Journal of Epidemiology and Community Health

Health inequalities are often examined through single axes such as class or ethnicity, obscuring how these dimensions interlock. This study applies a longitudinal intersectional approach to examine physical and mental health trajectories across five generations in the UK. We analysed 14 waves of the UK Household Longitudinal Study (2009-2024) using longitudinal Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA). We modelled SF-12 physical and mental health trajectories for 398 intersectional strata defined by gender, ethnicity, occupational class, and generation. Physical health inequalities widened with age, consistent with cumulative disadvantage, while mental health inequalities were more evident among later-born cohorts. The 'Boomer' generation exhibited a relatively flat mental health trajectory across its observed age range. In contrast, 'Generation Z' had lower predicted mental health, particularly among White British women with no work history - a group with poorer predicted trajectories than their South Asian peers. Our study shows how health inequalities are structurally differentiated by cohort and intersectional position. Policy responses should support proportionate universalism, combining broad population-level support with intensified action for groups showing poorer health.

Background: Unpaid caregiving is a recognised social determinant of health, yet most research treats it as a fixed exposure measured at a single time point, and little is known about how patterns of caregiving transitions relate to health behaviours. Methods: Secondary analysis of the UK Household Longitudinal Study (waves 2 to 13, approximately 2010 to 2023; n=25,049). Latent class analysis was applied to binary caregiving status across 12 waves to identify caregiving trajectories. Associations between trajectories and four health behaviours (physical inactivity, fruit and vegetable consumption, problematic drinking, current smoking) at waves 7 to 13 were estimated using logistic and linear regression, adjusting for sociodemographic, health and baseline behavioural confounders. Results: An eight-class solution identified a non-caregiving class comprising 62.9% (n=15,760) of the sample. Among caregivers (n=9,289), trajectories were Temporary (20.0%), Former-short (20.2%), Former-long (10.9%), Emerging-short (15.4%), Emerging-long (11.6%), Long-term (15.7%) and Recurrent (6.3%). In fully adjusted models, Recurrent caregivers had higher odds of smoking (OR=1.67, 95%CI: 1.17 to 2.40) compared with non-caregivers but lower odds of physical inactivity (OR=0.65, 95%CI: 0.53 to 0.81) and problematic drinking (OR=0.75, 95%CI: 0.59 to 0.94). Associations for other trajectory classes were largely attenuated after adjustment. Conclusion: The pattern and timing of caregiving transitions are an under-explored dimension of the caregiving experience. Recurrent caregivers had a distinctive profile, with elevated smoking but lower physical inactivity and problematic drinking. Recurrent caregiving should be recognised alongside intensity and duration, and support systems better equipped for people who move into and out of care repeatedly.

BackgroundSocial isolation (SI) is an established risk factor for chronic disease and mortality. How people travel, including the modes of transportation they use, may shape opportunities for social interaction and influence the impacts of SI. This study assessed heterogeneity of the association between SI and mortality across primary modes of non-commute transportation. MethodsWe analyzed cohort data from the UK Biobank, following participants aged 40-69 years from 2006 to 2022. SI at baseline was derived from three items and dichotomized. Cox models were used to estimate the association between SI and mortality, adjusting for socioeconomic factors, health behaviours, and comorbidities. Effect modification by participants primary mode of non-commute transportation was assessed using interaction terms with SI. ResultsThere were 490,114 participants with complete baseline exposure data. SI was associated with increased hazard of all-cause (Hazard Ratio [HR] = 1.34, 95% Confidence Interval [CI]: 1.31-1.38) and cardiovascular mortality (HR = 1.49, CI: 1.41-1.57). The association with cardiovascular mortality was stronger among participants who only used public transport compared with those who only used a car (interaction HR = 1.17, CI: 1.00-1.37). In contrast, using a car alongside active or public transport, compared to using a car alone, attenuated the association between SI and all-cause mortality (interaction HR = 0.93, CI: 0.87-0.99). ConclusionMixed transport, including a car, showed the greatest reduction in the association between SI and all-cause mortality. Our findings motivate further exploration of the role of transportation modes in enhancing social connection, mobility, and health.

Background: Previous studies indicated that regional fluctuations in COVID-19 impact were associated with socioeconomic, demographic and environmental factors early in the pandemic. It is unclear whether factors associated with regional COVID-19 mortality and SARS-CoV-2 infections changed over the course of the pandemic. Methods: We evaluated the association of ecological factors with municipality-specific COVID-19 mortality in the national population of Austria between January 2020 and June 2023. Analyses were conducted separately per calendar year and pooled across years via random-effects meta-analysis. Outcomes were analysed using univariable and multivariable zero-inflated negative binomial (ZINB) regression, including annually averaged environmental exposome exposure (including air pollution and UV radiation), socioeconomic, demographic and infection dissemination predictors with significance threshold set to p<0.005. Secondary analysis modelled SARS-CoV-2 infections using of negative-binomial model (NB). Two additional approaches for smaller predictor set selection were applied as sensitivity analyses. Results: Within the entire observation period 18,430 COVID-19 deaths were reported. In univariable analyses (pooled RR (99.5% CI)), COVID-19 mortality was significantly associated with the proportion of commuters (0.79 (0.73-0.86)), residents aged 75-84 (1.18 (1.01-1.37)) and [&ge;]85 years (1.29 (1.04-1.60)), residents with at most compulsory education (1.15 (1.02-1.29)), employed residents aged 15-64 (0.89 (0.85-0.93)), and homeowners (0.91 (0.83-0.99)), as well as with precipitation (0.94 (0.89-0.99)) and the average time with a mean temperature of 5-15 C (0.95 (0.90-0.99)). In multivariable analyses the share of population aged 85 or older (1.30 (1.09-1.54)) and home ownership (0.92 (0.87-0.98)) were independently significant. Mortality predictor estimates were relatively stable across pandemic years. Across 5,963,882 documented SARS-CoV-2 infections share of employed in 15- to 64-year-olds (1.01 (1.01-1.02)), part-time employment rate (1.01 (1.00-1.02)) and district level nursing care allowance recipiency (0.97 (0.95-0.98)) were associated with detected infections. Overnight stays, population 85 or older, income, compulsory education or less and air pollution all had multiple significant estimates with opposite directionality, leading to non-significant overall associations. Sensitivity analyses outcomes mirrored main analyses outcomes. Conclusions: Throughout the pandemic in Austria, demographic and socioeconomic factors were associated with COVID-19 mortality and infections, but many associations, especially for infections, were unstable over time. These findings underscore the importance of structural vulnerabilities in epidemic impact.

Disability is an important population-health concern, but adult-specific evidence on its distribution and socioeconomic patterning remains limited in Somaliland. This study estimated the prevalence and distribution of reported disability among adults in Somaliland and examined socioeconomic inequality, reported mental/psychological illness, and their co-occurrence. We conducted a cross-sectional secondary analysis of the 2020 Somaliland Health and Demographic Survey. The analysis included 14,579 adults aged [&ge;]18 years who were usual residents, had the disability module administered, and had a defined reported mental/psychological illness measure. Reported disability was defined as at least one positive response across seven disability domains: sight, hearing, speech, learning, mobility, self-care, and mental. Survey-weighted prevalence estimates and design-based comparisons were calculated. Survey-weighted logistic regression assessed associations with household wealth and other covariates. Socioeconomic inequality was assessed using a concentration index and the normalized Erreygers concentration index. Co-occurrence was evaluated by comparing observed joint prevalence with that expected under statistical independence and by survey-weighted logistic regression. The survey-weighted prevalence of any reported disability was 7.30% (95% CI 6.65-8.02). Sight was the most frequently reported domain (3.83%, 95% CI 3.19-4.59), followed by hearing (1.54%, 95% CI 1.20-1.97) and mobility (1.39%, 95% CI 1.14-1.70). Disability prevalence increased markedly with age, from 4.15% among adults aged 18-29 years to 23.96% among those aged [&ge;]60 years. The crude wealth pattern was non-monotonic and was not statistically detectable after adjustment for residence and region. The concentration index for reported disability was 0.0584 (SE 0.0284, p=0.0415). Reported mental/psychological illness had a weighted prevalence of 0.71% (95% CI 0.50-1.00). Both reported disability and reported mental/psychological illness occurred in 0.5032% of adults, compared with 0.05185% expected under statistical independence; the observed-to-expected ratio was 9.70 (95% CI 7.60-11.81). After adjustment for age group and sex, reported disability was strongly associated with reported mental/psychological illness (OR 42.99, 95% CI 18.45-100.18). Reported disability affected approximately one in fourteen adults in Somaliland and showed a marked age gradient and substantial geographic variation. The crude socioeconomic pattern was attenuated after adjustment for geographic context, while concentration analysis indicated modest marginal concentration toward higher wealth ranks. Reported mental/psychological illness was uncommon but co-occurred with reported disability more often than expected under independence. These findings provide an adult population baseline for Somaliland while highlighting the need to distinguish survey-reported disability from the separate mental/psychological illness construct and to interpret the findings within the limitations of cross-sectional, survey-reported measures.

Childhood experiences are important antecedents of adult flourishing, yet gender patterns in these experiences are under-studied in large global samples using a common survey instrument and population-based study design. From the Global Flourishing Study Wave 1 data (2022-2024), we analyzed responses from 203,430 adults (51% female, 49% male) in nationally representative samples from 21 nations on eight childhood-related items: experiencing physical or sexual abuse, feeling like an outsider in the family, feeling loved by one's mother or father, quality of relationship with one's mother or father, health growing up, and perceived family financial situation. Greater negative experiences were noted in more affluent nations (as measured by gross domestic product (GDP) per capita), with negative experiences generally reported more often among females than males, again especially in more affluent nations. Gender differences were more pronounced when it came to relationships with mothers compared to fathers. Perceptions regarding health and family finance while growing up did not show appreciable gender differences and had weaker correlations with other items.

Background: Childhood experiences contribute to health and wellbeing across the life course, yet research from low- and middle-income countries has largely focused on a few outcomes rather than broader patterns of adult wellbeing, behaviors, and social and financial circumstances. Methods: In this cross-sectional analysis, we used a nationally representative sample of adults in India (N = 12,765; aged [&ge;] 18 years) from the Global Flourishing Study (GFS) Wave 1 (2023) to examine associations between eight retrospectively reported childhood experience items, 45 adult outcomes, and two composite flourishing indices. Survey-weighted linear, logistic, and proportional-odds models adjusted for age, gender, education, and residential setting, with Bonferroni correction were used to assess associations and effect modification by gender. Findings: Although the breadth and strength of associations differed across childhood experiences, less favorable childhood experiences were generally associated with poorer wellbeing and flourishing, greater odds of adverse health outcomes, and reduced access to resources and safety in adult life. However, outcomes related to prosocial behaviors showed a different pattern: childhood abuse (physical or sexual) was associated with greater odds of volunteering (OR 1.31, 95% confidence interval or CI [1.13,1.51]), feeling like an outsider in one's family with greater odds of donating (OR 1.80, 95% CI [1.52,2.13]), volunteering (OR 1.53, 95% CI [1.28,1.82]), and helping a stranger (OR 1.49, 95% CI [1.27,1.74]). Associations were broadly similar between females and males, with little evidence of gender differences. Interpretation: Associations of childhood adversity with poorer health and increased prosocial behavior in adult life may reflect unmeasured social, cultural, or dispositional factors and heterogeneous life-course responses. Nevertheless, these findings support strengthening child-protection, financial assistance programs, and mental health services in India.

Background: Built environment characteristics have been associated with depressive symptoms, whilst active travel behaviour is linked to improved mental health. However, it remains unclear whether active travel buffers associations between increased exposure to the built environment and worse mental health. Methods: In this pre-registered study, participants were 10,310 mothers (mean age = 28.11, SD = 4.83) participating in the Avon Longitudinal Study of Parents and Children (ALSPAC). A latent built environment factor was measured at study enrolment, active travel behaviour at a 2-year follow-up, and depressive symptoms at a 4-year follow-up. Moderation was examined using adjusted linear regression models including an interaction term between the built environment factor and active travel behaviour. Results: The built environment factor was positively associated with depressive symptoms ({beta} = 0.023, p = .012). Active travel behaviour was not associated with depressive symptoms ({beta} = -0.002, p = .854) and did not moderate the association between the built environment factor and depressive symptoms ({beta} = -0.002, p = .865), after adjusting for covariates, including age, familial depressive history, socioeconomic risk factors, physical activity, baseline depressive symptoms and smoking. Conclusion: Contrary to expectations, active travel behaviour does not modify associations between the built environment and depressive symptoms. These findings provide no evidence that active travel mitigates mental health risks associated with the built environment in this population.

Recent industry surveys have reported widespread concern about mental health, working conditions, and harassment in the UK film and television industry, but no peer-reviewed empirical study has examined the determinants of occupational burnout in this workforce. The present study tested whether physical health, mental wellbeing, perceived public stigma, intrinsic job quality, and sexual harassment exposure predict burnout in industry professionals. A cross-sectional online survey was completed by 415 individuals across more than 100 job titles, with 286 also completing an optional harassment module. Mental wellbeing sat well below population norms, with 68% scoring in the range indicative of probable depressive symptoms and 82% in the high-exhaustion range on the Maslach Burnout Inventory General Survey. Mental wellbeing and intrinsic job quality were the strongest predictors of burnout (R2 = .56), with meaningfulness accounting for most of the job-quality effect. Working hours independently predicted emotional exhaustion. Harassment exposure was associated with burnout in women but not men, approximately 30% mediated by mental wellbeing; sexist behaviour directly predicted exhaustion in women. Workers with a disability reported higher stigma. Burnout was strongly associated with intent to leave, and the findings collectively indicate an industry-wide occupational health concern requiring structural rather than individual-level intervention.

OBJECTIVE To assess associations of ambient UV with cardiovascular and cancer mortality across US Health Service Areas (HSAs), prioritise outcomes by signal and attributable burden, assess racial and ethnic variation, with UK Biobank corroboration. DESIGN Ecological analysis of HSAs using linear regression of crude mortality on ambient UV and social vulnerability, with correction for multiple comparisons. SETTING US HSAs and UK Biobank. DATA SOURCES Publicly available US data and UK Biobank data accessed under Application 82526. PARTICIPANTS 704 808 annual cardiovascular deaths (aged [&ge;]65) and 565 287 annual cancer deaths (aged [&ge;]50) from populations of 52.8 and 115.2 million; UK Biobank analyses included 412 665 individuals. MAIN OUTCOME MEASURES Cardiovascular, all-cancer, and body-site-specific cancer mortality; regression slope per interquartile-range increase in UV ({beta} UV/IQR), modelled attributable burden for US data, and hazard ratios for the UK Biobank data. RESULTS Higher UV was associated with lower cardiovascular ({beta}UV/IQR -68.3 deaths/100 000; P<0.001) and all-cancer mortality (-43.2; P<0.001), corresponding to 36 043 (5.1%) and 49 789 (8.8%) fewer US deaths annually, respectively. Associations varied by race and ethnicity. Cardiovascular findings were directionally consistent between US and UK datasets. All-cancer mortality and 10 of 18 cancers were inversely associated with UV in the US; UK analyses found inverse associations for all-cancer and two individual body-site-specific cancers. Twelve cancers showed directionally concordant associations across the datasets, of which ten were inverse. Lung cancer showed the strongest inverse association in each dataset. CONCLUSIONS Higher UV was associated with lower cardiovascular and cancer mortality across US HSAs, with modelled attributable burdens exceeding 5%; UK Biobank findings provided partial corroboration. Twelve of 18 site-specific cancers were directionally concordant between datasets. US race-stratified heterogeneity did not follow a skin-colour gradient, suggesting residual confounding.

Background: COVID-19 movement restrictions reduced social contact worldwide, curbing viral spread but with unequal economic consequences where social safety nets are limited. Little evidence exists on how these impacts varied by occupation, wealth and age in resource-constrained settings. This paper examined pre-pandemic contact and lockdown-related change. Methods: The paper documents analysis of a population-representative survey (N=8,499) in Manicaland, Zimbabwe, during April-May 2021, capturing typical weekday contacts before and during the first COVID-19 lockdown. Negative binomial regression models assessed pre-lockdown contact counts by socio-economic characteristics, overall and by place (home, school, work, transport, entertainment); linear regression assessed predictors of lockdown declines. Results: Pre-COVID-19, respondents reported a median of 12 daily contacts (interquartile range [IQR] 4-47), with higher counts among manual labourers (incidence rate ratio [IRR] 2.21, 95% confidence interval [CI] 2.00, 2.44), retail and public sector workers (IRR 2.33, 95%CI 2.09, 2.60) and students (IRR 2.59, 95%CI 2.38, 2.82), males, wealthier respondents, under-30s, and urban and agricultural estate residents. Counts were highest in schools. During lockdown, contacts fell across all subgroups to a median of 8 (IQR 4-28). Declines were greatest among those with most pre-COVID-19 contacts: urban (mean -17.5, 95%CI -19.53, -15.37) and agricultural estate residents (-18.1, 95%CI -19.99, -16.13), students and teachers (-17.7, 95%CI -19.82, -15.59), males and 30-44 year olds. Drops were greatest in schools and on transport. Conclusion: Reductions in contact under blanket lockdown varied markedly between subgroups and places in Manicaland, Zimbabwe. Selectively targeting high-contact groups might have achieved similar transmission reductions while limiting economic damage, holding lessons for similar settings.

Financial well-being (FWB) encompasses objective and subjective financial status and may influence health. We developed and validated a parsimonious FWB index using data from 23,006 Health and Retirement Study (HRS) participants aged 50 years and older from 2006 to 2022. The FWB-5 Index was derived using correlated two-factor confirmatory factor analysis accounting for household clustering. Indicators included household wealth, household income-to-poverty ratio, monthly financial strain, satisfaction with one's financial situation, and perceived financial mastery. We assessed convergent and discriminant validity using the Consumer Financial Protection Bureau Financial Well-Being (CFPB-FWB) Scale and Satisfaction with Life Scale, respectively. Associations with pre-baseline socioeconomic factors and subsequent depressive symptoms and health conditions were examined to assess construct and predictive validity. Model fit indices supported the two-factor structure (robust comparative fit index = 0.99; robust root mean square error of approximation = 0.05). Correlations were stronger with the CFPB-FWB Scale (Spearman P = 0.80) than with life satisfaction (Spearman P = 0.43). Associations with socioeconomic factors and subsequent health outcomes were in the hypothesized directions. These findings support the FWB-5 Index as a parsimonious measure for examining financial well-being and its associations with health across HRS waves, including those predating the CFPB-FWB Scale.

Background: Social vulnerability is associated with adverse health outcomes, but existing social vulnerability indices often rely on cohort-based and self-reported data, potentially limiting their population-level applicability. Therefore, this study aimed to develop an SVI from routinely collected electronic health records (EHRs) using natural language processing (NLP) and examine its association with mortality and healthcare utilization. Method: EHR data from 193,629 individuals aged 35 to102 from the Wellbeing Services County of Central Finland between years 2010 and 2023 were used in this study. A 6 item SVI (total score 0 to 6) was developed from free-text clinical notes using deep-learning-based NLP. SVI scores were calculated at baseline and annually for individuals. Associations between baseline SVI and all cause mortality and healthcare utilization were assessed over 12-year follow-up using Cox and count models. Results: The mean baseline SVI among all participants was 0.35 (range 0 to 6). Women had higher SVI (0.39) than men (0.32, p<0.001). SVI increased with age. One unit increase in SVI was associated with a higher risk of mortality (Hazard Ratio (HR) 1.23; 95% Confidence Interval (CI) (1.21 to 1.24), a higher odds of using healthcare services (Odds Ratio (OR) = 1.20; 95% CI): 1.19 to 1.21) and a greater healthcare service use (Incidence Rate Ratio (IRR) = 1.07; 95% CI: 1.06 to 1.07). Discussion: An index capturing multiple domains of social vulnerability can be derived from EHRs using NLP. Higher SVI was associated with increased mortality and healthcare utilization. These findings support the potential of EHR data for assessing social vulnerability and related health risks.

Background Short-term weather conditions can trigger paediatric hospital admissions, but evidence remains limited on the health relevance of intraday temperature variability, humidity, and precipitation, and generally on which subgroups are most susceptible. Methods We conducted a nationwide case time-series study of Swedish children and adolescents aged 6-18 years using linked register data. Associations between daily mean temperature, intraday temperature variability, relative humidity, and precipitation and inpatient hospitalisations were estimated with Poisson regression (individual fixed effects) combined with distributed lag non-linear models over lags 0-21 days. Outcomes included all-cause hospitalisation and cause-specific admissions. Effect modification was examined by sex, age group, socioeconomic indicators, region, and calendar periods. Findings Among 4,638,247 children and adolescents in the cohort, 1,070,702 (23.1%) experienced at least one inpatient hospitalisation, contributing 1,736,169 hospitalisation events. All-cause hospitalisation increased with higher mean temperature, with risk highest at hot extremes. Intraday temperature variability showed a U-shaped association, with higher rates at both lowest and highest exposure levels. Relative humidity showed no association with hospitalisation risk. Higher precipitation was associated with increased hospitalisation risk, but estimates at high rainfall levels were imprecise. Stratified analyses indicated modest differences by sex and socioeconomic indicators, but clearer heterogeneity by age and region, with the highest risks among younger children and in East Sweden; associations varied across calendar periods and were imprecise for most cause-specific outcomes. Sensitivity analyses mostly showed that the main curve shapes were robust. Interpretation Short-term exposure to hot temperatures, both low and high intraday temperature variability, and higher levels of precipitation were associated with an increased risk of all-cause hospitalisation among children in Sweden, with clearer variation by age group and region than by sex or socioeconomic position. These findings support targeting paediatric climate-health preparedness and early-warning systems toward younger children and higher-risk regions such as eastern Sweden and extending such systems beyond mean temperature to include intraday temperature variability, a distinct, currently overlooked driver of risk that heat-focused systems are not designed to capture. Fundings This research was funded by Formas the Swedish Research Council for Sustainable Development (grant no. 2023-01774 and 2022-01845) and the Swedish Research Council (2025-02804 and 2022-06599).

Introduction: Raised blood pressure is an important cardiovascular risk factor in Cambodia; however, national averages may obscure substantial local geographic heterogeneity. We assessed the spatial distribution of raised blood pressure and its demographic, metabolic, behavioural, built-environment, and environmental correlates using the 2023 Cambodia STEPwise approach to noncommunicable disease (NCD) risk factor surveillance (STEPS) survey. Methods: We analysed 289 georeferenced primary sampling units (PSUs) from the 2023 Cambodia STEPS Survey. PSU-level case counts and numbers of adults with valid blood pressure data were modelled using a frequentist binomial generalised additive model with a two-dimensional Gaussian-process smooth. An explanatory model included selected PSU-level and contextual covariates; a separate mapping model used spatially continuous predictors to generate predictions on a 5-km grid. Design-based national and residence-specific prevalence estimates were calculated separately using the survey design and Step-2 weights. Results: Among 4,225 adults with valid blood pressure data, unweighted prevalence of raised blood pressure was 28.6%, compared with 18.8% after Step-2 weighting; weighted prevalence was 17.5% in rural areas and 21.7% in urban/suburban areas. Mean observed unweighted PSU-level prevalence was 29.0%. In the adjusted spatial explanatory model, the proportion aged 60-69 years ({beta}=1.969, SE=0.327; p<0.001) and overweight/obesity prevalence ({beta}=0.996, SE=0.265; p<0.001) were positive ecological correlates. The spatial model had lower Akaike information criterion and residual deviance than its non-spatial counterpart, although Bayesian information criterion was higher. Prediction uncertainty was greater in some sparsely sampled areas. Conclusions: Raised blood pressure showed significant geographic heterogeneity across Cambodia. Older age composition and overweight/obesity prevalence were positive PSU-level correlates, not individual-level causal effects. Predicted prevalence should be interpreted alongside uncertainty and should complement, rather than replace, design-based STEPS prevalence estimates for geographically informed NCD planning.

Background: Childhood lead exposure is a major global health concern. The 2025 Bangladesh Multiple Indicator Cluster Survey (MICS7) measured blood lead in a nationally representative sample of children aged 12-59 months for the first time. Preliminary reports suggested elevated blood lead was more common in wealthier urban households, contrary to the usual assumption. Methods: We analysed 10,622 children with a valid blood lead result (10,458 with complete covariate data for regression models). Elevated blood lead was defined as >=5 ug/dL. Prevalences are survey-weighted with design-based confidence intervals. Associations were estimated with survey-weighted logistic regression using stratified-cluster (Taylor-linearised) variance, and checked with a stratified bootstrap of primary sampling units and Benjamini-Hochberg false-discovery-rate control. Sensitivity analyses varied the outcome definition, the sample, and the weighting. Results: Survey-weighted prevalence of elevated blood lead was 38.5% (95% confidence interval [CI] 37.2-39.9%). Prevalence rose monotonically from 30.2% in the poorest to 51.9% in the richest wealth quintile. In the fully adjusted model, each wealth quintile was associated with 23% higher odds (adjusted odds ratio [AOR] 1.23, 95% CI 1.16-1.30), each level of maternal education with 20% lower odds (AOR 0.80, 95% CI 0.76-0.84), and urban residence with 37% higher odds (AOR 1.37, 95% CI 1.18-1.59). Household crowding was associated with higher odds (AOR 1.17 per person per room, 95% CI 1.10-1.24). The wealth-education interaction had AOR 0.95 (95% CI 0.92-0.98). In an exploratory contrast, weighted prevalence was 76.2% among children in the richest quintile with mothers having at most primary education versus 19.5% among those in the poorest quintile with mothers having higher secondary or tertiary education (prevalence ratio 3.9, 95% CI 2.6-6.0). Adjusted odds relative to Barishal ranged from 0.39 in Rajshahi to 3.29 in Dhaka. Conclusions: In this cross-sectional survey, elevated blood lead was more prevalent among wealthier and urban households and among children of less educated mothers, with large geographic variation. Lead prevention and source-identification efforts should therefore not be restricted to poor communities; prevalence remained high even in the poorest quintile. Interpretation is limited by substantial missing blood lead results and coding uncertainty.

ObjectivesTo estimate age trajectories of infant mortality among Palestinian refugees using electronic health records, addressing the scarcity of reliable mortality data in forced displacement settings. SettingPalestinian refugees living in Gaza, West Bank, Jordan, Syria and Lebanon. DesignWe fitted a Bayesian Negative Binomial model to observed death counts, using a flexible parametric function (a shifting power function) to capture the shape of the infant mortality curve, across strata to infer age trajectories of infant mortality. ParticipantsPalestinian refugees born in 2010-2020 and registered with UNRWA health services in Gaza, West Bank, Jordan, Syria and Lebanon. The sample was stratified by sex, field, gestational age and birth cohort. Main outcome measuresSurvival rate to age 1. ResultsOverall, the survival rate to age 1 was 98.64%, with slightly lower rates for males (98.57%) than females (98.68%). Across settings, West Bank refugees had the lowest infant mortality (99.08% survival rate), and Jordan refugees had the highest (98.22% survival rate). Results by gestational age showed a 98.85% survival rate at age 1 among term births compared to a 73.32% survival rate among very preterm births. Survival rates by cohort (births up to 2015 or after) were 98.78% and 98.42%, respectively. ConclusionOur findings highlight the potential of electronic health records for mortality monitoring in forced displacement settings as they reveal consistent mortality trajectories by sex and gestational age, while identifying meaningful variation across refugee settings and subgroups. Summary boxesO_ST_ABSWhat is already known in this topicC_ST_ABSWe searched PubMed and Google Scholar for articles published between Jan 1, 2000, and Feb 20, 2026, in English, using the terms "Palestinian refugees," "infant mortality," "neonatal mortality," and "UNRWA." We found a handful of studies estimating infant mortality among Palestinian refugees, mostly based on household surveys (eg, MICS, national statistical office surveys) or UNRWA surveys using preceding birth techniques. The preceding birth technique has notable limitations, including recall bias, small sample sizes, and selection bias. The majority of these studies focus exclusively on Palestinian refugees residing in Gaza. Estimates for Gaza suggest a sustained decline, from around 127 deaths per 1,000 births in 1960 to 20.2 per 1,000 births in 2006, with a slowdown thereafter and an increase in more recent years. A combined estimate (excluding Syria) across four settings where Palestinian refugees reside measures infant mortality at 18 per 1,000 births in 2011. What this study addsThis study uses a unique data linkage bringing together UNRWAs obstetric and child health records, providing more extensive information and a larger sample size than previous studies. This is also the first study to assess the data quality of these electronic records and to estimate age trajectories of infant mortality among Palestinian refugees. We developed a statistical strategy that estimated infant mortality trajectories covering all five UNRWA fields (Gaza, Jordan, Lebanon, Syria, and the West Bank) for children born in 2010-2020, and examined differences across subpopulations by sex, field, gestational age and cohort.

Background Italy experiences a substantial heat-related mortality burden, but evidence on cause-specific mortality across its heterogeneous climatic settings remains limited. We aimed to quantify cause-specific mortality attributable to summer heat in Italy at national and ecological region levels and to map its distribution across municipalities. Methods We analysed daily deaths classified by underlying cause in eight ICD-10 groups among individuals aged 18-64 years and 65 years or older across 7,864 municipalities during June-August, 2004-2023. Mortality data were linked to area-weighted ERA5-Land daily maximum temperature. Nonlinear temperature-mortality associations were estimated with Bayesian hierarchical Poisson models, fitted separately for each cause, age group, and ecological region, with municipality-level attributable fractions. Findings High temperatures were associated with mortality from a broad range of causes, particularly among individuals aged 65 years or older. Among the study population, heat-attributable fractions were highest for nervous system diseases (14.93%, 95% credible interval 14.22-15.69) and mental and behavioural disorders (14.47%, 13.55-15.39). Circulatory diseases accounted for the largest absolute burden, with 85,524 heat-attributable deaths (82,762-88,271) across the summers of the 20 years considered. Interpretation The mortality burden associated with summer heat in Italy extended well beyond circulatory and respiratory diseases, highlighting the relevance of a broader range of health outcomes. These findings support heat-health strategies that account for cause-specific and geographical differences in heat-related risk, with greater consideration of neurological and mental health outcomes alongside established cardiorespiratory risks. Funding NextGenerationEU (CUP: B53C23002660006); Imperial College Research Fellowship; NIHR Imperial Biomedical Research Center (BRC: NIHR203323).

Abstract Background Air pollution contributes substantially to morbidity and mortality in low-income countries, where reliance on solid fuels leads to high levels of household exposure. Colonisation of the upper respiratory tract by Streptococcus pneumoniae is a prerequisite for pneumococcal disease, and inhaled air pollutants may influence colonisation through impaired mucociliary clearance. Therefore, we investigated the association between S. pneumoniae colonisation and personal exposure to particulate matter (PM2.5) and carbon monoxide (CO) as well as temperature and relative humidity in older children in The Gambia. Methods We conducted a prospective study of 134 children aged 5-14 years across eight visits in rural Gambia. Personal 24-hour PM2.5, CO, temperature and relative humidity exposures were measured using personal monitors. Concurrently, combined nasopharyngeal/oropharyngeal swabs were collected at each visit, and S. pneumoniae colonisation was determined by microbiological culture. Mixed-effects logistic regression models were used to examine associations between environmental exposures and colonisation. Exposures were additionally decomposed into between-child and within-child components. Models were adjusted for age, season, and household income tertile. Results A total of 554 child visits with paired exposure and microbiological data were analysed. Overall, 24-hour geometric mean PM2.5 and CO were 12.6 {micro}g/m3 (95% CI 12.2-13.1) and 0.16 ppm (95% CI 0.14-0.19) respectively and overall S. pneumoniae colonisation prevalence was 39.7%. In conventional models, PM2.5, CO, temperature, and relative humidity were not significantly associated with S. pneumoniae colonisation after adjustment for confounders. In the within-between decomposition analysis, higher between-child temperature exposure was consistently associated with lower odds of colonisation (mutually adjusted model: OR 0.74, 95% CI 0.56-0.98; p = 0.034). Relative humidity showed an inverse within-child association in crude analysis (OR 0.70, 95% CI 0.52-0.93; p = 0.013), which attenuated after adjustment for season and other confounders. No associations were observed for PM2.5 or CO exposures. Conclusion At the exposure levels observed in this cohort of older children, PM2.5 and CO exposures were not independently associated with S. pneumoniae colonisation. The pattern observed for temperature suggests that longer-term temperature conditions may be more relevant to pneumococcal colonisation than short-term exposure variation in this setting.

Background: Non-optimal air temperature increases the risk of preterm birth, but how temperature-related risks may translate into future population burden remains uncertain. We aimed to estimate the association between temperature and preterm birth in Sweden and assess how preterm birth burden may change under plausible future temperature conditions. Methods: We conducted a nationwide population-based cohort study of singleton births in Sweden from 1973 to 2018. Weekly mean temperature was assigned at the parish level according to maternal residence. Cox proportional hazards models with a distributed lag nonlinear model were used to estimate nonlinear and delayed associations between temperature and preterm birth. The estimated exposure response relationship and baseline hazards were then incorporated into an individual-based microsimulation of gestational progression under projected temperatures for 2025 to 2055. Future projections were examined across multiple climate models under SSP1-2.6 and SSP3-7.0 scenarios. Outcomes included the annual number and cumulative incidence of preterm births and the temperature-attributable fraction. Results: Among 4,338,825 singleton births, 211,397 (4.9%) were preterm. Temperature preterm birth associations were modest overall. The clearest increase in hazard was observed following exposure to very low temperatures, particularly -10C at short lags. Higher temperatures showed no clear increase in risk. From 2025 to 2055, the annual cumulative incidence of preterm birth and the temperature-attributable fraction was expected to remain broadly stable, with limited differences between emissions scenarios. In contrast, the absolute number of preterm births was expected to over the projection period, primarily reflecting increases in the projected number of pregnancies rather than substantial changes in temperature-associated risk. Conclusions: Very low temperatures were associated with a modest short-term increase in preterm birth risk in Sweden, hot temperatures showed little evidence of increased risk. Applying these associations to future climate conditions suggested limited changes in preterm birth incidence or the proportion attributable to temperature through 2055. However, the absolute burden of preterm birth may increase as the population at risk grows. This highlights the importance of considering demographic change alongside climate projections when assessing future maternal and neonatal health burden.