a scoping review of flow research

DOI: 10.3389/fpsyg.2022.815665
Corpus ID: 247980880

A Scoping Review of Flow Research

C. Peifer , G. Wolters , +11 authors S. Triberti
Published in Frontiers in Psychology 7 April 2022

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Fostering flow experiences at work: a framework and research agenda for developing flow interventions, validated questionnaires in flow theory: a systematic review, the role of a restorative resource in the academic context in improving intrinsic and extrinsic motivation and flow within the job demands–resources model, psychological flow scale (pfs): development and preliminary validation of a new flow instrument that measures the core experience of flow to reflect recent conceptual advancements, psychological flow training: feasibility and preliminary efficacy of an educational intervention on flow, preliminary results of measuring flow experience in a software modeling tool: umpleonline, a scoping review on mapping the digital leadership constructs for educational settings: what we can learn, the influence of leader-subordinate emotional intelligence congruence on the flow experience: evidence from the liquor manufacturing industry, optimal experience in adult learning: conception and validation of the flow in education scale (eduflow-2), alone but flowing: the effects of autotelic personality and extraversion on solitary flow., 311 references, flow experience in physical activity: examination of the internal structure of flow from a process-related perspective, qualitative examination of flow experience among top japanese athletes, a cross-sectional survey study about the most common solitary and social flow activities to extend the concept of optimal experience, can research “send me high” addressing flow theory.

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Predicting flow at work: investigating the activities and job characteristics that predict flow states at work., the eduflow model: a contribution toward the study of optimal learning environments, flow at work: an experience sampling approach, flow and its affective, cognitive, and performance-related consequences, when good is good: a virtuous circle of self-efficacy and flow at work among teachers, related papers.

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Flow is a gratifying state of deep involvement and absorption that individuals report when facing a challenging activity and they perceive adequate abilities to cope with it (EFRN, 2014). The flow concept was introduced by Csikszentmihalyi in 1975, and interest in flow research is growing. However, to our best knowledge, no scoping review exists that takes a systematic look at studies on flow which were published between the years 2000 and 2016. Overall, 252 studies have been included in this review. Our review (1) provides a framework to cluster flow research, (2) gives a systematic overview about existing studies and their findings, and (3) provides an overview about implications for future research. The provided framework consists of three levels of flow research. In the first “Individual” level are the categories for personality, motivation, physiology, emotion, cognition, and behavior. The second “Contextual” level contains the categories for contextual and interindividual factors and the third “Cultural” level contains cultural factors that relate to flow. Using our framework, we systematically present the findings for each category. While flow research has made progress in understanding flow, in the future, more experimental and longitudinal studies are needed to gain deeper insights into the causal structure of flow and its antecedents and consequences.

Original language	English
Article number	815665
Number of pages	27
Journal
Volume	13
DOIs
Publication status	Published - 7 Apr 2022

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cultural level
individual level
scoping review

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T1 - A Scoping Review of Flow Research

AU - Peifer, Corinna

AU - Wolters, Gina

AU - Harmat, László

AU - Heutte, Jean

AU - Tan, Jasmine

AU - Freire, Teresa

AU - Tavares, Dionísia

AU - Fonte, Carla

AU - Andersen, Frans Orsted

AU - van den Hout, Jef

AU - Šimleša, Milija

AU - Pola, Linda

AU - Ceja, Lucia

AU - Triberti, Stefano

N1 - Funding Information: TF was funded by Psychology Research Centre (PSI/01662), School of Psychology, University of Minho, supported by the Foundation for Science and Technology (FCT) through the Portuguese State Budget (UIDB/PSI/01662/2020). JH was funded by I-SITE Université Lille Nord-Europe (ULNE), supported by the French state through the General Secretariat for Investment (SGPI) and the National Research Agency (I-SITE ULNE / ANR-16-IDEX-0004 ULNE).

PY - 2022/4/7

Y1 - 2022/4/7

N2 - Flow is a gratifying state of deep involvement and absorption that individuals report when facing a challenging activity and they perceive adequate abilities to cope with it (EFRN, 2014). The flow concept was introduced by Csikszentmihalyi in 1975, and interest in flow research is growing. However, to our best knowledge, no scoping review exists that takes a systematic look at studies on flow which were published between the years 2000 and 2016. Overall, 252 studies have been included in this review. Our review (1) provides a framework to cluster flow research, (2) gives a systematic overview about existing studies and their findings, and (3) provides an overview about implications for future research. The provided framework consists of three levels of flow research. In the first “Individual” level are the categories for personality, motivation, physiology, emotion, cognition, and behavior. The second “Contextual” level contains the categories for contextual and interindividual factors and the third “Cultural” level contains cultural factors that relate to flow. Using our framework, we systematically present the findings for each category. While flow research has made progress in understanding flow, in the future, more experimental and longitudinal studies are needed to gain deeper insights into the causal structure of flow and its antecedents and consequences.

AB - Flow is a gratifying state of deep involvement and absorption that individuals report when facing a challenging activity and they perceive adequate abilities to cope with it (EFRN, 2014). The flow concept was introduced by Csikszentmihalyi in 1975, and interest in flow research is growing. However, to our best knowledge, no scoping review exists that takes a systematic look at studies on flow which were published between the years 2000 and 2016. Overall, 252 studies have been included in this review. Our review (1) provides a framework to cluster flow research, (2) gives a systematic overview about existing studies and their findings, and (3) provides an overview about implications for future research. The provided framework consists of three levels of flow research. In the first “Individual” level are the categories for personality, motivation, physiology, emotion, cognition, and behavior. The second “Contextual” level contains the categories for contextual and interindividual factors and the third “Cultural” level contains cultural factors that relate to flow. Using our framework, we systematically present the findings for each category. While flow research has made progress in understanding flow, in the future, more experimental and longitudinal studies are needed to gain deeper insights into the causal structure of flow and its antecedents and consequences.

KW - contextual level

KW - cultural level

KW - individual level

KW - scoping review

UR - http://www.scopus.com/inward/record.url?scp=85123182445&partnerID=8YFLogxK

U2 - 10.3389/fpsyg.2022.815665

DO - 10.3389/fpsyg.2022.815665

M3 - Review article

C2 - 35465560

AN - SCOPUS:85123182445

SN - 1664-1078

JO - Frontiers in Psychology

JF - Frontiers in Psychology

M1 - 815665

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A Scoping Review of Flow Research

2022, Frontiers in Psychology

Related Papers

International Journal of Applied Positive Psychology

Amanda E Krause

In this study, we sought to develop-and provide preliminary validity evidence for scores derived from-a new Psychological Flow Scale (PFS). We propose a parsimonious model of three core dimensions of flow, reflecting the findings from a recent scoping review that synthesised flow research across scientific disciplines. The validation process for the PFS addressed recent conceptual criticisms of flow science regarding construct validity, theoretical compatibility, relational ambiguity, and definitional inconsistency. An initial review and analysis of the many flow measurements that exist found that these instruments either assess one, some, or none of the three core-dimensions of flow; often measuring similar dimensions that may bear resemblance to one of the three-dimensions but differ in dimensional meaning. PFS item development involved a phase of theoretical scrutiny, review of existing instruments, item generation, and expert review of items. Subsequently, 936 participants were recruited for scale development purposes, which included sample testing, exploratory factor analysis, and confirmatory factor analysis. This factor analytic process showed evidence for three distinguishable dimensions 'under' a single general or higher-order factor (i.e., global flow). With respect to external aspects of validity, flow scores correlated positively with perceptions of competence, self-rated performance, autotelic personality, and negatively with anxiety and stress scores. In conclusion, we present preliminary evidence for the theoretical and operational Public Significance Statement This article presents evidence of validity for a new Psychological Flow Scale (PFS) that assesses the core aspects of the flow state, and has been designed to be utilized across domains and scientific disciplines. Confirmatory findings suggest that the response scale is a suitable fit to assess flow globally, whilst the dimensions of absorption, effortless control, and intrinsic reward can be assessed by the three subscales. Flow scores correlated positively with perceptions of competence, self-rated performance, autotelic personality; and correlated negatively with anxiety and stress. The article offers suggestions regarding important aspects of flow measurement.

In this study, we sought to develop—and provide preliminary validity evidence for scores derived from—a new Psychological Flow Scale (PFS). We propose a parsimonious model of three core dimensions of flow, reflecting the findings from a recent scoping review that synthesised flow research across scientific disciplines. The validation process for the PFS addressed recent conceptual criticisms of flow science regarding construct validity, theoretical compatibility, relational ambiguity, and definitional inconsistency. An initial review and analysis of the many flow measurements that exist found that these instruments either assess one, some, or none of the three core-dimensions of flow; often measuring similar dimensions that may bear resemblance to one of the three-dimensions but differ in dimensional meaning. PFS item development involved a phase of theoretical scrutiny, review of existing instruments, item generation, and expert review of items. Subsequently, 936 participants were ...

Disha Rupayana

Carlton J. Fong

Flow is an intrinsically motivating state of consciousness characterized by simultaneous perception of high challenge and skill. The position that challenge–skill balance is the primary antecedent for achieving a flow state is unclear, and more research is needed to examine its impact on flow within multiple domains. Therefore, a meta-analysis was conducted on 28 studies examining the challenge–skill balance related to flow and intrinsic motivation in a variety of contexts. The results indicated that the relationship between challenge–skill balance and flow was moderate, and smaller with intrinsic motivation. Moderator analyses revealed weaker correlations when individuals were from an individualistic culture, in work or education contexts, using experience sampling method, and self-reporting state flow vs. trait. Compared to other theorized antecedents, challenge–skill balance was a robust contributor to flow along with clear goals and sense of control.

Stress and Health

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The Palgrave Handbook of Motivation for Language Learning

Katalin Piniel

This chapter explores possible connections between flow and motivation and suggests expanding the motivation research agenda in SLA. The flow experience is defined as “the holistic sensation that people feel when they act with total involvement” (Csikszentmihalyi, Beyond boredom and anxiety: Experiencing flow in work and play. San Francisco, CA: Jossey-Bass, [1975] 2000, p. 36), which typically accompanies an activity that people perform for its own sake and for enjoyment. The chapter begins with an overview of flow theory and its links with motivation. Then, by following up on issues in mainstream education research (including collective flow experiences and flow in classrooms), ideas for the application of flow theory in language learning contexts are presented. The final section in the chapter discusses how already existing SLA research frameworks can serve as fertile ground for investigating flow experiences in language learning.

Clifford Mallett

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A Scoping Review of Flow Research

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A Scoping Review of Flow Research
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Advancing our understanding of psychological flow: A scoping review of conceptualizations, measurements, and applications

Affiliation.

1 School of Human Sciences (Exercise and Sport Science), The University of Western Australia.
PMID: 34898235
DOI: 10.1037/bul0000337

Research on psychological flow is well established, although criticisms remain regarding conceptual and measurement issues associated with the construct. This scoping review maps flow-related research across scientific disciplines, examining the conceptualization, measurement instruments, and outcomes of flow between 2012 and 2019. Across 236 sources that met the review criteria, 108 different flow-related constructs were measured by 141 instruments, and 84 possible antecedents were identified. Despite the varied approaches, a common set of overarching antecedent constructs included "optimal challenge" and "high motivation," and recurring characteristics of the flow experience itself included "absorption," "effort-less control," and "intrinsic reward." Applied studies-albeit inconsistent in approach and largely correlational in nature-predominantly linked flow to "positive development" (i.e., well-being and health), "high functioning," and "further engagement." We contextualize the findings of the review relative to important work on flow that has recently emerged (following the review period)-in doing so, we hope this review offers a contemporary framework that can be used for the study of flow across scientific disciplines. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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REVIEW article

A scoping review of flow research.

$\r\nCorinna Peifer*$

1 Department of Psychology, University of Lübeck, Lübeck, Germany
2 Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
3 Department of Psychology, Linnaeus University, Växjö, Sweden
4 ULR 4354 - CIREL - Centre Interuniversitaire de Recherche en Education de Lille, Université de Lille, Lille, France
5 Department of Psychology, Goldsmiths University of London, London, United Kingdom
6 School of Psychology, University of Minho, Braga, Portugal
7 Faculty of Human and Social Sciences, University Fernando Pessoa, Porto, Portugal
8 Department of Education, University of Aarhus, Aarhus, Denmark
9 Industrial Engineering and Innovation Sciences, Eindhoven University of Technology, Eindhoven, Netherlands
10 Institute of Psychology Henri Pieron, Université Paris 5 René Descartes, Paris, France
11 Department of Cultural Heritage and Environment, University of Milan, Milan, Italy
12 IESE Business School, University of Navarra, Barcelona, Spain
13 Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy

Flow is a gratifying state of deep involvement and absorption that individuals report when facing a challenging activity and they perceive adequate abilities to cope with it ( EFRN, 2014 ). The flow concept was introduced by Csikszentmihalyi in 1975, and interest in flow research is growing. However, to our best knowledge, no scoping review exists that takes a systematic look at studies on flow which were published between the years 2000 and 2016. Overall, 252 studies have been included in this review. Our review (1) provides a framework to cluster flow research, (2) gives a systematic overview about existing studies and their findings, and (3) provides an overview about implications for future research. The provided framework consists of three levels of flow research. In the first “Individual” level are the categories for personality, motivation, physiology, emotion, cognition, and behavior. The second “Contextual” level contains the categories for contextual and interindividual factors and the third “Cultural” level contains cultural factors that relate to flow. Using our framework, we systematically present the findings for each category. While flow research has made progress in understanding flow, in the future, more experimental and longitudinal studies are needed to gain deeper insights into the causal structure of flow and its antecedents and consequences.

Introduction

Flow “is a gratifying state of deep involvement and absorption that individuals report when facing a challenging activity and they perceive adequate abilities to cope with it” ( EFRN, 2014 ). The phenomenon was described by Csikszentmihalyi (1975) in order to explain why people perform activities for no reason but for the activity itself, without extrinsic rewards. During flow, people are deeply motivated to persist in their activities and to perform such activities again ( Csikszentmihalyi, 1975 ; EFRN, 2014 ). Csikszentmihalyi (1975 , 1990) distinguished up to nine characteristics of the flow experience: (1) challenge-skill-balance, (2) merging of action and awareness, (3) clear goals, (4) unambiguous feedback, (5) concentration on the task, (6) sense of control, (7) loss of self-consciousness, (8) time transformation, and (9) autotelic experience.

The first of these characteristics—the challenge-skill balance—gained much attention in flow research. In his Flow Channel Model, Csikszentmihalyi (1975) operationalized flow in the context of skills and challenges: if the individual’s skills meet the situational challenges, the individual is in the so-called flow channel and flow occurs. In later modifications of this model, as in the Experience Fluctuation Model (EFM), flow was said to occur if both challenges and skills are high and in balance (e.g., Massimini et al., 1987 ; Carli et al., 1988 ; Csikszentmihalyi, 1997 ). This assumption gained empirical support: for example, Inkinen et al. (2014) showed that if challenges and skills are high and in balance, this combination is characterized by an active and pleasant emotional experience, as described in the EFM. Also, a recent meta-analytical study confirmed the stability of challenge-skill balance as a condition of flow ( Fong et al., 2015 ), together with clear goals and sense of control.

Later, Nakamura and Csikszentmihalyi (2002) and Landhäußer and Keller (2012) sorted Csikszentmihalyi’s (1990) characteristics of flow experience into preconditions and components of flow. They also defined the balance between task demands and skills as a central precondition of flow, together with clear goals and clear feedback. They defined components of flow as concentration, merging of action and awareness, sense of control, autotelic experience, reduced self-consciousness, and transformation of time. Further conceptualizations of flow exist (e.g., Bakker, 2005 ; Engeser and Rheinberg, 2008 ; Abuhamdeh, 2021 ; Barthelmäs and Keller, 2021 ; for an overview see Engeser et al., 2021 ; Peifer and Engeser, 2021 ). Recently, Peifer and Engeser (2021) have critically discussed the existing components of flow and proposed an integration of those into the three meta-components absorption , perceived demand-skill balance , and enjoyment .

Since the introduction of the flow concept, there has been much research investigating the concept itself, its preconditions, and its consequences. The research shows that “flow experiences can have far-reaching implications in supporting individuals’ growth, by contributing both to personal wellbeing and full functioning in everyday life” ( EFRN, 2014 ). Potentially due to its positive consequences, flow research is further growing and there is a wealth of empirical articles dedicated to this phenomenon. However, due to the large amount of studies, there is a lack of a broad and systematic overview on flow research. Accordingly, this review aims to provide such a structured overview of flow research and to provide directions for future flow research.

Since 2012, the European Flow-Researchers’ Network (EFRN) has met on a yearly basis to foster scientific progress in flow research and application. Following this aim and having identified the described lack of agreement within flow research, the network decided in their meeting in November 2015 to unite their expertise and provide a scoping review on studies addressing flow experience published as of the year 2000. The advantage of a scoping review is that it collects, evaluates and presents the available research with a more systematic approach than is used in traditional review articles ( Arksey and O’Malley, 2005 ). Compared to meta-analyses or systematic reviews, a scoping review regards not just a specific, narrow research question, but a broad scope of research with respect to a certain concept ( Arksey and O’Malley, 2005 ), in our case, flow experience. Accordingly, a scoping review aims to identify and structure existing research in order to provide a framework and to build a basis for future research.

The scoping review follows three steps: first, we present a framework to structure flow research. Second, we review empirical flow research that has been published between 2000 and 2016. Third, based on our results, we discuss implications for future research.

Framework to Structure Flow Research

In order to structure and review the empirical research regarding flow experiences, the authors developed a framework (see Figure 1 ). The framework consists of three circles lying within each other and containing categories of flow research. The inner circle represents individual factors. On this individual level, we distinguish between the categories of personality, motivation, physiology, emotion, cognition, and behavior. The middle circle—the contextual level—represents the categories contextual and interindividual factors and the outer circle represents the cultural category. Within our framework, all categories contain preconditions or consequences of flow, and all categories can influence each other.

Figure 1. Categorization of flow research 2000–2016.

As proposed by Arksey and O’Malley (2005) , our scoping review was developed using the following 6 steps.

Identification of the Research Question

The importance of providing a scoping review on flow experience was identified during the 4th meeting of the European Flow Researchers’ Network (EFRN) in Braga (Portugal), 2015. To fulfill this aim, the network searched for a systematic overview of the existing flow research as a basis for future research. The finding of that literature search was that the number of publications on flow experience is growing, but that a systematic overview was not available. Accordingly, the EFRN decided to unite their expertise to develop such a systematic overview, i.e., a scoping review. To start, during the 4th EFRN meeting in Braga (Portugal), EFRN members worked on a preliminary framework to categorize flow research.

Literature Research

For the literature search, we consulted the platforms PsycInfo, PubMed, PubPsych, Web of Science and Scopus . We searched for empirical studies using the terms “ flow/optimal experience/challenge-skill balance” in order to cover different terms for flow which are typically used in the literature. Also, we excluded “cerebral blood flow” and “work-flow centrality,” as these terms produces many false hits. Further, we decided to add the term “ Csikszentmihalyi ” to the search, as we considered that reputable articles on flow would cite Csikszentmihalyi and, at the same time, many articles which are not related to flow experience would be excluded. We only included empirical studies that were published between 2000 and 2016. The resulting search string was (for PsycInfo):

(((“flow” or “optimal experience” or “challenge-skill balance”) and “Csikszentmihalyi”) not “cerebral blood flow” not “work-flow centrality”).af. and (“2000” or “2001” or “2002” or “2003” or “2004” or “2005” or “2006” or “2007” or “2008” or “2009” or “2010” or “2011” or “2012” or “2013” or “2014” or “2015” or “2016”).yr.

We did not include conference abstracts or articles that were not in the English language. Also, within this first step, we excluded publications that clearly did not deal with the topic of flow experience. The literature search was conducted in 2016 and updated in 2017 to cover also the full year of 2016.

Selection of Relevant Studies

Overall, we found 257 publications that were then rated by the authors with respect to their relevance for our scoping review. In the next step, publications were excluded if they did not contain original data on flow experience. Accordingly, twelve empirical studies were excluded because although the concept of flow was discussed, their data did not investigate flow experience. Forty-six articles were excluded because they were theoretical articles, reviews, meta-analyses or book chapters without original data. From the 257 publications, 199 empirical studies were included in the review ( Table 1 ).

Table 1. Overview of the studies included in this review ( N = 252).

Charting the Information

During the 5th EFRN meeting in Milan (Italy), in November 2016, the preliminary framework of flow research as agreed during the 4th EFRN meeting was adapted. Based on the identified articles within our literature research, categories were added if necessary to adequately describe the literature. The final framework that was used in this Scoping Review is depicted in Figure 1 .

During the meeting in Milan, experts from the EFRN were assigned to each category, and were responsible for that category in the following process. All experts are active flow researchers and members of the EFRN, who have published peer-reviewed papers in the field of their respective category. These experts are the team of authors of this Scoping Review.

In order to ensure a common understanding of the categories, the experts provided a clear description of their category. These were gathered, shared, and discussed between the authors. The outcome of step 4 was a final document which contained the agreed list of categories and their respective descriptions. This document forms the basis of the categorization of articles in the following step 5.

All articles were then distributed among the authors for them to rate their relevance for each category (see Figure 1 ) based on the abstracts. It was therefore possible that one article would be rated as being relevant for more than one category. Every article was independently reviewed by two authors. Empirical studies that were rated as relevant to the category by both authors were immediately included in the review of the category. Empirical studies that were only rated as relevant to the category by one author were again rated by the responsible expert(s). If he or she rated this article as relevant, it was also included in the review of the category. Otherwise, it was excluded.

Collating, Summarizing and Reporting of Study Results

A large table listing all articles with their respective categories as rated by the authors was sent to the experts (i.e., the authors for a specific category) in order to start the process of summarizing the study results. In addition to the articles in the table, experts could include further empirical articles which had not been found in the initial search that they considered relevant for their respective category. That way, we aimed at providing a broad picture of flow research, as required in a Scoping Review. Forty-one additional empirical studies were included in the review by our experts and twelve articles from the EFRN publication list. Table 1 presents all included empirical studies. Next, experts extracted all relevant articles for their category from the large table and created a table of articles of their category. The final tables of included articles for each category can be found in the Results section for the respective categories.

Based on this extraction, and on the description of the category, experts summarized the results of articles placed in their assigned category, thereby ignoring findings reported in an article that did not belong to that category: 93 of the articles are represented in more than one category, each time with a different focus (see Table 1 ). To achieve a coherent manuscript without too many redundancies, the content of each category was revised during an internal review process.

Discussion of the Results and Implications for Future Research

In addition to the summaries of the categories in the result section, experts collected points for discussion. These points were picked up and integrated into our general discussion of flow research, which built step 6 of our Scoping Review. During the 6th EFRN meeting in Tilburg (Netherlands, 2017), these points were discussed within the network and further elaborated. At this point, and in line with the aims of the EFRN, implications for future research which would foster scientific progress in flow research were identified.

The following section provides the expert summaries of each category. Table 2 provides an overview of all categories, the number of integrated articles and the operationalization of the respective category.

Table 2. Overview of categories.

Personality

The category Personality and Flow included studies that investigated personality traits and motives as stable individual factors. Studies that dealt with heritability or genes of flow proneness and individual differences were also included. Expert ratings revealed that 31 articles have met these inclusion criteria. Seven additional articles were included by our experts and two articles from the EFRN publication list. The final list of articles that were integrated into this section is depicted in Table 3 .

Table 3. Personality.

The personality studies on flow can be divided into four categories: (1) studies dealing with autotelic personality, (2) dispositional proneness to experience flow and its relation to Big Five personality traits, (3) the relationship of flow with other personality traits or motives and (4) flow and motive-fitting situations.

Studies Dealing With Autotelic Personality

Autotelic personality is the ability to enter a flow state relatively easily ( Csikszentmihalyi and Csikszentmihalyi, 1988 ) which was investigated in an interview-study from Sugiyama and Inomata (2005) . Moneta (2004) and Abuhamdeh and Csikszentmihalyi (2009) state that intrinsic motivation is associated with autotelic personality, but little is known about its exact components. Existing studies suggest that these components of autotelic personality are personal innovativeness, self-efficacy, control, focused attention ( Tan and Chou, 2011 ), and the achievement motive ( Baumann and Scheffer, 2011 ; Busch et al., 2013 ).

Dispositional Proneness to Experience Flow and Its Relation to Big Five Personality Traits

Flow proneness is a dispositional tendency to experience flow and there are large individual differences in the frequency and intensity of flow experiences. Several self-report questionnaires have been developed to measure the variation between individuals in flow proneness e.g., Jackson and Eklund’s Dispositional Flow Scale-2 ( Jackson and Eklund, 2002 ; Jackson et al., 2008 ; e.g., applied by Sinnamon et al., 2012 , Johnson et al., 2014 ); and the Swedish Flow Proneness Questionnaire (SFPQ, Ullén et al., 2012 ). Existing studies suggest that flow proneness is related to well-established personality traits and that this association has a biological basis: Ullén et al. (2012) found that flow proneness is correlated with the Big Five personality traits emotional stability (i.e., low neuroticism) and conscientiousness. In addition, trait flow is related to extraversion, openness to experience, and agreeableness ( Ullén et al., 2016 ). Other studies found that dispositional flow is associated with high extraversion and low neuroticism, and trait emotional intelligence in musicians ( Marin and Bhattacharya, 2013 ; Heller et al., 2015 ). In addition, openness and music-specific flow were found to be the strongest predictors of music practice ( Butkovic et al., 2015 ). In line with this, further studies suggest that extraversion and openness to experience are positively related to flow, while high neuroticism and introversion related to less flow experience ( Vittersø, 2003 ; Baumann and Scheffer, 2010 ; Mesurado and Richaud de Minzi, 2013 ; Bassi et al., 2014b ; Heller et al., 2015 ).

The Relationship of Flow With Other Personality Traits or Motives

Other personality traits also seem to be associated with flow experience: Bailis (2001) found that athletes’ trait self-handicapping score was positively related to optimal experience in competition. High mental toughness, i.e., a personal capacity supporting the process of high performance ( Jackman et al., 2016 ), perceived motivational climates, and individuals’ goal orientations ( Moreno Murcia et al., 2008 ) could account for differences in dispositional flow in athletes. Further, Kuhnle et al. (2012) found that self-control predicted flow experiences in eighth graders. Keller and Blomann (2008) found that a strong internal locus of control fosters flow under a skill-demand fit. Furthermore, studies suggest that action orientation fosters flow under skill-demand fit ( Keller and Bless, 2008 ) and even under suboptimal (no skill-demand fit) conditions ( Baumann et al., 2016 ). Beard and Hoy (2010 ; using state flow) and Vealey and Perritt (2015 ; using dispositional flow) found that optimism was positively related to flow whereas another study with Japanese students found that shyness predicted the frequency of flow experience ( Hirao et al., 2012b ). However, while empirical studies show that personality factors foster flow experiences, situational factors seem to have a bigger effect on flow ( Fullagar and Kelloway, 2009 ; Ullén et al., 2016 ).

Using the SFPQ, Mosing et al. (2012) measured genetic influences on flow proneness in a cohort of adult twins and multivariate twin modeling indicated a moderate heritability of flow proneness. De Manzano et al. (2013) used positron emission tomography (PET) and found a positive relation between flow proneness and D2 receptor availability in the striatum. Their results suggested that the differences in the dopamine system could reflect personality differences.

Flow and Motive-Fitting Situations

Studies indicate that motives foster flow experiences in motive-fitting situations ( Schattke, 2011 ; Oertig et al., 2014 ; Schüler et al., 2016 ). For example, Schüler et al. (2016) found that people scoring high on the autonomy motive experience flow in situations that satisfied participant’s autonomy-motive. Furthermore, Mills and Fullagar (2008) found that the need for autonomy moderated the relationship between flow and intrinsic motivation. Oertig et al. (2014) found that a high avoidance motive results in greater flow when performance-avoidance goals were induced. Schüler et al. (2010) found that the feeling of competence resulted in higher flow of participants who had a high achievement motive in sports [see also Schüler and Brandstätter (2013) ]. Furthermore, high achievement motive and high hope of success were positively correlated with flow experience of wall climbers’ and students ( Peterson and Miller, 2004 ; Schüler, 2007 ; Schattke, 2011 ; Schattke et al., 2014 ).

The category Motivation and Flow included studies that dealt with intrinsic or extrinsic motivation, interest, and volition. Also included were studies that dealt with motivational concepts such as self-determination, self-efficacy, self-regulation, and locus of control. Expert ratings revealed that 44 articles have met these inclusion criteria. Another eight articles were included by our experts and two articles from the EFRN publication list. The final list of articles that were integrated into this section is depicted in Table 4 .

Table 4. Motivation.

The motivation studies on flow can be divided into four categories: studies dealing with flow and (1) motivational indicators (volition, engagement, goal orientation, achievement motive, interest, intrinsic motivation), (2) self-determination (3) self-efficacy, and (4) social motivation.

Motivational Indicators

If “motivation” can be simplistically defined as “move to action,” for its part, “volition” can be simplistically defined as “will to persist in action.” Thus, if motivation promotes an intention to act, then volition protects it ( Corno, 2001 ). It was found that volition is positively linked to flow (e.g., Schattke, 2011 ). Another motivational indicator associated with flow is engagement, which “reflects an employee’s intention to throw their full self—heads, hands, and heart—into their work” ( Plester and Hutchison, 2016 , p. 4). Many studies investigated the association between the two concepts (e.g., Karageorghis et al., 2000 ; Shernoff et al., 2003 ; Montgomery et al., 2004 ; Rha et al., 2005 ; Steele and Fullagar, 2009 ; Belchior et al., 2012 ; Ulrich et al., 2014 ; Valenzuela and Codina, 2014 ; Pocnet et al., 2015 ; Mesurado et al., 2016 ; Plester and Hutchison, 2016 ). Goal orientation was also found to be linked to flow (e.g., Delle Fave and Massimini, 2005 ; Moreno Murcia et al., 2008 ; Schüler et al., 2010 ; Oertig et al., 2013 , 2014 ; Bonaiuto et al., 2016 ; Jackman et al., 2016 ; Ozkara et al., 2016 ), as well as the achievement motive (e.g., Engeser and Rheinberg, 2008 ; Baumann and Scheffer, 2011 ; Busch et al., 2013 ; Schüler and Brandstätter, 2013 ; Schattke et al., 2014 ; see Personality and Flow). Furthermore, interest, which can be described as a motivational state resulting from attraction to a certain domain or activity ( Reeve, 2008 ), was found to be related to flow (e.g., Eisenberger et al., 2005 ; Bressler and Bodzin, 2013 ; Bachen et al., 2016 ; Bricteux et al., 2017 ). Intrinsic motivation was investigated particularly often in its relation to flow, with evidence for a positive link found in various settings, such as education ( Schüler et al., 2010 ; Keller et al., 2011b ; Valenzuela and Codina, 2014 ; Meyer et al., 2016 ), Information and Communication Technologies (ICT) use ( Voiskounsky and Smyslova, 2003 ; Montgomery et al., 2004 ; Keller and Bless, 2008 ; Yan and Davison, 2013 ; Kim et al., 2014 ; Chen and Lu, 2016 ); daily activities ( Gaggioli et al., 2013 ) and physiological aspects ( Keller et al., 2011a ; Ulrich et al., 2014 ).

Self-Determination

Self-determination theory (SDT) “is an empirically derived theory of human motivation and personality in social contexts that differentiates motivation in terms of being autonomous and controlled” ( Deci and Ryan, 2012 , p. 416). Autonomous motivation combines forms of intrinsic motivation with those forms of extrinsic motivation, which go along with a sense of identification with the activity and its values; accordingly, it goes along with increased volition and self-endorsement ( Deci and Ryan, 2008 ). In contrast, controlled motivation is associated with experiencing the “pressure to think, feel, or behave in particular ways” ( Deci and Ryan, 2008 , p. 182). Many authors (e.g., Schüler et al., 2010 ; Schattke, 2011 ; Bassi and Delle Fave, 2012a , b ; Fulmer and Tulis, 2016 ) consider that flow experience is linked to autonomous motivation. Studies which examine flow in the context of self-determination theory showed for example that work-related flow is associated with both autonomous regulation and controlled regulation ( Bassi and Delle Fave, 2012a ). Furthermore, raising children in a way that promotes self-determination will help them to engage in activities which will enhance their flow experience ( Schattke, 2011 ). In another study, it was found that flow enhanced learning motivation in computer-based learning systems if participants experienced self-control ( Kim et al., 2014 ). Goal-directed activities with clear instructions are supported in environments where the individual feels autonomous and self-determined (e.g., providing choices). These activities are motivating as well as flow-inducing ( Novak et al., 2003 ). Conceptually, and on the approach-avoidance spectrum, the approach aspect of goals is likely to promote intrinsic motivation because it facilitates challenge appraisals and task absorption, whereas the avoidance aspect of goals is likely to undermine intrinsic motivation because it evokes threat appraisals, anxiety, and self-concern ( Elliot, 2005 ).

Self-Efficacy

This category of studies within this section reviews studies dealing with flow and self-efficacy, i.e. the “people’s judgments of how well they can organize and execute, constituent cognitive, social, and behavioral skills in dealing with prospective situations” ( Bandura, 1983 , p. 467). The degree of self-efficacy affects the initiation, persistence and effort in activities ( Bandura, 1977 ), and is, thus, an influential motivational theory. Results of empirical studies confirm that self-efficacy is linked with flow frequency and higher levels of challenge and skills showing that self-efficacy predicts flow over time ( Rodríguez-Sánchez et al., 2011a ; Heutte et al., 2016 ). Collective efficacy beliefs predict collective flow over time ( Salanova et al., 2014 , see sections Interindividual Factors and Flow and Cognition and Flow ). High levels of efficacy beliefs have a positive impact on flow experiences in academic settings ( Salanova et al., 2006 ; Bassi et al., 2007 ; Heutte et al., 2016 ). Various aspects of Bandura’s (1986) self-regulation learning model were shown to exert a significant and positive effect on flow ( Lee and LaRose, 2007 ; Rodríguez-Sánchez et al., 2011a ; Chen and Sun, 2016 ).

Social Motivation

Some first studies highlight the social motivational conditions of flow ( Sawyer, 2003 ; Armstrong, 2008 ; Walker, 2010 ; Heutte et al., 2016 ). Although this requires further investigation, it seems that the quality of interpersonal relationships, supporting in particular basic psychological needs (autonomy, competence, and relatedness), will support a motivational climate favorable to the emergence of flow within a group.

The category Physiology and Flow included studies that used physiological and/or neuropsychological methods (e.g., ECG, EEG, EMG, fMRI, eye-tracking, saliva sampling, etc.) to measure the relationship of physiological parameters with flow. Expert ratings revealed that nine articles meet these inclusion criteria. Another twelve articles were included by the experts. The final list of articles integrated into this section is set out in Table 5 .

Table 5. Physiology.

Subtopics identified in the literature include flow’s relationship with (1) physiological arousal as represented by sympathetic (SA) and parasympathetic activation (PA), and cortisol, (2) facial muscle activation (FMA) and (3) neural activity.

Physiological Arousal

Flow was found to relate negatively to cardiac output and systolic blood pressure, and positively to diastolic blood pressure and heart rate ( de Manzano et al., 2010 ; Gaggioli et al., 2013 ; Harris et al., 2017 ). Furthermore, mixed associations of flow with SA were found, with some studies showing positive associations ( Nacke and Lindley, 2008 ; de Manzano et al., 2010 ; Gaggioli et al., 2013 ; Ulrich et al., 2016b ), other studies showing negative associations ( Harmat et al., 2015 ; Tozman et al., 2015 ; Harris et al., 2017 ) and—under stress—the relationship was found to be inverted u-shaped ( Peifer et al., 2014 ; Tozman et al., 2015 ). Two studies found no association between flow and SA ( Kivikangas, 2006 ; Hirao et al., 2012a ). Similarly, PA has been negatively associated with flow ( de Manzano et al., 2010 ; Keller et al., 2011a ), but under stress, studies identified a positive relationship ( Peifer et al., 2014 ) and an inverted u-shaped relationship ( Tozman et al., 2015 ). Respiratory depth, related to PA, increased during flow ( de Manzano et al., 2010 ). Regarding flow and cortisol, studies have found a positive association ( Keller et al., 2011a ), no association ( Brom et al., 2014 ), a negative effect of high cortisol on flow ( Peifer et al., 2015 ) and an inverted u-shaped relationship between cortisol and flow in stress-relevant conditions ( Peifer et al., 2014 ; Tozman et al., 2015 ).

Facial Muscle Activation

Studies examining FMA found associations with flow for the Zygomaticus Major ( de Manzano et al., 2010 ; Nacke et al., 2011 ), Orbicularis Oculi ( Nacke et al., 2011 ), and Corrugator Supercilii ( Kivikangas, 2006 ). In this sub-category, findings were also inconsistent.

Neural Activity

Neuroscientific research showed that flow was characterized by greater activation of the “multiple-demand system,” which is involved in task-relevant cognitive functions, and reduced activation of the default mode network ( via a relative increase in the dorsal raphe nucleus), which is linked to self-referential processing ( Ulrich et al., 2014 , 2016a , 2016b ). Computer gamers reporting flow showed increased activity in the neocerebellum, somatosensory cortex, and motor areas, possibly indicating a synchronization between reward-related brain structures and task-relevant cortical and cerebellar areas during flow ( Klasen et al., 2012 ). Larger stimulus-preceding negativities (SPNs) were found during flow, indicating increased motivation and anticipatory attention ( Meng et al., 2016 ). Experts experiencing more flow had greater right temporal cortical activity when imagining the activity, possibly reflecting the automaticity of a highly trained skill ( Wolf et al., 2015 ).

Of particular interest is frontal activity during flow, inspired by the Hypofrontality Hypothesis suggested by Dietrich (2004) . The Hypofrontality Hypothesis states that analytical and meta-conscious capacities are temporarily suppressed during flow, physiologically indicated by a downregulation of prefrontal activity. Respective findings support no association of flow with frontal activity ( Harmat et al., 2015 ), or a greater activation of the ventrolateral prefrontal cortex ( Yoshida et al., 2014 ). Findings regarding EEG activity were similarly mixed: Nacke et al. (2011) found no relationship, while Berta et al. (2013) found that alpha and lower- and mid-beta power predicted flow.

The category Emotion and Flow included studies that dealt with a wide range of concepts associated with different components of the emotional experience, which tends to be generally associated with a certain subjective degree of pleasure and displeasure, or positive and negative experiences, such as affect, mood, wellbeing, enjoyment, activation, or excitement. Although a unique and clear definition of emotion does not exist in these articles, the relation of emotion with flow experience seems to follow a clear understanding of the kind of emotional components that can be relevant when studying this relationship. Although the concept of emotion, in its broad sense, can integrate cognitive, affective, and behavioral or even physiological aspects, this section tried to avoid overlapping with others that are specifically devoted to one of these components in its relation with flow experience (e.g., cognition and flow). Expert ratings revealed that 40 articles have met these inclusion criteria. Four additional articles were included by our experts and five articles from the EFRN publication list. The final list of articles that were integrated into this section is depicted in Table 6 .

Table 6. Emotion.

The identified studies show four main subtopics, i.e., (1) affect, (2) wellbeing, (3) enjoyment, and (4) emotional contagion. Studies investigated relationships of the emotional concepts with several components of flow, in particular with challenge-skill balance ( Delespaul et al., 2004 ; Delle Fave and Massimini, 2005 ; Sugiyama and Inomata, 2005 ; Schweinle et al., 2008 ; Tramonte and Willms, 2010 ; Robinson et al., 2012 ; Panadero et al., 2014 ; Sartori and Delle Fave, 2014 ). In general, these studies showed that high challenge-skill balance is associated with higher positive emotional states (e.g., activation, excitement, positive affect).

Regarding the first subtopic, several studies suggest a positive relationship between flow and positive affect. Of relevance is the study by Baumann and Scheffer (2010) showing that achievement flow is supported by dynamic changes in positive affect, highlighting the role of reduced and restored positive affect. Some other findings show that flow predicts positive mood or positive affect ( Eisenberger et al., 2005 ; Schüler, 2007 ; Collins et al., 2009 ; Fullagar and Kelloway, 2009 ; Baumann and Scheffer, 2010 ; Tobert and Moneta, 2013 ; Inkinen et al., 2014 ; Bachen et al., 2016 ; Ozkara et al., 2016 ). The reverse relationship also exists, with studies demonstrating that both positive and negative affect are significant predictors of flow experience (e.g., Collins et al., 2009 ; Kopačević et al., 2011 ; Hirao and Kobayashi, 2013 ; Tobert and Moneta, 2013 ). Cseh et al. (2015) demonstrated that flow is purported to have positive consequences on affect and performance. Some other studies looked at the relationship between flow and affect in different groups of participants ( Rogatko, 2009 ; Fullagar et al., 2013 ; Bassi et al., 2014a ; Fink and Drake, 2016 ; Tyagi et al., 2016 ), different activities or domains ( Pinquart and Silbereisen, 2010 ; Engeser and Baumann, 2016 ; Silverman et al., 2016 ), or in relation to specific variables, for example, the quality of a relationship or experiential wisdom ( Karageorghis et al., 2000 ; Graham, 2008 ; Rathunde, 2010 ), and trait emotional intelligence ( Marin and Bhattacharya, 2013 ; see Personality and Flow ).

In studies considering wellbeing, flow experience tends to be positively associated with the concept of emotional wellbeing ( Wanner et al., 2006 ), and psychological wellbeing ( Bassi et al., 2014a , b ), with others showing that flow experience can predict psychological wellbeing ( Steele and Fullagar, 2009 ; Bassi et al., 2014b ), life satisfaction ( Collins et al., 2009 ; Chen et al., 2010 ; Bassi et al., 2014b ), happiness ( Csikszentmihalyi and Hunter, 2003 ), job satisfaction ( Maeran and Cangiano, 2013 ), course satisfaction ( Shin, 2006 ), and e-satisfaction and e-loyalty ( Hsu et al., 2013 ).

Regarding enjoyment, studies showed that it is positively associated with flow, with authors trying to understand which flow dimensions are related to the perception of enjoyment and under what circumstances ( Wright et al., 2007 ; Wissmath et al., 2009 ; Thin et al., 2011 ; Diaz and Silveira, 2013 ; Inkinen et al., 2014 ; Schmierbach et al., 2014 ). In a diary study which aimed at examining the relationship between flow experiences and energy both during work and non-work, results indicated that the flow-characteristics absorption and enjoyment were associated with energy only after work, accompanied by feeling more vigorous and less exhausted ( Demerouti et al., 2012 ).

Emotional Contagion

Two studies brought the topic of flow to collective and group contexts. It was shown that positive collective gatherings could stimulate shared flow experiences, promoting personal wellbeing and social cohesion ( Zumeta et al., 2016 ). In the group context of a classroom, it was shown that Students’ perceptions of their classmates’ flow as well as their teachers’ flow were related to their own reported flow experience ( Culbertson et al., 2015 ). Authors concluded that their finding can be explained by contagion effects of flow within the group, in line with emotional contagion theory ( Hatfield et al., 1994 ).

The category Cognition and Flow included studies that dealt with perception, attention, decision-making, and cognitive control. Also, brain studies referring to cognitive processes during flow experiences and effortless attention were reviewed in this section. Studies dealing with embodied cognition (e.g., body image, agency, intentions) and effects of flow experiences on cognitive processes (e.g., memory and reasoning) were reviewed. Expert ratings revealed that 26 articles met these inclusion criteria. Two additional articles were included by our experts and one article from the EFRN publication list. The final list of articles that were integrated into this section is presented in Table 7 .

Table 7. Cognition.

Cognition studies on flow can be divided into two main areas: (1) those that studied its relationships with cognitive processes, and (2) those that analyzed cognitive aspects of flow-related processes while considering flow in specific applied contexts.

First of all, flow itself can be considered a state of consciousness in which an individual is fully concentrated on, paying attention to and engaged in a certain activity ( Delle Fave and Massimini, 2005 ); at the same time, flow can be considered as a process or a dynamic mental activity characterized by clear goals, a match between capacity and challenge, absence of disturbances, experience of mastery, etc. ( Pearce et al., 2005 ; Kawabata and Mallett, 2011 ). There is not a discrepancy between state and process—rather they can be seen as related and interdependent; a flow state typically occurs when an individual engages in a process with the formerly mentioned characteristics.

Relationships With Cognitive Processes

Flow is related to attentional processes. For example, as demonstrated by Harris et al. (2017) , sustained attention toward the task is needed as a component of flow. Indeed, from a cognitive point of view, when attention is hindered by other processes or stimuli, flow experience is reduced or blocked. For instance, in the experiment by Guizzo and Cadinu (2016) , feeling objectified by men’s gaze draws women’s attention away from the rewarding activity and decreases flow. However, studies on flow proneness highlight no relation or very weak relation with intelligence in two large samples ( Ullén et al., 2012 ), showing that although flow is related to cognitive processes, it is only weakly associated with cognitive ability. In general, cognitive studies tend to confirm the skill-demands compatibility hypothesis in the generation of flow ( Payne et al., 2011 ; Schiefele and Raabe, 2011 ; Harris et al., 2017 ). Moreover, flow has been found to be positively related to an intuitive approach to decision making ( Kuhnle and Sinclair, 2011 ). Consistently, flow seems to be disassociated from sense of agency or the impression of being the author of one’s own actions ( Vuorre and Metcalfe, 2016 ). Indeed, sense of agency is partially influenced by metacognitive, complex judgments of authorship over the action ( Synofzik et al., 2008 ), which are more influenced by overall evaluation of one’s own control over the task, while flow appears to be associated with positive assessment and enjoyment of the overall experience. In other words, the reporting of having experienced an optimal experience is not related to feel more or less to be the author of one’s own actions. Neuropsychological data also showed that flow is associated with sense of control ( Ulrich et al., 2014 , see Physiology and Flow ). Further, it was found that cognitive flexibility ( Moore, 2013 ) and mindfulness predicted flow ( Kee and John Wang, 2008 ; Moore, 2013 ). Studies on flow involving creative activities highlighted that flow was not affected by cognitive load ( Cseh et al., 2016 ). Rather, flow experience could help banish or reduce unwanted cognitive processes (e.g., intrusive thoughts, rumination), for example in cancer patients ( Reynolds and Prior, 2006 ).

Cognitive Aspects of Flow-Related Processes in Specific Contexts

The most popular field of research with regards to flow and cognitive processes are studies related to learning. Ortner et al. (2014) analyzed the effects of computerized adaptive testing (CAT) vs. computerized fixed item testing (FIT) on Students’ motivation and flow using a matrices non-verbal computer-based test assessing reasoning on the basis of figural items. The CAT version adapts to the learner’s online performance selecting items on the basis of the learner’s previous response, while the FIT version features fixed items increasing in difficulty. Contrary to hypotheses, fixed item testing obtained superior ratings of motivation and no differences between the conditions were found for flow. In a study by Konradt and Sulz (2001) , most of the participants entered flow while using a hypermedia learning system, independently of task condition (scanning or browsing the contents); importantly, however, flow was not associated with improved learning. Diaz and Silveira (2013) analyzed flow experiences in high school music students attending a summer music camp; the highest ranked flow-inducing activities showed strong associations between attention and enjoyment. Another study ( Winberg and Hedman, 2008 ) compared guiding/open instructions during a learning task and considered their effects on flow components. Guiding instructions correlated with high levels of “challenge,” “enjoyment,” and “concentration” and low levels of “perception of control,” while the opposite happened for the other condition. However, Pearce et al. (2005) found that a “process” (rather than a state) model of flow more adequately explains students’ outcomes, in that skills may change over time during learning (e.g., growing). In this sense, flow should probably be measured more times than just once after or during the learning process. Schweinle et al. (2008) employed experience sampling methods to analyze flow following 12 class lessons. They found that individual affect was influenced by the interaction of challenge and skill while social affect and efficacy were more impacted by perceived skill than by challenge (see Emotion and Flow ). This is consistent with studies attempting to integrate flow with social-cognitive theory, namely, the idea of behavior resulting from cognitive processes and external/environmental influences ( Lee and LaRose, 2007 ; Rodríguez-Sánchez et al., 2011a ). These studies found that high self-efficacy, or the belief about one’s own abilities to perform a given action, may be a predictor of optimal experience (see Motivation and Flow ).

Another important field of flow research is sports. For example, Swann et al. (2017) employed interviews to explore the characteristics of clutch performances (i.e., performance under pressure) in professional athletes. They found that clutch performances are different from flow, in that they are characterized by heightened awareness, deliberate concentration and intense effort. Also, an “inductive” qualitative research study on golfers ( Swann et al., 2015a ), or in other words, a methodology that did not intend to confirm flow characteristics as described by traditional theory but instead intended to capture the experience of the participants as described by them, suggested that flow was self-aware, observable and characterized by altered cognitive and kinesthetic perceptions.

Finally, flow has been found to be positively related to transportation and spatial presence while watching movies ( Wissmath et al., 2009 ). Transportation has been defined as the “process where all mental systems and capacities become focused on events in the narrative” ( Green and Brock, 2000 , p. 701), with high involvement and absorption of the user in the movie he or she is watching, while sense of presence consists in the sensation of “being” inside a real or virtual environment, related to the impression of being able to enact one’s own intentions ( Triberti and Riva, 2015 ).

The category Behavior and Flow included studies that dealt with flow and different forms of behavior such as performance (e.g., in-role/extra-role performance, physical, athletic, creative, or cognitive performance), risk taking, consumption behavior, online behavior, and addiction, as well as variables that are closely related to performance and motivate high performance such as engagement, commitment, and persistence. Expert ratings revealed that 46 articles have met these inclusion criteria. Another six articles were included by our experts and one from the ERFN publication list, although they were not found in the literature search. The final list of articles that were integrated into this section is set out in Table 8 .

Table 8. Behavior.

Within this category, the following subtopics could be identified: (1) The relationship between flow and different kinds of performance in different contexts, (2) variables that are related to high performance such as engagement and commitment, and (3) other forms of behavior such as risk taking, consumption behavior, online behavior, and addiction.

Performance

Most studies dealing with flow and behavior address the topic of performance, and they show a positive relationship between flow and performance in most cases (e.g., Demerouti, 2006 ; Engeser and Rheinberg, 2008 ; Min et al., 2015 : productivity in design process). For work-related performance, it was found that flow at work is positively related with in-role ( Demerouti, 2006 ) and extra-role performance ( Eisenberger et al., 2005 ; Demerouti, 2006 ). Baumann and Scheffer (2011) additionally found that the flow achievement motive is positively associated with work efficiency according to multisource feedback. The positive effects of flow on performance could also be shown at the team-level ( Aubé et al., 2014 ). Likewise, Kuo and Ho (2010) found that flow has positive effects on employee-reliability and paying attention to customers’ needs.

Besides work-related performance, several other studies deal with the topic of flow and athletic and physical performance (e.g., Bailis, 2001 ; Jackson et al., 2001 ): Most studies find a positive relation between flow and physical performance ( Schüler and Brunner, 2009 ; Bakker et al., 2011 ), including performance under pressure ( Swann et al., 2017 ). Similarly, training and preparation appear to have a positive effect on flow and mediate effects on performance ( Schüler and Brunner, 2009 ; Swann et al., 2015b ). Swann et al. (2015a) also find that flow is related to changes in the behavior of golfers (such as playing faster, staying calm, and showing a confident body language).

In terms of performance at school and/or cognitive performance in general, flow was found to be positively related to exam performance ( Schüler, 2007 ), cognitive performance ( Engeser and Rheinberg, 2008 ; Harris et al., 2017 ) and goal progress ( Schüler et al., 2010 ). The achievement flow motive also predicts academic success ( Busch et al., 2013 ). Guizzo and Cadinu (2016) find that low levels of flow are associated with decreased cognitive performance in an attention to response task. Furthermore, studies suggest that practice and learning in general are positively related to flow experience ( Brinthaupt and Shin, 2001 ; Pearce et al., 2005 ; Marin and Bhattacharya, 2013 ; Valenzuela and Codina, 2014 ; Heller et al., 2015 ; Bressler and Bodzin, 2016 ) and that flow is positively associated with reengagement in a task ( Keller et al., 2011b ; Pratt et al., 2016 ). Another study found that flow and learning retention in gaming were also positively associated ( Hong et al., 2013 ). Flow also presented positive effects on performance in online games ( Thornton and Gilbert, 2011 ). Overall, there seems to be a positive relation between flow and enhanced performance (for an overview see Landhäußer and Keller, 2012 ). However, two studies did not find a positive association between flow and performance ( Konradt and Sulz, 2001 ; Culbertson et al., 2015 ). The former authors, however, suggest that the students in their investigation experienced flow and therefore felt self-confident and were not open to learn for a following quiz (for more explanations, see Culbertson et al., 2015 ). Several studies find a positive relationship between flow experiences and enhanced creativity or engagement in creative tasks ( Byrne et al., 2003 ; Griffiths, 2008 ; Cseh et al., 2015 ; Dawoud et al., 2015 ; Zubair and Kamal, 2015a , b ), especially in the field of music ( MacDonald et al., 2006 ; Wrigley and Emmerson, 2013 ).

Variables That Are Related to High Performance

With respect to variables that are related to high performance, flow seems to be positively related with student engagement in the classroom ( Shernoff et al., 2003 ; Mesurado et al., 2016 ) and with learning engagement ( Bassi et al., 2007 ). Furthermore, several studies have found a positive relation between the fact of “being active” and flow ( Bassi et al., 2012 : engagement in meaningful rehabilitation activities; Drengner et al., 2008 ; Graham, 2008 ; Dawoud et al., 2015 ). Another study by Seddon et al. (2008) finds while investigating a 6-year online collaboration (working together in an online setting) that flow and engagement in that collaboration were positively related.

Other Forms of Behavior

With respect to other forms of behavior, Schüler and Nakamura (2013) found that risk behavior and flow were positively associated but only for inexperienced climbers; the relationship is mediated by self-efficacy beliefs. In line with that, Delle Fave et al. (2003) found that the opportunity to experience flow motivates climbers to take part in a risky expedition. Urmston and Hewison (2014) also find a positive relationship between flow and risk taking in learning. A study by Szymanski and Henning (2007) found that flow was negatively related to women’s self-objectification behavior. Further studies on self-objectification behavior were not found. Furthermore, Niu and Chang (2014) found that flow is positively associated with unplanned buying and that it moderates the positive relationship between internet addiction and consumer behavior. Liu and Shiue (2014) found that flow fosters purchase intention in online games. Another study found that experiencing flow was positively related with engagement in a human-animal-interaction game ( Cheok et al., 2011 ). Hsu et al. (2013) find that flow and e-loyalty are positively related.

Context Factors

The category Context Factors and Flow included studies that investigated different contexts and activities in which flow occurs (e.g., different kinds of work, study, sports etc.), as well as contextual characteristics/external circumstances that foster or hinder flow (e.g., differences in environmental characteristics, external demands and resources). Expert ratings revealed that 84 articles met these inclusion criteria. Another three articles were included by our experts and seven from the ERFN publication list, although they were not found in the literature search. The final list of articles that were integrated into this section is shown in Table 9 .

Table 9. Context factors.

In this category, the following subtopics were identified: (1) Flow in different contexts and activities and how they affect flow, (2) contextual factors and their relationships with flow, and (3) the fit of contextual factors with characteristics of the individual.

Flow in Different Contexts and Activities

Flow is always investigated during a certain activity in a certain context, and their variety in the identified studies is large: (a) work- or study-related activities such as work, learning ( Peterson and Miller, 2004 ; Rathunde and Csikszentmihalyi, 2005 ; Wright et al., 2007 ; Ceja and Navarro, 2011 ; Stephanou, 2011 ; Demerouti et al., 2012 ; Ryu and Parsons, 2012 ; Debus et al., 2014 ; Escartin Solanelles et al., 2014 ; Hernandez et al., 2014 ), and teaching ( Coleman, 2014 ), (b) leisure ( Rodríguez-Sánchez et al., 2011b ), (c) professional dancing ( Hefferon and Ollis, 2006 ; Panebianco-Warrens, 2014 ), (d) music festivals ( Jonson et al., 2015 ), (e) creative activities such as designing clothes ( Min et al., 2015 ) and visiting arts courses or making art ( Reynolds and Prior, 2006 ; Bass, 2007 ; Jones, 2013 ; van der Hoorn, 2015 ), (f) gaming (e.g., Ivory and Magee, 2009 ; Thin et al., 2011 ; Bressler and Bodzin, 2013 , 2016 ) and several online activities (e.g., Guo and Poole, 2009 ; Faiola et al., 2013 ; Hsu et al., 2013 ; Meyer and Jones, 2013 ; Wang et al., 2015 ), (g) research activities ( Hudock, 2015 ; Zha et al., 2015 ) and information technology use ( Pilke, 2004 ), (h) sports (e.g., Koehn and Morris, 2014 ; Deol and Singh, 2016 ; training vs. competition; Swann et al., 2012 , 2015a ), (i) translation activities ( Mirlohi et al., 2011 ), (j) psychological rehabilitation activities (e.g., Bassi et al., 2012 ; Nissen-Lie et al., 2015 ), (k) extreme contexts such as rituals ( Lee, 2013 ) and extreme weather during climbing ( Bassi and Delle Fave, 2010 ) and even (l) first-aid activities, whereby professionals experienced more flow than volunteers ( Sartori and Delle Fave, 2014 ). This large list shows that flow can occur in a large variety of activities and contexts ( Diaz and Silveira, 2013 ).

Are there differences between activities in their likelihood to produce flow? In general, it was found that flow is higher during working-activities compared to (active and passive) leisure activities ( Engeser and Baumann, 2016 ). For example, Bassi and Delle Fave (2012a) found that school teachers experienced more flow during work than during free-time (see: paradox of work; Csikszentmihalyi and LeFevre, 1989 ). The paradox of work states that although work is commonly associated as an unpleasant activity, individuals experience more flow—a pleasant state—during work than during free-time ( Csikszentmihalyi and LeFevre, 1989 ). In contrast, MacNeill and Cavanagh (2013) found that school leaders experienced more flow in non-school contexts. Rodríguez-Sánchez et al. (2011b) found that the flow component enjoyment was higher during non-working activities whereas absorption was higher during working activities. Magyaródi and Oláh (2015) found that work, sports and creative activities were the most typical solitary activities and work and sports were the most typical social activities that foster flow. Of course, flow has also been investigated in social contexts (e.g., Ryu and Parsons, 2012 ). For a better overview, the authors of this scoping review decided to define “ interindividual factors ” as a separate category (see below). At work, planning, problem solving, and evaluative activities especially seem to foster flow ( Nielsen and Cleal, 2010 ).

Contextual Factors and Their Relationships With Flow

The research explored in this scoping review shows that there are many contextual factors that are associated with flow at work. Maybe that is why Ceja and Navarro (2012) found in their study that there are many abrupt changes in experiencing flow at work; While flow is a self-reinforcing inner state of consciousness, contextual factors are external circumstances which cannot fully be controlled by an individual. A change of contextual factors can thus interrupt flow—and the more contextual factors exist that affect flow, the more likely are such sudden changes in flow. It was found that the motivating job characteristics of Hackman et al. (1975) are context factors that are positively associated with flow in the workplace ( Demerouti, 2006 ; Maeran and Cangiano, 2013 ). In line with this, it was found that subjective relevance ( Shernoff et al., 2003 ; Dawoud et al., 2015 ), importance ( Rha et al., 2005 ; Engeser and Rheinberg, 2008 ), and meaningfulness ( Banfield and Burgess, 2013 ; Hsu et al., 2013 ; Jonson et al., 2015 ; Bonaiuto et al., 2016 ) are positively associated with flow. All of these are concepts at the interface between person and context; if a context (e.g., a certain task or environment) aligns with the needs, values or motives of a person, it will become subjectively relevant, important and meaningful. Moreover, feedback and support are relevant precursors of flow ( Bakker, 2005 ; Guo and Poole, 2009 ; Steele and Fullagar, 2009 ; Panadero et al., 2014 ; Swann et al., 2015a ). Creative tasks (e.g., sketching: Cseh et al., 2016 ) or having the opportunity for creativity ( Moneta, 2012 ) seems also to be positively associated with flow. Having a clear goal ( Shin, 2006 ; Guo and Poole, 2009 ; van Schaik et al., 2012 ) and a clear role ( Steele and Fullagar, 2009 ; Panadero et al., 2014 ) as well as having control ( Shernoff et al., 2003 ) or autonomy ( Bakker, 2005 ) are positively associated with flow. Furthermore, it was found that being prepared ( Swann et al., 2012 ) and being recovered in the morning is positively associated with flow at work during the day ( Debus et al., 2014 ). Smith et al. (2012) found that organizational safety climate is associated with flow. In general, having enough resources is positively associated with flow at work ( Mäkikangas et al., 2010 ); a study by Emanuel et al. (2016) found that job resources (e.g., support from supervisor and autonomy) are positively associated with the flow experience of journalists. In addition, an internal locus of control was found to be positively associated with freelance journalists’ flow experience.

There are several factors of a game’s design that seem to facilitate flow. In general, interactivity and playfulness are positively associated with flow ( Rha et al., 2005 ; Voiskounsky et al., 2005 ; Cheok et al., 2011 ; Hong et al., 2013 ; Khan and Pearce, 2015 ) in gaming and in the working or learning context ( Dawoud et al., 2015 ; Meyer et al., 2016 ), while one study found that the content is more important for flow than the interaction ( Marston, 2013 ). Sharitt (2010) additionally found that a balance of difficulty was an important criterion for flow-associated game design. Lastly, instruction type is also relevant for flow: Winberg and Hedman (2008) found in an experimental design that guided instructions foster the flow components of enjoyment and concentration whereas free guiding instructions facilitate the flow component of control.

Fit of Contextual Factors With Characteristics of the Individual

Besides general context factors, the fit of the context to the individual (see also Personality and Flow ) seems to particularly matter: Moneta (2012) found evidence that a person-environment-fit fosters flow. In this respect, the best investigated flow condition is the fit between challenges of the activity and skills of the person, i.e., the challenge skill balance ( Gnoth et al., 2000 ; Eisenberger et al., 2005 ; Engeser and Rheinberg, 2008 ; Freer, 2009 ; Bassi et al., 2012 ; Belchior et al., 2012 ; Hsu et al., 2013 ; Harris et al., 2017 ; ease of use; Voiskounsky and Smyslova, 2003 ; Keller and Bless, 2008 ; Katuk et al., 2013 ; Llorens et al., 2013 ; Wrigley and Emmerson, 2013 ; Koehn and Morris, 2014 ; Sartori and Delle Fave, 2014 ; Sartori et al., 2014 ; Wang and Hsu, 2014 ). In line with this, Schmierbach et al. (2012) found that the possibility to personalize a game facilitates flow. A study from Baumann et al. (2016) found that a dynamic (i.e., varying demands) and not a static challenge-skill balance is best for flow. Similar results were found by Ceja and Navarro (2009) who state that flow experiences follow a complex dynamic. In general, and in association with the challenge-skill balance, having enough resources ( Delle Fave and Bassi, 2009 ; Bakker et al., 2011 ) and risk or uncertainty ( Urmston and Hewison, 2014 ) are associated with flow. Another example for a flow-promoting fit between the context and the individual was shown by Vittersø et al. (2001) , who found that a fit between individual’s preferred recreational mode and the recreational activity (e.g., being active or passive) was positively associated with flow.

Interindividual Factors

The category Interindividual Factors and Flow included studies that dealt with flow in social contexts, measured at the individual or collective level and as a social phenomenon (e.g., team flow, group flow, social flow etc.). Studies which looked at the effects of flow on more than one individual (e.g., small groups, social settings, networks, and other collectives) were also included. Expert ratings revealed that twelve articles met these inclusion criteria. Another article was included by our experts, although they were not found in the literature search. The final list of articles that were integrated into this section is shown in Table 10 .

Table 10. Interindividual factors.

Even though many human activities are done in social settings, the research on collective flow has not been vast, but the number of contributions is recently growing. As subtopics, we differentiate the experience of flow at the individual level , while being part of a social context (cf. Walker, 2010 ), from the experience of flow at the collective level , as if the collective has an experience of flow (cf. Sawyer, 2003 ).

Interpersonal Flow Studies at the Individual Level

Walker (2010) differentiates solitary flow experiences from social flow experiences, the latter varying on the degree of interdependence (ranging from co-active to highly interdependent). He found that participants in highly interdependent (sport) teams reported more joy than individuals performing less interdependently. Ryu and Parsons (2012) investigated social flow in the context of collaborative mobile learning and found that experiencing social flow is positively associated with the mobile learning experience. In addition, Bakker et al. (2011) studied team member flow experience among young soccer players. In short, the results indicate that social support and performance feedback from the coach are important facilitators of flow.

Magyaródi and Oláh (2015) found that for interpersonal flow experiences in social settings the level of perceived challenges should be high, as well as the level of cooperation, the immediateness/clarity of feedback, and the perceived level of skills. van Schaik et al. (2012) studied flow within an immersive virtual environment for collaborative learning. They found that the flow enablers challenge-skill match, goal clarity and feedback mediated the relationship between task constraints and learning experience. In the context of a group music composition task, MacDonald et al. (2006) found that the “no fear of failure” condition contributed to better flow. Moreover, they found that higher levels of flow related to a higher quality level of the output. In music teaching, Bakker (2005) found a crossover of the teacher’s experience of flow to students through contagion. In addition, Keeler et al. (2015) found that group singing reduces stress and fosters social flow at the individual level.

In the context of work, Smith et al. (2012) found that flow moderates the effect of leadership styles on job satisfaction and organizational commitment and partially mediates the effect on safety climate. Gute et al. (2008) found through the analysis of existing interview reports from highly creative persons that parents who foster both integration (e.g., providing emotional support) and its opposite, differentiation, (e.g., stimulation to work on personal goals) cultivate environments for creativity and flow. Using Csikszentmihalyi’s flow theory, Boyns and Appelrouth (2011) investigated the suspension of activity in public isolation and found that for most participants, “non-doing” leads to counterparts of the flow characteristics (e.g., boredom and anxiety).

Interpersonal Flow Studies at the Collective Level

Pioneering research in this perspective is the work of Keith Sawyer who defined group flow as a collective state that occurs when a group is performing at the peak of its abilities ( Sawyer, 2003 , p. 167). In this line, Salanova et al. (2014) found that collective efficacy beliefs predict collective flow over time, and that the two constructs are reciprocally related. Also, Zumeta et al. (2016) investigated shared flow during positive collective tambours/drummer (Tamborrada) gatherings. They found that positive collective gatherings stimulate shared flow experiences and in turn promote personal wellbeing and social cohesion.

Cultural Factors

Culture can be seen both as an antecedent and as a consequence of flow experience. On the one hand, culture directs the individual toward actions, behaviors and activities that can more or less favor the experience of flow activities ( Delle Fave et al., 2011 ); on the other hand, flow affects the actions of individuals, their decision-making processes, their focus of attention and their focus of behavior on certain purposes, which cause elements of culture ( Inghilleri et al., 2014 ). Considering this premise in the category Cultural Factors and Flow , studies were included that did cross-cultural investigations or dealt with individualism or collectivism, culture and the construction of the self, social identity, or special artifacts (e.g., Manga). Additionally, studies that addressed specific countries were also included here. Expert ratings revealed that 13 articles met these inclusion criteria. Another three articles were included by our experts, although they were not found in the literature search. The final list of articles that were integrated into this section is depicted in Table 11 .

Table 11. Cultural factors.

To understand the interaction between flow and culture, there are two main frameworks of research: the cross-cultural perspective, focusing on a comparison of flow experience between different cultures, and the cultural perspective, focusing on the role of flow in the diffusion or the maintenance of specific relevant cultural phenomena.

Cross-Cultural Perspective

Even if flow has been recognized as a universally valued subjective state ( Asakawa, 2010 ; Delle Fave et al., 2011 ; Csikszentmihalyi and Wong, 2014 ), several studies collect data about cross-cultural differences in the flow experience (e.g., Garces-Bacsal, 2016 ). Results in this field seem not to be proposing a unique view about which kind of culture gives more opportunity to its members to experience flow. Despite studies finding higher frequency and intensity of flow in Western societies compared to non-Western ones ( Asakawa, 2010 ; Liu et al., 2015 ; Mesurado et al., 2016 ), Western individuals seem to have a lower propensity to experience flow in meaningful social activities, related to future goals and linked to personal growth ( Coatsworth et al., 2005 ; Asakawa and Csikszentmihalyi, 2010 ; Montijo and Mouton, 2016 ). Group activities involved with flow are associated with higher reports of social identification in collectivistic societies than in individualistic ones ( Mao et al., 2016 ). Data shows that flow experience is more intense within the members of cultures characterized by a good balance between the values of both autonomy and relatedness ( Busch et al., 2013 ).

Cultural Perspective

Flow seems to be involved in the spread and the maintenance over time of several specific cultural phenomena. Flow experience represents a useful concept to reach a deep knowledge of youth behavioral trends ( Niu and Chang, 2014 ) and it seems to be involved in several leisure activities that are characteristic of different cultural environments ( Jonson et al., 2015 ; Tanaka and Ishida, 2015 ). Furthermore, flow correlates with extrinsic and intrinsic religious orientations ( Brown and Westman, 2008 ). An Italian study ( Guizzo and Cadinu, 2016 ) demonstrated that flow disruption can depend on the degree to which people rely on society beauty ideals typically promoted by Western media. Further, flow can play a key role exerting influence on the quality of the migration experience ( Delle Fave and Bassi, 2009 ; Lee, 2013 ). Despite the implication that flow can foster positive cultural and societal phenomena ( Delle Fave and Bassi, 2009 ; Lee, 2013 ; Jonson et al., 2015 ), its amoral character can also lead to dysfunctional ones (i.e., Niu and Chang, 2014 ). Evidence in this area of interest are still scarce and further research is needed to clarify and validate results.

General Discussion

With this Scoping Review, we aimed to (1) present a framework to structure flow research and (2) provide a systematic overview on empirical flow research of the years 2000–2016. In this general discussion, we summarize the results of this review, outline central points of discussion and describe strengths and weaknesses identified in the literature. Following this, we address our final aim: (3) to discuss the implications of our review for future research.

Firstly, we provided a framework to structure flow research. Secondly, this was then used to collate and summarize the existing literature in the field. Thirdly, based on the first and second, we are able to discuss implications for future research.

The framework distinguishes between individual, interindividual, contextual and cultural levels. Most research has been done on the individual level, with Personality (40 studies; Table 3 ), Motivation (54 studies; Table 4 ), Emotion (49 studies, Table 6 ), Cognition (26 studies; Table 7 ), and Behavior (53 studies; Table 8 ) being the largest categories. On the individual level, the Physiology of flow (21 studies; Table 5 ) is the least studied category; however, in recent years there is a growing trend of research being conducted in this area. There are 94 context level studies ( Table 9 ). In comparison, research on flow at the interindividual (13 studies; Table 10 ) and cultural level is underrepresented (16 studies; Table 11 ).

In a Nutshell: Discussion of Findings Within the Categories

The personality studies on flow were divided into four categories: autotelic personality, dispositional proneness to experience flow, flow and motive-fitting situations and other motives and personality traits. Several dimensions seem to characterize the concept of autotelic personality which are related to flow. However, there is still no widely agreed upon definition of the autotelic personality. Studies on individual differences in flow experiences depend on both situational variables, e.g., the environmental opportunities to engage in flow promoting activities, and personality traits (i.e., openness to experience, extraversion, and conscientiousness). Situational factors seem to have a stronger influence on flow experiences ( Fullagar and Kelloway, 2009 ; Ullén et al., 2016 ). However, more research is needed to specify the relationship of dispositional and situational factors to predict flow experiences.

Achievement motives and other motives and personality traits, (i.e., optimism, autonomy, self-handicapping, self-control) also seem to be associated with flow experience. However, the variety and even inconsistency (e.g., shyness and mental toughness) of personality traits and motives associated with flow, make it difficult to draw overall conclusions. Relating personality traits and motives to fitting situations seems to be a more promising way to investigate the effects of personality traits and motives on flow in the future.

Flow experience is historically linked to motivation (see e.g., Heutte et al., 2021 ). In line with this, results of this category showed that many motivational indicators, such as volition, engagement, goal orientation, achievement motive, interest, and intrinsic motivation are positively related to flow. Flow was also investigated in the context of self-determination, with results showing associations of flow with autonomous and controlled motivation. Results thus indicate that flow can be considered one of the major volitional theories. This is also in line with results of a meta-analysis by Fong et al. (2015) , that highlights the links between flow antecedents (e.g., concentration, merging of action and awareness, and feedback) and sense of autonomy, one of the central components of self-determination. Finally, self-efficacy was an often investigated motivational concept, with results confirming a relationship between self-efficacy and flow. While first studies in this category were largely correlational, more recent studies have started to investigate models that integrate various motivational concepts (often from Bandura or Deci and Ryan’s theories) as predictors of flow using structural equation models.

A new and promising challenge in the category Motivation concerns modeling research studies that investigate both collective motivational conditions and social dimensions of flow (see Salanova et al., 2014 ; Heutte et al., 2016 ). However, in order to fulfill this aim, this work requires construction and validation of multidimensional and short, specific measurement instruments for flow, which also include collective motivational dimensions of flow.

Studies on the physiology of flow are yet in their infancy and results are scarce and inconsistent. While the first studies in this category were mostly correlational, more recent studies have started to investigate flow using experimental designs. Some studies regard flow as a predictor of certain physiological states. Others regard physiological states as predictors of flow. A clear physiological pattern of flow has not yet been identified, but this seems to be the next major task for research on the physiology of flow. Presumably, the physiological pattern during flow will not be represented by a single physiological indicator, but rather by a combination of several different physiological indicators. Current developments of machine learning may help to identify such a pattern. Once a physiological pattern of flow is identified, this will help flow research to find a deeper understanding of the flow concept. Flow can then be measured continuously during an activity, without the need to interrupt people. Accordingly, the dynamics of flow over time can be assessed, as well as the variations of flow intensity. Still, it is unlikely that there will be just the one flow-characteristic pattern; rather the physiology of flow depends on the particular activity that one is doing, with people in flow showing the optimal physiological activation to meet task demands (see Peifer, 2012 ). Building upon this, the second future research question is how context conditions, such as characteristics of the task (e.g., difficulty) or conditions at the interface between context and person, (e.g., task relevance) moderate the typical physiology of flow.

Studies under the topic of emotion and flow cover a wide range of concepts and variables related to affect, wellbeing, or specific feelings like enjoyment. In general, results show a clear association between flow and positive emotional states. There is clearly a predominant focus on the study of positive affect, with only few studies analyzing the relationship between negative affect and flow, so more research is needed here. The majority of the studies investigated the role of flow as a predictor of different emotional aspects, showing that the reversed relationship is less studied. Flow and related emotional aspects have been studied mainly from an individual or subjective perspective, with social components of flow and emotion becoming an emergent research issue. Studies under this topic shed light on the importance of understanding the emotional functioning of flow experience to improve its positive outcomes in individuals’ lives. Results of the various studies show a large spectrum of practical implications in different areas, such as sports, educational contexts, the video game industry, organizational areas, general health, or quality of life.

Cognition studies on flow are extremely broad and touch on very different topics. Most of these look at flow in specific fields and include some cognitive variables but without a main focus on them and also without deeper discussion of the cognitive aspect of flow. “Attention” appears in several “cognition and flow” studies, but how flow and attention exactly are linked is not sufficiently explained. For example, some studies point to attention skills as a necessary precondition for obtaining flow, whilst other studies find that sometimes, people with poor attention skills can still find flow in, for example, activities where they have high levels of interest and engagement. More research is needed to understand the relation of flow with cognitive processes. This research could also help both deepening and widening some of the research questions that have emerged from the reviewed studies, relating, for example, to the disassociation between sense of control and sense of agency in flow experiences, or the understanding of the exact role of awareness in optimal experience.

Overall, many effects of flow on behavioral outcomes were shown. Most studies in this category dealt with performance-related outcomes and found positive association between the two. However, one has to be careful when interpreting direction of the effects: Most studies in this category are correlational only and therefore it is not possible to deduce the direction of effects. Landhäußer and Keller (2012) argue that flow, on the one hand, has a direct positive effect on performance, because individuals in flow are highly concentrated. On the other hand, individuals have a higher motivation to re-engage in a task when flow was experienced resulting in higher performance through practice ( Landhäußer and Keller, 2012 ). Accordingly, there is a clear need for longitudinal studies and for identifying moderators and mediators in the relationship between flow and performance in order to specify the direction of effects. Other studies looking at behavioral outcomes such as customer-oriented behavior and (online) consumption-behavior hold interesting implications for organizations, advertisement and therapy, though again more longitudinal and experimental research should be conducted to reach more solid conclusions and to start designing useful interventions to increase performance and wellbeing.

Contextual Factors

In summary, flow occurs in many different contexts and activities, and there are many contextual factors that promote flow. A fit between contextual factors (e.g., demands) and individual characteristics (e.g., skills; see also section on personality and flow) seems to play a particularly important role in the emergence of flow. However, this category contains many articles, as it includes all environmental factors which may affect flow experience. It is presumably the broadest category within this review. While we have at least distinguished the social environment as a sub-category within the contextual level, future frameworks could further distinguish different environmental factors, such as factors on the task level, the social/organizational level (for work settings) and factors at the interface of the individual with the task and the organization. A framework which has recently tried to implement such a structure is the three spheres framework of flow antecedents ( Peifer and Wolters, 2021 ). In addition, it could be useful to differentiate direct interaction from more indirect social influence such as organizational climate.

Overall, studies in this category were yet quite scarce, but we could see a growing tendency to measure, conceptualize and investigate interindividual factors of flow. This is evidenced by a growing number of studies published in more recent years within the timeframe of our review. Furthermore, within the EFRN, we see a growing number of conference contributions and EFRN members starting to investigate flow in social contexts. We conclude that there is increasing awareness of interaction effects among people in relation to flow experiences. When reviewing the existing literature, we found that the research on interpersonal flow lacks a broad conceptualization and is instead limited to individual flow experiences while being part of a collective (e.g., dyad, group). A clear challenge of future flow research is to differentiate individual flow in social contexts from social flow as a social phenomenon with potentially different qualities than individual flow. A recent suggestion to differentiate flow and team flow was made by Peifer et al. (2021) , suggesting that flow and team flow share the central components of individual flow, while team flow-specific components are added. In their studies, van den Hout et al. (2018) bridge individual experiences of flow with collective experiences of flow. In their conceptualization of team flow, they differentiate individual experiences of flow while being part of a team dynamic, with experiences of flow at the team level, where the team dynamic (or team process) itself, as a coherent unit, is flowing . When all members that are part of the team dynamic are experiencing flow while executing their personal tasks/roles for the team, and the collective itself is flowing a unique experience emerges, which they refer to as full team flow , that is originated by seven prerequisites and four experiential characteristics ( van den Hout et al., 2019 ; van den Hout and Davis, 2021 ).

Future directions include studying interindividual flow through the grounded theory approach (see Csikszentmihalyi, 1975 ), conceptual cross-fertilization with social and organizational psychology, and developing reliable self-reported and behavioral measures of the phenomenon, experimentation and longitudinal studies. Social flow and its emotional features appear as an emergent issue in flow studies. However, finding a measure for assessing interindividual flow as a group phenomenon without passing through aggregation of self-reported individual data is a major methodological challenge for future research of this topic.

Culture and Flow represents an important theoretical perspective and several theoretical and empirical contributions in this field have been collected recently in specific scientific books (i.e., Delle Fave et al., 2011 ; Csikszentmihalyi and Wong, 2014 ; Inghilleri et al., 2014 ). Despite this, we notice a general lack of published empirical articles dealing with flow in the cultural context, even if existing research shows its underlying relevance for investigating flow-fostering activities. Furthermore, flow has the potential to interact significantly with cultural phenomena of different nature, both positive and negative for human beings. Thus, we suggest that future research should put additional emphasis on the effects of culture on flow and vice versa.

Overarching Aspects for Future Research and Limitations of This Review

After having discussed the specific open research questions for each category, we would now like to outline general aspects for future research, which we could identify as overarching topics and as limitations of this review. In particular, these concern (1) definitional and operational issues, (2) methodological issues and the resulting problems of causal conclusions regarding antecedents and consequences of flow, as well as (3) the time frame of this scoping review.

Definitional and Operational Issues

Many studies worked with different definitions and operationalization of flow experience so one must be careful when comparing results. For example, some studies (e.g., Baumann and Scheffer, 2011 ; Oertig et al., 2014 ) used the Flow Short Scale ( Rheinberg et al., 2003 ). Others used the Practice Flow Inventory ( Heller et al., 2015 ), Jacksons’ and Eklunds’ (2002) Dispositional Flow Scale-2 ( Sinnamon et al., 2012 ) the Flow State Scale-2 ( Wrigley and Emmerson, 2013 ) or the EduFlow model ( Heutte et al., 2016 ). While beyond the scope of this review, for future research, there is a need to find a common definition and operationalization of the flow concept, including a common measure of flow which is used in future research to enhance the comparability of results. The EFRN has started to fulfill this aim by agreeing on a definition of flow (see section “Introduction”), and members of the EFRN have suggested models to aggregate components of flow and team flow (e.g., van den Hout et al., 2018 ; Heutte et al., 2021 ; Peifer and Engeser, 2021 ; Peifer et al., 2021 ). The next steps will be to discuss and agree on models and respective measurements.

Methodological Issues

In general, while conducting the review, the authors found many correlative studies, and causal interpretation of such data is not possible. Many of the reported studies suggest a causal interpretation of their results based on theoretical assumptions. However, this is problematic, as different theoretical assumptions also seem possible. In conclusion, antecedents and consequences of flow are not yet as clear as they should be, considering the immense amount of studies which have been conducted. While this is beyond the scope of this review, future reviews should focus on a systematic look at the methods behind the studies. Here, we want to emphasize that what is needed in the future is mainly longitudinal and experimental studies.

Another methodological aspect which we found as an overall topic is that most of the research was conducted with (young) adults; there is a lack of flow research on children as well as adolescent and elderly populations. In general, there is a need for studies testing more complex models to understand multiple relations between variables.

Time Frame and Inclusion Criteria of This Scoping Review

Our Scoping Review provides a systematic overview on flow research between the years 2000 and 2016. A task force of flow research from the EFRN united their expertise in order to provide a sound scientific summary and discussion of flow research in these years and implications for future research. The work on this scoping research started in November 2015, during the EFRN meeting in Braga, Portugal. The literature search was conducted in 2016 and updated in 2017 in order to cover all articles until the end of the year 2016. The process of writing and revising the article took a long time and another update of the literature search would have exceeded the word limit of a journal article, particularly as flow research has been further increasing in more recent years.

Furthermore, we set strong exclusion criteria by only allowing studies that mentioned “ Csikszentmihalyi” and that were listed in specific search platforms. We selected the most relevant platforms for our literature search, thereby excluding other platforms (e.g., CINAHL, ProQuest, SocIndex, and SocAbs). Therefore, it is entirely possible that not all relevant flow studies are included in our review. As experts were allowed to add additional studies they considered relevant, we hope that in the final analysis we have identified the majority of relevant studies. Furthermore, we only included studies that were published in the English language, and there are certainly interesting results published in other languages that are not covered here.

While the time frame as well as the strong exclusion criteria are clear limitations of this review, we still believe that the provided overview will help to stimulate and direct future flow research.

Flow research between 2000 and 2016 has made huge progress in understanding flow. Our review provides a framework to cluster flow research and gives a systematic overview about existing studies and their findings in the field. While much research has been done in the past, our review derives future lines of research to foster scientific progress in flow research.

Author Contributions

CP: project coordinator, introduction and discussion. GW: project coordinator, literature research, discussion, behavior, and context factors. ST: professional advice during the process. GW and LH: personality. JHe and GW: motivation. CP and JT: physiology. TF, DT, and CF: emotion. ST and FA: cognition. JHo and MŠ: interindividual factors. LP: cultural factors. LC: review of parts of the manuscript. All authors: categorization and selection of abstracts.

TF was funded by Psychology Research Centre (PSI/01662), School of Psychology, University of Minho, supported by the Foundation for Science and Technology (FCT) through the Portuguese State Budget (UIDB/PSI/01662/2020). JH was funded by I-SITE Université Lille Nord-Europe (ULNE), supported by the French state through the General Secretariat for Investment (SGPI) and the National Research Agency (I-SITE ULNE / ANR-16-IDEX-0004 ULNE).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

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

Acknowledgments

We would like to thank Ruth T. Naylor for proofreading an early version of this manuscript.

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Keywords : flow, scoping review, individual level, contextual level, cultural level

Citation: Peifer C, Wolters G, Harmat L, Heutte J, Tan J, Freire T, Tavares D, Fonte C, Andersen FO, van den Hout J, Šimleša M, Pola L, Ceja L and Triberti S (2022) A Scoping Review of Flow Research. Front. Psychol. 13:815665. doi: 10.3389/fpsyg.2022.815665

Received: 15 November 2021; Accepted: 17 January 2022; Published: 07 April 2022.

Reviewed by:

Copyright © 2022 Peifer, Wolters, Harmat, Heutte, Tan, Freire, Tavares, Fonte, Andersen, van den Hout, Šimleša, Pola, Ceja and Triberti. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Corinna Peifer, [email protected]

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

Open access
Published: 26 June 2024

WHO, WHEN, HOW: a scoping review on flexible at-home respite for informal caregivers of older adults

Maude Viens 1 , 2 ,
Alexandra Éthier 1 , 2 ,
Véronique Provencher 1 , 2 &
Annie Carrier 1 , 2

BMC Health Services Research volume 24 , Article number: 767 ( 2024 ) Cite this article

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As the world population is aging, considerable efforts need to be put towards developing and maintaining evidenced-based care for older adults. Respite services are part of the selection of homecare offered to informal caregivers. Although current best practices around respite are rooted in person centeredness, there is no integrated synthesis of its flexible components. Such a synthesis could offer a better understanding of key characteristics of flexible respite and, as such, support its implementation and use.

To map the literature around the characteristics of flexible at-home respite for informal caregivers of older adults, a scoping study was conducted. Qualitative data from the review was analyzed using content analysis. The characterization of flexible at-home respite was built on three dimensions: WHO , WHEN and HOW . To triangulate the scoping results, an online questionnaire was distributed to homecare providers and informal caregivers of older adults.

A total of 42 documents were included in the review. The questionnaire was completed by 105 participants. The results summarize the characteristics of flexible at-home respite found in the literature. Flexibility in respite can be understood through three dimensions: (1) WHO is tendering it, (2) WHEN it is tendered and (3) HOW it is tendered. Firstly, human resources ( WHO ) must be compatible with the homecare sector as well as being trained and qualified to offer respite to informal caregivers of older adults. Secondly, flexible respite includes considerations of time, duration, frequency, and predictability ( WHEN ). Lastly, flexible at-home respite exhibits approachability, appropriateness, affordability, availability, and acceptability ( HOW ). Overall, flexible at-home respite adjusts to the needs of the informal caregiver and care recipient in terms of WHO , WHEN , and HOW .

This review is a step towards a more precise definition of flexible at-home respite. Flexibility of homecare, in particular respite, must be considered when designing, implementing and evaluating services.

Peer Review reports

It is an undeniable fact that the world population is aging [ 1 ]. The World Health Organization [ 1 ] estimates that from 2015 to 2050, the percentage of people over 60 years of age will nearly double (from 12 to 22%). Governments must therefore put in place policies, laws and funding infrastructures to provide evidence-based social services and healthcare that are in line with best practices to allow people to age in place [ 2 ]. Aging in place refers to “the ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level” [ 3 ]. Relevant literature indicates that people do not want to age or end their lives in institutionalized care; most wish to receive care in their home and remain in their community with their informal caregivers [ 4 ].

There is then a need to adequately support informal caregivers (caregiver) in the crucial role that they have in allowing older adults to age in their own home. A caregiver is “a person who provides some type of unpaid, ongoing assistance with activities of daily living or instrumental activities of daily living” [ 5 ]. In their duties, caregivers of older adults are responsible for a considerable amount of homecare [ 6 ]: Transportation, management of appointments and bills, domestic chores, etc. Private and public organizations offer a plethora of services to support caregivers of older adults (e.g., support groups, housekeeping, etc.), including respite. Respite is a service for caregivers consisting in “the temporary provision of care for a person, at home or in an institution, by people other than the primary caregiver” [ 7 ]. Maayan and collaborators [ 7 ] characterize all respite services according to three dimensions: (1) WHERE : The place; in a private home, a daycare centre or a residential setting, (2) WHEN : The duration and planning; ranging from a couple of hours to a number of weeks, planned or unplanned, and finally, (3) WHO : The person providing the service; this may be trained or untrained individuals, paid staff or volunteers. Respite is widely recognized as necessary to support caregivers of older adults [ 8 , 9 ]. Indeed, a large number of studies identify the need and use for respite [ 9 , 10 , 11 , 12 ]. For example, Dal Santo and colleagues (2007) found that caregivers of older adults ( n = 1643) used respite to manage stressful caregiving situations, but also to have a “time away”, without having to worry about their caregiving role [ 13 ]. At-home respite seems to be favoured over other forms of respite, even with the perceived drawbacks, such as the privacy breach of having a care worker in one’s home [ 14 , 15 ].

Studies suggest that caregivers of older adults seek flexibility as a main component of respite [ 16 , 17 , 18 ]. Flexibility, in line with person-centered care, allows respite that addresses their needs, rather than being services that are prescribed according to other criteria [ 16 , 17 ]. Thus, flexibility, both in accessing and in the respite itself, is essential [ 19 , 20 , 21 , 22 , 23 ]. Although there seems to be a consensus around the broader definition of respite, there is no literature reviewing the characteristics of flexible at-home respite. Some studies and reports from organizations and governments document the flexible characteristics of their models, but there are few literature reviews that address them, specifically [ 18 , 22 , 24 ]. Both reviews by Shaw et al. [ 18 ] and Neville et al. [ 19 ] concede that an operational definition of respite ( WHEN , WHERE , WHO ) is not clear. Neville et al. [ 19 ] conclude that “respite has the potential to be delivered in flexible and positive ways”, without addressing these ways. The absence of a unified definition for flexible at-home respite contributes to the challenges of implementing and evaluating services, as well as measuring their effect. Although respite services are deemed necessary, they are seldom used [ 19 , 25 , 26 , 27 ]; as little as 6% of all caregivers receiving any kind support services in Canada actually use them. In scientific literature, the under-usage of respite services is a shared reality around the world [ 28 ]. One of the main reasons for this under-usage is the overall lack of flexibility in both obtaining and using respite [ 29 , 30 ]. Synthesizing the characteristics of flexible at-home respite services is the first steppingstone to a common operational definition. This could contribute to increasing respite use through the implementation or enrichment of programs in ways that answer the dyad’s (caregiver and older adult) needs.

Consequently, to support the implementation and evaluation of homecare programs, the objective of this study was to synthesize the knowledge on the characteristics of flexible at-home respite services offered to caregivers of older adults.

A scoping review [ 32 , 33 , 34 ] was conducted, as part of a larger multi-method participatory research known as the AMORA project [ 31 ] to characterize flexible at-home respite. Scoping reviews allow to map the extent of literature on a specific topic [ 32 , 34 ]. The six steps proposed by Levac et al. [ 32 ] were followed: [ 1 ] Identifying the research question; [ 2 ] searching and [ 3 ] selecting pertinent documents; [ 4 ] extracting ( or charting ) relevant data; [ 5 ] collating, summarizing and reporting findings; [ 6 ] consultation with stakeholders. The sixth step is optional.

Identifying the research question

The research question was: “What are the characteristics of flexible at-home respite services offered to caregivers of older adults?” As the research was conducted, this question was divided into three sub-questions:

WHO is tendering flexible respite?

WHEN is flexible respite tendered?

HOW is flexible respite tendered?

Identifying relevant documents

The search strategy consisted of two methods. First, the key words (1) respite (2) informal caregivers (3) older adults in the title or abstract allowed to identify relevant documents (Table 1 ). Initially included, the term “ flexib *” was removed from the search, given the low number generated (60 versus 1,179 documents without). The first author and a librarian specialized in health sciences research documentation conducted the literature research in July of 2021 and updated it in December of 2022 in 6 databases ( Ageline , Cochrane , CINAHL , Medline , PsychInfo , and Abstracts in Social Gerontology ). The expanded research strategy then consisted of the identification of relevant documents from the selected bibliography and one article that was found by searching for unavailable references (alternative article).

Study selection

To review the most recent literature on flexible at-home respite service characteristics, the research team focused on writings within a 20-year span, as have other reviews (e.g., [ 35 , 36 ]); documents thus had to be published between 2001 and 2022. The research team selected documents written in French or English, only. Included documents had to come from either (1) scientific literature (i.e., articles in an academic journal presenting an empirical study or reviews) or (2) reports and briefs from government, homecare organizations or research centres. All study designs were included. The research team convened that at-home respite is an (1) individual (i.e., not in a group) service (although, theoretically, two persons living in the same household could receive it) from (2) a professional or a volunteer that occurs (3) in the home and that (4) it requires no transport for the dyad. To select documents related to flexible at-home respite, the research team identified those in which the respite displayed an ability to adapt to the dyad’s needs on at least one characteristic of the service, as presented by Maayan and collaborators ( WHERE [Not relevant to this review, as it focuses on at-home respite] , WHO , WHEN ). The team concluded that these three dimensions lacked the precision to globally characterize the service. Indeed, they did not describe access to or activities occurring during respite, or, as the team called it, the HOW (Fig. 1 ). Excluded documents were those covering several services at once, preventing the differentiation of elements that were specific to at-home respite services. As this is a scoping review, the research team did not include a critical appraisal of individual sources of evidence [ 32 , 34 ].

Following the step-by-step Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMAScR) guidelines [ 37 ], the research team met to define the selection strategy. First, they screened the documents by their titles and abstracts, before determining their eligibility, based on their full text. Considering the limited human and financial resources, at each step of the PRISMAScR, a second team member assessed 10% of the documents independently to co-validate the selection; the goal was to reach 80% of agreement between both team members regarding document inclusion or exclusion. If an agreement was not reached, they would meet to obtain a consensus. The research team used Zotero reference management software to store documents as well as a cloud-based website to collaborate on the selection.

Conceptual mapping of results: HOW , WHEN , WHO

Charting the data

The first author charted (or extracted) both quantitative and qualitative data. To quantitatively characterize documents, contextual data (country of origin, year of publication, type of documents, etc.) was extracted in a Microsoft Excel table. For the qualitative data, the research team created an extraction table in Microsoft Word that included the three dimensions of respite ( WHO , WHEN and HOW) and one “ other ” dimension, as to not force any excerpts under the three dimensions. To co-validate the data charting, the second and third authors replicated 10% of the process. Expressly, the first author extracted elements related to a flexible characteristic of the at-home respite ( WHO , WHEN , HOW or other ). Considering limited resources, the third and second authors both co-validated the extraction of 10% of the documents. Authors met to reach a consensus where a disagreement arose.

Collating, summarizing, and reporting the results

The research team used content analysis to “attain a condensed and broad description of the phenomenon” [ 38 ]. To do so, data was prepared (familiarization with the data and extraction of pertinent excerpts) and organized (classification of excerpts) to build a characterization of flexible at-home respite. In this scoping review, a deductive content analysis began with three main categories ( WHO , WHEN , HOW ), with the addition of the temporary “ other ” category. Content analysis aimed to divide these categories into several generic categories, which subdivided into sub-categories (Fig. 2 ), inductively. This allowed to define the three main categories. While the WHO and the WHEN categories describe the service itself (time, duration, qualified staff, etc.), the HOW category is specific to the interface between the organization offering respite and the dyad (assessing the needs of the dyad, coordinating care, etc.). An interface is a situation where two “subjects” interact and affect each other [ 39 ]. In the context of homecare services, Levesque, Harris and Russell (2013) have defined that interface as access [ 40 ]. Therefore, to define the generic categories of the HOW , the team used the five dimensions of their access to care framework: Approachability, appropriateness, affordability, availability and acceptability [ 40 ]. Approachability relates to users recognizing the existence and accessibility of a service [ 40 ]. Appropriateness encompasses the alignment between services and users’ needs, considering timeliness and assessment of needs [ 40 ]. Affordability pertains to users’ economic capacity to allocate resources for accessing suitable services [ 40 ]. Availability signifies that services can be reached, both physically and in a timely manner [ 40 ]. Acceptability involves cultural and social factors influencing users’ willingness to accept services [ 40 ]. In other words, the HOW category focuses on the organizational or professional aspects of the service and how they can be adapted to the dyad.

To co-validate the classification, the research team met until they were all satisfied with the categorization. The first author then completed the classification. After classifying 20% of the documents, the second author would comment the classification. When the authors reached an agreement, the first author would move on to the classification of another 20%. First and second authors would meet when disagreements about classification and categories arose, to confer and adjust. Finally, all categories were discussed with the third author, until a consensus was reached. Once categorization was achieved, the team prepared a synthesis report. In this report, the team defined the main categories ( WHO , WHEN, HOW , other ) and their generic and sub-categories (Fig. 2 ) with pertinent excerpts from the reviewed literature. In summary, the results of the scoping review characterize flexible at-home respite under three attributes: WHO , WHEN and HOW .

Content analysis: Types of categories according to Elo and Kyngäs (2007) ( with examples from results )

Consultation

Rather than conducting a focus group as suggested by Levac and collaborators [ 32 ], the team chose to triangulate the results with those from a survey as a consultation strategy. Specifically, the research team took advantage of a survey being conducted with relevant stakeholders in the larger study (AMORA project), as it allowed to respect the scoping review’s allocated resources. The survey aimed to define flexible at-home respite and the factors affecting its implementation and delivery. A committee including a researcher, a doctoral student and a representative of an organization funding homecare services in Québec (Canada), developed the survey following the three stages proposed by Corbière and Fraccaroli [ 41 ]. It originally included a total of 21 items: Thirteen [ 13 ] close-ended and 8 open-ended questions. Of these 8, 2 addressed the characteristics of an ideal at-home service and suggestions regarding respite and were used here for triangulation purposes. The questionnaire was published online, in French, on the Microsoft Forms ® platform in the summer of 2020. Recruitment of participants (caregivers and people from the homecare sector) was done via email, by contacting regional organizations (Eastern Townships, Québec, Canada). In addition, the 18 senior consultation tables spread throughout the territory of the province of Québec were solicited; working in collaboration with governmental instances in charge of services to older adults and caregivers, these tables bring together representatives for associations, groups or organizations concerned with their living conditions.

The goal was to triangulate the scoping review’s results, i.e., to identify what was common between the literature and real-world experiences, and, as such, to bring contextual value to the results. Accordingly, the team analyzed data using mixed categorization [ 42 ]. The categories from the scoping review served as a starting point (closed categorization), leaving room to create new categories, as the analysis progressed (open categorization). Once all the data (scoping and survey) was categorized, the team identified the characteristics according to sources. To do so, the team tabulated the reoccurrence of each category in the survey, in the scoping review, or in both. They then integrated the results to provide one unified categorization of flexible at-home respite. The AMORA project was approved by the research ethics committee of the Integrated University Health and Social Services Centre (CIUSSS) of the Eastern Townships (project number: 2021–3703).

Of the 1,301 papers retrieved through the database searches, 1,146 were not eligible based on title and abstract, while 116 were excluded after reading their full texts, resulting in 39 included documents (Fig. 3 ). Documents were mainly excluded because they did not provide details about the respite service and its flexibility. The expanded search yielded three additional documents, resulting in a total of 42 documents, included in this scoping review. This section details (1) the characteristics of the selected documents and (2) the characterization of flexible at-home respite.

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMAScR) flow chart of the scoping review process [ 37 ]

Characteristics of selected documents

The majority (86%) of the documents in the review (Table 2 ) are from after 2005, with only 14% of the documents published before 2005, and are from 9 countries; United States ( n = 18; 42%), United Kingdom ( n = 11; 26%), Australia ( n = 4; 10%), Canada ( n = 2; 5%), Ireland ( n = 2; 5%), France ( n = 2; 5%), Belgium ( n = 2; 5%), Germany ( n = 1; 2%), New Zealand ( n = 1). The types of documents were diverse: 68% ( n = 28) were empirical studies, 31% ( n = 13) theoretical papers and 1% ( n = 2) government briefs. Most ( n = 23; 56%) of the documents did not specify their research approach, while 10 and 9 took, respectively, a qualitative (23%) or quantitative approach (21%). Most documents address respite in the context of caregiving for someone living with Alzheimer’s disease or other neurocognitive disorders ( n = 25; 60%), while some targeted older adults in general ( n = 14; 34%), people in palliative care ( n = 4; 9%) or other older adult populations (for example, veterans) ( n = 3; 1%). Respite was usually tendered by community organizations specialized in homecare ( n = 32; 78%). Although the majority of the documents ( n = 31; 75%) did not address the type of region (rural, urban, or mixed) surrounding the caregivers, those who did ( n = 11; 26%) mainly reported being in a mixed environment ( n = 9; 21%).

Characteristics of survey participants

Although all 100 participants completed the questionnaire, 71 participants answered at least 1 of the 2 open-ended questions: Each question had 66 and 41 answers. Of those 71 participants, most of them were women ( n = 60; 85%). All participants were aged on average 55 years old (SD = 15). They were mostly from the Eastern Townships area ( n = 56; 79%). Most participants were either caregivers ( n = 24; 34%) or homecare workers ( n = 28; 39%), while some were service administrators ( n = 11; 15%), and some reported being both caregivers as well as working in the formal caregiving sector ( n = 7; 10%). Only one person reported themselves as an older adult having a caregiver.

Characterization of flexible at-home respite

The characterization of flexible at-home respite will be presented below in three main categories which are WHO , WHEN , and HOW . Of note, 10 (24%) of the included documents had three categories of flexible components, 16 (38%) had 2 categories and 1 category. Almost all documents discussed the HOW of flexible at-home respite ( n = 40, 95%). Out of the 33 categories constructed with the scoping review, only 6 (18%) were not reported in the questionnaire: (1) planned respite ( WHEN ), (2) screening of dyads ( HOW ), (3) determining frequency of respite ( HOW ), (4) coordination of care ( HOW ), (5) voucher approach ( HOW ) and (6) acceptability to low-income households ( HOW ). Moreover, the questionnaire added three characteristics that were not present in the scoping review: (1) respite needs to be approachable, (2) the organization must be prompt** and adhocratic** and (3) able to deliver respite regardless of the season** (availability). Generic or sub-categories present only in the scoping review are identified with 1 asterisk (*), while those present only in the questionnaire have 2 (**).

In the selected documents, the WHO dimension of flexible at-home respite services can be broken down into three qualifiers: (1) Compatible , (2) qualified and (3) trained (Table 3 ). This dimension includes all human resources contributing to homecare (administrative staff, governing bodies, paid and volunteer care workers). First, the workforce behind flexible respite is compatible , meaning it has personal characteristics and profiles relevant to homecare for caregivers of older adults [ 17 , 53 , 62 , 63 , 68 ]. Gendron and Adam explain this by describing how the role of the care worker in Baluchon Alzheimer™ goes beyond training: “The nature of their work with [Baluchon Alzheimer™] requires particular human and professional qualities that are quite as important as academic credentials” [ 53 ]. Personal characteristics such as flexibility [ 53 , 62 , 63 , 68 ], empathy and patience [ 17 , 53 , 62 ] are deemed essential attributes. Secondly, the workforce is qualified : It has the necessary skills, abilities and knowledge from past professional [ 14 , 45 , 62 , 70 ] and personal experience [ 62 ] to work, or volunteer, with caregivers of older adults. For a program like Baluchon Alzheimer™, “the backgrounds of the baluchonneuses vary […]; all have experience in gerontology” [ 53 ]. Other areas of qualification in the included documents are a nursing background [ 18 , 45 ] or knowledge related to dementia [ 69 ]. Finally, flexible at-home respite requires a trained workforce engaged in the process of acquiring knowledge and learning the skills to provide respite services to caregivers of older adults. For example, homecare organizations can offer specific training on various topics, depending on their target clientele: Dementia [ 44 ], palliative care [ 59 ], or homecare in general [ 44 ].

The WHEN dimension of flexible at-home respite contains 4 temporal features: (1) Time , (2) duration , (3) frequency and (4) predictability (Table 4 ). First, flexible respite is available on a wide range of possible time slots. For example, the service is “available 24 hours, but typically from 9 am to 10 pm” [ 64 ]. Secondly, flexible respite is accessible on a wide range of possible durations . The Community Dementia Support Service (CDSS) is an example of flexibility in duration by “[being] totally flexible, being available from 2 to 15 hours per week” [ 69 ]. Thirdly, the service is offered in different frequencies : It can be either recurrent or occasional, or a combination of both [ 18 , 64 , 66 ]. The last feature of the WHEN dimension is flexibility in predictability ; the respite service can be planned* or not. A study on respite services in South Australia found that most providers (93%) planned the respite care with the dyad, but that emergency or crisis services were still offered by 35% of them [ 50 ].

At-home respite is flexible when it demonstrates approachability : Caregivers can identify that some form of respite exists and can be reached (Table 5 ). For the respite service to be approachable, the organization needs to be reaching out to dyads; it proactively makes sure that caregivers of older adults have information on services, know of their existence and that they can be used. For example, the El Portal program put in place “advisory groups that included the local clergy, representatives from businesses, caregivers, and service providers who were used for outreach work” [ 66 ]. The organization also screens* dyads to assess their eligibility for respite, as well as for other services from the same program or organization. For example, the North Carolina (U.S.A.) Project C.A.R.E. has an initial assessment that considers the range of homecare services available, rather than just assessing for eligibility for a program [ 57 ]. In addition, flexible respite requires the organization to set attainable and inclusive requirements for eligibility, as to not discourage use [ 24 , 57 , 61 , 66 ]. Finally, the organization communicates consistently with the dyad. As Shanley explains in their literature review, “there are clear and open ways for carers to express concerns about the service, and an open mechanism is available for dealing with these concerns constructively” [ 17 ]. In addition, the survey participants discussed two other characteristics. First, for respite to be approachable, the organization is prompt**, respecting a reasonable delay between the request and the beginning of the service (wait list). Second, it is adhocratic**, meaning the organization does not depend on complex systems of rules and procedures to operate i.e., bureaucracy.

The second access dimension of flexible at-home respite is appropriateness (Table 6 ): The fit between respite services and the dyad’s needs, its timeliness, the amount of care spent in assessing their needs and determining the correct respite service. For the respite service to be appropriate, the organization assesses needs by collecting details about the dyad’s needs; this can include, but is not limited to, clinical, psychological, or social evaluation. The organization then proposes respite services from a wide range of options or packages: A multi-respite package, as presented by Arksey et al., can simply be the combination of at least two different respite services [ 44 ]. For the service to be appropriate, the organization also paces the respite. Apprehension towards service appropriateness can be mitigated by a gradual introduction to homecare, for example when the respite is presented as a trial [ 68 ]. The organization determines the service with the dyad and defines its different characteristics ( WHEN * , WHO ) so interventions correspond to their needs. The organization then determines the appropriate activities to do with the dyad during the respite. For example, the caregiver of older adults can be encouraged to use respite time for leisure (sleep, physical activity, etc.) [ 45 ], while the care worker supports the beneficiary in engaging in an activity such as a walk or a board game [ 14 ]. Furthermore, the organization coordinates* the services for the dyad and acts as a “respite broker” to arrange all aspects of care; this is especially relevant for programs that include a “care budget” that can be used at the caregivers’ discretion [ 58 ]. Finally, for the respite to be appropriate, the organization assures that it is in continuity with other health services, by connecting the dyads to pertinent resources. As described by Shaw, respite should be “embedded in a context that includes assessment, carer education, case management and counselling” [ 18 ].

The third access dimension of flexible at-home respite is affordability , referring to the economic capacity of the dyad to spend resources to use appropriate respite services (Table 7 ). The included documents only explored the direct cost of respite: The amount of money a dyad must pay to receive services. For the respite to be affordable, its direct cost is either (1) adapted, where the cost is modulated according to the dyad’s financial resources, for example on a sliding scale, based on income or (2) nonexistent [ 44 ].

Next, flexible at-home respite must demonstrate availability (Table 8 ): Services can be reached both physically and in a timely manner. Firstly, the organization offers respite in the dyads’ geographic area. Shanley described an at-home mobile respite program designed to reach rural and remote areas, where two care workers visit different locations for set periods of time [ 17 ]. Moreover, one sub-characteristic identified exclusively by the survey participants was seasonality. Indeed, the dyad has access to respite, regardless of the season**. Thus, the geography category is broken down between the access to service (1) in rural or remote areas and (2) notwithstanding the season. Flexibility in availability also requires that the dyads have access to unlimited respite time; the organization does not assign a finite bank of hours. Finally, the organization proposes diverse payment methods to the dyads. The consumer-directed approach is a way that homecare organizations offer flexibility. A care budget is allocated to the caregiver to purchase hours from homecare agencies or to hire their own respite workers. This includes payments to family members or friends to provide respite care [ 79 ]. An example of a type of consumer-directed approach is the use of vouchers*: Credit notes or coupons to purchase service hours from homecare agencies [ 44 ].

Finally, access to flexible at-home respite also relates to acceptability (Table 9 ): The cultural and social factors determining the possibility for the dyad to accept respite and the perception of the appropriateness of seeking services. For the respite to be acceptable, the organization targets and caters to the cultural diversity represented in their local population. The organization is also able to identify and to accommodate underserved groups. In the included documents, underserved groups lacked access to respite for two reasons: (1) Geographic isolation or (2) the requirements to be eligible to “traditional homecare” does not apply to them, for example, for younger people with dementia and people with HIV/AIDS [ 17 ]. The organization can target and cater to low-income households*. Rosenthal Gelman and his collaborators detail a program where, after realizing that low-income caregivers have greater unmet needs, special funds were set aside for respite care vouchers to be distributed [ 70 ].

This scoping review conducted with Levac and colleagues’ method [ 32 ] synthesized the knowledge on the characteristics of flexible at-home respite services offered to caregivers of older adults, from 42 documents. The results provide a synthesis of the characteristics of flexible at-home respite discussed in the literature. The three dimensions of flexibility in respite relate to (1) WHO is tendering it, (2) WHEN it is tendered and (3) HOW it is tendered. First, human resources ( WHO ) must be compatible with the homecare sector as well as being trained and qualified to offer respite to caregivers of older adults. The second feature of flexible respite is temporality ( WHEN ): The time, duration, frequency, and predictability of the service. The last dimension, access ( HOW ), refers to the interface between the respite and the users. Flexible at-home respite exhibits approachability, appropriateness, affordability, availability, and acceptability. In the light of what we learned, flexible at-home respite could be characterized as a service that has the ability to adjust to the needs of the dyad on all three dimensions ( W HO , WHEN , HOW ). However, this seems to be more of an ideal than a reflection of reality.

The survey provided complementary results to the review; the concordance between the two is strong (27/33 = 82%). Six [ 6 ] characteristics were missing from the survey results, including planned respite and the voucher approach ( HOW ). Moreover, the survey added three elements to the review results: The organization’s adhocracy ( HOW ) and promptness ( HOW ) as well as its ability to offer services, regardless of the season ( HOW ). These mismatches might reflect the Québec (and possibly Canadian) landscape of homecare. For example, in the Québec homecare system, respite is mostly planned, it is therefore not surprising that people only mention that unplanned respite is lacking. The “voucher system” was not mentioned in the survey, probably in part because it does not exist in the province of Québec. Additionally, navigating the healthcare system to have free or affordable homecare can be treacherous [ 80 ]. In short, older adults have to go through (1) evaluation(s) by a social worker from a hospital or another public healthcare organization and (2) various administrative tasks ( adhocratic ) [ 2 ], before possibly being put on a waiting list ( prompt ) [ 81 ]. In addition, Canada can experience harsh winters ( seasonality ) that can make transport, which is an integral part of homecare, particularly laborious. Although those categories could reflect the particularity of homecare in Canada, a promising follow up on this review would be to compare the characteristics of flexible respite from one territory to another. It would contribute to providing a more operational definition of flexible at-home respite.

The remainder of this discussion will focus on two main points before touching on the limitations and strengths of this review. First, flexibility in at-home respite seems exceptional. Second, respite care workers are as skilled as they are underappreciated.

This review, in coherence with the literature, highlights the fact that respite services generally lack flexibility: This is the conclusion of several studies on respite [ 7 , 64 , 82 ]. A pattern seems to emerge in the countries represented in the review: Community organizations specialized in homecare (public and/or privately funded) offer respite on predetermined time slots, usually prescribed between traditional office hours (9 AM to 6 PM) [ 50 ]. This lack of flexibility could be explained in part by the rigidity of the structure of homecare services and the fact that its funding does not allow for customizable and punctual services [ 17 , 62 , 73 ]. Nevertheless, there were some examples of flexible respite models, such as Baluchon Alzheimer™ and consumer-directed approaches. Baluchon Alzheimer™ offers long-term at-home respite (4 to 14 days) by qualified and trained baluchonneuses . Prior to the relay of the caregivers, the baluchonneuse takes the time to learn about the dyad, including their environment and routine [ 53 , 62 ]. Caregivers report feeling refreshed upon their return and appreciate the diaries (or logbooks) that the baluchonneuse meticulously fills out [ 53 ]. Another example would be consumer-directed approaches, where caregivers are attributed a budget to hire their own care worker. Allowing caregivers to choose their care worker (either from a self-employed carer or family and friends) can increase the quality of care and satisfaction, while providing relatively affordable care, especially in a situation of labour shortage [ 51 , 79 ]. Even though these two models are a demonstration of how respite can be adapted to the caregiver-senior dyad, for the most part, flexibility is lacking on all three dimensions of respite ( WHO , WHEN , HOW ).

Secondly, the results from the scoping review highlight how homecare as a profession is often overlooked. Indeed, the reviewed documents state the necessary set of skills to offer respite; the level described is one of highly specialized care professionals with important liability. These skills must also transcend advanced knowledge and qualifications, to include interpersonal capabilities [ 17 , 53 , 62 , 63 , 68 ]. Furthermore, care workers must also be flexible to offer a wide range of service time and duration, in addition to being ready to provide “on-the-go” respite [ 53 , 68 ]. Yet, the occupation of homecare worker is an underappreciated and underpaid position [ 83 ]. Community care, like respite, is generally not a priority for social and healthcare funding [ 24 ]. This can be explained in part by the neoliberal approach to care in which the target is to minimize spending and maximize (measurable) outcomes [ 84 ]. Homecare outcomes are often overlooked in favour of service delivery evaluation, in part because they are difficult to measure [ 44 ]. This approach can also lead to prioritizing third party contracting instead of including respite in the range of public services, as to save on expenses related to employment (insurance and other benefits) [ 85 ]. Another contributor is that funding is used for service administration and not to adequately provide services or remunerate care workers [ 86 ]. Finally, care workers are mostly women, known for doing the invisible work that is at the heart of respite care (emotional support, etc.) [ 87 ]. A telling example from the reviewed documents is that Baluchon Alzheimer™ refers to their care workers as baluchonneuses (feminine form) and not baluchoneurs (masculine form) [ 53 ]. Consequently, the homecare sector is faced with recruitment and retention challenges [ 44 , 64 , 88 ]. Authors of the documents included in the review addressed the fact that flexibility in service meant that service providers had to function with excess capacity; for example, by building an “employee bank” to cover all the hours of the day and emergency calls [ 44 ]. Ultimately, staff turnover and shortage caused in part by the work being underappreciated could create a vicious cycle, leading to inflexibility in respite. In short, overlooking and underestimating the crucial and specialized work of homecare workers can contribute to staff turnover, which in turn could result in a lack of flexibility of at-home respite.

Limitations and strengths

The review’s methodological approach has some limitations and strengths. First, according to Levac, Colquhoun and O’Brien [ 32 ], research teams could conduct a sixth step in their scoping study, consisting in consulting experts through a focus group or workshop. This last phase aims at providing further insight into the review’s results and to begin the knowledge translation process. The team did not conduct a traditional consultation phase. Instead, they triangulated the review’s results through a questionnaire. This method was of interest, because of the natural concordance between the results and the considerable number of participants ( n = 100). The survey still allowed to refine the characterization of respite, but further knowledge transfer to homecare actors and caregivers is necessary. Although innovative, there is a need to further investigate the validity of this approach as a consultation phase. Secondly, the theme of flexible at-home respite may have narrowed the search and identification of relevant documentation, and therefore caused the team to overlook some of the literature. Empirical studies and reviews on respite seldom include a detailed description of services [ 89 , 90 , 91 ]. This made it challenging to understand what services are like, operationally, for the dyad and to judge their flexibility. In addition, it complexified the extraction of relevant data, as descriptions were sparse and scattered throughout the documents. The team worked to mitigate these limitations in the documentation research and data charting phase. To begin, they sorted through all the literature on at-home respite for caregivers of older adults. In other words, the team not only searched for, but also included any explicit mention of flexibility. After selection, the extraction tables allowed enough versatility to include all the flexible characteristics of service, regardless of their placement in the text (introduction, methodology or discussion) or length. Another limitation is that, due to resource constraints, only 10% of the document selection and extraction was assessed by two reviewers, although a minimum of 80% of agreement was met and discussions were used to reach consensus where a disagreement arose. To conclude, strengths of this review include the extensiveness and diversity of the documents and its rigorous methodology, co-validated by a peer and an experienced researcher, with assistance from a specialized librarian.

This review has both scientific and practical implications. From a scientific point of view, the results contribute to the body of knowledge on flexible respite service models for caregivers of seniors, an under-documented topic. To our knowledge, this is the first review that aims to characterize flexible at-home respite. Our results suggest the relevance of further documenting the factors influencing the implementation and delivery of flexible respite services, as well as the consequences of the lack of flexibility in respite services, which may lead to service underuse. Moreover, researchers could focus on documenting respite programs in countries that are not represented in this review. There were notably no documents from the continents of Asia and Africa. Unfortunately, good practices can go unreported in peer-reviewed publications; therefore, a review focusing on government reports and publications aimed at professionals could shed some light on promising respite models. From a practical point of view, this review serves as a starting point for the implementation of flexible home respite that is tailored to the caregivers’ and older adults’ needs. Our characterization of flexible at-home respite can be used to guide the improvement of existing respite services and to design new resources that reflect best practices in homecare, ultimately contributing to successful aging in place for older adults.

Data availability

The data supporting this study’s findings are available from the corresponding author, upon reasonable request.

Abbreviations

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

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Acknowledgements

The team thanks the Université de Sherbrooke’s library and archives service for their support. The team also want to thank everyone who participated in the survey.

This article describes a part of a larger study on flexible respite funded by the Fonds de la recherche du Québec (#309508) – Santé and the Conseil de recherches en sciences humaines du Canada (#892-2019-3075). Annie Carrier and Véronique Provencher are Fonds de recherche du Québec – Santé Junior 1 and Junior 2 researchers (#296437 and #297008, respectively). Alexandra Éthier is a Canadian Institutes of Health Research - Research Graduate Scholarships – Doctoral Program recipient (#476590 − 71729).

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MV conducted the review and co-wrote the article with AE. AE co-validated the study selection and co-wrote the article. AC co-validated the study selection, data charting and reviewed the article. VP reviewed the article. All authors read and approved the final manuscript.

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Viens, M., Éthier, A., Provencher, V. et al. WHO, WHEN, HOW: a scoping review on flexible at-home respite for informal caregivers of older adults. BMC Health Serv Res 24 , 767 (2024). https://doi.org/10.1186/s12913-024-11058-0

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AEM Educ Train
v.5(3); 2021 Jul

The scoping review: A flexible, inclusive, and iterative approach to knowledge synthesis

Michael gottlieb.

1 Department of Emergency Medicine, Rush University Medical Center, Chicago Illinois, USA

Mary R. C. Haas

2 Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor Michigan, USA

Michelle Daniel

3 Department of Emergency Medicine, University of California at San Diego School of Medicine, La Jolla California, USA

Teresa M. Chan

4 Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton Ontario, Canada

INTRODUCTION

The body of medical education research has exploded in recent years. A push for a communal effort among education researchers to answer the “big questions” and support evidence‐based approaches to education has resulted in a significant rise in the number of medical education publications. 1 , 2 , 3 Sifting through this expanding body of work can present a daunting task. For example, PubMed, which is generally considered one of the primary databases for health sciences literature, contains over 30 million citations and counting. 4 Additional education‐specific and other searchable databases contain billions more citations through which to sort. 5

For medical educators balancing clinical work with teaching and research, finding efficient ways to manage a rapidly expanding volume of literature has become increasingly difficult. In addition to the challenges of time constraints and the sheer size of available databases, knowledge syntheses in medical education are fraught with challenge due to the breadth and complexity of the field. Out of this milieu, collaborations such as the Best Evidence in Medical Education (BEME) that works to publish high‐quality systematic reviews have emerged to address the increasing need for efficient yet comprehensive assessment and synthesis of the literature. 6

The health educator's toolbox for knowledge synthesis includes a variety of methods, ranging from traditional health professions education systematic reviews to newer methodologies such as realist and scoping reviews. 7 Although scoping reviews have become an increasingly popular method, concerns have been raised about the rigor, merit, and appropriate application of this approach. 8 Herein, we describe scoping review methodology, the study questions to which this method is optimally suited, a rigorous approach for conducting them, and common pitfalls to avoid.

WHY AND WHEN TO PERFORM THIS METHODOLOGY

Scoping studies are particularly well suited to complex topics, where the literature base is broad and not yet comprehensively reviewed. The intent is to rapidly map key concepts corresponding to a particular research domain, including the primary sources and types of evidence currently available. 9 Arksey and O’Malley 10 provide four goals with which scoping review methodology appropriately aligns: to investigate the extent, range, and nature of research activity; to determine the value of performing more in‐depth or focused systematic reviews; to summarize and disseminate research findings; and to identify existing gaps in the literature.

The inclusive, flexible, and iterative nature of scoping reviews distinguishes them from other forms of knowledge synthesis. 11 In contrast to traditional health professions education systematic reviews, scoping reviews do not adhere to strict methodological rules nor necessitate assessment of quality of evidence. 10 Whereas systematic reviews typically involve a well‐defined question and preidentification of inclusion criteria, scoping studies tend to examine broader topics; include a variety of study designs; and allow for evolution in the population (P), intervention (I), comparator (C), and outcomes (O) under study. 10 In contrast to narrative or literature reviews, scoping reviews require authors to perform analytical reinterpretation of the literature. 12 , 13 Accordingly, the final write‐up of the scoping review is also flexible; its structure, content, and length can be adapted to the volume and type of literature reviewed. 11 The scoping review also uniquely entails “charting” of the literature, whereby the authors generate a “map” reflective of the primary studies, corresponding to the review question(s). 10 , 12 Because the map generally reflects researchers who may represent different disciplines examining the topic in question from different lenses, it is often multilayered. 11 , 14 Finally, unlike other review methodologies, the scoping review process is iterative, allowing those conducting this type of review to deal with themes that are noted in the literature on a whole. This aspect of scoping reviews corresponds to a more constructivist approach and makes scoping reviews more aligned with other knowledge syntheses that seek to amalgamate large swaths of literature instead of deductively narrowing down a larger body of literature to a singular answer.

HOW TO PERFORM THIS METHODOLOGY

Scoping reviews must be conducted in a rigorous and transparent manner (i.e., the approach to searching for and synthesizing the evidence should be “systematic”). 15 They should be documented with sufficient detail to enable them to be replicated by others. While scoping reviews differ from other forms of systematic reviews because they do not have a rigid, preset protocol, some recommend that an a priori protocol should still be created and made publicly available. 16 A number of key steps must be followed to properly perform a scoping review. Table 1 provides an illustrative example. Table 2 highlights common pitfalls encountered with this technique.

Illustrative example of a scoping review

Steps	Workplace‐based Assessment Data in Emergency Medicine: A Scoping Review of the Literature
Step 1: Identify the research question
Step 2: Identify the relevant studies
Step 3: Select the studies to be included in the review
Step 4: Chart the data
Step 5: Collate, summarize, and report the results
Step 6: Consult with key stakeholders

Abbreviation: WBA, workplace‐based assessment.

Common pitfalls encountered in scoping reviews

Based on prior literature on scoping reviews, we have identified some common problems encountered by authors performing a scoping review.

Many guidance papers for scoping reviews suggest that consulting stakeholders or experts can be of high yield for the last step of a scoping review. The rationale for this step is to ensure that your mapping resonates with those most knowledgeable about and impacted by the subject domain. Arksey and O’Malley highlight that consulting experts in the domain (e.g., those who have published in this area) will help you to identify any missing literature within your analysis. Levac et al. suggest that the usage of stakeholder consultation may provide similar help and should be a required component.

Depending on their size, scoping reviews can take a number of months to complete. Sometimes by the time you have completed your scoping review, new evidence has emerged in the field. It is best practice to quickly repeat your search at the end as you are mapping the literature for the time frame that has elapsed since your original search. Since you already have your inclusion/exclusion criteria and extraction forms streamlined by this stage, adding a few more papers to update analyses requires limited additional effort.

Pham et al. found that less than one‐third of scoping reviews used graphics to represent their data. Consider moving beyond just tabular representations of your findings. Visual aids may help better explain concepts and trends than overly lengthy tables.

While the intent of scoping reviews is often to map a field and identify gaps for scholars within a domain to advance research or innovation, medical education practitioners may also desire a concise summary of takeaways from the paper. If possible, consider suggesting policy or practice‐oriented recommendations. Consider including a variety of end‐users in the consultation stage to facilitate this.

Pham et al. found that only 22% of scoping reviews reported a quality assessment. Although this is controversial, it is important for authors leading scoping reviews to whether the final list of papers may be filtered by some sort of quality assessment tool to provide readers with insights about the quality of the literature. While not all scoping reviews will have the same requirement for determining quality of the literature within the field, it can be helpful to map the state of the literature in an area to determine what types of studies are needed next within a field. However, as Thomas et al. point out, the heterogeneity of the types of scholarship that may occur in a health professions or medical education search may make it difficult to make firm assessments of quality for the various types of literature. Tools like the Medical Education Research Study Quality Instrument (MERSQI), the Newcastle‐Ottawa scale, or the visual approach to risk of bias assessment from the BEME guide may be used to complete quality assessments of health professions education scholarship. ,

Abbreviations: BEME, Best Evidence in Medical Education.

The first step comprises identifying the research question. 10 Researchers should formulate one overarching question in the area of interest. For scoping reviews, initial searches should be broad and inclusive. Investigators can narrow the inclusion criteria after they have a better sense of the data. Ultimately, the research team must clearly articulate the scope of their inquiry. 12 The researchers should define terms, because these will be used to inform their search strategy. Minimally, the target population, overarching concept, and outcomes of interest should be articulated to clarify the focus of the review. 12 Researchers should consider the purpose and goals of the review when articulating their research question, to ensure that the study has meaningful and relevant implications for educational policy, practice, or research. Prior to proceeding to the next step, reviewers must conduct a pilot search and iteratively refine their question and inclusion criteria, to ensure both the viability and the feasibility of the review. Scoping reviews aim to “map” the literature and are unlikely to add value if the number of primary papers is too small. If the number of primary papers is too large, the research team must consider their capacity (e.g., available time, budget, resources, and personnel) to successfully conduct the review. When limiting the scope, researchers need to provide a rationale and justification for their decisions as well as acknowledge the potential limitations with regard to scope and applicability. 12 Those new to the field should be wary of this phase of the study since it can prevent wasting time on a question where a scoping review is simply not feasible (e.g., there is no literature to synthesize or the literature is simply too vast and unwieldy).

The second step involves identifying relevant studies. 10 In this stage, reviewers must determine their search strategy. The strategy should be exhaustive and rigorous. Engaging a medical librarian to assist with the search can improve the quality of the search. 12 Once the search has been created, pilot the search strategy and ensure that it captures the key articles in the field of interest. The investigators should consider time span and whether the search will include all articles since database inception or only those within a certain time period. Any time limitations should have a clear rationale (e.g., Twitter emerged in 2006). In addition to common medical education research databases (e.g., PubMed, PsychINFO, CINAHL, ERIC, EMBASE), investigators should consider hand searching reference lists of relevant articles and reviews, key journals, conference abstracts, and online journals (e.g., MedEdPublish, MedEdPORTAL) as well as engaging with experts to assess for potential missed articles. Investigators should consider using a review reference manager (e.g., Covidence [Melbourne, Australia], DistillerSR [Ontario, Canada], Rayyan [Doha, Qatar]) to facilitate tracking and storage of articles.

The third step is study selection. 10 Two investigators should independently screen all abstracts and full texts, with disagreements resolved by discussion or involvement of a third person. Authors less familiar with the rigor required of systematic reviews often negate this step and charge through a structured review on their own. However, having at least two investigators screening is critical to minimize bias and error. The screening investigators should meet at the outset for calibration. Since coding behavior changes both between and within individuals over time, screeners should plan to reconvene several times to ensure consistency. Study selection is an iterative process that often involves post hoc modifications to the inclusion and exclusion criteria. Investigators should engage in this process in a reflexive manner, which may require repeating steps and components of the search as the reviewers gain familiarity with and understanding of the literature. During this stage, investigators should track the number of studies screened, assessed for eligibility, and included in the review as well as the reasons for exclusion at each stage. This should ideally be presented as a flow chart in the form of a modified PRISMA diagram. 17 Measures of inter‐rater reliability should be considered whenever feasible, but the evolving nature of the inclusion criteria in scoping reviews can make measurement of kappa statistics challenging beyond the initial title and abstract screening.

The fourth step involves charting the data. 10 During this step, investigators should utilize a “narrative” or “descriptive‐analytic” model when approaching the data collection. 10 Typically, at least two independent reviewers will be needed for this stage. Early on, reviewers should meet to determine whether their approach to data extraction is consistent with the research question and purpose. Reviewers should use a data extraction form to facilitate extraction and sorting. The data extraction will also likely be iterative, and researchers should continually update the data extraction form. When charting the data, researchers should focus on synthesizing and interpreting the data to identify themes. Once data extraction is complete, the researchers will need to present the data in a more narrative format to contextualize the findings within the study design and setting, so it is important to keep this in mind when selecting the data for extraction.

The fifth step consists of collating, summarizing, and reporting the results. 10 Data will then need to be charted and thematically organized. Charting of the data often consists of basic numerical analyses, such as grouping by geographic region, population, and time period. This can help to identify trends in research efforts and where there are significant gaps. Next, researchers should organize the information through thematic analysis. Arksey and O’Malley 10 recommend using the data table as a starting point, combined with researcher discussion using the “descriptive‐analytic” model to determine the final themes. This often shares similarities with qualitative content analytic techniques. Reviewers should utilize a clear and consistent reporting structure to reduce biases and better allow others to replicate the findings. While Arksey and O’Malley 10 espouse that scoping reviews should not include quality analyses, these can be important components of mapping and contextualizing the current literature. To understand the data and future directions for research, one must first understand the quality of said data; however, this point remains controversial. 7 , 14 In fact, Pham et al. 18 reported that only 22% of scoping reviews reported a quality assessment. When presenting the data, researchers should utilize tables and figures to demonstrate the main data while the text should serve to supplement and enhance, but not duplicate, the table. Researchers should also ensure that the final outcome or end‐product aligns with the purpose of the intended study. Finally, researchers must consider and present the findings in light of the broader context of research, policy, and practice.

The final step is consultation. Arksey and O’Malley listed consultation as a highly encouraged but optional sixth step while Levac et al. 10 , 12 proposed that it should be a required component. We highly recommend this sixth step, because it often significantly enhances the quality of the work. This step may provide additional information, including references and resources. This may also provide valuable perspectives, meaning, and applicability to the study findings. Consultation is typically performed immediately after stage five and should involve multiple stakeholders, including experts in the field, as well as users and recipients of the interventions. Researchers should describe how they will collect the data (e.g., interviews, focus groups, surveys) and how the data will be analyzed, reported, and integrated into the overall study outcome. Investigators may also want to utilize this stage to identify dissemination strategies and also to get a sense from target audience members about the implications of the findings for the field at large. The experts consulted can often provide thoughtful insights into the relevance and broader implications the findings and help investigators better engage with scholarly conversation around the topic.

MARKERS OF RIGOR

Various groups have worked to define the structure and content of methodologically sound scoping reviews. Arksey and O’Malley 10 initially defined a six‐step approach in 2007. In 2010, Levac and colleagues 12 expanded this to provide additional details and rigor. In 2018, Tricco et al. 17 created the Preferred Reporting Items for Systematic reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) to provide clear reporting guidelines. In Table 3 , we provide a summary of the major frameworks for scoping reviews.

Summary of the major frameworks for scoping reviews

Steps	Arksey and O’Malley	Levac et al.	PRISMA‐ScR
Step 1: Identify the research question
Step 2: Identify the relevant studies
Step 3: Select the studies to be included in the review
Step 4: Chart the data
Step 5: Collate, summarize, and report the results
Step 6: Consult with key stakeholders

Abbreviation: PRISMA‐ScR, Preferred Reporting Items for Systematic Review and Meta‐Analysis–Scoping Review Extension.

Scoping reviews can be a powerful tool to map the current literature for the purposes of determining gaps and problems within a new field or area. Once completed, a scoping review may provide new insights into existing gaps in the literature and lead to further research, innovation, and scholarship. Those new to medical education may find scoping reviews to be a useful methodology to apply when venturing into a new scholarly conversation within a particular field of study.

Gottlieb M, Haas MRC, Daniel M, Chan TM. The scoping review: A flexible, inclusive, and iterative approach to knowledge synthesis . AEM Education and Training . 2021; 5 :e10609. 10.1002/aet2.10609 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Supervising Editor: Susan Farrell, MD.

This paper is in the following e-collection/theme issue:

Published on 27.6.2024 in Vol 13 (2024)

Effects of Sound Interventions on the Mental Stress Response in Adults: Protocol for a Scoping Review

Authors of this article:

Marina Saskovets 1 , PsyS ;
Zilu Liang 1 , PhD ;
Ian Piumarta 1 , PhD ;
Irina Saponkova 2 , PsyS

1 Faculty of Engineering, Kyoto University of Advanced Science, Kyoto, Japan

2 Department of Psychology, St Petersburg University, St Petersburg, Russian Federation

Corresponding Author:

Marina Saskovets, PsyS

Faculty of Engineering

Kyoto University of Advanced Science

18 Yamanouchi Gotanda-cho

Kyoto, 615-8577

Phone: 81 9049473689

Fax:81 0754966200

Email: [email protected]

Background: Sound therapy methods have seen a surge in popularity, with a predominant focus on music among all types of sound stimulation. There is substantial evidence documenting the integrative impact of music therapy on psycho-emotional and physiological outcomes, rendering it beneficial for addressing stress-related conditions such as pain syndromes, depression, and anxiety. Despite these advancements, the therapeutic aspects of sound, as well as the mechanisms underlying its efficacy, remain incompletely understood. Existing research on music as a holistic cultural phenomenon often overlooks crucial aspects of sound therapy mechanisms, particularly those related to speech acoustics or the so-called “music of speech.”

Objective: This study aims to provide an overview of empirical research on sound interventions to elucidate the mechanism underlying their positive effects. Specifically, we will focus on identifying therapeutic factors and mechanisms of change associated with sound interventions. Our analysis will compare the most prevalent types of sound interventions reported in clinical studies and experiments. Moreover, we will explore the therapeutic effects of sound beyond music, encompassing natural human speech and intermediate forms such as traditional poetry performances.

Methods: This review adheres to the methodological guidance of the Joanna Briggs Institute and follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist for reporting review studies, which is adapted from the Arksey and O’Malley framework. Our search strategy encompasses PubMed, Web of Science, Scopus, and PsycINFO or EBSCOhost, covering literature from 1990 to the present. Among the different study types, randomized controlled trials, clinical trials, laboratory experiments, and field experiments were included.

Results: Data collection began in October 2022. We found a total of 2027 items. Our initial search uncovered an asymmetry in the distribution of studies, with a larger number focused on music therapy compared with those exploring prosody in spoken interventions such as guided meditation or hypnosis. We extracted and selected papers using Rayyan software (Rayyan) and identified 41 eligible papers after title and abstract screening. The completion of the scoping review is anticipated by October 2024, with key steps comprising the analysis of findings by May 2024, drafting and revising the study by July 2024, and submitting the paper for publication in October 2024.

Conclusions: In the next step, we will conduct a quality evaluation of the papers and then chart and group the therapeutic factors extracted from them. This process aims to unveil conceptual gaps in existing studies. Gray literature sources, such as Google Scholar, ClinicalTrials.gov, nonindexed conferences, and reference list searches of retrieved studies, will be added to our search strategy to increase the number of relevant papers that we cover.

International Registered Report Identifier (IRRID): DERR1-10.2196/54030

Introduction

The mental stress response exerts a profound influence at various levels in both the brain and the body. At the neural level, the amygdala (often referred to as “the emotional center”) plays a pivotal role by triggering rapid reactions to potential threats. The prefrontal cortex, responsible for rational decision-making, is also impacted. Additionally, the hypothalamus- pituitary-adrenal axis becomes activated, prompting the release of stress hormones such as cortisol, which affects bodily functions. Physiologically, the cardiovascular system responds by increasing heart rate and constricting blood vessels, redirecting blood flow to vital organs. These combined effects in the brain and body demonstrate the intricate interconnectedness of the stress response, underscoring its significance in shaping human behavior and health outcomes.

In the classical definition, stress is seen as a universal response to disrupted homeostasis [ 1 ]. From the point of view of the autonomic nervous system, we have 2 opposite reactions. One reaction is the stress response, which is accompanied by the arousal of the sympathetic nervous system, and a fight-or-flight response, which could lead to mydriasis, increased heart rate and force contraction, vasoconstriction, bronchodilation, glycogenolysis, gluconeogenesis, lipolysis, sweating, decreased motility of the digestive system, secretion of the epinephrine and cortisol from the adrenal medulla, and relaxation of the bladder wall. Opposing this reaction are the relaxation response, the activation of the parasympathetic nervous system, and the rest-and-digest response (which involves miosis, bronchoconstriction, increased activity of the digestive system, and contraction of the bladder walls) [ 2 ]. Chronic distress can worsen the quality of life, impair performance, lead to mental health problems, and aggravate bodily illnesses.

Ample evidence documented sound therapy’s integrative impact on the psycho-emotional and physiological outcomes, which makes it helpful for treating stress-related conditions such as pain syndromes, depression, and anxiety [ 3 - 6 ]. Sound therapy techniques have become widespread over the past decades, mainly focusing on music among other types of sound stimulation.

There is also evidence suggesting that a similar effect can be exerted by poetry therapy [ 7 - 9 ]. Similar features in the processing of speech and music are also evident at the level of brain activity. For example, in a study by Maess et al [ 10 ], it was shown that the Broca area, traditionally associated with language, is also involved in the processing of musical syntax. However, a comprehensive list of sound components that hold the potential for therapeutic influence remains ambiguously defined. There is a blind spot in understanding sound, such as speech therapeutic intervention and the impact of the spoken word.

In the case of speech, there are 8 paralinguistic features: pitch, tempo, loudness, resonance, timbre, intonation range, syllabic duration, and rhythm [ 11 ]. Despite this variety of features, studies on paralinguistic characteristics are scarce. The investigation of the effects of speech acoustics on changing mind-body conditions is just beginning. It is still unclear which combination of acoustic features (eg, prosody, pitch, loudness, and timbre) might work more effectively. We do not know whether there are individual differences in sound perception and, if so, whether they depend on cultural context, personal experience, characteristics of the listener’s nervous system, etc. We do not know whether a positive effect of sound is necessarily associated with subjective pleasure during listening, or whether there are conditions under which intervention would be beneficial regardless of subjective emotional preference. We plan to complete a scoping review of laboratory experiments, clinical trials, and randomized controlled trials to elucidate this field and investigate the capacity of sound stimulation to manage mental and physiological stress.

The main research question we intend to answer through this review is “what are the therapeutic factors of sound in the case of reducing mental stress and stress-related conditions in human adults?” For example, it might be rhythm, emotional prosody, environmental context of presentation of sound stimuli, individual preferences, or something else. Secondary research objectives will be to clarify body responses (physiological effects measured by biomedical technologies and devices) as well as subjective experiences (psychological effects measured by surveys and questionaries) associated with sound interventions.

We will incorporate investigations that delve into the responses of the hypothalamic-pituitary-adrenal axis and the autonomic nervous system as indicators of stress, supplemented by self-reported data and introspective surveys as markers of emotional stress. Our primary result of interest will be the neural mechanisms underpinning the therapeutic influence of sound. Beyond this, we are also interested in a comparison of delivery methods and sound sample choices for understanding the “active components” of sound in the therapeutic process.

Novelty of This Work

There are reviews of music therapy and the effects of music, but there are currently no reviews that include a “polymodal” approach. This is particularly true of the therapeutic value of the human voice, the acoustic effects of which can be masked by the content of speech. The novelty of our review lies in a conceptually new perspective on sound interventions.

This section describes our protocol design, selection criteria, data extraction, and analytic methods.

Protocol Design

In this study, we will follow the Joanna Briggs Institute Updated Methodological Guidance for the Conduct of Scoping Review [ 12 ]. It outlines the main steps to follow when conducting work using the evidence synthesis approach.

Inclusion Criteria

To be selected for inclusion in our review, research articles must meet the following criteria.

Participants

Human adults are often exposed to diverse stress conditions that will be represented in a paper by the following keywords: stress-related abnormalities, anxiety, depression, stressful life conditions, personal crises, emergency, grief, loss, deprivation, burnout, occupational hazard, experimental stress, stress reduction, stress coping, relaxation skills, emotional flexibility, and mindfulness. These are associated with mental stress and can occur both inside the clinic and with healthy people, including artificial experimental stress.

This research excludes the outcomes within which health conditions can be treated with sound therapy but are not primarily caused by mental stress. However, they may be related to it because of difficult social conditions or disability. Meanwhile, the main malfunction can be found in a different area. For instance, this review does not consider the outcomes related to the pain syndromes or psychiatric disabilities (eg, bipolar disorder and schizophrenia). As for the other excluded outcomes, the work does not review Alzheimer or Parkinson disease, age-related cognitive changes, autism spectrum disorders, tinnitus, and hyperacusis.

Regarding excluded populations, our work does not take studies on animals, participants younger than 18 years of age, and participants with hearing disabilities into consideration.

The concept of the research is to study the sound intervention healing factors and provide an explanation of how and why a sound intervention works. All types of passive sound interventions, such as listening to instrumental music, poetry, human voices, nature sounds, etc, will be included. Our work will also clarify the conceptual basis that guides researchers in choosing one or the other sound sample for intervention, and why the authors consider some sound samples to be more effective than others.

As for kinds of sound intervention, various types of therapy (sound, music, poetry, and acoustic stimulation in hypnosis) are regarded, with sound intervention, guided relaxation, and guided meditation. Moreover, the study will consider issues with voice-guided imagery, affective prosody, expressive sounds, delivering emotions by music and voice, and voice-guided mental health.

Regarding the context of the research, it incorporates the potential positive or harmful influence of sound in the areas of media, arts, and therapeutic and cultural practices. The study will remain in the psychophysiological context, which involves tracking instrumentally measurable body responses and subjective experiences. It will clarify the effectiveness of sound therapy as quantified by stress markers such as salivary cortisol, heart rate variability, electrodermal activity, neuroimaging markers, or other validated measures.

Considering the study types, the work will include not only randomized controlled trials and clinical trials but also laboratory and field experiments. We have deliberately limited the range of studies to controlled trials, clinical trials, and laboratory and field experiments to use more rigorous scientific information, as the field of sound therapy is often subject to a wide range of biases and speculations, which is currently beyond our research interest. All publications are in the English language. Although it is not recommended by the Joanna Briggs Institute Updated Methodological Guidance for the Conduct of Scoping Reviews to apply language restrictions, we do not currently have the resources for relevant translations from multiple languages. Even though automatic translators are available, they produce translations of different quality for different languages, which may misrepresent the results.

Considering the search strategy, we will use PubMed, Web of Science, Scopus, and PsycINFO or EBSCOhost databases. Since the neurobiology of music and sound therapy emerged as a separate field in the 1990s, the search strategy covers research from 1990 to the present day . We will also consider gray literature sources such as Google Scholar, ClinicalTrials.gov, nonindexed conferences, and searching the reference lists of retrieved studies.

Evidence Screening, Selection, and Data Extraction

A clinical psychologist, MS, leads all aspects of the review, including literature search, extraction, screening, and data analysis. IS assists with the literature search and extraction and performs independent screening. Disagreements are resolved through discussion and consensus with other research team members, ZL and IP.

The complete string for the search strategy used across all identified medical databases (PubMed, Web of Science, Scopus, and PsycINFO or EBSCOhost) is formulated as follows: “(stress or anxiety or relax*) and (“sound therapy” or “music therapy” or “guided relaxation” or “guided meditation” or hypno* or ASMR or MBSR) and (prosody or song or poetry or voice or paralinguistics or paralanguage) NOT (children or infants or animal or teen).”

A 2-step process is used to select studies. First, we will screen citation titles, abstracts, and keywords and classify each citation as “include,” “exclude,” “unclear,” or “duplicate.” Next, full-text reports for “include” and “unclear” citations are read, with a final decision made about inclusion or exclusion. Reference management is performed in Rayyan. After the screening, we will construct a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses extension) flow diagram [ 13 ] showing citations and full-text reports reviewed, included, and excluded. Data extraction, qualitative analysis, and data charting will then take place.

Data Analysis and Synthesis

We will combine a descriptive analysis guided by the questions given at the beginning of this protocol and a thematic analysis that induces themes from the papers. Two reviewers will conduct independent data extraction from the full-text papers at this stage. Key data will be structured and placed in tables according to predetermined templates.

Two tables for primary data extraction will contain detailed information about each included study, as well as the relevant key findings regarding the review questions for original papers. The first table will serve as a summary of basic information and will include the sections mentioned in Textbox 1 .

The second table will detail the “intervention” and “key findings” sections. We will elaborate 2 aspects of “intervention.” First, we will detail the parameters of the sound samples that the authors considered significant components of the intervention (pitch, tempo, rhythm, emotional tone, prosody, etc). Second, it is essential to provide details about the context of sound presentation, which can encompass a broad spectrum of factors, ranging from considering the individual features and preferences of the research participants to cultural context. For the “key findings” section, we are interested in detailing how mental stress was defined, and precisely which psychological and physiological markers were measured to track changes in the state of the participants. These may include autonomic responses such as heart rate variability or electrodermal activity, biochemical responses, brain activity measurements, behavioral responses, results from psychological questionnaires, and others.

After systematically describing the therapeutic aspects of sound in the presented papers, we will proceed with charting and categorizing. Based on the tables, we will review the effectiveness data of sound interventions, rank sound types according to their popularity of use, and identify gaps in research concerning potentially promising but infrequently used sound impact categories. We will also track which components of stress states (bodily responses, behavioral responses, subjective experiences, etc) are most sensitive to sound interventions. Furthermore, we will explore which varieties of clinical stress–related issues are most successfully addressed through sound therapy.

We will not conduct quality appraisal (risk of bias assessment) in this scoping review, which is consistent with the framework proposed by Arksey and O’Malley, as well as the Joanna Briggs Institute Methodological Guidance for Scoping Reviews [ 12 ].

First author (year): indicating the first author and publication year.
Sampling: the country where the study was conducted, sample size, and population type (nurses, students, patients from a specific clinic, etc).
Study type: randomized controlled trial, clinical trial, laboratory experiment, etc.
Intervention (sound type): the type of sound stimulation as described in the article (music, voice, nature sounds, etc).
Target or conditions: the target condition or issue that the sound stimulation aims to impact (different mental stress types or stress-related clinical conditions such as anxiety, burnout, etc).
Key findings: the primary findings of the study, such as clinical outcomes, body-mind responses, effectiveness, etc.

This section presents preliminary results that include searches of the main bases that do not consider the analysis of gray sources. According to the search strategy, we generated a search query that was used in 4 databases. Using the operator “and” we combined 3 fields. The first field consists of mental stress, stress related, or the opposite. The second field consists of interventions, in which sound plays a significant role. We included not only interventions based on sound explicitly but also those in which sound is not the central focus, such as speech instruction or performance. The third field consists of the terms related to the voice and the paralinguistic (intonation and acoustic) component. By combining the search fields in this way, we expect to identify a blind spot in the study of sound therapy, namely those papers that appeal to the therapeutic components of sound in natural speech, along the same lines as many music studies do.

The initial query was structured such that the “and” operator combined groups of factors, such as findings, intervention, and specification of studies related to acoustic characteristics of oral speech, and the “not” operator excluded an irrelevant portion of the population.

Running this query on PubMed generated 1467 results. Interestingly, including only “music therapy” in the “intervention” section generated 1370 results. However, when all other types of sound intervention except “music therapy” were included, only 191 results were returned. This illustrates a significant emphasis on research related to music and a lack of studies for other sound types. It is important to note that for therapies such as directed meditation, hypnosis, or other formal practices associated with oral speech, studies focusing on the conceptual and semantic aspects of the intervention are widely presented in these studies. Even so, they fall outside the scope of our review.

Within the focus of our work, it is crucial to highlight the paralinguistic component, which is invariably present in any oral speech interaction. For that purpose, we added a group of factors, related to the acoustic characteristics of voice, to our search query.

Searching all the databases identified 2027 papers. After removing duplicates, 1924 papers remained. We performed an initial screening of those papers using Rayyan software. We first eliminated inappropriate papers by unambiguous, incontrovertible attributes such as year of publication, paper language, and study design. We then screened by title and abstract using the predefined legibility criteria outlined in the methodology section of this study. After abstract screening, we identified 41 eligible papers. As of October 2023, we are in the full-text analysis phase. Results have been organized according to the PRISMA flowchart format [ 13 ] ( Figure 1 ).

Principal Findings

The anticipated main finding of this study would be a comprehensive overview of empirical research on sound interventions, aiming to elucidate the mechanisms underlying their positive effects. The focus lies on identifying therapeutic factors and mechanisms of change associated with various sound interventions, including but not limited to music therapy.

A preliminary search with various query options shows a lack of research beyond music therapies. In methods using natural speech, such as poetry therapy, guided imagination, and guided meditation, the acoustic component is masked by the semantic component (the part of the intervention that can be separated from the vocal expression and conveyed as text). We suggest grouping the therapeutic factors of sound as a potential way to overcome these blind spots ( Figure 2 ).

Stimuli for sound intervention can be described at different levels of generality: starting with basic characteristics, such as frequency (pitch) and amplitude (volume), and then moving on to more complex processing levels, such as tempo, rhythm, and melody (the sound patterns that can be determined through analysis of spectro-acoustic characteristics) [ 11 ]. These parameters can be defined for any stimulus, whether it is music, speech, or a nature sound. We can then define the emotional-expressive component, in terms of basic emotions (calm, sad, joyful, ecstatic, etc), which remains a common characteristic for speech and music (modern programs for identifying emotions in voice and music use similar emotion classifications [ 14 ]) Thus, we see that dividing sound stimulation into the categories of “music”, “speech”, and “natural sounds” is a very high level of generalization that may hide some basic common features.

We noticed that many articles focus on higher-level attributes, for example, distinguishing groups of participants who listen to “nature sounds” versus “music,” without specifying which particular music and nature sounds were chosen. For example, the murmuring of a stream, the rumbling of a rockfall, the chirping of birds, and the screams of fighting cats can all be considered sounds of nature. These examples can provoke a wide range of emotional responses in a listener. Conversely, some sound examples are difficult to define unambiguously. An example might be a vocal expression in opera singing, modern electronic music, or traditional rituals and folklore performances. In some borderline cases, if the listener does not initially know the situational context, then it is difficult to determine whether a sound is speech, music, or from nature.

Following this observation, we consider situational, personal, and cultural contexts in our analysis. After a preliminary review of papers on abstracts, we found several papers focusing on factors such as personal preferences or freedom of selecting sound samples at the intervention time.

A cluster of papers also suggests country-centric interventions, such as traditional music or poetry, implicitly recognizing the importance of cultural context [ 15 ]. Often, both the authors and participants in these experiments hail from the country of origin of the music or poetry used in therapeutic sound interventions. However, only a few studies consider that the therapeutic effect may stem from the sound itself and cultural learning. In the latter case, such interventions may be more effective for native listeners. In our review, we aim to focus on these papers to explore the correlation of therapeutic factors of different levels.

Limitations

Although the aim of the study is to elucidate the mechanisms underlying sound interventions, we may encounter an incomplete understanding of the mechanisms due to the lack of scientific consensus regarding strict definitions in this field. Considering its complexity and multifaceted nature, it may be more appropriate to conclude existing research approaches rather than the very mechanisms of sound therapy. Even a surface review at the level of abstracts shows us the fragmentation and ambiguity of the categorization used by the authors to compare different types of sounds. The range of characteristic analyses extends from the physical features (comparing sound effects of different frequencies), or grouping by context (live presence vs records and free choice of intervention vs predetermination), to categorization by abstract, culturally specific concepts (comparing the effectiveness of sounds by country of origin). Although the study mentions a comprehensive search strategy, it is possible that some trials were missed due to limitations in the search terms or databases used. In addition, this study focuses on the literature in English, which hides from us data published in other languages. This imposes some limitations on the understanding of global research on this topic.

Conclusions

As an expected result of this study, we are going to identify different approaches and concepts underlying sound interventions. The comparison of different sound interventions could reveal specific strengths and weaknesses of each approach in addressing various psycho-emotional and physiological conditions. This could lead to more targeted recommendations for sound therapy apps. Moreover, by exploring the therapeutic effects of natural speech and poetry, the study might uncover additional benefits and potential apps of these sound forms beyond traditional music therapy. Also, we are going to categorize identified therapeutic factors based on their specific characteristics, such as acoustic properties, emotional associations, or cognitive engagement. The study might identify specific sound elements or combinations that are most effective for mental stress treatment leading to more targeted sound therapy protocols. Including gray literature sources could reveal valuable insights and potentially identify novel sound interventions or therapeutic apps not yet documented in mainstream research.

Acknowledgments

This study would not have been possible without the support of the Kyoto University of Advanced Science.

Data Availability

Data sharing is not applicable to this article as no data sets were generated or analyzed during this study.

Authors' Contributions

MS performed conceptualization, data curation, formal analysis, investigation, methodology, project administration, visualization, and writing (original draft). ZL contributed to conceptualization, funding acquisition, methodology, project administration, resources, supervision, validation, and writing (review and editing). IP conducted supervision, validation, and writing (review and editing). IS handled data curation, investigation, validation, visualization, and writing (review and editing).

Conflicts of Interest

None declared.

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Abbreviations

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews

Edited by S Ma; submitted 30.10.23; peer-reviewed by S Rego, M Fotuhi; comments to author 23.03.24; revised version received 29.04.24; accepted 01.05.24; published 27.06.24.

©Marina Saskovets, Zilu Liang, Ian Piumarta, Irina Saponkova. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 27.06.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.

Open access
Published: 22 June 2024

Considering planetary health in health guidelines and health technology assessments: a scoping review protocol

Thomas Piggott ORCID: orcid.org/0000-0003-1643-5386 1 , 2 ,
Maheen Raja 1 ,
Charlotte T. J. Michels 3 ,
Alina Herrmann 4 , 5 ,
Karolina Anna Scahill 6 , 7 ,
Andrea J. Darzi 1 , 8 ,
Laura Jewell 2 ,
KM Saif-Ur-Rahman 9 , 10 ,
Hendrik Napierala 11 ,
Ruben Heuer 12 ,
Rebecca L. Morgan 1 , 13 ,
Grigorios I. Leontiadis 14 ,
Ignacio Neumann 1 , 15 , 16 ,
Holger Schünemann 1 , 17 &
Fiona A. Miller 18

Systematic Reviews volume 13 , Article number: 163 ( 2024 ) Cite this article

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This protocol outlines a scoping review with the objective of identifying and exploring planetary health considerations within existing health guidelines and health technology assessments (HTA). The insights gained from this review will serve as a basis for shaping future Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidance on planetary health.

We will adhere to the JBI methodology for scoping reviews. We will conduct a comprehensive search and screening of results in all languages across various databases including MEDLINE, EMBASE, CINAHL, Global Health, Health Systems Evidence, Greenfile, and Environmental Issues. Additionally, we will supplement this search with resources such as the GIN library, BIGG database, Epistemonikos , GRADE guidelines repository, GRADEpro Guideline Development Tool Database, MAGICapp, NICE website, WHO websites, and a manual exploration of unpublished relevant documents using Google incognito mode. Two independent reviewers will screen and assess the full texts of identified documents according to the eligibility criteria. The following information from each full text will be extracted: document title; first author’s name; publication year; language; document type; document as a guideline or HTA; the topic/discipline; document purpose/study objective; developing/sponsoring organization; the country in which the study/guideline/HTA report was conducted; definition of planetary health or related concept provided; types of planetary health experts engaged; study methods; suggested methods to assess planetary health; use of secondary data on planetary health outcomes; description for use of life cycle assessment; description for assessing the quality of life cycle; population/intended audience; interventions; category; applicable planetary health boundaries; consideration of social justice/global equity; phase of intervention in life cycle related to planetary health addressed; the measure of planetary health impact; impact on biodiversity/land use; one health/animal welfare mention; funding; and conflict of interest. Data analysis will involve a combination of descriptive statistics and directed content analysis, with results presented in a narrative format and displayed in tables and graphs.

The final review results will be submitted to open-access peer-reviewed journals for publication when they become available. The research findings will also be disseminated at relevant planetary health conferences and workshops.

Systematic review registration

Open Science Framework ( https://osf.io/3jmsa ).

Peer Review reports

Methodological developments in health guidelines and technology assessments have achieved notable progress over the past decades, supporting health decision-making, practice, and the population for which the guidance serves. However, improvements in health status and health care delivery have caused overexploitation of our planet’s resources, accompanied by pollution and the disturbance of the Earth’s vital systems [ 1 ]. These unintended consequences have driven climate change and impacted planetary health. Health system interventions make significant contributions to greenhouse gas (GHG) emissions: 5.2% of global GHGs [ 2 ], up to 10% of GHGs in the USA [ 3 ], and other negative consequences for the planet’s health [ 4 ].

There is increasing interest in planetary health as demonstrated by new journals and fields of research. This work builds on a long-standing history of considering environmental and sustainability-related considerations [ 5 ]. Planetary health extends this work to argue that human health, animal health, and the planet’s health are inextricably linked [ 6 ]. In particular, the use of Life Cycle Assessments (LCA) to assess the environmental impacts of health interventions is growing [ 7 ]. However, the term planetary health has only grown substantially within opinion pieces, rather than in published original research [ 8 ]. To date, there has been little attention paid to the integration of planetary health considerations in health technology assessments (HTAs) and health guideline decision-making. This lack of consideration and negligence of the health system, and society more broadly, towards planetary health fails to recognize the interconnectedness between human health, animal health, and the planet’s health [ 6 ]. As the climate crisis accelerates it is becoming increasingly clear that health guidelines and HTAs should consider planetary health [ 9 ].

Global guideline developers are progressively employing the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology in the pursuit of guideline development. This approach, recognized for its reliability and logical underpinnings, serves as a robust framework for transitioning from evidence to the establishment of recommendations [ 10 ]. The GRADE approach yields comprehensive summaries of evidence (accompanied by evaluations of evidence certainty) and graded recommendations (entailing evaluations of recommendation strength and comprehensive evidence certainty). The GRADE approach for developing recommendations using the evidence-to-decision (EtD) framework addresses a broad range of criteria including benefits, harms, the balance of effects, certainty of evidence, resources required, cost-effectiveness, equity, acceptability, and feasibility. The EtD framework allows flexibility in the criteria considered to inform decision-making by either adding or broadening existing criteria (e.g., considering political and health system factors within acceptability and feasibility) [ 11 ], modifying criteria based on user perspective (e.g., clinical, individual, diagnostic), or by truncating the criteria [ 12 ] considered during the decision-making process. However, the current EtD criteria do not explicitly prompt consideration of planetary health.

Guidelines have recently begun incorporating environmental and planetary health considerations [ 13 , 14 ]. By addressing planetary health, HTA reporters and guideline developers will be supported to assess the potential differential impacts of health interventions more comprehensively on both human health and the environment. This integration may prompt guideline developers and HTA reporters to proactively address and mitigate negative planetary health effects resulting from healthcare practices, such as the overuse of single-use plastics, carbon emissions from transportation, or other environmentally harmful impacts. This scoping review will thoroughly investigate and identify planetary health considerations in current health guidelines and HTAs. It will ultimately inform the development of future GRADE guidance on consideration of planetary health to inform decision-making [ 15 ].

The proposed scoping review will follow the methodology outlined by the JBI (formerly Joanna Briggs Institute) for conducting scoping reviews [ 16 , 17 ] and will adhere to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews (PRISMA-ScR [ 18 ]). Recent updates of PRISMA 2020 [ 19 ], specifically the scoping review modifications as detailed in the scoping review chapter of the JBI manual on evidence synthesis [ 20 ], will also be taken into consideration (Additional file 1).

The primary purpose of this protocol is to predefine the review’s objectives, review questions, eligibility criteria, methodologies, and reporting guidelines, to ensure transparency. The protocol functions as a plan for the scoping review and is designed to mitigate potential reporting biases. Any deviations from the established protocol during the review will be clearly addressed and explained within the complete scoping review [ 20 ]. The protocol was registered in the Open Science Framework ( https://osf.io/3jmsa ).

A collaborative effort was initiated, bringing together a team of global experts specializing in guideline methodology and planetary health, with the purpose of contributing to this scoping review. To enhance our application of the JBI scoping review guidance and PRISMA-ScR, and to refine our screening, study selection, and data extraction, pilot testing phases were undertaken at each step. The pilot phase aimed to achieve the following objectives: (a) evaluate and enhance the methods outlined in the protocol; (b) establish and train a team of reviewers (c) establish essential group procedures; (d) create and enhance the required tools; (e) fine-tune the process and content of data extraction; and (f) ascertain the scope of our work. During the pilot, we employed an adapted approach, and after its conclusion, we further refined the methods for the proposed scoping review. This section outlines the fundamental methods employed in the proposed scoping review.

Review question

Our goal will be to address the following review questions:

What are dimensions of planetary health that have been considered in health guidelines and HTAs?

How have guideline development methodologies suggested that health guidelines or HTAs consider the environment, climate change, or planetary health?

What are the methods that health guidelines and HTAs have used to incorporate evidence and assess the certainty of the evidence of planetary health outcomes?

Eligibility criteria

According to The Lancet definition, planetary health is defined as “The achievement of the highest attainable standard of health, wellbeing, and equity worldwide through judicious attention to the human systems—political, economic, and social—that shape the future of humanity and the Earth's natural systems that define the safe environmental limits within which humanity can flourish. Put simply, planetary health is the health of human civilization and the state of the natural systems on which it depends” [ 8 ]. The intricate mechanisms underpinning the linkage between human health and the surrounding natural systems remain multifaceted and occasionally elusive. This discourse shifts its focal point primarily towards outcomes that transcend human-centric considerations. The concept of focus here will predominantly be on non-human-centric outcomes because past HTAs and health guidelines have historically concentrated on direct human outcomes. Thus, the imperative emerges to place substantial emphasis on the well-being of animals and the equilibrium of natural systems as measured by the planetary boundaries concept, with the recognition that the ultimate preservation of human health is fundamentally interconnected between all [ 21 , 22 , 23 ].

We will include any human health guidelines or HTAs covering the breadth of clinical, health system, and public health topics, that also address planetary health outcomes (including a focus on animal health and natural systems). We will include the most recent version of the report if there are multiple versions. We will include methodological papers or handbooks that provide insight into how to address planetary health in the guideline or HTA process. We will include guidelines and HTAs published in any language, employing translation tools when studies are included beyond the languages of our team. We will not restrict eligibility based on geography or the level of government/region a guideline is focused on.

Types of sources

This scoping review will focus on health guidelines and HTAs that address planetary health outcomes including those that have a focus on animal health, natural systems, and the environment.

Exclusion criteria

In our exclusion criteria, we will exclude any studies or reports not directly related to planetary health. This includes reports or studies unrelated to health guidelines or health technology assessments. Additionally, we will exclude LCA modeling studies that do not form a part of a guideline or HTA. Furthermore, if an abstract does not explicitly reference planetary health, one health, ecosystem health, climate change, or related concepts we will exclude it from consideration for full-text screening. Concepts related to sustainability that are not relevant to environmental or planetary health, such as sustainable financing, will also be excluded. Lastly, studies focusing solely on the impacts of climate change or the environment on health (i.e., not the opposing direction of health interventions on the environment) will not be included in our review.

Search strategy

The search strategy was developed in consultation with a health sciences librarian at McMaster University. The search will identify guidelines and HTAs that have addressed planetary health outcomes or considerations. We will complete a primary search of the literature using the following databases: Ovid MEDLINE, EMBASE, CINAHL, Global Health, Health Systems Evidence, Greenfile, and Environmental Issues. We will complement this search with the GIN international guideline library and registry of guidelines in development [ 24 ], BIGG international database of GRADE guidelines [ 25 ], Epistemonikos GRADE guidelines repository [ 26 ], GRADEpro GDT Database of GRADE EtD’s and Guidelines [ 27 ], MAGICapp [ 28 ], National Institute for Health and Care Excellence (NICE) website [ 29 ], and the World Health Organization website [ 30 ]. We will also complement this with a search for online content on Google incognito mode with similar search terms to identify any unpublished documents of relevance. In addition, the search will be further complemented by utilizing another ongoing scoping review of handbooks on guideline development, that identified 120 international guideline development handbooks by diverse organizations, to search for references to planetary health in these handbooks [ 31 ]. The search strategy for different databases has been provided in the Additional file 2: Appendix 1 .

Evidence selection

A web-based software platform Covidence (Covidence Systematic Review Software VHI, Melbourne, Australia) will be used to automatically remove duplicates and to screen the retrieved articles. The screening of citations will be carried out in two phases, both of which will go through pilot testing. Two review authors will independently screen the title and abstract of the citations based on the prespecified inclusion and exclusion criteria. A simple screening algorithm as outlined in Additional file 3: Appendix 2 will be employed. Any discrepancies will be resolved through a third reviewer.

Two reviewers will individually assess the full texts of the identified eligible documents based on the predetermined criteria for eligibility. Any conflicts will be resolved by a third reviewer. The reasons for exclusion will be documented in the full-text screening phase. A simple screening algorithm as outlined in Additional file 4: Appendix 3 will be employed. All pertinent complete guideline texts and HTA reports will be gathered and shared using an online folder. This folder will encompass associated documents and supplementary materials. The comprehensive details of the search results and the study inclusion process will be thoroughly documented in the final scoping review. This information is visually presented using a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram [ 19 ] in Fig. 1 and will continue to be updated in the final scoping review once the data extraction process begins. Additional details can be found in the PRISMA-P checklist (see Additional file 1).

PRISMA flow diagram depicting search results before data extraction

Data extraction

Using a pilot-tested and standardized extraction form, a team of experienced reviewers will be responsible for extracting data from the guidelines and HTA reports incorporated in this scoping review. One reviewer will perform preliminary data extraction, and this will be verified by a second reviewer. Any disagreements will be resolved through discussion or involving another reviewer. The team will convene for regular meetings to address any potential concerns that might arise. These meetings will also serve the purpose of maintaining consistency and providing training to all reviewers. The primary investigator of the project will then review and refine the extracted data for each guideline and/or HTA. The following data will be extracted: document title; first author’s names; publication year; language; document type (peer review publication, guideline handbook, report, grey literature, other); whether the document is a guideline or HTA; the topic/discipline (respirology, gastroenterology, nutrition, anesthesia, other); document purpose/study objective; developing/sponsoring organization; country in which the study/guideline/HTA report was conducted (USA, UK, Canada, Australia, Germany, other); definition of planetary health or related concept provided; types of planetary health experts engaged (engineer, one health/veterinary, economist, modelling expert, geologist/earth scientist, other); study methods; suggested methods to assess planetary health (LCA, other modelling approach, use of existing databases, direct measurement, expert input on impact, other); whether the study uses secondary data on planetary health outcomes; description for use of LCA; description for assessing quality of life cycle; population/intended audience; interventions; category (human health, animal health/one health, natural systems, environment, other); applicable planetary health boundaries (climate change, change in biosphere integrity, stratospheric ozone depletion, ocean acidification, biogeochemical flows, land-system change, freshwater use, atmospheric aerosol loading, introduction of novel entities); consideration of social justice/global equity; phase of intervention in life cycle related to planetary health addressed (goods production, goods transport, patient/staff travel, diagnostic tests, facility requirements, infection prevention and control (IPAC) requirements, disposal impacts, other); measure of planetary health impact (carbon dioxide emissions, methane emissions, other greenhouse gas emission, nitrogen/phosphorous inputs, energy input, water use, waste production, monetary equivalents of impact, other); impact on biodiversity/land use and one health/animal welfare mentioned; funding (not transparent, public funding, private funding, both public and private funding, other), conflict of interest (reported or not reported).

Data analysis and presentation

Data analysis will involve a combination of content analysis using both deductive and inductive approaches, along with the utilization of descriptive statistics. Part of the data collected, specifically the yes/no items, will be converted into quantitative form, and basic descriptive statistical methods will be employed to examine their distribution.

We will employ directed content analysis [ 32 ] to examine the textual data, with the flexibility to uncover emergent codes as well. To examine the data extracted from the guidelines/HTAs, two coders will each perform iterative rounds of analysis. Following the initial extraction, the case studies will be elucidated, and distinct themes will be identified within different categories of studies (e.g., guideline topics, and methods papers). As we go through the coding process, they will underline the important and relevant sections in the text and choose a term, phrase, or description to best capture its meaning. The codes developed during the pilot phase will serve as predetermined codes in the analysis, with additional codes being added as necessary. Codes sharing similar concepts will be organized into categories. When appropriate, explanations and examples from the text will accompany the codes or categories. The coders will not aim to quantify the frequency of code occurrences. These codes and categories will be utilized to populate the following predefined themes: goods production, goods transport, patient/staff travel, diagnostic tests, facility requirements, IPAC requirements, and disposal impacts. Additional themes will be introduced as required.

The risk of bias and the quality of the studies will be assessed for primary research papers, health guidelines/HTAs using the Risk of Bias In Non-randomized Studies of Exposures/Interventions (ROBINS I/E) tool and Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument respectively [ 33 , 34 , 35 ]. The quality of the theoretical or commentary papers included in the scoping review will not be assessed, as it is not typically done in scoping reviews [ 17 , 36 ].

In our final conclusive assessment, we will present the results of our search using an adapted PRISMA flowchart [ 19 ]. We will also provide a concise overview of the fundamental attributes of the guidelines included, along with the outcomes of the screening procedure. Results of the analysis will be presented narratively, with codes and classifications for each topic presented in a table, as appropriate, and the quantified data presented in graphs. Any discrepancies or modifications from the established protocol will be duly documented within the final scoping review.

Discussion and preliminary results (pilot phase)

Our team, comprised of ten reviewers, undertook a comprehensive three-part pilot exercise encompassing title and abstract screening, full-text screening, and a data extraction pilot exercise. Throughout the pilot phase, we implemented an adapted approach allowing us to address unforeseen challenges and incorporate valuable insights from our team’s collective experience. Upon the conclusion of each pilot exercise, we further refined the methods for the proposed scoping review. We provide the dates of key milestones in the scoping review process in Table 1 .

Title-abstract screening pilot exercise

In the title-abstract pilot exercise that was completed in October 2023, 50 articles were randomly selected from the compiled search results. Ten independent reviewers assessed inclusion and exclusion criteria by screening titles and abstracts of each using the Title-Abstract Screening Form (Additional file 3: Appendix 2 ). Reviewers’ assessments, showing variability, were compiled for discussion in a scheduled meeting to resolve discrepancies. By resolving discrepancies amongst the results, the discussions and group feedback led to refinements clarifying the inclusion/exclusion criteria, which were as follows. There would be no exclusion based on study design, but we acknowledged that a focus on guidelines or HTAs (question 2) might be limiting. Life Cycle Assessment modeling studies or other modeling studies that were not part of a guideline or HTA will be excluded. Studies lacking explicit references to planetary health, one health, ecosystem health, climate change, or related concepts in the abstract will also be excluded. Additionally, concepts unrelated to environment/planetary health, such as sustainable financing, will also be excluded, along with studies describing the impacts of climate change or the environment on health. This refinement process allowed for a more targeted and precise selection of articles for subsequent phases.

Full-text screening pilot exercise

In the full-text pilot exercise that was completed in November 2023, 10 articles were strategically selected by the study leads to encompass both inclusion and exclusion scenarios, providing a basis for discussing common mistakes. Ten independent reviewers were tasked with evaluating the inclusion and/or exclusion criteria for all ten references by evaluating the full text using the Full-Text Screening Form (Additional file 4: Appendix 3 ). This form directed reviewers to assess whether the study addressed planetary health, the impact of an intervention on planetary health, and its relation to health guidelines or HTAs. Additionally, reviewers were asked to evaluate whether the study served as an example/case study of implementing planetary health considerations in guideline or HTA decision-making, and if it offered advice or suggestions, without an example/case study, on addressing planetary health considerations. The results of the exercise exhibited variability and were compiled for discussion in a scheduled meeting to reconcile discrepancies. In response to group discussions and feedback, specific criteria were clarified including what constitutes a guideline. For this study, guidelines encompass any clinical, health system, or public health guideline offering actionable statements based on evidence reviews, panel recommendations, consensus statements, position or policy statements, scientific statements, or other clear processes. Furthermore, studies focusing on policy or decision-making considerations of planetary health that lack a focus on guidelines or HTAs will be excluded.

Data extraction pilot exercise

In the data extraction pilot exercise that was completed in January 2024, five articles meeting the inclusion criteria were selected by the study leads. Ten independent reviewers were tasked with extracting data using Additional file 5: Appendix 4 : Data Extraction Form. Following data extraction, a scheduled meeting with the review team was organized to address potential inconsistencies in extraction. The form underwent significant modifications based on feedback from the team, incorporating additional items such as the topic/discipline of the study, type of planetary health experts engaged, planetary health boundaries, consideration of social justice/global equity, impact on biodiversity/land use, and impact on one health/animal welfare. These pilot exercises allowed for the refinement of the data extraction methodology for the following stages of the study (Additional file 6: Appendix 5 ; Additional file 7: Appendix 6 ).

This protocol provides a description of the objectives, inclusion and exclusion criteria, methods, and analysis of a scoping review to be undertaken by an international interdisciplinary group of experts. The comprehensive findings of this scoping review will be made accessible and published in a peer-reviewed journal once they become available. To inform future guidance on planetary health within the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria, the primary aim of our scoping review is to identify and examine planetary health considerations in current health guidelines and health technology assessments.

The review is currently in progress and we are targeting finalizing the analysis and submitting it in 2024. Preliminary work towards GRADE guidance on planetary health was presented at the GRADE Working Group meeting in Miami in May 2024. The scoping review actively informs the ongoing development of guidance on the consideration of planetary health in health guidelines and HTAs.

Addressing planetary health in health technology assessment (HTA) reports and guidelines will provide essential support for a more comprehensive evaluation of the potential impacts of health interventions on both human health and the environment. This holistic approach will encourage guideline developers and HTA reporters to take proactive measures in addressing and mitigating adverse effects on planetary health caused by healthcare practices, including issues such as excessive use of single-use plastics, transportation-related carbon emissions, and other environmentally detrimental impacts. Hence, promoting a healthier future for all life forms and the Earth.

Availability of data and materials

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

Abbreviations

Appraisal of Guidelines for Research and Evaluation II

Evidence to Decision

Grading of Recommendations, Assessment, Development, and Evaluations

Greenhouse Gas

Health Technology Assessments

Infection Prevention and Control

Life Cycle Assessments

Risk of Bias in Non-randomized Studies of Exposures/Interventions

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Contributions

TP made substantial contributions to the study conceptualization, design, data collection, pilot analysis, and decision to publish. MR made substantial contributions to the study design, data collection, pilot analysis, and protocol writing. CM, AH, KAS, AJD, LJ, KMS, HN, RH, and RLM made contributions to the data collection and pilot analysis. GIL, IN, HS, and FAM made contributions to the study design. All authors read and approved the study protocol.

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Alina Herrmann is a member of the German Alliance of Climate Change and Health (KLUG), and an honorary spokesperson on climate change and health at the German Society of General and Family Medicine (DEGAM). Holger Schünemann is the GRADE working group co-chair.

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Additional file 1: prisma-p 2015 checklist., additional file 2: appendix 1. search strategy approach., additional file 3: appendix 2. title-abstract screening form., additional file 4: appendix 3. full text screening guide (in covidence)., additional file 5: appendix 4. data extraction form., additional file 6: appendix 5. sample included studies for validating search., additional file 7: appendix 6. search notes., rights and permissions.

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Piggott, T., Raja, M., Michels, C.T.J. et al. Considering planetary health in health guidelines and health technology assessments: a scoping review protocol. Syst Rev 13 , 163 (2024). https://doi.org/10.1186/s13643-024-02577-2

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Covidence Knowledge Base The Covidence Knowledge Base contains a suite of articles offering overviews of the software, help getting started, and information about review settings, importing records, data extraction, exporting data, FAQs and more.
Getting Started with Covidence - Video Collection This collection of video tutorials covers: -Signing in and out -Creating a new review and inviting co-reviewers -Importing citations -Screening titles & abstracts -How to breeze through screening
Getting Started with Covidence (Webinar - 1 Hour) The Covidence 101 training webinar includes a live demo providing an overview of the systematic review workflow, and showcasing some of the most popular features.

Tutorials: Exporting Records from Databases into Covidence

Covidence Knowledge Base: Importing references in Covidence

Video Overviews by Database

Education Source with ERIC is also hosted on EBSCO
PsycINFO and MEDLINE are also hosted on EMBASE

PRISMA - Checklist & Diagram

PRISMA ( P referred R eporting I tems for S ystematic R eviews and M eta- A nalyses) is an evidence-based set of minimum items for reporting information in systematic reviews and meta-analyses.

Specific PRISMA resources include:

Prisma checklist.

A 27 item checklist whose items refer to the preferred content of a for reporting systematic reviews and meta-analyses, including suggested content for the title, abstract, methods, results, discussion and funding.

PRISMA Extensions

Extensions to the PRISMA Checklist to facilitate the reporting of different types or aspects of systematic reviews/meta-analyses (e.g., checklists for reporting scoping reviews, individual patient data)

PRISMA Diagram Templates

Word Document Templates - PRISMA Website
This file is View Only. To create your own diagram in GoogleDrawings using this template: "File> Make a copy"
Image can be downloaded as PDF, PNG, JPG, or SVG
PRISMA Diagram Generator - ShinyApp.io

PRISMA Data Table

This view-only GoogleDoc shows a table you can use to track the basic data that is needed to complete a PRISMA diagram, including an example table.

Example PRISMA Diagram

Source:

Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review. Current Diabetes Reports, 2 (11), 46. https://doi.org/10.1007/s11892-021-01414-3

Video Overview: Filling Out a PRISMA Flow Diagram (2020 Version; 8 minutes, 32 seconds)

Still have questions about constructing a PRISMA diagram using the 2020 template?

This article, published in the Journal of the Medical Library Association, answers some frequently asked questions about using the PRISMA 2020 format.

Rethlefsen, M. L., & Page, M. J. (2022). PRISMA 2020 and PRISMA-S: common questions on tracking records and the flow diagram. Journal of the Medical Library Association : JMLA , 110 (2), 253–257. https://doi.org/10.5195/jmla.2022.1449

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IMAGES

(PDF) A Scoping Review of Flow Research
Scoping review flow diagram. on August 20, 2022 by guest. Protected by...
Flow diagram of scoping review
Flow diagram showing the adopted scoping review method.
Scoping Review Flow Diagram
PRISMA Scoping Review Flow Diagram

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Scoping Review Article

COMMENTS

A Scoping Review of Flow Research
Accordingly, a scoping review aims to identify and structure existing research in order to provide a framework and to build a basis for future research. The scoping review follows three steps: first, we present a framework to structure flow research. Second, we review empirical flow research that has been published between 2000 and 2016.
A Scoping Review of Flow Research
The flow concept was introduced by Csikszentmihalyi in 1975, and interest in flow research is growing. However, to our best knowledge, no scoping review exists that takes a systematic look at studies on flow which were published between the years 2000 and 2016. Overall, 252 studies have been included in this review.
(PDF) A Scoping Review of Flow Research
A Scoping Review of Flow Research. Corinna Peifer 1 *, Gina Wolters 2, László Harmat 3, Jean Heutte 4, Jasmine T an 5, T eresa Freire 6, Dionísia Tavares 6, Carla Fonte 7, Frans Orsted Andersen 8,
(PDF) A Scoping Review of Flow Research
The flow concept was introduced by Csikszentmihalyi in 1975, and interest in flow research is growing. However, to our best knowledge, no scoping review exists that takes a systematic look at studies on flow which were published between the years 2000 and 2016. Overall, 252 studies have been included in this review.
A Scoping Review of Flow Research
Flow is a gratifying state of deep involvement and absorption that individuals report when facing a challenging activity and they perceive adequate abilities to cope with it (EFRN, 2014). The flow concept was introduced by Csikszentmihalyi in 1975, and interest in flow research is growing. However, to our best knowledge, no scoping review exists that takes a systematic look at studies on flow ...
A Scoping Review of Flow Research
Flow is a gratifying state of deep involvement and absorption that individuals report when facing a challenging activity and they perceive adequate abilities to cope with it (EFRN, 2014). The flow concept was introduced by Csikszentmihalyi in 1975, and interest in flow research is growing. However, to our best knowledge, no scoping review ...
(PDF) A Scoping Review of Flow Research
With this Scoping Review, we aimed to (1) present a framework Heutte et al., 2021). In line with this, results of this category to structure ﬂow research and (2) provide a systematic overview showed that many motivational indicators, such as volition, on empirical ﬂow research of the years 2000-2016.
PDF A Scoping Review of Flow Research Abstract
The scoping review follows three steps: first, we present a framework to structure flow research. Second, we review empirical flow research that has been published between 2000 and 2016. Third, based on our results, we discuss implications for future research. Framework to structure flow research To structure and review the empirical research ...
A Scoping Review of Flow Research
The flow concept was introduced by Csikszentmihalyi in 1975, and interest in flow research is growing. However, to our best knowledge, no scoping review exists that takes a systematic look at studies on flow which were published between the years 2000 and 2016. Overall, 252 studies have been included in this review.
A Scoping Review of Flow Research
Flow is a gratifying state of deep involvement and absorption that individuals report when facing a challenging activity and they perceive adequate abilities to cope with it (EFRN, 2014). The flow ...
Advancing our understanding of psychological flow: A scoping review of
This scoping review maps flow-related research across scientific disciplines, examining the conceptualization, measurement instruments, and outcomes of flow between 2012 and 2019. Across 236 sources that met the review criteria, 108 different flow-related constructs were measured by 141 instruments, and 84 possible antecedents were identified. ...
A scoping review of scoping reviews: advancing the approach and
As it provides a rigorous and transparent method for mapping areas of research, a scoping review can be used as a standalone project or as a preliminary step to a systematic review ... A flow diagram was used to display the flow of articles from the initial search to final selection in 35.8% of reviews (123/344). Characteristics of included ...
Undertaking a scoping review: A practical guide for nursing and
Scoping reviews are an increasingly common form of evidence synthesis. They are used to address broad research questions and to map evidence from a variety of sources. Scoping reviews are a useful form of evidence synthesis for those in nursing and midwifery and present opportunities for researchers to review a broad array of evidence and ...
Frontiers
Accordingly, a scoping review aims to identify and structure existing research in order to provide a framework and to build a basis for future research. The scoping review follows three steps: first, we present a framework to structure flow research. Second, we review empirical flow research that has been published between 2000 and 2016.
PDF Scoping reviews: What they are & How you can do them
Arksey and O'Malley (2005) identified 4 reasons: To examine the extent, range and nature of available research on a topic or question. To determine the value of undertaking a full systematic review. To summarize and disseminate research findings across a body of research evidence (e.g. that is heterogeneous and/or complex)
Scoping Reviews
Khalil et al 2021. In this paper, the JBI Scoping Review Methodology Group discuss the challenges that may be faced in the conduct and publishing of scoping reviews, such as developing an a-priori protocol, developing implications or recommendations for research, policy or practice and a lack of understanding of scoping reviews by journal ...
1: Flow Diagram for the scoping review process adapted ...
A scoping review was conducted to synthesise evidence from a variety of study designs in order to clarify key concepts and identify gaps in the published literature, using the Arksey and O'Malley ...
Tutorials & Tools for Literature Reviews
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) is an evidence-based set of minimum items for reporting information in systematic reviews and meta-analyses.Specific PRISMA resources include: PRISMA Checklist. A 27 item checklist whose items refer to the preferred content of a for reporting systematic reviews and meta-analyses, including suggested content for the ...
Fathers Nutrition Knowledge and Child Feeding Practices Associated with
This scoping review was designed with reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, 40 as well as the Arksey and O'Malley's 41 5 stage framework. Therefore, our review identified the research question, identified relevant studies, selected eligible studies ...
Steps for Conducting a Scoping Review
An overview of the steps involved in conducting scoping reviews is provided below. Go to: Creating the research question is a vital first step. 1 3 5 A question that is too broad increases the number of papers for consideration, which may affect the feasibility of the review. 5 A question that is too narrow may compromise the breadth and depth ...
WHO, WHEN, HOW: a scoping review on flexible at-home respite for
A scoping review [32,33,34] was conducted, as part of a larger multi-method participatory research known as the AMORA project [] to characterize flexible at-home respite.Scoping reviews allow to map the extent of literature on a specific topic [32, 34].The six steps proposed by Levac et al. [] were followed: [] Identifying the research question; [] searching and [] selecting pertinent ...
PDF A Scoping Review of Flow Research
Our Scoping Review provides a systematic overview on flow research between the years 2000 and 2016. A task force of flow research from the EFRN united their expertise in order to provide a sound ...
Doppler Sonography Evaluation of Median Nerve Intraneural Blood Flow: A
This systematic review aims to determine the extent, scope, and nature of research using the sonographic measurement of intraneural blood flow within the median nerve and to identify, characterize, and compare image acquisition and analysis protocols that have been reported as potential candidate techniques for standardizing research and clinical applications.
Literature Reviews
7. Create Flow Diagram. The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram is a visual representation of the flow of records through different phases of a systematic review. It depicts the number of records identified, included and excluded. It is best used in conjunction with the PRISMA checklist. Example:
Undertaking a scoping review: A practical guide for nursing and
Scoping reviews are an increasingly common form of evidence synthesis. They are used to address broad research questions and to map evidence from a variety of sources. Scoping reviews are a useful form of evidence synthesis for those in nursing and midwifery and present opportunities for researchers to review a broad array of evidence and ...
The scoping review: A flexible, inclusive, and iterative approach to
Explain why a scoping review is the appropriate approach. Provide an explicit statement of the questions and objectives being addressed. Step 2: Identify the relevant studies. Create a plan for the search, including databases, search terms, time span, and language. Consider time, budget, and personnel.
JMIR Research Protocols
The completion of the scoping review is anticipated by October 2024, with key steps comprising the analysis of findings by May 2024, drafting and revising the study by July 2024, and submitting the paper for publication in October 2024.
Considering planetary health in health guidelines and health technology
The proposed scoping review will follow the methodology outlined by the JBI (formerly Joanna Briggs Institute) for conducting scoping reviews [16, 17] and will adhere to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews (PRISMA-ScR []).Recent updates of PRISMA 2020 [], specifically the scoping review modifications as detailed ...
Tutorials & Tools for Literature Reviews
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) is an evidence-based set of minimum items for reporting information in systematic reviews and meta-analyses.Specific PRISMA resources include: PRISMA Checklist. A 27 item checklist whose items refer to the preferred content of a for reporting systematic reviews and meta-analyses, including suggested content for the ...
Fathers Nutrition Knowledge and Child Feeding Practices Associated with
This scoping review examines the literature on fathers' nutrition knowledge and feeding practices with childhood overweight/obesity. Methods. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and Arksey and O'Malley (2005) framework, multiple databases were searched.

A Scoping Review of Flow Research

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Further Explorations into the Conundrum of Flow Process

A Scoping Review of Flow Research

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A Scoping Review of Flow Research

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Advancing our understanding of psychological flow: A scoping review of conceptualizations, measurements, and applications

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Publication types

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Miscellaneous

REVIEW article

Introduction

Framework to Structure Flow Research

Identification of the Research Question

Literature Research

Selection of Relevant Studies

Charting the Information

Collating, Summarizing and Reporting of Study Results

Discussion of the Results and Implications for Future Research

Personality

Studies Dealing With Autotelic Personality

Dispositional Proneness to Experience Flow and Its Relation to Big Five Personality Traits

The Relationship of Flow With Other Personality Traits or Motives

Flow and Motive-Fitting Situations

Motivational Indicators

Self-Determination

Self-Efficacy

Social Motivation

Physiological Arousal

Facial Muscle Activation

Neural Activity

Emotional Contagion

Relationships With Cognitive Processes

Cognitive Aspects of Flow-Related Processes in Specific Contexts

Performance

Variables That Are Related to High Performance

Other Forms of Behavior

Context Factors

Flow in Different Contexts and Activities

Contextual Factors and Their Relationships With Flow

Fit of Contextual Factors With Characteristics of the Individual

Interindividual Factors

Interpersonal Flow Studies at the Individual Level

Interpersonal Flow Studies at the Collective Level

Cultural Factors

Cross-Cultural Perspective

Cultural Perspective

General Discussion

In a Nutshell: Discussion of Findings Within the Categories

Contextual Factors

Overarching Aspects for Future Research and Limitations of This Review

Definitional and Operational Issues

Methodological Issues

Time Frame and Inclusion Criteria of This Scoping Review

Author Contributions

Conflict of Interest

Publisher’s Note

Acknowledgments

WHO, WHEN, HOW: a scoping review on flexible at-home respite for informal caregivers of older adults

Identifying the research question

Identifying relevant documents

Study selection