SSM - Population Health

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.

Background Physical activity (PA) and body mass index (BMI) shape cardiovascular risk, particularly in women. Yet, little research exists examining intersectional social axes shaping PA and BMI inequities among women living in the United States (US). Methods Data included women sampled in the 2015-2020 National Health and Nutrition Examination Survey. We used Intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (I-MAIHDA) via linear models to examine PA (n=,4591) and BMI (n=4,596) inequities across intersectional strata defined by race/ethnicity, age, education, nativity, and work status. We further quantified the contribution of these strata to the observed inequities and estimated additive fixed effects. Results In the null model, intersectional strata explained 4.6% and 13.8% of the variance in PA and BMI inequities, respectively, with 99.2% for PA and 97.5% for BMI explained by age, race/ethnicity, education, nativity, and occupation status. On average, Asian and Black women, those aged 35-49 years, those born outside the US, and those with less than a high school diploma had the lowest predicted mean PA. For BMI, Black and Hispanic/Latino women and those younger than 64 years had the highest mean BMI. Conclusion PA and BMI inequities are mostly explained by race/ethnicity, age, education, nativity, and work status. Our findings offer insights into universal and potential policy-informed health promotion strategies that may be tailored to women with these social identities and lived experiences that have shaped physical activity and body mass index inequities.

Background Persons experiencing homelessness (PEH) have a 2-3-fold greater risk for cardiovascular disease (CVD) mortality compared with domiciled counterparts. Evidence has repeatedly shown elevated chronic disease burden, reduced access to many types of care, and lower utilization of medication to control CVD risk factors in clinical settings dedicated to providing health care to PEH. There are federally funded health clinics targeting barriers to access for patient populations experiencing homelessness in place. These clinics are frequently overwhelmed and limited by their scope to primary care despite well documented burdens of co- and tri-morbid conditions. There is scarce evidence on differences between access, quality, and experiences of care delivered relative to other safety-net models. Method The 2022 Health Center Patient Survey (HCPS) was collected on behalf of the Health Resources and Services Administration (HRSA). The HCPS is a nationally representative, three-staged, sample-based survey collected via 1:1 interview with clinic patients. The survey assessed sociodemographics, health conditions and behaviors, access to and utilization of care, and patients? experiences with comprehensive services they received at HRSA-funded Federally Qualified Health Centers (FQHCs), including community health centers (CHC), healthcare for the homeless (HCH) clinics, and public housing primary care (PHPC) clinics. One hundred and three unique awardees and 318 health center sites were recruited, and 4,414 patient interviews were completed. Investigators analyzed patient characteristics and multiple survey items related to AHA?s Essential 8 metrics for differences between HCH and CHC patient responses. Results HCH clinics had fewer elderly patients (~7%) than CHCs (~17%). Reported 7-day physical activity measures, average sleep below 7 hours per day, and Lifetime smoking (>100 cigarettes; OR=4.2, p<0.001) were all greatest among HCH patients. Fewer HCH patients reported ever having or recent lipid tests (both p<0.001). HCH patients were more likely to report hypertension (p=0.003) but less likely to report receiving nutrition advice (all p<0.05). HCH patients were less likely to be taking medication even if it was prescribed (p<0.001). Adjustments for differences in age or CVD history were able to explain some observed differences but increased the magnitude of other disparities. Conclusions CVD burden differs across the various HRSA funding mechanisms for clinics, as do demographics and multiple metrics of health behaviors and biomarkers of cardiovascular health. Greater disease burden in HCH patients is likely compounded by increased risk factors and underperformance in providing health education interventions.

Background Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 and the Free Maternal Healthcare Policy (FMHCP) in 2008 to remove financial barriers and promote universal health coverage. Despite these landmark policies, socioeconomic inequalities in maternal healthcare utilisation may persist. This study quantifies socioeconomic inequalities in antenatal care (ANC) receipt and place of delivery and decomposes the key drivers of inequality using the most recent nationally representative survey data. Methods We analysed the 2022 Ghana Demographic and Health Survey women's file, restricting to women who reported a live birth in the five years preceding the survey (n = 5,134; weighted population {approx} 4.66 million). Outcome variables were adequate ANC ([&ge;]4 visits, and [&ge;]8 visits in sensitivity analysis) and place of delivery (home, public facility, private facility). The concentration index (CI) was computed for adequate ANC, and the Wagstaff decomposition method was applied to quantify the contribution of wealth, education, residence, NHIS membership, and access barriers. Multinomial logistic regression examined factors associated with place of delivery. Missing data were handled using multiple imputation by chained equations (20 datasets). All analyses accounted for the complex survey design. Results Overall, 88.6% (95% CI: 87.0-90.2%) of women achieved [&ge;]4 ANC visits. The concentration index for adequate ANC was 0.0391 (95% CI: 0.0291-0.0491; p < 0.001), indicating statistically significant pro-rich inequality. Using the WHO threshold of [&ge;]8 visits, the CI increased more than fourfold to 0.1728 (95% CI: 0.1428-0.2028). Home delivery was most prevalent among the poorest women (46.7%), while private facility delivery dominated among the richest (46.1%). Decomposition showed that rural residence (16.4%), NHIS membership (16.4%), and geographical region (15.6%) were the largest positive contributors to pro-rich inequality, whereas secondary education exerted the strongest equalising effect (-22.5%). NHIS membership was associated with lower odds of home delivery (RRR = 0.24, 95% CI: 0.18-0.32) but did not eliminate the wealth gradient. Together, included determinants explained 71.3% of total inequality. Conclusions Despite high coverage of basic ANC, substantial and policy-relevant socioeconomic inequalities persist in maternal healthcare utilisation in Ghana. Inequalities widen markedly when the stricter WHO standard is applied. Educational attainment and rural residence are primary drivers; NHIS alone is insufficient to achieve equity. Policies should address non-financial barriers, strengthen rural health infrastructure, invest in public facility quality, and promote girls' secondary education to reduce persistent maternal health disparities.

The end-of-career stage of the police lifecycle represents a profound shift in identity and psychological stability, yet it remains historically neglected in research. This mixed-methods study investigated perspectives of UK police leavers and those approaching retirement (N = 325) regarding desired improvements to organisational support. Content analysis identified four themes: Holistic support and long-term welfare, Institutional culture and professional worth, Navigating the structural transition, and Individual and systemic perspectives. Findings suggest that the psychological contract between the officer and the organisation is often breached at the exit point, shifting from a relational bond to a transactional disposal. Middle-ranking officers and early leavers report the highest levels of institutional abandonment. To address these gaps, this paper makes recommendations for developing effective transitions. By implementing post-service welfare, and adopting structured resettlement models, police organisations can fulfil their duty of care and mend the psychological contract for those who have served.

ABSTRACT: Importance: Rural urban disparities in chronic disease prevalence are well established; however, the extent to which individual level socioeconomic status (SES) contributes to these disparities remains unclear. Objective: To examine the associations of rurality and SES with the prevalence of five most burdensome chronic diseases among adults. Design: We conducted a retrospective cross sectional study of adults across 27 Upper Midwest counties using the Expanded Rochester Epidemiology Project (E REP) medical record data linkage system to evaluate associations between rurality, SES and chronic disease prevalence. Prevalence of clinically diagnosed asthma, diabetes, hypertension, coronary heart disease, and mood disorders was identified from International Classification of Diseases ICD9/10 codes over a five-year period (2014 to 2019). Setting: Population based Participants: Adults over 18 years residing in the 27 E REP counties, excluding those missing rural urban residence status. Exposure: HOUSES index, an individual level measure of SES, served as the primary measure, while rurality based on Rural Urban Commuting Area (RUCA) codes 4-10 was the secondary measure. Main Outcome: Prevalence of the five clinically diagnosed chronic diseases was identified using ICD9/10 codes from 2014 to 2019. Mixed effect logistic regression models were used and adjusted for demographics and general medical examination receipt, to assess rural urban and SES differences for prevalence of each chronic disease. Results: Among 455,802 adults with available HOUSES index, 42.8% lived in rural areas, 53.8% were female and 87.4% were non-Hispanic White. In the unadjusted analysis, rural and urban populations showed comparable asthma and CHD prevalence, while mood disorders, hypertension, and diabetes were more common in urban areas. After adjusting for demographic factors and healthcare utilization, rural urban differences were no longer statistically significant, whereas SES remained strongly associated with all diseases in a dose response manner (e.g., adjusted Odds Ratio for hypertension (ref: HOUSES index Q4): 1.14, 1.27, and 1.42 for HOUSES index Q3, Q2, and Q1, respectively). Conclusions and Relevance: Individual level SES measured by the HOUSES index, was more strongly associated with chronic disease prevalence than rurality, supporting its integration into population health assessment and risk stratification.

PurposeTo characterize maternal transport patterns in Iowa, a state with levels of maternal care and without formal perinatal regions, and assess whether transport decisions reflect efficient, risk-appropriate coordination. MethodsWe analyzed 2010-2023 Iowa birth records, which included 2,251 maternal transports between obstetric facilities across 106 unique routes. We characterized transport patterns and applied a community detection algorithm to identify "communities" of obstetric facilities that disproportionately transport among themselves. FindingsSuburban and rural counties have elevated transport rates compared to urban counties. 2,189 transports (97%) were from lower-to higher-level facilities. Among these, 2,037 (93%) were to Level III tertiary care centers. 567 transports (25.2%) bypassed a closer facility offering an equivalent or higher level of care than its destination facility. Health system affiliation was associated with bypassing transport, indicating potential organizational rather than purely geographic drivers of transport decisions. Three "communities" of obstetric facilities largely shaped by geographic proximity were identified. ConclusionsAlthough Iowa does not have formal perinatal regions, patterns of maternal transport are mostly in line with three de facto regions. Some potential inefficiencies were identified, such as obstetric facilities transporting to a farther facility when a closer facility offered the same level of care or higher. These findings may help identify opportunities to enhance care coordination among obstetric facilities, optimize maternal transport networks, and improve regionalization of maternal care.

Introduction: Economic opportunity is a core pillar of the American Dream but is not distributed equally across communities. Substantial evidence has identified economic opportunity as an independent social determinant of health, but relatively little is known about opportunity's relationship with other socioeconomic characteristics such as income. Here we address this gap in the literature to examine how area-level economic opportunity modifies the income-health gradient. Methods: We used multivariable ordinary least squares models to estimate the association between self-reported health and economic opportunity across household income levels for working age adults (ages 25-64). Our measures of income and health come from the 2010-2019 Current Population Survey Annual Social and Economic Supplements. Our measure of economic opportunity was drawn from Opportunity Insights and represents the county-averaged national income percentile rank attained in adulthood for individuals born to parents at the 25th percentile of the income distribution. We adjusted for a wide range of individual- and county-level demographic and socioeconomic characteristics. Results: We find that county-level economic opportunity modified the gradient in self-reported health and household income among working-age adults. Effects were particularly pronounced in the lowest income deciles -- an interdecile increase in economic opportunity was associated with closing almost 33% of the gap in health between the lowest and highest income deciles. The results were robust to sensitivity analyses. Conclusion: We show that local area economic opportunity flattens the relationship between household income and health, with lower-income individuals benefitting the most from living in high opportunity areas.

Decarceration, the process of reducing incarceration rates, is increasingly viewed as a strategy to improve population health and reduce health inequities. Yet, evidence on its health effects remains limited and may depend on how decarceration occurs. We developed a national decarceration "atlas" to characterize the mechanisms and dynamics of decarceration across more than 2,800 U.S. counties between 1999-2019. Using longitudinal county-level jail and prison data, we identified four operational types of decarceration: reduced pretrial detention, reduced jail time, reduced prison admissions, and reduced prison time. Nearly two-thirds of counties, including most rural counties, experienced at least one decarceration type during the study period. Declines typically followed periods of recent growth and were relatively modest in magnitude, with median reductions of 19% to 38% ten years after onset. The frequency and timing of decarceration types varied by urbanicity, state, and region, with many counties experiencing multiple mechanisms concurrently. Validation against documented case studies of state and local decarceration demonstrated alignment with known legislative and de facto drivers, while revealing substantial sub-state heterogeneity. This atlas provides a scalable framework and hypothesis-generating resource to support comparative studies of decarceration's heterogeneous health effects.

Objective. Menopause is a significant physiological transition with implications for health outcomes (e.g., cardiometabolic), yet gaps remain in understanding the menopause transition, including how menopause timing and type influence health outcomes. Large-scale cohort studies in midlife (age~40-60) females, including the All of Us Research Program (AoURP), provide opportunities to study menopause across diverse populations and data modalities. We characterized menopause-related data in AoURP, focusing on age distributions and concordance between EHR diagnosis codes and self-reported survey responses. Methods. We analyzed menopause-related survey, EHR diagnostic code, and genomic data among ~396,000 participants in AoURP with female sex. We summarized menopause data across modalities, overlap between survey, EHR, and genomic data, and age distributions overall and across sociodemographic characteristics. Results. Among ~396,000 females, surveys captured ~193,000 menopause observations, nearly seven times more than structured EHR diagnoses (~28,000), suggesting under- ascertainement in EHR data. Nearly all females (~99%) with an EHR menopause diagnosis also reported menopause in the survey. Approximately 22,000 participants had intersected EHR, survey, and genomic menopause-related data. Survey-based age patterns matched expectations, with participants <40 years predominantly reporting pre-menopausal status and those >60 years predominantly reporting post-menopausal status. A small subset (N{approx}1,700; 4%) (age>70 years) reported no menopause, suggesting response or recall bias. EHR menopause codes were concentrated after age>45 years, with a notable spike at age 65. Modest differences in survey-based menopause age distributions were observed by sociodemographic characteristics (e.g., race, ancestry). Conclusions. These findings inform sampling strategies, power calculations, phenotype definition, and study design for menopause research using AoURP.

Background: The two-child benefit cap, implemented in April 2017, restricted Universal Credit and Child Tax Credit to the first two children in households with three or more children. We evaluate the impact of the two-child benefit cap on parental mental, general, and financial health, as well as investigate how this may differ in particular sociodemographic and economic subgroups based on sex, ethnicity and income. Methods: Data was obtained from parents (youngest child aged 5 or under) in the UK Household Longitudinal Survey from 2009 to 2023. Outcomes included parental mental health (psychological distress and life satisfaction), general health (health-related quality of life (HRQoL), self-rated health and health satisfaction), and financial health (current financial situation and financial outlook). We used complementary policy evaluation methods with different strengths and assumptions to triangulate evidence and strengthen inference: interrupted time series (ITS), difference-in-differences (DiD) and controlled time series analysis (CITS). Subgroup analyses were stratified by sex, ethnicity, and income. Findings: Across methods, findings consistently indicate that the policy worsened life satisfaction, self-rated health, health satisfaction, and financial health for parents of 3+ children. Findings were less consistent across methods for psychological distress and HRQoL. For instance, for psychological distress ITS and CITS indicate adverse impacts of the policy; however, one DiD model did not support this conclusion due to greater average worsening in the control group between the pre- and post-periods. Subgroup analyses indicate greater mental health and general health impacts in lower income, male and ethnic minority parents; while financial health was negatively impacted in all subgroups examined. Conclusions: Using repeated cross-sectional panel data and triangulating across causal inference methods, we conclude that the two-child benefit cap in the UK had a measurable adverse impact on most health outcomes examined, with worse outcomes for male, lower income and ethnic minority parents.

Female genital cutting (FGC) is identified within global health and human rights discourse as aligned with gender inequality and female disempowerment. The persistence of FGC in high-prevalence societies is assumed to reflect womens limited influence over decisions concerning their daughters. Yet anthropological research has questioned whether this interpretation adequately reflects how FGC is organized within practicing communities. Across two studies with 176,728 participants from 15 African and Asian countries, we examine whether mothers attitudes toward FGC predict daughters circumcision status and whether this relationship varies with regional FGC prevalence. Multilevel logistic regression models show that maternal attitudes strongly predict daughter circumcision status across both datasets. Contrary to expectations derived from disempowerment frameworks, the association between maternal attitudes and daughter outcomes is not weaker in high-prevalence contexts, it is stronger. These findings suggest that interpretations of FGC as reflecting female disempowerment may mischaracterize the social dynamics of societies in which FGC is common. Policy implications of the findings are discussed.

Abstract Importance Stigma and discrimination against transgender and gender-diverse people are prevalent across many settings and may contribute to substantial health disparities. Objective To synthesize global evidence on the prevalence of stigma, discrimination, and resilience among transgender (trans) and gender-diverse adults. Data Sources A systematic search was conducted in PubMed, Embase, CINAHL, Cochrane Central, LILACS, and PsycInfo for articles published between January 1, 2010 and January 2, 2023. This database search was supplemented by grey literature and secondary reference searches. Article Selection Studies were eligible if they presented primary quantitative data on prevalence of stigma, discrimination, and/or resilience among trans and gender-diverse adults (aged 18 and over), with no restrictions on study design, language, or geographic region. Data Extraction and Synthesis Two independent reviewers extracted data using standardized forms, with discrepancies resolved by consensus. The JBI Critical Appraisal Checklist for Prevalence Articles was used to assess risk of bias. Random effects meta-analysis was conducted for dichotomous prevalence measures using inverse variance weighting and logit transformation; non-dichotomous prevalence data were summarized descriptively. Main Outcomes and Measures Outcomes included prevalence estimates for various forms of stigma (anticipated, perceived, internalized, and experienced), discrimination in legal/institutional settings (housing, healthcare, employment, police/prison), and resilience. Results A total of 97 articles, with data from 72,158 unique trans and gender-diverse participants across 26 countries, met inclusion criteria. Studies showed moderate levels of anticipated stigma, perceived stigma, and internalized stigma. Meta-analyses of 36 studies provided pooled estimates of discrimination prevalence across multiple domains: 21.4% in housing (e.g., eviction, rental denial), 24.6% in healthcare (e.g., denial of care, mistreatment), 32.8% in employment (e.g., hiring bias, workplace harassment), and 39.1% in police/prison settings (e.g., profiling, mistreatment). High heterogeneity was observed across studies, reflecting regional and methodological differences. Resilience scores ranged from moderate to high, indicating variation within trans and gender-diverse communities. Conclusions and Relevance This systematic review and meta-analysis found that stigma and discrimination against trans and gender-diverse adults are pervasive globally. Variation in stigma and discrimination across settings and regions underscores the need for targeted interventions and policy reforms. Funding World Health Organization through a grant from the Elton John AIDS Foundation and the Bill and Melinda Gates Foundation.

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.

Dropout from essential maternal health services across pregnancy, childbirth, and the postnatal period remains a major barrier to improving maternal and neonatal outcomes in Bangladesh. This study examined stage-specific dropout patterns along the maternal continuum of care and identified factors associated with discontinuation. We analysed nationally representative data from the Bangladesh Demographic and Health Survey 2022 for 5,162 women with a recent live birth. Dropout from antenatal care, skilled birth attendance, and postnatal care was examined using multivariable logistic regression to estimate adjusted odds ratios and 95% confidence intervals, with comparisons to BDHS 2017-18 and assessment of regional variation. Only 44% of women received four or more antenatal care visits. Of these, 33% delivered with a skilled birth attendant, and among those receiving both antenatal care and skilled delivery, only 15% received postnatal care within 48 hours. Overall, 57% dropped out before completing adequate antenatal care, with additional dropouts between antenatal care and delivery (10%) and between delivery and postnatal care (18%). Compared with 2017-18, overall dropout from the maternal continuum of care more than doubled in 2022 (5.0% to 11.7%), driven by increased antenatal care dropout, while skilled birth attendance dropout declined and postnatal care dropout increased slightly. Higher maternal education, household wealth, media exposure, and womens decision-making power were consistently associated with lower odds of dropout, whereas higher birth order increased dropout risk. Substantial regional variation was observed, with the highest overall dropout in Sylhet and the lowest in Khulna. High dropout from the maternal continuum of care in Bangladesh occurs predominantly at the antenatal care stage and is shaped by socioeconomic status, birth order, womens access to information, and regional disparities. Strengthening early antenatal engagement and womens decision-making autonomy is critical to improving continuity of maternal care and reducing preventable maternal and neonatal risks.

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.

Background. Vietnam's disease burden has shifted from communicable, maternal, neonatal, and nutritional (CMNN) causes to non-communicable diseases (NCDs), but the tempo, drivers, and regional positioning of this transition have not been jointly quantified. We characterised Vietnam's epidemiological transition 1990-2023 against ten Southeast-Asian (SEA) peers. Methods. Using Global Burden of Disease 2023 data, we computed joinpoint-regression AAPC with 95% CI (BIC-penalised, up to three break-points) for age-standardised DALY rates and cause-composition shares. We applied Das Gupta three-factor decomposition to 1990-2023 absolute DALY change (population-size, age-structure, age-specific-rate effects) and benchmarked Vietnam's NCD share against an SDI-conditional peer trajectory via leave-one-out quadratic regression. Premature mortality was quantified as WHO 30q70 under both broad NCD and strict SDG 3.4.1 definitions, using Chiang II life-table adjustment identically across all eleven countries. Findings. The CMNN age-standardised DALY rate fell from 13,295.9 to 4,022.1 per 100,000 (AAPC -4.63%/year; 95% CI -4.80 to -4.46); the NCD rate fell only from 21,688.2 to 19,282.8 (AAPC -0.37; -0.45 to -0.30). NCD share of total DALYs rose from 52.99% to 70.67% (+17.67 pp; AAPC +1.09). Vietnam ranked fourth of eleven SEA countries in 2023 (up from sixth in 1990) and sat 5.3% above the SDI-expected trajectory. Das Gupta decomposition attributed the +10.63 million NCD DALY increase to population growth (+6.26 M) and ageing (+6.08 M); rate change removed only 1.71 M. Premature NCD mortality fell from 25.02% to 21.80% (broad, 12.9% reduction) and from 22.17% to 19.50% (SDG 3.4.1, 12.0%; Vietnam sixth of eleven) - far short of the SDG 3.4 one-third-reduction target. Interpretation. Vietnam has entered a disability- and ageing-dominated NCD phase. Meeting SDG 3.4 by 2030 requires population-scale primary prevention sized to demographic momentum.

Importance Missed outpatient appointments, including no-shows and cancellations, may disrupt continuity of care and be associated with worse outcomes, but long-term system-wide patterns and clinical implications are not well characterized. Objective To characterize variation in missed appointment rates in the Veterans Health Administration (VHA) over time and by geographic location, visit modality, and preexisting conditions, and to evaluate associations between missed appointment rates and adverse outcomes among veterans with posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI). Design Cohort study using VHA Corporate Data Warehouse outpatient appointment data from January 1, 2000, through December 31, 2024. Setting National integrated health care system of the VHA. Participants System analysis includes all scheduled outpatient appointments with a valid status, and outcome analysis includes veterans with PTSD (n = 1 429 890) or TBI (n = 554 553), diagnosed before 2023. Exposures For system -level analyses, missed appointment rates were calculated. In outcome analyses, 2023 missed appointment rates were categorized into tertiles within the cohort and appointment type. Main Outcomes and Measures One year risks of all-cause hospitalization, all-cause mortality, and hospitalization or death beginning January 1, 2024. Results Among 2,162,520,880 outpatient appointments from 2000 to 2024, 6.5% were no-shows and 25.4% were canceled. Across facilities, no-show rates ranged from 3.5% to 14.1%, patient-initiated cancellation rates from 9.7% to 26.0%, and clinic-initiated cancellation rates from 8.5% to 17.9%. In 2023, veterans with amputation, Parkinson disease, PTSD, or TBI had higher missed appointment rates than veterans without these conditions. Among veterans with PTSD, the highest no-show tertile, compared with none, was associated with higher mortality (HR, 1.91; 95% CI, 1.84-1.98) and hospitalization or death (HR, 1.07; 95% CI, 1.05-1.08). Among veterans with TBI, the highest no-show tertile was associated with hospitalization or death (HR, 1.65; 95% CI, 1.61-1.69). Conclusions and Relevance Missed outpatient appointments were common in the VHA and varied substantially across facilities and over time. Among veterans with PTSD or TBI, higher missed appointment rates, particularly no-shows, were associated with increased risks of hospitalization and mortality, suggesting that these patterns may help identify high-risk veterans for targeted outreach.

Understanding depressive symptoms dynamics and their determinants is crucial for designing effective mental health support initiatives. This study compared two methods for describing youth depressive symptoms trajectories and investigated associations of early-life factors (maternal education, maternal perinatal depression, domestic violence, physical, emotional, or sexual abuse, bullying victimisation, psychiatric disorder) with trajectory features. Prospective data from 8,264 mostly White European participants (54% female), including self-reported Short Moods and Feelings Questionnaires on ten occasions between 10-25 years, were used. Trajectories were summarised using functional principal component analysis (FPCA) and P-splines linear mixed-effect (PLME) models. Estimated derivatives were used to obtain magnitude and age of peak symptoms and peak symptoms velocity. Both methods performed comparably, but PLME models tended to over-smooth trajectories. Peak symptoms and peak velocity were higher and occurred >1 year earlier in females than males. All early-life factors were associated with higher peak symptoms, and most associated with higher and earlier peak velocity. Abuse and bullying additionally associated with earlier age of peak symptoms. FPCA is a useful alternative for characterising depressive symptoms trajectories and informing time-sensitive preventative measures to reduce impact of depression before symptoms reach their peak. Early-life stressors may accelerate timeline and intensity of symptoms escalation during adolescence. Lay summaryUnderstanding development of depressive symptoms and factors shaping them is crucial for designing effective mental health support initiatives. This study used data from over 8,000 young people regularly followed up from before birth to compare two cutting-edge methods for describing depressive symptoms trajectories and examined how known risk factors for adulthood depression relate to the severity and rate of change of depressive symptoms in adolescence. We found that both methods performed well and that the peaks in depressive symptoms and their rate of change were, on average, higher and occurred over a year earlier in females than males. Our findings additionally suggest that early-life stressors (e.g., abuse, bullying) may accelerate the development of depression, highlighting the importance of early prevention.

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.