SSM - Population Health

BackgroundLiterature on sexual assault prevalence among homeless women is limited, with few studies disaggregating risk by geography, resource access, mental health, LGBTQ status, or disability. ObjectiveThis study provides two distinct meta-analyses to ascertain the aggregated overall prevalence (k=20 studies) and the aggregated 12-month prevalence (k=14 studies) of sexual assault among homeless women. By examining each recall period independently, we elucidate cumulative burden throughout the life cycle and annual risk, offering unique insights for public health interventions. By synthesizing global data, we aimed to clarify risks for women with disabilities, mental illness, or Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, Plus (LGBTQ+) identities to inform crisis care interventions. MethodsFollowing PRISMA 2020 guidelines, six databases were searched for studies published after 2010 reporting sexual assault prevalence in homeless women. Twenty studies met the inclusion criteria. Random-effects meta-analyses were performed using a logit transformation. Heterogeneity was assessed with I{superscript 2} and Cochrans Q; publication bias with funnel plots and Eggers test. ResultsThe pooled lifetime prevalence of sexual assault was 39.2 % (95 % CI 25-56 %), and 12-month prevalence was 22 % (95 % CI 16-30 %). Heterogeneity was extreme (I{superscript 2} = 97 %). Subgroup analyses showed the highest prevalence among women with disabilities (92 %, single study), followed by LGBTQ+ (33 %) and women with mental illness (34 %). HIV-positive women had the lowest prevalence (2.6 %). Eggers test indicated no publication bias (p = 0.64). ConclusionHomeless women face disproportionately high rates of sexual assault, far exceeding the general female population, with particularly elevated estimates among women with disabilities, LGBTQ+ women, and those with mental illness. These preliminary findings highlight the need for improved screening practices and tailored public health interventions to address sexual assault in doubly vulnerable populations. Standardizing definitions of sexual assault and investigating risk factors could lead to more tailored public health interventions. HighlightsO_LIMarked Epidemiologic Burden: Nearly 40% of homeless women report lifetime sexual assault. C_LIO_LIPersistent risk: One in five homeless women assaulted within the past 12 months. C_LIO_LIMarginalized Impact: Rates highest among disabled, LGBTQ+, and HIV+ women. C_LIO_LIHigh Variability: Extreme heterogeneity (I{superscript 2} {approx} 97%) shows research inconsistency. C_LIO_LIResearch Priority: Standardize methods and definitions to improve accuracy. C_LI

BackgroundIn economically transitioning China, rising objective SES has coincided with increased depression prevalence. This study examines whether material accumulation is linked to greater psychological strain and how subjective status perception is associated with lower depression risk. MethodsWe analyzed a Chinese national sample (N = 19,049, PBICR2022). ObjectiveSES was constructed via PCA (income, education, employment, housing); subjective SES was measured on a 7-point scale. Depression was assessed using the PHQ-9 (cutoff [&ge;] 10). Bootstrapped mediation and Response Surface Analysis (RSA) mapped the topography of depression risk. ResultsObjective SES showed a positive total association with depression (c = 0.154, P < .001), but subjective status perception suppressed this association: higher objective SES predicted higher subjective status, which in turn predicted lower depression (indirect effect = -0.1086, 95% CI: [-0.127, -0.091]). RSA showed that depression risk was driven primarily by subjective rank rather than objective resources, with diminishing returns at higher levels. The indirect pathway was 2.75-fold stronger among never-married than married individuals and more pronounced among men, yet robust across geographic regions despite cross-provincial migration. LimitationsCross-sectional design precludes causal inference; subjective SES used a single-item measure, and common method variance cannot be fully excluded. ConclusionsMental well-being depends less on absolute resources and more on internalized social position. The inverse association of subjective status with depression is stable across regions but contingent on social anchors like marriage. Public health policy must address status anxiety among vulnerable groups, particularly unmarried men.

BackgroundPersons 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. MethodThe 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 AHAs Essential 8 metrics for differences between HCH and CHC patient responses. ResultsHCH 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. ConclusionsCVD 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. Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABSO_LIPatients accessing Health Care for the Homeless clinics demonstrate unique cardiovascular risk profiles characterized by higher rates of inadequate sleep, smoking history, and pre-diabetes compared to Community Health Center patients, even after adjusting for sociodemographic factors. C_LI What Are the Clinical Implications?O_LITraditional cardiovascular disease risk assessment tools and prevention strategies may need to be recalibrated for homeless populations, as standard clinical metrics and screening approaches may not fully capture the complex interplay of behavioral, environmental, and social exposures affecting this vulnerable group. C_LI Research PerspectiveO_ST_ABSWhat New Question Does This Study Raise?C_ST_ABSO_LIHow do structural inequities and comorbid conditions resulting in and from homelessness impact health in ways that may not be captured by conventional risk assessment tools? C_LI What Question Should be Addressed Next?O_LIWhat modifications to evidence-based cardiovascular interventions are needed to effectively serve people experiencing homelessness, and how can these interventions be integrated into Health Care for the Homeless clinics and other FQHCs? C_LI

BackgroundYoung 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.

This study investigated the wellbeing of UK police officers transitioning out of service, examining retirees, early leavers, and those within 12 months of retirement (N = 370). Using the Job Demands-Resources model, the research identifies a wellbeing paradox: leavers demonstrate high resilience and subjective wellbeing alongside significantly elevated psychological distress compared to general population norms. Findings reveal that recently retired ([&le;]5 years) and soon-to-retire groups are particularly vulnerable, reporting lower quality of life and higher distress than long-term retirees. Perceived organisational support and resilience emerged as critical buffers against the psychological burden of a policing career. However, participants identified significant unmet needs for career, financial, and mental health guidance during the transition. The study highlights that the anticipatory retirement period is an acute window of vulnerability, suggesting that proactive, targeted organisational interventions are essential to mitigate the lasting psychological burden of policing and ensure successful civilian transitions.

We examined the impact of COVID-19 pandemic onset (2020 April) on homicide mortality in the United States. We conducted a single interrupted time series analysis using homicide events from the National Vital Statistics System that occurred over six years (2017-2022), with COVID-19 onset as an interruption. Monthly homicide deaths rates were calculated per 100,000 person-years to create a monthly time series. We used autoregressive integrated moving average regression, adjusted for seasonality, to model the immediate and sustained trend changes in the homicide mortality rate ratios due to the pandemic. We stratified models by length of stay-at-home order, race and ethnicity, sex, age, and weapon used to examine effect measure modification. In Jan 2017, the US homicide mortality rate was 5.9/100,000 PY. While there were annual seasonal changes, the overall time trend before April 2020 was stable. However, with COVID-19 onset, the overall homicide mortality rate ratio increased by 32% (95% CI: 0.23, 0.41), which persisted through 2022 without additional trend changes, but with seasonal variations. Immediate increases with stable sustained trends in homicide rates were also observed in most stratified analyses. COVID-19 pandemic onset is associated with US homicide mortality rates immediately increasing and remaining stable and higher afterwards.

Introduction Perinatal Empowerment is widely referenced in maternity care research, yet its use often lacks clear conceptual definitions and validated measures. Existing instruments do not capture the multidimensional nature of perinatal empowerment, including both external dimensions (e.g., gender equity, resource access), and internal dimensions (e.g., confidence, agency and informed decision making). This gap has limited the ability to rigorously evaluate how healthcare experiences shape empowerment during pregnancy, birth, and the postpartum period. Aim To develop a valid and reliable instrument that measures dimensions of perinatal empowerment, both external and internal. Methods Instrument development followed the seven-step MEASURE framework. Initial item generation was guided by a concept analysis, a scoping review of existing instruments, and feedback from international midwifery experts. A preliminary 51-item instrument underwent expert content validity review, resulting in 48 items, which were then pilot-tested with six pregnant and postnatal women. A large-scale validation study was conducted via an international online survey (N=155). Psychometric testing included exploratory factor analysis (EFA), reliability assessment using Cronbachs , known-groups validity testing, and regression analyses adjusting for potential confounders. Results EFA supported two overarching dimensions--external and internal empowerment--with six factors across 30 final items (18 external, 12 internal). Sampling adequacy was high, and item loadings exceeded recommended thresholds. Internal consistency was strong for both dimensions (=0.88 external; =0.87 internal). Women receiving midwifery continuity of care reported significantly higher empowerment scores across total, external, and internal dimensions compared with other care models (p<.001). Differences between primiparous and multiparous women were not statistically significant. Conclusion The MPower instrument represents a conceptually grounded, psychometrically robust measure of multidimensional perinatal empowerment in high-income settings. Further validation in more diverse populations is needed to refine the instrument and expand its applicability across clinical and research contexts.

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.

Study question: Does twin status and zygosity (monozygotic vs. dizygotic; same-sex vs. opposite-sex) predict fertility outcomes and intergenerational reproductive patterns compared with singletons? Summary answer: Among females, dizygotic twins had modestly higher completed fertility than singletons and monozygotic twins and were more likely to have a twin birth. Fertility did not differ meaningfully among males. These differences were restricted to the twin generation and did not persist in the next generation, indicating sex-specific and generation-specific effects rather than intergenerational transmission. What is known already: Dizygotic twinning is associated with heritable hyperovulation and higher natural fertility but less is known about whether being a twin or zygosity influences reproductive outcomes across generations. Study design, size, duration: A population-based longitudinal cohort study using part of the Finnish Twin Cohort and national population registers. Participants included monozygotic (MZ; N = 4,068), same-sex dizygotic (SSDZ; N = 8,890), opposite-sex dizygotic (OSDZ; N = 8,474) twins, and singleton controls (N = 1,193,404) born between 1945-1957 (total N =1,254,103; 49.1% female), their mothers, their children, and their grandchildren. Participants/materials, setting, methods: Fertility outcomes (number of biological children, age at first birth, childlessness, multiple births) were derived from Finnish population registers. Analyses followed a preregistered plan (https://osf.io/qbwv3) Main results and the role of chance: Differences in fertility between singletons and twins were modest and varied by sex and zygosity. Differences were observed generally in the mothers of twins and female twins themselves, with limited differences in the offspring of twins as compared to the offspring of singletons. Twins were slightly older at first birth, had fewer total biological offspring, but were more likely to have a twin birth. Dizygotic twins in particular differed from monozygotic twins and singletons. Limitations, reasons for caution: Findings are limited to individuals born in mid-20th-century Finland and thus generalizability to recent populations or non-Nordic contexts may be restricted. Further, analyses are observational, and causal inference is limited due to alternative motivation behind fertility rates like social or cultural reasons. Wider implications of the findings: These findings suggest that zygosity and sex interact to shape reproductive outcomes, offering insight into genetic and environmental contributions to fertility. They highlight the value of large twin cohorts for studying intergenerational reproductive trends and the representativeness of twins in population-based fertility research.

Introduction: Even though state minimum wage (MW) is a policy lever that affects income and poverty and can prevent of violence, no prior study has comprehensively evaluated its impact in the United States (US). In this study, we estimated the impact of at least a $1 USD increase in state MW above the federal MW on overall, firearm, and non-firearm homicide mortality and examined its impact on racialized inequities. Methods: We conducted a quasi-experimental study using controlled interrupted time series (CITS) and synthetic controlled interrupted time series (SCITS) approaches to examine immediate and sustained impact of state MW increases. We used state-month level homicide victimization mortality data from 2010-2019. Homicide victimization death was identified using International Classification of Disease codes, 10th revision. State MW data was obtained from the Bureau of Labor Statistics. Results: Demographic and social variables from intervention, never-exposed, and always-exposed states were similar to each other and representative of the total US population from all 50 states. The CITS results show that after MW increases in the intervention states, these states experienced a sustained decline of -0.22 (-0.37, -0.07) homicide victimizations/ 100,000 person-years/ year relative to the never-exposed states and -0.39 (-0.59, -0.18) relative to always-exposed states. This resulted in 5,657 fewer homicide victimization deaths in the intervention states over four years of post-MW increase period compared to the never-exposed states. SCITS results were similar to the CITS results, and the majority of sustained declines were observed in firearm-related deaths and among Black population. Conclusion: MW increase was associated with a reduction in homicide victimization rates, which were robust in multiple sensitivity analyses, more pronounced for firearm-related homicide deaths, and reduced homicide victimization inequities for Black Americans.

ObjectiveMenopause 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. MethodsWe 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. ResultsAmong [~]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). ConclusionsThese findings inform sampling strategies, power calculations, phenotype definition, and study design for menopause research using AoURP.

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.

Background Childhood socioeconomic position (SEP) is a key determinant of later life health. Understanding the extent to which adult SEP mediates this association into early old age is important for explaining how health inequalities are propagated across generations and how they might be addressed in later life. To our knowledge, no prospective study has examined whether childhood SEP remains associated with health at the threshold of older age and the extent to which any such association is mediated by adult SEP. Methods We used data from the 1958 British Birth Cohort, a prospective study that has followed participants since birth, drawing on earlier data collected at birth and ages 33 and 55 years and newly collected data from the age 62 sweep. Using interventional causal mediation analyses, we assessed whether adult occupational class, education, housing tenure, and income mediate associations between childhood social class (manual vs non manual) and health at age 62 (self rated health, C reactive protein [CRP], cholesterol ratio, Glycated hemoglobin [HbA1c], and N terminal pro B type natriuretic peptide [NT proBNP]). Findings Associations between childhood SEP and self rated health, CRP, cholesterol ratio, and HbA1c persisted after accounting for adult SEP. Mediation was outcome specific and differed by sex. Among men, occupational class mediated 39% of the association with self rated health (indirect effect RR 0.90, 95% CI 0.86,0.95) and education mediated 27% (0.93, 0.90,0.96). Among women, education mediated 10% (0.95, 0.91,0.98) and housing tenure mediated 6% (0.97, 0.94,0.99). Indirect effects for CRP were smaller, and mediation was minimal for cholesterol ratio, HbA1c, and NT proBNP Interpretation Population level improvements in adult SEP could reduce, but are unlikely to eliminate, later life health inequalities associated with childhood SEP. Reducing these inequalities will require policies that address disadvantage in early life and improve adult financial and employment conditions. Funding UK Economic and Social Research Council

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.

BackgroundExposure to trauma is associated with poor mental health, but little is known about how trauma profiles differ between ex-servicewomen and civilian women. Differences in trauma exposure may arise before, during, and after military service. ObjectiveTo characterise trauma profiles in ex-servicewomen and civilian women in the UK using separate latent class analyses, and to examine associations between trauma class membership and mental health outcomes within each group. MethodsData were drawn from the UK Biobank and stratified by serving status. Ex-servicewomen (n = 446) were compared with civilian women (n = 54,068). Within each group, sixteen lifetime traumatic experiences were assessed, and latent class analysis was applied to identify trauma profiles. Multinomial logistic regression examined associations between class membership and sociodemographic characteristics, and logistic regression assessed associations between trauma classes and mental health difficulties. ResultsFive trauma classes were identified for both ex-servicewomen and civilian women. Ex-servicewomen were less likely than civilians to belong to the low-trauma class (33.0% vs 62.8%) and reported higher exposure to childhood trauma and intimate partner violence. Among civilians, all trauma classes were associated with elevated odds of depression, anxiety, self-injurious thoughts and behaviours (SITB), as well as reduced meaning in life. Among ex-servicewomen, associations were less consistent; only severe cumulative trauma was linked to all adverse mental health outcomes, while other classes showed no differences in anxiety compared to ex-servicewomen with low trauma exposures. ConclusionTrauma profiles and their mental health correlates differ between ex-servicewomen and civilian women. These differences may reflect early life vulnerabilities, military experiences, and post-service exposures. Although ex-servicewomen reported higher levels of trauma, the associations between trauma classes and mental health were less pronounced than among civilians. HighlightsO_LIEx-servicewomen showed substantially higher prevalence of trauma exposure compared to civilian women, with the greatest differences in childhood adverse events and intimate partner violence C_LIO_LISeparate latent class analyses identified five distinct trauma profiles in both groups, with ex-servicewomen considerably less likely to belong to the low-trauma class than civilian women (33.0% vs 62.8%). C_LIO_LIThe association between trauma exposure and mental health outcomes was less consistent among ex-servicewomen than civilian women, suggesting that military service may involve resilience factors that moderate the trauma-mental health relationship. C_LI

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.

Background: Whole-population linked administrative data platforms provide an opportunity to generate evidence on early life multidimensional disadvantage to inform resourcing and service provision to families with complex needs. Methods: We used individual-level de-identified data from nine administrative data sources included in the Better Evidence Better Outcomes Linked Data (BEBOLD) platform. The population included all children born in South Australia between 2004-2011 (n=143,083), and their parents. We described the prevalence and distribution of multiple disadvantages affecting children from the 12 months before birth to age 5. Eleven domains of parental disadvantage were created: economic, education, access to services, mental health, substance misuse, smoking during pregnancy, domestic and family violence, health, child protection contact, justice system contact, and death. We investigated the concordance of our measure with an area-level socioeconomic measure used in government reporting. Results: One in two children (48%) were exposed to at least one disadvantage domain, and one in seven (14%) were exposed to three or more domains before age five. Economic disadvantage was most prevalent, affecting one in four (27%) children, of which 75% were exposed to additional forms of disadvantage. Substance misuse, domestic and family violence, and justice system contact were the least likely domains to occur in isolation. Only 54.4% who experienced five or more disadvantage domains were classified in the area-level socioeconomic measure's 'most disadvantaged' quintile. Conclusion: Early life exposure to parental disadvantage can be highly multidimensional. Measurement across different systems is important for informing coordinated service provision for families with complex needs.