International Journal of Environmental Research and Public Health

17 pages, 887 KB

Open AccessArticle

Burnout Among Italian Nurses: Organizational Correlates, Workload Burden, and Workforce Sustainability in a National Cross-Sectional Study

by Angelo Cianciulli, Giovanni Boccia, Marco Ferrara, Antonietta Pacifico, Roberta Manente, Michele Nappa, Domenico Fornino, Anna Di Gisi, Emanuela Nuccio, Fabrizio Liguori and Emanuela Santoro

Int. J. Environ. Res. Public Health 2026, 23(7), 890; https://doi.org/10.3390/ijerph23070890 (registering DOI) - 10 Jul 2026

Abstract

Background: Nurse burnout is a major occupational health problem with implications for workforce retention, quality of care, and patient safety. Contemporary evidence consistently links burnout to increased missed care, adverse events, and reduced safety climate, underscoring the need for updated national data and [...] Read more.

Background: Nurse burnout is a major occupational health problem with implications for workforce retention, quality of care, and patient safety. Contemporary evidence consistently links burnout to increased missed care, adverse events, and reduced safety climate, underscoring the need for updated national data and identification of modifiable organizational factors. Objective: To describe burnout levels among Italian nurses using the Copenhagen Burnout Inventory (CBI) and to examine associations between burnout, job satisfaction, weekly working hours, and key sociodemographic and professional characteristics. Methods: We conducted a national, observational cross-sectional online survey (Google Forms) between April and May 2026. Convenience and snowball sampling were used via professional social media channels and nursing-related institutional pages. Burnout was measured using the Copenhagen Burnout Inventory (CBI; 19 items covering personal, work-related, and patient-related burnout). Responses were converted to standardized 0–100 scores (higher scores = higher burnout); total burnout was computed as the mean of the three subscales. Job satisfaction was assessed on a 1–5 Likert scale. Group comparisons used Mann–Whitney U and Kruskal–Wallis tests; associations used Spearman’s rho; multivariable linear regression was fitted to examine factors independently associated with burnout. Results: The sample included 557 nurses; 84.6% were women, 37.0% were aged <30 years, and participants covered all Italian macro-areas (North 52.4%, Centre 21.5%, South 12.4%, Islands 13.6%). Mean burnout scores (0–100) were: total 50.80 ± 18.87, personal 60.11 ± 19.53, work-related 53.30 ± 22.25, patient-related 38.99 ± 22.77. Using conventional cut-offs (<33 low; 33–66 moderate; >66 high), 19.4% had low, 59.8% moderate, and 20.8% high burnout. Total burnout correlated positively with weekly working hours (ρ = 0.180, p < 0.001) and negatively with job satisfaction (ρ = −0.620, p < 0.001). In multivariable models, higher job satisfaction remained the strongest independent factor associated with lower burnout, while working >40 h/week remained independently associated with higher burnout. Conclusions: Burnout among Italian nurses was prevalent at moderate-to-high levels. Job satisfaction emerged as the main organizational factor associated with burnout, while higher workload was also significantly associated with greater burnout levels. These findings highlight the importance of organizational strategies addressing working conditions to support nurse well-being and patient safety. Full article

(This article belongs to the Special Issue Occupational Burnout and Workplace Well-Being: Prevention, Detection, Assessment and Intervention Strategies)

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38 pages, 2595 KB

Open AccessReview

Community Health Impacts of Pesticide Exposure: Pathways, Vulnerable Populations, and Public Health Responses

by Turki Kh. Faraj

Int. J. Environ. Res. Public Health 2026, 23(7), 889; https://doi.org/10.3390/ijerph23070889 (registering DOI) - 10 Jul 2026

Abstract

Pesticide use remains important in modern agriculture, vector control, and household pest management. However, exposure to pesticide active ingredients and residues remains a persistent public health concern. In addition to active ingredients, people may also be exposed to other constituents of commercial pesticide [...] Read more.

Pesticide use remains important in modern agriculture, vector control, and household pest management. However, exposure to pesticide active ingredients and residues remains a persistent public health concern. In addition to active ingredients, people may also be exposed to other constituents of commercial pesticide formulations, such as adjuvants and solvents, which can influence overall toxicity and health outcomes. These exposures may occur among direct applicators and may also affect other populations through contaminated air, water, soil, food, clothing, and household surfaces. This narrative review examines pesticide exposure from a community health perspective, emphasizing occupational, para-occupational, residential, dietary, drinking-water, airborne, and cumulative exposure pathways. It highlights vulnerable groups, including agricultural workers, children, pregnant women, women in agricultural communities, older adults, people with chronic illness, and marginalized rural populations. Evidence reviewed in this article links pesticide exposure with acute poisoning, respiratory effects, neurobehavioral and neurodevelopmental outcomes, cancer-related risks, reproductive and developmental effects, endocrine and metabolic disruption, cardiovascular outcomes, dermatological reactions, immune dysregulation, and biomarker-based subclinical changes. Beyond disease endpoints, pesticide exposure may also affect household income, education, mental well-being, food security, livelihoods, and intergenerational health. Major challenges include weak exposure assessment, underreporting, limited biomonitoring in low- and middle-income settings, and inconsistent community-level indicators. Strengthening surveillance, risk communication, integrated pest management, safer storage and disposal, protective regulation, and community-centered biomonitoring is essential to reduce pesticide-related health burdens. Full article

(This article belongs to the Topic Environmental Exposure and Health Risks for Vulnerable Populations)

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18 pages, 308 KB

Open AccessArticle

Bridging Formal Health Services and Community Care for Improved Access to Culturally Appropriate End-of-Life Support for Migrant Communities

by Rosemary Leonard, Joy Paton and Peta Hinton

Int. J. Environ. Res. Public Health 2026, 23(7), 888; https://doi.org/10.3390/ijerph23070888 (registering DOI) - 10 Jul 2026

Abstract

The research aimed to understand the different cultural needs relating to death and dying of migrant populations in Western Sydney, Australia, and how end-of-life care can be provided in culturally safe ways which can, in turn, inform the policies that shape palliative care [...] Read more.

The research aimed to understand the different cultural needs relating to death and dying of migrant populations in Western Sydney, Australia, and how end-of-life care can be provided in culturally safe ways which can, in turn, inform the policies that shape palliative care and bereavement service delivery. The mixed methods design for this study used an online quantitative survey using the Death Literacy Index, key informant qualitative interviews, culture-based community focus groups, and individual Photovoice interviews with carers. In all, 266 participants across the three largest migrant communities and local area health services took part in the research. The results revealed the importance of cultural practices and rituals for people at end of life and that providing space for these is crucial to cultural safety in service contexts, in addition to relational trust and the need for community input to improve the services that affect them. There is also a need for greater knowledge and understanding in the end-of-life space through two-way exchanges between communities and service providers. Finally, there are important ways that the existing services can facilitate cultural safety and ways of increasing the availability of culturally appropriate end-of-life and bereavement services for the community. Full article

(This article belongs to the Special Issue Breaking Down Barriers: Ensuring Healthcare Access for Migrant and Refugee Communities)

23 pages, 1095 KB

Open AccessArticle

Effects of Immediate and Delayed Repeated Cold Exposure After Physical Exertion: A Randomized Controlled Trial

by Callum Buehler, Ronja Romitti, Vanessa Wellauer, Ron Clijsen and Erich Hohenauer

Int. J. Environ. Res. Public Health 2026, 23(7), 887; https://doi.org/10.3390/ijerph23070887 - 9 Jul 2026

Abstract

Background: Local cryotherapy is widely used to support recovery after exercise-induced muscle damage, but the optimal timing of cold application remains unclear. This study evaluated whether immediate or delayed local cooling influences recovery from exercise-induced muscle fatigue. Methods: Forty-eight healthy adults (39 women, [...] Read more.

Background: Local cryotherapy is widely used to support recovery after exercise-induced muscle damage, but the optimal timing of cold application remains unclear. This study evaluated whether immediate or delayed local cooling influences recovery from exercise-induced muscle fatigue. Methods: Forty-eight healthy adults (39 women, 9 men; age 22 ± 3 years) performed a single-leg eccentric leg-extension protocol to induce delayed-onset muscle soreness (DOMS) and were randomized to immediate cooling (ICG), delayed cooling (DCG; starting 24 h post-exercise), or control (CG) in a 1:1:1 ratio. Reusable gel packs (20 min per session) were applied to the vastus lateralis. DOMS, maximal voluntary isometric contraction (MVIC), creatine kinase (CK), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and ultrasound-derived muscle thickness (MT) were assessed at baseline and at 24, 48 and 72 h post-exercise and analyzed using linear mixed-effects models. Results: No condition or condition-by-time interactions were detected for the primary outcomes (DOMS, MVIC). Significant linear time effects were observed for DOMS, CK and ESR; MVIC decreased acutely and gradually recovered. A contrast-specific time-by-condition interaction for CRP did not indicate a systematic recovery advantage, and MT showed only minor temporal fluctuations. Conclusion: Neither immediate nor delayed cooling provided a meaningful recovery advantage over the control. The protocol reproducibly elicited fatigue and recovery dynamics, supporting its utility as a framework for future cryotherapy research. Full article

(This article belongs to the Special Issue Physical Therapy Across the Continuum of Care: Integrating Health Promotion, Treatment, and Rehabilitation)

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44 pages, 3101 KB

Open AccessArticle

Equity-Preserving Public Health Resource Allocation Using Multi-Objective Safe Reinforcement Learning: Evidence from Thailand

by Nopparat Songserm, Rapeepan Pitakaso, Thanatkij Srichok, Surajet Khonjun, Natthapong Nanthasamroeng, Sarayut Gonwirat, Paweena Khampukka, Peerawat Luesak, Sasitorn Kaewman and Alongkorn Chaiyasa

Int. J. Environ. Res. Public Health 2026, 23(7), 886; https://doi.org/10.3390/ijerph23070886 - 9 Jul 2026

Abstract

Background: Equitable allocation of public health budgets across multiple intervention domains remains a major challenge in regional health governance. In Thailand’s Health Region 10, annual healthcare budgets must address diverse health burdens across several provinces, while current planning approaches rely on expert deliberation [...] Read more.

Background: Equitable allocation of public health budgets across multiple intervention domains remains a major challenge in regional health governance. In Thailand’s Health Region 10, annual healthcare budgets must address diverse health burdens across several provinces, while current planning approaches rely on expert deliberation and historical precedent without systematic exploration of alternative allocation strategies. Public health resource allocation decisions are inherently multi-criteria, integrating health impact, cost-effectiveness, equity, disease severity, clinical and ethical priorities, feasibility, and alignment with national health policy agendas—dimensions that cannot be reduced to a single metric. This study introduces H-RL-MUSYA (Hierarchical Reinforcement Learning for Multi-Domain Unified System of Yielding Adaptive allocations), a decision-support framework designed to assist—not replace—public health practitioners by systematically generating and evaluating a menu of Pareto-efficient allocation strategies across four priority domains: nutrition, mental health, behavioral risk, and accident prevention. The framework explicitly acknowledges that DALYs averted and cost-effectiveness ratios are valuable but partial indicators, and that final resource allocation must integrate additional considerations—including underpinning health policies, priority population needs, feasibility, and contextual judgment—that lie beyond the model’s scope. Results: Applied to Thailand’s Health Region 10 (4.6 million inhabitants), H-RL-MUSYA identified 127 Pareto-efficient policies yielding a representative compromise allocation that averted 847,293 DALYs (34.1% improvement over historical allocations), improved cost-effectiveness by 31.3%, and reduced the health equity Gini coefficient from 0.243 to 0.187. A 12-month prospective pilot confirmed +23.1% composite health improvement with 91% stakeholder acceptance. Conclusions: H-RL-MUSYA demonstrates that AI-assisted policy exploration can meaningfully enrich public health decision-making by surfacing non-intuitive allocation strategies and quantifying equity–efficiency trade-offs, while human expertise, policy context, and democratic deliberation remain essential for final allocation decisions. Full article

13 pages, 469 KB

Open AccessArticle

Joint Associations of Maternal Smoking and Pre-Pregnancy BMI with Term Low Birthweight and Small-for-Gestational-Age Births: A Cross-Sectional Analysis of 2024 United States Birth Data

by Anthony J. Kondracki, Wei Li and Ying Sun

Int. J. Environ. Res. Public Health 2026, 23(7), 885; https://doi.org/10.3390/ijerph23070885 - 9 Jul 2026

Abstract

Low birthweight (LBW; <2500 g) remains a persistent public health concern in the United States, with important implications for infant survival and long-term health. Maternal smoking and pre-pregnancy body mass index (BMI) are key determinants of fetal growth, yet their joint effects in [...] Read more.

Low birthweight (LBW; <2500 g) remains a persistent public health concern in the United States, with important implications for infant survival and long-term health. Maternal smoking and pre-pregnancy body mass index (BMI) are key determinants of fetal growth, yet their joint effects in term infants are not well characterized. Our analysis of the 2024 U.S. National Center for Health Statistics (NCHS) birth data restricted to 2,973,679 singleton term births (37–41 weeks) reveals that 2.8% of infants were born LBW and 8.1% small-for-gestational-age (SGA). Smoking during pregnancy (2.2%) was associated with higher odds of LBW (aOR 2.19; 95% CI: 1.92, 2.51), SGA (aOR 1.90; 95% CI: 1.85, 1.96), and combined SGA/LBW (aOR 2.75; 95% CI: 2.66, 2.84) than nonsmoking. Underweight BMI was associated with higher odds of SGA/LBW (aOR 1.95; 95% CI: 1.89, 2.01) and overweight/obesity with lower odds of SGA (aOR 0.69; 95% CI: 0.68, 0.70) than normal BMI. Joint associations of BMI and smoking on term SGA/LBW were strongest (aOR 5.14; 95% CI: 4.62, 5.73) among underweight smokers. The additive scale interaction was positive for underweight smokers and negative for overweight/obese smokers. Targeted interventions addressing smoking cessation and optimal maternal weight may reduce risks. Full article

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21 pages, 329 KB

Open AccessArticle

Adolescent Solastalgia and Climate Distress in Colombia: Psychosocial Correlates Across Urban, Semiurban, and Rural Contexts

by Marcela Guapacha-Montoya and Felipe Agudelo-Hernández

Int. J. Environ. Res. Public Health 2026, 23(7), 884; https://doi.org/10.3390/ijerph23070884 - 9 Jul 2026

Abstract

Background: Environmental degradation and climate-related territorial transformation are increasingly recognized as social determinants of adolescent mental health. However, empirical evidence on solastalgia among young people in the Global South remains limited. This study aimed to examine psychosocial, health-related, school-related, family, and territorial [...] Read more.

Background: Environmental degradation and climate-related territorial transformation are increasingly recognized as social determinants of adolescent mental health. However, empirical evidence on solastalgia among young people in the Global South remains limited. This study aimed to examine psychosocial, health-related, school-related, family, and territorial factors associated with solastalgia among school-attending adolescents in Colombia. Methods: A quantitative, cross-sectional analytical study was conducted between August 2025 and February 2026 with 1005 adolescents from three Colombian territories undergoing different forms of environmental transformation: an urban setting affected by construction-related change, a semiurban setting affected by agricultural transformation, and a rural setting affected by extractivism. Solastalgia was assessed using the Brief Solastalgia Scale. Psychosocial, health-related, school-related, and contextual variables were measured using validated or locally supported instruments. Bivariate analyses, multiple linear regression, and non-parametric territorial comparisons were conducted. Results: Solastalgia differed significantly across territorial groups, with the semiurban group showing the highest mean ranks for solastalgia, followed by the rural and urban groups. However, territorial comparisons showed heterogeneous psychosocial and health-related patterns rather than a uniform gradient across all outcomes. Older age was independently associated with higher solastalgia scores. In the final regression model, solastalgia was independently associated with resilience, substance use screening, suicide risk, age, physical health status, conflict resolution, concern about climate change, and territorial origin. The model explained 42.9% of the variance in solastalgia scores. Territorial origin contributed a small but statistically significant additional proportion of explained variance. Conclusions: Adolescent solastalgia in Colombia is not reducible to individual psychological vulnerability. It reflects a broader socioecological configuration involving emotional distress, perceived health, psychosocial resources, school-related experiences, concern about climate change, and place-based environmental transformation. These findings support the need for school-based and community-based public health responses that integrate adolescent mental health care with environmental protection, cultural safety, and territorial justice. Full article

(This article belongs to the Special Issue Eco-Wellbeing and Social-Affective Dynamics: Integrating Environmental and Emotional Dimensions of Public Mental Health)

19 pages, 481 KB

Open AccessArticle

Indigenization, Personalization, and Intersections: A Qualitative Study to Identify Essential Components for Developing an Indigenous-Centered Dementia Care Model in Alberta

by Jaiden Kuchinka, Richard T. Oster, Zahra Goodarzi, Zack Marshall, Lynn Jackson, Jayna Holroyd-Leduc, Vivian Ewa, Lisa Bourque Bearskin, Dallas Seitz, Jennifer D. Walker and Pamela Roach

Int. J. Environ. Res. Public Health 2026, 23(7), 883; https://doi.org/10.3390/ijerph23070883 - 8 Jul 2026

Abstract

Current models of dementia care often perpetuate the legacies of colonization, which highlights the need for a culturally congruent approach. This research describes the necessary components to co-develop a freely available Indigenous-centered dementia model of care in partnership with Indigenous individuals living with [...] Read more.

Current models of dementia care often perpetuate the legacies of colonization, which highlights the need for a culturally congruent approach. This research describes the necessary components to co-develop a freely available Indigenous-centered dementia model of care in partnership with Indigenous individuals living with dementia, their families, and communities. To prioritize ethical and decolonial research approaches, sequential focus groups were used alongside Keeoukaywin (The Visiting Way)—an Indigenous methodology deeply rooted in Métis and Cree ways of knowing—guided by a group of advisors and Elders. The data were co-analyzed using reflexive thematic analysis guided by Indigenous principles. Three themes were generated: Indigenization, Personalization, and the Intersection of Challenges and Innovations, to illustrate how dementia care can be operationalized and adapted to various cultural and care contexts. This research offers a foundation for developing dementia care that truly aligns with Indigenous ways of doing. Full article

(This article belongs to the Special Issue Dementia Prevention and Care in Indigenous Communities: Opportunities to Advance Cognitive Health Equity)

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10 pages, 256 KB

Open AccessArticle

The Association Between Intimate Partner Violence and Prior-to-Pregnancy Fear of Childbirth Among Nulligravid Women: Implications for Preconception and Obstetric Care

by Meserret Aslan and Sümeyye Öztürk

Int. J. Environ. Res. Public Health 2026, 23(7), 882; https://doi.org/10.3390/ijerph23070882 - 8 Jul 2026

Abstract

Background/Objectives: Fear of childbirth may begin before pregnancy and may be shaped by earlier traumatic and relational experiences. This study examined the association between intimate partner violence (IPV) and prior-to-pregnancy fear of childbirth among non-pregnant women and considered its implications for preconception and [...] Read more.

Background/Objectives: Fear of childbirth may begin before pregnancy and may be shaped by earlier traumatic and relational experiences. This study examined the association between intimate partner violence (IPV) and prior-to-pregnancy fear of childbirth among non-pregnant women and considered its implications for preconception and obstetric care. Methods: This descriptive, correlational, cross-sectional study was conducted online in Türkiye between 1 January and 31 May 2025 after approval from the Non-Interventional Scientific Research Ethics Committee of Istanbul Atlas University (23 December 2024; No. 10/07). The sample comprised 125 nulligravid women, defined as women who had never previously been pregnant, who were aged 18 years or older, were not currently pregnant, were living with an intimate partner, were literate in Turkish, and reported no psychiatric disorder. Data were collected using a Personal Information Form, the Husband Violence Against Women Scale (HVWAS), and the Fear of Childbirth Prior to Pregnancy Scale (FCPPS). Descriptive statistics, Spearman correlation analysis, Mann–Whitney U tests, and Kruskal–Wallis tests were performed. Results: The mean age of participants was 28.84 ± 5.47 years. The mean HVWAS score was 46.11 ± 12.51, and the mean FCPPS score was 36.05 ± 13.56. HVWAS scores were weakly positively correlated with prior-to-pregnancy fear of childbirth (rho = 0.207, p = 0.020). An exploratory association was observed between educational level and HVWAS scores (p = 0.019); however, the educational subgroups were highly unequal in size. No significant association was found between educational level and FCPPS scores (p = 0.219). Conclusions: Higher HVWAS scores were weakly associated with greater prior-to-pregnancy fear of childbirth. Because of the cross-sectional design, the direction and causality of this association cannot be determined. Confidential assessment of IPV and childbirth-related fear during preconception counseling and women’s health encounters may assist in identifying women who could benefit from further psychosocial evaluation and support. Full article

(This article belongs to the Special Issue Trauma-Informed Healthcare for Women)

21 pages, 4315 KB

Open AccessArticle

Weather-Enhanced Machine Learning for Time-Resolved Risk Stratification of Clinically Managed Hymenoptera-Related Sting Events in an Urban German Region

by Mohamad Amer Nashtar, Theodor Baars, Nicoleta-Alexandra Stille, Isabella Traut, Ali Canbay, Klaus Zeppenfeld, Mustafa K. Özçürümez and Antonios Katsounas

Int. J. Environ. Res. Public Health 2026, 23(7), 881; https://doi.org/10.3390/ijerph23070881 - 8 Jul 2026

Abstract

Background: Insect stings, particularly those caused by Hymenoptera such as wasps and bees, are frequent triggers of severe allergic reactions and anaphylaxis, yet the ability to predict short-term risk periods based on environmental conditions has not been systematically evaluated. Meteorological factors influence both [...] Read more.

Background: Insect stings, particularly those caused by Hymenoptera such as wasps and bees, are frequent triggers of severe allergic reactions and anaphylaxis, yet the ability to predict short-term risk periods based on environmental conditions has not been systematically evaluated. Meteorological factors influence both insect activity and human exposure, highlighting a relevant gap in preventive risk assessment. Methods: This exploratory single-center study was conducted in Bochum, Germany, an urban region within the Rhine-Ruhr metropolitan area. A 17-year retrospective dataset (2005–2022) of clinically treated Hymenoptera-related sting events was analyzed to explore time-resolved, weather-informed patterns using artificial intelligence (AI)-based machine learning. The study emphasizes methodological feasibility and pattern identification rather than clinical prediction. Daily weather parameters were transformed into expert-informed indicators capturing current-season and carry-over environmental conditions. A multilayer perceptron (MLP) was trained to identify periods of increased sting occurrence, and model performance was evaluated primarily using recall to capture rare-event signals. Results: A total of 346 clinically significant sting events were recorded. Weather variables showed strong spatial coherence across four stations and were associated with intra-seasonal clustering of sting events rather than absolute annual incidence. Exploratory analyses suggested that earlier seasonal onset correlated with higher sting counts (Pearson R = −0.52; p = 0.037). Weekly aggregation improved model performance compared with daily prediction. The cross-validated MLP showed moderate recall (0.431) and high specificity (0.86), supporting exploratory risk stratification; however, post hoc benchmarking did not demonstrate consistent superiority over simpler baseline approaches. Conclusions: This study combines a long-term clinical insect sting dataset with high-resolution meteorological data to explore time-resolved, weather-informed risk patterns using machine learning. The findings demonstrate the technical feasibility of exposure-based risk stratification in a rare-event setting. However, benchmarking showed that the MLP did not consistently outperform simpler baseline approaches for binary warning of elevated-risk periods. This proof-of-concept should therefore be interpreted as exploratory and not as a stand-alone warning system, supporting further external validation in larger, multi-center cohorts before clinical, public health, or digital health implementation can be considered. Full article

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11 pages, 1063 KB

Open AccessProject Report

Eye Safety of Light-Emitting Diodes in Toys: The Results of Three Years of Market Surveillance

by Dina Attia, Olivier Enouf, Francine Behar-Cohen and Christophe Martinsons

Int. J. Environ. Res. Public Health 2026, 23(7), 880; https://doi.org/10.3390/ijerph23070880 - 6 Jul 2026

Abstract

Between 2021 and 2023, the French market surveillance authority anonymously bought a sample of 50 toys containing a total of 103 individual LEDs from French retailers and had them tested by third-party laboratories accredited to perform tests in compliance with the international standard [...] Read more.

Between 2021 and 2023, the French market surveillance authority anonymously bought a sample of 50 toys containing a total of 103 individual LEDs from French retailers and had them tested by third-party laboratories accredited to perform tests in compliance with the international standard for electric toy safety IEC 62115, editions 2003 and 2017. Compliance with the harmonized EN IEC version of this standard is mandatory in the European Union under directive 2009/48/EC. The results revealed that 15 toys (30% of the tested toys) had at least one LED that did not comply with the eye safety requirements: 10 LEDs were non-compliant with respect to the retinal blue-light hazard, and 5 LEDs were non-compliant with respect to the retinal thermal hazard. A subsample of 10 toys with a total of 19 LEDs was assessed using the respective test methods corresponding to the 2003 and 2017 editions of the standard. The 2017 test method was found to be more permissive than the 2003 test method, a conclusion explained by the use of different risk assessment distances. Full article

(This article belongs to the Section Environmental Health)

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22 pages, 628 KB

Open AccessReview

Plain Packaging: One of the Plain Simple Solutions for Nicotine Reduction in the Middle East

by Mohammed Al-Hamdani, Steven M. Smith, Rana Abouzoor and Courtney McKay

Int. J. Environ. Res. Public Health 2026, 23(7), 879; https://doi.org/10.3390/ijerph23070879 - 6 Jul 2026

Abstract

Tobacco use remains a major public health challenge and continues to be highly prevalent across the Middle East despite the implementation of conventional tobacco-control policies, including taxation, smoking restrictions, advertising bans, and graphic warning labels. Although these measures have contributed to reductions in [...] Read more.

Tobacco use remains a major public health challenge and continues to be highly prevalent across the Middle East despite the implementation of conventional tobacco-control policies, including taxation, smoking restrictions, advertising bans, and graphic warning labels. Although these measures have contributed to reductions in tobacco use, additional strategies are needed to further reduce prevalence rates. This manuscript presents a narrative review examining plain packaging as a tobacco-control policy option for Middle Eastern countries. Plain packaging standardizes tobacco product packaging through the use of uniform fonts and colors on a plain background and is recommended by the World Health Organization Framework Convention on Tobacco Control. This narrative review synthesizes existing literature and regional policy developments to outline six key reasons supporting the adoption of plain packaging in the Middle East: evidence on effectiveness, underutilization, cost-free implementation, its role as a starting point toward tobacco endgame strategies, public support, and challenges posed by emerging nicotine products. Overall, plain packaging represents a viable and underutilized policy option that could strengthen existing tobacco-control efforts and support long-term reductions in tobacco use across the Middle East. Full article

25 pages, 946 KB

Open AccessArticle

Physical Activity and Healthy Aging: Functional, Cognitive, and Sleep Predictors Associated with Fall Risk in Older Adults

by Marilia Salete Tavares, Sara Lucia Silveira de Menezes, Walace Monteiro, Camila Tavares Rodrigues, Daniel Joppert, Thiago Rodrigues Gonçalves, Joana da Costa Pinto D’Avila, Paulo Henrique de Moura, Jorge Ferreira da Silva Junior and Adalgiza Mafra Moreno

Int. J. Environ. Res. Public Health 2026, 23(7), 878; https://doi.org/10.3390/ijerph23070878 - 6 Jul 2026

Abstract

Falls among older adults are a major public health concern due to their association with functional decline and increased healthcare utilization. This study investigated factors associated with fall occurrence by comparing older adults enrolled in a community-based physical activity program with sedentary older [...] Read more.

Falls among older adults are a major public health concern due to their association with functional decline and increased healthcare utilization. This study investigated factors associated with fall occurrence by comparing older adults enrolled in a community-based physical activity program with sedentary older adults. This observational cross-sectional study included 67 older adults: 35 participants enrolled in the Niterói 60 Up program (G60UP; 68 ± 4 years) and 32 sedentary older adults in a sedentary comparison group (SCG; 70 ± 7 years). Assessments included anthropometric measurements, medication use, Timed Up and Go (TUG), Tinetti Performance-Oriented Mobility Assessment, Mini-Mental State Examination (MMSE), Pittsburgh Sleep Quality Index (PSQI), and orthostatic testing. Compared with the SCG, G60UP participants reported fewer falls during the previous year (0.26 ± 0.51 vs. 0.78 ± 0.83; p = 0.005), higher Tinetti scores (24.51 ± 2.54 vs. 18.28 ± 5.94; p < 0.001), shorter TUG times (8.66 ± 1.63 vs. 13.00 ± 4.31; p < 0.001), higher MMSE scores, better sleep quality (lower PSQI scores), and lower blood pressure and abdominal adiposity indicators. In the total sample, fall occurrence was associated with lower Tinetti scores (ρ = −0.416; p < 0.001), longer TUG times (ρ = 0.321; p = 0.008), older age (ρ = 0.328; p = 0.007), higher Conicity Index (ρ = 0.281; p = 0.021), and poorer sleep quality (ρ = 0.243; p = 0.047). No variable remained independently associated with falls in the exploratory multivariable logistic regression model. Participants enrolled in the 60 Up program presented more favorable functional, cognitive, sleep-related, and health-related profiles than those in the SCG. Due to the cross-sectional design, these findings should be interpreted as associations rather than causal relationships. Full article

(This article belongs to the Special Issue Sleep Disorders and Cognitive Impairment)

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21 pages, 323 KB

Open AccessArticle

Recognising Gender Discrimination: The Recognition–Normalisation Paradox in Italy and Lithuania

by Giulia Lausi

Int. J. Environ. Res. Public Health 2026, 23(7), 877; https://doi.org/10.3390/ijerph23070877 - 5 Jul 2026

Abstract

Gender discrimination is a widespread phenomenon in contemporary societies; however, people often acknowledge its existence without challenging it. This study introduces the concept of the ‘recognition–normalisation paradox’, defined as the simultaneous recognition of gender discrimination and its mitigation through interpretative frameworks that render [...] Read more.

Gender discrimination is a widespread phenomenon in contemporary societies; however, people often acknowledge its existence without challenging it. This study introduces the concept of the ‘recognition–normalisation paradox’, defined as the simultaneous recognition of gender discrimination and its mitigation through interpretative frameworks that render it socially acceptable, and proposes a theoretical framework based on predictive elaboration and social cognition to explain its cognitive underpinnings. Semi-structured interviews were conducted with 25 participants (14 in Italy, 11 in Lithuania) of both genders, analysed using an integrated qualitative–quantitative approach with ATLAS.ti (v. 26.0.1). The findings reveal that recognition and normalisation systematically coexist within the same narrative sequences. The cross-national analysis indicates that, whilst the paradox is structurally invariant in both contexts, its specific configuration differs: in Italy, normalisation operates predominantly through routinised relational and familial expectations, whereas in Lithuania it is achieved through discursive relativisation and contextual distancing. These findings challenge the view that normalisation reflects an absence of recognition, reframing it as a phenomenon that can be interpreted as a form of inferential processing. The implications for interventions promoting gender equality are discussed. Full article

(This article belongs to the Special Issue Gender, Violence Exposure and Mental Health Through Intersectional Lenses)

36 pages, 695 KB

Open AccessArticle

Recognition and Resistance in Early Psychotherapeutic Encounters: Therapist Response Style, Narcissistic Admiration and Rivalry, and Public Mental Health Engagement

by Avi Besser and Virgil Zeigler-Hill

Int. J. Environ. Res. Public Health 2026, 23(7), 876; https://doi.org/10.3390/ijerph23070876 - 5 Jul 2026

Abstract

Early engagement with psychotherapy is a public mental health issue because potential patients’ first appraisals of psychological care may shape treatment expectations, willingness to continue, and openness to receiving effective support. In first-contact therapeutic encounters, people respond not only to the content of [...] Read more.

Early engagement with psychotherapy is a public mental health issue because potential patients’ first appraisals of psychological care may shape treatment expectations, willingness to continue, and openness to receiving effective support. In first-contact therapeutic encounters, people respond not only to the content of a therapist’s intervention but also to the interpersonal meaning conveyed by the therapist’s response style. Guided by a recognition–resistance framework and models of narcissistic self-regulation, we examined how therapist response style and trait narcissistic admiration and rivalry shape early appraisals of psychological care in a vignette-based psychotherapeutic encounter. In a between-subjects vignette experiment, Hebrew-speaking adults in Israel (N = 972) were randomly assigned to read a validation-based, recognition-supportive, autonomy-supportive therapist response or a more directive and challenging response to the same clinical scenario. Participants then reported perceived recognition, autonomy-related resistance, anticipated alliance, therapist credibility, expected benefit, and willingness to continue. The validation-based response elicited higher perceived recognition, lower autonomy-related resistance, and greater willingness to continue. Perceived recognition and autonomy-related resistance mediated the effects of response style on all therapy-related outcomes. Narcissistic admiration predicted more favorable appraisals, and narcissistic rivalry predicted lower recognition and greater resistance, but neither moderated style effects nor indirect pathways. Recognition and autonomy-related resistance emerged as proximal appraisal pathways linking therapist response style to anticipated engagement with psychological care in this analogue vignette context. However, the predicted moderation and moderated-mediation effects involving narcissistic admiration and rivalry were not supported. This pattern suggests that, in the present design, admiration and rivalry functioned more as general appraisal orientations than as differential-susceptibility moderators of therapist response style. The moderated-mediation component of the recognition–resistance framework should therefore be regarded as unsupported pending independent replication and more ecologically valid tests. These findings position first-contact therapist communication as a candidate modifiable feature of public mental health engagement, with implications for future research on treatment uptake, early retention, trust in services, and access to effective psychological care. Full article

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

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12 pages, 378 KB

Open AccessArticle

Relationship Between Odds of Reporting a Fall in the Past Year and Health Literacy Among Community-Dwelling Older Adults in Japan: A Preliminary Cross-Sectional Study

by Akihiko Murayama, Ken Hirukawa and Tomoyuki Shinohara

Int. J. Environ. Res. Public Health 2026, 23(7), 875; https://doi.org/10.3390/ijerph23070875 - 5 Jul 2026

Abstract

Background/Objectives: Research on falls among community-dwelling older adults has revealed limited knowledge regarding health literacy. This study aimed to evaluate health literacy in community-dwelling older adults in Japan and to clarify its relationship with the odds of reporting a fall in the past [...] Read more.

Background/Objectives: Research on falls among community-dwelling older adults has revealed limited knowledge regarding health literacy. This study aimed to evaluate health literacy in community-dwelling older adults in Japan and to clarify its relationship with the odds of reporting a fall in the past year. Methods: A preliminary cross-sectional study was conducted from January 2024 to May 2025, involving 218 community-dwelling older adults. The study collected data on age, sex, presence of multiple diseases, use of the long-term care insurance system, the Brief-Balance Evaluation Systems Test (Brief-BESTest), the Rapid Dementia Screening Test (RDST), the Communicative and Critical Health Literacy (CCHL) scale, and fall reports in the past year. Results: After excluding four participants, 214 participants (age, 76.9 ± 6.4 years; 61 men and 153 women) were included in the analysis. Of these, 43 (20.1%) participants had reported a fall. A binary logistic regression analysis was performed, adjusting for confounding factors (age, RDST score, and Brief-BESTest score). The reporting of a fall in the past year (falls/non-falls) was used as the dependent variable, and the CCHL score as the independent variable. The results showed that the CCHL score was associated with the reporting of a fall (odds ratio, 0.61; 95% confidence interval, 0.40–0.93). Conclusions: These findings suggest that higher CCHL scores, reflecting better communicative and critical health literacy, are associated with lower odds of reporting a fall. However, because of the cross-sectional design of this study, no causal relationship can be inferred. Future longitudinal studies with larger sample sizes are needed to clarify the temporal relationship between health literacy and falls, examine whether this association is causal, and investigate whether the relationship is linear or whether clinically meaningful threshold effects exist. Full article

(This article belongs to the Special Issue Achieving Effective Fall Prevention and Intervention for Older Adults)

21 pages, 1867 KB

Open AccessArticle

Long-Term Trends and Prognosis in Cardiovascular Mortality in the Kazakhstani Population Living Around the Semipalatinsk Nuclear Test Site

by Dariya Shabdarbayeva, Lyudmila Pivina, Nailya Chaizhunussova, Andrey Orekhov, Galiya Alibayeva, Meruyert Massabayeva, Assel Baibussinova, Gulnara Batenova, Zhanargul Smailova, Saulesh Apbassova, Saule Kozhanova, Madina Abenova, Alexandra Lipikhina, Asset Izdenov, Diana Ygiyeva, Raushan Dosmagambetova and Altay Dyussupov

Int. J. Environ. Res. Public Health 2026, 23(7), 874; https://doi.org/10.3390/ijerph23070874 - 5 Jul 2026

Abstract

Background: The purpose of the study is the assessment of mortality from cardiovascular diseases (CVDs) and their dose–response relationships and the calculation of the number of years of life lost (YLL) in Kazakhstani residents living in territories around the Semipalatinsk nuclear test site. [...] Read more.

Background: The purpose of the study is the assessment of mortality from cardiovascular diseases (CVDs) and their dose–response relationships and the calculation of the number of years of life lost (YLL) in Kazakhstani residents living in territories around the Semipalatinsk nuclear test site. Materials and Methods: The study is based on the State Scientific Automated Medical Registry (SSAMR) database. The study included 3482 residents of the Abay and Beskaragai districts exposed to radiation and 1886 residents of the Kokpekty district (control group). The median equivalent radiation dose for the exposed group was 864.0 mSv, compared to 64.4 mSv in the control group. The study period was from 1949 to 2024. Results: Mortality rates in the exposed group exceeded those of the comparison group throughout the study. The relative risk (RR) of mortality was 1.41 for all CVDs, 2.0 for stroke, 7.88 for chronic cerebrovascular disease (CCVD), and 2.39 for congenital heart disease (CHD). Age-standardized mortality rates were higher in the radiation-exposed population, with the highest excess risk recorded in 1960–1964 (RR = 5.31; 95% CI 4.32–6.53). The number of YLL from acute myocardial infarction (AMI) was 6097.0 in the exposed group versus 5893.0 in the comparison group, 3857.5 from hemorrhagic stroke versus 1996.9, and 2696.6 from CHD versus 957.7. An increase in radiation dose by 1 cSv was associated with an 8.5% increase in the odds of death from CVDs (OR = 1.085; 95% CI 1.075–1.094; p < 0.001). Radiation dose demonstrated good predictive ability for mortality from cardiovascular diseases (AUC = 0.700). Conclusions: The results indicate an increased risk of CVD mortality among residents of radiation-contaminated areas of Kazakhstan throughout the study period. Full article

(This article belongs to the Section Environmental Health)

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30 pages, 827 KB

Open AccessSystematic Review

“I Was Embarrassed to Go and See a Counsellor”: Stigma Experienced by Individuals Diagnosed with Mental Illness (A Systematic Review and Meta-Synthesis)

by Oladapo Akinlotan, Dinithi Vidanage and Allen O’connor

Int. J. Environ. Res. Public Health 2026, 23(7), 873; https://doi.org/10.3390/ijerph23070873 - 4 Jul 2026

Abstract

Background: Stigma is a persistent barrier to psychosocial wellbeing and recovery of individuals with mental illnesses. Aim: This study aims to examine stigma experienced by individuals diagnosed with mental illnesses. Method: A systematic review and meta-synthesis of peer-reviewed qualitative primary [...] Read more.

Background: Stigma is a persistent barrier to psychosocial wellbeing and recovery of individuals with mental illnesses. Aim: This study aims to examine stigma experienced by individuals diagnosed with mental illnesses. Method: A systematic review and meta-synthesis of peer-reviewed qualitative primary studies followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Five databases: CINAHL Ultimate, APA PsycArticles, APA PsycINFO, MEDLINE Ultimate, and Embase were searched for studies published between 2021 and 2025. A total of 17 studies were included after rigorous screening. Results: Thematic analysis identified three major themes and fifteen sub-themes. These are manifestations of stigma (prevalence of stigma, operation of stigma, stigma related to mental health diagnosis, stigma related to motherhood and impacts of stigma), multiple factors shaping stigma (ignorance and misunderstanding, spiritual and religious beliefs, family and friends, cultural beliefs) and management of stigma (management strategies, internalising stigma, isolation due to stigma, disclosure of mental illness, non-disclosure of mental illness and help-seeking for mental illness). Conclusions: Stigma related to mental illness remains widespread and continues to influence individuals’ experiences, relationships, and help-seeking behaviours. Addressing stigma through improved mental health awareness and supportive environments is essential to promote recovery and wellbeing. Full article

(This article belongs to the Special Issue Reducing Stigma and Discrimination in Global Mental Health)

18 pages, 554 KB

Open AccessArticle

Perspectives Among Veterans with Chronic Pain and Co-Occurring Mild Traumatic Brain Injury: Mixed-Method Findings from a Neuromodulation and Yoga Intervention

by Amy M. Kemp, Kelly Krese, Bella Etingen, Bridget A. Cotner, Sadie Walker, Ibuola Kale, Miriam R. Rafferty, Sandra Kletzel, Rachana P. Shah, Sabrina Bedo, Sarmistha Chaudhuri, Alexandra L. Aaronson, Kyla Z. Donnelly, Sonia Bobra, Andrea Billups, Pei-Shan Yen, Dulal Bhaumik, Theresa L. Bender Pape and Amy A. Herrold

Int. J. Environ. Res. Public Health 2026, 23(7), 872; https://doi.org/10.3390/ijerph23070872 - 3 Jul 2026

Abstract

Chronic pain is the leading cause of disability worldwide and frequently co-occurs with mild traumatic brain injury among Veterans (mTBI + CP), creating complex treatment challenges and a need for novel, non-pharmacological interventions. This study evaluated a pilot intervention combining intermittent theta burst [...] Read more.

Chronic pain is the leading cause of disability worldwide and frequently co-occurs with mild traumatic brain injury among Veterans (mTBI + CP), creating complex treatment challenges and a need for novel, non-pharmacological interventions. This study evaluated a pilot intervention combining intermittent theta burst stimulation (iTBS), a neuromodulatory approach, with the evidence-based LoveYourBrain Yoga program to enhance rehabilitation outcomes. In a six-week open-label trial, ten Veterans with mTBI + CP received weekly iTBS followed by yoga sessions. Pilot quantitative outcomes included quality of life (Traumatic Brain Injury Quality of Life [TBI-QoL]) and functional ability (Mayo Portland Adaptability Inventory-4 [MPAI-4]), assessed pre- and post-intervention, alongside qualitative semi-structured interviews and interdisciplinary clinical notes. Significant improvements were observed in TBI-QoL Fatigue (p = 0.021) and MPAI-4 Grief and Loss (p = 0.016), with clinically meaningful but non-significant gains in Ability and Adjustment. Qualitative findings revealed improved pain management and enhanced self-management, with participants describing better emotional regulation, more effective coping strategies, and stronger social connections. Some benefits were more evident in qualitative data than in standardized measures. These pilot findings suggest that combining iTBS with mind–body therapy may provide complementary tools for pain management and functional recovery in Veterans with mTBI + CP, supporting further investigation of integrated neuromodulation and behavioral interventions. Full article

(This article belongs to the Special Issue Invisible Wounds: Addressing Veterans' Mental Health Challenges by Centering Their Experiences and Perspectives)

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