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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. The European Medical Association (EMA), Ocular Wellness & Nutrition Society (OWNS) and Italian Society of Nephrology Nurses (SIAN) 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 22.4 days after submission; acceptance to publication is undertaken in 2.9 days (median values for papers published in this journal in the second 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)

Imprint Information Journal Flyer Open Access ISSN: 2227-9032

Latest Articles

18 pages, 309 KB

Open AccessArticle

Individual-Level Cyber-Risk Indicators and Patterns of Cyberbullying Involvement Among Korean Adolescents

by Yoewon Yoon and Kyoung Yeon Moon

Healthcare 2026, 14(3), 376; https://doi.org/10.3390/healthcare14030376 (registering DOI) - 2 Feb 2026

Background/Objectives: Although cyberbullying among adolescents has been widely studied, relatively little attention has been paid to the overlapping roles through which cyberbullying is experienced. This study reconceptualizes cyberbullying involvement by classifying perpetration, victimization, and witnessing into eight mutually exclusive involvement types, enabling [...] Read more.

Background/Objectives: Although cyberbullying among adolescents has been widely studied, relatively little attention has been paid to the overlapping roles through which cyberbullying is experienced. This study reconceptualizes cyberbullying involvement by classifying perpetration, victimization, and witnessing into eight mutually exclusive involvement types, enabling systematic and non-overlapping comparison of adolescents’ experiences. The study further examines how engagement in individual-level cyber-risk indicators is associated with different patterns of cyberbullying involvement. Methods: The study analyzed nationally representative data from the 2022 Cyberbullying Survey conducted by the Korea National Information Society Agency, including 9693 students from elementary, middle, and high schools across South Korea. Individual-level cyber-risk indicators were assessed through multiple dimensions, including risky online behaviors, intensity of digital activity, peer environments, and awareness of harmful online behaviors. Multinomial logistic regression analyses were conducted to examine associations between individual-level cyber-risk indicators and the eight types of cyberbullying involvement. Results: Engagement in individual-level cyber-risk indicators was associated with increased odds of involvement in at least one cyberbullying type. Risky online behaviors and exposure to peers engaging in cyberbullying were linked to higher likelihood of both single and overlapping involvement patterns, whereas greater acceptance of harmful online behaviors was consistently associated with lower odds of victimization. Conclusions: These findings underscore cyberbullying as a relational and context-dependent phenomenon shaped by everyday digital practices and peer norms rather than isolated individual behavior. From a school social work perspective, the results support preventive, environment-focused interventions, including school-based media literacy education and institutionalized cyberbullying response systems, as promising strategies for reducing cyberbullying involvement among adolescents. Full article

(This article belongs to the Special Issue Research and Survey on the Mental Health of Children and Adolescents: Second Edition)

31 pages, 513 KB

Open AccessSystematic Review

The Psychological Impact of In Vitro Fertilization (IVF): A Gender Systematic Review

by Maria Grammenou, Vasiliki Michou, Aikaterini Itziou, Arsenios Tsiotsias and Panagiotis Eskitzis

Healthcare 2026, 14(3), 375; https://doi.org/10.3390/healthcare14030375 (registering DOI) - 2 Feb 2026

Objective: In Vitro Fertilization (IVF) has revolutionized reproductive medicine, offering hope to individuals and couples facing infertility. However, the psychological impact of IVF varies significantly based on gender, necessitating a systematic review of the existing literature. This review explores the emotional effects of [...] Read more.

Objective: In Vitro Fertilization (IVF) has revolutionized reproductive medicine, offering hope to individuals and couples facing infertility. However, the psychological impact of IVF varies significantly based on gender, necessitating a systematic review of the existing literature. This review explores the emotional effects of IVF on both men and women, highlighting gender-specific psychological responses throughout the treatment process. Methods: A systematic literature search using various databases (such as PubMed) was made. Studies published in English from the years 2000 to 2023 were included in the review. Results: A total of 47 studies examined the psychological impact of IVF on both women and men, covering the IVF programming period, the initial stages of IVF treatment, and subsequent stages, as well as the long-term psychological distress effects of IVF in both genders. Both female and male infertile patients are dealing with anxiety, depression and low quality of life. However, women were found to experience higher levels of psychological distress, including increased anxiety and depression symptoms, compared to men at nearly all stages of IVF treatment. Conclusions: Understanding these gender-specific differences is crucial for developing targeted psychological support interventions to improve mental well-being during IVF treatments. Full article

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16 pages, 418 KB

Open AccessArticle

Association of Health Literacy with Sociodemographic Factors and Medication Adherence Among Primary Health Care Users in Montenegro

by Amela Rastoder Celebic, Snezana Radovanovic, Ivana Simic Vukomanovic, Milos Stepovic, Jovana Radovanovic Selakovic, Viktor Selakovic, Olgica Mihaljevic, Katarina Janicijevic, Svetlana Radevic, Sanja Ilic, Marija Sorak, Nela Djonovic, Batric Babovic, Stefan Milojevic, Mihael Djacic and Radica Zivkovic Zaric

Healthcare 2026, 14(3), 374; https://doi.org/10.3390/healthcare14030374 (registering DOI) - 2 Feb 2026

Background/Objectives: Health literacy represents the ability to access, understand, appraise, and apply health information for making appropriate health decisions. It is closely linked to education, income, employment, and overall health outcomes. Limited health literacy is associated with poor self-care, inadequate treatment adherence, and [...] Read more.

Background/Objectives: Health literacy represents the ability to access, understand, appraise, and apply health information for making appropriate health decisions. It is closely linked to education, income, employment, and overall health outcomes. Limited health literacy is associated with poor self-care, inadequate treatment adherence, and increased healthcare utilization. This study aimed to assess the level of health and medication adherence behaviors among primary health care users in Montenegro and examine its association with key demographic and socioeconomic factors. Methods: A cross-sectional, multicenter study was conducted among 202 primary health care users at the Primary Healthcare Center Danilovgrad, Plav and Ulcinj, Montenegro. Data were collected using a demographic questionnaire, the standardized European Health Literacy Questionnaire (HLS-EU-Q-47), and the Attitudes towards Medication Adherence Self-Reported Questionnaire (ADHERE-7). Statistical analyses included descriptive statistics, χ² tests, and univariate and multivariate regression. Results: The mean HLS-EU-Q Index was 33.55 ± 8.05. Significant differences in literacy levels were observed by age (p = 0.022), material status (p = 0.043), and self-rated health (p = 0.020). In multivariate ordinal regression analysis, lower income (<400 €) was associated with lower odds of belonging to a higher health literacy category (OR = 0.22, 95% CI: 0.02–0.92, p = 0.039), while no statistically significant associations were observed for gender, education level, or employment status after adjustment. The mean ADHERE-7 score of the study population was 21.78 ± 5.19. When analyzed in relation to the level of health literacy, the highest mean ADHERE-7 score was observed among participants with excellent health literacy (24.28 ± 4.90). Lower levels of health literacy were associated with lower odds of belonging to higher health literacy categories among participants reporting selected non-adherence behaviors, including missing therapy 3–4 times per week (OR = 0.30), frequently skipping prescribed medication when feeling well (OR = 0.03), and reducing or omitting therapy due to perceived lack of benefit or high costs (OR range: 0.10–0.31). Conclusions: Health literacy among primary care users in Montenegro is moderate, with a substantial proportion exhibiting limited literacy. Low income is a key determinant of limited literacy, and limited health literacy was associated with poorer medication adherence. Targeted educational and policy interventions are needed to improve health literacy and reduce health inequalities. Full article

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17 pages, 13706 KB

Open AccessArticle

Improvement in Cervical Spinal Alignment and Posture May Redefine Recovery Pathways for Motor Vehicle Collision Whiplash Injury: A Multicenter Retrospective Consecutive Case Series

by Michael L. Underhill, Curtis A. Fedorchuk, Cole G. Fedorchuk and Douglas F. Lightstone

Healthcare 2026, 14(3), 373; https://doi.org/10.3390/healthcare14030373 (registering DOI) - 2 Feb 2026

Background/Objectives: Motor vehicle collision (MVC) cervical acceleration–deceleration (CAD) spine injuries are prevalent, costly, and complicated conditions. CAD injuries, or whiplash-associated disorders (WAD), present with neuromusculoskeletal signs and symptoms. In total, 50% of MVC WAD/CAD injuries result in chronic neck-related disability, of which 30% [...] Read more.

Background/Objectives: Motor vehicle collision (MVC) cervical acceleration–deceleration (CAD) spine injuries are prevalent, costly, and complicated conditions. CAD injuries, or whiplash-associated disorders (WAD), present with neuromusculoskeletal signs and symptoms. In total, 50% of MVC WAD/CAD injuries result in chronic neck-related disability, of which 30% are moderate-to-severe. Poor recovery is associated with little-to-no recovery after 3 months. This study reports on health outcomes of patients with MVC/CAD injuries treated with Chiropractic BioPhysics^® (CBP^®) spinal rehabilitation beyond little-to-no recovery in neck pain (NP) and disability after 3-to-4 months. Methods: This multicenter retrospective consecutive series reports on patients who met inclusion/exclusion criteria from a records review from two private practices with advanced training in CBP^®. Results: In total, 51 patients (26 males), 18–74 years-of-age (mean age 42.8 ± 3.6 years), presented with post-MVC NP and disability. Pre-treatment radiographs revealed decreased cervical curvature (ARA C2-C7) measuring −10.3 ± 2.0° (ideal is −42.0°) and anterior head translation (Tz C2-C7) measuring 28.5 ± 2.0 mm (ideal is 0 mm). The pre-treatment NP numeric rating scale (NRS) scored 6.0 ± 1.0, and the neck disability index (NDI) scored 54.3 ± 9.3% (severe). Patients were treated using CBP^® for 64.5 ± 4.7 visits over 31.6 ± 3.7 weeks. Post-treatment radiographs revealed an improved ARA C2-C7 to −22.5 ± 2.3° and Tz C2-C7 to 15.9 ± 1.6 mm (p < 0.001). Subsequent 3-to-4-month re-exam showed little-to-no change in NP and disability outcomes. Post-treatment outcomes at a mean 18.5 weeks after the 3-to-4-month re-exam showed significant (p < 0.001) improvements in NP NRS to 1.1 ± 0.7 and NDI to 6.8 ± 5.5 (minimal). Conclusions: CBP^® improves cervical lordosis and posture, which may help improve moderate-to-severe WAD/CAD spine injuries beyond 3-to-4 months of little-to-no recovery. Full article

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22 pages, 4680 KB

Open AccessArticle

Optimizing Cooperative Community Hospital Selection for Post-Discharge Care with NSGA-II Algorithm

by Zhenli Wu, Yunxuan Li and Xin Lu

Healthcare 2026, 14(3), 372; https://doi.org/10.3390/healthcare14030372 (registering DOI) - 2 Feb 2026

Background: With the growing emphasis on full-process disease management, efficient post-discharge care has become increasingly critical. Although prior studies have examined follow-up services, resource allocation, and facility location in primary healthcare, model-based optimization of collaborative frameworks between comprehensive hospitals and primary care [...] Read more.

Background: With the growing emphasis on full-process disease management, efficient post-discharge care has become increasingly critical. Although prior studies have examined follow-up services, resource allocation, and facility location in primary healthcare, model-based optimization of collaborative frameworks between comprehensive hospitals and primary care systems remains limited. Methods: We study a cooperative community hospital selection problem involving contractual cooperation, patient engagement, and follow-up resource allocation. A multi-objective mixed-integer programming model is developed to maximize patient accessibility and minimize total hospital costs, and an NSGA-II-based heuristic is proposed for solution generation. A real-world case study using data from a comprehensive hospital in Chengdu, China, is conducted. Results: The proposed approach produces a Pareto set that quantifies the accessibility–cost trade-off and reveals a knee region with diminishing returns: moderate expansion of cooperating providers substantially improves accessibility, whereas further expansion yields limited additional gains while increasing hospital cost. Sensitivity analyses indicate that cost-related parameters and follow-up frequencies are key drivers of the trade-off. Conclusions: The proposed optimization framework serves as an implementable decision aid for designing hospital–primary care collaboration for post-discharge follow-up: it supports partner selection and capacity planning and indicates levers to improve performance. Full article

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11 pages, 194 KB

Open AccessArticle

Transforming Relational Care Values in AI-Mediated Healthcare: A Text Mining Analysis of Patient Narrative

by So Young Lee

Healthcare 2026, 14(3), 371; https://doi.org/10.3390/healthcare14030371 (registering DOI) - 2 Feb 2026

Background: This study examined how patients and caregivers perceive and experience AI-based care technologies through text mining analysis. The goal was to identify major themes, sentiments, and value-oriented interpretations embedded in their narratives and to understand how these perceptions align with key [...] Read more.

Background: This study examined how patients and caregivers perceive and experience AI-based care technologies through text mining analysis. The goal was to identify major themes, sentiments, and value-oriented interpretations embedded in their narratives and to understand how these perceptions align with key dimensions of patient-centered care. Methods: A corpus of publicly available narratives describing experiences with AI-based care was compiled from online communities. Natural language processing techniques were applied, including descriptive term analysis, topic modeling using Latent Dirichlet Allocation, and sentiment profiling based on a Korean lexicon. Emergent topics and emotional patterns were mapped onto domains of patient-centered care such as information quality, emotional support, autonomy, and continuity. Results: The analysis revealed a three-phase evolution of care values over time. In the early phase of AI-mediated care, patient narratives emphasized disruption of relational care, with negative themes such as reduced human connection, privacy concerns, safety uncertainties, and usability challenges, accompanied by emotions of fear and frustration. During the transitional phase, positive themes including convenience, improved access, and reassurance from diagnostic accuracy emerged alongside persistent emotional ambivalence, reflecting uncertainty regarding responsibility and control. In the final phase, care values were restored and strengthened, with sentiment patterns shifting toward trust and relief as AI functions became supportive of clinical care, while concerns related to depersonalization and surveillance diminished. Conclusions: Patients and caregivers experience AI-based care as both beneficial and unsettling. Perceptions improve when AI enhances efficiency and information flow without compromising relational aspects of care. Ensuring transparency, explainability, opportunities for human contact, and strong data protections is essential for aligning AI with principles of patient-centered care. Based on a small-scale qualitative dataset of patient narratives, this study offers an exploratory, value-oriented interpretation of how relational care evolves in AI-mediated healthcare contexts. In this study, care-ethics values are used as an analytical lens to operationalize key principles of patient-centered care within AI-mediated healthcare contexts. Full article

(This article belongs to the Section Digital Health Technologies)

16 pages, 2645 KB

Open AccessArticle

Point-of-Care Bilirubin Testing in Neonates: Comparative Performance of Blood Gas Analysis and Transcutaneous Bilirubinometry

by Andrew Xu, Bincy Francis, Kay Weng Choy, George Francis Dargaville, Amy Surkitt, David Tran, Rami Subhi and Wei Qi Fan

Healthcare 2026, 14(3), 370; https://doi.org/10.3390/healthcare14030370 (registering DOI) - 1 Feb 2026

Background: Neonatal jaundice is a common condition with potentially severe complications such as bilirubin-induced neurological dysfunction and kernicterus. While serum bilirubin (SBR) remains the standard laboratory measurement, point-of-care methods, such as transcutaneous bilirubinometry (TcB) and blood gas analysers (BGAs), offer rapid, less [...] Read more.

Background: Neonatal jaundice is a common condition with potentially severe complications such as bilirubin-induced neurological dysfunction and kernicterus. While serum bilirubin (SBR) remains the standard laboratory measurement, point-of-care methods, such as transcutaneous bilirubinometry (TcB) and blood gas analysers (BGAs), offer rapid, less invasive alternatives. Direct comparisons of their diagnostic accuracy remain limited. Objective: The aim of this study was to assess and compare diagnostic accuracy and clinical utility of TcB and BGA against SBR in neonatal hyperbilirubinaemia screening. Methods: This retrospective study included neonates (n = 221) with concurrent SBR, BGA, and TcB measurements (n = 333). Assessment was via Passing–Bablok regression, Bland–Altman analysis, and Spearman correlation. Diagnostic performance was evaluated against jaundice thresholds in phototherapy charts (≥95th percentile threshold). Subgroup analyses considered phototherapy status, haemoglobin concentration, and Fitzpatrick skin type. Results: BGA showed stronger agreement with SBR (R² = 0.88) than TcB (R² = 0.43). BGA remained accurate regardless of phototherapy or haemoglobin levels. TcB accuracy declined post-phototherapy with reduced predictive value in darker-skinned neonates (Fitzpatrick III–VI) and increased false discovery rates. Both methods demonstrated low sensitivity (45.8%) but high specificity (>95%) and negative predictive value (~91%) for clinically significant hyperbilirubinaemia. BGA had a higher diagnostic odds ratio (47.5) than TcB (19.3). When individual patient sequential SBR and BGA measurements were compared for jaundice tracking (n = 175), there was high correlation, (r = 0.971) with no statistical differences, and 50% of measurements achieving agreement within 10 μmol/L. Conclusions: BGA is a more reliable alternative to SBR than TcB, particularly in time-critical or resource-limited settings. While TcB remains a non-invasive screening tool, limited accuracy post-phototherapy and with darker skinned neonates indicate confirmatory SBR testing. These findings support the selective and context-aware use of BGA and TcB to optimise neonatal hyperbilirubinaemia management and reduce interventions. Full article

(This article belongs to the Section Clinical Care)

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18 pages, 859 KB

Open AccessArticle

Association Between Physical Activity Level, Quality of Life Determinants, Internet Use, and Orthorexia Among Sport Science Students Living in Naples: An Observational Study

by Daniela Vitucci, Sara Dei, Rosa Ghirelli, Agnese Turi, Domenico Martone, Andreina Alfieri, Stefania Orrù, Annamaria Mancini and Pasqualina Buono

Healthcare 2026, 14(3), 369; https://doi.org/10.3390/healthcare14030369 (registering DOI) - 31 Jan 2026

Background: In recent years, growing attention has been paid to the lifestyle factors that influence young adults’ well-being. University students represent young adults at risk of Sedentary Behavior (SB) and mental distress. Sport Science students represent a health-conscious population, less prone to mental [...] Read more.

Background: In recent years, growing attention has been paid to the lifestyle factors that influence young adults’ well-being. University students represent young adults at risk of Sedentary Behavior (SB) and mental distress. Sport Science students represent a health-conscious population, less prone to mental distress. This study aims to investigate the associations between physical activity (PA) levels, different determinants of quality of life (QoL), orthorexia nervosa (ON) symptoms, and internet use among Sport Science students living in Naples. Methods: An online survey comprising General Data (GD) and eight validated questionnaires was used to assess PA levels, mood, sleep quality, eating habits, and digital behavior in a population of university students enrolled in Sport Science courses at Parthenope University, Naples. The statistical analyses included descriptive statistics, Student’s t-test, a Mann–Whitney U Test, frequencies, chi-square tests, and a Spearman’s rank correlation. All the analyses were performed using JASP and Jamovi software. Results: We surveyed 775 students (472 M; 303 F; 22.85 ± 3.85 y; BMI 23.74 ± 3.63 kg/m²). Regarding the MET-min/week, 65% of participants reported being highly active, 28% moderately active, and 7% inactive. Poor sleep quality was reported by 20% of those surveyed. Additionally, 84% of participants declared average internet use, which positively correlated with their emotional profile and sleep quality. High PA levels were directly associated with the presence of ON symptoms in 27% of the participants, most of whom exercised in gyms. Conclusions: To our knowledge, this is the first study conducted on a study population of Sport Science University students addressing the complex and interconnected relationships between PA levels, QoL, ON symptoms, and internet use. Full article

(This article belongs to the Section Public Health and Preventive Medicine)

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14 pages, 385 KB

Open AccessArticle

The Psychometric Properties of the Moberg Pick-Up Test (MPUT) to Assess Fine Motor Skills in Adults with Haemophilia

by Arnika Lorenz, Fabian Tomschi, Alexander Schmidt, Holger Stephan, Joschua Wiese and Thomas Hilberg

Healthcare 2026, 14(3), 368; https://doi.org/10.3390/healthcare14030368 (registering DOI) - 31 Jan 2026

Background/Objectives: Haemophilia-related bleedings primarily affect the musculoskeletal system, and functional tests are used in clinical management. Yet, fine motor skills of the upper extremities have not been evaluated in adult persons with haemophilia (PwH). The Moberg Pick-Up Test (MPUT) assesses fine motor [...] Read more.

Background/Objectives: Haemophilia-related bleedings primarily affect the musculoskeletal system, and functional tests are used in clinical management. Yet, fine motor skills of the upper extremities have not been evaluated in adult persons with haemophilia (PwH). The Moberg Pick-Up Test (MPUT) assesses fine motor skills but has only been psychometrically evaluated in other cohorts. This study aims to examine its psychometric properties in PwH. Methods: A total of 40 moderate or severe PwH A or B were included. The MPUT, consisting of three trials, was conducted twice by rater A and once by rater B. The best performance per hand of each MPUT was used. Subjective hand function (Duruöz Hand Index (DHI) and numeric rating scale (NRS)), elbow joint status (Haemophilia Joint Health Score (HJHS)), pain (NRS), and wrist range of motion (ROM) were utilised for convergent validity evaluation. Inter-rater and test–retest reliability were determined through intraclass correlation coefficients (ICCs) for raw and log10-transformed data. Results: Inter-rater and test–retest reliability demonstrated moderate-to-excellent ICCs for both data types (ICC range: 0.624–0.918). The DHI correlated moderately with the average MPUT score of both hands (r = 0.410; p = 0.016). Left-hand MPUT scores did not correlate with left elbow HJHS scores, whereas right-hand MPUT scores correlated with right elbow HJHS scores (r = 0.396, p = 0.018). Subjective left-hand function (NRS) correlated with the results of the MPUT (r = 0.433; p = 0.009). Conclusions: The MPUT is a reliable and partially valid tool and can be useful to assess fine motor skills in PwH. Full article

(This article belongs to the Special Issue Physical Exercise in Chronic Diseases: Assessment, Implementation and Effectiveness)

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12 pages, 260 KB

Open AccessArticle

Ethical Conflicts and Knowledge of the Code of Ethics Among Occupational Therapists in Spain

by Daniel Emeric-Méaulle, Pablo A. Cantero-Garlito and Ana A. Laborda-Soriano

Healthcare 2026, 14(3), 367; https://doi.org/10.3390/healthcare14030367 (registering DOI) - 31 Jan 2026

Objective: This study characterized Spanish occupational therapists’ knowledge of the national Code of Ethics and perceptions of professional ethics and examined associations with sociodemographic and educational variables. It quantified knowledge of key Code elements (approving body and professional values), described ethics education and [...] Read more.

Objective: This study characterized Spanish occupational therapists’ knowledge of the national Code of Ethics and perceptions of professional ethics and examined associations with sociodemographic and educational variables. It quantified knowledge of key Code elements (approving body and professional values), described ethics education and participation in formal ethical support structures, and identified resources used to manage ethical conflicts in routine practice. Methods: A descriptive cross-sectional online survey was administered between March and September 2022. The analytical sample included 596 occupational therapists practicing in Spain. The questionnaire assessed participant characteristics, ethics education, knowledge and perceived importance of the Code, participation in ethics committees or similar structures, experience of ethical conflicts, and conflict-management strategies. Descriptive and bivariate analyses were conducted (p < 0.05). Results: Respondents were mostly women (86.6%) and aged 20–40 years. Although 65.3% reported university ethics education and 73.2% rated the Code as important/very important, 11.4% were unaware of its existence. Only 28.2% identified the approving body, and 16.3% correctly identified the professional values included in the Code. Ethical conflicts were reported by 43.1%. When conflicts occurred, respondents most often consulted the interdisciplinary team (25.5%) or occupational therapy colleagues (24.3%), whereas few consulted the Code (4.5%) or an ethics committee (2.7%). Ethics education and greater professional experience were associated with higher Code knowledge. Conclusions: Occupational therapists in Spain endorse professional ethics, yet actionable knowledge and use of the Code and engagement with formal support structures remain limited. Strengthening practice-oriented ethics education and accessible deliberation mechanisms may improve ethical decision-making. Full article

(This article belongs to the Special Issue Ethical Challenges in Healthcare Professions: Decision-Making in Uncertain Scenarios)

11 pages, 253 KB

Open AccessArticle

Determinants of Severe Financial Distress in U.S. Acute Care Hospitals: A National Longitudinal Study

by James R. Langabeer, Francine R. Vega, Audrey Sarah Cohen, Tiffany Champagne-Langabeer, Andrea J. Yatsco and Karima Lalani

Healthcare 2026, 14(3), 366; https://doi.org/10.3390/healthcare14030366 (registering DOI) - 31 Jan 2026

Background: Financial sustainability remains a central challenge for U.S. hospitals as rising operating costs, shifting federal reimbursement, and policy uncertainty intensify economic pressures. This study estimates the prevalence and recent changes in financial distress among U.S. short-term acute care hospitals. Methods: [...] Read more.

Background: Financial sustainability remains a central challenge for U.S. hospitals as rising operating costs, shifting federal reimbursement, and policy uncertainty intensify economic pressures. This study estimates the prevalence and recent changes in financial distress among U.S. short-term acute care hospitals. Methods: We conducted a national longitudinal analysis of all U.S. short-term acute care hospitals from 2021 to 2023 using financial and operational data from Medicare cost reports linked with community-level data from the American Community Survey. Financial distress was measured using the Altman Z-score, with severe distress defined as Z ≤ 1.8. Logistic regression models were used to identify organizational, operational, and market characteristics associated with distress. Results: The proportion of hospitals classified as severely financially distressed increased from 18.6% in 2021 to 22.0% in 2023. Operating margins and returns on assets declined significantly over the study period, while mean Z-scores showed a modest but non-significant downward trend. In adjusted models, urban hospitals had higher odds of distress (OR 1.27, 95% CI 1.15–1.40, p < 0.001), as did hospitals with longer average lengths of stay (OR 1.07 per day, 95% CI 1.04–1.09, p < 0.001) and higher debt-to-equity ratios (OR 1.05 per unit, 95% CI 1.05–1.06, p < 0.001). Higher occupancy rates were protective (OR 0.31, 95% CI 0.25–0.40, p < 0.001). Larger market population was also associated with increased distress risk (OR 1.61, 95% CI 1.21–2.14, p = 0.001), while other market characteristics were not significant. Conclusions: Financial distress remains widespread and appears to be increasing among U.S. acute care hospitals. Operational efficiency, capital structure, and local market scale are key drivers of financial vulnerability, highlighting the need for targeted strategies to strengthen hospital resilience and preserve access to essential acute care services. Full article

(This article belongs to the Section Healthcare Organizations, Systems, and Providers)

16 pages, 705 KB

Open AccessReview

Exploring the Relationship Between Caring and Missed Nursing Care: A Scoping Review

by Gregor Romih, Majda Pajnkihar and Dominika Vrbnjak

Healthcare 2026, 14(3), 365; https://doi.org/10.3390/healthcare14030365 (registering DOI) - 31 Jan 2026

Background/Objectives: Missed nursing care is a recognized indicator of nursing quality and safety, while caring is a foundational concept in nursing practice. Few studies have empirically examined their relationship. This scoping review aimed to map and synthesize existing evidence on the conceptualisation, [...] Read more.

Background/Objectives: Missed nursing care is a recognized indicator of nursing quality and safety, while caring is a foundational concept in nursing practice. Few studies have empirically examined their relationship. This scoping review aimed to map and synthesize existing evidence on the conceptualisation, measurement approaches, and empirical relationships between caring and missed nursing care. Methods: The review was conducted using JBI methodology, reported according to PRISMA-ScR guidelines, and was registered in the Open Science Framework. Literature was searched in PubMed, CINAHL Ultimate (EBSCOhost), MEDLINE (EBSCOhost), and Web of Science, with additional grey literature searches in ProQuest Dissertations & Theses and Google Scholar. The review included studies examining caring in relation to missed nursing care across any healthcare setting. All study designs were considered. Data were extracted using an extraction tool, developed based on JBI guidelines, and piloted. Data were analyzed descriptively, tabulated, and summarized narratively. Results: Five quantitative cross-sectional studies met the inclusion criteria, conducted between 2012 and 2024 in the Philippines and Slovenia. Caring was assessed using the Caring Behaviors Inventory, Caring Ability Inventory, or CARE-Q, while missed nursing care was measured using the MISSCARE Survey or the Missed Nursing Care Scale. Most studies used Watson’s Theory of Human Caring, Duffy’s Quality Caring Model, or the Missed Nursing Care Model as theoretical frameworks. Across studies, caring behaviours and caring ability were negatively associated with missed nursing care. Conclusions: Caring can function as a moral and relational ideal and as a measurable and actionable factor related to patient outcomes. However, the evidence base remains limited, with inconsistent theoretical foundations and a lack of experimental studies. Future research should adopt theory-based, experimental approaches with diverse samples to explore causal mechanisms and evaluate strategies that strengthen caring competence and caring organizational cultures. Full article

(This article belongs to the Section Healthcare Quality, Patient Safety, and Self-care Management)

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15 pages, 912 KB

Open AccessArticle

Healthcare Costs and Mortality Trends of Elderly ICU Patients: Evidence from an Eight-Year Cohort Study in China

by Xiaohui Zhu, Meiping Wang, Yawei Guo and Li Jiang

Healthcare 2026, 14(3), 364; https://doi.org/10.3390/healthcare14030364 (registering DOI) - 31 Jan 2026

Background/Objectives: Elderly patients represent a growing proportion of ICU admissions, raising concerns about outcomes and healthcare costs. Evidence from China remains limited, yet understanding cost and mortality patterns is critical for optimizing care in aging populations. Methods: We retrospectively analyzed 31,535 ICU patients [...] Read more.

Background/Objectives: Elderly patients represent a growing proportion of ICU admissions, raising concerns about outcomes and healthcare costs. Evidence from China remains limited, yet understanding cost and mortality patterns is critical for optimizing care in aging populations. Methods: We retrospectively analyzed 31,535 ICU patients admitted from 2014 to 2021. After 1:1:1 matching on severity, comorbidities, sex, and admission type, three groups were formed: elderly (≥80 years), older (65–79 years), and younger (16–64 years), with 3398 patients each. Costs were inflation-adjusted, and outcomes compared across groups with appropriate statistical models. Results: Elderly patients accounted for 11.5% of admissions, had the longest ICU stay (4.5 vs. 3.8 vs. 3.1 days, p < 0.001), and the highest ICU (11.5%) and hospital (13.5%) mortality. Among non-surgical patients, elderly incurred the lowest costs; however, surgery reversed this pattern, producing a 124% increase. Expenditures were mainly driven by drugs and consumables. From 2014 to 2021, consumables rose from 32.0% to 42.0% of total costs, whereas drug costs declined. Inflation-adjusted hospital costs remained stable over time, while mortality among elderly patients decreased significantly (19.5% in 2014 vs. 8.8% in 2021; OR 0.86 per year, p < 0.001). Conclusions: Elderly ICU patients demonstrate unique cost and outcome profiles. While non-surgical elderly patients are less costly, surgery substantially increases expenses. Mortality declined over time without a rise in real costs, suggesting improved efficiency of critical care. These findings support tailored resource allocation and policy planning for aging ICU populations. Full article

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21 pages, 812 KB

Open AccessArticle

Improving Hand Hygiene Compliance in a Resource-Limited ICU Using a Low-Cost Multimodal Quality Improvement Intervention

by Sadia Qazi, Muhammad Amir Khan, Athar Ud Din, Naimat Saleem, Eshal Atif and Muhammad Atif Mazhar

Healthcare 2026, 14(3), 363; https://doi.org/10.3390/healthcare14030363 - 30 Jan 2026

Background/Objective: Hand hygiene is a cornerstone of infection prevention; however, compliance is inconsistent in intensive care units (ICUs), particularly in resource-constrained settings. This study evaluated whether a low-cost, multimodal quality improvement intervention could improve process-level hand hygiene compliance using routine, episode-based audits embedded [...] Read more.

Background/Objective: Hand hygiene is a cornerstone of infection prevention; however, compliance is inconsistent in intensive care units (ICUs), particularly in resource-constrained settings. This study evaluated whether a low-cost, multimodal quality improvement intervention could improve process-level hand hygiene compliance using routine, episode-based audits embedded in the ICU practice. Methods: We conducted a single-cycle Plan-Do-Study-Act quality improvement project in a 12-bed mixed medical–surgical ICU in Pakistan (December 2023–January 2024). Hand hygiene performance was assessed using the unit’s routine weekly episode-based audit protocol, aligned with the WHO Five Moments framework. A targeted multimodal intervention comprising education, point-of-care visual reminders, audit feedback, and leadership engagement was implemented between the pre- and post-intervention phases (four weeks each). Non-applicable moments were scored as “compliant by default” according to the institutional protocol. A sensitivity analysis was performed excluding these moments to calculate pure adherence. Compliance proportions were summarized using exact 95% Clopper–Pearson confidence intervals without inferential testing. Results: A total of 942 audit episodes (471 per phase) generated 4710 moment-level assessments were generated. Composite hand hygiene compliance increased from 63.1% pre-intervention to 82.0% post-intervention [absolute increase: 18.9 percentage points (pp)]. Sensitivity analysis excluding non-applicable moments demonstrated pure adherence improvement from 54.2% to 82.5% (+28.3 pp), confirming a genuine behavioral change rather than a measurement artifact. Compliance improved across all five WHO moments, with the largest gains in awareness-dependent moments targeted by the intervention: before touching the patient (+27.0 pp) and after touching patient surroundings (+40.0 pp). Week-by-week compliance remained stable within both phases, without immediate post-intervention decay. Conclusions: A pragmatic, low-cost multimodal intervention embedded in routine ICU workflows was associated with substantial short-term improvements in hand hygiene compliance over a four-week observation period, particularly for awareness-dependent behaviors. Episode-based audit systems can support directional process monitoring in resource-limited critical care settings without the need for electronic surveillance. However, its long-term sustainability beyond one month and generalizability to other settings remain unknown. Sensitivity analyses are essential when using “compliant by default” scoring to distinguish adherence patterns from measurement artifacts. Full article

(This article belongs to the Special Issue Innovative Approaches in Preventing and Controlling Healthcare-Associated Infections: Emerging Challenges in Nursing Care)

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16 pages, 380 KB

Open AccessArticle

Comparative Analysis of Oral Bacterial Profiles in Parkinson’s Disease According to Periodontal Status: A Clinical Case Series

by Dragoș Nicolae Ciongaru, Silviu Mirel Piţuru, Stana Păunică, Marina Cristina Giurgiu, Ioana Bujdei-Tebeică and Anca-Silvia Dumitriu

Healthcare 2026, 14(3), 362; https://doi.org/10.3390/healthcare14030362 - 30 Jan 2026

Introduction: Parkinson’s disease can influence oral health by impairing motor function and altering salivary composition, potentially affecting the oral microbiome. Materials and Methods: The objectives of this study are fourfold: (a) to compare the prevalence of bacterial species associated with periodontal disease in [...] Read more.

Introduction: Parkinson’s disease can influence oral health by impairing motor function and altering salivary composition, potentially affecting the oral microbiome. Materials and Methods: The objectives of this study are fourfold: (a) to compare the prevalence of bacterial species associated with periodontal disease in patients with and without Parkinson’s disease (PD), (b) to assess whether the coexistence of periodontal disease in PD patients contributes to an imbalance in the oral microbiome, (c) to evaluate the correlation between periodontal clinical indices (plaque index, tartar index, bleeding index, and probing depth) and the concentrations of specific periodontopathogenic bacterial species, and (d) to explore the potential implications of these evidences for clinical management and preventive strategies in Parkinson’s patients. The main objective of this study is to compare periodontal clinical indices (plaque index, tartar index, bleeding index, and probing depth) and the bacterial profile of patients with periodontal and Parknson’s disease. Two groups were included: 15 patients with periodontal disease (control group) and 16 patients with both periodontal and Parkinson’s disease (study group). Microbial samples were collected from the periodontal pockets at baseline and analyzed using the Polymerase Chain Reaction (PCR) Perio-Ident 12 kit to detect major periodontal pathogens. Results: Periodontal indices showed no statistically significant differences between groups, although the study group presented lower mean tartar index (49.31% vs. 67.4%, p = 0.069), bleeding on probing (44.31% vs. 56.67%, p = 0.137), and plaque index (66% vs. 68.93%, p = 0.754). Median bacterial loads were generally higher in control group, with Tannerella forsythia, but without statistically significant difference (p = 0.072). Significant correlations between plaque index and multiple pathogens occurred only in control gorup, suggesting disrupted plaque–pathogen dynamics (p < 0.05). Conclusions: The results highlight the potential value of integrating clinical and microbiological assessment when managing periodontal disease in patients with Parkinson’s disease. Full article

(This article belongs to the Section Public Health and Preventive Medicine)

14 pages, 699 KB

Open AccessArticle

The Influence of Preoperative Oral Carbohydrate Administration on the Perioperative Period in Children and Adolescents After Orthopedic Procedures—A Pilot Study

by Iwona Zaporowska-Bugajewska, Tomasz Mazurek, Szymon Wałejko, Justyna Napora and Wioletta Mędrzycka-Dąbrowska

Healthcare 2026, 14(3), 361; https://doi.org/10.3390/healthcare14030361 - 30 Jan 2026

Background: Preoperative fasting is one of the most difficult stages of hospitalization for children and their caregivers. The popularization of preoperative oral polycarbohydrate preparations is an important element influencing the comfort of hospitalized children. The aim of the study was to assess the [...] Read more.

Background: Preoperative fasting is one of the most difficult stages of hospitalization for children and their caregivers. The popularization of preoperative oral polycarbohydrate preparations is an important element influencing the comfort of hospitalized children. The aim of the study was to assess the effect of carbohydrate administration on perioperative blood glucose (PBG), the occurrence of complications in the pre- and postoperative periods, and satisfaction in children and adolescents. Material and methods The study was a comparative-observational one, and the following research methods were used: an author’s diagnostic questionnaire, observation, and analysis of medical documentation. The research group consisted of 50 patients from the Pediatric Orthopedic Department who received an oral polycarbohydrate solution up to 2 h before anesthesia. The control group consisted of 50 patients who fasted for more than 6 h before anesthesia. The study was conducted between February and May 2024. Results: The patients were assessed using a measurement of venous blood glucose taken immediately before the administration of premedication. Parents completed a questionnaire regarding their child’s perioperative period. Conclusions: The glucose level in patients who received a polycarbohydrate preparation is higher than in children who did not. The administration of polycarbohydrate preparations influences the feeling of thirst and hunger in the postoperative period in children and adolescents. Oral administration of a polycarbohydrate preparation up to 2 h before anesthesia does not cause regurgitation in children and adolescents. Patients who received an oral polycarbohydrate preparation tolerated the waiting period before anesthesia better. Preoperative fasting is, apart from the insertion of venous access, the most stressful situation for children and adolescents during hospitalization. The supply of oral polycarbohydrate preparations has a positive effect on pediatric patients in the perioperative period. Full article

16 pages, 530 KB

Open AccessArticle

Associations Between 24 h Movement Behaviours and Cognitive Abilities in Slovak Adolescents: A Cross-Sectional Study

by Beata Ruzbarska, Lenka Hnidkova, Mojmir Trebunak, Erika Chovanova, Dalibor Dzugas and Peter Kacur

Healthcare 2026, 14(3), 360; https://doi.org/10.3390/healthcare14030360 - 30 Jan 2026

Background: Twenty-four-hour movement behaviours (physical activity, sedentary time, and sleep) may be associated with adolescent cognitive performance, but evidence from Central/Eastern Europe is limited. Methods: A total of 82 Slovak adolescents (15–19 years) completed tests of IQ, attention, and visual memory. Participants wore [...] Read more.

Background: Twenty-four-hour movement behaviours (physical activity, sedentary time, and sleep) may be associated with adolescent cognitive performance, but evidence from Central/Eastern Europe is limited. Methods: A total of 82 Slovak adolescents (15–19 years) completed tests of IQ, attention, and visual memory. Participants wore a wrist accelerometer 24/7 for seven consecutive days (processed in GGIR v3.0–3). Moderate-to-vigorous physical activity (MVPA), total sedentary time, and sleep duration were derived from accelerometry; physical activity was also self-reported using the Physical Activity Questionnaire for Adolescents (PAQ-A). Non-parametric tests and Spearman correlations were applied; sleep × MVPA interaction models (robust HC3 standard errors) were adjusted for age and sex. Results: MVPA was low (median 32.9 min/day; 11% met ≥60 min/day), while sedentary time was high (median 652.6 min/day). Associations between movement behaviours and cognition were generally small, and no sleep × MVPA interaction effects were observed. The PAQ-A overestimated device-based MVPA (mean bias +1.68 units; 95% limits of agreement +1.10 to +2.25), with greater overestimation in girls and older adolescents. Conclusions: In this convenience sample, 24 h movement patterns were suboptimal, and their associations with cognition were modest and exploratory. Larger longitudinal studies are needed to confirm these findings. Full article

(This article belongs to the Special Issue Physical Activity in Childhood and Adolescence: Preventing Health Risks Through Sport and Diagnosis)

21 pages, 525 KB

Open AccessReview

Care as a Central Concept: Dimensions, Inequalities and Challenges in Chronic Care in Contemporary Societies: A Narrative Review

by Dolores Torres-Enamorado and Rosa Casado-Mejía

Healthcare 2026, 14(3), 359; https://doi.org/10.3390/healthcare14030359 - 30 Jan 2026

Background/Objective: Feminist theories and feminist economics have contributed to making visible the structural relevance of care work in sustaining capitalist societies and social reproduction, arguing that care must be addressed as a political phenomenon rather than a merely domestic issue. This perspective [...] Read more.

Background/Objective: Feminist theories and feminist economics have contributed to making visible the structural relevance of care work in sustaining capitalist societies and social reproduction, arguing that care must be addressed as a political phenomenon rather than a merely domestic issue. This perspective is particularly pertinent in contemporary healthcare, where chronic care represents one of the major public health challenges in a context of population ageing and increasing prevalence of chronic diseases. The aim is to contribute to a critical understanding that can support the development of public policies recognizing care as a fundamental pillar of socio-healthcare provision and as a matter of collective responsibility. Methods: A narrative literature review with a critical feminist approach was conducted using PubMed/MEDLINE, Scopus, and Web of Science. Results: A total of 299 records were identified, of which 30 studies were included following screening and eligibility assessment. Care is an essential element for sustaining life, although it has historically been rendered invisible, feminized, and relegated to the private sphere. Chronicity requires simultaneous consideration of the material dimension of care (as work), the subjective dimension (including emotional bonds and moral responsibility), and the political dimension (shaped by power relations). Global care chains reveal persistent inequalities related to gender, class, and race. Conclusions: Care is a structural, political, and transnational category that sustains life and healthcare systems. In the field of chronic care, the recognition, redistribution, and socialization of care are essential for achieving social justice and for safeguarding the dignity of both caregivers—predominantly women—and care recipients. Full article

(This article belongs to the Section Chronic Care)

12 pages, 1298 KB

Open AccessArticle

Risk-Adjusted Inpatient Falls as Indicators of Health System Performance During the COVID-19 Pandemic

by Masae Satoh, Toko Nakahori and Tomoko Shimada

Healthcare 2026, 14(3), 358; https://doi.org/10.3390/healthcare14030358 - 30 Jan 2026

Background/Objectives: Inpatient falls are widely used patient safety indicators, yet their behavior under periods of large-scale health system stress remains insufficiently understood. This study aimed to evaluate whether risk-adjusted inpatient fall indicators can capture changes in hospital safety performance during such periods, using [...] Read more.

Background/Objectives: Inpatient falls are widely used patient safety indicators, yet their behavior under periods of large-scale health system stress remains insufficiently understood. This study aimed to evaluate whether risk-adjusted inpatient fall indicators can capture changes in hospital safety performance during such periods, using a prolonged system disruption as an empirical context. The study period was a priori divided into three phases (pre-pandemic, initial pandemic, and later pandemic) according to changes in COVID-19 admission burden and system stress intensity. Methods: We conducted a retrospective observational time-series analysis using daily inpatient fall events and census data from a Japanese acute care hospital between December 2018 and March 2023 (50,140 inpatients; 962 falls). Expected fall rates were estimated using a validated pre-disruption prediction model, and observed/expected (O/E) ratios were calculated to assess risk-adjusted safety performance. Ordinary least squares regression models adjusted for calendar month and seasonal Fourier terms were used to examine temporal associations between fall outcomes and indicators of hospital-level system burden. Results: Both observed and expected fall rates increased during the study period, whereas O/E ratios declined only in the later phase, indicating improvement in risk-adjusted safety performance despite rising intrinsic patient risk. Seasonal patterns in fall outcomes were disrupted during the early phase of system stress but re-emerged over time. Associations between system burden indicators and fall outcomes were most pronounced in the early phase and attenuated in later phases. Conclusions: Risk-adjusted monitoring of inpatient falls provides insight into dynamic changes in hospital safety performance during periods of large-scale system stress and subsequent adaptation. This indicator can also be interpreted as a benchmarking scale for future month-to-month and seasonal safety surveillance beyond crisis contexts. Full article

(This article belongs to the Special Issue Fall Prevention and Geriatric Nursing)

14 pages, 623 KB

Open AccessArticle

Demographic and Clinical Correlates of Quality of Life Domains in Spinal Cord Injury

by Monika Zackova, Paola Rucci, Golcin Maknouni, Simona Udriste, Emanuele Salvatori and Maria Cristina Pirazzoli

Healthcare 2026, 14(3), 357; https://doi.org/10.3390/healthcare14030357 - 30 Jan 2026

Background/Objectives: In patients with spinal cord injury (SCI), quality of life (QoL) is increasingly recognized as an important indicator of their ability to sustain both the rehabilitation process and post-rehabilitation community reintegration, and it plays a crucial role in prognosis. The primary purpose [...] Read more.

Background/Objectives: In patients with spinal cord injury (SCI), quality of life (QoL) is increasingly recognized as an important indicator of their ability to sustain both the rehabilitation process and post-rehabilitation community reintegration, and it plays a crucial role in prognosis. The primary purpose of this study was to identify the demographic and clinical correlates of different QoL domains as perceived by patients hospitalized after SCI. Methods: We conducted a cross-sectional study on a single day in the units of the Montecatone Rehabilitation Institute (MRI), the largest Italian center for intensive rehabilitation of individuals with SCI. We administered the World Health Organization Quality of Life–Short Version (WHOQOL-BREF), which consists of 26 items rated on a five-point Likert scale. Study participants included 88 adults with SCI; a total of 74% were male, with a mean age of 53.3 years (SD = 15.05). The lesion was traumatic in 74% of cases and complete in 59%. Physical health showed a weak negative association with age (r = −0.213, p = 0.05), whereas social QoL demonstrated a significant positive association with age (r = 0.215, p = 0.046). Psychological QoL was significantly lower in females compared with males (46.9 vs. 55.1, p < 0.05) and in patients living alone compared with those not living alone (46.1 vs. 54.6, p < 0.05). Conclusions: Clinicians should consider routine assessment of QoL to personalize post-discharge therapeutic plans and to implement targeted interventions aimed at improving outcomes in patients with SCI. Full article

(This article belongs to the Section Healthcare Quality, Patient Safety, and Self-care Management)

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