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Understanding the value of inclusive education and its implementation: A review of the literature

• Published: 07 September 2020
• Volume 49 , pages 135–152, ( 2020 )

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• Anthoula Kefallinou 1 ,
• Simoni Symeonidou 1 , 2 &
• Cor J. W. Meijer 1  

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European countries are increasingly committed to human rights and inclusive education. However, persistent educational and social inequalities indicate uneven implementation of inclusive education. This article reviews scholarly evidence on inclusion and its implementation, to show how inclusive education helps ensure both quality education and later social inclusion. Structurally, the article first establishes a conceptual framework for inclusive education, next evaluates previous research methodologies, and then reviews the academic and social benefits of inclusion. The fourth section identifies successful implementation strategies. The article concludes with suggestions on bridging the gap between inclusive education research, policy, and practice.

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Kefallinou, A., Symeonidou, S. & Meijer, C.J.W. Understanding the value of inclusive education and its implementation: A review of the literature. Prospects 49 , 135–152 (2020). https://doi.org/10.1007/s11125-020-09500-2

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Research Article

Social inclusion of students with special educational needs assessed by the Inclusion of Other in the Self scale

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute for Management Research, Nijmegen Center for Economics, Radboud University, Nijmegen, The Netherlands

• Jana Vyrastekova

• Published: April 28, 2021
• https://doi.org/10.1371/journal.pone.0250070
• Reader Comments

How does the participation of students with special educational needs (SEN) in mainstream education affect their social inclusion? We introduce a single-item pictorial measure, the Inclusion of Other in the Self (IOS), to compare the social inclusion of SEN students attending mainstream regular schools to social inclusion of SEN students attending special schools. We collected responses from 138 parents of SEN students aged 4–20, to obtain data on the loneliness, friendships and social inclusion of SEN students. The parents of SEN students attending regular schools did not perceive their children to be less included than parents of SEN students attending special schools. School context decreased SEN students’ perceived loneliness independent of the school type. And while most SEN students’ friendships were formed at school, SEN students attending regular schools had more friends, and these were more likely to live in the same neighborhood. Overall, the social inclusion of SEN students across school types was not affected by the school type, only by the school’s inclusive characteristics.

Citation: Vyrastekova J (2021) Social inclusion of students with special educational needs assessed by the Inclusion of Other in the Self scale. PLoS ONE 16(4): e0250070. https://doi.org/10.1371/journal.pone.0250070

Editor: Vitomir Kovanovic, University of South Australia, AUSTRALIA

Received: January 20, 2020; Accepted: March 30, 2021; Published: April 28, 2021

Copyright: © 2021 Jana Vyrastekova. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author received no specific funding for this work.

Competing interests: The author has declared that no competing interests exist.

Introduction

The participation of students with special educational needs (SEN) in regular schools is frequently disputed on the grounds that their social inclusion is failing. SEN students in regular schools were identified as being more lonely than their non-SEN classmates [ 1 – 3 ], having fewer friends and interactions with peers [ 4 – 6 ], and being more likely to be bullied [ 7 ]. These concerns arise from studies comparing SEN students to non-SEN students, using measures of social inclusion that are based on sociometric methods and observational data. Social inclusion is defined in these studies as the presence of reciprocal friendships, interactions between SEN and non-SEN students, the social status of SEN students as perceived by non-SEN students, and the acceptance of SEN students by their classmates [ 8 ].

We propose that comparing the social inclusion of SEN students across educational contexts is a relevant but missing piece of evidence in the current discussion. To evaluate the impact of including SEN students in regular schools as an alternative to their schooling in segregated context of special schools, we have to compare their social inclusion across the school contexts, rather than to compare the social inclusion of SEN students to that of non-SEN students. We offer such a comparison across school contexts, and introduce a new approach to assessing social inclusion based on a subjective perspective of social inclusion. Indeed, recent research shows that although SEN and non-SEN students achieve different outcomes on sociometric measures in regular schools, their perceptions of quality of friendships do not differ [ 9 ]. This suggests that the currently used sociometric methods for assessing social inclusion might underestimate the sense of belonging and social inclusion that SEN students experience in regular schools. Therefore, we also offer a new measure of social inclusion, and respond to the call to create new methods of evaluation of social inclusion [ 8 ].

Our approach is inspired by the literature on subjective well-being [ 10 – 12 ], which has contributed significantly to our understanding how the ultimate goal of economic progress—human well-being–is linked to its traditionally frequently used economic indicators, like income. If the ultimate goal is to achieve the highest possible well-being for an individual, why not assess this well-being directly? Using this approach, it has become apparent that an increase in income does not necessarily translate into an increase in all aspects of well-being [ 13 ]. Furthermore, by directly measuring well-being, the researchers have been able to study factors that underlie well-being (e.g., social relationships) and the impact well-being has on individual’s health or labor market outcomes. The challenge of working with subjective measures of social inclusion is comparable to the challenge that the researchers have faced when introducing subjective well-being measures in economics [ 14 ]. However, there are likely benefits from accepting such a challenge. The new insights that we have gained thanks to the measures of subjective well-being put forth in the literature have resulted in contributions to the formulation of economic policy goals [ 15 ] and have motivated policy-makers to consider subjective well-being complementary to the income measures of economic success.

What is more, the foundation for applying a subjective perspective on all aspects of well-being of SEN students, including social inclusion, is found in the Article 7.3 of the United Nations Convention on the Rights of Persons with Disabilities [ 16 ] stating that: “States Parties shall ensure that children with disabilities have the right to express their views freely on all matters affecting them , their views being given due weight in accordance with their age and maturity , on an equal basis with other children , and to be provided with disability and age-appropriate assistance to realize that right . ” We therefore propose to further the understanding of factors promoting social inclusion in education by adopting a well-validated, simple and easy to administer pictorial measure Inclusion of Other in the Self Scale (IOS) [ 17 ] as a subjective measure of social inclusion. In this study, we use this measure to address how including of SEN students in regular schools affects their social inclusion compared to SEN students in segregated special schools.

This research contributes to the vibrant ongoing normative and empirical discussions about the impact of inclusion in education [ 18 – 20 ]. Inclusion means more than integration of the SEN students in the mainstream system, by placing SEN students in the mainstream schools without a transformation of the education system. The UN Convention on the Human Rights of Persons with Disabilities, Article 24 [ 21 ] recognizes the right of inclusive education for all learners, calling for an education system adapted to the needs of all learners. This legal foundation of inclusion in education has driven efforts to include SEN students in schools with all learners worldwide. However, the success of social inclusion of SEN students, with its goal: " to facilitate true social inclusion a person needs to be both connected and have a sense of belonging ” [ 22 ] remains disputed, although there is a range of positive findings in support of inclusive education.

Early inclusion in education has, for example, been found to increase mutual understanding [ 23 , 24 ]. In addition, the academic achievements of SEN students are higher in regular schools than in special segregated schools [ 25 – 27 ] and the academic achievements of non-SEN students are not negatively affected by inclusion; on the contrary, non-SEN students perform slightly better in inclusive settings with SEN classmates [ 28 – 30 ]. There is also a measurable positive impact on the number of reciprocal friendships and peer acceptance [ 31 ] for non-SEN students attending inclusive classrooms. Despite this evidence on the positive impact of inclusion in education, however, it remains unclear whether including SEN students in regular schools promotes or harms their social inclusion.

Our study is based in the Netherlands which ratified the United Nations Convention on the Rights of People with Disabilities in 2016. Although formally, this awards the right of inclusive education to all learners, the education of SEN students in the Netherlands at the time of our study still took place in two parallel systems: in special schools, with access restricted by eligibility (i.e. by proof of special educational needs), and in regular schools, which occasionally integrate SEN students. We use the existence of this dual system of education for SEN students in the Netherlands, to assess whether their social inclusion varies with the school type.

The contribution of our study is twofold. First, we propose a simple pictorial measure of relationship with others, the IOS Scale [ 17 ], to assess the social inclusion of SEN students. This novel approach to social inclusion focuses on the perception of being included, rather than on demonstrations of inclusion and evaluations via interactions with others. Second, we use this measure of social inclusion to address our research question. How does the social inclusion of SEN students differ across school types, when comparing SEN students attending regular schools to SEN students attending special schools? Data on friendships arising in school and outside of school, together with a short measure of loneliness at home and at school further clarify the impact of including SEN students in regular schools on their social inclusion. This approach offers a new perspective on the impact of including SEN students in the regular schools.

Inclusive education stands high on the international education policy agenda [ 32 ]. Article 24 of the United Nations Convention on the Rights of Persons with Disabilities [ 16 ] states that the States Parties must guarantee that: “ [p]ersons with disabilities can access an inclusive , quality and free primary education and secondary education on an equal basis with others in the communities in which they live .” Inclusive education is further described in the Convention as a way to achieve the social inclusion of persons with disabilities [ 33 ].

The country where we performed our study, the Netherlands, ratified the United Nations Convention on the Rights of Persons with Disabilities in 2016 but has maintained a dual system of special and mainstream regular schools [ 34 ]. The primary phase in the Dutch education system comprises children 4–12 years of age, and is followed by obligatory secondary education [ 35 ]. Since 2014, when the Appropriate Education Act (Wet Passend Onderwijs) was introduced in the Netherlands, local school consortia have been made responsible for offering an adequate education to every student with the hope of promoting inclusive education. Contrary to the expectations, the inclusion of SEN students in regular schools due to this act has not generally increased [ 34 ], although there were significant regional variations associated with varying models of financing the support of SEN students [ 36 ]. In 2016/17, about 2% of primary school students in the Netherlands attended special schools [ 37 ]. When the special educational needs of a student are established by a committee of the regional school consortium, a SEN student can be placed either at a special school or, conditional upon approval by the school, at a regular school, in which case regionally varying financing models are used to finance the placement. This coexistence of regular and special school placement of SEN students in the Dutch system allowed us to address the impact of the alternative student placement on their social inclusion. Since the placement is not random, and may depend on the school and student characteristics, we account for both these factors in our analysis.

Social inclusion is a complex concept, broadly understood as an interaction between interpersonal relationships and community participation [ 38 ]. Assessing the achievement of such a broad concept is difficult, and it is therefore useful to operationalize social inclusion via its relational aspects, namely the feeling of connectedness and sense of belonging [ 39 ]. Feeling of connectedness and sense of belonging represent basic human motivations [ 40 ] and address the extent to which a person identifies as a part of his or her own social context and feels as belonging to it, instead of feeling alone. Feelings of connectedness and a sense of belonging therefore stand central in perceiving social inclusion.

Social inclusion is thus not only about being a part of something as a passive participant or bystander but also about perceiving oneself as connected and emotionally positively affected. To give an example of the difference between social inclusion and participation, a person may be a member of a hobby group or a class at school, perceiving oneself as part of a group, but experience the lack of connection on the emotional level, and feel lonely. Mere participation is not sufficient for being socially included. Higher levels of belonging, and perceived social inclusion, are associated with lower levels of loneliness.

Another aspect that is considered a demonstration of social inclusion is friendships, often defined as reciprocal relationships within a dyad or a group. Friendships fulfill multiple functions in life: they provide support, access to information, safety, entertainment, and health [ 41 , 42 ]. It has been proposed that children and young adults with disabilities are particularly dependent on friendships arising at school due to the restrictions they might experience in other types of social contacts, such as after-school activities or in joining sports or hobby clubs [ 43 , 44 ]. Social scientists propose that homophily, associating with others similar to oneself, serves as a strong organizing principle in social relations and forming friendships. In short: “ Similarity breeds connection ” [ 45 ]. SEN students might experience low homophily in regular schools, among a majority of non-SEN students. Additionally, social comparisons could negatively affect SEN students’ self-concept in regular schools, due to exposure to peers with social and cognitive skills unaffected by the SEN student’s characteristics [ 46 ].

On the other hand, it is also possible that the selected subgroup of SEN students that is accepted by the regular schools in a dual educational system coincides with the group of the most socially adjusted SEN students. If this selection effect is present, we would expect SEN students attending regular schools to feel less lonely, and be more included than SEN students attending special schools, however not only at school, but also at home. The measure of loneliness at home is a control variable for the selection effect possibly accompanying the admission of SEN students to regular schools due to the characteristics of the SEN students associated with social inclusion.

Based on this exposition, we can identify multiple mechanisms by which including SEN students in regular schools could result in a harsher social environment for them, negatively affect their ability to form friendships, drive feelings of loneliness at school, and result in low social inclusion, when controlling for the possible selection effect via individual student and school characteristic. We test the hypotheses that SEN students attending regular schools achieve lower social inclusion, have fewer friends and feel more lonely at school, compared to SEN students attending special schools, using IOS Scale as a measure of social inclusion.

Participants

The data collection took place between December 2016 and March 2017 and was organized via an online questionnaire disseminated by three Dutch organizations representing the interests of citizens with disabilities or chronic disease, or their parents: IederIn (Dutch umbrella organization for people with a physical disability, mental disability or chronic illness), Dutch Patient Association ( https://www.patientenfederatie.nl/ ), and National Platform of Mental Health ( http://www.platformggz.nl/lpggz/ ). This helped to guarantee the credibility of the data collection. The questionnaire was posted on the social media pages of these organizations, meaning that the sample cannot be considered representative of the whole population. This study participants represent a group of parents of SEN students (aged 4–20) seeking information provided by these organizations.

Prior to the data collection, we obtained approval for this study from the Ethical Committee of the Faculty of Management, Radboud University, The Netherlands. Each participant, the parent of a SEN student, gave informed consent for the data provided to be used for this research, by clicking on the approval box before starting the questionnaire. In total, 138 parents of SEN students (aged 4–20) who completed the questionnaire gave informed consent to participate and have their data used for this research. Among them, 68 respondents reported about a SEN student attending a special school, and 70 about a SEN student attending a regular school.

Table 1 contains the characteristics of the SEN students by school type, reported upon by their parents. These SEN students had various types of disability, and the mode was one type of disability. Both genders were represented, though the proportion of boys was somewhat higher (62%). A Mann-Whitney test indicated that age of SEN students did not significantly differ for regular schools (Mdn = 11) and for special schools (Mdn = 12), U(N regular = 70, N special = 68) = 2020.5, p = 0.124.

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https://doi.org/10.1371/journal.pone.0250070.t001

Inclusion of Other in the Self.

We use the pictorial IOS Scale [ 17 ] as a measure of social inclusion. The single-item IOS pictorial scale consists of seven pictures, each presenting two circles. The two circles show increasing overlap starting from the first to the seventh picture ( Fig 1 ). The extent of the overlap is intuitively understood by the respondents as the closeness of the relationship between the subjects presented in the two circles, for example between the responder and the “Other” identified in the circle; a higher overlap stands for a closer relationship. The respondent is asked to indicate which of the seven pictures best represents the relationship with the “Other”. In our study, the relationship between the SEN student and “Other” where this stands for “Other students at school” is reported by the parents of the SEN students. The IOS measure is understood in various contexts as a question about the closeness of relationship with others and being a part of the community; it is intuitive and performs reliably across contexts. Due to its simplicity, it has been proposed as a toolkit for younger audiences [ 47 ] and successfully applied to explain a broad range of relational behaviors such as citizenship [ 48 ], socially responsible decisions [ 49 ], or being a part of a community [ 50 ].

In our study, “Self” referred to “My child” and “Other” referred to “Other students at school”.

https://doi.org/10.1371/journal.pone.0250070.g001

The IOS measure has recently attracted the attention of behavioral scientists studying the impact of social relationships. Gächter et al. [ 51 ] constructed an Index of Relationship Closeness based on several social relationships measuring tools and showed that IOS is highly correlated with this index. They concluded that IOS is a “psychologically meaningful and highly reliable measure of subjective closeness of relationships”, and effectively replaces more extensive and complex measures. Based on this research validating IOS as a measure of a sense of belonging and connectedness with others, we propose that the IOS measure is suitable to capture these elements of social inclusion.

Our study obtained data on the social inclusion of SEN students using the IOS measure from parental proxy reports. We relied on the existing evidence suggesting that although parents may systematically under- or overestimate certain areas of child’s well-being, they also have a fairly good understanding of the child’s overall well-being and his/her relationship with peers [ 52 ]. To account for the parents’ imperfect insight into the social inclusion of their children, we systematically added an alternative answer “I do not know/I do not wish to answer this question” in the questionnaires when collecting the IOS Scale and likewise did so for the Loneliness measure discussed below.

Loneliness.

Loneliness was assessed by a short 3-item Loneliness in children scale [ 53 ] composed of the answers to the questions: (1) I feel alone at school/at home; (2) I feel left out of things at school/at home; (3) I’m lonely at school/at home, measured with a 5-point Likert scale, and evaluated both for the school and home context, respectively. This very short scale is based on the original 24-item scale, has correlated with r = .84 with the full scale [ 54 ], was proposed as a promising measure of loneliness, and has been shown to link with self-reported loneliness [ 55 ]. We constructed the loneliness variable as the sum of the responses to the three questions quoted above. Loneliness has been linked to the perception of being rejected by others, and to social dissatisfaction [ 56 ]. By asking the loneliness question in two contexts, at school and at home, we could address how the school type affects loneliness, compared to the baseline loneliness experienced at home.

Friendships.

We collected information on friendships arising in and outside of school by asking how many friends the SEN student had in each context. The friendships were reported by parents, without the researcher giving an explicit definition of what was understood as friendship. We also asked for the number of online friends, not to pollute the reports with friendships that might arise in a virtual context, but not lead to contact. While virtual friendships may represent an important source of social interaction, especially for disabled youth [ 57 ], we focused on friendships that open the possibility of social inclusion in the same neighborhood where the student lives. To this end, we also asked where most of the friends lived: in particular, we asked whether they lived in the same neighborhood at the SEN student, to address whether friendships started at school promote the creation of social networks in own community, in the place where the SEN students live.

School characteristics.

The SEN students in our sample attended either a special or a regular school, and we categorized these schools by their formal status, as reported by the parents. Each school is thus either categorized as a special or a regular school. Special schools are schools that only admit SEN students, based on evidence of special educational needs. However, the schools can also differ in school culture, which may have impacted on the social inclusion of the SEN students. Therefore, we adopted twelve questions from the Index for Inclusion [ 58 ] to measure how inclusive the school is in its acceptance of diversity, its didactic choices, and the social environment it created. These selected questions (see the Supplementary files) capture how welcoming the school was, how it protected each child’s well-being, and made didactic choices for diversity and collaboration. The answers were obtained on a 5-point Likert scale, and summarized into a single variable, by summing up the responses in the variable SchoolInclusion, ranging from 12 to 60. The higher the value of the variable, the more inclusive the school was for all learners.

We also account for the possibility that parental reports might distort the actual inclusion as perceived by their children and this effect could be mediated by the parent’s perception of the school. For example, parents might be inflating the reports for students attending a regular school. This could happen if parents feel more accepted by their child’s school in the case of a regular school willing to accept a SEN student. The variable ParentalInclusion was based on answers to the question “The school works in partnership with me as parent/care-taker”on a 5-point Likert scale between Totally Disagree and Totally Agree, and was adopted to control for the possibility that parents’ reports on the degree of child inclusion were conflated by their own perceptions of how inclusive the school was.

Data analyses.

This paper studies how SEN students’ social inclusion is affected by their school placement, in special or regular schools, along with loneliness and friendships arising at school and outside school. We first summarized each of the variables, and addressed whether SEN students in special and regulars schools differed in their subjectively perceived social inclusion, loneliness and friendships. We used Mann-Whitney U tests to detect the median differences in the distributions of social inclusion and loneliness under the two school types. The Spearman rank-based correlation coefficient was applied to correlate loneliness at home and school with the subjective perception of inclusion at school, and we tabulated the distribution on the friendships arising at school and outside school.

Our next step was to perform a regression analysis to address whether subjectively perceived social inclusion at school could be explained by the type of school, while controlling for loneliness at home, and friendships at school. We estimated an ordered logit model with the dependent variable being the IOS Scale, ranging from 1 (least included) to 7 (most included), including school type as the main variable. We accounted for the objective classification of schools by their admission criteria as regular of special schools, and also for the fact that these schools might differ in their school culture, as captured by the SchoolInclusion variable.

We also included the ParentalInclusion variable, which captured how included the parents themselves felt at the school of their own choice. In addition, individual student characteristics age, gender, and number of handicaps could affect inclusion, and were added in the regressions as variables Age, Female, and MoreThan1Handicap, respectively. Another bias would be if parents reported the child’s personality type: a socially well-adjusted student with many friends at home might be projected as such at school, even when this was incorrect. We controlled for this by the FriendsNotAtSchool variable, indicating the number of friends that the student had outside the school.

Inclusion of Other in the Self scale

Fig 2 contains information on the main variable we introduced to measure social inclusion—the IOS Scale. Only 4/138 respondents indicated that the IOS question was too difficult to answer. Most of the responses referred to one of the three least-overlapping circles (responses 1, 2 or 3 in Fig 1 ), with 63% of SEN students from special schools and 46% of SEN students from regular schools associated with these three lowest levels of inclusion. Importantly, we found no significant difference in the reports for the SEN students attending regular and special schools. A Mann-Whitney test indicated that IOS did not significantly differ for SEN students attending regular schools (Mdn = 3) and for those attending special schools (Mdn = 3), U(N regular = 70, N special = 64) = 1967.5, p = 0.217. Reports on the IOS Scale did not support that including SEN students in regular schools was associated with them being perceived as less included by their parents, compared to the perceptions of parents of their special school attending peers.

https://doi.org/10.1371/journal.pone.0250070.g002

First, we studied the measure of loneliness of SEN students at home. We asked whether there were systematic differences between SEN students attending regular and special schools, to exclude a selection effect. A Mann-Whitney test indicated that SEN students attending regular schools did not significantly differ in how lonely their parents perceived them to be at home (Mdn = 12) from SEN students attending special schools (Mdn = 12), U (N regular = 67, N special = 66) = 2185.0, p = 0.679. Both groups were on average perceived to be on the lonely side, with an average short scale value of 9.6 vs. 10.6 for students of regular vs. special schools, respectively, where 9 was the neutral score. A Mann-Whitney test further showed that SEN students attending regular schools did not significantly differ in how lonely their parents perceived them to be at school (Mdn = 10) from SEN students attending special schools (Mdn = 12), U(N regular = 66, N special = 64) = 1708.0, p = 0.058.

Overall, parents of SEN students mostly perceived SEN students to be less lonely at school than at home, independent of school type, see Table 2 for distribution of the cases when a SEN student’s loneliness at school and at home was compared on an individual level, and classified as more, equally, of less lonely at school than at home, for both school types.

https://doi.org/10.1371/journal.pone.0250070.t002

Furthermore, we addressed the link between the IOS measure and loneliness. As expected, we found that the IOS measure was highly and significantly correlated with a short measure of loneliness assessed in the same context (school), lending support to its validity (Spearman correlation coefficient 0.508, p = 0.000), while the association with loneliness in an unrelated context (at home) was much weaker (Spearman correlation coefficient 0.173, p = 0.048).

Friendships

The information on the number of friends at school and outside school is summarized in Fig 3a and 3b , respectively, by presenting the number of friendships in three categories: no friend, one friend, and more than one friend. This approach is less sensitive to outliers than looking at the actual number of friends. Using an outlier-insensitive test on the number of friends, Mann-Whitney test indicated that SEN students at regular schools had significantly more friends at school (Mdn = 2) than SEN students at special schools (Mdn = 1), U(N regular = 64, N special = 61) = 1549.5, p = 0.043. But, Mann-Whitney test also indicated that there was no difference in the number of friends arising outside school for SEN students at regular schools (Mdn = 0) and for SEN students at special schools (Mdn = 0), U(N regular = 69, N special = 65) = 2066.5, p = 0.344. We observed that most of the friendships of SEN students were formed at school, independent of the school type, but more friendship were formed at regular schools than at special schools.

a. Friends not at school, by school type. b. Friends at school, by school type.

https://doi.org/10.1371/journal.pone.0250070.g003

We further observed that friends of SEN students attending regular schools were significantly more likely to live in the same neighborhood, in 45.7% (32/70) of cases, than friends of SEN students attending special schools, in 14.7% (10/68) of cases (Fisher exact test, p = 0.000). This observation is easily understood in the local context of our study, the Netherlands, where special schools have a larger catchment area than regular schools. Consequently, if friendships mostly arise at school, friends of SEN students attending regular schools will be more likely coming from the same neighborhood than friends of SEN students attending special schools.

School characteristics

A Mann-Whitney test indicated that regular schools in our sample scored significantly higher on the variable SchoolInclusion (Mdn = 41) than special schools in our sample (Mdn = 45), U(N regular = 55, N special = 48) = 965.5, p = 0.019.

Regression analysis

We have observed that school type did not affect how socially included the SEN students were as perceived by their parents, but we have only looked at bivariate analysis so far. Table 3 shows the multinomial logit regression results, supporting our observation that IOS measure, the dependent variable, was not negatively affected by the attendance of a regular school. Indeed, the school type seemed not to be related to the SEN students’ social inclusion, as reported by their parents. Neither the school type, nor the student’s individual characteristics affected the level of IOS reported. The results also suggested that parents did not systematically perceive social inclusion through the lens of being more accepted as a partner at school. The variable ParentalInclusion was not significant. The only variable that affected the IOS measure was the SchoolInclusion variable, addressing the school’s inclusive culture. Including an interaction between the school type and SchoolInclusion variable in the regressions remained insignificant. We therefore omitted this interaction from the reported regression models.

https://doi.org/10.1371/journal.pone.0250070.t003

In conclusion, these regression results support the idea that attending regular school did not negatively affect the social inclusion of the SEN students assessed by the IOS measure. The dummy variable Regular was not significant, while the SchoolInclusion variable was highly significant in all models: a school scoring higher on the inclusive characteristics was linked to higher social inclusion as measured by the IOS. At the same time, the interaction effect of the SchoolInclusion variable with the school type remained insignificant. Therefore, we conclude that the school type did not affect the SEN student’s social inclusion, only the inclusive culture of the school itself, independent of the school type.

Our study presents a methodological innovation for measuring social inclusion by a simple pictorial measure IOS Scale, using the perception of being socially included as a relevant input to evaluate the success of failure of social inclusion of SEN students at school. This measure has been extensively validated in previous research, and has an excellent track record of addressing both close social relationships and the feeling of belonging of an individual toward a specified “other” category, be it another group of people, a cultural category, or even oneself in another point in time [ 59 – 62 ]. The feeling of belonging is central for the definition of social inclusion, and we suggest that this scale is a suitable measure of social inclusion in various contexts, e.g. at home or school. Our observation that the IOS Scale correlates with a loneliness measure obtained for the same context (school), but not with a loneliness measured in a different context (home), supports that the IOS Scale taps into the social inclusion aspect of belonging, and not merely into the feeling of being alone.

Using the IOS Scale as a measure of social inclusion represents a shift in focus from purely relying on sociometric methods for assessing social inclusion, such as peer acceptance, interactions with others, peer ranking, and bilateral friendships [ 6 , 63 – 65 ]. Individuals obtaining lower values for such measures are identified as being less socially included. We advocate complementing such measures with subjective measures like the IOS measure, to incorporate the voice and perceptions of the involved individuals, or their parents/care-takers as in our study, with the goal of furthering the discussions on success or failure of inclusion in education.

Our study has some limitations that need to be addressed and which demand more research. Most importantly, we obtained data by using parental proxy reports. There is a long line of research in health and assessment of quality of life literature, suggesting that parental proxy reports do not always achieve fit with child reports [ 66 ]. Parental characteristics, or family context [ 67 ], may affect the extent to which a parent is able to empathize with a child. At the same time, research on subjective well-being of children with disabilities shows that an overlap of child and parent reports may be rather satisfactory in the field of perceived friendship [ 52 ], though direct reports are preferable whenever possible. In this study, we have benefited from collaboration with organizations collecting information from parents, which resulted in a convenience sample of parents reporting on their children. This allowed us to take a first step in using the IOS Scale to learn how the social inclusion of SEN students is perceived by their parents. However, this approach should not be understood as a perfect substitute for reports of those involved in the education contexts of various types, the SEN students themselves. Focus on data collection from the SEN student population, along with self-reports, is a desirable route for future research to give voice to the SEN students themselves, as is research that further clarifies the fit between parental and child reports of the IOS measure.

Additionally, this study’s recruitment channel, via organizations supporting children’s rights, might have resulted in the overrepresentation of parents actively seeking education contexts fitting their children, and follow-up studies should focus on parents underrepresented in these groups. Two related concerns are (i) a selection effect, which could be present if parents of SEN students more likely to achieve social inclusion are also more likely to apply for admission into regular schools, and (ii) a projection effect, arising if parents across different school types adjust differently to the perceptions of their children’s social inclusion. Such self-confirming bias, for example, could prevent parents of children admitted into regular schools from recognizing the failing social inclusion of their children in the selected educational setting. We use the variables FriendsNotAtSchool and ParentalInclusion to address these issues in our regression analysis, and the regression results suggest that these effects do not drive our results.

The main result of our study is that social inclusion of SEN students, as measured by the parental reports of the IOS measure, was not significantly predicted by the school category, which can be interpreted as no negative impact of the inclusion of SEN students in regular schools. At the same time, the variable SchoolInclusion, based on the inclusive characteristics was a significant predictor of a higher perceived social inclusion of SEN students. This variable is composed of answers to questions on how welcoming the school was, supporting collaboration and inclusion of all learners, making decisions to protect each child’s well-being, and making didactic choices that acknowledge diversity and support collaboration. In our sample, the regular schools scored higher on this variable than the special schools; however, the fact that the dummy variable categorizing the schools remained insignificant suggests that there is a variation among the schools within this category, so that the SchoolInclusion variable explains social inclusion. This leads us to point out that promoting school characteristics aligned with inclusive education is a promising pathway to SEN students’ social inclusion.

Conclusions

Researchers have repeatedly raised concerns that letting SEN students attend regular schools might fail to achieve their social inclusion [ 5 , 64 , 65 , 68 – 71 ]. These studies could be taken as a warning sign not to overstate the value of inclusive education for achieving the goal of social inclusion. We assert that such warnings about SEN students’ social inclusion do not address whether the special school environments are more effective in realizing the social inclusion of SEN students. This can be answered by studying social inclusion of SEN students across school contexts. To address this question, we introduce a new tool for the methodological toolbox of social inclusion research.

We propose to adopt a simple pictorial IOS Scale [ 17 ] to assess social inclusion as the subjective perception of being included. In this, we are inspired by the literature on subjective well-being and its contribution policy design, and by the human rights perspective on giving voice to the individuals affected by the policies, such as education policies [ 72 ]. We hope that the introduction of subjective social inclusion measures can further help to understand the impact of policies promoting social inclusion, and constructively contribute to social inclusion research.

In order to contribute to this objective, we applied the IOS Scale to compare the social inclusion of SEN students across school types. We observed that parents of SEN students attending regular schools did not perceive their social inclusion to be lower compared to reports of parents of SEN students attending special schools. Parental reports also indicated that SEN students scored low on inclusion at both types of schools: this identifies an undesirable phenomenon that deserves attention. We also observed that SEN students were generally perceived by their parents as less lonely at school than at home, independent of the school type. School also played an important role as a friendship incubator for SEN students. SEN students in our sample formed most friendships at school, independent of the school type. However, SEN students attending regular schools had more friends, and their friends lived closer to them than the friends of SEN students attending special schools. This indicates that letting SEN students attend regular schools had an important positive spillover impact on their social inclusion, by forming their social networks locally, in the communities where they live.

We consider the relevance of these findings to lie in the realm of policy development, since they offer new insights into the social inclusion of SEN students by comparing their social inclusion across school types. In the present comparison, letting SEN students attend regular schools was not associated with negative consequences for their social inclusion. On that note, our findings highlight the importance of interventions aiming at schools’ inclusive practices, as those were found to increase social inclusion.

Supporting information

https://doi.org/10.1371/journal.pone.0250070.s001

https://doi.org/10.1371/journal.pone.0250070.s002

https://doi.org/10.1371/journal.pone.0250070.s003

Acknowledgments

This study was made possible thanks to the cooperation and support of IederIn, the Dutch Patient Association, the National Platform of Mental Health, and all people involved in the data collection, and intensive discussions at the preliminary stages of the study. My special thanks go to Gepke Boezaard from IederIn. All remaining errors are my own.

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• 35. Schuman H. The Netherlands. In: Wehmeyer ML, Patton JR, editors. The Praeger International Handbook of Special Education. Santa Barbara, CA: ABC-CLIO, LLC; 2017. p. 310–26. Available from: https://books.google.de/books?id=vBANMQAACAAJ
• 37. Inspectie van het Onderwijs. De staat van het onderwijs. Onderwijsverslag over het jaar 2016/17. 2017. Available from: https://mijn.govunited.nl/blg-221895.pdf%0Awww.destaatvanhetonderwijs.nl
• 58. Boot T, Ainscow M. Index for Inclusion. 3rd ed. Bristol, UK: Centre for Studies on Inclusive Education (CSIE); 2011.

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• v.5(1); 2021

Educating for diversity, equity, and inclusion: A review of commonly used educational approaches

Leonor corsino.

1 Department of Medicine, Division of Endocrinology, Metabolism, and Nutrition, Duke School of Medicine, Durham, North Carolina, USA

2 Duke Clinical and Translational Science Institute, Community-Engaged Research Initiative Core, Duke School of Medicine, Durham, North Carolina, USA

Anthony T. Fuller

3 Department of Neurosurgery, Division of Global Neurosurgery and Neurology, Duke University School of Medicine, Durham, North Carolina, USA

4 Duke Global Health Institute, Duke University, Durham, North Carolina, USA

5 Duke Clinical and Translational Science Institute, Center for Pathway Programs, Duke School of Medicine, Durham, North Carolina, USA

Diversity, equity, and inclusion (DEI) are fundamentally important concepts for advancing clinical and translational science (CTS) education. CTS education spans a wide range of disciplines from cell biology to clinical and community/population research. This large scope both in terms of intellectual areas and target groups requires an understanding of existing educational approaches for DEI as we translate DEI from mere concepts into equitable actions within CTS education. In this  review, we provide the readers with the most common DEI educational approaches, including cultural humility, bias training, and improving mentoring to diversify the workforce. DEI educational materials can achieve maximal success and long-term impact when implemented as institutional-wide interventions, and the materials are not seen as an isolated or independent curriculum. Approaches, strategies, and programs to achieve this are many. However, many questions remain unanswered about what the best approach, strategies, and programs are to be implemented in institutional-wide education that will be embedded in CTS education.

Diversity, equity, and inclusion (DEI) are fundamentally important concepts for advancing clinical and translational science (CTS) education. In recent years, increased societal consciousness has led to the precipitous rise in the usage of DEI in everyday vernacular. Often, when concepts become ubiquitous, their meanings morph such that individuals may have completely different ideas of the concept’s definition, or they become “code” that can lead some audiences to opt-out.

For the purpose of this review, we use diversity and inclusion as concepts in alignment with the National Institute of Health (NIH) definitions, given the NIH’s position as a major funder of CTSs. Diversity is defined by the NIH as “the range of human differences, including but not limited to race, ethnicity, gender, sexual orientation, age, social class, physical ability or attributes, religious or ethical value system, national origin, and political beliefs” [ 1 ]. While inclusion is defined as “involvement and empowerment, where the inherent worth and dignity of all people is recognized” [ 1 ]. For equity, we define this concept as “the state, quality, or ideal of being just, impartial, and fair” [ 2 ].

DEI work in CTS education requires an intentional focus on those already practicing in CTS as well as a focus on the training and education for the next generation of practitioners and investigators. CTS is uniquely positioned to reinforce inequities or entirely reshape and reduce inequities; therefore, the additional focus on trainees allows influence not only on the scientific questions that will be asked but also the scientific environment that they will inhabit. CTS education also spans a wide range of disciplines from cell biology to clinical and community/population research [ 3 ]. This large scope both in terms of intellectual areas and target groups requires an understanding of existing educational approaches for DEI as we translate DEI from mere concepts into equitable actions within CTS education.

CTS education is positioned within an academic environment that will either support or stifle DEI efforts. Environmental factors contributing to the support or stifling of DEI efforts include the makeup of the institution’s faculty, staff, leaders, and students alongside the institution’s evaluation procedures and policies. These environmental factors are distinct from educational materials created specifically to increase an institution’s members’ understanding of DEI. It is entirely plausible that an institution can have high-quality, innovative, and well-intended educational DEI materials within an environment that hinders its impact on its CTS educational community. The converse is also true. This reality is why we believe that within the CTS education community, despite our paper’s focus on DEI educational approaches, we must not only focus solely on the development and implementation of high-quality educational DEI materials, but also invest in cultivating just, equitable, and supportive learning environments.

While preparing for writing this review, we approached the intersection of DEI within CTS education with the broadest scope possible and then began narrowing. Our initial search terms brought up thousands of articles that spanned the spectrum from articles about educational environments to DEI materials. We choose to focus our paper on DEI educational materials and approaches, which narrowed the articles to a more manageable range. Each article in our search was examined to develop a list of the most common DEI educational approaches, and then we dove deeper into each approach to highlight the most salient features for the CTS educational community.

Educational Approaches and Programs

Several approaches have been pursued for educating DEI. In this section, we will provide a summary of some of the existing educational approaches and programs created and developed to enhance cultural humility, ameliorate bias, and improve mentoring to diversify the workforce in science. We recognize that due to the increasing body of literature in this significance and evolving area of research and education, it is impossible to be fully inclusive of all the work that has been done and is ongoing.

Cultural Humility

Cultural humility is defined as a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of her/his own beliefs and cultural identities [ 4 ]. Cultural humility training, usually referred to as cross-cultural training and education, is commonly offered to an array of professionals. The main goal of this training is to enhance cross-cultural interactions and increase personal awareness of one’s values and beliefs to increase the understanding and acceptance of others [ 5 , 6 ].

Although training in cultural humility is not new and has been implemented for decades, the approaches to implementation and its inclusion in research training are relatively new [ 4 ]. Traditionally, training to increase cultural humility utilizes workshops as its main pedagogical method [ 6 ]. These workshops are usually didactic, delivered for several hours or 1–2 days. This can lead many to perceive them as superficial. Further, those who are compelled to attend may find them divisive and uncomfortable [ 6 , 7 ].

Cultural immersion, based on the principle that immersion in another’s culture, practices, and language is an effective means of learning about oneself “in” another culture, has been utilized as another method to teach cultural humility [ 8 ]. Cultural immersion focuses on (1) increasing students’ capacity for empathy by exposing them to a different worldview, (2) developing critical self-reflection/self-awareness, (3) experiencing traditional cultural practices, and (4) exploring traditional and contemporary values and beliefs, focusing on the culture’s strengths [ 8 ]. Several studies have documented the impact and benefits of cultural immersion as a method to teach cultural humility [ 9 ]. Similarities among the studies include short-term immersion into a culture different than own, reflective journaling, daily writing, and debriefings [ 10 ].

A recently published systematic review looking into cultural immersion educational programs for healthcare professionals reports a total of 9 studies with a total of 94 participants with experiences in 14 culturally diverse environments. The interventions and assessments utilized by each program include didactic lecture, study abroad experience, semi-structured interviews, focus groups, journaling, and reflective papers. The authors concluded that participants in immersion programs demonstrated growth in the cognitive, affective, perpetual, cultural dissonance, and skills/engagement domains. The paper concluded that cultural immersion experiences can produce a positive multidomain effect in its participants.[ 10 ].

New approaches to delivering cultural humility training have been proposed. A group of investigators from the Rush Institute for Healthy Aging proposed the QIAN (Humbleness) curriculum: the importance of self-questioning and critique, bi-directional cultural immersion, mutually active listening, and the flexibility of negotiation curriculum. The QIAN curriculum is based on Chinese philosophy and is inspired by ancient Chinese thinkers. The investigators proposed a model that incorporates the following: (1) Question asking: questions regarding our own assumptions about the world, where the assumptions come from, constant self-questioning and self-critique; (2) Immersion: immersion that goes beyond exposure to other cultures; (3) Active listening: active listening with the body (gestures and body languages), mind (stories and narratives), and soul (feelings and emotions); and (4) Negotiation: willingness to negotiate mutually acceptable alternatives carries equal weight as learning each other’s preference. [ 7 ]

Another approach proposed to deploy cultural humility training includes an art-based curriculum. Art-based training for cultural humility has been proposed as an innovative and creative way of training health professionals. Art-based interventions that highlight self-reflecting artmaking facilitated insight, understanding, awareness, and competency [ 11 ].

Simulation is another method proposed for increasing cultural humility. Simulation for developing cultural humility has been utilized as a new pedagogical approach in nursing [ 12 – 14 ]. A review article published in 2017 looking at Cultural Competency and Cultural Humility in Simulation-Based Education identified a total of 16 studies. Within the 16 studies included in the review, a total of four themes emerged: (1) cultural sensitivity and cultural competence, (2) insight and understanding, (3) communication, and (4) confidence and comfort. However, the methods varied widely within these studies. At the end, the authors concluded that no one study existed at the time that describes the use of simulation to teach cultural humility [ 15 ]. Since the publication of this article, several others have shown the utility and the need of simulation as a new and innovative method to teach cultural humility [ 16 , 17 ].

Bias Training

Bias, conscious, or unconscious has been cited as a major contributing factor in health and health care disparities and underrepresentation of historically minority groups in science and academia [ 18 ]. The term “implicit bias” or “unconscious bias” gained significant attention and has been the subject of many publications. The “unconscious bias hypothesis” which is widely quoted in social psychology research, portends that bias can occur without recognition [ 19 ]. Bias is usually referred to as both stereotypes and prejudices and as “the negative evaluation of one group and its members relative to another” [ 20 ]. While studies have documented bias in health care delivery [ 21 ], additional research has shown the impact of unconscious bias in research, admissions, hiring policies, and underrepresented minorities (URMs) progression in academia [ 22 – 24 ].

To educate for DEI, it is necessary to address the significant impact that bias plays in our day-to-day lives as researchers, health care providers, educators, and leaders. The recognition of the impact of bias in all aspects of academic medicine is the main force behind the increasing number of materials and approaches developed and implemented to increase awareness of bias and its impact. Although it is not possible to eliminate our own unconscious bias, it is potentially possible to ameliorate its impact on our decisions while treating patients, conducting research, interviewing, and leading [ 25 ].

Numerous programs, educational materials, and approaches have been developed to address bias. It is challenging to provide a complete summary of the existing data and publications pertaining to unconscious bias due to the exponential increase in the number of publications within the last decade. However, for the purpose of this review, we will provide the readers with the most common approaches utilized and proposed to increase awareness, knowledge, and skills development to address the impact of bias in all aspects of academia including CTS education.

Awareness, Knowledge, and Skills

To address biases, we need to become aware that they exist and their impact on behavior. Approaches to increased awareness are currently being implemented. One highly utilized tool is the Implicit Association Test (IAT). The IAT is currently the only available objective measurement of unconscious bias. The IAT measures the differential association of two target concepts with attributes. IAT, developed in 1998 by Banjani and Greenland [ 26 ], has been extensively utilized by many studies addressing unconscious bias [ 27 ]. Although the IAT is widely utilized and there is research proving its validity [ 28 ], there is some controversy regarding it’s utility [ 29 ]. One of the main critiques of the test is to what extent awareness predicts behavior [ 30 ]. Despite the limitations of the test, its utility to increase awareness and its free availability makes it a valuable tool for bias awareness.

Research and publications reporting curriculum and programs developed to address the issue of racial bias in academic medicine are vast. The research ranges from programs targeting medical students [ 31 , 32 ], residents [ 33 ], faculty [ 34 ], and search committees [ 35 ]. Overall, commonalities within these programs and educational materials comprise the use of workshops, multimedia presentations, small group discussions, interactive audience polling, self-reflection, and clinical vignettes or case studies.

Educational materials focused on interventions to acquire skills to reduce the impact of bias are less commonly reported. However, some information exists regarding strategies to prevent implicit bias. Four strategies that show potential for reducing implicit bias include: (1) pursuing egalitarian goals by learning to associate minority groups with goals that promote fairness and equity, this potentially helps cutting the stereotype off even before they appeared; (2) identifying common identities by shifting the attention from differences and focus more on common interests and activities; (3) counter-stereotyping by focusing on the individual unique attributes and behaviors; and (4) perspective-taking by taking the perspective of the minority group [ 36 ].

Improving Mentoring to Impact Clinical Translational Science Education

CTS education will not be successfully achieved without deliberate attention to improve mentoring to diversify the workforce. Diversifying the workforce has been recognized as an important and necessary priority to further scientific discoveries, eliminate health disparities, improve minority health, and achieve patient-centered outcomes [ 37 ]. Robust mentorship has been cited as a way to enhance workforce diversity in health sciences and research [ 38 ]. Research has shown that trainees from URM groups receive less mentoring than their White peers [ 39 ]. Further, improving mentoring to increase DEI in research has been identified as a priority by the NIH [ 39 ]. The NIH directly addressed the science of diversity, citing the racial, ethnic, gender, and economic balance of the US biomedical research workforce as limiting the promise of building knowledge and improving the nation’s health [ 40 ]. To that end, the National Research Mentoring Network (NRMN) a nationwide consortium of biomedical professionals and collaborating institutions sponsored by the NIH works to provide all trainees across scientific disciplines with evidence-based mentorship and professional development programming that emphasizes the benefits and challenges of diversity, inclusivity, and culture within mentoring relationships and, more broadly, the research workforce. The goal of the NRMN is to increase the diversity of biomedical research by enhancing the mentorship and career development of individuals from diverse backgrounds, communities, and cultures [ 41 ].

The evidence-based curriculum, activities, and training resources available via the NRMN are grounded in a robust conceptual model, authentically address bias, stereotype threat, and cultural ignorance, focus on the formal preparation of both mentors and mentees, builds upon process-based, community-building approaches to mentor and mentee training, and include established multimodal training formats and proven train-the-trainer efforts that allow for rapid scale-up and sustainability.

Considering the extensive efforts by the NRMN in the development of a publicly available curriculum to train mentors and mentees to improve mentoring practice that will lead to DEI in research, we encourage others to explore and engage in activities to deploy this training widely. We recognized that there are potential limitations experienced by some academic institutions to fully deploy the curriculum, such as lack of time, financial support, and other resources including trained facilitators. However, it is challenging to educate for DEI when diversity in the scientific workforce is not achieved.

The NRMN curriculum has been adapted and implemented successfully by Clinical and Translational Science Awards (CTSAs) around the country. Through the Institute for Clinical and Translational Research (ICTR), the Entering Mentoring training materials were adapted for use with CTSA mentors. In a randomized controlled trial, the entering mentoring materials were implemented at 16 CTSA institutions across the country [ 42 ]. In this study, a total of 283 mentor–mentee pairs were recruited. Mentors were randomized to the 8-hour training group or to the control group. The curriculum is implemented in a small group of mentors that engage in discussions based on case studies and activities. The curriculum was deployed by two facilitators and in four 2 hours sessions. The curriculum focuses on six core competencies: (1) maintaining effective communication, (2) aligning expectations, (3) assessing understanding, (4) addressing diversity (5) fostering independence, and (6) promoting professional development. Evaluation of the curriculum demonstrated improvement in mentors’ skills important for successful mentoring such as communication and evaluation skills [ 43 ].

Implementation, Dissemination, and Evaluation

Increased attention and focus on DEI has led to the development of a wide array of educational materials with varying levels of quality and distinct pedagogical approaches. Sifting through the options to select the best and most impactful approaches requires the same attention to detail and scientific rigor as any other topic in CTS. Practically, this means that deliberate attention is given to the selection of educational materials, to the choice of the faculty, staff, and students who will administer and receive the educational materials, and to the environment in which the materials are being implemented.

DEI educational materials can achieve maximal success and long-term impact when implemented as institutional-wide interventions, and the materials are not seen as an isolated or independent curriculum. DEI education must be viewed as integral and intertwined with the successful mastery of every topic and aspect within CTS. Programs and institutions across the country are at different stages in the process of fully integrating DEI into their curriculum. Most have communicated acknowledgment of DEI’s importance by placing it within their mission statements. Undoubtedly, this is an important step towards full-scale systemic changes in the structures, environment, and educational materials.

As programs and institutions begin their journeys in DEI development and integration, dissemination becomes imperative. Dissemination serves a tripartite purpose by providing a channel for iteration, refinement, and sharing of best practices. The Association of American Medical Colleges’ (AMMC) MedEdPORTAL Diversity, Inclusion, and Health Equity Collection is a good example of a dissemination platform (Table  1 ). Through this and other mechanisms, work being done at a single program or institution can contribute to the growing body of work in this space. Collective knowledge development through dissemination is a key lever for success as programs and institutions grapple with the daunting task of dismantling racism, sexism, ageism, ableism, and a multitude of other isms.

Curriculum and educational approaches and materials resources

Rigorous evaluation of DEI educational interventions is an additional lever for success. There is a desperate need to try to get this “right,” which means there must be a way for CTS educators to know which DEI educational materials are better and what impact are to be expected. Checklists, audits, toolkits, and evaluation surveys have already been created [ 44 ].

Unmet Needs and Barriers

Institutional and program willingness, adequately trained and resourced staff, and receptive students are only part of the complex puzzle of educating for DEI in CTS. Unmet needs are embedded and widespread within each of these areas. Most institutions and programs have a general willingness to engage in DEI work and are faced with resistance [ 45 ].

Across the board exists the need to see the value and then to invest the time, funding, and development of qualified instructors. Until recently, DEI work has been an afterthought or has garnered increased attention due to tragedy and exposure of inequities.

Putting DEI into Practice

Academic institutions and CTSAs within these institutions recognize the value of DEI in the advancement of sciences. As such, implementing approaches to further educate stakeholders for DEI are important. Our simple conceptual framework focused on two distinct ideas: the creation of a conducive environment and the creation and implementation of educational materials and curriculum. The framework highlights the importance of the environment when it comes to fostering DEI. Without a supportive and conducive environment, advancement to ameliorate racism and bias in research and academic institutions is close to impossible.

Although, in this study, we focused mostly on describing some of the most used approaches to educate for DEI as we cannot overemphasize the impact of the environment. To implement training in cultural humility, bias training, and mentoring training, it is critical to have an environment that supports these initiatives. For example, the testing and implementation of mentoring training at several CTSAs around the country were possible with the support from NIH funding and buy-in by CTSAs leadership.

Similarly, training in bias and cultural humility requires dedicated effort to hire, train, develop, and implement new and existing materials. To that end, the creation of diversity and inclusion offices, centers for equity, and institutes dedicated to these efforts are important and, as such, should be fully supported and resourced. Also, the efforts to educate for DEI are no longer isolated and are becoming more and more critical components of research, training, and education. However, more is still needed. For example, validated measurements to assess the short and long-term impact of bias training. In the meantime, to what extent training that aims to change very rooted bias has an impact on research remains unknown. Finally, there is a need to continue the conversation, the creation, implementation, research, and innovation in DEI education.

Educating for DEI and dismantling racism in research and academic institutions is a national priority. Approaches, strategies, and programs to achieve this are many. However, many questions remain unanswered pertaining to what the best approach, strategies, and programs are to implement institutional-wide education that will be embedded in CTS education. Further, as we continue to explore, test, and implement these approaches, strategies, and programs, other questions remain regarding the best assessments to determine their impact.

Acknowledgment

The authors would like to thank Ms. Maureen Cullins for her editorial support.

Disclosures

Dr. Corsino receives funding for her role as co-director for the Duke CTSI Community Engagement Research Initiative Core by the CTSA grant UL1TR002553 and received funding for her former role as associate director for the Duke School of Medicine Office of Faculty Mentoring Training by the CTSA grant UL1TR002553. She also received NIH funding for her former role as co-director for the REACH Equity Center Training and Education Core 5U54MD012530-03. Dr. Corsino is a former Diversity Strategist in the Duke School of Medicine Office of Diversity and Inclusion. She is currently a co-investigator in the NIH-funded U01GM132374. Dr. Fuller has no conflicts of interest to declare. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH or the Duke School of Medicine.

Review of Translating Human Rights in Education by Julia Biermann (2022)

• Olusola Ogundola Ph.D. Student, Wellness and Inclusive Services in Education, Rowan University

In the international discourse on the global mandate on inclusive education, Julia Biermann's Translating Human Rights in Education: The Influence of Article 24 UNCRPD in Nigeria and Germany stands out as a contemporary work that sheds light on the tensions of implementing the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD) in diverse geographical milieus.

Author Biography

Olusola ogundola, ph.d. student, wellness and inclusive services in education, rowan university.

Ph.D. Student, Wellness and Inclusive Services in Education, Rowan University

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REVIEW article

A systematic review of midwives’ training needs in perinatal mental health and related interventions.

• 1 Centre referent de rehabilitation psychosociale, GCSMS REHACOOR 42, Saint-Étienne, France
• 2 University Claude Bernard Lyon1, Research on Healthcare Performance (RESHAPE) INSERM U1290, Lyon, France
• 3 AURORE Perinatal Network, Hospices civiles de Lyon, Croix Rousse Hospital, Lyon, France
• 4 Departments of Psychiatry and Child & Adolescent Psychiatry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
• 5 Medical Library, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
• 6 University Hospital of Saint-Étienne & EA 7423 (Troubles du Comportement Alimentaire, Addictions et Poids Extrêmes (TAPE), Université Jean Monnet - Saint-Etienne), Saint-Etienne, France
• 7 University Hospital of Saint-Étienne, Department of Child and Adolescent Psychiatry, France & Marc Jeannerod Institute of Cognitive Sciences UMR 5229, CNRS & Claude Bernard University, Lyon, France

Background: Midwives may be key stakeholders to improve perinatal mental healthcare (PMHC). Three systematic reviews considered midwives’ educational needs in perinatal mental health (PMH) or related interventions with a focus on depression or anxiety. This systematic review aims to review: 1) midwives’ educational/training needs in PMH; 2) the training programs in PMH and their effectiveness in improving PMHC.

Methods: We searched six electronic databases using a search strategy designed by a biomedical information specialist. Inclusion criteria were: (1) focus on midwives; (2) reporting on training needs in PMH, perinatal mental health problems or related conditions or training programs; (3) using quantitative, qualitative or mixed-methods design. We used the Mixed Methods Appraisal Tool for study quality.

Results: Of 4969 articles screened, 66 papers met eligibility criteria (47 on knowledge, skills or attitudes and 19 on training programs). Study quality was low to moderate in most studies. We found that midwives’ understanding of their role in PMHC (e.g. finding meaning in opening discussions about PMH; perception that screening, referral and support is part of their routine clinical duties) is determinant. Training programs had positive effects on proximal outcomes (e.g. knowledge) and contrasted effects on distal outcomes (e.g. number of referrals).

Conclusions: This review generated novel insights to inform initial and continuous education curriculums on PMH (e.g. focus on midwives’ understanding on their role in PMHC or content on person-centered care).

Registration details: The protocol is registered on PROSPERO (CRD42021285926)

1 Introduction

Perinatal Mental Health Problems (PMHPs) affect parents during pregnancy and the first year after childbirth and commonly consist of anxiety, non-psychotic depressive episode, psychotic episodes, post-traumatic stress disorder and adjustment disorder. Despite being often associated with poor parental and child outcomes ( 1 ), PMHPs remain predominantly unrecognized, undiagnosed and untreated ( 2 ).

Given their role in perinatal care providing multiple occasions to discuss perinatal mental health ( 3 ) - midwives may be key stakeholders to improve the detection, referral and management of PMHPs. Parents usually welcome midwives’ interest in their mental health and report to prefer discussing mental health issues with obstetric providers than with mental health providers ( 4 , 5 ). Assessing perinatal mental health (PMH) and detecting symptoms of postpartum depression, anxiety and psychosis are part of the essential competencies for midwifery practice according to the International Confederation of Midwives (2019) ( 6 ). However, and despite being in general interested in assessing perinatal mental health (PMH) and wellbeing ( 7 ), midwives report feeling less comfortable with putting competencies related to PMH into practice compared to those related physical health ( 8 , 9 ).

To our knowledge, three literature reviews have been conducted on midwives’ educational needs in perinatal mental health ( 7 , 10 , 11 ). These reviews reported a lack of knowledge, skills and confidence influential at different levels of the care pathway, e.g. detection, decision-making about referral and support. However, there remain some limitations to the current body of evidence. First, all reviews found low-to-moderate quality studies coming predominantly from high-income countries. Second, two out of three reviews ( 10 , 11 ) - conducted in 2017 (n=17 articles) and 2022 (43 articles) - focused on perinatal depression or perinatal anxiety and did not cover the full range of PMHPs as well as related conditions (e.g. substance use disorder, serious mental illness (SMI)) or autism). The third review ( 7 ) conducted in 2017 (n=22 articles) covered a wider range of PMHPs using an integrative review design, the other two ( 10 , 11 ) being systematic reviews. Third, previous reviews ( 7 , 10 , 11 ) focused on midwives’ knowledge, skills and attitudes and context-related factors. However, it remains unclear whether improvements in these areas translate into in routine clinical practice (e.g. improved detection of PMHPs or facilitated decision-making about referral to mental health providers). Fourth, case identification - using formal or informal screening methods - have contrasted effects on referral rates ( 7 ) and patient outcomes [e.g. limited effects of screening on depressive symptoms ( 12 , 13 )]. Fifth, two systematic reviews reported on training programs in perinatal depression [n=7 studies ( 10 ), n=12 studies ( 14 )]. However, these reviews included mixed samples [e.g. 37% midwives in Wang et al., 2022 ( 14 ) and 54% midwives in Legere et al., 2017 ( 10 )] and did not target the same set of skills [e.g. improving knowledge and detection ( 10 ); providing evidence-based interventions ( 14 )]. Reviews either investigated midwives’ training needs ( 7 , 11 ) or training interventions ( 10 , 14 ). The literature on training programs in PMH for student midwives and midwives remains scarce [n=4 studies ( 10 )]. A synthesis of evidence before this study is presented on Table 1 .

Table 1 Evidence before this study.

The present review primarily aims to identify and review: 1) midwives’ educational/training needs in PMH (i.e. beyond perinatal depression or anxiety to include PMHPs, SMI, substance use disorder, and autism); 2) the existing interventions and their effectiveness in improving detection and management of PMHPs.

2.1 Search strategy

The protocol for this systematic review was reported according to PRISMA guidelines ( 15 ). The search strategy was designed by a biomedical information specialist (WMB) from the Medical Library of Erasmus MC, University Medical Center Rotterdam ( 16 ). We searched Embase, MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials, CINAHL and, PsycINFO for published, peer reviewed original articles. The search combined terms for (1) perinatal mental health problems, serious mental illness (i.e. schizophrenia, mood disorders, personality disorders, anxiety), eating disorders, substance use disorders or autism, and (2) midwives’ knowledge, attitudes, skills or training needs, as well as existing training programs for midwives on PMH. We included only published articles in English or French. No time restriction was set. The search was updated prior to publication on 21 June 2023. We hand-searched the reference list of three systematic literature reviews ( 7 , 10 , 11 ) for additional relevant articles. The full search strategy, search terms and syntax are presented in online Supplementary Table 1 .

2.2 Inclusion/exclusion criteria

To be included, articles had to meet all the following criteria: 1) focus on midwives (included midwives, nurse-midwives, registered midwives, registered midwives tutors, registered midwives prescribers and registered advanced midwives practitioners - referred as “midwives” in this review); 2) reporting on midwives’ training needs in PMH, PMHPs or related conditions or existing training programs that focus on the use of screening tools to detect PMHPs, on PMH in general or specific aspects of PMH; 3) using quantitative, qualitative or mixed-methods design. For training programs, we included uncontrolled and controlled studies (placebo, TAU or active comparators).

Our exclusion criteria were: 1) no full text available or studies published in languages other than English or French; 2) grey literature because the aim of this systematic review was to guide the development of future interventions; 3) training programs on psychological interventions (e.g. cognitive behavior therapy) because this review focused on interventions aiming at improving midwives’ training on essential competencies related to PMH (e.g. PMH assessment, detection, referral and support of parents with PMHPs).

2.3 Selection and coding

The screening process was conducted in two separate stages: 1) Two authors (M.D. and J.D) independently screened the title and abstracts of all non-duplicated papers excluding those not relevant. Potential discrepancies were resolved by consensus; 2) Two authors (M.D. and J.D) independently applied eligibility criteria and screened the full-text papers to select the included studies. Disputed items were solved discussing together and reading further the paper to reach a final decision. Supplementary Tables 2 , 3 present the list of included/excluded studies. Inter-rater reliability was calculated (kappa=0.90).

2.4 Data extraction

Two authors (MD and JD) performed independently the data extraction. For each study, we extracted the following information: general information (author, year of publication, country, design, type of study, population considered, period), assessment tools or methods, cultural aspects, the main findings and variables relating to quality assessment. For studies reporting on training programs, we also extracted information about the intervention (nature, type, length, targeted skills or outcomes, format), outcome measures and effectiveness on midwives’ knowledge, attitude, skills or routine use of screening tools to detect PMHPs or parents’ outcomes (e.g. depressive symptoms). Tables 2 – 6 present the factors associated with knowledge, skills, confidence and decisions about screening, referral or support. Supplementary Tables 4 , 5 present the detailed characteristics of the included studies.

Table 2 Factors influencing the level of knowledge and skills.

Table 3 Factors influencing confidence and the perception of being well-equipped.

Table 4 Factors influencing decisions about screening.

Table 5 Factors influencing decisions about referral.

Table 6 Factors influencing decisions about support.

2.5 Quality assessment

Quality assessment was realized using the Mixed Methods Appraisal Tool (MMAT) ( 61 ). MMAT is a validated instrument to assess the methodological quality of qualitative, randomized controlled trials, non-randomized trials, descriptive studies, and mixed methods studies. It is comprised of five 5-item subscales assessing different aspects of quality (e.g. appropriateness of the selected design/methods/measurements, integration of quantitative and qualitative parts for mixed-methods studies). Two researchers (MD and JD) independently assessed methodological quality using the MMAT and extracted MMAT scores for each article. Discrepancies were resolved through consensus. The MMAT overall quality score and detailed scores are provided in Supplementary Tables 4 , 5 . The study protocol was registered on PROSPERO on November 1, 2021 (CRD42021285926).

Of the 9650 articles found during searches from inception to June 26 th 2023, 4969 references remained after removing all duplicates. Based on titles and abstracts, 4772 papers were excluded for lack of relevance. Our search strategy yielded 197 full-text articles. After conducting a full-text analysis of all these papers, we ended up with 66 relevant papers (47 on knowledge, skills or attitudes and 19 on training programs; PRISMA diagram on Figure 1 ).

Figure 1 PRISMA diagram.

3.1 Study characteristics

The characteristics of the 66 included studies are presented on Tables 7 , 8 . Most studies were conducted in high-income countries (89.4%) and published after 2015 (50%). Study designs were quantitative (n=33; 50%), qualitative (n=22; 33.3%) or mixed-methods (n=11; 16.7%). Samples included qualified midwives (n=37; 56.0%), qualified midwives and other perinatal health providers (n=17; 25.8%) and student midwives (n=11; 16.7%). Qualified midwives had a variable level of training in PMH ranging from none to 90% (specified in 24 studies; most covered topics: general information about PMH and PMHPs; least covered topics: interviewing/counseling skills, psychopharmacology and suicide risk assessment). Eight studies (12.1%) reported on midwives’ mental health nursing experience (ranging from 0.8% to 30%) or placement experience in a mental health setting or a mother-baby unit during their studies (ranging to 9% to 23.2%). Four studies (6%) mentioned family or personal experience of mental health problems ranging from 25% to 66.3%. Most studies covered the entire perinatal period (n=44; 66.7%) and reported on PMHPs (n=32; 48.5%). The definition of PMHPs was highly variable across the studies (e.g. inclusion of conditions usually not considered as PMHPs, such as schizophrenia, bipolar disorder, personality disorders, self-harm, suicide eating disorders or SUD in 16 studies; definition restricted to anxiety, depression, postpartum psychosis and/or posttraumatic stress disorder in 9 studies; unspecified in 7 studies). One third of the included studies used validated instruments to assess outcomes (n=16; 36.4%). Five studies (7.6%) investigated the influence of cultural aspects on the detection and management of PMHPs.

Table 7 Research characteristics of the 66 studies included in the review.

Table 8 Research characteristics of the training programs included in the review.

Of 15 studies reporting on a training program using a quantitative or a mixed-methods design, three used a waiting-list control group (20%; one randomized controlled trial (RCT)) and 13 (86.7%) were uncontrolled. Sample size was small in most studies (< 50 participants; n=9 studies). Nine studies (47.3%) reported contact with persons with lived experience when designing their training program. The training programs were heterogeneous in nature (initial training, n=6, 31.6%; continuous education, n=13, 68.4%), type, format and duration (ranging from 2 minutes to a fifteen-week module). All studies assessed training outcomes either immediately after (n=15; 79%) or up to 3 months after the intervention is delivered (n=4; 21%).

3.2 Quality assessment

The overall assessment score ranged from low (n=30, 45.4%; n=13, 68.4% for training programs) to high (n=11, 16.7%; n=2, 10.5%). For quantitative or mixed-methods studies, the reasons were convenience sampling (n=61 studies, 92.4%), sample size, low response rate (n=18 studies > 60%), limited use of validated outcome measures (36.4%), use of self-reported measures, absence or short duration of the follow-up period, limited integration of the results in mixed-methods studies and lack of controlled/RCT studies to evaluate the effectiveness of training programs. For qualitative studies, the reasons were interpretation bias (e.g. no investigator triangulation, the data being analyzed by only one researcher), absence of data saturation and lack of reflexivity.

3.3 Narrative review

Many studies found that midwives felt ill equipped to care for parents with PMHPs [e.g. ranging from 69.2% of 815 midwives in Jones et al., 2011 ( 17 ) to 82.2% of 157 midwives in Noonan et al., 2018 ( 28 )]. The reasons included insufficient initial training/continuous education on PMH (n=2 studies), perception that PMH assessment is not part of their role (n=2 studies), lack of knowledge about the detection, referral and management of PMHPs (n=12 studies). Compared with other perinatal health providers (GPs, health visitors, maternal child health nurses; n=11 studies), midwives had lower knowledge on PMH (n=2), felt less confident in the detection, referral or management of PMHPs (n=3) and had more negative attitudes toward their role in perinatal mental healthcare (PMHC) ( 57 ) or suicide prevention ( 40 ). Self-reported barriers to discuss PMH issues or self-reported interviewing skills did not differ between nurses and midwives ( 25 ). Student midwives’ knowledge, skills and attitudes in PMH did not clearly differ from those of qualified midwives (n=5 studies). On the job experience, learning from peers and attending to workshops/conferences were midwives’ main sources of knowledge (n=3 studies).

The factors positively associated with knowledge about PMHPs included the perception to be well equipped to provide PMHC (66.7% significance), previous training in PMH (50% significance), younger age ( 17 ), shorter work experience in general and as a midwife (20% significance), frequent contact with parents with PMHPs (50% significance) and type of practice (33.3% significance). Mental health nursing experience was positively associated with the perception to be well equipped to provide PMHC, but not with higher knowledge about PMH ( 8 ). No significant association was found between confidence in providing PMHC and other factors [e.g. age, personal experience of mental health problems, frequent contact with parents with PMHPs ( 29 )], except for PMH education and case identification ( 8 ). Compared with suicide risk assessment and other conditions (e.g. postpartum psychosis, SMI, eating disorders or posttraumatic stress disorder; n=4 studies), midwives reported higher knowledge, better skills and more confidence in detecting and managing perinatal depression and anxiety. Midwives felt in general ill equipped to care for postpartum psychosis, eating disorders, posttraumatic stress and SMI (n=10 studies) and reported ambivalent or negative attitudes toward parents with these conditions (n=7 studies). Knowledge about PMHPs varied according to the assessment method [i.e. higher self-report knowledge than researcher-rated knowledge ( 19 , 43 )] and the timing of perinatal period (i.e. higher in the postpartum than during pregnancy, n=5 studies).

3.3.1 Detection/screening

The practices and policies around screening for PMHPs varied across studies. There was a considerable overlap between the factors influencing the decision to screen, refer and support parents with PMHPs. Midwives’ attitudes toward their role in PMHC (e.g. personal interest in PMHPs and perception that it is part of their role) played a central role in decision-making about opening discussions about PMH (n=12 studies), referral ( 42 , 57 ) and support parents with PMHPs (n=6). Cultural aspects and stigma toward parents with ethnic minority background (e.g. underestimation of depression and suicide risks) impacted midwives’ ability to detect and manage PMHPs and parents’ maternity care experiences (n=4 studies). Other common factors included lack of knowledge about PMHPs (n=20 studies), referral pathways (n=8) and treatment options (n=10), lack of time/clear referral pathways (n=22) and stigma related to preexisting mental health problems/SMI (n=8).

Midwives considered routine universal screening as useful in two studies ( 5 , 56 ). Facilitators included self-efficacy in screening (n=10 studies), person-centered care (n=3), the presence of a specialist team (n=2 studies) and mandatory routine screening (n=2). Barriers to screening included longer work experience ( 42 ), lack of knowledge about screening tools (n=11 studies), local/national guidelines on screening (ranging from 12.8% to 53%, n=4 studies), and negative attitudes toward the use of formal screening tools (n=12 studies). The relationship between personal/family experience of PMHPs was either positive [e.g. reduces stigma and allows to relate with parents ( 29 )] or negative ( 45 ). For student midwives, the presence of specialist midwives was both a facilitator [e.g. provides referral options and placement opportunities ( 50 )] and a barrier to screening [e.g. perception that it is not part of their role ( 43 )]. Of note, specialist midwives reported to lack confidence in opening discussions about PMH and to lack knowledge about SMI ( 21 ).

The reasons underlying negative attitudes toward the use of formal screening tools included perceiving the questions as intrusive (n=3 studies), not clearly understanding the purpose of doing so (n=3 studies), inexperience in conducting assessment and feeling compelled to undertake it as a standardized survey ( 23 ), the fear of “not doing it right” (n=2) and discomfort when disclosure occurs (n=7 studies). Some studies reported a flexible use of screening tools (e.g. modified wording or timing of the questions; n=4 studies) and one study outlined the importance of person-centered care in conducting assessment ( 23 ). Conversely, midwives who lacked clarity about their role in PMHC reported feelings of inadequacy resulting in a non-flexible use of screening tools and a distant and superficial manner of asking questions ( 23 ). Midwives reported to feel more comfortable in opening discussions about PMH during follow-up visits compared with the booking appointment (n=5 studies). Alternatives to formal screening included assessing previous psychiatric history/current symptoms ( 28 ), using general open-ended questions (n=5 studies), behavioral observation (n=4 studies) and labor debriefing ( 46 ). Training needs covered knowledge about PMHPs (n=9 studies), screening tools (n=4 studies) and cultural issues and interviewing/distress management skills (n=10 studies).

3.3.2 Referral/support

Midwives reported to feel confident in their ability to refer parents with PMHPs to other health providers including specialist mental health services (n=7 studies). The opposite was found for parents with postpartum psychosis, eating disorders or SMI. High self-reported confidence in referring parents to other providers did not in practice lead to a higher number of referrals ( 37 ). The proportion of midwives indicating to feel confident in supporting parents with PMHPs in self-report questionnaires ranged from 34% to 53% (n=5 studies). Accurate case identification ( 9 ), an established diagnosis of PMHP ( 53 ) and parents’ preferences ( 53 ) influenced decision-making about referral. Other factors included the intention to collaborate with other providers (n=2) or conversely a lack of trust/a reluctance to disclose sensitive information to other providers (n=3 studies).

3.3.3 Training outcomes

All training programs reported improved self-rated knowledge, skills, attitudes and confidence in screening, referring and supporting parents with PMHPs (n=19). Few significant positive training effects were reported due to small-sized samples and lack of controlled/RCT studies. Results included positive effects on empathic communication skills ( 62 , 63 ), case identification ( 64 , 65 ) and the detection of PMHPs in maternity wards ( 66 – 68 ). Contrasted results were found on the number of referrals [n=2 studies; 50% significance; positive effect on self-reported referrals in Pearson et al. (2019) ( 69 ) and no significant effect in Wickberg et al. (2005, 70 )]. No significant effects were found on depressive symptoms ( 70 ) and attitudes toward providing psychological support to parents with PMHPs ( 63 ). Participants’ satisfaction rates were high, the insight provided by parents with lived experience of PMHP being determinant for student midwives (n=4 studies). Barriers included an excessive workload ( 71 ) and for student midwives, elective participation and late delivery within midwifery studies ( 72 ). No difference related to the format of the intervention was reported.

4 Discussion

To our knowledge, this systematic review of 66 studies is one of the first exploring both the training needs in PMH identified by student midwives and midwives and the training programs designed for this population. Overall, a main finding of this systematic review is that although detection, referral and support of parents with PMHPs are part of the essential competencies for midwifery practice according to the ICM (2019) ( 6 ), their effective translation into routine clinical practice may depend on midwives’ understanding of their role in PMHC, i.e. finding meaning in opening discussions about PMH with all parents and the perception that this is part of their routine clinical duties. This suggests that this factor should be targeted by raining interventions aiming at improving detection and management of PMHPs, above and beyond knowledge, confidence, and skills.

Extending the findings of previous reviews ( 7 , 10 , 11 ), we found that although most midwives consider they have a role in PMHC (this aligning with ICM essential competencies for midwifery practice; 2019 ( 6 )), their understanding of that role remains often unclear. Several potential explaining factors have been identified. First, while this topic may be central for a meaningful engagement into providing PMHC, only a few training programs explored the role of midwives in PMHC ( 71 , 73 ). Second, there is a view - in particular in student midwives - that addressing PMH needs is less a priority than addressing physical health needs and that other providers should assume this responsibility ( 31 , 35 , 39 , 43 , 50 , 52 ). The interaction between this view, mental illness stigma and racism toward parents with ethnic minority background contributed to poorer maternity experiences and under-detection of PMHPs ( 19 , 35 , 73 ).

Third, some midwives consider their role as limited to assessing PMH and wellbeing and as appropriate, referring to other health providers ( 9 , 18 , 55 , 57 , 58 ), whereas others have a broad perception of their role that include providing support, psychoeducation and with adequate training counseling interventions ( 21 , 24 , 25 , 42 ). Recent meta-analyses showed positive effects of midwife-led counseling on anxiety and depressive symptoms after at least 3 days of training ( 14 , 74 ). This concurs with recent calls for a better integration of mental health and perinatal health care and an extension of the scope of midwifery practice to include strengths-based case management and psychological interventions for parents with PMHPs ( 50 , 75 – 77 ). Given there is some degree of difference between midwives’ perception of their role in PMHC and what is required as essential competencies for midwifery practice (ICM, 2019) ( 6 ), an explicit focus on midwives’ role in PMHC should be made in initial and continuous midwifery education ( 72 , 73 , 76 , 78 ). Fourth, most student midwives, midwives and specialist midwives reported negative attitudes toward parents with suicide ideations, postpartum psychosis and SMI ( 21 , 35 , 40 , 43 , 57 , 79 ). Aligning with this, Hawthorne et al. (2020) ( 79 ) found that student midwives had more negative attitudes toward persons with mental illness compared with mental health nursing students. However, other studies reported that midwives consider caring for parents with these conditions as part of their role but felt ill equipped to do so and expressed the need for additional training ( 8 , 28 , 29 , 34 , 39 , 49 ).

4.1 Implications for training interventions

While the need to improve midwives’ initial and continuous education in PMH is now well established ( 7 , 10 ), student midwives, midwives and even specialist midwives continue reporting to feel ill prepared to care for parents with PMHP in particular in case of co-occurring SMI ( 9 , 21 , 24 , 33 , 34 , 36 ). Moreover, the proportion of midwives who received education in PMH - in particular in topics such as mental health/suicide risk assessment - remains consistently low. Given suicide is the leading cause of maternal mortality in the 1 st year postpartum in high-income countries, this is concerning ( 1 , 80 ).

Aligning with previous research ( 7 , 10 , 11 ), this systematic review found that education/training programs had positive effects on proximal outcomes (e.g. midwives’ knowledge, skills, attitudes and confidence in providing PMHC) and contrasted effects on distal outcomes (e.g. screening in maternity wards, the number of referrals or depressive symptoms). This could be related to methodological bias (e.g. lack of RCT or quasi-experimental studies). There is a need for high-quality studies on interventions designed following the Medical Research Council framework for complex interventions ( 81 ), which proposes among other core elements to: 1) take into account the context of delivery; 2) use a clear theoretical basis (e.g. how the intervention is expected to produce positive effects and under which conditions) and; 3) promote a meaningful engagement of persons with lived experience among other relevant stakeholders.

According to Wadephul et al. (2018) ( 82 ) framework for assessing midwifery practice in PMH, knowledge, confidence, attitudes and organizational factors influence midwives’ ability to detect and manage PMHPs. However, higher knowledge about PMH does not necessarily translate into higher confidence in providing PMHC and the opposite ( 8 ). As reported in one of the articles included in this review ( 42 ) and aligning with the theory of planned behavior ( 82 ), additional factors such as individual values, e.g. personal interest in PMH, and behavioral intent (e.g. the intention to open discussions about PMH) could influence detection and decision-making about referral and support in PMHPs and thus be relevant for midwifery education.

To improve midwives’ engagement into PMHC, training programs should put PMH in context (e.g. the positive outcomes that could be achieved with appropriate support) before covering topics related to specific knowledge or skills ( 5 , 38 , 49 , 50 , 53 , 54 ). Instead of focusing only on biomedical aspects (e.g. the signs, risk factors, consequences and treatments of PMHPs), programs should propose a continuum approach of PMH that covers the positive aspects of the person’s life including wellbeing and personal recovery ( 83 – 86 ).

Extending the findings of previous reviews ( 7 , 10 , 11 ), training programs should target student midwives, midwives and specialist midwives and cover interviewing and distress management skills with a focus on specific aspects (e.g. opening discussions without feeling intrusive, using flexibly screening tools and reacting in case of a positive answer) ( 5 , 21 , 38 , 45 , 49 , 50 , 53 , 54 ). In addition, training programs should include clinical supervision by mental health providers during and after intervention delivery ( 14 ). Future studies should include a longer follow-up period, as the embedding of practice change requires a minimum of nine months after the intervention is delivered ( 87 ).

Finally, while contact with persons with lived experience is one of the most effective strategies to reduce mental illness stigma in the general public and in frontline health providers ( 88 , 89 ), this review found a very low proportion of training programs that engaged persons with lived experience in the conception and delivery of the intervention. Initial and continuous midwifery education curriculums on PMH should involve persons with lived experience - co-design and co-intervention - and include content about personal recovery/person-centered care ( 72 , 73 , 81 , 84 , 90 – 92 ).

4.2 Limitations

There are limitations. First, despite a growing number of published studies on midwives’ training needs in PMH and training interventions designed for this population (n=66 studies in this review vs. n=22 ( 7 ); n=17 ( 10 ); n=43 ( 11 );), the quality of the included studies remains low to moderate, a concerning finding given the clinical relevance of this topic that is also a considerable limitation. Among other methodological bias, the absence of a clear theoretical basis for designing interventions ( 81 ), the small or unjustified sample sizes, the lack of RCT/quasi-experimental studies, the absence of control groups (or active comparators in controlled studies) and the absence or short duration of follow-up makes unclear whether interventions have positive effects on proximal or distal outcomes. Future high-quality studies on this topic are therefore needed. Despite these limitations, the inclusion of quantitative, qualitative and mixed-methods studies provided a complete synthesis of the available evidence and consistent messages emerged across studies. Second, relevant studies may have been missed since we excluded studies published in other languages than English or French and did not include the grey literature in our searches.

5 Conclusion

This review generated novel insights to inform initial and continuous midwifery education curriculums on PMH (e.g. co-design with persons with lived experience, focus on midwives’ understanding on their role in PMHC or inclusion on content on person-centered care).

Author contributions

MD: Conceptualization, Formal analysis, Writing – original draft. CD: Writing – review & editing. ML: Conceptualization, Writing – review & editing. WB: Conceptualization, Data curation, Methodology, Writing – review & editing. CM: Writing – review & editing. JD: Conceptualization, Formal analysis, Project administration, Supervision, Validation, Writing – original draft.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

The authors wish to thank Dr. M.F.M. Engel and Mrs. C.D. Niehot medical information specialist from the Erasmus MC Medical Library for updating the search strategies. The authors are grateful to the reviewers of a previous version of the manuscript for their helpful comments.

Conflict of interest

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

Publisher’s note

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

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2024.1345738/full#supplementary-material

Supplementary Table 1 | Search strategy, search terms and syntax.

Supplementary Table 2 | List of excluded studies.

Supplementary Table 3 | List of included studies.

Supplementary Table 4 | Characteristics of included studies about midwives' knowledge, skills and attitude.

Supplementary Table 5 | Characteristics of included studies about midwives' needs for peripartum mental health training program.

Supplementary Table 6 | List of abbreviations.

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Keywords: midwifery, perinatal care, mental health services, education, attitude of health personnel, literature review

Citation: Dubreucq M, Dupont C, Lambregtse-Van den Berg MP, Bramer WM, Massoubre C and Dubreucq J (2024) A systematic review of midwives’ training needs in perinatal mental health and related interventions. Front. Psychiatry 15:1345738. doi: 10.3389/fpsyt.2024.1345738

Received: 28 November 2023; Accepted: 02 April 2024; Published: 22 April 2024.

Reviewed by:

Copyright © 2024 Dubreucq, Dupont, Lambregtse-Van den Berg, Bramer, Massoubre and Dubreucq. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Marine Dubreucq, [email protected]

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

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