The systematic review followed PRISMA guidelines [26] and was preregistered in PROSPERO (BLINDED FOR REVIEW) on 03.05.2024. Searches were conducted on 22.01.2024 across seven databases. The initial search included title and abstract searches, however, due to the overwhelming volume of studies returned by database queries, searches in EBSCOhost, ProQuest, and Web of Science were limited to titles, while PubMed included both title and abstract searches. This method aimed to obtain balance between comprehensiveness and feasibility, ensuring the search process remained manageable while still capturing pertinent studies relevant to the review’s objectives. According to the Population, Intervention, Comparison, Outcome (PICO) framework [27] keywords covered the population (e.g., secondary school, high school), intervention (e.g., education, promotion) in regard to the context (e.g., health, medical). Comparison and outcome were not defined to include interventions of different designs beyond controlled trials and addressing different outcomes to be grouped qualitatively in the qualitative synthesis. A manual citation search of relevant reviews was also performed to identify additional sources. Supplementary Material A includes the search string for each database.

Studies were included if they: (1) reported on planned healthcare career promotional activities for secondary school students, (2) focused on participants aged 12–18, (3) were published between 2013–2024, (4) peer-reviewed journal publications, and (5) examined knowledge, interest, attitudes, career pathways, or related concepts. Exclusion criteria included: (6) lack of explicit reporting on relevant outcomes, (7) non-career interventions, (8) focus on non-secondary school populations, (9) mixed-age participant groups without separation, (10) primary focus on academic preparation, (11) non-direct patient care healthcare career focus, (12) non-English full text, and (13) multimedia publications, theses, protocols, conference proceedings, book chapters, and reviews. Only promotional initiatives for direct patient care careers were considered, excluding healthcare research careers. For example, initiatives promoting careers in cancer research would be excluded whereas initiatives promoting a career as an oncologist would be included. Science, technology, engineering and math (STEM) initiatives were excluded unless explicitly referencing direct patient care careers. Academic preparatory programs were also excluded unless they served as a supplementary component rather than the primary focus.

Results from databases and citation searches were screened with a two-phase process. The initial phase consisted of title and abstract screening. Papers retained in this phase were then assessed for full-text screening. Among the full-text articles, only those meeting the eligibility criteria were included. The entire selection process was completed by the first author. In select cases, where the inclusion status of a study was not clear, consensus was achieved via consultation with the second author. The selection process was performed in the time frame from 02.02.2024 to 01.04.2024.

For each of the studies eligible for the systematic review, the following information were collected and reported into an Excel file: author’s name, year of publication, initiative name, goal/objective of the initiative, study design, sample, target population, theory, initiative provider, initiative description (format, special design features, setting, duration, activities, planning and preparation, funding) and evaluation (outcome of interest, methods and results). Results were coded whether the estimated overall effect increased (+), had no effect (N.S), or decreased (−).

Once collected, all data were reviewed and categorized. Outcomes were categorized into one or more of the predefined categories in line with the Adapted MOA model, including knowledge, interest, attitudes, and career pathways. Initiative formats were categorized into eight broad types guided by the following definitions: (1) afterschool program (i.e., a series of structured sessions specifically designed to support students’ exploration of healthcare careers outside regular school curriculum and regular school hours), (2) course (i.e., formal academic course with defined learning objectives and assessment), (3) enrichment camp (i.e., a short-term, immersive experience designed to introduce student participants to various aspects of healthcare professions), (4) exposure event (i.e., a structured event exposing students to different healthcare careers, settings, roles and activities), (5) exposure program (i.e., a series of intermittent events exposing students to different healthcare careers, settings, roles and activities), (6) internship (i.e., hands-on experience in a professional healthcare setting), (7) mentorship (i.e., pairing students with healthcare representatives to provide guidance, support and insights), (8) continuum (i.e., a multi-session, continuous support program).

To assess the risk of bias, modified versions of established checklists were used, including adaptations of Consolidated Criteria for Reporting Qualitative Research (COREQ) [28], Case Report (CARE) guidelines [29], and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist [30]. Adjustments were made to fit the context of healthcare career promotion initiatives for secondary students. Each study was graded based on relevant checklist criteria, with scores converted to a 0–1 scale for cross-methodological comparison. Studies were categorized as high (0.75–1.0), moderate (0.50–0.74), or poor quality (0–0.49) based on methodological rigor and risk of bias, following Cochrane Handbook guidelines [31]. The adapted checklist is in Supplementary Material B.

Initiatives were predominately U.S. based, targeted towards underrepresented in medicine (URiM) and rural populations with the goals of increasing healthcare workforce diversity and rural healthcare workforce development. The overrepresentation of U.S.-based initiatives may stem from policy-driven efforts to increase healthcare workforce diversity [82], while the lack of European literature could be due to a focus on immediate workforce retention or due to the educational structure across most European nations, in which several systems consist of compulsory education followed by choice of educational tracks around age 15, usually between vocational and more academic paths [83]. This early career direction choice may result in a more integrated approach to career education being embedded earlier within school systems.

Concerning objectives, most initiatives focused on careers in nursing and medicine, reflecting a primary emphasis on these fundamental healthcare fields. However, many included specialized roles such as pharmacy, physical therapy and medical technologist positions. The diversity of career focus in these initiatives indicates an effort to broaden students' exposure to various healthcare pathways, yet the absence of certified nursing assistants (CNA) and healthcare aid professions is a notable gap, with only one publication specifically mentioning geriatric healthcare workers [71]. This is particularly relevant given increasing demand for long-term care workers and the ageing population requiring more comprehensive care [2]. The limited inclusion of these roles may reflect broader societal perceptions of these professions as less desirable careers, which may contribute to their underrepresentation in career promotion initiatives. Given the high turnover and workforce shortages in these professions [84], greater attention to their inclusion in early career initiatives may be warranted to challenge perceptions and ensure a well-rounded healthcare workforce.

Concerning the format, initiatives consistently highlighted the importance of hands-on activities and the inclusion of healthcare professionals in program delivery as suggested by various career theories and policy recommendations [15, 85]. Curricular design varied, ranging from disease-based approaches to medical scenario integration. Integrating medical simulations in the curriculum allows students to understand healthcare processes, from time of injury/symptom to diagnosis and treatment. They further allow students to recognize the professions that may be involved at each stage of care, while also educating students about specific diseases and injuries. Both approaches, along with body system designs and community health/health disparity initiatives, are valuable for their two-fold benefits. They increase awareness of direct patient care healthcare careers and enhance student health literacy, in terms of both procedural knowledge of healthcare systems and personal health. These benefits can lead to improved health outcomes and reduced unnecessary healthcare spending in the future.

As virtual and hybrid forms of delivery become more common, initiatives like The Saturday Academy [36] and MAYO Clinic CARES [74] suggest that digital and technology-enabled formats can achieve effectiveness comparable to in-person programs. The Saturday Academy is a 14-week weekly afterschool program designed to expose students to the field of dentistry, delivered fully virtually during the COVID-19 pandemic. The Mayo Clinic CARES program was also delivered during the COVID-19 pandemic in either hybrid or fully virtual formats, typically consisting of a 1-week enrichment camp followed by distance mentoring throughout the subsequent academic year. These approaches may expand reach to underserved populations by reducing geographic, logistical, and resource-related barriers; however, their implementation must account for persistent challenges related to the digital divide, including unequal access to reliable internet, devices, and digital literacy [86, 87]. In addition, successful adoption of virtual formats requires attention to infrastructure reliability, data privacy and security, availability of IT personnel, and ongoing troubleshooting and technical support. A gap identified through this review is the limited exploration of emerging technologies for direct patient care career promotion. Among these, virtual reality represents a promising example of a technology-enabled approach that could enhance access, particularly for rural and Indigenous students, by offering immersive career exploration experiences that may help mitigate the extent to which physical barriers and systemic disparities restrict access to career exploration opportunities commonly faced by these populations [88, 89]. Indigenous youth still face more barriers in terms of educational opportunities, due to reservation distance from urban centers and facilities, reduced networks and resources outside of reservations and higher safety and discrimination concerns [89]. In light of these barriers, it was questioned whether enrichment camp models requiring travel to urban centers are an appropriate method for indigenous populations [53]. Although virtual reality is well established in healthcare professional training [90–93], its application for secondary-level career exploration remains under-studied, as also highlighted by the Organisation for Economic Co-operation and Development (OECD) [94].

Another important finding from this review concerns the heterogeneity of target populations. Many initiatives focused on increasing healthcare workforce diversity, particularly for URiM groups like African American and Hispanic/Latinx students. However, some racial and ethnic minorities, such as Indigenous, Arabic, and Muslim students, were often overlooked, and LGBTQ+ identities were only considered in one initiative [43]. In order to create a truly inclusive healthcare workforce, capable of reducing health disparities and discrimination, it is essential to broaden the scope of these initiatives to include these often overlooked groups, while also ensuring programs address the historical and structural barriers that often limit these individuals from entering the healthcare workforce in the first place. Initiatives that were committed to diversity included targeted recruitment, culturally responsive curricula, and mentorship opportunities, but some lacked genuine commitment, appearing superficially aligned with diversity goals—potentially seeking funding without implementing substantial measures, such as failing to report URiM participant statistics in evaluations [45, 54–56] or omitting targeted recruitment for URiM populations [33, 38, 50, 74]. While these initiatives aim to address disparities through this targeted support and resource provision, it is important to remember that they operate within broader structural and systemic inequities, meaning their impact may be limited by factors beyond the scope of program design.

Furthermore, most initiatives were voluntary, requiring applications of self-selecting populations of students. A lack of school-mandated programs was observed, and is felt to be a missed opportunity, as such programs can clarify career aspirations and equalize opportunities for disadvantaged students [95]. While voluntary initiatives attract students already interested in direct patient care careers, mandatory initiatives can increase exposure to a wider range of students, fostering broader interest.

In contrast to what is suggested by career theories about beginning career exploration early [14, 15, 96], most initiatives targeted the 11th and 12th grades (ages 16–18). Super’s Developmental Self-Concept Theory suggests that direct patient care healthcare career initiatives should focus on early grades (7th to 9^th, ages 12–15) to build knowledge and positive attitudes, laying the foundation for vocational self-concepts, which refers to an individual’s perception of their abilities, interests, and identity in relation to career choices, before students enter the exploration phase in high school. Initiatives targeting youth in the growth and early exploration stages should therefore be mandatory, ensuring all students develop vocational interests, while resources are allocated efficiently to maximize impact, particularly for students who may lack exposure to these careers. Considering the theoretical evidence, it may be too late for students in 11th and 12th grade to fully explore and develop their knowledge and interests in direct patient care careers. This aligns with the initiative’s evaluations results, where a large portion of reviewed studies [32, 41, 43, 46, 47, 51, 63, 65, 79] reported participants having pre-existing interest in direct patient care careers, suggesting that interest is formed earlier.

Overall, initiatives promoting direct patient care career pathways, regardless of objective or format, were successful in increasing knowledge, changing attitudes, and influencing career pathways. While programs were generally effective in maintaining or reinforcing student interest, they were not always successful in increasing it. Of all the assessed outcomes, interest most frequently saw non-significant changes post-program, with several publications attributing this to a possible ceiling effect where students already had high levels of interest prior to program participation [32, 35, 62].

Yet, interest, attitude, knowledge and career pathway outcomes are interrelated, which implies that direct patient care career interventions for secondary-level students often aim to address multiple facets of career exploration simultaneously. This interrelationship underscores the applicability of the Adapted MOA Model (Figure 1), which provides a useful framework for understanding how these variables interact and contribute to shaping career pathways. For example, the healthcare diversity summer enrichment camp for grades 10–12 provided a 5-day, campus-based voluntary program where students engaged with healthcare professionals and students across pharmacy, nursing, and dental medicine through lectures, simulations, laboratory activities, and campus tours, while also learning about admissions pathways, financial aid, and career opportunities. This program reported positive outcomes in interest, knowledge, and career pathway intentions [38].

The long-term impact of initiatives, such as choosing a healthcare career pathway or sustained interest in direct patient care careers, has remained to be comparatively under investigated. Several authors highlight that this gap is largely due to practical constraints, including limited funding [36, 69, 73], human and infrastructural resources [43, 53, 76], and the absence of mechanisms to track participants over time [33, 43, 44, 50, 69, 75]. Without these resources, long-term assessments are challenging, particularly for hard-to-reach populations targeted by many rural and URiM programs. To mitigate these challenges, establishing participant tracking mechanisms at the onset of programs is recommended, with surveys that allow for participant matching identified as a feasible method for follow-up [38, 64, 72, 73]. In settings with limited resources, highly resource-intensive evaluation methods are generally discouraged, highlighting the need for practical and sustainable tracking strategies. As a result, it remains unclear whether short-term outcomes, such as increased interest or improved attitudes, translate into actual entry into, or retention within, healthcare career pathways.

The success of initiatives was influenced by policy landscapes, community involvement, funding, partnerships, and flexibility. Policy landscapes shaped funding availability and institutional support, often prompting local advocacy efforts and organizational backing to sustain initiatives. Engaging community stakeholders and demonstrating tangible, long-term benefits fostered sustained support, particularly in rural or medically underserved areas. While funding remains crucial, strategic planning and community involvement can enable initiatives to thrive even with limited resources [69, 76]. Beyond establishing partnerships, success requires a deep understanding of partner priorities, policies, and operational frameworks to align efforts effectively. Ultimately, cultivating strong, strategic partnerships and maintaining flexibility in initiative design and implementation are equally—if not more—critical than funding, ensuring initiatives can adapt to diverse needs and drive long-term impact.

However, the potential impact of increased early interest must be interpreted within broader contextual and system-level factors, including existing healthcare workforce shortages and downstream training capacity constraints, including limited professional school seats, clinical placement availability and levels of government and institutional support for expanding training capacity. While most included initiatives were delivered through universities, colleges, and/or in partnership with healthcare institutions, suggesting strong integration within existing training environments; this does not eliminate broader system-level capacity constraints. As a result, increased participation in such initiatives may still lead to increased competition for entry into professional programs. Such competition is not inherently negative and may support the selection of highly motivated candidates, provided workforce expansion occurs in parallel. These realities may also be usefully acknowledged within program design, for example, by preparing students for competitive selection processes and potential rejection as part of career development support.

The SEM [15] can guide direct patient care career initiative development by emphasizing the importance of considering these multiple contextual factors of influence. Effective initiatives should integrate microsystems such as peer groups, family, schools, and workplaces, while also considering exosystems like geographic location and socio-economic status to ensure accessibility. Additionally, broader macrosystem considerations, such as inclusive representation and retention strategies, should be incorporated to address issues like healthcare workforce shortages and to align with generational preferences, especially for digital natives like Generation Z and Alpha. Initiatives should incorporate technology and flexible learning environments to enhance engagement and appeal to the evolving preferences of future healthcare professionals.

The Integrated MOA-Informed Model (Figure 4) suggests that incorporating the review’s findings—along with developmental-stage-appropriate activities and socio-ecological influences—into initiative design can enhance youth knowledge, interest, and attitudes toward direct patient care careers, and ultimately healthcare career pathways. Specifically, Super’s Developmental Self-Concept Theory [14] informs age-appropriate engagement strategies, and the SEM [15] highlights the impact of environmental influences (peers, schools, workplaces, and broader systems). Together, these elements create a structured approach recommended for designing future sustainable and impactful initiatives that influence healthcare career pathways.

The conclusions drawn from this review are hampered by some limitations that need to be acknowledged. The predominance of studies from North America limits the generalizability of the findings particularly regarding the educational systems of other countries and applicability to low-middle income countries. Differences in education systems and workforce policies may influence both the implementation and relevance of such initiatives across regions. Educational structures shape when and how career exposure occurs, and policy priorities influence which strategies are funded (e.g., long-term early recruitment strategies versus short-term workforce needs) and shape the goals and design of early career initiatives. As a result, variation in both policy contexts and educational structures across regions may limit the direct applicability of these initiatives in other settings.

There is also a lack of standardized outcome measurement and theory-based literature, along with limited subgroup analysis based on participant age or grade, restricting our understanding of how different age groups are impacted. Additionally, the review excluded non-English publications and was conducted by a single screener with a North American perspective. Future research should address these limitations by exploring primary school programs, age-specific impacts, long-term success, including retention within healthcare professions in addition to initial entry, and the integration of new technologies like virtual reality and social media. Investigating program influence on health literacy, would also be valuable, as would further exploring the relationship between program outcomes and career pathways, particularly by controlling for pre-existing interest and age factors.