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  • Teens, Technology and Romantic Relationships
  • Chapter 4: Social Media and Romantic Relationships

Table of Contents

  • Introduction
  • Chapter 1: Basics of Teen Romantic Relationships
  • Chapter 2: How Teens Meet, Flirt With and Ask Out Potential Romantic Partners
  • Chapter 3: How Teens Incorporate Digital Platforms and Devices Into Their Romantic Relationships
  • Chapter 5: After the Relationship: Technology and Breakups
  • Chapter 6: Teen Relationship Struggles: From Potentially Innocuous to Annoying to Abusive Digital Behaviors
  • About This Report
  • Appendix A: Lesbian, Gay, Bisexual and Transgender Teens

Many Teens View Social Media and Text Messaging as a Space for Connection, Emotional Support – and Occasional Jealousy – in the Context of Their Relationships, Although Most Say Social Media Has a Relatively Minor Impact

Social Media Can Increase Emotional and Logistical Connections in Teen Relationships, but Most Teens Feel This Impact Is Relatively Modest

Many teens in relationships view social media as a place where they can feel more connected with the daily contours of their significant other’s life, share emotional connections and let their significant other know they care – although these sites can also lead to feelings of jealousy or uncertainty about the stability of one’s relationship. At the same time, even teens who indicate that social media has had an impact on their relationship (whether for good or for bad) tend to feel that its impact is relatively modest in the grand scheme of things.

Among teen social media users with relationship experience:

  • 59% say social media makes them feel more connected with what is going on in their significant other’s life, although just 15% indicate that it makes them feel “a lot” more connected. About one-third (35%) of these teens say social media does not make them feel more connected with their significant other.
  • 47% say social media offers a place for them to show how much they care about their significant other, with 12% feeling this way “a lot”; 45% do not feel that social media offers a venue for this type of interaction with their significant other.
  • 44% say social media helps them feel emotionally closer to their significant other, with 10% feeling that way “a lot.” Half (50%) do not feel that social media offers a space to feel emotionally closer.
  • 27% say social media makes them feel jealous or unsure about their relationship, with 7% feeling this way “a lot.” Roughly two-thirds (68%) do not feel jealous or unsure of their relationship due to social media.

Boys are a bit more likely than girls to view social media as a space for emotional and logistical connection with their significant other. Some 65% of boys with relationship experience who use social media agree that these sites make them feel more connected about what’s going on in their significant other’s life (compared with 52% of girls). Similarly 50% of boys say social media makes them feel more emotionally connected with their significant other, compared with 37% of girls. At the same time, even among boys this impact is fairly muted: Just 16% say social media makes them feel “a lot” more connected to their significant other’s life, while just 13% feel “a lot” more emotionally close to their significant other thanks to social media.

Teens in our focus group explained the way digital communication platforms – social media as well as texting – can enhance and expand on in-person meetings. One high school girl noted:

“I feel like it helps to develop a relationship because even if you meet someone in person, you can’t see them all the time or talk to them all the time to get to know them, so you text them or message them to get to know them better.”

Focus group teens told us how talking with their significant other over text and social media helped them overcome shyness and create a greater sense of connection:

“My boyfriend isn’t shy … but I’m more shy. And it gets easier for him to tell me everything in person, but when we’re … when I’m in person with him, like, it’s harder for me to tell him what I’m feeling. So like I’ll think about it when we’re together, and then like afterwards I’ll probably text him like what I was feeling and tell him my problems.”

Another high school girl relates how texting helped her relationship with her boyfriend:

[the relationship]

For some, one other useful feature of multiple digital communication platforms (e.g., texting, messaging apps, Twitter, Instagram) is that those platforms allow teens to manage communicating with multiple people and multiple romantic partners. One high school boy from our focus groups relates his strategy:

[are romantically involved with]

Photos and posts can be used by teens to incite jealousy in others, often former partners, and lead to jealous feelings for some teens. Teens in our focus group described peering at photos on their partner’s profile to look for suspicious images. One high school girl explains her calculus:

“It depends on like what they’re doing in the picture. If they’re just standing side by side, it’s like, chill. But if they’re like … if he’s got his arm on her or something, like, more. … Like I guess it just depends on your jealousy level if you can feel like, ‘oh, I know my man wants me.’ Or if you’re like ‘does he really want me?’ It just depends on the person.”

A Substantial Minority of Teen Daters Feel Their Significant Other Shows a Different Side of Themselves – or Is Less Authentic – on Social Media

As seen in our report on teen friendships , social media allows users to curate their online presence in a way that puts their best digital foot forward, or shows a different side of their personality than they can show offline. At the same time, this self-presentation can sometimes appear inauthentic or phony to others. Teens are especially attuned to this type of social curation: When it comes to teen friendships , fully 85% of teen social media users agree that social media allows people to show a side of themselves that they can’t show online. At the same time, 77% agree that people are less authentic and real on social media than they are in real life.

Teens tend to experience each of these behaviors to a lesser extent in the context of their romantic relationships than they do in their broader friend networks. But a substantial minority feel that their partner acts differently – in positive or negative ways — on social media than he or she does in real life. Among the 31% of teens who are “teen daters” who use social media:

  • 42% agree that their significant other shows a different side of themselves on social media than they do in person, with 9% agreeing strongly. Nearly six-in-ten (58%) disagree with this statement.
  • 36% agree that their significant other is less authentic and real on social media than they are offline, with 7% agreeing strongly. Roughly two-thirds (64%) disagree.

Girls are more likely to “strongly disagree” with the notion that their partner shows a different side of themselves on social media than they do offline: 13% of girls strongly disagree with this statement, compared with just 4% of boys. On the other hand, there are no differences between boys and girls on the question of whether their partner is less authentic on social media than they are in real life.

The Publicness Paradox: Many Teens Use Social Media to Publicly Express Affection for Their Partner and Support Their Friends’ Relationships, Even as They Feel Their Own Relationships are Too Visible to Others

37% of teens with dating experience have taken to social media to publicly express their affection for a significant other.

For a substantial minority of teens, social media offers a space to publicly express affection or solidarity with their romantic partner. Some 37% of teens with dating experience have used social media to tell their significant other how much they like them in a way that is visible to other people.

Teens from less well-off households, as well as those who have met a partner online, are especially likely to have done this. Among teens with relationship experience:

  • 47% of those from households earning less than $50,000 annually have used social media to publicly express affection for a significant other (compared with 33% of teens from higher-income households).
  • 54% of those who have met a partner or significant other online have used social media in this way, compared with 32% of those who have not met someone online.

63% of teen daters use social media to express support of others’ romantic relationships

Beyond publicly displaying affection and one’s own relationship, social media is a space where many teens can express public support or approval of others’ romantic relationships: 63% of teens with dating experience have posted or liked something on social media as a way to indicate their support of one of their friends’ relationships.

Girls are especially likely to publicly support their friends’ relationships using social media (71% of girls with dating experience have done so, compared with 57% of boys) although boys and girls are equally likely to publicly express affection for their own partner in social media environments.

In addition, teens from less well-off households (those earning less than $50,000 per year) engage in each of these behaviors at higher rates, compared with those from higher-income households. Among lower-income teens with dating experience, 73% (compared with 59% of higher-income teens) have supported their friends’ relationships on social media, while 47% of less well-off teens (and 33% of higher-income teens) have publicly expressed affection for their own partner in a public way on social media.

Teens in our focus group explained specific ways in which a relationship might be displayed on social media. As a high school boy related, people in relationships change “their status. And then other times, on Instagram it says in their bio, they put like the date that they started going out.” Changing “ profile pictures and then just regular pictures,” to be images of the couple is also a common method of displaying one’s relationship and relationship status. A high school boy explained what he believes must be on social media when dating someone. “You’ve got to put the date in the bio and her in the bio. For real. … You need to have the padlock emoji with a heart and two people holding hands. …On Facebook, you’ve got a cover photo… Or a date. Or just a date,” plus your beloved’s username or profile.

Focus group teens also noted that posting publicly about a relationship – noting the date you started the relationship in your bio, declaring your affection, posting photos – sometimes had to do with gaining a sense of status, expressing possessiveness or getting attention from peers:

High school boy 1: You just want people to know. With some people, it’s for the attention and stuff like that.

High school boy 2 : Well, speaking in terms of the way people generally seem to behave, it’s victory.

High school boy 1: And it’s also probably to tell people like, hey, back off. She’s mine or he’s mine.

Other focus group teens questioned how meaningful and authentic these social media displays of affection really were:

High school boy 1: “ How about the girls that post they love you every 20 minutes on Facebook.”

High School Boy 2: “ People are really quick to say I love you. A lot of people use it so loosely.”

High School Boy 1: “It don’t mean nothing no more.”

Many teen daters feel social media allows too many people to see what is happening in their relationship

But even as they use social media to support their friends’ relationships, many teen daters express annoyance at the public nature of their own romantic partnerships on social media. Fully 69% of teen social media users with dating experience agree that too many people can see what’s happening in their relationship on social media, with 16% indicating that they “strongly” agree. Just 31% of such teens disagree with this statement, and only a small percentage (2%) disagree “strongly.” Boys and girls, older and younger teens, and those from higher- and lower-income households are equally likely to agree with this statement.

Teens in our focus groups explained their concerns about people being overly involved, especially in breakups, and their discomfort with the permanence of posted content. One high school boy explained why someone might not want to post any details about their relationship on social media:

“I don’t know. Maybe they just want it to be their business. Then, you know, if you were to post it online and then you break up, you probably wouldn’t want to change it and then everyone asks you what happened, so you might not put it there in the first place. Just let it be the people you actually know who knows. … It comes back because it’s stuck there. It’s like a permanent tattoo.”

A middle school boy related:

[their relationship]

Other teens point to avoiding drama as a reason people kept relationships off social media. As a high school boy explained:

“A lot of people kind of don’t like it on social media because it doesn’t need to be on there. ‘Cause as long as the two know how they feel about each other, I feel like if you have it on social media, it’s like more drama. Because like more people ask questions and stuff like that.”

And some teens don’t post much about the relationship on social media because they’re not sure of the relationship status or they don’t want to seem like they’re bragging about their good fortune. A high school girl explained:

“Maybe they’re just not sure about it, too. I mean, I feel like that would be me. I wouldn’t really know if we were in a relationship yet, so I wouldn’t say anything about it. And I wouldn’t want to be obsessive about it, and I wouldn’t want people to think I was bragging either, so I just wouldn’t show anything.”

Occasionally, relationships are kept off social media to keep them from the prying eyes of parents. One middle school boy explained:

“Sometimes if your parents find out, I mean, my mom lets me have a girlfriend, but some protective parents … they sometimes don’t even let them out with their friends. One of my friends, he can never come out. But he liked a girl that I liked and he asked her out, and she said yeah. And then he went home and I walked home with him and I went by his house and then he told his dad and his dad said I had to leave. And then his dad slammed the door and started screaming.”

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Am Fam Physician. 2016;93(9):756-762

See related Editor's Note.

Related letter : Interpreting the Statistics on Potential Benefits of Prostate Cancer Screening

Author disclosure: Dr. Ebell is cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. Dr. Grad has no relevant financial affiliations.

In 2015, a group of primary care clinicians with expertise in evidence-based practice performed monthly surveillance of more than 110 English-language clinical research journals. They identified 251 studies that addressed a primary care question and had the potential to change practice if valid (patient-oriented evidence that matters, or POEMs). Each study was critically appraised and disseminated to subscribers via e-mail, including members of the Canadian Medical Association who had the option to use a validated tool to assess the clinical relevance of each POEM and the benefits they expect for their practice. This article, the fifth installment in this annual series, summarizes the 20 POEMs based on original research studies judged to have the greatest clinical relevance for family physicians. Key recommendations include questioning the need for backup throat cultures; avoiding early imaging and not adding cyclobenzaprine or oxycodone to naproxen for patients with acute low back pain; and encouraging patients with chronic or recurrent low back pain to walk. Other studies showed that using a nicotine patch for more than eight weeks has little benefit; that exercise can prevent falls that cause injury in at-risk older women; and that prostate cancer screening provides a very small benefit, which is outweighed by significant potential harms of screening and associated follow-up treatment. Additional highly rated studies found that tight glycemic control provides only a small cardiovascular benefit in patients with type 2 diabetes mellitus at the expense of hypoglycemic episodes; that treating mild hypertension can provide a modest reduction in stroke and all-cause mortality; that sterile gloves are not needed for minor uncomplicated skin procedures; that vasomotor symptoms last a mean of 7.4 years; and that three regimens have been shown to provide the best eradication rates for Helicobacter pylori infection.

Since 1994, a group of primary care clinicians with expertise in evidence-based practice has performed monthly surveillance of more than 110 English-language research journals. 1 Of approximately 20,000 research studies published during 2015 in these journals, 251 met prespecified criteria for validity, relevance, and practice change. A study was considered valid if it was well designed and avoided important biases such as failure to conceal allocation or failure to mask outcome assessment. Relevance depended on the research question (i.e., is it relevant to a primary care clinician?) and on the outcomes reported; only studies that reported patient-oriented outcomes, such as morbidity, mortality, or quality of life, were considered relevant. Finally, studies with the potential to change practice for a substantial number of physicians were prioritized over those that merely confirmed existing practice (i.e., they matter). Studies that meet all of these criteria are called POEMs, for patient-oriented evidence that matters. 2 Each POEM is summarized in a structured critical appraisal written by one of the six expert reviewers and peer reviewed by faculty and fellows of the University of Missouri Department of Family Medicine. Writing and disseminating the POEMs is supported by subscriptions, without industry support.

Since 2005, the Canadian Medical Association has sponsored a subscription to POEMs for its members. Each member has the option to receive the daily POEM by e-mail, and the option to rate it using a brief survey through the Information Assessment Method. The questionnaire for the Information Assessment Method is a validated tool that addresses relevance to clinicians, cognitive impact, use for practice, and expected health benefits if the results of the POEM would be applied. 3 For this article, we identified the 20 POEMs of 2015 that were rated highest for clinical relevance by Canadian Medical Association members. Each POEM was rated by at least 500 physicians, and at least 52% of respondents rated each of these top 20 POEMs as “totally relevant for at least one of your patients,” whereas less than 18% rated each as “not relevant for at least one of your patients.”

In the fifth installment of this annual series, 4 – 7 we summarize the clinical question and bottom-line answer for each of the 20 POEMs critically appraising an original research study, organized by topic and followed by a brief discussion. The bottom-line answers have been rewritten slightly from the original to stand alone without the complete synopsis and appraisal. We also briefly discuss POEMs summarizing practice guidelines that were judged to be highly relevant.

Respiratory Tract Infection

Four studies addressed the management of acute respiratory tract infection ( Table 1 ) . 8 – 12 Study 1 was a systematic review of the accuracy of rapid strep tests for streptococcal pharyngitis, and concluded that their accuracy is improving, with a sensitivity of 86%. 8 Because these tests miss only about one in six cases of streptococcal pharyngitis, the yield of backup cultures is small, particularly in adults, in whom strep is less common. Study 2 is from a British research group that has conducted a series of large trials of antibiotics for acute lower respiratory tract infection when pneumonia is not suspected. 10 The authors randomized 2,061 adults to receive amoxicillin, 1 g three times daily for seven days, or placebo (susceptibility of common respiratory pathogens to amoxicillin remains good in England). The overall findings were a number needed to treat (NNT) of 30 to prevent new or worsening symptoms, and a similar number needed to harm for adverse events caused by the antibiotic. There was a somewhat greater reduction in the duration of symptoms for patients with green sputum, and a greater reduction in symptom severity between days 2 and 4 for those with significant cardiopulmonary morbidities.

Although most systematic reviews examine the benefits of treatment, Study 3 examined the harms of amoxicillin and amoxicillin/clavulanate (Augmentin), which are commonly used to treat respiratory infection. 11 The authors identified 25 studies that reported harms in a placebo-controlled trial. They found (not surprisingly) that diarrhea was more common in patients receiving amoxicillin/clavulanate, but not in those receiving amoxicillin alone. On the other hand, one additional case of candidiasis occurred for every 23 patients treated with amoxicillin, with or without clavulanate.

The final study in this group, Study 4, provides insight into the causes of community-acquired pneumonia (CAP). 12 Researchers from the Centers for Disease Control and Prevention identified 2,259 inpatients with CAP at five hospitals. Each had an extensive evaluation for viral and bacterial cases of CAP using culture and polymerase chain reaction testing. At least one viral pathogen was detected in 23% of patients, at least one bacterial pathogen in 11% of patients, one or more of each in 3% of patients, and fungi or mycobacteria in 1% of patients. Despite a careful search, 62% of patients had no pathogen detected.

Back pain was a popular topic, with five studies addressing its diagnosis and treatment ( Table 2 ) . 13 – 17 Study 5 included 5,239 adults 65 years and older presenting to a primary care physician with a new episode of acute low back pain, of whom about one-fourth received imaging within six weeks of presentation (1,174 had plain film radiography and 349 had computed tomography or magnetic resonance imaging). 13 Propensity score matching, which matches patients who did and did not undergo imaging but were otherwise similar, was used to compare outcomes between patients. Although imaging increased costs, no clinical benefit was observed.

Two studies looked at common medical treatments for back pain. Study 6 was a systematic review that identified 13 good-quality randomized controlled trials (RCTs) comparing adequate dosages of acetaminophen with placebo, and found no clinically important short- or long-term benefits for patients with back pain, hip pain, or osteoarthritis. 14 This is disappointing, given the safety of acetaminophen compared with other drugs. Study 7 was an RCT of 323 adults with acute low back pain randomized to naproxen plus either placebo, cyclobenzaprine (Flexeril; 5 mg), or oxycodone/acetaminophen (5 mg/325 mg), all taken as one or two tablets every eight hours. 15 Adding cyclobenzaprine or oxycodone/acetaminophen did not improve any outcomes, but led to more adverse effects (number needed to harm of 8 for the former and 5 for the latter).

What about nondrug therapies? In Study 8, which was an RCT of 220 adults with acute low back pain presenting to their primary care physician, one-half of patients were randomized to receive a referral within 72 hours for physical therapy (PT), whereas the remainder received usual care. 16 The primary outcome was the Oswestry Disability Index, a 100-point measure of disability from back pain. Those receiving PT had a slightly greater improvement in the score (three points), but such a small improvement is unlikely to be noticeable by patients. There were some minor improvements on secondary outcomes, but the overall results do not support routine referral of patients with acute low back pain for PT. Finally, back pain often becomes chronic or recurrent. Study 9 was an Irish study that randomized 246 patients referred for PT to standard PT, a weekly exercise class tailored to patients with back pain, or a program of gradually increased walking. 17 Patients in the walking group were given a pedometer and told to walk at least 10 minutes per day, four days per week, increasing gradually to a target of 30 minutes per day for five days per week. The walkers achieved the best results of the three groups, with the lowest cost and greatest likelihood of sustained adherence to the program. Now, we just need to advocate for our communities to offer safe places to walk.

Screening and Prevention

Several trials evaluated the benefits (and harms) of clinical preventive services ( Table 3 ) . 18 – 20 Study 10 asked how long we should continue nicotine replacement therapy. 18 The researchers randomized 525 smokers to the nicotine patch for eight, 24, or 52 weeks; all received 12 counseling sessions (the first in person and the remainder by telephone). At one year, there was no significant difference between groups in abstinence rates (more than 20% for all three groups).

Falls are an important health problem, especially in older women. Study 11, a Finnish study, included 409 community-dwelling women 70 to 80 years of age who had fallen at least once in the previous year and were not taking vitamin D supplements. 19 Participants were randomized to receive 800 IU of vitamin D per day, twice-weekly exercise, both interventions, or neither. Although the total number of falls did not differ between groups, the number of falls requiring medical attention was halved in those participating in the exercise program.

In Study 12, the 13-year results of the European Randomized Study of Screening for Prostate Cancer were reported. 20 The percentage of men dying from prostate cancer was approximately 0.12% lower in the screened group, a number needed to screen of approximately 800. However, there was no effect on all-cause mortality. Despite its large size (182,160 men), the study was still not powered for this outcome.

Diabetes Mellitus

Although intensive glycemic control has long been recommended for patients with type 2 diabetes mellitus, recent studies found benefits and harms ( Table 4 ) . 21 – 23 Study 13, the Veterans Affairs Diabetes Trial, randomized 1,791 veterans with type 2 diabetes to intensive or usual glycemic control, with average A1C values of 6.9% and 8.4%, respectively. 21 The original study found no difference in cardiovascular events or mortality between groups. The current study reports a longer follow-up of 10 years for cardiovascular events and 12 years for overall mortality. The researchers found an NNT of 116 persons per year to prevent a composite of cardiovascular events (largely because of fewer nonfatal myocardial infarctions), but no difference in the likelihood of cardiovascular death or all-cause mortality. Study 14 provided a longer-term observational follow-up of participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, and found similar small reductions in the likelihood of cardiovascular events. 22 However, it is important to remember that the ACCORD trial was stopped early because a data safety and monitoring committee detected a clinically and statistically significant increase in cardiovascular and all-cause mortality in the intensive glycemic control group.

The story is somewhat different for patients with type 1 diabetes. In Study 15, a Swedish study used a registry of patients with type 1 diabetes to demonstrate a strong association between better glycemic control and lower cardiovascular mortality. Even for those with excellent glycemic control, though, cardiovascular mortality was higher than for persons without type 1 diabetes. 23

Cardiovascular Disease

The first of two cardiovascular studies ( Table 5 24 , 25 ) examined the effectiveness of treatment for mild hypertension (140/90 to 159/99 mm Hg). Most systematic reviews combine the aggregate data from studies, but the researchers in Study 16 were able to use individual patient-level data for 15,266 patients randomized to active treatment or placebo. 24 Over an average five years of treatment, the NNT to prevent one stroke was 173 (95% confidence interval [CI], 108 to 810), to prevent one cardiovascular death was 95 (95% CI, 55 to 1,188), and to prevent one death overall was 99 (95% CI, 66 to 273). These estimates are clinically and statistically significant, but the CIs are wide.

A 2011 meta-analysis of nine studies with more than 100,000 participants found fewer major cardiovascular events (NNT = 253 over seven years) but more major bleeding complications (number needed to harm = 261 over seven years) for patients without known cardiovascular disease who were randomized to aspirin as primary prevention. 26 Study 17 was a large Japanese trial that randomized adults 60 years and older with cardiovascular risk factors but no known cardiovascular disease to aspirin or control and then followed them for five years. 25 There were fewer nonfatal myocardial infarctions and transient ischemic attacks in the treatment group, but there were also more bleeding complications and no difference in all-cause mortality. Overall, the authors concluded that there was no net benefit of aspirin.


Several top POEMs did not fit into one of the previous categories, but they provide important guidance for family physicians ( Table 6 ) . 27 – 30 Study 18 is a systematic review of 143 studies comparing 14 different regimens with standard triple therapy (a proton pump inhibitor plus clarithromycin [Biaxin] plus either metronidazole [Flagyl] or amoxicillin) for Helicobacter pylori eradication. 27 Three regimens, described in Table 6 , 27 – 30 emerged as more effective than the others. Study 19 included 493 patients presenting to a primary care practice in Australia who were randomized to minor skin surgery with sterile gloves vs. boxed, nonsterilized gloves. 28 There was no difference in the likelihood of infection (9.3% in those treated with sterile gloves vs. 8.7% in those treated with nonsterile gloves). Finally, Study 20, a population-based prospective cohort study, followed 1,449 women 42 to 52 years of age to determine the duration of vasomotor symptoms during menopause. 30 The duration was longer for women whose symptoms began before menopause compared with those whose symptoms began after menopause (11.8 vs. 3.4 years). This information allows family physicians to better advise their patients.

These top 20 POEMs are based on an original research study or systematic review. Several POEMs that summarized practice guidelines were also highly rated. Guidelines from the U.S. Preventive Services Task Force included recommendations to not screen for thyroid disease, 31 to confirm the diagnosis of mild to moderate hypertension with ambulatory or home blood pressure monitoring, 32 and to screen patients who are obese for diabetes. 33 The American College of Physicians released guidelines that recommended against screening adults not at increased risk of cardiovascular disease, 34 and largely affirmed the recommendations of other organizations regarding cervical cancer screening. 35

The Department of Veterans Affairs and the Department of Defense have created guidelines for the use of lipid-lowering therapies 36 that are somewhat less aggressive than those of the American College of Cardiology and the American Heart Association (ACC/AHA), 37 recommending therapy for those with a 12% or higher 10-year risk of cardiovascular events, shared decision making for those between 6% and 12%, and no therapy for those with a 10-year risk less than 6%. They also recommend using a moderate, fixed-dose statin for most patients and not checking or following lipid levels.

Finally, the ACC/AHA guidelines on atrial fibrillation recommend that physicians use the CHA 2 DS 2 -VASc score (congestive heart failure; hypertension; age 75 years or older; diabetes; prior stroke, transient ischemic attack, or thromboembolism; vascular disease; age 65 to 74 years; sex category) to assess risk, prescribe warfarin (Coumadin) or novel oral anticoagulants, and consider rate control as an option. 38 The novel oral anticoagulants provide greater convenience with greater cost.

editor's note: This article was cowritten by Dr. Mark Ebell, who was a member of the U.S. Preventive Services Task Force (USPSTF) from 2012 to 2015 and currently serves as a consultant to the USPSTF. This article does not necessarily represent the views and policies of the USPSTF. Dr. Ebell is deputy editor for American Family Physician (AFP) and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. The POEMs described in this article stem from work that Dr. Ebell and his colleagues have been doing for the past two decades. Medical journals occasionally publish an article summarizing the best studies in a certain field from the previous year; however, those articles are limited by being one person's idiosyncratic collection of a handful of studies. In contrast, this article by Drs. Ebell and Roland Grad is validated in two ways: (1) the source material (POEMs) was derived from a systematic review of thousands of articles using a rigorous criterion-based process, and (2) these “best of the best” summaries were rated by thousands of Canadian primary care physicians for relevance and benefits to practice.

Because of Dr. Ebell's dual roles and ties to Essential Evidence Plus, the concept for this article was independently reviewed and approved by a group of AFP 's medical editors. In addition, the article underwent peer review and editing by four of AFP 's medical editors. Dr. Ebell was not involved in the editorial decision-making process.—Jay Siwek, MD, Editor, American Family Physician

The authors thank Wiley-Blackwell, Inc., for giving permission to excerpt the POEMs; Drs. Allen Shaughnessy, Henry Barry, David Slawson, Nita Kulkarni, and Linda Speer for their work in selecting and writing the original POEMs; the academic family medicine fellows and faculty of the University of Missouri–Columbia, for their work as peer reviewers; Pierre Pluye, PhD, for his work in codeveloping the Information Assessment Method; and Maria Vlasak for her assistance with copyediting the POEMs for the past 22 years.

Ebell MH, Barry HC, Slawson DC, Shaughnessy AF. Finding POEMs in the medical literature. J Fam Pract. 1999;48(5):350-355.

Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract. 1994;39(5):489-499.

Pluye P, Grad RM, Johnson-Lafleur J, et al. Evaluation of email alerts in practice: part 2. Validation of the information assessment method. J Eval Clin Pract. 2010;16(6):1236-1243.

Ebell MH, Grad R. Top 20 research studies of 2014 for primary care physicians. Am Fam Physician. 2015;92(5):377-383.

Ebell MH, Grad R. Top 20 research studies of 2013 for primary care physicians. Am Fam Physician. 2014;90(6):397-402.

Ebell MH, Grad R. Top 20 research studies of 2012 for primary care physicians. Am Fam Physician. 2013;88(6):380-386.

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  • Published: 18 March 2015

The neuroscience of mindfulness meditation

  • Yi-Yuan Tang 1 , 2   na1 ,
  • Britta K. Hölzel 3 , 4   na1 &
  • Michael I. Posner 2  

Nature Reviews Neuroscience volume  16 ,  pages 213–225 ( 2015 ) Cite this article

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  • Cognitive neuroscience

An Erratum to this article was published on 10 April 2015

It is proposed that the mechanism through which mindfulness meditation exerts its effects is a process of enhanced self-regulation, including attention control, emotion regulation and self-awareness.

Research on mindfulness meditation faces a number of important challenges in study design that limit the interpretation of existing studies.

A number of changes in brain structure have been related to mindfulness meditation.

Mindfulness practice enhances attention. The anterior cingulate cortex is the region associated with attention in which changes in activity and/or structure in response to mindfulness meditation are most consistently reported.

Mindfulness practice improves emotion regulation and reduces stress. Fronto-limbic networks involved in these processes show various patterns of engagement by mindfulness meditation.

Meditation practice has the potential to affect self-referential processing and improve present-moment awareness. The default mode networks — including the midline prefrontal cortex and posterior cingulate cortex, which support self-awareness — could be altered following mindfulness training.

Mindfulness meditation has potential for the treatment of clinical disorders and might facilitate the cultivation of a healthy mind and increased well-being.

Future research into mindfulness meditation should use randomized and actively controlled longitudinal studies with large sample sizes to validate previous findings.

The effects of mindfulness practice on neural structure and function need to be linked to behavioural performance, such as cognitive, affective and social functioning, in future research.

The complex mental state of mindfulness is likely to be supported by the large-scale brain networks; future work should take this into account rather than being restricted to activations in single brain areas.

Research over the past two decades broadly supports the claim that mindfulness meditation — practiced widely for the reduction of stress and promotion of health — exerts beneficial effects on physical and mental health, and cognitive performance. Recent neuroimaging studies have begun to uncover the brain areas and networks that mediate these positive effects. However, the underlying neural mechanisms remain unclear, and it is apparent that more methodologically rigorous studies are required if we are to gain a full understanding of the neuronal and molecular bases of the changes in the brain that accompany mindfulness meditation.

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This work was supported by the US Office of Naval Research. We thank E. Luders for her contributions to an earlier version of this manuscript. We benefited from discussions with R. Davidson and A. Chiesa. We thank four anonymous reviewers for their constructive comments and R. Tang for manuscript preparation.

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Yi-Yuan Tang and Britta K. Hölzel: These authors contributed equally to this work.

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Department of Psychological Sciences, Texas Tech University, Lubbock, 79409, Texas, USA

Yi-Yuan Tang

Department of Psychology, University of Oregon, Eugene, 97403, Oregon, USA

Yi-Yuan Tang & Michael I. Posner

Department of Neuroradiology, Technical University of Munich, Munich, 81675, Germany

Britta K. Hölzel

Massachusetts General Hospital, Charlestown, 02129, Massachusetts, USA

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Study designs that compare data from one or more groups at several time points and that ideally include a (preferably active) control condition and random assignment to conditions.

Study designs that compare data from an experimental group with those from a control group at one point in time.

Studies that assess the co-variation between two variables: for example, co-variation of functional or structural properties of the brain and a behavioural variable, such as reported stress.

(BOLD contrasts). Signals that can be extracted with functional MRI and that reflect the change in the amount of deoxyhaemoglobin that is induced by changes in the activity of neurons and their synapses in a region of the brain. The signals thus reflect the activity in a local brain region.

(ASL). An MRI technique that is capable of measuring cerebral blood flow in vivo . It provides cerebral perfusion maps without requiring the administration of a contrast agent or the use of ionizing radiation because it uses magnetically labelled endogenous blood water as a freely diffusible tracer.

The reliable patterns of brain activity that involve the activation and/or connectivity of multiple large-scale brain networks.

A parameter in diffusion tensor imaging, which images brain structures by measuring the diffusion properties of water molecules. It provides information about the microstructural integrity of white matter.

Derived from the eigenvalues of the diffusion tensor, their underlying biophysical properties are associated with axonal density and myelination, respectively.

A technique for coordinate-based meta-analysis of neuroimaging data. It determines the convergence of foci reported from different experiments, weighted by the number of participants in each study.

A method of analysing functional MRI data that is capable of detecting and characterizing information represented in patterns of activity distributed within and across multiple regions of the brain. Unlike univariate approaches, which only identify magnitudes of activity in localized parts of the brain, this approach can monitor multiple areas at once.

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Understanding and Evaluating Survey Research

A variety of methodologic approaches exist for individuals interested in conducting research. Selection of a research approach depends on a number of factors, including the purpose of the research, the type of research questions to be answered, and the availability of resources. The purpose of this article is to describe survey research as one approach to the conduct of research so that the reader can critically evaluate the appropriateness of the conclusions from studies employing survey research.


Survey research is defined as "the collection of information from a sample of individuals through their responses to questions" ( Check & Schutt, 2012, p. 160 ). This type of research allows for a variety of methods to recruit participants, collect data, and utilize various methods of instrumentation. Survey research can use quantitative research strategies (e.g., using questionnaires with numerically rated items), qualitative research strategies (e.g., using open-ended questions), or both strategies (i.e., mixed methods). As it is often used to describe and explore human behavior, surveys are therefore frequently used in social and psychological research ( Singleton & Straits, 2009 ).

Information has been obtained from individuals and groups through the use of survey research for decades. It can range from asking a few targeted questions of individuals on a street corner to obtain information related to behaviors and preferences, to a more rigorous study using multiple valid and reliable instruments. Common examples of less rigorous surveys include marketing or political surveys of consumer patterns and public opinion polls.

Survey research has historically included large population-based data collection. The primary purpose of this type of survey research was to obtain information describing characteristics of a large sample of individuals of interest relatively quickly. Large census surveys obtaining information reflecting demographic and personal characteristics and consumer feedback surveys are prime examples. These surveys were often provided through the mail and were intended to describe demographic characteristics of individuals or obtain opinions on which to base programs or products for a population or group.

More recently, survey research has developed into a rigorous approach to research, with scientifically tested strategies detailing who to include (representative sample), what and how to distribute (survey method), and when to initiate the survey and follow up with nonresponders (reducing nonresponse error), in order to ensure a high-quality research process and outcome. Currently, the term "survey" can reflect a range of research aims, sampling and recruitment strategies, data collection instruments, and methods of survey administration.

Given this range of options in the conduct of survey research, it is imperative for the consumer/reader of survey research to understand the potential for bias in survey research as well as the tested techniques for reducing bias, in order to draw appropriate conclusions about the information reported in this manner. Common types of error in research, along with the sources of error and strategies for reducing error as described throughout this article, are summarized in the Table .

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Sources of Error in Survey Research and Strategies to Reduce Error

The goal of sampling strategies in survey research is to obtain a sufficient sample that is representative of the population of interest. It is often not feasible to collect data from an entire population of interest (e.g., all individuals with lung cancer); therefore, a subset of the population or sample is used to estimate the population responses (e.g., individuals with lung cancer currently receiving treatment). A large random sample increases the likelihood that the responses from the sample will accurately reflect the entire population. In order to accurately draw conclusions about the population, the sample must include individuals with characteristics similar to the population.

It is therefore necessary to correctly identify the population of interest (e.g., individuals with lung cancer currently receiving treatment vs. all individuals with lung cancer). The sample will ideally include individuals who reflect the intended population in terms of all characteristics of the population (e.g., sex, socioeconomic characteristics, symptom experience) and contain a similar distribution of individuals with those characteristics. As discussed by Mady Stovall beginning on page 162, Fujimori et al. ( 2014 ), for example, were interested in the population of oncologists. The authors obtained a sample of oncologists from two hospitals in Japan. These participants may or may not have similar characteristics to all oncologists in Japan.

Participant recruitment strategies can affect the adequacy and representativeness of the sample obtained. Using diverse recruitment strategies can help improve the size of the sample and help ensure adequate coverage of the intended population. For example, if a survey researcher intends to obtain a sample of individuals with breast cancer representative of all individuals with breast cancer in the United States, the researcher would want to use recruitment strategies that would recruit both women and men, individuals from rural and urban settings, individuals receiving and not receiving active treatment, and so on. Because of the difficulty in obtaining samples representative of a large population, researchers may focus the population of interest to a subset of individuals (e.g., women with stage III or IV breast cancer). Large census surveys require extremely large samples to adequately represent the characteristics of the population because they are intended to represent the entire population.


Survey research may use a variety of data collection methods with the most common being questionnaires and interviews. Questionnaires may be self-administered or administered by a professional, may be administered individually or in a group, and typically include a series of items reflecting the research aims. Questionnaires may include demographic questions in addition to valid and reliable research instruments ( Costanzo, Stawski, Ryff, Coe, & Almeida, 2012 ; DuBenske et al., 2014 ; Ponto, Ellington, Mellon, & Beck, 2010 ). It is helpful to the reader when authors describe the contents of the survey questionnaire so that the reader can interpret and evaluate the potential for errors of validity (e.g., items or instruments that do not measure what they are intended to measure) and reliability (e.g., items or instruments that do not measure a construct consistently). Helpful examples of articles that describe the survey instruments exist in the literature ( Buerhaus et al., 2012 ).

Questionnaires may be in paper form and mailed to participants, delivered in an electronic format via email or an Internet-based program such as SurveyMonkey, or a combination of both, giving the participant the option to choose which method is preferred ( Ponto et al., 2010 ). Using a combination of methods of survey administration can help to ensure better sample coverage (i.e., all individuals in the population having a chance of inclusion in the sample) therefore reducing coverage error ( Dillman, Smyth, & Christian, 2014 ; Singleton & Straits, 2009 ). For example, if a researcher were to only use an Internet-delivered questionnaire, individuals without access to a computer would be excluded from participation. Self-administered mailed, group, or Internet-based questionnaires are relatively low cost and practical for a large sample ( Check & Schutt, 2012 ).

Dillman et al. ( 2014 ) have described and tested a tailored design method for survey research. Improving the visual appeal and graphics of surveys by using a font size appropriate for the respondents, ordering items logically without creating unintended response bias, and arranging items clearly on each page can increase the response rate to electronic questionnaires. Attending to these and other issues in electronic questionnaires can help reduce measurement error (i.e., lack of validity or reliability) and help ensure a better response rate.

Conducting interviews is another approach to data collection used in survey research. Interviews may be conducted by phone, computer, or in person and have the benefit of visually identifying the nonverbal response(s) of the interviewee and subsequently being able to clarify the intended question. An interviewer can use probing comments to obtain more information about a question or topic and can request clarification of an unclear response ( Singleton & Straits, 2009 ). Interviews can be costly and time intensive, and therefore are relatively impractical for large samples.

Some authors advocate for using mixed methods for survey research when no one method is adequate to address the planned research aims, to reduce the potential for measurement and non-response error, and to better tailor the study methods to the intended sample ( Dillman et al., 2014 ; Singleton & Straits, 2009 ). For example, a mixed methods survey research approach may begin with distributing a questionnaire and following up with telephone interviews to clarify unclear survey responses ( Singleton & Straits, 2009 ). Mixed methods might also be used when visual or auditory deficits preclude an individual from completing a questionnaire or participating in an interview.


Fujimori et al. ( 2014 ) described the use of survey research in a study of the effect of communication skills training for oncologists on oncologist and patient outcomes (e.g., oncologist’s performance and confidence and patient’s distress, satisfaction, and trust). A sample of 30 oncologists from two hospitals was obtained and though the authors provided a power analysis concluding an adequate number of oncologist participants to detect differences between baseline and follow-up scores, the conclusions of the study may not be generalizable to a broader population of oncologists. Oncologists were randomized to either an intervention group (i.e., communication skills training) or a control group (i.e., no training).

Fujimori et al. ( 2014 ) chose a quantitative approach to collect data from oncologist and patient participants regarding the study outcome variables. Self-report numeric ratings were used to measure oncologist confidence and patient distress, satisfaction, and trust. Oncologist confidence was measured using two instruments each using 10-point Likert rating scales. The Hospital Anxiety and Depression Scale (HADS) was used to measure patient distress and has demonstrated validity and reliability in a number of populations including individuals with cancer ( Bjelland, Dahl, Haug, & Neckelmann, 2002 ). Patient satisfaction and trust were measured using 0 to 10 numeric rating scales. Numeric observer ratings were used to measure oncologist performance of communication skills based on a videotaped interaction with a standardized patient. Participants completed the same questionnaires at baseline and follow-up.

The authors clearly describe what data were collected from all participants. Providing additional information about the manner in which questionnaires were distributed (i.e., electronic, mail), the setting in which data were collected (e.g., home, clinic), and the design of the survey instruments (e.g., visual appeal, format, content, arrangement of items) would assist the reader in drawing conclusions about the potential for measurement and nonresponse error. The authors describe conducting a follow-up phone call or mail inquiry for nonresponders, using the Dillman et al. ( 2014 ) tailored design for survey research follow-up may have reduced nonresponse error.


Survey research is a useful and legitimate approach to research that has clear benefits in helping to describe and explore variables and constructs of interest. Survey research, like all research, has the potential for a variety of sources of error, but several strategies exist to reduce the potential for error. Advanced practitioners aware of the potential sources of error and strategies to improve survey research can better determine how and whether the conclusions from a survey research study apply to practice.

The author has no potential conflicts of interest to disclose.

Leveraging collective action and environmental literacy to address complex sustainability challenges

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  • Published: 09 August 2022
  • Volume 52 , pages 30–44, ( 2023 )

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  • Nicole M. Ardoin   ORCID: 1 ,
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  • Mele Wheaton 3  

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Developing and enhancing societal capacity to understand, debate elements of, and take actionable steps toward a sustainable future at a scale beyond the individual are critical when addressing sustainability challenges such as climate change, resource scarcity, biodiversity loss, and zoonotic disease. Although mounting evidence exists for how to facilitate individual action to address sustainability challenges, there is less understanding of how to foster collective action in this realm. To support research and practice promoting collective action to address sustainability issues, we define the term “collective environmental literacy” by delineating four key potent aspects: scale, dynamic processes, shared resources, and synergy. Building on existing collective constructs and thought, we highlight areas where researchers, practitioners, and policymakers can support individuals and communities as they come together to identify, develop, and implement solutions to wicked problems. We close by discussing limitations of this work and future directions in studying collective environmental literacy.

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For socio-ecologically intertwined issues—such as climate change, land conversion, biodiversity loss, resource scarcity, and zoonotic diseases—and their associated multi-decadal timeframes, individual action is necessary, yet not sufficient, for systemic, sustained change (Amel et al. 2017 ; Bodin 2017 ; Niemiec et al. 2020 ; Spitzer and Fraser 2020 ). Instead, collective action, or individuals working together toward a common good, is essential for achieving the scope and scale of solutions to current sustainability challenges. To support communities as they engage in policy and action for socio-environmental change, communicators, land managers, policymakers, and other practitioners need an understanding of how communities coalesce and leverage their shared knowledge, skills, connections, and experiences.

Engagement efforts, such as those grounded in behavior-change approaches or community-based social marketing initiatives, that address socio-environmental issues have often emphasized individuals as the pathway to change. Such efforts address a range of domains including, but not limited to, residential energy use, personal transportation choices, and workplace recycling efforts, often doing so in a stepwise fashion, envisioning each setting or suite of behaviors as discrete spheres of action and influence (Heimlich and Ardoin 2008 ; McKenzie-Mohr 2011 ). In this way, specific actions are treated incrementally and linearly, considering first the individual barriers to be removed and then the motivations to be activated (and, sometimes, sustained; Monroe 2003 ; Gifford et al. 2011 ). Once each behavior is successfully instantiated, the next barrier is then addressed. Proceeding methodically from one action to the next, such initiatives often quite successfully alter a series of actions or group of related behaviors (at least initially) by addressing them incrementally, one at a time (Byerly et al. 2018 ). Following this aspirational logic chain, many resources have been channeled into such programs under the assumption that, by raising awareness and knowledge, such information, communication, and educational outreach efforts will shift attitudes and behaviors to an extent that, ultimately, mass-scale change will follow. (See discussion in Wals et al. 2014 .)

Numerous studies have demonstrated, however, that challenges arise with these stepwise approaches, particularly with regard to their ability to address complex issues and persist over time (Heimlich and Ardoin 2008 ; Wals et al. 2014 ). Such approaches place a tremendous—and unrealistic—burden on individuals, ignoring key aspects not only of behavioral science but also of social science more broadly, including the view that humans exist nested within socio-ecological systems and, thus, are most successful at achieving lasting change when it is meaningful, relevant, and undertaken within a supportive context (Swim et al. 2011 ; Feola 2015 ). Individualized approaches often require multiple steps or nudges (Byerly et al. 2018 ), or ongoing reminders to retain their salience (Stern et al. 2008 ). Because of the emphasis on decontextualized action, such approaches can miss, ignore, obfuscate, or minimize the importance of the bigger picture, which includes the sociocultural, biophysical, and political economic contexts (Ardoin 2006 ; Amel et al. 2017 ). Although the tightly trained focus on small, actionable steps and reliance on individual willpower may help in initially achieving success with initial habit formation (Carden and Wood 2018 ), it becomes questionable in terms of bringing about a wave of transformation on larger scales in the longer term. For those decontextualized actions to persist, they require continued prompting, constancy, and support in the social and biophysical context (Schultz 2014 ; Manfredo et al. 2016 ; Wood and Rünger 2016 ).

Less common in practice are theoretically based initiatives that embrace the holistic nature of the human experience, which occurs within complex systems spanning time and space in a multidimensional, weblike fashion (Bronfenbrenner 1979 ; Rogoff 2003 ; Barron 2006 ; DeCaro and Stokes 2008 ; Gould et al. 2019 ; Hovardas 2020 ). These systems-thinking approaches, while varying across disciplines and epistemological perspectives, envision human experiences, including learning and behavior, as occurring within a milieu that include the social, political, cultural, and historical contexts (Rogoff 2003 ; Roth and Lee 2007 ; Swim et al. 2011 ; Gordon 2019 ). In such a view, people’s everyday practices continuously reflect and grow out of past learning and experiences, not only at the individual, but also at the collective level (Lave 1991 ; Gutiérrez and Rogoff 2003 ; Nasir et al. 2020 ; Ardoin and Heimlich 2021 ). The multidimensional context in which we exist—including the broader temporal and spatial ecosystem—both facilitates and constrains our actions.

Scholars across diverse areas of study discuss the need for and power of collective thought and action, using various conceptual frames, models, and terms, such as collective action, behavior, impact, and intelligence; collaborative governance; communities of practice; crowdsourcing; and social movement theory; among many others (Table 1 ). These scholars acknowledge and explore the influence of our multidimensional context on collective thought and action. In this paper, we explore the elements and processes that constitute collective environmental literacy . We draw on the vast, relevant literature and, in so doing, we attempt to invoke the power of the collective: by reviewing and synthesizing ideas from a variety of fields, we strive to leverage existing constructs and perspectives that explore notions of the “collective” (see Table 1 for a summary of constructs and theories reviewed to develop our working definition of collective environmental literacy). A primary goal of this paper is to dialogue with other researchers and practitioners working in this arena who are eager to uncover and further explore related avenues.

First, we present a formal definition of collective environmental literacy. Next, we briefly review the dominant view of environmental literacy at the individual level and, in support of a collective take on environmental literacy, we examine various collective constructs. We then delve more deeply into the definition of collective environmental literacy by outlining four key aspects: scale, dynamic processes, shared resources, and synergy. We conclude by providing suggestions for future directions in studying collective environmental literacy.

Defining collective environmental literacy

Decades of research in political science, economics, anthropology, sociology, psychology, and the learning sciences, among other fields (Chawla and Cushing 2007 ; Ostrom 2009 ; Sawyer 2014 ; Bamberg et al. 2015 ; Chan 2016 ; Jost et al. 2017 ) repeatedly demonstrates the effectiveness, and indeed necessity of, collective action when addressing problems that are inherently social in nature. Yet theoretical frameworks and empirical documentation emphasize that such collective activities rarely arise spontaneously and, when they do, are a result of preconditions that have sown fertile ground (van Zomeren et al. 2008 ; Duncan 2018 ). Persistent and effective collective action then requires scaffolding in the form of institutional, sociocultural, and political economic structure that provides ongoing support. To facilitate discussions of how to effectively support collective action around sustainability issues, we suggest the concept of “collective environmental literacy.” We conceptualize collective environmental literacy as more than collective action; rather, we suggest that the term encapsulates action along with its various supporting structures and resources. Additionally, we employ the word “literacy” as it connotes learning, intention, and the idea that knowledge, skills, attitudes, and behaviors can be enhanced iteratively over time. By using “literacy,” we strive to highlight the efforts, often unseen, that lead to effective collective action in communities. We draw on scholarship in science and health education, areas that have begun over the past two decades to theorize about related areas of collective science literacy (Roth and Lee 2002 , 2004 ; Lee and Roth 2003 ; Feinstein 2018 ) and health literacy (Freedman et al. 2009 ; Papen 2009 ; Chinn 2011 ; Guzys et al. 2015 ). Although these evolving constructs lack consensus definitions, they illuminate affordances and constraints that exist when conceptualizing collective environmental literacy (National Academies of Sciences, Engineering, and Medicine [NASEM] 2016 ).

Some of the key necessary—but not sufficient—conditions that facilitate aligned, collective actions include a common body of decision-making information; shared attitudes, values, and beliefs toward a motivating issue or concern; and efficacy skills that facilitate change-making (Sturmer and Simon 2004 ; van Zomeren et al. 2008 ; Jagers et al. 2020 ). In addition, other contextual factors are essential, such as trust, reciprocity, collective efficacy, and communication among group members and societal-level facilitators, such as social norms, institutions, and technology (Bandura 2000 ; Ostrom 2010 ; McAdam and Boudet 2012 ; Jagers et al. 2020 ). Taken together, we term this body of knowledge, dispositions, skills, and the context in which they flourish collective environmental literacy . More formally, we define collective environmental literacy as: a dynamic, synergistic process that occurs as group members develop and leverage shared resources to undertake individual and aggregate actions over time to address sustainability issues within the multi-scalar context of a socio-environmental system (Fig.  1 ).

figure 1

Key elements of collective environmental literacy

Environmental literacy: Historically individual, increasingly collective

Over the past five decades, the term “environmental literacy” has come into increasingly frequent use. Breaking from the traditional association of “literacy” with reading and writing in formal school contexts, environmental literacy emphasizes associations with character and behavior, often in the form of responsible environmental stewardship (Roth 1992 ). Footnote 1 Such perspectives define the concept as including affective (attitudinal), cognitive (knowledge-based), and behavioral domains, emphasizing that environmental literacy is both a process and outcome that develops, builds, and morphs over time (Hollweg et al. 2011 ; Wheaton et al. 2018 ; Clark et al. 2020 ).

The emphasis on defining, measuring, and developing interventions to bring about environmental literacy has primarily remained at the individual scale, as evidenced by frequent descriptions of an environmentally literate person (Roth 1992 ; Hollweg et al. 2011 among others) rather than community or community member. In most understandings, discussions, and manifestations of environmental literacy, the implicit assumption remains that the unit of action, intervention, and therefore analysis occurs at the individual level. Yet instinctively and perhaps by nature, community members often seek information and, as a result, take action collectively, sharing what some scholars call “the hive mind” or “group mind,” relying on each other for distributed knowledge, expertise, motivation, and support (Surowiecki 2005 ; Sunstein 2008 ; Sloman and Fernbach 2017 ; Paul 2021 ).

As with the proverbial elephant (Saxe, n.d.), each person, household, or neighborhood group may understand or “see” a different part of an issue or challenge, bring a novel understanding to the table, and have a certain perspective or skill to contribute. Although some environmental literacy discussions allude to a collective lens (e.g., Hollweg et al. 2011 ; Ardoin et al. 2013 ; Wheaton et al. 2018 ; Bey et al. 2020 ), defining, developing frameworks, and creating measures to assess the efficacy of such collective-scale sustainability-related endeavors has remained elusive. Footnote 2 Looking to related fields and disciplines—such as ecosystem theory, epidemiology and public health, sociology, network theory, and urban planning, among others—can provide insight, theoretical frames, and empirical examples to assist in such conceptualizations (McAdam and Boudet 2012 ; National Research Council 2015 ) (See Table 1 for an overview of some of the many areas of study that informed our conceptualization of collective environmental literacy).

Seeking the essence of the collective: Looking to and learning from others

The social sciences have long focused on “the kinds of activities engaged in by sizable but loosely organized groups of people” (Turner et al. 2020 , para. 1) and addressed various collective constructs, such as collective behavior, action, intelligence, and memory (Table 1 ). Although related constructs in both the social and natural sciences—such as communities of practice (Wenger and Snyder 2000 ), collaborative governance (Ansell and Gash 2008 ; Emerson et al. 2012 ), and the collaboration–coordination continuum (Sadoff and Grey 2005 ; Prager 2015 ), as well as those from social movement theory and related areas (McAdam and Boudet 2012 ; de Moor and Wahlström 2019 )—lack the word “collective” in name, they too leverage the benefits of collectivity. A central tenet connects all of these areas: powerful processes, actions, and outcomes can arise when individuals coalesce around a common purpose or cause. This notion of a dynamic, potent force transcending the individual to enhance the efficacy of outcomes motivates the application of a collective lens to the environmental literacy concept.

Dating to the 1800s, discussions of collective behavior have explored connections to social order, structures, and norms (Park 1927 ; Smelser 2011 /1962; Turner and Killian 1987 ). Initially, the focus emphasized spontaneous, often violent crowd behaviors, such as riots, mobs, and rebellions. More contemporarily, sociologists, political scientists, and others who study social movements and collective behaviors acknowledge that such phenomena may take many forms, including those occurring in natural ecosystems, such as ant colonies, bird flocks, and even the human brain (Gordon 2019 ). In sociology, collective action represents a paradigm shift highlighting coordinated, purposeful pro-social movements, while de-emphasizing aroused emotions and crowd behavior (Miller 2014 ). In political science, Ostrom’s ( 1990 , 2000 , 2010 ) theory of collective action in the context of the management of shared resources extends the concept’s reach to economics and other fields. In education and the learning sciences, social learning and sociocultural theories tap into the idea of learning as a social-cognitive-cultural endeavor (Vygotsky 1980 ; Lave and Wenger 1991 ; Tudge and Winterhoff 1993 ; Rogoff 2003 ; Reed et al. 2010 ).

Collective action, specifically, and collective constructs, generally, have found their way into the research and practice in the fields of conservation, natural resources, and environmental management. Collective action theory has been applied in a range of settings and scenarios, including agriculture (Mills et al. 2011 ), invasive species management (Marshall et al. 2016 ; Sullivan et al. 2017 ; Lubeck et al. 2019 ; Clarke et al. 2021 ), fire management (Canadas et al. 2016 ; Charnley et al. 2020 ), habitat conservation (Raymond 2006 ; Niemiec et al. 2020 ), and water governance (Lopez-Gunn 2003 ; Baldwin et al. 2018 ), among others. Frameworks and methods that emphasize other collective-related ideas—like collaboration, co-production, and group learning—are also ubiquitous in natural resource and environmental management. These constructs include community-based conservation (DeCaro and Stokes 2008 ; Niemiec et al. 2016 ), community natural resource management (Kellert et al. 2000 ; Dale et al. 2020 ), collaboration/coordination (Sadoff and Grey 2005 ; Prager 2015 ), polycentricity (Galaz et al. 2012 ; Heikkila et al. 2018 ), knowledge co-production (Armitage et al. 2011 ; Singh et al. 2021 ), and social learning (Reed et al. 2010 ; Hovardas 2020 ). Many writings on collective efforts in the social sciences broadly, and applied in the area of environment specifically, provide insights into collective action’s necessary preconditions, which prove invaluable to further defining and later operationalizing collective environmental literacy.

Unpacking the definition of collective environmental literacy: Anchoring principles

As described, we propose the following working definition of collective environmental literacy drawing on our analysis of related literatures and informed by scholarly and professional experience in the sustainability and conservation fields: a dynamic, synergistic process that occurs as group members develop and leverage shared resources to undertake individual and aggregate actions over time to address sustainability issues within the multi-scalar context of a socio-environmental system (Fig.  1 ). This definition centers on four core, intertwined ideas: the scale of the group involved; the dynamic nature of the process; shared resources brought by, available to, and needed by the group; and the synergy that arises from group interaction.


When transitioning from the focus on individual to collective actions—and, herein, principles of environmental literacy—the most obvious and primary requisite shift is one of scale. Yet, moving to a collective scale does not mean abandoning action at the individual scale; rather, success at the collective level is intrinsically tied to what occurs at an individual level. Such collective-scale impacts leverage the power of the hive, harnessing people’s willingness, ability, and motivation to take action alongside others, share their ideas and resources to build collective ideas and resources, contribute to making a difference in an impactful way, and participate communally in pro-social activities.

Collective environmental literacy is likely dynamic in its orientation to scale, incorporating place-based notions, such as ecoregional or community-level environmental literacy (with an emphasis on geographic boundaries). On the other hand, it may encapsulate environmental literacy of a group or organization united by a common identity (e.g., organizational membership) or cause (e.g., old-growth forests, coastal protection), rather than solely or even primarily by geography. Although shifting scales can make measuring collective environmental literacy more difficult, dynamic levels may be a benefit when addressing planetary boundary issues such as climate change, biodiversity, and ocean acidification (Galaz et al. 2012 ). Some scholars have called for a polycentric approach to these large-scale issues in response to a perceived failure of global-wide, top-down solutions (Ostrom 2010 , 2012 ; Jordan et al. 2018 ). Conceptualizing and consequently supporting collective environmental literacy at multiple scales can facilitate such desired polycentricity.

Rather than representing a static outcome, environmental literacy is a dynamic process that is fluctuating and complex, reflective of iterative interactions among community members, whose discussions and negotiations reflect the changing context of sustainability issues. Footnote 3 Such open-minded processes allow for, and indeed welcome, adaptation in a way that builds social-ecological resilience (Berkes and Jolly 2002 ; Adger et al. 2005 ; Berkes 2007 ). Additionally, this dynamism allows for collective development and maturation, supporting community growth in collective knowledge, attitudes, skills, and actions via new experiences, interactions, and efforts (Berkman et al. 2010 ). With this mindset, and within a sociocultural perspective, collective environmental literacy evolves through drawing on and contributing to the community’s funds of knowledge (González et al. 2006 ). Movement and actions within and among groups impact collective literacy, as members share knowledge and other resources, shifting individuals and the group in the course of their shared practices (Samerski 2019 ).

In a collective mode, effectiveness is heightened as shared resources are streamlined, waste is minimized, and innovation maximized. Rather than each group member developing individual expertise in every matter of concern, the shared knowledge, skills, and behaviors can be distributed, pursued, and amplified among group members efficiently and effectively, with collective literacy emerging from the process of pooling diverse forms of capital and aggregating resources. This perspective builds on ideas of social capital as a collective good (Ostrom 1990 ; Putnam 2020 ), wherein relationships of trust and reciprocity are both inputs and outcomes (Pretty and Ward 2001 ). The shared resources then catalyze and sustain action as they are reassembled and coalesced at the group level for collective impact.

The pooled resources—likely vast—may include, but are not limited to, physical and human resources, funding, time, energy, and space and place (physical or digital). Shared resources may also include forms of theorized capital, such as intellectual and social (Putnam 2020 ). Also of note is the recognition that these resources extend far beyond information and knowledge. Of particular interest when building collective environmental literacy are resources previously ignored or overlooked by those in power in prior sustainability efforts. For example, collective environmental literacy can draw strength from shared resources unique to the community or even subgroups within the larger community. Discussions of Indigenous knowledge (Gadgil et al. 1993 ) and funds of knowledge (González et al. 2006 ; Cruz et al. 2018 ) suggest critical, shared resources that highlight strengths of an individual community and its members. Another dimension of shared resources relates to the strength of institutional connections, such as the benefits that accrue from leveraging the collective knowledge, expertise, and resources of organizational collaborators working in adjacent areas to further and amplify each other’s impact (Wojcik et al. 2021 ).


Finally, given the inherent complexities related to defining, deploying, implementing, and measuring these dynamic, at-times ephemeral processes, resources, and outcomes at a collective scale, working in such a manner must be clearly advantageous to pressing sustainability issues at hand. Numerous related constructs and approaches from a range of fields emphasize the benefits of diverse collaboration to collective thought and action, including improved solutions, more effective and fair processes, and more socioculturally just outcomes (Klein 1990 ; Jörg 2011 ; Wenger and Snyder 2000 ; Djenontin and Meadow 2018 ). These benefits go beyond efficient aggregation and distribution of resources, invoking an almost magical quality that defines synergy, resulting in robust processes and outcomes that are more than the sum of the parts.

This synergy relies on the diversity of a group across various dimensions, bringing power, strength, and insight to a decision-making process (Bear and Woolley 2011 ; Curşeu and Pluut 2013 ; Freeman and Huang 2015 ; Lu et al. 2017 ; Bendor and Page 2019 ). Individuals are limited not only to singular knowledge-perspectives and skillsets, but also to their own experiences, which influence their self-affirming viewpoints and tendencies to seek out confirmatory information for existing beliefs (Kahan et al. 2011 ). Although the coming together of those from different racial, cultural, social, and economic backgrounds facilitates a collective literacy process that draws on a wider range of resources and equips a gestalt, it also sets up the need to consider issues of power, privilege, voice, and representation (Bäckstrand 2006 ) and the role of social capital, leading to questions related to trust and reciprocity in effective collectives (Pretty and Ward 2001 ; Folke et al. 2005 ).

Leveraging the ‘Hive’: Proceeding with collective environmental literacy

This paper presents one conceptualization of collective environmental literacy, with the understanding that numerous ways exist to envision its definition, formation, deployment, and measurement. Characterized by a collective effort, such literacies at scale offer a way to imagine, measure, and support the synergy that occurs when the emphasis moves from an individual to a larger whole. By expanding the scale and focusing on shared responsibility among actors at the systems level, opportunities arise for inspiring and enabling a broader contribution to a sustainable future. These evolving notions serve to invite ongoing conversation, both in research and practice, about how to enact our collective responsibility toward, as well as vision of, a thriving future.

Emerging from the many discussions of shared and collaborative efforts to address socio-environmental issues, our conceptualization of collective environmental literacy is a first step toward supporting communities as they work to identify, address, and solve sustainability problems. We urge continued discussions on this topic, with the goal of understanding the concept of collective environmental literacy, how to measure it, and the implications of this work for practitioners. The conceptual roots of collective environmental literacy reach into countless fields of study and, as such, a transdisciplinary approach, which includes an eye toward practice, is necessary to fully capture and maximize the tremendous amount of knowledge, wisdom, and experience around this topic. Specifically, next steps to evolve the concept include engaging sustainability researchers and practitioners in discussions of the saliency of the presented definition of collective environmental literacy. These discussions include verifying the completeness of the definition and ensuring a thorough review of relevant research: Are parts of the definition missing or unclear? What are the “blank, blind, bald, and bright spots” in the literature (Reid 2019 p. 158)? Additionally, recognizing and leveraging literacy at a collective scale most certainly is not unique to environmental work, nor is adopting literacy-related language to conceptualize and measure process outcomes, although the former has consistently proven more challenging. Moreover, although we (the authors) appreciate the connotations and structures gained by using a literacy framework, we struggle with whether “environmental literacy” is the most appropriate and useful term for the conceptualizations as described herein; we, thus, welcome lively discussions about the need for new terminology.

Even at this early stage of conceptualization, this work has implications for practitioners. For scientists, communicators, policymakers, land managers, and other professionals desiring to work with communities to address sustainability issues, a primary take-away message concerns the holistic nature of what is needed for effective collective action in the environmental realm. Many previous efforts have focused on conveying information and, while a lack of knowledge and awareness may be a barrier to action in some cases, the need for a more holistic lens is increasingly clear. This move beyond an individually focused, information-deficit model is essential for effective impact (Bolderdijk et al. 2013 ; van der Linden 2014 ; Geiger et al. 2019 ). The concept of collective environmental literacy suggests a role for developing shared resources that can foster effective collective action. When working with communities, a critical early step includes some form of needs assessment—a systematic, in-depth process that allows for meaningfully gauging gaps in shared resources required to tackle sustainability issues (Braus 2011). Following this initial, evaluative step, an understanding of the components of collective environmental literacy, as outlined in this paper, can be used to guide the development of interventions to support communities in their efforts to address those issues.

Growing discussion of collective literacy constructs, and related areas, suggests researchers, practitioners, and policymakers working in pro-social areas recognize and value collective efforts, despite the need for clearer definitions and effective measures. This definitional and measurement work, in both research and practice, is not easy. The ever-changing, dynamic contexts in which collective environmental literacy exists make defining the concept a moving target, compounded by a need to draw upon work in countless, often distinct academic fields of study. Furthermore, the hard-to-see, inner workings of collective constructs make measurement difficult. Yet, the “power of the hive” is intriguing, as the synergism that arises from communities working in an aligned manner toward a unified vision suggests a potency and wave of motivated action essential to coalescing and leveraging individual goodwill, harnessing its power and potential toward effective sustainability solutions.

See Stables and Bishop’s ( 2001 ) idea of defining environmental literacy by viewing the environment as “text.”

The climate change education literature also includes a nascent, but growing, discussion of collective-lens thinking and literacy. See, for example, Waldron et al. ( 2019 ), Mochizuki and Bryan ( 2015 ), and Kopnina ( 2016 ).

This conceptualization is similar to how some scholars describe collective health literacy (Berkman et al., 2010 ; Mårtensson and Hensing, 2012 ).

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We are grateful to Maria DiGiano, Anna Lee, and Becca Shareff for their feedback and contributions to early drafts of this paper. We appreciate the research and writing assistance supporting this paper provided by various members of the Stanford Social Ecology Lab, especially: Brennecke Gale, Pari Ghorbani, Regina Kong, Naomi Ray, and Austin Stack.

This work was supported by a grant from the Pisces Foundation.

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Ardoin, N.M., Bowers, A.W. & Wheaton, M. Leveraging collective action and environmental literacy to address complex sustainability challenges. Ambio 52 , 30–44 (2023).

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Received : 11 July 2021

Revised : 11 January 2022

Accepted : 22 June 2022

Published : 09 August 2022

Issue Date : January 2023


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Social Cognitive and Addiction Neuroscience Lab at the University of Iowa

Research in the scanlab.

EEG cap

Research projects in the UIOWA Social Cognitive and Addiction Neuroscience Lab generally focus on one of the following areas:

The role of cognitive control in social behavior

Effects of alcohol on cognitive control 

Individual differences in neurobiologically based risks for addiction, primarily alcohol use disorder

Effects of incidental stimulus exposure on cognition and behavior (i.e., priming effects). 

The common theme around which these lines of work are integrated is the interplay between salience (i.e., motivational significance) and cognitive control (see Inzlicht, Bartholow, & Hirsch, 2015 ).

Salience, Cognitive Control, and Social Behavior

The interaction of salience and cognitive control is an enduring area of interest in the SCANlab, going back to Dr. Bartholow’s undergraduate days. In his undergraduate senior honors thesis, Dr. Bartholow found that participants asked to read résumés later recalled more gender-inconsistent information about job candidates. This general theme carried through to Dr. Bartholow’s dissertation research, in which he used event-related brain potentials (ERPs) to examine the neurocognitive consequences of expectancy violations. In that study, expectancy-violating behaviors elicited a larger P3-like positivity in the ERP and were recalled better compared to expectancy-consistent behaviors ( Bartholow et al., 2001 , 2003 ). Back then, we interpreted this effect as evidence for context updating (the dominant P3 theory at the time). As theoretical understanding of the P3 has evolved, we now believe this finding reflects the fact that unexpected information is salient, prompting engagement of controlled processing (see Nieuwenhuis et al., 2005 ).

Our research has been heavily influenced by cognitive neuroscience models of the structure of information processing, especially the continuous flow model ( Coles et al., 1985 ; Eriksen & Schultz, 1979) and various conflict monitoring theories (e.g., Botvinick et al., 2001 ; Shenhav et al., 2016 ). In essence, these models posit (a) that information about a stimulus accumulates gradually as processing unfolds, and (b) as a consequence, various stimulus properties or contextual features can energize multiple, often competing responses simultaneously, leading to a need to engage cognitive control to maintain adequate performance. This set of basic principles has influenced much of our research across numerous domains of interest (see Bartholow, 2010 ).

Applied to social cognition, these models imply that responses often classified as “automatic” (e.g., measures of implicit attitudes) might be influenced by control. We first tested this idea in the context of a racial categorization task in which faces were flanked by stereotype-relevant words ( Bartholow & Dickter, 2008 ). In two experiments, we found that race categorizations were faster when faces appeared with stereotype-congruent versus –incongruent words, especially when stereotype-congruent trials were more probable. Further, the ERP data showed that that this effect was not due to differences in the evaluative categorization of the faces (P3 latency), but instead reflected increased response conflict (N2 amplitude) due to partial activation of competing responses (lateralized readiness potential; LRP) on stereotype-incongruent trials. A more recent, multisite investigation (funded by the National Science Foundation ) extended this work by testing the role of executive cognitive function (EF) in the expression of implicit bias. Participants (N = 485) completed a battery of EF measures and, a week later, a battery of implicit bias measures. As predicted, we found that expression of implicit race bias was heavily influenced by individual differences in EF ability ( Ito et al., 2015 ). Specifically, the extent to which bias expression reflected automatic processes was reduced as a function of increases in general EF ability.

Another study demonstrating the role of conflict and control in “implicit” social cognition was designed to identify the locus of the affective congruency effect ( Bartholow et al., 2009 ), wherein people are faster to categorize the valence of a target if it is preceded by a valence-congruent (vs. incongruent) prime. This finding traditionally has been explained in terms of automatic spreading of activation in working memory (e.g., Fazio et al., 1986 ). By measuring ERPs while participants completed a standard evaluative priming task, we showed (a) that incongruent targets elicit response conflict; (b) that the degree of this conflict varies along with the probability of congruent targets, such that (c) when incongruent targets are highly probable, congruent targets elicit more conflict (also see Bartholow et al., 2005 ); and (d) that this conflict is localized to response generation processes, not stimulus evaluation.

Salience, Cognitive Control, and Alcohol

Drinking alcohol is inherently a social behavior. Alcohol commonly is consumed in social settings, possibly because it facilitates social bonding and group cohesion ( Sayette et al., 2012 ). Many of the most devastating negative consequences of alcohol use and chronic heavy drinking also occur in the social domain. Theorists have long posited that alcohol’s deleterious effects on social behavior stem from impaired cognitive control. Several of our experiments have shown evidence consistent with this idea, in that alcohol increases expression of race bias due to its impairment of control-related processes ( Bartholow et al., 2006 , 2012 ).

But exactly how does this occur? One answer, we believe, is that alcohol reduces the salience of events, such as a control failure (i.e., an error), that normally spur efforts at increased control. Interestingly, we found ( Bartholow et al., 2012 ) that alcohol does not reduce awareness of errors, as others had suggested ( Ridderinkhof et al., 2002 ), but rather reduces the salience or motivational significance of errors. This, in turn, hinders typical efforts at post-error control adjustment. Later work further indicated that alcohol’s control-impairing effects are limited to situations in which control has already failed, and that recovery of control following errors takes much longer when people are drunk ( Bailey et al., 2014 ). Thus, the adverse consequences people often experience when intoxicated might stem from alcohol’s dampening of the typical “affect alarm,” seated in the brain’s salience network (anterior insula and dorsal anterior cingulate cortex), which alerts us when control is failing and needs to be bolstered ( Inzlicht et al., 2015 ).

Incidental Stimulus Exposure Effects

A fundamental tenet of social psychology is that situational factors strongly affect behavior. Despite recent controversies related to some specific effects, we remain interested in the power of priming, or incidental stimulus exposure, to demonstrate this basic premise. We have studied priming effects in numerous domains, including studies showing that exposure to alcohol-related images or words can elicit behaviors often associated with alcohol consumption, such as aggression and general disinhibition.

Based on the idea that exposure to stimuli increases accessibility of relevant mental content ( Higgins, 2011 ), we reasoned that seeing alcohol-related stimuli might not only bring to mind thoughts linked in memory with alcohol, but also might instigate behaviors that often result from alcohol consumption. As an initial test of this idea, in the guise of a study on advertising effectiveness we randomly assigned participants to view magazine ads for alcoholic beverages or for other grocery items and asked them to rate the ads on various dimensions. Next, we asked participants if they would help us pilot test material for a future study on impression formation by reading a paragraph describing a person and rating him on various traits, including hostility. We reasoned that the common association between alcohol and aggression might lead to a sort of hostile perception bias when evaluating this individual. As predicted, participants who had seen ads for alcohol rated the individual as more hostile than did participants who had seen ads for other products, and this effect was larger among people who had endorsed (weeks previously) the notion that alcohol increases aggression ( Bartholow & Heinz, 2006 ). Subsequently, this finding has been extended to participants’ own aggression in verbal ( Friedman et al., 2007 ) and physical domains ( Pedersen et al., 2014 ), and has been replicated in other labs (e.g., Bègue et al., 2009 ; Subra et al., 2010 ).

Of course, aggression is not the only behavior commonly assumed to increase with alcohol. Hence, we have tested whether this basic phenomenon extends into other behavioral domains, and found similar effects with social disinhibition ( Freeman et al., 2010 ), tension-reduction (Friedman et al., 2007), race bias ( Stepanova et al., 2012 , 2018 a, 2018 b), and risky decision-making (Carter et al., in prep.). Additionally, it could be that participants are savvy enough to recognize the hypotheses in studies of this kind when alcohol-related stimuli are presented overtly (i.e., experimental demand). Thus, we have also tested the generality of the effect by varying alcohol cue exposure procedures, including the use of so-called “sub-optimal” exposures (i.e., when prime stimuli are presented too quickly to be consciously recognized). Here again, similar effects have emerged (e.g., Friedman et al., 2007; Loersch & Bartholow, 2011 ; Pedersen et al., 2014).

Taken together, these findings highlight the power of situational cues to affect behavior in theoretically meaningful ways. On a practical level, they point to the conclusion that alcohol can affect social behavior even when it is not consumed, suggesting, ironically, that even nondrinkers can experience its effects.

Aberrant Salience and Control as Risk Factors for Addiction

Salience is central to a prominent theory of addiction known as incentive sensitization theory (IST; e.g., Robinson & Berridge, 1993 ). Briefly, IST posits that, through use of addictive drugs, including alcohol, people learn to pair the rewarding feelings they experience (relaxation, stimulation) with various cues present during drug use. Eventually, repeated pairing of drug-related cues with reward leads those cues to take on the rewarding properties of the drug itself. That is, the cues become infused with incentive salience, triggering craving, approach and consummatory behavior.

Research has shown critical individual differences in vulnerability to attributing incentive salience to drug cues, and that vulnerable individuals are at much higher risk for addiction. Moreover, combining incentive sensitization with poor cognitive control (e.g., during a drinking episode) makes for a “potentially disastrous combination” ( Robinson & Berridge, 2003 , p. 44). To date, IST has been tested primarily in preclinical animal models. Part of our work aims to translate IST to a human model.

In a number of studies over the past decade, we have discovered that a low sensitivity to the effects of alcohol (i.e., needing more drinks to feel alcohol’s effects), known to be a potent risk factor for alcoholism, is associated with heightened incentive salience for alcohol cues. Compared with their higher-sensitivity (HS) peers, among low-sensitivity (LS) drinkers alcohol-related cues (a) elicit much larger neurophysiological responses ( Bartholow et al., 2007 , 2010 ; Fleming & Bartholow, in prep.); (b) capture selective attention ( Shin et al., 2010 ); (c) trigger approach-motivated behavior ( Fleming & Bartholow, 2014 ); (d) produce response conflict when relevant behaviors must be inhibited or overridden by alternative responses ( Bailey & Bartholow, 2016 ; Fleming & Bartholow, 2014), and (e) elicit greater feelings of craving (Fleming & Bartholow, in prep.; Piasecki et al., 2017 ; Trela et al., in press). These findings suggest that LS could be a human phenotype related to sign-tracking , a conditioned response reflecting susceptibility to incentive sensitization and addiction ( Robinson et al., 2014 ).

Recently, our lab has conducted two major projects designed to examine how the incentive salience of alcohol-related cues is associated with underage drinking. One such project, funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA; R01-AA020970 ), examined the extent to which pairing beer brands with major U.S. universities enhances the incentive salience of those brands for underage students. Major brewers routinely associate their brands with U.S. universities through direct marketing and by advertising during university-related programming (e.g., college sports). We tested whether affiliating a beer brand with students’ university increases the incentive salience of the brand, and whether individual differences in the magnitude of this effect predict changes in underage students’ alcohol use. We found (a) that P3 amplitude elicited by a beer brand increased when that brand was affiliated with students’ university, either in a contrived laboratory task or by ads presented during university-related sports broadcasts; (b) that stronger personal identification with the university increased this effect; and (c) that variability in this effect predicted changes in alcohol use over one month, controlling for baseline levels of use ( Bartholow et al., 2018 ).

A current project, also funded by the NIAAA ( R01-AA025451 ), aims to connect multiple laboratory-based measures of the incentive salience of alcohol-related cues to underage drinkers’ reports of craving, alcohol use, and alcohol-related consequences as they occur in their natural environments. This project will help us to better understand the extent to which changes in drinking lead to changes in alcohol sensitivity and to corresponding changes in the incentive salience of alcohol-related cues.

McKinsey Global Private Markets Review 2024: Private markets in a slower era

At a glance, macroeconomic challenges continued.

research study 2015

McKinsey Global Private Markets Review 2024: Private markets: A slower era

If 2022 was a tale of two halves, with robust fundraising and deal activity in the first six months followed by a slowdown in the second half, then 2023 might be considered a tale of one whole. Macroeconomic headwinds persisted throughout the year, with rising financing costs, and an uncertain growth outlook taking a toll on private markets. Full-year fundraising continued to decline from 2021’s lofty peak, weighed down by the “denominator effect” that persisted in part due to a less active deal market. Managers largely held onto assets to avoid selling in a lower-multiple environment, fueling an activity-dampening cycle in which distribution-starved limited partners (LPs) reined in new commitments.

About the authors

This article is a summary of a larger report, available as a PDF, that is a collaborative effort by Fredrik Dahlqvist , Alastair Green , Paul Maia, Alexandra Nee , David Quigley , Aditya Sanghvi , Connor Mangan, John Spivey, Rahel Schneider, and Brian Vickery , representing views from McKinsey’s Private Equity & Principal Investors Practice.

Performance in most private asset classes remained below historical averages for a second consecutive year. Decade-long tailwinds from low and falling interest rates and consistently expanding multiples seem to be things of the past. As private market managers look to boost performance in this new era of investing, a deeper focus on revenue growth and margin expansion will be needed now more than ever.

A daytime view of grassy sand dunes

Perspectives on a slower era in private markets

Global fundraising contracted.

Fundraising fell 22 percent across private market asset classes globally to just over $1 trillion, as of year-end reported data—the lowest total since 2017. Fundraising in North America, a rare bright spot in 2022, declined in line with global totals, while in Europe, fundraising proved most resilient, falling just 3 percent. In Asia, fundraising fell precipitously and now sits 72 percent below the region’s 2018 peak.

Despite difficult fundraising conditions, headwinds did not affect all strategies or managers equally. Private equity (PE) buyout strategies posted their best fundraising year ever, and larger managers and vehicles also fared well, continuing the prior year’s trend toward greater fundraising concentration.

The numerator effect persisted

Despite a marked recovery in the denominator—the 1,000 largest US retirement funds grew 7 percent in the year ending September 2023, after falling 14 percent the prior year, for example 1 “U.S. retirement plans recover half of 2022 losses amid no-show recession,” Pensions and Investments , February 12, 2024. —many LPs remain overexposed to private markets relative to their target allocations. LPs started 2023 overweight: according to analysis from CEM Benchmarking, average allocations across PE, infrastructure, and real estate were at or above target allocations as of the beginning of the year. And the numerator grew throughout the year, as a lack of exits and rebounding valuations drove net asset values (NAVs) higher. While not all LPs strictly follow asset allocation targets, our analysis in partnership with global private markets firm StepStone Group suggests that an overallocation of just one percentage point can reduce planned commitments by as much as 10 to 12 percent per year for five years or more.

Despite these headwinds, recent surveys indicate that LPs remain broadly committed to private markets. In fact, the majority plan to maintain or increase allocations over the medium to long term.

Investors fled to known names and larger funds

Fundraising concentration reached its highest level in over a decade, as investors continued to shift new commitments in favor of the largest fund managers. The 25 most successful fundraisers collected 41 percent of aggregate commitments to closed-end funds (with the top five managers accounting for nearly half that total). Closed-end fundraising totals may understate the extent of concentration in the industry overall, as the largest managers also tend to be more successful in raising non-institutional capital.

While the largest funds grew even larger—the largest vehicles on record were raised in buyout, real estate, infrastructure, and private debt in 2023—smaller and newer funds struggled. Fewer than 1,700 funds of less than $1 billion were closed during the year, half as many as closed in 2022 and the fewest of any year since 2012. New manager formation also fell to the lowest level since 2012, with just 651 new firms launched in 2023.

Whether recent fundraising concentration and a spate of M&A activity signals the beginning of oft-rumored consolidation in the private markets remains uncertain, as a similar pattern developed in each of the last two fundraising downturns before giving way to renewed entrepreneurialism among general partners (GPs) and commitment diversification among LPs. Compared with how things played out in the last two downturns, perhaps this movie really is different, or perhaps we’re watching a trilogy reusing a familiar plotline.

Dry powder inventory spiked (again)

Private markets assets under management totaled $13.1 trillion as of June 30, 2023, and have grown nearly 20 percent per annum since 2018. Dry powder reserves—the amount of capital committed but not yet deployed—increased to $3.7 trillion, marking the ninth consecutive year of growth. Dry powder inventory—the amount of capital available to GPs expressed as a multiple of annual deployment—increased for the second consecutive year in PE, as new commitments continued to outpace deal activity. Inventory sat at 1.6 years in 2023, up markedly from the 0.9 years recorded at the end of 2021 but still within the historical range. NAV grew as well, largely driven by the reluctance of managers to exit positions and crystallize returns in a depressed multiple environment.

Private equity strategies diverged

Buyout and venture capital, the two largest PE sub-asset classes, charted wildly different courses over the past 18 months. Buyout notched its highest fundraising year ever in 2023, and its performance improved, with funds posting a (still paltry) 5 percent net internal rate of return through September 30. And although buyout deal volumes declined by 19 percent, 2023 was still the third-most-active year on record. In contrast, venture capital (VC) fundraising declined by nearly 60 percent, equaling its lowest total since 2015, and deal volume fell by 36 percent to the lowest level since 2019. VC funds returned –3 percent through September, posting negative returns for seven consecutive quarters. VC was the fastest-growing—as well as the highest-performing—PE strategy by a significant margin from 2010 to 2022, but investors appear to be reevaluating their approach in the current environment.

Private equity entry multiples contracted

PE buyout entry multiples declined by roughly one turn from 11.9 to 11.0 times EBITDA, slightly outpacing the decline in public market multiples (down from 12.1 to 11.3 times EBITDA), through the first nine months of 2023. For nearly a decade leading up to 2022, managers consistently sold assets into a higher-multiple environment than that in which they had bought those assets, providing a substantial performance tailwind for the industry. Nowhere has this been truer than in technology. After experiencing more than eight turns of multiple expansion from 2009 to 2021 (the most of any sector), technology multiples have declined by nearly three turns in the past two years, 50 percent more than in any other sector. Overall, roughly two-thirds of the total return for buyout deals that were entered in 2010 or later and exited in 2021 or before can be attributed to market multiple expansion and leverage. Now, with falling multiples and higher financing costs, revenue growth and margin expansion are taking center stage for GPs.

Real estate receded

Demand uncertainty, slowing rent growth, and elevated financing costs drove cap rates higher and made price discovery challenging, all of which weighed on deal volume, fundraising, and investment performance. Global closed-end fundraising declined 34 percent year over year, and funds returned −4 percent in the first nine months of the year, losing money for the first time since the 2007–08 global financial crisis. Capital shifted away from core and core-plus strategies as investors sought liquidity via redemptions in open-end vehicles, from which net outflows reached their highest level in at least two decades. Opportunistic strategies benefited from this shift, with investors focusing on capital appreciation over income generation in a market where alternative sources of yield have grown more attractive. Rising interest rates widened bid–ask spreads and impaired deal volume across food groups, including in what were formerly hot sectors: multifamily and industrial.

Private debt pays dividends

Debt again proved to be the most resilient private asset class against a turbulent market backdrop. Fundraising declined just 13 percent, largely driven by lower commitments to direct lending strategies, for which a slower PE deal environment has made capital deployment challenging. The asset class also posted the highest returns among all private asset classes through September 30. Many private debt securities are tied to floating rates, which enhance returns in a rising-rate environment. Thus far, managers appear to have successfully navigated the rising incidence of default and distress exhibited across the broader leveraged-lending market. Although direct lending deal volume declined from 2022, private lenders financed an all-time high 59 percent of leveraged buyout transactions last year and are now expanding into additional strategies to drive the next era of growth.

Infrastructure took a detour

After several years of robust growth and strong performance, infrastructure and natural resources fundraising declined by 53 percent to the lowest total since 2013. Supply-side timing is partially to blame: five of the seven largest infrastructure managers closed a flagship vehicle in 2021 or 2022, and none of those five held a final close last year. As in real estate, investors shied away from core and core-plus investments in a higher-yield environment. Yet there are reasons to believe infrastructure’s growth will bounce back. Limited partners (LPs) surveyed by McKinsey remain bullish on their deployment to the asset class, and at least a dozen vehicles targeting more than $10 billion were actively fundraising as of the end of 2023. Multiple recent acquisitions of large infrastructure GPs by global multi-asset-class managers also indicate marketwide conviction in the asset class’s potential.

Private markets still have work to do on diversity

Private markets firms are slowly improving their representation of females (up two percentage points over the prior year) and ethnic and racial minorities (up one percentage point). On some diversity metrics, including entry-level representation of women, private markets now compare favorably with corporate America. Yet broad-based parity remains elusive and too slow in the making. Ethnic, racial, and gender imbalances are particularly stark across more influential investing roles and senior positions. In fact, McKinsey’s research  reveals that at the current pace, it would take several decades for private markets firms to reach gender parity at senior levels. Increasing representation across all levels will require managers to take fresh approaches to hiring, retention, and promotion.

Artificial intelligence generating excitement

The transformative potential of generative AI was perhaps 2023’s hottest topic (beyond Taylor Swift). Private markets players are excited about the potential for the technology to optimize their approach to thesis generation, deal sourcing, investment due diligence, and portfolio performance, among other areas. While the technology is still nascent and few GPs can boast scaled implementations, pilot programs are already in flight across the industry, particularly within portfolio companies. Adoption seems nearly certain to accelerate throughout 2024.

Private markets in a slower era

If private markets investors entered 2023 hoping for a return to the heady days of 2021, they likely left the year disappointed. Many of the headwinds that emerged in the latter half of 2022 persisted throughout the year, pressuring fundraising, dealmaking, and performance. Inflation moderated somewhat over the course of the year but remained stubbornly elevated by recent historical standards. Interest rates started high and rose higher, increasing the cost of financing. A reinvigorated public equity market recovered most of 2022’s losses but did little to resolve the valuation uncertainty private market investors have faced for the past 18 months.

Within private markets, the denominator effect remained in play, despite the public market recovery, as the numerator continued to expand. An activity-dampening cycle emerged: higher cost of capital and lower multiples limited the ability or willingness of general partners (GPs) to exit positions; fewer exits, coupled with continuing capital calls, pushed LP allocations higher, thereby limiting their ability or willingness to make new commitments. These conditions weighed on managers’ ability to fundraise. Based on data reported as of year-end 2023, private markets fundraising fell 22 percent from the prior year to just over $1 trillion, the largest such drop since 2009 (Exhibit 1).

The impact of the fundraising environment was not felt equally among GPs. Continuing a trend that emerged in 2022, and consistent with prior downturns in fundraising, LPs favored larger vehicles and the scaled GPs that typically manage them. Smaller and newer managers struggled, and the number of sub–$1 billion vehicles and new firm launches each declined to its lowest level in more than a decade.

Despite the decline in fundraising, private markets assets under management (AUM) continued to grow, increasing 12 percent to $13.1 trillion as of June 30, 2023. 2023 fundraising was still the sixth-highest annual haul on record, pushing dry powder higher, while the slowdown in deal making limited distributions.

Investment performance across private market asset classes fell short of historical averages. Private equity (PE) got back in the black but generated the lowest annual performance in the past 15 years, excluding 2022. Closed-end real estate produced negative returns for the first time since 2009, as capitalization (cap) rates expanded across sectors and rent growth dissipated in formerly hot sectors, including multifamily and industrial. The performance of infrastructure funds was less than half of its long-term average and even further below the double-digit returns generated in 2021 and 2022. Private debt was the standout performer (if there was one), outperforming all other private asset classes and illustrating the asset class’s countercyclical appeal.

Private equity down but not out

Higher financing costs, lower multiples, and an uncertain macroeconomic environment created a challenging backdrop for private equity managers in 2023. Fundraising declined for the second year in a row, falling 15 percent to $649 billion, as LPs grappled with the denominator effect and a slowdown in distributions. Managers were on the fundraising trail longer to raise this capital: funds that closed in 2023 were open for a record-high average of 20.1 months, notably longer than 18.7 months in 2022 and 14.1 months in 2018. VC and growth equity strategies led the decline, dropping to their lowest level of cumulative capital raised since 2015. Fundraising in Asia fell for the fourth year of the last five, with the greatest decline in China.

Despite the difficult fundraising context, a subset of strategies and managers prevailed. Buyout managers collectively had their best fundraising year on record, raising more than $400 billion. Fundraising in Europe surged by more than 50 percent, resulting in the region’s biggest haul ever. The largest managers raised an outsized share of the total for a second consecutive year, making 2023 the most concentrated fundraising year of the last decade (Exhibit 2).

Despite the drop in aggregate fundraising, PE assets under management increased 8 percent to $8.2 trillion. Only a small part of this growth was performance driven: PE funds produced a net IRR of just 2.5 percent through September 30, 2023. Buyouts and growth equity generated positive returns, while VC lost money. PE performance, dating back to the beginning of 2022, remains negative, highlighting the difficulty of generating attractive investment returns in a higher interest rate and lower multiple environment. As PE managers devise value creation strategies to improve performance, their focus includes ensuring operating efficiency and profitability of their portfolio companies.

Deal activity volume and count fell sharply, by 21 percent and 24 percent, respectively, which continued the slower pace set in the second half of 2022. Sponsors largely opted to hold assets longer rather than lock in underwhelming returns. While higher financing costs and valuation mismatches weighed on overall deal activity, certain types of M&A gained share. Add-on deals, for example, accounted for a record 46 percent of total buyout deal volume last year.

Real estate recedes

For real estate, 2023 was a year of transition, characterized by a litany of new and familiar challenges. Pandemic-driven demand issues continued, while elevated financing costs, expanding cap rates, and valuation uncertainty weighed on commercial real estate deal volumes, fundraising, and investment performance.

Managers faced one of the toughest fundraising environments in many years. Global closed-end fundraising declined 34 percent to $125 billion. While fundraising challenges were widespread, they were not ubiquitous across strategies. Dollars continued to shift to large, multi-asset class platforms, with the top five managers accounting for 37 percent of aggregate closed-end real estate fundraising. In April, the largest real estate fund ever raised closed on a record $30 billion.

Capital shifted away from core and core-plus strategies as investors sought liquidity through redemptions in open-end vehicles and reduced gross contributions to the lowest level since 2009. Opportunistic strategies benefited from this shift, as investors turned their attention toward capital appreciation over income generation in a market where alternative sources of yield have grown more attractive.

In the United States, for instance, open-end funds, as represented by the National Council of Real Estate Investment Fiduciaries Fund Index—Open-End Equity (NFI-OE), recorded $13 billion in net outflows in 2023, reversing the trend of positive net inflows throughout the 2010s. The negative flows mainly reflected $9 billion in core outflows, with core-plus funds accounting for the remaining outflows, which reversed a 20-year run of net inflows.

As a result, the NAV in US open-end funds fell roughly 16 percent year over year. Meanwhile, global assets under management in closed-end funds reached a new peak of $1.7 trillion as of June 2023, growing 14 percent between June 2022 and June 2023.

Real estate underperformed historical averages in 2023, as previously high-performing multifamily and industrial sectors joined office in producing negative returns caused by slowing demand growth and cap rate expansion. Closed-end funds generated a pooled net IRR of −3.5 percent in the first nine months of 2023, losing money for the first time since the global financial crisis. The lone bright spot among major sectors was hospitality, which—thanks to a rush of postpandemic travel—returned 10.3 percent in 2023. 2 Based on NCREIFs NPI index. Hotels represent 1 percent of total properties in the index. As a whole, the average pooled lifetime net IRRs for closed-end real estate funds from 2011–20 vintages remained around historical levels (9.8 percent).

Global deal volume declined 47 percent in 2023 to reach a ten-year low of $650 billion, driven by widening bid–ask spreads amid valuation uncertainty and higher costs of financing (Exhibit 3). 3 CBRE, Real Capital Analytics Deal flow in the office sector remained depressed, partly as a result of continued uncertainty in the demand for space in a hybrid working world.

During a turbulent year for private markets, private debt was a relative bright spot, topping private markets asset classes in terms of fundraising growth, AUM growth, and performance.

Fundraising for private debt declined just 13 percent year over year, nearly ten percentage points less than the private markets overall. Despite the decline in fundraising, AUM surged 27 percent to $1.7 trillion. And private debt posted the highest investment returns of any private asset class through the first three quarters of 2023.

Private debt’s risk/return characteristics are well suited to the current environment. With interest rates at their highest in more than a decade, current yields in the asset class have grown more attractive on both an absolute and relative basis, particularly if higher rates sustain and put downward pressure on equity returns (Exhibit 4). The built-in security derived from debt’s privileged position in the capital structure, moreover, appeals to investors that are wary of market volatility and valuation uncertainty.

Direct lending continued to be the largest strategy in 2023, with fundraising for the mostly-senior-debt strategy accounting for almost half of the asset class’s total haul (despite declining from the previous year). Separately, mezzanine debt fundraising hit a new high, thanks to the closings of three of the largest funds ever raised in the strategy.

Over the longer term, growth in private debt has largely been driven by institutional investors rotating out of traditional fixed income in favor of private alternatives. Despite this growth in commitments, LPs remain underweight in this asset class relative to their targets. In fact, the allocation gap has only grown wider in recent years, a sharp contrast to other private asset classes, for which LPs’ current allocations exceed their targets on average. According to data from CEM Benchmarking, the private debt allocation gap now stands at 1.4 percent, which means that, in aggregate, investors must commit hundreds of billions in net new capital to the asset class just to reach current targets.

Private debt was not completely immune to the macroeconomic conditions last year, however. Fundraising declined for the second consecutive year and now sits 23 percent below 2021’s peak. Furthermore, though private lenders took share in 2023 from other capital sources, overall deal volumes also declined for the second year in a row. The drop was largely driven by a less active PE deal environment: private debt is predominantly used to finance PE-backed companies, though managers are increasingly diversifying their origination capabilities to include a broad new range of companies and asset types.

Infrastructure and natural resources take a detour

For infrastructure and natural resources fundraising, 2023 was an exceptionally challenging year. Aggregate capital raised declined 53 percent year over year to $82 billion, the lowest annual total since 2013. The size of the drop is particularly surprising in light of infrastructure’s recent momentum. The asset class had set fundraising records in four of the previous five years, and infrastructure is often considered an attractive investment in uncertain markets.

While there is little doubt that the broader fundraising headwinds discussed elsewhere in this report affected infrastructure and natural resources fundraising last year, dynamics specific to the asset class were at play as well. One issue was supply-side timing: nine of the ten largest infrastructure GPs did not close a flagship fund in 2023. Second was the migration of investor dollars away from core and core-plus investments, which have historically accounted for the bulk of infrastructure fundraising, in a higher rate environment.

The asset class had some notable bright spots last year. Fundraising for higher-returning opportunistic strategies more than doubled the prior year’s total (Exhibit 5). AUM grew 18 percent, reaching a new high of $1.5 trillion. Infrastructure funds returned a net IRR of 3.4 percent in 2023; this was below historical averages but still the second-best return among private asset classes. And as was the case in other asset classes, investors concentrated commitments in larger funds and managers in 2023, including in the largest infrastructure fund ever raised.

The outlook for the asset class, moreover, remains positive. Funds targeting a record amount of capital were in the market at year-end, providing a robust foundation for fundraising in 2024 and 2025. A recent spate of infrastructure GP acquisitions signal multi-asset managers’ long-term conviction in the asset class, despite short-term headwinds. Global megatrends like decarbonization and digitization, as well as revolutions in energy and mobility, have spurred new infrastructure investment opportunities around the world, particularly for value-oriented investors that are willing to take on more risk.

Private markets make measured progress in DEI

Diversity, equity, and inclusion (DEI) has become an important part of the fundraising, talent, and investing landscape for private market participants. Encouragingly, incremental progress has been made in recent years, including more diverse talent being brought to entry-level positions, investing roles, and investment committees. The scope of DEI metrics provided to institutional investors during fundraising has also increased in recent years: more than half of PE firms now provide data across investing teams, portfolio company boards, and portfolio company management (versus investment team data only). 4 “ The state of diversity in global private markets: 2023 ,” McKinsey, August 22, 2023.

In 2023, McKinsey surveyed 66 global private markets firms that collectively employ more than 60,000 people for the second annual State of diversity in global private markets report. 5 “ The state of diversity in global private markets: 2023 ,” McKinsey, August 22, 2023. The research offers insight into the representation of women and ethnic and racial minorities in private investing as of year-end 2022. In this chapter, we discuss where the numbers stand and how firms can bring a more diverse set of perspectives to the table.

The statistics indicate signs of modest advancement. Overall representation of women in private markets increased two percentage points to 35 percent, and ethnic and racial minorities increased one percentage point to 30 percent (Exhibit 6). Entry-level positions have nearly reached gender parity, with female representation at 48 percent. The share of women holding C-suite roles globally increased 3 percentage points, while the share of people from ethnic and racial minorities in investment committees increased 9 percentage points. There is growing evidence that external hiring is gradually helping close the diversity gap, especially at senior levels. For example, 33 percent of external hires at the managing director level were ethnic or racial minorities, higher than their existing representation level (19 percent).

Yet, the scope of the challenge remains substantial. Women and minorities continue to be underrepresented in senior positions and investing roles. They also experience uneven rates of progress due to lower promotion and higher attrition rates, particularly at smaller firms. Firms are also navigating an increasingly polarized workplace today, with additional scrutiny and a growing number of lawsuits against corporate diversity and inclusion programs, particularly in the US, which threatens to impact the industry’s pace of progress.

Fredrik Dahlqvist is a senior partner in McKinsey’s Stockholm office; Alastair Green  is a senior partner in the Washington, DC, office, where Paul Maia and Alexandra Nee  are partners; David Quigley  is a senior partner in the New York office, where Connor Mangan is an associate partner and Aditya Sanghvi  is a senior partner; Rahel Schneider is an associate partner in the Bay Area office; John Spivey is a partner in the Charlotte office; and Brian Vickery  is a partner in the Boston office.

The authors wish to thank Jonathan Christy, Louis Dufau, Vaibhav Gujral, Graham Healy-Day, Laura Johnson, Ryan Luby, Tripp Norton, Alastair Rami, Henri Torbey, and Alex Wolkomir for their contributions

The authors would also like to thank CEM Benchmarking and the StepStone Group for their partnership in this year's report.

This article was edited by Arshiya Khullar, an editor in the Gurugram office.

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research study 2015

Could your car make you sick? Study highlights potentially cancerous toxins in vehicles

Americans may be breathing in cancer-causing chemicals while driving, recent research suggests.

A study published in the journal Environmental Science & Technology has sparked discussions about the potentially harmful toxins that could be lurking in the cabins of vehicles.

"Certainly the indoor air quality can cause health symptoms ," Dr. Ken Speath, M.D., the division chief and medical director for occupational and environmental medicine at Northwell Health on Long Island, New York, told Fox News Digital.


It is important to be mindful of what you're breathing in at home, at the office, at school and even in cars, according to Speath, who was not involved in the study.

"There can be situations where levels of harmful chemicals get high enough to potentially cause health harms," he said.


"A car is a closed small space — so whatever is in the air is certainly going to be breathed in."

The peer-reviewed study looked at 101 owned vehicles in the U.S., model year 2015 or newer.

The researchers concluded that harmful flame-retardant chemicals — including those suspected of potentially causing cancer and some neurological issues — may be polluting the air inside vehicles.


"Flame retardant chemicals, which are intentionally added to vehicle interiors to meet flammability standards, are released into the cabin air from the materials to which they were applied," lead author Rebecca Hoehn, a scientist at Duke University, told Fox News Digital.

"People in these vehicles may be exposed to these chemicals."

Seat foam was the only material the researchers measured, Hoehn said, but other interior materials could also contain the chemicals.

"Considering the average driver spends about an hour in the car every day, this is a significant public health issue ," Hoehn warned.

"It’s particularly concerning for drivers with longer commutes, as well as child passengers, who breathe more air pound for pound than adults."

The chemicals detected in the car cabins included a flame retardant called tris (1-chloro-isopropyl) phosphate (TCIPP), which is currently being investigated as a potential carcinogen by the U.S. National Toxicology Program.

Other flame retardants — tris (1, 3-dichloro-2-propyl) phosphate (TDCIPP) and tris (2-chloroethyl) phosphate (TCEP) — were also detected. 

These are "two Californian Proposition 65 carcinogens linked to neurological and reproductive harms," according to a press release.

Higher concentrations of the flame retardants were found during warmer weather.

"We found that the same cars, sampled in both winter and summer, had higher concentrations of flame retardants in the cabin air during the warm summer months," Hoehn told Fox News Digital.

Flame retardants are added to vehicles to meet the National Highway Traffic Safety Administration Federal Motor Vehicle Safety Standard (FMVSS 302), which mandated their use in the 1970s, the release stated.

Flame retardants have been the "focus of concern for some time," Speath told Fox News Digital.

More information is needed to determine the health risks these chemicals pose in humans, he said.


"A number of these have been demonstrated in studies to have health harms in animals," he said.

"That doesn’t necessarily mean that would be true for humans, but it raises that possibility, so we need to study these chemicals more in relation to their effects on humans."

Emanuela Taioli, M.D., PhD, the director of the Institute for Translational Epidemiology at Icahn School of Medicine at Mount Sinai in New York City, was also not part of the study, but shared her reactions.

"This is a very relevant finding, since it may prompt changes in cars’ upholstery, as well as in other parts of the car where there is foam," she told Fox News Digital via email.

"We also want to know more about this finding and monitor whether it is replicated by other investigators."

Stephen Showalter, a home inspector and indoor environmental air consultant with Showalter Property Consultants in Maryland, said he typically interviews clients about their history of illness, then tests for potential sources of sickness in buildings, cars, RVs and boats. 

Mold is a common culprit when it comes to health issues triggered by one’s environment, he said in an interview with Fox News Digital.


Dr. Daniel Johns, a member of the International Society of Environmentally Acquired Illnesses and a chiropractor who practices in Annapolis, Maryland, echoed Showalter’s concerns about mold-related health issues.

Johns also cautioned that cars can be a daily source of mold exposure.

"Any water that leaks from a window, sunroof or convertible can get into the carpet and cause mold growth," he said during an interview with Fox News Digital. 

"Mold can start growing on a wet surface within 24 to 48 hours."

For families with small children, spilled sippy cups could play a role when it comes to mold in cars , Johns warned.

"The water seeps into the upholstery and doesn't get noticed or properly dried out, and the whole seat can become moldy," he said.

"Every time you sit on the seat, it releases a mold spore cloud into the car. Once that happens, you can't clean it away. The upholstery must be removed and replaced."

The impact of these potentially harmful pollutants can vary from one person to the next, experts told Fox News Digital.

People metabolize chemicals and toxins in different ways, according to Taioli. 

"Metabolism happens through enzymes that the body produces," he said. 

"Each of us has a different genetic profile that defines our metabolic capacity. As a consequence, the same amount of toxin may be metabolized better/faster by some, and worse/slower by others."

While further research on car-borne chemicals is needed, experts say people can take measures to limit exposure.

"People may be able to reduce their exposure by ventilating their cars," Hoehn advised. 

"For example, rolling down the windows to let out contaminated air , or pulling in fresh air with climate control systems, should reduce concentrations. 

Controlling your vehicle’s cabin temperature may also reduce exposure, she added. 

"Parking in a garage or shade instead of full sun may reduce the cabin temperature and limit the extent of flame retardant release," Hoehn said.

The researchers also called for action from regulatory agencies and vehicle manufacturers. 


"Ultimately, reducing the amount of flame retardants added to vehicles in the first place would provide the greatest reduction in exposure risk," Hoehn noted.

"If flammability standards for vehicles could be revised to meet fire safety guidelines without the use of added flame retardants, risk of flame retardant exposure from personal vehicles could be greatly reduced."

Having your car’s air quality and surfaces tested is one way to reduce the risk of exposure to allergens, toxins and chemicals, experts told Fox News Digital.

To prevent mold in a vehicle, Showalter recommends keeping your windows up when it rains or snows to prevent water from permeating the carpet or fabric.

He also cautioned about leaky air conditioners, which can foster mold growth in vehicles, and about leaving wet items in the car.

Lastly, before buying a used car, he said it is important to check the vehicle’s history to make sure it doesn’t have flood damage, which can lead to mold and other issues.

If you think you are experiencing illness due to chemical exposure in your car, home or office, it’s best to see a health care professional to discuss your symptoms.

Fox News Digital reached out to several major car companies for comment.

For more Health articles, visit .

Original article source: Could your car make you sick? Study highlights potentially cancerous toxins in vehicles

The researchers concluded that harmful flame-retardant chemicals — including those suspected of potentially causing cancer and some neurological issues — may be polluting the air inside vehicles. iStock


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