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Quasi-experimental Design in Education

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• v.13(1); Jan-Feb 2006

The Use and Interpretation of Quasi-Experimental Studies in Medical Informatics

Associated data.

Quasi-experimental study designs, often described as nonrandomized, pre-post intervention studies, are common in the medical informatics literature. Yet little has been written about the benefits and limitations of the quasi-experimental approach as applied to informatics studies. This paper outlines a relative hierarchy and nomenclature of quasi-experimental study designs that is applicable to medical informatics intervention studies. In addition, the authors performed a systematic review of two medical informatics journals, the Journal of the American Medical Informatics Association (JAMIA) and the International Journal of Medical Informatics (IJMI), to determine the number of quasi-experimental studies published and how the studies are classified on the above-mentioned relative hierarchy. They hope that future medical informatics studies will implement higher level quasi-experimental study designs that yield more convincing evidence for causal links between medical informatics interventions and outcomes.

Quasi-experimental studies encompass a broad range of nonrandomized intervention studies. These designs are frequently used when it is not logistically feasible or ethical to conduct a randomized controlled trial. Examples of quasi-experimental studies follow. As one example of a quasi-experimental study, a hospital introduces a new order-entry system and wishes to study the impact of this intervention on the number of medication-related adverse events before and after the intervention. As another example, an informatics technology group is introducing a pharmacy order-entry system aimed at decreasing pharmacy costs. The intervention is implemented and pharmacy costs before and after the intervention are measured.

In medical informatics, the quasi-experimental, sometimes called the pre-post intervention, design often is used to evaluate the benefits of specific interventions. The increasing capacity of health care institutions to collect routine clinical data has led to the growing use of quasi-experimental study designs in the field of medical informatics as well as in other medical disciplines. However, little is written about these study designs in the medical literature or in traditional epidemiology textbooks. 1 , 2 , 3 In contrast, the social sciences literature is replete with examples of ways to implement and improve quasi-experimental studies. 4 , 5 , 6

In this paper, we review the different pretest-posttest quasi-experimental study designs, their nomenclature, and the relative hierarchy of these designs with respect to their ability to establish causal associations between an intervention and an outcome. The example of a pharmacy order-entry system aimed at decreasing pharmacy costs will be used throughout this article to illustrate the different quasi-experimental designs. We discuss limitations of quasi-experimental designs and offer methods to improve them. We also perform a systematic review of four years of publications from two informatics journals to determine the number of quasi-experimental studies, classify these studies into their application domains, determine whether the potential limitations of quasi-experimental studies were acknowledged by the authors, and place these studies into the above-mentioned relative hierarchy.

The authors reviewed articles and book chapters on the design of quasi-experimental studies. 4 , 5 , 6 , 7 , 8 , 9 , 10 Most of the reviewed articles referenced two textbooks that were then reviewed in depth. 4 , 6

Key advantages and disadvantages of quasi-experimental studies, as they pertain to the study of medical informatics, were identified. The potential methodological flaws of quasi-experimental medical informatics studies, which have the potential to introduce bias, were also identified. In addition, a summary table outlining a relative hierarchy and nomenclature of quasi-experimental study designs is described. In general, the higher the design is in the hierarchy, the greater the internal validity that the study traditionally possesses because the evidence of the potential causation between the intervention and the outcome is strengthened. 4

We then performed a systematic review of four years of publications from two informatics journals. First, we determined the number of quasi-experimental studies. We then classified these studies on the above-mentioned hierarchy. We also classified the quasi-experimental studies according to their application domain. The categories of application domains employed were based on categorization used by Yearbooks of Medical Informatics 1992–2005 and were similar to the categories of application domains employed by Annual Symposiums of the American Medical Informatics Association. 11 The categories were (1) health and clinical management; (2) patient records; (3) health information systems; (4) medical signal processing and biomedical imaging; (5) decision support, knowledge representation, and management; (6) education and consumer informatics; and (7) bioinformatics. Because the quasi-experimental study design has recognized limitations, we sought to determine whether authors acknowledged the potential limitations of this design. Examples of acknowledgment included mention of lack of randomization, the potential for regression to the mean, the presence of temporal confounders and the mention of another design that would have more internal validity.

All original scientific manuscripts published between January 2000 and December 2003 in the Journal of the American Medical Informatics Association (JAMIA) and the International Journal of Medical Informatics (IJMI) were reviewed. One author (ADH) reviewed all the papers to identify the number of quasi-experimental studies. Other authors (ADH, JCM, JF) then independently reviewed all the studies identified as quasi-experimental. The three authors then convened as a group to resolve any disagreements in study classification, application domain, and acknowledgment of limitations.

Results and Discussion

What is a quasi-experiment.

Quasi-experiments are studies that aim to evaluate interventions but that do not use randomization. Similar to randomized trials, quasi-experiments aim to demonstrate causality between an intervention and an outcome. Quasi-experimental studies can use both preintervention and postintervention measurements as well as nonrandomly selected control groups.

Using this basic definition, it is evident that many published studies in medical informatics utilize the quasi-experimental design. Although the randomized controlled trial is generally considered to have the highest level of credibility with regard to assessing causality, in medical informatics, researchers often choose not to randomize the intervention for one or more reasons: (1) ethical considerations, (2) difficulty of randomizing subjects, (3) difficulty to randomize by locations (e.g., by wards), (4) small available sample size. Each of these reasons is discussed below.

Ethical considerations typically will not allow random withholding of an intervention with known efficacy. Thus, if the efficacy of an intervention has not been established, a randomized controlled trial is the design of choice to determine efficacy. But if the intervention under study incorporates an accepted, well-established therapeutic intervention, or if the intervention has either questionable efficacy or safety based on previously conducted studies, then the ethical issues of randomizing patients are sometimes raised. In the area of medical informatics, it is often believed prior to an implementation that an informatics intervention will likely be beneficial and thus medical informaticians and hospital administrators are often reluctant to randomize medical informatics interventions. In addition, there is often pressure to implement the intervention quickly because of its believed efficacy, thus not allowing researchers sufficient time to plan a randomized trial.

For medical informatics interventions, it is often difficult to randomize the intervention to individual patients or to individual informatics users. So while this randomization is technically possible, it is underused and thus compromises the eventual strength of concluding that an informatics intervention resulted in an outcome. For example, randomly allowing only half of medical residents to use pharmacy order-entry software at a tertiary care hospital is a scenario that hospital administrators and informatics users may not agree to for numerous reasons.

Similarly, informatics interventions often cannot be randomized to individual locations. Using the pharmacy order-entry system example, it may be difficult to randomize use of the system to only certain locations in a hospital or portions of certain locations. For example, if the pharmacy order-entry system involves an educational component, then people may apply the knowledge learned to nonintervention wards, thereby potentially masking the true effect of the intervention. When a design using randomized locations is employed successfully, the locations may be different in other respects (confounding variables), and this further complicates the analysis and interpretation.

In situations where it is known that only a small sample size will be available to test the efficacy of an intervention, randomization may not be a viable option. Randomization is beneficial because on average it tends to evenly distribute both known and unknown confounding variables between the intervention and control group. However, when the sample size is small, randomization may not adequately accomplish this balance. Thus, alternative design and analytical methods are often used in place of randomization when only small sample sizes are available.

What Are the Threats to Establishing Causality When Using Quasi-experimental Designs in Medical Informatics?

The lack of random assignment is the major weakness of the quasi-experimental study design. Associations identified in quasi-experiments meet one important requirement of causality since the intervention precedes the measurement of the outcome. Another requirement is that the outcome can be demonstrated to vary statistically with the intervention. Unfortunately, statistical association does not imply causality, especially if the study is poorly designed. Thus, in many quasi-experiments, one is most often left with the question: “Are there alternative explanations for the apparent causal association?” If these alternative explanations are credible, then the evidence of causation is less convincing. These rival hypotheses, or alternative explanations, arise from principles of epidemiologic study design.

Shadish et al. 4 outline nine threats to internal validity that are outlined in ▶ . Internal validity is defined as the degree to which observed changes in outcomes can be correctly inferred to be caused by an exposure or an intervention. In quasi-experimental studies of medical informatics, we believe that the methodological principles that most often result in alternative explanations for the apparent causal effect include (a) difficulty in measuring or controlling for important confounding variables, particularly unmeasured confounding variables, which can be viewed as a subset of the selection threat in ▶ ; (b) results being explained by the statistical principle of regression to the mean . Each of these latter two principles is discussed in turn.

Threats to Internal Validity

Adapted from Shadish et al. 4

An inability to sufficiently control for important confounding variables arises from the lack of randomization. A variable is a confounding variable if it is associated with the exposure of interest and is also associated with the outcome of interest; the confounding variable leads to a situation where a causal association between a given exposure and an outcome is observed as a result of the influence of the confounding variable. For example, in a study aiming to demonstrate that the introduction of a pharmacy order-entry system led to lower pharmacy costs, there are a number of important potential confounding variables (e.g., severity of illness of the patients, knowledge and experience of the software users, other changes in hospital policy) that may have differed in the preintervention and postintervention time periods ( ▶ ). In a multivariable regression, the first confounding variable could be addressed with severity of illness measures, but the second confounding variable would be difficult if not nearly impossible to measure and control. In addition, potential confounding variables that are unmeasured or immeasurable cannot be controlled for in nonrandomized quasi-experimental study designs and can only be properly controlled by the randomization process in randomized controlled trials.

Example of confounding. To get the true effect of the intervention of interest, we need to control for the confounding variable.

Another important threat to establishing causality is regression to the mean. 12 , 13 , 14 This widespread statistical phenomenon can result in wrongly concluding that an effect is due to the intervention when in reality it is due to chance. The phenomenon was first described in 1886 by Francis Galton who measured the adult height of children and their parents. He noted that when the average height of the parents was greater than the mean of the population, the children tended to be shorter than their parents, and conversely, when the average height of the parents was shorter than the population mean, the children tended to be taller than their parents.

In medical informatics, what often triggers the development and implementation of an intervention is a rise in the rate above the mean or norm. For example, increasing pharmacy costs and adverse events may prompt hospital informatics personnel to design and implement pharmacy order-entry systems. If this rise in costs or adverse events is really just an extreme observation that is still within the normal range of the hospital's pharmaceutical costs (i.e., the mean pharmaceutical cost for the hospital has not shifted), then the statistical principle of regression to the mean predicts that these elevated rates will tend to decline even without intervention. However, often informatics personnel and hospital administrators cannot wait passively for this decline to occur. Therefore, hospital personnel often implement one or more interventions, and if a decline in the rate occurs, they may mistakenly conclude that the decline is causally related to the intervention. In fact, an alternative explanation for the finding could be regression to the mean.

What Are the Different Quasi-experimental Study Designs?

In the social sciences literature, quasi-experimental studies are divided into four study design groups 4 , 6 :

• Quasi-experimental designs without control groups
• Quasi-experimental designs that use control groups but no pretest
• Quasi-experimental designs that use control groups and pretests
• Interrupted time-series designs

There is a relative hierarchy within these categories of study designs, with category D studies being sounder than categories C, B, or A in terms of establishing causality. Thus, if feasible from a design and implementation point of view, investigators should aim to design studies that fall in to the higher rated categories. Shadish et al. 4 discuss 17 possible designs, with seven designs falling into category A, three designs in category B, and six designs in category C, and one major design in category D. In our review, we determined that most medical informatics quasi-experiments could be characterized by 11 of 17 designs, with six study designs in category A, one in category B, three designs in category C, and one design in category D because the other study designs were not used or feasible in the medical informatics literature. Thus, for simplicity, we have summarized the 11 study designs most relevant to medical informatics research in ▶ .

Relative Hierarchy of Quasi-experimental Designs

O = Observational Measurement; X = Intervention Under Study. Time moves from left to right.

The nomenclature and relative hierarchy were used in the systematic review of four years of JAMIA and the IJMI. Similar to the relative hierarchy that exists in the evidence-based literature that assigns a hierarchy to randomized controlled trials, cohort studies, case-control studies, and case series, the hierarchy in ▶ is not absolute in that in some cases, it may be infeasible to perform a higher level study. For example, there may be instances where an A6 design established stronger causality than a B1 design. 15 , 16 , 17

Quasi-experimental Designs without Control Groups

Here, X is the intervention and O is the outcome variable (this notation is continued throughout the article). In this study design, an intervention (X) is implemented and a posttest observation (O1) is taken. For example, X could be the introduction of a pharmacy order-entry intervention and O1 could be the pharmacy costs following the intervention. This design is the weakest of the quasi-experimental designs that are discussed in this article. Without any pretest observations or a control group, there are multiple threats to internal validity. Unfortunately, this study design is often used in medical informatics when new software is introduced since it may be difficult to have pretest measurements due to time, technical, or cost constraints.

This is a commonly used study design. A single pretest measurement is taken (O1), an intervention (X) is implemented, and a posttest measurement is taken (O2). In this instance, period O1 frequently serves as the “control” period. For example, O1 could be pharmacy costs prior to the intervention, X could be the introduction of a pharmacy order-entry system, and O2 could be the pharmacy costs following the intervention. Including a pretest provides some information about what the pharmacy costs would have been had the intervention not occurred.

The advantage of this study design over A2 is that adding a second pretest prior to the intervention helps provide evidence that can be used to refute the phenomenon of regression to the mean and confounding as alternative explanations for any observed association between the intervention and the posttest outcome. For example, in a study where a pharmacy order-entry system led to lower pharmacy costs (O3 < O2 and O1), if one had two preintervention measurements of pharmacy costs (O1 and O2) and they were both elevated, this would suggest that there was a decreased likelihood that O3 is lower due to confounding and regression to the mean. Similarly, extending this study design by increasing the number of measurements postintervention could also help to provide evidence against confounding and regression to the mean as alternate explanations for observed associations.

This design involves the inclusion of a nonequivalent dependent variable ( b ) in addition to the primary dependent variable ( a ). Variables a and b should assess similar constructs; that is, the two measures should be affected by similar factors and confounding variables except for the effect of the intervention. Variable a is expected to change because of the intervention X, whereas variable b is not. Taking our example, variable a could be pharmacy costs and variable b could be the length of stay of patients. If our informatics intervention is aimed at decreasing pharmacy costs, we would expect to observe a decrease in pharmacy costs but not in the average length of stay of patients. However, a number of important confounding variables, such as severity of illness and knowledge of software users, might affect both outcome measures. Thus, if the average length of stay did not change following the intervention but pharmacy costs did, then the data are more convincing than if just pharmacy costs were measured.

The Removed-Treatment Design

This design adds a third posttest measurement (O3) to the one-group pretest-posttest design and then removes the intervention before a final measure (O4) is made. The advantage of this design is that it allows one to test hypotheses about the outcome in the presence of the intervention and in the absence of the intervention. Thus, if one predicts a decrease in the outcome between O1 and O2 (after implementation of the intervention), then one would predict an increase in the outcome between O3 and O4 (after removal of the intervention). One caveat is that if the intervention is thought to have persistent effects, then O4 needs to be measured after these effects are likely to have disappeared. For example, a study would be more convincing if it demonstrated that pharmacy costs decreased after pharmacy order-entry system introduction (O2 and O3 less than O1) and that when the order-entry system was removed or disabled, the costs increased (O4 greater than O2 and O3 and closer to O1). In addition, there are often ethical issues in this design in terms of removing an intervention that may be providing benefit.

The Repeated-Treatment Design

The advantage of this design is that it demonstrates reproducibility of the association between the intervention and the outcome. For example, the association is more likely to be causal if one demonstrates that a pharmacy order-entry system results in decreased pharmacy costs when it is first introduced and again when it is reintroduced following an interruption of the intervention. As for design A5, the assumption must be made that the effect of the intervention is transient, which is most often applicable to medical informatics interventions. Because in this design, subjects may serve as their own controls, this may yield greater statistical efficiency with fewer numbers of subjects.

Quasi-experimental Designs That Use a Control Group but No Pretest

An intervention X is implemented for one group and compared to a second group. The use of a comparison group helps prevent certain threats to validity including the ability to statistically adjust for confounding variables. Because in this study design, the two groups may not be equivalent (assignment to the groups is not by randomization), confounding may exist. For example, suppose that a pharmacy order-entry intervention was instituted in the medical intensive care unit (MICU) and not the surgical intensive care unit (SICU). O1 would be pharmacy costs in the MICU after the intervention and O2 would be pharmacy costs in the SICU after the intervention. The absence of a pretest makes it difficult to know whether a change has occurred in the MICU. Also, the absence of pretest measurements comparing the SICU to the MICU makes it difficult to know whether differences in O1 and O2 are due to the intervention or due to other differences in the two units (confounding variables).

Quasi-experimental Designs That Use Control Groups and Pretests

The reader should note that with all the studies in this category, the intervention is not randomized. The control groups chosen are comparison groups. Obtaining pretest measurements on both the intervention and control groups allows one to assess the initial comparability of the groups. The assumption is that if the intervention and the control groups are similar at the pretest, the smaller the likelihood there is of important confounding variables differing between the two groups.

The use of both a pretest and a comparison group makes it easier to avoid certain threats to validity. However, because the two groups are nonequivalent (assignment to the groups is not by randomization), selection bias may exist. Selection bias exists when selection results in differences in unit characteristics between conditions that may be related to outcome differences. For example, suppose that a pharmacy order-entry intervention was instituted in the MICU and not the SICU. If preintervention pharmacy costs in the MICU (O1a) and SICU (O1b) are similar, it suggests that it is less likely that there are differences in the important confounding variables between the two units. If MICU postintervention costs (O2a) are less than preintervention MICU costs (O1a), but SICU costs (O1b) and (O2b) are similar, this suggests that the observed outcome may be causally related to the intervention.

In this design, the pretests are administered at two different times. The main advantage of this design is that it controls for potentially different time-varying confounding effects in the intervention group and the comparison group. In our example, measuring points O1 and O2 would allow for the assessment of time-dependent changes in pharmacy costs, e.g., due to differences in experience of residents, preintervention between the intervention and control group, and whether these changes were similar or different.

With this study design, the researcher administers an intervention at a later time to a group that initially served as a nonintervention control. The advantage of this design over design C2 is that it demonstrates reproducibility in two different settings. This study design is not limited to two groups; in fact, the study results have greater validity if the intervention effect is replicated in different groups at multiple times. In the example of a pharmacy order-entry system, one could implement or intervene in the MICU and then at a later time, intervene in the SICU. This latter design is often very applicable to medical informatics where new technology and new software is often introduced or made available gradually.

Interrupted Time-Series Designs

An interrupted time-series design is one in which a string of consecutive observations equally spaced in time is interrupted by the imposition of a treatment or intervention. The advantage of this design is that with multiple measurements both pre- and postintervention, it is easier to address and control for confounding and regression to the mean. In addition, statistically, there is a more robust analytic capability, and there is the ability to detect changes in the slope or intercept as a result of the intervention in addition to a change in the mean values. 18 A change in intercept could represent an immediate effect while a change in slope could represent a gradual effect of the intervention on the outcome. In the example of a pharmacy order-entry system, O1 through O5 could represent monthly pharmacy costs preintervention and O6 through O10 monthly pharmacy costs post the introduction of the pharmacy order-entry system. Interrupted time-series designs also can be further strengthened by incorporating many of the design features previously mentioned in other categories (such as removal of the treatment, inclusion of a nondependent outcome variable, or the addition of a control group).

Systematic Review Results

The results of the systematic review are in ▶ . In the four-year period of JAMIA publications that the authors reviewed, 25 quasi-experimental studies among 22 articles were published. Of these 25, 15 studies were of category A, five studies were of category B, two studies were of category C, and no studies were of category D. Although there were no studies of category D (interrupted time-series analyses), three of the studies classified as category A had data collected that could have been analyzed as an interrupted time-series analysis. Nine of the 25 studies (36%) mentioned at least one of the potential limitations of the quasi-experimental study design. In the four-year period of IJMI publications reviewed by the authors, nine quasi-experimental studies among eight manuscripts were published. Of these nine, five studies were of category A, one of category B, one of category C, and two of category D. Two of the nine studies (22%) mentioned at least one of the potential limitations of the quasi-experimental study design.

Systematic Review of Four Years of Quasi-designs in JAMIA

JAMIA = Journal of the American Medical Informatics Association; IJMI = International Journal of Medical Informatics.

In addition, three studies from JAMIA were based on a counterbalanced design. A counterbalanced design is a higher order study design than other studies in category A. The counterbalanced design is sometimes referred to as a Latin-square arrangement. In this design, all subjects receive all the different interventions but the order of intervention assignment is not random. 19 This design can only be used when the intervention is compared against some existing standard, for example, if a new PDA-based order entry system is to be compared to a computer terminal–based order entry system. In this design, all subjects receive the new PDA-based order entry system and the old computer terminal-based order entry system. The counterbalanced design is a within-participants design, where the order of the intervention is varied (e.g., one group is given software A followed by software B and another group is given software B followed by software A). The counterbalanced design is typically used when the available sample size is small, thus preventing the use of randomization. This design also allows investigators to study the potential effect of ordering of the informatics intervention.

Although quasi-experimental study designs are ubiquitous in the medical informatics literature, as evidenced by 34 studies in the past four years of the two informatics journals, little has been written about the benefits and limitations of the quasi-experimental approach. As we have outlined in this paper, a relative hierarchy and nomenclature of quasi-experimental study designs exist, with some designs being more likely than others to permit causal interpretations of observed associations. Strengths and limitations of a particular study design should be discussed when presenting data collected in the setting of a quasi-experimental study. Future medical informatics investigators should choose the strongest design that is feasible given the particular circumstances.

Supplementary Material

Dr. Harris was supported by NIH grants K23 AI01752-01A1 and R01 AI60859-01A1. Dr. Perencevich was supported by a VA Health Services Research and Development Service (HSR&D) Research Career Development Award (RCD-02026-1). Dr. Finkelstein was supported by NIH grant RO1 HL71690.

SYSTEMATIC REVIEW article

Analysis of personal competences in teachers: a systematic review.

• 1 Department of Psychology, University of Almería, Almería, Spain
• 2 Department of Psychology, Universidad Autónoma de Chile, Santiago, Chile

Background: The relevance of teachers’ emotional and social competencies in education has been highlighted as they enable them to establish effective relationships, manage emotional situations and create positive learning environments. The absence of these competencies can lead to emotional exhaustion and negatively affect the classroom environment, thus stressing the need to strengthen these skills so that teaching professionals can adapt to the changing demands of the educational environment.

Objective: The primary aim of this paper is to analyze the existing programs for training socioemotional skills in teachers and evaluate their effectiveness. To achieve this, a systematic review of the literature is conducted, focusing on the empirical research existing to date that promotes and enhances these skills through intervention programs.

Methods: A literature search was performed using the electronic databases Psycinfo, Psicodoc, Psychology Database, Pubmed, Science Direct and Dialnet Plus, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were eligible for inclusion in this review if they investigated the effectiveness of interventions and training protocols for enhancing personal competencies of a sample of participants composed of teachers.

Results: Activities aimed at strengthening personal competencies in teachers tend to have a positive impact on areas such as job satisfaction, professional commitment, emotional management, and stress reduction, which has a favorable impact on students. However, the effectiveness of these interventions may vary depending on the design of the study and the individual characteristics of the participants.

Conclusion: The importance of training educators in personal and emotional skills is highlighted, due to its feasibility and the benefits it implies for both educators and students. Valuable insights for future practices, emphasizing the need for continuous training, digital technologies, mentoring, and holistic well-being to improve educational quality and job satisfaction for teachers are provided.

1 Introduction

The school’s mission has evolved from merely transmitting academic content to fostering competencies and values for the personal development of students by promoting their socio-emotional skills ( Pérez-Fuentes et al., 2019 ; Zych, 2022 ). Current education system aims to ensure the complete development and well-being of both teachers and students, promoting socio-emotional connections and subsequently enhancing their personal competencies, thereby reducing vulnerability to risky behaviors ( Sandoval, 2014 ; Pérez-Fuentes et al., 2019 ). To achieve the transfer of necessary knowledge, skills, values, and principles for the ethical, socio-affective, and intellectual development of students, teachers need specific personal competencies that enhance the teaching-learning process, and address individual and collective characteristics ( Lytle et al., 2018 ). Personal competencies include encompassing self-knowledge and emotional and cognitive control ( Galvis, 2007 ), and optimism, sociability, emotional understanding, and self-efficacy, have been highlighted as some of them, among others ( Pérez-Fuentes et al., 2019 ).

Therefore, teachers constantly face a wide variety of challenges in educational institutions ( Clandinin et al., 2015 ; Funes, 2016 ). Sometimes, these challenging situations exceed an individual’s personal resources and, far from fostering a positive emotional environment, there is an increase in student and teacher attitudes that are detrimental and have a negative impact on student learning and the well-being of the entire educational community ( Schutz et al., 2009 ; Extremera et al., 2019 ).

Education professionals who have an adequate personal repertoire of competencies are able to recognize and understand their own emotions and those of others and, therefore, use this information effectively to guide their behavior and make appropriate decisions in the classroom ( Schutz et al., 2009 ; García, 2013 ). Teachers’ personal competencies refer to the ability of teachers to recognize, understand and regulate their own emotional states, establish effective interpersonal relationships, and promote the development of socioemotional skills in the educational environment, such as emotional self-awareness, emotional self-regulation, motivation, empathy and social skills ( Salovey and Mayer, 1990 ; García, 2013 ). It has been observed that the presence of these psychological skills is related to greater job satisfaction, a greater sense of excitement for the performance of their teaching work, better management of emotionally demanding situations and a reduction in job burnout since these competencies enable them to adapt to different personal and professional contexts ( Salovey and Mayer, 1990 ; Bakker and Demerouti, 2017 ; Mérida López et al., 2020 ). Another factor that becomes important in teachers is metacognition, which refers to the ability to control one’s cognitive processes by enabling one to understand oneself and others in terms of mental states, such as feelings, convictions, intentions, and desires, and to be able to reflect on one’s own and others’ behaviors ( Iacolino et al., 2023 ). Thus, teachers who have a better repertoire of emotional regulation are more likely to be more effective in achieving their academic goals, creating quality social relationships and appropriately managing classroom functioning, preventing the occurrence of negative classroom situations and problems associated with adolescent disruptive behavior, such as bullying (in the classroom or through the Internet, interpersonal violence and substance abuse) ( Sutton, 2004 ; Pérez-Fuentes et al., 2021 ; Molero et al., 2023 ).

Teachers with good personal competencies tend to create an emotionally safe classroom environment that favors the learning and socioemotional development of students, who develop skills such as empathy, peaceful conflict resolution and the cultivation of life skills; and benefit their state of well-being, the academic performance of their students and their personal development within the educational environment ( Lasauskiene and Rauduvaite, 2015 ; Aristulle and Paoloni-Stente, 2019 ; Molero et al., 2022 ; Al-Jbouri et al., 2023 ). In contrast, teachers who lack good emotional skills tend to experience emotional exhaustion and may transmit negative emotions to their students, generating an unfavorable classroom environment for learning and hindering the establishment of positive relationships and effective conflict resolution, as well as the occurrence of burnout in students and a detriment in their school performance ( Bermúdez and Amaíz, 2017 ; Martos et al., 2018 ; Calleja et al., 2019 ; Laudadío and Mazzitelli, 2019 ). Teachers who experience stress, job distress and burnout tend to have a lower sense of job satisfaction and a higher number of absenteeism episodes at work, as well as poorer teaching performance, with negative effects on both classroom climate and student performance and, therefore, with detrimental consequences for the quality of the educational abilities imparted ( Gkontelos et al., 2023 ).

There are empirical studies that have been aimed at the development and implementation of designs, interventions, formations or trainings to strengthen social and emotional skills in students ( Campayo-Muñoz and Cabedo-Mas, 2017 ; Badau and Trifan, 2022 ; Al-Jbouri et al., 2023 ). However, the need for comprehensive and continuous training of teachers in social–emotional skills has been highlighted in order to promote and develop their personal competencies ( Aristulle and Paoloni-Stente, 2019 ). Although there are works focused on teachers’ emotions ( Sutton and Wheatley, 2003 ), the evolution of society and the current challenges in the educational field require a constant updating of interventions and trainings aimed at strengthening teachers’ personal competencies, and social and emotional abilities given the associations between the capacity for emotional regulation and personal fulfillment and job satisfaction ( Brackett et al., 2010 ). Personal competencies are critical to the well-being and academic success of teachers and their students who, in addition to benefiting from the presence of them, are also harmed by their absence ( Jennings and Greenberg, 2009 ; Kelly et al., 2019 ). Research and interventions to date have provided valuable information, but there is a need to continue to review and update the literature to adapt to the changing needs of the educational environment. The development of personal competencies in teachers is essential to creating positive learning environments and fostering students’ social–emotional growth ( Jennings and Greenberg, 2009 ).

Given the benefits and risks associated with personal competencies in teachers, this paper aims to explore existing studies on socioemotional training programs for teachers. The objective is to analyze how this kind of competencies have been trained and the effectiveness of the included programs. To achieve this, a systematic review of the literature was conducted, focusing on empirical studies that aim to promote and enhance these skills in teachers through different intervention programs.

2 Methodology

To achieve greater rigor in the process, this systematic review was based and developed according to the standards indicated by the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA methodology ( Page et al., 2021 ).

2.1 Search strategy

The following databases were used for the search and review of documents: Psycinfo, Psicodoc, Psychology Database, Pubmed, Science Direct and Dialnet Plus. Based on the objective of this review, the search was to collect studies that addressed a training program aimed at fostering the development of personal competencies with participants who worked as teachers in an educational institution. For this reason, the chosen databases are particularly relevant to the subject matter of the study due to their specialized focus on psychological and educational research, which is relevant for studies on socioemotional skills.

To collect as many publications as possible, two search formulas were established and reviewed using a series of Spanish and English terms as descriptors combined with the Boolean operators “AND” and “OR,” some of them searched for in the title of the publication (ti) and others in the abstract (ab). The two search formulas used in the databases were as follows (the first with English terms and the second with Spanish terms): (1) ti(“emotional competencies” OR “emotional skills” OR “psychosocial competencies” OR “psychosocial skills” OR “personal competencies” OR “personal skills” OR “psychosocial well-being” OR “social–emotional competencies”) AND ab[(Intervention OR treatment OR training OR enhance OR improvement OR program) AND (teacher OR professor)]; and (2) ti(“emotional competencies” OR “emotional skills” OR “psychosocial competencies” OR “psychosocial skills” OR “personal skills” OR “personal skills” OR “psychosocial well-being” OR “social–emotional competencies”) AND ab[(Intervention OR treatment OR training OR training OR enhance OR improvement OR program) AND (teacher OR professor)].

In all the databases and for all the searches performed, the following filters were applied: type of document (scientific journal article, with full text access and evaluated by experts), date (from 2010 to 2023) and language (Spanish and English). The databases used and the results of each search are shown in Table 1 , detailing the publications obtained before applying the filters (initial results) and the results that passed the filters (final results).

Table 1 . Databases and search results.

2.2 Eligibility criteria

Once the eligibility criteria were established and applied, two reviewers independently examined each of the titles and abstracts of the remaining papers to assess their potential eligibility. When the abstract was not sufficient to assess its selection and inclusion in the present work, an exhaustive review of the full text was carried out. Any discrepancies detected in the selection of papers were resolved by consensus. We excluded those studies that did not meet these criteria or did not provide relevant information to respond to the proposed objective.

To establish the exclusion and inclusion criteria, the model known as PICOS ( Landa-Ramírez and Arredondo-Pantaleón, 2014 ) was followed.

Based on this strategy, guidelines have been developed to reject or include documents in this study through its four elements:

1. Population: studies that provided samples of teachers of any educational level were chosen for this review.

2. Subject of interest: all the studies that carry out a training program with the objective of enhancing personal competencies with teachers have been considered.

3. Context: we selected research related to the educational field, excluding intervention studies carried out in any other type of professional context.

4. Study design: the documents included are empirical scientific articles, peer-reviewed and published in both Spanish and English from 2010 to the present. This publication date filter had the intention of compiling and analyzing as many intervention studies as possible. Studies that were narrative, review or intervention proposals were discarded, as well as those that were descriptive in nature and studies that did not address the training of personal competencies. In addition, articles whose text was not in Spanish or English were excluded.

2.3 Studies selection process

Of the 303 publications initially identified, 196 were selected after applying the filters. The title and abstract were reviewed to confirm their inclusion in the review, leaving 26 available. Finally, of the remaining 26 studies, 13 were rejected after review of the full text, leaving 13 papers selected and included in the review. The selection process of the publications included and reviewed in this work can be seen in Figure 1 .

Figure 1 . Flow diagram of the studies selection process.

A synthesis of the selected studies has been carried out. Table 2 shows the most relevant results of the papers reviewed and included in this work. From left to right, the authors, date of publication and country of origin of each study are shown first. Next, the number of participants and their occupation are shown. Next, the design of each study, the objectives established, the measuring instruments used, the data to be highlighted on the training carried out and, finally, the results obtained are indicated.

Table 2 . Synthesis of the selected studies.

It should be noted that Spain is the country that has implemented the largest number of programs in this line of research, being the origin of eight of the 13 studies reviewed. It is also worth mentioning that the most recent study is that of Caires et al. (2023) and the oldest corresponds to Karimzadeh et al. (2012) . The largest sample is observed in the work of Schoeps et al. (2019) , of 340 participants, while the smallest had 20 teachers ( Chianese and Prats, 2021 ). Five of the samples analyzed are composed of future teachers, i.e., Education students, while the rest of the participants were teachers working in different educational institutions (either public or private schools, and at different formative levels: Pre-school, Primary and/or Secondary). It was found that the most used design was quasi-experimental and, finally, although all the studies had the same research objective (to foster emotional skills in teachers), a great variety was found in the measurement instruments used, the intervention used, its duration, and the results obtained.

Bustamante and Mejía (2019) designed 12 workshops of two hours each, based on EI skills and aimed at fostering the development of competencies such as emotional self-awareness, empathy, emotional regulation, motivation, assertive communication, teamwork, and conflict resolution in teachers of a training center. The activities, both face-to-face and experiential, such as dance and theater, allowed the participants to express positive emotions and manage well-being, based on internal dialogue, attention, concentration, stress control and assertiveness. The results showed favorable effects on the development of competencies: they improved in coping with setbacks and work stress; in the management and expression of emotions, although they were not significant.

In the study conducted by Caires et al. (2023) , they carried out an emotional education program consisting of six 90-min sessions in which socioemotional training was applied to future teachers. Participants indicate that, according to their experience, the program positively impacted four of the five domains covered by the program framework: self-awareness, social awareness, relationship skills, and responsible decision making. Results showed that participants experienced an improvement in their emotional repertoire, including the ability to express and understand their own and others’ emotions, as well as empathy and emotional connection.

The training by Castillo-Gualda et al. (2017) followed the RULER method, a social–emotional intervention based on the EI model of Mayer and Salovey (1997) with a duration of three months (eight sessions of three hours each) and the development of EI skills: improving job satisfaction, the level of teaching commitment, and the reduction of work stress levels. Through a face-to-face methodology, teachers improved their emotional understanding (understanding the causes and consequences of their emotions), expanded their emotional vocabulary, acquired a greater emotional management repertoire, and increased their feelings of job satisfaction and performance (personal fulfillment, job effectiveness, and greater concentration and motivation at work). However, no significant differences were obtained in the levels of burnout measured.

Chianese and Prats (2021) applied a Coaching in Education Program (CEd) that consisted of two phases (the first lasted 15.5 h and the second 9.5 h). Group training, individual sessions (face-to-face and online) and peer coaching sessions were conducted. Both qualitative and quantitative results showed a general improvement in these competencies, although the latter were not significant. According to the students, classroom management turned out to be more practical and they were more motivated after the training. On the other hand, teachers and the management team alluded to participation and space for reflection inside and outside the classroom as facilitators of change (justified by the authors as a possible contagion effect), as well as lack of time and overlapping with similar programs as variables that hindered improvement.

Dolev and Leshem’s (2016) work consisted of 12 group workshops and 10 personal coaching sessions, conducted over a 2-year period, as part of an EI training program. Participants conclude that they experienced improvements in their emotional competencies and related behaviors, and that these changes had a positive impact on their work. In addition, many participants showed improvements as reported on the EQ-i measure.

Harvey et al. (2016) worked on classroom environments, relationships, patterns, beliefs, and emotional coaching. Through an emotional coaching of three semi-structured workshops called Quality Learning Circles (based on cognitive-behavioral therapy), each lasting one day and developed over a three-month period, as well as in a follow-up session, peer support was provided, performance practices were compared, and skills tested were reflected upon. The results show an improvement in the teachers’ relationships, boundary setting and emotional awareness. However, not all of them improved and just over a third worsened in the data related to classroom climate. No change in improvement was observed in the students.

The 14-week program of Izquierdo et al. (2022) was based on the work of five dimensions: intrapersonal, interpersonal, stress management, adaptation, and mood/humor. The didactic approaches used in the classroom and their contribution to the development of competencies were analyzed, personal and professional strengths and skills of teachers were discovered, and the development of innovative methodologies and teamwork among teachers, strategies for their emotional development and for effective conflict resolution, work organization, time, communication, and leadership, among others, were encouraged. The dimensions addressed improved significantly in the participants of the intervention condition, highlighting the state of mind, a relevant factor in the creation of a more positive and healthier educational environment.

Karimzadeh et al. (2012) conducted an emotional intelligence teacher (EIT) program for 10 two-hour sessions over 10 weeks, the training provided teachers with a series of practical activities to perform on their own and in the classroom to promote the development of each EI skill, creating a more stable and productive learning environment through positive social interaction, engagement, and academic performance among students. The results showed a significant increase in social–emotional skills and their components in teachers, as well as a positive correlation between increased emotional skills and mental health.

During 10 weeks of a four-month period with two sessions of two hours each, Palomera et al. (2017) integrated an emotional training of active and cooperative methodology in a compulsory subject. Students were organized in small groups and deepened in the competencies introduced by their teacher: self-esteem, emotional regulation, empathy, assertiveness, and social skills; and individual and group practices (role plays, case studies, video analysis, self-reports, group dynamics) were carried out among them. Using audiovisual recordings and scores based on group coordination, communication skills, the quality of the content presented and creativity in the design of the practice, it was possible to increase creativity, self-esteem, and oratorical confidence, and to improve the empathic concern and assertiveness of the future teachers. However, they allude to a “sleeper effect” to explain that the effects at follow-up, 6 months or more after completion, are greater than those observed in the post measures.

Schoeps et al. (2019) organized teachers into seven groups and participated in an intervention program based on the EI skills model of Mayer et al. (2016) , completing seven sessions of two hours each (over three months) on experiential dynamics: visualization/meditation, role-playing exercises, and discussions. At the beginning, group cohesion and EI skills were worked on, and in the last two sessions, assertiveness, conflict resolution, self-esteem and empathy were practiced in a natural context. Through the development of emotional skills and abilities, participants significantly reduced their levels of depression and anxiety, and decreased their levels of burnout : they felt less indifference towards work, psychological exhaustion, and feelings of guilt. On the other hand, motivation and commitment remained stable in both groups and, although the experimental group reported feeling more life satisfaction and higher self-esteem than the control group, this result was not maintained over time.

Torrijos et al. (2016) taught an Emotional Education program (Pro-Emociona) in which participants worked on six thematic blocks (emotional recognition and regulation, self-motivation, empathy, and social competencies) through a practical, active, and participatory methodology lasting 30 h in total (two weekly sessions of 3 h). Participants refer to the need, importance, and usefulness of developing this type of competencies both for their teaching practice and for their personal and social well-being. The self-report measure and the satisfaction questionnaire reflect higher levels of intrapersonal competencies (emotional awareness, regulation, and motivation) and interpersonal competencies (empathy and social skills) once the training is completed.

Zych and Llorent (2020) applied an intervention program inspired by the social and emotional learning approach of Elbertson et al. (2009) . Over ten sessions of one and a half hours each, they addressed awareness, understanding and emotional management: self-esteem, empathy, assertiveness and responsible decision making. In the intervention group, the program was incorporated into the regular curriculum as a mandatory course called School Climate and Culture of Peace in Early Childhood Education, while the control group followed their regular curriculum, which includes group work, role-playing and some content directly and indirectly related to these competencies. The classes were interactive, with group work, practical examples and role-plays in which participants worked in teams. The results reflect an improvement in the emotional clarity of the intervention group and in participants with low initial level in socioemotional competencies, a statistically significant improvement was found in emotional repair and self-management.

Finally, the author Zych together with other collaborators ( Zych et al., 2022 ) implemented an intervention program based on at least 4 tasks carried out in each subject that was part of the plan for the promotion of social and emotional competencies. These tasks were interactive activities, with techniques such as role-playing and group work, designed to promote empathy, social competencies and emotional understanding and management. It was possible to promote social and emotional competencies in the participants of the intervention group, compared to those of the control group.

4 Discussion

The objective of this review was to analyze a series of experimental studies designed to enhance personal competencies in teachers at different educational levels, with the aim of collecting the work that has been done to date with this population in any educational context in the world. To this end, 13 documents were compiled and analyzed, revealing a certain variety in the approaches, interventions and results of the studies carried out.

First, it was observed that Spain was the country where the largest number of studies following this line of research was developed, indicating a significant interest in the topic in the Spanish educational context. Regarding the participants, some differences were found in the size of the samples, the largest being 340 teachers ( Schoeps et al., 2019 ), while the smallest sample was composed of 20 teachers in the study by Chianese and Prats (2021) . In addition, five of the samples analyzed were composed of prospective teachers, while the rest were made up of practicing teachers in different educational institutions. This diversity of participants provides a broader view of the effects of interventions at different stages of the teaching career. It was also noted that the most recent study corresponds to Caires et al. (2023) , while the oldest is that of Karimzadeh et al. (2012) . In addition, it is highlighted that the quasi-experimental has been the most employed in the reviewed studies.

Given the objective of the present systematic review, all the studies reviewed have shared the objective of enhancing the personal competencies of teachers through different training programs under the premise that EI-based skills can be improved with educational intervention ( Izquierdo et al., 2022 ).

The school we once knew has evolved, transitioning from merely teaching academic content to fostering students’ socio-emotional skills with the aim of enhancing their competencies and values to promote personal growth ( Pérez-Fuentes et al., 2019 ; Zych, 2022 ). The current education system seeks the holistic development and well-being of both teachers and students by strengthening socio-emotional connections to reduce vulnerability to risky behaviors ( Sandoval, 2014 ; Pérez-Fuentes et al., 2019 ) and to achieve this, teachers need specific personal competencies ( Galvis, 2007 ; Lytle et al., 2018 ; Pérez-Fuentes et al., 2019 ).

In line with this, several studies have demonstrated the effectiveness of programs that promote these personal competencies through effective interventions ( Zych et al., 2022 ). For instance, Bustamante and Mejía (2019) developed an emotional training program that had favorable effects on the overall development of socio-emotional skills. Other programs have targeted specific competencies such as the ability to express and understand emotions, feel empathy and connection ( Caires et al., 2023 ), leadership, kindness, understanding, and student responsibility/freedom ( Harvey et al., 2016 ), self-esteem, empathy, and confidence in public speaking, as well as a significant reduction in fear of public communication ( Palomera et al., 2017 ), and skills in emotional perception, understanding, and regulation ( Castillo-Gualda et al., 2017 ). Some programs have focused on personal competencies related to intrapersonal and interpersonal intelligence, stress management, adaptability, and mood ( Izquierdo et al., 2022 ), and on teachers’ emotional skills through emotional intelligence, improving aspects such as emotional repair, self-management, and motivation ( Dolev and Leshem, 2016 ; Zych and Llorent, 2020 ).

These programs have provided significant benefits, such as overall improvements in emotional competencies, more practical classroom management, and increased student motivation, as well as changes in participation and reflection ( Chianese and Prats, 2021 ). They have also positively impacted the promotion of work-related variables associated with job satisfaction and performance ( Castillo-Gualda et al., 2017 ), proving effective in the short-and long-term prevention of burnout and emotional symptoms ( Schoeps et al., 2019 ), and improving teachers’ mental health ( Karimzadeh et al., 2012 ).

A great diversity was found in terms of the measurement instruments used, the content of the training sessions, the duration of these trainings, and the results finally obtained in each study. This variety reflects the fact that there is no single, uniform approach to the promotion of emotional skills in teachers, although it may be necessary to design personalized approaches adapted to the specific needs of each group of participants. When analyzing the effects of the exercises presented, it was found that the development of emotional competencies in teachers was generally favorable, although not all the results were statistically significant. This type of interventions aimed at fostering emotional skills in teachers can have positive effects on certain aspects of their professional well-being, such as job satisfaction, teacher commitment, emotional regulation, and stress reduction at work; variables that have a beneficial impact on a student body made up of children and adolescents. However, it is important to note that the results vary according to the design of the study, the duration and nature of the intervention, as well as the characteristics of the participants. More research with rigorous designs and incorporating programs of this type consistently across the curriculum and at all levels is needed, as schools using the social and emotional learning program have been found to report improvements in academic success, less problem behavior, and better-quality educator-student relationships ( Karimzadeh et al., 2012 ). Therefore, it is necessary to investigate this line of action since there is little empirical literature that proposes the development of experimental training programs with education professionals to enhance their cognitive, emotional, and social skills.

5 Conclusions

The results showed that training education professionals in personal and emotional skills is feasible and has numerous positive implications, both for themselves and for the rest of the educational community, especially the students. In this work, the objective was to review training programs aimed at improving personal skills in the educational context with teachers and educators.

One of the main limitations identified in this systematic review is the heterogeneity of the interventions. Programs can vary widely in terms of content, duration, frequency, and methodology, which makes direct comparison between studies difficult, as each intervention may be designed and applied differently, according to the professional delivering it and responding to specific needs of the contexts in which they are implemented. Another limitation to be highlighted is the cultural and geographical context in which the studies are conducted since intervention programs carried out in different cultural and geographical contexts may present results that are not directly applicable to other settings. Sociocultural characteristics, educational systems, and local norms and values can influence the effectiveness of interventions and how they are received by participants, underscoring the relevance of considering the context when interpreting study results and designing intervention programs for different educational environments.

Despite the mentioned limitations, this systematic review has provided valuable insights that can inform future practices in personal competency training for teachers. Training personal competencies in teachers not only improves educational quality but also contributes to educators’ well-being and job satisfaction. Future practice lines should focus on the integration of continuous training, the use of digital technologies, evaluation and feedback systems, personalized research, and the promotion of holistic well-being. These integrated and sustainable approaches will ensure effective and adaptable development of personal competencies in teachers, preparing educators to face the challenges and opportunities of the contemporary educational environment.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Author contributions

PM-M: Writing – original draft, Writing – review & editing, Conceptualization, Investigation, Methodology, Validation, Visualization. MM-J: Conceptualization, Investigation, Methodology, Resources, Supervision, Validation, Writing – review & editing, Visualization. MP-F: Conceptualization, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing, Visualization. JG-L: Conceptualization, Investigation, Methodology, Resources, Supervision, Validation, Writing – review & editing, Visualization.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This publication is part of the I+D+i PID2020-119411RB-I00 funded by MCIN/AEI/10.13039/501100011033/and FEDER “Una manera de hacer Europa”.

Acknowledgments

The authors thanks to the aid for pre-doctoral contracts for the training of doctors, contemplated in the State Training Sub-programme of the State Programme to Develop, Attract and Retain Talent, within the framework of the State Plan for Scientific, Technical and Innovation Research 2021-2023, granted to Pablo Molina Moreno (reference: PRE2021-097460).

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.

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Keywords: teachers, education, emotions, programs, personal competencies

Citation: Molina-Moreno P, Molero-Jurado MdM, Pérez-Fuentes MdC and Gázquez-Linares JJ (2024) Analysis of personal competences in teachers: a systematic review. Front. Educ . 9:1433908. doi: 10.3389/feduc.2024.1433908

Received: 16 May 2024; Accepted: 26 July 2024; Published: 06 August 2024.

Reviewed by:

Copyright © 2024 Molina-Moreno, Molero-Jurado, Pérez-Fuentes and Gázquez-Linares. 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: María del Mar Molero-Jurado, [email protected]

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• Open access
• Published: 10 August 2024

Training approaches for the dissemination of clinical guidelines for NSSI: a quasi-experimental trial

• Elisa Koenig 1 , 2 ,
• Ulrike Hoffmann 1 , 2 ,
• Jörg M. Fegert 1 , 2 ,
• Ferdinand Keller 1 , 2 ,
• Maurizio Sicorello 3 ,
• Jennifer Spohrs 1 ,
• Laura Kraus 4 ,
• Sandra Nickel 1 ,
• Christian Schmahl 3 , 5 ,
• Birgit Abler 6 ,
• Tina In-Albon 4 ,
• Julian Koenig 7 ,
• Dennis Ougrin 8 ,
• Michael Kaess 9 , 10 ,
• Paul L. Plener 1 , 11 &

the Star-Consortium

Child and Adolescent Psychiatry and Mental Health volume  18 , Article number:  99 ( 2024 ) Cite this article

Metrics details

Non-suicidal self-injury (NSSI) is of high clinical relevance due to its high prevalence and negative long-term implications. In 2016, the German consensus-based clinical guidelines for diagnostic, assessment and treatment of NSSI in childhood and adolescence were published. However, research indicates that clinical guidelines are often poorly implemented in clinical practice. One crucial part of this process is the training of healthcare professionals to transfer knowledge and capacities to bring guideline recommendations into clinical practice.

The effect of three different dissemination strategies (printed educational material, e-learning, and blended-learning) on the NSSI guidelines´ recommendations was examined among 671 physicians and psychotherapists via an online-survey. The quasi-experimental study included three measurement points (before the training, after the training, 3-month follow-up) and mixed effects models were used to test for changes in knowledge, competences and attitudes toward NSSI and treatment. Moreover, the transfer of gained competences to practical work and user satisfaction were reviewed.

With all three training formats, the intended changes of the outcome variables could be observed. Hereby, the printed educational material condition showed the lowest improvement in the scores for the ‘negative attitudes toward NSSI and those who self-injure’. The training effect remained stable throughout the follow-up measurement. The highest application rate of acquired intervention techniques in clinical practice was reported for the blended-learning condition. For all three training strategies, user satisfaction was high and evaluation of training quality was positive, with printed educational material receiving the lowest and blended-learning the highest evaluations.

Conclusions

In summary, all three training formats were perceived to be of high quality and seem to be suited to cover the needs of a heterogeneous group of physicians and psychotherapists. The choice of training method could be driven by considering which training goals are desired to be achieved and by the benefit-cost ratio allowing for tailored training approaches.

Non-suicidal self-injury is defined as deliberate, self-directed damage of body tissue without suicidal intent and for purposes not socially or culturally sanctioned [ 1 ]. Studies found a lifetime prevalence of 17–35% in adolescents for at least one incident of NSSI [ 2 , 3 , 4 ]. The DSM-5 proposed diagnostic criteria for NSSI and included it as a condition for further study. The criteria include repetitive nature of the self-injurious behaviour with at least 5 incidents within the last year as well as functional, motivational and emotional aspects of NSSI [ 5 ]. Applying these DSM-5 criteria for NSSI, rates among child and adolescent community samples range from 1.5 to 6.7% [ 6 ]. Even higher prevalence rates are found in inpatient clinics [ 7 ] and in youth welfare [ 8 ]. NSSI peaks around the age of 15 and decreases in late adolescence [ 9 , 10 ] but bears long-term risks, including increased rates of suicide attempts and suicides [ 11 , 12 ]. Considering the high prevalence of NSSI, it is very likely that a high number of (mental) healthcare professionals get in contact with patients who self-injure at some point during their work including diagnosing, managing, transferring and/or treating NSSI. In conclusion, NSSI is of high clinical relevance due to its high prevalence and long-term implications.

There have been guidelines on the broader concept of self-harm (defined as any intentional self-poisoning or self-injury, irrespective of suicidal intent), such as the guidelines of the National Institute for Health and Care Excellence (NICE) [ 13 , 14 , 15 ]; however, it was not until 2016 that the German consensus-based clinical guidelines for diagnostic assessment and ltreatment of NSSI in childhood and adolescence were published as the first internationally published guidelines on NSSI specifically [ 16 , 17 ]. These guidelines aim at optimizing diagnostic processes and treatment of NSSI, improving care for patients with NSSI [ 18 ]. Recent meta-analyses imply that patients treated with guideline-adherent treatments improve to a greater degree and more quickly than patients treated with treatment-as-usual [ 19 ] and that guideline implementation strategies may influence patient outcomes positively [ 19 , 20 ]. However, research indicates that evidence-based clinical guidelines are poorly implemented in clinical practice and require active action for implementation [ 20 , 21 , 22 , 23 ]; this also applies to mental health guidelines [ 24 , 25 , 26 ] and the NICE guideline on self-harm [ 27 ]. To overcome this gap, efforts must be made to disseminate evidence-based knowledge into clinical practice. An important prerequisite for guidelines to enfold their positive impact is for professionals to have the necessary knowledge and capacities for evidence-based procedures [ 19 ]. Thus, continuous education plays a crucial role in offering healthcare professionals the information they need to deliver patient care according to guideline recommendations [ 21 , 28 ]. However, studies suggest that there is a lack of training of (mental) health care professionals for self-harm [ 27 , 29 , 30 , 31 , 32 ].

E-learning has become increasingly popular in offering education for (mental) health professionals on evidence-based treatment recommendations, especially during the COVID-19 pandemic [ 33 ]. E-learning has the advantage of providing low-threshold, easy and flexible access to training programs and has been proven to be effective in (continuous) education for healthcare professions, being at least as effective as traditional learning approaches [ 34 , 35 , 36 , 37 , 38 , 39 ]. The shortcomings of e-learning include the lack of interpersonal communication/exchange and challenges in offering direct practical application of skills including individualized feedback [ 40 , 41 , 42 ]. Blended learning, as the combination of e-learning and face-to-face learning, can overcome these shortcomings and combine the advantages of both e-learning and face-to-face learning. According to various meta-analyses, blended learning is at least as effective as traditional learning [ 43 , 44 , 45 , 46 ] and e-learning [ 45 ] in health education. A more ‘traditional’ way of disseminating knowledge is printed educational materials (PEMs). A recent meta-analysis suggested that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals’ practice outcomes. However, the effectiveness of PEMs compared to other interventions or of PEMs as part of a multifaceted intervention is uncertain [ 47 ].

To date, no studies have provided insights into the effect of dissemination strategies on NSSI guidelines. However, continuous education programs for professionals dealing with the prevention and/or intervention of suicidality have been explored in several studies. One found improved self-perceived knowledge and confidence among staff of psychiatric departments who received a blended-learning train-the-trainer programme about suicide guidelines in contrast to professionals who were exposed only to traditional guideline dissemination (e.g., internet, newsletter, books, publications and congresses) [ 48 ]. A blended-learning approach including role-play training for mental health professionals on the assessment and management of suicide risk was also found to improve clinical skills such as perceived behavioural control or the development of a treatment plan [ 49 ]. Another study revealed higher levels of self-evaluated knowledge about suicide and greater confidence in having a conversation about suicidal behaviour among undergraduate psychology students receiving an e-learning module compared to a wait list control group [ 50 ]. Ghoncheh and colleagues [ 51 ] explored suicide prevention e-learning-modules in a wait list control group design among 190 gatekeepers. The results demonstrated that the perceived and actual knowledge and perceived self-confidence of gatekeepers in the experimental group improved significantly compared to those in the wait list control group. These studies show the benefit of blended-learning [ 48 , 49 ] and e-learning [ 50 , 51 ] in training health professionals in dealing with suicidality, but they do not directly compare those dissemination strategies. In their meta-analysis of the effectiveness of blended-learning in health professions, Liu and colleagues [ 45 ] also concluded that there are only a few studies comparing blended-learning with e-learning. Considering the evidence available about training professionals in evidence-based interventions for mental health in general, there is mounting evidence demonstrating the need for dissemination and training strategies taking an active approach beyond the provision of manuals or self-study [ 52 , 53 ]. For example, a dissemination trial testing three strategies (manual only, review of the manual plus access to a training Web site, or review of the manual plus a didactic seminar followed by supervised casework) for training 78 community-based clinicians in cognitive-behavioural therapy found that clinicians’ ability was significantly greater for those who participated in the seminar plus supervision condition than for those assigned to the manual only condition, with intermediate ratings for the Web condition [ 54 ]. Likewise, meta-analyses point to the potential benefits of simulation-based education, such as role-play in suicidal crisis intervention – whether, for example, as the sole form of intervention or as part of a blended-learning format – in relation to improving attitudes, knowledge, skills and behaviours of health professionals [ 55 , 56 , 57 ]. To summarize, the current body of research first indicates the potential of e-learning and blended-learning in the dissemination of evidence-based knowledge and skills and second suggests that more active training approaches, such as role-plays, are more likely to enhance health professionals´ competences. However, to our knowledge, no studies have directly compared different dissemination interventions for evidence-based guidelines, especially regarding NSSI. The aim of the current study was therefore to examine the effect of three different dissemination strategies of the German NSSI guidelines among (mental) healthcare professionals (printed educational material, e-learning, blended-learning) on the acquisition of knowledge, competences, positive attitudes, transfer to practical work and acceptance of the respective dissemination strategies. This selection of training modalities is intended to build on and expand the existing research literature by directly comparing current and promising training approaches (e-learning and blended-learning) while including printed educational material as a widely used, low-threshold and easy-to-create training strategy in the comparison. Based on previous studies, we hypothesized that printed educational material would result in the lowest improvement in all assessed professionals´ outcomes (H1) because it has the lowest interactive approach among the three training modalities. As the blended-learning- and the e-learning-conditions differed only in the presentation of the course module on the specific intervention ‘Therapeutic Assessment’ (see description below), we assumed that blended-learning only performs better than e-learning in the uptake on that intervention into practical work, but that there are no differences between the two conditions in the remaining variables (H2). The study was part of the cooperative project STAR (Self-injury: Treatment, Assessment, Recovery), funded by the German Federal Ministry of Education and Research. The results and procedures are reported in accordance with the CONSORT-SPI 2018 [ 58 , 59 ].

Design and procedure

Three different training strategies (printed educational material (PEM), e-learning (EL), and blended-learning (BL)) were developed and evaluated with a quasi-experimental pretest-post test design among physicians and psychotherapists.

For recruitment, professional associations and chambers of psychotherapists and physicians were contacted to distribute information about the project by their mailing lists. Additionally, the project was promoted at professional conferences, via mailing lists and social media channels. As the trainings started at four time points during the project phase (see below), recruitment took place between 08/2018 and 08/2020.

Persons interested in the project and the study could register on the project homepage. Eligible persons were included in the study. The study inclusion criteria comprised residence in Germany and being graduated as physician or psychotherapist, because these professions are the main target group of the clinical guidelines. To reduce the dropout rate for BL, participants received information at project registration where the face-to-face workshops of the BL-condition were planned to take place (Berlin, Düsseldorf, Ulm). All persons who confirmed to be willing to attend a workshop in one of those cities, were included in the BL-condition. The other persons were randomly assigned to either the PEM- or EL-condition, with the PEM-condition being over randomized to account for the extended number of participants in the EL due to transfer from the BL- to the EL-condition (see ‘Participants and dropout’). Randomization was managed by an external company providing the website, system support and programming using computer-generated random numbers. Thus, the research team and participants were not aware of the randomization sequence; they were aware of the intervention assignment after allocation though. Participation in the trainings was free of charge, and participants were free to complete the training at their own pace as long as it was completed within three months.

The data were assessed pseudonymously via online questionnaires at three measuring points, T1-T3. Participants had to complete T1 to gain access to the training method to which they were assigned. After they completed the training, they were asked to fill in the post intervention questionnaire (T2). Participants received a certificate of training participation (including professional credits) only if they completed T2. As the surveys were conducted pseudonymously, the information and evaluation given by the participants in the questionnaire were not related to the certification. For certification, it was only important that T2 was completed, not how T2 was completed. Participants were informed of that procedure. Participants were regularly reminded by automatically sent emails to complete their training and assessments. Three months after the training was completed, they were asked to participate at T3. To encourage completion of T3, participants who had been assigned to the PEM-condition were offered the option to participate in the e-learning training after completing the T3-assessment, and participants who had been assigned to the EL- or BL-condition were offered the opportunity to receive the printed educational material after completing the questionnaire at T3. It took approximately 30 min to complete each assessment (T1, T2, T3).

The trial duration was adapted a priori according to the project funding. Four time points were defined when a cohort (consisting of the three study conditions) started and training participation was possible: 12/2018-02/2019; 04/2019-07/2019; 10/2019-01/2020; 09/2020-12/2020. The last cohort was postponed due to the COVID-19 pandemic in hopes of being able to conduct face-to-face workshops at a later date; ultimately, no in-person workshops could be held in the last cohort so that participants who were allocated to the BL-condition were transferred to the EL-condition. The study stopped once the follow-up assessments of the fourth cohort were completed.

Sample size

Other studies exploring different approaches for the training of medical professionals in suicide prevention have shown large Cohen d effect sizes of approximately 1.0 for the acquisition of knowledge and between 0.7 and 1.1 for self-confidence [ 48 , 50 ]. Additionally, a study among gatekeepers on the efficacy of a web-based adolescent suicide prevention programme revealed large effect sizes for actual knowledge, perceived knowledge and perceived self-confidence [ 51 ]. Given these findings, we decided to choose an estimated effect size of d = 0.7. To detect this effect size, assuming an alpha of 0.05 and a statistical power of 1 − beta = 0.90, the total sample size resulted in 131, i.e., 44 per group (calculations based on G-Power 3.1.9.7). As we observed dropout rates of approximately 60% from T1 to T3 in our own projects evaluating e-learning courses for professionals, we aimed for a minimum group size of n  = 110 for T1 to allow for attrition over time.

Ethical considerations

Participation in the study was voluntary, and the data were assessed pseudonymously. All participants were informed beforehand about the study and provided online informed consent. The online course included information on the national telephone helpline in case participants experienced emotional stress triggered by training content. This study was approved by the medical ethical committee of Ulm University (311/18) on 29th August 2018.

Interventions

PEM consisted of an A5-size brochure with a short, compact summary of the NSSI guidelines structured in four topics: ‘Classification’, ‘Epidemiology and Aetiology’, ‘Diagnostic Assessment’ and ‘Intervention’ which included information on ‘Therapeutic Assessment’. Therapeutic assessment (TA) is a brief, manualized intervention based on cognitive-analytic therapy that can be delivered in different settings by professionals from a range of disciplines [ 60 ]. TA comprises three main elements: (1) construct a diagram with the individual vicious circle that includes triggering situations, dysfunctional basic assumptions, resulting behaviours and their consequences; (2) identify potential exits of the circle; and (3) subsequently, address an ‘understanding letter’ to the patient where the issues discussed during the session are summarized and a follow-up appointment for further therapeutic care is offered. TA training was shown to be feasible and was associated with improved quality of self-harm assessment [ 61 ]. In total, the PEM contained approximately 60 pages including a pocket card with a flow chart and key facts about NSSI. It was certified within the continuing medical education system with 2 CME points. Currently, the developed brochure is available on the project homepage [ 62 ].

Learning material for EL was provided as texts, interview clips with experts, case-based exercises, good practice videos and further information such as worksheet templates for therapy. The EL texts were nearly identical to the information given in PEM, but the additional material provided more in-depth insight into the topic. Compared to PEM, EL included a more descriptive module on ‘Therapeutic Assessment’ with a focus on exercising the application of TA (the processing time for the module was appx. 135 min). Therefore, first a good practice video and understanding letter were presented and afterwards participants were invited to perform the three main elements of TA (construction of a vicious cycle, identification of potential exits, writing of an understanding letter) on the platform based on a given case vignette with video sequences of a simulated therapist-patient TA session. The processing time of EL was estimated to be approximately 7.5 h. EL was accredited with 18 CME points. Currently, the online course is not available for participation.

The BL-condition was identical to the EL-condition, except for module 5 ‘Therapeutic Assessment’, which was taught during a half-day face-to-face workshop (appx. 3.5 h) instead of online, resulting in a total processing time of approximately 9 h. The face-to-face workshop was led by one to two members of the research team and of the STAR-consortium with clinical theoretical and/or practical expertise on NSSI (psychotherapists, psychiatrists). It was held in the last month of the three-month participation period and comprised a short summary of the learning contents of modules 1 to 4 (appx. 35 min) and a theoretical input to module 5, which included the same good practice video and understanding letter as in the EL-condition (appx. 80 min). Subsequently, participants were assigned to groups of two to complete an on-site role-play (patient-physician/psychotherapist) of TA (appx. 60 min). Afterwards, experiences and questions were discussed within the whole group (appx. 25 min). BL was also certified with 18 CME points.

Outcome measures and evaluation of training quality

Primary outcomes: competences and attitudes (assessed t1, t2, t3).

Knowledge about NSSI was measured with a self-administered multiple-choice test of 15 questions, which included five answer choices on average (range from 4 to 8). Two questions specified that exactly one choice is correct, and for further data analysis, one point was awarded for each question if it was answered correctly. The other 13 questions indicated that at least one of the choices was correct. For the data analysis, we checked for each choice whether it was answered correctly (i.e., wrong choices not ticked and true choices ticked), and points were awarded accordingly. This procedure led to possible results ranging from 0 points to 70 points. The Cronbach´s alpha in this study was 0.72, indicating an acceptable internal consistency. The questions and choices were created based on the content of the trainings. One example of a question is: ‘Which of the following statements about associated symptoms and comorbidities in NSSV is/are correct?’ with the following answer choices: ‘persons who injure themselves suffer from a borderline personality disorder’, ‘NSSI occurs only in combination with a mental disorder’, ‘children/adolescents who injure themselves are more likely to commit suicide in the future’, ‘people who injure themselves are suicidal’, ‘people who show self-injuring behaviour during adolescence are more likely to show destructive behaviour during adulthood, too (i.e. substance abuse)’, ‘affective disorders are among the most common comorbidities in NSSI’.

To assess perceived competences regarding NSSI , participants were asked to rate 10 items on a 5-point Likert scale from 1 (do not agree at all) to 5 (agree totally); for example ‘I know how to proceed in a case of NSSI’. These items were partly self-created and partly adapted from a questionnaire used in an evaluation of workshops about suicidality and self-injury for school staff [ 63 ]. For analyses, the mean of the sum score of all items was computed. The Cronbach´s alpha in this study was 0.89, indicating good internal consistency.

Positive attitudes toward the effectiveness of NSSI treatment were assessed with five items taken from an attitude scale developed by Crawford and colleagues [ 64 ] that included statements such as ‘It is not useful for children/adolescents who self-harms to have contact with me’. Participants could express their consent to the statements on a 4-point scale from 1 (do not agree at all) to 4 (agree totally). The mean of the sum score of all items was used for analyses. The Cronbach´s alpha in this study was 0.64, indicating a questionable internal consistency.

Participants were asked to rate their attitudes toward NSSI and those who self-injure on a 5-point Likert scale ranging from 1 (do not agree at all) to 5 (agree totally). The scale comprises 15 items, for example, ‘I find it hard to understand people who self-injure’. The scale was composed of self-created items and items from various other questionnaires and studies [ 31 , 65 , 66 , 67 ]. Higher values reflect more negative attitudes toward NSSI and those who self-injure. The average sum score of all the items was used for the analyses. In this study, the newly composed scale reached a Cronbach´s alpha of 0.77, reflecting an acceptable internal consistency.

Transfer to practical work (assessed T3)

Only at T3 was the extent to which participants applied the short intervention ‘Therapeutic Assessment’, which was part of all trainings (yes /no/ not specified), assessed. If participants conducted TA, they were asked, how often (four categories from ‘up to ca. 25% cases of NSSI’ to ‘75 – 100%’) and which element(s) of TA was/were applied (construction of diagram, searching for potential exits, writing an understanding letter). Moreover, participants estimated how helpful they found application of TA on a 5-point Likert scale ranging from 1 (do not agree at all) to 5 (agree totally). If participants indicated not having applied TA, they could choose from a list of reasons why.

Training evaluation (T2)

To ensure the quality of the learning formats, user satisfaction and evaluation of their training were surveyed at T2 with 16–32 items, depending on the training condition. Nine items were evaluated in all three conditions, and seven items were rated on a 6-point scale ranging from 1 (not true at all) to 6 (absolutely true) (example: ‘the contents are relevant for my professional context’). Two items measured perceived level of training (5-point scale from 1 (too low) to 3 (exactly right) to 5 (too high)) and perceived depth of information (5-point scale from 1 (too superficial) to 3 (exactly right) to 5 (too specific)).

Demographic characteristics and covariates

The demographic characteristics collected included gender (male/female), year of birth, country of residence, profession (Medical Psychotherapist, Child and Adolescent Psychiatrist, Paediatrics, General Practitioner, Other Physician, Adult Psychotherapist, Child and Adolescent Psychotherapist) and working context (psychiatric, psychotherapeutic or psychosomatic clinic for children/adolescents; psychiatric, psychotherapeutic or psychosomatic clinic for adults; paediatric clinic; other clinic; psychiatric, psychotherapeutic or psychosomatic practice/outpatient clinic for children/adolescents; psychiatric, psychotherapeutic or psychosomatic practice/outpatient clinic for adults; paediatric practice/outpatient clinic, other practice/outpatient clinic; social paediatric centre; public health service; counselling work (e.g. specialist counselling centre, educational counselling, family counselling; other)). For description of demographic characteristics, working context was categorized into ‘inpatient’ (comprising the first four answer options listed above), ‘outpatient’ (comprising the following four answer options listed above) and ‘other’ (comprising the last four answer options listed above).

As covariates, the frequency of previous experience with NSSI in the work context, personal experience with people who self-injure (including one self) and attendance at previous trainings on the topic were surveyed at T1, as was attendance at other trainings on NSSI parallel to/after participation in the project at T2 and T3.

Statistical analyses were performed using the Statistical Package for the Social Sciences SPSS 28.0.1. For sample description, nominal data are presented as frequencies, while continuous data are presented as mean (M) and standard deviation (SD).

To analyse the overall difference between the three training conditions over time, linear mixed-effects models with fixed factors training (PEM, EL, BL), time (T1, T2, T3) and the interaction between the two were applied for the different primary outcome variables: knowledge about NSSI as assessed by the MC-Test, competences regarding NSSI, attitudes toward effectiveness of treatment and attitudes toward NSSI and those who self-injure. Graphical inspection of the normal distribution and homoscedasticity of the residuals of the dependent variables revealed no major violation of those assumptions. Furthermore, mixed-effects models have been shown to be robust against violations [ 68 , 69 ].

The influence of covariates (age, sex, professional group (physician/psychotherapist), work experience, cases of NSSI confronted with professionally, personal experience with people who self-injure (including one self), and participation in other trainings on the topic during training participation) was analysed exploratorily by calculating mixed-effects models for each covariate separately, and significance of interaction effects, including the respective covariate (training x time x covariate), was checked.

As it was not possible to skip items in the online-questionnaires, there were no missing data within one questionnaire. Missing values within one proband between different measuring points due to dropout from the study were handled using the Full Information Maximum Likelihood (FIML) method which estimates model parameters by taking into account the available data under the assumption of missing-at-random which seems justified for the drop-outs.

Differences among trainings in practical transfer were analysed using one-way ANOVAs and chi-square tests. When appropriate, Cramer’s V (V) was calculated. The impact of covariates was explored by conducting a binary logistic analysis with the application of TA as a criterion and training approaches as well as the covariates listed above as predictors. For training evaluation, descriptive analyses and one-way ANOVAs were used. When conducting ANOVA, some variables violated the assumption of a normal distribution. As one-way ANOVA has proven to be robust against violations of a normal distribution [ 70 , 71 ], it was still applied. When there was no homogeneity of variance, Welch ANOVA was conducted.

For all analyses, group assignments followed an, as-treated’ principle. For interpretation of the main analysis, i.e. the interaction effect of training x time for the four primary outcome variables, we corrected the level of significance from p  = .05 to p  = .0125 according to the test of four hypotheses. For interpretation of all the other analyses, a level of significance of p  = .05 was applied, unless multiple comparisons between the three training conditions were conducted. In these cases, the critical p value was adjusted using Bonferroni adjustment.

Participants and dropout

In total, 1,269 persons registered on the project homepage to participate in one of the trainings. A total of 450 persons were excluded from the study because they did not live in Germany and/or did not indicate that they were physicians or psychotherapists. Of the remaining 819 persons, 257 were allocated to PEM, 168 to EL and 394 to BL. T1 assessment was completed by 207 participants (80.5%) in PEM, 134 participants (79.8%) in EL and 330 participants (83.8%) in BL. Participants assigned to BL who could not attend one of the offered face-to-face workshops ( n  = 186) were transferred to EL and thus were included in the EL sample. Participants who attended at one of the workshops and thus stayed in BL and completed T2 did not differ in age, gender, profession, work context, work experience or number of cases of NSSI being confronted with professionally, compared to participants who were transferred from BL to EL and completed T2 (‘BL-in-EL’), indicating that the randomization effect was not impaired by this procedure. This resulted in group sizes of PEM = 207, EL = 320 and BL = 144 for T1. Finally, outcome data were obtained for 158 participants in PEM, 259 in EL and 89 in BL (T2). Thus, of the 671 participants who completed T1 and had access to their training, 506 participants finished their training and completed T2 (dropout rate: 24.6%). The dropout rate from T1 to T2 was 23.7% in PEM, 27.6% in EL and 38.2% in BL (for EL and BL, the participants who were transferred from BL to EL were neglected because this would bias the dropout rate). No significant differences between those who dropped out and those participants who successfully completed the course and filled out T2 were found in terms of age, gender, profession, work context, work experience or number of cases of NSSI being confronted with professionally. We retained 99 participants (62.7%) of PEM, 137 (52.9%) for EL and 56 (62.9%) for BL for the 3-month follow-up assessment (T3). Therefore, in total 292 participants completed T3-assessment. There were no significant differences between the participants who dropped out from T2- to T3-assessment and the participants completing T3 for the listed variables. The flow of participants through the trial is illustrated in the Fig.  1 . The sample characteristics of the dropout groups can be found in Additional file 1 (Table S1 ).

Flow of participants through the trial. PEM, printed material; EL, E-Learning; BL, Blended-Learning; BL-in-EL, participants originally allocated to BL who were transferred to EL due to nonparticipation at the workshop

Sample characteristics of participants who successfully completed their training

Demographic and work-related data of successful participants (i.e., participants who successfully completed all exams) are presented in Table  1 . The majority of the sample was female, the average age was M(SD)  = 43.80 (9.25) years. Most of the participants worked as psychotherapists. Slightly more worked in an outpatient context than in an inpatient context. On average, the participants had M(SD)  = 10.34 (8.68) years of work experience.

Outcome data

Competences and attitudes.

Table  2 depicts the estimated mean scores for the four dependent variables separated by the training method for each time point. Additional file 2 (Table S2 ) shows the descriptive statistics of the dependent variables by training condition and measurement point. To evaluate differences between the different training strategies over time, mixed effects models were calculated for each dependent variable including all time points and data from all 671 participants who completed T1 and started their training. All the dependent variables developed in the expected direction across the three measurement points (i.e., increase in mean values for knowledge about NSSI, competences regarding NSSI, positive attitudes toward the effectiveness of treatment and decrease in values for negative attitudes toward NSSI and those who self-injure). The statistical analyses revealed a significant main effect of time for all the variables (53.8 >  F  < 508.6, all ps < 0.001; not displayed in Table  2 ). Additionally, there was a significant training-time interaction effect for negative attitudes toward NSSI and those who self-injure. Comparisons of the estimated fixed parameters demonstrated that the effect of PEM differed significantly from that of EL and BL.

Explorative analyses of covariates revealed that only the interaction effect of training x time x sex was significant ( p  = .011) for the dependent variable ‘competences regarding NSSI’, indicating that male participants profited more from PEM over time than female participants and that female participants profited more from EL than male participants did (see Additional file 3 (Table S3 ) for more details). When multiple comparisons were accounted for by applying the Bonferroni adjustment, significance was not reached any more though.

Transfer to practical work

To compare the application rate of TA between training approaches, analyses were conducted while neglecting the answer option “not specified”. 48% of participants of BL-condition indicated having applied TA in their work setting (25 of 52) compared to 40% in EL (47 of 118) and 25% in PEM (17 of 69) ( χ 2 [ 2 ] = 7.64, p  = .022, V = 0.179). To explore the impact of covariates on the application rate of TA, a binary logistic regression model was conducted with the application of TA as the criterion and the following predictors: dissemination strategy, age, sex, professional group, work experience, cases of NSSI confronted with professionally, personal experience with people who self-injure (including one self) and participation in other trainings on the topic. The model was statistically significant (χ² [ 10 ] = 23.59, p  = .009, N  = 238) and showed good model fit with a small amount of explained variance (Hosmer-Lemeshow-Test: χ² [ 8 ] = 9.01, p  > .05; Nagelkerkes R² = 0.129). The significant predictors included dissemination strategy ( p  = .033, OR = 1.466, 95%-KI[1.032, 2.081], professional group ( p  = .002, OR = 0.334, 95%-KI[0.169, 0.659] and cases of NSSI confronted with professionally ( p  = .006, OR = 0.745, 95%-KI[0.603, 0.919] (see Additional file 4 (Table S4 ) for more details). Regarding the professional group, 22 of 79 physicians stated that they applied TA (27.8%), whereas 67 of 159 psychotherapists did (42.1%). Taking a closer look, physicians and psychotherapists did not differ in their application rate of TA in the EL-condition (16 of 41 physicans, 39%, vs. 31 of 76 psychotherapists, 40.8%), but in the BL-condition, 5 of 15 physicians (33.3%) applied TA, while 20 of 37 psychotherapists did (54.1%) and in the PEM-condition only 1 of 23 physicians applied TA (4.3%) compared to 16 of 46 psychotherapists (34.8%). With regard to the extent of professional contact with NSSI cases, our results indicate that the more often professionals have been confronted with NSSI cases, the more likely they were to apply TA.

Among those participants who applied TA, participants of PEM, EL and BL did not differ significantly in terms of the frequency of application. Among the three main elements of TA, ‘construction of diagram’ and ‘searching for potential exits’ were applied most often (appx. 90% respectively). Only a minority wrote an ‘understanding letter’. The training conditions did not differ in terms of the frequency of application. Estimation of how helpful participants found TA, if applied, was high and did not differ among trainings. Among the reasons for not applying TA, ‘necessary setting not present’ was among the most frequently mentioned reasons. Participants of BL had the lowest rates of reasons related to perceived deficits in competence or not feeling familiar enough with the intervention (see Table  3 ).

Training evaluation

Table  4 shows agreement with different statements about quality and user satisfaction, which were assessed in all three conditions. Satisfaction with and evaluation of the three different training methods were positive, with most mean values being greater than 5 on a scale from 1 to 6 with 6 reflecting the most positive evaluation. In general, the results showed that participants in BL gave the best evaluation, while those in PEM gave the worst evaluations; moreover, some of those differences were significant.

The level of training was judged to be appropriate by 75.9% of PEM, 90% of EL and 89.9% of BL. The depth of information was perceived as being exactly right by 61.4% of PEM, 79.5% of EL and 82% of BL. A total of 38% of PEM stated to find the depth of information ‘a little too superficial’.

Given the high clinical relevance of NSSI, it is crucial to educate professionals effectively about evidence-based guideline recommendations. Our study showed that all three training formats developed for the dissemination of NSSI guidelines contributed to the intended changes in different variables, including an increase in knowledge about NSSI, an increase in perceived competences regarding NSSI and of self-evaluated positive attitudes toward the effectiveness of treatment, as well as a decrease in negative attitudes toward NSSI and those who self-injure. The training effect remained stable upon the follow-up assessment three months later. For all three dissemination strategies, user satisfaction was high and the evaluation of training quality was positive. We were able to attract a substantial number of physicians and psychotherapists to participate in the project. Thus, all three training formats seem to be of high quality and capable of covering the needs of a heterogeneous group of physicians and psychotherapists. Our hypotheses were partially confirmed. Comparing the different dissemination strategies for competences and attitudes, we found significant group x time interaction effects for negative attitudes; specifically, the PEM-condition was statistically significantly less effective than EL and BL were, but the clinical significance of the statistical differences must be judged as rather low and may be neglected. EL and BL did not significantly differ in these variables. Clear differences between training conditions were revealed in the transfer to practical work, with PEM having the lowest uptake rate of TA and BL the highest. Thus, H1 was not confirmed, but H2 was.

Therefore, our study suggested that all three training formats are beneficial for strengthening the competencies of physicians and psychotherapists in dealing with NSSI and achieve similar outcomes despite the very different conceptual didactical approaches of PEM compared to EL and BL, implying different levels of required human, financial and time resources for development and despite unequal processing time. The additional learning material incorporated in EL and BL (such as case-based exercises or videos) did not enhance the acquisition of knowledge, competences or positive attitudes in our study, contrary to our expectations. A meta-analysis by Richard et al. concluded that simulation (such as role-play) is promising for practical training in suicidal crisis intervention but they also stated that strength of the evidence is limited [ 55 ]. Greater differences in these variables between PEM and the other approaches might occur after a longer period of time. The good results of PEM may also reflect the benefits of a brief and compact educational approach by providing a summary of the guidelines for quick reference and the preference of (mental) health professionals for having something ‘on hand’ [ 72 , 73 ]. Additionally, satisfaction with PEM was similar to EL- and BL-condition. One possible explanation for that finding is that participants felt that the effort required to complete their training was well proportionate to the perceived benefits. Moreover, participants knew that they would receive the opportunity to complete one of the other trainings (i.e. PEM received access to EL; EL and BL received PEM) once their condition was completed within the study. Thus, although it is the most passive dissemination strategy we included, our study suggested that well-developed print material can offer a well-accepted, inexpensive and feasible dissemination approach for guidelines [ 74 ].

In accordance with H2, BL had the highest application rate of TA. This could indicate that the possibility of practicing TA during the face-to-face workshop increases the chance that people actually apply TA in their work context. Also other findings have shown the potential of experiential exercises for the acquisition of clinical skills among health professionals in regard to suicidality and self-harm [ 49 , 55 , 61 ]. It should also be noted, however, that the three dissemination strategies differed not only in their training format but also in their processing time. Consequently, our findings could also imply that more extensive training is more effective for transferring to practical work. This finding is in line with the findings of the review by Frank, Becker-Haimes and Kendall on therapist training in evidence-based interventions for mental health, which revealed that more intensive training models show promise for changing therapist behaviour [ 53 ]. As former studies on TA training outcomes use more extensive training than our study does (e.g., five half-day TA training sessions [ 61 ]), it is encouraging that even less comprehensive TA training sessions, such as those used in our study, have positive effects. Our results indicate that physicians benefitted less than physicians from the PEM- and BL-training approaches regarding the application of TA. One explanation for that could be that, in EL, physicians were able to review material and good-practice videos as often as they needed, whereas psychotherapists could apply TA more quickly in PEM- and BL-condition because they are more familiar with the therapeutic nature of TA. If so, future dissemination strategies should tailor their content more to the respective target group. However, as these analyses were exploratory, the results should be interpreted with caution.

Taking the perspective of training providers, the study supports a dose-response relationship: the more investment is put into the development of a training, the more benefit it shows. Printed educational material is the training format with the lowest threshold for participation and it requires the least resources to develop compared to the other two training strategies – and had the least positive effects compared to one or both of the other training formats, although overall, it is still at a high level. Compared to PEM, an e-learning format requires more effort and resources to be developed. In our study, EL had better effects on some variables than did PEM. One might argue that those differences in efficacy are not enough to justify the extended efforts for the development of an e-learning training. On the other hand, an online course is easily scalable concerning the number of participants, once it is developed, and it is easier to update than PEM. Compared to EL, BL again needs a lot more resources for the organization and execution of the face-to-face part, especially considering the higher dropout rate we observed in the BL-condition. To reduce dropout, it would probably need more possible dates and venues for the face-to-face workshops and/or more flexibility are needed to retain participants in a BL format. For professionals, it is more challenging to integrate a face-to-face workshop in their daily work practice. In particular, the impact of the COVID-19 pandemic highlighted the need for more flexible training formats, such as online workshops. Another promising possibility would be to integrate a blended-learning format in existing infrastructures within an institution and use face-to-face workshops to practice newly acquired skills and/or case supervision [ 75 , 76 ]. BL and EL did not differ in most of the variables assessed, but BL had the highest rate of TA application. Additionally, BL might support other desired outcomes (such as exchange, networking), we did not assess in comparison to the other two learning formats. If this justifies the greater effort of conducting BL compared to EL, it is surely a question of which training goals are aimed at being achieved. If the acquisition of practical capacity is the main focus, our study indicates that BL is the best option. Considering the positive effects we found for PEM, a combination of e-learning and printed educational material could be a good way to transfer competences and retain learning effects over time without causing financial and time barriers for both participants and providers, as a blended-learning format involves.

The subject of this study was the improvement of competences regarding and the application of clinical guidelines for NSSI in children and adolescents. It seems reasonable to assume that the results can also be transferred to the dissemination of other guidelines, although characteristics of the guidelines (level of evidence, length, practical orientation etc.) affect their actual use [ 73 ] and therefore might have an impact on the effect of different dissemination strategies. For the application of the Dutch multidisciplinary suicide prevention guideline, a blended-learning approach with an e-learning-supported Train-the-Trainer programme proved effective in improving guideline adherence, self-perceived knowledge and confidence of individual professionals working in psychiatric departments [ 48 ], as well as an e-learning module for undergraduate psychology students [ 50 ]. However, these studies did not compare different training formats. To our knowledge, there are no additional studies on the effectiveness of (different) dissemination strategies for other national guidelines for the management of NSSI or self-harm. Our results could inform future conceptualizations of guideline dissemination, for example, of the NICE guidelines on self-harm, especially given the fact that awareness and knowledge of the NICE guidelines were found to be low [ 27 ].

Generally, it is still unclear what makes the uptake of guideline recommendations into clinical practice successful. While some studies point toward the benefit of multifaceted interventions [ 21 ], more recent reviews have not found evidence that multifaceted interventions are more effective than single-component interventions [ 74 , 77 ]. The competence of individual professionals may be only one part of a more comprehensive dissemination strategy in addition to implementation strategies targeting healthcare organizations and patients, suitable on-site structures of mental health care, acceptance of guidelines-based care by patients, or positive attitudes of professionals toward the use of guidelines [ 19 , 78 , 79 ], but it is undoubtedly a necessary part of any dissemination strategy. The positive effect of comprehensive or tailored implementation strategies has been demonstrated, for example, for the implementation of evidence-based practices for psychosis treatment [ 80 ], of guidelines for depression [ 78 , 81 ] or of suicide prevention guidelines [ 82 ].

The strengths of the study include the direct comparison of different dissemination strategies with the inclusion of innovative training formats (e-learning and blended-learning), a large sample size and the multiple assessment design, including a 3-month follow-up. Limitations of the study include that the results might not be generalizable to other professionals, given that participants who enrolled in the project probably represent a self-selected sample of especially interested and motivated (mental) health professionals. Moreover, the participants had already good background knowledge about NSSI before starting the training which might impart the generalizability of this study, too, because it is still unclear whether prior knowledge has positive, negative or negligible effects on learning [ 83 ]. For example, on the one hand learners with high prior knowledge could show less gain of competences than learners with lower prior knowledge due to a ceiling effect or by preventing learners from finding new and better problem solutions than those they applied before. On the other hand, it is also possible that learners with high prior knowledge show a higher gain of competences than learners with lower prior knowledge because high prior knowledge facilitates the interpretation and encoding of new information [ 83 ]. Another limitation relates to the randomization procedure. Participants were partly randomized based on their preference (allocation to BL if attendance at workshop sites was judged as ‘possible’ beforehand). This can lead to a selective sample of more motivated participants in BL and biased estimates of treatment effects [ 84 ]. On the other hand, this step was necessary to enable the planning of the face-to-face workshops in advance (e.g., search for possible venue sites, decision on number of face-to-face workshops etc.) and the participation of interested healthcare professionals in the study, which, under the circumstance of full randomization, could not have enrolled. Comparative analyses showed that participants who attended one of the workshops and stayed in the BL-condition and participants who were transferred from the BL- to the EL-condition due to nonattendance at a workshop did not differ in demographic variables. This finding indicates that the randomization effect was not impaired by this procedure. Additionally, other studies including a face-to-face training condition on empirically supported treatment reported practical challenges in randomization, such that not all study participants could be randomized [ 54 ]. Sholomskas and colleagues argue that studies in which the ability to fully randomize participants is limited by differences in the practical demands associated with the various experimental conditions and conclusions regarding effectiveness based on non randomized groups may be similar to those based on randomized samples [ 54 ]. The dropout rate for BL was still fairly high, which limits the validity and reliability of the results of this group. On the other hand, providers might quite likely face similar barriers when offering face-to-face workshops. Dropout might even be greater in study conditions such as ours, especially when there is the opportunity to still receive training (in our case, EL) and no fees are charged. Another limitation of our study concerns the assessment methods used. Although we applied some items from validated questionnaires, we had to construct items ourselves because no existing validated measures were appropriate for our study purpose. Therefore, the final questionnaires were not validated in their used form. Even instruments for the clinical assessment of NSSI itself largely lack sufficient information on their validity and reliability [ 85 ]. Consequently, the observed improvements and evaluations might not be solely due to the dissemination format. Furthermore, as the questionnaires relied on self-reports, it should be noted that the effects found in our study do not prove that the trainings led to actual behavioural changes in participants in their clinical practice beyond self-reports and to a reduction in the severity of patients’ symptoms. Therefore, we cannot make statements about the clinical significance of our findings, but previous studies indicate that training professionals in guideline recommendations leads to improved patient care [ 19 , 20 ]. Future research should focus on further comparisons of different training strategies (instead of comparing one training format to a (wait list) control condition). Particularly in light of the COVID-19 pandemic and its impact on further education approaches, formats of synchronous ‘face-to-face’ online workshops with focus on role-plays and exercises to foster practical capacities should be explored as possible replacements for non digital, ‘real-person’ workshops. Ideally, future studies should include outcome data objectively assessing the change in daily work practices of (mental) health care professionals and/or patient outcomes.

There is a high prevalence of NSSI during childhood and adolescence, and NSSI can have negative long-term implications if left untreated. Effective training strategies are a crucial part of disseminating evidence-based clinical knowledge among (mental) health professionals and consequently of improving patient care. This is the first study comparing different training strategies for the dissemination of the consensus-based clinical guidelines for NSSI in childhood and adolescence. It shows that we developed high-quality, effective trainings on NSSI for (mental) health care professionals, going beyond the transfer of theoretical knowledge but also improving self-perceived (practical) competences, self-efficacy, and attitudes. The developed training strategies imply different levels of demanded resources for development and implementation, but they are all feasible and well-accepted means to disseminate the clinical guidelines. The results provide clues for the dissemination of other clinical guidelines in regard to training strategies for professionals. They indicate that the choice of training method could be driven by considering, which training goals are aimed at being achieved and the benefit-cost ratio allowing for tailored training approaches.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to reasons of data security but are available from the corresponding author upon reasonable request.

Abbreviations

Analysis of variance

approximately

Adult psychotherapist

• Blended-learning

Child and adolescent psychiatrist

Child and adolescent psychotherapist

Continuing medical education

Coronavirus disease 2019

Diagnostic and statistical manual of mental disorders, 5th version

Exempli gratia = for example

et cetera = and other similar things

Id est = that is

Multiple-choice-test

Medical psychotherapist

Size of subsample

Size of total sample

Non-suicidal self-injury

Printed educational materials

Standard deviation

Self-injury: treatment, assessment, recovery

Therapeutic assessment

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Acknowledgements

We would like to thank the cooperative effort of the entire STAR consortium as well as all the participants.

The members of the STAR consortium are Paul L. Plener (Department for Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany, Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria), Jennifer Spohrs (Department for Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany), Birgit Abler (Department of Psychiatry and Psychotherapy III, Ulm University, Ulm, Germany), Sandra Nickel (Department for Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany), Elisa Sittenberger (Department of Psychiatry and Psychotherapy III, Ulm University, Ulm, Germany), Lisa Schischke (Department of Psychosomatic Medicine and Psychotherapy, Ulm University Medical Centre, Ulm, Germany), Alina Geprägs (Department for Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany), Isabell Liebhart (Department for Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany), Andreas Witt (University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland), Cedric Sachser (Department for Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany), Rebecca Brown (Department for Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany), Vera Münch (Department of Paediatrics and Adolescent Medicine, Ulm University Medical Centre, Ulm, Germany), Elisa König (Department for Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany), Jörg M. Fegert (Department for Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany), Ulrike Hoffmann (Department for Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany), Christian Schmahl (Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany), Inga Niedtfeld (Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany), Maurizio Sicorello (Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany), Jenny Zähringer (Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany), Tina In-Albon (Clinical Child and Adolescent Psychology and Psychotherapy, University of Kaiserslautern-Landau, Landau, Germany), Laura Kraus (Clinical Child and Adolescent Psychology and Psychotherapy, University of Kaiserslautern-Landau, Landau, Germany), Hasan-Hüseyin Isik (Clinical Child and Adolescent Psychology and Psychotherapy, University of Kaiserslautern-Landau, Landau, Germany), Michael Koelch (Department of Child and Adolescent Psychiatry, Neurology, Psychosomatics, and Psychotherapy, University Medical Centre Rostock, Rostock, Germany), Olaf Reis (Department of Child and Adolescent Psychiatry, Neurology, Psychosomatics, and Psychotherapy, University Medical Centre Rostock, Rostock, Germany), Anna Michelsen (Department of Child and Adolescent Psychiatry, Neurology, Psychosomatics, and Psychotherapy, University Medical Centre Rostock, Rostock, Germany), Andreas G. Chiocchetti (Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Frankfurt, Goethe-Universität, Frankfurt am Main, Germany), Silvia Lindlar (Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Frankfurt, Goethe-Universität, Frankfurt am Main, Germany), Regina Waltes (Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Frankfurt, Goethe-Universität, Frankfurt am Main, Germany), Michael Kaess (Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany, University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland), Julian Koenig (Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany), Markus Mössner (Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany), Patrice van der Venne (Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany), Saskia Höper (Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany), Elisa Flach (Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany), Alexandra Edinger (Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany), Stephanie Bauer (Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany), Margarete Mattern (Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany), Sabine Herpertz (Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany), Ulrich Ebner (Mental mHealth Lab, Chair of Applied Psychology, Institute of Sports and Sports Science, Karlsruhe Institute of Technology (KIT), Germany), Philip S. Santangelo (Mental mHealth Lab, Chair of Applied Psychology, Institute of Sports and Sports Science, Karlsruhe Institute of Technology (KIT), Germany).

The project was funded by the German Federal Ministry of Education and Research (grant number: 01GL1747A).

Open Access funding enabled and organized by Projekt DEAL.

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Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University Hospital, Ulm, Germany

Elisa Koenig, Ulrike Hoffmann, Jörg M. Fegert, Ferdinand Keller, Jennifer Spohrs, Sandra Nickel, Paul L. Plener, Alina Geprägs, Isabell Liebhart, Cedric Sachser, Rebecca Brown & Elisa König

German Center of Mental Health (DZPG), Partner site Ulm, Germany

Elisa Koenig, Ulrike Hoffmann, Jörg M. Fegert, Ferdinand Keller, Inga Niedtfeld & Jenny Zähringer

Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany

Maurizio Sicorello, Christian Schmahl & Hasan-Hüseyin Isik

Clinical Child and Adolescent Psychology and Psychotherapy, University of Kaiserslautern-Landau, Landau, Germany

Laura Kraus, Tina In-Albon & Elisa Sittenberger

German Center of Mental Health (DZPG), Partner site Mannheim, Germany

Christian Schmahl

Department of Psychiatry and Psychotherapy III, Ulm University, Ulm, Germany

Birgit Abler

Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany

Julian Koenig, Markus Mössner, Patrice van der Venne, Saskia Höper, Elisa Flach, Alexandra Edinger, Stephanie Bauer, Margarete Mattern & Sabine Herpertz

Youth Resilience Unit, WHO Collaborating Centre for Mental Health Services Development, Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK

Dennis Ougrin & Andreas Witt

Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany

Michael Kaess

University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland

Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria

Paul L. Plener

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Contributions

EK, UH, JMF and PLP provided substantial contributions to the conception and design of the study. EK wrote the article and conducted the data analysis. FK supported the data analysis. All the authors contributed to the conception, design and/or interpretation of the data. All the authors contributed to reviewing/revising the paper for important intellectual content. All the authors provided final approval before submission.

Corresponding author

Correspondence to Elisa Koenig .

Ethics declarations

Ethical approval and consent to participate.

The project was reviewed by the ethical committee of the University of Ulm, which confirmed on August 29, 2018, that the work did not constitute medical research on humans and that therefore, no vote from the Ethical Committee was required. Written informed consent was obtained from the participants. All the authors confirm that all the methods were carried out in accordance with the relevant guidelines and regulations and in accordance with the Declaration of Helsinki.

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Not applicable.

Competing interests

Within the last five years, PLP received speaker honoraria from GSK, Infectopharm, Janssen and an advisor honorarium from Boehringer-Ingelheim. He receives royalties from Hogrefe Publishers.All the other authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

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Collaborators of the of the Star-Consortium are listed in “Acknowledgment”.

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Koenig, E., Hoffmann, U., Fegert, J.M. et al. Training approaches for the dissemination of clinical guidelines for NSSI: a quasi-experimental trial. Child Adolesc Psychiatry Ment Health 18 , 99 (2024). https://doi.org/10.1186/s13034-024-00789-x

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DOI : https://doi.org/10.1186/s13034-024-00789-x

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Table of Contents

Quantitative research aims to quantify data and apply statistical analysis to explain a phenomenon, test hypotheses, or predict outcomes. It plays a significant role across disciplines in modeling human behavior and natural systems and using measurable, objective data. Based on analysis goals, there are four fundamental quantitative research types: descriptive, correlational, quasi-experimental, and experimental. Let’s demystify them in detail.

Descriptive Quantitative Research

As the name suggests, descriptive research describes specific characteristics of individuals, groups, systems, or environments using numerical data from sources like surveys, interviews, or observation techniques. Quantitative data and statistics help summarize large volumes of information to calculate frequencies, determine mean/median values, and find variability around them. Public opinion polls and census surveys are typical examples that provide valuable descriptive insights.

Correlational Quantitative Research

This research uses correlation analysis without deliberate intervention to explore statistical relationships between two or more variables. It studies naturally occurring data to discover patterns and correlations that may exist in areas like psychology, healthcare, and social sciences. For instance, correlational studies may determine connections between income level and health outcomes. Correlation does not necessarily indicate causation but offers clues on variables needing deeper investigation.

Quasi-Experimental Research

Unlike pure lab experiments, quasi-experimental research occurs in natural settings, but the researcher actively introduces an intervention to study participants. Comparison groups, before-after analysis, matched samples, and time series designs provide substantial control over variables. Market research frequently employs these techniques, like assessing a new app’s usage over time across similar customer segments. While not as rigorous as pure experiments, quasi-experiments have more real-world applicability.

Experimental Quantitative Research

Considered the gold standard, experiments exercise maximum control over all outcome variables. Researchers manipulate one or more independent variables to study the effect on a carefully selected dependent variable while eliminating external influences through randomization, controlled settings, and strict procedures. Experiments establish causal relationships and are common in medicine, psychology, and physics. Clinical trials for testing drug effects demonstrate the critical role of experimental research.

Quantitative Research Methodology

Quantitative research methodology systematically collects and analyzes numerical data to explain or validate theories and hypotheses. It relies on variables that can be measured and quantified to derive statistics like frequency, mean, and standard deviation that give insights into the phenomenon. Data collection methods are designed to maximize objectivity, reliability, and generalizability through surveys, controlled experiments, structured observation, etc. The quantitative data then undergoes statistical analysis to conclude, test claims, and generalize findings confidently with measurable evidence across larger populations. Adherence to rigorous quantitative methods lends credibility and validates the research.

Familiarity with these fundamental quantitative research approaches , their purposes, usage scenarios, and methodology is essential for research success across academic and professional domains.

What are the four main types of quantitative research designs?

The four fundamental quantitative research types are – descriptive, correlational, quasi-experimental, and experimental. They differ in critical aspects, such as the amount of researcher intervention, data collection settings, and analysis goals.

What kind of statistics are used in descriptive quantitative research?

Descriptive research relies on statistical analysis, such as determining frequencies, mean, median, mode values, variability, and percentage distributions, to summarize large volumes of data on individuals, groups, or environments.

How are quasi-experiments different from pure lab experiments?

While they study cause-effect relationships, quasi-experiments occur in natural settings instead of controlled lab environments. However, unlike correlational studies, which observe variables in their natural occurrence, quasi-experiments actively introduce an intervention. This provides more realism while exercising substantial control.

When is correlational research helpful?

Correlational research helps study trends, patterns, and relationships between variables in real-world contexts across disciplines like public health, psychology, business, etc. It serves as a preliminary research method to identify variables needing further analysis through experiments.

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