SSM - Population Health

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.

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.

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.

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. 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.

Socioeconomic inequalities in health and well-being are a major public health concern, particularly in ageing populations. Education is a key determinant shaping multiple aspects of health outcomes. We used cross-sectional data from wave 9 of the German sample (n=4,148) of the Survey of Health, Ageing and Retirement in Europe (SHARE) to test whether formal education is associated with well-being in later adulthood, with health literacy, self-rated health, and preventive health behaviours as possible mediators. Our results showed that education was positively associated with greater well-being, but only via indirect pathways. Specifically, self-rated health, health literacy, and fruit and vegetable consumption mediated the relationship between education and well-being accounting for 54.7, 24.7, and 12.6 percent of the total effect, respectively. In addition, there were significant positive correlations between education and health literacy, as well as high-intensity physical activity, daily fruit and vegetable consumption, more preventive health check-ups, and less smoking. In contrast, alcohol consumption was more common among those with higher levels of education. All health behaviours and health literacy were correlated directly or indirectly (i.e., mediated by health) with well-being. These findings highlight the importance of examining indirect pathways linking education to well-being in later life. Interventions aimed at improving health literacy and promoting healthy behaviours may help reduce educational inequalities in quality of life among older adults.

ObjectivesRising temperatures are a major climate-related hazard for U.S. workers, increasing heat-related illness and a broad range of occupational injuries through indirect pathways often overlooked in economic evaluations. We examined the association between temperature and occupational injury and illness and quantified heat-attributable injuries (including illnesses) and costs in New York State. MethodsWe conducted a time-stratified case-crossover study of 591,257 workers compensation (WC) claims during the warm season (2016-2024). Daily maximum temperature was linked to injury date and county and modeled using natural cubic splines, with effect modification by industry and worker characteristics. ResultsInjury risk increased with temperature, becoming statistically significant at approximately 78{degrees}F. Relative to 65{degrees}F, injury odds increased to 1.06 (95% CI: 1.01-1.10) at 80{degrees}F, 1.12 (1.07-1.18) at 90{degrees}F, and 1.17 (1.11-1.23) at 95{degrees}F. Overall, 5.0% of claims (2,322 annually) were attributable to heat. At temperatures [&ge;]80{degrees}F, an estimated 1,729 excess injuries occurred annually, generating approximately $46 million in WC costs. An estimated $3.2 million to $36.1 million in medical expenditures were associated with incomplete claims, likely borne outside the WC system. ConclusionsThese findings demonstrate substantial economic costs not fully captured within WC and support workplace heat protections as a cost-containment strategy that can reduce health care spending and strengthen workforce resilience.

BackgroundWomens autonomy in healthcare decision-making has become one of the most critical yet inequitably distributed determinants of health outcomes, gender equity, and sustainable development worldwide. In Northern Nigeria, the presence of ethnic and socio-cultural inequality is frequently concealed by the aggregated statistics of a region. MethodsThis cross-sectional secondary analysis utilized the 2024 Nigeria Demographic and Health Survey. The sample included 9,998 married women (15-49 years) identifying as Hausa, Fulani, or Kanuri in Northern Nigeria. Healthcare autonomy was categorized as husband/partner alone, respondent alone, or joint decision-making. Analysis included weighted descriptive statistics, Rao-Scott adjusted chi-square tests for residential associations, and complex sample multinomial logistic regression to identify multivariable correlates while adjusting for sampling weights, strata, and clusters. ResultsMean age was 30.38 years. Most participants lacked formal education (69.6%) and resided in rural areas (72.0%). Husband-only decision-making predominated (72.6%), while 22.5% reported joint and 4.9% independent autonomy. Joint decision-making was significantly higher in urban (33.3%) than rural areas (18.3%; Adjusted F=50.892, p<0.001). In adjusted models (Reference: Kanuri), Hausa and Fulani women had substantially lower odds of joint decision-making relative to husband-only outcomes. Rural residence correlated with lower odds of both independent and joint agency. Notably, wealth status was not a significant predictor after adjustment (p > 0.05). ConclusionsEthnicity and residence are robust determinants of healthcare autonomy among women in Northern Nigeria, persisting regardless of education or wealth. This "socio-cultural paradox" suggests that economic interventions alone are insufficient. Policies must complement socioeconomic approaches with culturally responsive strategies addressing household power dynamics and entrenched social norms.

Background: Nigeria bears one of the highest maternal mortality burdens globally, with skilled birth attendance (SBA) remaining critically low in many regions. Understanding the independent determinants of SBA is essential for designing targeted interventions. Methods: This cross sectional study analyzed 21,465 births from the 2018 Nigeria Demographic and Health Survey (NDHS), a nationally representative household survey using stratified two stage cluster sampling. SBA was defined as delivery attended by a doctor, nurse, midwife, or auxiliary midwife. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals for the associations between SBA and maternal education, household wealth, place of residence, geopolitical region, maternal age, parity, and antenatal care (ANC) utilization, after accounting for confounding. Results: The overall prevalence of SBA was 44.9%. In the fully adjusted model, higher education (aOR = 7.01, 95% CI: 5.68-8.67), richest wealth quintile (aOR = 6.27, 95% CI: 5.27-7.46), and attending [&ge;]4 ANC visits (aOR = 3.80, 95% CI: 3.51-4.11) were the strongest independent predictors of SBA. Regional inequalities were pronounced, with SBA prevalence ranging from 17.7% in the North West to 85.6% in the South West. Crude effect estimates for education and wealth were substantially attenuated after adjustment, indicating large confounding by correlated socioeconomic factors. Conclusions: Maternal education, household wealth, ANC utilization, and geopolitical region are independent determinants of SBA in Nigeria. Scaling up ANC programs represents the most immediately actionable intervention, while long term gains require investment in girls' education and wealth equity. Targeted strategies for the northern regions are urgently needed. Keywords: skilled birth attendance, maternal mortality, Nigeria, DHS, antenatal care, logistic regression, health equity

Background: Prediabetes is highly prevalent in older adults and is characterized by heterogeneous clinical trajectories, including regression to normoglycemia and progression to diabetes. While prediabetes has been associated with impaired physical function and frailty, the longitudinal impact of both a single diagnosis and dynamic glycemic transitions on functional outcomes remains unclear. We aimed to evaluate associations between baseline prediabetes and glycemic transitions over time with trajectories of functional capacity and frailty in older adults. Methods: We conducted a pooled analysis of harmonized data from five nationally representative longitudinal aging cohorts (MHAS, HRS, CHARLS, ELSA, CRELES) within the Gateway to Global Aging Data, including adults aged [&ge;]50 years with [&ge;]1 HbA1c measurements. Prediabetes was defined per ADA criteria (HbA1c 5.7-6.4%). Functional outcomes included activities of daily living (ADL), instrumental ADL (IADL), and frailty assessed using Fried phenotype, FRAIL scale, and a deficit-accumulation Frailty Index (FI). Mixed-effects Poisson models estimated incidence rate ratios (IRRs) for baseline prediabetes, while generalized estimating equations assessed time-varying glycemic status and transition trajectories. Models were adjusted for age, sex, cohort, and time-varying covariates, with sensitivity analyses including BMI, smoking, and alcohol intake. Findings: Among 18,571 participants (median follow-up 13.6 years), baseline prediabetes was associated with increased progression of functional deficits and frailty compared with normoglycemia, including higher FI values and accelerated FI progression. Prediabetes was associated with higher incidence of ADL, IADL, and multimorbidity deficits from early follow-up, although time-dependent changes in incidence rates were not significant. In time-varying analyses (n=7,840), both prediabetes and diabetes were associated with higher incidence of functional deficits compared with normoglycemia, with diabetes showing the strongest effects across all outcomes. Diabetes was associated with greater FI burden and accelerated progression, whereas prediabetes showed a smaller increase, with attenuation over time. Among individuals with baseline prediabetes, regression to normoglycemia occurred in 20.8% and was associated with increased incidence of ADL and frailty deficits. In contrast, progression to diabetes occurred in 24.3%, and was associated with lower risk of incident ADL and Fried frailty deficits compared to stable prediabetes. Interpretation: Prediabetes is associated with increased risk of functional decline, frailty, and deficit accumulation in older adults, independent of progression to diabetes. Regression to normoglycemia was associated with higher risk of functional deterioration. These findings suggest that prediabetes reflects a state of metabolic vulnerability linked to biological aging rather than solely a precursor to diabetes and highlights a need to reframe its clinical significance in older populations. Funding: This research was supported by Instituto Nacional de Geriatria in Mexico. Keywords: Prediabetes; Glycemic transitions; Frailty; Functional decline; Aging; Multimorbidity

Background: Few studies have examined racioethnic disparities in cardiovascular disease (CVD) in women after breast cancer treatment, who are at higher risk due to cardiotoxic cancer treatment. Methods: Based on the Pathways Heart Study of women with a history of breast cancer, this analysis examines the association between cardiometabolic risk factors (hypertension, diabetes, and dyslipidemia) and CVD events with self-reported race and ethnicity, as well as genetic similarity. Multivariable logistic and Cox proportional hazards regression models were used to test race and ethnicity and genetic similarity with prevalent and incident cardiometabolic risk factors and CVD events. Results: Of the 4,071 patients in this analysis, non-Hispanic Black (NHB), Asian, and Hispanic women were more likely to have prevalent and incident diabetes than non-Hispanic White (NHW) women. Analysis of genetic similarity revealed results consistent with self-reported race and ethnicity. For CVD risk, NHB women were more likely to develop heart failure and cardiomyopathy than NHW women. In contrast, Hispanic women were at lower risk of any incident CVD, serious CVD, arrhythmia, heart failure or cardiomyopathy, and ischemic heart disease, which was consistent with the associations found with Native American ancestry. Conclusions: This is the largest multi-ethnic study of disparities in CVD health in breast cancer survivors, demonstrating corroborating findings between self-reported race and ethnicity and genetic similarity. The results highlight disparities in cardiometabolic risk factors and CVD among breast cancer survivors that warrant more research and clinical attention in these distinct, high-risk populations.

BackgroundDrowning remains a major global public health challenge. This study examined whether the timing and trajectories of urbanisation--beyond the current built environment--are associated with subnational drowning mortality. MethodsWe linked satellite-derived measures of built-environment change (GHSL), population crowding (WorldPop), surface water exposure (JRC Global Surface Water), and infrastructure proxies (VIIRS/DMSP nighttime lights) to GBD 2021 drowning mortality estimates across 203 ADM1 regions in 12 countries (2006-2021; 3,248 region-year observations). Temporal predictors captured recent expansion, development "newness" ([&le;]10-year built share), acceleration/volatility, and a crowdingxgrowth interaction. We screened predictors using LASSO (10-fold cross-validation) and fitted mixed-effects models with region random intercepts. Distributed-lag models tested temporal precedence and development age, and income-stratified models assessed heterogeneity. ResultsAdding temporal predictors improved fit beyond contemporaneous built-environment measures ({Delta}AIC=177; {Delta}BIC=147). In adjusted models, crowdingxgrowth was strongly positively associated with drowning mortality, and a higher share of recent development was associated with higher mortality. Lag models showed a development age gradient: older built environment was most protective. Associations differed by income group, with several key coefficients reversing sign across strata. DiscussionDrowning mortality appears shaped by development histories as well as present-day conditions, with risk concentrated in rapidly changing, dense settings and the newest built environments. Cross-context heterogeneity suggests mechanisms and prevention priorities are unlikely to be uniform. ConclusionsDevelopment timing and trajectories help explain subnational drowning mortality beyond current built form alone. Prevention and planning should prioritise transition-period safety strategies in newly developing and rapidly densifying areas.

ABSTRACT Background Before obtaining professional medical care, many people in peri-urban and rural Pakistan contact herbalists, spiritual healers, and unlicensed caregivers. This study examined the social, economic, and cultural factors influencing the use of informal care by analysing the health-seeking behaviours of individuals in the Faisalabad District. Methods An exploratory mixed-methods study was conducted in Makkuana and the surrounding villages of Faisalabad District, Punjab. The quantitative component involved a cross-sectional survey of 69 adults using a structured questionnaire adapted from the I-CAM-Q. The qualitative component comprised twelve in-depth interviews and two focus group discussions. Descriptive statistics and chi-square analysis were used for quantitative data. Thematic analysis, guided by the Health Belief Model and Andersen's Behavioural Model, was applied to qualitative data. Results The mean age of participants was 40.4 years; 62.3% were female, and 79.7% had monthly household incomes below PKR 60,000. Of the 69 participants, 68 (98.6%) sought care from an informal provider first, most commonly an unqualified practitioner (50.7%), herbal practitioner (29.0%), or homeopath (17.4%). Trust was the leading reason for provider choice (43.5%), followed by proximity (24.6%) and low cost (15.9%). Complications were reported by 21.7% of participants, and 39.1% later required formal care for the same illness. Eight qualitative themes emerged: structural and economic barriers to formal care; proximity and convenience as determinants of informal care; trust, familiarity, and social networks; cultural and religious normalisation of traditional practices; poor doctor-patient communication in formal settings; perceived safety and naturalness of alternative remedies; awareness deficits about provider qualifications; and treatment-related harm and delayed escalation to formal care. Conclusion Informal health care seeking is nearly universal in this community, driven by intersecting economic, structural, cultural, and interpersonal factors. Enhancing primary care affordability, accessibility, and the quality of provider-patient communication together with culturally sensitive health literacy programs, is essential to redirect care seeking toward qualified providers.

Background Depressive symptoms among reproductive-aged women represent a major public health concern in low- and middle-income countries, yet systematic screening remains limited. In most population survey datasets, the low prevalence of depression results in severe class imbalance, which challenges conventional machine learning models. Therefore, we develop and evaluate a bagging-based ensemble machine learning framework to predict depressive symptoms among reproductive-aged women using highly imbalanced Bangladesh demographic and health survey (BDHS) 2022 data. Methods The sample comprised women aged 15-49 years drawn from BDHS 2022 data. Depressive symptoms were defined using the Patient Health Questionnaire (PHQ-9 [&ge;]10). Candidate predictors were drawn from sociodemographic, reproductive, nutritional, psychosocial, healthcare access, and environmental domains. Feature selection was performed using Elastic Net (EN), Random Forest (RF), and XGBoost model. Five classifiers (EN, RF, Support Vector Machine (SVM), K-nearest neighbors (KNN), and Gradient Boosting Machine (GBM)) were trained using both oversampling-based approaches and the proposed ensemble framework. Model performance was evaluated on an independent test set using accuracy, sensitivity, specificity, F1-score, and the normalized Matthews correlation coefficient (normMCC). Results Approximately 4.8% of women were identified with depressive symptoms. The proposed bagging ensemble framework consistently achieved more balanced predictive performance than oversampling-based models. Average normMCC improved from 0.540 (oversampling) to 0.557 (ensemble). RF and GBM ensembles demonstrated notable improvements in identifying depressive cases, while the EN ensemble achieved the highest overall performance and sensitivity. Threshold optimization yielded stable normMCC across models, indicating robust trade-offs between sensitivity and specificity. Conclusions Bagging-based ensemble learning provides a more robust and balanced approach than synthetic oversampling for predicting depressive symptoms in highly imbalanced population survey data. This approach has important implications for improving early identification and population-level mental health surveillance in resource-constrained settings.

Background Individuals experiencing or at risk of homelessness face substantial barriers to preventive eye care that are poorly addressed by standard service models. Interdisciplinary optometry-social work collaboration offers a rights-based approach to improving engagement and continuity of care. Methods A convergent mixed-methods study was conducted between February and August 2024 at a multidisciplinary community centre. Clients experiencing or at risk of homelessness received integrated optometry and social work assessment and were prioritised as high, medium, or low based on combined clinical and social risk. Social work follow-up was guided by the Triple Mandate and W-Questions framework. Quantitative data were summarised using mean (SD), median [IQR], or n (%). Qualitative case notes were analysed using content analysis with inductive coding and secondary review for consistency. Results A total of 165 clients had priority categories coded (high: 68; medium: 47; low: 154). Demographic data were available for 132 clients (60% male; mean age 49.5 years [SD 16]); 27% had not completed high school, 89% reported weekly income below AUD 1000, and 28% had vision impairment. Two hundred forty-five case-note entries were consolidated into 146 unique records. SMS (46%) and phone calls (38%) were the most documented contact methods, although only 21% of calls were answered; missed calls (13%) and disconnected numbers (7%) were common. Multi-modal contact was more frequently documented for higher-priority clients. Appointment assistance was the most recorded facilitator (71%), while rights-based supports, including interpreter and transport assistance, were infrequently documented (<=5%). Qualitative analysis identified unstable communication, reliance on informal supports, and service fragmentation as key influences on recall outcomes. Conclusion This study supports an interdisciplinary, rights-based optometry-social work model to address barriers to preventive eye care among people experiencing or at risk of homelessness. Embedding structured handovers and tiered recall processes within community-based services may strengthen continuity and accountability for high-priority clients. Future implementation should evaluate outcomes related to equity of reach, service integration, and sustained engagement in care.

BackgroundAccess to safe, equitable, and affordable surgical and anesthesia care is critical to reducing the burden of surgical diseases in Africa. To understand the state of access in South Sudan, we conducted a baseline assessment of surgical services in Central Equatoria State (CES) in May 2024. ObjectivesThis study aimed to survey public healthcare facilities in CES capable of providing essential surgical services. We used the capacity to perform cesarean section, laparotomy, and open fracture management--Bellwether procedures--as a proxy for assessing workforce, infrastructure, financing, information management, and service delivery. MethodsWe used a validated and contextualized Surgical Assessment Tool developed by the Harvard Program on Global Surgery and Social Change and the World Health Organization. Data were collected at the facility level and summarized descriptively using percentages, means (standard deviations), medians (minimum, maximum), and visualized in graphs, charts, and tables. ResultsAll three public health facilities assessed could perform Bellwether procedures for their catchment populations. However, workforce availability, financing, and surgical infrastructure were major constraints. The surgical workforce density was 2.27 surgical, anesthesia, and obstetric specialists per 100,000 population. Specialized procedures--such as repair of cleft lip and palate, clubfoot, and hydrocephalus shunt--were unavailable at all sites. None had magnetic resonance imaging (MRI) machines. The total average annual facility budget was $918,850, ranging from $3,960 to $800,000 at the teaching hospital--insufficient for proper operations. ConclusionWhile Bellwether procedures are routinely performed, access to quality and affordable care is compromised by deficits in workforce, financing, and infrastructure. We recommend that the Ministry of Health scale this survey nationally and develop a surgical policy and strategic plan focused on improving infrastructure, workforce, and financing for surgical and anesthesia care in South Sudan.

Objective To analyse sociodemographic determinants of maternal health indicators in Kenyas conflict-affected regions. Methods A cross-sectional secondary analysis of the 2022 Kenya Demographic and Health Survey (KDHS) was conducted. Conflict-affected counties were identified using ACLED (>25 fatalities). The sample included 1,060 women aged 15-49 years. Outcomes were adequate antenatal care (ANC 4+), facility delivery, and skilled birth attendance (SBA). Predictors included age, education, wealth, employment, residence, and county; intimate partner violence was adjusted for. Weighted descriptive statistics, chi-square tests, and multivariable logistic regression were applied (p<0.05). Results Six counties met conflict criteria. While 90.2% of women attended at least one ANC visit, only 53.5% achieved ANC 4+. Facility delivery and SBA were 68.2% and 72.2%, respectively. Adolescents (15-19) were least likely to attain adequate ANC; women aged 20-24 had higher odds (aOR=1.83; 95% CI: 1.01-3.34). Education strongly predicted outcomes: higher education increased ANC 4+ (aOR=2.74; 95% CI: 1.19-6.34) and facility delivery (aOR=2.72; 95% CI: 1.15-6.47). Wealth showed strong gradients: middle quintile increased facility delivery (aOR=5.50; 95% CI: 2.14-14.14), while richer quintile increased SBA (aOR=11.04; 95% CI: 2.06-59.25). Rural residence reduced facility delivery (aOR=0.32) and SBA (aOR=0.22). County disparities persisted. IPV was not independently associated. Conclusion Maternal health indicators in conflict-affected Kenya follow a marked inequity gradient. Adolescents, rural residents, and socioeconomically disadvantaged women are most excluded. Strengthening adolescent ANC continuity, reducing rural access barriers, and investing in education and economic empowerment are critical for improving outcomes.

Drowning remains a major global public health challenge, yet how built environment characteristics shape population-level drowning risk remains poorly understood. This study linked satellite-derived built environment data to subnational drowning mortality estimates across 203 regions in 12 countries from 2006-2021. It found that built environment associations with drowning mortality are complex, non-linear, and shaped by development context. Urban extent was strongly protective, while built area near water showed protection overall but increased risk when combined with high population crowding. Almost all drowning mortality variance occurred between regions rather than within regions over time, indicating risk is predominantly determined by place-based characteristics. Income-stratified analyses revealed profound heterogeneity: crowding was protective in low-to middle-income settings but near-null in high-income regions, while waterfront development captured very different realities across contexts. These findings highlight the importance of tailoring drowning prevention strategies to local built environment configurations and development contexts.

Cardiovascular disease (CVD) remains the leading cause of mortality in the United States, despite being largely preventable through effective management of risk factors. This study evaluates the impact of Phase II cardiac rehabilitation (CR) on functional capacity and quality of life, using data from the Montana Outcomes Project Cardiac Rehabilitation Registry. Functional capacity improvements were assessed via the six-minute walk test (6MWT) and Dartmouth COOP questionnaire, with statistical analyses exploring the influence of CR session attendance, demographic factors, and referring diagnoses. Results demonstrated significant gains in 6MWT, with a mean improvement of 330.73 feet (p < .0001), and quality of life scores across all subgroups. A dose-response relationship was observed, indicating greater improvements with increased CR sessions (p < .0001), though diminishing returns were observed beyond 24-35 visits. Demographic factors and complex conditions influenced outcomes, underscoring the need for tailored strategies to enhance CR access and effectiveness. These findings highlight the critical role of CR in improving patient outcomes and emphasize the importance of addressing barriers to participation in underserved populations.

Drug overdose deaths in the United States reached record levels during the fentanyl era before recently declining. A plausible hypothesis is that a sudden drop in fentanyl purity beginning in 2023 caused the downturn in overdose mortality. We evaluated this hypothesis by replicating a published analysis with regional overdose data, using models that account for time trends and autocorrelation, and negative control indicators to test for spurious correlation. When fentanyl purity was rising, the national purity series did not track overdose increases in most regions and showed only a modest association in the West. When both purity and mortality later declined, the observed associations were also seen with unrelated macroeconomic indicators that shared the same time pattern. National fentanyl purity alone does not provide a sufficient explanation for recent overdose declines.