Health & Place

Urban mobility may provide insight into population health by capturing how residents connect to services, resources, and urban systems. This is relevant for communities facing higher disease burden and limited resources, where reduced connectivity may signal barriers to care, healthy environments, and participation. Mobility patterns are furthermore shaped by socioeconomic position, housing, environmental quality, facilities access, lifestyle patterns, and population composition. Mobility-health associations may therefore reflect underlying social and environmental disadvantage rather than mobility itself, risking misdirected public-health policy responses. This ecological cross-sectional study examined associations between aggregated mobile phone-based mobility and health outcomes in The Hague, Netherlands, from January-July 2019. Mobile phone mobility was measured as mean outgoing mobility distance across eight regions. Contextual and health indicators were available at neighbourhood-level and were aggregated or linked to regions where required. Health outcomes were operationalised as indicators of disease burden, including cardiometabolic medication prescriptions, polypharmacy, and a syndemic-based measure of interacting health conditions. Contextual domains were selected using spatial clustering and ordinary least squares models, after which residual mobility-health associations were assessed. Outgoing mobility varied across regions and was strongly patterned by contextual factors. Lifestyle, housing, physical environment, and income accounted for 73.2% of variance in outgoing mobility. After adjustment, residual mobility showed weak, non-significant associations with cardiometabolic medication prescription, polypharmacy, and the syndemic-based measure. Sensitivity analyses supported these findings. Aggregated mobility should not be interpreted as a straightforward independent determinant of health. Instead, it appears to function as an integrative marker of urban context, spatial structure, and population composition.

Summary Background: Spatial variation in heat-related mortality remains poorly understood, particularly at fine geographical scales. We conducted a nationwide small-area study to examine the association between spatial variation in heat-related mortality and environmental, demographic, health, and socio-economic factors. Methods: We obtained daily all-cause mortality data for people aged [≥] 65 years during the summers of 2011-2023 and linked them with municipality-level daily temperature estimates from the ERA5-Land reanalysis dataset. We applied a two-stage Bayesian hierarchical model to estimate small-area heat-related mortality and assess the contribution of community characteristics to spatial variability. Findings: Heat-related mortality showed marked geographical differences, with the highest rates in southern and southeastern Italy. Across municipalities, the relative risk at the 90th temperature percentile, relative to the minimum mortality temperature, ranged from 1.06 to 1.33. The heat-attributable fraction exceeded 6% in several southern municipalities, while excess mortality surpassed 8 deaths per 1,000 inhabitants in parts of the Po Valley, Tuscany, Apulia, and Sicily. National heat-attributable mortality peaked in 2022, with an estimated 17,828 deaths (95% credible intervals: 17,339, 18,285) among older adults. Municipalities with higher average temperatures, less green space, higher obesity prevalence, and more residents aged [≥] 85 years had higher heat-related mortality. Educational attainment and employment were among the strongest modifiers of spatial variation. Interpretation: Our findings highlight substantial small-area differences in heat-related mortality across Italy and identify socio-economic deprivation as a key determinant of vulnerability. Heat is likely to disproportionately affect disadvantaged communities, reinforcing the need for adaptation strategies addressing social inequality. Funding: Imperial College Research Fellowship; Italian Ministry of Health PNC (CUP J55I22004450001); NIHR Imperial Biomedical Research Center (BRC NIHR203323).

Greenspace has been associated with a wide range of health outcomes and conditions related to functional limitation and disability. Yet less is known about how the spatial morphology of greenspace relates to disability prevalence across different stages of the life course. This study examines associations between greenspace morphology and disability prevalence among children, working-age adults, and older adults in urban census tracts across the contiguous United States. Using national land-cover data, we quantified morphological metrics at the census-tract level, including greenspace percentage, density, mean size, connectedness, shape complexity, inter-greenspace distance, and diversity. These indicators were linked with age-specific disability prevalence obtained from the American Community Survey. Spatial lag regression models were used to account for spatial dependence while adjusting for socio-demographic and contextual characteristics. Across age groups, higher greenspace percentage was consistently associated with lower disability prevalence (children: {beta} = -0.081, 95% CI: -0.096 to -0.066; adults: {beta} = -0.804, -0.858 to -0.750; older adults: {beta} = -1.132, -1.250 to -1.013). Among children, patch density ({beta} = -0.045, -0.061 to -0.029), mean patch area ({beta} = -0.029, -0.040 to -0.018), connectedness ({beta} = -0.051, -0.069 to -0.032), diversity ({beta} = -0.036, -0.051 to -0.020), and inter-greenspace distance ({beta} = 0.056, 0.039 to 0.073) were all associated with disability prevalence, whereas shape complexity was not ({beta} = 0.004, -0.010 to 0.018). Among working-age adults, associations were observed for mean area ({beta} = -0.023, -0.090 to -0.002), connectedness ({beta} = -0.127, -0.243 to -0.011), shape complexity ({beta} = -0.123, -0.174 to -0.072), diversity ({beta} = -0.146, -0.201 to -0.091), and inter-greenspace distance ({beta} = 0.151, 0.059 to 0.242), whereas patch density was not significantly associated with disability prevalence ({beta} = -0.013, -0.048 to 0.022). In older adults, all examined greenspace morphology metrics showed significant associations with disability prevalence, including patch density ({beta} = -0.445, -0.842 to -0.049), diversity ({beta} = -0.126, -0.188 to -0.065), and inter-greenspace distance ({beta} = 0.455, 0.409 to 0.501). Overall, the findings suggest that higher greenspace percentage, larger patch size, greater connectedness, greater diversity, and more spatially clustered greenspace distributions are associated with lower disability prevalence across the life course, although the strength and consistency of these associations varied across age groups. The study provides national-scale evidence for incorporating greenspace morphology into urban planning and public health strategies to support more inclusive and health-supportive urban environments.

Ambient temperature is emerging as an environmental factor that may influence cognitive performance in ageing populations. This is particularly relevant in Australia, where people live across diverse climatic regions spanning alpine to tropical conditions. We examined daily temperatures and cognitive performance in 1,873 midlife and older adults (1,297 women, mean age 61.0 years) who completed the Creyos online battery (formerly Cambridge Brain Sciences). Twelve tasks assessed memory, visuospatial processing, language, attention, and executive function. Task scores were linked to postcode-level contemporaneous weather data. The scores were analysed in relation to maximum and minimum air and wet-bulb temperatures and postcode- and month-relative temperature percentiles. Regression models adjusted for age, sex, education, socioeconomic status, and climate zone, with season included for air and wet-bulb measures. Higher minimum, but not maximum, temperature was associated with poorer performance on Paired Associates, a task assessing associative memory. This pattern was observed for air temperature, wet-bulb temperature, and temperature percentile, suggesting poorer memory performance after warmer nights, both in absolute terms and relative to local seasonal norms. Temperature was not significantly associated with performance on any other task, including measures of short-term/working memory, visuospatial processing, language, attention, or executive function. These findings suggest a task-specific association between higher overnight temperature and poorer associative memory performance, rather than a general reduction in cognition. Further studies incorporating personal exposure and sleep measures are needed to clarify whether night-time thermal conditions affect cognitive health in midlife and older populations.

Climate change draws attention to the planetary health perspective in sport and exercise sciences, that is, to physical activity that supports both human wellbeing and environmental sustainability. Active commuting is a sustainable form of physical activity with well-established somatic health benefits. However, more knowledge is needed on its relationship with mental health. We examined dose-response associations between active commuting, anxiety symptoms, and mental wellbeing among Finnish adults, and whether green commuting environment moderates these relationships. We used data from the cross-sectional Environment and Health Survey collected in June-September 2023 in the ten largest cities in Finland. Employed participants with data on anxiety symptoms (Generalized Anxiety Disorder-7, GAD-7), mental wellbeing (World Health Organization-Five Well-Being Index, WHO-5), commuting profile over a year (mode, frequency, distance, and perceived greenness along the commute route), and sociodemographic and lifestyle factors were included (n=1,672; mean age 45.3 years; 53.8% women). Active commuting was defined as travelling the entire commute by walking or cycling (including e-biking) that was converted into approximated annual km/week and MET-h/week. We used linear and logistic regression with restricted cubic splines to evaluate dose-response associations, adjusted for key covariates. The role of perceived greenness was tested using an active commuting x commute greenness interaction term. We found no dose-response relationships between active commuting and anxiety symptoms or mental wellbeing in any of the models. No effect modification by commute greenness was observed. More research on how active commuting may support planetary health from a mental health perspective is needed.

Residential greenness has been associated with reduced heat-related illness, yet the specific role of greenspace morphology at the neighborhood scale remains insufficiently understood. This study quantified the relationship between heat-related illness and multiple dimensions of greenspace morphology using an eight year (2016-2023) unbalanced panel dataset comprising 19,021 block group year observations across 2,427 census block groups in Arizona, USA. One meter high resolution National Agricultural Imagery Program aerial imagery was classified to calculate greenspace percentage, number of greenspaces, average size, shape complexity, connectedness, and distantness, at the block group level. We applied conditional spatial autoregressive models with a negative binomial distribution to estimate associations between each morphology metric and yearly heat-related illness counts, adjusting for sociodemographic and geographic covariates. We found higher greenspace percentage, aggregation, shape complexity, connectedness, and density were consistently associated with lower heat-related illness risk. A one standard deviation increases in shape complexity corresponded to a 12.4% decrease in expected heat-related illness counts (IRR=0.876, 95% CI: 0.834-0.921). Similarly, increases in greenspace percentage (14.6% decrease; IRR=0.855, 95% CI: 0.827-0.885), number of greenspace patches (3.7% decrease; IRR=0.963, 95% CI: 0.937-0.990), average size (4.5% decrease; IRR=0.955, 95% CI: 0.923-0.989), and connectedness (5.5% decrease; IRR=0.945, 95% CI: 0.918-0.972) were all protective. In contrast, larger inter greenspace distances were associated with increased heat-related illness risk (6.1% increase; IRR=1.061, 95% CI: 1.033-1.091). Our findings highlight the critical importance of multiple dimensions of greenspace morphology in mitigating heat-related health risks. These results suggest that heat reduction planning with greening initiatives should consider not only the amount of greenspace but also its spatial configuration to maximize cooling and result in health benefits.

Background: Urban environmental and lifestyle factors during early life may influence pubertal timing, but the combined effects of multiple environmental exposures within an exposome analytical framework remain poorly understood. Objective: To examine the association between early-life urban environmental exposures and pubertal timing, and to explore whether these exposures interact with early-life nutritional factors, namely breastfeeding duration and childhood diet quality. Methods: Data from two European population-based birth cohorts were analysed: Generation XXI (G21, Portugal; n=5263; 51.5% girls) and INfancia y Medio Ambiente (INMA, Spain; n=1019; 50.1% girls). Urban environmental exposures including indicators of air pollution, traffic, built environment, and natural spaces were estimated at 4 early-life stages at both cohorts: pregnancy (INMA only), birth, 1 year, and 4-5 years of age. Pubertal development timing was assessed using Tanner staging and/or the Pubertal Development Scale (PDS), and age at menarche was self-reported. Exposome-Wide Association Study (ExWAS) models and unsupervised clustering followed by ordinal logistic regression models were used to examine single- and multi-exposure associations, respectively. Regression models were fitted adjusting for relevant child characteristics, maternal factors, and household socioeconomic conditions, and corrected for multiple testing. Results: Individuals living in more unfavourable urban environments characterised by higher building density, air pollution, and lower access to natural spaces showed earlier pubertal timing according to multiple outcomes, across multiple early-life exposure periods, and in both cohorts. In the G21 cohort, these environmental profiles were associated with earlier age at menarche, particularly for exposures at 1-1.5 and 4-5 years (e.g., 1-1.5y: {beta}=-0.172, FDR-adjusted p-value=0.041), while in the INMA cohort, boys exposed to more unfavourable environmental profiles showed more advanced pubertal development, also particularly for exposures at 1-1.5 and 4-5 years of age (e.g., 1-1.5y; {beta}=0.572, FDR-adjusted p-value=0.008). Among environmental domains, air pollution and traffic were the factors most consistently associated with pubertal timing. Regarding early-life nutritional factors, longer duration of exclusive breastfeeding was associated with a lower Tanner stage among girls in G21. No significant interactions between breastfeeding duration and environmental exposure clusters were observed. Conclusion: Early-life urban environmental exposures, particularly air pollution and traffic, may influence pubertal timing. Exclusive breastfeeding may have a protective role against earlier pubertal development. These findings highlight the importance of improving urban environmental conditions and promoting breastfeeding to support healthy developmental trajectories.

Background: Climate change is an escalating global health threat, with sub-Saharan Africa disproportionately affected due to entrenched spatial inequalities, high exposure to environmental hazards, and limited adaptive capacity. Increasingly frequent extreme weather events (EWEs), including floods and cyclones, are reshaping the material and social conditions of place, with implications for mental health and wellbeing. However, evidence remains limited, particularly multi-country qualitative research that examines how mental health impacts are produced through lived experiences of place in contexts of recurring environmental disruption and structural vulnerability. This study explored the mental health and wellbeing impacts of EWEs among individuals with lived experience of such events in Mozambique, Burkina Faso, South Africa, and Kenya, using participatory methods that centred community narratives and place-based accounts of everyday life. Methods: This qualitative study employed digital storytelling as a participatory visual method to examine how EWEs are experienced and narrated across diverse socio-spatial contexts. A total of 37 participants (8 to 10 per country) were recruited from rural, peri-urban, and informal urban settlements with recent exposure to flooding or cyclone events. Participants produced digital stories during facilitated five-day workshops. These narratives were analysed using inductive and deductive thematic analysis informed by Braun and Clarke's framework, with attention to the spatial and relational production of distress and coping. Results: Across Mozambique, Burkina Faso, South Africa, and Kenya, findings show that the mental health impacts of EWEs are deeply embedded in place-based conditions and are cyclical, cumulative, and relational rather than confined to discrete disaster events. Participants described how repeated environmental disruptions reconfigured everyday life in place, generating ongoing uncertainty, anticipatory anxiety during rainfall periods, and acute fear during floods and cyclones. Loss of housing, livelihoods, infrastructure, and social anchors of place contributed to enduring psychological distress, which was frequently reactivated by subsequent environmental cues such as heavy rain, wind, and deteriorating physical environments. Persistent anxiety, hypervigilance, sleep disturbance, and emotional distress were reported across all sites. While social and community networks constituted critical infrastructures of care within place, these were often simultaneously overwhelmed as entire communities experienced shared disruption. Limited and delayed institutional responses further compounded spatial and social precarity. Conclusions: This study provides a comparative participatory account of how EWEs shape mental health through their embeddedness in place across diverse sub-Saharan African contexts. The findings demonstrate that psychological distress is produced through the interaction of repeated environmental exposure, structural inequality, and disrupted place-based infrastructures of daily life, rather than emerging solely as a post-disaster outcome. These results underscore the need for climate-responsive mental health and psychosocial support that is integrated into place-based disaster risk governance, alongside strengthened social protection and community infrastructure that can sustain wellbeing in contexts of recurring environmental instability.

Introduction: Child health and well-being in Kalaallit Nunaat (Greenland) remain a major public health concern, yet systematic, population-level research is limited. Previous studies have focused on isolated indicators such as vaccination coverage and infant mortality, without capturing the broader structural and social determinants shaping childrens lives. The Meeqqat Peqqissut project addresses this gap by developing a cross-sectoral, register-based approach to identify both risk and health promoting factors influencing child health and well-being for alle children in Kalaallit Nunaat. Grounded in the Indigenist Ecological Systems Model (IESM) and complemented by the Peqqissuserput framework, the project adopts a strengths-based perspective that emphasizes resilience and culturally embedded determinants of well-being. Methods: Meeqqat Peqqissut is a collaboration between the Centre for Public Health in Greenland and Statistics Greenland. The study integrates longitudinal register data linked via personal identification numbers, combining healthcare records (COSMIC), socio-economic data from Statistics Greenland, municipal case management systems (Get Organized), and police records. Additional sources include education and social services. Data will be combined and analysed on Statistics Greenlands secure platform using advanced methods such as latent class and trajectory analyses. A participatory approach ensures continuous dialogue with practitioners to validate data quality and contextual relevance. Results: The project supports evidence-based strategies for improving child health and well-being in Kalaallit Nunaat and contributes to the national public health strategy Inuuneritta III. It aligns with the Kalaallit Nunaat governments research strategy for 2022-2030, as it aims to support sustainable societal development by contributing to improved public health and reducing social health inequalities. Ethical approval has been obtained from the Scientific Ethics Committee in Kalaallit Nunaat (VEK 2025-12). Conclusion: The Meeqqat Peqqissut project will provide a robust, cross-sectoral evidence base to strengthen efforts to improve child health and reduce social health inequalities in Kalaallit Nunaat. By integrating administrative data and applying an Indigenous, strengths?based framework, the study advances understanding of structural and social determinants of well?being. The project establishes a sustainable approach to equity?oriented child health monitoring and will inform policy, practice, and long?term public health action.

Background: The effect of extreme temperatures on miscarriage is not well understood. Even less understood is the gestational period most vulnerable to extreme temperature exposure, as early miscarriages are often missed in incident datasets. We employ a birth-rate based approach to infer the risk of miscarriage in response to extreme temperature exposure by gestational week. Methods: We conducted a population-based ecological study using birth registry data from the 7,948 municipalities of Italy between 2013 and 2024 (4.5 million births). The analyses were stratified by five climatically coherent macro-regions (Ecoregions). To infer unreported pregnancy losses, we regressed birth rates dated from the last menstrual period against weekly temperatures across gestational weeks 3-21, accounting for temporal seasonality and spatial heterogeneities. Findings: Exposure to heat (mean weekly temperature of 30.4 degree/C) during gestational weeks 3-4 was associated with a reduction of birth rates of 1.62 (0.71 - 2.51)%, and of 1.91 (0.92 - 2.88)% to mean weekly temperature of 1.6 degree/C. Whilst heat was found to be harmful during gestational weeks 3-4 and 18-21, cold spells were found to be consistently harmful from the 3th up to the 12th week, depending on the Ecoregion. Interpretation: Pregnancies are vulnerable to extreme temperatures during the post-conceptual period and the second trimester. The findings underscore the need for a pre-conceptual cohort to clarify the mechanisms of loss, and urge public health action to protect pregnancies from the beginning of gestation.

Socioeconomic, demographic, and health system structures may have shaped COVID-19 pandemic impact across populations, but past analyses typically examined few factors. We systematically examined correlates of COVID-era excess mortality, considering 2,745 county-level variables of demography, race/ethnicity, income, insurance, education, employment, housing, and health system. Pearson correlation coefficients (CCs) were obtained for the most recent available pre-pandemic value against age-standardized county excess-death for each year during 2020-2024. Counties were population-weighted. Variables were grouped by meaning into 11 semantic super-clusters. Overall, 17.3% of variables reached at least a moderate correlation level (|CC| > 0.30) and 2.8% reached strong correlations (|CC| > 0.45). Strongest correlations were seen for college attainment (CC -0.54), uninsurance among adults 40-64 (+0.53), and high income (-0.53). At least moderate correlations were seen for 9.1% of variables in 2020 and 8.5% in 2021, but only 1.8%, 0%, and 1.3% in 2022, 2023, and 2024, respectively. Similar patterns of concentration of moderate correlations in the first two pandemic years appeared in both elderly and non-elderly populations. Of 472 variables with |CC| > 0.30, 362/395 moderate-band and 77/77 strong-band variables belonged to demography and socioeconomic super-clusters. Only 7% of health system variables reached |CC| > 0.30, versus 31% of socioeconomic and demographic variables. Using the most recent available value until 2023 or 2015, different population weighting, and Spearman correlations yielded similar results. Overall, these ecological analyses suggest strong relationships of socioeconomic structure and demographics rather than health-care resources/supply with excess mortality across US counties especially during 2020-2021.

Abstract Background Neighborhood socioeconomic disadvantage may contribute to inequities in access to dental care by influencing the geographic distribution of providers. The Area Deprivation Index (ADI) is a validated measure of neighborhood deprivation, but its association with dental workforce availability has not been examined statewide in California. This study evaluated the relationship between neighborhood deprivation and dental provider density across California ZIP Code Tabulation Areas (ZCTAs). Methods We conducted a cross-sectional ecological study of California ZCTAs using publicly available data from the National Plan and Provider Enumeration System (April 2026), the Neighborhood Atlas 2023 ADI, and 2024 U.S. Census population estimates. Active dental providers were linked to ZCTAs and provider density was calculated per 10,000 residents. ADI was aggregated to the ZCTA level using the median ADI national percentile. Negative binomial regression was used to assess the association between ADI and dental provider density, with population included as an offset. Secondary analyses examined California-specific ADI quartiles, dental deserts, and specialist versus general dentist availability. Results The final analytic sample included 1,426 California ZCTAs representing 39,016,384 residents and 37,945 active dental providers. Greater neighborhood deprivation was significantly associated with lower dental provider density. Each one-percentile increase in ADI corresponded to a 1.8% reduction in provider density (incidence rate ratio [RR] 0.9823, 95% confidence interval [CI] 0.9799-0.9847; p < 0.001). Compared with the least deprived quartile, the most deprived quartile had 61% fewer dental providers (RR 0.39, 95% CI 0.34-0.45; p < 0.001). Overall, 15.9% of ZCTAs contained no active dental providers, increasing from 6.8% in the least deprived quartile to 31.1% in the most deprived quartile. Specialist availability demonstrated an even steeper deprivation gradient, with specialist density declining by 86% between the least and most deprived quartiles.

ABTRACT Background Children from low- and middle-income countries are particularly vulnerable to air pollution, a major environmental health risk, due to the immaturity of their lungs and their proximity to sources of household pollution. This study aimed to investigated the effect of exposure to biomass combustion through domestic and maternal occupational activities on respiratory health of children living in disadvantaged urban areas of Abidjan, Cote dIvoire. Methods Between February and December 2023, we conducted a cross-sectional observational study among children <16 years from households of women using biomass fuel for cooking (Group (G) 1), engaged in occupational fish smoking activities (G2), or primarily using gas for domestic cooking (G3). We assessed reported respiratory symptoms through standardized questionnaires and the presence of lung function impairments (LFI) though pulmonary function tests (spirometry and Rint). We assessed the association between study groups and key covariates with respiratory symptoms and LFI using mixed-effects regression models. Results Of 210 children enrolled - 119 (56.8%) female, median age 9 (6-12) years, 82 (39.0%) in G1, 47 (22.4%) in G2, and 81 (38.6%) in G3 - 15 (7.1%) reported wheezing in the last 12 months, 82 (39.0%) reported dry cough at night, 9 (4.9%) presented with dyspnea and 5 (2.7%) had chest pain on clinical examination, for an overall proportion of children with reported respiratory symptoms of 43.8% (92/210). Of 176 children who underwent pulmonary function testing, 59 (33.5%) had LFI detected, including 34 (45.9%) in G1, 8 (22.2%) in G2, and 17 (25.8%) in G3 (p = 0.011). Study group was associated with respiratory symptoms (G1 vs G3; aOR 3.82, 95% CI 1.68-8.68; p < 0.001), as well as with LFI (p = 0.042). Girls were at greater risk of LFI than boys (aOR 2.69, 95% CI 1.24-5.80; p = 0.012). Children whose mothers used charcoal or wood as cooking fuel had higher odds of respiratory symptoms (OR 2.61, 95% CI 1.22-5.58; p = 0.013) but no association was found with LFI (p = 0.459) compared with unexposed children. Conclusion Respiratory symptoms and lung function impairments were highly prevalent among children living disadvantaged, especially when mothers cook with wood or charcoal. Targeted maternal awareness and broader interventions to reduce household air pollution in disadvantaged urban areas are urgently needed to protect long-term respiratory health.

Aims To explore how workplace environments and racialised hierarchies shape racial inequities in career progression and how the Covid-19 pandemic response influenced these inequities. Design Longitudinal and cross-sectional qualitative study using semi-structured interviews. Methods Semi-structured interviews were conducted with 27 student nurses, healthcare assistants and qualified nurses and 24 senior leaders and management staff recruited in England between January 2019 and March 2021. Data were analysed using thematic analysis. Results Data from 51 healthcare professionals were included in the analysis. Guided by sociological theory on inequality diversions and racialised organisations, three main themes were identified: (1) hidden pipelines to career progression highlights how racial positioning influences unequal career trajectories shaped by informal networks, organisational norms and perceptions of competence; (2) impact of the response to the Covid-19 pandemic illustrates how the pandemic disrupted and reinforced racialised career barriers and (3) psychological effects of racialised inequities on racially minoritised staff captures the emotional burden of navigating these inequities. Conclusion NHS staff perspectives on racialised inequities in career progression highlight the power informal networks have in staff accessing managers who control opportunities. While some staff found new opportunities during the Covid-19 response, others, particularly senior racially minoritised staff, felt redeployments and remote working further hindered their development.

Short-term environmental exposures have been linked to cognitive and behavioral outcomes, although many reported associations may reflect broader geographic and contextual differences. Using longitudinal data from the All of Us Research Program (2018--2024), we linked daily weather and air-pollution exposures to repeated attention-related and subjective cognitive outcomes. Associations were evaluated using pooled, fixed-effects, lagged, and event-study analyses. Additional machine-learning analyses were conducted to explore potential heterogeneity and latent psychosocial structure. Replication analyses were performed using the 2024 Behavioral Risk Factor Surveillance System (BRFSS). Several environmental exposure measures showed small associations with cognitive outcomes in pooled analyses, but most attenuated substantially after accounting for within-location temporal variation. Mediation, sensitivity, and machine-learning analyses yielded similar conclusions. In contrast, mental-health burden, loneliness, and social functioning were consistently associated with subjective cognitive difficulty and exhibited substantially larger effect sizes than environmental exposures. Similar patterns were observed in BRFSS. Exploratory AI-assisted analyses yielded findings broadly consistent with the primary longitudinal analyses. These findings suggest that short-term environmental perturbations may have limited associations with cognitive outcomes after accounting for within-location variation, whereas psychosocial factors appear to be more consistently associated with subjective cognitive burden.

Abstract Background: Open defecation remains a major public health challenge in Ghana and across sub-Saharan Africa, with persistent rural-urban inequalities undermining progress toward Sustainable Development Goal 6.2 (SDG 6.2). Despite two decades of national sanitation programming, structural and equity barriers continue to constrain progress. A repeated cross sectional analyses and longitudinal analysis combining WHO-standardised inequality measures, temporal trend modelling, and projections remain absent from the literature for Ghana. Methods: National, rural, and urban open defecation prevalence (2000-2024) was analysed using WHO Health Equity Assessment Toolkit (HEAT) data. Four inequality measures: Difference, Ratio, Population Attributable Risk (PAR), and Population Attributable Fraction (PAF), quantified rural-urban disparities. Joinpoint regression identified statistically significant trend inflection points across MDG and SDG eras. ARIMA models projected prevalence to 2030 under status quo, accelerated, and decelerated scenarios; hold-out validation confirmed high forecast accuracy across all series (MAPE <1%). Results: National prevalence declined from 20.31% to 17.79% (AAPC: -0.55%, p<0.001), with a joinpoint at 2016 (95% CI: 2015-2017) after which decline slowed during the SDG era. Rural prevalence rose marginally (AAPC: +0.07%) with no significant joinpoints across the 25-year period; urban prevalence also increased (AAPC: +0.76%). Rural prevalence exceeded urban more than threefold by 2024 (R=3.38); PAF improved from -62.62% to -48.85%, indicating a substantial national burden attributable to rural disadvantage. Under the status quo scenario, national and rural prevalence are projected at 17.24% and 30.88% by 2030, far exceeding the SDG 6.2 threshold. Conclusion: Despite modest national progress, substantial rural-urban inequalities remain entrenched, and Ghana is unlikely to achieve SDG 6.2 under current trajectories. Accelerated, equity-focused interventions targeting structurally disadvantaged rural populations are urgently required to reduce sanitation inequalities and improve health outcomes.

Objectives Increased risk of childhood obesity up to age six years has been linked to higher maternal allostatic load (AL), the physical manifestation of repeated stress exposure. However, associations are less evident when using psychological stress indicators, and data mainly come from higher income countries. Using psychological and physiological stress markers, this study evaluates maternal stress exposures and child risk of obesity in Peruvian women and their children, ages 5 to 15 years, living in a disadvantaged urban area. Methods Maternal stress exposures included mental distress (12-item General Health Questionnaire scores of 5+ for moderate/high and <5 for no/low distress) and AL (lower/moderate/higher AL assessed from Latent Profile Analysis of hair cortisol, BMI, waist circumference, systolic and diastolic blood pressure). Child outcomes included BMI-for-age and waist circumference-for-age z scores (BAZ and WCAZ). Linear regression analyses were conducted, adjusting for confounders and reported as coefficients and 95% confidence intervals (95% CI). Results Versus mothers with no/low distress, those with moderate/high distress had children with 0.40 (95% CI: -0.66,-0.13) and 0.32 lower (-0.53,-0.11) child BAZ and WCAZ respectively. Versus lower AL mothers, moderate AL mothers had children with 1.15 (0.41,1.88) and 0.74 (0.20,1.28) greater BAZ and WCAZ while higher AL mothers had children with 1.43 (0.95,1.92) and 0.91 (0.50,1.32) greater BAZ and WCAZ respectively. Conclusions Children of mothers with higher AL were at greater risk of overweight or obesity, which may add to the rising burdens of non-communicable diseases in resource-constrained settings as well as the related social, economic, and public health costs.

Background: Mortality analysis traditionally focuses on the single underlying cause of death (UCD), which obscures the wider morbidity process at the end of life. Multiple causes of death (MCoD) data, recording all conditions on the death certificate, are increasingly used as a proxy for end-of-life multimorbidity, yet how accurately they represent it remains underinvestigated. We assessed whether recorded causes reflect end-of-life health conditions or rather the chain of events leading to death. Methods: Using linked Danish registers (Population, Cause of Death, Chronic Diseases, and Cancer), we studied residents aged 50+ diagnosed with COPD, dementia, diabetes, or cancer who died in 2010-2022 (ranging from 38779 to 224330 per disease cohort). We examined how often each diagnosed disease appeared on the certificate, its location and selection as the UCD, factors associated with its appearance (logistic regression), disease-specific mortality (multiple decrement life tables), and disease associations (Cause of Death Association Indicator, CDAI). Results: Cancers appeared on the death certificate far more often than chronic diseases (around 75% versus 19-58%) and were usually recorded in Part 1 and selected as the UCD, whereas chronic diseases were rarely the UCD. The odds of a disease appearing depended on factors such as age at and time since diagnosis. When a diagnosed disease was recorded, the certificate traced a coherent path to death; when it was absent, ill-defined causes became more common. The CDAI highlighted specific association pathways between diseases. Conclusions: MCoD data capture only part of the chronic disease burden present at death and should be interpreted cautiously as a proxy for end-of-life multimorbidity. They are, however, well suited to describing the pathways leading to death.

Short-term environmental exposures have been linked to cognitive and attention-related outcomes, but the robustness of these associations remains uncertain. We linked daily weather and air-pollution exposures to repeated measures of subjective cognitive difficulties and attention-related outcomes among participants in the All of Us Research Program from 2018 to 2024. Associations were evaluated using complementary longitudinal and causal-inference approaches, including fixed-effects, lagged-exposure, and event-study analyses. Machine-learning methods were used to characterize heterogeneity and latent psychosocial structure, and findings were independently evaluated using 2024 Behavioral Risk Factor Surveillance System data. Several environmental exposure measures were associated with cognitive outcomes in pooled analyses; however, most associations attenuated substantially after accounting for within-location temporal variation. In contrast, mental-health burden, loneliness, and impaired social functioning remained consistently associated with subjective cognitive difficulty across analytical approaches. Similar patterns were observed in the validation dataset. These findings suggest that some observed environmental associations may reflect broader geographic and contextual differences rather than short-term environmental effects. Overall, psychosocial factors demonstrated more consistent associations with subjective cognitive difficulties than short-term environmental exposures across multiple analytical frameworks and independent datasets.

Background. Current exposure-health models rely on averaged, residential-based environmental exposures, failing to account for human movement. This aggregation can lead to exposure misclassification and biased exposure-response estimates, potentially distorting our understanding of the true health effects of environmental conditions. We developed exposure disaggregation regression models that explicitly account for human movement when linking environmental exposures to health outcomes. Methods. By weighting pixel-level exposures according to distance from home as a simple proxy for human movement, our model linked disaggregated environmental exposures to individual-level health outcomes. Weights were either fixed a priori or derived from a latent distance-decay power parameter learned from the data. We additionally evaluated model performance under a nonlinear exposure-response relationship. Model performance was assessed across multiple sample sizes (N = 1,114; 50,000; and 100,000). A simulation study examined parameter recovery using bias, empirical standard error (EmpSE), and credible interval coverage. As a case study, Demographic and Health Surveys (DHS) data from Albania were used to link acute respiratory infection (ARI) outcomes among children under five to pixel-level NDVI within a 3 km buffer around DHS cluster centroids, and the proposed models were applied to these data. Results. Across all models (fixed-weight, learned-weight, and restricted cubic spline models), parameter recovery improved with increasing sample size. At N = 1,114, estimates were biased and imprecise, with incorrect effect direction for exposure-response parameters (e.g., learned-weight {beta}1 bias = - 0.79; EmpSE = 2.61; coverage = 0.88). In contrast, the models accurately recovered parameters at larger sample sizes, including the latent distance-decay parameter (bias = - 0.02; EmpSE = 0.15; coverage = 0.95 at N = 100,000), demonstrating their ability to reliably learn movement-based exposure weights when sufficient data were available. Conclusion. Instead of relying on arbitrarily-sized buffers, this statistical framework provides a novel method for studying environmental exposure-health relationships whilst accounting for human movement. With sufficiently large sample sizes, it can accurately estimate the influence of disaggregated environmental exposures on individual-level health and help address exposure misclassification arising from residential-only metrics. This methodological framework remains scalable, interpretable, and adaptable to other exposures and outcomes, offering a foundation for future work that integrates richer mobility-informed exposure-health research.