European Journal of Public Health

Objectives: Longer lifespans lead to longer time on retirement, despite the efforts to raise the retirement age. Therefore, it is important to study how the retirement years can be spent without diseases. This study examined socioeconomic and sociodemographic differences in healthy years spent on retirement. Methods: We followed a cohort of retired Finnish municipal employees (N=4231, average follow-up 15.4 years) on national administrative registers for major chronic diseases: cancer, coronary heart disease, cerebrovascular disease, diabetes, asthma or chronic obstructive pulmonary disease, dementia, mental disorders, and alcohol-related disorders. Median healthy years on retirement and age at first occurrence of illness (ICD-10 and ATC-based) in each combination of sex, occupational class, and age of retirement were predicted using Royston-Parmar models. Prevalence rates for each diagnostic group were calculated. Results: Most healthy years on retirement were spent by women having worked in semi-professional jobs who retired at age 60-62 (median predicted healthy years 11.6, 95% CI 10.4-12.7). The least healthy years on retirement were spent by men having worked in routine non-manual jobs who retired after age 62 (median predicted healthy years 6.5, 95% CI 4.4-9.5). Diabetes was slightly more common among lower occupational class women, and dementia among manual working women having retired at age 60-62. Discussion: Healthy years on retirement are not enjoyed equally by women and men and those who retire early or later. Policies aiming to increase the retirement age should consider the effects of these gaps on retirees and the equitability of those effects.

Background Heatwaves increasingly threaten public health in the Mediterranean region, and Greece is among the hardest hit countries. Yet evidence on long-term adaptation, spatial vulnerability, and the contribution of human-induced climate change to heatwave-related mortality in Greece remains limited. Methods We analysed 2,144,957 all cause deaths in Greece during 2000 and 2019 using a time stratified case crossover design. We derived population weighted daily maximum temperatures at NUTS3 level from ERA5 reanalysis and WorldPop. We applied six heatwave definitions (HD1-HD6) varying by duration (2 or 3 consecutive days or more) and thresholds (90th, 95th, 99th percentiles). We fitted Bayesian hierarchical Poisson models to estimate heatwave-mortality associations varying by space and time. We additionally adjusted for relative humidity and national. We then combined these estimates with probabilistic climate attribution methods to quantify the number and proportion of heatwave-related deaths attributable to human induced climate change. Results Heatwaves raised mortality consistently, with relative risks from 1.08 (95% CrI (Credible Interval): 1.07- 1.09; HD1) to 1.15 (1.11- 1.20; HD6). Risks increased with heatwave intensity and duration and peaked among females and adults aged 85 years and older. We did not detect a consistent temporal decline in risk or marked spatial heterogeneity. Human induced climate accounted for 51-94% of heatwave related deaths across definitions. The proportion attributable to climate change rose over time. Conclusions Heatwaves already impose a major mortality burden in Greece, with more than half driven by anthropogenic climate change and little evidence of population level adaptation. These findings call for rapid emissions reductions and targeted adaptation, including stronger heat health warning systems and protection of vulnerable groups.

Socioeconomic inequalities in health and well-being are a major public health concern, particularly in ageing populations. Education is a key determinant shaping multiple aspects of health outcomes. We used cross-sectional data from wave 9 of the German sample (n=4,148) of the Survey of Health, Ageing and Retirement in Europe (SHARE) to test whether formal education is associated with well-being in later adulthood, with health literacy, self-rated health, and preventive health behaviours as possible mediators. Our results showed that education was positively associated with greater well-being, but only via indirect pathways. Specifically, self-rated health, health literacy, and fruit and vegetable consumption mediated the relationship between education and well-being accounting for 54.7, 24.7, and 12.6 percent of the total effect, respectively. In addition, there were significant positive correlations between education and health literacy, as well as high-intensity physical activity, daily fruit and vegetable consumption, more preventive health check-ups, and less smoking. In contrast, alcohol consumption was more common among those with higher levels of education. All health behaviours and health literacy were correlated directly or indirectly (i.e., mediated by health) with well-being. These findings highlight the importance of examining indirect pathways linking education to well-being in later life. Interventions aimed at improving health literacy and promoting healthy behaviours may help reduce educational inequalities in quality of life among older adults.

Background Education outcomes predict life chances. However, poverty, ill-health and disability are barriers to achievement. We examined determinants of academic attainment of children with and without major congenital anomalies in state-funded mainstream schools at ages 11 and 16 (key stages [KS] 2 and 4). Methods and Findings Routinely collected electronic records for children born in Wales 01/01/1998-31/12/2007 until 31/12/2019 were linked in the Secure Anonymised Information Linkage (SAIL) Databank. Education outcomes were explored using logistic regression, adjusting for: anomalies, maternal and child deprivation, prescribing, hospitalisation, gestation length, childs sex, and special education needs (SEN) provision. Children with anomalies were less likely to achieve academic standards: however, attainment was more closely associated with affluence. At age 11, 81.87% (7167/8754) with and 93.80% (232,450/247,814) without anomalies passed (odds ratio [OR] 0.30, 95% confidence intervals [CI] 0.28-0.32). At age 16, 46.76% (2070/4427) with and 56.10% (69,732/124,300) without anomalies achieved 5 General Certificates of Secondary Education (GCSEs) at grades C-A* including English/Welsh, Maths and Science (EWMS) (OR 0.69, 0.65-0.73). Discrepancies narrowed in adjusted analyses, particularly when SEN provision was accounted: aOR 0.72 (0.66-0.78) at KS2, and aOR 0.93, (0.87-1.00) for 5 GCSEs C-A* with EWMS. These GCSEs were achieved by 29.65% (307/1034) children with anomalies and 38.42% (10,875/28,305) of unaffected children in the most deprived quintile{dagger}: in the most affluent quintile, figures were 67.57% (547/810) and 74.98% (16,978/22,644). Children with anomalies, receiving maximum SEN support, eligible for Free School Meals (FSM) were the least successful: 5/192 (2.6%) passed 5 GCSEs C-A* with EWMS, as did 37/354 (10.4%) ineligible for FSM. The strongest associations with these GCSEs were SEN statements (aOR 0.07, 0.06-0.07), FSM eligibility (aOR 0.39, 0.37-0.41), and epilepsy (aOR 0.60, 0.45-0.80). However, data were unavailable for 15-18% of children, mainly those educated outside mainstream schools, and some co-morbidities. Generalisation of findings to other countries rests with readers. Conclusions Many children with anomalies from affluent households succeeded. The children left behind lived with poverty and ill-health from congenital anomalies and/or epilepsy. SEN provision mitigated the impact of disadvantage, but poor children with anomalies were unlikely to succeed. {dagger}taking maternal Welsh Index of Multiple Deprivation (WIMD) 2014 at birth.

Abstract Objective: Frailty is an important concern in old age. Inflammation can cause frailty. Anti-inflammatory food supplements can play a role in slowing down frailty processes and consequences. This study explored the views of people (aged 50-89 years) on the need to develop a frailty supplement, preferences for its form and how older people could be encouraged to use such a supplement. Design: We conducted semi-structured qualitative interviews and used a framework method to analyse the data. Participants: 30 participants from a city in the UK. Setting: These participants were recruited from social housing, care homes, foodbanks and the wider population. Participants were from diverse ethnic, gender and age backgrounds. Results: Participants identified a strong need for the development of a food-based supplement for frailty. They expressed excitement for the supplement and viewed it as something which they would be happy to integrate in their daily food routine. In terms of preferences, our participants wanted to have multiple options, however, a biscuit-based supplement was preferred by most. The participants preferences were mainly based on taste of the supplement, its effectiveness, convenience in use and affordability. Muslim participants in the sample said they would be happy to use this supplement if it was developed using Halal ingredients. In terms of creating awareness and encouraging people to use the proposed supplement, participants suggested a variety of marketing methods. These included: word of mouth, face to face sessions with older adults, social media, especially YouTube and advertising on TV. Conclusion: The participants were generally open to the idea of a food-based supplement and felt that it could easily fit with their existing food practices and lifestyles. Keywords: older adults, frailty, food supplement, co-creation, healthy ageing

Background Diverse epigenetic clocks are known to capture health risks associated with increased adiposity, but their estimates have never been combined to represent a holistic estimate of biological age acceleration (BAA). There is also a gap in research using epigenetic clocks to study adiposity in lower-middle income Asian countries. Methods and Findings Data from 1,745 participants (21.7{+/-}0.3 years old, 45% female) of the Cebu (Philippines) Longitudinal Health and Nutrition Survey were analyzed. BAA was calculated using PCHorvath 2, PCHannum, PCPhenoAge, PCGrimAge, PCDNAmTL, and DunedinPACE. After ascertaining suitability for factor analysis (Kaiser-Meyer-Olkin 0.81), factor analysis was used to create PCFactorAge. Analogously, FactorAge was created using Horvath, Hannum, PhenoAge, GrimAge, DNAmTL, and DunedinPACE. BMI, waist circumference (WC), and waist-to-height ratio (WHtR) were used to represent adiposity. Linear regression was used to test the association of each adiposity measure with each BAA measure. BMI, WC, and WHtR were positively associated with both BAA combinations: 5 kg/m2 higher BMI corresponded to 0.097 (p=0.015) standard deviation (SD) increase in FactorAge and 0.099 (p=0.004) SD increase in PCFactorAge; 10 cm increase in WC--with 0.091 (p=0.005) SD increase in FactorAge and 0.094 (p<0.001) SD increase in PCFactorAge; 0.1 increase in WHtR--with 0.164 (p=0.001) SD increase in FactorAge and 0.163 (p<0.001) SD increase in PCFactorAge. Additionally, WHtR was associated with meaningful increases in PhenoAge, PCPhenoAge, PCHorvath 2, PCHannum, PCGrimAge, and DunedinPACE. WC was positively associated with PCHorvath 2, PCHannum, PCPhenoAge, and DunedinPACE. BMI was positively associated with PCHannum, PCPhenoAge, and DunedinPACE. Conclusions Our study presents a novel approach to creating a BAA estimate using multiple epigenetic clocks and shows that adiposity measures predict this factor in a young Filipino cohort.

Objective: To investigate in the National School Feeding Program (PNAE) the local level drivers and barriers to the implementation of four guidelines: the banning of sugary drinks; restrictions on the procurement of processed and ultra-processed foods; the mandatory increase in weekly servings of fruits and vegetables offered to students; and mandatory direct procurement from family farmers. Design: Qualitative study that used semi-structured interviews. Street level bureaucracy theory informed the theoretical framework and thematic analysis. Setting: Brazilian municipalities, across the country five geographic regions (North, Northeast, Southeast, South, and Midwest). Participants: Stakeholders (e.g. nutritionists, school cooks, and food procurement managers) involved in the local implementation of the PNAE program across the country. Results: Ninety stakeholders were interviewed. Stakeholders reported having autonomy to perform their activities, collaboration and support from other members within the local government and food providers, adequate infrastructure such as a well-equipped kitchens, the availability of trained personnel, and political commitment as drivers for optimum program implementation. Reported barriers included lack of support and resistance to change among cooks, teachers and parents; insufficient physical and human resources; and limited political commitment. When barriers outweighed drivers, interviewees reported adapting their practices, often in restrictive ways that could compromise the implementation of the program. Conclusions: Drivers and barriers to local PNAE implementation were generally similar across studied municipalities, although their magnitude varied. In contexts of greater economic vulnerability and fiscal constraint, additional support and targeted actions from the federal government may be required to strengthen local implementation

Background Childhood sensory and intellectual disabilities represent significant yet under-recognized barriers to learning and human capital development. This study analyzes prevalence and severity of these conditions among 149.3 million children aged 5-19 years across 25 countries in Latin America and the Caribbean (LAC) using Global Burden of Disease 2023 data. Methods We extracted GBD 2023 estimates for vision loss, hearing loss, and intellectual disability across 25 LAC countries, stratified by age, sex, and severity. Regional estimates were calculated using population-weighted averages. Severity distributions were compared with OECD countries to contextualize regional patterns. Results: These conditions are estimated to affected 9,282,921 children (6.22%; 95% UI: 5.89-6.54%). Hearing loss was predominant, affecting an estimated 5.42 million (3.63%, 3.41-3.86), with 87.6% mild-to-moderate. Intellectual disability estimated to affected 2.56 million (1.71%, 1.58-1.85), with 61.7% borderline-to-mild. Vision loss estimated to affected 1.30 million (0.87%, 0.79-0.96), with 89% that can be effectively addressed with spectacles. Prevalence increased with age across all conditions. Male predominance was consistent for intellectual disability (2.00% vs 1.42%). Annual economic cost totaled US$19.3-29.0 billion, while comprehensive interventions would require US$9.45-14.23 billion with benefit-cost ratios of 2:1 to 15:1. Conclusions The distribution of children across milder levels of difficulty underscores the opportunity for education and public health systems to provide timely and accessible support. With approximately 88% of sensory impairments addressable through established technologies, investments in inclusive services can yield strong social and economic returns.

Objectives: Accurate classification of menopausal stage is fundamental to midlife health research. Although the Stages of Reproductive Ageing Workshop (STRAW+10) criteria provide gold-standard criteria, their application in research settings is inconsistent. Classification challenges are compounded in individuals without observable menstrual cycles due to surgical or contraceptive-induced amenorrhoea. The Reproductive Ageing in Women (RAW) Questionnaire and accompanying classification Framework was developed and validated to improve consistency and inclusivity when classifying menopausal stage. Study design: A multi-phase study was conducted between May 2022 and July 2025. Phase one involved questionnaire development based on STRAW+10 and the Menopause-Specific Quality of Life Questionnaire. Phase two assessed content validity via expert review (n=3). Phase three evaluated face validity using think-aloud interviews and focus groups (n=14). Phase four validated RAW within a cross-sectional cohort study (n=156), and assessed construct validity (n=30), test-retest reliability (6-21 days; n=128; Kendall's Tau-b and Cohen's kappa), and biological validity using follicle stimulating hormone (FSH). Results: Feedback supported clarity, relevance and usability, with refinements improving inclusivity for surgical and contraceptive-induced amenorrhoea. Construct validity demonstrated consistent application of classification criteria. Questionnaire classification showed 93% concordance with self-identified menopausal status in the construct sample and 87.8% agreement within the cohort sample. Test-retest reliability was excellent ({tau}, p=0.940, p<0.001). Follicle stimulating hormone levels differed across RAW-classified stages (p<0.001), with 96.1% concordance between RAW pre and postmenopausal classifications and FSH thresholds. Conclusions: Prioritising menstrual characteristics while incorporating age and symptom criteria improves methodological consistency and inclusivity in menopausal stage classification. Longitudinal validation is warranted to assess temporal sensitivity across the menopausal transition.

IntroductionIncreasing global prevalence of overweight and obesity underscores the need for context-specific evidence to guide preventive policy implementation. Previous modelling showed that promoting healthy indigenous foods, implementing a 20% tax on sugar-sweetened beverages (SSBs), and introducing mandatory kilojoule menu labelling in formal-sector restaurants in Kenya were health-promoting, cost-saving, and cost-effective. Cost-effectiveness evidence is strengthened when considered alongside broader policy implementation considerations. We engaged stakeholders to assess additional implementation considerations relevant to decision-makers and to evaluate the stakeholder engagement process used in the modelling study. MethodsUsing the Assessing Cost-Effectiveness approach, we conducted a stakeholder-engaged study with national-level Kenya stakeholders recruited through purposive and snowball sampling. Through deliberative dialogue at a hybrid workshop, stakeholders assessed implementation considerations such as equity, feasibility and sustainability using a colour-coded scoring tool. We evaluated the engagement process using an anonymous survey covering seven stakeholder-engaged research domains. We analysed responses thematically. ResultsAcross the three interventions, most implementation considerations for feasibility, reach and impact, affordability, acceptability, and sustainability were assessed as medium or high. Industry acceptability of kilojoule labelling and SSB tax and affordability of kilojoule labelling to industry were rated low. Equity scores varied. Stakeholders proposed complementary measures that could raise low ratings to favorable scores. Clarity on stakeholder roles was identified as a key strength of the engagement process, while competing time commitments limited participation. ConclusionStakeholder insights contextualise prior cost-effectiveness evidence within policy-relevant implementation considerations and inform current fiscal and regulatory debates. Evaluation of the stakeholder engagement process underscores its contribution to strengthening public health research.

BackgroundEvidence on the long-term impact of urban green and blue spaces (UGBS) interventions remains limited. This study is a 15-year evaluation of an urban greenway development in Belfast (United Kingdom), assessing the potential effects of this UGBS intervention on physical activity (PA), mental wellbeing and co-benefits. MethodsUsing quasi-experimental design, a repeated cross-sectional survey was conducted in 2010 (baseline), 2017 (post-opening) and 2023 (long-term follow-up) with about 1,200 adults participated each wave. Outcomes included PA, mental wellbeing, general health, quality of life, social capital and environmental perception. Multilevel mixed-effect regressions were performed to examine within-group changes at long-term follow-up. Difference-in-differences analysis investigated the between-group changes that might be attributed to the greenway. Additional comparative analyses included distance-decay analysis and comparison with population trends in Northern Ireland. ResultsAt six years after completion, the greenway intervention appears to buffer a decline in duration of PA - mainly from moderate-intensity activity (decline lower by 118.6 min/week, 95%CI: 3.9-232.2) but with no significant impact on the proportion of the population meeting the recommended PA level. The intervention is associated with a smaller decline in self-rated health (4.98 units; 95%CI: 0.62-9.34) relative to control group. Intervention association with mental wellbeing was positive but not significant (p=0.30). The greenway also showed positive effects on social capital and environmental perceptions, with impacts most evident in improving safety and trust in the local area. ConclusionThis study provides evidence to support the public health impact of UGBS and its long-term health and social benefits.

Background: Understanding the underlying mechanisms for differences in vaccine uptake between migrants and non-migrants is crucial in order to design targeted interventions encouraging vaccination and to ensure vaccine-related equity. Therefore, this study examined to what extent migration-related disparities in COVID-19 vaccination were associated with psychological factors, based on the established 5C model of vaccine behaviour (Confidence, Complacency, Constraints, Calculation, Collective Responsibility). Methods: Data were obtained from the German study "Corona Monitoring Nationwide - Wave 2" (RKI-SOEP-2 study), which was carried out between November 2021 and March 2022. The association between COVID-19 vaccination and migration status, while considering the psychological factors, was investigated using multivariable binary logistic regressions. A decomposition analysis (Karlson-Holm-Breen method) was conducted to examine the extent to which migration-related disparities in vaccine uptake were associated with the psychological factors of the 5C framework. Results: Migrants were less likely to be vaccinated against COVID-19 compared to non-migrants, especially participants from the Middle East and North Africa (MENA) region. Our decomposition showed that almost two-thirds of the disparities in COVID-19 vaccine uptake between migrants and non-migrants were associated with the psychological factors (first-generation: 61.2%, second-generation: 64.2%). Confidence in safety of the vaccine was the most relevant factor in the 5C framework. Furthermore, the results highlighted the importance of a differentiated analysis regarding country of origin: While the 5C model accounted for only 19.4% of the difference between participants from the MENA region and non-migrants, the proportion for participants from Eastern Europe was 73.5%, suggesting that the underlying mechanisms for the lower uptake in the MENA group need further investigation. Conclusions: Overall, migration-related disparities in COVID-19 vaccination were significantly associated with differences in psychological factors of vaccine behaviour. To increase vaccine acceptance within the heterogeneous group of migrants in general, tailored and proactive health communication interventions are needed.

Background: The two-child benefit cap, implemented in April 2017, restricted Universal Credit and Child Tax Credit to the first two children in households with three or more children. We evaluate the impact of the two-child benefit cap on parental mental, general, and financial health, as well as investigate how this may differ in particular sociodemographic and economic subgroups based on sex, ethnicity and income. Methods: Data was obtained from parents (youngest child aged 5 or under) in the UK Household Longitudinal Survey from 2009 to 2023. Outcomes included parental mental health (psychological distress and life satisfaction), general health (health-related quality of life (HRQoL), self-rated health and health satisfaction), and financial health (current financial situation and financial outlook). We used complementary policy evaluation methods with different strengths and assumptions to triangulate evidence and strengthen inference: interrupted time series (ITS), difference-in-differences (DiD) and controlled time series analysis (CITS). Subgroup analyses were stratified by sex, ethnicity, and income. Findings: Across methods, findings consistently indicate that the policy worsened life satisfaction, self-rated health, health satisfaction, and financial health for parents of 3+ children. Findings were less consistent across methods for psychological distress and HRQoL. For instance, for psychological distress ITS and CITS indicate adverse impacts of the policy; however, one DiD model did not support this conclusion due to greater average worsening in the control group between the pre- and post-periods. Subgroup analyses indicate greater mental health and general health impacts in lower income, male and ethnic minority parents; while financial health was negatively impacted in all subgroups examined. Conclusions: Using repeated cross-sectional panel data and triangulating across causal inference methods, we conclude that the two-child benefit cap in the UK had a measurable adverse impact on most health outcomes examined, with worse outcomes for male, lower income and ethnic minority parents.

Objectives Concerns about COVID-19 were a key driver of infection-prevention behaviour during the pandemic. The aim of this study was to gain an in-depth longitudinal understanding of the type and frequency of concerns experienced throughout the first two years of the COVID-19 pandemic. Design Content analysis of qualitative descriptions provided in a prospective longitudinal online survey as part of the COVID-19 UK Public Experiences (COPE) Study. Method At baseline (March/April 2020), when the UK entered its first national lockdown, 11,113 adults completed the COPE survey. Follow-up surveys were conducted at 3, 12, 18 and 24 months. Participants were recruited via the HealthWise Wales research registry and social media. Baseline surveys collected demographic and health data, and all waves included an open-ended question about COVID-19 concerns. Content analysis was used to identify the type and frequency of concerns at each time point. Results A total of 41,564 open-text responses were coded into six categories: personal harm (n=16,353), harm to others (n=11,464), social/economic impact (n=6,433), preventing transmission (n=4,843), government/media (n=1,048), and general concerns (n=1,423). The proportion of respondents reporting any concern declined from 75.3% at baseline to 65.8% at 24 months. Over time, concerns about personal harm increased (baseline 41.8% vs. 24-months 52.7%) whereas concerns about harm to others decreased (baseline 48.5% vs. 24-months 28.6%). Concerns about harm were also expressed in relation to clinical vulnerability, lack of trust in government/media, and perceived lack of adherence by others. These were balanced against concerns about wider social and economic impacts of restrictions. Conclusions Public concerns about COVID-19 evolved substantially over the first two years of the pandemic, reflecting changing perceptions of risk and responsibility. Monitoring concerns longitudinally is vital to help guide effective communication and behavioural interventions during future pandemics.

Background: Parental diabetes and obesity influence offspring phenotype, but their relative contributions remain unclear. Aim: To examine the relative contributions of parental diabetes and obesity to offspring overweight-obesity and glucose intolerance. Methods: We studied 200 offspring of mothers with diabetes in pregnancy (ODM; 176 indexes, 24 siblings), 176 mothers (133 gestational diabetes (GDM), 22 type 1, 21 type 2 diabetes), and 150 fathers. Controls included 177 offspring of non-diabetic mothers (ONDM), 177 mothers without diabetes in pregnancy, and 163 fathers. Overweight-obesity was defined by WHO criteria, central obesity as waist-to-height ratio >0.5, and glucose intolerance by ADA criteria (fasting glucose for <10 years; oral glucose tolerance test (OGTT) for >=10 years). Generalized linear mixed-effects models assessed parental determinants of offspring outcomes. Results: ODM were more overweight-obese, centrally obese, and glucose intolerant than ONDM. Younger ODM had higher capillary glucose (5.6 vs 5.1 mmol/L, p<0.001). Among ODM >=10 years, 37% had prediabetes and 5% diabetes versus 20% and 0% in ONDM. Overweight-obesity was associated with maternal (OR 7.81; 95% CI 2.19-27.85), paternal (OR 6.21; 95% CI 1.57-24.53), and biparental obesity (OR 9.59; 95% CI 2.73-33.69), but not parental diabetes. Glucose intolerance was associated only with maternal diabetes in pregnancy (OR 3.90; 95% CI 2.05-7.41). Conclusions: Preventing offspring obesity will require addressing parental obesity, whereas preventing glucose intolerance will require optimal glycemic control in the mothers before and during pregnancy.

BackgroundWomens autonomy in healthcare decision-making has become one of the most critical yet inequitably distributed determinants of health outcomes, gender equity, and sustainable development worldwide. In Northern Nigeria, the presence of ethnic and socio-cultural inequality is frequently concealed by the aggregated statistics of a region. MethodsThis cross-sectional secondary analysis utilized the 2024 Nigeria Demographic and Health Survey. The sample included 9,998 married women (15-49 years) identifying as Hausa, Fulani, or Kanuri in Northern Nigeria. Healthcare autonomy was categorized as husband/partner alone, respondent alone, or joint decision-making. Analysis included weighted descriptive statistics, Rao-Scott adjusted chi-square tests for residential associations, and complex sample multinomial logistic regression to identify multivariable correlates while adjusting for sampling weights, strata, and clusters. ResultsMean age was 30.38 years. Most participants lacked formal education (69.6%) and resided in rural areas (72.0%). Husband-only decision-making predominated (72.6%), while 22.5% reported joint and 4.9% independent autonomy. Joint decision-making was significantly higher in urban (33.3%) than rural areas (18.3%; Adjusted F=50.892, p<0.001). In adjusted models (Reference: Kanuri), Hausa and Fulani women had substantially lower odds of joint decision-making relative to husband-only outcomes. Rural residence correlated with lower odds of both independent and joint agency. Notably, wealth status was not a significant predictor after adjustment (p > 0.05). ConclusionsEthnicity and residence are robust determinants of healthcare autonomy among women in Northern Nigeria, persisting regardless of education or wealth. This "socio-cultural paradox" suggests that economic interventions alone are insufficient. Policies must complement socioeconomic approaches with culturally responsive strategies addressing household power dynamics and entrenched social norms.

BackgroundThe rapid growth of the worlds urban population has contributed to the expansion of informal urban settlements in many cities across the world. In these settings, lack of safe sanitation combined with high population density and poverty contributes to heightened health risks for often vulnerable populations. The aim of this study was to evaluate the effect of a shared, onsite sanitation intervention on the nutritional status of children in Maputo, Mozambique. MethodsThe Maputo Sanitation (MapSan) trial was a controlled before-and-after study to evaluate the effect of a shared, onsite sanitation intervention on child health in Maputo, Mozambique. Here, we report the effects on childhood stunting, wasting and underweight, and height-for-age, weight-for-height and weight-for-age z-scores. Children were enrolled aged 1-48 months at baseline and outcomes were measured before and 12 and 24 months after the intervention, with concurrent measurement among children in a comparable control arm. The primary analysis was intention-to-treat. The trial was registered at ClinicalTrials.gov, number NCT02362932. ResultsWe enrolled 757 and 852 children in the intervention and control groups respectively. There was no evidence for an effect of the intervention on any outcome at 12 or 24 months of follow-up except for wasting where there was very weak evidence for an effect (adjusted prevalence ratio: 0.497; 95% CI: 0.22-1.11; p=0.09). In two exploratory analyses - one including only those children born into compounds post-intervention and a second excluding children in control compounds which had independently improved their sanitation facilities during follow-up - we found that stunting increased in the intervention group whilst wasting decreased. ConclusionsThis study contributes to the growing evidence on the role of sanitation in shaping child health outcomes in informal urban settlements. We found no evidence for an effect on stunting and weak evidence for an effect on wasting. More research is needed to understand how sanitation can reduce childhood undernutrition in complex urban environments.

HighlightsO_LIHealth inequalities have widened over 15 years, favouring high-income groups C_LIO_LIInequality in physical activity & mental health widened the most pre-intervention C_LIO_LIPost-intervention, inequalities persisted but stayed relatively unchanged. C_LIO_LILong-term illness and unemployment were key drivers of inequality C_LIO_LIThe greenway may have slowed down the inequality widening but the impact is limited C_LI BackgroundEvidence concerning health inequalities following urban green and blue space UGBS) interventions is limited. This study examined the changes in health inequalities after a major urban regeneration project, the Connswater Community Greenway (CCG), in Belfast, UK. MethodCross-sectional household surveys were conducted in 2010/11 (baseline), 2017/18 (immediately after completion), and 2023/24 (long-term follow-up) with a sample of approximately 1,000 adults each wave. Using concentration indices (CI), income-related health inequalities for three outcomes (physical activity, mental wellbeing and quality of life) were measured. A regression-based decomposition of concentration index examined the contribution of sociodemographic factors to the observed inequalities underpinning each outcome over time. ResultsAcross three waves, there was widening of inequalities over the 15-year period across all three health outcomes, with those from high-income groups reported higher levels of physical activity (CI=0.33, SE=0.026), better mental wellbeing (CI=0.03, SE=0.003), and better quality of life (CI=0.09, SE=0.008). The widening inequalities mainly occurred during the construction phase of CCG (2010-2017) and remained stable post-intervention (2017-2023). Decomposition analysis revealed that the pro-poor concentration of long-term illness and unemployment was the key driver that together explained approximately 51%-76% of the inequalities. ConclusionThe CCG was limited in reducing health inequalities which were mainly driven by long-term illness and unemployment - factors beyond the direct scope of the UGBS intervention - resulting in low-income groups likely to fall further behind the wealthier groups. The widening of inequality is consistent with findings from other public interventions that did not have a primary equity focus.

BackgroundDrowning remains a major global public health challenge. This study examined whether the timing and trajectories of urbanisation--beyond the current built environment--are associated with subnational drowning mortality. MethodsWe linked satellite-derived measures of built-environment change (GHSL), population crowding (WorldPop), surface water exposure (JRC Global Surface Water), and infrastructure proxies (VIIRS/DMSP nighttime lights) to GBD 2021 drowning mortality estimates across 203 ADM1 regions in 12 countries (2006-2021; 3,248 region-year observations). Temporal predictors captured recent expansion, development "newness" ([&le;]10-year built share), acceleration/volatility, and a crowdingxgrowth interaction. We screened predictors using LASSO (10-fold cross-validation) and fitted mixed-effects models with region random intercepts. Distributed-lag models tested temporal precedence and development age, and income-stratified models assessed heterogeneity. ResultsAdding temporal predictors improved fit beyond contemporaneous built-environment measures ({Delta}AIC=177; {Delta}BIC=147). In adjusted models, crowdingxgrowth was strongly positively associated with drowning mortality, and a higher share of recent development was associated with higher mortality. Lag models showed a development age gradient: older built environment was most protective. Associations differed by income group, with several key coefficients reversing sign across strata. DiscussionDrowning mortality appears shaped by development histories as well as present-day conditions, with risk concentrated in rapidly changing, dense settings and the newest built environments. Cross-context heterogeneity suggests mechanisms and prevention priorities are unlikely to be uniform. ConclusionsDevelopment timing and trajectories help explain subnational drowning mortality beyond current built form alone. Prevention and planning should prioritise transition-period safety strategies in newly developing and rapidly densifying areas.

Background Non communicable diseases (NCDs) are significant public health concerns in Bangladesh, placing a heavy burden on the healthcare system. While the situation before COVID-19 was well-documented, it is unclear how the pandemic has impacted the prevalence and risk factors of these diseases. This study provides the first comparative assessment of the prevalence and determinants of diabetes mellitus (DM) and hypertension (HTN) before and after the pandemic, utilizing comprehensive multilevel data source and mixed-effects modeling to capture the shifting epidemiological burden. Methods We analyzed biomarker data from two nationally representative Bangladesh Demographic and Health Surveys (BDHS) 2017-18 and 2022. Diagnosis followed WHO guidelines for fasting blood glucose and blood pressure. Mixed-effect logistic regression models were employed to identify risk factors while accounting for the hierarchical survey design. The Intra-class Correlation Coefficient (ICC) was calculated to quantify the proportion of variance attributable to unobserved community-level heterogeneity. Results The study indicates a profound shift in the national burden of NCDs. Diabetes prevalence more than doubled, from 23% in 2017-18 to 49% in 2022, while hypertension prevalence declined from 22% to 15%, a pattern that may reflect survival bias among individuals with severe comorbidities. The previously strong bidirectional association between DM and HTN weakened in the post pandemic period, hypertension continued to predict diabetes (AOR = 1.17), but diabetes was no longer a significant predictor of hypertension. Community-level determinants became substantially more influential, with local environmental factors playing a much larger role in shaping diabetes prevalence compared to the pre-pandemic period. Urban residence emerged as a significant new risk factor for diabetes in 2022 (AOR = 1.62; 95% CI: 1.34-1.96). Furthermore, the socioeconomic gap in diabetes risk narrowed as the disease affected more wealth groups, while higher educational attainment continued to serve as a protective factor against hypertension (AOR = 0.64; 95% CI: 0.54-0.75). Conclusion The post pandemic landscape of NCDs in Bangladesh shows a clear divergence, marked by a rapid increase in diabetes contrasted with a stabilization in hypertension prevalence. Through comparative mixed effects modeling, this study advances beyond simple prevalence comparisons to demonstrate the growing impact of urban environments and community level factors on metabolic health. These evolving patterns underscore the need for integrated public health strategies that address emerging environmental risks and geographically specific vulnerabilities to support progress toward Sustainable Development Goal Target3.4. Keywords: Bangladesh, BDHS, Community-level variability, COVID 19, Diabetes mellitus, Hypertension, Mixed-effects modeling, Non-communicable diseases, Public health