Healthcare

34 pages, 3672 KB

Open AccessArticle

Explainable Text-Based Depression and Suicide Risk Prediction from Social Media Using Deep Learning and Graph Neural Networks

by Atiq Ur Rehman, Abid Iqbal, Ali Sayyed, Zaheer Aslam, Muhammad Ismail Mohmand and Ghassan Husnain

Healthcare 2026, 14(11), 1440; https://doi.org/10.3390/healthcare14111440 - 22 May 2026

Abstract

Objectives: The rise in the frequency of mental health concerns (depression and suicide) expressed on social media calls for reliable, explainable, and efficient computational methods for mental health surveillance. In this paper, we propose an interpretable framework for text-based detection of post- and [...] Read more.

Objectives: The rise in the frequency of mental health concerns (depression and suicide) expressed on social media calls for reliable, explainable, and efficient computational methods for mental health surveillance. In this paper, we propose an interpretable framework for text-based detection of post- and community-level mental health risk on social media. Methods: The framework combines (i) Secretary Bird Optimization (SBO) for feature selection of informative linguistic and psychological features, (ii) a BERT (Bidirectional Encoder Representations from Transformers)—CNN (Convolutional Neural Network) model for post-level reasoning, and (iii) a Graph Neural Network (GraphSAGE) for community-level reasoning. The graph is estimated based on semantic similarity between posts and author relations, instead of social interactions (e.g., mentions, replies) between authors. We use SHAP and LIME for model interpretability, uncertainty, and calibration analysis to evaluate the trustworthiness of predictions. Results: The model delivers 93.1% accuracy, 0.91 F1-score, and 0.944 ROC-AUC on the eRisk and CLPsych datasets using a strict user-disjoint validation strategy. SBO lowers the number of features by about 38%, leading to better generalization. The graph-based model enables improved learning of post and user representations by capturing relational dependencies. Conclusions: Our approach offers an explainable and robust means of detecting mental health risk from text. Graph-based representations of semantic and authorship interactions enable community-level analyses, while interpretability and uncertainty estimation facilitate possible human-in-the-loop decision-making. This research does not explicitly consider a human-in-the-loop experiment. Full article

(This article belongs to the Special Issue Innovative Suicide Prevention Methods: The Role of New Technologies and Medical Services in Saving Lives)

16 pages, 802 KB

Open AccessArticle

Association of Type D Personality with Disability and Quality of Life in Patients with Chronic Nonspecific Low Back Pain

by Esra Şahingöz Bakırcı, Muhammed Balcı and Tuğba Alışık

Healthcare 2026, 14(11), 1439; https://doi.org/10.3390/healthcare14111439 - 22 May 2026

Abstract

Background and Objectives: This research aimed to compare Type D personality characteristics and self-esteem between individuals with chronic NSLBP and healthy controls, while also exploring their relationships with functional status, psychological symptoms, and quality of life within the patient group. Materials and Methods: [...] Read more.

Background and Objectives: This research aimed to compare Type D personality characteristics and self-esteem between individuals with chronic NSLBP and healthy controls, while also exploring their relationships with functional status, psychological symptoms, and quality of life within the patient group. Materials and Methods: In this cross-sectional investigation, 34 patients with chronic NSLBP were compared with 34 healthy controls with similar age and sex distribution. Pain intensity was quantified via the Visual Analog Scale (VAS), while functional impairment was evaluated using the Oswestry Disability Index (ODI). Psychological profiling included the Type D Scale-14 (DS14) for personality traits, the Rosenberg Self-Esteem Scale (RSES) for self-worth, and the Hospital Anxiety and Depression Scale (HADS) for emotional distress. Health-related quality of life was captured through the 12-Item Short Form Health Survey (SF-12). Results: Type D personality was significantly more prevalent in the NSLBP group than in controls (50% vs. 20.6%, p = 0.011). Patients with NSLBP had significantly higher negative affectivity (NA) scores (p < 0.001) and anxiety scores (p = 0.007) and lower SF-12 Physical Component Summary scores (p < 0.001) than controls. Pain intensity and disability were positively correlated with Type D personality traits, particularly NA and the Type D composite score. In exploratory subgroup analyses, patients with Type D personality also had higher pain intensity, disability, anxiety, and depression scores and lower SF-12 Mental Component Summary (MCS) scores than those without Type D personality. In adjusted regression analyses within the NSLBP group, Type D personality was associated with higher VAS (p = 0.004) and ODI scores (p = 0.007) and lower SF-12 MCS scores (p = 0.003). Conclusions: Type D personality characteristics were more frequent in patients with chronic NSLBP than in healthy controls and were associated with higher pain intensity, greater disability, higher anxiety and depressive symptom scores, and poorer mental quality-of-life scores within the patient group. In contrast, self-esteem did not differ significantly between patients and controls. Due to the inherent constraints of a cross-sectional framework and the potential construct redundancy between NA and emotional distress, the current results signify correlational links rather than definitive causality. Consequently, subsequent prospective research is vital to delineate the temporal dynamics and the long-term predictive value of Type D personality traits in the progression of chronic NSLBP. Full article

13 pages, 542 KB

Open AccessArticle

Associations Between Physical Activity Intensity, Resilience, Self-Esteem and Health-Related Quality of Life in University Students: A Structural Equation Modeling Approach

by Zhangyu Yang, Gracia Cristina Villodres, Jianfei Ye, Xing Zhang, Li Huang and José Joaquín Muros

Healthcare 2026, 14(11), 1438; https://doi.org/10.3390/healthcare14111438 - 22 May 2026

Abstract

Background: University students often face significant psychological challenges and lifestyle disruptions that may compromise their mental resources and health-related quality of life (HRQoL). Although associations between physical activity (PA) and mental health have been widely reported, few studies have integrated different PA [...] Read more.

Background: University students often face significant psychological challenges and lifestyle disruptions that may compromise their mental resources and health-related quality of life (HRQoL). Although associations between physical activity (PA) and mental health have been widely reported, few studies have integrated different PA intensities, sedentary behavior, and psychological resources jointly related in one analytical model. Objective: This study investigated the relationships among vigorous (VPA), moderate (MPA), and light (LPA) physical activity, sedentary behavior (SB), resilience (RES), self-esteem (SE), and HRQoL in a sample of Chinese university students. Methods: A cross-sectional survey included 1560 university students from six universities in China, with a mean age of 19.43 ± 1.15 years; the sample comprised 434 males (27.8%) and 1126 females (72.2%). Relationships among the variables were tested using path analysis within a structural equation modeling framework. Results: Greater PA engagement was related to higher RES, SE, and HRQoL, whereas SB was not significantly associated with RES. All three PA intensities were positively associated with RES, although the magnitude of these associations varied. In addition, RES was also related to higher SE and HRQoL, and SE was related to higher HRQoL. Conclusions: These findings suggest that PA is associated with psychological resources and HRQoL among university students. Longitudinal and intervention studies are needed to determine the directionality and mechanisms underlying these relationships. Full article

(This article belongs to the Special Issue Integrating Physical, Mental, and Psychosocial Health in Primary Care: Collaborative Management Approach)

20 pages, 521 KB

Open AccessReview

Integrative Literature Review on the Lived Experiences of Parents of Children with a Rare Disease

by Assunta Guillari, Keti Ballfusha, Chiara Palazzo, Maurizio Di Martino and Vincenza Giordano

Healthcare 2026, 14(11), 1437; https://doi.org/10.3390/healthcare14111437 - 22 May 2026

Abstract

Background/Objectives: Rare diseases have a substantial impact not only on affected individuals but also on their families, particularly parents who assume primary caregiving roles. Despite increasing attention to rare conditions, parents’ experiences remain fragmented across the literature. This integrative review aimed to synthesise [...] Read more.

Background/Objectives: Rare diseases have a substantial impact not only on affected individuals but also on their families, particularly parents who assume primary caregiving roles. Despite increasing attention to rare conditions, parents’ experiences remain fragmented across the literature. This integrative review aimed to synthesise existing evidence on the experiences and multidimensional impact of caring for a child with a rare disease on parents. Methods: An integrative review was conducted following Whittemore and Knafl’s methodology and reported according to PRISMA 2020 guidelines. A systematic search was performed across MEDLINE, CINAHL, PsycINFO, PsycARTICLES, and Scopus from 1 November 2025 to 31 January 2026. Twenty-two studies (qualitative, quantitative, mixed-methods, and reviews) were included. Data were analysed using thematic synthesis. Results: Three interrelated themes were identified: (1) the diagnostic journey, characterised by prolonged uncertainty, fragmented care, and the pivotal role of communication; (2) multidimensional caregiving burden, encompassing emotional, social, economic, and physical impacts, with notable gender differences; and (3) adaptive trajectories, involving dynamic coping processes, parental upskilling, and meaning-making. Across studies, caregiving burden emerged as a cumulative and system-influenced phenomenon, while adaptation was found to coexist with ongoing uncertainty rather than representing a linear resolution. Conclusions: Caring for a child with a rare disease profoundly affects parents across multiple domains. The findings highlight the need for integrated, family-centred care models, improved diagnostic communication, and sustained psychosocial support. Implications for nursing practice: Nurses play a key role in recognising caregiver burden, supporting adaptive processes, and promoting effective communication throughout the diagnostic and care trajectory. Full article

(This article belongs to the Section Chronic Care)

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11 pages, 254 KB

Open AccessArticle

The Effect of Menopausal Symptoms on Subjective Well-Being

by Derya Yuksel Koçak and Cem Koçak

Healthcare 2026, 14(11), 1436; https://doi.org/10.3390/healthcare14111436 - 22 May 2026

Abstract

Background: Menopausal symptoms may adversely affect women’s overall health and well-being. Aim: This study investigated the effects of menopausal symptoms on subjective well-being in women in the 40–65 age group. Methods: The study sample consisted of 510 women, with 318 postmenopausal and 192 [...] Read more.

Background: Menopausal symptoms may adversely affect women’s overall health and well-being. Aim: This study investigated the effects of menopausal symptoms on subjective well-being in women in the 40–65 age group. Methods: The study sample consisted of 510 women, with 318 postmenopausal and 192 perimenopausal participants. Data were gathered using a Sociodemographic Information Form, the Menopause Rating Scale (MRS), and the Subjective Well-being Scale (SWBS), all administered as self-report instruments. Menopausal status was determined using the Stages of Reproductive Aging Workshop +10 criteria. Descriptive statistics, Chi-square test, Pearson correlation, and regression analyses were used. Results: Three regression models were specified to investigate the relationship between menopausal symptoms and subjective well-being. Model 1 demonstrated that overall menopausal symptoms were significant negative predictors of subjective well-being (B = −0.749, SE = 0.156, β = −0.260, t = −4.788, p < 0.001, 95% CI [−1.06, −0.44], R² = 0.068). Model 2 showed that both urogenital symptoms (B = −1.208, SE = 0.517, β = −0.139, t = −2.336, p = 0.020, 95% CI [−2.22, −0.20]) and somatic symptoms (B = −2.068, SE = 0.731, β = −0.168, t = −2.830, p = 0.005, 95% CI [−3.50, −0.64]) were significant negative predictors. Model 3 indicated that psychological symptoms significantly and negatively predicted subjective well-being (B = −1.114, SE = 0.262, β = −0.233, t = −4.253, p < 0.001, 95% CI [−1.63, −0.60], R² = 0.054). Conclusions: The findings highlight the importance of comprehensive health strategies and demonstrate that psychological symptoms significantly impact overall well-being. Full article

21 pages, 2521 KB

Open AccessArticle

Public–Private Partnerships as a Catalyst for Healthcare Transformation in Saudi Arabia: Evaluating the Impact on Accessibility, Quality, and Sustainability Under Vision 2030

by Salem Bauones and Mohammed J. Alsaadi

Healthcare 2026, 14(11), 1435; https://doi.org/10.3390/healthcare14111435 - 22 May 2026

Abstract

Background: PPPs are central to Saudi Arabia’s Vision 2030 healthcare transformation, yet evidence on their impact on accessibility, quality, and sustainability remains limited. The purpose of this study was to evaluate the perceived associations between PPP implementation under Vision 2030 and three healthcare [...] Read more.

Background: PPPs are central to Saudi Arabia’s Vision 2030 healthcare transformation, yet evidence on their impact on accessibility, quality, and sustainability remains limited. The purpose of this study was to evaluate the perceived associations between PPP implementation under Vision 2030 and three healthcare system outcomes—service accessibility (geographical, financial, technological), care quality (clinical outcomes, patient satisfaction, efficiency), and reform sustainability (economic, operational, adaptive)—from the perspectives of healthcare professionals and patients in Saudi Arabia. Methods: A cross-sectional, mixed-methods design was employed. Surveys were administered to 150 healthcare professionals and 210 patients at PPP-operated facilities (response rates of 61.2% and 65.6%, respectively). Descriptive and inferential statistics—including t-tests, ANOVA, chi-square tests, and multiple regression analysis adjusted for age, sex, education, household income, comorbidities, and facility type were used to assess associations between PPP initiatives and outcomes. Instrument reliability was confirmed (Cronbach’s α ≥ 0.7), and content validity was supported by an expert-panel content validity index of 0.91. Thematic analysis of open-ended responses captured stakeholder perceptions and challenges (inter-coder κ = 0.83). Results: Among professionals, 56.6% reported improved accessibility following the implementation of PPP, with 60.6% endorsing telemedicine as a key facilitator. However, 64.6% indicated financial access remained unchanged or worsened due to persistent out-of-pocket expenditures, and a statistically significant urban–rural gap was observed (p = 0.008). Quality indicators showed positive trends, including improved patient outcomes (52%), reduced waiting times (60.6%), and high satisfaction with hygiene and safety (74%). Sustainability assessments were cautiously favorable (mean financial viability = 3.4/5), though subsidy dependence remained a concern. Adjusted regression analysis identified financial accessibility (β = 0.31, p < 0.001) and reduced waiting times (β = 0.23, p = 0.005) as variables significantly associated with patient-reported outcomes. Conclusions: PPPs were associated with measurable improvements in healthcare accessibility, quality, and efficiency in Saudi Arabia. However, achieving the Vision 2030 objectives requires reforms that address financial equity, service distribution, workforce nationalization, and governance. Full article

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

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17 pages, 264 KB

Open AccessArticle

Subgroup Differences in Parenting Stress and Life Satisfaction Among Parents of Children with Disabilities Receiving Adapted Physical Activity Services

by Jinwoo Park and Seunghyun Jang

Healthcare 2026, 14(11), 1434; https://doi.org/10.3390/healthcare14111434 - 22 May 2026

Abstract

Background/Objectives: Parenting stress and life satisfaction are important indicators of family well-being and parent mental health in families of children with disabilities. However, limited empirical attention has been given to how these outcomes differ among parents whose children receive adapted physical activity (APA) [...] Read more.

Background/Objectives: Parenting stress and life satisfaction are important indicators of family well-being and parent mental health in families of children with disabilities. However, limited empirical attention has been given to how these outcomes differ among parents whose children receive adapted physical activity (APA) services within South Korea’s Developmental Rehabilitation Service system. This cross-sectional study examined subgroup differences in parenting stress and life satisfaction according to sociodemographic, disability-related, and service-utilization characteristics among parents of children receiving APA services. Methods: Data were collected from 295 parents of school-aged children with disabilities enrolled in APA services at child development centers. Welch-type tests, Welch’s ANOVA or one-way ANOVA, Pearson correlation analyses, Benjamini–Hochberg FDR adjustment, and supplementary analyses of covariance (ANCOVA) were used to examine group differences and the stability of selected associations after adjustment for prespecified covariates. Confirmatory factor analysis and gender-based measurement invariance testing were also conducted for the adapted parenting stress scale. Results: Parenting stress subdomains were positively correlated with one another (r = 0.19–0.53) and negatively correlated with life satisfaction (r = −0.28 to −0.40). Female parents reported higher social and psychological stress than male parents. Household income showed the largest association with economic stress, and significant differences were also observed according to parental age, education level, disability severity, and selected service-utilization characteristics. Some associations remained after ANCOVA adjustment, whereas others were attenuated or emerged only after adjustment. Conclusions: The findings indicate subgroup differences in parenting stress and life satisfaction among parents of children receiving APA services. Because the study used a cross-sectional, self-reported design with convenience sampling and an adapted instrument, the results should be interpreted as preliminary associative evidence rather than evidence of causal or service-specific effects. Future longitudinal, comparative, and service-level research is needed to clarify how APA service contexts relate to caregiver well-being over time. Full article

(This article belongs to the Special Issue Family Care and Mental Health Delivery to Improve Welfare of Children and Parents: Second Edition)

14 pages, 1592 KB

Open AccessArticle

Workflow Bottlenecks and Staff Readiness in an NHS Emergency Urology Clinic: A Prospective Service Evaluation to Inform Future AI-Supported Triage

by ChingHao Chen, Alice Cotton, Lorin Gresser and Tet Yap

Healthcare 2026, 14(11), 1433; https://doi.org/10.3390/healthcare14111433 - 22 May 2026

Abstract

Background/Objectives: Efficient patient flow in urgent urology services is critical to timely care delivery, yet workflow bottlenecks in specialty clinics remain underexplored. This study aimed to identify workflow bottlenecks, evaluate patient flow and staff attitudes, and explore clinician readiness for digital decision-support in [...] Read more.

Background/Objectives: Efficient patient flow in urgent urology services is critical to timely care delivery, yet workflow bottlenecks in specialty clinics remain underexplored. This study aimed to identify workflow bottlenecks, evaluate patient flow and staff attitudes, and explore clinician readiness for digital decision-support in a high-volume NHS emergency urology walk-in clinic. Methods: A two-week observational study was conducted at an emergency urology service in London. Time-stamped pathway data were collected for 80 patient journeys to identify total clinic duration. Differences associated with investigation ordering and senior escalation were analyzed using t-tests. Clinicians (n = 34) completed a questionnaire assessing perceptions of AI, and nursing staff provided qualitative feedback on operational pressures. Results: Mean total clinic journey time was 2 h 42 min, with the post-assessment phase accounting for 64% of total duration. Investigation ordering was the principal source of delay: patients undergoing investigations remained significantly longer in clinic than those who did not (3 h 17 min vs. 2 h 15 min, p < 0.05), and doctor-to-discharge time more than doubled (2 h 20 min vs. 1 h 2 min, p < 0.005). Senior escalation did not significantly prolong patient flow. Staff surveys demonstrated moderate trust in and comfort with AI as a decision-support tool. Nursing feedback highlighted inappropriate attendances, limited staffing, and workspace constraints as key stressors. Discussion: Delays were primarily driven by investigation ordering rather than senior review, identifying investigation timing as a potential target for future pathway optimisation. Conclusions: Investigation-related delays were the dominant workflow bottleneck. While no AI system was deployed in this study, these findings provide empirical groundwork to inform the design and prospective evaluation of AI-supported triage in specialty acute care settings. Full article

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24 pages, 357 KB

Open AccessArticle

Care Needs and Care Options for Frail Older People Living Alone in Italy: An Exploratory Mixed Study

by Maria Gabriella Melchiorre, Marco Socci, Giovanni Lamura and Sabrina Quattrini

Healthcare 2026, 14(11), 1432; https://doi.org/10.3390/healthcare14111432 - 22 May 2026

Abstract

Background/Objectives: People aged 65 years and older who live alone and have limited functional abilities need support in many circumstances and for a variety of activities. This study was conducted to explore the available formal and informal help for seniors, using findings [...] Read more.

Background/Objectives: People aged 65 years and older who live alone and have limited functional abilities need support in many circumstances and for a variety of activities. This study was conducted to explore the available formal and informal help for seniors, using findings from the “Inclusive Ageing in Place” (IN-AGE) study. Methods: This descriptive study was carried out in 2019 in three Italian regions, i.e., Lombardy in the north, Marche in the centre, and Calabria in the south, and involved 120 older people who lived at home, either alone or with a personal/private care assistant (PCA). Using a mixed-methods approach revealed both qualitative (thematic/content analysis of narratives) and quantitative (quantifications of statements) results. Results: This study identified several needs of seniors in different circumstances concerning basic and instrumental activities of daily living (ADL and IADL), health, and mobility in/outside the home. The seniors reported that support was provided primarily by their families, followed by friends and neighbours. Public home services were considered insufficient. The participants also reported using mobility aids and instances of self-sufficiency. Conclusions: These results highlight the need to improve support services for frail seniors and to better integrate formal and informal caregiving to facilitate ageing in place and promote the well-being of older people. Adequate interventions should be implemented for both older people and their family caregivers, who play a central role in care. Full article

(This article belongs to the Special Issue The Role of Psychological, Environmental, and Social Factors in the Promotion of Older Adults’ Health and Well-Being)

19 pages, 2108 KB

Open AccessArticle

Albumin, mNUTRIC and NRS-2002: Predicting Mortality in Elderly ICU Fracture Patients

by Hatice Zeynep Atlı, Osman Yağız Atlı, Ayşe Müge Karcıoğlu, Merve Tokatlı Doğan, Gözde Şengül Ayçicek, Semih Aydemir, Mesher Ensarioğlu, Onur Küçük and Yavuz Kutay Gökçe

Healthcare 2026, 14(11), 1431; https://doi.org/10.3390/healthcare14111431 - 22 May 2026

Abstract

Objective: The primary objective was to evaluate whether admission serum albumin predicts six-month all-cause mortality in older adult patients admitted to the intensive care unit (ICU) after simple fracture surgery, and to compare its predictive performance with the modified Nutrition Risk in the [...] Read more.

Objective: The primary objective was to evaluate whether admission serum albumin predicts six-month all-cause mortality in older adult patients admitted to the intensive care unit (ICU) after simple fracture surgery, and to compare its predictive performance with the modified Nutrition Risk in the Critically Ill (mNUTRIC) score and the Nutrition Risk Screening 2002 (NRS-2002). The secondary objectives were to identify baseline predictors of six-month mortality and high-risk mNUTRIC classification. Methods: This retrospective cohort study included patients aged ≥65 years admitted to the ICU of a tertiary care hospital after surgery for a simple fracture between July and December 2024. Demographic data, comorbidities, admission laboratory values (including albumin, prealbumin, and 25-hydroxy vitamin D, the latter included as an adjunctive nutritional biomarker), APACHE II, SOFA, mNUTRIC, and NRS-2002 scores were recorded. Postoperative complications and admission durations were evaluated. Binomial logistic regression models were constructed for six-month all-cause mortality and nutritional risk group classification. Receiver operating characteristic (ROC) analysis with the Youden Index was performed to determine cutoff values. Results: A total of 172 patients (mean age 80.84 ± 7.72 years; 67.4% female) were analyzed. Six-month all-cause mortality was 22.7%. Serum albumin (OR 0.823, 95% CI 0.729–0.928, p = 0.002) and ICU admission duration (OR 1.413, 95% CI 1.101–1.812, p = 0.007) were independent predictors of six-month all-cause mortality, whereas mNUTRIC, NRS-2002, and vitamin D were not. Neither mNUTRIC nor NRS-2002 scores differed significantly between survivors and non-survivors. In nutritional risk group analysis, age (OR 1.117, p = 0.001) and APACHE II (OR 1.694, p = 0.001) were independent predictors of high mNUTRIC risk. Head-to-head ROC analysis for the primary outcome of six-month all-cause mortality showed that admission serum albumin (AUC 0.698, 95% CI 0.604–0.793) provided significantly better discrimination than mNUTRIC (AUC 0.570, DeLong p = 0.046) and NRS-2002 (AUC 0.550, DeLong p = 0.039). In a sensitivity model restricted to admission-time variables (albumin, age, APACHE II, vitamin D, Charlson Comorbidity Index), admission albumin remained an independent predictor (OR 0.830, 95% CI 0.747–0.923, p < 0.001) and age emerged as a further independent predictor (OR 1.062, p = 0.034). Conclusions: Serum albumin outperformed mNUTRIC and NRS-2002 in predicting six-month all-cause mortality among older adult post-fracture ICU patients. Because neither mNUTRIC nor NRS-2002 discriminated between survivors and non-survivors, these scores alone cannot be recommended as mortality-prediction tools in this orthogeriatric ICU population. Whether admission albumin adds incremental value to existing nutritional scoring in this setting requires prospective, adequately powered validation. Full article

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13 pages, 206 KB

Open AccessArticle

Implementation Burden and Hidden Labor in a Multisite Digital Psychiatry Trial

by Linda Rubene-Kesele

Healthcare 2026, 14(11), 1430; https://doi.org/10.3390/healthcare14111430 - 22 May 2026

Abstract

Background: Multisite digital psychiatry trials increasingly rely on complex onboarding and implementation processes at local research sites. While outcome-focused evaluations are common, less attention has been paid to the site-level labor required to operationalize such studies in real-world settings, particularly at smaller or [...] Read more.

Background: Multisite digital psychiatry trials increasingly rely on complex onboarding and implementation processes at local research sites. While outcome-focused evaluations are common, less attention has been paid to the site-level labor required to operationalize such studies in real-world settings, particularly at smaller or resource-constrained sites. This study addresses this gap by examining hidden implementation labor from a single-site reflexive perspective. Methods: This study adopts a reflexive qualitative case study approach to examine onboarding and implementation processes at a single research site participating in a multisite digital psychiatry trial (ClinicalTrials.gov: NCT04953208). The analysis draws on longitudinal experiential data, supported by site-specific documentation, onboarding timelines, troubleshooting records, device-management materials, data quality assurance activities, and internal communications generated during site coordination and implementation activities. Results: Five interrelated themes were identified: hidden labor and role overload; resource scarcity at small research sites; fragmented remote communication and technical coordination; multi-role professional contexts and competing demands; and the impact of external systemic disruptions. Findings show how administrative, technical, logistical, and coordination tasks were absorbed into individual roles, often exceeding initial role expectations. Despite limited resources, the site achieved high performance through intensified individual effort, masking the true implementation burden. This pattern is conceptualized as a high-performance paradox, in which apparent site efficiency may conceal substantial hidden labor and role compression. Conclusions: This site-level reflexive account highlights the central role of hidden labor in sustaining implementation in multisite digital psychiatry trials. Recognizing and explicitly resourcing implementation work, particularly at small research sites, may improve feasibility, sustainability, and equity across study settings. The study contributes a practice-based methodological perspective on how implementation burden can be identified through reflexive analysis of site-level trial processes. Full article

(This article belongs to the Special Issue Public and Digital Approaches in Mental Health)

14 pages, 246 KB

Open AccessArticle

Psychosocial Aspects of Infertility and Medically Assisted Reproduction in Serbia: A COMPI-Based Single Centre Study

by Lidija Tulic, Jelena Dotlic, Tatjana Madic, Dejan Uljarevic, Aleksandar Dmitrovic, Lone Schmidt, Mariana Veloso Martins, Jelena Stojnic, Jelena Micic, Jovan Bila and Dragisa Sljivancanin

Healthcare 2026, 14(10), 1429; https://doi.org/10.3390/healthcare14101429 - 21 May 2026

Abstract

Background: Infertility affects millions of people causing grave societal and health consequences (poor physical and mental wellbeing). Aims: To translate and validate the COMPI scale in Serbian and examine associations of infertility-related stress, coping strategies and evaluation of care with medically assisted reproduction [...] Read more.

Background: Infertility affects millions of people causing grave societal and health consequences (poor physical and mental wellbeing). Aims: To translate and validate the COMPI scale in Serbian and examine associations of infertility-related stress, coping strategies and evaluation of care with medically assisted reproduction (MAR) outcomes in female Serbian infertility patients. Methods: The study included patients undergoing MAR for four months. Participants completed a socio-demographic and gynecologic questionnaire, the Serbian-translated COMPI scale, Beck Anxiety Inventory (BAI) and Zung Self-Rating Depression scale (ZDS). Serbian COMPI was validated in the classic manner. Associations between COMPI scores and pregnancy outcomes were analyzed by Spearman’s correlation and multivariable regression. Results: A total of 107 women participated and 24.3% achieved pregnancy. The Serbian COMPI demonstrated high internal consistency (Cronbach alpha = 0.838). Compared with reference COMPI data, personal, social and marital stress scores were higher, while meaning-based coping and marital benefit scores were lower. Regression analysis showed that higher marital stress, partner communication difficulties and meaning-based coping were associated with higher pregnancy likelihood. Conclusions: Serbian patients undergoing MAR reported high infertility-related stress and predominantly used active coping strategies. Patients who applied meaning-based coping were more likely to achieve pregnancy. Full article

(This article belongs to the Special Issue Coping with Emotional Distress)

10 pages, 1190 KB

Open AccessArticle

Single-Center Retrospective Study of Hospitalized Hepatitis A Cases in Southern Bulgaria, 2015–2023

by Meri Hristamyan, Simona Zlatanova, Vanya Rangelova and Ilia Tsachev

Healthcare 2026, 14(10), 1428; https://doi.org/10.3390/healthcare14101428 - 21 May 2026

Abstract

Background/Objectives: The hepatitis A virus (HAV) infection continues to represent a considerable public health issue in Eastern Europe, particularly in Bulgaria, where incidence rates exceed the EU average. This study sought to investigate the epidemiological and clinical aspects of acute hepatitis A in [...] Read more.

Background/Objectives: The hepatitis A virus (HAV) infection continues to represent a considerable public health issue in Eastern Europe, particularly in Bulgaria, where incidence rates exceed the EU average. This study sought to investigate the epidemiological and clinical aspects of acute hepatitis A in Southern Bulgaria between 2015 and 2023 and to assess changes during the COVID-19 pandemic period. Methods: A retrospective descriptive-analytic study was conducted among 1810 hospitalized patients with confirmed acute HAV infection at a tertiary infectious diseases center from 2015 to 2023. Demographic, clinical, laboratory, and temporal data were analyzed, comparing the pre-pandemic period (2015–2019) with the pandemic phase (2020–2023). Results: Most hospitalized cases occurred during the pre-pandemic period (88.0%), with epidemic peaks observed in 2016–2017. Individuals under 18 years comprised 69.9% of cases, with a median age of 9 years and a slight male predominance of 54.9%. A notable seasonal pattern was identified, characterized by peaks in autumn and early winter. Patients hospitalized during the pandemic period were significantly older compared with the pre-pandemic period (median age 14 vs. 8 years, p < 0.001). Adults experienced significantly longer hospitalization and higher ALT, AST, total bilirubin, and direct bilirubin levels compared with pediatric patients (all p < 0.001). The median duration of hospitalization was 7 days (IQR 6–10). Two in-hospital deaths were recorded, corresponding to a case fatality rate of 0.11%. Conclusions: Hepatitis A in Southern Bulgaria mostly impacts children but exhibits changing epidemiological trends, underscoring the necessity for focused preventative methods, such as vaccination and enhanced surveillance. Full article

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20 pages, 932 KB

Open AccessArticle

Associations Between Active Myofascial Trigger Points, Electromyographic Activity and Kinesiophobia in Chronic Non-Specific Neck Pain

by Julián Müller-Thyssen-Uriarte, María Orosia Lucha-López, César Hidalgo-García, Rocío Sánchez-Rodríguez, Lucía Vicente-Pina, Loreto Ferrández-Laliena, Sofía Monti-Ballano, Pierre Vauchelles-Barré and José Miguel Tricás-Moreno

Healthcare 2026, 14(10), 1427; https://doi.org/10.3390/healthcare14101427 - 21 May 2026

Abstract

Introduction: Chronic non-specific neck pain (CNSNP) is a prevalent condition where active myofascial trigger points (A-MTrPs) are commonly detected in cervical muscles and may be associated with altered electromyographic activity (EMGact). However, their association with EMGact during functional tasks remains unclear. Objectives [...] Read more.

Introduction: Chronic non-specific neck pain (CNSNP) is a prevalent condition where active myofascial trigger points (A-MTrPs) are commonly detected in cervical muscles and may be associated with altered electromyographic activity (EMGact). However, their association with EMGact during functional tasks remains unclear. Objectives: This study aimed to explore this relationship, hypothesizing that A-MTrPs in cervical muscles would be associated with altered EMGact. Methods: An analytical cross-sectional exploratory study was conducted in 52 patients with CNSNP. Surface EMGact of the sternocleidomastoid (SCM), anterior scalene (AS), and upper trapezius (UT) muscles was recorded during the craniocervical flexion test (CCFT) and an isometric shoulder abduction task (ABD-90). Linear mixed-effects models were constructed to identify factors associated with EMGact. Age, pain intensity, pain duration, analgesic dose, anti-inflammatory dose, and kinesiophobia score were included as covariates, while gender, physical activity level, and the presence or absence of A-MTrPs were included as categorical factors. Results: At the 22 mmHg CCFT level, analgesic consumption was positively associated with peak EMGact and average AS activation (B = 0.791 and B = 0.223, respectively) and with SCM peak EMG act (B = 0.510). At the same level, kinesiophobia was associated with average SCM EMGact (B = 0.231). At the 26 mmHg CCFT level, average AS activation remained positively associated with analgesic consumption (B = 0.148) and SCM without A-MTrPs was associated with lower EMGact compared to SCM with A-MTrPs. At the 30 mmHg CCFT level, kinesiophobia was negatively associated with average EMGact of AS. In the UT muscle, during ABD-90, kinesiophobia was negatively associated with both peak (B = −0.378) and average EMGact (B = −0.132). Conclusions: The presence of A-MTrPs may be related to SCM EMGact during CCFT in individuals with CNSNP, while analgesic consumption and kinesiophobia also could be associated with cervical muscles EMGact during functional tasks. Full article

(This article belongs to the Special Issue New Approaches in Invasive and Non-Invasive Rehabilitation: From Basic Science to Clinical Intervention—Second Edition)

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28 pages, 2766 KB

Open AccessArticle

An Experimental Study on the Effectiveness and Usefulness of 360° Virtual Reality Simulation in Korean Medical Education: A Pilot Study

by Hyun-Kyung Sung, Yongtaek Oh, Mikyung Kim, Eun-Jin Kim, Ju-Hee Lee, Yejin Han and Namin Shin

Healthcare 2026, 14(10), 1426; https://doi.org/10.3390/healthcare14101426 - 21 May 2026

Abstract

Background: Virtual reality (VR) simulations provide immersive, interactive learning environments that can support clinical skill development in medical education. However, evidence for its application in Korean medical education remains limited. This pilot study aimed to develop and evaluate HaniE-VR1, a 360° VR simulation [...] Read more.

Background: Virtual reality (VR) simulations provide immersive, interactive learning environments that can support clinical skill development in medical education. However, evidence for its application in Korean medical education remains limited. This pilot study aimed to develop and evaluate HaniE-VR1, a 360° VR simulation program designed to teach ultrasound-guided pharmacopuncture. Methods: A one-group pre–post experimental design was used with 60 undergraduate students from the College of Korean Medicine (pre-intervention n = 60; post-intervention n = 59, due to one missing post-survey response). The primary outcomes were changes in self-efficacy (MASS) and ultrasound skill-related performance (OSAUS). Secondary outcomes included VR awareness, usability, satisfaction, presence, and cognitive load. Participants completed a VR-based training session using a Meta Quest 3 headset. Effect sizes (Cohen’s d) were calculated for pre–post comparisons. Statistical significance was set at p < 0.05. Results: Post-intervention findings showed significant improvements in self-efficacy (MASS: 3.21 ± 0.51 to 3.54 ± 0.61, p < 0.001, d = 0.66) and ultrasound skill performance (OSAUS: 2.66 ± 0.73 to 3.54 ± 0.71, p < 0.001, d = 1.16). VR awareness also improved significantly (4.33 ± 0.66 to 4.76 ± 0.56, p < 0.001, d = 0.65). Participants reported acceptable usability (SUS = 69.49) and high satisfaction (4.51 ± 0.56), confidence (4.32 ± 0.53), and presence (4.40 ± 0.65). Cognitive load and simulator sickness were minimal. Conclusions: The HaniE-VR1 program was associated with improvements in perceived clinical competence, self-efficacy, and learning satisfaction, demonstrating acceptable usability and preliminary educational potential. VR simulations represent a feasible, safe, and engaging approach for integrating experiential learning into Korean medical curricula. Given the exploratory nature of this pilot study, findings should be interpreted with caution, and future controlled research is warranted. Full article

(This article belongs to the Special Issue Integration of Artificial Intelligence (AI), Virtual/Augmented Reality (VR/AR) and Machine Learning (ML) in Clinical Practice: Patient Care, Clinician–Patient Interaction, and Clinical Decision-Making)

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16 pages, 297 KB

Open AccessArticle

Physical Activity and Quality of Life Among Caregivers of Children with Duchenne Muscular Dystrophy

by Sedat Yiğit, İrem Akgün, Kübra Coşkun, Murat Ali Çınar, Serkan Usgu and Peren Perk

Healthcare 2026, 14(10), 1425; https://doi.org/10.3390/healthcare14101425 - 21 May 2026

Abstract

Background/Objectives: Duchenne muscular dystrophy (DMD) is a rare progressive neuromuscular disorder associated with increasing care demands. Despite the critical role of caregivers, their physical activity (PA) levels and health-related quality of life (HRQoL) have not been sufficiently investigated. This study aimed to compare [...] Read more.

Background/Objectives: Duchenne muscular dystrophy (DMD) is a rare progressive neuromuscular disorder associated with increasing care demands. Despite the critical role of caregivers, their physical activity (PA) levels and health-related quality of life (HRQoL) have not been sufficiently investigated. This study aimed to compare PA levels and HRQoL between caregivers of children with DMD and caregivers of typically developing children. Methods: This cross-sectional observational study included 44 individuals: caregivers of children with DMD (n = 22) and caregivers of typically developing children (n = 22). The 36-Item Short-Form Health Survey (SF-36) was used for assessing HRQoL and the International Physical Activity Questionnaire—Short Form (IPAQ-SF) for determining PA levels. Results: IPAQ-SF-derived metabolic equivalent of task (MET) values and PA levels were similar between the groups (DMD caregivers: 1744.63 ± 1163.22, controls: 1945.09 ± 1042.12; p > 0.05). Caregivers of children with DMD demonstrated significantly poorer scores in several SF-36 domains, including vitality, social functioning, role limitations due to physical problems, bodily pain, and mental health (p < 0.05), with the largest difference observed in role limitations due to emotional problems (DMD caregivers: 45.27 ± 28.33, controls: 84.83 ± 24.63; p < 0.05). Physical functioning and general health perception scores were comparable (p > 0.05). Conclusions: Caregivers of children with DMD experience substantial impairments in multiple HRQoL domains, particularly those related to psychosocial well-being and pain, despite comparable PA levels and physical functioning. These findings suggest that reduced HRQoL is not directly explained by PA alone and highlight the need for multidisciplinary interventions targeting psychological health, pain management, and social well-being. Full article

15 pages, 275 KB

Open AccessArticle

Social Perception of Natural Background Radiation and Its Implications for Public Health Communication

by Juliánna Szakács, Mihai Ioan Georgescu, Gellért-Gedeon Deák, Eszter Bajkó, Simona Toncean Florentina, Florina Ruta and Călin Avram

Healthcare 2026, 14(10), 1424; https://doi.org/10.3390/healthcare14101424 - 21 May 2026

Abstract

Background: Public perception of environmental (natural background) radiation represents an important challenge for public health communication, as risk perception is often influenced more by information quality and institutional trust than by objective exposure levels. Methods: A cross-sectional survey was conducted among 481 respondents [...] Read more.

Background: Public perception of environmental (natural background) radiation represents an important challenge for public health communication, as risk perception is often influenced more by information quality and institutional trust than by objective exposure levels. Methods: A cross-sectional survey was conducted among 481 respondents using a structured questionnaire assessing self-perceived knowledge, information sources, perceived radiation risk, institutional trust, and health-related attitudes. Results: Significant gender differences were observed in self-reported knowledge about radioactivity, with men more frequently reporting higher knowledge levels than women (p < 0.001), while no significant differences emerged between urban and rural respondents; logistic regression analysis showed that lower perceived risk was associated with lack of medical information (OR = 0.32, 95% CI: 0.14–0.71) and absence of avoidance behavior (OR = 0.23, 95% CI: 0.11–0.47), whereas low trust in medical institutions was associated with higher odds of perceiving natural background radiation as dangerous (OR = 1.84, 95% CI: 1.21–2.80). Conclusions: Effective radiation risk communication requires more than the dissemination of information; it must also address public concerns, enhance institutional trust, and provide clear, credible, and accessible health-related messages. Tailored communication strategies are essential to bridge the gap between expert knowledge and public perception. Full article

22 pages, 707 KB

Open AccessArticle

From Stress to Burnout: Exploring the Protective and Predictive Factors for Nurses’ Well-Being

by Suad Dukhaykh and Shaikhah Bawzeer

Healthcare 2026, 14(10), 1423; https://doi.org/10.3390/healthcare14101423 - 21 May 2026

Abstract

Background/Objectives: Occupational stress is a prevalent issue in healthcare settings, particularly among nurses, and is often associated with increased levels of burnout and reduced well-being. This study aims to examine the relationship between occupational stress and burnout among nurses, with a particular focus [...] Read more.

Background/Objectives: Occupational stress is a prevalent issue in healthcare settings, particularly among nurses, and is often associated with increased levels of burnout and reduced well-being. This study aims to examine the relationship between occupational stress and burnout among nurses, with a particular focus on the mediating role of job satisfaction and the moderating role of self-efficacy. Methods: A quantitative research design was employed using data collected from 245 nurses in Saudi Arabia through a bilingual survey instrument incorporating validated psychological measures. Statistical analyses were conducted to test the direct, mediating, and moderating relationships among the study variables. Results: The findings indicate that occupational stress is positively associated with burnout and negatively related to job satisfaction. Job satisfaction was found to partially mediate the relationship between stress and burnout, suggesting that reduced job satisfaction serves as a key mechanism through which stress contributes to burnout. In contrast, self-efficacy did not demonstrate a significant moderating effect in this relationship. Conclusions: This study contributes to the occupational health literature by highlighting the critical role of job satisfaction in mitigating the adverse effects of stress on burnout among nurses. The findings offer practical implications for healthcare leaders and policymakers seeking to design targeted interventions aimed at enhancing job satisfaction, reducing burnout, and improving nurses’ overall well-being. Full article

(This article belongs to the Special Issue Burnout, Perceived Efficacy and Job Satisfaction of Nurses: Leadership, Management and Organizational Perspectives)

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21 pages, 3946 KB

Open AccessArticle

Automated Facial Emotion Recognition System Detects Altered Emotional Processing During Craving Induction in Individuals with Substance Use Disorder

by Joaquin García-Estrada, Diana Emilia Martínez-Fernández, Iris del Socorro Pérez-Alcaraz, Carlos Joel Mondragón-Gomar, Irene G. Aguilar-García, Sonia Luquin and David Fernández-Quezada

Healthcare 2026, 14(10), 1422; https://doi.org/10.3390/healthcare14101422 - 21 May 2026

Abstract

Background: Substance Use Disorder (SUD) is characterized by recurrent craving episodes frequently associated with emotional dysregulation and altered reward processing. This study aimed to evaluate whether emotional states associated with craving episodes can be detected through automated facial emotion recognition during controlled [...] Read more.

Background: Substance Use Disorder (SUD) is characterized by recurrent craving episodes frequently associated with emotional dysregulation and altered reward processing. This study aimed to evaluate whether emotional states associated with craving episodes can be detected through automated facial emotion recognition during controlled emotional induction. Methods: Forty-one participants completed a 14-day ecological momentary assessment (EMA) monitoring anxiety and craving levels, followed by an emotional induction task using standardized stimuli from the EmoMadrid database and addiction-related images. Facial expressions were recorded and analyzed in real time using a computational facial emotion recognition model trained on the FER-2013 dataset. Results: Participants with SUD exhibited significantly reduced positive emotional valence and emotional activation in response to positive stimuli compared with healthy controls (HC), with large effect sizes observed for emotional valence (Hedges’ g = 1.76) and emotional activation (Hedges’ g = 1.33). Item-level analyses revealed that most between-group differences occurred in stimuli depicting social interactions. Individuals with SUD also showed higher frequencies of fear-related facial expressions and lower frequencies of disgust-related expressions compared with HC, with moderate effect sizes observed for both emotional dimensions (Hedges’ g = 0.72; p = 0.02). Conclusions: These results suggest that people with SUD have changes in how they process emotions, showing less response to positive things and unique facial expressions related to craving. However, given the relatively modest and clinically heterogeneous sample, the findings should be interpreted cautiously and require replication in larger and more homogeneous populations. Full article

(This article belongs to the Special Issue Substance Abuse, Mental Health Disorders, and Intervention Strategies)

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