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The Harvard Educational Review (HER) is a scholarly journal of opinion and research in education. The Editorial Board aims to publish pieces from interdisciplinary and wide-ranging fields that advance our understanding of educational theory, equity, and practice. HER encourages submissions from established and emerging scholars, as well as from practitioners working in the field of education. Since its founding in 1930, HER has been central to elevating pieces and debates that tackle various dimensions of educational justice, with circulation to researchers, policymakers, teachers, and administrators.

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2023-2024 Harvard Educational Review Editorial Board Members

Maya Alkateb-Chami Development and Partnerships Editor, 2023-2024 Editor, 2022-2024 [email protected]

Maya Alkateb-Chami is a PhD student at the Harvard Graduate School of Education. Her research focuses on the role of schooling in fostering just futures—specifically in relation to language of instruction policies in multilingual contexts and with a focus on epistemic injustice. Prior to starting doctoral studies, she was the Managing Director of Columbia University’s Human Rights Institute, where she supported and co-led a team of lawyers working to advance human rights through research, education, and advocacy. Prior to that, she was the Executive Director of Jusoor, a nonprofit organization that helps conflict-affected Syrian youth and children pursue their education in four countries. Alkateb-Chami is a Fulbright Scholar and UNESCO cultural heritage expert. She holds an MEd in Language and Literacy from Harvard University; an MSc in Education from Indiana University, Bloomington; and a BA in Political Science from Damascus University, and her research on arts-based youth empowerment won the annual Master’s Thesis Award of the U.S. Society for Education Through Art.

Jane Choi Editor, 2023-2025

Jane Choi is a second-year PhD student in Sociology with broad interests in culture, education, and inequality. Her research examines intra-racial and interracial boundaries in US educational contexts. She has researched legacy and first-generation students at Ivy League colleges, families served by Head Start and Early Head Start programs, and parents of pre-K and kindergarten-age children in the New York City School District. Previously, Jane worked as a Research Assistant in the Family Well-Being and Children’s Development policy area at MDRC and received a BA in Sociology from Columbia University.

Jeannette Garcia Coppersmith Content Editor, 2023-2024 Editor, 2022-2024 [email protected]

Jeannette Garcia Coppersmith is a fourth-year Education PhD student in the Human Development, Learning and Teaching concentration at the Harvard Graduate School of Education. A former public middle and high school mathematics teacher and department chair, she is interested in understanding the mechanisms that contribute to disparities in secondary mathematics education, particularly how teacher beliefs and biases intersect with the social-psychological processes and pedagogical choices involved in math teaching. Jeannette holds an EdM in Learning and Teaching from the Harvard Graduate School of Education where she studied as an Urban Scholar and a BA in Environmental Sciences from the University of California, Berkeley.

Ron Grady Editor, 2023-2025

Ron Grady is a second-year doctoral student in the Human Development, Learning, and Teaching concentration at the Harvard Graduate School of Education. His central curiosities involve the social worlds and peer cultures of young children, wondering how lived experience is both constructed within and revealed throughout play, the creation of art and narrative, and through interaction with/production of visual artifacts such as photography and film. Ron also works extensively with educators interested in developing and deepening practices rooted in reflection on, inquiry into, and translation of the social, emotional, and aesthetic aspects of their classroom ecosystems. Prior to his doctoral studies, Ron worked as a preschool teacher in New Orleans. He holds a MS in Early Childhood Education from the Erikson Institute and a BA in Psychology with Honors in Education from Stanford University.

Phoebe A. Grant-Robinson Editor, 2023-2024

Phoebe A. Grant-Robinson is a first year student in the Doctor of Education Leadership(EdLD) program at the Harvard Graduate School of Education. Her ultimate quest is to position all students as drivers of their destiny. Phoebe is passionate about early learning and literacy. She is committed to ensuring that districts and school leaders, have the necessary tools to create equitable learning organizations that facilitate the academic and social well-being of all students. Phoebe is particularly interested in the intersection of homeless students and literacy. Prior to her doctoral studies, Phoebe was a Special Education Instructional Specialist. Supporting a portfolio of more than thirty schools, she facilitated the rollout of New York City’s Special Education Reform. Phoebe also served as an elementary school principal. She holds a BS in Inclusive Education from Syracuse University, and an MS in Curriculum and Instruction from Pace University.

Pennie M. Gregory Editor, 2023-2024

Pennie M. Gregory is a second-year student in the Doctor of Education Leadership (EdLD) program at the Harvard Graduate School of Education. Pennie was born in Incheon, South Korea and raised in Gary, Indiana. She has decades of experience leading efforts to improve outcomes for students with disabilities first as a special education teacher and then as a school district special education administrator. Prior to her doctoral studies, Pennie helped to create Indiana’s first Aspiring Special Education Leadership Institute (ASELI) and served as its Director. She was also the Capacity Events Director for MelanatED Leaders, an organization created to support educational leaders of color in Indianapolis. Pennie has a unique perspective, having worked with members of the school community, with advocacy organizations, and supporting state special education leaders. Pennie holds an EdM in Education Leadership from Marian University.

Jennifer Ha Editor, 2023-2025

Jen Ha is a second-year PhD student in the Culture, Institutions, and Society concentration at the Harvard Graduate School of Education. Her research explores how high school students learn to write personal narratives for school applications, scholarships, and professional opportunities amidst changing landscapes in college access and admissions. Prior to doctoral studies, Jen served as the Coordinator of Public Humanities at Bard Graduate Center and worked in several roles organizing academic enrichment opportunities and supporting postsecondary planning for students in New Haven and New York City. Jen holds a BA in Humanities from Yale University, where she was an Education Studies Scholar.

Woohee Kim Editor, 2023-2025

Woohee Kim is a PhD student studying youth activists’ civic and pedagogical practices. She is a scholar-activist dedicated to creating spaces for pedagogies of resistance and transformative possibilities. Shaped by her activism and research across South Korea, the US, and the UK, Woohee seeks to interrogate how educational spaces are shaped as cultural and political sites and reshaped by activists as sites of struggle. She hopes to continue exploring the intersections of education, knowledge, power, and resistance.

Catherine E. Pitcher Editor, 2023-2025

Catherine is a second-year doctoral student at Harvard Graduate School of Education in the Culture, Institutions, and Society program. She has over 10 years of experience in education in the US in roles that range from special education teacher to instructional coach to department head to educational game designer. She started working in Palestine in 2017, first teaching, and then designing and implementing educational programming. Currently, she is working on research to understand how Palestinian youth think about and build their futures and continues to lead programming in the West Bank, Gaza, and East Jerusalem. She holds an EdM from Harvard in International Education Policy.

Elizabeth Salinas Editor, 2023-2025

Elizabeth Salinas is a doctoral student in the Education Policy and Program Evaluation concentration at HGSE. She is interested in the intersection of higher education and the social safety net and hopes to examine policies that address basic needs insecurity among college students. Before her doctoral studies, Liz was a research director at a public policy consulting firm. There, she supported government, education, and philanthropy leaders by conducting and translating research into clear and actionable information. Previously, Liz served as a high school physics teacher in her hometown in Texas and as a STEM outreach program director at her alma mater. She currently sits on the Board of Directors at Leadership Enterprise for a Diverse America, a nonprofit organization working to diversify the leadership pipeline in the United States. Liz holds a bachelor’s degree in civil engineering from the Massachusetts Institute of Technology and a master’s degree in higher education from the Harvard Graduate School of Education.

Caroline Tucker Co-Chair, 2023-2024 Editor, 2022-2024 [email protected]

Caroline Tucker is a fourth-year doctoral student in the Culture, Institutions, and Society concentration at the Harvard Graduate School of Education. Her research focuses on the history and organizational dynamics of women’s colleges as women gained entry into the professions and coeducation took root in the United States. She is also a research assistant for the Harvard and the Legacy of Slavery Initiative’s Subcommittee on Curriculum and the editorial assistant for Into Practice, the pedagogy newsletter distributed by Harvard University’s Office of the Vice Provost for Advances in Learning. Prior to her doctoral studies, Caroline served as an American politics and English teaching fellow in London and worked in college advising. Caroline holds a BA in History from Princeton University, an MA in the Social Sciences from the University of Chicago, and an EdM in Higher Education from the Harvard Graduate School of Education.

Kemeyawi Q. Wahpepah Co-Chair, 2023-2024 Editor, 2022-2024 [email protected]

Kemeyawi Q. Wahpepah (Kickapoo, Sac & Fox) is a fourth-year doctoral student in the Culture, Institutions, and Society concentration at the Harvard Graduate School of Education. Their research explores how settler colonialism is addressed in K-12 history and social studies classrooms in the United States. Prior to their doctoral studies, Kemeyawi taught middle and high school English and history for eleven years in Boston and New York City. They hold an MS in Middle Childhood Education from Hunter College and an AB in Social Studies from Harvard University.

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• Open access
• Published: 23 March 2018

The nature and nurture of education

• Pankaj Sah 1 ,
• Michael Fanselow 2 ,
• Gregory J. Quirk 3 ,
• John Hattie 4 ,
• Jason Mattingley   ORCID: orcid.org/0000-0003-0929-9216 1 &
• Tracey Tokuhama-Espinosa 5  

npj Science of Learning volume  3 , Article number:  6 ( 2018 ) Cite this article

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Learning is a life-long endeavour that continues from infancy to old age. We each navigate the learning process in different ways, yielding to our experiences and the circumstances in which we find ourselves. For many people, formal education takes place between the ages of 6–18, where we are educated based on core curricula that are delivered through a schooling system. Many countries have some form of compulsory education for children until they reach adulthood, but the route through the school system can vary greatly. In many first world countries, the choice is between public schools, generally funded by the state, and private schools which are funded through a combination of individual tuition fees, and religious or corporate institutions. School education is generally required by government mandate, and the cost of admission and tuition in public schools is borne by the state. In contrast, entry into a private school is often primarily dependent on socioeconomic status and some form of selection process—either formal testing or religious affiliation.

In many countries, studies have suggested that students attending private schools attain better educational outcomes, and long-term socioeconomic benefits. These data are then used by private schools to encourage attendance in this selective system. Private schools are generally expensive but may provide more individualized programs of study with better student–faculty ratios then those provided by public schools.

The choice parents make in selecting schools for their children, and the differences between public and private schools has been the subject of much debate, that is largely couched in social and economic terms. In a collection of manuscripts published in npj Science of Learning , two groups of researchers have approached this discussion from an interesting new direction—genetics. The Nature versus Nurture question has been greatly debated for many years, because it is not entirely clear which is the greatest influence on human development and behaviour. Although we are all born with a specific set of genes, with no control over our genetic allocation, we now know our life-style choices and different experiences though development and maturity also influence gene expression, and thus exert control over our behaviour via epigenetic modifications. Epigenetic mechanisms regulate the structure and activity of the genome in response to cellular and environmental cues, one such mechanism involves DNA methylation. Thus, biological processes are controlled by a combination of inherited genes and the life-long impact of epigenetic modifications that regulates their expression. Who we are is not simply a result of either nature or nurture but rather is shaped by a combination of these factors. Recent advances in genomic and epigenomic sequencing, have led to a growing interest in using this information to predict biological outcomes, and disease pathogenesis and help guide individuals in lifestyle choices and behaviour.

Two papers 1 , 2 published in npj Science of Learning have worked to address the question of 'Does an individual’s genetic makeup, and epigenetic modification, affect his or her educational attainment?'. Educational attainment is a measure of the highest level of education that an individual has completed at the end of full-time compulsory education. Educational attainment has been shown to strongly correlate with mental and physical health, as well as socioeconomic status, and is one of the strongest predictors of lifetime success, not only economically but also in terms of health and longevity.

In one study, 1 Smith–Woolley and colleagues looked at educational attainment in three groups of students in Britain that attended either: public schools, private schools or selective schools. The researchers found that as previously reported, students in private schools had higher levels of educational attainment than those in public schools. They then examined the genetic differences between students in these groups, and surprisingly, there were differences in genetic markers between them. Interestingly, when differences in genetics were accounted for, educational attainment differences between students attending the different schools disappeared.

In another study, 2 van Dongen and colleagues examine the DNA methylation status of genes in people with different levels of educational attainment. They found differential sites of DNA methylation at specific regions (loci) correlate with educational attainment and the methylation status of these sites are largely influenced by environmental factors such as smoking. These sites of differential methylation were found to be located in and near genes with neuronal, immune and developmental functions. Differential levels of DNA methylation in these regions could impact the expression of these genes during critical periods of childhood development. Together, the two studies point to the role of genetics and epigenetic changes in educational outcome. Two accompanying perspective pieces, one by Nick Martin 3 and the other by Sue Thompson, 4 provide a commentary on the implications of these studies from the genetic 3 and educational 4 viewpoint.

There is a growing interest in genomic and epigenomic sequencing of different populations, with the data generated being incorporated into many different databases. Large-scale projects like the ENCODE (Encyclopedia of DNA Elements) Consortium, which is an international collaboration of research groups funded by the National Human Genome Research Institute (NHGRI), and the British 100,000 genomes project, led by Genomics England, are leading the way in trying to understand how these factors influence biological processes. The two studies published in npj Science of Learning raise the question of the use of genomic data to help predict educational outcomes. Just as the management of our health is increasingly being found to be affected by genetic and epigenetic determinants, it may be that individuals progress through the education system based upon these factors as well.

Smith-Woolley, E. et al. Differences in exam performance between pupils attending selective and non-selective schools mirror the genetic differences between them. npj Sci. Learn. https://doi.org/10.1038/s41539-018-0019-8 (2018).

van Dongen, J. et al. DNA methylation signatures of educational attainment. npj Sci. Learn. https://doi.org/10.1038/s41539-018-0020-2 (2018).

Martin, N. Getting to the genetic and environmental roots of educational inequality. npj Sci. Learn. https://doi.org/10.1038/s41539-018-0021-1 (2018).

Thomson, S. Achievement at school and socioeconomic background—an educational perspective. npj Sci. Learn. https://doi.org/10.1038/s41539-018-0022-0 (2018).

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Queensland Brain Institute, The University of Queensland, Brisbane, QLD, 4072, Australia

Pankaj Sah & Jason Mattingley

Staglin Center for Brain and Behavioral Health, University of California, Los Angeles, Los Angeles, CA, USA

Michael Fanselow

School of Medicine, University of Puerto Rico, San Juan, Puerto Rico

Gregory J. Quirk

Graduate School of Education, The University of Melbourne, Parkville, Australia

John Hattie

Applied Educational Research Center, Latin American School of Social Sciences, Harvard Extension School, Harvard University, Cambridge, MA, USA

Tracey Tokuhama-Espinosa

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Sah, P., Fanselow, M., Quirk, G.J. et al. The nature and nurture of education. npj Science Learn 3 , 6 (2018). https://doi.org/10.1038/s41539-018-0023-z

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Received : 07 February 2018

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DOI : https://doi.org/10.1038/s41539-018-0023-z

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Greater Good Science Center • Magazine • In Action • In Education

Parenting & Family Articles & More

Our best education articles of 2020, readers and editors pick the most interesting and insightful articles from the past year about teaching, learning, and the keys to well-being at school..

In February of 2020, we launched the new website Greater Good in Education , a collection of free, research-based and -informed strategies and practices for the social, emotional, and ethical development of students, for the well-being of the adults who work with them, and for cultivating positive school cultures. Little did we know how much more crucial these resources would become over the course of the year during the COVID-19 pandemic.

Now, as we head back to school in 2021, things are looking a lot different than in past years. Our most popular education articles of 2020 can help you manage difficult emotions and other challenges at school in the pandemic, all while supporting the social-emotional well-being of your students.

In addition to these articles, you can also find tips, tools, and recommended readings in two resource guides we created in 2020: Supporting Learning and Well-Being During the Coronavirus Crisis and Resources to Support Anti-Racist Learning , which helps educators take action to undo the racism within themselves, encourage their colleagues to do the same, and teach and support their students in forming anti-racist identities.

Here are the 10 best education articles of 2020, based on a composite ranking of pageviews and editors’ picks.

Can the Lockdown Push Schools in a Positive Direction? , by Patrick Cook-Deegan: Here are five ways that COVID-19 could change education for the better.

How Teachers Can Navigate Difficult Emotions During School Closures , by Amy L. Eva: Here are some tools for staying calm and centered amid the coronavirus crisis.

Six Online Activities to Help Students Cope With COVID-19 , by Lea Waters: These well-being practices can help students feel connected and resilient during the pandemic.

Help Students Process COVID-19 Emotions With This Lesson Plan , by Maurice Elias: Music and the arts can help students transition back to school this year.

How to Teach Online So All Students Feel Like They Belong , by Becki Cohn-Vargas and Kathe Gogolewski: Educators can foster belonging and inclusion for all students, even online.

How Teachers Can Help Students With Special Needs Navigate Distance Learning , by Rebecca Branstetter: Kids with disabilities are often shortchanged by pandemic classroom conditions. Here are three tips for educators to boost their engagement and connection.

How to Reduce the Stress of Homeschooling on Everyone , by Rebecca Branstetter: A school psychologist offers advice to parents on how to support their child during school closures.

Three Ways to Help Your Kids Succeed at Distance Learning , by Christine Carter: How can parents support their children at the start of an uncertain school year?

How Schools Are Meeting Social-Emotional Needs During the Pandemic , by Frances Messano, Jason Atwood, and Stacey Childress: A new report looks at how schools have been grappling with the challenges imposed by COVID-19.

Six Ways to Help Your Students Make Sense of a Divisive Election , by Julie Halterman: The election is over, but many young people will need help understanding what just happened.

Train Your Brain to Be Kinder (video), by Jane Park: Boost your kindness by sending kind thoughts to someone you love—and to someone you don’t get along with—with a little guidance from these students.

From Othering to Belonging (podcast): We speak with john a. powell, director of the Othering & Belonging Institute, about racial justice, well-being, and widening our circles of human connection and concern.

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Here’s How Data Can Help Unlock Education Equity

Tc’s renzhe yu, alex bowers, and youmi suk break down their ongoing, different approaches to the same goal: high quality education for all.

Now more than ever, educational equity — ensuring all students have access to meaningful educational opportunities, from college preparation and career assistance to support resources to civic participation — is crucial across America. However, the journey towards educational equity demands a multifaceted approach, with cross-collaboration and data at the helm. That’s where a core aspect of TC’s educator preparation and overall ethos comes into play, seeking to narrow the opportunity gaps millions of U.S. students face. 

While The Center for Educational Equity , established in 2005, focuses on research and policy around fair school funding and civic participation, three TC faculty members are finding unique ways to leverage data for equity. Renzhe Yu , Assistant Professor of Learning Analytics and Educational Data Mining, is leveraging data analytics to uncover the unintended consequences of the rapid adoption of generative artificial intelligence. Alex Bowers , Professor of Education Leadership, is showcasing the power of learning analytics and interoperable data sets to identify and address critical indicators of equity. Youmi Suk , Assistant Professor of Applied Statistics, is harnessing big educational data and cutting-edge machine learning methods to address questions about equity and fairness in educational practice.

Renzhe Yu, Assistant Professor of Learning Analytics and Educational Data Mining; Alex Bowers, Professor of Education Leadership; Youmi Suk, Assistant Professor of Applied Statistics (Photo: TC Archives)

• To reveal the bias and unintended consequences of generative artificial intelligence , Renzhe Yu performs large-scale data analytics.
• In order to identify issues of equity in a transparent way, Alex Bowers utilizes learning analytics and public data.
• Working to improve test fairness and curriculum planning , Youmi Suk draws connections between psychometrics, causal inference and algorithmic fairness.

(Image: iStock)

How Data Analytics Can Address the Growing Digital Divides

Stemming from Yu’s interest in learning how to “equip ourselves to better address existing issues related to education inequity,” his most pressing research focuses on understanding how the mass adoption of generative artificial intelligence has exacerbated digital divides in schools and institutions. Explored in a forthcoming working paper, the project uses large-scale text data from the education system to examine differences in everyday teaching and learning experiences as well as institutional attitudes toward generative AI.

“There are students who are more tech-savvy, there are instructors who are more experienced in using technologies, there are institutions that are more open-minded…and they have probably taken good advantage of ChatGPT and other generative AI tools in the past year,” explains Yu. But there’s also a significant number of students, parents, instructors, and institutions that don’t have that kind of access or awareness. “Although it’s just one year, the emergence of this technology may have widened these gaps,” says Yu.

To explore this growing divide, Yu and his research team focused on real-world data sources instead of conducting lab-controlled experiments in order to see how these relationships are playing out in real life. Because of his familiarity with the tech industry and the still-common impulse to innovate without considering the way that entire populations can be left behind, Yu says, “it’s really important to identify these unintended consequences in the early phase of life for these technologies.”

Yu’s other research interest in algorithmic bias — where he has long been exploring how algorithms used for decision making are treating learners differently based on race or other socio-demographic markers — is also made more urgent by the emergence of generative AI tools because if biased algorithms are “having dynamic conversations with students, [as is the case with generative AI,] the negative consequences of any bias in the process would be even more concerning.”

Ultimately, Yu hopes that his work provides perspective that is often ignored in the innovation process in order to create an education system that achieves equity with the help of advanced technology. 

How Data Can Inform Equity Efforts in School Policy and Conversation

Meanwhile, Bowers is looking at new ways school leaders can use reliable, evidence-based data practices to support equity efforts in schools nationwide. “One of my goals is to help bring communities together around the data that already exists for them—that’s already available, and help empower those communities,” he explains.

His recent work focuses on building collaboration with urban schools to identify data-driven equity practices and outcomes in education. In using a multidimensional framework, Bowers is hoping to facilitate more meaningful discussions with school communities by moving away from stigmatizing variables like standardized test scores and graduation rates.

“I think school districts are excited to have a definition of equity that they can bring into these community conversations, both with the school board, but also with teachers, parents, students.”

The project is fueled by his earlier research , which explores the value of interoperable, equitable datasets, along with a report that he co-authored with the National Association of Elementary School Principals (NAESP). The comprehensive report details the 16 indicators for assessing equity in education, including academic outcomes like test scores, graduation rates, behavioral data, and opportunities such as student engagement, access to quality learning, pre-K experiences, and more.These indicators give administrators and teachers a more transparent lens to examine school performance.

“It can help us move into a framework of, "How are we serving our students?" "Are we serving our communities?" It's moving away from fixating on the gaps and the outcomes and [instead] trying to problem solve as a collaborative opportunity through which we can bring in existing data.”

How Interdisciplinary Approaches to Analyzing Data Can Promote Fairness

For clearer reading.

Causal Inference: An interdisciplinary subfield that determines the cause of an observed effect by considering assumptions, design and estimation strategies.

Psychometrics: A subfield of psychology centered on theories and applications of measurement, assessment and testing.

A leading researcher exploring test accommodation effectiveness, Suk takes a multi-pronged approach to her main research goal of “developing and applying quantitative methods to address practical and important problems in the educational, social, and behavioral sciences.” One of her central projects is forging a connection between test fairness, a field of study that has been developed over 60 years, and algorithmic fairness, an emerging field with high stakes as algorithmic models are utilized in all aspects of life. 

“We can leverage the people, the methods and the concepts developed in test fairness in order to facilitate understanding of algorithmic fairness,” says Suk who is incorporating psychometrics and causal inference concepts into her work. “And it can go both ways. If there's any new discussion happening around algorithm fairness, we can leverage that discussion to make assessments and tests fairer.” As a part of this work, Suk is crafting new frameworks to investigate test fairness on the individual level instead of on the group level, based on the discussions on individual fairness within the algorithmic fairness research.

Her work is also directly informing her recent research on fair and personalized math curriculum recommendations for high school students, funded by the National Science Foundation. It’s known that students get the most benefit from personalized recommendations but “we have to be aware there may be some unconscious bias [in the recommendations],” explains Suk. To address this, Suk is applying algorithmic fairness constraints to create more equitable recommendations for high school students.

Through her varied research, Suk ultimately hopes to “create equitable and fair testing environments for all students and personalized curriculum plans that empower every student to succeed.”

— Sherri Gardner and Jaqueline Teschon

Tags: Evaluation & Learning Analytics Bias Education Leadership Evaluation & Learning Analytics

Programs: Applied Statistics Cognitive Science in Education Education Leadership Learning Analytics Measurement and Evaluation

Departments: Human Development Organization & Leadership

Published Monday, Apr 22, 2024

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‘Back to school’ means anytime from late July to after Labor Day, depending on where in the U.S. you live

About 70% of the 46.7 million public school students in the United States are now back in class, according to a new Pew Research Center analysis. Depending on where you grew up or live now, your reaction might be, “That sounds about right,” “Already?” or “What took them so long?”

Pew Research Center conducted this analysis to determine when public schools in the United States start classes. We collected school start dates for the 2023-24 school year from a nationally representative, stratified random sample of 1,573 districts.

To create this dataset, we began with a stratified random sample of 1,500 public school districts that was used in a 2023 Center analysis of school district mission statements (this analysis only covers “regular” public school districts and their equivalents; institutions such as charter schools and specialized state-run schools are excluded). That sample had been drawn from a comprehensive list of public school districts maintained by the National Center for Education Statistics (NCES). For more details for how that earlier sample was selected, read the methodology for that analysis.

We then supplemented that stratified sample in several ways:

• One district no longer exists and was removed from the dataset.
• Because school districts in Vermont, New Hampshire and New York City are classified not as “regular local districts” but as “component districts,” the initial sample missed them. So we drew an additional sample of 72 districts from those areas and added it to the original sample.
• The lone districts in Hawaii and Washington, D.C., neither of which were initially selected, were also added so that at least one district from all 50 states and the District of Columbia would be represented.

The data was weighted to account for each district’s probability of selection in both the initial and supplementary samples. Then it was calibrated so that both the weighted number of districts and the weighted number of students matched the totals for all eligible districts in the NCES list.

After these adjustments, we had a sample of 1,573 districts. For each one, we manually searched its website to find its 2023-24 calendar. If we couldn’t find a calendar (or a functioning website), we called the district office. In the end, we found start dates for 1,551 districts; the rest were coded as “no data.”

In most cases, districts had a single reopening date for all of their schools. When start dates varied, we used the date that applied to the most grade levels. In the few cases where we couldn’t determine that reliably, we went with the earliest reopening date on the calendar.

In some districts, certain schools may follow a “year-round” calendar rather than the “traditional” calendar (late summer/early fall to late spring/early summer). In those cases, we used the start date on the traditional calendars, since those were more comparable to the vast majority of U.S. school districts. As of the 2017-18 school year, only about 3% of public schools were on any type of year-round schedules , according to the U.S. Department of Education’s National Teacher and Principal Survey.

Student enrollment figures are taken from the NCES database and are for the 2021-22 school year. In addition, each district was coded as belonging to one of the U.S. Census Bureau’s nine geographic divisions for regional analysis.

Some, but not all, U.S. school districts offer prekindergarten classes. Student weights for each district in the sample include pre-K students when appropriate, but start dates are based on grades K-12.

Information on the laws and policies governing school start dates in each state came from the Education Commission of the States , a nonprofit research organization that serves education policymakers throughout the country.

For most U.S. K-12 students, the school year runs about 180 days, spread over roughly 10 months with a long summer vacation. Within that broad timeframe, however, there are substantial regional variations, according to our analysis of over 1,500 public school districts. (The analysis only covers “regular” public school districts and their equivalents; institutions such as charter schools and specialized state-run schools are excluded.)

For example, school tends to start earlier in southern regions than farther north, broadly speaking. More than two-thirds of students in the U.S. Census Bureau’s East South Central division – Alabama, Kentucky, Mississippi and Tennessee – went back to school the week of Aug. 7. They joined another 19% of students who had started classes earlier. In the West South Central division (Arkansas, Louisiana, Oklahoma and Texas), 94% of students returned to school between Aug. 7 and Aug. 18.

But in the six New England states, almost no one goes back to school before the week of Aug. 28. And students in the Middle Atlantic states – New Jersey, New York and Pennsylvania – go back even later: About three-quarters won’t hit the books until after Labor Day, which falls on Sept. 4 this year.

Even within regions, districts in the southernmost states sometimes start classes earlier than those farther north. For instance, within the sprawling South Atlantic division, sampled districts in its southernmost states (Florida and Georgia) have similar start-date patterns to those in the East South Central region, while the division’s northernmost jurisdictions (Maryland, Delaware and D.C.) more closely resemble districts in regions up north.

Some states stand apart from the overall trends in their region in other ways. In the West North Central region, for instance, roughly two-thirds of public school students start classes between Aug. 14 and Aug. 25. However, Minnesota law requires schools to start after Labor Day in most cases, and the vast majority of sampled Minnesota districts will go back after the holiday.

In the Census Bureau’s eight-state Mountain division, which stretches from the Canadian border to the Mexican border, nearly half of public school students overall return to school between Aug. 14 and Aug. 25. But almost all of the sampled districts in Arizona and New Mexico, the two southernmost states in that division, start one to three weeks earlier.

Why do start dates vary so much?

While such geographic variations are fairly apparent, the reasons for them are less clear. State laws certainly play a part: 16 states establish windows, either by statute or rule, for when school must start, according to data from the Education Commission of the States and individual state education agencies. But even in those states, the rules are fairly loose – merely requiring school to start before or after a certain date – and waivers for individual districts are not uncommon.

Contrary to popular belief, the school calendar isn’t a relic of the nation’s agrarian past . In fact, into the early 20th century, rural schools typically operated summer and winter sessions, with children working on farms in spring and fall to help with planting and harvesting. Urban schools, on the other hand, were open nearly year-round, though many children attended sporadically or for just part of the year.

Between roughly 1880 and 1920, urban and rural school calendars converged into more or less the pattern we know today, driven by factors such as pressure from education reformers, the high cost of keeping schools open year-round, the shift from one-room schoolhouses to age-graded education , and lower attendance in urban schools during the summer months (especially as family vacations grew in popularity).

Another possible explanation, for both the traditional calendar and the regional clustering of start dates, is “network effects,” in which a given standard becomes more useful as it’s adopted more widely. It’s easier, for instance, for a school district to recruit teachers from neighboring districts if those districts are on similar schedules.

School start dates could vary even more in the future with climate change. Some education experts predict hotter temperatures may force districts to adjust their start dates or times , especially in places like the Southwest, if schools can’t update air conditioning systems or make other accommodations.

Note: This is an update of a post originally published Aug. 14, 2019.

Drew DeSilver is a senior writer at Pew Research Center

Most Americans think U.S. K-12 STEM education isn’t above average, but test results paint a mixed picture

About 1 in 4 u.s. teachers say their school went into a gun-related lockdown in the last school year, about half of americans say public k-12 education is going in the wrong direction, what public k-12 teachers want americans to know about teaching, what’s it like to be a teacher in america today, most popular.

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The relationship between education and health: reducing disparities through a contextual approach

Anna zajacova.

Western University

Elizabeth M. Lawrence

University of North Carolina

Adults with higher educational attainment live healthier and longer lives compared to their less educated peers. The disparities are large and widening. We posit that understanding the educational and macro-level contexts in which this association occurs is key to reducing health disparities and improving population health. In this paper, we briefly review and critically assess the current state of research on the relationship between education and health in the United States. We then outline three directions for further research: We extend the conceptualization of education beyond attainment and demonstrate the centrality of the schooling process to health; We highlight the dual role of education a driver of opportunity but also a reproducer of inequality; We explain the central role of specific historical socio-political contexts in which the education-health association is embedded. This research agenda can inform policies and effective interventions to reduce health disparities and improve health of all Americans.

URGENT NEED FOR NEW DIRECTIONS IN EDUCATION-HEALTH RESEARCH

Americans have worse health than people in other high-income countries, and have been falling further behind in recent decades ( 137 ). This is partially due to the large health inequalities and poor health of adults with low education ( 84 ). Understanding the health benefits of education is thus integral to reducing health disparities and improving the well-being of 21 st century populations. Despite tremendous prior research, critical questions about the education-health relationship remain unanswered, in part because education and health are intertwined over the lifespans within and across generations and are inextricably embedded in the broader social context.

We posit that to effectively inform future educational and heath policy, we need to capture education ‘in action’ as it generates and constrains opportunity during the early lifespans of today’s cohorts. First, we need to expand our operationalization of education beyond attainment to consider the long-term educational process that precedes the attainment and its effect on health. Second, we need to re-conceptualize education as not only a vehicle for social success, valuable resources, and good health, but also as an institution that reproduces inequality across generations. And third, we argue that investigators need to bring historical, social and policy contexts into the heart of analyses: how does the education-health association vary across place and time, and how do political forces influence that variation?

During the past several generations, education has become the principal pathway to financial security, stable employment, and social success ( 8 ). At the same time, American youth have experienced increasingly unequal educational opportunities that depend on the schools they attend, the neighborhoods they live in, the color of their skin, and the financial resources of their family. The decline in manufacturing and rise of globalization have eroded the middle class, while the increasing returns to higher education magnified the economic gaps among working adults and families ( 107 ). In addition to these dramatic structural changes, policies that protected the welfare of vulnerable groups have been gradually eroded or dismantled ( 129 ). Together, these changes triggered a precipitous growth of economic and social inequalities in the American society ( 17 ; 106 ).

Unsurprisingly, health disparities grew hand in hand with the socio-economic inequalities. Although the average health of the US population improved over the past decades ( 67 ; 85 ), the gains largely went to the most educated groups. Inequalities in health ( 53 ; 77 ; 99 ) and mortality ( 86 ; 115 ) increased steadily, to a point where we now see an unprecedented pattern: health and longevity are deteriorating among those with less education ( 92 ; 99 ; 121 ; 143 ). With the current focus of the media, policymakers, and the public on the worrisome health patterns among less-educated Americans ( 28 ; 29 ), as well as the growing recognition of the importance of education for health ( 84 ), research on the health returns to education is at a critical juncture. A comprehensive research program is needed to understand how education and health are related, in order to identify effective points of intervention to improve population health and reduce disparities.

The article is organized in two parts. First, we review the current state of research on the relationship between education and health. In broad strokes, we summarize the theoretical and empirical foundations of the education-health relationship and critically assess the literature on the mechanisms and causal influence of education on health. In the second part, we highlight gaps in extant research and propose new directions for innovative research that will fill these gaps. The enormous breadth of the literature on education and health necessarily limits the scope of the review in terms of place and time; we focus on the United States and on findings generated during the rapid expansion of the education-health research in the past 10–15 years. The terms “education” and “schooling” are used interchangeably. Unless we state otherwise, both refer to attained education, whether measured in completed years or credentials. For references, we include prior review articles where available, seminal papers, and recent studies as the best starting points for further reading.

THE ASSOCIATION BETWEEN EDUCATION AND HEALTH

Conceptual toolbox for examining the association.

Researchers have generally drawn from three broad theoretical perspectives to hypothesize the relationship between education and health. Much of the education-health research over the past two decades has been grounded in the Fundamental Cause Theory ( 75 ). The FCT posits that social factors such as education are ‘fundamental’ causes of health and disease because they determine access to a multitude of material and non-material resources such as income, safe neighborhoods, or healthier lifestyles, all of which protect or enhance health. The multiplicity of pathways means that even as some mechanisms change or become less important, other mechanisms will continue to channel the fundamental dis/advantages into differential health ( 48 ). The Human Capital Theory (HCT), borrowed from econometrics, conceptualizes education as an investment that yields returns via increased productivity ( 12 ). Education improves individuals’ knowledge, skills, reasoning, effectiveness, and a broad range of other abilities, which can be utilized to produce health ( 93 ). The third approach, the Signaling or Credentialing perspective ( 34 ; 125 ) has been used to explain the observed large discontinuities in health at 12 or 16 years of schooling, typically associated with the receipt of a high school and college degrees, respectively. This perspective views earned credentials as a potent signal about one’s skills and abilities, and emphasizes the economic and social returns to such signals. Thus all three perspectives postulate a causal relationship between education and health and identify numerous mechanisms through which education influences health. The HCT specifies the mechanisms as embodied skills and abilities, FCT emphasizes the dynamism and flexibility of mechanisms, and credentialism identifies social responses to educational attainment. All three theoretical approaches, however, operationalize the complex process of schooling solely in terms of attainment and thus do not focus on differences in educational quality, type, or other institutional factors that might independently influence health. They also focus on individual-level factors: individual attainment, attainment effects, and mechanisms, and leave out the social context in which the education and health processes are embedded.

Observed associations between education and health

Empirically, hundreds of studies have documented “the gradient” whereby more schooling is linked with better health and longer life. A seminal 1973 book by Kitagawa and Hauser powerfully described large differences in mortality by education in the United States ( 71 ), a finding that has since been corroborated in numerous studies ( 31 ; 42 ; 46 ; 109 ; 124 ). In the following decades, nearly all health outcomes were also found strongly patterned by education. Less educated adults report worse general health ( 94 ; 141 ), more chronic conditions ( 68 ; 108 ), and more functional limitations and disability ( 118 ; 119 ; 130 ; 143 ). Objective measures of health, such as biological risk levels, are similarly correlated with educational attainment ( 35 ; 90 ; 140 ), showing that the gradient is not a function of differential reporting or knowledge.

The gradient is evident in men and women ( 139 ) and among all race/ethnic groups ( 36 ). However, meaningful group differences exist ( 60 ; 62 ; 91 ). In particular, education appears to have stronger health effects for women than men ( 111 ) and stronger effects for non-Hispanic whites than minority adults ( 134 ; 135 ) even if the differences are modest for some health outcomes ( 36 ). The observed variations may reflect systematic social differences in the educational process such as quality of schooling, content, or institutional type, as well as different returns to educational attainment in the labor market across population groups ( 26 ). At the same time, the groups share a common macro-level social context, which may underlie the gradient observed for all.

To illustrate the gradient, we analyzed 2002–2016 waves of the National Health Interview Survey (NHIS) data from adults aged 25–64. Figure 1 shows the levels of three health outcomes across educational attainment levels in six major demographic groups predicted at age 45. Three observations are noteworthy. First, the gradient is evident for all outcomes and in all race/ethnic/gender groups. Self-rated health exemplifies the staggering magnitude of the inequalities: White men and women without a high school diploma have about 57% chance of reporting fair or poor health, compared to just 9% for college graduates. Second, there are major group differences as well, both in the predicted levels of health problems, as well as in the education effects. The latter are not necessarily visible in the figures but the education effects are stronger for women and weaker for non-white adults as prior studies showed (table with regression model results underlying the prior statement is available from the authors). Third, an intriguing exception pertains to adults with “some college,” whose health is similar to high school graduates’ in health outcomes other than general health, despite their investment in and exposure to postsecondary education. We discuss this anomaly below.

Predicted Probability of Health Problems

Source: 2002–2016 NHIS Survey, Adults Age 25–64

Pathways through which education impacts health

What explains the improved health and longevity of more educated adults? The most prominent mediating mechanisms can be grouped into four categories: economic, health-behavioral, social-psychological, and access to health care. Education leads to better, more stable jobs that pay higher income and allow families to accumulate wealth that can be used to improve health ( 93 ). The economic factors are an important link between schooling and health, estimated to account for about 30% of the correlation ( 36 ). Health behaviors are undoubtedly an important proximal determinant of health but they only explain a part of the effect of schooling on health: adults with less education are more likely to smoke, have an unhealthy diet, and lack exercise ( 37 ; 73 ; 105 ; 117 ). Social-psychological pathways include successful long-term marriages and other sources of social support to help cope with stressors and daily hassles ( 128 ; 131 ). Interestingly, access to health care, while important to individual and population health overall, has a modest role in explaining health inequalities by education ( 61 ; 112 ; 133 ), highlighting the need to look upstream beyond the health care system toward social factors that underlie social disparities in health. Beyond these four groups of mechanisms that have received the most attention by investigators, many others have been examined, such as stress, cognitive and noncognitive skills, or environmental exposures ( 11 ; 43 ). Several excellent reviews further discuss mechanisms ( 2 ; 36 ; 66 ; 70 ; 93 ).

Causal interpretation of the education-health association

A burgeoning number of studies used innovative approaches such as natural experiments and twin design to test whether and how education causally affects health. These analyses are essential because recommendations for educational policies, programs, and interventions seeking to improve population health hinge on the causal impact of schooling on health outcomes. Overall, this literature shows that attainment, measured mostly in completed years of schooling, has a causal impact on health across numerous (though not all) contexts and outcomes.

Natural experiments take advantage of external changes that affect attainment but are unrelated to health, such as compulsory education reforms that raise the minimum years of schooling within a given population. A seminal 2005 study focused on increases in compulsory education between 1915 and 1939 across US states and found that a year of schooling reduced mortality by 3.6% ( 78 ). A re-analysis of the data indicated that taking into account state-level mortality trends rendered the mortality effects null but it also identified a significant and large causal effect on general health ( 88 ). A recent study of a large sample of older Americans reported a similar pattern: a substantial causal effect of education for self-rated health but not for mortality ( 47 ). School reform studies outside the US have reported compelling ( 122 ) or modest but significant ( 32 ) effects of schooling on health, although some studies have found nonsignificant ( 4 ), or even negative effects ( 7 ) for a range of health outcomes.

Twin design studies compare the health of twins with different levels of education. This design minimizes the influence of family resources and genetic differences in skills and health, especially for monozygotic twins, and thus serves to isolate the effect of schooling. In the US, studies using this design generated robust evidence of a causal effect of education on self-rated health ( 79 ), although some research has identified only modest ( 49 ) or not significant ( 3 ; 55 ) effects for other physical and mental health outcomes. Studies drawing on the large twin samples outside of the US have similarly found strong causal effects for mortality ( 80 ) and health ( 14 ; 16 ; 51 ) but again some analyses yielded no causal effects on health ( 13 ; 83 ) or health behaviors ( 14 ). Beyond our brief overview, readers may wish consult additional comprehensive reviews of the causal studies ( 40 ; 45 ; 89 ).

The causal studies add valuable evidence that educational attainment impacts adult health and mortality, even considering some limitations to their internal validity ( 15 ; 88 ). To improve population health and reduce health disparities, however, they should be viewed as a starting point to further research. First, the findings do not show how to improve the quality of schooling or its quantity for in the aggregate population, or how to overcome systematic intergenerational and social differences in educational opportunities. Second, their findings do take into account contexts and conditions in which educational attainment might be particularly important for health. In fact, the variability in the findings may be attributable to the stark differences in contexts across the studies, which include countries characterized by different political systems, different population groups, and birth cohorts ranging from the late 19 th to late 20 th centuries that were exposed to education at very different stages of the educational expansion process ( 9 ).

TOWARD A SOCIALLY-EMBEDDED UNDERSTANDING OF THE EDUCATION-HEALTH RELATIONSHIP

To date, the extensive research we briefly reviewed above has identified substantial health benefits of educational attainment in most contexts in today’s high-income countries. Still, many important questions remain unanswered. We outline three critical directions to gain a deeper understanding of the education-health relationship with particular relevance for policy development. All three directions shift the education-health paradigm to consider how education and health are embedded in life course and social contexts.

First, nearly universally, the education-health literature conceptualizes and operationalizes education in terms of attainment, as years of schooling or completed credentials. However, attainment is only the endpoint, although undoubtedly important, of an extended and extensive process of formal schooling, where institutional quality, type, content, peers, teachers, and many other individual, institutional, and interpersonal factors shape lifecourse trajectories of schooling and health. Understanding the role of the schooling process in health outcome is relevant for policy because it can show whether interventions should be aimed at increasing attainment, or whether it is more important to increase quality, change content, or otherwise improve the educational process at earlier stages for maximum health returns. Second, most studies have implicitly or explicitly treated educational attainment as an exogenous starting point, a driver of opportunities in adulthood. However, education also functions to reproduce inequality across generations. The explicit recognition of the dual function of education is critical to developing education policies that would avoid unintended consequence of increasing inequalities. And third, the review above indicates substantial variation in the education-health association across different historical and social contexts. Education and health are inextricably embedded in these contexts and analyses should therefore include them as fundamental influences on the education-health association. Research on contextual variation has the potential to identify contextual characteristics and even specific policies that exacerbate or reduce educational disparities in health.

We illustrate the key conceptual components of future research into the education-health relationship in Figure 2 . Important intergenerational and individual socio-demographic factors shape educational opportunities and educational trajectories, which are directly related to and captured in measures of educational attainment. This longitudinal and life course process culminates in educational disparities in adult health and mortality. Importantly, the macro-level context underlies every step of this process, shaping each of the concepts and their relationships.

Enriching the conceptualization of educational attainment

In most studies of the education-health associations, educational attainment is modeled using years of schooling, typically specified as a continuous covariate, effectively constraining each additional year to have the same impact. A growing body of research has substituted earned credentials for years. Few studies, however, have considered how the impact of additional schooling is likely to differ across the educational attainment spectrum. For example, one additional year of education compared to zero years may be life-changing by imparting basic literacy and numeracy skills. The completion of 14 rather than 13 years (without the completion of associated degree) could be associated with better health through the accumulation of additional knowledge and skills as well, or perhaps could be without health returns, if it is associated with poor grades, stigma linked to dropping out of college, or accumulated debt ( 63 ; 76 ). Examining the functional form of the education-health association can shed light on how and why education is beneficial for health ( 70 ). For instance, studies found that mortality gradually declines with years of schooling at low levels of educational attainment, with large discontinuities at high school and college degree attainment ( 56 ; 98 ). Such findings can point to the importance of completing a degree, not just increasing the quantity (years) of education. Examining mortality, however, implicitly focused on cohorts who went to school 50–60 years ago, within very different educational and social contexts. For findings relevant to current education policies, we need to focus on examining more recent birth cohorts.

A particularly provocative and noteworthy aspect of the functional form is the attainment group often identified as “some college:” adults who attended college but did not graduate with a four-year degree. Postsecondary educational experiences are increasingly central to the lives of American adults ( 27 ) and college completion has become the minimum requirement for entry into middle class ( 65 ; 87 ). Among high school graduates, over 70% enroll in college ( 22 ) but the majority never earn a four-year degree ( 113 ). In fact,, the largest education-attainment group among non-elderly US adults comprises the 54 million adults (29% of total) with some college or associate’s degree ( 113 ). However, as in Figure 1 , this group often defies the standard gradient in health. Several recent studies have found that the health returns to their postsecondary investments are marginal at best ( 110 ; 123 ; 142 ; 144 ). This finding should spur new research to understand the outcomes of this large population group, and to glean insights into the health returns to the postsecondary schooling process. For instance, in the absence of earning a degree, is greater exposure to college education in terms of semesters or earned credits associated with better health or not? How do the returns to postsecondary schooling differ across the heterogeneous institutions ranging from selective 4-year to for-profit community colleges? How does accumulated college debt influence both dropout and later health? Can we identify circumstances under which some college education is beneficial for health? Understanding the health outcomes for this attainment group can shed light on the aspects of education that are most important for improving health.

A related point pertains to the reliability and validity of self-reported educational attainment. If a respondent reports 16 completed years of education, for example, are they carefully counting the number of years of enrollment, or is 16 shorthand for “completed college”? And, is 16 years the best indicator of college completion in the current context when the median time to earn a four-year degree exceeds 5 years ( 30 )? And, is longer time in college given a degree beneficial for health or does it signify delayed or disrupted educational pathways linked to weaker health benefits ( 132 )? How should we measure part-time enrollment? As studies begin to adjudicate between the health effects of years versus credentials ( 74 ) in the changing landscape of increasingly ‘nontraditional’ pathways through college ( 132 ), this measurement work will be necessary for unbiased and meaningful analyses. An in-depth understanding may necessitate primary data collection and qualitative studies. A feasible direction available with existing data such as the National Longitudinal Survey of Youth 1997 (NLSY97) is to assess earned college credits and grades rather than years of education beyond high school.

As indicated in Figure 2 , beyond a more in-depth usage of the attainment information, we argue that more effective conceptualization of the education-health relationship as a developmental life course process will lead to important findings. For instance, two studies published in 2016 used the NLSY97 data to model how gradual increases in education predict within-individual changes in health ( 39 ; 81 ). Both research teams found that gradual accumulation of schooling quantity over time was not associated with gradual improvements in health. The investigators interpreted the null findings as an absence of causal effects of education on health, especially once they included important confounders (defined as cognitive and noncognitive skills and social background). Alternatively, perhaps the within-individual models did not register health because education is a long-term, developing trajectory that cannot be reduced to point-in-time changes in exposure. Criticisms about the technical aspects of theses studies notwithstanding ( 59 ), we believe that these studies and others like them, which wrestle with the question of how to capture education as a long-term process grounded in the broader social context, and how this process is linked to adult health, are desirable and necessary.

Education as (re)producer of inequality

The predominant theoretical framework for studying education and health focuses on how education increases skills, improves problem-solving, enhances employment prospects, and thus opens access to other resources. In sociology, however, education is viewed not (only) as increasing human capital but as a “sieve more than a ladder” ( 126 ), an institution that reproduces inequality across generations ( 54 ; 65 ; 103 ; 114 ). The mechanisms of the reproduction of inequality are multifarious, encompassing systematic differences in school resources, quality of instruction, academic opportunities, peer influences, or teacher expectations ( 54 ; 114 ; 132 ). The dual role of education, both engendering and constraining social opportunities, has been recognized from the discipline’s inception ( 52 ) and has remained the dominant perspective in sociology of education ( 18 ; 126 ). Health disparities research, which has largely dismissed the this perspective as “specious” ( 93 ), could benefit from pivoting toward this complex sociological paradigm.

As demonstrated in Figure 2 , parental SES and other background characteristics are key social determinants that set the stage for one’s educational experiences ( 20 ; 120 ). These characteristics, however, shape not just attainment, but the entire educational and social trajectories that drive and result in particular attainment ( 21 ; 69 ). Their effects range from the differential quality and experiences in daycare or preschool settings ( 6 ), K-12 education ( 24 ; 136 ), as well as postsecondary schooling ( 5 ; 127 ). As a result of systematically different experiences of schooling over the early life course stratified by parental SES, children of low educated parents are unlikely to complete higher education: over half of individuals with college degrees by age 24 came from families in the top quartile of family income compared to just 10% in the bottom quartile ( 23 ).

Unfortunately, prior research has generally operationalized the differences in educational opportunities as confounders of the education-health association or as “selection bias” to be statistically controlled, or best as a moderating influence ( 10 ; 19 ). Rather than remove the important life course effects from the equation, studies that seek to understand how educational and health differences unfold over the life course, and even across generations could yield greater insight ( 50 ; 70 ). A life course, multigenerational approach can provide important recommendations for interventions seeking to avoid the unintended consequence of increasing disparities. Insofar as socially advantaged individuals are generally better positioned to take advantage of interventions, research findings can be used to ensure that policies and programs result in decreasing, rather than unintentionally widening, educational and health disparities.

Education and health in social context

Finally, perhaps the most important and policy-relevant emerging direction to improving our understanding of the education-health relationship is to view both as inextricably embedded within the broad social context. As we highlight in Figure 2 , this context underlies every feature of the development of educational disparities in health. In contrast to the voluminous literature focusing on individual-level schooling and health, there has been a “startling lack of attention to the social/political/economic context” in which the relationships are grounded ( 33 ). By context, we mean the structure of a society that varies across time and place, encompassing all major institutions, policy environments, as well as gender, race/ethnicity, age, and socioeconomic stratification. Under what circumstances, conditions, and policies are the associations between education and health stronger or weaker?

Within the United States, the most relevant units of geo-political boundaries generating distinct policy contexts are states, although smaller geographic units are also pertinent ( 44 ; 100 ). Since the 1980s, the federal government has devolved an increasing range of key socioeconomic, political, and health-care decisions to states. This decentralization has resulted in increasing diversity across states in conditions for a healthy life ( 96 ; 101 ). A recent study demonstrates how different environments across US states yield vastly different health returns to education ( 100 ). State-level characteristics had little impact on adults with high education, whose disability levels were similarly low regardless of their state of residence. In contrast, disability levels of low-educated adults were not only high but also varied substantially across states: disability was particularly high in states that have invested less in the social welfare of its residents, such as Mississippi, Kentucky, and West Virginia. Highly-educated adults, particularly white adults and men who can convert education into other resources most readily, use personal resources to protect their health like a ‘personal firewall’ ( 97 ). Their less-educated peers, meanwhile, are vulnerable without social safety nets. Demonstrating the potential for informing policy in this area, the findings directly identify state policies that influence the extent to which educational attainment matters for health and longevity. These include economic policies including state income tax structures and education expenditures per capita, as well as policies influencing social cohesion in a state, such as income inequality and unemployment rates. Beyond the US, investigators can leverage differences in political systems across countries to assess the impact of different welfare regimes on the education-health associations, as some European researchers began generating ( 41 ; 82 ).

Similar to variation across geo-political boundaries, research on variation across time can highlight policies and conditions that mitigate or inflate health disparities. How has the education-health association changed over time? In recent decades, the association has become increasingly strong, with widening disparities in health outcomes across education ( 53 ; 77 ; 86 ; 116 ; 143 ). These increases started in the 1980s ( 17 ) at the same time that social inequality began rising with the political embrace of pro-market neoliberal policies ( 33 ). Since then, the United States has been increasingly marked by plummeting economic wellbeing (except for the wealthiest Americans), growing economic segregation, emerging mass incarceration, downward social mobility, and despair in many working-class communities ( 17 ; 95 ; 129 ). Conversely, in the two decades prior (1960s and 70s), social disparities in health were decreasing ( 1 ; 72 ). During those decades, many pro-social policies such as Civil rights legislation, War on Poverty programs, and racial desegregation were improving social inequalities. Macro-level political forces, clearly, can influence not only social but also health inequalities ( 104 ). Two facts follow: growing disparities are not inevitable and changes in the education-health relationship may be strongly linked to social policies. While some of the growth in educational inequalities may be attributable to changes in educational composition of the population with increasingly negatively select groups of adults at the lowest levels of schooling, these compositional changes likely play only a minor role in the overall trends ( 38 ; 58 ). Linking education and health to the broader social context brings to the forefront the ways in which we, as individuals and a collective society, produce and maintain health disparities.

Implications for Policy and Practice

Reducing macro-level inequalities in health will require macro-level interventions. Technological progress and educational expansion over the past several decades have not decreased disparities; on the contrary, educational disparities in health and mortality have grown in the US. Moreover, the consistent, durable relationship between education and health and the multitude of mechanisms linking them suggests that programs targeting individual behaviors will have limited impact to counteract disparities. Thus, we argue that future findings from the new research directions proposed here can be used to intervene at the level of social contexts to alter educational trajectories from an early age, with the ultimate goal of reducing health disparities. We note two promising avenues for policy development.

One potential solution may focus on universal federal and state-level investment in the education and well-being of children early in the life course to disrupt the reproduction of social inequalities and change subsequent educational trajectories. Several experimental early-education programs such as the Perry Preschool Project and Carolina Abecedarian Project have demonstrated substantial, lasting, and wide-ranging benefits, including improved adult health ( 25 ; 57 ; 102 ). These programs provided intensive, exceptionally high-quality, and diverse services to children, and it is these characteristics that appear central to their success ( 138 ). Further research on the qualitative and social dimensions of education and their effects on health can inform future model educational programs and interventions across all ages.

Another important issue for both researchers and policymakers pertains to postsecondary enrollment and attrition, and their effects on health. Educational expansion in the college-for-all era has yielded high post-secondary enrollment, but also unacceptable dropout rates with multiple detrimental consequences, including high rates of student debt ( 64 ) and stigma ( 76 ), which may negatively affect health. Emerging studies found that college dropouts fail to benefit from their postsecondary investments. Next we need to understand under what circumstances college goers do reap health benefits, or how their postsecondary experience can be modified to improve their health.

For both of these avenues, effective implementation will need further research on the specific institutional characteristics and social contexts that shape the schooling effects. However, in designing interventions and policies, we need to be aware of the dual role of education as a drive and reproducer of inequality. Individuals from advantaged backgrounds may be better positioned to take advantage of new educational opportunities, and thus any interventions and programs need to ensure that marginalized populations have equal or greater access in order to avoid the unintended consequence of further intensifying disparities. Finally, researchers and policymakers should engage in a dialogue such that researchers effectively communicate their insights and recommendations to policymakers, and policymakers convey the needs and challenges of their practices to researchers.

Education and health are central to individual and population well-being. They are also inextricably embedded in the social context and structure. Future research needs to expand beyond the individual-focused analyses and hypothesize upstream ( 96 ), taking a contextual approach to understanding education and health. Such an approach will require interdisciplinary collaborations, innovations in conceptual models, and rich data sources. The three directions for further research on health returns to education we outlined above can help generate findings that will inform effective educational and health policies and interventions to reduce disparities. During this critical time when health differences are widening and less educated Americans are experiencing social and health declines, research and policy has the opportunity to make a difference and improve the health and well-being of our population.

Contributor Information

Anna Zajacova, Western University.

Elizabeth M. Lawrence, University of North Carolina.

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LGBTQIA+ Cultural Competence in Physical Therapist Education and Practice: A Qualitative Study from the Patients’ Perspective

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Melissa C Hofmann, Nancy F Mulligan, Kelly Stevens, Karla A Bell, Chris Condran, Tonya Miller, Tiana Klutz, Marissa Liddell, Carlo Saul, Gail Jensen, LGBTQIA+ Cultural Competence in Physical Therapist Education and Practice: A Qualitative Study from the Patients’ Perspective, Physical Therapy , 2024;, pzae062, https://doi.org/10.1093/ptj/pzae062

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The purpose of this study was to explore the experiences of cultural competence and humility among patients of the lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) community in physical therapy. Researchers sought to understand the perspectives of adults over 18 years old who have received physical therapy and identify as a member of the LGBTQIA+ community.

A phenomenological qualitative approach was utilized for this study. Patients were recruited through social media and LGBTQIA+ advocacy organizations across the United States. Twenty-five patients agreed to participate in the study. Focus groups and individual interviews were conducted using a semi-structured interview guide informed by Campinha-Bacote's domains of cultural competence (cultural awareness, skill, knowledge, encounter, and desire) to collect individual experiences, discussions, thoughts, perceptions, and opinions.

Three central themes and subthemes emerged from the data and were categorized according to cultural acceptance (societal impact, implicit and explicit bias), power dynamics between the in-group and out-group (out-group hyperawareness of their otherness), and participant solutions (policy, training, education).

An LGBTQIA+ patient’s experience is influenced by the provider cultural acceptance, and the resulting power dynamics that impact LGBTQIA+ patients’ comfort, trust, and perceptions of care. Enhanced patient experiences were found more prevalent with providers that possessed elevated levels of education or experience with this community, supporting Campinha-Bacote’s assumption that there is a direct relationship between level of competence in care and effective and culturally responsive service.

Awareness of the underlying issues presented in these themes will assist in the development of effective solutions to improve LGBTQIA+ cultural competence among physical therapists and physical therapist assistants on a systemic level.

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UFF-UF holds virtual teach-in to discuss academic freedom, future of higher education

State education reform legislation poses difficulties for professors, students and locals.

The click of a Zoom link brought over 30 people together April 17 for a discussion of academic freedom through the lens of UF professors, students and Gainesville community members. 

In honor of the National Day of Action for Higher Education for the Public Good, the United Faculty of Florida-UF spearheaded a virtual teach-in addressing recent state legislation targeting universities and the future of higher education. The meeting was co-hosted by UF history professor Paul Ortiz and Steve Kirn, a retired member of the UF College of Business, who introduced speakers from the university and beyond. 

“Our students, staff and faculty have really been on the front lines of holding the line in support of academic freedom,” Ortiz said in the meeting. 

Signed into law in 2023, Florida House Bill 999 sought to drastically change state education, prohibiting the allocation of state or federal grant money toward diversity, equity and inclusion programs. UF fired 13 full-time DEI employees and eliminated 15 administrative appointments for faculty March 1, enacting the closure of the Office of the Chief Diversity Officer and affiliated DEI contracts. 

Sharon Austin, a UF political science professor and UFF-UF member, said she experienced microaggressions and discrimination as a Black woman enrolled in a college without DEI programs in the 1980s. 

“It was a hostile environment,” she said in the meeting. 

Students could lose pride in their universities much like she did in hers, Austin said. 

In light of the recent threat to multiple RTS routes through campus and farther into the Gainesville area, Zefnia Durham stressed the importance of public transportation for students. As a bus driver, he served as president of the Amalgamated Transit Union Local 1579 and represented the SOS campaign seeking to protect RTS. 

Compromising bus routes limits those who can’t afford on-campus living, he said. 

“If you don’t have access to get to the education, what good is the education for you?” Durham said in the meeting. 

UFF-UF President and Engineering Professor Meera Sitharam provided an overview of the “outbreak” of state legislation targeting K-12 and higher education since 2020, including the “Stop WOKE” act and “Don’t Say Gay” bill among others threatening unions and international cooperation. 

“We got this poisonous combination of mindlessness, apathy and authoritarianism,” Sitharam said in the meeting. 

She is currently undergoing post-tenure review as mandated by the 2023 Senate Bill 266. 

Anna Peterson, a UFF-UF member and religion professor, learned the “Stop WOKE” act prohibited the discussion of critical race theory two weeks before the next semester began in Summer 2022. She added it to her curriculum shortly after but feared students would report her, Peterson said. 

“I was a little concerned. It was kind of a trust fall,” she said in the meeting. 

International faculty, especially those of Chinese descent, were impacted greatly by the passage of Senate Bill 846 in 2023 that prohibited UF’s collaboration with any “foreign country of concern,” including China and Iran among others, said Zhong-Ren Peng, International Center for Adaptation Planning and Design director and UFF-UF member. 

“We are not able to recruit top graduate assistants from those certain countries of concern,” Peng said in the meeting. “That really affects our research.”

In a time where threats to education have become common, sharing information and experiences with one another is critical to spreading awareness, said Rafael Ramirez Solorzano, UFF-UF member and Latin American studies professor. 

He explained his experience teaching at UF as a queer person of color, which he described as having a target on his back. He said the university has seen a “BIPOC faculty flight.”

“Students come to me, specifically students of color, saying, ‘I don’t have anyone to work with,’” he said in the meeting.  

In light of the Israel-Hamas war, Meir Schochet, a UF junior and Jewish Voice for Peace vice president, said his organization has witnessed student organizations fight threats of disbandment, including Students for Justice in Palestine. 

“We must continue to be loud and refuse to comply with demands to silence our free thoughts and speech,” he said in the meeting. 

UF Sunrise Movement President Sofia Aviles was accompanied by Campbell Al-Khafaji, president of Climate Action Gator, along with members of both organizations to discuss the UF Green New Deal , an initiative to fight climate change, a term that has also faced backlash from the Florida legislature. 

The teach-in was concluded with additional resources provided by Adolfho Romero, Samuel Proctor Oral History Program project coordinator, and a final statement from Kirn, the event’s co-host.

“We must come together,” he said in the meeting. 

Contact Rylan DiGiacomo-Rapp at [email protected] . Follow her on X @rylan_digirapp.

Rylan DiGiacomo-Rapp is a second-year journalism and environmental science major covering enterprise politics. She previously worked as a metro news assistant. Outside of the newsroom, you can usually find her haunting local music venues.

DeSantis signs bill mandating communism education in Florida public schools By Diego Perdomo | Apr. 18

UF administrator trespassed, no longer employed at university for alleged fistfight By Alissa Gary | Apr. 19

Florida bill impacts classrooms two years later By Delia Rose Sauer | Apr. 22

UF Student Government is corrupt, opaque and ineffective. What do we do? By Ronin Lupien | Apr. 18

Remembering Bob Graham: Former senator and Florida governor dies at 87 By Annie Wang | Apr. 22

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Training nurses in an international emergency medical team using a serious role-playing game: a retrospective comparative analysis

• Hai Hu 1 , 2 , 3   na1 ,
• Xiaoqin Lai 2 , 4 , 5   na1 &
• Longping Yan 6 , 7 , 8  

BMC Medical Education volume  24 , Article number:  432 ( 2024 ) Cite this article

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Metrics details

Although game-based applications have been used in disaster medicine education, no serious computer games have been designed specifically for training these nurses in an IEMT setting. To address this need, we developed a serious computer game called the IEMTtraining game. In this game, players assume the roles of IEMT nurses, assess patient injuries in a virtual environment, and provide suitable treatment options.

The design of this study is a retrospective comparative analysis. The research was conducted with 209 nurses in a hospital. The data collection process of this study was conducted at the 2019-2020 academic year. A retrospective comparative analysis was conducted on the pre-, post-, and final test scores of nurses in the IEMT. Additionally, a survey questionnaire was distributed to trainees to gather insights into teaching methods that were subsequently analyzed.

There was a significant difference in the overall test scores between the two groups, with the game group demonstrating superior performance compared to the control group (odds ratio = 1.363, p value = 0.010). The survey results indicated that the game group exhibited higher learning motivation scores and lower cognitive load compared with the lecture group.

Conclusions

The IEMT training game developed by the instructor team is a promising and effective method for training nurses in disaster rescue within IEMTs. The game equips the trainees with the necessary skills and knowledge to respond effectively to emergencies. It is easily comprehended, enhances knowledge retention and motivation to learn, and reduces cognitive load.

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Since the beginning of the twenty-first century, the deployment of international emergency medical teams in disaster-stricken regions has increased world wide [ 1 ]. To enhance the efficiency of these teams, the World Health Organization (WHO) has introduced the International Emergency Medical Team (IEMT) initiative to guarantee their competence. Adequate education and training play a vital role in achieving this objective [ 2 ].

Nurses play a vital role as IEMTs by providing essential medical care and support to populations affected by disasters and emergencies. Training newly joined nurses is an integral part of IEMT training.

Typical training methods include lectures, field-simulation exercises, and tabletop exercises [ 3 , 4 , 5 ]. However, lectures, despite requiring fewer teaching resources, are often perceived as boring and abstract. This may not be the most ideal method for training newly joined nurses in the complexities of international medical responses. However, simulation field exercises can be effective in mastering the knowledge and skills of disaster medicine responsiveness. However, they come with significant costs and requirements, such as extended instructional periods, additional teachers or instructors, and thorough preparation. These high costs make it challenging to organize simulation exercises repeatedly, making them less ideal for training newly joined nurses [ 6 ].

Moreover, classic tabletop exercises that use simple props, such as cards in a classroom setting, have limitations. The rules of these exercises are typically simple, which makes it challenging to simulate complex disaster scenarios. In addition, these exercises cannot replicate real-life situations, making them too abstract for newly joined nurses to fully grasp [ 7 , 8 ].

Recently, game-based learning has gained increasing attention as an interactive teaching method [ 9 , 10 ]. Previous studies have validated the efficacy of game-based mobile applications [ 11 , 12 ]. Serious games that align with curricular objectives have shown potential to facilitate more effective learner-centered educational experiences for trainees [ 13 , 14 ]. Although game-based applications have been used in disaster medicine education, no serious computer games have been designed specifically for training newly joined nurses in an international IEMT setting.

Our team is an internationally certified IEMT organization verified by the WHO, underscoring the importance of providing training for newly joined nurses in international medical responses. To address this need, we organized training courses for them. As part of the training, we incorporated a serious computer game called the IEMTtraining game. In this game, players assume the roles of IEMT nurses, assess patient injuries in a virtual environment, and provide suitable treatment options. This study aims to investigate the effectiveness of the IEMTtraining game. To the best of our knowledge, this is the first serious game specifically designed to train newly joined nurses in an IEMT setting.

The IEMTtraining game was subsequently applied to the training course for newly joined nurses, and this study aimed to investigate its effectiveness. To the best of our knowledge, this is the first serious game specifically designedto train newly joined nurses in an IEMT setting.

Study design

This study was conducted using data from the training records database of participants who had completed the training. The database includes comprehensive demographic information, exam scores, and detailed information from post-training questionnaires for all trainees. We reviewed the training scores and questionnaires of participants who took part in the training from Autumn 2019 to Spring 2020.

The local Institutional Review Committee approved the study and waived the requirement for informed consent due to the study design. The study complied with the international ethical guidelines for human research, such as the Declaration of Helsinki. The accessed data were anonymized.

Participants

A total of 209 newly joined nurses needed to participate in the training. Due to limitations in the size of the training venue, the trainees had to be divided into two groups for the training. All trainees were required to choose a group and register online. The training team provided the schedule and training topic for the two training sessions to all trainees before the training commenced. Each trainee had the opportunity to sign up based on their individual circumstances. Furthermore, the training team set a maximum limit of 110 trainees for each group, considering the dimensions of the training venue. Trainees were assigned on a first-come-first-served basis. In the event that a group reached its capacity, any unregistered trainees would be automatically assigned to another group.

In the fall of 2019, 103 newly joined nurses opted for the lecture training course (lecture group). In this group, instructors solely used the traditional teaching methods of lectures and demonstrations. The remaining 106 newly joined nurses underwent game-based training (game group). In addition to the traditional lectures and demonstrations, the instructor incorporated an IEMTtraining game to enhance the training experience in the game group.

The IEMTTraining game

The IEMTtraining game, a role-playing game, was implemented using the RPG Maker MV Version1.6.1 (Kadokawa Corporation, Tokyo, Tokyo Metropolis, Japan). Players assumed the roles of rescuers in a fictional setting of an earthquake (Part1 of Supplemental Digital Content ).

The storyline revolves around an earthquake scenario, with the main character being an IEMT nurse. Within the game simulation, there were 1000 patients in the scenario. The objective for each player was to treat as many patients as possible to earn higher experience points compared to other players. In addition, within the game scene, multiple nonplayer characters played the role of injured patients. The players navigate the movements of the main character using a computer mouse. Upon encountering injured persons, the player can view their injury information by clicking on them and selecting the triage tags. The player can then select the necessary medical supplies from the kit to provide treatment. Additionally, the player is required to act according to the minimum standards for IEMTs, such as registration in the IEMT coordination cell and reporting of injury information following the minimum data set (MDS) designed by the WHO [ 15 , 16 ]. This portion of the training content imposes uniform requirements for all IEMT members, hence it is necessary for IEMT nurses to learn it. All correct choices result in the accumulation of experience points. Game duration can be set by the instructor and the player with the highest experience points at the end of the game.

Measurement

We have collected the test scores of the trainees in our training database to explore their knowledge mastery. Additionally, we have collected post-training questionnaire data from the trainees to investigate their learning motivation, cognitive load, and technology acceptance.

Pre-test, post-test, and final test

All trainees were tested on three separate occasions: (1) a “pre-test”before the educational intervention, (2) a “post-test”following the intervention, and (3) a “final test”at the end of the term (sixweeks after the intervention). Each test comprised 20 multiple-choice questions (0.5 points per item) assessing the trainees’ mastery of crucial points in their knowledge and decision-making. The higher the score, the better the grade will be.

Questionnaires

The questionnaires used in this study can be found in Part 2 of the Supplemental Digital Content .

The learning motivation questionnaire used in this study was based on the measure developed by Hwang and Chang [ 17 ]. It comprises seven items rated on a six-point scale. The reliability of the questionnaire, as indicated by Cronbach’s alpha, was 0.79.

The cognitive load questionnaire was adapted from the questionnaire developed by Hwang et al [ 18 ]. It consisted of five items for assessing “mental load” and three items for evaluating “mental effort.” The items were rated using a six-point Likert scale. The Cronbach’s alpha values for the two parts of the questionnaire were 0.86 and 0.85, respectively.

The technology acceptance questionnaire, which was only administered to the game group, as it specifically focused on novel teaching techniques and lacked relevance tothe lecture group, was derived from the measurement instrument developed by Chu et al [ 19 ]. It comprised seven items for measuring “perceived ease of use” and six items for assessing “perceived usefulness.” The items were rated on a six-point Likert scale. The Cronbach’s alpha values for the two parts of the questionnaire were 0.94 and 0.95, respectively.

The lecture group received 4 hours of traditional lectures. Additionally, 1 week before the lecture, the trainees were provided with a series of references related to the topic and were required to preview the content before the class. A pre-test was conducted before the lecture to assess the trainees’ prior knowledge, followed by a post-test immediately after the lecture, and a final test 6 weeks after training.

In the game group, the delivery and requirements for references were the same as those in the lecture group. However, the training format differed. The game group received a half-hour lecture introducinggeneral principles, followed by 3 hours of gameplay. The last halfhour was dedicated to summarizing the course and addressing questions or concerns. Similar to the lecture group, the trainees in this group also completed pre-, post-, and final tests. Additionally, a brief survey ofthe teaching methods was conducted at the end of the final test (see Fig.  1 ).

General overview of the teaching procedure. Figure Legend: The diagram shows the teaching and testing processes for the two groups of trainees. Q&A: questions and answers

Data analysis

All data were analyzed using IBM SPSS Statistics (version 20.0;IBM Inc., Armonk, NY, USA). Only the trainees who participated in all three tests were included in the analysis. In total, there were 209 trainees, but 11 individuals (6 from the lecture group and 5 from the game group) were excluded due to incomplete data. Therefore, the data of 198 trainees were ultimately included in the analysis.

In addition, measurement data with a normal distribution were described as mean (standard deviation, SD). In contrast, measurement data with non-normal distributions were expressed as median [first quartile, third quartile]. Furthermore, enumeration data were constructed using composition ratios.

Moreover, a generalized estimating equation (GEE) was employed to compare the groups’ pre-, post-, and final test scores. The Mann–Whitney U test was used to compare the questionnaire scores between the two groups. The statistical significance was set at a level of 0.05.

Among the data included in the analysis, 97 (48.99%) participants were in the lecture group, and 101 (51.01%)were in the game group.

The number of male trainees in the lecture and game groups was 30 (30.93%) and 33 (32.67%), respectively. The mean age of participants in the lecture group was 27.44 ± 4.31 years, whereas that of the game group was 28.05 ± 4.29 years. There were no significant differences in sex or age (Table  1 ). Regarding the test scores, no significant differences were found between the two groups in the pre- and post-tests. However, a significant difference was observed in the final test scores conducted 6 weeks later (Table 1 ).

According to the GEE analysis, the overall scores for the post-test and final test were higher compared to the pre-test scores. Additionally, there was a significant difference in the overall test scores between the two groups, with the game group demonstrating superior performance compared to the control group (odds ratio = 1.363, p value = 0.010). Further details of the GEE results can be found in Part 3 of the supplementary materials .

Table  2 presents the results of the questionnaire ratings for the two groups. The median [first quartile, third quartile] of the learning motivation questionnaire ratings were 4 [3, 4] for the lecture group and 5 [4, 5] for the game group. There were significant differences between the questionnaire ratings of the two groups ( p  < 0.001), indicating that the game group had higher learning motivation for the learning activity.

The median [first quartile, third quartile] of the overall cognitive load ratings were 3 [3, 4] and 4 [4, 5] for the game and lecture groups, respectively. There was a significant difference between the cognitive load ratings of the two groups ( p  < 0.001).

This study further compared two aspects of cognitive load: mental load and mental effort. The median [first quartile, third quartile] for the mental effort dimension were 3 [2, 3] and 4 [4, 5] for the game and lecture groups, respectively (p < 0.001). For mental load, the median [first quartile, third quartile] were 4 [3, 4] and 4 [3, 4] for the game and lecture groups, respectively. There was no significant difference in the mental load ratings between the two groups ( p  = 0.539).

To better understand the trainees’ perceptions of the use of the serious game, this study collected the feedback of the trainees in the game group regarding “perceived usefulness” and “perceived ease of use,” as shown in Table 2 . Most trainees provided positive feedback on the two dimensions of the serious game.

To the best of our knowledge, this IEMT training game is the first serious game intended for newly joined nurses of IEMTs. Therefore, this study presents an initial investigation into the applicability of serious games.

Both lectures and serious games improved post-class test scores to the same level, consistent with previous studies. Krishnan et al. found that an educational game on hepatitis significantly improved knowledge scores [ 20 ]. Additionally, our study showed higher knowledge retention in the game group after 6 weeks, in line with previous studies on serious games. In a study on sexually transmitted diseases, game-based instruction was found to improve knowledge retention for resident physicians compared to traditional teaching methods [ 21 ]. The IEMTtraining game, designed as a role-playing game, is more likely to enhance knowledge retention in newly joined nurses in the long term. Therefore, serious games should be included in the teaching of IEMT training.

This study demonstrated improved learning motivation in the game group, consistent with previous research indicating that game-based learning enhances motivation due to the enjoyable and challenging nature of the games [ 22 , 23 ]. A systematic review by Allan et al. further supports the positive impact of game-based learning tools on the motivation, attitudes, and engagement of healthcare trainees [ 24 ].

As serious games are a novel learning experience for trainees, it is worth investigating the cognitive load they experience. Our study found that serious games effectively reduce trainees’ overall cognitive load, particularly in terms of lower mental effort. Mental effort refers to the cognitive capacity used to handle task demands, reflecting the cognitive load associated with organizing and presenting learning content, as well as guiding student learning strategies [ 25 , 26 ]. This reduction in cognitive load is a significant advantage of serious gaming, as it helps learners better understand and organize their knowledge. However, our study did not find a significant difference in mental load between the two groups. Mental load considers the interaction between task and subject characteristics, based on students’ understanding of tasks and subject characteristics [ 18 ]. This finding is intriguing as it aligns with similar observations in game-based education for elementary and secondary school students [ 27 ], but is the first mention of game-based education in academic papers related to nursing training.

In our survey of the game group participants, we found that their feedback regarding the perceived ease of use and usefulness of the game was overwhelmingly positive. This indicates that the designed game was helpful to learners during the learning process. Moreover, the game’s mechanics were easily understood by the trainees without requiring them to investsignificant time and effort to understand the game rules and controls.

This study had some limitations. First, this retrospective observational study may have been susceptible to sampling bias due to the non-random grouping of trainees. It only reviewed existing data from the training database, and future research should be conducted to validate our findings through prospective studies. Therefore, randomized controlled trials are required. Second, the serious game is currently available only in China. We are currently developing an English version to better align with the training requirements of international IEMT nurses. Third, the development of such serious gamescan be time-consuming. To address this problem, we propose a meta-model to help researchers and instructors select appropriate game development models to implement effective serious games.

An IEMT training game for newly joined nurses is a highly promising training method. Its potential lies in its ability to offer engaging and interactive learning experiences, thereby effectively enhancing the training process. Furthermore, the game improved knowledge retention, increased motivation to learn, and reduced cognitive load. In addition, the game’s mechanics are easily understood by trainees, which further enhances its effectiveness as a training instrument.

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Abbreviations

World Health Organization

International Emergency Medical Team

Minimum Data Set

Generalized estimating eq.

Standard deviation

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Acknowledgements

We would like to thank all the staffs who contribute to the database. We would like to thank Editage ( www.editage.cn ) for English language editing. We also would like to thank Dr. Yong Yang for statistics help. We would like to thank The 10th Sichuan University Higher Education Teaching Reform Research Project (No. SCU10170) and West China School of Medicine (2023-2024) Teaching Reform Research Project (No. HXBK-B2023016) for the support.

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Both Hai Hu and Xiaoqin Lai contributed equally to this work and should be regarded as co-first authors.

Authors and Affiliations

Emergency Management Office of West China Hospital, Sichuan University, The street address: No. 37. Guoxue Road, Chengdu City, Sichuan Province, China

China International Emergency Medical Team (Sichuan), Chengdu City, Sichuan Province, China

Hai Hu & Xiaoqin Lai

Emergency Medical Rescue Base, Sichuan University, Chengdu City, Sichuan Province, China

Day Surgery Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China

Xiaoqin Lai

Department of Thoracic Surgery, West China Tianfu Hospital, Sichuan University, Chengdu City, Sichuan Province, China

West China School of Nursing, Sichuan University, Chengdu City, Sichuan Province, China

Longping Yan

West China School of Public Health, Sichuan University, Chengdu, Sichuan, China

West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China

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HH conceived the study, designed the trial, and obtained research funding. XL supervised the conduct of the data collection from the database, and managed the data, including quality control. HH and LY provided statistical advice on study design and analyzed the data. All the authors drafted the manuscript, and contributed substantially to its revision. HH takes responsibility for the paper as a whole.

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Correspondence to Hai Hu .

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Hu, H., Lai, X. & Yan, L. Training nurses in an international emergency medical team using a serious role-playing game: a retrospective comparative analysis. BMC Med Educ 24 , 432 (2024). https://doi.org/10.1186/s12909-024-05442-x

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Received : 05 November 2023

Accepted : 17 April 2024

Published : 22 April 2024

DOI : https://doi.org/10.1186/s12909-024-05442-x

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