The author reviewed the research on the impact of cognitive biases on professionals’ decision-making in four occupational areas . Two main findings emerged. First, the literature reviewed shows that a dozen of cognitive biases has an impact on professionals’ decisions in these four areas, overconfidence being the most recurrent bias. Second, the level of evidence supporting the claim that cognitive biases impact professional decision-making differs across the areas covered. Research in finance relied primarily upon secondary data while research in medicine and law relied mainly upon primary data from vignette studies (both levels of evidence are found in management). Two research gaps are highlighted. The first one is a potential lack of ecological validity of the findings from vignette studies, which are numerous. The second is the neglect of individual differences in cognitive biases, which might lead to the false idea that all professionals are susceptible to biases, to the same extent. To address that issue, we suggest that reliable, specific measures of cognitive biases need to be improved or developed. For instance, people tend to overestimate the accuracy of their judgments (overconfidence bias), to perceive events as being more predictable once they have occurred (hindsight bias), or to seek and interpret evidence in ways that are partial to existing beliefs and expectations (confirmation bias). In fact, the seminal work of Kahneman and Tversky on judgment and decision-making in the 1970s opened up a vast research program on how decision-making deviates from normative standards  toward the first piece of information . This study aims to address the following research questions:Assess the claim that CB impact professionals’ decision-makingAssess the level of evidence reported in the empirical studiesIdentify the research gapsWe take a narrative approach to synthesizing the key publications and representative empirical studies to answer these research questions. To the best of our knowledge, this study is the first literature review on this research topic covering multiple areas together. This review is narrative, as opposed to a systematic review, which is one of its limitations. However, it aims to be useful both to researchers and professionals working in the areas covered.The present paper is structured as follows. The Methods section provides details about the methodology used to conduct the literature review. In the following sections, we review the key findings in each of the four occupational areas covered. Finally, in the Discussion section, we answer the three research questions addressed in light of the findings reviewed.We conducted a systematic literature search using the Web of Science (WoS) database with the search terms “cognitive biases AND decision making.” The search criteria included research articles, review articles, or book chapters with no restriction regarding the time period. We focused on the WoS database as the “Web of Science Categories” filter would offer a practical mean to select the applied areas covered. Admittedly, the results of our review might have been different had we covered more databases; however, as our strategy was to review the key publications and representative empirical studies in each of the areas selected, we reasoned that virtually every database would have led to these records.n = 436), which merged the categories “Management” (n = 260) and “Business” (n = 176); medicine (n = 517), which merged the categories “Psychiatry” (n = 261), “Health Care Sciences Services” (n = 112), “Medicine General Internal” (n = 94), “Radiology Nuclear Medicine Medical Imaging” (n = 22), “Critical Care Medicine” (n = 14), and “Emergency Medicine” (n = 14); and law (n = 110) and finance (n = 70). Noteworthy, while the category “Psychology Applied” was associated with a significant number of publications (n = 146), a closer examination revealed that the majority of them was related to other applied areas . Accordingly, this category was not included in the review. The abstracts selected were reviewed according to two inclusion criteria: (1) the article had a clear focus on cognitive biases and decision-making ; (2) the article reported a review (narrative or systematic) on the topic or a representative empirical study. This screening led to a selection of 79 eligible articles, which were all included in the review.The PRISMA flowchart in The life of any organization is made of crucial decisions. According to A defining feature of strategic decisions is their lack of structure. While other areas of management deal with recurring, routinized, and operationally specific decisions, strategic issues and problems tend to be relatively ambiguous, complex, and surrounded by risk and uncertainty . How do The “heuristics and biases” program revived the interest for bounded rationality in management with the idea that decision-makers may use heuristics to cope with complex and uncertain environments, which in turn may result in inappropriate or suboptimal decisions e.g., . Indeed,To our knowledge, no systematic review of empirical research on the impact of heuristics and CB on strategic decision-making has been published to date. Whereas the idea that CB could affect strategic decisions is widely recognized, the corresponding empirical evidence is quite weak. Most research on this topic consists in narrative papers relying upon documentary sources and anecdotal evidence e.g., . In factpotential key significance in the context of strategic decision-making .The work of ex ante, but merely look around for decisions to make. In a similar vein, It is not difficult to list examples of poor strategic decisions that can be readily interpreted – in hindsight – as the result of heuristics and biases. However, the claim that CB influence strategic decisions requires to be tested more directly through laboratory research and experimental studies . It is wAnother CB that led to a large amount of empirical research in strategic management is CEO overconfidence. Overconfidence has various aspects: overprecision, overestimation, and overplacement . RegardiManagers also overestimate their abilities, particularly with regard to the illusion of control. In their review on risk perception among managers, Finally, executives also appear to be overconfident with regard to overplacement. The case of CB in finance is special. In the 1980s, CB were invoked to account for observations on markets in disagreement with the predictions of standard finance. This paradigm relies upon expected utility theory, assuming that investors make rational decisions under uncertainty . Standard finance produced core theoretical concepts, such as arbitrage, portfolio theory, capital asset pricing theory, and efficient market hypothesis, all assuming rational investors. In the 1970s, some observations on financial markets relative to trading behavior, volatility, market returns, and portfolio selection turned out to be inconsistent with the framework of standard finance . Psychological biases (micro level) were invoked as theoretical explanations of these market anomalies (macro level), launching the field of behavioral finance . In partHere, we focus on investment decision-making in individual investors  and how Two CB have been particularly studied in investment decision-making: overconfidence and disposition effect  designed to elicit a particular bias. A typical example of vignette study is that of On the other hand, studies that investigated the While vignette-based studies are the most frequent, researchers in this area have used diverse strategies . For insex post  were based on hypothetical vignettes; (2) 34% of studies (N = 73) investigated medical personnel; (3) 82% of the studies (N = 175) were conducted with representative populations; (4) 68% of the studies (N = 145 studies) confirmed a bias or heuristic in the study population; (5) the most studied CB are loss/gain framing bias , omission bias , relative risk bias , and availability bias ; (6) the results regarding loss/gain framing bias are mixed with 39% of studies (N = 28) confirming an effect, 39% (N = 28) confirming an effect only in a subpopulation, and 22% (N = 16) disconfirming any effect; (7) 25 of 29 studies (86%) supported the impact of relative risk bias on medical decisions; and (8) 14 of 18 studies (78%) supported the impact of omission bias on medical decisions.To date, two systematic reviews have been published on the impact of CB on medical decision-making. Reviewing a total of 213 studies, N = 12) targeted CB in diagnostic tasks; (2) framing effect (N = 5) and overconfidence (N = 5) were the most common CB while tolerance to risk or ambiguity was the most commonly studied personality trait (N = 5); and (3) given that the large majority of the studies (85%) targeted only one or two biases, the true prevalence of CB influencing medical decisions remains unknown. Moreover, there was a wide variability in the reported prevalence of CB. For example, when analyzing the three most comprehensive studies that accounted for several CB  and experimental studies in which judges are asked to decide on hypothetical cases. In archival studies, researchers examine if judges’ decisions in actual cases exhibit features of irrationality. For instance, On the other hand, vignette studies consist in presenting judges with hypothetical scenarios simulating real legal cases. As in the medical field, researchers have primarily relied on such studies. A representative study is that of In particular, numerous studies have investigated the impact of anchoring effects on judicial decisions see . While tAccordingly, numerical values, such as a damage cap e.g., , the amoM = 24.41 months) than when told that the sentence should be 12 months (M = 17.64) for the same crime. This anchoring effect was independent of the perceived relevance of the sentencing demand, and judges’ experience. Along with anchoring, the impact of hindsight bias in the courtroom has been also well documented, mainly in liability cases . When deOutcome information has been shown to affect jurors’ decisions about punitive damage awards  and theiThere is also significant evidence that confirmation bias  may impaThe goal of the present paper was to provide an overview of the impact of CB on professional decision-making in various occupational areas . In all of them, there has been tremendous interest in that issue as revealed by a vast amount of research. Our review provided significant answers to the three research questions addressed.First, the literature reviewed shows that, overall, professionals in the four areas covered are prone to CB. In management, there is evidence that risky-choice (loss/gain) framing effects and overconfidence (among CEOs) impact decision-making. In finance, there is strong evidence that overconfidence and the disposition effect (a consequence of loss aversion) impact individual investors’ decision-making. Regarding medical decision-making, the systematic review of Second, the level of evidence supporting the claim that CB impact professionals’ decision-making differs across the four areas covered. In medicine and law, this issue has been primarily evidenced in vignettes studies. Such primary data provide a relevant assessment of CB in decision-making but they face the issue of ecological validity (see below). Accordingly, a mid-level of evidence can be assigned to these findings. On the other hand, following the method of revealed preference by which the preferences of individuals are uncovered through the analysis of their choices in real-life settings, the impact of CB on financial decision-making has been evidenced through secondary data , indicating a higher level of evidence. In management, both levels of evidence are found (framing effects were demonstrated in vignette studies while CEO overconfidence was evidenced through secondary data).A practical implication of these findings is the need for professionals to consider concrete, practical ways of mitigating the impact of CB on decision-making. In finance, this issue has been tackled with programs that aimed to improve financial literacy . In mediper se that confirmation bias impedes judges’ decisions in their regular work. Addressing that issue requires to use more ecological settings, such as mock trials in the case of judicial decision-making (Thirdly, our review highlights two major research gaps. The first one is a potential lack of ecological validity of the findings from vignette studies, which are numerous . Considen-making .The second research gap is the neglect of individual differences in CB. This limit was found in the four areas covered. Individual differences have been neglected in decision-making research in general . Indeed,The issue of individual differences is of primary importance when considering CB in decision-making, especially among professionals. In finance for example, the measurement of the disposition effect at the individual level revealed significant individual differences, 20% of investors showing no disposition effect or a reverse effect . Taking Addressing the issue of individual differences in bias susceptibility requires having standardized, reliable measures . While rThe author confirms being the sole contributor of this work and has approved it for publication.The author declares 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.


Error related potentials (ErrP), which are elicited in the EEG in response to a perceived error, have been used for error correction and adaption in the event related potential (ERP)-based brain computer interfaces designed for typing. In these typing interfaces, ERP evidence is collected in response to a sequence of stimuli presented usually in the visual form and the intended user stimulus is probabilistically inferred (stimulus with highest probability) and presented to the user as the decision. If the inferred stimulus is incorrect, ErrP is expected to be elicited in the EEG. Early approaches to use ErrP in the design of typing interfaces attempt to make hard decisions on the perceived error such that the perceived error is corrected and either the sequence of stimuli are repeated to obtain further ERP evidence, or without further repetition the stimulus with the second highest probability is presented to the user as the decision of the system. Moreover, none of the existing approaches use a language model to increase the performance of typing. In this work, unlike the existing approaches, we study the potential benefits of fusing feedback related potentials (FRP), a form of ErrP, with ERP and context information  in a Bayesian fashion to detect the user intent. We present experimental results based on data from 12 healthy participants using RSVP Keyboard™ to complete a copy-phrase-task. Three paradigms are compared: [P1] uses only ERP/LM Bayesian fusion; [P2] each RSVP sequence is appended with the top candidate in the alphabet according to posterior after ERP evidence fusion; corresponding FRP is then incorporated; and [P3] the top candidate is shown as a prospect to generate FRP evidence only if its posterior exceeds a threshold. Analyses indicate that ERP/LM/FRP evidence fusion during decision making yields significant speed-accuracy benefits for the user. Event related potentials (ERPs) are commonly employed in the design of non-invasive electroencephalography (EEG)-based brain computer interfaces (BCIs) to detect the user intent  conditioned on ERP likelihoods and LM-based priors. The mode of posterior distribution is selected as prospect symbol that is presented to the user, either after every sequence or after a confidence threshold is reached. The prospect symbol is an additional visual stimuli, which induces an EEG response that is indicative of that prospect's correctness. We refer to this response as feedback related potential (FRP), which takes the form of an ErrP/non ErrP indicating an incorrect/correct prospect symbol being presented. After the prospect symbol is presented and the new FRP evidence is obtained, through the Bayesian graphical model, the FRP evidence is fused with the EEG and LM-based evidence and the posterior distribution of the symbols is updated. Given the low signal-to-noise-ratio of EEG, we take an iterative update approach by presenting multiple sequences of ERP and FRP stimuli to the user to compute a more robust estimate, until the posterior reaches an information theoretic confidence threshold. User intent is then selected using maximum a posteriori (MAP) inference.Existing typing BCIs that attempt to use ERP/FRP jointly typically fall into one of these categories: a flag produced by the ErrP classifier results in (a) the deletion of the last selection made using the ERP classifier , rather than using FRP as a switch Gonzalez-Navarro et al. ; Orhan eTo illustrate the efficacy of our approach we use RSVP Keyboard™  paradigm is a minimally gaze dependent alternative for matrix presentation paradigms, that is aimed to induce ERPs for intent detection. In the RSVP paradigm, the symbols are rapidly presented as a time series on a prefixed location on the screen in a pseudo-random order, to evoke the response when the target symbol appears  that represents k, t of the epoch k, c denotes for candidate, |Ac(t)| is the number of symbols presented in the t-th sequence, Ap(t) at instant t (p denotes for prospect). In addition, t respectively. We assume that the user intent is not changing within an epoch. Hence, given that every y(·), z(·) correspond to binary class labels for ERP, FRP responses. Hence, z(āt): = δ. Nc and Np are the maximum number of “sequences” and “prospect symbols” that can be used in an epoch if a desired confidence level is not reached in reasonable duration. In the case that we do not use FRP evidence, the right box from the graphical model from Here, Here, we present three different evidence acquisition paradigms: (i) [P1], (ii) [P2], and (iii) [P3] as shown in Baseline): In this paradigm a set of pseudo-randomly ordered stimuli are presented to the user to elicit ERP. Each stimulus is a trial. Sets of trials that are presented with no time gaps are called a sequence Ac(t). Every sequence can only contain up to one target stimulus. After each sequence, the posterior distribution over the character set is computed and a decision is made if the maximum probability exceeds a predefined threshold or a time limit is reached. Otherwise, the system continues with more sequences.[P1] : In this paradigm we first query the user with ERP sequences in a similar fashion as [P1], then the mode of posterior is depicted as a prospect symbol i.e. Ap(t). Ap(t) is then presented on a prefixed location of the screen, like in regular RSVP trials, to induce FRP in EEG. Depending on the instructions given to the user, this FRP may take the form of an error-related potential (ErrP) indicating an incorrect prospect symbol being presented. The collected EEG in response to each prospect symbol is used to update the posterior using the PGM shown in [P2] : This paradigm is similar to [P1] and [P2] but the top candidate is shown as a prospect symbol to generate FRP evidence only if its posterior probability exceeds a threshold. The graphical model presented in [P3]  inference mechanism for intent detection. The graphical model presented in t, as the mode of posterior distribution:We estimate the prospective symbol k up to t; Ac(t); k at instant t; Ap(t). For [P2] and [P3] the FRP EEG evidence t.where ak is given. Then for epoch k and at time instant t, after observing the query sets Ac(t) and Ap(t), the maximum a posteriori can be computed using the objective function in (2).To compute the posterior distribution in (1), we utilize the assumptions of the graphical model presented in ak all EEG evidence from different trials are independent, and simplify the first two terms of Equation (2) as:We can further assume that conditioned on the unknown symbol p(ec|1) for target and p(ec|0) for non-target classes, and (iii) class conditional distributions over the FRP EEG evidence p(ep|0) and p(ep|1). We have implemented the proposed ERP and FRP data acquisition paradigms using the RSVP Keyboard™ framework , we need to estimate (i) the context prior that we estimated using a language model n − 1. Let mth previously typed character. Then:To compute In our system, we use a 6-gram language model, which is trained on the NY Times portion of the English Gigaword corpus , 22–38 years old. After a calibration session, participants were asked to perform a copy phrase task of RSVP Keyboard™. The data were collected according to the guidelines of an IRB-approved protocol at Northeastern University (IRB 130107).In RSVP Keyboard™, the EEG signal is acquired using a g.USBamp biosignal amplifier with active g.Butterfly electrodes at a sampling rate of 256 Hz, from 16 EEG sites : Fp1, Fp2, F3, F4, Fz, Fc1, Fc2, Cz, P1, P2, C1, C2, Cp3, Cp4, P5, and P6. To improve the signal-to-noise ratio (SNR), and to eliminate drifts, signal is filtered by an FIR linear-phase bandpass filter with cutoff frequencies  Hz and a notch filter at 60 Hz. Typically, a wideband filter, such as a [0.05–30] Hz filter is recommended to avoid the potential distortion of ERP waveforms Luck, . In our ith, of type j in response to a trial, as we defined in Equation (7). More specifically, ith; and ith. After pre-processing,In order to capture the ERP and FRP, while omitting the possible motor reposes  over target and non-target classes. p(ec(a)|1), p(ec(a)|0) over the ERP evidences; and p(ep(a)|1), p(ep(a)|0) over the FRP evidences, using kernel density estimation (KDE). We employ Gaussian kernel with a bandwidth computed using the Silverman's rule from the recorded labeled data  evidence and language model prior are fused using the assumptions of the graphical model presented in copy phrase tasks, each task being performed on a separate day. In each day, the user performs the task pursuing one of [P1], [P2], and [P3] paradigms. The order of the paradigms are randomly assigned to the users to avoid the learning impact on the typing performance.All users participate in three copy phrase task includes typing the following ten different phrases.A WILL” BITE YOU,THE DOG “THE” MOVIES,GO TO “CARE” IS CRUCIAL,GOOD HEALTH “BOWL” SUNDAY,SUPER “DAY,”EAT THREE TIMES A “SEAT” FROM THE LEFT,THE THIRD “FIND” ME FUNNY,MY PARENTS “PAID” FOR LUNCH,SHE ALSO “BUYS” US TIME,SOMETHING THAT “SITS” QUIETLY,THE COMPOSER “THE” or “WILL” are very easy to type because their initial letters are very likely based on the LM prior. However, the words such as “PAID” or “BUYS” are very difficult to type. Each phrase includes a missing word and the users are asked to complete these words. Here, the target words are written in bold. The entire sentence is shown to the user before each phrase is being typed. We use different phrases with different difficulty levels in terms of prior probability provided by the language model. For instance, the words such as “calibration tasks: calibrationERP and calibrationFRP. CalibrationERP is used to learn the statistics of the ERP classifier (target vs. non target), using the calibration mode of the system to record labeled EEG data. Typically, each calibrationERP session consists of 100 sequences of symbols. Before each sequence, the user is asked to attend to a particular symbol. Then a sequence consisting of the target symbol and 9 other non-target symbols is presented to the user in a random order. CalibrationFRP is used to learn the statistics of the FRP classifier (correct vs. non correct) using the copy mode of the system to record labeled EEG data. To obtain compatible evidence, we simulated [P2] and [P3] paradigms to collect supervised FRP EEG data.Prior to each copy phrase task all participants perform two calibrationFRP, we modify the LM probabilities, in order to record enough labeled data for correct and non correct classes. Users are asked to rest between calibrations and copy phrase tasks and continue once they felt ready.During Ac(t) is selected based on the posterior probability (fusion of evidence + LM). In [P1], the trial symbol is shown for 150 ms followed by a 50 ms blank screen . The interval between successive sequences is 500 ms. In [P2] and [P3], after ERP evidence is collected, the trial symbol is shown for 0.9 s followed by a 0.1s blank screen for the FRP evidence. Decision symbol is shown for 2 s. The maximum number of sequences allowed in an epoch is 100 for calibration tasks . In copy phrase tasks, the maximum number of sequences allowed in an epoch is 8 . In paradigm [P3], the posterior probability for showing the prospect symbol is set as αp = 0.66. Note that, we do not employ an αp during paradigm [P2] because we already show the prospect symbol after every ERP sequence. For all three paradigms , the posterior probability threshold for decision is set as αd = 0.9.The length of each trial is 500 ms for all paradigms, there are 10 trials in one ERP sequence and 1 trial  in one FRP sequence. Baseline), [P2], and [P3].Using the data collected in the human-in-the-loop copy phrase and calibration experiments described in section 3, we report the effect of the three evidence acquisition paradigms: [P1]  as described in section 3.2, we compare the offline target vs. non-target stimuli and correct vs. incorrect feedback classification results for the three data acquisition paradigms, [P1], [P2], and [P3]. We then compare classification accuracies across different acquisition paradigms by employing AUC values as the measure of EEG evidence classification accuracy. In particular, using the calibration data obtained in the Human-in-the-loop calibration experiment   such as SSVEPs, our ERP/ErrP based BCI speller has a slight advantage in accuracy  experiments with 12 healthy participants using RSVP Keyboard™, three strategies are compared: [P1]-Baseline, which only fuses ERP/LM evidence; [P2]-AlwaysFRP, where each RSVP sequence is followed by an FRP trial using the top candidate in the alphabet according to posterior after ERP/LM evidence fusion; [P3]-ConfirmFRP, where the top candidate is shown as a prospect to generate FRP evidence only if its posterior exceeds a threshold, possibly after multiple ERP-evidence acquisition sequences.We performed several analyses on the Human-in-the-loop copy phrase experiment results, which are: (i) accuracy , (ii) speed (in the form of ITR), (iii) Information Transfer Rate (ITR) (bits/sequence). Our results show that by using enough FRP evidence in addition to ERP evidence and language model (LM), the typing speed could be increased compared to a model that does not use FRP evidence. Overall, both proposed strategies [P2] and [P3], which utilize FRP evidence outperform [P1] in terms of accuracy. Moreover, [P2] yields significant speed and accuracy and, therefore, ITR improvements compared to [P1] and also performs better compared to [P3]. These results could be due to the fact that for [P3] we do not collect enough FRP evidence during copy-phrase tasks, and that [P2] causes less mental fatigue due to its deterministic presentation method. We think that, for a Brain-Computer Interface which is designed to be used daily, it is crucial to improve the speed as well as the accuracy. Our results suggest that, probabilistic fusion of the FRP evidence can bring the true performance of a BCI one step closer to the objective.According to the results, BCI users can benefit from the fusion of the FRP evidence to the decision making, if there are enough FRP evidences. Based on the analyses, we propose a BCI typing system capable of employing multiple evidence acquisition paradigms. This system, after individual assessments, will be able to determine the most profitable evidence presentation/inference paradigm as per user preference, capabilities, and EEG signal statistics.show the top candidate, gather EEG evidence, and update the posterior. Clearly the independence assumption is incorrect, if not for the auto-correlation of EEG time series, due to the overlapping time windows that are used for trial-EEG-evidence extraction. Consequently, in an improved ERP/FRP/LM fusion framework that can be designed in the future, the following issues need to be considered more carefully: (1) a signal model that captures the temporal dependency of EEG features extracted for each trial, (2) the temporal cost of gathering a sequence-worth of ERP evidence vs. FRP evidence by showing the current top prospect. Therefore, in future work, we plan to address these issues and develop an ERP/FRP/LM fusion mechanism for BCI spellers that will dynamically decide whether to gather more ERP evidence, more FRP evidence, or neither during intent inference. The inference framework does not strictly rely on EEG evidence, therefore, we will also explore multi-modal physiological evidence fusion using signal sources such as EMG or eye-gaze trajectories.We demonstrate theoretically that probing the users intent with FRP-acquisition using the current top candidate is an optimal strategy in an active learning framework employing the independent-trial-EEG-evidence assumption paradigm. This approach constitutes an improvement over previous literature employing ERP paradigms alone. In earlier work, we demonstrated that showing the top letters according to the current posterior in a sequence for ERP evidence acquisition is similarly optimal under the same independence assumption (Moghadamfalahi et al., The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Northeastern University Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.PG-N and DE conceived of the presented idea. PG-N and MM designed and performed the FRP experiments. All authors contributed to the analysis of the results and to the writing of the manuscript.This work was supported by NSF IIS-1149570, IIS-1118061, CNS-1136027, CNS-1544895, and SMA-0835976, by NIDR-H133E140026 and NIDLRR 90RE5017-02-01, and by NIH 5R01DC009834.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.


A significant number of individuals suffer from low back pain throughout their lifetime, and the medical costs related to low back pain and disc herniation are gradually increasing in Korea. Korean medicine interventions have been used for the treatment of lumbar intervertebral disc herniation. Therefore, we aimed to update the existing Korean medicine clinical practice guidelines for lumbar intervertebral disc herniation. A review of the existing guidelines for clinical treatment and analysis of questionnaires targeting Korean medicine doctors were performed. Subsequently, key questions on the treatment method of Korean medicine used for disc herniation in actual clinical trials were derived, and drafts of recommendations were formed after literature searches using the Grading of Recommendations, Assessment, Development and Evaluation. An expert consensus was reached on the draft through the Delphi method and final recommendations were made through review by the development project team and the monitoring committee. Fifteen recommendations for seven interventions for lumbar disc herniation were derived, along with the grade of recommendation and the level of evidence. The existing Korean medicine clinical practice guidelines for lumbar intervertebral disc herniation have been updated. Continuous updates will be needed through additional research in the future. With the ageing of the intervertebral disc, the compression force increases, squeezing out the nucleus pulposus through the fissure and resulting in the mechanical pressure on the spinal nerve that causes low back pain (LBP) and radiating pain, known as lumbar intervertebral disc herniation (LHIVD) .In Korea, the overall annual incidence rate for spinal disease was a median of 16,387 per 100,000 individuals in 2016. The incidence rate and annual costs per patient increased by 7.6% and 14.7%, respectively, over the period from 2012 to 2016. The incidence and medical expenses of LHIVD were the highest in patients aged under 60 years [Several clinical practice guidelines (CPGs) with a focus on Western medicine are available for LHIVD, such as CPGs for the diagnosis and treatment of LHIVD with radiculopathy  . In KoreIn 2015, the Korea Institute of Oriental Medicine (KIOM) developed guidelines for LHIVD based on an acknowledgment of the need to amend the CPG evaluation instrument using the Appraisal of Guidelines for Research and Evaluation (AGREE) II [We collected and analyzed new data with previous data that was used as evidence in the latest KM CPGs for LHIVD , which wA development committee analyzed previously developed CPGs for LHIVD and selected the key clinical questions with the results of the questionnaire survey. The Korean Acupuncture and Moxibustion Medicine Society, Society of Korean Medicine Rehabilitation, Association of the Spine and Joint Korean Medicine, and related experts reviewed and approved the key questions. After screening, quality evaluation, and synthesis of the retrieved literature, the recommendations were drafted. Expert consensus was reached on the draft using the Delphi method. After an internal review, an external review by the Korean Medical Standard Clinical Practice Guideline Project Group and the monitoring committee was conducted. Subsequently, the CPGs were reviewed and certified by the relevant group.The expert committee consisted of a working group and a review committee. The working group collected evidence on the key clinical questions and drafted the CPGs. The multidisciplinary experts, including economic evaluators, clinical experts, methodology experts, and guide users, participated in this activity. The review committee group reviewed the draft version and decided on the final recommendations.Acupuncture, pharmacopuncture, herbal medicine, Tuina manual therapy, moxibustion, thread-embedding acupuncture (TEA), and cupping were evaluated as KM interventions. The effects of single treatment, combination treatment, and differences in the effect according to the technique of the same treatment method were set for each intervention as three categories of clinical questions.In the comparative intervention, the active control group included all interventions actually used for therapeutic purposes in Western medicine, and the category of conventional treatments applied as a combination therapy encompassed all the current KM and Western medicine interventions actually used for therapeutic purposes.The following international databases were used: PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Citation Information by NII, and J-stage. The following Korean databases were used: KoreaMed, Korean Medical Database, Korean Studies Information Service System, National Digital Science Library, Korea Institute of Science and Technology Information, and Oriental Medicine Advanced Searching Integrated System. The search process was performed by setting the search period until May 2019, including the data from the last CPGs. Details regarding the search strategy and PICO approach are shown in the Two independent reviewers performed the screening procedure. Duplicate articles were excluded, and the selection and exclusion processes through the title, abstract, and full-text review were performed sequentially. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) were adopted.(1)KM treatment vs. active control.(2)KM treatment + conventional treatment vs. conventional treatment.(3)Specific technique of KM treatment vs. another technique of same KM interventionRandomized controlled clinical trial studies (RCTs) adopting the following three designs and including adult patients with LHIVD were selected based on the PICO approach:1. Non-RCTs, such as literature reviews, case reports, observational studies, and animal experiments.2. Unclear presentation of the evaluation tool or method.3. In the case of an intervention that cannot be used in the clinical field or an intervention that cannot be viewed as a medical practice.4. When the specific effect of the intervention alone cannot be confirmed due to the design problems of the experimental group and the control group.The exclusion criteria were as follows:The Cochrane Risk of Bias Evaluation tool  was usedThe evidence gathered for each clinical question was synthesized and analyzed through a meta-analysis. The analysis was conducted using RevMan 5.3, provided by Cochrane.The evidence was synthesized for each evaluation index of the evidence documents included in each clinical question. For a continuous variable, the mean difference (MD) was derived, and for a nominal variable, the risk ratio (RR) was derived to evaluate the magnitude and significance of the effect.The magnitude and significance of the effect were used to establish a basic grade at the level of evidence and evaluate non-precision. The sample size of the data synthesized for each indicator was applied to the imprecision evaluation, and the heterogeneity data (I2) derived during the evidence synthesis process was applied to the inconsistency item when evaluating the level of evidence.We used the GRADE, developed by the Cochrane GRADE working group, to determine the level of evidence and the grade of recommendation . In the The GRADE categorizes the level of evidence into four categories: high, moderate, low, and very low . In the (1)The recommendations should contain a specific and accurate description of what management is appropriate for a particular situation and patient based on the evidence.(2)The key recommendations should be easily identifiable.(3)The recommendations and the supporting evidence should be linked.(4)The level of recommendation should be properly expressed.(5)The patients or population targeted for the recommendation and the recommended intervention should be specified in as much detail as possible.Recommendations were prepared according to the following principles:The level of recommendation was determined by the magnitude of the benefit or harm. Based on the level of evidence, focusing on the level of confidence in the effect, comparison between the desired and unwanted effects, reliability of values and preferences, and use of resources was conducted.When the benefit outweighs the harm, the use of the intervention is recommended and the recommendation grade A is assigned. According to the degree, grades B, C, and D are assigned separately.If the CTB level of evidence is derived based on the textbook of KM prescribed by the Ministry of Health and Welfare and the Ministry of Food and Drug Safety and textbooks of the KM College, the utilization in the clinical field is evaluated and the Good Practice Point (GPP) grade was assigned through the expert consensus process of the development committee. An external consensus was conducted using the Delphi technique. The definitions and notations of the recommendation grades are summarized in According to the 23 main items of AGREE II,  the contOur CPGs confirmed 15 recommendations based on the 7 types of KM treatments containing interventions, comparators, level of evidence, and grade of recommendation for the key clinical questions . PRISMA The level of evidence and recommendations were derived based on 24 RCTs ,33,34,35p < 0.001), pain , and function  than active control treatment.Acupuncture, electroacupuncture, and warm needle acupuncture were compared with active control treatments, such as Western medicine, injection, and physical therapy. The meta-analysis showed that acupuncture was more effective in improving overall symptoms .The level of evidence and recommendations were derived based on 15 RCTs ,47,48,49p < 0.001), pain , and function . However, the heterogeneity (I2 = 80%) between studies was high; therefore, the level of evidence was evaluated at one level lower due to inconsistency. As a result of the meta-analysis, acupuncture combined with conventional treatments, such as moxibustion, herbal medicine, Western medicine, injection, and physical therapy, was more effective than usual conventional therapy in improving the overall symptoms .The level of evidence and recommendations were derived based on seven RCTs ,55,56,57p < 0.001), pain , and function  compared to acupuncture monotherapy.As a result of the meta-analysis, the addition of thermal stimulation or electrical stimulation during acupuncture was effective in improving the overall symptoms .The level of evidence and recommendations were derived based on eight RCTs ,63,64,65p < 0.001) than superficial-insertion acupuncture. However, the level of evidence was evaluated to be one level lower due to inconsistency owing to the high heterogeneity (I2 = 88%) observed between studies. There was no significant difference in pain improvement .The meta-analysis showed that deep-insertion acupuncture was more effective in improving the overall symptoms .p = 0.10).As a result of a search for RCTs comparing moxibustion and active control treatment for LHIVD, one study  was founIn the classical literature contained in the textbooks of the College of KM , moxibusIn a questionnaire study that surveyed the treatment status of LHIVD among KM doctors, 102 of 373 respondents (27.3%) answered that they used moxibustion .The clinical evidence for the effect of moxibustion for LHIVD was found to be insufficient. However, based on the evidence from classical literature according to the development strategy of our guidelines, the level of evidence was assessed to be CTB. Considering the high utilization of moxibustio, the GPP grade was assigned through a clinical expert consensus process.In conclusion, moxibustion is recommended for improving pain with LHIVD based on the consensus of the expert group (CTB/GPP).The level of evidence and recommendations were derived based on five RCTs ,69,70,71p < 0.001), pain , and function  than usual conventional therapy, such as acupuncture or Tuina monotherapy.As a result of the meta-analysis, the combination of moxibustion and conventional treatments, such as acupuncture and Tuina manual therapy, was more effective in improving the overall symptoms .The level of evidence and recommendations were derived based on four RCTs ,73,74,75p < 0.01) and function , p < 0.001) compared to moxibustion not causing deqi sensation. However, due to the lack of quality of the supporting literature and the number of subjects included, the level of evidence was evaluated at two levels lower due to the risk of bias and imprecision.The meta-analysis showed that moxibustion causing deqi sensation was effective in improving the overall symptoms .The level of evidence and recommendations were derived based on seven RCTs ,80,81,82p < 0.001), pain , and function  than active control treatments, such as Western medicine and traction treatment.The results of the meta-analysis showed that herbal medicine was more effective in improving the overall symptoms ; therefore, the level of evidence was lowered by two grades.In conclusion, herbal medicine should be considered to improve the overall symptoms of LHIVD (B/Moderate).The level of evidence and recommendations were derived based on 22 RCTs ,102,103 p < 0.001), pain , and function  than usual conventional therapy.As a result of the meta-analysis, the combination of conventional herbal medicine with usual conventional treatments, such as acupuncture, pharmacopuncture, Tuina manual therapy, Western medicine, injection, physical therapy, and integrated treatment, was more effective in improving the overall symptoms .The level of evidence and recommendations were derived based on eight RCTs ,109,110 p < 0.001), pain , and function  than usual conventional therapy. Since the overall number of evidence documents and the number of subjects included in studies was small, the level of evidence was lowered by one grade due to imprecision.The meta-analysis showed that the combination of pharmacopuncture with conventional treatments, such as acupuncture and Tuina manual therapy, was more effective in improving the overall symptoms .The level of evidence and recommendations were derived based on 10 RCTs ,119,120 p < 0.001), pain , and function  compared to active control treatments, such as Western medicine, injection, and traction treatment.As a result of the meta-analysis, Tuina manual therapy was effective in improving the overall symptoms .The level of evidence and recommendations were derived based on 32 RCTs ,146,147 p < 0.001), pain , and function  than conventional treatment. However, the heterogeneity (I2 = 76%) between studies was high; therefore, the level of evidence was evaluated at one level lower due to inconsistency.As a result of the meta-analysis, the combination of Tuina manual therapy with conventional treatments, such as acupuncture, herbal medicine, injection, and traction therapy, was more effective in improving the overall symptoms .The level of evidence and recommendations were derived based on 12 RCTs ,158,159 p < 0.001), pain , and function  than active control treatments, including acupuncture and complex treatment. However, in terms of overall symptom improvement, the risk of bias was high; therefore, the level of evidence was lowered by one grade.As a result of the meta-analysis, TEA was more effective in improving the overall symptoms .The level of evidence and recommendations were derived based on seven RCTs ,165,166 p < 0.001), pain , and function  compared to usual conventional therapy. However, in the area of overall symptom improvement, heterogeneity (I2 = 80%) between studies was observed, and the level of evidence was lowered by one level due to inconsistency.As a result of the meta-analysis, the combination of TEA and conventional treatments, such as acupuncture, herbal medicine, and traction treatment, was more effective in improving the overall symptoms .The level of evidence and recommendations were derived based on five RCTs ,170,171 p < 0.001) compared to conventional therapy without cupping. However, there was no significant difference in pain improvement ; therefore, the level of evidence was evaluated as very low due to the high imprecision.As a result of the meta-analysis, the combination of cupping and conventional treatment had a significant effect on the overall symptom improvement .CPGs are systematically developed statements to assist practitioners and patient decisions about the appropriate healthcare for specific clinical circumstances.Among the several standard methods used to develop CPGs, we mainly used the GRADE to assess the quality of evidence. We applied seven types of interventions to the clinical question. In a preliminary study, it was found that the studied interventions were used frequently in the actual clinical field . The stuWhen the intervention was applied alone, acupuncture and Tuina manual therapy were evaluated as A grade, herbal medicine and TEA were evaluated as B grade, and moxibustion was evaluated as GPP grade. Each single treatment was compared to active control treatments, including drugs, injection therapy, and physical therapy. This comparison showed that KM treatment can be used as an alternative to conventional treatment.For herbal medicine, the level of evidence was lowered by two grades due to the inconsistency and imprecision observed in terms of pain and function improvement. For TEA, the level of evidence was lowered by one grade due to the risk of bias. Further research is required to expand the evidence.When intervention was applied as combination therapy, the combination of acupuncture with active control treatment, combination of moxibustion with acupuncture or Tuina manual therapy, combination of herbal medicine with active control treatment, and combination of Tuina manual therapy with active control treatment were evaluated as A grade, and the combination of pharmacopuncture with active control treatment, combination of TEA with active control treatment, and combination of cupping treatment with active control treatment were evaluated as B grade. Conventional therapies include Western medicine and KM treatments. This comparison showed that KM treatment can be used as a complementary treatment to conventional treatments.Regarding the combination of pharmacopuncture with active control treatment, the level of evidence was lowered by one grade due to imprecision because the overall number of evidence documents and the number of subjects included in the studies were small. For the combination of Tuina manual therapy with active control treatment and combination of TEA with active control treatment, the level of evidence was evaluated as one level lower due to the inconsistency owing to the high heterogeneity between studies. Further research is required to expand the evidence.In actual clinical practice, KM techniques have different treatment techniques. Among them, we developed recommendations for the depth of acupuncture, thermal and electrical stimulation with acupuncture, and deqi sensation caused by moxibustion. Additional heat or electrical stimulation during acupuncture was classified as grade A. Deep-insertion acupuncture was evaluated as B grade, and moxibustion causing deqi sensation was evaluated as C grade. For deep-insertion acupuncture, the level of evidence was evaluated as one level lower due to inconsistency owing to the high heterogeneity between studies. Regarding moxibustion that causes deqi sensation, the level of evidence was evaluated at two levels lower due to the risk of bias and imprecision owing to the lack of quality of the supporting data and the n umber of subjects included. Further research is required to expand the evidence.Our CPGs have several limitations. First, there are limitations in the search strategy. Since the terms were not the same for each treatment intervention, it was difficult to present a standardized method for selecting a search word, and there were limitations in establishing a consistent level of search strategy due to the different terms by country.Second, there are some qualitative limitations that include cases where bias risk evaluation factors were not presented, cases that were not blinded, and cases where there were limitations in the design of the study. Moreover, some studies had limitations, such as study inconsistency and imprecision, and a lack of evaluation indicators, such as segmentation, safety, and economics.Finally, there are methodological limitations that do not reflect the diversity of KM treatment techniques. Few studies have compared and analyzed the detailed elements of KM treatments. There may be some disparity from the actual clinical practice in the method of synthesizing KM treatments, including various detailed attributes, into a certain category and arriving at a conclusion. Except for the diagnosis of LHIVD, there is insufficient evidence to consider clinical variables, such as severity.To overcome the limitations of our CPGs, a number of clinical studies are needed to accumulate evidence. In addition, to acquire data on stability and provide recommendations that can be realistically applied in the clinical field, it is necessary to expand the scope to case reports and observational studies while using RCTs as supporting literature in CPGs. A close review of more clinical experts is necessary to prevent the deterioration of quality.


Mean weight-change between baseline and endpoint  was −4.4 (SD 3.38) kg, and degree of weight change was associated with session attendance  = 6.356, p < 0.0005). There were positive effects on participants’ weight, health-related behaviours, and quality of life. The intervention content  and structure were adapted during implementation to better suit national guidelines and local population needs. RE-AIM was found to be a useful framework for evaluating and adapting an existing evidence-based weight management programme in line with local population needs. This could be a more cost-effective approach, compared to developing new programmes, for delivering public health goals relating to obesity, nutrition, and physical activity.Obesity is widespread, with serious health consequences; addressing it requires considerable effort at a public health level, incorporating prevention and management along with policies to support implementation. Behavioural weight-management programmes are widely used by public health bodies to address overweight and obesity. Shape-Up is an evidence-based programme combining a structured behavioural intervention  within a peer-learning framework. This study was a service-evaluation of Shape-Up, as delivered in Rotherham by a local leisure provider, and included a secondary analysis of data collected in the community by service providers. The RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework was used to explore programme effectiveness, implementation, and whom it reached. A total of 141 participants were included. Compared to local demographics, participants were older, at 48.9 (SD 14.47) years, with a lower employment rate (41% employed) and greater proportion female . Mean BMI was 38.0 (SD 7.54) kg/m The scoThis service evaluation is novel in using RE-AIM to perform a structured detailed service evaluation of the real-world use of the Shape-Up intervention to support progress towards public health goals. In assessing the intervention along different dimensions, it was possible to see that a wider programme of standardised service evaluations would offer valuable evidence towards further refining and improving this evidence-based intervention. Structured weight-management programmes, such as Shape-Up, take considerable amounts of expertise, time, and financial resource to develop. However, tailoring weight-management interventions to meet the needs of local populations is also required if such programmes are to deliver public health outcomes. It makes economic sense for existing evidence-based approaches to be adapted using a structured approach that supports research and evaluation efforts to understand what works for whom. This study suggests that RE-AIM would be a useful framework for evaluating and adapting evidence-based weight-management programmes.


Intergovernmental policy is targeting public ocean literacy to help achieve the societal changes needed to reach a sustainable ocean agenda within a 10-year timeframe. To create a culture of care for the ocean, which is under threat from Anthropocentric pressures, informed ocean citizens are central to upholding meaningful actions and best practices. This research focuses on recreational ocean users, specifically surfers and how their blue space activities may inform understanding of ocean processes and human-ocean interconnections. The Ocean Literacy Principles were used to assess ocean awareness through surfing interactions. An online survey questionnaire was completed by 249 participants and reduced to a smaller sample focus group. Qualitative and quantitative data were triangulated to develop further understanding of surfer experiences, using the social-ecological systems framework to model surfing outcomes. The results found that surfers indeed receive ocean literacy benefits, specifically three out of the seven Ocean Literacy Principles and that ocean literacy is a direct benefit many surfers in the sample group receive. By identifying synergies between the Ocean Literacy Principles, variables within coastal ecosystems and user (surfer) interactions, this research offers novel insight into opportunities for integrating ocean sustainability strategies through blue space activity mechanisms and coastal community engagement. The Anthropocene has imposed great pressure on ocean ecosystems. With climate change, biodiversity loss and marine plastic pollution ,2,3,4 leOcean literacy is defined as “an understanding of the ocean׳s influence on us—and our influence on the ocean” which, according to recent studies is “fundamental to living and acting sustainably” . While tThe Ocean Literacy Framework is made up of seven principles and 24 concepts and during the last 15 years has grown to be acknowledged as an integral part of marine citizenship . A globaEmerging research through the European-funded Horizon 2020 Seas Oceans and Public Health in Europe Project (SOPHIE) studies these interconnections in depth and provide resources which link the conservation of blue spaces to be necessary to manage, maintain and increase the health and well-being of humans ,16. The In addition, the inter-disciplinary research area of communities and blue spaces (particularly oceans and seas) is currently limited. International studies about the outdoors, environmental literacy, and human well-being, in comparison have reached a coalescence with a consensus that green spaces are good for health ,20 and uThis research introduces a case study to explore ocean literacy mechanisms within recreational ocean activities and user groups in more depth. It considers how ocean literacy might be ingrained into human–ocean interactions with specific reference to surfing.Surfing takes place in the nearshore, coastal zone and can be a completely solo endeavour, with minimal equipment needed (a surfboard and wetsuit in colder temperatures) . AlthougAccording to Borne, surf culture “bears a striking resemblance to the concept of sustainability; creating an enticing marriage between the two”  (p. 224)Although there is an absence of any data about the ocean literacy of surfers within scientific literature, Ingersoll  testifieIn exploring the convergence zone of surfers and their awareness of the ocean, the hypothesis is that surfing produces ocean literacy (which its participants utilise) and is therefore, a potential mechanism for increased ocean literacy. By sampling a group of the surfing population, based predominantly in Europe, primary data was collected to reveal surfer feedback on ocean literacy principles. This research considers how the dynamic, fluctuating and highly varied surfing system might directly relate to ocean literacy learning pathways within coastal communities and is an opportunity to develop further ocean sustainability social awareness and engagement strategies.A mixed-methods approach was used to explore the hypothesis that surfers are ocean literate due to regular exposure to coastal and ocean system variables and their ability to navigate surf breaks (to receive benefits and avoid risks) naturally equips them with ocean literacy. A collection of qualitative and quantitative surfer data was collected to balance resource user feedback  with statistical data from a sample of the surfing population. The main objective of the study was to ascertain whether Ocean Literacy Principles are statements surfers agree with and whether surfer variables, such as how often they surf, or their ability, might impact their answers on the Ocean Literacy (OL) Principles.The research followed a sequential explanatory design, starting with quantitative data collection and analysis and leading onto more in-depth qualitative data collection based on individual (surfer) perspectives  (p. 211)As the research project took place during the first COVID-19 lockdown procedures (May 2020), in situ research collection at the beach or in person was not possible. Many countries implemented a ban on surfing, therefore due to social distancing and quarantine limitations, an anonymised online survey was produced. Participants of the questionnaire were given the option to sign up to a focus group at the end of the survey by entering their email address and from this a small group were randomly selected and contacted. Demographics were deliberately left out of the first survey to focus on surfer variables (and avoid participant drop off from too many questions). However, a demographic survey was released to ensure that a range of ages, genders, nationalities, and ethnicities across surfers in Europe were represented. Informed consent was obtained from all subjects involved in the study, with participants filling in consent forms for the survey questionnaire and qualitative data collection.Ethical approval was received by the GSI School Research Ethics Panel (SREP) for a period of 1 year from 21 May 2020 under the terms of Anglia Ruskin University’s Research Ethics Policy. Reference number: GSISREP-1920-002.A total of 249 participants completed the surfing survey which was released on 5 June 2020 via the Online Surveys website through Anglia Ruskin University  and distThere were 12 questions, with the first 4 determining surfer variables based on a diving study looking at the motivation, experience, frequency, and location of divers in relation to environmental engagement . The surQuestions 5–7 asked about surfing motivation, barriers, and emotional impact of aforementioned barriers. In Question 5 (What are the benefits you receive from surfing?) the answer “connection with the ocean” was used to represent ocean literacy aspects of surfing . For question 8 participants were only asked to answer YES or NO to whether they agreed with the following statements (1–7 OL principles) to obtain a dichotomous result. They were not informed of the ocean literacy principles or framework. All statements are correct (according to the OL framework) and participants were encouraged to think about the statements before making their selection because it could not be changed. Question 9 asked what was responsible for their previous answer to understand the origins of their proposed ocean literacy.The research hypothesis is that surfers in the sample group would be intuitively ocean literate. However, due to the absence of scientific evidence of the connection between surfing and ocean literacy, the research also followed the assumption that the terminology “ocean literate” is not prominently used by surfers . Due to its origins within the education sector (rather than surfing mainstream) and connotations literacy has with reading and writing, “ocean literacy” is a term much more likely to be used by scientists, teachers, or academics , which, χ2) tests were used to assess the statistical significance of the quantitative findings. The surfer variables  were tested for independence against the other variables using a χ2 test for independence to determine whether or not there was a significant association between categorical variables.Chi-squared plastic pollution crisis? Would humanity becoming more ocean literate and more systems literate be part of it? .As a surfer would you say you employ certain aspects of systems thinking to receive benefits such as: physical exertion, mental clarity, connection to the ocean and fun and avoid risks such as: bad conditions, overcrowding, injury?A written interview comprised of the following 6 open-ended questions.These were sent out to the same participants via email to obtain specific qualitative answers, with data later coded to find evidence of ocean literacy principles, clarify quantitative data observations, as well as to track any emergent themes about the wider concept of marine conservation. Having spent time discussing ocean literacy in the focus group as a primer, these questions went deeper into connections between surfing and ocean literacy. After all qualitative data was collected, evidence of the variables was found through reflective thematic analysis. To find evidence of the ocean literacy principles, the interview data was subjected to a text query using key words from each ocean literacy principle.The Social Ecological Systems (SES) framework was used as an overarching conceptual methodology while conducting the research . Within The results from the surfer variables showed there were higher frequencies of certain “categories” of surfers, including: 52.6% surfing for more than 10 years; 46.2% surfing 1–5 times a week; 43.4% moving between a few different spots in their local area; and 45.2% of intermediate ability. The results from the statistical tests found that the categories do not fit a uniform distribution, as shown in The survey asked participants to name the main driver(s) behind why they surf, the origins of their ocean awareness, and to scale how much they valued the ocean. Descriptive statistics showed a tendency towards a high understanding, awareness, and appreciation of ocean ecosystems. “Ocean literacy” was substituted for “connection to the ocean” to represent enjoying the relational aspects of surfing. The highest number (91.2%) of participants choose “connection to the ocean” as a motivating factor for surfing, with 77.4% of participants attributing surfing to their understanding of the ocean . 55.8% of participants highly value ecosystems due to surfing (ranked 1st). In terms of threats to surfing ecosystems 72.7% of surfers had become aware of plastic pollution through surfing in multiple ways and 95.5% said they would take action by cleaning plastic off the beach (both the highest tendencies). 59.2% of participants said they would sign up to a citizen science programme and 42.2% to a focus group, to help ocean conservation. However, only 71 people entered their email address to join the focus group, showing that given the opportunity only 28.5% of participants would actually engage.p-value was <0.05, and therefore, we can accept there is a relationship between the frequency variable and certain ocean understanding. The results show that how often surfers go surfing is significant with regards to their understanding of “the ocean shaping the features of Earth” (OL Principle 2) and “the ocean and humans being interconnected” (OL Principle 6). . The statistical analysis found no correlation of significance except between Frequency and Ocean Literacy Principles 2 and 6. For these, the The qualitative data shows how there are many variations in ocean literacy outcomes. Despite similarities, surfers experience differences throughout their individual surfing interactions with the variables helping explain and categorise these differences.Experience is key to being able to read waves, with Participant E embracing the learning process.“As I’m still a beginner/improver surfer, I’m not at the point where my reading of waves necessarily means I catch more of them, but what I love is the process of trying to understand each individual break that I visit.”Participant C noted how having time out from surfing brought about more appreciation for it, which relates to frequency.“I think there’s definitely such a thing as a surfing withdrawal symptoms, if you haven’t surfed in a while. If you’ve been stuck on a job or in a city, and then you get back to the sea, you’re just so thrilled to be in the water.”Results showed that surfing benefits vary due to surfing manoeuvres and conditions, but are still positive, if, such as Participant C, the surfer has a level of ability.“If I’ve had a really good surf, like a stand-up barrel or something, I’m just, I’m over the moon. It’s like a hundred percent.”Having a local beach means the privilege of access to physical and emotional benefits of surfing, which also links to localisation.“We’d just done a really long journey and got straight out to the car and went for a quick surf. It was really sloppy conditions. It was just a bit of fun and a bit of exercise.... but it helped to stretch and de-stress.” (Participant A)“It helps educate me with life lessons and allows me to demonstrate that I am capable of overcoming overwhelming problems”; passion; “Following a passion for surfing has inspired me to learn and raise my awareness about the interconnections of life and our environment”; and collaboration; “There’s a sharing part of the sport that make us belong to a community. Communities evolve together by learning, teaching, sharing, experiencing.” (Participant F).Motivation to surf and the positive outcomes (in reference to connection) showed up in the qualitative data, including: experiential learning; “When you’re surfing, you’re part of the ocean, Surfing and its effects are less...static. It not a gentle soak, its participation in the ocean. Participation in its energy and alive-ness.”Participant D commented on the interactive elements. “As a woman, it can be intimidating to surf in crowds with men without a friend so this can sometimes hinder whether I get out or not” (Participant ID: 607219-607210-61306670).There were a range of barriers mentioned by participants, in addition to conditions and personal reasons (highest answers in the quantitative data) that included: “sharks”; “financial pressures”; “proximity”; “childcare”; and “gender-based abuse”. One participant elaborated further. Participants mentioned marine plastic pollution as the most concerning ocean sustainability issue, as opposed to climate change, biodiversity loss and de-coastalisation. They responded with highly emotional and emphatic data in the qualitative analysis.“It is sad and frustrating when you leave a surf having collected crisp packets, tampon applicators, and fishing gear on your way out. It deeply affects me when I see the beach covered in plastics. My heart breaks for the creatures of the world.” (Participant E).“No. (it would not stop me from surfing)”Participant C “Yes, not for safety though, just for sadness.”Participant D “It would if the water was full of it, like it has been in some countries I’ve visited.”Participant E While all were aware of plastic pollution in the marine environment through surfing, when asked whether plastic pollution would actually stop them surfing the answers ranged.The “other” answers in the questionnaire showed how surfing could provide both the interaction and the outcome for knowing about these issues.“I was aware of plastic pollution before surfing, however it became a more important issue for me through surfing.”(Interaction) (Participant ID: 607219-607210-61170018)“Having an interest in the ocean for surfing, encourages me to learn more about [plastic pollution] by watching documentaries etc.”(Outcome) (Participant ID: 607219-607210-61866951)“I wouldn’t say that I consciously employ aspects of systems thinking, but can see on reflection that I do” (Participant E).The qualitative data showed evidence that surfers employ systems thinking while surfing, but perhaps without knowing it. Participant B explained how their perspective changes once in the sea.“When I’m thinking about going for a surf I think about the conditions and if the waves are going to be good, but once I’m in the water, I notice how clear it is, the temperature, if there’s fish and wildlife.”Participant D inserted themselves into a dynamic system, noticing how the benefits they receive rely on the conditions working in their favour.“Everything is deeply interrelated. Understanding all the cogs rely on each other is a big part of surfing. Whether that’s conditions that need to come together for a wave to work  or mental ”.All participants confirmed that surfing helped increase their awareness and understanding of the ocean, including participant B.“Surfing has definitely made me more ocean literate. Understanding how waves work helps me to choose the right wave (most of the time!), which helps me receive the most benefit from surfing, physically, and mentally.”This happens for another, with an added sense of mindfulness.“Reading waves slows me down, makes me more mindful of my surroundings and of nature, and takes me out of all of the other stuff in my head.” (Participant E).“When I was a teenage surfer in Cape Town, South Africa I could tell what the conditions were like when I woke up in the morning. Now after living in Croyde, United Kingdom for the past 5 years, I can do the same thing. I think human beings can feel atmospheric pressure, which relates to winds. Temperatures are also relevant to pressure.” (OL Principle 3: The ocean is a major influence on the weather and climate).While the qualitative data failed to produce any evidence of Ocean Literacy Principles 1, 2, 4, and 7, the other three Principles were acknowledged by participants. Participant C admitted using intuition regarding the weather and talked about how sensory perception helped to predict surf conditions in different locations. “I have picked out a few pieces of plastic from the ocean when I have been surfing and considering how much trash we collect on beach cleans, I think ocean ecosystems are already being damaged by microplastics and trash.” (OL Principle 5: The ocean supports a great diversity of life and ecosystems).Exposure to marine pollution in surfing environments has made participants think about and take action to protect ocean ecosystems., for example participant C. “I have a more emotional connection to the water since surfing, I am more aware on its effects on my mental well-being.” (Participant D) (OL Principle 6: The ocean and humans are inextricably interconnected).One participant commented on how being in sea water provided therapeutic benefits. The mixed-methods approach culminated with a cross section of results from the survey and interviews regarding evidence of ocean literacy. The findings confirmed that the Ocean Literacy Principles from the surfer sample population were most familiar with were Principles 3, 5, and 6 . These findings were built into a surfing SES model as seen in This study serves to provide a sound basis for the argument that ocean literacy is an intrinsic benefit received by surfers, through the coastal-based recreational activity of surfing. Concluding whether surfing is a reliable and consistent mechanism for ocean literacy, however, is still open for debate. A self-assessment protocol was used to determine ocean literacy levels of surfers, which has its limitations and does not necessarily equate to actual, observed levels of ocean literacy. While the quantitative data results imply that surfing participants are knowledgeable across all Ocean Literacy Principles , the qualitative results reveal gaps with an absence of ocean literacy principles 1, 2, 4, and 7, in the analysis.Therefore, to measure more accurately in future research, it would be worth drawing on systematic methodology devised by Brennan et al. . They am“Ocean literacy is a brilliant systems thinking learning tool” although one that has remained ambiguous in the surfing world. More studies, such as Ferreira et al. [Research by Reineman  concludea et al. , who pro“Ocean literacy is a privilege, extended only to the very few who get to live by the water, or can afford to visit it.” which is also the case for surfing. Privilege, access, and inequity are themes beyond the scope of this study but are what De Bell et al. [However, focus group Participant A reminds us that l et al.  address l et al. , exploitl et al. , and a sl et al. . The resl et al. .When considering social aspects of surfing in terms of health benefits, there is literature concerning the therapeutic benefits of blue space ,70; yet Surfing, in this sense, is a key case study on how humans interact with the ocean as it “reflects a relationship to practice, place, and community that enables and restricts, but this complexity is difficult to articulate” . Whilst The overall results from this study provide extensive evidence that conceptualising surfing as a social-ecological system (SES) is an appropriate framework to explore the inter-disciplinary and interconnecting components of the surfing system. Within the surfing system, evidence of Ocean Literacy Principles shows that surfing is an example of informal education. This outdoor, out of classroom learning that Sacco et al.  call “liBourne  (p. 222)In terms of sustainability, surfing is not exempt from systems archetypes such as “Limits to growth”  (p. 27) The global network of surfers is now united by the inclusion of surfing in the (2020) Olympics . This siThe participants in this research are clearly concerned about the state of local surf ecosystems and the ocean at large, and the coastal zone is where more marine stewards are needed. Surfers have already shown potential to monitor environmental indicators, shifting their role from steward to citizen scientist . NotableThe success of these previous surfing-citizen science studies (in the peer reviewed and published sense), supports the proposal that more scientific research by surfers within surf breaks, however niche, is thoroughly needed to fill knowledge gaps across the inter-disciplinary human ocean system research area. Evidence that surfers would embrace this role is supported by Whyte’s “Saltwater Citizen” theory   and explWith surfers expressing concern regarding plastic pollution in this study, the question to ask is to what extend can they be relied on to continue the management of surf breaks? To maintain healthy and functioning surf ecosystems, sustainability principles, and frameworks of sustainable development are needed to outweigh incentive for growth  and addrThis study echoes Scheske et al. , who calScientific disciplines have only recently come together to consider the importance of how Earth’s bodies of water (human and ocean) interact . Even thThis study shows surfers, and potentially other recreational ocean users, use systems thinking at an intuitive level. This is an exciting prospect when considering opportunities to increase public ocean literacy within inter-disciplinary marine science. Also, thinking systemically is key to rebalancing and reframing ocean sustainability on a global scale, with collaboration and joint action at the core.Ocean literacy could be a vital tool to awaken non-surfing humans to their dynamic relationship with the ocean, inspiring action to not only understand better, but to take on a role of stewardship and help drive societal behaviour change ,96. WhilAccording to the research embedded in the Seas Oceans and Public Health project, improving ocean literacy levels could also help improve understanding of risks and benefits to health from interacting with the ocean. A recent meta-analysis reflects how multiple marine stakeholders have different priorities, therefore, citizen engagement needs to consider this whilst working systemically and taking a participatory approach . Self-efThis study concludes that surfers receive ocean literacy benefits—specifically understanding and awareness of Ocean Literacy Principles 3, 5, and 6—and that surfing waves within coastal ecosystems is a potential mechanism for ocean literacy. There are many variables within the surfing SES, which produce a variation of interactions and outcomes, yet the results show frequency—how often surfers surf—is statistically significant with regards to surfer ocean literacy levels. Despite extensive data collection, there is not enough scientific evidence to support the theory that the surfing SES contains proven mechanisms for high levels of ocean literacy.However, this research serves as a foundation on which to build on and argues there is a clear prospect to develop more knowledge about how ocean literacy is produced through the surfing SES. It identifies surfing as an opportunity to extend current ocean literacy learning pathways.the ocean is a major influence on the weather and climate;the ocean supports a great diversity of life and ecosystems;the ocean and humans are inextricably interconnected.Surfing, rather than simply a sport, lifestyle, or subculture, is an example of the interconnectedness of humans and the ocean, with surfers learning key principles through their surfing exploits, including:Surfers are untapped data points with levels of ocean literacy that could be useful to ocean science and a prime example of a global ocean community that will soon exceed 35 million participants, who could demonstrate a “culture of care” . There i