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A practical guide for health researchers

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Health sciences articles from across Nature Portfolio

The health sciences study all aspects of health, disease and healthcare. This field of study aims to develop knowledge, interventions and technology for use in healthcare to improve the treatment of patients.

Decoding the phenotypic mosaic of aging

The Integrated Care for Older People program of the World Health Organization is intended as a catalyst to empower communities to cocreate personalized interventions and usher in an era of precision healthy longevity, in which the needs, values and preferences of older people are centered. A study from France now presents early screening data and reveals distinct phenotypic trajectories towards adverse outcomes.

• Liang-Kung Chen

Years lived with and years lost to multiple long-term condition combinations that include diabetes

We introduced time-based metrics to analyze multiple long-term condition (MLTC) combinations of two or more conditions that include diabetes, among adults in England. We calculated the median age of MLTC onset and years of life lived with and lost to the MLTC, and examined MLTC burdens from both individual perspectives and community perspectives.

Changes in the glycosylation of circulating IgG predict future Crohn’s disease onset

Patients with Crohn’s disease display an altered serum IgG glycosylation signature that is detectable many years before clinical diagnosis and is associated with increased levels of pathogenic anti-mannan antibodies. The altered IgG glycoforms activate innate immune cells, in a preclinical phase, promoting the transition to intestinal inflammation.

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Latest Research and Reviews

A real-world observation of patients with glioblastoma treated with a personalized peptide vaccine

Despite new treatment options, prognosis for patients with glioblastoma (GBM) remains poor. Here the authors report the clinical course of patients with GBM treated with a personalized neoantigen-derived peptide vaccine treated within the scope of an individual healing attempt.

• Pauline Latzer
• Henning Zelba
• Saskia Biskup

Pseudodominant inheritance of retinitis pigmentosa in a family with mutations in the Eyes Shut Homolog ( EYS ) gene

• Enzo Di Iorio
• Ginevra Giovanna Adamo
• Francesco Parmeggiani

Disparities in clinical studies of AI enabled applications from a global perspective

• Sabarinath Vinod Nair

The effect of education based on planned behavior theory on women’s knowledge and attitudes about human papillomavirus

• Leila Rafeie
• Fatemeh Vizeshfar
• Narjes Nick

Correlation analysis between renal papillae Hounsfield density (PHD) and endoscopic papillary description in stone formers

• Christophe Almeras
• Jacques Assoun
• Benjamin Pradere

Associations of adipose insulin resistance index with pancreatic β cell function (inverse) and glucose excursion (positive) in young Japanese women

• Satomi Minato-Inokawa
• Keisuke Fukuo

News and Comment

Unlocking implant success: the impact of surgical techniques on primary stability in the posterior maxilla.

• Sundas Jamil

What is the potential of antibacterial, antiviral and antifungal photodynamic therapy in dentistry?

• Ana Luisa Amaral
• Michael R. Hamblin
• Sérgio Araújo Andrade

Comment on: Prescribing semaglutide for weight loss in non-diabetic, obese patients is associated with an increased risk of erectile dysfunction: a TriNetX database study

• Selman Unal

Fragmentation in medicine harms patients and hinders research

Transforming the fragmented silos of medicine into a wheel of collaboration holds the key to tackling complex health challenges for generations to come.

• Vivek Subbiah

Utility of PSA screening in transgender women receiving oestrogens

• Maria Chiara Masone

Urology’s carbon footprint

• Louise Lloyd

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Statement of dr. diana zuckerman, president, national center for health research, march 8, 2023.

March 8, 2023: Today the FDA announced that 19 women were reported in medical publications who developed squamous cell carcinoma (SCC) in the capsule around breast implants. This is more than the 10 women that FDA reported in September. Several of the women died.  It is important to know that 24 cases of SCC have been reported to the FDA, but it is not known if these cases overlap with the 19 that were published or if some of the 24 cases were reported more than once. Some of the women had silicone gel implants, some had saline implants, some textured, some smooth.  Some of the women got breast implants for augmentation, others for reconstruction after mastectomy.  That means that all women with breast implants need to be aware of this risk, even though it may be rare.

Last September, the FDA also reported 12 cases of lymphomas different from anaplastic large cell lymphoma (ALCL) that were also caused by breast implants.  The agency has not updated those numbers.

NCHR Report:  Breast Implant Illnesses: What’s the Evidence?

Debate swirls over the risks of breast implants, and physicians and patients are justifiably confused by the conflicting information available.  Despite surgeons’ claims that implants are proven safe, more than 70,000 women with breast implants have reported that they have serious symptoms that they refer to as “breast implant illness.”  Our new report finds clear evidence that implants increase the chances of those symptoms and removing implants usually improves’ their health.  Women considering breast implants after mastectomy or for cosmetic reasons will want to know about this report and of this Patient Informed Consent   checklist and black box warning .  The checklist and black box warning were developed by the Breast Implant Working Group, which consisted of Dr. Diana Zuckerman (National Center for Health Research), a past and current president of the American Society of Plastic Surgeons, Karuna Jaggar (Breast Cancer Action), Judy Norsigian (Our Bodies Ourselves) and breast implant patient advocates.  The checklist was endorsed by their organizations, as a requirement to be read and signed by all potential breast implant patients.

NCHR Report: The Health Risks of MRIs with Gadolinium-Based Contrast Agents

Magnetic resonance imaging (MRI) is a common diagnostic procedure that can improve the quality of medical care and save lives. Gadolinium-based contrast agents are used with MRIs to improve diagnostic accuracy. However, in 2006, it was determined that patients with severe kidney dysfunction who underwent MRIs with contrast could develop a serious condition called nephrogenic systemic fibrosis (NSF).  In recent years, there is increasing concern that gadolinium can be harmful even for patients whose kidneys are not impaired.  Read this  report to learn more.

NCHR Report:  Is TMS Proven Effective for Depression?

Transcranial magnetic stimulation (TMS) devices have stimulated the brains of tens of thousands of patients in the U.S., often as a treatment for depression.  TMS treatment typically costs $300 per session, usually 5 days/week for 4 to 6 weeks.  And yet, there is no clear evidence that it works at all, or is more beneficial than the much less expensive and more convenient antidepressant medications.  This report examines the questionable effectiveness of TMS, and could save you thousands of dollars and a very frustrating experience.

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Research to reduce health threats from climate change.

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Placebo Workshop: Translational Research Domains and Key Questions

Date and time.

The National Institute of Mental Health (NIMH) will host a virtual workshop on the placebo effect. The purpose of this workshop is to bring together experts in neurobiology, clinical trials, and regulatory science to examine placebo effects in drug, device, and psychosocial interventions for mental health conditions.

Topics will include interpretability of placebo signals within the context of clinical trials, how to isolate active response from placebo effects, and psychosocial implications of placebo response.

The workshop will be open to the scientific community and the public at large.  

Sponsored by

The National Institute of Mental Health’s  Division of Translational Research (DTR) .

Registration

This workshop is free, but registration is required   .

If you have questions about this workshop or need reasonable accommodations, please email Doug Meinecke, Ph.D. and Erin King, Ph.D. Requests need to be made five business days before the event. 

Day 1. Thursday, July 11

12:00-12:05 p.m.

NIMH Welcome Remarks

Shelli Avenevoli, Ph.D.  NIMH staff

12:05-12:20 p.m.

Introduction and Workshop Overview

• Workshop goals
• Placebo definition
• Introduction to placebo mechanisms

Tor Wager, Ph.D.

12:20-1:10 p.m.

Historic Perspectives on Placebo in Drug Trials

• Industry and regulatory perspectives

Part 1: The Scale of the Placebo Problem , Ni Aye Khin, MD

Part 2: Strategies and Results , Michael Detke, MD, Ph.D.

1:10-1:35 p.m.

Current State of Placebo in Regulatory Trials

• Mitigation and control of placebo response in drug trials

Title TBD Tiffany Farchione, M.D., FAPA

1:35-1:50 p.m.

1:50-2:30 p.m.

Current State of Placebo in Device Trials

• Historical perspectives and current challenges

Sham in device trials: Historical perspectives and lessons learned , Sarah Hollingsworth “Holly” Lisanby, MD

Challenges and Strategies in Implementing Effective Sham Stimulation for Noninvasive Brain Stimulation Trials , Zhi-De Deng, Ph.D.

2:30-3:10 p.m.

Current State of Placebo in Psychosocial Trials

• How is placebo defined in the context of psychosocial interventions?

What is the psychosocial “placebo pill”? Transferring the Placebo Construct to  Psychosocial Trials ,   Winfried Rief, Ph.D.

A social neuroscience approach to placebo analgesia,  Lauren Atlas, Ph.D.

3:10-4:00 p.m.

Panel Discussion

• Identification of gap areas and current challenges

Moderators: Carolyn Rodriguez, M.D., Ph.D. Alexander Talkovsky, Ph.D. All Day 1 and Day 2 speakers

Day 2. Friday, July 12

12:00-12:15 p.m.

Day 1 Recap and Day 2 Overview

Cristina Cusin, M.D.

12:15-1:30 p.m. (6, 20-minute talks with 5 minutes for questions each)

Measuring & Mitigating the Placebo Effect

• What are the basic mechanisms of the placebo response?
• Cross cutting commonalities in predicting placebo response
• Psychosocial and interpersonal effects

Placebo and nocebo effects: Predictive factors in laboratory settings, Luana Colloca, MD, Ph.D.

Genetics and the Placebo Response in Clinical Trials and Medicine, Kathryn Hall, Ph.D., MPH

Disentangling the physiological, psychological and neural mechanisms supporting mindfulness-based analgesia from placebo , Fadel Zeidan, Ph.D

1:30-1:40 p.m.

1:40-2:55 p.m.

Measuring & Mitigating the Placebo Effect (continued)

• Which outcomes are susceptible to placebo response?
• What are other measures of placebo response besides biological?
• Novel biological and behavioral approaches to address the placebo effect in research

2:55-3:55 p.m.

Moderators: Ted Kaptchuk, M.D. Matthew Rudorfer, M.D. All Day 1 and Day 2 speakers

3:55-4:00 p.m.

Closing Remarks

Cristina Cusin, MD

Research Topics & Ideas: Healthcare

100+ Healthcare Research Topic Ideas To Fast-Track Your Project

Finding and choosing a strong research topic is the critical first step when it comes to crafting a high-quality dissertation, thesis or research project. If you’ve landed on this post, chances are you’re looking for a healthcare-related research topic , but aren’t sure where to start. Here, we’ll explore a variety of healthcare-related research ideas and topic thought-starters across a range of healthcare fields, including allopathic and alternative medicine, dentistry, physical therapy, optometry, pharmacology and public health.

NB – This is just the start…

The topic ideation and evaluation process has multiple steps . In this post, we’ll kickstart the process by sharing some research topic ideas within the healthcare domain. This is the starting point, but to develop a well-defined research topic, you’ll need to identify a clear and convincing research gap , along with a well-justified plan of action to fill that gap.

If you’re new to the oftentimes perplexing world of research, or if this is your first time undertaking a formal academic research project, be sure to check out our free dissertation mini-course. In it, we cover the process of writing a dissertation or thesis from start to end. Be sure to also sign up for our free webinar that explores how to find a high-quality research topic.

Overview: Healthcare Research Topics

• Allopathic medicine
• Alternative /complementary medicine
• Veterinary medicine
• Physical therapy/ rehab
• Optometry and ophthalmology
• Pharmacy and pharmacology
• Public health
• Examples of healthcare-related dissertations

Allopathic (Conventional) Medicine

• The effectiveness of telemedicine in remote elderly patient care
• The impact of stress on the immune system of cancer patients
• The effects of a plant-based diet on chronic diseases such as diabetes
• The use of AI in early cancer diagnosis and treatment
• The role of the gut microbiome in mental health conditions such as depression and anxiety
• The efficacy of mindfulness meditation in reducing chronic pain: A systematic review
• The benefits and drawbacks of electronic health records in a developing country
• The effects of environmental pollution on breast milk quality
• The use of personalized medicine in treating genetic disorders
• The impact of social determinants of health on chronic diseases in Asia
• The role of high-intensity interval training in improving cardiovascular health
• The efficacy of using probiotics for gut health in pregnant women
• The impact of poor sleep on the treatment of chronic illnesses
• The role of inflammation in the development of chronic diseases such as lupus
• The effectiveness of physiotherapy in pain control post-surgery

Topics & Ideas: Alternative Medicine

• The benefits of herbal medicine in treating young asthma patients
• The use of acupuncture in treating infertility in women over 40 years of age
• The effectiveness of homoeopathy in treating mental health disorders: A systematic review
• The role of aromatherapy in reducing stress and anxiety post-surgery
• The impact of mindfulness meditation on reducing high blood pressure
• The use of chiropractic therapy in treating back pain of pregnant women
• The efficacy of traditional Chinese medicine such as Shun-Qi-Tong-Xie (SQTX) in treating digestive disorders in China
• The impact of yoga on physical and mental health in adolescents
• The benefits of hydrotherapy in treating musculoskeletal disorders such as tendinitis
• The role of Reiki in promoting healing and relaxation post birth
• The effectiveness of naturopathy in treating skin conditions such as eczema
• The use of deep tissue massage therapy in reducing chronic pain in amputees
• The impact of tai chi on the treatment of anxiety and depression
• The benefits of reflexology in treating stress, anxiety and chronic fatigue
• The role of acupuncture in the prophylactic management of headaches and migraines

Topics & Ideas: Dentistry

• The impact of sugar consumption on the oral health of infants
• The use of digital dentistry in improving patient care: A systematic review
• The efficacy of orthodontic treatments in correcting bite problems in adults
• The role of dental hygiene in preventing gum disease in patients with dental bridges
• The impact of smoking on oral health and tobacco cessation support from UK dentists
• The benefits of dental implants in restoring missing teeth in adolescents
• The use of lasers in dental procedures such as root canals
• The efficacy of root canal treatment using high-frequency electric pulses in saving infected teeth
• The role of fluoride in promoting remineralization and slowing down demineralization
• The impact of stress-induced reflux on oral health
• The benefits of dental crowns in restoring damaged teeth in elderly patients
• The use of sedation dentistry in managing dental anxiety in children
• The efficacy of teeth whitening treatments in improving dental aesthetics in patients with braces
• The role of orthodontic appliances in improving well-being
• The impact of periodontal disease on overall health and chronic illnesses

Tops & Ideas: Veterinary Medicine

• The impact of nutrition on broiler chicken production
• The role of vaccines in disease prevention in horses
• The importance of parasite control in animal health in piggeries
• The impact of animal behaviour on welfare in the dairy industry
• The effects of environmental pollution on the health of cattle
• The role of veterinary technology such as MRI in animal care
• The importance of pain management in post-surgery health outcomes
• The impact of genetics on animal health and disease in layer chickens
• The effectiveness of alternative therapies in veterinary medicine: A systematic review
• The role of veterinary medicine in public health: A case study of the COVID-19 pandemic
• The impact of climate change on animal health and infectious diseases in animals
• The importance of animal welfare in veterinary medicine and sustainable agriculture
• The effects of the human-animal bond on canine health
• The role of veterinary medicine in conservation efforts: A case study of Rhinoceros poaching in Africa
• The impact of veterinary research of new vaccines on animal health

Topics & Ideas: Physical Therapy/Rehab

• The efficacy of aquatic therapy in improving joint mobility and strength in polio patients
• The impact of telerehabilitation on patient outcomes in Germany
• The effect of kinesiotaping on reducing knee pain and improving function in individuals with chronic pain
• A comparison of manual therapy and yoga exercise therapy in the management of low back pain
• The use of wearable technology in physical rehabilitation and the impact on patient adherence to a rehabilitation plan
• The impact of mindfulness-based interventions in physical therapy in adolescents
• The effects of resistance training on individuals with Parkinson’s disease
• The role of hydrotherapy in the management of fibromyalgia
• The impact of cognitive-behavioural therapy in physical rehabilitation for individuals with chronic pain
• The use of virtual reality in physical rehabilitation of sports injuries
• The effects of electrical stimulation on muscle function and strength in athletes
• The role of physical therapy in the management of stroke recovery: A systematic review
• The impact of pilates on mental health in individuals with depression
• The use of thermal modalities in physical therapy and its effectiveness in reducing pain and inflammation
• The effect of strength training on balance and gait in elderly patients

Topics & Ideas: Optometry & Opthalmology

• The impact of screen time on the vision and ocular health of children under the age of 5
• The effects of blue light exposure from digital devices on ocular health
• The role of dietary interventions, such as the intake of whole grains, in the management of age-related macular degeneration
• The use of telemedicine in optometry and ophthalmology in the UK
• The impact of myopia control interventions on African American children’s vision
• The use of contact lenses in the management of dry eye syndrome: different treatment options
• The effects of visual rehabilitation in individuals with traumatic brain injury
• The role of low vision rehabilitation in individuals with age-related vision loss: challenges and solutions
• The impact of environmental air pollution on ocular health
• The effectiveness of orthokeratology in myopia control compared to contact lenses
• The role of dietary supplements, such as omega-3 fatty acids, in ocular health
• The effects of ultraviolet radiation exposure from tanning beds on ocular health
• The impact of computer vision syndrome on long-term visual function
• The use of novel diagnostic tools in optometry and ophthalmology in developing countries
• The effects of virtual reality on visual perception and ocular health: an examination of dry eye syndrome and neurologic symptoms

Topics & Ideas: Pharmacy & Pharmacology

• The impact of medication adherence on patient outcomes in cystic fibrosis
• The use of personalized medicine in the management of chronic diseases such as Alzheimer’s disease
• The effects of pharmacogenomics on drug response and toxicity in cancer patients
• The role of pharmacists in the management of chronic pain in primary care
• The impact of drug-drug interactions on patient mental health outcomes
• The use of telepharmacy in healthcare: Present status and future potential
• The effects of herbal and dietary supplements on drug efficacy and toxicity
• The role of pharmacists in the management of type 1 diabetes
• The impact of medication errors on patient outcomes and satisfaction
• The use of technology in medication management in the USA
• The effects of smoking on drug metabolism and pharmacokinetics: A case study of clozapine
• Leveraging the role of pharmacists in preventing and managing opioid use disorder
• The impact of the opioid epidemic on public health in a developing country
• The use of biosimilars in the management of the skin condition psoriasis
• The effects of the Affordable Care Act on medication utilization and patient outcomes in African Americans

Topics & Ideas: Public Health

• The impact of the built environment and urbanisation on physical activity and obesity
• The effects of food insecurity on health outcomes in Zimbabwe
• The role of community-based participatory research in addressing health disparities
• The impact of social determinants of health, such as racism, on population health
• The effects of heat waves on public health
• The role of telehealth in addressing healthcare access and equity in South America
• The impact of gun violence on public health in South Africa
• The effects of chlorofluorocarbons air pollution on respiratory health
• The role of public health interventions in reducing health disparities in the USA
• The impact of the United States Affordable Care Act on access to healthcare and health outcomes
• The effects of water insecurity on health outcomes in the Middle East
• The role of community health workers in addressing healthcare access and equity in low-income countries
• The impact of mass incarceration on public health and behavioural health of a community
• The effects of floods on public health and healthcare systems
• The role of social media in public health communication and behaviour change in adolescents

Examples: Healthcare Dissertation & Theses

While the ideas we’ve presented above are a decent starting point for finding a healthcare-related research topic, they are fairly generic and non-specific. So, it helps to look at actual dissertations and theses to see how this all comes together.

Below, we’ve included a selection of research projects from various healthcare-related degree programs to help refine your thinking. These are actual dissertations and theses, written as part of Master’s and PhD-level programs, so they can provide some useful insight as to what a research topic looks like in practice.

• Improving Follow-Up Care for Homeless Populations in North County San Diego (Sanchez, 2021)
• On the Incentives of Medicare’s Hospital Reimbursement and an Examination of Exchangeability (Elzinga, 2016)
• Managing the healthcare crisis: the career narratives of nurses (Krueger, 2021)
• Methods for preventing central line-associated bloodstream infection in pediatric haematology-oncology patients: A systematic literature review (Balkan, 2020)
• Farms in Healthcare: Enhancing Knowledge, Sharing, and Collaboration (Garramone, 2019)
• When machine learning meets healthcare: towards knowledge incorporation in multimodal healthcare analytics (Yuan, 2020)
• Integrated behavioural healthcare: The future of rural mental health (Fox, 2019)
• Healthcare service use patterns among autistic adults: A systematic review with narrative synthesis (Gilmore, 2021)
• Mindfulness-Based Interventions: Combatting Burnout and Compassionate Fatigue among Mental Health Caregivers (Lundquist, 2022)
• Transgender and gender-diverse people’s perceptions of gender-inclusive healthcare access and associated hope for the future (Wille, 2021)
• Efficient Neural Network Synthesis and Its Application in Smart Healthcare (Hassantabar, 2022)
• The Experience of Female Veterans and Health-Seeking Behaviors (Switzer, 2022)
• Machine learning applications towards risk prediction and cost forecasting in healthcare (Singh, 2022)
• Does Variation in the Nursing Home Inspection Process Explain Disparity in Regulatory Outcomes? (Fox, 2020)

Looking at these titles, you can probably pick up that the research topics here are quite specific and narrowly-focused , compared to the generic ones presented earlier. This is an important thing to keep in mind as you develop your own research topic. That is to say, to create a top-notch research topic, you must be precise and target a specific context with specific variables of interest . In other words, you need to identify a clear, well-justified research gap.

Need more help?

If you’re still feeling a bit unsure about how to find a research topic for your healthcare dissertation or thesis, check out Topic Kickstarter service below.

16 Comments

I need topics that will match the Msc program am running in healthcare research please

Hello Mabel,

I can help you with a good topic, kindly provide your email let’s have a good discussion on this.

Can you provide some research topics and ideas on Immunology?

Thank you to create new knowledge on research problem verse research topic

Help on problem statement on teen pregnancy

This post might be useful: https://gradcoach.com/research-problem-statement/

can you provide me with a research topic on healthcare related topics to a qqi level 5 student

Please can someone help me with research topics in public health ?

Hello I have requirement of Health related latest research issue/topics for my social media speeches. If possible pls share health issues , diagnosis, treatment.

I would like a topic thought around first-line support for Gender-Based Violence for survivors or one related to prevention of Gender-Based Violence

Please can I be helped with a master’s research topic in either chemical pathology or hematology or immunology? thanks

Can u please provide me with a research topic on occupational health and safety at the health sector

Good day kindly help provide me with Ph.D. Public health topics on Reproductive and Maternal Health, interventional studies on Health Education

may you assist me with a good easy healthcare administration study topic

May you assist me in finding a research topic on nutrition,physical activity and obesity. On the impact on children

I have been racking my brain for a while on what topic will be suitable for my PhD in health informatics. I want a qualitative topic as this is my strong area.

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Shots - Health News

Fda gives thumbs down to mdma for now, demanding further research.

A dose of MDMA. The drug has been studied as a treatment for PTSD and FDA has declined to approve it so far, asking for further research. Travis Dove for The Washington Post/Getty Images hide caption

On Friday, drugmaker Lykos Therapeutics received word from the Food and Drug Administration that the agency has decided not to approve MDMA-assisted therapy for PTSD at this time. Instead, the agency asked the drugmaker to further study the safety and efficacy of the treatment.

The heavily anticipated announcement came in the form of a “complete response letter” from the FDA to Lykos, according to a company press release.

It represents a significant setback for the company and the broader movement to bring psychedelics into the mainstream of mental health care.

“It’s a huge blow to the field,” says Dr. Boris Heifets , an anesthesiologist at Stanford University whose lab studies psychedelics.

Lykos said it plans to request a meeting with the FDA to ask for reconsideration of the decision.

Lykos’ CEO Amy Emerson called the FDA’s request for another phase 3 trial “deeply disappointing,” and said conducting the study “would take several years.”

She added that many of the requests from the agency “can be addressed with existing data, post-approval requirements or through reference to the scientific literature."

The treatment had garnered considerable support from patients, leaders in the field of mental health and psychedelics and politicians from both parties. In recent weeks, advocates mounted a major public pressure campaign, emphasizing the dire need for new and effective treatments for veterans and the millions of people affected by PTSD.

Many in the psychedelics industry had viewed this as a pivotal moment. The FDA decision on MDMA could be seen as a bellwether for other drugs that are in the pipeline like psilocybin and LSD, which are both considered “classic psychedelics” unlike MDMA.

But Dr. Mason Marks believes the FDA’s decision doesn’t spell trouble for the broader field because the agency has signaled repeatedly it’s open to psychedelic research.

“I think this is a unique case,” says Marks, a law professor and senior fellow with the Project on Psychedelics Law and Regulation at Harvard Law School's Petrie-Flom Center.

“I don't think there's any sign that progress is going to be slowed. If anything, it might intensify because the other companies might see an opportunity to really get in there and compete,” he says.

The wave of enthusiasm around MDMA's therapeutic potential has come from research scientists at top academic centers and even the Department of Veterans Affairs.

Supporters of the drug were dismayed by Friday's decision.

“The FDA’s decision is disgraceful,” said Heroic Hearts Project, a veterans organization that had lobbied for FDA approval citing the many veteran suicides in a statement. “This is the epitome of bureaucratic red tape – and the result is people will keep dying.”

Opposition to the Lykos’ application had gained momentum in recent months, culminating in a contentious public meeting when advisors to the FDA voted against the evidence backing the treatment, largely based on concerns about shortcomings in the clinical research.

In its press release, Lykos said the FDA echoed the issues raised by the committee.

The committee's downvote put the FDA in a tricky spot, given that it historically sides with the advisors.

“As discussed at the advisory committee meeting, there are significant limitations to the data contained in the application that prevent the agency from concluding that this drug is safe and effective for the proposed indication,” an FDA spokesperson said to NPR in an email.

“We will continue to encourage research and drug development that will further innovation for psychedelic treatments and other therapies.”

Those hoping to see MDMA make it to market argue that concerns about the quality of the research were overblown and, in some cases, focused on issues with the study design that weren’t unique to MDMA.

The trials “undoubtedly had problems,” says Stanford's Heifets , but the FDA could have dealt with those concerns by approving the treatment with strict restrictions around how it’s administered and a requirement to do a post-market study.

He worries the decision to deny approval will stifle innovation and funding into other novel treatments, including MDMA-like drugs that are being developed.

“The FDA has gone against advisory committee advice [in the past]. It has approved drugs with abuse potential,” says Heifets. “None of this is that radical, so I think they could have done something else here.”

On the other hand, Marks says that approval would have required the FDA to “pile on” so many restrictions because of concerns about the Lykos’ application that ultimately it would have been “impractical” for the treatment to reach many people.

He also wonders whether the all-out publicity blitz by Lykos and its allies was, in the end, “counterproductive” because it put the FDA in an awkward position by making the decision so politicized.

“This is not the end of the road for Lykos,” he says, “It will cost them financially, but it doesn’t mean they can’t ultimately succeed.”

The push to establish MDMA-assisted therapy as a legitimate treatment for PTSD stretches back two decades.

Researchers affiliated with the nonprofit Multidisciplinary Association for Psychedelic Studies, or MAPS, pioneered the early studies and developed the therapy protocol embedded in the treatment. That work ultimately set the stage for the drugmaker, which was incubated by MAPS, to press forward with larger human trials and seek approval from federal regulators.

Lykos has raised more than $100 million in anticipation of FDA approval of its MDMA therapy.

Optimism around the treatment largely stems from the company’s promising phase 3 clinical trials, which together enrolled about 200 people. The most recent one, published last year, showed just over 70% of participants no longer met the diagnostics criteria for PTSD after three therapy sessions with MDMA, compared to about 48% who had the same talk therapy protocol but took a placebo.

Follow-up research from the company showed participants were still benefiting from the treatment at least half a year after their last dosing session.

“Although disappointing, this move by the FDA highlights the importance of conducting rigorous research into the safety and efficacy of MDMA-assisted therapy,” says Alan Davis , director of the Center for Psychedelic Drug Research and Education at the Ohio State University, “Despite this setback, I am hopeful that there will be a better outcome down the road after more research is completed in the coming years.”

Debate over the merits of the Lykos’ application has become increasingly divisive, with allegations that misconduct and bias in the clinical trials compromised the findings and undermined its safety. The drugmaker and many of the therapists involved in the research have steadfastly denied those claims.

It’s unclear to what extent any of this factored into the FDA’s deliberation on the therapy.

In response to Friday’s decision, Emerson reiterated the company’s plan to push the research forward, saying they’d “work tirelessly and use all available regulatory pathways to find a reasonable and expeditious path forward for patients.”

Given what’s required to conduct another trial, Heifets believes psilocybin is now poised to gain approval ahead of MDMA.

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More Evidence Links Ultraprocessed Foods to Dementia

Recent research, including a new study on processed meat, has suggested these foods can affect brain health. Experts are trying to understand why.

By Dana G. Smith and Alice Callahan

People who regularly eat processed red meat, like hot dogs, bacon, sausage, salami and bologna, have a greater risk of developing dementia later in life. That was the conclusion of preliminary research presented this week at the Alzheimer’s Association International Conference.

The study tracked more than 130,000 adults in the United States for up to 43 years. During that period, 11,173 people developed dementia. Those who consumed about two servings of processed red meat per week had a 14 percent greater risk of developing dementia compared to those who ate fewer than three servings per month.

Eating unprocessed red meat, like steak or pork chops, did not significantly increase the risk for dementia, though people who ate it every day were more likely to report that they felt their cognition had declined than those who ate red meat less often. (The results of the study have not yet been published in a journal.)

The vast majority of processed meats are classified as “ ultraprocessed foods ” — products made with ingredients that you wouldn’t find in a home kitchen, like soy protein isolate, high fructose corn syrup, modified starches, flavorings or color additives. Many of these foods also have high levels of sugar, fat or sodium, which have long been known to adversely affect health.

Ultraprocessed foods, which also include items like sodas, flavored yogurts, instant soups and most breakfast cereals, make up a huge part of the American diet. They account for about 58 percent of the calories consumed by both children and adults, on average. In the last decade, researchers have linked these foods to health conditions including heart disease, Type 2 diabetes, obesity and some types of cancer and gastrointestinal diseases.

Now scientists are examining the connection between these foods and brain health.

What does the research suggest?

Several studies published in the past few years have found an association between eating more ultraprocessed foods and cognitive decline. In one study of more than 10,000 middle-aged adults in Brazil , for example, people who consumed 20 percent or more of their daily calories from ultraprocessed foods experienced more rapid cognitive decline, particularly on tests of executive functioning, over the course of eight years.

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Health Services Plan

Find out more about the recommendations from the Expert Advisory Committee for a more connected system.

In July 2023, the Victorian Department of Health commissioned an Expert Advisory Committee (the Committee) to examine the design and governance of Victoria's health services system. Over 10 months they explored many of the challenges experienced by patients, communities and our health workforce within the system.

The Committee have now developed the Health Services Plan, which provides a number of recommendations for a more connected system that delivers the right care, at the right time, in the right place, for all Victorians. The Plan is outlined through 3 key pillars of reform:

• Establishing Local Health Service Networks (Networks) – geographic groupings responsible for planning and managing care so that it meets the population health needs of their communities.
• Formalised relationships between each Network and a women's, a children's and a major tertiary hospital, ensuring every Victorian has seamless access to specialist care and expertise when they need it.
• A Victorian Role Delineation Framework, which will support collaboration across the system through setting out the roles and responsibilities of every health service site, aligned to their size and capability.

The Government will accept 21 recommendations in full, and accept in principle 5 recommendations:

• Recommendation 4.6 - Likely amendments to groupings and boundaries based on further consultation with the sector. The Government will provide guidance to health service boards on principles to underpin Local Health Service Network groupings. Health services will then be able to propose groupings for their region for approval by Government.
• Recommendation 6.1 - The department will undertake further work to consider this while ensuring no reduction in service provision.
• Recommendation 7.2 - Hospitals will not be forced to consolidate to form LHSNs.
• Recommendation 8.1 - The department will continue to support those health services that wish to consolidate. The Government does not accept the recommendation on forced consolidation of health services.
• Recommendation 9.2 - Further work is needed to understand the impact of these reforms across healthcare the Commonwealth is responsible for.

The Government does not accept recommendation 7.1 relating to directed consolidations of health services outlined in the report.

Further work will now be undertaken on the accepted recommendations.

Reviewed 08 August 2024

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Addressing Health Disparities through Community Participation: A Scoping Review of Co-Creation in Public Health

Sergio morales-garzón.

1 Public Health, History of Science and Gynaecology Department, Miguel Hernández University, 03550 Alicante, Spain

Lucy Anne Parker

2 CIBER in Epidemiology and Public Health, 28029 Madrid, Spain

Ildefonso Hernández-Aguado

Manuel gonzález-moro tolosana, maría pastor-valero.

3 Programa de Pós-Graduação em Saúde Coletiva, Departamento de Medicina Preventiva, Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo 05508-220, Brazil

Elisa Chilet-Rosell

Background: There is general agreement regarding the relevance of community involvement in public health policy, practice, and research to reduce health inequities. Objective: This review aims to analyse the experiences of community engagement in public health actions, with particular attention to methodologies used and how community participation is articulated. Method and Analysis: We searched the Web of Science, EBSCO, and ProQuest for scientific articles published in peer-reviewed journals. We recorded methodological aspects, the approach to equity, actors that participated in the actions, and participation of the community in different phases (agenda setting, design, implementation, and evaluation). Results: Of 4331 records, we finally included 31 studies published between 1995 and 2021. Twelve studies referred to Community-Based Participatory Research as the framework used. The actions addressed equity, mainly by tackling economic vulnerability (n = 20, 64%) and racial discrimination (n = 18, 58%). Workshops were the most used method. Participation was frequently observed in the design and implementation phases of the action, but it was reduced to community feedback in the evaluation. Conclusions: Co-created public health actions offer the opportunity to reduce health inequity and promote social change; yet, further effort is needed to involve communities in the entire cycle of decision making.

1. Introduction

Multilateral health institutions, public health agencies, and the scientific community agree that the involvement of communities in public health policy, practice, and research is a necessary condition for achieving their goals and reducing social inequalities in health [ 1 , 2 , 3 ]. Among the ten essential public health services that should be implemented in all communities, according to the Centers for Disease Control and Prevention (U.S.), two are related to community participation: “Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it”, which is a first step towards fostering community participation; and, “Strengthen, support, and mobilize communities and partnerships to improve health” [ 4 ]. Active citizen participation, empowerment, and community mobilization have been inherent features of Health Promotion since its origins and are, in fact, a requirement of good public health practice [ 5 , 6 ]. Public health ethical frameworks include community participation as a requirement for different actions. The Nuffield Council on Bioethics (U.K.) recommends minimising interventions that are introduced without the individual consent of those affected, or without procedural justice arrangements (such as democratic decision-making procedures) which provide adequate mandate [ 7 ]. Similarly, the principles of the ethical practice of public health of the American Public Health Association (U.S.) indicate that public health institutions should provide communities with the information they have that is needed for decisions on policies or programs, and that they should obtain the community’s consent for their implementation. Moreover, public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members [ 8 ].

Consequently, the participation of citizens and communities in public health practice is not an option; it is a core part of public health action. The challenge is to identify the ideal forms, degrees, and procedures of participation to ensure that policies, programs, and interventions achieve optimal outcomes in terms of health, wellbeing, and equity. A variety of approaches have been described in public health practice and research to engage citizens and communities. Whatever approach is taken to incorporate community participation in public health activities, it must address the continuing challenge of inequalities in health and wellbeing.

Given that the social determinants of health inequalities are potentially modifiable, community engagement interventions can play a key role in the reduction of health inequalities. The evaluation of such interventions suggests they offer the ability to identify health inequalities and particular aspects that are uniquely identifiable through community participation [ 9 ]. According to the review carried out by Heimburg and Ness [ 10 ], public health and co-creation find their nexus in the importance they lend to community participation and the application of a more human-centred approach in any health action. In other words, they find their union in the fundamental aspect of the community and its wellbeing. Some of the terms and methodologies related to participation are outlined below.

1.1. Citizen and Community Engagement in Public Health

The National Institute for Health and Clinical Excellence (U.K.) views community engagement as “encompassing a range of approaches to maximise the involvement of local communities in local initiatives to improve their health and wellbeing and reduce health inequalities. This includes needs assessment, community development, planning, design, development, delivery, and evaluation” [ 11 ].

Community engagement is applied both to improve service delivery and to enhance the capacity and empowerment of communities to improve their health [ 12 ]. Participation of citizens in improving the delivery of health interventions can help to tailor the design of interventions to users’ needs, and to facilitate implementation and adherence. Yet, this is not the only kind of involvement of lay people that health promotion requires to achieve its goals. The participation of target populations can also contribute to improving the reach of interventions designed by professionals and to facilitate maximum coverage, removing difficulties of access and reception by the most marginalised groups [ 13 ]. Regarding public health policy, when the need for community involvement is invoked, reference is often made to the fact that it leads to more democratic and inclusive policies. Effective participation increases individual and collective control; this genuinely devolves sufficient power to the population to promote health equity by addressing the social conditions that contribute to poor health, in collaboration with professionals, health authorities, and other stakeholders [ 14 , 15 ].

A Science for Policy report by the Joint Research Centre (JRC) (BE), the European Commission’s science and knowledge service, indicates that “a boost in democratic legitimacy, accountability and transparent governance can be one of the main positive outcomes of community engagement” [ 16 ]. Among the recommendations, the JRC document states that, “A better use and integration of citizens’ inputs can potentially expand the evidence or expert-based paradigm towards a citizen-based policy-making. This implies that not only more types of knowledge are needed at the table, but also the recognition that community engagement is a matter of democratic rights to be differentiated from pure interests.” There is an interest in the involvement of citizens and communities in public policy in the European Union that is reflected in various actions, such as the promotion of citizen science, which, by involving citizens in the production of knowledge, has been proposed as a facilitator of more inclusive policy-making [ 17 ].

It is important to note that the term community, as used here, is understood as a set of heterogeneous individuals, institutions, and associations interacting and sharing social, economic, geographical, or sentimental characteristics. It is defined by a sense of belonging and shared perspective [ 18 ]. In analysing health improvement from community participation in research, a report by the National Academies of Sciences, Engineering, and Medicine (U.S.) concluded that projects with community power groups must put issues of power, race, and inequality at the centre of the discussion; otherwise, it is easy for projects to move in tactical and not necessarily enriching directions [ 19 ]. In fact, the research model that has been most frequently applied to address health inequalities is Community-Based Participatory Research [ 20 , 21 ], which does so by addressing power imbalances through equitable community engagement [ 22 , 23 ].

1.2. Community-Based Participatory Research

Israel et al. defined Community-Based Research as focusing on social, structural, and physical environmental inequities through the active involvement of community members, organizational representatives, and researchers in all aspects of the research process [ 24 ]. Partners contribute their expertise to enhance the understanding of a given phenomenon and integrate the knowledge gained with action to benefit the community involved. Compared to other models of community engagement that have successfully addressed health disparities, Community-Based Participatory Research has three components that are considered key drivers of success: engagement of community partners at all stages of research development, including the dissemination of findings; facilitating knowledge exchange between the community and academic partners; and achieving a balance between research and action [ 22 , 23 ]. The possibilities, realities, and challenges of this research approach were reviewed by Wallerstein and Duran, who examined the challenges of achieving a truly balanced researcher–community relationship for issues such as power, privilege, participation, community consent, racial and/or ethnic discrimination, and the role of research in social change [ 25 ]. This last aspect is one of the ongoing challenges in public health: how this transformative research paradigm influences practice and policy to reduce disparities. The same authors also investigated the barriers and limitations in intervention and implementation sciences, and concluded that Community-Based Participatory Research has an important role in expanding the reach of translational intervention and implementation sciences to influence practices and policies for eliminating disparities [ 25 ]. In this regard, attention is given to the idea of “co-creation”, that is, developing and implementing actions or interventions in partnership with the community. Several researchers have considered its potential for improving the implementation of community-involved actions aimed at changing the social determinants of health [ 26 , 27 ]. The idea of co-creation, as a way of getting actions implemented through collaboration, provides an additional way to achieve a public health policy and practice that is closer to community priorities and helps to overcome the implementation challenges [ 27 ].

1.3. Cocreation and Public Health

The term “co-creation” finds its origin in the public sector and public management [ 28 ]. Voorberg at al. have clarified its meaning by making a difference between three types of co-creation: citizens as co-implementers, co-designers, or co-initiators. In their review, they found that co-creation/co-production is a practice to be found in numerous policy sectors, but predominantly in health care and education. In the health field, co-creation was from the outset related to the improvement of the design of consumer goods and services to adapt better to the expectations of end-users [ 28 ]. Hence, its diffusion in the design of health actions or technologies aimed at specific individuals has been relatively wide. In the field of public health, there are also examples closely related to more individual actions and service delivery (hand washing, screening, etc.). However, its application in more complex public health programs has not been as frequent, as it is not only a matter of adapting the intervention to the end-user; the end-users also take part in all stages of intervention design and implementation. They are both the target population and active stakeholders, who initiate population-level changes in health through their effective involvement. Assuming the complexity inherent within health, wellbeing, and equity within a socioecological framework of complex adaptive systems, Von Heimburg and Cluley explored existing links between co-creation and Health Promotion to outline the potential to integrate these approaches in public value-creation [ 26 ]. They stated that a shared moral ethos renders co-creation an appropriate approach for complexity-informed Health Promotion practice, and to nurture further development of Health Equity in All Policies. Yet, they noted that some conceptualizations of co-creation can lead to increasing inequity through disparity in participation. Addressing questions of power and decision-making about who participates, how they participate, and to what extent in the creation of public health policy is one of the key issues when examining the potential role of co-creation in contributing to the achievement of public health goals [ 26 , 29 ].

As co-creation is becoming a core principle of public sector reform, it is advisable to have an overview of experiences that, in practice, have applied co-creation to generate and implement public health actions that incorporate the principle of equity. The purpose of this research is to review these experiences to contrast what methodologies have been used, how the participation of citizens and communities has been articulated, and what effects on health and equity have been observed.

2. Materials and Methods

This scoping review was developed following the Arksey and O’Malley methodological framework, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We specifically searched for articles examining co-created public health actions based on equity. As there is controversy about the conceptualisation of co-creation and as it is an emerging issue in public health research, a scoping review would be the best approach to ‘map’ the relevant literature in the field of interest. The scoping review was carried out to answer the research question: “What methods have been used in co-created public health actions that incorporate the principle of equity, how does community or citizen participation tend to be articulated, and what effects on health and equity have been observed?”.

2.1. Search Strategy

We performed a search for scientific articles published in peer-reviewed journals, in English, French, Portuguese, or Spanish, from the first available date until the last search on the first of June 2021 in the Web of Science, EBSCO, and ProQuest. Articles published electronically up to this date were included, although their final publication date may have been later. We acknowledge that some potentially relevant papers in other languages, such as German or Japanese, have not been included. The research group identified potential keywords by brainstorming terms closely linked to our research question. Specifically, we considered terms linked to co-creation (such as citizen science, human centered design, community networks, integrated governance), public health (such as health policies, health promotion, health interventions), and equity (such as equality, inequity, inequality).

The final search strategy was developed for use in the Web of Science, and was structured in three parts: it includes a part for participatory concepts, such as “co-creation or open science”; a part for institutional actions, such as “Public Health or Public policies”; and a part for equity, with terms such as “Inequity or Disparity”. Then the search strategy was adjusted for each database ( Appendix A ).

2.2. Identifying Relevant Studies

We included reports, published in peer-reviewed journals or grey literature, that described co-created public health actions which address health equity. That is, actions (programmes and policies) that have been developed through collaboration with different stakeholders (including citizens) in the ideation, prioritization, planning, implementation, and/or evaluation of public health actions to improve health and achieve health equity. We considered both studies/experiences which describe original public health actions designed through co-creation, and studies reporting implemented public health actions that had been previously derived from a co-creation process. Only actions that included the participation of citizens were included; although, we accepted community leaders as the spokespersons/representatives of the citizens. Systematic reviews were also utilized if they included papers that fulfilled the inclusion criteria.

We excluded theoretical studies with no concrete action and those aimed at describing self-care (e.g., co-created apps for individual management of health problems or individual educational interventions). We also excluded studies in which population participation was limited to surveying users of public health interventions, to improve and fine-tune the instruments/actions or to evaluate the effectiveness of programs.

2.3. Study Selection

Both the specificity of the terms used in the search strategy and the inclusion criteria were tested by applying them independently to two consecutive series of twenty titles; abstracts followed by group discussion. Before starting the selection of articles, duplicates between the databases were excluded. All authors participated in the study selection. In the first step, two authors independently reviewed the title and abstract of each potential reference (see flow diagram in Figure 1 ). Uncertainties and disagreements were resolved by reviewing the full text of the study and by discussion and arbitration with a third author.

Flow diagram of search and selection.

2.4. Data Extraction and Synthesis

We extracted the data from the studies in duplicate, and any discrepancies between the two extractions were resolved by a third researcher. We grouped the information extracted from the selected articles into three areas.

The first consists of the basic information of the article, as well as the location of the fieldwork, the objective of the co-creation action, and the health issue addressed. We also noted the theoretical model applied to develop the co-created action, as referred to by the authors: Community-Based Participatory Research (CBPR) or any other interchangeable term used, such as Community-Based Participatory Service or Community-Based Participatory Action Research, Participatory Action Research (PAR), and Experienced-Based Co-design (EBCD).

The second area of interest relates to the employed methodology, the equity approaches, and the community participation in the different phases of the action. We defined 5 categories to describe the methods: Group discussions; Workshops; Interviews; Observation; or Surveys. We considered group discussions to be any facilitated meeting with multiple participants, including formal focus groups. They may include structured questions, but lean towards a more natural group conversation on an underlying subject. To be considered a workshop, the facilitated meetings with multiple participants must include activities to develop, learn and/or improve skills, or to undertake a practical action. Actions may include reviewing collated epidemiological information, making an inventory or map of all relevant issues (resources, threats etc.), and may be exclusively dedicated to the development of a specific participatory methodology such as photovoice or storytelling. We used standard definitions for interviews, observation, and surveys [ 30 ]. Each action could include different methodologies. Regarding the approach to equity in the projects reviewed, we defined four categories: economic vulnerability (improving the economy of people in low-income situations); racial discrimination (improving the situation of people who suffer discrimination due to their community origin, ethnicity, and similar); gender discrimination (improving the situation of people who suffer discrimination due to their sex or gender identity); and other social discrimination (improving the situation of marginalised communities and/or people who suffer discrimination other than racial or gender discrimination). Regarding community participation, we considered community to be a specific group of people who: usually live in a defined geographical area; share the same culture, values, and norms; and organise themselves into a social structure, according to the type of relationships that the community has developed over time. Its members are aware of their identity as a group and share common needs and a commitment to meeting them. We defined the following phases in which community can participate: agenda setting (selection and identification of issues to work on); design (deciding a specific group of actions); implementation (carrying out the activities); and evaluation (the process of measuring the success of the implemented actions). Due to the inclusive nature of our review question, not all studies had 4 phases.

Finally, we extracted information on the types of actors that participated in the actions besides the community. We considered promotors of the action as the people who conceived the initiative and classified them into 4 categories: academic (universities, schools, and educational institutions); governmental (political organizations such as councils, town halls, or politicians); healthcare institutions (hospitals, clinics, and health departments); and private organizations (businesses, foundations). Some actions also included other stakeholders, and these were also classified into 4 categories: Public Institutions (schools, universities, hospitals, town halls, or similar); Civil society and NGOs (groups of people who share a common interest, typically addressing a social or political issue, and create an organization to defend it; this includes formal non-profit organizations that operate independently of government); and private organizations (for-profit businesses, including their associated foundations).

After removing duplicates, we screened 4331 abstracts and titles, of which 139 potentially met the inclusion criteria and were selected for full-text review. We rejected a further 108 articles that did not fully meet our inclusion criteria; 31 studies were included in the final review ( Figure 1 ).

Reviewed papers were published between 1995 and 2022 and the most frequent year of publication was 2020. More than half of the analysed projects were undertaken in North America (n = 17, 55%), while there were five in European countries (16%), four in Australasia (13%), four in Africa (13%) and one in Central America (3%, Mexico). CBPR was the theoretical framework most referred to by the authors (n = 12, 38%). Other frequently referred to frameworks included PAR and EBCD (n = 7, 22%). The studies described co-created public health actions with a variety of objectives ( Table 1 ) and addressed a broad range of health issues ( Table 2 ). Ten actions (32%) addressed health disparities in a more general sense, while others addressed specific health problems (such as cancer, diabetes, suicide, and gender violence), environmental issues (such as air pollution, food security, and climate change), and behavioural determinants (such as tobacco use, alcohol, and physical activity).

Country, objective, promotors, and other stakeholders involved in the 31 co-created public health actions based on equity reviewed.

Participatory methodology, equity focus, and community participation in 31 co-created public health actions reviewed.

* In the community participation section of the table, grey shaded cells show the phases that were included in the project schedule. As such, if a cell is white it means that this phase was not included in the study report. In grey cells, only cells that are indicated with a check included the community in the corresponding phase.

The majority of the studies used workshops to develop their co-created public health actions (n = 27, 87%), while discussion groups were used in 20 studies (64%) and interviews in 16 (51%). Observation and surveys were used less frequently (n = 8, 25%, respectively). Regarding the different activities and methods used in the workshops, eight studies (29%) used workshops to develop photovoice (a participatory methodology that includes participants taking and selecting photos about a subject to reflect and explore issues, opinions, and ideas). Another eight (29%) developed mapping group activities, understood as the systematic identification of all relevant issues (such as resources or threats) by the participants, using maps (conceptual or otherwise) or by listing them as an inventory. Four studies (14%) used workshops to undertake storytelling, where stories were developed by participants to illustrate the relevant elements of an issue and encourage reflection. Other activities developed by workshops included theatre and the creation of a school newspaper ( Table 2 ).

The most frequent way to incorporate equity into action was to address economic vulnerabilities (n = 20, 64%), followed by racial discrimination (n = 18, 58%). Other social discrimination (such as people in a vulnerable situations due to drug abuse) and gender discrimination were less frequent (n = 3, 9% and n = 2, 6%, respectively). We found studies which addressed economic vulnerability together with other issues such as racial or social discrimination (n = 11, 35%). There were no studies that addressed more than one type of discrimination (social, racial, or gender; Table 2 ).

Not all studies included all four phases of the co-creation process in their schedule (agenda setting, design, implementation, and evaluation). The agenda setting phase was included in all 31 studies; although, seven (22%) studies did not include the community in this part. Thirty studies (96%) included the design phase, of which one (3%) did not include the community. Twenty-six studies (83%) included implementation of the action that was co-created, all involving the community. Sixteen studies (51%) included an evaluation of the co-creation in the report, of which 12 (75%) included the community. It was also found that the evaluation phase was normally reduced to community feedback or, in the rest of the studies (n = 14, 49%), scrapped from the process ( Table 2 ).

Table 2 describes the types of organizations that appear to have promoted the action, and the other stakeholders involved. We found that all the projects were launched with academic institutions as the principal promotor, followed by healthcare institutions (n = 19, 61%) or governmental departments (n = 11, 35%) which normally appear as active supporters or data providers. Private organizations appear promoting co-creation just in three studies (9%). When analysing the participation of other stakeholders, we found that social organizations (understood as civil associations and volunteer organizations) appear as the principal interested group in co-created public health actions (n = 14, 45%), followed by private businesses (n = 8, 25%), a category which included the foundations of private companies such as Kellogg’s. Four actions (12%) also included public institutions as stakeholders.

4. Discussion

Our scoping review shows that various health issues have been addressed using participatory methods to cocreate public health actions that incorporate the principle of equity. However, despite the literature citing cocreation as an effective method for reducing health inequalities, the findings from this scoping review show the community was rarely involved in the entire cycle of decision making, which may limit the social change intended by the action. Furthermore, the scope of different equity issues that were approached was somewhat limited. Most of the studies addressed economic vulnerabilities, working specifically in low-income neighbourhoods or communities. There appears to be room to deepen the knowledge base on co-created public health actions to address other equity issues, particularly those addressing different forms of discrimination.

Most of the actions reviewed were launched in high-income countries, most frequently the United States. This can be explained by the function of the research industry, which is commonly concentrated where the economic and academic capacity, followed by governmental support, allows the development and publishing of research. It would not be correct to think that low-income countries have no equity-focused, participative initiatives in public health because there are no papers published. Furthermore, in our analysis of the institutions that promoted the action, we can see that academic institutions predominate; these stakeholders are, again, more likely to publish the research in peer-reviewed journals. It is possible that other actions that would have met our inclusion criteria have been carried out by non-academic institutions, but have not been detected in our search strategy because they are unpublished.

According to the literature, participatory methods are commonly used to address specific health disparities and inequities [ 20 , 62 ]. Cocreation is frequently implemented in deprived communities, and it is an appropriate instrument for meeting public health objectives [ 28 , 29 ]. In line with the critiques given by Vargas et al., we agree that projects tend to focus more on the implementation of the actions, rather than the processes used to elicit community participation in the cocreation process [ 63 ]. Harnessing the full power of co-created public health initiatives to tackle health inequalities will require community members to be actively and equitably involved in all phases of the action. Participation in the earlier phases of the action may be particularly important to achieve meaningful impacts in equity, because participants can define the issues that are important to them and improve the visibility and understanding of health disparities that may otherwise be overlooked by stakeholders. Regarding the models cited by the authors, CBPR appears as the most-used in studied actions, which is consistent with the literature that presents CBPR as the most adequate model to address health disparities [ 25 ]. Even though CBPR proposes the engagement of communities to promote social changes that benefit those communities, we found the community was rarely involved in the entire cycle of decision making [ 20 ]. In our scoping review, only six actions included the community in the whole decision process. Of those, Ali et al. discussed that it was hard to maintain the contact and interest of participants; Newman et al. found difficulties with community involvement in the identification of priorities, which may not be uniform and could affect the selection process. According to the literature, power may remain concentrated in agents within academic settings, as well as economic and political institutions, whereas socially excluded individuals are powerless [ 64 ].

In accordance with Cowdell et al. [ 65 ], the community usually participate more in activities like providing and discussing information, rather than in data analysis or dissemination. Our scoping showed that communities were normally engaged in the practical phases of the decision-making process (design and implementation), whilst in agenda setting and evaluation the participation decreased remarkably. This may suggest that the community tends to be included in processes that do not need a high qualification or a technical profile.

According to Halvorsrud et al. [ 62 ], there is a lack of validated tools to evaluate the process of co-creation. This may explain why many of the described actions failed to include the evaluation phase in their studies. However, this fact should be considered in light of the evidence shown by Marsillo et al., who explain that co-creation is normally based on “Hic and Nunc” approaches and is scarcely designed with longitudinal or mixed methods that compare the initial situation and the outcome [ 66 ]. In the same sense, the qualitative nature of co-creation makes the evaluation a complex field.

Group meetings and activities have been pointed out as a fundamental part of the participatory process to communicate with the community and to join different points of view. Furthermore, it is a useful way to promote collaboration between participants, incorporate different perspectives, and guarantee community change [ 21 ]. We found that group meetings were an essential methodology used in most of the public health actions reviewed. The actions addressed equity in several environments including economical inequities, by focusing on low-income groups, and discrimination, by focusing efforts on specific social groups. Contrary to the literature, which shows co-creation is limited when it comes to working with ethnic minorities [ 36 ], we found that over half of the actions were developed with minority ethnic groups.

This review aimed to analyse equity-focused public health actions that have been co-developed with communities. Although using community involvement to reduce social inequalities in health is not a widely shared assumption, there is evidence available to support the idea. O’Mara-Eves at al. [ 9 ] evaluated the effectiveness of public health interventions that engage the community and found that public health interventions using community engagement strategies for disadvantaged groups were effective in terms of health behaviours, health consequences, health behaviour self-efficacy, and perceived social support. Through participation, the community could set, facilitate, design, and implement actions to change their situation. Sandra Carlisle postulate that, although community awareness is a fundamental part of social development, awareness is not the only fundamental part of social change [ 21 ]. There is an important function played by researchers, which consists of supporting changes and actions.

Our scoping review aimed to evidence the necessity of developing public health actions through the community as a synonym for inclusion and evolution in public health policymaking, especially with collectives that suffer discrimination. We decided to start by contextualizing the state of equity actions based on co-creation. We found evidence of the practice being used as a means of connecting with the community for research or evaluation processes in this field, although significant gaps remain.

5. Conclusions

Our review demonstrates that co-creation is a growing field of inquiry to address health inequity. This may be motivated by the importance that some international organizations have placed on co-creation, in previous years. For example, the European Union in its Horizon program defines co-creation as a guarantee of the growth of citizen science and innovation in providing public services. We found that co-creation can be undertaken with a number of different traditional, participatory methodologies such as CBPR or PAR.

It is important to consider what has already been done to understand what is effective when designing new initiatives to empower communities. Our study is helpful in this sense because it identified experiences in the public health area which aimed to address health disparities through community participation. These experiences include several examples of how scientific evidence can be adapted and implemented by implicating and encouraging communities. This study shows that health promotion, as the public health definition says, is possible through the whole population’s effort.

Search Equation Used in Each Bibliographic Database to Identify Articles Examining Co-Created Public Health Actions Based on Equity.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualisation, L.A.P., I.H.-A., M.G.-M.T., M.P.-V. and E.C.-R.; methodology, S.M.-G., L.A.P. and E.C.-R.; formal analysis, S.M.-G., L.A.P., I.H.-A., M.G.-M.T., M.P.-V. and E.C.-R.; investigation, S.M.-G., L.A.P. and E.C.-R.; writing—original draft preparation, S.M.-G., L.A.P., I.H.-A. and E.C.-R.; writing—review and editing, S.M.-G., L.A.P., I.H.-A., M.G.-M.T., M.P.-V. and E.C.-R.; visualisation, S.M.-G.; supervision, L.A.P. and E.C.-R. All authors have read and agreed to the published version of the manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

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After private equity takes over hospitals, they are less able to care for patients, top medical researchers say

After private-equity firms acquire hospitals , the facilities’ assets and resources diminish significantly, leaving the facilities less equipped to care for patients, according to a new study by physician researchers at the University of California at San Francisco, Harvard Medical School and the City University of New York’s Hunter College.

Published Tuesday in the  Journal of the American Medical Association,  the research highlights a pattern of asset stripping at health care facilities purchased by private-equity firms, its researchers said, and is the first study to analyze the activity nationwide. 

“It’s a very striking finding and should change the way people think about private equity in hospitals,” said Dr. Stephanie  Woolhandler , a distinguished professor of public health at Hunter, part of CUNY, and one of seven authors of the study. “The PE firms say, ‘We bring new capital into hospitals.’ It turns out that’s not quite true.”

Assets studied in the research consist of land, buildings, major hospital equipment and information technology. The study found that during the two years after a private-equity acquisition, total capital assets at private equity-acquired hospitals declined by 15% on average while assets rose by an average of 9% at other hospitals. That makes for a net difference of 24%, the researchers found, equivalent to a loss of $28 million in total assets per hospital.The research studied 156 hospitals acquired by private-equity firms from 2010 to 2019 comparing them with 1,560 hospitals of similar size in similar communities that were not bought by private equity. The pattern of diminished assets persisted and widened five years after acquisition, the study reported.

Depleted assets translate to a reduced level of care, Woolhandler told NBC News, noting that equipment, buildings and technology are resources needed for patient care. “There are real dangers to the health care that people get if you deplete all the capital from a hospital,” she added.

Private-equity firms borrow money to buy companies that they hope to sell in a few years at a profit. Independent academic research shows that such leveraged buyouts result in far more bankruptcies than acquisitions that do not use so much debt and the deals can result in significant job losses for rank-and-file workers.Health care has been a primary focus of private-equity purchases in recent years, with over $500 billion invested in the industry by firms such as Apollo Global Management, The Blackstone Group, The Carlyle Group and KKR. The  American Investment Council , the industry lobbying group, says private equity improves health care. 

But increased patient falls and infections follow private-equity takeovers of hospitals, recent research shows, and residents of nursing homes owned by private-equity firms experience 10% greater mortality rates than those owned by other types of entities.

“Previous studies have found that patients are endangered and costs increase in the wake of private-equity acquisitions,” said Dr. Elizabeth Schrier, a resident physician at the University of California, San Francisco, and a lead author of the new research.

The report on asset-stripping in private equity-owned hospitals comes amid the collapse of Steward Health Care, a hospital chain recently owned by private equity that filed for bankruptcy in May, leaving patients and workers at 31 facilities adrift. Last  week , the Senate’s Health, Education, Labor and Pensions committee announced an investigation into the Steward crisis. 

Until 2020, Steward was owned by Cerberus Capital, a private-equity firm led by Steve Feinberg. In 2010, Cerberus bought a nonprofit chain known as Caritas Christi Health Care for around $250 million. The firm and its investor partners reaped an $800 million profit when it divested a decade later.

Along the way, Steward sold the land under its hospitals, generating a gain for investors but increasing the company’s costs significantly.

A Cerberus spokesman said in a  statement that it’s unfair and incorrect to characterize the Steward land sale as “looting” the company, as Sens. Ed Markey and Elizabeth Warren, both Massachusetts Democrats, have done. “During our nearly 11-year ownership of Steward, we supported the revitalization of failing community hospitals into a leading healthcare system,” the statement continued. “Cerberus’ long-term investment made it possible for Steward to continue to serve its communities, employ tens of thousands of professionals, and positively impact millions of patients’ lives.”

Amid rising numbers of health care takeovers by private equity, at least 10 states are ramping up  scrutiny  on the transactions to prevent patient harm, such as rising health care costs or the effects of monopolization. On July 1, Indiana began requiring that private-equity partnerships proposing transactions with health care companies valued at $10 million or more to notify the state’s attorney general 90 days before the proposed deal. While approval of the transaction is not mandatory, the attorney general can analyze antitrust concerns or issue a civil investigative demand for more information.

California, Connecticut, Illinois and Nevada are among the other states enacting new laws bringing scrutiny to private equity’s health care acquisitions.

Health care is not the only industry in which some private-equity owners have stripped companies’ assets. The Red Lobster restaurant chain  failed  in part because its private-equity owner sold off the company’s prime real estate, generating gains for itself. Meanwhile, Red Lobster had to pay rent on the properties, raising its costs and ultimately hobbling its operations.

Gretchen Morgenson is the senior financial reporter for the NBC News Investigative Unit. A former stockbroker, she won the Pulitzer Prize in 2002 for her "trenchant and incisive" reporting on Wall Street.

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Where Rubber Meets the Road: EPA Researchers Study the Environmental and Health Impacts of Tires

Published August 7, 2024

To some people, tire pollution might draw up an image of a blown-out or discarded tire on the side of a highway, or stockpiled old tires behind a garage. However, the issue of tire pollution is more complex and prolific than at first glance, as every step of a tire’s life cycle, from production to use to disposal, can impact our environment, health and wildlife.

Meet Our Researchers

Meet EPA Ecologist Paul Mayer, Ph.D.

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To address growing concerns of tire pollution and a specific pollutant called 6PPD-quinone (6PPD-Q) , EPA researcher Dr. Paul Mayer led an effort to investigate the life cycle of tires and their impacts on the environment. The resulting article, “ Where the rubber meets the road: Emerging environmental impacts of tire wear particles and their chemical cocktails ,” is a holistic examination and data compilation of tires as complex pollutants across three levels: their whole state (e.g., tire production or disposal in landfills), as particulates (i.e., as they are worn down), and as “chemical cocktails.”

The research team illustrated that the production of over 3 billion tires annually requires massive amounts of natural resources, including fossil fuels, water, and agricultural space to grow natural rubber, which has been linked to deforestation. The manufacturing process involves chemical mixtures that emit carcinogens (cancer-causing substances) and radioactive compounds. Over 800 million tires are disposed of annually and burned for fuel or broken down and recycled into products such as artificial turf infill, asphalt, landscape mulch and doormats. These processes may introduce hazards such as contact exposure to chemicals and heavy metals, inhalation, ingestion, and other risks associated with tire crumb. Further, tire piles can catch fire and burn for long periods of time, emitting harmful pollutants such as fine particulate matter (PM2.5) .

The researchers found that one tire will shed between two and fourteen pounds of rubber particles due to road wear (from initial use to initial disposal). These particles may be small enough to be picked up by wind and carried for up to a month before they are deposited on land. Larger particles can be caught in stormwater runoff and transported along curbs and through stormwater systems where they are typically deposited into a local waterway. Constituents of these particles, pollutants such as microplastics , heavy metals, hydrocarbons, and other toxic chemicals can then pollute local water and soil.

The researchers also conducted a life cycle analysis of rubber tires, following one product unit from creation to disposal, identifying information gaps in tire related research along the way. The rate and volume of tire wear particle release may differ between tire brands and types. The size, shape, and surface properties of tire particles can impact the methods of their emission and transport. Further research is also needed to characterize the toxicity of tire pollutants and their health effects, including determining alternative chemicals for use in the manufacturing process and conducting longer term studies on populations of sensitive species. More accurate data on tire particle and chemical emissions based on climate, population density, and transportation infrastructure is needed to support the development of effective methods of tire pollution reduction, remediation, and risk management. These information gaps and many others identified by the research team show that tire wear particles and chemicals present a strong risk to human health and the environment, and action should be taken to research and mitigate this issue.

Several research teams across the EPA are working on addressing information gaps specifically related to the pollutant 6PPD-Q. 6PPD-Q is the product of a reaction between 6PPD, a chemical added in the tire manufacturing process, and ozone in the air. EPA-funded research in 2020 showed 6PPD-Q in stormwater to be highly toxic to several salmonid fish species and lethal to the threatened and endangered populations of coho salmon. This species is a culturally, economically, and ecologically important resource for many Tribal nations along the Pacific Northwest coast and its connected waterways. Healthy and accessible salmon populations are critical to the health and wellbeing of Tribes, including the practice and protection of Tribal Treaty Rights.

EPA ecologist Dr. Jonathan Halama is using the advanced EPA model Visualizing Ecosystem Land Management Assessments (VELMA) to learn more about the fate and transport of 6PPD-Q from tire particles in stormwater. Through the analysis of current stormwater management systems and estimated roadway deposition patterns based on traffic count data, Halama and his team are working to understand the processes influencing tire particle flow paths and to determine hotspots where 6PPD-Q is concentrated within a watershed. Using VELMA to find these 6PPD-Q hotspots can help researchers prioritize the locations and types of stormwater management designs to reduce 6PPD-Q levels most effectively.

In 2023, the EPA developed a draft analytical method to identify 6PPD-Q in surface waters and stormwater. In addition to tire life cycle analysis and stormwater management modeling, there are multiple research efforts within the EPA and in collaboration with external partners that focus on 6PPD-Q. EPA researchers are developing measurement methods for 6PPD-Q in air and sediment, tools to screen the toxicity of environmental samples, and health hazard screening values. To further protect coho salmon and other sensitive aquatic species, researchers are also investigating brake and tire emission rates of particulates, 6PPD, and metals, health effects of tire wear particles and 6PPD-Q on aquatic life, and potential alternative chemicals to 6PPD in tires.

Dr. Mayer presented about tires as complex pollutants at EPA’s Water Research Webinar on June 26th, 2024. You can watch a recording of the session here .

Learn more about the Science

• Where the rubber meets the road: Emerging environmental impacts of tire wear particles and their chemical cocktails
• Watershed analysis of urban stormwater contaminant 6ppd-q hotspots and stream concentrations using a process-based ecohydrological model
• A ubiquitous tire rubber-derived chemical induces acute mortality in coho salmon
• Tire Pollution and 6PPD-Quinone Publications
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Popular health supplements are causing liver damage, research shows

• Published: Aug. 09, 2024, 7:47 a.m.

Turmeric is one of six supplements causing health issues requiring hospitalization, researchers have found. (Getty Images) Getty Images

• Ann Marie Barron | [email protected]

STATEN ISLAND, N.Y. — Popular supplements used by more than 15 million Americans may be putting their liver health at risk, according to health researchers.

Research has revealed the extent of the damage being caused by taking popular botanical supplements including turmeric, green tea, the stress-relieving ashwagandha and weight-loss aid Garcinia cambogia.

For this most recent study, University of Michigan health researchers in Ann Arbor looked at data from 2017 to 2021, covering 9,685 people, and found that nearly 4.7% of U.S. adults had used one of the six potentially toxic supplements within the previous 30 days. The resulting paper, “Estimated Exposure to 6 Potentially Hepatoxic Botanicals in U.S. Adults,” appeared in JAMA Network Open this month .

Supplement users were mostly taking these botanicals on their own, not under medical advice, for a range of issues: Turmeric is taken for joint health and arthritis, green tea extract is thought to boost energy levels, G. cambogia is taken for weight loss, black cohosh is taken to manage hot flushes and red yeast rice is taken for heart health.

The study was specifically concerned with green tea extract, not drinking tea, which has no link to liver toxicity – though a limit of eight cups a day is recommended, according to a report in New Atlas, a science and technology publication.

And while news of liver toxicity connected to these supplements is not new, having been reported to be on the rise for some time now, including in this 2022 study , medical researchers are concerned that people are unaware that they come with a serious risk of overdose.

Hospitalizations increased from 7% to 20% over the decade between 2004 and 2014, the new study found.

“Use of herbal and dietary supplements (HDSs) accounts for an increasing proportion of drug hepatotoxicity cases,” researchers, led by Alisa Likhitsup, an assistant professor of gastroenterology, told New Atlas

Drug-induced hepatotoxicity is an acute or chronic liver injury also known as toxic liver disease, with a host of symptoms including yellowing of the skin, fatigue, nausea, rash, itching and upper-right abdominal pain, according to the National Library of Medicine. And, while it can be treated by removing the toxic trigger, it can lead to serious consequences — including the patient needing a liver transplant or even death if it is left untreated.

The researchers are not campaigning for abstinence, but urge users to be vigilant with ingredients and dosages, especially if they’re taking a combination of them or other medications, according to the report.

“In light of the lack of regulatory oversight on the manufacturing and testing of botanical products, it is recommended that clinicians obtain a full medication and HDS use history when evaluating patients with unexplained symptoms or liver test abnormalities,” they wrote in the study. “Considering widespread and growing popularity of botanical products, we urge government authorities to consider increasing the regulatory oversight on how botanicals are produced, marketed, tested, and monitored in the general population.”

‘A coin flip’

Regulatory processes surrounding these supplements are not as stringent as for prescription medicines, and chemical testing of products has revealed inconsistencies between what’s advertised on the bottle and what dose is in a tablet, researchers reported.

“In a previous study, we found that there was a great deal of mislabeling of some of these products,” said Dr. Robert Fontana, a Michigan Medicine a hepatologist, professor of medicine and the study’s senior author.

“We performed analytical chemistry and found about a 50% mismatch between stated ingredients on the label and what they actually contained, which is quite alarming,’' Fontana said. “If you buy a supplement and it says it has a certain ingredient, it’s basically a coin flip if that’s true or not.”

In the studied population, the highest proportion of people consumed turmeric (3.46%), followed by green tea (1.01%), ashwagandha and black cohosh (0.38%), garcinia cambogia (0.27%), and red yeast rice products (0.19%), researchers reported.

And clinical trials into the efficacy of these supplements have not provided robust evidence of their benefits compared to their risks when they’re taken at higher doses, the researchers reported.

Safe amounts of each supplement depends on any prescription medicines an individual may be taking, as well as their baseline liver health and other medical conditions.

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