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Socio-demographic predictors of not having private dental insurance coverage: machine-learning algorithms may help identify the disadvantaged

For accessing dental care in Canada, approximately 62% of the population has employment-based insurance, 6% have some publicly funded coverage, and 32% have to pay out-of pocket. Those with no insurance or pub...

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Machine learning algorithms using national registry data to predict loss to follow-up during tuberculosis treatment

Identifying patients at increased risk of loss to follow-up (LTFU) is key to developing strategies to optimize the clinical management of tuberculosis (TB). The use of national registry data in prediction mode...

#Bartender: portrayals of popular alcohol influencer’s videos on TikTok ©

Despite widespread use of the short-video social media platform TikTok © , limited research investigates how alcohol is portrayed on the platform. Previous research suggests that a driver of alcohol content on TikT...

Energy, nutrient and overall healthiness of processed packaged foods in Fiji, a comparison between 2018 and 2020

In Fiji, packaged foods are becoming increasingly available. However, it is unknown if nutrition composition of these foods has changed. This study aims to assess changes in energy, nutrient content and health...

A cohort study of self-perception of ageing and all-cause mortality among older adults in China: a multiple mediators analysis

Positive self-perception of aging (SPA) is a well-known predictor of longevity, while how and to what extent SPA is linked with all-cause mortality among older adults is still unclear. This study aims to eluci...

Family cohesion and quality of life significantly affecting personality changes in adult epilepsy patients: a case-control study

The goal of epilepsy treatment is not only to control convulsive seizures but also to improve the quality of life of patients. This study aimed to investigate personality changes and the risk factors for their...

Assessment of handwashing impact on detection of SARS-CoV-2, Staphylococcus aureus , Escherichia coli on hands in rural and urban settings of Côte d’Ivoire during COVID-19 pandemic

Handwashing is the first line of hygiene measures and one of the oldest methods of preventing the spread of infectious diseases. Despite its efficacy in the health system, handwashing is often inadequately pra...

Feasibility and acceptability of a cohort study baseline data collection of device-measured physical behaviors and cardiometabolic health in Saudi Arabia: expanding the Prospective Physical Activity, Sitting and Sleep consortium (ProPASS) in the Middle East

Physical behaviors such physical activity, sedentary behavior, and sleep are associated with mortality, but there is a lack of epidemiological data and knowledge using device-measured physical behaviors.

Risk factors and their association network for young adults’ suicidality: a cross-sectional study

Understanding the intricate influences of risk factors contributing to suicide among young individuals remains a challenge. The current study employed interpretable machine learning and network analysis to unr...

Cold waves and fine particulate matter in high-altitude Chinese cities: assessing their interactive impact on outpatient visits for respiratory disease

Extreme weather events like heatwaves and fine particulate matter (PM 2.5 ) have a synergistic effect on mortality, but research on the synergistic effect of cold waves and PM 2.5 on outpatient visits for respirator...

Process evaluation of implementation of the early stages of a whole systems approach to obesity in a small Island

The small Atlantic island of St Helena is a United Kingdom Overseas Territory (UKOT) with a high prevalence of childhood obesity (over a quarter of 4–5 and 10–11 year olds) and, anecdotally, adulthood obesity ...

Risk of not being in employment, education or training (NEET) in late adolescence is signalled by school readiness measures at 4–5 years

Not being in employment, education, or training (NEET) is associated with poor health (physical and mental) and social exclusion. We investigated whether England’s statutory school readiness measure conducted ...

The state of health in the European Union (EU-27) in 2019: a systematic analysis for the Global Burden of Disease study 2019

The European Union (EU) faces many health-related challenges. Burden of diseases information and the resulting trends over time are essential for health planning. This paper reports estimates of disease burden...

The association between non-alcoholic fatty liver disease and urinary incontinence among adult females in the United States

Non-alcoholic fatty liver disease (NAFLD) and urinary incontinence (UI) are both highly prevalent and age-related diseases. Nevertheless, the link between NAFLD and UI is unclear. Hence, the study was designed...

Factors influencing risk perception during Public Health Emergencies of International Concern (PHEIC): a scoping review

The unknownness and dread potential of a risk event shapes its perceived risk. A public health emergency of international concern (PHEIC) declaration by the World Health Organisation (WHO) is a signal for such...

Examining determinants of stunting in Urban and Rural Indonesian: a multilevel analysis using the population-based Indonesian family life survey (IFLS)

In Indonesia, chronic malnutrition leading to stunted growth in children represents a significant issue within the public health domain. The prevalence of stunting varies between urban and rural areas, reflect...

Associated lifestyle factors of elevated plasma aldosterone concentration in community population, gender-stratified analysis of a cross-sectional survey

Aldosterone plays important parts in development of cardio-metabolic diseases as end product of renin-angiotensin-aldosterone system. However, factors elevating circulating aldosterone are not clear, and lifes...

Human resource shortage in India’s health sector: a scoping review of the current landscape

For healthcare delivery to be optimally effective, health systems must possess adequate levels and we must ensure a fair distribution of human resources aimed at healthcare facilities. We conducted a scoping r...

Effects of electronic screen exposure time on hypertensive disorders in pregnancy: a retrospective cohort study

We previously conducted a case-control study and found that exposure to electronic screen before nocturnal sleep was associated with hypertensive disorders in pregnancy (HDP). Hence, we carried out this cohort...

The relationship between oxidative balance scores and chronic diarrhea and constipation: a population-based study

Oxidative stress is closely related to gut health. Exposures to oxidative stress in one’s diet and lifestyle can be evaluated by the oxidative balance score (OBS). However, the relationship between OBS and int...

The effect of physical fitness on psychological health: evidence from Chinese university students

Despite frequent discussions on the link between physical and mental health, the specific impact of physical fitness on mental well-being is yet to be fully established.

New sagittal abdominal diameter and transverse abdominal diameter based equations to estimate visceral fat area in type 2 diabetes patients

Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) are considered gold standards for measuring visceral fat area (VFA). However, their relatively high prices and potential radiation exposure limit th...

Lag effect of ambient temperature on respiratory emergency department visits in Beijing: a time series and pooled analysis

Although the association between ambient temperature and mortality of respiratory diseases was numerously documented, the association between various ambient temperature levels and respiratory emergency depart...

The effect of soy isoflavones supplementation on metabolic status in patients with non-alcoholic fatty liver disease: a randomized placebo controlled clinical trial

Non-alcoholic fatty liver disease (NAFLD) accounts as a crucial health concern with a huge burden on health and economic systems. The aim of this study is to evaluate the effect of soy isoflavones supplementat...

Smokeless tobacco consumption among women of reproductive age: a systematic review and meta-analysis

Smokeless tobacco (SLT) poses many negative health impacts. Despite its longstanding presence in societies across the world, the health implications of SLT have only been rigorously studied in recent decades. ...

Prevalence of HIV-related stigma manifestations and their contributing factors among people living with HIV in Sweden – a nationwide study

With access to  antiretroviral therapy (ART) HIV infection is a chronic manageable condition and non-sexually transmissible. Yet, many people living with HIV still testify about experiencing HIV-related stigma...

Disease burden of mental disorders among children and adolescents considering both co-morbidities and suicide in Northeastern China

Few studies have assessed the burden of mental disorders among children and adolescents considering the impact of co-morbidities and suicide on disability adjusted life years (DALYs).

Factors associated with antiretroviral treatment adherence among people living with HIV in Guangdong Province, China: a cross sectional analysis

Understanding factors associated with antiretroviral treatment (ART) adherence is crucial for ART success among people living with HIV (PLHIV) in the “test and treat” era. Multiple psychosocial factors tend to...

Postpartum depression symptoms: prevalence, risk factors, and childbirth experiences in Palestine

Worldwide mothers are suffering from postpartum depression (PPD) which impairs mothers’ well-being, children, and families, and leads to adverse outcomes for mothers and their growing newborns. Low and middle-...

COVID-19 vaccine intentions and attitudes in Black American emerging adults with asthma

Emerging adults (aged 18–29) are less likely to receive the COVID-19 vaccine than any other adult age group. Black Americans are less likely than non-Hispanic white Americans to be fully vaccinated against COV...

Physical activity and functional social support in community-dwelling older adults: a scoping review

Globally, the population of older people is increasing and is estimated to reach nearly 2.1 billion by 2050. Physical activity (PA) is one of the key components for successful ageing. However, PA decreases wit...

Structural relations of illness perception, fatigue, locus of control, self-efficacy, and coping strategies in patients with multiple sclerosis: a cross-sectional study

Patients with multiple sclerosis (MS) experience extensive problems due to fatigue and illness perception. Reducing these problems may improve these patients’ quality of life (QoL). Accordingly, the current st...

Community medical service construction: identifying factors that influence medical choice for patients with non-communicable chronic diseases in the Southwest China

Community medical institutions play a vital role in China’s healthcare system. While the number of these institutions has increased in recent years, their construction contents remain insufficient. The potenti...

Impact of COVID-19 on women living with HIV who are survivors of intimate partner violence

Women living with HIV (WLWH) experience higher rates of intimate partner violence (IPV) compared to women without HIV, but there has been minimal research to date on the impact of the COVID-19 pandemic on the ...

Prediction of adolescent weight status by machine learning: a population-based study

Adolescent weight problems have become a growing public health concern, making early prediction of non-normal weight status crucial for effective prevention. However, few temporal prediction tools for adolesce...

Air pollution, life’s essential 8, and risk of severe non-alcoholic fatty liver disease among individuals with type 2 diabetes

The impacts of long-term exposure to air pollution on the risk of subsequent non-alcoholic fatty liver disease (NAFLD) among participants with type 2 diabetes (T2D) is ambiguous. The modifying role of Life’s E...

Assessment of secular trends of three major gynecologic cancers burden and attributable risk factors from 1990 to 2019: an age period cohort analysis

This study aims to assess the long-term trends in the burden of three major gynecologic cancers(GCs) stratified by social-demographic status across the world from 1990 to 2019. To assess the trends of risk fac...

Parental hesitancy toward children vaccination: a multi-country psychometric and predictive study

Understanding vaccine hesitancy, as a critical concern for public health, cannot occur without the use of validated measures applicable and relevant to the samples they are assessing. The current study aimed t...

Cognition as mediator of pulmonary function and risk of sarcopenia among older adults

The relationship between lung function and sarcopenia remains ambiguous. The primary aim of this study was to investigate the potential association between lung function and sarcopenia in the older adults, as ...

Association of physical activity and screen time with cardiovascular disease risk in the Adolescent Brain Cognitive Development Study

According to the Physical Activity Guidelines Advisory Committee Scientific Report, limited evidence is available on sedentary behaviors (screen time) and their joint associations with physical activity (steps...

Dental caries prevalence in children during temporary protective care according to type of abuse

This study investigated the correlation between the prevalence of dental caries and the presence and type of abuse.

Bivariate extreme value analysis of extreme temperature and mortality in Canada, 2000-2020

Climate change increases the risk of illness through rising temperature, severe precipitation and worst air pollution. This paper investigates how monthly excess mortality rate is associated with the increasin...

Physical activity has decreased in Finnish children and adolescents from 2016 to 2022

Varying trends in children’s and adolescents’ physical activity (PA) have been reported during the last 10–20 years. Trends in sedentary behavior (SB) have been studied only rarely. The purpose of the present ...

Factors facilitating and hindering South Asian immigrant adults from engaging in exercise and physical activity – a qualitative systematic review

Exercise and physical activity are key components of management in patients with rheumatic musculoskeletal diseases (RMD), but people of the South Asian communities have a lower level of engagement with these ...

Longitudinal association of health behaviors and health-related quality of life with military spouse readiness

Unhealthy behaviors impose costs on health-related quality of life (HRQOL) reducing productivity and readiness among military members (Hoge et al., JAMA 295:1023–32, 2006; Mansfield et al. 362:101–9, 2010). Am...

Living in urban or rural environments affect the sleep quality of the elderly in Bushehr (Southern Iran): emphasizing the active and inactive of the elderly

Sleep disorders have a significant negative impact on mental and physical health, especially among the elderly. Various factors can affect the sleep quality of elderly people. The aim of this research to inves...

“That was one of my most difficult and biggest challenges”: experiences, preconditions and preventive measures of health-oriented leadership in virtual teams – A qualitative study with virtual leaders

Health-oriented leadership (HoL) has a positive impact on health- and work-related outcomes of employees in face-to-face settings. Increased digitization during the COVID-19 pandemic has led to many changes an...

How Ohio public library systems respond to opioid-related substance use: a descriptive analysis of survey results

Public libraries in the United States have experienced increases in opioid-related substance use in their communities and on their premises. This includes fatal and non-fatal overdose events. Some libraries ha...

Assessing family function: older adults vs. care nurses: a cross-sectional comparative study

This study aimed to assess family function in home care for older adults. Understanding family dynamics is essential for providing quality care to older adults choosing to age in place.

The epidemiology of major depression among adults in Norway: an observational study on the concurrence between population surveys and registry data – a NCDNOR project

Mental health problems, and major depression in particular, are important public health issues. Following trends in the prevalence of major depression is difficult because of the costs and complications of dia...

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• 15 May 2024

Neglecting sex and gender in research is a public-health risk

• Sue Haupt 0 ,
• Cheryl Carcel 1 &
• Robyn Norton 2

Sue Haupt is an honorary senior research fellow at Peter MacCallum Cancer Centre in Melbourne, Australia, and a research associate at The George Institute for Global Health, Women’s Health Program, Centre for Sex and Gender Equity in Health and Medicine, University of New South Wales (UNSW) Sydney, Australia.

You can also search for this author in PubMed   Google Scholar

Cheryl Carcel is the head of the brain health programme at The George Institute for Global Health UNSW Sydney, Australia.

Robyn Norton is a founding director of The George Institute for Global Health, a professor of public health at UNSW Sydney and chair of global health at Imperial College London, UK.

Illustration: Sophi Gullbrants

You have full access to this article via your institution.

In 2022, clinical trials indicated that a drug called lecanemab could slow cognitive decline in people with Alzheimer’s disease; soon after the results were published, the global Alzheimer’s community heralded lecanemab as a momentous discovery. However, closer inspection of the data by independent investigators revealed that the drug might significantly help men, but not women 1 .

The finding is a reminder that, even though tremendous advances are being made in the clinical application of cutting-edge technologies, such as gene editing and artificial intelligence (AI), there is a remarkable lack of understanding about how many aspects of human health are affected by variables as seemingly basic as sex and gender.

Sex and gender in science

Over the past decade or so, funders and publishers have made extensive efforts to encourage researchers to address the effects of sex and, in human studies, gender where appropriate. Thanks in part to these efforts, more insights are beginning to emerge. For Alzheimer’s and many other diseases that are common causes of death, including cardiovascular diseases, cancer, chronic respiratory conditions and diabetes, a person’s sex and gender can influence their risk of developing the disease, how quickly and accurately they are diagnosed, what treatment they receive and how they fare.

But even for the most-studied conditions, many questions remain. Few investigators have begun to probe the interrelationships between sex and gender , for example. And in cases in which researchers are managing to unpick the multifaceted effects of sex, this knowledge is not being sufficiently incorporated into the design of clinical trials or adequately changing the practice of medicine.

The consideration of sex and, where appropriate, gender in biological research must become routine — especially as molecular genetics, biomedical engineering and AI open up possibilities for treatments that are better tailored to the needs of individuals. Likewise, the culture of medicine must be transformed so that approaches to treatment evolve in response to the data. This will require further engagement from funders and publishers, but action from many other players, too. Pharmaceutical companies and intergovernmental organizations, among others, must acknowledge three things: how sex and gender can have huge effects on health outcomes; how these effects are often disregarded in basic research and clinical trials; and that change can come only through increasing awareness among all stakeholders of the importance of shifting the dial.

Health outcomes affected

In most human clinical records so far, sex is reported by physicians or participants in studies ticking one of two boxes: ‘female’ or ‘male’. In those clinical studies in which data are collected on chromosomes, hormone levels, reproductive anatomy or other sex characteristics, these features will frequently reflect a person’s sex assigned at birth. But this is not always the case. Added to this, sex and gender have often been used interchangeably, but they are not the same and they do not always align. Current definitions of gender include the social, psychological, cultural and behavioural aspects of being a man or woman (whether cisgender or transgender), non-binary or identifying with one or more other evolving terms 2 .

In several countries, new recommendations about how researchers should obtain data on people’s sex and gender should mean that, in the future, investigators will be able to more-accurately probe the roles of both in human health. But in general, there has been incomplete capture of information for sex and gender so far, including for individuals whose sex characteristics and/or gender identities don’t fall into a binary categorization scheme.

Women are more likely to die after a severe heart attack than are men. Credit: Simon Dawson/Reuters

In this article, consistent with much of the published population-wide data, we refer to a woman as someone who identifies with that gender and was assigned female sex at birth (a cis woman), and a man as someone who identifies with that gender and was assigned male sex at birth (a cis man). But we recognize that participants in the studies we describe might not have been asked about both their gender and their sex.

For all sorts of non-communicable diseases, there are differences between men and women in the average age at which they are diagnosed, the average age at which they die and even in their rates of death.

We need more-nuanced approaches to exploring sex and gender in research

Such variations, from the earlier onset of cardiovascular diseases in men to the more frequent occurrence of Alzheimer’s disease in women, might stem from differences in biology, which can affect people’s likelihood of developing a disease and how they respond to treatment. Or these discrepancies might stem from variation in people’s exposure to the environmental factors that trigger the disease, how they manage their condition, how they are treated by carers and so on, all of which can be influenced by a person’s gender. Often, a combination of factors will be at work.

Take heart attacks. Studies conducted over the past decade have revealed extensive sex differences in the expression of certain genes in heart tissue, which in turn affect the type and function of the cells that make up the heart.

Such variation could help to explain why men are likely to have a heart attack for the first time around six years earlier than women — in the United States, at 65.6 years old in men compared with 72 years old in women 3 — and why (in Australia, at least) heart attacks are at least twice as common in men relative to women of comparable ages (see go.nature.com/3qbvrxq ). Likewise, although mechanisms are yet to be fully understood, it is plausible that differences in people’s biology help to explain why women are more likely to experience pain between their shoulder blades, nausea or vomiting and shortness of breath during a heart attack; why men are more likely to experience chest pain and increased sweating; and why women are nearly twice as likely as are men to die after a severe heart attack.

Yet, when it comes to the risk of dying, social and environmental factors — shaped by gender — also seem to be important.

Tobacco consumption increases a person’s risk of having a heart attack, and smoking is much more common among men globally. Worldwide, around 37% of men smoke compared with around 8% of women . Also, in part because health-care professionals and others are more familiar with the heart attack symptoms commonly seen in men, when women have a heart attack, they are more likely to delay seeking help, and carers are often slower to intervene 4 . In fact, in a study of more than 500,000 people who experienced a heart attack and were admitted to hospital in the United Kingdom between 2004 and 2013, women were 37% more likely to receive an incorrect initial diagnosis after a severe heart attack than were men 5 . Even when women tell their physicians that they have chest pain, they are two to three times less likely to be referred to a cardiologist than are men 6 .

A similarly complicated picture has been emerging in relation to strokes 7 — another cardiovascular disease — and, in the past few years, in relation to cancer.

Smoking is more common among men than women globally. Credit: Behrouz Mehri/AFP/Getty

Most cancers that occur in non-reproductive organs develop earlier in men than they do in women. In the United States, oesophageal cancer is 4.5 times more likely to occur and cause death in men than in women, for example, and lung cancers, the most common drivers of cancer-associated deaths worldwide, kill around 40% more men than women 8 .

Just as with heart disease and stroke, some of this variation seems to stem from behavioural differences. Tobacco consumption increases a person’s risk of developing several cancers 7 . For thyroid cancers, however, women are more likely to develop the disease than are men — three times more likely in some places — which suggests that other factors might drive the different rates of this particular cancer in women and men 9 . But tumours typically arise because of problems with cells’ genetic-repair systems, together with inadequate damage clearance, and genetic differences between men and women that affect cancers are beginning to emerge.

Male–female comparisons are powerful in biomedical research — don’t abandon them

Much more research is needed to understand how sex affects the rate at which genes mutate, cells’ capacities to repair and clear damaged DNA, and when genetic damage starts causing disease. Yet research led by one of us (S.H.) on lung adenocarcinoma, the most common type of lung cancer, suggests that women can survive for longer than men after they are diagnosed, in part thanks to cancer-defence genes in women driving more-robust immune responses 10 . X chromosomes encode many genes that are linked to immunity, and women with two X chromosomes might express these genes at higher levels than men with XY chromosomes.

Responses to cancer treatments also differ between men and women. Chemotherapies tend to work better in women than in men. This could be because it can take longer for women’s bodies to clear certain drugs, which could partly explain why women are also 34% more likely than men to experience harmful side effects 11 . Moreover, women with lung cancer typically have better outcomes after surgery, which they undergo more often than men 8 . This is probably due, at least in part, to women having less advanced disease when they are diagnosed than men do 12 . But the generally stronger immune responses in women might also help their recovery 8 .

Too often ignored

Despite these compelling indications that sex and gender matter, when it comes to many diseases that are leading causes of death, many researchers and health practitioners still fail to adequately take sex and gender into account. They might also be influenced by conscious or unconscious bias.

In the case of heart disease, the differences in gene expression and cellular make-up and activity found in men and women’s hearts highlight the need for sex-specific cardiac tissue models, sustained by sex-appropriate vasculature 13 . (Women on average have smaller hearts with narrower vessels compared with men.) Currently, researchers tend to construct heart models using either animal or human cells, but without necessarily ensuring that cells are sourced from individuals of only one sex per model. In fact, identifying sex disparities in basic heart biology is crucial to engineering relevant heart models with stem cells, for example, which investigators are now developing to aid the study of heart disease 13 .

For both heart disease and stroke, because of decades of under-representation of women in clinical trials, many of today’s standard treatments are based on studies of what happens in men who weigh around 70 kilograms. In clinical trials conducted for stroke and heart conditions between 2010 and 2017, women worldwide were under-enrolled relative to the prevalence of these diseases in the general population — by around 20% 14 . There is also significant underfunding of research for many conditions that are more prevalent in women compared with those that are more common in men (see ‘Disparities in health and disease’).

Source: A. A. Mirin J. Womens Health 30 , 956–963 (2021).

Basic research on cancer is similarly riddled with problems. Take the sex of the cell lines that are stored in commercial cell banks, which have been studied for decades and are the source of much of today’s textbook knowledge. For lung cancers, male lines outnumber female lines by two to one. For liver cancers, the ratio is seven to one. Until a few years ago, few researchers studying cancer in cultured cells in the lab even considered the sex of the cells they were studying. Also, the standard media in which cells are grown is frequently supplemented with fetal calf serum from a mixture of male and female calves, and so contains both male and female sex hormones. And phenol red, a dye commonly used to monitor the pH of tissue culture media mimics the hormone oestrogen 8 .

To add to the difficulties, research findings that emerge from the use of these cell lines are often tested in mice of only one sex. The results of these studies are then used to guide human trials that include both men and women participants. And in oncological clinical trials, just as with stroke and heart disease, women are still under-enrolled relative to the burden of disease they experience 7 .

Inclusivity in human trials will ensure the best possible outcomes for all participants, including cis and trans women and men, gender-diverse and intersex people (see ‘Inclusivity in practice’). Studies are showing, for example, that circadian rhythms — which can affect heart function and might impact how drugs are metabolized — differ between men and women 15 . So how might they compare in non-binary or transgender people? Likewise, knowledge about the immune responses of people with atypical numbers of sex chromosomes is likely to be crucial when it comes to the use of immune checkpoint inhibitors and other immune therapies for treating cancer. Those with Klinefelter syndrome, for example, who, similar to cis women, are at a higher risk of developing breast cancer than are cis men, have multiple X chromosomes that are rich in genes involved in the immune response.

Inclusivity in practice

How researchers include diverse groups of people in clinical trials with enough participants to be able to uncover between-group differences is a challenge.

Women represent nearly half of the population, but they are still under-represented in many clinical trials for numerous diseases, even in cases in which disease prevalence for women has been measured. For smaller population groups, such as transgender people, there are not enough data to even know what representative inclusion looks like. In fact, even if participation does reflect the prevalence of disease in the broader population in any one trial, teasing out effects might require combining the results of multiple studies in meta-analyses.

Advisory governing boards for pharmaceutical companies, such as the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use, funders and regulatory agencies could help with this by ensuring that terminology is adequately and consistently defined, and that populations are properly profiled.

Heightened awareness

Routinely taking sex and gender into account in research and using that knowledge to change health care could benefit billions of people. So what’s needed to make this happen?

Policy changes — such as the US National Institutes of Health’s 2016 call for the inclusion of male and female sexes in studies involving cells, tissues and animals — are crucial. But for many researchers, such calls seem burdensome, especially because studying more than one sex can increase costs. ( Sample sizes might need to be increased to achieve sufficient statistical power when comparing groups.)

Alongside initiatives from funders and publishers, awareness must be built — among students, researchers, clinicians, medical ethics committees, research governance bodies and community groups — of the ramifications of failing to consider sex and gender, and how to correct the problem.

Accounting for sex and gender makes for better science

Efforts led by the Canadian Institutes of Health Research (CIHR) are encouraging. Even though the permeation of knowledge from research to health care has been glacial, between 2011 and 2019, the proportion of all research grant applications submitted to the CIHR that took sex into consideration increased from around 22% to 83%. Gender as a variable is now also included in many of the human studies funded by the CIHR .

Several initiatives have contributed to this. As an example, as well as asking grant applicants to include a section in their research proposals on whether they are considering sex and gender and how they will do so, or why this is not considered applicable, the CIHR has provided training for scientists and organized workshops involving researchers and specialists in sex and gender. Applicants are more likely to receive funding if they provide a satisfactory rationale for their choices.

Convincing people in leadership roles — in governments, laboratories, medical ethics boards, education and so on — of the importance of including sex and gender in research is especially crucial. More studies demonstrating the financial costs of not doing so could help. Between 1997 and 2000, for instance, eight prescription drugs were retracted from the US market because inadequate clinical testing in women had failed to identify that the drugs put women at greater risk of developing health problems than men. This error cost pharmaceutical companies and taxpayers an estimated US$1.6 billion per drug 16 .

The scale of transformation needed will also require more engagement from global players.

Even as far back as 2007, the 60th World Health Assembly — the decision-making body of the World Health Organization (WHO) — passed a resolution to urge researchers to split their data according to sex and to include gender analyses where appropriate. Steps to improve care for transgender people or those with diverse genders are also starting to be taken; in December last year, the WHO established a Guideline Development Group, to provide recommendations on how to address the health of transgender and gender-diverse people . But more extensive efforts, comparable to all United Nations member states committing to target 5.b of the 2015 Sustainable Development Goals by 2030, will be crucial. (This target is to “enhance the use of enabling technology, in particular information and communications technology, to promote the empowerment of women”.)

Lastly, under the guidance of regulatory bodies such as the European Medicines Agency and the scientific entrepreneur community, the pharmaceutical industry must do more to ensure that preclinical work is robust, and that products are tested on enough people of different sexes and genders. Many leading pharmaceutical companies acknowledge on their websites the importance of including diverse groups in clinical trials , but evidence of actions to address the issue is only just emerging.

Awareness of the problems around sex and gender is growing fast. And although many are concerned that medical applications of AI will perpetuate already existing biases 17 , promising developments are emerging in the use of machine learning to make diagnoses that are appropriate for people’s sex and gender.

For decades, for instance, physicians worldwide have been determining whether a person has had a heart attack by using the Global Registry of Acute Coronary Events (GRACE) score, which was derived from trials mainly involving men. In 2022, the application of machine learning to data that had been split for men and women refined the predictors for women. And these revised predictors did a better job of matching individuals to appropriate interventions 18 .

Greater awareness, the wealth of data now emerging and the possibilities presented by new tools, from AI to gene editing, could mean a new era for research and medicine.

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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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Gun Violence and Pretrial Detention—Addressing Public Perception and Public Health

• 1 Department of Criminology and Criminal Justice, University of Maryland, College Park
• 2 Department of Criminal Justice, University of Central Florida, Orlando
• Original Investigation Evaluating Firearm Violence After New Jersey’s Cash Bail Reform Jaquelyn L. Jahn, PhD; Jessica T. Simes, PhD; Jonathan Jay, DrPH JAMA Network Open

State and local policymakers are tasked with promoting public safety, often through passing legislation. In doing so, they must attend to serious public health matters, including growing concerns over myriad consequences of mass incarceration. Jahn and colleagues 1 investigated how these priorities overlap by estimating the association between the implementation of bail reform legislation and rates of gun violence in New Jersey. Using synthetic control methods, the authors compared postpolicy trends in gun violence against a matched comparison group of 36 jurisdictions that did not implement bail reform. The authors found no statistically significant changes in the rates (per 100 000) of firearm mortality or shootings following the implementation of bail reform in New Jersey, compared with the synthetic control group. As such, their findings did not support the assertion of commentators who hastily branded bail reform as a progressive policy that would seriously threaten public safety. Specifically, during the study period, the policy change did not result in an increase in gun violence at the community level, and the number of individuals held in pretrial detention in fact decreased.

With respect to policy, Jahn and colleagues 1 suggest that to reduce gun violence and well-documented racial disparities, responses should be effective and fair. Recent estimates from the Prison Policy Initiative 2 report that approximately 1.9 million people in the US are incarcerated across federal, state, local, and tribal correctional facilities, for a per capita rate of 583 per 100 000 people. For context, the incarceration rates per 100 000 people in other countries, including Norway (54), Canada (104), Portugal (111), China (121), Mexico (166), South Africa (248), and Trinidad and Tobago (276), are far lower. Furthermore, of the approximately 550 000 individuals held in local jails across the country, 448 000, or 81.45%, have not been convicted and remain in pretrial detention largely due to financial hardship. 2 As such, bail reform passed in New Jersey in 2017 eliminated cash bail and, instead, instituted a risk assessment wherein judges weighed factors such as prior criminal record in determining whether to release arrestees pretrial. Incarceration has numerous deleterious health outcomes, including increased prevalence of infectious diseases, chronic medical conditions, aggravated substance abuse, exacerbated mental health conditions, and increased mortality rates. 3 Furthermore, incarcerated individuals’ family members bear the brunt of a wide range of collateral consequences. Specifically, an abundant body of research suggests that children with incarcerated parents develop behavioral and mental health problems during adolescence and are at heightened risk of depression, anxiety, and addiction into adulthood. 3 Mass incarceration, including holding arrestees in pretrial detention, has both direct and indirect adverse health outcomes, adversely impacting entire communities.

Alarming rates of gun violence are a common public safety concern among neighborhood residents and public officials alike. In fact, recent estimates suggest that in 2020, 79% of US homicides and 53% of suicides involved a firearm. 4 Moreover, firearm-related fatalities are disproportionately concentrated among young Black male individuals residing in disadvantaged community contexts (eg, poverty, unemployment, and housing instability). 4 Specifically, some of the highest rates of gun violence are concentrated among inner-city youths aged 10 to 24 years. Compared with other developed countries, the US continues to lead in gun deaths. Moreover, firearm-related violence trends also coincide with surges in commercial gun sales. 5 Compelling evidence suggests that easy access to guns precipitates firearm-related injuries and fatalities. As such, policymakers find themselves at a crossroads. For example, they are often implored to effectively address gun violence without exacerbating the negative outcomes associated with mass incarceration.

Several cities across the nation have sought solutions to fatal and nonfatal shootings by leveraging the criminal justice system and community partners. For example, Newark, New Jersey, typifies cities with a notable history of gun violence. In response, the city has implemented community-based strategies such as the Newark Community Street Team (NCST). The violence reduction initiative engages local community members who serve as interventionists, working to peacefully resolve interpersonal disputes that otherwise may have turned deadly. The NCST routinely meets with neighborhood residents and Newark Police Department (NPD) leaders. NPD’s authentic and respectful engagement with community members recognizes them as valuable stakeholders, evincing the mayor’s commitment to collective efficacy, building cohesion among neighborhood residents with the goal of enlisting them as public safety partners. In 2019, compared with the previous year, the most violent area of the city, the fifth precinct, saw a 58% reduction in murders and 28% decrease in nonfatal shootings. 6

Law enforcement agencies nationwide have also attempted to reduce violence and disorder by deploying foot patrols within designated hot spots—that is, small geographic areas (eg, street segments or intersections) that are responsible for a disproportionate amount of crime, such as frequent gun violence. Police intervention in the form of foot patrols enables officers to serve as capable guardians and deter potential crimes while simultaneously creating spaces for positive police-community engagement. In Newark, the strategy was associated with a 42% reduction in overall violence, including a 60% decrease in nonfatal shootings and homicides within a fourth precinct designated hot spot, compared with the overall zone, which received routine patrol activity. 7

Finally, several police agencies have implemented focused deterrence, or pulling-levers strategies, to reduce violent crime. The pillars of the initiative are direct communications from law enforcement officials (eg, prosecutor or police chief) to high-risk individuals (and groups) that offenders will face certain and swift legal sanctions should their behavior continue. They are also offered a wide range of social services, including job training and educational opportunities. Conversely, person-based crime reduction approaches (eg, stop, question, and frisk) have been found to blanket entire high-crime communities where people of color disproportionally reside, ultimately eroding residents’ trust in, and the legitimacy of, the police. Focused deterrence is an evidence-based approach that leverages data to identify high-risk offenders rather than subjecting entire neighborhoods to heightened police surveillance. In a recent systematic review that investigated the effectiveness of focused deterrence strategies, 19 of the 24 studies found empirical support for statistically significant crime reduction. 8

We applaud Jahn and colleagues 1 for casting much needed light on important social justice issues facing the nation. Specifically, their research shows that state-level policy changes can simultaneously address public perception of criminal justice system unfairness and citizen concern about rising crime. Local crime-fighting strategies such as the NCST demonstrate the value of effective solutions informed by the social context in which crime occurs. As such, crime reduction strategies should not be conceptualized or implemented in a one-size-fits-all manner, but rather as targeted, data-driven approaches.

Published: May 22, 2024. doi:10.1001/jamanetworkopen.2024.12929

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Brunson RK et al. JAMA Network Open .

Corresponding Author: Rod K. Brunson, PhD, Department of Criminology and Criminal Justice, University of Maryland, 2220P Lefrak Hall, 7251 Preinkert Dr, College Park, MD 20742 ( [email protected] ).

Conflict of Interest Disclosures: None reported.

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Brunson RK , Chillar VF. Gun Violence and Pretrial Detention—Addressing Public Perception and Public Health. JAMA Netw Open. 2024;7(5):e2412929. doi:10.1001/jamanetworkopen.2024.12929

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Why writing by hand beats typing for thinking and learning

Jonathan Lambert

If you're like many digitally savvy Americans, it has likely been a while since you've spent much time writing by hand.

The laborious process of tracing out our thoughts, letter by letter, on the page is becoming a relic of the past in our screen-dominated world, where text messages and thumb-typed grocery lists have replaced handwritten letters and sticky notes. Electronic keyboards offer obvious efficiency benefits that have undoubtedly boosted our productivity — imagine having to write all your emails longhand.

To keep up, many schools are introducing computers as early as preschool, meaning some kids may learn the basics of typing before writing by hand.

But giving up this slower, more tactile way of expressing ourselves may come at a significant cost, according to a growing body of research that's uncovering the surprising cognitive benefits of taking pen to paper, or even stylus to iPad — for both children and adults.

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In kids, studies show that tracing out ABCs, as opposed to typing them, leads to better and longer-lasting recognition and understanding of letters. Writing by hand also improves memory and recall of words, laying down the foundations of literacy and learning. In adults, taking notes by hand during a lecture, instead of typing, can lead to better conceptual understanding of material.

"There's actually some very important things going on during the embodied experience of writing by hand," says Ramesh Balasubramaniam , a neuroscientist at the University of California, Merced. "It has important cognitive benefits."

While those benefits have long been recognized by some (for instance, many authors, including Jennifer Egan and Neil Gaiman , draft their stories by hand to stoke creativity), scientists have only recently started investigating why writing by hand has these effects.

A slew of recent brain imaging research suggests handwriting's power stems from the relative complexity of the process and how it forces different brain systems to work together to reproduce the shapes of letters in our heads onto the page.

Your brain on handwriting

Both handwriting and typing involve moving our hands and fingers to create words on a page. But handwriting, it turns out, requires a lot more fine-tuned coordination between the motor and visual systems. This seems to more deeply engage the brain in ways that support learning.

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"Handwriting is probably among the most complex motor skills that the brain is capable of," says Marieke Longcamp , a cognitive neuroscientist at Aix-Marseille Université.

Gripping a pen nimbly enough to write is a complicated task, as it requires your brain to continuously monitor the pressure that each finger exerts on the pen. Then, your motor system has to delicately modify that pressure to re-create each letter of the words in your head on the page.

"Your fingers have to each do something different to produce a recognizable letter," says Sophia Vinci-Booher , an educational neuroscientist at Vanderbilt University. Adding to the complexity, your visual system must continuously process that letter as it's formed. With each stroke, your brain compares the unfolding script with mental models of the letters and words, making adjustments to fingers in real time to create the letters' shapes, says Vinci-Booher.

That's not true for typing.

To type "tap" your fingers don't have to trace out the form of the letters — they just make three relatively simple and uniform movements. In comparison, it takes a lot more brainpower, as well as cross-talk between brain areas, to write than type.

Recent brain imaging studies bolster this idea. A study published in January found that when students write by hand, brain areas involved in motor and visual information processing " sync up " with areas crucial to memory formation, firing at frequencies associated with learning.

"We don't see that [synchronized activity] in typewriting at all," says Audrey van der Meer , a psychologist and study co-author at the Norwegian University of Science and Technology. She suggests that writing by hand is a neurobiologically richer process and that this richness may confer some cognitive benefits.

Other experts agree. "There seems to be something fundamental about engaging your body to produce these shapes," says Robert Wiley , a cognitive psychologist at the University of North Carolina, Greensboro. "It lets you make associations between your body and what you're seeing and hearing," he says, which might give the mind more footholds for accessing a given concept or idea.

Those extra footholds are especially important for learning in kids, but they may give adults a leg up too. Wiley and others worry that ditching handwriting for typing could have serious consequences for how we all learn and think.

What might be lost as handwriting wanes

The clearest consequence of screens and keyboards replacing pen and paper might be on kids' ability to learn the building blocks of literacy — letters.

"Letter recognition in early childhood is actually one of the best predictors of later reading and math attainment," says Vinci-Booher. Her work suggests the process of learning to write letters by hand is crucial for learning to read them.

"When kids write letters, they're just messy," she says. As kids practice writing "A," each iteration is different, and that variability helps solidify their conceptual understanding of the letter.

Research suggests kids learn to recognize letters better when seeing variable handwritten examples, compared with uniform typed examples.

This helps develop areas of the brain used during reading in older children and adults, Vinci-Booher found.

"This could be one of the ways that early experiences actually translate to long-term life outcomes," she says. "These visually demanding, fine motor actions bake in neural communication patterns that are really important for learning later on."

Ditching handwriting instruction could mean that those skills don't get developed as well, which could impair kids' ability to learn down the road.

"If young children are not receiving any handwriting training, which is very good brain stimulation, then their brains simply won't reach their full potential," says van der Meer. "It's scary to think of the potential consequences."

Many states are trying to avoid these risks by mandating cursive instruction. This year, California started requiring elementary school students to learn cursive , and similar bills are moving through state legislatures in several states, including Indiana, Kentucky, South Carolina and Wisconsin. (So far, evidence suggests that it's the writing by hand that matters, not whether it's print or cursive.)

Slowing down and processing information

For adults, one of the main benefits of writing by hand is that it simply forces us to slow down.

During a meeting or lecture, it's possible to type what you're hearing verbatim. But often, "you're not actually processing that information — you're just typing in the blind," says van der Meer. "If you take notes by hand, you can't write everything down," she says.

The relative slowness of the medium forces you to process the information, writing key words or phrases and using drawing or arrows to work through ideas, she says. "You make the information your own," she says, which helps it stick in the brain.

Such connections and integration are still possible when typing, but they need to be made more intentionally. And sometimes, efficiency wins out. "When you're writing a long essay, it's obviously much more practical to use a keyboard," says van der Meer.

Still, given our long history of using our hands to mark meaning in the world, some scientists worry about the more diffuse consequences of offloading our thinking to computers.

"We're foisting a lot of our knowledge, extending our cognition, to other devices, so it's only natural that we've started using these other agents to do our writing for us," says Balasubramaniam.

It's possible that this might free up our minds to do other kinds of hard thinking, he says. Or we might be sacrificing a fundamental process that's crucial for the kinds of immersive cognitive experiences that enable us to learn and think at our full potential.

Balasubramaniam stresses, however, that we don't have to ditch digital tools to harness the power of handwriting. So far, research suggests that scribbling with a stylus on a screen activates the same brain pathways as etching ink on paper. It's the movement that counts, he says, not its final form.

Jonathan Lambert is a Washington, D.C.-based freelance journalist who covers science, health and policy.

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Environmental Pollution in the Moscow Region According to Long-term Roshydromet Monitoring Data

• Published: 02 November 2020
• Volume 45 , pages 523–532, ( 2020 )

Cite this article

• G. M. Chernogaeva 1 , 2 ,
• L. R. Zhuravleva 1 ,
• Yu. A. Malevanov 1 ,
• N. A. Fursov 3 ,
• G. V. Pleshakova 3 &
• T. B. Trifilenkova 3  

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Long-term Roshydromet monitoring data (2009–2018) on the pollution of the atmosphere, soil, and surface water are considered for the Moscow region (Moscow city within its new boundaries and the Moscow oblast). The air quality in the megacity (Moscow) and in background conditions (Prioksko-Terrasny Reserve) is compared.

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Air Quality in Russian Cities for 1991–2016

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Izrael Institute of Global Climate and Ecology, 107258, Moscow, Russia

G. M. Chernogaeva, L. R. Zhuravleva & Yu. A. Malevanov

Institute of Geography, Russian Academy of Sciences, 119017, Moscow, Russia

G. M. Chernogaeva

Central Administration for Hydrometeorology and Environmental Monitoring, 127055, Moscow, Russia

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Russian Text ©The Author(s), 2020, published in Meteorologiya i Gidrologiya, 2020, No. 8, pp. 9-21.

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Chernogaeva, G.M., Zhuravleva, L.R., Malevanov, Y.A. et al. Environmental Pollution in the Moscow Region According to Long-term Roshydromet Monitoring Data . Russ. Meteorol. Hydrol. 45 , 523–532 (2020). https://doi.org/10.3103/S1068373920080014

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Received : 06 February 2020

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Accepted : 06 February 2020

Published : 02 November 2020

Issue Date : August 2020

DOI : https://doi.org/10.3103/S1068373920080014

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KFF Health Tracking Poll May 2024: The Public’s Use and Views of GLP-1 Drugs

Alex Montero , Grace Sparks , Marley Presiado , and Liz Hamel Published: May 10, 2024

• Methodology

Key Findings

• The latest KFF Health Tracking Poll finds that about one in eight adults (12%) say they have ever taken a GLP-1 agonist – an increasingly popular class of prescription drugs used for weight loss and to treat diabetes or prevent heart attacks or strokes for adults with heart disease – including 6% who say they are currently taking such a drug. The share who report ever taking these drugs rises to four in ten (43%) among adults who have been told by a doctor that they have diabetes, a quarter who have been told they have heart disease, and one in five (22%) who have been told by a doctor that they are overweight or obese in the past five years 1 . Public awareness of GLP-1 drugs has increased in the past year, with about one-third (32%) of adults now saying they have heard “a lot” about these drugs, up from 19% in July 2023.
• Most adults who have taken GLP-1 drugs say they took them to treat a chronic condition including diabetes or heart disease (62%), while about four in ten say they took them primarily to lose weight.
• About half (54%) of all adults who have taken GLP-1 drugs say it was difficult to afford the cost, including one in five (22%) who say it was “very difficult.” While most insured adults who have taken these drugs say their insurance covered at least part of the cost, even among insured adults about half (53%) say the cost was difficult to afford 2 .
• While 8% of adults ages 65 and older say they have taken a GLP-1 medication for a chronic condition, just 1% say they have ever taken a GLP-1 drug to lose weight, which may reflect Medicare’s lack of coverage for prescription drugs used for weight loss. Nearly four in ten (37%) adults ages 65 and older report being told by a doctor they are overweight or obese in the past five years.
• With Medicare currently prohibited by law from covering prescription drugs used for weight loss, six in ten adults say they think Medicare should cover the cost of these drugs when prescribed for weight loss for people who are overweight, including more than half of Democrats, independents and Republicans. Similar shares of the public continue to support Medicare coverage of these drugs for weight loss even after hearing arguments for and against this proposal.

Use, Access and Affordability of GLP-1 Drugs

KFF’s latest Health Tracking Poll examines the public’s views and use of an increasingly popular group of drugs that include Ozempic, Wegovy, Mounjaro and others that belong to a class of prescription medications known as GLP-1 agonists 3 . GLP-1 drugs have garnered an increasing amount of media attention and some notable celebrity endorsements in the U.S., with much of the focus on their use for weight loss, though many of these drugs are also prescribed to treat diabetes or reduce risk of heart attack or stroke.

A large and increasing share of the public say they have heard about GLP-1 drugs, with about eight in ten (82%) adults saying they have heard at least “a little” and about three in ten (32%) saying they have heard “a lot” about these drugs. The share of the public who report having heard about these drugs has increased since July 2023 when seven in ten adults reported having heard at least “a little” about these drugs and one in five (19%) said they had heard “a lot.”

The share who say they have heard “a lot” about these drugs rises to at least four in ten among those who have ever been told by a doctor that they have diabetes (45%) or heart disease (41%) or have been told by a doctor in the past five years that they are overweight or obese (42%) – the primary conditions these drugs are prescribed for.

Across age groups, awareness of these drugs is highest among older adults. About four in ten adults ages 50 to 64 and 65 and older say they have heard “a lot” about GLP-1 drugs, compared to about one-third of adults ages 30-49 (32%) and one in six adults ages 18-29 (17%). Notably, older adults are more likely than their younger peers to have been told by a doctor that they have diabetes or heart disease.

Adults with annual household incomes of $90,000 or greater are more likely than those with lower household incomes to say they have heard “a lot” about these drugs.

Overall, 12% of adults say they have ever used GLP-1 drugs, including 6% who say they are currently using them. The share who report ever taking these drugs rises to about four in ten (43%) among adults who have been told by a doctor that they have diabetes, a quarter (26%) of adults who have been told they have heart disease, and one in five (22%) adults who have been told by a doctor that they are overweight or obese in the past five years (some of whom also have diabetes or heart disease).

Black adults are somewhat more likely than White adults to report ever taking these drugs (18% v. 10%), while 13% of Hispanic adults say they have taken these drugs. KFF’s analysis of Centers for Disease Control (CDC) data shows that Black and Hispanic adults in the U.S. have a higher rate of obesity than White adults. For additional information on obesity rates and racial disparities, see KFF’s policy watch: What are the Implications of New Anti-Obesity Drugs for Racial Disparities?

Similar shares of adults regardless of gender, income, or health insurance coverage report taking these drugs.

Among the 12% of adults who have ever taken GLP-1 drugs, most report taking them, at least in part, to treat a chronic condition like diabetes or heart disease, with fewer saying they took them only to lose weight. Among those who have taken these drugs, six in ten (62%) say they took them to treat a chronic condition like diabetes or heart disease, including about four in ten (39%) who took them only to treat a chronic condition and one in four (23%) who say they took them to both treat a chronic condition and to lose weight. About four in ten (38%) adults who have taken these drugs report using them only to lose weight.

Among all adults, 7% say they have taken or are taking these drugs to treat a chronic condition such as diabetes or heart disease – either alone (5%) or in combination with intent of losing weight (3%) – while 5% of adults report ever taking these drugs to lose weight but not to treat a chronic condition.

About one in five (19%) adults ages 50-64 say they have ever taken GLP-1 drugs, higher than the shares reported by other age groups. Among adults ages 50-64, 15% say they have taken GLP-1 drugs to treat a chronic condition and 5% say they’ve taken them for weight loss only. Few adults under age 50 report having taken these drugs to treat chronic conditions, but similar shares of 18–29-year-olds (7%) and 30–49-year-olds (6%) report having taken them for weight loss. Among adults ages 65 and over, 8% say they have taken a GLP-1 medication for a chronic condition, while just 1% say they have taken these drugs only to lose weight, which may be a reflection of Medicare’s lack of coverage for prescription drugs used for weight loss. Nearly four in ten (37%) adults ages 65 and older report being told by a doctor they are overweight or obese in the past five years.

Alongside the relatively high cost of GLP-1 drugs in the U.S., there have been recent reports of shortages or limited availability of these drugs occurring as demand increases. Recent news reports have emphasized that some adults are seeking generic or compounded versions of these drugs through sources such as medical spas or compounding pharmacies, which may sell products claiming to be name-brand GLP-1s that have not been vetted by the F.D.A.

About eight in ten (79%) adults who have taken GLP-1 drugs report getting these drugs or a prescription for them from their primary care doctor or a specialist, while fewer report getting them from an online provider or website (11%), a medical spa or aesthetic medical center (10%), or from somewhere else (2%).

In the U.S., list prices for GLP-1 drugs can range from $936 to $1,349 before insurance coverage, rebates or coupons. Most insured adults who have taken GLP-1 drugs say their insurance covered at least part of the cost. Among adults with health insurance who report ever taking these drugs, over half (57%) say their health insurance covered part of the cost of these drugs and they paid the rest, while one in four (24%) say their health insurance covered the full cost. One in five (19%) insured adults who have taken GLP-1s say they paid for the full cost themselves.

Despite the fact that few insured adults say they paid the full cost of these drugs themselves, many report difficulty affording them. About half of adults who have taken GLP-1s say it was difficult to afford the cost of these drugs. Among those who have taken these drugs, about half (54%) – including 53% of those with health insurance – say it was either “somewhat” or “very difficult” to afford to pay for these drugs, including one in five (22%) who say it was “very difficult,” including a similar share of adults with health insurance (23%).

Public Opinion on Medicare Coverage of GLP-1s for Weight Loss

While some Medicare drug plans cover the cost of some GLP-1s such as Ozempic or Wegovy when prescribed to treat diabetes or prevent heart attacks or strokes for adults with heart disease, Medicare is currently prohibited by law from covering drugs when prescribed for weight loss – for more information, see KFF’s issue brief on Medicare coverage of GLP-1s . KFF’s latest Health Tracking Poll finds that most adults think Medicare should cover the cost of these drugs when prescribed for weight loss for people who are overweight, with support remaining largely unchanged after hearing arguments for and against this proposal.

Overall, six in ten adults (61%), including similar shares across age groups, say they think Medicare should cover the cost of these drugs when prescribed for weight loss for people who are overweight, a share that rises to about seven in ten (71%) among those who have ever taken these drugs.

While more than half of adults across partisans say Medicare should cover the cost of these drugs for weight loss, Democrats (66%) are somewhat more likely than Republicans (55%) to say this.

Attitudes on some policy proposals may change when the public hears different arguments in favor or against certain proposals. After asking whether Medicare should cover the cost of GLP-1s when prescribed for weight loss for people who are overweight, the poll presented two different arguments for and against this proposal:

Argument against: Some people say that if Medicare covers the cost of these drugs, it could increase premiums paid by people with Medicare and place financial pressure on the Medicare program and the federal budget.

Argument in favor: Others say that if Medicare covers the cost of these drugs, it could help more people afford these medications and improve health and quality of life for people who are overweight.

After being presented with these arguments, the public’s attitudes remain largely unchanged, with six in ten adults still saying they think Medicare should cover the cost of these drugs when prescribed for weight loss for people who are overweight. Attitudes also remained largely unchanged among adults 65 and older, among those who have taken GLP-1s and those who have not, and among independents and Republicans. Among Democrats, there is a slight increase in the share who say Medicare should cover the cost after hearing these arguments (71% after v. 66% before).

• Health Costs
• Tracking Poll
• Prescription Drugs
• Heart Disease
• Medicare Part D
• TOPLINE & METHODOLOGY

news release

• Poll: 1 in 8 Adults Say They’ve Taken a GLP-1 Drug, Including 4 in 10 of Those with Diabetes and 1 in 4 of Those with Heart Disease 

Also of Interest

• Medicare Spending on Ozempic and Other GLP-1s Is Skyrocketing
• A New Use for Wegovy Opens the Door to Medicare Coverage for Millions of People with Obesity
• What are the Implications of New Anti-Obesity Drugs for Racial Disparities?
• How Do Prices of Drugs for Weight Loss in the U.S. Compare to Peer Nations’ Prices?

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Til November, he's the world's most interesting man

Andy Crosby is an impresario of all things political polls; he's going to be a popular guy the next few months

Andy Crosby is the guy you want at your dinner party in the next few months. With about six months until "Decision 2024," he's elbows deep in presidential polls, scouring their methodology, debunking them when necessary. 

Crosby, who is an assistant professor in the School of Public Policy, became immersed with surveys and polls about 10 years ago. He teaches survey research at UCR, and he designs, consumes, or analyzes polls and surveys every week, even when it isn't a presidential election year.  

"Although we rely on polling and survey research to inform us on a wide variety of public policy matters, relatively less energy has been dedicated to understanding how to better create and consume surveys," said Crosby, who joined UCR's faculty in fall 2023. "My goal is to work with students and the broader community to help people be more prepared to both design and consume surveys."

With the presidential primaries and elections approaching, the numbers of polls is increasing - which means Crosby is spending a lot more time comparing polls. Many leading polls have Donald Trump edging out Joe Biden. But are those polls any good? And is it too early to pay any attention to polls? It's a good time to check in with UCR's resident polling expert. 

Stories in the past couple days have asserted Trump is leading Biden in five of six key states. How do you access the methodology behind these polls?

Siena College/New York Times is a trusted pollster and I trust the results of these polls. Their sampling methodology allows for more precise results (for example, the polls are stratified by party to make sure that the poll reaches voters from each party) and they are transparent with both their findings and methods. As a consumer of this poll, it should be reassuring to see the extensive disclosure of both their findings and methods.

What did the polls tell us about a Biden-Trump election in May 2020?

Most major polls had Biden leading Trump, although the margin varied somewhat by poll and by date. For example, a Washington Post-ABC News poll conducted May 25-28, 2020 showed Biden leading Trump, 53-43 percent.

In the May 19 USA Today, columnist Rex Huppke asserts: “Anyone using polling data to assert anything with even a modicum of certainty is a fool.” He is referring to the fact presidential elections are six months out. Is he right?

To some degree. Polls represent a snapshot in time. I generally view polls today as accurate for what they are trying to measure – that is, what voters think today. I would not yet use current polls to predict the outcome in November. Voters do sometimes change their minds between May and November. Part of the reason they may change their mind is due to events that occur during that time – for example, we will likely have at least two presidential debates that may help to inform voters on which candidate more closely represents their views. As such, polls closer to the election are likely to be more accurate.

In what proximity to presidential elections is it worth tuning in to polls?

Even though current polls will not necessarily predict the outcome of the November election, I view current polls as valuable. These polls tell us what voters think now – for example, what they feel the biggest issues are facing the country. That said, if I wanted to predict the election, the polls as we get closer to the election will likely be the most accurate. Recent research demonstrates this increase in accuracy over time and argues that the optimal lead time is approximately two to three months prior to the election, depending on how much error one is willing to accept. I also expect to see a large increase in the number of polls in the last 100 days prior to the election based on previous data.

Is there data that speaks to the historical accuracy of polls six months before a presidential election?

Polls six months prior to the election tend to have larger errors, with six months out still including a considerable amount of error. As I mentioned above, recent research suggests that two to three months out is an optimal lead time.

What do the polls tell us about the effect Robert F. Kennedy Jr. may have on the election returns?

The polls tell us that Kennedy certainly has support among the electorate, but I would use caution translating that into election returns at this point. Part of the reason for this is that Kennedy is not yet on the ballot in all 50 states, although he has an active effort to achieve ballot access in more states. Once we have a fuller picture of Kennedy’s ballot access, we can start to better gauge the potential effect of Kennedy’s candidacy on elections.

What are your favorite polls, and why?

I personally admire the work of NORC at the University of Chicago. More generally, polls that use probability sampling (that is, random selection) are generally considered among the highest-quality polls. These polls are generally considered more accurate than nonprobability samples (for example, approaching someone in a mall and asking them questions), which have become more popular in recent years. Transparency about polling methods (for example, knowing who sponsored the research) is also extremely important. The American Association for Public Opinion Research (AAPOR) Transparency Initiative is the gold standard for this type of disclosure, and I would trust polls that are a member of the AAPOR TI more than polls that are not.

Are there widely quoted polls for which you question the methodology?

Sometimes the answer to this question depends more on the method than the outlet. Even national media outlets (such as the Washington Post) sometimes report the results of polls that use different methods for different stories. I generally use extra caution with polls that do not use probability sampling and/or polls that disclose their methods. The difference in accuracy between randomly sampling registered voters and walking up to people in the mall can be stark. Similarly, if you as a consumer of a poll or survey cannot find basic information about how the poll was conducted (e.g., who was sampled, who funded the poll), I would be reluctant to trust the results of that poll.

Is it more difficult to poll voters accurately today than it once was? Easier?

In general, high-quality polls are quite accurate today, and have been for quite some time. The difference between today and past years is that response rates are going down – for example, telephone response rates today are typically less than 10%. Although lower response rates do not necessarily mean lower quality results, more effort and resources may be needed to reach the same quality estimate.

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