Key Points Question Is neighborhood-level violence associated with incidence of major depressive disorder (MDD) during and after armed conflict? Findings In a cohort study including 10 623 participants within 151 neighborhoods in Nepal, the occurrence of 2 or more beatings within 1 km was associated with incidence of MDD in those who were children at the start of the armed conflict (MDD incidence, 12.69% vs 5.08% in a matched unexposed sample), but not for older individuals. Meaning Because the youngest children may be the most at risk during times of violence, with mental health consequences lasting long after conflict has subsided, they should be prioritized for population-level interventions.

Objectives To identify social and structural barriers to timely utilisation of qualified providers among children under five years in a high‐mortality setting, rural Mali and to analyse how utilisation varies by symptom manifestation. Methods Using baseline household survey data from a cluster‐randomised trial, we assessed symptom patterns and healthcare trajectories of 5117 children whose mothers reported fever, diarrhoea, bloody stools, cough and/or fast breathing in the preceding two weeks. We examine associations between socio‐demographic factors, symptoms and utilisation outcomes in mixed‐effect logistic regressions. Results Almost half of recently ill children reported multiple symptoms (46.2%). Over half (55.9%) received any treatment, while less than one‐quarter (21.7%) received care from a doctor, nurse, midwife, trained community health worker or pharmacist within 24 h of symptom onset. Distance to primary health facility, household wealth and maternal education were consistently associated with better utilisation outcomes. While children with potentially more severe symptoms such as fever and cough with fast breathing or diarrhoea with bloody stools were more likely to receive any care, they were no more likely than children with fever to receive timely care with a qualified provider. Conclusions Even distances as short as 2–5 km significantly reduced children’s likelihood of utilising healthcare relative to those within 2 km of a facility. While children with symptoms indicative of pneumonia and malaria were more likely to receive any care, suggesting mothers and caregivers recognised potentially severe illness, multiple barriers to care contributed to delays and low utilisation of qualified providers, illustrating the need for improved consideration of barriers.

Individual-level social support protects against major depressive disorder (MDD) among adults exposed to trauma. Little is known about the consequences of community-level interventions in the general population.OBJECTIVE To determine the potential consequences of neighborhood social infrastructure on incident MDD in a high-risk general population. DESIGN, SETTING, AND PARTICIPANTSThis longitudinal, multilevel study estimated associations between a neighborhood-level program in a case-control design and subsequent individual outcomes across 10 years (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015) in a cohort of young adults. Exogenously placed social programs simulate natural experiment conditions in a high-poverty population experiencing armed conflict (1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006). The western Chitwan valley in Nepal has a general population at high risk of MDD, with neighborhoods exposed to interventions to improve social support. From a random sample (response rate 93%) selected to represent the general population in 2016, participants aged 25 to 34 years in 2006 were studied. These individuals resided within 149 neighborhoods that varied in their availability of active social support programs. The analyses were conducted between October 2020 and November 2021.EXPOSURES The Small Farmers Development Program (SFDP) uses shared, joint liability financial credit among neighbors to build social capital and cohesion within neighborhoods. MAIN OUTCOMES AND MEASURES Onset of DSM-IV MDD after the conflict, assessed by the Nepal-specific, clinically validated World Mental Health Composite International DiagnosticInterview with a life history calendar. The hypothesis tested was that exposure to SFDP reduced adult onset of MDD. RESULTSOf the 1917 survey participants, 886 (46.2%) were women, and 856 (44.7%) were of Brahmin or Chhetri ethnicity. Of the 149 neighborhoods, 21 had an active SFDP group, and 156 of 1917 (8.1%) participants experienced MDD between 2006 and 2015. Discrete-time hazard models showed participants living in neighborhoods with an SFDP experienced incident MDD at nearly half the rate as others (odds ratio = 0.55; 95% CI, 0.30-1.02; P = .06). A multivariate, multilevel matching analysis showed the incidence of MDD among adults living in neighborhoods with an SFDP was 19 of 256 (7.4%), compared with 33 of 256 (12.9%) in the matched sample with no SFDP (z = 2.05; P = .04). CONCLUSIONS AND RELEVANCELiving in a neighborhood with community-level social support infrastructure was associated with reduced subsequent rates of adult-onset MDD, even in this high-risk population. Investments in such infrastructure may reduce population-level MDD, supporting clinical focus on potentially unpreventable cases.