The Lancet Public Health

Aims: To assess whether recent declines in U.S. rolling 12-month-ending drug overdose death counts are projected to continue, compare the retrospective performance of short-term forecasting models, and estimate national and regional 12-month changes. Design: Comparative time-series forecasting study with a retrospective March 2025-February 2026 forecast evaluation and subsequent 12-month-ahead projections through February 2027. Setting: United States and four U.S. Census regions: Northeast, Midwest, South, and West. Cases: Aggregate drug overdose deaths reported in the National Center for Health Statistics Vital Statistics Rapid Release system (VSRR) and identified using ICD-10 underlying cause-of-death codes X40-X44, X60-X64, X85, and Y10-Y14. Measurements: The primary outcome was the monthly series of rolling 12-month-ending overdose deaths. Candidate models included ARIMA, generalized additive models, Prophet, and AICc-ranked n-sub-epidemic models. Models were calibrated using January 2020-February 2025 data and evaluated against March 2025-February 2026 observations using mean absolute error, mean squared error, empirical 95% prediction interval coverage, and weighted interval score (WIS). Individual models were ranked by retrospective WIS, and normalized inverse-WIS weights were used to construct ensembles from the top-ranked models. Final forecasts were generated for March 2026-February 2027 after recalibrating models using January 2020-February 2026 data. Results: Retrospective WIS performance differed geographically: GAM performed best nationally and in the Midwest and West, the leading n-sub-epidemic model in the Northeast, and ARIMA in the South. Median forecasts from all individual models and ensembles projected declines from February 2026 to February 2027 nationally and in each region, although prediction intervals varied substantially. Individual national median projections ranged from declines of 12.8% to 25.8%, while weighted-ensemble median projections indicated declines of 20.5% to 21.7%. Projected weighted-ensemble declines were larger in the Northeast (25.4%-30.0%) and Midwest (24.3%-26.3%) than in the South (16.6%-19.5%) and West (18.0%-21.8%). Summary: Ensemble forecasts of the reported provisional VSRR series were consistent with continued declines in rolling annual overdose death counts nationally and across U.S. Census regions. The projected magnitude of decline differed by region and model specification. Because the forecasts used provisional rolling 12-month-ending counts, they should be interpreted as surveillance projections rather than exact monthly mortality predictions.

Background England's population is ageing rapidly, with those aged 80 years and older projected to increase 85% by 2047. Aging populations may change the dynamics of future pandemics, since older individuals face higher risks of severe outcomes and require a disproportionate share of early vaccine supply, for certain respiratory infections, despite having fewer social contacts. The net pandemic-risk implications of these competing effects cannot be resolved without dynamic transmission modelling. Methods We used an age-structured stochastic SARS-CoV-2 transmission model, previously calibrated to the real-time COVID-19 epidemic across seven NHS regions of England. Running the fitted model under the ONS principal population projection for 2047 as a counterfactual, we held all non-pharmaceutical interventions fixed and scaled vaccine supply to overall population growth. Nine counterfactual scenarios spanned three vaccine deployment strategies and three ONS migration assumptions. Findings The basic reproduction number remained largely unchanged by the projected age distribution. However, under the central counterfactual scenario, cumulative hospital admissions in the first two years of the pandemic were 674,004 - a 40.3% increase over the historic baseline - and hospital deaths increased by 49.4%, disproportionate to the 13.9% total population increase. Trajectories were similar before the Delta variant emerged but diverged thereafter, as a larger elderly cohort delayed vaccine protection in younger, higher-contact groups. Projected burden was robust to migration assumptions (664,451--689,833 admissions). Vaccine deployment strategy had substantially greater influence, with admissions ranging from 625,859 (optimistic age-scaled deployment) to 1,193,883 (non-scaled). Interpretations Population ageing will disproportionately amplify England's pandemic burden, driven primarily by the interaction between a growing elderly cohort and fixed age-ordered vaccine allocation, rather than by population growth alone. This vulnerability is largely independent of future migration uncertainty but is strongly modifiable through demographically-adaptive vaccine deployment planning developed before, not during, the next pandemic.

In February 2021, Oregon became the first US state to decriminalize possession of small amounts of all commonly used illicit drugs (Measure 110); twenty-four days later, Washington's Supreme Court Blake ruling produced a weaker, shorter-lived decriminalization. Evaluations of these policy periods have focused on overdose deaths, with contested results; their association with the mental health of the general population is unknown. Using surveillance data on 6.3 million adult interviews (2011-2024) and synthetic control methods with permutation inference, we find frequent mental distress an estimated 2.15 percentage points higher in Oregon than in its synthetic counterfactual (largest positive gap among 45 jurisdictions; two-sided rank 2/45, p = 0.044, though not significant under the alternative fit-normalized statistic), with directionally consistent estimates in Washington and a joint test on the pair at p = 0.015. The increase concentrates in self-reported distress, among women and young adults, and is not mirrored in diagnoses, police-recorded partner violence or suicide.

Background: Multiple factors can drive heat susceptibility, but are typically analyzed individually. This study investigates high-dimensional heterogeneity across multiple domains in the effect of hot days on emergency hospitalizations across German districts. Methods: We obtained emergency hospitalization rates per 1,000 in 3-day windows for the summers of 2005-2023 from the German Diagnosis-Related Groups-Statistic, linked with spatio-temporal temperature information. A hot day was defined as at least one day above the district-level 98th percentile heat index. Multiple characteristics of the demographic, health/social, and environmental domains were selected as potential effect modifiers. We implemented a generalized random forest, where outcome and propensity scores were modeled with fixed effects estimators to control for seasonality and district-level confounding. We divided the conditional average treatment effects (CATE) into quartiles to map their spatial distribution and identify key effect modifiers via the variable importance and observed indicator profiles across quartiles. Results: We found substantial variation across districts regarding heat-related emergency hospitalizations. The top three indicators for predicting this effect heterogeneity were the percentage of people seeking protection, population below age 6, and air pollution levels. The observed indicator profile for the most susceptible districts was characterized by a larger percentage of vulnerable populations, higher car density, and fewer hospital beds. Conclusion: There is substantial variation in heat susceptibility across and within districts in Germany. We propose an approach that can help understanding such complex interplay of indicators from different domains driving heterogeneity.

Introduction: Risk of recurrent opioid use during buprenorphine-naloxone (bup-nx) treatment is dynamic and remains elevated after initiation, with vulnerability shaped in part by treatment intensity and gaps between visits, yet routine outpatient care relies on episodic encounters and retrospective data. This mismatch can delay recognition of emerging instability and limit timely treatment adjustments. This paper reports the development and specification of an intervention strategy to address this mismatch. Methods: We used a structured, multi-phase design process to specify and configure a measurement-based care (MBC) strategy for bup-nx treatment (Bup-MBC) in outpatient addiction clinics through three phases: (1) a systematic review of patient-reported outcome measures (PROMs) for substance use treatment; (2) a qualitative needs assessment using the Theoretical Domains Framework and COM-B (Capability, Opportunity, Motivation-Behavior) model to identify gaps in risk monitoring, agency, and trust; and (3) iterative co-design with multidisciplinary clinicians to refine workflow fit and trust-preserving use of data. Patients informed item and feedback content during the needs assessment but did not participate in the co-design cycles. Results: Bup-MBC integrates (1) brief between-visit PROMs (e.g., withdrawal, craving, adherence); (2) immediate non-punitive patient feedback; (3) clinician-facing summaries and non-directive prompts in the electronic health record (EHR); and (4) an opt-in between-visit outreach pathway with predefined safety triggers, all configured within existing EHR and patient portal infrastructure. It targets patient and clinician capability to recognize changes in risk, opportunity for action through structured monitoring and visit preparation, and trust and agency through non-punitive communication, without adding substantial burden. The full measure set, severity bands, and question-to-action map are provided as supplementary material. Key trade-offs included prioritizing single-item measures for feasibility, balancing opt-in outreach with safety overrides, and assuming routine clinician use of summaries. Conclusion: This development study specifies an EHR-integrated MBC strategy for outpatient bup-nx treatment. As single-center design work with co-design limited to clinicians and delivery contingent on portal or text-message access, its outputs are hypotheses about mechanism and fit rather than demonstrated effects. Feasibility studies are needed to evaluate uptake, acceptability, workflow fit, and effects on treatment.

Objectives Outpatient buprenorphine-naltrexone (bup-nx) treatment reduces overdose risk, yet many patients still return to use or disengage from treatment. We sought to understand how patients and prescribers experience and manage relapse risk, monitoring, and treatment agency in routine bup-nx treatment to identify gaps in current practice. Methods We conducted a qualitative needs assessment using semi structured, critical incident interviews with patients receiving outpatient bup-nx and prescribers who manage bup-nx treatment. Interviews examined situations involving relapse risk and empowerment in treatment decisions. We structured data collection and analysis using the Theoretical Domains Framework and COM B model to characterize determinants. Transcripts were coded deductively and inductively until code level saturation was reached. Results Participants (9 patients, 8 prescribers) described nine treatment needs mapped to the Capability, Opportunity, and Motivation components of the COM B model. These themes highlighted how patient agency in bup-nx treatment was constrained by physiologic and emotional states, with withdrawal, craving, pain, and distress often overriding longer term goals. Relapse vulnerability was experienced as dynamic and intensifying between visits, while clinical detection remained anchored to visit bound assessments, urine drug testing, refill patterns, and crisis driven contact, creating blind spots. Structural friction (pharmacy rules, insurance disruptions, transportation and housing instability), stigma from family and recovery communities, and motivational processes tied to fluctuating readiness and trust in monitoring further shaped engagement, disclosure, and dosing decisions; the same monitoring tools could either support honest disclosure or provoke concealment when perceived as punitive. Conclusions Relapse risk and agency in bup-nx treatment are negotiated as dynamic processes within structurally constrained and trust sensitive systems. Addressing the identified capability, opportunity, and motivation gaps will require patient centered, trust preserving approaches to monitoring and shared decision making.

Background: Non-optimal air temperature increases the risk of preterm birth, but how temperature-related risks may translate into future population burden remains uncertain. We aimed to estimate the association between temperature and preterm birth in Sweden and assess how preterm birth burden may change under plausible future temperature conditions. Methods: We conducted a nationwide population-based cohort study of singleton births in Sweden from 1973 to 2018. Weekly mean temperature was assigned at the parish level according to maternal residence. Cox proportional hazards models with a distributed lag nonlinear model were used to estimate nonlinear and delayed associations between temperature and preterm birth. The estimated exposure response relationship and baseline hazards were then incorporated into an individual-based microsimulation of gestational progression under projected temperatures for 2025 to 2055. Future projections were examined across multiple climate models under SSP1-2.6 and SSP3-7.0 scenarios. Outcomes included the annual number and cumulative incidence of preterm births and the temperature-attributable fraction. Results: Among 4,338,825 singleton births, 211,397 (4.9%) were preterm. Temperature preterm birth associations were modest overall. The clearest increase in hazard was observed following exposure to very low temperatures, particularly -10C at short lags. Higher temperatures showed no clear increase in risk. From 2025 to 2055, the annual cumulative incidence of preterm birth and the temperature-attributable fraction was expected to remain broadly stable, with limited differences between emissions scenarios. In contrast, the absolute number of preterm births was expected to over the projection period, primarily reflecting increases in the projected number of pregnancies rather than substantial changes in temperature-associated risk. Conclusions: Very low temperatures were associated with a modest short-term increase in preterm birth risk in Sweden, hot temperatures showed little evidence of increased risk. Applying these associations to future climate conditions suggested limited changes in preterm birth incidence or the proportion attributable to temperature through 2055. However, the absolute burden of preterm birth may increase as the population at risk grows. This highlights the importance of considering demographic change alongside climate projections when assessing future maternal and neonatal health burden.

Introduction The role of population-wide smoking cessation campaigns is uncertain as smoking prevalence reaches historically low levels. We examined whether the Power to Quit campaign in England, which aimed to increase uptake of evidence-based cessation support, particularly digital aids, was associated with changes in quitting behaviour. Methods We analysed nationally-representative cross-sectional surveys of adults in England who smoked in the past year, conducted immediately before (n=803) and after (n=1,713) the campaign (February-April 2026). Logistic regression estimated associations with quit attempts, digital cessation support, local Stop Smoking Services (SSS), and quit success, overall and by social grade. Exploratory analyses examined participants recognising campaign materials (n=799). Smoking Toolkit Study (STS) data (January 2023-June 2026; n=11,442) were used to contextualise findings against longer-term trends. Results In the primary pre/post analysis, there were increases in quit attempts (48.4% to 52.3%, aOR=1.16 [95%CI=0.97-1.38]), attempts involving digital support (16.0% to 18.4%, aOR=1.18 [0.92-1.50], and attempts involving SSS (2.4% to 3.6%, aOR=1.53 [0.89-2.65]), although estimates were uncertain. Associations were larger among participants recognising campaign materials (quit attempts: 64.9%, aOR=1.82 [1.47-2.26]; digital support: 28.7%, aOR=1.88 [1.44-2.45]; SSS: 5.4%, aOR=2.14 [1.19-3.88]). Increases in support uptake were particularly evident among less advantaged adults. There was no clear evidence of a change in quit success. STS data showed increases in support uptake continued from before the campaign. Conclusions Power to Quit coincided with increased engagement with cessation support, particularly among less advantaged adults and those recognising campaign materials. Increases in support continued pre-campaign trends, indicating that the contribution of the campaign occurred within a broader period of changing cessation behaviour.

Background: Previous studies indicated that regional fluctuations in COVID-19 impact were associated with socioeconomic, demographic and environmental factors early in the pandemic. It is unclear whether factors associated with regional COVID-19 mortality and SARS-CoV-2 infections changed over the course of the pandemic. Methods: We evaluated the association of ecological factors with municipality-specific COVID-19 mortality in the national population of Austria between January 2020 and June 2023. Analyses were conducted separately per calendar year and pooled across years via random-effects meta-analysis. Outcomes were analysed using univariable and multivariable zero-inflated negative binomial (ZINB) regression, including annually averaged environmental exposome exposure (including air pollution and UV radiation), socioeconomic, demographic and infection dissemination predictors with significance threshold set to p<0.005. Secondary analysis modelled SARS-CoV-2 infections using of negative-binomial model (NB). Two additional approaches for smaller predictor set selection were applied as sensitivity analyses. Results: Within the entire observation period 18,430 COVID-19 deaths were reported. In univariable analyses (pooled RR (99.5% CI)), COVID-19 mortality was significantly associated with the proportion of commuters (0.79 (0.73-0.86)), residents aged 75-84 (1.18 (1.01-1.37)) and [&ge;]85 years (1.29 (1.04-1.60)), residents with at most compulsory education (1.15 (1.02-1.29)), employed residents aged 15-64 (0.89 (0.85-0.93)), and homeowners (0.91 (0.83-0.99)), as well as with precipitation (0.94 (0.89-0.99)) and the average time with a mean temperature of 5-15 C (0.95 (0.90-0.99)). In multivariable analyses the share of population aged 85 or older (1.30 (1.09-1.54)) and home ownership (0.92 (0.87-0.98)) were independently significant. Mortality predictor estimates were relatively stable across pandemic years. Across 5,963,882 documented SARS-CoV-2 infections share of employed in 15- to 64-year-olds (1.01 (1.01-1.02)), part-time employment rate (1.01 (1.00-1.02)) and district level nursing care allowance recipiency (0.97 (0.95-0.98)) were associated with detected infections. Overnight stays, population 85 or older, income, compulsory education or less and air pollution all had multiple significant estimates with opposite directionality, leading to non-significant overall associations. Sensitivity analyses outcomes mirrored main analyses outcomes. Conclusions: Throughout the pandemic in Austria, demographic and socioeconomic factors were associated with COVID-19 mortality and infections, but many associations, especially for infections, were unstable over time. These findings underscore the importance of structural vulnerabilities in epidemic impact.

Background: People with disabilities (PWD) represent over one-quarter of the US population and disproportionately experience chronic pain, yet limited research explores disparities they face in opioid use disorder (OUD) treatment. Objective: To examine disparities across disability status regarding opioid use disorder (OUD)-related outcomes and understand how chronic pain interacts with these associations. Methods: We completed a cross-sectional, secondary analysis of data from the All of Us Research Program, including 370,722 adults with electronic health record data available between January 2021-September 2023. We identified prevalence of disability, chronic pain, OUD, receipt of medications for OUD (MOUD), and OUD remission using diagnostic codes. We performed interaction analyses between chronic pain, disability subtype, and MOUD receipt in affecting OUD outcomes. Results: OUD was more common among individuals with physical (aOR: 2.74, 95% CI: 2.54-2.95), cognitive (2.19, 1.94-2.45), and multiple disabilities (2.43, 2.19-2.68), compared to those without disabilities. Among patients with OUD, those with physical disabilities were less likely to receive MOUD (0.81, 0.69-0.94). Compared to those without disabilities, chronic pain was associated with higher probabilities of OUD diagnosis and lower probabilities of MOUD and OUD remission across all subjects. These relationships were stronger for OUD diagnosis in cognitive disabilities, MOUD in multiple disabilities, and OUD remission in physical disabilities. Conclusions: Disability and chronic pain jointly shape disparities in OUD treatment and underscore the urgent need for care models that integrate OUD treatment with pain management and address the unique access challenges faced by people with disabilities.

Background The historic decline in childhood pneumonia mortality was driven substantially by single-pathogen vaccines against Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae. Yet the pathogen spectrum underlying child pneumonia deaths is diversifying: the effective number of pathogens rose from 5.57 in 1990 to 9.94 in 2023, and the residual burden is shifting toward opportunistic and hospital-associated pathogens for which no licensed childhood vaccines exist. This paper asks how resources should be sequenced between single-pathogen interventions and platform investments as this transition proceeds. Methods We analyzed Global Burden of Disease Study 2023 deaths from 29 pathogens in ages 0-19 years by super-region, combined with WHO/UNICEF Estimates of National Immunization Coverage (WUENIC) for PCV3 and Hib3. We quantified the spectrum transition under two denominators (26- and 29-pathogen calibers), constructed a share-by-intervenability matrix assigning each pathogen to a dominant intervention channel (vaccine-reachable, mixed, platform-sensitive) under explicit classification rules, compared platform-sensitive deaths with a transparently computed scenario of residual vaccine-preventable deaths, and cross-classified pathogens by age tropism and poverty lock. We anchored platform interventions to verified published evidence. Results The vaccine-preventable group share fell from 54.0% to 40.2% while the opportunistic/hospital group rose from 18.1% to 23.1% (29-pathogen caliber, 1990-2023). Super-region vaccine coverage showed no significant association with pathogen-share change (PCV3 Spearman rho = 0.108, p = 0.818; Hib3 rho = -0.036, p = 0.939), a null result we report as evidence that simple coverage-burden correlations do not hold at the regional level, not as evidence against vaccine value. In 2023, vaccine-reachable pathogens accounted for 441,410 deaths (45.7%, channel including COVID-19), mixed for 126,926 (13.1%), and platform-sensitive pathogens for 396,995 (41.1%). Platform-sensitive deaths were 2.9-5.1 times the scenario estimate of residual vaccine-preventable deaths (52,435-77,512). Nine of 14 classifiable pathogens fell into the poverty-locked, infant-tropic cell (480,922 deaths; Fisher OR = 9.0, p = 0.1758). Conclusions The marginal value of single-pathogen strategies declines as the spectrum diversifies and residual deaths concentrate in platform-sensitive, poverty-locked, infant-tropic pathogens. Vaccine scale-up remains a certain and sizeable opportunity; the next increment of marginal resources should increasingly fund platform capabilities (oxygen systems, antimicrobial access and stewardship, infection prevention and control, referral, and nutrition) delivered as a package to the populations where the residual burden is locked.

Background: Risk of recurrent overdose is elevated following non-fatal overdose (NFOD) survival; timely interventions may reduce this risk. The specific role of mental health care in reducing recurrence is relatively underexplored, and post-overdose care has seldom been examined for sex differences. This study examined sex differences in the association between mental health-related primary care contacts following NFOD and overdose recurrence risk among people in British Columbia (BC) with a documented depression diagnosis history. Methods: This was a nested case-control study using linked administrative health data from the Provincial Health Services Authority Platform for Analytics and Data. The source cohort (n=7,022) comprised BC residents with a history of a documented depression diagnosis between 2010-2014 and at least one NFOD between 2015-2024. Cases experienced a recurrent overdose within one year of their index overdose; controls were selected using incidence density sampling. Exposures were the presence and number of mental health related primary care contacts in the 30- or 90-day window following the index overdose. Conditional logistic regression models were used to estimate adjusted incidence rate ratios (aIRRs) and confidence intervals (CI), overall and by sex. Secondary analyses were conducted using psychiatrist contacts. Results: Mental-health related primary care contact rates were low, with only 16.3% and 28.1% of the cohort with any contact within 30 and 90 days, respectively. Mental health-related primary care contacts were more strongly associated with reduced recurrence risk in the 30-day window (any contact aIRR: 0.57 [CI: 0.46-0.71]) than in the 90-day window (aIRR: 0.78 [CI: 0.65-0.94]). Any contact within 30 days was more strongly associated with lower recurrence risk among males (aIRR: 0.53 [CI: 0.39-0.72]) than among females (aIRR: 0.67 [CI: 0.50-0.91]), whereas associations between the number of contacts and recurrence risk were similar for males and females. Any psychiatrist contact within 30 days was more strongly associated with lower recurrence risk among females (aIRR: 0.50 [CI: 0.34-0.73]) than males (aIRR: 0.70 [0.52-0.95]). Discussion: Mental health-related care contacts shortly following NFOD were associated with lower overdose recurrence risk among people with a documented depression diagnosis history, with modest sex differences that varied by provider type. Low rates of contacts overall suggest gaps in access to care following NFOD, particularly among males. Further research on sex differences in post-overdose care are warranted.

Background. Medical imaging is central to modern diagnosis and treatment, yet its contribution to population level survival has rarely been quantified, and the few existing estimates have been interpreted as evidence that imaging directly extends life. Whether national imaging utilisation reflects a distinct clinical mechanism or a broader process of health system development has not been formally tested. Methods. Longitudinal ecological panel study of 38 OECD countries, 2000 to 2024 (950 possible country years). CT and MRI availability and utilisation were linked to life expectancy at birth, treatable and preventable mortality, and seven cause specific mortality outcomes. Two-way fixed-effects models with country and year fixed effects and country clustered standard errors were adjusted sequentially for log GDP per capita, log health expenditure per capita, population aged [&ge;]65 years, physician density and smoking prevalence. Three falsification families were specified: lead-exposure (placebo) models regressing current life expectancy on future imaging utilisation; negative control exposures with no diagnostic-imaging pathway to survival; and wild cluster bootstrap inference. Results. In the principal adjusted model, CT utilisation at a three year lag was associated with higher life expectancy ({beta} = 0.85 years per 100 additional examinations per 1,000 inhabitants, 95% CI 0.16 to 1.54; cluster robust p = 0.015; bootstrap p = 0.034; n = 339, 29 countries). Scanner availability showed weaker, generally non-significant associations. All three falsification analyses failed to support a modality-specific effect. Future CT utilisation predicted current life expectancy as strongly as past utilisation (three year lead {beta} = 0.86, 95% CI 0.15 to 1.57, p = 0.017), consistent with high within-country autocorrelation of the exposure (r = 0.64 at three years). Radiotherapy equipment density, a therapeutic rather than diagnostic technology, showed an equal and more precise association ({beta} = 0.85 per 10 units per million, 95% CI 0.32 to 1.38, p = 0.0017), as did PET scanner density and health expenditure, whereas physician density showed none. Associations were stronger for preventable ({beta} = -43.3 per 100,000, p = 0.0002) than treatable mortality ({beta} = -13.5, p = 0.19), and all were attenuated to the null under country specific linear trends. Conclusions. National CT utilisation is a robust ecological correlate of life expectancy but does not behave as a causal determinant under falsification. It is best understood as a marker of health system capital development. Claims that imaging adds years of life are not supportable on ecological evidence of this kind.

We analyse the effect of waiting time for elective musculoskeletal treatment on labour market outcomes in England using hospital records for working-age adults who received treatment between April 2015 and March 2023 to Census, tax and benefit records. To address clinical prioritisation and unobserved severity, we leveraged provider-level waiting time as an instrument for individual waiting time and estimated two-stage least squares models adjusted for baseline labour market outcomes, demographic and socioeconomic characteristics, and provider, referral-time and procedure fixed effects. We find that longer waits reduce annual employee earnings, with effects persisting for up to five years. For an additional four weeks of waiting, the largest estimated annual losses range from {pound}301 for osteoarthritis to {pound}487 for other joint disorders. There was no evidence of effects on employment status or benefit receipt, suggesting that delays primarily operate through reduced productivity or hours worked among those who remain employed. Reducing waiting times may not only improve health outcomes but help patients maintain earnings and support economic

Unhealthy retail outlets, including liquor stores, bars, convenience stores, and fast food, are concentrated in lower-income neighbourhoods. This is a well-documented cross-sectional fact; the process that sustains it is not. A neighbourhood can hold more because more open there or because those already there survive longer, and these point to different responses. We assembled an establishment-level panel of every business in Rhode Island from 2016 to 2025 (480,923 geocoded establishment-years across nine annual cross-sections), following the same outlets year to year, and classified and counted unhealthy outlets by census tract. We estimated the tract income gradient three ways (negative binomial regression, a concentration index, and a Bayesian spatial model), tested its stability, and decomposed it into openings and closures. The gradient was strong, stable, and robust: about 30 percent fewer unhealthy outlets per resident per standard deviation of higher income, with racial composition and poverty no longer associated once income was included. It was reproduced through entry, not survival: closures were even-handed across income, while new unhealthy outlets opened about 2.2 times as often per resident in the lowest-income tracts as in the highest. This entry was not unhealthy-specific: new healthy food retail tilted toward lower-income tracts at least as strongly, and the unhealthy share of openings did not rise as income fell. The standing burden was nonetheless dominated by convenience stores and off-premise alcohol. Efforts to reshape the retail environment will have more leverage on new openings than on the existing stock, through instruments defined by outlet type.

Abstract Background: Having a usual source of care (USC) supports continuity and access to health services. Recent national trends among U.S. children have not been comprehensively characterized. We examined changes in USC prevalence, subgroup heterogeneity, and reported reasons for not having a USC using the 2015-2024 Medical Expenditure Panel Survey. Methods: We analyzed the 2015-2024 Medical Expenditure Panel Survey Household Full-Year Consolidated Data. Annual prevalence rates were estimated for children aged 0 to 17 years overall and by sex, age group, race and ethnicity, and insurance status. The reported reasons for not having a USC were grouped to low perceived need, preference or self-management, access or continuity barrier, and other reasons. The distribution of grouped reasons was analyzed for each study year. Temporal differences in yearly estimates were evaluated using two-sample z-tests between 2015 and 2019 and between 2015 and 2024, and average annual changes were estimated using generalized linear regression. Results: Overall USC prevalence declined from 92.9% (95% confidence interval [CI], 91.9%, 93.8%) in 2015 to 87.2% (95% CI, 85.1%, 89.2%) in 2024. The estimated average annual change was -0.8 percentage points (95% CI, -1.0 to -0.6). Declines were observed across most subgroups and were largest among uninsured children, whose prevalence decreased from 78.4% to 53.6%. Low perceived need remained the most common reported reason for not having a USC, while the proportion reporting access or continuity barriers decreased and the proportion classified as other reasons increased. Conclusions: Estimates based on the Medical Expenditure Panel Survey indicated a substantial decline in the prevalence of having a USC among U.S. children, with notable heterogeneity by insurance status and race and ethnicity. Further research is needed to determine whether the decline reflects changing access, organization and use of pediatric care, survey measurement, or a combination of these factors.

Background Respiratory infections remain the leading infectious cause of death among children and adolescents, yet the share of these deaths that could be averted with currently feasible care is not routinely quantified. Existing amenable-mortality frameworks rely on cause lists and population-level mortality benchmarks and do not exploit information on how many episodes occur. We propose an episode-fatality-ratio (EFR) frontier approach and apply it to lower respiratory infections (LRI), whooping cough (pertussis) and upper respiratory infections (URI) in 204 countries, 1990-2023. Methods For each cause, country and year we computed EFR = deaths/incident episodes using Global Burden of Disease (GBD) 2023 estimates for ages 0-19 years. The frontier was defined as the 10th-percentile country EFR within each GBD super-region, cause and year; avoidable deaths = max(0, deaths - episodes x frontier EFR). Primary estimates are deterministic; 95% uncertainty intervals (UIs) come from 2,000 Monte Carlo draws. Sensitivity analyses varied the frontier percentile, applied an aspirational global frontier, constructed pertussis counterfactuals, and recomputed all estimates within the single under-5 age band. Results In 2023, 333,803 childhood deaths from lower respiratory infections (95% UI 289,123-417,460; 46.9% of LRI deaths) were avoidable. Summing the three causes deterministically gives 391,034 avoidable deaths (46.5% of 840,444); the combined figure is a deterministic sum, and a UI is available for the LRI component only. The pertussis (43,958; 39.0%) and URI (13,273; 81.0%) estimates are secondary: their deterministic point values fall below their own Monte Carlo intervals and the underlying death estimates carry very wide uncertainty (global pertussis UI 12,545-321,874). Avoidable deaths fell from 1,050,468 (44.9%) in 1990, but between 2019 and 2023 the avoidable share for LRI+URI barely moved (48.7% to 47.7%) while absolute avoidable deaths fell 14.5%, a pattern consistent with stalled convergence to the frontier. Sub-Saharan Africa plus South Asia held 73.1% of avoidable deaths in 2023 versus 41.8% in 1990; ten countries accounted for 59.1%. Conclusion Nearly half of childhood respiratory-infection deaths remain avoidable relative to within-region best practice, and the residual burden is increasingly concentrated in low-income settings. In the pertussis counterfactual, most countries kept pace with their regional frontier, so further gains require advancing the frontier itself through quality-of-care improvements.

Importance: Preschool children in care are at high risk for psychosocial health concerns. Population-based evidence is limited. Objective: Estimate prevalence of psychosocial health concerns in children in care and not in care, and assess care-status differences stratified by deprivation. Design: Population-based cross-sectional study using 27-30 Month Health Review data from April 2013 to March 2023. Setting: Universal health review program in Scotland. Participants: 7887 children in care and 445 547 children not in care. Exposures: Care status at review, classified as in care or not. Main Outcomes and Measures: Four outcome categories (emotional, behavioral, and/or attentional; personal and/or social; speech, language, and/or communication; and other developmental concerns) plus an aggregate indicator of any of the four. We estimated adjusted odds ratios between children in care and not in care, including variation with deprivation. Models adjusted for sex, age, ethnicity, and deprivation. Results: Psychosocial health concerns were more common in children in care (2290; 29.0%) than children not in care (77 836; 17.5%; relative risk 1.66). Concerns were more common in children in care across all outcomes. The adjusted odds ratio comparing children in care with children not in care for any recorded concern was 1.86 (95% CI, 1.77-1.96). Adjusted odds ratios varied by outcome from 1.57 (95% CI, 1.49-1.66) for speech, language, and/or communication concerns to 2.49 (95% CI, 2.34-2.66) for emotional, behavioral, and/or attentional concerns. Relative inequities between children in care and not in care decreased with increasing deprivation from aOR of 1.58 (95% CI, 1.45-1.72) in the most deprived fifth of areas to 2.61 (95% CI, 2.25-3.03) in the least deprived fifth. Prevalence of any recorded concern increased with deprivation in both care groups. The relative risk comparing the most deprived with least deprived fifth of areas was 1.46 (95% CI, 1.29-1.66) among children in care and higher at 2.34 (95% CI, 2.29-2.40) among children not in care. Conclusions and Relevance: Psychosocial health inequities are evident at an early age between children in care and not in care, and vary with deprivation. Support for children in care and children living in more deprived areas should be prioritized.

Background Under-five mortality remains a major public health challenge in Zambia despite substantial reductions over recent decades. Demographic and Health Survey (DHS) data are commonly analysed using Cox proportional hazards models; however, violations of the proportional hazards assumption and unobserved cluster-level heterogeneity may compromise inference. This study compared advanced survival modelling approaches to determine the most appropriate framework for analysing under-five mortality using pooled Zambia DHS data. Methods We conducted a pooled secondary analysis of the 2018 and 2024 Zambia Demographic and Health Survey child recode datasets. The analysis included 9,982 children, among whom 266 died before their fifth birthday. A survey-weighted Cox proportional hazards model was fitted as the reference model and assessed using Schoenfeld residual diagnostics. To address identified methodological limitations, an extended Cox model, a shared-frailty model, and a Bayesian survival model were subsequently fitted. Model performance, assumptions, and the consistency of adjusted hazard ratio estimates were compared across modelling approaches. Results The global Schoenfeld test indicated violation of the proportional hazards assumption ({chi}2=51.26, p=0.002). In the adjusted extended Cox model, male children had higher mortality risk than females (aHR 1.95, 95% CI 1.40-2.73), while children with gestation [&ge;]9 months had lower mortality risk than those with shorter gestation (aHR 0.21, 95% CI 0.14-0.32). Average and large birth size were associated with lower mortality compared with small birth size (aHR 0.47, 95% CI 0.34-0.66 and aHR 0.57, 95% CI 0.39-0.84, respectively). Newborn health checks before discharge were associated with lower mortality (aHR 0.50, 95% CI 0.38-0.66), as was any antenatal care (aHR 0.25, 95% CI 0.09-0.75). A high-risk fertility pattern involving fourth or higher births with an interval [&ge;]24 months was also associated with lower mortality (aHR 0.57, 95% CI 0.41-0.80). The shared-frailty model produced similar estimates, including increased mortality among male children (aHR 1.39, 95% CI 1.08-1.78) and twins or multiple births (aHR 2.74, 95% CI 1.36-5.53). Bayesian estimates were broadly consistent with the extended Cox model. Conclusions Advanced survival models provided a more robust analytical framework than the conventional Cox model for evaluating under-five mortality in nationally representative DHS data. While the extended Cox model accommodated time-varying effects, the shared-frailty model captured unobserved cluster-level heterogeneity, and the Bayesian model confirmed the stability of parameter estimates. Incorporating these complementary approaches can improve the validity of survival analyses and strengthen evidence for child survival research and policy in low- and middle-income settings.

Introduction. By the end of 2023, many low-income countries had not reached 50% COVID-19 vaccine coverage, while most high-income countries had exceeded 80%. It remains unclear whether receiving vaccine deliveries translated into faster population coverage. We examined cross-national inequalities in the timing of the vaccine rollout and whether deliveries through the COVID-19 Vaccines Global Access (COVAX) facility were associated with subsequent national uptake. Methods. We conducted an observational study of 218 countries and territories using country-level data up to December 2023. We used generalized additive mixed models to identify country-level correlates of coverage at an early and a later stage of the pandemic, survival analysis to compare the time to 50% coverage between COVAX Advance Market Commitment (AMC) and non-AMC countries, and an event study to estimate the association between the timing of the first COVAX delivery and subsequent monthly coverage in AMC countries. Results. AMC-supported countries reached 50% coverage substantially more slowly than non-AMC countries. The hazard of reaching the threshold was 0.17 times that of non-AMC countries at month 1 (95% CI 0.07 to 0.41) and 0.53 times at month 18 (95% CI 0.33 to 0.85). One year after rollout began, 65.9% of AMC countries (95% CI 56.7 to 76.6) had not reached 50% coverage, compared with 21.1% of non-AMC countries (95% CI 15.1 to 29.5). The timing of COVAX deliveries was not significantly associated with subsequent national uptake in any post-delivery month. In the early stage of rollout, higher maternal mortality was associated with lower coverage, while a larger urban population was associated with higher coverage. By the end of the observation period, larger household size was associated with lower coverage, while higher health expenditure and a larger urban population were associated with higher coverage. Conclusion. Receiving COVAX deliveries was not, on its own, associated with faster coverage. Coverage differences were more consistently associated with country-level structural and health-system characteristics, while we found no significant association with the timing of the first COVAX delivery. Achieving vaccine equality likely requires strengthening the capacity of health systems to convert deliveries into administered doses, and preparedness efforts should invest in last-mile delivery capacity ahead of future emergencies.