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

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

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

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.

BackgroundEvaluations of complex care programs for high-need patients have yielded mixed results, and identifying patient subgroups may reveal differential intervention effects. This study aimed to use latent class analysis (LCA) to identify high-need patient subgroups within a randomized trial of the Camden Coalitions Core Model and to examine differences in healthcare utilization and care team engagement. Methods & FindingsWe conducted a post-hoc exploratory analysis of a randomized controlled trial (ClinicalTrials.gov: NCT02090426) involving 780 adults aged 18 [-] 80 years in Camden, New Jersey, who had multiple chronic conditions and frequent hospitalizations. Participants were assigned to receive multidisciplinary care management delivered by nurses, social workers, and community health workers for 3 [-] 4 months following hospital discharge, or to usual care. LCA incorporated medical, behavioral, and social risk factors, as well as prior hospital utilization, to identify patient subgroups. Outcomes included inpatient readmissions and emergency department visits over two consecutive 6-month post-discharge periods, along with service hours delivered to intervention patients. Four patient classes emerged: (1) Behavioral Health & Housing Instability, (2) Multi-system Medical Complexity, (3) Pulmonary Health & Substance Use, and (4) Lower Overall Complexity. In the second 6-month follow-up period, intervention patients had lower readmission rates compared with controls (-6.4 percentage points; 90% CI, -12.2 to -0.5). Subgroup differences included reduced readmissions in Class 4 and fewer emergency department visits in Class 1. Service intensity varied across classes, with Class 1 receiving the highest number of staff hours and Class 2 the lowest. ConclusionPatient segmentation revealed meaningful variation in healthcare utilization outcomes and care team engagement across high-need subgroups, suggesting that tailoring complex care interventions to specific patient profiles may improve program effectiveness and equity.

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

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

ObjectiveAlthough trauma-focused psychotherapies are effective for posttraumatic stress disorder (PTSD), recovery under routine outpatient conditions remains variable. We examined whether participation in a structured Specialty Care (SC) model integrating clinician specialization, flexible treatment density, and coordinated navigation was associated with accelerated PTSD recovery compared with standard outpatient care. MethodsWe conducted a retrospective matched cohort study (2024-2025) of U.S. adults with active PTSD symptoms (PTSD Checklist for DSM-5 score [&ge;]31) receiving care through an employer-sponsored digital mental health platform. Access to SC was determined by employer benefit design. Propensity-score matching with weighting balanced cohorts on baseline severity and demographics. Primary outcomes included longitudinal PTSD symptom trajectories and time to recovery, remission, and reliable improvement. Secondary outcomes assessed depressive symptoms (PHQ-9). Linear mixed-effects and Cox proportional hazards models were applied. ResultsThe matched sample included 356 SC and 9,409 standard care participants. SC participants received higher treatment intensity, including greater session volume and faster early follow-up, and greater care navigation engagement. SC participation was associated with steeper PTSD symptom decline ({beta} = -1.3 per log-week, p < .001) and a higher likelihood of recovery (hazard ratio = 1.31; 95% CI, 1.10-1.57). At 12 weeks, predicted recovery was 29% in SC versus 23% in standard care. Depressive symptoms improved in both groups, without significant differences in time to categorical recovery. ConclusionsUnder routine outpatient conditions, a structured SC model was associated with accelerated PTSD recovery, suggesting that reorganization of outpatient delivery may improve real-world outcomes.

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.

This study examined gender attitudes and self-perceptions of culturally positive traits (bravery, leadership, and competitiveness) among 838 eight-year-old children (422 boys, 416 girls) in rural Pakistan. We assessed their attitudes patterns, and explored associations with mental health and academic outcomes. Overall, 35% of boys and 39% of girls attributed positive traits to both genders (egalitarian), associated with high self-perceptions of positive traits and more favorable outcomes. Children who endorsed gender stereotypes tended to favor their own gender, i.e. attribute positive traits only to their own gender. 5.5% of boys who attributed positive traits to women only (women-attributing) had lower Urdu ({beta}= -0.50, 95% CI: -0.80, -0.20) and Math ({beta}= -0.76, 95% CI: -1.06, -0.46) scores, while 12.7% of girls who attributed positive traits to men only (men-attributing) had modestly higher Math scores ({beta}= 0.21, 95% CI: -0.03, 0.46). 9.5% of boys and 15.4% of girls attributed different positive traits to both genders (mixed-attributing), which was associated with poorer outcomes, including higher depressive symptoms among boys ({beta}= 0.45, 95% CI: 0.09, 0.82). 36.0% of boys and 33.4% of girls reported high self-perception of positive traits, but self-perception alone was not strongly associated with outcomes. Findings suggest that, by middle childhood, children in rural Pakistan exhibit distinct gender attitudes that link with developmental outcomes. Notably, women-attributing and mixed-attributing attitudes were linked to poorer academic and mental health outcomes especially among boys, indicating potential educational and psychosocial costs of holding nonconforming gender views in patriarchal contexts.

ObjectiveTo examine racial and ethnic inequities in wealth and health among New York City adults. MethodsWe conducted the 2024 NYC Racial Wealth and Health Gap Survey using a stratified quota sample of 2,866 adults across 11 racial and ethnic groups. Wealth was measured through self-reported assets and debts, and health through self-reported status and psychological distress. We calculated descriptive statistics across groups and used quantile regression to test for significant differences in assets and debts compared with White respondents. ResultsWhite and Chinese respondents reported the highest median net worth ($142,000 and $320,000), while Other Black and Puerto Rican respondents reported the lowest ($25 and $160). Lower wealth was associated with poorer health and higher psychological distress. Prevalence of excellent or very good health increased from 36% in the lowest wealth quartile to 59% in the highest, with the steepest wealth-health gradients among Chinese and Multiracial respondents. ConclusionWealth inequities are linked to health disparities across racial and ethnic groups in New York City. Surveillance of local wealth data can guide equity-focused policies addressing economic and racial drivers of health disparities.

BackgroundThe COVID-19 pandemic disrupted access to sexual and reproductive health (SRH) services, including contraception. Understanding contraceptive use during this period is critical for strengthening health system resilience in small developing states. ObjectiveTo identify factors associated with contraceptive use among reproductive-age women during the COVID-19 pandemic in Barbados. MethodsA cross-sectional online survey was conducted in Barbados between April 28 and May 3, 2020 among adults aged [&ge;]18 years. This analysis is restricted to women aged 18-49 years. Current contraceptive use (yes/no) was assessed among non-pregnant respondents. Associations with sociodemographic factors, relationship status, and psychosocial distress (Hospital Anxiety and Depression Scale [HADS] were examined using bivariate tests and logistic regression. Variables, alcohol and marijuana use had >15% missing data which limited. ResultsA total of 1,094 women aged 18-49 years completed the survey and were included in descriptive analyses. At the time of the survey, 2.7% (n=29) reported being pregnant and 7.3% (n=80) reported not being pregnant but planning pregnancy; the majority 89.7%, (n=981) were neither pregnant nor planning pregnancy. Among non-pregnant women with contraceptive data, 34.2% (n=333) reported current contraceptive use. Moderate-to-severe anxiety symptoms were reported by 36.5%, and moderate or clinically significant global distress by 39.0%. Contraceptive use was significantly associated with HADS anxiety (p=0.021) and HADS global distress (p=0.016), but not depression (p=0.211). Women who were partnered (p=0.014) or married/cohabitating (p<0.001) were more likely to report contraceptive use compared with single women. University education was strongly associated with contraceptive use (p<0.001). Women aged 26 - 39 years were more likely to use contraception relative to those aged 40 - 49 years, while women aged 18 - 25 years were less likely. ConclusionsDuring the early phase of the COVID-19 pandemic in Barbados, contraceptive use among non-pregnant reproductive-age women was associated with psychosocial distress (especially anxiety), relationship status, education, and age. Emergency preparedness in small developing states should prioritize continuity of SRH services, mental health integration, and access to self-managed contraceptive options.

Many Asian American (AA) subgroups experience disproportionate rates of cardiometabolic (CMB) conditions, yet the contextual drivers of these disparities remain unclear. Little is known about the role of Asian residential segregation, often conceptualized as Asian enclaves, with limited prior work largely ignoring region of origin and nativity. Using six years of population-based survey data from New York City (N>6,000 AAs) linked with multiple sources of community data, we examine how residence in ethnicity-specific enclaves relates to CMB risks (obesity, hypertension, and diabetes), whether these associations differ by nativity, and the extent to which neighborhood socioeconomic conditions, the built environment, social cohesion, and institutional support account for observed associations. Our combined concentration-based and spatial clustering analysis identified five East Asian enclaves and six South Asian enclaves, with no geographic overlap between the two. Logistic regression analyses show that residence in an East Asian enclave was associated with lower odds of obesity (OR=0.63), while residence in a South Asian enclave was linked to higher odds of diabetes (OR=1.42) and hypertension (OR=1.46). These associations were present only among foreign-born individuals. After adjusting for neighborhood characteristics, the lower obesity risk in East Asian enclaves persisted, while elevated risks in South Asian enclaves were partly reduced. Both suggest a role for unmeasured enclave factors, including cultural and food environments. Our findings challenge the view that Asian enclaves are monolithically health-promoting and redirects scholarly attention toward disaggregated approaches to investigating AA health disparities.

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

ImportancePrevention-focused health policy requires analytic frameworks capable of detecting changes in population health and associated costs within policy-relevant time horizons, particularly in managed care systems where premiums reflect actuarial risk rather than realized medical expenditures. ObjectiveTo evaluate a healthstate-based analytic framework (CareMaps) for measuring population health dynamics, disease progression, and associated costs using longitudinal Medicaid managed care claims data. Design, Setting, and ParticipantsRetrospective longitudinal analysis of deidentified Medicaid managed care claims in New Mexico from 2011 through 2014. The study included individuals aged 0 to 64 years enrolled in managed care plans. ExposuresChronic disease burden categorized into mutually exclusive, ordered healthstates based on the number of chronic conditions. Main Outcomes and MeasuresCounty- and managed care organization (MCO) level prevalence of healthstates, transition rates between healthstates, and healthstate-specific cost estimates derived from capitation premiums and medical loss ratio defined medical expenditures. ResultsThe CareMaps framework identified specific geographic and MCO level variation in chronic disease prevalence, healthstate transition rates, and per-member spending patterns that were not fully explained by actuarial risk adjustment. Transitions from nonchronic to chronic healthstates varied markedly across counties, indicating heterogeneity in disease progression and prevention related outcomes. Conclusions and RelevanceA healthstate based analytic framework applied to longitudinal Medicaid managed care data enables standardized measurement of population health dynamics and associated costs within policy relevant time horizons. Such approaches may support evaluation of preventive care performance, inform risk adjustment, and enhance public-sector oversight of managed care programs.

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.