Preventive Medicine

OBJECTIVE: To describe (1) US emergency department-treated pickleball injury burden and the injury-to-participation measure among total players, with burden among adults aged 60 to 79 years as a descriptive subgroup, and (2) determine whether general internet search interest for 'pickleball' is also associated with total pickleball-related injuries. DESIGN: Ecological time series study, United States, 2014 to 2023. DATA SOURCES: National Electronic Injury Surveillance System (NEISS) emergency department microdata yielded 1,738 adjudicated pickleball cases, 921 of them orthopedic, weighted to an estimated 101,450 injuries nationally. Google Trends, English Wikipedia pageviews, and GDELT news volume served as general pickleball attention signals, with the Trends index for 'sourdough' as a negative control. Sports and Fitness Industry Association (SFIA) participation estimates supplied a total player denominator. MAIN OUTCOME MEASURES: Annual national injury estimates with design-based 95 percent confidence intervals; injury-to-participation measures; and correlations between total pickleball-related injuries and general pickleball attention signals before and after removing trend and seasonality. RESULTS: Estimated emergency department-treated pickleball injuries rose 17.5-fold, from 1,391 in 2014 (highly unstable) to 24,294 in 2023. 70 percent of adjudicated cases involved adults aged 60 to 79. During 2017-2023, injury estimates rose 4.0-fold and participation rose about 4.4-fold. No temporal trend was detected in the injury-to-participation measure (P=0.59). Search interest looked like an excellent proxy: in annual levels it correlated with total pickleball-related injuries at R=0.96, and Pickleball Wikipedia pageviews at R=0.98. However, so did searches for "sourdough", at R=0.76. Removing trend and seasonality left little (monthly residual R=0.084; year-on-year R=0.28 over 96 months, 2015-2023), and the seasons ran opposite, with injuries peaking in February and searches in July, such that, on 12-month mean profiles, the sourdough negative control fitted the injury season (R=0.96) while pickleball ran against it (R=-0.40). General pickleball search interest and pickleball news coverage remained correlated in year-on-year changes in 2017-2023 (R=0.64), whereas their corresponding correlations with total pickleball-related injuries in 2017-2023 were 0.25 and 0.20. CONCLUSIONS: The absolute burden of emergency department-treated pickleball injury has grown substantially, but the available surveillance data cannot resolve whether the sport has become more hazardous per participant. The observed rise is consistent with growth in exposure alone. The strong correlation between search interest and injury counts was not specific, the association was substantially attenuated after detrending, and the seasonal patterns were opposed. These descriptive results do not establish that search interest can substitute for injury surveillance, and series that rise together should not be assumed to be related.

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.

Objective: To examine associations of health insurance status, household income, and cost-related healthcare barriers with receipt of a routine medical checkup among U.S. adults. Methods: This cross-sectional study analyzed 2024 Behavioral Risk Factor Surveillance System data. Survey-weighted descriptive estimates and multivariable logistic regression incorporated sampling weights, strata, and primary sampling units. The outcome was a routine medical checkup within the previous 12 months. Results: Among 321,592 complete cases, 78.0% of U.S. adults reported a recent routine checkup. Cost-related barriers (adjusted odds ratio [AOR], 0.56; 95% confidence interval [CI], 0.54-0.57) and uninsurance (AOR, 0.28; 95% CI, 0.27-0.29) were associated with lower checkup utilization. Lower household-income groups generally had lower adjusted odds than adults with incomes of $200,000 or more. Conclusions: Insurance, income, and reported cost barriers were independently associated with routine checkup utilization. Findings are descriptive and do not establish causal effects. Keywords: health insurance; household income; cost-related barriers; routine medical checkup; healthcare utilization; BRFSS

Introduction: Vaping public education campaigns are a central prevention strategy for young adults (YAs), but message effectiveness varies widely and formative testing typically evaluates one message attribute at a time. This study examined how four perceptual dimensions, including cognitive engagement, social relevance, emotional arousal, and emotional valence, relate to perceived message effectiveness (PME), and whether multiple combinations of these dimensions correspond to similarly high PME. Methods: In a cross-sectional online message-testing study conducted from March to April 2025, 540 U.S. YAs who vape each evaluated 15 messages randomly sampled from a corpus of 229 text-image vaping public education messages, yielding 8,100 message evaluations. Cross-classified multilevel models estimated associations between each perceptual dimension and PME. An Explainable Boosting Machine probed nonlinear associations, and k-means clustering of high-predicted-PME perceptual configurations identified distinct profiles. Analyses were conducted in 2026. Results: Cognitive engagement (b = 0.20, 95% CI [0.18, 0.22]) and social relevance (b = 0.15, 95% CI [0.13, 0.17]) showed the strongest associations with PME, followed by emotional arousal (b = 0.06, 95% CI [0.04, 0.08]); emotional valence showed no linear association (b = 0.00, 95% CI [-0.02, 0.02]). The Explainable Boosting Machine revealed a U-shaped valence pattern, with higher predicted PME at both the negative and positive ends of the scale. Clustering yielded five distinct perceptual profiles with similarly high predicted PME (4.10-4.25). Conclusions: Multiple perceptual configurations correspond to similarly high PME, supporting a configurational approach to formative message testing rather than a single optimal message formula.

Social media influencers serve as a key source of health information for adolescents but often lack expertise, have commercial motives, and may spread misleading or harmful content. This study examines the health-related content shared by influencers, the prevalence of advertising, and how adolescents evaluate potential benefits and risks. Using a mixed-methods approach, we employed a quantitative descriptive method involving citizen science (Study 1) and a qualitative content analysis (Study 2). In Study 1, 336 adolescents from 16 Austrian schools documented and categorized 2,147 posts from 255 influencers. The most common topics included sports and fitness (50.5%), beauty ideals (29.6%), food and nutrition (27.6%), and cooking (19.1%). Although advertisements appeared in 41.5% of posts, adolescents rated 60.4% of them as beneficial and only 4.5% as harmful. The qualitative analysis of a subsample of the 90 most prominent posts showed that adolescents appreciated motivational aspects (e.g., healthy eating) but often overlooked problematic elements such as misleading claims, sexualized body ideals, and the linking of health messages to commercial products. Enhancing persuasion knowledge and critical thinking through education, along with stricter regulation of harmful products, is crucial to safeguarding youth online.

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

Background: Cardiovascular-Kidney-Metabolic Syndrome (CKMS) is defined as a cluster of disease conditions that are highly prevalent in the U.S. population. This study aims to assess psychosocial adversities at different CKMS stages in a large survey of U.S. adults, measured by lack of emotional support, low life satisfaction, and loneliness. Methods: This cross-sectional study used data on 159,511 adults from the 2023 Behavioral Risk Factor Surveillance System (BRFSS) survey. Proxy CKMS stages (0, 1, 2/3, and 4) were determined using self-reported health conditions. Separate multivariable logistic regression models were estimated to obtain the predictive margins of respective psychosocial attributes across proxy CKMS stages. Results: Compared to adults at lower CKMS stages (Stages 0 and 1), adults at advanced CKMS stages (Stages 2/3 and 4) generally reported having higher psychosocial toll. At CKMS stage 4, the predicted probabilities of lack of emotional support, low life satisfaction, and loneliness were 6.96, 3.24, and 10.10 percentage points (pp) higher, respectively, than at stage 0. Compared to stage 1, the corresponding differences were 5.92, 2.89, and 9.65 pp. At CKMS stage 2/3, the corresponding differences were 4.36, 1.66, and 5.69 pp compared to stage 0 and 3.33, 1.32, and 5.25 pp compared to stage 1. The high burden at advanced CKMS stages was generally evident across sex, and different socioeconomic status conditions manifested by income and education. Conclusions: Findings of this study suggest that adults with advanced CKMS stages were more likely to experience a psychosocial toll. Further research is warranted to facilitate strategies for improving psychosocial wellbeing of CKMS patients.

Objectives To describe active surveillance (AS) outcomes following introduction of an MRI-informed pathway, examine whether baseline PI-RADS/Likert scores identify men with earlier AS discontinuation, and assess the acceptability of dietary fibre supplementation in men on AS. Patients and methods We conducted a retrospective audit of 420 men enrolled in AS at Aberdeen Royal Infirmary between 2012 and 2022. Men were grouped into an MRI-informed pathway (n=198) or biopsy-first pathway (n=222). Time to AS discontinuation for any reason was analysed using Kaplan-Meier methods and log-rank tests. An exploratory analysis compared men with baseline PI-RADS/Likert scores of 4-5 and 2-3. Ten men on AS also completed semi-structured interviews analysed using the Theoretical Framework of Acceptability. Results Median follow-up was 3.1 years (IQR 1.6-5.1). Overall, 208 men (49.5%) discontinued AS, including 176 because of disease progression. Median time to discontinuation was 4.9 years (95% CI 4.4-5.6). It was shorter in the MRI-informed pathway than in the biopsy-first pathway (4.1 vs 5.6 years; log-rank p<0.01). Among 167 men with recorded baseline MRI scores, 44 (26.3%) had PI-RADS/Likert 4-5. Median time to discontinuation was 2.9 years in this group compared with 4.0 years for scores 2-3 (p<0.01). Interview participants were generally willing to consider dietary fibre supplementation, although gastrointestinal effects and study procedures were anticipated burdens. Conclusion AS discontinuation occurred earlier in the MRI-informed pathway, although differences in patient selection and surveillance practice should be considered when interpreting this finding. PI-RADS/Likert 4-5 identified a sizeable subgroup with earlier all-cause AS discontinuation that may help inform recruitment to future intervention studies. Dietary fibre supplementation was acceptable in principle, supporting further feasibility work.

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

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.

Abstract Background: Heart failure (HF) is a major public health challenge in ageing populations and a leading cause of unplanned hospital readmissions. Biological, social, and economic factors contribute to recurrent hospitalisation, but gaps remain in understanding how these factors interact and patterns of healthcare use following hospitalisation. Methods: We conducted an explanatory sequential mixed-methods study of patients aged ?60 years with an HF hospital admission between 2016 and 2020 who completed the Sax Institute?s 45 and Up Study baseline questionnaire. Data were linked to Admitted Patient Data Collection, Medicare Benefits Schedule, and Pharmaceutical Benefits Scheme data. HF readmission within 30 days of the index admission was the outcome. Cox proportional hazards models estimated crude and adjusted hazard ratios (HRs and adjHRs) with 95% confidence intervals (CIs). Kaplan-Meier curves and log-rank tests compared survival between groups. Time-series plots mapped healthcare interactions over 1 year following the index admission. Results: Among 4,252 patients with HF, 409 were readmitted within 30 days. Significant predictors included age ?80 years (adjHR, 1.30; 95%CI, 1.01?1.67), 1 chronic condition (adjHR, 2.49; 95%CI, 1.41?4.40), ?2 chronic conditions (adjHR, 1.75; 95%CI, 1.04?2.95), and alcohol consumption above national guidelines (adjHR, 1.45; 95%CI, 1.06?1.98). Time-series analysis indicated that participants with readmission had more frequent out-of-hospital health service contact following their initial HF admission than those without readmission. Conclusions: Older age, chronic conditions, and high alcohol intake increased 30-day HF readmission risk. Differences in healthcare use after admission highlight opportunities for targeted and coordinated post-discharge care.

Background Population research increasingly relies on integrating data across studies to understand patterns of health and disease at broader scales. Such integration expands sample size and supports multimodal analyses, but independent cohort studies are often not directly comparable due to differences in instruments, timing, and measurement structure. Data harmonization addresses this challenge by transforming heterogeneous variables into comparable measures, allowing datasets collected under different protocols to be analyzed jointly, but published harmonization efforts seldom include an analysis conducted on the integrated dataset itself. Methods We developed an integrated dataset, combining two longitudinal cohorts, the Boston Puerto Rican Health Study (BPRHS) and the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT). Comparability between variables was established through an explicit framework distinguishing availability from construct comparability, and the evidence supporting comparability is reported by class of feature, including tests of measurement invariance and differential test functioning for the multi-item psychosocial scales. To support transparency and reuse, we provide an open-source Python pipeline and structured metadata describing variable alignment and transformations. As a worked example of downstream use, we conducted a Random Forest analysis predicting diabetes status. Results The integrated dataset comprises 539 harmonized variables across four BPRHS visits and two PROSPECT visits, each documented with its source variable, question wording, and transformation. In the worked example, the integrated dataset retained predictive signal relative to cohort-specific models and improved performance for the smaller cohort. Conclusions These findings illustrate how transparent, documented cross-cohort integration can support predictive population health research while making the basis for comparability explicit.

Introduction: Monitoring transitions in cigarette and electronic nicotine vapor product (ENVP) use is important for understanding how marketplace and regulatory changes have affected product use patterns, but information from national surveys is often delayed by several years. Methods: The Rutgers Omnibus Study is a quarterly serial, rapid-response, web-based convenience survey. Using a Markov multistate transition model, we estimated transition rates and one-year transition probabilities between never, non-current, ENVP-only, cigarette-only, and dual use among 5,292 adults aged 18-45 who participated in at least two of Waves 1-16 (February 2022-February 2026), as well as overall transition hazard ratios by sex, age group, and race & ethnicity in a multivariable model. Results: About 40% of individuals using cigarettes (39.5%; 95% CI: 36.9-42.0) or ENVP (40.1%; 95% CI: 36.4-43.7), and 60% of those using both products (60.8%; 95% CI: 58.3-63.2) were predicted to remain in those states after one year. Female participants began using cigarettes from never use (adjusted hazard ratio [aHR] 0.44; 95% CI: 0.29-0.66) or non-current use (aHR 0.65; 95% CI: 0.48-0.88) at lower rates than male participants. Participants aged 35-45 years initiated ENVP-only use from non-current use (aHR 0.34; 95% CI: 0.23-0.51) at a lower rate than those aged 18-34 years. Compared to non-Hispanic White participants, non-Hispanic Black participants initiated ENVP-only use from never use at a higher rate (aHR 4.39; 95% CI: 2.09-9.25). Conclusion: Rapid response surveys can provide important preliminary information on tobacco use transition patterns while we wait for the slower release of nationally representative survey data.

Importance: Oral nicotine pouches (ONPs) are tobacco-leaf-free nicotine products that have experienced a substantial increase in sales in recent years. Objective: To determine how ONP experimentation, initiation, and cessation rates differ by other tobacco product use and sociodemographic characteristics. Design: Nationally representative longitudinal cohort study; data from Waves 7 and 8 (2022-2024) of the Population Assessment of Tobacco and Health (PATH) Study. Setting: US civilian, non-institutionalized population. Participants: Adults in Waves 7 and 8 of PATH. Of 27,800 eligible participants, 24,640 with complete information on the exposure and outcome were included. Exposures: Other tobacco product use (cigarette-only, electronic nicotine delivery system [ENDS]-only, smokeless tobacco [SLT]-only, and multiproduct use) and sociodemographic characteristics (sex, race and ethnicity, age, and educational attainment). Main Outcomes: Hazard rates and ratios of transitioning between never, current, and non-current ONP use, defined by ever and past-30-day use, overall and by exposure group. Rates are estimated in univariable weighted multistate transition models. Results: Among 24,640 participants, 23,555 (96.7%) never used, 802 (2.5%) non-currently used, and 283 (0.8%) currently used ONPs in 2022. From 2022-24, ONP initiation was higher among those using cigarettes only (HR 3.34, 95% CI 1.59-7.02), ENDS only (HR 9.68, 95% CI 2.89-32.5), SLT only (42.4, 95% CI 22.3-80.7), or multiple products (HR 18.4, 95% CI 7.11-47.8) compared to those who did not use these tobacco products. Those who used cigarettes only (HR 3.02, 95% CI 1.24-7.34), ENDS only (HR 2.03, 95% CI 1.11-3.71), or multiple products (HR 2.61, 95% CI 1.12-6.09) discontinued ONPs at higher rates than those using no other products. Men had higher ONP initiation and lower cessation rates than women, adults ages 35+ years had lower initiation rates than those ages 18-24, and non-Hispanic Black participants had higher cessation rates than non-Hispanic White participants. Conclusions and Relevance: Initiation of ONPs was higher among those who used other tobacco products, highlighting the need to investigate whether ONPs replace these products or lead to poly-tobacco use. Higher cessation rates among those using cigarettes only or ENDS only may suggest experimentation rather than sustained use.

Background: Workplace discrimination and violence against health workers including sexual harassment is a societal problem worldwide. We aimed to assess the frequency, predictive factors, and effects of sexual harassment using a nationwide survey of physicians working in Switzerland. Materials and Methods: We conducted a self-administered questionnaire survey of physicians working in Swiss healthcare institutions. The questionnaire assessed experiences of sexual harassment at work, including frequency, types, and sources of harassment. It also asked about the impact of sexual harassment, whether incidents were reported, and what actions were taken following a report. Results: Among the 1837 physicians that participated in the survey, 575 (31.3%) had experienced sexual harassment at least once during their career. Among those reporting sexual harassment, 39.1% of women and 13.2% of men had experienced harassment at least once in their job. Women reported more verbal harassment, while men reported more physical harassment. Women were also more likely to face both forms combined. The main sources of harassment were colleagues of the same profession (46.7%), patients (42.3%), and superiors (41.0%). The most frequently reported impacts included stress (60.1%), emotional exhaustion (34.7%), reduced motivation at work (30%), and considering leaving the job (7.5%). Gender-men was associated with a lower likelihood of experiencing harassment 0.24 (0.18 to 0.31), whereas working in the German-speaking region was associated with a slightly higher likelihood of having experienced sexual harassment at least once (OR 1.35, 95% CI:1.02-1.81). Conclusions: Sexual harassment is common among physicians in Swiss healthcare institutions. It adversely affects the mental health and career trajectories of both men and women yet remains widely underreported due to fears of reprisals and inaction. Institutions should effectively intervene to ensure that reported incidents result in appropriate actions, and that those who report them receive adequate protection from reprisals.

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

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

Background Cancer stigma contributes to low cervical cancer screening rates among Nepali women. However, no stigma reduction interventions have been implemented thus far in Nepal. This study assessed the effectiveness of a muticomponent cervical cancer stigma reduction intervention on cancer stigma scores and cervical cancer screening uptake rates among urban Nepali women. Methods A two-arm, parallel cluster-randomized trial was conducted in Budhanilkantha Municipality, Kathmandu District, Nepal. Twelve administrative wards were randomized in a 1:1 ratio to the intervention or control group, with wards serving as the unit of randomization and individual women as the unit of analysis. A total of 310 women aged 30-60 years who had not undergone cervical cancer screening during the previous five years were enrolled. The three-hour intervention included cervical cancer education, a video featuring cervical cancer survivors, participatory group discussions, and myth-versus-fact activities addressing cancer stigma. Cancer stigma was assessed two months after the intervention using the Nepali version of the Cancer Stigma Scale. Cervical cancer screening uptake was assessed six months after the intervention. Data were analyzed using intent-to-treat and as treated approaches with a generalized estimation equation with logistic regression. Results From June 2022 to February 2023, 310 women were enrolled. At 2 months, stigma data were available for 248 participants (120 intervention, 128 control). In the intention-to-treat analysis, the odds of cancer stigma were lower in the intervention group than in the control group (OR 0.25, 95% CI 0.08 to 0.8; p=0.022). Odds were also lower for the severity domain (OR 0.31, 95% CI 0.10 to 0.90; p=0.048) and awkwardness domain (OR 0.21, 95% CI 0.08 to 0.56; p=0.001) with no differences in other subdomains. At 6 months, the odds of cervical cancer screening was 3.9 times greater in the intervention group than in the control group (95% CI: 1.1-13.20, p=0.028). As treated analysis reinforced these findings, with lower odds of stigma (AOR:0.09, 95% CI: 0.01-0.53, p=0.007), severity (AOR:0.16, 95% CI: 0.06-0.42, p<0.001), and awkwardness (AOR:0.1, 95% CI: 0.02-0.44, p=0.02). Cervical cancer screening odds was 4.02 times higher in the intervention group (95% CI:1.1-13.7, p=0.026). Conclusions Compared with the control condition, participants allocated to a community-based multicomponent intervention designed to reduce cancer stigma had lower odds of elevated cancer stigma two months after the intervention and higher odds of cervical cancer screening by six months. Larger cluster-randomized trials with more clusters and longer follow-up are needed to assess the reproducibility, durability, and generalizability of these findings.

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

Background: The decline of mental health among adolescents in the UK over the past two decades has occurred amidst many societal and technological changes making it difficult to identify drivers of these trends. We aimed to identify which aspect of life showed the most rapid deterioration in satisfaction in the UK since 2009 and which aspects have become increasingly correlated with mental health. Methods: Between 2009 and 2024, 15,829 adolescents aged 10-15 rated their satisfaction with life as well as five aspects of life (family, friends, school, schoolwork, appearance), via the UK Household Longitudinal Study. Population-weighted regressions were used to estimate annual summary statistics on these items (means, proportions) and the relative associations between satisfaction items and socioemotional difficulties, as measured by the Strengths and Difficulties Questionnaire (SDQ). Meta-regressions estimated linear changes over time, with interactions testing for heterogeneity across sexes, age-groups, and household income. Results: Mean satisfaction with life dropped over the 16 years of study (B=-0.028, 95% CI=-0.034, -0.022), as did satisfaction with all five aspects of life. Satisfaction with school declined most rapidly (B=-0.027, 95% CI=-0.034,-0.020), becoming accelerated in the most recent 5-year window (2020-24; B=-0.139, 95% CI=-0.178,-0.099). The proportion of dissatisfied individuals rose most rapidly for schoolwork, particularly for females. Satisfaction with appearance became increasingly associated with general life satisfaction (B=0.009, 95% CI=0.005, 0.013, p<.001) and socioemotional difficulties (B=-0.051, 95% CI=-0.073,-0.029, p<.001) over time. Conclusions: Our findings add to international evidence for academic pressure and school environments as plausible drivers of recent declines in life satisfaction, particularly among female adolescents. Future studies should aim to identify the specific aspects of school life that are influencing adolescent mental health and the impact of existing educational policies on student wellbeing should be evaluated.