literature review about extracurricular activities

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• Published: 01 September 2020

Not everything helps the same for everyone: relevance of extracurricular activities for academic achievement

• Álvaro Balaguer   ORCID: orcid.org/0000-0002-8727-4690 1 ,
• Edgar Benítez   ORCID: orcid.org/0000-0001-7632-5109 2 ,
• Aranzazu Albertos   ORCID: orcid.org/0000-0002-3590-8364 1 &
• Sonia Lara 1  

Humanities and Social Sciences Communications volume  7 , Article number:  79 ( 2020 ) Cite this article

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Participation in organized Extracurricular Activities has contributed to improve academic achievement. However, this does not happen in the same way; it depends on sex, age, or parental educational level. Our objective is to know the importance of these factor interactions’ in the explanation of academic achievement. The sample consisted of 1148 adolescents, aged between 12 and 18 years, 52% of whom were female. Participants completed the Extracurricular Activities questionnaire, and academic and sociodemographic data were collected. The results show that differences in academic achievement depend on the adolescent stage. In early adolescence, girls improve in academic achievement, as well as with better parental education, reading of books and activity duration. On the contrary, in the middle and late adolescence, academic achievement improves with not participating in collective sports and reduced activity breadth, although parental educational level follows the same trend as in the early adolescence. These results reinforce the evolutionary hypothesis of specialization in the choice of activities throughout adolescence. In this sense, some proposals for schools that advocate for greater integration of curricular and non-curricular elements are discussed.

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Introduction

The class “extracurricular activities” (EA) constitutes a positive youth developmental asset (Durlak et al., 2010 ; Eccles and Gootman, 2002 ; Eisman et al., 2016 ; Farb and Matjasko, 2012 ; Mueller et al., 2011 ) and covers a broad range of categories that share some essential elements (Hansen et al., 2010 ). Indeed, competent adults supervise these activities, which often involve peer interaction. They also have regular attendance schedules, offer practical learning opportunities and enable young people to spend time engaged in their own interests (Hansen and Larson, 2007 ).

EA does not form part of the school curriculum and, unlike formal education, student participation is voluntary. Adolescents often develop meaningful relationships with their peers and their instructors. This fact creates an appropriate context in which to develop identity, initiative, and social skills (Hirsch et al., 2011 ; Larson et al., 2006 ). These aspects help in theorizing about organized activities and contribute to different processes of adolescent development.

Moreover, investigations of the types of activities that involve youth in their free time have identify the relevant components that promote positive development in supervised/structured environments or, specifically, in extracurricular programs or activities. Positive youth development programs incorporate manifold elements that promote such development, with importance directed toward adult–adolescent relationships that tend to involve young people over time (Roth et al., 1998 ).

Type of activity

Studies of different types of EA address various development experiences (Eccles and Gootman, 2002 ), such as sports, performing arts, service clubs, and faith-based youth groups (Vandell et al., 2015 ). Research shows differences between sports and artistic EA, based on the results they promote in youth (Hansen et al., 2003 ; Im et al., 2016 ). Thus, evidence shows that artistic activities improve adolescent adjustment, as well as the participants’ self-knowledge, self-discipline, and artistic talents (Hansen et al., 2003 ).

Sports EA not only prevent risk behaviors, but also improve the social and academic abilities of youth (Darling, 2005 ). However, collective sports contribute to a lower level of academic, social, or preventive skills promotion than other types of EA (Hansen et al., 2010 ; Wilson et al., 2010 ).

Bartko and Eccles ( 2003 ) classify adolescents very involved in sports, spending more time with friends, and performing other EA in different groups, with high participation rates in school clubs, tasks, and reading for pleasure. For Im et al. ( 2016 ), participation in sports and artistic activities predicts an increase of self-efficacy in academic competence, so EA provides a context in which students can face and overcome challenges and increase the level of their skill, thus building trust.

Based on the approach of Mahoney et al. ( 2005 ), Reading books for pleasure would not be an organized extracurricular activity. In fact,

“these activities are generally voluntary, have regular and scheduled meetings, maintain developmentally based expectations and rules for participants in the activity setting (and sometimes beyond it), involve several participants, offer supervision and guidance from adults, and are organized around developing particular skills and achieving goals” (Mahoney et al., 2005 , p. 4).

Nonetheless, Reading books it is very relevant for youth development, relating to greater participation in a wider breadth of activities, as well as greater engagement in both extracurricular and curricular tasks (Bartko and Eccles, 2003 ).

Activity engagement

For EA to function as more effective assets requires youth engagement (Weiss et al., 2005 ) though factors such as breadth, intensity and duration (Bohnert et al., 2010 ; Busseri and Rose-Krasnor, 2009 ; Busseri et al., 2006 ). The benefits of participation in EA, both in the curricular field and in the personal development of the young person, depend on the characteristics of their participation experience. In turn, such experiences depend on their engagement, whether psychological (e.g. duration) or behavioral (e.g. breadth, intensity). However, a consensus on the conceptualization of participation should specify the aspects of behavioral and psychological engagement (Eisman et al., 2016 ).

Breadth of activities

Breadth refers to the number of EA that involve youth. The study of Breadth provides a broad description of the range of student skills and interests (Bohnert et al., 2010 ; Busseri and Rose-Krasnor, 2009 ; Busseri et al., 2006 ; Linver et al., 2009 ).

The range of activities refers to the participation in different activities in a certain period and may refer to the total number of activities in which a young person engages (Busseri and Rose-Krasnor, 2009 ) or the total number of different types of activities (Eccles and Barber, 1999 ). Contrary to participation in a single activity, a wide range of participation allows young people greater diversity of learning experiences, supportive interactions with adults, and broad networks of peers (Bohnert et al., 2010 ; Eccles and Barber, 1999 ; Vandell et al., 2015 ).

Duration of activities

The duration or consistency of participation in EA refers to the maintenance over time. “Dosage has been conceptualized in terms of consistency and continuity over time, measured as the proportion of periods in which youth engage in activities” (Pierce et al., 2013 ; in Vandell et al., 2015 ).

Longitudinal studies have measured consistency of participation among both elementary and middle-school children (see National Institute of Child Health and Human Development Early Child Care Research Network, 2004 ; Pierce et al., 2013 ) and in adolescents (see Mahoney et al., 2003 ; Zaff et al., 2003 ). The participation in EA over the years could increase the benefits for youth development, as a result of greater exposure to such opportunities (Eisman et al., 2016 ; Tudge et al., 2009 ).

Differences in adolescents’ activity participation

Sex differences in adolescents’ activity participation.

Sex relates to participation in EA, with girls showing more behavioral engagement in EA except in sports (Denault and Poulin, 2009b ; Eccles et al., 2003 ; Kleiner et al., 2004 ). Indeed, boys are more likely than girls to participate in sports, while girls are more likely than boys to participate in classes and clubs (Kleiner et al., 2004 ) or artistic EA (Luthar et al., 2006 ). The impact of EA on positive development is higher for boys (Pierce et al., 2010 ; Urban et al., 2009 ). No evidence indicates differences in participation according to sex, rather than age (Eisman et al., 2016 ). In any case, evidence of gender-related differences in the effects of EA is scarce.

Regarding risk behaviors, according to Eccles et al. ( 2003 ), participation in a competition sports team in late adolescence for both sexes is associated with higher alcohol consumption, the opposite of participation in artistic activities.

Stage differences in adolescents’ activity participation

Eisman et al. ( 2016 ) argue that the stage of development of the young person determines the importance of each type of engagement. In early adolescence, people tend to participate in a wider range of EA. Indeed, the breadth of participation could be more relevant in early adolescence than in late adolescence, because exploring different interests and strengthening bonds with peers characterizes early adolescence (Bohnert et al., 2010 ; Busseri and Rose-Krasnor, 2009 ). Also, as mentioned, the breadth of participation enables more learning opportunities and broader networks with different groups of peers and supportive adults (Vandell et al., 2015 ).

The young persons’ persistence in an activity depends on different factors, such as the activity itself, personal characteristics, and interests, and other environmental aspects, such as family circumstances, peers, and school or community characteristics (Vandell et al., 2015 ). Accordingly, as progress is made in developmental stages, adolescents develop greater control over their use of time (Fredricks and Eccles, 2010 ) and refine their personal interests. Consequently, in middle-to-late adolescence, young people participate in fewer activities, but with more intensity (Busseri et al., 2006 ; Denault and Poulin, 2009a ) and interest.

Indeed, leaving a type of activity may reflect the progression of development. Thereby, young people begin testing different EA, then focus on a smaller number of them as their interests become more defined (Badura et al., 2016 ; Rose-Krasnor et al., 2006 ), ranging from participating in a wide range of activities to a small number over time (Denault and Poulin, 2009a ; Eccles and Barber, 1999 ; Rose-Krasnor et al., 2006 ). In fact, participation in EA cannot change throughout adolescence (Eisman et al., 2016 ; Zaff et al., 2003 ) or change constantly along this stage (Farb and Matjasko, 2012 ), despite disagreements about whether such participation increases (Mahoney et al., 2003 ) or decreases (Denault and Poulin, 2009b ).

Parental education level differences in adolescents’ activity participation

Taking account of the context in which young people live is essential to understand the characteristics of their participation in EA. Research on differences in participation have been focus more in terms of socioeconomic factors (Luthar et al., 2006 ; Pedersen, 2005 ; Quinn, 1999 ;Vandell et al., 2015 ) than in differences related to parental education (Kingdon et al., 2017 ).

Parental education level is associated with participation in EA, in that youth whose parents have a higher educational level tend to participate more in activities than those whose parents have lower educational levels (Bartko and Eccles, 2003 ; Eisman et al., 2016 ; Feldman and Matjasko, 2007 ; Linver et al., 2009 ; Vandell et al., 2015 ), and parental education level also predicts their children’s duration in activities (Eisman et al., 2016 ).

EA associations with academic achievement

The relationship between participation in EA and improvements in academic achievement have been extensively studied. How adolescents decide to manage their free time is a protective factor related to academic achievement in higher grades, as well as to recovering from low GPAs (Eccles et al., 2003 ; Linver et al., 2009 ; Peck et al., 2008 ; Roth et al., 2010 ).

Participation in EA also relates to furthering the adolescent’s permanence in the educational system by improving their behavior and school attendance (Simpkins et al., 2004 ). Participation in EA improves other relevant aspects of curricular success, such as lower school dropout rates (Mahoney, 2000 ) and the school climate, in terms of associations with friendship and prosocial behavior with peers, as well as less aggressive behavior toward them (Eccles and Templeton, 2002 ).

Participants in sports activities experience lower academic achievement than those who participate in artistic activities (Eccles et al., 2003 ). Reading books is a protective factor in preventing school failure, and it improves academic achievement in early (Kingdon et al., 2017 ) and late adolescence (e.g. Horbec, 2012 ; Whitten et al., 2019 ). Adolescents reading books during their extracurricular schedule has been related to higher academic aspirations (McGaha and Fitzpatrick, 2010 ). Conversely, lack of reading has been related to difficulties in the transition to college (Rubin, 2008 ).

Most of the research that associating EA with academic achievement shows the latter as an outcome that participation improves (Eisman et al., 2016 ; Linver et al., 2009 ). Although both breadth and duration have been related to academic achievement (Palma et al., 2014 ), behavioral engagement (i.e. breadth) shows more predictive ability (Barber et al., 2005 ; Eisman et al., 2016 ; Fredricks and Eccles, 2006 ). However, duration—evaluated as consistent participation in a wide range of EA—has also predicted higher grades and academic achievement in studies that control for sex and parental education (Darling et al., 2005 ; Zaff et al., 2003 ).

The traditional controversy over whether breadth contributes to improving academic achievement (Linver et al., 2009 ) has given way to recent findings that indicate the relation of breadth to improvement in early adolescence (Eisman et al., 2016 ; Roth et al., 2010 ). However, the same would not happen in late adolescence, when duration is the more consistent predictor (Eisman et al., 2016 ).

Regarding the relationship between participation in EA and academic achievement in terms of sex and age, younger girls show the highest academic achievement (Kingdon et al., 2017 ; OECD, 2015 ), depending on the type of activity. For instance, an association has been found between reading books and academic achievement in early adolescence (i.e., schoolchildren between 12 and 14 years old) (Kingdon et al., 2017 ).

Aims and hypothesis

Despite the abundant literature on the effects of different EA on academic performance, empirical evidence is lacking for the relationship between extracurricular variables, such as breadth and duration, and academic achievement in Hispanic (including Spanish) contexts. Therefore, we aimed to investigate in such a context two groups of noncurricular factors—EA and sociodemographic variables—and a key curricular variable, academic achievement. In particular, we consider sex, age (distinguishing between early middle and late adolescence) and parental education level as sociodemographic variables.

On the other hand, as variables of EA, we take into account the breadth—understood as Busseri and Rose-Krasnor ( 2009 ) state it—and duration of participation, the type of activity (i.e., individual sport, collective sport and arts), and add an informal activity traditionally related to academic achievement, the reading of books. Associations of EA and sociodemographic variables with academic achievement were analized.

The hypotheses of the investigation are:

Types of activities (i.e., reading of books, artistic, and individual or collective sports) are associated with academic achievement, controlling for sex, age, and parental education level.

Duration of EA is associated with academic achievement, controlling for sex, age, and parental education level.

Breadth of EA is associated with academic achievement, controlling for sex, age, and parental education level.

Participants

Participants were recruited at 10 schools randomly selected from among all secondary schools in the province of Zaragoza, in Spain. We requested participation from students in grades 7, 9, and 11 (around 12, 14, and 16 years old, respectively). In total, 1148 students completed the survey, with balanced distributions by sex (50.2% female) and age (distribution of ages can be found in Table 1 ).

Instruments

EA (Hermoso et al., 2010 ) contains descriptive data about performing organized activities after school hours. From among adolescents who participated in such organized activities, data for a series of dummy variables were collected, covering the number of courses underway, the type of activity (sports and/or arts), and other items related to students’ perceptions of participation. Experts assessed and critiqued the questionnaire, and it fulfilled the requirements of external, internal, and content validity.

Sociodemographic variables data on sex, age, and parental education level were collected.

Academic achievement attends to a self-report of the previous course GPA.

This study was carried out in accordance with the recommendations of the Council of the British Educational Research Association in its second edition of the Ethical Guidelines for Educational Research ( 2011 ). Subjects received no compensation for participating in the study. Compliance with these ethical standards was guaranteed at all time.

The objectives and characteristics of the study were explained to the principals and counselors, who agreed to participate. Afterwards, they transferred the study objectives and questionnaires to the tutors from the different groups. Prior to completion, families were informed by a letter of the purpose of the study and procedure, and participants’ anonymity was ensured. In the same letter, the volunteers were informed of participation and the possibility of excluding from the activity those children whose families did not consent to participation, given that the data was collected during class time.

Data analyses

The age of the participants was dichotomized at the median, which resulted in one group between 12 and 14 years of age and the other between 15 and 18 years of age. For the evaluation of parental education level, three categories were considered: primary basic studies, middle studies, and university studies. The participant was assigned to one according to the highest level either parent had reached. For sports activities, participants were asked if the child was currently involved in individual or collective sports activities.

For the identification of artistic activities, if they were currently participating in dance, theater, music, or plastic-arts activities, any positive response on any of these activities was considered an affirmative response for this type of activity in its entirety. Also, they were asked directly if they were currently dedicating their time to reading books. The time devoted to EA was determined by asking the respondents to report during how many courses they had carried out these activities.

Finally, regarding the breadth of EA, the definition of Busseri and Rose-Krasnor ( 2009 ) was adopted, which proposes breadth as the total number of activities in which a young person engages. The response variable related to academic achievement was obtained by asking for the final grade in the immediately preceding course, reported on a scale from 1 to 8. However, for the descriptive analysis, this variable was categorized as “deficient” (below minimum approval level), “sufficient” (between minimum approval level and up to 5 units), or outstanding (higher than 5 units).

For the evaluation of the proposed hypotheses, a multilevel model of main effects was evaluated, where covariates and evaluation factors were taken as fixed effects, and the school to which the student belonged was categorized as a random effect. The estimation method was through restricted maximum likelihood with the Satterthwaite method for calculating the degrees of freedom. The residuals of the model were evaluated for their normality by means of skewness and kurtosis criteria. A significance value of p  < 0.05 was used. For post hoc comparisons, t -tests protected by Fisher were used in cases where the factor had more than two levels; for the rest of the cases, the F -test was considered sufficient. Due to the differential effect of the age of the respondents on the confounding and response variables, the proposed model was estimated independently for each age group.

In total, 549 (47.8%) males and 599 (52.2%) females were recruited, a greater proportion of whom were 12–14 years of age, with parents who had a high educational level (see Table 1 ). Regarding the response variable “academic achievement”, the three categories presented show a similar distribution; however, girls show better achievement than boys by more than 10 percentage points in the superior category.

The analysis of variance (Anova) of the multilevel model, proposed for the evaluation of academic achievement as a dependent variable, shows that the responses related to the evaluated variables corroborate the differentiated behavior by age group. For the younger group (12–14 years old), sex, reading books, and duration of EA are significant factors associated with academic achievement, contrary to the results for the older group (15–18 years old) for whom collective sports activities and breadth of EA was significantly related to academic achievement. Only parental education level presented a similar effect for both age groups (Table 2 ).

The analysis of means showed that for the sex-related factor, between 12 and 14 years of age, the girls had better academic achievement (see Table 3 and Fig. 1a ). For the level of education of the parents, those young people whose parents only reported levels of primary education showed the lowest academic achievement, compared to those with both medium levels and high levels of parental education. Regarding collective sports activities, the practice of these activities by the older students affected positively to academic achievement, as Fig. 1b shows. On the contrary, the effect of reading books was found among the younger ones as a promoting factor of academic achievement, also shown in Fig. 1b . Finally, for the variables of time and breadth, a differential in behavior was found again. For the younger students, the time spent most affected their academic achievement, by increasing it. For the older students, breadth was a predictor of academic achievement—in this case, the low level of dispersion is the weaker association, compared to the medium and high levels that present the best values (see Fig. 1c ).

a Sex and parental education level; b breadth and duration of EA; and c collective sports activity and reading of books.

The main contribution of this paper is the study of these characteristics in Hispanic, concretely, Spanish contexts, which is not very common in the scientific literature. Our results indicate that adolescents’ choices of EA participation are associated with academic achievement, as other investigations have shown (Badura et al., 2016 ; Bartko and Eccles, 2003 ; Eisman et al., 2016 ; Linver et al., 2009 ), but this association differs according to sex, age, type of activity, and parental education level. As the previous literature shows, boys participate more in sports activities while girls do more in artistic activities (Darling, 2005 ; Kleiner et al., 2004 ; Luthar et al., 2006 ), and participation is higher in early adolescence than in late adolescence (Denault and Poulin, 2009b , 2009a ; Rose-Krasnor et al., 2006 ).

Regarding the control variables in the prediction of academic achievement, the youngest girls have the highest grades, as has been found previously (Badura et al., 2016 ; OECD, 2015 ). On the other hand, a higher level of parental education is associated with higher academic achievement, in both early and late adolescence (Bartko and Eccles, 2003 ). The study by Roth et al. ( 2010 ) produces the same result, as well as an association with a smaller number of behavioral problems, but only when youths with high levels of participation were compared with peers who did not attend EA. Kingdon et al. ( 2017 ) found that reading and involvement of mothers are protective factors against the decrease in academic achievement in boys, as well as a predictor of future achievements, especially among low-income groups.

Addressing the first hypothesis (i.e., type of activity is associated with academic achievement), academic achievement relates negatively with collective sport EA in late adolescence. This is in line with the previous literature where sports activities relate to lower academic achievement than other types of EA, such as artistic activities (Badura et al., 2016 ; Darling, 2005 ; Darling et al., 2005 ; Eccles et al., 2003 ; Hansen et al., 2010 ; Wilson et al., 2010 ). However, this relationship was not significant in the study by Im et al. ( 2016 ). Linver et al. ( 2009 ) showed that students who participated only in sports EA had more positive results in academic achievement than those with little or no participation in organized activities, but worse academic achievement than those who participate in sports plus other activities, such as school, community, or religious groups.

We did not obtain a significant association between artistic EA and academic achievement, contrary to the results obtained in other studies, where artistic activities, not sports, provide greater reinforcement for academic achievement (Im et al., 2016 ), but only in girls (Luthar et al., 2006 ) or in late adolescents (Eccles et al., 2003 ).

Moreover, our work confirms the results of previous research by finding an association between reading books and academic achievement in early adolescence, namely, schoolchildren between 12 and 14 years old, the same age segment that Kingdon et al. ( 2017 ) reports. However, unlike our results, other research has found the same relation in late adolescence (e.g. Horbec, 2012 ; Whitten et al., 2019 ).

Regarding the second and third hypotheses (duration and breadth are associated with academic achievement), our results are in line with previous research, in which breadth (Fredricks, 2012 ; Fredricks and Eccles, 2006 ; Linver et al., 2009 ; Mahoney et al., 2006 ) and Duration (Darling, 2005 ; Darling et al., 2005 ; Eccles et al., 2003 ; Fredricks and Eccles, 2006 ; Zaff et al., 2003 ) relate to improvement of academic achievement. Nevertheless, our results show that duration is better predictor than breadth, contrary to previous literature (Barber et al., 2005 ; Eisman et al., 2016 ; Fredricks and Eccles, 2006 ).

However, we found that duration of EA is a predictor of academic achievement only in early adolescence, as Roth et al. ( 2010 ) and Eisman et al. ( 2016 ) show. On the other hand, in late adolescence, breadth is an important factor that enhances academic achievement as Eisman et al. ( 2016 ) show, but contrary to the results of Roth et al. ( 2010 ). Our findings confirm the evolutionary hypothesis that Eisman et al. ( 2016 ) present. In this sense, the stage of development of the young person would indicate the importance of the type of engagement (behavioral or psychological). Thus, in early adolescence, breadth would be more important, as those young people are more likely to seek a wide range of EA participation experiences (Busseri and Rose-Krasnor, 2009 ), to test which are more deserving of the investment of their free time. Thus, in late adolescence, they have already acquired greater control over time itself (Fredricks and Eccles, 2010 ), allowing more intense on specific activities and reducing the range of breadth (Busseri et al., 2006 ; Denault and Poulin, 2009b ).

While the literature reports that participating in EA has a positive relationship with academic achievement, this is only true to a certain extent, since too long a duration has a negative impact (Fredricks, 2012 ; Fredricks and Eccles, 2010 ; Palma et al., 2014 ). Indeed, the overprogramming hypothesis (OSH) suggests a point at which the resulting participation becomes counterproductive in terms of benefits to the young person (Fredricks and Eccles, 2010 ; Mahoney et al., 2006 ). An explanation for this could be that much time invested in EA interferes with time that could be devoted to the family, curricular tasks, or other moments that the young person needs (Fredricks and Eccles, 2010 ; Mahoney and Vest, 2012 ; Palma et al., 2014 ), regardless of whether this occurs in early, middle, or late adolescence.

After all, the positive effects of participation in EA are manifest. Mahoney et al. ( 2005 ) reveal that participation in activities—voluntary, school and extracurricular—increases participation and school achievement because it facilitates the acquisition of interpersonal skills and positive social norms, membership in prosocial peer groups, and strengthening of emotional and social connections with the school itself.

Both the curricular and extracurricular schedules can trigger differential benefits in young people, nourishing the student in a beneficial way throughout adolescent development, through the interrelation of both contexts.

Limitations and future directions

According to Eisman et al. ( 2016 ), limitations of research on participation in EA and association with academic achievement may include a selection bias toward adolescents who start high school with higher levels of self-acceptance. They are more likely to participate (or be selected) in organized activities due to the high levels of skill required to participate, together with higher academic achievement.

Another limitation is that data on the intensity of participation have not been collected. It would be interesting to check in future studies how differences in intensity of participation over time relate to academic achievement by determining the proportion of time when participation occurs, as Vandell et al. ( 2015 ) shows. In any case, the main limitations of the investigation are the instrument used is a self-report and that it is a cross-sectional study, so longitudinal studies are required to make a causal explanation possible.

In fact, it should be added that the quantitative design prevents drawing broader conclusions. A multi-method design are more consistent and would enrich the information around the students’ perceptions, especially regarding the reasons why the activities are chosen. And, in this sense, would also deepen into the reasons why these activities are not chosen, as well as whether the offer suit all groups of adolescents.

An additional limitation is that no more complex models were evaluated (i.e., models with interactions). However, an attempt to correct that limitation included doing independent analyses for each of the age groups, but other factors can interact, such as sex with the other variables. But for statistical robustness, we do not consider that model. A longitudinal study that asks about behavior in recent years could try to correct that bias.

Besides, future research should also be directed to investigate the level of participation of students in these activities—performance, persistence, concentration, autonomy, etc.—and its relationship with their characteristics as students and their academic and social success in school.

In addition, this model is proposed for students with a common academic background. Therefore, students whose academic trajectories were not in the courses of the ordinary curricular approach were taken out of the study. We refer to students enrolled in curricular diversification or alternative curricular proposals for being unable to follow the ordinary academic trajectory.

Data availability

The datasets analyzed during the current study are available on the following repository link: https://zenodo.org/record/3689261#.XlgI32hKiUk

Code availability

The code is the following: EDI FEB 12 2020.

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Balaguer, Á., Benítez, E., Albertos, A. et al. Not everything helps the same for everyone: relevance of extracurricular activities for academic achievement. Humanit Soc Sci Commun 7 , 79 (2020). https://doi.org/10.1057/s41599-020-00573-0

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The role of extra-curricular activities in increasing student engagement

Asian Association of Open Universities Journal

ISSN : 2414-6994

Article publication date: 23 November 2021

Issue publication date: 14 December 2021

The first objective of this study is to review the mechanism of conducting extra-curricular activities (ECAs) in the open and distance learning (ODL) setting. To achieve this objective, the procedure of ECAs at the Virtual University of Pakistan has been studied. The second objective of this study is to find the impact of ECAs on student engagement.

Design/methodology/approach

This is a cross-sectional quantitative study. The questionnaire has been used to collect the data. The purposive sampling technique has been used, while this study's sample size is 970. An independent sample t -test has been used to find the difference between the groups.

This study shows a significant difference between the engagement levels of students who have been part of any ECA at university compared to the students who never participated in any ECA.

Research limitations/implications

The results have been derived from the data gathered from one university only that might hinder the generalizability of the findings. The same study can be conducted in other ODL institutions to authenticate the findings.

Practical implications

This study will help in realizing the policymakers of ODL about the importance of ECCAs. This study has also discussed an existing system of conducting ECCAs in an ODL setting that can be generalized and implemented across all the ODL universities to enhance student engagement.

Originality/value

This study has highlighted the importance of ECAs in ODL institutions that have been neglected since forever. This study is novel because it has highlighted the importance of social interaction of students in ODL and its relation with student engagement that has not been highlighted by any study so far.

• Student engagement
• Extra-curricular activities
• Co-curricular activities

Munir, S. and Zaheer, M. (2021), "The role of extra-curricular activities in increasing student engagement", Asian Association of Open Universities Journal , Vol. 16 No. 3, pp. 241-254. https://doi.org/10.1108/AAOUJ-08-2021-0080

Emerald Publishing Limited

Copyright © 2021, Saba Munir and Muhammad Zaheer

Published in Asian Association of Open Universities Journal . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

The emergence of knowledge economies has made everyone realize that individuals must focus on continuous education to thrive in the current competitive environment ( Sharma, 2018 ). Open and distance learning (ODL) has been proved to be a viable source for making education accessible at minimum cost to all, removing the boundaries of gender, age, economic status or physical proximity ( Bordoloi, 2018 ). ODL has been playing an essential role in disseminating education to the masses for many decades. But its existence has become inevitable during the last couple of years that have brought a revolutionary change in the perspective and policies of the education sector across the world due to coronavirus disease 2019 (COVID-19) ( Almaiah et al. , 2020 ). Although distance education in terms of policies, procedures and technologies has significantly emerged, few variables in the ODL chain are still missing or are in their infancy, “Student Affairs” is one of those variables ( Dare et al. , 2005 ). Among various student-related issues, the most ignored one is extra-curricular activities (ECAs) in ODL. Along with enhancing the physical and mental abilities of students, ECAs provide multiple benefits to the concerning educational institutions including, student retention ( Flores-Gonzälez, 2000 ), better employability skills in students ( Lau et al. , 2014 ), student motivation and student engagement ( Gunuc and Kuzu, 2015 ). ODL institutions can also achieve the benefits offered by ECAs by making these a part of their academic calendar.

Few studies have highlighted the importance of ECAs in open distance education ( Foley and Marr, 2019 ; Ruth, 2005 ). However, literature still lacks in providing a widely accepted mechanism of implementing ECAs in ODL institutions and explains the impact on non-traditional students. The role of ECAs is still unclear in the ODL institutions, and there is a strong need for a better understanding of the long-term impact of ECAs ( Stuart et al. , 2011 ).

The current research attempts to study the impact of participation in ECAs on student engagement in the ODL setting. This study highlights that an ODL institute like a conventional institute can balance academic knowledge, personal development and extra-curricular engagement to provide a learning environment that facilitates students' personal and professional grooming.

To study the mechanism of conducting ECAs at an ODL institute.

To find the impact of participation in ECAs on student engagement.

Literature review

ECAs are activities that students perform other than earning a degree during their education at a particular institute. Stuart et al. (2011) defined ECAs as “all activities beyond ‘the classroom’, such as involvement in university clubs and societies, paid and voluntary employment, family commitments, religious activity.” As the name suggests, these are separate from students' primary curriculum to earn a degree. There is no second opinion about the importance of ECAs in a student's life. Via ECAs, students' employability or work skills can be enhanced ( Tran, 2017 ). Many universities worldwide have already included ECAs in their strategies to improve students' employability skills ( Al-Ansari et al. , 2016 ). ECAs allow students to work in natural settings, and according to Osman (2011) , skills gained through practical learning have a more profound impact on students. They can build better collaborative working skills. In their study on business graduates, Lau et al. (2014) found that students who participate in ECAs rate their creativity, communication skills, leadership and self-promotion skills higher than their fellow students who do not participate in ECAs. Few studies highlighted that participation in certain ECAs could help students access large firms, secure jobs, avoid unemployment and increase academic achievements ( Eide and Ronan, 2001 ). Academic achievement is the most compelling factor for the parents and the students as all students' future endeavors depend on it. Stuart et al. (2011) linked high involvement in ECAs with higher marks in academics.

Kaufman and Gabler (2004) emphasized the importance of ECAs. They stated that institutions should allow their students to participate in ECAs to build their human, cultural and social capital. In a study on alumni of various UK-based universities, Stuart et al. (2011) found that alumni related their self-confidence, well-being and happiness with university's social activities. They linked the social aspect of the ECAs with the networking that ultimately helped them secure a good job. Participation in various activities like sports, music, dance and community services increases students' chances of admission to higher education institutions (HEIs). These activities increase students' self-confidence and exposure ( Kaufman and Gabler, 2004 ). Aoyagi et al. (2020) studied the factors that motivate students to participate in various ECAs. Among different factors, the prominent ones were the sense of responsibility and continuity, the spirit of challenge, and advancement. Participation in such activities enhances the students' skills and increases their motivation ( Wallhead et al. , 2014 ), and this increased motivation leads towards better academic results. These activities enhance certain skills or interests and improve affiliation with the institution.

Researchers have always focused on ECAs at the school or college level, while less work has been done on its role at the university level. The studies are scarce when we talk about the ECAs at online distance learning institutions. The academicians focus on developing learning objectives to ascertain a student's knowledge from the course work. Still, they rarely give their students a conducive environment to groom or transform personally and professionally. It is easier for traditional institutions to arrange ECAs at their premises to engage their students. In an ODL setting, geographic dispersion and time constraints make it difficult for the institutions to arrange such activities ( Fontaine and Cook, 2014 ). According to Tucker (2003) , non-traditional students are less interested in ECAs as they balance their family, degree and work obligations. Holding this view for many years, ODL institutions have ignored the importance of ECAs. But now, the trend is changing; these days, we can find diversity in ODL in terms of students. Today, in ODL institutions, we can find a young 20-year-old student who is full time perusing the bachelor's degree or a 50-year-old who is doing the MPhil to progress in career, a housewife with children, or a young girl doing her diploma in psychology. Considering this diversity, researchers and academicians have realized that non-traditional students should also be provided with the chance of participation in ECAs as it provides them with the same depth of experiential learning as the campus-based students ( Dare et al. , 2005 ). These students are also part of the institutional community, and they should be provided with all the programs or activities offered to traditional campus-based students.

Participation in ECAs increases students' affiliation with their institution, and the absence of such activities can cause a disconnection or weaken the identification with their alma mater ( Ruth, 2005 ). The lack of interaction can cause the feeling of isolation in the ODL students. In previous literature on distance learning, the relationship between student success and a sense of connection with the institution is missing. Krauth and Carbajal (1999) found a strong relationship between the sense of connection and completion and satisfaction. This connection between institution and student can be enhanced with student services and ECAs. It can be the most effective way to employ the highest level of socialization, interest, sense of achievement and involvement in the participants, enhancing student engagement.

Student engagement has gained the academic researchers' special attention as an essential source of decreasing boredom, dropout rates and increasing achievement levels ( Fredricks, 2011 ). Student engagement plays a vital role in the academic and intellectual development of the student and improves student performance ( Dassanayake and Senevirathne, 2018 ; Sun and Rueda, 2012 ).

Sense of engagement encourages students to actively participate in the classroom, ultimately leading to better academic and social outcomes ( Siddiqi, 2018 ).

Gunuc and Kuzu (2015) defined engagement as “the quality and quantity of students' psychological, cognitive, emotional and behavioral reactions to the learning process, as well as to in-class/out-of-class academic and social activities, to achieve successful learning outcomes” (p. 3). The construct of student engagement consists of three dimensions: emotional, behavioral and cognitive. Fredricks et al. (2004) conducted a comprehensive study on the concept of engagement and gave a detailed literature review of all the dimensions of engagement. They defined behavioral engagement as the student's involvement in learning and academic tasks, school-related activities and positive conduct. Emotional engagement deals with a student's feelings towards belongingness with the institution and the positive or negative reactions towards the institute and the activities.

In contrast, Fredricks et al. (2004) explained cognitive engagement as a student's level of investment in learning and acquiring complex skills. Measuring student engagement is challenging in ODL settings than traditional face-to-face learning and should be measured differently ( Henrie et al. , 2015 ). Different factors can enhance student engagement like campus environment, association with peers or institutions, etc. For this study, authors have taken ECAs as a source of student engagement.

Various ODL institutions have started offering ECAs for their students. Fontaine and Cook (2014) studied the co-curricular activities' strategy of a distance learning school of pharmacy and health professions. The school required students to get registered with any professional association to get their field's real-time experience. This model is specified to the medical profession only. Moreover, they have not included ECAs in this model.

Participation in ECAs increases student engagement.

Extra-curricular activities at the Virtual University of Pakistan

Virtual University of Pakistan (VUP) is a federal university established in 2002. Virtual University is a distance learning university having more than 200 campuses across Pakistan. VUP is catering to the educational needs of students across the country and living overseas ( Zaheer and Munir, 2020 ). Considering the need for out-of-the-class activities and their impact on students' academic performance and grooming, VUP established its ECAs plan under the platform of “LIFE At VU” in 2014. Since then, VUP has successfully conducted its annual activities named “Student Week” every year, having many students participate in clubs and societies.

This section provides the overall procedure of conducting ECAs at VUP.

Societies/clubs

Currently, 15 societies/clubs are working at VUP to promote students' physical, intellectual, ethical and leadership abilities. These societies/clubs cater to students' extra-curricular needs in competitions like photography, debates, sports, dramatics, entrepreneurship and voluntarism.

How it works

The VUP is an online distance learning institution. It is critical to involve students in ECAs to enhance their physical and mental growth and give them an experience of excitement and thrill associated with activities other than coursework and studies.

Activities where no physical presence is required.

Activities where the physical presence of the students is required.

Activities with no physical presence

VUP designed its system utilizing information technology (IT) in a way that maximum students could participate. A web portal is created where students can submit their creative material online. Every student has been assigned a unique VU-ID that can be used to log in to the portal or get registered in any competition or be a member of any club/society. Students who want to be part of Camera Club, Literary Club, IT Club or Society for the rising entrepreneurs are the main focus of this portal.

This paper will take the camera club as an example and discuss its functionality in distance learning institute.

Announcement of competition

Every year before the commencement of Student Week, Camera Club announces a competition where a theme is given. All the students of VUP (national and international) are invited to submit three photographs on the given theme. According to the theme, a tab for photo competition (as shown in the below-given image) is available on the website (societies.vu.edu.pk), where students submit original photographs taken by them (see Figure 1 ).

After the due date, initial screening is done, and shortlisted photographs (original, according to the theme) are uploaded on the website, and voting is opened for all the students. Each student from VUP can vote for one picture. Meanwhile, the expert photographers make the evaluation. The result is declared with the percentage of experts' opinion and voting of students, as shown in Figure 2 .

During this whole competition, the students are not required to visit any campus; students can submit their creative work online without the limitation of time and place.

The same procedure is followed for other societies where physical presence is not required like, essay competitions, poetry competitions, programming and idea competitions, etc.

Activities where the physical presence of the students is required

Few activities need the physical presence of students like sports and performing arts. These activities need a different approach. VUP has its presence across the country by its campuses in more than 100 cities of Pakistan that have been divided into five regions, and every region is further divided into sub-regions.

Announcement of competitions

Every year during “student week” competitions are announced in all the categories like debates, short play, singing and sports activities (cricket, badminton, table tennis etc.). For this study, we shall take cricket as an example of physical presence-based activities in ODL.

After the competition announcement, all the sportsmen/sportswomen must register themselves on society's web portal ( http://societies.vu.edu.pk/Pages/Home.aspx ) under the relevant competition. Every campus manager can see the registered students of his/her campus. After the deadline, all the sub-regions' students are called for trials where a sub-region team is selected. A tournament is conducted at each region where all the teams of sub-regions compete to represent a region. In the grand event conducted at the central level, five teams representing each region compete for Student Week's winning trophy.

The same procedure is followed for debating competitions, singing competitions, painting competitions and other sports activities.

VUP has been conducting ECAs successfully through this system since 2014 and has engaged thousands of students in various competitions.

Methodology

This is an explanatory study using a cross-sectional design. Individual students of VUP are unit of analysis in the study. It is a quantitative study in which survey research has been employed using an online structured questionnaire.

Target population

This study's target population is all the students enrolled at VUP during the year 2013–2018. Virtual University started its ECAs in 2014, so the starting year has been set as 2013. Due to COVID-19, student week has been suspended since 2019, so 2018 has been selected as the end year.

Sampling technique and sample size

Purposive sampling has been used to collect the data. With the IT department's help at VUP, the online questionnaire link was sent through e-mail to all the students enrolled during 2013–18. An e-mail was also sent to all the students registered in any society at the “Life at VU” web portal. Campus managers were also involved in getting maximum response from the students. Around 1,500 responses were received; after excluding the missing data and incomplete responses and responses of students who were not part of VUP during 2013–18, the data of 907 students were available for further analysis.

Data collection

A survey questionnaire has been used to get the responses from students. Different researchers have developed questionnaires to measure student engagement at the university level, while few authors attempted to measure engagement in ODL settings like Dixson (2015) and ( Yang, 2011 ). But these questionnaires have focused on the content or procedures of the curriculum. Considering the study's unique nature, which focuses on ECAs, none of the questionnaires used in ODL related research could be used. However, an instrument developed by Gunuc and Kuzu (2015) that measures students' psychological engagement, cognitive engagement and emotional engagement was used in the study. This study is being conducted on the ODL students; so, only one dimension, “psychological engagement”, has been measured, using two sub-dimensions: valuing and sense of belonging. The questionnaire consisted of 14 items.

Reliability analysis

The questionnaire consisted of 14 items, 3 items measured valuing, and 11 items measured belongingness.

The instrument's reliability has been 0.921, which is considered very good. This high-reliability score indicates that the instrument was consistent in measuring the underlying concepts.

Data analysis

The primary aim of this study is to measure the effects of ECAs on student engagement. For this purpose, two groups have been identified—those who have never participated in any ECA and those who participated in any such activity.

Table 1 shows group statistics. Code “1” was assigned to those who participated in ECAs, and code “2” was given to those who did not participate in the ECAs.

Table 1 shows that 429 students participated in ECAs while 478 did not take part in ECAs. The mean of student engagement for participating students is 4.077 and for non-participating students is 3.927.

To check if the mean difference between the two groups shown in Table 1 is statistically significant, an independent sample t -test has been applied to measure the differences in students' engagement level with their institution. The data set complied with all the assumptions of the t -test. Dependent variable engagement is measured on a continuous scale; the independent variable is participation, a categorical variable, observations were independent of each other, the dependent variable is normally distributed. Homogeneity of variance is established through Levene's test ( Pallant, 2011 ).

Table 2 shows the results of the t -test.

Levene's test shows that both groups came from populations with equal variances as p -value 0.377 is greater than 0.05. It exhibits that one of the assumptions of the t -test, homogeneity of variance, is established. The t -test results indicate a statistically significant difference in the students' overall engagement, who participate and who do not participate in the ECAs. This result shows that taking part in ECAs significantly affects students' engagement in distance learning.

Student engagement is made up of two sub-categories valuing and belongingness. After establishing the overall significance of student engagement of participating and non-participating students in ECAs, the statistical significance of valuing and belongingness is discussed individually.

Table 3 shows the t -test result of valuing.

Participation in ECAs does not affect the valuing of the students towards their institution. It implies that students appreciate their alma mater in any case, whether they participate or do not participate in ECAs.

Table 4 shows the independent sample t -test regarding the students' belongingness towards their institution.

It is evident from Table 4 that participation and non-participation in ECAs are highly significantly different phenomena. The mean score of those who participated in the ECAs was 3.9018, while those who did not participate was 3.6213. The difference was highly significant, showing that participation enhances students' sense of belongingness towards their institution.

It is a common belief that a healthy body keeps a healthy mind, and to act upon this universal advice, educational institutes conduct ECAs for their students. The conduct of such activities in traditional on-campus institutions is a norm and routine. But arranging these activities in a distance learning institute where students are separated by time and space is a big challenge. The VUP accepted this challenge and initiated ECAs at the university in 2014. These activities range from indoor games like online gaming, painting and badminton to outdoor games like cricket and futsal.

Moreover, competitions like debating, drama and fine arts are also being held. Students from all over the country and overseas participate in these games and contests. Arrangement of all these activities, which are termed “Student Week”, has been a new trend in distance learning institutions. This is a unique practice that has made students more enthusiastic and connected.

This study also focused on the students' reaction towards participation in ECAs. The study results show that student participation in ECAs positively affects the overall student engagement with the university. For this study, participation is an independent categorical variable, and psychological engagement has been taken as a dependent variable comprised of two dimensions, valuing and belongingness. Valuing is defined as students' feelings towards their institution and the value they associate with being part of that institution ( Gunuc and Kuzu, 2015 ). While, belongingness is defined as the feelings of students that they are accepted by other members of their institution (teachers, students) ( Goodenow, 1992 ). Ndudzo (2013) found that students' engagement in ODL is driven by the communication between students and universities and the relationship between students. These ECAs are a source of interaction between peers and the universities. The same has been found in our study. Table 5 shows a significant difference in students' belongingness who participated in ECAs compared to those who did not. It explains that communication and interaction between students and the university can increase students' engagement and affiliation with their institution. Foley and Marr (2019) found that students' participation in ECAs enhances the sense of belonging to a community in ODL setting. Henrie et al. (2015) also observed that participation in society/clubs could improve students' belongingness, supporting the findings of the current study.

In contrast, no significant difference in the “Valuing” dimension of engagement has been found in the participation or non-participation group. It shows that students give value to their university irrespective of their participation in any ECAs. It can be inferred that taking part in ECAs does not affect the value they give to their institution, as getting admission reflects the value given to their choice.

When the composite variable “Engagement” comprising valuing and belongingness was tested, it was statistically significant, as shown in Table 3 . Students who participated in ECAs showed a higher mean score of 4.0772 than those who did not, with a mean score of 3.9275. This result confirms the proposed hypothesis that participation in ECAs increases student engagement. If an institution wants to increase student engagement, ECAs are among the many sources that can be used. These activities increase student engagement, self-confidence, employability skills and motivation, which is the educational institution's ultimate objective.

Though a large number of students participate in ECAs, still many students do not participate. There are certain reasons for non-participation in ECAs. VUP is an online distance learning institute where students get admission due to flexibility and ease of study. Many students are working professionals who are unable to join ECAs due to their job commitments. Tran (2017) also identified students' job commitments as a reason of less participation in ECAs. Location can pose a barrier for student participation ( Dickinson et al. , 2021 ). Due to cultural barriers, the travel of female students becomes an impediment to participation in ECAs. However, by participating in online competitions, some students compensate for their absence in games that require physical presence.

To increase the participation of students in ECAs, VUP is using multiple sources like e-mails, text messages or social media. Social media is an effective source to increase students' interest in various activities ( Robbins and Singer, 2014 ). Considering the importance of social media, VUP has launched an independent Facebook page of “Life at VU” with the aim to provide students with a platform where they can share their experiences of various competitions and socialize with other students. The social media presence of ODL institutes can enhance student engagement and participation ( Morton et al. , 2019 ).

Limitations and directions for future research

The results of this study have been derived from the data gathered from one university only that might hinder the generalizability of the findings. Future studies can replicate the same study in other ODL institutions to authenticate the findings. The mechanism of ECAs discussed in this study is developed based on the available resource and cultural and structural dynamics of the institution and the country. ODL institutions of other countries can design it as per their dynamics. Moreover, a comparative study of different countries can be conducted in future to see the differences in approach of conducting ECAs and student engagement.

This study found that ECAs in ODL can be conducted successfully. Students in ODL complain about being socially disconnected; such practices can mitigate these negative perceptions towards ODL as VUP has been conducting such activities for the last seven years.

It was also found that participation in ECAs enhances students' belongingness to their institution, resulting in student retention and lowers the dropout rate in ODL.

This study attempts to bring into light an important factor of student engagement in ODL that has been ignored. This study has provided empirical evidence that ECAs are equally crucial for conventional and non-conventional learners.

Life at VU portal

Photo competition

Group statistics

Independent samples test (Valuing)

Independent samples test (Belonging)

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Extracurricular activities in medical education: an integrative literature review

1 Office of Medical Education, Ajou University School of Medicine, Suwon, South Korea

Hyeyoon Jeong

2 Department of Medical Education, Ajou University School of Medicine, Suwon, South Korea

Associated Data

The dataset used during the current study is available from the corresponding author upon reasonable request.

The importance of extracurricular activities (EAs) has been emphasized in medical education. These activities could enhance medical students’ emotional and physical health and afford them developmental opportunities. Despite the growing amount of research related to this theme, few studies review and synthesize the existing literature. This study aims to provide an understanding of the educational implications of EAs in medical colleges and constructs an integrated conceptual framework concerning their types and learning outcomes by literature review.

An integrative literature review was conducted following Torraco’s method, with the aim to generate a new framework for the given topic. The authors utilized Scopus and PubMed as databases, using search terms “extracurricular,” “medical,” and “students.” Initially, titles and abstracts were screened to include relevant studies, and the researchers verified the eligibility of the articles by following the inclusion and exclusion criteria. Of the 263 articles identified, 64 empirical studies were selected for further review.

EAs in undergraduate medical education can be classified into direct extracurricular activities and indirect extracurricular activities, the latter of which is sorted into nine sub-categories. We identified seven main categories regarding the learning outcomes of EAs. In addition to general activities (e.g., pro-social activities, team sports), some distinctive activities such as research have been largely addressed in previous studies. The results of EAs were discussed in relation to academic growth, career development, and psychological experiences.

Conclusions

This review identified the types and learning outcomes of EAs in the context of medical education, thereby suggesting ways to improve the quality of EAs and maximize their educational effects.

The schedules of medical students are characterized by a heavy academic load, frequent tests, and clinical clerkships. They also invest their time and effort in extracurricular activities (EAs). More than 60% of medical students participate in EAs [ 1 , 2 ] and spend 9.8 h per week on them [ 3 ]. EAs are essential in the context of medical education because these activities serve as a buffer against the stress and burnout developed in an academically taxing environment [ 2 , 4 ]. Additionally, they provide medical students with developmental opportunities to foster self-esteem, build constructive peer relationships, and enhance student agency [ 5 ]. With the global inclination toward student-centered education and the idea that the fundamental goal of assessment should be to foster students’ competence and subsequent learning momentum, a criterion-referenced grading system is highly regarded by many educators [ 6 , 7 ]. The significance of EAs in medical education is growing because it deals with diverse activities to promote personal development across various domains that cannot be cultivated only by the curriculum [ 8 ].

The concept of EA has been defined differently by various scholars. However, recent studies reflect a consensus that EAs, as academic or non-academic activities that are conducted under the auspices of the school and occur outside of regular classroom time, are not part of the curriculum [ 9 – 11 ]. Generally, EAs do not involve grading or account for academic credits, and participation is optional and voluntary for students [ 10 ].

Previous studies classify EAs based on the characteristics of the activities (see [ 12 , 13 ]). Instead of classifying EAs based on prescribed norm, researchers tended to group EAs together if they seem to look alike. Therefore, an agreed categorization of these activities does not exist. The Michigan Study of Adolescent Life Transitions (MSALT), a longitudinal study of sixth-graders in Southeastern Michigan from 1983 to 1997, made progress in defining the types of EAs by grouping the activities [ 14 ]. Through this study, Eccles and her colleagues (2003) distinguished types of EAs as (1) pro-social activities─church attendance and/or volunteer and community service type activities, (2) performance activities─school band, drama, and/or dance, (3) team sports─one or more school teams, (4) school involvement─student government, pep club and/or cheerleading and, (5) academic clubs─debate, foreign language, math or chess clubs, science fair, or tutoring in academic subjects [ 14 ]. Meanwhile, Bartkus and his colleagues (2012) put EAs on a continuum that ranges from direct to indirect [ 10 ] rather than grouping EAs into static categories. They defined a direct extracurricular activity (DEA) as “one that is more closely associated with the student’s major or curriculum” and an indirect extracurricular activity (IEA) as “one that is relatively unrelated to the student’s major or curriculum.” [10, p.699]. They evaluated each EA how closely the content of EA related to academics to specify the type of EA. The classification of direct and indirect EAs by Bartkus et al. (2012) is meaningful because it provides a secure conceptual basis to encompass a wide range of activities.

A growing body of research investigates EAs in medical education. However, these are conducted in fragmented ways, which could restrict a holistic understanding of the given topic [ 10 ]. For example, there are ample studies about research activities in medical colleges, though they were not limited to the extracurricular programs (for a review, see [ 15 ]). The most prevalently investigated outcome of EA participation in colleges is academic achievement (e.g., [ 11 ]). Even though EAs are encouraged in medical education, it is difficult to find a comprehensive study that covers the types of activities offered and their effects. A comprehensive model of EAs in medical education which elaborates on their types and outcomes would contribute to a deeper understanding of EAs and medical education.

The aim of this study is to review the research and summarize what kinds of EAs are being conducted and their outcomes in medical colleges. This study seeks to present a comprehensive model that contains both EAs types and EA outcomes in medical education.

The integrative literature review is a form of research that generates new frameworks and perspectives about the topic by reviewing, critiquing, and synthesizing representative literature in an integrated manner [ 16 ]. Torraco (2005)’s method has been widely used in the field of Human Resource Development (HRD) where new topics are constantly emerging, and a holistic conceptualization and synthesis of the literature is needed. This method is particularly useful when a large body of studies has been conducted, but no comprehensive perspective from which to view a certain topic has been developed. We utilized an integrative literature review to capture the dynamics and development and present a holistic view as previous studies on EAs in medical schools become more abundant and diversified [ 16 ]. Moreover, considering that this method addresses complex relationships between constructs, utilizing it would be appropriate to deal with dynamics among different types of EAs and their outcomes in medical colleges.

While undertaking initial research in September 2022, the authors utilized the Scopus and PubMed databases, using the keywords “extracurricular,” “medical,” and “students” to identify the most relevant articles. This initial search yielded 221 matching articles, which were pared down using a staged review [ 16 ]. A staged review is the process of narrowing down apposite articles and examining them more critically. In most cases, an initial review of abstracts is conducted, and then an in-depth review takes place [ 16 ]. Generally, this approach allows researchers to gain more thorough coverage of relevant articles while minimizing the risk of overlooking pertinent information or including irrelevant sources.

The article inclusion criteria required that all articles were peer-reviewed, available in full text, written in English, and published in the last ten years (2013- September 2022). Moreover, we only included those articles elaborating on EAs in undergraduate medical education. The criteria of exclusion are as follows. First, studies with non-undergraduate medical students (e.g., nursing students, veterinary medicine students, etc.) were excluded. Studies about graduate medical students who participated in EAs in their undergraduate years were included. Second, descriptive studies that reported the constructs of medical students regarding EAs were excluded (e.g., perception or motivation about EA participation). Third, articles that did not explicitly explain the learning outcomes of EAs in medical schools were omitted. Screening and reviewing were carried by a team of three researchers, and any disagreement was resolved by discussion. Figure  1 shows the process of screening and selecting articles for review.

Flow diagram of the screening and selecting processes

The screening process yielded 64 articles for further review (Table  1 ). In terms of geographical distribution, we found that approximately 60% of studies ( n  = 38) were conducted in Anglophone countries, including the United States, the United Kingdom, Canada, Dominican Republic, and Australia. The research from Asian countries ( n  = 12), European countries ( n  = 9), South American ( n  = 4), and African country ( n  = 1) followed. Some studies did not specify the academic year of the students, and the number of them. Most of the articles presented a quantitative study ( n  =  46 ), where the data were mostly collected via questionnaires. Twelve studies utilized mixed methods, especially qualitative interviews with quantitative questionnaires or qualitative self-reports with quantitative questions. There were six qualitative studies in which the scholars mainly applied the interview method with self-reflection and a qualitative survey. Although no particular chronological trends were detected across the chosen time period, we found that extensive research has been conducted in recent years.

Description of the articles in the integrative literature review

For the types of and outcomes of EAs, some articles overlapped in more than one category when they covered several EAs or the EA was multifaceted with various effects (Fig.  2 ).

Integrative model of the types and outcomes of extracurricular activities in medical education

Types of EAs

EAs can be divided into direct and indirect EAs, with the indirect category comprising sub-categories. The research team extracted the types of EAs reported on the target articles and counted the number of targeted articles that belong to each category. A DEA is an EA that is closely related to the learners’ major or formal curriculum, while an IEA is relatively unassociated with them [ 10 ]. The former included 18 articles [ 25 , 30 , 33 , 39 , 44 , 46 , 48 , 49 , 51 , 57 – 60 , 66 , 69 , 71 , 73 , 76 ] and the latter comprised 47 articles.

IEAs contain the characteristics of activities within nine categories (pro-social activities, performance activities, team sports, school involvement, academic clubs, research activities, career development, unspecified, et cetera). The classification of IEAs was based on five criteria from the MSALT [ 14 ]. Pro-social activities include social organizations or social events [ 14 ] and were discussed in 11 articles [ 2 , 19 , 21 , 22 , 29 , 37 , 50 , 53 , 54 , 61 ]. Performance activities indicate artistic activities [ 14 ] and comprised five articles [ 2 , 3 , 37 , 47 , 75 ]. Team sports involve participation in one or more school sports teams [ 14 ] and included seven articles [ 2 , 34 , 36 , 52 , 61 , 72 , 74 ]. School involvement represents a self-governing body or entertaining club [ 14 ] and included four articles [ 3 , 23 , 31 , 61 ]. Academic clubs refer to debate or math clubs, or science fairs [ 14 ] which do not directly relate to the regular curriculum. These comprised five articles [ 2 , 37 , 42 , 43 , 56 ]. Activities about research and career development, which are unique traits of medical education, were also added here. Research activities offer students opportunities to be involved directly or indirectly in scientific research like thesis writing, attending academic conferences, and special lectures on research methodology, and included six articles [ 24 , 27 , 55 , 61 , 64 , 66 ]. Career development covers activities to explore career paths as a prospective medical expert and included four articles [ 21 , 23 , 25 , 32 ]. Additionally, there were 11 unspecified IEAs that could not be identified in the targeted articles [ 17 , 18 , 20 , 28 , 35 , 40 , 63 , 65 , 67 , 70 , 78 ]. Ten other non-classified IEAs included counseling [ 45 , 77 ], teaching [ 3 , 38 ], mindfulness [ 26 ], professional exchanges [ 62 ], Asian-American-related EAs [ 68 ], video games [ 47 ], international exchanges [ 41 ], and distinction [ 23 ].

Outcomes of EAs

The research team perused the results and discussion sections of the target articles, extracted the keywords, and coded the keywords into six categories: academic outcomes, health system science (HSS) competency, psychological outcomes, teamwork and communication skills, research engagement and competency, and career development. The keywords that did not belong to any categories above were grouped under “miscellaneous topics.”

Academic outcomes

Academic outcomes are further categorized into three domains: knowledge, skill, and attitude. In total, 15 articles reported academic outcomes. Academic knowledge can be measured by test scores or course averages; two studies used a grade point average (GPA) [ 64 , 67 ] and one used a percentile rank [ 3 ]. Most researchers provided a test to measure the students’ knowledge of a specific topic [ 44 , 51 , 57 , 60 , 64 , 71 , 76 ] (e.g., anatomic knowledge, ultrasound knowledge). They used pre-and post-tests to evaluate the effect of EAs and found a positive relation between academic performance and EA participation. However, the COMLEX Level 1 performance was not related to the EA [ 78 ].

Only three papers reported academic skills as outcomes of EA participation [ 47 , 60 , 73 ], two of which showed that hands-on practice in the extracurricular program was helpful in improving diagnostic reasoning and procedural skills [ 60 , 73 ]. Academic attitude includes a perceived understanding of the learned knowledge or skills or self-reported confidence about one’s clinical skills [ 48 , 60 , 75 , 76 ] and absence at school [ 72 ]. Generally, EA participation increased self-reported understanding and confidence. In one study, however, it did not boost confidence in using ultrasound, even though it increased ultrasound knowledge [ 57 ].

Health system science (HSS) competency

HSS is a framework to understand healthcare as a system focusing on patient care [ 79 ]. HSS has six core domains: health care structure and process, health system improvement, value in health care, population, public, and social determinants of health, clinical informatics and health technology, and healthcare policy and economics [ 79 ]. Eight articles reported improved competency under health system improvement and population and public health. Under health system improvement, students showcased a more positive attitude toward quality improvement [ 43 , 46 ] and increased knowledge of healthcare management [ 45 ]. Students also learned about underrepresented populations [ 23 , 68 ], infectious diseases, and preventive strategies [ 29 , 49 , 50 ], which fell under population and public health.

Psychological outcomes

14 articles surveyed the psychological states and motivations of students as a potential outcome of EAs. Most of them focused on negative states: stress and burnout [ 2 , 17 , 23 , 26 , 34 – 36 , 39 , 61 , 65 ], anxiety, and aggression [ 17 , 20 ]. Two papers investigated positive states: tolerance of ambiguity and uncertainty [ 52 ], and work-life balance [ 70 ]. Generally, EA participation alleviated the negative states and increased the positive states. However, the amount of time invested in EAs was not related to burnout and even showed low efficacy [ 37 ].

Two papers dealt with motivation, each of which investigated goal orientation and intrinsic motivation. Under goal orientation, engaging in physical activity was positively associated with the mastery approach [ 36 ]. Under intrinsic motivation, students reported higher autonomy in extracurricular sessions than in mandatory sessions [ 30 ].

Teamwork and communication skills

Medical students need to develop teamwork and communication skills as they have to collaborate with other health professionals while attending to patients. Seven articles investigated the effects of EA on teamwork and communication skills. Students who participated in EAs considered teamwork valuable [ 22 ], reported increased knowledge, exhibited positive perception of nurses and pharmacists [ 62 ], and showed improved cultural competency [ 41 ], leadership [ 31 ], and communication skills [ 29 , 45 , 66 ].

Research engagement and competency

Research engagement is one of the four student engagement domains in health professional education [ 80 ]. It is essential for medical students to conduct research and develop research competency considering the importance of evidence-based medicine and the critical role of the physician-scientist [ 81 ]. Six articles investigated various variables related to research. One study compared the students’ knowledge of critical thinking and research methods before and after an ultrasound workshop [ 66 ]. Two papers measured attitudes toward research and self-perfection about research skills [ 27 , 64 ], and two studies investigated actual involvement in research, like continuing research in a Ph.D. program and conference attendance [ 24 , 53 ]. One study reported that EA participation increased both intention and interest in paper publishing and actual paper publishing [ 55 ]. EAs were beneficial for increasing research skills and knowledge and cultivating a positive and more enthusiastic attitude toward research.

Career development

The careers of most medical students seem to be determined upon their admission to the medical college. However, students require more time to determine their preferred choice of major as they determine their career path. Ten articles investigated the outcomes related to knowledge and attitude about specialized medical fields, and five articles focused on professionalism. Among the articles on career choice, some measured the match rate [ 19 , 21 , 25 , 77 ], the students’ interest in and intention to apply to specific majors [ 25 , 32 , 54 , 59 ], or the knowledge and perception of the majors [ 31 , 32 , 39 , 54 , 76 , 77 ]. Professionalism was mainly about patient care [ 22 , 54 , 75 ] and medical ethics [ 33 , 69 ]. These researchers reported that having exposure to specific fields helped students develop a favorable attitude and deepen their understanding of the specialties, which contributed to the development of professionalism.

Miscellaneous topics

The outcomes from 13 articles did not fall into the six categories mentioned above. Three articles reported that EA participants could help students manage their time and stress [ 26 , 31 , 66 ]. They found a workshop about stress [ 66 ] or leadership [ 31 ], and a mindfulness program [ 26 ] helped self-management. Five articles investigated the relation between EAs and physical health or physical ability [ 18 , 28 , 58 , 63 , 74 ], such as the prevalence of tuberculosis infection, vaccination coverage, and visual-spatial abilities. Two articles mentioned time use; participation in academic-scientific programs negatively predicted the use of social networks [ 56 ], and students reported that they lost time due to EA participation [ 23 ]. Students reported that they could communicate and feel connected with faculty and students by participating in EAs [ 23 , 42 ]. The last two studies explored what the other researchers had not dealt with; confidence [ 38 ] and passion in teaching and emotional intelligence [ 40 ], both of which were positively related to EA participation.

This review synthesized the types and effects of EAs in medical colleges. To our knowledge, this is the first attempt to develop an overarching picture of the importance of EAs in undergraduate medical education and their implications. The use of the integrative model in this paper helps in gaining a comprehensive understanding of the role of EAs in colleges with distinctive characteristics of medical education.

We embodied the type of EAs by categorizing unique EAs that were found in medical education. In earlier education studies, EAs were generally classified. Shamsudin et al. (2014) sorted EAs into physical, educational, and social programs [ 82 ]. Gilman et al. (2004) differentiated structured collaborative activities from solitary and non-structured activities [ 83 ]. Contrarily, the MSALT classification system had the advantage of providing subdivisions based on activity characteristics [ 84 ]. However, a concrete EA-type system reflecting the features of undergraduate medical students was needed, in that this classification system was for adolescents. We additionally sorted research activities and career development activities in the process of presenting the integrated model. We expanded the MSALT classification to fit it within the context of medical education.

Our findings about the outcomes of EAs reflect the features of medical education, replicating the prior studies on higher education [ 85 ]. Firstly, as reported in previous research, EA participation increased GPA [ 86 , 87 ]. It also developed medical knowledge, skills, and self-perception of the learned materials and skills. While HSS is considered as a third curriculum [ 79 ], concerns have been raised about the feasibility of adding class time for HSS to the regular curriculum due to its hectic nature [ 88 ]. We present studies where students can develop their HSS competency in EAs. Secondly, EA studies in medical education focused more on negative states like stress and burnout, while studies on non-medical undergraduate students focused on mental health or well-being [ 89 , 90 ]. This is likely because stress and burnout are prevalent among medical students [ 61 ]. Thirdly, medical students, like engineering students, developed their knowledge, attitude, and skills needed for teamwork [ 91 ]. Fourthly, EAs related to scholarly research enhanced students’ research engagement and research competency, which is in line with the article that investigated research engagement in health professional education [ 80 ]. In medical education, extracurricular research programs focused on fostering positive research attitudes and increasing research involvement, while mandatory research programs focused on developing research knowledge and skills [ 92 ]. Also, medical students deepened their understanding and interest in specific specialties and developed professionalism through EA participation. This may imply that the regular curriculum, including clerkships, provides limited opportunities for exploring specialties. Lastly, the typical outcomes among miscellaneous topics were physical health and physical ability. Only two articles demonstrated a sense of belonging and communication with others as positive outcomes of EA. Medical students’ motivation for EA participation includes networking [ 1 , 93 ] and interaction with faculty and peers, which has a positive effect on students’ satisfaction and career motivation [ 94 ]. These need to be considered as important outcomes in medical education.

Even though we tried our best to comprehensively investigate all apposite studies, the selection criteria might have excluded some relevant articles. That is, we might have missed some relevant studies because of the nature of the search strings used, that is, if the keywords did not appear in the title or abstract. For example, there were no studies found about EA by racial or cultural organizations like Latino Medical Student Association (LMSA), or Student National Medical Association (SNMA), even though they play a huge role in medical education. It might be because research about LMSA or SNMA might not use the keyword “extracurricular activity” as they are big enough not to be named under EA, or it might be a limitation of the database we used as we searched articles on Scopus and PubMed only. Furthermore, this review excluded studies published in languages other than English. Thus, we could not capture the dynamics of EAs in non-English speaking countries; this may lead to an increased risk of bias and limit the generalizability of findings. In the process of deriving an integrative model, we might have missed some distinguishing features of EAs that are specific to the social, institutional, and educational context of individual countries and schools. However, three main researchers took turns examining the articles to derive the most balanced and integrated model.

We would like to propose further research suggestions based on the results and discussion. First, future studies in medical education should prioritize establishing a clear definition of EAs and their subdivisions using standardized categories, based on a thorough analysis of previous studies. This is because the systematization of conceptual definition and classification system guarantees the accumulation of productive knowledge. Second, further research exploring the balanced and effective growth of students’ capacities through EA is needed. We outlined the effects of EAs; EA participation outcomes are related to factors that are rarely covered in the regular curriculum, and the effects of EA can span across several domains. Further research on the usage of EAs for students' holistic development is warranted. Third, follow-up research will be required to overcome the bias toward quantitative research and encourage qualitative research. It is expected that researchers will be able to find the unforeseen aspect and effects of EA through various qualitative methods such as interviews, focus groups, and observational records.

Based on our work, we make the following recommendations for medical educators. First, we recommend that medical educators provide students with diverse and balanced EAs to provide them with rich learning experiences. This is because the outcomes of EAs can be derived differently depending on the EA type. Second, schools need to explain the expected outcomes of EAs and regularly follow up on the students to ensure they benefit from EAs without losing time and stamina. It is difficult to gauge the effects of EAs, as they are not often assessed. Furthermore, it is possible that students feel stressed or lose study time owing to EA participation. Schools can assist the students' choice and participation in EAs by explaining and assessing the effect of EAs.

This study aimed to collect and synthesize previous articles that dealt with the EAs in undergraduate medical education and their learning impacts, thereby presenting an integrative model of the given topic. Despite a growing emphasis on EAs and the emergence of various types of research, there is no holistic approach to embrace the broadness of previous studies in a collective way. Therefore, this integrative review attempted to expand the understanding of the relevance and implications of EAs to the learning experiences of undergraduate medical students.

EAs in undergraduate medical school were classified into two main categories: DEAs and IEAs. The latter can be further classified into nine categories. It was found that IEA is more widely implemented than DEA, among which pro-social activities ranked at the top, followed by team sports and research activities. Regarding the outcomes of EAs, we identified seven main categories. Most of the selected articles dealt with academic outcomes and career development, which are deeply related to major-specific knowledge, clinical skill, and interest or intention to pursue a certain medical specialty. Psychological outcomes such as burnout and stress represented the second most common category, which reflects the distinctive nature of a medical education context.

Acknowledgements

Not applicable.

Abbreviations

Authors’ contributions.

Research theme: HJ. Study design: SK, HJ, HC. Data collection: SK, HJ, HC. Supervision: JY. Writing manuscript: SK, HJ, HC. Literature review: SK, HJ, HC. Data analysis: SK, HJ, HC. Preparation of figures and supplementary material: SK, HC. Critical review: JY. All authors have read and approved the manuscript.

This study did not receive funding.

Availability of data and materials

Declarations.

The authors declare that they have no competing interests.

Publisher’s Note

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

Sejin Kim, Hyeyoon Jeong, and Hyena Cho are co-first authors.

Extracurricular activities in medical education: an integrative literature review

Affiliations.

• 1 Office of Medical Education, Ajou University School of Medicine, Suwon, South Korea.
• 2 Department of Medical Education, Ajou University School of Medicine, Suwon, South Korea.
• 3 Department of Medical Education, Ajou University School of Medicine, Suwon, South Korea. [email protected].
• PMID: 37087451
• PMCID: PMC10122317
• DOI: 10.1186/s12909-023-04245-w

Background: The importance of extracurricular activities (EAs) has been emphasized in medical education. These activities could enhance medical students' emotional and physical health and afford them developmental opportunities. Despite the growing amount of research related to this theme, few studies review and synthesize the existing literature. This study aims to provide an understanding of the educational implications of EAs in medical colleges and constructs an integrated conceptual framework concerning their types and learning outcomes by literature review.

Methods: An integrative literature review was conducted following Torraco's method, with the aim to generate a new framework for the given topic. The authors utilized Scopus and PubMed as databases, using search terms "extracurricular," "medical," and "students." Initially, titles and abstracts were screened to include relevant studies, and the researchers verified the eligibility of the articles by following the inclusion and exclusion criteria. Of the 263 articles identified, 64 empirical studies were selected for further review.

Results: EAs in undergraduate medical education can be classified into direct extracurricular activities and indirect extracurricular activities, the latter of which is sorted into nine sub-categories. We identified seven main categories regarding the learning outcomes of EAs. In addition to general activities (e.g., pro-social activities, team sports), some distinctive activities such as research have been largely addressed in previous studies. The results of EAs were discussed in relation to academic growth, career development, and psychological experiences.

Conclusions: This review identified the types and learning outcomes of EAs in the context of medical education, thereby suggesting ways to improve the quality of EAs and maximize their educational effects.

Keywords: Extracurricular activities; Medical students; Outcome of extracurricular activities; Type of extracurricular activities; Undergraduate medical education.

© 2023. The Author(s).

Publication types

• Education, Medical*
• Education, Medical, Undergraduate*
• Social Behavior

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Extracurricular Activities and Academic Achievement: A Literature Review

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Extracurricular activities in medical education: an integrative literature review

• Sejin Kim 1   na1 ,
• Hyeyoon Jeong 2   na1 ,
• Hyena Cho 2   na1 &
• Jihye Yu 2  

BMC Medical Education volume  23 , Article number:  278 ( 2023 ) Cite this article

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The importance of extracurricular activities (EAs) has been emphasized in medical education. These activities could enhance medical students’ emotional and physical health and afford them developmental opportunities. Despite the growing amount of research related to this theme, few studies review and synthesize the existing literature. This study aims to provide an understanding of the educational implications of EAs in medical colleges and constructs an integrated conceptual framework concerning their types and learning outcomes by literature review.

An integrative literature review was conducted following Torraco’s method, with the aim to generate a new framework for the given topic. The authors utilized Scopus and PubMed as databases, using search terms “extracurricular,” “medical,” and “students.” Initially, titles and abstracts were screened to include relevant studies, and the researchers verified the eligibility of the articles by following the inclusion and exclusion criteria. Of the 263 articles identified, 64 empirical studies were selected for further review.

EAs in undergraduate medical education can be classified into direct extracurricular activities and indirect extracurricular activities, the latter of which is sorted into nine sub-categories. We identified seven main categories regarding the learning outcomes of EAs. In addition to general activities (e.g., pro-social activities, team sports), some distinctive activities such as research have been largely addressed in previous studies. The results of EAs were discussed in relation to academic growth, career development, and psychological experiences.

Conclusions

This review identified the types and learning outcomes of EAs in the context of medical education, thereby suggesting ways to improve the quality of EAs and maximize their educational effects.

Peer Review reports

The schedules of medical students are characterized by a heavy academic load, frequent tests, and clinical clerkships. They also invest their time and effort in extracurricular activities (EAs). More than 60% of medical students participate in EAs [ 1 , 2 ] and spend 9.8 h per week on them [ 3 ]. EAs are essential in the context of medical education because these activities serve as a buffer against the stress and burnout developed in an academically taxing environment [ 2 , 4 ]. Additionally, they provide medical students with developmental opportunities to foster self-esteem, build constructive peer relationships, and enhance student agency [ 5 ]. With the global inclination toward student-centered education and the idea that the fundamental goal of assessment should be to foster students’ competence and subsequent learning momentum, a criterion-referenced grading system is highly regarded by many educators [ 6 , 7 ]. The significance of EAs in medical education is growing because it deals with diverse activities to promote personal development across various domains that cannot be cultivated only by the curriculum [ 8 ].

The concept of EA has been defined differently by various scholars. However, recent studies reflect a consensus that EAs, as academic or non-academic activities that are conducted under the auspices of the school and occur outside of regular classroom time, are not part of the curriculum [ 9 , 10 , 11 ]. Generally, EAs do not involve grading or account for academic credits, and participation is optional and voluntary for students [ 10 ].

Previous studies classify EAs based on the characteristics of the activities (see [ 12 , 13 ]). Instead of classifying EAs based on prescribed norm, researchers tended to group EAs together if they seem to look alike. Therefore, an agreed categorization of these activities does not exist. The Michigan Study of Adolescent Life Transitions (MSALT), a longitudinal study of sixth-graders in Southeastern Michigan from 1983 to 1997, made progress in defining the types of EAs by grouping the activities [ 14 ]. Through this study, Eccles and her colleagues (2003) distinguished types of EAs as (1) pro-social activities─church attendance and/or volunteer and community service type activities, (2) performance activities─school band, drama, and/or dance, (3) team sports─one or more school teams, (4) school involvement─student government, pep club and/or cheerleading and, (5) academic clubs─debate, foreign language, math or chess clubs, science fair, or tutoring in academic subjects [ 14 ]. Meanwhile, Bartkus and his colleagues (2012) put EAs on a continuum that ranges from direct to indirect [ 10 ] rather than grouping EAs into static categories. They defined a direct extracurricular activity (DEA) as “one that is more closely associated with the student’s major or curriculum” and an indirect extracurricular activity (IEA) as “one that is relatively unrelated to the student’s major or curriculum.” [10, p.699]. They evaluated each EA how closely the content of EA related to academics to specify the type of EA. The classification of direct and indirect EAs by Bartkus et al. (2012) is meaningful because it provides a secure conceptual basis to encompass a wide range of activities.

A growing body of research investigates EAs in medical education. However, these are conducted in fragmented ways, which could restrict a holistic understanding of the given topic [ 10 ]. For example, there are ample studies about research activities in medical colleges, though they were not limited to the extracurricular programs (for a review, see [ 15 ]). The most prevalently investigated outcome of EA participation in colleges is academic achievement (e.g., [ 11 ]). Even though EAs are encouraged in medical education, it is difficult to find a comprehensive study that covers the types of activities offered and their effects. A comprehensive model of EAs in medical education which elaborates on their types and outcomes would contribute to a deeper understanding of EAs and medical education.

The aim of this study is to review the research and summarize what kinds of EAs are being conducted and their outcomes in medical colleges. This study seeks to present a comprehensive model that contains both EAs types and EA outcomes in medical education.

The integrative literature review is a form of research that generates new frameworks and perspectives about the topic by reviewing, critiquing, and synthesizing representative literature in an integrated manner [ 16 ]. Torraco (2005)’s method has been widely used in the field of Human Resource Development (HRD) where new topics are constantly emerging, and a holistic conceptualization and synthesis of the literature is needed. This method is particularly useful when a large body of studies has been conducted, but no comprehensive perspective from which to view a certain topic has been developed. We utilized an integrative literature review to capture the dynamics and development and present a holistic view as previous studies on EAs in medical schools become more abundant and diversified [ 16 ]. Moreover, considering that this method addresses complex relationships between constructs, utilizing it would be appropriate to deal with dynamics among different types of EAs and their outcomes in medical colleges.

While undertaking initial research in September 2022, the authors utilized the Scopus and PubMed databases, using the keywords “extracurricular,” “medical,” and “students” to identify the most relevant articles. This initial search yielded 221 matching articles, which were pared down using a staged review [ 16 ]. A staged review is the process of narrowing down apposite articles and examining them more critically. In most cases, an initial review of abstracts is conducted, and then an in-depth review takes place [ 16 ]. Generally, this approach allows researchers to gain more thorough coverage of relevant articles while minimizing the risk of overlooking pertinent information or including irrelevant sources.

The article inclusion criteria required that all articles were peer-reviewed, available in full text, written in English, and published in the last ten years (2013- September 2022). Moreover, we only included those articles elaborating on EAs in undergraduate medical education. The criteria of exclusion are as follows. First, studies with non-undergraduate medical students (e.g., nursing students, veterinary medicine students, etc.) were excluded. Studies about graduate medical students who participated in EAs in their undergraduate years were included. Second, descriptive studies that reported the constructs of medical students regarding EAs were excluded (e.g., perception or motivation about EA participation). Third, articles that did not explicitly explain the learning outcomes of EAs in medical schools were omitted. Screening and reviewing were carried by a team of three researchers, and any disagreement was resolved by discussion. Figure  1 shows the process of screening and selecting articles for review.

Flow diagram of the screening and selecting processes

The screening process yielded 64 articles for further review (Table  1 ). In terms of geographical distribution, we found that approximately 60% of studies ( n  = 38) were conducted in Anglophone countries, including the United States, the United Kingdom, Canada, Dominican Republic, and Australia. The research from Asian countries ( n  = 12), European countries ( n  = 9), South American ( n  = 4), and African country ( n  = 1) followed. Some studies did not specify the academic year of the students, and the number of them. Most of the articles presented a quantitative study ( n  =  46 ), where the data were mostly collected via questionnaires. Twelve studies utilized mixed methods, especially qualitative interviews with quantitative questionnaires or qualitative self-reports with quantitative questions. There were six qualitative studies in which the scholars mainly applied the interview method with self-reflection and a qualitative survey. Although no particular chronological trends were detected across the chosen time period, we found that extensive research has been conducted in recent years.

For the types of and outcomes of EAs, some articles overlapped in more than one category when they covered several EAs or the EA was multifaceted with various effects (Fig.  2 ).

Integrative model of the types and outcomes of extracurricular activities in medical education

Types of EAs

EAs can be divided into direct and indirect EAs, with the indirect category comprising sub-categories. The research team extracted the types of EAs reported on the target articles and counted the number of targeted articles that belong to each category. A DEA is an EA that is closely related to the learners’ major or formal curriculum, while an IEA is relatively unassociated with them [ 10 ]. The former included 18 articles [ 25 , 30 , 33 , 39 , 44 , 46 , 48 , 49 , 51 , 57 , 58 , 59 , 60 , 66 , 69 , 71 , 73 , 76 ] and the latter comprised 47 articles.

IEAs contain the characteristics of activities within nine categories (pro-social activities, performance activities, team sports, school involvement, academic clubs, research activities, career development, unspecified, et cetera). The classification of IEAs was based on five criteria from the MSALT [ 14 ]. Pro-social activities include social organizations or social events [ 14 ] and were discussed in 11 articles [ 2 , 19 , 21 , 22 , 29 , 37 , 50 , 53 , 54 , 61 ]. Performance activities indicate artistic activities [ 14 ] and comprised five articles [ 2 , 3 , 37 , 47 , 75 ]. Team sports involve participation in one or more school sports teams [ 14 ] and included seven articles [ 2 , 34 , 36 , 52 , 61 , 72 , 74 ]. School involvement represents a self-governing body or entertaining club [ 14 ] and included four articles [ 3 , 23 , 31 , 61 ]. Academic clubs refer to debate or math clubs, or science fairs [ 14 ] which do not directly relate to the regular curriculum. These comprised five articles [ 2 , 37 , 42 , 43 , 56 ]. Activities about research and career development, which are unique traits of medical education, were also added here. Research activities offer students opportunities to be involved directly or indirectly in scientific research like thesis writing, attending academic conferences, and special lectures on research methodology, and included six articles [ 24 , 27 , 55 , 61 , 64 , 66 ]. Career development covers activities to explore career paths as a prospective medical expert and included four articles [ 21 , 23 , 25 , 32 ]. Additionally, there were 11 unspecified IEAs that could not be identified in the targeted articles [ 17 , 18 , 20 , 28 , 35 , 40 , 63 , 65 , 67 , 70 , 78 ]. Ten other non-classified IEAs included counseling [ 45 , 77 ], teaching [ 3 , 38 ], mindfulness [ 26 ], professional exchanges [ 62 ], Asian-American-related EAs [ 68 ], video games [ 47 ], international exchanges [ 41 ], and distinction [ 23 ].

Outcomes of EAs

The research team perused the results and discussion sections of the target articles, extracted the keywords, and coded the keywords into six categories: academic outcomes, health system science (HSS) competency, psychological outcomes, teamwork and communication skills, research engagement and competency, and career development. The keywords that did not belong to any categories above were grouped under “miscellaneous topics.”

Academic outcomes

Academic outcomes are further categorized into three domains: knowledge, skill, and attitude. In total, 15 articles reported academic outcomes. Academic knowledge can be measured by test scores or course averages; two studies used a grade point average (GPA) [ 64 , 67 ] and one used a percentile rank [ 3 ]. Most researchers provided a test to measure the students’ knowledge of a specific topic [ 44 , 51 , 57 , 60 , 64 , 71 , 76 ] (e.g., anatomic knowledge, ultrasound knowledge). They used pre-and post-tests to evaluate the effect of EAs and found a positive relation between academic performance and EA participation. However, the COMLEX Level 1 performance was not related to the EA [ 78 ].

Only three papers reported academic skills as outcomes of EA participation [ 47 , 60 , 73 ], two of which showed that hands-on practice in the extracurricular program was helpful in improving diagnostic reasoning and procedural skills [ 60 , 73 ]. Academic attitude includes a perceived understanding of the learned knowledge or skills or self-reported confidence about one’s clinical skills [ 48 , 60 , 75 , 76 ] and absence at school [ 72 ]. Generally, EA participation increased self-reported understanding and confidence. In one study, however, it did not boost confidence in using ultrasound, even though it increased ultrasound knowledge [ 57 ].

Health system science (HSS) competency

HSS is a framework to understand healthcare as a system focusing on patient care [ 79 ]. HSS has six core domains: health care structure and process, health system improvement, value in health care, population, public, and social determinants of health, clinical informatics and health technology, and healthcare policy and economics [ 79 ]. Eight articles reported improved competency under health system improvement and population and public health. Under health system improvement, students showcased a more positive attitude toward quality improvement [ 43 , 46 ] and increased knowledge of healthcare management [ 45 ]. Students also learned about underrepresented populations [ 23 , 68 ], infectious diseases, and preventive strategies [ 29 , 49 , 50 ], which fell under population and public health.

Psychological outcomes

14 articles surveyed the psychological states and motivations of students as a potential outcome of EAs. Most of them focused on negative states: stress and burnout [ 2 , 17 , 23 , 26 , 34 , 35 , 36 , 39 , 61 , 65 ], anxiety, and aggression [ 17 , 20 ]. Two papers investigated positive states: tolerance of ambiguity and uncertainty [ 52 ], and work-life balance [ 70 ]. Generally, EA participation alleviated the negative states and increased the positive states. However, the amount of time invested in EAs was not related to burnout and even showed low efficacy [ 37 ].

Two papers dealt with motivation, each of which investigated goal orientation and intrinsic motivation. Under goal orientation, engaging in physical activity was positively associated with the mastery approach [ 36 ]. Under intrinsic motivation, students reported higher autonomy in extracurricular sessions than in mandatory sessions [ 30 ].

Teamwork and communication skills

Medical students need to develop teamwork and communication skills as they have to collaborate with other health professionals while attending to patients. Seven articles investigated the effects of EA on teamwork and communication skills. Students who participated in EAs considered teamwork valuable [ 22 ], reported increased knowledge, exhibited positive perception of nurses and pharmacists [ 62 ], and showed improved cultural competency [ 41 ], leadership [ 31 ], and communication skills [ 29 , 45 , 66 ].

Research engagement and competency

Research engagement is one of the four student engagement domains in health professional education [ 80 ]. It is essential for medical students to conduct research and develop research competency considering the importance of evidence-based medicine and the critical role of the physician-scientist [ 81 ]. Six articles investigated various variables related to research. One study compared the students’ knowledge of critical thinking and research methods before and after an ultrasound workshop [ 66 ]. Two papers measured attitudes toward research and self-perfection about research skills [ 27 , 64 ], and two studies investigated actual involvement in research, like continuing research in a Ph.D. program and conference attendance [ 24 , 53 ]. One study reported that EA participation increased both intention and interest in paper publishing and actual paper publishing [ 55 ]. EAs were beneficial for increasing research skills and knowledge and cultivating a positive and more enthusiastic attitude toward research.

Career development

The careers of most medical students seem to be determined upon their admission to the medical college. However, students require more time to determine their preferred choice of major as they determine their career path. Ten articles investigated the outcomes related to knowledge and attitude about specialized medical fields, and five articles focused on professionalism. Among the articles on career choice, some measured the match rate [ 19 , 21 , 25 , 77 ], the students’ interest in and intention to apply to specific majors [ 25 , 32 , 54 , 59 ], or the knowledge and perception of the majors [ 31 , 32 , 39 , 54 , 76 , 77 ]. Professionalism was mainly about patient care [ 22 , 54 , 75 ] and medical ethics [ 33 , 69 ]. These researchers reported that having exposure to specific fields helped students develop a favorable attitude and deepen their understanding of the specialties, which contributed to the development of professionalism.

Miscellaneous topics

The outcomes from 13 articles did not fall into the six categories mentioned above. Three articles reported that EA participants could help students manage their time and stress [ 26 , 31 , 66 ]. They found a workshop about stress [ 66 ] or leadership [ 31 ], and a mindfulness program [ 26 ] helped self-management. Five articles investigated the relation between EAs and physical health or physical ability [ 18 , 28 , 58 , 63 , 74 ], such as the prevalence of tuberculosis infection, vaccination coverage, and visual-spatial abilities. Two articles mentioned time use; participation in academic-scientific programs negatively predicted the use of social networks [ 56 ], and students reported that they lost time due to EA participation [ 23 ]. Students reported that they could communicate and feel connected with faculty and students by participating in EAs [ 23 , 42 ]. The last two studies explored what the other researchers had not dealt with; confidence [ 38 ] and passion in teaching and emotional intelligence [ 40 ], both of which were positively related to EA participation.

This review synthesized the types and effects of EAs in medical colleges. To our knowledge, this is the first attempt to develop an overarching picture of the importance of EAs in undergraduate medical education and their implications. The use of the integrative model in this paper helps in gaining a comprehensive understanding of the role of EAs in colleges with distinctive characteristics of medical education.

We embodied the type of EAs by categorizing unique EAs that were found in medical education. In earlier education studies, EAs were generally classified. Shamsudin et al. (2014) sorted EAs into physical, educational, and social programs [ 82 ]. Gilman et al. (2004) differentiated structured collaborative activities from solitary and non-structured activities [ 83 ]. Contrarily, the MSALT classification system had the advantage of providing subdivisions based on activity characteristics [ 84 ]. However, a concrete EA-type system reflecting the features of undergraduate medical students was needed, in that this classification system was for adolescents. We additionally sorted research activities and career development activities in the process of presenting the integrated model. We expanded the MSALT classification to fit it within the context of medical education.

Our findings about the outcomes of EAs reflect the features of medical education, replicating the prior studies on higher education [ 85 ]. Firstly, as reported in previous research, EA participation increased GPA [ 86 , 87 ]. It also developed medical knowledge, skills, and self-perception of the learned materials and skills. While HSS is considered as a third curriculum [ 79 ], concerns have been raised about the feasibility of adding class time for HSS to the regular curriculum due to its hectic nature [ 88 ]. We present studies where students can develop their HSS competency in EAs. Secondly, EA studies in medical education focused more on negative states like stress and burnout, while studies on non-medical undergraduate students focused on mental health or well-being [ 89 , 90 ]. This is likely because stress and burnout are prevalent among medical students [ 61 ]. Thirdly, medical students, like engineering students, developed their knowledge, attitude, and skills needed for teamwork [ 91 ]. Fourthly, EAs related to scholarly research enhanced students’ research engagement and research competency, which is in line with the article that investigated research engagement in health professional education [ 80 ]. In medical education, extracurricular research programs focused on fostering positive research attitudes and increasing research involvement, while mandatory research programs focused on developing research knowledge and skills [ 92 ]. Also, medical students deepened their understanding and interest in specific specialties and developed professionalism through EA participation. This may imply that the regular curriculum, including clerkships, provides limited opportunities for exploring specialties. Lastly, the typical outcomes among miscellaneous topics were physical health and physical ability. Only two articles demonstrated a sense of belonging and communication with others as positive outcomes of EA. Medical students’ motivation for EA participation includes networking [ 1 , 93 ] and interaction with faculty and peers, which has a positive effect on students’ satisfaction and career motivation [ 94 ]. These need to be considered as important outcomes in medical education.

Even though we tried our best to comprehensively investigate all apposite studies, the selection criteria might have excluded some relevant articles. That is, we might have missed some relevant studies because of the nature of the search strings used, that is, if the keywords did not appear in the title or abstract. For example, there were no studies found about EA by racial or cultural organizations like Latino Medical Student Association (LMSA), or Student National Medical Association (SNMA), even though they play a huge role in medical education. It might be because research about LMSA or SNMA might not use the keyword “extracurricular activity” as they are big enough not to be named under EA, or it might be a limitation of the database we used as we searched articles on Scopus and PubMed only. Furthermore, this review excluded studies published in languages other than English. Thus, we could not capture the dynamics of EAs in non-English speaking countries; this may lead to an increased risk of bias and limit the generalizability of findings. In the process of deriving an integrative model, we might have missed some distinguishing features of EAs that are specific to the social, institutional, and educational context of individual countries and schools. However, three main researchers took turns examining the articles to derive the most balanced and integrated model.

We would like to propose further research suggestions based on the results and discussion. First, future studies in medical education should prioritize establishing a clear definition of EAs and their subdivisions using standardized categories, based on a thorough analysis of previous studies. This is because the systematization of conceptual definition and classification system guarantees the accumulation of productive knowledge. Second, further research exploring the balanced and effective growth of students’ capacities through EA is needed. We outlined the effects of EAs; EA participation outcomes are related to factors that are rarely covered in the regular curriculum, and the effects of EA can span across several domains. Further research on the usage of EAs for students' holistic development is warranted. Third, follow-up research will be required to overcome the bias toward quantitative research and encourage qualitative research. It is expected that researchers will be able to find the unforeseen aspect and effects of EA through various qualitative methods such as interviews, focus groups, and observational records.

Based on our work, we make the following recommendations for medical educators. First, we recommend that medical educators provide students with diverse and balanced EAs to provide them with rich learning experiences. This is because the outcomes of EAs can be derived differently depending on the EA type. Second, schools need to explain the expected outcomes of EAs and regularly follow up on the students to ensure they benefit from EAs without losing time and stamina. It is difficult to gauge the effects of EAs, as they are not often assessed. Furthermore, it is possible that students feel stressed or lose study time owing to EA participation. Schools can assist the students' choice and participation in EAs by explaining and assessing the effect of EAs.

This study aimed to collect and synthesize previous articles that dealt with the EAs in undergraduate medical education and their learning impacts, thereby presenting an integrative model of the given topic. Despite a growing emphasis on EAs and the emergence of various types of research, there is no holistic approach to embrace the broadness of previous studies in a collective way. Therefore, this integrative review attempted to expand the understanding of the relevance and implications of EAs to the learning experiences of undergraduate medical students.

EAs in undergraduate medical school were classified into two main categories: DEAs and IEAs. The latter can be further classified into nine categories. It was found that IEA is more widely implemented than DEA, among which pro-social activities ranked at the top, followed by team sports and research activities. Regarding the outcomes of EAs, we identified seven main categories. Most of the selected articles dealt with academic outcomes and career development, which are deeply related to major-specific knowledge, clinical skill, and interest or intention to pursue a certain medical specialty. Psychological outcomes such as burnout and stress represented the second most common category, which reflects the distinctive nature of a medical education context.

Availability of data and materials

The dataset used during the current study is available from the corresponding author upon reasonable request.

Abbreviations

Extracurricular Activity

Direct Extracurricular Activity

Indirect Extracurricular Activity

Michigan Study of Adolescent Life Transitions

Human Resource Development

Grade Point Average

Health System Science

Latino Medical Student Association

Student National Medical Association

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Examining the role of community resilience and social capital on mental health in public health emergency and disaster response: a scoping review

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The ability of the public to remain psychologically resilient in the face of public health emergencies and disasters (such as the COVID-19 pandemic) is a key factor in the effectiveness of a national response to such events. Community resilience and social capital are often perceived as beneficial and ensuring that a community is socially and psychologically resilient may aid emergency response and recovery. This review presents a synthesis of literature which answers the following research questions: How are community resilience and social capital quantified in research?; What is the impact of community resilience on mental wellbeing?; What is the impact of infectious disease outbreaks, disasters and emergencies on community resilience and social capital?; and, What types of interventions enhance community resilience and social capital?

A scoping review procedure was followed. Searches were run across Medline, PsycInfo, and EMBASE, with search terms covering both community resilience and social capital, public health emergencies, and mental health. 26 papers met the inclusion criteria.

The majority of retained papers originated in the USA, used a survey methodology to collect data, and involved a natural disaster. There was no common method for measuring community resilience or social capital. The association between community resilience and social capital with mental health was regarded as positive in most cases. However, we found that community resilience, and social capital, were initially negatively impacted by public health emergencies and enhanced by social group activities.

Several key recommendations are proposed based on the outcomes from the review, which include: the need for a standardised and validated approach to measuring both community resilience and social capital; that there should be enhanced effort to improve preparedness to public health emergencies in communities by gauging current levels of community resilience and social capital; that community resilience and social capital should be bolstered if areas are at risk of disasters or public health emergencies; the need to ensure that suitable short-term support is provided to communities with high resilience in the immediate aftermath of a public health emergency or disaster; the importance of conducting robust evaluation of community resilience initiatives deployed during the COVID-19 pandemic.

Peer Review reports

For the general population, public health emergencies and disasters (e.g., natural disasters; infectious disease outbreaks; Chemical, Biological, Radiological or Nuclear incidents) can give rise to a plethora of negative outcomes relating to both health (e.g. increased mental health problems [ 1 , 2 , 3 , 4 ]) and the economy (e.g., increased unemployment and decreased levels of tourism [ 4 , 5 , 6 ]). COVID-19 is a current, and ongoing, example of a public health emergency which has affected over 421 million individuals worldwide [ 7 ]. The long term implications of COVID-19 are not yet known, but there are likely to be repercussions for physical health, mental health, and other non-health related outcomes for a substantial time to come [ 8 , 9 ]. As a result, it is critical to establish methods which may inform approaches to alleviate the longer-term negative consequences that are likely to emerge in the aftermath of both COVID-19 and any future public health emergency.

The definition of resilience often differs within the literature, but ultimately resilience is considered a dynamic process of adaptation. It is related to processes and capabilities at the individual, community and system level that result in good health and social outcomes, in spite of negative events, serious threats and hazards [ 10 ]. Furthermore, Ziglio [ 10 ] refers to four key types of resilience capacity: adaptive, the ability to withstand and adjust to unfavourable conditions and shocks; absorptive, the ability to withstand but also to recover and manage using available assets and skills; anticipatory, the ability to predict and minimize vulnerability; and transformative, transformative change so that systems better cope with new conditions.

There is no one settled definition of community resilience (CR). However, it generally relates to the ability of a community to withstand, adapt and permit growth in adverse circumstances due to social structures, networks and interdependencies within the community [ 11 ]. Social capital (SC) is considered a major determinant of CR [ 12 , 13 ], and reflects strength of a social network, community reciprocity, and trust in people and institutions [ 14 ]. These aspects of community are usually conceptualised primarily as protective factors that enable communities to cope and adapt collectively to threats. SC is often broken down into further categories [ 15 ], for example: cognitive SC (i.e. perceptions of community relations, such as trust, mutual help and attachment) and structural SC (i.e. what actually happens within the community, such as participation, socialising) [ 16 ]; or, bonding SC (i.e. connections among individuals who are emotionally close, and result in bonds to a particular group [ 17 ]) and bridging SC (i.e. acquaintances or individuals loosely connected that span different social groups [ 18 ]). Generally, CR is perceived to be primarily beneficial for multiple reasons (e.g. increased social support [ 18 , 19 ], protection of mental health [ 20 , 21 ]), and strengthening community resilience is a stated health goal of the World Health Organisation [ 22 ] when aiming to alleviate health inequalities and protect wellbeing. This is also reflected by organisations such as Public Health England (now split into the UK Health Security Agency and the Office for Health Improvement and Disparities) [ 23 ] and more recently, CR has been targeted through the endorsement of Community Champions (who are volunteers trained to support and to help improve health and wellbeing. Community Champions also reflect their local communities in terms of population demographics for example age, ethnicity and gender) as part of the COVID-19 response in the UK (e.g. [ 24 , 25 ]).

Despite the vested interest in bolstering communities, the research base establishing: how to understand and measure CR and SC; the effect of CR and SC, both during and following a public health emergency (such as the COVID-19 pandemic); and which types of CR or SC are the most effective to engage, is relatively small. Given the importance of ensuring resilience against, and swift recovery from, public health emergencies, it is critically important to establish and understand the evidence base for these approaches. As a result, the current review sought to answer the following research questions: (1) How are CR and SC quantified in research?; (2) What is the impact of community resilience on mental wellbeing?; (3) What is the impact of infectious disease outbreaks, disasters and emergencies on community resilience and social capital?; and, (4) What types of interventions enhance community resilience and social capital?

By collating research in order to answer these research questions, the authors have been able to propose several key recommendations that could be used to both enhance and evaluate CR and SC effectively to facilitate the long-term recovery from COVID-19, and also to inform the use of CR and SC in any future public health disasters and emergencies.

A scoping review methodology was followed due to the ease of summarising literature on a given topic for policy makers and practitioners [ 26 ], and is detailed in the following sections.

Identification of relevant studies

An initial search strategy was developed by authors CH and DW and included terms which related to: CR and SC, given the absence of a consistent definition of CR, and the link between CR and SC, the review focuses on both CR and SC to identify as much relevant literature as possible (adapted for purpose from Annex 1: [ 27 ], as well as through consultation with review commissioners); public health emergencies and disasters [ 28 , 29 , 30 , 31 ], and psychological wellbeing and recovery (derived a priori from literature). To ensure a focus on both public health and psychological research, the final search was carried across Medline, PsycInfo, and EMBASE using OVID. The final search took place on the 18th of May 2020, the search strategy used for all three databases can be found in Supplementary file 1 .

Selection criteria

The inclusion and exclusion criteria were developed alongside the search strategy. Initially the criteria were relatively inclusive and were subject to iterative development to reflect the authors’ familiarisation with the literature. For example, the decision was taken to exclude research which focused exclusively on social support and did not mention communities as an initial title/abstract search suggested that the majority of this literature did not meet the requirements of our research question.

The full and final inclusion and exclusion criteria used can be found in Supplementary file 2 . In summary, authors decided to focus on the general population (i.e., non-specialist, e.g. non-healthcare worker or government official) to allow the review to remain community focused. The research must also have assessed the impact of CR and/or SC on mental health and wellbeing, resilience, and recovery during and following public health emergencies and infectious disease outbreaks which affect communities (to ensure the research is relevant to the review aims), have conducted primary research, and have a full text available or provided by the first author when contacted.

Charting the data

All papers were first title and abstract screened by CH or DW. Papers then were full text reviewed by CH to ensure each paper met the required eligibility criteria, if unsure about a paper it was also full text reviewed by DW. All papers that were retained post full-text review were subjected to a standardised data extraction procedure. A table was made for the purpose of extracting the following data: title, authors, origin, year of publication, study design, aim, disaster type, sample size and characteristics, variables examined, results, restrictions/limitations, and recommendations. Supplementary file 3 details the charting the data process.

Analytical method

Data was synthesised using a Framework approach [ 32 ], a common method for analysing qualitative research. This method was chosen as it was originally used for large-scale social policy research [ 33 ] as it seeks to identify: what works, for whom, in what conditions, and why [ 34 ]. This approach is also useful for identifying commonalities and differences in qualitative data and potential relationships between different parts of the data [ 33 ]. An a priori framework was established by CH and DW. Extracted data was synthesised in relation to each research question, and the process was iterative to ensure maximum saturation using the available data.

Study selection

The final search strategy yielded 3584 records. Following the removal of duplicates, 2191 records remained and were included in title and abstract screening. A PRISMA flow diagram is presented in Fig.  1 .

PRISMA flow diagram

At the title and abstract screening stage, the process became more iterative as the inclusion criteria were developed and refined. For the first iteration of screening, CH or DW sorted all records into ‘include,’ ‘exclude,’ and ‘unsure’. All ‘unsure’ papers were re-assessed by CH, and a random selection of ~ 20% of these were also assessed by DW. Where there was disagreement between authors the records were retained, and full text screened. The remaining papers were reviewed by CH, and all records were categorised into ‘include’ and ‘exclude’. Following full-text screening, 26 papers were retained for use in the review.

Study characteristics

This section of the review addresses study characteristics of those which met the inclusion criteria, which comprises: date of publication, country of origin, study design, study location, disaster, and variables examined.

Date of publication

Publication dates across the 26 papers spanned from 2008 to 2020 (see Fig.  2 ). The number of papers published was relatively low and consistent across this timescale (i.e. 1–2 per year, except 2010 and 2013 when none were published) up until 2017 where the number of papers peaked at 5. From 2017 to 2020 there were 15 papers published in total. The amount of papers published in recent years suggests a shift in research and interest towards CR and SC in a disaster/ public health emergency context.

Graph to show retained papers date of publication

Country of origin

The locations of the first authors’ institutes at the time of publication were extracted to provide a geographical spread of the retained papers. The majority originated from the USA [ 35 , 36 , 37 , 38 , 39 , 40 , 41 ], followed by China [ 42 , 43 , 44 , 45 , 46 ], Japan [ 47 , 48 , 49 , 50 ], Australia [ 51 , 52 , 53 ], The Netherlands [ 54 , 55 ], New Zealand [ 56 ], Peru [ 57 ], Iran [ 58 ], Austria [ 59 ], and Croatia [ 60 ].

There were multiple methodological approaches carried out across retained papers. The most common formats included surveys or questionnaires [ 36 , 37 , 38 , 42 , 46 , 47 , 48 , 49 , 50 , 53 , 54 , 55 , 57 , 59 ], followed by interviews [ 39 , 40 , 43 , 51 , 52 , 60 ]. Four papers used both surveys and interviews [ 35 , 41 , 45 , 58 ], and two papers conducted data analysis (one using open access data from a Social Survey [ 44 ] and one using a Primary Health Organisations Register [ 56 ]).

Study location

The majority of the studies were carried out in Japan [ 36 , 42 , 44 , 47 , 48 , 49 , 50 ], followed by the USA [ 35 , 37 , 38 , 39 , 40 , 41 ], China [ 43 , 45 , 46 , 53 ], Australia [ 51 , 52 ], and the UK [ 54 , 55 ]. The remaining studies were carried out in Croatia [ 60 ], Peru [ 57 ], Austria [ 59 ], New Zealand [ 56 ] and Iran [ 58 ].

Multiple different types of disaster were researched across the retained papers. Earthquakes were the most common type of disaster examined [ 45 , 47 , 49 , 50 , 53 , 56 , 57 , 58 ], followed by research which assessed the impact of two disastrous events which had happened in the same area (e.g. Hurricane Katrina and the Deepwater Horizon oil spill in Mississippi, and the Great East Japan earthquake and Tsunami; [ 36 , 37 , 38 , 42 , 44 , 48 ]). Other disaster types included: flooding [ 51 , 54 , 55 , 59 , 60 ], hurricanes [ 35 , 39 , 41 ], infectious disease outbreaks [ 43 , 46 ], oil spillage [ 40 ], and drought [ 52 ].

Variables of interest examined

Across the 26 retained papers: eight referred to examining the impact of SC [ 35 , 37 , 39 , 41 , 46 , 49 , 55 , 60 ]; eight examined the impact of cognitive and structural SC as separate entities [ 40 , 42 , 45 , 48 , 50 , 54 , 57 , 59 ]; one examined bridging and bonding SC as separate entities [ 58 ]; two examined the impact of CR [ 38 , 56 ]; and two employed a qualitative methodology but drew findings in relation to bonding and bridging SC, and SC generally [ 51 , 52 ]. Additionally, five papers examined the impact of the following variables: ‘community social cohesion’ [ 36 ], ‘neighbourhood connectedness’ [ 44 ], ‘social support at the community level’ [ 47 ], ‘community connectedness’ [ 43 ] and ‘sense of community’ [ 53 ]. Table  1 provides additional details on this.

How is CR and SC measured or quantified in research?

The measures used to examine CR and SC are presented Table  1 . It is apparent that there is no uniformity in how SC or CR is measured across the research. Multiple measures are used throughout the retained studies, and nearly all are unique. Additionally, SC was examined at multiple different levels (e.g. cognitive and structural, bonding and bridging), and in multiple different forms (e.g. community connectedness, community cohesion).

What is the association between CR and SC on mental wellbeing?

To best compare research, the following section reports on CR, and facets of SC separately. Please see Supplementary file 4  for additional information on retained papers methods of measuring mental wellbeing.

• Community resilience

CR relates to the ability of a community to withstand, adapt and permit growth in adverse circumstances due to social structures, networks and interdependencies within the community [ 11 ].

The impact of CR on mental wellbeing was consistently positive. For example, research indicated that there was a positive association between CR and number of common mental health (i.e. anxiety and mood) treatments post-disaster [ 56 ]. Similarly, other research suggests that CR is positively related to psychological resilience, which is inversely related to depressive symptoms) [ 37 ]. The same research also concluded that CR is protective of psychological resilience and is therefore protective of depressive symptoms [ 37 ].

• Social capital

SC reflects the strength of a social network, community reciprocity, and trust in people and institutions [ 14 ]. These aspects of community are usually conceptualised primarily as protective factors that enable communities to cope and adapt collectively to threats.

There were inconsistencies across research which examined the impact of abstract SC (i.e. not refined into bonding/bridging or structural/cognitive) on mental wellbeing. However, for the majority of cases, research deems SC to be beneficial. For example, research has concluded that, SC is protective against post-traumatic stress disorder [ 55 ], anxiety [ 46 ], psychological distress [ 50 ], and stress [ 46 ]. Additionally, SC has been found to facilitate post-traumatic growth [ 38 ], and also to be useful to be drawn upon in times of stress [ 52 ], both of which could be protective of mental health. Similarly, research has also found that emotional recovery following a disaster is more difficult for those who report to have low levels of SC [ 51 ].

Conversely, however, research has also concluded that when other situational factors (e.g. personal resources) were controlled for, a positive relationship between community resources and life satisfaction was no longer significant [ 60 ]. Furthermore, some research has concluded that a high level of SC can result in a community facing greater stress immediately post disaster. Indeed, one retained paper found that high levels of SC correlate with higher levels of post-traumatic stress immediately following a disaster [ 39 ]. However, in the later stages following a disaster, this relationship can reverse, with SC subsequently providing an aid to recovery [ 41 ]. By way of explanation, some researchers have suggested that communities with stronger SC carry the greatest load in terms of helping others (i.e. family, friends and neighbours) as well as themselves immediately following the disaster, but then as time passes the communities recover at a faster rate as they are able to rely on their social networks for support [ 41 ].

Cognitive and structural social capital

Cognitive SC refers to perceptions of community relations, such as trust, mutual help and attachment, and structural SC refers to what actually happens within the community, such as participation, socialising [ 16 ].

Cognitive SC has been found to be protective [ 49 ] against PTSD [ 54 , 57 ], depression [ 40 , 54 ]) mild mood disorder; [ 48 ]), anxiety [ 48 , 54 ] and increase self-efficacy [ 59 ].

For structural SC, research is again inconsistent. On the one hand, structural SC has been found to: increase perceived self-efficacy, be protective of depression [ 40 ], buffer the impact of housing damage on cognitive decline [ 42 ] and provide support during disasters and over the recovery period [ 59 ]. However, on the other hand, it has been found to have no association with PTSD [ 54 , 57 ] or depression, and is also associated with a higher prevalence of anxiety [ 54 ]. Similarly, it is also suggested by additional research that structural SC can harm women’s mental health, either due to the pressure of expectations to help and support others or feelings of isolation [ 49 ].

Bonding and bridging social capital

Bonding SC refers to connections among individuals who are emotionally close, and result in bonds to a particular group [ 17 ], and bridging SC refers to acquaintances or individuals loosely connected that span different social groups [ 18 ].

One research study concluded that both bonding and bridging SC were protective against post-traumatic stress disorder symptoms [ 58 ]. Bridging capital was deemed to be around twice as effective in buffering against post-traumatic stress disorder than bonding SC [ 58 ].

Other community variables

Community social cohesion was significantly associated with a lower risk of post-traumatic stress disorder symptom development [ 35 ], and this was apparent even whilst controlling for depressive symptoms at baseline and disaster impact variables (e.g. loss of family member or housing damage) [ 36 ]. Similarly, sense of community, community connectedness, social support at the community level and neighbourhood connectedness all provided protective benefits for a range of mental health, wellbeing and recovery variables, including: depression [ 53 ], subjective wellbeing (in older adults only) [ 43 ], psychological distress [ 47 ], happiness [ 44 ] and life satisfaction [ 53 ].

Research has also concluded that community level social support is protective against mild mood and anxiety disorder, but only for individuals who have had no previous disaster experience [ 48 ]. Additionally, a study which separated SC into social cohesion and social participation concluded that at a community level, social cohesion is protective against depression [ 49 ] whereas social participation at community level is associated with an increased risk of depression amongst women [ 49 ].

What is the impact of Infectious disease outbreaks / disasters and emergencies on community resilience?

From a cross-sectional perspective, research has indicated that disasters and emergencies can have a negative effect on certain types of SC. Specifically, cognitive SC has been found to be impacted by disaster impact, whereas structural SC has gone unaffected [ 45 ]. Disaster impact has also been shown to have a negative effect on community relationships more generally [ 52 ].

Additionally, of the eight studies which collected data at multiple time points [ 35 , 36 , 41 , 42 , 47 , 49 , 56 , 60 ], three reported the effect of a disaster on the level of SC within a community [ 40 , 42 , 49 ]. All three of these studies concluded that disasters may have a negative impact on the levels of SC within a community. The first study found that the Deepwater Horizon oil spill had a negative effect on SC and social support, and this in turn explained an overall increase in the levels of depression within the community [ 40 ]. A possible explanation for the negative effect lays in ‘corrosive communities’, known for increased social conflict and reduced social support, that are sometimes created following oil spills [ 40 ]. It is proposed that corrosive communities often emerge due to a loss of natural resources that bring social groups together (e.g., for recreational activities), as well as social disparity (e.g., due to unequal distribution of economic impact) becoming apparent in the community following disaster [ 40 ]. The second study found that SC (in the form of social cohesion, informal socialising and social participation) decreased after the 2011 earthquake and tsunami in Japan; it was suggested that this change correlated with incidence of cognitive decline [ 42 ]. However, the third study reported more mixed effects based on physical circumstances of the communities’ natural environment: Following an earthquake, those who lived in mountainous areas with an initial high level of pre-community SC saw a decrease in SC post disaster [ 49 ]. However, communities in flat areas (which were home to younger residents and had a higher population density) saw an increase in SC [ 49 ]. It was proposed that this difference could be due to the need for those who lived in mountainous areas to seek prolonged refuge due to subsequent landslides [ 49 ].

What types of intervention enhance CR and SC and protect survivors?

There were mixed effects across the 26 retained papers when examining the effect of CR and SC on mental wellbeing. However, there is evidence that an increase in SC [ 56 , 57 ], with a focus on cognitive SC [ 57 ], namely by: building social networks [ 45 , 51 , 53 ], enhancing feelings of social cohesion [ 35 , 36 ] and promoting a sense of community [ 53 ], can result in an increase in CR and potentially protect survivors’ wellbeing and mental health following a disaster. An increase in SC may also aid in decreasing the need for individual psychological interventions in the aftermath of a disaster [ 55 ]. As a result, recommendations and suggested methods to bolster CR and SC from the retained papers have been extracted and separated into general methods, preparedness and policy level implementation.

General methods

Suggested methods to build SC included organising recreational activity-based groups [ 44 ] to broaden [ 51 , 53 ] and preserve current social networks [ 42 ], introducing initiatives to increase social cohesion and trust [ 51 ], and volunteering to increase the number of social ties between residents [ 59 ]. Research also notes that it is important to take a ‘no one left behind approach’ when organising recreational and social community events, as failure to do so could induce feelings of isolation for some members of the community [ 49 ]. Furthermore, gender differences should also be considered as research indicates that males and females may react differently to community level SC (as evidence suggests males are instead more impacted by individual level SC; in comparison to women who have larger and more diverse social networks [ 49 ]). Therefore, interventions which aim to raise community level social participation, with the aim of expanding social connections and gaining support, may be beneficial [ 42 , 47 ].

Preparedness

In order to prepare for disasters, it may be beneficial to introduce community-targeted methods or interventions to increase levels of SC and CR as these may aid in ameliorating the consequences of a public health emergency or disaster [ 57 ]. To indicate which communities have low levels of SC, one study suggests implementing a 3-item scale of social cohesion to map areas and target interventions [ 42 ].

It is important to consider that communities with a high level of SC may have a lower level of risk perception, due to the established connections and supportive network they have with those around them [ 61 ]. However, for the purpose of preparedness, this is not ideal as perception of risk is a key factor when seeking to encourage behavioural adherence. This could be overcome by introducing communication strategies which emphasise the necessity of social support, but also highlights the need for additional measures to reduce residual risk [ 59 ]. Furthermore, support in the form of financial assistance to foster current community initiatives may prove beneficial to rural areas, for example through the use of an asset-based community development framework [ 52 ].

Policy level

At a policy level, the included papers suggest a range of ways that CR and SC could be bolstered and used. These include: providing financial support for community initiatives and collective coping strategies, (e.g. using asset-based community development [ 52 ]); ensuring policies for long-term recovery focus on community sustainable development (e.g. community festival and community centre activities) [ 44 ]; and development of a network amongst cooperative corporations formed for reconstruction and to organise self-help recovery sessions among residents of adjacent areas [ 58 ].

This scoping review sought to synthesise literature concerning the role of SC and CR during public health emergencies and disasters. Specifically, in this review we have examined: the methods used to measure CR and SC; the impact of CR and SC on mental wellbeing during disasters and emergencies; the impact of disasters and emergencies on CR and SC; and the types of interventions which can be used to enhance CR. To do this, data was extracted from 26 peer-reviewed journal articles. From this synthesis, several key themes have been identified, which can be used to develop guidelines and recommendations for deploying CR and SC in a public health emergency or disaster context. These key themes and resulting recommendations are summarised below.

Firstly, this review established that there is no consistent or standardised approach to measuring CR or SC within the general population. This finding is consistent with a review conducted by the World Health Organization which concludes that despite there being a number of frameworks that contain indicators across different determinants of health, there is a lack of consensus on priority areas for measurement and no widely accepted indicator [ 27 ]. As a result, there are many measures of CR and SC apparent within the literature (e.g., [ 62 , 63 ]), an example of a developed and validated measure is provided by Sherrieb, Norris and Galea [ 64 ]. Similarly, the definitions of CR and SC differ widely between researchers, which created a barrier to comparing and summarising information. Therefore, future research could seek to compare various interpretations of CR and to identify any overlapping concepts. However, a previous systemic review conducted by Patel et al. (2017) concludes that there are nine core elements of CR (local knowledge, community networks and relationships, communication, health, governance and leadership, resources, economic investment, preparedness, and mental outlook), with 19 further sub-elements therein [ 30 ]. Therefore, as CR is a multi-dimensional construct, the implications from the findings are that multiple aspects of social infrastructure may need to be considered.

Secondly, our synthesis of research concerning the role of CR and SC for ensuring mental health and wellbeing during, or following, a public health emergency or disaster revealed mixed effects. Much of the research indicates either a generally protective effect on mental health and wellbeing, or no effect; however, the literature demonstrates some potential for a high level of CR/SC to backfire and result in a negative effect for populations during, or following, a public health emergency or disaster. Considered together, our synthesis indicates that cognitive SC is the only facet of SC which was perceived as universally protective across all retained papers. This is consistent with a systematic review which also concludes that: (a) community level cognitive SC is associated with a lower risk of common mental disorders, while; (b) community level structural SC had inconsistent effects [ 65 ].

Further examination of additional data extracted from studies which found that CR/SC had a negative effect on mental health and wellbeing revealed no commonalities that might explain these effects (Please see Supplementary file 5 for additional information)

One potential explanation may come from a retained paper which found that high levels of SC result in an increase in stress level immediately post disaster [ 41 ]. This was suggested to be due to individuals having greater burdens due to wishing to help and support their wide networks as well as themselves. However, as time passes the levels of SC allow the community to come together and recover at a faster rate [ 41 ]. As this was the only retained paper which produced this finding, it would be beneficial for future research to examine boundary conditions for the positive effects of CR/SC; that is, to explore circumstances under which CR/SC may be more likely to put communities at greater risk. This further research should also include additional longitudinal research to validate the conclusions drawn by [ 41 ] as resilience is a dynamic process of adaption.

Thirdly, disasters and emergencies were generally found to have a negative effect on levels of SC. One retained paper found a mixed effect of SC in relation to an earthquake, however this paper separated participants by area in which they lived (i.e., mountainous vs. flat), which explains this inconsistent effect [ 49 ]. Dangerous areas (i.e. mountainous) saw a decrease in community SC in comparison to safer areas following the earthquake (an effect the authors attributed to the need to seek prolonged refuge), whereas participants from the safer areas (which are home to younger residents with a higher population density) saw an increase in SC [ 49 ]. This is consistent with the idea that being able to participate socially is a key element of SC [ 12 ]. Overall, however, this was the only retained paper which produced a variable finding in relation to the effect of disaster on levels of CR/SC.

Finally, research identified through our synthesis promotes the idea of bolstering SC (particularly cognitive SC) and cohesion in communities likely to be affected by disaster to improve levels of CR. This finding provides further understanding of the relationship between CR and SC; an association that has been reported in various articles seeking to provide conceptual frameworks (e.g., [ 66 , 67 ]) as well as indicator/measurement frameworks [ 27 ]. Therefore, this could be done by creating and promoting initiatives which foster SC and create bonds within the community. Papers included in the current review suggest that recreational-based activity groups and volunteering are potential methods for fostering SC and creating community bonds [ 44 , 51 , 59 ]. Similarly, further research demonstrates that feelings of social cohesion are enhanced by general social activities (e.g. fairs and parades [ 18 ]). Also, actively encouraging activities, programs and interventions which enhance connectedness and SC have been reported to be desirable to increase CR [ 68 ]. This suggestion is supported by a recent scoping review of literature [ 67 ] examined community champion approaches for the COVID-19 pandemic response and recovery and established that creating and promoting SC focused initiatives within the community during pandemic response is highly beneficial [ 67 ]. In terms of preparedness, research states that it may be beneficial for levels of SC and CR in communities at risk to be assessed, to allow targeted interventions where the population may be at most risk following an incident [ 42 , 44 ]. Additionally, from a more critical perspective, we acknowledge that ‘resilience’ can often be perceived as a focus on individual capacity to adapt to adversity rather than changing or mitigating the causes of adverse conditions [ 69 , 70 ]. Therefore, CR requires an integrated system approach across individual, community and structural levels [ 17 ]. Also, it is important that community members are engaged in defining and agreeing how community resilience is measured [ 27 ] rather than it being imposed by system leads or decision-makers.

In the aftermath of the pandemic, is it expected that there will be long-term repercussions both from an economic [ 8 ] and a mental health perspective [ 71 ]. Furthermore, the findings from this review suggest that although those in areas with high levels of SC may be negatively affected in the acute stage, as time passes, they have potential to rebound at a faster rate than those with lower levels of SC. Ongoing evaluation of the effectiveness of current initiatives as the COVID-19 pandemic progresses into a recovery phase will be invaluable for supplementing the evidence base identified through this review.

• Recommendations

As a result of this review, a number of recommendations are suggested for policy and practice during public health emergencies and recovery.

Future research should seek to establish a standardised and validated approach to measuring and defining CR and SC within communities. There are ongoing efforts in this area, for example [ 72 ]. Additionally, community members should be involved in the process of defining how CR is measured.

There should be an enhanced effort to improve preparedness for public health emergencies and disasters in local communities by gauging current levels of SC and CR within communities using a standardised measure. This approach could support specific targeting of populations with low levels of CR/SC in case of a disaster or public health emergency, whilst also allowing for consideration of support for those with high levels of CR (as these populations can be heavily impacted initially following a disaster). By distinguishing levels of SC and CR, tailored community-centred approaches could be implemented, such as those listed in a guide released by PHE in 2015 [ 73 ].

CR and SC (specifically cognitive SC) should be bolstered if communities are at risk of experiencing a disaster or public health emergency. This can be achieved by using interventions which aim to increase a sense of community and create new social ties (e.g., recreational group activities, volunteering). Additionally, when aiming to achieve this, it is important to be mindful of the risk of increased levels of CR/SC to backfire, as well as seeking to advocate an integrated system approach across individual, community and structural levels.

It is necessary to be aware that although communities with high existing levels of resilience / SC may experience short-term negative consequences following a disaster, over time these communities might be able to recover at a faster rate. It is therefore important to ensure that suitable short-term support is provided to these communities in the immediate aftermath of a public health emergency or disaster.

Robust evaluation of the community resilience initiatives deployed during the COVID-19 pandemic response is essential to inform the evidence base concerning the effectiveness of CR/ SC. These evaluations should continue through the response phase and into the recovery phase to help develop our understanding of the long-term consequences of such interventions.

Limitations

Despite this review being the first in this specific topic area, there are limitations that must be considered. Firstly, it is necessary to note that communities are generally highly diverse and the term ‘community’ in academic literature is a subject of much debate (see: [ 74 ]), therefore this must be considered when comparing and collating research involving communities. Additionally, the measures of CR and SC differ substantially across research, including across the 26 retained papers used in the current review. This makes the act of comparing and collating research findings very difficult. This issue is highlighted as a key outcome from this review, and suggestions for how to overcome this in future research are provided. Additionally, we acknowledge that there will be a relationship between CR & SC even where studies measure only at individual or community level. A review [ 75 ] on articulating a hypothesis of the link to health inequalities suggests that wider structural determinants of health need to be accounted for. Secondly, despite the final search strategy encompassing terms for both CR and SC, only one retained paper directly measured CR; thus, making the research findings more relevant to SC. Future research could seek to focus on CR to allow for a comparison of findings. Thirdly, the review was conducted early in the COVID-19 pandemic and so does not include more recent publications focusing on resilience specifically in the context of COVID-19. Regardless of this fact, the synthesis of, and recommendations drawn from, the reviewed studies are agnostic to time and specific incident and contain critical elements necessary to address as the pandemic moves from response to recovery. Further research should review the effectiveness of specific interventions during the COVID-19 pandemic for collation in a subsequent update to this current paper. Fourthly, the current review synthesises findings from countries with individualistic and collectivistic cultures, which may account for some variation in the findings. Lastly, despite choosing a scoping review method for ease of synthesising a wide literature base for use by public health emergency researchers in a relatively tight timeframe, there are disadvantages of a scoping review approach to consider: (1) quality appraisal of retained studies was not carried out; (2) due to the broad nature of a scoping review, more refined and targeted reviews of literature (e.g., systematic reviews) may be able to provide more detailed research outcomes. Therefore, future research should seek to use alternative methods (e.g., empirical research, systematic reviews of literature) to add to the evidence base on CR and SC impact and use in public health practice.

This review sought to establish: (1) How CR and SC are quantified in research?; (2) The impact of community resilience on mental wellbeing?; (3) The impact of infectious disease outbreaks, disasters and emergencies on community resilience and social capital?; and, (4) What types of interventions enhance community resilience and social capital?. The chosen search strategy yielded 26 relevant papers from which we were able extract information relating to the aims of this review.

Results from the review revealed that CR and SC are not measured consistently across research. The impact of CR / SC on mental health and wellbeing during emergencies and disasters is mixed (with some potential for backlash), however the literature does identify cognitive SC as particularly protective. Although only a small number of papers compared CR or SC before and after a disaster, the findings were relatively consistent: SC or CR is negatively impacted by a disaster. Methods suggested to bolster SC in communities were centred around social activities, such as recreational group activities and volunteering. Recommendations for both research and practice (with a particular focus on the ongoing COVID-19 pandemic) are also presented.

Availability of data and materials

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

Abbreviations

Social Capital

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This study was supported by the National Institute for Health Research Research Unit (NIHR HPRU) in Emergency Preparedness and Response, a partnership between Public Health England, King’s College London and the University of East Anglia. The views expressed are those of the author(s) and not necessarily those of the NIHR, Public Health England, the UK Health Security Agency or the Department of Health and Social Care [Grant number: NIHR20008900]. Part of this work has been funded by the Office for Health Improvement and Disparities, Department of Health and Social Care, as part of a Collaborative Agreement with Leeds Beckett University.

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DW, JSo and JSt had the main idea for the review. The search strategy and eligibility criteria were devised by CH, DW, JSo and JSt. CH conducted the database searches. CH and DW conducted duplicate, title and abstract and full text screening in accordance with inclusion criteria. CH conducted data extraction, CH and DW carried out the analysis and drafted the initial manuscript. All authors provided critical revision of intellectual content. All authors approved the final manuscript.

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Hall, C.E., Wehling, H., Stansfield, J. et al. Examining the role of community resilience and social capital on mental health in public health emergency and disaster response: a scoping review. BMC Public Health 23 , 2482 (2023). https://doi.org/10.1186/s12889-023-17242-x

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Published : 12 December 2023

DOI : https://doi.org/10.1186/s12889-023-17242-x

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