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: Rising rates of young people Not in Education, Employment, or Training (NEET) in the UK have recently coincided with declining youth physical and mental health but no study has asked whether this reflects a growing proportion of young people with health problems (prevalence) or those with health problems becoming more likely to be NEET (penalty). Methods: Using 15 years of Understanding Society data (2009-23), we analysed 15,242 respondents aged 16-24 (66,160 observations). We employed three complementary approaches: descriptive trends, Blinder-Oaxaca-Kitagawa (BO) probit decomposition comparing 2009-2013 and 2019-2023 against a 2014-2018 reference period, and fixed-effects (FE) Poisson models with lagged health status. Exposures included self-reported health conditions or disability (SRHD), psychological distress , diagnosed conditions and socio-demographic factors. Findings: NEET rates were lowest in 2014-18 (10.5-11.5%) and higher in 2009-13 (12-15%) and 2019-23 (15-16%). Higher prevalence of SRHD, psychological distress, diagnosed depression and multimorbidity explained changes in NEET prevalence across both the 2009-13 to 2014-2018 and 2014-18 to 2019-23 periods. No change in penalty was observed for any health variable across periods, except for an increase in the penalty for SRHD between the 2009-13 to 2014-18 periods. Interpretation: Rising NEET rates among UK youth are driven largely by more young people having physical and psychological ill health. Whilst labour market and education accommodations remain important, reducing NEET rates will require reversing the decline in youth health, not just accommodating it.

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.

Background: Health visiting in England is a universal service designed to identify family need and offer more support where needed (proportionate universalism). We know little about how local areas deliver services for families facing adversity or their associated outcomes. Methods: Using linked Community Services Data Set and Hospital Episode Statistics data (2018-20) for 57/152 areas, we (a) described health visiting service delivery for children whose mother had a previous hospital admission with mental health issues, alcohol/substance misuse or violence/abuse recorded (study definition of adversity), (b) identified common service delivery patterns using latent class analysis; and (c) tested whether patterns were associated with child and maternal outcomes, overall and in terms of inequalities for families facing adversity. We conducted four experts-by-experience workshops to aid interpretation. Results: Three service delivery patterns for families facing adversity emerged, distinguished primarily by the intensity and age-distribution of contacts. In areas where health visiting was delivered with a high intensity across the whole 0-5 years age range (rather than targeted primarily at babies), children were more likely to meet expected levels of development at age 2-2.5 years (ORadj: 0.79, 95% CI:0.63-0.99) and child inequalities in injury-related hospital admissions and some developmental domains were reduced. Conclusions: We found that a pattern of health visiting aligned with proportionate universalism was associated with mitigating disadvantage for families facing adversity. With limited outcomes and forms of adversity captured in our study, we cannot say which service delivery pattern is best, but our findings evidence the potential of health visiting to reduce inequalities.

Background We examined whether two key housing quality indicators, energy efficiency and household overcrowding, were associated with lower respiratory tract infection (LRTI) hospital admissions in infants. Methods We used a cohort of all singleton births in Scotland 2010-2012, created through linked vital statistics and health data. LRTI admissions were characterised in hospital records. Overcrowding (defined using the national room standard) and median postcode-level energy efficiency were defined using maternal Census and postcode-level Energy Performance Certificate data linked to the cohort, respectively. We used logistic regression to model the odds of at least one infant LRTI admission. Results The cohort included 136,123 infants of whom 4.0% had at least one LRTI admission. Overcrowding was more common among infants of younger mothers and those in rented housing. Energy efficiency was lower among infants of older mothers, living in owner occupied homes, in less deprived areas. Compared with infants living in homes with excess rooms (under-occupied housing), those whose homes were below, or met, the minimum room standard had higher odds of LRTI admission (adjusted odds ratio 1.07, 95% CI 0.98-1.17; 1.10, 95% CI 1.03-1.17, respectively). Postcode-level energy efficiency was not associated with LRTI admission odds. Conclusion Overcrowding was more common in socioeconomically disadvantaged households and associated with increased risk of LRTI admission in infancy. Lower energy efficiency was associated with factors commonly linked to socioeconomic advantage and was not associated with LRTI admissions. Improving access to housing with adequate living space may reduce the burden of LRTIs in early life.

Background: High rates of young people who are not in education, employment or training (NEET) are a major societal concern in the UK. Whilst other studies have highlighted that adolescent health can predict NEET status in young adulthood, robust and recent longitudinal evidence remains limited. Methods: This study used data from the Millennium Cohort Study, a longitudinal study of people born in the UK in the early 2000s, to estimate the extent to which mental health conditions, physical health conditions and health behaviours during adolescence predict NEET status in early adulthood (median age: 23). Co-occurrence of exposures was also considered and population attributable fractions were calculated to account for differences in exposure prevalence. Results: Among 8,374 young people, 12.5% were NEET at age 23; approximately two thirds were seeking work and one third were economically inactive. Estimates adjusted for demographic factors indicated that multiple health exposures increased risk of being NEET at age 23, with mental health conditions predicting greater risk than physical health conditions and health behaviours. For instance, a longstanding mental health condition more than doubled the risk of being NEET (adjusted relative risk [aRR] = 2.39, 95% CIs = 1.85, 3.09), while autism (aRR = 3.60, 95% CIs = 2.69, 4.83) and ADHD (aRR = 3.25, 95% CIs = 2.38, 4.44) more than tripled the risk. A greater number of reported adolescent mental health conditions was associated with greater risk of being NEET in young adulthood. Obesity predicted being NEET at age 23 (aRR = 1.54, 95% CIs = 1.18, 2.01) and obesity accompanied by a mental health condition further increased risk (aRR = 2.01, 95% CIs = 1.38, 2.93). Follow-up analyses indicated that associations between adolescent mental health and young adult NEET status were more pronounced for females than males and for the economically inactive than those seeking work. Conclusions: Findings indicate that adolescent health, especially mental health, strongly predicts being NEET in early adulthood. Early, integrated health and education interventions may help reduce later educational and labour market disengagement.

Objectives The association between occupational physical activity (OPA) and cardiovascular disease (CVD) may depend on how OPA is classified. This study examined the association between OPA and incident CVD using individual level and occupational group level classifications, and assessed whether factors contributing to attenuation differed. Methods A total of 137,592 employed UK Biobank participants aged 40 to 69 years who were free of CVD at baseline were included. OPA was classified using (i) individual level self reported physical activity at work and (ii) occupational group level two digit Standard Occupational Classification. Associations with incident CVD were examined using Cox proportional hazards models. Attenuation of associations by sociodemographic, lifestyle, health, occupational and psychosocial factors was assessed using univariate adjustments and Heller's coefficient. Results During 1,656,378 person-years of follow up (median 12.6 years), 10,465 incident CVD events occurred. The association between OPA and CVD differed markedly according to exposure classification. High individual level self reported OPA was associated with increased CVD incidence after full adjustment [hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.10 to 1.27]. In contrast, no association was observed when OPA was classified at the occupational-group level using Standard Occupational Classification groupings (HR 1.00, 95% CI 0.94 to 1.06). Sociodemographic and health factors accounted for the greatest attenuation across both classifications, whereas psychosocial factors contributed primarily to associations based on individual-level self-reported OPA. Conclusions The association between occupational physical activity and incident cardiovascular disease differed substantially according to how OPA was classified. These findings highlight exposure classification as a critical consideration when interpreting evidence on the physical activity paradox.

Objective We characterized social determinants of health (SDOH) in U.S. children who ever and never had Long COVID. Methods We used cross-sectional data from the 2022-2023 National Health Interview Survey (N=14,993 children 0-17 years). Parents reported child- and household-level information. Long COVID was defined as ever experiencing symptoms lasting [&ge;]3 months that were not present prior to having COVID-19. We produced weighted prevalence estimates by Long COVID status for 3 SDOH domains (Social and Community Context, Healthcare Access and Quality, and Economic Stability) and used Rao-Scott chi-squared tests to examine differences. Results In Social and Community Context, children who ever had Long COVID more often resided in single parent households (33.2% vs. 20.3%; p<0.0001), with someone with severe depression or mental illness (18.5% vs. 8.3%; p<0.0001) or substance abuse (16.7% vs. 8.1%; p<0.0001) or had a lifetime of being disparaged by adults in the home (9.2% vs. 3.9%; p=0.0009). In Healthcare Access and Quality, children who ever had Long COVID more often had public insurance (e.g., Medicaid) (51.3% vs. 41.6%; p=0.02), higher healthcare use, and difficulty paying medical bills (23.2% vs. 12.2%; p<0.0001). In Economic Stability, children who ever had Long COVID had lower parental education, lower food security, and higher participation in social safety net programs (p<0.01 for all comparisons). Conclusion Children who ever had Long COVID more frequently experienced adverse SDOH compared to their peers who never had Long COVID. These findings may help identify children who may benefit from additional resources related to their Long COVID care.

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.

Seasonal Influenza and COVID-19 vaccination programmes are critical for reducing morbidity and mortality in older adults, yet uptake remains uneven across populations. We aimed to profile vaccination attitudes and examine predictors of COVID-19/influenza vaccination uptake among a UK participatory surveillance system - FluSurvey. We analysed FluSurvey data from participants aged [&ge;]65 years who were eligible for both vaccines in the 2023-2024 and 2024-2025 Autumn - Winter seasonal campaigns. Descriptive analyses examined self-reported attitudes to influenza vaccination. Logistic regression examined factors (age, sex, socioeconomic status, education, employment, transport, smoking and chronic conditions) associated with influenza and COVID-19 vaccination uptake in each season, adjusting for confounders. Belonging to a risk group and reducing risk of influenza were frequently reported motivations for influenza vaccination, while building natural immunity and concerns around safety and adverse effects were frequently reported barriers. Individuals vaccinated against COVID-19 were more likely to receive an influenza vaccination (aOR2023-2024=13.90 [9.28-21.17]; aOR2024-2025=8.54 [5.82-12.60]), and vice-versa (aOR2023-2024=13.91 [9.30-21.19]; aOR2024-2025=8.52 [5.81-12.58]). Lower educational attainment was associated with lower odds of COVID-19 vaccination (aOR2023-2024=0.59 [0.45-0.78], aOR2024-2025: 0.56 [0.39-0.79]). Other results were weaker or demonstrated variation by season. Our findings highlight recent attitudes and barriers to influenza and COVID-19 vaccination among the FluSurvey cohort, which may inform approaches to improve vaccination coverage in the population.

Background: Young people who are Not in Education, Employment, or Training (NEET) represent a major public health and societal challenge. Existing evidence has linked adolescent mental health problems and health risk behaviours to NEET but has largely treated NEET as a static, rather than longitudinal outcome and overlooked the combined effects of multiple health conditions. Methods: Using data from 5,262 participants born between 1993 and 2000 in the UK Household Longitudinal Study, this study examined the independent and combined associations of adolescent mental health problems (emotional symptoms, conduct problems, hyperactivity) and health risk behaviours (regular smoking, drug use, alcohol use, and high social media use) with ever-NEET status, NEET chronicity, and NEET trajectories from ages 16 to 24, using modified Poisson, proportional odds, and multilevel logistic regression models, respectively. Findings: All mental health problems were associated with ever-NEET status (RRs 1.24-1.27) and NEET chronicity (ORs 1.41-1.98); emotional symptoms showed a widening disadvantage with age, while the disadvantages associated with conduct problems and hyperactivity remained stable. Among health risk behaviours, regular smoking showed the strongest and most persistent relationships with NEET (ever-NEET RR 1.54; chronicity OR 1.64); drug use was related to ever-NEET status (RR 1.37) and an increasing disadvantage after age 21-22, while alcohol use and social media use showed limited associations. NEET risk generally increased with the number of co-occurring conditions, but for recurrent NEET (three or more occasions), risk was only elevated at three or more co-occurring conditions. Interpretation: Adolescent health exposures were associated with NEET risk during ages 16-24, but the strength and pattern varied by exposure and outcome, offering potential insights into the timing and emphasis of any interventions.

Importance: Estimates of SARS-CoV-2 vaccine effectiveness (VE) from observational studies may be biased if healthier (healthy vaccinee effect; HVE) or less healthy individuals are preferentially vaccinated. Quantifying HVE is essential for interpreting VE estimates for informed vaccination policy. Objective: To assess the HVE by comparing all-cause mortality, cancer mortality, and deaths from external causes between vaccinated and unvaccinated individuals. Design, Setting, and Participants: This nationwide retrospective cohort study used Austrian national registry data from 2021 to August 31, 2022, and included the entire adult population of Austria with no previously documented SARS-CoV-2 infection on January 1, 2021. Cox regression was used to estimate hazard ratios (HRs) for mortality comparing vaccinated with unvaccinated individuals while adjusting for age, sex and Austrian long-term care allowance (ALTCA) recipiency, stratified by vaccinations (1 to 4). Analyses were performed for the whole observation period, 3-month blocks (quarters) and the 2 months with highest and lowest COVID-19 disease burden per year. Additionally, newly vaccinated individuals were matched on day of vaccination based on the aforementioned covariates plus highest education and HRs were assed for the two weeks following vaccination. Exposure: Receipt of at least 1 dose of SARS-CoV-2 vaccine. Main Outcomes and Measures: All-cause mortality, cancer mortality, and deaths from external causes (e.g., falls and transport accidents). Results: Among 7,416,077 eligible adults, all-cause mortality was lower among vaccinated than unvaccinated individuals regardless of vaccination number. Differences in risk were greatest shortly after vaccination and attenuated over time. E.g., adjusted all-cause HRs in the quarter after vaccination introduction were 0.46, 0.52, 0.38 and 0.43 for vaccinated vs unvaccinated individuals for 1, 2, 3 and 4 vaccinations, respectively. Respective HRs for the first 2 weeks after vaccination in the matched analysis were 0.24-0.32 across all vaccinations. Findings for cancer mortality and deaths from external causes paralleled those for all-cause mortality. Conclusions and Relevance: A pronounced HVE was observed for SARS-CoV-2 vaccination during the pandemic, evidenced by markedly lower mortality from causes not plausibly related to vaccination (cancer, external causes) among vaccinated individuals. This bias needs to be accounted for when interpreting observational estimates of SARS-CoV-2 VE.

Adverse experiences in childhood (AEs) typically refer to undesirable events, including child maltreatment and household challenges. Various survey measures and linked routine data in the Born in Bradford Birth Cohort (BiB) datasets can provide a contemporary understanding of the distribution of AEs in the population and the factors related to their occurrence. This study aimed to identify relevant survey data on AEs collected from BiB families and to summarise the prevalence of AEs from birth to early adolescence (ages 12-15) among BiB children. We included BiB children who participated in the follow-ups - Growing Up (GUp, n=5253) and Age of Wonder (AoW, n=2662). Four AEs were identified - parental mental illness, parental substance use, children not living with both parents in the same home, and being bullied by peers. The survey data included 1) health, substance use, living arrangements, and children's bullying experience reported by parent(s) at baseline (2007-2011, around birth) and/or GUp (2017-2022, during mid-childhood), and 2) bullying experience and living arrangements self-reported by children at AoW (2022-2024, during early adolescence). Additionally, we included parents' primary care records regarding any mental illness or substance use. Overall, 3371 (64.2%) children experienced at least one of the four AEs between birth and early adolescence. The most common AE was parental mental illness, whereas parental substance use was the least common. Children across all sociodemographic groups experienced AEs. Asian children, or those whose mothers were not materially deprived, appeared less likely to experience AEs. Conversely, children of White or Mixed ethnicities, or whose mothers were materially deprived, were more likely to experience AEs. Consistent with similar studies, our findings show that AEs are widespread but disproportionately affect certain sociodemographic subgroups among BiB children. These disparities can be reduced by early-years policies that provide practical family support, guided by continuously collected AE data.

Background: Adults with disability tend to need more healthcare and to have less capacity to pay for it. Kenya replaced the National Hospital Insurance Fund (NHIF) with the Social Health Authority (SHA) in October 2024, so KDHS 2022 is the last pre-transition national survey containing these measures. We examined differences by disability status in health insurance coverage, healthcare use, and outpatient payment before the transition, including how insurance coverage varied across disability severity and what could be observed about insurer contributions at the point of care. Methods: Cross-sectional analysis of the KDHS 2022 person recode, covering adults aged 18 and above in the long-questionnaire subsample that carried the disability, insurance and service-use modules. Disability used the Washington Group Short Set (WG-SS). Survey-weighted quasi-Poisson models gave prevalence ratios under three adjustment sets with marginal standardised differences; severity categories were contrasted directly; amounts and payer sources were analysed among those who reported paying, with bounds where payer source is unrecorded. Results: Of 40,197 adults, 6.7% met the WG threshold. Uninsurance was higher among them unadjusted (PR 1.10) and after adjustment for sex, age group and residence (PR 1.10, 95% CI 1.06 to 1.13; +6.7 percentage points), and was attenuated after adding wealth and education (PR 1.01, 95% CI 0.98 to 1.04; 0.6 percentage points, 95% CI -1.3 to 2.5). Outpatient use and hospitalisation were higher in every specification (fully adjusted PR 1.63, 14.0 percentage points, 95% CI 11.7 to 16.3; and PR 2.15, 7.7 percentage points, 95% CI 5.9 to 9.6; both p < 0.001). Among outpatient users with disability, 90.5% reported paying, insured or not. Among respondents who reported paying, insurance was associated with a lower probability that any part of the payment was made in cash (PR 0.89, p < 0.001), while among those who did pay cash the conditional cash amount was higher. Among insured outpatient users with disability who reported paying and had a recorded payer split, 15.1% had a recorded insurer contribution. Because payer information was not collected when no payment was reported, the corresponding proportion among all insured outpatient contacts was bounded between 11.9% and 32.9%. Conclusions: Adults with disability had higher crude uninsurance, but this difference was attenuated to the null after adjustment for wealth and education. They also had substantially higher outpatient use and hospitalisation, which persisted under every adjustment set. Most outpatient users reported making a payment at their last visit regardless of insurance status, while the insurer contribution could only be partially observed because payer information was not collected when no payment was reported. These estimates provide a pre-transition benchmark, against which SHA-era measurement should assess payment at the point of care alongside insurance coverage.

Background Child marriage/cohabitation before 18 years of age disproportionately affects girls worldwide, but its impacts on mental health are poorly understood. Existing research is mostly cross-sectional, hence unable to estimate causal impacts or longer-term outcomes of child marriage. Methods We analysed longitudinal cohort data across Ethiopia, India, Peru, and Vietnam from Young Lives to investigate the relationship between child marriage/cohabitation and life satisfaction and emotional symptoms. We used linear regression, difference-in-differences estimation (DiD), and propensity score matching (PSM) to examine short and longer-term impacts from age 19 to 29. Findings Across countries 5% (Peru) to 20% (India) of girls were child brides. Child marriage/cohabitation predicted lower life satisfaction -- pooled estimates at age 19 (-0.25 [95%CI=0.40,-0.10]), across 19-29 (-0.22 [95%CI=-0.32,-0.13]), and heterogeneity estimates suggest consistently negative impacts across countries. However, child brides have lower life satisfaction at age 8 even before marriage occurs, likely due to pre-existing disadvantages such as poverty that increase child marriage likelihood. DiD and PSM analyses confirm that most of the differences are due to pre-existing vulnerability and there is a small additional impact of child marriage on worse life satisfaction at age 19 (pooled matched estimate -0.09 [95%CI=-0.19, 0.00]). No differences in emotional symptoms were observed, nor any differences by age of marriage within the child-married sample. Interpretation Child brides have lower life satisfaction from childhood through to early adulthood, which is mostly explained by prior disadvantages and risk factors, with a small additional impact of child marriage itself.

Maternal depressive symptoms are a major public health concern in low- and middle-income countries (LMICs), yet evidence on their relationship with early childhood development (ECD) remains mixed. This study examined the association between maternal depressive symptoms and ECD outcomes during infancy and toddlerhood, and whether household composition moderated these associations. Additionally, we examined whether child stimulation activities were associated with ECD outcomes across both timepoints. We analysed data from 769 mother-child dyads drawn from a cluster-randomised controlled trial conducted in the Cajamarca region of Peru. Maternal depressive symptoms were assessed during infancy (approximately 5 months) using the DASS-21 depression subscale. Child development was assessed during infancy (mean age 5.2 months) using the CREDI and during toddlerhood (mean age 28.7 months) using the GSED Long Form. Associations were examined using linear regression models, adjusting for demographic, household, social, and caregiving covariates. Effect modification by number of siblings under 6 years and number of adults in the household was assessed. Approximately one in six mothers (17.4%) reported any depressive symptoms. Maternal depressive symptoms were neither associated with child development outcomes in infancy (adjusted {beta} = 0.01, 95% CI [-0.01, 0.01]) nor in toddlerhood (adjusted {beta} = -0.01, 95% CI [-0.07, 0.05]). No significant moderation was observed for either household composition variable. Among the covariates examined in the adjusted models, child stimulation activities showed the strongest independent association with child development at both timepoints, regardless of maternal depressive symptom status. We found no evidence that maternal depressive symptoms were associated with child development during infancy or toddlerhood, and household composition did not moderate these associations. These findings suggest that the relationship between maternal depressive symptoms and early child development may be more complex than previously assumed in this rural Andean context. However, the absence of an association in this study should not be interpreted as evidence that maternal depressive symptoms are unimportant, as previous research has documented important effects on maternal wellbeing, family functioning, and child outcomes.

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.