Journal Description
Healthcare
Healthcare
is an international, scientific, peer-reviewed, open access journal on health care systems, industry, technology, policy, and regulation, and is published semimonthly online by MDPI. European Medical Association (EMA) and Ocular Wellness & Nutrition Society (OWNS) are affiliated with Healthcare and their members receive discounts on the article processing charges.
- Open Access— free for readers, with article processing charges (APC) paid by authors or their institutions.
- High Visibility: indexed within Scopus, SCIE and SSCI (Web of Science), PubMed, PMC, and other databases.
- Journal Rank: JCR - Q2 (Health Policy and Services) / CiteScore - Q1 (Leadership and Management)
- Rapid Publication: manuscripts are peer-reviewed and a first decision is provided to authors approximately 21.5 days after submission; acceptance to publication is undertaken in 2.6 days (median values for papers published in this journal in the first half of 2025).
- Recognition of Reviewers: reviewers who provide timely, thorough peer-review reports receive vouchers entitling them to a discount on the APC of their next publication in any MDPI journal, in appreciation of the work done.
- Companion journals for Healthcare include: Trauma Care and European Burn Journal.
- Journal Cluster of Healthcare Sciences and Services: Geriatrics, Journal of Ageing and Longevity, Healthcare, Hospitals, Hygiene, International Journal of Environmental Research and Public Health and Nursing Reports.
Impact Factor:
2.7 (2024);
5-Year Impact Factor:
2.8 (2024)
Latest Articles
Resilience as a Predictor of Indirect Trauma Among Korean Adolescents: A Cross-Sectional Correlational Study
Healthcare 2025, 13(19), 2491; https://doi.org/10.3390/healthcare13192491 - 30 Sep 2025
Abstract
Background/Objectives: Adolescents aged 13–18 are exposed to traumatic content even without direct experience, owing to the increasing media coverage of disasters. Such indirect exposure can result in post-traumatic stress symptoms, including intrusion, avoidance, and hyperarousal, as well as associated emotions such as sadness,
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Background/Objectives: Adolescents aged 13–18 are exposed to traumatic content even without direct experience, owing to the increasing media coverage of disasters. Such indirect exposure can result in post-traumatic stress symptoms, including intrusion, avoidance, and hyperarousal, as well as associated emotions such as sadness, anger, and guilt. These effects may persist for months, reflecting the vulnerability of adolescents during cognitive and emotional development. This study examined resilience and social support as protective predictors against indirect trauma. Methods: A cross-sectional correlational design was employed, with middle- and high-school students aged 13–18 years in Seoul, South Korea, as participants. Indirect trauma, resilience, and perceived social support were assessed using validated self-report instruments. Correlation analyses were conducted, followed by stepwise regression. Owing to multicollinearity, resilience was retained as the sole predictor in the final model. Results: The average indirect trauma score was 1.20 out of 4, and 59.2% of participants exhibited partial or full post-traumatic stress disorder. The mean resilience and social support scores were 3.47 and 3.82 out of 5, respectively. Resilience was positively correlated with social support (r = 0.60, p = 0.001). The regression analysis indicated that resilience significantly predicted indirect trauma (β = 0.82, p < 0.001), accounting for 66.4% of the variance, whereas social support showed no direct effect. Conclusions: Resilience emerged as a key predictor of indirect trauma, underscoring its importance in mitigating distress. Although social support did not directly predict trauma, its positive correlation with resilience suggests potential indirect effects. These findings highlight the need to strengthen resilience and expand school-based counseling and support systems to help adolescents deal with indirect trauma.
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Open AccessArticle
Evaluating the Perceptions, Expectations, and Concerns of Community Pharmacists in Germany Regarding Prescribing by Pharmacists
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Niklas Zimmermann, Jan Siefert, Trudi McIntosh and Ágnes Mészáros
Healthcare 2025, 13(19), 2490; https://doi.org/10.3390/healthcare13192490 - 30 Sep 2025
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Background: Expanding the role of healthcare professionals could improve patient care. Workforce shortages and financial challenges within the healthcare system have led to non-medical prescribing models, such as pharmacist prescribing in several countries. However, in Germany, the prescribing authority remains with medical
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Background: Expanding the role of healthcare professionals could improve patient care. Workforce shortages and financial challenges within the healthcare system have led to non-medical prescribing models, such as pharmacist prescribing in several countries. However, in Germany, the prescribing authority remains with medical professionals, leaving pharmacist prescribing unexplored. Objectives: The aim of this study was to assess community pharmacists’ perceptions of the concept of prescribing by pharmacists, to investigate general concerns, and to evaluate the overall readiness and willingness of community pharmacists to take on prescribing responsibilities. Methods: A cross-sectional anonymous online survey of community pharmacists was conducted between August and October 2023. The 22-item questionnaire included demographic characteristics, daily work routines, and statements regarding the concept of prescribing by pharmacists. The data were coded and analyzed using IBM SPSS Statistics version 28.0.1. Results: The key finding was that attitudes toward prescribing by pharmacists were generally very positive, regardless of the pharmacists’ age and the size of the city in which the pharmacy was located. This positive perception was reflected by 82.3% of the participants, indicating support for the concept of prescribing by pharmacists in Germany. Additionally, 81.8% expressed confidence in taking on a prescribing role after completing the necessary qualifications and training, which 85.9% of all participants considered a basic requirement. Conclusions: Most participants expressed strong support for prescribing by pharmacists and indicated openness to its implementation on a certain scale while addressing the importance of further and specialized training.
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Trends in the Prevalence and Case Characteristics of Child Sexual Abuse in Mexico, 2018–2023
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Leonor Rivera-Rivera, Marina Séris-Martínez, Paola Adanari Ortega-Ceballos, Arturo Reding-Bernal, Claudia I. Astudillo-García, Lorena Elizabeth Castillo Castillo and Luz Myriam Reynales-Shigematsu
Healthcare 2025, 13(19), 2489; https://doi.org/10.3390/healthcare13192489 - 30 Sep 2025
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Background: Child sexual abuse (CSA) is a serious public health concern that violates the rights of children. In Mexico, little is known about the actual figures for this type of violence. Objective: This study aimed to determine trends in the prevalence
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Background: Child sexual abuse (CSA) is a serious public health concern that violates the rights of children. In Mexico, little is known about the actual figures for this type of violence. Objective: This study aimed to determine trends in the prevalence and case characteristics of CSA in a representative sample of children in Mexico. Materials and Methods: Data from the National Health and Nutrition Survey (ENSANUT) for 2018, 2020, 2021, 2022 and 2023 were used (n = 24,179). Proportions of CSA were estimated using the weighted mean of a binary variable, and the variance of the estimated proportion was calculated using the Taylor linearization method. Logistic regression models were estimated, and Adjusted Odds Ratios (AORs) with 95% Confidence Intervals (95% CIs) were obtained. Results: The prevalence of CSA ranged from 2.22% (2018) to 5.66% (2023). There was an increasing trend in CSA between 2018 and 2021, which was even more pronounced (154.95%) between 2018 and 2023 (p < 0.001). The main perpetrator in CSA cases was a family member (78.51%), and most victims did not report the abuse to the authorities. Girls were more likely to experience CSA (AOR = 2.83, 95% CI: 1.72–4.68), and as years passed (from 2018 to 2023), the likelihood of becoming a victim of CSA increased. Conclusions: CSA is a problem that has increased in recent years in Mexico. It is noteworthy that the main perpetrator is within the family, which may influence the lack of reporting of these cases. In view of this situation, it is necessary to implement strategies to prevent CSA in children, involving mothers, fathers, and caregivers.
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AI-Enhanced Lower Extremity X-Ray Segmentation: A Promising Tool for Sarcopenia Diagnosis
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Hyunwoo Park, Hyeonsu Kim and Junil Yoo
Healthcare 2025, 13(19), 2488; https://doi.org/10.3390/healthcare13192488 - 30 Sep 2025
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Background/Objectives: Sarcopenia, characterized by progressive loss of skeletal muscle mass and strength, significantly impacts physical function and quality of life in older adults. Traditional measurement methods like Dual-energy X-ray absorptiometry (DEXA) are often inaccessible in primary care. This study aimed to develop
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Background/Objectives: Sarcopenia, characterized by progressive loss of skeletal muscle mass and strength, significantly impacts physical function and quality of life in older adults. Traditional measurement methods like Dual-energy X-ray absorptiometry (DEXA) are often inaccessible in primary care. This study aimed to develop and validate an AI-driven auto-segmentation model for muscle mass assessment using long X-rays as a more accessible alternative to DEXA. Methods: This was a retrospective validation study using data from the Real Hip Cohort at Inha University Hospital in South Korea. 351 lower extremity X-ray images from 157 patients were collected and analyzed. AI-based semantic segmentation models, including U-Net, V-Net, and U-Net++, were trained and validated on this dataset to automatically segment muscle regions. Model performance was assessed using Intersection over Union (IoU) and Dice Similarity Coefficient (DC) metrics. The correlation between AI-derived muscle measurements and the DEXA-derived skeletal muscle index was evaluated using Pearson correlation analysis and Bland–Altman analysis. Results: The study analyzed data from 157 patients (mean age 77.1 years). The U-Net++ architecture achieved the best segmentation performance with an IoU of 0.93 and DC of 0.95. Pearson correlation demonstrated a moderate to strong positive correlation between the AI model’s muscle estimates and DEXA results (r = 0.72, *** p < 0.0001). Regression analysis showed a coefficient of 0.74, indicating good agreement with reference measurements. Conclusions: This study successfully developed and validated an AI-driven auto-segmentation model for estimating muscle mass from long X-rays. The model provides an accessible alternative to DEXA, with potential to improve sarcopenia diagnosis and management in community and primary care settings. Future work will refine the model and explore its application to additional muscle groups.
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Open AccessArticle
Unveiling Social Media Content Related to ADHD Treatment: Machine Learning Study Using X’s Posts over 15 Years
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Alba Gómez-Prieto, Alejandra Mercado-Rodriguez, Juan Pablo Chart-Pascual, Cesar I. Fernandez-Lazaro, Francisco J. Lara-Abelenda, María Montero-Torres, Claudia Aymerich, Javier Quintero, Melchor Alvarez-Mon, Ana Gonzalez-Pinto, Cesar A. Soutullo and Miguel Angel Alvarez-Mon
Healthcare 2025, 13(19), 2487; https://doi.org/10.3390/healthcare13192487 - 30 Sep 2025
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Background: Public discourse on social media plays an increasingly influential role in shaping health-related perceptions and behaviours. Individuals share experiences, concerns, and opinions beyond clinical settings around different issues. X (formerly Twitter) provides a unique lens through which to examine how different treatments
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Background: Public discourse on social media plays an increasingly influential role in shaping health-related perceptions and behaviours. Individuals share experiences, concerns, and opinions beyond clinical settings around different issues. X (formerly Twitter) provides a unique lens through which to examine how different treatments are perceived, used, and debated across diverse communities over time. Objective: The study aims to (a) identify the types of ADHD medications mentioned in posts, depending on language and user type; (b) evaluate the popularity of content related to these medications, considering language and user type; (c) analyse temporal changes in the frequency of mentions between 2006 and 2022; and (d) examine the distribution of tweets across different content categories. By addressing these objectives, this study provides insights into public perceptions of ADHD medications, which may help healthcare professionals better understand online discussions and improve their communication with patients, facilitating more informed treatment decisions. Methods: An observational study was conducted analysing 254,952 tweets in Spanish and English about ADHD medications from January 2006 to December 2022. Content analysis combined inductive and deductive approaches to develop a categorisation codebook. BERTWEET and BETO models were used for machine learning classification of English and Spanish tweets, respectively. Descriptive statistical analysis was performed. Results: Overall, stimulant medications were posted more frequently and received higher engagement than non-stimulant medications. Methylphenidate, dextroamphetamine, and atomoxetine were the most commonly mentioned medications, especially by patients, who emerged as the most active users among the English tweets. Regarding medical content, tweets in English contained more than twice the number of mentions of inappropriate use compared to those in Spanish. There was a high content of online medication requests and offers in both languages. Conclusions: In this study, conducted on X, discussions on ADHD medications highlighted concerns about misuse, adherence, and trivialisation, with clear differences between English and Spanish tweets regarding focus and type of user participation. These findings suggest that monitoring social media can provide early signals about emerging trends, helping clinicians address misconceptions during consultations and informing public health strategies aimed at the safer and more responsible use of ADHD medications.
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Open AccessArticle
Targeted Physical Function Exercises for Frailty and Falls Management in Pre-Frail Community-Dwelling Older Adults: A Randomized Controlled Trial
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Ioannis Savvakis, Athina Patelarou, Enkeleint A. Mechili, Eirini Stratidaki, Evridiki Patelarou and Konstantinos Giakoumidakis
Healthcare 2025, 13(19), 2486; https://doi.org/10.3390/healthcare13192486 - 30 Sep 2025
Abstract
Background/Objectives: Exercise is essential for older adults to maintain or improve their physical condition. This study aimed to investigate whether improvements in physical performance, functional mobility, and balance through targeted physical function exercises could positively influence Concerns about Falling (CaF) and frailty in
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Background/Objectives: Exercise is essential for older adults to maintain or improve their physical condition. This study aimed to investigate whether improvements in physical performance, functional mobility, and balance through targeted physical function exercises could positively influence Concerns about Falling (CaF) and frailty in pre-frail community-dwelling older adults. Methods: We conducted an 18-month randomized controlled trial involving 112 pre-frail community-dwelling older adults aged 65 years or older. 55 individuals in the control group (CG) and 57 in the intervention group (IG) were assessed. The IG participated in a home-based physical function exercise program. Primary outcomes included Physical Performance (Short Physical Performance Battery, SPPB), Functional Mobility (Timed Up and Go, TUG), Balance (Berg Balance Scale, BBS), CaF (Falls Efficacy Scale–International, FES-I), and Frailty status (SHARE-FI). Assessments were conducted at baseline, 6, 12, and 18 months. Results: The IG showed significant improvements in BBS (p < 0.01, partial eta2 0.17), SPPB (p < 0.01, partial eta2 0.13), TUG (p < 0.01, partial eta2 0.14) and FES-I (p < 0.01, partial eta2 0.07) compared to the CG and their baseline after 6, 12 and 18 months of intervention. By 18 months, frailty status improved in the IG, with 12.3% classified as non-frail compared to 2.0% in the CG, while 14.5% of the CG transitioned to frailty versus none in the IG. Discussion: The intervention appears to support improvements in physical function and may contribute to reductions in CaF and beneficial changes in frailty status among pre-frail community-dwelling older adults.
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(This article belongs to the Special Issue Advances in Chronic Disease Management, Rehabilitation, and Health Outcomes)
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Physical Therapists’ Use of Behavior Change Strategies to Promote Physical Activity for Individuals with Neurological Conditions
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Amber LaMarca, Gwendolyn Larsen, Kathleen D. Lyons and Julie Keysor
Healthcare 2025, 13(19), 2485; https://doi.org/10.3390/healthcare13192485 - 30 Sep 2025
Abstract
Background/Objectives: People living with neurological conditions are inactive despite widespread literature showing physical activity (PA) is beneficial for this population. To impact long term changes in PA behavior, physical therapists treating individuals with neurological conditions need to provide effective PA promotion in
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Background/Objectives: People living with neurological conditions are inactive despite widespread literature showing physical activity (PA) is beneficial for this population. To impact long term changes in PA behavior, physical therapists treating individuals with neurological conditions need to provide effective PA promotion in combination with behavior change techniques (BCTs). The purpose of this study is to (1) characterize the use of BCTs during neurorehabilitation, and (2) to gain an understanding of considerations related to PA promotion. Methods: Observations of outpatient physical therapy encounters with subsequent semi-structured interviews were conducted. Observations were transcribed with detailed field notes and analyzed with descriptive analysis and deductive coding. Interviews were analyzed with thematic analysis. Results: Observations indicated that PA promotion in neurorehabilitation practice emphasizes home exercise programs, with less focus on aerobic activity. The most common BCTs used were instruction on how to perform the behavior, behavioral practice and rehearsal, and social support. Primary themes that impacted physical therapist use of BCTS for PA promotion included knowledge, decision processes, perceived role, beliefs, environmental context, and social influences. Conclusions: PA promotion from physical therapists in neurorehabilitation is not targeting activity guidelines and there is uncertainty about using behavior change strategies and PA guidelines for PA promotion.
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(This article belongs to the Special Issue Adherence and Behavior Change in Health and Rehabilitation Interventions)
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Comparative Evaluation of Ultrasound Measurement of the Plantar Fascia Between Expert and Novice Technicians
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Alba Larriba-Pérez, Mª Carmen Ledesma-Alcázar, María Teresa García-Martínez, Carmen García-Gomariz, José-María Blasco and Paula Cobos-Moreno
Healthcare 2025, 13(19), 2484; https://doi.org/10.3390/healthcare13192484 - 30 Sep 2025
Abstract
Background and Objectives: Plantar fasciitis is one of the most common foot pathologies, and its diagnosis and clinical follow-up increasingly rely on the use of ultrasound. The aim of this study is to compare the reliability of ultrasound measurements of plantar fascia
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Background and Objectives: Plantar fasciitis is one of the most common foot pathologies, and its diagnosis and clinical follow-up increasingly rely on the use of ultrasound. The aim of this study is to compare the reliability of ultrasound measurements of plantar fascia thickness between an expert technician, with more than 5 years of ultrasound experience, and a novice technician, with no prior ultrasound experience—both of whom are podiatrists. This allows us to assess whether operator experience significantly influences the results. Methods: An observational, descriptive, and cross-sectional study was designed with a sample of 60 healthy patients aged between 20 and 32 years. The thickness of the plantar fascia in both feet was measured using ultrasound. Each patient was evaluated by two observers (one expert and one novice) using a Vinno E35 ultrasound machine. Results: The results of the analysis indicated that there were no statistically significant differences in the measurements obtained either between the two technicians or between the left and right feet of the same individual, as the calculated p-value in both cases was greater than the conventional threshold of 0.05. This suggests that the measurements were consistent regardless of the operator or the side being evaluated. Nevertheless, when examining the differences in the time required to measure the plantar fascia between the two technicians, the situation was different. In this case, the data distribution did not meet the assumption of normality, as evidenced (p-value of less than 0.001). Furthermore, it was observed that the experienced technician not only completed the measurements in a shorter amount of time but also demonstrated less variability in those times, indicating a more efficient and standardized approach to the procedure. In contrast, the novice technician initially took longer and exhibited greater inconsistency; however, as the study progressed, a noticeable and progressive learning effect became apparent. Specifically, from approximately the midpoint of the study onward, the novice technician showed a significant improvement, achieving faster and more consistent measurement times compared to the earlier stages of the research. Conclusions: The study demonstrates that ultrasound measurements of the plantar fascia are consistent between technicians. However, the expert technician performs the measurements with greater speed and precision, and a learning effect is evident in the novice technician.
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(This article belongs to the Special Issue Research on Podiatric Medicine and Healthcare)
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Open AccessArticle
From Uncertainty to Consent: Educational Intervention Effects on Knowledge and Willingness to Donate Organs After Death
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Aruzhan Asanova, Saule Shaisultanova, Dana Anafina, Gulnur Daniyarova, Vitaliy Sazonov, Aidos Bolatov, Aigerim Abdiorazova and Yuriy Pya
Healthcare 2025, 13(19), 2483; https://doi.org/10.3390/healthcare13192483 - 30 Sep 2025
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Background: The willingness to donate organs after death remains low in many populations, often due to informational and psychological barriers. This study assessed the impact of an educational lecture on knowledge and attitudes toward postmortem organ donation among university students in Kazakhstan. Methods:
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Background: The willingness to donate organs after death remains low in many populations, often due to informational and psychological barriers. This study assessed the impact of an educational lecture on knowledge and attitudes toward postmortem organ donation among university students in Kazakhstan. Methods: A total of 129 students completed a pre-lecture questionnaire on donation attitudes, knowledge, and barriers; 97 also completed the post-lecture assessment. Changes were analyzed using paired t-tests, repeated-measures ANOVA, and logistic regression. Participants were grouped by attitudinal changes to identify predictors of consent. Results: Knowledge about organ donation increased significantly after the lecture (p < 0.001), with larger gains among females and non-medical students. The number of participants who were willing to donate rose from 27 to 56 (p < 0.001). About 37% showed a positive shift, while 3% shifted toward refusal. In the initially ambivalent group (n = 49), female gender (AOR = 35.6), greater knowledge gain (AOR = 3.03), and lower perceived barriers (AOR = 0.05) predicted a change towards consent. Uncertainty about how to express consent was the only significantly differing barrier (p = 0.036). Conclusion: A brief educational lecture effectively increased knowledge and willingness to donate. Targeted information on procedural aspects may reduce indecision and promote informed donor registration.
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Open AccessArticle
Active Breaks in Primary and Secondary School Children and Adolescents: The Point of View of Teachers
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Michela Persiani, Andrea Ceciliani, Gabriele Russo, Laura Dallolio, Giulio Senesi, Laura Bragonzoni, Marco Montalti, Rossella Sacchetti and Alice Masini
Healthcare 2025, 13(19), 2482; https://doi.org/10.3390/healthcare13192482 - 29 Sep 2025
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Background/Objectives: Engaging in regular physical activity (PA) and reducing sedentary behaviors benefits youth health, especially for those with disabilities. However, two-thirds of European children remain insufficiently active. In schools, Active Breaks, brief 5–15 min PA sessions led by teachers during or between lessons,
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Background/Objectives: Engaging in regular physical activity (PA) and reducing sedentary behaviors benefits youth health, especially for those with disabilities. However, two-thirds of European children remain insufficiently active. In schools, Active Breaks, brief 5–15 min PA sessions led by teachers during or between lessons, offer a feasible strategy to increase movement. This study investigated teachers’ perceptions of ABs by comparing implementers and non-implementers, examining facilitators and barriers to implementation, and exploring their potential to support the inclusion of students with disabilities. Methods: An observational cross-sectional study was conducted among primary and secondary school teachers in the Emilia-Romagna region (Italy), all of whom had completed a 6 h training course on the implementation of ABs. Data were collected using an ad hoc questionnaire consisting of four sections: sociodemographic data, an adapted Attitudes Toward Physical Activity scale, ABs’ practicality/sustainability, and inclusiveness. Results: Overall, 65% of teachers reported implementing ABs, with higher adoption in primary (69.5%) than secondary schools (58.6%). Implementers reported more positive perceptions and attitudes across individual, classroom, and school-support domains (p < 0.05). In addition, primary teachers consistently scored higher than their secondary counterparts, particularly in terms of class characteristics and benefit perceptions (p < 0.001). Most teachers, especially in primary schools (84.2%), reported no difficulties, although one-third of secondary teachers reported challenges. Exploratory factor analysis on barrier items identified two dimensions (practical/logistical feasibility; institutional/procedural difficulties), but internal consistency was low. Teachers mainly reported using motor activities, with sessions lasting 5–10 min, typically scheduled mid-morning. Inclusion analysis revealed that 60% of teachers had students with disabilities in their classes. While most students participated without adjustments, 25% required occasional or consistent modifications. Conclusions: ABs are a practical and inclusive strategy to reduce SBs in schools. However, not all teachers are currently able to implement them, due to varying contextual constraints, levels of support, and perceived barriers. Primary school settings appear more conducive to their integration, whereas secondary schools may require more tailored support. Fostering teacher confidence, peer collaboration, and inclusive planning can enhance both the implementation and long-term sustainability of educational initiatives.
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(This article belongs to the Section Public Health and Preventive Medicine)
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Psychometric Evaluation of the Pittsburgh Sleep Quality Index in Korean Breast Cancer Survivors: A Confirmatory Factor Analysis
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Mi Sook Jung, Moonkyoung Park, Kyeongin Cha, Xirong Cui, Ah Rim Lee and Jeongeun Hwang
Healthcare 2025, 13(19), 2481; https://doi.org/10.3390/healthcare13192481 - 29 Sep 2025
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Background/Objectives: Poor sleep quality is a prevalent and burdensome concern among breast cancer survivors. However, its assessment relies heavily on the Pittsburgh Sleep Quality Index (PSQI), whose latent structure has shown inconsistent support across populations. This study aimed to examine the underlying
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Background/Objectives: Poor sleep quality is a prevalent and burdensome concern among breast cancer survivors. However, its assessment relies heavily on the Pittsburgh Sleep Quality Index (PSQI), whose latent structure has shown inconsistent support across populations. This study aimed to examine the underlying factor structure and reliability of the PSQI among Korean breast cancer survivors using confirmatory factor analysis. Methods: A cross-sectional survey was conducted with 386 non-metastatic breast cancer survivors recruited from a university cancer center in South Korea. Ten competing one-, two-, and three-factor models were identified in previous studies and tested using confirmatory factor analysis with maximum likelihood estimation. Model fit was assessed with χ2/df, Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR), and model parsimony was compared using Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC). Results: The mean global PSQI score was 7.46 (SD = 3.95), and 72.8% of participants were classified as poor sleepers. Among the tested model, a three-factor solution provided the best fit (χ2/df = 0.795, CFI ≈ 1.000, TLI ≈ 1.000, RMSEA ≈ 0.000, SRMR = 0.017) and achieved the lowest AIC and BIC values. This finding indicates the most favorable balance between fit and parsimony. This three-factor model delineates three distinct but related domains: perceived sleep quality, sleep efficiency, and daily disturbances. The global PSQI demonstrates acceptable reliability. Conclusions: These findings support the three-factor structure of the PSQI as the most valid representation of sleep quality among Korean breast cancer survivors. These results underscore the importance of population-specific validation of sleep measures and confirm the clinical utility of this measure as a multidimensional tool for assessing sleep in survivorship care.
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Open AccessReview
Think Outside the Block: Rehabilitation Continuum After ACL Reconstruction with Adaptive Macro-Blocks—A Narrative Review
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Giandomenico Campardo, Roberto Ricupito, Carlotta Vercesi, Firas Mourad, Georgios Kakavas and Florian Forelli
Healthcare 2025, 13(19), 2480; https://doi.org/10.3390/healthcare13192480 - 29 Sep 2025
Abstract
Background: Conventional rehabilitation after anterior cruciate ligament reconstruction often follows a rigid, phase-based model. This structure may overlook individual differences in healing, neuromuscular control, and psychological readiness, leading to low return-to-sport rates and a high risk of reinjury. Methods: This narrative review proposes
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Background: Conventional rehabilitation after anterior cruciate ligament reconstruction often follows a rigid, phase-based model. This structure may overlook individual differences in healing, neuromuscular control, and psychological readiness, leading to low return-to-sport rates and a high risk of reinjury. Methods: This narrative review proposes a flexible rehabilitation framework based on overlapping progression blocks. Inspired by principles of strength and conditioning, motor learning, and cognitive training, this model emphasizes continuous, individualized development instead of fixed timelines. Results: The proposed model integrates essential components—such as joint mobility, muscle activation, motor control, and psychological factors—throughout the entire recovery process. Functional testing is redefined as a dynamic and ongoing diagnostic tool that helps clinicians identify areas needing further development, rather than acting as a simple pass/fail gateway. Progression is guided by demonstrated readiness rather than time or phase completion. Conclusions: Rehabilitation using adaptive, overlapping progression blocks offers a more holistic and responsive approach. It allows for better personalization, supports safer decision-making, and improves the transition back to sport through sustained development of physical and cognitive capacities.
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(This article belongs to the Special Issue Advances in Physical Therapy for Sports-Related Injuries and Pain)
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Open AccessSystematic Review
Thoracic Manual Therapy With or Without Exercise Improves Pain and Disability in Subacromial Pain Syndrome: A Systematic Review of Randomized Trials
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Román Robles-Pérez, Rodrigo Vallejo-Martínez, Andoni Carrasco-Uribarren, Sandra Jiménez-del-Barrio, Héctor Hernández-Lázaro and Luis Ceballos-Laita
Healthcare 2025, 13(19), 2479; https://doi.org/10.3390/healthcare13192479 - 29 Sep 2025
Abstract
Objectives: The aim of this systematic review was to evaluate the effectiveness of thoracic manual therapy with or without exercise for improving clinical outcomes (pain, disability, range of motion (ROM), quality of life (QoL) and satisfaction) in patients with subacromial pain syndrome (SPS).
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Objectives: The aim of this systematic review was to evaluate the effectiveness of thoracic manual therapy with or without exercise for improving clinical outcomes (pain, disability, range of motion (ROM), quality of life (QoL) and satisfaction) in patients with subacromial pain syndrome (SPS). Methods: A systematic review was conducted following PRISMA guidelines. Randomized controlled trials (RCTs) involving thoracic manual therapy with or without thoracic exercise for patients with SPS were included. Databases searched included PubMed, PEDro, Cochrane Library, and Web of Science up to April 2025. The methodological quality was evaluated with the PEDro scale. Results: Seven RCTs involving 393 patients were included. Interventions ranged from thoracic manipulation alone to combinations with exercises. Better outcomes were reported for every clinical outcome evaluated: pain, disability, ROM, QoL and satisfaction. However, methodological heterogeneity and variability in follow-up durations limited result generalizability. Conclusions: Thoracic manual therapy applied in isolation or with exercise was reported to have positive effects in reducing pain and disability in patients with SPS, especially in the short term. These findings support the inclusion of thoracic interventions as complementary strategies in shoulder rehabilitation programs. Future high-quality trials with long-term follow-up are needed to confirm and standardize these approaches.
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(This article belongs to the Special Issue Physical Therapy and Rehabilitation in Sports)
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Open AccessReview
Psychological and Spiritual Support for Parents of a Premature Baby in the Intensive Care Unit: Scoping Review
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Barbara Kegl, Urška Novak, Rosemarie Franc and Nataša Mlinar Reljić
Healthcare 2025, 13(19), 2478; https://doi.org/10.3390/healthcare13192478 - 29 Sep 2025
Abstract
Background: Psychological and spiritual support is crucial, especially in challenging life situations, trials, and when facing the unimaginable distress experienced by parents of premature babies in the intensive care unit. This scoping review aims to identify the psychological and spiritual support needed by
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Background: Psychological and spiritual support is crucial, especially in challenging life situations, trials, and when facing the unimaginable distress experienced by parents of premature babies in the intensive care unit. This scoping review aims to identify the psychological and spiritual support needed by parents of premature babies in intensive care units. Methods: The databases PubMed, CINAHL Ultimate and Web of Science were searched in April 2025. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines were followed. The extraction table was used to extract significant information from each source of evidence. Descriptive data analysis was used to present results. Results: The search identified 1353 hits, and 17 sources of evidence were included in the review. The results indicate that psychological and spiritual support has been implemented in clinical practice. The main category Psychological and spiritual needs of parents of preterm babies in intensive care was designed using subcategories: psychological needs of parents of preterm babies in intensive care, and spiritual needs of parents of preterm babies in intensive care. Conclusions: In the context of continuous and holistic healthcare for preterm babies in intensive care units, psychological and spiritual support represent essential and interrelated components. Spiritual support for parents is frequently underrecognized and insufficiently addressed.
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(This article belongs to the Section Mental Health and Psychosocial Well-being)
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Open AccessArticle
The Interplay Between Immunological and Inflammatory Markers as Key Prognostic Indicators in Elderly Patients with COVID-19
by
Corina Popazu, Violeta Diana Oprea, Alina-Maria Lescai, Aurelia Romila, Marius Petrea, Robert Marius Grosu, Adriana Liliana Vlad, Daniela-Ioanina Prisăcaru and Alexia Anastasia Ștefania Baltă
Healthcare 2025, 13(19), 2477; https://doi.org/10.3390/healthcare13192477 - 29 Sep 2025
Abstract
Background: The COVID-19 pandemic has disproportionately affected the elderly population, with inflammation and impaired immune response being key drivers of disease progression. Clinicians require predictive models integrating immunological and inflammatory biomarkers to optimize risk stratification in this vulnerable group. Methods: We retrospectively
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Background: The COVID-19 pandemic has disproportionately affected the elderly population, with inflammation and impaired immune response being key drivers of disease progression. Clinicians require predictive models integrating immunological and inflammatory biomarkers to optimize risk stratification in this vulnerable group. Methods: We retrospectively analyzed 1429 elderly patients (aged >60 years) admitted with COVID-19 between March 2020 and August 2022. Demographic, clinical, and laboratory data were collected at admission. Correlation and regression analyses were performed to assess the prognostic significance of hematological and inflammatory markers. Results: Lymphopenia and neutrophilia were predominant findings, frequently associated with elevated C-reactive protein levels. Correlation analyses revealed significant associations between inflammatory markers and discharge status or death, while lymphocytes exerted a protective effect, reducing mortality risk by 14.4%. Notably, a higher platelet-large cell ratio (PLCR) was linked to increased mortality, suggesting an important contribution of thrombosis to severe COVID-19. Conclusions: Our findings indicate that immunological and inflammatory markers may serve as significant predictors of outcomes in elderly COVID-19 patients. While the predictive power of the model remains limited, these biomarkers can contribute to a better understanding of patient trajectories and may inform therapeutic strategies.
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A Cluster Analysis of EPOCH Questionnaire Data from University Students in Sichuan, China: Exploring Group Differences in Psychological Well-Being and Demographic Factors
by
Juan Wan, Lijuan Ren, Yufei Tan, Yin How Wong, Ching Sin Siau and Lei Hum Wee
Healthcare 2025, 13(19), 2476; https://doi.org/10.3390/healthcare13192476 - 29 Sep 2025
Abstract
(1) Background: University students face increasing mental health challenges, with sociodemographic disparities shaping well-being outcomes and highlighting the need for machine learning approaches to identify distinct psychological profiles. (2) Methods: This cross-sectional study surveyed 4911 Chinese university students (aged 18–25) using the EPOCH
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(1) Background: University students face increasing mental health challenges, with sociodemographic disparities shaping well-being outcomes and highlighting the need for machine learning approaches to identify distinct psychological profiles. (2) Methods: This cross-sectional study surveyed 4911 Chinese university students (aged 18–25) using the EPOCH Questionnaire, which measures Engagement, Perseverance, Optimism, Connectedness, and Happiness. Data were collected via WenjuanXing (WJX), with recruitment promoted through official channels. Well-being profiles were identified through exploratory K-means clustering, with internal validity and the optimal cluster number assessed using the silhouette coefficient. (3) Results: Cluster analysis identified two distinct groups: Cluster 0 (41.09%) with higher well-being scores and Cluster 1 (58.91%) with lower scores. Differences across all five EPOCH dimensions exceeded 1.0, most notably in Optimism (Δ = 1.31) and Happiness (Δ = 1.37). A subgroup of concern within Cluster 1 (n = 92), primarily male sophomores from rural, low-income, multi-child families receiving financial aid, showed particularly low scores in Connectedness (Δ = −0.57) and Happiness (Δ = −0.43). In contrast, a high well-being subgroup in Cluster 0 (n = 108), mainly urban female freshmen from high-income, only-child families, exhibited elevated scores, especially in Connectedness (Δ = 0.69) and Happiness (Δ = 0.65). (4) Conclusions: This exploratory clustering study identified distinct well-being profiles among Chinese university students, with demographic and socioeconomic vulnerabilities associated with diminished psychological well-being, particularly in Connectedness, Happiness, and Optimism. These findings highlight the need for targeted interventions that integrate psychosocial support with financial assistance to reduce inequalities and promote flourishing.
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(This article belongs to the Topic Communications Challenges in Health and Well-Being, 2nd Edition)
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Open AccessArticle
Lessons Learned from the Policies Developed for the Management of the COVID-19 Pandemic in Northern Cyprus: A Mixed-Methods Study
by
Seren Fatma Osmanogullari, Nazemin Gilanliogullari and Macide Artac Ozdal
Healthcare 2025, 13(19), 2475; https://doi.org/10.3390/healthcare13192475 - 29 Sep 2025
Abstract
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Background/Objectives: The COVID-19 (Coronavirus Disease, 2019) pandemic affected all countries in a variety of ways, and forced policymakers to adapt national health infrastructure. In this context, the strategic adaptation and policy evolution of small island states are understudied. Therefore, the objective of
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Background/Objectives: The COVID-19 (Coronavirus Disease, 2019) pandemic affected all countries in a variety of ways, and forced policymakers to adapt national health infrastructure. In this context, the strategic adaptation and policy evolution of small island states are understudied. Therefore, the objective of this study was to quantitatively analyse the relationship between confirmed COVID-19 cases and health policy decisions in Northern Cyprus. We also examined the shifting management strategies employed during the pandemic using a replicable statistical analysis framework. Methods: In this mixed-methods study, we used systematic thematic analysis to categorise official policy decisions from March 2020 to December 2022. Yearly linear regression models using SPSS and Python correlated the monthly number of decisions with the number of confirmed COVID-19 cases. The analyses included R2 values, p-values, and visualisations with 95% confidence intervals. Results: The findings of this study highlight a three-phase strategic period. In 2020, the results (R2 = 0.03, p = 0.63) showed no significant relationship, indicating initial uncertainty. The results (R2 = 0.60, p = 0.003) indicate a strong negative correlation in 2021, which reflects the consistency of the proactive suppression strategies adopted. Conversely, for 2022, the results (R2 = 0.79, p < 0.001) show a strong positive correlation representing the shift to a reactive mitigation strategy, in which the government responded based on case peaks. Conclusions: This study’s primary finding is that strategic agility was key to managing the pandemic. For small island states in particular, the effectiveness of geographic advantages like border control depends on a coherent strategy that transcends initial uncertainty. Our data-driven framework provides a tool for analysing this strategic evolution and guiding responses to future pandemics.
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Telemedicine in Times of Crisis—A SWOT Assessment Based on Romanian Healthcare Professionals’ Perceptions
by
Gianina-Valentina Băcescu Ene, Corina Mărginean, Damiana-Maria Vulturar, Corina Eugenia Budin, Ruxandra-Mioara Râjnoveanu and Doina Adina Todea
Healthcare 2025, 13(19), 2474; https://doi.org/10.3390/healthcare13192474 - 29 Sep 2025
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Background and Objectives: Unlike previous studies that have examined telemedicine primarily in pandemic contexts, this research adopts a dual-crisis perspective, assessing perceptions during both pandemics and armed conflicts. Recent health crises, including the COVID-19 pandemic and armed conflicts, have exposed vulnerabilities in health
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Background and Objectives: Unlike previous studies that have examined telemedicine primarily in pandemic contexts, this research adopts a dual-crisis perspective, assessing perceptions during both pandemics and armed conflicts. Recent health crises, including the COVID-19 pandemic and armed conflicts, have exposed vulnerabilities in health systems and underscored the need for evidence-based strategies to enhance resilience. Telemedicine has emerged as an essential tool for ensuring continuity of care, mitigating workforce shortages, and improving access for vulnerable groups. This study examines healthcare professionals’ perceptions of telemedicine in Romania across two exceptional contexts—pandemics and armed conflict—focusing on applicability, systemic integration, and limitations. Methods: A cross-sectional descriptive survey was conducted among 409 healthcare professionals. Perceptions were analyzed using a SWOT framework and descriptive statistics (percentiles, median) to identify strengths, weaknesses, opportunities, and threats in both scenarios. Results: Perceptions of telemedicine were shaped by prior experience, with strong support for its use in both contexts. Strengths included adaptability and improved access, while weaknesses highlighted technical barriers, insufficient training, and the risk of clinical errors. Threats referred to poor coordination across facilities and cultural or language barriers. Opportunities highlighted the potential for digital infrastructure and integration into preparedness frameworks. Conclusions: Telemedicine is positioned as a strategic tool for strengthening national health resilience. Adaptive, context-sensitive policies, combined with investments in infrastructure and workforce capacity, are essential for integrating telemedicine into emergency preparedness and ensuring sustainable, inclusive responses to future crises. This dual-crisis approach represents the novelty of our study, demonstrating how telemedicine can serve as a strategic tool for resilience in both epidemiological and conflict-related emergencies.
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Open AccessCommentary
Midwifery Leadership in a Changing World—Why Is This So Challenging? A Reflective Commentary
by
Marie Lewis
Healthcare 2025, 13(19), 2473; https://doi.org/10.3390/healthcare13192473 - 29 Sep 2025
Abstract
Background: Midwifery leadership is central to delivering safe, high-quality maternity care. Yet despite sustained investment in leadership development and governance frameworks, UK national reviews consistently identify leadership as a weakness. Understanding why this persists is vital to achieving meaningful improvement. Objective: This paper
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Background: Midwifery leadership is central to delivering safe, high-quality maternity care. Yet despite sustained investment in leadership development and governance frameworks, UK national reviews consistently identify leadership as a weakness. Understanding why this persists is vital to achieving meaningful improvement. Objective: This paper offers a reflective commentary on the challenges of midwifery leadership in the UK, drawing on national evidence, leadership theory, and professional experience. Methods: A reflective commentary approach was adopted, informed by over 30 years of practice across clinical, academic, and national improvement roles. The discussion integrates insights from national maternity inquiries, academic literature, international comparisons, and leadership theories including compassionate, courageous, and adaptive leadership. Findings: Structural and cultural barriers—including workforce shortages, rising clinical complexity, tensions between midwifery- and medically led models of care, and punitive governance systems—limit the effectiveness of midwifery leadership. These conditions erode psychological safety, fuel attrition, and constrain succession planning. Reflection on professional experience highlights the impact of these dynamics on leaders’ ability to act with confidence and influence. Evidence also points to the value of relational, values-based behaviours—compassion, courage, adaptability, and systems thinking—in enhancing resilience and outcomes. International examples show that supportive policy environments and greater autonomy enable midwifery leadership to thrive. Conclusions: Midwifery leadership requires both individual capability and structural support. Practical priorities include dismantling punitive cultures, embedding Safety-II approaches, investing in leadership development, and enabling professional autonomy. Without such systemic reform, the ambitions of the NHS Long Term Plan will remain at risk, regardless of individual leaders’ skills.
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(This article belongs to the Special Issue Midwifery-Led Care and Practice: Promoting Maternal and Child Health)
Open AccessArticle
The COVID-19 Pandemic as a Global Crisis: Aspects of University Students’ Well-Being During the Quarantine in Greece
by
Elisabeth K. Andrie, Evangelia Georgia Kostaki, Evanthia Sakellari, Sophie Leontopoulou and Areti Lagiou
Healthcare 2025, 13(19), 2472; https://doi.org/10.3390/healthcare13192472 - 29 Sep 2025
Abstract
Background: The COVID-19 pandemic and the rapid transition to emergency online learning affected the academic and social lives of young people. This study aimed (a) to examine how university students’ well-being was influenced during the second stage of the lockdown due to the
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Background: The COVID-19 pandemic and the rapid transition to emergency online learning affected the academic and social lives of young people. This study aimed (a) to examine how university students’ well-being was influenced during the second stage of the lockdown due to the COVID-19 pandemic (2020–2021) in Greece and (b) to explore the relationship between university students’ online learning competence and well-being during the pandemic in two universities in Greece. Methods: A cross-sectional study was conducted during 2021 among the students at the Universities of West Attica and Ioannina. Participants completed a self-administered online questionnaire including demographics, the General Health Questionnaire-12, the Flourishing Scale Questionnaire, and an Online Education Experience Questionnaire. Focusing on the Flourishing Scale Questionnaire, factor analysis, reliability, and validity of the identified underlying factor were estimated and multivariable median regression analysis was performed to investigate determinants of well-being. Results: 1103 students participated, 73.6% were female, and 80.4% were aged <25 years. Analysis revealed satisfactory convergent validity and high reliability of the Flourishing Scale Questionnaire (Cronbach’s alpha coefficient = 0.88). Over 50% of the participants reported high levels of well-being. Students with greater confidence in using basic online learning tools and satisfaction with living conditions during lockdown reported well-being (p < 0.001). In contrast, those who reported dissatisfaction with their living conditions (p = 0.002) or whose living arrangements were influenced by financial concerns (p = 0.046) reported unwellness. Conclusions: The results provided useful insight into the complex interrelations between the COVID-19 pandemic quarantine, online education, and young people’s well-being, especially nowadays, when education, employment, and entertainment increasingly rely on internet-delivered modes for young people.
Full article
(This article belongs to the Special Issue Expanding Competency of Primary Health Care: Emotional and Bio-Social Meanings for General Practice Consultation—2nd Edition)

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