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• Research article
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• Published: 15 September 2018

Research capacity building frameworks for allied health professionals – a systematic review

• Janine Matus   ORCID: orcid.org/0000-0002-3067-8870 1 ,
• Ashlea Walker 1 &
• Sharon Mickan 1 , 2  

BMC Health Services Research volume  18 , Article number:  716 ( 2018 ) Cite this article

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Building the capacity of allied health professionals to engage in research has been recognised as a priority due to the many benefits it brings for patients, healthcare professionals, healthcare organisations and society more broadly. There is increasing recognition of the need for a coordinated multi-strategy approach to building research capacity. The aim of this systematic review was to identify existing integrated models and frameworks which guide research capacity building for allied health professionals working in publicly funded secondary and tertiary healthcare organisations.

A systematic review was undertaken searching five databases (Medline, CINAHL, Embase, AustHealth and Web of Science) using English language restrictions. Two authors independently screened and reviewed studies, extracted data and performed quality assessments using the Mixed Methods Appraisal Tool. Content and thematic analysis methods were used to code and categorise the data.

A total of 8492 unique records were screened by title and abstract, of which 20 were reviewed in full-text. One quantitative study and five qualitative studies were included, each of which describing a research capacity building framework. Three interconnected and interdependent themes were identified as being essential for research capacity building, including ‘supporting clinicians in research’, ‘working together’ and ‘valuing research for excellence’.

Conclusions

The findings of this systematic review have been synthesised to develop a succinct and integrated framework for research capacity building which is relevant for allied health professionals working in publicly funded secondary and tertiary healthcare organisations. This framework provides further evidence to suggest that research capacity building strategies are interlinked and interdependent and should be implemented as part of an integrated ‘whole of system’ approach, with commitment and support from all levels of leadership and management. Future directions for research include using behaviour change and knowledge translation theories to guide the implementation and evaluation of this new framework.

Trial registration

The protocol for this systematic review has been registered with PROSPERO. The registration number is CRD42018087476 .

Peer Review reports

There is a burgeoning interest in strategies to enhance research capacity building for healthcare professionals. The recent Strategic Review of Health and Medical Research in Australia (2013) recommended that research should be fundamentally embedded in the health system, and that the healthcare workforce should be involved in research to drive continuous improvement [ 1 ]. Research capacity building has been defined as “a process of developing sustainable abilities and skills enabling individuals and organisations to perform high quality research” [ 2 ], or “a process of individual and institutional development which leads to higher levels of skills and greater ability to perform useful research” [ 3 ].

While there is no single agreed upon definition of “allied health” in the international literature, allied health professions are commonly grouped together by exclusion from medical and nursing/midwifery, and include but are not limited to physiotherapy, occupational therapy, speech pathology, social work, psychology, podiatry and pharmacy [ 4 ]. The benefits of allied health professionals participating in research are manifold. At a clinician level, benefits include enhanced attitudes towards research [ 5 ], an increased uptake of research evidence into practice [ 6 , 7 ], and the development of critical thinking skills and a culture of evidence-based practice [ 8 ]. Clinicians who participate in research are also more likely to experience greater job satisfaction [ 9 , 10 ].

At a service level, having healthcare professionals involved in research may positively influence the infrastructure and processes of client care [ 11 ]. A sound base of high quality research evidence is needed to inform the delivery of evidence-based healthcare and strategic service planning and policy making [ 5 , 8 , 10 , 12 , 13 ]. An additional benefit is being able to evaluate and demonstrate the quality and efficiency of the healthcare services being provided [ 6 ]. This is especially a priority for the allied health workforce due to the relatively low level of evidence for many allied health interventions [ 8 , 10 , 14 ]. Allied health professionals need to produce research evidence to demonstrate the efficiency and cost-effectiveness of their interventions and models of service delivery, or else they will increase their vulnerability to having aspects of their work delegated to traditional medical and nursing professionals, not being able to maintain current roles, diversify into new areas or expand their scope of practice [ 6 , 8 ].

At a broader societal level, benefits of clinicians engaging in research include the potential of more successful translation and impact of research findings into clinical practice, thereby enhancing patient outcomes [ 15 , 16 , 17 ]. Indeed, having healthcare professionals involved in identifying research questions that arise from real-life problems and gaps in clinical practice and assisting with designing research methodologies may increase the likelihood that research projects will generate practical solutions which are readily translated into practice [ 17 ].

Previous research has demonstrated that allied health professionals are motivated to participate in research by intrinsic and extrinsic factors which align to these benefits. The most commonly reported motivators are to address problems in practice, build the evidence base to inform service delivery, provide the best possible care for patients and enhance their job satisfaction and career opportunities [ 6 , 10 , 18 , 19 ].

The aim of research capacity building in a healthcare setting is to strengthen health professionals’ existing clinical expertise with complementary research skills [ 8 ]. This enables them to contribute to the production of high-quality research which advances the knowledge base of their profession, demonstrates the effectiveness of interventions, influences funding bodies, and enables evidence-based practice [ 8 ]. Building research capacity may be targeted across three different levels including foundational skills in using research (e.g. understanding how to search for, appraise and consciously apply research evidence to inform practice), participating in research (e.g. assisting with participant recruitment and data collection) and leading research (e.g. developing research protocols and applying for funding).

Allied health professionals have been reported to have a high level of interest in undertaking research [ 20 , 21 , 22 ]. However, despite their interest and the recognised benefits, allied health research engagement remains limited due to a number of challenges and barriers including a lack of time and funding, other work roles taking priority, a lack of research skills and a lack of support from managers and colleagues [ 10 , 19 ]. As building allied health research capacity has been recognised as a priority [ 10 ], a range of different research capacity building approaches have been recommended and implemented across publicly funded healthcare organisations in Australia [ 9 , 23 ] and internationally [ 8 , 24 ].

Most of the extant literature describes single-strategy research capacity building initiatives, interventions or programs. Some of these strategies have been focussed at the level of individuals and teams, such as identifying those clinicians who express motivation and intention to do research and those who are seeking a challenge, improved job satisfaction or increased professional development opportunities [ 10 , 19 , 22 ] and providing these clinicians with protected time, education and training, resources and mentoring from more experienced researchers [ 10 , 18 , 22 , 25 , 26 , 27 ]. For example, a research internship model for podiatrists resulted in increased research output, as measured by the number of abstracts, publications and further research training [ 28 ].

Dedicated research leadership/facilitator or conjoint positions have been found to be associated with increased organisation and team domain scores on the Research Capacity and Culture tool, as well as increased research skills and outputs [ 7 , 29 , 30 ]. Similarly, academic-practice partnerships have been reported as an important strategy for increasing research capacity, engagement and output [ 10 , 27 , 31 , 32 ]. For example, a large proportion of research outputs by clinical staff within one large publicly funded health service were the result of work led by, or in collaboration with, academic partners [ 27 ].

Strategies which have been implemented at the level of the organisation include embedding research activities in strategic plans, visions, missions and values, developing targets or key performance indicators (KPIs) for research [ 19 ] and role descriptions to attract research interested and active applicants [ 10 ]. Organisation level strategies also include incorporating research into clinical roles, increasing funding for appropriate backfill of clinical positions, supporting staff with joint clinical and academic appointments [ 6 ] and creating opportunities to engage in research through secondment [ 6 , 8 , 12 , 27 ]. It has been suggested that organisations may benefit from strategically prioritising funding for those projects which have the greatest potential to directly impact on patient care [ 8 ].

Some authors have recognised that a single strategy approach is not sufficient, but that a “whole of organisation approach” or “whole of system approach” is required for building research capacity and culture in allied health [ 10 , 12 , 33 , 34 , 35 ]. A recent rapid review of allied health research frameworks has recommended multiple strategies across individual, organisational and policy levels to embed a culture of allied health research into healthcare services [ 36 ]. Authors have suggested that strategies are interlinked and interdependent, such that strategies implemented at one level can have an impact on other levels. Therefore, the use of coordinated and integrated multi-level strategies at individual, team, organisational and system levels has been recommended [ 18 , 25 , 33 , 37 ]. However, there currently is no single framework, model or set of recommendations to guide research capacity building approaches for allied health professionals in publicly funded secondary or tertiary healthcare settings.

The aim of this systematic review was to identify, appraise and synthesise existing models and frameworks which describe integrated and practical approaches to research capacity building for allied health professionals in publicly funded secondary or tertiary healthcare organisations. This review intended to search for both models and frameworks, the most common methods of conceptualising combinations of strategies. A model usually describes and guides the process of implementing an intervention, including a temporal sequence of steps, stages or phases of the process. In contrast, a framework usually identifies the hypothesised factors which may influence an outcome without describing the process for achieving this outcome. A framework may also provide a structure for planning and evaluating interventions. Neither models or frameworks necessarily address the causal mechanisms of change [ 38 ]. The protocol for this systematic review has been registered with PROSPERO. The registration number is CRD42018087476.

Search methods

In collaboration with authors AW and JM, a senior librarian developed a detailed search strategy in the following five electronic databases: Medline (Ovid), Embase (Elsevier), CINAHL (Ebsco), AustHealth (Informit) and Web of Science (Clarivate Analytics). Terms and synonyms relating to research capacity building, allied health, hospital and healthcare service/organisation, model and framework were used. Database searches were conducted on the 19th and 27th June 2017. An example of the search strategy used in Medline is found in Additional file  1 . The search terms were adapted as required to search the other four databases. Reference lists of included articles were additionally reviewed. Where full-text articles were not available, or clarification was required, one of the authors (JM) contacted the study authors to request the relevant information.

Study inclusion and exclusion criteria

The eligibility criteria for this study are described in Table  1 below. As the purpose of this systematic review was to address an identified need for evidence-informed allied health research capacity building approaches in a publicly funded secondary and tertiary healthcare organisation, the inclusion and exclusion criteria have been tightly scoped to reflect this. Only studies published in the English language and between January 2005 and June 2017 were included. These decisions were made in the interest of resourcing feasibility.

Study selection

Search results and additional references were collated into a reference database (Endnote) and any duplicates deleted. All titles and abstracts were independently screened by two authors to identify studies that potentially met the eligibility criteria. Full text copies of these articles were retrieved and independently assessed for eligibility by two authors. Disagreements were resolved by discussion and consensus agreement, and if required, input from a third author.

Data extraction and quality assessment

Data were independently extracted and analysed by two authors, using a data extraction form developed to include information pertaining to study location, participant demographics, purpose, definition of research capacity building, methodology and study design. Disagreements were resolved through discussion and consensus agreement.

The extent to which each study is likely to be influenced by bias was independently evaluated by two authors using the Mixed Methods Appraisal Tool (MMAT). This tool was designed to concomitantly appraise the methodological quality of studies with diverse designs including qualitative, quantitative and mixed methods research [ 39 ]. Two consistent screening criteria are complemented by four methodological criteria for each study design.

A total of 8492 unique records were assessed for eligibility by screening titles and abstracts. Of these, 20 were reviewed in full-text and six were included in the review [ 9 , 29 , 33 , 37 , 40 , 41 ]. Figure  1 illustrates the number of studies which were screened based on title/abstract and full-text, with reasons for exclusion documented.

Flow diagram of process to identify eligible studies

A total of one quantitative and five qualitative studies were included. Studies originated in Australia ( n  = 4) and the UK ( n  = 2). All studies defined research capacity as the ability to engage in, perform or carry out quality research. All six studies met the definition of framework rather than model. The studies varied in terms of the composition of their frameworks and in the way that these had been developed, implemented and evaluated. Each framework describes number of research capacity building approaches. Refer to Table  2 for a description of the included studies.

Risk of bias within studies

All studies had a clear research question or objective and collected relevant data to address it. Studies varied in their methodology and in how comprehensively this was reported. Based on their MMAT scores, all six studies were judged to be of appropriate and comparable quality to be included in a narrative synthesis. Refer to Table  3 below for a descriptive summary of the methodological quality and risk of bias of each study using the MMAT criteria.

Data analysis

Qualitative analysis was used to synthesise findings. Initial steps of the qualitative analysis involved an attempt to directly compare the overarching research capacity building approaches described in each framework. The total number of approaches was 33, ranging from three to eight per framework. Please refer to Table 2 for details of these approaches. However due to differences in terminology and classification, it was not possible to compare these approaches directly. Due to variations in their purpose, content and theoretical design, no single framework was able to explain all of the approaches included in the others.

Instead, a content analysis method [ 42 ] was used to code and categorise the individual components of each approach (total number = 162), which were defined for the purpose of this review as the discrete strategies and conditions within each approach that were found to be conducive to research engagement and capacity building. These coded components were then grouped according to their frequency and emerging patterns of similarity and consistency in their content, both within and across the frameworks.

Next, an inductive thematic analysis was undertaken following the phases described by Braun & Clarke [ 43 ]. Phases included searching for underlying patterns of meaning among the coded components and groups of components, generating preliminary themes, reviewing the themes, and naming the themes [ 43 ]. This process was recursive and made use of thematic mind maps to explore relationships between the codes and themes. Each preliminary theme was reviewed to ensure that its included codes formed a coherent pattern. Some themes were consolidated while others were subdivided or reworked to ensure both internal homogeneity and external heterogeneity.

Ultimately, three interconnected and interdependent themes were identified as being essential for building research capacity. These are ‘supporting clinicians in research’, ‘working together’ and ‘valuing research for excellence’. These themes are supported by 17 subthemes. Two authors contributed independently to the analysis and met regularly to challenge each other’s assumptions and cross-check the validity of the preliminary and final themes to help maintain trustworthiness, credibility and accountability of the findings [ 44 ]. All authors agreed on the final themes. Please refer to Table  4 for an overview of the final themes and subthemes and to Additional file  2 for a detailed list of all coded and categorised components which are presented as lists of strategies linked to each subtheme.

Theme 1: supporting clinicians in research

Research capacity is built by supporting allied health professionals to develop research knowledge, skills and confidence. A range of strategies were documented in the literature and have been summarised into the following sub-themes:

relevant education and training for undertaking aspects of the research process such as writing grant and ethics applications;

opportunities to learn and apply skills in practice including assisting with collecting data for research projects, identifying research questions, leading small research projects and participating in journal clubs;

a research friendly workplace which accommodates and values individual clinicians’ research interests, motivations, abilities, time commitments and career paths;

mentoring and coaching from more experienced researchers;

access to resources including library, software, desk and computer use;

protected time and funding including support to apply for external research funding;

a system of reward and recognition through the provision of greater career opportunities, research career pathways and financial incentives;

support to undertake formal post-graduate study including higher degrees by research (HDR);

mix of clinicians with different levels of research skills within each team.

Theme 2: working together

Research capacity building is supported and enhanced when allied health professionals work with others in order to exchange ideas, knowledge, skills and resources and build a ‘critical mass’ of research-active staff. This may be achieved by developing:

strategic collaborations, partnerships, linkages and networks within and between teams, services and organisations including universities and industry;

shared purpose / drivers for research;

coordinated and team-based projects;

opportunities to share research expertise with others in the team and wider networks.

Theme 3: valuing research for excellence

To build research capacity in a healthcare setting, allied health professionals need to feel that their engagement in research is valued as contributing to excellent service delivery. This may be fostered by:

demonstrating visible support of and endorsement of research at the management level, including developing structured processes and systems for research and restructuring clinical roles to include some time for research;

prioritising research as part of a health service’s core business by including research in the service’s vision, mission, strategic plans, key performance indicators and role descriptions;

prioritising research projects which are close to / relevant to practice and in line with strategic priorities,

reporting, disseminating and applying locally developed research findings to inform practice.

The findings of this systematic review have been synthesised to develop a succinct and integrated framework for research capacity building which is relevant for allied health professionals working in publicly funded secondary and tertiary healthcare organisations. Three themes (‘supporting clinicians in research’, ‘working together’ and ‘valuing research for excellence) and 17 subthemes have been identified. Each subtheme is linked to a number of strategies which may be implemented at individual, team, organisational and policy levels as part of the ‘whole of system’ approach which has been recommended in the literature [ 12 , 33 , 36 , 45 ]. Although attempts were made to categorise strategies according to these structural levels, it was subsequently recognised that many strategies are applicable at more than one level. For example, for research to be considered part of core business, it needs to be valued by individual clinicians and by all levels of management across teams and the organisation and recognised within policy. This new framework consolidates many single-strategy research capacity building initiatives, interventions or programmes described in the literature, and provides further evidence to suggest that they are interlinked and interdependent and therefore benefit from being delivered in an integrated way to ensure maximum impact.

Although this review searched for both models and frameworks, only frameworks were found. It seems that frameworks are inherently better suited to guide research capacity building, because they do not include a clear linear process for how research capacity building interventions should be implemented. A number of factors appear to influence the outcomes of research capacity, culture and engagement and are useful for guiding the design and evaluation of interventions. However, the way in which interventions are implemented is highly dependent on context, such as the specific strengths, weaknesses, interests, needs and priorities of each individual, team and organisation.

A fundamental concept which was identified across all three themes is the importance of commitment and multi-faceted support from all levels of leadership and management. A research culture has been described as “an environment within an organisation that enables and supports research to generate new knowledge and opportunities to translate evidence into practice” [ 18 ] and has been reported to be essential for building research capacity [ 19 , 33 ]. Previous studies have found that senior management and leadership support for research appears to have a significant impact on an organisation’s research culture [ 7 , 20 , 35 , 36 , 46 ] and individual health professionals’ engagement in research [ 29 , 31 ]. The findings of this review further emphasise that in order to build and sustain research engagement, leaders and managers should recognise the benefits of having research-active practitioners in the workforce and consider research to be part of their core business alongside clinical practice [ 8 , 19 , 27 ]. Another implication is the importance of investing in collaborations with internal and external partners, mentors and colleagues who can support clinicians to undertake research within their existing roles, which is consistent with previous recommendations in the literature [ 22 , 25 , 32 ].

Limitations

As the purpose of this systematic review was to inform a broader research capacity building project being conducted in a large publicly funded secondary and tertiary healthcare organisation, a decision was made to tightly scope the search strategy and eligibility criteria to maximise relevance to our context. A limitation of this decision is that the results may not be transferable to other contexts.

Overall, there is a paucity of published evidence-informed research capacity building models and frameworks which are suitable for allied health. Moreover, the extant literature about research capacity building is poorly indexed using variable search terms. For example, different terms and definitions are used to describe models and frameworks. As a result, it was challenging to construct a search strategy which captured all relevant articles. There is a need for a better taxonomy of terms relating to research capacity building to assist with indexing, searching and identifying relevant articles.

Another limitation was that the term ‘primary care’ is inconsistently used in the literature. Although this term usually refers to settings where clinicians work independently and have first contact with clients, through hand searching of the literature, we have found three articles which use the term ‘primary care’ but refer to a population which meets this study’s criteria of secondary care. Therefore, it is possible that other studies have been missed because they were not captured by the search strategy.

This systematic review developed a succinct and integrated framework for allied health research capacity building. This framework may be used to inform and guide the design and evaluation of research capacity building strategies targeting individuals, teams, organisations and systems. This framework provides structure in terms of specific strategies which can be monitored using process and outcome measures to determine short- and long-term impacts. Future directions for research include using behaviour change and knowledge translation theories to guide the implementation and evaluation of this framework. Another opportunity is to evaluate the transferability of this framework to other healthcare professions and settings.

Abbreviations

Mixed Methods Appraisal Tool

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Acknowledgements

Sarah Thorning, Senior Librarian, Gold Coast Health.

This project did not receive any (external competitive) funding. In-kind funding was provided by the Gold Coast Hospital and Health Service to pay for the project officer secondment of a permanently employed clinician.

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Search strategy and a detailed list of all coded components mapped against the subthemes are included in the additional files. All other pertinent data is included in the final manuscript. Further data regarding excluded studies is available on request from the authors.

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AW and JM completed the abstract screening. JM, AW and SM completed the full-text screening. JM and SM completed the data extraction. JM and SM led the writing of the introduction, methods, results and discussion in the manuscript. All authors read and approved the final manuscript.

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Matus, J., Walker, A. & Mickan, S. Research capacity building frameworks for allied health professionals – a systematic review. BMC Health Serv Res 18 , 716 (2018). https://doi.org/10.1186/s12913-018-3518-7

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A new framework for allied health professionals aims to promote a culture of research

Health and Social Care Services Research

doi: 10.3310/alert_45217

This is a plain English summary of an original research article . The views expressed are those of the author(s) and reviewer(s) at the time of publication.

‘ Shaping Better Practice Through Research: A Practitioner's Framework ’ is the first framework designed to help Allied Health Professionals (AHPs) in all roles and at all career levels carry out research.

The framework provides guidance on research activities, collaboration, how research relates to career development and how it informs practice. It could foster a stronger tradition of research among AHPs.

AHPs make up a third of the UK’s health and social care workforce, with skills ranging from emergency care to language therapy and dietary advice. This group has huge potential for using research-based practice to improve the health and wellbeing of their patients. But with little tradition of research in these fields, many AHPs need support.

The new, common framework attempts to unify disciplines, using language they all share, to build a stronger culture of research for all AHPs.

What’s the issue?

AHPs are a diverse group of health and social care professionals. They include physiotherapists, occupational therapists, radiographers, paramedics, dietitians, speech and language therapists, art, music and dance therapists, along with operating department practitioners and professionals specialising in feet (podiatrists), eyes (orthoptists), artificial limbs or devices (prosthetists/orthotists).

With a broad scope of influence on health and wellbeing, they are well-placed to impact the lives of individuals and populations. More than 65,500 AHPs work in the NHS, and they make up a third of the UK’s health and social care workforce. They play a critical role in ensuring that future developments in healthcare reflect the needs of the public.

These professions often come with high clinical caseloads and immense time pressure. They also lack a tradition of research. Many AHPs do not feel confident engaging in research. They may see their knowledge and skills as inferior to other healthcare professionals and as a result, need substantial support to develop research skills.

A culture of research brings benefits both to individuals and the system. Professionals say that having a research interest improves their job satisfaction and career progression.  Institutions where research is encouraged have been shown to have higher rates of patient satisfaction, better outcomes for patients, improved efficiency within the organisation and reduced staff turnover.

Existing research frameworks for AHPs are specific to the individual professions. They vary in their descriptions of research knowledge and skills. Researchers set out to bring these frameworks together in a single document. Their aim was to create a common framework to help AHPs at all stages of their career engage in research. This could help break down barriers to research activity and build a stronger research culture.

What’s new?

Researchers identified and analysed 19 existing AHP research frameworks. They converted this content into statements describing how the required levels of research skills increase in step with developing levels of seniority. So, a junior practitioner would be expected to have an awareness of research; a consultant practitioner would need advanced abilities.

The researchers organised these statements into themes. They then ran a workshop for stakeholders including AHP professionals, regional training providers, clinicians, national workforce planning policy representatives, and members of the NIHR Clinical Research Network and the Council for Allied Health Professions Research (CAHPR) strategy group. They made recommendations on how the common framework could be used in practice. It was adapted and added to during this process to create a final version.

‘Shaping Better Practice Through Research: A Practitioner Framework’ is the name of the final document. It provides advice on collaboration, career development and research-informed practice; and guidance on the following eight domains of research:

• career development
• research methods
• carrying out research safely and effectively (delivery)
• putting research results into practice
• collaborating with others in research
• management and leadership
• education and training
• strategy and planning

The framework describes four levels of research skills - Awareness, Core, Intermediate, Advanced – and looks in detail at aspects of these research domains. For example, ethics and informed consent is part of the safe delivery of research.  A junior practitioner at ‘Awareness’ level, understands confidentiality and can undertake consent and recruitment. An established practitioner at ‘Core’ level knows about legal requirements and can carry out a risk assessment. A clinical researcher at ‘Intermediate’ level can plan the ethical conduct of research. A consultant practitioner at ‘Advanced’ level has knowledge of licensing authorities.

Why is this important?

This is the first common framework designed to enhance and support AHP research.

Its unified approach and shared language could help drive research activity and evidence-informed practice across a variety of health and social care settings. Building a culture of research for AHPs could improve services for patients and increase career satisfaction for practitioners.

The framework could be used in workforce planning, policies, and guidance. It could be used in parallel with existing appraisal systems in career planning, and to support the integration of research results into everyday practice. It aims to stimulate discussion and reflection, and to move towards having a workforce that routinely carries out research.

What’s next?

The framework needs to be tested across a range of practice settings.

The current version could be further developed to give practical advice on what steps are needed to achieve the aims of the framework. The advice should be relevant to all settings and all levels of expertise, including entry-level. Featuring case studies in the framework may help with implementation. The researchers hope to secure further funding to pursue these developments and to consult a wider, international panel of AHP stakeholders.

You may be interested to read

The full paper: Harris J, and others.  Developing a consolidated research framework for clinical allied health professionals practising in the UK . BMC Health Serv Res. 2020;20:852

The Council for Allied Health Professions Research (CAHPR) Research Practitioner's Framework: Shaping Better Practice Through Research: A Practitioner Framework , 2019

The NIHR Clinical Research Network’s Allied Health Professionals Strategy 2018-2020

NHS England report: Allied Health Professions into Action: Using Allied Health Professionals to transform health, care and wellbeing, 2017

Funding:  This research was jointly funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber (CLAHRC YH), and the Council for Allied Health Professions Research (CAHPR).

Conflicts of Interest:  The study authors declare no conflicts of interest.

Disclaimer:  Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

NIHR Evidence is covered by the creative commons, CC-BY licence . Written content and infographics may be freely reproduced provided that suitable acknowledgement is made. Note, this licence excludes comments and images made by third parties, audiovisual content, and linked content on other websites.

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Exercise and physical activity for health promotion and rehabilitation in community dwelling very old adults or nursing home residents

Körperliches Training und körperliche Aktivität zur Gesundheitsförderung und Rehabilitation bei hochaltrigen zu Hause lebenden Erwachsenen oder Pflegebedürftige

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• Published: 11 November 2021
• Volume 51 , pages 405–409, ( 2021 )

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• Bettina Wollesen 1 &
• Michael Brach 2  

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The aging of the world’s population fundamentally affects medical care, health care systems, and society. More specifically, demographic, and societal trends have far-reaching implications for clinical care, medical research, and health care policy. Regular exercise or physical activity as well as an active lifestyle have been shown to influence the intercept, slope, and pace of age-related changes. However, the important role of exercise and physical activity as well as sports science related to physical activity and exercise is still underrepresented in this area of geriatric research.

Keeping an active lifestyle increases health, prevents disease, and helps to maintain quality of life

Therefore, this special issue primarily publishes studies examining age-related changes of cognitive, perceptual, and motor functions that affect the mobility of older individuals and their activities of daily living. Also, more and more studies investigate quality of life, well-being, education, and other relevant aspects in healthy older adults after retirement, and in very old adults and inhabitants of long-term care facilities. Over the last few decades it has been shown that engaging in different sports and exercise activities and keeping an active lifestyle increases health, prevents disease, and helps to maintain the quality of life in these target groups.

Three primary pathways to gain positive benefits by sports interventions can be differentiated: (1) physical activity and tailored exercises to increase different outcomes of cognitive and motor fitness, (2) social engagement, psychosocial parameters, and mental health and (3) cognitive stimulation, which is also associated with physical and global functioning (e.g., activities of daily living (ADL), instrumental activities of daily living (IADLs)), cognitive functioning (especially memory and executive functions) as well as increased quality of life (Newsom, Shaw, August, & Strath, 2018 ; Warburton & Bredin, 2017 ; Chodzko-Zajko et al., 2009 ; Smith, Banting, Eime, O’Sullivan, & Van Uffelen, 2017 ; Kramer & Colcombe, 2018 ; Brasure et al., 2018 ).

In this special issue, we use these pathways to structure the presented studies from all disciplines of human movement science as well as areas of motor control and learning, sport and exercise psychology, social psychology and philosophy of human movement, public health, and physical rehabilitation.

Physical activity and tailored exercises to increase different outcomes of cognitive and motor fitness

The main goals for regular exercise in older age are often associated with maintaining physical fitness as well as mobility and independence. The ability to mobilize safely is a key indicator of health and independence in old age because it allows ongoing social participation and prevents falls. Therefore, it is of great interest to identify factors that influence mobility as well as gait pattern and at the same time can be addressed by appropriate training (Cadore, Rodríguez-Mañas, Sinclair, & Izquierdo, 2013 ; Valenzuela et al., 2020 ; Vlietstra, Hendrickx, & Waters, 2018 ). A variety of systematic reviews have confirmed positive effects of physical and balance training on the reduction of risks related to falls, number of falls (Chang et al., 2004 ; Chan et al., 2015 ; Sherrington et al., 2020 ), and benefits for daily activities (Chou, Hwang, & Wu, 2012 ; Tak, Kuiper, Chorus, & Hopman-Rock, 2013 ). However, the differentiation within physical activity’s subcategories is often unnoticed by other health professionals as well as by older persons. Terms like mobility, physical activity, or sport are differently defined and used in different disciplines and in daily language. Therefore, the article by Freiberger and Notthoff ( 2021 ) within this special issue focuses on exercise as a planned, structured, repetitive program which is often used interchangeably with physical activity (PA). The authors show overlaps between PA and exercise and the relevance of the differences for practice. Moreover, they describe the differences in wording between health care professionals, sport scientists and older lay persons to enhance the understanding for professionals.

While this article has been written as “short communication”, the writing and reviewing process revealed that the elaboration of several aspects and implications of the topic would exceed this article type by far. Thus, authors, reviewers and editors would like to encourage further discussion on this neglected topic, which should also lead to empirical analyses.

A specific idea to enhance PA in older adults are lifestyle-integrated exercises. One successful, internationally intervention is the Lifestyle-integrated Functional Exercise (LiFE) program by Clemson et al. ( 2012 ). It integrates physical activity, balance, and strength activities into daily tasks of older adults, with the main goal to reduce falls. However, the overall positive effects of the program led to several adaptions of the original LiFE program to other target groups. Therefore, the second article in this issue by Hezel et al. ( 2021 ), provides a first systematic overview of LiFE modifications and their specifications, the current evidence regarding the feasibility and effectiveness, and challenges and potential of those different LiFE modifications. Current studies show strong effectiveness of the original LiFE program in terms of reducing falls, improving motor performance, and increasing PA. Current research focuses also on the challenges (transfer into daily life, appropriate task challenges, technology) and potential (cost-effectiveness, large-scale implementation) of different LiFE modifications and proposes new avenues for adapting LiFE in different target groups and settings.

Nevertheless, there is strong evidence that structured exercise programs in healthy and prefrail older individuals can effectively improve everyday functionality and mobility, while reducing physical frailty (de Labra, Guimaraes-Pinheiro, Maseda, Lorenzo, & Millán-Calenti, 2015 ; Giné-Garriga, Roqué-Fíguls, Coll-Planas, Sitja-Rabert, & Salvà, 2014 ). In addition, the positive effect of regular PA on cognition and on the prevention of diseases (such as cardiovascular diseases, diabetes, osteoporosis, or sarcopenia) has already been demonstrated (e.g., Pasanen, Tolvanen, Heinonen, & Kujala, 2017 ).

In addition to these general benefits of exercise increasing fitness levels in older age, there is a growing body of evidence that exercise interventions should integrate the specific requirements of the target groups as well as relevant training principles to enlarge the individuals’ adaptation (Erickson et al., 2019 ; Hecksteden & Meyer, 2018 ; Herold, Müller, Gronwald, & Müller, 2019 ). These aspects gained more attention with the German Prevention Act of 2015. It incorporates that German nursing care insurances must provide preventive services in nursing homes that are aiming at promoting the health of residents by maintaining or improving several domains, such as physical functioning and mobility, cognition, and quality of life (GKV-Spitzenverband, 2018 ). Therefore, a lot of research projects started to develop and to examine new targeted inventions. In this issue, Klotzbier et al. ( 2021 ) present preliminary results of a large multicenter approach (Cordes et al., 2019 ). Within this large randomized controlled trial (RCT), the authors integrated the instrumented Timed-Up-and-Go (iTUG) to observe intervention effects of multicomponent exercises for nursing home residents with respect to attendance rates. The study results showed positive intervention effects of the iTUG, especially when participants exhibit high attendance rates. Regarding these intervention effects one might assume that better physical performance levels will also increase the overall mobility of this target group. However, this transfer cannot be generalized. It is more presumable that inactivity will be observed in nursing home residents, even if they are able to walk independently or with a walking aid.

One of the reasons for this may be limited ability about finding one’s way around the care facility and its environment. Moreover, most activities of daily living require dynamic integration of sights, sounds, and movements as people navigate through complex environments (Faulkner et al., 2007 ). Therefore, the effect of dual-task (DT) training on dual-task performance is a growing field of research interest and currently reports overall positive benefits on cognitive–motor performance (e.g., Wollesen, Wildbredt, van Schooten, Lim, & Delbaere, 2020 ; Wollesen & Voelcker-Rehage, 2014 ). Additional studies investigated practice effects of motor-–cognitive dual-task management training on DT walking performance (Wollesen et al., 2017 a; Wollesen, Schulz, Seydell, & Delbaere, 2017 b; Wollesen et al., 2021 ). Results showed that DT practice, in combination with strategies to maintain or to recover balance and task prioritization strategies led to improved gait quality. Another study by J. S. Brach and colleagues found that task-orientated motor learning enhanced the motor control of walking, whereas standard exercise did not (Brach et al., 2015 ).

To combine the positive effects of DT managing training with orientation aspects, a study by Fricke et al. ( 2021 ) present an innovative program in this issue. They integrated six novel and target group-specific spatial orientation exercises into an established DT multicomponent training for nursing home residents and evaluated their feasibility. Additionally, the authors assessed the training’s preliminary impact on mobility and life satisfaction. Next to the positive results, this article shows relevant materials and necessary steps when conducting a targeted intervention.

Social engagement, psychosocial parameters, and mental health

Three articles of the current issue deal with this pathway.

First, sociopsychological aspects of demographic change and their consequences on healthy aging are reflected within the qualitative interview study by Sobiech & Leipert ( 2021 ). The authors do not define age(ing) in the light of immutable changes, but as something more adaptable. They refer to healthy lifestyles, which aim at the self-responsible management of physical risks through fitness and discipline and the individuals’ ability to expand their freedom of action. Their study examined the question of how older women in Germany and America, who are active in fitness gyms, position themselves in relation to social discourses of successful age(ing), how they take these up in their body concepts and practices, and finally, how they judge bodies that differ from fitness ideals.

Regarding the psychological well-being of nursing home residents, group-based physical activity adds high and long-term value to these participants. In the second study, Wolter, Dohle & Sobo ( 2021 ) contribute to the idea of interdisciplinary thinking and the networking of local structures (e.g., sports clubs). Their project helps local sports clubs to collaborate with providers of outpatient and inpatient care to start new sports programs. The authors report on findings of qualitative interviews with representatives of sports clubs with the focus on chances and barriers for local partnerships between sport clubs and care. The study contributes to our understanding of the relationship between exercise, physical activity, and health on the individual level, but also on the community level, and across all sectors

In addition to these practical implications, the study by Schoot, Johnen & Klotzbier ( 2021 ) provides the translation and validation of the Laurens Well-Being Inventory for Gerontopsychiatry (LWIG), an instrument for another relevant aspect with age-related research. The cross-sectional, descriptive study design was conducted with N  = 104 long-term nursing home residents (f = 57, m = 47) aged 60 to 99 years (mean: 79.5, SD: ±9.11). The final German version of the LWIG consists of 19 items with three subscales: psychological well-being (WB), social WB, and physical WB. The LWIG-GER showed good overall reliability with McDonald’s ω of 0.83; the LWIG-GER dimensions’ scores were significantly correlated with depression, functional performance, activities, falls anxiety, and education. Therefore, the authors conclude that the German language version of the LWIG is a reliable and valid tool for measuring WB in nursing home residents and believe that the LWIG-GER questionnaire can broaden and deepen our understanding of residents’ perception of quality of care and their environment.

Cognitive stimulation to increase global, physical, and cognitive functioning

There is a lot of evidence showing that engaging in a physical active lifestyle prevents cognitive decline and for example neuropsychiatric symptoms like depression in later life. These aspects were addressed within the longitudinal study by Krell-Rösch et al. ( 2021 ) within this issue. Their prospective cohort study with >3000 cognitively unimpaired persons aged ≥50 years (1570 males; 74 years median age) examined the consequences of the lack of engaging in light, moderate, and vigorous intensity PA and the presence of neuropsychiatric symptoms (agitation, anxiety, apathy, appetite change, sleep/nighttime disturbance, depression, irritability, clinical depression, clinical anxiety). The study showed that after a median follow-up of 6.3 years, 599 participants developed incident mild cognitive impairment (MCI). Not engaging in vigorous intensity PA and having sleep or nighttime disturbance, clinical depression or clinical anxiety was associated with an increased risk of incident MCI. The results underpin the relevance of regular physical exercise to maintain mentally and cognitively fit with increasing age.

The study by Prinz et al. ( 2021 ) refers to one of the most common causes of the need for care in old age: dementia. It has been predicted that different forms of dementia will be responsible for around 60% of the admissions to nursing homes. To ensure that people with dementia enjoy a pleasant retirement despite their need for care, it is important to develop ways of preserving their cognitive and motor skills, thus enhancing their quality of life. Prinz et al. based their approach on studies indicating that a combination of PA and music has positive effects on dementia patients. Therefore, the aim of their study was to develop a music-based exercise program for people with dementia and analyze its influences on cognitive and motor skills as well as quality of life. Thus, 49 dementia patients were divided into an intervention group ( n  = 32) and a control group ( n  = 16). The intervention group performed a multidimensional music-based exercise program over 12 weeks, while the control group received the usual treatments. The intervention group improved in hand grip strength, mobility, and balance after 3 months, whereas the control group deteriorated in many parameters. Also, cognitive parameters, e.g. executive functions, were enhanced by the intervention. The multidimensional music-based exercise program was well received by the target group. Therefore, the authors conclude that music-based exercise programs may be a promising addition to medication therapies.

Another program with the aim to increase activities of daily living in individuals with dementia was conducted by Bezold et al. ( 2021 ) and is reported in this issue. In their 16-week multimodal intervention within a multicenter randomized controlled trial involving 319 participants aged ≥65 years with mild to moderate dementia, they investigated the participants’ individual response to the exercise program and whether baseline cognitive and motor performance explain activities of daily living performance. The authors also compared baseline cognitive and motor performance between positive-responders, non-responders, and negative-responders. They examined cognitive and motor performance as potential cofounders of activities of daily living by conducting multiple regression analyses. The results showed no significant time×group effects on activities of daily living. However, 20–32% of participants responded positively to the intervention, i.e., improved activities of daily living performance from baseline to follow-up. The positive responders had worse baseline motor performance compared to non-responders. Cognitive and motor performance explained up to 51.4% of variance in activities of daily living.

Unfortunately, the multimodal exercise program had no significant overall effect on activities of daily living in individuals with dementia. Therefore, the authors recommend that future research should focus on the individualization of physical exercise programs considering heterogeneous characteristics of individuals with dementia.

Summary and future directions

As this special issue is the result of an open call on a specific subject, the contributions were not expected to cover the topic systematically. Instead, we present a variety of studies: Regarding the “pathways” above, four papers relate to (1) physical activity and tailored exercises to increase different outcomes of cognitive and motor fitness, three papers to (2) social engagement, psychosocial parameters, and mental health and three papers to (3) cognitive stimulation, which is also associated with physical and global functioning. Most of the papers relate to preparation (Fricke et al., 2021 ; Wolter et al., 2021 ; Prinz et al., 2021 ) and conduction (Hezel et al., 2021 ; Bezold et al., 2021 ) of specified interventions. Two papers deal with the development and validation of instruments (Klotzbier et al., 2021 ; Schott et al., 2021 ). Two studies observed ageing cross-sectionally (Sobiech et al., 2021 ) and as development (Krell-Rösch et al., 2021 ) in relation to PA, exercise and corresponding attitudes.

Such a broad spectrum is typical for sport science as well as for gerontology. Certainly, a summary in a few lines is not possible. Instead, we want to point out two observations:

Over the years, we observe a development to more precise descriptions and definitions, more diversity and combinations of methods, more willingness to include views and feedback from “scientific neighborhoods” in our field.

However, the amount and different levels of complexity both of interventions (e.g., exercise, session, all-day behavior levels) and of effects (e.g., movement parameters, behavior and activity components, health factors) still seems to be the largest challenge for designing research and interpreting the results in our field.

Both observations require specific activities in order to communicate and to cooperate trans- and interdisciplinarily. Examples for such a focus on science as such could be:

Short overviews to prepare a certain topic or method for scientists from other disciplines or fields.

Work on a common language or at least on certain terms, which are jointly usable (as an initiative, see Freiberger & Notthoff 2021 in this issue)

Standardization for better comparison of results, at first within one’s own field, then across fields—at least possibilities and limits of comparability should be assessed.

The editors are convinced that networking and cooperating is key to further developments, more than just continuing current paths and finding new topical directions of research. The editors of this issue would like to thank all authors and reviewers for their contributions and fruitful discussions.

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Wollesen, B., Brach, M. Exercise and physical activity for health promotion and rehabilitation in community dwelling very old adults or nursing home residents. Ger J Exerc Sport Res 51 , 405–409 (2021). https://doi.org/10.1007/s12662-021-00781-z

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Study Protocol

Protocol for the Swiss COhort of Healthcare Professionals and Informal CAregivers (SCOHPICA): Professional trajectories, intention to stay in or leave the job and well-being of healthcare professionals

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Center for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, Lausanne, Switzerland

Roles Writing – original draft, Writing – review & editing

Roles Methodology, Writing – review & editing

Affiliation La Source School of Nursing, HES-SO University of Applied Sciences and Arts of Western Switzerland, Lausanne, Switzerland

Roles Writing – review & editing

Roles Conceptualization, Methodology, Writing – review & editing

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Affiliation Lausanne University Hospital, Human Resources Direction, Lausanne, Switzerland

• Isabelle Peytremann-Bridevaux, 
• Vladimir Jolidon, 
• Jonathan Jubin, 
• Emilie Zuercher, 
• Leonard Roth, 
• Lucie Escasain, 
• Tania Carron, 
• Nelly Courvoisier, 
• Annie Oulevey Bachmann, 
• Ingrid Gilles

• Published: August 29, 2024
• https://doi.org/10.1371/journal.pone.0309665
• Peer Review
• Reader Comments

Introduction

Healthcare professionals’ shortage, low job satisfaction, high levels of burnout, and excessive staff turnover are some of the challenges health systems face worldwide. In Switzerland, healthcare stakeholders have called to address the health workforce crisis and have pointed out the scarcity of data on the conditions of healthcare professionals (HCPs). Hence, the Swiss Cohort of Healthcare Professionals and Informal Caregivers (SCOHPICA) was developed to study the career trajectories, well-being, intention to stay in or leave the position/profession/health sector, and their determinants, of HCPs and informal caregivers, respectively. This paper describes the protocol for the HCPs cohort of SCOHPICA and discusses its implications.

SCOHPICA is a prospective open cohort using an explanatory sequential mixed methods design. All types of HCPs working directly with patients and practicing in Switzerland are eligible, irrespective of their healthcare setting and employment status. Baseline and annual follow-up electronic surveys will take place once a year, featuring both core questions and modules developed according to information needs. While outcome variables are HCPs’ trajectories, well-being, intention to stay in or leave the position/profession/health sector, independent variables include organizational, psychosocial, and psychological determinants, as well as occupational (professional) and sociodemographic factors. The qualitative phase will be organized every two years, inviting participants who agreed to take part in this phase. The findings from quantitative analyses, along with the issues raised by healthcare stakeholders in the field, will guide the topics investigated in the qualitative phase.

Using innovative methodologies, SCOHPICA will gather nationwide and longitudinal data on HCPs practicing in Switzerland. These data could have numerous implications: promoting the development of research related to HCPs’ well-being and retention intentions; supporting the development of policies to improve working conditions and career prospects; contributing to the evolution of training curricula for future or current healthcare professionals; aiding in the development of health systems capable of delivering quality care; and finally, providing the general public and stakeholders with free and open access to the study results through an online dashboard.

Citation: Peytremann-Bridevaux I, Jolidon V, Jubin J, Zuercher E, Roth L, Escasain L, et al. (2024) Protocol for the Swiss COhort of Healthcare Professionals and Informal CAregivers (SCOHPICA): Professional trajectories, intention to stay in or leave the job and well-being of healthcare professionals. PLoS ONE 19(8): e0309665. https://doi.org/10.1371/journal.pone.0309665

Editor: Fatma Refaat Ahmed, University of Sharjah College of Health Sciences, UNITED ARAB EMIRATES

Received: November 10, 2023; Accepted: August 15, 2024; Published: August 29, 2024

Copyright: © 2024 Peytremann-Bridevaux et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The project has been funded by different sources. It has received starting grants from the Swiss Academies of Arts and Sciences, the Swiss Federal Office of Public Health, the Swiss Health Observatory and the Fondation pour l’Université de Lausanne. There is no involvement nor influence of these funders on any stage of the present study, including its protocol, design, data collection and analyses, and results publications and dissemination.

Competing interests: The authors declare that they have no competing interests.

1. Introduction

Healthcare professionals (HCPs) are the cornerstone of health systems. Achieving high performing health systems and the highest standards of healthcare requires a sufficient supply of HCPs who are well-trained, adequately distributed throughout the system, and who have appropriate working conditions to be able to provide care that is accessible, equitable and of good quality [ 1 , 2 ]. In this sense, the World Health Organization (WHO) sets the following health workforce objectives for 2030: (1) to increase the performance of the health workforce; (2) to match investments in the health workforce to population needs; (3) to build health institution capacity at all levels; (4) and to reinforce data collection on the health workforce [ 2 ].

European countries are facing considerable challenges with their health and care workforce. A recent WHO report highlighted personnel shortages, insufficient recruitment and retention, migration of qualified workers, unattractive working conditions, and poor access to continuing professional development opportunities, as current issues which are threatening health systems [ 1 ]. The report also stressed the poor mental health of the workforce across Europe, related to long working hours, inadequate professional support and staff shortages. Several of these problems were exacerbated during the COVID-19 pandemic, as healthcare systems suffered high pressure and the workforce had to cope with increased workloads, job-related stress, and physical and mental health risks [ 3 ]. The issue of HCPs’ retention has been a concern for over a decade [ 4 ]. Since 2012, the European Union has launched several programs, such as the Join Action Plan [ 5 ] and the Support for the Health Workforce Planning and Forecasting Expert Network, [ 6 ] aimed at improving the retention of HCPs and addressing their shortage. In Switzerland, efforts have been made by health departments of the universities of applied sciences, which collaborated to create the Competence Network Health Workforce [ 7 ]. This network aims to define a national strategy to tackle shortages of HCPs. At the political level, the Swiss population approved a constitutional law in 2021, compelling Swiss cantons and the federal government to ensure the sufficient availability of qualified nurses, and therefore to collect data to monitor the implementation of this new law [ 8 ]. Despite these actions, data and analytical capacity are lacking, which jeopardizes the strategic planning of the health workforce [ 1 ]. In sum, data is currently not sufficient to address existing challenges, and to effectively plan, manage, coordinate and inform decisions on the health workforce.

Health workforce research has covered various areas, mainly relating to HCP’s physical and mental health [ 9 – 13 ], and aspects related to the functioning of the healthcare system, such as absenteeism, career changes, figures of HCPs who are employed or undertaking training (and their projections), turnover and intention to stay in/leave their position/profession [ 14 – 18 ]. Four areas require further investigation, nevertheless. Firstly, more in-depth analyses are needed on the interconnections, causal relations and mediating pathways between the determinants of HCPs’ well-being and intention to stay in/leave the position/profession/health sector. That is, to date, research has mainly focused on the individual role of organizational (e.g., recognition, leadership, work environment, workload), psychosocial (e.g., cohesion and social support at the workplace), psychological (e.g., stress, resilience, engagement), and sociodemographic (e.g., age, gender, seniority) determinants [ 19 – 22 ]. Secondly, the professional trajectories of HCPs, from initial training to retirement, remain understudied. Currently, most studies have relied on cross-sectional study designs which do not fully capture the longitudinal experience of HCPs. Also, to our knowledge, life history calendar (LHC), a tool designed to collect retrospective data from participants by maximizing their possibilities of recalling past events completely and accurately [ 23 , 24 ], has not been used in health workforce research yet. LHCs have proven successful across various contexts, including studies on the trajectories of unemployed and vulnerable individuals, the sexual life of young people [ 25 , 26 ], and in general population surveys [ 27 ]. These studies have shown that 1) LHCs are more efficient than traditional sociodemographic questions for collecting retrospective data; 2) the data collected is reliable [ 28 ]; and 3) online versions of LHCs can be used to reach large samples of participants [ 29 , 30 ]. Using LHC could help understand HCPs’ career trajectories thoroughly, from their training to their current situation, and provide a typology of professional trajectories. Concerning past cohort studies on HCPs, only a limited number of these studies have explored multiple healthcare professions, and these did not delve into professional trajectories of HCPs or their relation to HCPs’ well-being and intention to stay in/leave their job [ 31 – 36 ]. Given their suitability to study the dynamics of ever-changing health workforce markets, it is particularly appropriate to consider cohort studies following participants over time and allowing for the monitoring of their trajectories [ 37 ]. Thirdly, despite a wealth of literature on HCPs, it has mainly focused on physicians or nurses and other healthcare professions have been understudied [ 1 , 38 ], and few studies covered a variety of healthcare professions [ 37 , 39 , 40 ]. Importantly, as a recent review pointed out [ 41 ], issues of well-being and intentions to leave the profession have affected HCPs other than physicians and nurses, yet these professions have received far less attention. Finally, it is key to investigate settings beyond the two most frequently studied, namely hospitals and general practices.

In Switzerland, the deteriorating working conditions of HCPs and staff shortages have been stressed by scientific studies and reports for several years, and this situation has worsened since the COVID-19 pandemic. Reports from the Swiss Health Observatory have predicted that a large number of HCPs would need to be hired to meet population needs, and that physicians’ supply in the ambulatory sector would not be sufficient by 2030 [ 42 – 45 ]. Additionally, a recent report has highlighted that 70,000 nursing staff will be needed by 2029, which encompasses both workforce replacements needs and the increased demand for additional staff stemming from population healthcare needs [ 46 ]. In fact, the coverage rate is predicted to be lower than 80% with a clear deficit between workforce supply and projected needs [ 46 , 47 ]. This situation mirrors an international trend. Indeed, the WHO has projected a shortage of 15 million HCPs by 2030. In Germany, for example, estimates for the required number of HCPs in 2030 ranged from approximately 263,000 to nearly 500,000 full-time equivalents [ 48 ]. Similarly, as of September 2023, the UK’s National Health Service (NHS) reported 121,000 full-time equivalent vacant positions [ 49 ]. Finally, several reports have indicated that the United States will face a shortage of up to 124,000 physicians by 2033 and will require 200,000 nurses annually to meet the increasing care demand [ 50 ]. As in other countries, Swiss healthcare stakeholders have stressed the paucity of data, hindering effective monitoring, planning, and managing of the health workforce. Research projects aimed at both collecting data and leveraging HCPs retention have also been conducted in the Swiss context. These have investigated job stress, job satisfaction, burnout, and intention to leave the job/profession [ 51 – 65 ]. However, like studies conducted in other countries, these publications mostly concentrated on nurses and physicians (mainly in hospital setting), and both nationwide and longitudinal data across multiple healthcare sectors are lacking to understand HCPs’ professional trajectories, well-being, and intention to stay in/leave their position/profession/health sector.

In this international and Swiss context, we developed the Swiss COhort of Healthcare Professionals and Informal CAregivers (SCOHPICA) to collect nationwide and longitudinal data to better understand the trajectories and work experience of HCPs, and help to tackle the Swiss health workforce crisis. Considering mixed methods and using both quantitative and qualitative data, the HCPs cohort of SCOHPICA aims at 1) investigating the professional trajectories of HCPs from the completion of their training onwards; 2) examining the intention to stay in or leave the position/profession/health sector, well-being, and their determinants; 3) providing an in-depth understanding of the mechanisms leading HCPs to stay in/leave the position/profession/health sector; 4) making the data and results available to all healthcare stakeholders, researchers and the public in general, through a secured data repository and an online interactive platform. The SCOHPICA project is conducted by an interdisciplinary team based at Unisanté, La Source School of Nursing–University of Applied Sciences and Arts (HES-SO), and Lausanne University Hospital, all located in Lausanne, Switzerland.

2.1. Study design

SCOHPICA is a national prospective open cohort that uses an explanatory sequential mixed methods design, initially collecting quantitative data and subsequently explaining the quantitative results with in-depth qualitative data, to foster a more comprehensive and complete understanding of specific research questions [ 66 ]. While the longitudinal design will collect essential quantitative data on HCPs, the qualitative phase will provide in-depth analyses of issues identified in the quantitative phase.

Although SCOHPICA aims to study both HCPs and informal caregivers (ICs), who are key but often neglected actors of the health system, the present protocol focuses on HCPs since the implementation of SCOHPICA’s informal caregivers’ cohort will start in the Spring of 2024 (the protocol for the ICs part of SCOHPICA will be published separately).

2.2. Population and setting

All HCPs (e.g., general practitioners, specialist physicians, nurses, nurse aides, paramedics, medical assistants, pharmacists, physiotherapists, psychologists, dieticians, etc.) working directly with patients and currently practicing in Switzerland, irrespective of the setting (e.g., hospitals, clinics, nursing homes, private practices, community services) and their employment status (e.g., self-employed, salaried), are eligible to participate in SCOHPICA. Students and HCPs who left their profession or are retired, at the time of the baseline survey, are not eligible to participate in the study. However, participants who leave their job or their profession after having joined SCOHPICA will be retained in the cohort. Finally, HCPs who are unable to read any of the Swiss national languages (French, German and Italian) are not eligible.

2.2.1. Sample size.

In the quantitative phase, SCOHPICA aims to collect data from 5,000 to 10,000 unique baseline HCPs, whom we will follow over the years. The latter sample size was estimated to achieve satisfactory measurement precision around the outcome variables, and sufficient power for global cross-sectional and longitudinal analyses, as well as cluster analysis of professional trajectories. Sample size calculations considered the expected values (and variability) of outcome variables as reported in previous research, a type I error of α = 0.05 (two-sided) and 95% confidence intervals around the possible values of outcome variables.

Since SCOHPICA is an open cohort, new participants will be recruited every year between October 1 st and January 31 of the following year. This will contribute to increasing the number of participants and improving the statistical power needed to conduct relevant sub-group and stratified analyses.

For the qualitative phase, participants who agreed to be contacted in the baseline survey will be invited for individual or group sessions. Every two years, we aim to conduct about 15 group sessions, each consisting of eight HCPs, totaling 120 participants. This target may be adapted according to the characteristics of participants, the chosen topic, the specific method [ 67 ] and data saturation assessment [ 68 ]. Participants will be invited based on the topics that need to be deepened, particularly those stemming from the analyses of previously collected quantitative data. We will use purposive sampling and will aim to obtain a heterogeneous sample, covering different sociodemographic profiles, linguistic regions, sectors of activity (e.g., hospital sector, private practices), as well as professions that have been affected by personnel shortage (e.g., nurses, general practitioners, pharmacy assistants). Since a second aim of the qualitative part will be to explore specific professional trajectories, participants will also be selected according to profiles of trajectories emerging from the quantitative analyses.

2.2.2. Recruitment of healthcare professionals.

Due to the absence of comprehensive records nor registries of all HCPs practicing in Switzerland (i.e., providing access to HCPs’ contact details), multiple communication and recruitment strategies are used to reach HCPs through different organizations. Professional, state and umbrella associations of all types of HCPs at national, regional and cantonal levels (i.e., the 26 administrative divisions of Switzerland), as well as HCPs employers (e.g., hospitals, home care), are contacted to request their support in recruiting their members. Communication packages are created for recruitment purpose and provided to these entities so they may share SCOHPICA’s information, website and electronic questionnaire link with their members, for example through ad-hoc emails, newsletters and their own websites. Finally, social media are also used (our own institutional platforms and those of organizations promoting the recruitment). Records of the contact details of all the organizations and individuals who are contacted, and those who are willing to support the recruitment process, are kept for future annual recruitments.

Additionally, short articles are published in the journals of professional associations, the project is presented at large conferences in Switzerland, and a kick-off meeting including a press conference was held in September 2022. To promote awareness of SCOHPICA among stakeholders and the general public, a series of conferences and events focused on the health workforce are being organized and conducted.

2.3. Data collection and measures

SCOHPICA comprises quantitative and qualitative data collection phases, as detailed in the sections below and summarized in Fig 1 .

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https://doi.org/10.1371/journal.pone.0309665.g001

2.3.1. Quantitative phase.

Baseline survey . Baseline data is collected using a self-reported electronic questionnaire accessible to all HCPs working in Switzerland on SCOHPICA website ( www.scohpica.ch ). The questionnaire contains ~140 questions, including three open-ended questions on professional aspects, and takes approximately 30 minutes to complete. Originally developed for HCPs working in hospitals and health institutions, it is slightly adapted for HCPs working in private practices. At the end of the questionnaire, participants are asked to provide their email address if they wish to be contacted for follow-up surveys; they are also asked whether they agree to be contacted to participate in SCOHPICA’s subsequent qualitative phase (i.e., individual and group sessions). SCOHPICA first baseline survey took place between October 1, 2022 and January 31, 2023.

Outcome variables . The main outcomes of SCOHPICA are:

• Professional trajectories, created based on socio-professional information (from baseline, LHC and follow-up surveys)
• Intention to stay in the position / profession / health sector (3 items; 5-point scale from No , not at all to Yes , absolutely )
• Intention to leave the position / profession / health sector (3 items; 5-point scale from Very unlikely to Very likely )
• Well-being, assessed with the Flourish Index (10 items; 10-point scale from Extremely unhappy to Extremely happy) [ 56 ]

Independent variables . Determinants of the intent to stay/leave and well-being. The questionnaire collects data on the determinants of the above-mentioned outcomes, as presented in Table 1 . These determinants were selected based on preliminary systematic reviews targeting the nursing professions, physicians and allied HCPs [ 22 , 41 ], as well as on discussions with experts from the SCOHPICAs’ national support panel, including the Swiss Federal Office of Public Health, HCPs Swiss platform, HCPs’ associations, representatives of universities and universities of applied sciences. This allowed for identifying the most important determinants affecting HCPs’ well-being and intentions to stay in/leave the position/profession/health sector. We chose the following validated scales to measure these determinants (see details in Table 1 ):

• Quantitative workload inventory [ 69 ]: workload.
• Copenhagen Psychosocial Questionnaire (COPSOQ; [ 70 ]): control over working time; possibilities for development; work-life conflict; influence at work; sense of community at work; meaning of work; job satisfaction.
• Practice Environment Scale of the Nursing Work Index (PES-NWI; [ 71 ]): staffing and resources.
• Global transformational leadership scale [ 72 ]: transformational leadership.
• Intensity of interprofessional collaboration [ 73 ]: interprofessional practice.
• Recognition at work scale [ 74 ]: recognition from managers, colleagues and patients.
• Rushton moral resilience scale [ 75 ].
• Intolerance of uncertainty scale [ 76 ].
• The one-item MBI:EE [ 77 ]: non-proprietary single-item of burnout.
• Self-rated health single item [ 78 ].
• Organizational Support Subscale of the Nursing Work Index [ 79 ]: perceived quality of care.

https://doi.org/10.1371/journal.pone.0309665.t001

Four none-validated items were drawn from a study by Shanafelt and colleagues [ 80 ] to complement the assessment of perceived quality of care. Moreover, two questions were developed by the research team to assess “Preparedness to work reality”, as no validated scale is currently available for this construct. We conducted a qualitative pre-test of the questionnaire with 20 participants from diverse backgrounds.

Additionally, the baseline questionnaire collects information on respondents’ work and occupation-related aspects ( Table 2 ). Socio-professional information included: employment status, professional status, employment rate, occupational context, current profession, training and specialization, additional training, years of professional experience, main occupational domain, hours worked per day, days worked per week, type of work shift, type of work schedule, managerial responsibilities, country of education, other past profession(s), modification of employment rate in past 12 months, number of employers/occupational context/job location changes since starting to work in healthcare, career interruption(s) of one year or longer, unemployment period(s), work-related accident(s)/sick leave(s), healthcare sector throughout career, healthcare sector of first employment, work location, and commuting time to work. Sociodemographic information included: gender, year of birth, nationality, marital/partnership status, children, informal caregiving status, monthly individual incomes, monthly household incomes, and residency location.

https://doi.org/10.1371/journal.pone.0309665.t002

Follow-up surveys . Follow-up surveys will be implemented annually using a questionnaire that includes an unchanged core set of questions across all survey waves. Additionally, modules of questions may be added or removed based on the HCPs’ current situation, emerging priority topics and results of previous surveys.

In fall 2024, the follow-up survey will include an online life history calendar (LHC), a tool allowing the retrospective and accurate collection of data on individuals’ past professional and non-professional events [ 23 , 24 ]. Respondents will be invited to complete the LHC in the first or second year after completing the baseline questionnaire.

2.3.2. Qualitative phase.

Respondents who accepted to be contacted in the baseline survey will be invited for individual or group sessions which will take place every two years. These will last about 60 to 90 minutes.

Topics to be investigated in individual and group sessions will emerge from the annual quantitative analyses, as well as from the needs and issues reported by healthcare stakeholders and experts in the field over time. These will be selected to deepen the understanding of (among other topics): 1) the interrelations between the determinants of the intention to stay in/leave the position/profession/health sector, and well-being; 2) the specific profiles of professional trajectories emerging from quantitative analyses (and their relation to the intention to stay in/leave the position/profession/health sector); and 3) the profiles of those HCPs who actually left their position/profession/health sector.

The qualitative method approaches used in the project will vary according to the specific topics under investigation. However, the project will mainly use the phenomenological [ 81 , 82 ] and concept mapping [ 83 ] approaches. These two methods are particularly appropriate: 1) to understand how individuals experience and construct meaning on phenomenon they experience using both their inner perceptions and environment appraisal; 2) to construct a collective and structured representation of a topic that produces “an interpretable pictorial view of ideas and concepts and how these are interrelated” [ 84 ]. Concept mapping provides a visual representation of complex data. It allows for synthesizing complex qualitative information in a relatively short timeframe, making it easier to identify relationships and emergent themes.

In line with phenomenological and concept mapping approaches, we will conduct individual or group sessions, including one-to-one interviews. The use of individual or group sessions will be guided by the specific methodology underlying each approach (i.e. the 6 steps of concept mapping, alternating brainstorming and individual sessions) or by the nature of the topics under investigation. For example, topics such as interprofessional collaboration are well-suited to group sessions which favor the sharing of experiences and facilitate the examination of contexts that promote well-being and retention. Other topics which are more sensitive and personal, such as burnout, may be better explored through one-to-one interviews.

2.4. Data management

The software Le Sphinx iQ2 and Le Sphinx iQ3 are used for the survey design, data collection and generation of databases. Databases will be converted to R/SPSS/Stata formats for analyses. Individual and group sessions will be recorded and integrally transcribed, and audio recordings will be deleted. To preserve respondents’ confidentiality, their names will not appear in databases (nor in interview transcripts) used for analyses. All data will be stored in a secured institutional server. The project complies with the General Data Protection Regulation (GPRD) as well as the requirements from the Cantonal Research Ethics Committee, Vaud (CER-VD).

2.5. Data analysis

2.5.1. quantitative phase..

First, descriptive analyses will summarize the distributions of each variable, including patterns of missing data. The internal consistency of score variables will be evaluated with Cronbach’s alpha. Then, bivariate analyses will be conducted, which will inform the development of multivariate regression models to adjust for potential confounding factors. Mixed-effects models will be considered to account for data dependency structures. The effects of organizational, psychosocial and sociodemographic factors on well-being and intention to stay in/leave the position/profession/health sector will be examined with regression analyses, and structural equation modelling (SEM) will be used to assess mediating pathways and causal relations.

Additionally, we will perform sequence analysis with LHC data [ 85 ]. Specifically, we will apply optimal matching and clustering techniques to construct a typology of HCP’s professional trajectories. Then, the longitudinal profiles thus identified will be related to the sociodemographic information and determinants from the baseline survey.

Sample characteristics such as age, gender and professional group will be systematically compared with available national statistics, and weighted analyses will be considered in case of structural discrepancies.

The default approach to address missing observations will be to either replace nonresponses with informed choices of values wherever possible or proceed with multiple imputation. Listwise deletion will only be considered in specific cases, such as univariate analyses. For participants with missing answers in items of dimensions (instruments), their scores will be calculated based on the mean of the items to which they answered, provided they answered more than 50% of the items and at least two items within the dimension, and if the dimension’s internal consistency proved to be acceptable.

All quantitative analyses will be performed using R (Stata, SPSS or another specific statistical software may also be used).

2.5.2. Qualitative phase.

For the qualitative data analysis, the analytical strategy will depend on the specific qualitative approach. In the case of “concept mapping”, a participatory research method in public health described by Burke et al. [ 83 ] and based on the work of Trochim [ 84 ], researchers engage participants in the process of creating concept maps, allowing them to visually represent their thoughts. In this framework, participants are involved in collaborative mapping sessions, which not only enable a deeper exploration of their perspectives but also actively involve them in the data collection and analysis process [ 86 ]. Concept mapping is divided into six steps: 1) Preparation; 2) Generation, 3) Structuring, 4) Representation, 5) Interpretation, and 6) Utilization, which help to ensure a rigorous and systematic approach to data analysis and interpretation.

Concerning the phenomenological approach, data from individual and group sessions will be fully transcribed and analyzed following the 6 steps process recommended by Smith and colleagues [ 87 ]: 1) full reading of transcripts, 2) first annotations, 3) emergent themes identification, 4) construction of links between themes, 5) iterating process among all the cases (i.e. individual or group sessions), 6) identification of links between cases.

To integrate qualitative and quantitative data into our analysis, we will follow Creswell and Plano’s Joint Display technique [ 66 ]. To implement this technique, we will use the Pillar Integration Process (PIP), a systematic process of mixed-methods data integration consisting of four steps: Listing, Matching, Checking and Pillar Building [ 88 ].

MAXQDA or ATLAS.ti softwares will be used for qualitative analyses, as well as IRaMuTeQ for textual data analysis (i.e., to analyze open-ended questionnaire responses).

2.6. Ethical considerations

SCOHPICA is an observational cohort study which does not expose participants (i.e., HCPs) to health risks. In the surveys, and individual and groups sessions, respondents participate upon their free will and without compensation, and they can withdraw from participation at any time. At baseline, before accessing the electronic questionnaire, participants are directed to a consent form where they indicate, first whether they agree to take part in the study under the conditions outlined in an information sheet, and then, whether they consent to the use of their data in future studies. They are then directed to the questionnaire by clicking “yes”, while clicking “no” to the first consent closes the questionnaire. Individuals’ data is coded so respondents cannot be identified without the corresponding key, and data is handled with strict adherence to confidentiality standards. This double consent is valid for the quantitative part of SCOHPICA; for the qualitative part, a specific informed consent will be required.

Although this research project may not directly benefit research participants, it has the potential to indirectly benefit them and other HCPs in the future. Namely, this project primarily holds social value because by offering insights into the determinants of HCPs’ well-being and trajectories, it will contribute to informing strategic political and institutional decisions concerning the health workforce, such as interventions aimed at improving HCPs retention and working conditions.

Ethical approval was obtained from the Cantonal Research Ethics Committee, Vaud (CER-VD), Switzerland (project ID: 2022–01410) and the project was registered on ClinicalTrials.gov, identifier: NCT05571488. A separate ethics committee approval will be necessary for the qualitative phases of SCOHPICA.

3. Results and data dissemination

Since SCOHPICA data and results are essential for decision-making and research in healthcare, they will be widely and publicly disseminated. Firstly, results will be reported and accessible on an online interactive platform (i.e. dashboard) with data visualization tools such as reports, indicators, tables, and charts. Secondly, SCOHPICA de-identified datasets and metadata will be made available upon request through a secured data repository in accordance with the FAIR principles. Finally, dissemination of study results will also be done through scientific peer-reviewed and lay publications, as well as presentations at international, national and regional conferences, reaching both scientific and non-scientific audiences.

4. Discussion

The HCPs part of SCOHPICA described in this protocol is an ambitious and innovative project which collects nationwide and longitudinal data among healthcare professionals (HCPs) to better understand their professional trajectories, work conditions and experiences, and well-being. This project has unique characteristics which will contribute to both academic research and policy-making in the field of health workforce. It is highly relevant for the international research community as it contributes to understudied health services research areas, using both quantitative and qualitative data. Firstly, this project covers all types of practicing HCPs, whereas previous research did not have such a comprehensive coverage of health professions, allowing to compare their diverse experiences and conditions. Secondly, it applies a longitudinal approach, incorporating both a cohort design and the use of LHC, an original trajectory data collection method not previously used among HCPs. These unique and innovative approaches will provide new evidence on the multiple determinants affecting the health workforce. Combined with advanced statistical techniques, such as structural equation modelling, this will help to uncover how the interconnections and pathways between these determinants shape professional trajectories, intentions to stay in/leave the position/profession/health sector, and well-being of HCPs. Thirdly, this project is important for Swiss healthcare stakeholders who have stressed the lack of data on all types of HCPs in Switzerland, which is crucial for addressing healthcare system issues. If actions are not taken, inadequate workforce planning may exacerbate attrition and burnout, resulting in staff shortages, increased workloads and greater difficulties in organizing healthcare [ 89 , 90 ]. Thus, SCOHPICA’s results and data are key to design management and policy interventions aimed at improving the health workforce conditions and retaining HCPs. In this regard, the Swiss Federal Office of Public Health has commissioned SCOHPICA with providing indicators for monitoring the conditions of nursing and care staff, beginning in 2024. Moreover, several Departments of Health of Swiss cantons have requested specific reporting concerning their local health workforce. Fourthly, SCOHPICA’s results dissemination strategy goes beyond traditional methods since the results will be published on an online interactive platform with data visualization options allowing users to customize the reporting. Additionally, the data will be available on a data repository, which will facilitate research collaborations and support policy-making addressing key issues related to the health workforce. Finally, thanks to a grant from the Fondation pour l’Université de Lausanne, the dissemination of results to all stakeholders and civil society, through public forums and consensus forums, will be made possible.

Apart from the above-mentioned strengths of SCOHPICA, its limitations should be considered. First, non-probability sampling is used as it is not feasible to draw representative samples of all HCPs and obtain their contact emails in the current Swiss context. To assess the representativeness of our sample of participants, we will compare their socio-demographic characteristics (i.e., gender, age and professional groups) with relevant national statistics, data from professional associations or Swiss published studies, where available. Second, some HCPs subgroups may be under-represented during the initial years of the project, such as specific professional categories that are more challenging to recruit. With the successful demonstration of SCOHPICA’s feasibility through the first recruitment, we are confident that participation from the various professions will rapidly increase in the future. Third, as in studies using a similar methodology, there is a risk of selection bias if individuals who do not respond to the survey systematically differ in their individual characteristics from the respondents. Since we will not have information on non-respondents, it will not be possible to compare their characteristics with those of respondents. Yet, we expect that yearly recruitments will help increase SCOHPICA’s sample size and better represent the Swiss health workforce. Forth, SCOHPICA relies on self-reported data, which may be susceptible to recall and social desirability biases, potentially introducing measurement bias. To reduce such bias, SCOHPICA questionnaire relied on widely used and validated questions, and the questionnaire was pre-tested in the three national languages. Finally, participants may drop out or become lost to follow-up during the course of the study. This attrition phenomenon can introduce bias if the characteristics of those who drop differ from those who remain in the study. We will assess this bias by comparing key characteristics of respondents who quit and those who remain in SCOHPICA. Additionally, we will mitigate participant dropout by making it easy and motivating for them to participate and stay in the study. For instance, we will present results and show how they are used by stakeholders, make the data and results available to all, send New Year cards to participants, minimize the frequency of contacts and follow-ups, and maintain up-to-date contact information to sustain communication, even if participants relocate.

To conclude, SCOHPICA targets understudied areas in the health workforce domain, filling knowledge gaps and addressing existing limitations. It will provide relevant data and evidence by studying all types of HCPs practicing in Switzerland, considering the various determinants of professional trajectories, intention to stay in or leave the position/profession/healthcare sector, and well-being. Facilitating access to data and results will be particularly valuable to national and international healthcare stakeholders and researchers. By supporting the monitoring, planning, and management of the Swiss health workforce, SCOHPICA will be key for tackling health system challenges, designing future policies, implementing ad hoc interventions and promoting the delivery of high quality of care.

Acknowledgments

The conceptualization and launch of this project would not have been possible without the support of partners from different institutions, administrative and communication staff, part-time assistants and interns from Unisanté, the Institut et Haute Ecole de la Santé La Source and the Lausanne University Hospital, scientific experts and SCOHPICA’s advisory panel including Aide et soins à domicile Suisse, ARTISET, Association suisse des infirmières et infirmiers, Competence Network Health Workforce, la Conférence des directrices et directeurs cantonaux de la santé, Médecins de famille et de l’enfance Suisse, pharmaSuisse, Swiss Federal Office of Public Health, Swiss Health Observatory, the Swiss Medical Association, Swiss Nurse Leaders, Unisanté and University of Lausanne. We also would like to thank all individuals and the professional, state and umbrella associations of HCPs at national and cantonal level who supported SCOHPICA’s first 2022 recruitment phase of HCPs). Last but not least, we would like to thank all the participants for contributing their time and participating in this study.

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The Emergence of Mpox: Epidemiology and Current Therapeutic Options

Samriddhi ranjan.

1 College of Public Health, George Mason University, 4400 University Drive Fairfax, Fairfax, VA 22030 USA

Kanupriya Vashishth

2 Advance Cardiac Centre Department of Cardiology, PGIMER, Chandigarh, 160012 India

3 NGO Praeventio, Tartu, Estonia

Hardeep Singh Tuli

4 Department of Biotechnology, Maharishi Markandeshwar Engineering College, Maharishi Markandeshwar (Deemed to Be University), Mullana-Ambala, Haryana, 133207 India

Associated Data

This document includes citations for all the data that were analysed throughout the literature review.

The world recently witnessed the emergence of new epidemic outbreaks like COVID-19 and mpox. The 2022 outbreak of mpox amid COVID-19 presents an intricate situation and requires strategies to combat the status quo. Some of the challenges to controlling an epidemic include present knowledge of the disease, available treatment options, appropriate health infrastructures facilities, current scientific methods, operations concepts, availability of technical staff, financial funds, and lastly international policies to control an epidemic state. These insufficiencies often hinder the control of disease spread and jeopardize the health of countless people. Also, disease outbreaks often put a huge burden on the developing economies. These countries are the worst affected and are immensely dependent on assistance provided from the larger economies to control such outbreaks. The first case of mpox was reported in the 1970s and several outbreaks were detected thereafter in the endemic areas eventually leading to the recent outbreak. Approximately, more than 80,000 individuals were infected, and 110 countries were affected by this outbreak. Yet, no definite vaccines and drugs are available to date. The lack of human clinical trials affected thousands of individuals in availing definite disease management. This paper focuses on the epidemiology of mpox, scientific concepts, and treatment options including future treatment modalities for mpox.

Introduction

Amidst the COVID-19 pandemic, another public health concern emerged as a potential threat to afflict people globally, i.e. an abrupt increase in the incidence of mpox (monkeypox) cases. Indeed, starting from mid-May 2022, cases of human mpox have significantly risen in several non-endemic countries worldwide, leading to the declaration of the ongoing outbreak of mpox as a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO) in July 2022 [ 1 , 2 ]. Mpox disease is caused by the mpox virus (MPXV), a double-stranded DNA virus from the Orthopoxvirus genus, belonging to the Poxviridae family [ 2 , 3 ]. The same genus includes the variola virus, a known causative agent of smallpox [ 2 ]. Genetically, MPXV is identified with two types of clads. Clad I, also known as Congo Basin clad, is mostly clustered in the Central-South Cameroon region till DRC. Infections from this clad are more severe with case fatality rates (CRF) > 10%. Clad II also referred to as West African clad, commonly distributed in western Cameroon to the Sierra Leon area, is further divided into sub-clad groups as IIa and IIb (also now referred to as clad III) having a CRF < 1% [ 4 , 5 ]. Overall reported human case fatality rates (CFRs) range between 3.6 and 10.6% in the endemic regions [ 2 ]. In the current 2022 outbreak, clad IIb was predominant [ 6 , 7 ]. To date, the exact animal reservoir for the mpox virus (MPXV) has remained unknown. However, few native African rodents (Gambian giant rats) and squirrels are suspected to be natural reservoirs of the virus. Common species which were frequently infected with MPXV are squirrels, Gambian giant rats, strip mice, dormice, and primates [ 8 ].

Emergence of Mpox

The first outbreak of mpox was reported in 1958 in a group of 10 captive monkeys at the Statens Seruminstitut, Copehengan, Denmark, and Centre d’Enseignement et de Recherches de Medecine aeronautique, Paris. No human infection was reported in individuals who were in close contact with infected monkeys. Subsequently, the mpox outbreak occurred for the first time in humans between 1970 to 1971 [ 9 ]. The first case was reported in a 9-month-old boy residing in a remote village of the Democratic Republic of Congo (DRC), admitted to a local hospital suspected of smallpox infection. Samples from infected individuals were sent to the WHO Smallpox Reference Center, Moscow, revealing mpox infections in virus isolates [ 10 ]. When inspected from family, monkeys were part of the diet, and their skins were also processed in this area. However, no other cases including secondary infections were reported in the community. Nonetheless, seven more cases were reported during this time period [ 9 ]. The World Health Organization in 1967 took the initiative to collaborate with laboratories to conduct cooperative studies. This was to conduct serological surveys, identify mpox outbreaks, and determine the natural foci of the virus. However, these surveys failed to state any major findings and concluded mpox is not a widespread disease and can exist only in the local environment [ 9 ]. Ever since, there has been a subsequent upsurge of mpox cases, mostly recorded in the DRC province. Approximately, 80% of the cases were reported in this region from the years 1970–1997 [ 11 ]. For the past five decades, DRC is the most affected country with mpox; no other country had reported an mpox outbreak to such an extent [ 12 ].

The initial mpox outbreak that was reported in DRC mostly affected children below 10 years of age. A slight male predominance was observed in the systemic review conducted by Beer and Rao [ 11 ]. Most of the initial outbreaks occurred among individuals living in small rural areas or residing close to humid evergreen tropical forests or individuals commonly involved with bushmeat hunting [ 11 ]. Geographically, the spread of infection from 1970 to 2003 concentrated in the Central and Western parts of Africa (Table 1). Countries which frequently reported infections were Cameroon, the Central African Republic, Gabon, Sierra Leone, Liberia, Nigeria, and Cote d’Ivoire, yet greater outbreaks were mostly detected in DRC [ 13 ]. An active surveillance programme was carried out by WHO between the years 1981 to 1986 reporting total confirmed cases of 338 and 33 deaths, an almost 20 times rise in the reported case after the surveillance [ 10 , 11 ]. A slight drop in the incidence of disease was observed between the period of 1993–1995. But soon after, DRC witnessed a major outbreak from 1996–1997 [ 13 ]. A total of 511 cases were recorded with a surge in secondary transmission rates of up to 78% and a fatality rate between 1 and 5% [ 10 , 13 ].

In 2003, the mpox outbreak occurred for the first time in the USA, outside the African continent. The index case was a 3-year-old girl, bitten by an infected prairie dog, imported from Ghana along with other African rodents to the USA [ 14 ]. A total of 71 cases were reported, including both suspected and laboratory-confirmed cases, as per the CDC report [ 15 ]. During the period of 2005, mpox was registered for the first time in the dry savannah region of Sudan. Overall, 40 cases both suspected and confirmed were recorded. In this outbreak, a change in the genomic structure of MPXV was observed as compared to the MPXV traditionally reported in DRC suggesting the adaptability of MPVX in dry regions from humid evergreen tropical forests [ 10 ]. In the year 2018, mpox travelled for the first time to the UK and was reported in the European continent. Only two cases were registered, in individuals, which had a travel history to Nigeria [ 16 ]. Nevertheless, with the advent of 2022, the world saw a major outbreak of mpox (Table ​ (Table1 1 ).

Decade-wise spread of mpox across different countries between 1970 and 2020 9,10

Mpox Outbreak 2022

Mpox is endemic in Central and West Africa, where hundreds of cases were detected annually for many years, acquired mostly from wild animals and most rarely from infected humans [ 1 , 3 ], which results in a sporadic spillover of cases in humans as observed in the MPVX endemic regions [ 5 ]. However, in the 2022 outbreak of mpox, most of the cases were reported in non-endemic countries like N. America, S. America, and Europe (Fig.  1 ) [ 17 ]. Although the origin of the 2022 outbreak is still unknown, it is highly likely that the initial infection has been imported from an endemic country, allowing the circulation of the virus through close physical contacts among humans [ 1 , 18 ]. For the first time, mpox was documented with transmission chains in countries which had no immediate contact with Central or Western Africa [ 19 , 20 ]. This suggests a probability of undetected MPXV circulating in the local population in the outbreak-hit regions causing disease transmission in humans [ 17 ]. Being a DNA virus, mpox is more stable in nature and may have possibly evolved as a potent virus causing infections in humans in the due course of time [ 17 ]. Daniel et al. reported 6–12 times higher mutation rates in mpox as previously estimated [ 6 ]. Human to human transmissibility of mpox has also evolved in these decades [ 21 , 22 ]. Vertical infection of mpox has been also reported. Pregnant mothers infected with mpox had miscarriages during the first trimester of pregnancy [ 6 ]. Perinatally acquired mpox infection was registered in a 9-day year old neonate as well [ 23 ]. Transmissibility of infection within the family especially from parents to children have also been stated to increase [ 20 , 22 ]. The degree of transmissibility of the diseases, popularly known as R 0 , reported in the 1980 for mpox was 0.83. However, in the 2022 outbreak, the R 0 reported was 1.1–2.4 [ 21 , 24 ]. Pan et al. suggested the increase in the R 0 is due to decreased immunity of individuals due to the absence of smallpox immunization and high contact rates of infection in the MSM community [ 6 ].

Countries reporting mpox historically vs countries reporting an mpox outbreak as recorded in an early March 2023 report by CDC 19

As per the WHO, till 17 March 2023, the total confirmed cases for mpox were 86,601, with 1265 probable cases reported with 112 deaths. Globally, 110 countries were affected by mpox so far (Fig.  2 ) [ 20 ]. Approximately 34.7% of cases were reported in America, the worst affected country [ 20 ]. Majority of the infection occurred through household contacts (43%) and by sexual encounters (43%) [ 20 , 22 ]. Commonly affected individuals were young males who were not vaccinated against smallpox and have had sex with men. There was a slight male predisposition, with the median age reported as 34 years (IQR: 29–41). Around, 98% of individuals who were infected were either gay or bisexual, among which 41% of the people were HIV infected [ 4 ].

Mpox number of cases and deaths recorded in early March 2023 across the continent as per the report by CDC 19

On 23 July 2022, mpox was declared a public health emergency by the Public Health Emergency of International Concern (PHEIC), depicting a risk of international spread, along with significant international coordination to control the disease [ 25 ].

Clinical presentation of this disease includes three distinct phases, i.e. incubation, prodrome, and rash [ 2 ]. The incubation period can last for 3 to 20 days with the median being 7 days followed by the prodrome phase that is characterized by lethargy, myalgia, headache, fever, and lymphadenopathy which may last up to 5 days (Fig.  3 ) [ 2 , 4 , 18 ]. Lymphadenopathy is one of the critical features of the progression of the disease and often reported before the development of skin lesions [ 18 ]. Fever is usually followed by multiple papular, ulcerative, and vesiculopustular skin lesions [ 4 ], which progress from macules to papules, vesicles, pustules, crusts, and lastly scab, presenting for up to 4 weeks [ 2 , 18 ]. In 95% of the cases, skin lesions appears [ 4 ]. Common anatomical sites for skin lesions were anogenital with approximately 73% of cases followed by trunk, arms or legs, face, and eventually palms and soles, only accounting for 10% of the cases. Lesions developed contain infectious virus particles, through which the infection can be transmitted directly with human contacts [ 2 ]. Secondary complications include pneumonia, encephalitis, keratitis, gastroenteritis, sepsis, and secondary bacterial infections, affecting mostly patients with a previous diagnosis of HIV infection [ 2 , 4 , 5 ].

Common features reported in mpox infection 4

Current Treatment Modalities and Prevention

The strategy for the prevention and treatment of mpox is very similar to the treatment of Orthomyxovirus infection [ 26 ]. The 2022 outbreak revealed the urgency to control the spread of mpox as it has caused a potential threat in many countries [ 27 ]. Presently, there is no definitive cure for mpox infection, mild symptoms are manageable, and further complications can be avoided in patients with mpox with the help of supportive care [ 28 , 29 ]. Studies have depicted that patients with mild symptoms recover without any treatment [ 30 – 32 ]. Treatment options available for smallpox are also effective in the treatment of mpox, as the clinical presentation of mpox and smallpox is very similar. These include the vaccinia vaccine, vaccinia immune globulin (IVG), and antiviral agents such as cidofovir, tecovirimat, and brincidofovir [ 32 ]. Furthermore, CDC recommends the use of the potential treatment options should be done depending upon the severity of the cases and for serious emergency cases, as the current drugs pose severe adverse effects, and their therapeutic efficacy is still uncertain [ 33 ]. Antiviral drugs are a choice of treatment in immunocompromised patients, in patients with complicated lesions, in pregnant women infected with mpox, in breast-feeding women, and in the paediatric population [ 34 ]. Tecovirimat is the first line of action antiviral recommended for the treatment of smallpox; it works by inhibiting the viral envelope protein, thereby blocking the final steps of virus maturation and release from infected cells, inhibiting the spread. As per the CDC guidelines, emergency access use of tecovirimat is allowed for compassionate use, for the treatment of Orthopoxvirus infections, such as mpox [ 35 , 36 ]. Cidofovir and its oral analogue brincidofovir are commonly approved drugs for the treatment of smallpox; both act by inhibiting viral DNA polymerase. Different studies have evaluated the effect of brincidofovir against Orthopoxvirus infections [ 37 ]. Studies done by Lanier et al. and others on the effect of cidofovir and brincidofovir have been evaluated for mpox with some success [ 34 , 37 ]. As per the recommended guidelines by CDC, preexposure smallpox vaccination has been advised for veterinarians, monkeypox contacts, healthcare workers caring for mpox patients, researchers, and field investigators [ 38 ]. Prior immunization with the smallpox vaccine has demonstrated some proven protective effects against mpox due to the cross-protective immunity provided by the smallpox vaccine. Furthermore, the severity of clinical manifestations is also reduced [ 39 ]. Currently, three available smallpox vaccines with the US national stockpile, i.e. JYNNEOSTM, ACAM2000, have been licenced (2007) for smallpox, the most recent being Aventis Pasteur Smallpox Vaccine (APSV) which could be potentially used for mpox on a case-to-case basis, under an investigational new drug (IND) protocol. JYNNEOSTM, a third-generation and live viral vaccine, is produced from the modified vaccinia Ankara-Bavarian Nordic [ 40 – 42 ]. Licenced in 2019, JYNNEOSTM is an attenuated non-replicating orthopoxvirus. It is now indicated for both smallpox and mpox prevention for adults. Further, ACAM2000, a second-generation vaccine constituted of live vaccinia virus, under the emergency access ACAM2000 is allowed for mpox during the outbreak. Researchers have demonstrated that these vaccines can be used as pre- and post-treatment options, i.e. either in preventing the infection and the disease or in ameliorating the infection and disease [ 34 , 43 , 44 ]. Studies have demonstrated that pregnant women, children less than 8 years of age, and immunocompromised patients should be given antiviral treatment than vaccination. These vaccines, although approved, have shown some local and systematic side effects such as fever, muscle pain, vaccinia, abdominal and back pain, fatigue, headache, lymphadenopathy, etc. [ 42 – 44 ]. Researchers have also highlighted the need for maintaining appropriate social barriers such as avoiding close contact with affected individuals, avoiding contact with skin lesions of individuals infected with MPXV, etc. [ 44 – 46 ]. Vaccinia immune globulin intravenous (VIGIV) is a choice of treatment in case of severe infection with mpox, though there is a paucity of data about its effectiveness in treating mpox. VIGIV is also under SNS and can be administered under investigational new drugs held by CDC [ 29 , 30 , 47 – 49 ]. Therefore, the treatment options and the repurposing of vaccines need to be considered on a case-to-case basis depending on the severity of cases and the immune state of patients [ 50 ] (Fig. ​ (Fig.4 4 ).

A Symptoms and B mechanism of action of mpox antiviral therapy: cidofovir, brincidofovir, vaccinia immune globulin, and tecovirimat [ 50 ] 

Key Fundamental Findings of the Narrative Review

Some major key findings related to mpox are as follows: mpox was solely endemic to the region of DRC [ 11 ]. There has been a slow and steady increase in mpox cases which has adapted itself to develop into the current outbreak. Secondly, the 1996–1997 DRC outbreak highlighted the increase in secondary transmission rates of mpox, potentially getting adapted to spread in the human population [ 13 ]. Thirdly, the MPXV had adapted to thrive itself from the humid evergreen regions to the dry savannah region of Sudan, as observed in the 2005 outbreak, thus further demonstrating its environmental adaptability to flourish [ 10 ]. Lastly, international travel and commerce have given a wider chance for the disease to spread as reported in the 2003 and 2018 outbreaks of mpox in the USA and the UK [ 14 , 16 ]. All these above factors have led to the 2022 outbreak of mpox, affecting every continent across the globe (Fig.  5 ).

Global spread of mpox in 2023 outbreak 19

Most of the consistent outbreak guidelines available from WHO or CDC only account for people with a high risk of exposure; these guidelines are based on the best available evidence which is based upon risk–benefit analysis and other factors [ 51 ]. Available drugs for the treatment of choice are also limited and lack evidence-based studies in humans [ 29 , 30 , 48 ]. This depicts an extensive need to increase the sustainable funding option to enhance our understanding of the development of new drugs and vaccines to curtail the spread of mpox.

Implication in Future Research

The environmental, behavioural, and social reasons behind the 2022 mpox outbreak remain unknown to date [ 1 ]. A deeper understanding of mpox genetics and biochemistry is essential to control its outbreak. It is currently unclear how mpox is closely related and linked to the viral strain that is primarily found in western Africa, as well as the potential routes of rapid transmission. To further understand the immune defence mechanisms against MPXV, more research is needed on the human systemic and mucosal immune responses. As DNA viruses are more adept to correct mutations; therefore, it is unlikely that the mpox virus will suddenly change during human transmission [ 24 , 52 ]. It is yet unknown, whether vaccinations and earlier infections have given the population immunity. Additionally, exploratory studies are required to pinpoint the precise mpox virus reservoir, understand how the virus spreads naturally, and determine the causes of the present increase in cases across several nations. Currently, no potent drugs are available and limited evidence-based studies are being conducted for the treatment of mpox [ 29 ]. Most of the available choices of treatment are discussed in this paper (Fig.  6 ). Therefore, it becomes essential to investigate the domain of natural products with antiviral properties. This provides alternative treatment options, to prevent human to human spread of infection and restrict virus amplification in the host organisms. There is a recent increased interest among the scientific community to look into the numerous bioactivities of structurally unrelated natural compounds [ 53 , 54 ]. Plant-derived polyphenol resveratrol has beeb shown to significantly suppress replication of MPXV affecting probably the viral DNA synthesis and inducing a comparable effect to the well-characterized Orthopoxvirus inhibitor, i.e. cytosine-1-β- d -arabinofuranoside (AraC) [ 55 ]. Due to the pleiotropic action of natural compounds and lack of systemic toxicity, plant-derived agents may represent target compounds to be explored in future clinical trials to enrich the drug arsenal against Orthopoxvirus infections. Parallel to this, early detection of infected patients who are potentially capable of transmitting the infection is also crucial, pointing to the need for improved diagnosis (particularly in atypical clinical presentations and asymptomatic cases), and better availability of molecular tests. Besides, such continual efforts of preclinical scientists and pharmaceutical companies, availability of health infrastructures, and medical staff are of critical importance—a situation still aggravated by the ongoing COVID-19 pandemic. A high-risk patient population is possibly in danger of mpox nosocomial transmission and deserves more attention. Therefore, it is crucial to administer the proper supportive care [ 24 ]. Consequently, it is necessary to improve genomic sequencing capabilities to identify the mpox viral clade(s). The primary necessities are to combat the spread of mpox while dealing with the ongoing COVID-19 pandemic and to include suitable and timely information campaigns for people at risk. It is challenging to create an evidence-based classification of drug safety and effectiveness having a brief history of mpox. Further studies on various animal models, which may affect medication exposure, are also encouraged. The focus of larger research should be on identifying the patients who are most at risk for consequences from mpox infection as well as the best timing for initiating and completing antiviral therapy.

Different treatment modalities in mpox

The emergence of new diseases is one of the incessant threats which mankind can face. Persistent interference between the environment and humans creates an opportunity for new infections to evolve. Over 75% of the pathogens, which are newly emerging, are zoonotic in nature [ 56 ]. Several diseases like HIV/AIDS, Nipah, SARS, and Ebola including mpox have recently appeared. International travel and commerce and human behaviour often help disease to spread [ 56 ]. With the first emergence of mpox in 1958, little is still known about its reservoir host and vector of the disease. Despite repeated outbreaks of mpox over the past years, it has failed to gather scientific attention. There is a lack of understanding of mpox transmission dynamics and disease evolution. In the areas endemic to mpox, regular disease surveillance is lacking. This also includes the need to promote funding for capacity building required for surveillance of the disease, research activities, and testing facilities [ 17 , 57 ]. The role of central bodies like the World Health Organization plays a major role in controlling such outbreaks. However, non-compliance to guidelines and regulations by health agencies like WHO severely impacts the control measures [ 25 ]. Boosting vaccine development and effective drug development is essential to prevent future outbreaks. In addition, new plant-derived products could be further developed and can be promoted as they potentially have lesser side effects for mpox treatment.

Abbreviations

Author Contribution

SR, KV, and KS: conceptualization and writing; HST: editing and proofreading. All authors reviewed the manuscript.

Data Availability

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The authors declare no competing interests.

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