Social Science & Medicine

We investigate the determinants of several measures of psychological distress and work and social adjustment, using data from a large survey covering six countries and three continents over the COVID-19 pandemic. Our analysis reveals substantial cross-country heterogeneity and identifies a strong effect of COVID-19 specific measures of distress onto generic ones, but not the other way around. The results confirm the importance of controlling for individual characteristics, which help explain some of the cross-country differences. Finally, they also highlight specific categories of individuals who have recorded extremely high levels of psychological distress.

BackgroundSocial isolation is strongly associated with poor mental health. The COVID-19 pandemic and ensuing social restrictions disrupted young peoples social interactions and resulted in several periods during which school closures necessitated online learning. We hypothesise that digitally excluded young people would demonstrate greater deterioration in their mental health than their digitally connected peers during this time. MethodsWe analysed representative mental health data from a sample of UK 10-15-year-olds (N = 1387); Understanding Society collected the Strengths and Difficulties Questionnaire in 2017-19 and thrice during the pandemic (July 2020, November 2020 and March 2021). We employed cross-sectional methods and longitudinal latent growth curve modelling to describe trajectories of adolescent mental health for participants with and without access to a computer or a good internet connection for schoolwork. OutcomesAdolescent mental health had a quadratic trajectory during the COVID-19 pandemic, with the highest mean Total Difficulties score around December 2020. The worsening and recovery of mental health during the pandemic was greatly pronounced among those without access to a computer, although we did not find evidence for a similar effect among those without a good internet connection. InterpretationDigital exclusion, as indicated by lack of access to a computer, is a tractable risk factor that likely compounds other adversities facing children and young people during periods of social isolation. FundingBritish Psychological Society; School of the Biological Sciences, University of Cambridge; NIHR Applied Research Centre; Medical Research Council; Economic and Social Research Council; and Emmanuel College, University of Cambridge.

The COVID-19 pandemic has reached almost every corner of the world. Without a pharmaceutical solution, governments have been forced to implement regulations and public policies to control social behavior and prevent the spread of the virus. There is dramatic evidence of the social and economic effects of these measures and their disparate impact on vulnerable communities. Individuals living in urban informal settlements are in a structurally disadvantaged position to cope with a health crisis such as the COVID-19 pandemic. This paper examines the socioeconomic impact of the crisis brought by the pandemic in informal settlements in Chile. We use a three-wave panel study to compare the situation in informal settlements before and during the health crisis. We show that households living in informal settlements are paying a high toll. Their employment loss is dramatic, substantially larger than the loss reported in the general population, and has particularly affected the inmigrant population. We also find that the pandemic has triggered neighborhood cooperation within the settlements. Targeted government assistance programs have reached these communities; however, this groups coverage is not enough to counteract the magnitude of the crisis. Our results suggest that governments, the non-profit sector, and the community need to urgently provide economic support and protections to individuals living in informal settlements and consider this opportunity for long-term improvements in these marginalized communities. HighlightsO_LIGovernments have implemented large-scale non-pharmaceutical interventions to control the spread of the COVID-19 pandemic C_LIO_LIThese measures have had dramatic social and economic effects on the population, particularly affecting vulnerable communities C_LIO_LIIndividuals living in urban informal settlements are in a structurally disadvantaged position to cope with this crisis C_LIO_LIUsing panel data, we document a dramatic employment loss among informal settlements dwellers, substantially larger than the general population C_LIO_LIThe pandemic has also triggered neighborhood cooperation within the settlements as well as targeted government assistance, but not enough to counteract the magnitude of the economic loss C_LI

Race is commonly used as a proxy for multiple features including socioeconomic status. It is critical to dissociate these factors, identify mechanisms that impact infant outcomes, such as birthweight, and direct appropriate interventions and shape public policy. Demographic, socioeconomic, and clinical variables were used to model infant birthweight. Non-linear neural networks better model infant birthweight than linear models (R2 = 0.172 vs. R2 = 0.145, p-value=0.005). In contrast to linear models, non-linear models ranked income, neighborhood disadvantage, and experiences of discrimination higher in importance while modeling birthweight than race. Consistent with extant social science literature, findings suggest race is a linear proxy for non-linear factors. The ability to disentangle and identify the source of effects for socioeconomic status and other social factors that often correlate with race is critical for the ability to appropriately target interventions and public policies designed to improve infant outcomes as well as point out the disparities in these outcomes.

BackgroundPregnancy intentions are shaped by interrelated factors across individual, relational and societal contexts. This study employs a Conceptual Hierarchical Model (CHM) to examine pregnancy intentions among womxn and their partners. MethodsData were drawn from baseline measurements of the Dutch prospective BluePrInt study on unintended pregnancy. It included 911 participants (womxn and partners) who recently experienced an unexpected pregnancy, which they aborted or continued. Pregnancy intentions were assessed using the London Measure of Unplanned Pregnancy. Key variables included sociodemographics, social support, partner relationship, interpersonal violence, and mental health. A CHM guided multiple regression analyses, with additional analysis of sex differences. ResultsFindings indicated that educational attainment and social support were indirectly associated with pregnancy intendedness, while age, religiosity, cohabitation, and life satisfaction showed direct associations, with no evidence of a moderating effect of sex. ConclusionsPeople who perceive their context as suitable for raising a child, who feel supported, and who have greater personal capacity to parent, perceive their initially unexpected pregnancy as more intended. Policies should promote social and relational stability universally, rather than targeting those experiencing unintended pregnancies. Reproductive counseling should address ambivalence and broader personal circumstances.

BackgroundChildhood adversity is multi-layered, extending beyond the family to include broader neighborhood and health contexts. MethodsChildren were followed from birth into young adulthood (16-42 years) using nationwide register data on multi-layered childhood adversity and mortality. Individual adversity included perinatal adversity (preterm or small-for-gestational-age) and mental and physical health service use. Family adversity included five distinct groups using group-based multi-trajectory modelling based on 12 adversities. Neighborhood adversity included material deprivation in small-area geographical zones. We evaluated associations of these layers with all-cause mortality using survival analyses. Findings1,235,519 individuals born between 1980 and 2001, were followed up until Dec 31, 2022, capturing 7,320 deaths. Children facing high family adversity were more likely to have perinatal adversity, use health services, and live in deprived neighborhoods. Each layer separately predicted mortality, with for example high physical health service use (HR: 2.36; 95% CI: 2.24; 2.48) and living in a deprived neighborhood (HR: 1.20; 95% CI: 1.14; 1.26) being associated with higher mortality. Cross-layer interactions were most pronounced between family adversity and child health or perinatal adversity. The highest mortality risk was observed among those with both high family and individual adversity: HR: 7.16 (95% CI: 6.40; 8.01) compared to those with low adversity. InterpretationThe co-occurrence and interaction of childhood adversities across different layers can create highly vulnerable groups, deepening lifelong health inequalities. This underscores the importance of a comprehensive, multi-layered approach that targets individual vulnerabilities as well as the broader social environment. FundingThe European Research Council. RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSWe searched for relevant studies in PubMed with no language restrictions from inception to March 31, 2025, using the terms (("Childhood adversity" OR "Adverse Childhood Experiences" OR "Early life adversity OR "Perinatal" OR Neighbo*rhood deprivation") and ("[mortality] OR "premature mortality" OR "death" OR "suicide")". We identified studies investigating how individual forms of childhood adversity contribute to the risk of mortality in young adulthood, but only a limited number of studies investigating intersections of different forms of adversity in smaller samples. We also identified several conceptual frameworks that have emphasized the importance of considering multiple, intersecting forms of adversity across developmental contexts. Empirical studies that comprehensively investigate the intersections of multiple forms of adversity simultaneously remain limited. Added value of this studyBy leveraging large-scale, multi-layer life-course data, the study examines emergent patterns of childhood adversity arising from co-occurring and interacting adversities across individual, family, and neighborhood layers, and relate this to mortality in young adulthood. We demonstrate that adversity is not confined to isolated domains: children exposed to family adversity are more likely to experience perinatal complications, health difficulties, and residence in deprived neighborhoods. Importantly, we show that these adversities are not only independently associated with mortality but can also interact across layers, where adversity at one level amplifies the harmful effects of adversity at another. Such cross-layer interactions help identify highly vulnerable subgroups of children who experience multiple interacting adversities already during childhood. Implications of the available evidenceChildhood adversity is a multi-layered phenomenon that cannot be fully understood through single-domain analyses. Our findings suggest that public health and social policies must address adversity more broadly, considering the interplay between individual vulnerability, family adversity, and the structural conditions of the communities in which children grow up. These insights can inform more targeted interventions; from reducing premature births and supporting families in adversity to promoting mental health and tackling broader social determinants such as poverty, education, and neighborhood conditions. By adopting a multi-layered, life course approach to childhood adversity, health and social systems can better identify and support highly vulnerable subgroups of children facing adversity, ultimately reducing intergenerational cycles of disadvantage.

BackgroundStudies on contextual effects on health often suffer from compositional bias and selective migration into contexts. Natural experiments among migrants may allow for the causal effect of contexts in generating health inequalities to be examined. We synthesised the evidence on and health from natural experiments among migrant populations. MethodsSystematic literature review searching the databases PubMed/MEDLINE, The Cochrane Library, Web of Science, CINAHL and Google Scholar for literature published until October 2022. 5870 studies were screened independently in duplicate using pre-defined criteria for inclusion: quantitative natural experiment methodology, migrant study population, context factor as treatment variable and health or healthcare outcome variable. Synthesis without meta-analysis was performed following data extraction and quality appraisal. FindingsThe 46 included natural experiment studies provide causal evidence for the negative effects of neighbourhood disadvantage on physical health and mortality, while finding mixed effects on mental health. Studies comparing migrants with those that stayed behind demonstrate the detrimental effects of migration and adverse post-migratory contexts on physical health and mortality, while demonstrating favourable effects for mental health and child health. Natural experiments of policy contexts indicate the negative impacts of restrictive migration and social policies on healthcare utilization, mental health and mortality as well as the positive health effects when restrictions are lifted. InterpretationNatural experiments can serve as powerful tools in reducing bias through self-selection. With careful consideration of causal pathways, results from migration contexts can serve as a magnifying glass for the effects of context for other population groups. Studies demonstrate the negative impacts for health which lie at the nexus of context and health. At the same time, they uncover the potential of health and welfare programs to counteract the disadvantages created by othering processes and promote healthy (post-migratory) contexts. FundingGerman Science Foundation (FOR: 2928/ GZ: BO5233/1-1). Panel 1: research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed/MEDLINE to identify pre-existing reviews on contextual effects on health with the following search terms: ((review[Title/Abstract]) AND (((context[Title]) OR (neighbourhood[Title])) OR (small-area[Title]))) AND (health[Title]). Eight reviews existed and pointed to consistent, but small effects of neighbourhood disadvantage on physical and mental health outcomes, as well as on child and adolescent health. However, these reviews also point to the methodological shortcomings of most studies, which are unable to disentangle compositional from contextual effects. In order to improve causal inference, natural experiments are needed. Natural experiments have previously delivered crucial evidence on the causal effects of public health interventions including suicide prevention, air pollution control, public smoking bans and alcohol taxation. Added value of this studyThis review uses natural experiments among migrants to contribute to the existing evidence base by synthesising insights on the causal mechanism of contextual effects. It uses migration as an example to assess how contextual factors, ranging from policy environments to neighbourhood characteristics, generate or exacerbate inequalities among societies. We thereby circumvent and avoid limitations of other reviews on these topics, by exploiting five main sources of variation of contextual exposures: residential dispersal, arbitrary eligibility cut-offs, on-/off-timing of events, regional variation, and place of birth. Based on these, we identify three main types of natural experiments among migrant populations: 1) Studies "using" migration as an example to analyse contextual health effects or neighbourhoods in the post-migration phase; 2) Studies examining interactions between changes in environmental factors following migration processes as compared to those staying behind; and 3) Studies using natural experiments to study policy effects. The synthesised evidence confirms and provides causal evidence for the negative effects of neighbourhood disadvantage on physical health and mortality, while effects on mental health are mixed. The body of literature demonstrates that migration processes can unfold detrimental effects on physical health and mortality through adverse post-migratory contexts, while also demonstrating favourable effects for mental health and child health depending on the respective context. Our synthesis further provides causal evidence for the negative impacts of restrictive migration and social policies on healthcare utilization, mental health and mortality as well as the positive health effects when restrictions are lifted. Implications of all available evidenceThe evidence presented here demonstrates the health disadvantages faced by migrants in the immediate post-settlement phase, which are exacerbated by restrictive health, social and visa policies. More broadly, however, the evidence points to neighbourhood disadvantage as a crucial and causal mechanism underlying health inequities at a societal level. At the same time, studies uncover the potential of health and welfare programs to counteract the disadvantages created by othering processes and instead promote healthy contexts. Such evidence is valid beyond migrant populations and allows inference of the positive effects of inclusive health and welfare programs for other marginalized groups and the population as a whole.

BackgroundLifespan inequality arises both from heterogeneity (e.g., in sex or race) and from unavoidable individual stochasticity. By treating a heterogeneous population as a mixture we can (and many have) partition variance in lifespan into a between-group component due to heterogeneity and a within-group component due to chance. Until now, such studies have treated factors singly. It is now possible to analyze multiple factors and their contributions to variance. ObjectiveThis paper is the first to exploit the new analysis for multi-factor studies. Multi-factor data are painfully rare, but a remarkable study by Bergeron-Boucher et al. presented U.S. life tables under all 54 combinations of four factors (sex, marital status, education, race). Our objective is to quantify the contributions of these factors and their interactions to lifespan inequality. MethodsThe population is treated as a mixture of 54 groups, with a mixture distribution either flat or proportional to population size of the different factor combinations. Components of the variance in remaining longevity, for starting ages from 30 to 85 years, are calculated using marginal mixture distributions. ResultsEven accounting for four factors and their interactions, between-group heterogeneity accounts for only 7% (population-weighted mixing) to 10% (flat mixing) of lifespan variance. Education and its interactions make the largest contribution. Contributions of two-way, three-way, and four-way interactions are orders of magnitude smaller. This suggests new ways of displaying, summarizing, and interpreting inequality as measured in multi-factor studies. ContributionMulti-factor studies can now be used to identify sources of variance in longevity and other demographic outcomes.

Adventurousness is speculated to improve happiness but also predispose to risky behaviors. Since non-experimental studies can suffer from confounding and reverse causation, and personality traits cannot be randomized, it is challenging to unravel how adventurousness impacts the mind and behavior. Mendelian randomization (MR), a quasi-randomization technique that uses genetic variants as instruments to avoid confounding and reverse causation, is an attractive option in this setting. We used MR to explore self-reported adventurousness and 10 cognitive and behavioral traits. Adventurousness decreased neuroticism and mood swings and increased years of schooling. In contrast, it also predisposed to risky behaviors (increasing the number of lifetime sexual partners, the propensity to speed in an automobile, and lifetime smoking, and decreasing the age of first having sexual intercourse). The results suggest being adventurous "cuts both ways", evincing bivalent influences and underscoring the reality that trade-offs often accompany many human personality constructs.

BackgroundDespite evidence that pregnancy intentions are complex, unintended pregnancy remains studied using binary measures and few studies have examined combinations of factors contributing to pregnancy intention. This study aimed to identify groups of pregnant people with similar combinations of characteristics and exposures, and study the association between these groups and level of pregnancy intention. MethodsThis study, part of a population-based cohort study of pregnant people and partners (RISE UP study), uses cross-sectional surveys linked to routine data. Latent class analysis identified groups of pregnant people in The Hague distinguished by shared socioeconomic and reproductive characteristics and positive and negative exposures. Linear regression assessed the association between class membership and level of pregnancy intention, adjusted for recruitment location, gestational age at survey, and survey year. ResultsIn the final sample of 560 pregnant people, four classes were identified. Two reflected general stability, differing by gravidity: high stability, multigravida and high stability, primigravida. Two reflected greater socioeconomic adversity and fewer positive exposures, differing by presence of negative exposures: partial stability and cumulative adversity. Compared to the high stability, multigravida class, pregnancy intention was significantly lower in the partial stability class (adjusted beta = -0.71 95%CI (-1.31 - -0.11)) and the cumulative adversity class (adjusted beta = -1.81 95%CI (-2.31 - -1.30)). DiscussionCumulative adversity and partial stability were associated with lower pregnancy intention, supporting suggestions that pregnancy intention may indicate underlying systemic inequalities. Policy and care providers, including midwives, should address these inequalities and tailor support to individual needs.

Partners resemble each other on many traits, such as health and education. The traits are usually studied one by one in data from established couples and with potential participation bias. We studied all Norwegian parents who had their first child between 2016 and 2020 (N=187,926) and the siblings of these parents. We analysed grade point averages at age 16 (GPA), educational attainment (EA), and medical records with diagnostic data on 10 mental and 10 somatic health conditions measured 10 to 5 years before childbirth. We found stronger partner similarity in mental (median r=0.14) than in somatic health conditions (median r=0.04), with ubiquitous cross-trait correlations for mental health conditions (median r=0.13). GPA correlated 0.43 and EA 0.47 between partners. High GPA or EA was associated with better mental (median r=-0.16) and somatic (median r=-0.08) health in partners. Elevated correlations for mental health (median r=0.25) in established couples indicated convergence. Analyses of siblings and in-laws revealed deviations from direct assortment, suggesting instead indirect assortment based on related traits. Adjusting for GPA and EA reduced partner correlations in health with 30-40%. This has implications for the distribution of risk factors among children, for genetic studies, and for studies of intergenerational transmission.

It is unclear how much costs economic difficulties incur to the health and social care sector, which is a critical research gap to support the economic case for preventing child poverty. We examine the health and social service costs due to families entering into, and transitioning out of, social assistance used as a proxy measure for economic difficulties. We analyzed register data on all Finnish children born in 1997 in the framework of a non-randomized target trial. Inverse probability treatment weighting techniques were used to make the comparison group similar to the treatment group in terms of 29 pretreatment variables. Entry to social assistance was associated with some 1398-2591{euro} (50%) higher cumulative health and social care costs of the children three years after their families transitioned to social assistance, compared to the group that did not enter to social assistance system. This difference was primarily attributed to higher social care costs. Continued social assistance use was associated with some 1018-2775{euro} (31%) higher costs compared to the comparison group that exited social assistance. These findings support an economic argument to prevent families from entering economic difficulties and to help those in such situations to transition out.

Child height is a significant predictor of human capital and economic status throughout adulthood. Moreover, non-unitary household models of family behavior posit that an increase in womens bargaining power can influence child health. We study the effects of an inheritance policy change, the Hindu Succession Act (HSA), which conferred enhanced inheritance rights to unmarried women in rural India, on child height. We find robust evidence that the HSA improved the height and weight of children. In addition, we find evidence consistent with a channel that the policy improved the womens intrahousehold bargaining power within the household, leading to improved parental investments for children. These study findings are also compatible with the notion that children do better when their mothers control a more significant fraction of the family. Therefore, policies that empower women can have additional positive spillovers for childrens human capital. (JEL D13, I12, I13, J13, J16, J18, K13, O12, O15, Z12, Z13)

Early life adversity (ELA) has been linked to accelerated epigenetic aging. While positive parenting is hypothesized to buffer the effects of ELA, its role in mitigating epigenetic age acceleration remains unclear. Data from 2,039 children (49.7% female; 46.7% Black, 26.5% Hispanic, 19% White non-Hispanic) in the Future of Families and Child Wellbeing Study were included. Home threat, community threat, and parenting were measured from ages 3 to 9 (2001- 2010). Epigenetic age acceleration was assessed at ages 9 and 15 (2007-2017). Positive parenting reduced the pace of epigenetic aging in contexts of low, but not high, community threat ({beta} = .026, p = .039). Interventions across multiple socioecological systems may be necessary to prevent the biological embedding of ELA.

Physical activity is unequally practiced across populations: relative to more privileged individuals, deprived people are less likely to be physically active. However, pathways underlying the association between deprivation and physical activity remain overlooked. Here, we examined whether the association between several indicators of deprivation (administrative area deprivation and self-reported individual material and social deprivation) and physical activity was mediated by body mass index (BMI). In addition, consistent with an intersectional perspective, we tested whether this mediating pathway was moderated by participants gender and we hypothesized that the mediating effect of BMI would be stronger among women, relative to men. We used two independent large-scale studies to test the proposed pathways cross-sectionally and prospectively. In a first sample composed of 5,723 British adults (Study 1), BMI partly mediated the cross-sectional association between administrative area deprivation and self-reported physical activity. Moreover, relative to men, the detrimental effect of deprivation on BMI was exacerbated among women, with BMI mediating 3.1% of the association between deprivation and physical activity among women (vs 1.5% among men). In a second sample composed of 8,358 European older adults (Study 2), our results confirmed the findings observed in Study 1: BMI partly mediated the prospective association between perceived material and social deprivation and self-reported physical activity. Moreover, compared to men, the effect of deprivation on BMI was more pronounced among women, with BMI respectively mediating 8.1% and 3.4% of the association between material and social deprivation and physical activity among women (vs 1.3% and 1.2% among men). These findings suggest that BMI partly explained the detrimental association between deprivation and physical activity, with this effect being stronger among women. Our study highlights the need to further consider how gender may shape the mechanisms behind the association between disadvantaged socio-economic circumstances and physical activity.

BackgroundThe negative correlation between life purpose levels and subsequent morbidity and mortality is interpreted as evidence that a higher sense of life purpose causes healthier and longer lives. Causation, however, could run the other direction as a decline in health is, by definition, associated with greater morbidity and mortality risk and may also cause a decline in life purpose. We examine the relation between objective measures of changes in health and changes in purpose to better understand the causal mechanisms linking purpose to health and mortality. MethodsProspective cohort sample of 12 745 individuals aged 50 and older who were eligible to participate in the 2006, 2010, or 2014 Health and Retirement Study Psychosocial and Lifestyle questionnaire. The final sample consists of 15 034 observations measured over three four-year periods from 5 147 individuals. Controlling for standard covariates, we examined the relation between changes in purpose and 14 contemporaneous and subsequent objectively measured changes in health--lung function, grip strength, walking speed, balance, and physician diagnoses of hypertension, diabetes, cancer, lung disease, heart condition, stroke, psychiatric problem, arthritis, dementia, and Alzheimers disease. FindingsThere is strong evidence that negative health shocks cause a decline in life purpose as individuals who suffer a negative health shock experience a statistically meaningful contemporaneous decline in life purpose for 12 of the 14 changes in health metrics. In contrast, there is relatively weak evidence that a decline in purpose contributes to a deterioration of future health. InterpretationMuch of the relation between life purpose levels and mortality risk arises from reverse causation--a decline in health causes both increased mortality risk and lower life purpose. There is little evidence that life purpose interventions would alter future morbidity or mortality. FundingNone. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed and Google Scholar with no language or date restriction for the term "life purpose" and found four comprehensive reviews of the life purpose or psychological well-being (which included life purpose in the set of psychological well-being metrics) literatures in the last three years and a 2016 meta-analysis of the relation between life purpose and mortality. Although acknowledging the possibility that reverse causation plays a role in linking life purpose levels to subsequent morbidity and mortality, the prevalent view appears to be that even when controlling for current health levels, higher life purpose causes behavioral, biological, or stress buffering changes that, in turn, cause lower future morbidity and mortality. Added value of this studyBy focusing on changes in health, changes in life purpose, and a longer horizon, we find strong evidence that changes in health cause changes in life purpose, but, contrary to the conclusions of most previous work, there is little evidence changes in life purpose cause changes in behavior, biology, or stress-buffering that, in turn, cause changes in future health. Implications of all the available evidenceAlthough life purpose intervention--either at the provider level or in public policy--may have benefits, there is little evidence to suggest it will cause greater longevity or lower future illness.

How do patterns of socioeconomic inequality shape the risk of child fatality in urban areas? Studies have demonstrated that intentional and accidental deaths of children are highly clustered into areas of social disadvantage. However, in complex urban settings, the risk of death to children is likely to exhibit a more localized spatial structure characterized by rapid changes in child fatality risk. The present research uses Bayesian hierarchical modeling to detect spatial discontinuities in child fatality risk in transition areas defined by elevated levels of economic hardship and inequality (EHI). The analysis detected 413 neighborhood boundaries characterized by extreme differences in EHI (i.e., a difference of four deciles). Living in proximity to a boundary of extreme difference, called a social frontier, is associated with a 22% higher relative risk of child fatality beyond measures of neighborhood racial segregation, concentrated disadvantage, residential mobility, and immigrant concentration. The significance of identifying neighborhoods characterized as a social frontier where children may benefit from additional preventive interventions is discussed in context.

Life expectancy differences across racial/ethnic and economic groups persist in the U.S., but little is known about the combined effects of racial and income segregation in explaining old age survival across neighborhoods. We operationalized neighborhoods using census tracts, with 65,655 of them nested within 3,015 counties, nested within 49 states. We linked census track life table data for ages 45-74 (n=196,965) from the National Vital Statistics System with 5-year population estimates (2011-2015) stratified by race/ethnicity and income from the American Community Survey. We measured racial/ethnic and income segregation using the Index of Concentration of the Extremes at the census tract level, and the indexes of dissimilarity and exposure at the county level. Using three-level random intercept models, we assessed the direct and contextual relationship between survival at ages 45-74 with racial/ethnic and income segregation. Regardless of racial/ethnic stratification, a high concentration of neighborhood poverty was associated with a lower probability of survival relative to affluent neighborhoods (-4.83%; 95% CI -4.86, -4.79), although the relationship was larger in neighborhoods with high concentration of Blacks (-5.61%; -5.67, -5.54). Black-white county-level unevenness also had the largest negative association in those neighborhoods (-0.26%; -0.32, -0.20). Furthermore, Black isolation was negatively associated with a lower survival probability (-0.21%; -0.29, -0.13), but Hispanic isolation was positively associated (0.23%; 0.16, 0.30). Opposite relationships resulted from Black-White (0.06; -0.01, 0.14) and Hispanic-White (-0.13; -0.21, -0.05) interactions. Finally, high exposure to neighborhood poverty/affluence was associated with lower/higher probability of neighborhood survival, but the associations were the strongest for Blacks. SignificanceRacial/ethnic and income residential segregation have been associated with negative health outcomes and increased risk of mortality in the U.S. We tested the association between residential segregation at different geographic levels with the survival probability at ages 45-74 across rural/urban neighborhoods. Results indicate that the racial/ethnic and income geographic composition of the population are important factors for explaining this relationship. That is, poverty concentration, minority-white unevenness, and exposure to poverty, had detrimental outcomes for all communities, irrespective of their racial/ethnic composition. However, while minority-isolation/-exposure to whites is detrimental/protective for Black communities, the opposite happened in Hispanic communities. Our research provides important insights in understanding the extent to which residential segregation explains survival disparities across neighborhoods based on their race/ethnicity composition.

To date, the discourse on bodily autonomy has been narrowly focused on contraception and abortion and needs to be expanded to include experiences of agency during pregnancy and birth. Disrespect and mistreatment are widely reported in low resource countries but very little is known about experiences of perinatal care in high resource countries and how to improve care for minoritized populations. MethodsWe examine experiences of autonomy in decision-making during pregnancy among people who were pregnant in Canada between 2009 and 2022, using a large national dataset of patient-reported experiences and outcomes that were collected via a cross-sectional online survey. We measured autonomy with a globally validated patient-reported experience measure, the My Autonomy in Decision-Making (MADM) scale. To assess variations in autonomy by identity or life circumstances, we conducted multivariable regression analyses, controlling for pregnancy year, repeat observations, and place of residence and stratifying by model of care (physician or midwife-led). In a separate analysis, we tested contextual factors such as onset of prenatal care, length of appointments, and model of care (physician-led or midwife-led) that might reduce disparities in autonomy among minoritized childbearing people. FindingsDiverse participants (n=5389) reported on 7049 interactions with healthcare providers. In the adjusted models, autonomy scores were significantly lower among those with high school education or less (physician-led care: IRR=0.86, 95 % CI: 0.82-0.92; midwife-led care: IRR=0.93, 95% CI: 0.88-0.98) and newcomers to Canada (physician-led care: IRR=0.97, 95 % CI: 0.93-0.99). Scores were higher among pregnant people with majorized identities and circumstances, i.e. those who reported low discrimination (physician-led care: IRR=1.21, 95 % CI: 1.15-1.26; midwife-led care: IRR=1.06, 95% CI: 1.02-1.11), no disability (physician-led care: IRR=1.07, 95 % CI: 1.02-1.13; midwife-led care: IRR=1.04, 95% CI: 1.00-1.09), no need for social services (physician-led care: IRR=1.11, 95 % CI: 1.04-1.19; midwife-led care: IRR=1.13, 95% CI: 1.06-1.21), identified as heterosexual (physician-led care: IRR=1.10, 95 % CI: 1.06-1.15; midwife-led care: IRR=1.03, 95% CI: 1.01-1.06), Cis gender (midwife-led care: IRR=1.08, 95% CI: 1.01-1.16), and had sufficient income to meet financial obligations (physician-led care: IRR=1.18, 95 % CI: 1.11-1.24), compared to the reference groups. Several modifiable factors were linked to higher autonomy, including early entry into prenatal care, sufficient time during prenatal appointments, and midwife-led care. Midwife led care was the only contextual factor that was associated with significant increases in autonomy scores for minoritized people. ConclusionsSelf-determination, including the ability to lead decisions during pregnancy, birth and the postpartum period, is a reproductive right, yet minoritized communities reported significant loss of autonomy. Differences persisted across models of care, pointing to structural inequities in patient-led decision-making during pregnancy.

We estimate the associations between community socioeconomic composition and changes in COVID-19 vaccination levels in eight large cities at three time points. Between March and April, low SES communities had significantly lower change in percent vaccinated than high SES communities. Between April and May, this difference was not significant. Thus, the large vaccination gap between communities during restricted vaccine eligibility did not narrow when eligibility opened up. The link between COVID-19 vaccination and community disadvantage may lead to a bifurcated recovery where advantaged communities move on from the pandemic more quickly while disadvantaged communities continue to suffer.