Andrew James Baxter

Background: Life expectancy has increased worldwide, in part due to reduced infant mortality. However, inequalities between countries persist. Gross domestic product (GDP) is a widely used means of assessing a country’s economic performance. We assessed global trends in inequalities in life expectancy and infant mortality comparing countries ranked by GDP per capita from 1990 to 2022. Methods: Data on life expectancy, infant mortality rate, GDP per capita (nominal US$) and population size worldwide for 1990 to 2022 were retrieved from the World Bank. Slope and Relative Indices of Inequality were calculated using regression models to estimate global health inequalities across GDP-ranked countries with weights for population size to represent the global population. Results: The global gap in life expectancy at birth reduced from 28.80 to 19.88 years between 1990 and 2022, while relative inequalities fell from 1.61 to 1.32. The absolute gap in infant mortality fell from 116.97 deaths per 1000 live births to 48.31 but relative inequalities increased (6.76 to 11.38). Progress in levels of global inequality stalled after 2010, with increasing inequalities after 2019. For life expectancy at age 60, both absolute and relative inequalities increased over time from 5.67 to 7.77 years and 1.41 to 1.50, respectively. Conclusion: Progress has been made in reducing health inequalities across the global population since 1990, but this has slowed for over a decade, and inequalities in life expectancy at age 60 have increased. Global policy initiatives to address global health inequalities and particularly older age adult mortality are needed.

We provide new evidence on the mental health and healthcare utilisation impacts of the roll-out of Universal Credit, one of the most significant welfare reforms in Europe in recent decades. Designed to simplify the benefit system and strengthen work incentives by merging six means-tested programmes into a single payment, Universal Credit also introduced features that may adversely affect mental health. Exploiting the plausibly exogenous, staggered geographical introduction of Universal Credit across England between 2013 and 2018, we implement a difference-in-differences design using comprehensive small-area administrative data on clinically recorded mental health and related healthcare utilisation. We find adverse effects of Universal Credit exposure on population mental health: a 0.10 standard-deviation increase in clinically diagnosed depression prevalence and a 0.06 standard-deviation rise in antidepressant prescribing, alongside a smaller 0.03 standard-deviation increase in mental health-related hospital admissions and attendances. In natural units, these correspond to approximately 113,742 additional cases of diagnosed depression, 29,993 extra hospital admissions and attendances, and 1.29 million additional antidepressant prescriptions annually by 2018. Results are robust across specifications, sensitivity analyses, spatial aggregation, and alternative estimators. Because outcomes are measured at the small-area level, our estimates capture population-wide effects that combine direct impacts on Universal Credit recipients with spillovers to non-recipients. Indicative valuations imply sizeable associated quality-of-life losses and direct healthcare costs of approximately £2.84 billion per year. These findings show that welfare reforms can generate substantial mental health externalities, and that the health and healthcare-system consequences of social policy belong squarely within its design and evaluation.

Introduction: Universal Credit (UC) was a large-scale reform of the UK welfare system, replacing six existing benefits. UC aimed to simplify claims and encourage more claimants into work. Previous research has found evidence of harm to the mental health of recipients, potentially exacerbating existing health inequalities. We identify the effect of UC on self-reported measures of psychological well-being, treating the phased rollout from 2013 to 2018 as a natural experiment. Methods: We estimated differences in psychological well-being outcomes associated with the staggered introduction of the UC across local authorities, using areas where UC was not yet available as controls. We included working-age (aged 18–64 years) respondents of the Annual Population Survey in Great Britain from 2012 to 2019 (n=245 658), living in low-income households. We used the four self-reported measures of psychological well-being recorded in the survey: Life Satisfaction, Happiness, Life Worthwhile and Anxiety. We tested for differential effects by disability, age, caring responsibilities, sex, country, ethnicity, education and household structure. Results: UC was associated with per-claimant decreases in Life Satisfaction (−0.66; 95% CI −1.01 to −0.30), Happiness (−0.41; 95% CI −0.77 to −0.05) and Life Worthwhile (−0.73; 95% CI −1.03 to −0.42), and increases in Anxiety (+0.79; 95% CI 0.30 to 1.27). These changes were 2–6 times as large as the effects on well-being of the COVID-19 pandemic. Respondents in Wales and Scotland saw comparatively greater effects compared with those in England across several outcomes. UC exposure saw greater comparative increases in anxiety among people with disabilities (+0.19; 95% CI 0.12 to 0.27), single people (+0.13; 95% CI 0.06 to 0.21) and people aged under 25 years (+0.27; 95% CI 0.15 to 0.39). Conclusions: The introduction of UC had adverse effects across all four measures of well-being. Vulnerable groups typically experienced greater harms, reinforcing calls for reforms to UC to reduce the health and well-being impacts of poverty and unemployment.

We provide new evidence on the mental health and healthcare utilisation impacts of the roll-out of Universal Credit, one of the most significant welfare reforms in Europe in recent decades. Designed to simplify the benefit system and strengthen work incentives by merging six means-tested programmes into a single payment, Universal Credit also introduced features that may adversely affect mental health. Exploiting the plausibly exogenous, staggered geographical introduction of Universal Credit across England between 2013 and 2018, we implement a staggered difference-in-differences design using comprehensive small-area administrative data on clinically recorded mental health and related healthcare utilisation. We find substantial adverse effects of Universal Credit exposure: a 0.10 standard-deviation increase in clinically diagnosed depression prevalence, a 0.03 standard-deviation increase in mental health-related hospital admissions and attendances, and a 0.06 standard-deviation rise in antidepressant prescribing. In natural units, these correspond to approximately 113,742 additional cases of diagnosed depression, 29,993 extra hospital admissions and attendances, and 1.29 million additional antidepressant prescriptions annually by 2018. Results are robust across specifications, sensitivity analyses, spatial aggregation, and alternative estimators. Because outcomes are measured at the small-area level, our estimates capture population-wide effects that combine direct impacts on Universal Credit recipients with spillovers to non-recipients. Indicative valuations imply sizeable associated quality-of-life losses and direct healthcare costs of approximately £2.84 billion per year. These findings highlight that welfare reforms can generate substantial mental health externalities and underscore the importance of incorporating health and healthcare system consequences into social policy design and evaluation.

Background: The Education Maintenance Allowance (EMA) encourages people in low-income households to stay in education. It was abolished in England but continues in the rest of the UK (RUK). We investigated if the abolition of the EMA was associated with psychological distress using a difference-in-difference design. Methods: The sample of 1328 observations was drawn from Understanding Society participants aged 16/17 at the start of the academic years 2009–2018 and in the bottom income decile. Exposure to the EMA policy regime was identified using an interaction between the UK area (RUK vs England) and EMA policy period. The 2009/2010 academic years indicated the EMA period, 2011 the transition period (when EMA receipt was limited to existing recipients) and 2012–2018 post-EMA. The primary outcome was the General Health Questionnaire-12 (GHQ-12) score ranging 0–36. Other outcomes include the 12-item Short-Form Health Survey (SF-12) and a physical health falsification outcome. Linear regression using robust SEs, adjusting for sex and month of interview, was conducted. Results: In England, relative to RUK and the EMA period, the transition period (Coef 4.20; 95% CI 1.12 to 7.28) and the post-EMA period (Coef 2.89; 95% CI 0.67 to 5.11) were associated with worse GHQ-12 scores. Results for other mental health outcomes were similar, with no associations with the falsification outcome. Conclusions: Young people living in low-income households in England appeared to have worse mental health following the removal of the EMA, compared with RUK. However, it is not possible to rule out the potential contribution of cointerventions, such as the raising of mandatory age for education to 17 years in 2013 and 18 years in 2015.

Introduction Colonoscopy is the gold standard investigation of the bowel. Adequate cleansing is a prerequisite of a good quality examination. However, inadequate bowel preparation occurs in 20% of procedures, limiting the accuracy of the test. Predictive models devised by Dik et al and Gimeno-Garcia et al, stratified the risk of poor bowel preparation using a cumulative score. This study aims to assess the validity of these models using an independent cohort Methods Data generated from the EBOPS study was utilised. Adequacy was defined using the Boston Bowel Preparation Scale (BBPS), with a score of ≥ 2 in each segment. Each participant had a score derived from each predictive score, with high risk defined as a score ≥ 2 in the Dik et al score and ≥ 1.225 in the Gimeno Garcia score. Descriptive analyses, AUROC and an assessment of calibration were conducted between the models and the EBOPS independent cohort. Results 507 participants were included. 89 (17.5%) had inadequate preparation. 31% of the cohort had a Dik et al score ≥ 2 with a sensitivity of 46%, specificity of 71%, PPV of 29.7% and NPV 84% for poor preparation. 48% of the cohort had a Gimeno-Garcia score of ≥1.225 with a sensitivity for inadequate bowel preparation of 60%, specificity of 55%, PPV of 26% and NPV of 84%. AUROC was 0.71 for the Dik et al model and 0.7 for the Gimeno-Garcia model. Conclusions A similar performance of the predictive models is observed with this independent cohort, compared with the initial internal validation. The models do identify a cohort of patients at high risk of poor bowel preparation with a modest degree of discrimination, allowing a stratification of those at an elevated risk.

Objectives To assess sexual behaviour, and sexual and reproductive health (SRH) outcomes, after 1 year of the COVID-19 pandemic in Britain. Methods 6658 participants aged 18–59 and resident in Britain completed a cross-sectional web-panel survey (Natsal-COVID-Wave 2, March-April 2021), 1 year after the first lockdown. Natsal-COVID-2 follows the Natsal-COVID-Wave 1 survey (July-August 2020) which captured impacts in the initial months. Quota-based sampling and weighting resulted in a quasi-representative population sample. Data were contextualised with reference to the most recent probability sample population data (Natsal-3; collected 2010–12; 15 162 participants aged 16–74) and national surveillance data on recorded sexually transmitted infection (STI) testing, conceptions, and abortions in England/Wales (2010–2020). The main outcomes were: sexual behaviour; SRH service use; pregnancy, abortion and fertility management; sexual dissatisfaction, distress and difficulties. Results In the year from the first lockdown, over two-thirds of participants reported one or more sexual partners (women 71.8%; men 69.9%), while fewer than 20.0% reported a new partner (women 10.4%; men 16.8%). Median occasions of sex per month was two. Compared with 2010–12 (Natsal-3), we found less sexual risk behaviour (lower reporting of multiple partners, new partners, and new condomless partners), including among younger participants and those reporting same-sex behaviour. One in 10 women reported a pregnancy; pregnancies were fewer than in 2010–12 and less likely to be scored as unplanned. 19.3% of women and 22.8% of men were distressed or worried about their sex life, significantly more than in 2010–12. Compared with surveillance trends from 2010 to 2019, we found lower than expected use of STI-related services and HIV testing, lower levels of chlamydia testing, and fewer conceptions and abortions. Conclusions Our findings are consistent with significant changes in sexual behaviour, SRH, and service uptake in the year following the first lockdown in Britain. These data are foundational to SRH recovery and policy planning.

Background Contraceptive services were significantly disrupted during the COVID-19 pandemic in Britain. We investigated contraception-related health inequalities in the first year of the pandemic. Methods Natsal-COVID Wave 2 surveyed 6658 adults aged 18–59 years between March and April 2021, using quotas and weighting to achieve quasi-representativeness. Our analysis included sexually active participants aged 18–44 years, described as female at birth. We analysed contraception use, contraceptive switching due to the pandemic, contraceptive service access, and pregnancy plannedness. Results Of 1488 participants, 1619 were at risk of unplanned pregnancy, of whom 54.1% (51.0%–57.1%) reported routinely using effective contraception in the past year. Among all participants, 14.3% (12.5%–16.3%) reported switching or stopping contraception due to the pandemic. 3.2% (2.0%–5.1%) of those using effective methods pre-pandemic switched to less effective methods, while 3.8% (2.5%–5.9%) stopped. 29.3% (26.9%–31.8%) of at-risk participants reported seeking contraceptive services, of whom 16.4% (13.0%–20.4%) reported difficulty accessing services. Clinic closures and cancelled appointments were commonly reported pandemic-related reasons for difficulty accessing services. This unmet need was associated with younger age, diverse sexual identities and anxiety symptoms. Of 199 pregnancies, 6.6% (3.9%–11.1%) scored as ‘unplanned’; less planning was associated with younger age, lower social grade and unemployment. Conclusions Just under a third of participants sought contraceptive services during the pandemic and most were successful, indicating resilience and adaptability of service delivery. However, one in six reported an unmet need due to the pandemic. COVID-induced inequalities in service access potentially exacerbated existing reproductive health inequalities. These should be addressed in the post-pandemic period and beyond.