Participants who continue across the full duration of longitudinal studies often differ from those lost to attrition, defined as discontinuing participation for any reason, and some participants may sporadically miss assessments. Complex participation patterns, such as in multicenter chronic disease cohorts, have not been studied. We aimed to implement an approach to identify participation subgroups and factors associated with theses. We applied our approach in the SPIN Cohort, a multicenter, longitudinal systemic sclerosis (SSc) cohort, because it is an example of an open-ended cohort with no planned end date and complex participation patterns. We used group-based trajectory modeling to identify participation subgroups and multinomial logistic regression to identify predictors of subgroup membership. Data were obtained for 2883 participants from 54 sites in 7 countries. We identified 5 participation subgroups: Ongoing Participation (29%), Immediate Attrition (29%), Mid-Term Attrition (19%), Long-Term Attrition (12%), and Ongoing Sporadic (11%) participation. Older age and sites outside the United States were associated with lower odds of belonging to all subgroups other than Ongoing Participation. Compared to Ongoing Participation, several sociodemographic variables were associated with higher odds of being in the Immediate Attrition group. Our method can be applied to other cohorts with complex participation patterns.
As one of the most disruptive life events, layoffs are pervasive in the US labor market, while little is known about cumulative layoff experience across adulthood in relation to subsequent cognitive function. We investigated the association between cumulative layoffs spanning over 41 years of adulthood and subsequent domain-specific cognition among US working-age adults. Data were from 6421 adults in National Longitudinal Survey of Youth 1979. Cumulative layoff experience was defined as the number of jobs ending in a layoff from 1979-2020: zero (never, n = 4503), one (n = 1402), and ≥ two (n = 516). Domain-specific latent cognitive factor scores were assessed in 2020 using confirmatory factor analysis. Multivariable-adjusted linear regression models were fit to investigate the association of interest. Results suggest that cumulative layoff experience was associated with lower latent factor scores in episodic memory (β = -0.045, 95% CI: -0.100 to 0.010, one layoff vs. never; β = -0.086, 95% CI: -0.171 to -0.001, ≥two layoffs vs. never; P trend 0.037), but not in attention, orientation, or language domains. Given its ubiquity in the US labor market, layoffs may represent an important and understudied risk factor for episodic memory function among US adults.
We investigated combinations of preterm birth, preeclampsia and offspring birthweight by gestational age in a first pregnancy and cross-over risk of gestational diabetes mellitus (GDM) in second pregnancy. The Medical Birth Registry of Norway provided data for 561 873 mothers with first and second births without diabetes prior to second pregnancy, 1985-2020. We combined first pregnancy preterm birth (<37 weeks), preeclampsia and birthweight by gestational age quartiles (Q1-4) into one exposure (16 categories). Relative risks with 95% confidence intervals for GDM in second pregnancy were estimated, keeping mothers with first term birth without preeclampsia and offspring in Q1 as reference. Women with first offsprings in Q4 had high risk of subsequent GDM, however, in combinations with preterm birth and preeclampsia the risk of GDM progressively increased: Compared to 0.9% GDM risk in the reference group, the risk increased to 1.8% for Q4 term births without preeclampsia (aRR 2.1 [95% confidence interval 2.0-2.3]), 2.5% for Q4 preterm births without preeclampsia (aRR 3.3 [2.8-3.8]), 4.2% for Q4 term birth with preeclampsia (aRR 5.6 [4.8-6.4]) and 7.8% for Q4 preterm birth with preeclampsia (aRR 10.1 [7.4-13.7]). Combinations of first pregnancy exposures were associated with a progressive cross-over risk of GDM in second pregnancy.
This essay examines the evolving relationship between public health expertise and politics in the United States, focusing on the emergence of state advisory boards during and after the COVID-19 pandemic. While public health decision-making has always involved political trade-offs, recent developments reflect a more direct politicization of federal institutions, including changes in advisory committee composition, constraints on scientific autonomy, and declining public trust. In response, several states have created independent advisory bodies to review federal guidance and guide vaccination policy. This article draws on examples from the Western States Scientific Safety Review Workgroup and a state vaccine advisory committee in Connecticut. These initiatives represent an important institutional adaptation to contested federal expertise. However, the latest proliferation of state advisory structures may also fragment scientific authority, complicate coordination during emergencies, and introduce new challenges for accountability and equity. The growing role of state-level expertise reveals the emergence of a more polycentric form of public health governance, raising questions about how scientific authority is organized, trusted, and contested in an era of political polarization. (Am J Public Health. Published online ahead of print September 3, 2026:e1-e7. https://doi.org/10.2105/AJPH.2026.308661).
Objectives. To describe challenges and lessons learned during state and local health department responses to the 2024‒2025 highly pathogenic avian influenza A(H5N1) outbreaks. Methods. We conducted semistructured interviews from August to November 2025 with Department of Health and Agriculture staff from states with confirmed or probable A(H5N1) human cases. We conducted 15 total interviews with 37 participants from 10 US states. Interview transcripts were inductively and deductively coded to identify generalizable lessons that might improve future outbreak response efforts. Results. Key themes included difficulty accessing farms and reaching at-risk populations; lack of sufficient guidelines for proactively responding to zoonotic outbreaks that could have human health implications; the importance of maintaining preparedness planning, capacity, and infrastructure; and uncertainty around future capacity to respond to outbreaks because of resource constraints and changes in federal leadership. Conclusions. Although this study focused on responses to A(H5N1) outbreaks, the findings are indicative of the nation's overall readiness for biological threats. Prioritization of capacity building for infectious disease outbreaks, including robust health department funding to support continued disease surveillance, is critical to prevent more widespread transmission. (Am J Public Health. Published online ahead of print September 3, 2026:e1-e7. https://doi.org/10.2105/AJPH.2026.308656).
Objectives. To assess the association between low perceived neighborhood safety and loneliness. Methods. We used data from the Social Determinants of Health and Health Equity module of the 2024 Behavioral Risk Factor Surveillance System (BRFSS). The sample included 317 320 respondents from 35 US states. Using logistic regression, we estimated the association between low perceived neighborhood safety and feelings of loneliness after adjustment for demographic characteristics, social support, living alone, diagnosis of depressive disorder, urbanicity, and state of residence. Results. The findings showed that low perceived neighborhood safety is associated with higher odds of loneliness. In comparison with adults who felt extremely safe in their neighborhoods, the adjusted odds ratios for feeling lonely were 1.06 among those who felt safe (95% confidence interval [CI] = 0.96, 1.16), 1.38 among those who felt unsafe (95% CI = 1.17, 1.62), and 1.68 among those who felt extremely unsafe (95% CI = 1.24, 2.27). Conclusions. Low perceived neighborhood safety is a key place-based correlate of loneliness. Improving neighborhood safety may represent an important, and potentially overlooked, pathway through which place-based conditions contribute to loneliness and related health risks. (Am J Public Health. Published online ahead of print September 3, 2026:e1-e4. https://doi.org/10.2105/AJPH.2026.308677).
Objectives. To assess trends in prenatal syphilis screening and treatment in the United States and evaluate newborn syphilis screening. Methods. We conducted a retrospective cohort study using Medicaid (2014-2021) and commercial insurance claims (2010-2023). We assessed syphilis screening by trimester, repeat screening (> 1 trimester), temporal trends, treatment with benzathine penicillin G or nonrecommended antibiotics, and screening of infants born to pregnancies diagnosed with syphilis within 30 days of birth. Results. Syphilis screening occurred in 75.2% of Medicaid-insured and 92.8% of commercially insured pregnancies; 51.8% and 81.7%, respectively, were screened in the first trimester. Screening increased in Medicaid (67.6% to 80.5%) and remained high in the commercially insured cohort (91.0% to 94.0%). Repeat screening more than doubled in both cohorts. Approximately half of pregnancies diagnosed with syphilis had evidence of benzathine penicillin G treatment, whereas 5% to 6% had evidence of nonrecommended antibiotics. Infant screening was rarely identified, likely reflecting incomplete capture in claims data. Conclusions. Prenatal syphilis screening in the United States may fall short of recommendations, although increasing repeat screening is encouraging progress. (Am J Public Health. Published online ahead of print September 3, 2026:e1-e10. https://doi.org/10.2105/AJPH.2026.308657).
This essay explores the global antiscience phenomenon, characterizing the rapid spread of misinformation as an "infodemic" linked to rising social and political opposition. To address this growing threat to global public health, it applies a transdisciplinary framework integrating complexity and syndemic theories to analyze the public health science enterprise. The evidence suggests that antiscience activism operates as a complex adaptive system, fueled by nonlinear social interactions and emotional narratives on internet-mediated platforms. Widespread breakdowns in bidirectional science-society communication and sociopolitical disparities interact synergistically to exacerbate adverse health outcomes, functioning as an information syndemic. To counteract these forces, public health strategies must move beyond the traditional "deficit model" of one-way messaging. Potential solutions include adopting targeted media campaigns, employing cognitive inoculation strategies, promoting widespread media literacy, and training a new generation of scientists to engage in two-way dialogues with the public. (Am J Public Health. Published online ahead of print September 3, 2026:e1-e9. https://doi.org/10.2105/AJPH.2026.308672).
This study examined changes in COVID-19-related death certification practices (ie, reporting COVID-19 in Part I of the death certificate) and the quality of cause-of-death (COD) reporting (acceptable and rejected causal sequences) in the United States from 2020 to 2023. In 2020, 2021, 2022, and 2023, 385 293, 463 273, 246 196, and 76 024 death certificates, respectively, mentioned COVID-19. COVID-19 was selected as the underlying COD in 91%, 90%, 76%, and 65% of these certificates, corresponding to reporting COVID-19 in Part I in 93%, 91%, 78%, and 67% of certificates, respectively. Acceptable causal sequences were reported in 51%, 51%, 45%, and 41% of certificates, whereas rejected causal sequences were reported in 21%, 22%, 23%, and 23%, respectively. Using 2020 as the reference year, the adjusted odds ratios (95% confidence intervals) for 2023 were 0.18 (0.18, 0.18) for reporting COVID-19 in Part I, 0.77 (0.76, 0.78) for reporting acceptable causal sequences, and 1.14 (1.12, 1.16) for reporting rejected causal sequences. In conclusion, COVID-19-related death certification practices changed substantially over the study period, paralleling the decline in the virulence of SARS-CoV-2. The quality of COVID-19-related COD reporting declined modestly from 2020 to 2023.
The COVID-19 pandemic led to stay-at-home orders, resulting in sudden changes in movement patterns and social restrictions that impacted mental health. This study examined changes in individual behaviors during the pandemic using detailed smartphone-based activity data and determined whether behaviors and green space exposure buffered against mental health concerns. A total of 224 twins from the Washington State Twin Registry provided smartphone location data and completed a baseline survey and up to seven waves of follow-up surveys on mental health outcomes (ie, anxiety, depression, and stress). Objective measures of activities, locations, and time spent in green space were collected using Google Location History. Green space exposures were assessed using all location data. Associations between activities, locations, green space, and each mental health outcome were assessed using linear mixed models. There were changes in activities and locations from baseline to wave 1; by wave 7, the direction and magnitude of changes varied across measures, with some remaining above and others below their baseline levels. Mental health outcomes were associated with a subset of locations, activities, and green space measures although associations were not observed consistently across all exposure-outcome combinations examined.
BACKGROUND:Despite the association between lower perceived neighborhood social cohesion (PNSC) and higher risk of hypertension, there is limited research on this relationship. This population-based study examined the association between PNSC and incident hypertension among a nationally representative population of older adults across racial and/or ethnic groups and sex. METHODS:Data were obtained from 2,998 US older adult participants (mean age=62.5 years, SD=8.12) from the Health and Retirement Study. Normotensive participants at baseline (2006 or 2008) were assessed for hypertension incidence at 4- and 8-year follow-up visits. PNSC was classified into tertiles. Weighted Cox proportional hazards regression was used to estimate the association between PNSC and incident hypertension. Interaction terms (PNSC and racial and/or ethnic group, PNSC and sex) were included in models adjusted for appropriate covariates (sex, racial and/or ethnic group, education, body mass index, alcohol use, cigarette smoking status), and models were stratified by racial and/or ethnic group and sex. RESULTS:Overall, 40.5% of the study population developed hypertension. Low perceived neighborhood social cohesion (versus high) was associated with increased hypertension risk (HR=1.22, 95% CI: 1.08-1.37). This association was the strongest among Black adults (HR=2.28, 95% CI: 1.23-4.25) and Black females (HR=3.40, 95% CI: 1.34-8.62), though the interaction terms were not statistically significant (p-values for interaction >0.05). CONCLUSIONS:Individuals perceiving low neighborhood social cohesion may have increased hypertension risk, particularly among Black females. Future studies could test potential underlying mechanisms that explain this association and implement community-based interventions promoting cohesive communities as a potential strategy for reducing disparities in hypertension risk.
Depression analyses in UK Biobank may be affected by selection bias due to incomplete participation in the optional Mental Health Questionnaire. We used one-sample Mendelian randomization (MR) to assess the causal effects of BMI, educational attainment (EA), and CRP on depression, applying inverse probability of selection weighting (IPW) and the instrumental variable for selection (IVsel) to adjust for selection into the MHQ sample. Sensitivity analyses included the use of psychiatrist consultation as a proxy outcome. MR analyses indicated that higher BMI increased the risk of depression (OR=1.09 [1.05, 1.13]), EA was protective (OR=0.81 [0.75, 0.88]), and there was limited evidence that CRP affected depression (OR=1.01 [0.92, 1.10]). Estimates obtained using IPW and IVsel were broadly consistent, although with IVsel estimates closer to the null, within BMI (ORIPW = 1.10 [1.05, 1.15], ORIVsel = 1.04 [1.02, 1.06]), EA (ORIPW = 0.81 [0.74, 0.88], ORIVsel = 0.93 [0.90, 0.96]) and CRP (ORIPW = 1.03 [0.92, 1.15], ORIVsel = 1.00 [0.97, 1.04]). Proxy outcome analyses suggested similar patterns of selection bias, supporting their utility for assessing potential bias in MHQ-restricted analyses. Bias-adjustment methods and sensitivity analyses provide a framework to assess the impact of selection bias in large cohort studies with optional components.
BACKGROUND:To assess the long-term (12-month) effects of computerized cognitive stimulation versus stimulating leisure activities in adults with subjective cognitive impairment (SCI) and mild cognitive impairment (MCI). METHODS:A 12-month follow-up of a single-blind randomized controlled trial was conducted in primary care centres in Zaragoza, Spain, including 50 adults aged = 50 years with SCI or MCI. Participants were allocated to one of three groups: the computerized cognitive stimulation group (IG1, n=18), the stimulating leisure activities group (IG2, n=16), or a control group (CG, n=16). The primary outcome was global cognitive function; secondary outcomes included memory, verbal fluency, activities of daily living, and mood. Effect sizes were calculated using bootstrapped partial eta-squared (?2p) Results. At 12 months, significant between-group differences were observed in depressive symptoms according to the GDS-15 score (p = 0.005, ?2p = 0.209) and anxiety levels measured by the Goldberg Index score (p < 0.001, ?2p = 0.295). Both intervention groups (IG1 and IG2) showed sustained improvements in depressive symptoms, while anxiety levels remained stable in the intervention groups and worsened in the CG. CONCLUSIONS:Participation in computerized cognitive stimulation or stimulating leisure activities associates with sustained, long-term improvements in depressive symptoms and levels of anxiety, supporting the effectiveness of non-pharmacological interventions in primary healthcare.
Using data from 4549 US adults in a national cohort and a difference-in-differences design, we estimated the average treatment effect on the treated to assess whether receiving tests from COVIDTests.gov-a free, direct-to-household program launched in January 2022-increased testing for severe acute respiratory syndrome coronavirus 2. Receiving tests was associated with a 13.8-percentage-point testing increase in March 2022 (95% confidence interval = 3.3, 24.2), the only estimate robust to pretrend sensitivity adjustments, with later effects attenuating. Participation was lower among groups with greater health risks and access barriers. (Am J Public Health. Published online ahead of print August 20, 2026:e1-e5. https://doi.org/10.2105/AJPH.2026.308527).
Objectives. To examine whether receipt of public assistance among pregnant populations moderates the association between economic stress and prenatal substance use. Methods. The HEALthy Brain and Child Development (HBCD) Study is a 27-site ongoing US longitudinal cohort investigation. We analyzed 2023-2024 data from 1422 pregnant participants who completed their first HBCD visits. We used logistic regression to examine the association between economic stress and substance use (alcohol, tobacco, opioids, cannabis) during pregnancy, stratified by number of public assistance programs from which participants received benefits. Results. Economic stress was positively associated with substance use (odds ratio [OR] = 1.41; 95% confidence interval [CI] = 1.33, 1.50). This relationship was strongest among participants with no public assistance (OR = 1.25; 95% CI = 1.05, 1.44) and remained positive in the low- and medium-assistance groups; however, it was negative in the highest receipt category (OR = 0.70; 95% CI = 0.50, 0.97). Conclusions. Our findings suggest that increased receipt of public assistance corresponded to a weaker association between economic stress and substance use during pregnancy. Public Health Implications. Reduced access to safety-net programs may compound economic stressors related to prenatal substance use, with potential downstream implications for maternal and child outcomes. (Am J Public Health. Published online ahead of print August 20, 2026:e1-e10. https://doi.org/10.2105/AJPH.2026.308628).
