Health & Place

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.

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: 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.

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.

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.

The introduction of salt iodization is associated with improved health and socioeconomic outcomes, but is not yet universally adopted and not always sustained. Using a quasi-experimental event study with difference-in-differences over space and time, we quantify the impacts of iodine deficiency in utero and infancy on childhood mortality and later academic achievement in Ethiopia, comparing cohorts born just before and after the May 1998 border closure that interrupted access to iodized salt. Rural children with fewer months of early-life exposure to iodized salt scored lower on standardized secondary-school exams, especially in districts with low environmental iodine, with excess deaths emerging in infancy and persisting through early childhood. These findings reveal the long-term benefits of salt iodization for health and education, especially for people with low intake of iodine from environmental sources.

Background: Cardiovascular disease (CVD) remains the leading cause of mortality among older U.S. adults, yet the contribution of neighborhood-based structural racism remains inadequately quantified. This study quantifies the association between the Structural Racism Effect Index (SREI) and CVD mortality among adults aged {greater than or equal to}65 years, evaluating how this relationship varies across U.S. geographic regions to identify key areas for intervention. Methods: This ecological study applied a hierarchical Bayesian spatiotemporal framework to 2017-2020 Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) data to estimate the association between SREI and CVD mortality across 3,007 U.S. counties. SREI was modeled continuously and categorically, adjusting for sociodemographic covariates. Population attributable fractions (PAF) and attributable deaths (AD) quantified the potentially preventable burden and its spatial disparities. Results: From 2017 to 2020, approximately 2.79 million CVD deaths were observed, with significant spatial clustering (Moran's I = 0.35, p < 0.001). Each standard-deviation increase in SREI was associated with 13% higher CVD mortality (IRR: 1.13, 95% CrI: 1.12-1.15). A positive dose-response gradient was observed across SREI quartiles, with mortality 24% higher in the highest quartile than in the lowest (IRR: 1.24, 95% CrI: 1.20-1.28). The PAF was 6.94% (95% CrI: 6.13-7.73), corresponding to 193,472 potentially preventable deaths. High exceedance probabilities (>0.95) were concentrated in the Southeast, Appalachia, and the Midwest. Conclusions: Structural racism is a spatially patterned, dose-dependent predictor of older adult CVD mortality, underscoring the need for public health monitoring and neighborhood-based upstream interventions where disease burden is concentrated. Keywords: Structural Racism Effect Index; Neighborhood disadvantage; Cardiovascular Disease Mortality; Bayesian Spatiotemporal Analysis; Population Attributable Fraction; Health Disparities; Health Equity.

Introduction: Multimorbidity clusters have been associated with increased dementia risk. While lifestyle factors may modify dementia risk, their role in multimorbidity clusters remains unclear. Method: Data from UK Biobank was used to identify clusters of chronic conditions using latent class analysis, assess their associations with dementia risk using Cox regression, and potential moderating effects of lifestyle factors. Results: We included 465,175 participants (mean age (SD) = 56.52 (8.01), 53.87 % female). Five clusters were identified and significantly associated with increased dementia risk, with the cardiometabolic (HR = 2.14, p < 0.001) and mental health cluster (HR =1.99, p < 0.001) exhibiting the highest risk. Only moderate physical activity lowered dementia risk in the pain-dominated multimorbidity cluster (HR = 0.77, p = 0.039). Discussion: Lifestyle factors including physical activity may protect against dementia in specific multimorbidity clusters. Future research involving objective and multiple lifestyle measures is needed.

Background Literature investigating mediation of the association between child abuse and dementia has largely considered composite adverse childhood experience scores rather than individual adverse experiences, despite evidence that different experiences have different impacts on dementia risk. Additionally, prior studies consider mediators in isolation, despite known associations between mediators which may impact indirect pathways from child abuse to dementia. Objectives To investigate whether potentially modifiable health and lifestyle factors mediate the association between child abuse and dementia. Methods We used data from the English Longitudinal Study of Ageing to investigate associations between child abuse and dementia (N:5,448). Indirect pathways through four mediator categories (education, health behaviours, mental health and cardiovascular health) were examined. We used regression modelling to estimate associations between child abuse, mediators and dementia, and causal mediation analysis using the g-formula to estimate the joint indirect effect through the mediators. Results Individuals who experienced child abuse had, on average, an 80% higher hazard of dementia, compared to those who did not (RTE HR:1.80, 95% CI:1.21-2.39). Mental health mediators showed strong associations with both child abuse and dementia. Evidence for other mediators was weaker. Education, health behaviours, mental health and cardiovascular health mediated approximately 18% of the association. Sensitivity analysis revealed that almost all this mediation occurred through mental health. Conclusions Child abuse was associated with higher risk of dementia. Joint mediation analysis suggested that education, health behaviours, cardiovascular health, and mental health accounted for a relatively small proportion of the observed association, with most mediation occurring through mental health. Future research must focus on other potential pathways from child abuse to dementia, including biological and social mechanisms.

Objectives: Estimate the prevalence and sociodemographic correlates of adolescent-reported food insecurity experiences from 2019-2021. Methods: Repeat cross-sectional data were collected in November-December 2019, 2020, and 2021 from adolescents aged 10-17 years living in the ten Canadian provinces (n = 11,057). The prevalence of ten items and five food insecurity subconstructs based on the 10-item Child Food Insecurity Experiences Scale was estimated. Weighted multinomial logistic regression assessed associations between sociodemographic characteristics and food insecurity experiences as a four-level (no, few, several, or many experiences) variable. Results: Across 2019-2021 among adolescents, the prevalence of worrying about food scarcity ranged between 18.4%-22.5%, worrying about parental/guardian ability to get food ranged between 22.8%-26.9%, and not being able to get the food they wanted ranged between 23.5%-26.1%. Close to or above one in four adolescents affirmed the uncertainty (range: 26.9%-29.9%) and compromised diet quality or preferences (range: 23.5%-26.1%) subconstructs. In 2021, adolescents identifying as Black had a higher relative risk ratio of few food insecurity experiences (adjusted relative risk ratio (ARRR): 2.04 [95% CI: 1.20, 3.47], p-value: <0.01) and adolescents identifying as Indigenous had a higher relative risk ratio of several food insecurity experiences (2.38 [1.10, 5.15], p-value 0.03) compared to adolescents identifying as White. The relative risk ratio of having few, several, or many food insecurity experiences also differed by age, sex-at-birth, perceived income adequacy, and region. Conclusion: The type and number of experiences reported underscores the value of directly measuring food insecurity. Interventions to mitigate food insecurity's adverse consequences are warranted.

Background Personal choice in health behaviours raises difficult questions: when individuals freely decline effective preventive interventions, who should bear the resulting costs? This tension is acute in insurance systems where resources are pooled, yet all health systems pursuing Universal Health Coverage must navigate the boundary between collective solidarity and individual accountability. During the COVID-19 pandemic, vaccines were freely available to members of South African private medical schemes, creating conditions in which non-vaccination could plausibly be examined as a matter of personal choice rather than constrained access. This study applied a luck egalitarian framework to assess whether non-vaccination reflected personal choice or constrained circumstance, and to quantify resulting excess costs. Methods A contextual review assessed barriers to vaccination. Using de-identified claims data for approximately 550,000 individuals (March 2020 to December 2022), logistic regression estimated each person's predicted probability of vaccination based on demographic and clinical factors, with observed and predicted rates compared across strata to infer choice versus circumstance. A zero-inflated negative binomial model estimated predicted expenditure among vaccinated members, applied to the full population to simulate universal vaccination. Excess costs were calculated across predicted probability strata. Results Predicted and observed vaccination rates were closely aligned, suggesting that residual non-vaccination in higher-probability groups reflected personal choice rather than constrained circumstance. Observed costs exceeded predicted costs by 22% under universal vaccination, concentrated among older adults and those with comorbidities. Among those with a 60 to 70% predicted probability of vaccination, observed costs exceeded predicted costs by 127.6%. In contrast, among younger, low-risk members, predicted costs slightly exceeded observed expenditure, as vaccination costs were not offset by reduced hospitalisation. Conclusion Risk pooling depends on solidarity, yet non-vaccination due to personal choice shifts costs in ways that challenge fairness in community-rated insurance. These findings highlight the need for transparent deliberation about when personal responsibility should inform equitable health financing design.

Although a strand of scholarship on pandemic prevention flourished in the wake of the COVID-19 pandemic, a theoretically informed empirical analysis of global governance entrepreneurs and practitioner perspectives is lacking. This gap is salient given the need to consider the nuances, political realities, and feasibility of real-world governance practice, particularly with the recent adoption of the Pandemic Agreement under the World Health Organisation. In this paper, nexus governance and regime complex theory guides an analysis of recommendations for potential real-world governance responses for pandemic prevention from wildlife trade for human consumption elicited from global governance entrepreneurs and practitioners through semi-structured interviews and document analysis. Recommendations on future governance practice largely focused on strengthening coordination across various policy sectors to improve use of existing institutional arrangements, with particular emphasis on better integration of the biodiversity conservation policy sector within global pandemic prevention governance, as well as reform of the World Organisation for Animal Health and the Convention on International Trade in Endangered Species of Fauna and Flora. With governance deficits for prevention of pandemics emerging from the wildlife trade left by the now largely concluded Pandemic Agreement, a renewed research agenda on shared governance pathways becomes paramount.

Introduction: Climate change disproportionately affects disadvantaged communities, yet construction workforce education rarely addresses interconnected pathways linking energy efficiency, nature exposure, and public health. Green-blue infrastructure delivers co-optimized benefits: reducing building energy consumption 15-30% while decreasing heat-related mortality by approximately 3.9% per degree Celsius of urban cooling (Gasparrini et al., 2017) -- epidemiological benchmarks that inform the dose-response functions embedded in the Ecosystem Justice Translator (EJT). This protocol describes, to our knowledge, the first randomized controlled trial evaluating a curriculum intervention designed to develop planetary health competencies and environmental justice awareness among high school students pursuing construction careers. Methods and analysis: This two-arm, parallel-group randomized controlled trial targets enrollment of N=200 high school students (ages 14-18) from construction career pathway programs in the San Francisco Bay Area (over-recruitment target N=250; 25% buffer for attrition). Students are individually randomized 1:1 to intervention (Community-Centered Design curriculum integrating the Ecosystem Justice Translator) or control (traditional Virtual Design and Construction curriculum), stratified by school site using block randomization. The 6-month intervention features the Ecosystem Justice Translator (EJT) -- a computational system using large language models to translate community health equity concerns into quantifiable investment priorities. The EJT's 51-theme health equity taxonomy was derived from validated public health frameworks (Centers for Disease Control and Prevention [CDC] Social Vulnerability Index, Environmental Protection Agency [EPA] EJScreen, Healthy People 2030). Primary outcome is Health-Integrated Equity Consciousness Index (HI-ECI), measured at baseline, 3, 6 (primary endpoint), and 12 months. Analysis uses intention-to-treat linear mixed-effects models with random intercepts for participants. The minimum required sample (n=26 per arm; G*Power, two-tailed a=0.05, 80% power, Hedges' g=0.80) is exceeded by enrolled N=200, which provides >99% power at Hedges' g=0.80 and supports multi-site confirmatory factor analysis. Ethics and dissemination: This protocol has been approved by Stanford University Institutional Review Board (IRB eProtocol #84369, approved February 13, 2026). Parental consent from a parent or guardian and written assent from each student participant are required prior to enrollment. All instruments, curriculum materials, and EJT source code will be released open-source under CC BY-NC-SA 4.0, permitting free use for educational, research, and non-profit purposes, concurrent with primary publication. Commercial licensing may be pursued separately through Stanford University Office of Technology Licensing (OTL docket S25-565). Trial registration: ClinicalTrials.gov NCT07315919. Pre-results. Protocol version 4.0, June 2026.

Importance: Loneliness is associated with premature mortality and poor mental health and was declared an epidemic by the US Surgeon General in 2023, but national surveillance has relied on state-based or experimental online surveys. In 2024, the National Health Interview Survey measured loneliness directly for the first time. Objective: To estimate the national prevalence of loneliness among US adults, identify the sociodemographic groups with the highest burden, and quantify associations with mental health, health status, and health care use. Design: Cross-sectional analysis of the 2024 National Health Interview Survey, a nationally representative household survey conducted continuously from January to December 2024. Setting: US households; face-to-face and telephone interviews. Participants: 32 629 sampled civilian noninstitutionalized adults aged 18 years or older (response rate, 47.9%); 31 470 (96.4%) had valid loneliness data. Exposures: Frequent loneliness, defined as feeling lonely always or usually on a 5-category item (always, usually, sometimes, rarely, never). Main Outcomes and Measures: Survey-weighted prevalence of loneliness overall and by sociodemographic characteristics, and associations of frequent loneliness with serious psychological distress (Kessler 6 scale score 13 or higher), frequent feelings of depression and anxiety, life dissatisfaction, fair or poor self-rated health, receipt of counseling or therapy, cost-related unmet mental health care need, and emergency department use. Results: In 2024, 4.9% (95% CI, 4.6%-5.2%) of US adults, an estimated 12.2 million people, felt lonely always or usually, and 23.7% (95% CI, 23.1%-24.3%), an estimated 59.3 million, felt lonely at least sometimes. Prevalence of frequent loneliness was highest among adults with family income below the federal poverty level (10.3%), adults with disability (13.6%), adults living alone (9.0%), and American Indian or Alaska Native adults (12.2%). Adults aged 65 years or older had the lowest prevalence of any age group (4.0%) and adults aged 18 to 29 years the highest (6.3%). After adjustment for sociodemographic characteristics, frequent loneliness was associated with serious psychological distress (adjusted odds ratio, 14.5; 95% CI, 12.1-17.3), life dissatisfaction (9.0; 95% CI, 7.6-10.8), cost-related unmet mental health care need (4.3; 95% CI, 3.5-5.2), and emergency department use (1.8; 95% CI, 1.5-2.0). Conclusions and Relevance: Loneliness among US adults was patterned by poverty, disability, and household structure rather than older age. These estimates from the nation's principal household health survey provide a benchmark for monitoring loneliness and suggest that strategies for social connection should address material hardship and access to mental health care.

Abstract Background. Chronic low-level exposure to lead, cadmium, mercury, and arsenic remains a determinant of premature mortality in the U.S. general population, but previous hazard-ratio analyses do not characterize how exposure shifts the lower tail of the survival distribution, where premature mortality is concentrated. Objectives. We estimated the association of whole-blood lead, whole-blood total mercury, urinary cadmium, and the sum of urinary inorganic and methylated arsenic species with the 10th, 25th, and 50th conditional quantiles of follow-up time to all-cause mortality among U.S. adults aged 40 years and older. Methods. NHANES Continuous 1999 to 2018 was linked to the National Death Index through December 31, 2019 (n = 29,652). Censored quantile regression was fit per metal on the log2 scale at quantiles {tau}{0.10, 0.25, 0.50}. A restricted-cubic-spline (RCS) censored-quantile-regression was fit for blood lead and urinary cadmium to investigate the threshold effect. Results. Over a median follow-up of 9.1 years, 7,215 deaths were ascertained. A doubling of urinary cadmium was associated with -1.57 years of follow-up (95% CI: -2.08, -1.07) at the 10th conditional quantile, -1.50 (-2.04, -0.96) at the 25th, and -1.49 (-1.93, -1.04) at the median (Benjamini Hochberg q < 0.001 throughout). A doubling of whole-blood lead was associated with -0.70 years (95% CI: -0.99, -0.40) at the 10th conditional quantile, -0.62 (-0.92,-0.31) at the 25th, and -0.61 years (-0.89, -0.34) at the median; the absolute loss was largest at {tau} = 0.10 for both metals. Urinary arsenic-metabolite sum was not associated with conditional follow-up at the estimable quantiles. Despite adjustment for dark and fatty-fish intake or DHA/EPA, whole-blood total mercury was associated with longer follow-up (i.e., negatively associated with mortality risk), possibly due to residual confounding by broader dietary or socioeconomic factors, rather than a true protective effect. The cadmium association was additionally robust to the mutual adjustment of lead. Discussion. Low-to-moderate urinary cadmium and whole-blood lead were associated with fewer years of follow-up survival at the lower-tail and median conditional quantiles of survival, with the largest absolute losses at the lower tail of the conditional survival distribution, where premature mortality is concentrated. These findings support continued reductions in U.S. cadmium exposure and lead with particular benefit for adults most vulnerable to premature death.

Abstract Background: Despite considerable reductions in under-five mortality during the Millennium Development Goal era, progress towards Sustainable Development Goal (SDG) 3.2 remains uneven across Africa. Identifying countries at greatest risk of missing the target is essential for prioritizing interventions and resource allocation. Methods: A Bayesian spatial forecasting ecological study was conducted using 2024 country-level data from 49 African countries obtained from UNICEF. Spatial dependence was assessed using Global Moran's I and Local Indicators of Spatial Association. Bayesian structured additive regression models with Gaussian, Gamma, and Exponential likelihoods were fitted using Integrated Nested Laplace Approximation (INLA) and compared using the Deviance Information Criterion (DIC), Watanabe-Akaike Information Criterion (WAIC), and conditional predictive ordinates. Posterior exceedance probabilities were estimated, an SDG Failure Index (SFI) and a Priority Intervention Index (PII) were developed, and Bayesian posterior predictive simulations were performed to estimate country-specific probabilities of attaining SDG 3.2 by 2030. Results: Significant spatial clustering of under-five mortality was observed with (Moran's I = 0.355, p < 0.001), and hotspots in Benin, Cameroon, and Nigeria. The Gamma model provided the best fit (DIC = 114.92; WAIC = 111.71). Diarrhoea was the only significant predictor (posterior mean=0.030; 95% credible interval: 0.004-0.056). Twenty-three countries (46.9%) were classified as high risk, whereas only five (10.2%) had achieved SDG 3.2. West Africa recorded the highest mean mortality (7.05%) and North Africa the lowest (1.64%). Bayesian projections indicated that only five countries were likely to achieve SDG 3.2 by 2030, while 41 (83.7%) were unlikely to do so. Conclusion: Considerable geographical inequalities in under-five mortality persist across Africa, and most countries remain off-track for achieving SDG 3.2 by 2030. The integration of exceedance probability mapping, the SDG Failure Index, the Priority Intervention Index, and Bayesian probability forecasting provides a practical framework for monitoring progress and prioritizing countries requiring accelerated action towards achieving SDG 3.2.

Importance: In adolescence, attempts to lose weight are common, but their long-term impacts on mental and physical health are not known. Objective: To investigate the association between adolescent dieting and exercising to lose weight and adult trajectories of depressive symptoms and body mass index (BMI). Design: A longitudinal cohort study of children born between April 5 and 11, 1970, and followed up to age 51 years. Setting: Adolescents in the 1970 British Cohort Study in England, Wales and Scotland. Participants: A total of 4,650 adolescents with available exposure data. Exposures: Self-reported lifetime dieting or exercising for weight loss measured at age 16 years. Main Outcomes and Measures: Depressive symptoms measured with the nine-item Malaise Inventory, and BMI derived from self-reported height and weight, at ages 26, 30, 34, 42, 46, and 51 years. Results: Among 4,650 adolescents (56.7% girls, 97.7% White), 1,938 (41.7%) had dieted and 343 (7.4%) had exercised for weight loss by age 16 years. In fully adjusted analyses controlling for a wide range of child- and family-based confounders including prior BMI and emotional difficulties, there was evidence that adolescents who had dieted had higher adult depressive symptom trajectories (adjusted mean difference [aMD] 0.13, 95% CI 0.03-0.24, p=0.015) and higher and increasing adult BMI trajectories than those who had not dieted. There was also evidence that adolescents who exercised for weight loss had higher adult depressive symptom (aMD 0.18, 95% CI 0.02-0.34, p=0.031), and BMI trajectories (aMD 0.37, 95% CI -0.03, 0.78, p=0.071), though evidence of the latter was weak. Conclusions and Relevance: Behaviours aimed at weight loss occurring in adolescence might be a shared risk factor for depressive symptoms and high BMI in adulthood. If causal, these findings could suggest that reducing pressures to lose weight in adolescence may help prevent poor mental and physical health across the lifecourse.