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Articles on Physical education

Displaying 1 - 20 of 36 articles.

New government guidance for PE lets teachers and pupils down

David Grecic , University of Central Lancashire ; Alan Thomson , University of Central Lancashire , and Andrew Sprake , University of Central Lancashire

Is exercise really good for the brain? Here’s what the science says

Matthieu P. Boisgontier , L’Université d’Ottawa/University of Ottawa and Boris Cheval , Université de Genève

Girls should get the chance to play football at school – but PE needs a major rehaul for all students

Shrehan Lynch , University of East London

School playgrounds are getting squeezed: here are 8 ways to keep students active in small spaces

Brendon Hyndman , Charles Sturt University ; Jessica Amy Sears , Charles Sturt University , and Vaughan Cruickshank , University of Tasmania

Outdoor education has psychological, cognitive and physical health benefits for children

Jean-Philippe Ayotte-Beaudet , Université de Sherbrooke and Felix Berrigan , Université de Sherbrooke

London’s Olympic legacy: research reveals why £2.2 billion investment in primary school PE has failed teachers

Vicky Randall , University of Winchester and Gerald Griggs

How sport can help young people to become better citizens

Vaughan Cruickshank , University of Tasmania and Casey Peter Mainsbridge , University of Tasmania

Missing out on PE during lockdowns means students will be playing  catch-up

Jora Broerse , Victoria University ; Cameron Van der Smee , Federation University Australia , and Jaimie-Lee Maple , Victoria University

Disabled children still face exclusion in PE – here’s what needs to change

Tom Gibbons , Teesside University and Kevin Dixon , Northumbria University, Newcastle

Taking the circus to school: How kids benefit from learning trapeze, juggling and unicycle in gym class

Marion Cossin , Université de Montréal

Thinking of choosing a health or PE subject in years 11 and 12? Here’s what you need to know

Brendon Hyndman , Charles Sturt University and Vaughan Cruickshank , University of Tasmania

Aussie kids are some of the least active in the world. We developed a cheap school program that gets results

Taren Sanders , Australian Catholic University ; Chris Lonsdale , Australian Catholic University ; David Lubans , University of Newcastle ; Michael Noetel , The University of Queensland , and Philip D Parker , Australian Catholic University

When men started to obsess over  six-packs

Conor Heffernan , The University of Texas at Austin

PE can do much more than keep children fit – but its many benefits are often overlooked

David Grecic , University of Central Lancashire ; Andrew Sprake , University of Central Lancashire , and Robin Taylor , University of Central Lancashire

Distance learning makes it harder for kids to exercise, especially in low-income communities

Katelyn Esmonde , Johns Hopkins University and Keshia Pollack Porter , Johns Hopkins University

Kids need physical education – even when they can’t get it at school

Collin A. Webster , University of South Carolina

Learning through adventure: the many skills that can be taught outside the classroom

Gary Stidder , University of Brighton

Kids aren’t getting enough exercise, even in sporty Seattle

Julie McCleery , University of Washington

Bushwalking and bowls in schools: we need to teach kids activities they’ll go on to enjoy

Vaughan Cruickshank , University of Tasmania ; Brendon Hyndman , Charles Sturt University , and Shane Pill , Flinders University

How children who dread PE lessons at school can be given a sporting chance

Kiara Lewis , University of Huddersfield

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Senior Lecturer in Health and Physical Education, University of Tasmania

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Professor of Sport and Physical Education, University of Central Lancashire

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• Published: 17 December 2020

Physical education class participation is associated with physical activity among adolescents in 65 countries

• Riaz Uddin 1 , 2 , 3 ,
• Jo Salmon 1 ,
• Sheikh Mohammed Shariful Islam 1 , 3 &
• Asaduzzaman Khan 2 , 3  

Scientific Reports volume  10 , Article number:  22128 ( 2020 ) Cite this article

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In this study we examined the associations of physical education class participation with physical activity among adolescents. We analysed the Global School-based Student Health Survey data from 65 countries (N = 206,417; 11–17 years; 49% girls) collected between 2007 and 2016. We defined sufficient physical activity as achieving physical activities ≥ 60 min/day, and grouped physical education classes as ‘0 day/week’, ‘1–2 days/week’, and ‘ ≥ 3 days/week’ participation. We used multivariable logistic regression to obtain country-level estimates, and meta-analysis to obtain pooled estimates. Compared to those who did not take any physical education classes, those who took classes ≥ 3 days/week had double the odds of being sufficiently active (OR 2.05, 95% CI 1.84–2.28) with no apparent gender/age group differences. The association estimates decreased with higher levels of country’s income with OR 2.37 (1.51–3.73) for low-income and OR 1.85 (1.52–2.37) for high-income countries. Adolescents who participated in physical education classes 1–2 days/week had 26% higher odds of being sufficiently active with relatively higher odds for boys (30%) than girls (15%). Attending physical education classes was positively associated with physical activity among adolescents regardless of sex or age group. Quality physical education should be encouraged to promote physical activity of children and adolescents.

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Introduction.

Physical activity is essential for health and wellbeing of children and adolescents 1 . Physical activity improves musculoskeletal, cardiac, metabolic, psychosocial, and cognitive health, and enhances cardiorespiratory and muscular fitness of children and adolescents 1 , 2 , 3 , 4 . Regular participation also decreases adiposity in those who are overweight 3 . For optimal health benefits, the current international guidelines (i.e., the World Health Organization [WHO]) recommends that those aged 5–17-years accumulate at least 60 min of moderate-to-vigorous physical activity daily 5 . Globally, four out of five (81%) adolescents aged 11–17 years do not meet this recommendation and are insufficiently active 6 . Such inactive behaviours during adolescence have both current and future ramifications on health and wellbeing as behaviours such as physical activity established during adolescence can carry over to adulthood 7 , 8 . Therefore, pragmatic strategies to promote physical activity during adolescence around the globe are of critical importance 9 .

Adolescent physical activity occurs in different settings and domains including at home, in the community, for transportation, and at school. Opportunities for physical activity at school include during recess and lunch breaks, school sport and physical education lessons. Physical education classes may provide resources and opportunities for students to accumulate the daily physical activity level and can contribute to daily energy expenditure 10 , 11 . Recent meta-analyses found that 41% of secondary school 12 and 45% of elementary school 13 physical education lessons comprised moderate-to-vigorous physical activity. In many countries, physical education provides children and adolescents the understanding and motivation for an active lifestyle and also creates an environment to acquire knowledge and skills for physical activity throughout life 14 , 15 . In addition, adolescents who may have limited access to space and equipment outside of school can benefit from attending physical education classes at school 10 , 11 . School-based physical education, therefore, can be an accessible source of physical activity for many adolescents and can help develop an active healthy lifestyle 16 . In addition to the number of physical education classes, access to high-quality physical education experience (e.g., teacher behaviours, learning outcomes), which forms the foundation for lifelong engagement in physical activity, is also important for children and adolescents 17 , 18 , 19 .

Available evidence suggest that participation in physical education classes are positively associated with higher levels of physical activity 20 , 21 , 22 , 23 , 24 . However, the evidence is mostly based on single-country studies from high-income countries with limited multi-country study and lack of representation of low- and lower-middle-income countries 25 . A recent multi-country study reported country- and regional-level differences in physical education class participation, which was also differed by sex, age, and country-income classification 26 . In addition, delivery, content and quality of physical education also vary within and between countries 27 , 28 . It is often provided infrequently in schools across countries, and therefore the potential impact on total moderate-to-vigorous physical activity among boys and girls may be limited 29 . In order to obtain a comprehensive global perspective on the relationship between physical education and physical activity, large multi-country studies with representative samples are essential. Given the context and the opportunities that exist in schools for physical activity promotion, in this study, we aimed to examine whether participation in physical education classes (i.e., number of physical education class attendance) is associated with sufficient level of physical activity among adolescents (overall, and by sex and age-group) from 65 countries around the globe. We hypothesised that higher number of physical education class participation would be positively associated with sufficient level of physical activity among adolescents.

Data source

Data for this study were from the Global School-based Student Health Survey (GSHS), a population-based survey of school-going children and adolescents around the world 30 . In all participating countries, the GSHS uses the same standardised sampling technique and study methodology. All participants completed a standardised self-administered anonymous questionnaire, which included, but was not limited to, questions on demographics (e.g., age, sex), participation in physical education classes and physical activity. GSHS adopted questionnaire items, including items to measure physical activity and physical education from the Youth Risk Behavior Survey of American Adolescents. Countries, where GSHS were implemented, were encouraged to use culturally appropriate examples, words, and phrases to ensure sociocultural adaptability of the items. Furthermore, using a rigorous translation and back-translation process with the assistance of WHO and US CDC, countries were allowed to translate the questionnaire into their local language 31 .

As of 8 December 2019, 98 countries/territories around the globe had at least one GSHS dataset publicly available with the surveys being conducted between 2007 and 2016. For countries with more than one GSHS dataset, we used the most recent one available. Of the 98 countries, 84 countries had data on PA, while 67 countries had data on physical education. Two countries (Niue and Tokelau) were excluded from the analyses due to their small sample size (n < 140). The analytical sample consists of 206,417 adolescents aged 11 or younger to 17 years from 65 countries. Only a small proportion of students (1.05%) were in the age group “11 years old or younger”, and for modelling purposes, they were considered as 11 years old for this analysis, as it was not possible to determine what proportion of 1.05% students were younger than 11 years old. All countries provided nationally representative samples.

The GSHS received ethics approval from the Ministry of Education or a relevant Institutional Ethics Review Committee, or both in each of the participating countries. Only those adolescents and their parents who provided written or verbal consent participated. As the current study used retrospective, de-identified, publicly available data, ethics approval was not required for this secondary analysis. Detailed methods of the GSHS have been described on both the US CDC and the WHO websites 30 , 32 .

Outcome measure—physical activity participation

Physical activity was assessed with one item: ‘During the past 7 days, on how many days were you physically active for a total of at least 60 min per day?’ The response options were 0–7 days. Consistent with the WHO recommendations 5 , we defined participants as ‘sufficiently active’ who did ≥ 60 min/day of physical activity on seven days of the week.

Study factor—physical education participation

Physical education class attendance was assessed with one item: ‘During this school year, on how many days did you go to physical education (PE) class each week?’ The responses were classified into three groups: ‘0 day/week’, ‘1–2 days/week’, and ‘≥ 3 days/week’ as used elsewhere 25 , 33 .

Adolescents self-reported age, sex, and daily hours of sitting (when not in school or doing homework) in the survey. Food insecurity was assessed by asking: ‘During the past 30 days, how often did you go hungry because there was not enough food in your home?’ with response options being never, rarely, sometimes, most of the time, and always. As the GSHS did not include any direct measure of socioeconomic status, this variable was used as a proxy measure of socioeconomic status 34 , 35 . Self-reported height and weight were used to compute body mass index (BMI), which was categorised as underweight (BMI < −2SD), overweight (BMI >  + 1SD), and obese (BMI >  + 2SD), relative to median BMI, by age and sex based on the WHO Child Growth Standards 36 .

Statistical analyses

Of the 65 countries with data on physical activity and physical education, nine countries were from Africa, 20 from the Americas, 15 from Eastern Mediterranean, five from South East Asia, and 16 from the Western Pacific region. Using the World Bank country classification, collected at the time of the survey for the respective countries, seven countries were classified as low‐income, 21 lower‐middle‐income, 18 upper‐middle‐income, and 18 high-income. Income classification information was not available for Cook Island. The prevalence estimates of physical activity and physical education were obtained by using a Stata command ‘svyset’ to take into account sampling weights and the clustered sampling design of the surveys.

In examining the country-level association of physical education with physical activity, a set of covariates was considered including age, sex, weight status (i.e., BMI), food insecurity, and sitting time. Sitting time was considered as an adjusting factor given its demonstrated association with physical activity in adolescents 37 . Given the binary nature of physical activity outcome, logistic regression analysis with robust standard errors was used to examine the association at the country level, by taking into account the sampling weight that was applied to each participant record to adjust for non-response and the varying probability of selection. This GSHS weighting factor was applied in an identical way to estimate the association in each participating country. Within the GSHS protocol, weighting accounted for the probability of selection of schools and classrooms, non-responding schools and students, and distribution of the population by sex and grade.

Random effects meta-analysis was used to generate pooled estimates of the association between physical education and physical activity for the overall sample, by country income category (e.g., low-income, lower-middle income, upper-middle income, and high-income), and by WHO region, stratified by sex and age groups (11–14 years vs 15–17 years). Two age groups (11–14 years [early adolescence] and 15–17 years [middle adolescence]) 38 were considered to stratify the analysis in order to examine whether the association estimates vary across phases of adolescence. This analysis used DerSimonian and Laird method 39 with the estimate of heterogeneity being taken from the Mantel–Haenszel model. As the GSHS were conducted across different cultural settings in 65 countries around the world over a long period of time (2007–2016), it was reasonable to assume that the association estimates across countries were likely to vary from survey to survey, which supports the use of random effects meta-analysis that can adjust heterogeneity among studies 40 . The percentage of variability in estimates across studies that is attributable to between study heterogeneity (I 2 ) in our analysis ranges from 54.3 to 80.2%, which suggests a strong presence of heterogeneity in the association estimates, and further supports the use of random effects meta-analysis. All adjusted estimates of the association parameters are presented in the form of odds ratio (OR) and 95% confidence interval (CI). All analyses were conducted by StataSE V14.0.

Ethics approval and consent to participate

The GSHS received ethics approval from both a national government administration and an institutional review board or ethics committee. Only adolescents and their parents who provided written/verbal consent participated. As the current study used retrospective publicly available data, we did not require ethics approval from any Institutional Ethics Review Committee for this secondary analysis.

The mean age of the participating adolescents (n = 206,417) was 14.35 (SD = 1.45) years, 54.4% aged 11–14 years, and 49.2% were girls. The prevalence of sufficient physical activity was 15.0%, with boys having higher prevalence (18.3%) than girls (11.5%). Over half (56.5%) of adolescents participated in physical education classes 1–2 days/week (boys 54.7%; girls 58.3%) and about a quarter (24.2%) participated in physical education classes ≥ 3 days/week (boys 26.8%; girls 21.6%). As shown in Fig.  1 , the overall percentage of adolescents being sufficiently active was greater for those who attended more physical education classes in both sexes.

Proportion of adolescents sufficiently physically active by participation in physical education classes, Global School-based Student Health Survey, 2007–2016.

Estimates of associations of physical education class participation with sufficient physical activity by country are shown in Table 1 . The country-level analysis shows that 50 out of 65 participating countries (77%) demonstrated significant and positive associations between attending physical education classes ≥ 3 days/week and being sufficiently active with 33 countries (51%) revealing at least double the odds (OR ≥ 2.0) of meeting physical activity guidelines. For example, Bolivian adolescents who attended physical education classes ≥ 3 days/week had threefold odds of reporting sufficient physical activity compared with their counterparts who attended no physical education class (OR 3.00, 95% CI 1.93–4.67). In examining the association between attending physical education classes 1–2 days/week and being sufficiently active, 20 countries (31%) demonstrated significant positive associations. For example, Thai adolescents who attended physical education classes 1–2 days/week had double the odds to reporting sufficient physical activity compared with their counterparts who attended no physical education class (OR 2.11, 95% CI 1.39–3.19). As shown in Table 1 , attending physical education classes ≥ 3 days/week was positively and strongly associated with physical activity in all WHO regions with South East Asia region showing the strongest association (OR 2.89, 2.11–3.97), followed by Africa (OR 2.45, 1.72–3.48) and Western Pacific region (OR 2.40, 1.92–3.00). The analysis also showed evidence of positive and moderate association between attending physical education classes 1–2 days/week and being sufficiently active in all WHO regions with the pooled association estimates ranging from OR 1.19 (1.01–1.41) in the Americas region to OR 1.86 (1.03–3.36) in South East Asia.

Overall, adolescents who took physical education classes ≥ 3 days/week, compared to those who did not take any physical education classes, had double the odds of being sufficiently active (OR 2.05, 95% CI 1.84–2.28) with no apparent gender (OR 2.09, 1.88–2.33 for boys; and OR 1.95, 1.69–2.25 for girls) or age (OR 2.19, 1.93–2.48 for 11–14-year-old; and OR 2.03, 1.80–2.28 for 15–17-year-old adolescents) differences (Table 2 ). Adolescents who participated in physical education classes 1–2 days/week had 26% higher odds of being sufficiently active (OR 1.26, 1.15–1.37) with relatively higher odds for boys (OR 1.30, 1.17–1.46) than girls (OR 1.15, 1.03–1.29) and younger adolescents aged 11–14 years (OR 1.28, 1.16–1.42) that older adolescents aged 15–17 years (OR 1.19, 1.08–1.32).

The odds of attending physical education classes ≥ 3 days/week and being sufficiently active were lower in country with higher income (Table 2 ). In low-income countries, adolescents who participated in physical education classes ≥ 3 days/week had 137% higher odds of being sufficiently active (OR 2.37, 1.51–3.73) with comparable odds for boys (OR 2.51, 1.70–3.70) and girls (OR 2.36, 1.31–4.26) and slightly higher odds for younger (OR 2.94, 1.92–4.51) than older adolescents (OR 2.32, 1.36–3.96). In high-income countries, the odds of being sufficiently active was 85% higher for adolescents who attended physical education classes ≥ 3 days/week (OR 1.85; 1.52–2.25) with no apparent gender (boys OR 1.89, 1.50–2.37; girls OR 1.69, 1.36–2.10) or age (younger OR 1.83, 1.47–2.28; older OR 1.80 (1.48–2.19) differences. In lower-middle income countries, adolescents who attended physical education classes 1–2 days/week had 39% higher odds of being sufficiently active (OR 1.39, 1.19–1.62) compared to their counterparts who did not take any physical education classes, with relatively higher odds for boys (OR 1.46, 1.21–1.76) than girls (OR 1.30, 1.03–1.65), and similar odds for younger (OR 1.36, 1.09–1.68) and older adolescents (OR 1.33, 1.16–1.51).

Boys of South East Asian region who participated in physical education classes ≥ 3 days/week had the highest odds of being sufficiently active (OR 3.29, 1.97–5.47), followed by the boys of Africa region (OR 2.41, 1.74–3.33) (Supplementary Table S1 ). Girls of Western Pacific and Africa region who participated in physical education classes ≥ 3 days/week had the highest odds of being sufficiently active (OR 2.68, 1.89–3.77, and OR 2.63, 1.63–4.26, respectively). Even by attending physical education classes 1–2 days/week, boys of the Americas region and girls of Africa region can increase their odds, though not considerably, of being sufficiently active (OR 1.29, 1.06–1.58, and OR 1.41, 1.15–1.73, respectively).

Both younger and older adolescents in all WHO regions demonstrated positive association between ≥ 3 days/week physical education class attendance and meeting the physical activity recommendations (Supplementary Table S1 ). Younger adolescents in South East Asia (OR 3.03, 2.42–3.79) and Africa (OR 2.95, 2.07–4.20), and older adolescents in South East Asia (OR 3.24, 1.57–6.67) who participated in physical education classes ≥ 3 days/week had over three times higher odds of being sufficiently active. There were moderate positive associations between physical education class attendance for 1–2 days/week and meeting the physical activity recommendations for younger adolescents in Africa (OR 1.38, 1.03–1.84), the Americas (OR 1.29, 1.07–1.56), and Eastern Mediterranean regions (OR 1.24, 1.06–1.44), and for older adolescents in Africa (OR 1.24, 1.03–1.48), Eastern Mediterranean (OR 1.26, 1.07–1.49), and Western Pacific region (OR 1.19, 1.01–1.41).

To our knowledge, this is the most extensive global study to assess the association of physical education class attendance with physical activity of adolescents, based on nationally representative samples from 65 countries around the globe. The key finding of our study is that adolescents, irrespective of sex or age, who had a higher frequency (≥ 3 days/week) of physical education class attendance had significantly higher odds of meeting the WHO’s physical activity recommendations. The estimates of association between the frequency of attending physical education and meeting physical activity recommendations were lower among countries with higher income. We observed some regional differences with South East Asia having the highest associations and the Americas having the lowest. Our findings suggest that adolescents, especially girls and those aged 15–17 years, are mostly benefited from a higher frequency (i.e., ≥ 3 days/week) of physical education participation. Our study also found some benefits of less frequent participation in physical education classes (1–2 days/week) in meeting the physical activity guidelines, which is encouraging. About one-third of the countries demonstrated positive association between less frequent participation in physical education classes and meeting the physical activity recommendations, and such association was prominent in boys and younger adolescents in all but low-income countries. Our study thus argues that even less frequent participation in physical education classes can bring some benefits for some adolescents.

Our finding that a higher frequency of physical education class attendance was positively associated with meeting the physical activity recommendations is consistent with other studies in children and adolescents 20 , 21 , 24 , 25 . It has been argued that participation in physical education classes acts as a positive reinforcement to “keep young people going” by being more physically active with less time in sedentary behaviour throughout the day 25 . Physical education classes provide children with an opportunity to familiarise themselves with different types of physical activity, motivates them to be active within the school environment, and potentially also encourages more out-of-school physical activity 41 . Physical activity during physical education classes may reduce fatigue and improve mood by changing neurophysiological stimulation and the brain’s information processing function (i.e., cerebral cortex), which may improve children’s preparedness to move more throughout the day 25 . While the frequency of physical education class is important, it is also critical that children have access to quality physical education 18 , 19 . Previously, researchers have suggested that in spite of the traditional class-based and sports-centred physical education curriculum, physical education ought to be a health-centred dynamic learning experience for children 19 , 42 . Quality physical education is important for age-appropriate cognitive learning and to acquire fitness, develop motor skills and psychosocial and emotional skills, which can help children to lead an active lifestyle, inside and outside of the school environment, throughout their life course 18 , 19 , 42 . Given the role of physical education for active and healthy lifestyle, different stakeholders, including United Nations agencies (i.e., UNESCO) 19 , European Commission 17 , have recommended to ensure quality physical education for children and adolescents, and called for political commitments and actions from Governments and supports from the international communities.

In our study, adolescents boys and girls in low-income countries with ≥ 3 days/week physical education class attendance had the highest odds of meeting the physical activity recommendations, and the associations became smaller (yet significant) with a higher country income classification for both sexes. A previous 12-country study 25 reported similar findings for boys, but not for girls. Unlike our study that is based on self-reported data, the earlier study used a device-based physical activity measure and included Australia and other high-income countries of Europe and North America. In addition to high-income countries, our study included adolescents from low- and lower-middle-income countries. It is possible that for many children, regardless of sex or country income, schools provide the most pragmatic and readily accessible opportunities for various physical activity, while out-of-school physical activity options, logistics, and environments might be variable 10 , 11 . The environments, in general, may be more supportive of out of school physical activity for children in high-income countries than their counterparts in low-income countries; however, high-income countries may have other challenges including gender and socioeconomic disparities in physical activity. For example, children from high-poverty neighbourhood may have fewer opportunities for out of school physical activity in many high-income countries 43 , 44 . Appreciating the heterogeneity in resources for physical education within- and across countries, all governments should consider schools as the primary focus to promote an active and healthy lifestyle among children and adolescents, which is likely to be a cost-effective and opportunistic initiative to get them moving. Our findings also show that physical education is potentially more important in South East Asia than the Americas in promoting physical activity. In addition to environmental support, such variations could be a sign of the quality of the respective physical education programs, including time allocated for physical education across the countries. There is a large heterogeneity in weekly time allocated for physical education in countries around the globe. For example, weekly time for physical education of secondary school students in Bangladesh (180 min) is reportedly higher than in Peru (90 min) 28 . Research is needed to understand whether physical education classes are designed to facilitate physical activity and/or how much time students actually spend in physical activity during physical education classes. It is also important to understand how physical education lessons can help the students to develop skills so that they can be more active both inside and outside of school. This information can help in designing a physical education curriculum with balanced components of physical activity and physical education lessons on other health and wellbeing so that the students can develop a healthy lifestyle. Opportunities for quality physical education should be equitable and inclusive, and available for all children regardless their gender, disability status, socio-economic position, and cultural or religious backgrounds, and the delivery of physical education should be ensured for marginalised and vulnerable groups 19 .

The strengths of our study are the inclusion of a large number of countries around the globe, representing different world regions and income groups. All countries included in our study provided nationally representative data. We used the GSHS sample weighting to account for distribution of the population by age and sex in countries for whose data were analysed. Any potential skewness, by sex or age, in the observed data is unlikely to impact the weighted analysis results. All countries where GSHS was implemented, used a standardised data collection procedure. In all countries, a standardised questionnaire with the same survey items to assess physical activity and physical education class attendance was used, which facilitated our regional comparisons. We adjusted our estimates for several potential covariates to avoid possible confounding effects of these factors.

The findings of our study should be interpreted in light of its limitations. Data for our study were collected using self-reported questionnaire; these data are vulnerable to social desirability and recall bias. Unavailability of GSHS data from European and North American countries, some of the Latin/Central American and Asia and Pacific countries, limits the generalisability of the findings only to the GSHS participating countries. Although a standardised questionnaire was used in all participating countries, there is a lack of information on the reliability and validity of GSHS measures across different countries or cultures. Physical education classes can have different meanings and can constitute different components, including a knowledge-based curriculum component (i.e., lessons and discussions) and/or skill-based physical activity session, in different settings. We did not have any information on components of physical education classes across the participating countries. The cross‐sectional design of the study limits our ability to make any causal inferences from the association estimates. Some adolescents in our study may have had difficulties with understanding the questionnaire because of poor reading skills. In this study, we used data collected between 2007 and 2016, which may have biased the results because of the period effect.

Conclusions

Our study suggests a positive association between regular participation in physical education classes and meeting the physical activity guidelines among children and adolescents around the globe regardless of sex or age group. The odds were lower in high- than low-income countries. The benefits of regular participation in physical education classes to enhance physical activity are universal across all WHO regions, with the highest being observed among adolescents from South East Asian countries. Even less frequent participation in physical education classes (i.e., 1–2 days a week) was related to higher odds of being sufficiently active in all but low-income countries, especially in boys. Thus, the findings support the importance of physical education for ensuring sufficient physical activity among school-going children and adolescents around the globe. Countries must not miss the opportunity to ensure schools deliver a daily or at least 3 days per week of well-designed physical education classes, which can play a vital role in creating active nations around the world.

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Acknowledgements

The authors would like to thank the US Centers for Disease Control and Prevention and the World Health Organization for making the Global School-based Student Health Survey (GSHS) data publicly available for analysis. The authors thank the GSHS country coordinators and other staff members. R.U. is supported by Alfred Deakin Postdoctoral Research Fellowship. J.S. is supported by a National Health and Medical Research Council Leadership Level 2 Fellowship (APP 1176885). S.M.S.I. is supported by the Institute for Physical Activity and Nutrition, Deakin University and a post doctorate fellowship from the National Heart Foundation of Australia (Award #102112).

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Uddin, R., Salmon, J., Islam, S.M.S. et al. Physical education class participation is associated with physical activity among adolescents in 65 countries. Sci Rep 10 , 22128 (2020). https://doi.org/10.1038/s41598-020-79100-9

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Introduction.

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‘Physical education makes you fit and healthy’. Physical education's contribution to young people's physical activity levels

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S. Fairclough, G. Stratton, ‘Physical education makes you fit and healthy’. Physical education's contribution to young people's physical activity levels, Health Education Research , Volume 20, Issue 1, February 2005, Pages 14–23, https://doi.org/10.1093/her/cyg101

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The purpose of this study was to assess physical activity levels during high school physical education lessons. The data were considered in relation to recommended levels of physical activity to ascertain whether or not physical education can be effective in helping young people meet health-related goals. Sixty-two boys and 60 girls (aged 11–14 years) wore heart rate telemeters during physical education lessons. Percentages of lesson time spent in moderate-and-vigorous (MVPA) and vigorous intensity physical activity (VPA) were recorded for each student. Students engaged in MVPA and VPA for 34.3 ± 21.8 and 8.3 ± 11.1% of lesson time, respectively. This equated to 17.5 ± 12.9 (MVPA) and 3.9 ± 5.3 (VPA) min. Boys participated in MVPA for 39.4 ± 19.1% of lesson time compared to the girls (29.1 ± 23.4%; P < 0.01). High-ability students were more active than the average- and low-ability students. Students participated in most MVPA during team games (43.2 ± 19.5%; P < 0.01), while the least MVPA was observed during movement activities (22.2 ± 20.0%). Physical education may make a more significant contribution to young people's regular physical activity participation if lessons are planned and delivered with MVPA goals in mind.

Regular physical activity participation throughout childhood provides immediate health benefits, by positively effecting body composition and musculo-skeletal development ( Malina and Bouchard, 1991 ), and reducing the presence of coronary heart disease risk factors ( Gutin et al. , 1994 ). In recognition of these health benefits, physical activity guidelines for children and youth have been developed by the Health Education Authority [now Health Development Agency (HDA)] ( Biddle et al. , 1998 ). The primary recommendation advocates the accumulation of 1 hour's physical activity per day of at least moderate intensity (i.e. the equivalent of brisk walking), through lifestyle, recreational and structured activity forms. A secondary recommendation is that children take part in activities that help develop and maintain musculo-skeletal health, on at least two occasions per week ( Biddle et al. , 1998 ). This target may be addressed through weight-bearing activities that focus on developing muscular strength, endurance and flexibility, and bone health.

School physical education (PE) provides a context for regular and structured physical activity participation. To this end a common justification for PE's place in the school curriculum is that it contributes to children's health and fitness ( Physical Education Association of the United Kingdom, 2004 ; Zeigler, 1994 ). The extent to which this rationale is accurate is arguable ( Koslow, 1988 ; Michaud and Andres, 1990 ) and has seldom been tested. However, there would appear to be some truth in the supposition because PE is commonly highlighted as a significant contributor to help young people achieve their daily volume of physical activity ( Biddle et al. , 1998 ; Corbin and Pangrazi, 1998 ). The important role that PE has in promoting health-enhancing physical activity is exemplified in the US ‘Health of the Nation’ targets. These include three PE-associated objectives, two of which relate to increasing the number of schools providing and students participating in daily PE classes. The third objective is to improve the number of students who are engaged in beneficial physical activity for at least 50% of lesson time ( US Department of Health and Human Services, 2000 ). However, research evidence suggests that this criterion is somewhat ambitious and, as a consequence, is rarely achieved during regular PE lessons ( Stratton, 1997 ; US Department of Health and Human Services, 2000 ; Levin et al. , 2001 ; Fairclough, 2003a ).

The potential difficulties of achieving such a target are associated with the diverse aims of PE. These aims are commonly accepted by physical educators throughout the world ( International Council of Sport Science and Physical Education, 1999 ), although their interpretation, emphasis and evaluation may differ between countries. According to Simons-Morton ( Simons-Morton, 1994 ), PE's overarching goals should be (1) for students to take part in appropriate amounts of physical activity during lessons, and (2) become educated with the knowledge and skills to be physically active outside school and throughout life. The emphasis of learning during PE might legitimately focus on motor, cognitive, social, spiritual, cultural or moral development ( Sallis and McKenzie, 1991 ; Department for Education and Employment/Qualifications and Curriculum Authority, 1999 ). These aspects may help cultivate students' behavioural and personal skills to enable them to become lifelong physical activity participants [(thus meeting PE goal number 2 ( Simons-Morton, 1994 )]. However, to achieve this, these aspects should be delivered within a curriculum which provides a diverse range of physical activity experiences so students can make informed decisions about which ones they enjoy and feel competent at. However, evidence suggests that team sports dominate English PE curricula, yet bear limited relation to the activities that young people participate in, out of school and after compulsory education ( Sport England, 2001 ; Fairclough et al. , 2002 ). In order to promote life-long physical activity a broader base of PE activities needs to be offered to reinforce the fact that it is not necessary for young people to be talented sportspeople to be active and healthy.

While motor, cognitive, social, spiritual, cultural and moral development are valid areas of learning, they can be inconsistent with maximizing participation in health-enhancing physical activity [i.e. PE goal number 1 ( Simons-Morton, 1994 )]. There is no guidance within the English National Curriculum for PE [NCPE ( Department for Education and Employment/Qualifications and Curriculum Authority, 1999 )] to inform teachers how they might best work towards achieving this goal. Moreover, it is possible that the lack of policy, curriculum development or teacher expertise in this area contributes to the considerable variation in physical activity levels during PE ( Stratton, 1996a ). However, objective research evidence suggests that this is mainly due to differences in pedagogical variables [i.e. class size, available space, organizational strategies, teaching approaches, lesson content, etc. ( Borys, 1983 ; Stratton, 1996a )]. Furthermore, PE activity participation may be influenced by inter-individual factors. For example, activity has been reported to be lower among students with greater body mass and body fat ( Brooke et al. , 1975 ; Fairclough, 2003c ), and higher as students get older ( Seliger et al. , 1980 ). In addition, highly skilled students are generally more active than their lesser skilled peers ( Li and Dunham, 1993 ; Stratton, 1996b ) and boys tend to engage in more PE activity than girls ( Stratton, 1996b ; McKenzie et al. , 2000 ). Such inter-individual factors are likely to have significant implications for pedagogical practice and therefore warrant further investigation.

In accordance with Simons-Morton's ( Simons-Morton, 1994 ) first proposed aim of PE, the purpose of this study was to assess English students' physical activity levels during high school PE. The data were considered in relation to recommended levels of physical activity ( Biddle et al. , 1998 ) to ascertain whether or not PE can be effective in helping children be ‘fit and healthy’. Specific attention was paid to differences between sex and ability groups, as well as during different PE activities.

Subjects and settings

One hundred and twenty-two students (62 boys and 60 girls) from five state high schools in Merseyside, England participated in this study. Stage sampling was used in each school to randomly select one boys' and one girls' PE class, in each of Years 7 (11–12 years), 8 (12–13 years) and 9 (13–14 years). Three students per class were randomly selected to take part. These students were categorized as ‘high’, ‘average’ and ‘low’ ability, based on their PE teachers' evaluation of their competence in specific PE activities. Written informed consent was completed prior to the study commencing. The schools taught the statutory programmes of study detailed in the NCPE, which is organized into six activity areas (i.e. athletic activities, dance, games, gymnastic activities, outdoor activities and swimming). The focus of learning is through four distinct aspects of knowledge, skills and understanding, which relate to; skill acquisition, skill application, evaluation of performance, and knowledge and understanding of fitness and health ( Department for Education and Employment/Qualifications and Curriculum Authority, 1999 ). The students attended two weekly PE classes in mixed ability, single-sex groups. Girls and boys were taught by male and female specialist physical educators, respectively.

Instruments and procedures

The investigation received ethical approval from the Liverpool John Moores Research Degrees Ethics Committee. The study involved the monitoring of heart rates (HRs) during PE using short-range radio telemetry (Vantage XL; Polar Electro, Kempele, Finland). Such systems measure the physiological load on the participants' cardiorespiratory systems, and allow analysis of the frequency, duration and intensity of physical activity. HR telemetry has been shown to be a valid and reliable measure of young people's physical activity ( Freedson and Miller, 2000 ) and has been used extensively in PE settings ( Stratton, 1996a ).

The students were fitted with the HR telemeters while changing into their PE uniforms. HR was recorded once every 5 s for the duration of the lessons. Telemeters were set to record when the teachers officially began the lessons, and stopped at the end of lessons. Total lesson ‘activity’ time was the equivalent of the total recorded time on the HR receiver. At the end of the lessons the telemeters were removed and data were downloaded for analyses. Resting HRs were obtained on non-PE days while the students lay in a supine position for a period of 10 min. The lowest mean value obtained over 1 min represented resting HR. Students achieved maximum HR values following completion of the Balke treadmill test to assess cardiorespiratory fitness ( Rowland, 1993 ). This data was not used in the present study, but was collated for another investigation assessing children's health and fitness status. Using the resting and maximum HR values, HR reserve (HRR, i.e. the difference between resting and maximum HR) at the 50% threshold was calculated for each student. HRR accounts for age and gender HR differences, and is recommended when using HR to assess physical activity in children ( Stratton, 1996a ). The 50% HRR threshold represents moderate intensity physical activity ( Stratton, 1996a ), which is the minimal intensity required to contribute to the recommended volume of health-related activity ( Biddle et al. , 1998 ). Percentage of lesson time spent in health enhancing moderate-and-vigorous physical activity (MVPA) was calculated for each student by summing the time spent ≥50% HRR threshold. HRR values ≥75% corresponded to vigorous intensity physical activity (VPA). This threshold represents the intensity that may stimulate improvements in cardiorespiratory fitness ( Morrow and Freedson, 1994 ) and was used to indicate the proportion of lesson time that students were active at this higher level.

Sixty-six lessons were monitored over a 12-week period, covering a variety of group and individual activities ( Table I ). In order to allow statistically meaningful comparisons between different types of activities, students were classified as participants in activities that shared similar characteristics. These were, team games [i.e. invasion (e.g. football and hockey) and striking games (e.g. cricket and softball)], individual games (e.g. badminton, tennis and table tennis), movement activities (e.g. dance and gymnastics) and individual activities [e.g. athletics, fitness (circuit training and running activities) and swimming]. The intention was to monitor equal numbers of students during lessons in each of the four designated PE activity categories. However, timetable constraints and student absence meant that true equity was not possible, and so the number of boys and girls monitored in the different activities was unequal.

Number and type of monitored PE lessons

Student sex, ability level and PE activity category were the independent variables, with percent of lesson time spent in MVPA and VPA set as the dependent variables. Exploratory analyses were conducted to establish whether data met parametric assumptions. Shapiro–Wilk tests revealed that only boys' MVPA were normally distributed. Subsequent Levene's tests confirmed the data's homogeneity of variance, with the exception of VPA between the PE activities. Though much of the data violated the assumption of normality, the ANOVA is considered to be robust enough to produce valid results in this situation ( Vincent, 1999 ). Considering this, alongside the fact that the data had homogenous variability, it was decided to proceed with ANOVA for all analyses, with the exception of VPA between different PE activities.

Sex × ability level factorial ANOVAs compared the physical activity of boys and girls who differed in PE competence. A one-way ANOVA was used to identify differences in MVPA during the PE activities. Post-hoc analyses were performed using Hochberg's GT2 correction procedure, which is recommended when sample sizes are unequal ( Field, 2000 ). A non-parametric Kruskal–Wallis ANOVA calculated differences in VPA during the different activities. Post-hoc Mann–Whitney U -tests determined where identified differences occurred. To control for type 1 error the Bonferroni correction procedure was applied to these tests, which resulted in an acceptable α level of 0.008. Although these data were ranked for the purposes of the statistical analysis, they were presented as means ± SD to allow comparison with the other results. All data were analyzed using SPSS version 11.0 (SPSS, Chicago, IL).

The average duration of PE lessons was 50.6 ± 20.8 min, although girls' (52.6 ± 25.4 min) lessons generally lasted longer than boys' (48.7 ± 15.1 min). When all PE activities were considered together, students engaged in MVPA and VPA for 34.3 ± 21.8 and 8.3 ± 11.1% of PE time, respectively. This equated to 17.5 ± 12.9 (MVPA) and 3.9 ± 5.3 (VPA) min. The high-ability students were more active than the average- and low-ability students, who took part in similar amounts of activity. These trends were apparent in boys and girls ( Table II ).

Mean (±SD) MVPA and VPA of boys and girls of differing abilities

Boys > girls, P < 0.01.

Boys > girls, P < 0.05.

Boys engaged in MVPA for 39.4% ± 19.1 of lesson time compared to the girls' value of 29.1 ± 23.4 [ F (1, 122) = 7.2, P < 0.01]. When expressed as absolute units of time, these data were the equivalent of 18.9 ± 10.5 (boys) and 16.1 ± 14.9 (girls) min. Furthermore, a 4% difference in VPA was observed between the two sexes [ Table II ; F (1, 122) = 4.6, P < 0.05]. There were no significant sex × ability interactions for either MVPA or VPA.

Students participated in most MVPA during team games [43.2 ± 19.5%; F (3, 121) = 6.0, P < 0.01]. Individual games and individual activities provided a similar stimulus for activity, while the least MVPA was observed during movement activities (22.2 ± 20.0%; Figure 1 ). A smaller proportion of PE time was spent in VPA during all activities. Once more, team games (13.6 ± 11.3%) and individual activities (11.8 ± 14.0%) were best suited to promoting this higher intensity activity (χ 2 (3) =30.0, P < 0.01). Students produced small amounts of VPA during individual and movement activities, although this varied considerably in the latter activity ( Figure 2 ).

Mean (±SD) MVPA during different PE activities. ** Team games > movement activities ( P < 0.01). * Individual activities > movement activities ( P < 0.05).

Mean (±SD) VPA during different PE activities. ** Team games > movement activities ( Z (3) = −4.9, P < 0.008) and individual games ( Z (3) = −3.8, P < 0.008). † Individual activities > movement activities ( Z (3) = −3.3, P < 0.008). ‡ Individual game > movement activities ( Z (3) = −2.7, P < 0.008).

This study used HR telemetry to assess physical activity levels during a range of high school PE lessons. The data were considered in relation to recommended levels of physical activity ( Biddle et al. , 1998 ) to investigate whether or not PE can be effective in helping children be ‘fit and healthy’. Levels of MVPA were similar to those reported in previous studies ( Klausen et al. , 1986 ; Strand and Reeder, 1993 ; Fairclough, 2003b ) and did not meet the US Department of Health and Human Services ( US Department of Health and Human Services, 2000 ) 50% of lesson time criterion. Furthermore, the data were subject to considerable variance, which was exemplified by high standard deviation values ( Table II , and Figures 1 and 2 ). Such variation in activity levels reflects the influence of PE-specific contextual and pedagogical factors [i.e. lesson objectives, content, environment, teaching styles, etc. ( Stratton, 1996a )]. The superior physical activity levels of the high-ability students concurred with previous findings ( Li and Dunham, 1993 ; Stratton, 1996b ). However, the low-ability students engaged in more MVPA and VPA than the average-ability group. While it is possible that the teachers may have inaccurately assessed the low and average students' competence, it could have been that the low-ability group displayed more effort, either because they were being monitored or because they associated effort with perceived ability ( Lintunen, 1999 ). However, these suggestions are speculative and are not supported by the data. The differences in activity levels between the ability groups lend some support to the criticism that PE teachers sometimes teach the class as one and the same rather than planning for individual differences ( Metzler, 1989 ). If this were the case then undifferentiated activities may have been beyond the capability of the lesser skilled students. This highlights the importance of motor competence as an enabling factor for physical activity participation. If a student is unable to perform the requisite motor skills to competently engage in a given task or activity, then their opportunities for meaningful participation become compromised ( Rink, 1994 ). Over time this has serious consequences for the likelihood of a young person being able or motivated enough to get involved in physical activity which is dependent on a degree of fundamental motor competence.

Boys spent a greater proportion of lesson time involved in MVPA and VPA than girls. These differences are supported by other HR studies in PE ( Mota, 1994 ; Stratton, 1997 ). Boys' activity levels equated to 18.9 min of MVPA, compared to 16.1 min for the girls. It is possible that the characteristics and aims of some of the PE activities that the girls took part in did not predispose them to engage in whole body movement as much as the boys. Specifically, the girls participated in 10 more movement lessons and eight less team games lessons than the boys. The natures of these two activities are diverse, with whole body movement at differing speeds being the emphasis during team games, compared to aesthetic awareness and control during movement activities. The monitored lessons reflected typical boys' and girls' PE curricula, and the fact that girls do more dance and gymnastics than boys inevitably restricts their MVPA engagement. Although unrecorded contextual factors may have contributed to this difference, it is also possible that the girls were less motivated than the boys to physically exert themselves. This view is supported by negative correlations reported between girls' PE enjoyment and MVPA ( Fairclough, 2003b ). Moreover, there is evidence ( Dickenson and Sparkes, 1988 ; Goudas and Biddle, 1993 ) to suggest that some pupils, and girls in particular ( Cockburn, 2001 ), may dislike overly exerting themselves during PE. Although physical activity is what makes PE unique from other school subjects, some girls may not see it as such an integral part of their PE experience. It is important that this perception is clearly recognized if lessons are to be seen as enjoyable and relevant, whilst at the same time contributing meaningfully to physical activity levels. Girls tend to be habitually less active than boys and their levels of activity participation start to decline at an earlier age ( Armstrong and Welsman, 1997 ). Therefore, the importance of PE for girls as a means of them experiencing regular health-enhancing physical activity cannot be understated.

Team games promoted the highest levels of MVPA and VPA. This concurs with data from previous investigations ( Strand and Reeder, 1993 ; Stratton, 1996a , 1997 ; Fairclough, 2003a ). Because these activities require the use of a significant proportion of muscle mass, the heart must maintain the oxygen demand by beating faster and increasing stroke volume. Moreover, as team games account for the majority of PE curriculum time ( Fairclough and Stratton, 1997 ; Sport England, 2001 ), teachers may actually be more experienced and skilled at delivering quality lessons with minimal stationary waiting and instruction time. Similarly high levels of activity were observed during individual activities. With the exception of throwing and jumping themes during athletics lessons, the other individual activities (i.e. swimming, running, circuit/station work) involved simultaneous movement of the arms and legs over variable durations. MVPA and VPA were lowest during movement activities, which mirrored previous research involving dance and gymnastics ( Stratton, 1997 ; Fairclough, 2003a ). Furthermore, individual games provided less opportunity for activity than team games. The characteristics of movement activities and individual games respectively emphasize aesthetic appreciation and motor skill development. This can mean that opportunities to promote cardiorespiratory health may be less than in other activities. However, dance and gymnastics can develop flexibility, and muscular strength and endurance. Thus, these activities may be valuable to assist young people in meeting the HDA's secondary physical activity recommendation, which relates to musculo-skeletal health ( Biddle et al. , 1998 ).

The question of whether PE can solely contribute to young people's cardiorespiratory fitness was clearly answered. The students engaged in small amounts of VPA (4.5 and 3.3 min per lesson for boys and girls, respectively). Combined with the limited frequency of curricular PE, these were insufficient durations for gains in cardiorespiratory fitness to occur ( Armstrong and Welsman, 1997 ). Teachers who aim to increase students' cardiorespiratory fitness may deliver lessons focused exclusively on high intensity exercise, which can effectively increase HR ( Baquet et al. , 2002 ), but can sometimes be mundane and have questionable educational value. Such lessons may undermine other efforts to promote physical activity participation if they are not delivered within an enjoyable, educational and developmental context. It is clear that high intensity activity is not appropriate for all pupils, and so opportunities should be provided for them to be able to work at developmentally appropriate levels.

Students engaged in MVPA for around 18 min during the monitored PE lessons. This approximates a third of the recommended daily hour ( Biddle et al. , 1998 ). When PE activity is combined with other forms of physical activity support is lent to the premise that PE lessons can directly benefit young people's health status. Furthermore, for the very least active children who should initially aim to achieve 30 min of activity per day ( Biddle et al. , 1998 ), PE can provide the majority of this volume. However, a major limitation to PE's utility as a vehicle for physical activity participation is the limited time allocated to it. The government's aspiration is for all students to receive 2 hours of PE per week ( Department for Education and Employment/Qualifications and Curriculum Authority, 1999 ), through curricular and extra-curricular activities. While some schools provide this volume of weekly PE, others are unable to achieve it ( Sport England, 2001 ). The HDA recommend that young people strive to achieve 1 hour's physical activity each day through many forms, a prominent one of which is PE. The apparent disparity between recommended physical activity levels and limited curriculum PE time serves to highlight the complementary role that education, along with other agencies and voluntary organizations must play in providing young people with physical activity opportunities. Notwithstanding this, increasing the amount of PE curriculum time in schools would be a positive step in enabling the subject to meet its health-related goals. Furthermore, increased PE at the expense of time in more ‘academic’ subjects has been shown not to negatively affect academic performance ( Shephard, 1997 ; Sallis et al. , 1999 ; Dwyer et al. , 2001 ).

Physical educators are key personnel to help young people achieve physical activity goals. As well as their teaching role they are well placed to encourage out of school physical activity, help students become independent participants and inform them about initiatives in the community ( McKenzie et al. , 2000 ). Also, they can have a direct impact by promoting increased opportunities for physical activity within the school context. These could include activities before school ( Strand et al. , 1994 ), during recess ( Scruggs et al. , 2003 ), as well as more organized extra-curricular activities at lunchtime and after school. Using time in this way would complement PE's role by providing physical activity opportunities in a less structured and pedagogically constrained manner.

This research measured student activity levels during ‘typical’, non-intensified PE lessons. In this sense it provided a representative picture of the frequency, intensity and duration of students' physical activity engagement during curricular PE. However, some factors should be considered when interpreting the findings. First, the data were cross-sectional and collected over a relatively short time frame. Tracking students' activity levels over a number of PE activities may have allowed a more accurate account of how physical activity varies in different aspects of the curriculum. Second, monitoring a larger sample of students over more lessons may have enabled PE activities to be categorized into more homogenous groups. Third, monitoring lessons in schools from a wider geographical area may have enabled stronger generalization of the results. Fourth, it is possible that the PE lessons were taught differently, and that the students acted differently as a result of being monitored and having the researchers present during lessons. As this is impossible to determine, it is unknown how this might have affected the results. Fifth, HR telemetry does not provide any contextual information about the monitored lessons. Also, HR is subject to emotional and environmental factors when no physical activity is occurring. Future work should combine objective physical activity measurement with qualitative or quantitative methods of observation.

During PE, students took part in health-enhancing activity for around one third of the recommended 1-hour target ( Biddle et al. , 1998 ). PE obviously has potential to help meet this goal. However, on the basis of these data, combined with the weekly frequency of PE lessons, it is clear that PE can only do so much in supplementing young people's daily volume of physical activity. Students need to be taught appropriate skills, knowledge and understanding if they are to optimize their physical activity opportunities in PE. For improved MVPA levels to occur, health-enhancing activity needs to be recognized as an important element of lessons. PE may make a more significant contribution to young people's regular physical activity participation if lessons are planned and delivered with MVPA goals in mind.

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Author notes

1REACH Group and School of Physical Education, Sport and Dance, Liverpool John Moores University, Liverpool L17 6BD and 2REACH Group and Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 2ET, UK

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Journal of Teaching in Physical Education

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Print ISSN:  0273-5024             Online ISSN:  1543-2769

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Volume 43 (2024): Issue 2 (Apr 2024)

JTPE is published quarterly in January, April, July, and October.

The purpose of the Journal of Teaching in Physical Education is to communicate national and international research and stimulate discussion, study, and critique of teaching, teacher education, and curriculum as these fields relate to physical activity in schools, communities, higher education, and sport. The journal publishes original reports of empirical studies in physical education together with integrative reviews and analyses of educational and methodological issues in the field. Research using a variety of methodological approaches is acceptable for publication. Well-designed replication of previous research is also strongly encouraged. Brief research notes also will be reviewed for possible publication. The coeditors and editorial board encourage the submission of manuscripts that extend knowledge within the focus of the journal.

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All Human Kinetics journals require that authors follow our manuscript guidelines in regards to use of copyrighted material, human and animal rights, and conflicts of interest as specified in the following link: https://journals.humankinetics.com/page/author/authors

In preparing articles for submission to the Journal of Teaching in Physical Education , authors must follow the Publication Manual of the American Psychological Association (7th ed., 2020).

All articles must include an abstract of 100–150 words typed on a separate page along with three to six key words not used in the title. When submitting, you will be prompted to fill in the abstract in a specific box. Please also include the abstract in the manuscript file that is uploaded. JTPE editorial personnel request that a structured abstract format is used that includes labeling the following sections within the abstract paragraph: Purpose, Method, Results, and Discussion/Conclusion. Non-traditional papers (e.g., photovoice, reviews, position papers) may use other labeling systems. The entire manuscript must be double-spaced. Line numbers should be inserted, continuous throughout the text, to facilitate the review process. Tables must be prepared using Microsoft Word’s table-formatting functions. Manuscripts should be no longer than 30 total pages, inclusive of title page, abstract pages, main text, references, figures, and tables. Occasionally, the journal editors will consider longer submissions, but authors are asked to request editorial approval before submitting papers longer than 30 pages. Special attention should be given to the accuracy of the references and APA style. Figures must be crisp, clear, and properly labeled. Do not submit low-resolution electronic files. Manuscripts should not be submitted to another journal at the same time. All quantitative studies must report effect sizes. To facilitate blind review, the first page of the manuscript should include only the title of the manuscript and the date of submission. The manuscript itself should contain no clues as to the author’s identity. A separate cover sheet with contact information is no longer required because the necessary identifying information is entered when registering with the online submission system.

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Makel and Plucker (2014) proposed that replication is a powerful avenue to accumulate understanding by checking the validity of knowledge from previous research and enables questions concerning generalization across populations or contexts. Schmidt (2009) suggests that there are two primary forms of replication studies. The first includes "operational" replications that test the validity of the original data using similar procedures and research designs. The second are "constructive" replications, which attempt to replicate a research finding with different situations and different subjects, to determine if the basic findings of the original study can be applied to other participants and circumstances and is therefore linked to the wider notion of replication. In addition to the Manuscript Guidelines listed above, any Replication study submitted to JTPE must fall into one of these two categories. 

Makel, M.C., & Plucker, J.A. (2014). Facts are more important than novelty: Replication of the education sciences. Educational Researcher , 43 , 304–316. Schmidt, S. (2009). Shall we really do it again? The powerful concept of replication is neglected in the social sciences. Review of General Psychology , 13 , 90–100. 

Research Notes submitted to JTPE should meet the following guidelines:

Research Notes may consist of replication studies, data re-analyses studies, validation studies of existing instruments, and comments and dialogues on previously published papers. Manuscripts should use 12-point Times New Roman font and should be double-spaced (as per APA guidelines), with length not exceeding 14 pages, including text, references, tables, and figures. Consecutive line numbers should be inserted throughout the text to facilitate the review process. Submissions must include an abstract of 150 words or less. Research Notes should conform to the Publication Manual of the American Psychological Association (7th ed., 2020).

Review and Publishing Process

Research Notes follow the same review and publishing process as regular manuscripts.

The Journal of Teaching in Physical Education is committed to publishing reviews of recent books that contribute to physical education, physical education teacher education, and related fields. In some instances, the book review editor may identify books worthy of review and ask scholars to author a book review. In other instances, scholars may propose to review a book based on their interest and expertise. Prospective book review authors should first contact the section editor to discuss their interest and ensure that the book they wish to review is a fit for JTPE and is not already under review.  The current book review section editor is Dr. Michael Hemphill ( [email protected] ).

Review Format

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• Published: 02 April 2024

The effect of the Sport Education Model in physical education on student learning attitude: a systematic review

• Junlong Zhang 1 ,
• Wensheng Xiao 2 ,
• Kim Geok Soh 1 ,
• Gege Yao 3 ,
• Mohd Ashraff Bin Mohd Anuar 4 ,
• Xiaorong Bai 2 &
• Lixia Bao 1  

BMC Public Health volume  24 , Article number:  949 ( 2024 ) Cite this article

878 Accesses

Metrics details

Evidence indicates that the Sport Education Model (SEM) has demonstrated effectiveness in enhancing students' athletic capabilities and fostering their enthusiasm for sports. Nevertheless, there remains a dearth of comprehensive reviews examining the impact of the SEM on students' attitudes toward physical education learning.

The purpose of this review is to elucidate the influence of the SEM on students' attitudes toward physical education learning.

Employing the preferred reporting items of the Systematic Review and Meta-analysis (PRISMA) statement guidelines, a systematic search of PubMed, SCOPUS, EBSCOhost (SPORTDiscus and CINAHL Plus), and Web of Science databases was conducted in mid-January 2023. A set of keywords associated with the SEM, attitudes toward physical education learning, and students were employed to identify relevant studies. Out of 477 studies, only 13 articles fulfilled all the eligibility criteria and were consequently incorporated into this systematic review. The validated checklist of Downs and Black (1998) was employed for the assessment, and the included studies achieved quality scores ranging from 11 to 13. The ROBINS-I tool was utilized to evaluate the risk of bias in the literature, whereby only one paper exhibited a moderate risk of bias, while the remainder were deemed to have a high risk.

The findings unveiled significant disparities in cognitive aspects ( n  = 8) and affective components ( n  = 12) between the SEM intervention and the Traditional Teaching (TT) comparison. Existing evidence suggests that the majority of scholars concur that the SEM yields significantly superior effects in terms of students' affective and cognitive aspects compared to the TT.

Conclusions

Nonetheless, several issues persist, including a lack of data regarding junior high school students and gender differences, insufficient frequency of weekly interventions, inadequate control of inter-group atmosphere disparities resulting from the same teaching setting, lack of reasonable testing, model fidelity check and consideration for regulating variables, of course, learning content, and unsuitable tools for measuring learning attitudes. In contrast, the SEM proves more effective than the TT in enhancing students' attitudes toward physical learning.

Systematic review registration

( https://inplasy.com/ ) (INPLASY2022100040).

Peer Review reports

Introduction

In recent years, the "student-centered" teaching model, as a more effective alternative to the traditional "teacher-centered" teaching model, has gained increasing attention and recognition from education scholars and departments worldwide [ 1 , 2 ]. Metzler [ 3 ] identified a series of "student-centered" teaching models based on constructivism and social learning theories, each developed for specific course objectives [ 4 , 5 ]. Furthermore, it is widely acknowledged that instructional models are in a constant state of development, involving the generation, testing, refinement, and further testing processes under different educational objectives. These instructional models are designed to enable students to acquire a depth and breadth of knowledge in physical education [ 6 ]. In this regard, a series of instructional models have been identified as effective means to achieve specific objectives. Consequently, numerous studies have established that placing students at the center of the instructional process is the most effective approach [ 7 ], allowing for the assessment of the impact of these models on students' learning in physical education. For instance, Cooperative Learning (CL), rooted in the idea of learning together with others, through others, and for others [ 8 ], aims to promote five essential elements [ 9 ]: interpersonal skills, processing, positive interdependence, promoting interaction, and individual responsibility. The underlying concept of Teaching Game for Understanding (TGFU) involves shifting the focus from technical aspects of gameplay to the context (tactical considerations) through modification of representation and exaggeration [ 4 , 10 ]. Emphasizing placing learners in game situations where tactics, decision-making, and problem-solving are non-negotiable features, despite incorporating skill practice to correct habits or reinforce skills [ 11 ], TGFU is structured around six steps: game, game appreciation, tactical awareness, decision-making, skill execution, and performance. Teaching for Personal and Social Responsibility (TPSR), designed by Hellison [ 12 ], aims to cultivate personal and social responsibility in young people through sports activities, defining four major themes: integration, transfer, empowerment, and teacher-student relationships. It revolves around five responsibility goals: respecting the rights and feelings of others, effort (self-motivation), self-direction, caring (helping), and transferring beyond the "gym" [ 13 ]. The SEM comprises six key structural features: season, affiliation, formal competition, culminating events, record-keeping, and festivity. SEM seeks to provide students with authentic, educationally meaningful sporting experiences within the school sports context, aiming to achieve the goal of developing capable, cultured, and enthusiastic individuals [ 14 ]. This suggests a subtle intersection between SEM's developmental goals and enhancing students' learning attitudes (cognitive and emotional), laying the foundation for the selection of teaching model types in this study.

In previous SEM-centered reviews, the focus primarily centered on the model's positive impact on students' personal and social skills [ 15 , 16 ], motor and cognitive development [ 16 ], motivation [ 17 , 18 ], basic needs [ 18 ], prosocial attitudes [ 18 ], and learning outcomes [ 19 ], and it is concluded that the implementation of SEM has a positive effect on improving students' performance in these aspects. While these reviews contribute valuable insights, they exhibit certain limitations, such as a lack of comprehensive exploration of the model's impact on the cognitive and emotional dimensions in the context of school-based physical education. Therefore, our study attempts to bridge this gap by delving into the nuanced intersection between SEM and students' learning attitudes, aiming to provide a more comprehensive understanding of its impact on educational environments.

In the field of education, a focus on practical application and scholarly discourse is crucial and commendable [ 20 , 21 ]. From a practical perspective, research should offer valuable resources for curriculum designers, educators, and policymakers [ 22 , 23 , 24 , 25 ]. In theoretical terms, the contribution of research lies in addressing gaps in the literature by elucidating dimensions within physical education that remain insufficiently explored [ 26 ]. Our study is dedicated to significantly impacting physical education teaching through the practical application and scholarly discourse surrounding SEM. By revealing the subtle interactions between SEM and attitudes, we aim to provide valuable curriculum implementation recommendations for designers, practitioners, and policymakers, filling the gaps in how SEM shapes learning attitudes in educational environments.

In the realm of attitude research, scholars have traditionally classified attitude components into three types: single-component, two-component, and three-component. Advocates of the single-component view contend that attitudes are confined to the emotional dimension. For example, Fazio and Zanna [ 27 ] define attitude as "an evaluative feeling caused by a given object" (p. 162). Two-component researchers posit that attitudes comprise cognition and emotion, with the affective component measuring emotional attraction or feelings toward the object, and the cognitive component representing beliefs about the object's characteristics [ 28 , 29 ]. Bagozzi and Burnkrant [ 30 ] compared the effectiveness of one-component and two-component attitude models, concluding that incorporating both cognitive and emotional dimensions enhances attitude effectiveness. On the contrary, proponents of the three-component perspective argue that attitudes encompass cognition, emotion, and behavior, suggesting that cognitive and emotional responses to an object influence behavior. However, the three-component view has faced skepticism, with some researchers finding that attitude measurement explains only about 10% of behavior variance. Studies reporting higher correlations often focus on attitudes and behavioral intent rather than explicit behavior itself [ 31 , 32 , 33 ]. Our research places a deliberate emphasis on investigating the intersection between the SEM and attitudes to address a noticeable gap in the existing scholarly landscape. While none of the reviewed literature approached the subject from an attitude theory perspective, we prioritize this theoretical framework, acknowledging that attitudes significantly influence student learning [ 16 , 34 ]. Consequently, the exploration of the interplay between SEM and attitudes is considered indispensable for attaining a thorough comprehension of SEM's potential impact in educational contexts. By integrating attitude theory into this inquiry, there is an aspiration to unveil nuanced insights into the cognitive and emotional dimensions influenced by SEM, thereby enriching the understanding of the model's pedagogical implications.

The chosen systematic review approach in this study aims to enhance the reader's understanding of the research methodology, thereby strengthening the overall scientific rigor of the study [ 35 ].

Protocol and registration

This review adheres to the guidelines set forth by the Preferred Reporting Project for Systematic Review and Meta-Analysis (PRISMA). The review has been registered on the International Registry Platform for Systematic Review and Meta-Analysis Programmes (INPLASY) under the registration number INPLASY2022100040. More information about the review can be found at the following link: https://inplasy.com/ .

Search strategy

In October 2004, Siedentop initiated SEM workshops, attracting widespread attention from scholars both domestically and internationally, marking the beginning of SEM practices [ 36 , 37 ]. Subsequently, in many advanced countries such as the United States, New Zealand, Australia, and the United Kingdom, SE has become a mainstream approach in physical education instruction [ 38 ]. Therefore, the retrieval period for this review is set from October 2004 to December 2023, encompassing relevant articles published during this timeframe. A systematic search of four electronic databases was conducted for relevant articles: SCOPUS, PubMed, EBSCOhost (SPORT Discus and CINAHL Plus), and Web of Science. The search aimed to identify studies on the effects of SEM on attitudes toward physical education learning. We employed advanced search methods and added the following search terms: ("Sport Education Model" OR "Sport Education" OR "Sport season") AND ("learning attitude" OR "sports attitude" OR "cognitive" OR "cognition" OR "usefulness" OR "importance" OR "perceptions" OR "affective" OR "emotional" OR "enjoyment" OR "happiness" OR "well-being" OR "Blessedness" OR "subjective well-being") AND ("student" OR "pupil" OR "scholastic" OR "adolescent" OR "teenager"). The search expressions were combined using logical operators. We also sought assistance from librarians in the field to ensure comprehensive results. Furthermore, we manually examined the reference lists of the included studies to identify additional relevant literature and validate the effectiveness of our search strategy.

Eligibility criteria

We employed the Picos framework, encompassing Population, Intervention, Comparison, Outcomes, and Study Design, as the inclusion criteria for this systematic review (Table  1 ). Furthermore, the selected literature adhered to the following additional criteria: (i) it comprised full English texts published in peer-reviewed journals; (ii) the interventions were conducted within the context of physical education, with a comprehensive description of the intervention process and content; (iii) the effects of the SEM and TT on students' learning attitudes (cognitive and emotional) were compared on at least one dimension; (iv) quasi-experimental designs employing objective tests and measurements, along with studies presenting evaluation results, were considered. Exclusion criteria encompassed studies that combined physical education models with other teaching methods or models (hybrid or invasive). Initially, the search strategy was guided by a librarian, and duplications were eliminated by importing the retrieved literature into Mendeley reference management software. Subsequently, decisions regarding literature exclusion and retention were made through the screening of titles and abstracts. Ultimately, articles deemed highly relevant were read in full. The primary outcome aimed to assess attitudes (cognitive and affective) toward physical learning based on the SEM.

The search strategy was guided by a librarian, and the obtained literature was imported into Mendeley reference management software for duplicate removal. Decisions regarding literature inclusion and exclusion were made based on the screening of titles and abstracts. Articles that were deemed highly relevant were read in their entirety. The primary focus of this review was to assess attitudes (cognitive and affective) toward physical learning, specifically based on the SEM. The designation "not relevant" is employed to characterize articles subjected to thorough scrutiny, which fail to make substantive contributions to the fundamental focus of our research. More precisely, those articles deemed irrelevant were those that omitted consideration of the pivotal variables under examination, namely, cognitive and emotional dimensions. Furthermore, they were not situated within the milieu of a scholastic educational framework for physical education (SEM). This methodological approach has been instituted to uphold the establishment of a centralized and cohesive dataset requisite for subsequent analytical procedures [ 39 ] (See Fig.  1 ).

PRISMA summary of the study selection process

Study selection

Prior to conducting the search, consultation with an experienced librarian was sought to develop an effective retrieval strategy. Following this, two independent reviewers conducted the literature search. All retrieved studies were imported into Mendeley literature management software to identify and eliminate duplicates. Initially, the literature was screened based on the titles by two independent evaluators, who excluded irrelevant studies. Subsequently, the abstracts of the initially selected literature were reviewed against pre-established inclusion criteria to determine their eligibility for inclusion in the study. Finally, the full text of the included literature was reviewed by two authors, who extracted relevant information. In the case of any disagreements, a third author (K.G.S.) was involved in the review process.

Data extraction and quality assessment

The data extraction process involved collecting the following information: (1) author and year of publication; (2) research design, including the type of experiment or teaching project; (3) population details, such as student category, total number of students, age range, and gender distribution, as well as group size; (4) intervention characteristics, including the total number of interventions, weekly frequency of interventions, duration of each intervention, and consistency of intervention location; (5) a comparison group, typically involving the TT and country information; (6) results, which encompassed the measurement tools used, specific indicators measured, and the research findings. The collected data were independently summarized and reviewed by two authors, with the involvement of a third author to resolve any discrepancies or disagreements.

The methodological quality of the selected articles in this systematic review was assessed using the validated checklist developed by Downs and Black [ 40 ]. The checklist consisted of 27 items, which were categorized into three domains: reporting (items 1–10), validity (external validity: items 11–13; internal validity: items 14–26), and statistical power (item 27). Each item was scored, resulting in a total score ranging from 0 to 27, with higher scores indicating higher methodological quality.

In this review, the cross-sectional and longitudinal surveys were scored in detail using the Downs and Black checklist to evaluate the strengths and weaknesses of each study [ 40 ]. The scoring process involved two primary assessors independently assessing the selected studies. In case of any ambiguity or disagreement, a resolution was reached through reconciliation. If disagreements persisted, the assessment was conducted by one of the co-authors until a consensus was reached.

The classification criteria for the scores were as follows: studies with a score below 11 were considered to have low methodological quality, scores ranging from 11 to 19 indicated medium quality, and scores higher than 20 indicated high methodological quality [ 41 ]. Upon assessment, it was found that all selected articles in this review fell within the medium-quality range (see Table  2 ).

The studies risk of bias

The Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool encompasses seven evaluation areas, which are further divided into three distinct stages: pre-intervention, intervention, and post-intervention. The pre-intervention stage includes two evaluation areas: confounding bias and selection bias of participants. The intervention stage focuses on the evaluation of bias in the classification of interventions. The post-intervention stage comprises four evaluation areas: bias due to deviations from intended interventions, bias due to missing data, bias in the measurement of outcomes, and bias in the selection of reported results. Each evaluation area is composed of multiple signaling questions, amounting to a total of 34 signaling questions.

Methodical quality

The articles underwent assessment using the validated checklist developed by Downs and Black (1998): 11–13 (mean = 12.38; median = 12; mode = 12 & 13). All the articles demonstrated a medium level of quality, indicating their suitability for inclusion in this review. Furthermore, it suggests the potential for higher-quality articles in future studies. Among the thirteen included articles, five were published within the last three years, constituting one-third of the included literature. This observation highlights the ongoing research interest and significance of the SEM in the investigation of various teaching models. In terms of the Hypothesis/aim/objective, participant characteristics, interventions, main findings, data variability, probability values, statistical tests, detailed intervention descriptions, reliable outcome measures, participant source ( n  = 12), participant grouping ( n  = 11), and random allocation ( n  = 3) were adequately addressed. However, aspects such as reporting measurement outcomes in the introduction or methods section, confounder distribution, adverse events following the intervention, characterization of lost-to-follow-up patients, data analysis, blinding of participants and assessors, adjustment for confounding, and identification of chance results with a probability less than 5% ( n  = 0) were not thoroughly addressed. Although the implementation of blind subjects, therapists, and assessors in teaching experiments poses challenges, future research should strive for higher quality and stronger levels of evidence [ 23 ].

After a detailed reading of the literature that meets the inclusion criteria of this review and the extraction and sorting of important information, it is presented in Table  3 .

The bias risk assessment results are summarized in Table  4 , which includes information such as author/date, field of study, study type, risk assessment tool, and overall rating. The main sources of bias identified were confounding factors and outcomes measurement. The evaluation revealed that only two experimental studies in the Confounders field had a moderate risk of bias, while the rest had a high risk of bias. All included literature demonstrated low risk in terms of subject selection, classification of recommended interventions, and deviation from established interventions. Furthermore, one-third of the literature showed low-risk missing data [ 23 , 42 , 50 , 51 ], while other studies did not provide relevant information. Lastly, nearly a third of the literature showed missing data for low-risk.

Overview of sports and experiment design

All thirteen papers included in this review utilized a pre-posttest design. The sports covered in these studies encompassed basketball, volleyball, soccer, ultimate Frisbee, table tennis, hockey, Polskie ringo, ball games, and body movements. Some studies examined two exercise programs [ 23 , 43 ], while the majority of research focused on basketball [ 44 , 52 , 53 ]. The participants in the course experiments were primarily college and high school students, with a limited number of studies investigating primary and junior high school students. The distribution of participants included college students (3), high school students (8), primary school students (1), and junior high school students (1). The sample sizes in these studies ranged from 40 to 508. Since the selected studies were teaching experiments, most of them involved mixed-sex classes, with four studies not specifying the gender of the students. Only one study established three experimental classes and two control classes [ 50 ], while the remaining studies had one experimental class and one control class. The number of interventions ranged from 8 to 25, with each intervention lasting between 45 and 90 min.

The majority of studies in the selected literature directly applied the SEM as the intervention. Five of the studies incorporated constructivism theory [ 48 ], self-determination theory [ 23 , 44 , 47 ], and ARCS learning motivation theory [ 52 ]. None of the literature investigated from the perspective of attitude theory. Furthermore, none of the selected studies mentioned the teaching standards or syllabus used to design the course content, nor did they provide explanations for the rationale behind the experimental teaching content. The number of interventions in the trials ranged from 8 to 25, with up to half of the studies using fewer than 18 interventions [ 42 , 47 , 48 , 49 , 50 , 52 , 53 ], the recommended class hours for large unit teaching are not met [ 54 ]. The duration of each intervention was most commonly reported as 45 or 60 min [ 42 , 43 , 44 , 47 , 49 , 50 , 51 , 52 , 53 ]. The frequency of weekly interventions varied from 1 to 5, but the majority of studies implemented interventions once a week [ 23 , 42 , 43 , 46 , 47 , 48 , 49 ]. The intervention frequency was generally low, and there was a scarcity of studies with higher intervention frequency. With the exception of one article that conducted the intervention in two schools without providing an explanation [ 50 ], the remaining studies were conducted within the same school.

The control classes in the selected literature implemented similar TT and forms, despite variations in naming used by scholars from different countries or even within the same country. The TT employed in the control classes were mainly Direct Instruction in Australia [ 43 , 46 , 47 , 51 , 52 ], Morocco [ 50 ], and Spain [ 42 , 43 , 44 ], In China, the traditional teaching models were referred to as TT [ 48 , 52 ] and Latent Growth Model [ 49 ]; Traditional Style in the United States and England [ 42 ], American Skill-drill-game [ 44 , 45 ], and multiactivity model [ 23 ].

Measuring instruments and main outcomes

The findings of this investigation were classified based on the impact of the SEM on various aspects of students' attitudes toward physical education: cognitive and affective domains. Through the segregation of subjects and constituents from prior research, the favorable and unfavorable indicators of affective and cognitive dimensions were predominantly derived from the existing body of literature.

The effect of SEM on student cognitive

In this literature review, it was evident that all the included studies reached a unanimous conclusion that the overall effectiveness of the SEM surpassed that of the TT. Among these studies, eight of them specifically evaluated students' cognitive performance [ 23 , 42 , 43 , 45 , 48 , 50 , 52 ]. Various assessment instruments were employed, such as the Intrinsic Motivation Inventory (IMI) [ 42 , 43 , 45 ], the Amotivation subscale of the Academic Motivation Scale (AMS) [ 23 ], the attitude questionnaire [ 48 ], the Spanish version of the Sport Satisfaction Instrument (SVSSI) [ 50 ], the ARCS Learning Motivation Scale, the Physical Education Affection Scale (PEAS) [ 52 ], and the ALT-PE data were collected using momentary time sampling for each team by trained coders [ 53 ].

The study participants encompassed junior high school students [ 43 ], high school students [ 23 , 42 , 45 , 48 , 50 ] and College students [ 52 , 53 ]. Most of these investigations revealed that following the intervention of the physical education course, the cognitive abilities of students in the intervention group exhibited significant improvement, surpassing those of the control group instructed through the TT. Conversely, no significant changes were observed within the control group before and after the experiment [ 23 , 42 , 48 , 50 ]. Nevertheless, one study reported a significant decrease in cognitive abilities among students in the control group before and after the experiment [ 54 ], the other two studies showed that both the experimental and control groups showed significant improvements, but the experimental group showed significantly greater improvements [ 52 , 53 ].

The effect of SEM on student's affective

In this comprehensive review, all the included studies examined students' affective aspects. The assessment instruments employed were as follows: Intrinsic Motivation Inventory (IMI) [ 42 , 43 , 44 , 45 , 47 ], Amotivation subscale of the Academic Motivation Scale (AMS) [ 23 ], Intention to be Physically Active Scale (IPAS) [ 46 ], the attitude questionnaire [ 48 ], Physical activity enjoyment scale (PACES) [ 49 ], the Spanish version of the Sport Satisfaction Instrument (SVSSI) [ 50 ], Positive and Negative Affect Scale (PANASN) [ 51 ] and the Physical Education Affection Scale (PEAS) [ 52 ].

The study participants encompassed primary school students [ 51 ], Junior high school students [ 43 ], high school [ 23 , 42 , 44 , 45 , 46 , 47 , 48 , 50 , 51 ] and College students [ 49 , 52 ]. Out of the 12 studies, four reported positive and/or negative interests or enjoyment among students. Among these, two studies indicated that the experimental group students exhibited significantly higher positive affect than the control group students [ 47 , 51 ]. However, the measurement results varied within the control group. One study reported no significant improvement [ 47 ], while another study showed significant improvement, but the effect was significantly greater in the experimental group compared to the control group [ 51 ]. Furthermore, one study demonstrated no significant difference between the two groups as the test indicators did not exhibit significant changes before and after the experiment [ 46 ].

Regarding the investigation of negative affect, three studies reported that the experimental group students exhibited significantly lower negative affect compared to the control group [ 47 , 51 ], with a significant decrease in negative affect observed in the experimental group while no significant change was noted in the control group. Additionally, one study showed no significant difference and no significant improvement in the test results between the two groups before and after the experiment [ 46 ].

Among the remaining eight studies, it was not specified whether the investigation focused on positive or negative effects. Among them, two studies solely compared the improvement effects between the experimental and control groups without conducting intra-group comparisons before and after the experiment, and the results revealed that the experimental group exhibited significantly better outcomes than the control group [ 45 , 49 ]; the remaining six studies conducted comparisons not only between groups before and after the experiment but also within each group. Five studies demonstrated a significant increase in the affected index of the experimental group, while the control group exhibited no significant change [ 23 , 42 , 44 , 48 , 52 ], and one study revealed that the experimental group displayed a significant improvement, while the control group experienced a significant decline [ 43 ].

This paper presents a comprehensive review of the effects of the SEM on students' attitudes towards physical education. Its aim is to distinguish this study from other published research on the application of the SEM interventions among students. The findings indicate that the SE model has the potential to enhance students' attitudes toward physical education in terms of cognition and affect. However, certain factors such as the lack of data on junior high school students and gender differences, the frequency and duration of intervention per week, the variation in the learning environment across groups taught in the same setting, the rationale behind the course content, and the selection of tools for measuring learning attitudes may influence the experimental outcomes. Nonetheless, considering the positive results observed in these studies, is SEM an effective way to interfere with students' attitudes toward physical education learning? In conjunction with the information presented in the " Results " section, this review offers a detailed analysis of the impact of various dimensions of student attitudes toward physical education learning.

As anticipated, eleven out of the thirteen studies included in this review focused on ball games, which aligns with the competitive nature of these sports [ 55 ]. This choice is well-suited to the seasonal characteristics of the Sports Education Model (SEM) [ 56 , 57 ]. When considering gender comparisons, incorporating gender research can enhance the reliability of experimental findings [ 58 , 59 ]. However, in all the studies included, the majority of researchers only used mixed experimental and control groups, without comparing gender distinctions. If significant differences exist in the effect of SEM on the learning attitudes of students of different genders, it would significantly impact the accuracy of the experimental results.

Regarding the frequency, number, and duration of each intervention, some scholars have suggested that these factors may have different effects on the experimental outcomes [ 60 ], However, among the thirteen studies reviewed, the largest number of interventions was only 25 [ 23 ], and most studies had fewer than 20 interventions. Most studies had fewer than 18 interventions. This deviates from the use of large unit teaching advocated by some scholars to enhance students' systematic cognition and learning experience of a sports event [ 54 , 61 ]. In the reform of the school curriculum, the State Council of China issued the Curriculum Standards for Physical Education and Health for Compulsory Education (2022 edition) for students, which also clearly mentioned that the length of class hours for large units should not be less than 18 lessons.

In terms of the rationality of classroom teaching form and content, Hastie et al. [ 62 ] developed an Instructional Checklist to evaluate the effectiveness of the SEM and TT. However, only four of the included studies addressed this aspect [ 46 , 47 , 50 ]. Regarding the selection of measurement tools, none of the studies examined students' learning attitudes using scales developed based on attitude theory. According to the two-component proponents of attitude, attitude theory defines attitude as the affective and cognitive (positive or negative) evaluation of individuals toward the object of attitude [ 28 , 29 , 30 , 63 ]. Failing to assess student attitudes using survey instruments developed based on the structural composition of attitudes is problematic, as these instruments may not accurately measure attitudes [ 64 ]. The critical concern regarding the assessment of student attitudes using survey instruments developed based on the structural composition of attitudes requires a more thorough explanation. This is particularly important because relying on instruments that do not align with the multi-dimensional nature of attitudes, encompassing affective, cognitive, and conative components, may lead to inaccurate measurements [ 64 ]. To elaborate further, historical quantitative investigations in physical education pedagogy often utilized instruments such as Kenyon's [ 65 ] or Simon and Smoll's [ 66 ], which might not capture the complete construct of attitude. For instance, Kenyon's instrument conceptualizes physical activity rather than attitude as a multidimensional construct, while Simon and Smoll's instrument, developed for adults, may not be entirely valid for children. This unidimensional perspective on attitude, focusing solely on the affective dimension, is problematic, as it overlooks the multi-component nature of attitude, as acknowledged in studies by Gonzàles [ 67 ], Mohsin [ 68 ], and Oppenheim [ 69 ]. Therefore, future research endeavors should delve into the intricacies of attitude assessment tools, considering the developmental differences and the multidimensional nature of attitudes to ensure comprehensive and accurate measurement in the context of physical education pedagogy.

The existing literature provides sufficient evidence to support the significant superiority of physical education courses over TT in enhancing students' cognition of physical education learning. The cognitive dimension refers to individuals' evaluation of concepts and beliefs related to specific people, things, and objects, forming a multi-perspective system [ 32 , 49 ]. The development of ideas and beliefs relies on a solid foundation of knowledge about people and things. Students' cognition of physical education learning serves as a prerequisite for fostering positive attitudes toward physical education [ 70 ]. However, among the eight studies included in this review that examined the cognitive components of attitudes, seven studies concluded that SEM and TT had a more significant impact on improving students' perception of attitudes toward physical education learning [ 23 , 42 , 43 , 45 , 48 , 50 , 53 ]. Most of these studies indicated that students' perception of physical education learning did not change significantly under TT. Only one study found that both SEM and TT showed significant improvements before and after the experiment, with no significant difference in the degree of improvement between them [ 52 ]. However, it is noteworthy that the study by Chu et al. [ 49 ] lacked a thorough examination of the model fidelity for both the SEM and TT. The absence of a robust fidelity check raises concerns about the reliability and validity of the observed improvements reported in both SEM and TT groups before and after the experiment. Without ensuring that the implemented instructional models were faithfully executed as intended, it becomes challenging to attribute the observed improvements solely to the effectiveness of the instructional methods. Consequently, the study reports significant improvements in both SEM and TT without a discernible difference in the degree of improvement between them. This underscores the importance of conducting comprehensive model fidelity checks to enhance the credibility and interpretability of research findings, particularly when comparing the effectiveness of different instructional models in educational settings. Although most studies support the significant superiority of the SEM in enhancing students' perception of physical education learning compared to traditional instruction, it is important to note that five out of seven studies were conducted with high school students, limiting the generalizability of the findings to broader populations. This represents a crucial gap in the existing literature regarding learning cognition in physical education. Furthermore, despite having mixed-gender classes, the studies did not include a comparative analysis of students from different genders. Therefore, it is necessary to conduct additional comparative studies on the SEM and TT, encompassing various learning stages and considering the cognition of physical education learning among students of different genders, to enrich the breadth of results.

The majority of sports scholars hold the view that the SEM is superior to the TT in fostering students' emotional experiences in sports learning. The affective dimension pertains to the emotions and emotional experiences of individuals based on cognitive factors related to specific people, things, or objects, such as interest or enjoyment [ 32 , 49 ]. By comparing SEM and TT, eleven out of the thirteen studies analyzing improvements in student physical education learning confirmed that SEM significantly outperformed TT in enhancing student interest or enjoyment [ 23 , 42 , 43 , 44 , 45 , 47 , 48 , 49 , 50 , 51 , 52 ]. Only one study found that both SEM and TT did not lead to significant improvements in student interest or enjoyment, as there were no significant changes in test results before and after the learning social work experiment in both groups [ 46 ]. Notably, three of the studies involved opposite outcomes of positive and negative effects [ 46 , 47 , 51 ], and one study exclusively reported negative affect [ 50 ]. These divergent results underscore the complexity of the relationship between instructional models and students' attitudes towards physical education. Future research endeavors should delve deeper into the factors contributing to such variations, exploring potential moderating variables, instructional nuances, or contextual influences that may elucidate the observed disparities. These findings not only deserve attention for their immediate implications but also emphasize the need for nuanced investigations that can inform the refinement and optimization of instructional approaches in the field of physical education.

Moreover, among the four studies involving 20 or more interventions, three studies conducted within-group comparisons of SEM and TT before and after the experiment [ 23 , 43 , 45 ], and the frequency of weekly interventions varied. One study with a low intervention frequency found a significant decrease in emotional aspects among students in the TT group before and after the experiment [ 43 ]. However, two studies with high intervention frequency found no significant changes in the emotional aspects of students in the TT group before and after the experiment [ 23 , 44 ]. These results contradict Chen's argument (2019) that prolonged treatment may lead to adverse emotions such as anxiety and depression. However, these limited findings do not provide strong evidence and require further validation in future studies with larger sample sizes.

Limitations

In summary, this review presents substantial evidence supporting the superiority of the SEM over TT in enhancing students' attitudes toward physical education learning. However, there are several limitations to consider. Firstly, none of the included studies reported gender differences, which limits the richness and specificity of the research findings. Gender differences, if present, could potentially impact the accuracy of the overall results. Secondly, the studies did not address the influence of class size on teaching experiment outcomes. Determining the optimal number of students per group and the ideal number of groups is an important consideration for achieving optimal teaching effects. Inappropriate, insufficient, or excessive sample sizes can affect the quality and accuracy of experiments [ 71 ]. Thirdly, most studies did not account for the experimental environment or control participants' physical activities outside the experimental setting, which may influence students' attitudes toward physical education learning. Additionally, the studies generally did not consider the impact of factors such as climate and time on students' attitudes during the teaching experiments. Lastly, none of the studies included in this review conducted any short-term or long-term follow-up of students after the trial, making it challenging to determine the long-term effects of SEM on students' attitudes toward physical education learning.

The systematic review conducted provides compelling evidence supporting the positive impact of the SEM on students' attitudes toward physical education learning. However, it is important to note that most of the literature included in this review focused on high school and college students, while there were fewer findings for other school age groups. Urgently needed are comprehensive research initiatives that prioritize investigating the impact of the SEM on attitudes towards physical education learning across diverse age groups, including primary and middle school students. This will contribute to a more inclusive understanding of SEM's effectiveness, ensuring that its benefits are explored and validated across various educational stages, thus providing a solid foundation for evidence-based instructional practices in physical education. Additionally, although SEM is an established teaching model, recent research has shown an increase in its popularity in physical education, with five out of the thirteen studies published in the last three years. Nevertheless, it is crucial to approach the results with caution due to the limitations identified in this study.

To further deepen our understanding of the effectiveness of SEM in improving students' attitudes toward physical education learning, it is imperative to address the issue of model fidelity checks for both SEM and TT. The study highlighted the absence of a thorough examination of the model fidelity in certain investigations, which raises concerns about the reliability and validity of the observed improvements reported in both SEM and TT groups before and after the experiment. Future research should prioritize rigorous fidelity checks to enhance the credibility and interpretability of research findings when comparing the effectiveness of different instructional models.

Moreover, the identified divergent outcomes in some studies, including those with opposite positive and negative effects, as well as studies reporting exclusively negative affect, underscore the complexity of the relationship between instructional models and students' attitudes towards physical education. Therefore, future investigations should explore potential moderating variables, instructional nuances, or contextual influences contributing to such variations. This comprehensive approach will not only help refine our understanding of SEM's impact on attitudes but also aid in the selection of teaching models that align with the demands of contemporary times.

To optimize the study of SEM's influence on students' physical education learning attitudes, it is recommended to increase the number and frequency of interventions appropriately. Additionally, future research endeavors should consider demographic factors such as the gender and age of the students, contributing to a more nuanced understanding of SEM's impact across different populations. This continued exploration will not only verify the advantages of SEM in promoting students' physical education learning but also enrich the research outcomes concerning the influence of SEM on students' attitudes, addressing the identified gaps and fostering advancements in physical education pedagogy.

Availability of data and materials

The data set supporting the conclusions of this article is included within the article.

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Conceptualization, J.Z., K.G.S., and A.M.; methodology, J.Z., K.G.S., and A.M.; formal analysis, J.Z., K.G.S., and A.M.; investigation, J.Z., W.X., and X.B.; data curation, J.Z., L.B., and G.Y.; writing—original draft preparation, J.Z., K.G.S., A.M., and G.Y.; writing—review and editing, G.Y. All authors have read and agreed to the published version of the manuscript.

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Zhang, J., Xiao, W., Soh, K.G. et al. The effect of the Sport Education Model in physical education on student learning attitude: a systematic review. BMC Public Health 24 , 949 (2024). https://doi.org/10.1186/s12889-024-18243-0

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New Research Examines Physical Education in America

By Morgan Clennin, PhD, MPH, Kaiser Permanente of Colorado, University of South Carolina, and National Physical Activity Plan

School-based physical education (PE) is recommended by the Community Guide as an effective strategy to promote physical activity among youth. Unfortunately, many have speculated that PE exposure has declined precipitously among U.S. students in the past decade. Limited resources and budgets, prioritization of core academic subjects, and several other barriers have been cited as potential drivers of these claims. However, few large-scale studies have explored the merit of these claims – leaving the answers following questions unknown:

Has PE attendance decreased among U.S. students in the past decades?

What policies and practices are in place to support quality PE?

To answer these questions, the President’s Council on Sports, Fitness & Nutrition tasked the National Physical Activity Plan Alliance (NPAPA) to review the available evidence and summarize their findings. The primary objective of this effort was to better understand PE exposure over time to inform national recommendations and strategies for PE.

The NPAPA began by establishing a collaborative partnership with experts in the federal government, industry, and academia. The group analyzed existing national data sources that could be used to examine changes in PE attendance and current implementation of PE policies and practices. These efforts culminated in a final report and two peer-reviewed manuscripts. A summary of the group’s findings are outlined below.

Key Findings:

• 1/2 of U.S. high school students did not attend PE classes—which is consistent over the 24-year period studied (1991-2015).
• The percentage of U.S. high school students reporting PE attendance did not change significantly between 1991 and 2015 for the overall sample or across sex and race/ethnicity subgroup.
• Daily PE attendance did decrease 16% from 1991 to 1995 then attendance rates remained stable through 2015.
• > 65% of schools implemented 2-4 of the 7 essential PE policies
• Implementation of PE policies varied by region, metropolitan status, and school level.
• Data indicates minority students have been disproportionately affected by cuts to school PE programs during the past two decades.

Recommendations Based on Key Findings:

• Prioritize efforts to expand collection of surveillance data examining trends in PE attendance among elementary and middle school students.
• Develop policies to improve PE access for all students in order for PE to contribute to increased physical activity among youth.
• Adopt policies and programs that prioritize PE to maximize the benefits of PE.
• Utilize the findings of these efforts to target professional development and technical assistance for PE practitioners.

The Education sector of the NPAP provides evidence-based strategies and tactics that can guide efforts to support the provision of quality PE to all students. More information, and links to the respective manuscripts, can be found on the NPAPA website: http://physicalactivityplan.org/projects/physicaleducation.html

The Office of Disease Prevention and Health Promotion (ODPHP) cannot attest to the accuracy of a non-federal website.

Linking to a non-federal website does not constitute an endorsement by ODPHP or any of its employees of the sponsors or the information and products presented on the website.

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Physical Fitness Linked to Better Mental Health in Young People

A new study bolsters existing research suggesting that exercise can protect against anxiety, depression and attention challenges.

By Matt Richtel

Physical fitness among children and adolescents may protect against developing depressive symptoms, anxiety and attention deficit hyperactivity disorder, according to a study published on Monday in JAMA Pediatrics.

The study also found that better performance in cardiovascular activities, strength and muscular endurance were each associated with greater protection against such mental health conditions. The researchers deemed this linkage “dose-dependent,” suggesting that a child or adolescent who is more fit may be accordingly less likely to experience the onset of a mental health disorder.

These findings come amid a surge of mental health diagnoses among children and adolescents, in the United States and abroad, that have prompted efforts to understand and curb the problem.

The new study, conducted by researchers in Taiwan, compared data from two large data sets: the Taiwan National Student Fitness Tests, which measures student fitness performance in schools, and the National Insurance Research Databases, which records medical claims, diagnoses prescriptions and other medical information. The researchers did not have access to the students’ names but were able to use the anonymized data to compare the students’ physical fitness and mental health results.

The risk of mental health disorder was weighted against three metrics for physical fitness: cardio fitness, as measured by a student’s time in an 800-meter run; muscle endurance, indicated by the number of situps performed; and muscle power, measured by the standing broad jump.

Improved performance in each activity was linked with a lower risk of mental health disorder. For instance, a 30-second decrease in 800-meter time was associated, in girls, with a lower risk of anxiety, depression and A.D.H.D. In boys, it was associated with lower anxiety and risk of the disorder.

An increase of five situps per minute was associated with lower anxiety and risk of the disorder in boys, and with decreased risk of depression and anxiety in girls.

“These findings suggest the potential of cardiorespiratory and muscular fitness as protective factors in mitigating the onset of mental health disorders among children and adolescents,” the researchers wrote in the journal article.

Physical and mental health were already assumed to be linked , they added, but previous research had relied largely on questionnaires and self-reports, whereas the new study drew from independent assessments and objective standards.

The Big Picture

The surgeon general, Dr. Vivek H. Murthy, has called mental health “the defining public health crisis of our time,” and he has made adolescent mental health central to his mission. In 2021 he issued a rare public advisory on the topic. Statistics at the time revealed alarming trends: From 2001 to 2019, the suicide rate for Americans ages 10 to 19 rose 40 percent, and emergency visits related to self-harm rose 88 percent.

Some policymakers and researchers have blamed the sharp increase on the heavy use of social media, but research has been limited and the findings sometimes contradictory. Other experts theorize that heavy screen use has affected adolescent mental health by displacing sleep, exercise and in-person activity, all of which are considered vital to healthy development. The new study appeared to support the link between physical fitness and mental health.

“The finding underscores the need for further research into targeted physical fitness programs,” its authors concluded. Such programs, they added, “hold significant potential as primary preventative interventions against mental disorders in children and adolescents.”

Matt Richtel is a health and science reporter for The Times, based in Boulder, Colo. More about Matt Richtel

Understanding A.D.H.D.

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The disorder can put a strain on relationships. But there are ways to cope .

Though meditation can be beneficial to those with A.D.H.D., sitting still and focusing on breathing can be hard for them. These tips can help .

ORIGINAL RESEARCH article

Life satisfaction among spanish children and adolescents participating in physical education.

• 1 Facultad de Ciencias del Deporte, Universidad de Extremadura, Cáceres, Spain
• 2 Universidad de Las Americas, Chile, Santiago, Santiago Metropolitan Region (RM), Chile
• 3 Faculty of Sports Sciences, University of Extremadura, Cáceres, Spain

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Life satisfaction has been determined as a cognitive indicator of subjective wellbeing, a term that acquires vital relevance during adolescence as a protective factor against numerous psychological, mental and social disorders. Therefore, the objectives of this study are: 1) to evaluate differences in life satisfaction as a function of gender and school environment in Spanish children and adolescents; and 2) examine the possible associations between life satisfaction and age and/or body mass index (BMI) of the student body. For this purpose, a cross-sectional study was carried out with 723 students (aged 6 to 18 years) in which the "Satisfaction with life Scale" was applied, consisting of 5 items that measure self-perception of life satisfaction. Nonparametric statistics (Mann-Whitney U test) were used to explore differences in scores according to sex and school environment, in addition to Spearman's Rho test to identify associations between scale scores and students' age and BMI. Significant differences were obtained in terms of sex in favor of the male gender, and between the two environments of the centers in favor of the rural ones. In addition, the two variables explored (age and BMI) showed significant inverse associations with life satisfaction levels. Therefore, educational interventions and policies must take this information into account to design and develop actions aimed at improving this cognitive factor.

Keywords: life satisfaction, Adolescent, Children, Physical Education, Students, School

Received: 24 Jan 2024; Accepted: 03 May 2024.

Copyright: © 2024 Gómez-Paniagua, Castillo-Paredes, Galán Arroyo and Rojo-Ramos. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Antonio Castillo-Paredes, Universidad de Las Americas, Chile, Santiago, Santiago Metropolitan Region (RM), Chile Carmen Galán Arroyo, Faculty of Sports Sciences, University of Extremadura, Cáceres, Spain

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

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• Published: 01 May 2024

Low-cost otolaryngology simulation models for early-stage trainees: a scoping review

• Joselyne Nzisabira 1 , 2   na1 ,
• Sarah Nuss 1 , 3   na1 ,
• Estephanía Candelo 1 , 4 , 5 ,
• Ernest Aben Oumo 1 , 2 ,
• Keshav V. Shah 1 , 6 ,
• Eric K. Kim 1 , 7 ,
• Joshua Wiedermann 1 , 8 ,
• Ornella Masimbi 2 ,
• Natnael Shimelash 2 &
• Mary Jue Xu 1 , 7 , 9  

BMC Medical Education volume  24 , Article number:  483 ( 2024 ) Cite this article

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Metrics details

Medical simulation is essential for surgical training yet is often too expensive and inaccessible in low- and middle-income countries (LMICs). Furthermore, in otolaryngology-head and neck surgery (OHNS), while simulation training is often focused on senior residents and specialists, there is a critical need to target general practitioners who carry a significant load of OHNS care in countries with limited OHNS providers. This scoping review aims to describe affordable, effective OHNS simulation models for early-stage trainees and non-OHNS specialists in resource-limited settings and discuss gaps in the literature.

This scoping review followed the five stages of Arksey and O’Malley’s Scoping Review Methodology. Seven databases were used to search for articles. Included articles discussed physical models of the ear, nose, or throat described as “low-cost,” “cost-effective,” or defined as <$150 if explicitly stated; related to the management of common and emergent OHNS conditions; and geared towards undergraduate students, medical, dental, or nursing students, and/or early-level residents.

Of the 1706 studies screened, 17 met inclusion criteria. Most studies were conducted in HICs. Most models were low-fidelity (less anatomically realistic) models. The most common simulated skills were peritonsillar abscess aspiration and cricothyrotomy. Information on cost was limited, and locally sourced materials were infrequently mentioned. Simulations were evaluated using questionnaires and direct observation.

Low-cost simulation models can be beneficial for early medical trainees and students in LMICs, addressing resource constraints and improving skill acquisition. However, there is a notable lack of contextually relevant, locally developed, and cost-effective models. This study summarizes existing low-cost OHNS simulation models for early-stage trainees and highlights the need for additional locally sourced models. Further research is needed to assess the effectiveness and sustainability of these models.

Question: What is the current landscape of low-cost otolaryngology-head and neck surgery simulation for early medical trainees and students?

Finding: In this scoping review we identified 17 studies that met inclusion criteria. Most studies were developed in high-income countries, and most models were not locally sourced.

Meaning: There is a notable lack of low-cost OHNS simulation models that are relevant for early medical trainees and students.

Peer Review reports

Introduction

Medical simulation is a valuable component of training [ 1 ]. Historically, simulation usage has been predominantly centered in high-income countries (HICs). Consequently, there exists an opportunity to expand access to simulation education in low- and middle-income countries (LMICs) [ 2 , 3 ]. While low-cost simulation models have been explored in HICs, the specific models used in these settings may not be applicable to LMICs due to lacking the same resources. Studies have demonstrated that using locally sourced materials and readily available devices is cost-effective [ 4 ]. Furthermore, low-fidelity, or less anatomically realistic, simulation may confer similar benefits compared to high-fidelity, or highly anatomically realistic, simulation though with lower costs [ 5 , 6 ]. Despite the potential benefits of simulation in LMICs, there is limited literature, particularly for surgical specialties where workforce shortages, ethical considerations, and financial constraints limit opportunities for practice [ 7 ].

In otolaryngology-head and neck surgery (OHNS), simulation training has an opportunity to address the burden of disease centered in LMICs through training of general practitioners (GPs) and primary care providers in regions where subspecialists are limited. The burden of OHNS disease is high, with 1.5 billion people worldwide experiencing hearing loss, primarily in LMICs [ 8 ]. Paradoxically, low-income countries have 50 times fewer OHNS providers than high income countries [ 9 ]. Given the burden of OHNS disease far outweighs the current number of providers, it is imperative to train primary healthcare provider to help increase access to essential OHNS care. Simulation is a central component of many HIC OHNS training programs [ 10 , 11 , 12 , 13 ], [ 14 ], ; however, many models are largely directed at the skill set of senior residents and physicians. Given that primary care providers such as GPs in LMICs may be the first or only providers available in rural or first-level hospitals, the opportunity to develop skills that are critical for managing OHNS emergencies and common conditions is essential to developing confidence and preventing morbidity and mortality.

To address the gap in simulation models for primary care practitioners in common and emergent OHNS conditions, this scoping review aims to describe and evaluate available low-cost OHNS simulation models geared toward early-stage medical trainees or GPs.

Study design

Given limited and heterogenous literature, a scoping review was selected and conducted in February 2023 in accordance with Arksey and O’Malley’s Scoping Review Methodology and following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Extension for Scoping Reviews Guidelines [ 15 , 16 ]. The search strategy aimed to address the research question regarding the outcomes of using low-cost OHNS simulation models for early-stage trainees in education.

Literature search

A search strategy was developed to capture the maximal results, which included the main search concepts of “simulation,” “otolaryngology,” “education,” and “low cost.” These terms were combined using Boolean operators OR (within critical constructed concepts) and AND (between key concepts). The specific search strategy was adapted to each data base. The search was conducted in the following databases: PubMed, MEDLINE, EBSCO, Scopus, Science Direct, CINAHL, EMBASE, and Web of Science (Supplemental Table 1 ).

Inclusion criteria included studies of any language that discussed the development or implementation of a physical model of the ear, nose, or throat that were explicitly described as “low-cost,” “cost-effective,” or defined as <$150 if explicitly stated related to the care or management of OHNS conditions (operative or non-operative). Models were only considered if they were applicable for training of undergraduate students, medical, dental, or nursing students, and/or early-level residents, and we excluded simulations that would not be applicable to a GP (i.e., advanced OHNS resident level skills). Original research of any study type was included. Letters to the editor, abstracts, systematic reviews, virtual reality simulations, electronic simulations, and studies that utilized mannequin models were not included.

The study team completed a primary title and abstract screening using a Covidence database (Veritas Health Innovation Ltd, Melbourne) based on the search criteria. Two reviewers each independently screened the titles and abstracts of all identified articles for relevance to the research question. A third independent reviewer resolved disagreements over article eligibility. In the full-text review, data was extracted and recorded following the Arksey and O’Malley’s “descriptive-analytical” approach for data extraction, and the information was summarized from selected articles on an Excel spreadsheet [ 15 ]. At least two authors reviewed extracted data from the included articles. A third reviewer resoled any remaining conflicts. Snowball sampling was used to identify gray literature from study reference lists.

Statistical analysis

Outcomes included study characteristics (authors, year, language, journal of publication, study design), context (study country, target population) simulation details (specialty of simulation model, cost, fidelity of model, materials used, local sourcing of materials, condition being simulated), and model evaluation (evaluation of surgical skill and efficacy of model). Summary statistics were performed using Microsoft Excel. Categorical variables were presented as counts and percentages n(%). There were no continuous data.

The initial search returned 3355 studies. After 1649 duplicates were removed, 1706 studies underwent title and abstract screening. Of these, 1607 were excluded. Ninety studies were screened for full text review based on inclusion and exclusion criteria. Seventy-four studies met inclusion criteria (Fig.  1 ). Table  1 provides an overview of the included low-cost simulation models for essential OHNS conditions.

PRISMA Flow diagram of data analysis procedure

Characteristics of studies

Of the studies examined, 82% ( n  = 14) of studies were conducted in HICs, and the majority were conducted in the United States or in the United Kingdom (Fig.  2 ). 94% ( n  = 16) of the studies utilized a cross-sectional study design. Most articles targeted general OHNS care ( n  = 8, 47%). 35% ( n  = 6) of the models were low-fidelity models (less anatomically realistic). The characteristics of the studies are summarized in Table  2 . Simulation fidelity was assessed using the Simulation Fidelity (SiFi) scale, a validated 6-point scale to describe simulation fidelity across five domains, with scores of 0–1 meaning low-fidelity, 2–3 meaning medium fidelity, and 4–5 meaning high fidelity (Table  3 ) [ 17 ].

Global distribution of Low-Cost ENT Simulation Model Studies

Reflexivity Statement

This scoping review emerged from collaborative work within the Global OHNS Initiative involving LMIC and HIC researchers. This piece was written to promote more accessible and equitable avenues to education and training for LMIC researchers. Our authorship group consists of five LMIC authors and five HIC authors. Five of the ten authors are women. All authors contributed substantially to the conception, drafting, and revision of this piece. All authors approved the final version. Everyone has agreed to be accountable for all aspects of the work, aligning with ICJME Authorship Criteria

The most common simulated skills were peritonsillar abscess aspiration ( n  = 6, 35%), cricothyrotomy ( n  = 4, 24%), myringotomy with tube placement ( n  = 2, 12%), and other ear models (2, 12%). Nasal packing ( n  = 1, 6%), auricular hematoma ( n  = 1, 6%), and tracheostomy care ( n  = 1, 6%) were also included.

One (6%) study was geared towards medical students, eight (47%) towards residents, two (12%) towards both medical students and residents, one (6%) towards nurses, one towards anesthesia students, and one (6%) towards paramedics. Out of the eight resident-focused models, three were geared towards emergency medicine residents. Two (12%) models were geared towards attendings or consultants, and both models were included given the models’ transferability to simulate other more basic skills.

Eleven (65%) models reported a dollar value associated with their model. The average price per model was $52.00 USD (range: $10 - $150). Prices were all converted directly to USD and were standardized to a 2024 estimated cost. The remaining models were described as “low-cost” by authors without specific information about the cost of the materials. Fifteen (88%) studies reported using locally sourced materials. Model reusability is reported in Table  1 .

Simulation evaluation

Sixteen (94%) studies assessed model efficacy. Models were evaluated using both questionnaires ( n  = 8, 47%), direct observation of skills ( n  = 4, 24%), or both ( n  = 4, 24%). Three of the eight studies that included direct observation (38%) used video monitoring to evaluate clinical skill. Participant questionnaires included a variety of themes such as participants’ comfort with the skill, model realism, ease of use, and participant confidence performing the skill.

Given the substantial burden of OHNS disease worldwide and current limited OHNS workforce, simulation training tools tailored for primary care providers are critical in developing OHNS knowledge and skills to increase access to OHNS care globally [ 8 , 9 ]. Existing low-cost OHNS simulations primarily target residents and consultants and can often overlook the essential skill set required by GPs [ 18 , 19 ]. These skills encompass emergent and common OHNS conditions such as epistaxis, emergent surgical airway, and ear and nose foreign body removal. Equipping medical students and early-trainees with basic OHNS care skills is vital. This type of task shifting can alleviate delays in care, transportation challenges, and alleviate the burden on tertiary centers.

This is the first study to evaluate low-cost OHNS simulations tailored to GPs and early-trainee education, emphasizing locally sourced models. The low number of studies identified in this review highlights that simulations addressing the skill set of early trainees and primary care providers is an area for future educational research depending on regional needs and resource availability. Our findings describe the available low-cost simulations in OHNS and highlights insufficient availability of such models. Future work should focus on developing additional low-cost, contextually appropriate models to bridge gaps in healthcare training and delivery in resource-constrained settings.

A variety of approaches have been employed to develop low-cost OHNS simulation models. For instance, studies such as those by Chudek et al. (2021, UK) and Taylor et al. (2014, USA) utilized inexpensive materials like latex gloves, custard, and latex moulage for simulating peritonsillar abscess aspiration [ 1 , 2 ]. These models offer a cost-effective solution for training primary care providers in essential procedures.

Conversely, studies such as Bright et al. (2021, India) and Bhalla et al. (2021, UK) employed thermoplastic ray cast and cork as materials for nasopharyngeal swabbing and peritonsillar abscess aspiration simulations, respectively [ 3 , 4 ]. While these models may have slightly higher initial costs, their reusable components contribute to long-term cost-effectiveness and sustainability.

Moreover, innovative approaches were seen in studies like Botto et al. (2019, Italy) and Ozkaya Senuren et al. (2020, Turkey), where wooden tablets and sheep trachea were utilized for cricothyrotomy simulations [ 5 , 6 ]. These models demonstrate adaptability to local resources and highlight the potential for contextually appropriate simulation solutions.

In terms of dissemination and implementation, workshops, online resources, and collaborative initiatives with local healthcare organizations could facilitate the adoption of these low-cost simulation models. By sharing detailed instructions and training materials, such as those provided by Molin et al. (2020, USA), the reach and impact of these models can be expanded to benefit primary care providers in diverse settings [ 7 ].

Simulated medical models have proven highly effective in imparting essential OHNS procedure skills and can provide an important avenue to improve surgical training in resource constrained environments. However, our data show that most low-cost simulation models ( n  = 14, 82%) are developed and utilized in HIC, which aligns with prior studies that report a lack of locally developed low-cost simulations in LMIC contexts [ 7 ]. Furthermore, many “low-cost” simulation models rely on high-cost materials such as 3D printers or specialized mannequins, which may not be available in LMICs. When considering model sustainability and applicability of these models in LMICs, it is important to recognize the limitations of certain high-fidelity models in such resource-constrained environments. Prior studies demonstrate that low fidelity simulation models do not necessarily lead to worse skill outcomes, which emphasizes the potential of low-cost, less intricate models as valuable tools for skill acquisition [ 5 , 20 ].

A previous systematic review of low-cost simulations in OHNS identified 18 studies on low-cost ENT simulations [ 14 ]. However, only five of these simulations were relevant to GPs as shown in Table  4 . In contrast, our study included 17 simulations directly applicable to GPs. There is potential for expanding the range, reach, and applications of existing models. Most of the models in our study focused on peritonsillar abscess simulations, which may not always fall within a GP’s scope of practice. Future efforts should focus on exploring simulation models that use locally sourced materials and align with the skill requirements of primary care providers in LMICs. Specifically, investigations into simple yet effective simulation approaches, such as task trainers or hybrid models incorporating both physical and virtual elements, could be prioritized to address the diverse educational needs and resource constraints in these settings. Specifically, more models focusing on skills like epistaxis management and nasal/ear foreign body removal are essential to address common conditions encountered by primary care providers in LMICs.

Additionally, several of the existing models could be adapted for a broader set of GP-level skills, such as using ear models for foreign body removal and cerumen management, in addition to myringotomy. There is also a clear need for alternatives to animal models, which can be harder to procure or reuse, leading to higher operation and maintenance costs. Additionally, most models in this study did not explore the use of locally sourced materials. Collaborating with LMICs to adapt models to utilize locally available materials is an essential next step to enhance accessibility and effectiveness. Finally, our study identified heterogeneity in evaluations of the efficacy of these simulations in augmenting the knowledge, skills, and confidence of GPs. This suggests that future research should incorporate standardized metrics that evaluate educational utility of low-cost OHNS simulations.

Our study has several limitations. Not all the studies we included provided exact cost information for the simulations, which, if available, could have contributed to our understanding of the cost-effectiveness of these models. Reusability of the models was reported, however not incorporated into the cost calculation. We also did not independently evaluate fidelity and instead relied on fidelity assessments as reported by the authors for the scope of this study. Furthermore, excluding studies involving 3D printing or mannequins might have resulted in overlooking potentially useful insights regarding the development and components of these models. As 3D printing technology becomes more affordable, cost and access may not be a barrier in the future, opening exciting possibilities for its integration into future research studies and innovations across various fields. Additionally, a notable portion of the studies reviewed did not compare efficacy directly to high-fidelity models, highlighting the need for further research regarding the effectiveness of these simulations.

Low-cost, locally sourced OHNS simulations for GPs, early trainees, and students hold immense promise in LMICs. This tailored simulation-based training not only addresses the financial constraints faced by educational institutions but also considers local factors, including the local burden of OHNS diseases, available resources, hospital infrastructure, and the distinct roles and responsibilities of GPs in these settings. By conducting country-specific studies, these simulations could offer a practical and sustainable solution to enhance OHNS knowledge and skills among primary care providers, ultimately improving healthcare delivery and patient outcomes. Our scoping identified a range of potential simulation models that hold promise for replication in LMICs, along with crucial gaps that warrant exploration for the development of contextually relevant, low-cost models.

Data availability

The papers used to extract data for this manuscript are all publicly available on one of the following platforms: PubMed, MEDLINE, EBSCO, Scopus, Science Direct, CINAHL, EMBASE, and Web of Science.

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Acknowledgements

The authors would like to thank the Global Otolaryngology-Head and Neck Initiative for facilitating this collaboration. We would like to thank Chris Wen, John Bukuru, Patrick Balungwe, Nabin Lageju, and Tianzeng Chen for their contributions to reviewing the manuscript.

SRN is supported by the Fogarty International Center and National Institute of Mental Health, of the National Institutes of Health under Award Number D43 TW010543. This study is a part the study funded by NIH grant number NIH/FIC- 5R21HD103052-02. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Joselyne Nzisabira and Sarah Nuss contributed equally to this work.

Authors and Affiliations

Global Otolaryngology-Head and Neck Surgery (OHNS) Initiative, Durham, NC, USA

Joselyne Nzisabira, Sarah Nuss, Estephanía Candelo, Ernest Aben Oumo, Keshav V. Shah, Eric K. Kim, Joshua Wiedermann & Mary Jue Xu

School of Medicine, University of Global Health Equity, Butaro, Rwanda

Joselyne Nzisabira, Ernest Aben Oumo, Ornella Masimbi & Natnael Shimelash

Brown University Warren Alpert Medical School, Providence, RI, USA

Fundación Valle del Lili, Cali, Colombia

Estephanía Candelo

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Florida, Jacksonville, FL, USA

Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

Keshav V. Shah

Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, USA

Eric K. Kim & Mary Jue Xu

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic , Rochester, USA

Joshua Wiedermann

National Clinician Scholars Program, University of California, San Francisco, USA

Mary Jue Xu

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JN contributed to the study design, team management, data extraction, data analysis, manuscript writing, and final manuscript review SN contributed to the study design, team management, data extraction, data analysis, manuscript writing, and final manuscript review EC contributed to the data extraction, data analysis, manuscript revisions, and final manuscript review EAO contributed to the data extraction, data analysis, manuscript revisions, and final manuscript reviewKVS contributed to the data extraction, data analysis, manuscript revisions, and final manuscript reviewEKK contributed to the data extraction, data analysis, manuscript revisions, and final manuscript reviewJW contributed to the project oversight, data interpretation, manuscript revisions, and final manuscript reviewOM contributed to the study conception, study design, project oversight, data interpretation, manuscript revisions, and final manuscript review NS contributed to the study conception, study design, project oversight, data extraction, data interpretation, manuscript revisions, and final manuscript reviewMJX contributed to the study conception, study design, project oversight, data interpretation, manuscript revisions, and final manuscript review.

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Nzisabira, J., Nuss, S., Candelo, E. et al. Low-cost otolaryngology simulation models for early-stage trainees: a scoping review. BMC Med Educ 24 , 483 (2024). https://doi.org/10.1186/s12909-024-05466-3

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‘Nothing About Us, Without Us’: Research Priorities for Autistic Girls, Women and Gender Diverse People in Australia

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• Rachel Grove   ORCID: orcid.org/0000-0001-6669-9385 1 ,
• Hayley Clapham 1 ,
• Tess Moodie 1 ,
• Sarah Gurrin 1 &
• Gabrielle Hall 1  

Autistic girls, women and gender diverse people have specific needs that are underrepresented in research. Research priorities are often established by funding bodies, researchers, parents, carers and health professionals and may not meet the needs of the diverse Autistic community. This co-produced project aimed to identify what research would benefit the lives of Autistic girls, women and gender diverse people in Australia. We interviewed 47 Autistic girls, women and gender diverse people aged seven and above and obtained feedback from an additional 411 Autistic people through an online survey. Autistic young people identified six key research priorities including (1) better understanding and support at school, (2) understanding our experiences, strengths and challenges, (3) autism specific mental health support, (4) Autistic friendships and relationships, (5) experiences of gender diversity and (6) accommodations to make life easier for us. Eight key research priority areas were identified by Autistic adults including (1) understanding and supporting specific needs in adulthood, (2) experiences of trauma, abuse and sexual violence, (3) supporting mental health and wellbeing, (4) addressing barriers in healthcare, (5) understanding and supporting physical health needs, (6) addressing barriers in education and the workplace, (7) understanding the role of society, embracing neurodiversity and the importance of Autistic identity and (8) co-designing research and supports with Autistic people. We provide a discussion around the importance of focusing on these research priority areas in future autism research in Australia.

Community Summary

This study was led by Autistic people. It aimed to develop research areas that are important to Autistic girls, women and gender diverse people aged seven and above in Australia. Autistic people aged between 7 and 17 identified six research areas they thought were important. These included being understood and supported at school, understanding their strengths and challenges, receiving mental health support, Autistic friendships and relationships, experiences of gender diversity and accommodations to make life easier for Autistic young people. Eight research areas were identified by Autistic adults, including understanding and supporting their needs in adulthood, experiences of trauma, abuse and sexual violence, supporting mental health and wellbeing, addressing barriers in healthcare, education and the workplace, understanding and supporting physical health needs, understanding the role of society, embracing neurodiversity and Autistic identity and co-designing research and supports with Autistic people.

Avoid common mistakes on your manuscript.

Introduction

Autistic people are calling for research that is driven by the Autistic community, aligned with the disability rights principle of ‘nothing about us without us’. Despite this, research priorities have historically been dictated by funding bodies or the non-autistic research community, and often do not correspond with the needs of Autistic people (Pellicano et al., 2014 ). A recent study outlined that, similar to the UK, Canada and the US, the majority of funding in Australia is allocated to biological research, rather than to topics that have been identified as important to the Autistic and autism communities Footnote 1 , such as supports and services (den Houting & Pellicano, 2019 ). In addition, priorities for autism research have often been set by parents, carers, health professionals and researchers. While there have been some recent attempts to engage the Autistic and autism communities in developing research priority areas in the US (Frazier et al., 2018 ), the UK (Cusack & Sterry, 2016 ; Pellicano et al., 2014 ), New Zealand (Emerson et al., 2023 ) and Australia (Australian Autism Research Council, 2019 ; Clark et al., 2022 ; Gatfield et al., 2016 ), Autistic people make up a small minority of the samples included in this research. This ranges from 7% in the UK, 9% in the US, to between 20% and 40% in some Australian and New Zealand studies. The number of Autistic people in this research has increased over time, with the most recent update by the Australasian Autism Research Council (AARC) conducting focus groups in which 60% of the participants were Autistic adults (AARC, 2021 ). However, there is no research to date that has developed research priorities based solely on the perspectives of Autistic adults (Chown et al., 2023 ). In addition, the needs of Autistic young people are often represented by proxies such as parents, carers or health professionals. While these are valuable perspectives, we need to empower young Autistic people to determine what research they think will benefit their lives.

Autistic people with intersectional identities also have unique experiences and specific needs that should be identified, addressed and prioritised in research. Autistic girls and women experience higher rates of mental and physical health conditions (Kassee et al., 2020 ; Tint et al., 2023 ), sexual violence (Cazalis et al., 2022 ) and have specific sexual and reproductive health needs (Graham Holmes et al., 2022 ). There is also evidence that Autistic women report higher rates of emergency department visits, hospitalisations, family doctor and neurologist visits than Autistic men (Tint et al., 2023 ), despite experiencing additional barriers to accessing these services. Almost 80% of the Autistic people who completed the AARC 2019 consultation on autism research priorities identified the need for research focused on women and girls, highlighting the need for more research in this area. Trans and gender diverse Autistic people also experience additional health inequities, including greater disparities in mental and physical health conditions (Wallisch et al., 2023 ), more unmet health needs (Wallisch et al., 2023 ) and a lack of access to gender-affirming care (Bruce et al., 2023 ; Strauss et al., 2021 ). There is a significant lack of research into the needs of Autistic gender diverse people, with research tending to focus on prevalence rates rather than on their research and support needs. It is imperative to understand the nature and impact of the inequity experienced by Autistic gender diverse people, and include their experiences, needs and priorities in research (Gratton et al., 2023 ).

Autistic academics are calling for the inclusion of Autistic people as partners in research, rather than just as research participants (Chown et al., 2017 ; den Houting, 2019 ). Participatory research engages, consults, co-produces and supports community-led and community controlled research with the Autistic community (den Houting, 2021 ). In this project, we used participatory research principles to co-produce research priorities for Autistic girls, women and gender diverse people in Australia. Co-production involves researchers and community members working together as equal partners from the beginning of the research process to develop a research question, design and implement a research project (den Houting, 2021 ). It is also critical to ensure that power and control over the project is shared by both researchers and community members (den Houting, 2021 ). This co-produced project asked Autistic girls, women and gender diverse people aged seven and above about what research would benefit their lives. This included cisgender girls and women, transgender, non-binary, gender diverse people and anyone who was socialised or identified as a woman or girl. We used the term gender diverse within this project to fit with the recommendations outlined by the United Nations (United Nations Office of the High Commissioner for Human Rights, 2023 ) and the Victorian Government ( 2021 ) in Australia. We acknowledge that language in this space is dynamic and are always open to feedback from the community on what language is appropriate and inclusive. This project aimed to identify separate research priorities for Autistic adults and Autistic young people, to account for their unique perspectives and needs.

Community Involvement

This project was led by a group of Autistic women (HC, SG, GH) and gender diverse (TM) adults working with a non-autistic researcher (RG). Regular meetings with all members of the research team occurred prior to the initial stages of the research, to develop the research questions, methodology and funding proposal. All Autistic members of the research team were paid for their time and an Autistic research assistant (GH) was employed to conduct the interviews. During the data collection phase, regular meetings occurred between GH and RG, with the broader team meeting frequently to discuss the transcripts generated as part of the qualitative data collection phase, leading to the development of the draft themes and subthemes. The research team then developed the online questionnaire to be utilised in stage two of the project, assisted with recruitment and advertising the project, and met frequently to discuss and develop the final set of research priorities. RG led the writing of the manuscript, with all members providing significant input into the quotes selected for inclusion. All authors made a significant contribution to the final manuscript. The whole research team were also involved in the dissemination of the research priorities through the development of a video, webpage and webinar ( https://www.uts.edu.au/autistic-women-and-girls-research-priorities ). These participatory methods were used to ensure that this research was informed by lived experience, to ensure that the questions and results were interpreted from an Autistic perspective and are meaningful and relevant to the Autistic community.

The project was conducted in two stages. Semi-structured interviews were completed, followed by an online survey. Decisions to structure the project in this way were made by the Autistic members of the research team. This was to ensure that we were able to capture rich data through the qualitative interviews and develop research priorities from the experiences of Autistic girls, women and gender diverse people, rather than imposing a pre-determined set of priorities for feedback as part of an online survey. We also used this methodology to ensure that we were able to obtain this information directly from Autistic young people, rather than through a proxy. Recruitment for both stages of the project was completed online, with the project advertised on social media through peak autism and disability organisations across Australia. We included Autistic girls, women and gender diverse people aged seven and above, who were currently living in Australia. We included Autistic people with either a formal diagnosis or who self-identified as Autistic. This is due to the reported barriers to accessing a diagnosis, including costs, the complexity of the healthcare system, as well as stigma, and a lack of support from health professionals (Huang et al., 2020 ; Lewis, 2017 ). It was important that self-identifying Autistic people were included in this research to ensure that we did not preference the needs of Autistic people who are able to access a diagnosis. Cisgender Autistic men were excluded from the project.

Stage 1: Semi-Structured Interviews

Semi-structured interviews were completed with 47 Autistic girls, women and gender diverse people. All interviews were conducted by an Autistic woman (GH). Sensory and communication needs were supported throughout this process, and everyone was invited to complete the interview in the way that suited them best, including over text, email, phone, or via video, audio, or the chat function on zoom. Young people were invited to have a parent or carer with them at any stage of the interview. However, we aimed to hear from young people individually where possible, to gain their direct perspectives. During the interviews, we asked a series of open-ended questions related to diagnosis, self-identification, day to day experiences, support, and research topics. These open-ended questions were provided to the interviewees prior to their interview, so that they had time to reflect on, or prepare their answers. Interviews were video and audio recorded, and then transcribed verbatim. The transcribed interviews were sent to each interviewee, to provide them with the opportunity to amend or add additional information. The interviewees were also asked to complete a short online background questionnaire that asked for demographic information, as well as about co-occurring conditions, employment and education.

Stage 2: Online Survey

The second stage of the project obtained additional feedback from 411 Autistic girls, women and gender diverse people on the draft research priorities that were identified separately for adults and young people during stage one. Autistic girls and gender diverse young people aged 7 to 17 were asked to rate each of the six draft priority areas on a three-point scale from ‘very important’, ‘a little important’ to ‘not important’. They were then asked to choose the two most important subtopics under each research priority heading. Autistic women and gender diverse adults (>= 18 years) were asked to rate the eleven draft research priority areas from most (1) to least (11) important. They were then asked to select the top three subtopics under each priority area. An open text field also enabled Autistic adults to identify any other research priority areas that they felt were important. A short background questionnaire was completed to obtain demographic information, as well as details about co-occurring conditions, employment and education.

Participants

We interviewed 16 Autistic girls and gender diverse young people aged between 8 and 17 (Mean = 12, SD = 3). All the Autistic young people we interviewed were formally diagnosed as Autistic, with an age of diagnosis between 4 and 14 years (Mean = 8, SD = 3). 19% of these Autistic young people identified as non-binary and 94% were from a White European background. All the Autistic young people we interviewed used spoken communication and 13% reported an intellectual disability. Co-occurring mental health conditions were reported by 75%, and 56% reported one or more physical health condition.

Interviews were completed with 31 Autistic women and gender diverse adults aged between 21 and 63 (Mean = 39, SD = 12). Age of formal identification ranged between 3 and 55 years (Mean = 33, SD = 13). 17% of the adults we interviewed self-identified as Autistic, with age of self-identification ranging from 21 to 49 years (Mean = 34, SD = 11). The majority (77%) of the Autistic adults we interviewed were from a White European background, with 3% identifying as Aboriginal or Torres Strait Islander. A large proportion (70%) were in paid employment, 63% had completed a university degree and all used spoken communication. 40% of the Autistic adults we interviewed were parents, 50% of whom had Autistic children. Physical health conditions were reported by 63%, with 83% reporting one or more co-occurring mental health condition.

The online survey was completed by 81 Autistic girls and gender diverse young people, aged between 7 and 17 (Mean = 12, SD = 3). Most had received a formal diagnosis between the ages of 3 and 17 (Mean = 10, SD = 4), with 6% self-identifying as Autistic (Range = 12 to 16 years, Mean = 14, SD = 2). 37% of the Autistic young people we surveyed identified as gender diverse, 1% reported a co-occurring intellectual disability and 5% were non-speaking. One or more co-occurring mental health conditions were reported by 82% of Autistic young people, with 32% reporting one or more physical health condition. A large proportion (72%) were from a White European background, with 5% identifying as Aboriginal or Torres Strait Islander.

330 Autistic women and gender diverse adults aged between 18 to 71 (Mean = 36, SD = 11) completed the online survey. Age of formal identification ranged between 3 and 69 years (Mean = 32, SD = 12), with 22% of the adults we surveyed self-identifying as Autistic (Range = 12 to 60; Mean = 35, SD = 11). 20% were gender diverse, 2% reported an intellectual disability and 1% were non-speaking. More than half (54%) had completed a university degree and 67% were currently employed. Of the 48% of Autistic parents who completed the survey, 59% also had Autistic children. Most of the Autistic adults we surveyed (86%) were from a White European background, with 3% Aboriginal and Torres Strait Islander peoples included in the data. Co-occurring mental health conditions were reported by 91%, with 51% reporting one or more co-occurring physical health condition.

Data Analysis

The interview data was analysed using Braun and Clarke’s ( 2006 , 2019 ) method for reflexive thematic analysis. This method was able to capture both semantic and latent meanings within the data, as well as provide both descriptive and interpretative accounts. The data was conceptualised within the social model of disability (Oliver, 1983 ) and analysed using a social ecological lens, which conceptualises health as impacted by individual, interpersonal, community, policy and societal factors (Bronfenbrenner, 1989 ; McLeroy et al., 1988 ). Themes were developed using an inductive, or bottom up, approach. This involved identifying shared patterns of meaning within the interview transcripts. The data analysis was informed by the backgrounds and experiences of the team members, including training in psychology (RG and SG), disability advocacy (HC, GH and TM), nursing (GH) and gender-based violence (TM). RG listened to the audio of each interview twice. The transcripts were then coded based on the direct information that was provided within each individual interview. These codes were reviewed by GH and the other Autistic members of the research team (HC, TM and SG) and the data was coded again prior to the themes being identified. This process was iterative, and the themes were discussed and refined over multiple meetings with the research team. The themes were then developed into research priorities based on their shared meaning. This was done separately for Autistic adults and Autistic young people. Eleven draft research priorities were identified for Autistic women and gender diverse adults, including subtopics under each of these priority areas (total of 65 subtopics). Six draft research priority areas were identified for Autistic girls and gender diverse young people, including 28 subtopics. These draft research priority areas are outlined in Table  1 .

The online survey data for Autistic adults was ranked from one to eleven, with the subtopics under each priority area ranked according to how often they were selected as one of the top three subtopics. Following this, the research team discussed any areas where the research priority areas and subtopics overlapped, and these were combined. While completing this process, it was ensured that the top three priorities under each draft priority area were retained within the final set of research priorities for Autistic women and gender diverse people. The additional comments provided by the Autistic adults who responded to the survey were also reviewed to identify any additional areas of research that were not included in the initial draft priority areas. These were discussed by the research team to determine if there was sufficient consensus to include them, and those identified were then included as subtopics where appropriate. A similar process was followed for the online survey data for Autistic girls and gender diverse young people. However, this was also undertaken in consultation with an Autistic young person, who assisted with finalising the research priority areas for Autistic young people. This process resulted in six final research priorities for Autistic girls and gender diverse young people, including 26 subtopics (see Fig.  1 ). Eight priority areas were identified for Autistic women and gender diverse adults, including 35 subtopics (see Fig.  2 ).

Table  2 provides demographic information for the interview and survey data. Additional details about co-occurring physical and mental health conditions are provided in Table  3 .

Research Priorities for Autistic Girls and Gender Diverse Young People

Autistic girls and gender diverse young people identified six key research priority areas that would benefit their lives. These are outlined in Fig.  1 .

Research priorities for Autistic girls and gender diverse young people

Better Understanding and Support at School

The first research priority area identified by Autistic girls and gender diverse young people is related to the need for an increased understanding of their learning experiences, including “that I learn differently to all the other students” (YP14). Autistic young people also spoke about the challenges that arise from being in an environment that often is not responsive, accepting or accommodating to their diverse learning needs:

Schools… should improve a bit on how much the teachers know about autism in general and neurodivergence, ADHD, all these different things. Because it’s very common and schools aren’t always set up to help these kids. I think there could be quite a lot of improvement in the education system (YP7).

There is also a need for teaching staff to respond to the needs of their Autistic students, particularly related to stimming and self-regulation. This includes understanding the impact of sensory sensitives in the classroom related to hearing “all the different conversations all at once and it’s highly overwhelming and you can’t focus in on one that you might need to be listening to” (YP16).

Additional research subtopics included understanding experiences of bullying, as well as research focused on how to provide a better understanding of Autistic girls and gender diverse young people in the education system:

The fact that I can be in a school system where I don’t receive the support I need because I’m not visibly struggling. I think there needs to be more awareness spread of how autism looks and that it’s not a little mould that someone can fit into (YP16).

Understanding our Experiences, Strengths and Challenges

The second research priority area outlines the need to understand and support both the strengths and challenges experienced by Autistic girls and gender diverse young people. This includes research to better understand experiences of puberty and what it is “going to actually do to the rest of my life” (YP2), as well as “the physical conditions that come along with [being Autistic]” (YP4). There is also a need for research focused on understanding and supporting sensory differences, self-regulation needs and “that stimming and stuff makes me happy” (YP6). The impact of gender roles and stereotypes on Autistic girls and gender diverse young people was also noted to be important:

I was a bit confused about all this stuff because I didn’t really see representation of an Autistic person that looked or acted like me, a girl, a teenager, all of these things (YP7).

Autistic girls and gender diverse young people also highlighted their incredible strengths, including “my ability to accept people for who they are. I think I’m a very genuine person and I can see people… what they might be struggling with and what strength they might have” (YP16) and “I’m very funny and I like helping people” (YP8). This highlighted the importance of recognising strengths such as compassion and wanting to help others, alongside the challenges experienced by Autistic girls and gender diverse young people.

Autism Specific Mental Health Support

Autistic girls and gender diverse young people identified the need for research focused on how to better support their mental health. This includes further understanding their experiences of misdiagnosis and the impact of masking:

Our desire to fit that mould means we do mask a lot of ourselves and we do hide who we truly are to try and fit that. I think becoming yourself is a big journey that takes a lot of work and a lot of self-acceptance that we so badly want to fit that neurotypical mould that when we realise that we can’t, there’s a lot of mental juggling that we have to do (YP16).

Autistic girls and gender diverse young people also outlined the need for research to understand their experiences of burnout and the impacts of “constantly trying to fit in with everyone and having no idea, and I would have massive burnouts and that just depleted me” (YP9). Mental health was also impacted by society through “a pattern of Autistic people, girls in particular, crashing in their early teens... because of having to deal with increased social pressures” (YP7). Autistic girls and gender diverse young people are asking for critical research into how to adapt mental health supports to meet their needs.

Autistic Friendships and Relationships

The fourth research priority area focuses on the need to better understand social experiences, connections and relationships. This includes understanding how “I can get very stressed with too much social stuff, which is hard because I’m actually a very social person… If I spend a lot of time with people I have to take a few days to recover” (YP7). Autistic girls and gender diverse young people also identified the need to understand their communication differences such as finding it “difficult to know when to reply and when not to speak” (YP5) and experiences of feeling “like [we] don’t belong” (YP3). This priority area also highlighted the importance of Autistic friendships and connections with other Autistic people and how “thinking that I wasn’t the only one… made me feel a lot better” (YP8).

Experiences of Gender Diversity

There is a need for research that focuses on understanding “the relationship between autism and gender diversity and the challenges of an Autistic person in understanding gender” (YPS4). Autistic girls and gender diverse young people emphasised the importance of approaching this research from a place of acceptance of gender diversity, with the need to “focus on support first” (YP7), rather than trying to understand why Autistic people may not identify with their gender assigned at birth or the gender binary. It is critical that future research is conducted in partnership with young Autistic gender diverse people, to ensure that research priorities or recommendations for supporting Autistic gender diverse young people are inclusive and appropriate.

Accommodations to Make Life Easier for Us

The final research priority area identified the need for research focused on “how we can make life easier” (YP13) for Autistic young people. This was related to both research and advocacy, and the need for “charities focused on actual support for Autistic people” (YP7). Autistic girls and gender diverse young people also highlighted the need for the re-evaluation of the current diagnostic process to ensure they are identified earlier. As one young person told us:

I spent years struggling in school until I mentally broke. I think this is an issue that needs to be addressed. Why does it take so long to help Autistic females? Why do we have to be mentally exhausted? (YPS6).

Autistic girls and gender diverse young people also identified the importance of challenging how society views autism and the need for acceptance from broader society, but also within research, as “a lot of people misunderstand [us]… even researchers usually misunderstand [us] and treat [us] like babies” (YP4). Research focused on “more regional” (YP1) access, support “for the rest of my life” and concerns that “when I get older, how is it going to change their reaction to me being Autistic” (YP2) is also needed. Autistic girls and gender diverse young people also highlighted the importance of “including Autistic people in the conversation” (YP7) when it comes to research, and the importance of Autistic identity as “something that you should be teaching to other Autistic girls, that it’s nothing to be ashamed of. If anything, it’s something to be proud of” (YP12).

Research Priorities for Autistic Women and Gender Diverse Adults

Figure 2 outlines the final research priority areas identified by Autistic women and gender diverse people.

Research priorities for Autistic women and gender diverse adults

Understanding and Supporting Specific Needs in Adulthood

The first research priority area identified the need for understanding autism across the lifespan. The Autistic women and gender diverse people we spoke to reported that the accommodations provided are based “around children… there’s nothing for adults” (AD30) and that “it’s like once you’re out of nappies no one’s interested…No one wants to know about an Autistic adult” (AD15). Autistic women and gender diverse people also identified the need for research to understand the impact of day-to-day challenges such as “adulting… cooking, cleaning, organising paying the bills” (AD2) and for this to be linked to funding and support. Research also needs to focus on understanding the sensory experiences of Autistic women and gender diverse people, including how “women are more sensory orientated, that we have more sensory needs than men” (AD14), and the impacts of “taking all [the] senses in” (AD11). It is also important to consider the “sensory aspect” of “having my period each month” (AD2) and the need for funding bodies to accommodate the need for “simple things like sensory clothing; you can get underpants and socks, but you can’t buy bras” (AD30).

Additional subtopics identified under this priority area were related to understanding intimate relationships and friendships, including the importance of “having someone I can be safe with” (AD25) and “how you actually participate in a physical sexual relationship if you have lots of sensory issues” (AD1). There is also a significant lack of research focused on Autistic adult’s experiences of housing and financial instability. One Autistic adult spoke about their experience of being in an assisted living facility and how “this space that I’m in I’m made to feel like it’s not mine and how I choose to have it is not okay” (AD5). Finally, Autistic women and gender diverse people identified the need for research to understand their experiences of being a parent, as “everything around parenting and autism seems to be focused on parents of [Autistic] children, not [Autistic] parents” (AD20).

Experiences of Trauma, Abuse and Sexual Violence

The second research priority area identified by Autistic women and gender diverse people highlights the importance of understanding the experiences and impacts of being “forced into these situations that are traumatic” (AD16) and “how to avoid the continual pattern of repeated trauma in Autistic women’s lives” (AD19). This includes research on sexual violence, to understand their experiences of being “sexually assaulted by someone I thought I trusted” (AD27), “instances of assault from my male peers” (AD4) and that “teenage girls that are Autistic would be highly susceptible to being taken advantage of” (AD30). There is also a need to understand abusive relationships and the impacts of being “financially abused, I was emotionally abused. I was gaslighted” (AD22). Abuse and trauma need to be considered not only within interpersonal relationships, but also within systems and society, to better understand the supports that Autistic women and gender diverse people need. Some examples provided within this study were related to the child protection system and being “scared of having my daughter taken away from me” (AD8) and accessing funding for support:

How do you prove child abuse? How do you prove spousal abuse, when nobody believed you at the time?… The whole system is intrusive and abusive (AD22).

The impacts of “abuse of various types combined with autism caused incredible trauma. Complex repetitive trauma” (AD10) highlights the urgent need for research focused on how to prevent violence against Autistic women and gender diverse people and provide trauma informed care and support. This is critical for gender diverse Autistic people, who experience higher rates of discrimination and gender-based violence.

Supporting Mental Health and Wellbeing

Autistic women and gender diverse people identified the need for research that focuses on supporting their mental health and wellbeing. It is important to understand mental health and wellbeing within the context of gender roles and neuro-normative expectations in society, and “feeling that you have to really fit in… a square hole when you’re a round peg” (AD9). The Autistic women and gender diverse people we spoke to described the significant impacts of fitting with these societal expectations on their mental health, including on meltdowns and shutdowns, and the need for these to be better understood:

It’s a nightmare. It’s constant stress. I have a meltdown nearly every single day (AD12).

This was also related to “a lot of… burnout moments” and “a few stints in the mental health system because of that” (AD26). These experiences also highlighted the need for research to understand the impacts of misdiagnosis of “personality disorders. Things that I felt didn’t really fit” (AD13), that were “completely just wrong” (AD10) and being “placed through a lot of trauma… saying I was depressed, I was this” (AD28). This was sometimes associated with receiving harmful care such as being “heavily… inappropriately drugged” (AD10), as well as inappropriate treatment that failed to consider the impact of sensory differences:

I have had years of [Cognitive Behaviour Therapy]… all that sort of therapy has never worked. And they didn’t take into account when I mentioned, the lights are so bright in the shops and the noise is too much… I was always told that was anxiety. No, it’s not anxiety, it’s actually sensory overload (AD13).

Autistic women and gender diverse people are calling for research that focuses on co-designing therapeutic supports and for current therapeutic approaches to be adapted to meet their needs. This is critical to ensure that Autistic people are not “stuck for 20 odd years in the mental health system. Because it breaks you” (AD13). There is also a need to develop Autistic-led and co-produced models of wellbeing to understand “how to help Autistic people have a good life on their own terms” (AD7). Research also needs to consider the experiences and needs of Autistic women and gender diverse people with high support needs who “do not have the privilege of being able to mask my autism” (ADS1). These differing experiences need to be incorporated into research and support programs for Autistic adults.

Addressing Barriers in Healthcare

Further research is needed to identify and address the barriers and health inequities experienced by Autistic women and gender diverse people within the health care system. This includes understanding their experiences of navigating, accessing and receiving medical care. There is a significant need to increase health professionals’ understanding of autism, to meet the needs of their Autistic patients and improve the quality of and provision of healthcare. This includes understanding the presentation of autism in girls, women and gender diverse people, to ensure “that the GP is going to know about autism in women and not just think that it’s a thing for little boys with behavioural problems” (AD29). There is also a need for research into how to provide education for health professionals. As one Autistic adult stated:

They are not seeing it, they are not taught it. I don’t believe they have the education… I feel that’s a big area that needs somehow needs changing (AD13).

Autistic women and gender diverse people identified the need for research that addresses the barriers they experience being a “woman with a disability trying to navigate the healthcare system” (AD17) including “dealing with doctors and going into hospital… bright lights, people running in and out” (AD16). Others described the need to address the impacts of the “patriarchal nature of medicine” (AD17), as well as common experiences of gaslighting and not feeling understood or supported by healthcare professionals. As one autistic adult described:

I’ve had these diseases for nine years now… That’s nine years of the same specialist. And really it’s only been in the last couple of years that he’s starting to listen to some of the things that I say (AD15).

Research needs to then identify how to tackle these barriers, not only at the individual or interpersonal level, but from a whole system perspective through making changes within society and policy. This includes addressing additional barriers such as “being regional. The local area doesn’t seem to have the resources, medically, mental health wise or anything, to support people” (AD22). It is also critical to understand the healthcare experiences of Autistic people with high support needs who “have been denied medical and mental health care because of my level of autism” (ADS1).

Understanding and Supporting Physical Health Needs

In addition to addressing these barriers in healthcare, Autistic women and gender diverse people also identified the need for research that focuses on recognising and supporting their physical health needs. This includes a better understanding of their experiences of ageing and “how as I age my body is going to change and I don’t know what’s going to happen because there is no long-term research” (AD28). Research also needs to focus on specific experiences of physical health such as having different “presentations in my diseases… the textbooks don’t agree with” (AD15), as well as the impacts of having multiple chronic health conditions; “if I start reeling off my health problems, I would need another 45 minutes, and that’s if I just name the conditions” (AD12). It is critical for research focused on the specific physical health conditions that Autistic women and gender diverse people may be more likely to experience, such as being “super hypermobile” (AD26) and having “chronic pain” (AD19). In addition, this priority area outlines the need for research focused on how to support the sexual and reproductive health needs of Autistic women and gender diverse people, including pregnancy and “childbirth as an Autistic person” (AD16). There is also a need to better understand the impact of “puberty and anything to do with menstruation” (AD10) and experiences of menopause; “we hit menopause… and our whole sensory system goes offline, and restructures itself” (AD14).

Addressing Barriers in Education and the Workplace

The sixth research priority area identified the need for research within the higher education system and the workplace to further understand the barriers and gaps that currently exist within these environments. Specific research areas include understanding experiences of learning and education and the impact this has on Autistic women and gender diverse people. As one Autistic adult described:

The education system is structured to fail these girls, to fail these women, and it goes on even after diagnosis… continually pigeoning us into these ideals of the way that we have to be… Constantly punished for being awesome, for being opiniated, for thinking outside the square, and actually having a very different view of the world (AD28).

Research into the support needs of Autistic women and gender diverse people within the education system, including experiences of not receiving “much support or understanding of anything, other than you can get an extension” (AD21) and the importance of providing teachers “with information about their students’ disabilities” so they can “better support their students” (AD2) is also required. The voices of Autistic people with high support needs also need to be included in this research, to address the harms that they often experience such as “seclusion and restraint in education settings” (ADS1).

Subtopics related to employment identified the need to better understand barriers to employment, including that “the interview process that you go through to get a job is not Autistic-friendly at all” (AD30). Others also described stereotypes as an additional barrier to employment, including how some employers “commonly advertise [for] a very specific kind of Autistic person”:

It always seems to be the very data, analytical, puzzle loving guy… advertising, researching and understanding only those sort of Autistic people, is leaving behind all kinds of people who aren’t like that… I end up feeling like, if I’m not that kind of person, is there any upside to my own ‘autism’ within a job? I also wonder how many other girls out there feel the same way (AD21).

Autistic women and gender diverse people are calling for research into how best to provide education to both teachers and employers. This is particularly relevant not only for new teachers, but also for “educating teachers or people of a generation who are about sixty and up… or people who have that cookie-cutter mindset of what autism is” (AD18). There is also a need for research into how to make learning environments and workplaces more accessible and supportive for Autistic women and gender diverse people. As one Autistic adult stated:

The infrastructure isn’t there or the education isn’t there… It really is a massive issue of equality and equity, and I feel like I’m always just hanging onto my job, and the only way I can do it is to play the part (AD9).

Understanding the Role of Society, Embracing Neurodiversity and the Importance of Autistic Identity

Autistic women and gender diverse people identified the need for research related to providing a better understanding of the role of society in shaping their experiences:

I think when it comes to Autistic girls, the message is given to us… you have to be polite. You have to do this and hug your uncle… do all the right social niceties. It’s a stronger message to girls (AD22).

This research priority also includes understanding the impacts of “adapting to meet other people’s needs” (AD14), the need for “more understanding of the differences in communication styles” (AD12) and social preferences of Autistic people and how “all of those social and sensory interactions take [their] toll” (AD1). Research into the intersection between gender roles and social expectations on masking and mental health is also critical. The Autistic women and gender diverse people we spoke to described feeling the need to mask their gender identity, “accumulated a very thick mask even once I knew that trans people were a thing” (AD5) and the impacts of having “spent my whole life masking” on “my mental health, and even my physical health” (AD19).

There is a need to embrace neurodiversity as the framework by which we celebrate, accept and support Autistic people and their way of being to provide “a broader understanding of the rich tapestry of Autistic people” (AD6). Research also needs to focus on “how you assist Autistic people [to] deconstruct a life that was constructed by neurotypicals. And then use a different framework to actually allow them to construct a life that’s actually based on their values” (AD6). Furthermore, there is a need to focus on the important role that Autistic identity, community and culture play in the wellbeing of Autistic people. The importance of fostering Autistic community was described by one Autistic adult:

I feel like that needs to be part of the diagnosis process… don’t teach them how to socialise with neurotypical people…Take them into groups of Autistic people where they can be themselves and be accepted and loved for who they are… Because this is your people (AD7).

Another Autistic adult spoke about the importance of recognising the strengths of Autistic young people and supporting them to flourish:

I think these girls, these strengths and these brains need to be embraced and utilised. I look at … these brilliant, brilliant human beings… I wished that I had those tools, and that I was allowed to thrive and to be who I am when I was that young (AD28).

Co-Designing Research and Supports with Autistic People

The final priority area identified by Autistic women and gender diverse people focuses on the need for Autistic people to be a fundamental part of the design process when it comes to autism research and supports. While the other seven research priorities indicate the topics that should be prioritised, this final research priority identifies the way in which this research should be conducted. Research “from the Autistic perspective” (AD14) is critical to develop research and support programs that are meaningful and relevant for Autistic women and gender diverse people. This research needs to be informed by the perspectives of all Autistic people, including non-speaking Autistic people, Autistic people with an intellectual disability and “Autistic women with very high support needs” (ADS3). It is also crucial for future research to identify research topics that are important to, and benefit, Autistic women and gender diverse people from diverse and marginalised backgrounds. The different experiences of Autistic people from migrant backgrounds was highlighted by one Autistic adult:

[Autistic] migrant women… are made to feel that any differences are due to race or culture… that’s one of the main reasons why I didn’t get diagnosed till I was 55…. Any differences, you tend to put this cultural interpretation… social difficulties are interpreted as cultural behaviour or lack of English (AD8).

This study aimed to develop key research areas that will benefit the lives of Autistic girls, women and gender diverse people in Australia. A number of the research priority areas correlate with some of those identified in previous research in Australia, including health and wellbeing, education, employment, service delivery, gender, diversity and inclusion (AARC, 2019 , 2021 ). However, we identified the unique experiences, perspectives and needs of Autistic girls, women and gender diverse people within these priority areas. This included the impacts of specific factors such as gender roles, stereotypes of autism and neuro-normative expectations for Autistic girls, women and gender diverse people. These societal factors need to be considered within any research related to health and wellbeing, given their impact on burnout, misdiagnosis, mental and physical health. In addition, we identified the need to understand the specific physical health needs of this community, by identifying commonly occurring physical health conditions they experience, as well as how to support their sexual and reproductive health needs. There were also additional barriers identified specifically for Autistic women and gender diverse adults related to navigating the healthcare system, including not being understood by health professionals and incidents of gaslighting, or being made to question their own experiences or perceptions. Research in this area is particularly important for Autistic gender diverse people, who report more barriers to accessing gender-affirming care (Strauss et al., 2021 ).

There were also several additional priority areas that were identified by Autistic girls, women and gender diverse people in our study. Autistic adults identified the need for research focused on trauma, abuse and sexual violence. This includes understanding the risk factors for, and experiences of abuse and sexual violence within intimate partner and family relationships. While the current study did not focus on quantifying these experiences, our findings add to the emerging literature on Autistic people’s experiences of interpersonal and sexual violence (Cazalis et al., 2022 ; Gibbs et al., 2021 ; Gibbs & Pellicano, 2023 ) and outline a clear need for research in this area. According to the Australian Bureau of Statistics (ABS), approximately 11% of the Australian population are diagnosed with Posttraumatic Stress Disorder (PTSD) in their lifetime, increasing to 14% for women aged between 16 and 85 (ABS, 2020 ). However, our sample reported a substantially higher prevalence, with up to 40% of Autistic adults and 12% of young Autistic people reporting a diagnosis of PTSD. Gender diverse people also experience higher rates of verbal, physical, sexual and intimate partner violence than cisgender people (Callander et al., 2019 ; Hill et al., 2020 ; Yerke & DeFeo, 2016 ). These disparities underscore the importance of trauma-informed research and supports tailored for Autistic women and gender diverse people. Autistic women and gender diverse people also identified research priorities related to supporting their specific needs in adulthood, including day-to-day domestic tasks, the experiences and needs of Autistic parents, as well as research related to housing and financial instability. While these areas are under researched, there is some emerging literature focusing on Autistic parents (Gore et al., 2023 ; Heyworth et al., 2022 ), as well as experiences of homelessness amongst Autistic people (Garratt & Flaherty, 2021 ). Our findings highlight the need for additional research focused on how to support the specific needs of Autistic women and gender diverse people in these areas.

This is the first study to identify specific research priorities for Autistic girls and gender diverse young people. Our findings highlight that Autistic young people want to be part of the research that has an impact on their lives. Young people identified the need for research to support them within the education system, as well as to understand their physical and mental health needs. Gender roles, stereotypes and social pressures were also shown to significantly impact on Autistic girls and gender diverse young people, highlighting the need to consider the intersection of autism and gender identity within research and clinical practice. One of the key priority areas identified by Autistic girls and gender diverse young people was related to understanding the support needs of young gender diverse Autistic people. While this was identified by Autistic adults as important, this was highlighted as a critical area of need for Autistic young people in this study. This may be due to the increasing social awareness of gender diversity and legal protections for the rights of gender diverse people that young people are more likely to have been exposed to compared with the Autistic adults we interviewed. However, it also reflects the mismatch between the limited research in this area that often focuses on understanding the prevalence of Autistic people who may identify as gender diverse, rather than on their needs (Corbett et al., 2022 ). It is imperative for research focused on how to support Autistic gender diverse young people in healthcare, education and all facets of society. Working in partnership with Autistic gender diverse people is critical, to design research that is inclusive of this community.

There were several priority areas that were identified by both Autistic adults and young people. The first of these is related to mental health and wellbeing. This is not surprising, given the very high rates of mental health conditions reported by the Autistic girls, women and gender diverse people we spoke to, which ranged from 75 to 82% for Autistic young people and between 83 and 91% for Autistic adults. This is in stark contrast to the rates identified within the wider Australian population, with 45% of women aged between 16 and 85 (ABS, 2020 ) and approximately 13% of girls aged between 12 and 17 (Australian Institute of Health and Welfare, 2021 ) experiencing a mental health condition in their lifetime. In addition, young gender diverse Autistic people report higher rates of mental health conditions compared with non-autistic gender diverse people (Strauss et al., 2021 ), indicating the need for additional support. However, it is important to note that the high rates outlined in our study may also reflect the misdiagnosis noted by the Autistic girls, women and gender diverse people in this research, something which we did not specifically capture in this study. Autistic girls, women and gender diverse people outlined how traditional therapeutic supports had not worked well for them in the past, and the need for mental health supports to be adapted to meet their needs. They also described the need for research that focuses on how gender norms and expectations impact on masking, burnout and mental health. This is particularly important for gender diverse Autistic people, who experience additional stigma (Maroney & Horne, 2022 ) and higher rates of mental health conditions (Wallisch et al., 2023 ). Our findings highlight the need to provide education to health professionals to enable them to better support both the mental and physical health needs of Autistic girls, women and gender diverse people.

Autistic adults and young people also described their experiences of feeling misunderstood or mistreated by researchers and the importance of including “Autistic people in the conversation” (YP7) within research projects and teams. Both Autistic adults and young people identified clear priorities related to how autism research should be conducted, through the co-design of both research and supports with Autistic people. This is critical to ensure that research meets the needs of the Autistic community. Our findings are consistent with recent research conducted in New Zealand, that identified the importance of lived experience in research, as well as the need to include the perspectives of Autistic people with a diverse range of support needs (Emerson et al., 2023 ). We need to identify research areas that are important to Autistic people from diverse and marginalised backgrounds in Australia, as well as prioritise the perspectives of Aboriginal and Torres Strait Islander peoples, non-speaking Autistic people and those with intellectual disability and high support needs. To achieve this, we recommend including a diverse range of Autistic people as active members in research teams, to ensure that our research reflects the full diversity of the Autistic community in Australia.

Our research emphasises the importance of breaking down stereotypes and embracing neurodiversity both within research and in society, and supporting Autistic identity, community and culture to enhance wellbeing (Botha et al., 2022 ; Cooper et al., 2021 ; Ferenc et al., 2022 ). There is also a need to focus not only on the challenges experienced by Autistic girls, women and gender diverse people, but also on their strengths. We need to approach autism research using a gendered lens, socio-ecological model (Bronfenbrenner, 1989 ), underpinned by the neurodiversity paradigm (Pellicano & Houting, 2022 ) and social model of disability (Kim, 2021 ) to shift the focus from the individual, to understanding the interrelated influences of various factors at interpersonal, community and societal levels.

Recommendations for Educators, Employers and Healthcare Professionals

There are valuable ways that the education, employment and healthcare sector can begin to make changes to better support the needs of Autistic girls, women and gender diverse people. This starts by listening to, learning from and sharing decision making power with Autistic people. Practical strategies include making an investment to ensure all staff have undertaken training in how to best support Autistic people within each of these sectors. Ideally this training should be neurodiversity-affirming, and developed and delivered by Autistic people. Healthcare services can make a commitment to establishing consumer groups for Autistic women, girls and gender diverse people, to provide valuable insight into how their practices and services can be more inclusive and accessible, including making environments sensory friendly and adapting communication techniques to capture the diversity of communication styles in the Autistic community. Mandatory training in trauma-informed practice is critical, given the prevalence of abuse and violence towards Autistic women, girls and gender diverse people. Work accommodation plans tailored to the needs of Autistic employees need to be provided to make the workplace more accessible, including support for flexible working arrangements. This also needs to be accompanied by sensory friendly workplaces, schools and tertiary institutions that meet the sensory needs of Autistic girls, women and gender diverse people. This includes quiet spaces for Autistic students to access whenever they need to. These spaces will not only support Autistic people, but also make these environments more accessible for everyone. In addition, it is critical that Autistic students have access to counsellors, psychologists and social workers who have experience in supporting the needs of Autistic girls, women and gender diverse people in an educational setting.

At an individual level, it is also important for researchers, educators, employers and healthcare professionals to think about how they can better engage with, listen to and learn from Autistic people. This might include attending professional development run by Autistic people, or reading literature written by Autistic authors. It is also important to engage in self-reflection to identify gaps in knowledge and areas where individual competence can be enhanced. This process of reflection and learning is ongoing, as no two Autistic people are the same and the needs of each individual Autistic student, employee or patient must be understood. Creating a safe space where Autistic girls, women and gender diverse people are supported to communicate, learn, interact and process in their own way is paramount. This means being open to doing things differently and being led by the Autistic person. It is imperative that all sectors commit to ongoing learning about autism, and more specifically the experiences of Autistic women, girls and gender diverse people. Removing stereotypical assumptions and stigma is foundational to ensuring that Autistic women and girls can flourish in employment, education and be better supported to access mental and physical healthcare.

Limitations

This research includes the perspectives of Autistic girls, women and gender diverse people in Australia and may not reflect the research priorities of Autistic people worldwide, particularly in non-Western and lower and middle income countries. In addition, the people we spoke to were predominantly from a White European background, had received a diagnosis later in life, had a high level of education and were employed. While we captured a more diverse range of people in our survey, we need to ensure that we include the perspectives of all Autistic people in research, including Autistic people with intellectual disability, high support needs, complex communication needs and from marginalised backgrounds. Within this research project we were unable to reflect this diversity in the way that we wanted to from the outset, and left parts of the Autistic community feeling “invisible” (AS1). Without the inclusion of all Autistic people, we will remain firmly in our “echo chamber of privilege” (Reframing Autism, 2021 ) within autism research, only hearing the perspectives of the same select few. We as a research community need to look at how and why we are still failing Autistic people through not including their perspectives in our research. This includes ensuring that we correct the imbalance of power and shift the concept of ‘autism experts’ from researchers to Autistic people themselves. We also need to identify how research teams are doing this well, and be open to changing our research methods to ensure that they are accessible and inclusive, to capture the experiences and meet the needs of all Autistic people.

Conclusions

This study highlighted key research areas for Autistic girls, women and gender diverse people in Australia. We are making a direct call to action by asking autism researchers to focus on these key priority areas and ensure that this research is Autistic-led or authentically co-produced (Grove et al., 2022 ). We need researchers to start listening to and working with Autistic people on the research priorities that are meaningful to them, and that will have a direct and positive impact throughout their lives. Focusing on the research priority areas identified in our study will lead to a better understanding of the experiences, perceptions and needs of Autistic girls, women and gender diverse people in Australia, which will positively impact their health and wellbeing, quality of life, and access to supports and services.

Data Availability

Given the sensitive nature of the information contained in this data, it is not available to be shared.

We refer to the Autistic and autism communities in this publication The Autistic community is made up of Autistic people. The autism community includes non-autistic people who are connected to Autistic people in various ways, including as allies, family members and people who support or regularly work with Autistic people. We also capitalise the word Autistic in this publication, to acknowledge the culture and community associated with Autistic identity. This is similar to the use of capitalisation within the Deaf community.

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Acknowledgements

We would like to acknowledge and express our gratitude to all the Autistic people who gave their time and told their stories to contribute to this research. We would also like to acknowledge prior members of the Autistic advisory group who were involved in the initial development of this project. We would also like to thank Violet for contributing to the development of the research priorities for Autistic young people.

This project was funded by a University of Technology Sydney (UTS) Chancellor’s Fellowship and a UTS Social Impact grant.

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All authors contributed to the study conception and design, including the research questions and methodology. Preparation of materials, data collection and analysis were performed by all authors. Qualitative interviews were completed by Gabrielle Hall. The first draft of the manuscript was written by Rachel Grove and all authors contributed to subsequent versions of the manuscript. All authors read and approved the final manuscript.

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This study was performed in line with the principles of the Declaration of Helsinki. Ethics approval was received from the Human Research Ethics Committees of the University of Technology Sydney (UTS) on the 10/03/2020: UTS HREC REF NO - ETH19-4538.

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Written informed consent was obtained from all Autistic girls, women and gender diverse people included in the study.

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Grove, R., Clapham, H., Moodie, T. et al. ‘Nothing About Us, Without Us’: Research Priorities for Autistic Girls, Women and Gender Diverse People in Australia. J Autism Dev Disord (2024). https://doi.org/10.1007/s10803-024-06330-5

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