The effect of health-care privatisation on the quality of care.

Over the past 40 years, many health-care systems that were once publicly owned or financed have moved towards privatising their services, primarily through outsourcing to the private sector. But what has the impact been of privatisation on the quality of care? A key aim of this transition is to improve quality of care through increased market competition along with the benefits of a more flexible and patient-centred private sector. However, concerns have been raised that these reforms could result in worse care, in part because it is easier to reduce costs than increase quality of health care. Many of these reforms took place decades ago and there have been numerous studies that have examined their effects on the quality of care received by patients. We reviewed this literature, focusing on the effects of outsourcing health-care services in high-income countries. We found that hospitals converting from public to private ownership status tended to make higher profits than public hospitals that do not convert, primarily through the selective intake of patients and reductions to staff numbers. We also found that aggregate increases in privatisation frequently corresponded with worse health outcomes for patients. Very few studies evaluated this important reform and there are many gaps in the literature. However, based on the evidence available, our Review provides evidence that challenges the justifications for health-care privatisation and concludes that the scientific support for further privatisation of health-care services is weak.

Epidemiology and Scenario Simulations of the Middle East Respiratory Syndrome Corona Virus (MERS-CoV) Disease Spread and Control for Dromedary Camels in United Arab Emirates (UAE).

Middle East Respiratory Syndrome (MERS-CoV) is a coronavirus-caused viral respiratory infection initially detected in Saudi Arabia in 2012. In UAE, high seroprevalence (97.1) of MERS-CoV in camels was reported in several Emirate of Abu Dhabi studies, including camels in zoos, public escorts, and slaughterhouses. The objectives of this research include simulation of MERS-CoV spread using a customized animal disease spread model (i.e., customized stochastic model for the UAE; analyzing the MERS-CoV spread and prevalence based on camels age groups and identifying the optimum control MERS-CoV strategy. This study found that controlling animal mobility is the best management technique for minimizing epidemic length and the number of affected farms. This study also found that disease dissemination differs amongst camels of three ages: camel kids under the age of one, young camels aged one to four, and adult camels aged four and up; because of their immunological state, kids, as well as adults, had greater infection rates. To save immunization costs, it is advised that certain age groups be targeted and that intense ad hoc unexpected vaccinations be avoided. According to the study, choosing the best technique must consider both efficacy and cost.

Social media network analysis of Smallholder livestock farming communities in the United Kingdom.

The creation of targeted policies and actions to help small-scale livestock keepers and reduce the risks associated with disease outbreaks in this sector is hampered by the scarcity of information about smallholder farmers. Smallholders play a crucial part in disease outbreaks containment, hence there is a need for better monitoring methods that take this population into account while gathering data. According to the literature, these communities frequently use social media as a channel for communication and information exchange. In this study we conducted social network analysis of an influential smallholder within the UK and visualised the user follower network. Additionally, we performed influential user analysis, Twitter user categorisation, and community detection to uncover more insights into the livestock farming networks. Our findings reveal distinct communities within the smallholder farming sector and identify influential users with the potential to impact information dissemination and animal health practices. The study also highlights the role of community structure in surveillance and control of animal diseases and emphasises the need for further research to refine our understanding of these communities and their unique characteristics. This work contributes to the growing body of literature on small-scale livestock farming in the UK and underscores the importance of incorporating smallholder communities into disease surveillance and control efforts.

Agnogenic practices and corporate political strategy: the legitimation of UK gambling industry-funded youth education programmes.

Agnogenic practices-designed to create ignorance or doubt-are well-established strategies employed by health-harming industries (HHI). However, little is known about their use by industry-funded organizations delivering youth education programmes. We applied a previously published framework of corporate agnogenic practices to analyse how these organizations used them in three UK gambling industry-funded youth education programmes. Evidential strategies adopted previously by other HHI are prominent in the programmes' practitioner-facing materials, evaluation design and reporting and in public statements about the programmes. We show how agnogenic practices are employed to portray these youth education programmes as 'evidence-based' and 'evaluation-led'. These practices distort the already limited evidence on these educational initiatives while legitimizing industry-favourable policies, which prioritize commercial interests over public health. Given the similarities in political strategies adopted by different industries, these findings are relevant to research and policy on other HHI.

Spatio-temporal evaluation of social media as a tool for livestock disease surveillance.

Recent outbreaks of Avian Influenza across Europe have highlighted the potential for syndromic surveillance systems that consider other modes of data, namely social media. This study investigates the feasibility of using social media, primarily Twitter, to monitor illness outbreaks such as avian flu. Using temporal, geographical, and correlation analyses, we investigated the association between avian influenza tweets and officially verified cases in the United Kingdom in 2021 and 2022. Pearson correlation coefficient, bivariate Moran's I analysis and time series analysis, were among the methodologies used. The findings show a weak, statistically insignificant relationship between the number of tweets and confirmed cases in a temporal context, implying that relying simply on social media data for surveillance may be insufficient. The spatial analysis provided insights into the overlaps between confirmed cases and tweet locations, shedding light on regionally targeted interventions during outbreaks. Although social media can be useful for understanding public sentiment and concerns during outbreaks, it must be combined with traditional surveillance methods and official data sources for a more accurate and comprehensive approach. Improved data mining techniques and real-time analysis can improve outbreak detection and response even further. This study underscores the need of having a strong surveillance system in place to properly monitor and manage disease outbreaks and protect public health.

Global inequalities in mental health problems: understanding the predictors of lifetime prevalence, treatment utilisation and perceived helpfulness across 111 countries.

Socio-economic inequalities in mental health problems are found in measures covering prevalence, treatment utilisation, and treatment helpfulness. However, whether these inequalities exist globally and what factors explain between-country variation is unclear. We use a nationally representative individual-level survey dataset (Wellcome Global Monitor, 2020) in 111 countries (N = 117,088) to test if socio-economic factors (household income, education), psycho-social factors (stigma perception, trust in health professionals) and country-level factors (GDP, Gini, health expenditure) predict (1) self-reported lifetime prevalence of anxiety and depression symptomology, (2) treatment utilisation and (3) perceived treatment helpfulness talking to a mental health professional and taking prescribed medication. Multi-level logistic regression models were used. Across both HICs and LMICs, being in the richest income quintile within each country is associated with a lower probability of experiencing symptoms of anxiety and depression compared to the poorest quintile (OR = 0.67 CI[0.64-0.70]), as well as a higher probability of talking to a mental health professional (OR = 1.25[1.14-1.36]), and of perceiving this treatment as very helpful (OR = 1.23[1.07-1.40]). However, being among the richest income quintile is not associated with taking prescribed medication (OR = 0.97[0.89-1.06]) and its perceived helpfulness (OR = 1.06[0.94-1.21]) across all countries. Trust in health practitioners is associated with higher mental health professional utilisation (OR = 1.10[1.06-1.14]) and helpfulness (OR = 1.32[1.25-1.40]). This analysis reveals a global 'triple inequality in mental health', whereby disadvantages of lower SES individuals persist in three outcomes (lifetime prevalence, treatment utilisation and helpfulness). Treatment utilisation and helpfulness also vary by trust in healthcare professionals and treatment type. Policymakers must address all three inequalities and their fundamental causes.

Quantitative Textual Analysis as a means to explore corporate interests in food safety.

The growing body of scholarship on the commercial determinants of health has, so far, mostly employed qualitative methods but this is now being complemented by a small, yet growing, corpus of quantitative studies. We illustrate the use of one such method, quantitative text analysis (QTA), in a case study of submissions to a public consultation on a draft scientific opinion by the European Food Safety Authority on the chemical acrylamide, demonstrating how this method can be used and insights that might be drawn from it. We use Wordscores as one example of QTA to illuminate the diverse positions taken by actors submitting comments and then assess whether the final policy documents moved towards or away from the positions taken by different stakeholders. We find a broadly uniform position among the public health community, opposed to acrylamide, contrasting with industry positions that were not monolithic. Some firms recommended major amendments to the guidance, largely reflecting the impact on their practices, while policy innovators seeking ways to reduce acrylamide in foods aligned with the public health community. We also find no clear movement in the policy guidance, likely because most submissions supported the draft document. Many governments are required to conduct public consultations, some attracting enormous numbers of responses, with little guidance on how best to synthesise the responses so the default position is often a count of those for and against. We argue that QTA, primarily a research tool, might usefully be applied in analysing public consultation responses to understand better the positions taken by different actors.

Do cash transfers alleviate common mental disorders in low- and middle-income countries? A systematic review and meta-analysis.

A large literature has demonstrated the link between poverty and mental ill-health. Yet, the potential causal effects of poverty alleviation measures on mental disorders are not well-understood. In this systematic review, we summarize the evidence of the effects of a particular kind of poverty alleviation mechanism on mental health: the provision of cash transfers in low- and middle-income countries. We searched eleven databases and websites and assessed over 4,000 studies for eligibility. Randomized controlled trials evaluating the effects of cash transfers on depression, anxiety, and stress were included. All programs targeted adults or adolescents living in poverty. Overall, 17 studies, comprising 26,794 participants in Sub-Saharan Africa, Latin America, and South Asia, met the inclusion criteria of this review. Studies were critically appraised using Cochrane's Risk of Bias tool and publication bias was tested using funnel plots, egger's regression, and sensitivity analyses. The review was registered in PROSPERO (CRD42020186955). Meta-analysis showed that cash transfers significantly reduced depression and anxiety of recipients (dpooled = -0.10; 95%-CI: -0.15, -0.05; p<0.01). However, improvements may not be sustained 2-9 years after program cessation (dpooled = -0.05; 95%-CI: -0.14, 0.04; ns). Meta-regression indicates that impacts were larger for unconditional transfers (dpooled = -0.14; 95%-CI: -0.17, -0.10; p<0.01) than for conditional programs (dpooled = 0.10; 95%-CI: 0.07, 0.13; p<0.01). Effects on stress were insignificant and confidence intervals include both the possibility of meaningful reductions and small increases in stress (dpooled = -0.10; 95%-CI: -0.32, 0.12; ns). Overall, our findings suggest that cash transfers can play a role in alleviating depression and anxiety disorders. Yet, continued financial support may be necessary to enable longer-term improvements. Impacts are comparable in size to the effects of cash transfers on, e.g., children's test scores and child labor. Our findings further raise caution about potential adverse effects of conditionality on mental health, although more evidence is needed to draw robust conclusions.

When do democratic transitions reduce or increase child mortality? Exploring the role of non-violent resistance.

What explains variation across countries in the effect of democratization on child mortality rates? Democratic transitions, on average, improve health outcomes but there is substantial variation across countries in whether democratization leads to lower-than-expected child mortality post-transition. As yet, there is no convincing quantitative explanation for this variation. In this paper, we argue that whether you have a protest-led or violence-led democratic transition alters the trajectory of child mortality post-transition. Our paper makes two contributions. First, we offer a more detailed account of how the type of resistance movement promoting regime change affects health post-transition. We also draw on novel data to categorise the movements producing democratic transitions as violent or peaceful, moving beyond earlier work which operationalised peaceful democratizations in terms of battle-related deaths. Second, we extend earlier research by examining whether the nature of the democratization movement constitutes a necessary cause of higher or lower-than-expected child mortality following democratization. Across 51 transitions, countries that have a protest-led transition have lower-than-expected child mortality rates after the transition to democracy than countries with other kinds of movements (ß = -0.17, p = 0.003). Countries with violence-led transitions, meanwhile, have, on average, higher-than-expected child mortality rates after their transition (ß = 0.20, p = 0.001). These associations hold when we adjust for covariates (including all possible combinations of various confounding variables). We also find evidence that protest-led transitions may be a necessary condition for avoiding increased child mortality post-transition. Finally, we conduct a deviant case analysis of transitions that appear to be contrary to our theory, finding that these cases are likely instances of measurement error. Democratization may not always improve health, but such health improvements are more likely when regime change is protest-led. This is because such movements are more likely to build broad coalitions committed to consensual politics post-transition, a critical feature of successful democracies.

Does capping social security harm health? A natural experiment in the UK.

In this paper, we examine the mental health effects of lowering the UK's benefit cap in 2016. This policy limits the total amount a household with no-one in full-time employment can receive in social security. We treat the reduction in the cap as a natural policy experiment, comparing those at risk of being capped and those who were not, and examining the risk of experiencing poor mental health both before and after the cap was lowered. Drawing on data from ~900,000 individuals, we find that the prevalence of depression or anxiety among those at risk of being capped increased by 2.6 percentage points (95% confidence interval: 1.33-3.88) compared with those at a low risk of being capped. Capping social security may increase the risk of mental ill health and could have the unintended consequence of pushing out-of-work people even further away from the labour market.

Female political representation and the gender health gap: a cross-national analysis of 49 European countries.

BACKGROUND: Does increased female participation in the social and political life of a country improve health? Social participation may improve health because it ensures that the concerns of all people are heard by key decision-makers. More specifically, when women's social participation increases this may lead to health gains because women are more likely to vote for leaders and lobby for policies that will enhance the health of everyone. This article tries to examine whether female participation is correlated with measures of health inequality. METHODS: We draw on data from the World Health Organization Health Equity Status Report initiative and the Varieties of Democracy project to assess whether health is better and health inequalities are smaller in countries where female political representation is greater. RESULTS: We find consistent evidence that greater female political representation is associated with lower geographical inequalities in infant mortality, smaller inequalities in self-reported health (for both women and men) and fewer disability-adjusted life-years lost for women and men. Finally, we find that greater female political representation is not only correlated with better health for men and women but is also correlated with a smaller gap between men and women because men seem to experience better health in such contexts. CONCLUSIONS: Greater female political representation is associated with better health for everyone and smaller inequalities.

FAIR data pipeline: provenance-driven data management for traceable scientific workflows.

Modern epidemiological analyses to understand and combat the spread of disease depend critically on access to, and use of, data. Rapidly evolving data, such as data streams changing during a disease outbreak, are particularly challenging. Data management is further complicated by data being imprecisely identified when used. Public trust in policy decisions resulting from such analyses is easily damaged and is often low, with cynicism arising where claims of 'following the science' are made without accompanying evidence. Tracing the provenance of such decisions back through open software to primary data would clarify this evidence, enhancing the transparency of the decision-making process. Here, we demonstrate a Findable, Accessible, Interoperable and Reusable (FAIR) data pipeline. Although developed during the COVID-19 pandemic, it allows easy annotation of any data as they are consumed by analyses, or conversely traces the provenance of scientific outputs back through the analytical or modelling source code to primary data. Such a tool provides a mechanism for the public, and fellow scientists, to better assess scientific evidence by inspecting its provenance, while allowing scientists to support policymakers in openly justifying their decisions. We believe that such tools should be promoted for use across all areas of policy-facing research. This article is part of the theme issue 'Technical challenges of modelling real-life epidemics and examples of overcoming these'.

Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013-20: an observational study of NHS privatisation.

BACKGROUND: The effects of outsourcing health services to for-profit providers are contested, with some arguing that introducing such providers will improve performance through additional competition while others worry that this will lead to cost cutting and poorer outcomes for patients. We aimed to examine this debate by empirically evaluating the impact of outsourced spending to private providers, following the 2012 Health and Social Care Act, on treatable mortality rates and the quality of health-care services in England. METHODS: For this observational study, we used a novel database composed of parsable procurement contracts between April 1, 2013, and Feb 29, 2020 (n=645 674, value >£25 000, total value £204·1 billion), across 173 clinical commissioning groups (CCGs; regional health boards) in England. Data were compiled from 12 709 heterogenous expenditure files primarily scraped from commissioner websites with supplier names matched to registers identifying them as National Health Service (NHS) organisations, for-profit companies, or charities. We supplemented these data with rates of local mortality from causes that should be treatable by medical intervention, indicating the quality of health-care services. We used multivariate longitudinal regression models with fixed effects at the CCG level to analyse the association of for-profit outsourcing on treatable mortality rates in the following year. We used the average marginal effects to estimate total additional deaths attributable to changes in for-profit outsourcing. We provided alternative model specifications to test the robustness of our findings, match on background characteristics, examine the potential impact of measurement error, and adjust for possible confounding factors such as population demographics, total CCG expenditure, and local authority expenditure. FINDINGS: We found that an annual increase of one percentage point of outsourcing to the private for-profit sector corresponded with an annual increase in treatable mortality of 0·38% (95% CI 0·22-0·55; p=0·0016) or 0·29 (95% CI 0·09-0·49; p=0·0041) deaths per 100 000 population in the following year. This finding was robust to matching on background characteristics, adjusting for possible confounding factors, and measurement error in our dataset. Changes to for-profit outsourcing since 2014 were associated with an additional 557 (95% CI 153-961) treatable deaths across the 173 CCGs. INTERPRETATION: The privatisation of the NHS in England, through the outsourcing of services to for-profit companies, consistently increased in 2013-20. Private sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of health-care services. FUNDING: Wellcome Trust.

How do income changes impact on mental health and wellbeing for working-age adults? A systematic review and meta-analysis.

BACKGROUND: Lower incomes are associated with poorer mental health and wellbeing, but the extent to which income has a causal effect is debated. We aimed to synthesise evidence from studies measuring the impact of changes in individual and household income on mental health and wellbeing outcomes in working-age adults (aged 16-64 years). METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, PsycINFO, ASSIA, EconLit, and RePEc on Feb 5, 2020, for randomised controlled trials (RCTs) and quantitative non-randomised studies. We had no date limits for our search. We included English-language studies measuring effects of individual or household income change on any mental health or wellbeing outcome. We used Cochrane risk of bias (RoB) tools. We conducted three-level random-effects meta-analyses, and explored heterogeneity using meta-regression and stratified analyses. Synthesis without meta-analysis was based on effect direction. Critical RoB studies were excluded from primary analyses. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). This study is registered with PROSPERO, CRD42020168379. FINDINGS: Of 16 521 citations screened, 136 were narratively synthesised (12·5% RCTs) and 86 meta-analysed. RoB was high: 30·1% were rated critical and 47·1% serious or high. A binary income increase lifting individuals out of poverty was associated with 0·13 SD improvement in mental health measures (95% CI 0·07 to 0·20; n=42 128; 18 studies), considerably larger than other income increases (0·01 SD improvement, 0·002 to 0·019; n=216 509, 14 studies). For wellbeing, increases out of poverty were associated with 0·38 SD improvement (0·09 to 0·66; n=101 350, 8 studies) versus 0·16 for other income increases (0·07 to 0·25; n=62 619, 11 studies). Income decreases from any source were associated with 0·21 SD worsening of mental health measures (-0·30 to -0·13; n=227 804, 11 studies). Effect sizes were larger in low-income and middle-income settings and in higher RoB studies. Heterogeneity was high (I2=79-87%). GRADE certainty was low or very low. INTERPRETATION: Income changes probably impact mental health, particularly where they move individuals out of poverty, although effect sizes are modest and certainty low. Effects are larger for wellbeing outcomes, and potentially for income losses. To best support population mental health, welfare policies need to reach the most socioeconomically disadvantaged. FUNDING: Wellcome Trust, Medical Research Council, Chief Scientist Office, and European Research Council.

The Association of Traumatic Brain Injury with Neurologic and Psychiatric Illnesses among Individuals Experiencing Homelessness: A Systematic Review and Meta-analysis.

Homeless individuals are more likely than others to experience a traumatic brain injury (TBI), but it is uncertain if such individuals are more likely to experience neuropsychiatric illnesses. METHODS: A systematic review was performed with searches in Medline, Embase, and PsychINFO for studies reporting on homeless persons with TBI and neuropsychiatric illnesses. A random-effects model was used to calculate odds ratios for having any neuropsychiatric diagnosis. RESULTS: Of 420 articles indexed, 19 were included for systematic review and 17 for meta-analysis reporting on 11,474 and 8,757 individuals, respectively. The pooled odds of a homeless individual with a TBI having any neurologic illness were 2.57 (95% CI [1.97, 3.44]; I2 = 68.0%) and 2.01 (95% CI [1.81, 2.25]; I2 = 79.2%) for any psychiatric illness. CONCLUSIONS: The odds of having a neuropsychiatric illness among homeless individuals with TBI are substantially higher than in the domiciled population with TBI.

Field evaluation of diagnostic sensitivity (DSe) and specificity (DSp) of common tests for amoebic gill disease (AGD) and complex gill disease (CGD) in cultured Atlantic salmon (Salmo salar) in Scotland using Bayesian latent class models.

Amoebic gill disease (AGD) and complex gill disease (CGD) are the most significant marine gill diseases in salmon aquaculture in Scotland. Little is published about diagnostic performance of tests to detect these diseases, making it difficult to interpret test results. We estimated diagnostic sensitivity (DSe) and specificity (DSp) of common tests for AGD (gross AGD score, qPCR for Neoparamoeba perurans, histopathology) and CGD (gross proliferative gill disease (PGD) score, gross total gill score, histopathology). Because specifications in our sampling protocol implemented to encourage consistency across the farms might affect diagnostic performance of histopathology (historically the reference standard for gill diseases), we used Bayesian latent class models without reference standard. Cases and non-cases were based on less, medium, and severe stringent case definitions, representing different cut-off levels for the different tests. Gross gill scores for both diseases were excellent in designating non-diseased fish, DSps were generally around 1. To detect CGD, DSe of gross total gill score and gross PGD score were between respectively 0.81 (0.73 - 0.91 lower to upper 95% credible interval) and 0.53 (0.46 - 0.64) for medium stringent case definitions, and to detect AGD the DSe for the gross AGD score was between 0.53 (0.48-0.57) and 0.14 (0.07 - 0.22) for respectively the less and severe stringent case definition. Thus, gross gill scores were medium to good in designating truly diseased fish, implying some false negatives are expected. For CGD the DSe for gross total gill scores were the highest, for AGD it was the qPCR test at a DSe of 0.92 (0.86 - 0.99). For both diseases, DSe was lowest for histopathology, e.g. 0.23 (0.16 - 0.30) for AGD and 0.1 (0.07 - 0.14) for CGD under medium stringent case definitions, perhaps due to collecting the second gill arch on the right rather than the worst affected arch, whilst PCR sampling and gross gill scoring included multiple (PCR) or all (gross scoring) gill arches. The diagnostic goals of these tests differ; gross gill scoring provides a low-cost presumptive diagnosis, PCR a non-lethal confirmation of the presence of a specific pathogen and histopathology provides information on the underlying aetiology of gill damage as well as the extent, severity, and chronology of gill disease. An effective gill health surveillance strategy is likely to incorporate multiple diagnostic tools used in a complementary manner.