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We know enough about the problems in research to start demanding solutions

Several problems with health research are now widely recognised. But to challenge the status quo we need to offer clear solutions and convince patients, the public, and policy makers to support change, say Stephen Bradley, Kath Sansom, and Erick H Turner

Serious concerns have dogged health research for decades . The coronavirus pandemic has exposed these systemic failures to a wider public that has never been more engaged in science and medicine. As doctors and researchers, we have failed to fix these problems on our own. We now have an opportunity to join patients and the public to demand solutions.     

The problems include, but are not restricted to, failure to publish all research findings, inadequate sharing of study methodologies, and inconsistent disclosure of conflicts of interest. As a consequence of these failures, much of the global expenditure spent on medical research is wasted and genuine scientific discovery is hindered by findings that cannot be reproduced .

Haven’t these problems already been fixed?

Reforms like mandatory clinical trial registration have brought some additional transparency. Unfortunately, registration information is often cursory and usually doesn’t include trial protocols and analytic plans. So-called “outcome switching” is easily concealed and, even when called out, rarely rectified . Crucially, the expectation to register studies does not extend to most non-trial research, such as observational or lab-based studies, which are equally vulnerable to shoddy practices. 

While many of the problems in medical research have been well described, there is little agreement as to their solutions. Where solutions have been proposed, they are often vague, such as “improving education.” As profound biases in medical research continue to reward “positive,” interesting, or novel findings, worthy sentiments are not enough.

Our failure to remedy this situation is a betrayal of public trust. Attempts to ascertain whether study authors have conflicts of interest should not be met with frustration, as experienced by one of us (KS) . These concerns have been echoed by Baroness Cumberlege’s inquiry into women affected by the hormone pregnancy test Primodos, sodium valproate, and pelvic mesh . Hopefully, the inquiry’s recommendations, including that the GMC register doctors’ financial and non-financial interests, will be acted on.     

Campaign with patients and the public to demand change

Yet aside from some researchers and patients who have tried to get answers for themselves, awareness of the crisis in research remains limited. Excluding the wider public from this debate is a wasted opportunity, since, as both funders of research and as patients, they have the biggest stake in rectifying these problems. Without mobilising support for reform from outside, as well as inside, the research establishment, it seems unlikely that we can challenge the status quo of mediocre and opaque research practices.  

Fortunately, research and patient campaigners have a compelling message to offer the public and policy makers: implementing simple measures to improve openness and quality could increase the effectiveness of medical research expenditure . The pressure exerted by the House of Commons Science and Technology Committee, under Norman Lamb, to improve publication of trial results by NHS organisations and universities suggests that there is a willingness among policy makers to address these issues.

What are the solutions?

One barrier to achieving change is that it is difficult to explain these complex problems, as they are not fully understood even by many in healthcare and research. Perhaps more important has been our failure to articulate clear, achievable solutions to these problems. The lesson of successful reform movements of the past is that achieving change requires campaigners to cohere around an achievable, yet impactful set of demands.  

As members of an international collaboration of patients and researchers, we have drafted a declaration that includes three demands to improve health research: 

1) Mandatory registration of conflicts of interest

Researchers could maintain a comprehensive and up to date register of their interests, for example through ORCID , which could be linked to all publications. 

2) Journals’ adoption of Registered Reports

Registered Reports are a publication format whereby authors submit methods prior to data collection and analysis and, if these satisfy peer review, journals preliminarily commit to publication, regardless of whether the subsequently obtained results are statistically significant or “noteworthy.”  Currently, the number of participating journals is approximately 250, but this is only 1% of all journals indexed in MEDLINE .

3) Mandatory registration of publicly funded research

Comprehensive documentation, such as protocols, analytic code , and, when possible, study data for all publicly funded research, should be made available on a repository affiliated to the World Health Organization. This will allow researchers and the public who fund research to verify it is reproducible. 

These demands were chosen as well defined and implementable measures to increase transparency and reduce waste in medical research. They are real world measures and our demands are necessarily imperfect. Even if they were achieved overnight, many serious problems would remain. 

We accept that our demands might not be the right ones–we welcome suggestions for alternatives. But to begin to rectify the scandal of poor medical research, those who are serious about overcoming the problems need to unite to win the backing of the public and policy makers in order to promote and implement practical solutions.

The Declaration to Improve Health Research is available at osf.io/k3w7m . Follow on twitter: @TA_Declaration   

Stephen Bradley is a GP and clinical research fellow at the University of Leeds. Twitter @DryBreadnRadio

Kath Sansom is a journalist, patient campaigner, and founder of “Sling the Mesh.” Twitter @KathSansom @MeshCampaign ( https://slingthemesh.wordpress.com )

Erick Turner is a psychiatrist-researcher and transparency advocate. He previously worked on drug regulation in the United States Food and Drug Administration (FDA) @eturnermd1

Conflicts of interest: Stephen Bradley receives funding from Cancer Research UK for PhD research. He is also a member of the executive committee of the Fabian Society, which is a think tank affiliated to the Labour Party. Kath Sansom works as a journalist. She was harmed by vaginal mesh and leads the “Sling the Mesh” campaign. 

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• How to Define a Research Problem | Ideas & Examples

How to Define a Research Problem | Ideas & Examples

Published on November 2, 2022 by Shona McCombes and Tegan George. Revised on May 31, 2023.

A research problem is a specific issue or gap in existing knowledge that you aim to address in your research. You may choose to look for practical problems aimed at contributing to change, or theoretical problems aimed at expanding knowledge.

Some research will do both of these things, but usually the research problem focuses on one or the other. The type of research problem you choose depends on your broad topic of interest and the type of research you think will fit best.

This article helps you identify and refine a research problem. When writing your research proposal or introduction , formulate it as a problem statement and/or research questions .

Table of contents

Why is the research problem important, step 1: identify a broad problem area, step 2: learn more about the problem, other interesting articles, frequently asked questions about research problems.

Having an interesting topic isn’t a strong enough basis for academic research. Without a well-defined research problem, you are likely to end up with an unfocused and unmanageable project.

You might end up repeating what other people have already said, trying to say too much, or doing research without a clear purpose and justification. You need a clear problem in order to do research that contributes new and relevant insights.

Whether you’re planning your thesis , starting a research paper , or writing a research proposal , the research problem is the first step towards knowing exactly what you’ll do and why.

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As you read about your topic, look for under-explored aspects or areas of concern, conflict, or controversy. Your goal is to find a gap that your research project can fill.

Practical research problems

If you are doing practical research, you can identify a problem by reading reports, following up on previous research, or talking to people who work in the relevant field or organization. You might look for:

• Issues with performance or efficiency
• Processes that could be improved
• Areas of concern among practitioners
• Difficulties faced by specific groups of people

Examples of practical research problems

Voter turnout in New England has been decreasing, in contrast to the rest of the country.

The HR department of a local chain of restaurants has a high staff turnover rate.

A non-profit organization faces a funding gap that means some of its programs will have to be cut.

Theoretical research problems

If you are doing theoretical research, you can identify a research problem by reading existing research, theory, and debates on your topic to find a gap in what is currently known about it. You might look for:

• A phenomenon or context that has not been closely studied
• A contradiction between two or more perspectives
• A situation or relationship that is not well understood
• A troubling question that has yet to be resolved

Examples of theoretical research problems

The effects of long-term Vitamin D deficiency on cardiovascular health are not well understood.

The relationship between gender, race, and income inequality has yet to be closely studied in the context of the millennial gig economy.

Historians of Scottish nationalism disagree about the role of the British Empire in the development of Scotland’s national identity.

Next, you have to find out what is already known about the problem, and pinpoint the exact aspect that your research will address.

Context and background

• Who does the problem affect?
• Is it a newly-discovered problem, or a well-established one?
• What research has already been done?
• What, if any, solutions have been proposed?
• What are the current debates about the problem? What is missing from these debates?

Specificity and relevance

• What particular place, time, and/or group of people will you focus on?
• What aspects will you not be able to tackle?
• What will the consequences be if the problem is not resolved?

Example of a specific research problem

A local non-profit organization focused on alleviating food insecurity has always fundraised from its existing support base. It lacks understanding of how best to target potential new donors. To be able to continue its work, the organization requires research into more effective fundraising strategies.

Once you have narrowed down your research problem, the next step is to formulate a problem statement , as well as your research questions or hypotheses .

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

Methodology

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

All research questions should be:

• Focused on a single problem or issue
• Researchable using primary and/or secondary sources
• Feasible to answer within the timeframe and practical constraints
• Specific enough to answer thoroughly
• Complex enough to develop the answer over the space of a paper or thesis
• Relevant to your field of study and/or society more broadly

Research questions anchor your whole project, so it’s important to spend some time refining them.

In general, they should be:

• Focused and researchable
• Answerable using credible sources
• Complex and arguable
• Feasible and specific
• Relevant and original

Your research objectives indicate how you’ll try to address your research problem and should be specific:

A research aim is a broad statement indicating the general purpose of your research project. It should appear in your introduction at the end of your problem statement , before your research objectives.

Research objectives are more specific than your research aim. They indicate the specific ways you’ll address the overarching aim.

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Research Topics & Ideas: Healthcare

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

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

NB – This is just the start…

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

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

Overview: Healthcare Research Topics

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

Allopathic (Conventional) Medicine

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

Topics & Ideas: Alternative Medicine

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

Topics & Ideas: Dentistry

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

Tops & Ideas: Veterinary Medicine

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

Topics & Ideas: Physical Therapy/Rehab

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

Topics & Ideas: Optometry & Opthalmology

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

Topics & Ideas: Pharmacy & Pharmacology

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

Topics & Ideas: Public Health

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

Examples: Healthcare Dissertation & Theses

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

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

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

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

Need more help?

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

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15 Comments

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

Hello Mabel,

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

Can you provide some research topics and ideas on Immunology?

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

Help on problem statement on teen pregnancy

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

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

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

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

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

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

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

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

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

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

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Adding diversity to your research process: A new system

by Hoag Levins, University of Pennsylvania

Insufficient diversity in clinical trials and other research cohorts is widely recognized as one of American health care's greatest problems and one that continues to skew scientific data and conclusions in ways that disadvantage enormous numbers of people.

It's a problem that has been the subject of endless national discussions, debate, investigations, analysis, and general wheel-spinning throughout the highest levels of the health care policy community.

For instance, a 2022 consensus study at the National Academies of Sciences, Engineering, and Medicine (NAM) that looked back over the past 30 years of effort to diversify clinical trials found that "progress has largely stalled on participation of racial and ethnic minority population groups. …An equitable clinical research enterprise would include trials and studies that match the demographics of the disease burden under study. However, we remain far from achieving this goal."

Failed FDA action

A March 2022 article in Health Affairs detailed a postmortem on a five-year-long Food and Drug Administration (FDA) "action program" aimed at improving diversity and transparency in clinical trials for new drugs. The authors reported that they "failed to find evidence that the FDA action plan improved representation of Black trial participants."

It is against this general background that in 2021, two closely affiliated University of Pennsylvania research centers—the Palliative and Advanced Illness Research Center (PAIR) and the Center for Health Incentives and Behavioral Economics (CHIBE)—launched their own effort to find ways to increase diversity within their organizations' clinical trials and other research studies.

"Many events in 2020 and 2021 galvanized renewed energy within our organization around long-standing social injustices," said PAIR Director and LDI Senior Fellow Scott Halpern, MD, Ph.D. "Many of our researchers and staff were actively looking for ways to respond and recognized the need for greater emphasis on justice and inclusion in our own research processes. We quickly realized that charging a group to lead the way in producing guidance for equitable research practices would enable us all to learn from them, and best accomplish our shared goals."

Joint research practices working group

This resulted in the creation of the Joint Research Practices (JRP) Working Group.

"The goal of the JRP was to identify best practices and produce guidelines for the incorporation of equity, inclusion, and access across the arc of the research process," said Rachel Kohn, MD, MSCE, Co-Lead of the JRP and LDI Senior Fellow.

"Initially, we reached out to peer institutions to see if anyone was working on something similar. But we found that even in places where there was a lot of work being done surrounding health equity and social justice, there was no group working on identifying the fundamental methodology and practices that could be used for making specific parts of the research process more diversified, equitable, and accessible by underrepresented populations."

Kohn said additional extensive literature reviews "provided no overall guidelines as to how to perform equitable, inclusive, and accessible research throughout an entire research process."

She is an Assistant Professor of Pulmonary, Allergy, and Critical Care at the Perelman School of Medicine and a core faculty member at PAIR. The other Co-Lead of the JRP is Jingsan Zhu, MS, MBA, Director of Data Analytics at CHIBE.

Creating a new system

Quietly and out of public view over the last three years, the JRP has conducted the brainstorming, data gathering, analysis, and organization required to create a comprehensive system of guidelines and best practice documentation that has been tested within their own organizations' research projects.

The JRP is made up of staff members from PAIR and CHIBE who are all involved in managing various kinds of clinical trials, prospective cohorts, and incentive and behavioral economics research. Their voluntary work on the JRP occurred outside of their formal daily duties.

In February, the Journal of General Internal Medicine published their paper titled "Operationalizing Equity, Inclusion, and Access in Research Practice at a Large Academic Institution," detailing their new system for how to make clinical trials and other research processes more diverse, equitable, and just.

"It would be hard to overstate how much this group has accomplished in so little time," said Halpern. "What's even more inspiring is that all of the energy and productivity came from the JRP members' hearts. It's been inspiring to witness this volunteer, grassroots effort at work, and hardly a day goes by that we don't newly incorporate some of their guidance into another of our studies."

Kohn noted that the initial focus of the work on projects within PAIR and CHIBE is now expanding. "Our goal is to network and collaborate as widely as possible to disseminate this work to the broader research community both within Penn and externally across the country."

JRP guidelines

The JRP guidelines and best practices documents focus on the major obstacles that make the recruitment and retention of subjects from underrepresented communities so difficult–language barriers, social disadvantage, money, and the personal trust that evolves out of eliminating these barriers effectively.

The JRP guidelines cover:

• Participant payment and incentives
• Language interpretation and translation
• Plain language in research communications
• Readability of study materials
• Inclusive language for scientific communications

"It's still common for many studies to specifically call for English speaking subjects only," said Kohn. "This is highly problematic, particularly given the number of limited English proficiency (LEP) patients who live in our country and also in light of the enormous numbers of new immigrants who are arriving."

Accommodating social determinants

Some of the JRP recommendations are heavily informed by considerations related to social determinants of health. For instance, the guidelines note the importance of staging study visits with subjects in close proximity to their homes to eliminate the need to travel, and to pay for travel when it is required. Similarly, they recommend paying for food, child care, and elder care that can be impediments to participating in a study.

Other recommendations call for the research project to be flexible about payment and include a variety of payment options relevant to the participants' needs. The payment guideline's sections include Ethnical Considerations; Equity Considerations; Research Risks and Benefits; Payment Methods and Timing; Size of Payment; Regulations and Governance; Planning and Administration; and References for further information.

The JRP guideline documents have been gathered into a downloadable "Toolkit" on both the PAIR and CHIBE websites.

Consultation service

In addition, the JRP has created a consultation service called " Practicing Equitable Research and Knowledge Sharing (PERKS)." Already used by more than 30 Penn researchers, it enables a researcher to directly tap into JRP expertise about how a particular part of a research process might be made more diverse and equitable.

When asked what has been one of the more noteworthy insights she's taken from this experience, Kohn said "I think clinicians are generally aware that past research may have been conducted in an inequitable or unjust way, but they are not necessarily aware or familiar with the nuanced research methodology that might contribute to bias or inequity today.

"As a busy clinician myself, I think we are all trying to glean the main takeaways from research and doing our best to interpret groundbreaking research so that we can apply it clinically into our practice. But the goals of diversity and justice really require us to slow down and reflect about some of the operational decisions that were made and what their downstream effects might be on health equity."

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These are the 10 biggest global health threats of the decade

Global warming and conflict zones are among the main obstacles. Image:  REUTERS/Goran Tomasevic - RC186A78C7A0

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Stay up to date:, global health.

• The WHO released the top 10 global healthcare challenges in the coming decade.
• Global warming, conflict zones and unfair healthcare provision are among the main obstacles.
• Many healthcare challenges are interconnected and will require a coordinated international effort to overcome.
• Experts are concerned governments around the world are failing to invest sufficient funds in overcoming these issues.

The world can’t afford to do nothing – that's the World Health Organization’s message on the release of its report listing the most urgent health challenges for the coming decade.

All of the health challenges on the WHO list are urgent – and many are linked. And each challenge requires a coordinated effort from the global health sector, policymakers, international agencies and communities, the organization says. However, there is concern global leaders are failing to invest enough resources in core health priorities and systems.

Have you read?

Why the 21st century's biggest health challenge is our shared responsibility, here are 3 ways ai will change healthcare by 2030, to bring universal healthcare to africa, the private sector must get involved.

These are the main challenges on the list.

1. Elevating health in the climate debate The climate crisis poses one of the biggest threats to both the planet and the health of the people who live on it.

Emissions kill around 7 million people each year, and are responsible for more than a quarter of deaths from diseases including heart attacks, stroke and lung cancer. At the same time, more – and more intense – extreme weather events like drought and floods increase malnutrition rates and help spread infectious diseases like malaria.

2. Delivering health in conflict and crisis

The already difficult task of containing disease outbreaks is made more challenging in countries rife with conflict.

Nearly 1,000 attacks on healthcare workers and medical facilities in 11 countries were recorded in 2019, leaving 193 medical staff dead. Despite stricter surveillance, many healthcare workers remain vulnerable.

For the tens of millions of people forced to flee their homes, there is often little or no access to healthcare.

3. Making healthcare fairer

The gap between the haves and have-nots is growing, especially in terms of access to healthcare.

People in wealthy nations can expect to live 18 years longer than their poorer neighbours, and wealth can determine access to healthcare within countries and individual cities, as well. Rising global rates of diseases like cancer, diabetes and chronic respiratory conditions have a greater impact on low- and middle-income countries, where medical bills can quickly deplete the limited resources of poorer families.

4. Expanding access to medicines Although many in the world take access to medication for granted, medicines and vaccines are not an option for almost one-third of the global population.

The challenge of expanding access to medicines in areas where few, if any, healthcare products are available includes combatting substandard and imitation medical products . In addition to putting lives at risk by failing to treat the patient’s condition, these products can undermine confidence in medicines and healthcare providers.

5. Stopping infectious diseases

Infectious diseases continue to kill millions of people, most of them poor. This picture looks unlikely to change in the near future.

Preventing the spread of diseases like HIV, tuberculosis and malaria depends on sufficient levels of funding and robust healthcare systems. But in some areas where they are most needed, these resources are in short supply.

Greater funding and political will is required to develop immunization programmes, share data on disease outbreaks and reduce the effects of drug resistance.

6. Preparing for epidemics

Airborne viruses or diseases transferred by mosquito bite can spread quickly, with potentially devastating consequences.

Currently, more time and resources are spent reacting to a new strain of influenza or an outbreak of yellow fever, rather than preparing for future outbreaks. But it’s not a question of if a dangerous virus will come about – but when.

Epidemics are a huge threat to health and the economy: the vast spread of disease can literally destroy societies.

In 2017, at our Annual Meeting, the Coalition for Epidemic Preparedness Innovations (CEPI) was launched – bringing together experts from government, business, health, academia and civil society to accelerate the development of vaccines against emerging infectious diseases and to enable access to them during outbreaks.

Our world needs stronger, unified responses to major health threats. By creating alliances and coalitions like CEPI, which involve expertise, funding and other support, we are able to collectively address the most pressing global health challenges.

Is your organisation interested in working with the World Economic Forum to tackle global health issues? Find out more here .

7. Protecting people from dangerous products

Many poorer parts of the world face malnutrition and food insecurity, while at the same time, global obesity levels and diet-related problems are on the rise. We need to rethink what we eat, reduce the consumption of food and drinks high in sugar, salt and harmful fats, and promote healthy, sustainable diets. To this end, the WHO is working with countries to develop policies that reduce our reliance on harmful foodstuffs.

Health workers are in short supply the world over. Sustainable health and social care systems depend on well-paid and properly trained staff who can deliver quality care. WHO research predicts that by 2030, there will be a shortfall of 18 million health workers, mostly in low- and middle-income countries.

New investment is needed to properly train health workers and provide decent salaries for people in the profession, it says.

9. Keeping adolescents safe

Every year, more than 1 million adolescents – aged between 10 and 19 – die. The main causes include road accidents, suicides, domestic violence and diseases like HIV or lower respiratory conditions. But many of these premature deaths are preventable. Policymakers, educators and health practitioners need to promote positive mental health among adolescents, to prevent illicit drug use, alcohol abuse and self harm. Programmes that raise awareness of things like contraception, sexually transmitted infections and pregnancy care help address some of the underlying causes of adolescent fatalities.

10. Earning public trust Delivering safe, reliable healthcare to patients involves first gaining their confidence and trust; a trust which can be undermined by the rapid spread of misinformation on social media. For example, the anti-vaccination movement has led to an increase in deaths from preventable diseases. But social media can also be used to spread reliable information and build public trust in healthcare. Community programmes are another way to boost confidence in healthcare provision and practices that prevent the spread of diseases, such as vaccinations or condom use.

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World Economic Forum articles may be republished in accordance with the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Public License, and in accordance with our Terms of Use.

The views expressed in this article are those of the author alone and not the World Economic Forum.

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Biden Signs Executive Order to Expand Research on Women’s Health

The president said that improving women’s health was crucial to ensuring a healthy, stable economy.

Biden Signs Executive Order to Boost Women’s Health Research

The executive order is aimed at addressing the underrepresentation of women in health research..

We’ve launched the first ever White House initiative on women’s health research to pioneer the next generation of scientific research and discovery in women’s health. Think of all the breakthroughs we’ve made in medicine across the board, but women have not been the focus. And today — [applause] today, we’re jumpstarting that investment by dedicating $200 million in the National Institutes of Health to tackle some of the most pressing health problems facing women today. With the executive order I’m about to sign, I’m directing the most comprehensive set of executive actions ever taken to improve women’s health — ever taken. And I’m going to ensure that women’s health is integrated and prioritized across the entire federal government. It’s not just in women’s health, not just at N.I.H., the National Science Foundation or the Defense Department, the Environmental Protection Agency. I mean, across the board. This is really serious.

By Zolan Kanno-Youngs

Reporting from Washington

President Biden on Monday signed an executive order to expand the federal government’s research into women’s health, including midlife conditions like menopause, arthritis and heart disease, as well as issues specifically affecting women in the military.

In what the White House described as the “most comprehensive” action by a president on women’s health research, Mr. Biden directed federal agencies to ensure that they are using federal funds to research health conditions and diseases that disproportionately affect women.

Standing alongside the first lady, Jill Biden, and Vice President Kamala Harris, Mr. Biden said improving women’s health was crucial to guaranteeing a healthy, stable economy.

“There’s not a damn thing a man can do a woman can’t do,” Mr. Biden said. “To state the obvious, if you want to have the strongest economy in the world, you can’t leave half of the country behind.”

Carolyn M. Mazure, a psychologist and a professor at the Yale School of Medicine, who is the chairwoman of the White House initiative on Women’s Health Research, told reporters on Sunday night that health conditions like heart disease, Alzheimer’s, menopause and fibroids would be a focus of the expanded research effort.

“I’m not even a betting woman,” said Maria Shriver, the former first lady of California, who also attended the event, “but I’ll bet today that this is the first time a president of the United States has ever signed an executive order that mentions the words ‘menopause’ and ‘women’s midlife health’ in it.”

After the U.S. Supreme Court overturned Roe v. Wade in 2022 and the Alabama Supreme Court ruled last month that frozen embryos should be considered children , threatening in vitro fertilization, the Biden campaign has increasingly accused Republicans of undermining women’s health. During his State of the Union address this month, Mr. Biden said such decisions would motivate women to vote in the November election, while also saying his White House would commit to investing in women’s health in the year ahead.

“You can’t lead America with old ideas and take us backwards,” Mr. Biden said, adding, “To lead the land of possibilities, you need a vision for the future laying out what we can and should do and what we’re going to do.”

Mr. Biden’s executive order will require agencies to report annually their investments in women’s health research and to study ways that artificial intelligence can be used to advance such research. The National Institutes of Health will increase by 50 percent investments in small businesses focused on women’s health. The Defense Department also plans to invest $10 million to learn more about cancers and mental health issues affecting women in active military service.

The White House has called on Congress to pass a plan to invest $12 billion to create a new fund for women’s health research at the National Institutes of Health. In the meantime, the executive order signed on Monday directed the N.I.H. to spend $200 million on women’s health research. Dr. Biden traveled to Cambridge, Mass., last month to announce the first step of the women’s health initiative: $100 million to support women’s health researchers and start-up companies.

Zolan Kanno-Youngs is a White House correspondent, covering President Biden and his administration. More about Zolan Kanno-Youngs

The independent source for health policy research, polling, and news.

The Implications of COVID-19 for Mental Health and Substance Use

Nirmita Panchal , Heather Saunders , Robin Rudowitz , and Cynthia Cox Published: Mar 20, 2023

Note: This brief was updated on March 20, 2023 to incorporate the latest available data. Concerns about mental health and substance use remain elevated three years after the onset of the COVID-19 pandemic, with 90% of U.S. adults believing that the country is facing a mental health crisis, according to a recent KFF/CNN survey. The pandemic has affected the public’s mental health and well-being in a variety of ways, including through isolation and loneliness, job loss and financial instability, and illness and grief.

Over the course of the pandemic, many adults reported symptoms consistent with anxiety and depression, with approximately four in ten adults reporting these symptoms by early 2021, before declining to approximately three in ten adults as the pandemic continued (Figure 1). Additionally, drug overdose deaths have sharply increased – largely due to fentanyl – and after a brief period of decline, suicide deaths are once again on the rise. These negative mental health and substance use outcomes have disproportionately affected some populations, particularly communities of color and youth. As the end of the declaration of the public health emergency nears – on May 11, 2023 – many people continue to grapple with worsened mental health and well-being and face barriers to care.

This brief explores mental health and substance use during, and prior to, the COVID-19 pandemic. We highlight populations that were more likely to experience worse mental health and substance use outcomes during the pandemic and discuss some innovations in the delivery of services. We analyze and present findings using the most recent data available at the time of this publication – including the Household Pulse Survey and the CDC WONDER database . Key takeaways include:

• Symptoms of anxiety and depression increased during the pandemic and are more pronounced among individuals experiencing household job loss, young adults, and women. Adolescent females have also experienced increased feelings of hopelessness and sadness compared to their male peers.
• Deaths due to drug overdose increased sharply across the total population coinciding with the pandemic – and more than doubled among adolescents. Drug overdose death rates are highest among American Indian and Alaska Native people and Black people.
• Alcohol-induced death rates increased substantially during the pandemic, with rates increasing the fastest among people of color and people living in rural areas.
• After briefly decreasing, suicide deaths are on the rise again as of 2021. From 2019 to 2021, many communities of color experienced a larger growth in suicide death rates compared to their White counterparts. Additionally, self-harm and suicidal ideation has increased faster among adolescent females compared to their male peers.
• Several changes have been implemented in the delivery of mental health and substance use services since the onset of the pandemic, including the utilization of telehealth, steps to improve access to treatment for opioid use disorders, expansion of school-based mental health care, and the rollout of the 988 crisis line. As the public health emergency declaration comes to an end, it is possible that some of these changes will be interrupted.

Prevalence of Mental Illness and Substance Use During the Pandemic

Anxiety and depression.

The pandemic was associated with a high prevalence of anxiety and depression symptoms in adults. Research suggests that these symptoms increased during the pandemic, but the extent of this increase is unclear . 1 Throughout the pandemic, symptoms of anxiety and depression have been more pronounced among several populations.

For example, individuals experiencing household job loss were more likely than their counterparts to report symptoms of anxiety and/or depression (53% vs. 30%) in February 2023 (Figure 2). Job loss and unemployment – which have long been associated with adverse mental health outcomes – increased substantially early on in the pandemic .

Fifty percent of young adults (ages 18-24) reported anxiety and depression symptoms in 2023, making them more likely than older adults to experience mental health symptoms (Figure 2). Young adults have experienced a number of pandemic-related consequences – such as closures of universities, transitioning to remote work, and loss of income or employment – that may contribute to poor mental health. Additionally, young adults in college settings may encounter increased difficulty accessing treatment .

Symptoms of anxiety and/or depression were also elevated among women (36%) compared to men (28%) in February 2023 (Figure 2). Even before the pandemic, women were  more likely  than men to report mental health disorders, including serious mental illness.

Concerns about youth mental health further increased with the onset of the pandemic and the recent uptick in gun violence . In a recent KFF/CNN survey , roughly half of parents (47%) said the pandemic had a negative impact on their child’s mental health, including 17% who said it had a “major negative impact”. Poor mental health has been more pronounced among adolescent females in particular. As shown in Figure 3, the gap in the share of adolescent females and males reporting feelings of hopelessness and sadness – symptoms indicative of depressive disorder – widened from 2019 (47% vs. 27%, respectively) to 2021 (57% vs. 29%, respectively). Many female adolescents also reported adverse experiences in 2021, which can negatively impact mental health.

Substance use and deaths

The pandemic has coincided with an increase in substance use and increased death rates due to substances. In 2021, there were over  106,600 deaths  due to drug overdose in the U.S. – the highest on record. This spike in deaths has primarily been driven by substances laced with synthetic opioids, including illicitly manufactured fentanyl .

Further, the overall drug overdose death rate rose by 50% during the pandemic (Figure 4), but varied across states . While drug overdose death rates increased across all racial and ethnic groups, the increases were larger for people of color compared to White people. White people continue to account for the largest share of deaths due to drug overdose per year, but  people of color  are accounting for a growing share of these deaths over time. In 2021, the highest drug overdose death rates were among American Indian Alaska Native (AIAN) people (56.6 per 100,000), Black people (44.2 per 100,000), and White people (36.8 per 100,000) (Figure 4). Differences in drug overdose deaths by sex were also exacerbated during the pandemic. As shown in Figure 4, the gap in the drug overdose death rates between males and females increased from 2019 (29.6 vs. 13.7 per 100,000, respectively) to 2021 (45.1 vs. 19.6 per 100,000, respectively).

Research suggests that substance use among adolescents has declined, yet drug overdose deaths have sharply increased among this population, primarily due to fentanyl-laced substances . Among adolescents, drug overdose deaths have more than doubled from 2019 (282 deaths) to 2021 (637 deaths) following a period of relative stability. 2 Male, Black, and Hispanic youth have experienced the highest increases in deaths due to drug overdose.

During the pandemic, excessive drinking increased along with alcohol-induced deaths. Alcohol-induced death rates increased by 38% during the pandemic, with rates the highest and increasing the fastest among AIAN people. AIAN people died of alcohol-induced causes at a rate of 91.7 per 100,000 in 2021, six times more than the next highest group – Hispanic people at a rate of 13.6. Black people also experienced significant increases in alcohol-induced deaths during COVID, with rates increasing more than 45% (Figure 5). Both rural and metropolitan areas experienced an increase in alcohol-induced deaths during the pandemic, but rural areas saw the largest increase (46% increase compared to 36%).

Suicidal ideation and deaths

Concerns about suicidal ideation and suicide deaths have also grown during the pandemic. Notably, self-harm and suicidal ideation has increased among adolescent females. Thirty percent of adolescent females seriously considered attempting suicide in 2021 compared to 14% of their male peers (Figure 6). Other analyses found that as the pandemic progressed, emergency department visits for  suicide attempts  increased among adolescents, primarily driven by females.

Suicide deaths in the U.S. began to increase in 2021 after briefly slowing in 2019 and 2020 , although some research suggests that some  suicides  may be misclassified as drug overdose deaths since it can be difficult to determine whether drug overdoses are  intentional . From 2019 to 2021, many communities of color experienced a larger growth in suicide death rates compared to their White counterparts. 3 In 2021, suicide deaths by firearm accounted for more than half ( 55% ) of all suicides in the U.S., but varied greatly across states .

The pandemic has also raised concerns about mental illness, suicide, and substance use among other populations. Essential workers and people with chronic health conditions may have experienced worsened mental health due to increased risk of contracting or becoming severely ill from COVID-19. Many of these individuals, particularly those with chronic conditions , were already at-risk of experiencing poor mental health outcomes prior to the pandemic. LBGT+ people have historically faced mental health problems at higher rates than their non-LGBT+ peers. The pandemic has continued to negatively impact LBGT+ people’s mental health in disproportionate ways. In addition, people experiencing prolonged COVID-19 symptoms, or long COVID , may be more likely to develop new mental health conditions or to experience worsening of existing ones.

Changes in the Delivery of Mental Health and Substance Use Disorder Services

Leading up to the pandemic, many people faced barriers accessing mental health and substance use disorder services for reasons including costs, not knowing where to obtain care, limited provider options, and low rates of insurance acceptance. Young adults, Black adults, men, and uninsured people were less likely to receive services compared to their peers.

In recent years, access to care barriers may have worsened due to pandemic disruptions and closures, workforce shortages, and increased demand for services. In response to growing need, some policies and strategies were implemented to address access challenges, such as growth of telehealth, improved access to opioid use disorder treatment, the expansion of school-based mental health services, and the rollout of 988; however, challenges remain.

The delivery of mental health and substance use disorder services via telehealth grew sharply during the pandemic. By 2021, nearly 40% of all mental health and substance use disorder outpatient visits were delivered through telehealth. These behavioral health services via telehealth have also been more utilized in rural areas than urban areas during the pandemic. This underscores the role telehealth can play in improving access to behavioral health services in rural areas, which often face additional provider and resource shortages . Further, community health centers – which serve low-income and medically underserved communities, including communities of color and those in rural areas – experienced a large increase in behavioral health visits in 2021, largely driven by telehealth. During the pandemic, many state Medicaid programs expanded coverage of behavioral health telehealth services. This includes broadening the range of behavioral health services offered virtually and allowing for more provider types to be reimbursed for telehealth services. Many  state  Medicaid programs reported that telehealth has helped maintain and expand access to behavioral services during the pandemic. Some private payers have also  improved  coverage for mental health and substance use services by removing pre-pandemic telehealth coverage restrictions. Although telehealth can broaden access to care, in-person care may be necessary or preferred for some or for those experiencing challenges with technology and digital literacy.

As opioid-related overdose deaths have sharply increased, measures to improve access to treatment have been implemented. Following the onset of the pandemic , the federal government allowed for new  flexibilities  in opioid use disorder (OUD) treatment to ease access barriers, for example allowing for take-home methadone doses and covering telehealth treatment, and the Biden administration has  proposed  making these flexibilities permanent. Further, the 2023  Consolidated Appropriations Act   eliminated  the X-waiver requirement for prescribing buprenorphine, which substantially increases the number of providers who are authorized to prescribe buprenorphine to treat OUD. Voluntary guidelines for providers have also been issued to help reduce opioid overprescribing and misuse. At the same time, the Drug Enforcement Agency recently proposed returning to previous rules that required in-person visits before prescribing controlled substances to patients via telehealth, though there are some exceptions.

In response to growing mental health concerns among youth, integration of mental health services in school-based settings became a priority. Recent legislation aims to expand mental health care in schools – a setting that is easily accessible by children and adolescents. Specifically, legislation provides funding to expand and train mental health providers in schools; implement suicide, drug, and violence prevention programs; and provide trauma support services, among others. Further, recognizing Medicaid’s importance  in covering and financing behavioral health care for  children , CMS is now required to provide updated guidance on how to support and expand school-based behavioral health services. The recently passed Consolidated Appropriations Act (CAA) continues to build on prior pandemic-era legislation that promotes access to behavioral health care for children. For example, to ensure more stable coverage for low-income children the CAA requires states to provide 12 months of continuous eligibility for children in Medicaid and CHIP.

An easy-to-remember number for the suicide and behavioral health crisis hotline, 988, was launched in 2022 . On July 16, 2022, the  federally mandated   crisis number ,  988 , became available to all  landline and cell phone users , providing a single three-digit number to access a network of over 200 local and state funded crisis centers where those in need may receive crisis counseling, resources and referrals. After 988 implementation, national answer rates increased alongside increases in call volume. Long-term sustainable funding of local 988 crisis call centers remains uncertain in many states. In addition to 988, some states are developing behavioral health crisis response systems, such as mobile crisis or crisis stabilization units, which will enable a specialized behavioral health response for behavioral health crises that require intervention. The  CAA included provisions aimed at strengthening and evaluating 988 and the developing behavioral health crisis continuum.

Despite steps taken to improve the delivery of mental health and substance use services, challenges remain. Provider workforce challenges are widespread, with nearly half of the U.S. population ( 47% ) living in a mental health workforce shortage area . Shortages may contribute to access challenges and contribute to increases in psychiatric boarding in emergency rooms. Additionally, provider network directories are often outdated, further contributing to access challenges. While recent legislation has taken steps in response – including funding for at least 100 new psychiatry residency positions, grants for mental health peer support providers, and improvements to provider directories through the CAA – these are relatively small measures in the face of big access challenges. The lack of a diverse mental health care workforce may contribute to limited mental health treatment among people of color. Separately, even with insurance coverage, individuals with mental health needs face challenges accessing care. While Medicaid enrollees have limited out-of-pocket costs there is variation in who is eligible and the range of services covered across states . Additionally, the end of Medicaid’s continuous enrollment provision – on March 31, 2023 – could result in millions of disenrollments over the next year which could disrupt access to behavioral health services. Among private insurance enrollees, enrollees, with mental illness face high out-of-pocket costs; and these costs vary substantially across states . While most adults with mental illness have private insurance, rates of mental illness and substance use disorders are most prevalent among nonelderly adults with Medicaid.

Looking Ahead

Although steps have been taken to address negative mental health impacts stemming from the pandemic, mental health and substance use concerns remain elevated. Heightened racism and increasing gun violence may also contribute to poor mental health outcomes. Further, negative mental health impacts have been more pronounced among several populations, including communities of color, young adults and children – populations which have historically experienced increased barriers to care. Additionally, despite renewed discussions and new federal grants for state parity enforcement under the CAA, challenges with mental health parity persist – including lack of clarity on specific protections, low compliance rates, and slow federal enforcement. Finally, the COVID-19 public health emergency will end in May 2023, which may at least partially unravel steps taken toward delivering mental health services via telehealth and improving access to substance use disorder services.

History has shown that the mental health impact of disasters outlasts the physical impact, suggesting today’s elevated mental health needs will continue well beyond the coronavirus outbreak itself. As we emerge from the COVID-19 pandemic and the federal public health emergency draws to an end, it will be important to consider how the increased need for mental health and substance use services may persist long term, even as new cases and deaths due to COVID-19 hopefully subside.

This work was supported in part by Well Being Trust. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

The Household Pulse Survey (HPS) is a rapid response survey that has provided real-time data during the pandemic and includes a 4-item Patient Health Questionnaire (PHQ-4) anxiety and depression screening scale. In order to understand how the prevalence of anxiety and depression may have shifted in the adult population during the onset of the pandemic, mental health estimates from HPS were compared against pre-pandemic data from the National Health Interview Survey, which also includes the 4-item PHQ scale. However, recent research finds that these comparisons may not be reliable given lower response rates and over estimation in HPS; and are no longer included in this brief.

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KFF analysis of Centers for Disease Control and Prevention, Wide-ranging Online Data for Epidemiologic Research (WONDER). Accessed at: https://wonder.cdc.gov/mcd-icd10-expanded.html

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• Latest Federal Data Show That Young People Are More Likely Than Older Adults to Be Experiencing Symptoms of Anxiety or Depression

Also of Interest

• Medicaid Coverage of Behavioral Health Services in 2022: Findings from a Survey of State Medicaid Programs
• Mental Health and Substance Use State Fact Sheets
• Mental Health and Substance Use Considerations Among Children During the COVID-19 Pandemic
• Mental Health Impact of the COVID-19 Pandemic: An Update
• Mental Illnesses May Soon Be the Most Common Pre-Existing Conditions
• State Data on Mental Health and Substance Abuse
• April 2022 Web Event: The Future of Mental Health Coverage & Access
• Medicaid Behavioral Health Services: Data Collection

Maternal mental health problems are 'No. 1 complication in pregnancy'

Child and maternal health experts shared the challenge of providing wraparound care and extended research during a panel discussion on women’s health.

Leigh Anne Kelley

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A discussion on women’s health in Washington, D.C., represented a collaboration between Children’s National Hospital and Fralin Biomedical Research Institute at VTC. Melissa Schooley (from left) moderated a panel that included Nia Imani Bodrick, Catherine Limperopoulos, and Brittany Howell. Photo by Leigh Anne Kelley for Virginia Tech.

Modern medicine treats patients independently, but when it comes to women’s health, physicians and researchers stressed the need for a holistic approach during a recent panel discussion on maternal health in Washington, D.C.

“Maternal health is children’s health,” said  Catherine Limperopoulos , chief and director of the Developing Brain Institute at Children’s National Hospital. “Many people aren’t aware that maternal mental health problems” — such as postpartum depression and anxiety — “are the No. 1 one complication in pregnancy.”

Limperopoulos was one of three featured speakers for the March 7 discussion on maternal health sponsored by Children’s National and the Fralin Biomedical Research Institute at VTC, which has research programs in brain and behavior development in Roanoke on the Virginia Tech Health Sciences and Technology campus and cancer research programs in Roanoke as well the Children’s National Research & Innovation Campus in Washington, D.C.

As a pediatrician with Children’s National,  Nia Imani Bodrick  is directly involved in caring for patients. She said while women may put off care for themselves, they prioritize pediatric visits for their children — making those regular wellness checks an ideal time to intervene.

Bodrick said there’s a need to support projects such as  HealthySteps , which began as a research program and has been integrated into pediatric practices in 25 states, Germany, and Washington, D.C., including Bodrick’s.

“One of the best things we do is we screen for postpartum depression up to six months, and we keep short-term mental health on staff,” Bodrick said, although recruiting and retaining those providers is a challenge. The evidence-based program also is designed to identify and address a child’s developmental delays early and ensure families have the support they need.

At the Fralin Biomedical Research Institute, Assistant Professor  Brittany Howell  studies factors that influence healthy infant brain development in her Maternal Influence on Neurodevelopment (MIND) Lab. Howell is also an investigator on the national  HEALthy Brain and Child Development Study .

She explained the need for more research into factors that influence a child’s early years and said the timelines of budget cycles and the structure of research funding often don’t take into account unique attributes of maternal health and rapid changes that take place during early childhood.

Howell also said maternal health research would benefit from increased funding, giving the example of breast milk and the milk microbiome. “It’s an amazingly dynamic fluid, yet we know next to nothing,” she said. More study could provide evidence-based recommendations to clinicians and families, she said.

Comments during the event resonated with President Joe Biden’s proposal for broader support for women’s health research in general in his State of the Union address, which took place the same day. During the address, he said “women are more than half of our population, but research on women’s health has always been underfunded.”

The event was moderated by  Melissa Schooley , a member of Fralin Biomedical Research Institute’s advisory board and vice president of global reimbursement, health policy, and government affairs for  Abiomed , a health technology company. Schooley has been a leader in the Abiomed Women’s Initiative to drive awareness of heart failure risks unique to women and the need for broader screening and access to therapy, including therapy to promote heart recovery.

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'We exist': New Middle Eastern or North African census category helps community members feel seen

Swara Salih, a 32-year-old Kurdish American, has been reluctantly ticking “white” on federal forms his whole life. But that’s not what he sees when he looks in the mirror.

“My entire life I’ve been a brown kid, I’ve had darker skin than my white friends,” Salih told NBC News. “I was very culturally confused in that way as a kid, like, ‘What am I supposed to be?’ I’m not white, I’m not Black, I’m not Latino.”

The new Middle Eastern or North African category announced by the Office of Management and Budget on Thursday will help shed the cloak of invisibility draped on members of the community, like Salih, for decades, experts say.

The addition of this category to the OMB’s standards for race and ethnicity for the first time in U.S. history means that an estimated 8 million Americans who trace their origins to the Middle East and North Africa will no longer have to choose “white” or “other” on federal forms, including the U.S. census.

“We were forced to identify as something we were not, and in a way that erased the community and erased any data on the community,” said Abed Ayoub, the national executive director of the American-Arab Anti-Discrimination Committee (ADC), one of the first advocacy groups to push for an identifier for MENA Americans. “We’re a different community and we have not been able to — since we’ve been here — get an accurate picture of who we are.”

The new identifier will have six subcategories beneath it that include Lebanese, Iranian, Egyptian, Syrian, Iraqi and Israeli, which were selected to represent the largest population groups in the U.S., an OMB spokesperson said. The identifier will also include a blank space where people can write in how they identify if their ethnicity isn’t one of the subcategories.

While advocacy groups don’t think the geographical addition goes far enough to capture the diversity of the region, they say it’s a long-awaited step in the right direction.

Undercounted, underrepresented and unnoticed

The lack of an identifier for Americans from the Middle East and North Africa has left them undercounted, underrepresented and unnoticed in U.S. society.

MENA Americans can trace their origins to more than a dozen countries, including Egypt, Morocco, Iran, Turkey and Yemen. The region is racially, ethnically and religiously diverse, and people from there can be white, brown or Black, as well as identify with an ethnic group, like Arab, Amazigh, Kurdish, Chaldean and more. Migration from countries in the region to the U.S. began in the late 1800s and picked up in recent decades largely because of political turmoil, according to the  Migration Policy Institute .

The largest MENA group in the U.S. is Arab Americans, according to data collected by advocacy groups. The new identifier came days before the start of Arab American Heritage Month on April 1.

Tariq Ra'ouf, 33, a Palestinian American, described feeling like his identity was being erased when having to tick “white” on job applications.

“When I’m filling them out it’s like, ‘This is ridiculous,’ because I’m not white,” Ra'ouf said. “And then, if I say that I’m white, I might lose out on opportunities at companies who are looking to hire culturally and ethnically diverse employees. Who knows how many applications people might have missed because they are forced to put down a race that doesn’t represent them.”

The MENA and white communities are different in many ways, including culturally, socioeconomically and politically. A MENA identifier will help federal agencies collect crucial data that will in turn improve policy decisions, said Maya Berry, the executive director of the Arab American Institute (AAI). The lack of an identifier has meant that research on the community has largely been anecdotal, and it led to its members losing out on federal resources such as health and social services.

“That category is the way that we address that our community has been rendered invisible in the data for decades,” Berry said. “There’s a direct harm when communities do not have the kind of information that is needed about them, anywhere from the issues that we saw during the Covid pandemic , to the way congressional districts are drawn, to health research about our folks, to protecting our civil rights.”

Even the 8 million MENA Americans that advocacy organizations estimate live in the U.S. may be an undercount, Ayoub says.

“We’re going to have clear data on the number of folks from the region that are in this country, where we live — everything from our spending habits to health issues to education,” Ayoub says of the addition of the identifier. “In this day and age, you really need data to be a strong advocate for your community. And this will allow for us to get a better picture of who our community is.”

Ra'ouf is excited he won’t have to misrepresent himself anymore.

“I think it’s about time,” he said. “It’s a little frustrating that it took so long to get to this point. But mostly, I think it’s just exciting because we’ll be able to truly get a bigger sense of how many of us there are in this country, and get better representation.”

A decadeslong effort

Getting a MENA identifier on the census has been a decadeslong, back-and-forth effort by groups such as the ADC and AAI.

The Census Bureau had already tested the category in 2015 and found   it yielded data that provided better insight into the MENA community. The category was abandoned when the Trump administration came to power.

The OMB announced the long-awaited update more than a year after the Federal Interagency Technical Working Group on Race and Ethnicity Standards recommended adding the identifier as a new category . This is the first time the OMB has updated the standards for race and ethnicity since 1997; prior to this change, there were five categories for data on race and two for ethnicity: American Indian or Alaska Native; Asian; Black or African American; Native Hawaiian or Other Pacific Islander; White; Hispanic or Latino; and non-Hispanic or Latino.

The OMB instructed all federal agencies “to begin updating their surveys and administrative forms as quickly as possible,” according to a statement. Federal agencies have five years to bring all data collection into compliance with the updated standards, which means Americans can begin seeing this update in documents within that time.

Berry says we may see a “ripple effect” in which nongovernmental institutions, such as hospitals and universities, adopt the OMB’s new standards.

“Let’s say I’m a hospital and I want to apply for federal research grants. I would absolutely make sure that I was matching federal standards,” Berry said. “I can’t imagine a single aspect of our society — companies, health institutions, universities, corporations — that’s not going to want to be aligned with federal standards.”

Not a perfect solution

Experts warn that the category is not the exact solution they were advocating for, and could lead to another undercount of the diverse community in the U.S.

Countries such as Somalia and Sudan are included in the 22 countries that make up the Arabic-speaking world, according to the ADC , and many hailing from those nations identify as Arab as well as African. But the OMB’s new category does not include a way for Afro-Arabs to identify themselves, a sticking point for experts who weighed in on the change.

“Let’s say I’m Sudanese — I check MENA because I identify ethnically within the MENA category and I write ‘Sudanese’ in the space,” Berry explained. “I am not sure that they will still be coded within MENA, because the code for Sudanese now is Black or African American.”

Prior to the existence of a MENA category, many MENA Americans would tick “other” on the census, write in their identities and be tallied into the white community anyway — Berry worries the same will happen to Afro-Arabs.

“And just like before, we didn’t want to be exclusively white. Moving forward, we can’t have a category that excludes Afro-Arabs from being part of MENA if that’s how they want to identify,” Berry said.

While people are free to tick more than one box, it’s not clear how hyphenated MENA identities will be tallied, Berry said.

Ayia Almufti, a 25-year-old Iraqi American, disagrees with the use of the term "Middle East" for the category, which was coined and used by European officials in the 19th century for the region in accordance with its proximity to Europe.

"I prefer SWANA (Southwestern Asia and North Africa) any day," she said, adding that the new category is still an upgrade.

Ayoub also warned of not including Armenian Americans in the MENA category, many of whom were forced to relocate to countries in the Middle East during the Armenian g enocide and may identify ethnically as Middle Eastern.

A way to have avoided this would have been to let the Census Bureau, which conducts the statistical research on race and ethnicity, formulate the category question based on its findings, said Berry.

In a statement , the Census Bureau said it follows standards set by the OMB and that it will develop plans to implement it in censuses and surveys, like the annual American Community Survey and the decennial census.

Both Berry and Ayoub say they will continue to advocate for better representation of the community.

For now, Ra'ouf hopes this update will give future generations what he didn’t get growing up.

“The feeling of actually being able to check off what you actually are is a feeling that I think none of us really have gotten to experience,” Ra'ouf said. “And I think for the kids, and everyone growing up and filling out those boxes in the future, I hope that it will add some sense of pride.”

Even though it’s not a perfect category, Salih says it beats having to identify as white without benefiting from the privilege that it offers, especially against the backdrop of anti-Arab and Islamophobic sentiment .

“I think that it allows us to assert our identities in a society which has by and large wanted to shun us, to ban us from coming here,” Salih said. “But now we’re able to say more officially, ‘No, we are here. We exist.’”

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FTC Releases 2023 Privacy and Data Security Update

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The Federal Trade Commission released its Privacy and Data Security Update for 2023 that highlights the FTC’s work to protect consumer privacy and respond to the evolving ways that companies use consumer data such as in the development of artificial intelligence models and misuse of health data.

“The FTC is taking bold actions to challenge the indiscriminate collection and monetization of consumers’ data,” said Samuel Levine, Director of the FTC’s Bureau of Consumer Protection. “We are securing meaningful remedies to protect consumers’ information, rather than placing the burden on consumers to protect themselves.”

The publication highlights the FTC’s privacy and data security work in the last few years. Through 2023, the FTC has brought 97 privacy cases and 169 Telemarketing Sales Rule and CAN-SPAM cases since 1999, as well as 89 data security cases. In addition to its law enforcement work, the agency also has engaged in rulemaking and policy work to push companies to bolster privacy protections for consumers and implement safeguards to secure consumer data.

Between 2021 and 2023, the FTC has taken action to address privacy and security threats in several key areas including:

• Artificial Intelligence : The FTC has brought a number of enforcement actions related to the collection, retention, or use of consumers’ personal information to develop or deploy machine learning or similar algorithms. For example, the FTC alleged that  Amazon Alexa violated the Children’s Online Privacy Protection Act (COPPA) by indefinitely retaining children’s voice recordings, which it used to improve its speech recognition algorithm. Last year, the agency also brought a case against  Rite Aid over charges it failed to take reasonable steps to ensure that the AI facial recognition technology it deployed in its retail stores did not erroneously flag people as shoplifters or other wrongdoers.
• Health Privacy:  Protecting the privacy and security of consumers’ sensitive health information has long been a top FTC priority. Last year, the FTC gave final approval to an order banning  BetterHelp , an online counseling service, from sharing sensitive health data for advertising with Facebook and other third parties and requiring it to pay $7.8 million to provide partial refunds to consumers. Also in 2023, the FTC banned  GoodRx from sharing sensitive health data with applicable third parties for advertising and also required the company to pay a civil penalty for violating the Health Breach Notification Rule, the agency’s first action under the rule.
• Children’s privacy : The FTC also has worked vigorously to protect children’s privacy through its enforcement of COPPA. In addition to the FTC’s action against Amazon, the agency has brought several other COPPA-related actions including cases involving major gaming companies and education technology providers. For example, the FTC obtained a record $275 million penalty against  Fortnite maker Epic Games , which also was required to adopt strong privacy default settings for both children and teens and other protections, and brought an action against  ed tech provider Edmodo for using children’s personal information for advertising in violation of COPPA and outsourcing its responsibilities under COPPA to schools. In late 2023, the FTC also proposed key changes to  strengthen and update the COPPA Rule that would further limit the ability of companies to condition access to services on monetizing children’s data.
• Geolocation Data:  As with health data, location data can reveal highly sensitive information about people by tracking their visits to such places as reproductive health clinics, houses of worship, and domestic violence shelters. Given this, the FTC has taken action to protect such data. In 2022, the FTC sued  data broker Kochava Inc . for selling geolocation data from hundreds of millions of mobile devices that can be used to trace the movements of individuals to and from sensitive locations.

The FTC also has remained active in targeting companies that fail to implement reasonable data security measures to protect consumer data. In 2022 and 2023 alone, the FTC announced or finalized enforcement actions against  Global Tel*Link , Drizly ,  Chegg , and  CafePress for data security failures.

The agency also has worked to ensure companies comply with the Fair Credit Reporting Act, which sets out requirements for companies that use data to determine creditworthiness, insurance eligibility, suitability for employment, and to screen tenants. The FTC has brought 117 FCRA cases and obtained more than $137 million in civil penalties. This includes a 2023 action that the FTC and Consumer Financial Protection Bureau brought  against Trans Union LLC and a subsidiary for failing to ensure the accuracy of tenant screening reports by including inaccurate and incomplete eviction records about consumers, hampering their ability to obtain housing.

In addition to vigorous enforcement, the FTC has engaged in rulemaking and other policy work to establish baseline standards that protect consumers’ privacy. In the past few years, the Commission has proposed rules to  clarify the applicability of the Health Breach Notification Rule to health apps , and  strengthen COPPA . It has also issued an advanced notice of proposed rulemaking to explore rules that would crack down on  harmful surveillance and lax data security , and published a  policy statement that makes clear that is against the law for companies to force parents and schools to surrender their children’s privacy rights to be able to learn remotely.

The lead staffer on this update was Katherine McCarron in the FTC’s Bureau of Consumer Protection.

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Homelessness and Public Health: A Focus on Strategies and Solutions

David a. sleet.

1 School of Public Health, San Diego State University, San Diego, CA 92182, USA; moc.liamg@teelsadivad

2 Veritas Management, Inc., Atlanta, GA 30324, USA

Louis Hugo Francescutti

3 School of Public Health, University of Alberta, Edmonton, AB T6G 1C9, Canada

4 Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB T6G 1C9, Canada

5 Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada

On any given night, hundreds of thousands of people are homeless in the United States and Canada. Globally, the problem is many times worse, making homelessness a global public health and environmental problem. The facts [ 1 ] are staggering:

• On a single night in January 2020, 580,466 people (about 18 out of every 10,000 people) experienced homelessness across the United States—a 2.2% increase from 2019.
• While 61% percent of the homeless were staying in sheltered locations, the remainder—more than 226,000 people—were in unsheltered locations on the street, in abandoned buildings, or in other places not suitable for human habitation.
• Homelessness has increased in the last four consecutive years.
• The increase in unsheltered homelessness is driven largely by increases in California.
• In 2020, 171,575 people in families with children experienced homelessness on a single night.
• A total of 3598 homeless people were children under the age of 18 without an adult present.
• Veterans comprised 8% of all homeless adults (over 46,000 veterans struggle with homelessness).
• People of color are significantly over-represented among those experiencing homelessness.

A layman’s definition of homelessness is usually “a person that has no permanent home”. However, many scholars have divided the broad group of people characterized as homeless into three (or more) categories:

• - People without a place to reside;
• - People in persistent poverty, forced to move constantly, and who are homeless for even brief periods of time;
• - People who have lost their housing due to personal, social, or environmental circumstances.

While this definition refers specifically to homeless individuals, it is equally applicable to homeless families.

Homelessness is closely connected to declines in physical and mental health. Homeless persons experience high rates of health problems such as Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) and Hepatitis A infections, alcohol and drug addiction, mental illness, tuberculosis, and other serious conditions. The health problems facing homeless persons result from various factors, including a lack of housing, racism and discrimination, barriers to health care, a lack of access to adequate food and protection, limited resources for social services, and an inadequate public health infrastructure. Legal and policy interventions have often been used to attempt to address homelessness, although not always from a public health perspective.

In health care, for example, if someone experiencing homelessness comes to an emergency department for medical aid, once treated, the only alternative is to release the patient back onto the street. This creates an endless cycle of emergency department visits, increasing costs and expending resources in the health care system.

Recent work [ 2 ] has emphasized the important role of public health, the health care system, and health care providers in homelessness prevention. In this Special Issue of the International Journal of Environmental Research and Public Health (IJERPH), we have brought together researchers, practitioners, and community organizers to articulate the public health problem of homelessness and identify clear strategies to reduce homelessness and provide more adequate health care and housing for this population. We also explore solutions for important subpopulations, including adults, families with children, adolescents, women, transitional aged youth, and those suffering from mental illness, PTSD, alcohol dependency, mental illness, adverse childhood experiences, and chronic homelessness.

We address many of these issues in the context of public health and explore the public health implications and potential solutions to homelessness, focusing on contemporary and emerging research and innovative strategies, and highlighting best practices to address homelessness among key populations. The papers in this Special Issue attempt to answer several questions related to homelessness and public health, such as:

• What is the extent of homelessness and why do people become homeless?
• What are the public health and health services implications of homelessness?
• What role does housing play as a precursor to and potential solution for homelessness?
• What public health and health care interventions are being employed, and what effectiveness is being achieved?
• What long-term strategies can be developed to prevent homelessness?

The 13 research papers and one commentary in this Special Issue are summarized as follows:

• Conceptualizing an Interdisciplinary Collective Impact Approach to Examine and Intervene in the Chronic Cycle of Homelessness. This study by Abdel–Samad et al. [ 3 ] focuses on a novel, interdisciplinary academic–practice partnership model for addressing the problem of homelessness. Whereas singular disciplinary approaches may fall short in substantially reducing homelessness, this approach draws from a collective impact model that integrates discipline-specific approaches through mutually reinforcing activities and shared metrics. The paper describes what is necessary for capacity-building at the institution and community levels, the complementary strengths and contributions of each discipline in the model, and future implementation goals to address homelessness in the Southern California region using a cross-disciplinary approach.
• Mental Illness and Youth-Onset Homelessness: A Retrospective Study among Adults Experiencing Homelessness . Iwundu et al. [ 4 ] conducted a retrospective study and evaluated the association between the timing of homelessness onset (youth versus adult) and mental illness. The results indicated that mental illness (as a reason for current homelessness) and severe mental illness comorbidities were each associated with increased odds of youth-onset homelessness, providing a basis for agencies that serve at-risk youth in order to address mental health precursors to youth homelessness.
• Well-Being without a Roof: Examining Well-Being among Unhoused Individuals Using Mixed Methods and Propensity Score Matching. Ahuja et al. [ 5 ] found that the mean overall well-being score of unhoused participants was significantly lower than that of matched housed participants, with unhoused participants reporting lower mean scores for social connectedness, lifestyle and daily practices, stress and resilience, emotions, physical health, and finances. The unhoused participants had a statistically significantly higher mean score for spirituality and religiosity than their matched housed counterparts. The qualitative interviews highlighted spirituality and religion as a coping mechanism for the unhoused.
• Combatting Homelessness in Canada: Applying Lessons Learned from Six Tiny Villages to the Edmonton Bridge Healing Program. Authors Wong et al. [ 6 ] discuss the Bridge Healing Program in Edmonton, Alberta, a novel approach to combatting homelessness by using hospital emergency departments (ED) as a gateway to temporary housing. The program provides residents with immediate temporary housing before transitioning them to permanent homes. The paper discusses effective strategies that underlie the Tiny Villages concept by analyzing six case studies and applying the lessons learned to improving the Bridge Healing Program and reducing repeat ED visits and ED lengths of stay among homeless individuals.
• Change in Housing Status among Homeless and Formerly Homeless Individuals in Quebec, Canada: A Profile Study. Kaltsidis et al. [ 7 ] used a cluster analysis to develop a typology of the housing status change for 270 currently or formerly homeless individuals who were residing in shelters and temporary or permanent housing. The findings suggest that the maintenance or improvement in the housing status requires the availability of suitable types and frequencies of service use (enabling factors) that are well-adapted to the complexity of health problems (needs factors) among homeless individuals. Specific interventions, such as outreach programs and case management, are prioritized as necessary services, especially for individuals at a higher risk of returning to homelessness.
• Urban Stress Indirectly Influences Psychological Symptoms through Its Association with Distress Tolerance and Perceived Social Support among Adults Experiencing Homelessness. To investigate the simultaneous impact of intrapersonal characteristics (distress tolerance) and interpersonal characteristics (social support) and their association with homelessness, Hernandez et al. [ 8 ] recruited homeless adults from six homeless shelters in Oklahoma City who self-reported urban life stress, distress tolerance, social support, major depressive disorder, and PTSD symptoms. Based on the resulting associations, their findings stress the importance of implementing interventions aimed at increasing social support for homeless persons, something that may also increase skill development for distress tolerance and indirectly lead to a reduction in depression and PTSD.
• “I Felt Safe”: The Role of the Rapid Rehousing Program in Supporting the Security of Families Experiencing Homelessness in Salt Lake County, Utah. Garcia and Kim [ 9 ] describe their research into The Road Home (TRH) program, which provides services to homeless individuals and families. TRH is known for their emergency shelters and also administers the Rapid Rehousing Program (RRHP), designed to help homeless families transition back into stable housing. After collecting qualitative data from focus groups with participants and families, landlords, case managers, and service providers, they make recommendations for program improvements that can increase the residential security of families experiencing homelessness.
• “It’s Just a Band-Aid on Something No One Really Wants to See or Acknowledge”: A Photovoice Study with Transitional Aged Youth Experiencing Homelessness to Examine the Roots of San Diego’s 2016–2018 Hepatitis A Outbreak. In this study, Felner et al. [ 10 ] examined the experiences and needs of transitional aged youth (TAY) aged 18–24 experiencing homelessness who may have been uniquely affected by an unprecedented outbreak of hepatitis A virus (HAV). The findings documented a stigmatization of TAY, interventions that failed to address root causes of the outbreak, and interactions with housing- and social support-related resources that limited rather than supported economic and social mobility. The findings have implications for understanding how media and public discourse, public health interventions, and the availability and delivery of resources can contribute to and perpetuate stigma and health inequities faced by TAY experiencing homelessness.
• Predictors of Overnight and Emergency Treatment among Homeless Adults. Iwundu et al. [ 11 ] aimed to identify the sociodemographic predictors associated with overnight and emergency hospital treatment among a sample of homeless adults. Participants were recruited from a shelter in Dallas, Texas and were predominantly uninsured, low-income men and women from various social and ethnic groups. In logistic regression models, gender emerged as the only predictor of overnight treatment in a hospital and treatment in an emergency department. Women were more likely than men to be treated overnight and use emergency care. The authors concluded that interventions and policies targeted toward homeless women’s primary health care needs would reduce health care costs.
• Association of Problematic Alcohol Use and Food Insecurity among Homeless Men and Women. In a study on alcohol use and food insecurity among homeless men and women, Reitzel et al. [ 12 ] investigated the link between problematic alcohol use and food insecurity among homeless adults in Oklahoma. Problematic alcohol use was measured using the Alcohol Quantity and Frequency Questionnaire and the Patient Health Questionnaire. Food insecurity was measured with the USDA Food Security Scale-Short Form. The results indicated that heavy drinking and probable alcohol dependence/abuse were each associated with increased odds of food insecurity. The results question whether alcohol may take precedence over eating or food purchases among this population of homeless individuals.
• Exploring Tiny Homes as an Affordable Housing Strategy to Ameliorate Homelessness: A Case Study of the Dwellings in Tallahassee, FL. “Tiny Homes” is an emerging strategy to combat homelessness, and Jackson et al. [ 13 ] raise a number of questions about the intentions, efficacy, and policy feasibility of this strategy. The paper seeks to understand the strategies used by stakeholders to plan, design, and implement a “Tiny Homes” strategy, and to assess their effectiveness. Using a case study, they examined how the community was planned, the experiences of residents, and the constraints to success. Their findings highlighted how funding constraints and NIMBYism (Not in My Backyard-ism) stymied stakeholder efforts to achieve equity and affordability, resulting in the inability to achieve project aims to develop affordable housing that served homeless populations.
• Predictors of Emergency Department Use among Individuals with Current or Previous Experience of Homelessness. The study by Gabet et al. [ 14 ] assessed the contributions of predisposing, enabling, and needs factors in predicting emergency department (ED) use among 270 individuals with a current or previous experience of homelessness. Participants were recruited from types of housing in Montreal, Quebec (Canada) and were interviewed about their ED use at baseline and again 12 months later. The findings revealed two needs factors associated with ED use: having a substance use disorder and low perceived physical health. Two enabling factors—the use of ambulatory specialized services and stigma—were also related to ED use. ED use was not associated with the type of housing. The authors suggest that improvements are needed to manage substance use disorders and the physical health of homeless individuals in order to reduce ED use.
• Being at the Bottom Rung of the Ladder in an Unequal Society: A Qualitative Analysis of Stories of People without a Home. The Mabhala and Yohannes article [ 15 ] examines the stories of homeless people and their perceptions of their social status using interviews in three centers for homeless people in Cheshire, in the English Northwest. Education, employment, and health were three domains that provided a theoretical explanation for the reasons that led to their homelessness. Participants catalogued their adverse childhood experiences, which they believe limited their capacity to meaningfully engage with social institutions for social goods, such as education, social services, and institutions of employment. They conclude that, although not all people who are poorly educated, in poor health, and unemployed end up being homeless, a combination of these together with multiple adverse childhood experiences may weaken resilience and contribute to homelessness.
• Commentary: Investing in Public Health Infrastructure to Address the Complexities of Homelessness. In a final commentary, Allegrante and Sleet [ 16 ] introduce the notion that investments in public health infrastructure are needed to address the complexities of homelessness, including the continued threats posed by SARS-CoV-2 (COVID-19) and its variants. The lack of affordable housing, widespread unemployment, poverty, addiction and mental illness, which all contribute to the risk of homelessness, would be well-served by improving the fundamental public health infrastructure. They argue that homelessness is exacerbated by system-wide infrastructure failures at the municipal, state and federal governments and from the neglect to invest in public infrastructure, including a modern public health system.

In conclusion, shelter is a basic human need. Thus far, we have an inadequate understanding of all the medical and nonmedical, public health, and infrastructural influences that drive homelessness and why so many people are living without adequate shelter. Housing is one of the most critical factors in addressing homelessness and one of the best-researched social determinants of health. Several articles here focus on innovative approaches to providing temporary or permanent housing for those who need it, and it is well known that selected housing interventions can improve health and decrease health care costs. From that perspective, some professionals in the field contend that housing equates to health [ 17 ] and that improved housing options for homeless individuals and families would advance population-level health.

Many of the articles in this Special Issue [ 18 ] focus on specific aspects of life, quality of life, and co-morbidities related to behavioral and social variables influencing homelessness. Explored in detail are factors such as lack of housing, distress, wellness, emergency department use, mental health, drug and alcohol addiction, poverty, low educational attainment, inadequate health care and social services, adverse childhood experiences, ongoing infections, unemployment, and public health infrastructure. In addition to highlighting the impact these factors can have on the likelihood that someone would become homeless, many of the articles also provide recommendations for relevant policies, practices, and interventions that could help reduce homelessness and improve overall well-being.

The intersection of environmental, behavioral, and social factors, in addition to the lack of an adequate infrastructure, must also be considered when studying the determinants of homelessness and designing appropriate interventions. Our ultimate goal in producing this Special Issue of IJERPH is to encourage the development of better evidence to inform public health, social services, and medical care policies and practices that will result in better health for homeless populations.

Acknowledgments

We thank the authors and reviewers for their commitment to preparing and editing these manuscripts and for adding to the knowledge base of this important public health problem.

Conflicts of Interest

The authors declare no conflict of interest.

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