International Journal of Environmental Research and Public Health

17 pages, 450 KB

Open AccessArticle

Preferences for Chronic Pain Treatment Among Indigenous Peoples Living in the Pacific Northwest

by Andrea K. Newman, Mark P. Jensen, Kara Link, Kathy Littlebull, Molly Fuentes, Chantelle E. Roberts, Robin John and Ryan G. Pett

Int. J. Environ. Res. Public Health 2026, 23(4), 502; https://doi.org/10.3390/ijerph23040502 - 14 Apr 2026

Abstract

There is a significant need for culturally appropriate psychological treatments for chronic pain among American Indian/Alaska Native (AI/AN) peoples. This study used Indigenous community-based participatory research methods with the Portland Area Indian Health Services—Yakama Service Unit (YSU) to gather information needed for developing [...] Read more.

There is a significant need for culturally appropriate psychological treatments for chronic pain among American Indian/Alaska Native (AI/AN) peoples. This study used Indigenous community-based participatory research methods with the Portland Area Indian Health Services—Yakama Service Unit (YSU) to gather information needed for developing culturally adapted psychological treatments for AI/AN individuals with chronic pain. This study included remote semi-structured focus groups with 16 AI/AN individuals with chronic pain to identify pain treatment preferences (Aim 1) and priorities for pain treatment outcome domains (Aim 2). Thematic analyses were conducted with Atlas.ti (version 23.2.1). Results indicated a high interest in psychological interventions and concern that referral to psychological treatment meant that pain is “not real.” Pain intensity and pain interference were identified as the most important outcome domains. To measure pain intensity, the 0 to 10 Numerical Rating Scale was most preferred. The findings support the potential utility of culturally adapted psychological treatments for chronic pain for AI/AN individuals and provided information regarding the adaptations that would be most useful. Full article

(This article belongs to the Special Issue Community-Informed Health Promotion Interventions with Indigenous Communities)

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28 pages, 1216 KB

Open AccessArticle

Smart Vape Detection in Schools for Mitigating Student E-Cigarette Use

by Robert Sharon, Lidia Morawska and Lindy Osborne Burton

Int. J. Environ. Res. Public Health 2026, 23(4), 501; https://doi.org/10.3390/ijerph23040501 - 14 Apr 2026

Abstract

Adolescent vaping has become a persistent health and behavioural challenge in schools, yet many institutions lack reliable tools to detect and respond to concealed e-cigarette use. This study addresses this problem by evaluating the real-world performance of a low-cost “Internet of Things” (IoT) [...] Read more.

Adolescent vaping has become a persistent health and behavioural challenge in schools, yet many institutions lack reliable tools to detect and respond to concealed e-cigarette use. This study addresses this problem by evaluating the real-world performance of a low-cost “Internet of Things” (IoT) vape detection system deployed across 37 high-risk restroom and change-room locations at a large Australian Independent school. The aim was to determine whether an IoT-based environmental monitoring platform could accurately identify vaping events, support timely staff intervention, and provide actionable insights into student behaviour patterns. A longitudinal case study design was used, collecting continuous particulate matter (PM_2.5 and PM₁₀) data at one-minute intervals over an 18-month period, where PM₂.₅ and PM₁₀ refer to particulate matter with aerodynamic diameters ≤ 2.5 µm and ≤ 10 µm, respectively, reported in micrograms per cubic metre (µg/m³). Threshold-based alerting, cloud-based data processing, and school-led Closed-circuit television (CCTV) verification were combined to assess detection accuracy, temporal trends, and operational responses. The system recorded more than 300 vaping-related incidents, with clusters aligned to predictable times of day and higher prevalence among senior students. Operational detection performance was high, with alert events characterised by rapid, concurrent PM_2.5 and PM₁₀ excursions consistent with vaping-related aerosol profiles, although staff responsiveness declined over time due to alert fatigue and competing priorities. A major environmental smoke event demonstrated the need for context-aware logic to reduce false positives. The findings demonstrate that real-time aerosol monitoring is not only technically reliable but also highly effective in detecting vaping within school environments. These perspectives help explain why user engagement, alert fatigue, and institutional follow-through are as critical as sensor accuracy itself. Ultimately, the effectiveness of vape detection relies on strong organisational commitment, well-defined response workflows, and alignment with broader wellbeing and policy strategies. When these elements are in place, such systems can evolve from simple detection tools into intelligent, integrated components of school health governance. Full article

25 pages, 482 KB

Open AccessArticle

HIV/STI Prevention Strategies During COVID-19 Among PrEP-Eligible Cisgender Women in New York State: A Qualitative Analysis

by James M. McMahon, Natalie M. Leblanc, Janie E. Simmons, Keosha Bond, Whitney Irie, Danielle C. Alcena-Stiner, Lindsay Batek and Chen Zhang

Int. J. Environ. Res. Public Health 2026, 23(4), 500; https://doi.org/10.3390/ijerph23040500 - 14 Apr 2026

Abstract

PrEP-eligible cisgender women underutilize PrEP, and little is known about how PrEP fits within broader HIV/STI prevention ecologies shaped by personal preferences and relationship contexts. These ecologies inform prevention strategies that shift with relationship dynamics and vary by race/ethnicity, age, and setting; the [...] Read more.

PrEP-eligible cisgender women underutilize PrEP, and little is known about how PrEP fits within broader HIV/STI prevention ecologies shaped by personal preferences and relationship contexts. These ecologies inform prevention strategies that shift with relationship dynamics and vary by race/ethnicity, age, and setting; the COVID-19 pandemic further influenced these contexts. Data were drawn from the Women’s Study in Sexual Health and Empowerment (WISE), a mixed-methods study of PrEP-eligible cisgender women in New York City and Rochester, NY. One-time semi-structured interviews were conducted with 48 women from the WISE cohort. Women described tailoring prevention to relationship context, often initiating relationships with condoms and later relying more on trust and periodic HIV/STI testing. Strategies included situational condom use, combination prevention with PrEP and HIV/STI testing, and PrEP initiation or discontinuance as perceived risk changed. Women also reported challenges negotiating condom use, including partner resistance, and some described abstinence as a deliberate strategy. Comparative analyses identified patterns by race/ethnicity, age, and site. Pandemic-related disruptions reduced opportunities for new partnerships, altered relationship dynamics, and shifted some prevention conversations toward SARS-CoV-2 exposure risk. Findings highlight the need for women-centered, culturally and contextually tailored prevention services that strengthen PrEP access and routinized HIV/STI testing while accounting for relationship dynamics. Full article

(This article belongs to the Special Issue Women and Pre-Exposure Prophylaxis for HIV Prevention)

22 pages, 761 KB

Open AccessArticle

Prevalence of Internet Addiction Among Thai Pharmacy Students: A Cross-Sectional Study

by Titawadee Pradubkham, Thuksaorn Sukket, Suphakorn Pimcharee, Kittisak Wichaiyo and Wiraphol Phimarn

Int. J. Environ. Res. Public Health 2026, 23(4), 499; https://doi.org/10.3390/ijerph23040499 - 14 Apr 2026

Abstract

The internet is increasingly embedded in daily life; however, excessive use may lead to internet addiction, adversely affecting health and academic performance. This study aimed to determine the prevalence of internet addiction and its association with depressive symptoms among pharmacy students at Mahasarakham [...] Read more.

The internet is increasingly embedded in daily life; however, excessive use may lead to internet addiction, adversely affecting health and academic performance. This study aimed to determine the prevalence of internet addiction and its association with depressive symptoms among pharmacy students at Mahasarakham University. A cross-sectional survey was conducted between 1 October and 31 December 2025 among undergraduate pharmacy students (years 1–6) aged ≥18 years who provided voluntary consent. Data were collected via street-based and online self-administered questionnaires validated for content and reliability. Descriptive and inferential statistics were applied, and binary logistic regression was used to identify associated factors. Among 396 participants, the mean internet use was 9 h 43 min per day. The prevalence of excessive use (risk) was 75.95%, while 17.47% met criteria for internet addiction. High to very high psychological problems were significantly associated with internet addiction (aOR = 3.89; 95% CI: 1.70–8.89; p = 0.001). Risk of depression (2Q) was also significantly associated (aOR = 2.67; 95% CI: 1.39–5.15; p = 0.003). Internet addiction is strongly associated with mental health factors, highlighting the need for targeted prevention and institutional mental health interventions. Full article

23 pages, 1003 KB

Open AccessSystematic Review

Association of Serum ADA Levels in Pulmonary Tuberculosis: A Systematic Review and Meta-Analysis

by Jirarat Songsri, Jongkonnee Thanasai, Jitbanjong Tangpong, Anchalee Chittamma and Wiyada Kwanhian Klangbud

Int. J. Environ. Res. Public Health 2026, 23(4), 498; https://doi.org/10.3390/ijerph23040498 - 14 Apr 2026

Abstract

Background: The early diagnosis of pulmonary tuberculosis (PTB) remains a global challenge. While serum adenosine deaminase (ADA) has been associated with tuberculosis-related immune activation, its consistency across different regions and laboratory methods remains unclear. This study aims to evaluate group-level differences in serum [...] Read more.

Background: The early diagnosis of pulmonary tuberculosis (PTB) remains a global challenge. While serum adenosine deaminase (ADA) has been associated with tuberculosis-related immune activation, its consistency across different regions and laboratory methods remains unclear. This study aims to evaluate group-level differences in serum ADA levels and identify factors influencing these variations. Methods: A systematic search was conducted across PubMed, Embase, and Scopus up to February 2026. A meta-analysis using a random-effects model was performed to calculate the pooled standardized mean difference (SMD), reflecting group-level differences in serum ADA levels between PTB patients and control groups. Results: Thirty-four studies were included. Serum ADA levels were significantly higher in PTB patients compared to healthy controls (SMD = 3.15, 95% CI: [2.51–3.79], p < 0.0001) and other respiratory diseases (SMD = 2.06, 95% CI: [1.38–2.74], p < 0.0001). Subgroup analyses revealed that geographical region and ADA measurement methods did not significantly account for the observed high heterogeneity (I² > 95%), indicating that ADA elevation was consistently observed across studies. Conclusions: Serum ADA levels were significantly elevated in patients with PTB, indicating a consistent biological association with disease status. However, given the high heterogeneity and the absence of diagnostic accuracy measures (e.g., sensitivity and specificity), these findings should not be interpreted as evidence of clinical diagnostic performance. Further diagnostic test accuracy studies are required to establish its clinical utility. Full article

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

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13 pages, 518 KB

Open AccessArticle

Preparing the Long-Term Care Sector for Future Health Crises: A Set of Practical Pandemic Management Staffing Strategies

by Ibrahim Abughori, Houssem Eddine Ben-Ahmed, Megan Kaulius, Maura MacPhee, David Keselman, Lara Croll, Ramtin Hakimjavadi, Alison Phinney and Farinaz Havaei

Int. J. Environ. Res. Public Health 2026, 23(4), 497; https://doi.org/10.3390/ijerph23040497 - 14 Apr 2026

Abstract

Utilizing an integrated knowledge translation framework (iKT), the purpose of this study was to identify best practices for long-term care (LTC) staffing in British Columbia, Canada, based on learnings from the COVID-19 pandemic. Through multiple data sources, including an electronic survey provided to [...] Read more.

Utilizing an integrated knowledge translation framework (iKT), the purpose of this study was to identify best practices for long-term care (LTC) staffing in British Columbia, Canada, based on learnings from the COVID-19 pandemic. Through multiple data sources, including an electronic survey provided to LTC operators and knowledge-generation forums held with LTC community members, four staffing recommendations were created. Our major findings emphasize how the pandemic exposed and further exacerbated LTC workforce shortcomings and provide rich, contextual information to help create efficacious and practical outcomes and enhance public health. Our recommendations include conducting contingency planning for potential crises, increasing the use of volunteers, implementing recruitment and retention strategies for the LTC workforce, and standardizing evaluations of staffing adequacy and resident outcomes. These investments can serve to strengthen LTC currently and to protect against potential future health crises. This project highlights how lived experience can be utilized to address health inequities and bolster public health outcomes. Full article

(This article belongs to the Section Health Care Sciences)

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25 pages, 2421 KB

Open AccessArticle

Ordinal Clinical Outcome Modeling with Temporal Validation to Support Hospital Capacity Planning During Acute Infectious Disease Burden

by Tsolmon Sodnomdavaa and Uyanga Gantumur

Int. J. Environ. Res. Public Health 2026, 23(4), 496; https://doi.org/10.3390/ijerph23040496 - 14 Apr 2026

Abstract

Acute infectious diseases represent a persistent public health burden that exerts sustained pressure on hospital bed capacity, treatment resources, and the allocation of the healthcare workforce. Strengthening hospital-level preparedness and resource planning requires reliable early-risk stratification tools that remain robust to real-world temporal [...] Read more.

Acute infectious diseases represent a persistent public health burden that exerts sustained pressure on hospital bed capacity, treatment resources, and the allocation of the healthcare workforce. Strengthening hospital-level preparedness and resource planning requires reliable early-risk stratification tools that remain robust to real-world temporal shifts. However, many existing clinical prediction studies simplify inherently ordered outcomes into binary categories and rely on random data splits, limiting their relevance for real-world health system decision-making. In this study, we developed and evaluated an ordinal machine learning framework using clinical data from 5066 patients hospitalized with acute infectious diseases between 2022 and 2024. Recovery trajectories were modeled as an ordinal outcome, reflecting changes in status between admission and discharge. Models were trained on 2022–2023 data and externally evaluated on a fully isolated 2024 cohort to assess temporal generalizability under realistic deployment conditions. Performance was evaluated using order-aware metrics, including Quadratic Weighted Kappa, Macro-F1, Balanced Accuracy, and ordinal mean absolute error, with explicit analysis of clinically meaningful error structures. Although predictive performance under future holdout validation was modest, misclassifications were predominantly concentrated between adjacent recovery levels, and no clinically critical extreme errors were observed. Model reliability was further assessed through calibration analysis, bootstrap-based uncertainty estimation, and temporal stability of explanatory patterns. Finally, ordinal predictions were translated into structured risk stratification categories aligned with hospital bed management, treatment prioritization, and workforce allocation logic. These findings demonstrate the methodological potential of temporally validated ordinal modeling as a proof-of-concept framework. Given the modest predictive performance and the absence of key clinical variables, the current model should not be regarded as a ready-made clinical decision-support tool, but rather as a foundation for further development with richer data in future research. monitoring prioritization. In practical terms, this framework demonstrates how ordinal predictions could, in principle, be structured for use at admission points. However, given the modest predictive performance observed, further development with richer clinical data is required before deployment. Full article

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15 pages, 707 KB

Open AccessArticle

Occupational Stressors and Dual Health Burden: Associations Between Body Mass Index and Common Mental Disorders Among Hospital and Manufacturing Employees in Indonesia

by Herqutanto, Muchtaruddin Mansyur, Annisa Maulidina and Muhammad Abror Rizani Fahmi

Int. J. Environ. Res. Public Health 2026, 23(4), 495; https://doi.org/10.3390/ijerph23040495 - 14 Apr 2026

Abstract

This comparative cross-sectional study simultaneously investigated the dual health burden of body mass index (BMI) and common mental disorders (CMDs) driven by occupational stressors in two stepwise regression models. By classifying stress exposure into three clinically relevant tiers (low, moderate, and severe) in [...] Read more.

This comparative cross-sectional study simultaneously investigated the dual health burden of body mass index (BMI) and common mental disorders (CMDs) driven by occupational stressors in two stepwise regression models. By classifying stress exposure into three clinically relevant tiers (low, moderate, and severe) in two distinctive populations—a hospital and a manufacturing company—we used the validated SDS-30 and SRQ-20 instruments. The robust multiple regression models uncovered a highly nuanced landscape of employee well-being that highlights the context-dependent nature of psychosocial hazards. The most compelling findings emerged from the interaction analyses, which demonstrated that the physical and mental consequences of severe stress do not impact the workforce uniformly. Regarding mental health, severe occupational stress proved to be a potent catalyst for CMD symptoms, but this psychological toll was significantly magnified within the hospital sector relative to the manufacturing environment. An opposite, yet equally context-dependent, pattern emerged regarding physical health. In the main-effects-adjusted model, the severity of occupational stressors did not demonstrate a statistically significant linear association with an overall increase in BMI. However, the interaction model revealed a hidden vulnerability: employees in operational field roles who report severe stress are highly susceptible to severe BMI increases compared with admin personnel. While administrative staff may face sedentary risks, field workers under severe stress likely endure higher physiological allostatic load, erratic shift patterns that disrupt circadian metabolic rhythms, and potentially poorer dietary coping mechanisms during active labor. This combination of physical exhaustion and severe psychological tension severely disrupts metabolic homeostasis, forcing the redistribution of adipose tissue and driving the observed BMI spike. Full article

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12 pages, 396 KB

Open AccessArticle

The Impact of the Transition into First Employment on Smoking Behavior Among Young Workers in China

by Lingyun Meng, Yuxiao Hu, Jinqing Tao and Rong Zheng

Int. J. Environ. Res. Public Health 2026, 23(4), 494; https://doi.org/10.3390/ijerph23040494 - 14 Apr 2026

Abstract

Existing research highlights the importance of young people in smoking prevention efforts, yet the smoking behavior of young workers remains underexplored. This study aims to examine whether the transition into first employment influences cigarette smoking among young Chinese workers and to explore the [...] Read more.

Existing research highlights the importance of young people in smoking prevention efforts, yet the smoking behavior of young workers remains underexplored. This study aims to examine whether the transition into first employment influences cigarette smoking among young Chinese workers and to explore the underlying mechanisms. Using data from the China Family Panel Studies (CFPS) and a difference-in-differences approach, we find that the transition into first employment significantly increases smoking intensity. Further analysis shows that this transition is associated with reduced life satisfaction, reflecting exposure to occupational stress such as high workload and time pressure, for which smoking may serve as a coping strategy. In addition, the transition into first employment is associated with increased drinking frequency, indicating greater social engagement in workplace settings where smoking and drinking are often embedded in social interactions. These findings suggest that tobacco control policies should target the first employment transition period by enforcing smoke-free regulations in workplaces and by integrating smoking prevention into pre-employment health education. Focusing on young workers during their first entry into the labor market offers a promising strategy to reduce future smoking prevalence in China. Full article

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23 pages, 8589 KB

Open AccessReview

Research Trends on Pesticide Exposure and Cancer Development: A Global Literature Review (2005–2024)

by Murugappan Sivagami and Robin Haunschild

Int. J. Environ. Res. Public Health 2026, 23(4), 493; https://doi.org/10.3390/ijerph23040493 - 14 Apr 2026

Abstract

This study examines the global research landscape on the relationship between pesticide exposure and cancer using bibliometric and scientometric approaches. A total of 3908 records published between 2005 and 2024 were retrieved from the Web of Science database using an elaborate search strategy [...] Read more.

This study examines the global research landscape on the relationship between pesticide exposure and cancer using bibliometric and scientometric approaches. A total of 3908 records published between 2005 and 2024 were retrieved from the Web of Science database using an elaborate search strategy incorporating pesticide-related keywords (e.g., atrazine, glyphosate, DDT, chlorpyrifos) and general cancer descriptors (cancer and neoplasm). The analysis explores publication trends, citation patterns, keyword co-occurrence, and co-citation networks to understand the evolution of research in this field. The results reveal a consistent increase in publication output, indicating growing global attention to pesticide-related health risks. Keyword burst analysis and temporal thematic assessment highlight a clear evolution in research focus, shifting from early studies on occupational exposure and epidemiological risk assessment toward recent emphasis on toxicity, oxidative stress, and mechanistic pathways underlying carcinogenesis. The findings provide important insights for future research, public health policy, and regulatory frameworks, emphasizing the need for interdisciplinary approaches. By identifying emerging themes and research gaps, this study offers a broad understanding of the development of pesticide–cancer research and supports efforts to mitigate the health impacts of pesticide exposure. Full article

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22 pages, 496 KB

Open AccessSystematic Review

Joint Modeling of Longitudinal and Survival Data in Public Health and Biomedical Research: A Systematic Review

by Weize Wang, Zoran Bursac and Nan Hu

Int. J. Environ. Res. Public Health 2026, 23(4), 492; https://doi.org/10.3390/ijerph23040492 - 13 Apr 2026

Abstract

We conducted a PRISMA-guided systematic review to summarize recent methodological advances in joint modeling. A PubMed search for English-language, peer-reviewed, full-text available articles published between 1 January 2019 and 30 January 2025 was conducted using the keywords “joint model”, “joint modeling”, “longitudinal and [...] Read more.

We conducted a PRISMA-guided systematic review to summarize recent methodological advances in joint modeling. A PubMed search for English-language, peer-reviewed, full-text available articles published between 1 January 2019 and 30 January 2025 was conducted using the keywords “joint model”, “joint modeling”, “longitudinal and survival”, “longitudinal and time-to-event”, and “public health”, resulting in 70 methodological studies from 793 records after screening. Original studies proposing methodological innovations in joint modeling were eligible, while clinical applications, reviews, comparative or predictive studies, and articles without full text were excluded. The reviewed methods introduced advances in both longitudinal and/or survival sub-models, including generalized linear mixed models, functional or latent class approaches, and flexible survival models, such as frailty, accelerated failure time, B-spline, and competing risks models. In total, 49% of the studies focused on longitudinal sub-model adaptations. This review is subject to limitations, including potential omission of relevant studies due to database, search term, and language restrictions. These developments have enhanced the flexibility of joint models for analyzing complex data structures, particularly in cardiovascular and oncology research, as well as broader public health applications. Despite these advances, challenges remain, including handling high-dimensional sparse data, reducing computational burden, and the lack of standardized evaluation metrics. This research received no external funding. Full article

(This article belongs to the Special Issue Advances in Biostatistics for Cardiovascular and Cancer Research)

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14 pages, 295 KB

Open AccessArticle

Relationships Between Physical Activity, Sleep, Psychological Well-Being, and Academic Performance Among Native American College Students

by Olutosin Sanyaolu, Brandy Reeves-Doyle, Afolakemi C. Olaniyan, Tarenina Max, Adetoun Asala and Esther Osime

Int. J. Environ. Res. Public Health 2026, 23(4), 491; https://doi.org/10.3390/ijerph23040491 - 13 Apr 2026

Abstract

Background: College students’ well-being is a critical determinant of academic success, and for Native American students, cultural strengths, resilience, and community support are key in fostering persistence in higher education. Alongside these assets, health behaviors are key contributors to psychological well-being (PWB) and [...] Read more.

Background: College students’ well-being is a critical determinant of academic success, and for Native American students, cultural strengths, resilience, and community support are key in fostering persistence in higher education. Alongside these assets, health behaviors are key contributors to psychological well-being (PWB) and academic performance. This study examined how modifiable health behaviors, such as physical activity (PA) and sleep duration, relate to PWB and academic performance among Native American college students. Methods: A secondary data analysis was conducted using a nationally representative sample of Native Americans (N = 1914) from the Spring 2023 American College Health Association-National College Health Assessment (ACHA-NCHA) survey. Independent variables include meeting PA guidelines (≥150 min moderate or ≥75 min vigorous/week) and sleep duration (categorized as poor or good). The Diener Flourishing Scale measured PWB. Academic performance was measured based on self-reported cumulative grade averages. Findings: Biological sex and PA were significantly associated, χ² = 40.60, p < 0.001, with a higher proportion of males meeting PA guidelines. Students with good sleep reported higher PWB than others, F(1, 1817) = 62.08, p < 0.001. Similarly, students who met PA guidelines reported higher PWB, F(1, 1817) = 35.71, p < 0.001. Poor sleep was associated with lower odds of higher academic performance (B = −0.33, p < 0.001). Contrarily, PA was not significant (p = 0.350). PWB was positively associated with academic performance (B = 0.031, p < 0.001). Conclusions: Sleep and PWB are key factors associated with both PWB and academic performance, while PA is associated with PWB. These findings highlight the importance of relevant interventions that promote these factors to support overall well-being, academic success, and retention among Native American college students. Full article

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

26 pages, 1193 KB

Open AccessArticle

Digital Governance at the Street Level: A Mixed-Methods Study of Systemic Resilience and ‘Human-in-the-Loop’ Telemedicine in Rural Thailand

by Nathachon Tarnthong and Chitralada Chaiya

Int. J. Environ. Res. Public Health 2026, 23(4), 490; https://doi.org/10.3390/ijerph23040490 - 13 Apr 2026

Abstract

While telemedicine has proliferated globally, its sustainable implementation in resource-constrained settings remains understudied. This study evaluates the efficacy, determinants of patient satisfaction, and systemic resilience of a “Home Ward” model at a rural Thai community hospital. Employing a convergent mixed-methods design, we surveyed [...] Read more.

While telemedicine has proliferated globally, its sustainable implementation in resource-constrained settings remains understudied. This study evaluates the efficacy, determinants of patient satisfaction, and systemic resilience of a “Home Ward” model at a rural Thai community hospital. Employing a convergent mixed-methods design, we surveyed 51 participants and conducted in-depth interviews with service users (n = 5) and a multidisciplinary team (n = 7). Multiple linear regression revealed high patient satisfaction ( = 3.70), explaining 67.3% of the variance (R² = 0.673). Notably, Perceived Usefulness (β = 0.589, p < 0.001) and the Effectiveness of Symptom Monitoring (β = 0.317, p < 0.05) significantly predicted satisfaction. Conversely, Overall System Quality was not a significant predictor (β = 0.142, p > 0.05), highlighting a ‘Low-Tech, High-Touch’ paradox. Qualitative analysis elucidated this through the “Human-in-the-Loop” mechanism, where Village Health Volunteers (VHVs) and healthcare providers bridge the digital divide. However, the study identifies an “invisible workload”—non-formalized discretionary effort—that sustains this resilience. Findings suggest that rural digital health governance should prioritize human intermediaries and pragmatic utility over purely technical upgrades. The study concludes that long-term sustainability requires institutionalizing human support networks while mitigating the exploitation of healthcare personnel’s goodwill. Full article

21 pages, 484 KB

Open AccessArticle

The Effect of Digital Literacy Training on Physical Activity App Acceptance and Behavioral Intentions among Older Women: An Experimental Study

by Silvija Baubonytė

Int. J. Environ. Res. Public Health 2026, 23(4), 489; https://doi.org/10.3390/ijerph23040489 - 13 Apr 2026

Abstract

Physical activity apps offer significant potential to promote physical activity and active aging; however, their acceptance among older adults remains limited, often due to insufficient digital literacy. This study aimed to examine whether targeted, app-specific digital literacy training can improve eHealth literacy, acceptance [...] Read more.

Physical activity apps offer significant potential to promote physical activity and active aging; however, their acceptance among older adults remains limited, often due to insufficient digital literacy. This study aimed to examine whether targeted, app-specific digital literacy training can improve eHealth literacy, acceptance of physical activity apps, and behavioral intentions among older women, drawing on the Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) extended with a personal innovativeness construct. A total of 63 older women (M = 67.0, SD = 4.6) were randomly assigned to an experimental (n = 32) or control group (n = 31). The experimental group participated in a nine-week digital literacy training focused on practical use of physical activity apps. Measures were collected before and after the intervention. Data were analyzed using repeated-measures MANOVA and ANOVAs. A significant Group × Time interaction was observed for technology acceptance (Wilks’ Λ = 0.41, F (7, 54) = 11.14, p < 0.001, η_p² = 0.59). The experimental group showed significant improvements across all measured constructs. The largest effects were found for eHealth literacy (η_p² = 0.39) and intention to use physical activity apps (η_p² = 0.24). App-specific digital literacy training can enhance technology acceptance and support physical activity–related intentions among older women, highlighting its potential to reduce digital barriers and promote active aging. The findings reflect short-term, self-reported changes in technology acceptance and behavioral intentions. Full article

34 pages, 473 KB

Open AccessReview

Experiences and Outcomes of Peer Navigation and Support Interventions for Adolescents on HIV Treatment in Sub-Saharan Africa: A Qualitative Evidence Synthesis

by Bernard Nhlanhla Mabuza, Charné Petinger and Brian van Wyk

Int. J. Environ. Res. Public Health 2026, 23(4), 488; https://doi.org/10.3390/ijerph23040488 - 13 Apr 2026

Abstract

Adolescents living with HIV (ALHIV) face ongoing challenges with treatment adherence and engagement in care, resulting in lower viral suppression rates compared to adults. Peer navigation has shown promise in supporting psychosocial well-being and adherence among adults, but evidence specific to adolescents in [...] Read more.

Adolescents living with HIV (ALHIV) face ongoing challenges with treatment adherence and engagement in care, resulting in lower viral suppression rates compared to adults. Peer navigation has shown promise in supporting psychosocial well-being and adherence among adults, but evidence specific to adolescents in sub-Saharan Africa (SSA) remains limited. This qualitative evidence synthesis (QES) describes and assesses the quality of qualitative and mixed-methods studies on peer navigation and support interventions for ALHIV receiving antiretroviral therapy in SSA. Eligible studies, published in English between January 2015 and October 2025, were identified through a comprehensive search strategy in PubMed, Scopus, CINAHL, and APA PsycArticles. Data were extracted and analyzed thematically using Atlas.ti, and aligned with the Context–Intervention–Mechanism–Outcome (CIMO) framework. PNs in the studies were young people living with HIV who provided education, counselling and adherence support to their peers who were ALHIV. Effective programmes featured structured training, supportive supervision, and flexible delivery models adapted to adolescents’ preferences. Mechanisms of change included trust-building, emotional support, disclosure coaching and empowerment. Reported outcomes included improved adherence, clinic attendance and various psychosocial indicators. However, challenges such as stigma, role ambiguity, limited remuneration, and lack of policy guidance constrained the sustainability and scalability of PN programs. Overall, peer navigation interventions appear effective in strengthening adolescent HIV care when PNs are adequately trained, supervised and contextually adapted. The variation in how peer navigation and support interventions for ALHIV are delivered and designed, along with the lack of standardization of the interventions, may affect the generalizability of the findings and the rollout of PN programs across SSA. Full article

(This article belongs to the Special Issue Achieving HIV Management Through Nursing and Public Health Interventions)

25 pages, 642 KB

Open AccessArticle

Perceived Individual and Systemic Impact of a Digital Wellbeing Package for Health and Care Workers Five Years Post-Release: A Qualitative Study

by Holly Blake, Neelam Mahmood and Ikra Mahmood

Int. J. Environ. Res. Public Health 2026, 23(4), 487; https://doi.org/10.3390/ijerph23040487 - 13 Apr 2026

Abstract

This study explores health and care workers’ perceptions of the longer-term influence of a rapidly developed digital support package designed to promote psychological wellbeing during the COVID-19 pandemic. A qualitative design was used, involving semi-structured interviews with 20 health and care professionals, including [...] Read more.

This study explores health and care workers’ perceptions of the longer-term influence of a rapidly developed digital support package designed to promote psychological wellbeing during the COVID-19 pandemic. A qualitative design was used, involving semi-structured interviews with 20 health and care professionals, including frontline clinicians and senior leaders, who had used and disseminated a theory-informed digital wellbeing package, accessed globally by 82,425 users within its first year. Interviews conducted in 2025 examined participants’ accounts of perceived effects at individual, professional, and organisational levels. Data were analysed using reflexive thematic analysis informed by public mental health, organisational resilience, and implementation science perspectives. Four themes were identified: enhanced psychological wellbeing and coping; changes to professional practice and fatigue management; reframing resilience as a collective and organisational responsibility; and the sustainability and ongoing relevance of the resource beyond the pandemic. Participants described experiences such as reduced stress and anxiety, improved sleep and emotional regulation, sustained use of cognitive–behavioural strategies, and perceived improvements in functioning at work. Some participants also reported that the resource informed their thinking about leadership, psychological safety, and wellbeing practices, and described its continued relevance five years post-release. These qualitative findings illustrate how the digital wellbeing intervention was experienced by participants and how they interpreted its relevance over time. The study suggests that digitally delivered, theory-informed resources may have perceived value for individual capacity building, professional practice, and organisational approaches to resilience within health systems facing ongoing structural pressures. Full article

(This article belongs to the Special Issue Digital Health for Prevention, Equity, and Service Delivery Improvement)

14 pages, 503 KB

Open AccessArticle

Frailty Through a One Health Lens: Biological Sex, Mental Health, and Oral Function in Physically Active Older Adults

by Luciano Maia Alves Ferreira, José Brito, Catarina Colaço, Marcelo Palinkas, Ricardo Brites, Maia e Maia Fischel e Andrade, João Tiago Botelho, José João Baltazar Mendes, Selma Siessere and Simone Regalo

Int. J. Environ. Res. Public Health 2026, 23(4), 486; https://doi.org/10.3390/ijerph23040486 - 12 Apr 2026

Abstract

Frailty is a multifactorial geriatric syndrome marked by reduced physiological reserves and increased vulnerability to adverse outcomes. This multicenter observational study adopted a One Health approach to examine the association between frailty and biological sex, denture use, and antidepressant medication, as well as [...] Read more.

Frailty is a multifactorial geriatric syndrome marked by reduced physiological reserves and increased vulnerability to adverse outcomes. This multicenter observational study adopted a One Health approach to examine the association between frailty and biological sex, denture use, and antidepressant medication, as well as their impact on bite force, in two transnational cohorts of physically active older adults. The sample included 499 individuals aged ≥60 years (295 from Brazil and 204 from Portugal), all with functional dentition and regular physical activity. Frailty was assessed using the adapted Fried phenotype and classified as non-frail (G0), pre-frail (G1), or frail (G2). Oral health, depressive symptoms (CES-D), bite force, and self-reported use of dentures and antidepressants were analyzed. Frailty was significantly associated with biological sex (p < 0.001), with higher prevalence among women, especially in G2. Antidepressant use was associated with frailty in the Portuguese cohort (p < 0.001) and in the total sample (p = 0.005), but not in Brazil. No significant association was observed between denture use and frailty. However, Brazilian participants without dentures showed significantly higher bite force (p < 0.001), indicating a functional oral health effect. Frailty was associated with female sex and antidepressant use, while bite force emerged as a complementary functional marker for geriatric assessment. Full article

(This article belongs to the Section Global Health)

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20 pages, 628 KB

Open AccessArticle

When Drivers Step Off the Bus: Well-Being and Turnover Intention in the Public Transport Sector

by Diana Carbone, Andrea Colabucci and Francesco Marcatto

Int. J. Environ. Res. Public Health 2026, 23(4), 485; https://doi.org/10.3390/ijerph23040485 - 12 Apr 2026

Abstract

Voluntary turnover represents a critical challenge in essential public services, where workforce attrition affects both employee well-being and service quality. The primary objective of this study was to identify the psychosocial predictors of well-being profiles and turnover intention among public transport workers, using [...] Read more.

Voluntary turnover represents a critical challenge in essential public services, where workforce attrition affects both employee well-being and service quality. The primary objective of this study was to identify the psychosocial predictors of well-being profiles and turnover intention among public transport workers, using the Job Demands–Resources model as a theoretical framework. A cross-sectional study design was employed, with 131 employees of an Italian public transport company completing a questionnaire assessing turnover intention and key psychosocial factors (job satisfaction, perceived work-related stress, work engagement, meaning of work, and perceived workplace safety). The analytical strategy integrated Latent Profile Analysis (LPA), logistic regression, and path analysis. LPA identified two distinct well-being profiles: a “low well-being profile,” with high perceived stress and low engagement and meaning of work; and a “high well-being profile,” with low stress and high engagement and work meaning. Logistic regression analyses showed that satisfaction with pay and the intrinsic nature of work tasks predicted membership in the high well-being profile. Path analysis indicated that profile membership significantly predicted turnover intention, with employees in the high well-being profile reporting lower turnover intention. Additionally, satisfaction with supervision, perceived workplace safety, and age showed direct effects on turnover intention. These findings highlight the organizational and psychological resources that can increase employee well-being and retention in the public transport sector, offering insights for preventive interventions and for promoting safer and more sustainable public transport systems. Full article

(This article belongs to the Special Issue The Importance of Psychosocial Work Environment for Occupational Health Promotion and Workforce Retention)

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8 pages, 455 KB

Open AccessCommentary

Over Two Million Life-Years at Risk: Why Gaza’s Health Reconstruction Is a Moral Imperative

by Alessandro Vitale, Mohammad Abu Hilal, Umberto Cillo, Isabella Frigerio and Andrew A. Gumbs

Int. J. Environ. Res. Public Health 2026, 23(4), 484; https://doi.org/10.3390/ijerph23040484 - 12 Apr 2026

Abstract

The concept of “Healthocide,” first defined by Abi-Rached and colleagues, describes the deliberate and systematic destruction of health systems as a weapon of war. Nowhere is this phenomenon more extensively documented than in Gaza, where the collapse of healthcare infrastructure since October 2023 [...] Read more.

The concept of “Healthocide,” first defined by Abi-Rached and colleagues, describes the deliberate and systematic destruction of health systems as a weapon of war. Nowhere is this phenomenon more extensively documented than in Gaza, where the collapse of healthcare infrastructure since October 2023 has been rapid, wide-ranging, and intentionally sustained. The consequence is not only immediate excess mortality, but also profound, long-term loss of population health measured in life-years, a metric that captures both premature death and reductions in expected lifespan. To address the aftermath of such destruction, we propose the framework of “Healthogenesis,” defined as a Palestinian-led, equity-driven, and rights-anchored approach to health system reconstruction in which international actors serve as enablers rather than agenda-setters. The aim of Healthogenesis is not merely to restore pre-war capacity, but to build a resilient, sovereign, and future-proof health ecosystem. Using available demographic and mortality data, we estimate that more than three million life-years have already been lost in Gaza since October 2023. Projection models suggest that an additional 1.1 to 2.2 million life-years could be lost over the coming decade unless an organized programme of reconstruction begins immediately. Quantifying harm in life-years reframes the discourse from moral outrage to measurable obligation. If Healthocide names the crime, then Healthogenesis outlines the cure: a coherent, data-anchored, ethically grounded roadmap for rebuilding a devastated health system and protecting the health futures of an entire population. Full article

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