Social Science & Medicine

The use of human diversity classifications like race, ethnicity, ancestry, or migration background entails a range of scientific as well as social consequences, therefore, a careful application is vital. In this article, we present results from a systematic literature review and subsequent quantitative content analysis based on 546 papers focusing on classifications applied in life sciences studies at German research institutions. Our aim is to capture a snap-shot of current classification practices applied to categorize humans across various disciplines and fields in a specific national context that remains underexposed in this regard. The review substantiates a) the results from earlier studies that point to heterogeneity, inconsistency and vagueness of human classifications used in the life sciences, and b) underlines the presumed specificity of the German science context, where the term "race" is comparatively little used. Our findings stress the need for German researchers to partake in the ongoing international debate on the practice of human classification in the life sciences to advance the international and interdisciplinary transferability of scientific results and, first and foremost, to avoid unintended effects such as overgeneralization, racialization, and stigmatization.

BackgroundThe COVID-19 pandemic has disproportionately impacted womens mental health, although most evidence has focused on mental illbeing outcomes. Previous research suggests that gendered differences in time-use may explain this disparity, as women generally spend more time doing psychologically taxing activities than men. We investigated gender differences in the long-term trajectories of life satisfaction, how these were impacted during the pandemic, and the role of time-use differences in explaining gender inequalities. MethodsWe used data from 6766 (56.2% women) members of the 1970 British Cohort Study (BCS70), a nationally representative birth cohort of people born in Great Britain in 1970, who were alive and residing in the UK between May 2020 and March 2021. Life satisfaction was prospectively assessed between the ages of 26 (1996) and 51 (2021) using a single question with responses ranging from 0 (lowest) to 10 (highest). We analysed life satisfaction trajectories using piecewise latent growth curve models and investigated whether gender differences in the change in the life satisfaction trajectories with the pandemic were explained by self-reported time spent doing different paid and unpaid activities. FindingsWomen had consistently higher life satisfaction than men prior to the pandemic ({Delta}intercept,unadjusted=0.213 [95% CI: 0.087, 0.340], p=.001) and experienced a more accelerated decline with the pandemic onset ({Delta}quad2,unadjusted=-0.018 [-0.026, -0.011], p<.001). Time-use differences did not account for the more accelerated decrease in womens life satisfaction levels with the pandemic ({Delta}quad2,adjusted=-0.016 [-0.031, -0.001], p=.035). InterpretationOur study shows pronounced gender inequalities in the impact of the pandemic on the long-term life satisfaction trajectories of adults in their 50s, with women losing their historical advantage over men. Self-reported time-use differences did not account for these inequalities, suggesting that they could be linked to other factors including the mental load (invisible, unrecognised labour disproportionately undertook by women) or the menopausal transition.

It is widely recognized that trust is an essential element in how people engage with data sharing and underpins efforts to use data to improve care quality and understand population-level health trends, and consequently improve health inequalities. However, research into public trust in the data sharing and healthcare settings may rely on oversimplified notions of what trust entails, and what is involved in trusting relationships in this setting has not been widely explored. Relatedly, the way that trust manifests as a function of perceived trustworthiness is unestablished. Here, we analyze data from 2000 participants who completed a questionnaire about how they place trust in entities including family, the healthcare system, and corporations when it comes to their personal health data. We find that the reasons people place trust differ depending on the relationship and circumstance, and suggest that trustworthiness is an underlying quality that manifests and is perceived differently under different conditions. Future work into trust relationships should account for this varying presentation of trust, and perceptions of trustworthiness, when it comes to exploration of relationships between people, institutions, and systems.

PurposeThis study examines how different forms of social isolation, such as living alone, lack of community engagement, and unemployment, are associated with mental health in mid-life (ages 42-46), a life stage often overlooked when examining the impacts of social isolation. MethodsUsing longitudinal data (1999-2016) from two British birth cohort studies: 1970 British Cohort Study N=16,585 and the 1958 National Child Development Study N=15,806, this study investigated whether different forms of isolation have independent effects, contribute to cumulative risk, or interact additively or multiplicatively. ResultsIndependent effects varied by isolation type and mental health outcomes. Being out of employment was linked to higher psychological distress and lower life satisfaction and self-rated health, while living alone was only associated with lower life satisfaction. Limited contact with friends and relatives and a lack of community engagement were associated with lower life satisfaction and self-rated health. Greater social isolation corresponded to increased psychological distress, lower life satisfaction, and poorer self-rated health, demonstrating cumulative risk. Effects appeared additive rather than multiplicative. No consistent sex or cohort differences were observed. ConclusionThe study underscores the need to examine both separate and combined effects of social isolation across the complete mental health state. Isolation in its various forms was detrimental for mental health in mid-life and was most consistently linked to lower life satisfaction. Efforts to reduce isolation and its negative mental health impacts must recognise the complexity of these experiences.

ObjectiveExplore self-reported racial discrimination in healthcare. MethodsRepresentative population sample, Switzerland, repeated cross-sectional data 2016 to 2024 (N=15,525). ResultsContrary to expectation, respondents from the migration-related population (foreign citizens, foreign born, migration background, first/second generation) report less racial discrimination than members of the majority population. Over time, we see an increase in the non migration-related population reporting (racial) discrimination in healthcare, while the share for the migration-related population is constant. The validity of the instrument is demonstrated with reported discrimination at work and in housing and the results are reliable across specifications and statistical controls. ConclusionWe speculate that in some cases, reported racial discrimination may express unmet expectations in healthcare more generally.

We show that large declines in maternal mortality can be achieved by raising womens political participation. We estimate that the recent wave of quotas for women in parliament in low income countries has resulted in a 9 to 12% decline in maternal mortality. Among mechanisms are that gender quotas lead to an 8 to 10% increase in skilled birth attendance, a 6 to 12% increase in prenatal care utilization and a 4 to 11% decrease in birth rates. JEL codesI14, I15, O15.

BackgroundSocial transition, defined as all outward changes in gender expression to align with and affirm ones gender identity, has been richly described in qualitative studies, but quantitative research often lacks the detail required to capture its full complexity. To date, no studies have quantitatively examined how this process varies in young people over time. MethodsLongitudinal data were obtained from 234 trans and gender diverse Australian young people (ages 8-17) attending a specialist paediatric gender service across at least two annual waves from 2017 to 2024. Social transition was operationalised using three practices (name, pronouns, and appearance) across five contexts (home, school, online, with friends, and extended family). For each practice, we captured the contexts in which a change had been enacted or was desired in the future. FindingsMost young people reported changes to their enacted social transition (73.9%) and adjustments in their social transition goals (60.7%) over time. Grouping of participants with similar social transition trajectories identified that most (78.6%) met their goals by the final wave, while many of those who had not were still progressing toward them (50.0%). Progress varied by gender, with trans boys significantly more likely than trans girls to meet their social transition goals. ConclusionIn our longitudinal clinical cohort of gender diverse young people, social transition encompassed diverse practices, contexts, and goals, which evolved over time. Despite this variability, clusters of trajectories emerged, indicating that groups of young people can follow similar patterns, while maintaining unique experiences.

Background: As medicine grows increasingly technological and scientific, biomedical researchers working to bring new knowledge to bear on clinical practice face a key question: when is a new intervention or treatment ready for clinical use? Because this is both a technical and ethical dilemma, it is crucial to examine the social history of how different approaches to this question emerge and the values or assumptions they embed. Methods: We examine the rise and proliferation of an increasingly common framework for assessing the value of new biomedical data or technology, "actionability," through a computational analysis of published scientific literature referencing this and related terms, including topic modeling and Medical Subject Headings (MeSH) term analysis of over 7000 scientific abstracts indexed in PubMed. Results: We find that actionability, as a term, began appearing more commonly in published literature in the mid-2000s, and proliferated throughout the 2010s and into the 20s. While originally used primarily in research on healthcare quality and implementation, the concept's rise in popularity is ultimately driven by uptake in the fields of clinical genetics and oncology. Conclusions: The adoption of actionability in these fields suggests that actionability as a conceptual framework may be most valuable to areas of translational medicine seeking to make sense of increasing amounts of data and technological innovation with differing levels of scientific validity and clinical utility. Recognizing this value, we also caution that actionability drives our attention primarily towards whether a test or piece of information can lead to action, not whether that action has proven benefits. As clinicians and researchers face difficult questions about how to sort through growing amounts of data to generate knowledge that can have a real impact on patient health, empirical bioethics should play a key role in analyzing the trade-offs and impacts of different approaches.

We evaluate impacts heterogeneity of an Early Childhood Intervention in Colombia, with respect to the Educational Attainment Polygenic Score (EA4 PGS) constructed from DNA data based on GWAS weights from a European population. We find that the EA4 PGS is predictive of several measures of child development, mothers IQ and, to some extent, educational attainment. We also show that the impacts of the intervention are significantly greater in children with low PGS, to the point that the intervention eliminates the initial genetic disadvantage. Lastly, we find that children with high PGS attract more parental stimulation; however, the latter increases more strongly in children with low PGS. JEL CodesC21, J13, I24

We leverage powerful time-series data from a national longitudinal sample measured before the COVID-19 pandemic and during the worlds eighth most stringent COVID-19 lockdown (New Zealand, March-April 2020, N = 940) and apply Bayesian multilevel mediation models to rigorously test five theories of pandemic distress. Findings: (1) during lockdown, rest diminished distress; without rest psychological distress would have been ~ 1.74 times greater; (2) an elevated sense of community reduced distress, a little, but elevated government satisfaction was inert. Thus, the psychological benefits of lockdown extended to political discontents; (3) most lockdown distress arose from dissatisfaction from personal relationships. Social captivity, more than isolation, proved challenging; (4-5) Health and business satisfaction were stable; were they challenged substantially more distress would have ensued. Thus, lockdown benefited psychological health by affording safety, yet only because income remained secure. These national longitudinal findings clarify the mental health effects of stringent infectious disease containment.

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.

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.

Extroverts may enjoy lower mortality than introverts under normal circumstances, but the relationship may be different during an airborne pandemic when social contact can be deadly. We used data for midlife Americans surveyed in 1995-96 with mortality follow-up through December 31, 2020 to investigate whether the association between extroversion and mortality changed during the COVID-19 pandemic. We hypothesized that excess mortality during the pandemic will be greater for extroverts than for introverts. Results were based on a Cox model estimating age-specific mortality controlling for sex, race/ethnicity, the period trend in mortality, and an additional indicator for the pandemic period (Mar-Dec 2020). We interacted extroversion with the pandemic indicator to test whether the relationship differed between prepandemic and pandemic periods. Prior to the pandemic, extroversion was associated with somewhat lower mortality (HR=0.93 per SD, 95% CI 0.88-0.97), but the relationship reversed during the pandemic: extroverted individuals appeared to suffer higher mortality than their introverted counterparts, although the effect was not significant (HR=1.20 per SD, 95% CI 0.93-1.54). Extroversion was associated with greater pandemic-related excess mortality (HR=1.20/0.93=1.29 per SD, 95% CI 1.00-1.67). Compared with someone who scored at the mean level of extroversion, mortality rates prior to the pandemic were 10% lower for a person who was very extroverted (i.e., top 12% of the sample at Wave 1), while they were 12% higher for someone who was very introverted (i.e., 11th percentile). In contrast, mortality rates during the pandemic appeared to be higher for very extroverted individuals (HR=1.15, 95% CI 0.77-1.71) and lower for those who were very introverted (HR=0.70, 95% CI 0.43-1.14) although the difference was not significant because of limited statistical power. In sum, the slight mortality advantage enjoyed by extroverts prior to the pandemic disappeared during the first 10 months of the COVID-19 pandemic. It remains to be seen whether that pattern continued into 2021-22. We suspect that the mortality benefit of introversion during the pandemic is largely a result of reduced exposure to the risk of infection, but it may also derive in part from the ability of introverts to adapt more easily to reduced social interaction without engaging in self-destructive behavior (e.g., drug and alcohol abuse). Introverts have been training for a pandemic their whole lives.

We examine the mortality effects of a 1947 school reform in Japan, which extended compulsory schooling from primary to secondary school by as much as 3 years. The abolition of secondary school fees also indicates that those affected by the reform likely came from disadvantaged families who could have benefited the most from schooling. Even in this relatively favorable setting, we fail to find that the reform improved later-life mortality up to the age of 87 years, although it significantly increased years of schooling. This finding suggests limited health returns to schooling at the lower level of educational attainment.

ObjectiveTo examine the association between childhood health and adult health outcomes. MethodsWe used data from the 1970 British Cohort Study, which follows participants from age 10 to age 51. Childhood health at age 10 was measured using the Rutter Scale for emotional and behavioural difficulties and self-reported physical health problems that occurred within the last 12 months. We estimated associations using logistic regression models, applying inverse probability weighting to adjust for sample attrition. All models controlled for a wide range of background characteristics reflecting childhood circumstances. ResultsWe find evidence of associations between health at age 10 and health outcomes at age 51. Severe emotional and behavioural difficulties in childhood were most strongly associated with both the likelihood of experiencing depressive symptoms (relative risk [RR]: 1.85, 95% CI: 1.26-2.56) and with reporting a long-term health condition that affects the amount or type of work (RR: 1.68, 95% CI: 1.19-2.24). Childhood physical health problems were also associated with a higher likelihood of long-term conditions affecting work (RR: 1.38, 95% CI: 1.10-1.68), though we found no statistically significant association with depressive symptoms in midlife. ConclusionChildhood mental and physical health were associated with adult health outcomes more than four decades later. These findings highlight the potential long-term implications of early-life health for wellbeing in midlife, supporting the case for early intervention and sustained support throughout childhood.

We here address the causal relationship between maternal depression and child human capital using UK cohort data. We exploit the conditionally-exogenous variation in mothers genomes in an instrumental-variable approach, and describe the conditions under which mothers genetic variants can be used as valid instruments. An additional episode of maternal depression between the childs birth up to age nine reduces both their cognitive and non-cognitive skills by 20 to 45% of a SD throughout adolescence. Our results are robust to a battery of sensitivity tests addressing, among others, concerns about pleiotropy and the maternal transmission of genes to her child.

Patient cost-sharing in medical care constrains total health spending, presumably with little harm to underlying patient health. This paper re-evaluates the link between cost-sharing and health, studying Colombias entire formal sector workforce with individual-level health care utilization records linked to payroll data and vital statistics. Given discrete breaks in outpatient cost-sharing imposed at multiple income thresholds by Colombias national health system, we use a regression discontinuity design and find that outpatient cost-sharing reduces use of outpatient care, resulting in fewer diagnoses of common chronic diseases and increasing subsequent emergency room visits and hospitalizations. Ultimately, these effects measurably increase mortality, and disproportionately so among the poor - raising the absolute difference in 7-year mortality risk by 0.80 and 0.23 deaths per 1,000 individuals at lower- and higher-income thresholds, respectively. To the best of our knowledge, this study is the first to show a relationship between cost-sharing and adult mortality risk in lower-income countries, a relationship important to incorporate into social welfare analyses of cost-sharing policies. One Sentence SummaryOutpatient cost-sharing in medical care discourages use - but over time, also increases costly hospital service use and raises mortality risk.

BackgroundThe study tests whether financial hardship and uncertainty have increased during the COVID-19 pandemic and the early stage of the subsequent cost-of-living crisis and whether these might explain increased psychological distress among the UK population. MethodsWe derive two cohorts from Understanding Society, a study representative of the UK population. Cohort 1 (C1) starts in 2016 and includes a 3-year follow-up until 2019. Cohort 2 (C2) starts in 2019 and ends in 2022. We provide descriptive statistics on financial hardship and uncertainty and apply parallel Latent Growth Modelling (LGM) on each cohort to explain variations in psychological distress (GHQ-36) based on baseline and follow-up financial trajectories. The sample is adjusted using cross-sectional weights and inverse probability weights for attrition. ResultsFinancial hardship rates do not differ across cohorts but a marginal increase of 10 percent in financial uncertainty is observed in 2022 for C2. No significant difference in associations is observed across cohorts in the LGM with constant financial hardship increasing the GHQ-36 slope by 0.89 (95%CI=0.76;1.02) and 0.89 (95%CI=0.73;1.05) units in C1 and C2 and constant financial uncertainty increasing it respectively by 0.95 (95%CI=0.74;1.17) and 1.04 (95%CI=0.82;1.25). Baseline hardship and uncertainty increase the intercept by 2.39 (95%CI=2.11;2.67) and 1.74 (195%CI=1.38;2.10) in C1 and 2.97 (95%CI=2.65;3.29) and 2.12 (95%CI=1.75;2.49) in C2. DiscussionThe uncertainty caused by the 2022 cost-of-living crisis might have contributed to increase psychological distress within the UK population. Stronger detrimental effects might be expected if financial hardship were to increase.

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.

Background: Rising rates of young people Not in Education, Employment, or Training (NEET) in the UK have recently coincided with declining youth physical and mental health but no study has asked whether this reflects a growing proportion of young people with health problems (prevalence) or those with health problems becoming more likely to be NEET (penalty). Methods: Using 15 years of Understanding Society data (2009-23), we analysed 15,242 respondents aged 16-24 (66,160 observations). We employed three complementary approaches: descriptive trends, Blinder-Oaxaca-Kitagawa (BO) probit decomposition comparing 2009-2013 and 2019-2023 against a 2014-2018 reference period, and fixed-effects (FE) Poisson models with lagged health status. Exposures included self-reported health conditions or disability (SRHD), psychological distress , diagnosed conditions and socio-demographic factors. Findings: NEET rates were lowest in 2014-18 (10.5-11.5%) and higher in 2009-13 (12-15%) and 2019-23 (15-16%). Higher prevalence of SRHD, psychological distress, diagnosed depression and multimorbidity explained changes in NEET prevalence across both the 2009-13 to 2014-2018 and 2014-18 to 2019-23 periods. No change in penalty was observed for any health variable across periods, except for an increase in the penalty for SRHD between the 2009-13 to 2014-18 periods. Interpretation: Rising NEET rates among UK youth are driven largely by more young people having physical and psychological ill health. Whilst labour market and education accommodations remain important, reducing NEET rates will require reversing the decline in youth health, not just accommodating it.