Journal of Epidemiology and Community Health

Background: Whole-population linked administrative data platforms provide an opportunity to generate evidence on early life multidimensional disadvantage to inform resourcing and service provision to families with complex needs. Methods: We used individual-level de-identified data from nine administrative data sources included in the Better Evidence Better Outcomes Linked Data (BEBOLD) platform. The population included all children born in South Australia between 2004-2011 (n=143,083), and their parents. We described the prevalence and distribution of multiple disadvantages affecting children from the 12 months before birth to age 5. Eleven domains of parental disadvantage were created: economic, education, access to services, mental health, substance misuse, smoking during pregnancy, domestic and family violence, health, child protection contact, justice system contact, and death. We investigated the concordance of our measure with an area-level socioeconomic measure used in government reporting. Results: One in two children (48%) were exposed to at least one disadvantage domain, and one in seven (14%) were exposed to three or more domains before age five. Economic disadvantage was most prevalent, affecting one in four (27%) children, of which 75% were exposed to additional forms of disadvantage. Substance misuse, domestic and family violence, and justice system contact were the least likely domains to occur in isolation. Only 54.4% who experienced five or more disadvantage domains were classified in the area-level socioeconomic measure's 'most disadvantaged' quintile. Conclusion: Early life exposure to parental disadvantage can be highly multidimensional. Measurement across different systems is important for informing coordinated service provision for families with complex needs.

Background Meat processing plants in Alberta, Canada experienced among North America's largest COVID-19 outbreaks. We examined health impacts among workers by occupational hierarchy and equity-relevant characteristics. Methods This exploratory sequential mixed-methods study was guided by community-based participatory research and the PROGRESS-Plus framework. Multilingual qualitative interviews and surveys using validated instruments were conducted among meat plant workers who experienced outbreaks. Interviews were analysed using inductive-deductive thematic analysis. Multivariable logistic regression and linear regression estimated associations between occupational group, racialization, facility, and self-reported COVID-19 diagnosis, physical and mental health, and mean Everyday Discrimination Scale score. We integrated findings using joint displays. Findings Qualitative and integrated analysis of thirty-six interviews described occupational hierarchy shaping unequal protection, limited communication, constrained agency, and psychosocial harms, amplified by income insecurity and family separation. Among 187 survey respondents, compared with general labour, skilled labour (aOR 0.38; 95% CI 0.15-0.89) and management (aOR 0.13; 95% CI 0.01-0.75) had lower odds of reported COVID-19 diagnosis. Compared with Black workers, other racialized workers had lower odds of reporting fair or poor mental (aOR 0.24; 95% CI 0.09-0.58) and physical health (aOR 0.20; 95% CI 0.06-0.54). Compared with workers from the primary facility, others reported lower mean everyday discrimination scores ({beta} = -0.54; 95% CI -0.96 to -0.12). Interpretation COVID-19 harms followed workplace social hierarchies. Pandemic preparedness should combine infection-control measures with paid sick leave and income protection, multilingual communication, enforceable anti-discrimination standards, and independent reporting mechanisms. Funding Canadian Institutes for Health Research (CIHR Application no. 469206). Keywords COVID-19, immigrant workers, migrants, essential workers, health equity, occupational health, PROGRESS Plus

Background Health inequalities between occupational or social class groups are pervasive and persistent. Healthcare professionals have better health outcomes compared to the general population. Whether this is a result of healthcare education, favourable socio-demographic characteristics among professionals or other effects is not certain and the extent to which single healthcare occupational groups exhibit inequalities is unknown. We have described self-rated health and quantified geographic health inequalities among a single occupational group of Registered Nurses compared to the general population. Methods We analysed nationally representative samples from the 2011 UK Censuses across England, Wales and Scotland in the Office for National Statistics Longitudinal Study and Scottish Longitudinal Study. Self-rated health and socio-demographic characteristics for the study population are described. Inequalities in health by area deprivation among Registered Nurses and the General Population are quantified. Logistic regression analysis was used to assess the association between Nurse status and self-rated health, adjusting for socio-demographic variables. Results Among economically active, working age adults (n = 478,802), we identified 9,180 Registered Nurses resident in England, Wales and Scotland. 59% of Registered Nurses reported very good self-rated health, with only 1% reporting poor or very poor health. A smaller proportion of Registered Nurses reported less than good health than the General Population at every level of area deprivation and had smaller absolute (4.1 percentage points vs. 9.1) and relative (RR: 1.5 vs. 2.0) inequalities between residents in the most and least deprived areas. Registered Nurses have an increased likelihood of reporting good or better health compared to the general population (Scotland OR: 1.3, 95% CI: 1.2 - 1.5, England & Wales OR: 1.4, 95% CI: 1.3 - 1.5) after adjusting for socio-demographic factors. Discussion Registered Nurses report better health compared to the general population and have smaller inequalities in health by area deprivation. However, unfair and avoidable geographical differences in health are present even in this socioeconomically privileged professional group. After adjusting for socioeconomic and demographic factors, the positive association between being a Registered Nurse and having good self-rated health remained.

Objectives We aimed to describe the characteristics of children and young people referred to social prescribing across the UK and understand what social prescribing looks like for these young people. Additionally, we aimed to explore whether access to and experiences of social prescribing vary with age and have changed from 2017 to 2025. Overall, we aimed to identify whether social prescribing reduces or exacerbates health inequalities among children and young people, and whether this has changed over time. Design Analysis of social prescribing electronic health records Setting Social prescribing hubs and services across the UK that use Access Elemental (a cloud-based social prescribing platform) Participants 52,585 individuals referred to social prescribing in 2017-2025 aged 4-25 years (mean=20.04, SD=4.71), of whom 57% were female, 39% male, <2% were in other gender groups, and 3% did not disclose their gender Primary and secondary outcome measures We summarised the characteristics of young people and described the care pathway received. We then used regression models to test whether these factors differed by age and over time. Results Most individuals were aged 18 and over, 91% lived in urban areas and 58% lived in the top three most deprived deciles of the UK. Most were referred by GPs or other allied health workers (79%) and mental health was the leading reason for referral (44%). The typical pathway included 4.64 social prescribing contacts (SD=7.70) totalling 66 minutes (SD=108), with 34% receiving an onward referral to community support. The average age of those referred to social prescribing increased over time. Conclusions Our findings indicate that social prescribing currently has limited reach for those under 18 and this disparity may be increasing. It was promising that children and young people referred to social prescribing were more likely to live in deprived areas. However, given current findings, more work is needed to increase the reach of social prescribing for children and young people across the UK.

Introduction Education is a core social determinant of health for children and adolescents. Unfortunately, academic achievement, health, and wellbeing of adolescents have decreased in many developed countries in the past decade. The purpose of the Wellbeing and Education linkages in school-aged children (WELL-ED) study is to examine associations of school absences and academic achievement with use of school-based and community-based health and social welfare services. In addition, we will assess user experiences and multi-sector services pathways of school-aged children for a better understanding of how the service system could respond to the needs of children. Methods and analysis WELL-ED is a large population-based study that combines register data on school absences and educational support from municipalities with register data on healthcare and social service use collected from wellbeing services counties in Finland. The study cohort includes all children who attended mandatory education in public schools in Southern Finland in school year 2023-2024. A smaller cohort of adolescents in school year 8 was invited to complete a user experience survey. The primary outcomes of this study are related to equity of service use. Ethics and dissemination The Regional Committee on Medical Research Ethics of the Helsinki and Uusimaa Hospital District (2803/2024) has approved the WELL-ED study protocol. For the survey, adolescents in year 8 and parents of adolescents younger than 15 provided informed consent. Results will be published in peer-reviewed journals, summaries will be sent to participating municipalities and wellbeing services counties and press releases will be written on key findings.

Background: The ECAIL trial, launched in 2017, targets hard-to-reach families and evaluates a multicomponent childhood obesity prevention intervention. At a maternity hospital in Lille, France, healthcare providers screened pregnant women experiencing social vulnerability, and dietitians delivered a home-based intervention until age 2. The COVID-19 pandemic led to a six-month suspension in 2020. This study compared eligibility and participation before the pandemic and after resumption, and examined how the pandemic and subsequent cost-of-living crisis shaped implementation and reach. Methods: We analyzed 5,744 eligibility questionnaires distributed at the maternity ward. Inclusion criteria included [&ge;]1 indicator of social vulnerability (e.g., socioeconomic disadvantage, precarious housing, or social isolation). To capture implementation experiences, a psychosocial researcher conducted a focus group with six dietitians delivering the intervention; it was recorded, transcribed, and analyzed thematically focusing on reach, acceptability, and adaptation. Results: Eligibility increased from 29.7% (n=955) prepandemic to 33.6% (n=849) after resumption, while the distribution of vulnerability criteriaremainedsimilar across periods:78.3% received social/medical benefits; employment was not the main source of household income for 58.7%; 24.4% experienced financial hardship; 14.7% reported social isolation; 6.0% lived in precarious housing; and 19.0% had three or more vulnerabilities. Participation among eligible women remained stable (24.6%; n=443). Qualitative findings indicated dietitians satisfaction and participants enthusiasm for the resumption of home visits, particularly in addressing social isolation. After resumption, the introduction of a pre-visit COVID-19 questionnaire reduced missed appointments. Converging qualitative and quantitative findings indicated sustained, and in some cases strengthened, provider engagement despite pandemic-related strain on hospital services. Conclusions: This study shows that a complex intervention can maintain reach and acceptability through adaptive implementation under major contextual disruptions.The rapid resumption of home-based services emerged as a robust strategy for engaging and retaining socially disadvantaged families, highlighting the importance of flexible, context-sensitive approaches during social and economic crises.

Background: Many mental health problems originate in childhood, highlighting the need for early preventive approaches. Preventive services to promote children's mental health are offered in the health, education, and social sectors (H-E-S) but are often not used by certain at-risk groups or early enough. To identify children at-risk and provide needs-oriented support, professionals from all sectors must be well trained, collaborate closely to refer to specialized services for specific mental health problems or risk factors, and understand the regional psychosocial support system and its services. A comprehensive approach to preventing mental health problems requires structured planning and a systematic overview of all institutions and services in the region and their collaboration. This study aims to map the preventive mental health and psychosocial support service system and the collaboration between institutions across three sectors (H-E-S) in two exemplary city districts. The study is integrated into a whole-district approach to child mental health promotion that is being implemented in one of the researched city districts, and its results will inform further activities there. Methods: We use a mixed-methods approach, combining qualitative interviews with a quantitative survey to map psychosocial services for children aged 4 to 10 and their families across the H-E-S sectors in two socioeconomically disadvantaged city districts in East and West Germany. All institutions that potentially offer psychosocial services for children and families will be approached to recruit professionals (e.g., schools, practices, counseling centers). To understand the regional psychosocial support system, we will analyze existing services and their characteristics (e.g., target groups, intervention types) descriptively. Social network analysis will be applied to gain an in-depth understanding of collaboration between institutions, to identify potential gaps in services and pathways, and to inform an intervention aimed at improving interinstitutional and intersectoral collaboration. Discussion: To our knowledge, this is the first study to comprehensively analyze regional preventive psychosocial support systems for children and families across sectors at the community level. Previous mappings of psychosocial services have focused on a single sector (e.g., health) or specific diagnoses only. The psychosocial preventive landscape spanning the H-E-S sectors involves complex financing structures and referral logics. Understanding the characteristics of the existing support landscape requires a systematic and comprehensive approach. Our study advances service mapping and operationalization methods in public health research. Additionally, the findings will inform recommendations for improving comprehensive prevention approaches in the selected city districts.

Introduction. Routine childhood immunisation is frequently disrupted in conflict-affected settings, leaving many children unvaccinated (zero-dose [ZD]). Their vaccination is now a global priority, but published evidence on restoring immunisation services in these settings is limited. We evaluated a nurse-led, community-based Expanded Programme on Immunisation adapted to a conflict-affected setting in Myanmar, focusing on factors associated with full immunisation (FI) among ZD children. Methods. This mixed-methods observational cohort study enrolled children from November 2023 to December 2025; analyses of FI outcomes were restricted to children enrolled >=18 months, with primary analyses focused on ZD children. Associations between programme delivery factors including vaccination opportunity (the ratio of vaccination sessions available to visits required for FI based on age and vaccination schedule [accelerated versus routine]) and FI were assessed using mixed-effects logistic regression with a random intercept for site. Programme cost and qualitative data from document review and questionnaires were also analysed. Results. Of 13,263 children enrolled, 6563 (49%) were in the analytic cohort; 2,684 (20%) were ZD. Among ZD, 452 (17%) were FI at 12 months and 1329 (50%) at 18 months. Accelerated schedule (OR 3.00, 95% CI 1.11-8.13) and greater vaccination opportunity (OR 2.1 per 0.5 unit increase in opportunity, 95% CI 1.8-2.4) were strongly associated with FI at 12 months, with smaller effects at 18 months. The cost per fully immunised ZD child was US$147, primarily reflecting substantial vaccine costs. Qualitative findings indicate that community engagement increased demand and access, but insecurity and logistical challenges limited service continuity and vaccination opportunities. Conclusion. FI improved over time but remained suboptimal through 18 months. Vaccination opportunity and schedule influenced the timing of FI, but sustained follow-up was critical for completion. Community-based delivery enabled restoration of immunisation services where formal systems had collapsed, demonstrating what is possible and what it demands in active conflict.

Objective: To verify the association between perceived social & emotional support and self-reported food insecurity in the United States Design: Cross-sectional secondary data analysis Setting: Behavioral Risk Factor Surveillance System (BRFSS) data from 2024, collected via a nationwide telephone survey. Food insecurity was defined as responding always, usually, or sometimes to "During the past 12 months how often did the food that you bought not last, and you didn't have money to buy more?" Social support was measured using a BRFSS item assessing the frequency with which respondents received the social and emotional support they needed. Adjusted logistic regression models were used to assess the relationship between these variables while controlling for a wide variety of demographic, socioeconomic, and health status factors. Participants: Adults (n = 190,577) aged 18-80 years old (72.3% non-Hispanic White) Results: Individuals who reported only "sometimes" receiving the social and emotional support they need were more likely to report food insecurity as compared to those who "always" receive such support (aOR = 1.75; 95% CI 1.56, 1.96). Conclusions: These findings indicate that decreased social support may put individuals at higher risk of food insecurity. Future work should seek to understand the mechanisms of this association to inform targeted policy and other interventional programs.

Background Physical inactivity and sedentary behaviour are major contributors to non-communicable diseases (NCDs) and are unevenly distributed across populations, disproportionately affecting migrants and ethnic minority groups. Somali communities in the UK experience multiple structural and socio-economic disadvantages; however, evidence on physical activity and associated inequities remains limited. This study examined physical activity, sedentary behaviour, and related barriers and facilitators among Somali residents in Sheffield, United Kingdom. Methods A cross-sectional mixed-methods study was conducted among Somali adults (n = 238). Quantitative data were collected using the International Physical Activity Questionnaire Short Form (IPAQ-SF) and analysed using descriptive statistics and ordinal logistic regression. Qualitative data were obtained from two focus group discussions (n = 14) and analysed using inductive thematic analysis to explore socio-cultural, environmental, and structural determinants of physical activity. Results No statistically significant predictors of physical activity were identified in the adjusted analysis; however, consistent trends indicated lower activity levels among older adults and those in employment. Qualitative findings revealed multiple, intersecting barriers rooted in structural inequities, including migration-related lifestyle changes, reduced incidental activity, sedentary occupations, limited health literacy, language barriers, financial constraints, and gendered responsibilities. Cultural norms and environmental conditions further shaped behaviour. Facilitators included community-based, culturally tailored interventions, peer support, gender-sensitive programmes, and adaptation of traditional practices. Conclusion Somali residents in Sheffield face overlapping structural and socio-cultural barriers to physical activity that are not fully captured by quantitative measures alone. Equity-oriented, culturally competent, and community-led interventions addressing both systemic and behavioural determinants are essential to improve access to physical activity and reduce health inequalities and NCD risk.

BACKGROUND: The UK National Institute for Health and Care Excellence recommends routine enquiry about domestic violence and abuse (DVA) in maternity care. We aimed to explore patterns and predictors of DVA enquiry during routine first antenatal care ( booking) appointments with midwives in South East London. METHODS: We conducted an observational cohort study using cross-sectional data collected through the St Thomas Hospital midwifery service between 1st January 2019 and 31st March 2023. Pseudonymised data were extracted from maternity records, comprising demographics, mental and physical health information, social factors, and DVA enquiry. We used linear mixed modelling to test associations between predictors and DVA enquiry. RESULTS: The dataset comprised 7,932 booking appointments with 7,007 women (median age: 32 years; ethnicity: 52% White, 27% Black, 7% Asian, and 15% other). Enquiry was made about current experiences of DVA in 79.4% of appointments. Black-identifying women (OR=1.28, 95% CI [1.11,1.46]) and those born in Sub-Saharan Africa (OR=1.37 [1.14,1.64]) were more likely to be asked than white-identifying and UK-born women. Single women were more likely to be asked than married or cohabiting women (OR=1.22 [1.08,1.38]). Those living in more deprived neighbourhoods were more likely to be asked (OR=1.07 [1.01,1.14]). Multivariable modelling found that being born in Sub-Saharan Africa or Southern Europe, and living alone but with additional support were all associated with increased DVA enquiry, while being born in North America or requiring an interpreter were associated with decreased enquiry CONCLUSIONS: Despite recommendations for routine DVA enquiry during all booking appointments, a substantial proportion of pregnant individuals were not asked between 2019 to 2023. Predictors of DVA enquiry reflected practical barriers (e.g. language), and known or perceived predictors of DVA risk (e.g. deprivation). Our findings suggest that midwives consciously or unconsciously prioritise DVA enquiry for women they believe are at greatest risk, against national guidelines.

Introduction: Socioeconomic deprivation is often associated with poorer health outcomes, but some studies suggest the opposite for Lyme disease. Here we test two hypotheses to explain this: differences in (i) local landcover of high risk habitats such as woodlands (landscape hypothesis) and (ii) outdoor recreation in such habitats (behaviour hypothesis). Methods: We analysed reported Lyme disease incidence data for 824 data zones in the city of Glasgow, UK, against deprivation rank (based on indicators relating to income, employment, health, education, crime and housing). We then tested how these relate to woodland cover and indices of urban greenspace usage (per capita and per ha of greenspace). Additionally, we measured Lyme disease hazard (density of infected ticks) in 32 greenspaces and tested relationships with deprivation, woodland and greenspace usage. Results: More advantaged data zones (data zones with low deprivation rank) had higher Lyme disease incidence. These areas had more woodland and woodland cover was positively correlated with both Lyme disease incidence and hazard. Deprivation did not correlate with greenspace usage, nor did greenspace usage correlate with Lyme disease incidence. Intensely used greenspaces had lower infected tick densities, consistent with a human disturbance effect on wildlife that carry ticks. Conclusions: Differences in woodland cover, but not outdoor recreation behaviour, can help explain our finding of higher Lyme disease incidence in more advantaged areas. However, to further test the behaviour hypothesis, we need more detailed data on outdoor recreation activity per capita both locally and in rural areas, as well data on mitigation behaviours.

BackgroundWork-related stress (WRS) accounts for 52% of self-reported work-related ill-health. In 2004, the Health and Safety Executive (HSE) developed the Management Standards (MS), aimed at helping organisations reduce WRS. This work investigates WRS post implementation, with reference to six MS risk factor domains: control, support, relationships, demand, change, and role. MethodCases of WRS were extracted from The Health and Occupation Research (THOR) database and mapped to the six domains. Trends in WRS incidence rates attributed to each of the domains were split at 2004 and compared with the overall WRS trend using mixed generalised regression models. ResultsBefore 2004, annual incidence in WRS increased by 1.4%(-0.5%,3.1%), whereas after 2004, there was a decrease of -0.9%(-1.5%,-0.2%), based on 10,815 WRS cases reported between 1996 and 2019. Three of the six MS domains (demands, relationships, and change) were reported in [~]82% of cases. Pre-2004, four of the six domains were observed to be increasing per year. Post 2004, cases increasingly contained multiple precipitating events e.g. demands + another (+2.6% per year) and relationships + another (6.1%). Reports of the two most common domains decreased post 2004 (demands -0.46%, relationships -0.55% per year), whereas incidence in less common domains increased (change 1.1%, support 2.4%, control 4.8%, role 4.7%). ConclusionTrends in WRS, and their common risk factors appear to be decreasing gradually, since introduction of MS in 2004. However, less common risk factors are becoming more prominent, contributing to reporting of WRS with multiple risk factors.

Background: Mortality rates have declined across most high-income countries for decades, but recent evidence suggests a slowdown in improvements or a shift to increasing mortality, particularly among working-age populations. The international distribution and drivers of these trends remain incompletely understood. Methods: Mortality trends during 2012-2019 were analysed using all-cause and cause-specific data from 30 countries. Trends were estimated via linear regression. K-means clustering with Dynamic Time Warping identified countries and ICD-10 chapters with similar temporal trajectories. Results: Trends varied substantially by nation. While Japan, Switzerland, and the Republic of Korea maintained consistent declines in all-cause mortality rates, increases were concentrated in the United States, Canada, and the United Kingdom, most prominently in persons aged 30-59 years. However, cause-specific analysis showed that rising mortality was not confined to these countries: most countries exhibited increases in at least one ICD-10 chapter, with several European countries showing increases across multiple chapters. Across countries, a small set of causes recurred among increasing trends, including external causes (self-harm, drug poisoning) at younger ages and chronic conditions (cardiovascular and liver diseases, specific cancers) in mid-life. Notably, ill-defined causes of death consistently appeared among the increasing causes across countries and age groups. Conclusions: Mortality increases in the 2010s were geographically more widespread than previously recognized. The recurrent rise in mortality from ill-defined causes suggests that an important component of mortality change remains poorly characterized. These findings indicate that stalled health progress is a systemic challenge across many high-income societies.

Background: The traditional wealth index, based on principal component analysis (PCA), used in the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), suffers from urban bias, distorting estimates of health inequality. We compared the traditional index (PEAR1) with an alternative two-component polychoric PCA index (POLY2) using annual expenditure from 12 LSMS surveys as the gold standard to determine which provides more accurate SEP measures for equitable policy targeting. Methods: We compared the traditional wealth index (PEAR1) with a two-component polychoric PCA approach (POLY2) using 12 LSMS (Living Standards Measurement Study) surveys (2015-2022) from 12 African countries. Annual household consumption expenditure was the gold standard. We assessed agreement using weighted Cohen's kappa and validated against education (proportion of households with secondary or higher education) using the concentration index (CIX) and slope index of inequality (SII). Results: The POLY2 index showed higher agreement with expenditure quintiles (average national weighted kappa = 43.3%) than the PEAR1 index (35.1%), with notable improvements in urban (43.5% vs. 27.5%) and rural (35.3% vs. 22.4%) areas. POLY2 also attenuated extreme household distributions observed in PEAR1. Education validation showed that POLY2 produced intermediate inequality gradients between the flatter expenditure-based gradient and the steeper PEAR1-based gradient. Conclusion: The POLY2 wealth index is superior to the traditional index, reducing urban-rural bias and providing more accurate socioeconomic classifications. Its adoption in large-scale surveys such as DHS and MICS is recommended to improve equitable monitoring of health inequalities in low- and middle-income countries.

Lower cognitive ability measured in childhood or late adolescence has been consistently associated with higher mortality risk across adulthood. However, this evidence largely relies on single assessments, leaving it unclear to what extent mortality risk reflects cognitive differences established early in life versus developmental divergence during adolescence - a period of substantial neurocognitive plasticity. Using two nationally representative Swedish cohorts comprising 9,412 males born in 1948 and 1953, we linked cognitive ability assessed in primary school at age 13 years and military conscription at age 18 years to all-cause and cause-specific mortality recorded in nationwide registers through 2025. We decomposed late-adolescent cognitive ability into childhood cognitive level and adolescent cognitive change and evaluated their independent associations with mortality. Childhood cognitive level (HR = 0.81; 95% CI, 0.78-0.85) and adolescent cognitive change (HR = 0.84; 95% CI, 0.79-0.89) independently predicted lower mortality risk, also after adjustment for parental education. Childhood cognitive level and adolescent cognitive change showed partially distinct cause-specific patterns. Childhood cognitive level was most strongly associated with mortality from intrinsic causes, whereas adolescent cognitive change showed relatively stronger associations with external causes, particularly accidental deaths. Although adolescent cognitive change was associated with psychosocial factors including education and psychiatric diagnosis at conscription, its association with mortality persisted after adjustment for these factors. These findings suggest that cognitive development during adolescence carries independent prognostic information regarding long-term survival beyond cognitive level established by late childhood, highlighting adolescence as a consequential period for lifelong health.

Background People with severe mental health conditions (SMHC) and caregivers in South Africa experience high rates of poverty. The PRIZE feasibility trial found that recovery groups were broadly acceptable and feasible and potentially effective in reducing relapse. Addressing economic needs was identified as a means to increase impact. This study aimed to understand experiences of financial insecurity and acceptability of poverty alleviation interventions as an adjunct to psychosocial interventions amongst people with SMHC and caregivers. Methods We conducted two focus group discussions and 12 in-depth interviews in isiXhosa with a total of 14 people with SMHC and 13 caregivers who had participated in PRIZE in Eastern Cape Province, South Africa. An inductive thematic analysis was conducted. Results We identified four major themes. Theme 1: Financial insecurity as a defining influence on life. We found that financial security was crucial to recovery, through bringing status and dignity. However, participants experienced substantial financial insecurity, which impacted on social and mental wellbeing. Financial insecurity was entrenched due to fractured and violent communities, cycles of debt and stigma amongst employers. Theme 2: Government disability grants are not a panacea. Difficulties accessing disability grants included problems attending assessments and rejection of applications. Whilst they were generally welcomed, receipt of disability grants sometimes caused problems such as increased stigma and family disagreements about how the money should be spent. Theme 3: Group savings offer conditional hope if carefully managed. Several caregivers had longstanding experiences of stokvels (community-based credit unions). However, some were fearful of group members absconding with funds. Participants emphasised that trust, safety and fairness are essential for successful group savings. Theme 4: Income-generating activities are desired but need capital and come with safety concerns. Many had ideas and motivation for small businesses but stressed the need for financial capital, skills training and financial literacy support. There were serious concerns that owning a business or gaining wealth could make one a target of crime. Conclusion Poverty alleviation interventions could positively impact on the wellbeing of people with SMHC and caregivers in South Africa as an adjunct to psychosocial interventions and psychiatric care. Approaches could include supporting access to social protection or existing savings groups, and nesting new savings groups or income generation initiatives into psychosocial interventions. Any model would need to incorporate robust mechanisms to ensure the safety of participants. All approaches would be enhanced by parallel social and public health interventions to build social capital and reduce violence in neighbourhoods.

Research on under-vaccination often segments populations using demographic or administrative variables that are operationally useful but fail to capture identity dimensions relevant to vaccination decisions. Drawing on social identity theory, we propose an identity-landscape approach distinguishing identity membership, identity centrality, and multidimensional identity structure. Using a cross-sectional survey of 1,000 UK parents, we measured 65 identity indicators, identity-importance ratings, and their association with attitudinal and behavioural hesitancy toward childhood vaccination using validated scales. Beyond established socio-demographic predictors, alternative-medicine and natural-lifestyle identities, as well as affiliation with social media networks, were linked to greater hesitancy. Greater centrality of religion and political affiliation within personal identity was also associated with higher hesitancy. Principal component analysis suggested that individuals actively engaged across multiple societal issues were more hesitant, whereas stereotypically male-gendered engagement was associated with lower hesitancy. An identity-focused population segmentation may identify previously unrecognized undervaccinated groups and inform innovative tailored immunization campaigns.

Introduction Access to quality early childhood development (ECD) services remains limited for families working in economic settings in many low-and middle-income countries. This study examined the associations between participation in integrated ECD centres of integrated ECD centres located in market and cross-border communities in Rwanda and childcare access, child nutrition, caregiving practices, and developmental outcomes. Methods A repeated cross-sectional pre-post evaluation without a comparison group was conducted between 2023 and 2025 across eight markets and cross-border ECD centres in Rwanda. Quantitative data were analyzed with logistic regression models adjusted for socio-demographic characteristics, while qualitative data were analysed thematically. University of Rwanda College of Medicine and Health Sciences Institution review board approved the study (No.366/CMHS IRB/2023). Results The proportion of children aged 6-23 months who achieved minimum meal frequency increased from 26.6% to 57% (AOR=2.35; 95% CI: 1.01-5.49), and those meeting minimum acceptable diet increased from 15.4% to 51.4% (AOR=4.51; 95% CI: 1.77-11.45). Stunting declined from 32.6% to 15.7% (AOR=0.45; 95% CI: 0.32-0.63) and underweight from 9.3% to 4.3% (AOR=0.55; 95% CI: 0.32-0.97). The proportion of children aged 24-59 months who were developmentally on track increased from 77.9% to 93.8% (AOR=3.85; 95% CI: 2.23-6.65). Households reported higher income at endline, and the centres generated strong demand for childcare services. However, reports of scolding and physical punishment increased between surveys. Conclusions Integrated ECD centres in market and cross-border settings were associated with improved child feeding practices, nutritional status, and developmental outcomes among children from vulnerable working families in Rwanda. Place-based childcare models may represent a promising strategy for expanding access to integrated ECD services while supporting womens economic participation in economic settings.

While SARS-CoV-2 and influenza continue to place a significant burden on population health, within-household differences in decisions towards vaccination and seeking care across these two pathogens, and across sociodemographic groups, remain largely unexplored. By conducting a household-level survey in Illinois, we found that many individuals made inconsistent decisions about vaccination: among all adults, 29% were vaccinated for only one of COVID-19 or influenza, and among those with children in the home, 39% lived with a child whose influenza or COVID-19 vaccination status differed from their own. A higher proportion of adults were vaccinated against COVID-19 compared to influenza, while the opposite was true for those younger than 18 years old. These differences hold even when accounting for disparities in coverage by age, race/ethnicity, political affiliation, and socioeconomic status. While vaccinated individuals consistently reported wanting to protect themselves or others, those who declined vaccination reported highly heterogeneous reasons ranging from resource constraints to distrust or misconceptions about vaccination. These differences are even more pronounced for COVID-19, with larger partisan gaps and higher refusal driven by safety concerns, lack of trust, or religious reasons than those who decide not to get the influenza vaccine. In contrast to vaccination, the decision to seek medical care when sick showed opposite sociodemographic trends, that are likely attributable to illness severity. Our findings highlight that closing gaps in COVID-19 and influenza vaccination coverage will require an integrative strategy that accounts for diverse motivations, fears, and barriers to access, while addressing social inequalities common to both diseases.