International Journal of Environmental Research and Public Health

29 pages, 1097 KB

Open AccessPerspective

Improving Breast Cancer Outcomes Through Quality Care: Call to Action for the Implementation of the Breast Cancer Care Quality Index (BCCQI)

by Maira Caleffi, Mary Ajango, Aydah M. Al-Awadhi, Ricki Fairley, Andrea B. Feigl, Ana Rita González, Victoria Harmer, Naveena Nekkalapudi, Toyin Saraki, Victoria Wolodzko Smart, Araceli Fernandez-Cerdeño, João Victor Rocha, Ilaria Lucibello and Namita Srivastava

Int. J. Environ. Res. Public Health 2026, 23(2), 207; https://doi.org/10.3390/ijerph23020207 (registering DOI) - 6 Feb 2026

Abstract

Breast cancer is the most common cancer among women worldwide and a leading cause of mortality. Stark differences in outcomes across income levels, regions, population groups, and healthcare systems reflect deep inequities in access to early detection, diagnosis, and treatment. Due to remarkable [...] Read more.

Breast cancer is the most common cancer among women worldwide and a leading cause of mortality. Stark differences in outcomes across income levels, regions, population groups, and healthcare systems reflect deep inequities in access to early detection, diagnosis, and treatment. Due to remarkable scientific advances and many global initiatives, breast cancer is often perceived as a “finished agenda”. This Call to Action, led and endorsed by a multidisciplinary panel of international experts in breast cancer care, policy, and healthcare systems, provides a structured approach to guide countries in improving breast cancer care through the Breast Cancer Care Quality Index (BCCQI), a unified, expert-endorsed tool that translates broad guidance into practical metrics. The Call to Action outlines a framework for country profiling across the BCCQI dimensions: early detection, timely diagnosis, comprehensive management, and strong and resilient healthcare systems. Applying a structured self-assessment matrix linked to tiered recommendations, the Call to Action supports country performance assessment and the development of context-sensitive roadmaps for concrete interventions. By linking assessment to actionable guidance, the Call to Action underscores the urgency of coordinated national efforts and international support to close existing gaps and accelerate progress toward high-quality breast cancer care for all patients. Full article

(This article belongs to the Special Issue Breast Health and Cancer Awareness: Addressing Breast Cancer Disparities from Etiology to Survivorship)

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30 pages, 6432 KB

Open AccessArticle

Pedestrians’ Perceptions of Motorized Traffic in Suburban–Rural Areas of a Metropolitan Region: Exploring Measurement Perspectives

by Dan Andersson, Lina Wahlgren and Peter Schantz

Int. J. Environ. Res. Public Health 2026, 23(2), 206; https://doi.org/10.3390/ijerph23020206 - 6 Feb 2026

Abstract

Background: Since World War II, the number of motorized vehicles has increased dramatically. Yet, few studies have evaluated how perceptions of single and multiple motorized traffic variables, in different combinations, influence pedestrians’ appraisals of the route environment in relation to whether it [...] Read more.

Background: Since World War II, the number of motorized vehicles has increased dramatically. Yet, few studies have evaluated how perceptions of single and multiple motorized traffic variables, in different combinations, influence pedestrians’ appraisals of the route environment in relation to whether it facilitates or deters walking. We have previously illuminated this in an inner urban area of a metropolitan region. This study aims to scrutinize these matters in the suburban–rural parts of the same metropolitan area. For comparative reasons, we use the same methods as used for the inner urban area. Our hypothesis is that these kinds of perceptions, to some extent, may be context-specific. Methods: Relations between pedestrians’ perceptions of motorized traffic variables (flow and speeds of motor vehicles, noise, and exhaust fumes) and combinations of them, as well as if appraisals of route environments hinder–stimulate walking and are unsafe–safe for reasons of traffic, have been evaluated. This was studied in the suburban and rural areas of Greater Stockholm, Sweden. The pedestrians (n = 233) rated their route environment with the Active Commuting Route Environment Scale (ACRES). Correlation, multiple regression, and mediation analyses were used to study the relationships. Results: The regression analyses showed that noise was the primary negative predictor variable in relation to hindering–stimulating walking. With respect to the other outcome, unsafe–safe traffic, none of the variables had a significant relation. The mediation analyses showed that (1) vehicle speed had an indirect effect on unsafe–safe traffic via noise, (2) both vehicle speed and vehicle flow had, via noise, indirect effects on hinders–stimulates walking, and (3) vehicle speed had, via vehicle flow, an indirect effect on noise and exhaust fumes. Conclusions: In suburban–rural route environments, noise protrudes as a hindering variable for walking. The mediation analyses showed that vehicle speed intensified noise and had negative effects on both outcomes. Therefore, by reducing vehicle speed, noise levels will be lowered, and the walking experience is likely to be enhanced, which can influence the amount of walking. The results are further illuminated through the exploration of existing and potential future research strategies. Full article

(This article belongs to the Section Environmental Health)

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19 pages, 1729 KB

Open AccessArticle

Association of PFAS, Metals, Phthalate and Organophosphate Metabolites with Depression Among U.S. Adults

by Olamide Ogundare and Emmanuel Obeng-Gyasi

Int. J. Environ. Res. Public Health 2026, 23(2), 205; https://doi.org/10.3390/ijerph23020205 - 6 Feb 2026

Abstract

Depression is a major public health concern, and evidence continues to show that environmental toxicants may contribute to its development. This study evaluated the association between depressive symptoms and per- and polyfluoroalkyl substances (PFAS), heavy metals, phthalates, and organophosphate metabolites using data from [...] Read more.

Depression is a major public health concern, and evidence continues to show that environmental toxicants may contribute to its development. This study evaluated the association between depressive symptoms and per- and polyfluoroalkyl substances (PFAS), heavy metals, phthalates, and organophosphate metabolites using data from NHANES 2017–2018. Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9). Environmental exposure variables were analyzed using multivariable linear regression and Bayesian Kernel Machine Regression (BKMR). All models adjusted for demographic, socioeconomic, behavioral, and clinical covariates. In multivariable linear regression models adjusted for demographic, socioeconomic, behavioral, and clinical covariates, higher urinary dimethylphosphate concentrations were significantly associated with increased depressive symptom scores (β = 0.15; 95% CI: 0.04, 0.27; p = 0.0098). Mono-(2-ethylhexyl) phthalate (MEHP) was also positively associated with PHQ-9 scores (β = 0.001; 95% CI: 0.0003, 0.0019; p = 0.0043). Because environmental mixtures tend to follow non-linear patterns, BKMR analysis was run. BKMR analyses indicated that organophosphate metabolites exhibited the greatest overall contribution to depressive symptoms (group posterior inclusion probability = 0.7875), with diethylphosphate emerging as the most influential individual exposure within the group (conditional PIP = 0.7211). Exposure–response functions suggested non-linear and threshold relationships for several metabolites. These findings identify specific organophosphate and phthalate metabolites as potential contributors to depressive symptoms and support the importance of evaluating chemical mixtures rather than single exposures. Additional longitudinal studies are needed to clarify temporal relationships and to inform public health efforts aimed at reducing exposure to organophosphate pesticides and endocrine-disrupting chemicals. Full article

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22 pages, 1541 KB

Open AccessArticle

Environmental Stressors and Intimate Partner Violence in Urban Tanzania: A Thematic and Visual Analysis from Dar es Salaam

by Deo Mshigeni and Salome Kapella Mshigeni

Int. J. Environ. Res. Public Health 2026, 23(2), 204; https://doi.org/10.3390/ijerph23020204 - 5 Feb 2026

Abstract

Background: This study explores the interplay between environmental stressors and intimate partner violence (IPV) in Dar es Salaam, Tanzania. Methods: Drawing on participants’ interviews, visual ethnography, thematic analysis, and a review of secondary sources, the research examines how resource scarcity, displacement, and climate [...] Read more.

Background: This study explores the interplay between environmental stressors and intimate partner violence (IPV) in Dar es Salaam, Tanzania. Methods: Drawing on participants’ interviews, visual ethnography, thematic analysis, and a review of secondary sources, the research examines how resource scarcity, displacement, and climate change intersect with social determinants of health to intensify IPV. Results: Using an ecological systems perspective, the study demonstrates how structural vulnerabilities and environmental degradation disproportionately affect residents of informal urban settlements, particularly women, who face intersecting vulnerabilities due to poverty, inadequate services, and gender-based discrimination. Conclusions: The findings from this study underscore the need to integrate gender-sensitive urban planning and policy that address both environmental risks and existing social inequalities, thereby enhancing household and community resilience. Full article

(This article belongs to the Special Issue Role of Social Determinants in Health of Vulnerable Groups)

14 pages, 318 KB

Open AccessArticle

Healthcare Providers’ Perspectives on Telemedicine for NCD Management During and After COVID-19 in India: A Qualitative Study

by Mohd Shannawaz, Isha Rathi, Nikita Shah, Shazina Saeed and Amrish Chandra

Int. J. Environ. Res. Public Health 2026, 23(2), 203; https://doi.org/10.3390/ijerph23020203 - 5 Feb 2026

Abstract

Non-communicable diseases (NCDs) remain a major contributor to global morbidity and mortality, with India bearing a substantial share of this burden. The COVID-19 pandemic disrupted routine clinical care and accelerated the transition to telemedicine for chronic disease management. This study explores healthcare providers’ [...] Read more.

Non-communicable diseases (NCDs) remain a major contributor to global morbidity and mortality, with India bearing a substantial share of this burden. The COVID-19 pandemic disrupted routine clinical care and accelerated the transition to telemedicine for chronic disease management. This study explores healthcare providers’ perspectives on the use of telemedicine for NCD care during and after the pandemic, including its perceived benefits, limitations, and future relevance within the broader digital health landscape. Semi-structured interviews were conducted with 33 purposively selected healthcare providers with experience in telemedicine for NCD care between February and June 2025, audio-recorded, transcribed verbatim, and thematically analyzed using NVivo 15. Providers reported that telemedicine supported continuity of care, reduced the need for in-person visits, facilitated medication adherence, and offered reassurance for patients during periods of restricted mobility. However, limitations were identified, including the inability to conduct physical examinations, connectivity challenges, and low digital literacy, particularly among older adults. While overall satisfaction with telemedicine was positive, participants emphasized the need for strengthened digital infrastructure, greater patient awareness, and simplified platforms to improve usability. The findings underscore telemedicine’s continued relevance for NCD management beyond the pandemic, contingent on improved accessibility and system integration. Full article

11 pages, 985 KB

Open AccessArticle

Impact of 8 Weeks of Moderate- Versus High-Intensity Interval Training on Sleep Quality

by Jean Bourgeois, Charlotte Domange and Bert Celie

Int. J. Environ. Res. Public Health 2026, 23(2), 202; https://doi.org/10.3390/ijerph23020202 - 4 Feb 2026

Abstract

Sleep is a fundamental aspect of physiological and psychological functioning, and the beneficial effect of exercise on sleep quality and quantity, depending on training modality, remains underexplored. This study compared the effects of high-intensity interval training (HIIT) versus a moderate-intensity continuous training (MICT) [...] Read more.

Sleep is a fundamental aspect of physiological and psychological functioning, and the beneficial effect of exercise on sleep quality and quantity, depending on training modality, remains underexplored. This study compared the effects of high-intensity interval training (HIIT) versus a moderate-intensity continuous training (MICT) regime on sleep quality. Twenty-five participants (sixteen men, nine women) were randomly assigned to 8-week HIIT or MICT programs. Anthropometric data, blood pressure, and maximal exercise tests (VO_2max, lactate, heart rate) were conducted one week before and after training. Sleep quality was evaluated daily through self-reported perception and duration and via the Pittsburgh Sleep Quality Index (PSQI) at baseline, one week, and two weeks post-intervention. Data were analyzed in SPSS version 29 using repeated-measures ANOVA. PSQI scores improved significantly over time (p = 0.013), regardless of modality, with no significant group or interaction effects. Cardiorespiratory fitness improved for all participants, with significant gains in VO_2max (p = 0.009), maximal aerobic speed (p < 0.001), and reduced maximal heart rate (HIIT: p = 0.003; MICT: p = 0.021). Sleep perception showed no significant change during training (p = 0.063), with a slight improvement trend. In conclusion, exercise training improves sleep quality regardless of modality. Running three sessions per week for eight weeks enhances both aerobic and cardiorespiratory fitness, along with sleep quality. Physical activity is therefore an effective non-pharmacological strategy to improve sleep. Full article

(This article belongs to the Section Exercise and Health-Related Quality of Life)

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14 pages, 304 KB

Open AccessArticle

Psychosocial and Behavioral Correlates of Sleep Duration and Sleep Disturbance Among Lesbian, Gay, and Bisexual Women

by Jennifer M. Jabson Tree and Katherine Buchman

Int. J. Environ. Res. Public Health 2026, 23(2), 201; https://doi.org/10.3390/ijerph23020201 - 4 Feb 2026

Abstract

Introduction: Sleep is an essential dimension of good physical and mental health. Lesbian, gay, and bisexual (LGB) women experience inequities in sleep duration and disturbance compared to heterosexual women. Psychosocial and behavioral characteristics are important to sleep in the general population; they may [...] Read more.

Introduction: Sleep is an essential dimension of good physical and mental health. Lesbian, gay, and bisexual (LGB) women experience inequities in sleep duration and disturbance compared to heterosexual women. Psychosocial and behavioral characteristics are important to sleep in the general population; they may advance our understanding about sleep inequities among LGB women and provide key information for developing promising interventions. Methods: Data for this project were provided by the Women’s Health Initiative (WHI). The sample size for this project was 1436: 884 LG women and 552 bisexual women. Outcome variables were sleep duration and disturbance. The authors sought to clarify the associations, including the strength, between psychosocial factors and sleep outcomes among LGB women. Associations between psychosocial characteristics, health behaviors, and sleep outcomes were tested using multivariable, hierarchical, nested, linear regression models, stratified by sexual orientation. Results: Social strain, social function, optimism, and negative emotional expressiveness were significantly associated with sleep outcomes for LGB women. Health behaviors were not consistently or strongly associated with sleep outcomes for LGB women. Conclusions: The findings point to the importance of social strain, social function, negative emotional expressiveness, and optimism in LGB women’s sleep. It is possible that LGB women’s sleep could be improved with evidence-based interventions that use our findings. Full article

(This article belongs to the Special Issue Advancing Equitable Healthcare Access for Sexual and Gender Minorities and Beyond)

17 pages, 1273 KB

Open AccessArticle

Developing an Index to Measure Structural Racism: Methodological Process, Challenges, and Considerations

by Christopher M. Amissah, Alisha A. Crump, Yu-Hua Fu, Sheela Khadka, Jennifer Contreras, Salene M. W. Jones, Bryce B. Reeve and Ester Villalonga-Olives

Int. J. Environ. Res. Public Health 2026, 23(2), 200; https://doi.org/10.3390/ijerph23020200 - 3 Feb 2026

Abstract

Access to valid and reliable measures of structural racism is essential for addressing health inequities, yet few validated ecological-level indices exist for assessing structural racism affecting Black and Hispanic populations in the United States. Guided by the National Institute on Minority Health and [...] Read more.

Access to valid and reliable measures of structural racism is essential for addressing health inequities, yet few validated ecological-level indices exist for assessing structural racism affecting Black and Hispanic populations in the United States. Guided by the National Institute on Minority Health and Health Disparities framework, our interdisciplinary team undertook the development of an ecological-level structural racism index. In the process, we encountered substantive methodological and data-related challenges that warrant explicit documentation. This paper describes the methodological process used to identify and select indicators of structural racism, including a modified Delphi consensus process involving social epidemiologists, health inequality researchers, community members, economic inequality specialists, and psychometricians. We outline a five-step approach for extracting and harmonizing geographic-level data from publicly available sources and discuss key challenges encountered, including limited availability of granular geographic data, insufficient data documentation guidelines, inconsistent reporting frequencies, and difficulties in adapting publicly available datasets for structural racism measurement. Rather than presenting a finalized index, this paper serves as a methodological guide and cautionary account for researchers seeking to develop ecological measures of structural racism, emphasizing the importance of transparency, adaptability, and rigorous data selection in advancing public health equity research. Full article

(This article belongs to the Special Issue Health Inequities: Structural Causes, Intervention Strategies, and Methodological Challenges)

16 pages, 307 KB

Open AccessProtocol

Back-on-Track: Protocol for Randomised Controlled Feasibility Trial of Behavioural Activation in Farmers with Mood Problems

by Alison Kennedy, Richard Gray, Martin Jones, Anna Greene, Lauren Mitchell, Meera Senthuren, Suzy Malseed, Feby Savira, Kelly Barnes, Kate Gunn and Susan Brumby

Int. J. Environ. Res. Public Health 2026, 23(2), 199; https://doi.org/10.3390/ijerph23020199 - 3 Feb 2026

Abstract

The mental health of people living in farming communities has been identified as an important public health issue. Cumulative exposure to a range of situational factors contributes to heightened risk of poor mental health and suicide. Access to evidence-based psychological treatments is limited [...] Read more.

The mental health of people living in farming communities has been identified as an important public health issue. Cumulative exposure to a range of situational factors contributes to heightened risk of poor mental health and suicide. Access to evidence-based psychological treatments is limited by the availability of skilled mental health professionals. The aim of this trial—co-designed by members of the farming community—is to establish the feasibility of conducting randomised controlled, trial-testing, peer-worker-delivered Behavioural Activation in the farming community. We will undertake a single-blind, parallel group, randomised controlled feasibility trial in rural Australia. People living in farming communities aged over 15 years and experiencing moderate to moderately severe depression symptoms will be included in the trial. Participants will be randomly allocated on a 1:1 ratio to 10 sessions of peer-worker-delivered behavioural activation (Back-on-Track) or a self-help workbook (Managing Stress on the Farm). Peer workers are members of the farming community that have completed training in behavioural activation and demonstrated competence. Feasibility outcomes include establishing recruitment rates, willingness to be randomised, dropout rate from trial, acceptability of peer delivered behavioural activation, and willingness to complete trial measures. The trial will contribute high quality evidence of the feasibility of undertaking a full-scale, randomised controlled trial of peer-delivered Behavioural Activation in farming communities in rural Australia. Full article

13 pages, 510 KB

Open AccessArticle

Association Between SARS-CoV-2–Related Experiences and Smoking Cessation in Switzerland: A Repeated Cross-Sectional Study

by Eloïse Cuvit, Margot Guth, Semira Gonseth Nusslé, Valérie D’Acremont and Carole Clair

Int. J. Environ. Res. Public Health 2026, 23(2), 198; https://doi.org/10.3390/ijerph23020198 - 3 Feb 2026

Abstract

The COVID 19 pandemic may have influenced smoking behaviours, including decisions to quit smoking. This study aimed to investigate smoking cessation following the first two waves of the COVID-19 pandemic in Switzerland and to assess whether cessation differed according to participants’ SARS-CoV-2–related experiences. [...] Read more.

The COVID 19 pandemic may have influenced smoking behaviours, including decisions to quit smoking. This study aimed to investigate smoking cessation following the first two waves of the COVID-19 pandemic in Switzerland and to assess whether cessation differed according to participants’ SARS-CoV-2–related experiences. Data from SérocoViD, a Swiss repeated cross-sectional study comprising five surveys in the canton of Vaud, was used. A total of 2454 participants aged 15 years and older from the first (May–July 2020) and third (February 2021) surveys were included. Association between SARS-CoV-2 infection experiences and cigarette smoking cessation were analyzed using logistic regression; both factors were unadjusted and adjusted for age and gender. Overall, 21.2% of participants reported being ex-smokers, but only a small proportion of the entire study population (i.e., including both smokers and non-smokers) reported quitting during the pandemic (0.5% in the first sample, 1.5% in the second). Participants who were smokers before the pandemic and had undergone diagnostic testing for SARS-CoV-2 showed a trend toward smoking cessation during the pandemic (non-adjusted odds ratio = 2.15; 95% confidence interval: 0.79–5.87). No such trends were found with a positive diagnostic test or serological result, or with COVID-19-like symptoms. These findings suggest that individuals seeking testing may be more health-conscious, potentially contributing to smoking cessation. For these individuals, the pandemic may represent a critical opportunity to promote smoking cessation, which should be leveraged by healthcare professionals and public health policies. Full article

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20 pages, 351 KB

Open AccessArticle

Cultural Self-Construal and Sustainable Mental Health in Japan: The Role of Subjective, Objective, and Autonomous Selves

by Youngsun Yuk and Eiko Matsuda

Int. J. Environ. Res. Public Health 2026, 23(2), 197; https://doi.org/10.3390/ijerph23020197 - 3 Feb 2026

Abstract

Maintaining sustainable mental health is an increasing societal challenge in Japan, where psychological distress and sleep problems have become major public health concerns. This study examined how three culturally grounded dimensions of self-construal—Subjective Self (SS), Objective Self (OS), and Autonomous Self (AS)—relate to [...] Read more.

Maintaining sustainable mental health is an increasing societal challenge in Japan, where psychological distress and sleep problems have become major public health concerns. This study examined how three culturally grounded dimensions of self-construal—Subjective Self (SS), Objective Self (OS), and Autonomous Self (AS)—relate to both positive and negative indicators of psychological adjustment among Japanese adults. This study aimed to examine whether internally guided forms of self-regulation (SS and AS) function as psychological resources, whereas externally guided self-regulation (OS) operates as a potential vulnerability factor in a culturally tight social context. By simultaneously examining multiple indicators of adjustment, this research clarifies how culturally shared self-regulatory patterns are linked to distress and sleep difficulties that affect large segments of the population. From a public health perspective, the findings highlight socially reinforced risk and protective patterns that can inform population-level prevention and mental health promotion in settings such as schools, workplaces, and communities, rather than relying solely on individual clinical intervention. These results underscore the importance of integrating cultural psychology into public health frameworks aimed at promoting sustainable mental health in contemporary and increasingly diverse social environments. Full article

20 pages, 2126 KB

Open AccessArticle

What Makes a Neighborhood? Associations Between Behavioral and Psychosocial Factors and Perceptions of Neighborhood Environments Among Community-Dwelling Older Black and Latino Adults

by Crystal M. Glover, Ana W. Capuano, Tianhao Wang, Brittney S. Lange-Maia, David A. Bennett, David X. Marquez, Lisa L. Barnes, Julie A. Schneider and Melissa Lamar

Int. J. Environ. Res. Public Health 2026, 23(2), 196; https://doi.org/10.3390/ijerph23020196 - 3 Feb 2026

Abstract

How people perceive their neighborhoods can impact their aging trajectories, with less known regarding neighborhood perceptions among older adults from minoritized groups. This study examined the impacts of behavioral and psychosocial factors on neighborhood perceptions among non-Latino (NL) Black and Latino older adults. [...] Read more.

How people perceive their neighborhoods can impact their aging trajectories, with less known regarding neighborhood perceptions among older adults from minoritized groups. This study examined the impacts of behavioral and psychosocial factors on neighborhood perceptions among non-Latino (NL) Black and Latino older adults. Participants (N = 506) were NL Black (n = 372) and Latino (n = 134) older adults (

\bar{x}

age = 79 years) without dementia. Participants completed a modified Perceptions of Neighborhood Environments Scale (mPNES; higher scores indicate more favorable perceptions) and measures of behavioral and psychosocial factors. We performed fully saturated linear regression analyses to assess how each factor related to the mPNES, followed by stepwise linear regression analyses to determine final predictive models for the full sample and each ethnoracial group. For the full sample, higher purpose in life, more physical activity, less discrimination, and higher income were associated with higher mPNES scores. For NL Black older adults, more physical activity, less discrimination, and higher income were associated with higher mPNES scores. For older Latinos, more purpose in life and a larger social network size were associated with higher mPNES scores. Distinct associations exist by ethnoracial group and suggest unique considerations to facilitate positive neighborhood perceptions among NL Black and Latino older adults. Full article

(This article belongs to the Section Behavioral and Mental Health)

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14 pages, 442 KB

Open AccessArticle

Development of an Oral Health Index and Its Association with Oral Health-Related Quality of Life and Cardiovascular Risks: A Cross-Sectional Study

by Vanessa Carvajal Soto, Larissa Knysak Ranthum, Luiz Felipe Manosso Guzzoni, Marcela Claudino, Eduardo Bauml Campagnoli and Marcelo Carlos Bortoluzzi

Int. J. Environ. Res. Public Health 2026, 23(2), 195; https://doi.org/10.3390/ijerph23020195 - 3 Feb 2026

Abstract

The OHI demonstrated moderate internal consistency and consistent associations with oral health-related quality of life and cardiovascular risk indicators. Objective: The primary objective was to propose and internally assess an Oral Health Index (OHI) which integrates multiple clinically assessed oral health variables. The [...] Read more.

The OHI demonstrated moderate internal consistency and consistent associations with oral health-related quality of life and cardiovascular risk indicators. Objective: The primary objective was to propose and internally assess an Oral Health Index (OHI) which integrates multiple clinically assessed oral health variables. The secondary objective was to investigate its association with oral health-related quality of life (OHRQoL) and common clinical cardiovascular risk (CVR) factors. Material and Methods: This observational study included 191 participants. Seven parameters (tooth loss, periodontal disease, endodontic involvement, residual roots, extractions due to periodontitis, inflammatory oral mucosal diseases, and dental maintenance and rehabilitation status) were combined using Z-scores to compute the OHI, with higher scores indicating poorer oral health. CVR factors included age/sex thresholds, education level, BMI, smoking status, diabetes, hypertension, pulse pressure, and lung function. OHRQoL was assessed using the Oral Health Impact Profile. Results: Higher OHI scores were associated with poor oral health-related quality of life. Participants with cardiovascular risk factors had significantly higher OHI scores. The analysis demonstrated that the OHI was directly associated with worse oral health-related quality of life and a greater cardiovascular risk burden, independent of age, sex, and comorbidities. Conclusions: This study proposed and internally assessed the Oral Health Index, designed to integrate multiple clinical parameters into a single standardized measure of oral health. The OHI demonstrated moderate internal consistency and showed consistent associations with poorer oral health conditions, reduced oral health-related quality of life, and a greater cardiovascular risk burden. Full article

(This article belongs to the Special Issue Oral Health Outcomes from Childhood to Adulthood)

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14 pages, 738 KB

Open AccessArticle

A Mixed Methods Evaluation of a Whole Food Plant-Based Nutrition Program for Medical Students

by Tai Metzger, Deena Sukhon, Sophie Fisher, Zaheen Hossain and Virginia Uhley

Int. J. Environ. Res. Public Health 2026, 23(2), 194; https://doi.org/10.3390/ijerph23020194 - 31 Jan 2026

Abstract

Background/Objectives: Whole food, plant-based (WFPB) diets have been associated with reduced cardiovascular risk and enhanced overall health. However, nutrition education in medical training remains limited. This study evaluated an experiential WFPB intervention known as the “Plant Plunge.” Methods: A total of [...] Read more.

Background/Objectives: Whole food, plant-based (WFPB) diets have been associated with reduced cardiovascular risk and enhanced overall health. However, nutrition education in medical training remains limited. This study evaluated an experiential WFPB intervention known as the “Plant Plunge.” Methods: A total of 64 medical student participants attended weekly one-hour nutrition seminars on campus led by a local nonprofit, received complimentary WFPB lunches, and were encouraged to eat a WFPB diet for four weeks. Semi-structured interviews explored program perceptions. Pre- and post-intervention assessments measured nutrition knowledge, and a post-program survey assessed attitudes toward the intervention. Results: We analyzed a total of 14 interviews, 25 pre- and post-intervention knowledge assessments, and 49 post-intervention surveys. Qualitative analysis identified seven major themes: (1) improved physical health outcomes; (2) increased awareness of nutrition’s role in medicine; (3) concerns about feasibility and accessibility of WFPB diets; (4) personal empowerment and behavioral change; (5) educational value of seminars; (6) social engagement and peer support; and (7) relevance to future clinical practice. Mean scores on the knowledge assessment significantly improved from 73.3% to 87.0% (p = 0.045) following the Plant Plunge. Survey responses revealed that 65% of participants agreed that they increased knowledge of food ingredients, 54% indicated increased likelihood of selecting plant-based options, and 43% agreed that finding WFPB foods was easy, with 16% disagreeing. Conclusions: The Plant Plunge improved medical students’ nutrition knowledge, dietary attitudes, and perceived readiness for lifestyle counseling while offering an experiential model of nutrition education. Short, experiential nutrition programs may serve as scalable approaches to strengthen nutrition training and support chronic disease prevention. Full article

14 pages, 496 KB

Open AccessArticle

Potential Lead Risk and Water Consumption Behavior in the Chicago Area: A Coordinated Oral Health Promotion (CO-OP) Study Analysis

by Natalie Crnosija, Kathleen R. Diviak and Molly Martin

Int. J. Environ. Res. Public Health 2026, 23(2), 193; https://doi.org/10.3390/ijerph23020193 - 31 Jan 2026

Abstract

Municipally provided water is low-cost, considered safe in most communities, and usually fluoridated to improve oral health. Yet, many Chicago region families report relying on other water sources. We investigated if safety and quality concerns were associated with these decisions; we also investigated [...] Read more.

Municipally provided water is low-cost, considered safe in most communities, and usually fluoridated to improve oral health. Yet, many Chicago region families report relying on other water sources. We investigated if safety and quality concerns were associated with these decisions; we also investigated whether there were spatial trends related to lead risk associated with water choice preferences. We used self-reported water consumption behavior data from the Coordinated Oral Health Promotion (CO-OP) Study, a longitudinal cohort of young children and their families. Respondents’ residences (N = 331) were geolocated at the census tract level. We evaluated associations between parent demographics, estimated lead risk and water preferences. Among those who “Never” gave their children tap water, we investigated demographic characteristics associated with viewing tap water as “Not safe”. Sixty-five percent (n = 216) of caregivers report that their child “Never” drinks tap water. Ordinal logistic regression indicates that parents aged <30 years are more likely to respond “Never” relative to “Sometimes” or “Always” (OR = 1.89; CI = 1.04, 3.40). Among those in the “Never” category, we grouped reasons into safety concerns (n = 114), observed quality concerns (n = 48), and preference (n = 40). We found that the decision not to give children municipal water is not aligned with the estimated lead risk. Understanding water consumption choice mechanisms is important for communities seeking safe and quality drinking water. Full article

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14 pages, 1233 KB

Open AccessArticle

Pupils’ Acceptance and Plate Waste of Sorghum-Based Breakfasts in South African School Feeding Programmes: A Mixed-Methods Study Across Five Provinces

by Hema Kesa, Eridiong Onyenweaku and Alex Dimitri Tchuenchieu Kamgain

Int. J. Environ. Res. Public Health 2026, 23(2), 192; https://doi.org/10.3390/ijerph23020192 - 31 Jan 2026

Abstract

Sorghum-based porridges are a key component of breakfast meals in South African school feeding programmes. While these meals support learner nutrition and educational outcomes, their effectiveness depends on learner acceptance and the extent of plate waste. This study assessed acceptance and plate waste [...] Read more.

Sorghum-based porridges are a key component of breakfast meals in South African school feeding programmes. While these meals support learner nutrition and educational outcomes, their effectiveness depends on learner acceptance and the extent of plate waste. This study assessed acceptance and plate waste of two sorghum-based porridges—Mabele (100% sorghum) and Morvite (pre-cooked sorghum, 75–100% depending on flavour, with possible inclusion of soya, cow’s milk, and wheat/gluten)—compared with instant maize meal, Jungle Oats (100% wholegrain oats), within the Tiger Brands Foundation breakfast programme. Patterns of waste and underlying reasons were examined across five provinces. A mixed-methods approach was used in 25 primary schools across Gauteng, KwaZulu-Natal, Limpopo, North West, and Northern Cape. Quantitative data were collected through 10-day food waste diaries completed by Volunteer Food Handlers and analysed using descriptive statistics, ANOVA, and regression models. Qualitative data were obtained from 75 semi-structured staff interviews and 25 learner focus groups, analysed thematically using ATLAS.ti version 22. Overall, food waste was low, with “no food waste” reported in over half of the observations. Acceptance of sorghum-based products varied. Morvite was generally well accepted, whereas Mabele was frequently disliked in some provinces. Key drivers of waste included food dislike, poor preparation, bland flavour, and learner absenteeism, with serving conditions and a lack of utensils as secondary factors. Although waste was modest, variability in acceptance of sorghum-based porridges suggests the need to improve preparation quality, flavour, and serving conditions to enhance programme effectiveness. Full article

(This article belongs to the Special Issue Indigenous Foods: Bridging Tradition and Innovation for Global Nutrition and Health)

31 pages, 3452 KB

Open AccessArticle

Counterintuitive PM_2.5 Increases During COVID-19 Lockdown in Ilo, Peru: Coastal Meteorology and Cardiovascular Implications

by José Antonio Valeriano-Zapana, Mario Román Flores-Roque, Leonel Alonso Paccosonco-Sucapuca, Yudith Milagros Cari-Cari, Daniel Álvarez-Tolentino and Alex Huaman De La Cruz

Int. J. Environ. Res. Public Health 2026, 23(2), 191; https://doi.org/10.3390/ijerph23020191 - 31 Jan 2026

Abstract

The COVID-19 pandemic created a natural experiment to assess air quality responses to emission reductions, yet evidence from Latin American coastal industrial cities remains scarce. This study examined how meteorological variability modulated the effects of COVID-19 restrictions on air quality in Ilo, a [...] Read more.

The COVID-19 pandemic created a natural experiment to assess air quality responses to emission reductions, yet evidence from Latin American coastal industrial cities remains scarce. This study examined how meteorological variability modulated the effects of COVID-19 restrictions on air quality in Ilo, a medium-sized coastal industrial city in southern Peru (~67,000 inhabitants). We analyzed daily concentrations of PM₁₀, PM_2.5, NO₂, O₃, and SO₂ across six pandemic phases (January–December 2020) using multiple linear regression, variance decomposition, and Random Forest models. A health impact assessment translated PM_2.5 changes into cardiovascular mortality estimates using Global Burden of Disease 2021 coefficients. Despite reduced anthropogenic activity, PM_2.5 increased by 34% during early reopening (May–June: 16.9 vs. 12.6 µg/m³ baseline), whereas NO₂ decreased consistently (13–19%), SO₂ declined up to 65%, and O₃ more than doubled (+108%) in austral winter. Variance decomposition revealed that O₃ variability was almost entirely meteorology-driven (98%), while PM_2.5 and NO₂ showed balanced contributions from meteorology and restrictions (~50% each). The PM_2.5 increase corresponded to approximately 3 additional cardiovascular deaths per 100,000 population annually. Coastal meteorology can counteract emission reductions, generating counterintuitive air quality responses and underscoring the need for meteorological normalization in policy evaluation. Full article

(This article belongs to the Section Environmental Health)

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27 pages, 971 KB

Open AccessArticle

Teacher Well-Being and Burnout Resilience: Dimensional Independence, Pandemic Burden, and Profile Analysis in Primary Education

by Sofia Christopoulou, Hera Antonopoulou, Raphael Zapantis, Evgenia Gkintoni and Constantinos Halkiopoulos

Int. J. Environ. Res. Public Health 2026, 23(2), 190; https://doi.org/10.3390/ijerph23020190 - 31 Jan 2026

Abstract

Background: Primary school teachers are experiencing unprecedented occupational stress due to technological demands, varied student needs, and the enduring psychological effects of the COVID-19 pandemic. Although burnout research is extensive globally, evidence regarding Greek primary educators remains scarce, particularly in post-pandemic contexts where [...] Read more.

Background: Primary school teachers are experiencing unprecedented occupational stress due to technological demands, varied student needs, and the enduring psychological effects of the COVID-19 pandemic. Although burnout research is extensive globally, evidence regarding Greek primary educators remains scarce, particularly in post-pandemic contexts where Mediterranean cultural values, economic constraints, and centralized governance may yield unique patterns. Methods: This cross-sectional study examined professional burnout among 102 primary school teachers in Achaia prefecture, Greece, during autumn 2022. The Greek-validated Maslach Burnout Inventory-Educators Survey assessed emotional exhaustion, depersonalization, and personal accomplishment. The psychological impact of COVID-19 was evaluated alongside demographic and occupational factors. Analyses included descriptive statistics, nonparametric tests, correlation analyses, hierarchical clustering, and multiple regression models. Results: The sample exhibited mixed burnout profiles, with 42.2% indicating low emotional exhaustion (while 35.3% showed high levels) and 67.6% showing minimal depersonalization. Bivariate analysis revealed that the psychological burden of COVID-19 was significantly correlated with depersonalization (r = 0.339, p < 0.001) but not with emotional exhaustion (r = 0.078, ns) or personal achievement. However, multivariate regression controlling for demographic factors revealed a suppression effect: pandemic burden emerged as the strongest predictor of emotional exhaustion (β = 0.52, p < 0.001), while its association with depersonalization became non-significant. Cluster analysis identified four distinct profiles: Emotionally Strained (49.0%), Resilient (32.4%), Detached (15.7%), and At-Risk (2.9%). Gender significantly predicted emotional exhaustion (model R² = 0.136), while rural location and years of service predicted depersonalization (model R² = 0.225). Conclusions: Greek primary school teachers demonstrated remarkable resilience after the pandemic, maintaining professional effectiveness despite emotional challenges. The suppression effect observed for COVID-19 burden—significantly associated with depersonalization bivariately but with emotional exhaustion multivariately—highlights the importance of examining both direct and demographically mediated stress pathways. The dimensional independence observed, particularly personal achievement's resilience to external stressors, contests unified burnout models and indicates that targeted interventions addressing specific burnout dimensions may be more effective than holistic approaches. Full article

(This article belongs to the Special Issue Psychosocial Impact in the Post-pandemic Era)

15 pages, 897 KB

Open AccessSystematic Review

Effective Interventions to Prevent Breastfeeding-Related Nipple-Areolar Lesions: A Systematic Review

by Ana Chagas, Fernanda Moura, Monise Bispo, Lays Medeiros, Isabelle Costa and Rhayssa Araújo

Int. J. Environ. Res. Public Health 2026, 23(2), 189; https://doi.org/10.3390/ijerph23020189 - 31 Jan 2026

Abstract

This study synthesizes the evidence on effective interventions for the prevention of breastfeeding-related nipple-areolar injuries. A systematic review was performed and guided by the evidence synthesis manual of the Joan Briggs Institute, carried out in six databases, with only intervention studies. Interventions with [...] Read more.

This study synthesizes the evidence on effective interventions for the prevention of breastfeeding-related nipple-areolar injuries. A systematic review was performed and guided by the evidence synthesis manual of the Joan Briggs Institute, carried out in six databases, with only intervention studies. Interventions with a positive outcome for the prevention of nipple-areolar lesions were considered effective. Methodological quality was assessed by the Grading of Recommendations Assessment, Development and Evaluation. The final sample of 14 articles found the following to be effective strategies: educational practices (simulations and demonstrations of the breastfeeding technique, with a qualified professional or by video) and the use of peppermint (aqueous solution or gel), extra virgin olive oil, honey, guaiazulene ointment, and venix caseosa. Each intervention was used in specific situations and ways, which should be considered for use in clinical practice. The interventions discussed can help prevent nipple-areolar lesions and breastfeeding difficulties, encouraging breastfeeding. Full article

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