Observational tools can help refine practice design and guide the creation of effective learning environments. The intention of this study was to design and validate an observational instrument for assessing physical literacy that remains more faithful to the philosophically complex and holistic nature of the concept.Framed by concepts of ecological dynamics, the emergent games-based assessment tool enables capture of children's interactions with their environment, providing insight on the manifestation of physical literacy within physical education games. The design and validation of the instrument consisted of a multistage process: (1) design of the observational instrument and establishing face validity; (2) pilot observation study; (3) expert qualitative and quantitative review to establish content validity; (4) observation training; and (5), establishing observer reliability.V coefficient was used to determine content validity. Results achieved demanding levels of validity (V ≥ 0.78) for all retained measurement variables. Cohen's κ values for inter- and intra-observer reliability ranged from 0.331 to 1.00 and 0.552 to 1.00, generally reporting “substantial” agreement during inter-observer analysis and “substantial” to “almost perfect” agreement during intra-observer analysis.Following expert qualitative and quantitative evaluation, Aiken's The final model of the emergent games-based assessment tool, with 9 ecological conceptualisations of behaviour, 15 measurement variables, and 44 categorical observational items was found to be valid and reliable, providing both educators and researchers with a useful mechanism to assess physical literacy during gameplay. Observational instruments and methodologies are important to the study and wider development of physical education as a subject. Observational tools help to inform and guide the practice of teachers in their quest to design effective learning environments for children and youth. The last twenty years has seen significant investment in the development and application of systematic observational tools, enabling the identification of key teacher and child behaviours for effective learning and development during physical education and sport lessons –5. The pPhysical literacy has rapidly permeated the practice and policy discourse among physical educators . WhiteheA physically literate individual moves with poise, economy and confidence in a wide variety of physically challenging situations. The individual is perceptive in “reading” all aspects of the physical environment, anticipating movement needs or possibilities and responding appropriately to these, with intelligence and imagination. Physical literacy requires a holistic engagement that encompasses physical capacities embedded in perception, experience, memory, anticipation and decision-making.Commonly expressed themes within the literature highlight that physical literacy involves equal consideration of movement competence, attributes, behaviours, knowledge, understanding and the valuing of interactions with the physical world . AlthougTo help contextualise this study, we have summarised the key pillars of ecological dynamics  used in the design of the instrument, highlighting how they align to features of the physical literacy construct. Applied to a games-based context, wayfinding might reveal itself through the functionally effective solving of emergent, task-orientated movement challenges. For example, successfully negotiating emerging and disappearing gaps between competing players, or finding ways of distributing the ball favourably in regard to immediate task goals would be reflective of an individual's embodied knowledge and capacity to effectively navigate the performance environment. Since individuals perceive affordances in terms of their relevance and functionality, it is possible to develop an ecological understanding of cognition and decision making by integrating principles of affordances and attunement into the creation of observational assessments. From a physical literacy perspective, seeking and exploiting important information in the environment reflects embedded knowledge and understanding, as well as supporting the ability to effectively adapt to novel situations and settings. Contested and uncontested distribution, signalling for the ball, off-ball movements to break or establish dyadic stability, and effectively tracking play are examples of variables that would provide insight to an individual's attunement to affordances presented in small-sided games, revealing features of the cognitive domain of physical literacy.Within an ecological dynamics framework it is possible to view motivation as the value or meaning given particular affordances, while intentionality captures the value and meaning of affordances during, and as a consequence of movement. Operationalising a person's intentionality as an expression of agency within an ecological dynamics conceptualisation of physical literacy is connected to the oscillating dynamics of the activity context and the perception of relevant information to enable exploitation of circumstances in an appealing manner. Coadaptive network formation when supporting play offensively, moderation of defensive pressure to close down, overload, or swarm opposition players, and defensive functionality in attempting or performing interceptions are examples of variables that provide insight to features of physical literacy's affective domain in small-sided games. Functional Movement Skills capture the qualities that allow individuals to negotiate their environment in the completion of intended task goals. Effective individual-environment interactions require holistic engagement whereby initial action results in further revelation of new affordances for competing and cooperating players and the individual themselves. The physically literate individual will demonstrate a fuller repertoire of emergent behaviours in pursuit of achieving task and performance goals, where cognition, perception, and action comprise the articulated functional movement observed. Heterogeneous or homogenous ball distribution; distribution distance, and direction, evidences features of physical literacy's movement competency domain in small-sided games.This is the first tool of which we are aware that frames physical literacy assessment and evaluation through a “games environment” providing representative design  as well To establish the validity and reliability of the emergent game-based assessment a multistage development process as outlined by Brewer and Jones , and recThe initial design of the observational instrument has been detailed previously in Wilkie et al. . In brieBefore this validation and reliability study, an initial pilot feasibility test evaluated the emergent games-based assessment tool, with the objective of making modifications, where necessary. The original category system design was comprised of three ecological conceptualisations of behaviours, 18 measurement variables and 42 categorial observation items. The category system for the emergent game-based assessment tool was developed into an electronic coding module allowing digital video-based tagging (Dartfish Pro) to be completed. Feasibility pilot testing with 10-minutes of physical education games footage was completed by the lead author. This approach ensured all technical and tactical behaviours were identified within the observational instrument. During this process, numerous scenarios not included in the initial list of behaviour categories were identified, and following subsequent meetings with the academic and technical experts these further categories were defined and added to the coding instrument. The feasibility testing resulted in adding behaviours that previously had not been defined at a theoretical level, but which manifested during games play . Similarly, at this stage of the design and validation process the reported frequencies across behaviour categories was reviewed, with the intent to use the data to demarcate, define, and confirm behaviour categories . At this point the observational manual was created in which the nine ecological conceptualisations of behaviours, 20 measurement variables and 61 categorial observation items  were named and defined. The outcomes related to the design of the observational instrument after the first two stages (development of the category system and pilot study) have been defined and described in detail previously . The inclusion criteria established for forming the expert panel were: (1) post graduate qualifications in pedagogy or Sports Science; (2) to be active practitioners or researchers in the field of pedagogy, physical education, or Sports Science; (3) to hold senior leadership or academic positions within their educational institutions ; (4) have a minimum of 10 years' experience within their field of expertise; and (5) to be able to demonstrate knowledge transfer within their field of expertise . Following similar approaches adopted within other sport observational instrument design and validation studies , 27, 28,fficient , 35, to Following the finalisation of the modified coding instrument an observer training programme was delivered. Rigorous observer training has been identified as particularly valuable in establishing the reliability and objectivity of an observation instrument . To thiskmeans cluster approach was utilised (R Core Team 2019) to detect and organise data into a number of groups via the elbow method. This analysis enabled the grouping of individuals with similar levels of physical literacy into higher and lower-physical literacy categories. All movie-test clips were taken from a fixed, elevated, court side position. This perspective allowed for all participants, and features of the playing area to be captured within the field of view. The movie-test recordings were provided to the observers as an electronic video file , with frame-by-frame playback options. Overall, 30 in-possession, 30 offensive off-ball, and 30 defensive off-ball events comprised the movie-test. A 90-clip movie-test was considered optimal as it provided acceptable variety in behaviours and enabled observers to complete the trial in a reasonable timeframe (90–120 min). The two trained observers conducted the electronic coding over a 14-day period, with a minimum of 7 days between the original and retest.To measure observer reliability, procedures outlined by Brewer and Jones  were folV coefficients , whereas 1 indicates highest response (“highly pertinent” or “very well defined”) from all experts  and eliminated if Aiken's V was ≤0.77. Of the remaining items deemed pertinent, the adequacy (definition) of the items was modified if Aiken's V was ≤0.77 and eligible for modification between 0.78 and 0.86 (95%–99% confidence level).All statistical analyses were performed in Microsoft® Excel® for Microsoft 365 (version 2301). The content validity of the quantitative evaluation of both pertinence and adequacy (definition) by the expert practitioners was determined by using Aiken's ficients . Aiken'sonstruct . Aiken'struct  was used to measure the inter-rater reliability (between the observer responses) and intra-rater reliability  of the observers using emergent games-based assessment tool. Cohen's κ was the preferred measure of reliability with categorical data, since it accounts for the likelihood of agreement by chance  with an average of 12.86 years' experience in their respective fields. All experts held post graduate qualifications in pedagogy or Sports Science, leadership or senior academic positions within their educational institutions, and were able to demonstrate knowledge transfer within their field of expertise. Aiken's Expert review resulted in 5 measurement items being eliminated from the tool. Additionally, 9 of the remaining variables reported values lower than 0.78 in the aspects of Adequacy (definition). These item descriptions were revised and improved following the recommendations of the experts. V from the quantitative evaluation by the expert panel reported all variables not eliminated had an Aiken's V value >0.78 and were consequently considered relevant for inclusion . Where these items were still deemed pertinent the descriptions were revised and refined following the qualitative commentary and recommendations of the experts. This process resulted in revising definitions of nine observational items . The number of experts that participated in the current study was greater than the number in similar studies validating observational instruments in sport e.g., , 37, 41], 4137, 4relevant . There wtems see . The revtems see , 43. Ju tems see  identifitems see . The comThe level of intra- and inter-observer agreement reported (Stage 5) confirms that after familiarisation with the coding instrument and the completion of the observer training programme the instrument can be considered reliable. All aspects of the emergent game-based assessment tool reported “fair-perfect” strength of agreement for reliability, with 83% of behaviours reporting “substantial” or better scores. The scale of analysis used in the emergent games-based assessment , capturing key affordances that a child attunes to and how they are functionally playing the game, results in a complex observational process being undertaken. Since van der Mars  indicateThere is an emerging rationale for research to look beyond established measures of physical proficiencies, or decontextualised, reductionist measures of the affective and cognitive domains and be creative in the development of nonconventional approaches to the evaluation of physical literacy , 39. Barof, and for, learning in physical education to become a realistic possibility, due to how easily it can be embedded into existing practice employing games as part of the curriculum. Charting progress allows for the consideration of physical literacy at an individual level, recognising it is unique to the person, their endowment, and organism constraints (for learning in this manner is conducted principally to support and promote students' learning, creating a virtuous circle of teaching and student progression informing future steps in curriculum delivery. By comparison, assessment of learning enables the evaluation of the effectiveness of a learning process, typically associated with accountability, certification, or intervention evaluation. Linked to the key stage two National Curriculum for physical education (of, and for, learning. The National Curriculum identifies movement skills in isolation and in combination, the application of basic principles of attacking and defending, and the ability to compare current performance to past performance, recognising their own success as foci for development. The emergent games-based assessment can support practitioner evaluation of physical literacy in a formative, ipsative manner supporting assessment for learning, or alternatively in a broader, summative fashion, supporting assessment of learning, within the wider framework of the National Curriculum.Additionally, the feasibility of primary school physical education teachers, who are already balancing a burdensome work schedule being able to undertake appropriate assessments for whole classes remains unclear . Essiet straints . Monitorstraints . Assessmducation , the emeSome of the limitations noted are not dissimilar to those previously reported in other studies of observational research tools and include issues such as analysis complexity due to detailed categorisation , the labThis study found the ecological emergent games-based assessment tool to be valid and reliable, providing both educators and researchers with a useful mechanism to assess physical literacy during small-sided modified games. This is the first tool, of which we are aware, that frames physical literacy assessment and evaluation through an ecological dynamics rationale. Tapping into children's knowledge of the environment, revealed through children's perception of affordances, their intentionality, and how they functionally move to effectively wayfind through performance environments provides novel insight into how physical literacy manifests itself through embodied individual-environment interactions. The emergent games-based assessment values the holistic and multidimensional orientation of the physical literacy construct and has the potential to chart growth over time, support assessment for learning, and enable educators to better understand children's knowledge of the environment and how physical literacy reveals itself through embedded actions. Such insight could develop deeper understandings of the physical literacy construct, in addition to supporting a fulfilling physical literacy journey.


Guiding the development of longitudinal competencies in communication, ethics and professionalism underlines the role of portfolios to capture and evaluate the multiple multisource appraisals and direct personalised support to clinicians. However, a common approach to these combined portfolios continues to elude medical practice. A systematic scoping review is proposed to map portfolio use in training and assessments of ethics, communication and professionalism competencies particularly in its inculcation of new values, beliefs and principles changes attitudes, thinking and practice while nurturing professional identity formation. It is posited that effective structuring of portfolios can promote self-directed learning, personalised assessment and appropriate support of professional identity formation.Krishna’s Systematic Evidence-Based Approach (SEBA) is employed to guide this systematic scoping review of portfolio use in communication, ethics and professionalism training and assessment.PubMed, Embase, PsycINFO, ERIC, Scopus and Google Scholar databases.Articles published between 1 January 2000 and 31 December 2020 were included.The included articles are concurrently content and thematically analysed using the split approach. Overlapping categories and themes identified are combined using the jigsaw perspective. The themes/categories are compared with the summaries of the included articles in the funnelling process to ensure their accuracy. The domains identified form the framework for the discussion.12 300 abstracts were reviewed, 946 full-text articles were evaluated and 82 articles were analysed, and the four domains identified were indications, content, design, and strengths and limitations.This review reveals that when using a consistent framework, accepted endpoints and outcome measures, longitudinal multisource, multimodal assessment data fashions professional and personal development and enhances identity construction. Future studies into effective assessment tools and support mechanisms are required if portfolio use is to be maximised. The Systematic Evidence-Based Approach methodology adopts the structure of systematic reviews and flexibility of narrative reviews to synthesise a reproducible and accountable evaluation of diverse methodological sources, settings, physician populations and specialities.This review evaluates the impact of longitudinal development of communications, ethics and professionalism competencies and their impact on professional identity formation.Given that communications, ethics and professionalism are sociocultural constructs, geopolitical sociocultural differences may raise questions as to the applicability of these findings beyond the European and North American medical education systems.As the number of articles included is limited, the review’s ability to assess the long-term effectiveness of portfolios may be compromised.Evidence for the effective embodiment of ethical and professional principles, communication skills and appropriate use of empathy in clinical practice requires a longitudinal and often multisource perspective. With ethics and professionalism sharing longitudinal developmental trajectories and intimately entwined with communication skills and competencies, the three competencies are increasingly considered together. In practice longitudinal communication, ethics and professionalism (CEP) programmes appear in the curricula of the top 10 medical schools featured on the QS World University Rankings 2020.8–12However, while previous reviews into the teaching of ethics,25A Systematic Evidence-Based Approach (SEBA) guided Systematic Scoping Review (SSR) (henceforth SSR in SEBA) is proposed to map CEP portfolio use in medicine to guide the design, structuring and support of a proposed programme.16 27 28 35 41 48 51–5610.1136/bmjopen-2022-067048.supp1Supplementary dataAn expert team comprised of a medical librarian from the Yong Loo Lin School of Medicine (YLLSoM) at the National University of SingaporeWhat is known about CEP portfolios?’. The secondary research questions were ‘what role do CEP portfolios have in teaching and assessing CEP development?’.The research and expert team determined the primary research question: ‘A population, intervention, comparison and outcome (PICOs) format, outlined in 58 59The research team developed search strategies and carried out independent reviews for relevant publications in the PubMed, Embase, PsycINFO, ERIC, Scopus and Google Scholar databases  accessed through the National University of Singapore (NUS) library portal. These individual lists of titles were discussed online and Sandelowski and Barrosoarticulate, defend, and persuade others of the “cogency” or “incisiveness” of their points of view or show their willingness to abandon views that are no longer tenable’ was applied to achieve consensus on the final list of titles to be scrutinised.Six members of the research team created individual lists of titles to be included, while three other members of the research team carried out hand searches and ancestry searches of seven leading journals in medical education  were separated from grey literature, perspectives, editorials, letters and non-data-based articles drawn from bibliographic databases (henceforth non-data driven). These two groups were separately thematically analysed.The Best Evidence Medical Education Collaboration GuideThis SSR in SEBA suggest that overlaps in ethics, professionalism and communication skills, knowledge, attitudes and competencies reaffirm the concurrent training and assessments of CEP competencies in portfolios.86 120 121Yet to be effective, CEP portfolios require policing and underscore the need for trainedWith these requisites met, evidence of changes in CEP knowledge, skills and competencies suggests a shift in the thinking, attitudes and conduct of clinicians. The Krishna-Pisupati model posits that sustained changes in practice, beliefs, values and principles will result in changes in the clinician’s belief systems which, in turn, inform their self-concepts of identity and shape their PIF.The generalisability of the results of this study is limited by the identified studies selected for review. First, the majority of the papers included originate from Europe and North America. Given that CEP is a sociocultural construct, these geopolitical sociocultural differences raise questions as to the applicability of these findings beyond the European and North American medical education systems. Second, as the number of articles included is limited, the SSR in SEBA’s ability to assess the long-term effectiveness of portfolios may be compromised.The suggestion that CEP portfolios can capture, instruct and assess PIF requires further study. While there have been posits on how such evaluations could be made, such tools remain unrealised and must be the focus of coming studies. One possible starting point for the design of such tools may be theories such as the Krishna-Pisupati model, which attempts to link PIF to changes to belief systems and concepts of personhood. This may provide a grander view of PIF that spans the undergraduate and postgraduate settings and provide the basis for directing support and feedback for clinicians. As we look forward to furthering efforts to study the effects of CEP portfolios on the PIF of clinicians, we also believe the specific impact of these potentially resource-heavy and financially costly intervention should be at the centre of future initiatives.


Nutrition health has become a major public health issue in both high and middle-income countries. Nutrition literacy is an important indicator to evaluate the effect of public health intervention and one of the important concepts in health promotion. Thus, this study aimed to verify the reliability and validity of a nutrition literacy assessment questionnaire (NLAQ) and investigate the associated factors of nutrition literacy among college students.N = 774). We employed the Cronbach’s alpha coefficient, exploratory and confirmatory factor analysis to evaluate the reliability and validity. We used latent profile analysis to classify the nutrition literacy. We conducted Chi-square test and binary logistic regression to identify the influencing factors.We conducted a cross-sectional online survey of college students from April to November 2022 in Wuhan . College students’ disciplines , mothers’ education level , and fathers’ occupation type  had impacts on nutrition literacy.The Cronbach’s alpha coefficient of the NLAQ and its dimension was ranging from 0.837 to 0.909. The common factors were consistent with the original dimensions. All indicators met the requirements (χThe NLAQ has good reliability and validity, and could be used as a measurement tool to evaluate college students’ nutrition literacy. Schools and families should take targeted measures to improve the college students’ nutrition literacy.The online version contains supplementary material available at 10.1186/s12889-023-17062-z. Nutrition literacy is understood as a ‘specific form of health literacy’, and defined as the individual capacity to obtain, process, and understand basic nutrition information for making appropriate nutrition decisions –3. GivenDifferent researchers have developed various nutrition literacy measurement tools according to different types of populations. According to Nutbeam’s concept of health literacy, nutrition literacy is categorized into three forms: functional, interactive, and critical , 6. MostNumerous factors significantly affect the health literacy level among college students. Researchers in different countries using the health literacy questionnaire have confirmed that sociodemographic variables , learning characteristics , family environment  could affect health literacy –22. MeanDietary nutrition is increasingly recognized as a major public health concern in China, particularly among college students owing to the rapid population growth of highly educated citizens. Foreign researchers have also developed different nutrition literacy assessment instruments for various occupational groups, and explored the impact of college students’ sociodemographic characteristics on health literacy around the world. Therefore, strengthening the verification and influencing factors of nutrition literacy among college students in China is urgently needed. The nutrition literacy assessment questionnaire (NLAQ) is the first tool that specially designed for Chinese college students to assess their nutrition literacy level . Howevern = t2pq/d2 = 743  [The pre-survey results showed that the nutrition literacy level was 35.0%. The sample size was calculated by the formula: = 0.035) . This saThe present study was an observational cross-sectional study. We conducted this survey in Wuhan, which is the capital of Hubei Province, and locates in Central China. The city has more than 80 universities with a total of 1.683 million college students, which is comparatively higher than other provincial capitals in China. However, only seven universities in Wuhan were included in the construction of the “211” project, which was officially launched in 1995 with the approval of the State Council. We collected data using two-stage stratified cluster random sampling in seven “211” project universities. At the first stage, we selected two universities based on the comprehensive strength of seven universities. The first university covers 11 subject categories, which include disciplines related to nutritional literacy, while the second university covers only 8 subject categories. At the second stage, we stratified 59 schools of the two universities into humanities and social sciences, science and engineering, and medical categories based on their respective disciplines. Then, we selected two schools from the humanities and social sciences, six schools from the science and engineering, and three schools from the medicine category for random sampling based on the proportion of disciplines in universities. The staff from teaching offices in 11 departments used WeChat tools to distribute the questionnaire via the Wenjuanxing platform from April to November 2022 and reminded them to participate in this survey voluntarily. A total of 926 samples were collected, of which 774 were valid, and the sample effective rate was 83.58%. The flowchart in Fig. The self-administered questionnaire was divided into two parts.Part 1 consisted of general personal, academic, and family environment characteristics. General personal characteristics include gender, nationality, age, and living costs (in CNY). Academic characteristics include online learning time, disciplines, and academic performance. Family environment characteristics include residential area, average annual household income (in CNY), parents’ education level and parents’ occupation type.The NLAQ was developed by Chinese researchers on the basis of stage-specific “critical nutrition literacy” scales , 16, 29.P < 0.05 indicated a statistically significant difference.The SPSS (version 21.0), AMOS (version 19.0), and MPLUS (version 8.3) software were used for statistical analysis. Quantitative data were expressed as mean and standard deviation. Qualitative data were expressed as frequency and percentage. Cronbach’s alpha coefficient and item-total correlation coefficient were applied to measure the reliability analysis. Construct validity was assessed through exploratory and confirmatory factor analyses. Standardized factor loading (λ), measurement error (θ), average variance extracted (AVE), and construct reliability (CR) were used to measure convergent validity. Latent profile analysis (LPA) was employed to determine the category of nutrition literacy among college students. Chi-square test and binary logistic regression were utilized for univariate and multivariate analysis, respectively. Several fit indices such as the Akaike information criterion (AIC), Bayesian information criterion (BIC), adjusted-Akaike information criterion (ABIC), bootstrap likelihood ratio test (BLRT), Lo–Mendell–Rubin test (LMRT) and entropy were selected as the basis for classification in LPA . GeneralA KMO value higher than 0.7 was considered to be acceptable for factor analysis according to Kaiser’s point of view . The folAn overall Cronbach’s alpha coefficient of 0.909 was obtained from the reliability analysis. In the questionnaire, internal consistency was determined for obtaining, understanding, and evaluation and application of dietary nutrition information on the questionnaire with Cronbach’s alpha values of 0.887, 0.899, and 0.837, respectively. These values were all above 0.8, suggesting that the instrument had good reliability at these three levels . The ite2, and P values were 0.9, 6233.912, and < 0.001, with a cumulative variance contribution rate of 71.878%. The factor loadings of each item were consistent with the theoretical assumptions after the oblique rotation. Factors 1, 2, and 3 correspond to understanding information, obtaining information, and the evaluation and application information. Further, the factor loading of each item ranged from 0.667 to 0.880  and the θ values were lower than 0.5 except for Q1_4 (0.518). The AVE and CR of each indicator were greater than 0.6 and lower than 0.8, indicating that the questionnaire had good convergence validity. All potential variables at different levels passed the convergence validity test. The λ, θ, AVE, and CR values are shown in Table Table Table Univariate analysis revealed that general personal characteristics  had no effect on the dietary health literacy of college students, but academic characteristics  and family characteristics such as family address, family income, parents’ education level and occupation type had different nutrition literacy levels Table .All the significant predictors of nutrition literacy in the univariate analysis were incorporated into the binary logistic regression model, and the results are presented in Table By confirming the reliability and validity of the NLAQ, and exploring factors that influenced college students’ nutrition literacy, our study revealed that 1) the NLAQ had good reliability and validity, and 2) academic characteristics and family environment-related factors could promote the nutrition literacy level of students.Reliability analysis reflects the stability of a scale’s structure . This stEffectiveness refers to the degree to which the instrument being tested corresponds precisely to the reality . This stThe score for nutrition literacy level did not exceed 3.5 points. The main reason for the low level of overall nutrition literacy may be caused by the acquisition of nutrition information. The channels for obtaining nutritional information in this scale focused on new media, ignoring the important fact that college students could also obtain nutritional information from the classroom or other channels. This work also used LPA to identify distinct classes of nutrition literacy levels among Chinese college students. The optimal model was determined through comparison of several fit indices and visual inspection of the scree plot. All fitting indices of the two-profile model all met the criteria, which indicated the model had strong discrimination.The nutrition literacy level of medical students was higher than that of non-medical students, an outcome which was consistent with most domestic studies on health literacy , 37, 38.This study had some limitations. First, sample bias may exist in this work because the sample was limited to two universities in the Wuhan area. Second, the NLAQ used in this research was designed from functional perspective, continued exploration and verification is necessary using the scales designed from other perspectives. Third, the cross-sectional design of this research did not produce very precise or convincing results and generated uncertainty regarding the outcomes.This study confirmed that the NLAQ has good reliability and validity could be used as a measurement tool to evaluate college students’ nutrition literacy. Academic characteristics including disciplines and family environment characteristics including the mothers’ education level and fathers’ occupation type were significant predictors of nutrition literacy. Moreover, society and universities should pay greater attention to students with these characteristics, and take targeted measures to improve the nutrition literacy of college students. Further research is also needed to design more nutrition literacy scales aimed at other populations and explore other factors that influence the nutrition literacy levels.Additional file 1. Fit indicator criteria in confirmatory factor analysis.Additional file 2. The results of exploratory factor analysis of nutrition literacy assessment questionnaire among college students.Additional file 3. Nutrition literacy assessment questionnaire among college students.


The findings from research studies and best practice guidelines should form the foundation of eye care delivery. As a health care practitioner, you are not best serving your patients if you make decisions based only on your experience and what you learnt during training – especially if you trained some time ago! Although both these sources of learning are valuable, they are not enough. Modern health practitioners are expected to stay up to date with the latest knowledge relevant to their field and to practice evidence-based medicine.Evidence-based medicine is about using the best available evidence, combined with your own clinical expertise, to make decisions about a patient's health care that respect their values and expectations. But what is the best available evidence, and how can you find it?If you consider that thousands of research articles are published in eye care journals every year, and that many of them charge high fees for access, it's no surprise that staying up to date with all the latest research in your field is a challenge for most people.Instead, you may find yourself looking for evidence to answer a specific question. For example, say that you've heard about the potential of collagen crosslinking to prevent the progression of keratoconus, and you want to know whether to start using it. What is the evidence that it works, and that it is safe?Before you start looking for evidence, it is helpful to remind yourself of the different levels of evidence (see panel). Strong sources of evidence, such as systematic reviews, allow you to be more confident in the decisions you make; however, when such evidence is not available, it is useful to know what other types of evidence to look for.www.pubmed.gov) is a large, open access , online database which contains many of the medical research studies which are conducted around the world. Because it is free, and comprehensive, it is a useful starting point when looking for studies on a particular topic.PubMed , what is feasible/realistic in a particular health care context, and where there are gaps in the evidence. Another very important factor to consider is what patients themselves prefer once they have had the different options clearly and coherently explained to them. Practicing medicine is an art as well as a science, and it is important to personalise the management approach for each patient.The evidence in this list is arranged from strongest to weakest. Note that each level can be of high or low quality and have a high or low risk of bias or confounding.Systematic review of randomised controlled trials. Systematic reviews look at all the studies that have been done on a specific health problem, selecting and assessing them using rigorous, standardised methods. It may include a meta-analysis, which is a statistical analysis of the quantitative results of the studies included in the systematic review. Meta-analyses can provide a more precise estimate of an effect than is possible by looking at individual studies.Randomised controlled trial (RCT). Participants in the study are randomly allocated into groups, usually to receive or not receive an experimental treatment or intervention. The random allocation helps to ensure a fair comparison (see article 5: Good Research)Systematic review of cohort or case-control studies.Cohort study. This usually involves many study participants who are observed over a long period (commonly years). The onset of a particular disease  can then be compared between people with different levels of exposure .Case-control study. People who have a disease  are compared to a similar group of people  who don't have the disease (controls). Researchers then work out the level of exposure in the past  and compare them between the two groups.Case series or case reports. A single report, or a series of reports, involving patients with a particular disease and who may have been given a similar treatment.Expert opinion. This is used where research studies haven't been done on a particular area and people who have experience or expertise on a particular area say what their opinion is.Please see the references for more detailed definitions.


Prior research found that people differ notably in the levels of eHealth literacy, and this study tests a theoretical account of some of those individual differences. Drawing on life history theory, we propose that low eHealth literacy is partly the outcome of people adopting a resource-allocation strategy emphasizing early and fast reproduction, namely, a fast life-history strategy.N = 1,036) that measured Chinese adult respondents’ eHealth literacy, childhood environmental harshness and unpredictability, and fast life-history strategy. Covariates included health-information seeking online, self-rated health, sex, age, education level, and monthly income.We conducted a cross-sectional survey study (Supporting a life-history explanation of eHealth literacy, childhood environmental harshness and unpredictability negatively predicted eHealth literacy through fast life-history strategy and mainly the insight-planning-control dimension of it. Harshness, not unpredictability, also directly and negatively predicted eHealth literacy after fast life-history strategy was controlled for.Our findings suggest that the psychological mechanisms associated with human life-history strategies produce at least some of the individual differences in levels of eHealth literacy, including those related to neuroticism, socioeconomic status, self-rated health and social capital. Thus, a possible way to increase future generation’s eHealth literacy and thereby their health is to reduce the harshness and unpredictability of the environment in which they grow up, thereby making them more likely to adopt a relatively slow life-history in their adulthood. BWith eHEALS, prior research found that levels of eHealth literacy positively correlated with the tendency to seek health information online , levels To this end, we tested in this study an evolutionary psychological account of eHealth literacy drawing on life history theory. Life history theory starts as an evolutionary biological theory  but has 1.1.1.2.Much prior research examined the demographic, personality, health, and social psychological correlates of eHealth literacy, and From why, for example, socioeconomic status, self-rated health, and social capital positively whereas neuroticism negatively correlates with eHealth literacy. This explanation entails identifying the psychological mechanisms that underlie the motivation and ability to acquire eHealth literacy, and this research aims to do so by drawing on life history theory.These findings provided much insight into the sources of the individual difference in the levels of eHealth literacy. However, an even better understanding of eHealth literacy may be gained by explaining 1.3.Life history theory  concerns how organisms allocate resources between three basic life activities, namely physical maintenance, growth, and reproduction . Physica1.3.1.Individuals differ in when to prioritize somatic effort versus reproduction, and different prioritization decisions entail trade-offs . At one At the other extreme, one may trade somatic effort for reproduction. Doing so helps maximize offspring quantity and reduce the risk of death before first reproduction. However, reproducing early and fast diverts resources away from maintenance and/or growth, decreasing one’s own physical and socioeconomic competence and the quality of their offspring.These two allocation strategies—prioritizing somatic effort or reproduction—are, respectively, called a slow or a fast life-history strategy . Because1.3.2.The harshness and unpredictability of one’s early developmental  environment are two important determinants of people adopting a slower or faster life-history strategy . EnvironPrior research has revealed a suite of psychological mechanisms that help execute a fast life-history strategy due to people growing up in a harsh and/or unpredictable environment. For example, both childhood environmental harshness and unpredictability have been found to negatively predict school performance and positively predict present orientation, impulsivity, and risk proneness either directly or through fast life-history strategy .Prior research has also demonstrated the unique effects of childhood environmental harshness and unpredictability on outcome variables of interest. For example, harshness was found to negatively predict sense of control and positively predict present orientation and risk diversification under primes of mortality or financial threats . MarangeOn the other hand, unpredictability—not harshness—was found to negatively predict physical health in adulthood, altruistic concerns, and the tendency to adopt a deliberate cognitive style but positively predict the number of sex partners, aggressiveness, and the desire for instant gratification . Notably1.4.Because fast life-history strategists—as a result of growing up in a harsher and/or unpredictable environment—would tend to trade somatic effort  for reproduction, they should generally be less motivated to engage in health-promoting behaviors . Supportfast (relative to slow) life-history strategists would generally be less motivated to develop—and thus have lower levels of—eHealth literacy. Regarding mechanism, the multiple skillsets necessary to developing eHealth literacy (see Section 1.1) are unlikely to acquire overnight but entail sustained and disciplined investment of cognitive resources into relevant areas of learning and practicing. Specifically, developing eHealth literacy likely includes (1) gaining knowledge on health in general and/or particular diseases , and developing eHealth literacy is thus by definition a health-promoting behavior. Therefore, life history theory predicts that diseases , (2) disdiseases , (3) evadiseases , (4) comdiseases , and (5)diseases . Those adiseases .On average, fast (relative to slow) life-history strategists lack planning, patience, and self-control. Planning is a core dimension of slow life-history strategy . At the Harshness and unpredictability may also directly and negatively predict eHealth literacy. For example, growing up in a harsh environment tends to deprive one of their accesses to media and computers and even education. This would thwart the development of several if not all of the basic types of literacy that eHealth literacy entails. Meantime, the stochastic changes of an environment would disrupt information gathering , comprehension , evaluation , and use . These considerations lead us to predict that childhood environmental harshness (Prediction 2a) and unpredictability (Prediction 2b) would negatively and directly predict eHealth literacy after controlling for fast life-history strategy.2.2.1.Jishu Yun,N = 1,036. The final sample consisted of 59.7% female, had an average age of 34.8 years , had a median education level of completing senior high school, and had a median income level of earning between 4,500 and 6,000 RMB per month.We recruited 1,082 Chinese adult Internet users to participate in the study for a small payment. The study was conducted in Chinese in November, 2021 via 2.2.strongly disagree, 7 strongly agree) (α = 0.88) with larger scores indicating higher levels of eHealth literacy. Respondents were then asked to complete a four-item measure of seeking health information online  (α = 0.76) with larger values indicating more frequent health-information seeking online. We included this variable to control for respondents’ experience with using the Internet for health purposes.After providing informed consent, respondents were asked to complete the eight-item eHEALS scale on eHealth literacy (1 y agree) . The scay agree) . The scaK scale that comprises 20 cognitive and behavioral indicators of a slow life-history strategy . Mini-K has been widely used in prior work and demonstrated sufficient validity assessed with diverse samples . We computed the averages of the items, and reversed the averages by subtracting them from 8 so that larger values indicate a faster life-history strategy.From the scale, we dropped the three questions on secure romantic partner attachment because they had low inter-item reliability in our prior work conducted in China. We also dropped the question on religiosity because it likely has low variance in China, and did not include the item on relationship with father due to a programming oversight. The remaining 15 items showed satisfactory internal consistency . This is because our hypothesis suggests that childhood environmental harshness and unpredictability would negatively predict levels of eHealth literacy through mechanisms related to present orientation, impulsivity, and lack of self-control (Section 1.4). We computed the average scores of the remaining items to index non-IPC (Cronbach’s α = 0.80). This is because, at least with our sample, the reliability of the other dimensions of Mini-K  was low (Cronbach’s αs < 0.60). We reversed both IPC and non-IPC to make them consistent with our measure of fast life-history strategy.From the 15 items of Mini-K, respondents were asked to complete a nine-item scale of childhood environmental unpredictability   . The scay agree] . The scavery unhealthy, 5 very healthy), and provide information on their age, sex, education level, and monthly income.Lastly, respondents were then asked to rate their current health  and directly (Predictions 2a and 2b). We estimated a path model as depicted in As predicted, harshness and unpredictability positively and significantly predicted fast life-history strategy, which negatively and significantly predicted eHealth literacy. The indirect effect of harshness was ß = −0.02, with the 95% bias-corrected confidence interval (CI) based on 10,000 resamples estimated . The indirect effect of unpredictability was ß = −0.03, with the 95% CI estimated . These results supported Predictions 1a and 1b.Also as predicted, harshness—after we controlled for fast life-history strategy, unpredictability, and all covariates—negatively and significantly predicted eHealth literacy. However, the direct correlation between unpredictability and eHealth literacy was not significant. These results supported Prediction 2a but not Prediction 2b.Further, health-information seeking online and self-rated of health positively—whereas age and income negatively—predicting eHealth literacy. There was no evidence that respondents’ sex or education level predicted eHealth literacy.3.3.r| > 0.56)  , and we As 4.In this study, we tested a life-history explanation of eHealth literacy in a cross-sectional survey study with a reasonably large sample of Chinese adults. As predicted, childhood environmental harshness and unpredictability negatively predicted eHealth literacy through fast life-history strategy after controlling for relevant covariates. When we divided the measure of fast life-history strategy into IPC  and non-IPC, IPC but not non-IPC predicted eHealth literacy and mediated the correlation between childhood environmental unpredictability (but not harshness) and eHealth literacy. In contrast, after controlling for fast life-history strategy (or IPC reversed) and covariates, harshness but not unpredictability directly and negatively predicted eHealth literacy. These findings largely supported the life-history explanation of eHealth literacy.4.1.fast life-history strategy in zero-order correlations  and self-rated health positively predicted eHealth literacy . A likelelations  and—withelations .As in prior studies, we found that education, income, and self-rated health all positively correlated with eHealth literacy in zero-order correlations . However4.2.Prior research found that neuroticism negatively correlated with eHealth literacy . We did does negatively correlate with eHealth literacy but Notably, 4.3.r = −0.60; K with large effect sizes  positively correlated with eHealth literacy . Because4.4.First, we used eHEALS to measure eHealth literacy, but eHEALS has been subject to debates over its content validity  . Over thSecond, the measures of childhood environmental harshness and unpredictability were retrospective in nature and might have subject to the influence of personal memory. Thus, future research may consider using a panel design that uses objective measures of one’s childhood environment and measures respondents’ eHealth literacy at later stage of the study. This design would also help establish the causal effects—if any—of environmental features on levels of eHealth literacy.At the same time, the measure of childhood environmental harshness varied considerably from study to study. In the studies cited in this research, for example, that variable was indexed by extrinsic mortality risks , resourcWe measured harshness and unpredictability, respectively, as resource availability and chaotic home life because they appeared the most common choices in the work we reviewed for this study. Importantly, the studies that adopted those measures concern the likely mechanisms  underlying the association between life-history strategies and levels of eHealth literacy. In other words, prior findings formed the basis of our operational decisions. However, future research might consider using updated measures of harshness and unpredictability  to repliLastly, future research may consider testing the life-history explanation of eHealth literacy with respondents from other countries and regions of the world than China. We are confident in the validity of our hypothesis because both life history theory and eHEALS have been validated cross-culturally. However, the cross-cultural validity of the life-history explanation of eHealth literacy remains to be verified with empirical data.5.This study found that Chinese people who grew up in a harsher and/or more unpredictable environment were more likely to have lower levels of eHealth literacy and this was partly because they had lower levels of insight, planning, and self-control. Those findings suggest that the psychological mechanisms associated with human life-history strategies produce at least some of the individual differences in the levels of eHealth literacy. Thus, a possible way to increase future generations’ eHealth literacy is to reduce the harshness and unpredictability of their childhood environments, thereby increasing the likelihood of them adopting a slow life-history strategy.https://osf.io/yct4w/?view_only=85ba790d30644db58b2875a7be99868c.The original contributions presented in the study are publicly available. This data can be found here: Ethical approval was not required for the studies involving humans because the institution the authors are affiliated with only requires ethical approval for biomedical research. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.WF conceived and designed the study and collected data. WF and JZ analyzed data and wrote the manuscript and reviewed the manuscript. All authors contributed to the article and approved the submitted version.This research was supported by Sun Yat-sen University’s startup fund to JZ, (grant no: 17000-12230014).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Guidelines have become indispensable tools for clinical practice. Guidelines prepared by international or national professional societies, e.g., European Society for Gynaecological Endoscopy (ESGE), European Society of Human Reproduction and Embryology (ESHRE) and American Society of Reproductive Medicine (ASRM), or national authorities, e.g., National Institute for Health and Care Excellence or governmental bodies do not only influence decision making in the clinic but can also form the basis for reimbursement (or lack of it) of diagnostic and therapeutic procedures.The majority of the above-mentioned guidelines are evidence-based and follow a well-defined methodology for preparation. The steps for evidence-based guideline development include the recruitment of content experts from diverse backgrounds related to the clinical condition of interest as well as methodologists and users including patients. The guideline development group formulates questions to be answered, which often follow a certain format such as PICO  as much as possible . Once thIn this issue of Facts, Views and Vision we publish two articles that are relevant to the methodology of evidence-based guidelines and their place in guiding the clinical practice. Tummers et al.  present The other article in this issue by Wattiez et al.  describeBoth papers are interesting to read and provide food for thought. In our opinion they both highlight the fact that evidence-based and experience-based medicine have their own limitations and are not mutually exclusive but rather complementary for sound clinical practice. Indeed, evidence-based medicine, by definition, integrates the best available scientific evidence with clinical expertise and patient value and preferences . While a


The mental health and wellbeing of care-experienced children and young people  is poorer than non-care-experienced populations. The Care-experienced cHildren and young people’s Interventions to improve Mental health and wEll-being outcomes Systematic review (CHIMES) aimed to synthesise the international evidence base for interventions targeting subjective wellbeing, mental health and suicide amongst care-experienced young people aged ≤ 25 years.For the first phase of the review, we constructed an evidence map identifying key clusters and gaps in interventions and evaluations. Studies were identified through 16 electronic databases and 22 health and social care websites, in addition to expert recommendations, citation tracking and screening of relevant systematic reviews. We charted interventions and evaluations with a summary narrative, tables and infographics.n = 77). Interventions primarily targeted children and young people’s skills and competencies (n = 9 interventions), the parental functioning and practices of carers (n = 26), or a combination of the two (n = 15). While theoretically under-specified, interventions were largely informed by theories of Attachment, Positive Youth Development, and Social Learning Theory. Current evaluations prioritised outcomes (n = 86) and processes (n = 50), with a paucity of study reports including theoretical descriptions (n = 24) or economic evaluations (n = 1). Interventions most frequently targeted outcomes related to mental, behavioural or neurodevelopmental disorders, notably total social, emotional and behavioural problems (n = 48 interventions) and externalising problem behaviours (n = 26). There were a limited number of interventions targeting subjective wellbeing or suicide-related outcomes.In total, 64 interventions with 124 associated study reports were eligible. The majority of study reports were from the USA (Future intervention development might focus on structural-level intervention theories and components, and target outcomes related to subjective wellbeing and suicide. In accordance with current methodological guidance for intervention development and evaluation, research needs to integrate theoretical, outcome, process and economic evaluation in order to strengthen the evidence base.PROSPERO CRD42020177478. Children and young people with experience of living in care represent a diverse population, with significant international variation in nomenclature and classification . They caWhile not a clearly defined population, evidence reports that care-experienced individuals generally have poorer mental health and wellbeing, and higher rates of suicide attempts, compared to non-care-experienced groups –9. IndivThere has been significant development in international intervention research to target reported issues. A number of literature and systematic reviews have synthesised the evidence base for social and healthcare approaches –25, withDespite their contributions, there are two key limitations associated with extant syntheses, relating to both scope and methodology. The first limitation is a focus on a limited range of countries ; specifiThis differentiation is imperative, as there is suggestion that interventions can be ineffective due to an over-reliance on individual-level approaches that are minimally disruptive , and theThere are a number of organising frameworks to help locate interventions in different parts of the social system, including the socio-ecological model, with versions originating from child development and public health research , 36. TheThe second limitation with existing reviews is that they tend to restrict syntheses to outcome evaluations, with scant attention paid to interventions’ programme theory, the context of evaluation, the process of implementation, acceptability or cost-effectiveness. Even recent comprehensive NICE reviews , which dIntegration of these different evidence types is important in understanding how interventions operate and generate effects within their delivery context, and their potential transportability to other health and social care systems. This integrated approach to evaluation, which draws on a range of evidence, is recommended by a range of methodological guidance on intervention development, adaptation and evaluation –40. As sWhat are the targeted socio-ecological domains, theories and outcomes addressed in mental health and wellbeing interventions for care-experienced children and young people?What are the types of evidence generated as part of intervention evaluations?The Care-experienced cHildren and young people’s Interventions to improve Mental health and wEll-being outcomes Sytematic review (CHIMES) was a complex systems informed, multi-method review that aimed to synthesise international evidence on programme theory, process evaluation, outcome evaluation, equity harms, and economic evaluation . For theIn charting the available evidence on interventions and types of evidence, the map informed the scope and feasibility of the second phase of the systematic review. For example, the map identified sufficient randomised controlled trials to conduct meta-analysis for relevant outcomes. The second review phase involved method-level syntheses for outcome evaluations, process evaluations, equity harms and economic evaluations. These were then integrated into an overarching review-level synthesis, where data from one synthesis  supported explanation of another synthesis  . The thiWe generated an evidence map, drawing on systematic mapping guidance . EvidencWe integrated a comprehensive programme of stakeholder involvement throughout the CHIMES review. Regarding the evidence map, we consulted with three key groups of stakeholders at the outset to refine and confirm the focus and scope of the review. These groups were as follows: (1) CASCADE Voices ; (2) The Fostering Network in Wales Young Person Forum (group of care-experienced young people who provide advice and guidance to the charity on their programmes of work); and (3) All Wales Fostering Team Managers Forum . The central priorities of these groups were to focus on wellbeing and suicide-related outcomes, and to map interventions according to a socio-ecological schema. This latter priority related to stakeholders’ perception of a lack of structural interventions at the organisational and policy level, and a need to establish if this is a significant evidence gap and how it might be addressed moving forward.The inclusion parameters for the review were defined according to the Population, Intervention, Comparator, Outcome and Study Design (PICOS) framework:Intervention participants could be care-experienced children and young people . They could operate across the following socio-ecological domains: intrapersonal; interpersonal; organisational; community; and policy. They could be mono-component or multi-component. There were no a priori criteria for implementation . Pharmacological interventions were excluded.For outcomes evaluations, a comparator had to be specified and could include: treatment as usual; other active treatment; or no specified treatment.Interventions had to target one of three domains of primary outcomes: subjective wellbeing ; mental, behavioural or neurodevelopmental disorders as specified by the International Classification of Disease (ICD)-11; and suicide-related outcomes . Measurement could be dichotomous, categorical or continuous. Outcomes had to be obtained for the child or young person, but could be ascertained through clinical assessment, self-report or report by another informant. Excluded primary outcomes included substance misuse and eating disorders, which have some conceptual overlap with the eligible outcomes, but are large literatures that could form the basis of separate reviews. We mapped all secondary outcomes included in eligible study reports .Different study designs were eligible according to the research question targeted. Study reports could describe an intervention’s programme theory; outcome evaluation  or non-randomised design); process evaluation that reported on context, implementation and/or acceptability ; and economic evaluation .We identified study reports from sixteen electronic bibliographic databases: Applied Social Sciences Index and Abstracts (ASSIA); British Education Index; Child Development & Adolescent Studies; CINAHL; Embase; Education Resources Information Center (ERIC); Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Health Management Information Consortium (HMIC); International Bibliography of the Social Sciences; Medline; PsycINFO; Scopus; Social Policy & Practice; Sociological Abstracts; and Web of Science. We identified additional peer-reviewed studies and grey literature through searching websites of 22 relevant social and health care organisations. Searches were conducted May–June 2020 and updated April–May 2022. We contacted 32 subject experts and 17 third sector organisations for recommendations, particularly regarding grey literature and in progress studies. We screened relevant systematic reviews and conducted forward and backward citation tracking with included study reports. The search strategy was developed in Ovid Medline and adapted to the functionality of each platform (Supplement A). Searches were undertaken from 1990 to coincide with the ratification of the United Nations Convention on the Rights of the Child . Study rWe uploaded retrieved citations to the Evidence for Policy and Practice Information and Coordinating (EPPI) Centre’s review software EPPI Reviewer version 4.0 for storage and management. Study titles were screened by one reviewer to identify clearly irrelevant retrievals, with irrelevant reports checked by a second reviewer. Title and abstracts were screened independently and in duplicate by two reviewers. Where there was a conflict on exclusion, the study report progressed to the next stage of screening. Full texts were screened independently and in duplicate with conflicts resolved through discussion or recourse to a third reviewer. An inclusion criteria proforma guided selection, which was tested and calibrated with a subset of retrievals. The same inclusion criteria were applied to study reports from databases and grey literature. Study quality or publication process (e.g. peer review) was not part of the inclusion criteria and was assessed as part of quality appraisal.We coded eligible study reports for the evidence map according to country; publication date; intervention type; target population; intervention name; intervention characteristics; programme theory; evidence type; study design; and intervention outcome domains. Intervention characteristics were further coded in accordance with the Template for Intervention Description and Replication (TIDieR) Checklist for Intervention Development . To suppScoping review and systematic mapping methods supported the mapping of the evidence base , 49. FolA total of 15,068 unique study reports were identified. Of these, 888 were screened at full text, with 64 interventions being included that linked to 124 study reports ; UK (n = 22); Netherlands (n = 6); Belgium (n = 3); Australia (n = 3); Portugal (n = 3); Canada (n = 2); Ireland (n = 2); Israel (n = 2); Germany (n = 1); Spain (n = 1); Sweden (n = 1); and both the USA and UK (n = 1).Study reports were published between 1994 and 2022. Interventions were from twelve countries: USA  targeted the interpersonal domain. They primarily focused on the skills, knowledge and confidence of foster and kinship carers through training curricula and professional-delivered support. A small number of interventions promoted children and young people’s positive relationships with biological families, largely with the aim of facilitating reunification [n = 17). Seven were delivered between 7 and 12 months.The majority of interventions  provided group-based curricula and mentoring by a trainee social worker . Group-bn = 2), 7–12 months (n = 1), 13–24 months (n = 2), or delivery duration was not specified (n = 3).A further eight interventions primarily included intrapersonal and interpersonal targeting activities, but had a range of organisational- and community-based support to reinforce change mechanisms, support linkage to other interventions and optimise delivery. This included Keeping Foster and Kinship Parents Supported and Trained (KEEP) , 161, MuThere were a limited number of structural-level interventions: one had a focus on organisational culture and ethos , 151; foA subset of 13 interventions, with 24 study reports, included a clearly articulated programme theory , which mapped onto three sets of causal mechanisms. First was to build a therapeutic environment that could be supportive of positive development and prosocial relationships [The majority of interventions foregrounded interpersonal theories of change ; socio-emotional functioning difficulties (n = 17); internalising problem behaviours (n = 22); and externalising problem behaviours (n = 26). There was a paucity of interventions that targeted subjective wellbeing (n = 11). Only four interventions targeted suicide-related outcomes, including suicidal ideation [Most interventions targeted mental, behavioural and neurodevelopmental disorders. Within this domain, interventions most frequently assessed outcome measurements of total social, emotional and behavioural problems  evaluated interventions (n = 31) that primarily targeted the intrapersonal or interpersonal domains [n = 9 study reports) [There were 86 outcome evaluations. Of these, 52 were randomised controlled trials (RCTs) and 34 were non-randomised evaluations. The majority of RCTs  , 182. Ofreports) –167, 171reports) , 182. ThThere was one partial economic evaluation, which estimated the relative costs and consequences of a new intervention compared to the estimated costs of usual care .The CHIMES systematic review aimed to synthesise international evidence on interventions targeting the mental health and wellbeing of care-experienced children and young people. The first phase of the review, an evidence map of the available literature, is reported presently.Mapping interventions by the socio-ecological domain targeted, the main cluster was intrapersonal and interpersonal approaches, often targeting children and young people’s skills and knowledge, or carers’ parenting practices. Some of these also combined organisational and community facing activities to optimise functioning and implementation. As identified in a range of systematic and practitioner reviews of parenting interventions for care-experienced children and young people –190, a cIn contrast, there was a clear gap in structural-level interventions targeting organisational, community and policy drivers. This is significant given that risk factors for poor mental health in this population include a constellation of family and child welfare system-level factors, which are embedded in a wider context of community-level challenges, such as economic opportunity and socio-economic deprivation . EquallyThe map identified a wealth of interventions targeting mental health, behavioural and neurodevelopmental disorders, specifically total social, emotional and behavioural problems. Conversely, there was a dearth of interventions targeting subjective wellbeing and suicide-related outcomes, despite care-experienced young people reporting relative adversity in these areas compared to the general population , 8. ThisThe evidence map has implications for future research. Presently the weight of available evidence is focused on outcome evaluation, although only a limited number consider the potential for equity harms . MethodoAs indicated, there remains a lack of description of interventions’ programme theory, with less than a fifth of included interventions reporting a theoretical basis. This is imperative in knowing how interventions interact with system conditions in the generation of outcomes. Given that the evidence base is predominantly located in the USA to date, this means that there is currently a lack of knowledge about the implementation of different approaches in diverse contexts, cultures and countries. Understanding how programme theories function in the USA evaluation context can offer insight into the potential replicability of effects elsewhere. It can then support efforts to adapt interventions to different settings or population subgroups, or to identify where transportation may not be suitable and new approaches need to be developed .Equally, while there continues to be expansion in the conduct of process evaluations, these tend to be conceptually and empirically thin, providing rudimentary summaries of reach and delivery. This is reflected in systematic reviews that currently synthesise process evaluation data, which largely detail barriers and facilitators to implementation . UnderstThere is also a paucity of economic evaluations, which reflects a wider issue identified in children’s social care research . FailingBeyond implications for evaluation research, there are also some initial suggestions for enhancing systematic reviews in the area of care-experienced populations. It is important that interventions are more comprehensively described in evaluations, preferably with the use of reporting guidance such as the TIDIeR Framework for intervention descriptions . SystemaThere are five central limitations associated with the evidence map. First, the literature around care-experienced populations can be challenging to identify, largely due to extensive international variations in terminology. As such, while the review searches were designed and tested to be sensitive, some study reports may have been missed. Second, the review was limited to studies conducted in higher-income countries, as classified by the Organisation for Economic Co-operation and Development (OECD). As a result, the review has limited generalisability to middle- and lower-income countries, and potentially higher-income countries that do not fall within this classification. Third, there was limited reporting of interventions and associated evaluations, which provided challenges in the cataloguing and mapping of study reports. There were further issues due to the under-specification of interventions’ programme theory. Fourth, study reports were aggregated to chart overarching evidence gaps and clusters. As a result, some of the diversity between interventions and countries is not fully described. Fifth, at the stage of evidence mapping, we did not quality appraise study reports. As such reporting of evidence clusters only reflects the quantity of interventions and evaluations.The present evidence map describes intervention and evidence clusters and gaps in relation to mental health and wellbeing interventions for care-experienced children and young people. With the predominance of intrapersonal and interpersonal interventions from the USA, future development and adaptation might focus on structural-level theories and components, paying attention to how they function in different contexts. They might also focus on subjective wellbeing and suicide-related outcomes. Intervention research needs to integrate theory, outcome, process and economic evaluation to strengthen the evidence base.


A publication bias has been argued to affect the fate of results in bilingualism research. It was repeatedly suggested that studies presenting evidence for bilingual advantages are more likely to be published compared to studies that do not report results in favor of the bilingual advantage hypothesis. This work goes back to the original claim and re-examines both the dataset and the classification of the studies that were employed. We find that the exclusion of published works such as doctoral dissertations, book chapters, and conference proceedings from the original dataset significantly inflated the presumed publication bias. Moreover, the estimation of the publication bias was affected by a classification bias that uses a mega-category that consists of both null and negative outcomes. Yet finding evidence for a bilingual disadvantage is not synonymous with obtaining a result indistinguishable from zero. Consequently, grouping together null and negative findings in a mega-category has various ramifications, not only for the estimation of the presumed publication bias but also for the field’s ability to appreciate the insofar hidden correlations between bilingual advantages and disadvantages. Tracking biases that inflate scientific results is important, but it is not enough. The next step is recognizing the nested Matryoshka doll effect of bias-within-bias, and this entails raising awareness for one’s own bias blind spots in science. Publication biases are pervasive in all fields of science. It was found that empirical studies that observe a statistically significant effect are more likely to be published than studies that report no significant effect ,2. This The field of bilingualism is not an exception to the null result penalty. For at least a decade, various scholars have voiced concern that the literature on bilingualism and its benefits on various cognitive domains  . This stCategory (iv) groups together two outcomes: an effect that shows a bilingual disadvantage and an effect statistically indistinguishable from zero. This choice to group these two types of results together in a null/negative mega-category that is then juxtaposed with the ‘positive results’ category is not accidental. It has its roots in the field’s predominant view of bilingual effects: sometimes they are seen, but sometimes not . This viclassification bias. This bias refers to how findings are assigned different labels, such as ‘evidence supporting the bilingual advantage hypothesis’ or ‘evidence challenging the bilingual advantage hypothesis’. To illustrate why the employed classification system is of utmost importance in the context of discussing bilingual effects on cognition, the Jar Metaphor [Across scientific fields, a good part of the established findings is byproducts of the prevailing biases . DiffereMetaphor  will be blue pencil hypothesis. B has found two red pencils, and they formulate a competing hypothesis called the red pencil hypothesis. At some point, B does not manage to take anything out of the jar , and based on this, they argue that since they have repeatedly failed to find a single blue pencil, the blue pencil hypothesis probably lacks the status of a robust phenomenon. Then, when it is again A’s turn to retrieve an object from the jar, they surprisingly find a red one. However, A suggests that this new finding does not challenge the validity of their blue pencil hypothesis because both A and B have previously agreed that there is a small margin of error in every pencil-selection event. Last, unexpectedly, B finds a bluish-looking pencil. However, after careful observation, they argue that this result cannot be taken as offering unequivocal support to the blue pencil hypothesis because the effect size of blueness is debatable. This pencil looks purple to B, and since purple contains red too, B interprets this finding as putative evidence in favor of their red pencil hypothesis. Eventually, it becomes evident that A and B engage with and interpret the same body of evidence in diametrically opposite ways.Imagine two people: A and B. A and B are given an opaque jar with the instruction to determine what it has inside. The jar contains blue and red objects that look like pencils, but A and B are not told so. They decide to take up the challenge of finding what is in the jar and agree on the following discovery process: They will take turns retrieving objects from the jar, observing them carefully, and then providing a hypothesis about them. After retrieving two blue pencils, A proposes that the content of the jar is blue pencils. This is labeled the separately assess their credibility. In contrast, if one employs the Jar Metaphor, there is no reason to call into question the validity of a subpart of the available evidence. Succinctly put, if the outcome of all or most pencil-selection events is true at the same time, regardless of which hypothesis one takes them to support, the source of contradiction does not lie in the results themselves. If the results are largely valid, what needs to be rethought is the “either blue or red” approach that both A and B have advanced. This is where an important lesson from biology that has repercussions for the classification system one puts forth enters the picture: observing an enhancement in one aspect of a system raises the question of what the compensation for this enhancement is, for one trait cannot increase without a decrease in another [The Jar Metaphor illustrates an important point: the theoretical light under which evidence is examined may color one’s perception of the obtained results . This, i another , given t another . trade-offs [Following this approach, it was recently suggested that bilingual advantages and disadvantages form ade-offs ,27: posiWhat does the picture of publication bias in bilingualism research look like if we alter the classification system? To address this question, the original results of de Bruin et al. (2015) were re-analyzed . LeavingThe dataset of de Bruin et al. (2015) was re-analyzed . The abs10 factor of 1 suggests that the analyzed data are almost equally likely under either the null or the alternative hypothesis, providing inconclusive evidence. BFs larger than 3 are generally taken as weak-to-moderate evidence in favor of the alternative, values larger than 10 as strong evidence, and values larger than 30 as very strong evidence, while a BF10 > 100 can be interpreted as extreme support in favor of the alternative hypothesis [To perform the analyses, a Bayesian approach was used. Critics of the bilingual advantage hypothesis have voiced the opinion that a Bayesian approach is more appropriate than frequentist approaches when one seeks to examine the effects of bilingualism on cognition because it enables us to estimate how likely the data are to occur under the null vs. the alternative hypothesis . More sppothesis .Since the aim is to determine whether one category of findings fares better than the others in terms of publication status, four separate analyses (one per category) were run, plus an overall analysis that involves all categories together. The null hypothesis is that there are no statistically significant differences in terms of publication status in any category. To confirm the claim of de Bruin et al. about a publication bias that favors positive results, evidence for the alternative hypothesis should be found when analyzing category (i) that concerns bilingual advantages: The proportion of published studies should be significantly higher in this category.For the purposes of the present analyses, the variable ‘effects’ was coded in terms of the following values: positive, negative, mixed, or null . The vart-test suggests that the answer is negative. A BF10 = 0.109 suggests that the data are more probable under the null hypothesis . Therefore, all four categories were separately analyzed. Starting from the critical category of positive findings, where a strong effect of publication bias was expected, a Bayesian one sample t-test suggests that the data seem more probable under the null hypothesis, BF10 = 0.258. The picture remains the same in terms of not providing strong evidence for a publication bias when one analyzes the category that involves mixed results. A Bayesian one sample 10 = 1.693 corresponds to anecdotal evidence in favor of the alternative, which remains stable across different priors. In the case of negative results . Importantly, the post hoc comparisons given in 10 = 0.513) but between positive vs. null results (BF10 = 9.297). The differences between categories are shown in A Bayesian ANOVA that examines the effect of ‘category’ on publication status reveals only weak evidence in favor of the alternative hypothesis that there is such an effect (BFbias-within-bias), such that their synergistic interplay may give rise to a false or overinflated effect that finds its way into the published record. To provide a concrete example, the analyses presented above altered the classification system originally employed by de Bruin et al. but did not alter the original dataset. Focusing on the dataset itself, it seems that a second bias comes into play: the exclusion of published works such as doctoral dissertations, book chapters, and conference proceedings from the original dataset has significantly inflated de Bruin et al.’s estimation of the presumed publication bias. As mentioned in the Introduction, a good part of the established scientific findings is byproducts of the prevailing biases, and this holds across scientific fields . What ist-test finds weak-to-moderate evidence in favor of the null hypothesis that there is no difference between the two critical categories, ‘positive’ vs. ‘null/negative’ in terms of publication status (BF10 = 0.288). Importantly, this higher probability of the data under the null cannot be attributed to those studies that were published in or after 2014, that is, studies that fall outside de Bruin et al.’s cut-off point. Even if these studies are removed from the picture, taking only the studies published up to 2013, which could have been included in the original dataset but were not, the presumed effect against null/negative results is still not found. Again, a Bayesian independent samples t-test finds weak-to-moderate evidence in favor of the claim that the data are more probable under the null  tan say” , it becomes clear that pitting blue pencils  against red pencils , and then differently assessing the credibility of these two bodies of evidence as if they were unconnected amounts to a biased classification system that breaks the available evidence into fragments. In contrast, the trade-off approach seeks to replace this fragmented view of bilingual effects as stand-alone outcomes that are scattered across cognitive domains with the view that positive and negative outcomes may form correlations. The latter is so far undetermined, largely due to the fact that an overarching theory of bilingual effects is still missing [Put another way, if one accepts that positive and negative outcomes form  missing , as a co missing  for a si missing . The tak missing . The claclear executive-control component. Much research has suggested that executive functions contribute to successful word retrieval [In relation to the need to rethink de Bruin et al.’s classification, an anonymous reviewer suggests that there are so few negative findings according to the original dataset, and they split 50/50 in terms of publication status , so theyetrieval ,57,58, sTaking stock of the second bias, it seems that by virtue of excluding certain published outputs from the original dataset, the presumed publication bias was inflated, giving rise to an effect that does not seem to exist once all the relevant published outputs are factored in. Again, it is necessary to highlight that absence of evidence is not evidence of absence. It could be the case that a publication bias against results challenging the bilingual advantage hypothesis truly exists. Yet, this claim must be supported by evidence, and the dataset of de Bruin et al. does not offer this evidence once properly updated. exclusion bias . This is a type of publication bias that targets studies found in the so-called grey literature . These studies are often excluded from meta-analyses, quantitative analyses, and systematic reviews with grievous consequences. For instance, excluding grey literature, and restricting resources to a few widely used platforms may lead to biased estimates of effect sizes [Crucially, no scientific reason is offered for the inclusion of only journal articles into the original dataset . The pract sizes . Moreovect sizes . EvidentHaving established that various biases are behind the overinflation of the presumed publication bias against results that challenge the bilingual advantage hypothesis, it is useful to take a step back and ponder whether there is any evidence left to substantiate the original claim. For instance, the meta-analysis of de Bruin et al. (2015) provides a funnel plot that shows a clear asymmetry . Succinccategory of results the missing dots correspond to. The previous section has indeed established that the field of bilingualism research is not an exception to the null result penalty. However, observing that null results may be harder to publish does not validate the claim that the field is biased against results that find evidence for bilingual disadvantages. Several issues merit unpacking with respect to what kind of evidence the funnel plot asymmetry provides. First, it does not explain what Second, the expected symmetry is based on the critical assumption that there is no relationship between effect size and sample size. However, as Simonsohn (2017) argues, this assumption is false if researchers use larger samples to investigate effects that are harder to detect or when they simply adjust sample size based on what they know from previous literature . DiscussThird, a funnel plot asymmetry can arise for several reasons that may have nothing to do with publication bias. While a publication bias may give rise to an asymmetry, an asymmetry is not always due to a publication bias; it can emerge due to other reasons . In SimoTo sum up, de Bruin et al.’s (2015) concluding remark raises a valid, important point, which is confirmed by the results of the present work: “All data, not just selected data that supports a particular theory, should be shared, and this is especially true when it comes to data regarding issues that have enormous societal relevance and implications, such as bilingualism” .