual aspirations of stimulating future research and helping teachers to better understand whether and why Montessori education might be effective.

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Introduction.

Maria Montessori (1870–1952) was by any measure an extraordinary individual. She initially resisted going into teaching—one of the few professions available to women in the late 19th century—and instead became one of the very first women to qualify as a medical doctor in Italy. As a doctor she specialised in psychiatry and paediatrics. While working with children with intellectual disabilities she gained the important insight that in order to learn, they required not medical treatment but rather an appropriate pedagogy. In 1900, she was given the opportunity to begin developing her pedagogy when she was appointed director of an Orthophrenic school for developmentally disabled children in Rome. When her pupils did as well in their exams as typically developing pupils and praise was lavished upon her for this achievement, she did not lap up that praise; rather, she wondered what it was about the education system in Italy that was failing children without disabilities. What was holding them back and preventing them from reaching their potential? In 1907 she had the opportunity to start working with non-disabled children in a housing project located in a slum district of Rome. There, she set up her first 'Casa dei Bambini' ('children’s house') for 3–7-year olds. She continued to develop her distinctive pedagogy based on a scientific approach of experimentation and observation. On the basis of this work, she argued that children pass through sensitive periods for learning and several stages of development, and that children’s self-construction can be fostered through engaging with self-directed activities in a specially prepared environment. There was international interest in this new way of teaching, and there are now thousands of Montessori schools (predominantly for children aged 3–6 and 6–12) throughout the world. 1 , 2 , 3 , 4

Central to Montessori’s method of education is the dynamic triad of child, teacher and environment. One of the teacher’s roles is to guide the child through what Montessori termed the 'prepared environment, i.e., a classroom and a way of learning that are designed to support the child’s intellectual, physical, emotional and social development through active exploration, choice and independent learning. One way of making sense of the Montessori method for the purposes of this review is to consider two of its important aspects: the learning materials, and the way in which the teacher and the design of the prepared environment promote children’s self-directed engagement with those materials. With respect to the learning materials, Montessori developed a set of manipulable objects designed to support children’s learning of sensorial concepts such as dimension, colour, shape and texture, and academic concepts of mathematics, literacy, science, geography and history. With respect to engagement, children learn by engaging hands-on with the materials most often individually, but also in pairs or small groups, during a 3-h 'work cycle' in which they are guided by the teacher to choose their own activities. They are given the freedom to choose what they work on, where they work, with whom they work, and for how long they work on any particular activity, all within the limits of the class rules. No competition is set up between children, and there is no system of extrinsic rewards or punishments. These two aspects—the learning materials themselves, and the nature of the learning—make Montessori classrooms look strikingly different to conventional classrooms.

It should be noted that for Montessori the goal of education is to allow the child’s optimal development (intellectual, physical, emotional and social) to unfold. 2 This is a very different goal to that of most education systems today, where the focus is on attainment in academic subjects such as literacy and mathematics. Thus when we ask the question, as this review paper does, whether children benefit more from a Montessori education than from a non-Montessori education, we need to bear in mind that the outcome measures used to capture effectiveness do not necessarily measure the things that Montessori deemed most important in education. Teachers and parents who choose the Montessori method may choose it for reasons that are not so amenable to evaluation.

Despite its existence for over 100 years, peer-reviewed evaluations of Montessori education are few and they suffer from a number of methodological limitations, as will be discussed in Section 3. This review has three aims, namely to (1) identify some key elements of the Montessori educational method, (2) review existing evaluations of Montessori education, and (3) review studies that do not explicitly evaluate Montessori education but which evaluate the key elements identified in (1). My goal is to provide a review of the scientific evidence base for Montessori education, with the dual aspirations of stimulating future research and helping teachers to better understand whether and why Montessori education might be effective.

Some key elements of the Montessori educational method

The goal of this section is to isolate some key elements of the Montessori method, in order to better understand why, if Montessori education is effective, this might be, and what elements of it might usefully be evaluated by researchers. These are important considerations because there is considerable variability in how the Montessori method is implemented in different schools, and the name, which is not copyrighted, is frequently used without full adherence. 5 , 6 Nevertheless, some elements of the method might still be beneficial, or could be successfully incorporated (or, indeed, are already incorporated) into schools that do not want to carry the name 'Montessori' or to adhere fully to its principles. Pinpointing more precisely what—if anything—about the Montessori method is effective will enable a better understanding of why it works. Furthermore, it has been argued that there might be dangers in adopting wholesale and uncritically an educational method that originated over 100 years ago, in a world that was different in many ways to today’s. 7 If the method is to be adopted piecemeal, which pieces should be adopted? As outlined previously, two important aspects of Montessori’s educational method are the learning materials, and the self-directed nature of children’s engagement with those materials. Some key elements of each of these aspects will now be considered in turn.

The learning materials

The first learning materials that the child is likely to encounter in the Montessori classroom are those that make up the practical life curriculum. These are activities that involve pouring different materials, using utensils such as scissors, tongs and tweezers, cleaning and polishing, preparing snacks, laying the table and washing dishes, arranging flowers, gardening, doing up and undoing clothes fastenings, and so on. Their aims, in addition to developing the child’s skills for independent living, are to build up the child’s gross and fine motor control and eye-hand co-ordination, to introduce them to the cycle of selecting, initiating, completing and tidying up an activity (of which more in the next section), and to introduce the rules for functioning in the social setting of the classroom.

As the child settles into the cycle of work and shows the ability to focus on self-selected activities, the teacher will introduce the sensorial materials. The key feature of the sensorial materials is that each isolates just one concept for the child to focus on. The pink tower, for example, consists of ten cubes which differ only in their dimensions, the smallest being 1 cm 3 , the largest 10 cm 3 . In building the tower the child’s attention is being focused solely on the regular decrease in volume of successive cubes. There are no additional cues—different colours for example, or numbers written onto the faces of the cube—which might help the child to sequence the cubes accurately. Another piece of sensorial material, the sound boxes, contains six pairs of closed cylinders that vary in sound from soft to loud when shaken, and the task for the child is to find the matching pairs. Again, there is only one cue that the child can use to do this task: sound. The aim of the sensorial materials is not to bombard the child’s senses with stimuli; on the contrary, they are tools designed for enabling the child to classify and put names to the stimuli that he will encounter on an everyday basis.

The sensorial materials, are, furthermore, designed as preparation for academic subjects. The long rods, which comprise ten red rods varying solely in length in 10 cm increments from 10 cm to 1 m, have an equivalent in the mathematics materials: the number rods, where the rods are divided into alternating 10 cm sections of red and blue so that they take on the numerical values 1–10. The touchboards, which consist of alternate strips of sandpaper and smooth paper for the child to feel, are preparation for the sandpaper globe in geography—a globe where the land masses are made of rough sandpaper but the oceans and seas are smooth. The touchboards are also preparation for the sandpaper letters in literacy and sandpaper numerals in mathematics, which the child learns to trace with his index and middle fingers.

Key elements of the literacy curriculum include the introduction of writing before reading, the breaking down of the constituent skills of writing (pencil control, letter formation, spelling) before the child actually writes words on paper, and the use of phonics for teaching sound-letter correspondences. Grammar—parts of speech, morphology, sentence structure—are taught systematically through teacher and child-made materials.

In the mathematics curriculum, quantities 0–10 and their symbols are introduced separately before being combined, and large quantities and symbols (tens, hundreds and thousands) and fractions are introduced soon after, all through concrete materials. Operations (addition, subtraction, multiplication, division, the calculation of square roots) are again introduced using concrete materials, which the child can choose to stop using when he is able to succeed without that concrete support.

Principles running throughout the design of these learning materials are that the child learns through movement and gains a concrete foundation with the aim of preparing him for learning more abstract concepts. A further design principle is that each piece of learning material has a 'control of error' which alerts the child to any mistakes, thereby allowing self-correction with minimal teacher support.

Self-directed engagement with the materials

Important though the learning materials are, 8 they do not, in isolation, constitute the Montessori method because they need to be engaged with in a particular way. Montessori observed that the young child is capable of concentrating for long periods of time on activities that capture his spontaneous interest. 2 , 3 , 4 There are two features of the way that children engage with the learning materials that Montessori claimed promoted this concentration. The first is that there is a cycle of activity surrounding the use of each piece of material (termed the 'internal work cycle ' 9 ). If a child wishes to use the pink tower, for example, he will have to find a space on the floor large enough to unroll the mat that will delineate his work area, carry the ten cubes of the pink tower individually to the mat from where they are stored, then build the tower. Once he has built the tower he is free to repeat this activity as many times as he likes. Other children may come and watch, and if he wishes they can join in with him, but he will be able to continue on his own if he prefers and for as long as he likes. When he has had enough, he will dismantle the pink tower and reassemble it in its original location, ready for another child to use. This repeated and self-chosen engagement with the material, the lack of interruption, and the requirement to set up the material and put it away afterwards, are key elements aimed at developing the child’s concentration. 10

The second feature which aims to promote concentration is that these cycles of activity take place during a 3-h period of time (termed the 'external work cycle' 9 ). During those 3 h children are mostly free to select activities on their own and with others, and to find their own rhythm of activity, moving freely around the classroom as they do so. One might wonder what the role of the teacher is during this period. Although the children have a great deal of freedom in what they do, their freedom is not unlimited. The teacher’s role is to guide children who are finding it hard to select materials or who are disturbing others, to introduce new materials to children who are ready for a new challenge, and to conduct small-group lessons. Her decisions about what to teach are made on the basis of careful observations of the children. Although she might start the day with plans of what she will do during the work cycle, she will be led by her students and their needs, and there is no formal timetable. Hence the Montessori classroom is very different to the teacher-led conventional classroom with its highly structured day where short timeslots are devoted to each activity, the whole class is engaged in the same activities at the same time, and the teacher instructs at the front of the class.

In summary, there are two aspects of Montessori classrooms that are very different to conventional classrooms: the learning materials themselves, and the individual, self-directed nature of the learning under the teacher’s expert guidance. All the elements described here—the features of the learning materials themselves (e.g., each piece of material isolates just one concept, each contains a control of error that allows for self-correction, learning proceeds from concrete to abstract concepts) and the child-led manner of engagement with those materials (e.g., self-selection, repeated and active engagement, tidying up afterwards, freedom from interruption, lack of grades and extrinsic rewards) might potentially benefit development and learning over the teaching of the conventional classroom. We will return to many of the elements discussed here in the following two sections. (This has necessarily been only a brief survey of some of the most important elements of the Montessori method. Readers wanting to find out more are again directed to refs. 2 , 3 , 4 ).

Evaluations of Montessori education

There are few peer-reviewed evaluations of Montessori education, and the majority have been carried out in the USA. Some have evaluated children’s outcomes while those children were in Montessori settings, and others have evaluated Montessori-educated children after a period of subsequent conventional schooling. As a whole this body of research suffers from several methodological limitations. Firstly, few studies are longitudinal in design. Secondly, there are no good quality randomised control trials; most researchers have instead tried to match participants in Montessori and comparison groups on as many likely confounding variables as possible. Thirdly, if children in the Montessori group do score higher than those in the non-Montessori group on a particular outcome measure, then assuming that that effect can be attributed to being in a Montessori classroom, what exactly is it about Montessori education that has caused the effect? Montessori education is a complex package—how can the specific elements which might be causing the effect be isolated? At a very basic level—and drawing on two of the main aspects of Montessori education outlined above—is the effect due to the learning materials or to the self-directed way in which children engage with them (and can the two be separated)? Fourthly, there are presumably differences between Montessori schools (including the way in which the method is implemented) that might influence children’s outcomes, but studies rarely include more than one Montessori school, and sometimes not more than one Montessori class. Fifthly, and relatedly, there is the issue of 'treatment fidelity'—what counts as a Montessori classroom? Not all schools that call themselves 'Montessori' adhere strictly to Montessori principles, have trained Montessori teachers, or are accredited by a professional organisation. A sixth, and again related, point is that children’s experiences in Montessori education will vary in terms of the length of time they spend in Montessori education, and the age at which they attend. Finally, the numbers of children participating in studies are usually small and quite narrow in terms of their demographics, making generalisation of any results problematic. These methodological issues are not limited to evaluations of Montessori education, of course—they are relevant to much of educational research.

Of these, the lack of randomised control trials is particularly notable given the recognition of their importance in education. 11 , 12 Parents choose their child’s school for a host of different reasons, 13 and randomisation is important in the context of Montessori education because parents who choose a non-conventional school for their child might be different in relevant ways from parents who do not, for example in their views on child-rearing and aspirations for their child’s future. This means that if a study finds a benefit for Montessori education over conventional education this might reflect a parent effect rather than a school effect. Furthermore, randomisation also controls for socio-economic status (SES). Montessori schools are often fee-paying, which means that pupils are likely to come from higher SES families; children from higher SES families are likely to do better in a variety of educational contexts. 14 , 15 , 16 A recent report found that even public (i.e., non-fee-paying) Montessori schools in the USA are not representative of the racial and socioeconomic diversity of the neighbourhoods they serve. 17 However, random assignment of children to Montessori versus non-Montessori schools for the purposes of a randomised control trial would be very difficult to achieve because it would take away parental choice.

Arguably the most robust evaluation of the Montessori method to date is that by Lillard and Else-Quest. 18 They compared children in Montessori and non-Montessori education and from two age groups—5 and 12-year olds—on a range of cognitive, academic, social and behavioural measures. Careful thought was given to how to overcome the lack of random assignment to the Montessori and non-Montessori groups. The authors’ solution was to design their study around the school lottery that was already in place in that particular school district. All children had entered the Montessori school lottery; those who were accepted were assigned to the Montessori group, and those who were not accepted were assigned to the comparison (other education systems) group. Post-hoc comparisons showed similar income levels in both sets of families. Although group differences were not found for all outcome measures, where they were found they favoured the Montessori group. For 5-year olds, significant group differences were found for certain academic skills (namely letter-word identification, phonological decoding ability, and math skills), a measure of executive function (the card sort task), social skills (as measured by social reasoning and positive shared play) and theory of mind (as measured by a false-belief task). For 12-year olds, significant group differences were found on measures of story writing and social skills. Furthermore, in a questionnaire that asked about how they felt about school, responses of children in the Montessori group indicated that they felt a greater sense of community. The authors concluded that 'at least when strictly implemented, Montessori education fosters social and academic skills that are equal or superior to those fostered by a pool of other types of schools'. 18

Their study has been criticised for using just one Montessori school, 19 but Lillard and Else-Quest’s response is that the school was faithful to Montessori principles, which suggests that the results might be generalisable to other such schools. 20 That fidelity might impact outcomes has long been of concern, 21 and was demonstrated empirically in a further, longitudinal, study, 6 that compared high fidelity Montessori classes (again, from just one school), 'supplemented' Montessori classes (which provided the Montessori materials plus conventional activities such as puzzles, games and worksheets), and conventional classrooms. Children in these classes were 3–6 years old, and they were tested at two time-points: towards the beginning and towards the end of the school year. Although the study lacked random assignment of children to groups, the groups were matched with respect to key parent variables such as parental education. As in Lillard and Else-Quest’s earlier study, 18 outcome measures tapped a range of social and academic skills related to school readiness (i.e., children’s preparedness to succeed in academic settings). There were two research questions: firstly, do preschool children’s school readiness skills change during the academic year as a function of school type, and secondly, within Montessori schools, does the percentage of children using Montessori materials in a classroom predict children’s school readiness skills at the end of the academic year? Overall, the answer to both questions was “yes”. Children in the high-fidelity Montessori school, as compared with children in the other two types of school, showed significantly greater gains on measures of executive function, reading, math, vocabulary, and social problem-solving. Furthermore, the degree to which children were engaged with Montessori materials significantly predicted gains in executive function, reading and vocabulary. In other words, treatment fidelity mattered: children gained fewer benefits from being in a Montessori school when they were engaged in non-Montessori activities.

This study does not demonstrate definitively that the Montessori materials drove the effect: there might have been other differences between the high and lower fidelity classrooms—such as the teachers’ interactions with their pupils—that were responsible for the difference in child outcomes. 6 In a move to explore the role of the Montessori materials further, a more recent experimental study 22 removed supplementary materials, to leave just the Montessori materials, from two of the three classrooms in a Montessori school that served 3–6-year olds. Over a period of 4 months children in the classrooms from which supplementary materials were removed made significantly greater gains than children from the unchanged classroom on tests of letter-word identification and executive function, although not on measures of vocabulary, theory of mind, maths, or social problem-solving. The authors acknowledge weaknesses in the study design, including the small number of participants (just 52 across the three classrooms) and the short duration. Nevertheless, the study does provide a template for how future experimental manipulations of fidelity to the Montessori method could be carried out.

Fidelity is important because variation in how faithful Montessori schools are to the 'ideal' is likely to be an important factor in explaining why such mixed findings have been found in evaluations of the Montessori method. 6 For example, two early randomised control trials to evaluate Head Start in the USA did not find any immediate benefit of Montessori preschool programmes over other types of preschool programmes. 23 , 24 In both programmes, only 4-year olds were included, whereas the ideal in Montessori preschool programmes is for 3–6 year olds to be taught in the same class in order to foster child-to-child tutoring. 6 Furthermore, in one of the programmes 23 the ideal 3-h work cycle was reduced to just 30 min. 6 A more recent study of older children compared 8th grade Montessori and non-Montessori students matched for gender, ethnicity and socio-economic status. 25 The study found lower scores for Montessori students for English/Language Arts and no difference for maths scores, but the participating Montessori school altered the “ideal” by issuing evaluative grades to pupils and introducing non-Montessori activities. 6

These same limitations then make it difficult to interpret studies that have found 'later' benefits for children who have been followed up after a subsequent period of conventional education. In one of the studies discussed earlier, 23 social and cognitive benefits did emerge for children who had previously attended Montessori preschools and then moved to conventional schools, but these benefits did not emerge until adolescence, while a follow-up study 26 found cognitive benefits in Montessori males only, again in adolescence. Although such 'sleeper effects' have been widely reported in evaluations of early years interventions, they may be artefacts of simple measurement error and random fluctuations. 27 Importantly, if the argument is that lack of fidelity to the Montessori method is responsible for studies not finding significant benefits of Montessori education at younger ages, it is not logical to then credit the Montessori method with any benefits that emerge in follow-up studies.

Some studies report positive outcomes for certain curricular areas but not others. One, for example, investigated scores on maths, science, English and social studies tests in the final years of compulsory education, several years after children had left their Montessori classrooms. 28 Compared to the non-Montessori group (who were matched for gender, socioeconomic status, race/ethnicity and high school attended), the Montessori group scored significantly higher on maths and science, but no differences were found for English and social studies. What might explain this differential effect? The authors suggested that the advantages for maths might be driven by the materials themselves, compared to how maths is taught in conventional classes. 28 Alternatively, or perhaps in addition, children in Montessori classrooms might spend more time engaged in maths and science activities compared to children in conventional classes, with the amount of time spent on English and social studies not differing. However, the authors were unable, within the design of their study, to provide details of exactly how much time children in the Montessori school had spent doing maths, science, English and social studies, in comparison to the time that children in conventional classes were spending on those subjects.

Just as knowing what is going on in the Montessori classroom is vital to being able to interpret the findings of evaluations, so is knowing what is going on in the comparison classrooms. One of the earliest evaluations of Montessori education in the USA 29 speculated that Montessori would have found much to appreciate in one of the non-Montessori comparison classes, including its 'freedom for the children (moving about; working alone); its planned environment (innovative methods with tape recorder playback of children’s conversations; live animals, etc.); its non-punitive character (an “incorrect” answer deserves help, not anger; original answers are reinforced, but other answers are pursued); and its emphasis on concentration (the children sustained activity without direct supervision for relatively long periods of time)'. In some evaluations, the differences between Montessori and conventional classrooms might not actually be so great, which might explain why benefits of being educated in a Montessori classroom are not found. And even if the Montessori approach to teaching a particular curriculum area is different to those used in conventional classrooms, there are likely to be different, equally-effective approaches to teaching the same concepts. This is a suggested explanation for the finding that although children in Montessori kindergartens had an advantage relative to their conventionally-educated peers for base-10 understanding in mathematics, they did not maintain this advantage when tested 2 years later. 30

While most evaluations are interested in traditional academic outcomes or factors related to academic success such as executive functions, a small number have investigated creativity. For example, an old study 31 compared just 14 four and five-year-old children who attended a Montessori nursery school with 14 four and five-year olds who attended a conventional nursery school (matched for a range of parental variables, including attitudes and parental control). In a non-verbal creativity task, involving picture construction, they were given a blank sheet of paper, a piece of red gummed paper in the shape of a curved jellybean, and a pencil. They were then asked to think of and draw a picture in which the red paper would form an integral part. Each child’s construction was rated for originality, elaboration, activity, and title adequacy, and these ratings were then combined into a 'creativity' score. The group of conventionally-schooled children scored almost twice as high as the Montessori group. A second task involved the child giving verbal descriptions of seven objects: a red rubber ball, a green wooden cube, a short length of rope, a steel mirror, a piece of rectangular clear plastic, a piece of chalk, and a short length of plastic tubing. Each description was scored as to whether it was functional (i.e., focused on the object’s use) or whether it was a description of the object’s physical characteristics (i.e., shape, colour, etc.). Like the non-verbal creativity task, this task differentiated the two groups: whereas the conventionally educated children gave more functional descriptions (e.g., for the cube: “you play with it”), the Montessori children gave more physical descriptions (e.g., “it’s square, it’s made of wood, and it’s green”). A third task, the Embedded Figure Test, involved the child first being presented with a stimulus figure and then locating a similar figure located in an embedding context. Both accuracy and speed were measured. While the two groups did not differ in the number of embedded figures accurately located, the Montessori group completed the task significantly more quickly. The fourth and final task required children to draw a picture of anything they wanted to. Drawings were coded for the presence or absence of geometric figures and people. The Montessori group produced more geometric figures, but fewer people, than the conventional group.

The authors were careful not to cast judgement on the performance differences between the two groups. 31 They wrote that 'The study does, however, support the notion that differing preschool educational environments yield different outcomes' and 'Montessori children responded to the emphasis in their programme upon the physical world and upon a definition of school as a place of work; the Nursery School children responded on their part to the social emphasis and the opportunity for spontaneous expression of feeling'. They did not, however, compare and contrast the particular features of the two educational settings that might have given rise to these differences.

Creativity has been studied more recently in France. 32 Seven to twelve-year olds were tested longitudinally on five tasks tapping different aspects of creativity. 'Divergent' thinking tasks required children to (1) think of unusual uses for a cardboard box, (2) come up with ideas for making a plain toy elephant more entertaining, and (3) make as many drawings as possible starting from pairs of parallel lines. 'Integrative' thinking tasks required children to (1) invent a story based on a title that was provided to them, and (2) invent a drawing incorporating six particular shapes. Their sample was bigger than that of the previous study, 31 comprising 40 pupils from a Montessori school and 119 from two conventional schools, and pupils were tested in two consecutive years (no information is provided about whether pupils from different schools were matched on any variable other than age). For both types of task and at both time-points the Montessori-educated children scored higher than the conventionally-educated children. Again, the authors made little attempt to pinpoint the precise differences between schools that might have caused such differences in performance.

None of the studies discussed so far has attempted to isolate individual elements of the Montessori method that might be accounting for any of the positive effects that they find. There are several studies, however, that have focused on the practical life materials. A quasi-experimental study 33 demonstrated that the practical life materials can be efficacious in non-Montessori classrooms. More than 50 different practical life exercises were introduced into eight conventional kindergarten classes, while five conventional kindergarten classes were not given these materials and acted as a comparison group. The outcome measure was a fine motor control task, the 'penny posting test', whereby the number of pennies that a child could pick up and post through a one-inch slot in a can in two 30 s trials was counted. At pre-test the treatment and comparison groups did not differ in the number of pennies posted, but at post-test 6 months later the treatment group achieved a higher score than the comparison group, indicating finer motor control. A nice feature of this study is that teachers reported children in both groups spending the same amount of time on tasks designed to support fine motor control development, suggesting that there was something specific to the design of the practical life materials that was more effective in this regard than the conventional kindergarten materials on offer. And because the preschools that had used the practical life activities had introduced no other elements of the Montessori method, the effect could be confidently attributed to the practical life materials themselves.

An extension of this study 34 investigated the potential benefits of the practical life materials for fine motor control by comparing 5-year olds in Montessori kindergarten programmes with 5-year olds in a conventional programme (reported to have similarities in teaching mission and pupil background characteristics) on the 'flag posting test'. In this task, the child was given a solid hardwood tray covered with clay in which there were 12 pinholes. There were also 12 paper flags mounted on pins, six to the right of the tray and six to the left, and the child’s task was to place the flags one at time in the holes. The child received three scores: one for the amount of time taken to finish the activity, one for the number of attempts it took the child to put each flag into the hole, and one for hand dominance (to receive a score of 1 (established dominance) the child had to consistently use the same hand to place all 12 flags, whereas mixed dominance received a score of 0). Children were pre-tested at the beginning of the school year and post-tested 8 months later. Despite the lack of random assignment to groups, the two groups did not differ on pre-test scores, but they did at post-test: at post-test the Montessori group were significantly faster and significantly more accurate at the task, and had more established hand dominance. However, no attempt was made to measure how frequently children in both groups engaged with materials and activities that were designed to support fine motor control development. Furthermore, the children in the Montessori classrooms were at the age where they should also have been using the sensorial materials, some of which (for example, the 'knobbed cylinders' and 'geometric cabinet') are manipulated by holding small knobs, and whose use could potentially enhance fine motor control. At that age children would also have been using the 'insets for design', materials from the early literacy curriculum designed to enhance pencil control. Therefore, although the results of this study are consistent with the practical life materials enhancing fine motor control, the study does not securely establish that they do.

A further study 35 introduced practical life exercises into conventional kindergarten classes, while control kindergarten classes were not given these materials. 15 min were set aside in the experimental schools’ timetable for using the practical life materials, and they were also available during free choice periods. This time the outcome measure at pre-test and post-test was not fine motor skill but attention. There were benefits to attention of being in the experimental group, but only for girls—boys showed no such benefits. The differential gender impact of the practical life materials on the development of attention is puzzling. Girls did not appear to engage with the materials more than boys during the time that was set aside for using them, but no measure was taken of whether girls chose them more frequently than boys during the free choice periods. Similarly, there were no measurements of the time that children in both the experimental and control groups spent engaged in other activities that might have enhanced fine motor control. Nor is it clear whether it was the fine motor practice directly or rather the opportunity to select interesting activities (the teachers in the experimental schools commented on how interesting the children found the practical life activities) that was responsible for the benefits to attention that were recorded for girls.

Finally, it has been found that young adolescents in Montessori middle schools show greater intrinsic motivation than their peers in conventional middle schools (matched for an impressive array of background variables, including ethnicity, parental education and employment, home resources, parental involvement in school, and number of siblings). 36 The authors did not establish exactly which elements of the Montessori method might be responsible for this finding, but they did speculate that the following might be relevant: “students were provided at least 2 h per day to exercise choice and self-regulation; none of the students received mandatory grades; student grouping was primarily based on shared interests, not standardised tests; and students collaborated often with other students”. The authors did not evaluate the Montessori and non-Montessori groups on any measures of academic outcomes, but given the links between academic success and motivation at all stages of education (they provide a useful review of this literature), this link would be worth investigating in Montessori schools.

This section has discussed studies that have evaluated the Montessori method directly. To date there have been very few methodologically robust evaluations. Many suffer from limitations that make it challenging to interpret their findings, whether those findings are favourable, neutral or unfavourable towards the Montessori method. However, while randomised control trials could (and should) be designed to evaluate individual elements of the Montessori method, it is difficult to see how the random assignment of pupils to schools could work in practice (hence the ingenuity of the study reported in ref. 18 ). Nor could trials be appropriately blinded—teachers, and perhaps parents and pupils too, would know whether they were in the Montessori arm of the trial. In other words, although random assignment and blinding might work for specific interventions, it is hard to see how they could work for an entire school curriculum. Furthermore, given the complexity of identifying what it is that works, why it works, and for whom it works best, additional information, for example from observations of what children and teachers are actually doing in the classroom, would be needed for interpreting the results.

Evaluations of key elements of Montessori education that are shared with other educational methods

This final section examines studies that have not evaluated the Montessori method directly, but have evaluated other educational methods and interventions that share elements of the Montessori method. They, together with our growing understanding of the science underpinning learning, can add to the evidence base for Montessori education. Given the vast amount of research and the limited space in which to consider it, priority is given to systematic reviews and meta-analyses.

One of the best-researched instructional techniques is the use of phonics for teaching children to read. Phonics is the explicit teaching of the letter-sound correspondences that allow the child to crack the alphabetic code. Montessori’s first schools were in Italy, and Italian orthography has relatively transparent one-to-one mappings between letters and sounds, making phonics a logical choice of method for teaching children the mechanics of reading and spelling. English orthography is, however, much less regular: the mappings between letters and sounds are many-to-many, and for this reason the use of phonics as a method of instruction has been challenged for English. 37 Nevertheless, there is overwhelming evidence of its effectiveness despite English’s irregularities. 38 , 39 , 40 At the same time, great strides have been made in elucidating the neural mechanisms that underlie early reading and reading impairments, and these too demonstrate the importance to successful reading of integrating sound and visual representations. 41

As always in education, the devil is in the detail. Importantly, phonics programmes have the greatest impact on reading accuracy when they are systematic. 39 , 40 By 'systematic' it is meant that letter-sound relationships are taught in an organised sequence, rather than being taught on an ad hoc as-and-when-needed basis. However, within systematic teaching of phonics there are two very different approaches: synthetic phonics and analytic phonics. Synthetic phonics starts from the parts and works up to the whole: children learn the sounds that correspond to letters or groups of letters and use this knowledge to sound out words from left to right. Analytic phonics starts from the whole and drills down to the parts: sound-letter relationships are inferred from sets of words which share a letter and sound, e.g., \(\underline{h}\) at , \(\underline{h}\) en , \(\underline{h}\) ill , \(\underline{h}\) orse . Few randomised control trials have pitted synthetic and analytic phonics against one another, and it is not clear that either has the advantage. 40

The Montessori approach to teaching phonics is certainly systematic. Many schools in the UK, for example, use word lists drawn from Morris’s 'Phonics 44'. 42 , 43 Furthermore, the Montessori approach to phonics is synthetic rather than analytic: children are taught the sound-letter code before using it to encode words (in spelling) and decode them (in reading). One of the criticisms of synthetic phonics is that it teaches letters and sounds removed from their meaningful language context, in a way that analytic phonics does not. 44 It has long been recognised that the goal of reading is comprehension. Reading for meaning requires both code-based skills and language skills such as vocabulary, morphology, syntax and inferencing skills, 45 and these two sets of skills are not rigidly separated, but rather interact at multiple levels. 46 Indeed, phonics instruction works best where it is integrated with text-level reading instruction. 39 , 40 The explicit teaching of phonics within a rich language context—both spoken and written—is central to the Montessori curriculum. No evaluations have yet pitted phonics teaching in the Montessori classroom versus phonics teaching in the conventional classroom, however, and so whether the former is differentially effective is not known.

Research into writing supports Montessori’s view that writing involves a multitude of component skills, including handwriting, spelling, vocabulary and sentence construction. 47 , 48 Proficiency in these skills predicts the quality of children’s written compositions. 49 , 50 In the Montessori classroom these skills are worked on independently before being brought together, but they can continue to be practised independently. A growing body of research from conventional and special education classrooms demonstrates that the specific teaching of the component skills of writing improves the quality of children’s written compositions. 51 , 52 , 53 , 54

With respect to teaching mathematics to young children, there are many recommendations that Montessori teachers would recognise in their own classrooms, such as teaching geometry, number and operations using a developmental progression, and using progress monitoring to ensure that mathematics instruction builds on what each child knows. 55 Some of the recommended activities, such as 'help children to recognise, name, and compare shapes, and then teach them to combine and separate shapes' 55 map exactly on to Montessori’s sensorial materials such as the geometric cabinet and the constructive triangles. Other activities such as 'encourage children to label collections with number words and numerals' 55 map onto Montessori’s early mathematics material such as the number rods, the spindle box and the cards and counters. The importance of conceptual knowledge as the foundation for children being able to understand fractions has been stressed. 56 The Montessori fraction circles—which provide a sensorial experience with the fractions from one whole to ten tenths—provide just such a foundation, as do practical life exercises such as preparing snacks (how should a banana be cut so that it can be shared between three children?) and folding napkins.

Finally in this section, it is worth returning to the sustained attention and self-regulation that have been argued to characterise children’s engagement with the learning materials in the Montessori classroom. 2 , 3 , 4 These are important parts of the complex cognitive construct of executive functions (EFs), which also include inhibition, working memory and planning. Put simply, EFs are the set of processes that allow us to control our thoughts and actions in order to engage in motivated, goal-directed behaviour. That EFs are critical for academic success is backed by a wealth of research evidence. 57 , 58 , 59 , 60 , 61 Given this key role, EFs have become the target for a number of individually-administered interventions, full curricula, and add-ons to classroom curricula, such as CogMed (Pearson Education, Upper Saddle River, NJ), Tools of the Mind, 62 PATHS (PATHS Training LLC, Seattle, WA), music, yoga and martial arts. A review study compared these, including Montessori education, and concluded that compared to interventions such as CogMed that solely target EFs, 'school curricula hold the greatest promise for accessibility to all and intervening early enough to get children on a positive trajectory from the start and affecting EFs most broadly'. 63

Conclusions

Montessori education has been in existence for over a hundred years. Such longevity could well be due, at least in part, to its adaptability. 6 However, by its very nature, of course, greater adaptability means lower fidelity. This paper has discussed evidence that children may benefit cognitively and socially from Montessori education that is faithful to its creator’s principles, but it is less clear that adapted forms—which usually result in children spending less time engaged with self-chosen learning materials—are as effective. Nevertheless, studies suggest that the practical life materials can be usefully introduced into non-Montessori classrooms to support the development of young children’s fine motor skills and attention, and there is ample evidence from the wider educational literature that certain elements of the Montessori method—such as teaching early literacy through a phonic approach embedded in a rich language context, and providing a sensorial foundation for mathematics education—are effective. It has not been possible in this paper to give an exhaustive discussion of all the elements of Montessori education that might be beneficial, for example the lack of extrinsic rewards, the reduced emphasis on academic testing and lack of competition between pupils, the 3-year age-banding that fosters cross-age tutoring, or the presence of a trained teacher in the early years classroom.

Where does this leave Montessori education more than 100 years after its birth, and more than 60 years after the death of its creator? As others have noted, Montessori was a scientist who truly valued the scientific method and would not have expected her educational method to remain static. 64 Yet Montessori teachers often feel fear or uncertainty about being able to apply Montessori’s theories in new and innovative ways while still adhering to her underlying philosophical principles. 65 Ultimately, only empirical research, undertaken by teachers and researchers working together, can be our guide, because the questions that need answering are empirical in nature. Neuroscientific research—using neuroimaging methods which were not available in Montessori’s day—might also play a guiding role. For example, Montessori was prescient in her views that adolescence was a special time in development where the individual required a specially-designed form of education to address their needs. 66 Recent neuroimaging evidence points to adolescence as indeed being an important period for neural development, particularly for areas involved in executive functions and social cognition. 67 , 68 Montessori did not fully develop her ideas for the education of 12–18-year olds during her lifetime, but it is an area where current Montessorians might be able to take over the reins. Although some Montessori schools take pupils up to the age of 18, they are few and far between, and to my knowledge there are no published evaluations of their effectiveness. Developing a Montessori education for this age group in conjunction with the best of our current knowledge of developmental cognitive neuroscience has the potential to make a very positive contribution.

Nor did Montessori consider using her method with the elderly. In the context of a rapidly aging population and increasing numbers of elderly adults with acquired cognitive impairments such as those that result from Alzheimer’s disease, 69 it is interesting to note that the Montessori method is now being adapted for use with dementia patients, with the aim of improving functioning in activities of daily living, such as feeding, and in cognition. There is strong evidence for a reduction in difficulties with eating, weak evidence for benefits on cognition, and mixed evidence for benefits on constructive engagement and positive affect. 70 However, the quality of studies varies across domains; those evaluating effects on cognition have been of rather poor quality so far, and they have not yet examined whether there might be long-term effects. Nevertheless, given the challenges to developing successful medication for patients with Alzheimer’s disease despite a detailed knowledge of changes in their neurobiology, it would be sensible to continue the search for successful behavioural interventions alongside that for medical interventions. 71 One method for delivering Montessori-based activities to the elderly is via inter-generational programmes, whereby older adults with dementia are supported in teaching Montessori-based lessons to preschool children. Benefits have been reported for the adults involved, 72 but whether the children also benefit in particular ways from such inter-generational teaching has not been evaluated. Nor is it known whether a Montessori education in childhood or Montessori-based activities experienced in later life can protect the executive control circuits of the brain, as has been proposed for bilingualism. 73 A lifespan approach to the evaluation of the Montessori method involving both behavioural and neuroimaging methods might be valuable.

In sum, there are many methodological challenges to carrying out good quality educational research, including good quality research on the Montessori method. Arguably the most obvious challenge to emerge from the literature reviewed here is the practical difficulty of randomly allocating pupils to Montessori and non-Montessori schools in order to compare outcomes. The majority of studies have relied instead on trying to match pupils and teachers in Montessori and non-Montessori schools on a number of different variables, with the concomitant danger that unidentified factors have contributed to any difference in outcomes. Even if randomisation is achievable, studies need to be conducted on a large enough scale to not only allow generalisations to be made beyond the particular schools studied, but to also allow investigation of which children the Montessori method suits best. On a more optimistic note, recent experimental studies—whereby features of existing Montessori classrooms are manipulated in some way, or features of the Montessori method are added to non-Montessori classrooms—hold promise for investigating the effectiveness of particular elements of the Montessori method. The evidence base can be strengthened yet further by drawing on research of educational interventions with which it shares certain elements, and by drawing on related research in the science of learning. National and regional education systems are beset by regular swings of the pendulum, for example towards and away from phonics, 74 and towards and away from children working individually. 75 This means that elements of the Montessori method will sometimes be in vogue and sometimes not. It is therefore particularly important that Montessori teachers understand the evidence base that supports, or does not support, their pedagogy.

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I dedicate this work to Sandra Nash Petrek (1939–2017), an inspiring Montessorian.

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Education Improves Public Health and Promotes Health Equity

Robert a. hahn.

1 Centers for Disease Control and Prevention, Atlanta, GA, USA

Benedict I. Truman

This article describes a framework and empirical evidence to support the argument that educational programs and policies are crucial public health interventions. Concepts of education and health are developed and linked, and we review a wide range of empirical studies to clarify pathways of linkage and explore implications. Basic educational expertise and skills, including fundamental knowledge, reasoning ability, emotional self-regulation, and interactional abilities, are critical components of health. Moreover, education is a fundamental social determinant of health – an upstream cause of health. Programs that close gaps in educational outcomes between low-income or racial and ethnic minority populations and higher-income or majority populations are needed to promote health equity. Public health policy makers, health practitioners and educators, and departments of health and education can collaborate to implement educational programs and policies for which systematic evidence indicates clear public health benefits.

Education is a process and a product . From a societal perspective, the process of education (from the Latin, ducere, “to lead,” and e, “out from,” yield education, “a leading out”) intentionally engages the receptive capacities of children and others to imbue them with knowledge, skills of reasoning, values, socio-emotional awareness and control, and social interaction, so they can grow as engaged, productive, creative, and self-governing members of a society. 1 Of course, not all educational institutions achieve these goals for all children – far from it; educational institutions in the United States often fall short of goals, and too many students may be led into school failure, social dysfunction, and marginal living conditions with lifelong disadvantages.

Not all learning is acquired in a formal school setting. The process of education occurs at home, in school, and in the child’s community. Children in the United States spend a relatively small proportion of their waking hours in school – approximately 1,000 hours per year or about one fifth of their waking hours. 2 Thus there are many opportunities for informal education outside the school setting. 3 When researchers find evidence linking mental capacities, knowledge, feelings, and values with health outcomes, 4 not all consequences can be attributed to formal education.

As the product of the educational process, an education is the array of knowledge, skills, and capacities (ie, intellectual, socio-emotional, physical, productive, and interactive) acquired by a learner through formal and experiential learning. An education is an attribute of a person. And, although a person may be said to “have” a certain level of education at any particular moment, educational attainment is a dynamic, ever-evolving array of knowledge, skills, and capacities.

Although we conceive of education broadly, including both its formal and informal sources, the focus of our evidence review is the formal education that is measured in most research. Our recommendation also focuses on the formal education, from early childhood to college and beyond, that is, the subject of educational policy and, we argue, should also be the subject of public health policy.

In public health, researchers and practitioners have examined 3 principal relationships between education and health. First, health is a prerequisite for education : hungry children or children who cannot hear well, or who have chronic toothaches, eg, are hindered in their learning. 5 Second, education about health (ie, health education) occurs within schools and in many public health interventions; it is a central tool of public health. 6 Third, physical education in schools combines education about the importance of physical activity for health with promoting such activity. 7 Here we focus on 2 additional relationships between education and health. First, we propose that education as a personal attribute is a central conceptual component and essential element of health , similar to physical fitness. Second, we summarize the extensive literature demonstrating that formal education is a contributing cause of health .

We argue that education – the product and personal attribute acquired – is both a critical component of a person’s health and a contributing cause of other elements of the person’s concurrent and future health. Consistent with other definitions of health, a person who lacks basic elements of an education is not fully healthy. 8 , 9 For example, the 1978 Alma Ata International Conference on Primary Health Care defined “health” to include “a state of complete…mental and social well-being” – which we see as largely products of education. Attainment of a certain level of formal education by young adulthood affects lifelong health through multiple pathways. 8 , 10

We then argue that, because it is both an essential component and a major contributing cause of health, educational achievement broadly should be a legitimate arena for public health intervention. Thus, public health practitioners could legitimately promote educational programs to advance public health. Education should also be recognized as an essential requirement for the disruption of the cycle of poverty and inequities in health. The public health community should expand research to better understand the causal relationships between education and health, and thereby identify evidence-based educational policies that have great potential to improve public health.

A Broad Concept of Education

We propose a broad concept of education as a personal attribute, which includes not only subject-matter knowledge, reasoning, and problem-solving skills, but also awareness of one’s own emotions and those of others and control of one’s emotions (ie, “emotional intelligence”) 11 and associated abilities to interact effectively. “Education improves health because it increases effective agency, enhancing a sense of personal control that encourages and enables a healthy lifestyle. Education’s beneficial effects are pervasive, cumulative, and self-amplifying, growing across the life course.” 12

In 1983, the National Commission on Excellence in Education’s report, A Nation at Risk , launched a national conversation about the need for educational reform. 13 In 1990, the US Department of Labor initiated a program – the Secretary’s Commission on Achieving Necessary Skills – to determine critical capacities for a US workforce to be provided by the educational system. 14 The capacities proposed were based on “a three-part foundation” reflecting the broad notion of education that we propose: Basic Skills (reading, writing, arithmetic, mathematics, listening, speaking), Thinking Skills (creative thinking, decision making, problem solving, seeing things in the mind’s eye, knowing how to learn, reasoning), and Personal Qualities (responsibility, self-esteem, sociability, self-management, integrity/honesty). The project recommends as a central educational goal: “All American high school students must develop a new set of competencies and foundation skills if they are to enjoy a productive, full, and satisfying life.” 14 (p1) We would expand this list of outcomes to include a healthy life.

Education as an Element of Health

In our conception, basic education is an integral part of being healthy. A person is unhealthy if he or she lacks basic knowledge, the ability to reason, emotional capacities of self-awareness and emotional regulation, and skills of social interaction. These embodied personal attributes or mental capacities, the products of formal education as well as other learning experiences, are conceptually comparable to physical capacities of fitness and coordination – well-established components of health. “Education teaches a person to use his or her mind: Learning, thinking, reasoning, solving problems, and so on are mental exercises that may keep the central nervous system in shape the same way that physical exercise keeps the body in shape.” 8 (p738) A person is unhealthy who cannot conduct himself or herself effectively and achieve some level of “social well-being” – a critical element of the World Health Organization (WHO) conception of health, which recognized the contributions of social sectors beyond the health sector in promoting health. 9

The projects of several US and international health agencies reflect this concept of education as a component of health. For example, the US Centers for Disease Control and Prevention recognizes “cognitive health” in its Healthy Aging Program; although the focus of this program is prevention and control of Alzheimer’s disease, the “cognitive health” rubric suggests far broader considerations: “The public health community should embrace cognitive health as a priority, invest in its promotion, and enhance our ability to move scientific discoveries rapidly into public health practice.” 15 (p1) The National Institutes for Health similarly has a “healthy brain” program that recognizes cognitive as well as emotional capacities as elements of health. 16

Similar concepts are recognized internationally by the WHO, in accordance with its definition of health cited above. More recently, a WHO paper 17 included cognition and affect as 2 of 6 domains for the international comparison of health status .

Measures of Education as a Personal Attribute

Education is measured in a variety of ways. A common measure, years of schooling/educational attainment, is problematic insofar as time spent in school gives little indication of how the time is spent and what is learned. 2 School-level completion may be a better measure, but also varies in terms of the quality and quantity of what is learned. Standardized tests of subject-matter knowledge and reasoning skills may be still better for some purposes, but may offer challenges when compared across populations. 18

Some 19 , 20 have argued that teacher-assigned grades are an alternate, if not better, predictor of long-term outcomes than standardized tests because they reflect not only academic achievement, but also classroom social and learning skills that indicate abilities to learn and to interact successfully. The breadth of skills addressed by this measure better reflects the broad concept of education argued here. Subjectivity, personal preferences, and comparability are challenges with teacher-assigned grades as a measure of achievement.

Evidence of Causal Association

It may seem odd that, in the perspective developed here, education – the product and the personal attribute – is at once an element of health and a cause of health. The relationship is similar to that of physical fitness and health. Fitness is an element of health and an important cause of subsequent health – not only of physical fitness, but of other facets of health as well, including cardiac health and mental health. 21 – 23 In addition to providing extensive evidence that education is associated with health, we argue that the underlying causal process is conceptually similar to the causal relationships between physical activity or an infectious agent and health. We provide some evidence of causation, noting that the notion of causal proof in a traditional deterministic sense has been challenged. 24

Criteria to determine causality in public health developed by Sir Bradford-Hill in 1965 25 are still useful. They are:

• Strength of association linking hypothetical cause and outcome (as assessed, eg, by the magnitude of relative risks)
• Consistency of findings, eg, by different researchers in different settings
• Specificity – the connection of specific, narrow causes to specific outcomes
• Temporal sequence—the necessity of cause preceding consequence
• Dose–response relationship
• Plausibility in terms of current knowledge
• Coherence – similar to plausibility, the fit with other contemporary knowledge
• Experiment – offering the strongest support
• Analogy – the comparability of postulated causality with causality in similar phenomena

Most of the Bradford-Hill criteria clearly apply when linking education to health. An obvious exception is specificity, because education itself is a broad concept including many elements, and the causal consequences of education are also numerous and heterogeneous. Bradford-Hill did not regard specificity as essential, as in the case of cigarette smoke with its multiple health consequences. As Susser has argued, “Specificity enhances the plausibility of causal inference, but lack of specificity does not negate it.” 26 (p153)

The associations presented below satisfy several standard criteria for causation. At least 3 approaches are used: 1) observational cohort studies with concurrent controls, 2) natural quasi-experiments in education policy, and 3) educational experiments. In the sections that follow, we provide samples of evidence of the causal association between education and health, assessed first by various health-related outcomes: health risk and protective behaviors, wages and income (resources for health), self-assessed health, morbidity, mortality, and life expectancy. We then provide evidence from experimental studies. The literature on these topics is extensive 4 , 8 and here we describe only a few examples, from early childhood and beyond. Evidence of the association between measures of education – the personal attribute – and other health-related outcomes is positive, strong, and consistent.

Health Risk and Protective Behaviors Are Associated With Academic Achievement

Evidence of an association between high school student grades and risk behaviors in the United States is remarkably consistent; higher average grade achievement is associated with lower rates of risk behavior ( Figure 1 ). 27 One plausible explanation is that there is causation in the reverse direction of what is proposed here, ie, that risk behavior interferes with academic achievement; such reverse causation seems reasonable, eg, for watching television and using alcohol. Also plausible is that other factors, such as strong values, promote both academic achievement and self-protective behaviors, or that academic achievement is associated with knowledge, which leads to risk avoidance. Another explanation is that underlying psychological or environmental conditions are associated with risk behavior and academic problems. Causation in both directions is likely. The consistency of a dose response for multiple behaviors is consistent with an effect of educational success on the avoidance of risky behavior.

Health-risk behaviors and school grades, United States, 2009.

Source: www.cdc.gov/healthyyouth/health_and_academics/pdf/health_risk_behaviors.pdf .

There is also strong evidence of a dose response between years of education and many health-related risk and protective behaviors among US adults. Analysis of a representative survey of adults aged >25 years between 1990 and 2000 indicates that the prevalence of several risk behaviors is generally higher among those with fewer than nine years of formal education, begins to decline among those who have nine to 12 years of formal education, and continues to decline with additional years of education; this finding corresponds to the recognized importance of high school completion for subsequent health. 28 , 29

Wages and Income, Resources for Health, Are Associated With Educational Success

Wages and income are not health outcomes, but are closely linked with health outcomes because they provide access to health-related resources, such as healthy food, a safe environment, and healthcare. A recent analysis 30 of trends in US wages over more than 20 years finds higher wages consistently associated with higher educational attainment and a trend toward increasing differences in wages by educational status. In the causal chain, high educational attainment is antecedent to high wages or income. A recent study 31 linking individual kindergarten standardized achievement tests with wages at ages 25–27 years indicates a remarkable linear association accounting for 17% of the variability in the wage outcome – 20 years later ( Figure 2 ). Although high family income precedes and predicts educational success in children, controlling for such demographic characteristics of the kindergartner (including family income, household ownership, and marital status) diminishes, but by no means eliminates, the association found in this study.

Association between kindergarten test score percentiles and mean wage earnings, ages 25–27 years, Tennessee STAR program.

Source: Chetty, 2010.

Self-Assessed Health Is Associated With Educational Attainment

Self-assessed health is a well-established index of morbidity and predictor of mortality. 32 , 33 A recent study compares the association of educational attainment with self-assessed health in US and Canadian populations. 34 , 35 Controlling for basic demographics and income, those with less than a high school education in the United States are 2.4 times as likely as high school graduates and 4.1 times as likely as those with post-secondary education to rate their health as poor. Further adjusting these ratios for risk behaviors only moderately reduces the ratios, suggesting that education is related to self-reported health due to important factors in addition to risk behaviors.

It is plausible that health status affects the likelihood of educational achievement, but it is likely that the major force of causation is in the opposite direction. Not only is educational attainment closely associated with self-rated health, but the association increases with age when measured by the number of days per week reported as free of major symptoms. With increasing age, the gap in symptom-free days increases between those with a college degree, those with a high school degree or some college, and those with less than a high school degree, suggesting that the effects of education are pervasive throughout the lifespan, and that its consequences have cumulative effects on health over time. 36

Morbidity is Associated With Educational Attainment

In the United States, although higher self-reported rates of several conditions, such as prostate cancer and sinusitis, are reported among more adults with greater levels of education, for most conditions the reverse direction of association is evident. Rates of major circulatory diseases, diabetes, liver disease, and several psychological symptoms (sadness, hopelessness, and worthlessness) show higher rates among adults with lower educational attainment. 35

Mortality and Life Expectancy Are Associated With Educational Attainment

Evidence also exists of a strong association between educational attainment and mortality from many diseases. 37 The parallel relationship for three heterogeneous groups of illness or injury again suggests an underlying connection unrelated to the specific etiologic pathways of each cause of death ( Figure 3 ). 37 In addition, the modal age for completing formal education (the mid-20 s) substantially precedes the peak age for mortality in the United States (77 years of age) by many years, consistent with another Bradford-Hill principle, ie, the precedence of cause before effect.

Age-adjusted death rates among persons ages 25–64 years for several condition groupings, by sex and educational attainment. Selected US states, 1994–2005.

From the perspective of life expectancy, at age 25 in 2005, a man in the United States with less than a high school education could expect to live an additional 44.2 years to age 69.2 years; a man with a graduate degree could expect to live more than 15 years longer. At age 25 years, a woman in the United States with less than a high school education could expect to live to age 74.9 years; a woman with a graduate degree could expect to live more than 11 years longer. 38

Educational Experiments and Quasi-Experiments

True experiments in the field of education are uncommon. Nevertheless, several experiments have been conducted. Groups of children, often from low-income or minority families, have been exposed, sometimes with random assignment, to different forms of education and followed over time to determine long-term outcomes, including health-related outcomes, as shown in the following 3 examples of early childhood programs.

In the early 1960s, 3- and 4-year-olds with low IQs from low-income families were randomly assigned to either the High/Scope Perry Preschool Program – an educational program including home visits – or no intervention. Home visits were designed to strengthen parental engagement in the child’s education. Participants were periodically assessed until age 40. 39 Over several follow-up assessments, intervention participants had greater levels of educational attainment, income, and health insurance, lived in safer family environments, and had lower rates of tobacco and drug use and risky driving behavior than controls. At age 40 years, however, more intervention than control participants had chronic diseases, but fewer intervention participants had died.

In 1972, healthy infants at risk of academic difficulties because of their demographic circumstances (eg, poor, minority, single parents) were randomly assigned to the Carolina Abecedarian Project or a control intervention (offered social services, nutritional supplements, and healthcare services, but no educational program). 40 The Abecedarian preschool program focused on developing cognitive, social, language, and motor skills from birth through age 5 years. Before entering kindergarten, control and experimental children were again randomized into either routine schooling or a strengthened school program complemented by home visits for parental guidance to reinforce child learning. At follow-up, both the preschool and the early schooling programs were shown to be beneficial in terms of academic achievement; the preschool program had the larger effect. By age 21 years, participants in the early childhood education intervention (combining those with and without the strengthened primary school programming) had better health behaviors and better health than those who did not receive the early childhood education intervention. 41 By their mid-30 s, those exposed to the intervention, particularly males, had substantially more favorable cardiovascular risk profiles than those exposed to the control condition. 42

Finally, though not a true experiment, the Chicago Child-Parent Center program followed two groups of poor Chicago children aged 3 and 4 years: one exposed to an early childhood program and the other not exposed. Children residing in Chicago districts with federally funded kindergarten programs were eligible and selected on a “most-in-need basis”; comparison children lived in similarly poor neighborhoods with locally funded kindergarten programs. The Chicago Child-Parent Center provided educational enrichment from prekindergarten through the third grade, required parental involvement in the classroom a half-day per week, and provided nutrition and health services. At age 24 years, in comparison with control subjects, participants had lower rates of out-of-home placement (indicating child abuse), lower rates of arrests and conviction for violent behaviors, and lower rates of disability. 43

A recent review of the effects of early childhood educational programs indicates that programs with strong instructional components and those evaluated with strong study designs have large and enduring effects on the educational, social, and health outcomes of participants. 44

Several researchers have made use of natural quasi-experiments involving education policies that rapidly change years of schooling required, to evaluate the effects of the requirement on health-related and other outcomes. When state educational requirements change from 1 year to the next from 7 to 9 years, eg, cohorts of children of a certain age in that state will receive approximately 7 years of education, while their younger siblings will receive 9 years. The state where this policy is implemented may be compared by regression discontinuity analysis from before to after the change, but also with other states that have not made this change at the same time.

In one such study, Lleras-Muney 45 uses a sample of US census data to estimate the effects on mortality of changes in compulsory education requirements in 30 states, comparing birth cohorts before and after such changes between 1915 and 1939 with long-term follow-up data. Lleras-Muney concludes that each year of additional required schooling resulted in a reduction of mortality by 3.6% over 10 years, or gain of 1.7 years to life expectancy at 35 years of age. Although these data are old, it is likely that the general effects of increased educational requirements on mortality have not changed substantially. Other researchers have used regression discontinuity analysis to estimate the effects of education on rates of crime, arrest, and incarceration in the United States 46 and on teenage births in the United States and Norway. 47 Among researchers using this design, only Arendt 48 finds equivocal evidence regarding the effects of additional years of education on self-rated health, body mass index, and smoking in the United States, Canada, and Denmark. The heterogeneity of conditions affected by educational exposure again suggests a broad, nonspecific underlying “mechanism.”

The Fallacy of the Endowment Hypothesis

Gottfredson has proposed that intelligence – innate intellectual and associated ability – rather than educational attainment is the “fundamental cause” of socioeconomic inequalities in health, a proposal referred to as the “endowment hypothesis.” 49 Several basic features distinguish Gottfredson’s notion of intelligence from the concept of education as defined in this article: intelligence is regarded as “natural, not cultural,” “context-free,” and “highly heritable” – indicating a largely innate, biological foundation, little affected by environmental variability. From this vantage, education as conceived in this article may be regarded as largely determined by intelligence insofar as those with greater intelligence are both more likely to seek education and to succeed in acquiring it.

Gottfredson’s hypothesis is explicitly evaluated by others in a study of 2 US cohorts that assesses the contributions of education, income, and intelligence to 3 health outcomes: mortality, life-threatening illness, and self-rated health. 50 The researchers posit an alternative model, in which there are underlying “background influences on [socioeconomic status] and intelligence.” In this model, intelligence affects education and income, and both of these socioeconomic status characteristics in turn affect intelligence; a summary of research on this linkage 51 indicates that a year of education is associated with a gain of between 2 and 4 IQ points. In both study cohorts, intelligence during high school is measured by standardized and validated tests, the Henmon-Nelson test and the Wechsler Adult Intelligence Scale. The researchers find generally consistent evidence of pairwise dose–response associations between levels of education, income, and intelligence with each of 3 health outcomes.

The researchers then examine the questions: what is the effect of controlling the association of education and health outcomes for intelligence; of income and health outcomes controlling for intelligence; and of intelligence and health outcomes controlling for both education and income? This assessment allows answering 2 basic questions: how much does intelligence contribute to the effects of education and of income on health, ie, what are the effects of these determinants net the contribution of intelligence? And, to what extent are the effects of intelligence on health mediated by income and education? The researchers find that separately controlling the effects of education and income on health outcomes for intelligence alters the coefficients for education and income minimally and leaves all associations statistically significant at the 0.05 level or less, indicating that little of the effect of education on health is mediated by intelligence.

The effects of controlling the effects of intelligence on health for education and income are more complex. Only 1 of the 2 surveys finds a significant effect of intelligence on mortality ( P <.05); controlling for education and income eliminates the significance of this finding. Thus, the effect of intelligence on mortality is largely mediated by income and education. Both surveys find statistically significant effects of intelligence for both life-threatening illnesses and self-rated health; however, the effect magnitudes are diminished by a mean of 69.4% and statistical significance is again eliminated for all findings except for self-rated health in one of the surveys. These findings indicate that the effects of intelligence on health outcomes are largely mediated by education and income. 50 There is thus substantial evidence that education has a strong effect on health, independent of background intelligence. Innate intelligence may be a “fundamental cause” principally insofar as it leads to higher education and income.

Causal Pathways and Evidence Linking Education and Health

Building on the work of others, 10 , 52 we constructed a model indicating the three major pathways linking education and health outcomes in adulthood and including the several facets of education – knowledge, problem solving, emotional awareness and self-regulation, values, and interactional skills ( Figure 4 ). First is the psycho-social environment, including the individual’s sense of control, social standing, and social support, which reflects and bolsters capacity and agency. Second is work, through which the individual may achieve satisfaction and income, which allows access to many health-related resources. Finally, healthy behavior may protect an individual against health risks and facilitate negotiation of the healthcare system.

Pathways from educational attainment to health outcomes.

Ross and Wu 8 used 2 national probability samples of US adults to assess the effects of completed education on self-perceived health and reported physical functioning. They first assessed the association between education and each of three broad covariate groups – psycho-social environment; work; and health knowledge, literacy, and behaviors – that are themselves determinants of health outcomes ( Figure 4 ). 8 For each data source, they began with a model including as covariates only demographic characteristics of their samples. To the basic model, they first added employment and economic covariates, then social-psychological covariates, and finally risk behavior covariates, noting the changes in regression coefficients for educational exposures on health outcomes. This approach allowed assessment of the magnitude of each of these groups of covariates as pathways linking education to health-related outcomes. However, the relative contribution of each group of factors cannot be determined precisely, because these groups are unlikely to be causally independent, and covariate groups entered into the regression early are thus likely to show greater reductions in regression coefficients than those entered later.

In both samples, education was associated with all covariates in expected directions. The largest effect was for work-related variables, including income. Those with lower income not only had limited resources useful in maintaining health, but also may have experienced anxieties that exacerbate health problems. The effects of psycho-social resources were also statistically significant and of similar magnitude. Risk behavior and knowledge also contributed to the association between education and health by both measures. The 3 clusters of covariates together explain between 55% and 59% of the variance in self-reported health and between 46% and 71% of physical functioning in these surveys. This suggests that the smallest contribution to health outcomes is associated with health behaviors, which were entered last into the regression model. In both samples, education has a significant residual “direct” effect, independent of the three examined pathways. In summary, education’s association with improved health is attributable to greater work opportunities and rewards, a greater sense of control and social support, healthier behaviors, and a direct effect on health. Similar results are found by Cutler and Lleras-Muney, 28 who use different sources to assess associations between educational attainment, health behaviors, and mortality in the United States and Great Britain.

In a separate study, Ross and Mirowsky 53 provide evidence that the effect of higher levels of education on health is mediated principally by its contents, including values and skills imparted, and far less by means of status markers such as the diploma or the prestige of the degree-granting institution. Evidence for this conclusion derives from a regression analysis of national data including measures of years of education, receipt of diplomas, and school selectivity (based on test scores of entering freshmen). In another study, Reynolds and Ross 54 provide evidence that “the direct effect of education on well-being is greater than the direct effect of social origins, and the total effect of social origins is mediated mostly by education.” 54 (p226) Evidence derives from a regression analysis of two national data sources in which the researchers control for parental education, father’s occupation, and childhood poverty. They also find that a person’s level of education has a far greater effect on health if his or her parents were poorly educated than if they were well-educated. Unfortunately, in our society, parental and child educational levels are highly positively correlated, so that the children of parents with little education, who might benefit the most from higher levels of education, are least likely to receive that education. 55

Ross and Mirowsky 55 (pp597,598) conclude (emphasis added): “…certain policy implications follow. First, education policy is health policy. Second, health policy must address the educational opportunities of children raised by poorly-educated parents. Otherwise those children, in adulthood, will suffer the multiplicative health consequences of low parental education and low personal education…Structural amplification condemns some families to the concentration of low education with poor health across generations… Break that mediating link, and the moderating effect of higher education will suppress the health disadvantages of the socially disadvantaged origins. ”

High Societal Price in Health of Education Forgone

An estimate of the number of annual deaths attributable to lack of high school education among persons 25–64 years of age in the United States (237,410) exceeds the number of deaths attributed to cigarette smoking among persons 35–64 years of age (163,500) (Krueger et al., unpublished manuscript, 2013). 56 (The estimate of smoking-attributable mortality does not include adults younger than 35 years of age because mortality from smoking is negligible at this age.)

Several recent estimates have been made of economic costs to individuals, the government, and society of the failure of each American to achieve an optimal education. Although it may be argued that there is a moral duty to redress injustice and inequity regardless of cost, these estimates indicate the economic magnitude of this loss and the potential value of its redress.

Schoeni and colleagues 57 , 58 estimate the annual economic value of health forgone in the United States in 2006 by adults who lack a college education. For a population of 138 million aged 25 years or older with less than a college education, the economic value of the life and health forgone is US$1.02 trillion per year – 7.7% of US gross domestic product.

Levin and colleagues 59 provide an estimate of benefits to the government (in 2004 dollars) if those who did not finish high school had completed a high school education (or higher) with a diploma. Based on governmental benefits of income taxes associated with greater earnings of high school graduates and reduced costs of welfare and incarceration, Medicaid, and lifetime savings of approximately US$40,000 per capita in public health expenses, they estimated a total lifetime benefit of US$209,000 for each high school dropout if he or she had instead completed high school. They then examined the costs and benefits of 5 programs with demonstrated efficacy in improving rates of high school completion. Cost–benefit ratios range from 1.5 to 3.5, indicating substantial governmental benefit. 59

Education as a Domain of Public Health Action

Just as many areas of daily life are recognized domains of legitimate public health action – agriculture (eg, nutrition and food safety), transportation (eg, vehicle injuries, air pollution, and walking), immigration (eg, immigrant health and infection control), justice (eg, violent crime and prison health), urban design (eg, safety, walkable communities, and food deserts), and labor (eg, occupational safety and health) – so should education (beyond health education in schools) be recognized as a legitimate domain of public health action. Education is a critical component of health and, we argue, education is a major, long-term, multifaceted cause of health. In particular, education is a powerful means of breaking the cycle of poverty (which greatly affects ethnic and racial minority populations) and promoting health equity.(As this article was in press, the authors encountered an excellent paper by Cohen and Syme 60 which draws similar conclusions.)

Several federal agencies have supported “health in all policies,” 61 particularly through the National Prevention, Health Promotion and Public Health Council. 62 The US Department of Health and Human Services includes in its mission 63 to “engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge” and in its overarching goals to “Create social and physical environments that promote good health for all.”

States and the District of Columbia have also adopted a “health in all policies” perspective. California’s “CAL Health in all Policies” 64 – 66 recognizes the potential for education as a means of moving toward health equity. “Promote efforts that demonstrate positive effects in closing the achievement gap. Collaborate on advancing strategies, addressing the major factors that inhibit the learning of all students.” Counties (eg, Los Angeles, Baltimore) also have adopted a “health in all policies” perspective. 64 , 67 , 68

The effort to pursue multi-sectoral strategies for health improvement is international, practiced in the European Union, Australia, and elsewhere. The European Union has adopted a social determinants-based approach: “Health in All Policies addresses the effects on health across all policies such as agriculture, education, the environment, fiscal policies, housing, and transport. It seeks to improve health and at the same time contribute to the well-being and the wealth of the nations through structures, mechanisms, and actions planned and managed mainly by sectors other than health.” 69 (pXVIII)

In “A Framework for Public Health Action: The Health Impact Pyramid,” 71 Frieden writes, “Interventions that address social determinants of health have the greatest potential public health benefit” and contrasts social determinants – the base of the “health impact pyramid” – with higher strata in the pyramid. 70 (p594) Among social determinants, education is fundamental, because education forms the new members of society – children and youth. Effective teachers are facilitators of long-term health benefits. Beyond school health promotion, education as a means of public health intervention is more difficult to define, to administer, to measure, and to evaluate. It is cumulative, formative, and transformative, both for the individuals who experience it and for the society it recreates and modifies. Although these features make education more challenging than some other tools of public health, such challenges must not deter the public health community from working closely with the education community to investigate and understand this form of social determinant causation, evaluate the wide array of educational program types, and mobilize for action on this powerful force for public health benefits.

Acknowledgments

Many thanks to thoughtful readers and editors Randy Elder, Catherine Ross, Barbara Rimer, Kate W. Harris, Amy Brown, Heba Athar, and Kristen Folsom.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Biographies

Robert A. Hahn received his PhD in anthropology at Harvard University (1976) and his MPH in epidemiology from the University of Washington (1986). Since 1986, he has served as an epidemiologist at the US Centers for Disease Control and Prevention (CDC) in Atlanta and is a member of the Senior Biomedical Research Service. He is the author of Sickness and Healing: An Anthropological Perspective (1995) and co-editor of Anthropology and Public Health: Bridging Differences in Culture and Society (2008), with a second edition recently published. In 1998–1999, he worked as a Capitol Hill Fellow in the US House of Representatives Committee on Veterans Affairs and in the office of Congresswoman Louise Slaughter. He is currently coordinating scientist of systematic reviews on health equity for the CDC Guide to Community Preventive Services .

Benedict I. Truman earned his BS in chemistry and MD from Howard University and his MPH from the Johns Hopkins Bloomberg School of Public Health, where he completed a residency in preventive medicine and public health and served as chief resident. He has held scientific and leadership positions in state, local, and federal public health agencies and is the associate director for science at the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the US Centers for Disease Control and Prevention (CDC). In this role, he works with other scientists and program managers to ensure that the CDC’s scientific products and research ethics meet the highest standards of quality and integrity. He has published many peer-reviewed journal articles on educational interventions for health equity; prevention and control of infectious diseases and chronic noninfectious diseases; adolescent and school health; community preventive services guidelines; minority health and health disparities; employee performance and public health workforce development; and applied epidemiologic methods. He serves as the Consulting Editor for Infectious Diseases for the Journal of Public Health Management and Practice .

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Greater Good Science Center • Magazine • In Action • In Education

Our Best Education Articles of 2020

In February of 2020, we launched the new website Greater Good in Education , a collection of free, research-based and -informed strategies and practices for the social, emotional, and ethical development of students, for the well-being of the adults who work with them, and for cultivating positive school cultures. Little did we know how much more crucial these resources would become over the course of the year during the COVID-19 pandemic.

Now, as we head back to school in 2021, things are looking a lot different than in past years. Our most popular education articles of 2020 can help you manage difficult emotions and other challenges at school in the pandemic, all while supporting the social-emotional well-being of your students.

In addition to these articles, you can also find tips, tools, and recommended readings in two resource guides we created in 2020: Supporting Learning and Well-Being During the Coronavirus Crisis and Resources to Support Anti-Racist Learning , which helps educators take action to undo the racism within themselves, encourage their colleagues to do the same, and teach and support their students in forming anti-racist identities.

Here are the 10 best education articles of 2020, based on a composite ranking of pageviews and editors’ picks.

Can the Lockdown Push Schools in a Positive Direction? , by Patrick Cook-Deegan: Here are five ways that COVID-19 could change education for the better.

How Teachers Can Navigate Difficult Emotions During School Closures , by Amy L. Eva: Here are some tools for staying calm and centered amid the coronavirus crisis.

Six Online Activities to Help Students Cope With COVID-19 , by Lea Waters: These well-being practices can help students feel connected and resilient during the pandemic.

Help Students Process COVID-19 Emotions With This Lesson Plan , by Maurice Elias: Music and the arts can help students transition back to school this year.

How to Teach Online So All Students Feel Like They Belong , by Becki Cohn-Vargas and Kathe Gogolewski: Educators can foster belonging and inclusion for all students, even online.

How Teachers Can Help Students With Special Needs Navigate Distance Learning , by Rebecca Branstetter: Kids with disabilities are often shortchanged by pandemic classroom conditions. Here are three tips for educators to boost their engagement and connection.

How to Reduce the Stress of Homeschooling on Everyone , by Rebecca Branstetter: A school psychologist offers advice to parents on how to support their child during school closures.

Three Ways to Help Your Kids Succeed at Distance Learning , by Christine Carter: How can parents support their children at the start of an uncertain school year?

How Schools Are Meeting Social-Emotional Needs During the Pandemic , by Frances Messano, Jason Atwood, and Stacey Childress: A new report looks at how schools have been grappling with the challenges imposed by COVID-19.

Six Ways to Help Your Students Make Sense of a Divisive Election , by Julie Halterman: The election is over, but many young people will need help understanding what just happened.

Train Your Brain to Be Kinder (video), by Jane Park: Boost your kindness by sending kind thoughts to someone you love—and to someone you don’t get along with—with a little guidance from these students.

From Othering to Belonging (podcast): We speak with john a. powell, director of the Othering & Belonging Institute, about racial justice, well-being, and widening our circles of human connection and concern.

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Review article: medical education research: an overview of methods

Affiliation.

• 1 Department of Anesthesiology of The Ottawa Hospital & The University of Ottawa Skills and Simulation Centre, University of Ottawa, Ottawa, ON, Canada.
• PMID: 22215522
• DOI: 10.1007/s12630-011-9635-y

Purpose: This article provides clinician-teachers with an overview of the process necessary to move from an initial idea to the conceptualization and implementation of an empirical study in the field of medical education. This article will allow clinician-teachers to become familiar with educational research methodology in order to a) critically appraise education research studies and apply evidence-based education more effectively to their practice and b) initiate or collaborate in medical education research.

Source: This review uses relevant articles published in the fields of medicine, education, psychology, and sociology before October 2011.

Principal findings: The focus of the majority of research in medical education has been on reporting outcomes related to participants. There has been less assessment of patient care outcomes, resulting in informing evidence-based education to only a limited extent. This article explains the process necessary to develop a focused and relevant education research question and emphasizes the importance of theory in medical education research. It describes a range of methodologies, including quantitative, qualitative, and mixed methods, and concludes with a discussion of dissemination of research findings. A majority of studies currently use quantitative methods. This article highlights how further use of qualitative methods can provide insight into the nuances and complexities of learning and teaching processes.

Conclusions: Research in medical education requires several successive steps, from formulating the correct research question to deciding the method for dissemination. Each approach has advantages and disadvantages and should be chosen according to the question being asked and the specific goal of the study. Well-conducted education research should allow progression towards the important goal of using evidence-based education in our teaching and institutions.

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Leaders Are Readers: Q2 2024 Reading List

The suggested readings in this installment of the "Leaders Are Readers" series encourage leaders to value diverse perspectives, remember lessons from the past as they lead through change, explore strategies for turning a stressful mindset into a productive one, and create culturally aware AI policies and practices.

I've been thinking a lot about the seasons of life. I've reflected on them figuratively, considering which seasons are best to surrender to rather than fight against (parenting young kids, anyone?). I've also thought about them literally, considering the impact of changing light, temperature, and weather patterns embedded in the four seasons.

In modern society, the effects of the four seasons have, in many ways, been eliminated. We have temperature-controlled homes, lights that turn on and off with the flick of a switch, alarm clocks, and knowledge work that need not fluctuate with the weather. These advances are great, and I would never advocate ridding ourselves of them. But in our sprint to advance, we've created a seasonless world.

However, if we return to the idea of seasonality, we know that spring is a season of renewal—new leaves, crisp mornings, and new graduates. It's also a season of refreshment—fresh grass, fresh air, and fresh opportunities.

Some great reads have inspired me to refresh my thinking about leadership and life. As we enter the spring-to-summer season, I encourage you to pick up one or more of the following readings to reengage with seasonality and revitalize your thinking!

By Rob Henderson

Troubled by Rob Henderson is the first memoir I've included in the "Leaders Are Readers" series, and it's worth your time. On paper, Henderson is the perfect higher education success story. He had a tough childhood but overcame it by serving in the Air Force, attending Yale University as an undergraduate, and completing his PhD at the University of Cambridge.

But, as with most brief biographical outlines, that summary misses most of reality. Henderson never knew his birth father and grew up in foster care after he was removed from his birth mother as a young child. He bounced between foster homes for years before he was adopted. Henderson was drinking by the time he was in middle school, smoking marijuana and experimenting with other drugs shortly after, and doing his best not to get caught along the way. He struggled in school—not because he found the content difficult but because he just wasn't interested in it. A guidance counselor convinced him that the military might be a good option for him. With some reluctance, he joined the United States Air Force. Then, a long-odds scholarship program for military veterans at Yale helped Henderson get admitted—a fairytale story for higher education.

Yet, Henderson is now critical of parts of the higher education system, particularly elite universities like those he attended. He struggles with the entitlement of the "elite class"—students from wealthy, upper-class backgrounds who seem to fight for their right to be victims. He posits that their battle to be victims and paradoxically overcome their victimhood status has "spawned a potent blend of victimhood and superiority" through which "college extends adolescence to a laughable age." Footnote 1

Whether I agree with Henderson or not is beside the point. The fact that he raises some thoughtful questions about higher education is important. Leaders should know that not everyone on college campuses shares the same ideology, even if the loudest voices broadcasting similar perspectives suggest as much. According to a March 2023 Wall Street Journal-NORC poll, 56 percent of respondents no longer believe a college degree is worthwhile. Footnote 2 Yikes. Henderson would likely ask us to consider whether some of that skepticism results from the disenfranchisement that accompanies the politicization, polarization, and profundity of some college and university experiences.

You may not love everything Henderson says, but that's precisely why Troubled is worth reading.

Same as Ever: A Guide to What Never Changes

By Morgan Housel

Morgan Housel has been a favorite author of mine for years. He regularly writes for the Collaborative Fund, which you might enjoy if you're into shorter, blog-style writing. He's also the author of the bestselling book The Psychology of Money . Footnote 3 Housel is incredible at breaking down how people collectively think and act at the intersection of psychology, money, and history.

We live in a world that is perpetually changing. Here's an example: I recently attended a conference where 78 percent of the sessions included "AI" in the title. At last year's conference, only 8 percent of them did. Interestingly, many of the conversations at this year's conference echoed years past but through this new lens. The higher education community asked the same "What do we do now?" question during the financial crisis in 2008, amid the rise of the massive open online course in 2012, when GenZ students started bringing their smartphones to campus in the late 2010s, during the coronavirus pandemic in 2020, and more. You can trace the history of higher education through these moments.

I love Housel's new book, Same as Ever: A Guide to What Never Changes, because it reminds me that many things stay the same even when everything else changes:

• Traumatic events always leave scars and always change mindsets. From childhood trauma to organizational change, people affected by trauma will never forget it or think the same way afterward. Leaders who implement change as if people will simply switch their mindsets and move forward forget everything they've ever learned about changing people's lives.
• Trying too hard and creating unnecessary complexity always separates people. Many leaders use jargon and complexity to make themselves or their work seem more important or impactful. That approach has never worked. Instead, it creates—and will always create—division and confusion.
• Building things takes time and complexity; destroying them is simple and fast. From human life to thriving organizations, growth is often slow and requires immense intention. Destruction, though, can happen in seconds with very little work. This truth hits home in the context of building teams, impacting communities, and advancing important work.
• The best story always wins. We live in a world of data, but the fact remains that the best data always falls short of the best story. PowerPoint slides full of charts are interesting, but the stories behind the charts and figures are transformative. Footnote 4

Everyday Vitality: Turning Stress into Strength

By Samantha Boardman

I came across Samantha Boardman's book Everyday Vitality: Turning Stress into Strength a few years ago. I was immediately drawn to her definition of vitality : "The positive feeling of aliveness and energy that lies at the heart of a good day." Footnote 5 It is the strength to be resilient—to bend but not break under the stresses and challenges of everyday life.

We often use distancing strategies to handle stress—escaping to Netflix, gazing into our refrigerators, scrolling on our phones, and planning the next vacation. Perhaps we've made too much of a good thing. Our hyper focus on self-reflection and personal development may be preventing us from the change we need the most. Boardman argues that the key to vitality is "productive and meaningful actions" that are not "internal, not individual, nor do they require sustained self-immersion. On the contrary, they require engagement and interaction." Footnote 6

In many cases, change is best achieved comprehensively. When two or more changes complement each other, adherence is more likely. For example, I am more likely to reach my goal of being more present for my team at work if I link this effort to my ongoing war with the little glowing screen I take everywhere. Less screen time equates to more presence in the physical world—a win-win.

Boardman lays out practical ideas for connecting with others and moving beyond the self to contribute broadly from a place of vitality instead of stress. I can't imagine that a leader who operates from vitality wouldn't be more effective, ethical, and enduring than one who operates from stress and fear.

Spring is a good season for vitality. Go for a walk this week and look for vitality all around you. Then, check out Boardman's book and embrace a vitality-based leadership approach.

"Creating a Culture Around AI: Thoughts and Decision-Making"

By Courtney Plotts and Lorna Gonzales

Leadership cliches abound, but one adage that has resurfaced in many of my recent conversations is "culture eats strategy for breakfast." It's a fun metaphor, but it's far too narrow. The truth is that culture eats everything.

Courtney Plotts and Lorna Gonzales bring AI conversations to their most important inflection point in their article "Creating a Culture Around AI: Thoughts and Decision-Making." Footnote 7 Most of the discussions about AI that have bloomed in higher education since the launch of ChatGPT have focused on strategy—keeping students from cheating, creating syllabus statements, using AI to design courses or write emails, etc. Yet, the intriguing and impactful ideas have percolated beneath that focus, seemingly ignored in favor of simpler, cleaner questions.

As I read Plott's and Gonzales' work, I was struck with a few enticing questions. How will AI impact value, purpose, diversity, leadership, and workplace culture? No matter how clear the AI policy is in a syllabus statement, can an institution thrive if faculty members are worried, scared, or confused? If an institution has the best handbook on AI ever written, yet staff members are unclear on how integrity and service interact with AI, is the handbook better suited as kindling?

Plotts and Gonzales thoughtfully reflect on bias within and around AI and offer useful questions to ensure that the culture stays in the driver's seat during AI strategy discussions. They cover three approaches to AI adoption and share cultural questions that leaders should ask as they consider how to leverage AI at their institutions.

Leaders with AI on their agendas need to take a culture-focused approach. This quick, well-written article starts that conversation.

Closing Thoughts

Spring and summer are the perfect seasons for rejuvenation. I hope these readings inspire you to engage with seasonality and revitalize your thinking about life and leadership.

Be curious. Be well.

• Rob Henderson, Troubled: A Memoir of Foster Care, Family, and Social Class (New York: Gallery Books, Simon & Schuster, 2024), 248. Jump back to footnote 1 in the text. ↩
• Douglas Belkin, "Americans Are Losing Faith in College Education, WSJ-NORC Poll Finds," The Wall Street Journal, March 31, 2023. Jump back to footnote 2 in the text. ↩
• Morgan Housel, The Psychology of Money: Timeless Lessons on Wealth, Greed, and Happiness (Hampshire, UK: Harriman House, 2021). Jump back to footnote 3 in the text. ↩
• Morgan Housel, Same as Ever: A Guide to What Never Changes (Hampshire, UK: Portfolio, 2023). Jump back to footnote 4 in the text. ↩
• Samantha Boardman, Everyday Vitality: Turning Stress into Strength (New York: Penguin Life, 2022), x. Jump back to footnote 5 in the text. ↩
• Boardman, 15. Jump back to footnote 6 in the text. ↩
• Courtney Plotts and Lorna Gonzalez, "Creating a Culture Around AI: Thoughts and Decision-Making,"   EDUCAUSE Review, April 22, 2024. Jump back to footnote 7 in the text. ↩

Ryan MacTaggart is Associate Director, Professional Learning, at EDUCAUSE.

© 2024 Ryan MacTaggart. The content of this work is licensed under a Creative Commons BY-NC-ND 4.0 International License.

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After publishing an article critical of Israel, Columbia Law Review’s website is shut down by board

FILE - A student protester parades a Palestinian flag outside the entrance to Hamilton Hall on the campus of Columbia University, Tuesday, April 30, 2024, in New York. The student-run legal journal, Columbia Law Review, was taken offline Monday, June 3, 2024, after its board of directors objected to the publication of an article that accused Israel of genocide. (AP Photo/Mary Altaffer, Pool, File)

FILE - Protesters demonstrate against the war in Gaza outside the entrance to the campus of Columbia University, Tuesday, April 30, 2024, in New York. The student-run legal journal, Columbia Law Review, was taken offline Monday, June 3, 2024, after its board of directors objected to the publication of an article that accused Israel of genocide. (AP Photo/Mary Altaffer, File)

FILE - Police stand guard as demonstrators chant slogans outside the Columbia University campus, on April 18, 2024, in New York. The student-run legal journal, Columbia Law Review, was taken offline Monday, June 3, 2024, after its board of directors objected to the publication of an article that accused Israel of genocide. (AP Photo/Mary Altaffer, File)

FILE - Student protesters camp on the campus of Columbia University, Tuesday, April 30, 2024, in New York. The student-run legal journal, Columbia Law Review, was taken offline Monday, June 3, 2024, after its board of directors objected to the publication of an article that accused Israel of genocide. (Pool Photo/Mary Altaffer, File)

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NEW YORK (AP) — Student editors at the Columbia Law Review say they were pressured by the journal’s board of directors to halt publication of an academic article written by a Palestinian human rights lawyer that accuses Israel of committing genocide in Gaza and upholding an apartheid regime.

When the editors refused the request and published the piece Monday morning, the board — made up of faculty and alumni from Columbia University’s law school — shut down the law review’s website entirely. It remained offline Tuesday evening, a static homepage informing visitors the domain “is under maintenance.”

The episode at one of the country’s oldest and most prestigious legal journals marks the latest flashpoint in an ongoing debate about academic speech that has deeply divided students, staff and college administrators since the start of the Israel-Hamas war.

Several editors at the Columbia Law Review described the board’s intervention as an unprecedented breach of editorial independence at the periodical, which is run by students at Columbia Law School. The board of directors oversees the nonprofit’s finances but has historically played no role in selecting pieces.

In a letter sent to student editors Tuesday and shared with The Associated Press, the board of directors said it was concerned that the article, titled “Nakba as a Legal Concept,” had not gone through the “usual processes of review or selection for articles at the Law Review, and in particular that a number of student editors had been unaware of its existence.”

“In order to preserve the status quo and provide student editors some window of opportunity to review the piece, as well as provide time for the Law Review to determine how to proceed, we temporarily suspended the website,” the letter continued.

Those involved in soliciting and editing the piece said they had followed a rigorous review process, even as they acknowledged taking steps to forestall expected blowback by limiting the number of students aware of the article.

In the piece, Rabea Eghbariah, a Harvard doctoral candidate, accuses Israel of a litany of “crimes against humanity,” arguing for a new legal framework to “encapsulate the ongoing structure of subjugation in Palestine and derive a legal formulation of the Palestinian condition.”

Eghbariah said in a text message that the suspension of the law journal’s website should be seen as “a microcosm of a broader authoritarian repression taking place across U.S. campuses.”

Editors said they voted overwhelmingly in December to commission a piece on Palestinian legal issues, then formed a smaller committee — open to all of the publication’s editorial leadership — that ultimately accepted Eghbariah’s article. He had submitted an earlier version of the article to the Harvard Law Review, which the publication later elected not to publish amid internal backlash, according to a report in The Intercept .

Anticipating similar controversy and worried about a leak of the draft, the committee of editors working on the article did not upload it to a server that is visible to the broader membership of the law journal and to some administrators. The piece was not shared until Sunday with the full staff of the Columbia Law Review — something that editorial staffers said was not uncommon.

“We’ve never circulated a particular article in advance,” said Sohum Pal, an articles editor at the publication. “So the idea that this is all over a process concern is a total lie. It’s very transparently content based.”

In their letter to students, the board of directors said student editors who didn’t work on the piece should have been given an opportunity to read it and raise concerns.

“Whatever your views of this piece, it will clearly be controversial and potentially have an impact on all associated with the Review,” they wrote.

Those involved in the publishing of the article said they heard from a small group of students over the weekend who expressed concerns about threats to their careers and safety if it were to be published.

Some alluded to trucks that circled Columbia and other campuses following Hamas’ Oct. 7 attack on Israel, labeling students as antisemites for their past or current affiliation with groups seen as hostile to Israel.

The letter from the board also suggested that a statement be appended to the piece stating the article had not been subject to a standard review process or made available for all student editors to read ahead of time.

Erika Lopez, an editor who worked on the piece, said many students were adamantly opposed to the idea, calling it “completely false to imply that we didn’t follow the standard process.”

She said student editors had spoken regularly since they began receiving pushback from the board on Sunday and remained firmly in support of the piece.

When they learned the website had been shuttered Monday morning, they quickly uploaded Eghbariah’s article to a publicly accessible website . It has since spread widely across social media.

“It’s really ironic that this piece probably got more attention than anything we normally published,” Lopez added, “even after they nuked the website.”

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Readability of Patient Education Materials in Head and Neck Cancer : A Systematic Review

• 1 Department of Otolaryngology−Head & Neck Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland
• 2 Cochlear Center for Hearing and Public Health, Johns Hopkins University, Baltimore, Maryland
• 3 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
• 4 Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
• 5 Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
• 6 Mixed Methods Research Lab, Perelman School of Medicine, University of Pennsylvania, Philadelphia
• 7 Department of Otolaryngology−Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
• 8 Jefferson Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania
• 9 Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
• 10 Department of Population Health, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
• 11 Department of Medical Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
• 12 Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
• Invited Commentary Health Literacy is Health Equity Ciersten A. Burks, MD; Nosayaba Osazuwa-Peters, BDS, PhD, MPH, CHES; Michael J. Brenner, MD JAMA Otolaryngology–Head & Neck Surgery

Question   Are the available patient education materials (PEMs) on head and neck cancer (HNC) understandable to patients with HNC?

Findings   This systematic review found that more than one-third of patients demonstrated inadequate health literacy; however, none of the PEMs were written for the sixth-grade reading level as recommended by the American Medical Association.

Meaning   These findings indicate that improving the readability of HNC PEMs is crucial for mitigating the negative health impacts that arise when patients do not fully understand the information essential for fostering shared decision-making and facilitating clear communication regarding the disease and its treatment options.

Importance   Patient education materials (PEMs) can promote patient engagement, satisfaction, and treatment adherence. The American Medical Association recommends that PEMs be developed for a sixth-grade or lower reading level. Health literacy (HL) refers to an individual’s ability to seek, understand, and use health information to make appropriate decisions regarding their health. Patients with suboptimal HL may not be able to understand or act on health information and are at risk for adverse health outcomes.

Objective   To assess the readability of PEMs on head and neck cancer (HNC) and to evaluate HL among patients with HNC.

Evidence Review   A systematic review of the literature was performed by searching Cochrane, PubMed, and Scopus for peer-reviewed studies published from 1995 to 2024 using the keywords head and neck cancer , readability , health literacy , and related synonyms. Full-text studies in English that evaluated readability and/or HL measures were included. Readability assessments included the Flesch-Kincaid Grade Level (FKGL grade, 0-20, with higher grades indicating greater reading difficulty) and Flesch Reading Ease (FRE score, 1-100, with higher scores indicating easier readability), among others. Reviews, conference materials, opinion letters, and guidelines were excluded. Study quality was assessed using the Appraisal Tool for Cross-Sectional Studies.

Findings   Of the 3235 studies identified, 17 studies assessing the readability of 1124 HNC PEMs produced by professional societies, hospitals, and others were included. The mean FKGL grade ranged from 8.8 to 14.8; none of the studies reported a mean FKGL of grade 6 or lower. Eight studies assessed HL and found inadequate HL prevalence ranging from 11.9% to 47.0%.

Conclusions and Relevance   These findings indicate that more than one-third of patients with HNC demonstrate inadequate HL, yet none of the PEMs assessed were developed for a sixth grade or lower reading level, as recommended by the American Medical Association. This incongruence highlights the need to address the readability of HNC PEMs to improve patient understanding of the disease and to mitigate potential barriers to shared decision-making for patients with HNC. It is crucial to acknowledge the responsibility of health care professionals to produce and promote more effective PEMs to dismantle the potentially preventable literacy barriers.

• Invited Commentary Health Literacy is Health Equity JAMA Otolaryngology–Head & Neck Surgery

Read More About

Armache M , Assi S , Wu R, et al. Readability of Patient Education Materials in Head and Neck Cancer : A Systematic Review . JAMA Otolaryngol Head Neck Surg. Published online June 20, 2024. doi:10.1001/jamaoto.2024.1569

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• Published: 18 June 2024

Evaluation of a dementia awareness game for health professions students in Northern Ireland: a pre-/post-test study

• Stephanie Craig   ORCID: orcid.org/0000-0003-0783-4975 1 ,
• Heather E. Barry   ORCID: orcid.org/0000-0002-9684-8182 2 ,
• Gillian Carter   ORCID: orcid.org/0000-0002-0155-1002 1 ,
• Patrick Stark   ORCID: orcid.org/0000-0003-2659-0865 1 ,
• Gary Mitchell   ORCID: orcid.org/0000-0003-2133-2998 1 ,
• Sonya Clarke   ORCID: orcid.org/0000-0002-6871-0215 1 &
• Christine Brown Wilson   ORCID: orcid.org/0000-0002-7861-9538 1  

BMC Medical Education volume  24 , Article number:  677 ( 2024 ) Cite this article

45 Accesses

Metrics details

Dementia is a prevalent global health issue, necessitating comprehensive education for healthcare practitioners and students. Nursing and pharmacy students, provide support across healthcare settings often working as frontline caregivers. Therefore, it is imperative to equip these students with a profound understanding of dementia. The aim of this study was to evaluate whether a serious dementia game co-designed with stakeholders, students, and people living with dementia improved the attitudes of nursing and pharmacy students.

A pretest-posttest design was used to assess the attitudes of health professions students (nursing and pharmacy) towards dementia. The Approaches to Dementia Questionnaire (ADQ) was administered before and after playing a serious Dementia Game. The ADQ measured the total score, Hope subscale, and Recognition of Personhood subscale. Matched pairs t-test was used for analysis conducted with IBM SPSS statistics 27.

A diverse cohort of 505 participants from one university in Northern Ireland participated, with 461 matched pairs used for analysis. Both nursing and pharmacy students demonstrated a significant increase in overall dementia attitudes post-gameplay, with nursing students showing an increase from 79.69 to 83.59 and pharmacy students from 75.55 to 79.86. Subscales for Hope (Nursing = 28.77 to 31.22, Pharmacy = 26.65 to 29.20). and Recognition of Personhood also exhibited significant improvement (Nursing = 50.93 to 52.38, Pharmacy = 48.89 to 50.67). Demographic data revealed predominantly female participants, a lack of personal connections to dementia, and varied training experiences.

The study highlights the efficacy of the serious Dementia Game in enhancing attitudes to dementia amongst health professions students, indicating its potential as an educational tool. The study contributes to the growing body of evidence supporting serious games and gamification in healthcare education.

Peer Review reports

Throughout primary, secondary, and tertiary healthcare settings, healthcare professionals play a crucial role in providing comprehensive support [ 1 ] to those with dementia, from the initial stages of pre-diagnosis to end-of-life care [ 2 ]. Each year, over 10 million new cases of dementia are documented, with more than 55 million individuals affected globally [ 3 ]. Nurses and pharmacists are integral members of the healthcare workforce worldwide [ 4 , 5 , 6 , 7 ]. Consequently, individuals receiving a dementia diagnosis often receive assistance from both student nurses and student pharmacists, who represent the future of healthcare [ 8 , 9 ]. To prepare for their clinical placements, these students require a solid foundation in dementia education to effectively provide care and support to individuals living with dementia [ 10 ].

Within higher education institutions, dementia education must be integrated into the curriculum to adequately fulfil the educational requirements and standards set forth by the Nursing and Midwifery Council (NMC) and the General Pharmaceutical Council (GPhC). Within the author’s institution, dementia is extensively integrated into the nursing and pharmacy undergraduate programs, covering various biomedical aspects of care. These include the aetiology, pathophysiology, clinical manifestations of dementia diseases, nursing and medical interventions, pharmacology, non-pharmacological treatments, and palliative care. However, aspects of patients’ emotions upon diagnosis and how to communicate effectively with people living with dementia are not always explicitly covered in both undergraduate programmes. To address this gap, the Alzheimer’s Society ‘Dementia Friends’ program has been introduced to both programmes [ 11 , 12 ]. This initiative, part of a global effort, aims to raise awareness and cultivate empathy among learners, recognising the pivotal role of nurses and pharmacists in supporting individuals with dementia across various stages of care [ 11 , 13 ]. Moreover, the recent COVID-19 pandemic, alongside advancements in digital technology, has led to the emergence of more digital or asynchronous learning opportunities in higher education. One innovative approach is the use of digital serious games to enhance learning experiences.

A recent systematic review and meta-analysis [ 14 ] suggests that digital games can be equally beneficial as a stand-alone or multi-component programme while appealing to a wide population regardless of age or gender. Gamification is a concept that combines gaming components with teaching to raise student engagement levels in a classroom setting [ 15 ]. A serious game helps players learn the material and hone their skills through gaming [ 16 ]. A growing number of studies have shown that using “serious games” to train health professionals can increase participation, user retention, knowledge, and cooperation [ 14 , 17 ]. The use of serious games is a well-known teaching strategy in the realm of nursing education [ 16 , 18 , 19 , 20 , 21 , 22 ] and pharmacy education [ 23 , 24 , 25 ]. Supporters of digital gaming also stress the games’ accessibility and practicality [ 26 ]. Serious games offer a novel method of teaching and improving comprehension; for instance, knowledge of dementia could be enhanced through the use of serious games in healthcare education [ 27 ].

This study builds upon prior research demonstrating significant enhancements in nursing student knowledge following the use of a digital game [ 27 ]. Expanding upon this foundation, our aim is to broaden the scope of evaluation to explore the potential impact of serious games on not only knowledge acquisition but also on the cultivation of positive attitudes and values towards dementia among nursing and pharmacy students. To our knowledge, no empirical studies have evaluated the effectiveness of a digital serious game to enhance undergraduate nursing and pharmacy students’ attitudes of dementia. Therefore, the aim of this project was to evaluate the impact of a dementia serious game on the attitudes of nursing and pharmacy students.

Intervention—the dementia game

A digital serious game called The Dementia Game [ 28 ] was co-designed through stakeholder involvement, student nurses and with people living with dementia [ 29 ]. It is a web-based application (HTML5) that operates on any device with an internet connection. Multiple-choice questions regarding dementia are provided in a random order, and players must follow a path to the finish line by answering these questions correctly. These questions were jointly developed with people living with dementia to ensure key misconceptions about dementia were addressed. Points are awarded for answering questions correctly, and additional points are awarded for finishing the game. Players can challenge others to a game and record their scores. Participants have unlimited access to playing the Dementia Game and each game takes around 90 seconds to complete. The serious game is freely accessible here: www.dementiagame.com .

A pretest-posttest design was used to determine the effectiveness of the serious digital game on a cohort of health professions students (nursing and pharmacy undergraduate students). Before and after playing the Dementia Game, health profession students’ attitudes towards dementia were assessed using the Approaches to Dementia Questionnaire (ADQ) [ 30 ].

Participants

Potential participants were recruited by two gatekeepers who were independent from this study. The gatekeepers provided eligible participants (Table  1 ) with access to the serious game as part of their existing education on dementia before their first taught class on dementia. The gatekeepers also wrote to students to inform them about the evaluation for this study which involved a pre-test before playing and a post-test after playing. All participants were informed that they could play the game without undertaking the pre- or post-test. The total available sample was 624 ( n  = 544 from nursing and n  = 80 from pharmacy). Nursing students were in Year 1 of their degree, Pharmacy students were in Year 3 of their degree. A total of n  = 505 students responded to at least the pre-test survey (80.93% response rate) and n  = 461 fully completed the study (73.87% response rate).

Evaluation questionnaire

The 19-item Approaches to Dementia Questionnaire (ADQ) [ 30 ] with modifications validated by Cheston et al. [ 31 ] has been demonstrated to be a valid and reliable instrument [ 30 , 31 , 32 ]. Each item has a five-point Likert scale measuring level of agreement/disagreement, giving a possible total score range of 19–95, with higher scores demonstrating a more positive attitude towards people living with dementia. Two further subscales measure ‘Recognition of personhood’ focusing on how a person with dementia is viewed as an individual with capabilities; and ‘Hope’ indicating either an optimistic or pessimistic approach to someone with dementia. Overall, the ADQ makes it possible to assess health professions students’ attitudes towards dementia by measuring the extent to which those playing the game acknowledge people affected by dementia as unique individuals with the same value as any other person, and it also highlights any sense of optimism or pessimism the person had about the abilities and the future of a person affected by dementia [ 28 ].

A short demographic questionnaire of seven questions was also appended to the pre-game questionnaire, including three questions related to students’ experiences of knowing someone with dementia, working with those living with dementia, and training/education received about dementia.

Data collection

The students who chose to participate in the study completed the pre- and post-questionnaires during a four-week period when they had access to the game. The pre-test questionnaire was the initial time point (T 0 ), and participants had seven days to complete the questionnaire via a web link. Following the conclusion of the pre-test period, a weblink to the serious game was emailed to every participant, by one of the independent gatekeepers, who had completed the pre-test questionnaire and gave their online informed consent to play the game. The game was fully accessible to these participants across four weeks and there were no restrictions as to the number of times it could be played. At the midpoint of this gaming period (the end of week two), an email with instructions on how to access the game was redistributed to every participant by both gatekeepers. Access to the game was closed after four weeks. Participants were then emailed their post-test questionnaire (T 1 ) to complete. Participants had access to the post-test questionnaire for 14 days, and a reminder email was issued after one week (Fig.  1 ). Data collection was carried out between March 2022 and May 2023.

Data collection flow chart

This study received ethical approval by Queen’s University Belfast’s Faculty of Medicine, Health, and Life Sciences Research Ethics Committee (MHLS 22_57). Online informed consent was obtained from all questionnaire participants. All methods were performed in accordance with the Declaration of Helsinki [ 33 ].

All eligible participants ( n  = 505) were informed via email of the study and their ability to participate by a person unrelated to the project. It was highlighted that their decision to take part in the study was voluntary and would not affect how they progressed through the course or how well they performed on a module. Students needed access to their own laptop, tablet, or phone to complete the questionnaires and play the game. Participants were unable to interact with a non-digital format of the intervention or complete hard copies of the questionnaires due to the intervention’s mode of delivery.

Data analysis

All data were transferred from MS Forms to a MS Excel spreadsheet, where they were cleaned, coded and scored according to the ADQ guidelines. Data were quality checked by two members of the research team (PS and GC). Demographic data were reviewed using descriptive analysis. Matched pairs for the ADQ scores at baseline and follow-up were analysed using dependent t-tests, with a two-tailed significance level set at α = 0.05. Mean gain was reported for each, and a Bonferroni corrected alpha cut off to control for false positive risk with multiple significance tests ( p  < 0.008 was significant). Alpha (0.05) was divided by the number of significance tests (6) to get the value of p  = 0.008. Analysis was conducted using IBM SPSS statistics 27 [ 34 ].

In total, 505 participants completed the pretest questionnaire and subsequently played the Dementia Game (74 pharmacy students and 431 nursing students). Of these, 461 participants then also completed the posttest questionnaire, therefore only 461 matched pairs were used for analysis (reflecting 8.71% attrition from pre-test to analysis). This missing data occurred due to the students not completing the post-test questionnaire, despite having accessed the game. Participants were not supervised during data collection, and so this attrition could not be mitigated further. Table  2 provides the demographics of these respondents in addition to their responses to the three dementia-related questions posed. Of the 461 respondents, the vast majority were female ( n  = 418), with 82.4% ( n  = 380) between the age 18–25 years. Nearly two-thirds ( n  = 304) did not have a family member or close friend living with dementia, just over half (57%) had worked with people living with dementia, and 50.8% had no training/education about dementia. Of those that had completed some form of training or education about dementia ( n  = 225), the majority (62%, n  = 140) had done so outside of the university setting (Table  2 ).

Overall, the mean ADQ total score for the nursing students ( n  = 395) demonstrated a significant increase from 79.69 (± 6.08) pretest to 83.59 (± 6.08) posttest ( p  < 0.001). Similarly, a significant increase in mean scores were found for the Hope and Recognition of Personhood subscales (both p  < 0.001) (Table  3 ).

Overall, the mean ADQ total score for the pharmacy students ( n  = 66) demonstrated a significant increase from 75.55 (± 5.84) pretest to 79.86 (± 6.70) posttest ( p  < 0.001). As per the nursing students, a significant increase in mean scores were found for the Hope and Recognition of Personhood subscales (both p  < 0.001) (Table  4 ).

This study demonstrated a significant increase in overall attitudes to dementia following the game-based intervention. Predominantly, participants were female (418 out of 461), and approximately 82% were within the 18–25 age bracket. Notably, a substantial portion of participants lacked personal connections to people living with dementia as they did not have family members with the condition. Additionally, over half reported no formal dementia-specific training, with the majority of those who did receive training obtaining it externally. It’s also noted that a high number of student nurses have worked with people with dementia, but pharmacist students hadn’t. This would appear to indicate that, irrespective of personal experience, the dementia game has the potential to improve nursing and pharmacy student attitudes to dementia.

Among nursing students, a statistically significant improvement in dementia-related attitudes was observed post-gameplay, with average scores increasing from 79.69 to 83.59. This change was statistically significant, reflecting a meaningful advancement in understanding and recognising the personhood of individuals with dementia. Similarly, pharmacy students exhibited notable improvements in their dementia-related scores, rising from an average of 75.55 to 79.86 post-gameplay.

Asynchronous learning, as was a feature of the dementia serious game, while offering flexibility and convenience, comes with its own set of challenges [ 35 , 36 ]. One significant hurdle is the potential for conflicting schedules and external commitments among learners. This can make it difficult for students to allocate dedicated time for studying and engaging with course materials. Additionally, asynchronous learning requires a high degree of self-discipline and motivation, as there are no fixed class times or immediate interactions with instructors or peers. This lack of real-time engagement can sometimes lead to feelings of isolation or detachment from the learning process [ 37 ]. Moreover, without the structure of regular class meetings, students may struggle with time management and procrastination. It is essential for learners to actively manage their own progress and ensure they stay on track with the curriculum. Lastly, technological issues, such as access to reliable internet and compatible devices, can pose barriers to effective asynchronous learning for some individuals [ 38 ]. However, like previous studies on serious gaming, the response rate of 505/624 (80.93%) illustrates potential student appetite for participating in gamified modes of learning [ 27 , 28 , 39 ].

While the use of an asynchronous digital serious game proved effective in improving students’ attitudes towards dementia in this study, its application in healthcare education does not guarantee universally successful learning experiences [ 27 , 28 ].

Caserman and colleagues [ 40 ] suggest that there are limited serious games for healthcare education that adhere to rigorous quality standards addressing both the serious and game components. Well-designed serious games seek to cultivate positive emotions, motivating players to persist in their engagement, leading to heightened interest in the gameplay and improved academic performance [ 41 ]. A recent meta-analysis [ 42 ] on serious game use in education also advocated for understanding learners’ attitudes toward serious game-assisted learning, emphasising the need to design suitable pedagogical strategies catering to diverse learner needs and for educators to develop appropriate serious games, enhancing learning outcomes. Therefore, future evaluations of serious games should also evaluate student perspectives on game entertainment, the usability of the serious game, and student attitudes toward the integration of serious games in education.

Strengths/limitations

The study exhibits several strengths, including the integration of a co-designed serious game about dementia into nursing and pharmacy curricula at one university in Northern Ireland. Real-world stakeholder involvement in developing the serious game also ensures relevance and applicability. The large sample size of 505 participants with an 80.93% response rate across two healthcare disciplines is also a strength of this study as it enhances the reliability of the findings. This study also does have some limitations, including potential bias in sample demographics, predominantly comprising females in the 18–25 age group. This study did not include a control group, which limits generalisability. Additionally, recruiting a smaller number of pharmacy students posed challenges in statistical analyses, resulting in an uneven distribution between nurses and pharmacy students. Further, this study is limited to two disciplines at one university. Therefore, future work needs to include other professions across multiple universities. Finally, the study does not explore the entertainment value of the serious game, leaving room for future research in exploring the balance between seriousness and engagement.

Serious games can be an effective means of learning in educational settings. Well-designed serious games lead to heightened interest in the gameplay, which may improve academic performance. Engaged players are more likely to become deeply immersed in the learning experience provided by serious games. The current study demonstrates the impact of utilising a serious digital game on healthcare professional students’ understanding of dementia. Overall, there was a statistically significant increase in overall attitude towards dementia following the game-based intervention. Consequently, digital serious games hold the potential to reach a wide audience and emerge as a fitting tool for enhancing dementia awareness, as showcased in this research.

Data availability

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

Abbreviations

Medicine, Health, and Life Sciences

Approaches to Dementia Questionnaire

Northern Ireland

United Kingdom

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Acknowledgements

The authors express sincere appreciation to Mrs. Susan Carlisle, formally the Director of Education in the School of Nursing and Midwifery, and Mrs. Lyn Stevenson from the School of Pharmacy at Queen’s University Belfast, who acted as independent gatekeepers in facilitating access to both nursing and pharmacy students. Additionally, we would like to thank Melvin Bell and his colleagues at Focus Games Ltd for their support in this study.

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All authors have agreed on the final version of this paper and agree to be accountable for the findings. All authors have been involved in substantial contributions to the conception (SC, HB, GC, PS, GM, SC, CBW), design of the work (SC, CBW, GC, GM, ); the acquisition, analysis, interpretation of data (GC, PS); have drafted the work or substantively revised it (SC, GC, PS, GM). The authors read and approved the final manuscript (SC, HB, GC, PS, GM, SC, CBW).

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This study received ethical approval by Queen’s University Belfast’s Faculty of Medicine, Health, and Life Sciences Research Ethics Committee (MHLS 22_57) in 2022. Online informed consent was obtained from all questionnaire participants. All methods were performed in accordance with the Declaration of Helsinki [ 33 ].

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Craig, S., Barry, H.E., Carter, G. et al. Evaluation of a dementia awareness game for health professions students in Northern Ireland: a pre-/post-test study. BMC Med Educ 24 , 677 (2024). https://doi.org/10.1186/s12909-024-05656-z

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Received : 23 November 2023

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DOI : https://doi.org/10.1186/s12909-024-05656-z

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