SSM - Population Health

Bangladeshi immigrants are a rapidly growing U.S. immigrant population, yet little is known about how pre-migration healthcare experiences shape healthcare use after migration. This qualitative study explored how healthcare norms from Bangladesh influence the health-seeking behaviors of Bangladeshi immigrants in the U.S., the barriers and facilitators they encounter, and their perceptions of care quality. Semi-structured interviews were conducted with 29 Bangladeshi-born adults living in the U.S. from September 2020 to January 2021 and analyzed using the constant comparative method. Participants described healthcare expectations shaped by the healthcare system of Bangladesh, which is mostly out-of-pocket and resource-limited, including symptom-driven rather than preventive care, self-treatment, and family-based caregiving. In the U.S., they faced barriers such as insurance confusion, long waits, difficulty establishing care, coverage disruptions, financial concerns, and language challenges. While participants valued culturally and linguistically concordant care, preferences for Bangla-speaking or co-ethnic providers varied, especially when perceived quality was low. Community networks, online information, self-education, and self-advocacy helped facilitate care. Provider communication strongly shaped perceptions of U.S. healthcare: feeling heard, respected, and well-informed promoted trust, while dismissal or delayed diagnosis led to skepticism and avoidance. These findings suggest that healthcare engagement of Bangldeshi immigrants is shaped by both structural barriers and pre-migration norms. Improving access will require attention to subgroup-specific histories, insurance navigation, language access, and the relational quality of care.

This study examines the impact of various maternal factors and continuous labor support on birth outcomes among 124 birthing people in the Baltimore region of Maryland who sought and/or received doula care. The cohort primarily consists of Black birthing people and includes detailed data on maternal age, race, education level, employment status, health insurance status, income level, preexisting health challenges, and pregnancy or delivery-related health challenges. The study also explores whether the pregnancy was the birthing person's first, as well as neonatal outcomes such as NICU admission, low birth weight, and other newborn health concerns. Due dates and delivery dates were compared and analyzed, where available, to provide a comprehensive understanding of the timing of births among the cohort. The findings highlight known correlations between maternal socioeconomic factors, health factors, and adverse birth outcomes, emphasizing the critical role of doula support during the prenatal period and labor and delivery in improving maternal and neonatal health, as well as in providing culturally competent care and positive birth experiences. This research contributes to the growing body of evidence on the benefits of doula care, particularly for marginalized communities, and underscores the need for targeted interventions to address health disparities among Black Birthing persons.

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

Health systems increasingly record ICD-10 Z59 social-needs codes for housing, food, transportation, and related hardship to trigger referrals, report quality, and adjust risk. However code documentation occurs at varying rates and no study has separated what the code says about a patient's hardship from what it says about being documented at all. Using a linked electronic health record and claims corpus covering 4.95 million patients in 21 identifiable health systems, we matched 26,153 adults with a first outpatient Z59 code to similar uncoded patients and, as a negative control, repeated the entire design around an administrative code. Coding ranged from 1 percent to 24 percent of patients across systems and remained highly variable after adjustment for patient mix. A hardship code was associated with 67% (95% CI=1.61, 1.74) more emergency department (ED) visits and 43% ( 95% CI=1.38, 1.49) more hospital admissions in the next year (62 versus 49 of every 100 patients with any acute event). The administrative-code reproduced 46 percent of the Z59 association for ED visits and 70 percent for admissions. In the five systems with the most complete stay dates, no hardship-specific admission excess was detectable. Homelessness codes forecast two and a half times the ED visit rate. At national planning prices, excess emergency and preventable hospital care totaled roughly $2,000 to $2,500 per coded patient-year ($2,516 base scenario; about $1,100 under an exploratory assumed-discount scenario (not an estimate of hardship-attributable spending)), with the largest emergency burden among Medicaid patients. The Z code added no increment to clinical and utilization-based risk prediction models in any system.

Background: Maternal cigarette smoking is associated with adverse birth outcomes, but low birthweight may reflect preterm delivery, restricted fetal growth, or both. Contemporary evidence distinguishing smoking trajectories is limited. Objectives: To examine associations between maternal cigarette-smoking trajectories and low birthweight among U.S.-resident singleton live births in 2023 to 2024. Methods: We analyzed 5,861,166 U.S.-resident singleton live births in the 2023 to 2024 National Vital Statistics System natality files. Low birthweight was defined as birthweight <2,500 g. Trajectories were never smoking, quitting before pregnancy, quitting during pregnancy, persistent smoking, or other/intermittent smoking. Modified Poisson regression estimated adjusted risk ratios (aRRs) and 95% confidence intervals controlling for birth year and maternal, pregnancy, and infant characteristics. Results: Low-birthweight prevalence was 6.4% among never smokers, 7.7% among mothers who quit before pregnancy, 11.2% among those who quit during pregnancy, 14.6% among persistent smokers, and 10.2% among those with other/intermittent smoking. Compared with never smoking, adjusted risks were higher for quitting before pregnancy (aRR 1.06, 95% CI 1.03, 1.09), quitting during pregnancy (aRR 1.46, 95% CI 1.42, 1.51), persistent smoking (aRR 1.95, 95% CI 1.93, 1.98), and other/intermittent smoking (aRR 1.36, 95% CI 1.25, 1.49). Associations varied little by year (joint interaction P = 0.102). Conclusions: Persistent smoking showed the strongest association with low birthweight. Because the outcome combines preterm delivery and impaired fetal growth, the estimates should not be interpreted as associations with fetal growth restriction alone. Keywords Cigarette Smoking; Smoking Cessation; Pregnancy; Low Birthweight; Birthweight; United States

Chronic disease accounts for most health care expenditures in the United States (US), highlighting the need for approaches that address health across interconnected spiritual, mental/emotional, behavioral, physical (including environmental), and social domains. Whole person health (WPH) is increasingly recognized as important for alleviating chronic disease burdens but has not been well-described across various sociodemographic groups of US adults. Using cross-sectional data from the 2025 National Health Interview Survey, we sought to describe the prevalence of WPH and its components among US adults overall and by age, sex, and race along with ethnicity. Participants responded to the nine-item Whole Person Health Index (WPHI), which we used to assess continuous scores (range: 9-45, where higher scores indicated improved health) and ''optimal'' (excellent/very good vs. good/fair/poor) overall and domain-specific WPH. Using survey procedures, we estimated medians (IQR) and prevalence (95% CI) and compared subgroups using multiple comparison correction. Among 23,884 NHIS participants aged 18 years and older (mean age (SE)=48 (0.2) years), representing approximately 261,620,640 US adults, the median WPHI score was 33 (28-37) and slightly over half (57% [56%-58%]) of adults were classified as having ''optimal'' overall WPH. Optimal social/family connections (72% [72%-73%]) were frequently reported; ''optimal'' sleep was infrequently reported (36% [35%-37%]). WPH and its components were generally highest among younger adults. Men and women differed in WPH domains but not in overall WPH. Non-Hispanic (NH) American Indian/Native Alaskan and NH-Black adults generally had lowest prevalence of optimal WPH and its components, which was often higher among Hispanic/Latino adults and highest among NH-Asian and White adults. These results showing variation in WPH in the US may inform future investigations of WPH, related predictors and health outcomes, and health disparities.

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.

Health inequalities are often examined through single axes such as class or ethnicity, obscuring how these dimensions interlock. This study applies a longitudinal intersectional approach to examine physical and mental health trajectories across five generations in the UK. We analysed 14 waves of the UK Household Longitudinal Study (2009-2024) using longitudinal Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA). We modelled SF-12 physical and mental health trajectories for 398 intersectional strata defined by gender, ethnicity, occupational class, and generation. Physical health inequalities widened with age, consistent with cumulative disadvantage, while mental health inequalities were more evident among later-born cohorts. The 'Boomer' generation exhibited a relatively flat mental health trajectory across its observed age range. In contrast, 'Generation Z' had lower predicted mental health, particularly among White British women with no work history - a group with poorer predicted trajectories than their South Asian peers. Our study shows how health inequalities are structurally differentiated by cohort and intersectional position. Policy responses should support proportionate universalism, combining broad population-level support with intensified action for groups showing poorer health.

Background: While health system costs of COVID-19 are well documented, evidence on out-of-pocket costs to patients and families, including non-medical and time burden, is limited. This study aimed to estimate out-of-pocket medical, non-medical, and time burden of COVID-19 illness directly from patients and caregivers. Methods: Two cross-sectional surveys were fielded to national nonprobability samples of U.S. adults in Fall 2023: a personal burden survey (adult sample) and a caregiver burden survey (child sample). Surveys collected data on care setting, visit duration including travel and wait time, and medical and non-medical out-of-pocket costs. After applying quality-based exclusion criteria, 409 adult sample and 52 child sample responses were analyzed. Results: Over 87% of respondents were insured. Median out-of-pocket medical costs per visit were low, ranging from $5 (emergency department) to $10 (urgent care) in the adult sample, and from $0 (emergency department) to $75 (hospitalization) in the child sample. Median non-medical costs were $28 or less across care settings. Median time spent receiving care ranged from 90 minutes (primary care, child sample) to 300 minutes (emergency department, adult sample). Despite the relatively low reported out-of-pocket costs, COVID-related financial challenges were reported by 34% of the adult sample and 29% of the child sample, with the most common difficulty being paying non-medical bills (11% and 15%, respectively). Twelve percent in both groups reported problems paying COVID-19-related medical bills. Conclusions: In this post-pandemic non-probability sample, individual out-of-pocket costs for COVID-19 illness were relatively modest. However, time burden was substantial and one-third of respondents reported financial hardship. These estimates, including non-medical and time burden not captured in administrative data, can support more robust economic evaluations of COVID-19 prevention and treatment interventions.

Disability is an important population-health concern, but adult-specific evidence on its distribution and socioeconomic patterning remains limited in Somaliland. This study estimated the prevalence and distribution of reported disability among adults in Somaliland and examined socioeconomic inequality, reported mental/psychological illness, and their co-occurrence. We conducted a cross-sectional secondary analysis of the 2020 Somaliland Health and Demographic Survey. The analysis included 14,579 adults aged [&ge;]18 years who were usual residents, had the disability module administered, and had a defined reported mental/psychological illness measure. Reported disability was defined as at least one positive response across seven disability domains: sight, hearing, speech, learning, mobility, self-care, and mental. Survey-weighted prevalence estimates and design-based comparisons were calculated. Survey-weighted logistic regression assessed associations with household wealth and other covariates. Socioeconomic inequality was assessed using a concentration index and the normalized Erreygers concentration index. Co-occurrence was evaluated by comparing observed joint prevalence with that expected under statistical independence and by survey-weighted logistic regression. The survey-weighted prevalence of any reported disability was 7.30% (95% CI 6.65-8.02). Sight was the most frequently reported domain (3.83%, 95% CI 3.19-4.59), followed by hearing (1.54%, 95% CI 1.20-1.97) and mobility (1.39%, 95% CI 1.14-1.70). Disability prevalence increased markedly with age, from 4.15% among adults aged 18-29 years to 23.96% among those aged [&ge;]60 years. The crude wealth pattern was non-monotonic and was not statistically detectable after adjustment for residence and region. The concentration index for reported disability was 0.0584 (SE 0.0284, p=0.0415). Reported mental/psychological illness had a weighted prevalence of 0.71% (95% CI 0.50-1.00). Both reported disability and reported mental/psychological illness occurred in 0.5032% of adults, compared with 0.05185% expected under statistical independence; the observed-to-expected ratio was 9.70 (95% CI 7.60-11.81). After adjustment for age group and sex, reported disability was strongly associated with reported mental/psychological illness (OR 42.99, 95% CI 18.45-100.18). Reported disability affected approximately one in fourteen adults in Somaliland and showed a marked age gradient and substantial geographic variation. The crude socioeconomic pattern was attenuated after adjustment for geographic context, while concentration analysis indicated modest marginal concentration toward higher wealth ranks. Reported mental/psychological illness was uncommon but co-occurred with reported disability more often than expected under independence. These findings provide an adult population baseline for Somaliland while highlighting the need to distinguish survey-reported disability from the separate mental/psychological illness construct and to interpret the findings within the limitations of cross-sectional, survey-reported measures.

We analyse the effect of waiting time for elective musculoskeletal treatment on labour market outcomes in England using hospital records for working-age adults who received treatment between April 2015 and March 2023 to Census, tax and benefit records. To address clinical prioritisation and unobserved severity, we leveraged provider-level waiting time as an instrument for individual waiting time and estimated two-stage least squares models adjusted for baseline labour market outcomes, demographic and socioeconomic characteristics, and provider, referral-time and procedure fixed effects. We find that longer waits reduce annual employee earnings, with effects persisting for up to five years. For an additional four weeks of waiting, the largest estimated annual losses range from {pound}301 for osteoarthritis to {pound}487 for other joint disorders. There was no evidence of effects on employment status or benefit receipt, suggesting that delays primarily operate through reduced productivity or hours worked among those who remain employed. Reducing waiting times may not only improve health outcomes but help patients maintain earnings and support economic

Recent industry surveys have reported widespread concern about mental health, working conditions, and harassment in the UK film and television industry, but no peer-reviewed empirical study has examined the determinants of occupational burnout in this workforce. The present study tested whether physical health, mental wellbeing, perceived public stigma, intrinsic job quality, and sexual harassment exposure predict burnout in industry professionals. A cross-sectional online survey was completed by 415 individuals across more than 100 job titles, with 286 also completing an optional harassment module. Mental wellbeing sat well below population norms, with 68% scoring in the range indicative of probable depressive symptoms and 82% in the high-exhaustion range on the Maslach Burnout Inventory General Survey. Mental wellbeing and intrinsic job quality were the strongest predictors of burnout (R2 = .56), with meaningfulness accounting for most of the job-quality effect. Working hours independently predicted emotional exhaustion. Harassment exposure was associated with burnout in women but not men, approximately 30% mediated by mental wellbeing; sexist behaviour directly predicted exhaustion in women. Workers with a disability reported higher stigma. Burnout was strongly associated with intent to leave, and the findings collectively indicate an industry-wide occupational health concern requiring structural rather than individual-level intervention.

Background: Childhood experiences contribute to health and wellbeing across the life course, yet research from low- and middle-income countries has largely focused on a few outcomes rather than broader patterns of adult wellbeing, behaviors, and social and financial circumstances. Methods: In this cross-sectional analysis, we used a nationally representative sample of adults in India (N = 12,765; aged [&ge;] 18 years) from the Global Flourishing Study (GFS) Wave 1 (2023) to examine associations between eight retrospectively reported childhood experience items, 45 adult outcomes, and two composite flourishing indices. Survey-weighted linear, logistic, and proportional-odds models adjusted for age, gender, education, and residential setting, with Bonferroni correction were used to assess associations and effect modification by gender. Findings: Although the breadth and strength of associations differed across childhood experiences, less favorable childhood experiences were generally associated with poorer wellbeing and flourishing, greater odds of adverse health outcomes, and reduced access to resources and safety in adult life. However, outcomes related to prosocial behaviors showed a different pattern: childhood abuse (physical or sexual) was associated with greater odds of volunteering (OR 1.31, 95% confidence interval or CI [1.13,1.51]), feeling like an outsider in one's family with greater odds of donating (OR 1.80, 95% CI [1.52,2.13]), volunteering (OR 1.53, 95% CI [1.28,1.82]), and helping a stranger (OR 1.49, 95% CI [1.27,1.74]). Associations were broadly similar between females and males, with little evidence of gender differences. Interpretation: Associations of childhood adversity with poorer health and increased prosocial behavior in adult life may reflect unmeasured social, cultural, or dispositional factors and heterogeneous life-course responses. Nevertheless, these findings support strengthening child-protection, financial assistance programs, and mental health services in India.

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.

Background The consequences of prolonged exposure to obesity on biomarkers of myocardial stress and injury remain unclear. We examined associations of duration and cumulative severity of obesity from childhood to later adulthood with concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin I (hs-cTnI), and growth differentiation factor-15 (GDF-15) at age 62 years. Methods The sample comprised 4,901 participants in the 1958 National Child Development Study who had measurements of NT-proBNP, hs-cTnI, or GDF-15 at age 62 years and at least four BMI assessments between 7 and 62 years of age. Individual BMI trajectories were modelled, from which total duration of obesity and mean excess BMI (area between the trajectory and the age-specific obesity threshold divided by duration) were derived. Associations of ever versus never having been obese, obesity duration, and mean excess BMI with biomarker concentrations were examined using general linear regression models with progressive adjustment for early-life characteristics; contemporaneous cardiometabolic factors; and health behaviours, socioeconomic position, and psychosocial factors. Nonlinear associations of obesity duration were estimated using restricted cubic splines and subsequently approximated using linear splines. Results Overall, 26.3% of participants had ever experienced obesity. There was no evidence of an association between ever versus never having been obese and NT-proBNP. Among men, ever having been obese was associated with 11.00% (95% CI, 4.62-17.37) higher hs-cTnI in the fully adjusted model, whereas there was no evidence of an association among women. Ever having been obese was associated with higher GDF-15, although the association attenuated substantially after adjustment for contemporaneous cardiometabolic factors. Longer obesity duration was associated with higher concentrations of all three biomarkers in fully adjusted models, but the pattern differed by biomarker: hs-cTnI increased approximately linearly with duration, whereas NT-proBNP and GDF-15 remained relatively stable up to approximately 25 years of obesity before increasing with longer duration. In fully adjusted models, each additional year of obesity beyond 25 years was associated with 1.80% (95% CI, 0.54-3.06) higher NT-proBNP and 0.81% (95% CI, 0.25-1.36) higher GDF-15, while each additional year across the full range of obesity duration was associated with 0.41% (95% CI, 0.07-0.76) higher hs-cTnI. Among participants who had ever experienced obesity, each 1 kg/m2 higher mean excess BMI was associated with 4.02% (95% CI, 1.79-6.24) higher NT-proBNP and 2.00% (95% CI, 0.49-3.51) higher hs-cTnI in fully adjusted models; there was no evidence of an association with GDF-15. Conclusions Longer duration of obesity was associated with higher concentrations of biomarkers reflecting myocardial stress, injury, and cellular stress at age 62 years, with associations particularly evident after approximately 25 years of obesity for NT-proBNP and GDF-15. These findings suggest that duration of obesity may provide clinically relevant information beyond current obesity status, supporting its consideration as an additional dimension of cumulative obesity burden in cardiovascular risk assessment.

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: Girls are more likely than boys to experience psychological distress during adolescence. Drivers of this gender gap remain under-studied, despite its large impact on later life and outcomes, especially for women. Explanatory factors can be gendered in their prevalence (differential exposure) and/or in their impact (differential susceptibility). We developed a multi-domain framework of explanatory factors for distress and applied it in four low- and middle-income countries. Methods: We first proposed a framework of explanatory factors for psychological distress grouped into seven domains (biological, cognitive, psychological, behavioural, social, environmental and broader societal). We applied this framework to identify explanatory variables assessed in childhood and adolescence in the Young Lives longitudinal cohort studies in Ethiopia (N=908), India (N=952), Peru (N=634) and Vietnam (N=887). Distress symptoms at 18-19 years were measured with the Strengths and Difficulties Questionnaire Emotional Symptoms scale. Gendered prevalence of each explanatory factor was tested with Mann-Whitney tests, and gendered impact with country-specific linear regressions including a gender-by-factor interaction term. Exploratory boosted-tree machine-learning models, interpreted with SHAP values and permutation feature importance, examined the contribution of these factors to the gender gap in each country. Results: Distress was higher in girls than boys in every country, the gap ranging from 0.62 points in Ethiopia and Vietnam to 1.76 in India and 2.45 in Peru. Some explanatory factors were consistently gendered in prevalence (e.g. girls experienced greater role overload in each country), while others were gendered only in some countries (e.g. study amount was higher for girls in Peru and Vietnam, but not Ethiopia or India). Gendered impacts on distress displayed more variability across countries. For example, higher self-esteem was more protective for boys than girls in India, Peru and Vietnam, but more protective for girls in Ethiopia. The machine-learning models identified important predictors across all framework domains, though their salience varied by country. Conclusions: Our findings underscore the importance of considering multi-domain explanations for mental-health outcomes and observed inequalities in mental health. Large cross-country differences in the gender gap and in the prevalence and influence of explanatory factors caution against generalising drivers of mental-health outcomes and inequalities across contexts.

Abstract Objective To estimate the burden and patterns of multimorbidity and cardiometabolic multimorbidity among university employees undergoing a comprehensive health assessment programme, and to examine demographic and behavioural factors associated with multimorbidity. Design Cross-sectional study. Setting A public university in Maharashtra, India. Participants A total of 266 university employees who underwent a comprehensive health assessment were included. Main outcome measures Multimorbidity was defined as the presence of two or more of nine chronic conditions: hypertension, diabetes mellitus, dyslipidaemia, ischaemic heart disease, chronic kidney disease, thyroid disease, stroke, chronic obstructive pulmonary disease and cancer. Cardiometabolic multimorbidity was defined as the presence of two or more of hypertension, diabetes mellitus, dyslipidaemia, ischaemic heart disease and chronic kidney disease. Results Hypertension was identified in 119 participants (44.7%), comprising 50 participants with pre-existing hypertension and 69 newly identified during the assessment. Dyslipidaemia was present in 189 (71.1%) and diabetes mellitus in 45 (16.9%). Overall, 108 participants (40.6%) had multimorbidity and 103 (38.7%) had cardiometabolic multimorbidity. The prevalence of multimorbidity increased progressively with age, from 17.5% among participants aged <30 years to 83.3% among those aged [&ge;]60 years. The predominant exact multimorbidity patterns were hypertension with dyslipidaemia alone (49 participants) and hypertension, diabetes mellitus and dyslipidaemia (27 participants). Overall, 173 participants (65.0%) had at least one newly identified hypertension, diabetes mellitus or dyslipidaemia diagnosis. In multivariable logistic regression, age (adjusted OR [aOR] 1.058 per year, 95% CI 1.027 to 1.091), BMI (aOR 1.163 per kg/m2, 95% CI 1.076 to 1.257) and tobacco use (aOR 3.296, 95% CI 1.377 to 7.888) were independently associated with multimorbidity. The model had an area under the receiver operating characteristic curve of 0.731. Conclusion Multimorbidity affected approximately two in five university employees, with cardiometabolic conditions accounting for most of the observed disease clustering. Comprehensive health assessment identified a substantial burden of previously unrecognised chronic disease. Integrating institutional or occupational health assessment with longitudinal primary care follow-up may provide an opportunity for earlier detection, risk-factor modification and coordinated management of multimorbidity. Keywords: Multimorbidity; cardiovascular diseases; hypertension; diabetes mellitus; dyslipidaemia; occupational health; university employees; India

Objective: To compare healthcare access among U.S. children with attention-deficit/hyperactivity disorder (ADHD) only, autism only, and co-occurring ADHD-autism, and to identify social inequities associated with unmet care using recent nationally representative data. Methods: We analyzed combined 2023-2024 National Survey of Childrens Health data for 13,576 children aged 3-17 years with current ADHD and/or autism. Six healthcare-access outcomes were examined: forgone healthcare, unmet mental health care, no medical home, coverage gap or inadequate insurance, unmet specialist care, and unmet care coordination. Survey-weighted modified Poisson regression estimated adjusted prevalence ratios (aPRs) and 95 percent confidence intervals (CIs). Six multiply imputed poverty measures were combined using Rubins rules. Sensitivity models additionally adjusted for functional difficulty. Results: Compared with ADHD only, co-occurring ADHD-autism was associated with higher prevalence of forgone healthcare (aPR, 1.73; 95 percent CI, 1.38-2.16), no medical home (1.11; 1.02-1.20), inadequate or discontinuous insurance (1.14; 1.03-1.28), unmet specialist care (1.49; 1.14-1.94), and unmet care coordination (1.15; 1.04-1.28). Autism only was associated with unmet mental health care (1.49; 1.13-1.97) and care coordination (1.13; 1.02-1.25). Food insufficiency, housing instability, and non-supportive neighborhood conditions were consistently associated with poorer access. After adjustment for functional difficulty, associations remained for co-occurring ADHD-autism with forgone and specialist care and for autism only with unmet mental health care. Conclusions: Healthcare access inequities differed by neurodevelopmental diagnostic group and social context. Pediatric systems should strengthen care coordination, specialty and mental health access, insurance continuity, family navigation, and responses to food and housing hardship. Keywords: attention-deficit/hyperactivity disorder; autism spectrum disorder; healthcare access; health disparities; social determinants of health