How are small states defined in public health? A scoping review across 25 years of literature

Background

Small states face distinct public health challenges, including limited workforce capacity, restricted economies of scale, and heightened vulnerability to external shocks. However, inconsistent definitions of “small state” hinder meaningful comparisons, evidence synthesis, and policy development. The aim of this study was to examine how “small states” are defined in public health literature and assess implications for research, comparability, and policy relevance.

Methods

A scoping review was conducted following PRISMA-ScR. Four databases were searched for studies defining or characterising small states in a public health context published between 2000 and 2025. Definitions were analysed across six dimensions: population, geography, economic, political, socio-cultural, and framework-based classifications. A narrative synthesis and typology analysis were performed.

Results

A total of 124 studies were included. Population-based definitions were most common but varied widely (<1 million to < 5 million). Most studies (92.8%) used hybrid definitions combining multiple dimensions, most frequently population with geographic or economic criteria. Framework-based approaches were also prevalent. While conceptual clarity was generally moderate, justification and theoretical grounding were often limited. Over time, there was a clear shift toward multidimensional and vulnerability-informed definitions.

Conclusions

Definitions of “small states” are highly heterogeneous, yet most studies rely on hybrid, multidimensional approaches combining population with geographic and economic criteria. These factors limit cross-country comparability and hinder the ability to generate generalisable evidence for small states within global health research. Establishing a consensus-based, context-sensitive framework is critical to strengthen international benchmarking, inform global policy processes, and support coordinated action across small and similarly constrained settings.

Key messages

• Small states face unique public health challenges, but inconsistent definitions limit comparability and weaken the evidence base guiding policy and resource allocation.

• Adopting a consensus-based hybrid, multidimensional definition of small states is essential to improve comparability, evidence synthesis, and public health policy and resource allocation.