International Journal of Environmental Research and Public Health

13 pages, 368 KB

Open AccessArticle

Competitive Anxiety as a Predictor of the Occurrence, Quantity, and Severity of Injuries in Young Cuban Athletes

by Jesús Ríos-Garit, Yanet Pérez-Surita, Verónica Gómez-Espejo, Mario Reyes-Bossio and Verónica Tutte-Vallarino

Int. J. Environ. Res. Public Health 2026, 23(3), 354; https://doi.org/10.3390/ijerph23030354 (registering DOI) - 11 Mar 2026

Abstract

Previous studies suggest that elevated competitive anxiety may increase the likelihood of injury. The present research aims to examine the role of competitive anxiety as a predictor of injury occurrence, frequency, and severity. A cross-sectional, correlational design was conducted with 131 athletes (mean [...] Read more.

Previous studies suggest that elevated competitive anxiety may increase the likelihood of injury. The present research aims to examine the role of competitive anxiety as a predictor of injury occurrence, frequency, and severity. A cross-sectional, correlational design was conducted with 131 athletes (mean age = 16.49 years), predominantly male. Injury data were obtained through medical record review, and competitive anxiety was assessed using the Competitive Anxiety Inventory-2. Empirical frequency distributions, descriptive statistics, non-parametric tests, and logistic and ordinal regression models were employed. A high incidence of injuries was observed, although most were minor. Competitive anxiety was characterized by elevated levels of cognitive anxiety and self-confidence. Injured athletes exhibited greater overall competitive anxiety (r = 0.31, p < 0.001), with higher levels observed among those who sustained more injuries (ε² = 0.12, p = 0.001), and a very large effect was found in relation to injury severity (ε² = 0.17, p < 0.001). The occurrence of injury can only be predicted in 10.9–14.7% of cases through increased cognitive and somatic anxiety, whereas an increase across all dimensions of competitive anxiety predicts a greater number (13–14%) and severity (20.3–21.8%) of injuries. These findings underscore the importance of developing skills to manage competitive anxiety, particularly its cognitive dimension and maintaining optimal levels of self-confidence in young athletes. Full article

(This article belongs to the Special Issue Mental Health in Sport Injury and Rehabilitation: Intersecting Public Health Concerns)

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17 pages, 669 KB

Open AccessArticle

Assessing Surgical Capacity in Guam: Current Strengths and Future Goals

by Ryan V. Benavente, Eduardo B. Biala, Jr., Brandon A. Lopez, Megan Y. Gimmen, Eric T. Pineda, John Reinier F. Narvaez, Russell K. Woo, Neal A. Palafox and Lee E. Buenconsejo-Lum

Int. J. Environ. Res. Public Health 2026, 23(3), 353; https://doi.org/10.3390/ijerph23030353 (registering DOI) - 11 Mar 2026

Abstract

Introduction: Guam, the largest U.S. territory in Micronesia, plays a central role in surgical care for the local indigenous community and surrounding Pacific Island nations, yet remains underrepresented in surgical systems research. Methods: We conducted a mixed-methods study. Quantitative data were collected on [...] Read more.

Introduction: Guam, the largest U.S. territory in Micronesia, plays a central role in surgical care for the local indigenous community and surrounding Pacific Island nations, yet remains underrepresented in surgical systems research. Methods: We conducted a mixed-methods study. Quantitative data were collected on operating volume, personnel, infrastructure, and surgical services at Guam Memorial Hospital (GMH) and Guam Regional Medical City (GRMC). Semi-structured interviews with hospital leadership and surgical providers captured qualitative insights on strengths, challenges, and future plans. Results: GMH and GRMC collectively provide general emergency, obstetric, and basic pediatric surgery, although advanced subspecialty and oncologic care remain limited. Although surgeons are highly adaptable with broad-practice capability, challenges, including resource limitations, aging facilities, advanced presentation, and subspecialty recruitment, limit the cases that are operable on Guam, resulting in expensive medical transfer. Anticipated stressors such as oncologic and non-communicable disease burden may further strain the system, emphasizing the necessity for modernized facilities and targeted recruitment of surgeons with regional ties. Conclusion: Strengthening Guam’s surgical capacity is essential for the provision of oncologic care and the advancement of health equity across the Pacific region, emphasizing an urgent need for investment in infrastructure, locally relevant workforce training, and regional policy development. Full article

(This article belongs to the Special Issue Cancer Health Disparities in Prevention and Care)

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21 pages, 784 KB

Open AccessArticle

Assessment of Pregnant Women’s Knowledge, Attitudes, and Habits Regarding Oral Health: Development and Validation of a Measurement Instrument

by Helena Glibotić Kresina, Ivana Dabo, Sandro Kresina, Elizabeta Dadić Hero, Sara Kresina, Danko Bakarčić, Martina Mavrinac and Neda Smiljan Severinski

Int. J. Environ. Res. Public Health 2026, 23(3), 352; https://doi.org/10.3390/ijerph23030352 - 11 Mar 2026

Abstract

Oral health during pregnancy is a critical factor in preventing caries in both mothers and children. Croatia currently lacks validated psychometric instruments for reliably assessing knowledge, attitudes, and oral hygiene practices in the general population. This study aimed to develop and provide initial [...] Read more.

Oral health during pregnancy is a critical factor in preventing caries in both mothers and children. Croatia currently lacks validated psychometric instruments for reliably assessing knowledge, attitudes, and oral hygiene practices in the general population. This study aimed to develop and provide initial psychometric evidence for a comprehensive instrument for this purpose in Croatia, with potential relevance for future cross-cultural adaptation. Following Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines, an initial item pool was generated through literature review and expert consultation. The study was conducted from May 2024 to February 2025 in primary healthcare settings across Primorje-Gorski Kotar County (PGC). The validation study included 319 pregnant women. Exploratory factor analysis (EFA) revealed a six-factor structure with acceptable to strong factor loadings (ranging from 0.423 to 0.984). The instrument showed acceptable to good internal consistency (Cronbach’s α = 0.61–0.87) and excellent test–retest reliability (Pearson r = 0.993). Results indicated that knowledge about oral health was independent of attitudes and practices during pregnancy. Regression analyses were exploratory and did not provide evidence of predictive validity at this stage, suggesting that additional contextual and psychosocial factors should be considered in future modelling. The present study provides initial psychometric evidence supporting the proposed structure and reliability of the instrument; however, further confirmatory and longitudinal validation studies are required before broader implementation and generalization can be fully justified. Full article

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17 pages, 953 KB

Open AccessArticle

Socioeconomic Interventions for WHO’s End TB Strategy Targets: Insights from SIR Modelling in Kazakhstan

by Temirlan Ukubayev, Berik Koichubekov, Marina Sorokina and Donatas Austys

Int. J. Environ. Res. Public Health 2026, 23(3), 351; https://doi.org/10.3390/ijerph23030351 - 11 Mar 2026

Abstract

Background: Tuberculosis remains a major global public health challenge. Mathematical models are essential for strategic planning and evaluation of tuberculosis control programs, while addressing socioeconomic risk factors has proven key to accelerating incidence declines. Therefore, this study quantitatively assesses the impact of socioeconomic [...] Read more.

Background: Tuberculosis remains a major global public health challenge. Mathematical models are essential for strategic planning and evaluation of tuberculosis control programs, while addressing socioeconomic risk factors has proven key to accelerating incidence declines. Therefore, this study quantitatively assesses the impact of socioeconomic interventions on tuberculosis incidence in Kazakhstan. Methods: A modified SIR compartmental model was developed in Python 3.12 to simulate tuberculosis transmission dynamics. Parameters were calibrated using the Nelder–Mead simplex algorithm, and predictive performance was evaluated via hold-out validation. Scenario-based projections were generated to explore the impact of socioeconomic improvements on future tuberculosis incidence. Results: The calibrated SIR model demonstrated strong predictive accuracy, achieving a mean absolute percentage error of 2.3%. The sensitivity analysis revealed that the model is robust to moderate socioeconomic perturbations, with healthcare funding and unemployment rate as the primary uncertainty drivers. Scenario simulations showed that enhanced financial assistance for tuberculosis patients produced the largest effect beyond baseline. Optimization results indicate that 7.4% rise in GDP per capita, 10.2% increase in healthcare funding, 23.1% and 19.1% reductions in poverty and unemployment rates, and 40.2% growth in tuberculosis patient financial support relative to 2024 are sufficient to achieve the WHO’s End TB Strategy 2030 target. Conclusions: The model offers a valuable tool for tuberculosis forecasting and intervention evaluation, highlighting the synergistic role of socioeconomic measures in achieving global elimination goals. Full article

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

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31 pages, 874 KB

Open AccessArticle

Impact of the Osijek Multidisciplinary Biopsychosocial Program on Chronic Low Back Pain: A Prospective Randomized Controlled Study

by Dijana Hnatešen, Ivan Radoš, Iva Dimitrijević, Dino Budrovac, Vanja Matković and Ivana Gusar

Int. J. Environ. Res. Public Health 2026, 23(3), 350; https://doi.org/10.3390/ijerph23030350 - 11 Mar 2026

Abstract

This study aimed to assess the relative impact of the Osijek multidisciplinary biopsychosocial program for chronic low back pain (CLBP) compared with standard multimodal care with respect to pain intensity, disability, health-related quality of life, anxiety, depression, stress, and sleep quality using standardized [...] Read more.

This study aimed to assess the relative impact of the Osijek multidisciplinary biopsychosocial program for chronic low back pain (CLBP) compared with standard multimodal care with respect to pain intensity, disability, health-related quality of life, anxiety, depression, stress, and sleep quality using standardized self-assessment questionnaires and a smartwatch. A total of 128 patients treated at the Department of Pain Management, University Hospital Osijek, were randomly allocated to two groups. The multidisciplinary biopsychosocial group participated in a structured four-week program combining education, exercise, and individualized multidisciplinary care, while the multimodal group received conventional conservative treatment including pharmacotherapy and selected physical therapy modalities. The four-week intervention included standardized self-report questionnaires, a sociodemographic data form, and a Fitbit Charge 3 smartwatch for objective monitoring of sleep and physical activity. A significant reduction in pain intensity was observed across numerical scales and most questionnaire measures (Wilcoxon test, p < 0.01), except for the subscale assessing difficulties in performing daily activities due to sleep deprivation. Participants who underwent the multidisciplinary biopsychosocial treatment exhibited significant improvements (p < 0.03) in pain intensity, disability, health-related quality of life, stress, anxiety, and sleep quality compared with those receiving multimodal treatment. In both groups, a weak negative correlation was found between sleep quality and daily step count (Spearman’s rho = −0.234, p = 0.04). A multidisciplinary biopsychosocial program was associated with greater improvements in health-related quality of life, psychological well-being, and sleep quality in patients with chronic low back pain compared with a multimodal conservative approach. Increased daily physical activity was linked to improvements in anxiety and sleep. Although this study was designed as a randomized controlled trial, certain baseline differences between groups should be considered when interpreting the findings. Full article

(This article belongs to the Special Issue Exploring Quality of Life in Nursing and Patient Care)

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21 pages, 369 KB

Open AccessArticle

How Mothers and Childfree Women Redefine Fulfillment: A Comparative Study of Life and Marital Satisfaction in a Pronatalist Society

by Sinem Burcu Uğur, Nehir Yasan-Ak, Aylin Çiçekli and Seda Tan

Int. J. Environ. Res. Public Health 2026, 23(3), 349; https://doi.org/10.3390/ijerph23030349 - 10 Mar 2026

Abstract

In pronatalist societies where motherhood remains symbolically central to feminine identity, women’s well-being is shaped by gendered expectations surrounding reproduction. Within such contexts, understanding how different reproductive trajectories relate to marital and life satisfaction becomes particularly important. This study compared the marital and [...] Read more.

In pronatalist societies where motherhood remains symbolically central to feminine identity, women’s well-being is shaped by gendered expectations surrounding reproduction. Within such contexts, understanding how different reproductive trajectories relate to marital and life satisfaction becomes particularly important. This study compared the marital and life satisfaction of mothers and voluntarily childless women in Türkiye, a pronatalist society. A sequential explanatory mixed-method design was employed. Quantitative data were collected from 178 employed married women (31 voluntarily childless, 147 mothers) using standardized life and marital satisfaction scales. This was followed by in-depth interviews with 22 participants (11 from each group). The quantitative findings indicated no statistically significant differences in marital or life satisfaction between the two groups. However, qualitative analysis revealed that comparable experiences of satisfaction were constructed through distinct normative pathways. Mothers derived fulfillment from culturally validated maternal identities despite increased responsibilities, whereas childfree women constructed satisfaction around autonomy, relational equality, and deliberate ethical choice within a pronatalist context. While voluntary childlessness broadens the repertoire of feminine identities, motherhood remains a powerful symbolic reference point for both groups. Rather than signaling the erosion of pronatalist norms, the findings suggest their ongoing renegotiation within contemporary Turkish society. These dynamics underscore the importance of addressing role-based stigma and supporting diverse reproductive choices in efforts to promote women’s psychological well-being and social equity. Full article

(This article belongs to the Special Issue Reproductive Health Decision-Making Among Women and Couples)

18 pages, 445 KB

Open AccessArticle

Information Needs of Culturally and Linguistically Diverse Women with Endometriosis in Australia: A Qualitative Study

by Deniz Senyel, James H. Boyd and Melissa Graham

Int. J. Environ. Res. Public Health 2026, 23(3), 348; https://doi.org/10.3390/ijerph23030348 - 10 Mar 2026

Abstract

Culturally and linguistically diverse (CALD) women make up an important population of women with endometriosis in Australia. However, their experiences with the condition, particularly regarding their experiences with information on endometriosis, have not yet been studied. This qualitative descriptive study aimed to explore [...] Read more.

Culturally and linguistically diverse (CALD) women make up an important population of women with endometriosis in Australia. However, their experiences with the condition, particularly regarding their experiences with information on endometriosis, have not yet been studied. This qualitative descriptive study aimed to explore the information needs and preferences of CALD women living with endometriosis. A qualitative descriptive study, using semi-structured individual interviews with 11 CALD women aged 23–46 from Victoria, Australia, was undertaken. The data were analysed using thematic analysis. The women’s information needs focused on disease pathogenesis—including causes, symptoms, and progression—as well as disease management, such as medication and surgery, lifestyle factors, fertility treatment, and mental health support. The women suggested resources should be easy to understand, written in simple English, with minimal text and added visual elements. Stories from other women with endometriosis were also recommended, as were interactive formats that enable women to ask questions. While the women primarily preferred written information, they also welcomed formats such as webinars or workshops. This study highlights a need for improved information for CALD women with endometriosis. Information resources should be designed to meet women’s needs in both content and delivery. Full article

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21 pages, 482 KB

Open AccessReview

Effects of Bathtub Bathing and Sauna Practices on Cardiovascular and Systemic Health: A Narrative Review

by Masayo Nagai and Akiko Tanaka

Int. J. Environ. Res. Public Health 2026, 23(3), 347; https://doi.org/10.3390/ijerph23030347 - 10 Mar 2026

Abstract

Thermal bathing practices, including domestic hot-water immersion and sauna use, have been linked to cardiovascular and systemic health outcomes. However, the amount and type of evidence differ between these practices. This review examines current epidemiological and mechanistic findings and discusses their relevance to [...] Read more.

Thermal bathing practices, including domestic hot-water immersion and sauna use, have been linked to cardiovascular and systemic health outcomes. However, the amount and type of evidence differ between these practices. This review examines current epidemiological and mechanistic findings and discusses their relevance to cardiovascular health. A narrative review was conducted using Ichushi-Web and PubMed. Observational and interventional studies evaluating habitual bathtub bathing or sauna use in relation to physiological or health-related outcomes were included. Studies involving children or pregnant/postpartum women and those without relevant biological endpoints were excluded. In total, 45 studies met the inclusion criteria (17 on bathtub bathing and 28 on sauna use). Studies of habitual bathtub bathing, conducted mainly in Japan, have reported associations with lower arterial stiffness, improved glycemic control, and selected inflammatory or stress-related markers. Experimental work shows that hot-water immersion increases core body temperature, promotes peripheral vasodilation, and induces heat shock protein expression. Sauna bathing, investigated primarily in Finnish prospective cohorts, has been associated with lower cardiovascular and all-cause mortality, as well as favorable inflammatory and endothelial markers. Bathing conditions, age, sex, and cultural context appear to influence these findings. Thermal exposure produces circulatory and molecular responses relevant to cardiovascular regulation. Prospective data support associations between frequent sauna use and long-term outcomes, whereas evidence for domestic bathtub bathing is limited to observational studies of intermediate markers. Further research with clearly defined exposure parameters and clinical endpoints is needed to better understand the long-term cardiovascular implications of habitual thermal practices. Full article

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12 pages, 321 KB

Open AccessArticle

Association Between Daily Steps Measured by Accelerometry and Diabetes in ELSA-Brasil Participants

by Matheus Hortélio, Maria da Conceição Chagas de Almeida, Sheila Maria Alvim de Matos, Cristiano Penas Seara Pitanga, Ciro Oliveira Queiroz and Francisco José Gondim Pitanga

Int. J. Environ. Res. Public Health 2026, 23(3), 346; https://doi.org/10.3390/ijerph23030346 - 10 Mar 2026

Abstract

Diabetes mellitus (DM) is a chronic disease characterized by hyperglycemia and alterations in lipid and protein metabolism. Daily step count, measured using accelerometers integrated into wearable devices with artificial intelligence support, represents an important indicator of physical activity for the prevention and management [...] Read more.

Diabetes mellitus (DM) is a chronic disease characterized by hyperglycemia and alterations in lipid and protein metabolism. Daily step count, measured using accelerometers integrated into wearable devices with artificial intelligence support, represents an important indicator of physical activity for the prevention and management of DM when performed regularly at a minimum daily volume. Objective: We aimed to investigate the association between daily step count and DM and to determine the daily step cutoff point necessary to provide a protective effect among participants in the Longitudinal Study of Adult Health (LSAH). Methods: We performed a cross-sectional study that analyzed data from Wave 3 (2016–2018), including 12,636 participants. DM was the dependent variable, assessed by laboratory tests, and daily step count was the independent variable, measured by accelerometry. Associations were assessed using logistic regression, with odds ratios (ORs) and 95% confidence intervals (CIs). Results: A significant association was observed between daily step count and DM (OR = 0.76; 95% CI: 0.70–0.83). A cutoff point of 6880 steps/day was identified, with an area under the ROC curve of 0.58 (95% CI: 0.57–0.59). Conclusion: Daily step count appears to be associated with a protective effect against DM. Full article

(This article belongs to the Special Issue Physical Activity and Sedentary Behavior Across the Life Course: The Emerging Role of Artificial Intelligence)

16 pages, 720 KB

Open AccessArticle

The Impact of Parental Engagement in an Electronic Health (EHealth) Intervention on Physical Activity, Dietary Behaviors, and Sleep in Preschool-Aged Children

by Peng Zhou, Wenjiao Liu and Di Li

Int. J. Environ. Res. Public Health 2026, 23(3), 345; https://doi.org/10.3390/ijerph23030345 - 10 Mar 2026

Abstract

Background/Objectives: The characterization of varying levels of parental engagement is important for increasing understanding of how to tailor and maximize the effectiveness of parent-based eHealth interventions. In this study, we aimed to determine if parental engagement in the WeChat group of a [...] Read more.

Background/Objectives: The characterization of varying levels of parental engagement is important for increasing understanding of how to tailor and maximize the effectiveness of parent-based eHealth interventions. In this study, we aimed to determine if parental engagement in the WeChat group of a parent-based eHealth intervention affected preschoolers’ physical activity, diet, or sleep. Methods: We utilized baseline, post-test (12 weeks after baseline), and follow-up (12 weeks after post-test measurement) data from the intervention group in a parent-based eHealth intervention concerning children aged from three to six years, designed as a single-blinded randomized controlled trial with two parallel arms to explore the intervention’s influence on preschoolers’ physical activity, diet, and sleep. The parents in the intervention group were categorized into two groups: (1) The actively engaged group (53 parent–child dyads), defined as parents who actively posted and commented on modules at least once a week, either in the WeChat groups or through private messages with the researchers. (2) The lurker group (67 parent–child dyads), defined as parents who only responded to the weekly self-assessment messages and who, aside from this, showed no interaction within WeChat groups and did not privately message the researchers. Preschoolers’ physical activity was measured using ActiGraph wGT3X-BT, while their dietary behaviors and sleep were measured using parent-reported questionnaires. Generalized Estimating Equations using group and time as main effects and adjusted demographic information for covariates were computed to examine the effects of parental engagement in the eHealth intervention on preschoolers’ physical activity, diet, and sleep. Results: At post-test, higher levels of parental engagement were significantly associated with a marked increase in preschoolers’ moderate-to-vigorous and vigorous physical activity, alongside a notable reduction in weekend screen time. Furthermore, active parental engagement was linked to greater decreases in satiety responsiveness, desire to drink, and food fussiness compared to the ‘lurker’ group. However, no significant associations were observed between the level of parental engagement and preschoolers’ sleep-related outcomes. Conclusions: Further research with larger sample sizes and longer durations is needed to better investigate the potential of social media in parent-based interventions for promoting healthy lifestyles in children. Full article

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16 pages, 281 KB

Open AccessArticle

The Association Between Sociodemographic and Socioeconomic Factors and Meeting the Recommended Physical Activity Guidelines in Older Adults in the U.S.

by Betty R. Sierra Tamargo, Pura Rodríguez de la Vega and Noël C. Barengo

Int. J. Environ. Res. Public Health 2026, 23(3), 344; https://doi.org/10.3390/ijerph23030344 - 9 Mar 2026

Abstract

This study aimed to identify socioeconomic and demographic factors associated with meeting the recommended physical activity (PA) guidelines for older adults. This analytical, cross-sectional study used data from the 2022 NHIS, including 8189 older adults (≥65 years). Compliance with aerobic and strengthening PA [...] Read more.

This study aimed to identify socioeconomic and demographic factors associated with meeting the recommended physical activity (PA) guidelines for older adults. This analytical, cross-sectional study used data from the 2022 NHIS, including 8189 older adults (≥65 years). Compliance with aerobic and strengthening PA guidelines was the main outcome variable. Covariates included sex, education, income, relationship status, race, housing stability, urban/rural county, health status, and region. Unadjusted and adjusted logistic regression analyses estimated odds ratios (ORs) and 95% confidence intervals (CIs). Only 14.4% (n = 1235) of older adults met the PA guidelines. Odds of complying decreased by 40% in NH single/multiple races (OR 0.6; 95% CI 0.4–1.0). Men had higher odds (OR 1.4; 95% CI 1.2–1.6) of adhering than women. Compared with those with a bachelor’s degree, the odds of adhering were 1.4 (95% CI 1.2–1.7) for graduate participants, 0.3 (95% CI 0.2–0.4) for participants with less than HS education, 0.4 (95% CI 0.3–0.5) for HS graduates, and 0.7 (95% CI 0.6–0.8) for those with some college education. The odds decreased by 40% for those with an income-to-poverty ratio threshold < 1 (OR 0.6; 95% CI 0.4–0.9), 1–1.99 (OR 0.6; 95% CI 0.4–0.7), and 2–3.99 (OR 0.6; 95% CI 0.5–0.8) compared with ≥5. Healthcare providers should develop targeted interventions to address individuals’ unique circumstances and reduce these inequities. Full article

(This article belongs to the Special Issue Scaling Up Physical Activity Interventions in the Prevention of Chronic Diseases)

12 pages, 540 KB

Open AccessArticle

Factors Limiting Access to Surgical Treatment of Focal Epilepsy in Kazakh Population

by Mukhit Dossov, Balzhan Kassiyeva, Nazira Bekenova, Assel Baibussinova, Tamara Vochshenkova, Alisher Aitkaliyev, Akmaral Suleimenova and Aigul Kaptagayeva

Int. J. Environ. Res. Public Health 2026, 23(3), 343; https://doi.org/10.3390/ijerph23030343 - 9 Mar 2026

Abstract

Background/Objectives: Effective management represents a real opportunity to reduce the economic burden of focal epilepsy, which leads to the withdrawal of at least 0.7% of the working-age population from the labor force. The aim of this retrospective observational cross-sectional study is to identify [...] Read more.

Background/Objectives: Effective management represents a real opportunity to reduce the economic burden of focal epilepsy, which leads to the withdrawal of at least 0.7% of the working-age population from the labor force. The aim of this retrospective observational cross-sectional study is to identify barriers that limit access to surgical treatment for epilepsy among patients with focal epilepsy in Kazakh population. Methods: Medical reports from epileptologists on 3112 patients of the Epilepsy Center (Astana) in 2024 were reviewed. The study included original information on 1361 patients with a confirmed diagnosis of focal epilepsy, in accordance with ICD-10 codes G40.0–G40.2. Results: Timely detection of focal epilepsy was not associated with socio-demographic or regional factors in our sample. Logistic regression analysis showed that sex and social status did not affect whether patients underwent surgery. However, marital status, employment, and region were significant factors. Married and employed patients had higher odds of remaining non-operated. Among candidates for surgical treatment, 38.68% underwent surgery. Conclusions: The markedly higher odds of remaining non-operated outside Astana point to gaps in referral pathways and service availability, emphasizing the need for a comprehensive approach to managing focal epilepsy in countries undergoing rapid technological development. Full article

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20 pages, 322 KB

Open AccessArticle

An Exploratory Study of Research Needed for the Improvement of Care and Services for Persons with a Lived Experience of Mental Health Challenges

by Anton Isaacs, Sharon Lawn and Anna Baker

Int. J. Environ. Res. Public Health 2026, 23(3), 342; https://doi.org/10.3390/ijerph23030342 - 9 Mar 2026

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Abstract

Individuals with a lived experience are increasingly being included in the design of mental health services research. Obtaining perspectives of persons with a lived experience of mental health challenges on research that is important to them is an opportunity to achieve equity in [...] Read more.

Individuals with a lived experience are increasingly being included in the design of mental health services research. Obtaining perspectives of persons with a lived experience of mental health challenges on research that is important to them is an opportunity to achieve equity in allocating resources so that policy-makers and health research funders are made aware of the issues that matter to people who are affected by research. The purpose of this study is to explore lived experience perspectives on research needed for the improvement of care and services for persons with mental health challenges in order to improve the quality of care and service delivery. This qualitative study was conducted in Australia and was informed by biographical research and interpretive phenomenological analysis [IPA]. Twenty-one participants were interviewed for the study. The theme, ‘Access to care and early detection’ included eight categories. The theme, ‘Care and treatment’, included fifteen categories. The theme, Continuity of care’, included six categories. Research questions were developed for each category and serve as a first step towards initiating research on the identified topics. Research topics identified in this study were categorized as insufficiently researched, emerging areas of interest, or well researched with insufficient translation into practice. Full article

(This article belongs to the Special Issue Psychosocial Support for People Living with Mental Health Conditions, Their Families, Caregivers, and Support Networks)

17 pages, 321 KB

Open AccessArticle

Artistic and Playful Resources as Mental Health Support in the Life Trajectories of Trans and Gender-Diverse People: A Qualitative Study from a Public Health Perspective

by Eduardo Name Risk and Jhully Cristine Ananias Boaro

Int. J. Environ. Res. Public Health 2026, 23(3), 341; https://doi.org/10.3390/ijerph23030341 - 9 Mar 2026

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Abstract

Trans and gender-diverse (TGD) people experience significant mental health inequalities. These disparities are associated with structural stigma, social exclusion, and persistent barriers to accessing health services, representing a critical public health issue. Although existing research has largely emphasized biomedical and clinical responses, less [...] Read more.

Trans and gender-diverse (TGD) people experience significant mental health inequalities. These disparities are associated with structural stigma, social exclusion, and persistent barriers to accessing health services, representing a critical public health issue. Although existing research has largely emphasized biomedical and clinical responses, less is known about non-biomedical resources that support mental health across life trajectories. This qualitative study explored, based on participants’ narratives, how artistic and playful resources contribute to mental health across life trajectories, considering contexts of social inequities and social determinants of health. Four trans and gender-diverse participants aged 18–27 years were recruited through snowball sampling and took part in two in-depth semi-structured interviews conducted remotely. Data were analyzed using Reflexive Thematic Analysis combining deductive and inductive coding. Findings indicate that artistic and playful practices were described as non-biomedical resources for emotional regulation, coping with minority stress, identity affirmation, and social connection across different life stages. These practices were narrated as helping participants manage psychological distress associated with stigma, discrimination, and limited access to affirmative mental health care. From a public health perspective, the results underscore the importance of recognizing culturally situated, everyday expressive practices as complementary forms of mental health support. Integrating such resources into broader mental health strategies may contribute to more comprehensive, equitable, and non-pathologizing public mental health approaches for trans and gender-diverse populations. Full article

(This article belongs to the Special Issue Mental Health in Healthcare: Challenges and Perspectives from the Past to the Future)

13 pages, 385 KB

Open AccessArticle

Effect of Brief Guided Imagery on Short-Term Outcomes in Patients Undergoing First Elective Total Knee Arthroplasty: Randomized Controlled Trial

by Anat Kaplun, Omri Lubovsky, Ilia Prosso, Amit Sagi and Leonid Kalichman

Int. J. Environ. Res. Public Health 2026, 23(3), 340; https://doi.org/10.3390/ijerph23030340 - 8 Mar 2026

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Abstract

Background: Knee osteoarthritis, which is prevalent among older adults, often necessitates total knee arthroplasty (TKA) to alleviate pain and improve function. Postoperative pain and functional limitations remain significant challenges. Brief guided imagery (GI), a non-pharmacological intervention, shows promise in pain management but [...] Read more.

Background: Knee osteoarthritis, which is prevalent among older adults, often necessitates total knee arthroplasty (TKA) to alleviate pain and improve function. Postoperative pain and functional limitations remain significant challenges. Brief guided imagery (GI), a non-pharmacological intervention, shows promise in pain management but is underexplored in TKA patients. Aim: The aim of this study is to evaluate the effect of brief GI on postoperative pain, functional outcomes, and anxiety in patients undergoing their first elective TKA. Methods: Randomized controlled trial: 52 patients scheduled for first elective TKA were randomized to an intervention (brief GI plus standard care, n = 19) or control (standard care only, n = 23) group. Brief GI consisted of daily 2-min audio-guided exercises for up to 6 weeks after the operation. Outcome measures included pain intensity (NPRS), functional capacity (NFRS; WOMAC), and state anxiety (STAI). Assessments were conducted preoperatively (baseline), on the first postoperative day, weekly during the first five postoperative weeks, and again at the routine 5–6-week postoperative follow-up visit. Results: Of 52 enrolled participants, 42 completed the study. The intervention group reported significantly lower pain levels (NPRS) at weeks 2 (mean difference: 1.26, p = 0.042) and 5 (mean difference: 1.86, p = 0.004) compared to the control group, with a moderate effect size (Cohen’s d = 0.69–1.02). Functional outcomes (NFRS) were significantly better in the intervention group from week 1 through week 6 (p < 0.01). No significant differences were observed in WOMAC scores or STAI anxiety levels between groups. Conclusions: Brief GI, when integrated into postoperative care for TKA patients, significantly reduces pain and enhances functional outcomes over 6 weeks, though it does not affect anxiety levels. These findings support brief GI as a feasible adjunctive intervention for TKA recovery. Full article

(This article belongs to the Section Health Care Sciences)

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15 pages, 482 KB

Open AccessArticle

Awareness and Use of Folic Acid Among Pregnant Women in Western Ukraine: A Pilot Study

by Kateryna Hlushko and Oksana Boyarchuk

Int. J. Environ. Res. Public Health 2026, 23(3), 339; https://doi.org/10.3390/ijerph23030339 - 8 Mar 2026

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Abstract

Objective: Neural tube defects remain a significant global health concern. This pilot study assessed folic acid (FA) knowledge and supplementation practices among pregnant women in Ukraine. Methods: A cross-sectional survey was conducted among 95 pregnant women who completed a 22-item self-administered questionnaire assessing [...] Read more.

Objective: Neural tube defects remain a significant global health concern. This pilot study assessed folic acid (FA) knowledge and supplementation practices among pregnant women in Ukraine. Methods: A cross-sectional survey was conducted among 95 pregnant women who completed a 22-item self-administered questionnaire assessing FA awareness and socio-demographic characteristics. Results: Although 76.8% of participants reported planned pregnancies, only 25.3% used FA before conception, while 80.0% initiated supplementation after pregnancy recognition (p < 0.05). In bivariate logistic regression analysis, preconception counseling (OR = 7.7, 95% CI: 2.37–24.85), planned pregnancy (OR = 9.7, 95% CI: 1.22–76.25), previous FA supplementation (OR = 3.11, 95% CI: 1.20–8.33), and increasing maternal age (OR = 1.09 per year, 95% CI: 1.00–1.19) were significantly associated with preconception FA use. Sociodemographic factors were not significant predictors. For FA use during pregnancy, only previous supplementation remained significant (OR = 4.10, 95% CI: 1.10–14.29). Awareness of recommended FA use before (35.8%) and during pregnancy (48.4%) and knowledge of neural tube defect prevention (20.0%) were low and not associated with supplementation behavior. Conclusions: A substantial gap exists between recommended and actual FA use, particularly before conception. Strengthening preconception counseling may improve timely supplementation. Full article

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22 pages, 483 KB

Open AccessArticle

Beyond Handgrip: Associations Between Trunk Strength, Gait Speed, Resting Metabolic Rate, and Muscle Mass in Brazilian Older Women with Probable Sarcopenia

by Lucas Ferreira de Souza Campos, Juliana de Alcantara Silva Fonseca, Ana Clara de Souza Oliveira, Guilherme Moreira, Leonardo de Souza Correa, Pedro Henrique de Almeida Louza, Ana Carolina Dutra Tavares, Luana Lopes de Souza, Raquel Carvalho Castiglione, Hércules Rezende Freitas and Silvio Rodrigues Marques Neto

Int. J. Environ. Res. Public Health 2026, 23(3), 338; https://doi.org/10.3390/ijerph23030338 - 8 Mar 2026

Viewed by 126

Abstract

Sarcopenia is a complex condition marked by reductions in muscle strength, mass, and overall physical performance, which has significant consequences for functional autonomy and metabolic health in elderly women. This study aimed to examine the correlations between lower limb strength, functional capabilities, and [...] Read more.

Sarcopenia is a complex condition marked by reductions in muscle strength, mass, and overall physical performance, which has significant consequences for functional autonomy and metabolic health in elderly women. This study aimed to examine the correlations between lower limb strength, functional capabilities, and metabolic indicators in community-dwelling older women categorized according to the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria. A total of thirty-eight women aged ≥ 60 years underwent assessments, including anthropometric, hemodynamic, and metabolic evaluations, along with functional tests such as handgrip strength, chair-rise test, gait speed, Timed Up-and-Go, and maximal isometric hip extension strength (MIHE). The criteria for probable sarcopenia were established using the handgrip thresholds set by the EWGSOP2. Women identified as having probable sarcopenia displayed markedly lower MIHE, diminished gait speed, inferior performance in chair-rise and Timed Up-and-Go tests, decreased muscle mass, and a lower resting metabolic rate than their non-sarcopenic counterparts. MIHE exhibited robust correlations with muscle mass, resting metabolic rate, and functional performance metrics. These results suggest that assessments of lower limb and trunk strength yield pertinent insights beyond handgrip strength alone. Function-oriented evaluations may improve sarcopenia screening and facilitate the identification of older women at risk of functional and metabolic deficiencies in community-based environments. Full article

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

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17 pages, 1206 KB

Open AccessArticle

Leveraging Machine Learning to Predict Warfarin Sensitivity in the Puerto Rican Population: A Pharmacogenomic Approach

by Jorge E. Martínez-Jiménez, Yolianne Ortega-Lampón, Dylan Cedres-Rivera, Frances Heredia-Negrón, Abiel Roche-Lima and Jorge Duconge

Int. J. Environ. Res. Public Health 2026, 23(3), 337; https://doi.org/10.3390/ijerph23030337 - 7 Mar 2026

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Abstract

Warfarin is one of the most used oral anticoagulants, even after the arrival of non-vitamin K oral anticoagulants. Warfarin has been implicated in approximately one-third of emergency hospitalizations for adverse drug events among older adults in national U.S. data. Warfarin dose has been [...] Read more.

Warfarin is one of the most used oral anticoagulants, even after the arrival of non-vitamin K oral anticoagulants. Warfarin has been implicated in approximately one-third of emergency hospitalizations for adverse drug events among older adults in national U.S. data. Warfarin dose has been shown to vary between patients with up to 10 times the standard dose. This variability is due to multiple factors such as age, gender, diet, body size, co-medications, and the genetic background of the patient, where the genetic background accounts for 50% of warfarin dose variability among Europeans. Sadly, these findings do not apply to Caribbean Hispanic populations such as Puerto Ricans due to them having an admixed genetic profile. In the field of pharmacogenomics (PGx), the utility of machine learning (ML) has been used to predict individual drug responses by analyzing complex genetic and clinical data, which helps personalize medicine by tailoring treatments to a patient’s genetic makeup. Inclusion of ethno-specific variants has demonstrated improvement on the application of ML to a specific population. This study compares eight ML methods to predict warfarin sensitivity in Puerto Rican Caribbean Hispanics. This study is a secondary analysis of genetic and clinical data from 217 Puerto Rican patients treated with warfarin for thromboembolic disorders. After quality control filtering and exclusion of participant records with incomplete genetic and clinical data, 146 participants are retained for analysis. Data are divided into 65% and 35% to be used as training and test sets. Model performance is determined by comparing the precision and accuracy metrics, computed through the corresponding confusion matrixes. A gradient boosting classifier (GDB) achieves the highest overall accuracy (0.7500) and weighted precision of (0.7642); however, sensitivity for detecting warfarin-sensitive patients remains low. Feature importance analysis suggests that rs202201137 could contribute to model predictions, although overall detection of warfarin-sensitive individuals remains limited. Full article

(This article belongs to the Special Issue Proceedings of the 2024 and 2025 Research Centers in Minority Institutions (RCMI) Consortium National Conferences)

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17 pages, 812 KB

Open AccessArticle

Exploring the Italian Experience with Long-Acting Buprenorphine Formulations (LAIB) for the Treatment of Opioid Use Disorder: A Series of Narrative Interviews

by Vincenza Ariano, Anna Francesca Costanzo, Gemma Ferrante, Rossella Garofano, Vincenzo Lamartora, Sergio Manfré, Deborah Nordici and Lorenzo Somaini

Int. J. Environ. Res. Public Health 2026, 23(3), 336; https://doi.org/10.3390/ijerph23030336 - 7 Mar 2026

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Abstract

Long-Acting Buprenorphine Formulations (LAIB) have emerged as an alternative pharmacological approach for opioid use disorder, offering potential benefits extending beyond clinical stabilisation. Narrative medicine provides a unique approach to understand patients’ perspectives and experiences with sublingual buprenorphine and LAIB dispensed to fourteen patients [...] Read more.

Long-Acting Buprenorphine Formulations (LAIB) have emerged as an alternative pharmacological approach for opioid use disorder, offering potential benefits extending beyond clinical stabilisation. Narrative medicine provides a unique approach to understand patients’ perspectives and experiences with sublingual buprenorphine and LAIB dispensed to fourteen patients across different Italian Addiction Services, examining how they impact the emotional, social, and motivational dimensions of recovery. Narratives were analysed by thematic content across eight domains: dependence on daily treatment regimen, emotional impact, self-perception, determination to change, quality of life, craving and withdrawal symptoms, treatment adherence, social burden, and therapeutic relationship. Statements were categorised by valence; experiential patterns were qualitatively analysed. Sublingual buprenorphine, although effective, was associated with reduced autonomy, symptom control, and difficulties in balancing treatment, work and life. These aspects were correlated with worse adherence. The stigma and burden of daily intake can reduce motivation and hinder identity reconstruction. In this setting, transitioning to LAIB resulted in improved self-autonomy, emotional balance, symptom control, self-esteem, and reduced daily and psychological burden, craving and stigma, facilitating social reintegration, and strengthening the therapeutic relationship. The results emphasise the importance of including both experiential and narrative elements in clinical care, as this helps create more tailored, recovery-focused treatment pathways. Full article

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13 pages, 439 KB

Open AccessArticle

Cardiorespiratory Fitness, Body Fat, and Physical Activity as Predictors of Life Satisfaction in Teachers and Preschool Education Students: The Mediating Role of Self-Rated Health

by Ivana Nikolić, Snježana Mraković and Marko Badrić

Int. J. Environ. Res. Public Health 2026, 23(3), 335; https://doi.org/10.3390/ijerph23030335 - 7 Mar 2026

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Abstract

Objectives: This study aimed to examine the associations of physiological (VO₂max), morphological (body fat percentage), and behavioral factors (physical activity levels) with life satisfaction among teacher education and preschool education students, with a particular focus on self-rated health as a potential [...] Read more.

Objectives: This study aimed to examine the associations of physiological (VO₂max), morphological (body fat percentage), and behavioral factors (physical activity levels) with life satisfaction among teacher education and preschool education students, with a particular focus on self-rated health as a potential statistical mediator. Methods: The sample consisted of 228 students (95% female; mean age = 21.96 ± 4.24 years). Life satisfaction was assessed using the Satisfaction with Life Scale (SWLS), self-rated health (SRH) with a single-item measure of general health, physical activity (PA) with the IPAQ-SF questionnaire, cardiorespiratory fitness (VO₂max estimate) with the 20 m shuttle run test, and body fat percentage (BF%) with a bioelectrical impedance analyzer. Data were analyzed using hierarchical regression and mediation models with the PROCESS macro (Model 4). Results: SRH accounted for 17.2% of the variance in life satisfaction, emerging as the strongest correlate relative to physiological and morphological indicators. In the primary regression model, total PA accounted for an additional 2.3% of explained variance, whereas in a secondary parallel model, moderate PA accounted for 2.2%. Vigorous PA was not a significant correlate. Mediation analyses indicated that VO₂max was not directly associated with life satisfaction but showed a statistically significant indirect association through SRH. No significant indirect associations were found for BF%, individual activity intensities, or total PA. Conclusions: The results highlight the relevance of perceptual and behavioral health indicators in understanding the relationships among PA, physical fitness, and psychological well-being in this student population. The findings provide preliminary insight into how multiple health-related dimensions may relate to life satisfaction, underscoring the need for longitudinal research before more confident interpretations of practical relevance can be made. Full article

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12 pages, 640 KB

Open AccessArticle

Associating Dietary Sustainability with Health: A Focus on General and Central Adiposity

by Mariana Rei, Catarina Campos Silva, Duarte Torres, Colin Sage and Sara S. P. Rodrigues

Int. J. Environ. Res. Public Health 2026, 23(3), 334; https://doi.org/10.3390/ijerph23030334 - 7 Mar 2026

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Abstract

This study aims to explore the relationship between the Diet Sustainability Score (DSS) and health outcomes, specifically body mass index (BMI) and waist-to-height ratio (WHtR). Using data from 2287 Portuguese adults in the National Food, Nutrition, and Physical Activity Survey (IAN-AF 2015–2016), DSS [...] Read more.

This study aims to explore the relationship between the Diet Sustainability Score (DSS) and health outcomes, specifically body mass index (BMI) and waist-to-height ratio (WHtR). Using data from 2287 Portuguese adults in the National Food, Nutrition, and Physical Activity Survey (IAN-AF 2015–2016), DSS was calculated based on four dimensions: health-related nutritional attributes, environmental impact, economic affordability, and sociocultural acceptability. Logistic regression models were used to analyse associations between DSS and general adiposity (BMI classes: under/normal weight vs. overweight/obesity) and central adiposity (WHtR classes: healthy vs. unhealthy central adiposity). Models were adjusted for sex, age, education and physical activity level to control for potential confounders. Higher DSS is associated with reduced odds of overweight/obesity (OR = 0.91, 95%CI: 0.88, 0.94), and unhealthy central adiposity (OR = 0.91, 95%CI: 0.87, 0.95), suggesting that more sustainable dietary patterns are associated with more favourable adiposity profiles. This study highlights the importance of promoting sustainable diets as part of public health strategies aimed at addressing obesity and integrating health, environmental, economic, and sociocultural dimensions for more comprehensive, long-term population health improvements. Full article

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17 pages, 330 KB

Open AccessArticle

How Eudaimonia Impacts Global and Differential Life Satisfaction Independent of the General Mental Health Status

by Christopher Arnold and Beate Muschalla

Int. J. Environ. Res. Public Health 2026, 23(3), 333; https://doi.org/10.3390/ijerph23030333 - 6 Mar 2026

Viewed by 183

Abstract

Growing evidence highlights a rather long-term perspective on well-being. Eudaimonia—living meaningfully, acting in accordance with one’s values, and accepting hardship in pursuit of worthwhile goals—is associated with better mental and physical health, resilience, and higher global life satisfaction. However, there is a lack [...] Read more.

Growing evidence highlights a rather long-term perspective on well-being. Eudaimonia—living meaningfully, acting in accordance with one’s values, and accepting hardship in pursuit of worthwhile goals—is associated with better mental and physical health, resilience, and higher global life satisfaction. However, there is a lack of evidence investigating eudaimonia and its connection to satisfaction with specific life domains. This study explores how eudaimonia relates to global and domain-specific life satisfaction. A convenience general population sample (N = 394) was investigated by online questionnaire, assessing sociodemographic data, eudaimonia, health impairments, well-being, and satisfaction across 17 life domains with the Differential Life Burden Scale. High eudaimonia was associated with higher psychological well-being and work participation compared to individuals reporting low eudaimonia. Thereby people with high eudaimonia despite mental health problems reported higher satisfaction than those with mental health problems and low eudaimonia. People with high eudaimonia despite mental problems were similarly satisfied like people without mental problems but lower eudaimonia. For both global and domain-specific life satisfaction, individuals with and without mental health problems benefit from higher eudaimonia. Eudaimonia can be a valuable resource for mental health, overall life satisfaction, and satisfaction across various life domains. Full article

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

18 pages, 608 KB

Open AccessArticle

A Community-Based, Multidisciplinary Training Program to Improve HIV Services for US-Based African Immigrants: Lessons Learned over 5 Years of Implementation

by Chioma Nnaji, Rena C. Patel, Agatha O. Adigwe, Philip G. Day and Maria Fernanda Escobar

Int. J. Environ. Res. Public Health 2026, 23(3), 332; https://doi.org/10.3390/ijerph23030332 - 6 Mar 2026

Viewed by 160

Abstract

African immigrants in the U.S. face disproportionately high rates of HIV, yet existing services often lack alignment with their cultural and linguistic needs. Healthcare providers are rarely trained to address these gaps, contributing to persistent disparities in HIV prevention and care. Traditional in-house [...] Read more.

African immigrants in the U.S. face disproportionately high rates of HIV, yet existing services often lack alignment with their cultural and linguistic needs. Healthcare providers are rarely trained to address these gaps, contributing to persistent disparities in HIV prevention and care. Traditional in-house trainings for providers often have limited applicability. Collaborative, community-engaged approaches offer an opportunity to build culturally responsive, coordinated care. African Immigrant (AI) Health was a 5-year initiative integrating the Extension for Community Healthcare Outcomes model, Community of Practice model, and Commitment to Change (CtC) evaluation framework. We used an iterative process to improve the AI Health program based on participant feedback. Data were collected through pre/post-CtC questionnaires, case presentations, and discussion groups. CtCs were analyzed thematically and organized using the socioecological model. Over five years, 100+ providers enrolled, with 58 completing the program. Participants represented diverse healthcare roles, with a majority identifying as Black/African American (62%), female (81%), and residing in the Northeast region (57%). A total of 390 CtCs were developed, with the most common themes at the individual level. Most (54.5%) participants partially implemented their CtCs. Participants who implemented their CtCs reported improvements in culturally responsive care. Iterative adaptations enhanced engagement and retention. AI Health effectively supported providers in enhancing HIV care for African immigrants through culturally responsive training. Findings highlight the need for sustainable, longitudinal training models that integrate community expertise and call for policy and structural reforms to address systemic barriers to equitable HIV care. Full article

26 pages, 3451 KB

Open AccessArticle

Global Warming, Fertility, and Spermatogenesis Decline: Global and Regional Evidence from 195 Countries and Implications for Climate Adaptation Policy

by Ali Amini and Babak Behnam

Int. J. Environ. Res. Public Health 2026, 23(3), 331; https://doi.org/10.3390/ijerph23030331 - 6 Mar 2026

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Abstract

This study investigates whether long-term global warming is associated with fertility decline across 195 countries from 1960 to 2023, and whether this relationship varies by economic development and adaptive capacity. We analyze Total Fertility Rate (TFR) data from the World Bank alongside temperature [...] Read more.

This study investigates whether long-term global warming is associated with fertility decline across 195 countries from 1960 to 2023, and whether this relationship varies by economic development and adaptive capacity. We analyze Total Fertility Rate (TFR) data from the World Bank alongside temperature anomaly measures from NOAA and NASA using Pearson correlations and ordinary least squares (OLS) regression models. Regional analyses include Africa, Asia, Europe, the Middle East, and the Arctic, with GDP per capita serving as a proxy for economic development and adaptive capacity. Globally, temperature anomalies and fertility exhibit a strong negative correlation (

r \approx - 0.90

,

p < 0.001

). However, substantial regional heterogeneity emerges after controlling for GDP. In Africa (

r = - 0.89

) and the Middle East, temperature anomalies remain statistically significant predictors of fertility decline even after GDP adjustment (

β = - 0.99

,

p < 0.001

;

β = - 1.27

,

p < 0.001

, respectively). In contrast, temperature effects become statistically insignificant in South Asia, East Asia, Europe, and the Arctic once GDP is controlled, indicating that fertility decline in these regions is driven primarily by socioeconomic modernization rather than climatic stress. These findings suggest that global warming functions as a conditional demographic stressor whose impact depends critically on adaptive capacity. In regions with limited infrastructure, including constrained access to air conditioning, healthcare, and occupational heat protection, rising temperatures remain significant predictors of fertility decline, potentially mediated through heat-sensitive biological mechanisms such as impaired spermatogenesis. By contrast, in higher-income regions, high adaptive capacity appears to buffer reproductive systems from thermal stress, allowing socioeconomic factors to dominate fertility dynamics. Full article

(This article belongs to the Special Issue Environmental Factors Impacting Reproductive and Perinatal Health)

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22 pages, 341 KB

Open AccessArticle

Strength and Vulnerability: A Qualitative Study of Mental Health and Unmitigated Communion Among Female Migrants in Southeast England

by Patrick Nyikavaranda, Christina J. Jones, Marija Pantelic, Esohe Linda Abumwenre, Juliet Batista, Lijuan Wang, Mebrak Ghebreweldi, Tacye Turner, Priyamvada Paudyal, Dafni Katsampa and Carrie D. Llewellyn

Int. J. Environ. Res. Public Health 2026, 23(3), 330; https://doi.org/10.3390/ijerph23030330 - 6 Mar 2026

Viewed by 194

Abstract

Unmitigated communion (UC), the prioritisation of others’ needs over one’s own well-being, is a critical lens for understanding the mental health of female migrants. This qualitative study explores how UC intersects with constructions of strength and vulnerability within this population, particularly amid challenges [...] Read more.

Unmitigated communion (UC), the prioritisation of others’ needs over one’s own well-being, is a critical lens for understanding the mental health of female migrants. This qualitative study explores how UC intersects with constructions of strength and vulnerability within this population, particularly amid challenges such as adaptation, discrimination, and gendered roles. Using a feminist participatory methodology, the study was co-produced with 10 migrant women and three professionals. Semi-structured interviews were conducted with 18 female migrants from 13 countries, representing diverse languages, cultures, and lengths of stay in the UK. Data were thematically analysed using the Engaging Marginalised Communities by Building Relationships and Knowledge (EMBaRK) framework, which centres lived experience and equitable collaboration. Through this analytic process, three key themes were generated: (1) perceived strength and resilience shaped by societal pressures and internalised self-reliance; (2) gender roles and self-sacrifice, including traditional caregiving expectations and neglect of personal health; and (3) isolation and reluctance to seek support, marked by concealed mental health struggles and stigma. Participants’ narratives revealed shared tensions between resilience and vulnerability. The findings highlight the central role of unmitigated communion in shaping migrant women’s mental health and underscore the need for gender-responsive, culturally informed interventions that support women to balance caregiving with self-care. Full article

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

30 pages, 1040 KB

Open AccessSystematic Review

Healthcare Professionals’ Subjective Well-Being: A Systematic Review and Methodological Appraisal of Conceptual Models, Measurement Instruments, and Associated Factors

by Iluta Skrūzkalne, Evija Nagle, Otto Andersen, Jeļena Perevozčikova, Luule Sakkeus, Antanas Kairys, Ingūna Griškēviča, Silva Seņkāne, Andrejs Ivanovs and Ieva Reine

Int. J. Environ. Res. Public Health 2026, 23(3), 329; https://doi.org/10.3390/ijerph23030329 - 6 Mar 2026

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Abstract

The well-being of healthcare professionals (HCPs) is widely recognised as a critical construct related to workforce sustainability, patient safety, and healthcare system performance; however, research in this area remains conceptually fragmented. This systematic review identifies and critically analyses conceptual models, assessment instruments, and [...] Read more.

The well-being of healthcare professionals (HCPs) is widely recognised as a critical construct related to workforce sustainability, patient safety, and healthcare system performance; however, research in this area remains conceptually fragmented. This systematic review identifies and critically analyses conceptual models, assessment instruments, and factors associated with HCPs’ subjective well-being. A comprehensive literature search was conducted across six databases covering 2014 to 2024, focusing on quantitative empirical studies published in English in peer-reviewed journals. The review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study quality was assessed using the Joanna Briggs Institute criteria, and the methodological quality of measurement instruments was evaluated with the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist in validation-focused studies. Of the 7838 records initially identified, 48 studies met the inclusion criteria. Three primary thematic areas emerged: (1) conceptual models framing subjective well-being, (2) measurement instruments assessing subjective well-being, and (3) factors associated with subjective well-being among HCPs. Frequently applied conceptual frameworks included the job demands–resources model, Maslach burnout theory, and WHOQOL-related approaches. Commonly used instruments comprised the WHO-5, Maslach Burnout Inventory, and Mini-Z. In validation-focused studies assessed using COSMIN criteria, internal consistency and aspects of construct validity were generally reported as acceptable; however, reporting across measurement property domains was variable. Factors examined in relation to subjective well-being included workload, emotional exhaustion, social support, autonomy, and work–life balance. Overall, the reviewed literature demonstrates substantial variability in conceptual and methodological approaches and frequently focuses on single dimensions of well-being. These findings highlight the potential value of developing integrated, sector-specific frameworks to inform future measurement development and research in this field. Full article

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19 pages, 4253 KB

Open AccessArticle

Towards a Conceptual Participatory Framework to Promote Health Literacy in Adolescents by Integrating Self-Determination Theory and Game Design

by Michela Franchini, Giada Anastasi, Stefania Pieroni, Francesca Denoth, Benedetta Ferrante, Alessia Formica and Sabrina Molinaro

Int. J. Environ. Res. Public Health 2026, 23(3), 328; https://doi.org/10.3390/ijerph23030328 - 6 Mar 2026

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Abstract

Adolescents are heavy users of digital media but often lack critical skills, increasing their vulnerability to harmful online content. The integration of game elements into learning and training offers a promising strategy to support positive behavioural change and strengthen adolescents’ skills. This paper [...] Read more.

Adolescents are heavy users of digital media but often lack critical skills, increasing their vulnerability to harmful online content. The integration of game elements into learning and training offers a promising strategy to support positive behavioural change and strengthen adolescents’ skills. This paper describes the development of a conceptual framework for Dress-DIGITARIAN, a serious game aimed at improving health literacy, coping skills, and self-esteem, grounded in Self-Determination Theory (SDT). The framework was constructed to generate higher-order understanding through a multi-level process: analyzing general theory (SDT), integrating mid-range models (the Octalysis framework), and incorporating empirical insights derived from two data collection phases with the target population. This integrative approach informed and guided the game’s design through participatory methods. Developed through collaboration between schools and research institutions, this approach bridges theory and practice by aligning game mechanics with adolescents’ psychological needs. It also underscores the value of involving adolescents in research, not only to enhance scientific rigour but also to empower them as agents of change capable of contributing to health promotion policies and educational innovation. This study does not report the results of a completed intervention or outcome evaluation, which will be conducted in the sixth phase at the end of the current school year. Future research is needed to assess the model’s effectiveness and scalability and to identify areas for further refinement. Full article

(This article belongs to the Special Issue Health Promotion in Childhood and Adolescence)

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15 pages, 316 KB

Open AccessArticle

Using the Diffusion of Innovation Theory to Understand COVID-19 Booster Hesitancy in Adults

by Caseem C. Luck, Sarah Bauerle Bass, Katie Joan Singley, Ariel Hoadley, Kirsten Paulus, Imani Askew-Shabazz, Whitney Cabey, Malak Abuhillo, Patrick J. A. Kelly, Maria Rincon and Heather Gardiner

Int. J. Environ. Res. Public Health 2026, 23(3), 327; https://doi.org/10.3390/ijerph23030327 - 6 Mar 2026

Viewed by 183

Abstract

COVID-19 vaccine hesitancy is well documented, but less is known about booster hesitancy among fully vaccinated adults. A qualitative approach was employed to identify factors affecting COVID-19 booster hesitancy using diffusion of innovation (DoI) theory. The study was conducted in Philadelphia, Pennsylvania. In-depth [...] Read more.

COVID-19 vaccine hesitancy is well documented, but less is known about booster hesitancy among fully vaccinated adults. A qualitative approach was employed to identify factors affecting COVID-19 booster hesitancy using diffusion of innovation (DoI) theory. The study was conducted in Philadelphia, Pennsylvania. In-depth interviews (n = 30) were done with adults, including those who had (n = 9) and had not (n = 21) been boosted. Participants were categorized into DoI adopter groups or a “refuser” group for those with no intention of getting boosted. Transcripts were analyzed using an iterative coding process with consensus and triangulation to develop thematic categories. Participants had a mean age of 41 and were 63.3% Black; 20% were classified as innovators, 6.7% early adopters, 3.3% early majority, 6.7% late majority, 43.3% laggards and 20% refusers. Three themes varied across groups: level of perceived risk susceptibility of getting COVID-19 in the future, information needs and levels of vaccine literacy, and effects of ongoing institutional mistrust. Those in the laggard and refuser groups generally had lower vaccine literacy, higher levels of institutional mistrust, and were more likely to listen to friends and family for booster advice, all consistent with DoI adopter characteristics. These differences indicate important intervention targets to promote booster uptake, especially in those who have been previously vaccinated. Full article

(This article belongs to the Special Issue From Understanding to Action: Addressing Vaccine Hesitancy Across Sectors)

20 pages, 326 KB

Open AccessArticle

Residential Mobility, Housing Instability, Adverse Childhood Experiences, and the Moderating Role of Neighborhood Contexts

by Jaeyong Yoo, Satya Fisher and Jaehwan Kim

Int. J. Environ. Res. Public Health 2026, 23(3), 326; https://doi.org/10.3390/ijerph23030326 - 6 Mar 2026

Viewed by 163

Abstract

Housing instability, particularly frequent residential moves, has been associated with poor developmental outcomes, yet its relationship with adverse childhood experiences (ACEs) remains insufficiently understood at the national level. This study addresses this gap by investigating how frequent moves shape children’s exposure to ACEs, [...] Read more.

Housing instability, particularly frequent residential moves, has been associated with poor developmental outcomes, yet its relationship with adverse childhood experiences (ACEs) remains insufficiently understood at the national level. This study addresses this gap by investigating how frequent moves shape children’s exposure to ACEs, and whether community and household contexts influence these effects. Using the 2020–2021 National Survey of Children’s Health data, we ask two questions: (1) Do children who experience frequent moves face greater risk of ACEs? and (2) Do neighborhood and metropolitan contexts mitigate or exacerbate this association? Our contribution is twofold. First, we examine both directions of the relationship: how ACEs predict frequent moves and how frequent moves increase ACE exposure. Second, we incorporate contextual moderators, including supportive neighborhoods, safety, amenities, and urban residence, to provide a more nuanced account of how environments shape resilience or vulnerability. Using logistic and negative binomial regression models, we find that all ACEs significantly predict frequent moves, with parental divorce/separation showing the largest effect. Economic hardship is also a strong predictor of frequent residential mobility, and while food or cash assistance is associated with higher mobility, it moderates the hardship-mobility association. Supportive neighborhoods are associated with lower odds of moving. In turn, frequent moves more than double children’s risk of ACEs. Supportive and safe neighborhoods provide protective benefits, while detracting elements exacerbate adversity. We conclude that reducing frequent moves and strengthening neighborhood supports are critical strategies for mitigating childhood adversity. Full article

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

16 pages, 289 KB

Open AccessArticle

Multi-Stakeholder Perspectives on Barriers to Mental Health Support for Informal Caregivers

by Maria Lizette Rangel, Donaji Stelzig, Cassandra Martinez Enriquez and Hoda Badr

Int. J. Environ. Res. Public Health 2026, 23(3), 325; https://doi.org/10.3390/ijerph23030325 - 6 Mar 2026

Viewed by 173

Abstract

Background: Informal caregivers experience elevated psychological distress but face substantial challenges in accessing mental health support. Prior research has focused primarily on individual or interpersonal determinants, with less attention to how organizational, community, and policy contexts shape access and contribute to inequities in [...] Read more.

Background: Informal caregivers experience elevated psychological distress but face substantial challenges in accessing mental health support. Prior research has focused primarily on individual or interpersonal determinants, with less attention to how organizational, community, and policy contexts shape access and contribute to inequities in service availability. Methods: Fifty-one stakeholders, including 17 informal caregivers, 23 community health workers (CHWs), and 11 mental health professionals, completed a demographic survey and 60–90-min semi-structured interviews in English or Spanish. Data were analyzed using thematic analysis, combining deductive coding guided by the Socioecological Model with inductive identification of emergent themes. Results: Participants identified both barriers and supports influencing access to caregiver mental health support across socioecological levels. Individual-level barriers included limited mental health literacy, stigma, competing responsibilities, and language or technology challenges. Interpersonal barriers reflected family minimization of distress and limited encouragement for help-seeking. Organizational barriers involved program instability, restrictive eligibility criteria, long wait times, limited cultural responsiveness, and workplace constraints, while community-level influences included stigma and scarce affordable services. Policy-level barriers reflected immigration-related exclusions and the absence of caregiver-specific mental health coverage. Identified supports, such as CHW navigation and culturally responsive services, were often constrained by structural and organizational limitations. Conclusions: Caregivers face intersecting, multilevel barriers that constrain access to mental health support, while available supports are frequently insufficient to overcome structural constraints. Findings highlight the need for coordinated public health and systems-level strategies that address organizational and policy conditions shaping equitable access to caregiver mental health care. Full article

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Int. J. Environ. Res. Public Health, Volume 23, Issue 3 (March 2026) – 80 articles

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