holistic development case study

Transforming education for holistic student development

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Learning from education system (re)building around the world, amanda datnow , amanda datnow professor and chancellor’s associates endowed chair in the department of education studies - university of california, san diego @amandadatnow vicki park , vicki park associate professor in educational leadership - san diego state university's college of education, director - ed.d. program in educational leadership - san diego state university donald j. peurach , and donald j. peurach professor of educational policy, leadership, and innovation - university of michigan @dpeurach james p. spillane james p. spillane spencer t. and ann w. olin professor in learning and organizational change - northwestern university @jamespspillane.

September 13, 2022

This foundational summary report has seven companion case studies— Iowa BIG, USA , the International Baccalaureate , Ireland , India , British Columbia , Chile , and Singapore . All case studies bear remarkable similarities in their efforts to (re)build education systems—each is working in policy contexts pressing for academic quality and equity, while also facing additional incentives to support holistic student development.

The period since the founding of the United Nations Educational, Scientific, and Cultural Organization (UNESCO) in 1945 has been marked by an accumulating global agenda for transforming education for students in fundamental ways—including the recognition that education is a human right and a public good, that access is not tantamount to learning, and that academic learning is but one dimension of holistic student development (Figure 1). Each of these calls for global educational transformation has been invoked in response to crises regarding educational equity, quality, and purpose. These crises have been underscored by the COVID-19 pandemic, which brought the needs of the whole child to the forefront.

The global education policy arena is a crowded space, with many interests and voices competing for priority in motivating and framing agendas for improvement and innovation. In search of common ground, this report centers on two critical questions that should be matters of universal concern.

The first question is rhetorical, aiming to engage both heart and mind in considering efforts to build and rebuild academically focused education systems into humanistic education systems that also support the social, emotional, moral, and civic development of students:

What would it mean—and what would it take—to build education systems that develop every child as would that child’s own parents?

The second question is empirical, aiming to draw a diverse global audience into productive, evidence-informed conversation about complex and contentious issues of collective interest, one central issue being potential synergies between the pursuits of academic and holistic student development:

Is there evidence that it is even possible to (re)build academically focused education systems to support holistic student development?

In anticipation of the United Nations Transforming Education Summit in September 2022, this report explores the work of building and rebuilding education systems to support holistic student development. It focuses specifically on the journeys of seven education systems—situated in high-, middle-, and low-middle-income countries with democratic traditions—as they make the whole child the center of their work. They include national initiatives in Singapore, Ireland, and Chile; provincial, territorial, and local initiatives in Canada, India, and the United States; and a cross-national initiative in the International Baccalaureate. All seven systems operate in policy contexts pressing for measurable gains in students’ academic learning, and none seeks to compromise academic rigor. Yet all seven aim to go further by supporting the intellectual, physical, emotional, social, cultural, and moral development of students.

These are initiatives in which multiple stakeholders, in different positions and from different perspectives, are recognizing and heeding aspirations and logics, making meaning and sense, assuming agency and taking action, experiencing and learning, and adapting and coordinating. Indeed, in the work of building and rebuilding education systems, these initiatives also function as learning systems that produce the knowledge and capabilities needed to do all of these things, and more.

The findings

While different in many ways, the seven systems bear remarkable similarities in their efforts to (re)build education systems to support holistic student development. Each is working in policy contexts pressing for academic quality and equity while also facing additional incentives to support holistic student development.

Moreover, in these seven systems, efforts to (re)build education systems for holistic student development bear remarkable similarity to system (re)building for academic development , though imbued with new concern for moral legitimacy and responsibility alongside established concern for pragmatic legitimacy and technical effectiveness .

In these seven systems, education system building is multifaceted and involves 10 key lessons across three interrelated domains or forms of common work. Indeed, among the primary contributions of this report is a practical framework to guide diverse stakeholders in working together to transform education systems.

These seven systems work to manage their environments to build support for holistic student development among diverse stakeholders; address different institutional, cultural, and technical demands; and build partnerships for supporting reform. In so doing, they offer these key lessons for managing environments:

• Engage diverse stakeholders: Engage and coordinate among diverse stakeholders and leverage partnerships.
• Construct coherence: Create opportunities for diverse stakeholders to deliberate on different cultural norms, cognitive frameworks, and regulatory environments that inform schooling.
• Manage equity-and-rigor tension: Engage the perceived tensions between equity and rigor in deliberation about holistic development.

These systems also work to build or rebuild an educational infrastructure to enable approaches to instruction that can support holistic student development in schools. The following lessons are key for (re)building educational infrastructures for holistic student development:

4. Build social infrastructure: Build a social infrastructure that engages stakeholders about holistic student development and the entailments for instruction.

5. Develop instructional designs: Develop instructional designs that recognize and support instruction as a coproduction between students and teachers.

6. Design educational infrastructure: Design educational infrastructure to support new visions for instruction, and mobilize this infrastructure to support instructional improvement.

Finally, these systems work to integrate educational infrastructure with everyday practice in schools and classrooms. Their work highlights the following lessons:

• Balance common conventions with local discretion: Balance common systemwide conventions with the need for local discretion to promote and encourage reform.
• Distribute leadership: Develop and distribute leadership for instruction by, among other things, cultivating educator and student agency.
• Support infrastructure use: Support the use of educational infrastructure in school and classroom practice through professional learning.
• Monitor practice and performance: Conduct consistent, ongoing monitoring of practice and performance for continuous improvement and professional learning.

The domains of system-building work are interrelated and overlapping, involving continual attention to constructing coherence as institutional environments are in constant flux. Further, the work of different domains does not happen in any particular order: although managing environments is important early in a reform journey to build support for holistic student development, it remains just as crucial later in the journey.

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These three domains of education system building played out consistently in initiatives that otherwise varied in terms of the level of operation (cross-national, national, provincial, territorial, or local); their unique historical, societal, and policy contexts; and their different approaches to supporting holistic student development. Moreover, in no case did these seven systems put digital or information technologies in the first position as primary drivers of educational transformation, as efficient, quick alternatives to the difficult, long-term work of institution building. Rather, each placed instruction —the collaborative work of teachers and students—in the first position, and each engaged deeply in the development of infrastructures and organizations to support holistic student development at a large scale.

Considerations for collective conversation and action

Our findings provide high-level perspective on complex, large-scale systems transformation. Further research is needed to examine how the work of system (re)building is playing out throughout these seven systems, how those doing the work are managing successes and challenges, and how the work is bearing on the daily lives of students and teachers. Moreover, further research is needed across countries at varying levels of development—especially in low-income countries striving to increase access to schooling and to establish institutions supporting foundational literacy and numeracy, all while managing the dire consequences of the COVID-19 pandemic and climate change.

Even so, these portraits of system (re)building toward holistic student development across the seven case studies present educators, policymakers, and researchers with key initial lessons for undertaking this work. The systems take diverse on-ramps and multiple pathways toward holistic student development. Their points of departure and connection suggest that critical leverage points enable forward movement as they take moral, technical, and institutional cues from the larger environment.

A large part of managing the environment will be for systems to explicitly connect technical values for educational quality and equity with moral values for holistic student development, deliberating on and negotiating dilemmas with diverse stakeholders. Nurturing teaching and learning for holistic student development will take not only ambitious vision and goals but also education system building and rebuilding efforts to support everyday practice. If the goals are ambitious, so too must be the infrastructures for supporting their enactment. Infrastructure use in everyday school and classroom practice must be deliberately cultivated and supported.

With these lessons in mind, we encourage diverse stakeholders in systems to engage in collaborative conversations and action centered on the three domains of practical framing for systems transformation that have emerged from our exploration:

• Manage environments and relationships.
• Build educational infrastructure.
• Integrate educational infrastructure in practice.

Supporting diverse stakeholders in doing this work, in turn, will depend on researchers’ continuing exploration of diverse system transformation efforts—especially in systems being pressed to support holistic student development while also striving to increase access and support foundational learning. It will involve developing new types of collegial, global learning and networking among system leaders at all levels. And it will require developing creative new ways to draw local education professionals, parents, community members, and students into cross-national learning opportunities that create new possibilities, build their knowledge and capabilities, and fuel their agency. For—as captured by the journeys of the seven systems explored here—much of the burden of transforming education systems rests on the shoulders of local education professionals, parents, community members, and students.

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Names of the primary authors are listed in alphabetical order. The primary authors contributed equally to this report. Juan Bravo, Whitney Hegseth, Jeanne Ho, Devi Khanna, Dennis Kwek, Angela Lyle, Amelia Peterson, Thomas K. Walsh, Jose Weinstein, and Hwei Ming Wong all contributed sections to this report.

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Emily Markovich Morris, Laura Nóra, Richaa Hoysala, Max Lieblich, Sophie Partington, Rebecca Winthrop

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Understanding Holistic Development in Early Childhood: A Comprehensive Guide

• December 3, 2023

Understanding Holistic Development: A Comprehensive Overview

When speaking of holistic development, imagine it as a multi-layered approach that nurtures and helps early childhood learners thrive in every aspect of their lives. This approach doesn’t solely focus on one area but rather places emphasis on the overall growth of the child. This comprehensive approach views the child as a whole person and guides their development in all areas, including physical, mental, emotional, social, and spiritual realms.

A great way to visualise holistic development , is by picturing a blossom slowly unfurling each petal. In the same way, a child gradually unfolds their full potential in every aspect of their existence – their body grows stronger, their mind becomes more resilient, their emotions more stable, and their social connections more rich and meaningful. It’s not just about teaching the ABC’s and 123’s but more about helping the child discover and comprehend the world in their own unique way.

In essence, the concept of holistic development advocates for the interconnectivity of these multiple facets and acknowledges that a child’s development is not a compartmentalised process, but an interconnected web of growth. With this holistic framework, every aspect of the child’s life is considered important and interconnected in ways we may not immediately realise.

This might sound like a big responsibility to bear, but the importance of this holistic approach to early childhood development is truly remarkable. It forms the very foundations upon which the layers of a child’s life will be built.

All the developmental domains of a child – be it cognitive, physical, emotional or social, are interlinked and influence one another. Hence, a holistic developmental approach ensures the nurturing of every domain, providing the child with tools and experiences that help them develop in sync with their peers, and at their own pace.

So how do we actually implement this holistic approach in early childhood? It boils down to truly engaging with the child, observing their interests, responding to their needs, and setting up an environment conducive to their growth. It’s about recognising the individual character of each child, and fostering healthy relationships amongst peers, families, and the community.

With a guided, well-structured, and holistic approach, early childhood development has the power to mould, shape, and direct the life of a child in all its magnificence. It’s not about ‘filling a bucket’ with knowledge, but ‘igniting a fire’ for lifelong learning.

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The Importance of Holistic Development in Early Childhood

“Children are not things to be molded, but are people to be unfolded.” ~ Jess Lair

The essence of this quote outlines the very core of holistic development in early childhood. Emphasising the individual strengths and interests of a child, this approach nurtures them into well-rounded adults infused with a deep sense of self-awareness. So, why is holistic development in education, especially in early childhood education and care, so important? Holistic development is vital to children’s overall development because

it encompasses the child’s total development, taking into account their cognitive, physical, emotional, social and language growth. Let’s delve deeper into why this approach can make a pivotal difference in children’s lives.

The Holistic Approach: More than Just Academics

Traditional education models focus primarily on cognitive development, promoting knowledge retention and academic skills. A holistic approach, conversely, views the child as a whole entity, ensuring that their emotional, social and physical development isn’t overshadowed by academics.

This form of learning design recognises that children develop at their own pace in different areas. By nurturing individual growth areas rather than prescribing a one-size-fits-all curriculum, it allows children to explore and learn in their distinct personal manner.

Nurturing a Healthy Well-being

With a broad spectrum coverage of a child’s growth sectors, holistic development fosters physical health, emotional stability, and social skills, alongside cognitive abilities. Maintaining a balance among these domains contributes to children’s overall well-being and self-esteem, an invaluable cornerstone for adult life.

Emphasising Values and Ethics

Another noteworthy virtue of the holistic scheme is the importance it places on values and ethics. Children learn beyond educational boundaries, becoming proficient in respecting others, showing empathy, and understanding the difference between right and wrong; real-life skills rarely encapsulated in conventional methods of teaching.

Creating Stronger Connection with Environment

Holistic development encourages children to be aware of their environment and to build a relationship with the world around them. This understanding and appreciation of nature and the wider world help to develop responsible attitudes and shape well-rounded adults.

This connection goes far beyond mere understanding. It’s about fostering in children an appreciation of the world’s complexities and beauties. Holistic development helps children comprehend that they are an integral part in the grand scheme of things, hence, cultivating a sense of responsibility towards preserving our planet.

From an early age, they learn to respect the interconnectedness of all life forms, recognising that every action has consequences – some good, others not so. For instance, they start understanding that littering can harm the environment, which in turn can affect plants, animals, and ultimately, us. This consciousness helps them grow into eco-friendly citizens who make decisions thoughtfully.

Another aspect is experiencing the outdoors. Interaction with their natural surroundings is an excellent way for children to learn practical life skills. They get to see how different elements in nature interact with each other: the way the ants move food, how the leaves change colours, the way the stream shapes a path and so much more. These encounters not only stir their curiosity but also boost their observational skills and imagination.

Moreover, developing a solid connection with nature contributes to the child’s physical well-being. Outdoor activities provide opportunities for running, jumping, climbing, or just being active in general. We all know that an active body has positive impacts on an alert mind. And the best part – children are simply having fun while learning and growing.

Then there’s the emotional aspect. Ever noticed how spending time outdoors seem to brighten a child’s mood? The tranquillity of nature can help children reduce stress and anxiety levels. It offers them a serene place to vent out their feelings or thoughts, boosting their mental health.

In truth, a focus on forming a robust bond with the environment, as a part of holistic development, is probably one of the greatest gifts you can give a child. The lessons they learn from nature are life-long and precious, shaping them into balanced and responsible adults.

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Examples of Holistic Development in the early childhood learning environment

Witnessing how holistic development unfolds in the early learning environment can be a profound experience. It’s not merely about ticking off developmental milestones; instead, we’re looking at how numerous aspects integrate to promote a child’s fully rounded development. Let’s now look at some tangible examples of holistic development in action in early childhood settings.

Storytelling Time

Storytelling is much more than just a pleasant way to pass the time. It may seem simple, but it actually encourages several domains of development. While the children are enthralled by the plot and characters, they’re also developing their listening skills, broadening their vocabulary, and stimulating their imagination. More so, the discussion that follows can help to enhance their cognitive skills as they try to remember and understand the story. Therefore, such an activity cultivates not only their literacy skills but also their emotional, social, and cognitive development.

Outdoor Play

Outdoor play offers a wealth of opportunities for holistic development. As children run, climb, and explore, they’re improving their physical abilities and coordination. Watching a tiny seedling grow into a full-blown plant boosts their understanding of the natural world and cultivates their environmental awareness. Furthermore, learning to navigate their play with others, whether it’s taking turns on a slide or organizing a game of tag, significantly benefits their social and emotional growth.

Art and Craft Sessions

Art and craft are perfect illustrations of holistic development in practice. While children are engaged in creating their masterpieces, they are simultaneously developing fine motor skills, expressing their creativity and emotions, and learning about different materials and concepts. These sessions also offer plenty of opportunities for cognitive development, such as understanding shapes and patterns, recognising colours, and solving problems, like figuring out how to make things stick together.

Group Activities and Games

Group activities and games also support the holistic development approach. Engaging in a group puzzle, for instance, allows children to develop problem-solving abilities and cognitive skills. Additionally, it teaches them about teamwork, sharing, and the importance of communication, thereby facilitating their emotional and social growth.

These examples illustrate the versatility and practicality of a holistic approach to early childhood learning environments. They showcase how everyday activities, woven into the children’s routines, can significantly contribute to multiple developmental domains — setting the stage for a well-rounded growth and foundation.

Promoting Holistic Development Through Integrated Learning Approaches

You’re probably wondering, “how can we promote holistic development effectively in early childhood?” Well, one of the most effective ways is through integrated learning approaches. So, what’s this all about, then?

Integrated learning approaches, also known as interdisciplinary teaching, involves using different areas of learning (from arts to sciences to literacy and numeracy), and blending them together to create a comprehensive, well-rounded learning experience. The aim here is not just to teach ABCs and 123s, but to intertwine this with physical, emotional, social, and environmental learning as well.

What might an integrated learning approach look like?

An integrated learning approach strives to surpass educational silos by connecting numerous aspects. This fosters a space in which children can grasp and interact with their educational environment in a more rounded manner. It’s about the unity of various aspects of learning, including cognitive, physical, social, and emotional domains, leading to holistic development in children.

Characteristics of an Integrated Learning Approach

Evidently, integrated learning isn’t about studying different subjects at the same time. It’s a consolidated method of instructing young children which:

Encourages broader understanding: Integrated learning merges various aspects of knowledge. This fusion instils a deeper understanding of how things are interconnected. For instance, an art project about butterflies can be expanded to include aspects of science, counting, and storytelling.

Enhances critical thinking: Since integrated learning merges different subjects, children are encouraged to think analytically and solve problems creatively. They learn to approach a challenge from different perspectives – an essential skill in today’s world.

Ignites curiosity and creativity: Integrated learning is often project-based, enabling children to explore their interests. This personalised learning style boosts curiosity, creativity, and the enthusiasm to learn.

Improves life skills: An integrated learning approach isn’t just about academic skills. It also promotes soft skills like teamwork, leadership, and communication, making children more adaptable and confident.

All these benefits contribute to the holistic development of the child, ensuring they don’t just accrue knowledge, but develop the competencies needed to thrive in an ever-evolving world.

Embracing Integrated Learning and Holistic Development

Broadly, integrated learning emphasises hands-on experiences, collaboration, and real-life situational learning. It ditches the ‘one size fits all’ mentality, embracing the individuality of each child. While the journey towards integrated learning and holistic development may seem challenging, the pay-off is invaluable. It helps nurture well-rounded children who are not only academically equipped but also emotionally, ethically, and socially capable.

Admittedly though, implementing an integrated, holistic approach requires an intentional effort. As stakeholders in children’s development, we have a significant role, and it begins with recognising the immense potential of integrated learning for the wholesome growth of our children. This all sounds great and can offer amazing benefits but we recognise that there are challenges, which also come with opportunities.

Challenges and Opportunities in Promoting Holistic Development

Implementing a holistic development approach in early childhood education certainly comes with its unique set of challenges and opportunities. On the one hand, there are factors such as traditional education models, inadequate training for educators, and lack of awareness among parents that may pose difficulties. On the other hand, the potential benefits that holistic development presents make these hurdles worth overcoming.

Challenges:

Despite the undeniable benefits of adopting a holistic approach to early childhood development, there are some challenges that educators, parents, and institutions may encounter.

Understanding Individual Needs: One of the key tenets of holistic development is respecting and fostering individuality. This requires a deep understanding of each child’s unique needs, strengths, and weaknesses. Gaining this insight can be difficult, particularly in larger educational settings where the teacher-to-student ratio is high.

Resistance to Change: Some educational systems and frameworks are still rigidly structured around traditional methods that focus primarily on academic achievement. Implementing holistic learning approaches requires shifting mindsets and overcoming resistance to this new, broader view of a child’s development.

Resource Allocation: Holistic development often requires resources beyond basic academics, including various types of equipment and materials for physical development, dedicated spaces for creative and sensory exploration and time for outdoor activity and interaction. Providing this broad spectrum of resources can be a challenge, especially in under-resourced schools or early learning centres.

Despite these challenges, there are significant opportunities available when adopting a holistic approach to early childhood development.

Opportunities

Developing well-rounded individuals: Children who are taught using holistic methods can blossom into well-rounded individuals who are not only academically adept but also socially and emotionally mature, physically healthy and environmentally aware.

Promoting lifelong learning: Implementing holistic educational practices from an early age can foster a lifelong love of learning, paving the way for continual personal and professional growth.

Creating a more inclusive learning environment: Holistic approaches typically involve a variety of teaching techniques that cater to different learning styles, making education more inclusive and engaging for all children.

Nurturing resilience: Through a focus on emotional and mental well-being, holistic education can build resilience in children, enabling them to better face challenges and adapt to change throughout their lives.

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The Holistic Development of a Child During the Early Years

By: Author Tanja McIlroy

Posted on Last updated: 5 June 2024

Categories Child Development

Wondering what holistic development means and what you as a parent can do to support your child’s growth?

What is Holistic Development in Early Childhood?

Holistic development means developing the whole child – socially, emotionally, physically, intellectually and spiritually.

A child’s home and environment also impact their overall development.

Why is Holistic Development Important?

In order for children to succeed and reach their full potential, all aspects of their development must be given attention.

While it may be easy to default to focusing on a child’s intellectual abilities during the early years, it is equally important for a child to develop skills such as:

• emotional intelligence
• social ability
• fine and gross motor coordination
• responsibility
• and many other skills!

Holistic development is important and is the key to learning in the early years of childhood.

As a parent or teacher, you can start your children on an early learning path to success. 

What are the Five Aspects of Holistic Development?

The following are the five key areas of holistic development :

Physical development – all about growing and developing motor skills.

Social skills – how children interact with others and communicate in their world.

Emotional understanding – learning to express emotions in a healthy way.

Intellectual development – cognitive, creativity and acquiring skills for learning.

• Spiritual development – building morals, values and caring for the world.

The early years are a vital time to lay the foundation for a healthy and happy life.  

The following tips will help you create a holistic approach to educating your children.

How to Support the Holistic Development of A Child

Encouraging holistic development in the early years is the responsibility of parents and educators. Taking this approach to your children’s education is not difficult and just requires a little thought.

Starting in the early years, the holistic approach to education is about a balance between the home, the environment and the developing child. 

Physical Development

• Understand the physical milestones children will experience. Have a thorough knowledge of the importance of motor skills and how they are developed. 
• Engage in gross motor activities or big movements and explore ways to climb, jump, swing and run.
• Take time to practise fine motor skills , or small actions, like holding a crayon, moulding playdough , digging in the sand or playing with blocks.

Social Skills

• Build social skills by connecting your child with other children and adults. 
• Practise actions like sharing, taking turns, enjoying a meal together or going on an outing.

Emotional Development

• Create awareness of others through books and stories . 
• Learn empathy at home and in the community.
• Share experiences and discuss the outcomes of events.
• Be aware of children’s emotional needs .

Intellectual Development

• Developing children’s cognitive skills comes with exposure to play. Play and learn is a very real concept to focus on in the early years. Children are constantly learning at home during free play.
• Active participation is by far the best form of education.
• Reading to children adds to the dynamic of cognitive development creating an interest in many different topics and developing vocabulary .

Spiritual Development

• Talk about family morals and values, beliefs and traditions.
• Develop a sense of self and responsibility towards others 
• Teach children to take care of the environment outside of the home.
• Set up your child’s bedroom or play area intentionally and encourage your child to respect and enjoy his belongings.
• Participate in the community and branch out whenever possible.

A n Example of a Holistic Activity 

Try to plan activities from a holistic viewp oint. This may seem challenging at first, but in actual fact, many activities are naturally inclusive of these principles.  

Look at the family picnic as an example of a holistic activity . This outing is not just about going on a picnic.

A family picnic is full of opportunities to include social and emotional development while organising and helping with the picnic. 

Games at the picnic add to intellectual and gross motor development and a day of interacting with family is a great social-emotional activity .

Added to the picnic experience is time to connect to the outdoors, explore nature and show respect for the environment by not littering. 

In this way the picnic ticks all the boxes for organizing a holistic educational experience.

Activities That Do Not Foster Holistic Learning

Activities that are restrictive or sedentary are not going to allow for holistic development. 

Broadly speaking, children need to have the freedom to be actively involved in their surroundings. They need to develop their fine and gross motor skills.

Activities should help a child to develop cognitively as well as socially and emotionally.

Activities that are not interactive or hands-on tend to veer away from the holistic approach to development in the early years.

Creating an Environment for Holistic Development

The parts that make up holistic education do not take place individually. When creating a realistic holistic environment, it is very important that many of the individual aspects are included in activities. 

Being aware of the five components of holistic development makes it easier for parents to implement the all-around benefits of this concept.

Play and Learn

The idea of playing and learning may seem contradictory. However, this is the way children learn for the first few years. 

The value of play in creating a holistic environment is huge. It is through play that children learn so many basic skills. 

Play is an aspect of learning that children enjoy. It is non-threatening and the environment surrounding play is engaging.

Giving children the right play materials and the right environment to play in embraces the principles of holistic development. 

Parents need to allow their little ones time to explore and become familiar with their surroundings. Creating a safe play environment with the right educational toys and resources is important too. 

The Safe Play Environment

Knowing you have a safe environment for your child to play in is a very important aspect of holistic education. 

Parents need to have peace of mind when it comes to the activities their children are engaged in. Children need a safe area where they can explore freely and actively. 

Here are some points to consider when creating a safe area for play activities.

• Make sure the flooring is level, with some protective covering. It could be rubber matting or carpeting but something to protect your child from the inevitable hard falls.
• Keep outdoor equipment age-appropriate. Remember to check if it is safe to use, free of unwanted nails or splinters and in good order.
• Arrange equipment so there is enough space to run around between items.
• Watch out for sharp edges or pointed dangerous toys. Avoid these kinds of toys, particularly with your very young toddler.
• If your play area is outside it should be a fenced area for safety and security. In particular, look out for any kind of water hazard.
• Keep all dangerous substances away from a free play area. You need to know your child is safe so free exploration can take place.
• Buy your toys wisely. Check on the size, not too small with spare parts that can be a choking hazard or too large and unmanageable. It is wise to check what materials they are made with for parts that can fall off or are peeling and breaking.
• Organize the toys and have them in a safe, accessible spot. A toy basket is a good idea so the toys can be put away easily at ‘ tidy-up time .’ 
• Don’t have too many toys out at once. Rather choose a few at a time and change the contents of the toy basket every so often.
• Show your child how to play with the toys to teach respect for the things they play with. This is especially true for books. Show your child how to turn pages and not tear the paper of lovely storybooks.

Encouraging Creativity

Thinking creatively is a skill that will help your child to get ahead in all sorts of situations. The creative thinker solves problems , develops new ideas and is innovative. Creativity is not limited to artistic endeavour. 

It is important, in the holistic development of the young child, to find ways to try and experiment with new and different materials. Have interesting ‘hands-on’ types of materials available.

Put together a creativity box with paper, pencils and crayons, stickers, duct tape, glue and some recycled items like toilet rolls and used cardboard. The creativity box can be on standby for making things when your child is ready for some creativity.

Guiding some ideas and being supportive is another essential part of encouraging creativity . These five little ideas will keep you focused on creativity with positive reinforcement.

• Make sure there is time to be free to create.
• Always add words of encouragement, never criticism.
• Ask questions about the creation and how it came to be made.
• Share ideas – ‘brainstorm’ solutions.
• Be creative yourself.

Remember creative development is not only a matter of being artistic. Creative ideas are part of mathematical thinking, science , and technology– in fact, anything that has new ideas. 

Think out of the box yourself and provide dress-up clothes for drama days, or go on a picnic or treasure hunt, make homemade musical instruments or decorate biscuits in the kitchen. 

The area of creativity is limitless and most enjoyable.

The Importance of Developing Language Skills

Developing language skills through holistic play is a vital part of development in the early years of learning. Your child is like a little sponge just waiting to absorb every word you say.

Language skills help children with self-expression, communication and socializing. A child who can communicate is confident and ready to learn new things and explore new areas.

Foster language development by verbalizing your actions, playing games, going on walks and pointing out the scenery, sharing picture books and stories and singing rhymes and songs together.

Everything you do with your early learner becomes a language opportunity. Point to objects, repeat words and phrases and allow your little learner to imitate you all the time. Enriching language should come naturally.

Are you stuck for ideas?

Never fear, you may be surprised at how easy it is to find something that ticks the holistic box to do.

Keep the five elements in mind and go ahead and organize family outings, fun at home in the kitchen, friends over for playdates , and creative waste invention days. 

Ask yourself if your plan helps with:

Spiritual development – morals, values and caring for the world.

This may seem a bit daunting, but simply think ‘It’s all about me!’

Your child learns from within, to deal with the outside world and grow into a sociable, confident, caring human being appreciating the world around them.

 In his book, ‘Oh the places you’ll go.’ Dr Seuss wrote:

“Step with great care and great tact, Remember life’s a great balancing act! And will you succeed? Yes! You will indeed (98 and ¾ percent guaranteed!) “ Dr Seuss

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Wednesday 3rd of April 2024

Thank you so much for the information. I have learnt alot

Tanja McIlroy

You're very welcome!

Thursday 28th of March 2024

this information is brilliant and super helpful.

Friday 29th of March 2024

Thanks for reading!

Tuesday 20th of February 2024

The information is very helpful and educating.I think every parent and educator must know when preparing or engaging in a activity what is he /she developing. So that we develop our children holistically. Some only concentrate on the cognitive gains and neglecting the others tnx

Wednesday 21st of February 2024

Thanks for your comment, Prudence!

KEVIN KINGSWELL

Tuesday 25th of July 2023

GREAT STUFF FOR THIS GRANDPA SUPPLY TEACHER, HERE IN QUEENSLAND, AUSTRALIA---THANK YOU!

Tanja Mcilroy

You're welcome, Kevin! I'm glad you enjoyed this.

Wednesday 14th of June 2023

Waoh!A great piece.I'm enlightened and empowered as a parent

Thursday 15th of June 2023

Thanks for reading, Julius!

Birth To 5 Matters

Guidance by the sector, for the sector

Holistic development and learning

“Every child is a unique child who is constantly learning.” says the EYFS principle, emphasising that each everyday experience is an occasion for holistic development and learning, as seen in this example of a toddler enjoying his snack.

Enabling environments foster holistic approaches to early development and learning, recognising that different aspects are constantly connected in a child’s experiences.  In the EYFS, areas are described separately in order to break down the complexity of development and learning, but it is important to keep the whole child in mind.  As a child encounters objects, events and other people, all spheres of development and learning are in action at the same time, as in the example below of two children who are experimenting with water and a construction using tubing and plastic sheets.

Previous page: Specific Areas | Next page: Using Birth to 5 Matters to support development and learning

In This Issue

Systematic Reviews

Comparison studies, case studies, program evaluation, other descriptive studies, nature-based learning in the early years.

Nature-based learning (NBL) is an educational approach that engages children with the natural environment and natural elements as a pathway for learning. Although NBL often occurs in natural settings, it can also occur in built environments where natural elements are added to promote learning and skill development. NBL includes learning about the natural world, but extends to engagement in any subject, skill, or area and is often implemented in interdisciplinary ways.

The related studies highlighted in this Digest focus on NBL during the early years and include a number of different research designs. This Digest is organized a little differently than most — by research design rather than by type of benefit or outcome. Understanding what various research designs can and can’t tell us, and considering data from more than one research design, can lead to a broader and more accurate understanding of the topic of interest.

A systematic literature review uses a systematic process to gather and critically analyze prior research studies relating to a specific research question. Systematic reviews make an important contribution to a field of study by providing a summary and assessment of different studies on a single topic. Research questions framing the following systematic reviews focused on links between NBL and positive outcomes for children during the early years. Results provide evidence of NBL supporting both early childhood development and environmental sustainability. Further research is needed to strengthen the evidence linking NBL and child development outcomes and to identify the dose and quality of nature needed to promote desired outcomes. 

Early childhood environmental education delivers multiple benefits for young learners

This systematic review of the early childhood environmental education (ECEE) literature found strong evidence of positive outcomes associated with ECEE programs. The most frequently reported outcomes related to environmental literacy, cognitive development, and social-emotional development. Other positive outcomes related to physical development and language and literacy development. Of the 66 studies included in this review, 32 focused on programs in North America (25 in U.S.; seven in Canada), 16 in Europe, 12 in Australia and New Zealand, and six in Asia. Ardoin & Bowers, 2020. Early childhood environmental education: A systematic review of the research literature. 

Access Study

The contribution of nature play to child development and sustainability is extensive and rich

The 32 studies included in this systematic review of the literature reported a total of 98 positive child development outcomes of nature play.  When these outcomes were mapped to early childhood education for sustainability outcomes, nature play was determined to be a valid contributor to sustainability. Almost half of the studies (15) were from the United States, six from Canada, and less than five from five other countries (Turkey, United Kingdom, Australia, Greece, and China). Ernst et al. 2021. Contributions to sustainability through young children’s nature play: A systematic review.

Nature-based early childhood education may support children’s growth in multiple areas of social, emotional, and cognitive development

While the certainty of evidence was low, this review found consistent positive links between nature-based early childhood education and growth in self-regulation, nature relatedness, and play interaction. Possible pathways to the positive outcomes include more diversified play, increased creativity and imagination, and prosocial interactions with peers and teachers. A total of 36 studies representing 12 different countries were included in this review, with the U.S. being the most highly represented country. Johnstone et al. 2022. Nature-based early childhood education and children’s social, emotional and cognitive development: A mixed-methods systematic review.

Preschool teachers in Turkey believe that outdoor activities contribute to child development, yet generally hesitate taking children outside

Twenty qualitative studies were included in a systematic review and meta-synthesis of data focusing on outdoor activities and environments in early childhood education in Turkey. Findings indicate that both teachers and children appreciate the potential of the outdoors as a rich play and learning environment, yet teachers’ concerns about risks of injury and other issues limit their use of the outdoors. Ozturk & Ozer, 2021. Outdoor play activities and outdoor environment of early childhood education in Turkey: A qualitative meta-synthesis.

Comparison studies document observed differences and similarities between two or more subjects or groups. Comparison studies are not experimental, in that they do not subject one of the groups to a treatment, but rather observe a group that either by choice or circumstance has been subject to a treatment. The observations thus occur in more natural (versus contrived or experimental) settings. Observations in the following comparison studies focused on young children engaged in NBL and children not involved in NBL. Results in some areas of development — including play behaviors, scientific attitudes, and executive functioning — favored children engaged in nature-based learning.

Children attending nature preschools showed more enhanced peer play behaviors than children attending more traditional preschools

Four nature preschools and two non-nature preschools in the U.S. participated in a study investigating two components of school readiness: peer play interactions and learning behaviors. Nature preschool students showed positive gains over the year in peer play behaviors and on all dimensions of learning behaviors; non-nature preschool students showed growth only in one aspect of play behavior. Differences between the two groups in terms of play behaviors favored the nature preschool group. Burgess & Ernst, 2020. Beyond traditional school readiness: How nature preschools help prepare children for academic success.

Garden activities can promote preschool children’s scientific and nature-friendly attitudes

Preschoolers participating in a garden project in South Korea made significantly higher gains in scientific attitudes and nature-friendly attitudes than preschoolers not participating in the project. While in the garden, the participating group experienced self-directed and cooperative learning, engaged in the scientific process, demonstrated nature-friendly attitudes, and showed an increase in their sense of wonder. Kim et al. 2020. The power of garden-based curriculum to promote scientific and nature-friendly attitudes in children through a cotton project.

Nature preschools can be effective in promoting executive function skills, a critical component of school readiness

A study involving six high-quality preschools in the U.S. (four nature preschools and two non-nature preschools) found that nature and non-nature preschoolers grew in executive function skills beyond what would be expected from typically developing children. This research adds support to the growing literature on the benefits of nature preschools, and demonstrates that nature preschools can support aspects of school readiness as effectively as do traditional preschools. Zamzow & Ernst, 2020. Supporting school readiness naturally: Exploring executive function growth in nature preschools.  

Case study research involves observing, describing, and documenting details about a person, site, or program. Case studies are particularly helpful in answering questions about how or why things occur or work in real life contexts. The three case studies presented below demonstrate how positive growth in children’s play and learning behaviors relate to children’s engagement with affordances and/or the use of technology in natural environments. 

Preschool children find ways to use the affordances of an outdoor setting through different seasons and various weather conditions

This case study examined ways in which preschoolers in England used the affordances of an outdoor playspace in different seasons. The preschoolers — when given the choice — regularly played outside in all kinds of weather. Modifying and adapting resources and activities according to different weather conditions allowed the children to discover a new range of play and learning possibilities. Elliott, 2021. Whether the weather be cold, or whether the weather be hot … children’s play preferences outdoors across a year in one private pre-school setting.

Loose parts in an outdoor environment can enhance children’s play and promote their holistic development

For this case study, researchers in Wales observed and photographed preschool children over a two-year period as they used resources in an outdoor environment. Findings indicated that the children chose to engage with loose parts as a significant part of their play and that the diverse ways in which they used the loose parts promoted their cognitive, creative, and physical development. Boulton & Thomas, 2022. How does play in the outdoors afford opportunities for schema development in young children?

The use of iPads added to young children’s outdoor play, while also promoting their nature connectedness

Data collected over a 3-year period indicated that Canadian teachers — while initially concerned about young children’s use of electronic devices outdoors — came to appreciate the ways in which the technology inspired more physical activity, creativity, and nature connectedness. McGlynn-Stewart, Maguire & Mogyorodi, 2020. Taking it outside: Engaging in active, creative, outdoor play with digital technology.

A program evaluation involves the systematic collection of information about the activities, characteristics, and outcomes of programs. Most program evaluations are conducted to determine if — or to what extent — the program is achieving its stated purpose, and to identify ways to improve its effectiveness. The following program evaluation adds support to the idea that farm-based and nature-based preschool programs can be effective in supporting positive child development outcomes.

Farm-based preschools have the potential to promote positive change across multiple levels for children and families

Parent interviews and surveys were used to conduct an evaluation of Farm Sprouts, a farm-based and nature-based preschool program in the U.S. Parents felt that the program supported their young children’s development, positively impacted the family environment, and promoted increased connection to nature on a community level. Reported child development outcomes included improved skill and interest in engaging in conversations, and enhanced decision-making skills. Rymanowicz, Hetherington, & Larn, 2020. Planting the seeds for nature-based learning: Impacts of a farm- and nature-based early childhood education program.

Descriptive research is often used to describe the characteristics of a program or a population of people. Attempts to answer what, when, and how questions generally guide the descriptive research process. The studies in this section of the Digest are based on “How” questions and conclude with some recommendations based on the findings. 

Nature-trail activities can be used to promote inquiry-based science and math learning in young children

This paper describes how a group of pre-service early childhood teachers in the U.S. developed a set of nature trail activities geared toward pre-K to Grade 3 children. The paper also describes how these activities support not only Maine’s Early Learning and Development Standards but also the Next Generation Science Standards and Common Core Math Standards. Lee & Bailie, 2020. Nature-based education: Using nature trails as a tool to promote inquiry-based science and math learning in young children. 

One way teachers can support children’s interest in natural elements is to join them in their outdoor explorations

This study, involving four classes of Norwegian children (age 4 to 8), found that children’s interest in natural materials develops through stages. Teachers can support this interest by identifying the different stages, by having sufficient subject matter expertise, and by practicing social and cognitive congruence with the children. Skalstad & Munkebye, 2022. How to support young children’s interest development during exploratory natural science activities in outdoor environments.

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Holistic Development

• First Online: 22 July 2022

Cite this chapter

• Stephen P. Gordon 2  

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The term holistic in this chapter represents both systems thinking and the development of the whole person. Holistic school leaders use a variety of leadership styles and take a multidimensional view of events and situations. The successful school is a coherent school; school structures, programs, and renewal efforts are consistent with the school’s vision. Holistic curriculum content addresses students’ intellectual-cognitive, social, emotional, physical, aesthetic-artistic, moral, and spiritual development. A three-phase model of holistic curriculum development is presented. Holistic professional learning for teachers addresses their personal and professional lives; creative tensions that arise; and connections among professional learning, teaching, and student learning. Teaching to the whole student involves interesting and meaningful content; learning inside and outside of the school; a balance of individual, small-group, and large-group learning; and a combination of hands-on activity and reflection on that activity. There are several types of holistic assessment, including assessment by multiple assessors, multiple forms of assessment, assessment involving multiple aspects of student life, and assessment of student learning in relationship to the broader environment. A holistic teacher-family relationship requires capacity building on the part of teachers and families which can be facilitated in separate or joint meetings of the two groups. Holistic school-community relationships can be developed through off-hours programs at school, community service by students, and school-university partnerships.

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School of Holistic Development: A Case Study

1970, European Journal of Teaching and Education

Holistic development of students for life transformation through process of educational metamorphosis with the help of pentagonal model of integral education is the unique program of School of Holistic Development (SHD). With a vision to create and nurture the ‘Wholesome’ Personality of student to build ‘Winning Personalities and Comprehensive Global Professionals’ enabling them to meet challenges of career as well as life with skills, sensibility and sense of responsibility towards society and humanity by emphasizing on enhancing Employability of students by building Skills, Competencies and Multiple intelligence, Character, Values of Life are the objectives of the program. Inspired with this Indic approach SHD has designed a unique model of creating and fostering wholesome personalities through Integral Education. Indic wisdom of personality talks of five aspects (Panch Kosh). This ‘Pentagon’ of five ‘Koshas’ emphasizes five-dimensional development like Physical, Emotional, Psycho...

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Holistic citywide sanitation for an urban area in the Global South: A case study of the Noakhali Pourashava of Bangladesh

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Farhana Karim , Mohammad Mohinuzzaman , Nazifa Rafa , Sayed Mohammad Nazim Uddin , Rabby Hosen , Sajib Ahmed; Holistic citywide sanitation for an urban area in the Global South: A case study of the Noakhali Pourashava of Bangladesh. Journal of Water, Sanitation and Hygiene for Development 2024; washdev2024169. doi: https://doi.org/10.2166/washdev.2024.169

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Urban areas currently grapple with the consequences of poor sanitation systems and a burgeoning population. The issue remains acute for developing nations where financing and governance structures for urban sanitation remain inadequate. Using cutting-edge techniques such as shit flow diagrams (SFDs), city service delivery assessments (CSDAs), and SWOT analysis, this study provides an in-depth exploration of the sanitation scenario in the Noakhali Pourashava of Bangladesh. The study reveals a critical lack of sanitation infrastructure and inadequate fecal sludge management, with implications for public health and environmental sustainability. Findings indicate that only 3% of excreta enters the sewer system, while 88% is improperly disposed of through SFDs and CSDAs, the paper illustrates the existing sanitation facilities and service delivery mechanisms, highlighting areas for improvement. Recommendations include increased investment in sanitation infrastructure, public awareness campaigns, adoption of innovative technologies, improved stakeholder coordination, and addressing cultural and behavioral barriers. These insights aim to inform policy and decision-making processes to achieve sustainable and inclusive urban sanitation, ultimately improving public health and environmental outcomes in Noakhali and similar coastal urban areas.

Find out the fecal sludge treatment facilities in the town which discharge into the drain, water bodies, or open ground and help to understand the problem of inadequate disposal.

Integrating SFD, CSDA, and SWOT analysis, stakeholders can gain a comprehensive understanding of fecal sludge management and develop sustainable sanitation solutions.

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The Holistic Path to Mental Health

Finding balance and fulfillment..

Posted June 3, 2024 | Reviewed by Monica Vilhauer

• Balancing success and well-being via holistic mental health is crucial in today's demanding work culture.
• Holistic well-being considers physical, mental, emotional, societal, and spiritual aspects of life.
• The "Awaken" program and "Whole Person Wellness" initiative showcase holistic strategies' effectiveness.

The relentless pursuit of success often results in burnout , stress , and a pervasive sense of unfulfillment. In the midst of this hustle, mental health and wellness are frequently sidelined. But what if the key to true success lies in balancing professional achievements with personal well-being?

Embracing a holistic approach to mental health can empower individuals to thrive in every aspect of their lives. Holistic well-being considers all facets of a person's life—physical, mental, emotional, relational, societal, and spiritual .

In preparation for this post, I interviewed Julie Santiago, a holistic wellness expert, to explore the transformative power of a holistic approach to mental health. Through practical strategies, real-life examples, and valuable insights, we aim to help you achieve balance and fulfillment.

Understanding the Modern Mental Health Crisis

The modern work culture, characterized by long hours and relentless pressure, has significantly contributed to rising rates of burnout and mental health issues. According to the World Health Organization , depression and anxiety cost the global economy an estimated $1 trillion per year in lost productivity . Additionally, a study published in the Journal of Occupational Health Psychology found that individuals experiencing burnout are more likely to suffer from chronic health conditions, including cardiovascular diseases.

Exemplary Holistic Strategies in Action

One real-life example of a holistic strategy is the "Awaken" program that has proven to be transformative for over 50,000 participants. This comprehensive initiative not only offers personal development workshops but also integrates mindfulness practices and career coaching sessions. Participants engage in a journey of self-discovery and growth, learning how to navigate both personal and professional challenges with resilience and confidence . By fostering a supportive community and providing tailored guidance, the "Awaken" program empowers women to realize their full potential and achieve holistic well-being.

Another notable example is the "Whole Person Wellness" initiative by the Life Harmony Institute. This innovative program takes a holistic approach to health and wellness by addressing physical, mental, and emotional aspects. Through a combination of fitness classes, therapy sessions, and lifestyle coaching, participants learn to cultivate a balanced lifestyle that nourishes their body, mind, and spirit. By recognizing the interconnectedness of these elements, the "Whole Person Wellness" initiative equips individuals with the tools and knowledge to lead fulfilling lives characterized by vitality and harmony.

Real-Life Transformations

The true power of a holistic approach is evident in the transformative journeys of individuals. For example, consider Lauren, a mother of four and a corporate executive who was on the verge of burnout. By adopting holistic strategies, Lauren not only achieved a balance between her professional and personal life but also found a sense of fulfillment and well-being. Her story is a testament to the ability of holistic practices to foster profound, lasting change.

During an interview, Julie Santiago shared the story of another client, Dania, who initially felt skeptical about joining a holistic wellness program. Despite working with various professional coaches, Dania found that traditional coaching methods did not address the core issues affecting her well-being. Nevertheless, the holistic program helped Dania delve into the root causes of her dissatisfaction, enabling her to understand and transform her mental model. As a result, Dania improved her relationships with her family and found a new sense of peace and fulfillment in both her personal and professional life.

Practical Steps for Holistic Mental Health

For those looking to embark on a journey towards better mental health and well-being, here are some practical steps inspired by holistic principles:

• Mindfulness Practice: Begin each day with mindfulness meditation . Even five minutes of focused breathing can reduce stress and increase mental clarity.
• Physical Activity: Incorporate regular exercise into your routine. Whether it's a morning jog, a yoga session, or a dance class, physical activity can significantly boost your mood and energy levels.
• Feel Your Feelings: Learn to slow down and make space for yourself and your emotions. Refrain from using food, alcohol , shopping, or other compulsive behaviors as a means of avoidance.
• Healthy Boundaries : Set clear boundaries between work and personal life. Designate specific times for work and leisure, and stick to them. This separation is crucial for maintaining mental health.
• Community Support: Engage with a supportive community. Surrounding yourself with like-minded individuals can provide encouragement, accountability, and a sense of belonging.
• Personal Development: Dedicate time to personal development. Read books, attend workshops, or engage in activities that foster growth and self-discovery.

Bottom Line

A holistic approach to mental health and well-being offers a refreshing perspective in a world obsessed with external achievements. By focusing on a multidimensional strategy that encompasses all aspects of life, individuals can achieve true balance and fulfillment. As the demand for holistic well-being continues to rise, these methods stand as a beacon of hope for those seeking a more meaningful and balanced life. Embracing these principles can lead to lasting happiness , improved mental health, and a more harmonious existence.

Note: This post is part three of a series where I gather insights from experts in the areas of leadership , diversity, and wellness.

© 2024 Ryan C. Warner, Ph.D.

Alameri, F., Aldaheri, N., Almesmari, S., Basaloum, M., Albeshr, N. A., Simsekler, M. C. E., ... & Baltatu, O. C. (2022). Burnout and cardiovascular risk in healthcare professionals during the COVID-19 pandemic. Frontiers in psychiatry , 13 , 867233.

Ryan C. Warner, Ph.D. , is a sought-after speaker, researcher, consultant, and licensed clinical psychologist. He is the Founder and Chief Executive Officer of RC Warner Consulting.

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At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

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• Published: 20 June 2023

Trustworthy artificial intelligence and ethical design: public perceptions of trustworthiness of an AI-based decision-support tool in the context of intrapartum care

• Rachel Dlugatch 1 ,
• Antoniya Georgieva 2 &
• Angeliki Kerasidou 1  

BMC Medical Ethics volume  24 , Article number:  42 ( 2023 ) Cite this article

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Despite the recognition that developing artificial intelligence (AI) that is trustworthy is necessary for public acceptability and the successful implementation of AI in healthcare contexts, perspectives from key stakeholders are often absent from discourse on the ethical design, development, and deployment of AI. This study explores the perspectives of birth parents and mothers on the introduction of AI-based cardiotocography (CTG) in the context of intrapartum care, focusing on issues pertaining to trust and trustworthiness.

Seventeen semi-structured interviews were conducted with birth parents and mothers based on a speculative case study. Interviewees were based in England and were pregnant and/or had given birth in the last two years. Thematic analysis was used to analyze transcribed interviews with the use of NVivo. Major recurring themes acted as the basis for identifying the values most important to this population group for evaluating the trustworthiness of AI.

Three themes pertaining to the perceived trustworthiness of AI emerged from interviews: (1) trustworthy AI-developing institutions, (2) trustworthy data from which AI is built, and (3) trustworthy decisions made with the assistance of AI. We found that birth parents and mothers trusted public institutions over private companies to develop AI, that they evaluated the trustworthiness of data by how representative it is of all population groups, and that they perceived trustworthy decisions as being mediated by humans even when supported by AI.

Conclusions

The ethical values that underscore birth parents and mothers’ perceptions of trustworthy AI include fairness and reliability, as well as practices like patient-centered care, the promotion of publicly funded healthcare, holistic care, and personalized medicine. Ultimately, these are also the ethical values that people want to protect in the healthcare system. Therefore, trustworthy AI is best understood not as a list of design features but in relation to how it undermines or promotes the ethical values that matter most to its end users. An ethical commitment to these values when creating AI in healthcare contexts opens up new challenges and possibilities for the design and deployment of AI.

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Introduction

As artificial intelligence (AI) is becoming increasingly common in the medical and healthcare landscape, more importance is being placed on developing AI that is ethical and trustworthy. Despite consensus that trustworthiness is essential for the successful design, application, and acceptability of AI [ 1 , 2 ], what constitutes trustworthiness in relation to AI, and who should determine and define it, is less evident.

Approaches to technology design that integrate people’s values into it, such as value-sensitive design [ 3 ], embedding values [ 4 ], embedded ethics [ 5 , 6 ], ethics by design [ 7 ], and Responsible Research and Innovation [ 8 ], ostensibly place people at the forefront of the design process. Despite this emphasis on human values, however, perspectives of the public and direct stakeholders (i.e., those who interact directly with the technology in development) are often absent from the research and discourse on ethical AI design [ 9 , 10 ]. Meanwhile, international organizations and regulatory bodies are attempting to foster public confidence by publishing guidelines and codes of ethics; however, these initiatives are aimed at facilitating public trust rather than designing AI that is worthy of the public’s trust [ 11 ].

This research investigates the views of direct stakeholders to explore the meaning and role of trust in the design, development, and application of AI in a medical context. By artificial intelligence, we refer to data-driven and computer-based systems and software able to perform tasks normally associated with intelligent beings. Using a speculative case study, this paper sheds light on the perspectives of birth parents and mothers Footnote 1 regarding the introduction of AI-based cardiotocography (CTG) in the context of intrapartum care. Based on data collected in seventeen interviews with birth parents and mothers who were pregnant and/or had given birth in the last two years, this research places users’ perspectives at the forefront of the discourse on the ethical and trustworthy design and application of AI.

Trustworthy AI

Trustworthiness is a characteristic of an agent that denotes the agent’s competence to perform an action and her moral attitude or commitment towards those who depend on her to perform said action [ 13 , 14 ]. Being trustworthy is something more than just being predictable and reliable; rather, it signifies a moral characteristic or virtue [ 13 ]. For this reason, some have argued that trustworthiness is an inappropriate characteristic to attribute to inanimate objects, such as AI systems, as one cannot ascribe moral attitudes or virtues to agents that are not themselves moral agents [ 15 , 16 , 17 ]. Being reliable, namely acting in a predictable and consistent way, is much more fitting for agents that can act but do not qualify as moral agents. Others have defended the notion of trustworthy AI by arguing that attributing trustworthiness only to human agents reveals a narrow definition of trust [ 18 ], ignores academic and disciplinary disagreement regarding the conceptualization of trust and the role of non-human agents [ 19 ], and fails to take into account the common use of the words ‘trust’ and ‘trustworthy’ [ 19 ].

Whilst we agree with the argument that trustworthiness is relevant only to moral agents, we also acknowledge that in everyday language one might refer to an object or a technology as being trustworthy, as an (indirect) reference to the belief that the people and processes involved in making and deploying that object or technology are themselves trustworthy. It seems that it is in this more indirect understanding that the term ‘trustworthy AI’ is used in documents such as the guidelines published by European Commission’s High-level Expert Group on Artificial Intelligence [ 1 ]. The seven key requirements articulated in the document refer to standards and principles that need to be incorporated in the ways in which AI systems are developed and deployed, including structures for governance and oversight. Furthermore, in the White Paper published in 2020 by the European Commission entitled On Artificial Intelligence: A European Approach to Excellence and Trust , these key requirements are referred as the foundation upon which an ‘ecosystem of trust’ should be based, which is critical for ‘giv[ing] citizens the confidence to take up AI applications and give companies and public organizations the legal certainty to innovate using AI’ [ 2 ].

It is the acknowledgement that trust and trustworthiness can be an important enabling factor when it comes to the acceptability and use of AI by the public [ 2 , 20 , 21 , 22 , 23 ] that has driven the proliferation of published principles and guidelines for ethical AI by public bodies, private companies, and research institutions [ 11 ]. A study conducted by Jobin et al. [ 24 ] revealed 84 such documents. Yet, as the authors conclude, this plethora of guidelines highlights the need for a global agenda for ethical AI, which respects cultural and moral pluralism, but also the necessity of developing clear implementation processes.

Following from this short analysis, one way of understanding the notion of trustworthy AI is as the designing, developing, and implementing of AI tools and models in ways that adhere to and reflect certain values and principles conducive to warranting trust. In so far as the values embedded into AI tools are those valued by end-users, one could argue that building them in would indicate trustworthiness. This understanding is predicated on the view discussed in the next section that values, including ethical values, can be reflected in the way in which technologies are developed and used.

Ethical values in design

One way of implementing ethical values and principles into technology is by bringing ethical considerations, including stakeholders’ perspectives regarding ethical implications of new technologies, right from the start of the design process and throughout the lifecycle of technology development and deployment. This attitude reflects a generally accepted, albeit not uncontroversial view [ 25 ], that technologies are not value-neutral, but rather, through their development and deployment, technologies can promote or undermine certain values [ 26 , 27 ].

A number of methodologies have been proposed to facilitate the incorporation of ethics and ethical values into the design of data-driven technologies, such as AI. Value sensitive design [ 3 ], embedding values [ 4 ], embedded ethics [ 5 , 6 ], ethics by design [ 7 ], and Responsible Research and Innovation [ 8 ], are some of these methodologies that argue for the importance of integrating ethics into the entire process of AI systems development and deployment, as a way of ensuring these systems and technologies are ethical and socially responsible, and also able to respond to value change. However, even when ethics is incorporated into the design processes of AI systems, the voices of important stakeholders, such as end-users, might still be excluded thus making these tools, as well as the ethical recommendations regarding their development and deployment, less relevant to the people on the ground [ 28 ]. As such, relevant stakeholders, e.g. main user groups, should act as a primary source for identifying values to be promoted within technology design and deployment.

The context for the study: artificial intelligence and cardiotocography interpretation

Cardiotocography (CTG) is used by obstetricians and midwives to monitor the wellbeing of the fetus during pregnancy and/or during labor, especially for high-risk pregnancies. Ultrasound traducers are placed on the birthing parent’s or mother’s abdomen by a clinician, enabling the CTG to continuously record the fetal heart rate and uterine contractions [ 29 ]. The purpose of this electronic fetal monitoring is to identify babies who may suffer from hypoxic injury (lack of oxygen), and to assist clinicians in identifying whether an intervention—such as a caesarean section or assisted vaginal birth (with the use of ventouse and/or forceps)—is necessary [ 30 ]. The idea is that timely, corrective decisions can be made by healthcare professionals during labor if they can assess fetal wellbeing and the individual risk of hypoxia more reliably [ 31 ].

Although CTG was introduced into clinical practice in the late 1960s and has been a mainstay in obstetrics since then, there is little to no evidence that CTG has been effective in improving perinatal outcomes [ 32 ]. For example, rates of infant mortality and cerebral palsy (a complication associated with hypoxic-ischemic encephalopathy) have not been reduced with the use of CTG [ 30 ]. Meanwhile, rates of cesarean sections have risen [ 30 , 33 ]. Despite being endorsed for usage by major professional organizations, some studies seem to link widespread CTG usage with increased cases of mortality and morbidity to both birth parents and babies in high-income countries [ 33 , 34 ]. Use of CTG has also been criticized for restricting movement [ 30 ], being uncomfortable or not allowing women to stay in the bathtub, which has over time pushed the main manufacturers [ 35 , 36 ] to develop wireless and water-proof solutions.

One reason that CTG evaluations are unreliable is that the readings themselves are highly subjective [ 37 ]. Experts have been shown to interpret the same CTG trace differently from one another and even to contradict themselves [ 38 ]. Despite the introduction of guidelines to improve this ‘high inter- and intra-observer variability,’ however, CTG evaluation is still highly inconsistent [ 39 ]. Moreover, these guidelines are based on patterns of fetal heart rate that are imprecise, static, and otherwise insufficient for reliable CTG interpretation [ 37 ].

Due to the limitations of using CTGs to prevent adverse labor outcomes, there has been a growing interest in developing improved ways for CTG interpretation and beyond [ 37 ]. Artificial intelligence and machine learning approaches, for example, are being proposed as alternatives to conventional CTG interpretations, aiming to improve clinical practice through more accurate and objective assessments [ 40 ].

Leading in this domain, a computer-based analysis method under development is the Oxford System (OxSys), based on the CTG and labor data from nearly 100,000 prior births. OxSys incorporates known clinical risk factors (demographics and comorbidities) jointly with the automated analysis of the CTG and is ‘trained’ to estimate the risk for severe compromise at birth (fetal or neonatal death, neonatal encephalopathy, hypoxic-ischemic encephalopathy and the need for resuscitation and neonatal intensive care). The aim is to assist clinicians in detecting more reliably those at risk and communicating this with the birthing parent and their family, facilitating joint decision making to prevent severe perinatal outcomes. However, OxSys aims to also minimize the false positive rates and reduce as much as possible the rate of unnecessary interventions with their inherent risks [ 41 ].

In the context of OxSys and this particular research, the general term AI is used, but more specifically, OxSys is a data-driven computer-based algorithm/software, trained and tested with the data of hundreds of thousands prior births. The size of the data is crucial because adverse outcomes are rare and many clinicians will see in their lifetime only a few such cases. But OxSys allows advanced algorithms to ‘learn’ from the data of such rare events as well as that of many healthy births. After learning/training, the information from the prior data is distilled into the memory of the computer and, when a new birthing parent presents in front of the healthcare professional, their individual CTG trace and clinical risk factors together are analyzed by OxSys. The tool then provides an objective, data-driven estimate for the risk for this individual baby based on how it compares to the data of the large population in OxSys’s ‘memory.’ Essentially, OxSys is one more tool in the hands of clinicians which they can use together with the birthing parent and their specific clinical context to discuss the pros and cons of clinical options for intervention and make a joint decision based both on their individual needs and the data-driven objective risk estimate.

With their lives and their babies’ lives at stake, birth parents and mothers have the most to gain and the most to lose with the introduction of new technologies in perinatal care. In addition, given that there are unique challenges in labor decision making—such as making pressurized decisions while the laboring parent is in pain or on drugs—and also that expectations and preferences may differ from one person to the next, it is important to consider the wide spectrum of individual needs and perspectives to develop, design, and implement trustworthy AI. However, patient views and experiences are distinctly lacking from research on CTG monitoring [ 42 ]. Our team has sought to integrate the parents’ views and experiences within the core of OxSys’s development, leading to this study.

This study is part of an NIHR i4i Product Development Award that is developing an independently validated, trustworthy, and clinically relevant AI-based CTG (OxSys 3.0).

This study investigated the perspectives of birth parents and mothers regarding the introduction of AI-based CTG during term labor, with a focus on the issue of trust. Semi-structured interviews were conducted with seventeen birth parents and mothers who were pregnant and/or had given birth in the last two years, and who were based in England. The aim of these interviews was to capture what direct stakeholders believe the ethical issues are in the use of AI, the meaning and role of trust in the development and use of AI-based CTG, and how it should be used in practice.

The decision to conduct qualitative research, which allowed birth parents and mothers to delineate the ethical issues pertaining to trust, had a twofold purpose. First, it served to amplify users’ voices in the literature on the trustworthy development and deployment of AI in healthcare. Given that female participation in medical research pales in comparison to their male counterparts [ 43 , 44 ] and that research that falls under the umbrella ‘women’s health’ is often neglected and marginalized in the first place [ 45 , 46 , 47 ], enabling minoritized voices to generate and contribute to knowledge production might go some way also to address an ‘epistemic injustice’ [ 48 ]. Additionally, focusing on the views of people most affected by technological interventions in healthcare sheds new light on themes of significance beyond obstetrics and which may be extrapolated to other areas of medicine and the development of trustworthy AI more broadly.

Second, this qualitative approach facilitated the understanding—and therefore, paved the way for the incorporation—of users’ values into the design and implementation of an actual AI decision-support CTG software, OxSys 3.0. This research is part of a larger project that aims to improve clinical decision-making around labor management and CTG monitoring. Although any value-based design should be an iterative process, this study acted as the initial stepping stone in that process for the development and deployment of OxSys. It also represents a modest step in a broader movement to develop trustworthy and ethical AI in a society witnessing increasing technological interventions.

Participants

Seventeen birth parents and mothers were recruited for semi-structured interviews. The criteria for participation was that interviewees were based in England and were pregnant and/or had given birth in the last two years. Participants were recruited in the following ways: known contacts in National Childbirth Trust (NCT) groups, distribution of research flyers via email and social media (Twitter, Facebook groups and pages), cold contacting pregnancy and new parent support groups, posting research flyers in local community centers, and snowballing. Descriptions of the research given to prospective participants via email and social media stated that no knowledge of artificial intelligence was necessary and that interviews would be primarily based on personal experience and hypothetical situations. This point was made to avoid attracting only prospective participants who were already well-versed in the subject of artificial intelligence or comfortable talking about new technology. Furthermore, although most recruitment was done online because of the Covid-19 pandemic and because participation was open to people based anywhere in England, the recruitment strategy also specifically targeted areas of Oxford with high socioeconomic and ethnic diversity (e.g. East Oxford). 10 of the 83 neighborhood areas of oxford are among the 20% most deprived areas in England [ 49 ]. We distributed flyers to community centers and open spaces that serve this particular population of Oxford. Additionally, flyers stated that the research was being conducted by the University of Oxford and that participants would receive £20 vouchers. The flyer was submitted to MS IDREC alongside all the other project materials. It was reviewed and approved by MS IDREC.

We also endeavored to make participation inclusive by reaching out to support groups for parents from systemically disadvantaged backgrounds (i.e., due to ethnicity and/or socioeconomic status). Of these seventeen participants, six were pregnant at the time of interviewing, three of whom were pregnant for the first time. Out of the eleven participants who were not pregnant, nine had birthed one child, and two had given birth more than once.

Because this study was conducted during the Covid-19 pandemic, for health and safety reasons, recruitment and interviews took place online, on Microsoft Teams. The researcher (RD) allowed participants to schedule interviews to suit their needs. Interviews often took place around lunchtime, when participants’ children were down for a nap or when their partners were able to look after the children. Some interviews were conducted while the interviewee was nursing. Most calls were taken with video enabled, except for a few participants who opted to turn their cameras off, usually due to poor internet connection. All calls were audio recorded on an external encrypted device, an Olympus DS-9000. Interviews lasted 43 min on average.

Prospective interviewees were given Participant Information sheets and Informed Consent Forms to read before interviews took place. Informed consent was then taken verbally at the beginning of the call by the researcher (RD), who read through the Informed Consent Form aloud. Participants were also given permission to have a support person or partner on the call due to the potential sensitive nature of the conversation, but only two participants chose to do so.

AI was not used in interviewees’ care. As such, interviews focused on participants’ lived experiences of pregnancy and childbirth, as well speculative scenarios involving AI-based CTG in intrapartum care. Interviewees were first asked to reflect on their relationships with healthcare professionals, how decisions were made about their care, and their feelings about any encounters with technology (including but not limited to CTG). Then, participants were asked to share what came to mind when hearing the phrase ‘artificial intelligence,’ how they imagined AI could be used in medical contexts, and their feelings toward it. This was to assess participants’ level of knowledge pertaining to AI and any preconceptions they may have without first providing them with a definition which could influence their responses.

In the final portion of the interview, participants were given a brief description of an AI-based CTG (OxSys). Because participants were not experts in AI or CTG, it was necessary to describe OxSys in laymen’s terms rather than being overly technical. What was important to communicate to participants was that (i) an intelligent data-driven and computer-based fetal monitoring software would provide a risk assessment, and (ii) that the risk assessment would not necessarily determine the course of action taken but act as another piece of information for both the healthcare professional and laboring person to consider. The initial description was deliberately kept vague so as not to influence interviewees’ responses and see what issues participants raised on their own. For example, where the data was sourced from and what data points were included were left out of this initial description to see if participants were concerned about this issue without first being prompted. The same is true for who was developing OxSys, whether the OxSys considered other risk factors apart from heartrate, whether it has been proven to be more accurate than healthcare professionals, and more. These, amongst other issues, were later introduced by the interviewer (RD) if participants did not raise them unprompted.

After discussing how this type of technology differed or matched with their own ideas about AI, as well as their initial impressions and concerns, participants were then asked a series of questions to probe what they consider to be the ethical issues of introducing such a system, as well as what characteristics would make it ( un )trustworthy. Participants were encouraged to reflect on how introducing this kind of AI-based decision-support tool might impact the care they receive, their relationships with their doctors and midwives, their own decision-making capabilities, and their overall experience of giving birth. Given that the AI in question was not used in their care, this final portion of the interview was speculative. Nevertheless, it was contextualized and grounded in their lived experiences of pregnancy and childbirth. The interview guide for the semi-structured interviews is included in this publication as a additional file. Note that because of the semi-structured nature of the interviews, the interview guide was used to provide a general direction to the interview. During the interview, participants talked about what they felt was important, which the researcher then followed up. This means that each interview was different from the next, although all of them covered the general areas included in the interview guide.

While attention was paid to issues pertaining to trust and trustworthiness, semi-structured interviews allowed for flexibility and empowered participants to define the issues of greatest importance to them. Many participants said that they enjoyed having an opportunity to share their experiences, including the moments of pregnancy and childbirth that were a source of anger, frustration, and/or sadness, because they had never been given the opportunity to do so.

All interviews were transcribed verbatim by a transcription service that has a signed confidentiality agreement with the University.The transcription service received audio recordings from the researcher (RD) and returned written transcripts via an encrypted data exchange program.. RD then uploaded these transcripts to NVivo, a data analysis software, to organize and manage interview transcripts. Analysis was performed using thematic analysis [ 50 ], a method for systematically identifying and interpreting thematic patterns in qualitative data sets. After RD and AK read and familiarized themselves with the interview transcripts, RD coded the transcripts. Coding is a term in thematic analysis that refers to assigning a label to parts of interview text that speak to a particular topic or concept. Then, RD reviewed these codes and grouped them by overarching theme and then again into sub-themes. RD and AK met regularly to review these themes, to define and redefine them, and also to discuss how they related to and informed our research questions. RD and AK agreed on the themes most relevant to the question of what constitutes trustworthy AI in the context of intrapartum care. The themes selected for this paper were the ones most reinforced and echoed by our participants and were also most relevant to the project/work package designed by AK and the overall research project designed by AG.

Participants have been given pseudonyms for this paper. Direct quotations have been edited for readability only.

The findings of this study are split into three sections: (1) trustworthy AI-developing institutions, (2) trustworthy data from which AI is built, (3) trustworthy decisions made with the assistance of AI. These three themes emerged from interviews as being important to the evaluation of the trustworthiness of AI.

Trustworthy AI-developing institutions: the importance of promoting public good

The trustworthiness of the institution developing AI was perceived by participants as relevant to the overall trustworthiness of the AI system itself. When discussing the importance of who develops AI for use in medical contexts, participants emphasized the need for AI being developed and deployed for public good. Public good was expressed as medical tools and technologies that will benefit the birth parent/mother and baby and are equally available to all. Tools developed with the aim of generating profit were viewed as antithetical to promoting public good. Almost unilaterally, participants associated university researchers with developing technologies for public benefit, and private companies as being mainly motivated by profit. For this reason, patients characterized trustworthy development as that which had been carried about by independent and/or university researchers instead of for-profit private companies.

Below is a response from Rosie, a first-time pregnant woman, to a question about whether who had developed the AI in question would matter:

…you want to know that it’s not just someone trying to make money. You’d want it to be something independent, where you are like, ‘Is this people who are trying to make money, or is this people who are trying to make better outcomes for women in labor?’ That would definitely mean something.

As Rosie’s comment highlights, being motivated by financial gains was juxtaposed with maximizing better outcomes for birth parents and mothers. The idea that these two goals are incompatible was reiterated by most interviewees. Additionally, participants tended to believe that university researchers were more invested in improving health outcomes than those in private companies, such as Google. Lily, mother to several children, made these institutional associations explicit:

Yeah, I think if it was a university, that’s more reassuring than just Google. I just wonder what Google’s best interest would be though. Would it be financial? Whereas university researchers like yourself, you are actually quite interested in the health of the mother or whatever, whereas I don’t know if Google would be.

Jennifer, mother of one, reiterated these associations by expressing her distrust of monetization, something she does not affiliate with university-based research:

Whereas when it’s come from a university backing, I think I trust much more that the data’s been harvested in a way that’s not always had in the back of its mind, how do we monetize that?

As these comments reveal, the perceived difference between universities and private companies was not seen only as a signifier of a pragmatic difference between these institutions (e.g., with respect to their institutional aims and priorities), but was viewed as a ‘moral’ difference. In other words, participants perceived universities as being more trustworthy , in virtue of pursuing public good, than private companies. Moreover, this perceived difference impacted the way in which participants perceived the overall trustworthiness of the AI system itself. AI developed by trustworthy institutions (e.g., universities) was perceived as more trustworthy than AI developed by untrustworthy institutions (e.g., private companies).

Despite this conviction that the trustworthiness of the AI-developing institution matters, however, many interviewees conceded that if the AI system was already at the point of use in the NHS, it would indicate that it had been proven to improve outcomes for birth parents and mothers. In other words, participants believed that AI implemented in the NHS would have already been proven to satisfy their ethical requirement of promoting public good. Consider the following comments:

You kind of trust in your hospital that they would only get something that has been made to help kind of thing, and [made] by people we trust. –Rosie But if it got to the point that it was in healthcare on a sort of everyday basis, I would probably trust that it had got to that place [of improving outcomes], maybe naively, I don’t know. –Mary

That participants expressed trust in their healthcare system to prioritize their wellbeing is not a surprise, given that public trust in the NHS, particularly in relation to managing patient data, remains high [ 51 ]. What these quotes do reveal, however, is that there is more than one level at which public trust operates and in which commitment to public good can be demonstrated (or undermined): first, at the level of the institutions seeking to develop AI tools, and second, at the level of public institutions tasked with assessing and implement technologies on the ground. Given this linkage between the perceived trustworthiness of institutions and the perceived trustworthiness AI they develop and/or implement, this finding has potential implications for the role of institutions in the introduction of AI in healthcare.

Trustworthy data from which AI is built: reliable, unbiased, and consistent

Although necessary, an institutional commitment to public good was not sufficient for interviewees to deem the AI system that the institution developed as trustworthy. Participants acknowledged that while who builds AI is significant, AI can only be only as good as the data it is built from . As such, trustworthy AI needs to be derived from ‘trustworthy data,’ a phrase used by one participant but implied by many participants. ‘Trustworthy data’ in these discussions means reliable data, or data that is unbiased and inclusive.

Several participants spoke about their concerns regarding biases in datasets used for developing and training AI systems, thus outlining what would constitute un trustworthy data, and by extension, un trustworthy AI. More specifically, there was a recognition amongst interviewees that certain population groups, especially Black and Minority Ethnic (BAME) birth parents and mothers, suffer worse maternal outcomes. Although not their only concern, participants worried that data might not be as inclusive of BAME populations and therefore any systems developed using this data would be unreliable for them. As a result, the outputs of the AI would be less accurate for these groups, and thus they would not consider the AI itself as trustworthy. What is interesting is that interviewees associated AI trustworthiness with data reliability in terms of accuracy and inclusivity, even when they themselves did not belong to these marginalized groups.

The following quote establishes that participants want to know that data itself is trustworthy:

I think that’s another thing, that people want to know that data is trustworthy. —Jennifer

Building on this idea, another interviewee expressed trustworthy data in terms of its reliability:

              Obviously I’d want to know, where’s this data from? Is it reliable? –Rosie.

Although participants spoke of reliability in relation to data, further discussions elucidated that data itself was not participants’ main concern in and of itself. Reliability of input (data) was inextricably linked with reliability of output (in the case of AI-based CTG, a risk assessment), even amongst participants who openly acknowledged their limited knowledge of AI. As the following quote illustrates, reliability of output was framed in relation to bias, with unbiased outcomes stated as the ultimate goal to be achieved:

This is my completely limited knowledge, so this could be rubbish, but my understanding is AI is only as good as its inputs […] I think it would have to be based on a wide breadth of inputs and experiences for it to have proper and unbiased outcomes. —Mary

One person added that even though the perceived moral character and intentions of the institution developing the AI was of moral significance, good intentions cannot guarantee reliability, particularly in relation to the breadth of data used. Consider the following comment:

I would trust the ethics of a university doing it more, but again, fundamentally, if the issue is the data that you put in, then the university’s data can’t actually be any better than the private company’s. I do generally trust independent research more than private research. But I don’t think that it removes all of the issues. –Taylor

When probed further about reliability and data, Taylor brought up recent reports on BAME maternal health outcomes and mortality rates [ 52 , 53 , 54 ]. Like Taylor, several participants had read these reports in the news and raised the issue of implications of biased data sets for marginalized populations. Moreover, interviewees expressed the importance of having inclusive datasets so as not to reproduce these social and health inequalities. Underlying this need for reliability, then, is a desire for equity and solidarity in healthcare, in the form of ensuring the same reliability of outcome across all population groups. Taylor makes the point as follows:

I have some of the same concerns that I was talking about already around how do you make sure it’s not a biased data set? ... Just having done the research in passing, it comes up on stuff about maternal outcomes for Black and ethnic minority women and the fact that data will be in the system in the way it is currently. So there’s not a way round that kind of thing. [Minority groups] have a lot of complex medical stuff going on all at the same time [and] what the world looks like for those people is often really quite a long way from what the mainstream world looks like. And making decisions that are good for the majority of people often doesn’t work for people who are already in a significantly marginalized position. —Taylor

Another participant expressed a similar sentiment, adding that even though this would not affect her personally as a white woman, she nevertheless has concerns for others:

So deaths within mothers of Black and ethnic minorities far outstrip those of white individuals, and nobody knows why [….] And there was a big push to try and understand why those individuals are experiencing such a different end result or, you know, labor. And no one can really sort of pinpoint why that is. So I would have concerns, not for myself, but for others that those unknown factors aren’t being taken into consideration because it’s the unknowns when you’re trying to ask a computer to spit out the answer but you don’t know what the input is. So that’s another dynamic. I think there’s a point in there. –Fran

Finally, despite these concerns about biased data sets and unreliable outcomes for BAME parents, participants nevertheless shared an optimism that assessments performed by AI could be more reliable than those performed by humans. As the following comments show, in this context, reliability was framed in terms of consistency of outcome—namely, that the same inputs will generate the same outputs.

I think I would feel that [the] use of a large body of data by software could be really, really powerful and it could eliminate some of that personal bias stuff that everybody has. You know, healthcare professional scientists have it as well. –Emma To move it to being more evidence based, rather than it just being one person’s opinion, sounds fantastic to me. Obviously, I had quite a negative experience of every day coming away with a different feeling based on whichever individual I was talking to. So, to know that it’s actually just based on data, rather than one person’s opinion. That’s, that’s really reassuring. –Jennifer

As such, despite their concerns about the data AI is taking as inputs, participants generally felt positively about AI’s capacity for consistency of outputs. More importantly, however, reliability of outcomes for all population groups was perceived as important for the overall trustworthiness of the AI system. Therefore, while generating consistent outputs is one piece of this puzzle, the data from which AI is built must also fairly represent all population groups and be trustworthy in and of itself for the AI built from it to be considered trustworthy.

Trustworthy decisions made with the assistance of AI: human mediation and limits to machine autonomy

Even though participants acknowledged that AI could generate more consistent outputs, they nevertheless expressed concerns about the capacity of AI to make holistic assessments. For this reason, alongside the recognition that healthcare professionals have relevant clinical experience, participants asserted that AI should act as a supplement to, rather than a replacement for, healthcare professionals’ clinical judgments. According to the research sample, trustworthy decisions made with AI require human input and oversight, as it is humans (i.e., healthcare professionals) who are able to fully engage with the human (i.e., patient) in front of them. Furthermore, participants articulated a strong preference for decisions to be mediated by a healthcare professional for their ability to personalize care, including incorporating patients’ values into the decision-making process and communicating directly with patients.

Several participants articulated this point about AI supplementing healthcare professionals’ clinical decision making:

I think possibly I would always see it as a complement or a supplement to a healthcare professional that I trusted, not necessarily a replacement. –Jennifer I think as long as it’s well researched and I suppose as long as there’s a human eye to cast over it a little bit so you’re not purely at the sole mercy of a machine, as long as there’s some little bit of human contact there, then I think I would have a lot of confidence in it. –Chelsea

Additionally, when participants were asked whether they would trust their healthcare professional or AI in a case of clinical discrepancy, participants overwhelmingly said that they would trust the healthcare professional’s decision over AI. Several interviewees highlighted the importance of making holistic decisions, something they believed humans were more capable of than AI; others cited clinical experience of healthcare professionals as a relevant factor, too. The following quotes are interviewee responses to the question of whether they would trust their healthcare professional or AI to make a final decision about their care (such as needing to intervene in labor):

My gut would say the healthcare professional because they’re seeing me in the here and there, like now. They’ve got my notes. They can overlay that with what might have happened before. They know what’s happened in the run-up to that that day. –Fran I think I’d trust the doctor more. Because they have experience and they’re skilled. […] Because they can see, they can actually see . And also, a lot of emotions in our bodies can be interpreted in the wrong way by the machine. Maybe you’re just nervous or anxious and [AI-based CTG is] recording distress. –Tiffany

The desire and preference for personalized care, understood as care that took into consideration patients’ needs, values, and preferences as individual persons, was something that our participants returned to again and again. In discussing personal experiences of being treated more like a statistic rather than an individual person even in the current system, they expressed their concerns that the introduction of AI might exacerbate such attitudes. Consider this quote explaining how a decision for induction was made and communicated to one of our participants, Taylor:

I’m booked in for an induction in a week’s time that I don’t agree with. I know that the NICE guideline says that if there isn’t a specific set of problems, that the induction should be in about Week 39. I know that. I work in mental health myself. I’m pretty scientifically literate. And I’ve said to the registrars every time, ‘Look, this is what I want to happen. I’m happy with increased monitoring from Week 37. Can we do it this way?’ The registrars have said, ‘That sounds completely reasonable,’ on every occasion. They’ve taken it up to the consultant, who has never seen or spoken to me, and he’s said no. […] So, fundamentally, I think it’s because it’s hospital policy. […] I just want to feel like I got to make the decisions and that I understood why they were getting made and that they felt like they were made in my best interests and my baby’s best interests. –Taylor

Although this experience does not involve the use of AI, Taylor still felt that this ‘algorithmic decision’—in this case, in the form of hospital policies and guidelines—could detract from the type of holistic and personalized care that birth parents and mothers consider appropriate and ultimately trustworthy. By introducing AI into the care system and then relying on it to make final decisions for patient care, our participants’ feared that they would end up losing even more opportunities for holistic and personalized care, as there would be no healthcare professional with whom they would be able to discuss and reason. Although AI might be able to make certain care decisions for patients, it offers very little opportunity to communicate back, and being able to communicate their views and be confident that they are taken into account when planning their care was something participants in this study valued.

Finally, empathy was revealed as a final consideration for why participants would want decisions to be made with a doctor. Consider the following comments:

I think it’s just all about that care and connection really, you want to feel like you’re being well looked after and a machine doesn’t always give you that sort of feeling 100%; you still want someone there to, kind of, physically hold your hand a little bit. –Chelsea … [W]e need technology, but of course like that type of assistance will always be limited in many regards, and I think when you are an expecting mother you always need that kind of human touch. You want to be recognized and seen as a human. So I think like the healthcare professionals play an important role in reassuring mothers, and fathers, and explaining [things to] them … is just really, really important. It helps a long way when you are in a stressful and a non-stressful situation. So those things are very important no matter what technology will be introduced and how it is used. It’s just very important that there’s a good, good kind of communication going on at all times. –Charlie

Ultimately, the consensus amongst participants was that people should have the final say in any decision-making process. Nevertheless, this point does not suggest a weariness about healthcare professionals incorporating AI in their decision-making process. What is does suggest is that trustworthiness of AI is not independent from the way in which it is implemented on the ground but reliant on it.

This paper has explored the ways in which birth parents and mothers conceptualize trustworthy AI in the context of intrapartum care, filling a gap in the research on patient perspectives. A small number of qualitative studies have been published to date on patient perspectives regarding the introduction of AI tools in various parts of healthcare [ 55 , 56 , 57 ] but none, to our knowledge, on the specific area of intrapartum care that is examining the issue of trust.

Promotion of public good, reliability, fairness, personalized and holistic care, human mediation, and empathy were all deemed as necessary to the perceived trustworthiness of AI.

These findings shed new light on themes pertaining to the trustworthiness of AI and raise questions about how human values can be interpreted into the trustworthy development, design, and implementation of AI. Our findings chime with those of a large five-country survey based study regarding trust in AI [ 58 ] and shed new light on the topic by providing a more in-depth and nuanced perspective of these issues. They also raise questions about how human values can be interpreted into the trustworthy development, design, and implementation of AI. The remainder of this section explores some of these possibilities and the ethical challenges that may arise in the value-sensitive design process.

Institutions and public good

Patients and birth parents interviewed for this study expressed the view that public institutions such as universities and the NHS are more trustworthy than private companies because of their commitment to promoting public good, whereas private companies are driven by profit maximization. They attributed a moral significance in the motivation and aims of these stakeholders, which they viewed as part of their moral character and perceived trustworthiness. This position is not unique to participants of this research; other studies have also demonstrated the public’s skepticism regarding private companies’ motivations in the context of health [ 59 ]. Although there is philosophical disagreement about whether collective actors such as institutions and companies are moral actors and therefore warrant trust (or distrust) [ 60 ], this reported attitude towards universities and the NHS chimes with theoretical approaches to public trust as the trust warranted towards public institutions that aim at providing some kind of public good or benefit [ 61 ]. Motivation to serve a public good can be understood as an indication of an institution’s moral motivation and character, and thus indicate trustworthiness even if it cannot, in itself, guarantee trust.

However, research and development of medical products and devices, including medical AI, can be costly. Even if original research is led by universities using national healthcare system data, bringing these products to the patients at scale often requires budgets and expertise found in the private sector. This raises an ethical challenge for public institutions about how to involve and collaborate with private companies for the development and deployment of medical technologies, including AI, whilst preserving their trustworthiness and promoting public good.

It is important to bear in mind that public trust operates on multiple levels. As participants revealed, although they perceive public research institutions such as universities to be more trustworthy, they also trust the NHS to introduce only those technologies that are effective on the ground and beneficial to patients. This is because they rely on its processes for checking and validating the efficiency and effectiveness of new technologies, but also on its solidaristic character for making decisions that benefit all patients [ 62 ].

Collaborations between public and private institutions when it comes to the introduction of AI in healthcare could be perceived as trustworthy not because the private company would develop an interest in public good, but because a trustworthy institution would be overseeing the technology and its implementation on the ground, such as NHS Trusts or regulatory bodies that check and approve the introduction of new technologies (e.g. MHRA). A number of studies have tried to articulate criteria that would make such partnerships trustworthy. Horn and Kerasidou (2020) maintain that norms such as commitment to public good should be incorporated into these agreements. They suggest that requirements such as preferential access to technologies developed using NHS patient data, limiting the use of patient data to for-public-benefit purposes, and transparency and effective resolutions of conflicts of interests as well as use of trusted research environments to manage data use outside the NHS could promote trustworthy collaborations. Graham (2021) points at transparency, accountability, representation, and ensuring social purpose even if this at times might come to the expense of commercial gains, as ways of ensuring trust and confidence in public-private collaborations that aim at producing data-driven medical technologies like AI [ 63 ].

Data, reliability, and fairness

In the literature on CTG interpretation, reliability is expressed as one of the main potential benefits of incorporating machine learning and AI [ 40 ]. In this context, reliability refers to consistency (i.e., the same inputs producing the same outputs, unlike with humans who are subjective in their CTG interpretation), as well as accuracy (i.e., more thorough and nuanced data/inputs to generate more precise outputs). A more reliable CTG would detect more adverse perinatal outcomes while also minimizing false positive rates and unnecessary interventions [ 41 ].

Reliability, in terms of accuracy and consistency of output, was important to participants of this study. However, they also framed reliability primarily in relation to the concept of bias , thus linking reliability with the values of equity and fairness in the over- or under-representation of certain populations in datasets as well as output. In their view, a biased dataset, particularly one that did not include data from marginalized populations, such as BAME parents, was perceived as contrary to reliability. According to participants, in order for AI tools to be reliable, data used in their development should account for the heterogeneity of relevant patient populations so as not to reproduce existing social inequalities, such as worse maternal outcomes for BAME patients. With (health) equality being seen as essential for reliability, rather than a separate and additional value, the measurability of reliability is linked to justice, not consistency and accuracy alone. Furthermore, participants of this study pointed at another value, that of solidarity, which is less often mentioned in discussions regarding reliable AI [ 64 , 65 ]. By framing reliable AI as something that preserves and promotes mutual support and equal access to benefits for all populations, participants in this study might be reflecting the solidaristic character of their national healthcare system [ 62 ], as well as more widespread conceptions of healthcare as a form of public good to which all should have access [ 66 , 67 ].

There has been a considerable attention to issue of bias in the development and deployment of AI, including medical AI, and how to best understand, interpret and incorporate values such as fairness and equality in AI systems [ 68 , 69 , 70 , 71 ]. To address these issues, any weaknesses and bias in the dataset should be identified so its limitations can be understood. Then, developers can identify ways of overcoming these limitations. This might include continuous collection of more robust and inclusive data, so that the dataset itself is more representative of all population groups. Furthermore, there may be an argument for introducing fairness and equity type of considerations at the stage of product approval for medical use. One requirement might be that AI tools should produce and declare confidence or reliability scores for the different population groups to which these tools would be relevant. This way, those assessing (e.g. MHRA, FDA)—and later on, those using the tools (e.g., healthcare professionals)—might be in better position to make decisions regarding the reliability and effectiveness of these new technologies on different patient groups. Of course, this solution raises its own set of questions that relate to the way that principles of justice, fairness, and solidarity should be understood and translated into practice. For example, if AI is only reliable for some groups, should it not be used on others? If it benefits white birth parents and mothers only, then the tool could exacerbate health outcome disparities. Should there a reliability threshold AI must pass on all relevant population groups in order to be implemented on the ground?

Although this research does not provide solutions to these challenges, it nevertheless provokes the ethical questions that need to be addressed.

Decisions and holistic, patient-centered care

Participants were unanimous in their preference for decisions regarding their care being made by humans, not autonomous machines. This point reiterates the need for decisions to be mediated by healthcare professionals, but fundamentally reveals participant perceptions regarding the limits of AI in considering them as persons rather than a collection of data, as well as delivering patient-centered care [ 72 ]. There are a few ways in which design features of AI might be able to address this desire for personalized care. For example, the ability to input individual risk factors is a potential design decision that could address clinical relevancy of assessments and recommendations. Additionally, while the ability to input and personalize clinical risk factors is the most obvious way that AI-based CTG can increase personalization through design, it should also be noted that patients may have values, preferences, and risk thresholds that differ from their healthcare professionals. There is an argument to be made, then, that AI also requires value flexibility [ 73 ] to improve personalization capacities, not just flexibility in clinical inputs alone. In the case of AI-based CTG, this feature might look like adjusting for a patient’s risk threshold before an intervention is suggested.

However, although AI might be able to improve upon some aspects of personalization, the healthcare professional remains essential making individual assessments and providing patient-centered care. As Taylor’s experience highlighted, if personalization is primarily grounded in data derived from population groups (e.g., diabetics, birth parents and mothers over a certain age, etc.), patients may still feel like they are being reduced to data points and not being treated individually. There is also an argument that patient preferences and values should be considered and incorporated separately from AI-based clinical assessments. In addition, patients also want the ability to communicate back with their healthcare professionals and be part of a shared decision-making process, which requires dialogue, communication, and empathy. Ultimately, then, it is important not to focus on AI design alone but how its implementation on the ground can also enable healthcare professionals to perform more personalized, holistic, empathetic, and patient-centered medicine.

Participants’ understanding of AI as a tool at a healthcare professional’s disposal, at least in the case of AI-based CTG, aligns with its intended use case: as a decision- support tool, rather than as an autonomous decision maker . If AI is meant to be supportive rather than a replacement for healthcare professionals, guidelines should be put in place so that healthcare professionals do not over-rely on AI. Moreover, if healthcare professionals are meant to integrate this AI into their care, more research is needed on how clinical decisions are made so that this AI system can be seamlessly integrated into their practice to improve upon decision-making processes, including shared decision making with patients.

AI is often seen as a solution to inefficiency. It is thought of as something that can relieve time pressures on clinicians and alleviate the burden of staffing shortages. It is even imagined that as AI becomes more prominent in healthcare, the relationship between healthcare professionals and patients will become less important. However, despite the ever increasing kinds of technologies used in healthcare, it is evident that the trusting relationship between healthcare professionals and patients is still relevant. One participant even said that they would always see AI as a medical supplement ‘to a HCP I trusted.’ As such, developing that trusting relationship between patient and clinician is still of utmost importance—and potentially of greater significance—when introducing new technology into the healthcare space.

For this reason, any time saved with AI should be reinvested in the healthcare professional-patient relationship. This is not only so there is time and space for empathy and human-centered care, but also for improved (more holistic and personalized) clinical decision making.

Implications for OxSys Development

This research is part of a larger project to develop an AI-based CTG, OxSys. The results of this qualitative study were presented to the whole OxSys research team and discussed during group meetings. A workshop was also organized with members of the ethics group, patient involvement group, and development group to discuss the findings in more depth and consider further steps and take-home messages. During these meetings a number of action points were identified and discussed. In light of the here presented findings, the team discussed, firstly, potential strategies regarding the financing of the future development of OxSys and considered what kind of partnerships the project team should pursue. Secondly, the bias, fairness, and reliability points raised by the study participants led to a discussion regarding how the model can be continuously reevaluated and whether the model can correct for bias in the data. Furthermore, the possibility of including a confidence score for different populations as an add-on to the model was considered. Finally, and in relation to the third finding presented, the OxSys team was encouraged to see that their aim to build a decision-aid tool rather one that could be used to replace clinical expertise chimed with the views of our participants. A fruitful discussion evolved from this point regarding how risk scores could be presented to facilitate decision-making. For example, we discussed whether to present risk scores using a traffic-light color scheme, how to allow for personalization of risk assessments, whether it is possible to codify personal risk-perceptions regarding certain interventions (e.g. use of ventouse, forceps or caesarian section), and how to build in a functionality to allow users to focus on specific parameters of the risk score analysis. A number of points for actions to help refine the planned feasibility study were also extrapolated from our findings, including the point of appropriate training of healthcare professionals in using the tool.

Limitations

Although we found that we had reached data saturation after a preliminary thematic analysis of these seventeen interviews, we nevertheless recognize the limited size of our study. Further research with a greater sample size would make it easier to extrapolate themes and arguments about what birth parents and mothers (and patient groups more broadly) consider ethical and trustworthy AI. Additionally, this study did not collect personal data about participants, such as ethnicity, age, educational attainment, sexuality, and socioeconomic background. While abstaining from this kind of data collection protects participants’ privacy, it nevertheless limits the capacity for intersectional analysis. Future research may benefit from collecting this kind of data and exploring the ways in which people’s identities and experiences inform their values and world views, including where they might converge and diverge by population group (and within them, too).

Prospective participants were told that there was no need to have expertise in AI to participate in our research. However, it is worth acknowledging that research participants are a self-selecting group and may therefore be more interested in discussing the topic of our research, as well as open to talking to university researchers. Nevertheless, many interviewees explicitly stated that they felt uninformed about AI and even silly sharing what first came to mind when they thought of it (one participant laughed at herself when answering, ‘little robots on wheels’); yet, even these participants were able to think through some of ethical and practical issues that may arise with introducing new technology into maternity care. It is not possible to ascertain from our data whether our participant group were more informed or educated on issues that pertain to AI than the general population, and we concede that further research could explore the relationship between educational attainment and perceptions of AI, as well as birthing experiences more broadly. Moreover, although people who choose to participate in university research may be biased in favor of public institutions, the finding that the people find public institutions more trustworthy than private institutions, especially in a healthcare context, is corroborated by other research [ 59 ].

Finally, this research was premised on a speculative design scenario rather than lived experiences with the AI in development. In part, this was due to a practical limiting factor, namely that at the time of interviews, OxSys was not being trialed with birth parents and mothers. However, speculative research is also an important step in the process of ethical design; it enables values and perspectives of users to inform early iterations of the AI undergoing development, rather than being reduced to an afterthought. This type of approach has been referred to as ‘proactive orientation toward influencing design’ [ 3 ]. Nevertheless, further research that investigates people’s lived experiences with AI is also needed. Creating and implementing trustworthy AI is an iterative process that requires an understanding of the ethical challenges at every stage of its development [ 10 ]; therefore, the collection and evaluation of users’ perspectives should be sustained and carried forward in future research.

This paper explored birth parents’ and mothers’ perspectives regarding the trustworthiness of AI-based CTG, and more broadly, patient perspectives on the ethical issues associated with introducing AI in healthcare. The topics that participants of this study felt were most relevant to the theme of trustworthiness were institutions, including which institutions develop and implement AI; data, particularly the dataset from which AI is developed and how representative it is of various population groups; and AI-assisted decision-making, especially regarding the relative role(s) and autonomy of healthcare professionals and machines in the process. However, even though the participants of this study spoke about AI and their concerns regarding the introduction of new technology in intrapartum care, what they were really talking about was their concerns about the provision of healthcare as a whole. Underscoring these conversations about AI were the values that birth parents and mothers want to preserve in healthcare more broadly: solidarity, equality, fairness, and reliability, as well as values and practices like the promotion of public good, patient-centered care, holistic care, and personalized medicine in the healthcare system.

Ultimately, to ask what constitutes trustworthy AI in intrapartum is to consider what constitutes trustworthy healthcare in the first place. The way in which the development, design, and implementation of AI threaten or bolster the values that matter most to its users will determine how these key stakeholders evaluate its trustworthiness. Paradoxically, this means that the trustworthiness and ultimate success of AI is not dependent on its technology alone but on people —the user groups who are positioned to delineate the ethical values to preserve and maximize, and the developers, policy makers, and healthcare professionals who translate these values into design and practice.

Data availability

All relevant data are within the manuscript. The interview guide is included as a supplementary file. The data generated and analyzed during the current study are not publicly available as participants did not consent to data archiving and data will be destroyed 3 years after the end of the study as per MS IDREC requirements. Specific data is available from the first author on request.

Following the clinical and language guidelines by Brighton and Sussex University Hospitals Trust [ 12 ], we refer to this patient group as ‘birth parents and mothers.’ This approach of using ‘gender-additive language’ means that gender neutral language can coexist with language of womanhood and motherhood. This language allows transgender and non-binary parents to be included in perinatal discourse while not erasing the experiences of women. Not only is using gender-inclusive language morally responsible, but it also best represents the identities of participants of this study. At least one participant identified as non-binary, and as such, ‘birth parents and mothers’ is a more representative descriptor of the participants of this study than ‘mothers’ or ‘women.’

Abbreviations

• Artificial intelligence

Black, Asian, and minority ethnic

• Cardiotocography

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Acknowledgements

We would like to thank our research participants who willingly shared their views and perceptions for this study.

This study was funded by the UK National Institute of Health and Care Research (NIHR202117). The funding body played no role in the design of the study and collection, analysis, interpretation of data, and in writing the manuscript. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. AK was also supported by a Senior Fellowship from the Nuffield Department of Population Health at the University of Oxford.

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RD recruited participants, conducted the semi-structured interviews, coded and analyzed interview transcripts, wrote the first draft of the manuscript, and substantially revised the manuscript. AG conceived of and designed the overall project that this study used as case study and revised the manuscript. AK contributed to the design of the overall project, conceived of and designed the study, contributed to interpretation of data, and substantively revised the manuscript. All authors read and approved the final manuscript.

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This study received ethical approval from the Medical Sciences Interdivisional Research Ethics Committee (MS IDREC), a subcommittee of the Central University Research Ethics Committee (MS IDREC; R76709/RE001). All methods were carried out in accordance with relevant guidelines and regulations. The research protocol, research materials (including Participant Information Sheet, Informed Consent Form, advertising materials), and processes, including the informed consenting process described below, were assessed and approved by MS IDREC (MS IDREC; R76709/RE001).

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Dlugatch, R., Georgieva, A. & Kerasidou, A. Trustworthy artificial intelligence and ethical design: public perceptions of trustworthiness of an AI-based decision-support tool in the context of intrapartum care. BMC Med Ethics 24 , 42 (2023). https://doi.org/10.1186/s12910-023-00917-w

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Comparative study on remote sensing-based indices for urban ecology assessment: A case study of 12 urban centers in the metropolitan area of eastern India

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This study compared the effectiveness of two indices, the remote sensing ecological index (RSEI) and the comprehensive ecological evaluation index (CEEI), for assessing the ecological condition of 12 urban centers (UCs). RSEI primarily focused on vegetation cover using the normalized difference vegetation index (NDVI), while CEEI provided a more comprehensive evaluation by incorporating the vegetation health index (VHI) as an additional measure. The results indicated that Baruipur and Chandannagar exhibited relatively good ecological conditions based on both RSEI and CEEI, while Kolkata showed the poorest ecological condition among the analyzed UCs. CEEI displayed a wider range of values, reflecting a more comprehensive assessment of ecological conditions compared to RSEI. Spatially, Chandannagar consistently showed better ecological conditions, while Kolkata had the highest proportion of areas categorized as below average and declining in both indices. The study emphasized the importance of considering ecological conditions in urban planning processes and suggested incorporating RSEI and CEEI into such practices to ensure the conservation and enhancement of ecological health. However, it was noted that CEEI performed comparatively better than RSEI due to its ability to incorporate the vegetation health index, providing a more holistic assessment of ecological conditions. The study recommended refining and expanding the indices used in RSEI and CEEI by incorporating more relevant factors of urban ecology and utilizing advanced remote sensing techniques and high-resolution imagery. Overall, this study underscored the superiority of CEEI over RSEI in assessing urban ecology, enabling informed decisions for sustainable development and preservation of ecological health in urban areas.

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• urban centers

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Life cycle sustainability assessment of waste to energy systems in the developing world: a review.

1. Introduction

2. materials and methods, 3. overview of waste to energy technologies, 4. sustainability assessment of waste to energy technologies, 4.1. life cycle sustainability assessment for waste to energy technologies, 4.2. life cycle assessment for waste to energy technologies, 4.3. life cycle costing for waste to energy technologies, 4.4. social life cycle assessment for waste to energy technologies, 4.5. integration of lcsa components: lca, lcc and slca.

• Multi-attribute decision-making (MADM) methods, which are used to assess a finite set of options based on multiple criteria attributes;
• Multi-objective decision-making (MODM) methods, which are used to identify and evaluate Pareto optimal solutions on the efficient frontier of a mathematically constrained solution space;
• Data envelopment analysis (DEA), which is applied to analyze the efficiency of a sample of alternatives if the efficient frontier is not known [ 170 ].

5. Discussion

• Further research work on the techno-economic, environmental, and social implications of a hybrid implementation of WtE systems is required.
• More research work should be aimed towards the comprehensive study of new technologies, such as torrefaction, plasma arc gasification, fermentation (bio-ethanol production), bio-hydrogen production, use of microbial fuel cells, and esterification.
• Given the different performance of WtE technologies from a technical, economic, environmental, and social perspective based on qualitative and quantitative standards, the adoption of multi-criteria-based approaches that can simultaneously consider qualitative and quantitative criteria should be a platform for future work.

6. Conclusions and Further Research

• Continuing research and methodological development to ensure consistency, equity, and balance among the environmental, economic, and social domains of LCSA.
• Further enhancement of the data and stakeholder engagement processes to develop more regionally specific, recent, and relevant economic and social data. This should include further research on approaches to identify, prioritize, and calibrate social indicators in the sLCA component of LCSA.
• Methods to represent and calibrate the uncertainties in LCSA and its components should be further improved [ 68 ].
• Additional research on the combination and integration of LCSA results using multi-criteria decision-making frameworks and/or optimization models.

Author Contributions

Data availability statement, acknowledgments, conflicts of interest.

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Nubi, O.; Murphy, R.; Morse, S. Life Cycle Sustainability Assessment of Waste to Energy Systems in the Developing World: A Review. Environments 2024 , 11 , 123. https://doi.org/10.3390/environments11060123

Nubi O, Murphy R, Morse S. Life Cycle Sustainability Assessment of Waste to Energy Systems in the Developing World: A Review. Environments . 2024; 11(6):123. https://doi.org/10.3390/environments11060123

Nubi, Oluwaseun, Richard Murphy, and Stephen Morse. 2024. "Life Cycle Sustainability Assessment of Waste to Energy Systems in the Developing World: A Review" Environments 11, no. 6: 123. https://doi.org/10.3390/environments11060123

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