BMJ Public Health

Background Chemsex, drug use before/during sex to facilitate and enhance the experience, is undertaken by a minority of gay, bisexual and other men who have sex with men (GBMSM), but evidence of chemsex prevalence in England is limited. This study describes trends in chemsex prevalence between 2022-2025 and identifies factors associated with chemsex amongst GBMSM in England. Methods Data from the RiiSH study (2022-2025), an annual online cross-sectional survey of GBMSM recruited through social networking/dating apps and community partners, were analysed. Trends in chemsex prevalence and adjusted prevalence were estimated using log-binomial regression models. The following seven variables were candidate factors associated with chemsex and were assessed through logistic regression: age, sexual orientation, education, employment, HIV status, HIV PrEP use, and sexual health service (SHS) use. Results 5728 GBMSM were included in this study. Adjusted chemsex prevalence varied from 6.1% in 2022 to 4.2% in 2023, 5.1% in 2024 and 6.8% in 2025. Chemsex was more likely in GBMSM who were: gay (aOR=1.57 versus other sexual orientations; 95%CI 1.11-2.29, p=0.01), unemployed (aOR=3.08 versus employed full-time; 95%CI 2.19-4.26, p<0.001); aged 35-59 versus 16-34 years (p<0.001), with recent HIV PrEP use (aOR=3.79 versus no recent use; 95%CI 2.63-5.56, p<0.001), SHS use (aOR=2.23 versus no recent use; 95%CI 1.76-2.83, p<0.001), and living with HIV (aOR=3.16 versus negative/unknown HIV status; 95%CI 2.43-4.09, p<0.001). Conclusions Chemsex prevalence was low and stable between 2022-2025. PrEP and SHS use were associated with chemsex, supporting integration of specialist support services within SHS.

Background: Health visiting in England is a universal service designed to identify family need and offer more support where needed (proportionate universalism). We know little about how local areas deliver services for families facing adversity or their associated outcomes. Methods: Using linked Community Services Data Set and Hospital Episode Statistics data (2018-20) for 57/152 areas, we (a) described health visiting service delivery for children whose mother had a previous hospital admission with mental health issues, alcohol/substance misuse or violence/abuse recorded (study definition of adversity), (b) identified common service delivery patterns using latent class analysis; and (c) tested whether patterns were associated with child and maternal outcomes, overall and in terms of inequalities for families facing adversity. We conducted four experts-by-experience workshops to aid interpretation. Results: Three service delivery patterns for families facing adversity emerged, distinguished primarily by the intensity and age-distribution of contacts. In areas where health visiting was delivered with a high intensity across the whole 0-5 years age range (rather than targeted primarily at babies), children were more likely to meet expected levels of development at age 2-2.5 years (ORadj: 0.79, 95% CI:0.63-0.99) and child inequalities in injury-related hospital admissions and some developmental domains were reduced. Conclusions: We found that a pattern of health visiting aligned with proportionate universalism was associated with mitigating disadvantage for families facing adversity. With limited outcomes and forms of adversity captured in our study, we cannot say which service delivery pattern is best, but our findings evidence the potential of health visiting to reduce inequalities.

Background: Rising rates of young people Not in Education, Employment, or Training (NEET) in the UK have recently coincided with declining youth physical and mental health but no study has asked whether this reflects a growing proportion of young people with health problems (prevalence) or those with health problems becoming more likely to be NEET (penalty). Methods: Using 15 years of Understanding Society data (2009-23), we analysed 15,242 respondents aged 16-24 (66,160 observations). We employed three complementary approaches: descriptive trends, Blinder-Oaxaca-Kitagawa (BO) probit decomposition comparing 2009-2013 and 2019-2023 against a 2014-2018 reference period, and fixed-effects (FE) Poisson models with lagged health status. Exposures included self-reported health conditions or disability (SRHD), psychological distress , diagnosed conditions and socio-demographic factors. Findings: NEET rates were lowest in 2014-18 (10.5-11.5%) and higher in 2009-13 (12-15%) and 2019-23 (15-16%). Higher prevalence of SRHD, psychological distress, diagnosed depression and multimorbidity explained changes in NEET prevalence across both the 2009-13 to 2014-2018 and 2014-18 to 2019-23 periods. No change in penalty was observed for any health variable across periods, except for an increase in the penalty for SRHD between the 2009-13 to 2014-18 periods. Interpretation: Rising NEET rates among UK youth are driven largely by more young people having physical and psychological ill health. Whilst labour market and education accommodations remain important, reducing NEET rates will require reversing the decline in youth health, not just accommodating it.

Objective To measure the accuracy of clinical coding, clinician review, and a locally deployed large language model (LLM) in identifying alcohol, drug, and self-harm involvement in emergency department (ED) attendances, and quantify prevalence. Design Two-phase diagnostic accuracy study. In a validation week, the identification strategies were assessed against a conflict-adjudicated reference standard (n=2,256); the LLM was then applied to n=105,096 annual attendances at the same site. Setting UK Type 1 Emergency Department treating patients [&ge;]16yrs. Main outcome measures Prevalence quantification compared with the reference standard; sensitivity, specificity, and balanced accuracy of each strategy; monthly identification rates and adjusted annual prevalence. Results The reference standard identified 12.1% of attendances as involving alcohol, drugs, or self-harm (coding 6.0%; clinician 10.0%, LLM 15.6%). LLM balanced accuracy matched or outperformed clinician review in all three domains (alcohol 0.942 v 0.930, p=0.635; drug 0.959 v 0.791, p<0.001; self-harm 0.982 v 0.908, p=0.004). Coding recorded 1.07 domains per identified patient against 1.32 in the reference standard. Adjusted annual prevalence corresponded to 12,890 domain involvements per year not identifiable in coded data. Subdomain classification found at least 81.6% of self-harm attendances required medical assessment for injury or overdose before psychiatric review. Conclusions Clinical coding identified fewer than half of presentations involving alcohol, drugs, and self-harm and rarely captured co-occurring domains; under-recording was present across a full year. A locally deployed LLM generated more complete structured data from existing clinical text within NHS infrastructure, at a scale which is not feasible for manual review.

Sex workers remain disproportionately affected by HIV and mental health distress because their access to prevention and support services is shaped by stigma, criminalisation, violence, poverty, unequal client power, fear of disclosure and negative healthcare encounters. These pressures are particularly visible in district-level settings where sex workers must balance unstable income, personal safety and healthcare needs. A qualitative research design was used. Participants were recruited through purposive and snowball sampling. Twenty unique participants took part in the study: five participated in individual semi-structured interviews and 15 different participants attended two focus group discussions comprising seven and eight participants, respectively. No individual interview participant attended a focus group discussion. Participants were aged 18 years or older and lived or worked in the West Rand District. The interviews and focus group discussions were audio-recorded, transcribed verbatim and analysed through reflexive thematic analysis informed by Braun and Clarkes six-phase process, with data organisation supported by NVivo. Six themes were developed: sex work as economic survival rather than simple choice; HIV prevention under conditions of unequal client power; healthcare access shaped by stigma, fear and lack of confidentiality; mental health distress as part of everyday sex work; peer educators as trusted bridges to care; and the need for inclusive and differentiated support. HIV prevention and mental health support were interconnected through poverty, client negotiation, clinic mistrust, emotional distress and reliance on peer-led services. Economic insecurity, client power, stigma, weak confidentiality and psychological distress constrained access to HIV prevention and mental health support services. Peer educators facilitated access through information, referrals, emotional support and clinic navigation. Services should therefore be integrated, confidential, stigma-free and responsive to diverse gender identities, sexual orientations and sex-work settings.

Abstract Objective To describe variation in hospital costs among children with different combinations of health conditions, special educational needs or disability (SEND) and children social care (CSC) indicators. Study Setting and Design This cross-sectional study used regression analysis to test whether two-way and three-way interactions of cross-public sector service use (health, education and social care) are associated with higher hospital costs in England. Data Sources and Analytic Sample Hospital care costs between April 2022 and March 2023 for the 8.9 million children aged 5-18 years were obtained from linked administrative hospital, education or social care data in the ECHILD database. Children were classified into eight categories based on combinations of indicators of chronic health conditions, SEND or CSC. Principal Findings Over one-third (35.4%) of children had some hospital costs during the year. Average costs were 317GBP for all children and 895GBP for children with non-zero hospital costs. By age 18, few children had no indicator in any sector (35.1% of boys, 43.7% of girls) and indicators in all three sectors were not rare (7.1% of boys, 6.2% of girls). At age 5, children with indicators recorded in all three sectors had the highest hospital costs (2,952GBP for boys and 3,674GBP for girls). At age 18, males and females with indicators in all three sectors accounted for 21% and 23% of hospital costs, respectively. SEND and social care indicators without chronic health conditions were associated with only slightly higher hospital costs. Hospital costs were much higher for children with SEND if they also had a chronic health condition. Hospital costs were only higher for children with social care if they also had both a chronic health condition and SEND. Conclusions. Taking account of additional support from non-health sectors is important for understanding health sector costs. The compounding associations between use of other public sectors on health sector costs indicates scope for targeting of integrated care.

Background Community-led interventions for female sex workers (FSW) can improve HIV prevention and treatment outcomes by lowering self-stigma and strengthening social cohesion to improve service uptake. In Zimbabwe, the AMETHIST intervention trial integrated peer-led microplanning with self-help groups for FSW and demonstrated improved HIV treatment outcomes. We investigated the role of social cohesion and self-stigma in explaining these findings. Method We conducted a mixed-method analysis of data collected during AMETHIST. We re-analysed qualitative data from interviews and group discussions to identify narratives linking self-stigma, engagement with microplanners and/or self-help groups and HIV service use. We analysed quantitative data from endline respondent-driven sampling surveys for differences in self-reported measures of social cohesion and self-stigma between trial arms, and between those who did and did not participate in intervention activities or access services. Results In both arms, FSW self-reported engaging with peer supporters, participating in self-help groups and accessing HIV services. Qualitative narratives suggested peer support and group participation could reduce self-stigma and support service uptake. Lower levels of self-stigma were seen in the intervention arm (58.6% vs 63.2%; aOR 0.77; 95% CI 0.61-0.86). Social cohesion exceeded 50% across the whole sample, but was not associated with study arm, nor with engagement in intervention-related activities. Discussion Although qualitative data suggested some FSW felt their uptake of services was influenced by intervention components, quantitative analyses did not suggest either variable was on the causal pathway to the outcomes of the intervention. A limitation may have been the measurement of these complex constructs and the high levels of social cohesion across both study arms.

Background Preventing sexually transmitted re-infections brings health benefits and can be significantly less costly than treating their sequelae. Safetxt is a potential novel digital intervention developed to promote safer sexual behaviours. However, a recent randomised controlled trial of safetxt found no effect on reinfection at 1 year (OR 1.13, 95%CI: 0.98-1.31). We investigated if safetxt's effect was mediated through sexually risky behaviours. Methods We used data from 6248 young people with STIs from 92 UK sexual health clinics. The direct and indirect effects of safetxt on reinfection were estimated using the counterfactual approach. Condom use at last sexual encounter, number of sexual partners and STI testing were assessed as mediators. These were analysed singly and together, using regression models and a formal weighting approach. The assumptions of each approach were considered and tested. Analyses were repeated in the subgroup showing the most promising effect of safetxt: men who have sex with men or with men and women (MSM/MSMW). Results No evidence was found for the total, indirect or direct effects differing from the null. Despite not being significant, for MSM/MSMW, some of safetxt's effect on reducing reinfection was identified as being offset through its effect on number of sexual partners. Conclusions There was no evidence that safetxt's effect on reinfection was mediated through changes in sexually risky behaviours. Adaptations to specifically target these behaviours are unlikely to improve safetxt's overall effect. However, improving safetxt's effect on the number of sexual partners a participant has may improve its effect for MSM/MSMW.

Background: High rates of young people who are not in education, employment or training (NEET) are a major societal concern in the UK. Whilst other studies have highlighted that adolescent health can predict NEET status in young adulthood, robust and recent longitudinal evidence remains limited. Methods: This study used data from the Millennium Cohort Study, a longitudinal study of people born in the UK in the early 2000s, to estimate the extent to which mental health conditions, physical health conditions and health behaviours during adolescence predict NEET status in early adulthood (median age: 23). Co-occurrence of exposures was also considered and population attributable fractions were calculated to account for differences in exposure prevalence. Results: Among 8,374 young people, 12.5% were NEET at age 23; approximately two thirds were seeking work and one third were economically inactive. Estimates adjusted for demographic factors indicated that multiple health exposures increased risk of being NEET at age 23, with mental health conditions predicting greater risk than physical health conditions and health behaviours. For instance, a longstanding mental health condition more than doubled the risk of being NEET (adjusted relative risk [aRR] = 2.39, 95% CIs = 1.85, 3.09), while autism (aRR = 3.60, 95% CIs = 2.69, 4.83) and ADHD (aRR = 3.25, 95% CIs = 2.38, 4.44) more than tripled the risk. A greater number of reported adolescent mental health conditions was associated with greater risk of being NEET in young adulthood. Obesity predicted being NEET at age 23 (aRR = 1.54, 95% CIs = 1.18, 2.01) and obesity accompanied by a mental health condition further increased risk (aRR = 2.01, 95% CIs = 1.38, 2.93). Follow-up analyses indicated that associations between adolescent mental health and young adult NEET status were more pronounced for females than males and for the economically inactive than those seeking work. Conclusions: Findings indicate that adolescent health, especially mental health, strongly predicts being NEET in early adulthood. Early, integrated health and education interventions may help reduce later educational and labour market disengagement.

Background: Maternal postpartum checks with a general practitioner (GP) are recognised as an essential service in England and vital for recovery after pregnancy and reducing risk of long-term morbidity. Despite this, its reported fewer than of women have a record of the examination in the recommended 6-8 weeks, with observed disparities in uptake nationally. The impact of the COVID-19 pandemic disrupted delivery of these checks nationally, but there is limited data on the impact of the pandemic and its recovery for regional populations representing diversity and areas of dense poverty and ethnic minority populations. This study utilised region level data to assess the impact of COVID-19 on postnatal care. Methods: Anonymised electronic health records with clinical coded birth events for females, aged 16-49 years, were analysed for patients registered with a GP using the Greater Manchester Care Record (GMCR) between January 2018 and August 2023. Unique delivery episodes were defined and monthly rates calculated separately for women with a postnatal-related code within 4-, 6-, 8-, or 12-weeks or 1 year follow-up. Rates were also generated by key maternal demographics to assess any differences in postpartum care. Interrupted time series, modelling the onset of the pandemic estimated the IRR of 0.49 (95% CI 0.40-0.58). To assess the impact of maternal characteristics on the odds of non-attendance at examination, a logistic regression adjusting for various maternal characteristics was fitted. Results: There were 114,874 unique delivery episodes, relating to 85,076 women in the 12-week follow up cohort; 72,595 episodes to 55,784 women in 8-weeks and 28,846 episodes to 24,018 women in 6-weeks. The rate of postpartum checks was greater the longer the follow-up period. For checks within 8 weeks the first lockdown reduced from ~325 per 1000 delivery episodes in 2019 to 225 per 1000 by April 2020 (30.8%), which remained low, before returning to pre-pandemic rates by rates by October 2022. Rates remained lower overall for Black, or Asian women compared to White. Conclusion: The COVID-19 pandemic reduced postnatal follow-up in primary care across Greater Manchester, with rates frequently falling outside the recommended 6-8 week window. Significant disparities exist in the provision and uptake of these services. Improved integration of data across care sites, combined with enhanced risk management, could increase equity in access and support the timely delivery of care for those at greatest risk of postnatal complications and longer-term health issues.

Background Population-level administrative data cohorts hold huge potential for generating evidence to improve child health. Understanding the quality of these data is critical to enabling us to fully realise this potential. We aimed to evaluate linkage between children's health, education and social care administrative records (ECHILD) to identify possible sources of bias. Methods We created four cohorts to understand the drivers of inclusion/exclusion within ECHILD. For each cohort, we calculated the linkage rate by counting the total number of eligible individuals who appeared in the ECHILD linkage spine and any of the corresponding hospital/school component datasets. We then assessed whether linkage rates varied according to sociodemographic characteristics (year of birth, sex, ethnicity, region). Results ECHILD currently captures 34.2 million patients and 25.3 million pupils born between September 1984 and March 2023, aged 0-38 years. Over 90% of children with hospital birth records linked to a school record (rising to 93% for those born from 2014 onwards); 88% of children attending school in 2001/02 linked to a patient record (rising to 96% for those born in 2019/20), resulting in a total of 21 million linked individuals. Substantial variation existed between sociodemographic groups, with those living in London, residing in more deprived areas, or with recorded ethnicity other than White being less likely to be included. Conclusions Population-level datasets such as ECHILD often under-represent specific groups. Irrespective of the mechanisms by which individuals are excluded (e.g. opt outs, linkage errors or not interacting with services), those in minoritised ethnic groups and those living in more deprived areas are most affected. Linkage evaluations are critical for understanding who is and who is not included in analyses of these data so that researchers can account for potential sources of bias within analyses.

Purpose Despite the high documented prevalence of hunger and poor mental health in adolescent girls and young women (AGYW) in South Africa, this relationship remains understudied, with existing studies limited by their cross-sectional designs. This longitudinal study aimed to identify the association of hunger trajectories with anxiety and depressive symptoms, and hope in AGYW. Methods We used secondary data from the HIV Prevention Trials Network (HPTN) -068 conducted in rural Agincourt, South Africa. Complete data from 1779 AGYW collected at baseline (2011/12) and three annual follow-up visits were used. Hunger trajectories, measured using the Household Hunger Scale, were estimated via Group-Based Trajectory Modelling. Self-reported incident anxiety and depressive symptoms and hope were assessed based on AGYWs last two follow-up visits. Covariate adjusted modified Poisson regression models estimated the association between hunger trajectories and incident anxiety symptoms, incident depressive symptoms, and hope. Results Moderate-severe hunger was prevalent in 11.0%, 10.8%, and 6.0% of the households at baseline, follow-up 1, and 2, respectively. Incident anxiety symptoms were reported by 4.5%, incident depressive symptoms by 20.0% and hopelessness by 52.8% of the AGYW. Two hunger trajectories were identified- no hunger (82%) and marginal hunger (18%). Hunger trajectories were not associated with incident anxiety symptoms [RR:1.09, 95% CI: 0.55, 2.18], incident depressive symptoms [RR: 0.97; 95% CI: 0.72, 1.33] nor hope [RR: 1.00; 95% CI: 0.81, 1.23] in AGYW. Conclusion Better understanding of the factors that promote resiliency and mental health of AGYW in this setting is warranted to inform the design of interventions.

Background: Young people who are Not in Education, Employment, or Training (NEET) represent a major public health and societal challenge. Existing evidence has linked adolescent mental health problems and health risk behaviours to NEET but has largely treated NEET as a static, rather than longitudinal outcome and overlooked the combined effects of multiple health conditions. Methods: Using data from 5,262 participants born between 1993 and 2000 in the UK Household Longitudinal Study, this study examined the independent and combined associations of adolescent mental health problems (emotional symptoms, conduct problems, hyperactivity) and health risk behaviours (regular smoking, drug use, alcohol use, and high social media use) with ever-NEET status, NEET chronicity, and NEET trajectories from ages 16 to 24, using modified Poisson, proportional odds, and multilevel logistic regression models, respectively. Findings: All mental health problems were associated with ever-NEET status (RRs 1.24-1.27) and NEET chronicity (ORs 1.41-1.98); emotional symptoms showed a widening disadvantage with age, while the disadvantages associated with conduct problems and hyperactivity remained stable. Among health risk behaviours, regular smoking showed the strongest and most persistent relationships with NEET (ever-NEET RR 1.54; chronicity OR 1.64); drug use was related to ever-NEET status (RR 1.37) and an increasing disadvantage after age 21-22, while alcohol use and social media use showed limited associations. NEET risk generally increased with the number of co-occurring conditions, but for recurrent NEET (three or more occasions), risk was only elevated at three or more co-occurring conditions. Interpretation: Adolescent health exposures were associated with NEET risk during ages 16-24, but the strength and pattern varied by exposure and outcome, offering potential insights into the timing and emphasis of any interventions.

Background Alcohol is a leading modifiable risk factor for non-communicable disease. Zambia's National Alcohol Policy and the World Health Organization's target of a 10% relative reduction in the harmful use of alcohol both require that the trend be monitored. Alcohol items appear in four rounds of the Zambia Demographic and Health Survey (ZDHS), and those rounds are widely treated as a trend series, although whether they are one has never been tested. Methods Secondary analysis of ZDHS 2007, 2013-14, 2018 and 2024 (women aged 15-49, men aged 15-59). A direct current-use item is available in three rounds, with three different instruments for men and two for women. Four identification strategies were applied in ascending order of assumption: nesting bounds, which exploit the fact that a seven-day window falls within a thirty-day window and that within undated current status; restriction to the fieldwork months common to both rounds; a lifetime-use analogue available in 2024; and an instrument-constant partner-report series available in all four rounds, validated by linking each woman to her co-resident husband. Estimation throughout was design-based. Results The conventional series suggests a fall in current drinking among men from 42.0% (95% CI 39.9-44.1) in 2007 to 28.2% (95% CI 27.0-29.3) in 2024, and among women from 11.1% (95% CI 9.9-12.4) to 8.8% (95% CI 8.0-9.6). Neither change is sign-identified. Placed on a common thirty-day basis with matched fieldwork months, the 2013-14 to 2024 change lies between -7.6 and +1.2 percentage points for men and between -0.2 and +3.7 for women. The instrument-constant proxy fell from 53.7% in 2007 to 37.7% in 2018, then plateaued at 37.0% in 2024; a constant-decline model is rejected (Q = 15.9, 2 df, p = 0.0003). Sensitivity of the proxy against husbands' own reports fell from 86.0% to 66.8%. The 2024 cross-section is unaffected and is reported in full. Conclusions These data do not establish the apparent national decline in alcohol use. Differences in reported prevalence across ZDHS rounds substantially reflect instrument change, reference-period shift, fieldwork seasonality and decay in proxy reporting. On present evidence Zambia cannot monitor its alcohol commitments from national survey data. Trend monitoring would require a consistent alcohol module restored to the questionnaire, an occasion-based heavy-drinking item, and the reporting of fieldwork month.

Background Adolescents and young adults (AYAs) from key and priority populations face persistent challenges with sustained engagement in HIV pre-exposure prophylaxis (PrEP) care. While PrEP initiation has expanded across sub-Saharan Africa, evidence on long-term retention and determinants of disengagement among AYAs remains limited. We examined time to PrEP disengagement and associated factors among AYAs initiating PrEP in eastern Uganda. Methods We conducted a retrospective longitudinal analysis of routinely collected program data for AYAs aged 15-29 years from key and priority populations who initiated PrEP between 2019 and 2025 at Mbale Regional Referral Hospital. Time to PrEP disengagement was assessed using Kaplan-Meier survival analysis and Cox proportional hazards regression. Multivariable models adjusted for sociodemographic, relational, behavioral, and service delivery factors. Sensitivity analyses redefined the time origin to day 91 following PrEP initiation to reflect the programmatic 90-day grace period. Results Among 3,553 AYAs initiating PrEP, the median time to disengagement was 284 days (95% CI: 273-295). The median age was 24 years (interquartile range [IQR]: 20-26). The probability of remaining engaged in PrEP care declined from 60.1% at 90 days to 20.2% at 365 days. Survival patterns differed significantly by population category and sex at birth but not by age group. In adjusted analyses (N = 3,391), knowledge of a partners HIV status (aHR = 2.04; 95% CI: 1.82-2.29) and initiation through community-based services (aHR = 1.42; 95% CI: 1.17-1.72) were associated with faster disengagement. Married participants had lower hazards of disengagement compared with single participants (aHR = 0.69; 95% CI: 0.64-0.76). Reporting an STI syndrome (aHR = 0.42; 95% CI: 0.32-0.55) or recent gender-based violence (aHR = 0.76; 95% CI: 0.60-0.96) was associated with reduced disengagement. Findings were highly consistent in sensitivity analyses using an alternative risk-period definition. Conclusions PrEP disengagement among AYAs occurs rapidly following initiation, with substantial attrition within the first year. Relational factors, service delivery modality, and population-specific vulnerabilities strongly shape retention trajectories. These findings underscore the need for risk-responsive, differentiated PrEP delivery strategies that strengthen partner-based services, integrate STI and GBV screening, and adapt retention support for AYAs in community and facility settings.

BACKGROUND: Sexual pleasure is integral to sexual health, offering important physical and mental benefits. Yet, sex education programs often neglect pleasure, focusing instead on preventing sexual risk behaviors (SRBs), which young adults are particularly vulnerable to. AIM: This study investigates the association between SRBs and sexual pleasure in young adults and whether sex assigned at birth moderates this relationship. METHODS: Embedded within the Generation R cohort, 1010 young adults completed an online questionnaire assessing sexual pleasure using the six subscales of the Amsterdam Sexual Pleasure Inventory (ASPI 1.0), Arousal Enjoyment, Enjoyment-Related Self-Efficacy, Enjoyment-Related Self-Worth, Interaction Enjoyment, Bonding Enjoyment, and Sexual Experience Enjoyment, and various SRBs including sexual debut <15 years, six or more lifetime partners, frequent unprotected sex, and substance use during sex. Multiple linear regression analyses were performed for each SRB and sexual pleasure subscale, adjusting for demographics, self-esteem, relationship status, socioeconomic status, and psychopathology, with additional stratification by sex assigned at birth. OUTCOMES: The primary outcome measure is sexual pleasure, measured across six domains, examined in relation to SRBs. RESULTS: Fully adjusted regression analyses showed that engaging in SRB was positively associated with several dimensions of sexual pleasure. All SRBs were associated with higher Enjoyment-Related Self-Efficacy (ERSE) scores (p<0.002). Early sexual debut was additionally linked to higher Interaction Enjoyment scores, while having six or more lifetime partners was associated with increased Enjoyment-Related Self-Worth and Sexual Experience Enjoyment scores (p<0.002). Some associations, particularly involving ERSE, were only significant among males. Individuals without partnered sexual experience reported lower sexual pleasure scores. CLINICAL IMPLICATIONS: Incorporating sexual pleasure into sex education could promote a more balanced, realistic understanding of sexuality among young adults, emphasizing both enjoyment and responsible sexual decision-making. STRENGHTS & LIMITATIONS: Key strengths of this study are the use of the multidimensional Amsterdam Sexual Pleasure Inventory (ASPI 1.0) and the large population-based cohort study design, enabling a nuanced and generalizable analysis. This study is limited by potential selection and reporting bias, the cross-sectional design, residual confounding, and the absence of universally agreed-upon thresholds for defining SRBs. CONCLUSION: These findings suggest there is a positive association between engagement in SRB and sexual pleasure, possibly reflecting greater overall sexual experience. The stronger associations observed among males might reflect gendered differences in the role of self-esteem and societal expectations.

Introduction People with severe mental illness (SMI) and learning disabilities (LD) experience significant health inequalities, with diet-related conditions contributing substantially to early and preventable death. Despite high levels of nutritional risk, the presence and effectiveness of nutritional screening in mental health (MH) and LD settings remains under-researched. This study aimed to investigate nutritional screening practices in UK inpatient MH and LD services from the perspectives of dietitians. Methods A cross-sectional mixed-methods study was conducted using a novel 22-question online survey. Data was collected via the British Dietetic Association Mental Health Specialist Group (April-June 2025). Quantitative data was analysed descriptively and qualitative data by reflexive thematic analysis. Findings were integrated and presented thematically. Ethical approval was granted by Teesside University (2025Mar26544). Results Forty-seven dietitians participated, most with substantial dietetic experience, from a range of MH settings. Screening practices were widely established and supported by policy and audit. However, participants reported low confidence in screening translating into meaningful patient care. Barriers to screening included appropriateness of available tools, time constraints, difficulty engaging distressed patients and poor prioritisation of physical health. Digital integration and wider infrastructure were also important. Dietitians rarely undertook screening directly, instead holding secondary or leadership roles, while screening was most often completed by nursing staff who were often perceived to place limited importance on the process. Existing tools, particularly the Malnutrition Universal Screening Tool (MUST), were viewed as insufficiently capturing the broader nutritional risks relevant to MH/LD populations, leading some services to adopt bespoke, unvalidated tools. Conclusion Concerns regarding the suitability of existing nutritional screening tools in MH/LD settings are consistent with previous literature. However, we suggest cautious use of unvalidated bespoke tools. Whilst there was no clear front runner, MH specific tools such as the St Andrews Nutrition Screening Instrument (SANSI) and the NutriMental Screener warrant further evaluation. Importantly, findings indicate that optimising tool choice alone is unlikely to improve screening effectiveness. Nutritional screening must be embedded within clear care pathways, supported by organisational leadership, digital infrastructure, and multiprofessional engagement to move beyond procedural completion and support meaningful clinical action to improve patient care.

People with narcolepsy experience delays in diagnosis and inconsistent post-diagnosis care, but the pattern and scale of their healthcare use is poorly described. In this population-based cohort study, we used primary care and linked hospital activity data to compare healthcare use in people with narcolepsy (n=2,772) and a matched comparison group in England (n=13,860). Narcolepsy was defined by a first coded record in primary care or admitted care data between 02 January 1998 and 31 December 2019; this date was the index date for both groups. People with narcolepsy had approximately double the rate of healthcare use in the period from five years before to five years after the index date. Annually, this corresponded on average to an additional 1.9 (95% confidence interval (CI) 1.8-2.0) outpatient events, 0.36 (95% CI 0.30-0.42) admitted patient care events, 0.25 (95% CI 0.22-0.29) Accident & Emergency events and 4.3 (95% CI 3.9-4.7) primary care events per person. Service use in all settings peaked at index and remained elevated for at least 15 years either side. The elevated rates of possible-sleep related outpatient events (respiratory, neurology paediatric, and ear nose & throat) peaked in the year including and after the index date, at 1.50 (95% CI 1.41-1.59); before declining to <0.5 visits per person-year after five years. Our findings of sustained elevated use of healthcare by people with narcolepsy across NHS settings may reflect diagnostic delay, comorbidities, and ongoing narcolepsy-related healthcare needs being met largely outside specialist sleep care, highlighting opportunities to improve healthcare services.

Background: The first thousand days are a sensitive window for child health and social health inequalities. When routine care falls short, parents of young children turn to online sources and, recently, to generative artificial intelligence (AI). Evidence on their concerns, child-health literacy, and AI use is scarce. Objective: To describe health informational needs and concerns, child-health literacy, and use of AI for child-health questions, including differences by parental role and parity, among parents of young children. Methods: In this cross-sectional study, two anonymous self-administered online questionnaires were disseminated through a digital health application between May 12 and June 11, 2026, to French-speaking parents of at least one child aged 0 to 47 months in France. Questionnaire 1 covered unmet information needs, concerns across 16 topics, perceived intra-couple concordance, and confidence in routine care. Questionnaire 2 covered a four-item child-health literacy quiz and AI use (frequency, topics, 12-month trend, barriers, trust conditions, perceived effect on consultations, and disclosure). Results: In total, 12,634 parents responded (Questionnaire 1, n=5,410; Questionnaire 2, n=7,224), mostly mothers (94.6% and 92.9%). Most (61.8%) had searched for information without finding a clear, reliable answer, selecting a median of 4 (Interquartile range [IQR] 3-7) over 16 topics. Leading concerns were sleep (51.3%), nutrition (48.1%), and education (i.e., upbringing and behavior) (47.8%). Mothers were nearly twice as likely as fathers to select accident prevention (26.5% vs 16.3%) and parental mental health (38.7% vs 28.6%); first-time parents selected most topics more often than experienced parents, most markedly dental hygiene (43.8% vs 27.6%). The median child-health literacy score was 3 (IQR 3-4) on a 0-to-4 quiz, with 19.9% of parents scoring 2 or below; tooth-brushing age was the weakest item (68.4% correct). Mothers outscored fathers on every item. More than half of parents (54.2%) had used AI for a child-health question, 11.2% weekly; among those reporting a trend, 68.3% had increased AI use for child-health questions over the year and 6.2% decreased it. The main barriers to AI use were a preference for professionals (55.9%) and reliability concerns (48.7%); trust depended most on medical oversight of the tool (76.6%). AI use appeared additive, with 66.8% reporting no change in healthcare visit frequency. One third (35.5%) had told an AI something shared with neither a professional nor their network, rising to 64.1% among regular users. Conclusions: Parental informational needs were widespread and frequently unmet. AI has become a common and fast-rising source for child-health questions, at times a confidential one, used alongside rather than instead of professionals. Child-health literacy was generally high but uneven, with oral health the clearest gap. Strengths include the sample size and early-generative-AI timing; limitations include the cross-sectional design, self-report, digital-recruitment selection bias, and the small proportion of fathers.

Abstract Background: HIV self-testing (HIVST) has been promoted as a strategy to reach individuals who do not access facility-based testing. However, evidence on whether HIVST leads to more frequent testing among women of reproductive age in Uganda remains limited. This study evaluated the impact of HIV self-testing on recent HIV testing among women using nationally representative data. Methods: Data were drawn from the 2022 Uganda Demographic and Health Survey (UDHS), including 6,438 women aged 15-49 years. The primary outcome was recent HIV testing, defined as having tested for HIV within the 12 months preceding the survey. The treatment variable was ever having used HIV self-testing. Propensity score matching (PSM) with 1:1 nearest neighbour matching (caliper = 0.05) was used to balance observed covariates including parity, media exposure, education, residence, wealth quintile, health insurance, and age group. The average treatment effect on the treated (ATT) was estimated. Results: Among 6,438 women, 23.87% (1,537) reported ever using HIV self-testing. Recent HIV testing was observed in 67.4% of HIVST users compared to 47.4% of non-users (unmatched difference = 20%). After matching, HIVST use increased the likelihood of recent testing by 15.6 percent (ATT = 15.6%; SE = 0.052; t = 2.99). Covariate balance was achieved post-matching, with mean bias reduced from 20.5% to 0.7%, and the B statistic falling from 50.4% to 2.5% (below the 25% threshold). All standardized differences were substantially reduced, with education showing perfect balance (100% reduction) and wealth showing 97.6% reduction. Conclusion: HIV self-testing significantly increases recent HIV testing among women of reproductive age in Uganda. Expanding access to HIVST, particularly for women with lower education, those in poorer wealth quintiles, and those without media exposure, could improve testing frequency and support progress toward the UNAIDS 95-95-95 targets.