International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091207

Authors: Fadzai Chikwava Reinie Cordier Anna Ferrante Melissa O’Donnell

Despite extensive research on the risks faced by young people in out-of-home care, population-level evidence on how mental disorders develop and diverge through childhood, adolescence, and early adulthood remains limited. This study addresses this gap by modelling developmental trajectories across internalising, externalising, and psychotic domains. This retrospective population-based study examined developmental trajectories of internalising, externalising, and psychotic disorders among 414,746 young people born in Western Australia between 1993 and 2008. Using linked administrative data, group-based trajectory modelling was applied to compare young people with out-of-home care (OHC) experience, those with child protection (CP) contact but no OHC experience, and those with no CP contact. Two distinct trajectory groups were identified across all mental disorder types, based on participants with at least one recorded mental health episode. Most young people followed low stable mental disorder trajectories, while a smaller subgroup (fewer than 10% or slightly above 10% for psychotic disorders) showed elevated, increasing trajectories over time, with more pronounced escalation among those with OHC exposure, reflecting concentrated and complex developmental risk. These higher-risk trajectories reflected developmental variation in timing and severity, including earlier escalation of internalising and externalising disorders and later emergence of psychotic disorders. Factors associated with higher-risk trajectories included socio-demographic disadvantage, placement characteristics, and substance misuse. These findings indicate that mental health risk among young people with child protection involvement is not uniform but concentrated within particular model-derived developmental trajectory groups. Population-level linked data can enhance understanding of developmental mental health risk and support timelier, targeted, and integrated child protection, mental health, housing, and substance misuse responses.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091206

Authors: Nan Ei Moh Moh Kyi Tipsuda Pintakham Muhammad Samar Muhammad Naeem Rashid Surat Hongsibsong Kanokwan Kulprachakarn Anurak Wongta

Pesticide contamination in fruits and vegetables remains a critical food safety concern in Northern Thailand, posing risks to environmental and human health. Improving knowledge, attitude, and behavior (KAB) in food safety is essential for reducing pesticide exposure, particularly among migrant workers. This cross-sectional study evaluates food safety knowledge, attitude, behavior, and pesticide exposure among Myanmar migrant workers in Chiang Mai Province. Face-to-face interviews were conducted with 137 participants between August and September 2025 in Mueang, Mae Rim, and San Sai districts. Mann–Whitney U test and linear regression were used to explore demographic differences and associated factors of knowledge, attitude, and safety behavior. Most participants demonstrated adequate knowledge (65.7%) and positive attitude (80.3); however, 78.1% reported only moderate safety behavior. Higher knowledge and more favorable attitudes were observed among non-Shan ethnic groups and participants with higher education (p < 0.001). Women and non-farming workers exhibited significantly safer behavior (p < 0.05). Knowledge and attitude were strongly correlated (ρ = 0.556, p < 0.01), but neither was associated with safety behavior. Most participants had cholinesterase activity within the normal reference range (73.0% cellular AChE; 81.0% plasma BChE). Low enzyme activity was observed in 13.9% and 6.6% of participants, respectively. Enzyme activity did not differ significantly by occupation, sex, or ethnicity and was not significantly associated with KAB scores. Linear regression analyses identified ethnicity as significantly associated with knowledge and attitude; whereas, sex and occupation were significantly associated with safety behavior. These findings suggest that individual-level knowledge and attitude may not be sufficient to drive protective behavior among migrant workers, though the cross-sectional study design limits causal inference and generalizability.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091205

Authors: Cleomar Ana de Souza Valentim Ademir Alves de Melo Thiago Costa Florentino André Silva Valentim Marília Jesus Batista

Objective: We aimed to analyze factors associated with body mass index and nutritional status, including oral health, among older adults in Primary Health Care. Methods: We conducted a cross-sectional study of community-dwelling older adults aged ≥ 60 years, selected from five Health Units in a Brazilian city. A questionnaire was applied to collect the following data: sociodemographic data, anthropometric status assessed by Body Mass Index (BMI) (weight and height), oral health (number of teeth and self-perceived chewing ability: good, fair, or poor), cognition assessed using the 10-Point Cognitive Screener (10-CS), nutritional status using the Mini Nutritional Assessment (MNA), health literacy using the 14-item Health Literacy Scale (HLS-14), sarcopenia risk using the SARC-F questionnaire plus calf circumference (SARC-F + CC), and frailty using the Clinical Functional Vulnerability Index-20 (CFVI-20). The outcomes were Body Mass Index (BMI)-defined anthropometric status, dichotomized as non-excess weight (underweight/normal weight) vs. excess weight (overweight/obese), and nutritional status assessed by the Mini Nutritional Assessment (MNA), dichotomized into normal nutritional status vs. nutritional risk or malnutrition. Descriptive, bivariate (Chi-square test), and multiple binary logistic regression analyses were performed for each outcome (p < 0.05). Results: A total of 211 older adults participated in the study. The sample was 72% female, with a mean age of 70.41 (±7.45) years. In the adjusted regression analysis, the use of four or more medications (OR = 2.12; 95% CI: 1.08–4.17), sedentary behavior (OR = 3.09; 95% CI: 1.58–6.04), and absence of sarcopenia risk (OR = 4.99; 95% CI: 2.02–12.34) were associated with higher odds of overweight/obesity. Conversely, usual attendance at the neighborhood PHC unit (OR = 0.23; 95% CI: 0.07–0.72) and possible cognitive impairment (OR = 0.30; 95% CI: 0.08–0.98) were inversely associated with overweight/obesity. Nutritional risk or malnutrition was associated with edentulism (OR = 2.10; 95% CI: 1.05–4.23), poor chewing ability (OR = 2.48; 95% CI: 1.06–5.82), fair chewing ability (OR = 2.88; 95% CI: 1.29–6.47), and the presence of feelings of discouragement, sadness, or hopelessness (OR = 3.52; 95% CI: 1.78–6.96). Among participants with overweight/obesity, 28.4% were also classified as being at nutritional risk or malnourished according to the MNA. Conclusions: Among older adults in Primary Health Care, nutritional risk or malnutrition was associated with oral health and psychosocial characteristics, whereas overweight/obesity was associated with distinct clinical, healthcare-use, behavioral, cognitive, and functional characteristics, even after adjustment for sociodemographic, clinical, functional, and psychosocial characteristics. These findings support the importance of comprehensive multidisciplinary assessment and care to address the heterogeneous and coexisting nutritional challenges of aging.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091203

Authors: Pedro Stringelli-Brandão Fabrício Anibal Corradini Gilberto de Araújo Pereira Wellington Roberto Gomes de Carvalho Sybelle de Souza Castro

This study assessed the geographic, demographic, and temporal factors underlying the evolution of the HIV/AIDS epidemic across the health macroregions of Minas Gerais, Brazil, comparing the periods before (2009–2014) and after (2015–2022) the implementation of universal HIV notification and immediate antiretroviral therapy (ART). An ecological study was conducted using statewide surveillance and clinical monitoring databases. Epidemiological indicators, including HIV detection, AIDS incidence, AIDS-related mortality, ART coverage, and sustained viral suppression (SVS), were analyzed according to sex and health macroregion using generalized linear models with negative binomial regression and spatial analysis. HIV detection increased markedly following the expansion of mandatory notification, while ART coverage and SVS also increased significantly. In contrast, AIDS incidence and AIDS-related mortality declined during the later period. Substantial heterogeneity was observed across macroregions, with important differences in epidemiological indicators and HIV care cascade performance. These findings demonstrate that the benefits of expanded HIV detection and universal ART have not been distributed uniformly across the state. Regional disparities in access to diagnosis, treatment, and long-term care remain important barriers to HIV control, highlighting the need for targeted, region-specific public health strategies to reduce territorial inequalities and strengthen the HIV care cascade.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091204

Authors: Claudia L. Leung Priscilla Kukua Goka Ishmael Adu Barnabas Atangongo Rashid Atchulo Mansur Mohammed Musah Bingle Laud Boateng Keng-Yen Huang Neda Laiteerapong Anna Volerman Peter Mintir Amadu William Frank Hill Koomson

Adolescent mental health is a high priority in low- and middle-income countries (LMICs), yet perspectives may differ among youth and adult providers responsible for supporting mental health within schools. These differences may create challenges for designing contextually appropriate school-based preventive strategies. This qualitative study compared adolescent and school guidance and counseling coordinator (GCC) perspectives on factors influencing adolescent mental health and support in all 12 public senior high schools in Tamale, Ghana. GCC data were collected through semi-structured interviews informed by the Consolidated Framework for Implementation Research, and adolescent data was through human-centered design workshops. Data were analyzed using rapid qualitative analysis and organized using the Social Ecological Model. At the individual level, adolescents linked emotional distress, stress, and substance use to mental health challenges, whereas GCCs more commonly framed these as behavioral or academic challenges. At the interpersonal level, both groups identified peer relationships and confidentiality as important influences on help-seeking; adolescents emphasized trusted peer relationships, while GCCs described challenges implementing peer counseling approaches within schools. At the organizational level, adolescents emphasized teacher attitudes and punitive school responses to student distress, while GCCs emphasized staffing shortages, limited infrastructure, and insufficient institutional support. At the community level, both groups identified stigma and gendered social norms as barriers to mental health support. Adolescents and GCCs identified similar concerns but differed in how they understood adolescent mental health and support within schools. Integrating both youth and provider perspectives may strengthen multilevel school-based preventive strategies in resource-constrained settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091202

Authors: Rebekah Graham Louise Were Marcia Ranginui Charlton Trisha Benge

Parenting programs in Aotearoa New Zealand are typically designed by and for non-Indigenous parents of non-disabled children, yet are routinely promoted to all families, including Māori (the Indigenous people of Aotearoa) and families of disabled children, despite limited cultural relevance. This paper describes and discusses the co-creation of a culturally responsive program for whānau (families) of a disabled child, undertaken over three years using a participatory, culturally informed approach. Drawing on key practices from te Ao Māori (the Māori worldview)—including whakawhanaungatanga (relationship building), tuakana-teina (peer-to-peer support), and koha atu koha mai (reciprocity)—the team developed and iteratively tested a wānanga-style program across three stages of development (foundation building, program drafting, and program testing). Evaluation data was collected from participants (n = 16), facilitators (n = 3), and authors, using anonymous online surveys (participants, facilitators), in-person discussion (facilitators), and reflective observation (authors). Data analysis was pragmatic and participatory in design, prioritizing collective sense-making. Findings indicate that whānau highly valued dedicated time for wellbeing reflection, culturally grounded content (particularly the Whiti Te Rā wellbeing model), peer connection, and practical supports such as on-site childcare. The paper reflects on the intentionality required for working together, including the need to center Māori knowledge, flatten power dynamics, and slow down program development to prioritize relationship over output. This work contributes to community psychology and public health scholarship as an example of decolonial, anti-racist practice in community health program design. This paper offers a template for how culturally responsive, co-created program design and delivery can work in practice.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091201

Authors: Nipakorn Nanta Pongthorn Chanlearn Kriengkrai Srithanaviboonchai Arunrat Tangmunkongvorakul Suchada Thaweesit Sulaiporn Chonwilai Niwat Suwanphatthana Karoline Soerensen Patchara Benjarattanaporn Lucy R. Stackpool-Moore

Background: HIV-related stigma and discrimination remain barriers to equitable HIV prevention, treatment, and well-being in Thailand despite their longstanding inclusion in the national HIV response. This study examined contemporary experiences of stigma and discrimination among people living with HIV. Methods: The people living with HIV Stigma Index 2.0 was a community-led mixed-methods study conducted from August 2022 to January 2023. The quantitative survey enrolled 2508 people living with HIV from 24 provinces covering all 13 health regions, including general adults living with HIV, four key population groups, migrant workers, and young people. A nested qualitative study included 174 in-depth interviews across six population groups. Results: Sixteen percent of participants reported HIV-related discrimination in healthcare services in the previous 12 months, 4.7% reported community stigma in the past 12 months, 39.0% reported internalized stigma, and 2.7% experienced rights abuse in the past 12 months. Younger people living with HIV reported significantly higher levels of healthcare discrimination, community stigma, internalized stigma, and rights abuse than older participants and the general people living with HIV reference group. Compared with general people living with HIV, sex workers and people who use drugs reported significantly higher levels of community stigma; men who have sex with men, sex workers, people who use drugs, and migrant workers reported significantly higher internalized stigma; and transgender people and sex workers reported significantly higher levels of rights abuse. Qualitative findings highlighted anticipated and enacted stigma, confidentiality concerns, internalized stigma, intersecting identities, rights violations, and resilience. Conclusions: HIV-related stigma remains evident in healthcare, community, and personal domains. Younger people living with HIV and key populations were particularly vulnerable to HIV-related stigma, discrimination, and rights abuse. Responses should combine updated public communication, stigma-free and person-centered healthcare, protection of privacy and rights, support for internalized stigma and mental well-being, and sustained leadership of people living with HIV.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091200

Authors: Dana Iglesias Jesus Ruiz Emily C. Sheffield Margaret R. Helton

Rural maternity care in the United States faces an unprecedented crisis. As of 2022, more than half of rural hospitals lacked obstetric services, leaving many rural communities without local maternity care. This descriptive case study documents the implementation of maternity services at a 25-bed rural critical access hospital in North Carolina. We reviewed and coded data derived from the following sources from 2020–2025: institutional planning documents, clinical protocols, standard workflows, operational procedures, administrative records, meeting minutes, presentations and summaries, and published commentaries, manuscripts and articles related to the new maternity unit. We identified six critical domains for sustainability: (1) hospital and community engagement, (2) stable multidisciplinary staffing models, (3) emergency preparedness, (4) anesthesia service delivery, (5) financial sustainability, and (6) risk-appropriate scope of care. Successful implementation required integrated approaches across organizational dimensions facilitated by committed institutional leadership; community advocacy; innovative staffing models with family physicians, certified nurse-midwives, and certified registered nurse anesthetists; competency-based emergency training; Medicaid-based financial sustainability; and explicit risk stratification with clear interfacility communication protocols. Workforce sustainability emerged as the most significant ongoing challenge. Rural maternity service sustainability requires multifaceted, evidence-based approaches integrating workforce development, organizational infrastructure, financial mechanisms, and clear scope definitions. This case study demonstrates a model of perinatal regionalized and risk-appropriate care with replicable strategies that can inform efforts to address maternal health equity and strengthen rural health care systems.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091199

Authors: Szergej Malhazjan Bettina F. Piko

This scoping review aimed to map empirical interventions in teacher and educator populations in which burnout or burnout-related outcomes were evaluated from a broad mental health promotion and prevention perspective. Searches were conducted in Scopus, ERIC, PubMed/MEDLINE, and Web of Science. The search strategy was broadened to improve sensitivity by removing the mandatory study-design block and expanding intervention-related terminology. A structured evidence map was used to chart reports by intervention category, population, intervention level, study design, burnout-related outcome, follow-up, and research gaps, following PRISMA-ScR reporting principles and established scoping review methodological guidance. The final evidence base comprised 123 eligible reports. Interventions spanned cognitive-behavioral and rational-emotive approaches, mindfulness and mind–body programs, compassion- and emotion-focused interventions, social–emotional and trauma-informed approaches, professional development, classroom-management and instructional-practice interventions, and broader occupational or organizational approaches. Emotional exhaustion was the most frequently represented burnout-related dimension, although substantial heterogeneity was evident in intervention content, design, measurement, and follow-up. No formal risk-of-bias or methodological quality assessment was conducted. The evidence base is substantial but heterogeneous, and future research should more directly evaluate sustained, context-sensitive, organizational, and multilevel approaches alongside individual- and classroom/practice-level interventions.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091197

Authors: Gregorius Abanit Asa Nelsensius Klau Fauk Hailay Abrha Gesesew Paul R. Ward

Traditional male circumcision (TMC) is viewed as a rite of passage from childhood to manhood. In the Atoni Meto tribe in Indonesia, this practice requires initiates to engage in unprotected sexual intercourse with unrelated women following circumcision, thereby exposing both men and women to the risk of HIV transmission. However, there is a lack of validated questionnaires in Indonesia to measure knowledge and attitudes towards TMC and the associated risk of HIV transmission. This study aimed to develop and validate a questionnaire aimed at measuring the knowledge and attitudes of men aged 18 to 49 years in West Timor, Indonesia, regarding TMC and the risk of HIV transmission linked to the practice and subsequent sexual intercourse. A series of validations was conducted, including content validity, face validity, test-retest reliability, exploratory factor analysis, and inter-item correlation. The EFA was conducted with 140 participants. The Kaiser–Meyer–Olkin test for the knowledge factor was 0.759, and the attitudes factor was 0.797, with Bartlett’s test of sphericity p-value < 0.001 indicating that the data were suitable to proceed with further factor analysis. Cronbach’s alpha values for knowledge and attitudes were 0.861 and 0.824, respectively, suggesting good internal consistency. The questionnaire provides preliminary evidence of its validity and reliability in assessing Indonesian men’s knowledge and attitudes on TMC and HIV transmission.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091198

Authors: Ana Cristina Lindsay Monica Pereira Celestina V. Antunes Aysha G. Pires Denise Lima Nogueira

Cape Verdean immigrants are a growing yet understudied population in the United States (U.S.), with limited data on HPV and cervical cancer prevention knowledge. This descriptive qualitative study explored awareness, knowledge, beliefs, and perceptions related to HPV and cervical cancer prevention among Cape Verdean immigrant mothers of children aged 11–17 residing in Massachusetts, a state in the northeastern U.S. A qualitative descriptive design was used. Semi-structured interviews were conducted with 27 Cape Verdean immigrant mothers of adolescents aged 11–17 residing in the study area. Interviews were transcribed, translated, and analyzed thematically using inductive and deductive approaches guided by the literature and emergent narratives. MAXQDA was used for data management, and coding reliability was established through independent review by bilingual researchers. Participants demonstrated varying levels of awareness, ranging from comprehensive understanding to limited knowledge. Two major themes emerged: (1) knowledge and beliefs about cervical cancer and (2) knowledge and beliefs about HPV. Findings revealed fragmented knowledge, misconceptions about screening and transmission, and gendered perceptions of HPV as a “women’s issue.” While many mothers valued prevention and recognized HPV’s link to cervical cancer, uncertainties remained regarding vaccination, screening recommendations, and vaccine effectiveness. Findings highlight the need for culturally and linguistically tailored interventions addressing HPV misinformation, strengthening parental confidence, and supporting Cape Verdean mothers as informed health decision-makers to improve HPV vaccination and cervical cancer prevention.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091196

Authors: Jakeline López Rodríguez Josué Prieto Prieto Eduardo Mateos Martín Carlos Moreno Pascual

University employees are increasingly exposed to prolonged sitting, yet the relationships between daily sitting time, musculoskeletal symptoms (MSS), and health-related quality of life (HRQoL) in this occupational population remain insufficiently understood. This study aimed to estimate the prevalence, anatomical distribution, and chronicity of MSS among university employees and to explore their associations with daily sitting time and sociodemographic, occupational, and behavioural factors, as well as the relationships of these factors and MSS with HRQoL. A cross-sectional study was conducted among 893 academic and non-academic employees at a Spanish university. Participants completed an online questionnaire including sociodemographic and occupational characteristics, the Nordic Musculoskeletal Questionnaire, the 12-item Short Form Health Survey (SF-12), and the International Physical Activity Questionnaire. Multivariable logistic and linear regression models were used to examine factors associated with MSS and HRQoL. Female sex (OR = 1.58; 95% CI: 1.07–2.32), younger age (OR = 0.98; 95% CI: 0.96–0.99), and longer daily sitting time (OR = 1.001; 95% CI: 1.000–1.002) were associated with MSS after mutual adjustment. Overall, 82.8% of participants reported MSS during the previous 12 months, most frequently affecting the back (58.8%) and neck (49.2%). Daily sitting time was also associated with poorer mental HRQoL after mutual adjustment, whereas duration of work limitation due to MSS showed the strongest association with poorer physical HRQoL. Symptom prevalence was similar in academic and non-academic staff, although non-academic employees reported greater symptom chronicity and treatment use. MSS are highly prevalent among university employees and are associated with poorer HRQoL. Daily sitting time represents a potentially modifiable behavioural factor that should be considered in health promotion strategies within higher education institutions.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091195

Authors: Lāsma Spundiņa Una Veseta Agita Abele

PA is an important determinant of health and well-being; however, many university students, including healthcare students, do not achieve recommended activity levels despite their future role in health promotion. This study aimed to explore healthcare students’ perspectives on physical activity, including their habits, perceived barriers and facilitators, the relationship between physical activity and academic self-efficacy, and its role in their future professional identity. A qualitative descriptive design was applied using semi-structured individual interviews with 15 healthcare students. Data were analyzed using Braun and Clarke’s six-phase reflexive thematic analysis approach. Five interrelated themes were identified: physical activity as a resource for health, well-being, and academic functioning; academic demands shaping physical activity behavior; physical activity strengthening academic self-efficacy; physical activity as part of professional identity; and the university environment as a facilitator of physical activity. Students perceived physical activity as supporting physical and mental well-being, stress management, concentration, and daily functioning. Academic workload, limited time, fatigue, financial constraints, and motivational challenges were identified as barriers, whereas institutional support and flexible opportunities facilitated participation. Students also viewed physical activity as contributing to confidence, discipline, and their perceived credibility as future healthcare professionals. Supportive university environments may help healthcare students maintain active lifestyles and support the development of their role as health-promoting professionals.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091194

Authors: Letladi Kamogelo Moagi Mokoko Percy Kekana Bonelwa Sidumo

Mental health encompasses emotional, psychological, and social well-being, influencing how individuals’ function and cope with life events. In the agricultural industry, the use of machinery and chemicals to increase productivity exposes farmworkers to a range of occupational hazards. These hazards often create unsafe working conditions that can contribute to mental health problems, including anxiety and depression. This study explored the impact of the occupational hazards on the mental health of the farmworkers at Maruleng, Limpopo Province. A qualitative research approach and phenomenological research design were adopted. In-depth individual, semi-structured interviews were conducted with 15 farmworkers. The interviews were guided by a central question. Data were audio-recorded, transcribed and analysed using Tesch’s eight-step of open-coding method. The findings indicate that farmworkers in Maruleng are exposed to a range of occupational hazards that adversely affect their mental health. Participants reported experiencing significant psychological strain associated with unsafe working conditions on the farms. Employers were found to inadequately protect workers, as evidenced by poor maintenance of farm machinery, insufficient pesticides handling training, and the lack of appropriate and adequate personal protective equipment (PPE). The study concludes that limited institutional support and inadequate access to mental health services exacerbate risks to the health and safety of farmworkers in Maruleng. To address these challenges, mental health support should be strengthened through the implementation of employee assistance programmes on the farms and other relevant services. In addition, regular monitoring of machinery maintenance, working conditions and safety protocol practices on the farms is essential to ensure compliance with occupational health and safety standards.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091193

Authors: Nene A. Diallo John Molot Riina Bray Adrianna Trifunovski Rohini Peris

Multiple chemical sensitivity (MCS) is a chronic condition characterized by adverse multisystem reactions triggered by chemical exposures, including at low levels. The use of fragranced and disinfectant products within healthcare institutions was frequently reported by individuals with MCS as a challenge to accessing healthcare. This study was conducted during the COVID-19 pandemic, when infection control measures may have intensified the pre-existing chemical-exposure barriers for people with MCS. This study examines healthcare access among adults with MCS in Canada, including access to diagnosis and physicians and satisfaction with in-person and virtual care. A national cross-sectional online survey was conducted between January and February 2021 among adults living with MCS for at least one year prior to the pandemic. Quantitative and open-ended questions captured experiences related to diagnosis, access to physicians, and satisfaction with virtual and in-person healthcare. Of the 119 participants who completed the survey, most reported having a formal diagnosis of MCS (78.2%, n = 93, 95% CI 69.9–84.6). Among those who could not obtain an MCS diagnosis (N = 26), common barriers included obtaining any other diagnosis but MCS (61.5%, n = 16; 42.5–77.6), and the belief among medical professionals that MCS does not exist (57.7%, n = 15; 38.9–74.5). Among participants who gave reasons for dissatisfaction with virtual care (n = 32), 87.5% (71.9–95.0) cited the clinician’s lack of understanding of the condition, whereas technical problems were rarely reported (12.5%, 5.0–28.1). Among participants who reported dissatisfaction with in-person care (n = 41), 85.4% (71.6–93.1) cited the clinician’s lack of understanding of the condition, and 85.4% (71.6–93.1) cited chemical exposures, including scented disinfectants, soaps or sanitizers, while 80.5% (66.0–89.8) cited cleaning products on surfaces. Participants’ responses suggest that pandemic-related public health responses intensified pre-existing barriers to care for people with MCS by increasing chemical exposures and constraining access to knowledgeable providers. These findings highlight the need for healthcare systems and emergency preparedness frameworks that integrate chemical safety, disability inclusion, and provider education to ensure equitable access, including during public health crises.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091192

Authors: Delgermaa Sendmaa Namuun Ganbaatar Erdenetuul Nuden Enkhtuul Chuluun Anudari Batsukh Sundui-Yanjmaa Luvsangenden Khishigsuren Zuunnast Myagmartseren Dashtseren Naranbaatar Nyam Orgilmaa Regzedmaa Oyungoo Badamdorj

Background: Informal caregiving for individuals with intellectual disabilities can involve sustained psychological and social demands. This study assessed caregiver burden and psychological distress among informal caregivers of individuals with intellectual disabilities in Mongolia and examined their associations with caregiver and care-recipient characteristics. Methods: This descriptive cross-sectional study included 642 informal caregivers recruited from primary health care centers and the National Center for Mental Health in Ulaanbaatar. Psychological distress was assessed with the 42-item Depression Anxiety Stress Scales (DASS-42), and caregiver burden with the Zarit Burden Interview (ZBI). Results: The mean ZBI score was 39.03 ± 14.68, and 48.9% of caregivers had moderate-to-severe or severe burden. Severe or extremely severe symptoms were observed in 25.9% of participants for depression, 49.5% for anxiety, and 15.2% for stress. ZBI scores correlated positively with depression (r = 0.537), anxiety (r = 0.519), and stress (r = 0.584) (all p < 0.001). In multivariable models, higher ZBI scores remained associated with higher depression (β = 0.313), anxiety (β = 0.306), and stress scores (β = 0.355) (all p < 0.001). Conclusions: Caregiver burden and psychological distress were common and closely associated in this sample. Routine assessment of caregiver mental health, together with caregiver-focused psychosocial and community support, should be considered in services for individuals with intellectual disabilities.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091191

Authors: Nanda Win Pankaew Tantirattanakulchai Win Myint Thu Worapath Kratoo

Depression is a common mental health issue among migrant workers. This study was designed to investigate the effectiveness of a LINE-application-based PASS program on depression scores among Myanmar migrant factory workers in Samut Prakan, Thailand. This randomized controlled trial was conducted in nine factories in Samut Prakan, Thailand. One hundred and forty-four factory workers were randomly allocated between the intervention and control groups (72 participants in each group). The PASS program was implemented in the intervention group. A self-administered method was used at three time points—baseline, immediately after the intervention, and at the three-month follow-up. The generalized linear mixed model was used for statistical analysis. There were no statistically significant between-group differences in sociodemographic characteristics or depression at baseline. According to the generalized linear mixed model, the intervention group demonstrated a significantly greater reduction in depression scores than the control group (p < 0.001). The PASS program intervention significantly reduced depression scores, with sustained effects at three months. It also provides a suggestion for stakeholders, particularly public health organizations, that they need to implement measures to reduce depression and to prevent more serious psychological health issues among Myanmar migrant factory workers in the future.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091190

Authors: Fatima Tuz Zehra Amjad Junaid Bin Faidh Dougal Nolan Abraham Rudnick

Introduction: Mobile phone text messaging (Short Message Service; SMS) interventions are digital health strategies that may support mental health care. This scoping review examined related study designs, outcomes, and gaps across the literature. Methods: Systematic searches identified 38 eligible studies from 1542 abstracts. Data were extracted and thematically analyzed to identify trends and outcomes. Texting interventions were categorized as cognitive, motivational, instrumental/practical, or combined approaches. Results: Study design included randomized controlled trials (RCTs), quasi-experimental pilots and systematic reviews, with RCTs providing the strongest evidence for improvements in adherence and relapse prevention. Outcomes included behavioral measures (e.g., medication adherence, therapy homework completion, and reduced non-attendance) alongside clinical measures (e.g., symptom reduction and relapse prevention). Cognitive reminders that were most common reduced non-attendance and improved adherence, particularly for medication and appointments, although they were less effective in severe depression. Motivational and combined interventions demonstrated higher acceptability and engagement, particularly in adolescents and high-risk individuals. Success was influenced by diagnosis, age, gender, and social status, including adherence at baseline. Conclusions: Overall, text-based interventions were generally acceptable, accessible, and cost-effective for improving mental health engagement. Limitations included lack of long-term evaluations, technological barriers, and lack of personalization. Future research should address these gaps and include underrepresented populations.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091189

Authors: Edward Pontius Richard Lewis Susan Peixotto Paula Connor-Crouch

The COVID-19 pandemic placed prolonged, multi-year demands on the systems supporting frontline workers in healthcare, public safety, and education. In response, approximately 150 licensed behavioral-health professionals and credentialed educators, trained in Psychological First Aid (PFA), built and staffed the Maine FrontLine WarmLine (MFLWL) as unpaid Volunteers from 21 March 2020 through 31 May 2021 and began fielding calls in April 2020, contributing approximately 33,000 h of service. Although the MFLWL fielded 100 calls in aggregate, engagement persisted and expanded into Community Outreach, reaching approximately 250 frontline workers. To understand that paradox, this narrative case study analyzed two waves of open-ended Volunteer surveys (n = 22; n = 20) using consensus-based thematic analysis. Four themes emerged: a specific COVID-19 frontline focus; personal and professional Calling; an intentionally cultivated Culture of self-care and relational support; and stakeholder relationships marked by experienced systemic betrayal and moral injury. Low call volume, rather than eroding engagement, appears to have activated Volunteers’ sense of Calling, converting frustrated readiness into new capability and new avenues of service. From these findings, we derive Emerging Volunteer Engagement (EVE), a values-and-process framework situated within Disaster Ecology that positions Volunteers as principal drivers of disaster response rather than interchangeable resources, with implications for Volunteer organization, support, and liability policy in future disasters.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091188

Authors: Yaowaluck Meebunmak Kannika Kitnopkiat Parinyaporn Thanaboonpuang

Background: Loneliness, psychological stress, and low self-esteem are important mental health concerns among community-dwelling older adults and may negatively affect healthy ageing and quality of life. This study examined psychosocial outcomes associated with participation in a 4-week Hybrid Happy Reminiscence Program among community-dwelling older adults. Methods: A quasi-experimental pretest–posttest control group study was conducted between September and November 2025 among community-dwelling older adults in Don Tako Subdistrict, Ratchaburi Province, Thailand. Participants were recruited using purposive sampling based on predefined eligibility criteria and were subsequently assigned to either an experimental group (n = 30), which received the Hybrid Happy Reminiscence Program combining bi-weekly face-to-face group sessions with a digital intervention delivered through the LINE application, or a control group (n = 30), which received routine community care. No statistically significant between-group differences were detected in the measured baseline demographic characteristics (all p > 0.05). Primary outcomes included self-esteem, loneliness, and psychological stress. Results: Within the experimental group, self-esteem increased from baseline to posttest (t(29) = −8.07, p < 0.001), while loneliness (t(29) = 5.11, p < 0.001, Cohen’s d = 0.93) and psychological stress (t(29) = 6.59, p < 0.001, Cohen’s d = 1.20) decreased. At posttest, the experimental group had higher self-esteem than the control group (mean difference = 4.73, 95% CI: 3.23–6.23, t(58) = 6.32, p < 0.001) and lower loneliness scores (mean difference = −2.13, 95% CI: −3.27 to −1.00, t(58) = −3.78, p < 0.001). For psychological stress, the experimental group also had a lower mean score than the control group at posttest, although the confidence interval included zero (mean difference = −0.73, 95% CI: −1.51 to 0.04, t(58) = −1.89, p = 0.063). Conclusions: Participants receiving the Hybrid Happy Reminiscence Program showed greater post-intervention self-esteem and lower loneliness scores than those receiving routine community care. Although psychological stress decreased within the intervention group, the post-intervention between-group difference was not statistically significant. Given the quasi-experimental design and the non-random allocation procedure, these findings should be interpreted as group differences consistent with a possible beneficial effect of the program rather than definitive evidence of causality. Larger randomized controlled studies with longer follow-up periods are needed to confirm these findings and to distinguish intervention-specific effects from non-specific influences.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091187

Authors: Dinmuhamed Tazhdinov Nurlan Dzhainakbaev Akimzhan Zaynalov Abay Shepetov Ibrahim Aliosmanoglu Adilkhan Tokpanov Aray Aidarova

Background: Equitable access to kidney replacement therapy (KRT) remains a major challenge for patients living in geographically isolated, rural, and underserved settings. Organizational approaches, including tele-nephrology, remote patient monitoring, decentralized dialysis services, home dialysis support, rural outreach programs, and emergency preparedness strategies, have been increasingly used to address geographic and organizational barriers to KRT delivery. This review summarizes the available evidence on organizational approaches supporting remote and decentralized KRT delivery and examines their reported implications for healthcare accessibility, continuity of care, and service delivery. Methods: A structured literature search was conducted in PubMed/MEDLINE, Scopus, Web of Science Core Collection, and the Cochrane Library for studies published between January 2016 and January 2026. Publications considered relevant addressed organizational, healthcare delivery, implementation, or health-system approaches supporting KRT accessibility, continuity, or delivery in geographically isolated, rural, underserved, disaster-affected, humanitarian, or resource-limited settings. Studies describing conventional facility-based dialysis without an organizational or healthcare delivery component were excluded. Relevant information on study characteristics, KRT modality, organizational approaches, implementation components, healthcare accessibility, continuity of care, and reported barriers and outcomes was extracted and narratively synthesized. Results: A total of 749 records were identified, and 12 publications were retained for detailed synthesis. The publications addressed tele-nephrology, remote monitoring, home dialysis support, rural outreach, decentralized and community-based dialysis, and emergency preparedness. Study designs, settings, organizational models, and outcomes varied substantially. Reported findings concerned specialist access, home and decentralized dialysis pathways, dialysis continuity, healthcare utilization, and implementation feasibility. Most publications were observational, pilot, implementation-based, or qualitative, limiting causal inference and direct comparison across settings. Conclusions: The literature describes organizational approaches that may address specific barriers to KRT access and continuity. However, heterogeneous and predominantly non-comparative evidence is insufficient to establish causal effectiveness or superiority of any specific model. Multicenter comparative studies with standardized organizational, patient-centered, and economic outcomes are needed to assess effectiveness, scalability, and sustainability.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091186

Authors: Ruggero Andrisano Ruggieri Alberto Ragosta Luke Balcombe

A series of documented deaths by suicide following prolonged interactions with chatbots based on large language models (LLMs) has exposed the clinical risks of delegating emotional support to conversational artificial intelligence. This paper proposes a psychodynamic account of these events, integrating the bi-logical theory of Ignacio Matte Blanco, the Freudian theory of primary hallucination, and the analysis of demand elaborated by Carli and Paniccia. Two theoretical moves ground the account. First, the suicidal crisis is conceptualized not as a continuous state but as a pathological prevalence of symmetric logic that recurs and consolidates across acute moments, marked by the generalization, maximization, and irradiation of psychic pain and by the collapse of temporality; LLM-based chatbots, conversely, are conceptualized as systems of pure formal asymmetry lacking any symmetric, emotional, and embodied base. Second, their encounter generates what we call relational hallucination: an unconscious, structurally determined process, homologous to primary hallucination, through which the subject in crisis invests the chatbot with relational qualities perceived as real. Because the process obeys the laws of symmetric logic, it is resistant to correction by information alone, and it can consolidate cumulatively even across interactions that also contain deliberative, asymmetric elements such as planning. The chatbot, responding to the explicit request rather than to the unconscious demand it conveys, produces an amplificatory collusion that reinforces the premises of the crisis. The failure of algorithmic support in acute suicidal states is therefore ontological rather than technical. Implications for clinical training, regulation, and research are discussed, including testable hypotheses linking markers of symmetric prevalence to the intensity of chatbot attachment.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091185

Authors: Bryan Bayles Walter Den Xinyue Ye Xingmao Ma

The growing prevalence of obesity worldwide has been attributed not only to behavioral and genetic factors but also to chronic exposure to environmental chemicals known as obesogens. This review synthesizes current evidence on three underexamined classes of emerging environmental obesogens: per- and polyfluoroalkyl substances (PFAS), micro- and nano-plastics (MNPs), and tire-derived organic pollutants (TDOPs), with particular focus on their metabolic impacts and potential synergistic effects. These contaminants are widely detected in drinking water, food products and food-contact materials, and epidemiological evidence increasingly links them to dysregulation of lipid metabolism, impairment of glucose homeostasis, and obesity-related outcomes. These contaminants may disproportionately affect marginalized communities due to synergistic toxicity, systemic exposure disparities, and greater economic vulnerabilities. The review discusses shared exposure pathways, plausible molecular mechanisms, and heightened human vulnerability. Critical knowledge gaps are identified, including limited data on emerging PFAS, nanoplastics and their additives, chronic co-exposures, and analytical challenges in tracking human exposure. By integrating evidence across these contaminant classes, the review highlights the need for coordinated research efforts to better characterize the cumulative obesogenic burden of emerging environmental pollutants.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091184

Authors: Asiya Al Badi Shahira Al Maqbali Firdous Jahan Khulood Al Saadi Rabiya Zeeshan Maisa Hamed Al Kiyumi

Type 2 diabetes mellitus (T2DM) can substantially affect patients’ quality of life (QoL), yet evidence from Al-Buraimi Governorate, Oman, is limited. This study assessed diabetes-specific QoL and its associated sociodemographic and clinical factors among adults with T2DM attending a primary healthcare diabetes clinic. A cross-sectional analytical study was conducted among 364 adults with T2DM between October and December 2024. Face-to-face interviews were carried out to collect data using a validated Arabic Diabetes Quality of Life (DQoL) questionnaire and a structured clinical and sociodemographic form. Differences in overall DQoL scores were assessed using independent-samples t-tests and one-way ANOVA, followed by Games–Howell post hoc comparisons where appropriate. Multivariable linear regression was used to identify independent factors associated with overall DQoL. Higher DQoL scores indicated poorer QoL. In multivariate regression analysis, gender, education status (university versus high school graduates), HbA1c, duration of diabetes (5–10 years versus <5 years), treatment modality (diet alone versus oral medications) and diabetes-related complications were significantly associated with overall DQoL. These findings support incorporating diabetes-specific QoL assessment into patient-centered diabetes care, particularly for patients with poor glycemic control and diabetes-related complications.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091183

Authors: Anfal AL-Dalaeen Nour Batarseh Rama Aboalrob Leen Marie Abeer Ahmad Bahathig

Background: Modern lifestyles characterized by artificial light exposure, screen use, and altered sleep routines may be related to eating behaviors and dietary patterns relevant to the gut microbial environment. Although these factors have been investigated individually, limited evidence has examined self-reported light-exposure behaviors, sleep, eating behavior, and gut microbiota-related dietary patterns simultaneously within a single analytical framework. Objective: The aim of this study was to examine associations between five self-reported light-exposure behaviors and the global PSQI score, eating-behavior domains, and FFQ-GM-derived gut microbiota-related dietary pattern scores among adults in the recruited sample. Methods: A cross-sectional study was conducted among 518 adults aged 18–64 years recruited in Amman, Jordan, between April and May 2026 using convenience sampling. Participants completed the LEBA, the Arabic PSQI, the Arabic TFEQ-R18, and an Arabic-adapted gut microbiota-focused food frequency questionnaire (FFQ-GM). Associations were examined using Spearman’s rho and multivariable linear regression; multiplicity across the 25 LEBA factor–outcome coefficient tests was addressed using the Benjamini–Hochberg false discovery rate. Results: In the analyzed sample, 87.3% of participants had a global PSQI score > 5. Several LEBA factor–outcome coefficients had nominal p values < 0.05. Blue-light-filter use was positively associated with the global PSQI score (β = 0.29, p = 0.020), whereas phone use in bed (β = −0.43, p = 0.002) and light exposure before bedtime (β = −0.51, p = 0.009) were negatively associated with the global PSQI score. After false-discovery-rate adjustment across the 25 individual coefficient tests, most individual associations did not remain below the 0.05 threshold; therefore, these coefficient-level findings are interpreted as exploratory. Conclusions: Self-reported light-exposure behaviors were associated with questionnaire-derived sleep scores, eating-behavior domains, and FFQ-GM-derived gut microbiota-related dietary pattern scores. The cross-sectional design does not establish temporal direction, causality, or biological mechanism.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091182

Authors: Anani Basaldua Galarza Arturo Gamarra-Moreno Wini Ebelin Quispe Bautista Jose Antonio Rojas Guillén

Digital health is increasingly used to extend care in low-resource settings, yet improved access, feasibility, or acceptability does not necessarily demonstrate reduced health inequities. This scoping review mapped evidence on digital health and health equity in low-resource settings. Following the PRISMA extension for Scoping Reviews (PRISMA-ScR) and Joanna Briggs Institute (JBI) guidance, Scopus, Web of Science, and PubMed were searched on 20 May 2026 for English-language studies published between 2021 and 2026. After eligibility screening, two reviewers independently applied a review-specific seven-criterion cross-design rubric before thematic synthesis. Sixty-nine studies were included; all met the review-defined 19/21 threshold for sufficient reporting and relevance to synthesis. Evidence comprised implemented or evaluated interventions and services (n = 34), implementation, adoption, or contextual studies (n = 24), and protocols, development studies, or requirements analyses (n = 11). mobile health (mHealth) applications (n = 39) and telemedicine/telehealth (n = 32) predominated. Leading barriers involved connectivity, infrastructure, or device access (n = 31), digital literacy or usability (n = 22), and affordability or resource constraints (n = 20). Direct evidence of narrowed disparities remained limited. Digital health can support equity when it addresses defined access barriers and is affordable, usable, culturally responsive, locally supported, privacy-conscious, and integrated into actionable care pathways.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091181

Authors: Teresa Lindmayr Filippo Cacioppo Sophie Gupta Martin Lutnik Nikola Schütz Julia Oppenauer Michael Schwameis Roland Polacsek-Ernst Jan Niederdöckl

Background: Demographic change, worsening of general health risk profiles and lack of resources cause growing challenges in healthcare, especially in acute and emergency care. To explore the potential of digitally facilitated personalized patient flow management tools in acute care at Austrian emergency departments, we developed and validated a model to predict the individual probability of readmission after an initial acute treatment. Methods: For this exploratory study, a retrospective data analysis on 50,849 cases of acute treatment was conducted, which were retrievable from the routine dataset of the emergency department of the Medical University of Vienna at the tertiary care central hospital. The prediction model was developed based on cases documented between January 2013 and August 2018 and temporally validated using cases registered between August 2018 and April 2022. The prediction model was developed using multivariable Firth’s logistic regression and confirmed by temporal validation. Quality and usefulness were evaluated using calibration plots, Kaplan–Meier curves, C-statistics and decision curve analyses. Results: A total of 25,423 cases were analyzed in the development dataset (median age 59 years, IQR 41–73; 48.15% female), and 25,426 cases in the validation dataset (median age 51 years, IQR 32–70; 50.88% female). The incidence rates of readmission were 3.34 per 100 patient-years in the development dataset and 7.49 per 100 patient-years in the validation dataset. The final score included seven predictors: age > 50 years (“Yes”, 6 points), sex (“male”, 2 points), country of birth (“Austria”, 1 point), married/partnered (“Yes”, 2 points), place of residence Vienna (“Yes”, 5 points), internal medical reason for admission (“Yes”, 1 point), and clear diagnosis possible (“Yes”, 2 points). The final score showed good calibration (R2 = 0.952 and R2 = 0.891) and modest discrimination (C-indices: 0.60 and 0.62) in both the development and validation datasets. The decision curve analyses suggested clinical net benefit. The results of the sensitivity analyses indicated a robust model. Conclusions: A substantial rise in incidence rates indicates an urgent need for action. The present model showed good calibration but modest discrimination in predicting readmission after initial acute treatment at an emergency department. These findings support further refinement and external validation of the model before its potential use in digitally facilitated personalized patient flow management.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091180

Authors: Kirsten Kaya Roessler Martin Mau

As loneliness is a concern for many, both due to its associations with adverse health outcomes and due to its, by definition, negative connotations for the individual, it is important to identify ways to address it. The built environment may be one such way. The aim of this conceptual paper is to present a dialogue for understanding associations between the built environment and loneliness. This dialogue, developed through iteratively examining points of convergence and divergence between fundamentally different perspectives, synthesizes the theoretical basis from which the literature departs, providing the reader with a heuristic view to foster greater conceptual understanding. The first of these perspectives emphasizes how the built environment may influence loneliness through the narratives and architecture of places; in the second perspective, the relationship is construed as reciprocal, and historical and biographical atmospheres of places merge with individual understandings; and, finally, a third perspective emphasizes how people themselves influence perceptions of the built environment through shared memories with other people and certain rituals. Through the presentation of these three perspectives, we will argue that loneliness is related both to other people and, through various pathways, to aspects of the built environment.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091178

Authors: Niwat Songsin Kanokporn Somporn Rachanon Runnuch Prakasit Wannapaschaiyong

Electronic cigarette use among adolescents is an emerging public health concern, yet evidence from specific rural communities in Thailand remains limited. This cross-sectional study estimated the prevalence of e-cigarette use, described perceptions of e-cigarettes and attitudes toward e-cigarette use, and examined factors associated with overall attitude scores among 512 participants recruited from selected rural communities in Samut Songkhram Province, Thailand. The mean age was 18.46 years (SD = 1.37). Data were collected from December 2024 to August 2025 using a structured questionnaire and analyzed using descriptive statistics and multiple linear regression. Current e-cigarette use, defined as use within the previous 30 days, was reported by 5.86% of participants, while 18.36% reported lifetime use. Overall perceptions of e-cigarettes were classified as high (M = 2.52, SD = 0.34), whereas overall attitudes toward e-cigarette use were classified as good (M = 2.73, SD = 0.40). Sex was positively associated with overall attitude scores (B = 0.109, β = 0.097, p = 0.023), whereas perceptions of e-cigarettes were negatively associated with attitude scores (B = −0.473, β = −0.343, p < 0.001). The model explained 12.3% of the variance in overall attitudes. Among adolescents participating in this study from selected rural communities in Samut Songkhram Province, the findings indicate ongoing e-cigarette experimentation and highlight the potential importance of coordinated prevention strategies addressing peer influence, misconceptions, affective attitudes, and access through informal and online channels. These findings should be interpreted within the specific study setting and sampling design and should not be generalized to adolescents in rural Thailand as a whole.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091179

Authors: Liliya Kiselova Camila Maria Ribeiro Pacheco Ana Carolina Pucci de Mattos Andreia Noites Ana Paula Fontes Elaine Caldeira de Oliveira Guirro

Cesarean section is a surgical procedure that involves the extraction of the fetus, the placenta, and the fetal membranes through an abdominal and uterine incision. As one of the most common childbirth methods worldwide, its increasing prevalence has raised concerns regarding potential postoperative sequelae that may affect tissue mobility, pain perception, and functional recovery. However, detailed characterization of early cesarean scars remains limited. This study aimed to characterize the morphological, sensory, and biomechanical properties of cesarean section scars during the early postoperative phase. A cross-sectional observational study was conducted including 20 women evaluated between 15 and 30 days after cesarean delivery. Clinical and sensory assessments were performed using the Patient and Observer Scar Assessment Scale (POSAS 3.0) and pain evaluation. Tissue mobility was assessed using a modified adheremeter, while biomechanical properties were measured with the MyotonPRO device. Ultrasound imaging was used to evaluate structural tissue characteristics. The scars predominantly exhibited increased tissue stiffness and heterogeneous texture patterns. Participants reported moderate pain intensity (mean 4.15 ± 2.18), with slightly higher scores in the patient-reported POSAS compared with the observer scale. Ultrasound findings revealed dermal and hypodermal edema in most participants and signs of fibrosis, with regional heterogeneity in tissue adhesions. Biomechanical analysis confirmed reduced tissue deformability in scar tissue compared with adjacent healthy tissue. These findings indicate that early cesarean scars present relevant structural and functional alterations, highlighting the importance of early assessment to support individualized rehabilitation strategies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091177

Authors: Mandilakhe Mlungwana Tronic Sithole Monwabisi Faleni Sibusiso Cyprian Nomatshila Ziphelele Peter

Background: The Undetectable = Untransmittable (U=U) message that people with HIV who maintain an undetectable viral load on antiretroviral therapy cannot sexually transmit the virus is scientifically established, yet awareness among South African adolescents remains poorly understood. This study assessed teenagers’ knowledge, perceptions, and acceptance of U=U in Mossel Bay Municipality, Western Cape. Methods: A qualitative, descriptive-exploratory study using semi-structured interviews with 15 purposively sampled teenagers (aged 13–19) across six schools. Interviews were transcribed and thematically analysed in ATLAS.ti, with a second reviewer coding a subset of transcripts. Results: Basic HIV knowledge was consistently accurate, but U=U awareness was low; 60% (9/15) had never heard the term, and understanding among the rest was partial. Only 46.7% (7/15) had tested HIV, citing fear, procedural anxiety, and parental gatekeeping as barriers; testing-related stigma persisted even among those who tested negatively. Once introduced to U=U, participants responded with cautious hope, distinguishing between acceptance in friendships versus more conditional acceptance in romantic relationships. Stigma, endorsed by all participants, was the dominant barrier, compounded by traditional, religious, and family silence. Conclusions: Teenagers possess the capacity to understand U=U; once explained, no downsides were identified. The core challenge is reach and trust, not receptiveness. Curriculum integration, provider training, and peer-led messaging are recommended.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091176

Authors: Tsutomu Higaki Kaoru Maeda

Ankle postural control is essential for standing stability immediately after sit-to-stand (STS), a movement associated with falls in older adults. Although triceps surae stretching is commonly used before exercise, its immediate effects on post-STS postural sway remain unclear. This exploratory study investigated the effects of static (SS), dynamic (DS), and ballistic stretching (BS) on post-STS postural sway and directional shifts in the anteroposterior extremes of center-of-pressure (CoP) after STS in a repeated-measures design with 10 healthy young adults (8 males, 2 females, mean ± SD age: 20.1 ± 0.3 years, age range 20–21 years). On three separate days, participants performed STS at a same-day pre-stretching baseline and after one of the stretching modalities. A force plate measured CoP in the anteroposterior direction (CoPap) during 0–10, 0–3, and 3–10 s after standing, and the standard deviation of CoPap was calculated as an index of post-STS postural sway. For the primary outcome measure (0–3 s), directional shifts in the anteroposterior extremes of CoPap during the first trial were assessed based on the change in the anterior and posterior positions of CoPap from the pre-stretching baseline to the post-stretching condition. Two-factor repeated-measures ANOVA revealed no significant main effects or interactions across all time intervals (all p ≥ 0.187). For the primary outcome—the 0–3-s interval—no significant effects were observed for stretch modality (F(2, 18) = 1.177, p = 0.331, partial η2 = 0.116), trial (F(2, 18) = 0.314, p = 0.735, partial η2 = 0.034), or their interaction (Greenhouse–Geisser-corrected F(1.75, 15.72) = 1.170, p = 0.329, partial η2 = 0.115). Directional shifts in CoPap extremes showed 95% confidence intervals crossing zero across all modalities, with modest mean changes (<3%FL) and substantial inter-individual variability. In conclusion, acute triceps surae stretching did not significantly alter post-STS postural sway variability in this sample of healthy young adults, while preliminary descriptive findings highlight the importance of considering individual variability and directional CoP behavior in dynamic stability assessments.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091175

Authors: Do-Young Lee Hye Mi Lee

This study aimed to explore the maternal experiences of Korean migrant working women living in the United Arab Emirates (UAE) and to gain an in-depth understanding of the meaning and essence of these experiences. In-depth interviews were conducted with 10 Korean migrant working women who had experienced pregnancy while living in the UAE and had experience raising their children while living and working in the UAE. The collected data were analyzed using Colaizzi’s phenomenological method. A total of 13 themes were identified from the participants’ maternal experiences and organized into five theme clusters. The five theme clusters were “Transition to Pregnancy and Motherhood in a Foreign Land,” “The Dual Challenges of Childbirth and Recovery in an Unfamiliar Environment,” “Struggling at the Intersection of Work and Motherhood,” “Becoming a Mother in a Foreign Country,” and “Growing into Motherhood Through Diverse Sources of Support.” The findings of this study provide an in-depth understanding of how Korean migrant working women experience and reconstruct motherhood within a migration context and provide foundational evidence for developing culturally appropriate maternal healthcare services and nursing interventions.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091174

Authors: Dilek Baykal Şeyma Demiralay Rabia Takmaz Fatımanur Sude Keskin Hatice Demircioglu

Background: Disasters and chemical, biological, radiological, and nuclear (CBRN) incidents pose significant challenges to public health systems and require a well-prepared nursing workforce. Assessing nursing students’ disaster preparedness, CBRN attitudes, and self-efficacy is essential for identifying educational needs and strengthening future emergency response capacity. Methods: A total of 302 nursing students were recruited from universities in Istanbul between January–June 2024. Data were collected using an Information Form, the Nursing Student CBRN Attitude Scale, the Nursing Student CBRN Self-Efficacy Scale, and the Disaster Preparedness Scale. Results: While 92.7% of students considered CBRN important, 64.2% reported lacking knowledge. No gender differences emerged; however, significant correlations were found between knowledge of earthquakes and CBRN, students’ attitudes, self-efficacy, and preparedness. Conclusions: Self-efficacy levels increased with the academic year. Integrating disaster and CBRN education into nursing curricula with emphasis on applied training is crucial to strengthening future nurses’ preparedness and response capacity.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091173

Authors: Sarah Grace Frueh Jessica Alfano Wil Cruz-Ruiz Lissa Fortes Soares Sheryl Jeanty Janroy Caraan Dimitrios E. Bakatsias Brian Haldenwang Roxanne Karimi Xiayan Ye Sudheera Yaparatne Arjun K. Venkatesan Carrie A. McDonough Henry J. Bokuniewicz Christopher J. Gobler Kevin A. Reed Jaymie R. Meliker

Rainfall and groundwater fluctuations may influence the migration or dilution of contaminants from US Superfund sites. This pilot study was designed to provide empirical data on relationships between rainfall and contaminant concentrations in water near Superfund sites. Four heterogeneous Superfund sites on Long Island, New York, were selected to represent a range of contaminant profiles and hydrogeologic conditions. Baseline samples were collected in December 2022, with subsequent samples obtained following major storms through September 2023. Samples were collected on 11–24 different days across the sites and measured for 18 metals and 1,4-dioxane. Overall, we observed few consistent associations between rainfall and contaminant concentrations across sites. Two trends, however, were noted: (1) at Gowanus Canal, a surface water site, there was a negative association between rainfall and contaminant concentrations using same-day or prior-day rainfall; and (2) in effluent from a treatment well near Lawrence Aviation, negative associations were observed between prior month’s rainfall and contaminant concentrations. Rainfall appeared to dilute contaminant concentrations using different hydrogeological processes at two of the four Superfund sites in this pilot study with a small sample size and study site heterogeneity. Given the increased frequency and intensity of extreme rainfall events, it is important to continue probing links between rainfall and contaminants near Superfund sites with intensive monitoring campaigns.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091172

Authors: Osman Ulvi Saiful Momen Iftikhar Sikder Ubydul Haque

Makkah faces substantial heat-stress challenges associated with extreme temperatures, dense urban form, and the large numbers of pilgrims present during Hajj and Umrah, creating important public health concerns. Recent heat-related fatalities highlight the need for complementary strategies that address outdoor as well as indoor heat exposure, alongside conventional cooling approaches such as air conditioning. This article examines the potential role of nature-based and complementary engineered interventions in mitigating urban heat stress in Makkah, focusing on afforestation, urban greening, and the possible use of artificial water bodies, contingent on sustainable water management. Drawing on case studies and published evidence from arid and heat-prone regions, including China, Pakistan, Saudi Arabia, and the wider Middle East, we summarize reported cooling effects, implementation experience, and feasibility considerations and assess their potential relevance to Makkah. The perspective highlights critical challenges related to water scarcity, spatial constraints, ecological impacts, and governance, while proposing phased implementation pathways that could be evaluated incrementally. If carefully designed and integrated with urban planning and climate-adaptation strategies, nature-based and complementary interventions could potentially reduce human heat stress, reduce cooling demand, and strengthen climate resilience in Makkah. However, their effectiveness, water requirements, environmental impacts, and scalability require evaluation under Makkah-specific environmental and operational conditions.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091171

Authors: Michael Machiorlatti Nicolle M. Krebs Joshua E. Muscat

Cigarette smokers have different levels of nicotine dependence, which affect their daily cigarette consumption and ability to quit. Genetic factors play a role, and there is interest in tailored nicotine therapy based on an individual’s rate of nicotine metabolism, which can be measured by the ratio of 3′hydroxycotinine [3HC]-to-cotinine, e.g., the nicotine metabolite ratio [NMR]. However, many other behavioral factors or symptoms are considered important indicators of nicotine dependence. The current study uses machine learning (ML) and traditional statistical methods to rank the importance of NMR and non-NMR factors that contribute to nicotine addiction. Using data from the Pennsylvania Adult Smoking Study (PASS), we found that salivary NMR is a predictor of nicotine dependence in the most commonly used nicotine dependence scales, including the Fagerstrom Test for Nicotine Dependence, Heaviness of Smoking Index, and the Hooked On Nicotine Checklist. However, other predictor variables, such as waking urges, showed higher rankings than NMR, with findings dependent on the modeling approach. These results indicate that other factors besides NMR may be clinically useful for understanding the extent of dependence and approaches to quitting.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091169

Authors: Aléssio Tony Cavalcanti de Almeida Luciana Mendes Santos Servo Edvaldo Batista de Sá

Philanthropic hospitals are key providers within Brazil’s public healthcare system and benefit from the Certification of Beneficent Social Assistance Entities in Health (CEBAS-Saúde), a tax relief program designed to incentivize service provision in underserved areas. We analyze a balanced panel of 1641 philanthropic general hospitals from 2005 to 2019, employing a conditional Difference-in-Differences (DiD) model with heterogeneous treatment exposure and entropy balancing to ensure comparability between certified and non-certified hospitals. The results show that certification significantly improved geographic access, mainly by reducing macro-regional patient evasion—the outflow of patients seeking care outside their designated health regions. This effect, most pronounced after ten years of certification, translated into an average annual reduction of approximately 8700 avoided hospitalizations between 2015 and 2019. The reduction was particularly concentrated in small hospitals and in the Northeast region, where access barriers are historically greater. These findings suggest that CEBAS-Saúde is an effective policy instrument for strengthening the regionalization of healthcare provision, reducing geographic inequities, and addressing service gaps in areas with limited healthcare supply.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091170

Authors: Anahy Ordóñez-Zea Alberto Urzúa Jorge Méndez-Cornejo Edgardo Rojas-Mancilla Carmen Zambrano-Bravo Esteban Oñate-Henríquez Trinidad Parada Cristian Vidal-Silva

Accessible assessment of aerobic fitness is important for adults with metabolic syndrome when cardiopulmonary exercise testing is unavailable. This study aimed to evaluate participant-level agreement between Six-Minute Walk Test (6MWT)-based equations and estimates derived from total Bruce treadmill duration. Using a single-city cross-sectional method-comparison design, 105 newly recruited adults, comprising 67 women and 38 men, completed standardized 6MWT and graded treadmill assessments. Agreement was evaluated using mean bias, mean absolute error (MAE), root mean square error (RMSE), Pearson correlation, calibration, proportional-bias regression, and Bland–Altman limits of agreement. Mean Bruce-derived estimated peak oxygen uptake (VO2peak) was 23.42±1.87 mL·kg−1·min−1. Model 1 produced 15.90±1.72, with a mean bias of −7.53, an RMSE of 7.77, and limits of agreement from −11.29 to −3.76. Model 3 produced 16.78±3.28, with a mean bias of −6.65, an RMSE of 7.11, and limits from −11.60 to −1.70. Both models systematically underestimated Bruce-derived values, and Model 3 showed proportional bias. Model 2 produced 99.31±4.82% on its original age- and sex-adjusted percentage-predicted scale. It was not converted to mass-specific units because the participant-specific reference values required for a valid back-conversion were unavailable. The observed bias and limits of agreement indicated that Models 1 and 3 did not achieve close participant-level agreement with the Bruce-derived approach. Validation against directly measured oxygen uptake remains necessary before clinical or public-health use.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091168

Authors: David Lucas Sandrine Brient Bisi Moriamo Eveillard Annabelle Gressier Tanguy Le Grand Richard Pougnet Jean-Dominique Dewitte Brice Loddé

The journal retracts the article titled “Health Impact and Psychosocial Perceptions among French Medical Residents during the SARS-CoV-2 Outbreak: A Cross-Sectional Survey” [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091167

Authors: Michael L. Stellefson Gracie Avery Sarah Flora Ansley Boles Olivia Henry Rakshan Sivalingam Savanna Williams

Informal caregiving for individuals with chronic obstructive pulmonary disease (COPD) places substantial emotional and physical demands on caregivers. However, many educational resources remain difficult to use due to high reading levels, dense medical language, and limited accessibility. Given that a large proportion of U.S. adults experience challenges with health literacy, existing caregiver toolkits may not provide the clear, actionable guidance needed to support caregiver self-efficacy or improve patient outcomes. This study introduces a reproducible, three-phase workflow that uses generative artificial intelligence (AI) to simplify and refine caregiver education materials, with application to the COPD Caregiver’s Toolkit. Four AI tools were used to simplify text, followed by human-guided refinement using the Sydney Health Literacy Lab (SHeLL) health literacy editor to ensure conceptual accuracy and usability. Readability indices and blinded assessments were used to evaluate changes in understandability and actionability across versions. AI-assisted simplification improved readability and clarity while maintaining high levels of actionability and preserving key instructional content. This scalable, adaptable approach may help public health researchers and practitioners improve the accessibility of educational resources across settings. Multi-phase, human-in-the-loop AI workflows may reduce linguistic complexity and improve the dissemination of essential health information to caregiving populations.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091166

Authors: Zeibeda Sattar Aneeta Shajan Sheinaz Stansfield Michael Cave Humaira Khan Mushtaq Dakri William McGovern

Background: South Asian Muslim (SAM) communities remain significantly underserved by mainstream drug and alcohol (D&A) recovery services in England. Cultural and religious misalignment in service design creates structural barriers to engagement. Family members from SAM communities who support individuals with substance use disorders have identified structural, cultural, and religious barriers that hinder engagement with mainstream treatment services. This study builds on this body of evidence by working with service providers, commissioners and community stakeholders through participatory co-production to examine how these barriers can be addressed. Methods: Three participatory co-production workshops were held over a 12-week period. Data were also generated from a field visit to a culturally adapted recovery service and a content analysis of an Islamically adapted 12-step recovery workbook. Participants included commissioners, service providers, community ambassadors and service users (total n = 42 across three workshops; some participants attended more than one workshop). Results: Four interconnected themes that shaped recovery engagement were identified: (1) stigma and izzat operating as a collective structural risk management system; (2) confidentiality functioning as a precondition for engagement rather than a by-product of it; (3) service design, space and visibility as determinants of access; and (4) co-construction of religiously coherent recovery pathways. Low engagement among participants reflected rational risk management, in response to real social consequences, rather than cultural resistance. Conclusions: Findings suggest that inclusive recovery systems may benefit from the adaptation of mainstream services rather than the creation of parallel provision. Six evidence-based design principles are proposed for commissioners and service providers. Findings contribute to the evidence base for equitable health, culturally responsive D&A intervention design and have relevance beyond SAM communities to other marginalised faith communities across England.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091165

Authors: Aphiwe Khaya Yekani Lindiwe Modest Faye Ncomeka Sineke Monwabisi Faleni

Background: Hypertension is a major contributor to cardiovascular morbidity and mortality globally, with particularly poor control in disadvantaged communities. Although awareness is generally high, sustaining lifestyle changes and treatment adherence remains difficult. This study examined socioeconomic, behavioural, and health system factors associated with hypertension management and explored the role of community-engaged health education in strengthening primary health care. Methods: A cross-sectional descriptive study was conducted among 107 adults with hypertension attending public primary health care facilities. Data were collected using structured questionnaires covering socioeconomic status, health system access, medication adherence, lifestyle practices, and knowledge and attitudes. Descriptive statistics summarized participant characteristics, while chi-square tests and multivariable logistic regression identified factors associated with clinic attendance, dietary adherence, lifestyle practices, and self-management. Results: Awareness of hypertension (86.9%) and trust in clinic care (91.6%) were high; however, a clear knowledge practice gap was evident. Although 79.4% acknowledged the importance of lifestyle changes, only 45.8% followed a hypertension-specific diet. Structural barriers included low income (39.3% earning <R3 000/month) and long distances to clinics (46.7% living ≥5 km away). Health worker advice strongly predicted dietary adherence (OR = 6.36, p = 0.001), lifestyle adherence (OR = 4.24, p = 0.006), and overall self-management (OR = 12.46, p = 0.024), whereas knowledge alone did not. Conclusions: Hypertension management is constrained more by structural and health system factors than by lack of awareness. Strengthening primary health care counselling and community-based health education may improve sustained lifestyle change and outcomes.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091164

Authors: Miguel Medeiros da Silva Luiz Alves Morais Filho Janmilli da Costa Dantas Santiago Isaque Augusto Rosendo Costa Richardson Augusto Rosendo da Silva Cristiane da Silva Ramos Marinho

Objective: To analyze the association between income inequality and age-standardized mortality from diabetes mellitus and hypertensive diseases among adults aged 30–69 across Brazilian Federative Units (2012–2024). Methods: Ecological longitudinal study using balanced panel data from the 27 Federative Units. Data were retrieved from the Mortality Information System and IBGE/IPEA databases. Mortality rates were standardized using the direct method (WHO population). Trends were evaluated via Joinpoint regression, and associations were analyzed using mixed linear models with random intercepts and first-order autoregressive covariance structure. Results: Inequality decreased in 25 Federative Units, accompanied by rising income and declining poverty, whereas national aggregated analysis showed a linear increase in inequality (APC = 0.514%; p < 0.001). Overall mortality trends were stationary for diabetes (AAPC = −1.507%; p = 0.102) and hypertension (AAPC = −0.881%; p = 0.524), despite significant declines from 2021 to 2024. In adjusted mixed models, higher per capita household income was independently associated with lower diabetes mortality (β = −0.012; p = 0.031), while hypertension displayed an upward adjusted linear trend (β = 0.289; p = 0.001). Neither the Gini Index nor poverty rates maintained significant independent associations with mortality. Conclusions: After structural adjustment, only absolute per capita household income maintained an independent protective association with diabetes mortality, highlighting the relevance of material living conditions beyond inequality measures alone.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091163

Authors: Agata Kasprzak Karla Gabriela Gallo-Giunzioni

Family offenses constitute relational experiences that can have a profound impact on the psychological well-being of sons and daughters. Although forgiveness has been consistently associated with higher levels of well-being, the relational processes that account for this association remain underexplored, particularly from the perspective of adolescent and emerging adult sons and daughters. The present study used a cross-sectional design to examine whether the desire for reconciliation mediates the relationship between the positive and negative dimensions of forgiveness (affective, behavioral, and cognitive) and psychological well-being following a family offense. A non-probability convenience sample of 419 Spanish young people and emerging adults from the general population, aged between 16 and 25 years (M = 20.54, SD = 2.69), was recruited across Spain through university channels, social media and snowball sampling, and an online survey was completed. Participants completed the Enright Forgiveness Inventory (EFI-30), the Desire for Reconciliation Scale (DRS) and the Psychological Well-Being Scales for Youths–Short Form (PWB-YS-SF). Results indicated a pattern of associations consistent with the desire for reconciliation, mediating the relationship between all forgiveness dimensions and psychological well-being. These associations remained significant after adjusting for sociodemographic and offense-related covariates. However, the distinction between partial and full mediation across dimensions was not robust enough to correct for multiple testing, and when the overlap among the six highly intercorrelated dimensions was controlled, only positive affect and positive cognition retained a unique association with the desire for reconciliation. Overall, the findings suggest that the link between forgiveness and well-being in young people is partly accounted for by the desire to repair the family relationship.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091162

Authors: Jimmy T. Efird Genevieve N. Dupuis Yuk Ming Choi Cynthia Hau Sonia T. Anand Michael J. Davenport Maria Androsenko Kaitlin J. Cassidy Robert A. Lew Hongsheng Wu

Results of a clinical trial may misrepresent the target population. Inappropriate inclusion/exclusion criteria, selective recruitment, and differential participation may restrict the number of patients who consent to join the study. Frequently, they differ from the real-world population in terms of key outcome-related characteristics. Such biased selection may make the therapeutic agent seem more or less effective within a certain stratum. While block randomization and an intent-to-treat design can help to minimize confounding within the trial sample, differences may still exist with respect to the distribution of these variables in the population. To mitigate misleading conclusions, the current manuscript illustrates how to ‘population-adjust’ survival estimates in a clinical trial using the Beckett–Bayes expansion method. In contrast to other population adjustment methods, this novel approach involves substituting the probability of belonging to a specific sample stratum with the corresponding population data (i.e., population borrowing). As a regression-free technique, the method is not susceptible to model misspecification. A large clinical trial focusing on cardiovascular-related deaths in patients with hypertension is used as an example to illustrate the method. The proposed framework is promising and easy to implement when reliable population-level information is available.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091161

Authors: Olga Malas Marwa Khan Aisha Zubair

Background: Needle fear (NF), vaccination fear (VF), and conspiracy beliefs (CB) have been negatively associated with vaccination intention (VI), although the mechanisms linking these variables remain unclear. The aim of this cross-sectional exploratory study was to shed light on these relationships. Methods: The sample comprised 777 adults from the educational community in Pakistan (M = 23.39 years, SD = 6.83; 72.6% female), including students, academic/research staff, and administrative/support personnel. Descriptive and correlational analyses were conducted, followed by structural equation modelling (SEM) to examine the direct and indirect relationships among the study variables. Results: NF was not directly associated with VI. The best-fitting SEM model was the sequential model NF → VF → CB → VI. These findings suggest that the relationship between NF and VI is indirect through VF and CB. However, due to the cross-sectional design, the temporal direction of the associations cannot be established, and alternative explanations remain possible. Conclusions: These findings suggest that the relationship between NF and VI is indirect and is manifested through VF and CB. However, given the exploratory nature of this study and the use of ad hoc measures, further research is needed to determine whether VF and CB stem from NF or, alternatively, may serve as cognitive justifications for it.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091160

Authors: Juanita-Dawne R. Bacsu Marc Viger Alixe Ménard Maya Kluch-Morrell Anila Virani Claudia Gonzalez Wendy Hulko Jim Mann Melba Sheila D’Souza Matthew Lee Smith Myrna Norman Sheila Blackstock Mark Rakobowchuk

Although dementia-related stigma is well-documented, there is a paucity of research examining intergenerational activities to reduce stigma within rural settings. Using a World Café approach, the objective of this paper was to explore rural stakeholders’ ideas and perspectives on intergenerational strategies to reduce dementia-related stigma in rural communities. Seventy-five participants engaged in a facilitated workshop held in Kamloops, British Columbia, Canada, on 14 May 2025. Discussions were transcribed and analyzed using Braun and Clarke’s thematic analysis framework. The findings highlighted three themes for reducing dementia-related stigma in rural communities: (1) contact activities that promote meaningful interactions (e.g., shared hobbies, arts programs, and reminiscence activities) between people living with dementia and others across age groups; (2) educational interventions that enhance dementia knowledge and awareness (e.g., dementia information integrated into educational institutions across the life course); and (3) mixed interventions that combine contact-based and educational approaches. Moving forward, further research is needed to co-design, implement, and evaluate the impact of specific interventions. This study provides critical insights to inform the development of dementia stigma-reduction programs, policies, and interventions in rural settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091159

Authors: Trevor J. Murphy Megan Jung An-Fu Hsiao Nichole M. Martin Alec J. Jimenez Andrea Munoz Jennifer Lai-Trzebiatowski Tyler C. Smith Michael Hollifield

Background: This narrative concept-generating review proposes a theoretical and heuristic framework for conceptualizing established and emerging interventions for posttraumatic stress disorder (PTSD) including three categories: top-down/conscious (e.g., cognitive processing therapy, CPT), bottom-up/non-conscious (e.g., pharmacotherapy) and hybrid/conscious and non-conscious integration (e.g., eye movement desensitization and reprocessing, EMDR). The categorization offers a preliminary novel classification of well established and emerging interventions, while highlighting gaps in current treatment approaches. Methods: Clinical guidelines and review articles from 2008 through 2026 were used to create the framework; PubMed and Google Scholar databases were searched for relevant meta-analyses, systematic reviews, narrative reviews, and randomized clinical trials. A total of 27 treatment modalities were included presenting effect size data from 43 published articles. Results: Treatments across categories present mixed results for efficacy. While guideline recommended treatments offer more robust evidence, many understudied emerging interventions exhibit preliminary efficacy. At the intersection of conscious and non-conscious approaches, hybrid modalities may present unique potential benefits. However, superiority determinations between modalities cannot be made and further empirical validation of categorization is needed. Conclusions: The proposed framework highlights the need for increased investigation of treatments that address PTSD as an interconnected whole-body disorder to potentially expand care options.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091158

Authors: Diego De Leo Josephine Zammarrelli Elena Zamò Fausto Carlo De Rossi Francesca Lippi Martina Andrea Viecelli Luca Vannucci Cristina Bordignon

Background: Climate change is being recognized as a factor associated with increased suicidal behavior, especially in the older adult population. Extreme temperatures, thermal anomalies, and intense weather events can amplify pre-existing physical, psychological, and social vulnerabilities, increasing the risk of suicidal ideation and behavior in older adults. Objectives: This systematic review aims to map the literature on the relationship between climate change and suicidal behavior in older people, identifying risk and protective factors, as well as the prevention and intervention strategies aimed at this age group. Methods: A systematic review was conducted according to PRISMA guidelines. The literature search was performed in the EBSCO PsycINFO, Scopus and MEDLINE (PubMed) databases in the period 2007–2025, using combinations of the keywords “climate change”, “global warming”, “older adults”, “elderly”, “suicide”, “suicidal ideation” and related terms. Out of 35 studies, 16 articles were included in the final analysis. Results: Five thematic areas emerged from the analysis of the studies: (1) risk factors, (2) protective factors, (3) sociodemographic factors, (4) prevention and intervention strategies and (5) variables associated with suicidal behavior. Across the included studies, suicidal ideation, non-fatal attempts, and suicide mortality were examined with differing frequency and are reported separately in the thematic synthesis rather than pooled, reflecting the heterogeneity of outcome definitions and study designs. Significant limitations in the literature remain, including the paucity of longitudinal studies, the widespread use of aggregate data and the limited integration of environmental, social, and psychological factors. Conclusions: Climate change and extreme weather events may contribute to suicidal behavior in older adults. It is therefore necessary to develop multidimensional approaches that address structural vulnerabilities and promote the active role of older adults in climate resilience and social cohesion.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091157

Authors: Yirong Jia Catalina Turcu

Urban nature-based solutions (NbSs) are increasingly deployed to address climate risks, yet their health co-benefits remain poorly understood. This paper presents a secondary analysis of 90 peer-reviewed, English-language China-specific studies drawn from a registered systematic review covering January 2015 to April 2025. Evidence was analyzed by geographical distribution, NbS category, climate-adaptation pathway, health outcome, and greenness measurement, with complementary comparison against 88 non-China-specific studies. Air-quality pathways and physical-health outcomes predominated, whereas heat received less attention, and only one study examined flood-related health. Thirty studies (33.3%) were located wholly in eastern China, while 9 of the 31 mainland provincial-level jurisdictions lacked dedicated or separately reported evidence. Setting-based greenery dominated the five-category NbS classification. Of 126 association units, 100 (79.4%) were favorable; null or adverse findings were confined to specific exposures or contexts, including allergenic or low-diversity vegetation and reduced visibility. Although the two subsets covered broadly similar topics, China-specific studies relied more heavily on aggregate greenness indices (e.g., NDVI: 73.3% versus 45.5%), less often distinguished vegetation types or strata (14.4% versus 36.4%), and included no studies treating urban trees or community gardens as distinct exposures. These findings support five China-specific policy priorities and adapt four international policy themes to Chinese governance contexts.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091156

Authors: Adelinda Araújo Candeias Adriana Simões Félix

Population ageing, social isolation, and limited opportunities for meaningful contact between generations pose important challenges to healthy ageing and community well-being. This mixed-methods pilot study examined the feasibility, acceptability, co-creation process, and preliminary outcomes of the P-IN Programme, a community-based intergenerational intervention involving preschool children and older adults living in residential care. The programme was developed and implemented in partnership with a preschool and a residential care facility in Portugal and comprised ten intergenerational sessions shaped through an iterative co-creation process involving participants, professionals, and researchers. Twenty-three children, eighteen older adults, and five professionals contributed to the study. Quantitative pre–post assessment explored fluency in both generations and cognitive functioning, quality of life, subjective well-being, and social participation in older adults. Qualitative data examined intergenerational beliefs, participants’ experiences, relationships, and reciprocal learning, while also informing the co-creation process. Most quantitative outcomes remained stable, although cognitive functioning showed a moderate, non-significant effect. Perceived quality of life changed significantly in an unfavourable direction. In contrast, qualitative findings revealed broader and more relational representations of the other generation, alongside shared experiences and clearer recognition of reciprocal learning. The integration of both components showed that positive relational and experiential changes were not necessarily accompanied by changes in broader standardised outcomes. Overall, the P-IN Programme was feasible to implement and generally well received within the two participating community settings. These findings support further evaluation of co-created intergenerational programmes using larger samples, controlled designs, and longer-term follow-up.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091155

Authors: Md Badrul Hyder Ranjan Datta Didem Erman Mozharul Islam Mustahseem Chowdhury Ruksana Rashid Tanvir C. Turin

Climate change perception among youth has gained increasing scholarly attention; however, immigrant youth remain underrepresented in empirical research despite navigating climate change impacts across multiple sociocultural and geopolitical contexts. This study investigates (1) immigrant youths’ beliefs about climate change, (2) how climate risks are perceived across space and time, and (3) how they construct their climate change beliefs and associated risks. Drawing on Social Constructivism, and Risk Perception Theory, the study employs a qualitative descriptive design using eight focus group discussions with 41 immigrant youth aged 14–18 in Calgary, Canada. Reflexive thematic analysis reveals that immigrant youth widely recognise climate change as real and intensifying, with beliefs shaped through lived and observed environmental experiences, social interaction, family narratives, and transnational comparisons rather than abstract scientific reasoning alone. Climate risk perception emerges as complex and relational. Participants associated climate change with impacts on health, wellbeing, food security, and everyday life; however, they often perceived its most severe consequences as temporally and spatially distant. This produces a notable “belief–risk gap,” where acceptance of climate change does not translate into a strong sense of personal vulnerability or urgency. Risk perceptions are mediated by everyday experiences, institutional trust in the host country, and comparisons with other global crises. The findings highlight the critical role of transnational experiences in shaping climate understanding and advance an integrated interpretation linking socially constructed climate knowledge with perceptions of risk and psychological distance, with implications for climate communication and public health communication strategies for immigrant youth.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091154

Authors: Anyelle Barroso Saldanha Denise Lima Nogueira Tiago Neuenfeld Munhoz Marcia Maria Tavares Machado Luciano Lima Correia Ana Cristina Lindsay

Parenting practices involving violent discipline are a global health concern, particularly among low-income families. While the current literature offers general prevalence data, it lacks a comprehensive global perspective evaluating how diverse sociodemographic, cultural, and historical contexts intersect within disadvantaged households. This scoping review protocol aims to map the global evidence on parenting practices related to physical and psychological violence used as disciplinary practices against children within low-income contexts. Following the JBI Manual for Evidence Synthesis and PRISMA-ScR guidelines, we will conduct a comprehensive search across databases, including MEDLINE/PubMed (via the National Library of Medicine), CINAHL (EBSCO), APA PsycINFO (APA), Embase (Elsevier), ERIC, IBECS (via the VHL) and the WHO Global Index Medicus to capture global evidence published in recent years. Studies published in English, Portuguese, and Spanish between January 2015 and June 2026 that report violent disciplinary practices by parents or caregivers of children aged 1–8 years will be included. Rayyan software will assist with study selection. Mapping these practices across diverse socioeconomic settings may clarify current research gaps and synthesize the characteristics of families globally, shifting the interpretation of violent discipline from isolated parental choices to broader understanding of its social determinants and providing a clearer baseline to support future child protection research.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091153

Authors: Şehma Şen Meserret Aslan Songül Gökkaya Elif İlhan

Background: Breastfeeding myths held by healthcare professionals may affect the accuracy and consistency of counseling provided to women and families. This study evaluated nursing and midwifery students’ breastfeeding myths and associated factors. Methods: This descriptive, cross-sectional study included 218 nursing and midwifery students at a university in Türkiye. Data were collected using a Personal Information Form and the Breastfeeding Myths Scale (BMS). Descriptive statistics, nonparametric tests, Spearman correlation, and a multivariable generalized linear model with robust covariance estimates were used. Results: The mean age was 21.24 ± 1.80 years, and 196 participants (89.9%) were female. The mean BMS score was 67.43 ± 16.39; 214 students (98.2%) had low myth levels and 4 (1.8%) had high levels. In unadjusted analyses, scores differed by gender, department, academic year, family breastfeeding experience, perceived knowledge, and age. In the adjusted model, female students had lower scores than male students (B = −9.481, 95% CI: −18.261 to −0.700, p = 0.034), nursing students had lower scores than midwifery students (B = −4.557, 95% CI: −8.321 to −0.793, p = 0.018), and each one-year increase in age was associated with a 1.52-point decrease in BMS scores (B = −1.524, 95% CI: −2.884 to −0.163, p = 0.028). Academic year, parental education, family income, family breastfeeding experience, and perceived knowledge were not independently associated with BMS scores. Conclusions: Most students had low levels of breastfeeding myths. Female gender, nursing enrollment, and older age were associated with lower BMS scores; however, the gender finding should be interpreted cautiously because all male participants were nursing students.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091152

Authors: Jongseong Gwak Takayuki Fujie Akira Motohashi Tatsumi Tokunaga

Community-based digital transformation (DX) initiatives are increasingly used to promote healthy aging, although their effects are often evaluated using subjective self-reported measures. This study aimed to quantitatively evaluate a community DX health promotion initiative with Takashimadaira as its primary target area in Japan using wearable sensor data. A total of 500 community-dwelling older adults participated in the initiative, and wearable sensor data were obtained from 355 participants during the five-month observational period. The initiative combined wearable device distribution with event-information dissemination via the messaging platform. Daily step count and heart-rate indices were analyzed. Within-participant analyses showed significant increases in daily step counts in the information-provision groups, whereas the primary linear mixed-effects model showed no significant information-provision × time interaction for daily step count. Information provision was associated with differences in mean and minimum daily heart rate in cross-sectional analyses. Adherence and dropout also varied by residential area. Age, BMI, and exercise frequency were associated with several health-related indices, but these associations were not interpreted as evidence of wearable measurement validity. These findings demonstrate the potential utility of using wearable sensor data to evaluate longitudinal changes in health-related behavior and physiological signals in community-based DX initiatives, while also revealing important feasibility limitations, including substantial attrition (only 222 of 355 participants met the 14-day criterion; 90-day dropout 58.3%) and indicating that observed within-participant changes should not be interpreted as demonstrated intervention effects. Community context may also be relevant to sustained participation in such programs.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091151

Authors: Arvind Bagde Hannah Burton Sediqua Mctier Sanskar Chouhan Rajesh Singh Rathore Tammie Johnson Mandip Singh

Cannabis use is expanding rapidly across the United States, yet product quality and consumer safety knowledge remain significant public health concerns. This cross-sectional study surveyed 325 adults in Florida dispensary customers (n = 185) and general public participants (n = 140) to compare cannabis use patterns, purchasing behaviors, and safety awareness. Cannabinoid gummy products were characterized using texture analysis; oil and topical formulations were evaluated for label accuracy by high-performance liquid chromatography (HPLC) against USP specifications (90–110% of label claim). Inter-laboratory variability accelerated stability testing, and a machine learning microsimulation projecting knowledge trend (2026–2031) were also conducted. Texture analysis revealed substantial variability in mechanical properties across gummy brands. Oil and topical formulations demonstrated generally acceptable labeling accuracy, though significant inter-laboratory variability in CBD quantification was observed. Dispensary respondents reported more frequent cannabis use, stronger brand loyalty, greater perceived quality-of-life benefits, and higher product knowledge than the general public; however, critical safety knowledge gaps regarding THC–cardiovascular drug interactions and pregnancy risks persisted across both groups. These findings highlight the need for stronger product quality standards, standardized analytical testing, and targeted public health education to promote safe and informed cannabis use.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091150

Authors: Lāsma Spundiņa Una Veseta Agita Abele Māris Munkevics

PA is associated with numerous physical and mental health benefits, while self-efficacy is an important associated factor of health-related behaviors. However, evidence of the relationship between general self-efficacy and PA among healthcare students remains limited. This cross-sectional study included 747 healthcare students who completed an online survey comprising the General Self-Efficacy Scale (GSES), IPAQ-SF, and measures of PA habits. A subsample of 50 participants additionally completed one week of activity monitoring using a Fitbit Versa 4. Associations were examined using non-parametric tests, Spearman’s rank correlation analyses, and multivariable linear regression models. Higher general self-efficacy was associated with greater self-reported PA, more frequent PA habits, and better self-rated physical fitness. Self-efficacy was also weakly associated with lower sitting time during weekends, but not during working days. Bivariate associations between self-efficacy and physical activity-related measures were weak (|ρ| ≤ 0.284). Total self-reported PA remained independently associated with self-efficacy in multivariable models, while the association with exercise frequency was attenuated after accounting for self-rated physical fitness. Model explanatory power was modest (adjusted R2 = 0.054–0.073). No clear associations were observed between self-efficacy and objectively measured weekly steps or active zone minutes. The agreement between self-reported and device-based measures was partial. General self-efficacy was associated with self-reported PA and perceived physical fitness, although associations were modest. Findings should be interpreted cautiously given the cross-sectional design, small monitoring subgroup, and multiple exploratory comparisons. Longitudinal studies are needed to clarify temporal relationships.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091149

Authors: Kanokporn Somporn Niwat Songsin Sittichai Singsu Adithep Phranphithak

Background: Health-promoting behavior is central to healthy aging, and digital platforms are an increasingly important channel through which older adults encounter health information. This study examined demographic, health-status, and health-related social media use factors associated with health-promoting behavior among older adults in Samut Songkhram Province, Thailand, a small province with a disproportionately large share of older residents. Methods: A cross-sectional study was conducted among 402 community-engaged, functionally independent adults aged ≥ 60 years, recruited through a mixed multistage procedure with convenience recruitment at the individual level in the final stage, at community gathering points. Health-related social media use (22 items, four proposed content domains) and health-promoting behavior (31 items, six domains, adapted from the Health-Promoting Lifestyle Profile-II) were measured using structured, pilot-tested questionnaires. Associations were assessed with Spearman correlation and simultaneous multiple linear regression. Because regression diagnostics indicated heteroscedasticity, HC3 heteroscedasticity-consistent standard errors, 95% confidence intervals, and p-values were used as the primary regression inference. Results: Overall health-related social media use (M = 2.58, SD = 0.55) and health-promoting behavior (M = 3.34, SD = 0.48) were both classified as “high” under the pre-specified four-band descriptive convention. The adjusted model explained 54.65% of the variance in health-promoting behavior (R2 = 0.5465; adjusted R2 = 0.5349). Under HC3 robust inference, overall health-related social media use (β = 0.715, p < 0.001), marital status, bachelor’s-degree-or-higher education (inverse association), chronic condition status, and average monthly income (small inverse association, p = 0.032) were independently associated with the outcome. In a domain-specific sensitivity model, general/recreational use (B = 0.439, HC3 95% CI: 0.345 to 0.533, p < 0.001) and diverse types of use (B = 0.112, HC3 95% CI: 0.040 to 0.184, p = 0.002) were independently associated with health-promoting behavior, whereas duration of use and interpersonal health communication were not. Conclusions: Greater overall health-related social media use was associated with health-promoting behavior among community-engaged, functionally independent older adults; however, the domain-specific pattern suggests that this association primarily reflects broader digital/social engagement rather than specifically health-focused social media activity. Given the cross-sectional design, weak support for the proposed social-media subdomain structure, and the possibility of common-method variance and construct overlap, the findings should be regarded as hypothesis-generating and require confirmation in longitudinal or intervention studies using psychometrically refined measures.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091148

Authors: Joan Nankya Mutyoba Julius Kiwanuka Lourita Nakyagaba Sara Nsibirwa Emmanuel Seremba Ponsiano Ocama

Background: Strengthening hepatitis B(HBV) linkage and retention in care remains critical to the elimination of population health risks posed by HBV. Yet too few studies have assessed the effectiveness of peer-support-driven HBV care models in enhancing continuity in care in low-resource settings. Methods: We co-designed and evaluated the impact of a treatment peer-support (TPS) intervention on HBV linkage and retention in care at two study sites (Arua and Koboko Hospitals) located in the north-west sub-region of Uganda using a quasi-experimental interrupted time series design and assessed factors related to long-term retention. Results: After TPS intervention, changes in the post-intervention trends of linkage to care of 16.2% (95% CI: 3.3, 29.0) (p = 0.014) and 45.9% (95% CI: 26.1, 65.6) (p < 0.001) were observed for Arua and Koboko respectively. Differences between pre- and post-intervention trends were 11.9% (95% CI: 0.3, 23.5) (p = 0.044) and 34.6% (95% CI: 29.5, 39.7) (p < 0.001) for Arua and Koboko respectively. The post-intervention level change for early retention increased by 6.4% (95% CI: 0.4, 12.4) (p = 0.035) at Arua but not at Koboko (22.8%, 95% CI: −20.9, 66.5) (p = 0.306). At Arua, the TPS intervention correlated with an overall declining trend of −3.9% (95% CI: −5.4, −2.3) (p < 0.001), while at Koboko it correlated with a difference between pre- and post-intervention trends of 0.7% (95% CI: −0.01, 1.4) (p = 0.053). For long term retention, the TPS intervention correlated with a change in post-intervention trend of −1.5% (95% CI: −2.3, −0.7) (p < 0.001) and a difference between pre- and post-intervention trends of −1.4% (95% CI: −2.1, −0.6) (p < 0.001) at Arua hospital. At Koboko hospital, the TPS intervention was associated with a difference between pre- and post-intervention trends of 12.8% (95% CI: 9.8, 15.8) (p < 0.001). In the stratified analysis, early retention was associated with the TPS intervention at Koboko (aPR = 1.16, 95% CI: 1.05, 1.28) (p = 0.004) but not Arua (aPR = 1.01, 95% CI: 0.95, 1.06) (p = 0.771). At Arua hospital, a previous history of HBV treatment predicted early retention in care (aPR = 1.08, 95% CI: 1.05, 1.11) (p < 0.001), whereas at Koboko, a PLHBV having a “treatment buddy” (aPR = 1.21, 95% CI: 1.11–1.33) (p < 0.001), being aged 19–24 years (aPR = 1.39, 95% CI: 1.04, 1.88) (p = 0.026) and being aged 25–34 years (aPR = 1.38, 95% CI: 1.04, 1.83) (p = 0.023) predicted early retention. Conclusions: Innovative interventions are needed to advance linkage to care and shift the trajectory of retention in long-term HBV care, including approaches that target young people living with HBV.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091147

Authors: Grace Heyborne Sujeong Kim Choongwon Jeong Martin Tristani-Firouzi Edgar J. Hernandez Melissa A. Ilardo

Background: Despite having one of the highest prevalences of hypertension in Korea, Jeju Island maintains the lowest rate of stroke mortality nationwide. This paradoxical cardiovascular disease health profile raises questions about the underlying factors contributing to differential stroke risk in the Jeju population. Methods: We used health data from the Korea National Health and Nutrition Examination Survey (KNHANES) to investigate whether differences in regional stroke outcomes can be explained by known environmental and behavioral health contributors to increased cerebrovascular disease risk. We applied logistic regression with backward feature selection and cross-validation to identify predictors of parental history of stroke. Results: We found that individuals from Jeju Island were less likely to report a parental history of stroke compared to individuals from Seoul. This finding persisted even after adjusting for known cerebrovascular risk factors, including age, sex, SBP, antihypertensive use, dietary sodium intake, BMI, and hematocrit. Conclusions: Our results suggest that other hidden factors may contribute to the risk of cerebrovascular disease. Given the unique genetic architecture of the island, these findings prompt future analyses to explore whether genetic variation on Jeju contributes meaningfully to their reduced stroke mortality.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091146

Authors: Alexandru Mazareanu Claudia Grigorov Alin Pandea Maria Iacob Dragos George Balaiasa Tzvika Greenbaum Petr Konecny

In the original publication [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091145

Authors: Faith Summersett Williams Isabella Zaniletti Lindsay F. Schwartz Robert Garofalo Lisa M. Kuhns Karin Felsher Yiyang Liu Melissa Simon

POI and EOI are rare but impactful conditions among adolescents and young adults (AYAs). Little is known about the timing and incidence of mental health (MH) conditions among AYAs diagnosed with POI/EOI. Data were collected using MarketScan Medicaid administrative claims among females aged 12–25 with POI/EOI. Merative™ MarketScan® Research Databases are large, de-identified U.S. administrative healthcare claims databases that contain individual-level information on enrollment, inpatient and outpatient medical services, and outpatient prescription drug claims. The databases include commercially insured individuals, Medicare beneficiaries with employer-sponsored supplemental coverage, and selected Medicaid populations. Claims are linked longitudinally using unique encrypted patient identifiers, allowing individuals to be followed over time across healthcare settings. In addition to healthcare utilization, the databases include demographic characteristics, diagnosis and procedure codes, dates of service, and payment information, making them well suited for epidemiologic, health services, and outcomes research. We characterized prevalence and timing of MH diagnoses, examined MH subtypes, and estimated new-onset MH among those without prior MH. Comparisons were made to demographically matched controls without POI/EOI (matched on age and calendar time) and to diagnosis-anchored comparator groups. Among 859 AYAs with POI/EOI, 53.9% had any MH diagnosis, including 32.9% with MH diagnoses before and after POI/EOI diagnosis and 11.9% with new-onset MH after POI/EOI diagnosis. Of all anxiety disorders, 60.1% were present pre- and post-diagnosis, while 25.4% were new-onset after diagnosis. Depressive disorders showed a similar pattern, with 58.1% being pre- and post-diagnosis MH group and 22.3% being new-onset. In total, 49.4% of individuals with trauma-related disorders had the diagnosis both before and after POI/EOI diagnosis, while 30.1% had it as a new-onset. In adjusted models, POI/EOI was associated with increased odds of MH diagnoses after diagnosis (aOR ~2.1, 95% CI ~1.4–3.1). Prior MH diagnoses were the strongest predictor of MH after diagnosis (aOR ~12.1). AYAs with POI/EOI experience substantial MH burden, with elevated risk of new-onset MH conditions following diagnosis. Findings highlight the importance of early MH screening and integrated care models for AYAs.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091144

Authors: Kirsten Robertson (Kāi Tahu) Tui Kaitai-Martin (Kāi Tahu) Rob Thomson Diane Ruwhiu (Ngā Puhi) Maree Thyne

Māori experience inequities in the recognition of mate wareware and in access to dementia and aged care support in Aotearoa New Zealand. Less is known about how whānau experience supporting a whānau member with mate wareware, what support they find helpful, and what they consider important for mate wareware-friendly communities. This kaupapa Māori qualitative study involved a co-design phase with seven kaumātua, which informed the study questions and whānau hui guide, followed by ten in-depth whānau Māori hui involving 12 individual participants; the whānau hui formed the analytic dataset. Whānau hui data were analysed using reflexive thematic analysis. Four interconnected themes were developed: delayed recognition; whānau caregiving as collective strength alongside concentrated responsibility; sustaining wairua, identity, and belonging; and care transitions and structural barriers. Interpreted together, these themes informed a four-condition account of mana-preserving care, in which mana may be sustained or eroded through interactions among recognition and knowledge, whānau caregiving, wairua, identity and belonging, and service and institutional conditions at transitions. Where continuity fragmented, whānau frequently undertook integrative work to bridge gaps across people, places, culture, and services. The findings point to earlier mate wareware information and support through Māori-facilitated and community-based approaches, support that recognises concentrated caregiving responsibility, continuity across services and transitions, and routine practices that embed tikanga, while reducing reliance on whānau to compensate for fragmentation.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091143

Authors: Simona N. Shirley Bisakha Sen Ye Liu Rajarshi Dey Elizabeth H. Baker Laurie A. Malone

Background: Urban tree canopy, the proportion of a city’s land surface covered by trees, has been linked to physical and mental health benefits. This association is understudied in the U.S. Deep South despite its high burden of poor health and environmental inequity. This study examined associations between census tract-level tree canopy and self-reported mental and physical health in urban Alabama. Methods: We linked tract-level tree canopy estimates for Alabama metropolitan statistical areas with self-reported health and contextual measures from publicly available data, retaining tree canopy as the exposure of interest. A bootstrap-stabilized penalized variable-selection approach identified covariates from socioeconomic, demographic, housing, transportation, environmental, and health-related measures; we then mapped spatial distributions and fit spatial error multivariable models. Results: A higher proportion of land surface covered by trees was associated with a lower age-adjusted prevalence of adults who report 14 or more days during the past 30 days during which their mental health was not good (estimate: −0.0110; p < 0.001). A higher proportion of land surface covered by trees was also associated with a lower age-adjusted prevalence of adults who report 14 or more days during the past 30 days during which their physical health was not good (estimate: −0.0045; p = 0.002). Spatial error parameters persisted in both models, indicating residual spatial patterning not fully explained by canopy or the selected covariates. Conclusions: The findings extend the urban tree canopy literature to an understudied setting and demonstrate how publicly available tract-level data, combined with machine learning-guided covariate selection and spatial modeling, can generate actionable hypotheses for environmental health and equity research.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091142

Authors: Mildred Naamwintome Molle Sulemana Ansumah Saaka Cornelius K. A. Pienaah Elijah Bisung Isaac Luginaah

In semi-arid Ghana, girls bear primary responsibility for household water collection in communities without on-premises access, a burden intensified by climate change associated with rising temperatures and frequent droughts. Yet little is known about how this responsibility shapes their embodied health and well-being. Guided by a political ecology of health framework, this qualitative study examined how water insecurity shapes girls’ physical, psychosocial, and neurological health in two communities, Wechiau and Kandue, in Ghana’s Upper West Region. We conducted in-depth interviews with nineteen purposively selected girls aged 10 to 19 and analyzed the transcripts thematically. Four interconnected themes emerged: structural and political determinants of water access, environmental and ecological conditions, gendered social relations, and embodied health consequences. Financial barriers, governance failures, and infrastructure deficits force girls into long queues and repeated trips, a burden that falls disproportionately on girls under cultural norms exempting boys from water duties. This gendered allocation of labour produces gendered health harm, whereby girls sustain musculoskeletal pain and injury carrying heavy loads over hazardous terrain, while chronic time loss disrupts sleep, schooling, and psychological well-being. Girls with pre-existing conditions such as epilepsy face the most acute risk, as water fetching directly exacerbates their vulnerability to seizures. These findings show that addressing this crisis requires more than infrastructure investment. Coordinated public–private investment in water access must be paired with social protection for vulnerable households, gender-responsive water policy, and rainwater-harvesting strategies that confront the structural and gendered inequities placing this burden on girls.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091141

Authors: Sharon Mallon Jessica Runacres Fiona McCormack Victoria Riley Emily Motta-Yanac

Background: Gambling-related harm is recognised as a public health concern, yet limited synthesis has examined how shame, stigma and indebtedness shape help-seeking and suicidality across gendered and cultural contexts. This review addressed the following question: among individuals experiencing gambling-related harms, how do cultural and gender-based understandings of shame and indebtedness influence suicidality and help-seeking across diverse settings? Methods: This rapid review searched MEDLINE, PsycINFO and CINAHL, alongside grey-literature and reference-list searches, for studies since 2000. Included studies were appraised (CASP, MMAT, or MQC-SP) and synthesised narratively. Results: Twenty-six qualitative, quantitative and mixed-methods studies were included. Gambling was portrayed as socially embedded and normalised, while gambling-related harm remained associated with judgement. Shame was linked to concealment, self-management and delayed disclosure. Indebtedness was associated with concealment, relationship strain, and sometimes made previously hidden gambling-related harm visible; however, the evidence did not allow firm conclusions about its relationship with crisis or suicidality. Help-seeking commonly occurred after harms had escalated and was facilitated by confidential, non-judgemental and culturally appropriate support. Gender and culture shaped meanings of responsibility, control, family reputation and disclosure, but were rarely examined analytically. Conclusions: Public health responses should improve early recognition of gambling-related harm through clear, non-judgemental messaging and stronger links between support services. Further research should clarify how shame, stigma and indebtedness relate to disclosure and suicidal distress, and should evaluate public health messaging, early-support routes, self-directed interventions and support for affected others.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091140

Authors: Joy M. Rooney

Background: Subjective wellbeing frameworks are widely used to determine individual and collective holistic dimensions of wellness. Increasingly, they may be linked to objective measures for use in government wellbeing policy-making across the world, although their cultural sensitivity is questioned. Methods: Fifty-nine peer-reviewed studies published between 2000 and 2026 were identified following Boolean searches in open access journals, screened, and quality assessed. Translated Western-English frameworks of seven authorities were compared, as were those ten within indigenous cultural groups. Ten other studies for consideration included objective and cultural dimensions. The remainder were used in background and synthesis presentation. Results: Five themes were distinguished: use of solid theoretical background; conceptual rationale for framework; methodological limitations; links, convergence, divergence, and contradictions; conceptual rationale for interpretation of related findings and theoretical considerations. Within a cultural group, even with great care in translation, and semantic amendments, most authorities’ dimensions of wellbeing models were questioned. Many interesting and adequate indigenous frameworks need invariance and longitudinal testing. Studies including quantitative objective measures of wellbeing more clearly defined unique cultural group effects within their environments. Conclusions: Dimensions of wellbeing need to be created, validated and reliably evaluated within the cultural groups they are intended to be used, rather than using translations. Much more quantitative research is needed with lay-consultation before, during, and following longitudinal studies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091139

Authors: Marco Batista João Freitas Vera Simões Ana Conceição Marta Martins Eduardo Teixeira Paulo Rosa Hugo Louro

This study examined the relative contribution of sociodemographic, psychological, behavioral, and physiological factors to subjective well-being (SWB) among community gym users and investigated the indirect association between basic psychological need satisfaction and SWB through self-determined motivation. A cross-sectional study was conducted with 348 adults (31.53 ± 12.86 years) recruited from community gyms in Portugal. Participants completed validated measures of basic psychological need satisfaction, motivational regulation, life satisfaction, and positive and negative affect. Moderate-to-vigorous physical activity (MVPA) was assessed through self-reported weekly physical activity, and body composition through bioelectrical impedance. Hierarchical multiple linear regression and mediation analysis were performed. Missing data were addressed using multiple imputation. Psychological variables produced the largest increase in explained SWB variance (ΔR2 = 0.173, p < 0.001). MVPA added only 0.2% (ΔR2 = 0.002, p = 0.478), while body composition indicators added 1.0% (ΔR2 = 0.010, p = 0.303). The final model explained 21.7% of SWB variance. A significant indirect association through self-determined motivation was observed (B = 0.228, 95% CI [0.139, 0.324]). Psychological variables provided greater explanatory information about SWB than MVPA or body composition. The findings highlight the relevance of psychological experiences in exercise settings, while the cross-sectional design precludes causal interpretations.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091138

Authors: Nicola Magnavita

Polyendocrine metabolic ovarian syndrome (PMOS) is the most common endocrine disorder in working women. Workplace screening could contribute to the early diagnosis and treatment of this chronic condition. Fertile women who participated in a 2022 health food promotion campaign and had suspected eating disorders, overweight/obesity, metabolic abnormalities, sleep problems, or mental health concerns were interviewed about PMOS symptoms during their in-office medical examination. Twenty-eight of the 1170 women examined had symptoms of suspected PMOS. By 2023, 21 of these diagnoses had been confirmed by specialists. The prevalence of newly diagnosed PMOS among the women of childbearing age was 2.7% (CI95% 1.7; 4.2). The confirmation rate of the clinical suspicion of PMOS was 75% (CI95% 55.1; 89.3). Female workers with newly identified PMOS had a significantly higher frequency of eating disorders than their pre-menopausal colleagues and higher body mass index values, higher glycemia, and higher cholesterol values. PMOS patients also had higher depression symptom scores than other workers of childbearing age. In conclusion, with a short interview during mandatory medical examinations, the occupational physician can make a significant contribution to the diagnosis of PMOS, thereby hopefully improving the quality of life of women and reducing damage to their health.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091137

Authors: Louis Fang Alfred Allan Joanne M. Dickson

Purpose in life is a central motivational construct that has a profound influence on wellbeing. However, existing measures lack the breadth and precision needed to accurately capture this complex construct. In the present study, we aimed to develop a new measure rooted in a holistic, systems-based theoretical framework of purpose in life: the 18-item Multidimensional Measure of Purpose in Life II (MMOP-II). In Study 1, our confirmatory factor analyses in a sample of 303 university students (female = 82.5.%, white = 78.5%) supported a strong five-factor higher-order model fit, outperforming the three-factor and unidimensional alternatives. The Study 2 results replicated these findings in a sample of 290 community adults (female = 54%, white = 76.6%). The results from Study 2 also showed that the MMOP-II correlated with concurrent, convergent, and divergent validity measures in theoretically consistent ways. Across both studies, internal consistency reliability met adequate thresholds for all subscales as well as the total MMOP-II score. Overall, our results support purpose in life as a coherent, higher-order construct measurable by the MMOP-II. Future research should aim to examine the test–retest reliability of the MMOP-II and its generalizability in diverse samples.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091136

Authors: Areeba Irfan Jinnu Jimmy Zahraa Farhad Anugraha Lisa Ciju Reel Louai Aadith Soorya Arunkumar Maivizhichelvi Liju Susan Mathew Sneha Reji Jayakumary Muttappallymyalil

Adult vaccination is a critical component of preventive healthcare, reducing morbidity and mortality from vaccine-preventable diseases. Despite established recommendations, adult immunisation coverage remains suboptimal, particularly for vaccines beyond influenza and COVID-19. In the United Arab Emirates (UAE), limited evidence exists regarding adult vaccine uptake and determinants influencing immunisation behaviour within its diverse population. Understanding vaccine-specific coverage and associated sociodemographic, healthcare, and workplace factors is essential to guide targeted strategies that strengthen adult immunisation. A cross-sectional study was conducted among 1330 adults aged ≥ 18 years residing in the UAE. Data were collected using a structured self- or interviewer-administered questionnaire assessing uptake of recommended adult vaccines, including COVID-19, influenza, pneumococcal, herpes zoster, Tdap, and HPV. Sociodemographic characteristics, healthcare access, insurance status, workplace factors, and perceived barriers were also assessed. Descriptive statistics summarised vaccination coverage, and associations between uptake and key determinants were examined using SPSS version 30. Statistical significance was defined as p < 0.05. Overall, 71.0% reported receiving at least one adult vaccine. Uptake was highest for COVID-19 (64.9%) and influenza (57.8%), while pneumococcal, herpes zoster, and Tdap coverage remained low (12–13%). HPV uptake was 22.6% among females and 18.9% among males. Higher uptake was observed among females and adults. Social encouragement, insurance coverage, and healthcare access were associated with vaccination, whereas lack of awareness and logistical barriers hindered uptake. Although overall uptake was moderate, significant gaps persist. Integrating vaccination into routine healthcare services and addressing structural and communication barriers are necessary to improve adult vaccination coverage.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091135

Authors: Luis Armas Noel Singh Dias Sarah Rodriguez Brenda Barreto Jessy Dévieux

Rising global temperatures are intensifying the frequency, duration, and severity of extreme heat events, posing a growing public health burden worldwide. Heat exposure is increasingly recognized as a major contributor to morbidity and mortality, particularly in regions with high baseline temperatures and large vulnerable populations. This study examines long-term temperature trends and their unadjusted association with heat-related health outcomes across major cities in India and counties across South Florida from 2005 to 2023. Major cities in India are used as a high-burden reference setting with established heat adaptation strategies, providing a framework for understanding how similar risks are emerging in South Florida. This comparison is conceptual, given differences in data structure and availability across regions. A retrospective ecological analysis was conducted using secondary data. Climate variables included annual mean temperature, while health outcomes focused on age-adjusted heat-related hospitalization rates. Temporal trends were assessed using graphical analysis and exploratory statistical analysis to inform early public health adaptation strategies. South Florida exhibited a warming rate of approximately +0.0265 °F/year compared to +0.0230 °F/year in major Indian cities, indicating a slightly faster pace of temperature increase in the subtropical region. County-level regression models in South Florida showed strong model fit, with R2 values ranging from 0.356 to 0.615 (all p < 0.01), indicating a consistent positive relationship between summer mean temperature and heat-related hospitalization rates. Miami-Dade County demonstrated the strongest association (R2 = 0.615), while Palm Beach County showed greater variability despite maintaining a statistically significant relationship (p = 0.007). Across all counties, heat-related hospitalization trends increased over time in parallel with rising temperatures. These findings, even though exploratory and unadjusted, position South Florida as an emerging high-risk region, where increasing temperature trends are beginning to mirror patterns observed in historically heat-burdened settings such as India. Lessons from India’s implementation of heat action plans, early warning systems, and community-level interventions provide a framework for strengthening climate adaptation strategies in South Florida.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091134

Authors: Hui Guo Qiang Wang Yingqi Guo

Background: Postpartum depression (PPD) affects about 15–20% of women worldwide. While observational studies have increasingly linked nature exposure to improved perinatal mental health, the extent to which nature-based approaches constitute a viable non-pharmacological intervention for PPD remains unclear. This scoping review and evidence mapping aimed to systematically characterize the current evidence base for nature-based approaches in PPD and perinatal populations. Methods: We searched PubMed, Web of Science, PsycINFO, Embase, Cochrane Library, Medline, CNKI, and WanFang Data from inception to December 2025. Two independent reviewers screened titles/abstracts and full texts against predefined inclusion criteria, with disagreements resolved through discussion. Empirical studies investigating any nature-based approach (NBA) (e.g., nature exposure, green space, forest therapy) in pregnant or postpartum women were incorporated. The review followed the PRISMA extension for Scoping Reviews (PRISMA-ScR) guidelines. No formal risk-of-bias assessment was conducted, consistent with scoping review methodology. The narrative synthesis and evidence mapping methodology were used to classify findings by population type and research design. Results: Of 1245 screened records, 11 studies fulfilled the inclusion criteria. To address the specific question of nature-based approaches for PPD, we classified evidence by its directness: studies on women with clinically significant PPD symptoms were treated as direct evidence; studies on general perinatal populations were treated as indirect evidence. Evidence mapping uncovered a significant deficiency: there are no randomized controlled trials (RCTs) that have specifically assessed NBA for women with PPD. Direct evidence was confined to two qualitative studies elucidating favorable experiences of nature engagement among postpartum women facing mental health challenges. Indirect evidence from observational studies (n = 10) generally supported associations between exposure to residential green space—especially tree canopy cover—and reduced risk of PPD and psychological distress, although some studies reported null findings. Physical activity was identified as a partial mediator in several studies. Only one pilot RCT focused on general postpartum women, indicating feasibility but not achieving significant depression reduction. Conclusions: Although encouraging observational data suggest a correlation between nature exposure and improved perinatal mental health, robust RCT evidence for structured Nature-Based Interventions in postpartum depression populations is lacking. Subsequent research must formulate and evaluate standardized, theoretically informed NBA protocols specifically tailored for women experiencing PPD.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091133

Authors: Delvon T. Mattingly Meman Diaby Saber Feizy William A. Middleton Josie Ricketts Joy L. Hart Melinda Ickes Bethany Shorey Fennell

This study examined differences between daily and non-daily nicotine pouch (NP) use by adults across various contexts in the United States (U.S.). Data were drawn from a cross-sectional survey of adults (≥18 years) reporting past-year NP use (N = 1009). Differences between daily and non-daily use groups were assessed using chi-square tests. Among the sample, 17.5% reported daily NP use. Daily use was associated with greater intensity, higher nicotine strength, and distinct situational use, including at home, while commuting, and at work or school (all p < 0.01). Adults who used daily more often endorsed motivations related to stress reduction, craving management, convenience, and product appeal (p ≤ 0.03). Daily use was linked to perceiving NPs as less harmful relative to combustible and smokeless tobacco, and more addictive relative to combustible, vaporized, and smokeless products (p < 0.05). Current and former use of combustible tobacco products, but not other substances, was common and varied by daily/non-daily use. Finally, adults who used daily were more likely to report a diagnosed mental or behavioral health condition (p = 0.002). Daily NP use reflects more intensive and contextually flexible use with distinct motivations and perceptions, underscoring heterogeneity in use patterns and the need for continued surveillance and longitudinal research on potential health implications.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091132

Authors: Mothana Al Jabr Nouf Alalmaei Jory Almulhim Sadeem Saad Alkaluf Nour Ali Alnhwi Abdulrahman Alrashed Khalid Alkhawfi Doaa Alabdulkraim Saleh Alyousef Mohammed Yousef Al Mulhim Muthana Abdullah Al Sahlawi Ossama Zakaria

Chronic kidney disease (CKD) is an emerging public health problem, and low public awareness may result in late diagnosis and poor outcomes. We evaluated baseline knowledge of CKD among participants in a community awareness campaign and immediate knowledge change following a focused educational intervention. The study was designed as a biphasic pre- and post-intervention study that took place over the course of a 3-day public campaign that coincided with World Kidney Day on 13 March 2025. The campaign consisted of six educational stations on important topics of CKD, blood-pressure and blood-glucose measurements, with access to nephrologist consultation. Participants completed a validated questionnaire prior to and after attending the campaign. The changes in knowledge about kidney function, risk factors, symptoms, diagnostic methods, and treatment were evaluated. A total of 134 responses were received; 102 participants were eligible and completed both assessments. Knowledge scores and several item-level response proportions were higher immediately after campaign participation than before participation. The knowledge of diabetes mellitus as a risk factor for CKD increased from 34.3 to 80.4%, the knowledge of blood tests for renal assessment increased from 52.0 to 80.4%, and the knowledge of pharmacological treatments that slow down the progression of CKD increased from 52.9 to 78.4%. The percentage of people who think that herbal medicines are effective to treat CKD decreased from 19.6% to 8.8%. No demographic or clinical predictors of change in overall knowledge were statistically significant, although differences were seen in specific knowledge domains. These findings show higher CKD knowledge immediately after participation in a structured community campaign. Controlled studies with longer follow-up are needed to determine causality, durability, behavior change, and clinical impact.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091131

Authors: Anna Suraya Lelitasari Uci Sulandari Lulus Suci Hendrawati Edwina Rudyarti Yunita Sari Purba Putri Winda Lestari Defi Arjuni Ida Ayu Pusfitasari Diaz Rosita Dewi Cantika Fariyah Rahmah Nada Aqeel Faiz Deden Nursyafaat Sayhriel Imam Maryuni

(1) Background: Indonesia is one of the world’s largest consumers of asbestos, with widespread use of asbestos-cement roofing. Java Island, characterized by high population density and seismic vulnerability, presents a complex risk landscape for asbestos exposure. This study aimed to develop a district-level asbestos exposure risk map for Java by integrating asbestos roof prevalence, population density, and seismic hazard. (2) Methods: A descriptive, semi-quantitative approach was applied using secondary data from national statistics and geological hazard portals. Three variables—asbestos roof prevalence, population density, and seismic hazard—were categorized into five ordinal levels (very low to very high) and combined using GIS-based risk matrices to generate composite exposure risk maps. Sensitivity and statistical analyses were conducted to assess the robustness and internal consistency of the risk classification. (3) Results: Of 119 districts/municipalities, 43 (36%) were classified as very high risk and 45 (38%) as high risk under the primary GIS-based risk matrix classification. Major metropolitan corridors, including Greater Jakarta and Bandung, showed elevated risk where substantial asbestos use coincided with very high population density, whereas several southern and inland districts gained priority because of higher seismic hazard. Sensitivity analyses indicated that the classification was generally robust to moderate changes in weighting and threshold boundaries, although the predefined population density thresholds provided limited discrimination within Java. (4) Conclusions: Asbestos exposure risk in Java is both widespread and heterogeneous, shaped by the intersection of infrastructure, demographics, and seismic vulnerability. The map offers a practical tool for prioritizing asbestos control, public awareness campaigns, health surveillance, and disaster risk reduction measures in Indonesia.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091130

Authors: Francisco Epelde María Pilar Martínez López

Background: Oral creatine is biologically plausible as an adjunct in heart failure (HF), but its clinical efficacy and safety remain uncertain. Methods: We performed a PRISMA 2020 systematic review (PROSPERO CRD420261391605) of oral creatine supplementation in adults with HF. Randomized parallel-group and crossover trials formed the primary causal evidence base; non-randomized HF evidence was analyzed separately. Risk of bias was assessed with RoB 2 and certainty with GRADE. Results: Four randomized HF-only trials were identified as primary evidence, with one additional open-label HF study retained as exploratory evidence. Because studies differed in dose, duration, outcome definitions, measurement scales, crossover structure, and availability of variance data, meta-analysis was not considered defensible. Randomized evidence showed no consistent benefit for peak VO2, 6-min walk distance, quality of life, or cardiac systolic function. A preliminary signal was observed for selected peripheral muscle and muscle-energetic outcomes. Safety reporting was sparse and insufficient to establish long-term renal or clinical safety. Certainty was very low across critical outcomes. Conclusions: Current evidence does not support routine oral creatine supplementation in HF. Larger contemporary placebo-controlled trials with systematic safety surveillance are required.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091129

Authors: Anna Papadimitriou Eirini Karakasidou

Background: Eco-anxiety refers to an individual’s emotional response to environmental conditions such as air pollution and climate change. Eco-anxiety has been associated with various psychological variables; however, there is limited research on positive factors such as self-compassion. Previous studies have examined the relationship between eco-anxiety and certain dimensions of self-compassion, such as isolation and mindfulness, but have not investigated its relationship with self-compassion as a whole or with its other dimensions. Methods: The present cross-sectional study aims to address this gap by examining a sample of 586 adults of all genders from different regions of Greece. The participants were collected through convenience sampling and completed two scales: the Self-Compassion Scale and the Hogg Eco-Anxiety Scale (which has undergone a validation process in Greek). Results: Using linear multiple regression analysis, the results showed that isolation has a positive correlation with affective symptoms, rumination and behavioural symptoms. Mindfulness has a negative correlation with affective symptoms, behavioural symptoms and anxiety about personal impact. Anxiety about personal impact is positively associated with self-kindness and over-identification. Conclusions: Instead of assuming a uniform relationship between self-compassion and eco-anxiety, this dimensional approach may help clarify whether specific self-compassion processes are more relevant to particular emotional, cognitive, and behavioural manifestations of eco-anxiety.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091128

Authors: Nguyen Hoang Melis Selamoglu Isabella Papadopoulos Chi Lao Holly Wild Susan Kotwas Ines Rio Kim Turudia Dale Cridland Chris Barton

Background: Nicotine exposure is increasingly occurring through non-combustible products such as electronic cigarettes and nicotine pouches. Although sport participation is often considered protective against substance use, nicotine use appears to be increasingly normalised within performance-oriented sporting environments. Methods: This scoping review synthesised evidence on non-combustible nicotine use among amateur and university athletes. Following Joanna Briggs Institute (JBI) methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, the searches were conducted in Ovid MEDLINE, Web of Science, Embase, Scopus, SPORTDiscus, and CINAHL for peer-reviewed studies published from 2019 onwards that examined non-combustible nicotine use in these populations. Results: Eleven studies, predominantly cross-sectional and conducted in high-income Western countries, met the inclusion criteria. Nicotine use was more common among male athletes, younger athletes, and those participating in team and contact sports, particularly for e-cigarette use. Across studies, nicotine use was frequently characterised as socially normative and compatible with sport, influenced by peer networks, social identity, perceived harm reduction, and beliefs regarding performance enhancement, coping, and recovery. The evidence base was limited by inconsistent measurement approaches and a predominance of studies examining demographic correlates rather than behavioural drivers. Conclusions: Non-combustible nicotine use appears embedded within sport-specific social norms and performance-related beliefs, highlighting the need for theoretically informed research and sport-specific prevention strategies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091127

Authors: Jongkonnee Thanasai Anchalee Chittamma Supphachoke Khemla Atthaphong Phongphithakchai Moragot Chatatikun Jitbanjong Tangpong Sa-ngob Laklaeng Jirart Songsri Wiyada Kwanhian Klangbud

Background: Melioidosis is a potentially life-threatening infection caused by Burkholderia pseudomallei. Hepatic and splenic involvement are recognized manifestations of disseminated melioidosis; however, reported prevalence varies considerably across studies, and no quantitative synthesis has been available. This systematic review and meta-analysis aimed to estimate the pooled prevalence of hepatic, splenic, and concomitant hepatosplenic involvement in patients with melioidosis. Methods: A systematic search of PubMed, Embase, and Scopus was conducted from database inception to May 2026, following the PRISMA 2020 guidelines. Observational studies reporting hepatic and/or splenic involvement among patients with confirmed melioidosis were eligible. Random-effects meta-analyses were performed to estimate pooled prevalence with 95% confidence intervals (CIs). Subgroup analyses were conducted according to geographic region and age group. Methodological quality was assessed using the Joanna Briggs Institute critical appraisal checklist. Results: Fourteen eligible studies involving 1844 patients with melioidosis were included. The pooled prevalence of hepatic involvement was 11% (95% CI, 6–18%; I2 = 84.8%), splenic involvement was 15% (95% CI, 7–27%; I2 = 95.8%), and concomitant hepatosplenic involvement was 13% (95% CI, 4–34%; I2 = 89.5%). Subgroup analyses demonstrated significantly higher pooled prevalence of hepatic and splenic involvement in Southeast Asia than in Oceania (p = 0.0164 and p = 0.0003, respectively). No significant differences were observed between adult and pediatric populations for hepatic (p = 0.1607) or splenic involvement (p = 0.8243). Most included studies were judged to have a moderate risk of bias, and no evidence of small-study effects was identified for analyses of hepatic or splenic involvement. Conclusions: Hepatic and splenic involvement are common manifestations of melioidosis, affecting approximately one in nine and one in seven patients, respectively. Significant geographic variation suggests that disease burden is greater in Southeast Asia than in Oceania. These findings support the routine consideration of abdominal imaging in patients with suspected or confirmed melioidosis, particularly in endemic regions, to facilitate early recognition of visceral involvement. Further prospective multicenter studies using standardized imaging protocols are needed to refine prevalence estimates and improve understanding of hepatosplenic melioidosis.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091126

Authors: Rubaiya Anika Matthew Untalan Emanuela Taioli Stephanie Tuminello

Biological aging, quantified through molecular and physiological biomarkers, provides a dynamic assessment of the aging processes. Although organophosphate (OP) pesticide exposure is known to disrupt cellular and metabolic functions, causing inflammation, its relationship with phenotypic (biological) aging acceleration (PAA) remains understudied. We examined data from 1999–2008 and 2015–2018 National Health and Nutrition Examination Survey to determine the relationship between OP and PAA. Urinary levels of 6 Dialkyl-phosphate metabolites were used to assess OP exposure; participants were considered exposed if they had at least one urinary OP metabolite above the highest lower limit of detection (LLOD). Phenotypic age was estimated using BioAge R package combining nine laboratory biomarkers. PAA was derived as the residual from regressing phenotypic age onto chronological age. The association was assessed using survey-weighted linear regression. A total of 8988 participants with complete urinary, sociodemographic, and laboratory data were included; mean chronological age was 44.95 years (SE = 0.29), while mean phenotypic age was 43.19 years (SE = 0.31). In the fully adjusted model, individuals with detected OP metabolites had higher PhenoAgeAccel (β = 0.65; 95% CI: 0.14–1.17). OP metabolite detection was associated with greater PAA, extending limited literature and supporting further investigation of its implications for healthy aging.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091125

Authors: Kayla Etienne Peyton R. Willie Kimberly Lazarus Ivanee Cruz Valerie Daniel Maria Silva Fernanda Chelsie Warman Gray Maganga Bisola O. Ojikutu Sannisha K. Dale

Introduction: Racially and ethnically diverse women experience sub-optimal outcomes on both the HIV treatment and prevention cascade when compared to their white counterparts due to factors including racism, sexism, and xenophobia. While PrEP is a promising biomedical tool that can narrow this gap, similar trends are observed in PrEP utilization among culturally diverse women. We sought to explore the differences in diverse women’s preferences, challenges, and facilitators of PrEP uptake. Methods: From January 2022 to July 2023, thirty-one diverse women who could benefit from PrEP in Miami, FL, completed qualitative interviews with trained research staff to discuss their willingness, perceptions, and access to PrEP. Women also completed a demographic survey via Research Electronic Data Capture (REDCap). Semi-structured interviews were analyzed via NVivo using a hybrid inductive–deductive thematic analysis approach. Results: The majority of participants were Black (81%) and ethnically diverse (41.9% African American, 25.8% Hispanic/Latina, 16.1% Afro-Caribbean Black (non-Haitian) and 16.1% Haitian/Haitian American). Qualitative coding revealed numerous themes common across ethnic groups on (a) HIV transmission risk, reasons for prevention, and protective factors, (b) PrEP awareness, acceptability and willingness, (c) access to healthcare, and (d) relationships. Conclusions: To develop culturally sound interventions to increase PrEP uptake among women most impacted by HIV, an understanding of their perspectives and experiences is needed, as well as interventions/strategies informed by their insights.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091124

Authors: Pedro Carvalho Frulane de Souza Tatiana Arenas Mora Tiago Arruda Sanchez Erick Francisco Quintas Conde

Previous studies have shown that Bouldering Psychotherapy (BPT), an emerging integrative intervention combining bouldering with psychotherapeutic techniques, may promote improvements in mental health and well-being. This pilot study aimed to examine the effects of BPT on symptoms of depression and anxiety in a Brazilian population and explore participants’ perceptions of its psychological and social impacts. Eleven participants completed an eight-week BPT program and were compared with a matched control group. Symptoms of anxiety and depression were assessed before and after the intervention. Qualitative data were collected through semi-structured interviews and analyzed using word-frequency analysis and reflexive thematic analysis. The BPT group showed a significant reduction in depressive symptoms (p = 0.015, d = 0.66) and a marginally non-significant reduction in anxiety symptoms (p = 0.059, d = 0.44). The qualitative findings indicated perceived improvements in psychological well-being, emotional regulation, self-awareness, social connectedness, and psychological skills. Participants also reported transferring skills and insights acquired during the program to everyday life. Overall, the findings suggest that BPT may improve mental health, particularly depressive symptoms, while fostering supportive social relationships and positive psychological experiences. The results support the feasibility of adapting BPT to the Brazilian context and encourage further research on climbing-based psychotherapeutic interventions.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091123

Authors: Terhi Mustonen Kirsimarja Raitasalo Sari Castrén

Background: Problematic social media use among adolescents has emerged as a growing public health concern. This study examined gender differences in problems related to social media use and their behavioural, psychosocial, family-related, and school-related correlates among Finnish adolescents. Methods: In this cross-sectional study, binary logistic regression analyses were conducted using data from the Finnish sample of the 2024 European School Survey Project on Alcohol and Other Drugs (ESPAD), including 3293 adolescents aged 15–16 years. Results: Overall, 45% of girls and 30% of boys were classified as having problems related to social media use. Significant gender interactions were observed in the associations of gaming-related problems and perceived family socioeconomic status with problems related to social media use. Gaming-related problems were the strongest correlate, with a substantially stronger association among boys. Elevated psychological distress was associated with a higher likelihood of problems related to social media use, particularly among girls, whereas higher parental monitoring was associated with a lower likelihood only among girls. Truancy and plans for general upper secondary school were both associated with a higher likelihood of problems related to social media use among girls and boys. Conclusions: The findings suggest that problems related to social media use are closely linked to adolescent well-being and behaviour. Prevention and intervention efforts may therefore benefit from addressing problematic social media use as part of adolescent mental health and digital well-being strategies, combining universal approaches with targeted support for adolescents experiencing problematic patterns of digital media use.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091122

Authors: Sukontip Arunmonlaphat Yupayong Paha Pacharamon Soncharoen

Background: Non-communicable disease (NCD) emergencies, including hypoglycaemia, stroke, acute coronary syndrome, and hypertensive crisis, call for prompt action by households and communities. The psychosocial mechanisms associated with emergency management behavior in rural Thailand, however, are not well understood. Objectives: The study pursued three objectives. It described levels of NCD emergency management behavior and the characteristics of emergency events reported during the preceding six months. It examined associations linking knowledge, Health Belief Model (HBM) constructs, social support, participation, self-efficacy, and emergency management behavior. Then, it identified the constructs with the strongest relations to behavior, along with an indirect pathway operating through self-efficacy, via structural equation modelling. Methods: A cross-sectional study analyzed data from 1321 community adults in Sisaket Province, Thailand, drawn from an initial 1407 records after excluding 86 with age below 21 years, incomplete data on SEM variables, or invalid disease-status coding. A structured, interviewer-administered questionnaire measured knowledge of NCD emergencies, HBM constructs, social support, family and community participation, self-efficacy, and emergency management behavior. Covariance-based SEM with item parcels and maximum-likelihood estimation was conducted; knowledge was treated as an observed variable. Results: Mean age was 58.0 years (SD = 14.3); 15.5% reported a recent emergency event. Knowledge was moderate-to-low (mean = 5.79/10; KR-20 = 0.440). Model fit was acceptable (CFI = 0.980; RMSEA = 0.047; SRMR = 0.049). Discriminant validity was supported by the Fornell–Larcker criterion for all constructs. Participation was strongly associated with self-efficacy (β = 0.858) and with emergency management behavior (β = 0.433); self-efficacy was also associated with emergency management behavior (β = 0.354). Participation had the largest total effect on behavior (0.737), combining a direct effect (0.433) and an indirect, self-efficacy-related effect (0.304). All structural-path variance inflation factors (VIF) were below 5.0 except participation behavior (VIF = 6.19), which remained below the more permissive threshold of 10.0. Conclusions: NCD emergency management behavior in this rural community was most strongly associated with family and community participation and with self-efficacy. Because the design was cross-sectional, these findings indicate association rather than confirmed causal or mediating pathways. Programmes should combine scenario-based knowledge with participatory practice, family role preparation, rehearsal of emergency-service (1669) activation, and confidence-building activities.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091121

Authors: Zeina M. Alkhalaf Abdullah Alhauli

Background/Objectives: Artificial intelligence (AI) is increasingly embedded in menstrual and reproductive health applications, yet little is known about how women in conservative, rapidly digitizing regions evaluate AI-enabled menstrual tracking tools. This study investigates how perceived cultural fit and data privacy concerns are associated with women’s openness to AI-enabled menstrual tracking in Gulf Cooperation Council (GCC) countries. Methods: We conducted an online cross-sectional survey using a convenience sample of adult women residing in GCC countries (n = 273), measuring openness to AI menstrual tools, perceptions of cultural fit (e.g., respect for religious and cultural norms, endorsement by trusted institutions, Arabic language, GCC-specific design), privacy concerns (e.g., worries about who can access menstrual health data), and key sociodemographic characteristics and smartphone use. Results: Higher perceived cultural-contextual fit was strongly and positively associated with openness to AI-enabled menstrual tracking, whereas composite privacy concerns showed no statistically significant association once cultural fit and sociodemographic factors were controlled. Item-level analyses indicated that beliefs about cultural sensitivity and GCC-specific design were the most robust predictors of openness, while concerns about data access, authority endorsement, and language accessibility played a limited role. Homemakers reported higher openness than employed women. Conclusions: Overall, the findings suggest that, in this sample and model, GCC women’s openness to AI-enabled menstrual tracking was more strongly associated with perceived cultural alignment and local design than with the measured privacy-concern construct, highlighting the importance of culturally grounded, trust-building design and communication strategies for AI-based women’s health applications.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091120

Authors: Juliene G. Costa Igor M. Mariano Ana Clara R. Cunha Juliana C. Silva Ludimila F. Gonçalves Mateus L. Rodrigues Julia B. Tavares Victor Hugo V. Carrijo Ana Luiza Amaral Guilherme M. Puga

Cardiometabolic multimorbidity is highly prevalent among postmenopausal women and is associated with adverse metabolic outcomes and a greater burden of climacteric symptoms. This secondary analysis of a quasi-experimental controlled clinical trial investigated the effects of a 12-week aerobic training program on climacteric symptoms, menopause-related quality of life, body composition, and cardiometabolic biomarkers in postmenopausal women with and without cardiometabolic multimorbidity. Forty-one postmenopausal women (50–70 years) were allocated to a single-cardiometabolic-condition group (SINGLE, n = 18) or a multimorbidity group (MULTI, n = 23) and completed supervised walking/jogging aerobic exercise three times per week at 65–75% of heart rate reserve. Climacteric symptoms, quality of life, anthropometric measures, body composition, and biochemical markers were assessed before and after the intervention. Generalized Estimating Equations (GEEs) with Bonferroni post hoc adjustment were used to compare group, time and group*time interactions with alpha of 5%. Significant group-by-time interactions were observed for the Menopause Rating Scale total score and psychological symptoms, as well as for the Cervantes Scale total score, indicating greater improvements among women with multimorbidity. The MULTI group demonstrated significant reductions in overall menopausal symptoms, psychological symptoms, and menopause-related quality of life scores following training. Body weight, triglycerides, and very-low-density lipoprotein cholesterol also decreased significantly only in the MULTI group, whereas several body composition parameters improved over time regardless of cardiometabolic burden. These findings indicate that aerobic training may be associated with improvements in menopausal symptoms, quality of life, body composition, and selected cardiometabolic markers in postmenopausal women, with some outcomes showing greater changes among women with cardiometabolic multimorbidity.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091119

Authors: Naparat Doungchan Marisa Poomiphak Na Nongkhai Sulukkana Noiprasert Rajesh Kumar Ngamrayu Ngamdokmai

Overweight and obesity are concerns among young adults. This double-blind, randomized, placebo-controlled trial evaluated the efficacy and safety of Phikud Tri-Phon (PTP), a traditional Thai herbal decoction comprising Aegle marmelos, Morinda citrifolia, and Coriandrum sativum, for weight management in Thai females. Forty females aged 18–22 years with a body mass index (BMI) of 23.0–24.9 kg/m2 were randomly assigned to receive 150 mL of PTP decoction or a herbal-style placebo control twice daily for 6 weeks. Body composition, obesity-related indices, lipid profiles, and kidney and liver function markers were assessed at baseline and after the intervention. Per-protocol analyses included 17 participants in the PTP group and 16 in the placebo group. No statistically significant between-group differences were observed in body composition, obesity-related indices, lipid profiles, or kidney and liver biochemical markers after 6 weeks (p > 0.05). Although a device-derived metric of obesity degree decreased within the PTP group (p = 0.021), this change did not differ significantly from that of the placebo group (p = 0.894). No clinically meaningful between-group safety differences were identified during the 6-week study period.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091118

Authors: Binquan Liu Xinyu Fang Esben Strodl Guanhao He Zengliang Ruan Ximeng Wang Li Liu Weiqing Chen

Additional Affiliation [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091117

Authors: Karina Kendelhy Santos Patrícia Gomes Fonseca Túlio Silva Pereira Jéssica Madeira Bittencourt Maria Letícia Ramos-Jorge Maria Eliza da Consolação Soares Lívia Guimarães Zina Izabella Barbosa Fernandes

To assess the prevalence of molar–incisor hypomineralization (MIH) and identify the associated factors in Brazilian schoolchildren, a representative cross-sectional study was conducted Diamantina, Brazil, with a random sample of 316 (80.8% response rate) children aged 7 to 10 from public and private schools. The presence of MIH was assessed according to the criteria of the European Academy of Pediatric Dentistry (EAPD). Sociodemographic data and data related to the prenatal, perinatal, and postnatal periods, as well as child health, were obtained through a questionnaire sent to caregivers. Descriptive analyses and adjusted and unadjusted Poisson regression were performed, accounting for the sample weights, using Stata software (version 16.1). The prevalence of MIH was 21.2%. The adjusted model showed that children admitted to the neonatal intensive care unit (NICU) were 2.28 times more likely to have MIH (95% CI: 1.34–3.90). The present study identified a high prevalence of MIH among children aged 7 to 10 years in Brazilian schoolchildren. Children who were admitted to the NICU had a higher prevalence of MIH than those who did not. Given the cross-sectional design, study sample and regional context, these findings should be interpreted as associations rather than evidence of causal relationships.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091116

Authors: Wil Lieberman-Cribbin Jason J. Wang Bo Yang Joseph O’Hara Maria X. Sanmartin Liron Sinvani Jeffrey M. Katz Pina C. Sanelli

Stroke is a leading cause of death and foremost cause of disability in the United States, and extreme heat is the leading weather-related cause of death. We examined the association between ambient temperature and acute ischemic stroke (AIS) admissions in New York State. We leveraged an existing cohort of consecutive AIS admissions presenting to a large healthcare system during a ten-year period (January 2015–December 2024), identified based on discharge diagnosis codes for ischemic stroke. Meteorological data from gridMET (~4 km grids) were used to produce daily averages of maximum temperature (Tmax) for ZIP code tabulation area (ZCTA) boundaries in the New York metropolitan area, linked to residential ZIP codes. Time-stratified case-crossover models with distributed lags (0–1 days) were used to estimate the association between daily maximum temperature (evaluated as a 10 °F increase, 95th percentile temperature vs. median temperature, and 95 °F vs. median temperature) and AIS admissions, both for the entire year and restricted to warm season months of May–October. There were 27,926 AIS admissions from 2015 to 2024. The mean (standard deviation, SD) age was 71.7 (14.4) years, and 13,934 (49.9%) were female, while the mean (SD) Tmax was 62.8 (17.3) °F, and the mean 95th percentile Tmax was 87.9 °F. The relative risk (95% confidence interval) of AIS admissions was strongest on the same day of admission (10 °F increase: 1.041 (1.019, 1.064); 95th percentile: 1.105 (1.047, 1.165); 95 °F: 1.132 (1.059, 1.210), and effects were similar in warm season months. High daily maximum temperatures were associated with an increased risk of AIS admissions, with the highest risk on the same day of admission. These findings support the short-term impact of temperature on AIS admissions and can inform future public health efforts to reduce heat-related AIS risk in affected populations.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091115

Authors: Jamilya Saparbay Zhanat Spatayev Abylaikhan Sharmenov Assylmurat Zhumukov Chokhan Aytbayev Adina Kulanbayeva Gulnara Kulkayeva Yuliya Semenova Zhandos Burkitbayev Assan Zhexembayev

Background: Kazakhstan is among the most highly endemic countries for hepatic echinococcosis worldwide, yet no study systematically characterised the national hepatobiliary surgical burden of cystic (CE) and alveolar (AE) echinococcosis using administrative health data. Methods: National operative data from the Guaranteed Volume of Free Medical Care (GOBMP) and Compulsory Social Health Insurance (OSHI) Systems (1 January 2023–31 December 2025) were combined with institutional case series from the National Research Oncology Center (NROC), Astana (2021–2025). Cases were identified using ICD-10 diagnosis codes and ICD-9-CM procedure codes. Regional and species-specific differences in surgical approach were assessed using Pearson’s chi-square test; continuous variables were compared using the Mann–Whitney U test. Results: A total of 143 hepatic echinococcosis surgeries were performed nationally over the three-year period, with a 12.8% increase in annual volume (47 in 2023, 43 in 2024, 53 in 2025), though this year-to-year variation was not statistically significant (χ2 = 1.06, df = 2, p = 0.59). CE accounted for 74.8% of cases (n = 107), AE for 18.9% (n = 27), and unspecified hepatic echinococcosis for 6.3% (n = 9); the proportion of AE rose from 17.0% in 2023 to 26.4% in 2025. Astana performed 46.2% of all operations nationally, with its share increasing from 34.0% to 58.5% over the study period; together with Almaty, it accounted for 92.6% of all AE cases. Partial hepatic resection was the predominant procedure overall (81.1%), while AE was managed exclusively by resectional or lobar procedures (χ2 = 15.37, p = 0.004), with no percutaneous approaches used. In the NROC case series (n = 63), AE patients were older (median 43.5 vs. 33 years, p = 0.036) and had longer postoperative hospital stays (median 12 vs. 10 days, p = 0.015) than CE patients. Conclusions: Surgical management of hepatic echinococcosis in Kazakhstan is increasingly centralised in Astana and Almaty, with AE consistently requiring more extensive resectional surgery and greater healthcare resource use than CE. These findings support the development of a national echinococcosis registry and formal referral pathways to guide resource allocation and surgical planning.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091114

Authors: Jennifer Pierre Sheena Dorvil Jocelyn Valdez Shelby Boyle

Background: The COVID-19 pandemic exacerbated longstanding social and health inequities in predominantly Black and Latino communities in North and Central Brooklyn, in the form of disproportionately high hospitalization and mortality rates. Community organizations served as critical sources of information and resources during this period. Methods: The Bureau of Brooklyn Neighborhood Health within the NYC Health Department, conducted semi-structured virtual interviews with 19 representatives from 15 organizations that had partnered with the Bureau within the past five years. Interviews were conducted between November 2021 and February 2022. Transcripts were coded and analyzed using a hybrid deductive–inductive approach incorporating constant comparative techniques. Results: Partners described worsening food insecurity, inequitable vaccine and testing access, digital divide challenges, funding instability, staffing shortages, and escalating mental health needs. Organizations pivoted from routine operations to provide emergency food distribution, virtual programming, mental health support, advocacy, and disseminating information as trusted messengers in the community. Conclusions: Findings underscore the essential role of local community organizations in crisis response and recovery. Future preparedness efforts must center community expertise, strengthen cross-sector collaboration, streamline funding processes, and investments in social and digital infrastructures to advance health equity and community resilience.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091113

Authors: Otniel Alencar Bandeira Lucas Barros de Araújo Aline Franco da Rocha Estefanía Coello Gonçalves Canedo Vivian Vílchez Barboza Weber da Silva Robazza Gabriela Frutuozo Müller Gilberto Costa Teodozio Maria Lúcia do Carmo Cruz Robazzi

The extensive use of plastic-based materials in healthcare services has raised concerns about micro- and nanoplastic contamination in hospital environments, with potential implications for occupational health, environmental health, and public health nursing. This scoping review aimed to map the available evidence on occupational exposure to micro- and nanoplastics in healthcare settings, identifying exposure sources, pathways, potential health implications, and knowledge gaps, with particular attention to healthcare workers and nursing professionals. It was conducted following JBI methodology and reported according to PRISMA-ScR. Searches were performed in PubMed/MEDLINE, Scopus, Embase, LILACS, and SciELO for original studies published between January 2015 and December 2025 in English, Portuguese, or Spanish. Of 759 records identified, six studies met the eligibility criteria. Evidence was derived mainly from high-complexity healthcare settings, including operating theatres, anaesthetic rooms, laboratories, emergency departments, physiotherapy units, intensive care units, blood banks, and clinical areas. Indoor air, settled dust, disposable medical devices, plastic packaging, personal protective equipment, and plasticised materials were identified as potential exposure sources. Inhalation was the most frequently reported/inferred pathway, followed by dermal contact and indirect ingestion. Current evidence remains limited and heterogeneous, with scarce direct biomonitoring of micro- and nanoplastic particles and limited epidemiological data. Hospital environments may represent under-recognised settings for occupational exposure to micro- and nanoplastics, requiring standardised exposure assessment, environmental surveillance, biomonitoring, and preventive strategies aligned with occupational and public health nursing.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091112

Authors: Eduardo Chierrito Suélen Manoel Favero Mário Henrique da Mata Martins Flávia Aparecida Reitz Cardoso Rute Grossi-Milani

Background: Carbon-based energy systems drive climate change with growing pressure on public health, yet research on mental health, climate change, and carbon-intensive industries remains fragmented. Objective: This scoping review mapped how mental health outcomes of climate change relate to the carbon-based matrix, identifying conceptual approaches, methodological trends, and research gaps aligned with planetary health and the SDGs. Methods: This review was conducted following the Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, with searches in PubMed, Web of Science, and PsycINFO. Results: From 232 records, 38 studies (2015–2025) were included across six clusters: eco-anxiety and distress (n = 14); extreme events and mental disorders (n = 9); air pollution and neuropsychological outcomes (n = 7); environmental justice and vulnerable populations (n = 10); green spaces and resilience (n = 6); and public policy and sustainable responses (n = 7). The carbon-based matrix was proximally linked to mental health in studies on air pollution and extractivism, and served as context in studies on extreme climate events, food insecurity, and climate uncertainty. Conclusions: An equitable transition away from carbon-intensive systems is a public health priority, with co-benefits for mental well-being aligned with the SDGs.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091111

Authors: Vinita Oberoi Leedom Daniela B. Friedman Geoffrey I. Scott Dwayne E. Porter Russell S. Kirby

Background: Children with Down syndrome often have co-occurring physical conditions affecting well-being, and respiratory issues remain a leading cause of hospitalization and death among people with Down syndrome. Parents of children with Down syndrome experience stressors associated with respiratory illness and challenges navigating healthcare access. No prior qualitative study has examined parental perspectives on respiratory health specifically among children with Down syndrome. Identifying parental concerns can help in the development of strategies to mitigate respiratory ailments in children with Down syndrome. Methods: One-hour, semi-structured interviews were conducted among 24 families of children with Down syndrome to understand respiratory concerns. Findings were identified through codebook thematic analysis. Results: The themes identified included persistent concerns about respiratory health, repeated impact from acute and chronic respiratory issues, a rapid and unexpected decline in health during respiratory illness, insurance coverage concerns, and a lack of confidence in assessing air quality which could impact respiratory health. Conclusions: Insights gained from interviews of parents of children with Down syndrome can help policy makers identify opportunities to prevent and mitigate respiratory health problems. Findings underscore the importance of clinician responsiveness to parental concern about rapid deterioration and suggest that insurance coverage policies for this high-risk population warrant further research and policy consideration.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091110

Authors: Camryn Desjarlais Juliana Meneghetti Elder Darcey Sedgwick Annalijn I. Conklin

Land-based Indigenous food practices are integral to cultural identity and ancestral knowledge, and provide medicine for health and wellbeing. We surveyed Indigenous-specific grey literature, guided by Elder knowledge, from public information sources to identify the scope of Indigenous traditional foods in Canada and how food use aligned with major food groups. We analyzed extracted data using summary statistics and graphical display. We identified 96 resources reporting 401 distinct food items incorporated into Indigenous food practices across Canada. Prevalent food groups were meat/proteins (39%), vegetables (20%), berries/fruits (12%), and a mixed group (21%); grains were rarely reported (1%). We found 28 unique plant foods reported to have multiple uses. Across sources, the top 15 most common food items were various berries, fish and wild game. The total count of food items and diversity with food groups categories varied by Indigenous group and region. This research documents the breadth and depth of traditional Indigenous food knowledge throughout Canada, demonstrating a consumption pattern focused on wild meat, berries and foods from plant and tree leaves, roots and stems. This overview of Indigenous food knowledge can support Indigenous individuals and communities, researchers and healthcare providers to improve health and wellbeing of Indigenous people.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091109

Authors: Nell Oger Fabienne Glowacz

Despite growing evidence of the serious impact of intimate partner violence (IPV) on children, research on intervention practices in the psychosocial sector remains limited. This study investigates professionals’ perspectives on children exposed to IPV and how they address this issue in their practice. Using a sequential mixed-methods design, an online survey (N = 129) was followed by semi-structured interviews (n = 13). The findings reveal major limitations in interventions targeting children exposed to IPV, which help explain a significant gap between professionals’ perspectives—where children are recognized as victims of IPV and its substantial impact—and what is implemented in practice. In this context, children exposed to IPV often appear secondary both to children victims of other forms of abuse and to adult victims of IPV. Overall, these results underscore the need for specialized training and the development of targeted interventions to better address the specific needs of these children.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23091108

Authors: Adeline Ajuaye Patrick Develtere

Background: Community-based health insurance is an important strategy for extending healthcare access and financial protection to informal-sector populations. In Tanzania, the Improved Community Health Fund (iCHF) is implemented through region-specific models that differ in benefit packages, premium arrangements, and provider participation. However, evidence on how members experience these different implementation models remains limited. This study compared members’ experiences and perceptions of CHF implementation in Dodoma and Kilimanjaro, two regions operating different iCHF models. Methods: The study used data from a cross-sectional household survey conducted among 420 CHF-enrolled members in Dodoma and Kilimanjaro in January 2018. Data were collected using a structured, interviewer-administered household questionnaire covering socio-demographic characteristics, CHF enrolment history, registration and premium-payment experiences, benefit-package perceptions, trust in CHF management and community participation, perceived healthcare service quality, and perceived benefits of membership. Data were analyzed using descriptive statistics, cross-tabulations, and Pearson’s chi-square tests to assess regional differences. Results: Members generally reported positive experiences with CHF administration. Most had used their CHF cards, renewal intentions were high, premiums were considered affordable, payment arrangements were convenient, and local CHF management was generally perceived as trustworthy. Statistically significant regional differences were observed in renewal intention, satisfaction with CHF officers, perceived healthcare service quality, and perceived household benefit (p < 0.05). Dodoma respondents reported higher renewal intention and a higher proportion of households benefiting from CHF. The distribution of healthcare-quality ratings also differed significantly (p < 0.001): Kilimanjaro had a higher proportion rating care as excellent (16.1% vs. 2.9%), whereas Dodoma had a higher proportion rating care as good (44.6% vs. 38.9%). Challenges in both regions included limited benefit coverage, additional out-of-pocket payments, long waiting times, and limited perceived advantages of CHF membership. Conclusions: Regional differences were observed in members’ experiences; however, because the regional samples differed socioeconomically and the analysis was not adjusted for potential confounders, these differences should not be attributed to the iCHF models themselves. The findings describe members’ experiences during the 2018 pilot period and should not be interpreted as a direct description of current iCHF performance. The results nevertheless highlight the importance of benefit coverage, service responsiveness, financial protection, and healthcare quality alongside efficient administration.