International Journal of Environmental Research and Public Health

20 pages, 824 KB

Open AccessArticle

Economic Burden of Human Immunodeficiency Virus and Hypertension Care Among MOPHADHIV Trial Participants: Patient Costs and Determinants of Out-of-Pocket Expenditure in South Africa

by Danleen James Hongoro, Andre Pascal Kengne, Nasheeta Peer, Kim Nguyen, Kirsty Bobrow and Olufunke A. Alaba

Int. J. Environ. Res. Public Health 2025, 22(10), 1488; https://doi.org/10.3390/ijerph22101488 (registering DOI) - 25 Sep 2025

Abstract

Background: Human immunodeficiency virus and hypertension increasingly co-occur in South Africa. Despite publicly funded care, patients with multimorbidity face high out-of-pocket costs, yet limited evidence exists from the patient perspective. Purpose: To quantify the economic burden of comorbid HIV and hypertension, assess predictors [...] Read more.

Background: Human immunodeficiency virus and hypertension increasingly co-occur in South Africa. Despite publicly funded care, patients with multimorbidity face high out-of-pocket costs, yet limited evidence exists from the patient perspective. Purpose: To quantify the economic burden of comorbid HIV and hypertension, assess predictors of monthly out-of-pocket costs, and explore coping mechanisms. Methods: We conducted a cross-sectional analysis using patient-level data from the Mobile Phone Text Messages to Improve Hypertension Medication Adherence in Adults with HIV (MOPHADHIV trial) [Trial number: PACTR201811878799717], a randomized controlled trial evaluating short messages services adherence support for hypertension care in people with HIV. We calculated the monthly direct non-medical, indirect, and coping costs from a patient perspective, valuing indirect costs using both actual income and minimum wage assumptions. Generalized linear models with a gamma distribution and log link were used to identify cost determinants. Catastrophic expenditure thresholds (10–40% of monthly income) were assessed. Results: Among 683 participants, mean monthly total costs were ZAR 105.81 (USD 5.72) using actual income and ZAR 182.3 (USD 9.9) when valuing indirect costs by minimum wage. These time-related productivity losses constituted the largest share of overall expenses. Regression models revealed a strong income gradient: participants in the richest quintile incurred ZAR 131.9 (95% CI: 63.6–200.1) more per month than the poorest. However, this gradient diminished or reversed under standardized wage assumptions, suggesting a heavier proportional burden on middle-income groups. Other socio-demographic factors (gender, employment, education) not significantly associated with total costs, likely reflecting the broad reach of South Africa’s primary health system. Nearly half of the participants also reported resorting to coping mechanisms such as borrowing or asset sales. Conclusions: Comorbid HIV and hypertension impose substantial patient costs, predominantly indirect. Income disparities drive variation, raising equity concerns. Strengthening integrated human immunodeficiency virus—non-communicable diseases care and targeting financial support are key to advancing South Africa’s Universal Health Coverage reforms. Full article

(This article belongs to the Special Issue Health Inequalities in Primary Care)

12 pages, 608 KB

Open AccessArticle

Unlocking the Potential of mHealth: Integrating Behaviour Change Techniques in Hypertension App Design

by Emily Motta-Yanac, Riley Victoria, Naomi J. Ellis and Christopher James Gidlow

Int. J. Environ. Res. Public Health 2025, 22(10), 1487; https://doi.org/10.3390/ijerph22101487 (registering DOI) - 25 Sep 2025

Abstract

Background: Smartphone apps offer a promising avenue for delivering scalable interventions for hypertension self-management. This study aimed to characterise the behaviour change technique ontology (BCTO) elements present in apps available on popular platforms, map the theoretical domains framework (TDF), and describe the apps’ [...] Read more.

Background: Smartphone apps offer a promising avenue for delivering scalable interventions for hypertension self-management. This study aimed to characterise the behaviour change technique ontology (BCTO) elements present in apps available on popular platforms, map the theoretical domains framework (TDF), and describe the apps’ functionalities. Methods: A comprehensive search of app stores was conducted to identify relevant hypertension self-management apps. The identified apps were then analysed for BCTO elements, which were subsequently mapped to TDF. App functionalities and quality were assessed as well. Results: Functionalities such as self-monitoring were consistently observed across all app types, aligning with established hypertension self-management strategies. However, other key functionalities, including goal setting via reminders, communication with healthcare professionals, and data export capabilities, were less prevalent. AI-empowered apps incorporated a broader range of behaviour change techniques compared to non-AI and RCT-tested apps, suggesting a potentially more comprehensive approach to supporting behaviour change. The domains of “Knowledge”, “Emotions”, “Behavioural regulation”, “Skills”, and “Beliefs about Consequences” were most frequently targeted by app developers. AI-empowered apps incorporated a broader range of BCTs compared to non-AI and RCT-tested apps, potentially offering more comprehensive support for behaviour change. Conclusion: While existing hypertension self-management apps incorporate a variety of BCTs, there is room for improvement in terms of incorporating a wider range of functionalities and BCTOs, particularly those targeting more intrinsic and habitual aspects of behaviour. Full article

(This article belongs to the Special Issue uHealth Interventions and Digital Therapeutics for Better Diseases Prevention and Patient Care)

33 pages, 521 KB

Open AccessReview

The Relationship Between Climate Change and Breast Cancer and Its Management and Preventative Implications in South Africa

by Pululu Sexton Mahasa, Muambangu Jean Paul Milambo, Sibusiso Frank Nkosi, Geofrey Mukwada, Martin Munene Nyaga and Solomon Gebremariam Tesfamichael

Int. J. Environ. Res. Public Health 2025, 22(10), 1486; https://doi.org/10.3390/ijerph22101486 (registering DOI) - 25 Sep 2025

Abstract

This review aims to explore the implications of climate change for breast cancer management and prevention, with a focus on global strategies and interventions that can be applied in various contexts, including South Africa. Climate change has emerged as a significant global health [...] Read more.

This review aims to explore the implications of climate change for breast cancer management and prevention, with a focus on global strategies and interventions that can be applied in various contexts, including South Africa. Climate change has emerged as a significant global health concern, with far-reaching implications for various diseases, including cancer. This systematic review aims to synthesise epidemiological research examining the relationship between climate change and the incidence of breast cancer. We conducted a comprehensive literature search using main search terms, including “breast cancer,” “climate change,” “air pollution,” “water pollution,” “global warming,” and “greenhouse effect,” supplemented by the general term “breast” cancer across multiple databases. Our analysis identified studies that link environmental changes—such as rising temperatures, altered precipitation patterns, and increased exposure to pollutants—with breast cancer risk. Our findings highlight a potential association between climate-related factors, including heat stress, air and water pollution, endocrine-disrupting chemicals, and lifestyle changes influenced by environmental shifts, and the epidemiology of breast cancer. This review underscores the need for an integrated approach that incorporates climate science into public health strategies to mitigate breast cancer risk. By elucidating these connections, we aim to inform policymakers and healthcare professionals about the importance of addressing climate change not just as an environmental issue, but as a pressing determinant of health that may exacerbate cancer incidence, particularly in vulnerable populations. Further research is warranted to elucidate the underlying biological mechanisms and to develop targeted interventions that can address both climate change and its potential health impacts. Full article

16 pages, 319 KB

Open AccessArticle

Assessment of Health-Promoting Lifestyle Profile: A Cross-Sectional Study of Adolescents and Young Adults in Mongolia

by Erdenezul Uitumen and Klára Tarkó

Int. J. Environ. Res. Public Health 2025, 22(10), 1485; https://doi.org/10.3390/ijerph22101485 - 25 Sep 2025

Abstract

The study examined health-promoting lifestyles and their contributing factors among adolescents and young adults at three universities in Ulaanbaatar, Mongolia. A cross-sectional study was conducted from April to May 2024. A total of 827 participants were analyzed using the Health-Promoting Lifestyle Profile II [...] Read more.

The study examined health-promoting lifestyles and their contributing factors among adolescents and young adults at three universities in Ulaanbaatar, Mongolia. A cross-sectional study was conducted from April to May 2024. A total of 827 participants were analyzed using the Health-Promoting Lifestyle Profile II (HPLP-II). Exploratory and confirmatory factor analyses were performed using JASP to ensure cultural adaptation. Descriptive statistics, an independent t-test, one-way ANOVA, and a MANOVA were employed to analyze the data in SPSS. Post hoc analyses and effect sizes were conducted in cases of significance. The mean HPLP-II score was 2.60 (SD = 0.35). The highest mean score was on the interpersonal relationships subscale (M = 2.89; SD = 0.52), and the lowest was on the health responsibility subscale (M = 2.31; SD = 0.49). Our findings revealed that there were significant differences in the overall HPLP-II scores based on university, working status, and economic status. Additionally, the data revealed that for certain HPLP-II subscales, factors such as gender, residence type, and location of graduation schools were significant. Universities are potential settings for planning and implementing health promotion programs that encourage adolescents and young adults to take responsibility for their health and engage in physical activity. Full article

18 pages, 523 KB

Open AccessReview

Breaking the Silence: A Scoping Literature Review on Trauma-Informed Care for Black Women Navigating Sexual Health-Related Trauma

by Ayanna Troutman, Funlola Are, Ashley Okoye, Sarah Chiang, Destiny Craig, Anthony Akande and Irene Stafford

Int. J. Environ. Res. Public Health 2025, 22(10), 1484; https://doi.org/10.3390/ijerph22101484 - 25 Sep 2025

Abstract

Black women disproportionately experience sexual health-related trauma, yet their mental health needs are often inadequately addressed due to systemic barriers and stigma. This literature review examines trauma-informed care (TIC) frameworks tailored to Black women, emphasizing culturally responsive practices in addressing sexual health-related trauma. [...] Read more.

Black women disproportionately experience sexual health-related trauma, yet their mental health needs are often inadequately addressed due to systemic barriers and stigma. This literature review examines trauma-informed care (TIC) frameworks tailored to Black women, emphasizing culturally responsive practices in addressing sexual health-related trauma. By synthesizing findings from existing research, including the importance of intersectionality, culturally specific interventions, and community-centered approaches, this review highlights effective strategies for mental health providers. The review concludes with implications for enhancing TIC training and implementation in clinical settings which contributes to the advancement of equitable mental health services for Black women. Full article

(This article belongs to the Special Issue Promoting Women's Sexual and Reproductive Health)

13 pages, 681 KB

Open AccessArticle

Adherence to Antihypertensive Therapy: A Cross-Sectional Study Among Patients in the Republic of Kazakhstan

by Akbayan Markabayeva, Aiman Kerimkulova, Riza Nurpeissova, Gyulnar Zhussupova, Ayagyoz Umbetzhanova, Dinara Zhunussova, Alisher Idrisov, Ardak Zhumagaliyeva, Aliya Seidullayeva, Aigul Utegenova and Lyudmila Pivina

Int. J. Environ. Res. Public Health 2025, 22(10), 1483; https://doi.org/10.3390/ijerph22101483 - 25 Sep 2025

Abstract

Background: Poor adherence to antihypertensive therapy is a major barrier to effective blood pressure control, particularly in countries with a high burden of non-communicable diseases. In Kazakhstan, improving adherence is a key objective of the “Densaulyk” State Health Program (2020–2025). Objective: To assess [...] Read more.

Background: Poor adherence to antihypertensive therapy is a major barrier to effective blood pressure control, particularly in countries with a high burden of non-communicable diseases. In Kazakhstan, improving adherence is a key objective of the “Densaulyk” State Health Program (2020–2025). Objective: To assess medication adherence among patients with arterial hypertension in Kazakhstan and identify associated socio-demographic and clinical factors. Methods: A cross-sectional survey was conducted among outpatient hypertensive patients at a major urban medical center. Adherence was measured using the 8-item Morisky Medication Adherence Scale (MMAS-8). Socio-demographic characteristics, disease duration, and the number of prescribed medications were analyzed in relation to adherence levels. Results: Adherence was significantly associated with age, ethnicity, education, marital and financial status, disease duration, and treatment complexity. A notable share of participants demonstrated low to moderate adherence. The use of self-reported data may have introduced bias. Conclusions: Medication adherence in Kazakhstan is influenced by multiple interrelated factors. Targeted and culturally appropriate interventions—such as simplified regimens, digital tools, and broader access to subsidized drugs—are essential to improve long-term outcomes in hypertension management. Full article

15 pages, 431 KB

Open AccessArticle

Patient-Centered Leadership and Co-Design of Services for Breast Cancer Program in Nicaragua

by María Esther Suárez, Karen Vanessa Herrera, Alma Celeste Avilés, Gonzalo Granados, Ena Patricia García and Chepita Rivera

Int. J. Environ. Res. Public Health 2025, 22(10), 1482; https://doi.org/10.3390/ijerph22101482 - 25 Sep 2025

Abstract

Introduction: The direct participation and leadership of breast cancer patients in program design and implementation can facilitate a nuanced understanding of how individuals perceive and address challenges within their unique contexts. To achieve truly patient-centered care, patients must be formally integrated as a [...] Read more.

Introduction: The direct participation and leadership of breast cancer patients in program design and implementation can facilitate a nuanced understanding of how individuals perceive and address challenges within their unique contexts. To achieve truly patient-centered care, patients must be formally integrated as a critical component of multidisciplinary healthcare teams. Materials and Methods: A descriptive, retrospective observational study was conducted. A group of 122 patients (“Breast Unit”) was formed and actively implemented initiatives related to education, prevention, peer support, co-design, and institutional guidance over two years. A second group, consisting of 466 individuals diagnosed with and treated for breast cancer, served as the Beneficiary Patient group. From the “Breast Unit”, 93 patients responded to a structured interview about their experience. Results: The Breast Unit group developed strong leadership skills and collaborated with the multidisciplinary healthcare team to improve care workflows, contributing at both strategic and operational levels. In total, 97% of patients received their first oncology evaluation within 48 h, ensuring timely intervention. The percentage of early-stage breast cancer diagnoses improved, from 67% to 76%. Furthermore, patients who participated in the support group reported no new diagnoses of clinical depression in the past two years. Conclusions: By elevating the patient voice into a substantive role within leadership, strategic planning, and co-design initiatives, healthcare systems can advance a more equitable, effective, and sustainable model of care. Integrating patient contributions with multidisciplinary collaboration is essential for optimizing care processes, improving clinical outcomes. It strengthens the person-centered culture, impacting on a personal and organizational level. Full article

(This article belongs to the Special Issue Health and Health Equity in Latin America)

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30 pages, 1666 KB

Open AccessArticle

Food Swamps and Transportation Access: Intersecting Structural Determinants of Food Shopping and Access in Marginalized Urban Communities

by Summaya Abdul Razak, Abiodun T. Atoloye, Curtis Jalen Antrum, Kritee Niroula, Richard Bannor, Snehaa Ray, Emil Coman, Tania Huedo-Medina, Valerie B. Duffy and Kristen Cooksey Stowers

Int. J. Environ. Res. Public Health 2025, 22(10), 1481; https://doi.org/10.3390/ijerph22101481 - 25 Sep 2025

Abstract

The study examined the relationship between food swamps and self-reported food shopping frequency and perceived food access, while considering transportation mode and travel time. This Community-Based Participatory Research study surveyed residents from six neighborhoods in Hartford. Individual-level food swamp exposure (the ratio of [...] Read more.

The study examined the relationship between food swamps and self-reported food shopping frequency and perceived food access, while considering transportation mode and travel time. This Community-Based Participatory Research study surveyed residents from six neighborhoods in Hartford. Individual-level food swamp exposure (the ratio of unhealthy to healthy food stores within a 0.5-mile radius of participants’ homes) was measured both objectively (using GIS-based methods) and subjectively (through self-reporting). Poisson regression models assessed the associations between food swamps and outcomes (shopping frequency by store types and perceived access to food), with transportation mode and travel time as moderators. Of 304 participants, 51% lived in subjective (n = 153) and 71% in objective (n = 198) food swamps. Food swamp exposure was associated with greater shopping frequency at unhealthy outlets (β = 0.12, p < 0.001), less access to healthier food (β = −0.13, p < 0.001), and increased access to unhealthy food (β = 0.08, p < 0.001). Transportation significantly moderates these relationships; bus riders reported the highest rates of unhealthy food purchasing (β = 0.17, p < 0.001). Longer travel times increased both healthy and unhealthy food access (β = 0.01, p < 0.001 for each). Food swamps interact with public transportation to contribute to food shopping and access, underscoring the need for integrated food and transportation policies to address structural barriers and promote health equity in underserved urban communities. Full article

(This article belongs to the Special Issue 4th Edition: Social Determinants of Health)

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19 pages, 1180 KB

Open AccessArticle

Context-Dependent Effects of HIV Disclosure on Social Isolation Among Rural PLHIV: A Pilot Configurational Study

by John Matta and Jacob Grubb

Int. J. Environ. Res. Public Health 2025, 22(10), 1480; https://doi.org/10.3390/ijerph22101480 - 25 Sep 2025

Abstract

Social isolation is a critical but understudied concern for people living with HIV (PLHIV), particularly in rural U.S. communities where social visibility is high and access to supportive services is limited. Disclosure of HIV status is often framed as a health-promoting behavior that [...] Read more.

Social isolation is a critical but understudied concern for people living with HIV (PLHIV), particularly in rural U.S. communities where social visibility is high and access to supportive services is limited. Disclosure of HIV status is often framed as a health-promoting behavior that facilitates engagement with care and access to social support, yet it can also increase vulnerability to exclusion and isolation, especially where confidentiality is difficult to maintain. Using data from a pilot survey of rural PLHIV in the United States (

n = 17

), this study examines when disclosure may function adaptively and when it may coincide with a heightened social burden. A Social Isolation Index was constructed from 15 indicators of exclusion across family, community, and institutional domains. Disclosure was measured both by the number of people informed and whether sexual partners were told. Typological methods and Qualitative Comparative Analysis (QCA) were applied to explore how disclosure patterns relate to race, sexual identity, and reported isolation. The results indicate that disclosure is not uniformly protective: several participants who disclosed widely also reported high levels of isolation, with heterosexual and Black participants often reporting a higher cumulative burden. These findings challenge one-size-fits-all assumptions about disclosure in public health messaging and underscore the need for tailored strategies that recognize both disclosure and nondisclosure as potentially adaptive responses in rural and marginalized communities. Full article

(This article belongs to the Special Issue Social Factors Influencing Health Outcomes Among Persons Living with HIV)

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11 pages, 644 KB

Open AccessArticle

Unravelling the Association Between Trait Mindfulness and Problematic Social Media Use in Youth

by Elisa Galli, Marta Sannino, Zidane Dridi and Marco Giancola

Int. J. Environ. Res. Public Health 2025, 22(10), 1479; https://doi.org/10.3390/ijerph22101479 - 25 Sep 2025

Abstract

The compulsive and unregulated use of social media, also known as problematic social media use (PSMU), has raised increasing concerns about its detrimental impact on psychological well-being and daily functioning among young individuals. Understanding the psychological mechanisms underlying this behavioural pattern is essential, [...] Read more.

The compulsive and unregulated use of social media, also known as problematic social media use (PSMU), has raised increasing concerns about its detrimental impact on psychological well-being and daily functioning among young individuals. Understanding the psychological mechanisms underlying this behavioural pattern is essential, with personality traits emerging as a particularly relevant area of investigation. While some personality traits, such as narcissism, have received substantial attention, others remain overlooked. Through a cross-sectional design, this study examined how trait mindfulness, as captured in terms of awareness and acceptance, predicts PSMU while accounting for sociodemographics (age, sex, and education) and both grandiose and vulnerable narcissism. A total of 180 participants (mean_age = 22.16 years; SD_age = 2.47 years; 95 females) completed the Narcissistic Personality Inventory-13, the Hypersensitive Narcissism Scale, the Philadelphia Mindfulness Scale, and the Bergen Social Media Addiction Scale. Regression analyses indicated that only the acceptance of trait mindfulness significantly predicted PSMU. These findings suggest that cultivating a non-judgmental and open stance towards internal experiences may protect against PSMU through affect regulation and emotional acceptance. Full article

(This article belongs to the Special Issue The Impact of Internet and Social Media Use on Young People's Mental Health)

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12 pages, 1091 KB

Open AccessArticle

Open Data Are Urgently Needed for One Health-Based Investigations: The Example of the 2024 Salmonella Umbilo Multi-Country Outbreak

by Alessandra Mazzeo, Celestina Mascolo, Marco Esposito, Lucia Maiuro, Sebastiano Rosati and Elena Sorrentino

Int. J. Environ. Res. Public Health 2025, 22(10), 1478; https://doi.org/10.3390/ijerph22101478 - 25 Sep 2025

Abstract

In 2024, a significant Salmonella Umbilo outbreak was reported across the European Union and beyond, traced to contaminated vegetables originating from the Province of Salerno (Italy). Subsequent on-site inspections in the production area revealed a mismanaged manure storage tank, which became the focus [...] Read more.

In 2024, a significant Salmonella Umbilo outbreak was reported across the European Union and beyond, traced to contaminated vegetables originating from the Province of Salerno (Italy). Subsequent on-site inspections in the production area revealed a mismanaged manure storage tank, which became the focus of a GIS-based investigation aimed at locating nearby animal establishments. Within a 1-km radius—encompassing both the tank and the contaminated greenhouses—three buffalo farms were identified. Farm inspections revealed buffalo calves exhibiting enteric symptoms. Fecal samples collected from these animals led to the isolation of S. Umbilo genomically linked to the 2024 multi-country outbreak, as well as other serotypes. To thoroughly investigate, data from official EU and Italian databases were analyzed, to detect the presence of S. Umbilo in vegetables, buffalo, and other livestock within the Province of Salerno. However, the lack of access to critical data needed to clarify the epidemiological links at the human–animal–environment interface has hindered the full reconstruction of the outbreak dynamics. These limitations underscore the urgent need to implement One Health strategies by promoting interdisciplinary collaboration among veterinarians, physicians, food technologists, biologists and other professionals; leveraging official open access databases; and adopting emerging technologies as interoperable data systems and drone surveillance. Full article

(This article belongs to the Section Infectious Diseases, Chronic Diseases, and Disease Prevention)

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14 pages, 514 KB

Open AccessArticle

Barriers and Facilitators to Timely Diagnosis of Tuberculosis in Children and Adolescents in Karachi, Pakistan

by Sara Ahmad, Maria Jaswal, Amyn Abdul Malik, Maria Omar, Iraj Batool, Ammad Fahim, Hannah N. Gilbert, Carole D. Mitnick, Farhana Amanullah and Courtney M. Yuen

Int. J. Environ. Res. Public Health 2025, 22(10), 1477; https://doi.org/10.3390/ijerph22101477 - 24 Sep 2025

Abstract

Background: The diagnosis of tuberculosis (TB) in children and adolescents is often delayed. We conducted a study to understand the barriers and facilitators to the diagnosis of TB in children and adolescents in a not-for-profit private hospital in Karachi, Pakistan. Methods: We conducted [...] Read more.

Background: The diagnosis of tuberculosis (TB) in children and adolescents is often delayed. We conducted a study to understand the barriers and facilitators to the diagnosis of TB in children and adolescents in a not-for-profit private hospital in Karachi, Pakistan. Methods: We conducted a convergent mixed-methods study comprising quantitative surveys with caregivers of 100 TB patients < 18 years old and 40 semi-structured interviews with caregivers and healthcare providers. Results: Among TB patients whose caregivers were surveyed, 82% were adolescents 10–17 years old. Caregivers reported a median of 91 days (IQR 58–160) between symptom onset and treatment initiation. Time was divided relatively evenly between symptom onset and the first visit to a healthcare provider (median 73, IQR 42–130 days), and between this visit and TB diagnosis (median 65 days, IQR 30–114). While 69% of caregivers initially visited general physicians, many felt that these general physicians did not provide satisfactory healthcare. Caregivers mentioned financial constraints as a major barrier affecting all stages of the journey to diagnosis and treatment. Conclusions: Interventions that overcome financial barriers and strategies that enhance the capacity of private sector general physicians are necessary to reduce delays in TB diagnosis and treatment initiation for children and adolescents. Full article

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11 pages, 529 KB

Open AccessArticle

Demographic Differences in Periodic Limb Movement Index and Apnea–Hypopnea Index in a Diverse Clinical Cohort

by Lourdes M. DelRosso, Harshil Modi, Alec M. Chan-Golston, Prabhvir Sandhu, Viraj Jain and Moon Park

Int. J. Environ. Res. Public Health 2025, 22(10), 1476; https://doi.org/10.3390/ijerph22101476 - 24 Sep 2025

Abstract

This study investigated how age, sex, and ethnicity relate to the severity of periodic limb movement index (PLMI) and obstructive sleep apnea (OSA) in a diverse clinical population. A retrospective analysis was conducted on 711 adults who underwent diagnostic polysomnography between June 2022 [...] Read more.

This study investigated how age, sex, and ethnicity relate to the severity of periodic limb movement index (PLMI) and obstructive sleep apnea (OSA) in a diverse clinical population. A retrospective analysis was conducted on 711 adults who underwent diagnostic polysomnography between June 2022 and July 2024. The mean age was 57.2 years; 55.6% were female, and the sample was ethnically diverse (53.7% White, 31.6% Hispanic, 6.8% Asian, 6.1% Black, 1.8% Other). PLMI was significantly higher in older adults, males, and White participants. AHI was higher in males and peaked in middle-aged adults (44–62 years). Multivariable regression models showed that male sex independently predicted higher PLMI and AHI, while increasing age was associated with higher PLMI only. Black ethnicity was linked to lower PLMI, and Hispanic ethnicity to higher AHI. These findings emphasize the role of demographic factors in the presentation of sleep disorders and support the need for personalized approaches in screening and diagnosis. Recognizing at-risk subgroups may improve early detection and targeted interventions for both PLMS and OSA in diverse populations. Full article

(This article belongs to the Special Issue Exploring the Link—Better Sleep Equals Better Health)

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17 pages, 2357 KB

Open AccessArticle

Applying Design Thinking for Co-Designed Health Solutions: A Case Study on Chronic Kidney Disease in Regional Australia

by Anita Stefoska-Needham, Jessica Nealon, Karen Charlton, Karen Fildes and Kelly Lambert

Int. J. Environ. Res. Public Health 2025, 22(10), 1475; https://doi.org/10.3390/ijerph22101475 - 24 Sep 2025

Abstract

(1) Background: This paper outlines key issues to consider when implementing Design Thinking methodology in health-based qualitative research to achieve a meaningful outcome. The purpose is to share our learnings with others. (2) Methods: Using the case study of an Australian region with [...] Read more.

(1) Background: This paper outlines key issues to consider when implementing Design Thinking methodology in health-based qualitative research to achieve a meaningful outcome. The purpose is to share our learnings with others. (2) Methods: Using the case study of an Australian region with high rates of chronic kidney disease, we describe a design-led methodological approach (co-design) that ensures end users remain central to research for the lifespan of the project; from conception of the research question and protocol design, through to solution generation and change implementation. (3) Results: Representation of the four Design Voices—people with lived experience, expertise, intent, and design knowledge—was imperative to minimise bias towards researchers as the main drivers of the project. A commitment to the five core elements of design thinking (empathising, defining, ideating, prototyping, and testing) was maintained throughout the research. Empathising through direct interaction with users was crucial to creating a meaningful understanding of their problems and challenges. Ideation ensured user-centred solution generation, with solutions aligned with addressing the ‘real’ problem and creating an improved future state. (4) Conclusions: Incorporation of Design Thinking principles in health research is a valuable adjunct to traditional qualitative methodologies, with the potential to facilitate meaningful outcomes for people in our community experiencing a wicked health problem. Full article

(This article belongs to the Special Issue Access to Public Health Services and Challenges to Healthcare Management)

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25 pages, 448 KB

Open AccessArticle

Exploring Family Typologies and Health Outcomes in a Dutch Primary Care Population of Children Living in Urban Cities in the Netherlands: A Latent Class Analysis

by Samantha F. F. Groenestein, Matty R. Crone, Evelien M. Dubbeldeman, Stijntje Lottman, Jessica C. Kiefte-de Jong, Jet Bussemaker and Suzan van der Pas

Int. J. Environ. Res. Public Health 2025, 22(10), 1474; https://doi.org/10.3390/ijerph22101474 - 24 Sep 2025

Abstract

This study examined social and physical environmental exposures, health, and healthcare utilization among children aged 0–12 in urban areas. A population-based cross-sectional design was used, incorporating general practitioners’ data (2018–2019, n = 14,547), and societal and environmental data. Latent class analysis identified three [...] Read more.

This study examined social and physical environmental exposures, health, and healthcare utilization among children aged 0–12 in urban areas. A population-based cross-sectional design was used, incorporating general practitioners’ data (2018–2019, n = 14,547), and societal and environmental data. Latent class analysis identified three distinct classes based on child and family demographics: ‘Dutch-origin two-parent household’ (n = 7267), ‘households with diverse countries of origin’ (n = 4313), and ‘single-parent household’ (n = 2967). Binary and multinomial logistic regression examined associations with environmental factors and child health outcomes. Children from the Dutch-origin class most often had favorable family demographics, neighborhood conditions, and health outcomes. Children from the diverse countries of origin class most often faced adverse neighborhood conditions, had higher rates of physical or somatic health conditions, and higher healthcare costs. Children from the single-parent class more often had less favorable family demographics, a higher likelihood of mental health problems, more frequent general practitioner visits, and were often in contact with youth care. This study highlights how child and family demographics and social and neighborhood conditions impact child health and healthcare utilization. Future approaches should focus on strategies to build and strengthen family and community resilience and adopt family-centered, context-sensitive interventions. Full article

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11 pages, 283 KB

Open AccessArticle

What Motives Influence Parents’ Commitment to Their Children’s Sport Participation in the United States?

by Katherine N. Alexander, Daniel J. M. Fleming, Mitchell Olsen, Travis E. Dorsch and Kat V. Adams

Int. J. Environ. Res. Public Health 2025, 22(10), 1473; https://doi.org/10.3390/ijerph22101473 - 24 Sep 2025

Abstract

Background: The public often places value on youth sport involvement in the United States due to its potential to foster positive outcomes for participants. Although sport parents are key socializers and provide access to appropriate participation opportunities for children, less is known [...] Read more.

Background: The public often places value on youth sport involvement in the United States due to its potential to foster positive outcomes for participants. Although sport parents are key socializers and provide access to appropriate participation opportunities for children, less is known about how their perceptions of their child’s motives influence their sport commitments. Purpose: Therefore, the purpose of the present study was to understand how parents’ perceptions of their child’s motives for sport participation were associated with time/travel sport commitments. Methods: Participants (N = 1250) were parents in the United States reporting on their child’s youth sport participation. Measures assessed their perceptions of their child’s motives for sport involvement, how many hours per week and months per year they engaged in sport, and how far they tended to drive to facilitate sport opportunities. Multiple regressions were utilized. Results: Analyses revealed that the number of months per year was positively predicted by motives for being physically healthy and spending time with friends. Similarly, being with friends was a positive predictor of the number of weekly hours spent in organized sport and having fun positively predicted the distance driven to participate. Motives for becoming more physically attractive negatively predicted time and travel commitments. Conclusions: Overall, the present study sheds light on how the ways parents perceive their children’s motivations for participating in youth sport influences parents’ commitment to facilitating sport participation opportunities for their children. Full article

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

13 pages, 273 KB

Open AccessArticle

Knowledge of Health Services Access Among Hajj Pilgrims in Saudi Arabia During the 1445 H (2024 G) Season and Its Associated Demographic and Health-Related Factors

by Ghadah Sulaiman Alsaleh, Fahad A. Alamri, Jumanah Alhazmi, Lamis Alabdullatif, Faisal Fallatah, Mariyyah Alburayh and Anas Khan

Int. J. Environ. Res. Public Health 2025, 22(10), 1472; https://doi.org/10.3390/ijerph22101472 - 24 Sep 2025

Abstract

Background: The Hajj pilgrimage, a significant religious event, presents unique health challenges due to the large number of participants and the physical demands of the pilgrimage. Despite efforts by Saudi health authorities to provide comprehensive health services, the effectiveness of these interventions relies [...] Read more.

Background: The Hajj pilgrimage, a significant religious event, presents unique health challenges due to the large number of participants and the physical demands of the pilgrimage. Despite efforts by Saudi health authorities to provide comprehensive health services, the effectiveness of these interventions relies heavily on pilgrims’ knowledge of available services and emergency measures. Objectives: The aim of this study is to assess the level of knowledge of health services among Hajj pilgrims in Saudi Arabia during the 1445 H (2024 G) season and its associated demographic and health-related factors. Methods and Materials: This cross-sectional study was conducted during the 1445 H (2024 G) Hajj season with 1215 pilgrims, 51.7% male. Participants were randomly selected from selected pilgrimage accommodations or passing through the airport in Jeddah. Data were collected through face-to-face interviews using a structured questionnaire covering demographics, health characteristics, and knowledge of health services. Results: The study found that 62.1% of participants correctly believed that health services during Hajj were free of charge. Furthermore, 44.4% were aware of the emergency health number, with 31.5% exhibiting good knowledge. Bivariate analysis showed that younger participants had better knowledge (p < 0.001), and males were more likely than females to demonstrate partial or good knowledge (p = 0.011). Participants with university education were significantly more likely to have good knowledge, with 29.6% demonstrating good knowledge compared to 7.4% of illiterate participants (p < 0.001). Geographic region was also a factor, with 48.9% of Middle Eastern participants exhibiting good knowledge, compared to 27.1% of African and 23.6% of Asian participants (p < 0.001). However, multivariable logistic regression, revealed that only younger age (OR = 0.98, p = 0.005), university education (OR = 1.96, p = 0.024), and being from the Middle East (OR = 1.61, p = 0.009) were significant predictors of good knowledge of health services. Conclusions: The study identified significant gaps in pilgrims’ knowledge of health services during Hajj, with younger age, higher education, and Middle Eastern geographic region identified as independent predictors of better knowledge. These findings suggest the need for targeted health education initiatives, particularly for older pilgrims, those with lower educational attainment, and individuals from regions with lower awareness levels, to improve knowledge and potentially enhance health outcomes during Hajj. Full article

(This article belongs to the Section Health Care Sciences)

15 pages, 931 KB

Open AccessArticle

Understanding Family Functioning as a Protective Factor for Adolescents’ Mental Health from the Parental Perspective: Photovoice in Rural Communities of Ecuador

by Venus Medina-Maldonado, Majo Carrasco-Tenezaca, Molly Frey and Esteban Baus-Carrera

Int. J. Environ. Res. Public Health 2025, 22(10), 1471; https://doi.org/10.3390/ijerph22101471 - 24 Sep 2025

Abstract

Families in rural communities face a constellation of challenges that significantly hinder their ability to support adolescents. Our study aimed to explore family functioning as a protective factor for adolescent mental health from the perspective of parents in rural communities of southern Ecuador, [...] Read more.

Families in rural communities face a constellation of challenges that significantly hinder their ability to support adolescents. Our study aimed to explore family functioning as a protective factor for adolescent mental health from the perspective of parents in rural communities of southern Ecuador, using Photovoice as a participatory research tool. The research design corresponds to Participatory Action Research. Five Focus Group Discussions (FGDs) were conducted. A total of 29 parents of adolescents participated in the study. The research team employed qualitative content analysis for the interpretation phase. Through photographs and focus groups, parents commented on aspects of family life that they perceived as necessary for supporting adolescents, such as effective communication, cohesion, supervision, and expressions of care. The main conclusion indicated that the implementation of Photovoice converted participants from subjects to collaborators, allowing them to critically reflect on their behaviors while aiding or reinforcing in the co-creation of strategies. Full article

(This article belongs to the Special Issue Challenges and Advances in Nursing Practice in Latin America)

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12 pages, 293 KB

Open AccessArticle

The Impact of Swallowing Difficulties on Quality of Life in Adults with Intellectual Disabilities in Residential Care: Cross-Sectional Study

by Maya Izumi, Seijun Ganaha, Yuki Kai, Ikuri Konishi, Risa Kira and Sumio Akifusa

Int. J. Environ. Res. Public Health 2025, 22(10), 1470; https://doi.org/10.3390/ijerph22101470 - 24 Sep 2025

Abstract

Dysphagia is a common but often overlooked concern among individuals with intellectual disabilities and may negatively impact their quality of life. This study aimed to examine the association between swallowing function and health-related quality of life (HRQOL) among adults with intellectual disabilities in [...] Read more.

Dysphagia is a common but often overlooked concern among individuals with intellectual disabilities and may negatively impact their quality of life. This study aimed to examine the association between swallowing function and health-related quality of life (HRQOL) among adults with intellectual disabilities in residential care. Methods: We conducted a cross-sectional study involving 48 individuals in residential care facilities in Japan. Swallowing function was assessed with the Eating Assessment Tool-10 (EAT-10), and HRQOL with the EuroQol-5 Dimension, five-level version (EQ-5D-5L), in which higher index values denote better HRQOL. A generalized linear model (GLM) with gamma distribution was used to identify factors associated with EQ-5D-5L scores. Participants with lower EAT-10 scores (≤2) showed significantly higher EQ-5D-5L scores. In the GLM, better swallowing function was positively associated with EQ-5D-5L score (B = 0.21, p = 0.012). Sensitivity analysis confirmed the robustness of this association. Conclusions: Swallowing dysfunction is linked to reduced HRQOL in individuals with intellectual disabilities, underscoring the need for regular screening and intervention. Full article

15 pages, 1125 KB

Open AccessArticle

The Effects of the Modified LiiNK^® Recess Intervention on Muscular Strength, Neuromuscular Control, and Resilience in Elementary School Children

by Lauren M. Wagner, Robyn Braun-Trocchio, Phil Esposito, Hailey G. von Borck and Deborah J. Rhea

Int. J. Environ. Res. Public Health 2025, 22(10), 1469; https://doi.org/10.3390/ijerph22101469 - 24 Sep 2025

Abstract

The LiiNK Project^® is a well-researched recess intervention that integrates four 15 min recess breaks and a 15 min character development lesson daily. Previous literature has demonstrated this intervention is effective at 60 min daily to improve muscular strength (MusS) and neuromuscular [...] Read more.

The LiiNK Project^® is a well-researched recess intervention that integrates four 15 min recess breaks and a 15 min character development lesson daily. Previous literature has demonstrated this intervention is effective at 60 min daily to improve muscular strength (MusS) and neuromuscular control (NC) in elementary-aged children; however, it remains unclear whether similar benefits can be achieved when the intervention is modified to 30 min daily when the children reach fourth and fifth grade. Additionally, the LiiNK intervention has not examined psychological variables with physical assessments. Thus, the purpose of this study was to examine MusS, NC, and resilience at two time points in children who engaged in a modified LiiNK recess intervention. Fourth- and fifth-grade children (N = 164) from one school district participated in MusS, NC, and resilience assessments at two time points (September 2024 and January 2025). A two-way MANOVA was used to determine the assessment change score differences by grade and sex. No statistically significant main effects or interactions by grade, F (3, 160) = 1.95, p = 0.077, or sex, F (3, 160) = 1.13, p = 0.347, were found. These findings suggest 30 min of recess daily may be insufficient to produce developmental benefits observed in previous 60 min daily recess interventions. Full article

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14 pages, 274 KB

Open AccessArticle

A Community-Engaged Approach to Enhancing Participation in Genomic Research in Rare and Understudied Cancer Populations

by Saira Khan, Bailey Martin-Giacalone, Kayla Wallace, Briana Wilson, Christine Marx, Erin Linnenbringer, Jessica Mozersky, Melinda Bachini, Nancy Chollet, Dionne Stalling, Li Ding, Ryan C. Fields, Graham A. Colditz and Bettina F. Drake

Int. J. Environ. Res. Public Health 2025, 22(10), 1468; https://doi.org/10.3390/ijerph22101468 - 23 Sep 2025

Abstract

Few studies provide insights on how to incorporate community members’ perspectives of genomic research during the early phases of study development. Engaging with community members early and consistently throughout the research lifecycle could help identify and mitigate barriers to genomic research participation, particularly [...] Read more.

Few studies provide insights on how to incorporate community members’ perspectives of genomic research during the early phases of study development. Engaging with community members early and consistently throughout the research lifecycle could help identify and mitigate barriers to genomic research participation, particularly among groups with rare and understudied cancers. Methods: The Washington University Participant Engagement and Cancer Genome Sequencing (WU-PE-CGS) study formed a Participant Engagement Advisory Board (PEAB) consisting of patients, patient advocates, and patient advocacy organizations who represented the three understudied cancer populations: cholangiocarcinoma, early-onset colorectal cancer in Black Americans, and multiple myeloma in Black Americans. PEAB members were involved in PE-CGS from the time of the grant submission and provided input on key study procedures by participating in monthly project meetings and serving on the leadership team. PEAB recommendations are described in this process paper. Results: The PEAB provided key feedback on recruitment, consent, and survey development. Recruitment optimization focused on making the script more concise, tailoring to participant’s locale, and providing clearer participation expectations. Consent improvements prioritized key information, addressed data protection, and clarified the process of returning genetic results. Survey enhancements included refining scientific terminology and ensuring inclusivity across the cancer continuum. Conclusions: The PEAB provided valuable feedback that improved the development and implementation of WU-PE-CGS research processes. Incorporating the PEAB’s suggestions helped ensure that patients with rare and understudied cancers were successfully enrolled into the WU-PE-CGS. The PEAB will continue to contribute throughout all study phases. Full article

(This article belongs to the Special Issue Advancing Health Equity—Addressing Cancer Disparities)

14 pages, 301 KB

Open AccessArticle

Assessment of Prevalence and Determinants Associated with Hypertension Among the Adult Population in Hawtat Bani Tamim Province

by Mohammed Omar Musa Mohammed and Ahmed Saied Rahama Abdallah

Int. J. Environ. Res. Public Health 2025, 22(10), 1467; https://doi.org/10.3390/ijerph22101467 - 23 Sep 2025

Abstract

Hypertension is a global public health concern, with varying prevalence and risk factors across different populations. This study aimed to assess the prevalence of hypertension and identify its associated determinants among adults in Hawtat Bani Tamim Province. A cross-sectional study was conducted among [...] Read more.

Hypertension is a global public health concern, with varying prevalence and risk factors across different populations. This study aimed to assess the prevalence of hypertension and identify its associated determinants among adults in Hawtat Bani Tamim Province. A cross-sectional study was conducted among 384 adult participants. Data on sociodemographic characteristics, lifestyle factors, and clinical measurements were collected. Hypertension was diagnosed based on standard criteria. Logistic regression analysis was used to identify factors associated with hypertension, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. The overall prevalence of hypertension among the participants was 25.5%, with a higher rate observed in urban areas (15%) than in rural areas (10.4%). Multivariate analysis revealed that age was significantly associated with hypertension, with participants aged 20–30 years (OR = 0.181, 95% CI: 0.067–0.485), 31–40 years (OR = 0.235, 95% CI: 0.092–0.599), 41–50 years (OR = 0.184, 95% CI: 0.067–0.510), and 51–60 years (OR = 0.268, 95% CI: 0.104–0.690) having lower odds than those over 60 years. Males had a lower risk than females (OR = 0.423, 95% CI: 0.192–0.932). Individuals with lower educational levels were also found to have reduced odds of hypertension (secondary or less: OR = 0.315, 95% CI: 0.118–0.844; bachelor’s degree: OR = 0.294, 95% CI: 0.127–0.679) compared to postgraduates. Regarding BMI, normal weight (OR = 0.262, 95% CI: 0.126–0.544) and overweight (OR = 0.421, 95% CI: 0.220–0.805) individuals had lower odds of hypertension than obese participants. Marital status was a significant determinant, with married individuals having higher odds of hypertension (OR = 3.222, 95% CI: 1.807–6.110). Smoking was associated with a lower risk of hypertension (OR = 0.181, 95% CI: 0.067–0.485). Hypertension is prevalent among adults in Hawtat Bani Tamim Province, with significant associations observed for age, gender, education, BMI, marital status, and smoking. Targeted interventions addressing these risk factors are recommended to reduce the burden of hypertension in this population. Full article

(This article belongs to the Special Issue Advances in Biostatistics for Cardiovascular and Cancer Research)

22 pages, 49349 KB

Open AccessArticle

Prenatal Phthalate Exposures and Adiposity Outcomes Trajectories: A Multivariate Bayesian Factor Regression Approach

by Phuc H. Nguyen, Stephanie M. Engel and Amy H. Herring

Int. J. Environ. Res. Public Health 2025, 22(10), 1466; https://doi.org/10.3390/ijerph22101466 - 23 Sep 2025

Abstract

Experimental animal evidence and a growing body of observational studies suggest that prenatal exposure to phthalates may be a risk factor for childhood obesity. Using data from the Mount Sinai Children’s Environmental Health Study (MSCEHS), which measured urinary phthalate metabolites (including MEP, MnBP, [...] Read more.

Experimental animal evidence and a growing body of observational studies suggest that prenatal exposure to phthalates may be a risk factor for childhood obesity. Using data from the Mount Sinai Children’s Environmental Health Study (MSCEHS), which measured urinary phthalate metabolites (including MEP, MnBP, MiBP, MCPP, MBzP, MEHP, MEHHP, MEOHP, and MECPP) during the third trimester of pregnancy (between 25 and 40 weeks) of 382 mothers, we examined adiposity outcomes—body mass index (BMI), fat mass percentage, waist-to-hip ratio, and waist circumference—of 180 children between ages 4 and 9. Our aim was to assess the effects of prenatal exposure to phthalates on these adiposity outcomes, with potential time-varying and sex-specific effects. We applied a novel Bayesian multivariate factor regression (BMFR) that (1) represents phthalate mixtures as latent factors—a DEHP and a non-DEHP factor, (2) borrows information across highly correlated adiposity outcomes to improve estimation precision, (3) models potentially non-linear time-varying effects of the latent factors on adiposity outcomes, and (4) fully quantifies uncertainty using state-of-the-art prior specifications. The results show that in boys, at younger ages (4–6), all phthalate components are associated with lower adiposity outcomes; however, after age 7, they are associated with higher outcomes. In girls, there is no evidence of associations between phthalate factors and adiposity outcomes. Full article

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15 pages, 470 KB

Open AccessArticle

A Study of Relationships Between Mental Well-Being, Sleep Quality, Eating Behavior, and BMI: A Cross-Sectional Study Among University Students

by Linda Priede, Ilze Beitane and Loreta Beitane

Int. J. Environ. Res. Public Health 2025, 22(10), 1465; https://doi.org/10.3390/ijerph22101465 - 23 Sep 2025

Abstract

The study aimed to conduct a multifaceted assessment of university students’ mental health, sleep quality, eating behavior, and BMI, and to investigate the relationships between these factors. The DASS-42 (Depression, Anxiety, and Stress Scale), PSQI (Pittsburgh Sleep Quality Index), free-factor eating questionnaire R18V2, [...] Read more.

The study aimed to conduct a multifaceted assessment of university students’ mental health, sleep quality, eating behavior, and BMI, and to investigate the relationships between these factors. The DASS-42 (Depression, Anxiety, and Stress Scale), PSQI (Pittsburgh Sleep Quality Index), free-factor eating questionnaire R18V2, and BMI were the research instruments used. The study involved 397 university students, 59.9% of which were of a healthy weight. The average scores obtained in the student assessment indicated mild to moderate depression, moderate anxiety, and normal to moderate stress levels. The average uncontrolled eating score was 43.72 ± 14.69, cognitive restraint score—32.86 ± 30.58, and emotional eating score—31.14 ± 29.00. BMI was found to have a weak but significant correlation with cognitive restraint and emotional eating. Sleep quality was found to have a moderately strong correlation with depression, anxiety, and stress. A weak but significant correlation was confirmed between emotional eating and depression, anxiety, and stress. The students were at high risk of depression, anxiety, and stress, which was correlated with poor sleep quality and bad eating behavior. These results will be used to develop a support program that promotes students’ mental well-being, which is essential for academic success. Full article

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11 pages, 986 KB

Open AccessArticle

The Burden of Lip and Oral Cavity Cancer Among Women Across 204 Countries and Territories in the Context of the Framework Convention on Tobacco Control: An Interrupted Time Series Analysis

by Laila Menezes Hagen, Larissa Rodrigues Gasparini, Bruna Machado da Silva, Amanda Ramos da Cunha, Fernando Neves Hugo and José Miguel Amenábar

Int. J. Environ. Res. Public Health 2025, 22(10), 1464; https://doi.org/10.3390/ijerph22101464 - 23 Sep 2025

Abstract

Background: Historically, lip and oral cavity cancer (LOC) has been more prevalent among men, largely due to higher tobacco use in this group. However, over the past decades, smoking rates among women have risen and, in some regions, are approaching those of men. [...] Read more.

Background: Historically, lip and oral cavity cancer (LOC) has been more prevalent among men, largely due to higher tobacco use in this group. However, over the past decades, smoking rates among women have risen and, in some regions, are approaching those of men. This shift highlights the urgent need to analyze the burden of LOC specifically in women, as they may respond differently to tobacco control policies. This study assessed whether the World Health Organization Framework Convention on Tobacco Control (WHO-FCTC), launched in 2003, and the implementation of MPOWER measures have influenced LOC trends among women. Methods: A controlled interrupted time series was conducted from 1990 to 2021, with the launch of the WHO-FCTC considered the intervention point. A total of 204 countries and territories were initially categorized into two groups: those without (G1) and with (G2) MPOWER coverage. G2 was further subdivided based on the median MPOWER score from 2007 to 2020 into G2A (equal to or below the median) and G2B (above the median). Analyses were also stratified by Socio-Demographic Index (SDI) levels. Female LOC rates were obtained from the Global Burden of Disease Study 2021. Prais-Winsten segmented regression was applied to estimate annual percent changes (APCs) in LOC rates before and after the WHO-FCTC. Results: Prior to the WHO-FCTC, most trends for G1 and G2A were stable, while all trends for G2B were increasing. After 2003, LOC rates increased across all groups, especially in G2B. In high-SDI settings, rising trends in G2B remained unchanged post-intervention, whereas G1 and G2A shifted from stable to increasing. Among low-SDI groups, slopes were mostly not statistically significant. Conclusions: These findings suggest that the WHO-FCTC has had no measurable impact on reducing LOC burden among women so far. Instead, rates have continued to rise in many regions, signaling a concerning trend for women’s global health. Full article

(This article belongs to the Section Global Health)

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Int. J. Environ. Res. Public Health, Volume 22, Issue 10 (October 2025) – 25 articles

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