Preventive Medicine

Background. Although health mediation is widely studied in the U.S. through community health worker programs, evidence on their effectiveness in promoting cancer screening in Europe is limited. Since 2022, the "13 en Sante" program has implemented a multicomponent health mediation intervention -combining educational activities, outreach strategies, and navigation support- in socioeconomically disadvantaged neighbourhoods of Marseille, France. This study evaluates the effectiveness of this program in promoting breast, colorectal, and cervical cancer screening. Methods. A controlled before-after design based on two cross-sectional surveys was conducted in 2022 and 2024 in intervention or control neighbourhoods. Individuals aged 18-74 were randomly selected and interviewed via door-to-door questionnaires. Weighting was applied to account for stratified sampling and to align age and sex distributions with census data. Weighted logistic regression models were fitted for each cancer screening to estimate the intervention's effects on uptake and awareness at both individual and population levels. Findings. Overall, 4,523 individuals were included across the two cross-sectional surveys. The program successfully reached individuals facing cumulative socioeconomic barriers to healthcare access. No significant population-level effect was observed. At the individual level, declared exposure to health mediation was associated with significantly higher uptakes of breast and colorectal cancer screenings (breast: 54% vs 74%, OR=2.3 [1.1-4.5]; colorectal: 30% vs 50%, OR=2.8 [1.3-5.8]). In addition, colorectal cancer screening awareness was significantly higher among exposed participants (83% vs 93%, OR=8.1 [2.1-31]). Interpretation. This study provides the first evidence that a multicomponent health mediation intervention could effectively promote breast and colorectal cancer screening in disadvantaged French neighbourhoods. The study highlights screening-specific mechanisms of action that should be considered to further optimize intervention effectiveness. Funding. The survey was funded by the Regional Health Agency of Provence-Alpes-Cote d'Azur and Sante publique France.

BackgroundBetween May and December 2022, the UK Health Security Agency reported 3,585 cases of mpox. The 2022 global outbreak was characterised by transmission predominantly within sexual networks of gay and bisexual men (GBMSM). UK public health responses included information and vaccination campaigns, supported by behaviour change among GBMSM. We describe community reflections on the UK mpox outbreak and the responses to it. MethodsBetween August 2023 and April 2024, we conducted five focus groups with participants (n=27) recruited through community organisations in London and Manchester. Participants were predominantly gay men from ethnically diverse backgrounds. Data were analysed thematically. ResultsComing soon after COVID-19, the mpox outbreak intensified fears of returning to lockdown. Reports of GBMSM being most affected, and its framing in the media as a gay disease, coupled with warnings within GBMSM networks echoed earlier experiences of HIV. Those who had acquired mpox reported that media coverage had intensified their experiences of stigma and discrimination. Participants perceived vaccine roll out as inequitable; Furthermore, the perceived sudden cessation of public health messaging and advice left participants uncertain about ongoing risk and the need for prevention. ConclusionsParticipant reflections two years after the 2022 mpox outbreak demonstrate how previous pandemics shape emotional responses to new outbreaks. Key challenges included stigmatising media coverage, inequitable vaccine rollout, and sudden discontinuation of public health messaging. These findings highlight the importance of targeted, non-stigmatising and unambiguous communication from trusted sources during and after an outbreak. What is already known on this topicThe media response to the 2022 UK mpox outbreak led to stigma among GBMSM and public health measures were not equitably accessible What this study addsPeople from communities affected by the outbreak sought timely information from trusted sources. Communication needs do not end with outbreaks How this study might affect research, practice or policyThere is a need for ongoing public health work to build trusted networks who can maintain inter-outbreak communications and respond rapidly to outbreaks

Suicide is one of the worlds leading public health problems, with more than 720,000 deaths annually. Suicide has traditionally been studied from an individual perspective. However, research has increasingly highlighted the influence of community-level factors on suicide risk. This study aimed to (1) analyse the spatial distribution of suicide mortality at the provincial level in Spain (2018-2022); (2) perform stratified analyses by sex and age group; and (3) compare suicide risk across different phases of the COVID-19 pandemic. We used data from the Spanish National Institute of Statistics on 19,381 suicide deaths in 47 peninsular provinces between 2018 and 2022. Covariates included sociodemographic (e.g. aging rate, population density), economic (e.g. unemployment, GDP), and environmental (e.g. temperature) indicators. Bayesian hierarchical spatial Poisson regression models were fitted to estimate suicide risk and identify significant contextual variables. The general spatial model revealed a higher risk of suicide in provinces with lower population density, higher aging rates, and lower health expenditure. Other covariates such as gross domestic product, unemployment, or temperature were associated with specific sex or age groups. Suicide risk was highest in the northwestern provinces and lowest in the central regions. Stratified analyses showed similar patterns across gender and age groups, and between time periods, with some variations in spatial distribution. This study reveals significant spatial heterogeneity in suicide risk across Spanish regions, influenced by socio-demographic, economic, and environmental factors. These findings underline the importance of regionally tailored suicide prevention policies, especially in aging and low-density areas with low health investment. Key MessagesWe examined spatial patterns and socioeconomic and environmental determinants of suicide mortality in 50 Spanish provinces between 2018 and 2022. We found persistent geographical inequalities in suicide rates, with higher mortality in low-density provinces and those with older populations, and protective effects associated with health expenditure. These findings highlight the importance of place-based suicide prevention strategies that consider regional disparities and socioeconomic vulnerabilities.

ObjectiveExplore self-reported racial discrimination in healthcare. MethodsRepresentative population sample, Switzerland, repeated cross-sectional data 2016 to 2024 (N=15,525). ResultsContrary to expectation, respondents from the migration-related population (foreign citizens, foreign born, migration background, first/second generation) report less racial discrimination than members of the majority population. Over time, we see an increase in the non migration-related population reporting (racial) discrimination in healthcare, while the share for the migration-related population is constant. The validity of the instrument is demonstrated with reported discrimination at work and in housing and the results are reliable across specifications and statistical controls. ConclusionWe speculate that in some cases, reported racial discrimination may express unmet expectations in healthcare more generally.

IntroductionNational trends in youth suicide risk may mask significant regional variations within a country. This article attempts to account for spatio-temporal trends through a comparative analysis across South America and Europe. This paper analyzes the spatiotemporal patterns in suicide mortality among young people (10-29 years) in Argentina, Chile, Spain, and Uruguay during the period 1997-2021. MethodsOfficial data from vital statistics and population censuses of the four countries were analyzed. Spatiotemporal clusters were detected using Poisson-based scan statistics. Sociodemographic characteristics of high-and low-mortality clusters were compared with the rest of each country using Kruskal-Wallis and Wilcoxon tests. ResultsWith the exception of Chile, each country showed the emergence of spatiotemporal suicide clusters extending through 2021. Indicators of social fragmentation and lower socioeconomic status were most consistently associated with the formation of high-risk youth suicide clusters. ConclusionRecent national increases in youth suicide rates appear to be concentrated in specific sub-national regions, underscoring the need to target resources toward improving living conditions and mental healthcare access for young people in these areas.

ObjectivesCervical cancer is a preventable disease, and a properly implemented screening programme can reduce its incidence and mortality and potentially save resources. This study aimed to evaluate the cost-effectiveness of options for potential transformation of the nationwide screening programme in the Czech Republic, especially considering recent changes in HPV DNA testing recommendations. MethodsA microsimulation model was developed to assess the cost-effectiveness and health benefits of alternative screening strategies in the Czech Republic. The model simulated annual life cycles of women from age 15, comparing combinations of cytology and HPV testing. Input parameters used were obtained from national registries in the Czech Republic and from published literature. The analysis was conducted from the perspective of healthcare payers. Costs (2025 EUR) and LYs were discounted at a rate of 3% annually. Probabilistic sensitivity analysis was conducted. ResultsThe CEA showed that, compared to the current setting (annual cytology with co-test at 35, 45, 55), only specific co-testing strategies lead to a decrease in incidence and mortality but differ in benefits and economic efficiency. The lowest ICER was reported for a strategy combining cytology at two-year intervals and co-testing at four-year intervals from ages 30 to 65. Sensitivity analysis showed that the current strategy has the highest probability of cost-effectiveness at {euro}31,000 per LY gained. At higher values, this is replaced by a strategy with a 3-year interval co-test. ConclusionsBased on the models presented, co-testing appears to be cost-effective. The actual willingness to pay threshold will facilitate selection of the most-appropriate strategy.

PurposeThe objective of this study was to identify predictors of statin adherence in the primary and secondary prevention of CVD among patients in the first two years after the date of first prescription using real-world data. MethodsThe Electronic Practice Based Research Network Linked Dataset was used in this study. Statin adherence was calculated using a modified proportion of days covered (PDC) formula. Individuals with PDC [≥] 80% during the two years of observation period were considered as adherent. All analyses were performed with R software. Descriptive and multivariate logistic regression analyses were performed. Sensitivity analysis was performed using the Akaike Information Criterion model selection method. ResultsOverall, 3,432 patients accounting for 57,227 visits met the selection criteria. The mean PDC was 91.6% ({+/-}22.2%), and 72.0% of the patients were adherent to statins (PDC [≥] 80%) in the first two years after the date of first prescription. After adjusting for all other variables, statin adherence was positively associated with age (AOR 1.7, 95% CI 1.4 - 2.0), SEIFA index (AOR 1.8, 95% CI 1.2 - 2.6), polypharmacy (AOR 1.8, 95% CI 1.3 - 2.5) and comorbidities (AOR 1.4, 95% CI 1.1 - 1.7), and negatively associated with the number of statin types (AOR 0.6, 95% CI 0.5 - 0.9) and smoking status (AOR 0.7, 95% CI 0.6 - 0.9). The sensitivity analysis showed similar results as the regression model. ConclusionsStatin adherence is influenced by an aging, multimorbid population, who are exposed to polypharmacy, multiple statin options and socioeconomic diversity. Key pointsO_LIAdherence in the first two years after the first date of statin prescription was measured as proportion of days covered (PDC) C_LIO_LIThe mean PDC was 91.6% ({+/-}22.2%) C_LIO_LI72.0% of the patients were adherent to statins, with PDC [≥] 80% C_LIO_LIStatin adherence was positively associated with age, area-based social advantage and disadvantage index, polypharmacy and comorbidities C_LIO_LIStatin adherence was negatively associated with the number of statin types prescribed to the patients and the smoking status of patients C_LI Plain Language SummaryThe objective of this study was to identify predictors of statin adherence among patients in the first two years after the date of first prescription using real-world data. The dataset used was the Electronic Practice Based Research Network Linked Dataset. Statin adherence was calculated using proportion of days covered (PDC). A PDC [≥] 80% during the two years of observation period were considered as adherent. Overall, 3,432 patients were eligible for this study, and 72.0% of them were adherent to statins in the first two years after the date of first prescription. Statin adherence was positively associated with age, area-based social advantage and disadvantage index, number of medicines taken by the patient and number of chronic conditions that the patient suffered. Moreover, statin adherence was negatively associated with the number of statin types prescribed to the patients and smoking status of patients.

BackgroundWomen with limited or no English proficiency experience persistent barriers to accessing maternity care in the UK, contributing to well-documented inequalities in maternal and perinatal outcomes. NHS parent education classes are predominantly delivered in English, and provision of multilingual classes within individual maternity units is often limited and duplicative. Evidence to inform collaborative, cross-trust service models remains scarce. ObjectiveTo assess womens access to, preferences for, and perceived relevance of NHS parent education classes, with particular focus on willingness to travel across London to attend classes delivered in a preferred language, in order to inform equitable and efficient service design. MethodsA cross-sectional, multilingual survey was conducted as a quality improvement initiative across multiple London maternity networks. The survey was translated into 18 languages and captured sociodemographic characteristics, access to parent education, preferences for delivery format, timing, location, and language, and perceived relevance of content. Quantitative data were analysed descriptively and thematically. ResultsA total of 97 women participated in the survey (n=97), the majority of whom reported speaking at least one non-English language at home (79.4%, n=77). Regarding mode of delivery, 51.6% of women preferred in-person parent education classes (n=50), 15.5% preferred online delivery (n=15), and 32.9% reported no preference (n=32). Most participants reported access to a suitable device and reliable internet (85.6%, n=83) and confidence using online platforms (77.3%, n=75). In relation to timing and format, weekends were the most commonly preferred time for classes (40.2%, n=39), followed by weekdays during school hours (35.1%, n=34) and weekday evenings (24.7%, n=24). Nearly half of women preferred delivery across two 2-hour sessions (48.5%, n=47), while 30.9% reported no preference regarding session length or number (n=30); fewer preferred two 3-hour sessions (11.3%, n=11) or a single 4-hour session (8.3%, n=8). Regarding willingness to travel, 67.0% of participants reported they would attend parent education classes delivered outside their booking maternity unit (n=65). Overall, 68.0% were willing to travel up to 45 minutes for in-person classes (n=66), while 29.9% preferred not to travel (n=29). With respect to language of delivery, 40.2% of women preferred classes delivered in their native language (n=39), and a further 40.2% reported English with an interpreter as acceptable (n=39); fewer were comfortable relying on a partner or friend to translate (19.6%, n=19). Most participants perceived that delivery by a native-speaking health professional would improve trust and learning (75.3%, n=73), and an equal proportion expressed a preference for a female interpreter (75.3%, n=73). ConclusionsWomen with limited English proficiency demonstrate clear willingness to travel across maternity networks to access antenatal education in their preferred language. These findings support the development of collaborative, cross-trust models that standardise core antenatal content while centralising multilingual provision, reducing duplication and improving equity of access across London maternity services.

ObjectiveThe objective of this study was to explore the predictors of statin intolerance in the primary and secondary prevention of CVD among patients in the first two years after the date of first prescription using real-world data. MethodsThis study used the Electronic Practice Based Research Network Linked Dataset. An algorithm, which considered the muscle symptoms and creatinine kinase of patients, was used to identify statin intolerant patients. The R software was used for all analyses. Descriptive and multivariate logistic regression analyses were performed along with sensitivity analysis which was done using the Akaike Information Criterion model selection method. ResultsOverall, 4,016 patients accounting for 60,873 visits met the selection criteria. About 3.5% of the patients were statin intolerant. After adjusting for all other variables, statin intolerance was positively associated with gender (AOR 1.5, 95% CI 1.0 - 2.2), SEIFA index (AOR 3.8, 95% CI 2.3 - 6.7), employment status (AOR 2.4, 95% CI 1.1 - 5.7), and comorbidities (AOR 7.0, 95% CI 2.2 - 19.0). A similar direction of associations was seen for the exposures of the model from the sensitivity analysis and the regression model. However, since the unrecorded employment status showed a positive association, the sensitivity analysis suggests that the relationship may be influenced by residual confounding or information bias, indicating that this finding should be interpreted with caution. ConclusionStatin intolerance within the diverse community represented in the dataset is driven by gender, employment status, area-based social advantage and disadvantage index, and comorbidities.

Abstract/SummaryFinancial exploitation of older adults is an increasingly prevalent public health concern, yet few have characterized fraud prevalence longitudinally or evaluated whether financial exploitation vulnerability measures prospectively predict fraud outcomes. Using data from the Health and Retirement Study, we examined fraud prevalence across a 14-year period and tested whether the Perceived Financial Vulnerability Scale (PFVS) predicts subsequent fraud victimization among older adults. Fraud prevalence increased steadily over time, rising from 5.0% in 2008 (347 of N=6,920) to a peak of 10.2% in 2022 (448 of N=4,380). Higher PFVS scores measured in 2018 were associated with greater odds of fraud victimization reported in 2022 (OR=1.62, 95% CI [1.25-2.15], p<.001). Most individuals who later reported fraud fell within the highest group of PFVS scores up to five years earlier. Together, these findings highlight financial exploitation as an emerging aging-related vulnerability and support the PFVS as a brief indicator of future fraud risk.

ObjectivesTo quantify patterns of preventable death in Australian coronial findings, measure government compliance with coroner recommendations across jurisdictions, and identify case characteristics associated with recommendation issuance and acceptance. DesignCross-sectional computational text analysis of publicly available coronial findings using unsupervised topic modelling and rule-based classification. SettingAustralian coronial system, all eight state and territory jurisdictions, findings published on the Australasian Legal Information Institute (AustLII) database, 2000-2024. Participants9833 coronial findings and 2040 linked government responses. Main outcome measuresDeath-type topic prevalence, recommendation rate by jurisdiction, government response acceptance rate. ResultsTwenty-six death-type topics were identified, with medical/surgical deaths (12.5%), men-tal health (10.4%), and deaths in custody (8.6%) most prevalent. Overall, 45.6% of published find-ings contained formal recommendations (95% CI, 44.6-46.5%). Of 2040 government responses, 43.0% were unclassifiable (predominantly Victorian administrative cover letters). Among classifi-able responses, 53.2% were accepted (implemented, already implemented, or partially accepted), ranging from 26.0% (Western Australia) to 88.0% (Queensland). Multivariable logistic regression showed that jurisdiction was the strongest measured predictor of acceptance (pseudo R2 0.13 vs 0.14 with all covariates), though most variance remained unexplained. Among published findings, In-digenous Australians were represented in 10.1% (2.7 times the 3.8% population share).12 Findings involving medication errors had the highest recommendation rate (55.1%) but among the lowest acceptance rates (26.4%). ConclusionsAmong publicly available coronial findings, fewer than half contain formal recom-mendations. Government acceptance is low and structurally determined by jurisdiction rather than case characteristics, suggesting that legislative reform is needed to improve the systems preventive effectiveness.

BackgroundThe dynamic associations of lifestyle factors with fatigue and work ability in colorectal cancer (CRC) from pre-diagnosis, over rehabilitation until convalescence in the first year after rehabilitation are largely unexplored. MethodsN = 682 CRC patients were recruited for the MIRANDA cohort study in 4 German rehabilitation clinics. The five-component Healthy Lifestyle Score (HLS; smoking, alcohol, diet, physical activity, BMI) was assessed pre-diagnosis, during rehabilitation (which was up to 12 months after surgery), and 12 months after rehabilitation. Fatigue and the ability to work were assessed during rehabilitation and in 3-month-intervals thereafter. ResultsThe HLS was rather stable over time, whereas fatigue and ability to work improved in the first 3 months after rehabilitation and remained stable thereafter. Higher HLS points, either assessed prior diagnosis or during rehabilitation, were associated with lower fatigue and better ability to work during in-patient rehabilitation. Compliance with the smoking criterion was the most important factor. Compliance with the physical activity criterion during rehabilitation was also associated with fatigue and ability to work during rehabilitation. In longitudinal analysis adjusted for fatigue and ability to work at rehabilitation, pre-diagnosis adherence to the alcohol consumption criterion was associated with favorable changes of fatigue and ability to work from rehabilitation to 3- and 12-month follow-up. However, the total HLS and other life-style factors were not associated with the outcomes in longitudinal analysis. ConclusionsAddressing lifestyle factors during rehabilitation is an important cornerstone in fatigue management and can improve the ability to work of CRC patients.

IntroductionTobacco smoking remains a leading cause of preventable death in the UK. Although e-cigarettes are promoted as a harm-reduction option, longitudinal evidence on short-term health outcomes across different smoking transition pathways is limited. This study examined short-term associations between transitions to exclusive e-cigarette use, dual use, or cessation and physical health, mental health, and health-related quality of life, compared with continued smoking. MethodsA target trial emulation framework was applied to Waves 7-14 (2015-2024) of the UK Household Longitudinal Study, including 18,011 participant-wave observations from baseline smokers. Propensity score matching (1:3) was used to create comparable exposure groups. A doubly robust analysis-combining matching with Ordinary Least Squares regression-estimated outcomes using the SF-12 Physical (PCS) and Mental (MCS) Component Summary scores and a mapped EuroQol 5-Dimensions 3-Level version (EQ-5D-3L) index. The SF-12 is a validated generic health measure, where PCS and MCS are norm-based scores (mean = 50, SD = 10). The EQ-5D-3L index (range: 0 to 1) reflects overall health utility. ResultsCompared with continued smokers, exclusive e-cigarette users had higher short-term mental health scores (SF-12 MCS {beta} = 1.042; 95% CI: 0.229 to 1.855). In contrast, dual users had lower mental health scores ({beta} = -1.023; 95% CI: -1.574 to -0.472). Short-term physical health scores (SF-12 PCS) were lower among both exclusive switchers ({beta} = -0.670; 95% CI: - 1.287 to -0.053) and quitters ({beta} = -0.486; 95% CI: -0.853 to -0.119), with no evidence of short-term physical health improvement for any transition group. Dual users also had lower health-related quality of life (EQ-5D-3L {beta} = -0.016; 95% CI: -0.025 to -0.008). Subgroup analyses suggested heterogeneity by age and socioeconomic position, with poorer outcomes among older and more disadvantaged smokers. Sensitivity analyses produced directionally consistent findings. ConclusionExclusive switching to e-cigarettes was associated with higher short-term mental health scores, whereas dual use was associated with poorer mental health and health-related quality of life. These findings underscore the importance of distinguishing complete switching from dual use when designing harm-reduction policies and smoking cessation support.

BackgroundThe COVID-19 pandemic disrupted access to sexual and reproductive health (SRH) services, including contraception. Understanding contraceptive use during this period is critical for strengthening health system resilience in small developing states. ObjectiveTo identify factors associated with contraceptive use among reproductive-age women during the COVID-19 pandemic in Barbados. MethodsA cross-sectional online survey was conducted in Barbados between April 28 and May 3, 2020 among adults aged [&ge;]18 years. This analysis is restricted to women aged 18-49 years. Current contraceptive use (yes/no) was assessed among non-pregnant respondents. Associations with sociodemographic factors, relationship status, and psychosocial distress (Hospital Anxiety and Depression Scale [HADS] were examined using bivariate tests and logistic regression. Variables, alcohol and marijuana use had >15% missing data which limited. ResultsA total of 1,094 women aged 18-49 years completed the survey and were included in descriptive analyses. At the time of the survey, 2.7% (n=29) reported being pregnant and 7.3% (n=80) reported not being pregnant but planning pregnancy; the majority 89.7%, (n=981) were neither pregnant nor planning pregnancy. Among non-pregnant women with contraceptive data, 34.2% (n=333) reported current contraceptive use. Moderate-to-severe anxiety symptoms were reported by 36.5%, and moderate or clinically significant global distress by 39.0%. Contraceptive use was significantly associated with HADS anxiety (p=0.021) and HADS global distress (p=0.016), but not depression (p=0.211). Women who were partnered (p=0.014) or married/cohabitating (p<0.001) were more likely to report contraceptive use compared with single women. University education was strongly associated with contraceptive use (p<0.001). Women aged 26 - 39 years were more likely to use contraception relative to those aged 40 - 49 years, while women aged 18 - 25 years were less likely. ConclusionsDuring the early phase of the COVID-19 pandemic in Barbados, contraceptive use among non-pregnant reproductive-age women was associated with psychosocial distress (especially anxiety), relationship status, education, and age. Emergency preparedness in small developing states should prioritize continuity of SRH services, mental health integration, and access to self-managed contraceptive options.

BackgroundHelmet use is a proven safety measure that reduces the risk of head injury among cyclists and e-scooter riders. Despite legal requirements for pedal bikes and e-bikes in Australia, compliance varies, particularly among users of electric vehicles. The growing popularity of e-bikes and e-scooters in urban areas presents new public health challenges, yet observational data on helmet use, behavioural determinants, and the effectiveness of safety interventions remain limited. AimPhase 4 of the Helmet Use in Canberra study aims to identify demographic and behavioural predictors of unsafe riding and to explore perceived barriers and facilitators to helmet use, including compliance with existing regulations. MethodsA cross-sectional survey will be administered to Canberra residents aged 18 years or older, both online and in-person. The survey will assess attitudes toward helmet use, perceptions of head injury risk, and the deterrent effect of fines. Data will capture demographic characteristics, vehicle type, riding behaviours under varying conditions, and opinions regarding mandatory helmet laws and signage interventions. Survey responses will be de-identified, securely stored, and analysed using descriptive statistics and ordinal logistic regression to evaluate factors influencing compliance. Survey findings will be triangulated with observational and hospital data from earlier study phases. Expected ResultsThe survey is anticipated to provide insights into public attitudes toward helmet use, the perceived effectiveness of fines as behavioural deterrents, and the acceptability of policy interventions. These findings will inform evidence-based strategies to improve helmet compliance and reduce head injuries among urban riders. Trial RegistrationAustralian and New Zealand Clinical Trials Registry (ANZCTR) [ACTRN12626000245392].

Abstract This protocol is reported in accordance with the SPIRIT 2025 guidelines for clinical trial protocols. Introduction: Young children, from birth to age 5 y are particularly vulnerable to indoor air pollutants and respiratory pathogens. Portable air purifiers (or filtration) and upper-room ultraviolet germicidal irradiation (UVGI) are two widely used interventions with the potential to improve indoor air quality (IAQ) and reduce sick-related absences. However, a review of the literature revealed no real-world randomized studies evaluating their effectiveness in reducing young children's sick-related absences in early care and education (ECE) classrooms. Methods and Analysis: The OK-AIR study is a longitudinal, cluster-randomized 2x2 factorial trial conducted in Head Start centers using two implementation cohorts: Cohort 1 (five Head Start centers and 20 classrooms from 2023 to 2024) and Cohort 2 (11 centers and 59 classrooms from 2025 to 2026), with expanded inclusion of rural areas. Cohort 1 enrolled 204 children, 48 teachers and 5 site directors, and Cohort 2 enrolled 462 children, 97 teachers and 11 site directors. Within each center, four classrooms are randomized to: (1) control; (2) portable filtration; (3) upper-room ultraviolet germicidal irradiation (UVGI); or (4) both interventions. Cohort 2 was initially planned as a second factorial trial but was amended to a purifier-only design due to funding changes; details are provided in the protocol amendments section. We collect continuous IAQ data, including particulate matter (PM) with aerodynamic diameters [&le;]1 m (PM1), [&le;]2.5 m (PM2.5), [&le;]4 m (PM4), and [&le;]10 m (PM10); total volatile organic compounds (TVOCs) index; nitrogen oxides (NOx) index; carbon monoxide (CO), noise; temperature; and relative humidity, alongside daily child absences. Seasonal environmental surface swabs (dining tables and toilet flooring) are tested by Reverse-Transcriptase quantitative Polymerase Chain Reaction (RT-qPCR) for Influenza A/B, Respiratory Syncytial Virus (RSV), Human Parainfluenza Virus Type 3 (HPIV3), Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), and Norovirus. IAQ monitoring is structured across Winter, Spring, Summer, and Fall, including designated baseline/off-period weeks to characterize temporal and seasonal variability in environmental measures across classrooms and centers. Multi-informant surveys (Director, Teacher, Parent) capture contextual factors, and children's social-emotional development is assessed using teacher ratings on the Devereux Early Childhood Assessment (DECA). The primary outcome is the sick-related absence rate, analyzed as cumulative absences over the attendance year while accounting for clustering by school and classroom using generalized mixed-effects models. Secondary outcomes include children's social-emotional ratings, IAQ metrics and pathogen detection rates; analyses of IAQ incorporate time/seasonal structure, and season-stratified absenteeism analyses will be treated as secondary/exploratory refinements. An economic evaluation will estimate incremental intervention costs and cost-effectiveness/cost-benefit (such as cost per sick-related absence day averted). Ethics and Dissemination: This study was approved by the Institutional Review Board (IRB) at the University of Oklahoma. Findings will be shared through peer-reviewed publications; presentations at local, state, and national conferences; research briefs developed for lay and policy audiences; and community briefings prioritizing the participating early childhood programs and communities. ISRCTN Trial Registration: ISRCTN78764448 Disclaimer: The views expressed are those of the authors and do not reflect the official views of the Uniformed Services University or the United States Department of War. Strengths and Limitations of This Study: {middle dot} Real-world longitudinal cluster RCT: The study uses a rigorous longitudinal cluster-randomized 2x2 factorial design in real-world ECE settings. {middle dot} Combined interventions: Interventions target both air filtration and disinfection, allowing for combined and comparative evaluation. {middle dot} Objective air quality monitoring: Continuous monitoring of IAQ metrics provides objective and reliable data on environmental change. {middle dot} Environmental pathogen surveillance: qPCR on surface swabs yields an objective biological outcome to triangulate with IAQ and absences. {middle dot} Comprehensive context and child measures: Multi-method and multi-reporter data collection includes Head Start attendance records, continuous air monitoring, pathogen detection, contextual surveys completed by center directors, teachers, and parents, and standardized social-emotional assessments (DECA) completed by classroom teachers. Head Start program records providing children's longer-term health data available through Health Insurance Portability and Accountability Act (HIPAA) authorization. {middle dot} Clustered/temporal complexity: Seasonal design accounts for variation over time but may introduce complexity in modeling temporal effects. {middle dot} Practical Implications: Study findings will have practical implications for Head Start and other ECE programs striving to maximize child attendance with cost effective strategies. Keywords: Early childhood; Head Start; indoor air quality (IAQ); air purifiers; filtration; ultraviolet germicidal irradiation; cluster randomized trial; absenteeism; environmental pathogens; DECA; cost-benefit analysis

Importance: Lung cancer mortality in the United States has fallen substantially in recent decades, yet the relative influence of behavioral, environmental, socioeconomic, and therapeutic factors and their sex specific contributions remains unclear. Understanding these drivers is essential to sustain progress and reduce persistent disparities. Objective: To quantify how behavioral, environmental, socioeconomic, and therapeutic determinants collectively shaped US lung cancer mortality from 1994 to 2020, assess sex specific differences, and forecast mortality trajectories through 2030 using an integrated machine learning framework. Design, Setting, and Participants: Ecological time series study using publicly available national data from 1994 to 2020. Sex stratified analyses were conducted integrating lung cancer mortality, smoking prevalence, fine particulate matter PM2.5 exposure, Human Development Index HDI, per capita healthcare expenditure, healthcare inflation, insurance coverage, income inequality, and annual drug approvals. Exposures: Behavioral smoking, environmental PM2.5, socioeconomic HDI health expenditure inflation, uninsurance inequality, and therapeutic drug approval indicators. Main Outcomes and Measures: Age-standardized lung cancer mortality per 100000 population. Temporal changes were modeled using Joinpoint regression. Concurrent associations were assessed using multivariable and elastic net regression, and forecasts were estimated with AutoRegressive Integrated Moving Average models with exogenous variables ARIMAX. Results: From 1994 to 2020, mortality declined by 59 percent in men, from 52.9 to 21.7 per 100000, and by 40 percent in women, from 26.7 to 15.9 per 100000, with faster declines after 2015. Smoking and PM2.5 decreased by more than 45 percent but remained strongly correlated with mortality. In elastic net models, PM2.5 was the strongest predictor for men, while smoking was the strongest predictor for women. Per capita expenditure and HDI ranked higher for men, while uninsurance and income inequality were strong predictors for women. Mortality declines occurred during periods of major approvals of lung cancer drugs. Forecasts suggest continued but slower declines through 2030, with projected rates of 20.2 and 14.9 deaths per 100000 in men and women, respectively. Conclusions and Relevance: Sex specific declines in lung cancer mortality reflect different dominant correlates, with air pollution more important in men and smoking more important in women, while socioeconomic conditions and therapeutic advances also influence trends. Continued tobacco control, improved air quality, and equitable access to screening and modern treatment are essential to sustain further reductions in mortality. Keywords: Lung Neoplasms, Sex Factors, Air Pollution, Smoking, Socioeconomic Factors, Machine Learning

ObjectiveTo evaluate risk of early-onset dementia (EOD) after diagnosis of cancer among Medicaid beneficiaries. DesignLongitudinal observational study of Medicaid enrollment, inpatient, and outpatient claims data from 26 states and Washington, DC, 2001-2019. MethodsBeneficiaries aged 18-64 with [&ge;]6 months of enrollment were matched 1:1 on cancer status (lung, colon, breast, prostate) by age, sex, race, year and state. We estimated the weighted cumulative incidence functions of EOD at 1, 2, and 5 years after cancer diagnosis using the Aalen-Johansen estimator to account for the competing risk of death and cluster stratified analyses to account for matching. We calculated the corresponding risk differences (RD) and 95% confidence intervals (CI) using the 2.5th and 97.5th percentile of point estimates from 500 bootstrap resamples. ResultsThe 5-year risk of EOD was 4.7% (95%CI: 4.5,5.0) and 4.7% (95%CI: 4.4, 4.9) among those with and without lung cancer, respectively (RD:0.08; 95%CI: -0.27,0.42). The 5-year risk of EOD was 4.1% (95%CI: 3.8, 4.4) and 3.9% (95%CI:3.7,4.3) among those with and without colon cancer, respectively, (RD 0.18; 95%CI: -0.25,0.55). The 5-year risk of EOD was 3.0% (95%CI: 2.8,3.1) and 2.9% (95%CI: 2.7,3.0) among those with and without breast cancer, respectively, (RD 0.10; 95%CI: -0.14,0.43). The 5-year risk of EOD was 4.6% (95%CI: 4.3,4.9) and 5.3% (95%CI: 4.9,5.7) among those with and without prostate cancer, respectively; those with prostate cancer had a lower EOD risk (RD -0.66; 95%CI: -1.2,-0.16). ConclusionsEOD incidence peaked at 4-5% among beneficiaries with and without cancer. Diagnosis of lung, colon, breast and prostate cancers were not strongly associated with EOD within 5 years. Additional work is needed to identify risk factors for EOD.

BackgroundCommunity safety is a key determinant of mental well-being, yet racially and ethnically minoritised communities in the UK often face higher exposure to violence alongside barriers to formal protection and support. In these contexts, informal support networks may play a critical role in shaping how safety is experienced and how distress is managed. Although such networks are widely recognised as protective for mental well-being, there is limited qualitative research examining how they operate in relation to community safety in settings shaped by structural inequality. This study explores how informal support networks influence experiences of community safety and mental well-being among racially and ethnically minoritised groups in South East London. MethodsThis qualitative study draws on semi-structured interviews (n = 31) with racially and ethnically minoritised participants aged 16+ living or working in Lambeth and Southwark [South East London]. Using a co-produced qualitative design, community consultations informed the development of interview topics. Interviews explored informal support networks, experiences of community safety and their intersections with mental well-being. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis. ResultsFour themes were identified: (1) experiences of community safety and their mental health impacts; (2) gendered experiences of safety and responsibility; (3) formal support and its barriers; and (4) community and peer-led initiatives as a response to institutional distrust. ConclusionInformal support networks are central to everyday safety and emotional well-being, yet they cannot substitute for adequately resourced, culturally informed public provisions. Strengthening public infrastructure must involve meaningful collaboration with trusted community networks and address the intersectional needs of racially and ethnically minoritised groups.

ObjectiveTo characterize associations between tattooing and health status. MethodsWe used data from [~]27,000 respondents to the 2020-2022 Utah Behavioral Risk Factor Surveillance System (BRFSS). Multivariable Poisson regression was used to calculate prevalence ratios (PR) and 95% confidence intervals (CI) associating ever receiving a tattoo with physical/mental health status. ResultsIn this cross-sectional study, ever receiving a tattoo was associated with self-reported "poorer" vs. "excellent" overall health, particularly among women (PR=3.08 [95% CI: 2.26- 4.21]). Tattooing was also associated with obesity (women, PR=1.40 [95% CI: 1.22-1.61]; men, PR=1.21 [95% CI: 1.04-1.40]) and chronic pain (women, PR=1.59 [95% CI: 1.43-1.77]; men, PR=1.55 [95% CI: 1.37-1.76]). Tattooed individuals were more likely to have been diagnosed with a depressive disorder (women, PR=1.64 [95% CI: 1.53-1.75]; men, PR=1.55 [95% CI: 1.39-1.73]) and to have had six or more teeth removed, vs. none (women, PR=2.18 [95% CI: 1.61-2.96]; men, PR=2.88 [95% CI: 2.10-3.95]). ConclusionsPublic health entities may consider partnering with tattoo studios and conventions to provide information about nutrition, exercise, dental care, mental health resources, and health screenings.