Preventive Medicine

BackgroundBoth the COVID-19 pandemic and containment policies caused widespread psychological distress, yet their independent effects remain unclear. Disentangling these effects could inform future responses that balance physical and mental health. This study sought to estimate the effect of lifting versus maintaining containment policies on psychological distress, independent of pandemic severity. MethodsWe conducted a state-level longitudinal analysis using the Behavioral Risk Factor Surveillance System (BRFSS), a representative survey of US adults, restricted to the pandemic period preceding widespread vaccine availability (April 2020 to April 2021). The exposure was lifting versus maintaining containment policies (school closures, workplace closures, event cancellations, and full lockdown) from the Oxford COVID-19 Government Response Tracker. Exposure was measured during periods of low (<25/100,000 new cases) or declining (>14 days) pandemic severity. The primary outcome was prevalence of psychological distress, derived from a BRFSS survey item corresponding to a PHQ-4 score [&ge;]6. FindingsThree causal inference approaches yielded consistent evidence of transient policy-lifting effects: (1) synthetic control analysis of Maine showed a temporary 5.5 percentage-point reduction in psychological distress lasting three months before returning to counterfactual levels; (2) within-state fixed effects found immediately after lifting full lockdown, distress decreased by 5.68 [-8.67, -2.69] percentage points, declining by 30 days (-3.24 [-6.88, 0.39]) and negligible at 60 days (-0.94 [-3.77, 1.89]); (3) target trial emulation detected no significant effects from lifting versus maintaining policies for 90 days. InterpretationLifting containment policies in the first year of the pandemic produced immediate but transient reductions in psychological distress. These results suggest that extended containment policies were unlikely to account for persistent increases in distress during this period.

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.

Introduction Social media is a central part of young people's lives, yet research on its mental health effects remains mixed. We posit that these inconsistencies stem in part from treating youth as a homogeneous group, obscuring distinct behavioral patterns associated with divergent mental health and wellbeing trajectories. Objectives This study aimed to: (1) explore heterogeneity in social media engagement styles among U.S. youth aged 15-24; and (2) examine how these engagement styles are embedded within a broader system of mental health, wellbeing, emotional regulation, belonging, family and neighborhood context, and stress and adversity. Methods Data were drawn from a 2024 nationally representative cross-sectional survey of 2,563 U.S. youth, conducted as part of the Youth Mental Health Tracker initiative. We employed unsupervised clustering to identify five distinct social media engagement profiles. Subsequently, we used Bayesian network-based causal discovery to examine (a) upstream factors that emerge as drivers of engagement styles and (b) downstream outcomes influenced by profile membership in the learned system. Results Five profiles were identified: the Perpetually Plugged-In (31.3%), characterized by near-constant multifaceted social media use, for both positive and negative purposes across multiple domains of life; the Burned-Out Browsers (21.9%), with high exposure to negative and comparison-based content with frequent attempts to disengage; the Practical Navigators (20.7%) who engage in structured, goal-oriented use focused on learning, hobbies, and maintaining connections; the Positive Engagers (13.6%) with high social and identity-driven engagement; and the Light Touch Users (12.5%) who have low overall engagement and limited reliance on social media for connection, identity, or support. Causal analyses revealed that the Perpetually Plugged-In and Burned-Out Browsers had the worst mental health and wellbeing, with their engagement driven by different reasons. While both engagement profiles were influenced by similar psychosocial risk factors, they were distinguished by their dominant drivers: contemporaneous social stressors (bullying, discrimination, and emotional dysregulation) for Perpetually Plugged-In youth, versus adverse childhood experiences for Burned-Out Browsers. In contrast, Positive Engagers reported high social media engagement alongside the highest levels of social wellbeing, using social media for identity exploration and social support within a context of low cumulative stress and adversity. Conclusions Findings suggest that youth social media risk is not driven by intensity of use alone, but by the interaction between engagement style and offline emotional and social conditions. Policies focused solely on restricting access risk overlooking these differences and may inadvertently sever important sources of connection for many youth. Strategies should identify experiential risk signals while strengthening supportive contexts that enable healthier engagement. Overall, youth social media use is best understood as part of a broader psychosocial system, and recognizing this heterogeneity is essential for designing more targeted, equitable, and evidence-based interventions.

BackgroundCommercial motorcycle riders are among the most vulnerable road users in low- and middle-income countries and contribute substantially to the burden of road traffic injuries. The use of personal protective equipment (PPE), including helmets and protective clothing, reduces injury severity; however, uptake remains suboptimal. This study evaluated the effectiveness of a theory-driven health education intervention in improving knowledge, attitudes, and use of PPE among commercial motorcycle riders in Cameroon. MethodsA quasi-experimental, non-randomized controlled before-and-after study was conducted in Limbe (intervention) and Tiko (control) Health Districts between August 4, 2024, and April 6, 2025. Participants were recruited from a cohort of commercial motorcycle riders and followed over an eight-month intervention period. The intervention, guided by the Health Belief Model and developed using the Intervention Mapping framework, combined face-to-face sensitization sessions with mobile phone-based educational messaging adapted to participants literacy levels and communication preferences. Data were collected at baseline and endline using structured questionnaires and direct observation checklists. Intervention effects were estimated using difference-in-differences analysis with generalized estimating equations, adjusting for socio-demographic factors. ResultsA total of 313 riders were enrolled at baseline (183 intervention, 130 control), with 249 retained at endline (149 intervention, 100 control). The intervention was associated with significant improvements in PPE knowledge ({beta} = 2.91; 95% CI: 2.14-3.68; p < 0.001) and attitudes ({beta} = 5.76; 95% CI: 4.32-7.21; p < 0.001) compared with the control group. No statistically significant effect was observed for PPE practice scores ({beta} = 0.21; 95% CI: -0.09-0.52; p = 0.171). Among individual PPE items, helmet use increased significantly in the intervention group relative to the control group (AOR = 2.38; 95% CI: 1.19-9.45; p = 0.036), while no significant effects were observed for gloves, trousers, eyeglasses, or closed-toe shoes. ConclusionThe theory-driven health education intervention significantly improved knowledge and attitudes toward PPE and increased helmet use among commercial motorcycle riders but did not lead to broader improvements in the uptake of other protective equipment. These findings highlight the need for complementary structural and policy interventions to address persistent barriers to PPE use in similar low-resource settings. Trial registrationClinicalTrials.gov Identifier: NCT07087444 (registered July 28, 2025, retrospectively)

Background. Young sexual and gender minorities of color face compound health risks shaped by interlocking systems of racism, cisgenderism, and class inequality. Spatial health research documents that place shapes health, but existing methods cannot specify the mechanisms through which spatial configurations produce different health outcomes for differently positioned people. This gap prevents targeted intervention. ObjectiveTo develop and pilot test the Spatial Intersectionality Health Framework (SIHF), which specifies three mechanisms through which space produces intersectional health inequities: Layered (multiple oppressive systems activating simultaneously), Positional (the same space producing different health pathways by intersectional position), and Conditional (nominally protective spaces carrying hidden costs for specific positions). We also introduce and validate Intersectional Geographically-Explicit Ecological Momentary Assessment (IGEMA) as the methodology operationalizing SIHF across three data levels. MethodsThe GeoSense study enrolled 32 young sexual and gender minorities of color (ages 18-29) in New York City. IGEMA was implemented across three integrated levels: (1) GPS mobility tracking via participants personal smartphones, linked to census tract structural exposure indices across n=19 participants; (2) ecological momentary assessment of intersectional discrimination with multilevel modeling of mood, stress, and sleep outcomes; and (3) map-guided qualitative interviews with SIHF mechanism coding and intercoder reliability assessment across 92 coded records from 18 participants. This study was conducted as the pilot for NIH R01HL169503. ResultsAll three SIHF mechanisms were empirically detectable. A compound structural gendered racism index outperformed every single-axis alternative in predicting daily mood (b=-0.048, p=.001) and stress (b=0.121, p<.001). The Positional mechanism accounted for 71% of coded harm experiences. Intercoder reliability for mechanism assignment reached kappa=0.824 at Stage 2 reconciliation. Daily intersectional discrimination predicted greater sleep disturbance (b=1.308, p=.004). ConclusionsSIHF and IGEMA together provide an empirically testable framework for specifying how space produces intersectional health inequities. Mechanism specification, not spatial location alone, is the condition for designing research and intervention that reaches the source of harm for multiply marginalized populations.

BackgroundDisparities in injury and death indicate that Latinos and Hispanics are disproportionately affected by firearm violence. Understanding the factors that impact Latino and Hispanic engagement with firearm safety is integral to developing nuanced interventions, yet these factors remain largely understudied. This study explores the social ecological factors related to firearm safety engagement among Latino and Hispanic adults residing in New Mexico. MethodsThe study used a convergent mixed-methods design with quantitative and qualitative components. Data were collected from a predominantly Latino-Hispanic community experiencing high rates of firearm violence near Albuquerque, New Mexico. Quantitative data (n=303) were collected using a community-based survey with a non-random sample on firearm safety engagement, collective efficacy, and sociodemographic characteristics. Qualitative data (n=18) included semi-structured interviews from a subset of the survey population who expressed interest in participating. Quantitative data was used to explore descriptive statistics and correlations between reported levels of collective efficacy and firearm safety engagement. Qualitative data were used to explore the firearm safety experiences of Latino and Hispanic participants. AnalysesMultivariate regression analyses examined associations between collective efficacy (exposure) and engagement with firearm safety (outcome). I also explored associations across key domains: collective efficacy, neighborhood characteristics, individual characteristics, and sociodemographic factors. Interviews were analyzed using framework analysis to generate a cohesive thematic structure informed by a social ecological model. The results from the quantitative and qualitative data were then integrated to develop a robust understanding of social ecological factors related to firearm safety engagement using a mixed methods joint display. ResultsThere were 303 survey participants (40.6% male; 55.1% female; 4.3% other gender identity) and 18 interview participants in this study. 57.1% of survey participants reported engaging with at least one firearm safety practice or initiative. Results from multivariate regression indicated that higher collective efficacy ({beta} = 0.082, p = 0.002), higher informal social control ({beta} = 0.174, p = 0.001), stronger endorsement of gun safety principles ({beta} = 0.079, p < 0.001), being married vs. unmarried ({beta} = -0.334, p < 0.001), speaking Spanish in the home vs. English ({beta} = 1.048, p < 0.001), and not owning a gun ({beta} = - 0.638, p = 0.006) were significantly and positively associated with firearm safety engagement. Themes from the qualitative data included barriers (insecure environment; lack of meaningful engagement) and facilitators (location-specific contributors to safety; collective identity and pride) to firearm safety engagement, organized by social ecological domain. Mixed methods findings indicate factors associated with participants individual firearm safety engagement, while providing insights into the perceived barriers and facilitators across social ecological domains. DiscussionFindings from this mixed-methods study suggest that processes of empowerment and collective efficacy may contribute to greater firearm safety engagement within Latino and Hispanic communities. Findings expand injury prevention research by exploring the factors influencing firearm safety engagement among a marginalized and hard-to-reach population who have disproportionate experiences with firearm victimization, perpetration, and injury. ConclusionThis study offers unique methodological approaches by using concurrent mixed methods and collecting complementary data sources to understand firearm safety engagement among Latinos and Hispanics. Findings highlight the need for culturally specific and community-engaged interventions that address social ecological disparities to strengthen safety practices and reduce firearm-related harms.

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.

Background: Loneliness is common and deleterious to health. Yet little is known about its population burden and health correlates in the US. We aimed to determine the prevalence of loneliness and characterize its health and social functioning correlates among US adults. Methods: With data from the National Health Interview Study (2024), we used survey-weighted Poisson regression to estimate relative risks (RR) and 95% confidence intervals (CI) for frequent loneliness by levels of self-reported general health, social/emotional support, social functioning, and healthcare utilization, adjusted for age, sex, race/ethnicity, number of people in household, marital status, and psychological distress. Results: 12 million US adults reported usually or always feeling lonely, which was associated with worse general health and social/emotional support, work and social participation limitations, and healthcare disengagement. Conclusions: Loneliness affects millions of US adults, with substantial health and social functioning burden.

Introduction: Monitoring trends in transitions in the use of electronic nicotine delivery systems (ENDS) and cigarettes among youth is important for understanding the potential public health impacts of these products. Methods: Using a weighted Markov multistate transition model accounting for complex survey design, we estimated transition rates and one-year transition probabilities between never, non-current, ENDS-only, and cigarette use (with or without dual use of ENDS) among 26,744 youth aged 12-17 years who participated in at least two consecutive waves from Waves 2-7.5 (approximately 2015-2023) of the nationally representative Population Assessment of Tobacco and Health (PATH) Study. We also estimated transitions stratified by ages 12-14 and 15-17 years. Results. The one-year probability of ENDS-only initiation from never use among youth peaked in 2017-19 (Waves 4-5) at 4.0% (95%CI: 3.6-4.3%) and was higher for 15-17-year-olds at 5.8% (95%CI: 5.2-6.4%) than 12-14-year-olds at 2.2% (95%CI: 1.8-2.6%). In the following years, ENDS-only initiation rates declined and plateaued, with 2.6% (95%CI: 2.3-3.0%) initiation in 2022-23. Cigarette initiation from never use decreased over 2015-23 from 0.8% (95%CI: 0.6-1.0%) in 2015-16 to 0.1% (95%CI: 0.0-0.2%) in 2022-23. There was an increase in the fraction of youth who transitioned from non-current product use to ENDS-only use from 13.7% (95%CI: 7.5-20.0%) in 2015-16 to 35.1% (95%CI: 25.4-44.8%) in 2022-23, paired with a decrease in non-current use to cigarette use from 20.9% (95%CI: 11.8-30.0%) to 6.3% (95%CI: 1.7-10.8%). Transitions from ENDS-only or cigarette use to non-current use remained relatively constant over time at around 25% and 15% per year, respectively. Conclusion. ENDS-only use initiation has changed over time, peaking around 2019 and subsequently decreasing and plateauing, but cessation rates for both ENDS and cigarettes have remained relatively stable. Thus, interruption of tobacco product initiation may be the most effective approach to reducing tobacco product use among youth.

This study investigated retirement adjustment in retired police officers in the UK (N = 289), examining how time since leaving the service moderates the relationship between perceived organisational support and retirement adjustment while accounting for resilience. Results indicated a developmental trend: organisational support remains stable initially but becomes increasingly influential in later life. Using Johnson-Neyman analysis, a threshold of 32.07 years was identified, after which the association reaches statistical significance. These findings suggest an organisational legacy effect; for the older generation, the retrospective perception of being valued by the service acts as a durable psychological resource. This study offers a novel conceptualisation of long-term organisational influence by identifying a temporally delayed legacy effect that extends beyond existing models of retirement adjustment. The study advocate for lifelong wellbeing strategies that extend, recognising that the organisational relationship continues to shape adjustment outcomes decades after the conclusion of active duty.

BackgroundThe Global Youth Tobacco Survey (GYTS) is widely used to monitor tobacco use among adolescents worldwide. However, inconsistent analytical approaches particularly in handling complex survey designs and predictor selection limit comparability across countries, survey waves, and software platforms. Although much of the GYTS literature relies on proprietary tools such as SAS and SPSS, practical and transparent guidance on implementing reproducible, theory-informed analyses remains limited. A unified workflow that respects the surveys design while supporting cross-platform implementation is needed. MethodsWe developed a reproducible, open-source workflow for analysing GYTS data using R and Python. In R, analyses were conducted using the survey package (svydesign and svyglm) with constrained stepwise selection via stepAIC. In Python, a custom constrained stepwise procedure was implemented using statsmodels generalized linear models. The workflow explicitly incorporates survey weights, stratification, and clustering; harmonises variables across countries; protects a priori demographic covariates; and ensures consistent treatment of categorical predictors. The approach is illustrated using data from Zambia (n = 2,959) and pooled data from Ghana, Mauritius, Seychelles, and Togo (n = 15,914). Predictor selection was guided by Social Cognitive Theory and evidence from systematic reviews. ResultsThe constrained selection framework consistently retained key demographic variables (age, sex, and grade) while allowing data-driven selection of modifiable predictors using the Akaike Information Criterion. When identical constraints were applied, the R and Python implementations selected identical models and produced nearly equivalent point estimates (adjusted odds ratio differences <0.01), although Python-based confidence intervals did not account for clustering. Of 18 candidate predictors across individual, social, media, and policy domains, 14 were retained. The strongest independent predictors included awareness of tobacco products (OR = 5.61, 95% CI: 4.65- 6.78), peer smoking (OR = 4.57, 95% CI: 3.34-6.25), and exposure to tobacco marketing (OR = 2.34, 95% CI: 1.89-2.91). ConclusionsThis study provides a generalisable, theory-informed framework for predictor selection in complex survey data using open-source tools. The workflow supports consistent analyses across countries, survey waves, and software platforms, and is transferable to other youth and adult population surveys. All code and harmonisation resources are openly available to support reproducibility and adaptation. Plain-Language SummaryO_LIWhat we asked: Can we predict adolescent smoking using GYTS data in a way that is easy to follow and reproducible across software? C_LIO_LIWhat we did: Built a single workflow that respects survey design (weights, strata, clusters) and selects predictors using four explicit criteria: theoretical grounding in Social Cognitive Theory, empirical support from prior studies, relevance for intervention, and cross-country validity. Core demographics (age, sex, grade, region) were protected as essential confounders, while other predictors were selected based on statistical fit. The workflow runs equivalently in R and Python. C_LIO_LIWhy it matters: Many GYTS studies use weights only and ignore clustering and stratification, which makes confidence intervals too narrow. More importantly, most analyses include variables arbitrarily or let software drop important confounders automatically. Our approach ensures theoretically meaningful, policy-relevant variables are retained, producing more reliable and actionable results for prevention programs. C_LI

BackgroundLong COVID has emerged as a major public-health concern in the United States, yet geographic variation in its prevalence remains poorly understood. This study examines how state-level differences in COVID-19 vaccination, SARS-CoV-2 incidence, COVID-19 hospitalization, and chronic disease burden relate to adult Long COVID prevalence in the United States. MethodsWe conducted an ecological analysis using data from the 2023 Behavioral Risk Factor Surveillance System (BRFSS), from which we estimated state-level prevalence of self-reported Long COVID among adults. These estimates were linked with publicly available data on SARS-CoV-2 incidence, COVID-19 hospitalizations, COVID-19 vaccine coverage, and a multimorbidity indicator (>= 3 chronic conditions e.g., diabetes, obesity, chronic kidney disease) associated with higher risk for severe SARS-CoV-2. Multivariable linear regression models were fitted to assess the contribution of each factor adjusted for age and sex distribution, incorporating Rubins rules to account for uncertainty in prevalence estimates. ResultsAll examined factors--including SARS-CoV-2 incidence, hospitalization rates, and multimorbidity, vaccine coverage--varied by state. When modeled simultaneously and adjusting for age and sex distribution, only COVID-19 vaccine coverage and SARS-CoV-2 incidence were significantly associated with Long COVID prevalence. COVID-19 vaccine coverage showed a strong protective association, while SARS-CoV-2 incidence showed a modest positive association. Multimorbidity and hospitalization rates were not independently associated with adjustment. ConclusionsState-level variation in Long COVID burden appears most strongly driven by COVID-19 vaccine coverage and SARS-CoV-2 incidence. Promoting COVID-19 vaccination remains essential to reduce long-term impacts from SARS-CoV-2 infections.

Objectives. To test whether the association between household income and tooth retention differs by race/ethnicity and whether this interaction varies by reason for the most recent dental visit among US adults. Methods. We analyzed 13,190 adults in the National Health and Nutrition Examination Survey (2009 to 2018). Survey weighted linear regression estimated interactions between household income and race/ethnicity in models of tooth retention, stratified by reason for last dental visit. Results. Higher income was associated with greater tooth retention across groups, but income related gains were larger for Non-Hispanic White adults than for Non Hispanic Black and Mexican American adults, particularly in problem-focused care settings. In problem focused visits, each higher income category was associated with 0.5 additional teeth among White adults (95% CI 0.4, 0.6) versus 0.2 (95% CI 0.0, 0.4) among Black adults and 0.1 (95% CI 0.1, 0.3) among Mexican American adults. Racial differences were attenuated in routine check-up contexts. Conclusions. Income related gains in tooth retention differed by race/ethnicity and dental care context. Public Health Implications. Expanding access alone may be insufficient to reduce racial inequities in oral health.

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.

Background: Lung cancer screening can reduce lung cancer mortality through early detection, but uptake of the NHS Targeted Lung Health Check (TLHC) programme remains low. Behaviourally informed invitation messages have been proposed as a low-cost approach to increase attendance, but evidence of their effectiveness in lung cancer screening is mixed. Few intervention studies used evidence-based behaviour change frameworks, and rarely tailored invitation strategies to empirically identified barriers and enablers. Methods: In an online experiment, 3,274 adults aged 55-74 years and with a history of smoking were randomised to see one of four behaviourally informed invitation messages or a control message. Participants then rated their intention to attend a TLHC appointment, and selected barriers and enablers to attending from a pre-defined list, which were classified according to the Theoretical Domains Framework. Invitation messages were mapped to Behaviour Change Techniques using the Theory and Techniques Tool. Message conditions were compared on intention to attend TLHC using bootstrapped ANOVA followed by pairwise comparisons. Exploratory counterfactual mediation analyses examined the role of fear in intention to attend. Results: Behaviourally informed invitation messages did not meaningfully increase intention to attend TLHC compared with the control message. While a GP-endorsed message showed a small potential benefit relative to the other conditions, this finding was not robust after adjustment for multiple comparisons. Participants most frequently reported barriers related to Emotion (particularly fear), Social Influence, and Knowledge, while Beliefs about Consequences emerged as the primary enabler of attendance. Only around half of reported barriers and enablers were addressed by the invitation messages. Exploratory analyses found that fear was associated with lower intention to attend a TLHC appointment, yet none of the behaviourally informed messages appeared to reduce fear compared to the control message. Conclusions: Improving lung cancer screening uptake will likely require invitation messages that directly address emotional concerns, particularly fear, alongside credible recommendations. These findings highlight the importance of systematically aligning invitation message content with empirically identified behavioural influences when designing scalable interventions to improve lung cancer screening uptake.

Although the built environment has been identified as a risk factor for depressive symptoms, it is unclear whether these associations are driven by specific environmental features and whether they remain stable over time. In 10,310 ALSPAC women living in Bristol city, we conducted preregistered network analyses to investigate cross-sectional and longitudinal associations between built environment features (e.g., population density, green space and walkability) and depressive symptoms (at ages 28, 32 and 48 years). Contrary to our hypotheses, associations between individual built environment variables and depressive symptoms were consistently weak. Exploratory factor analyses indicated a built environment factor associated with depressive symptoms at baseline ({beta} = 0.148, p < .001) and 4-year follow-up ({beta} = 0.114, p = .011), but not at 18-year follow-up ({beta} = -0.005, p = .950). These findings suggest the combined influence of built environment features may explain depressive outcomes better than individual built environment measures alone.

BackgroundSafety data for most medications in pregnancy remain limited, yet pharmacological treatment is often necessary. Evidence on real-world medication use in pregnancy including over-the-counter products and folic acid is scarce, especially in Belgium. MethodsWe conducted a drug utilisation study using self-reported data from BELpREG, a prospective, web-based pregnancy registry established in November 2022. Pregnant individuals aged [&ge;]18 years receiving healthcare in Belgium can enrol voluntarily at any stage in pregnancy and complete online questionnaires at enrolment and every four weeks until delivery. All participants with follow-up beyond the first trimester were included, and trimester-specific cohorts were constructed based on completion of questionnaires after each trimester. Data were extracted in July 2025. ResultsThis study included 2,096 participants, of whom 1,767 were followed through trimester 2 and 1,136 through trimester 3. Median gestational age at enrolment was 16 weeks. Prevalence estimates of medication use were 80.2% in the six months before conception, 85.8% in trimester 1, 92.0% in trimester 2, and 94.9% in trimester 3. The most common classes were analgesics, vaccines, antihistamines, antianemic preparations, and drugs for acid-related disorders. Paracetamol was most frequently used (35.4% in trimester 1), typically short term (median 3 days), followed by doxylamine-pyridoxine (26.7% in trimester 1). Folic acid supplementation was nearly universal, though only 59.9% met national guideline-concordant criteria. Maternal vaccine uptake was substantial but incomplete, with 67.2% receiving pertussis, 41.5% influenza, and 21.5% COVID-19 vaccination. Exposure to potentially inappropriate or teratogenic medications was rare. ConclusionsMedication use during pregnancy in Belgium was nearly universal, with high use of paracetamol and doxylamine-pyridoxine. Folic acid and vaccine uptake were substantial, but often not guideline-concordant. Key PointsO_LIMedication use during pregnancy in Belgium was nearly universal, with over 85% of participants reporting use in the first trimester and 95% in the third. C_LIO_LIParacetamol (35% in the first trimester) and doxylamine-pyridoxine (27% in the first trimester) were the most frequently used medications. C_LIO_LIFolic acid use was widespread, yet only about 60% of participants followed national timing and duration recommendations. C_LIO_LIMaternal vaccine uptake was substantial, particularly for pertussis (67%), though not universal despite guideline recommendations C_LIO_LIBELpREGs self-reported data capture both prescription and over-the-counter medications, offering a complete picture of real-world use during pregnancy. C_LI Plain Language SummaryThis study looked at how often and when people in Belgium use medications, folic acid supplements, and vaccines during pregnancy. Using data from the BELpREG pregnancy registry, more than 2,000 pregnant participants completed online questionnaires about their health and medication use throughout pregnancy (every four weeks). Almost everyone reported taking at least one medication: 86% during the first trimester and 95% during the third. The most common medicines were paracetamol and doxylamine-pyridoxine. Nearly all participants used folic acid, but only about 60% followed national recommendations for starting timely before pregnancy and continuing through the first trimester. Many received recommended vaccines during pregnancy: about 67% for pertussis, 42% for influenza, and 22% for COVID-19; but uptake was still incomplete. Exposure to potentially inappropriate or teratogenic medications was rare. Because BELpREG collects self-reported data, including both prescribed and over-the-counter products, it provides a comprehensive picture of real-world medication use in pregnant people. Further, these findings help identify gaps between guideline recommendations and actual practice. Social Media QuoteMedication use in pregnancy is nearly universal in Belgium. Paracetamol and doxylamine-pyridoxine top the list. Folic acid and vaccine uptake are high but often not guideline-concordant. BELpREG data reveal unique self-reported real-world patterns. #BELpREG

IntroductionDuring the COVID-19 pandemic, incarcerated populations faced heightened risk of exposure due to healthcare barriers, restrictive environments, and pre-existing health conditions. Consequently, Correctional Officers (COs) faced increased risk of COVID-19 exposure. Given the health benefits of COVID-19 vaccination and the rise in vaccine hesitancy, this study examined the relationship between COs health beliefs and COVID-19 vaccine uptake. MethodsA health beliefs survey was administered to Massachusetts-based COs (n=118). Chi-squared Automatic Interaction Detection modeling and logistic regression was utilized to analyze the survey data. ResultsCOs with higher trust in vaccines and a prior positive COVID-19 test were most likely to get vaccinated voluntarily. Those with low trust in vaccines and no previous positive COVID-19 test were least likely to receive the vaccine. ConclusionDespite the severe impact of COVID-19 in correctional settings, and the evidence of vaccine efficacy against hospitalization and death, vaccine uptake among COs remains low.

BackgroundConcern about long-term health effects of repetitive head impacts in football has increased, but it remains unclear whether position-specific exposure patterns were associated with differential long-term all-cause mortality among elite players across the 20th century. MethodsWe conducted two retrospective cohort studies of elite male professional football players. The World Cup cohort included all players on the team rosters from FIFA World Cup tournaments (1930-1990), and the UEFA European Cup cohort included all players who appeared in annual quarterfinal, semifinal, or final matches (1956-1991). Vital status was ascertained through archival linkage. Playing position was harmonized into six categories. Age was the time scale. Cox proportional hazards models were stratified by birth cohort and adjusted for origin region; interaction models were used to estimate region-specific marginal hazard ratios. FindingsThe World Cup cohort included 4,223 players (2,330 deaths), and the European Cup cohort included 2,710 players (1,126 deaths). In the World Cup cohort, goalkeepers had lower mortality than midfielders (hazard ratio [HR] 0.73, 95% CI 0.63-0.84), whereas center-forwards had higher mortality (HR 1.27, 95% CI 1.08-1.50); mortality among center-backs was elevated but not statistically significant (HR 1.13, 95% CI 0.98-1.31). In the European Cup cohort, center-backs (HR 1.28, 95% CI 1.07-1.55) and other defenders (HR 1.20, 95% CI 1.02-1.42) had higher mortality than midfielders. Region-stratified marginal estimates indicated that elevated risks for central playing roles were greatest in Northwestern Europe and Central/Eastern Europe. InterpretationAmong footballers active during the 20th century, long-term all-cause mortality differed by playing position and varied by region, with higher risks concentrated in central attacking and defensive roles. These patterns were most pronounced in regions where aerial contests historically predominated, suggesting that long-term health risks associated with professional football participation vary by role-specific exposure profiles.

Background While a mobile lung cancer screening (mLCS) program can mitigate barriers to access, this study conducted a survey study to assess barriers and facilitators to mLCS which could inform the implementation of new mLCS programs or inform modifications to existing programs. Methods Patient eligibility included current age of 50 to 80 and had undergone any cancer screening at Moffitt Cancer Center (MCC) between January 1, 2023 and December 1, 2024. A web-based survey was administered from May 2025 to June 2025 which collected data on health behaviors, barriers, facilitators, screening preferences, and demographics. Descriptive statistics were used to quantify survey responses. Results Among participants who completed the survey, 73.4% reported no concerns about getting screened in a mobile screening unit, 67.9% reported concerned about the cost or if insurance covered mobile lung cancer screening, and 82.4% reported they would be screened if a voucher or insurance would pay for it. For preferences, 54.1% reported no preference for the time of year for a mobile screening event, 59.6% reported they will be willing to wait up to 30 minutes to get screened, and 44% would travel more than 20 minutes to get screened. There were no statistically significant differences in barriers and facilitators when the analyses were stratified by LCS eligibility. Conclusions We found acceptability of mobile lung cancer screening and preferences that are actionable including daytime weekday events, indoor waiting, short waits, proximity to home, clear cost coverage, and streamlined clinician recommendation.